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allergies: patient recorded as having no known allergies to drugs attending: chief complaint: t-bone motor vehicle crash major surgical or invasive procedure: s/p open reduction internal fixation of left sacrum fracture () history of present illness: 29m rear-passenger in t-bone collision at approximately 45-50 mph; asleep at the time, no memory of accident. c/o back pain in coccyx area and left hip. he was transported to for further care. past medical history: denies family history: noncontributory physical exam: pe at time of admission: vs: t 97.3, hr 104, bp 120/palp, spo2 99%ra, gcs 15 gen: awake, but in pain skin: scalp abrasion cv: tachycardic resp: ctab abd: fast exam negative; rectal exam with no gross bleeding gu: no blood at penile meatus ext: distal pulses palpable ms: l leg externally rotated spine: no spinal step-offs neuro: moving all extremities, normal patellar reflexes pertinent results: ct head: there is normal -white matter differentiation. there is no evidence of acute hemorrhage or shift of normally midline structures. the ventricles and sulci are unremarkable. there is no evidence of hydrocephalus. the basilar cisterns are patent. the visualized paranasal sinuses are clear. ct c-spine: there is a transverse fracture of the right occipital condyle with minimal displacement. the vertebral body heights and alignment are preserved. there is no prevertebral soft tissue swelling. degenerative changes including mild disc bulge at t1-t2 and ossification of the posterior longitudinal ligament is noted. tiny left apical pneumothorax. ct torso: the heart and great vessels are unremarkable. there is no pericardial or pleural effusion. incidental note is made of thymic remnant tissue. there is no axillary, hilar, or mediastinal lymphadenopathy. within the right upper lobe (2, 24) and right middle lobe (2, 29) and right lower lobe (2, 31) there are hazy ground-glass opacities in the periphery, which are concerning for area of lung contusion. there are tiny bilateral pneumothoraces, and tiny pneumomediastinum. the airways are patent to the subsegmental level. there is no focal consolidation identified. ct of the abdomen: the spleen, pancreas, adrenal glands, left kidney, liver, gallbladder are unremarkable. within the right kidney, there is a rounded hypodensity (2, 56), which likely represents a cyst, although possible renal laceration is not excluded. in addition, small amount of right perinephric fluid is identified (2, 53). small bowel loops are normal in caliber and without focal wall thickening. there is no free air identified. bone windows: there is no mesenteric or retroperitoneal lymphadenopathy identified. ct of the pelvis: the rectum, sigmoid colon, and bladder are unremarkable. there is no pelvic or inguinal lymphadenopathy. bone windows: there are fractures of the right posterior 11th rib, transverse processes of l2, l3, and l4. there appears to be a fracture of the left inferior articular process of l5. there is a minimally displaced left sacral fracture or (2, 94). a comminuted slightly displaced right superior pubic rami fracture, non-displaced left superior pubic ramus fracture and bilateral inferior rami fractures are identified. there is no significant pelvic hematoma identified. left leg xray: bilateral superior and inferior pubic rami fractures are redemonstrated, better seen on the recent ct. no other fracture or dislocation is present. no focal lytic or sclerotic osseous abnormality seen within the left femur. no radiopaque foreign bodies or soft tissue gas is noted. the left hip joint is preserved without significant degenerative changes. contrast is seen within the bladder which contains a foley catheter, with contrast also noted in the distal left ureter. mri spine: multiple traumatic sequelae throughout the cervical, thoracic and lumbar spine as detailed above. notably, the spinal cord appears well preserved with no definite spinal cord signal abnormalities. stir hyperintensities seen at multiple levels in the thoracic spine as detailed above with a superior endplate deformity at t5 consistent with fracture seen at that level on ct exam. also seen are signal abnormalities through the sacrum consistent with a fracture at that level. 06:17pm po2-37* pco2-56* ph-7.30* total co2-29 base xs--1 comments-green top 06:17pm glucose-129* lactate-2.3* na+-141 k+-3.4* cl--100 06:05pm urea n-13 creat-1.1 06:05pm lipase-172* 06:05pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 06:05pm wbc-14.4* rbc-4.91 hgb-13.5* hct-39.7* mcv-81* mch-27.5 mchc-33.9 rdw-12.9 06:05pm pt-13.6* ptt-26.3 inr(pt)-1.2* 06:05pm plt count-291 brief hospital course: patient came to the er s/p t-bone mvc sustaining multiple injuries. xray of chest and left leg and ct torso done. he was admitted to the trauma icu on the trauma surgery service with consults from ortho spine and orthopedics. he was kept npo/ivf, iv pain meds, foley to gravity, and bedrest/logroll precautions. mri of the cervical, thoracic and lumbar spine were done. hct remained stable at 35-36. he was transferred to floor, started pca for pain, and diet advanced as tolerated. he continued to have significant pain; he was switched to an oral pain regimen. he was then pre-op and consented for or by orthopedics. he was taken to the operating room for open reduction and internal fixation with percutaneous screw of left sacral fracture by orthopedics. his pca for pain control was restarted postoperatively. his diet was advanced; activity upgraded to touchdown weight bearing on left leg, and full weight bearing on right leg. oral pain medications were restarted. pt was consulted and have recommended rehab. he failed a voiding trial, the foley was replaced and flomax was started. he failed another voiding trial and the foley was yet again replaced. it is likely that due to his limited mobility and narcotics that he is having urinary retention. another voiding trail should be done in the next 4-5 days. plans underway for discharge to rehab. his cervical collar will need to remain on for at least 6 weeks, it may be eoved for showering as long as he keeps his head in proper alignment. medications on admission: none 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. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 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 bid (2 times a day) as needed. 5. enoxaparin 40 mg/0.4 ml syringe sig: one (1) injection subcutaneous daily (daily) for 4 weeks. 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal once a day as needed for constipation. 7. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml's po twice a day as needed for constipation. 8. flomax 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po at bedtime. discharge disposition: extended care facility: - discharge diagnosis: s/p motor vehicle crash right renal laceration with small perinephric hematoma right pulmonary contusions right l2-5 transverse process fractures left l5 transverse process fracture left sacral fracture right superior ramus fracture bilateral inferior ramus fracture right occipital and condylar fractures right t11 rib fracture small bilateral pneumothorax urinary retention discharge condition: hemodynamically stable, tolerating a regular diet, pain adequately controlled. discharge instructions: * keep your collar on for 6 weeks. you may remove it when taking showers, but be sure to keep your head straight. followup instructions: *1. follow-up with orthopedic spine surgeon dr. in 2 weeks. call his office at ( to schedule an appointment. *2. follow-up with orthopedic nurse in 2 weeks. call the office at ( to schedule an appointment. 3. follow-up with trauma surgeon dr. in 2 weeks. call his office at ( to schedule an appointment. *please inquire with the orthopedic office re: scheduling the orthopedic spine and orthopedics follow up appointments on the same day. Procedure: Repair of vertebral fracture Insertion of indwelling urinary catheter Diagnoses: Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Retention of urine, unspecified Closed fracture of one rib Traumatic pneumothorax without mention of open wound into thorax Urinary complications, not elsewhere classified Closed fracture of lumbar vertebra without mention of spinal cord injury Contusion of lung without mention of open wound into thorax Closed fracture of sacrum and coccyx without mention of spinal cord injury Closed fracture of pubis Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness Injury to kidney without mention of open wound into cavity, laceration Other motor vehicle traffic accident involving collision with motor vehicle injuring passenger in motor vehicle other than motorcycle

allergies: shellfish derived / codeine / iv dye, iodine containing attending: chief complaint: abdominal and back pain major surgical or invasive procedure: bentall procedure (. composite mechanical valve graft), replacement of hemi-arch, coronary artery bypass graft times one (svg to proximal rca) history of present illness: ms. is a 65 year old female who presented from an outside hospital with abdominal and back pain. a subsequent chest ct was performed and she was found to have a type a aortic dissection. past medical history: left renal cell cancer (s/p nephrectomy) hypothyroidism anxiety/ depression hyperlipidemia shingles gerd s/p open cholecystectomy s/p tah s/p r cataract s/p open l nephrectomy (rcc) social history: smoking: >15 pack years, quit 7 years ago. no alcohol use. lives at home with husband, independent with all adl. family history: patient unable to recall physical exam: t: 98.7, bp: 133-116/84-90, hr: 85, rr: 18, spo2: 100% 4l gen: anxious, irritable, a&o x3 cvs: rrr, nl s1s2 lungs: ctab abd: mild tenderness throughout, greatest in epigastric region. + normal bs, soft, nondistended extremity: no edema, no cyanosis neuro: normal strength and sensation of both ue and le. eom intact. pulses rad fem dp pt r 2+ 2+ 2+ 2+ 2+ l 2+ 2+ 2+ 2+ 2+ pertinent results: 11:10am pt-14.7* ptt-43.3* inr(pt)-1.3* 11:10am fibrinoge-218 11:10am plt count-171 11:10am wbc-17.8* rbc-2.09* hgb-5.9* hct-18.5* mcv-89 mch-28.2 mchc-31.8 rdw-14.3 01:26pm wbc-9.3 rbc-3.21* hgb-9.0* hct-28.4* mcv-89 mch-28.1 mchc-31.8 rdw-14.3 01:26pm albumin-3.4 calcium-7.4* phosphate-2.5* magnesium-1.7 01:26pm ck-mb-4 ctropnt-0.05* 01:26pm alt(sgpt)-44* ast(sgot)-49* ld(ldh)-160 ck(cpk)-209* alk phos-72 tot bili-0.6 01:26pm glucose-463* urea n-8 creat-1.0 sodium-135 potassium-3.4 chloride-95* total co2-37* anion gap-6 echocardiography report tee indication: aortic valve disease. coronary artery disease. left ventricular function. mitral valve disease. pericardial effusion. echocardiographic measurements results measurements normal range left ventricle - ejection fraction: >= 55% >= 55% findings left atrium: mild la enlargement. no spontaneous echo contrast or thrombus in the body of the laa. right atrium/interatrial septum: normal ra size. a catheter or pacing wire is seen in the ra. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness and cavity size. right ventricle: normal rv chamber size and free wall motion. aorta: mildly dilated ascending aorta. ascending aortic intimal flap/dissection.. aortic arch intimal flap/dissection. descending aorta intimal flap/aortic dissection. thickened aortic wall c/w intramural hematoma. flow in false lumen. aortic valve: three aortic valve leaflets. mildly thickened aortic valve leaflets (?#). no as. mild to moderate (+) 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: small to moderate pericardial effusion. 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 atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses and cavity size are normal. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. a mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. a mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. a mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. the aortic wall is thickened consistent with an intramural hematoma. there is flow in the false lumen. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a small to moderate sized pericardial effusion. post cpb: pre served -ventricualr systolic function mechanical valve in aortic position, well seated and with good leaflet excursion. trace ai (washing jets) pg = 22 mm hg. mg = 12 mm hg dissection in descending thoracic aorta. poor visualization of the ascending aorta. ====================================================== final report pa and lateral chest on at 15:12 hours indication: postop assessment. comparison: at 15:11. findings: again seen are bilateral pleural effusions with associated atelectasis. the lateral view suggests the effusions may have decreased slightly in size. pulmonary vasculature is of normal caliber and the prominent mediastinal contours are stable. there is no ptx. impression: little change versus prior with slight reduction in pleural effusions. dr. date/time: at 08:40 interpret md: , md test type: portable tte (focused views) son: , rdcs findings large left pleural effusion seen. this study was compared to the prior study of . left ventricle: low normal lvef. right ventricle: mild global rv free wall hypokinesis. aortic valve: bileaflet aortic valve prosthesis (avr). avr well seated, normal leaflet/disc motion and transvalvular gradients. pericardium: small pericardial effusion. effusion echo dense, c/w blood, inflammation or other cellular elements. no echocardiographic signs of tamponade. conclusions overall left ventricular systolic function is low normal (lvef 50-55%). rv with mild global free wall hypokinesis. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. there is a small pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , the lv and rv systolic function appear less vigorous. electronically signed by , md, interpreting physician 09:50 radiology report duplex dopp abd/pel study date of 9:20 am final report indication: 65-year-old female status post bentall, rule out renal artery stenosis. comparison: abdomen cta . findings: the right kidney measures 13.2 cm. there is no hydronephrosis. a small simple cyst is seen at the lateral margin of the right kidney measuring 0.8 x 1.0 cm. a single image of the left renal fossa demonstrates no abnormality (the patient is status post left nephrectomy). the pre-void bladder is only partially distended but is otherwise unremarkable. doppler examination: color doppler and pulse-wave doppler images were obtained. appropriate venous flow is seen in the main right renal vein. appropriate arterial waveforms demonstrating sharp upstrokes are seen in the right main renal artery. resistive indices of the intraparenchymal right renal arteries range from 0.63 to 0.70. impression: 1. small simple right renal cyst. no hydronephrosis and no solid renal mass. status post left nephrectomy. 2. no sign of renal artery stenosis. the study and the report were reviewed by the staff radiologist. , rdms dr. brief hospital course: ms. on arrival to underwent a chest ct and was found to have a type a aortic dissection. she was taken emergently to the operating room and underwent a bentall procedure (. composite mechanical valve graft)and replacement of hemi-arch, coronary artery bypass graft times one (svg to proximal rca) on . this procedure was performed by dr. . please see the operative note for details. she tolerated this procedure well and was transferred in critical but stable condition the the surgical intensive care unit. on pod1 her sedation was weaned she woke and was extubated and her pressors were weaned. her chest tubes were removed and beta blockade was initiated. her epicardial wires were removed and coumadin was begun for her mechanical valve. post operatively she had periods of being disoriented so narcotics were with held and she was frequently re-oriented. her home benzodiazepine was not restarted. she was transferred to the stepdown floor on pod2. her activity level was gradually advanced with the assistance of nursing ant physical therapy staff. her lopressor and other medications were titrated to effect. lisinopril and clonidine were added for blood pressure control. mrs. was extremely sensitive to coumadin w/ an inr as high as 14. hematolgy was consulted and recommended very low dose couamdin once her inr was <3.0. coumadin was resumed at 0.5 mg every other day. if coumadin dose is to be changed please notify dr at his office medications on admission: celexa 20 mg once daily xanax 0.5 mg once daily synthroid 75 mcg once daily protonix 40 mg once daily simvastatin 40 mg once daily (dced due to normal chol levels) discharge medications: 1. outpatient work pt/inr - first draw - inr goal for mechanical avr is 2.5-3. please check inr level every other day for the first two weeks and then three times a week due to sensitivity and response to coumadin coumadin to be followed by coumadin clinic at the office of dr. phone () fax (). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. 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* 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. coumadin 1 mg tablet sig: goal inr 2.5-3.0 tablets po once a day: dose 0.5mg every other day with last dose 9/22 - next dose with inr draw with results to dr . disp:*60 tablet(s)* refills:*2* 9. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 10. lopressor 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 11. clonidine 0.1 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 12. outpatient work chem and fax to dr. discharge disposition: home with service facility: community nurse care,inc discharge diagnosis: type a aortic dissection s/p repair pmh: left renal cell cancer (s/p nephrectomy) hypothyroidism anxiety/ depression hyperlipidemia shingles gerd psh: s/p open cholecystectomy s/p tah s/p r cataract s/p open l nephrectomy (rcc) discharge condition: good discharge instructions: please shower daily including washing incisions, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns pt/inr - first draw - inr goal for mechanical avr is 2.5-3. please check inr level every other day for the first two weeks and then three times a week due to sensitivity and response to coumadin coumadin to be followed by coumadin clinic at the office of dr. phone () fax (). followup instructions: dr (cardiac surgeon) in 2 weeks () please call for appointment dr (pcp) in weeks () please call for appointment. dr. to recommend cardiologist for follow up in weeks. please call for appointment coumadin to be followed by coumadin clinic at the office of dr. phone () fax (). inr to be drawn on . inr goal for mechanical avr is 2.5-3. please check inr level every other day for the first two weeks and then three times a week due to sensitivity and response to coumadin - please call dr office if any questions or concerns arise. also please check chemistries in one week and fax to dr. . wound check appointment 6 as instructed by nurse () Procedure: Open and other replacement of aortic valve (Aorto)coronary bypass of one coronary artery (Aorto)coronary bypass of one coronary artery Resection of vessel with replacement, thoracic vessels Resection of vessel with replacement, thoracic vessels Other repair of vessel Diagnoses: Esophageal reflux Unspecified acquired hypothyroidism Dysthymic disorder Other and unspecified hyperlipidemia Personal history of malignant neoplasm of kidney Dissection of aorta, thoracic Cardiac tamponade Dissection of coronary artery

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: intoxication / altered mental status major surgical or invasive procedure: ntd history of present illness: hpi: patient is a 50 yo man with pmh of chronic alcoholism, depression, chronic lbp, left anteroir cruciate tear unrepaired who was found down by friend today. been an alcoholic for many years. particularly depressed recently as is 5 yr anniversary of his father's death, and sister recently diagnosed with ca. drinking very heavily lately and not leaving house. multiple falls. poor po intake. found down with signs of trauma today and had ct at osh showing left frontal sdh. was apparently awake, speaking and following commands but had to be intubated for aggitation. past medical history: pmhx: chronic alcoholism, depression, chronic lbp, left anteroir cruciate tear unrepaired social history: social hx: alcoholic. dtr is . smokes, denies drugs. family history: family hx: na physical exam: physical exam: o: t: 97.1 bp: 113/75 hr: 119 r 24 o2sats 93 intubated gen: wd/wn, comfortable, nad. heent: pupils: 1mm and trace reactive. right eye lac/contusion. neck: hard collar. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. multiple contusions, various ages. neuro: mental status: intubated, sedated with versed. has just been bolused with versed and not moving or withdrawing to noxious stim. however, prior to bolus was spontaneously moving x 4 and withdrawing to noxoius stim. cranial nerves: i: not tested ii: pupils 1mm and trace reactive bilaterally. no blink to threat. iii, iv, vi: eyes midline. cannot doll maneuver. v, vii: face symmetric. viii: na ix, x: gag intact. : na. xii: na motor: not moving after recent versed bolus, but was withdrawing x 4 and moving spontaneously x 4 and symmetrically prior. sensation: as above. reflexes: b t br pa ac right 1 1 1 1 1 left 1 1 1 1 1 toes downgoing bilaterally upon discharge pt has a non-focal neurological exam pertinent results: 10:00pm blood wbc-11.3* rbc-4.64 hgb-14.3 hct-41.8 mcv-90 mch-30.8 mchc-34.2 rdw-13.2 plt ct-170 10:40am blood wbc-10.5 rbc-4.01* hgb-12.4* hct-35.5* mcv-89 mch-30.9 mchc-35.0 rdw-13.6 plt ct-453* 05:10am blood pt-12.7 ptt-21.6* inr(pt)-1.1 10:00pm blood pt-13.0 ptt-24.9 inr(pt)-1.1 10:00pm blood glucose-77 urean-12 creat-0.8 na-143 k-4.0 cl-106 hco3-22 angap-19 05:10am blood glucose-85 urean-9 creat-0.7 na-133 k-4.6 cl-98 hco3-27 angap-13 05:10am blood albumin-3.8 calcium-9.0 mg-2.5 05:10am blood phenyto-12.4 ct impression: 1. left convexity subdural hematoma associated with minimal rightward septum pellucidum shift. 2. apparent bifrontal hypodensities are likely artifactual, though attention is recommended on follow-up imaging. ct impression: slightly decreased left convexity subdural hematoma brief hospital course: pt was admitted to after found down at home after fall. pt with acute left sdh/ non surgical on admission. he was loaded with dilantin on admission and levels were followed. he was also noted to be hyponatremic and was placed on fluid restriction and salt tabs. on the pm of hospital day # 2 pt was experiencing dt's and was transferred to sicu for management. he was then transferred to the floor once stable. he was tremulous however then well controlled with ativan. he had episodes of hyponatremia and was fluid restricted with na return to normal value. he was seen by psychiatry for the history of depression and etoh abuse as well as assistance with managing his delerium. their recs were followed. he was then transferred to the va in for management medications on admission: ultram prn, bisocadyl. discharge medications: 1. docusate sodium 100 mg capsule sig: capsules po bid (2 times a day). 2. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 3. multivitamin tablet sig: one (1) tablet po daily (daily). 4. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 5. nicotine 7 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 6. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). 7. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 8. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 9. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for heartburn. 10. sodium chloride 1 gram tablet sig: one (1) tablet po tid (3 times a day). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours). 12. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 13. lorazepam 1 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for agitation. 14. haloperidol 1 mg tablet sig: 2.5 tablets po tid (3 times a day) as needed for agitation. discharge disposition: extended care facility: va discharge diagnosis: alcohol abuse acute left subdural hematoma discharge condition: neurologically stable 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. ?????? 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 an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. please have results faxed to . ?????? clearance to drive and return to work will be addressed at your post-operative office visit. 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 call ( to schedule an appointment with dr. , to be seen in 2 weeks. ??????you will need a ct scan of the brain without contrast. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Other chronic pain Tobacco use disorder Hyposmolality and/or hyponatremia Unspecified fall Depressive disorder, not elsewhere classified Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Lumbago Drug-induced delirium Alcohol withdrawal delirium Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hematemesis major surgical or invasive procedure: none history of present illness: mr. is a 75 year old man with colon ca s/p hemicolectomy , s/p bilateral ureteral stent placement now presenting with constipation, coffee grounds emesis and hematuria. he had been in usoh until today when he noted "weakness" and dizziness with standing. he also has been constipated with last bm 10 days prior. this bm was hard but brown and not black or tarry. has continued to pass flatus. denies abdominal pain, melena, hematochezia, chest pain, sob, fever, chills, lightheadedness, decreased po intake, nsaid or steroid use. his wife called ambulance to take him to ed for weakness and consripation and he had coffee grounds emesis x 2 in ambulance and subsequently in ed. he also reprots hematuria since stents and foley placed 4 days prior. denies any prior h/o gib or similar symptoms. . in the emergency department, initial vitals were: 97.8 91 142/79 16 98%ra. ng lavage was positive for hemoccult positive coffee grounds which did not clear after 1l. he was guaiac negative but was noted to have abdominal tenderness so ct abdomen/pelvis was obtained and revealed distended small and large bowel with air fluid levels suggestive of gastroenteritis. gi and surgery evaluated patient and recommended decompressing from above with ngt and enemas from below but no urgent indication for scope since hd stable. ua was positive and blood cx x 2 were drawn. he received 1lns, pantoprazole, levofloxacin, flagyl and zofran. labs significant for hct 34 from baseline 32 and cr 1.7 from baseline 2.0. . vitals prior to transfer to the icu were: 77 131/78 16 95%ra past medical history: metastatic adenocarcinoma consistent with colonic origin; involves serosa of small bowel colon cancer, stage iiib, status post hemicolectomy on in the setting of bowel obstruction, received 7 cycles of xeloda, stopped concern for progression of disease bilateral ureteral obstruction s/p b/l stent placement ; unclear etiology of obstruction per review of notes cva with residual r sided weakness and r facial droop hypertension diabetes (diet controlled) hyperlipidemia prostate cancer s/p treatment with external beam radiation "many years ago" - social history: married with children, supportive family. retired electrician for and currently lives in , ma with wife. denies tobacco, recreational drugs, or alcohol excess. family history: nc physical exam: vs on transfer to the floor: hr 78 bp 144/78 o2 98% on ra general: pleasant, well appearing elderly gentleman in nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. dry mm. op clear with dried blood in posterior op. ngt in place with gastroccult positive coffee grounds material in canister. neck: supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. systolic murmur heard best rusb. no rubs or . jvp=7-8cm lungs: ctab, good air movement biaterally. abdomen: flat abdomen. well healed midline scar. hypoactive bs. ttp over ruq where there is palpable bowel gas. no rebound or hsm extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. scar r knee skin: no rashes/lesions, ecchymoses. neuro: a&ox3. speech slow and deliberate. initially reported was in but later reoriented to in , ma. oriented to self and wife and able to relate her phone number. oriented to month and year but not date. appropriate. cn 2-12 intact. 5/5 strength throughout. + reflexes, equal bl. gait assessment deferred psych: listens and responds to questions appropriately, pleasant pertinent results: labs blood wbc-8.0 rbc-2.90* hgb-9.9* hct-27.9* mcv-96 mch-34.1* mchc-35.4* rdw-12.5 plt ct-303 glucose-153* urean-24* creat-1.1 na-133 k-4.2 cl-101 hco3-26 angap-10 alt-10 ast-17 alkphos-73 totbili-0.4 albumin-2.7* calcium-8.1* phos-3.5 mg-2.0 cholest-108 triglyc-90 hdl-39 chol/hd-2.8 ldlcalc-51 . pt-12.6 ptt-28.8 inr(pt)-1.1 . cea-20* . labs on admission: wbc-11.8*# rbc-3.55*# hgb-12.3*# hct-34.6* mcv-98 mch-34.8* mchc-35.6* rdw-13.4 neuts-87.0* lymphs-9.9* monos-2.4 eos-0.5 basos-0.1 plt count-241# . pt-12.0 ptt-19.6* inr(pt)-1.0 . glucose-175* urea n-31* creat-1.7* sodium-138 potassium-4.7 chloride-97 total co2-31 anion gap-15 . alt(sgpt)-5 ast(sgot)-17 ld(ldh)-173 alk phos-111 tot bili-0.4 lipase-107* . ua: blood-lg nitrite-neg protein-150 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-mod rbc->50 wbc-21-50* bacteria-mod yeast-none epi-0-2 . lactate-1.4 . microbiology: urine and blood cultures pending . imaging: . mri abdomen: extensive dilated loops of small bowel and colon with apparent transition deep in the pelvis at distal colon. diffuse surrounding enhancement and suggestion of wall thickening of the colon is of unclear etiology, but given the lack of preferential fdg uptake on pet findings, this more likely is attributed to a fibrotic process from prior radiation treatment and/or stricturing from superimposed ischemic episodes than a high grade tumor. however, given the presumed recent onset of these findings, with the remoteness of regional radiation treatment, neoplasm as a cause of this stricture cannot be excluded based on imaging. . pet/ct abd: no fdg avid foci to suggest metastatic or recurrent colon cancer. multiple dilated loops of small and large bowel consistent with ileus. increased abdominal ascites in comparison to ct of . right pleural effusion. . kub: upright and supine views of the abdomen show moderate-to-severe distention and wall thickening of the small bowel comparable to and distention of the colon but no air in the rectum. the largest hollow viscus crossing the abdomen from the left upper quadrant to the midline inferiorly is probably transverse colon. there may be gas in the sigmoid, but there is no gas in the rectum raising concern for distal obstruction, perhaps due to adhesions or more simply stool impaction. urinary stents are unchanged in position from the renal pelves to the bladder. . cxr: large dilated loops of bowel, no acute cardiopulmonary process . ct abd: distended small and large bowel with air fluid levels suggestive of gastroenteritis. mri: . extensive dilated loops of small bowel and colon with apparent transition deep in the pelvis at distal colon. diffuse surrounding enhancement and suggestion of wall thickening of the colon is of unclear etiology, but given the lack of preferential fdg uptake on pet findings, this more likely is attributed to a fibrotic process from prior radiation treatment and/or stricturing from superimposed ischemic episodes than a high grade tumor. however, given the presumed recent onset of these findings, with the remoteness of regional radiation treatment, neoplasm as a cause of this stricture cannot be excluded based on imaging. pathology : metastatic adenocarcinoma consistent with colonic origin; involves serosa of small bowel : peritoneal fluid: positive for malignancy, consistent with adenocarcinoma 6:30 pm urine source: catheter. final report urine culture (final ): yeast. >100,000 organisms/ml.. brief hospital course: 75 year old man with colon cancer s/p hemicolectomy and s/p bilateral ureteral stent placement initially admitted to the for ugib in setting of constipation and hematuria. was transferred to the floor once hemodynamically stable. ugib resolved, but constipation persisted. after an extensive workup, was found to have a partial lbo likely secondary to malignancy. . #1. partial lbo: the patient reported chronic constipation (bm q 7 days) worsening over the prior 3 weeks. had + flatus, but passing only very small stools. kub was suggestive of obstruction. flex sig and colonoscopy were initially attempted but failed to pass beyond 20 cm with poor visualization due to stool. the patient did not tolerate ngt decompression. a pet/ct showed dilated loops of small and large bowel with no vdg avid foci. a second attempt at colonoscopy showed an obstruction at approximately 30 cm beyond which the scope could not pass. gastrografin enemas were refused by the patient. mr d marked small and large bowel dilation with a transition point at the colosigmoid junction. this is likely due to external compression from metastatic disease. clinically, the patient's abdomen remains distended and tympanic, but soft and nontender. he continues to have flatus and very small, liquid stools. there is no abdominal pain and no nausea/vomiting. he was placed on tpn for persistent poor po intake. he was taken to the or on for palliative ileostomy. . #2. ugib: the patient initially presented with coffee grounds emesis in setting of constipation. etiology of ugib thought to be likely tear from repeated emesis. ng tube was placed to suction with gastroccult positive. stable hemodynamically during stay. the patient has not had a dramatic drop in hct. remained hd stable during stay without current evidence of active bleed. gi consulted performed egd showing food in the esophagus without evidence of active bleed. hct was trended upwards and the patient was maintained on ppis. . #3. uti/hematuria: likely related to foley and recent stent placement. was treated as complicated uti for 7 days with ciprofloxacin per urology. course has been completed. blood and urine cultures were negative. foley has since been d/ced and there is no evidence of uti. the patient is urinary incontinent. . #4. ureteral obstruction/s/p stent placement: the patient's creatinine has improved, max 2.5, down to 1.2 currently, since placement of bilateral stents and passing adequate uop. post void residuals have been <200. per urology recs, if >200, should give prophylactic antibiotics. . #5. s/p cva: the patient was kept on aggrenox. it was held on in anticipation of surgical intervention. . #6. htn: lisinopril was held in the setting of normal bps. . #7. hyperlipidemia: statin was discontinued on in the setting of lbo. . #8.8 diabetes: diet controlled at home. had fs qid and insulin sliding scale. . #9. h/o prostate cancer: the patient was continued on his home dose of flomax. he has been urinary incontinent. . #10. depression: the patient was continued on his home does of ssris. . ppx: pneumoboots, heparin sc code: dnr/dni emergency contact: wife surgery: patient continue to have symptoms of partial small bowel obstruction, poor food tolerance, abdominal distension and pain. he had a mri that showed extensive dilated loops of small bowel and colon with apparent transition deep in the pelvis at distal colon. the decision was made to take him to the operating room. on for exploratory laparotomy, we founded a copious amount of clear ascitic fluid in the abdominal cavity. palpation of the abdomen revealed carcinomatosis studding the mesentery, the small bowel, the residual large bowel and the liver. there was a loop of small bowel in the right lower quadrant that was solidly adherent to the retroperitoneum. he had a loop ileostomy in order to try to decrease acute symptoms of bowel obstruction. the patient was admitted to the general surgical service for evaluation and treatment. after a brief, uneventful stay in the pacu, the patient arrived on the floor npo, on iv fluids and antibiotics, with a foley catheter. the patient was hemodynamically stable. cv: the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. post-operatively, the patient was made npo with iv fluids. diet was advanced when appropiate, which was well tolerated. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and repleted when necessary. palliative care was consulted, they had an extensive meeting with patient and family. they both understand the goals of care are palliative and comfort oriented, patient and family decided they would like to have hospice involvement. ostomy nurse service was consulted, they worked extensively on ostomy care teaching and management. prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. patient was discharge to hospice for pain management and comfort. medications on admission: lipitor 10mg po daily flomax 0.4mg po daily keflex 500mg po tid since tylenol #3 prn lisinopril 10mg po daily effexor xr 37.5mg po daily cipro 250mg po daily? wife denies 100mg po tid mag citrate off aggrenox x 1 week . medications on transfer: bisacodyl pr pantoprazole 40mg iv q12h cephalexin 500mg q8h (day 6) zofran prn insulin ss ciprofloxacin 400mg iv q12h (day 2) 100mg venlafaxine 37.5mg qd tylenol prn atorvastatin 10mg qd discharge medications: 1. venlafaxine 37.5 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 2. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 3. lipitor 10 mg tablet sig: one (1) tablet po once a day. 4. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 2 weeks. disp:*85 tablet(s)* refills:*0* 5. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day) for 2 weeks. 6. lisinopril 10 mg tablet sig: one (1) tablet po once a day. tablet(s) 7. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 8. pantoprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 9. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 weeks. disp:*30 tablet(s)* refills:*0* 10. insulin sliding scale insulin sc sliding scale breakfast lunch dinner bedtime humalog humalog humalog humalog glucose insulin dose insulin dose insulin dose insulin dose 0-70 mg/dl proceed with hypoglycemia protocol 71-150 mg/dl 0 units 0 units 0 units 0 units 151-200 mg/dl 1 units 1 units 1 units 1 units 201-250 mg/dl 2 units 2 units 2 units 2 units 251-300 mg/dl 3 units 3 units 3 units 3 units 301-350 mg/dl 4 units 4 units 4 units 4 units 351-400 mg/dl 5 units 5 units 5 units 5 units 11. fluconazole 200 mg tablet sig: one (1) tablet po once a day for 4 days. disp:*4 tablet(s)* refills:*0* 12. morphine 20 mg/5 ml solution sig: 5mg po every four (4) hours as needed for severe pain or breathlessness: comfort care. disp:*30 ml* refills:*0* 13. lorazepam 2 mg/ml concentrate sig: one (1) po every six (6) hours as needed for anxiety or agitation: comfort care. disp:*30 ml* refills:*0* 14. atropine 1 % drops sig: two (2) drops ophthalmic every four (4) hours as needed for secretions: s/l comfort care. disp:*5 ml* refills:*0* discharge disposition: extended care facility: hospice at discharge diagnosis: partial large bowel obstruction discharge condition: mental status:confused - sometimes level of consciousness:lethargic but arousable activity status:out of bed with assistance to chair or wheelchair discharge 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 is 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, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. monitoring ostomy output/prevention of dehydration: *keep well hydrated. *replace fluid loss from ostomy daily. *avoid only drinking plain water. include gatorade and/or other vitamin drinks to replace fluid. *try to maintain ostomy output between 1000ml to 1500ml per day. *if ostomy output >1 liter, take 4mg of imodium, repeat 2mg with each episode of loose stool. do not exceed 16mg/24 hours. 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: appointment #1 md: dr. specialty: surgery please schedule an appointment in 2 week. ( appointment #2 md: dr specialty: urology date/ time: at 3:45pm location: , bldg, phone number: appointment #3 md: dr specialty: primary care date/ time: at 10am location: , phone number: md, Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Flexible sigmoidoscopy Flexible sigmoidoscopy Flexible sigmoidoscopy Exteriorization of small intestine Diagnoses: Anemia of other chronic disease Unspecified pleural effusion Urinary tract infection, site not specified 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 Personal history of malignant neoplasm of prostate Other specified intestinal obstruction Depressive disorder, not elsewhere classified Chronic kidney disease, unspecified Other late effects of cerebrovascular disease Personal history of malignant neoplasm of large intestine Rash and other nonspecific skin eruption Other ascites Hemorrhage of gastrointestinal tract, unspecified Dehydration Hydronephrosis Hematuria, unspecified Secondary malignant neoplasm of retroperitoneum and peritoneum Other late effects of cerebrovascular disease, facial weakness Other musculoskeletal symptoms referable to limbs

allergies: penicillins attending: chief complaint: severe headache x 1wk major surgical or invasive procedure: cerebral angiogram on with dr. history of present illness: 55 yo male who reports a headache x 1 week. he reports hitting his head about 2 weeks ago on a cabinet, then had the flu with vomiting and diarrhea. after vomiting he began to experience sharp headaches from the r occipital region to the right parietal area. the headache would be severe with vomiting and coughing. although he began to feel better, the headache continued. today, his wife felt he was groggy and slightly more lethargic and called 911. past medical history: gastritis htn borderline high cholesterol rheumatic fever at 18 yo tonsillectomy social history: works for woodworkers as a sales person. lives with wife, no children. reports alot of stress secondary to work and helping his father who is elderly. denies tobacco, etoh 1x wk, denies recreational drug use. family history: father: alive, nph, cardiac hx mother: deceased, ca siblings: 4, htn, nph physical exam: physical exam: o: t:98.5 bp: 125/80 hr: 62 r 16 o2sats 97% gen: wd/wn, comfortable, nad. heent: pupils: 2.5 to 2 bilaterally eoms intact w/o nystagmus extrem: warm and well-perfused. neuro: mental status: awake and alert; cooperative with exam, normal affect. orientation: oriented to person, said he was at , and thought it was recall: able to name current and past president. able to recall events; able to recall 3 current events language: speech fluent with good comprehension. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 2.5 to 2 mm bilaterally. visual fields reveal left visual field cut. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch toes downgoing on left, right does appear to have a left sided neglect- could "hear" the person on his left but would not turn towards him or acknowledge. upon discharge: awake alert oriented x 3 - non focal exam / distracted at times /poor at identifying social skills. pertinent results: ct head : impression: 1. large intraparenchymal hemorrhage within the right frontotemporal lobe with a small subdural component, neighboring mass effect with up to a 4 mm leftward shift of midline structures, and trace intraventricular extension along the occipital of the right lateral ventricle. these findings are relatively stable in comparison to the prior outside hospital study earlier this morning. 2. large frontal extra-axial spaces likely secondary to chronic frontal lobe atrophy. differential diagnosis remains broad, however given particulars of appearance, consideration can be given to frontotemporal dementia. cta head and neck : no vascular anomalies or aneurysms noted. ct head : impression: 1. essentially unchanged large intraparenchymal hemorrhage in the right frontotemporal lobe with a tiny subdural component. 2. unchanged mass effect as described. no new foci of hemorrhage. no evidence of developing hydrocephalus. cerebral angiogram : negative angiogram: no vascular anomaly or aneurysm seen. ct head : impression: 1. stable parenchymal hemorrhage at the right frontotemporal lobe with very small subdural component, likely representing slowly resolving hematoma, with stable mass effect. 2. extensive region of perihemorrhagic vasogenic edema, overall unchanged; however, the disproportionate edema, particularly anterosuperiorly, raises the possibility of an underlying lesion. enhanced mri is recommended for better characterization, as suggested previously. 3. no new focus of hemorrhage. brief hospital course: 55 yo male admitted after c/o a headache x 1 week. ct head revealed a right iph w/ effacement of the right lateral ventricle and small right sdh. he was admitted to the icu for close monitoring. a cta of the head and neck was done to r/o any vascular anomalies because of his report that the headache began after vomitting. his exam and head ct remained stable and on he was transferred from the icu to step down. on a diagnostic cerebral angiogram was done and showed no indication of aneurysm or venous anomaly; he was then transferred to the floor. physical therapy and occupational therapy was consulted and cleared the patient for home but felt that he would need cognitive rehab. medications on admission: calcium w/ vit d, atenolol/hctz 50/25, mvi discharge medications: 1. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 2. hydrochlorothiazide 12.5 mg capsule sig: capsules po daily (daily). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*0* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 7. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for headache. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: right intraparenchymal hemmorrhage right subdural hematoma discharge condition: stable & nonfocal exam but cognitive problems discharge instructions: *take your pain medicine as prescribed ??????exercise should be limited to walking; no lifting, straining, excessive bending ??????increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ??????unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, ibuprofen etc. ??????if you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in 7 days and fax results to . ??????clearance to drive and return to work will be addressed at your post-operative office visit 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 ??????fever greater than or equal to 101?????? f followup instructions: you will need an mri/mra, which you can at . please call dr. office to set this up. no driving until you are cleared to do so by your primary care physician please call your primary care physian to arrange for neuro-psych testing please call to schedule an appointment with dr. to be seen in 4 weeks. you will need a cat scan of the brain without contrast. please call with any questions or concerns. Procedure: Arteriography of cerebral arteries Diagnoses: Esophageal reflux Unspecified essential hypertension Intracerebral hemorrhage Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Rheumatic heart disease, unspecified Homonymous bilateral field defects

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: central line placement intubation ; extubation bronchoscopy ivc filter placement history of present illness: 46 year-old male with dmi with recent admission for dka and metastatic nsclc s/p xrt recently started on chemotherapy admitted with altered mental status. he was found by ems in his home in his underwear, incontinent of urine - what led ems to come to his home is unclear. review of omr, patient had not taken insulin in 3 days for unknown reason. of note, patient recently admitted with dka, though at that time was reportedly taking his medications as directed. . in the ed, 98.8 136 111/55 18 96% ra. patient was noted to be diaphoretic, ill-appearing, and with kussmaul respirations. initial laboratory evaluation was significant for k 8.3, hco3 8, glucose 1290, anion gap 43, ketonuria. ekg showed peaked t waves; patient received calcium gluconate, 1 amp hco3, albuterol nebs. he did not received kayexelate given concern for not being able to protect airway. potassium subsequently came down to 6.1 with unchanged ekg findings. he received 5l ns and was also started on an insulin drip, currently at a rate of 6 units per hour. an 18g piv and triple lumen (right groin) were placed. urine studies did not reveal infection. on transfer, patient with persistent ams, unable to answer questions. he has remained afebrile and with improved heart rate following fluid resuscitation; 170/72, 99%ra, 20-26. of note, head ct was initially ordered given ams, but not done once laboratory data returned. . on arrival to the icu, patient is unable to provide further history, and no further information is available in chart. patient unable to provide review of systems. does complain of nausea. past medical history: - nsclc - stage 4 disease, initially presented early with n/v secondary to his diabetic gastroperesis. during that admission, he was found to have a right effusion and a large 4.6 x 7.6 x 7.7 cm right hilar mass of slightly heterogeneous texture and infiltrative margins with peribronchial wall infiltration and septal thickening suggestive of lymphangitic carcinomatosis. his pleural fluid and tbna/ebbx of the mass all were positive for nsclca. he had pet scan on were he was found to have complete collapse of the right right lung and large pleural effusion s/p pleurex catheter placement for recurrent effusion , 10 rounds of radiation. - dm type 1, followed by , with history of dka (last admission in ) and also history of seizures related to hypoglcyemia. complicated by gastroparesis. - bipolar disorder - last manic episode 2.5 years ago. denies recent depressive episodes. hospitalizations ?schizophrenia documentation in prior notes: md c (psychiatrist). - dyslipidemia - htn social history: per prior admission note: he lives with his wife in /. he used to smoke ppd x 7 years, quit 1 month ago since diagnosis of lung ca, denies etoh. currently on leave from work due to medical illness. family history: per prior admission note: father died of lung ca at age 50 (non-smoker-probable asbestos exposure) and was apparently an alcoholic as well. mother diagnosed with colon ca age 43 and died at 63 of mets to lungs/brain. brother with a history of alcoholism and depression. physical exam: on transfer from to floor: 96.7, 110, 155/85, 23, 96% ra general: lying in bed, answers questions appropriately and following commands, nad lungs: basilar crackles on l, bronchial breath sounds on r; expiratory wheeze on l cv: tachycardic; regular rhythm, normal s1/s2, 2/6 sem at rusb radiating to carotids, also at lusb. abdomen: nondistended, hypoactive bowel sounds, soft, diffusely tender, greatest at ruq; unable to do ??????s sign as pt c/o pain with mild palpation; no rebound/guarding ext: warm, well-perfused, 2+ dp, 1+ edema at ankle pertinent results: on admission : wbc-9.9 rbc-4.02* hgb-10.7* hct-39.9* mcv-99*# mch-26.7* mchc-26.9*# rdw-15.4 plt ct-517* neuts-94* bands-0 lymphs-5* monos-1* eos-0 baso-0 atyps-0 metas-0 myelos-0 glucose-1290* urean-51* creat-1.9*# na-137 k-8.3* cl-85* hco3-9* angap-51* calcium-8.6 phos-2.6* mg-1.9 osmolal-410* asa-neg acetmnp-neg ethanol-neg ph-7.18* lactate-5.7* na-141 k-7.5* cl-95* calhco3-10* urine dipstick: blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-6.0 leuks-neg . on transfer from to floor : wbc-4.0 rbc-3.34* hgb-9.2* hct-28.4* mcv-85 mch-27.5 mchc-32.4 rdw-17.4* plt ct-56* pt-12.3 ptt-30.8 inr(pt)-1.0 glucose-166* urean-6 creat-0.6 na-144 k-3.3 cl-108 hco3-24 angap-15 alt-12 ast-17 alkphos-113 totbili-0.3 calcium-7.6* phos-2.5* mg-1.6 valproa-57 . haptoglobin: 303 . micro: , bcx: pending , ucx: no growth sputum: gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. mrsa: negative . imaging: cxr on admission (compared to ): 1. interval worsening of aeration of the right lung, likely due to combination of increased right pleural effusion and post-obstructive collapse due to known right hilar mass. superimposed consolidation is not excluded. 2. left lung remains well aerated. . abdomen x-ray : nonspecific bowel gas pattern without signs of bowel obstruction or free intra-abdominal air. there is prominent amount of stool seen throughout the cecum and the rectum. . cxr : compared to through : right lung is now entirely collapsed with little if any increase in the volume of right pleural effusion. tubing projecting over the left lower lung obscures what appears to be developing consolidation. left upper lobe is clear. et tube in standard placement. nasogastric tube passes below the diaphragm and out of view. no pleural effusion. . ct chest: 1. in situ pulmonary thrombosis, right interlobar artery. 2. interval complete collapse of the right upper lobe, progression of right lower lobe and middle lobe collapse. 3. unchanged endobronchial mass within the right lower lobe bronchus and unchanged severe loculated right pleural effusion. 4. unchanged multiple sub-5-mm pulmonary metastases, left lung. 5. new small left pleural effusion and left basilar atelectasis. 6. small amount of fluid within the gallbladder fossa is most likely due to fluid overload. . ct head: no evidence for hemorrhage. no large acute territorial infarct is identified. . leni: occlusive thrombus within one of the paired left posterior tibial veins and the left peroneal vein. there is nonocclusive thrombus mobile within the lumen of the right common femoral vein. . (prelim) successful placement of infrarenal non-retrievable ivc filter. . bronchoscopy: endobronchial lesion from carina to rll subsegments - all of these orifices appeared narrowed, erythematous and edematous, easily collapsible. ?extrinsic compression. no obvious secretions/mucous plugs. brief hospital course: course : #. diabetes type i, ketoacidosis: pt with type i dm. pt had hyperglycemia, acidosis, large anion gap, and ketonuria, large osmolar gap on admission, with partial respiratory compensation. serum potassium elevated on admission although likely total body potassium depleted given hyperglycemic diuresis. ekg with peaked t waves in ed. preceded by not taking insulin x3 days. pt was aggressively hydrated and was consulted. insulin drip was started and transitioned to sc insulin sliding scale once he was able to take po's. potassium corrected with correction of hyperglycemia and ekg changes resolved. pt received anti-emetics and reglan for gastroparesis. pt's dronabinol was d/c'd as it precipitates delirium. #. delirium, nos: likely related to dka as hyperosmolar state will cause contraction of neurons. with resolution of dka, pt's mental status improved although he continued to be agitated given his bipolar disorder. psych meds were restarted and pt received haldol prn for agitation, with further improvement in his mental status. # respiratory failure, acute: pt was intubated at time of coffee-ground emesis (see below) to protect airway agitation and vomiting. right lung was noted to be entirely collapsed on cxr with little if any increase in the volume of known malignant right pleural effusion. pt had bronchoscopy with results above. cta was done to evaluate lung collapse and pe was noted in r lung (see below). pt was successfully extubated and continued to oxygenate well on ra. # pulmonary embolism: pt noted to have right pulmonary embolism on chest ct. lenis positive for b/l dvt. it was felt that because pe and collapse are in same lung, pt may not be hypoxic as v-q may still be matched. ivc filter placed by ir to prevent clot to l lung to preserve function. pt was put on lovenox which was stopped given his thrombocytopenia and changed to fondaparineux as it has less likelihood of decreasing platelets. at the time of discharge, his platelets were at 200,000 and so fondaparineux was switched to enoxaparin (60 mg sq ). #. bleeding, gastrointestinal, nos: on the morning of admission, pt had episode of coffee-ground emesis. gi was consulted and felt it was most likely - tear. also possibility for ulceration given chemotherapy, radiation therapy. no intervention was performed given he was intubated and he was medically managed with iv ppi. pt required 1 unit prbcs for low hct on . he had no subsequent episodes of emesis. #. acute renal failure: cr 1.9 on admission (baseline cr 0.8). given large volume diuresis associated with dka, most likely prerenal etiology. atn also possibility. ?renal toxicity from recently started chemotherapeutic agents. arf resolved with ivf and cr at transfer was 0.6. #. malignant neoplams, lung: stage iv. s/p xrt. cycle 1 of gemcitibane, carboplatin started . pt with known malignant r pleural effusion. ip was consulted and did not find enough fluid to tap. pt's oncologist had little more to offer in way of treatment. family meeting held with hem/onc and icu team to explain situation with pt. palliative care was consulted to discuss goals of care and hospice options (full note in omr ). pt's pain medications were adjusted to home regimen (changed home percocet to short acting morphine for break through pain). code status discussion also intiated and final decision pending. #. bipolar disorder: pt's psych meds were intially held as pt was npo due to altered mental status and concern for aspiration. pt began to have visual and auditory hallucinations and suicidal ideations with no plan. he was put on 1:1 sitter and home psych meds (depakote, quietiapine, and venlafaxine) were restarted. psych was consulted who felt that 1:1 sitter unnecessary. lorazepam and dronabinol were stopped as they precipitate delirium. pt's agitation and hallucinations improved. # thrombocytopenia, nos: plt count decreasing since admission, most likely due to chemotherapy given , prior to admission. pt was transfused 1 unit of platelets. pt continued on ppi. in setting of altered mental status and agitation, ct head done which was negative for bleed. # hypertension, benign: not on medication therapy. course on medical floor: because of his poor performance status, his oncologist was not likely going to treat his nsclc, and palliative care was consulted; he made the decision to go home with hospice. his two biggest issues on the medical floor were hypoglycemia (he does not eat because he has no appetite), and he had low blood sugars for several nights requiring d50; followed along and adjusted his sliding daily. the decision was made to not give his sliding scale unless he eats and to give the sliding scale insulin after the meal. his other issue was tachycardia (sinus tachycardia in the 100's at rest increasing to 150's with ambulation); this was attributed to his known pulmonary embolism and was not treated. medications on admission: (per review of omr - last reviewed ; patient unable to confirm) albuterol 90 mcg/actuation aerosol 1-2 puffs ih q 6hrs prn wheeze alprazolam 0.5 mg tablet 1 tablet(s) by mouth three times a day depakote er 500mg po qam, 1000mg po qhs dronabinol 5mg capsule 3 (three) capsule(s) by mouth twice daily, before lunch and dinner as needed for loss of appetitie, nausea insulin detemir dosage uncertain insulin lispro 100 unit/ml solution ssi as directed by jdc four times a day metoclopramide 10 mg tablet 1 tablet(s) by mouth three times a day morphine 15mg tablet sustained release 3 (three) tablet(s) by mouth twice daily omeprazole dosage uncertain oxycodone-acetaminophen 5 mg-325 mg tablet tablet(s) by mouth every 4-6 hours as needed for pain prochlorperazine maleate 10 mg tablet 1 (one) tablet(s) by mouth every six (6) hours as needed for nausea quetiapine 300 mg tablet 1 tablet(s) by mouth twice a day, plus 100mg po qhs venlafaxine 75mg tab,sust rel osmotic push 24hr 3 (three) tab(s) by mouth qd dosing per psych docusate sodium 100 mg capsule 1 (one) capsule(s) by mouth twice a day (otc) nicotine 21 mg/24 hour patch 24 hr 1 patch(s) daily (daily) senna 8.6 mg tablet 1 tablet(s) by mouth twice a day as needed for constipation discharge medications: 1. morphine 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*120 tablet(s)* refills:*0* 2. divalproex 500 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po qam (once a day (in the morning)). 3. quetiapine 100 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 4. divalproex 500 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po qhs (once a day (at bedtime)). 5. quetiapine 100 mg tablet sig: three (3) tablet po bid (2 times a day). 6. venlafaxine 75 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po daily (daily). 7. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). 8. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). disp:*60 tablet sustained release(s)* refills:*0* 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 10. insulin glargine 300 unit/3 ml insulin pen sig: ten (10) units subcutaneous at bedtime. disp:*1 pen* refills:*2* 11. insulin lispro 100 unit/ml insulin pen sig: one (1) injection subcutaneous after meals and at bedtime as needed for sliding scale insulin: according to sliding scale. disp:*1 pen* refills:*5* 12. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation four times a day as needed for shortness of breath or wheezing. disp:*2 inhalers* refills:*3* 13. lovenox 60 mg/0.6 ml syringe sig: one (1) subcutaneous twice a day. disp:*60 60mg* refills:*2* discharge disposition: home with service facility: vna care hospice discharge diagnosis: diabetic ketoacidosis upper gi bleeding pulmonary embolism deep venous thrombosis s/p placement of ivc filter stage iv non small cell lung cancer secondary: brittle type i diabetes discharge condition: stable, normal oxygen saturations discharge instructions: you were admitted with diabetic ketoacidosis and were admitted to the intensive care unit. you developed bleeding in your upper gi tract and were intubated for airway protection. during the hospitalization, you were found to have a pulmonary embolism and deep venous thrombosis. you are being discharged home with hospice. . please take all of your medications as prescribed. if you develop any worsening pain, nausea, vomiting, shortness of breath, or any other concerning symptoms, please contact your hospice nurse. followup instructions: the following appointment has been scheduled for you, should you wish to keep it: provider: , md phone: date/time: 9:00 (hematology/oncology) please attend the following appointments: dr. (pcp) phone: date:time: 11:40am dr. or at diabetes center. please call to schedule an appt at in the next 2 weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Interruption of the vena cava Fiber-optic bronchoscopy Diagnoses: Thrombocytopenia, unspecified Acute kidney failure, unspecified Secondary malignant neoplasm of pleura Personal history of tobacco use Other and unspecified hyperlipidemia Acute respiratory failure Long-term (current) use of insulin Hematemesis Hyperosmolality and/or hypernatremia Bipolar disorder, unspecified Other pulmonary embolism and infarction Diabetes with neurological manifestations, type I [juvenile type], uncontrolled Diabetes with ketoacidosis, type I [juvenile type], uncontrolled Other alteration of consciousness Gastroparesis Malignant neoplasm of main bronchus Acute venous embolism and thrombosis of deep vessels of distal lower extremity Benign essential hypertension

allergies: no known allergies / adverse drug reactions attending: chief complaint: fatigue, fever, dysuria major surgical or invasive procedure: none history of present illness: 71m w/pmhx sig secondary progressive multiple sclerosis, wheelchair bound, with dm2 on hypoglycemics presented to his pcp office with 24 hours of fatigue, decreased appetite, and decreased urination. pt reported that he normally self-caths q8h but did not feel the need to do so in the last 24 hours. reports that he has had gradually increasing weakness and decreased ability to transfer himself out of his wheelchair. he reported nasal congestion, cough, and malaise for several days prior. in his pcp's office, he was found to have pyuria and a wbc to 24, and was refered to the ed. in the ed, initial vs were: t 97.0 p 80 bp 104/43 r 20. he was noted to be resting comfortably, and reported continued penile discomfort and mild nausea. he was noted to have mild abdominal tenderness on exam. he was found to have a lactate of 6.3, wbc 26, and creatinine 2.8 (baseline ~1.0) as well as a k 8.5 and glucose of 601. . he was subsequently given 50meq of bicarb and calcium gluconate 2mg for membrane stabilization, and started on an insulin drip and given 4l ns, with subsequent decrease of his glucose to 467 and then 215. his potassium decreased to 4.8, but his lactate remained elevated at 4.9. he received ceftriaxone for his uti. he was subsequently noted to have a systolic pressure to 75, thus a central line was started and he was given empiric vancomycin and zosyn due to his prior mild abdominal tenderness on exam. however, a subsequent ct scan did not demonstrate an acute intraabdominal process. due to consistently low pressures, he was started on levophed before transition to the floor. on arrival to the micu, his initial vitals were t 95.3, p 81, bp 99/62, r 22, 98% on ra. he stated that he was comfortable but felt weak and very tired. his saline was switched to d51/2 and his insulin reduced. an arterial line was placed due to his need for invasive management and pressor support. review of systems: (+) per hpi (-) denies chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness. denies shortness of breath or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - multiple sclerosis (diagnosed in , secondary progressive, wheelchair bound since , followed by dr. at ) - cad (s/p cabg ) - dm (on oral hypoglycemics, hba1c 8.1% in ) - dvt/pe - neurogenic bladder (straight caths self tid x 15 years) - bph - htn - hyperlipidemia - history of mrsa per osh records - depression with fixation of ideas social history: he lives with his wife, bound to wheelchair, has help every day for 1 hr in the morning. he denies tobacco, alcohol or illicits. family history: no family history of coronary artery disease physical exam: pe at the admission: vitals: 98, hr 76, bp 116/58, o2 sat 97% ra rr 12-22 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: distended, tender, not painful, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper extremities, cannot move lower extremities bilaterally, gait deferred, finger-to-nose intact pe at the discharge: vitals: 95.5 154/57 57 20 94ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: rrr nl s1 and s2. lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: distended, tender, not painful, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ edema. neuro: cnii-xii intact, 5/5 strength upper extremities, cannot move lower extremities bilaterally, lying in bed, responding appropriately to questions. pertinent results: labs at the dmission: 04:10pm blood wbc-26.8*# rbc-4.77 hgb-14.3 hct-43.2 mcv-91 mch-29.9 mchc-33.0 rdw-13.3 plt ct-297 04:10pm blood neuts-60 bands-32* lymphs-4* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 04:10pm blood hypochr-normal anisocy-occasional poiklo-normal macrocy-normal microcy-normal polychr-normal 04:10pm blood hypochr-normal anisocy-occasional poiklo-normal macrocy-normal microcy-normal polychr-normal 11:47pm blood plt ct-228 04:10pm blood glucose-601* urean-55* creat-2.8*# na-128* k-8.5* cl-97 hco3-15* angap-25* 06:51pm blood alt-25 ast-16 alkphos-63 totbili-0.4 11:47pm blood calcium-8.9 phos-1.7* mg-1.6 04:31pm blood lactate-6.3* labs at the discharge: 09:30am blood wbc-6.3 rbc-3.86* hgb-11.0* hct-33.6* mcv-87 mch-28.6 mchc-32.9 rdw-13.3 plt ct-240 05:20am blood pt-16.5* ptt-34.2 inr(pt)-1.6* 09:30am blood glucose-137* urean-23* creat-1.0 na-138 k-4.3 cl-110* hco3-20* angap-12. cxr: 1. no evidence of acute disease. 2. soft tissue fullness in the aortopulmonary window, probably artifactual or post-operative. however, when clinically appropriate, standard pa and lateral radiographs are recommended with optimal inspiration in order to reassess when possible clinically. correlation with prior radiographs, if available, could also be helpful. ct of the abdomen: 1. no acute intra-abdominal or intrapelvic process detected. specifically, there is no abscess. the appendix is not visualized, however, no secondary signs of appendicitis are detected. 2. markedly enlarged prostate. 3. thickened bladder wall may represent chronic neurogenic bladder but superimposed uti cannot be excluded. 4. nonspecific mild dilation of both ureters, slightly greater on the right, with no evidence of renal, ureteral or bladder calculi, possibly representing chronic obstruction. urine culture (final ): klebsiella pneumoniae. >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-------- 32 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: 71m w/multiple sclerosis and dm2 presented with urosepsis and dka. # urosepsis: pt has long-term ms leading to neurogenic bladder and a need for constant self-catheterisation and predisposition for the uti. per history patient was catheterizing less frequently with large quantities due to reduced urge. he was briefly septic with elevated lactate and wbc count, and hypotension requiring pressors in the icu. he was initially started on broad spectrum antibiotics including vancomycin and zosyn subsequently changed to vanco, cefepime, and levofloxacin. urine culture eventually gre pansensitive klebsiella pneumonia. he was continued on a 14 day course of ciprofloxacin, last day . pt was educated on methods of reducing risk of uti including frequent catheterization using sterile technique. pt should be self catheterizing at minimum three times a day, but usually more frequently. no more than 400cc urine should be kept in the bladder at any given time. larger quantities of output suggest patient should be catheterizing more frequently (4-5 times daily). he is expected to require some assistance with catheterization at rehab. # diabetes:although the patient is a type 2 diabetic on oral hypoglycemics, on presentation he had positive urine ketones and acidosis with blood glucose in the 600s. although his glucose has been moderately well-controlled on his home regimen, his concurrent sepsis and ensuing inflammatory state may have his blood glucose has been responsive to insulin ss . as his renal function improved, medical team preferred to resume oral hypoglycemic agents, which was preferable to patient also. . # : probably prerenal in origin due to hypotension/urosepsis. creatinine was improved at time of discharge was 1.0. pt was also noted to have hydroureter suggesting post renal pressure and that more frequent catheterization may be indicated. # ms: pt presents with no acute neurological sequelae. his weakness is likely due to his hypotension and sepsis. at time of discharge patient was working with physical therapy, compentent with transfers on board, (reduced from baseline which is standing on transfers). he will require daily physical therapy for strengthening. # h/o dvt/pe: pt was maintained on anticoagulation. inr was subtherapeutic at time of discharge (inr 1.6). warfarin was increased to 5mg daily and will likely need close monitoring in the short term(every other day) until tirated to inr , then again after discontinuation of ciprofloxain on . # depression: patient seemed to be in low mood with increased fixation on certain ideas. for example he was initially very concerned with the idea of starting insulin and became very fixated. later it was regarding self catheterization. this was discussed with dr. . patient had previously been on celexa and seroquel as outpatient. they were held on admission, and continued to be held upon discovery that he had not been compliant with celexa. there was concern seroquel would cause sedation in the acute setting. can be restarted when patient at baseline health. pt was full code during his admission. contact person: wife medications on admission: -ciprofloxacin 500 mg oral tablet take 1 tablet every 12 hours for 5 days -furosemide 20 mg oral tablet take 1 tablet daily -warfarin 2.5 mg oral tablet take 3.75mg for 3 days (tues, thurs, sat), 5mg for 4 days or as directed -metoprolol succinate (toprol xl) 25 mg oral tablet extended release 24 hr 1 tab daily -zolpidem 10 mg oral tablet take 1 tablet at bedtime -simvastatin (zocor) 20 mg oral tablet 1 tablet in the evening every day -glyburide 2.5 mg oral tablet 2 tabs po tid -warfarin 2.5 mg oral tablet take 1 tablet daily or as directed -metformin 500 mg oral tablet 1 tablet tid -fenofibrate micronized 134 mg oral capsule take one every day -enalapril maleate 5 mg oral tablet 1 po qd -finasteride 5 mg oral tablet take 1 tablet daily -nystatin (mycostatin) 100,000 unit/g topical powder use as directed. -calcium carbonate-vit d3-min (caltrate 600+d plus minerals) 600-400 mg-unit oral tablet 1 tab daily -omega-3 fatty acids 1,000 mg oral capsule 1 caps daily -sennosides (senna) 8.6 mg oral tablet 1 tab twice daily -aspirin ec 81 mg tab, delayed release available over the counter -multivitamin capsule po (multivitamins) 1 daily discharge medications: 1. warfarin 5 mg tablet sig: one (1) tablet po once a day. 2. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours): last day . 3. furosemide 20 mg tablet sig: one (1) tablet po once a day. 4. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 5. zolpidem 10 mg tablet sig: one (1) tablet po at bedtime. 6. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 7. enalapril maleate 5 mg tablet sig: one (1) tablet po once a day. 8. finasteride 5 mg tablet sig: one (1) tablet po once a day. 9. nystatin 100,000 unit/g powder sig: one (1) topical once a day. 10. caltrate 600+d plus minerals 600 mg calcium- 400 unit tablet sig: one (1) tablet po once a day. 11. omega-3 fatty acids 1,000 mg capsule sig: one (1) capsule po once a day. 12. sennosides 8.6 mg tablet sig: one (1) tablet po once a day. 13. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 14. multivitamin capsule sig: one (1) capsule po once a day. 15. fenofibrate micronized 134 mg capsule sig: one (1) capsule po once a day. 16. glyburide 5 mg tablet sig: one (1) tablet po three times a day. 17. metformin 500 mg tablet sig: one (1) tablet po tid (3 times a day). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: urosepsis multiple sclerosis acute kidney injury diabets mellitus 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: it was a pleasure to take care of you. you came because of the fever and urinary tract infection. the urine infection was so severe your blood pressure was low and you required icu stay. you were treated with antibiotics and your symptoms improved. while you were in the hospital your blood sugar were also high. this was treated with insulin. you were interested in treatements to prevent a bladder infection. we discussed with the infectious disease team and the urologiest that you should self catheterize your bladder more often. it is importnat that you have no more than 400 cc of urine in your bladder. catheterizing at minimum three times a day. also it is important that the catheter is sterile while doing the procedure. the following changes have been made to your medications: continue ciprofloxacin, last day . followup instructions: please follow up with your primary care doctor this week. she may request that you follow up with urology also. you will need follow up with clinic upon discharge from rehab. department: neurology when: monday at 11:30 am with: , md building: sc clinical ctr campus: east best parking: garage department: podiatry when: tuesday at 10:50 am with: , dpm building: ba ( complex) campus: west best parking: garage Procedure: Central venous catheter placement with guidance Diagnoses: Hyperpotassemia Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Disorders of phosphorus metabolism Long-term (current) use of insulin Personal history of venous thrombosis and embolism Multiple sclerosis Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Neurogenic bladder NOS Other specified disorders of kidney and ureter Hydroureter

allergies: vicodin / oxycodone attending: chief complaint: nausea, fatigue, and malaise major surgical or invasive procedure: cardiac catheterization aortic valve replacement utilizing a 27mm mosaic porcine valve history of present illness: mr. is a 74 male with history of endocarditis, ulcerative colitis s/p total colectomy with end ileostomy, chronic renal insufficiency who presented with nausea and malaise. for three weeks prior to admission, the patient felt food getting "stuck" about midway down his chest. no chest pain. on the day of admission, his wife noticed that he looked grey, very ill, and could not get out of the bed. she brought him to the ed. since , has lost 60 lbs, 10lbs over the past 2 weeks. his ileostomy output has remained unchanged. notes decreased urine output this past week. now admitted with acuter enal failure. past medical history: 1. endocarditis- patient diagnosed with vegitation on aortic leaflet and blood cx + for strep pnuemo currently getting pen g 2. uc- diagnosed age 21, s/p partial colectemy and repair, with ileostomy. 2. - in pt became dehydrated and hypotensive and had arf 3. osteoarthritis 4. ? gout- told he has this in the past, 2 yrs ago left middle finger swelling -> hand swelling then gone within same day social history: runs childcare company, accountant. uses wheelchair and walker. quit smoking in , former 3ppd x 20yrs. no etoh or illicit drug use. family history: father with cancer. mother with chf. states sister and brothers had congenital heart defects. physical exam: admission vs: 96.4 100/50 87 18 100%ra gen: nad, cheerful, alert heent: temporal wasting, perrl, sclera anicteric, dry mm, o/p with dried blood skin: decreased turgor, some bruises anterior shins, no rash, lesions, osler's nodes neck: no lad, no jvd cor: regular rhythm. soft systolic murmur, non radiating, loudest at llsb. distant heart sounds. pulm: ctab abd: soft. llq ileostomy bag full of dark brown liquid. non-tender. non-distended. ext: trace edema at ankles. +dp and pt pulses b/l. neuro: alert, oriented x 3. cn ii-xii intact. no dysarthria. speech fluent, language intact, recall intact. 5/5 strength upper extremities. 5/5 strength r leg. 3/5 strength l leg, painful rotation and flexion. no asterixis, dysmetria, dysdiadochokinesia. t/l/d: foley in discharge vs t bp 125/61 hr 85 sr rr 20 o2sat 96%-ra gen nad neuro a&ox3, nonfocal exam cor:rrr. sternum stable, incision: c/d/i pulm:ctab abd:soft, llq ileostomy bag full of dark liquid. ext:trace edema skin: his left gluteal has impairment of tissue approx 6 x 3 cm, intergluteal impairment 1 x 1 cm and right gluteal approx 5.5 x 1.5 cm. all open stage ii ulcers are red with irregular wound edges. there is a small amt of serosang drainage from the sites with no odor. the periwound tissue is fragile, intact with dark hyperpigmented tissue especially on the right lateral aspect. there is no s/s of erythema, edema, induration, fluctuance or crepitus. b/l ischium: left -intact purple discolored tissue approx 2.5 x 1 cm-no induration, erythema, edema right-epitheliazing stage ii ulcerated area approx 3.5 x 0.5 cm with no s/s of infection right heel: lateral aspect-2 x 1.5 cm intact darkly pigmented tissue suspicious for deep tissue injury post heel: 1 x 1.5 cm intact darkly pigmented tissue suspicious for deep tissue injury pertinent results: 03:20pm blood wbc-11.4* rbc-4.18* hgb-12.1* hct-33.8* mcv-81* mch-28.9 mchc-35.8* rdw-16.0* plt ct-240 03:20pm blood neuts-92.6* lymphs-3.9* monos-3.1 eos-0.2 baso-0.2 03:20pm blood pt-15.2* ptt-22.2 inr(pt)-1.3* 07:20am blood esr-95* 02:07pm blood glucose-165* urean-224* creat-15.1*# na-134 k-4.5 cl-90* hco3-6* angap-43* 07:05am blood alt-3 ast-7 alkphos-55 totbili-0.4 02:07pm blood ctropnt-0.05* 07:05am blood albumin-3.7 calcium-8.0* phos-12.1*# mg-2.0 iron-81 07:05am blood pth-338* 11:00am blood wbc-6.2 rbc-3.02* hgb-8.8* hct-25.0* mcv-83 mch-29.1 mchc-35.2* rdw-15.3 plt ct-375 11:00am blood plt ct-375 11:00am blood pt-13.9* inr(pt)-1.2* 11:00am blood glucose-122* urean-23* creat-1.5* na-139 k-3.1* cl-104 hco3-28 angap-10 06:50am blood alt-10 ast-14 ld(ldh)-174 alkphos-50 amylase-81 totbili-0.2 02:25pm blood %hba1c-6.2* 9:10 am tissue site: aorta aortic valve . gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final ): no growth. anaerobic culture (preliminary): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): fungal culture (preliminary): no fungus isolated. potassium hydroxide preparation (final ): no fungal elements seen. renal us: the right kidney measures 10.5 cm and the left kidney measures 10.3 cm. a 3.7 x 2.5 cm upper pole cyst of the right kidney is identified. there are multiple shadowing echogenic foci compatible with renal stones which are unchanged compared to the previous examination. a foley balloon is present within the bladder, which is decompressed and unable to be assessed. echo: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (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 aortic valve leaflets are mildly thickened. there is a 1.0 cm moderate-sized mass on the aortic valve (best seen in clips 52, 55) which may be consistent with a vegetation; however, a prolapsed leaflet cannot be excluded. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. moderate to severe (3+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. contrast barium esophagram: no evidence for stricture or obstructing lesion in the visualized portion of the esophagus. tertialy contractions. tee: 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. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. right ventricular chamber size and free wall motion are normal. there are three aortic valve leaflets. the non-coronary cusp is flail. since the leaflets fail to coapt, there is severe (4+) aortic regurgitation. the aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. the non-coronary cusp is perforated with a prior abcess at the tip. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. mri l spine: 1. no evidence of discitis or osteomyelitis. 2. multilevel degenerative joint disease, most prominent at the level of l4-s1. at these levels, there is mild-to-moderate neural foraminal narrowing bilaterally at the l4-l5 and mild-to-moderate right neural foraminal narrowing at the l5-s1 levels. there is associated mild spinal canal stenosis at the l4-l5 level. upper extremity us: 1. no evidence of deep vein thrombosis in the right arm. 2. thrombus in the right cephalic vein at the level of the antecubital fossa (the cephalic vein and the superficial vein). cxr medical condition: 74 year old man with s/p avr final report indication: 74-year-old man status post avr with decreased hematocrit and left-sided picc line placement. comparison: . frontal chest radiograph: there has been placement of a left sided picc line with tip at the cavoatrial junction. a right internal jugular sheath and dobbhoff tube are unchanged. there are expected postoperative changes following aortic valve replacement including left retrocardiac atelectasis and small bilateral pleural effusions. the study and the report were reviewed by the staff radiologist. dr. dr. echocardiography report , (complete) done at 8:56:23 am final referring physician information , c. , status: inpatient dob: age (years): 74 m hgt (in): 70 bp (mm hg): 114/56 wgt (lb): 200 hr (bpm): 76 bsa (m2): 2.09 m2 indication: severe aortic regurgitation due to endocarditis icd-9 codes: 440.0, 424.1 test information date/time: at 08:56 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 #: 2008aw2-: machine: echocardiographic measurements results measurements normal range left atrium - four chamber length: 4.7 cm <= 5.2 cm left ventricle - ejection fraction: 60% to 65% >= 55% left ventricle - stroke volume: 152 ml/beat left ventricle - cardiac output: 11.56 l/min left ventricle - cardiac index: 5.53 >= 2.0 l/min/m2 aorta - annulus: 2.3 cm <= 3.0 cm aorta - sinus level: 3.4 cm <= 3.6 cm aorta - sinotubular ridge: 2.7 cm <= 3.0 cm aorta - arch: 2.7 cm <= 3.0 cm aorta - descending thoracic: 2.5 cm <= 2.5 cm aortic valve - peak velocity: 1.6 m/sec <= 2.0 m/sec aortic valve - peak gradient: 11 mm hg < 20 mm hg aortic valve - mean gradient: 6 mm hg aortic valve - lvot vti: 40 aortic valve - lvot diam: 2.2 cm aortic valve - pressure half time: 171 ms findings left atrium: mild la enlargement. right atrium/interatrial septum: normal interatrial septum. no asd by 2d or color doppler. left ventricle: normal lv wall thickness and cavity size. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: simple atheroma in aortic arch. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. severely thickened/deformed aortic valve leaflets. aortic root abscess. no as. severe (4+) ar. mitral valve: moderate (2+) mr. tricuspid valve: normal tricuspid valve leaflets. mild to moderate +] tr. pulmonic valve/pulmonary artery: mild pr. 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. results were conclusions prebypass 1. the left atrium is mildly dilated. no atrial septal defect or pfo is seen by 2d or color doppler. 2. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is no aortic valve stenosis. there is a flail non coronary cusp leaflet .severe (4+) aortic regurgitation is seen. 6. moderate (2+) mitral regurgitation is seen. 7. there is no pericardial effusion. 8. dr. was notified in person of the results at the time of surgery. post bypass 1. patient is on phenylephrine infusion. 2. a well seated, well functioning tissue aortic bioprostetic is seen in the aortic position. no perivalvular leak is seen, no ar is noted. a mean gradient of 22mmhg is noted, with a cardiac output of 9. surgeon is aware. 3. left ventricular function remains good, with ef 65%. 4. mitral regurgitation is less than preop, now mild with vena contracta of 0.2cm i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 11:16 brief hospital course: mr. was admitted to the medical service with acute on chronic renal failure. on admission, he displayed mild congestive heart failure and possible septic polyarthritis. he was started on a course of nitrofurantoin for a urinary tract infection. preoperatively, he had already completed 8 weeks of antibiotics for aortic valve abscess, but continued with persistent 4+ aortic insufficiency. given his multiple medical issues, the renal, infectious disease and orthopaedic services were consulted prior to cardiac surgical intervention. he underwent extensive evaluation which included renal ultrasound, echocardiograms, spinal mri and multiple joint x-rays - please see result section for details. his acute renal insufficiency was attributed to pre-renal etiology. intake/output were monitored daily and he was hydrated accordingly. joint aspiration of the left hip found no evidence of infection. pan cultures were negative and he remained afebrile. once his creatinine improved, cardiac catheterization was performed which found no flow limiting coronary artery disease. preoperative course was also notable for superficial thrombophlebitis of right upper extremity and a stage 2 pressure ulcers of his coccyx, right heel and scrotum. prior to cardiac surgery, he was cleared by the dental service. on , dr. performed an aortic valve replacement. given his inpatient stay was greater than 24 hours, vancomycin was given for perioperative antibiotic coverage. for surgical details, please see seperate dictated operative note. following the operation, he was brought to the cvicu for invasive monitoring. within 24 hours, he awoke neurologically intact and was extubated without incident. given poor nutritional status, a dobhoff feeding tube was placed to ensure adequate caloric intake. double lumen picc line was also placed for poor intravenous access on . amiodarone was initiated for frequent premature atrial contractions. he otherwise remained in a normal sinus rhythm, maintained stable hemodynamics and transferred to the sdu on postoperative day two. vancomycin was continued until operative valve cultures remained negative. on pod4 he was transferred to rehabilitation at center medications on admission: otc nsaids (last dose of pcn ) discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 2. amiodarone 200 mg tablet sig: two (2) tablet po once a day: take 400mg daily for 1 week, then decrease to 200mg daily. disp:*60 tablet(s)* refills:*2* 3. ranitidine hcl 15 mg/ml syrup sig: one (1) po daily (daily). disp:*30 * refills:*2* 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 5. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). disp:*90 injection* refills:*2* 7. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. disp:*50 tablet(s)* refills:*0* 8. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po bid (2 times a day) for 7 days: assess need for further doses at end of course. disp:*14 tab sust.rel. particle/crystal(s)* refills:*0* 9. furosemide 10 mg/ml solution sig: one (1) injection injection (2 times a day) for 7 days: assess need for further doses at end of course. disp:*14 injection* refills:*0* 10. epoetin alfa 4,000 unit/ml solution sig: one (1) injection injection qmowefr (monday -wednesday-friday). disp:*qs injection* refills:*2* discharge disposition: extended care facility: for the aged - macu discharge diagnosis: aortic valve endocarditis(streptococcus pneumoniae) - s/p avr acute on chronic renal failure preoperative urinary tract infection superficial right upper extremity thrombophlebitis stage ii ulcers of coccyx, heel and scrotum ulcerative colitis, s/p colectomy with ileostomy history of atrial fibrillation osteoarthritis history of squamous cell carcinoma splenic and renal infarcts(secondary to endocarditis) discharge condition: stable discharge instructions: please shower daily including washing incisions, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: 1)dr. in weeks, call for appt () 2)dr. , clinic () at at 11:30am 3)dr. , pcp, see in weeks if possible, call for appt Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Open and other replacement of aortic valve with tissue graft Arthrocentesis Diagnoses: Acidosis Anemia in chronic kidney disease Unspecified pleural effusion Urinary tract infection, site not specified Acute kidney failure, unspecified Atrial fibrillation Chronic kidney disease, unspecified Pulmonary collapse Pressure ulcer, other site Osteoarthrosis, unspecified whether generalized or localized, site unspecified Pressure ulcer, lower back Acute and subacute bacterial endocarditis Pressure ulcer, heel Phlebitis and thrombophlebitis of superficial veins of upper extremities Ileostomy status Pressure ulcer, stage II Spinal stenosis, lumbar region, without neurogenic claudication Acquired absence of intestine (large) (small) Olecranon bursitis

allergies: vicodin / oxycodone attending: chief complaint: epistaxis major surgical or invasive procedure: none history of present illness: 74 year old male with history of uc s/p ileostomy, bacterial endocarditis (diagnosed , currently on penicillin-gk), , who presents with epistaxis, tachycardia, and melena. the patient had been discharged from rehab hospital the day prior to admission. the patient states he had nose bleeds on and off for past 2 days but at 0700 the day of admission it would not stop, and has tried pressure and vasoline without effect. states he has only occasionally had nose bleeds over past 20 years, but that they have been severe occaisionally. he noted that he has swallowed a lot of blood and had large clots coming from his nose and mouth. he has been taking ibuprofen 400mg q6hr for pain since discharge from hospital on . he also noted some melena out of his ostomy since the epistaxis. denies any lightheadedness, dizziness, fevers or chills. has never had melena or history of gi bleeding since his ileostomy (>20 yrs ago). of note he was recently discharged from rehab after a 10 day stay for bacterial endocarditis and also went into rapid a-flutter during last admit. his vitals were stable on arrival in the ed, but with profuse epistaxis. ed staff put in packing in nose and finally acheived hemostasis. melena out of ostomy guiac possitive, and he was admitted for epistasix vs gi bleeding. also with picc from prior admission. past medical history: 1. endocarditis- patient diagnosed with vegitation on aortic leaflet and blood cx + for strep pnuemo currently getting pen g 2. uc- diagnosed age 21, s/p partial colectemy and repair, with ileostomy. 2. - in pt became dehydrated and hypotensive and had arf 3. osteoarthritis 4. ? gout- told he has this in the past, 2 yrs ago left middle finger swelling -> hand swelling then gone within same day social history: president of child care development company, stopped smoking , but 3ppd x20yr, - etoh, - drugs, married, lives with wife family history: father- colon ca died age 56, mother- chf physical exam: ros: gen: - fevers, - chills, + weight loss eyes: - photophobia, - visual changes heent: - oral/gum bleeding, profound epistaxis cardiac: - chest pain, - palpitations, - edema gi: - nausea, - vomitting, - diarhea, - abdominal pain, - constipation, - hematochezia pulm: - dyspnea, - cough, - hemoptysis heme: - bleeding, - lymphadenopathy gu: - dysuria, - hematuria, - incontinence skin: - rash endo: - heat/cold intolerance msk: - myalgia, - arthralgia, - back pain neuro: - numbness, - weakness, - vertigo, - headache physical exam: vss: 98.2, 108/58, 88, 20, 100% gen: nad, temporal wasting pain: 0/0 heent: eomi, mmm, - op lesions, left nares packed with no drainage pul: cta b/l cor: rrr, s1/s2, - mrg abd: nt/nd, +bs, - cvat ext: - cc, trace pedal edema neuro: caox3, non-focal derm: stage 2 sacral decubitus pertinent results: ecg: sinus rhythm at 109 bpm, normal axis, normal pr, qrs, and qt intervals, normal r-wave progress, no st or t-wave changes. imaging: cxr: no acute cardiopulmonary process. 05:02am blood wbc-8.3 rbc-3.27* hgb-9.8* hct-28.2* mcv-86 mch-30.0 mchc-34.9 rdw-15.2 plt ct-212 04:46am blood wbc-8.2 rbc-3.30* hgb-10.0* hct-28.4* mcv-86 mch-30.3 mchc-35.3* rdw-15.0 plt ct-243 09:52am blood wbc-7.7 rbc-3.06* hgb-8.9* hct-27.0* mcv-88 mch-29.1 mchc-33.0 rdw-14.7 plt ct-328 07:45pm blood wbc-10.7 rbc-3.52* hgb-10.2* hct-31.3* mcv-89 mch-29.0 mchc-32.7 rdw-14.5 plt ct-373 01:15pm blood wbc-14.8*# rbc-4.23* hgb-12.0* hct-37.0* mcv-87 mch-28.4 mchc-32.5 rdw-14.8 plt ct-569* 01:15pm blood neuts-87.7* lymphs-7.6* monos-3.8 eos-0.8 baso-0.2 01:15pm blood pt-14.9* ptt-21.5* inr(pt)-1.3* 05:02am blood glucose-113* urean-28* creat-1.4* na-141 k-3.5 cl-114* hco3-19* angap-12 04:46am blood glucose-85 urean-43* creat-1.6* na-143 k-3.6 cl-117* hco3-17* angap-13 09:49pm blood glucose-109* urean-65* creat-1.9* na-136 k-5.0 cl-110* hco3-15* angap-16 01:15pm blood glucose-171* urean-63* creat-2.1* na-138 k-4.8 cl-106 hco3-15* angap-22* 05:02am blood albumin-2.3* calcium-7.8* phos-3.2 mg-1.7 04:59pm blood lactate-2.4* 05:00pm urine color-yellow appear-clear sp -1.016 05:00pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-mod 05:00pm urine rbc-* wbc-* bacteri-many yeast-none epi- 5:00 pm urine site: clean catch **final report ** urine culture (final ): no growth. brief hospital course: 1. acute blood loss anemia due to severe epistaxis, melena- - patient had nose packed in ed - transfused 3 units prbcs total during icu stay. - follow up with dr. this week for packing removal - major concern for upcoming use of large bolus heparin if needs cardiac surgery - no further bleeding - prbc transfusion will replete iron stores, no additional iron at this time - melena due to blood swallowing - precautionary ppi, given recent nsaid use, but no recurrent melena 2. acute renal failure on stage ii - returned to baseline - presumed due to bleeding, hypovolemia along with high nsaid use 3. bacterial endocarditis: - continued course of penicillin gk - note potential upcoming cardiac surgery. will need outpatient coordination between cardiac surgery and ent regarding safety of anticoagulation while on pump, and further need if a prosthetic valve is placed 4. positive urinalysis - do not feel this is a uti given negative cultures, would not treat, likely contaminant 5. moderate malnutrition - likely due to recent illness - discussed with wife, and plan for boost/ensure with each meal. family to encourage food intake for wound healing and upcoming potential surgery - nutrition consult with vna 6. sacral decubitus ulcer - wound care via vna - ambulation medications on admission: medications from recent discharge on : 1. acetaminophen 325 mg prn, fevers/pain 2. metoprolol 12.5 mg tid 3. insulin lispro 100 unit/ml solution sig: as per sliding scale subcutaneous asdir (as directed). 4. penicillin g pot in dextrose 3,000,000 unit/50 ml piggyback sig: one (1) intravenous q4h (every 4 hours) for 33 days: last dose on . 5. ibuprofen 400 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 6. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 9 days: last dose on . 11. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic tid (3 times a day) for 3 weeks: taper dose as follows: tid for one week (), then for one week (), then once daily for one week (), then stop. . discharge medications: 1. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic (2 times a day) for 2 days. disp:*1 bottle* refills:*0* 2. penicillin g pot in dextrose 2,000,000 unit/50 ml piggyback sig: two (2) million units intravenous q6h (every 6 hours) for 22 days. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day for 30 days. disp:*30 capsule, delayed release(e.c.)(s)* refills:*0* 4. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 5. metoprolol tartrate 25 mg tablet sig: 1 half tablet po three times a day. 6. insulin lispro 100 unit/ml cartridge sig: as per sliding scale subcutaneous three times a day. 7. oxycodone 5 mg capsule sig: one (1) capsule po every six (6) hours as needed for pain. 8. pantoprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 9. trazodone 50 mg tablet sig: 1 half tablet po at bedtime as needed for insomnia. discharge disposition: home with service facility: homecare discharge diagnosis: acute blood loss anemia severe epistaxis melena bacterial endocarditis acute renal failure decubitus sacral ulcer moderate malnutrition discharge condition: good discharge instructions: return to the hospital with fever, chills, difficulty breathing, worsened nose bleeding, chest pain, inability to urinate. you have been determined to be malnourished, presumably due to being so ill. you should make sure to have a full diet, along with supplements of ensure with each meal to help with wound healing and getting ready for your upcoming surgery you have ulcers on your lower back, which require careful wound care to heal. it is very important that you get up out of bed to help with wound healing. prior to having cardiac surgery, given the risk of your recurrent nosebleeds, you should have ent and cardiac surgery coordinate the use of high-dose blood thinners. do not drive or operate heavy machinery while using the oxycodone, as it may make you confused. followup instructions: provider: , md phone: date/time: 9:30 provider: , md phone: date/time: 10:45 provider: , md phone: date/time: 2:40 please make an appointment with dr. from ent for wenesday this week to remove the packing, and discuss future anticoagulation with blood thinners please contact your pcp . and/or dr. at the same number for an appointment in the next 1-2 weeks. Procedure: Transfusion of packed cells Control of epistaxis by posterior (and anterior) packing Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Hypotension, unspecified Blood in stool Osteoarthrosis, unspecified whether generalized or localized, site unspecified Pressure ulcer, lower back Acute and subacute bacterial endocarditis Ulcerative colitis, unspecified Dehydration Hypovolemia Ileostomy status Epistaxis Chronic kidney disease, Stage II (mild) Malnutrition of moderate degree Antirheumatics [antiphlogistics] causing adverse effects in therapeutic use

allergies: aspirin attending: chief complaint: sob on exertion major surgical or invasive procedure: swan-ganz catheterization history of present illness: 79 year-old female with history of sarcoidosis, moderate pulmonary hypertension, ild, and diabetes mellitus type 2 who presents with acute on chronic dyspnea. she is followed by dr. as an outpatient and was last seen by him on ; at that time, she was doing well, satting 95% on 4l at rest. her recent history is notable for an admission at the end of where she presented with worsening dyspnea, ruled out for pe, and was transitioned from prednisone to sildenafil. she has seen dr. in the interim and started on lasix for volume overload in the setting of right heart failure and prednisone-related fluid retention and weight gain. as noted above, she was been doing well, using a stable amount of supplemental oxygen at home and able to ambulate several feet with only mild dyspnea. two days prior to admission, however, she noted worsening dyspnea with exertion. she also developed a nonproductive cough but denied sick contacts, fevers, chills, arthralgias, and chest pain. her symptoms worsened and she called dr. office on the day of admission and was advised to present to the ed. in the ed, initial vs were: 98.1 141/53 73 26 84%4l. she was placed on a nrb with 100% o2 sat and given solumedrol 125 mg iv x 1. a chest x-ray showed bilateral interstial infiltrates and she was admitted to the micu for further management. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: # pulmonary artery htn, on 2lpm continuous with exertion to maintain o2 saturation > 88% (96% on 4l pulsed); ra sat as low as 76% w/ ambulation per dr. in . # sarcoidosis with ild, s/p right lower lobe resection in # hypertension # diabetes # renal insufficiency baseline creatinine 1.2-1.6 # osteoarthritis # iron deficiency anemia # osteopenia # hyperlipidemia # colonic adenomas # s/p hysterectomy # s/p cataract surgery social history: denies present or past tobacco or alcohol use. lives at home with her granddaughter. family history: her family history is notable for a mother who had a history of hypertension, diabetes, and coronary artery disease; a father with diabetes and coronary artery disease; and a brother also with hypertension, diabetes, and coronary artery disease. she denies any known history in her family of sarcoidosis or other lung diseases. physical exam: physical exam upon admission: vitals: t: 98.2 bp: 150/70 p: 80 r: 18 general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: bilateral rales at lung bases, no wheezes or rhonchi cv: regular rate and rhythm, normal s1 + s2, hsm, late diastolic murmur, no rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ le edema physical exam upon transfer to the floor: vitals: t 98.8, bp 115/52, hr 70, rr 19, o2 92% 6lnc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvd at 8 cm, no lad lungs: crackcles at right lung base, no wheezes or rhonchi cv: regular rate and rhythm, normal s1 + s2, hsm, late diastolic murmur, no rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. trace le edema pertinent results: labs upon admission: 05:57pm alt(sgpt)-13 ck(cpk)-97 05:57pm ck-mb-notdone ctropnt-<0.01 05:57pm anca-negative b 05:57pm -negative 05:57pm rheu fact-5 10:24am lactate-2.1* 10:10am glucose-208* urea n-13 creat-1.5* sodium-147* potassium-3.6 chloride-110* total co2-24 anion gap-17 10:10am ck(cpk)-114 ctropnt-<0.01 ck-mb-3 probnp-3560* 10:10am wbc-8.1 rbc-4.36 hgb-11.8* hct-36.2 mcv-83 mch-27.0 mchc-32.5 rdw-16.2* 10:10am neuts-76.7* lymphs-18.9 monos-2.5 eos-1.4 basos-0.5 plt count-271 10:10am pt-13.1 ptt-25.5 inr(pt)-1.1 labs upon discharge 06:20am blood wbc-9.1 rbc-4.05* hgb-10.9* hct-33.5* mcv-83 mch-27.0 mchc-32.7 rdw-15.5 plt ct-208 06:52am blood glucose-110* urean-47* creat-1.9* na-142 k-3.9 cl-101 hco3-28 angap-17 studies: ct chest: no pe, though evaluation of subsegmental vessels at left base is limited. new bilateral small effusions and compressive atalectasis with scattered thickened septal lines- ? edema, less likely changes related to sarcoid. tte: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is dilated with mild global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets are moderately 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. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. there is severe pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the right ventricle appears slightly larger and free wall motion appears similar to slightly more depressed. estimated pulmonary artery systolic pressure is now higher. cxr: bilateral interstitial opacities, no focal infiltrate, bibasilar atelectasis, likely small left pleural effusion admission ekg: nsr, nl axis, nl intervals, twis in v1-v4 (old except for v2), s-wave in i, q-wave in iii, twi in iii (all old) brief hospital course: 79 yo woman with h/o sarcoid, pulm htn and diastolic chf, presenting with acute on chronic sob volume overload. transfered to floor with subtle pe findings c/w residual volume overload. symptoms at rest improving with diuresis. comfortable breathing but using more o2 than baseline. 1. hypoxic respiratory failure: chest cta showed new pleural effusions and no pe. it was thought she might have acute diastolic chf. she was diuresed with 40mg iv lasix x2 with net fluid balance of -1l; however her creatinine increased from 1.4-1.8 so diuresis was stopped. tte showed worsend pah and right ventricular dilation. flu swab was negative. she was initially started on empiric vanc/zosyn, however, after the cta showed no evidence of pna these were discontinued and she remained afebrile. a swan-ganz catheter was placed and her wedge pressure was elevated as well as her pap. she was diuresed further (lasix 40mg iv x 3) with good effect. her o2 was able to be weaned down to 88-93% on 6l nc. aggressive diuresis was continued with lasix 80mg , with stable o2 sat in low 90s on 6l nc. she was called out to the floor on . she was evaluated by pt and d/c'd on with home pt services. she was d/c'd on 6l nc and lasix 80mg daily given evidence of residual volume overload on exam. she is to follow-up with her pcp to determine proper dose of lasix once she has become euvolemic. the patient was also counseled on the importance of low-salt diet and taking weights every 3-4 days, to prevent state of volume overload. 2. pulmonary hypertension/right heart failure: underwent right heart cath in and had pa pressure of 53/23. pa htn of unclear etiology, possibly secondary to sarcoidosis though pattern on chest ct not typical for this disease. unclear if worsened pah on tte on this admission is from hypoxia leading to constriction vs worsening disease. she was continued on sildenafil. because the patient has a preload-dependent rv, she was monitored during aggressive diuresis in-house. 3. hypertension: stable. she was continued on acei, ccb, and beta blocker. her vs were monitored in the setting of aggressive diuresis. 4. diabetes mellitus type ii: stable. oral medications were held and she was maintained on an iss. 5. acute on chronic renal insufficiency: creatinine at baseline of 1.5. in the setting of aggressive diuresis, patient's renal function declined with a high creatinine of 1.8. her renal function was closely monitored and her medications were renally dosed. upon discharge, her cr was 1.9 and thus her lasix dose was changed from to qd. ***pending issues for f/u*** 1. patient d/c'd on lasix 80mg qd. likely that once she is euvolemic, she will require lower maintenance dose (home dose had been 40mg ). should be reassessed with pcp. 2. patient had acute on chronic renal failure. cr was 1.9 upon dischared. renal function should be monitored as outpatient. medications on admission: sildenafil 20 mg po tid atenolol 100 mg po qd lisinopril 40 mg po bid nifedipine xl 120 mg po bid lasix 40 mg po qd simvastatin 80 mg po qd acetaminophen mg po q6h prn mvi calcium citrate + d 315-200mg 2 tablets glipizide 7.5 mg po qd discharge medications: sildenafil 50 mg po tid atenolol 100 mg po qd lisinopril 40 mg po bid nifedipine xl 120 mg po bid lasix 80 mg po qd simvastatin 80 mg po qd acetaminophen 325-650 mg po q6h prn mvi calcium citrate + d 315-200mg 2 tablets calcium acetate 1334 mg po tid discharge disposition: home with service facility: all care vna of greater discharge diagnosis: primary diagnosis: 1. chf exacerbation 2. hypoxia secondary diagnosis: 1. acute on chronic renal failure 2. pulmonary hypertension discharge condition: stable: patient not feeling shortness of breath, comfortable on nasal cannula. discharge instructions: you were admitted to the hospital for difficult breathing with activity. this was likely caused by too much fluid in your body. you were given medicine to remove the extra fluid. please limit the amount of salt in your diet. this will help protect your heart. you should weigh yourself frequently at home. please call your doctor if you gain more than 3 pounds. if you become short of breath, develop chest pain, notice any swelling in your legs, or feel lightheaded, you should go see your primary care doctor or return to the emergency department. please note that you were started on a new medication called calcium acetate for your kidneys. followup instructions: please remember your following appointments: 1. at 2:30pm: dr. phone: 2. at 9:00am: dr. phone: 3. at 11:00am: dr. phone: md, Procedure: Venous catheterization, not elsewhere classified Pulmonary artery wedge monitoring Diagnoses: Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Acute on chronic diastolic heart failure Other chronic pulmonary heart diseases Sarcoidosis Chronic kidney disease, unspecified Acute respiratory failure Postinflammatory pulmonary fibrosis Osteoarthrosis, unspecified whether generalized or localized, site unspecified Iron deficiency anemia, unspecified Disorder of bone and cartilage, unspecified Acquired absence of both cervix and uterus Other dependence on machines, supplemental oxygen Acquired absence of organ, lung

allergies: latex / benadryl / statins-hmg-coa reductase inhibitors / avapro / beta-blockers (beta-adrenergic blocking agts) / clonidine / metoprolol / diovan / adhesive / ultram / diltiazem / aspirin attending: chief complaint: asymptomatic right carotid stenosis major surgical or invasive procedure: right carotid endartarectomy history of present illness: is a 77-year-old who saw dr. in consult for carotid stenosis. she was having some vertigo and potentially three years ago had some left-hand weakness. she underwent carotid studies which showed greater than 80% right carotid stenosis, and is considered asymptomatic, despite the possibility of tias three years ago. the patient was started on a full strength aspirin as an outpatient and scheduled for elective right carotid endartarectomy which she had done on . past medical history: diastolic chf (preserved ef) htn gerd oa knee replacements social history: married, remote smoking history, no current substance use family history: daughter with hypothyroidism physical exam: 98.6, 98.6, 63, 129/53, 20, 98 ra cn ii-xii intact, slight left facial droop stable and present prior to admission cta bl rrr neuro exam - power throughout, sensation intact right nec incision - clean, dry, intact, healing well pertinent results: 02:00pm blood wbc-18.3* rbc-3.42* hgb-11.0* hct-30.0* mcv-88 mch-32.3* mchc-36.8* rdw-13.7 plt ct-272 03:25am blood wbc-11.0 rbc-2.87* hgb-9.3* hct-26.4* mcv-92 mch-32.5* mchc-35.3* rdw-12.6 plt ct-222 04:06am blood glucose-173* urean-29* creat-1.4* na-134 k-2.9* cl-97 hco3-26 angap-14 02:07am blood glucose-109* urean-47* creat-2.6* na-137 k-3.4 cl-96 hco3-28 angap-16 12:05pm blood na-138 k-3.1* cl-97 05:03am blood glucose-94 urean-51* creat-2.3* na-141 k-4.1 cl-101 hco3-29 angap-15 02:03pm blood na-139 k-4.6 cl-102 01:54am blood glucose-138* urean-66* creat-2.2* na-141 k-4.2 cl-100 hco3-30 angap-15 02:33pm blood urean-73* creat-2.3* na-139 k-4.1 cl-96 03:24am blood glucose-129* urean-86* creat-2.3* na-141 k-3.9 cl-97 hco3-30 angap-18 01:02am blood glucose-117* urean-100* creat-2.7* na-141 k-4.6 cl-95* hco3-31 angap-20 02:21am blood glucose-104* urean-116* creat-2.9* na-147* k-3.1* cl-101 hco3-31 angap-18 03:21pm blood na-147* k-3.5 cl-105 02:10am blood glucose-115* urean-107* creat-2.4* na-144 k-4.4 cl-108 hco3-25 angap-15 04:28pm blood glucose-113* urean-104* creat-2.2* na-149* k-3.6 cl-115* hco3-22 angap-16 12:18am blood glucose-127* urean-102* creat-2.1* na-152* k-3.2* cl-117* hco3-21* angap-17 07:58pm blood glucose-160* urean-83* creat-1.8* na-148* k-3.2* cl-120* hco3-17* angap-14 03:48am blood glucose-121* urean-80* creat-1.8* na-148* k-3.8 cl-119* hco3-19* angap-14 06:20am blood glucose-93 urean-49* creat-1.7* na-143 k-3.6 cl-115* hco3-20* angap-12 03:25am blood glucose-91 urean-42* creat-1.7* na-141 k-3.4 cl-111* hco3-19* angap-14 echocardiogram the left atrium is normal in size. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (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 number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. there is no aortic valve stenosis. moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is severe mitral annular calcification. trivial mitral regurgitation is seen. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. impression: preserved -ventricular systloic function. diastolic dysfunction with an estimated pcwp > 18 mmhg. moderated aortic regurgitation. moderate tricuspid regurgitation. borderline pulmonary artery hypertension. radiology report ct head w/o contrast study date of 11:04 am medical condition: 77 year old woman s/p cea and non-focal mental depression reason for this examination: altered mental status contraindications for iv contrast: none. wet read: npw tue 6:07 pm 1. scattered focal hypodensities likely indicating small vessel ischemic disease. age is indeterminate; attention on followup is advised. consider mr if clinically indicated and if there are no contraindications. 2. no evidence of hemorrhage, edema, masses, mass effect, or infarction. 3. the ventricles are mildly enlarged and the sulci are grossly normal in caliber and configuration. ventricular enlargement is likely secondary to normal age-related volume loss. final report indication for study: status post endarterectomy, depression, and altered mental status. study is to evaluate for possible structural or mass defects. comparison exam: there are no comparisons available. technique: multidetector ct-acquired axial images from the vertex to the level of c1 without contrast displayed with 5-mm slice thickness. ct head without contrast: there are scattered focal hypodensities of indeterminate age, most likely secondary to small vessel ischemic changes; attention to this finding on followup is advised. consider mr study if clinically indicated and if there are no contraindications. these scattered hypodensities follow no vascular distribution and are predominantly seen in the cortex. (in image 2a:8, image 2a:6 in the right and left inferior temporal lobes, and in 2a:12 in the anterior portion of the left lateral ventricle.) there are vascular calcifications seen in multiple locations- these are best seen in images 2a:12, 2a:9, and 2a:6. there is no evidence of hemorrhage, edema, mass effect, or major infarction. the ventricles are mildly enlarged secondary to normal age-related volume loss; the sulci are grossly normal in caliber and configuration. impression: 1. scattered focal hypodensities of indeterminate age, likely indicating small vessel ischemic disease; attention on followup is advised. mr can be considered if clinically indicated and there are no contraindications for assessment of acute infarction. 2. no evidence of hemorrhage or mass effect. note date: signed by on at 5:51 pm affiliation: bedside swallowing evaluation: history: thank you for referring this 77 year old woman admitted on for planned r cea in setting of greater than 80% right internal carotid artery stenosis. on pod #1, was tolerating clears rn notes. code blue was called for respiratory distress and pulmonary edema with hematoma at surgical site. pt intubated on , extubated , and reintubated due to intolerance associated with stridor, wheezing, and respiratory distress. extubated again on . when pt with persistent altered mental status, she was ordered for head ct on . results indicated scattered focal hypodensities of indeterminate age, likely indicating small vessel ischemic disease, but no evidence of hemorrhage or mass effect. rn notes from icu indicate pt with slurred speech, weak grasp, tongue deviating toward r and anterior spill of thin liquids. given negative head ct, it was felt mental status was associated with uremic etiology. on , ngt was placed and advanced post-pyloric. on , rn notes indicate pt tolerating clear liquids. most recent cxr on states "small left pleural effusion, otherwise clear lungs with stable cardiomegaly." wbc counts have fluctuated. today we were consulted to evaluate oral and pharyngeal swallow function to promote advancing to regular diet. today's rn, tolerating clears, purees, and meds. evaluation: the examination was performed while the patient was seated upright in the chair on the vicu. cognition, language, speech, voice: pt awake, oriented to name, , and month, correctly named date when cued to look at the calendar, responded "19..." when asked the year, responded no to , , and . expressive language was grossly fluent, utterances intermittently off-topic and confused, speech was intelligible, voice moderately hoarse and breathy. teeth: full upper dentures and lower partial in place. secretions: normal oral secretions. oral motor exam: mild left facial droop appreciated - daughter states multiple times that this is baseline from a few years ago. tongue protruded midline with mildly reduced strength, adequate rom. symmetrical palatal elevation noted. gag deferred. swallowing assessment: po trials included ice chips, thin liquid (tsp, cup, straw, consecutive), puree, and bites of saltine cracker. oral phase grossly wfl without anterior spill or oral residue. swallow initiation was timely with adequate laryngeal elevation on palpation. no coughing, throat clearing, wet vocal quality, or o2 desats with pos. summary / impression: ms. presented with a grossly functional swallowing mechanism without overt s/sx of aspiration. recommend she remain on po diet of thin liquids and regular consistency solids with assistance with meal set up and feeding as needed. please call, page, or re-consult if there are further concerns. this swallowing pattern correlates to a functional oral intake scale (fois) rating of 7. recommendations: 1. po diet: thin liquids, regular consistency solids. 2. meds whole with water as tolerated. 3. oral care. 4. assistance with meal set up and feeding as needed. 5. please call, page, or re-consult if there are further concerns. ____________________________________ , m.s., ccc-slp brief hospital course: 77f who was admitted on and had a right carotid endarterectomy with bovine pericardial patch angioplasty. she received 1500 cc of fluid during the case and had an ebl of 200 cc. at postoperative check, the patient was doing well, complaining of some increasing phlegm production, but neuro intact and stable. she was breathing 15 times a minute with an o2 sat of 100% on 3l nc. she was requiring a nitro gtt and intermittent hydralazine to keep her blood pressures in the desired range of 100-140. overnight she had some tachypnea and scattered wheezes, which improved after a nebulizer treatment and she maintained her sats on low nasal cannula. her neck incision did slowly ooze blood, requiring a few dressing changes but there was no airway compression or rapidly expanding hematoma. on , pod #1, the patient continued to have some increased work of breathing,decreased urine output, cxr showed some fluid overload and she was given lasix 80mg iv and put out about 100 cc of urine hourly throughout the day. she maintained her sats in the mid 90's throughout the day on 2-3l nc. at 9pm, her work of breathing continued to increase with rr 30-35, sats mid 90's, an additional 40mg of lasix was given, without much improvement in her respiratory status. a nonrebreather was placed and the patient continued to breath 30-42 times a minute satting 90-98%. her neck incision continued to appear intact, with no pulsatile mass or firmness. the patient was transferred to the icu and intubated for flash pulmonary edema. bnp was increased to 13,000, she also had a troponin leak to peak of .72. atrius cardiology followed the patient during her stay and felt that she was having demand ischemia secondary to the fluid overload and diastolic heart failure and did not feel she was having an mi. she had ongoing labile blood pressures requiring treatment. her creatinine trended up to the 2.6-3.0 range with adequate urine output and nephrology was consulted. they felt as if she had acute kidney injury in the setting of hemodynamic instability and acute tubular necrosis. they followed her care and her creatinine trended down but has not yet reached her baseline. on , pod#3, she had a low grade fever and her cxr showed concern for possible rll infiltrate and she was started on vancomycin/cefepime to empirically treat for vap. she was extubated and required reintubation after 2 hours for tachypnea, hypertension, respiratory distress. on , pod#4 it was decided to start a three day course of methylprednisolone for upper airway edema secondary to multiple attempts at intubation/extubation. she rested on the ventilator over the weekend during this steroid course and we continued diuresis, monitoring her creatinine. she did develop a metabolic alkalosis and hypokalemia which were treated. her blood pressure throughout her hospital stay was difficult to control and she required standing metoprolol, hydralazine, addition of po agents, and intermittent iv hydralazine/metoprolol at times. the patient completed her steroid course and was extubated on , and there was a question of heme-tinged output from her ogt, protonix was added. lavage was negative, egd was not required. she remained in the icu on and . diamox was used for ongoing diuresis, bicarb and creatinine were monitored with a goal of .5 l negative daily. after extubation she was slow to improve her mental status with an elevated bun/cr, and a head ct was performed which was grossly negative for an acute process. as her lab values normalized, and with her family at bedside, her mental status did improve gradually. the patient was transferred out of the icu on . she was given one day of trophic tf through a dophoff tube and then passed a bedside swallow test on . the dophoff was discontinued and her diet was advanced. her labs continued to trend down, she tolerated a regular diet, and her blood pressures were better controlled on her new regimen. her mental status improved significantly and she is now interactive and appropriate. she had some loose stools over the weekend and a c.diff was sent which was negative. she was out of bed and did well with pt who recommended discharge to home. we felt as if she would benefit from home pt as she strengthens. her discharge plan involves bp monitoring on a new regimen, and close follow up to alter that regimen as necessary. additionally, she will finish her 2 week course of iv antibiotics for ventilator acquired pneumonia. she will also benefit from some home physical therapy. she will follow up with dr. in 1 week and her primary physician . for hospital follow up/bp control. she should also follow up with her cardiologist dr. at the center. medications on admission: omeprazole 20', losartan 100', hctz 25'', fluticasone 50'', albuterol prn, asa 325, iron, discharge medications: 1. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). 2. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 4. vancomycin 750 mg recon soln sig: one (1) intravenous q48 for 3 doses. disp:*qs * refills:*0* 5. cefepime 2 gram recon soln sig: one (1) recon soln injection q24h (every 24 hours) for 3 doses. disp:*3 recon soln(s)* refills:*0* 6. hydralazine 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* 7. losartan 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 11. aspirin 325 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 12. iron 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 13. amlodipine 10 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: -status post right carotid endartarectomy with subsequent volume overload requiring intubation, diuresis. -hypertension: difficult to control, requiring multiple agents discharge condition: good discharge instructions: -continue antibiotics for 3 more doses at home. cefepime will be given once daily and vancomycin will be given every other day for a total of three more doses of each of the medications -physical therapy will work with you at home -home nursing will visit you at home, check your blood pressure, monitor your neurologic status and help with your iv antibiotics followup instructions: -follow up with nurse practitioner 2:20pm internal medicine b for a blood pressure check. -follow up with dr. for hospital follow up and blood pressure management next week. call her office to confirm appointment. -follow up with dr. next week. please call the office to schedule your follow up appointment: -follow up with your cardiologist dr. . call for an appointment. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other bronchoscopy Arterial catheterization Endarterectomy, other vessels of head and neck Procedure on single vessel Procedure on vessel bifurcation Central venous catheter placement with guidance Diagnoses: Anemia, unspecified Esophageal reflux Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Hematoma complicating a procedure Hypopotassemia Pulmonary collapse Occlusion and stenosis of carotid artery without mention of cerebral infarction Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Alkalosis Disorders of phosphorus metabolism 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 Hyperosmolality and/or hypernatremia Ventilator associated pneumonia Accidents occurring in residential institution Diastolic heart failure, unspecified Knee joint replacement Other abnormal glucose Acute edema of lung, unspecified Other fluid overload

allergies: bethanechol / levofloxacin attending: chief complaint: muscle spasms major surgical or invasive procedure: placement of a picc history of present illness: patient is a 55 y.o. male s/p c6 injury () c/b autonomic dysreflexia, spasticity, neurogenic bladder with chronic foley who presented from osh with increased episodes of autonomic dysreflexia that included muscle spasms, tachycardia, hypertension/hypotension in setting of uti. patient was initially admitted to unit for labile bp, including hypotension. patient reports recently being treated for uti at an osh with levofloxacin and macrobid. he was discharged home with macrobid. he endorses increasing episodes of autonomic dysreflexia over the past few days despite being treated for esbl uti. he presented to osh yesterday with these symptoms, and was transferred to for further management. the patient had endorsed chest pain that was not acs, and had cta chest that was negative for pe. . approximately 8 months ago he began experiencing episodes of autonomic dysreflexia. the muscle spasms associated with these episodes are extensor only and begin in his legs and move proximally to involve his hips, middle and upper back. each extensor spasm lasts only a few seconds, is recurrent every few minutes, and is painful, culminating in discomfort in the left chest region. associated with the spasms are: acute onset severe headaches, blurred vision, mild sweating/hot feeling, and a feeling of disorientation. systolic blood pressure (taken at work and at home) during these episodes is elevated to the 170-200 range. sitting upright helps reduce the spasms and symptoms of autonomic dysreflexia. . in the ed, initial vs were: 98.7 81 122/64 18 100, though he also had an episode of hypotension in the 60s. patient was given vancomycin for concern for sepsis. dropped pressures to the 60's. the patient received ivf and had a clonidine patch was removed. admitted to micu for hypotension with ? sepsis. . in the micu, patient continued to complain of spasms. he denied any dysuria, fevers, or chills. patient reports foley catheter was last changed about a week ago. his uti was positive for p. aeruginosa. his antibiotics were changed from zosyn to meropenem. his foley catheter was changed. . on the medicine floor, the patient endorses spasms. he denies chest pain/sob. he also denies f/c. he has no abdominal pain. he is concerned about his urologic care. he had been followed by a urologist until recently. he had a scheduled urodynamic eval that he was not able to keep his recent hospitalization. past medical history: (1) traumatic c6 quadroplegia from car accident in (2) neurogenic bladder, has had indwelling foley catheter for last 10 years. (3) dysreflexia - autonomic and somatic (4) spasticity (5) multiple utis (including esbl e. coli) social history: lives alone, not married, no children. smoked, quit 6 mos ago, 2-3 beers/night. denies illicits. works at va in . family history: non-contributory. physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining clear yellow urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. contractures of bilateral hands; external rotation of bilateral feet. exam at discharge: afebrile, 120/80s, hr 90s, 93% ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining clear yellow urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. contractures of bilateral hands; external rotation of bilateral feet. unchanged exam pertinent results: labs on admission: 06:20pm urine rbc-21-50* wbc- bacteria-mod yeast-none epi-0-2 06:20pm urine blood-lg nitrite-pos protein-25 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-tr 06:20pm urine color-straw appear-clear sp -1.035 06:20pm plt count-231 06:20pm neuts-71.0* lymphs-22.8 monos-4.8 eos-1.0 basos-0.4 06:20pm wbc-10.6# rbc-4.52* hgb-13.5* hct-38.3* mcv-85 mch-29.8 mchc-35.3* rdw-14.1 06:20pm estgfr-using this 06:20pm glucose-98 urea n-9 creat-0.7 sodium-137 potassium-3.9 chloride-96 total co2-25 anion gap-20 06:25pm lactate-3.9* images / studies: cxr: upright ap view of the chest: the left picc has been removed. the heart size remains top normal. the mediastinal and hilar contours are unremarkable. the lungs are grossly clear. no large pleural effusion or pneumothorax is seen. there are no acute osseous abnormalities. partially imaged is a cerclage wire within the cervical spine. impression: no acute cardiopulmonary abnormality. micro: - urine culture - p. aeruginosa see below - blood culture - ngtd - mrsa screen - pending **final report ** urine culture (final ): pseudomonas aeruginosa. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 2 s ciprofloxacin---------<=0.25 s gentamicin------------ 2 s meropenem------------- 0.5 s piperacillin/tazo----- 8 s tobramycin------------ <=1 s mrsa screen (-) , , and blood cultures pending urean creat na k cl hco3 angap 7 0.6 139 4.0 102 28 13 wbc rbc hgb hct mcv mch mchc rdw plt ct 6.8 4.38* 12.9* 37.5* 86 29.5 34.4 14.1 184 brief hospital course: 55 y.o. male s/p c6 injury () c/b autonomic dysreflexia, spasticity, neurogenic bladder with chronic foley who presents from osh with increased spasms, tachycardia, hypertension with a likely uti found in our ed to be hypotensive. # urinary tract infection/neurogenic bladder. patient likely has chronic urinary tract infection or incompletely eradicated urinary tract infection. he does have a recent history of esbl e. coli in the urine. he was initially started on zosyn as prior esbl e. coli was listed as sensitive, but given this is also a beta-lactam, he was converted to meropenem on the morning following admission. urine culture grew pan-sensitive pseudomonas. meropenem was continued, as patient had recent history of quinolone-resistent enterococcus uti and esbl e. coli in past few months. he was continued on home medications of detrol and imipramine. he was discharged on to rehab to complete a 10 day course of meropenem, a picc was placed prior to discharge. the patient will see dr. urology at on to establish care and for evaluation of his recurrent utis and possible uro-dynamic studies, as he does not have access to urologic care at home. # autonomic dysreflexia/spasticity - symptoms were likely exacerbated by urinary tract infections causing worsening of spasticity. previous exacerbations of autonomic dysreflexia have improved with treatment of underlying uti. bps were monitored closely and improved to baseline levels on teh morning following admission. the patient was continued on home doses of baclofen/diazepam/clonazepam. the patient required nitro paste twice in the setting of elevated bp, with good effect. # depression/anxiety. the patient was continued on home doses of imipramine, and sertraline. # osteopenia. likely due to non-weight bearing status, muscular atrophy, and possible autonomic nervous system changes. the patient was continued on his home calcium/vitamin d. # gerd. patient was continued on his home omeprazole. # fen: no ivf, replete electrolytes, heart healthy diet # prophylaxis: subcutaneous heparin, bowel regimen # access: peripherals # communication: patient # code: full (discussed with patient) medications on admission: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. sertraline 50 mg tablet sig: two (2) tablet po daily (daily). 3. imipramine hcl 10 mg tablet sig: one (1) tablet po bid (2 times a day). 4. detrol la 4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. 5. baclofen 10 mg tablet sig: two (2) tablet po qid (4 times a day). 6. multivitamin tablet sig: one (1) tablet po daily (daily). 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constip. 8. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily). 9. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 10. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 11. nitroglycerin 2 % ointment sig: inch transdermal prn dysreflexia as needed for sbp >190: recheck 1 hour after placing (or earlier if pt lightheaded). wipe off for bp <150. 12. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day). 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. diazepam 10 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for spacticity: hold for sedation, rr<12 15. tylenol 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for headache. 16. clonazepam 1mg tablet sig 1.5 tablets po every eight (8) hours. 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: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 5. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 6. imipramine hcl 10 mg tablet sig: one (1) tablet po bid (2 times a day). 7. baclofen 10 mg tablet sig: two (2) tablet po qid (4 times a day). 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily). 10. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 11. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 12. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day). 13. diazepam 10 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for spasticity. 14. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain/headache. 15. tolterodine 2 mg tablet sig: one (1) tablet po bid (2 times a day). 16. clonazepam 0.5 mg tablet sig: three (3) tablet po tid (3 times a day). 17. nitroglycerin 2 % ointment sig: one (1) inch transdermal prn as needed for sbp>190: recheck 1 hour after placing (or earlier if pt lightheaded). wipe off for bp <150. 18. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): please continue while at rehab. 19. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush: for picc management. 20. meropenem 500 mg recon soln sig: one (1) intravenous every six (6) hours for 10 days: course to complete on . discharge disposition: extended care facility: senior healthcare - discharge diagnosis: primary diagnoses: pseudomonas uti autonomic dysreflexia secondary diagnoses: depression and anxiety osteopenia gerd 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: it has been a pleasure to be involved in your care mr. while you have been a patient at . you were transferred here from because you were having muscle spasms, fast heart rate, and high blood pressure consistent with previous episodes of autonomic dysreflexia. in our emergency department you had low blood pressure and were admitted first to the icu and then to the general medicine . you were found to have a urinary tract infection with a bacteria called pseudomonas aeruginosa. we think that the uti probably exacerbated your autonomic dysreflexia. we treated your infection with an antibiotic called meropenem and you got better. we made plans for you to continue your treatment in a rehab center and to follow-up with a urologist as an outpatient. please note that the following medications have changed: -meropenem -no other changes were made to your medications. please see below for your follow up appointments. followup instructions: please follow-up with the following: department: surgical specialties when: monday at 1 pm with: , md building: campus: east best parking: garage Procedure: Venous catheterization, not elsewhere classified Diagnoses: Esophageal reflux Urinary tract infection, site not specified Dysthymic disorder Hypotension, unspecified Paraplegia Disorder of bone and cartilage, unspecified Pseudomonas infection in conditions classified elsewhere and of unspecified site Late effect of spinal cord injury Late effects of motor vehicle accident Autonomic dysreflexia Neurogenic bladder NOS

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: epigastric and mid back pain major surgical or invasive procedure: central venous line (ij) placement cardiac catheterization history of present illness: -- per admitting micu resident -- 56-year-old m w/ a h/o dm (on oral hypoglycemics) presents following two episodes of epigastric pain which he describes as colicky in nature. he said he has not gotten this before and it occured at 8 a.m. on the day of admission. it lasted 1 hour and he initially thought it was gastritis. the pain then radiated to his mid back and then resolved. he went to work and the pain recurred x 1-2 hours so he went to the er. he denies any association with food, any alleviating or exacerbating factors or any other symptoms. of note patient was in 2 weeks ago. denies any nausea, emesis, diarrhea or any other symptoms. . at baseline he is very functional, he is able to perform aerobic exercise on a daily basis x 20 minutes without doe or chest pain. no orthopnea, pnd or pedal edema. no other symptoms. no personal history of unexplained syncope or family history of scd. . in the er, vitals were: pain 8, t 99.8, hr 120, bp 104/81, rr 17, sao2 100%. ekg showed revealed ste in v1-v2 without q waves or other changes, sinus tachycardia so a code stemi was called. the patient was given 324mg aspirin, heparin 5000 units, metoprolol iv 20mg, clopidogrel 600mg po, nitro 0.4mg sl, nitroglycerin gtt, eptifibatide 20mg iv. the patient was taken to the cath lab and found to have only a 30-40% mid lad lesion- no intervention performed. during the procedure patient hypotensive to 81/49 and hr 115, afebrile given ivf, no antibiotics given for multiple hours, bandemia noted on cbc. patient sent to micu. patient without complaints in the icu, asking for food. past medical history: 1. diabetes mellitus - diagnosed in , on metformin 1000mg , no hgba1c in omr 2. nephrolithiasis - social history: psychiatrist at . married, two daughters, one at bu, one journalist. wife is child psychiatrist. from southern . -tobacco history: none -etoh: rarely -illicit drugs: none ever, no ivdu family history: parents alive. father dm (age 86), father had an mi at the age of 72. mother is well at the age of 80. brother w/ dm. uncle w/ a fatal mi at 58. no scd or unexplained car accidents. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: -- per admitting micu resident -- vs: t=102 bp=80/40 hr=110 rr=18-20 o2 sat=98% ra, prefering nc general: wdwn male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. 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. 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: : ekg: sinus rhythm. rsr' pattern in leads v1-v2 with associated ste. . trop-t: <0.01 . 137 100 19 199 agap=16 3.9 25 0.8 . alt: 945 ap: 104 tbili: 2.3 ast: 1179 lip: 45 . cbc 8.1 > 13.6 < 234 39.8 n:84 band:12 l:2 m:1 e:0 bas:0 atyps: 1 . pt: 13.1 ptt: 21.5 inr: 1.1 . urinalysis: negative . viral hepatitis serologies: hbsag: negative hbs-ab: borderline positive -- c/w titer of roughly 10 miu/ml hav-ab: positive hcv-ab: negative . ruq ultrasound: 1. mild gallbladder wall edema with no evidence of gallstones or gallbladder distension. 2. no evidence of thrombosis in the main portal vein. . ct torso: 1. heterogeneously enhancing liver with wall thickening and of the adjacent, nondistended gallbladder. these findings are non-specific, and can be seen in acute hepatitis. 2. small right pleural effusion. small amount of ascites collecting in the pelvis. 3. diverticulosis without acute diverticulitis. 4. no intra-abdominal fluid collection or evidence of other infectious process. . echo: the left atrium is normal in size. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is mildly dilated with normal free wall contractility. 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: mildly dilated right ventricle with normal global and regional biventricular systolic function. . cardiac cath: 1- selective coronary angography showed no obstructive cad. teh lmca, lcx and rca had were angiographically normal. the mid lad has a short intra- myocardial segment with 30-40% stenosis (mostly in systole). the distal lad was not a large vessel. 2- limited resting hemodynamic assessment showed normal systemic arterial bp (102/61 mmhg) and moderately elevated left-sided filling pressure (lved 24 mmhg). careful pullback across the aortic valve showed no significant gradient. 3- left ventriculography showed overall preserved lvef (55%0 with mild anterolateral hypokinesis. 4- aortic root angiography showed no evidence of aortic dissection or aortic regurgitation. final diagnosis: 1. non-obestructive coronary artery disease. 2. normal ventricular systolic function with mild anterolateral hypokinesis. 3. moderately-severe left-sided filling pressure with lvef 24 mmhg. 4. treat as presumed coronary spasm, especially if positive troponin/cpk-mb 4. medical management and further evaluation for non-cardiac cause of his symptoms mrcp: 1. normal caliber biliary tree without choledocholithiasis. no evidence of acute cholecystitis. 2. no cause for bacteremia identified. 3. small bilateral pleural effusions and atelectasis. brief hospital course: 56-year-old male w/ a pmhx of dm presenting with epigastric pain, found to have ste on ekg- brought to cath lab and found to have no significant disease and transferred to micu for concern of sepsis . # sepsis - patient received ~6l fluids upon admission to the micu and maintained a sbp in the 80s; he was started on dobutamine peripherally and once central venous line was placed, levophed briefly. patient responded well and blood pressures improved to sbp120-130s. patient was noted to have 11 -->16% bandemia and was empirically treated with vancomycin and zosyn. once sensitivities and speciation came back with gram negative rods and then e.coli, patient was treated with levofloxacin and zosyn, narrowed to zosyn. switched to ceftriaxone after sensitivities determined, as once-daily dosing would be more convenient at home. picc was placed after surveillance blood cultures were negative >48 hours. ct torso, ruq ultrasound, and mrcp were performed to evaluate for sources of bacteremia. ultimately, no clear source was found although it was possible that patient had an early cholangitis with a stone that passed before identification via ruq u/s or mrcp. the patient was discharged to complete a two week course of ctx. . # transaminitis - given history and negative ruq u/s + mrcp, likely ischemic hepatitis from hypotension from sepsis. patient with elevated ldh on admission, which is supportive of this etiology. viral hepatitis panel was sent and negative for hav, hbv, hcv. given patient's recent visit to , hepatitis e serologies were sent as well. this test, as well as autoimmune serologies (, anti-smooth muscle ab) are pending at time of discharge and should be followed up as an outpatient. lfts downtrended throughout hospital stay and were indicative of stabilization of liver insult. no significant evidence of liver synthetic dysfunction. . # ekg abnormalities - catherization showed no significant coronary artery disease. possible anterolateral wall motion abnormality was noted on catheterization but tte within normal limits. patient was briefly started on plavix 75mg but serial ekgs showed improvement of brugada pattern (st elevations more consistent with j point elevations). cardiology followed patient while in-house, s/p cardiac catherization but recommended followup as outpatient. . # dm2 - patient was continued on insulin sliding scale while in house. he is on metformin at home, last a1c 6.2%. restarted on metformin on discharge as lfts were indicating stabilization of liver function. . # code status during hospitalization was documented as full, confirmed with patient. medications on admission: 1. metformin 1000mg po bid 2. aspirin 81mg po daily . allergies: nkda discharge medications: 1. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: two (2) grams intravenous q24h (every 24 hours) for 8 doses: - (14 day total course). disp:*16 grams* refills:*0* 2. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. 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: home with service facility: home therapies discharge diagnosis: primary diagnosis. 1. sepsis from e. coli bacteremia 2. ischemic hepatitis secondary diagnoses: 1. diabetes mellitus discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you were seen at for epigastric pain. initially, based on your ekg, there was a concern that you may have an acute myocardial infarction. you were taken to the cardiac catherization lab, at which time no significant blockages were found. you became hypotensive during this period of time and were admitted to the micu for suspected sepsis. your blood cultures grew out e. coli and your liver enzymes were elevated, indicating hepatic damage. you required pressors for a short period of time to raise your blood pressure but quickly weaned off of this. you received intravenous antibiotics and fluids throughout your hospital stay and showed great improvement. you will be discharged home with a plan to complete a total of two weeks of intravenous antibiotics for your bloodsteam infection. a right upper quadrant ultrasound and mrcp showed no evidence of gallstones or biliary obstruction to explain the source of your liver enzyme elevation or bloodstream infection. at this time, we feel like the most likely etiology of your liver enzyme elevation is ischemic hepatitis from transient hypotension. the following medications were changed during your hospitalization: added ceftriaxone 2g/day to treat your bloodsteam infection followup instructions: we would like you to follow up with your pcp, . , in approximately two weeks after hospitalization. his office can be contact at . at that time, you should have a cbc/diff, ast, alt, alk phos, tbili checked. we are in the process of setting up follow up with electrophysiology in weeks to follow up on your ekg abnormalities during this admission. this appointment will be made in the next 1-2 days. please call to confirm the date and time of your appointment in the next few days. Procedure: Venous catheterization, not elsewhere classified Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Aortography Diagnoses: Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Severe sepsis Other and unspecified angina pectoris Septic shock Family history of ischemic heart disease Personal history of urinary calculi Septicemia due to escherichia coli [E. coli] Hepatitis, unspecified Orthopnea

allergies: ace inhibitors attending: chief complaint: diarrhea major surgical or invasive procedure: central line placed intubation history of present illness: east hospital medicine attending admission note date: time: 00:30 pcp: , . ] the patient is an 83 y/o female with h/o afib on coumadin, chf, htn, rheumatic hd who was recently admitted () for abdominal pain s/p perc chole tube placed for acute cholecystitis and mirrizzi syndrome. she now p/w diarrhea. she reports a 3d h/o worsening diarrhea and a fever to 101.0 today while at home. she describes the diarrhea as foul smelling and occuring four times per day, but did not notice any blood in her stool. she denies n/v/dysuria and any other symptoms. of note, on her last admission, she was placed on unasyn and then narrowed to cipro when blood and bile cultures grew out e. coli. this course was to end . upon review of omr, blood () and fluid (bile; ) cultures grew e. coli resistant to ampicillin and unasyn. in er: vs: 98.8 80 170/66 18 98%ra px: irreg irreg cv exam, guiac neg, green fluid in perc drain studies: sent for c. diff/stool cx fluids given: 1l ns meds given: ciprofloxacin iv 400mg consults called: surgery: no surgical indications vs prior to transfer to the floor: 77 19 145/57 100%ra review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. denies chest pain or tightness, palpitations, orthopnea, dyspnea on exertion. denies cough, shortness of breath, wheezes or pleuritic pain. denies nausea, vomiting, heartburn, constipation, brbpr, melena, or abdominal pain. no dysuria, urinary frequency. denies arthralgias or myalgias. denies rashes. no increasing lower extremity swelling. no numbness/tingling or muscle weakness in extremities. no feelings of depression or anxiety. all other review of systems negative. past medical history: ckd, stage iv, baseline cr 2-2.3 chronic atrial fibrillation on anti-coagulation htn diastolic dysfunction, mild systolic dysfunction rheumatic heart disease involving mitral valve with subsequent mild ms and 2+ mr, ai hypothyroidism pulmonary hypertension (tr gradient 61 on tte in ) oa - knees social history: lives with son, , who was admitted this weekend for a uti, and performs her adls independently. denies tobacco, etoh or drug use. family history: mother died traumatically at age 23. father died of stomach cancer at age 51. no brothers or sisters. physical exam: vs: 98.7 157/73 71 20 100%ra, 0/10 pain gen: no apparent distress heent: no trauma, pupils round and reactive to light and accommodation, no lad, oropharynx clear, no exudates cv: regular rate and rhythm, no murmurs/gallops/rubs pulm: clear to auscultation bilaterally, no rales/crackles/rhonchi gi: soft, non-tender, non-distended; no guarding/rebound; obese; perc chol tube in place draining bilious fluid ext: 2+ pitting leg edema b; no clubbing/cyanosis; 2+ distal pulses; peripheral iv present neuro: alert and oriented to person, place and situation; cn ii-xii intact, motor function globally derm: no lesions appreciated pertinent results: 08:20pm urine color-yellow appear-clear sp -1.011 08:20pm urine blood-neg nitrite-neg protein-150 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 08:20pm urine rbc-0-2 wbc-0 bacteria-occ yeast-none epi-0-2 08:20pm urine amorph-few 06:45pm glucose-87 urea n-26* creat-2.2* sodium-137 potassium-3.8 chloride-106 total co2-21* anion gap-14 06:45pm alt(sgpt)-14 ast(sgot)-23 alk phos-103 tot bili-0.6 06:45pm lipase-86* 06:45pm wbc-9.8 rbc-3.18* hgb-8.4* hct-26.1* mcv-82 mch-26.5* mchc-32.4 rdw-16.1* 06:45pm neuts-75.5* lymphs-19.2 monos-4.2 eos-0.6 basos-0.6 06:45pm plt count-286 . stool cx -clostridium difficile toxin a & b test (final ): reported by phone to , r.n. on at 0515. 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). brief hospital course: pt is an 83 y.o female with h.o afib on coumadin, ckd, htn, diastolic dysfxn/systolic dysfxn 25-30%, rhd, hypothyroidism, phtn recent cholecystitis s/p perc chole, e.coli bacteremia/bile who presented with watery diarrhea while on cipro. . #fever/c.diff colitis-likely precipitated by recent cipro usage. pt with positive c.diff toxin. pt was tx with po flagyl. ivf were given due to appearing dry on exam. . #s/p perc chole for cholecystitis (recent e.coli bacteremia/bile). general surgery were made aware of admission. perc tube was placed to gravity. cipro held due to c. diff. pt had compelted 10 days of tx. . #afib on coumadin-was rate controlled. therapeutic inr. pt was continued on bb, ccb, and coumadin. . #htn-continued carvedilol and losartan. . #ckd-baseline cr 2-2.7. #normocytic anemia-baseline 21-27 recently. stable during admission with no signs of active bleeding. on aranesp ast outpt. . #chronic systolic hf-pt with le edema but clear lungs and dry mm. continued on bb, losartan, simvastatin. metolazone for now given diarrhea. . on , pt was found unresponsive in cardiac arrest at 8:02pm on the floor, a code was called. cpr was started and pt was in pea arrest. pt was given epinephrine x 3, atropine x 2, bicarb x 2amps, mag x 2g, dextrose x 1 amp. pt was intubated and femoral line was placed. pt was given started on levo and neo gtts at max dose. ivf were given wide open. pt became minimally responsive and tried to pull at et tube, no pulse was felt, sbp was briefly at 60. pt was moved to . on arrival pt went into vt and was unresponsive. cpr was resumed. pt was shocked at 200 joules and went into pea arrest. pt was given atropine x 1, epinephrine x 3, bicarb x 2, mag x 2g, cal x 2grams. pt did not regain a pulse and cpr was stopped at 9pm. family were at the bedside and declined autopsy. hmed dr. was present during the code. icu attending was notified. death examination was at 9:15pm. pt chief cause of death was schf, immediate cause was cardiac dysrrythmia, and other causes were cholecystitis with recent percutaneous chole tube, c. diff diarrhea, and a fib. pt case was reported to the medical examiner due to recent procedure (tube placement). medications on admission: 1. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 2. carvedilol 12.5 mg tablet sig: one (1) tablet po bid 3. simvastatin 10 mg tablet sig: two (2) tablet po daily 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily 5. metolazone 2.5 mg tablet sig: one (1) tablet po daily 6. hectorol 2.5 mcg capsule sig: one (1) capsule po every mon-wed-fri. 7. vitamin d 50,000 unit one capsule po once a week. 8. aranesp (polysorbate) 60 mcg/0.3 ml one injection injection once a month. 9. combivent 18-103 mcg/actuation aerosol one puff inh qid prn sob or wheeze. 10. losartan 100 mg one (1) tablet po once a day. 11. coumadin 5 mg tablet po once a day 12. ciprofloxacin 500 mg 1.5 tablets po q24h thru . 13. omeprazole 20 mg (e.c.) one capsule po twice a day. discharge medications: none discharge disposition: expired discharge diagnosis: cardiac dysrrhythmia c. diff atrial fibrillation systolic congestive heart failure, chronic cholecystitis discharge condition: none discharge instructions: none none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Insertion of endotracheal tube Diagnoses: Congestive heart failure, unspecified Unspecified acquired hypothyroidism Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Other chronic pulmonary heart diseases Mitral valve insufficiency and aortic valve insufficiency Bacteremia Intestinal infection due to Clostridium difficile Chronic systolic heart failure Long-term (current) use of anticoagulants

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: malaise major surgical or invasive procedure: upper endoscopy colonoscopy history of present illness: mr is a 68 year old man with past medical history significant for copd, cll, hypertension, and recent admission for pulmonary embolus complicated by respiratory failure, intubation and a ventillator associated pneumonia, presenting from home with weakness, tremmor and fatigue and now found to have gpc bacteremia. patient reports progressive weakness for the past two days, but most concerning to him is bilateral upper extremity tremmor. he has never had this in the past, it is not associated with any numbness or tingling and is present all day. patient had recent hospital acquired pneumonia, treated until with vanc/cefepime, however now he feels his breathing is much improved. at time of discharge from the hospital he had a 2 liter oxygen requirement. he does however report some low grade fevers at rehab (~99.0) of note, he was recently started on trazodone and celexa 40mg daily. denies any cough or sputum production, has been active and able to ambulate with pt at rehab. at the time of discharge from rehab he had a 2l oxygen requirement. in the ed, initial vs were: 99.8 96 122/68 16 99% (2-3l ? vs ra). patient was given aspirin, morphine chronic neck pain, ns at 125/hr and admitted for further managmeent. vitals on admission were hr 100 111/74 15 99%3l on the floor, had a. fib with rvr in 120's. increased metoprolol to 125 from 100. this afternoon patient growing gpc's in blood (likely strep). got 250cc bolus at that point with bp in 90's systolic. hr increased to 130's with systolic bp in mid 80's. got further 500cc's, and bp improved to mid 90's. hr still 110 so go another 500cc bolus. following that patient with increasing respiratory distress with requiring nrb for oxygenation. given nebulizers but lasix held given hypotension earlier. now asked for icu transfer for increasing oxygen requirement. vanco/zosyn given on the floor. at time of icu evaluation patient with rr 24-26 on 5l via face mask and c/o shortness of breath. on arrival to icu satting in mid 90'd on 2l nc with stable bp of 110. past medical history: # chronic lymphoid leukemia (cll). # chronic obstructive pulmonary disease (copd). -- fvc 79% pred, fev1 71% pred, fev1/fvc 90% pred # -ventricular systolic failure with lvef 45% and dilated rv with signs of overload # pulmonary hypertension # pulmonary nodules # depression. # hypertension. # hyperlipidemia # peptic ulcer disease. # right eye cataract (s/p removal at the age of 12. he had an injury to his eye and has no vision in that eye for years) # deviated nasal septum, s/p surgery # cervical arthritis. # history of colon polyps (? adenoma). # history of herniated disks with chronic back pain # benign prostatic hypertrophy social history: he is married and lives with his wife in . she has significant emotional problems, which requires the patient to care for her almost constantly. he continues to smoke 1 pack a day, which he has done for at least 50 years and he is not interested at this time in quitting. he denies ethanol and illicit drug use. family history: mother died at age 85, complications of alzheimer's disease. father died at age 74, complications of congestive heart failure. he reports no history of colon cancer, polyps or coronary disease in his family. a brother developed disease. physical exam: vs hr 103, bp 104/72, rr 24 o2 98% nrb -> 95% 5l nc/fm gen: mild distress heent: ncat, right pupil surgical, neck supple, jvp difficult to ascertain lungs: rales at right base, otherwise clear, no wheezing abdomen: firm, ntnd, +bs ext: + peripheral edema of rle, lle trace edema neuro: aox3, appropriate pertinent results: labs on admission: 01:56pm plt smr-normal plt count-211 01:56pm hypochrom-1+ anisocyt-2+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-normal schistocy-1+ burr-1+ 01:56pm neuts-48* bands-0 lymphs-43* monos-6 eos-2 basos-0 atyps-1* metas-0 myelos-0 01:56pm wbc-18.2*# rbc-3.68* hgb-11.0* hct-33.9* mcv-92 mch-29.9 mchc-32.4 rdw-15.4 01:56pm b2micro-3.5* 01:56pm alt(sgpt)-23 ast(sgot)-16 ld(ldh)-238 alk phos-72 tot bili-0.8 01:56pm estgfr-using this 01:56pm urea n-18 creat-0.8 05:05pm pt-33.0* ptt-35.9* inr(pt)-3.3* 05:05pm plt count-231 05:05pm hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 05:05pm neuts-22* bands-3 lymphs-62* monos-7 eos-0 basos-0 atyps-6* metas-0 myelos-0 05:05pm wbc-14.2* rbc-3.91* hgb-11.6* hct-35.4* mcv-91 mch-29.7 mchc-32.8 rdw-16.1* 05:05pm tsh-2.4 05:05pm ck-mb-notdone 05:05pm ctropnt-<0.01 05:05pm ck(cpk)-15* 05:05pm glucose-101* urea n-17 creat-0.9 sodium-129* potassium-4.6 chloride-94* total co2-27 anion gap-13 05:16pm lactate-1.8 10:02pm urine rbc-0 wbc- bacteria-occ yeast-none epi-0-2 10:02pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-0.2 ph-5.0 leuk-sm 10:02pm urine color-yellow appear-clear sp -1.020 10:02pm urine osmolal-599 10:02pm urine hours-random creat-160 sodium-18 potassium-72 chloride-29 total co2-less than ======== microbiology: - blood culture: enterococcus faecalis | enterococcus faecalis | | ampicillin------------ <=2 s <=2 s daptomycin------------ s penicillin g---------- 0.5 s 4 s vancomycin------------ <=0.5 s 1 s - urine culture: klebsiella pneumoniae (sensitive to meropenem) - blood culture: negative - mrsa screen: negative - vre swab: positive - c diff: negative - abd wall fluid collection: negative - bcx: pending - ucx: yeast 10,000-100,000 organisms/ml ======== images/studies: ecg: atrial fibrillation with a ventricular rate of 90. rsr' pattern in leads v1-v2 with a qrs duration of 84. st-t wave changes in leads ii, iii, avf and v3-v5. compared to the previous tracing of no diagnostic interval change. cxr: findings: pa and lateral views of the chest are obtained. there has been interval removal of the picc line and left ij central venous catheter. comparison is also made with a ct chest from . extensive centrilobular and paraseptal emphysema is better assessed on prior ct, though accounts for the lucency in the upper lungs, primarily in the left paramediastinal region. the heart is enlarged. the coarsened interstitial markings are compatible with known underlying copd/emphysema. there is likely a stable small right pleural effusion. there is no definite sign of new consolidation. mediastinal contour is stable. the osseous structures are intact. impression: 1. chronic interstitial lung disease secondary to emphysema with prominent paraseptal emphysema accounting for left upper lobe lucency. 2. cardiomegaly. ecg: atrial fibrillation at a rate of 112. compared to tracing #1 no diagnostic interval change. ecg: marked baseline artifact. the rhythm is probably atrial fibrillation. poor r wave progression in leads v1-v3. st-t wave changes in leads ii, iii, avf and leads v2-v4. compared to the previous tracing of these changes are similar to those seen at that time. probably no diagnostic interval change. cxr: single portable chest radiograph: there is unchanged severe cardiomegaly. the mediastinal and hilar contours are stable. there has been significant interval improvement of interstitial pulmonary vascular congestion as demonstrated on radiograph one day prior. biapical cystic changes more prominent on the left due to emphysema are better demonstrated on prior ct. there is no focal consolidation to suggest acute pneumonia. there is no large effusion or pneumothorax. impression: 1. marked interval improvement of interstitial pulmonary vascular congestion since one day prior. 2. no focal consolidation to suggest pneumonia. tte: the left atrium is mildly dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed with septal hypokinesis (lvef= 45-50 %). the right ventricular cavity is mildly dilated with severe global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened. small (~0.5 cm) echodense structure(s) seen on the aortic side of the aortic valve similar to lambl's excrescence although somewhat thickened appearance raises suspicion of possible vegetation. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is moderate/severe mitral valve prolapse. an eccentric, laterally directed jet of moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a very small pericardial effusion. compared with the prior study (images reviewed) of , findings are similar. small echodense structure seen on aortic valve in the prior study slightly more prominent in the current study but could be due to differences in image quality. suggest transesophageal echocardiography to assess, if clinically indicated. cxr: emphysema is severe, mild pulmonary edema improved since . tiny left pleural effusion may be present. heart size normal. leftward mediastinal shift longstanding and does not indicate left lower lobe collapse. cxr: there is mild progression of consolidation seen in the left lower lobe. known extensive bilateral emphysema. increased diameter of the right pulmonary hilus is noted; however, when reviewing previous ct from , it is seen that this is not caused by pathologic mass. bilateral small pleural effusions, left slightly greater than right. the heart is normal sized. tee: no evidence of endocarditis. stretched pfo with resting left-right shunt. moderate, eccentric mitral regurgitation. complex but non-mobile descending aortic atheroma. ct abd/pelvis: 1. 0.6 x 1.0 cm right lower lobe nodular pulmonary density, which could represent scarring adjacent to the emphysematous bullae, but enlarging pulmonary nodule, potentially suspicious for malignancy, cannot be excluded. short interval followup is recommended with dedicated chest ct in three months. 2. 2.7 cm oval hypodense lesion in the left lateral abdominal wall, intramuscular in location, may represent a small abscess or less likely a hypoenhancing mass. this could be further evaluated with ultrasound. 3. diverticulosis without evidence of diverticulitis. this examination is not sensitive for the detection of colonic masses. no evidence of bowel obstruction. 4. emphysema, atelectasis, pleural effusions, and right atrial enlargement. 5. air within the urinary bladder. please correlate with any history of recent foley catheterization. 6. abdominal aortic aneurysm measuring up to 3.4 cm and right common iliac artery aneurysm. abd u/s: 3-cm left flank intramuscular fluid collection, which is amenable to ultrasound-guided aspiration. cta: 1. infrarenal aaa. no evidence of aortoenteric fistula. 2. right common iliac artery fusiform aneurysm. 3. narrowing and angulation of the celiac artery at region of median arcuate ligament may be due to respiratory phase of imaging. if median arcuate ligament syndrome is a clinical concern, mra would be performed with inspiratory and expiratory phase imaging. 4. severe emphysema. 5. right lower lobe nodule which requires follow-up, as previously advised. cxr: in comparison with study of , there is little overall change. extensive opacification is again seen at the left base silhouetting the hemidiaphragm and some shift of the mediastinum to that side. this is consistent with substantial volume loss in the left lower lobe. the costophrenic angle has been excluded from the image. viewed small right pleural effusion with continued engorgement of pulmonary vessel is consistent with elevated pulmonary venous pressure. colonoscopy: mucosa: area of erythema in the proximal ascending colon. be trauma from scope vs. underlying angioectasias. cold forceps biopsies were performed for histology at the proximal ascending colon. other no bleeding found. no mass lesions seen. impression: abnormal mucosa in the colon (biopsy) no bleeding found. no mass lesions seen. brief hospital course: 68 year old man with past medical history significant for copd, congestive heart failure, recent pulmonary embolism, and pneumonia admitted with respiratory distress, bacteremia. . # bacteremia/sepsis: blood cultures drawn on admission grew enterococcus faecalis. he was started on broad spectrum antibiotics including linezolid given concern for potential vre as he had recently been on vancomycin for treatment of pneumonia. sensitivities later revealed pan-sensitive enterococcus, and linezolid was changed to ampicillin. he did have an episode of tachycardia and hypotension on the floor, which responded to intravenous fluids. the infectious disease service was consulted. a trans-thoracic echo was performed to evaluate for possible vegetation, which showed an echodense structure on the aortic valve. to further evaluate, an transesophageal echo was obtained, which showed no endocarditis. subsequent cultures were negative, although the patient's vre rectal swab was positive. . # copd/respiratory distress: on , the patient was transferred to the icu for tachypnea and a worsening oxygen requirement in the setting of iv fluid administration for hypotension. it is likely that, in this patient with heart failure and advanced copd on 2l home o2, he has limited pulmonary reserve so that even mild pulmonary edema result in significant distress. he was given iv lasix boluses and nebulizer treatments with significant improvement in his respiratory status. there was no evidence of pulmonary infection on imaging and urine legionella was negative. he was transferred back to the medicine floor on . he was continued on outpatient tiotropium and inhaled steroids. . # lower gi bleed: on , the patient passed bloody bowel movements. his hematocrit dropped to 22. he was transferred back to the micu. he underwent egd, which was normal. he required transfusion of four units of packed rbcs. he underwent ct angiogram of his abdomen, which was negative for aortoenteric fistula. the patient subsequently underwent colonoscopy which was unrevealing for acute bleed, but erythematous mucosa was biopsied to evaluate for arteriovenous malformation. his aspirin and warfarin had been held, but were restarted on his day of transfer to rehab, as his hematocrit had been stable with no further bleeds for about a week. . # uti. urine culture with sensitive klebsiella. he completed a seven day course of ciprofloxacin. . # hyponatremia: variably attributed to siadh and hyervolemic hyponatremia. the patient was placed on conservative fluid restrictions. renal was consulted and the patient was also diuresed with iv and po furosemide. sodium levels subsequently normalized. . # atrial fibrillation: he was in atrial fibrillation with variable rate control. he was continued on rate control with lopressor and diltiazem. he was anticoagulated with warfarin for thromboembolic prophylaxis with a goal inr of . following his lower gi bleed, his systemic anticoagulation was held. he and the rehabilitation center were instructed to restart his warfarin (and aspirin) on the day of transfer. . #. weakness/tremor: believed to be related to recent addition of citalopram. the patient also takes trazodone, but did not display any other signs of serotonin syndrome such as nausea/vomitting/diarrhea. his tremor persisted to varying degrees . #. pulmonary hypertension/pe: no formal workup in setting of subacute pulmonary embolus. will need outpatient follow up. pe likely contributing to right ventricular volume overload and pulmonary hypertension as above. patient tolerated systemic anticoagulation until he experienced his gi bleed (see above). warfarin was subsequently held as noted above. . #. cll: the patient's wbc count trended down from its baseline level (20-30k) when the patient developed bacteremia (see above). as his bacteremia was treated, his wbc count rose to a level consistent with his baseline level. medications on admission: medications at time of transfer -vanco 1 gram q12 -zosyn 4.5 iv q8 -metoprolol 100 po tid -atrovent -ambien -tylenol -senna -docusate -mvi -nystatin -diltiazem 30 qid -albuterol q2h prn -tiotropium daily -aspirin 81mg daily -warfarin 4mg daily discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 2. ampicillin sodium 2 gram recon soln sig: two (2) grams injection q4h (every 4 hours) for 2 days: last dose will be evening dose on . 3. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) nebulizer treatment inhalation every four (4) hours as needed for wheezing/sob. 4. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 5. diltiazem hcl 30 mg tablet sig: two (2) tablet po qid (4 times a day). 6. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid (4 times a day) as needed for thrush. 7. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 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) as needed for constipation. 10. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 11. aspirin 81 mg tablet sig: one (1) tablet po once a day. 12. warfarin 4 mg tablet sig: one (1) tablet po at bedtime. discharge disposition: extended care facility: nursing home discharge diagnosis: primary: vancomycin-sensitive enterococcus septicemia gastrointestinal bleed of undetermined origin . secondary: urinary tract infection klebsiella atrial fibrillation musculoskeletal chest pain hypervolemic hyponatremia acute on chronic systolic congestive heart failure chronic lymphocytic leukemia pulmonary hypertension history of pulmonary embolism hypertension pulmonary nodules discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you came to the hospital for weakness, tremor and fatigue. you were found to have bacteria in your blood. you were given antibiotics intravenously and your symptoms improved. you also had a urinary tract infection that improved with antibiotics. . you had respiratory distress and had to go to the intensive care unit, where your breathing improved with medications to help remove fluid from your body. you later developed gastrointestinal bleeding and you had an upper endoscopy as well as a colonoscopy. your bleeding stopped, and your blood count was subsequently stable. please complete a 14-day course of antibiotics to end on . . we made the following changes to your medicines: - started ampicillin to treat your blood infection. please continue to take this through the evening of , to complete a fourteen day course - started furosemide 20 mg tabs, one tab by mouth once daily, to prevent excess fluid from accumulating in your body - started lidocaine 5% patches, applied once daily to area of rib pain - started lorazepam 0.5 mg tabs, one tab every eight hours as needed for anxiety - started docusate 100 mg tabs, one tab twice daily for softening your stools - started senna 8.6 mg tabs, one tab twice daily as needed for constipation - increased diltiazem to 30 mg tabs, two tabs by mouth every six hours - discontinued citalopram, as it may have been exacerbating your tremor - discontinued chlorthalidone - we had held your aspirin and warfarin (coumadin) after your bleed, but we have restarted both of these medications today, since your bleeding has stopped. . please call your doctor or return to the emergency room if you experience any fevers, worsening shortness of breath or chest pain, or other new concerning symptoms. please weigh yourself every day, and if you gain more than three lbs, call your doctor to discuss taking higher doses of diuretics. followup instructions: you are not currently assigned to a primary care physician. will be called within the next week with a new pcp . if you do not hear by next friday, please call at to establish primary care. your currently scheduled appointments are as follows: department: div. of gastroenterology when: wednesday at 3:00 pm with: , md building: ra (/ complex) campus: east best parking: main garage . department: hematology/oncology when: thursday at 2:30 pm with: , md building: sc clinical ctr campus: east best parking: garage . department: vascular surgery when: monday at 10:30 am with: vascular lab building: lm campus: west best parking: garage . department: vascular surgery when: monday at 11:10 am with: , md building: lm campus: west best parking: garage md Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Diagnostic ultrasound of heart Percutaneous abdominal drainage Closed [endoscopic] biopsy of large intestine Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Tobacco use disorder Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Atrial fibrillation Other chronic pulmonary heart diseases Depressive disorder, not elsewhere classified Sepsis Other and unspecified hyperlipidemia Other emphysema Long-term (current) use of anticoagulants Other diseases of lung, not elsewhere classified Other ascites Diarrhea Abdominal aneurysm without mention of rupture Hemorrhage of gastrointestinal tract, unspecified Antidepressants causing adverse effects in therapeutic use Streptococcal septicemia Other disorders of neurohypophysis Chronic lymphoid leukemia, without mention of having achieved remission Acute on chronic combined systolic and diastolic heart failure Essential and other specified forms of tremor Chronic pulmonary embolism

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever, hypotension major surgical or invasive procedure: transthoracic echocardiogram history of present illness: hpi: mr. is a 68 yom with copd (on 2-4l o2 baseline), cll, hypertension, pe (on coumadin c/b recent gi bleed requiring 4 units prbcs), chronic systolic heart failure (ef 35%), atrial fibrillation, and recent admission for enterococcus faecalis bacteremia treated with ampicillin, who was admitted from rehab facility on for hypotension, lethargy, and fever. . of note, e. faecalis during prior admission was treated with ampicillin. antibiotics were completed , however his picc was retained. he then had chills and night sweats during night for 3 days preceding admission. during this time he became febrile to 102 on , and picc was removed . blood culture drawn on at rehab reportedly grew gpc in chains. cxr, ua were reportedly negative. on the patient was noted to have sbp in the mid-80s (baseline 110-130s) with tachypnea and increased oxygen requirement (baseline 88-90% on nc 3-5l). vancomycin was considered but not given due to no iv access. he was transferred to . . in the ed, sbp 94, rr 26, hr 120s (irregularly irregular). blood, urine cultures sent. he received unasyn, levofloxacin, and ns 800cc. on arrival to floor from ed he was hypoxic with oxygen saturation in upper 70s and was found to have atrial fibrillation with rvr (rate 120-130s), tachypnea, and increasd crackles. oxygen was increased to 6l by nasal cannula with rapid improvement of oxygen saturation to 95%. abg 7.50 // 30 // 58. he was transferred to the micu. past medical history: - chronic lymphoid leukemia - copd (fvc 79% pred, fev1 71% pred, fev1/fvc 90% pred ) - -ventricular systolic failure, ef 45%; dilated rv with signs of overload - pulmonary hypertension - depression - hypertension - hyperlipidemia - peptic ulcer disease - right eye cataract (s/p removal at the age of 12. he had an injury to his eye and has no vision in that eye for years) - deviated nasal septum, s/p nasal septal surgery - cervical arthritis - history of colon polyps (? adenoma) - history of herniated disks - chronic back pain - pulmonary nodules - pulmonary embolism s/p intubation, complicated by vap - enterococcus faecalis bacteremia social history: married. most recently at nursing home; was previously at home. he smoked 1ppd >50 years, and quit within the past one month. he denies alcohol or illicit drug use. family history: mother died at age 85, complications of alzheimer's disease. father died at age 74, complications of congestive heart failure. he reports no history of colon cancer, polyps or coronary disease in his family. a brother developed disease. physical exam: 98.2, 125, 123/69, 22, 100% 6l nc gen: comfortable, mildy tachypneic heent: right surgical pupil; left pupil reactive to light; moist mucous membranes neck: jvp elevated approximately 12cm cv: irregularly irregular; tachycardic; normal s1/s2; no murmurs appreciated pulmonary: bibasilar crackles abdomen: hypoactive bowel sounds; soft, nontender, not distended ext: 1+ edema at ankles, trace to knees bilaterally; radial, dp pulses 2+ except left dp 1+ neuro: left eomi; left pupil reactive to light; cn ii-xii other than above intact psych: aox3; answers questions appropriately pertinent results: admission labs: 03:30pm wbc-13.6* rbc-3.97* hgb-11.1* hct-34.8* mcv-88 plt ct-293 03:30pm neuts-35* bands-0 lymphs-49* monos-8 eos-0 baso-0 atyps-8* metas-0 myelos-0 03:30pm hypochr-1+ anisocy-1+ poiklo-1+ macrocy-normal microcy-1+ polychr-1+ schisto-1+ burr-1+ 03:30pm pt-20.2* ptt-32.8 inr(pt)-1.9* 03:30pm glucose-95 urean-16 creat-1.0 na-137 k-4.3 cl-100 hco3-28 angap-13 03:30pm alt-19 ast-29 ck(cpk)-30* alkphos-64 totbili-0.6 03:30pm ck-mb-notdone ctropnt-0.03* probnp-* 03:30pm albumin-3.6 08:07pm type-art po2-58* pco2-30* ph-7.50* caltco2-24 base xs-0 04:07pm lactate-2.3* other pertinent labs: blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient discharge labs: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:31 15.9* 3.31* 8.6* 28.5* 86 25.9* 30.1* 18.7* 226 basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 06:31 21.1* 2.0* renal & glucose glucose urean creat na k cl hco3 angap 06:31 861 16 0.9 138 4.3 103 27 12 chemistry totprot albumin globuln calcium phos mg uricacd iron cholest 06:31 8.2* 3.0 1.9 micro: 3:40 pm blood culture enterococcus faecalis. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | enterococcus faecalis | | ampicillin------------ 0.5 s <=2 s daptomycin------------ s s linezolid------------- 2 s 2 s penicillin g---------- 2 s 4 s tetracycline---------- =>16 r vancomycin------------ 1 s 1 s blood culture, routine (preliminary): gram positive coccus(cocci). in pairs and chains. urine: 03:40pm color-yellow appear-clear sp -1.015 03:40pm blood-neg nitrite-neg protein-25 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-tr 03:40pm rbc-0-2 wbc- bacteri-none yeast-few epi-0-2 legionella: negative urine culture (final ): mixed bacterial flora sputum: sputumcx: gpr, budding yeast sputumcx: sparse growth commensal respiratory flora. chest x ray impression: left inferior hemithorax is excluded from the field of view. no interval change from prior with continued bilateral small pleural effusions and bibasilar airspace opacities, which may reflect infection or atelectasis. trans thoracic echo the left atrium is mildly dilated. the right atrium is moderately dilated. left ventricular wall thicknesses and cavity size are normal. there is moderate global left ventricular hypokinesis (lvef = 35%). there is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. there is moderate/severe mitral valve prolapse. an eccentric, posteriorly-directed jet of moderate to severe (3+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a small pericardial effusion. impression: mitral valve prolapse with moderate to severe regurgitation. moderate global biventricular systolic dysfunction. compared with the prior study (images reviewed) of , the findings are similar, although no distinct aortic valve mass is identified on today's study. overall lv function appears similar and was probably slightly overestimated on the prior study. lower extremity ultrasound impression: no evidence of dvt in bilateral lower extremities. trans esophageal echocardiogram 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. a very small patent foramen ovale is present. there is mild global left ventricular hypokinesis (lvef = 40-45 %). the right ventricular cavity is dilated with depressed free wall contractility. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. there are complex (>4mm), non-mobile atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are myxomatous with mild mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild to moderate (+) mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is a very small pericardial effusion. impression: no evidence of valvular vegetation, mass or abscess. biventricular systolic dysfunction. mild to moderate mitral regurgitation. compared with the findings of the prior study (images reviewed) of , the severity of mitral regurgitation is reduced. abdominal ultrasound: the liver is normal in size and echotexture. there is no focal or infiltrative liver lesion. the common bile duct is not dilated and measures 0.3 cm. there is no intra- or extra-hepatic biliary dilatation. the pancreas is unremarkable. the spleen is normal in appearance and mildly enlarged measuring 13.4 cm, previously measured 12.4 cm. the gallbladder is normal in appearance without stones. the main portal vein is patent with normal hepatopetal flow. there is diffuse calcified atherosclerosis throughout the abdominal aorta without aneurysm formation or significant stenosis noted. small bilateral pleural effusion is unchanged. impression: 1. no evidence of intra- or extra-hepatic biliary dilatation. 2. mild splenomegaly. 3. small bilateral pleural effusion. mr of the abdomen with iv gadolinium (mr enterography): t2-weighted dynamic images demonstrate normal peristalsis of the stomach and small bowel. the intra-abdominal portion of large and small bowel is unremarkable without inflammatory change, wall thickening, dilatation, stricture or mass lesion. there is a very small amount of free fluid layering along the margin of the liver. no significant abnormality detected of the solid abdominal organs. as demonstrated on the recent ct angiogram of the abdomen and pelvis is diffuse atherosclerotic plaque throughout the abdominal aorta. fusiform dilatation of the infrarenal abdominal aorta to 2.6 cm. the right common iliac artery is aneurysmally dilated to 1.6 cm. these findings are stable over the short interval compared to the recent ct angiogram of the abdomen and pelvis. mr of the pelvis with iv gadolinium (mr enterography): the pelvic portions of large and small bowel including terminal ileum and rectosigmoid are unremarkable without evidence of inflammatory change, wall thickening, stricture or mass lesion. stool is distributed throughout the colon and rectum. there is no free pelvic fluid. the bladder, prostate, seminal vesicles are unremarkable. multiplanar 2d and 3d reformations and subtraction images generated on an independent workstation were valuable in assessment for source of infection or bleeding. impression: 1. no source for gastrointestinal bleeding or nidus of infection identified. 2. atherosclerotic disease including infrarenal abdominal aortic aneurysm and right common iliac artery aneurysm not changed over the short interval compared to cta abdomen and pelvis . ct chest: there is stable severe emphysema with bullous change at the lung apices as well as the right lung base. there has been interval increase in the bilateral pleural effusions. there is some loculated fluid within the fissure on the left. there is also a new right lower lobe pulmonary nodule (series 2, 45) measuring roughly 7 mm. this is in the area of some scarring. no other pulmonary nodules are seen. there is atherosclerotic calcification of the aorta and coronary arteries. there is cardiomegaly with marked enlargement of the right atrium. there is dilation of the ivc and hepatic veins which can be seen in right-sided heart failure. note is made of a small amount of mucus within the left main stem bronchus. there is a pectus deformity. otherwise the osseous structures are unremarkable. impression: 1. interval increased bilateral pleural effusions. 2. stable severe emphysema. 3. new 7-mm right lower lobe pulmonary nodule. four month followup chest ct recommended. 4. cardiomegaly with enlarged right atrium and dilated ivc and hepatic veins, which can be seen in right-sided heart failure. brief hospital course: #. respiratory distress: the patient was admitted and transferred to the medicine floor. upon arrival he developed respiratory distress in the setting of atrial fibrillation with rvr and ivf administration in the ed, likely causing fluid overload in a patient with tenuous respiratory status at baseline, h/o copd and on home o2, with recent pe. the patient had an echo, which showed an ef of 35%. he was diuresed with iv lasix and showed improvement, o2 requirement decreased from 6lnc to 4lnc. rate control was obtained with digoxin (pt was loaded), diltiazem, and metoprolol. diltiazem was subsequently stopped. chest x ray showed bibasilar opacities and air-space opacities consistent with atelectasis vs pneumonia. he had a sputum which only showed mixed respiratory flora. lenis were obtained and were negative for dvt. the patient was subtherapeutic on his coumadin so a heparin bridge was briefly initiated until he became therapeutic. cardiac enzymes were also obtained and were negative x3 sets. once the patient stabilized he was transferred back to the medicine floor where he continued to require 2 to 4 l of oxygen. as he was not on oxygen prior to , it was thought that he was in acute heart failure with poor baseline reserve from his copd, so he was aggressively diuresed with lasix. he remained 2 l negative per day for 5 days with only mild improvement in his oxygen requirement (low 80s on ra - 94% 4l). chest ct was obtained and showed bilateral pleural effusions, stable severe emphasema, cardiomegally, and a new 7 mm right lower lobe pulmonary nodule. it was thought that his continued hypoxia was from acute chf with a component of recent pulmonary events. he was discharged on lasix 40 mg po daily, spironolactone 12.5 mg daily and home o2. #. enterococcus bacteremia: the patient presented from rehab with fevers. he had a positive blood culture at the rehab center and had his picc line removed (per report the tip was cultured and showed no growth). his first set of blood cultures obtained at was positive for enterococcus, pan-sensitive. because he had a recent positive vre swab, he was empirically treated with linezolid, but this was then changed to ampicillin after cultures showed it was sensitive. surveillance cultures remained negative until when they showed one culture positive for gram positive cocci. a transthoracic and trans esophageal echocardiogram were performed and showed no vegetations. the source of the patient's recurrent enterococcus bacteremia was further investigated, and gi was consulted to determine if he was seeding his blood from a source in the gut. because he had recently had a colonoscopy that was negative for a source (colon cancer), an mr enterography was performed to investigate the small bowel. this study was also unrevealing for a source of his bacteremia. the patient will need to continue ampicillin for a total of four week course to end on he will follow up with id on . his picc line was not centrally located at discharge but after discussion with pharmacy and nursing it was concluded it could be still be used as a midline for ampicillin administration. #. atrial fibrillation: the patient presented with atrial fibrillation with rapid ventricular rate. in the icu he was loaded with digoxin and started on diltiazem in addition to his metoprolol. he was rate controlled on this regimen with rates in the 80s-90s. eventually the diltiazem was discontinued and he remained well controlled. coumadin was continued and he was found to have a subtheraputic inr during which time he was bridged with heparin. his inr later became therapeutic and heparin was stopped. he should continue on the metoprolol, digoxin, and coumadin. #. hypertension: the patient was started on dogoxin, and diltiazem in addition to his home dose metoprolol as above for rate control. his blood pressure remained in the sbp 100s-120s on this regimen. he was also started on lasix for his chf. his diltiazem was discontinued and he was aggressively diuresed as his blood pressure could tolerate. he was not started on an ace inhibitor depite his low ejection fraction because he was heavily diuresed with lasix and his sbp remained 90's-110's after he was re-started on his po lasix dose. he should continue to take 40 mg po of lasix daily. he should discuss with his pcp the need to start an ace inhibitor due to his low ejection fraction. #. acute systolic chf: the patient had an echo with ef 35%, similar to prior a study on . it was thought that in the setting of sepsis and iv fluid administration as well as a fib with rvr, the patient had decompensation of his chf. he diuresed well to lasix 20mg iv, and was negative 1 to 2 liters a day during the course of his admission. his respiratory status improved, however he still required supplemental oxygen at discharge. he will need to continue his lasix and metoprolol. he was started on spironolactone 12.5 mg daily for mortality benefit and on simvastatin 20 mg daily. as above, he should eventually start an ace inhibitor if his blood pressure can tolerate it. he was given an appointment with dr. from cardiology for outpatient follow up. # urinary retention: the patient had a foley placed in the icu when he was being resuscitated. after the foley was removed he failed his voiding trial. he was started on finasteride and tamsulosin and his urinary retention improved. he will need to follow up with urology. he has an appointment on . # cll: the patient has known cll. his wbc count was elevated between 13 and 19, which was lower than baseline. there was no evidence of transformation. he can continue his regular follow up with oncology as an outpatient . # pulmonary nodule: seen on ct scan of the chest. the patient should have a follow up ct scan in four months. medications on admission: 5% lidocaine patch to r ribs 6a-6p daily aspirin 81 mg daily oxycodone 5 mg po q6h prn pain diltiazem 60 mg po qid kcl 20 meq po daily multivitamin daily spiriva 18 mcg inh lopressor 100 mg po bid pulmicort 90 mcg 2 puffs levalbuterol 0.63/3 ml q6h senna lasix 40 mg po qam ativan 0.5 mg po qhs remeron 7.5 mg po qhs unclear dosing, ?4 mg daily, scheduled for 3 mg po the night of admit which he did not receive. discharge medications: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): to area of pain. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 4. multivitamin capsule sig: one (1) capsule po once a day. 5. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 7. spironolactone 25 mg tablet sig: 0.5 tablet po daily (daily). 8. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 9. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 10. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 11. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 13. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 14. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). 15. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 16. budesonide-formoterol 80-4.5 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation twice a day. 17. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation twice a day. 18. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: three (3) ml inhalation every 4-6 hours as needed for shortness of breath. 19. ampicillin sodium 2 gram recon soln sig: one (1) recon soln injection q4h (every 4 hours) for 18 days. 20. oxygen please provide oxygen supplementation 3-4 l by nasal canula discharge disposition: extended care facility: nursing home - discharge diagnosis: primary: enterococcus bacteremia acute systolic chf copd atrial fibrilation urinary retention secondary diagnosis: chronic lymphocytic leukemia hypertension 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 came to the hospital because you were having fevers at your rehab center. you were found to have a blood infection with a bacteria called enterococcus. you were started on antibiotics for this infection. you had tests which showed that it was not coming from your heart. you also had an mri which showed that there is no evidence of cancer in your gut that could have caused this. you will need to continue to take antibiotics by iv until . you will need to follow up as an outpatient with the id doctors (see below). you also developed an episode of shortness of breath while you were in the hospital and had to be transferred to the icu. it was thought that your fast heart rate and chf caused you to be short of breath. you were given medicines to take fluid off and your breathing was better - although not back to your baseline from . it was thought that your chf and copd were contributing to your chronic shortness of breath. you will need to continue to take lasix to prevent fluid from building up in your lungs and causing you to be short of breath. you also developed some urinary retention. we have made an appointment for you with the urologist as an outpatient if your symptoms persist. please note the following changes to your medications: start: ampicillin 2 g iv every 4 hours until start: spironolactone 12.5 mg daily start: digoxin 0.125 mg daily start: finasteride 5 mg daily start: tamsulosin 0.4 mg daily start: metoprolol succinate 100 mg daily start: simvastain 20 mg daily start: symbicort 2 puffs twice a day stop: metorpolol tartrate (lopressor) stop: diltiazem stop: budesonide stop: kcl please go to your follow up appointments (see below) it was a pleasure taking part in your care, mr. . followup instructions: department: infectious disease when: thursday at 1:30 pm with: , m.d. building: lm campus: west best parking: garage department: pulmonary function lab when: thursday at 2:10 pm with: pulmonary function lab building: campus: east best parking: garage department: pft when: thursday at 2:30 pm department: surgical specialties when: wednesday at 9:30 am with: urology unit building: sc clinical ctr campus: east best parking: garage department: cardiac services when: monday at 11:00 am with: dr. building: sc clinical ctr campus: east best parking: garage Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Other chronic pulmonary heart diseases Depressive disorder, not elsewhere classified Sepsis Other and unspecified hyperlipidemia Other emphysema Long-term (current) use of anticoagulants Retention of urine, unspecified Personal history of venous thrombosis and embolism Hypoxemia Streptococcal septicemia Acute on chronic systolic heart failure Chronic lymphoid leukemia, without mention of having achieved remission

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: endotracheal intubation history of present illness: 68 yo m with a past medical history of cll, copd, htn presents with dyspnea over the last 4 months. patient was having workup done as an outpatient over last several months, which has included serial ct chest without contrast for pulmonary nodules, the most recent of which was on which demonstrated new peripheral lung nodules and question of rul mass which could be soft tissue scarring or malignancy. today patient had tte done which showed multiple abnormaliries, including right ventricular dilation and free wall hypokinesis. he was also noted to be tachycardic during echo. patient was advised by outpatient providers to come to ed. in terms of symptoms, patient reports that symptoms of dyspnea started 4 months ago, when he noticed feeling more short of breath while shoveling snow. she had occasionaly productive cough with white sputum but no hemoptysis. he reported to the ed that he had cp, but he denies cp to me. in the past, he could walk without difficutly and now he feels short of breath traveling less than 500 feet. today he was with his wife who was taking a mental health examination, and reportedly rushing more than usual, and this caused him to have more dyspnea than usual. he was experiencing this dyspnea while undergoing tte. cough is worse at night, and he has noticed some orthopnea recently, but denies pnd. in the ed, ekg was consistent with mfat and demonstrated twf inferiorly and anterior q waves with no comparisons. troponin was 0.02. ct head was negative. ct chest showed acute on chronic bilateral pe. patient was guaiac negative and heparin drip was started. oxygen was accidentally disconnected from the patient, and he desaturated to 77% and was visibily cyanotic. he came up to the 80s with 6l nc, and improved to 93% with nrb. patient becomes dyspnic with movement, but is comfortable while lying in bed. patient was additionally given protonix 40 mg ivx1, lopressor 5mg ivx1, 1.2 l ns, and fs asa. code status was discussed and per report full. on transver, vs were afebrile, 101, 138/89, 33, 99-100 nrb. in the icu, denies sob while at rest and feels better than when he presented to the ed. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies 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: 1. chronic lymphoid leukemia (cll). 2. chronic obstructive pulmonary disease (copd). 3. depression. 4. hypertension. 5. peptic ulcer disease. 6. right eye cataract (s/p removal at the age of 12. he had an injury to his eye and has no vision in that eye for years) 7. deviated nasal septum. 8. cervical arthritis. 9. history of colon polyps (? adenoma). 10. status post nasal septal surgery. 11. history of herniated disks. 12. depression? 13. benign prostatic hypertrophy? 14. pulmonary abnormalities with ct scan on showing no hilar or mediastinal lymphadenopathy, severe bullous, centrilobular and paraseptal emphysema, and multiple calcified and non-calcified lung nodules. 15. hyperlipidemia social history: he is married and lives with his wife in . she has significant emotional problems, which requires the patient to care for her almost constantly. he continues to smoke 1 pack a day, which he has done for at least 50 years and he is not interested at this time in quitting. he denies ethanol and illicit drug use. family history: mother died at age 85, complications of alzheimer's disease. father died at age 74, complications of congestive heart failure. he reports no history of colon cancer, polyps or coronary disease in his family. a brother developed disease. physical exam: (per admitting resident) vitals: t: 97.8 bp: 132/94 p: 96 r: 21 18 o2: 98% nrb 15 l general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, right eye blind and opacified over, left eye pupils reactive neck: supple, not elevated, no lad lungs: crackles left base cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: 1+ bilateral pitting edema bilaterally to knees, warm, well perfused, 2+ pulses, no clubbing, cyanosis. pertinent results: labs on admission: 06:15pm blood wbc-26.1* rbc-4.77 hgb-14.2 hct-44.1 mcv-93 mch-29.7 mchc-32.1 rdw-14.0 plt ct-139* 06:15pm blood neuts-13* bands-0 lymphs-84* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-0 06:15pm blood hypochr-3+ anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-normal 06:15pm blood pt-13.6* ptt-27.5 inr(pt)-1.2* 06:15pm blood plt smr-low plt ct-139* 06:15pm blood glucose-99 urean-23* creat-1.4* na-139 k-3.7 cl-103 hco3-26 angap-14 06:15pm blood alt-16 ast-22 ck(cpk)-134 alkphos-63 totbili-0.6 06:15pm blood ck-mb-4 probnp-* 06:15pm blood ctropnt-0.02* 06:15pm blood calcium-9.1 phos-3.4 mg-1.7 labs at discharge: 05:25am blood wbc-42.5* rbc-4.60 hgb-13.6* hct-42.3 mcv-92 mch-29.5 mchc-32.0 rdw-14.6 plt ct-156 05:25am blood pt-21.0* ptt-32.1 inr(pt)-1.9* 05:25am blood glucose-86 urean-24* creat-0.8 na-134 k-4.1 cl-96 hco3-33* angap-9 06:05am blood alt-256* ast-47* ld(ldh)-260* alkphos-71 totbili-1.3 05:25am blood calcium-8.8 phos-3.4 mg-1.8 ===================================== imaging: cta chest () - impression: 1. pulmonary embolism involving the basal segments of the left lower lobe. partially occlusive thrombus in the pulmonary arterial branches supplying the basal segments of the right lower lobe, possibly chronic given their eccentric appearance. 2. severe bullous emphysema with nodule in the right lung apex for which short interval followup is advised. 3. bilateral hilar lymphadenopathy may be related to patient's known cll. 4. cardiomegaly. 5. left adrenal nodularity, incompletely imaged though grossly stable from 08 exam. recommend ct or mri to further evaluate as needed. cta chest () - impression: 1. interval resolution of left basilar pulmonary emboli and interval improvement in eccentric clot at the right base. no new pulmonary emboli. 2. new bilateral pleural effusions, moderate on the right and trace on the left. small pericardial effusion, increased from the prior exam and small perihepatic ascites, also slightly increased from the prior exam. 3. severe emphysema with right apical nodule. again short-term followup is recommended as this has progressed from the study. ct head () - impression: no parenchymal edema. mri is more sensitive for detection of intracranial mass lesions. cxr ( - findings: as compared to the previous radiograph, the lung volumes have slightly decreased. newly appeared retrocardiac opacity with blunting of the costophrenic sinus. the changes are consequent of the left lower lobe pulmonary embolism documented on a ct from . the left upper lobe bulla is unchanged in extent. unchanged radiographic manifestations of extensive pulmonary emphysema. cxr () - findings: cardiomediastinal contours are unchanged. emphysema is again demonstrated with superimposed areas of opacity at both lung bases which was slightly improved compared to the recent study. small pleural effusion on the left also appears slightly better, and a small right effusion is unchanged. within the periphery of the left upper lobe, there is an apparently new focal area of opacity, possibly due to superimposition of structures at the level of the third anterior rib, but attention to this area on followup films is suggested to exclude a developing pneumonia. cxr () - findings: new endotracheal tube terminates 6.5 cm above the carina. otherwise, no relevant changes since recent study of less than one hour earlier. cxr pa and lat () - impression: slightly increased effusions. continued volume overload. brief hospital course: 68m with a past medical history of cll, copd, htn presents with dyspnea over the last 4 months and found to have bilateral pe. # pulmonary embolism: likely acute on chronic pe in the setting of cll. tte with signs of mild right heart strain. hemodynamically stable so not considered candidate for tpa or thrombectomy. started on heparin drip and bridged to coumadin. coumadin held briefly for supratherapeutic levels but then restarted. after transfer back to the icu and intubation (see below), pt did have significantly elevated inr, requiring vitamin k. inr responded appropriately. however, on the day of discharge, the patient was noted to have a drop in his inr such that it was no longer therapeutic. he was discharged on a lovenox bridge while his coumadin dose was adjusted to get him to his goal inr range of . at time of discharge, pt was breathing comfortably but still had an oxygen requirement of 2l. # respiratory distress: pt was initially called out to the medicine service on . however, on the following morning, he was noted to have worsening respiratory distress and was transferred back to the icu service. he ultimately required intubation for 2 days. it was felt that his respiratory distress was related to a combination of copd exacerbation as well as pneumonia. he was maintained on prednisone and nebs for his copd. he was started vancomycin/cefepime for his suspected pneumonia. he is being discharged on a prednisone taper. he is also being discharged to compete a 14-day course of vancomycin/cefepime. # copd exacerbation: patient became increasingly wheezy on exam during the first 1-2 days of this hospitalization and was started on treatment for a copd exacerbation. treated with azithromycin, a 3-day course of solumedrol followed by a prednisone taper, fluticasone, xopinex and ipratropium nebulizers. a humalog iss and ppi were started while he was on steroids. as above, he had worsening respiratory distress after his inital call-out to the floor, requiring transfer back to the icu and intubation x 2 days. it was felt that copd exacerbation was a likely component of his respiratory distress, so he was kept on his oral steroids. he was placed on a prednisone taper at discharge. # pneumonia: at the time of patient's decompensation and intubation (see above), it was felt that there could be a component of pneumonia contributing. cxr showed ?retrocardiac opacity. he was started on vanc/cefepime. being discharge to complete a 14-day course of vanc/cefepime. # radiologic findings: cta performed on admission showed a right apical nodular focus and recommended short interval followup. cta also showed left adrenal nodularity with ct or mri follow-up recommended. these findings should be followed up by the patient's pcp. # chf: tte with ef 40% and right heart strain. patient endorses symptoms of orthopnea, but may be related to acute pe. bnp elevated but no prior levels for comparison. minimal edema on exam and no elevation however cxr appearing more fluid overloaded than prior. responded well to 10mg iv lasix. restarted chlorthalidone and restarted beta-blocker, which was uptitrated for rate control (see below). patient was continued on chlorthalidone. respiratory status stable at the time of discharge, with patient still requiring 2l o2. # atrial fibrilation: patient had intermittent irregular tachycardias that on repeat ekgs were felt to be most likely atrial fibrillation (although at some points felt to be multifocal atrial tachycardia). initially started on diltiazem without significant improvement. had 12 beat run of v-tach on after which he was transitioned back to a beta-blocker. his home atenolol (prescribed for htn) was changed to metoprolol for the purpose of titrating. this was up-titrated for better rate control. diltiazem was also added back prior to d/c for better rate control. he was also placed on coumadin/lovenox as above for anticoagulation. # acute renal failure: originally presented with cr 1.3 vs baseline 1.0 likely pre-renal poor po intake, resumed to baseline with fluids. elevated again briefly in setting of lasix then again resolved. # troponin leak: mild troponin leak to 0.02 on admission likely due to right heart strain from underlying pe. ekg had some twis but no baseline ekg to compare. enzymes remained flat. # chest pain: brief episode, several days after admission, complained of some chest discomfort while eating, resolved within minutes. substernal, nonradiating. ekg showed some lateral t wave flattening felt most likely lead placement. cardiac enzymes flat. no further episodes of chest pain. # leukocytosis: cll with baseline wbc 25-30. when he decompensated and was intubated, he did have some fevers and more elevated wbc. thought to be possible pna. still had some leukocytosis above baseline later in his hospital course but was afebrile. leukocytosis had stabilized by the time of discharge. difficult to interpret this in the setting of his cll. pt will f/u with his outpatient hematologist. # hypertension: well-controlled, home atenolol changed to metoprolol as above. diltiazem also added as above. medications on admission: # albuterol sulfate - 90 mcg hfa aerosol q4-6h # atenolol-chlorthalidone - 50 mg-25 mg tablet daily # spiriva 18 mcg capsule inh daily # pulmicort unknown dose # acetaminophen discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) capsule inhalation once a day. 3. chlorthalidone 25 mg tablet sig: one (1) tablet po once a day. 4. prednisone 10 mg tablet sig: 1-2 tablets po as directed: take 2 tablets (20 mg) for one day, then take 1 tablet (10 mg daily) for three days, then stop taking. . 5. coumadin 1 mg tablet sig: four (4) tablet po once a day: inr needs to be checked every three days. coumadin dose should be adjusted accordingly with a goal inr of . 6. pulmicort flexhaler 90 mcg/inhalation aerosol powdr breath activated sig: two (2) puffs inhalation twice a day. 7. metoprolol tartrate 100 mg tablet sig: one (1) tablet po three times a day. 8. aspirin 81 mg tablet sig: one (1) tablet po once a day. 9. cefepime 2 gram recon soln sig: two (2) grams intravenous every twelve (12) hours for 6 days: to complete an 14 day course, ending on . 10. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) gram intravenous every twenty-four(24) hours for 6 days: to complete an 14 day course, ending on . 11. diltiazem hcl 30 mg tablet sig: one (1) tablet po every six (6) hours: hold for sbp<100 or hr<60. 12. enoxaparin 80 mg/0.8 ml syringe sig: seventy (70) mg subcutaneous q12h (every 12 hours): inr should be checked every three days and coumadin dose should be adjusted to keep pt in goal inr range of . once at goal inr, pt's lovenox can be discontinued. 13. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 14. outpatient lab work the patient should have his inr measured every 3 days. his goal inr is . his coumadin level should be adjusted by the md's at his rehab facility to keep him at his goal inr level. once he has reached his goal inr level, his lovenox can be discontinued. discharge disposition: extended care facility: nursing home - discharge diagnosis: primary diagnosis - pulmonary embolism - acute exacerbation of chronic obstructive pulmonary disease - hospital-acquired pneumonia secondary diagnosis - atrial fibrillation discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - requires assistance or aid (walker or cane) on 2 l of oxygen discharge instructions: you presented to the emergency department after you had an echocardiogram with some abnormal findings. you were found to have a blood clot in your lungs, which was treated with blood thinners. your hospital course was complicated by worsening breathing, secondary to your copd and a pneumonia, which required a breathing tube for a short period of time. your breathing improved, and you are now being discharged to a rehabilitation facility. changes to your medication: - continue your albuterol (proair), spiriva, and pulmicort - stop atenolol-chlorthalidone - start chlorthalidone 25 mg daily - start prednisone taper as directed - start coumadin 4 mg daily. you will have your inr monitored and your coumadin level adjusted to keep you at your goal inr of . - start lovenox 70 mg twice a day while your inr is below your goal range of - start metoprolol tartrate 100 mg every 8 hours - start diltiazem 30 mg every 6 hours - start aspirin 81 mg daily - start cefepime/vancomycin for 6 more days, to complete an 14-day course ending on - we are also starting you on nystatin to help with your mouth pain as above, your rehab facility should monitor your inr level and adjust your coumadin dose to keep you at your goal inr of . because your inr was below your goal of 2 on your day of discharge, you are being discharged on lovenox until your inr is within your goal range. it was a pleasure taking part in your medical care. followup instructions: you need to follow-up with your pcp, . , within 1 week after you are discharged home. you can call his office at to arrange an appointment. you also have the following follow-up appointments: department: pulmonary function lab when: thursday at 2:10 pm with: pulmonary function lab building: campus: east best parking: garage department: pft when: thursday at 2:30 pm department: medical specialties when: thursday at 2:30 pm with: dr. /dr. building: campus: east best parking: garage department: hematology/oncology when: tuesday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Insertion of endotracheal tube Diagnoses: Pneumonia, organism unspecified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Depressive disorder, not elsewhere classified Candidiasis of mouth Paroxysmal ventricular tachycardia Acute respiratory failure Other diseases of lung, not elsewhere classified Acute systolic heart failure Other pulmonary embolism and infarction Chronic lymphoid leukemia, without mention of having achieved remission Chronic pulmonary embolism

allergies: sulfa(sulfonamide antibiotics) attending: chief complaint: pancreatic mass major surgical or invasive procedure: : 1. pylorus-preserving pancreaticoduodenectomy 2. harvest of left internal jugular vein and portal vein excision with reconstruction history of present illness: the patient is a very pleasant 77-year-old who had presented in with acute pancreatitis. on imaging studies, he was noted to have a mass in the head of the pancreas. he subsequently underwent endoscopic ultrasound with fine-needle aspiration. cytology on these aspirates was nondiagnostic. he subsequently developed obstructive jaundice and on , he was noted to have a biliary stricture. a biliary stent was placed. he underwent a laparoscopic cholecystectomy with a presumed diagnosis of gallstone pancreatitis. the subsequent ct scan images showed complete resolution of pancreas mass. however, repeat showed persistence of biliary stricture. brushings of the biliary stricture are suspicious for adenocarcinoma. the patient is well known for dr. and she was followed the patient along. the patient also had cholecystectomy done with dr. in the past. dr. evaluated the patient for possible whipple procedure secondary to highly suspicious brushing results. during the evaluation all risks, goals and benefits were discussed with the patient and his family, and patient was scheduled for elective whipple on . past medical history: pmh: htn, vertigo episodes x2, giant cell arteritis , cad psh: lap ccy social history: he has an 18-pack-year history of tobacco, but quit 13 years ago. he drinks alcohol only occasionally. there are no environmental exposures. family history: mr. reports a family history of pancreatic cancer. his sister died of it at age . there is no other history of pancreatic disease or gi malignancy. physical exam: on discharge: vs: 98.6, 70, 138/69, 12, 95% ra gen: pleasan with nad neck: left longitudinal incision open to air with steri strips and c/d/i cv: rrr resp: ctab abd: bilateral subcostal incision open to air with staples, minimal erythema on middle portion of incision. rlq jp drains x 2 to bulb suction, site c/d/i and covered with drain dressing. extr: warm, no c/c/e pertinent results: 06:20am blood wbc-6.5 rbc-3.38* hgb-10.7* hct-33.0* mcv-98 mch-31.5 mchc-32.3 rdw-14.1 plt ct-205# 06:20am blood glucose-117* urean-10 creat-0.7 na-139 k-4.0 cl-105 hco3-29 angap-9 06:20am blood alt-81* ast-82* alkphos-91 totbili-2.7* 06:20am blood calcium-7.8* phos-3.8 mg-1.9 09:55am ascites amylase-10 09:55am ascites amylase-12 10:16am ascites totbili-7.7 albumin-less than liver doppler: impression: 1. patent main and right portal veins. flow within the left portal vein could not be detected. this could be due to technical factors or slow flow, however a thrombosed lpv cannot be excluded. 2. pneumobilia 3. right pleural effusion. abd ct: impression: 1. patent main, left and right portal veins; however, some non-critical narrowing of the presumed graft. 2. small non-hemorrhagic pleural effusions with adjacent compressive atelectasis. 3. generalized anasarca. brief hospital course: the patient was admitted to the general surgical service on for elective whipple procedure. on same day, the patient underwent pylorus-preserving pancreaticoduodenectomy (whipple) and portal vein excision with reconstruction, which went well without complication. the patient was transferred in icu after operation for observation. on pod # 1, patient was extubated and was transferred on the floor npo with an ng tube, on iv fluids, with a foley catheter and a jp x 2 drain in place, and epidural catheter for pain control. the patient was hemodynamically stable. neuro: the patient received fentanyl/bupivacaine via epidural catheter with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications. cv: the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. metoprolol was restarted on pod # 1. on pod # 2, patient was started on aspirin 325 mg daily per vascular surgery, he was discharge home on this medication as well. pulmonary: the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. gi: post-operatively, the patient was made npo with iv fluids. diet was advanced when appropriate, which was well tolerated. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and repleted when necessary. the patient had two jp drains placed intraoperatively. on pod # 4, one jp output increased up to 1 l and patient underwent liver doppler to rule out portal vein obstruction. the doppler revealed patent main and right portal veins, but left portal vein was doppler was limited. the patient's jp # 1 output still high, jp bilirubin was sent and was elevated (7). on pod # 5, patient underwent abdominal ct which demonstrated patent main, left and right portal veins; however, some non-critical narrowing of the presumed graft. the patient's jp output was started to slow down. on pod # 6 jp amylase was sent from both drains and was normal. the patient was discharged home with both jp to continue monitor their output. gu: the foley catheter discontinued at midnight of pod#4. the patient subsequently voided without problem. id: the patient's white blood count and fever curves were closely watched for signs of infection. wound was evaluated daily and small area of erythema was noticed on the middle part of the incision on pod # 3. the erythema subsided prior discharge, and though to be cause by staples. endocrine: the patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. no insulin was needed upon discharge. hematology: the patient was transfused with 2 units of prbc intraoperatively secondary to blood loss. post op patient's complete blood count was examined routinely; no further transfusions were required. prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay; 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. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: diazepam 5mg prn; lisinopril 5mg'; metoprolol tartrate 12.5mg''; percocet prn; asa 81mg'; calcium carbonate; vitamin d3; centrum discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*80 tablet(s)* refills:*0* 4. acetaminophen 500 mg tablet sig: two (2) tablet po q 8h (every 8 hours). 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*5* 8. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po once a day. 9. vitamin d3 1,000 unit capsule sig: one (1) capsule po once a day. 10. lisinopril 5 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: carenet discharge diagnosis: locally advanced cholangiocarcinoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: 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, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. 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. . jp x 2 drain care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *maintain suction of the bulb. *note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or vna nurse if the amount increases significantly or changes in character. *be sure to empty the drain frequently. record the output, if instructed to do so. *you may shower; wash the area gently with warm, soapy water. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. followup instructions: department: surgical specialties when: monday at 2:15 pm with: , md building: sc clinical ctr campus: east best parking: garage . please follow up with dr. (pcp) in weeks after discharge Procedure: Radical pancreaticoduodenectomy Other lysis of peritoneal adhesions Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Other excision of vessels, thoracic vessels Resection of vessel with replacement, abdominal veins Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of tobacco use Hemorrhage complicating a procedure Peritoneal adhesions (postoperative) (postinfection) Chronic pancreatitis Obstruction of bile duct Diverticulosis of colon (without mention of hemorrhage) Malignant neoplasm of duodenum Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Malignant neoplasm of pancreatic duct Dizziness and giddiness Giant cell arteritis Other specified misadventures during medical care Malignant neoplasm of tail of pancreas

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: aortic stenosis/ regurgitation major surgical or invasive procedure: aortic valve replacement (21mm st. porcine) history of present illness: this 86 year old white female has known aortic stenosis with progressive dyspnea on exertion and fatigue over 7 months. she has previously undergone catheterization to demonstrate clean coronaries, despite a prior anterior infaction in . she is admitted now for valve replacement. past medical history: coronary artery disease s/p ami ' ischemic cardiomyopathy (ef 35-40%) aortic stenosis/insufficiency hypertension hyperlipidemia diverticulitis past surgical history: right hip replacement s/p fracture(mva)' bowel resection(diverticular dz)-' incisional hernia repair ' bilat cataract removal ovarian cyst removal social history: race: caucasian last dental exam: 1 month ago lives with: husband occupation: retired college professor/-education() tobacco:quit 40 yrs ago, previously smoked 1ppwk x20yrs etoh:1 drink every other month family history: non-contributory physical exam: pulse: 54 resp: 16 o2 sat: 98%-ra b/p right: 160/72 left: height: 65 in weight: 176 lbs general: skin: dry intact heent: perrla eomi mmm, normal oropharynx neck: supple full rom , no jvd or lymphadenopathy chest: lungs clear bilaterally heart: rrr irregular murmur: blowing murmur abdomen: soft non-distended non-tender +bowel sounds extremities: warm , well-perfused edema: none varicosities: minimal neuro: grossly intact, a&o x3-mae, nonfocal exam pulses: femoral right: 2+ left: 2+ dp right: 1+ left: 1+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit: radiated murmur right: left: pertinent results: 02:10am blood wbc-13.1* rbc-3.41* hgb-10.1* hct-30.2* mcv-89 mch-29.7 mchc-33.4 rdw-14.4 plt ct-126* 06:20am blood na-135 k-4.5 cl-101 06:40am blood wbc-10.0 rbc-3.32* hgb-9.9* hct-29.6* mcv-89 mch-29.9 mchc-33.5 rdw-14.0 plt ct-122* 12:30pm blood wbc-6.9 rbc-2.57*# hgb-7.7*# hct-22.4*# mcv-87 mch-29.9 mchc-34.2 rdw-13.4 plt ct-122*# 06:40am blood glucose-113* urean-26* creat-1.1 na-138 k-4.2 cl-103 hco3-28 angap-11 01:35pm blood urean-10 creat-0.7 na-141 k-4.3 cl-115* hco3-22 angap-8 echocardiography report , (complete) done at 11:46:35 am final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 86 f hgt (in): bp (mm hg): / wgt (lb): hr (bpm): bsa (m2): indication: avr icd-9 codes: 786.05, 786.51, 424.1, 424.0 test information date/time: at 11:46 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 #: 2010aw-1: machine: echocardiographic measurements results measurements normal range left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *6.0 cm <= 5.6 cm left ventricle - ejection fraction: 45% to 50% >= 55% aortic valve - peak gradient: *56 mm hg < 20 mm hg aortic valve - mean gradient: 35 mm hg aortic valve - valve area: *0.6 cm2 >= 3.0 cm2 findings left atrium: no spontaneous echo contrast is seen in the laa. right atrium/interatrial septum: normal interatrial septum. left ventricle: mildly depressed lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal ascending aorta diameter. complex (>4mm) atheroma in the descending thoracic aorta. aortic valve: ?# aortic valve leaflets. severely thickened/deformed aortic valve leaflets. critical as (area <0.8cm2). moderate (2+) ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: mild tr. pulmonic valve/pulmonary artery: physiologic (normal) pr. 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. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. no tee related complications. conclusions pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is mildly depressed (lvef= 45 - 50 %). right ventricular chamber size and free wall motion are normal. there are complex (>4mm) atheroma in the descending thoracic aorta. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is a-paced, on no inotropes. preserved biventricular systolic fxn. there is a prosthetic aortic valve with no leak and no regurgitation. mean residual gradient = 10 mmhg. no mr. . aorta intact. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 13:01 brief hospital course: following admission she went to the operating room where aortic valve replacement was undertaken. she operative note for details. she weaned from bypass easily on propofol alone. she awoke anxious but intact, requiring nitroglycerin intravenously for bp control. she was extubated on pod 1 and oral agents (valsartan and lopressor). diuresis towards her preoperative weight was begun and she transferred to the floor on pod 2. physical therapy worked with her for strength and mobility. cts and temporary pacing wires were removed per protocols. she had a brief episode of atrial fibrillation in the 140s on pod 4, which was well tolerated. this was treated with iv lopressor and amiodarone with restoration of sinus rhythm. she remained volume overloaded and was discharged to rehab on iv lasix for 1 week. on pod 5 she was ready for discharge and went to rehab a mwmc in . medications on admission: metoprolol er 25 daily simvastatin 40 daily zetia 10 daily ntg-sl-prn aspirin 325 daily diovan 320 daily fish oil vitamin e 400iu daily vitamin d 500mg daily discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 2. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 3. simvastatin 40 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. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 6. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 7. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 8. amiodarone 200 mg tablet sig: as directed tablet po bid (2 times a day): 1 tab(200mg) for two weeks then one tab(200mg) daily. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. psyllium packet sig: one (1) packet po bid (2 times a day) as needed for constipation. 11. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 12. furosemide 10 mg/ml solution sig: four (4) injection twice a day for 1 weeks: 40mg iv lasix x 1 week, then re-evaluate. 13. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours) for 1 weeks. discharge disposition: extended care facility: tba discharge diagnosis: aortic stenosis/reguritation hypertension s/p aortic valve replacement s/p right total hip arthroplasty ischemic cardiomyopathy coronary artery disease s/p colon resection for diverticular disease s/p herniorraphy s/p cataract extractions hyperlipidemia s/p ovarian cystectomy discharge condition: alert and oriented x3, nonfocal ambulating with steady gait incisional pain managed with ultram incisions: sternal - healing well, no erythema or drainage edema: 1+ bilateral les 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. () at on at 9:00am cardiologist:dr. () on at 2:30pm please call to schedule appointments with: 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: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Arterial catheterization Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Personal history of tobacco use Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Other and unspecified angina pectoris Old myocardial infarction Hip joint replacement Other fluid overload Acquired absence of intestine (large) (small)

allergies: amoxicillin attending: chief complaint: right forearm laceration major surgical or invasive procedure: - irrigation and debridement right forearm wound, repair radial artery, ulnar artery, median nerves, multiple flexor tendons and muscle bodies. history of present illness: hpi: 21yom with possible intoxication today, possible clonodine ingestion and/or etoh involved in domestic dispute and punched his right hand through a house window with immediate laceration and bleeding distal forearm. he was seen at where concern for radial artery and median nerve injury. faint ulnar pulse dopplerable per report at outside hospital, transferred to for hand evaluation. non-dopplerable radial and ulnar pulses in ed. tetanus up to date, received ancef 1gm at 1:40pm at osh. denies any other injury, no hand pain, denies suicide attempt. last npo yesterday per patient. patient is under arrest with police escort at all times. past medical history: adhd social history: difficult relationship with family. occasional etoh use, denies tobacco, endorses marijuana. family history: n/c physical exam: avss nad aaox3, mentating well r upper extremity: rue with 20cm transverse volar wound closed with sutures, minimal serous drainage, clean and intact. no other areas of ecchymosis or obvious injury on extremity. arm and forearm are soft. non-tender to palpation anywhere away from wound. sensation intact radial and ulnar distributions, not present in median nerve distribution (thumb, index, ring) or superficial radial (thumb index dorsal web space) palpable radial pulse, brisk capillary refill all 5 digits <2sec. epl edc fdp fds fire but limited by pain edema. patient unable to cross fingers, attempts thumb index pinch but unable to complete, unable to thumb-5th digit grasp. pertinent results: 05:15pm wbc-13.9* rbc-3.73* hgb-11.3* hct-32.4* mcv-87 mch-30.2 mchc-34.8 rdw-12.9 10:31pm hgb-6.6* calchct-20 11:14pm hgb-6.9* calchct-21 01:05am hgb-7.7* calchct-23 03:00am pt-14.7* ptt-25.4 inr(pt)-1.4* 03:00am wbc-9.5 rbc-2.99* hgb-8.7* hct-25.3* mcv-84 mch-29.0 mchc-34.3 rdw-14.9 06:09am wbc-11.4* rbc-2.88* hgb-8.3* hct-24.3* mcv-84 mch-28.9 mchc-34.3 rdw-15.1 07:46am blood wbc-5.3 rbc-2.33* hgb-6.7* hct-19.5* mcv-84 mch-29.0 mchc-34.6 rdw-14.9 plt ct-114* 05:47am blood wbc-5.1 rbc-2.89* hgb-8.6*# hct-24.7* mcv-86 mch-29.7 mchc-34.7 rdw-14.8 plt ct-128* brief hospital course: the patient was admitted to the orthopaedic hand service after repair of a right forearm deep laceration. the patient was taken to the or and underwent an extensive repair and primary wound closure. see operative note for details. the patient tolerated the procedure without complications and was transferred to the icu in stable condition for q1 hour vascular checks. post operatively pain was controlled with po toradol, tylenol. he was continued on iv ancef. the patient tolerated diet advancement without difficulty. his preoperative hct was 32, post op 24, and on pod1 o/n hct 19 for which he was transfused 2u prbc with appropriate response and am hct 25. he was transferred out of the icu early pod2 and continued on q2-4hr vascular checks without issue. he was transitioned to po keflex, po asa 325mg qd for 4 weeks for anticoagulation, and toradol was discontinued. he had sufficient pain control on tylenol and aspirin. he was also evaluated by psychiatry and social work with all recommendations followed, no acute intervention. his edema decreased with elevation and wound remained intact, forearms soft. he is discharged to infirmary in custody with sheriff in stable condition. medications on admission: adderal discharge medications: 1. acetaminophen 650 mg po q6h 2. aspirin 325 mg po daily 3. cephalexin 500 mg po q6h duration: 10 days rx *keflex 500 mg 1 capsule(s) by mouth q6hrs disp #*40 capsule refills:*0 discharge disposition: extended care discharge diagnosis: traumatic deep laceration right forearm discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ******signs of infection********** should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -wound care: keep arm in splint, dressing does not need to be changed until follow up unless soak-through or need for acute wound eval. no baths or swimming for at least 4 weeks. any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. ******weight-bearing******* non weight bearing right arm keep in splint. ******medications*********** - resume your pre-hospital medications. - continue taking tylenol every 4-6 hours as needed for pain. maximum 4000mg per day. this is all you required the day of discharge. you are also taking aspirin. *****anticoagulation****** - take aspirin 325mg daily po. ******follow-up********** please follow up with the hand trauma clinic in approximately 10 days. please call to make an appointment. please follow up with your pcp regarding this admission and any new medications/refills. physical therapy: nwb rue. must stay flexed at all times. no therapy until follow up. treatments frequency: perfusion/vascular checks q8hrs. please ensure capillary refill is brisk in all 5 digits right hand. if any concern, apply pulse ox to digit to confirm good waveform. if further concern, may change dressing for wound evaluation and pulse check but hand must remain in splint flexed position at all times. no dressing changes required unless need to eval wound or soak-through. keep rue strict elevation followup instructions: ******follow-up********** please follow up with the hand trauma clinic in approximately 10 days. please call to make an appointment. please follow up with your pcp regarding this admission and any new medications/refills. Procedure: Closure of skin and subcutaneous tissue of other sites Suture of artery Excision of lesion of other soft tissue Suture of cranial and peripheral nerves Procedure on four or more vessels Suture of muscle or fascia of hand Other suture of tendon Diagnoses: Tobacco use disorder Acute posthemorrhagic anemia Injury to radial blood vessels Injury to ulnar blood vessels Injury to median nerve Attention deficit disorder with hyperactivity Home accidents Legal circumstances Suicide and self-inflicted injury by other specified means Personal history of allergy to penicillin Open wound of forearm, with tendon involvement Injury to radial nerve

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: 1. rigid bronchoscopy with dumon black bronchoscope. 2. flexible bronchoscopy. 3. balloon dilation of the basilar segments of the left lower lobe. 4. placement of left pleural pigtail catheter. 5. placement of right pleural pigtail catheter. 6. placement of tunneled hd catheter. history of present illness: 69m with a history of chf/ischemic cardiomyopathy ef 10% 6/09, esrd on hd, who presented to osh with sob on . of note the patient was recently admitted from with lue/lle edema and dvt was ruled out however they noted that he had a l sided pleural effusion and ? infiltrates so he was started on vanc and ceftaz for hospital acquired pna. he was d/c'ed on 5l of oxygen and when the vna visited him he was still sob on 4l of oxygen with cough and clear sputum production so he was taken to the ed and re-admitted. at the osh, a ct chest showed increase in the l pleural effusion, collapse of the l lung with obstruction of the l main stem bronchus, questionable endobronchial lesion vs mucous plug. he also had a r pleural effusion, ascites, anasarca and a l ventricular aneurysm. he was hemodialized 2.5l and a thoracentesis was performed removing 1l of pleural fluid which was negative for microorganisms. a bronchoscopy was performed showing a l main stem mucous plug, abnormal endobronchial mucosa with external compression that was so severe they were unable to safely advance the bronchoscope. they believed it was secondary to the lv aneurysm compressing the lmsb. a bal was performed showing oropharyngial flora and biopsies of the abnormal mucosa were sent to pathology. lue doppler was again repeated due to persistent lue edema which was negative. vq scan was low probability for pe. the patient was transfered to for stent placement. . on , he had rigid bronchoscopy with ip. following the procedure he became hypotensive and was started on levo and epi gtt. on bronchoscopy there was no endobronchial lesion seen however he did have extrinsic compression of lll segments. balloon dilation was performed, and left chest tube placed which drained ~2.5l. post procedure he remained intubated and on pressors and was admitted to the tsicu, where a right chest tube was placed while drained 1.5l. his icu course has been complicated by inability to wean pressor support. . he was started on vancomycin and zosyn given development of fevers with plan for 8 day course per ip. he was extubated on and has been on nc since then. he continues to put out approximately 1 l of pleural fluid from the left pigtail catheter. on the morning prior to transfer to the ccu he pulled out his aline and the tsicu team was unable to replace despite multiple attempts. his blood pressure cuff and aline were correlating. he has continued on max dose epinephrine since ip procedure and has required levophed intermittently during cvvh. . on arrival to the ccu, he appears comfortable and denies pain. he continues to have dyspnea but endorses improvement since stenting by ip. past medical history: 1. cardiac risk factors: + diabetes, + dyslipidemia, - hypertension 2. cardiac history: -cabg: na -percutaneous coronary interventions: unknown -pacing/icd: 3. other past medical history: -atrial fibrillation on coumadin -esrd on mwf hd in , etiology of renal failure unclear -ischemic cardiomyopathy ef 5-10% -s/p ppm/icd in -type i dm -hypothyroidism -pad with rle amputation at mid-calf -hcv per report -oa -h/o gib social history: ex-smoker with a 7 pack year history, quit at age 40. denies alcohol or drugs. lives with wife. family history: non-contributory physical exam: vs: tc 96.3 tm 98.6 bp=74/55 hr=80-90 rr= o2 sat= general: chronically ill appearing male, resting comfortably in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric eomi neck: supple, rij in place, no jvd appreciable cardiac: distant heart sounds rrr, no appreciable murmur lungs: bilateral chest tubes in place, resp were unlabored, no accessory muscle use. bibasilar crackles. abdomen: soft, nt, slightly distended, soft/reducible umbilical hernia, no hsm or tenderness. no abdominial bruits. extremities: s/p bka, lle with venous stasis dermatitis, slight arterial ulceration over ventral aspect of toes, no evidence of acute infection, palpable left dp. pertinent results: 09:50pm blood wbc-12.2* rbc-3.88* hgb-11.6* hct-35.6* mcv-92 mch-29.9 mchc-32.6 rdw-16.4* plt ct-417 09:50pm blood pt-16.5* ptt-25.2 inr(pt)-1.5* 09:50pm blood glucose-227* urean-31* creat-3.2* na-136 k-5.0 cl-101 hco3-26 angap-14 09:50pm blood calcium-7.9* phos-2.3* mg-1.8 01:46pm blood type-art po2-121* pco2-43 ph-7.44 caltco2-30 base xs-5 ct chest : 1. complete atelectasis of the left lung with a low-density material within the left main bronchus that may represent secretions although correlation with bronchoscopy is recommended. severe cardiomegaly with left ventricular enlargement and left ventricular calcification also contribute to the atelectasis of the lung. 2. bilateral pleural effusions, large. 3. extensive coronary calcifications. 4. evidence of prior granulomatous exposure. splenic hypodense wedge-shaped area that might represent infarcts. 5. anasarca. ascites. asymmetric thickening of the left breast tissue that might represent hematoma versus extensive edema due to patient positioning. cxr : findings: as compared to the previous radiograph, one chest tube has been inserted into each pleural space. both tubes show normal position. the right pleural space has completely cleared, in the left pleural space moderate remnant pleural effusion is seen. otherwise, the radiograph is unchanged. unchanged monitoring and support devices. unchanged cardiomegaly. no newly occurred focal parenchymal opacity suggesting pneumonia. no evidence of pneumothorax. . echo : the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated. there is severe global left ventricular hypokinesis (lvef = 10%). a large (2.6 x 2.1) echogenicity is seen in the left ventricle, adjacent to the lateral wall, consistent with thrombus. there is probable additional mural thrombosis closer to the apex. the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. midsystolic closure of the aortic leaflets is seen. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: massively dilated left ventricle with severe global systolic dysfunction and low cardiac output. dilated and hypokinetic right ventricle. probable left ventricular thrombus. moderate mitral and tricuspid regurgitation. moderate pulmonary hypertension. . cxr : the position of the multiple chest tubes and lines is essentially unchanged since the prior chest x-ray. the right lung is clear. there is some atelectasis in the lower lobe present. pneumothorax is still present on the left side, essentially unchanged since the prior chest x-ray. there is no right pneumothorax. impression: no significant change. no right pneumothorax. brief hospital course: mr. is a 69 yo m with severe ischemic cardiomyopathy (ef 5-10%), l mainstem bronchus compression lv enlargement s/p bronchoscopy, esrd on hd, course c/b post bronch hypotension and inability to wean pressor support. he expired at 12:50am. . hospital course: acute on chronic ischemic systolic heart failure with ef 5-10%, exacerbation likely combination of volume overload (up 30kg from dry weight) and positive pressure ventillation for rigid bronchoscopy. the patient already had a biventricular pacer for lv dysynchrony. cvvh was instituted for volume removal in the setting of the patient being 30kg over his dry weight. it was thought that this would improve his cardiac function by getting him back on the starling curve. the goal was for a 2-4kg diuresis daily. in order to achieve this the patient was kept on pressors to maintain a systolic blood pressure above 70. in order to achieve this he was titrated on levophed, epineprine, phenylephrine, midodrine, and vasopressin. his home beta blocker and ace inhibitor were held, but his home digoxin was continued. he required increased amount of pressors to maintain his blood pressure. the patient was mentating clearly until his systolic blood pressures fell below 50. he was full code through most of his hospitalization; however, a family meeting towards the end of his hospital course changed his code status to dnr/dni with no escalation of care. his blood pressure continued to fall despite maximal pressor therapy with all the medications listed above. he developed respiratory distress around midnight on requiring a non-rebreather. he expired in the presence of his family on at 12:50am. medications on admission: digoxin 0.125 mwf levothyroxine 50mcg' coumadin 1mg nystatin l groin midodrine 10mg' lantus 10u qhs renagel 800mg q8 humalog ss tid vanc 1g with hd for lue cellulitis until discharge medications: expired discharge disposition: expired discharge diagnosis: expired secondary to acute on chronic congestive heart failure complicated by hypotension refractory to pressors and respiratory distress discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Fiber-optic bronchoscopy Hemodialysis Venous catheterization for renal dialysis Other bronchoscopy Bronchial dilation Diagnoses: End stage renal disease Unspecified pleural effusion Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Ulcer of other part of foot Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Acute respiratory failure Cardiogenic shock Long-term (current) use of insulin Septic shock Long-term (current) use of anticoagulants Automatic implantable cardiac defibrillator in situ Cardiac pacemaker in situ Other ascites Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Acute on chronic systolic heart failure Below knee amputation status Venous (peripheral) insufficiency, unspecified Other diseases of trachea and bronchus Cardiomegaly

allergies: morphine attending: chief complaint: dyspnea major surgical or invasive procedure: redo right thoracotomy, removal of portion of posterior splinting mesh and tracheoplasty with mesh, flexible bronchoscopy with bronchoalveolar lavage history of present illness: ms is a 60f with tbm. she is s/p tracheobronchoplasty but had recurrence of sx. a tracheal stent was placed with noted improvement in dyspnea and cough. it was removed and pt has now returned to her baseline easy doe, cough but denies fever, sweats, chest pain or other related sx. she saw dr for a cardiac pre op eval, had a f/u bronch and is now planning on moving forward with redo tracheobronchoplasty. past medical history: pmh: fibromyalgia, hepatitis c, rul bronchiectasis, chronic bronchitis, hx of chemical pneumonitis . psh: s/p tracheoplasty, s/p bronchiectasis surgery, csxn x2, s/p breast augmentation (implants), s/p tonsils and adenoids, "eye operation as child". social history: quit smoking >20 yrs ago, smoked <1 ppd for about 10 years, denies etoh, no illicit drugs. family history: non-contributory physical exam: bp: 148/93. heart rate: 98. weight: 152. bmi: 29.7. temperature: 98.5. o2 saturation%: 98. gen:nad neck:no chest: clear ausc cor:rrr no murmur abd:deferred extrem: no cce pertinent results: 09:38am hgb-11.5* calchct-35 09:38am glucose-95 lactate-1.2 na+-138 k+-3.5 cl--106 02:28pm glucose-117* urea n-13 creat-0.6 sodium-141 potassium-3.9 chloride-108 total co2-27 anion gap-10 cxr : in comparison with the study of , the right ij catheter has been removed. no change in the appearance of the heart and lungs. elevation of the right hemidiaphragm anteriorly is again seen. large hiatal hernia is present. ba swallow :preliminary report dysphagia 1. large hiatal hernia. small caliber of the stomach passing through the preliminary reportdiaphragmatic hiatus delays passage of a 13 mm barium tablet. 2. no direct correlation of the above findings with the patient's symptoms of preliminary reportdysphagia bedside swallow : based on results of pt's recent barium swallow with impaired esophageal motility and hiatal hernia impacting speed of passage of po and pt's correlated symptom of sensation that food will not go down is likely globus sensation from her esophageal deficits. pt was educated on strategies such as keeping foods moist, alternating bites and sips, eating slowly and smaller meals in attempt to alleviate discomfort. brief hospital course: ms. was admitted to the hospital and taken to the operating room where she underwent a redo right thoracotomy, removal of portion of posterior splinting mesh and tracheoplasty with mesh and flexible bronchoscopy with bronchoalveolar lavage. she tolerated the procedure well and was extubated in the or. she returned to the sicu in stable condition with an epidural catheter for pain control. the pain service followed her closely and made adjustments in her epidural infusion to improve her pain control so as to make pulmonary toilet more effective. she maintained stable hemodynamics but did have a hematocrit drop from 33 intraop to 25 early post op. serial hematocrits were followed along with chest xrays and there was no evidence of active bleeding. following removal of her chest tube, her epidural catheter was also removed and she had adequate pain relief with oxycodone, tylenol, ibuprofen and tramadol. she was able to use her incentive spirometer effectively and cough and deep breath comfortably. she used a cpap mask at night and had ra saturations of 95% during the day. she was tolerating a regular diet in moderation but her liquid intake was poor which ultimately reflected in a creatinine bump from 0.6 to 1.2 within 24 hours. she was then rehydrated with 2 liters of fluid and her creatinine decreased to 0.9 but her hematocrit was also 22.8. she remained hemodynamically stable with a blood pressure of 110/70 . she complained of dysphagia to soft foods and some liquids and subsequently underwent a barium swallow which showed a large hiatal hernia but no other pathology. the speech and swallow therapist evaluated her at the bedside and found no mechanical problem or evidence of aspiration. she was given some hints on how to keep food moist to allow for easier passage. her pain medication was adjusted as she had inadequate pain control with oxycodone 5 mg q 4 hours along with tramadol, ibuprofen and tylenol. she was better controlled with 10 mg every 4 hours although not pain free. she did have a large ecchymotic area around her chest tube site which extended to the right hip and upper thigh but the areas were soft. her ibuprofen was reduced to 400 mg tid and she may ultimately stop it. she will use local heat or cool packs for comfort. her hematocrit remained stable at 25. she was discharged to home on and will follow up in the thoracic clinic in 2 weeks. medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. amphetamine salt combo *nf* (amphetamine-dextroamphetamine) 40 mg oral daily 2. losartan potassium 25 mg po daily 3. benzonatate 200 mg po tid 4. hydroxyzine 50 mg po hs 5. guaifenesin *nf* 1,200 mg oral 6. acetylcysteine 20% *nf* 5 mls other tid use 30 minutes after albuteral 7. tramadol (ultram) 50 mg po q4h:prn pain 8. omeprazole 20 mg po daily 9. sodium chloride 3% inhalation soln 1 neb neb tid:prn sob, cough supplied by respiratory 10. albuterol sulfate *nf* 90 mcg/actuation inhalation q 6 hrs sob 11. escitalopram oxalate 20 mg po daily discharge medications: 1. escitalopram oxalate 20 mg po daily 2. tramadol (ultram) 50 mg po q6h:prn pain rx *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours disp #*80 tablet refills:*1 3. acetaminophen 650 mg po q6h pain 4. adderall xr *nf* (amphetamine-dextroamphetamine) 40 mg oral daily reason for ordering: wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 5. docusate sodium 100 mg po bid 6. oxycodone (immediate release) 5-10 mg po q4h:prn pain rx *oxycodone 5 mg tablet(s) by mouth every four (4) hours disp #*100 tablet refills:*0 7. albuterol sulfate *nf* 90 mcg/actuation inhalation q 6 hrs sob 8. amphetamine salt combo *nf* (amphetamine-dextroamphetamine) 40 mg oral daily 9. sodium chloride 3% inhalation soln 1 neb neb tid:prn sob, cough supplied by respiratory 10. ferrous sulfate 325 mg po daily 11. guaifenesin *nf* 1,200 mg oral 12. omeprazole 20 mg po daily 13. senna 1 tab po bid:prn constipation 14. losartan potassium 25 mg po daily 15. ibuprofen 400 mg po q8h rx *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours disp #*100 tablet refills:*1 discharge disposition: home discharge diagnosis: recurrent tracheomalacia. 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 surgery to correct your tracheomalacia and you've recovered well. you are now ready for discharge. * continue to use your incentive spirometer 10 times an hour while awake. you should also use your cpap mask at night. * check your incisions daily and report any increased redness or drainage. cover the area with a gauze pad if it is draining. * if your chest tube site starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * you will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. use a stool softener or gentle laxative to stay regular. * no driving while taking narcotic pain medication. * take tylenol 650 mg every 6 hours in between your narcotic. * continue to stay well hydrated and eat well to heal your incisions * shower daily. wash incision with mild soap & water, rinse, pat dry * no tub bathing, swimming or hot tubs until incision healed * no lotions or creams to incision site * walk 4-5 times a day and gradually increase your activity as you can tolerate. call dr. office if you experience: -fevers > 101 or chills -increased shortness of breath, chest pain or any other symptoms that concern you. followup instructions: department: west clinic when: tuesday at 9:00 am with: , md building: de building ( complex) campus: west best parking: garage please report 30 minutes prior to your appointment to the radiology departmment on the of the for a chest xray. Procedure: Closed [endoscopic] biopsy of bronchus Other repair and plastic operations on trachea Other incision of larynx or trachea Diagnoses: Other iatrogenic hypotension Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Esophageal reflux Unspecified viral hepatitis C without hepatic coma Diaphragmatic hernia without mention of obstruction or gangrene Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Myalgia and myositis, unspecified Other diseases of trachea and bronchus Disruption of wound, unspecified

history of present illness: the patient is a 52 year old female with a history of right upper lobe bronchiectasis. she had a distant history at the age of 25 of aspirating some vinegar which subsequently required hospitalization for treatment of chemical pneumonitis. since then the patient has had progressive respiratory problems. initially it started with an active cough and eventually resulted in chronic bronchitis and recurring infections. these episodes of recurring bronchitis started approximately ten years ago and required intermittent antibiotics in the past three years. she has been on a constant stream of rotating antibiotics for three weeks and off for one week. the patient reports that during the week that she was off of antibiotics she began to feel sick, sleepy and developed a fever which promptly went away when she reinitiated antibiotic therapy. the patient usually develops fever with persistent cough building to episodes of bronchitis. she has never been admitted to the hospital for pneumonia but was admitted two years ago with shortness of breath versus pulmonary function course. the patient denies any chest pain, dyspnea on exertion or hemoptysis. the patient has been treated with prednisone in the past but reports that it did not help her and she wants to avoid it for fear of what might happen to her with chronic steroid use. the patient uses inhalers occasionally but reports that they are of minimal utility. past medical history: 1. fibromyalgia. 2. hepatitis c positivity with normal liver function tests. 3. right upper lobe bronchiectasis. 4. chronic bronchitis. 5. history of chemical pneumonitis. past surgical history: unremarkable. medications on admission: 1. zithromax. 2. levaquin. 3. singulair. 4. fosamax. 5. foradil. 6. ultram. 7. various inhalers. allergies: no known drug allergies. social history: the patient has approximate five pack year smoking history and no alcohol history. family history: significant for a father who died at the age of 49 of an myocardial infarction and mother who died at the age of 73 from chronic obstructive pulmonary disease. physical examination: on physical examination the patient is afebrile, vital signs are stable in no apparent distress. head was normocephalic, atraumatic. no scleral icterus noted. neck was soft, supple with no masses noted, no carotid bruits. heart was regular rate and rhythm, no murmurs. chest was clear to auscultation bilaterally. thorax was symmetrical with no masses or scars. the abdomen was soft, nontender, nondistended, positive bowel sounds. extremities showed no clubbing or edema. neurologically, the patient was grossly intact. laboratory data: computerized tomography scan preoperatively demonstrated moderate tracheal collapse and evidence of bronchiectasis throughout the right upper lobe. no evidence of bronchiectasis in the other lobes and there was no endobronchial lesions. hospital course: the patient is a 52 year old female with tracheobronchial malacia who presents to as a same day admission for tracheobronchoplasty. the patient was taken to the operating room on for said procedure by dr. and dr. . for a more detailed account, please see the operative report. postoperatively the patient was transferred to the floor. chest tube was discontinued on postoperative day #1. on postoperative day #2, epidural analgesia was discontinued as the epidural was capped and the patient was started on percocet and ibuprofen. the patient reported very poor pain control without the epidural and later in the day of postoperative day #2, the patient's epidural was restarted with straight local anesthetic with good effect. chest x-ray on postoperative day #2 revealed no pneumothorax. on postoperative day #4, the patient's pain control was much improved with local epidural which was later on in the day discontinued and the patient was again started on percocets and ibuprofen with moderate pain control. in addition, the patient was receiving morphine injections for breakthrough pain. on postoperative day #5, the patient was doing well, epidural was discontinued and the patient was deemed well enough to go home. the patient was comfortable with this plan with percocets and ibuprofen around the clock for pain control. discharge status: to home. discharge condition: good. discharge diagnosis: 1. tracheobronchial malacia. 2. fibromyalgia. discharge medications: 1. montelukast 10 mg p.o. q. day 2. percocet 1 to 2 tablets p.o. q. 4-6 hours prn for pain. 3. neurontin 300 mg p.o. q.h.s. 4. venlafaxine 300 mg p.o. q. am 5. trazodone 37.5 mg p.o. q.h.s. 6. ibuprofen 600 mg p.o. q. 6 hours 7. colace 100 mg p.o. b.i.d. 8. azithromycin 500 mg p.o. q. day. follow up: the patient is to follow up with primary care physician in two to four weeks and dr. in six weeks. please call for an appointment. , m.d. dictated by: medquist36 Procedure: Fiber-optic bronchoscopy Other lavage of bronchus and trachea Other repair and plastic operations on trachea Other repair and plastic operations on bronchus Diagnoses: Bronchiectasis without acute exacerbation Myalgia and myositis, unspecified Foreign body accidentally entering other orifice Unspecified chronic bronchitis Foreign body in other specified parts bronchus and lung

allergies: no known allergies / adverse drug reactions attending: addendum: : s/p t7-l1 fusion and instrumemtation, total laminectomy t11, multiple thoracic laminotimies, right iliac crest bone graft, dural closure for csf leak. operative note reports 1600cc blood loss. blood loss repleted with 4 u prbc, 2u ffp. no further bleeding reported. radiographic imagining: spinous process fracture c2, c3, c4, c5, c7. pre-vertebral soft tissue edema from c1-c4. mri: small anterior hematoma at level of c3-c4 without mass effect on spinal cord. cervical collar at all times with follow-up visit with ortho-spine. fitted for thoracic brace for out of bed use. discharge disposition: extended care facility: hospital - md Procedure: Linear repair of laceration of eyelid or eyebrow Closure of skin and subcutaneous tissue of other sites Closure of skin and subcutaneous tissue of other sites Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Other repair and plastic operations on spinal cord structures Fusion or refusion of 4-8 vertebrae Diagnoses: Acute posthemorrhagic anemia Open wound of scalp, without mention of complication Open wound of forehead, without mention of complication Closed fracture of second cervical vertebra Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Epilepsy, unspecified, without mention of intractable epilepsy Personal history of noncompliance with medical treatment, presenting hazards to health Closed fracture of seventh cervical vertebra Sprain of neck Closed fracture of other facial bones Contusion of lung without mention of open wound into thorax Laceration of skin of eyelid and periocular area Lack of housing Other alteration of consciousness Closed fracture of fourth cervical vertebra Street and highway accidents Accidental fall from or out of building or other structure Closed fracture of fifth cervical vertebra Alcohol abuse, in remission Closed fracture of seven ribs Open wound of face, unspecified site, without mention of complication Closed fracture of third cervical vertebra History of physical abuse Other accidental drowning or submersion Injury to dorsal nerve root

allergies: no known allergies / adverse drug reactions attending: chief complaint: trauma: fall injuries: l post rib fx r post rib fx r lung contusions l medial orbital wall fx t11 chance fx with post disloc on t10 c2-5,c7,t8-10 spinous process fx c2-c3 intraspin lig tear c1-c4 edema major surgical or invasive procedure: t7-l1 laminectomy, fusion (ortho spine) history of present illness: history of presenting illness this patient is a 43 year old male who presents after being found under bridge, half submerged in water. initially unresponsive, but now improved. ? seizure. ? 5-20 feet. ? etoh. thought that patient lying in water at least half hour. pt has h/o seizures, and now states that he thinks he might have seized. past medical history: psychiatric history: inpatient detox 3 times (2 at in , 1 at in or ). never taken meds, never seen a psychiatrist. aa did not help him much, did not attend. past medical history: denies social history: from , 1 sister, 2 brothers (1 in , 1 he does not keep in touch with 2/2 abuse). states was in the usmc from 87-89, d/c'ed for crystal meth in urine. has 1 son, 20, was not involved but tried contacting recently via facebook, upsetting son. lives under the bridge, inn helps with blankets and food. works as a bike courier fulltime. no close friends, few acquaintances, never a long term relationship (dates but women are not intereseted alcoholism family history: father - etoh physical exam: physical examination upon admission: hr: 84 bp: 120/p resp: 18 o(2)sat: 92 low constitutional: gcs 14 heent: 2 cm lac l eyebrow, small lac within l eyebrow, l cheek swelling with ecchymosis, midface stable, extraocular muscles intact, pupils equal, round and reactive to light oropharynx within normal limits, no blood in mouth; blood in l nares, no hemotympanum; no c spine tenderness chest: no crepitus cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: soft, fast negative for free fluid, nondistended pelvic: pelvis stable gu/flank: obvious deformity l midback with ecchymosis and swelling extr/back: 2+ pulses in le; abrasion llat calf neuro: speech fluent, moving all extremities pertinent results: 07:15am blood wbc-10.0 rbc-2.82* hgb-8.9* hct-26.0* mcv-92 mch-31.7 mchc-34.3 rdw-14.3 plt ct-270 09:55am blood wbc-11.9* rbc-2.89* hgb-9.2* hct-26.6* mcv-92 mch-31.8 mchc-34.6 rdw-14.4 plt ct-235 06:10pm blood wbc-13.4* rbc-3.31* hgb-10.8* hct-29.2* mcv-88 mch-32.5* mchc-36.9* rdw-14.3 plt ct-201 07:15am blood plt ct-270 09:55am blood plt ct-235 01:51am blood pt-14.8* ptt-27.5 inr(pt)-1.3* 03:00pm blood plt ct-244 07:15am blood glucose-93 urean-8 creat-0.5 na-139 k-3.8 cl-105 hco3-27 angap-11 09:55am blood glucose-130* urean-11 creat-0.5 na-140 k-3.8 cl-107 hco3-26 angap-11 06:55am blood glucose-135* urean-7 creat-0.7 na-140 k-3.8 cl-105 hco3-27 angap-12 01:51am blood alt-24 ast-67* ld(ldh)-282* alkphos-36* totbili-0.4 07:15am blood calcium-7.7* phos-2.6* mg-2.0 09:55am blood calcium-7.4* phos-2.4* mg-1.9 02:04am blood type-art po2-118* pco2-44 ph-7.39 caltco2-28 base xs-1 10:10pm blood type-art po2-127* pco2-41 ph-7.37 caltco2-25 base xs--1 01:28pm blood hgb-11.8* calchct-35 10:10pm blood freeca-1.08* 03:10pm blood freeca-1.25 chest x-ray: impression: 1. volume loss and diffuse opacities of the right lung. 2. rigth sided posterior rib fractures. 3. chronic left clavicle fracture. : head cat scan : impression: 1. volume loss and diffuse opacities of the right lung. 2. rigth sided posterior rib fractures. 3. chronic left clavicle fracture. : cat scan of abdomen and chest: impression: 1. chance fracture at t11 with posterior translation of t11 on t10 and locked facets at this level. high concern for spinal cord transection. multiple additional fractures as described. 2. right lung contusions. 3. high attenuation in the lumen of a rlq small bowel loop is of higher attenuation than the aorta and may related to ingested material. intraluminal hemorrhage secondary to small bowel injury would be less likely, but please clinically : cat scan of sinus and mandible: impression: 1. fracture of the medial left orbital wall with herniation of intraorbital fat into the ethmoid, but no evidence of medial rectus herniation. entrapment cannot be excluded by imaging. 2. extensive left facial hematoma and laceration. limited evaluation of other left facial bones due to positioning; no definite additional fractures seen. 3. fluid in the right mastoid tip air cells. : cat scan of the c-spine: impression: 1. spinous process fractures of c2, c3, c4, c5 and c7. likely disruption of the c2-3 interspinous ligament. 2. prevertebral edema from c1 through c4, which may be better assessed by mri, if clinically indicated. while this not mentioned in the wet , the consult note in the online medical record by orthopedic surgeon dr. indicates that dr. is aware of this finding. : cat scan of the lumbar spine: multiple lateral views show screws at the t12 and l1 body levels. a single image shows a posterior rod in place extending superiorly from the l1 body level with the superior margin not included. : mr of lumbar spine: impression: 1. following laminectomy and instrumented fusion from t7 to l1, there is good dorsal alignment of the vertebral column. 2. evidence of epidural collection/hematoma/post op seroma extending from t5 to t12 with moderate mass effect on the spinal cord. 3. extensive ligamentous injury at the cervical spine with prevertebral hematoma and diffuse hemorrhage in the posterior paravertebral soft tissues. small anterior epidural hematoma at levels c3 through c7 without relevant mass effect on the spinal cord. 4. no mr evidence of osseous fractures in addition to those identified by initial post trauma ct studies. : mr of thoracic spine: impression: 1. following laminectomy and instrumented fusion from t7 to l1, there is good dorsal alignment of the vertebral column. 2. evidence of epidural collection/hematoma/post op seroma extending from t5 to t12 with moderate mass effect on the spinal cord. 3. extensive ligamentous injury at the cervical spine with prevertebral hematoma and diffuse hemorrhage in the posterior paravertebral soft tissues. small anterior epidural hematoma at levels c3 through c7 without relevant mass effect on the spinal cord. 4. no mr evidence of osseous fractures in addition to those identified by initial post trauma ct studies. : mr of cervical spine: impression: 1. following laminectomy and instrumented fusion from t7 to l1, there is good dorsal alignment of the vertebral column. 2. evidence of epidural collection/hematoma/post op seroma extending from t5 to t12 with moderate mass effect on the spinal cord. 3. extensive ligamentous injury at the cervical spine with prevertebral hematoma and diffuse hemorrhage in the posterior paravertebral soft tissues. small anterior epidural hematoma at levels c3 through c7 without relevant mass effect on the spinal cord. 4. no mr evidence of osseous fractures in addition to those identified by initial post trauma ct studies. scoliosis series ( rad. ) good alignment ,hardware appropriate, mild degenerative changes l5, l5-s1 brief hospital course: 43 year old gentleman admitted to the acute care service after being found under a bridge partially submerged in water. upon admission, he was made npo, given intravenous fluids, and underwent radiographic imaging. he sustained multiple facial lacerations which were sutured. he was also found to have bilateral rib fractures, as well as cervical and thoracic spine injuries. he was admitted to the trauma sicu for monitoring. because of the extent of his cervical and thoracic injuries, he was evaluated by ortho-spine. he was taken to the operating room on hod #1 where he underwent a t7-l1 laminectomy and fusion. his operative course was notable for a siginficant blood loss of 1 liter. in addition to this, he required packed red blood cells to correct his blood loss. he was transported to the intensive care unit after the surgery still intubated and sedated on propofol. he was evaluated by plastic surgery and was found on imaging to have a left orbital wall fracture. for this injury, he was placed on sinus precautions and no further intervention. the neurology service was consulted regarding resuming his anti-seizure medication. his depakote was re-started per their recommendations. he has not had any seizure activity during his hospitalization. his post-operative course has been stable. he was fitted for a cervical-tlso brace and has used this when out of bed. he is tolerating a regular diet and voiding without difficulty. his vital signs are stable and he is afebrile. he has been evaluated by physical and occupational therapy and recommendations made for discharge to a rehabilition facility. he has been evaulated by psychiatry because of the nature of his injury and his history of poly-substance abuse to ascertain if this injury is self-inflicted. it was thought that this injury did not represent a suicide attempt. he is preparing for discharge with recommended follow-up with dr. , seizure specialist, opthamology, and ortho-spine. medications on admission: : celexa, depakote, neurontin discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) cc injection tid (3 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dryness. 4. bacitracin zinc 500 unit/g ointment sig: one (1) appl topical tid (3 times a day): to facial lacerations. 5. divalproex 500 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po bid (2 times a day). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 8. gabapentin 300 mg capsule sig: two (2) capsule po bid (2 times a day): start ...give dosing only . 9. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day): start on . 10. hydromorphone 2 mg tablet sig: 2-4 tablets po q3h (every 3 hours) as needed for pain: hold for increased sedation, resp. rate <12. 11. pantoprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 12. celexa 40 mg tablet sig: one (1) tablet po once a day: pt has not resumed related to causing him increased sedation. discharge disposition: extended care facility: hospital - discharge diagnosis: injuries: l post rib fx r post rib fx r lung contusions l medial orbital wall fx t11 chance fx with post disloc on t10 c2-5,c7,t8-10 spinous process fx c2-c3 intraspin lig tear c1-c4 edema discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane ( requires brace when out of bed) discharge instructions: you were admitted to the hospital after your were found in the water after falling off a bridge. it was thougth that you may have had a seizure. you sustained injuries to your ribs and back. you underwent a spinal fusion to stalize your back. you have a received a brace for getting out of bed. you are now preparing for discharge to a rehabilitation facility where you can regain further strenth and mobility. you must wear your cervical collar at all times and the tlso brace with the collar when you are out of bed. because of your orbital wall fracture, you will need to maintain sinus precautions. followup instructions: please follow up with acute care service in 2 weeks. you can schedule your appointment upon discharge. the telephone number is # please follow up with dr. in 2 weeks. you can schedule your appointment when you are discharged. the telephone number is # . you should also follow up with the epilepsy specialist. the telephone number to schedule your appointment is #. please follow up with the cognitive neurologist, dr. in weeks. the telephone number is # you will also need to follow up with the opthalmologist in weeks. the telephone number is # Procedure: Linear repair of laceration of eyelid or eyebrow Closure of skin and subcutaneous tissue of other sites Closure of skin and subcutaneous tissue of other sites Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Other repair and plastic operations on spinal cord structures Fusion or refusion of 4-8 vertebrae Diagnoses: Acute posthemorrhagic anemia Open wound of scalp, without mention of complication Open wound of forehead, without mention of complication Closed fracture of second cervical vertebra Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Epilepsy, unspecified, without mention of intractable epilepsy Personal history of noncompliance with medical treatment, presenting hazards to health Closed fracture of seventh cervical vertebra Sprain of neck Closed fracture of other facial bones Contusion of lung without mention of open wound into thorax Laceration of skin of eyelid and periocular area Lack of housing Other alteration of consciousness Closed fracture of fourth cervical vertebra Street and highway accidents Accidental fall from or out of building or other structure Closed fracture of fifth cervical vertebra Alcohol abuse, in remission Closed fracture of seven ribs Open wound of face, unspecified site, without mention of complication Closed fracture of third cervical vertebra History of physical abuse Other accidental drowning or submersion Injury to dorsal nerve root

allergies: augmentin attending: chief complaint: fever major surgical or invasive procedure: central line placement history of present illness: mr. is a 78m with stageiv nsclc on palliative tarceva who presents from his nursing facility with fevers x2d as high as 103.6f. per paperwork from rehab, he was given levofloxacin 500mg. . of note, he was recently admitted to the omed service, having presented with fevers and discharged on on cefpodoxime and azithromycin for suspected pneumonia. . in the ed, initial vs were t98 p 73 bp 86/51 rr 22 98% on . he was given vancomycin, cefepime, flagyl, acetaminophen, zofran, and started on peripheral dopamine. awake and mentating, making small amounts of dark urine. ct abdomen done for h/o 1day of diarrhea, noncontrast showed ?of colitis. got 5l of saline. bp remains 70's systolic on 15mcg dopamine and levophed. . on the floor, he denies any complaints - though initially reported some abdominal pain to the rn. review of systems otherwise negative, though unclear if patient's history is reliable. past medical history: past medical history: 1. hypertension 2. atrial fibrillation 3. copd 4. h/o bilateral hernia repair 5. aspiration . oncologic history: (per omr note by dr. 1. stage iib nonsmall cell lung cancer (adenocarcinoma) s/p surgical resection and adjuvant chemotherapy. 2. fdg avid left lower lung nodule with non-malignant biopsy in . 3. stage iv nonsmall cell lung cancer (bone and lung recurrence)diagnosed in . treatment: 1. status post right thoracotomy with right lower lobectomy, mediastinal lymph node sampling in . 2. status post 4 cycles of carboplatin 5auc and pemetrexed 500mg/m2 every 21 days of a 3 week cycle today. started in and last dose was given . 3. status post 3000 cgy of radiotherapy to left hip lesion completed in . 4. started erlotinib 150 mg/day in . 5. h/o mets to sacral spine s/p radiation, on narcotics for pain control social history: 70+ year h/o smoking. currently at rehab facility. family history: unknown cause of death of mother or father. the patient does have siblings that are alive. no recurrent cancers in the family. physical exam: on admission: vitals 96.3 102 101/58 21 100% on 4l general chronically ill appearing man, appears anxious heent sclera anicteric, dry mmm neck supple pulm lungs with few bibasilar rales l>r cv tachycardiac regular s1 s1 no m/r/g abd soft +bowel sounds tender to palpation throughout without rigidity or guarding extrem warm tr bilateral edema palpable distal pulses neuro awake and interactive, oriented to hospital in , does not know date derm no rash or jaundice lines/tubes/drains foley with yellow urine, rij pertinent results: on admission : wbc-10.9 rbc-3.71* hgb-10.3* hct-32.1* mcv-87 mch-27.8 mchc-32.2 rdw-17.1* plt ct-410 neuts-55 bands-27* lymphs-6* monos-10 eos-0 baso-0 atyps-0 metas-2* myelos-0 pt-17.9* ptt-33.4 inr(pt)-1.6* glucose-143* urean-35* creat-1.6* na-130* k-4.1 cl-94* hco3-26 angap-14 alt-17 ast-34 alkphos-60 totbili-0.7 albumin-2.6* calcium-7.6* phos-3.7 mg-2.0 feces positive for c. difficile toxin by eia ekg: probable sinus rhythm with low amplitude p waves (visible in lead v1) versus ectopic atrial rhythm. right bundle-branch block. left anterior fascicular block. q-t interval prolongation. compared to the previous tracing of p waves are less apparent. q-t interval is more prolonged. cxr: 1. stable post-surgical changes in the right lung from prior right lower lobectomy and upper wedge resection due to known non-small cell lung cancer. 2. hazy opacity in the left lower , reflect atelectasis. ct abd/pelvis: 1. bibasilar lung consolidations, worse when compared to prior exam. differential diagnosis includes infectious etiologies as well as a slow growing lesion such as bronchoalveolar carcinoma. clinical correlation is recommended. 2. no evidence of small bowel obstruction. colon appears relatively featureless with air-fluid levels and possibly pericolonic fat stranding versus third spacing. these findings may suggest a colitis. 3. extensive vascular calcifications. 4. large prostate. 5. s1 vertebral body fracture with buckling of the superior cortex, worse when compared to prior exam. left leni: impression: no left lower extremity dvt. kub: findings: small bowel loops containing air are seen without distension. there is a paucity of air in the left lower quadrant which might be due to liquid stool within the descending colon. no free air is seen on the right lateral decubitus film. the visualized osseous structures are unremarkable. the right lung base is not well seen with the dome of the diaghragm being pushed superiorly. this correlates with the right lower atelactasis on the corresponding ct. impression: no distended loops of bowel seen. brief hospital course: mr. is a 78m with stage iv nslc who presents with fevers from his rehab facility. . * hypotension: patient presented with hypotension concerning for sepsis. he was briefly on levophed and was taken off of pressors when sbp 100s-110s. his hypotension was probably due to hypovolemia from diuresis but severe hypotension in setting of developing sepsis was also considered. lactate down to 1.0 from 1.3 on admission with svo2 73. on the floors, his sbp's ranged in the 130's to 140's and he was restarted on his home doses of lasix was held for the several days prior to discharge because he was autodiuresing. he needs to be re-evaluated regularly for whether lasix needs to be restarted. he will likely need his lasix restarted at some point at rehab. his pressures remained stable throughout hospitalization. . * fever: patient's fever likely caused by c diff as patient is toxin positive, although aspiration pneumonia was also considered a possibility given evidence of dysphagia on prior video swallow. his underlying pulmonary malignancy predisposes him to a post-obstructive pneumonia. however the absence of cough or hypoxia made a pulmonary etiology less compelling. blood and urine cultures are negative. his c difficile colitis was originally treated with po vancomycin and iv flagyl. prior to discharge, as diarrhea began to resolve, he was switched to po flagyl alone, to be continued for a two week course (until ). . * l leg swelling and pain: patient had lower extremity pain edema greater on left than right after receiving fluid resuscitation in the icu. leni showed no evidence of dvt. he was diuresed with lasix until his fluid output was negative. he was autodiuresing on discharge so his lasix was held. his fluid status should be reassessed daily to determine if he needs to be restarted on lasix. * hyponatremia: patient's hyponatremia resolved after intravenous fluids, which supports hypovolemia as cause on admission. review of omr shows na's running ~130. at last discharge, thought to have a component of siadh. * acute renal failure: patient had creatinine elevated to 1.4 and fena was 0.1 on admission. creatinine has improved to 0.7-0.8 (his baseline). his acute renal failure has resolved and was likely pre-renal as it improved with ivf. * anemia: his hematocrit is down from admission but suspect this was secondary to hemoconcentration. his anemia is consistent with baseline. * nsclc: advanced disease, on palliative chemotherapy. social work and palliative care were consulted throughout this hospitalization and discussed goals of care with the family. erlotinib will be restarted on and should be taked every other day. he will follow up with dr. . * atrial fibrillation: his sotalol was restarted now that his hypotension resolved. # nutrition ?????? patient has aspiration risks and is unable to swallow pills easily. he was evaluated by nutrition and kept on a pureed diet with tid ensure. he also had an elevated inr despite not being on anticoagulation which possibly could be due to malnutrition. inr improved after administration of one dose of vitamin k. # oral thrush: patient failed nystatin swish and swallow. he was loaded with 400mg fluconazole and should continue 200mg daily until . #pain control: patient was maintained on methadone and diluadid prn during hospitalization. his methadone should be tapered and pain reassessed daily while in rehab. medications on admission: at rehab: erlotinib 100mg daily simvastatin 10mg daily lasix 20mg daily sotalol 80mg nifedipine 30mg daily methadone 15mg tid folate lidoderm patch , , mom, dulcolax, lactulose, senna, guiafenesin, colace, tylenol all prn zofran prn neurontin 300mg q12h heparin 5000 units sq tid discharge medications: 1. heparin (porcine) 5,000 unit/ml solution : one (1) injection injection tid (3 times a day). 2. metronidazole 500 mg tablet : one (1) tablet po q8h (every 8 hours): continue util . 3. neurontin 300 mg capsule : one (1) capsule po every twelve (12) hours. 4. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day) as needed for constipation: once diarrhea subsides, please start taking as standing dose . 5. methadone 10 mg tablet : one (1) tablet po tid (3 times a day). 6. simvastatin 10 mg tablet : one (1) tablet po daily (daily). 7. acetaminophen 325 mg tablet : 1-2 tablets po q4h (every 4 hours) as needed for pain: no more than 4g in 24 hours. 8. sotalol 80 mg tablet : one (1) tablet po bid (2 times a day). 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily): 12 hours on, 12 hours off. 10. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day). 11. nifedipine 30 mg tablet sustained release : one (1) tablet sustained release po daily (daily). 12. folic acid 1 mg tablet : one (1) tablet po daily (daily). 13. therapeutic multivitamin liquid : five (5) ml po daily (daily). 14. oral wound care products gel in packet : one (1) ml mucous membrane tid (3 times a day) as needed. 15. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed for fungal rash-groin. 16. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 17. simethicone 80 mg tablet, chewable : one (1) tablet, chewable po qid (4 times a day) as needed for gas. 18. dilaudid 2 mg tablet : 1-2 tablets po every four (4) hours as needed for pain. 19. senna 8.6 mg tablet : two (2) tablet po twice a day as needed for constipation: please start taking after diarrhea has resolved. 20. polyethylene glycol 3350 17 gram (100 %) powder in packet : one (1) dose po once a day as needed for constipation: please use as needed after diarrhea has resolved. 21. dulcolax 10 mg suppository : one (1) rectal once a day as needed for constipation: please start using as needed after diarrhea has resolved. 22. zofran 4 mg tablet : one (1) tablet po every eight (8) hours as needed for nausea. 23. ambien 5 mg tablet : one (1) tablet po at bedtime as needed for insomnia. 24. fluconazole 200 mg tablet : one (1) tablet po q24h (every 24 hours): continue until . 25. erlotinib 100 mg tablet : one (1) tablet po qod. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: 1. clostridium difficil colitis 2. dehydration 3. hyponatremia 4. hypotension secondary diagnosis: 1. non small cell lung cancer discharge condition: stable, afebrile bm's per day. discharge instructions: you were admitted to the hospital on with fevers secondary to clostridium dificile colitis (an infection in your colon). you are being treated with an antibiotic called flagyl. you need to continue this antibiotics until . you should stop taking lasix (water pill). your body has been eliminating excess fluid well without the lasix. your doctors your fluid status at rehab and decide whether or not you need lasix in future. you can continue to take methadone with dilaudid as needed for breakthrough pain. your doctors at rehab taper your methadone as needed. never drive while taking these medications or perform any activities requiring a fast reaction time. never drink alcohol with these medications. once your diarrhea stops, you should start taking colace and senna daily to prevent constipation, which is a common side effect of narcotics. you also had thrush in your mouth. continue to take fluconazole 200mg daily until . you should restart your erlotinib on and take it every other day. use miconazole for the fungal rash in your groin. apply it four times a day. please return to the emergency room if you have worsening diarrhea >10 bm per day, bloody/black stools, fever>100.4, chest pain, shortness of breath, or any other symptoms concerning to you. followup instructions: please follow up with dr. in weeks. md, Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Diagnoses: Anemia, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Chronic airway obstruction, not elsewhere classified Atrial fibrillation Candidiasis of mouth Septic shock Intestinal infection due to Clostridium difficile Malignant neoplasm of other parts of bronchus or lung Secondary malignant neoplasm of bone and bone marrow

allergies: valium / warfarin / morphine attending: chief complaint: pain in right chest major surgical or invasive procedure: paravertebral catheter placement for pain management history of present illness: this is a 85 year old male who was struck by a car while walking across the street. prior to the event, he states he was feeling well without dizziness or loss of balance. he states he lost consciousness for approximately 4-5 minutes, but he has no amnesia to the event. upon arrival to via ems, he was found to have a r pelvic acetabular fracture, as well as a r pneumothorax. he currently denies ha, nausea/vomiting, blurred vision. he takes asa and plavix daily for his proximal lad stent. past medical history: 1. dyslipidemia 2. hypertension 3. stenting of proximal lad 4. cva x 2 without residual disability. location of cva unknown 5. basal cell ca 6. l cea with stent social history: married, lives with wife. at nursing home as as custodial worker. former tobacco smoker. no etoh abuse. family history: non contributory physical exam: o: t: afebrile bp: 120/31 hr:73 r:23 o2sats:100% face tent gen: wd/wn, comfortable, nad. heent: normocephalic. staples intact to r parietal laceration. not actively bleeding. pupils: 3-2.5 bilat eoms: intact extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2.5 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. difficult to assess r leg acetabular fracture, but able to isolate muscle groups and good strength is noted. no pronator drift toes downgoing bilaterally pertinent results: 11:30am wbc-18.9* rbc-2.95* hgb-8.8* hct-26.4* mcv-90 mch-29.9 mchc-33.4 rdw-13.8 11:30am neuts-89.2* lymphs-6.2* monos-4.2 eos-0.3 basos-0.2 11:30am plt count-205 11:30am glucose-143* urea n-20 creat-1.1 sodium-144 potassium-4.4 chloride-115* total co2-21* anion gap-12 11:30am alt(sgpt)-64* ast(sgot)-100* ck(cpk)-977* alk phos-54 tot bili-0.4 11:30am alt(sgpt)-64* ast(sgot)-100* ck(cpk)-977* alk phos-54 tot bili-0.4 11:30am lipase-56 01:09pm glucose-133* urea n-19 creat-1.1 sodium-144 potassium-4.4 chloride-115* total co2-24 anion gap-9 01:09pm wbc-16.4* rbc-2.95* hgb-8.8* hct-26.2* mcv-89 mch-29.9 mchc-33.6 rdw-14.0 wbc rbc hgb hct mcv mch mchc rdw plt ct 07:30am 8.8 3.19* 9.4* 27.2* 85 29.4 34.6 15.2 99* !0/28/09 cardiac echo : the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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 left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. ct chest/abd/pelvis : 1. interval development of soft tissue stranding and haziness in the anterior mediastinum concerning for mediastinal hematoma. 2. interval placement of a right chest tube with interval decrease in size of right pneumothorax, now small, and with decreased shift of the mediastinum. subcutaneous emphysema extending along the right lateral and posterior chest, abdomen and pelvis. multiple right-sided rib fractures, with a displaced fracture of the right posterior 8th rib and multiple additional nondisplaced fractures, as above. 3. left upper lobe ground-glass opacity, may represent pulmonary contusion. 4. multiple areas of mesenteric stranding and haziness likely reflect mesenteric contusions with more confluent area inferior to the spleen containing areas of high density, likely reflecting small hemoperitoneum. 5. multiple pelvic fractures including right superior and inferior pubic rami with extension into the right acetabulum and a right iliac fracture. right pelvic hematoma adjacent to the right superior pubic rami fractures, grossly stable in size as compared to the prior study. large lateral right buttock hematoma with extensive overlying contusions/soft tissue induration. mild anterolisthesis of l4 over l5 of indeterminate age, but moderate adjacent degenerative changes suggests this could be chronic. recommend clinical correlation with point tenderness. 6. collapsed distal descending colon/proximal sigmoid colon with suggestion of mild wall thickening, new since prior study, bowel injury cannot be excluded. adjacent mild fat stranding in this area. 7. infrarenal abdominal aortic aneurysm. study not tailored for evaluation for dissection. 8. multiple incidental findings, including cholelithiasis. innumerable splenic calcifications as well as calcified mediastinal/hilar lymph nodes, most likely reflect prior granulomatous disease. head ct : 1. no evidence of fractures or misalignment of the cervical spine. 2. moderate-to-severe degenerative changes along the cervical spine, most severe from c3 through c7, with associated moderate spinal canal stenosis. 3. significant right pneumothorax. ct c spine : . small left acute subdural hematoma overlying the left temporal lobe, without significant mass effect or shift of normally midline structures. 2. large right pneumothorax, with shift of the mediastinum to the left, suggestive of tension. 3. small focus of contusion within the left upper lobe in the lung. 4. patchy areas of stranding throughout the mesentery, suspicious for mesenteric injury. 5. small focus of hemoperitoneum inferior to the tip of the spleen, without definite splenic injury identified, though limited by respiratory motion. 6. mildly displaced fractures involving the right inferior and superior pubic rami, likely extending into the acetabulum. mildly displaced right iliac fracture. 7. mildly displaced right eighth rib fracture. 8. marked atheromatous disease of the abdominal aorta, without definite acute aortic injury. head ct : 1. redistribution of subdural hemorrhage. minimal subarachnoid hemorrhage now detected. no mass effect. 2. minor sinus mucosal changes in the ethmoidal sinus. 3. new surgical staples at the skin overlying the right parietal bone towards the vertex. cxr : no evident pneumothorax. no interval change from prior. brief hospital course: mr. was evaluated by the trauma service in the emergency room then admitted to the trauma icu for further evaluation and management. he was seen by the cardiology service as he had st depression anterior, septal and laterally on his ekg. his troponin and ckmb index was normal so he underwent tte in light of his past history of nstemi'. there was no wall motion abnormalities and his ef was normal. the ekg changes were due to demand ischemia (ie pain, trauma ) in the setting of anemia. due to his rib fractures and uncontrolled pain, he had a paravertebral block placed for pain control which also helped his pain from a right chest tube placement for pneumothorax. subsequently a continuous infusion of ropivacaine was used through the paravertebral catheter which effectively controlled his pain. he was transfused with a total of 4 units of packed rbc's during his hospitalization. his lowest hematocrit was 26 and most recently has stabilized in the 27-30 range. he remained in the icu for close neuro monitoring due to his left subdural hematoma. he was placed on keppra for seizure prophylaxis as well. he had no neurologic deficits and a repeat head ct was unchanged. his aspirin and plavix were then resumed. during his stay in the icu he was evaluated by the orthopedic service for his pelvic fractures and they will be treated in a closed manner therefore his weight bearing status is advance weight bearing as tolerated. on he was transferred to the trauma floor where he continued to make good progress. his chest tube was removed on and a post pull film showed no pneumothorax or effusion. his oxygen was weaned off easily and he was able to participate in limited physical therapy due to his injuries. following removal of his paravertebral catheter his pain was controlled with oxycodone effectively. he continued to work with physical therapy and was able to stand and pivot from bed to chair with 1 assist. his appetite was gradually improving and he was having normal bowel movements. hopefully after a stint in rehab he will be able to go home with increased independence. medications on admission: zocor (unknown dose) metoprolol 50 mg po bid plavix 75 mg daily asa 81 mg po daily study drug for cad discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. simvastatin 10 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. senna 8.6 mg tablet sig: two (2) tablet po hs (at bedtime). 5. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day): thru 11//. 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 8. fondaparinux 2.5 mg/0.5 ml syringe sig: 2.5 mg subcutaneous daily (daily). 9. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 10. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). discharge disposition: extended care facility: discharge diagnosis: primary diagnosis s/p fall, pedestrian struck by car with 1. subdural hematoma 2. pelvic fracture (right inf pubic ramus,right iliac fracture, right ischium fracture, right posterior acetabular fracture) 3. right pneumothorax 4. right rib fractures 5,6,8 and 9 5. left upper lobe pulmonary contusion secondary diagnoses 1. cad with nstemi withstents in lad & circ 2. dyslipidemia 3. hypertension 4. cva x 2 without residual disability. location of cva unknown 5. basal cell ca 6. l cea with stent discharge condition: stable, tolerating a heart healthy diet,pain controlled with oxycodone discharge instructions: call your neurosurgeon( 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. ?????? 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 doctor 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. call dr. at for a follow up appointment in 2 weeks call the clinic at for a follow up appointment in 4 weeks with dr. Procedure: Insertion of intercostal catheter for drainage Injection or infusion of other therapeutic or prophylactic substance Injection of other agent into spinal canal Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Other and unspecified hyperlipidemia Personal history of other malignant neoplasm of skin Old myocardial infarction Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Traumatic pneumothorax without mention of open wound into thorax Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Traumatic subcutaneous emphysema Contusion of lung without mention of open wound into thorax Street and highway accidents Closed fracture of pubis Closed fracture of acetabulum Closed fracture of four ribs Closed fracture of ischium Closed fracture of ilium Unspecified external cause status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pancreatitis major surgical or invasive procedure: endotracheal intubation, central line history of present illness: 74 yo m h/o hiv, on haart and active etoh use, intially presented to hospital on for 4d weakness and lower abdominal pain with nausea and vomiting. lipase elevated to 194 and ct scan c/w severe pancreatitis without evidence of necrosis or pseudocyst. abdominal u/s showed fatty liver, sludge, no acute cholecystitis and hida scan normal. pancreatitis thought to be to alcohol use, also concern for drug reaction and haart meds held. initially received zosyn/flagyl in ed and was changed to levo/flagyl on the floor. given ivf and pain medication. pt was afebrile but developed a worsening leukocytosis with a left shift and also developed low grade fevers. repeat ct showed evidence of unchanged pancreatitis and concern for pseudocyst formation. antibiotics changed to zosyn on . has been npo, tpn was to start on day of transfer but did not happen. . pt was initially placed on ciwa scale, however remained confused and resless. negative head ct. per family, cognitive decline x1yr with decreased term mom. hospital course was complicated by worsening alcohol withdrawal requiring frequent on ciwa and transfer to icu for nursing needs. pt has also developed afib to 120s-130s, treated with iv digoxin and lopressor push, with stable bps in 150s/80s. inr 5.2 on admission, warfarin held and vitamin k started. hypernatremia to 161 developed on , fluids changed to d5w from ns. labs on transfer were significant for na 161 (134 on admission), k 3, ck 4278, ldh 1214, wbc 19.9, hct 35.2, inr 5.2 (given vitk x 1 sc). pt coming to with picc placed today, getting d5w20k@150ml/hr. on arrival to micu, pt unable to provide further history review of systems is otherwise past medical history: hiv, diagnosed in on haart, with cd4 >1000 and undetectable viral load htn a fib/flutter chronic lbp s/p surgery h/o hepatitis h/o pancreatitis ? h/o ulcer oa rectal polyp spina bifida occulta social history: regular etoh, glasses of beer daily. denies tob. lives alone. family history: noncontributory physical exam: on admission: general: aggitated, in restraints, does not follow commands heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla. dry mucus membranes with thrush. op clear. cardiac: irregular, tachycardia. normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. abdomen: distention, diffuse ttp as evident by moaning extremities: no edema, 2+ dorsalis pedis/ posterior tibial pulses. moves all extremities. skin: no rashes/lesions, ecchymoses. neuro: unable to fully assess pertinent results: ct abdomen and pelvis w/ contrast: impression: 1. severe pancreatitis with peripancreatic stranding and fluid, but no pancreatic necrosis or pseudocyst. reactive inflammation in the descending colon. 2. small blush along the course of a mesenteric vessel may represent a tiny pseudoaneurysm at the inferior margins of the inflammatory change. however this is not along the course of the dominant abdominal aortic vessels. 3. multiple renal hypodensities, most of which represent cysts, but the smallest of which cannot be fully characterized. lab results on admission: 09:40pm wbc-18.5* rbc-3.31* hgb-12.3* hct-37.4* mcv-113* mch-37.0* mchc-32.8 rdw-16.2* 09:40pm neuts-80.4* lymphs-13.2* monos-5.5 eos-0.6 basos-0.3 09:40pm plt count-426 09:40pm pt-44.8* ptt-40.9* inr(pt)-4.8* 09:40pm albumin-2.7* calcium-8.9 phosphate-2.2* magnesium-1.6 09:40pm glucose-132* urea n-26* creat-1.3* sodium-161* potassium-3.2* chloride-126* total co2-25 anion gap-13 10:57pm calcium-9.2 phosphate-2.3* magnesium-2.0 09:40pm alt(sgpt)-32 ast(sgot)-43* ld(ldh)-517* alk phos-72 amylase-404* tot bili-1.2 09:40pm lipase-19 10:57pm ck(cpk)-211* 10:58pm urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 10:58pm urine rbc-7* wbc-5 bacteria-few yeast-none epi-<1 02:27pm cerebrospinal fluid (csf) wbc-2 rbc-0 polys-1 lymphs-94 monos-5 02:27pm cerebrospinal fluid (csf) totprot-42 glucose-95 02:27pm cerebrospinal fluid (csf) herpes simplex virus pcr-test name 09:40pm blood alt-32 ast-43* ld(ldh)-517* alkphos-72 amylase-404* totbili-1.2 11:09am blood vitb12-744 folate-greater th brief hospital course: 74yo male with h/o hiv on haart and etoh abuse transfered from osh with pancreatitis and altered mental status. eventually made comfort measures only and deceased . hospital course by problem: . #. pancreatitis - patient arrived with severe pancreatitis as demonstrated on ct with evidence of pseudocyst. etiology thought likely secondary to alcohol abuse vs drug reaction, and his haart therapy was held at the osh and throughout his hospitalization here. he had an unremarkable ruq ultrasound, making cholelithiasis unlikely and his triglycerides were negative at 253. his lipase normalized within a couple of days, but he continued to have low-grade fevers. all of his cultures were negative except for one bottle of coagulase negative staph. his ??????s criteria was significant for age, wbc??????s and ldh on presentation and hct drop, base deficit, and fluid sequestration at 48hrs. with these six criteria, he already had a 40% chance mortality. he was initially kept npo and given aggressive fluid resuscitation, receiving 17l of fluid during his hospitalization. eventually another post-pyloric dobhoff was placed by ir and low-rate enteric feeding was started and tolerated well. he required considerable pain control with morphine, which combined with his altered mental status, caused respiratory failure and he had to be intubated. he also became hypotensive and required protracted support with norpinephrin. after a week of intubation, it became clear that though the patient's status had stabilized, it would be a long, drawn-out process and that the patient would be unlikely to regain his full baseline. his son and daughter discussed that their father had always been stubbornly independent and would not have wanted to live requiring extensive 24 hour care. it was decided to make the patient comfort measures only, and he was terminally extubated and pressors stopped . he passed away 6-7 hours later. #. altered mental status - patient arrived with altered mental status and a history of several months of neurologic decline. there was no evidence of hemorrhage or trauma on ct. his csf showed no infection and a tsh normal. he did not have signs of alcohol withdrawal and his status did not improve with benzodiazepenes. his cultures were always negative and he did not receive antibiotics. he showed some signs of becoming more reactive on exam, but did not becoming fully responsive at any point. . #. hiv - diagnosed in and on long-term haart therapy. his medications were held in the setting of this acute event. his outpatient id doctor who agreed with holding hiv meds during the pancreatitis. . #. atrial fibrillation: patient had a history of atrial fibrillation and arrived supratherapeutic with an inr of 4.8. his inr was allowed to drift down to 1.2. he was rate controlled initially with metoprolol and later was stable without medications. medications on admission: flomax 0.4mg daily tramadol 15-30mg tid atenolol 50mg daily coumadin 5mg daily efabirenz 200mg qhs combavir 1 tab tricor 145mg daily citalopram 45mg daily on transfer: vit k 5mg sq daily lopressor 10mg iv q6 zosyn 3.75mg iv q6 ativan digoxin 0.25mg iv daily (started ) protonix 40mg iv daily celexa 40mg po daily morphine 2-4mg iv q4 discharge medications: none discharge disposition: expired discharge diagnosis: primary diagnosis: severe pancreatitis secondary diagnosis: respiratory failure cardiopulmonary arrest atrial fibrillation discharge condition: deceased discharge instructions: none followup instructions: none md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Acidosis Abnormal coagulation profile Atrial fibrillation Atrial flutter Acute respiratory failure Cardiac arrest Osteoarthrosis, unspecified whether generalized or localized, site unspecified Paralytic ileus Other postprocedural status Anticoagulants causing adverse effects in therapeutic use Hyperosmolality and/or hypernatremia Lumbago Acute pancreatitis Asymptomatic human immunodeficiency virus [HIV] infection status Other and unspecified alcohol dependence, continuous Alcohol withdrawal Cyst of kidney, acquired Shock, unspecified Alcoholic fatty liver Spina bifida occulta

allergies: patient recorded as having no known allergies to drugs attending: addendum: final pathology of the retroperitoneal mass returned as seminoma (see path reports below). there are sparse cases of single demyelinating lesions occurring in pt's with seminomas, thought to be a paraneoplastic process. see: facial numbness in a man with inguinal and retroperitoneal masses. sr, mv, js. nat clin pract oncol. ;2(1):54-8 and solitary focal demyelination in the brain as a paraneoplastic disorder. jh, bertorini te, fc jr, tf, h, becske t, pg, handorf cr, horner lh, m??????nkem??????ller ke. med pediatr oncol. ;26(2):111-5. and paraneoplastic demyelinating disorder in the brain of a patient with seminoma. k, p, k, c, kostashuk e. j comput assist tomogr. -;22(1):136-8. retroperitoneal mass biopsy : diagnosis: retroperitoneal mass (parts 1 - 6) metastatic malignant neoplasm (see note). immunostains and morphology favor a germ cell tumor, seminoma. note: the tumor is composed of large cells with abundant clear cytoplasm, round nuclei with prominent central nucleoli in sheets with a background of lymphoid hyperplasia and necrotizing granulomas. tumor cells are positive for: c-kit negative for: cytokeratin cocktail, cd30 (immunoblasts only), s100 (macrophages only), afp, and plap (however, no internal control). an lca will be reported in an addendum. addendum: a stain for lca is negative (small lymphocytes only). addendum added by: dr. /jlh date: clinical: retroperitoneal mass. gross: the specimen is received in six parts, all labeled with the patient's name, ", " and the medical record number. part 1 is additionally labeled "left peritoneal mass biopsy frozen section." it consists of a fragment of soft tissue measuring 1 x 0.5 x 0.6 cm. the peripheral smear was done on the specimen. peripheral smear diagnosis by dr. is "sclerotic tissue with small lymphocytes, likely reactive." the specimen was entirely submitted in a. part 2 is additionally labeled "retroperitoneal mass, left frozen section #2." it consists of red tan multiple soft tissue fragments measuring 1 x 1 x 0.4 cm in aggregate. the surface of one of the fragments is smooth and probably has peritoneum. frozen section diagnosis by dr. is "poorly differentiated epithelioid neoplasm plus adjacent reactive/fibrotic tissue. insufficient for diagnosis." frozen section remnant is submitted in b, the remainder is submitted in c. part 3 is additionally labeled "retroperitoneal mass biopsy #3." it consists of red tan soft tissue fragments measuring 0.9 x 0.4 x 0.2 cm. the specimen is entirely frozen. frozen section diagnosis by dr. is "sclerotic tissue with chronic inflammation, no malignancy identified." the specimen is entirely submitted in d. part 4 is additionally labeled "retroperitoneal mass biopsy #4." it consists of multiple red tan soft tissue fragments measuring 1 x 1 x 1 cm in aggregate. no frozen section was performed on that specimen. the specimen is entirely submitted in e. part 5 is additionally labeled "retroperitoneal mass biopsy #5." it consists of multiple soft tissue fragments measuring 1 x 1 x 0.5 cm in aggregate. a portion of specimen was frozen. frozen section diagnosis by dr. is "positive for poorly differentiated epithelioid neoplasm." the specimen was submitted as follows: frozen section remnant in f, the remainder of the specimen is in g. part 6 is additionally labeled "retroperitoneal mass biopsy #6." it was received fresh from the operating room. it consists of fleshy and hemorrhagic soft tissue fragment measuring 2 x 1.5 x 1 cm in aggregate. the specimen is partially frozen. frozen section diagnosis by dr. is "lesional tissue present." the specimen is entirely submitted as follows: h = frozen section, i-l = remainder of the specimen. lypmh node flow cytometric immunophenotyping : specimen submitted: immunophenotyping, lymph node procedure date tissue received report date diagnosed by dr. /mrr?????? previous biopsies: retroperitoneal mass bx, retroperitoneal mass bx, retroperitoneal mass. (1 jar) left occipital lobe tumor, #2 left occipital lobe tumor, diagnosis: flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, fmc-7, kappa, lambda, and cd antigens 2, 3, 5, 7, 10, 19, 19, 20, 23, 45. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. b cells comprise 34% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. t cells comprise 59% of lymphoid gated events, express mature lineage antigens. interpretation non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. correlation with clinical findings and morphology (see s09-4354) is recommended. flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. discharge disposition: home with service facility: community health and nursing services discharge diagnosis: retroperitoneal mass: final pathology seminoma left posterior parietal lesion: final pathology demyelination followup instructions: he will follow with his oncologist in for treatment of the seminoma. md Procedure: Open biopsy of brain Biopsy of peritoneum Closed [percutaneous] [needle] biopsy of intra-abdominal mass Diagnoses: Obstructive sleep apnea (adult)(pediatric) Long-term (current) use of steroids Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Percutaneous transluminal coronary angioplasty status Morbid obesity Encephalopathy, unspecified Homonymous bilateral field defects Demyelinating disease of central nervous system, unspecified Other symbolic dysfunction Malignant neoplasm of specified parts of peritoneum Alexia and dyslexia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: confusion major surgical or invasive procedure: mri under anesthesia : open left parietal craniotomy for biopsy history of present illness: mr is a 58 y/o right handed man with history of dm2 and cad who presented from osh with increasing confusion, forgetfulness, peripheral vision loss and agraphia. the patient was in his usual state of health until when he was in a minor car accident after making a wrong turn on a familiar street, hitting a post from the r side. he was not injured in the fender-bender. the next day, he was forgetful and left his car door open when at work. on saturday , he stated to his wife that he felt "muttled", but did not complain of any specific deficits nor did his wife note any. however, the next day his daughter reported that he mixed up words when speaking with her. on monday (), he could not remember his address when asked by the auto-mechanic. he was able to go to work at court, but was worried when he could not figure out how to sign his name. specifically, he had difficulty writing letters and was perseverative. though he knew what he wanted to write, he was not able to do so correctly. this event prompted him to consult his pcp who discovered small right peripheral visual field deficit which mr. wife states was "about 10% of his vision". he had never had this before. he had no headache. his doctor requested a head ct which he had on . the ct scan revealed a left parietal/occipital mass. the next day, his symptoms persisted and he was admitted to this hospital. per his wife, in the days leading up to admission, mr. did not have any fever, cough, weight changes, nausea, vomiting, or diarrhea, or other signs of infection. he did not complain of numbness, weakness, tingling, or hearing changes. no recent travel or tick exposure. most recent immunization was influenza vaccine in , which he had received in prior years without problems. prior such episodes. on admission, his r visual field cut was noted to be more pronounced. over the next couple of days()), he had decreased speech production, decreased attention, and decreased orientation to his surroundings. he could not remember how to use the phone. because of his clinical deterioration and concern for high-grade glioma, on , he had a stereotactic brain biopsy of the left occipital/parietal mass. he was intubated and sedated until the morning of . during the night he was noted to not be moving his rue as much as the left, stat head ct was unchanged. he was extubated and given haldol 2.5mg for aggitation at 9:30am (1.5 hours before exam). he has been on broad-spectrum empiric abx (vanc/gent/levoflox) given concern for abscess though prelim path gram stain was sterile. he has also been placed on empiric keppra prophylaxis though no clinical episodes concerning for seizure. past medical history: 1. dm2 with poor control and peripheral neuropathy 2. coronary artery disease s/p cabgx4 and stent deployment circa 3. obstructive sleep apnea (uses cpap at night) 4. obesity 5. dyslipidemia 6. seasonal allergies social history: the patient is an atorney in . he is a college graduate and received the highest possible score on his lsat examination. he is married for 29 years and lives with his wife. does not use drugs. he has never had a blood transfusion. wife may be reached at , daughter may be reached at . family history: no family history of demyelinating disease such as ms, no history of neurologic conditions or autoimmune disorders. physical exam: t-97.5 bp-131/64 (126-154/57-65) hr-93(74-91)sr rr-20 o2sat-95% on fi40% ventimask gen: lying in bed restrained, nad heent: has neurosurgical wound on posterior left aspect of head, dry oral mucosa. neck: no tenderness to palpation, normal rom, supple, no carotid or vertebral bruit back: unable to assess cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: +bs soft, nontender ext: no edema skin: no rashes neurologic examination: ms: general: awake but drowsy, normal affect, very perseverative orientation: not oriented to person, place, time, or situation. attention: very inattentive, but temporarily redirectable. speech/: he is able to express basic thoughts and give basic yes/no replies; comprehension intact to simple commands, repetition intact to "today is a sunny day" but impaired to more abstarct sentence, could not name or read but claimed to not be able to see what was being shown and was inattentive memory: n/a due to inattention calculations: n/a due to inattention l/r confusion: appears confused, but difficult to assess given inattentiveness praxis: n/a due to inattention cn: i: not tested ii,iii: patient inattentive but appears to have a right homonomous hemianopsia, perrl 2mm to 1.5mm, iii,iv,v: eomi, no ptosis. no nystagmus v: sensation intact v1-v3 to lt vii: facial strength intact/symmetrical viii: hears finger rub bilaterally ix,x: palate elevates symmetrically, uvula midline : scm/trapezeii on left, on right. xii: tongue protrudes midline, no dysarthria motor: normal bulk and ?mild increased tone rle; no tremor, asterixis or myoclonus. pronator drift n/a due to inattention. delt tri we fe grip io c5 c6 c7 c6 c7 c8/t1 t1 l 5 5 5 5 5 5 5 r 3 3 3 3 3 3 3 ip quad hamst df pf l2 l3 l4-s1 l4 l5 s1/s2 l 5 5 5 5 5 5 r 4- 4- 4- 4- 4- 4- reflex: no clonus tri bra pat an plantar c5 c7 c6 l4 s1 cst l 0 0 0 2 0 extensor r 0 0 0 2 0 extensor sensation: grimaces and attempts withdrawal from noxious in all extremities purposefully coordination: finger-nose-finger normal on left but r not assess given hemiparesis. gait: n/a romberg: n/a pertinent results: 06:08am blood wbc-9.1 rbc-3.72* hgb-10.7* hct-32.6* mcv-88 mch-28.9 mchc-33.0 rdw-15.4 plt ct-121* 05:40am blood wbc-12.9* rbc-3.98* hgb-11.9* hct-35.0* mcv-88 mch-29.8 mchc-33.9 rdw-15.7* plt ct-186 08:40am blood wbc-9.4 rbc-4.03* hgb-11.8* hct-34.9* mcv-87 mch-29.3 mchc-33.9 rdw-15.7* plt ct-152 09:40pm blood wbc-11.1* rbc-4.03* hgb-12.0* hct-35.3* mcv-88 mch-29.8 mchc-34.1 rdw-15.5 plt ct-156 06:09am blood wbc-11.9* rbc-4.14* hgb-12.1* hct-35.1* mcv-85 mch-29.2 mchc-34.4 rdw-15.3 plt ct-185 06:15am blood wbc-11.4* rbc-4.12* hgb-12.4* hct-35.5* mcv-86 mch-30.0 mchc-34.8 rdw-15.4 plt ct-180 05:25am blood wbc-10.7 rbc-4.40* hgb-13.1* hct-38.0* mcv-86 mch-29.6 mchc-34.4 rdw-15.4 plt ct-209 07:20am blood wbc-7.7 rbc-4.35* hgb-12.7* hct-37.5* mcv-86 mch-29.2 mchc-33.8 rdw-15.2 plt ct-221 07:45am blood wbc-6.1 rbc-4.08* hgb-12.0* hct-35.5* mcv-87 mch-29.5 mchc-33.9 rdw-14.9 plt ct-205 04:13am blood wbc-7.4 rbc-3.70* hgb-11.1* hct-31.3* mcv-85 mch-30.1 mchc-35.6* rdw-15.3 plt ct-181 03:05am blood wbc-11.0 rbc-3.98* hgb-11.6* hct-33.5* mcv-84 mch-29.1 mchc-34.6 rdw-15.2 plt ct-207 02:44am blood wbc-9.3 rbc-4.16* hgb-12.1* hct-35.2* mcv-85 mch-29.1 mchc-34.4 rdw-15.4 plt ct-187 07:26pm blood wbc-13.9* rbc-4.06* hgb-11.9* hct-34.3* mcv-85 mch-29.4 mchc-34.8 rdw-15.5 plt ct-184 03:26am blood wbc-13.2* rbc-4.02* hgb-11.8* hct-33.7* mcv-84 mch-29.4 mchc-35.1* rdw-15.6* plt ct-205 04:14pm blood wbc-11.6* rbc-4.31* hgb-12.7* hct-36.7* mcv-85 mch-29.4 mchc-34.5 rdw-15.3 plt ct-220 07:50am blood wbc-8.2 rbc-4.61 hgb-13.5* hct-40.0 mcv-87 mch-29.3 mchc-33.7 rdw-15.2 plt ct-188 07:25am blood wbc-8.5 rbc-4.39* hgb-12.7* hct-37.5* mcv-86 mch-29.1 mchc-33.9 rdw-15.3 plt ct-200 05:48am blood wbc-11.6* rbc-4.19* hgb-12.6* hct-36.2* mcv-87 mch-30.1 mchc-34.8 rdw-15.3 plt ct-194 01:45am blood wbc-10.0 rbc-4.35* hgb-12.8* hct-37.1* mcv-85 mch-29.5 mchc-34.6 rdw-15.5 plt ct-235 11:00pm blood wbc-10.9 rbc-4.58* hgb-13.4* hct-38.8* mcv-85 mch-29.2 mchc-34.4 rdw-15.4 plt ct-230 06:15am blood neuts-75.4* lymphs-17.5* monos-6.0 eos-0.7 baso-0.4 11:00pm blood neuts-68.2 lymphs-20.7 monos-5.6 eos-4.5* baso-1.0 08:40am blood pt-14.0* ptt-23.0 inr(pt)-1.2* 10:30am blood pt-13.7* ptt-22.7 inr(pt)-1.2* 04:13am blood pt-15.2* ptt-20.7* inr(pt)-1.3* 03:05am blood pt-14.5* ptt-20.9* inr(pt)-1.3* 02:44am blood pt-14.9* ptt-23.3 inr(pt)-1.3* 03:26am blood pt-14.4* ptt-21.9* inr(pt)-1.3* 04:14pm blood pt-14.3* ptt-24.4 inr(pt)-1.2* 07:50am blood pt-15.0* ptt-26.1 inr(pt)-1.3* 07:25am blood pt-14.2* ptt-25.1 inr(pt)-1.2* 05:48am blood pt-14.7* ptt-24.5 inr(pt)-1.3* 01:45am blood pt-15.1* ptt-24.4 inr(pt)-1.3* 11:00pm blood pt-14.7* ptt-24.5 inr(pt)-1.3* 01:45am blood esr-28* 06:08am blood glucose-81 urean-10 creat-0.7 na-138 k-3.3 cl-101 hco3-27 angap-13 05:40am blood glucose-80 urean-12 creat-0.9 na-140 k-4.2 cl-105 hco3-26 angap-13 08:40am blood glucose-164* urean-15 creat-0.8 na-138 k-3.7 cl-105 hco3-26 angap-11 09:40pm blood glucose-259* urean-17 creat-0.9 na-140 k-4.3 cl-103 hco3-26 angap-15 06:09am blood glucose-54* urean-19 creat-0.8 na-141 k-3.5 cl-106 hco3-26 angap-13 06:15am blood glucose-112* urean-18 creat-0.8 na-140 k-3.9 cl-107 hco3-26 angap-11 06:15am blood glucose-155* urean-18 creat-0.8 na-137 k-4.4 cl-101 hco3-27 angap-13 05:25am blood glucose-216* urean-18 creat-0.7 na-139 k-4.4 cl-104 hco3-28 angap-11 07:20am blood glucose-235* urean-22* creat-0.8 na-137 k-4.2 cl-102 hco3-27 angap-12 07:45am blood glucose-262* urean-22* creat-0.8 na-137 k-4.5 cl-102 hco3-24 angap-16 04:13am blood glucose-270* urean-22* creat-0.8 na-138 k-4.1 cl-104 hco3-28 angap-10 03:05am blood glucose-111* urean-19 creat-0.7 na-138 k-4.3 cl-103 hco3-29 angap-10 02:44am blood glucose-172* urean-12 creat-0.8 na-139 k-4.3 cl-105 hco3-26 angap-12 03:26am blood glucose-263* urean-15 creat-0.8 na-136 k-3.9 cl-104 hco3-23 angap-13 04:14pm blood glucose-228* urean-18 creat-1.0 na-135 k-5.4* cl-102 hco3-23 angap-15 07:50am blood glucose-275* urean-16 creat-0.8 na-136 k-4.4 cl-101 hco3-23 angap-16 07:25am blood glucose-192* urean-14 creat-0.8 na-136 k-4.4 cl-100 hco3-26 angap-14 07:25am blood glucose-192* urean-14 creat-0.8 na-136 k-4.4 cl-100 hco3-26 angap-14 05:48am blood glucose-171* urean-16 creat-0.7 na-140 k-4.1 cl-103 hco3-26 angap-15 01:45am blood glucose-174* urean-14 creat-0.9 na-138 k-3.9 cl-102 hco3-27 angap-13 11:00pm blood glucose-105 urean-13 creat-0.7 na-140 k-4.0 cl-104 hco3-26 angap-14 05:40am blood alt-72* ast-54* ld(ldh)-277* alkphos-84 totbili-0.5 06:15am blood alt-91* ast-43* ld(ldh)-271* ck(cpk)-229* alkphos-88 totbili-0.5 02:08pm blood alt-62* ast-53* ld(ldh)-217 alkphos-96 amylase-14 totbili-0.3 03:26am blood ck(cpk)-1776* 04:14pm blood ck(cpk)-196* 01:45am blood alt-42* ast-38 alkphos-101 totbili-0.4 02:08pm blood lipase-11 03:26am blood ck-mb-30* mb indx-1.7 ctropnt-<0.01 04:14pm blood ck-mb-5 ctropnt-<0.01 05:40am blood calcium-8.2* phos-3.9 mg-2.1 uricacd-5.2 09:40pm blood calcium-8.4 phos-2.4*# mg-2.0 06:15am blood calcium-8.3* phos-4.0 mg-2.4 06:15am blood totprot-6.6 albumin-3.5 globuln-3.1 calcium-8.2* phos-3.5 mg-2.4 04:13am blood calcium-8.4 phos-3.4 mg-2.3 03:05am blood calcium-8.4 phos-4.0 mg-2.3 02:08pm blood albumin-3.6 02:44am blood calcium-8.9 phos-2.9 mg-2.0 03:26am blood calcium-8.6 phos-2.9 mg-1.9 04:14pm blood calcium-8.5 phos-3.2 mg-2.0 07:25am blood calcium-8.6 phos-3.3 mg-2.2 05:48am blood calcium-8.8 phos-3.5 mg-2.1 01:45am blood calcium-9.0 phos-3.6 mg-1.9 02:08pm blood hbsag-negative hbsab-negative hbcab-negative 02:08pm blood hcg-<5 06:57pm blood psa-0.1 02:08pm blood afp-1.9 01:45am blood crp-8.9* 06:15am blood pep-no specifi 06:15am blood hiv ab-negative 07:42am blood vanco-12.1 02:08pm blood hcv ab-negative 02:54am blood type-art po2-96 pco2-44 ph-7.40 caltco2-28 base xs-1 12:30pm blood type-art po2-110* pco2-44 ph-7.37 caltco2-26 base xs-0 08:45am blood type-art po2-155* pco2-36 ph-7.42 caltco2-24 base xs-0 03:34am blood type-art po2-102 pco2-38 ph-7.45 caltco2-27 base xs-2 10:09pm blood type-art po2-91 pco2-33* ph-7.46* caltco2-24 base xs-0 06:37pm blood type-art po2-240* pco2-39 ph-7.41 caltco2-26 base xs-0 04:30pm blood type-art po2-232* pco2-47* ph-7.35 caltco2-27 base xs-0 01:45pm blood type-art po2-204* pco2-36 ph-7.44 caltco2-25 base xs-1 intubat-intubated 11:48am blood type-art po2-199* pco2-41 ph-7.41 caltco2-27 base xs-1 intubat-intubated vent-controlled angiotensin converting 10 u/l enzyme mri brain : conclusion: left parietal lesion with inhomogeneous peripheral enhancement, surrounding edema, and strikingly slow diffusion in portions of the periphery. although a malignant neoplasm must be considered, the properties of the margin, including the diffusion characteristics, raise the possibility of an inflammatory or demyelinating process as discussed above. ct abd, pelvis : impression: 1. large left retroperitoneal soft tissue mass as well as large retroperitoneal lymphadenopathy. primary diagnostic considerations include paraganglioma, extra-adrenal pheochromocytoma and metastatic disease. 2: cholelithiasis. ct chest: : airways are patent to the subsegmental levels bilaterally. lung volumes are low bilaterally. bibasilar dependent atelectasis is visualized. no focal pulmonary nodule or mass is visualized. there is no axillary or mediastinal lymphadenopathy. atherosclerotic calcification is visualized of the coronary arteries as well as of the aorta. the heart and great vessels are otherwise unremarkable. note is made of a large amount of mediastinal fat. a large right pretracheal node measures 13x12 mm (3:14). a large right epicardiac node measures 13x9 mm brain mass pathology: 1. "left occipital lobe tumor #1" (a - b): demyelinated white matter with extensive macrophage and perivascular lymphocytic infiltrates (see note). 2. "left occipital lobe tumor #2" (c - d): demyelinated white matter with extensive macrophage and perivascular lymphocytic infiltrates (see note). 3. "left deep occipital tumor" (e - f): demyelinated white matter with extensive macrophage and perivascular lymphocytic infiltrates (see note). 4. "left occipital lobe tumor" (g): leptomeninges and gliotic white matter. note: by immunohistochemistry (blocks a-d), the majority of the lymphocytes are cd-3 and cd-8 positive cytotoxic cells. a smaller subset stains positive for cd4. only rare scattered b-lymphocytes are present, marking with cd20. cd68 highlights the diffuse infiltrates of macrophages within the white matter. polyoma virus ( and sv40), ebv latent membrane protein (lmp), and cmv immunostains are negative. . special stains were performed on blocks a-d. luxol fast blue (lfb) shows a near complete loss of myelin staining in the white matter, with scattered staining present within macrophages. no hemosiderin deposition is seen on iron stain arguing against a chronic vasculitis. bodian stain reveals areas within the white matter showing preserved demyelinated axons. in other white matter areas there is axon loss. the findings supportive of an acute and chronic primary demyelinating disorder (e.g., multiple sclerosis). clinical: specimen submitted: 1. left occipital lobe tumor #1 2. left occipital lobe tumor #2 3. deep left occipital tumor 4. left occipital lobe tumor. clinical diagnosis and data: tumor left brain. gross: the specimen is received fresh in four parts, labeled with the patient's name, ", " and the medical record number. part 1 is additionally labeled "left occipital lobe tumor #1". it consists of multiple tan-pink soft tissue fragments measuring 0.7 x 0.7 x 0.4 cm in aggregate. 50% of the specimen was frozen and smeared and the intraoperative diagnosis by dr. is: "brain with loss of parenchyma, macrophage, infiltrate, and gliosis and scattered atypical astroglia". the specimen is entirely submitted as follows: a = frozen section remnant, b = remaining tissue. part 2 is additionally labeled "#2 frozen left occipital tumor". it consists of multiple tan-pink soft tissue fragments measuring 1.5 x 0.7 x 0.3 cm in aggregate. 50% of the specimen was frozen and smeared and the intraoperative diagnosis by dr. is: "destructive white matter process, with gliosis, macrophages and scattered microglia. focal neutrophilic infiltrate". the specimen is entirely submitted as follows: c = frozen section remnant, d = all remaining tissue. part 3 is submitted for intraoperative consultation additionally labeled "left deep occipital tumor #3". it consists of multiple tan-pink soft tissue fragments that measure 0.8 x 0.7 x 0.3 cm in aggregate. 50% of the specimen was used for smear and frozen section. the frozen section and smear diagnosis by dr. is: " matter and necrotic white matter. smear contains some calcified and fibrotic material (? abscess wall)". the specimen is then entirely submitted as follows: e = frozen section remnant, f = all remaining tissue. part 4 is additionally labeled "left occipital lobe tumor". it consists of multiple tan-pink fragments that measure 0.5 x 0.2 x 0.1 cm in aggregate. the specimen is entirely submitted in cassette g. mri brain : 1. allowing for post-biopsy changes, the left parietal lesion appears similar to . pathology is pending. 2. no evidence of acute intracranial abnormalities. 3. normal head mra. eeg : impression: abnormal portable eeg due to the slow and disorganized background, bursts of generalized slowing, and additional focal delta slowing in the left posterior quadrant. the first two abnormalities signify a widespread encephalopathy. medications, metabollic disturbances, and infection are among the most common causes. the additional focal slowing indicates subcortical dysfunction in the left posterior quadrant, likely related to the reported mass. there were no clearly epileptiform features. retroperitoneal mass needle biopsy: diagnosis: left retroperitoneal mass, core biopsy: 1. fibrous tissue with lymphoplasmacytic inflammation; see hemepath note. 2. refer to separate cytology report (c09-3221) for additional information. hemepath note (dr. ): h&e sections show small, tight clusters of cd20-positive b-cells, with a small population of scattered cd3-positive t-cells. although a reactive process is favored, a low-grade b-cell lymphoma cannot be ruled out. clinical: rest of retroperitoneal mass. 58 year old male found to have large left retroperitoneal mass with lymphadenopathy. gross: the specimen is received in a formalin-filled container labeled with the patient's name ", f" and the medical record number and consists of multiple fragments of core biopsy and tissue measuring up to 1.0 cm in length. the specimen is strained through a biopsy bag and submitted entirely in a. retroperitoneal mass, needle biopsy touch-prep: suspicious for malignancy. a few clusters of highly atypical cells have large nuclei and prominent nucleoli. the cytoplasm is stripped and further classification is not possible scrotal us impression: 1. no testicular mass. normal epididymis. 2. diffusely heterogeneous left testis, without enlargement. this appearance likely reflects prior injury such as remote trauma or orchitis brief hospital course: this 58 yo man was admitted with confusion and right visual field loss as outlined in the hpi. his brain mri showed a large left posterior lesion, suspicious for tumor. since this may have been a met, a ct torso was pursued, which showed a large retroperitoneal mass with enlarged lymph nodes. he underwent an open biopsy of his brain lesion, and the intraop pathology suggested there were no tumor cells and this was a demyelinating lesion. he was placed on a 5-day course of iv solumedrol followed by a slow prednisone taper from 60 mg to off over ~ 2 weeks. he has improvement, but not complete resolution of his visual field loss and confusion. he also sustained some right weakness, particularly in the delt post brain surgery, however this improved to nearly full strength over days. he next received an ir-guided needle bx of his retroperitoneal mass. the touch-prep of this was suspicious for malignant cells, however the core histology just showed an inflammatory process. because of this disparity, he underwent a laproscopic biopsy of his retroperitoneal mass. the preliminary results of this suggested a cancer. the final pathology is still pending, but the pathologists were able to tell us that it was not a cancer that required immediate treatment. he received an oncology consult, and will be followed in the oncology clinic. during the duration of his admission, he was followed closely by the team. they changed his regimen to humalog 75/25 90/50/50 tid qac. his neurological exam on dc was significant for ongoing deficits in attention and memory and a right inferior quadrantanopsia. medications on admission: 1. plavix 2. humalog 160 units qam and qpm 3. humulin 20 units qam and qpm 4. metformin 300 mg qam and 200mg qpm 5. lyrica 200 mg discharge medications: 1. pregabalin 200 mg capsule sig: one (1) capsule po bid (2 times a day). 2. levetiracetam 250 mg tablet sig: three (3) tablet po bid (2 times a day): take 750 mg twice daily for 7 days, then 500 mg twice daily for 7 days, then stop. . disp:*70 tablet(s)* refills:*0* 3. bariatric rolling walker 4. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) puff inhalation (2 times a day). 6. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 7. insulin lispro protam & lispro 100 unit/ml (75-25) suspension sig: 50-90 units subcutaneous tid qac: take 90 units before breakfast, 50 units before lunch, and 50 units before dinner. disp:*1 month's supply* refills:*3* 8. your plavix was held at your admission and you should continue to hold this until final pathology on the retroperitoneal mass returns and you follow up with oncology discharge disposition: home with service facility: community health and nursing services discharge diagnosis: left posterior tumefactive demyelinating lesion retroperitoneal cancer, final pathology pending discharge condition: stable. ongoing trouble with attention and memory. discharge instructions: you were admitted with a large demyelinating lesion in the posterior part of your left brain, causing some confusion and visual loss. you were placed on a course of steroids and have improved over time. you also had a ct of your abdomen and were found to have a retroperitoneal mass, which was biopsied. the final results of this biopsy are pending at the time of discharge, but preliminary resulys sugges this is a type of cancer. you can follow up with both oncology and the clinic who can discuss these results with you. 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. followup instructions: follow-up appointment instructions - please call ( to schedule an appointment with dr. , to be seen in 2 weeks for a wound check. pcp: , m provider: . & phone: date/time: 11:00 dr. office from oncology will call you mon or tuesday for an appointment. if you do not hear from them by , call to schedule. Procedure: Open biopsy of brain Biopsy of peritoneum Closed [percutaneous] [needle] biopsy of intra-abdominal mass Diagnoses: Obstructive sleep apnea (adult)(pediatric) Long-term (current) use of steroids Aortocoronary bypass status Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Percutaneous transluminal coronary angioplasty status Morbid obesity Encephalopathy, unspecified Homonymous bilateral field defects Demyelinating disease of central nervous system, unspecified Other symbolic dysfunction Malignant neoplasm of specified parts of peritoneum Alexia and dyslexia

allergies: levaquin attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: coronary artery bypass x 4 (left internal mammary artery grafted to the left anterior descending artery, reverse saphenous vein graft to the posterior descending artery of the right coronary artery, reverse saphenous vein graft to the second obtuse marginal branch of the circumflex), reverse saphenous vein graft to the first obtuse marginal branch of the circumflex. history of present illness: 55 year old man with long history of back pain treated with many modalities without releif. finally referred for back surgery, as part of medical clearance had stress test that was abnormal and then referred for cardiac catheterization which revealed two vessel disease. past medical history: hypertension hypercholesteremia diabetes mellitus hepatitis c low back pain s/p tonsillectomy social history: lives with wife, works as security guard + current tobacco use-30 year pack history. +etoh-1 drink/day family history: mother with heart disease @ 50yo physical exam: dmission vs t hr 60sr bp 180/80 rr 20 o2sat ht 6'0" wt 185lbs gen nad skin unremarkable neck supple, no bruits or la chest cta-bilat cv rrr no murmur abdm soft, nt/+bs ext warm, well perfused. no varicosities neuro grossly intact, non focal exam discharge vs t 98.2 hr 68sr bp 149/89 rr 20 o2sat 96% ra gen nad neuro a&ox3, nonfocal exam pulm cta bilat. cv rrr, no murmur. sternum stable, incision cdi abdm soft, nt/+bs ext warm, well perfused, trace bilat edema. evh sites with steri strips-cdi pertinent results: 09:06am hgb-14.9 calchct-45 09:06am glucose-141* lactate-1.0 na+-139 k+-4.3 cl--103 01:03pm pt-16.7* ptt-30.4 inr(pt)-1.5* 01:03pm wbc-3.9* rbc-3.50* hgb-11.3*# hct-31.0* mcv-89 mch-32.2* mchc-36.3* rdw-13.7 06:25am blood wbc-8.4 rbc-3.61* hgb-11.6* hct-32.6* mcv-90 mch-32.0 mchc-35.6* rdw-13.9 plt ct-124* 06:25am blood plt ct-124* 02:31pm blood pt-15.0* ptt-32.7 inr(pt)-1.3* 06:25am blood glucose-123* urean-18 creat-0.8 na-140 k-4.6 cl-104 hco3-28 angap-13 06:25am blood mg-2.0 ============================================= , b m 55 radiology report chest (portable ap) study date of 12:54 pm , r. csurg fa6a sched chest (portable ap) clip # reason: please eval for pneumo s/p chest tube removal final report indication: chest tube removal. since the recent radiograph, multiple lines and tubes have been removed with no evidence of pneumothorax. cardiac silhouette appears enlarged from the pre-operative radiograph and may be slightly further increased from the prior postoperative radiograph, suggesting possible pericardial effusion. worsening bibasilar atelectasis and new small bilateral pleural effusions. dr. approved: 5:20 pm ==================================== echocardiography report , (complete) done at 9:46:20 am final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 55 m hgt (in): bp (mm hg): / wgt (lb): hr (bpm): bsa (m2): indication: intraoperative tee for cabg icd-9 codes: 402.90, 440.0, 424.1 test information date/time: at 09:46 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 #: 2009aw2-: machine: aw1 echocardiographic measurements results measurements normal range left atrium - long axis dimension: *6.5 cm <= 4.0 cm left atrium - four chamber length: *6.8 cm <= 5.2 cm left ventricle - septal wall thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.8 cm <= 5.6 cm left ventricle - ejection fraction: 55% >= 55% aorta - ascending: 3.3 cm <= 3.4 cm aorta - descending thoracic: *2.6 cm <= 2.5 cm aortic valve - lvot diam: 1.8 cm findings left atrium: marked la enlargement. elongated la. mild spontaneous echo contrast in the body of the la. no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. good (>20 cm/s) laa ejection velocity. all four pulmonary veins identified and enter the left atrium. right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. mild symmetric lvh with normal cavity size and global systolic function (lvef>55%). right ventricle: normal rv chamber size and free wall motion. aorta: focal calcifications in aortic root. normal ascending aorta diameter. focal calcifications in ascending aorta. mildly dilated descending aorta. simple atheroma in descending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. physiologic mr (within normal limits). tricuspid valve: tricuspid valve not well visualized. physiologic tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. no pr. 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. conclusions pre bypass the left atrium is markedly dilated. the left atrium is elongated. mild spontaneous echo contrast is seen in the body of the left atrium. 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. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (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. 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. physiologic mitral regurgitation is seen (within normal limits). dr. was notified in person of the results in the operating room at the time of the study. post cpb normal biventricular systolic function. thoracic aorta appears intact. no change from pre bypass findings. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 13:44 brief hospital course: mr was a same day admission to the operating room on . at that time he had coronary artery bypass grafting times four. please see operative report for details. in summary he had left internal mammary to left anterior descending artery, saphenous vein graft to obtuse marginal one, saphenous vein graft to obtuse marginal two, saphenous vein graft to posterior descending artery. his bypass time was one hundred thirteen minutes with a crossclamp time of eighty six minutes. he tolerated the operation well and was transferred to the cardiac surgery intensive care unit in stable condition. he remained hemodynamically stable in the immediate post operative period, his anesthesia was reversed, he was weaned from the ventilator and extubated. on post operative day one he was transferred to the step down floor for continued post operative recovery. his tubes, lines and drains were removed according to protocol over the next several days. additionally his diuretics and beta blockers were titrated to response and his activity level was advanced with physical therapy. on post operative day four he was ready for discharge home with visiting nurses. followup with dr in 4 weeks. medications on admission: lopressor xl 50' quinapril 40" simvastatin 10' diovan 160' asa 81' fish oil 1 cap daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. 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* 3. hydromorphone 2 mg tablet sig: 1-2 tablets po q 3-4 hrs as needed. disp:*60 tablet(s)* refills:*0* 4. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day for 10 days. disp:*20 capsule, sustained release(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 7. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 10 days. disp:*10 tablet(s)* refills:*0* 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*1* 10. quinapril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease: s/p coronary artery bypass grafting x4 pmh: hypertension, diabetes mellitus, hepatitis c, low back pain discharge condition: good discharge instructions: please shower daily including washing incisions, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month, and while taking narcotics no lifting more than 10 pounds for 10 weeks please call with any questions or concerns followup instructions: dr. in 4 weeks () dr. in 2 week dr in weeks dr. in 4 weeks please call for appointments wound check appointment 6 as instructed by nurse () 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 Pure hypercholesterolemia Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: coffee ground emesis major surgical or invasive procedure: egd history of present illness: briefly, patient is a 66 year man with a history of etoh abuse ( shots of vodka daily), pancreatitis, previous gi bleed, back pain and episodic hyponatremia who presented with 2 days of nausea and vomiting. he had recently increased his aspirin from 81 mg to 325 mg because of back pain. he states the emesis eventually had the appearance of coffee grounds. it was accompanied by luq pain. he also had one episode of diarrhea which prompted him to come into the hospital. he denies melena or brbpr. . in the ed, initial vs: 98.5 104 154/87 20 99. patient felt woozy and syncopized at triage. he had guiac negative stool and ng lavage with 500cc of dark brown material, then a clear yellow fluid. he was admitted to micu for close observation. in the micu, he was on a ppi gtt overnight, transitioned to iv bid dosing today. he was transfused 1 unit of prbcs for a hct 30->24. his last drink was monday night. he was placed on ciwa but has not scored high enough to receive benzodiazepines. gi is following and plans to scope later today. he has not had any further nausea or vomiting. he has been hemodynamically stable with sbps in 100s off his home antihypertensives. . ros: he has chronic shortness of breath with exertion. he also has urinary frequency for which he takes flomax. he denies any fevers, chills, night sweats, headache, chest pain, or constipation. past medical history: episodic hyponatremia chronic pancreatitis c/b pseudocyst, per patient hypertension hyperlipidemia dieulafoy lesion colonic polyps removed bph gerd etoh abuse h/o cocaine, mj abuse s/p complicated cholecystectomy s/p incisional ventral hernia repair s/p spinal hardware in place social history: describes "previous" alcohol abuse problems. his use is significantly decreased to 2-5 drinks at night to "calm myself down." teaches online courses. no family. smokes ppd. previously smoked much more. last used crack 15 years ago. still uses marijuana on occasion. lsd in . family history: no family hx of colon ca. father passed away age 66 to lung ca & htn. mother had massive stroke from uncontrolled htn at 53 years old. . physical exam: hr 71 bp 107/63 rr 13 o2 97 ra general: nad, seated in chair in icu room heent: pupils 2mm, dry mm cardiac: regular lung: ctab abdomen: +bs, nt, nd ext: no lesions on feet, warm pertinent results: 02:50pm blood wbc-7.9 rbc-3.82* hgb-10.1* hct-30.4* mcv-80*# mch-26.4* mchc-33.1 rdw-18.8* plt ct-312 07:53pm blood wbc-7.3 rbc-3.52* hgb-9.3* hct-28.8* mcv-82 mch-26.3* mchc-32.2 rdw-18.6* plt ct-244 03:29am blood wbc-5.1 rbc-2.98* hgb-7.8* hct-24.5* mcv-82 mch-26.2* mchc-31.9 rdw-18.5* plt ct-184 09:00am blood hct-31.0*# 05:00pm blood hct-30.5* 07:35am blood wbc-5.0 rbc-3.54* hgb-9.4* hct-28.5* mcv-81* mch-26.7* mchc-33.2 rdw-18.6* plt ct-228 05:35pm blood hct-31.3* 05:40am blood wbc-5.6 rbc-3.43* hgb-9.1* hct-27.8* mcv-81* mch-26.5* mchc-32.7 rdw-18.7* plt ct-230 10:45am blood hct-31.0* distal esophageal mucosal biopsy: squamous epithelium, no diagnostic abnormalities recognized. egd duodenal deformity grade b esophagitis in the lower third of the esophagus (biopsy) mucosa suggestive of short segment barrett's esophagus erythema in the stomach body and fundus cxr frontal views of the chest: lung volumes are low, but there is no consolidation or pleural effusion. there is no pneumothorax. the heart is not enlarged. there is no hilar or mediastinal enlargement. aortic arch calcifications are present. pulmonary vascularity is normal. spinal fixation hardware is noted in the lower thoracic spine. impressions: no acute cardiopulmonary abnormality. brief hospital course: mr. is 66 year old man with a history of alcohol abuse, chronic pancreatitis, and hyponatremia who was admitted with coffee ground emesis. . # upper gi bleed: mr. endoscopy on which revealed esophagitis, barrett's esophagus, irritation of the stomach, and duodenitis. he is to continue on a ppi. he spent one evening in the micu for observation. he received one unit of prbc for a hct of 24. he is to follow up with gi for an additional egd in three months. he is to follow up in the office within one month. he was advised to stop his aspirin and avoid all nsaids. . # anemia: he has an iron deficiency anemia with normal folate and b12. he needs a repeat colonoscopy scheduled. he may start iron supplementation. . # acute renal failure: cr baseline 0.6-0.8, 1.7 on admission. the elevation was likely prerenal. it returned to following ivf. . # hyponatremia: he has been noted to have diabetes insipidus in his medical record. however, his nephrologist believes he has episodic hyponatremia. mr. recently stopped his desmopressin on advice of his nephrologist. sodium was within normal limits. . # copd: we continued albuterol prn. . # hypertension: home regimen was held on admission. it was gradually restarted. . # bph: flomax held in the micu. restarted on floor. . # back pain: continued on home regimen of hydromorphone. . # alcohol abuse: patient was on a ciwa scale. he did not score. he was started on thiamine and folic acid. social work spoke with him about his alcohol abuse, but he was not interested in treatment. . code status: mr. was a full code during this admission. medications on admission: amitriptyline 25 mg by mouth as needed for at bedtime hydromorphone 4 mg by mouth one or two a day as needed for back pain lisinopril 20 mg by mouth daily lovastatin 40 mg by mouth daily omeprazole 20 mg by mouth daily tamsulosin 0.4 mg by mouth once a day aspirin 325 mg by mouth discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 2. iron 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 3. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 4. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 5. lovastatin 40 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 once a day. 7. hydromorphone 4 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for back pain. 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. multivitamin capsule sig: one (1) capsule po once a day. 11. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*30 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: blood loss anemia . secondary: esophagitis gastritis duodenitis alcohol abuse hypertension hyperlipidemia 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 bleeding from your gastrointestinal tract. you had an esophagogastroduodenoscopy (egd or a scope of your stomach) that showed inflammation of the esophagus, stomach, and small intestine. in the esophagus, there is evidence of cellular changes that will increase your risk of developing esophageal cancer. as a result, you need to take pantoprazole 40 mg twice a day. you also need a repeat egd in 3 months, which has been scheduled. you also need to have a colonoscopy to further investigate your anemia. all this inflammation is most likely related to your alcohol use. your blood work also suggests evidence of liver damage due to your alcohol use. you must stop drinking alcohol. please also avoid taking an aspirin, naproxen (aleve), or ibuprofen (advil) as these medications may also cause stomch ulcers and irritation that leads to bleeding. the following changes have been made to your medication: --please take pantroprazole 40 mg twice a day instead of your omperazole. --please also start taking an iron supplement daily. you may experience constipation, for which you can take an over the counter stool softener such as colace. --please also take the multivitamin, folic acid and thiamine. followup instructions: please go to clinic to have your hematocrit checked on monday, any time between 8:30am-7:00pm. your last hematocrit was 31. . you have a follow up appointment with dr. , who works with your primary care provider . , at 2:45pm. the clinic number is . . you have a follow up gastroenterology appointment with dr. na, for at 2:30pm. the clinic number is . md Procedure: Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Esophageal reflux Unspecified essential hypertension Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Hyposmolality and/or hyponatremia Chronic airway obstruction, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hypopotassemia Other and unspecified hyperlipidemia Duodenitis, without mention of hemorrhage Hemorrhage of gastrointestinal tract, unspecified Chronic pancreatitis Alcohol abuse, continuous Barrett's esophagus Other esophagitis Alcoholic gastritis, without mention of hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: addendum: was discharged to house. discharge disposition: extended care facility: house nursing home - md Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Tobacco use disorder Candidiasis of mouth Dysthymic disorder Acute myocardial infarction of inferoposterior wall, initial episode of care

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: myocardial infarction major surgical or invasive procedure: - coronary bypass grafting x4 with left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery, obtuse marginal artery and first diagonal artery. history of present illness: is a 56 year old man who presented to with upper back pain. he is without a significant past medical history but has not seen a physician in twenty years. he ruled in for a inferoposterior/lateral myocardial infarction and a cath revealed three vessel coronary artery disease. he was transferred to for evaluation for cadiac surgery. past medical history: coronary artery disease myocardial infaction social history: lives with:alone occupation:on disability for 21 yrs for depression/anxiety tobacco:2-2.5 packs per day, smokes marijuana frequently etoh:less than weekly family history: mother with congestive failure physical exam: pulse: 70 resp: 16 o2 sat: 97 b/p right:138/93 height: 55 weight:99 kg general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally distant breath sounds 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 pre cpb: 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 are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed (lvef= 50%) with a thinned and akinetic inferiobasal wall. 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 mildly thickened with good leaflet excursion and no aortic regurgitation. trivial mitral regurgitation is seen. post cpb: aortic contours intact the mr is now mild(slightly increased compared to prebypass) there is preserved rv systolic function the lvef is now 35%; there is hypokinesis of the inferior, inferolateral and inferoseptal wall. pre-op labs 03:02pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 05:04pm pt-13.3 ptt-24.3 inr(pt)-1.1 05:04pm plt count-204 05:04pm wbc-14.8* rbc-5.52 hgb-17.0 hct-51.2 mcv-93 mch-30.7 mchc-33.1 rdw-13.5 05:04pm %hba1c-5.9 eag-123 05:04pm albumin-4.7 magnesium-2.0 05:04pm ck-mb-58* mb indx-5.0 ctropnt-1.08* 05:04pm lipase-18 05:04pm alt(sgpt)-71* ast(sgot)-140* ld(ldh)-819* ck(cpk)-1170* alk phos-76 amylase-47 tot bili-0.6 05:04pm glucose-163* urea n-13 creat-1.0 sodium-137 potassium-4.1 chloride-102 total co2-23 anion gap-16 05:04pm blood ck-mb-58* mb indx-5.0 ctropnt-1.08* 12:16am blood ck-mb-37* mb indx-4.8 ctropnt-1.01* 09:25am blood ck-mb-27* mb indx-4.5 ctropnt-1.22* discharge labs: 05:00am blood wbc-10.9 rbc-3.53* hgb-11.3* hct-32.2* mcv-91 mch-32.1* mchc-35.2* rdw-13.6 plt ct-112* 05:00am blood plt ct-112* 05:00am blood glucose-111* urean-17 creat-1.0 na-138 k-4.0 cl-103 hco3-27 angap-12 05:20am blood wbc-11.0 rbc-4.01* hgb-13.0* hct-36.5* mcv-91 mch-32.3* mchc-35.5* rdw-13.9 plt ct-265# 05:20am blood glucose-104* urean-23* creat-1.0 na-140 k-4.0 cl-101 hco3-26 angap-17 brief hospital course: mr. was admitted to the on via transfer from for surgical management of his coronary artery disease. he was worked-up by the cardiac surgical service in the routine preoperative manner. plavix was stopped and allowed to washout. on , he was taken to the operating room where he underwent coronary artery bypass grafting. please see operative note for details, in summary he had: coronary bypass grafting x4 with left internal mammary artery to left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery, obtuse marginal artery and first diagonal artery. his bypass time was 139 minutes, with a crossclamp time of 104 minutes. he tolerated the procedure well and postoperatively he was taken to the intensive care unit for monitoring and recovery. over the next several hours, he awoke neurologically intact and was extubated. beta blockade, aspirin and a statin were resumed. on postoperative day one, he was transferred to the step down unit for further recovery. all tubes lines and drains were removed per cardiac surgery protocol. he was gently diuresed towards his preoperative weight. the physical therapy service was consulted for assistance with his postoperative strength an mobility. the remainder of his post-operative course was uneventful. by post-operative day #4 he was ready for discharge to house rehab. all follow-up appointments were advised.pt. needs a pcp and has been instructed to see this provider in few weeks. medications on admission: none 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. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*2* 5. 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* 6. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 7. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) for 5 days: please dispense 5 day supply. disp:*100 ml(s)* refills:*0* 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. discharge disposition: extended care facility: house nursing home - discharge diagnosis: coronary artery disease s/p coronary bypass grafting x4 myocardial infarction discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema 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 4) 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 5) no lifting more than 10 pounds for 10 weeks 6) 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. wednesday , 1:15pm, 2a cardiologist: dr. on at 12:40pm. please obtain a primary care provider and see him or her 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: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Tobacco use disorder Candidiasis of mouth Dysthymic disorder Acute myocardial infarction of inferoposterior wall, initial episode of care

allergies: azithromycin / zosyn / meropenem attending: chief complaint: sepsis major surgical or invasive procedure: ir drainage, ptc history of present illness: 70 m s/p whipple for duodenal adenoca presents from rehab with sepsis secondary to rll pna and new segment vi liver abscess. past medical history: pmhx: adenocarcinoma (duodenum), htn, peptic ulcer disease . pshx: s/p gastric resection for pud s/p revision with roux-en-y and partial gastrectomy in s/p whipple s/p . drainage of intra-abdominal abscess through reopening of recent laparotomy; repair of pancreaticojejunostomy through a bridge stent technique; mass closure of the abdominal wall for pancreatic and biliary fistula, and intra-abdominal abscess s/p tracheostomy s/p gj-tube placed on . s/p picc line placed on . s/p hepatic drains placed on -- removed s/p right-sided thoracentesis on . s/p j-tube placement via ec fistula and social history: he used to work as property manager but is now retired. married; wife and grown children very involved. he has 40 pack-year smoking history; quit a while back. no alcohol use. family history: non-contributory. physical exam: expired, no respiratory or cardiac activity, no spontaneous movement brief hospital course: mr. admitted with sepsis to pneumonia and hepatic abscess, went to ir for drainage he was transferred to the floor on , his course was complicated by persistent hyperkalemia , and an episode of hypoglycemia on . on he received a 500cc bolus and was transferred to ir for a ptc/cholangiogram which showed biliary sludge in cbd, normal intrahepatic biliary ducts, and placement of an int/ext biliary drain, a hepatic artery radical was inadverdently cannulated and this was immediately recognized and embolized. he was transferred to tsicu for hypotension and tachycardia where he was transfused 2 u prbc and resuscitated, initial attempts to wean to cpap failed. he became acidotic on repeat attempt to wean to cpap. nephrology was consulted on for hyperkalemia and suggested the patient might have type 1 rta. a head ct was done to evaluate mental status which showed no intracranial pathology. a cortisol stim test showed adrenal insufficiency and hydrocortisone was started at endocrinology's recommendation. transplant surgery (dr. was consulted and recommended ursodiol. : remained on vent for persistant acidosis. hydrocortisone tapered. tube feeds diluted to 1/2 strength, protein incr to 2g/kg/day. ptc output and stool output incr proportionally w/tf incr. vent weaned to cpap o/n, abgs slightly improved. : extubated successfully. ivf kvo. tube feeds were advanced to full strength due to unchanged diarrhea, acidosis gradually improved. transferred to the floor. doing well on floor, tube feeds gradually advanced : mr. was found to be tachypneic on the floor with worsening o2 sat and acidosis in the course of the day. an attempt to manage fluid overload apparent on exam and his cxr with lasix failed. he was intubated on the floor for a ph of 7.1 and subsequently transferred to the unit. after intubation he required fluid resuscitation likely secondary to propofol induced hypotension. a cta chest was negative for pe. : started on ivf for decreased urine output. bronchoscopy and bal were unremkarkable, tube feeds were decreased. a bedside tte performed by anesthesia showed ef 42% and global hypokinesis. he did well on sbts. : mr. had d5w increased to 75/hr for hypernatremia with medications changed to d5w as much as possible. a pull-back cholangiogram showed good drainage, and the ptc was removed. formal echo confirmed bedside findings, but cardiology felt the patient's previous echo was similar, and that he had possibly had an mi in early . extubated succesfully, hydrocortisone stopped at endocrinology recommendation without taper after good response on repeat stim and hypertension. started on cipro for pseudomonas in bal from on morning rounds, was alert, oriented and conversing with icu staff. shortly thereafter was found unresponsive with hypertension (sbp>200). head ct was done showing a large intraparenchymal hemorrhage with midline shift. on discussion between icu staff and dr. , this was felt to be an unrecoverable event, and on further discussion with the family the patient was made cmo and terminally extubated. he expired shortly thereafter medications on admission: fentanyl 50q72hrs, vanco 125"", flagyl 500"', iron 325', protonix 40', dronabinol 2.5", ursodiol 600", metoprolol 50" discharge medications: none discharge disposition: expired discharge diagnosis: intraparenchymal hemorrhage discharge condition: expired discharge instructions: n/a followup instructions: none Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Other endovascular procedures on other vessels Other cholangiogram Percutaneous aspiration of liver Other percutaneous procedures on biliary tract Percutaneous hepatic cholangiogram Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Pneumonia, organism unspecified Acidosis Hyperpotassemia Other postoperative infection Unspecified pleural effusion Unspecified essential hypertension Unspecified septicemia Sepsis Accidental puncture or laceration during a procedure, not elsewhere classified Pulmonary collapse Acute respiratory failure Hypotension, unspecified Cachexia 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 Intestinal infection due to Clostridium difficile Abscess of liver Accidental cut, puncture, perforation or hemorrhage during other specified medical care Glucocorticoid deficiency Personal history of malignant neoplasm of liver Accidents occurring in residential institution Other candidiasis of other specified sites

allergies: azithromycin / zosyn / meropenem attending: chief complaint: anemia, abdominal pain. major surgical or invasive procedure: none history of present illness: 69year old male, known very well to dr. , s/p a whipple in with postoperative complications of anastamotic leaks and failure to thrive, as well as a known ec fistula. he was recently discharged from the hospital after a long course of treatment for klebsiella bacteremia from hepatic abscesses and obstructive cholangitis and issues with enteral feedings. he was seen at dr. clinic last friday, at which time his pigtail drains were removed, because the previous abscesses had resolved, although new smaller ones, not amenable to drainage were noted. he was to continue his antibiotics for 2 more weeks after drain removal. . he now returns from with a reported hct of 20. he reports feeling fatigued, more from baseline. he says that he still has poor po appetite, but is tolerating tube feeds at 90cc/hr overnight. he does note that he has up to 3 loose bowel movements. past medical history: pmhx: adenocarcinoma (duodenum), htn, peptic ulcer disease . pshx: s/p gastric resection for pud s/p revision with roux-en-y and partial gastrectomy in s/p whipple s/p . drainage of intra-abdominal abscess through reopening of recent laparotomy; repair of pancreaticojejunostomy through a bridge stent technique; mass closure of the abdominal wall for pancreatic and biliary fistula, and intra-abdominal abscess s/p tracheostomy s/p gj-tube placed on . s/p picc line placed on . s/p hepatic drains placed on -- removed s/p right-sided thoracentesis on . s/p j-tube placement via ec fistula and social history: he used to work as property manager but is now retired. married; wife and grown children very involved. he has 40 pack-year smoking history; quit a while back. no alcohol use. family history: non-contributory. physical exam: on admission: vs: 97.5, hr 100, bp 120/80, rr 18, o2sat 99% genl: nad, gaunt cv: rrr resp: cta-b abd: s/nt/nd; jtube in place via ec fistula; bilious drainage in fistula bag extr: no c/c/e . at discharge: vs: gen: gaunt, thin in nad. heent: mild scleral icterus. o-p clear. neck: supple. lungs: cta(b) cor: rrr abd: scaphoid. multiple well-healed surgical incisions. lower abdominal ec fistula through which j-tube enters. j-tube intact/patent. ec fistula/j-t complex covered with ostomy appliance with bilious drainage. bsx4. soft/nd. extrem: no c/c/e. neuro: a+ox3. flat affect. pertinent results: on admission: 08:20pm glucose-99 urea n-34* creat-1.4* sodium-136 potassium-4.9 chloride-97 total co2-28 anion gap-16 08:20pm wbc-3.8*# rbc-2.42* hgb-7.5* hct-22.7* mcv-94 mch-30.8 mchc-32.9 rdw-15.9* 08:20pm neuts-58.8 lymphs-20.9 monos-7.7 eos-11.5* basos-1.1 08:20pm plt count-370 08:20pm pt-11.7 ptt-24.2 inr(pt)-1.0 . at discharge: 06:45am blood wbc-4.7 rbc-3.07* hgb-8.9* hct-28.5* mcv-93 mch-29.0 mchc-31.2 rdw-17.0* plt ct-233 02:47am blood neuts-91.8* lymphs-4.8* monos-2.6 eos-0.5 baso-0.2 06:45am blood plt ct-233 06:45am blood glucose-110* urean-18 creat-0.9 na-136 k-4.9 cl-102 hco3-29 angap-10 06:45am blood alt-14 ast-21 ld(ldh)-107 alkphos-567* totbili-4.4* 12:56pm blood lipase-61* 12:56pm blood ck-mb-notdone ctropnt-0.02* 02:38am blood ck-mb-notdone ctropnt-0.01 01:04am blood ck-mb-notdone ctropnt-0.02* 06:45am blood albumin-2.2* calcium-8.0* phos-2.7 mg-1.9 . imaging: ct abd/pelvis w/contrast: interval decrease in size of multiple gas containing hepatic fluid collections. there are new ill-defined hypodense lesions within the lateral right hepatic lobe, which are suspicious for new foci of infection given the short interval time course. there is a tiny new fluid collection in the right lateral abdominal wall in the area of prior drain, measuring approximately 1.8cm maximally. otherwise, no new fluid collections are identified. . portable abdominal x-ray: only a supine portable view of the abdomen is submitted for interpretation, precluding assessment for free intraperitoneal air. considering the clinical concern, either a fully upright or left lateral decubitus view would be recommended. a percutaneous feeding tube is present terminating in the expected location of the jejunum. a non-obstructive bowel gas pattern is visualized. . cxr: interval placement of right subclavian catheter terminating in the lower svc with no evidence of pneumothorax. examination is otherwise unchanged since the recent study except for development of linear atelectasis at the left lung base. . ecg: tracing submitted late and out of sequence. rhythm is probably sinus tachycardia but consider also possible atrial tachycardia given the markedly rapid rate. probable left anterior fascicular block. qtc interval may be prolonged but is difficult to measure. modest st-t wave changes. findings are non-specific. clinical correlation is suggested. since the previous tracing of marked tachycardia is now present and modest st-t wave changes are seen. intervals axes: rate pr qrs qt/qtc p qrs t 169 0 80 292/482 0 -53 62 . mrcp (mr abd w&w/oc): correlation is made with prior ct performed on . findings: again noted are multiple peripherally enhancing hepatic fluid collections containing foci of gas consistent with abscesses. allowing for differences in technique, these are not significantly changed in size, and no new collections are identified. for example, the collection within segment vii posteriorly measures 2.9 x 3.3 cm in its entirety, with the central fluid component measuring 1.7 x 1.1 cm. the central fluid component on prior ct measured 1.6 x 1.5 cm. the collection within segment measures 2.7 x 1.9 cm in its entirety, with the anterior central fluid component measuring 0.9 x 0.9 cm. this is difficult to compare to the prior ct, but appears stable to smaller. there are two foci of enhancement within the right lateral abdominal wall in the site of prior drainage catheter tracts. there are no focal fluid collections within the abdominal wall. again noted are postsurgical changes from whipple procedure. there is no intra- or extra-hepatic biliary dilatation. mrcp images are limited, but there is no obvious focal stricture. the remaining pancreas is atrophic and the pancreatic duct is mildly prominent. there are stable retroperitoneal lymph nodes. there are bilateral nonenhancing renal cysts. a cyst within the posterior left renal mid pole is bright on t1 pre-contrast images, consistent with hemorrhagic or proteinaceous fluid. the left kidney is mildly atrophic compared to the right. there is mild diffuse anasarca. susceptibility artifact is noted in the anterior abdominal wall from multiple surgical clips. the spleen and adrenal glands are normal. the visualed abdominal bowel loops are nondilated, and there is no ascites or new focal fluid collection. limited images of the lower chest demonstrate loculated right pleural fluid and atelectasis and minimal left pleural fluid. the visualized bone marrow signal is unremarkable. a percutaneous jejunostomy tube is identified. multiplanar reformations and subtraction images provided multiple perspectives for the dynamic series. impression: 1. multiple hepatic abscesses, not significantly changed in size given differences in technique. no new fluid collections are identified. there is enhancement within the right lateral abdominal wall in the region of prior drainage catheters, without focal fluid collection. 2. stable post-surgical changes from whipple, with no evidence of biliary dilatation. 3. bilateral renal cysts. brief hospital course: the patient was admitted to the general surgical service on for evaluation of the aforementioned problem. was continued on a regular diet with supplements, cycled tubefeeds via the j-tube, which enters the duodenum via a ec fistual, on home medications and oral antibiotics, the latter consisting of ciprofloxacin, clindamycin, and linezolid. these antibiotics were prescribed during his last admission for abdominal abscesses, which grew out pseudomonas, mrsa and beta strep. upon admission, his hgb was 7.5 and hct 22.7, for which he was transfused 2 units of prbcs without adverse event. nutrition, ostomy nurse, physical therapy, and occupational therapy were consulted early during this admission. infectious disease also followed the patient during the admission. overall, the patient was hemodynamically stable. on hd#2, the patient received an additional unit of prbcs responding with a hgb of 10.4 and hct of 31.4. urine and blood cultures were sent. he was given supplemental hydration with lactated ringer's via the j-tube. tolerated tubefeeds at goal, but only fair intake of his diet. early on , the patient became hypotensive, acutely confused and briefly unresponsive. he was transferred to the sicu. a cxr, ecg, labwork, and blood cultures were performed. a foley catheter and a-line were placed. the ekg was unremarkable, and the cxr showed moderate (r) pleural effusion increased, rightward mediastinal shift with opacification in (r) lower lobe most likely representing atelectasis. he was given a 1l lr bolus with good response. he was started on iv flagyl for possible colitis. a abdominal/pelvic ct with contrast demonstrated interval improvement in the hepatic fluid collection and a few small new collection less than 1.8cm in size. trophic tubefeeds were started. the next sicu day, his diet was restarted and trophic tubefeeds continued. he experienced another episode of hypotension on , and was again bolused with a total of 725ml lr with good response. tubefeeds were again held. a cvl was placed, and iv cefepime was added for temperature spikes to cover pseudomonas. on , he remained hemodynamically stable. he was restarted on tubefeeds, this time continuous advancing to goal, which he tolerated. given that he continued stable into , he was transferred back to the inpatient floor. early on , the patient again experienced an episode of confusion. heart rate was tachy between 104-125, other vital signs were stable. no fever or leukocytosis. labwork, blood and urine cultures were sent. later that morning, his mental status returned to baseline. on , the patient underwent mrcp, which revealed multiple hepatic abscesses, but not significantly changed in size given differences in technique, and no new fluid collections. given these finding demonstrating overall improvement and potential risks of interventional biospy, it was ultimately determined in consultation with infectious disease to forego planned ultrasound-guided aspiration and biopsy of one or more of the liver abscesses. infectious disease continued to follow along, updating antibiotic recommendations. on , cefepime, clindamycin, and cipro were discontinued, with the patient continued on flagyl. the lineolid was completed on . the flagyl will be continued until outpatient infectious disease follow-up appointment on . other than that mentioned above, the hospital course back on the floor was unremarkable. he ambulated early and frequently with nursing or physical therapy, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. the patient received subcutaneous heparin and venodyne boots were used during this stay. the patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. his labwork was monitored regularly; electolytes repleted when needed. after his foley was discontinued, he voided without problem with an adequate urine output. he tolerated cycled tubefeeds via the j-tube and a regular diet. marinol was added on to stimulate his appetite. he was also started on viokase and imodium prn for loose stools with improvement. at the time of discharge on , the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, although with poor intake, ambulating, voiding without assistance, and pain was well controlled. he was tolerating cycled tubefeeds via the j-tube, placed through the ec fistula. the ostomy appliance as ordered remained intact. the patient was discharged to an extended care facility. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: 1. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). 2. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical (2 times a day) as needed for pruritus. 3. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. 5. hydromorphone 2 mg tablet sig: 1-4 tablets po q3h (every 3 hours) as needed for pain. 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 7. zofran 8 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. 8. ammonium lactate 12 % lotion sig: one (1) liberal application topical four times a day as needed for dry skin, pruritus. 9. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 10. metoclopramide 10 mg tablet sig: one (1) tablet po qid 11. clindamycin hcl 150 mg capsule sig: three (3) capsule po q6h 12. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h 13. linezolid 600 mg tablet sig: one (1) tablet po q12h discharge medications: 1. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). 2. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical (2 times a day) as needed for pruritus. 3. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). disp:*10 patch 72 hr(s)* refills:*0* 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. 5. hydromorphone 2 mg tablet sig: 1-3 tablets po q3h (every 3 hours) as needed for pain. disp:*70 tablet(s)* refills:*0* 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 7. zofran 8 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. 8. ammonium lactate 12 % lotion sig: one (1) liberal application topical four times a day as needed for dry skin, pruritus. 9. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 10. dronabinol 2.5 mg capsule sig: one (1) capsule po bid (2 times a day). 11. amylase-lipase-protease 30,000-8,000- 30,000 unit tablet sig: two (2) tablet po tid with meals (). 12. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. 13. flagyl 500 mg tablet sig: one (1) tablet po every eight (8) hours: d/c date to be determined at infectious disease follow-up. discharge disposition: extended care facility: - discharge diagnosis: 1. recurrent cholangitis 2. refractory intra-hepatic abscesses 3. anemia discharge condition: stable discharge 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 is 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. . general drain care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *if the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character. be sure to empty the drain frequently. record the output, if instructed to do so. *ostomy bag around j-tube as directed by ostomy nurse discharge instructions (see page 2). *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . ostomy care and appliance changes: 1. cleanse peri tube skin with warm water and pat dry. 2. apply no sting barrier wipe to peritubular tissue 3. cut opening on coloplast urostomy pouch # 5585 1/8th inch larger apply seal on the back of the pouch. press into place. reapply backing onto pouch wafer with slit cut for easier removal. cut small opening into the anterior of the bag for tube attachment device. apply the tube attachment device to the pouch. 4. cut very small slit bilateral tube holder so that the feeding tube will slide thru. this material is stretchy so it does not need to be a large slit. 5. place pouch over the tube and with clamp slide through the tube attachment device and grab the feeding tube (may unscrew end piece to allow for smaller diameter to pass through tube holder.) stabilize the base of the tube and with the clamp pull the tube through the attachment device. 6. place the pouch on the skin and mold into place. 7. secure edges of pouch and holder with pink hy tape. 8. apply a warm pack over the pouching system to mold in place. 9. encourage patient to lie flat for 30 minutes after pouch change. 10. attach pouch to bedside drainage, other wise empty pouch when it is full. followup instructions: please call ( to arrange a follow-up appointment with dr. (pcp) in weeks. . provider: scan phone: date/time: 11:00 provider: , md phone: date/time: 11:45 . provider: , md phone: date/time: 10:10. location: , basement, . Procedure: Enteral infusion of concentrated nutritional substances Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Anemia of other chronic disease Unspecified pleural effusion Unspecified essential hypertension Unspecified protein-calorie malnutrition Paroxysmal ventricular tachycardia Hypotension, unspecified 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 Abscess of liver Diarrhea Dehydration Cholangitis Personal history of malignant neoplasm of other gastrointestinal tract Mechanical complication of colostomy and enterostomy Persistent postoperative fistula Body Mass Index less than 19, adult

allergies: azithromycin / zosyn attending: chief complaint: failure to thrive major surgical or invasive procedure: 1. ptc demonstrating approximately 1-cm focal high-grade stricture of the distal duct just proximal to the hepaticojejunostomy . 2. uncomplicated balloon cholangioplasty of the diseased segments with satisfactory results . 3. uncomplicated placement of 8 french, 25-cm internal-external biliary drain . history of present illness: the patient is a 69 year old man with a history of pud s/p gastric resection followed by roux-en-y in the distant past, recently hospitalized ~3 months following a whipple procedure , who presents with failure to thrive. he underwent the aforementioned procedure on , and had a very complicated post-operative course with anastomotic leak of the hepaticojejunostomy and of the pancreaticojejunostomy, associated with multiple intra-abdominal fluid collections (pathology revealed moderately differentiated t2n0 adenocarcinoma). he had multiple ir drains placed, and was taken back to the or on for repair of the pancreaticojejunostomy. his course was also complicated by allergic reactions to multiple antibiotics, acute renal failure, pulmonary failure requiring a tracheostomy, and cholangitis. he was dependent on tpn for an extended period of time. despite all of this, he was discharged home on doing well, afebrile, tolerating a regular diet, and ambulating with a walker. he was last seen by dr. on and was taking in reasonable po intake since then. he last underwent ercp on , which demonstrated a widely patent choledochojejunostomy, and his pd stent was removed. he is sent to the ed by his nurse, who found him to be orthostatic with sbp ~90 mmhg. he has not had nausea or vomiting, and denies fevers/chills at home. he has been taking adequate po intake by report and has been moving his bowels normally. past medical history: htn pud s/p perforation social history: he used to work as property manager but is now retired. married; wife and grown children very involved. he has 40 pack-year smoking history; quit a while back. no alcohol use. family history: non-contributory. physical exam: discharge day examination vs: 99.0 98.0 96 156/86 20 98ra gen: nad cv: rrr chest: ctab abd: s/nt/nd, well-healed abdominal incisions ext: wwp pertinent results: 04:30pm alt(sgpt)-72* ast(sgot)-53* alk phos-* tot bili-1.0 dir bili-0.6* indir bil-0.4 04:30pm ggt-624* 03:50pm glucose-95 urea n-20 creat-1.6* sodium-134 potassium-5.3* chloride-102 total co2-24 anion gap-13 03:50pm estgfr-using this 03:50pm calcium-8.8 phosphate-4.9* magnesium-1.6 03:50pm wbc-16.7*# rbc-3.59* hgb-10.4* hct-32.8* mcv-91 mch-28.9 mchc-31.6 rdw-15.7* 03:50pm neuts-86.5* lymphs-5.0* monos-1.0* eos-7.4* basos-0.1 03:50pm plt count-732* 03:50pm pt-14.4* ptt-26.1 inr(pt)-1.3* 12:56pm glucose-84 urea n-21* creat-1.3* sodium-138 potassium-4.5 chloride-104 total co2-26 anion gap-13 12:56pm alt(sgpt)-149* ast(sgot)-199* ld(ldh)-239 alk phos-3096* amylase-68 tot bili-1.0 12:56pm lipase-35 12:56pm wbc-7.9 rbc-3.05* hgb-9.1* hct-28.2* mcv-92 mch-29.7 mchc-32.1 rdw-15.8* 12:56pm neuts-64.0 lymphs-14.4* monos-3.9 eos-17.5* basos-0.2 12:56pm plt count-612* 12:56pm pt-14.1* ptt-27.8 inr(pt)-1.2* ct abdomen/pelvis : 1. mild intrahepatic biliary ductal dilation. please note , an early anastomotic narrowing at the hepaticojejunostomy cannot be excluded. 2. moderate bilateral pleural effusion and compressive atelectasis at the lung bases. 3. partial gastrectomy and whipple with distorted anatomy likely secondary to previously noted post-op complications. 4. increased soft tissue attenuation along the mesenteric root with mesenteric tethering and calcification, could represent scarring, however attention on followup ct is recommended. 5. multiple foci of contained extraluminal air, the largest abutting the anterior abdominal wall, likely trapped air along prior catheter sites. 6. hyperdense right renal cyst, could be hemorrhagic, unchanged. ir-guided placement of power picc : uncomplicated ultrasound and fluoroscopically guided dual lumen power picc line placement via the right basilic venous approach. final internal length is 41 cm, with the tip positioned in svc. the line is ready to use. ptc, ptbd, balloon cholangioplasty : 1. ptc demonstrating approximately 1-cm focal high-grade stricture of the distal duct just proximal to the hepaticojejunostomy. 2. uncomplicated balloon cholangioplasty of the diseased segments with satisfactory results. 3. uncomplicated placement of 8 french, 25-cm internal-external biliary drain. brief hospital course: admitted to surgical service for hydration and nutritional support. power picc line placed under ir guidance, tpn initiated. sbp 80s, cxr and blood cultures obtained, sbp improved with bolus. vanc / started. started flagyl. overnight, febrile to 102.5, tachycardic, initially hypertensive, tachypneic, hypoxic (chf)-> diuresed for resp distressed, then became hypotensive sbp 70s; transferred to sicu, transfused 2u prbc, resuscitated. ir for ptc showing 1cm high-grade stricture of distal duct just proximal to hepaticojejunostomy. balloon cholangioplasty of diseased segments. placed 8fr 25cm internal-external biliary drain. advanced diet to regular diet plus supplements. bile cultured. overnight, spiked fever 101.3 at mn, started fluc, ordered stool cx for c.diff, cxr, pan cx'd. transferred to floor. on tpn. still on vanc//flagyl/fluc. on megestrol. wbc 11.6->14.6. d/c'd megestrol, started dronabinol. foley removed at mn. overnight, noticed that skin became more flaky with continued abx use. wbc 14.6->15.0. dermatology consulted -> started lactic acid lotion. wbc 15->15. no new events. cxr done to assess interval change. bile cx growing vre, stopped vanc, started linezolid. ptc capped. afternoon tpn held for k 5.6, no ekg changes. tpn restarted with lower k+ content. discharged to rehab in stable condition: afebrile, vital signs stable, tolerating regular diet with tpn for nutritional support, ambulating without assistance. id recommends the following antibiotic course: 14 days total of linezolid and fluconazole. medications on admission: dilaudid prn omeprazole 20 mg po qd lopressor 25 mg po bid discharge medications: 1. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 2. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp <100; hr <60. 4. marinol 5 mg capsule sig: one (1) capsule po twice a day. 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheeze. 6. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob,wheezing. 7. ammonium lactate 12 % liquid sig: one (1) liberal appl topical (2 times a day) as needed for desquamation. 8. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po qid (4 times a day) as needed for itching. 9. 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. 10. pantoprazole 40 mg iv q24h 11. diphenhydramine 25 mg iv q6h:prn itching 12. 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. 13. 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. 14. ondansetron 4-8 mg iv q8h:prn nausea 15. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed): as directed per regular insulin sliding scale. 16. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours). 17. fluconazole in saline(iso-osm) 400 mg/200 ml piggyback sig: one (1) intravenous q24h (every 24 hours). discharge disposition: extended care facility: - discharge diagnosis: primary: septic shock, cholangitis, dehydration. secondary: s/p whipple in with complicated post-operative course discharge condition: good discharge 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. picc line: *please monitor the site regularly, and your md, nurse practitioner, or nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * your md to the emergency room immediately if the picc line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. do not use the picc line in these circumstances.please keep the dressing clean and dry. contact your nurse if the dressing comes undone or is significantly soiled for further instructions. followup instructions: please call ( to schedule a follow-up appointment with dr. in weeks. Procedure: Parenteral infusion of concentrated nutritional substances Other percutaneous procedures on biliary tract Dilation of intestine Percutaneous hepatic cholangiogram Diagnoses: Unspecified pleural effusion Unspecified septicemia Severe sepsis Personal history of tobacco use Pulmonary collapse 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 Septic shock Other specified disorders of biliary tract Rash and other nonspecific skin eruption Dehydration Cholangitis Personal history of malignant neoplasm of other gastrointestinal tract Acquired absence of organ, stomach

allergies: azithromycin / zosyn attending: chief complaint: peri-ampullary mass major surgical or invasive procedure: 1. whipple's resection. 2. open cholecystectomy. 3. enteroenterostomy x2 (with formation of roux limb for pancreaticobiliary drainage). 4. extended adhesiolysis. 5. reduction of internal hernia. history of present illness: this 69-year-old retired gentleman was referred to dr. for consultation for his bile duct obstruction problem by dr. . he has a very interesting history of prior abdominal surgeries including a gastric resection for peptic ulcer disease followed by a revision with a roux-en-y and partial gastrectomy in . he had thrived since then but recently was admitted last month for pruritus, pain, and jaundice. he also had sepsis at that point. an ercp was attempted to analyze the bile duct, but was unsuccessful due to the reroute in his gastrointestinal system. a percutaneous transhepatic cholangiogram tube was placed to drain this and remains in place now. he was treated with antibiotics, and he stabilized out. this has been analyzed radiographically, and there is an obstruction in the bile duct at the area of the ampulla. there is clearly a mass there, and it appears to be growing into the lumen of the duodenum. past medical history: htn pud s/p perforation social history: he used to work as property manager but is now retired. married; wife and grown children very involved. he has 40 pack-year smoking history; quit a while back. no alcohol use. family history: non-contributory. physical exam: vs: t:, bp:, hr:, p:, rr:, sao2: % ra gen: thin, gaunt gentleman appearing older than stated age in nad. heent: sclerae anicteric. o-p moist, intact. neck: supple. no lymphadenopathy. no jvd or bruits. lungs: cta(b). cardiac: rrr; nl s1/s2 w/o m/c/r. abd: scaphoid. multiple, well-healed surgical scars across abdomen. drain (r)uq intact with miniaml tan drainage. dsd in place w/o significant staining. normoactive bsx4. soft/nt/nd. extrem: no c/c/e. ms: marked generalized muscle atrophy. gait stable with assistance and walker. skin: as aboev, otherwise intact. neuro: a+ox3. pleasant, interacts appropriately. non-focal/grossly intact. pertinent results: 08:21pm blood wbc-11.5* rbc-2.85*# hgb-8.5* hct-25.2* mcv-89 mch-29.8 mchc-33.6 rdw-14.5 plt ct-400 06:00am blood wbc-21.2* rbc-2.99* hgb-8.8* hct-26.6* mcv-89 mch-29.4 mchc-33.1 rdw-14.6 plt ct-469* 04:24am blood wbc-13.0* rbc-2.80* hgb-8.1* hct-24.4* mcv-87 mch-28.9 mchc-33.2 rdw-14.9 plt ct-950* 05:13pm blood wbc-15.6* rbc-3.28* hgb-9.4* hct-28.3* mcv-86 mch-28.8 mchc-33.3 rdw-14.3 plt ct-1199* 04:24am blood glucose-157* urean-17 creat-0.9 na-133 k-4.0 cl-99 hco3-26 angap-12 04:24am blood calcium-7.8* phos-3.0 mg-1.7 05:49am blood triglyc-173* . specimen submitted: fs ampullary adenoma, duodenal mass, gall bladder, whipple specimen. diagnosis: i. ampullary adenoma (a-b): adenoma with small focus of intramucosal adenocarcinoma. ii. pancreaticoduodenectomy (c-an): adenocarcinoma of the duodenum, arising in an adenoma, see synoptic report. focal inactive pancreatitis with ductal mucinous metaplasia. dilation of common bile duct. rest of duodenum including margins, bile duct margin and pancreas free of tumor. iii. duodenal mass (ao-as): adenocarcinoma arising in an adenoma with invasion into the duodenal wall. iv. gallbladder (at-au): chronic cholecystitis. choledochal cyst lymph node with hyperplasia. no calculi or tumor. . radiology report ct abdomen w/contrast study date of 9:55 pm impression: 1. negative for pe. 2. right lower lobe atelectasis and consolidation. there is obstruction of the right bronchus intermedius. bronchoscopy should be considered. . 3. small amount of pleural fluid on the left with associated atelectasis. 4. unusual appearance of the left humerus, which is felt to be the result of the artifact. however, plain radiography of the left humerus is suggested when the patient's clinical condition permits in order to confirm this suspicion. 5. collection of gas and fluid subjacent to the anterior abdominal wall in the vicinity of several of the anastomotic sites. a drainage procedure has been planned. . radiology report ct guidance drainage study date of 2:09 pm impression: 1. the more inferior component of the complex gas and fluid collection (the portion which was mostly fluid) was aspirated, yielding, cloudy, pink fluid. this was sent for gram stain, culture, and amylase. 2. a 10 french drainage catheter was placed into the more superior aspect of the collection. aspiration of the catheter yielded bilious appearing fluid, which was sent for gram stain, culture, and amylase. 3. injection of the percutaneous biliary drain, demonstrated extravasation of contrast outside of the confines of the hepaticojejunostomy, with free extravasation outside of the jejunal limb, collecting around the region of the pigtail drainage catheter within the complex gas and fluid collection. . radiology report t-tube cholangio (post-op) study date of 11:23am impression: persistent bile leak at the anastomosis . small intestine: polypectomy; segmental resection; whipple procedure (pancreaticoduodenectomy, partial or complete, with or without partial gastrectomy synopsis macroscopic specimen type: whipple procedure. tumor site: duodenum. tumor configuration: exophytic (polypoid). tumor size greatest dimension: 5.5 cm. microscopic histologic type: adenocarcinoma (not otherwise characterized). histologic grade: g2: moderately differentiated. extent of invasion primary tumor: pt2: tumor invades muscularis propria. regional lymph nodes: pn0: no regional lymph node metastasis. lymph nodes number examined: 23 (plus 1 choledochal cyst lymph node). number involved: 0. distant metastasis: pmx: cannot be assessed. margins proximal margin: uninvolved by invasive carcinoma. distal margin: uninvolved by invasive carcinoma. circumferential/radial (mesenteric or retroperitoneal) margin: uninvolved by invasive carcinoma. bile duct margin: margin uninvolved by invasive carcinoma. pancreatic margin: margin uninvolved by invasive carcinoma. distance of carcinoma from closest margin: 30 mm. specified margin: retroperitoneum. venous (large vessel) invasion: absent. perineural invasion: absent. brief hospital course: this is a 69 year old male with a pancreatic mass who went to the or on for a whipple procedure and extended adhesiolysis. following the procedure, he was kept intubated and intermittently on vasopressors and kept in the pacu overnight for close monitoring post operatively. he was transfused 2 units rbc overnight for a low hematocrit. he was extubated on pod 1. he had a foley catheter in place, ng tube in place, ivf for hydration and pca for pain control and was transferred to the surgical floor. : ng tube removed : foley catheter removed, diet advanced to sips : diet advanced to clears, vancomcin and zosyn started, po medication started, d/c pca, ct torso performed for tachypnea and fever demonstrating no pulmonary embolus right lower lobe atelectasis, consolidation, obstruction of the right bronchus intermedius, and collection of gas and fluid adjacent to the anterior abdominal wall in the vicinity of several of the anastomotic sites. bronchoscopy performed. : diet npo, foley catheter replaced, ct guided drainage of abdominal fluid collection performed, also injection of the percutaneous biliary drain performed demonstrating extravasation of contrast outside of the confines of the hepaticojejunostomy, with free extravasation outside of the jejunal limb, collecting around the region of the pigtail drainage catheter within the complex gas and fluid collection. continued vancomycin, zosyn : picc line placed, tpn started, central line removed : continued tpn, vancomycin and zosyn : continued tpn, abx, t tube study performed demonstrating persistent leak, lenis performed demonstrating no dvt - : diet advanced to clears and then to regular, cont tpn, vancomycin, zosyn, started gentamicin : t tube study performed showing massive leak at hepaticojejunostomy anastomosis, biliary catheter exchanged, continued tpn, vancomycin, zosyn, gentamicin and regular diet : ct performed demonstrating new collection adjacent to multiple mesenteric vessels concerning for a large pseudo-aneurysm. new placement of an anterior abdominal drain, with persistent fluid and gas within the abdomen, and small areas of loculated fluid collections. : transfused one unit rbc for low hematocrit, fluconazole started (in addition to vancomycin, gentamicin and zosyn, brought to the operating room for open drainage of intra-abdominal abscess, repair of pancreaticojejunostomy through a bridge stent technique, and mass closure of the abdominal wall. he remained intubated following the procedure and was transferred to the icu for close monitoring. he had intermittent use of propofol and vasopressors. octreotide drip started. : the patient was extubated, continued on vancomycin, zosyn, gentamicin, fluconazole, transfused one unit of rbc, pca for pain control : resumed tpn, continued vancomycin, zosyn, gentamicin, fluconazole, octreotide : transferred to the floor with tpn, octreotide, vancomycin, zosyn, gentamicin, fluconazole : d/c octreotide drip and started octreotide sq, picc line placed, cont tpn, octreotide, vancomycin, zosyn, gentamicin, fluconazole : ct performed showing large collection anterior to the pancreas containing oral contrast material, from presumed leak, cont tpn, octreotide, vancomycin, zosyn, gentamicin, fluconazole : cont tpn, octreotide, vancomycin, zosyn, gentamicin, fluconazole, ct guided drainage performed with 8f pigtail catheter into a leaking bowel loop adjacent to the enterostomy site. 2 units rbc transfused : diet advanced to clears : diet reverted to npo, cont tpn, octreotide, zosyn, fluconazole, discontinued vancomycin, gentamicin : drain study performed showing pigtail catheter in the right upper quadrant, drainage tube in the right upper quadrant, two surgical drains in the left upper quadrant. injection of the drain showed prompt extravasation into the known intraperitoneal collection : cholangiogram performed demonstrating a persistent leak within the hepaticojejunostomy or pancreaticojejunostomy anastomotic region. uncomplicated exchange of existing biliary drain for a 10 french, 25-cm internal-external biliary drain. continued tpn, zosyn, fluconazole : discontinued zosyn, started meropenem, continued fluconazole and tpn : ugi study performed showing no evidence of obstruction. no extravazation of contrast identified in the upright position. onpassage of contrast beyond the proximal jejunum on supine imaging. : renal u/s performed for rising creatinine - grossly normal son evaluation of the kidneys and bladder, continued tpn, fluconazole, started ciprofloxacin and flagyl, discontinued meropenem : extensive whole body rash noted, dermatology started and felt to be drug reaction, continued tpn, cipro, flagyl, fluconazole : dialysis catheter placed and started hemodialysis q 3days, transferred to the unit for tachypnea, tachycardia and confusion : intermittently on vasopressors, started levofloxacin, discontinued ciprofloxacin, continued tpn, flagyl, fluconazole, transfused 2 units rbc, ct performed demonstrating persistent collection of extraluminal oral contrast material and gas within the anterior abdomen, just subjacent to anterior abdominal wall. the collection is smaller when compared to the most recent prior exam. : dermatology performed punch biopsies of skin demonstrating reactive drug rash : ir replaced biliary catheter, continued tpn, flagyl, fluconazole, started vancomycin enemas due to c diff positive, discontinued levofloxacin : transferred to the floor out of the icu, continued tpn, vanco enemas, flagyl, fluconazole, hemodialysis : diet advanced to clears, continued tpn, fluconazole, vanc enemas, flagyl, hemodialsis : transferred to icu for desatting; needs dialysis. : dialysis, 2 units prbc. ? aspiration event, resp arrest with intubation. : 2 units prbc. during afternoon, pt became hemodynamically unstable. started on neo gtt. evaluated with ecg, leni, xray, enzymes. : s/p ir for ptc replacement, more lethargic, cosyntropin stim test : hd, extubated, neo for hypotension : ptc cath pulled back, mrsa in sputum and bile, reintubated, on neo for hypotension, stress dose steroids started. : remains neutropenic from unknown etiology, hematology consulted, ct scan, sputum/blood cx sent, transient episode of bradycardia and hypotension with few seconds of unresponsiveness after turning : neupogen started, mucous plug - recovered after suctioning, stim 17.7-22 but endo believes test was not accurate. remains on dexamethasone 2.5mg , s/p dialysis, tpn : desat with mucus plug. restarted hydrocort 50 , lopressor3/5: tbili decreased despite ptc capped. renal signed off. continue water sips, no advancement for now. to repeat urine cx from new foley. : consent for trach, hydrocortisone discontinued, vancomycin discontinued, held off on hd, lasix 100 mg given with good diuresis, neutropenia resolved, neupogen dose 3 held : trach done. run of svt treated with 5 lopressor. spiked temp. pan cultured. : cipro/fluc d/ced, no dialysis per renal : passed pmv eval. : foley changed, ptc drain capped : no events : transferred out of icu to floor. diet advanced to clears. : diet put back to sips. pt on board. speech & swallow consult ordered. foley d'ced. : diet readvanced to clears. : transfused 2 units prbcs due to low crit. chest xray done as per speech/swallow. : ptc uncapped. id brought on board due to question of pneumonia as seen on chest xray. patient put on po medications, including lopressor . down for cholangiogram - normal tube cholangiogram demonstrating non-dilatation of the intrahepatic biliary tree and free passage of contrast; no obstruction or leak. biliary catheter replaced with the tip in the common hepatic duct. : transferred to tsicu with fever, rigors, hypotension, tachycardia, leukocytosis secondary to sepsis. started albumin 5% administered q8hours x 24 hours. urine output remained stable greater than 100ml/hr. cefipime added to iv vancomycin, flagyl, levaquin; patient defervesced. psychiatry continued to follow for delerium, hopelessness. : blood culture x1 with gram negative rods; continued on iv antibiotic therapy. remained hemodynamically stable. no events. passed speech & swallow study with dietary recommendations updated. : urinalysis positive for e.coli; creatinine improved. iv vanco changed to po; other iv antibiotics continued. albumin continued for tachycardia. picc placed; tpn started. remained hemodynamicaly stable. : levaquin and cefepime discontinued, iv bactrim started. continued on vanco po and flagyl. tolerating regular diet; tpn continued. arf resolving. hemodynamically stable with improving hct. : trasferred back to floor. heart rate consistently in 120s; hemodynamically stable. minimal po intake due to episodic nausea; prescibed reglan and zofran. continues on tpn. : stay-sutures discontinued. urine output stable. foley discontinued, replaced with condom catheter. po intake improving; continues on tpn. remianed stable. vanc oral liquid discontinued. : patient transfused two units prbc due to low crit. lasix administered. : pt. out of bed to chair. no other events. : ct scan of pelvis and abdomen done. no new collections seen. pt. hyperkalemic and given protocol of insulin, bicarb., etc. in evening, due to tachycardia and tachypnea, pt. transferred back to icu with suspected sepsis. cefepime begun as per id. : pt. given albumin for low pressures. pt. continued on vanc and bactrim. : cefepime discontinued. pt. stable and transferred back to the floor. : all antibiotics other than flagyl discontinued as patient's cultures negative. : pt. ambulatory with physical therapy treating. flagyl d'ced as per id. pt. hep locked and placed on po meds. : picc placed, tpn restarted. po lopressor begun and iv lopressor discontinued : eating well. tpn continued. foley discontinued; voided without problem. spiked fever to 101.7 po in evening; blood and urine cultures sent. : heart rate greater than 150; defervesced with po tylenol and heart rate returned to baseline. remined stable. cxr unremarkable. bile culture with gnr and gpc. id re-consulted. : went for chalnagiography/tube cholangiogram study in ir; ptc removed. received prophylactic iv antibiotics prior to study, otherwise antibiotics were not restarted on a regular basis. tolerated procedure well. : remined afebril/stable. no events. improved activity tolerance with physcial therapy. : continues stable on tpn, ambulating with pt, improving po intake. no events. : octreotide discontinued. continued on tpn, regular diet, phsycial therapy. : tracheostomy decannulated under medical supervision at the bedside without complication; patient remained stable w/o dyspnea. monitored by telemetry and continuous sao2 remainder of day and over night without incident. : appetite fair today. tpn discontinued. discharge planning underway. no events. : complaint of (r)uq abdominal pain when eating. no nausea, vomiting. no events. patient ready for discharge home with services. at the time of discharge, the patient was doing well, afebrile with stable viral signs. the patient was tolerating a regular diet, ambulating with assistance and a walker, voiding without assistance, and pain was well controlled. he will discharged home with and physical therapy. the patient and family received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: atenolol 25 po daily discharge medications: 1. one touch ultra 2 kit sig: one (1) kit miscellaneous asdir: glucometer testing qid. disp:*1 * refills:*0* 2. one touch ultrasoft lancets misc sig: one (1) lancet miscellaneous asdir achs: glucometer supplies. disp:*1 box* refills:*2* 3. one touch ultra test strip sig: one (1) strip in asdir achs: as directed per insulin sliding scale. disp:*100 strips* refills:*2* 4. alcohol pads pads, medicated sig: one (1) pad topical asdir: for use with glucometer testing. disp:*1 box* refills:*2* 5. dronabinol 5 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*0* 6. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. disp:*1 bottle, large* refills:*2* 7. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for fever or pain. 8. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*70 tablet(s)* refills:*0* 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 10. zofran 8 mg tablet sig: one (1) tablet po q8hours as needed for nausea. disp:*60 tablet(s)* refills:*2* 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 12. insulin regular human 100 unit/ml solution sig: one (1) injection injection asdir (as directed): as directed per insulin sliding scale. disp:*1 vial* refills:*2* 13. insulin syringe ultrafine ml 29 x syringe sig: one (1) injection miscellaneous asdir insulin administration. disp:*1 box* refills:*1* discharge disposition: home with service facility: discharge diagnosis: 1. ampullary adenoma. 2. bile duct stricture. 3. adenocarcinoma of the ampulla. 4. extensive adhesions, status post multiple operations. discharge condition: good discharge 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. fingerstick blood sugar monitoring: please check your fingerstick blood sugar first thing in the morning before eating breakfast, and just before dinner. record sugar greater than 170. jp drain care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever) or skin breakdown. *apply ostomy collection bag over jp tube as directed with rn assitance. *note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character. *you may shower; cover ostomy pouch with water-proof barrier, such as saran wrap. keep area clean and dry. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. followup instructions: please call ( to schedule a follow-up appointment with dr. in weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Percutaneous abdominal drainage Radical pancreaticoduodenectomy Other nonoperative replacements Cholecystectomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Other lysis of peritoneal adhesions Reopening of recent laparotomy site Other laparotomy Anastomosis of pancreas Closed biopsy of skin and subcutaneous tissue Repair of other hernia of anterior abdominal wall Other cholangiogram Other cholangiogram Suture of laceration of small intestine, except duodenum Other percutaneous procedures on biliary tract Replacement of stent (tube) in biliary or pancreatic duct Cannulation of pancreatic duct Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Esophageal reflux Acute kidney failure with lesion of tubular necrosis Other postoperative infection Unspecified pleural effusion Unspecified septicemia Severe sepsis Depressive disorder, not elsewhere classified Pulmonary collapse Acute respiratory failure Peritoneal adhesions (postoperative) (postinfection) 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 Intestinal infection due to Clostridium difficile Other specified disorders of biliary tract Dermatitis due to drugs and medicines taken internally Obstruction of bile duct Other specified antibiotics causing adverse effects in therapeutic use Malignant neoplasm of ampulla of vater Peritoneal abscess Other diseases of trachea and bronchus Foreign body in larynx Persistent postoperative fistula Benign neoplasm of liver and biliary passages Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Methicillin resistant pneumonia due to Staphylococcus aureus Penicillins causing adverse effects in therapeutic use Hernia of other specified sites without mention of obstruction or gangrene

allergies: azithromycin / zosyn / meropenem attending: chief complaint: failure to thrive, fevers major surgical or invasive procedure: 1. gj-tube placed on . 2. picc line placed on . 3. hepatic drains placed on . 4. right-sided thoracentesis on . 5. j-tube placement via ec fistula . 6. j-tube replacement via ec fistula . history of present illness: patient is a 69 yo m w/ h/o pud s/p gastric resection followed by roux-en-y in distant past, now s/p whipple in for ampullary carcinoma. the patient's post-op course was complicated by multiple leaks and an ec fistula. he was recently admitted for failure to thrive, abdominal pain and drainage from his ec fistula, at which time he had a j tube placed through the fistula tract. he had a ptc in place which was patent and was used to demonstrate a patent hepaticojej anastomosis. the patient had multiple fevers during his admission. blood cultures were negative, while cultures of the ptc drainage demonstrated clostridium perfringens. the patient returns to the hospital today with continued failure to thrive and fevers of 101.5 on admission. past medical history: pmhx: adenocarcinoma (duodenum), htn, peptic ulcer disease . pshx: s/p gastric resection for pud s/p revision with roux-en-y and partial gastrectomy in s/p whipple, as above s/p takeback for repair of pancreaticojejunostomy, as above social history: he used to work as property manager but is now retired. married; wife and grown children very involved. he has 40 pack-year smoking history; quit a while back. no alcohol use. family history: non-contributory. physical exam: on admission: vs: temp 99 bp 122/66 hr 100 rr 18 o2 sat 94% ra gen: nad, a&o, gaunt heent: scleral icterus resp: ctab no c/w/r cards: rrr no m/r/g abd: soft, nondistended. ttp in ruq. skin: mild jaundice. ext: no cyanosis/edema . at discharge: vs: 98.7 po, 89, 124/73, 18, 97% ra gen: thin, cachectic in nad. heent: min. scleral icterus. o-p clear. neck: supple. lungs: cta(b) cor: rrr abd: scaphoid. bsx4. ec fistula intact/patent. ostomy appliance intact. jpx2 intact/patent with minimal drainage (less than 10ml/daily). soft/nd. extrem: no c/c/e. neuro: a+ox3. interacts approrpiately. pertinent results: 06:16am blood wbc-13.8* rbc-2.54* hgb-7.6* hct-24.5* mcv-96 mch-29.8 mchc-30.9* rdw-14.8 plt ct-683* 04:15pm blood wbc-18.5* rbc-2.66* hgb-8.0* hct-25.5* mcv-96 mch-30.0 mchc-31.3 rdw-15.2 plt ct-482* 06:16am blood plt ct-683* 01:17pm blood pt-17.1* ptt-33.8 inr(pt)-1.5* 04:15pm blood plt ct-482* 04:15pm blood pt-16.0* ptt-28.4 inr(pt)-1.4* 06:16am blood glucose-97 urean-16 creat-1.1 na-134 k-4.4 cl-97 hco3-31 angap-10 04:15pm blood glucose-120* urean-31* creat-1.3* na-129* k-4.7 cl-95* hco3-26 angap-13 06:50am blood alt-15 ast-29 alkphos-596* amylase-41 totbili-3.1* 04:15pm blood alt-40 ast-47* alkphos-930* amylase-24 totbili-4.0* 06:50am blood lipase-12 04:15pm blood lipase-10 06:16am blood albumin-2.3* calcium-8.0* phos-4.6* mg-2.2 iron-pnd 04:15pm blood albumin-2.3* calcium-8.4 phos-3.4 mg-2.1 06:16am blood vanco-20.8* 11:57pm blood vanco-20.8* micro: blood culture, routine (final ): klebsiella pneumoniae. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 2 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s ct abdomen/pelvis (): impression: 1. interval decrease in size of two hepatic abscesses recently drained, with pigtail catheters remaining in place. 2. stable appearance, or possibly slight increase in size of abscess collection in segment vii, which had been aspirated on , but was unable to be drained. 3. unchanged appearance of tiny ill-defined foci in the dome of the right lobe of the liver, likely representing additional small areas of abscess, too small for drainage. 4. unchanged large right pleural effusion, and associated right lower lobe collapse. 4:10 pm abscess 2nd lower liver. **final report ** gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and chains. 1+ (<1 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. wound culture (final ): 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.. staph aureus coag +. sparse growth. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- 2 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ <=1 s anaerobic culture (final ): presumptive clostridium septicum. moderate growth. . echo: this study was compared to the prior study of . left atrium: normal la size. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). tdi e/e' < 8, suggesting normal pcwp (<12mmhg). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. paradoxic septal motion consistent with conduction abnormality/ventricular pacing. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. normal ascending aorta diameter. aortic valve: mildly thickened aortic valve leaflets (3). no as. no masses or vegetations on aortic valve. trace ar. mitral valve: normal mitral valve leaflets. no mvp. no mass or vegetation on mitral valve. trivial mr. tricuspid valve: normal tricuspid valve leaflets. no mass or vegetation on tricuspid valve. physiologic tr. normal pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. conclusions: the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (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 aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: no echocardiographic evidence of endocarditis. normal global and regional biventricular systolic function. compared with the prior study (images reviewed) of , the heart rate is now slower. trivial aortic regurgitation is now seen. brief hospital course: 69 year old man with a history of peptic ulcer disease s/p gastric resection followed by roux-en-y in distant past (), now s/p whipple in for ampullary carcinoma complicated by enterocutaneous fistula's and failure to thrive. the patient was pan cultured and subsequently followed closely by the infectious disease service. he was placed on flagyl, cipro and aztreonam. his initial blood cultures from were + klebsiella and they presumed he had cholangitis as a source for his gram negative bacteremia. unfortunately he continued to spike temperatures and was hypotensive therefore he transferred to the icu for closer management. his antibiotics were adjusted due to his prior h/o esbl ecoli. gentamycin was added as was vanco for mrsa coverage. his hemodynamics were stable and his wbc was coming down. based on an abdominal ct which was done on and showed multiple fluid collections, he was sent to ir on and had 2 drains placed and a 3rd site aspirated. these were cultured and grew pseudomonas, mrsa and beta strep. his antibiotic regimen included clindamycin, ciprofloxicin and bactrim ds however on he had another temperature spike and was recultured. on and 21 his blood cultures were positive for enterococcus therefore his picc line was removed. his chest xray showed an enlarging right effusion for which he underwent thoeracentesis and he returned to interventional radiology for manipulation of his drains to aspirate any undrained collections. his bactrim was subsequently changed to linazolid. final recommendations from the infectious disease service include the continuation on linazolid, ciprofloxicin and clindamycin for 14 days after the drains are removed along with weekly cbc with diff, bun creat and lft's. he will follow up in 2 weeks with dr. . from a nutrition standpoint, his fibersource tube feedings were infusing at 90cc/hr over an 18 hour period however he had many interruptions in his feedings secondary to the tube either being dislodged or removed by the patient. concurrently he was on a regular diet which he intermittently tolerated well. due to the fact that the feeding could not be replaced until the week of and he was feeling better and anxious to get home, he was discharged on and will return for placement of the feeding tube next week. his pain was controlled with a fentanyl patch and oral dilaudid for breakthrough. he was up and ambulating without difficulty. he will be discharged with follow-up for wound and drain care, and will follow up with dr. in 2 weeks with a repeat abdomional ct. medications on admission: 1. ursodiol 300 mg capsule sig: two (2) capsule po twice a day. 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 3. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*150 tablet(s)* refills:*2* 4. dilaudid 2-4mg po q4hours prn pain discharge medications: 1. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). disp:*10 patch 72 hr(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*1* 3. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day. tablet(s) 5. hydromorphone 2 mg tablet sig: 1-4 tablets po q3h (every 3 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 6. metoclopramide 10 mg tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*0* 7. ammonium lactate 12 % lotion sig: one (1) appl topical qid prn () as needed for pruritus. disp:*1 tube* refills:*0* 8. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical (2 times a day) as needed for pruritus. disp:*1 tube* refills:*0* 9. clindamycin hcl 150 mg capsule sig: three (3) capsule po q6h (every 6 hours). disp:*170 capsule(s)* refills:*1* 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*28 tablet(s)* refills:*1* 11. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*30 tablet(s)* refills:*1* 12. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 13. zofran 8 mg tablet sig: one (1) tablet po three times a day as needed for nausea. disp:*10 tablet(s)* refills:*4* discharge disposition: home with service facility: discharge diagnosis: 1. cholangitis, gram negative sepsis. 2. failure-to-thrive. 3. right pleural effusion. discharge condition: stable discharge instructions: you were admitted to the hospital for failure to thrive while at home. at this time, we believe that your condition is stable and safe to go home. 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. . general drain care: . *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *if the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character. be sure to empty the drain frequently. record the output, if instructed to do so. *wash the area gently with warm, soapy water. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. *please flush the two drains with 10ml sterile saline twice daily. . ostomy care and appliance changes: . *monitor skin integrity at abdominal fistula site. *steps of care: small fistula pouch # 9773 *using the pattern trace it onto the paper side of the pouch and then cut the drawing out *make radial cut around the cut opening to allow the pouch to mold to his contours, remove release paper *using a strip of coloplast past strip stretch it to fit around the cut opening and secure it to the adhesive surface of the pouch *treat the peri-fistula skin with stomahesive powder and dust off the excess. dab no-sting barrier wipe peri-fistula skin. *center the pouch over the fistula and apply being sure to mold the pouch to his contours *change appliance: 2 times per week ( & thursday), and as needed. followup instructions: , md (infectious disease) phone: date/time: 11:30. you will need an abdominal ct the day before this appointment. this will be set up by dr. office. you will be contact on , regarding the date and time to return to next week to have the feeding tube replaced by dr. . you will also be contact by dr. office regarding your next follow-up appointment. please call ( with any questions. other appointments: provider: ,one date/time: 8:00 provider: west outpatient radiology phone: date/time: 9:30 Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Thoracentesis Percutaneous aspiration of liver Percutaneous aspiration of liver Replacement of tube or enterostomy device of small intestine Replacement of tube or enterostomy device of small intestine Diagnoses: Unspecified pleural effusion Sepsis Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure 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 Abscess of liver Mechanical complication due to other implant and internal device, not elsewhere classified Other septicemia due to gram-negative organisms Cholangitis Personal history of malignant neoplasm of other gastrointestinal tract Persistent postoperative fistula Body Mass Index less than 19, adult

allergies: nifedipine / lisinopril attending: chief complaint: found down major surgical or invasive procedure: - cerebral angiogram with coiling of ruptured left pcomm artery aneurysm - evd placement evd replaced history of present illness: this ia an 80 year old man with history of dm, htn, on 81, found down by his wife at 2:30 am. on arrival to ed, gcs was 5 and he was intubated in the ed. ct head revealed bilateral sah and neurosurgery was consulted. past medical history: dm, htn, hl social history: he is married and lives with his wife. was tobacco free for >12 months and he occasionally used etoh. family history: non-contributory physical exam: at admission: v: intubated motor: withdraws to pain, posturing o: t: bp: 163/91 hr:65 r o2sats: 100% heent: pupils: 2-1.5 eoms neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. no c/c/e. neuro: mental status: intubated orientation: intubated cranial nerves: i: not tested ii: pupils equally round and reactive to light, to mm bilaterally. visual fields are full to confrontation. motor/sensory: localizes to pain in b le; withdraws in b ue toes downgoing bilaterally physical exam upon discharge: expired pertinent results: csf studies: 09:47am cerebrospinal fluid (csf) wbc-5800 hct,fl-14* polys-77 lymphs-8 monos-0 eos-3 macroph-12 09:47am cerebrospinal fluid (csf) totprot-1150* microbiology: positive cultures sputum gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): multiple organisms consistent with oropharyngeal flora. respiratory culture (final ): moderate growth commensal respiratory flora. enterobacter aerogenes. sparse growth. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. piperacillin/tazobactam sensitivity testing performed by microscan. sputum gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): multiple organisms consistent with oropharyngeal flora. smear reviewed; results confirmed. respiratory culture (final ): sparse growth commensal respiratory flora. enterobacter aerogenes. moderate growth. identification and sensitivities performed on culture # (). imaging: : cta head/neck: impression: 1. extensive subarachnoid hemorrhage with a large 1-cm sized aneurysm arising at the junction of the left posterior cerebral artery and posterior communicating artery as described above. 2. intraventricular extension of hemorrhage with mild hydrocephalus. 3. duplicated origin of the left vertebral artery with one of the left vertebral arteries arising directly from the aortic arch and the second left vertebral artery arising from the left subclavian artery. ct cspine- impression: 1. no evidence of acute fracture or malalignment. multilevel degenerative joint changes, as described above.mri would be more sensitive for ligamentous injury. 2. nasogastric tube is coiled in the oropharynx. ct head- impression: 1. expected post-evd changes. 2. slightly increased size of lateral ventricles when compared to the most recent prior study performed six hours earlier with increased subarachnoid hemorrhage layering in the occipital horns of the lateral ventricles. 3. unchanged extensive bilateral subarachnoid hemorrhage with intraventricular extension. 4. stable small parafalcine and right temporal subdural hematomas. 5. generalized loss of -white matter differentiation suggesting diffuse cerebral edema slightly increased from six hours earlier. cerebral angio- echo- 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. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trivial mitral regurgitation is seen. there is no pericardial effusion. impression: limited study. normal global and regional biventricular systolic function. no major valvular disease seen. head ct- 1. new focus of hemorrhage measuring 27 x 25 mm along the superior track of the evd without mass effect or edema involving the right frontal lobe. 2. bilateral subdural hematomas extending along the posterior convexity at the cerebral hemispheres bilaterally has layering along the tentorium, increased significantly from 21 hours prior. 3. decreased size of lateral ventricles compared to the most recent prior studies. 4. unchanged extensive bilateral subarachnoid hemorrhage with evidence of redistribution from . 5. generalized loss of -white matter differentiation consistent with diffuse cerebral edema. tcd abnormal tcd evaluation. below normal velocities of the bilateral middle cerebral arteries, anterior cerebral anteries, posterior cerebral arteries, and internal carotid artery siphons may have been due to poor temporal and ophthalmic windows. mildly increased p.i. indices have a differential of increased intracranial pressure or possibly distal stenosis, including from small vessel disease. there was no evidence of vasospasm. recommend repeat tcd on . eeg this is an abnormal continuous icu monitoring study because of the presence of a severe diffuse encephalopathy manifest by diffuse voltage suppression and loss of fast frequencies over all head regions but showing asymmetry in the right occipital pole. the background itself is dramatically abnormal with a frontal central rhythmic theta and virtually no posterior rhythms. no clear seizure discharges were identified. cta head 1. expected evolution of subarachnoid blood products with no evidence of new hemorrhage. 2. stable parenchymal hemorrhage along the ventriculostomy tract with stable position of catheter and decrease in size of ventricles. this is associated with more prominent subdural collections bilaterally, likely reative to shunting. 3. no evidence of infarct following coiling of the left pcom aneurysm. 4. small caliber of left posterior cerebral artery as well as the bilateral a1 segments which is unchanged from and thus unlikely to represent vasospasm. tcd mildly abnormal tcd evaluation. above normal velocities of the proximal right middle cerebral artery and the left posterior cerebral artery. there was no evidence of vasospasm. recommend repeat tcd on . tcd mildly abnormal tcd evaluation. above normal velocities of the proximal right middle cerebral artery and the left posterior cerebral artery. there was no evidence of vasospasm. recommend repeat tcd on . cxr et tube and right subclavian line are in standard placements and a nasogastric tube can be traced to the upper stomach but the tip is indistinct. upper lungs are clear. heterogeneous opacification in both lower lungs is either atelectasis or pneumonia. the involvement at the right base is the greater of the two, and it is essentially unchanged since . heart size is normal. mediastinal veins are mildly engorged. no pneumothorax. tcd mildly abnormal tcd evaluation. above normal velocities of the proximal right middle cerebral artery. there was no evidence of vasospasm. recommend repeat tcd on . cxr unchanged appearance. probably left basal atelectasis and/or effusion cxr lines and tubes are in standard position. there are persistent low lung volumes. mild cardiomegaly is accentuated by low lung volumes. bibasilar opacities, larger on the left side, are unchanged, consistent with atelectasis. the upper lungs are grossly clear. there are no new lung abnormalities, pneumothorax or enlarging pleural effusions. tcd abnormal tcd evaluation. severe vasospasm of the right proximal middle cerebral artery. this represents a marked worsening compared to the tcd results from . clinical correlation is needed cta head 1. moderate vasospasm of the intracranial vessels including the basilar, distal m1 segment of the right mca and m2 and m3 segments of the bilateral mca increased from with persistent narrowing/vasospasm of the bilateral a1 and a2 segments of the acas, unchanged from . 2. status post coiling of large left pcom aneurysm with expected redistribution of subarachnoid hemorrhage and no evidence of new hemorrhage. 3. slightly resolved intraparenchymal hemorrhage within the right frontal lobe along the superior evd tract with unchanged position of evd and stable size of ventricles from . 4. slightly increased bilateral hypodense subdural hematomas along the anterior cerebral convexities without significant change in mass effect and no shift of normally midline structures. 5. stable posterior hyperdense subdural hematoma. cta head 1. new hyperdense focus at the tip of the external ventricular drain, which may represent a focus of acute hemorrhage or clot. 2. minimal increase in ventricular size from 23 to 26 mm. 3. otherwise, unchanged exam with subarachnoid hemorrhage and bilateral subdural collections cxr compared to the exam from the prior day, there is no significant interval change. ct head 1. interval evolution of a right frontal parenchymal hemorrhage along the shunt catheter. interval decrease in the intraventricular hemorrhage. no new change in the size of the ventricles. 2. bihemispheric subdural hematomas and subarachnoid hemorrhage, not significantly changed since the prior study. 3. pansinus opacification relates to the endotracheal intubation. eeg this is an abnormal continuous icu monitoring study because of a severe diffuse encephalopathy. superimposed upon this encephalopathy are some subtle lateralizing features suggesting greater damage to the right hemisphere. there are multifocal paroxysmal sharp transient suggesting irritability. these tended also to have right hemisphere predominance. tcd abnormal tcd evaluation. moderate vasospasm of the right proximal middle cerebral artery. this was not markedly different from the tcd results of . the left mca had below normal velocities but this was probably due to technical factors. clinical correlation is needed. recommend repeat tcd on . cxr as compared to the previous radiograph, there is no relevant change. the monitoring and support devices are in constant position. the lung volumes have minimally decreased. the diameter of the vascular structures is at the upper range of normal, potentially indicative of mild fluid overload, but no overt pulmonary edema is present. moderate retrocardiac atelectasis. no new parenchymal opacities in the ventilated areas of the lung parenchyma. ct head 1. right transfrontal external ventricular drain with blood products along the evd track and decreased post-operative right frontal pneumocephalus from . 2. stable intraventricular hemorrhage with blood products in the anterior of the right lateral ventricle and layering posteriorly within the occipital horns of the lateral ventricles. 3. evidence of redistributed subarachnoid hemorrhage, unchanged in extent. 4. stable frontal hypodense and posterior hyperdense subdural hematomas. 5. no evidence of acute hemorrhage or large vascular territorial infarct eeg this is an abnormal continuous icu monitoring study because of severe diffuse encephalopathy with subtle features suggesting great right hemisphere pathology. there are a number of paroxysmal sharp features to the record. no clear interictal epileptic discharges were noted. the right side tends to predominate in terms of the sharp features. compared to the prior day's recording, there were no significant changes. cxr there are low lung volumes. mild cardiomegaly is accentuated by the low lung volumes. bibasilar atelectases have minimally improved. et tube is in the standard poition. ng tube is out of view below the diaphragm. a right picc line catheter tip is in the upper svc. ct head unchanged position of the right frontal approach internal ventricular drain catheter with slightly increased adjacent pneumocephalus. multicompartmental hemorrhage and some degree of edema unchanged compared to recent study. bil. subdural fluid collections, increased since the initial study of -? superimposed intracranial hypotension. correlate clinically and followup. cxr as compared to the previous radiograph, there is no relevant change. the monitoring and support devices are constant. there is unchanged appearance of the low lung volumes and the moderate retrocardiac atelectasis as well as the mildly enlarged cardiac silhouette. no larger pleural effusions. no newly appeared focal parenchymal opacities. mri brain: impression: 1. multicompartmental hemorrhage and bil. subdural fluid collections as described above, better characterized on the prior ct head studies. 2. scattered small foci of increased dwi signal with decreased adc signal, related to ischemic/infarction-related changes. the etiology of this is unclear and it is also unclear if these explain the patient's quadriplegia. correlate clinically to decide on the need for further workup. 3. bil. mastoid fluid and mucosal thickening. mri c-spine: 1. multilevel, multifactorial degenerative changes with changes and moderate canal stenosis at c3-4 from disc extrusion and bulge and ligamentum flavum thickening and deformity on the cord at this level. 2. evaluation for marrow edema from trauma or ligamentous injury or cord signal intensity changes is limited given the lack of sagittal stir and axial t2-weighted sequence. these were not done due to technical issue. the patient will be brought back, for the additional sequences, which will be performed as a separate study. 3. multilevel moderate foraminal narrowing with deformity of the nerves in these locations. cxr: the left lower lobe atelectasis is unchanged. vascular congestion is unchanged but no overt edema is seen. right central venous line tip is at the level of mid svc. et tube and the ng tube are in appropriate location, unchanged since the prior study. ct head- impression: 1. right frontal approach shunt catheter has an extraventricular course, terminating at the septum pellucidum. 2. mild increase in the parenchymal hemorrhage surrounding the shunt catheter in the right frontal lobe. 3. bihemispheric subarachnoid and intraventricular hemorrhage, subdural hematomas have not significantly changed since the prior study. ct head- impression: 1. status post ventriculostomy catheter placement from right frontal approach without a definitive intraventricular course as described on prior report. 2. similar appearance of bilateral subdural collections with similar to slightly increased subarachnoid hemorrhage and definite increase in intraventricular hemorrhage. this finding was discovered at 9:39 a.m. and discussed with at 9:43 a.m. on by dr. over the phone. 3. similar appearance of air and blood products around the course of the ventriculostomy catheter within the right frontal parenchyma. brief hospital course: the patient was admitted to the neurosurgery icu for q1 neurochecks and vital signs. she was started on nimodipine 60mg q 4 hours and seizure prophylaxis. strict sbp less < 130 parameters was initiated and she was kept npo. an evd was placed at 15cm h20 and a ct was performed which confirmed good placement. in the am of she underwent a cerebral angiogram and coiling of a left pcomm artery aneurysm. she was transferred back to the sicu post procedure. a portable head ct was performed in the am which revealed a new hemorrhage along the evd track and increased sdh. baseline tcd's were performed. an echo and eeg were also requested. the echo showed lvef>55%, and the eeg showed diffuse encephalopathy with no evidence of clinical seizures. on his collar was cleared, and on his ivf were decreased from 100cc/hr to 75cc/hr. on his evd was raised to 20, he had a cta that showed more porminent hygromas and no vasospasm. overnight, icps were stable and evd draining adequately. on , patient w/d bue and triple flexes ble. his drain remains at 20 and tcds are negative for vasospasm. on , tcds with no evidence of vasospasm. ivf were discontinued and lasix ws given for diuresis with goal of 2l negative. on , the external ventricular drain was at 20 h2o cm above the tragus. the patient had a low grade fever of 100. icp were . family meeting****. a cta was performed which was consistent with spasm r mca & basilar arteries. on , the external ventricular drain stopped draining. a nchct was performed which was stable and did not show any hydrocephalas. the patient was tachypneic and hypertensive. on exam the patient withdrew to noxious stimulous in all 4 extremities. on , the external ventricular catheter was clamped 0800. teh clamping trial failed at 1130 am whe the patient icp elevated to 27-29. the serum bun was noted to be 40 which was elevated from the mid 20s on . ancef 2 gm tid was added for empiric evd coverage as the evd site was slightly edematous and warm on palpation. wbc was slightly elevated at 13.4. on : the evd site appearance was improved. there was no erythema and improved edema. the ivf 100 at cc/hr wa sdiscontinued. the evd stopped draing at 0600, 1200, and 4pm and each time tpa was instilled in the line for 20 mints to obtain patency.a nchct was performed which was stable. on exam the patient opened the left eye to noxous stimuli,minimal withdrew to noxious in the bilateral upper eextremities, and triple flexion was exhibited in the bilateral lower extremities. the serum bun was improved to 33. the wbc improved to 12.3 a tcd was performed which showed right mca spasm which was stable when compared to . the external ventricular drain was lowered to 10 h2o mmhg above the tragus. an eeg was ordered to evaluate for seizure activity and to evaluate the further requirment of keppra. the eeg was consistent with no seizures. his icp waveform was dampened at 011 on and it was flushed with return of waveform. on his exam remained poor overall, his drain output began to slow and tpa was instilled at 1430, clamped for 30 mins, and when re-opened there was brisk drainage of csf. during the day of , his evd was functioning well. in the evening it was no longer draining and flushing did not help. the tubing was pulled back a bit then began draining. head ct to confirm placement was performed. on csf was sent and mri head and c-spine imaging was done. mri revealed multiple small infarcts but nothing to explain mental status. the results were discussed in a family meeting as well as goals of care. it was decided to proceed with trach and peg planning. on the evd continued to be tenuous with periods of non-drainage requiring flushing and tpa. his neurological exam remained unchanged. on in the early am the evd required tpa infusion again for non-drainage. this was infused after a head ct was performed and stable. at approx 8:30am the patients blood pressure rose to over 200, icp increased to 70's with a wave form. it was also noted to have new blood around the evd dressing. neurological exam was stable but the patient was taken for a stat head ct. ct revealed new acute ivh. the findings were discussed with the sicu staff and family. at this time it was recommended that care be withdrawn and not proceeding with trach and peg. the family was in agreement with this plan and asked for evd and et tube to be removed as soon as possible. he was started on a morphine gtt and these were both performed. the patient passed away of respiratory failure with the family at the bedside in the afternoon of . medications on admission: allopurinol 100qd, , 81, atenolol 50qd, lipitor 20 qd, avandia, colchicine 0.6, losartan, ntg prn discharge medications: n/a discharge disposition: expired discharge diagnosis: aneurysmal subarachnoid hemorrhage intraventricular hemorrhage hydrocephalus encephalopathy cerebral vasospasm discharge condition: n/a discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Injection or infusion of thrombolytic agent Injection or infusion of thrombolytic agent Arteriography of cerebral arteries Arterial catheterization Computerized axial tomography of head Endovascular (total) embolization or occlusion of head and neck vessels Central venous catheter placement with guidance Insertion or replacement of external ventricular drain [EVD] Insertion or replacement of external ventricular drain [EVD] Diagnoses: Hyperpotassemia Obstructive hydrocephalus Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Subarachnoid hemorrhage Personal history of tobacco use Intracerebral hemorrhage Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute respiratory failure Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Encephalopathy, unspecified Tachycardia, unspecified Mechanical complication of nervous system device, implant, and graft

allergies: no known allergies / adverse drug reactions attending: chief complaint: 6 months left sided chest pain major surgical or invasive procedure: coronary artery bypass grafting x5: 1. left internal mammary artery to left anterior descending artery. 2. bypass from ascending aorta, sequential, to the obtuse marginal 1, then to the obtuse marginal 2. 3. bypass from ascending aorta to the diagonal artery using reversed autologous saphenous vein graft. 4. bypass from ascending aorta to the posterior descending artery branch of the right coronary artery using reversed autologous saphenous vein graft. history of present illness: 73 year old male, known to our services, with a 6 month history of chest pain. left-sided chest discomfort initially occurred infrequently, but is now occurring several times a day. it is only associated with exertion, and resolves with rest and nitro. he currently is taking anywhere from sl nitro tablets to relieve pain but never has had to take multiple tabs for relief. he also notes some similar symptoms when laying down, however this resolved with sitting up or taking otc antacids. on had cardiac cath that revealed severe 3 vessel coronary artery disease. he was referred for surgery and presents today for surgical work-up. past medical history: 1. positive ppd. has not been treated. denies sick contacts. cxr negative in . 2. cri with creatinine of 1.8. recently told to decrease colcichine/probenecid. 3. depression - followed by psychiatry 4. gerd - responsive to antacids/omeprazole with improvement 5. gout 6. benign prostatic hypertrophy and overactive bladder 7. hypertension 8. basal cell ca 9. mild osa-not on home cpap 10. coronary artery disease past surgical history: none social history: lives with: wife contact: wife phone # ation: computers cigarettes: smoked no etoh: denies illicit drug use: denies family history: mother - diabetes father - hepatitis b and liver ca, cad brothers - one had a cabg, the other stents both in their 60's physical exam: pulse:90 resp:18 o2 sat:99% b/p right: 156/87 left:151/86 height: 5 feet 5 inches weight: 157 lbs general: well-developed male in no acute distress skin: dry intact heent: perrla eomi , l upper eye with fatty deposit. partial upper dentures. 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 _____ 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: none pertinent results: intra-op tee conclusions pre-bypass the left atrium is normal in size. 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. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with hypokinesis in the inferior and inferoseptal region. estimated lvef is 50-55%. the remaining left ventricular segments contract normally. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. there are complex (>4mm) atheroma in the aortic arch. there are simple atheroma in the ascending and 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 appears structurally normal with trivial mitral regurgitation. post bypass: intact thoracic aorta. normal rv and lv systolic function. overall lvef 55%. no new valvular findings. previously hypokinetic inferior wall is moving better . brief hospital course: the patient was brought to the operating room on where the patient underwent cabg x 5. 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 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. he received a unit of prbc on pod 3 for hct 22%. hct would rise to 28%. he was started on flomax and foley was re-placed for failure to void. the foley was discontinued again and he was able to void without difficulty. the patient was evaluated by the physical therapy service for assistance with strength and mobility. on pod 4 he developed tachycardia in the 110s and hypotension with sbp in the 90s and 80s. he remained stable and was monitored overnight. heart rate remained in the low 100s and bp would dip to the 90s. he is asymptomatic and medications were titrated accordingly. by the time of discharge on pod 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to rehab in good condition with appropriate follow up instructions. expected length of stay at rehab is less than 30 days. medications on admission: preadmission medications listed are correct and complete. information was obtained from webomr. 1. bupropion (sustained release) 150 mg po qam 2. metoprolol succinate xl 50 mg po daily 3. nitroglycerin sl 0.3 mg sl prn cp 4. omeprazole 40 mg po daily 5. oxybutynin 5 mg po qid 6. simvastatin 5 mg po daily 7. aspirin 81 mg po daily 8. carboxymethylcellulose sodium *nf* 0.5 % ou daily discharge medications: 1. aspirin 81 mg po daily 2. bupropion (sustained release) 150 mg po qam 3. omeprazole 40 mg po daily 4. simvastatin 5 mg po daily 5. acetaminophen 325-650 mg po q4h:prn pain 6. docusate sodium 100 mg po bid 7. furosemide 20 mg po daily duration: 1 weeks 8. metoprolol tartrate 12.5 mg po bid hold for hr < 55 or sbp < 90 and call medical provider. 9. milk of magnesia 30 ml po q6h:prn constipation 10. oxycodone-acetaminophen (5mg-325mg) tab po q4h:prn pain rx *oxycodone-acetaminophen 5 mg-325 mg tablet(s) by mouth every four (4) hours disp #*40 tablet refills:*0 11. potassium chloride 20 meq po daily duration: 1 weeks hold for k+ > 4.5 12. tamsulosin 0.4 mg po hs 13. carboxymethylcellulose sodium *nf* 0.5 % ou daily discharge disposition: extended care facility: for the aged - discharge diagnosis: 1. positive ppd. has not been treated. denies sick contacts. cxr negative in . 2. cri with creatinine of 1.8. recently told to decrease colcichine/probenecid. 3. depression - followed by psychiatry 4. gerd - responsive to antacids/omeprazole with improvement 5. gout 6. benign prostatic hypertrophy and overactive bladder 7. hypertension 8. basal cell ca 9. mild osa-not on home cpap 10. coronary artery disease past surgical history: none discharge condition: alert and oriented x3 nonfocal ambulating, deconditioned sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage trace lower extremity edema 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** followup instructions: you are scheduled for the following appointments: surgeon dr. , md phone: date/time: 1:00, cardiologist dr. , md phone: date/time: 9:40 please call to schedule the following: primary care dr. , s. in weeks **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 Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Obstructive sleep apnea (adult)(pediatric) Anemia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux 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 Gout, unspecified Depressive disorder, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Hypotension, unspecified Personal history of other malignant neoplasm of skin Tachycardia, unspecified Edema Hypertonicity of bladder Nonspecific reaction to tuberculin skin test without active tuberculosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: r-sided hemiparesis major surgical or invasive procedure: none history of present illness: 50 yo rhm with history of niddm and htn, last in usual state of health 11 pm when went to bed. he awoke at 1 am to go to the bathroom and found to have right-sided weakness. his co-workers were unable to contact him the following morning and called ems when he did not show up for work. he was found to be lying on the floor, with slurred speech and right-sided weakness. he was sent to , found to have l pca, r temporal, r parietal, and possible uncal herniation on ct head and transferred to . patient denies any headache, vertigo, nausea, vomiting, fevers, chills, or palpitations. past medical history: htn, niddm, nephrolithiasis social history: works for a government agency, no toxic habits. family history: mother with niddm and stroke in her 70s, father with ich while on heparin during a surgical procedure. maternal uncles with strokes in their 70s. physical exam: vs t 97.9 (tmax 98.2) p 62 (62-120) bp 108/45 (88-135/45-77) rr 8-23 spo2 92-96% gen; overweight male, dishevled, appears mildly older than stated age heent; mucus membranes moist, no carotid bruits cv; rrr, +s1,s2, no murmurs pulm; cta b/l abd; soft, nt,nd extr; no edema neuro; mental status; opens eyes to voice, cooperative, oriented to person, "hospital" (unsure of ) and stated year was . able to do dow forwards but not backwards. slurred speech. anomia with common objects but resolved on repeat testing. able to read 1st word of sentence. no l/r confusion. cn; pupils 3mm--> 2mm b/l, r homonymous hemianopsia, eomi, no nystagmus. left gaze preference but crosses midline. sensation intact v1-v3. r facial droop. hearing intact to finger rub bilaterally, trapezius weak on right, tongue deviates to right. motor exam; normal bulk, decreased tone in r arm. no drift or tremor in l arm. 5/5 strength in left deltoid, bicep, tricep, wf, we, fe, ff, ip, h, q, df, pf. 0/5 strength in rue, 2/5 strength in rle (no voluntary movements but did move leg on bed). no withdrawl in rue or rle to noxious stimuli. sensation; intact to light touch throughout. decreased to pinprick in rue. no extinction to dss. reflexes; 1+ throughout, upgoing toe on r coordination; fnf normal on l, unable to assess on r. pertinent results: admission labs wbc 15.7 hct 41.8 platelets 252 na 141, k 4.2, cl 102, co2 29, bun 21, cr 0.7, gluc 244 cpk 204, 139 trop < 0.01 x2 ua neg for infection, 30 prot, 1000 gluc, 150 ket pt 11.5, ptt 22.4, inr 1.0 tsh 2.1 t chol 183, hdl 41, ldl 106, trig 182 hba1c 9.0 cxr ; limited study. low lung volumes. no definite consolidation to suggest infection or aspiration. if clinical concern persists, repeat radiographs should be obtained. cta head/neck; 1. large acute infarct in the left pca territory, as well as additional smaller infarcts in the right parietal and temporal lobes. 2. encephalomalacia of the right cerebellar hemisphere, likely from prior infarct . 3. completely occluded left internal carotid artery, with partial reconsitution of the proximal left m1 segment, occlusion of distal left m1, with reconstitution of the left m2 segment of the mca, likely from leptomeningeal collaterals. 3. multifocal areas of stenosis and narrowing, particularly involving the right mca, right vertebral artery, and left eca. tte; the left atrium is normal in size. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers (cannot definitively exclude). left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. 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. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. mri brain; 1. large acute infarct in the left posterior cerebral artery territory. likely thrombus in the temporal branches of the left posterior cerebral artery. 2. multiple other acute cortical and white matter supratentorial infactions involving multiple vascular territories, suggestive of embolic etiology. 3. occlusion of the left internal carotid artery, better assessed on the preceding cta. tee; 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. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers (rest/valsalva). overall left ventricular systolic function is 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 to 38 cm from the incisors. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. ct head w/o contrast study date of 12:26 am findings: the left pca territory, evolving infarct is again visualized, with now the infarct territory measures lower attenuation in the prior study, consistent with evolution. the right parietal and occipital cortical and subcortical areas of low attenuation are also relatively unchanged consistent with evolving acute/subacute infarcts. the area of encephalomalacia from chronic right cerebellar infarct is unchanged. there is no evidence of hemorrhagic transformation. there is no evidence of new infarction. there is no mass effect or shift of normally midline structures. the ventricles and sulci are normal in size and configuration. the osseous structures are unremarkable. mucus retention cyst is noted in the right maxillary sinus. impression: 1. evolving multifocal bilateral infarcts. 2. unchanged encephalomalacia from chronic right cerebellar infarct. brief hospital course: mr. is a 50-year-old right-handed male with history of htn and niddm who was transferred here from after ct head revealed large l pca infarct and smaller infarcts in r temporal and parietal lobes and an old r cerebellar infarct as well as concern for early left-sided uncal herniation. # multiple strokes of likekly embolic origin: cta showed occlusion of the l ica and narrowing of the r vertebral artery. the presence of multiple bilateral infarcts was concerning for a proximal source of embolization (cardiac or aortic arch). he also was found to have leukocytosis with wbc of 20,000 at the time of admission. he was afebrile with no cardiac murmur on exam or peripheral stigmata of endocarditis however, this was a concern. the patient was initially admitted to the intensive care unit for monitoring. his neurological exam remained unchanged during the 48 hours in the unit. he had no arrhythmias on telemetry, and both a tte and tee were performed but did not reveal a cardiac source of emboli. he was started on aspirin 325 mg daily. he was not a candidate for immediate anticoagulation given the large size of his strokes. repeat head ct on was without evidence of hemorrhage. given this, it is recommended that the patient transition from aspirin therapy to coumadin starting on . his neurologic exam as remained stable. he should follow-up in the clinic in 6 weeks for repeat evaluation. # diabetes: hga1c on admission was 9.0. the patient was maintained on his anti-diabetic medications with an additional insulin sliding scale for optimum glycemic control. given his poorly controlled diabetes, the patient may benefit from transition to a purely insulin based regimen of his diabetes. # hypercholesterolemia: ldl was 106. the patient was started on zocor 40 mg daily. # leukocytosis: the patient had a leukocytosis of 20,000 when admitted but no source of infection was identified. he was afebrile and all blood and urine cultures have been negative to date. is it possible that the patient developed an aspiration pneumonitis in the setting of stroke and this is now resolving. he has not recieved antibiotics. # headache: the patient intermittantly reported headache which was felt to be tension headache in nature. he recieved tylenol but occasionally required additional medications. we recommend the use of ultram if his pain is not relieved by tylenol. medications on admission: amaryl 4 mg , metformin 1000 mg , januvia 100 mg daily, lisinopril 10 mg daily, urocid 1080 mg discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily): please discontinue on . 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 4. glimepiride 4 mg tablet sig: one (1) tablet po bid (). 5. sitagliptin 100 mg tablet sig: one (1) tablet po daily (). 6. lisinopril 10 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. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 9. acetaminophen 325 mg tablet sig: two (2) tablet po every six (6) hours as needed for pain. 10. insulin regular human 100 unit/ml solution sig: per sliding scale units injection three times a day: please see insulin sliding scale. 11. ultram 50 mg tablet sig: one (1) tablet po every 4-6 hours: for pain not relieved by tylenol. tablet(s) 12. warfarin 5 mg tablet sig: one (1) tablet po once a day: to start on . 5mg per day until inr > 2, then adjust dose accordingly. 13. heparin (porcine) 5,000 unit/ml syringe sig: one (1) injection three times a day: while patient is immobile. discharge disposition: extended care facility: tba discharge diagnosis: left pca, r temporal and parietal strokes discharge condition: open eyes to voice, answers questions and follows verbal commands. his speech is slurred. names objects inconsistently. head & eyes are deviated to the left. he has right-sided neglect, right facial droop and complete right hemiplegia. pupils are ~ 3mm each and are reactive. the right toe is up; the left is mute. sensations are diminished on the right. he has no bruits or murmurs. discharge instructions: patient to be transferred to rehab for further care. please follow up with dr. (neurology) as instructed. return to the emergency department for any worsening speech difficulties or new weakness or numbness. followup instructions: , md phd (neurology) (. building. Procedure: Diagnostic ultrasound of heart Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Occlusion and stenosis of carotid artery without mention of cerebral infarction Compression of brain Pneumonitis due to inhalation of food or vomitus Cerebral embolism with cerebral infarction Hemiplegia, unspecified, affecting unspecified side Cerebral atherosclerosis Facial weakness Tension headache

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypoxemic/hypercarbic respiratory failure major surgical or invasive procedure: bal on picc placement self extubation and re-intubation extubation history of present illness: mr. is a 44 yo man with a history of recent methamphetamine use, chronic pain, and asthma who presented to an osh with dyspnea, progressing to hypoxemic/hypercarbic respiratory failure and is now being transferred to the for further management. mr. presented to with a 3 days of generalized malaise, uri symptoms and progressive shortness of breath. he had been started on biaxin for possible bronchitis the day prior to admission, but was more somnolent the next morning and his wife called the rescue squad. by report from the outside hospital, history revealed that he had smoked crystal meth 5 days prior to admission. no fevers or chills. on admission to the osh () he had a blood gas of 7.36/50/74. he was subsequently started on 70% oxygen with a gas of 7.41/40/53. cxr revealed bilateral pulmonary infiltrates, with consolidation in the left upper lobe and the right base per outside hospital report, that were felt to be due to pneumonia versus inhalation injury from crystal meth. he went on to require nonrebreather and then bipap. of note he was afebrile throughout his hospital course, but did have a leukocytosis with of 12,000 on admission rising as high as 25,800 on . a bronchoscopy was performed on which showed 2900 wbcs, mostly neutrophils, but so far gram stain and culture negative. his blood cultures, urine cultures and sputum cultures have all been no growth to date. he was started on vanc/levo and bactrim to cover for pcp (hiv test negative 2 months prior). he was also placed on iv steroids given the possibility of pcp. positive troponin was also noted, which increased to 1.22 with some nonspecifioc ekg changes per report (no prior study for comparison) which was thought to be due to demand. on he became increasingly short of breath and his gas was 7.2/81/91, and the decision was made to intubate him at that time. he was subsequently transferred to the for further management. past medical history: -asthma -chronic msk pain, on chronic opiates at home -hx of illicit drug use including ghb, marijuana, and crystal meth -? of bipolar disorder social history: lives with his wife although he is not sexually active with her but rather with other men. on disability for over 10 years. smokes 2 pack/day x ? years. recent crystal meth use. h/o cocaine use. family history: heart disease in his mother physical exam: on admission: vitals: t: 97.5 bp: 146/75 hr: 64 rr: 22 ac/vt 400/peep 10/fio2 100% gen: intubated and sedated but moderately alert, well nourished heent: perrl, sclera anicteric, no conjunctival hemorrhage, et tube and og tube in place neck: right subclavian in place cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: lungs with diffuse bilateral crackles anteriorly abd: soft, nt, nd, +bs ext: no c/c/e, no splinter hemorrhages neuro: following commands and alert, moving all 4 extremities, nonfocal skin: warm, no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: admission labs: 01:50pm blood wbc-16.6*# rbc-3.48*# hgb-10.5*# hct-31.3*# mcv-90 mch-30.2 mchc-33.6 rdw-16.2* plt ct-244 01:50pm blood neuts-89* bands-2 lymphs-5* monos-1* eos-0 baso-0 atyps-0 metas-3* myelos-0 nrbc-1* 01:50pm blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-normal microcy-normal polychr-1+ schisto-1+ 01:50pm blood pt-15.3* ptt-27.9 inr(pt)-1.4* 01:50pm blood plt smr-normal plt ct-244 01:50pm blood glucose-106* urean-16 creat-0.6 na-138 k-4.5 cl-101 hco3-31 angap-11 01:50pm blood alt-17 ast-34 ld(ldh)-393* ck(cpk)-42 alkphos-166* totbili-0.2 01:50pm blood ck-mb-4 ctropnt-0.08* 01:50pm blood albumin-2.3* calcium-7.1* phos-2.1* mg-1.9 03:14pm blood type-art temp-37.5 tidal v-600 peep-10 fio2-70 po2-71* pco2-52* ph-7.38 caltco2-32* base xs-3 cxr: there are no old films available for comparison. the et tube is 3.8 cm above the carina. there are bilateral alveolar infiltrates, lower lobe greater than upper lobe. ng tube tip is in the stomach. there is right subclavian line with tip in the svc. there is a dilated loop of bowel in the abdomen. it is unclear if this is colon or stomach. . most recent cxr : infiltrates cleared. . micro: all cultures (bal, sputum, h pylori, flu swab) negative, except beta blucan elevated - non specific) brief hospital course: a/p mr. is a 44 yo man with a history of methamphetamine use, chronic pain, and asthma who presented with dyspnea, progressing to hypoxemic/hypercarbic respiratory failure as well as elevated troponin, and is now being transferred to the for further management. 1. acute respiratory failure, unclear etiology - on arrival to the he was intubated, with cxr showing bilateral interstitial infiltrates, and appearance of the chest x ray was consistant with infectious pneumonia versus pulmonary edema versus injury from drug inhalation. it was felt that infection was likley given the leukocytosis with bandemia, although he had been afebrile. he was treated with a course of vanc/levo as well as bactrim given radiographic appearance that was concerning for pcp. was also continued on steroids and nebs to treat any copd component that may be present. he had a negative serology for hiv 2 months ago, and repeat test from was also negative. ucx, bcx and bal from osh were negative. blood cultures from were negative. bal done on the day of admission showed purulent material in the rll, but cultures were negative as was afb and pcp . bactrim was discontinued. he was ventilated per ardsnet protocol with initial requirements for peep of 15 and high fio2 to maintain oxygenation. the hypoxia improved and he was able to be weaned to minimal vent settings over the course of several days, concurrent with improvement of the infiltrates on his cxr. of note, sedation was a problem for him as he became quite agitated on fentanyl/versed drip. he was maintained on propofol for sedation, with baseline levels of fentanyl and diazepam to treat/prevent any withdrawl (high home levels of home benzo and opiate). he had several aspiration events over the course of hospitalization whenever his sedation was lightened. he was able to be extubated on hospital day 5, and did well although he continued to be tachypnic, likely from continued anxiety and perhaps benzo withdrawl. vanc and flagyl were discontinued at day 7, and levofloxacin was continued for completion of a 14 day course. he completed his course, and was off oxygen at discharge. . 2.elevated troponin - troponin was elevated at the osh peaking at 1.22 with report of minor nonspecific st changes on ekg, and no elevated ck. troponin was already declining when he left for transfer to the and continued to trend down in the . ekg here showed no evidence of ischemic change and tte was normal. troponin bump was felt to be most likely due to demand ischemia. given his risk factors (smoking, htn, hyperlipidemia, he would likely benefit from an outpatient stress test. he was treated here with 81mg asa, statin, b blocker. . 3. asthma/copd - mr. has a known diagnosis of asthma, and his lungs appeared somewhat hyperinflated on cxr. given his extensive smoking history, it was felt that there may also be an element of copd impacting his course. he was treated with steroid taper and standing nebulizers. . 4. chronic pain/polysubstance abuse - was initially very difficult to sedate on versed/fentanyl and so this was weaned down early and sedation was maintained with propofol. of note, he was on home doses of clonazapam 4mg with alprazolam 1mg prn. with weaning of the versed he began to show some signs of benzo withdrawl (tachycardic, diaphoretic, increased bp, fever) and was started back on some iv ativan, which did not seem meet his needs. on the advice of pharmacy, he was started on diazepam iv 20mg q4hrs standing, with additional doses prn for maitenance of sedation as propofol was weaned down. he was also put on his home dose of fentanyl for his chronic pain and to minimize opiate withdrawl. social work was also consulted re: polysubstance abuse. . 5. hematemesis - he has a brief episode of hematemesis while intubated following a bout of coughing. this did not recur and his hematocrit remained stable. an h. pylori was sent and is still pending. . 6. nutrition - he was started on tube feeds, but continued to have high residuals as well as several aspiration events throughout his stay, despite treatment with metaclopramide. tube feeds were intermittently held, and following extubation he failed a speech and swallow, necessitation replacement of the ng tube for nutrition. a more aggressive bowel regimen was also started. . 7. acute delirium - he had an apparent delirium, with difficult to control agitation. he improved after discharge from the icu, although he did have persistent severe anxiety. he was slowly restarted on his psychiatric medications with improvement. comm: wife dr (pcp) medications on admission: meds at home gabapentin 800mg omeprazole 20mg qod alprazolam 1mg qd clonazepam 4mg thorazine 200mg qhs propranolol 10mg effexor 225mg qd fentanyl patch 50 mcg q72hrs percocet 10mg prn breakthrough pain albuterol inhaler 2 puffs q6hrs meds at transfer fentanyl iv drip simvastatin 40mg qd maalox prn effexor 75mg qhs vecuronium 5mg q4hrs prn tylenol 650mg q6hrs prn pain methylprednisilone 40mg iv tid reglan 10mg iv q6hrs versed drip neurontin 200mg asa 81mg qd inderal 10mg protonix 40mg iv qd lorazepam 1mg q6hrs prn bactrim 300mg iv tid (-) levaquin 500mg qd (-) vancomycin 1gm q12hrs (-) discharge medications: 1. lipitor 20 mg tablet sig: one (1) tablet po once a day. 2. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. venlafaxine 225 mg tab,sust rel osmotic push 24hr sig: one (1) tab,sust rel osmotic push 24hr po once a day. 6. gabapentin 400 mg capsule sig: two (2) capsule po bid (2 times a day). 7. chlorpromazine 100 mg tablet sig: one (1) tablet po hs (at bedtime). 8. alprazolam 1 mg tablet sig: one (1) tablet po once a day as needed. 9. propranolol 80 mg capsule,sustained action 24 hr sig: one (1) capsule,sustained action 24 hr po daily (daily). 10. clonazepam 2 mg tablet sig: two (2) tablet po twice a day. 11. abilify oral 12. hydrochlorothiazide oral 13. outpatient lab work bmp, , results to dr. . discharge disposition: home discharge diagnosis: acute hypoxic respiratory failure deconditioning severe anxiety chronic pain syndrome bipolar disorder dysphagia dehydration discharge condition: improved, on room air, tolerating diet, walking independently, slightly tachycardic with ambulation. discharge instructions: you were transferred from another hospital to our icu, where you were admitted with respiratory failure. you were intubated and on a ventilator for almost one week. all the infectious causes were evaluated and were negative. you may have had a viral infection leading to severe lung disease, worsened by your smoking. you improved after you left the icu, and got your strength back fully. . return to the ed if you develop worsened shortness of breath, or cough, chest pain, palpitations, nausea, vomiting, diarrhea, difficulty eating, difficulty walking, severe anxiety, or confusion. . resume your home medications, including all of your psychiatric medications. take less thorazine than usual until you are used to it again, and less klonopin. followup instructions: follow up with your primary care doctor and your psychiatrist. . bmp , results to dr. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Other chronic pain Subendocardial infarction, initial episode of care Anxiety state, unspecified Acute respiratory failure Chronic obstructive asthma with (acute) exacerbation Hematemesis Dehydration Bipolar disorder, unspecified Delirium due to conditions classified elsewhere Opioid abuse, unspecified Dysphagia, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: unstable angina major surgical or invasive procedure: emergency cabg x3 with iabp (svg to lad, svg to om, svg to pda) emergent left heart catheterization and coronary angiogram, placement of iabp history of present illness: this 62 year old white male presented to er with severe angina, shortness of breath, tingling down his left arm, and a new lbbb. he had a prior infarction with ptca in . acute coronary syndrome with shock was diagnosed and therefore, he went urgently to the catheterization lab. in the lab he developed acute respiratory distress requiring intubation. critical left main, lad and circumflex disease were found as well as occlusive rca disease. an iabp was placed for cardiogenic shock and a decision was made to proceed with emergent coronary revascularization for myocardial salvage. past medical history: myocardial infarction in coronary angioplasty social history: lives with brother no tobacco or recreational drugs occasional etoh family history: unknown physical exam: awake, alert and oriented. 2/4 strength left arm, 3/4 strength left leg. full rom sensation seems intact. there is some neglect of left side, unsteady gait when looks up while walking. mild right facial weakness. gag and swallowing intact. lungs- clear cor- sr 60-60 exts- without edema wounds- clean and dry. stable sternum pertinent results: conclusions pre-bypass: the left atrium is 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. no spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe regional left ventricular systolic dysfunction with complete akinesis of anteroseptal and anterior walls along with moderate depression of the entire lateral wall. the inferior and inferolateral walls are severely hypokinetic as well.. no masses or thrombi are seen in the left ventricle and the apex was not well visualized.. overall left ventricular systolic function is severely depressed (lvef= 10 to 15 %). rv has mild global free wall hypokinesis. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. iabp was initially 6cm below the left sca and was repositioned to 2cm below the left sca. dr. was notified in person of the results on mr. immediately after anesthesia induction and teeexam.. post-bypass: patient is on infusions milrinone, levophed and epinephrine and iabp preserved rv systolic function. mild improvement in septal wall motion abnormalities. lvef 25%. mild to moderate mr (this was not seen in the preoperative or prebypass period) intact thoracic aorta. trivial tr. iabp is positoned well, i certify that i was present for this procedure in compliance with hcfa regulations. interpretation assigned to , md, interpreting physician 05:25am blood hct-35.1* 06:15am blood wbc-6.0 rbc-3.64* hgb-11.4* hct-33.6* mcv-92 mch-31.3 mchc-33.9 rdw-13.8 plt ct-332 02:40am blood wbc-15.1* rbc-4.55* hgb-14.5 hct-41.2 mcv-91 mch-31.9 mchc-35.2* rdw-13.1 plt ct-287 05:25am blood pt-24.3* inr(pt)-2.4* 06:15am blood glucose-112* urean-10 creat-1.1 na-139 k-3.9 cl-106 hco3-23 angap-14 02:40am blood glucose-242* urean-13 creat-1.2 na-139 k-4.0 cl-101 hco3-21* angap-21* 02:48am blood alt-26 ast-18 ld(ldh)-312* alkphos-100 amylase-45 totbili-0.4 07:31pm blood alt-68* ast-69* ld(ldh)-636* alkphos-214* amylase-35 totbili-1.0 , r. csurg csru sched ct head w/o contrast clip # reason: r/o bleed into cva medical condition: 62 year old man with reason for this examination: r/o bleed into cva contraindications for iv contrast: none. provisional findings impression: ajy wed 12:12 pm pfi: right frontal lobe hypodensities consistent with evolution of known infarct. no evidence for hemorrhage, significant edema, or mass effect. final report history: 62-year-old male with recent cva. evaluate for hemorrhagic conversion. comparison: cta of the head from and mri of the brain from . technique: contiguous axial images were obtained through the brain without the administration of iv contrast. findings: there has been interval development of multiple partially confluent hypodense foci in the right frontal lobe, in territory consistent with known recent cva. this is consistent with expected evolution of ischemic infarct. there is no evidence for hemorrhage, significant edema, mass effect, shift of midline structures, or effacement of cisterns. the osseous structures remain unremarkable without suspicious lytic or sclerotic lesions. visualized paranasal sinuses and mastoid air cells remain clear. impression: 1. new right frontal lobe subcortical hypodensities, consistent with expected evolution of ischemic infarction. 2. no evidence for hemorrhage, significant edema, or mass effect. the study and the report were reviewed by the staff radiologist. dr. dr. . approved: wed 1:23 pm imaging lab cardiology report ecg study date of 5:29:56 am sinus rhythm. first degree a-v block. long qtc interval. poor r wave progression. possible anterior myocardial infarction, age undetermined. clinical correlation is suggested. non-specific intraventricular conduction delay. anterior t wave changes suggest myocardial ischemia. low qrs voltage in the limb leads. compared to the previous tracing of the ventricular rate is slower. the p-r interval is longer. anterolateral t wave changes are more pronounced. read by: , k. brief hospital course: mr. presented to the ed with an acute mi on , with cardiogenic shock and was taken to the cath lab where angiography revealed an 80% lm lesion and an occluded rca. an iabp was placed in the cath lab where he was intubated due to respiratory distress and chf. he received plavix, integrilin and heparin and then was transferred to the or emergently in cardiogenic shock for revascularization. his ef was noted to be 10-15% by echo in the or with a large area of infarct. he weaned form bypass on epinephrine, levophed, milrinone, insulin, and propofol drips. he had a significant amount of ventricular ectopy post operatively and electrolytes were repleted.he received amiodarone as well. he subsequently remained stable postoperativley.thge epinephrine then the levophed were slowly weaned, keeping his map>65mmhg. the iabp was weaned to 1:2 and removed on pod 2. the amiodarone and milrinone were continued and extubation occurred on pod 2. the milrinone was weaned and discontinued as an acei was begun, and he remained stable. he was then transferred to the step down floor on pod 3. the chest tubes and wires were removed. he was seen in consultation by the physical therapist. he was noted to have bursts of atrial tachycardia and therefore was seen by electrophysiology who recommended continuation of the amiodarone and a repeat echocardiogram in a month. due to paf and the low lvef he was anticoagulated with coumadin. on the evening of pod 7 () he was noted to have an unsteady gait and felt exhausted. there was left sided weakness of the leg/arm with neglect. the stroke team was notified and an emergent cta demonstrated occlusion of the right internal carotid extending to the right mca with distal collateralization. no intervention was indicated beyond the ongoing anticoagulation and he was transferred to the icu for monitoring. carotid ultrasound on confirmed no flow through the right internal carotid artery. there was no stenosis of the left internal carotid. head ct/cta on demonstrated a right ica occlusion with good collaterals and distal flow. he transiently required neosynephrine for bp support to maintain cerebral perfusion and all negative inotropes were discontinued. he remained stable from a cardiac standpoint throughout the remainder of his hospitalization.physical therapy continued to work with the patient in the icu and after his return to the floor. family meeting with pt/ot cleared him for discharge to home with sister-in-law on . medications on admission: asa 81 mg daily discharge disposition: home with service discharge diagnosis: coronary artery disease s/p emergency coronary artery bypass grafting acute myocardial infarction with shock s/p remote coronary angioplasty postoperative stroke occlusion of right carotid artery discharge condition: good discharge instructions: shower daily, no baths or swimming no lotion, creams, or powders on any incision no driving for one month and until off all narcotics no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5 report any redness or drainage of incisions take all medications as directed followup instructions: see dr. in weeks see dr. in weeks see dr. in 4 weeks Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart Insertion of endotracheal tube Arteriography of cerebral arteries Arterial catheterization Arterial catheterization Implant of pulsation balloon Magnetic resonance imaging of brain and brain stem Nonoperative removal of heart assist system Computerized axial tomography of head Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Paroxysmal ventricular tachycardia Other specified cardiac dysrhythmias Alkalosis 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 Cardiogenic shock Other left bundle branch block Acute myocardial infarction of other specified sites, initial episode of care Hemiplegia, unspecified, affecting unspecified side Iatrogenic cerebrovascular infarction or hemorrhage Occlusion and stenosis of carotid artery with cerebral infarction Facial weakness Other premature beats

allergies: no known allergies / adverse drug reactions attending: chief complaint: stemi major surgical or invasive procedure: cardiac catheterization with stent placement history of present illness: 79 m with history of htn, hl, recent left parieto-occipital ich with hematoma evacuation on , presents initially to hospital with chest pain. described to be acute onset of substernal chest pain without radiation. at , ekg had inferior -elevations, was given 324mg aspirin and 2 sl ntg, which improved pain. he was started on nitro drip with subsequent drop in systolic bp to 70 mmhg. nitro drip was stopped and he remained pain free, -segments however remained elevated. osh cardiology declined cardiac catheterization given recent hemorrhagic cva, and was therefore transferred here for further evaluation. . upon arrival, patient initially without chest pain. the patient has expressive aphasia secondary to cva making history somewhat limited. he report no radiation of chest pain, although with mild associated shortness of breath. his wife/hcp describes recent chest "twinges" with exertion over the past two weeks, but none at rest until this evening when he was awoke from sleep with pain. they both deny any new/changed neurologic defecits and report aphasia and hand coordination have improved. . he was initially hemodynamically stable with sinus bradycardia of 60bpm, bp 125/75 mmhg, rr 16bpm, sao2 100% on 2l nc. at the time he was in no acute distress, with clear lung fields, and normal s1s2 on cardiac exam without murmurs, rubs, or gallops. his extremities are warm with good distal pulses and no edema. ekg at the time showed sinus bradycarda, normal axis and intervals, inverted t-waves inferiorly. . neurosurgery was consulted who said that it is fine to anticoagulate. . the chest pain then returned and lead ii on telemetry was noted to again have -elevation. he was taken urgently to the cardiac cathterization lab, was found to have a large distal 90% rca proximal thrombus and diffusely diseased lad with 40% proximal and 60-70% mid vessel. export thrombectomy was performed and ic integrillin was administered with successful integrity bms stent placement. past medical history: 1. cardiac risk factors: -diabetes, +dyslipidemia, +hypertension 2. cardiac history: - cabg: none - percutaneous coronary interventions: none - pacing/icd: none 3. other past medical history: left parieto-occipital ich with hematoma evacuation on social history: achieved a master's in music and worked as a professional musician. he is married with . . he never smoked. he never used any drugs, and he uses drinks per week, sometimes two bourbons up to three in one day. family history: positive for his mother and father who had heart disease as well as his brother who is deceased in the early 70s due to a lymphoma. he has one sister that is alive. two daughters and one son that are alive and healthy. physical exam: t 98.0 bp 123/77 (120-144) p 69 (60s-80s) rr 18 98% ra uo: 330 in/1150 out over 24 hrs yesterday. heent: jvp flat cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. short systolic murmur heard best in llsb. lungs: ctab, no crackles, wheezes or rhonchi anteriorly and laterally. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: trace edema, no c/c. no femoral bruits. pertinent results: 07:15am blood wbc-5.7 rbc-4.37* hgb-13.2* hct-41.1 mcv-94 mch-30.3 mchc-32.2 rdw-13.1 plt ct-210 07:15am blood glucose-109* urean-15 creat-0.9 na-142 k-4.0 cl-102 hco3-32 angap-12 07:15am blood calcium-9.3 phos-3.7 mg-2.2 echo the left atrium and right atrium are normal in cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (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 stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. 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: mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. brief hospital course: 79 m with history of htn, hl, recent left parieto-occipital ich with hematoma evacuation on presents with chest pain found to have thrombus of rca s/p stenting with resolution of chest pain. . # rca thrombus/inferior-posterior-?right ventricle stemi: pt with large rca found to have thrombus subtotally occluding artery. chest pain resolved after stenting and patient treated with ic integrillin. ecg reveals interior-posterior stemi with iii>ii and i and avl depression, with questionable involvement of rv as well given borderline elevation in rv leads. furthermore, pt with hypotension on ng, lending evidence to preload dependence. pt also with bradycardia at time likely due to rca involvement. post cath he was admitted to the ccu. he was continued on aspirin and plavix (which will continue for 1 year). his blood pressure and pulse stabilized. echo showed lvef 55%. he was called out the floor, where he remained stable. he was discharged home on aspirin, plavix, metoprolol, lisinopril and atorvastatin. . # ich: his neuro status was closely monitored given the use of aspirin and plavix with his recent ich with hematoma evacuation. his speech appeared at baseline. he had no other symptoms. his neurologist was contact to discuss care. . # htn: on lisinopril at home. started metoprolol and increased lisinopril. . # hld: switch from pravastatin to high dose atorvastatin. . # gerd: takes prilosec at home. . # bph: continue flomax medications on admission: calcium carbonate 500 mg by mouth metoprolol 50 mg b.i.d. prilosec 20 mg daily pravachol 40 mg per day trazodone p.r.n. flomax 0.4 mg by mouth qhs melatonin lisinopril 5 mg kcl 20 meq daily trazadone 25 mg qhs discharge medications: 1. clopidogrel 75 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. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 4. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 5. 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* 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*0* 8. ranitidine hcl 150 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*0* 9. calcium carbonate 500 mg calcium (1,250 mg) capsule sig: one (1) capsule po twice a day. 10. melatonin oral discharge disposition: home with service facility: discharge diagnosis: -elevation myocardial infarction hypertension left parieto-occipital intracranial hemorrhage 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 presented to the hospital with a heart attack and were taken to the cardiac catheterization lab where you recieved a stent to one of your blocked heart vessels. your pain resolved and you were discharged home in a stable condition. new medications: please do not stop taking aspirin and plavix medications under any circumstances without consulting with your cardiologist. 1. aspirin 81 once daily 2. clopidogrel (plavix) 75mg once daily for at least a year 3. atorvastatin 80mg once daily 4. ranitidine 150 mg twice daily medications changed: 1. lisinopril: dose increased from 5mg to 10mg once daily 2. metoprolol: dose increased from 50 twice a day to 100mg once daily medications stopped: 1. pravastatin. switched to atorvastatin 2. omeprazole. switched to ranitidine followup instructions: name: , : internal medicine address: 545a centre , , phone: **youre dr visit you within 24-48 hours for a follow up visit from your hospital stay.** department: cardiac services when: wednesday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: neurology when: wednesday at 2:00 pm with: drs. & haussen building: sc clinical ctr campus: east best parking: garage md, Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization 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 Esophageal reflux Unspecified essential hypertension Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Acute myocardial infarction of inferoposterior wall, initial episode of care Late effects of cerebrovascular disease, aphasia

allergies: no known allergies / adverse drug reactions attending: chief complaint: hypotension, atrial fibrillation with rapid ventricular response following third round of high dose methotrexate infusion major surgical or invasive procedure: hd mtx infusion history of present illness: 56 m with history of dlbcl, receiving r-chop (c6d10 today) and hd mtx (c3d2 today), admitted for third round of hd mtx. received mtx on at 20:15. he is being transferred to the icu for afib with rvr with rates into the 170-180s, and hypotension with sbp to 82/60. during his last admission for cycle 2 of hd mtx, he also developed afib with rvr in setting of hd mtx infusion. usually as an outpatient, when his heart is not being stressed, he is in sinus rhythm. takes metoprolol 12.5 tid at home. . last night with initiation of mtx infusion, patient developed afib with rvr. despite an increase in metoprolol from 12.5 tid to 25 tid, his rates were still in the 140-150s all night, difficult to control. icu consult was called when blood pressure dipped to 82/60 in setting of persistent tachycardia. he was given diltiazem 10 mg iv x2 with some transient improvement in hr. patient is asymptomatic throughout all this, denies chest pain, sob, palpitations, dizziness, nausea, vomiting, lightheadedness. he has been receiving sodium bicarbonate and fluids as part of hd mtx protocol. vitals prior to transfer to icu were: 97.2, 98/62, 89, 20, 96%ra past medical history: past oncologic history: dlbcl stage ivb-e - developed new back pain - developed low grade fever of 99s and symptomatic - developed nightly drenching night sweats - seen for above symptoms. initial work up notable for transaminase elevations with ast/alt of 72/88, crp 209.4, new anemia to h/h 11.1/34.8. serologies for lymes, ehrlichiosis, cmv, babesiosis, hav, hbv, and hcv are negative. spep and upep are unremarkable but quantitative igs are not done. - and mri showed increased signal intensity in the marrow spaces in the spine as well as scattered enhancing lesions in several vertebrae - ct torso without obvious adenopathy, thoracic, abdominal, or pelvic pathology - evaluated in clinic. found to have worsening anemia to h/h of 10.7/31.6, low reticulocyte count, new thrombocytosis to 632, elevated ferritin to 2067, rising transaminases to ast/alt of 86/141 with an alk phos up to 174, an ldh of 588, and normal b12 and folate. - bone marrow biopsy with fibrosis and organizing bone, indeterminate. dry tap. - ldh up to 1664, ca up to 10.5, ferritin 3805, crp above assay, more anemic. repeat bmbx showed large atypical cells which co-express b-cell marker cd20 along with cd10 and bcl-2 c-myc negative c/w dlbcl. admitted at that time. - c1d1 r-da- (rituximab 375 mg/m2, etoposide 50 mg/m2, doxorubicin 10 mg/m2, vincristine 0.5 mg, cyclophosphamide 750 mg/m2, prednisone 100 mg) c/b afib w rvr - c2d1 r-daepoch (rituximab 375 mg/m2, etoposide 60 mg/m2, doxorubicin 12 mg/m2, vincristine 0.5 mg, cyclophosphamide 900 mg/m2, prednisone 100 mg) - found to have line associated dvt, line pulled and started fundaparinox - admitted w trilobar pe, switched to heparin and dced on enoxaparin - c1d1 r-chop s/p r- x 2 (rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 1.4 mg/m2 capped at 2 mg on d1 with prednisone 100 mg po on d1-5) - c2d1 r-chop s/p r- x 2 (rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 1.4 mg/m2 capped at 2 mg on d1 with prednisone 100 mg po on d1-5) - admission for c1 high dose methotrexate 3.5 g/m2 with leucovorin rescue on d15 of the r-chop cycle - cycle #2 high-dose mtx 3.5g/m2. . other medical history: - trilobar pes while on fundaparinox - line associated rue dvt - idiopathic dvt in his 30s - afib with rvr - osa not on cpap - hld on atorvastatin and coq10 - mononucleosis in his teens social history: - tobacco: rare cigars in his youth. - alcohol: 1-2 drinks per night, less so now. - illicits: denies. - occupation: computers bank. - exposures: worked for a landscaping company years ago and used pesticides. formerly in the navy. - living situation: lives in with his wife. - travel: within the last year to , , and ny. - diet: no raw meats or unpasteurized dairy, no game. - pets: 2 dogs, sometimes they have ticks. family history: - mother: died suddenly in her 50 of a ruptured brain aneurysm. - father: hyperlipidemia. - cousin: osteosarcoma. physical exam: admission physical exam: gen: nad, aaox3 heent: mmm, op clear, no jvd, no cervical/axillary/supraclavicular lad, neck supple cv: irregularly irregular, s1s2, no m/r/g chest: cta b/l, no w/r/r abd: soft, nt, nd, +bs, no hsm ext: wwp, no e/c/c skin: no rashes or lesions neuro: cn ii-xii grossly intact, 2/2 strength throughout, normal coordination pertinent results: admission labs: wbc-3.8* rbc-3.77* hgb-12.5* hct-36.3* mcv-96 mch-33.1* mchc-34.4 rdw-15.8* plt count-216 neuts-48* bands-9* lymphs-28 monos-7 eos-0 basos-0 atyps-4* metas-1* myelos-2* promyelo-1* hypochrom-normal anisocyt-1+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-normal ovalocyt-1+ burr-occasional . albumin-4.4 calcium-9.7 phosphate-3.8 magnesium-2.0 uric acid-6.8 alt(sgpt)-44* ast(sgot)-22 ld(ldh)-171 tot bili-0.3 glucose-101* urea n-17 creat-1.0 sodium-135 potassium-4.0 chloride-99 total co2-25 anion gap-15 . discharge labs: 04:51am blood wbc-5.0 rbc-3.47* hgb-11.6* hct-33.3* mcv-96 mch-33.4* mchc-34.8 rdw-16.0* plt ct-228 04:51am blood neuts-87.9* lymphs-9.1* monos-2.2 eos-0.6 baso-0.3 04:51am blood pt-10.6 ptt-33.9 inr(pt)-1.0 04:51am blood glucose-114* urean-9 creat-0.9 na-137 k-4.1 cl-104 hco3-28 angap-9 04:51am blood alt-72* ast-36 ld(ldh)-190 alkphos-68 totbili-0.4 04:51am blood calcium-9.1 mg-2.1 06:07am blood mthotrx-0.05 05:40pm blood mthotrx-0.19 08:50pm blood mthotrx-1.0 . urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg color-straw appear-clear sp -1.002 . microbiology urine culture - negative blood culture - pending brief hospital course: brief hospital course this is a 56 year old gentleman with dlbcl on r-chop and hd mtx, here for 3rd cycle of hd mtx, with course complicated by hypotension, afib with rvr following mtx infusion. he was treated with diltiazem briefly while hospitalized. . active issues: #. afib with rvr - patient has developed afib with rvr in setting of hd mtx in the past, likely because of stress of high rate infusion of meds and fluids. unfortunately, fluid infusion could not be stopped as kidneys need to be continuously perfused in order to prevent mtx crystallizing in renal tubules. patient was asymptomatic during this time. during last admission, patient was started on metoprolol 25mg tid and during this admission, cardiology recommended diltiazem 30mg qid for added rate control. per outpatient cardiology notes, plan is for patient to have stress test and then to initiation propafenone. patient was also started on lovenox when he had his first episode of atrial fibrillation, and was continued on this during admission. of note, patient was ruled out for acute coronary syndrome with cardiac enzymes negative x 3. his heart rate was controlled with uptitration of metoprolol and he was started on diltiazem with uptitration of the dose to 90 qid with prn 10mg iv for heart rate > 120. his heart rate was ultimately controlled. he was back in sinus rhythm after discontinuation of requisite ivf for methotrexate. after discussion with cardiology, he was sent home back on metoprolol, at 25 mg twice daily of tartrate, to facilitated from three times daily dosing 12.5 prior to admission. he was instructed to call his cardiologist on the monday following discharge to schedule closer follow-up. diltiazem was discontinued. . #. hypotension - most likely due to arrhythmia causing decreased cardiac output. no signs of infection as patient afebrile with normal white count. blood cultures were sent on transfer to icu and were negative or pending. also may consider cardiogenic etiology, as patient is at risk for cardiomyopathy given recent chemotherapy, he was ruled out on for an mi. in addition, hypotension may have been related to calcium channel blocker and beta blocker used for rate control. hypotension resolved with rate control. . #. dlbcl - stage ivb-e. overall outpatient oncology plan is to treat with chop/ x 6 with hd mtx x 4 for cns ppx. today he is c6d10 r-chop, c3d2 hd mtx. has been having good urine output during the course of this admission. he wa continued on leucovorin rescue. mtx levels were followed at 24, 48 and 72 hours and he was continued on bicarbonate @ 100 cc/hr. acyclovir and bactrim were initially held but restarted on discharge. he was on a low acid diet. he was asked to follow-up with his hematology-oncologist on the monday following discharge. his primary oncologist was notified of his discharge. . inactive issues #. chronic peripheral neuropathy - symptoms ongoing, suspected to be prior chemotherapy. patient continued on vitamin b6. . #. hx pe, dvt - history of multiple dvts in the past, found to have extensive right-sided tri-lobar pe on while on fondaparinux. on enoxaparin 80 mg sq as outpatient. patient had no complaints of shortness of breath or pleuritic chest pain during admission and was continued on outpatient dose of enoxaparin. . transitional issues: code status: full follow-up: outpatient stress test, cardiology f/u with dr. pending studies: blood cultures from medications on admission: acyclovir 400 mg tablet tid enoxaparin 80 mg/0.8 ml twice a day lorazepam 1-2 mg q6h prn nausea/anxiety/insomnia metoprolol tartrate - 12.5 mg three times a day ondansetron hcl - 8 mg tablet every 8 hours as needed for nausea. oxycodone 5 mg tablet - every four (4) hours as needed for pain prochlorperazine maleate - 10 mg tablet 3 times daily prn nausea sulfamethoxazole-trimethoprim ds - monday, wednesday, friday aspirin - 81 mg qd docusate sodium 100 mg capsule prn constipation pyridoxine - 250 mg tablet twice a day sennosides - 8.6 mg tablet prn constipation sodium bicarbonate - 650 mg tablet, 2 tablet(s) for 2d pta discharge medications: 1. enoxaparin 80 mg/0.8 ml syringe sig: one (1) subcutaneous q12h (every 12 hours). 2. lorazepam 1 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for nausea/anxiety/insomnia. 3. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 4. acyclovir 400 mg tablet sig: one (1) tablet po three times a day. 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 6. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 7. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po three times a day as needed for nausea. 8. bactrim ds 800-160 mg tablet sig: one (1) tablet po monday/wednesday/friday. 9. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 10. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 11. pyridoxine 250 mg tablet sig: one (1) tablet po twice a day. 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 13. sodium bicarbonate 650 mg tablet sig: two (2) tablet po twice a day: take for 2 days prior to admission for high dose methotrexate. discharge disposition: home discharge diagnosis: primary: atrial fibrillation with rapid ventricular rate secondary: diffuse large b-cell lymphoma trilobar pulmonary embolisms/history of deep vein thromboses 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 for high dose methotrexate administration. your course was complicated with the development of atrial fibrillation with rapid ventricular rate and low blood pressure. due to your rapid heart rate and low blood pressure, you were transferred to the intensive care unit for further monitoring. in the icu, your heart rate and blood pressure was controlled with a medication called diltiazem. your heart rate improved as well as your blood pressures. as your atrial fibrillation occurred in the setting of your methotrexate administration, cardiology felt you could continue to take your metoprolol at 25 mg two times a day while at home. if you develop any symptoms of atrial fibrillation, specifically rapid heart rate, you may increase your metoprolol to 50 mg two times a day per the cardiology team, and please contact your cardiologist dr. immediately. if any other symptoms develop, including light headedness, chest pain, shortness of breath, or any symptoms that concern you, please report to the emergency room. . some of your medications have changed stop taking metoprolol tartrate 12.5 mg 3x a day start taking metoprolol tartrate 25 mg 2x a day . please continue to take the rest of your medications as prescribed. . please make a follow up appointment with your hematologist/oncologist when the offices open on monday . . it has been a pleasure taking care of you mr. ! followup instructions: you have the following follow-up appointments: . department: cardiac services when: friday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage . department: dermatology and laser when: thursday at 7:30 am with: , md building: (, ma) campus: off campus best parking: free parking on site . please remember to schedule a hematology/oncology appointment when the offices open on . they can be reached at: ( md Procedure: Injection or infusion of cancer chemotherapeutic substance Diagnoses: Other iatrogenic hypotension Obstructive sleep apnea (adult)(pediatric) Atrial fibrillation Other and unspecified hyperlipidemia Other malignant lymphomas, unspecified site, extranodal and solid organ sites Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Personal history of venous thrombosis and embolism Unspecified hereditary and idiopathic peripheral neuropathy Encounter for antineoplastic chemotherapy Antineoplastic chemotherapy induced anemia

allergies: tegretol / keppra attending: chief complaint: seizures increasing in frequency major surgical or invasive procedure: ; right craniotomy and temporal lobectomy history of present illness: 24yo gentleman, who had a seizure for the first time in , but no further seizures until . in the seizures returned at first very sporadically (once every couple months) but over the past 2 years these have increased in frequency (weekly). mr does describe an aura, "a weird feeling" before he gets his seizures for which he has ativan. he describes his seizures as "blackouts" with cycling movement of his legs and were classified as complex partial seizures. he immediately falls asleep for approximately 30 minutes. he has been tried on multiple medications but has had no improvement in his seizure control.admission to the epilepsy service was undertaken and he was noted to have r temporal lobe seizure onset with secondary spread to bilaterally and globally. he presents today to discuss temporal lobectomy. past medical history: epilepsy depression social history: he is currently a master's degree student at , studying mechanical engineering. he denies cigarette smoking, alcohol use, and drug use. he does not drive anymore. he is currently on medical leave until . family history: there is no family history of seizures or epilepsy. physical exam: gen: wd/wn, comfortable, nad. heent: pupils: eoms intact neck: supple. lungs: cta bilaterally. cardiac: rrr abd: soft, nt extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension cranial nerves: i: not tested ii: pupils equally round and reactive to light, 5 to 4 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: intact to light touch, propioception coordination: normal on finger-nose-finger pertinent results: mri brain pre-op: there is no mass, hemorrhage, edema, shift of normally midline structures, or other abnormality. the ventricles and sulci are normal in size and configuration for the patient's age. the medial temporal lobes appear unremarkable, with no evidence of abnormal signal in the hippocampi, or hippocampal atrophy. soft tissues and visualized paranasal sinuses appear unremarkable. ct head post-op expected post operative pneumocephalus and ecephalomalacia. sulcal effacement in the right frontal lobe and minimal mass effect on the frontal of the right lateral ventricle may reflect mild edema. mri brain post-op: 1. post-surgical changes following a right temporal craniotomy and temporal lobectomy, with small foci of hemorrhagic products noted within the surgical bed. 2. small subdural effusions overlying the frontal lobes bilaterally, and layering along the falx, without mass effect. brief hospital course: pt electively presented and underwent a craniotomy and right temporal lobectomy. he tolerated the procedure well and was trasnferred to the icu. on pod 1 he was deemed stable enough for transport to the sdu on 11. he remained stable there until when he was found to have one episode of seizure. as a result of this neurology was called to consult. he did not have another episode of seizure and on was complaining of hiccups so thorazine was started. he worked with pt/ot to determine disposition planning and cleared for home with outpatient service. medications on admission: zonisamide, lamictal, citalopram 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 daily (daily). 3. ranitidine hcl 150 mg tablet sig: 0.5 tablet po bid (2 times a day) for 4 weeks. disp:*28 tablet(s)* refills:*0* 4. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 5. lamotrigine 100 mg tablet sig: two (2) tablet po bid (2 times a day). 6. zonisamide 100 mg capsule sig: four (4) capsule po daily (daily). 7. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 8. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for headache. disp:*30 tablet(s)* refills:*0* 9. dexamethasone 2 mg tablet sig: taper tablet po taper for 5 days: 4mg q 8hrs x 1 day,2 mg q8hrs x 1 da, 2mg q12hrs x 1 day. 1mg q12hs x1 day, 1mg qday x1 then d/c. disp:*qs tablet(s)* refills:*0* 10. outpatient physical therapy evaluate and treat discharge disposition: home discharge diagnosis: epilepsy discharge condition: mental status: clear and coherent. level of consciousness: lethargic but arousable. 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 were on a medication such as coumadin (warfarin), or plavix (clopidogrel), or aspirin, prior to your injury, do not restart until cleared by your surgeon. ?????? 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: follow-up appointment instructions ??????please return to the office in days(from your date of surgery) for removal of your staples/sutures and/or 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 6 weeks. ??????you will need a ct scan of the brain without contrast. Procedure: Operations on two or more extraocular muscles involving temporary detachment from globe, one or both eyes Lobectomy of brain Diagnoses: Depressive disorder, not elsewhere classified Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy Temporal sclerosis

allergies: no known allergies / adverse drug reactions attending: chief complaint: fatigue, dark stool major surgical or invasive procedure: edg c-scope small bowel follow thru history of present illness: 69 female h/o nash, upper gib in secondary to gastric ulcers presenting with two days of black stool and fatigue. . patient with recent admission from - for klebseilla urosepsis/pyelo as well as presumed c.dif colitis. infectious work-up notable for osh urine and blood cultures both positive for klebsiella. patient was started on gentamycin, transitioned to cefepime -> cipro and discharged on 1st-generation cephalosporin, cefadroxil. additionally, patient noted to have watery bm/day with associated leukocytosis. though cdiff toxin and pcr returned negative decision made to empirically treat for colitis with flagyl. additional issues during that hospitalization: 1. anemia. hct trended down from 31.3 on admission to 26.5 on hd4 but then remained stable. iron studies were consistent w/anemia of chronic disease. normal b12, folate. no note of guaiac + stool. 2. ?cirrhosis. patient with h/o nash. labs significant for elevated inr, low albumin. exam with e/o progressive liver disease: spider angiomas, ascites. hbv and hcv titers were negative. pt reported rare etoh. plan to proceed with outpatient biopsy. no egd in our system. . patient discharged and returned home. had been in usoh when developed painless melena, generalized weakness and orthostasis x2 days. reports associated nausea with one episode of vomiting brown material, denies abdominal pain, dysphagia, hoarseness, tenesmus, chest pain, palpitations. does endorse ~20lb weight loss over last month in setting of hospitalization; denies fevers, chills, sweats. reports gastric ulcers in past with vomiting of coffee ground emesis but never black stools. this feels somewhat similiar to previous episode. . in the ed, initial vs 98.2 108 135/44 24 100% ra. frank melena on exam. labs with hct: 20.1 (25 on ), inr: 1.3. patient type and crosses x4u. gi consulted. patient started on ppt bolus + ggt. unable to pass ngt in ed (6 attempts) failure thought secondary to irregular anatomy. no transfusion as of yet though received 2l ns. vs prior to transfer: hr 104 128/58 20 100%ra. access: 2 18g bilaterally. . on arrival to the micu, patient without complaint though does cite intermittent nausea as well as slow speech. denies abdominal pain. . review of systems: (+) per hpi; doe (-) 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: type 2 diabetes (insulin-dependent) hypertension nash hypercholesterolemia osteoarthritis depression upper gi bleed, gastric ulcers social history: lives alone at home, has worked at financial as a scanner for past 17 years. no tobacco, alcohol or drug use. family history: significant for heart disease and diabetes. mother has afib, husband died of liver disease physical exam: on admission: general: alert, oriented, no acute distress, slow speech heent: conjunctival pallor, mmm, oropharynx clear without exudates or lesion, no subinguinal jaundice neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, soft sem, rubs, gallops, no peripheral edema abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: pale, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs -------------- 10:35pm blood wbc-10.6 rbc-2.20* hgb-6.7* hct-20.1* mcv-92 mch-30.6 mchc-33.4 rdw-18.3* plt ct-229 10:35pm blood neuts-64.8 lymphs-30.5 monos-3.7 eos-0.5 baso-0.4 10:35pm blood pt-14.6* ptt-25.1 inr(pt)-1.3* 10:35pm blood ret aut-5.1* 10:35pm blood glucose-244* urean-61* creat-1.2* na-139 k-4.5 cl-108 hco3-15* angap-21* 10:35pm blood alt-28 ast-43* ld(ldh)-204 alkphos-86 totbili-0.4 10:35pm blood albumin-3.5 calcium-9.9 phos-4.3 mg-1.8 10:35pm blood hapto-118 10:58pm blood lactate-4.0* . discharge labs -------------- 06:05am blood wbc-6.3 rbc-3.56* hgb-10.6* hct-31.0* mcv-87 mch-29.8 mchc-34.2 rdw-19.7* plt ct-144* 06:00am blood glucose-150* urean-17 creat-0.9 na-141 k-3.7 cl-110* hco3-21* angap-14 06:00am blood calcium-9.1 phos-3.8 mg-1.7 . microbiology ------------ 12:16 pm serology/blood source: venipuncture. **final report ** helicobacter pylori antibody test (final ): positive by eia. (reference range-negative). . imaging ------- egd 9/26 esophagus: other no esophageal varices seen. stomach: normal stomach. duodenum: mucosa: mild erythema at the junction between the duodenal bulb and the second portion of the duodenum consistent with duodenitis. other findings: no source of bleeding identified to explain melena. impression: no esophageal varices seen. abnormal mucosa in the duodenum no source of bleeding identified to explain melena. otherwise normal egd to second part of the duodenum recommendations: plan for colonoscopy tomorrow morning. please start moviprep tonight. advance diet to clears. npo after midnight. stop ppi drip. . colonoscopy: findings: other no bleeding source identified to explain anemia and melena. impression: no bleeding source identified to explain anemia and melena. otherwise normal colonoscopy to cecum recommendations: will proceed with inpatient capsule endoscopy. d/c ppi. colonoscopy should be repeated given fair preparation. therefore, small polyps may have been missed. . capsule endoscopy : 1. multiple angioectasias were seen from the mid jejunum to the distal ileum. 2. no active bleeding sites were seen in the small bowel. summary & recommendations summary: multiple angioectasias were seen from the mid jejunum to the ileum. no active bleeding sites were seen in the small bowel at this time. . small bowel enteroscopy : the scope was advanced upto mid/distal jejunum the distal most portion of the small bowel reached was tattood with ink. four to five angioectasias noted in the jejunum. apc treatment of the angioectasias were performed with success. (injection, thermal therapy) a previously administered capsule (pillcam) was noted in the colon or distal small bowel by fluoroscopy. otherwise normal small bowel enteroscopy to mid jejunum . cxr on admission: findings: no previous images. the heart is normal in size and there is no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. brief hospital course: 69 female h/o upper gi bleed in secondary to gastric ulcers presenting with two days of black stool and fatigue. . active issues ------------- # gastrointestinal bleed. thought to be related to gi bleed after report of 2 days of melena. gi was consulted on admission. differential diagnosis included bleeding gastric or esophageal ulcer, - tear, variceal bleeding, or malignancy. she was initially on pantoprazole gtt transitioned to pantoprazole 40mg iv bid, then to po therapy for h. pylori treatment. she underwent upper endoscopy and colonoscopy without clear source of bleed. gi recommended further investigation with a capsule study to better visualize the small bowel, which showed multiple angioectasias in the small bowel. in the icu, she was transfused 6 units prbc for a hct of 20.5 with resulting bump to 28, which then remained stable. additional anemia work-up including hemolysis labs, reticulocyte count were within normal limits. patient was without further episodes of gi bleeding while hospitalized. small bowel enteroscopy was performed and aforementioned angioectasias were cauterized. patient was discharged with stable hematocrit. she does not require gastroenterology follow-up, but should return to for repeat imaging if she experiences another gi bleed. . # helicobacter pylori infection: patient was noted to have positive h. pylori testing, and was started on omeprazole, clarithromycin and amoxicillin for planned 14-day course, which she will continue as an outpatient. . # toxic-metabolic encephalopathy. per patient as well as daughter; patient more mentally slow in the days preceding admission. patient denied any focal complaints however felt as if her speech was slurred. she had a non-focal neurologic exam. kidney and liver function was only mildly abnormal, then improved. patient was without asterixis. tsh was within normal limits. after acute treatment of anemia, patient's confusion resolved. . # dyspnea. likely related to anemia. no focal consolidation or signs of volume overload on exam or chest x-ray. patient was transfused with improvement in symptoms. . # acute kidney injury. mild elevation in creatinine to 1.2 on admission. likely pre-renal in etiology in setting of gi bleed/hypovolemia. patient received 2 liters of normal saline in the ed as well as 6 units prbcs in the icu with improvement of creatinine to 1.0. . chronic issues --------------- # diabetes mellitus type ii. poorly controlled with last a1c in : 10.6. po diabetic regimen was held while npo and she was maintained on an insulin sliding scale . # hyperlipidemia. continued home rosuvastatin. # depression. continued fluoxetine . transition of care ------------------ # follow-up: patient has scheduled follow-up with her pcp. does not require gastroenterology follow-up, but should return to for repeat imaging if she experiences another gi bleed. there are no pending studies at the time of discharge. # code status: full (discussed with patient) . # contact: , daughter medications on admission: 1. fluoxetine 10 mg capsule sig: three (3) capsule po daily (daily). 2. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 3. lantus 100 unit/ml solution sig: forty (40) units subcutaneous at bedtime. 4. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 5. glyburide 5 mg tablet sig: one (1) tablet po twice a day. 6. rosuvastatin 10 mg tablet sig: one (1) tablet po once a day. 7. apidra 100 unit/ml solution sig: twenty five (25) units subcutaneous four times a day. discharge medications: 1. fluoxetine 10 mg capsule sig: three (3) capsule po daily (daily). 2. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 3. lantus 100 unit/ml solution sig: forty (40) units subcutaneous at bedtime. 4. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 5. glyburide 5 mg tablet sig: one (1) tablet po twice a day. 6. rosuvastatin 10 mg tablet sig: one (1) tablet po once a day. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day) for 13 days. disp:*26 capsule, delayed release(e.c.)(s)* refills:*0* 8. clarithromycin 250 mg tablet sig: two (2) tablet po q12h (every 12 hours) for 13 days. disp:*52 tablet(s)* refills:*0* 9. amoxicillin 250 mg capsule sig: four (4) capsule po q12h (every 12 hours) for 13 days. disp:*104 capsule(s)* refills:*0* 10. apidra 100 unit/ml solution sig: twenty five (25) units subcutaneous four times a day. 11. insulin syringes (disposable) 1 ml syringe sig: one (1) syringe miscellaneous as needed. disp:*100 syringes* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis: gastrointestinal bleeding, likely from small bowel angioectasias acute blood loss anemia helicobacter pylori infection acute renal failure, prerenal secondary diagnosis: metabolic encephalopathy diabetes mellitus type ii, uncontrolled hypertension hyperlipidemia depression 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 came for further evaluation of bloody bowel movements. further tests showed that you likely bled from your small intestine, from blood vessel malformations called angioectasias. a colonoscopy, egd, capsule endoscopy and small bowel enteroscopy was performed to identify these areas. it was also found that you have an infection with helicobacter pylori, for which you are being treated. it is important that you continue your medications and follow-up with the appointments listed below. the following changes have been made to your medications: we added omeprazole, clarithromycin and amoxicillin to treat an infection in your stomach called h. pylori. please take these medications for the full course outlined. followup instructions: pcp : wednesday, at 11:30am with: ,md location: healthcare - upper falls address: , , phone: department: liver center when: tuesday at 10:20 am with: , md building: lm bldg () campus: west best parking: garage department: surgical specialties when: thursday at 10:00 am with: , md building: campus: east best parking: garage md Procedure: Other endoscopy of small intestine Colonoscopy Endoscopic control of gastric or duodenal bleeding Diagnoses: Acidosis Pure hypercholesterolemia Toxic encephalopathy Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Depressive disorder, not elsewhere classified Long-term (current) use of insulin Primary hypercoagulable state Angiodysplasia of intestine with hemorrhage Helicobacter pylori [H. pylori] Other chronic nonalcoholic liver disease

allergies: levaquin / lisinopril / metoprolol / fentanyl / hydromorphone attending: chief complaint: shortness of breath, chest pain major surgical or invasive procedure: - left thoracotomy, lysis of adhesions, repair of left chest wall hernia using 1-mm -tex mesh. history of present illness: mrs. is a 40 year old female who underwent left axillary thoracotomy with resection of schwannoma of the mediastinum by dr. on . she has had left lung herniation since but has refused repair in the past. for the past two weeks she has had significantly more pain at the site and some shortness of breath. she was admitted to the surgical service for repair. past medical history: ms heartburn, dysphagia cervical myelopathy psh: app () hysterectomy, tubal lig. () bladder surgery () neck, chest/lung biopsy () social history: she did smoke occasionally in the past, but quit 18 years ago. she admits to occasional alcohol ingestion. family history: na physical exam: vital signs temp: 98.6 bp: 156/82 hr: 98. rr: 16. o2%: 97 physical exam: gen: nad, aao lungs: cta b/l chest: healed axillary incisions times 2, palpable herniation of l lung through chest wall with cough abd: sntnd ext: no e/c/c pertinent results: : ct chest - no local or distal disease recurrence. the lung parenchyma and pleura bulge the intercostal space at the site of previous thoracotomy with no focal hernia or trapped lung. 04:40am blood wbc-15.0* rbc-3.90* hgb-11.9* hct-34.1* mcv-88 mch-30.5 mchc-34.8 rdw-13.4 plt ct-542* 04:40am blood glucose-114* urean-13 creat-0.9 na-142 k-3.3 cl-101 hco3-31 angap-13 c diff negative brief hospital course: the patient was admitted to the surgical service for preoperative evaluation. she underwent spirometry testing on the morning of and was cleared for surgery. she was taken to the operating room on for repair of her left chest wall hernia. an epidural was placed pre-operatively. she tolerated the procedure well, was extubated in the operating room and transferred to the floor post operatively. she had a pca for pain control. she had a foley in place, chest tube in place. - diet advanced clears to regular, ivf stopped - the patient developed respiratory distress and was transferred to the icu for continued monitoring and care. bipap was started and she was eventually intubated for airway distress. she was started on vancomycin and zosyn. - continued ventilatory support, antibiotics discontinued - extubated without issues, diet advanced to regular - chest tube removed, continued regular diet, oob ambulating, transferred to the floor, epidural removed, foley catheter removed and she voided - pain well controlled, ambulating without assistance, discharged home medications on admission: clonidine patch 3qwk, diovan 160", lasix 40', nasonex prn, albuterol neb prn, ventolin neb prn, advair 50/500", lipitor 80', omeprazole 20', colace 100" discharge medications: 1. valsartan 160 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*90 tablet(s)* refills:*2* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 5. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qmon (every monday). disp:*15 patch weekly(s)* refills:*2* 6. beclomethasone dipropionate 80 mcg/actuation aerosol sig: eighty (80) mcg inhalation (2 times a day). disp:*60 neb* refills:*2* 7. advair diskus 500-50 mcg/dose disk with device sig: one (1) inh inhalation twice a day as needed for shortness of breath or wheezing. disp:*2 inh* refills:*2* 8. 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. disp:*90 neb* refills:*0* 9. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 2 weeks. disp:*60 tablet(s)* refills:*0* 10. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) neb inhalation every four (4) hours as needed for shortness of breath or wheezing. disp:*90 neb* refills:*0* 11. acetylcysteine 20 % (200 mg/ml) solution sig: one (1) neb miscellaneous every six (6) hours as needed for shortness of breath or wheezing. disp:*90 neb* refills:*0* 12. colace 100 mg capsule sig: one (1) capsule po twice a day for 2 weeks. disp:*28 capsule(s)* refills:*0* discharge disposition: home discharge diagnosis: left chest wall hernia discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent 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. * 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. incision care: -your steri-strips will fall off on their own. please remove any remaining strips 7-10 days after surgery. -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. followup instructions: please call the office of dr. at to arrange a follow up appointment in 2 weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arterial catheterization Reopening of recent thoracotomy site Other repair of chest wall Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Other operations on lung Diagnoses: Acidosis Other iatrogenic hypotension Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Anxiety state, unspecified Iatrogenic pneumothorax Other diseases of lung, not elsewhere classified Diarrhea Obesity, unspecified Multiple sclerosis Acute on chronic systolic heart failure Pleurisy without mention of effusion or current tuberculosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache major surgical or invasive procedure: none history of present illness: 65 year old male from on vacation with wife, was at dinner when at 7:45 pm last evening when he complained of a headache, shortly after, attempted to stand and fell to the ground. the patient was amnestic to fall, but was responsive and oriented when questioned by his wife who is rn. the patient was taken to an outside facility via ambulance, mental status declined in the ambulance but emt was unable to intubate him given his body habitus. he was intubated at the outside facility and a head ct showed a large cerebellar hemorrhage with intraventricular extent ion and herniation. shortly after the ct the patients systolic blood pressure dropped to 60, non responsive to fluid bolus and the pt. was started first on dopamine and then neo-synephrine for support. past medical history: gout, obstructive sleep apnea social history: married, lives with wife, here on vacation from family history: non contributory physical exam: on admission:physical exam: t: bp:102/42 supported on neo-synephrine and dopamine hr: 82 r 16 on cmv o2 sats 95% gen: intubated, not sedated heent: pupils: right 5mm nr, left 6mm non reactive neck: supple. extrem: warm and well-perfused. neuro: cranial nerves: i: not tested ii: pupils as above no cough/gag/corneals motor: ? flicker toe movement to deep noxious, likely reflexive. toes downgoing bilaterally upon discharge: deceased pertinent results: radiology report ct head w/o contrast study date of 1:15 am impression: 1. diffuse subarachnoid hemorrhage with intraventricular extension as described above. a probable focus of left cerebellar intraparenchymal hemorrhage. bilateral subdural hematoma layering along the tentorium, left more than right and blood in the thecal sac in the upper cervical spine, lower extent not included. 2. significant mass effect and diffuse cerebral edema with bilateral uncal herniation. brief hospital course: this is a 65 year old male with sudden onset headache staus post fall who was with decline in mental status. he was intubated and hypotensive transferred here on vasopressors to sustain his blood pressure. upon arrival the patient had no cough,corneal, or gag reflex. he was admitted on to the intensive care unit .his head ct was consistent with diffuse cerebral edema and uncal herniation. on exam, his pupils were fixed and dilated. the wife made decision to awaiting family before making the patient cmo. the patient was left intubated but the ventialtor was turned off per the wifes request at 415 am. the pt stopped breathing and was asystolic and expired at 430 am on with the family atthe bedside. organ bank was called and the patient will be a tissue donor. medications on admission: unknown discharge medications: none discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Diagnoses: Obstructive sleep apnea (adult)(pediatric) Obstructive hydrocephalus Gout, unspecified Subarachnoid hemorrhage Cerebral edema Subdural hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: addendum: discharge delayed secondary to syncopal episode on . complete syncope work up and cardiology consult was obtained before discharge home. they recommended d/c of norvasc and start on metoprolol 12.5mg which was instatuted. patient decided on that she would like to go to rehab for a short period before returning home. major surgical or invasive procedure: none past medical history: motorcycle accident 30 years ago, had craniotomy, extensive left arm surgery due to trauma causing weakness and zygomatic fracture. htn social history: prior marine, lives alone independently, dnr at baseline, nonsmoker, no alcohol family history: nc physical exam: exam on discharge: non focal. able to ambulate independently and do stairs. pertinent results: 05:45pm urine blood-neg nitrite-neg protein-neg glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 05:45pm urine color-yellow appear-clear sp -1.009 05:45pm pt-17.5* ptt-30.4 inr(pt)-1.6* 05:45pm neuts-73.3* lymphs-21.4 monos-4.3 eos-0.4 basos-0.7 05:45pm wbc-19.3* rbc-4.30 hgb-12.7 hct-38.5 mcv-90 mch-29.5 mchc-32.9 rdw-13.9 05:45pm calcium-8.4 phosphate-2.1* magnesium-2.0 05:45pm estgfr-using this 05:45pm glucose-210* urea n-18 creat-0.8 sodium-139 potassium-3.7 chloride-105 total co2-19* anion gap-19 08:10pm type-art rates-16/ tidal vol-450 peep-5 o2-100 po2-442* pco2-32* ph-7.49* total co2-25 base xs-2 aado2-263 req o2-49 -assist/con intubated-intubated 05:00am blood wbc-7.0 rbc-3.85* hgb-11.1* hct-33.8* mcv-88 mch-28.9 mchc-32.8 rdw-14.0 plt ct-298 05:45pm blood neuts-73.3* lymphs-21.4 monos-4.3 eos-0.4 baso-0.7 05:00am blood plt ct-298 05:00am blood glucose-95 urean-13 creat-0.6 na-142 k-3.6 cl-106 hco3-27 angap-13 05:00am blood calcium-8.1* phos-3.8 mg-1.9 brief hospital course: patient was ready for discharge on when after getting up to go to the bathroom and having a bowel movement she had a syncopal episode. she passed out and was caught by her nurse, reportidly she was unresponsive for one min. cardiology was called for a consultation, their recommendations were to give the patient a fluid bolus and check electrolytes. her potassium was repleated. per cardiology's recommendaton her amlodipine was discontinued and she was placed on metoprolol 12.5mg with hold parameters for a heart rate less than 60 and systolic blood pressure less than 110. physicial therapy re-evaluated the patient and cleared her for discharge home with a walker for assistance, but patient decided that she would like to go to rehab upon discharge. medications on admission: norvasc discharge medications: 1. methimazole 10 mg tablet sig: one (1) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion. discharge disposition: extended care facility: livingcenter - discharge diagnosis: traumatic brain injury discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: general instructions ?????? take your 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. for one week. 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. md Procedure: Insertion of endotracheal tube Closure of skin and subcutaneous tissue of other sites Diagnoses: Unspecified essential hypertension Accidental fall on or from other stairs or steps Diarrhea Syncope and collapse Open wound of knee, leg [except thigh], and ankle, without mention of complication Contusion of face, scalp, and neck except eye(s) Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall major surgical or invasive procedure: none history of present illness: hpi: y/o female fell down 3 stairs at the post office. had loc at scene but was awake and gsc 14 at hospital (lost point for orientation.) she was found to have a traumatic sah was given dilantin then transferred here for further care. she was transferred here via ambulance and was found to an acute change on arrival. past medical history: motorcycle accident 30 years ago, had craniotomy, extensive left arm surgery due to trauma causing weakness and zygomatic fracture. htn social history: prior marine, lives alone independently, dnr at baseline, nonsmoker, no alcohol family history: nc physical exam: pt in process of being intubated when examined. patient is in collar has right occipital hematoma eyes open, awake, trying to mouth words, trying to sit up moving uppers symmetrically. questionably moving lowers to commands. appears to be full strength in upper extremities. moving left leg less than right. pupil right surgical left ; patient was quickly intubated for airway protection had vomitted. physical exam: o: t: bp:158/80 hr: 94 r 20 o2sats 100% exam upon discharge: alert and oriented x3, motor full, no pronator drift pertinent results: ct/mri: prior left frontal craniotomy site noted. small bilateral traumatic sah at convexity labs:pt: 17.5 ptt: 30.4 inr: 1.6 head ct: impression: overall, no significant change in appearance of convexity subarachnoid blood compared to the previous ct of . brief hospital course: pt was admitted to neurosurgery and monitored closely. she remained neurologically stable. repeat ct was stable. she was transferred to the floor. diet and activity were advanced. she was evaluated by pt and felt suitable for discharge home with services. medications on admission: norvasc and otc discharge medications: 1. amlodipine 2.5 mg tablet sig: one (1) tablet po daily (daily). 2. methimazole 10 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: livingcenter - discharge diagnosis: traumatic brain injury discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: general instructions ?????? take your 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. for one week. 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: Insertion of endotracheal tube Closure of skin and subcutaneous tissue of other sites Diagnoses: Unspecified essential hypertension Accidental fall on or from other stairs or steps Diarrhea Syncope and collapse Open wound of knee, leg [except thigh], and ankle, without mention of complication Contusion of face, scalp, and neck except eye(s) Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection

allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: pulmonary intubation history of present illness: ms. is an 82 year-old woman with a history of cad s/p cad s/p mi with cabg in , 2 of om/lcx and des of lm in , severe ischemic cardiomyopathy with ef 18%, s/p placement of dual chamber icd/ppm, who presents with acute onset shortness of breath. history is obtained from her daughter. . one month prior to admission had been contact by pcp who relayed lab abnl that were consistent with dehydration and encouraged po hydration as well as liberalization of salt-restricted diet. . per report patient has been experiencing gradual onset malaise for the past 2-3 days. at baseline she is able to ambulate around the house without shortness of breath, and she has been unable to do this for several days. yesterday she had intermittent palpitations and shortness of breath daughter attributed to anxiety. she awoke today acutely short of breath. ems was activated. her daughter denies any recent fevers or chills, cough, chest pain, lower extremity edema, pain with urination. she does endorse chronic constipation and mild abdominal discomfort for the past few days (last bowel movement two days prior to admission). . in the ed, initial vs 120 146/80 36 95% on facemask. ekg with lbbb which was consistent with prior. cxr notable for pulmonary vascular congestion and bilateral effusions. her o2 sat fell and bipap was started. she was given 40 mg of iv lasix, 4 mg iv morphine, nitro sl. abg at that time 7.11/71/81 on bipap. she was intubated with succ/etomidate for mixed hypoxic/hypercarbic respiratory failure, then started on fentanyl/midazolam. peri-intubation her blood pressure fell to 60s (despite only 5 of peep). r ij cvl was placed. and levophed was started. on the levophed, her bp initially rose and stabilized however dropped prior to transfer necessitating dopamine initiation. she diuresised ~800cc in ed to the 40mg iv lasix. repeat abg prior to transfer, 7.28/41/69 on 500/15, 100% fiox, peep 8 . on arrival to the ccu her maps>60 on combination levophed and dopamine; o2 saturations 100% on fio2 100 vt: 500 24/8. abg on arrival 7.35 co2: 35 o2 204. levophed downtitrated and lasix gtt initiated for treatment fo chf exacerbation. . ros: unable to attain past medical history: 1. cardiac risk factors: (-)diabetes, (+)dyslipidemia, (+)htn 2. cardiac history: # cad s/p mi with cabg in (in , ) # percutaneous coronary interventions: des x2 in om/cx placed in . des in lm in . ( hospital in ) # pacing/icd: placement of ppm/icd in (guidant icd placed on ) # ischemic cmp; -- tte: ef: 20-25%; severe regional left ventricular dysfunction with an aneurysm of the anterior/anteroapical wall. mild to moderate mitral regurgitation # atrial fibrillation per osh records . other past medical history: # ckd. baseline creatinine 1.6-2.0. multifactorial origin thought to be secondary to atrophic right kidney, longstanding hypertension, and prior cardiac events. # solitary kidney (due to nephrolithiasis/pyelonephritis) # pituitary adenoma # thyroid nodule # chronic pain # right sided bell's palsy . social history: from , has been in the united states for 13 years. widowed. lives with daughter, her husband and 2 children. walks with cane at baseline, requires assistance with some adls. no history of tobacco/alcohol/drugs . family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . physical exam: on ccu admission: . . general: sedated, intubated. withdrawls to pain; opens eyes to command heent: ncat, perrla, sclera anicteric. conjunctiva were pink; og tube and et tube in place neck: supple with jvp elevated 10 cm. cardiac: rrr; hard to discern murmur in setting of rhonchorous bs anteriorly. lungs: breath sounds b/l; rhonchorus bs anteriorly abdomen: soft, nt, nd. no hsm or tenderness. extremities: no pedal edema appreciated. 1+ dps and pts. skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: sedated; withdraws to pain, responds to voice when sedation lessened . pertinent results: . admission labs: 10:48pm glucose-126* urea n-28* creat-1.3* sodium-140 potassium-3.7 chloride-108 total co2-22 anion gap-14 10:48pm ck(cpk)-122 10:48pm ck-mb-5 ctropnt-0.04* 10:48pm calcium-8.6 phosphate-3.0 magnesium-1.8 10:48pm wbc-12.5* rbc-3.76* hgb-11.9* hct-34.5* mcv-92 mch-31.7 mchc-34.5 rdw-13.9 10:48pm neuts-77* bands-5 lymphs-8* monos-10 eos-0 basos-0 atyps-0 metas-0 myelos-0 10:48pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 10:48pm plt smr-normal plt count-229 07:19pm urine color-straw appear-clear sp -1.006 07:19pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 07:19pm urine rbc-7* wbc-1 bacteria-none yeast-none epi-0 07:19pm urine rbc-7* wbc-1 bacteria-none yeast-none epi-0 07:19pm urine granular-1* hyaline-18* 07:19pm urine mucous-occ 04:26pm type-art temp-36.3 rates-24/ tidal vol-500 peep-8 o2-100 po2-204* pco2-35 ph-7.36 total co2-21 base xs--4 aado2-474 req o2-81 -assist/con intubated-intubated 04:26pm lactate-1.3 04:26pm freeca-1.21 03:47pm glucose-146* urea n-27* creat-1.3* sodium-141 potassium-4.1 chloride-110* total co2-21* anion gap-14 03:47pm alt(sgpt)-11 ast(sgot)-20 ld(ldh)-262* alk phos-51 tot bili-0.5 03:47pm lipase-58 03:47pm albumin-3.7 calcium-8.3* phosphate-3.8 magnesium-1.8 iron-88 03:47pm wbc-11.6* rbc-3.90* hgb-12.2 hct-37.1 mcv-95 mch-31.3 mchc-32.8 rdw-14.0 03:47pm neuts-88* bands-8* lymphs-3* monos-1* eos-0 basos-0 atyps-0 metas-0 myelos-0 03:47pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-2+ microcyt-normal polychrom-normal 03:47pm plt smr-normal plt count-290 03:47pm pt-37.1* ptt-31.1 inr(pt)-3.7* 11:34am type-art tidal vol-500 peep-8 o2-100 o2 flow-24 po2-69* pco2-41 ph-7.28* total co2-20* base xs--6 aado2-603 req o2-99 -assist/con intubated-intubated vent-controlled 11:11am urine hours-random 11:11am urine uhold-hold 11:11am urine color-straw appear-clear sp -1.006 10:10am lactate-1.5 10:04am comments-green top 10:04am glucose-146* lactate-1.8 na+-142 k+-5.3 cl--111 tco2-19* 09:50am glucose-166* urea n-28* creat-1.4* sodium-137 potassium-5.3* chloride-107 total co2-18* anion gap-17 09:50am estgfr-using this 09:50am ctropnt-<0.01 09:50am ck-mb-4 09:50am wbc-13.7*# rbc-4.34# hgb-13.5# hct-41.6# mcv-96 mch-31.2 mchc-32.5 rdw-13.9 09:50am neuts-55.0 lymphs-39.5 monos-4.1 eos-0.9 basos-0.6 09:50am plt count-280 09:50am pt-29.8* ptt-27.7 inr(pt)-2.9* . discharge labs: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:05 11.0 3.50* 10.7* 32.9* 94 30.7 32.6 13.7 290 differential neuts bands lymphs monos eos baso atyps metas 06:81.0* 13.1* 4.6 0.6 0.7 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 06:05 290 06:05 22.0* 2.0* lab use only 06:05 chemistry renal & glucose glucose urean creat na k cl hco3 angap 06:05 111*1 49* 1.5* 144 3.7 105 29 14 . imaging on this admission: . ecg : sinus rhythm with borderline sinus tachycardia and ventricular premature beat. probable atypical left bundle-branch block with left axis deviation. since the previous tracing of the same date sinus tachycardia rate is slower and ventricular ectopy is present. otherwise, probably no significant change. tte : the left ventricular cavity size is top normal/borderline dilated. there is severe regional left ventricular systolic dysfunction with akinesis of almost all segments apart from the inferior and inferolateral walls which are mildly hypokinetic. there is an anteroapical left ventricular aneurysm. right ventricular chamber size and free wall motion are normal. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. impression: severe regional left ventricular dysfunction with an aneurysm of the anterior/anteroapical wall. mild to moderate mitral regurgitation. compared with the prior study (images not available for review) of , the degree of mitral regurgitation has probably increased. lv systolic historical imaging: the left ventricular cavity size is top normal/borderline dilated. there is severe regional left ventricular systolic dysfunction with akinesis of almost all segments apart from the inferior and inferolateral walls which are mildly hypokinetic. there is an anteroapical left ventricular aneurysm. right ventricular chamber size and free wall motion are normal. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. impression: severe regional left ventricular dysfunction with an aneurysm of the anterior/anteroapical wall. mild to moderate mitral regurgitation . 2d-echocardiogram: (): the left atrium is normal in size. there is a very large antero-apical left ventricular aneurysm. there is severe regional left ventricular systolic dysfunction with akinesis of almost all segments apart from the inferior and inferolateral walls which are mildly hypokinetic. a left ventricular mass/thrombus cannot be excluded - the apex is not well seen. right ventricular chamber size and free wall motion 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. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. . impression: severe regional left ventricular dysfunction with a large aneurysm of the anterior wall. mild mitral regurgitation and trace aortic regurgitation. pulmonary artery systolic pressure could not be estimated. . cxr: impression: bibasilar opacities and cardiomegaly may relate to chf in the appropriate clinical setting, with bibasilar opacities relating to pleural effusions and overlying atelectasis, underlying consolidation cannot be excluded. . persantine mibi: () summary of data from the exercise lab: dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. interpretation: left ventricular cavity size is severely enlarged. rest and stress perfusion images reveal multiple fixed perfusion defects including a severe anterior and apical defect as well as moderate anterolateral and distal inferolateral defects. gated images reveal global hypokinesis. the calculated left ventricular ejection fraction is 18%. there is no prior for comparison. impression: 1) multiple fixed perfusion defects including a severe anterior and apical defect as well as moderate anterolateral and distal inferolateral defects. 2) severe left ventricular enlargement with global hypokinesis and an lvef of 18%. . cardiac cath: per prior discharge summary: osh records for cath performed in . "cath done with balloon pump support, om and lcx dilation, des x2 in om/cx, lm dilated, des in lm crossing intermediate artery. the cx was considered as a non-jeopardized side branch and the origin was stented across. long term plavix recommended." . tte : the left ventricular cavity size is top normal/borderline dilated. there is severe regional left ventricular systolic dysfunction with akinesis of almost all segments apart from the inferior and inferolateral walls which are mildly hypokinetic. there is an anteroapical left ventricular aneurysm. right ventricular chamber size and free wall motion are normal. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. . brief hospital course: ms is a 82 year-old woman with severe ischemic cardiomyopathy ef 20-25% admitted to the ccu with acute on chronic chf exacerbation resulting in respiratory failure. . # acute on chronic systolic heart failure: on admission to the ed clinical picture was consistent with pulmonary edema, cxr notable for pulmonary vascular congestion and bilateral effusions. her o2 sat fell and bipap was started. she was given 40 mg of iv lasix, 4 mg iv morphine, nitro sl. abg at that time 7.11/71/81 on bipap. she was intubated with succ/etomidate for mixed hypoxic/hypercarbic respiratory failure, then started on fentanyl/midazolam. peri-intubation her blood pressure fell to 60s (despite only 5 of peep). r ij cvl was placed. and levophed was started. on the levophed, her bp initially rose and stabilized however dropped prior to transfer necessitating dopamine initiation. she diuresised ~800cc in ed to the 40mg iv lasix. repeat abg prior to transfer, 7.28/41/69 on 500/15, 100% fiox, peep 8 on arrival to the ccu her maps>60 on combination levophed and dopamine; o2 saturations 100% on fio2 100 vt: 500 24/8. abg on arrival 7.35 co2: 35 o2 204. levophed and dopamin were subsequently weaned and patient was treated with lasix gtt for duresis with good response. she was extubated on day 2 and remained respiratorily stable. los at discharge from ccu was -5l. . as for etiology for her chf exacerbation this is attributable to excess fluid intake and dietary indiscretion on the days preceeding her admission. other potential causes are thought unlikely: she had no signs or symptoms of infection, ucx and bcx were negative; her clinical complaints, ekg, tte and biomarkers were not suggestive of an ischemic event. . the patient was transfered to the cardiology floor where home meds were restarted. she is discharged with torsemide, metoprolol, digoxin, atacand and warfarine as outlined below. . . # af w/ rvr: this developed with concurrent hypotension on . ventricular rate was as high as 170 and in this setting patient got shocked by her icd 7 times without conversion. amiodarone + digoxin were iv loaded with subsequent return to sinus rythm. ep were consulted, icd was interrogated and data was c/w afib with rvr. icd was reset appropriately. patient was subsequently well rate controlled with metoprolol, digoxin and amiodarone. she is discharged on the same as outlined below. . # coronary artery disease: ekg currently difficult to interpret for ischemia given lbbb which is old. tte unchanged from prior with no evidence of new wma. biomarkers peaked at trop 0.04, mb 5. continued on statin and bb. was started on asa 81. . # chronic kidney disease. multifactorial in setting of atrophic right kidney, longstanding hypertension, and prior cardiac events. baseline creatinine 1.3-1.8. cr was 1.5 on dsicharge. . # abdominal pain. patient with long history of chronic constipation. was treated with laxatives with consequent bm and resolution of abdominal pain. . # hypertension: had some episodes of hypotension during this admission first in the setting of intubation then in the setting of af/rvr. subsequently stabilized and currently normotensive on low doses of bb and . . # code: full during this admission; confirmed, hcp: daughter . # dispo: patient is discharged to rehabilitation facility. . . post discharge issues: - follow i/o daily weights and fluid status. - adjust duretic and bp medication as needed. - aldosterone antagonist may be added on in the out patient setting after and bb therapy. - contionue coumadin for anticoagulation of lv aneurysm; adjust dosage as needed for goal inr = . - f/u bcx result from which is still pending at discharge medications on admission: medications (reconciled with daughter) coumadin 2.5mg po qd crestor 20mg qd atacand 16mg po qd meclizine 25mg po tid omeprazole 20mg po imdur 60mg po qd torsemide 20mg po qd calcitriol 0.25mg 1 tab qod prunelax 15mg prn nitroglycerin prn chest pain colace 100mg po bid dulcolax 5mg prn qd lactulose 30ml prn constipation . discharge medications: 1. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm: please check inr daily until stable. 2. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. atacand 16 mg tablet sig: one (1) tablet po once a day: hols sbp < 100. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: 1-2 tablets po once a day as needed for constipation. 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily) as needed for constipation. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. torsemide 5 mg tablet sig: one (1) tablet po daily (daily). 9. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 10. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 11. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks: then decrease to 200 mg daily. 12. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day. 13. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). discharge disposition: extended care facility: discharge diagnosis: primary diagnosis: ventricular tachycardia acute on chronic systolic congestive heart failure secondary diagnosis: ischemic cardiomyopathy dyslipidemia hypertension chronic kidney disease coronary artery disease constipation discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure taking care of you at . you had an acute exacerbation of your systolic congestive heart failure and needed increased amounts of diuretics to get rid of the fluid. you required intubation to help you breathe. you also had ventricular tachycardia, a dangerous rhythm that was controlled by starting amiodarone and metoprolol. you have not had any of this rhythm for the last 48 hours. you were confused but this is improving as you are getting better. we made the following changes to your medicines: 1. decrease coumadin to 1mg daily as amiodarone can increase coumadin level 2. decrease torsemide to 5 mg daily 3. start colace, senna and mirilax to treat your constipation 4. stop taking prunelax, lactulose, bisacodyl and dulcolax 5. stop taking meclizine and imdur 6. start taking metoprolol to slow your heart rate 7. start taking amiodarone to keep you in a normal rhythm 8. start taking digoxin to help your heart beat more effectively weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. followup instructions: , l. the office will call you with an appt in weeks. please call them if you have not received an appt. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Chronic kidney disease, unspecified Acute respiratory failure Hypotension, unspecified Cardiac pacemaker in situ Acute on chronic systolic heart failure

allergies: statins-hmg-coa reductase inhibitors attending: chief complaint: transfer from osh for large brain hemorrhage major surgical or invasive procedure: none history of present illness: 83 year old female with h/o mild alzheimer's disease, l cea in 05, htn, elevated lipids, bladder ca (no known metastasis), who presents as a transfer from osh with unresponsiveness, l blown pupil and a very large intra cranial hemorrhage on ct. daughter reports that she was last seen well yesterday. this morning she spoke to her over the phone and she sounded weird. she replied "ok doc", she was speaking slowing and then stopped talking. she went to her house and found her on the floor in the kitchen, snoring. she was taken to osh where she was found to have a dilated left pupil, she was intubated and a ct head showed a devastating hemorrhage affecting almost all right hemisphere with significant shift. she was transferred here for evaluation by neurosurgery who found it an extremely poor surgical candidate. the family opted to make her cmo. past medical history: mild alzheimer's disease, l cea in 05 htn, elev lipids, bladder ca (no known metastasis), social history: patient recently lost husband and lives alone with help from family. long past smoking history, occ alcohol use, no drugs family history: nc physical exam: :99.1 intial bp:240/92 -> 180/85 hr:59 on mechanical ventilation r:15 o2sats 100% on vent gen: intubated elderly lady, non-responsive. neck: in cervical collar lungs: mechanical breath sounds b/l, present on both sides cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neurologic examination: mental status: intubated, unresponsive to noxious stimuli with some decrebrating posturing cranial nerves: pupils unreactive; r 2mm and l 4mm, no corneal, normal doll's face appears symmetric, tongue midline motor: no movement to noxious stimuli, some decerebrating posturing. increased tonus throughout sensation: no retraction to noxious stimuli refl: upgoing toes coordination and gait: unable to examine pertinent results: 01:19pm urine hours-random 01:19pm urine gr hold-hold 01:19pm urine color-yellow appear-clear sp -1.016 01:19pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 01:19pm urine rbc-0 wbc-0-2 bacteria-few yeast-none epi-0-2 01:19pm urine hyaline-0-2 01:19pm urine amorph-few 12:50pm ph-7.40 comments-green top 12:50pm glucose-214* lactate-1.8 na+-142 k+-4.4 cl--107 tco2-21 12:50pm hgb-13.1 calchct-39 o2 sat-99 12:50pm freeca-1.12 12:35pm urea n-49* creat-1.6* 12:35pm estgfr-using this 12:35pm lipase-35 12:35pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:35pm urine hours-random 12:35pm urine hours-random 12:35pm urine gr hold-hold 12:35pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 12:35pm wbc-16.2* rbc-3.74* hgb-11.7* hct-35.7* mcv-95 mch-31.4 mchc-32.9 rdw-14.1 12:35pm pt-11.9 ptt-20.7* inr(pt)-1.0 12:35pm plt count-244 12:35pm fibrinoge-378 12:35pm urine color-yellow appear-clear sp -1.015 12:35pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 12:35pm urine rbc-0 wbc-0 bacteria-few yeast-none epi-0-2 12:35pm urine hyaline-0-2 brief hospital course: 83 year old female with h/o mild alzheimer's disease, cea in 05, htn, elev lipids, bladder ca, who presents as a transfer from osh with unresponsive with fixed dilated pupils, decerebrating postering and very extensive r intra cranial hemorrhage on ct, with significant shift and uncal herniation; deemed non-operable by neurosurgery and incompatible with survival. patient was made cmo by family and expired the following day. medications on admission: hctz 25mg qd zetia 10mg qd amlodipine 10mg qd plavix 75mg qd synthriod 100mg qd atenolol 50mg qd discharge medications: expired discharge disposition: expired discharge diagnosis: expired large brain hemorrhage discharge condition: expired discharge instructions: expired followup instructions: expired md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Intracerebral hemorrhage Compression of brain Myelodysplastic syndrome, unspecified Other and unspecified hyperlipidemia Personal history of malignant neoplasm of bladder Alzheimer's disease

allergies: no known allergies / adverse drug reactions attending: addendum: patient is going to rehab with a ng tube for feeds, but has cleared a swallow eval by speech therapy and can have a soft diet with nectar thick fluids. tube feeds can be cycled and discontinued if patient taking adequate po. discharge disposition: extended care facility: healthcare center - md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Clipping of aneurysm Arteriography of cerebral arteries Diagnoses: Tobacco use disorder Mitral valve disorders Unspecified essential hypertension Hyposmolality and/or hyponatremia Other chronic pulmonary heart diseases Cerebral aneurysm, nonruptured Aphasia Diseases of tricuspid valve Diabetes insipidus Unspecified disorder of thyroid

allergies: no known allergies / adverse drug reactions attending: chief complaint: partially coiled left mca aneurysm major surgical or invasive procedure: left crani for mca aneursym clipping history of present illness: ms. is a 54 y/o female with a subarchnoid hemorrhage on who was found to have multiple aneursyms. she had a prolonged hospitilization and underwent coiling of a right mca, right ica and partial left mca aneursym. she returned from her rehab facility for this procedure. past medical history: htn multiple cerberal aneurysms aphasia social history: +tobacco, occasional alcohol per family. family history: stroke no known aneurysms in family physical exam: prior to surgical procedure: patient ,perrl, eom intact, cn 2-12 grossly intact, moves all extremities, ? of some right upper extremity weakness. expressive and receptive aphasia. exam on discharge: , x 4, does not follow commands, expressive and receptive apahsia. cranial incision sutured with sutures. pertinent results: cerebral angio: successful clipping of the left middle cerebral artery bifurcation aneurysm with a careful preservation of the base, which gives rise to m2 branches. 2-mm aneurysm is again noted arising from the left m1 segment and oriented laterally and inferiorly. these findings were discussed with dr. , referring neurosurgeon. nchct: 1. left craniotomy, with 1.5-cm extra-axial fluid/air collection compressing the cerebral parenchyma. 2. new hypodensities in the left cerebral hemisphere and right frontal lobe, which may represent postoperative edema and/or infarcts. 3. bilateral coil packs. 4. moderate paranasal sinus disease. brief hospital course: ms. was admitted from her rehab facility to undergo an elective left craniotomy and left mca aneurysm clipping. operative course was uncomplicated. post operatively she was taken intubated to the angio suite for a diagnostic cerebral angiogram. angiogram confirmed successufl clipping of the left mca aneurysm and patent vasculatrue w/o evidence of vasospam. patient was observed in the icu for two days and transferred to the floor on . speech therapy worked with the patient and cleared her for a soft diet with nectar thick liquids. medications on admission: asprin 325mg daily pepcid 20mg discharge medications: 1. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day). 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. acetaminophen 650 mg/20.3 ml solution sig: one (1) po q6h (every 6 hours) as needed for headache. 5. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for headache. 6. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 8. phenytoin 125 mg/5 ml suspension sig: one (1) po q12h (every 12 hours). 9. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: healthcare center - discharge diagnosis: left mca aneurysm global aphasia discharge condition: mental status: confused - always, speech not clear. level of consciousness: 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 with a mild shampoo taking care not to scrub around your incision. ?????? 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. ?????? 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 or rehab, but please have the results faxed to . ?????? 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 10 days(from your date of surgery) for removal of your sutures and/or a wound check. you can have your sutures removed at your rehab facility if coming to dr. office is too difficult. ??????please call ( to schedule an appointment with dr. , to be seen in 3 months, no imaging needed for this visit. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Enteral infusion of concentrated nutritional substances Clipping of aneurysm Arteriography of cerebral arteries Diagnoses: Tobacco use disorder Mitral valve disorders Unspecified essential hypertension Hyposmolality and/or hyponatremia Other chronic pulmonary heart diseases Cerebral aneurysm, nonruptured Aphasia Diseases of tricuspid valve Diabetes insipidus Unspecified disorder of thyroid

allergies: no known allergies / adverse drug reactions attending: chief complaint: collapsed major surgical or invasive procedure: : right evd placement : cerebral angiogram with successful coil embolization of left mca bifurcation aneurysm and successful coil embolization of the right internal carotid artery terminus aneurysm with attempted coil embolization of the right mca bifurcation. angiogram with stent of right mca stent assisted coiling of right mca aneurysm peg placement history of present illness: 53f with no significant pmh who reportedly collapsed at a party earlier tonight around 7:30pm. she was initially taken to an osh where a ct showed diffuse sah. she was intubated and transferred to for further management. upon arrival she was noted to be fighting the ett and was given fentanyl and versed around 11:30pm. upon examination 1 hour later off sedation she does not open her eyes or follow any commands, has no spontaneous movement, but does withdraw to noxious stimuli in all extremities. repeat ct/cta pending. spoke with son and daughter at bedside who report that she had been previously healthy with no medical problems. does and drink occasional alcohol but takes no medications at home, including no aspirin or blood thinners. no known hx of aneurysm in the past. past medical history: none per family social history: +tobacco, occasional alcohol per family. family history: stroke no known aneurysms in family physical exam: on admission: physical exam: gen: intubated, received fentanyl and versed at 23:26, currently off sedation. gcs 6, hunt and grade iv. heent: ncat. pupils 3mm to 2mm b/l. neck: limited by ms and presence of ett, no clear nuchal rigidity lungs: +rhonchorous breath sounds bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: intubated, no eye opening to voice or noxious. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2mm bilaterally. +corneal reflexes b/l. iii, iv, vi: +roving eye movements v, vii: face appears symmetric viii: unable to assess ix, x: unable to assess, pt intubated : unable to assess xii: unable to assess motor: weakly withdraws to noxious in all extremities sensation: withdraws to noxious stimulation reflexes: b t br pa ac right 2 2 2 2 1 left 2 2 2 2 1 toes downgoing bilaterally on discharge perrl at 5 to 4mm bilaterally patient is easily arousable, tracks examiner, unable to follow commands, but moves uppers and lowers spontaneously. pertinent results: cta head/neck : at least three saccular aneurysms are identified, one is located at the bifurcation of the right internal carotid artery, measuring approximately 10 x 6 mm in coronal projection and approximately 7.5 mm in transverse dimension (image 38, series 604b). the second aneurysm is visualized at the bifurcation of the right middle cerebral artery, measuring approximately 7.3 mm in transverse dimension and approximately 6.6 x 7.3 mm in coronal projection. the third multilobulated aneurysm is identified at the bifurcation of the left middle cerebral artery, measuring approximately 8 mm in transverse dimension 7 x 9 mm in coronal projection. the posterior circulation appears unremarkable, the neck vessels are also normal in contour and origin with no evidence of narrowing or stenosis. the bone structures demonstrate mild degenerative changes consistent with posterior spondylosis at c6/c7 level. chest xray : findings: there are diffuse bilateral ground-glass opacitiesconcerning for moderate pulmonary edema. there is a small linear opacity at the left lung base, likely atelectasis. there is no pleural effusion. increased lucency at the left costophrenic angle; attention on the next radiograph to exclude basal pneumothorax. hilar, mediastinal and cardiac silhouette within normal limits. ct head : impression: 1. extensive bilateral subarachnoid hemorrhage, stable since the prior study. multiple known right and left mca aneurysms, better evaluated on the prior cta study. 2. no ct evidence of infarction. 3. diffuse cerebral edema with effacement of the hemispheric sulci. no evidence of herniation. 4. moderate interval decrease in the ventricular size, status post placement of evd catheter. ct head : impression: 1. status post coiling of right mca and left mca aneurysms. diffused cerebral edema. 2. otherwise, no change from at 9am. echo : the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 5-10 mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with hypokinesis of the mid inferior, mid inferolateral, and mid anterior walls. the remaining segments contract normally (lvef = 50%). the estimated cardiac index is normal (>=2.5l/min/m2). 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 stenosis or aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal left ventricular cavity size with regional systolic dysfunction in an atypical/non-coronary artery distribution. mild mitral regurgitation. pulmonary artery hypertension. chest xray : heart size and mediastinal silhouettes are unremarkable. interval improvement in widespread parenchymal opacities, most likely consistent with interval improvement of pulmonary edema. bibasilar opacities are still present, most likely residual although atelectasis cannot be excluded. chest xray : impression: interval worsening of the mild-to-moderate pulmonary edema and mild increase in the mild-to-moderate left pleural effusion. head ct : impression: 1. slight redistribution of the bilateral subarachnoid hemorrhage with associated bilateral cerebral sulcal effacement, stable. no extra-axial or intraparenchymal hemorrhage evident. 2. ventricular size and left ventriculostomy catheter tip positioned in the third ventricle, stable. 3. there is now a small amount of acute hemorrhage and adjacent edema, surrounding the left transfrontal venticulostomy catheter tract, new since the previous study. head cta : impression: 1. evolving infarctions in the paramedian frontal lobes, in the anterior cerebral artery territories, and in the lateral left frontal lobe, in the middle cerebral artery territory. 2. stable subarachnoid hemorrhage with associated sulcal effacement. 3. stable small hemorrhage and mild edema along the course of the left frontal ventriculostomy catheter. the ventricles have slightly decreased in size. no residual intraventricular hemorrhage seen. 4. limited evaluation of the a1 and proximal a2 segments of the anterior cerebral arteries, and of the m1 segments of the middle cerebral arteries, due to streak artifact. decreased caliber of the proximal a2 segment of the left anterior cerebral artery, and of the superior division branches of the left middle cerebral artery, cannot be excluded. 5. residual filling of the left mca terminus aneurysm around the coil pack. no evidence of residual filling of the coild right ica terminus aneurysm on limited evaluation. 6. unchanged, untreated right mca bifurcation aneurysm. the previously noted 2 mm aneurysm versus infundibulum at the left ica terminus is poorly seen due to artifacts. lenis : impression: no evidence of dvt in the bilateral lower extremities. cta head : impression: 1. evolving infarctions in bilateral frontal lobes, right insula, and right temporoparietal lobes, which have increased in size as compared to the prior study. 2. stable subarachnoid hemorrhage with associated sulcal effacement. a left frontal ventriculostomy catheter with associated small hemorrhage along its course. the ventricles are stable in size as compared to the prior study. 3. limited evaluation of the a1 and proximal a2 segments of the anterior cerebral arteries and the m1 segments of the middle cerebral arteries due to the streak artifact. a decrease in the caliber of the proximal a2 segment of the left anterior cerebral artery and at the superior division branches of the left middle cerebral artery cannot be excluded; however, the overall appearance is unchanged since the recent study. 4. retrograde filling of the left middle cerebral artery bifurcation aneurysm around the coil pack. no evidence of retrograde filling of the coiled right internal carotid artery terminus aneurysm. 5. unchanged right middle cerebral artery bifurcation aneurysm. the previously noted 2-mm aneurysm versus infundibulum at the left internal carotid artery terminus is poorly-seen due to artifact. tcd: abnormal tcd evaluation. increased velocities of both mca consistent with mild vasospasm. this represents improvement compared to the tcd from . cxr: findings: indwelling support and monitoring devices are unchanged in position. heart is upper limits of normal in size. improving pulmonary vascular congestion and decrease in patchy bibasilar opacities. no new or worsening lung or pleural abnormalities. cxr: the left lung edema best seen on the film has nearly resolved. et tube is seen in unchanged correct position. cardiomediastinal silhouette and hilar contours are unremarkable. there are no pleural effusions or pneumothoraces. a left-sided picc line is again seen with its tip in the right atrium. a dobbhoff tube is seen with its tip in the stomach. ct head: 1. no developing hydrocephalus or midline shift. unchanged left ventriculostomy drain position. 2. evolving multifocal infarcts. 3. no new foci of intracranial hemorrhage. cxr: stable cxr: stable ct head:impression: 1. evolving bilateral frontal and right insular infarcts. 2. status post bilateral mca branch aneurysm coil embolization; trace residual subarachnoid blood. 3. status post ventriculostomy catheter removal with encephalomalacia along the tract and gas within the lateral ventricles lower extremity doppler ultrasound negative for dvt ct head 1. status post bilateral mca branch aneurysm coil embolization. 2. no evidence of hydrocephalus ct head impression: 1. interval resolution of previously seen cerebral and basal ganglia enhancement, suggesting that these were related to contrast staining from the patient's prior angiogram. 2. tiny right frontal sulcal hyperdensity may represent a small focus of subarachnoid hemorrhage. no other sites of hemorrhage are seen. ct torso impression: 1. no retroperitoneal hematoma. 2. 5-mm non-obstructive right renal stone. 3. subsegmental bibasilar atelectasis. lenies findings: grayscale and doppler images of the right and left common femoral, superficial femoral, popliteal, and proximal calf veins were obtained. there is wall-to-wall flow with normal response to compression and augmentation in all visible veins. partially imaged inguinal lymph nodes are not enlarged. impression: no dvt in either lower extremity. brief hospital course: 53f who was admitted to with a sah. she arrived intubated and sedated. the patient continued to fight the vent and was given additional sedation. a cta head showed multiple aneurysms at mca/m2. off sedation one hour later she was withdrawing all four extremities with reactive pupils and corneals. she was taken to the neuro icu where she was monitored closely. she was started on dilantin and nimodipine. early morning on she was noted to have a exam change where she was only withdrawing three extremities and a evd was placed. a repeat head ct showed a stable sah and proper evd cath placement. she was taken to angiogram on am. in angio: dr coiled the two larger aneurysms (mca and l m2). the dome of the largest (l m2) is coiled and secured but will need further intervention. the second largest (r mca) is coiled but will need further intervention. the third smaller/stable one (r m2) is not coiled but has a broad neck so wi11 need a stent assisted coiling at a later time. post-angio her sheath was kept in place and removed later in the afternoon. at this time it was noted that she was posturing with all four extremities. her evd was functioning and her icps were less than 10. pupils were symmetric and reactive. we did a repeat head ct that remained stable with diffused cerebral edema. sedation was held and after an hour her exam improved to were she localized briskly with lue, withdraws briskly the ble, but the rue had no movement. overnight, she was monitored closely with no other incident. on her wbc was elevated with a temperature spike. a bronchoscopy was discussed but deferred for concern for her unsecured aneurysm by the icu team, but has been approved by neurosurgery. her cardiac enzymes continue to trend down. an echo was done which showed an ef > 50%. tcds were done which were normal. on she remained stable throughout the day. initially it appeared her rue was weaker but then improved in the afternoon. tcd was normal. overnight there were intermitted times when her evd would stop draining and her icps would elevate to 25. her drain was flushed with normal saline distally and proximally then dropped down to -5, the evd would then drain and continue to do so. this occurred about three times overnight. a head ct was obtained as a planning measure for tpa. mannitol 25gm iv was given x1 and her profolol was increased. no tpa was given overnight. on her evd continued to drain, her csf was clear. her exam remained stable. during her icu course she continued to have intermittent low grade fever and cultures as of have been negative. she was extubated on but did not tolerate it and required to be reintubated withing 40 minutes. on tcd showed possible vasospasm of r mca with velocities 111. cta was performed which was consistent with evolving infarctions in the paramedian frontal lobes, in the anterior cerebral artery territories, and in the lateral left frontal lobe, in the middle cerebral artery territory. there was stable subarachnoid hemorrhage with associated sulcal effacement. the patient failed extubation due to stridor and possible upper airway obstruction and was re intubated within 40 mins of extubation without difficulty. on the patients exam was stable. she was making brief eye contact . the left upper extremity was purposeful and localized briskly. the right upper extremity fluctuated moving on the bed spontaneously verses withdrawal, the bilateral lower extremities moves spontaneously and intermittently withdrew to painful stimulus, the pupils were consistently reactive on : the patient's exam was stable. a tcd was performed which was consistent with moderate to severe spasm. the ivfluid was increased to 75cc/hr. lenis were performed which were negative. the patient spiked a fever to 101.5 and the sub clav central line was changed to picline. the icp was 8 most of the day. the evd was at 10 draining 5-10cc/hr. a csf culture was sent. on : the patient was pan cultured in early am for a t max of 102. the tcd stable (moderate spasm). the cta head was consistent with no interval change.the famotidine discontinued as the tube feedings were at goal. there was some question of seizure activity (spasm of lue) a 20 min eeg was performed which showed no seizure activity. the sbp goal was increased to 140-160 which was maintained all day given her tcd report. when the patient was sleeping in the afternoon she required a vasopressor gtt to keep the sbp 140-160. on she remained febrile and required a cooling blanket. given her fevers, extubation was held. her evd was raised from 10 to 15 without any increase to her icps. tcd showed moderate spasm to the l mca. she went to angio on to evaluate her vessels. a coil was migrating to the r mca so a stent was placed and she was started on plavix. her exam remained stable. on she remained febrile but her exam remained stable. her evd was raised to 20 and was tolerated overnight. she was also placed on propofol for aggitation with et tube. there was no extubation of the ett due to copious thick white secretions sputum culture and mini-bal which was consistent with gram negative rods, gram positive cocci)the patient was started on a ventilator assited pneumonia bundle -- which includes:vanco/cefep/tobra. on , the evd was clamped and patient's exam remained stable. she has increased secretions. on , the evd continued to be clamped. the intercranial pressures were normal. the head ct was consistent with no developing hydrocephalus or midline shift. the transcranial dopplers were normal and did not show vasospasm. on : the evd was discontinued and 2 staples were placed for skin closure. a cerebral spinal fluid sample was sent for culture, gram stain negative with no growth to date. the patient was extubated. the old evd incsion staples placed on were removed. on exam, the patient opened her eyes spontaneously, moved all extramities purposfully/antigravity/ equally but did not follow commands. the pupils were equal and reactive. the hematocrit was stable at 24.8 with a hgb or 8.3. on , a head ct was performed that was overall stable, showing a small amount of air within the ventricular system, attributable to evd removal. ventricular size was stable and there was no evidence of hemorrhage. overall the patient's neurological exam improved and she was sitting up in a chair. physical therapy and occupational therapy were consulted. on lower extremity doppler ultrasounds were done bilaterally for screening and demonstrasted no evidence of dvt. pt/ot and speech were consulted during her stay. pt/ot recommended acute rehab. pt continued on tubefeeds as indicated by nutrition. she failed her speech and swallow eval and remained on tubefeeds. her nimodopine was discontinued. she went to the neurointerventional suite for stent assisted coiling of her r mca aneurysm. post operatively she was transferred to the icu for further care. on the evening of the 10th she was bradycardic wihtout known cause. she aslo had a seven second pause. this is currently being observed without further episode. she underwent a ct of the torso to r/o retroperitoneal bleed - this was negative. she was transferred to the step down unit on on telemetry with ongoing screen for rehap placement. she was seen by endocrine for a low tsh. their recommendations were to follow this up as an outpt and this level is likely due to her icu stay and medications, repeat tsh is recommended in 6 weeks along with a tpo and anti thyroglobulin antibodies. medications on admission: none discharge medications: 1. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 2. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 3. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for constipation. 4. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 5. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 30 days. 7. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 8. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 9. 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. 10. 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. 11. morphine sulfate 2-4 mg iv q4h:prn pain 12. aspirin 325 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: hospital - discharge diagnosis: subarachnoid hemorrhage intraventricular hemorrhage hydrocephalus post op pyrexia increased intercranial pressure pulmonary edema respiratory failure right ica terminus aneurysm 6.1 x 6.9 cm. right mca bifurcation 6.2 x 4.1 cm. / with daughter sac left mca bifurcation daughter sac 4.8 x 4.4 cm, and the more superior parent sac measured 5.3 x 6.3 cm. terminal left ica infundibulum dysphagia incontinence 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: angiogram with embolization and/or stent placement medications: ?????? take aspirin 325mg (enteric coated) once daily . continue plavis 75mg for one month ?????? 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. ?????? 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 followup instructions: ??????please call ( to schedule an appointment with dr. , to be seen in 4 weeks. ?????? you will not need imaging at this time please follow up in six weeks with your primary care provider to follow up and recheck your thyroid studies as you appeared to be hyperthyroid. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Injection or infusion of platelet inhibitor Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Arteriography of cerebral arteries Arteriography of cerebral arteries Closed [endoscopic] biopsy of bronchus Cranial or peripheral nerve graft Insertion of one vascular stent Unilateral thyroid lobectomy Percutaneous angioplasty of intracranial vessel(s) Procedure on single vessel Procedure on vessel bifurcation Percutaneous insertion of intracranial vascular stent(s) Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils Central venous catheter placement with guidance Insertion or replacement of external ventricular drain [EVD] Diagnoses: Obstructive hydrocephalus Tobacco use disorder Subarachnoid hemorrhage Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Cerebral aneurysm, nonruptured Cerebral edema Ventilator associated pneumonia Acute edema of lung, unspecified Acute respiratory failure following trauma and surgery Postprocedural fever

allergies: medroxyprogesterone / ethoxzolamide / codeine / demerol / keflex attending: chief complaint: chronic type b aortic dissection, vasovagal syncope over the summer. major surgical or invasive procedure: : 1. ultrasound-guided puncture of bilateral common femoral artery. 2. bilateral placement of catheter into aorta. 3. thoracic aortogram. 4. endo graft repair of thoracic aortic dissection using 40 x 15, 40 x 10 and 34 x 10 and 31 x 10 endoprosthesis. 5. perclose closure of bilateral common femoral arteriotomies. history of present illness: this 82-y.o. female has been followed for a type b aortic dissection. this occurred in . there has been some enlargement of the descending thoracic aorta proximally due to aneurysmal enlargement and vascular surgery has been following her for continued enlargement. she told dr. she suffered what sounds like lacunar stroke over the summer and this has been complicated by some memory deficit and some occasional seizures. she was in a skilled nursing facility and is currently at the facility and will be home to independent living relatively soon. she had a followup ct scan done which showed areas that have increased in size. past medical history: type b aortic dissection hypertension hypercholesterolemia paroxysmal atrial fibrillation dysphagia with esophageal stricture cva with seizures vs vasovagal syncope hiatal hernia gastritis irritable bowel syndrome migraines memory loss ? dementia psh: bladder suspension social history: retired, lives alone in . quit tobacco use 10 years ago - 20-pack year history; no etoh at current time. family history: non-contributory. physical exam: general: well-developed, well-nourished elderly female in no acute distress. uses walker for ambulation. skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur 1/6sem abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: none varicosities: superficial neuro: grossly intact pulses: femoral right/left: 2+ dp right/left: 1+ pt /left: 0 radial right/left: 2+ carotid bruit right/left: none pertinent results: 11:20am pt-16.7* ptt-27.4 inr(pt)-1.5* 01:40pm freeca-1.16 01:40pm hgb-10.7* calchct-32 01:40pm glucose-109* lactate-1.1 na+-139 k+-3.8 cl--102 03:18pm pt-17.5* ptt-36.7* inr(pt)-1.6* 03:18pm plt count-148* 03:18pm neuts-58.0 lymphs-30.8 monos-8.2 eos-2.7 basos-0.3 03:18pm wbc-4.3 rbc-3.10* hgb-9.4* hct-28.4* mcv-92 mch-30.4 mchc-33.1 rdw-16.1* 03:18pm calcium-8.4 phosphate-3.2 magnesium-1.7 03:18pm glucose-118* urea n-21* creat-0.8 sodium-141 potassium-3.9 chloride-107 total co2-29 anion gap-9 cardiac echocardiogram: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened and myxomatous. there is moderate bileaflet mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. carotid ultrasound: bilateral mild plaque with 1-39% ica stenosis. right vertebral artery was not seen. normal left vertebral flow. no prior studies available for comparison. chest cta: (dr. read) partially thrombosed type b aortic dissection, this extends from just distal to the subclavian artery to the level of the renal arteries. entire distal thoracic and abdominal portion is thrombosed. there is one patent area of the false channels in the upper chest. a small fenestration can be seen in the membrane feeding this patent area of the false channel. this area has enlarged from 4.5 to 5.3 cm since her last scan six months ago. brief hospital course: pt admitted for below reason 1. chronic type b aortic dissection involving the thoracic and abdominal aorta. 2. thoracic aortic aneurysm secondary to #1. she underwent a: procedures: 1. repair of descending thoracic aortic aneurysm with thoracic aortic stent grafting. stent graft data: stent graft #1 is a tag, catalog number , batch code number . second graft is a tag graft, catalog number , batch code . third graft is a tag graft, catalog number , batch code . fourth graft is a tag graft, catalog number , batch code . 1. thoracic and abdominal aortography. 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 pacu for further stabilization and monitoring. she was then transferred to the vicu for further recovery. 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 to a rehabilitation facility in stable condition. to note she did have post operative fevers. multiple cultures, cxr's etc were obtained. vre in urine cx. treatment with linazolid po x 5 days. received prbc for hypotensive post operatively. hct stable on dc. patient also had some post operative confusion. geriatric saw pt. changed some medications. post operative sicu psychosis. medications on admission: norvasc 2.5mg qd, celexa 30mg qd, keppra 500mg , prilosec 40mg qd, simvastatin 20mg qd, vitamin d 400 qd, prednisone 5mg qd, coumadin 3mg qd (last dose ? or 23), labetolol 100mg , ferrous sulfate 325mg qd, tums 500mg discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. hydrocortisone acetate 1 % ointment sig: one (1) appl rectal tid (3 times a day) as needed for rectal discomfort. 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. acetaminophen 325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain/fever. 7. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm: inr goal is . 8. labetalol 100 mg tablet sig: three (3) tablet po bid (2 times a day). 9. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. levetiracetam 500 mg tablet sig: 0.5 tablet po bid (2 times a day). 12. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 13. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 14. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 15. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 16. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 17. amlodipine 2.5 mg tablet sig: one (1) tablet po daily (daily). 18. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: healthcare of discharge diagnosis: type b proximal thoracic aortic dissection with associated aneurysm. penetrating ulcer of the thoracic aorta. discharge condition: stable. 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: scan phone: date/time: 11:45 provider: , md phone: date/time: 12:30 Procedure: Diagnostic ultrasound of heart Aortography Endovascular implantation of graft in thoracic aorta Diagnoses: Other iatrogenic hypotension Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Atrial fibrillation Unspecified transient mental disorder in conditions classified elsewhere Diaphragmatic hernia without mention of obstruction or gangrene Other late effects of cerebrovascular disease Infection with microorganisms without mention of resistance to multiple drugs Epilepsy, unspecified, without mention of intractable epilepsy Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Dissection of aorta, thoracoabdominal Syncope and collapse Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Stricture and stenosis of esophagus Irritable bowel syndrome Memory loss

allergies: medroxyprogesterone / ethoxzolamide attending: chief complaint: type b dissection major surgical or invasive procedure: none history of present illness: 81 y-o lady presents as transfer from with diagnosis of type b aortic dissection. she presented to on following an episode of syncope and chest pain at home. on arrival to ed she was in af with rapid ventricular response - she was immediately given beta blockers for rate control. troponins peaked at 0.09. she was admitted to the icu and started on coumadin. other diagnoses upon admission included a uti and a left lower lobe presumed pneumonia. over the course of her stay at , the patient had complaints of decreased appetite and vague abdominal pain. her lfts were elevated on arrival, and her transaminases were in the 600 and 700 range. a ruq ultrasound of her gb was obtained and was negative for cholecystistis. a cta of her chest and abdomen were obtained yestereday and showed a type b aortic dissection that started just distal to the left subclavian takeoff and extended to just above the level of the renal arteries. per report, the true aortic lumen supplies the mesenteric and celiac arteries. however, based on the patient's consistently rising lfts, there is concern that the dissection may now be extending into the celiac artery. the patient was therefore transferred to for bp control and for potential intervention of the patient's type b dissection. at the current time, the patient reports no chest pain or leg pain. she denies a history of claudication. she has vague abdominal pain and has had decreased appetite over the past week. she is no longer nauseated and has not been vomiting in the past 72 hours. she reports that her bp normally runs 150-200 systolic. past medical history: htn, hyperlipidemia, dysphagia w/esophageal stricture, hiatal hernia, gastritis, ibs, migrains social history: quit tobacco use 10 years ago - 20-pack year history; no etoh at current time family history: non-contributory physical exam: on admission vs: t 99.3, r bp 140/72, l bp 132/68; hr 90; rr 16, 96% 3l gen: nad, a&o x 3 neck: supple, no bruits lungs: clear b/l, no wheezes cv: rrr, nl s1 and s2, no m/r/g abd: soft, nt, nd, no masses, no gaurding, no rebound ext: no c/c/e vasc: fem dp pt r 2+ 1+ 2+ d l 2+ 1+ 2+ d pertinent results: 07:31pm blood wbc-9.6 rbc-3.24* hgb-10.7* hct-31.4* mcv-97 mch-32.9* mchc-34.0 rdw-13.1 plt ct-220 02:04am blood wbc-10.9 rbc-2.85* hgb-9.4* hct-26.6* mcv-93 mch-32.9* mchc-35.2* rdw-15.3 plt ct-189 03:13am blood wbc-13.6* rbc-3.00* hgb-9.7* hct-27.8* mcv-93 mch-32.4* mchc-34.9 rdw-14.5 plt ct-294 03:00am blood wbc-9.7 rbc-2.82* hgb-9.0* hct-26.3* mcv-94 mch-31.9 mchc-34.1 rdw-13.8 plt ct-307 07:31pm blood glucose-161* urean-19 creat-0.6 na-133 k-3.8 cl-95* hco3-28 angap-14 02:04am blood glucose-130* urean-25* creat-0.6 na-133 k-4.1 cl-102 hco3-21* angap-14 03:00am blood glucose-107* urean-20 creat-0.6 na-131* k-3.8 cl-100 hco3-24 angap-11 07:31pm blood alt-667* ast-1233* ld(ldh)-490* alkphos-389* amylase-57 totbili-2.4* 12:32pm blood alt-282* ast-216* alkphos-225* amylase-113* totbili-1.4 03:00am blood alt-128* ast-104* alkphos-218* amylase-51 totbili-0.9 12:32pm blood lipase-188* 03:00am blood lipase-27 03:00am blood calcium-8.1* phos-2.8 mg-1.9 12:32pm blood tsh-0.93 12:45pm blood ammonia-14 03:13am blood hapto-148 03:35am blood hbsag-negative hbsab-negative hbcab-negative hav ab-positive . imaging: ct abd pelvis: conclusion: direct comparison with the outside study is difficult due to lack of intravenous contrast on the outside examination. 1. type b aortic dissection with extension of the dissection into the upper abdomen. the false lumen is partially thrombosed in its course in the chest and almost completely thrombosed in its course in the upper abdomen. 2. the celiac artery, superior mesenteric artery, and the renal arteries arise from the true lumen. the hepatic arteries are patent in their visualized course. although these are not assessed in their entirety and a doppler ultrasound of the liver would help clarify further if there is continued suspicion for abnormal hepatic flow. 3. large bibasal effusions with atelectasis at the lung bases, more marked on the left. 4. a 23 x 19 mm hyperdense cyst at the lower pole of the left kidney should be further assessed with a dedicated renal ultrasound. . us of gallbladder: impression: no liver lesions seen. no gallstones identified and no biliary dilatation. patent portal vein and patent hepatic artery. . ct of head: impression: old right cerebellar infarct and likely small vessel ischemic disease. if clinical concern persists for acute event, consider mr imaging. no evidence for intracranial hemorrhage. . mri of head: impression: limited study with only diffusion and t1 sagittal images acquired. no acute infarct seen. . echo: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened and myxomatous. there is moderate bileaflet mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. bileaflet mitral valve prolapse with moderate mitral regurgitation. mild pulmonary hypertension. . carotid us: impression: bilateral mild plaque with 1-39% ica stenosis. right vertebral artery was not seen. normal left vertebral flow. no prior studies available for comparison. . ct abd and pelvis: impression: 1. no evidence of retroperitneal hemorrhage. 2. stable bilateral pleural effusions. 3. diverticulosis without evidence of diverticulitis. 4. intimal flap in the descending aorta, consistent type b aortic dissection, which cannot be completely evaluated on this non-contrast study. brief hospital course: assessment and plan: this is a 81 f transferred from osh for management of a type b aortic dissection. now w/ transaminitis, clearing mental status, anemia of unknown etiology and fever. . # fever: had a low-grade fever on admission. per osh report, was treated for a pna and uti in the past week. no focal signs/sx of infection per patient (denies cough, diarrhea). did spike a temperature while here but likely from a femoral line infection. the line was removed and she did not have any fevers 24 hours after the removal. did have slightly positive ua, even after foley was discontinued. femoral line was removed, and tip sent for culture. no significant growth from tip yet. cxr from shows pleural effusions but no clear infiltrate. . # type b aortic dissection: dissection is distal to lsc and extends to renal arteries. she was transferred to transaminitis and concern for celiac artery involvement. per vascular surgery, the plan is for medical management. transaminitis may have been from hypoperfusion or secondary to heavy tylenol use at home. did not appear to be hypoperfusing from scans done here. stopped tylenol and monitored lfts. they went down and will be monitored as outpatient. no clear answer but has stabalized. we will continue labetolol bp control, patient well controlled. . # htn: goal systolic bp 130-150 for control of the type b dissection. was initially monitored on iv medicines in the icu, but was eventually weaned off iv meds and started on labetolol and lisinopril. patient has been close to goal and stabalized on meds. . # anemia: normocytic. unclear . s/p 3 u prbc since admission, 2 units on and 1 u . did seem to bump hct appropriately after her transfusion. per the nursing report, no gross blood after disimpaction. per patient, had a colonoscopy 2 years ago that was wnl. guaiac negative. no signs of bleeding or rp bleed on ct scan. still does not have known source of blood loss. the patient should be monitored as an outpatient and likely will need a colonoscopy. she was on heparin for her afib during this time, which may be contributing to the blood loss from her colon or somewhere else. she will be discharge on coumadin. . # transaminitis: from hypoperfusion vs. possible gallstone pancreatitis. looking at labs, did not quite have high enough lipase to really be a gallstone pancreatitis, but this transient elevation could be from the passing of a stone. transaminitis was resolving on discharge. hepatitis a total antibody was positive. as an outpatient, if transaminitis persists can consider sending test for igg and igm hepatitis a. # paroxysmal afib: had some afib with rvr while in the icu. was stabalized with iv beta blocker. currently in sinus. given infarcts on ct head, is at high risk for strokes. continue labetolol. was bridged on heparin because of this high risk of stroke, and was started on coumadin on . does not need to be bridged as the risk of stroke is low once discharge to rehab. please continue coumadin treatment and check inr daily until therapeutic in 1.5-2.0 range and then adjust coumadin as needed. . # ? nstemi: by report, trops elevated at osh but this was in the setting of afib w/ rvr. no focal wma on echo. currently w/o cp. continue statin, asa, labetalol w/ goal hr < 70. likely was not an nstemi, but troponin leak from rvr stress. . # hypoxia: mostly around 93% on 2l. went down to 90% on room air. did have large bilateral pleural effusions on ct chest from . ? from atelectasis. also treated recently for pna. repeat cxr showed small bilateral effusions with possible atelectasis. plan is to ambulate patient and encourage incentive spirometry, in hopes that her oxygenation will improve. was not on o2 before admission. she worked with pt and did not require any oxygen and had appropriate ambulatory saturation levels. she can continue o2 as needed for comfort at rehab, and should be easily weaned with is and movement. . # dysphagia: was npo while sick in the icu, advance diet and mental status improved. she has known chronic dysphagia from esophageal strictures. she has been cleared by speech and swallow and will be on solid foods and thin liquids, but will need to remain on aspiration precautions. . # altered mental status: resolved. likely encephalopathy. ct head w/ old right cerebellar infarct and likely small vessel ischemic disease. the encephalopathy was probably multifactorial and improved as her medical problems improved. . # gastritis: continued ppi . . # was for rehabilition as she was severely deconditioned after being in bed for 2 weeks. she should work with pt and increase her strength and independent ambulation with hopes of eventually being independent at home again. medications on admission: asa 81 famotidine 40 simvastatin 10 tylenol 650 mom 30 colace 100" melatonin 1 reglan 10 lisinopril 40 metoprolol 100" discharge medications: 1. influen tr-split vac (pf) 45 mcg/0.5 ml syringe sig: one (1) ml intramuscular asdir (as directed). 2. pneumococcal 23-valps vaccine 25 mcg/0.5 ml injectable sig: one (1) ml injection asdir (as directed). 3. warfarin 2.5 mg tablet sig: one (1) tablet po once a day. 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 9. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. lisinopril 30 mg tablet sig: one (1) tablet po daily (daily). 12. labetalol 300 mg tablet sig: one (1) tablet po tid (3 times a day). 13. enoxaparin 30 mg/0.3 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours): 30mg q 12 hours. 14. saline nasal 0.65 % aerosol, spray sig: one (1) spray nasal five times a day as needed for dry nose/mouth. discharge disposition: extended care facility: house nursing & rehabilitation center - discharge diagnosis: type b aortic dissection fever of unknown etiology hypertension normocytic anemia transaminitis hypoxia paroxysmal atrial fibrillation discharge condition: stable discharge instructions: you were brought into the hospital with an aortic dissection. vascular surgery evaluated you, and medically managed you by controlling your blood pressure. it is important that you take your blood pressure medications daily. please see your primary care physician or go the emergency room if you have chest pain, light headedness, shortness of breath, or back pain. followup instructions: please call your primary care doctor from rehab for an appointment within one week. Procedure: Enteral infusion of concentrated nutritional substances Diagnoses: Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Fever, unspecified Encephalopathy, unspecified Dissection of aorta, unspecified site Dissection of other artery

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: neurosurgery requested consult from neurology to take over the care of mr . major surgical or invasive procedure: none history of present illness: mr was transferred from center on for an intracranial bleed. mr is a 79-year-old right handed man with atrial fibrillation previously on coumadin (and asa). according to dr. note (because the patient is currently intubated and ventilated), he had a history of multiple falls, and he presented to center on with left hip and leg pain. there was no reported head trauma. on he was found to be confused, speaking nonsensical words, and his brain imaging showed a hemorrhage in the left lateral ventricle. his inr was 1.9, and he received vitamin k, and 1u of ffp. he was then transferred to , where he was admitted to neurosurgery. past medical history: -lung cancer (underwent left sided lobectomy 25 years ago) -atrial fibrillation -hyperlipidemia -hypertension social history: social hx: drinks 2 scotches daily, non-smoker family history: unknown physical exam: o: t:100.8 bp: 130/69 hr: 86 propofol at 30 mcg (off for 10 min prior to examination), given dilantin 1 g ac/0.4/20/5 (98%) gen: intubated, ventilated, c-spine collar on (neck has not been cleared) lungs: cta bilaterally. cardiac: irregular. s1/s2 abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: unable to assess. cranial nerves: anisocoria r>l, r 4--->3 mm, l 3---->2mm, eyes rolling upwards when he started to seize dolls eyes could not be assessed as neck has not been cleared positive corneals and nasal tickle, weak gag motor: increased tone and rhythmic twitching 0.5-1 hz in the arms, legs, and trunk throughout (previous episode at 14:30 h) sensation: no withdrawal from noxious stimuli reflexes: b t br pa ac right 1 1 1 1 0 left 1 1 1 1 0 toes equivocal b/l pertinent results: 10:35pm blood wbc-9.1 rbc-4.18* hgb-13.7* hct-38.4* mcv-92 mch-32.7* mchc-35.5* rdw-13.7 plt ct-205 10:35pm blood neuts-87.6* lymphs-8.8* monos-3.4 eos-0.1 baso-0.1 10:35pm blood pt-21.1* ptt-29.7 inr(pt)-2.0* 10:35pm blood glucose-163* urean-20 creat-1.0 na-136 k-3.7 cl-99 hco3-26 angap-15 03:33am blood alt-13 ast-24 ld(ldh)-243 alkphos-70 totbili-0.9 10:35pm blood calcium-9.9 phos-3.1 mg-1.7 07:15am blood triglyc-165* hdl-31 chol/hd-6.6 ldlcalc-140* 04:20pm blood tsh-0.83 04:20pm blood free t4-1.5 01:53am blood vanco-13.0 06:12am blood digoxin-0.5* aldosterone, lc/ms/ms 4 renin pending brief hospital course: transferred to neurology icu team: 1. eeg 11/ 30 to 12/ 02: negative for seizures. dc'd pht. he was on etoh withdrawal. 2. af: *off ac, but started asa 81 qd on 12/ 01. *rate control was difficult: on metoprolol, diltiazem, and digoxin, 3. htn: difficult to control: on clonidine, labetalol, hctz, amlodipine, plus the above mentioned agents. required a ntg drip for 2 hours on 12/ 09/ 08 4. id: uti (u cx ecoli pansensitive) was treated and resolved. in addition, he had an aspiration pna (rul)treated for 7 days. sputum cx: gram positive cocci in pairs and clusters. started on nafxillin 2 g q6h on 12/ 03 (evening), stopped vancomycin and zosyn on 12/ 04). 5. extubated (12/ 04) 6. dvt ppx: on hep sc 5000 tid started on 12/ 01. 7. contact family: health care proxy confirmed he is full code this 79 yo man was admitted with bilateral intraventricular hemorrhage to the icu intubated. his icu course was complicated by pna and uti that were treated with full courses of antibiotics. his icu course was also complicated by persistent htn and tachycardia. cardiology was consulted and his rate and bp were controlled with a panoply of pharmacological agents, which were eventually titrated to an oral regimen that could be administered on the general floor. efforts to elucidate secondary causes of htn were unrevealing. once transferred to the general floor, he remained afebrile and his bp and hr remained well controlled. his lipid panel was elevated and so his dose of home pravastatin was increased. per discussion with both his family and pcp, history of multiple falls recently precludes him from re-starting his coumadin despite his af. his neurological exam on discharge was notable for ongoing disorientation, mild right nlf flattening, moving all ext antigravity, though probably with some weakness r > l, upgoing toes bilaterally, and able to transfer from bed to chair with max assist, but unable to functionally ambulate. medications on admission: coumadin 3mg pravastatin 20mg lisinopril (dose unclear) verapamil 240mg bisoprolol 5mg aspirin 81mg omeprazole 20mg 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. 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 4. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 5. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. 8. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 9. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 10. metoprolol tartrate 50 mg tablet sig: 2.5 tablets po tid (3 times a day). 11. hydrochlorothiazide 12.5 mg capsule sig: two (2) capsule po daily (daily). 12. clonidine 0.1 mg tablet sig: one (1) tablet po tid (3 times a day). 13. diltiazem hcl 60 mg tablet sig: one (1) tablet po qid (4 times a day). 14. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 15. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). 16. digoxin 125 mcg tablet sig: one (1) tablet po once a day. 17. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: discharge diagnosis: intraventricular hemorrhage sleep apnea discharge condition: stable discharge instructions: you have had a bleed into your brain ventricles, and your coumadin was stopped. because of your history of recurrent falls, it will not be restarted. please return to the er if you experience any sudden weakness, change in sensation, vision, or language, any severe headaches, vertigo, or anything else that concerns you seriously. followup instructions: provider: , md phone: please follow-up with your pcp 1-2 weeks of discharge. provider: , .d. phone: date/time: 2:00 provider: , md , md (sleep clinic) phone: date/time: 8:00am location: neurology Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Insertion of endotracheal tube Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Alcohol detoxification Transfusion of other serum Diagnoses: Obstructive sleep apnea (adult)(pediatric) Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Other convulsions Alcohol abuse, unspecified Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Methicillin susceptible pneumonia due to Staphylococcus aureus Other encephalopathy Anticoagulants causing adverse effects in therapeutic use Hyperosmolality and/or hypernatremia Fall from other slipping, tripping, or stumbling Delirium due to conditions classified elsewhere History of fall Benign essential hypertension Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Other musculoskeletal symptoms referable to limbs Dysphagia, oral phase

allergies: lipitor / metoprolol attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass graft x1 (lima-lad) past medical history: past medical history: -diabetes type i -orif of right wrist -s/p fasciotomy of left leg for compartment syndrome -s/p fractured calcaneus c/b prolonged healing period -diabetic retinopathy s/p laser surgery ou -basal cell cancer from left lower extremity -hypertension -hypercholesterolemia -retinal hemorrhage x2 after laser surgery social history: caucasian rn on . lives in with partner. non-. rare etoh family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; father died of lung cancer in 50's, uncle had cad in 60's. pertinent results: intra-op echo findings left atrium: no spontaneous echo contrast is seen in the laa. right atrium/interatrial septum: normal interatrial septum. left ventricle: overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. : normal ascending diameter. simple atheroma in descending . 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. 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. conclusions pre-procedure: no spontaneous echo contrast is seen in the left atrial appendage. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic . 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 pericardial effusion. post-procedure: the patient is in sr on no infusions. preserved biventricular systolic fxn. no ai, no mr. . i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 14:51 brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent cabgx1 (lima-lad). overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. cefazolin was used for surgical antibiotic prophylaxis. pod 1 the patient was extubated, alert and oriented and breathing comfortably. the patient was neurologically and hemodynamically stable on no inotropic or vasopressor support. pateint reports depression and profound hypoglycemia with beatblockers so, diltiazem was started. ms. 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 and was cleared for discharge to home. ms. developed hematuria on pod#3. she notified the surgical team on pod#4. she had mild right sided low back pain that she thought was musculoskletal which was relieved with percocet. she denied dysuria. renal ultrasound was negative. her urinalysis was postive and she was started on cipro course. her hematuria improved but did not completely resolve on pod#5. she remained afebrile with a wbc 4.9. she was cleared for discharge to home by dr. on pod#5 in good condition, ambulating freely with appropriate follow up instructions. her sternal wound was healing well without drainage or redness. her niaspan was not resumed due to her risk of hypoglycemia per her endocrinologist. medications on admission: asa 325', diltiazem 120', lantus 12u qam, novolog ss, lisinopril 20', lorazepam 0.5mg q6/prn, mvi, niaspan 1500', plavix 75', pravastatin 40' discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. 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* 5. 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* 6. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 7. 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* 8. lantus 100 unit/ml cartridge sig: sixteen (16) units subcutaneous once a day. disp:*1 cartiridge* refills:*2* 9. furosemide 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*5 tablet(s)* refills:*0* 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. disp:*10 tablet(s)* refills:*0* discharge disposition: home with service facility: home care discharge diagnosis: hypertension, hyperlipidemia,s/p stents rca , lcx , insulin dependent diabetic with insulin pump, diabetic retinopathy- s/p laser surgery ou complicated by retinal hemorrhage x2 , anemia of chronic disease, s/p orif r wrist ', s/p fasciotomy rle compartment syndrome, s/p fractured calcaneus c/b prolonged healing, s/p excision of basal cell carcinoma of left lower extremity discharge condition: alert and oriented ambulation independently sternal incision clean and dry. no leg incision- no 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 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. on at 1pm. please call to schedule appointments with your primary care dr. in weeks cardiologist dr. in weeks you have a wound check in 2 weeks on . Procedure: Single internal mammary-coronary artery bypass Diagnostic ultrasound of heart Transfusion of packed cells Diagnoses: Anemia of other chronic disease Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Percutaneous transluminal coronary angioplasty status Long-term (current) use of insulin Hematuria, unspecified Background diabetic retinopathy Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled

allergies: penicillins attending: chief complaint: right knee pain major surgical or invasive procedure: - right above the knee amputation and removal of hardware history of present illness: ms. is a 67 year old woman with a right chronic displaced periprosthetic distal femur fracture infected nonunion withright foot chronic draining foot ulcer who has elected to undergo a right above the knee amputation. past medical history: dm, cri on dialysis, cad, ^chol, htn, urostomy, colostomy social history: n/c family history: n/c physical exam: at the time of discharge: avss nad wound c/d/i without erythema brief hospital course: the patient was admitted on and, later that day, was taken to the operating room by dr. for a right above the knee amputation and removal of hardware without complication. please see operative report for details. postoperatively the patient was admitted to the icu for hypotension. she was transiently on pressors. the patient was initially treated with a pca followed by po pain medications on pod#1. the patient received iv antibiotics for 24 hours postoperatively, as well as coumadin for dvt prophylaxis starting on the morning of pod#1. the drain was removed without incident on pod#1. the foley catheter was removed without incident. the surgical dressing was removed on pod#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. the patient was followed by the nephrology and dialysis services and underwent hemodialysis as an inpatient. on pod1 the patient became hypotensive after hemodialysis and responded to and iv fluid bolus. she was transferred to the floor on pod2. while in the hospital, the patient was seen daily by physical therapy. labs were checked throughout the hospital course and repleted accordingly. at the time of discharge the patient was tolerating a regular diet and feeling well. the patient was afebrile with stable vital signs. the patient's hematocrit was stable, and the patient's pain was adequately controlled on a po regimen. the operative extremity was neurovascularly intact and the wound was benign. the patient was discharged to home with services or rehabilitation in a stable condition. the patient's weight-bearing status was nonweight bearing. medications on admission: amaryl 4, asa, ativan 1, compazine 5, lantus 16 hs, neurontin 100 tid, nexium 40, nitrostat, zofran, plavix, tylenol, vicodin discharge medications: 1. gabapentin 100 mg capsule sig: one (1) capsule po tid (3 times a day). 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*80 tablet(s)* refills:*0* 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable 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. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 6. warfarin 1 mg tablet sig: 1.5 tablets po once daily at 4 pm: inr goal 1.5 - 2.0 for 3 weeks. inr to be followed by , . disp:*20 tablet(s)* refills:*2* discharge disposition: extended care facility: commons discharge diagnosis: right chronic displaced periprosthetic distal femur fracture infected nonunion with right foot chronic draining foot ulcer discharge condition: stable discharge instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. please follow up with your pcp regarding this admission and any new medications and refills. 3. resume your home medications unless otherwise instructed. 4. you have been given medications for pain control. please do not operate heavy machinery or drink alcohol when taking these medications. as your pain improves, please decrease the amount of pain medication. this medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. you may not drive a car until cleared to do so by your surgeon or your primary physician. 6. please keep your wounds clean. you may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. no dressing is needed if wound continues to be non-draining. any stitches or staples that need to be removed will be taken out in clinic 2 weeks after your surgery. 7. please call your surgeon's office to schedule or confirm your follow-up appointment at 2 weeks. 8. please do not take any nsaids (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. anticoagulation: please continue coumadin with an inr goal of 1.5-2.0. after completing the coumadin, please take aspirin 325mg twice daily for an additional three weeks. 10. wound care: please keep your incision clean and dry. it is okay to shower after pod#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. check wound regularly for signs of infection such as redness or thick yellow drainage. staples will be removed in clinic in 2 weeks. 11. vna (once at home): home pt/ot, dressing changes as instructed, wound checks. 12. activity: nonweight bearing on the operative leg. no strenuous exercise or heavy lifting until follow up appointment. followup instructions: provider: , md phone: date/time: 1:30 md Procedure: Hemodialysis Amputation above knee Removal of implanted devices from bone, femur Diagnoses: Hyperpotassemia Other iatrogenic hypotension Anemia in chronic kidney disease Renal dialysis status Coronary atherosclerosis of native coronary artery Acute posthemorrhagic anemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Ulcer of other part of foot Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Knee joint replacement Nonunion of fracture Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Colostomy status Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft Other artificial opening of urinary tract status Other mechanical complication of other internal orthopedic device, implant, and graft

allergies: patient recorded as having no known allergies to drugs attending: addendum: htn: mr was hypertensive to 180/100, we has restarted on his home dose of lisinopril and given lasix (20mg po) for ongoing diuresis. ongoing bp medication titration may be needed. delirium: the patient remains disoriented to hospital name and date. however he has continued to improve since extubation and is able to respond to questioning coherently. thought to be secondary to residual sedation medication (received fentanyl and dilaudid post extubation) and icu delirium discharge disposition: extended care facility: - md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Fiber-optic bronchoscopy Endoscopic sphincterotomy and papillotomy Arterial catheterization Endoscopic insertion of stent (tube) into bile duct Endoscopic insertion of stent (tube) into pancreatic duct Diagnoses: Unspecified essential hypertension Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Alkalosis Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Delirium due to conditions classified elsewhere

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bile leak major surgical or invasive procedure: 1) ercp 2) bronchoscopy history of present illness: 62yo m pod#2 s/p lsc ccy at transferred for management of suspected bile leak. he had an otherwise uncomplicated ccy after presenting to the ed with biliary colic. his post-operative course was notable for increased abdominal pain. he began to show peritoneal signs with increased distention today. a ruq ultrasound at mt. a was inconclusive, and a hida was performed today which showed contrast leaking to the gallbladder fossa and the peritoneal cavity as well as transit to the small bowel. given the anticipated need for urgent intervention, including ercp and likely percutaneous drain placement, mr. was transferred to . prior to transfer, he had been receiving both toradol and dilaudid for pain. he was started on flagyl and levofloxacin. his vital signs were stable prior to transfer. he had an ngt and a foley placed. he was made npo. he currently feels like his pain is well-controlled. he denies cp, but does have abdominal pain with deep inspirations. past medical history: pmh: htn, hyperlipidemia psh: lsc ccy social history: unemployed, used to work on computers. drinks ~1 glass wine/night, denies tobacco or illicits. family history: nc physical exam: on admission: gen: nad, appears slightly somnolent but interactive cor: slightly tachycardic, normal s1 and s2, no m/r/g lungs: ctab abdomen: obese, distended and somewhat firm. ttp throughout but particularly ruq. no rebound, mild anticipatory guarding. bs absent. le: nt, ne pertinent results: admission labs: 09:30pm wbc-14.3* rbc-3.95* hgb-12.9* hct-37.1* mcv-94 mch-32.7* mchc-34.9 rdw-13.2 09:30pm neuts-93.6* lymphs-3.9* monos-2.1 eos-0.4 basos-0.1 09:30pm plt count-192 09:30pm pt-13.5* ptt-25.2 inr(pt)-1.2* 09:30pm glucose-157* urea n-22* creat-0.9 sodium-137 potassium-3.7 chloride-96 total co2-35* anion gap-10 09:30pm alt(sgpt)-44* ast(sgot)-34 alk phos-57 amylase-54 tot bili-5.9* dir bili-3.3* indir bil-2.6 09:30pm lipase-27 . . ct abdomen/pelvis small amount of fluid and air in gallbladder fossa, which could be from recent cholecystectomy. small amount of perihepatic fluid and small amount of fluid tracking along the right paracolic gutter into the pelvis which could be consistent with a bile leak. small hiatal hernia. small right sided pleural effusion with adjacent compressive atelectasis. . cxr : low lung volumes with increased vascular diameter, cardiomegaly, widened mediastinum. atelectasis at right base. no pleural effusions or consilidations. ett 6cm above carina. ngt in place. brief hospital course: 62m pod #3 s/p cholecystectomy at osh, complicated by bile leak, transferred to for ercp from . the ercp on showed a bile leak from the cystic duct. a sphincterotomy was performed with placement of biliary and pancreatic duct stents. the ercp service recommends repeat for removal of stents in three weeks. his aspirin and plavix were held, and should restart . during his mac sedation he had a hypoxic event likely due to aspiration. he was empirically started on levofloxacin and flagyl. flagyl was discontinued on . as of he is stable and ready for transfer back to . medications on admission: medications: lisinopril 10mg po qd lipitor 10mg po daily aspirin 81mg po daily multivitamin daily . medications on transfer discharge medications: 1. albuterol 0.083% neb soln 1 neb ih q6h:prn shortness of breath or wheezing 2. levofloxacin 500 mg iv q24h 3. famotidine 20 mg iv q12h 4. furosemide 40 mg iv once 5. hydromorphone (dilaudid) 0.25 mg iv once discharge disposition: extended care facility: - discharge diagnosis: bile leak status post laparoscopic cholecystectomy discharge condition: per receiving facility, is alert and responsive on discharge discharge instructions: patient being transferred to for continuation of care (dr. , surgical service) followup instructions: resume previous care md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Fiber-optic bronchoscopy Endoscopic sphincterotomy and papillotomy Arterial catheterization Endoscopic insertion of stent (tube) into bile duct Endoscopic insertion of stent (tube) into pancreatic duct Diagnoses: Unspecified essential hypertension Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Alkalosis Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Delirium due to conditions classified elsewhere

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: osteoarthritis left knee, morbid obesity, and scarred fibrosis of the skin late effect of motor vehicle accident left knee. major surgical or invasive procedure: 1. excision of previous skin graft in preparation of recipient flap site left knee. 2. local flap mobilization left knee. 3. free vascularized right latissimus dorsi myocutaneous flap to anterior and lateral aspect of left knee. 4. application long-leg splint. 5. primary plastic closure latissimus dorsi donor site (greater than 50 cm). history of present illness: ms. is a 68 year old lady with severe osteoarthritis. she has had total knee replacement with an excellent result on the right side and wished very much to have one on the left side. problem here was soft tissue. within the past few years she was involved in a pedestrian motor vehicle accident and sustained a loss of tissue on the anterior and lateral aspect of her left leg. this was treated initially with a skin graft i believe at the . she has been evaluated by her joint surgeons who correctly noted that a total knee replacement on the left side "would be perilous and indeedquite unsuccessful unless she had adequate soft tissue coverage". past medical history: lv hypertrophy/diastolic dysfunction dyslipidemia htn obstructive sleep apnea h/o nph s/p vp shunt placement obesity (s/p gastric banding ) gerd osteoarthritis depression social history: tobacco use in the past. denies alcohol use. family history: non-contributory physical exam: pre-procedure pe per anesthesia record : wt-240 lbs pulse-->57/min b/p-->140/58 o2sat-->93% general: wd overweight mental/psych: a/o airway: as documented in detail on anesthesia record dental: good head/neck range of motion; free range of motion, no carotid bruits heart: rrr lungs: clear to auscultation abdomen: soft obese nt extremities: no ankle edema; extensive scarring on left knee, left pedal pulses non palp but present w/doppler other: neck supple, no cerv lad pertinent results: 08:38pm glucose-171* urea n-13 creat-0.8 sodium-142 potassium-4.2 chloride-109* total co2-25 anion gap-12 08:38pm estgfr-using this 08:38pm calcium-8.1* phosphate-4.0 magnesium-1.7 08:38pm wbc-11.5*# rbc-4.16* hgb-12.0 hct-36.9 mcv-89 mch-28.8 mchc-32.5 rdw-13.9 08:38pm plt count-293 brief hospital course: the patient was admitted to the plastic surgery service on and had a right latissimus dorsi myocutaneous free flap to left knee. the patient tolerated the procedure well. . immediately post operative, she was admitted to the surgical intensive care unit for flap monitoring. the patient did quite well on her first post operative day with good vioptix data and reassuring physical exam. she was called out to the floor, but had a 7 beat run of non-sustained vt in the icu. she received magnesium sulfate and remained in a normal sinus rhythm after that. she was kept in the icu an additional night and transferred to the floor on pod 2. . on postoperative day 3, she was transitioned to oral pain medications. she was slow to mobilize and her foley remained in place. she worked with physical therapy to get up and out of bed. . she continued with pt throughout the remainder of her hospitalization. her foley catheter was removed on pod 5. . prior to discharge she had a thermoplastic splint palced by ot to allow knee to stay in 20-25 flexion at rest. . neuro: post-operatively, the patient received dilaudid iv/pca with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications. . 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: post-operatively, the patient was given iv fluids until tolerating oral intake. her diet was advanced when appropriate, which was tolerated well. she was also started on a bowel regimen to encourage bowel movement. foley was removed on pod#5. intake and output were closely monitored. . id: post-operatively, the patient was started on iv cefazolin, then switched to po cephalexin on pod#6. the patient's temperature was closely watched for signs of infection. . prophylaxis: the patient received subcutaneous lovenox during this stay, and was encouraged to get out of bed with assistance as early as possible. . at the time of discharge on pod#6, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. the patient is being discharged to a rehabilitation facility to continue her aggressive physical therapy. medications on admission: 1. atenolol 2. celexa 3. ranitidine 4. simvistatin 5. valsartan discharge medications: 1. aspirin 81 mg tablet, chewable sig: 1.5 tablet, chewables po daily (daily) for 30 days. 2. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, ha, t>100 degrees: max 4000mg/day. 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 5. atenolol 50 mg tablet sig: one (1) tablet po daily (daily): hold if sbp < 100 hr < 60. 6. valsartan 160 mg tablet sig: one (1) tablet po daily (daily): hold if sbp < 100 . 7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for moderate to severe pain: max 12/day. max 4000mg tylenol/day. 8. enoxaparin 30 mg/0.3 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours) for 30 days. 9. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). 10. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 12. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 13. keflex 500 mg capsule sig: one (1) capsule po every six (6) hours for 14 days: needs keflex for as long as drains remain in. discharge disposition: extended care facility: at discharge diagnosis: 1. osteoarthritis left knee. 2. morbid obesity. 3. scarred fibrosis of the skin late effect of motor vehicle accident left knee. 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: followup instructions: -you should continue taking the antibiotics as prescribed. -elevate your left leg as much as possible and maintain it in a splint. -please keep your left leg dry - if your left leg begins to worsen after discharge with an acute increase in swelling or pain, please call dr. office. . drains: 1. you have two drains to care for and to measure output from. 2. clean around the drain site(s), where the tubing exits the skin, with hydrogen peroxide. 3. strip drain tubing, empty bulb(s), and record output(s) times per day. 4. a written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. you may shower daily. no baths until instructed to do so by dr. . . drain discharge instructions you are being discharged with drains in place. drain care is a clean procedure. wash your hands thoroughly with soap and warm water before performing drain care. perform drainage care twice a day. try to empty the drain at the same time each day. pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. record the amount of drainage fluid on the record sheet. reestablish drain suction. . 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 do not take these meds with additional tylenol. * 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 softerner 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 follow up with dr. in 1 week. please call his office to schedule an appointment for a follow up visit: ( md Procedure: Reconstruction of eyelid with tarsoconjunctival flap Radical excision of skin lesion Full-thickness skin graft to other sites Diagnoses: Obstructive sleep apnea (adult)(pediatric) Esophageal reflux Unspecified essential hypertension Personal history of tobacco use Depressive disorder, not elsewhere classified Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Morbid obesity Osteoarthrosis, unspecified whether generalized or localized, lower leg Presence of cerebrospinal fluid drainage device Heart disease, unspecified Late effects of motor vehicle accident Scar conditions and fibrosis of skin

allergies: no known allergies / adverse drug reactions attending: chief complaint: left sided weakness major surgical or invasive procedure: none history of present illness: hpi: the pt is a 86 y/o man who presents as a an osh transfer for iph med flight to ed. here he was intubated and had sedation over the flight. history gathered from wife over telephone. she states that he was in perfect health with no complaints, was outside clearing ice around the house with no problems. this a.m around am she heard a thump and went to go see that he was lying on the floor of the bathroom with slurred speech (lying on his left side?) she called ems and he was taken to an osh. at the osh per verbal secondary report he had slurred speech and spontaneous movement of the rue. he had a bp of 189/83. past medical history: hyperthyroid ?bph? glaucoma - social history: lives with wife. retired. family history: per wife no history of head bleeds physical exam: general: intubated sedated. heent: nc/at, no scleral icterus noted, neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: rhonchi b/l cardiac: rrr, nl. s1s2, soft early systolic murmur abdomen: soft, nt/nd extremities: no edema bilaterally, 2+ dp pulses bilaterally. skin: multiple cherry angiomas and skin tags neurologic: -mental status: intubated gcs 1-1-4. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm. iii, iv, vi: dolls eye ok. -motor: normal bulk. tone increased in left ue, and b/l le's some withdraw to pain. right side more then left. -sensory: withdrew all 4 limbs to pain stimuli -dtrs: pat ach l 2 2 0 r 2 0 0 plantar response were mute bilaterally. pertinent results: 04:25pm tsh-2.2 04:25pm t3-72* 04:25pm phenytoin-9.0* 04:25pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 12:55pm urine color- appear-cloudy sp -1.025 12:55pm urine blood-lg nitrite-neg protein-75 glucose-tr ketone-150 bilirubin-neg urobilngn-neg ph-8.0 leuk-tr 12:55pm urine rbc-* wbc-* bacteria-many yeast-none epi-0 12:55pm urine 3phosphat-few 09:07am rates-/14 tidal vol-600 peep-5 o2-100 po2-514* pco2-40 ph-7.38 total co2-25 base xs-0 aado2-178 req o2-38 intubated-intubated 08:28am type- ph-7.30* comments-green top 08:28am glucose-148* lactate-1.4 na+-141 k+-4.3 cl--103 tco2-26 08:28am freeca-1.09* 08:25am urea n-23* creat-0.8 08:25am estgfr-using this 08:25am wbc-11.5* rbc-4.16* hgb-13.3* hct-38.7* mcv-93 mch-31.9 mchc-34.4 rdw-12.8 08:25am plt count-198 08:25am pt-12.7 ptt-22.1 inr(pt)-1.1 08:25am fibrinoge-330 brief hospital course: the pt is a 86 y/o man who presents with right frontal iph. etiology unknown but given edema suggestive of underlying process rather then purely secondary to uncontrolled hypertension. we have asked that neurosurgery get involved as this may be amenable to drainage. we will otherwise cont with medical management. ct head demonstrated a large r frontal iph 5.3 x 3.4 cm, no significant midline shift, no evidence of transtentorial herniation : admitted to ticu. l radial a-line placed. rpt ct head showed stable hemorrhage. : sedation off, extubated. frequent suctioning, coughing, not much clearing of ms. at 1800 for poor cough, airway protection, depressed ms reintubated. neuro aware. on cpap 5/5 at 40%, ett 23 at lip. uop 2 hours prior midnight ~ 5 cc, bolused 1l lr, maintenance changed to 100 cc lr/hr. : uop 25 cc in early am. mri head performed, demonstrated multiple infarcts making a secondary bleed into an ischemic area more likely. the small bilateral punctate infarcts are suspicious for a central, embolic source. a meeting was held and the family expressed pt would want cmo. pt extubated and made cmo and passed away on . medications on admission: methimazole 5mg daily xalatan ou daily. discharge medications: deceased discharge disposition: expired discharge diagnosis: deceased discharge condition: deceased discharge instructions: deceased followup instructions: deceased Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Diagnoses: Unspecified essential hypertension Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Intracerebral hemorrhage Cerebral edema Other conditions of brain Flaccid hemiplegia and hemiparesis affecting unspecified side

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain, fevers, chills, and mid diarrhea. major surgical or invasive procedure: : ercp with sphincterotomy, stone and biliary sludge removal and pancreatic stent placement. : laparoscopic cholecystectomy history of present illness: ms. is a 72 year old female who was admitted yesterday to hospital for abdominal pain, fevers, chills, and mid diarrhea. she had a which was concerning for cholecystitis and she was treated with ertapenem. she had a rising t. bili today to 5, so she was transferred to hopsital for ercp. during the ercp, she was found to have a ampullary polyp. she also developed a. fib with rvr to 140s, thoug her blood pressure remained stable. she was sent to the ed where she received diltiazem 10 mg iv boluses x 2 and then was started on a diltiazem drip. . in the ed, initial vital signs were hr of 80 on diltiazem drip at 10 mg/hour, bp 96/46, rr 18, 99% on 2l nc. she was given unasyn for treatment of cholecystitis. she was given morphine for abdominal pain that she states is similar to prior episodes of pancreatitis. she was given diltiazem 30 mg po and diltiazem drip was stopped as patient was in nsr. additionally, she expressed frustration with being transferred to multiple hopsitals over the day and requested to leave ama, however, she was convinced to stay. . upon arrival to the floor, patient reports mild epigastric pain which is improved with morphine. she denies fevers, chills, diarrhea, chest pain, chest pressure, weight loss, weight gain, shortness of breath, cough. past medical history: hypertension diabetes diastolic dysfunction asthma social history: patient lives alone, but her daughter is nearby and she occasionally stays with her daughter. she denies alcohol or tobacco use. family history: there is no family history of liver, gallbladder, or pancreas diseases. physical exam: on admission: vitals: afebrile, hr 67, bp 124/42, 98% on 2lnc general: no acute distress heent: sclera icteric, oropharynx clear neck: supple, jvp not elevated lungs: crackles at right base, otherwise clear cv: regular rate and rhythm, normal s1 + s2, +2/6 systolic murmur at rusb, abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, negative sign gu: no foley ext: warm, well perfused, 2+ pulses, trace pedal edema on discharge: vs: 98.1, 72, 140/88, 18, 94% ra general: awake and alert, nad heent: nc/at, sclera icteric, neck supple, oropharynx clear heart: rrr with rare pacs lungs: ctab abdomen: normal post surgical tenderness along incisions, otherwise soft, non-distended. bs x 4. gu: no foley ext: warm, positive peripheral pulses 2+, trace pedal edema. pertinent results: 07:40pm blood wbc-8.0 rbc-3.89* hgb-10.6* hct-32.9* mcv-85 mch-27.1 mchc-32.1 rdw-13.6 plt ct-201 07:40pm blood pt-12.5 ptt-24.1 inr(pt)-1.1 07:40pm blood glucose-102* urean-17 creat-0.8 na-141 k-3.6 cl-102 hco3-27 angap-16 07:40pm blood alt-241* ast-255* ck(cpk)-372* alkphos-164* totbili-5.2* 02:01am blood albumin-3.2* calcium-9.2 phos-3.8 mg-1.7 08:50pm urine blood-lg nitrite-neg protein-neg glucose-neg ketone-50 bilirub-sm urobiln-4* ph-5.0 leuks-neg 08:50pm urine rbc-* wbc-0-2 bacteri-occ yeast-none epi-0-2 07:30am blood wbc-5.1 rbc-4.04* hgb-11.1* hct-35.2* mcv-87 mch-27.4 mchc-31.5 rdw-14.1 plt ct-298 07:30am blood glucose-76 urean-8 creat-0.7 na-141 k-4.1 cl-107 hco3-22 angap-16 07:30am blood alt-70* ast-38 alkphos-92 amylase-49 totbili-0.8 07:30am blood lipase-76* : echocardiography the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef 70-80%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. there are focal calcifications in the aortic arch. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the left ventricular inflow pattern suggests impaired relaxation. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion brief hospital course: ms. is a 72 year old female with htn, diastolic chf, asthma, admitted to osh with gnr bacteremia with cholesytitis, cholangitis, and gallstone pancreatitis, transferred to following unsuccessful ercp complicated by a. fib with rvr. 1. gnr bacteremia. likely source of gnr bacteremia is cholecysitis/cholangitis. patient's bp remained stable though patient was initially tachcyardic in setting of a. fib with rvr, now resolved with diltiazem. cultures done at osh revealed e.coli sensitive to cipro & unsasyn. she was continued on unasyn and cipro for double gn coverage. surgery co-managed this patient, who underwent successful ercp on during which a gallstone was removed, resolving biliary obstruction. on patient underwent laparoscopic cholecystectomy. post surgery patient's wbc was within normal range, patient was afebrile. she was discharged home without any antibiotic coverage. . 2. cholecystitis/cholangitis. patient admitted to osh with elevated lfts, abdominal pain, and sono consistent with cholecystitis. given that lfts were consistent with an obstructive picture, an ercp was performed on . source of gnr bacteremia was thought to be from a biliary source. the patient was continued on antibiotics as above, and was transferred to surgery once stable for further management. on patient underwent laparoscopic cholecystectomy. surgery was done without complications. post surgery patient was continue on antibiotics. wbc was normal. . 3. pancreatitis. likely sedcondary to gallstone pancreatitis. she was initially hydrated with ivfs, kept npo, and her pain managed with morphine. her lipase was downtrending. on patient underwent laparoscopic cholecystectomy. surgery was done without complications. post surgery patient's diet was advanced slowly to regular/diabetic, patient tolerated diet well. patient's liver enzymes were normal prior disharge, her lipase was slightly elevated. . 4. a. fib with rvr. paroxysmal and recurrent. pt reports yrs of palpitations. developed a.fib with rvr in setting of procedure, which resolved initially after diltiazem drip and continuation on diltiazem 30 po but returned x5hrs on floor, with spontaneous return to sr. given patient's chads score of 3, she may be a candidate for anticoagulation and should be scheduled with pcp to discuss this further. with diltiazem 30mg po patient heart rate continue to be sinus rhythm with occasional pacs. patient was started on aspirin 325 mg po qday and her diltiazem was converted to diltiazem er 240mg po qday per cardiology recommendation. patient will have a follow up with cardiologist on regarding further a-fib management. . 5. htn. anti-hypertensives were held in the setting of cholangitis/cholecystitis. patient's bp was closly monitored during hospital stay and her sbp was 120s-150s. patient was instructed to restart all her home anti-hypertensive medication after discharge and follow up with her pcp for further management. . 6. asthma. continued home advair, and given prn nebs. . 7. diabetes. kept on hiss and monitored fingersticks. on discharge was started on diabetic diet with low carbohydrates. she did not require exogenous insulin at discharge. . 8. diastolic chf. cardiomegaly on cxr. echo demonstrated elevated lv filling pressures with preserved ef (70-80%) and no wall motion abnormalities. per patient, she was told she had a "large heart" following her first pregnancy at age 26. during hospitalization patient didn't demonstrate any symptoms of chf exacerbation. lung x-ray was grossly normal, patient has trace lower extremities edema. patient denies sob or doe. patient will follow-up with cardiology as an outpatient. . at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a diabetic regular diet, ambulating, voiding without assistance, and pain was well controlled. she was discharged with vna services. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: medications on admission: aspirin 81 mg po qday lisinopril 20 mg po qday singular 10 mg po qday advair 250/50 hydrochlorothiazide 25 mg po qday proair hfa 90 two inalation rn prilosec 20 mg po qday fosamax 70 mg po qweek discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 3. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po once a day. disp:*30 capsule, sustained release(s)* refills:*2* 4. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 5. singulair 10 mg tablet sig: one (1) tablet po once a day. 6. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 7. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 9. proair hfa 90 mcg/actuation hfa aerosol inhaler sig: two (2) inhalation four times a day as needed for shortness of breath or wheezing. 10. fosamax 70 mg tablet sig: one (1) tablet po once a week. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for fever or pain. 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* discharge disposition: home with service facility: multicultural vna discharge diagnosis: 1. gallstone pancreatitis. 2. cholecystitis/cholangitis discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: general discharge instructions: 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, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. 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 steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. followup instructions: 1. provider: , md phone: date/time: 1:00. 3, . 2. please folow up with your pcp 2 weeks after discharge. 3. provider: , md phone: date/time: 10:20 am. 7, cardiology Procedure: Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Laparoscopic cholecystectomy Endoscopic insertion of stent (tube) into bile duct Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Asthma, unspecified type, unspecified Sepsis Cholangitis Acute pancreatitis Chronic diastolic heart failure Septicemia due to gram-negative organism, unspecified Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction

allergies: keflex / ciprofloxacin attending: chief complaint: b/l le edema and non healing ulcers, now awaiting icd placement by ep major surgical or invasive procedure: 1. ultrasound-guided puncture of right common femoral artery. 2. contralateral second-order catheterization of the left common femoral artery. 3. abdominal aortogram. 4. serial arteriogram of the left lower extremity. 5. right second toe amputation, open. 6. left fourth toe amputation, open. 7. debridement of bilateral venous stasis ulcerations. 8. single chamber icd implantation history of present illness: mr. is a 74 yo male with known long standing dm ii, and chronic non-healing ulcers of the le's bilaterally. patient has several ulcers of the anterior tibias, calves and dorsum of the feet. patient states that he recently had an open aortic valve replacement at in (porcine). after this, he was sent to a cardiac rehab where he was noted to have worsening le edema and ulcers of the calves and shins. these were debrided and unaboots were applied to the legs. on removal of the unaboots, there was worsening of the ulcerations and the toes became more discolored. he has a history of pvd, and underwent lle angiogram with left at angioplasty in by dr. . he most recent nivs showed b/l tibial disease. on the day of admission, he came from wound care clinic where his affected toes were noted to be black and bleeding and he was admitted to the vascular service. . while on the vascular service he was felt to have non healing ulcers, necrotic toes and likely venous insufficency. he was started on vanco, cipro, and flagyl. he underwent angiography on which revealed severe pvd and bilateral lower extremity ischemia with gangrene. the decision was made to observe for improvement while on antibiotics. . patient had a witnessed syncopal episode and was found to be immediately non-responsive, pulseless. a cold blue was called. cpr was initiated. initial rhythm strip in code showed v. fib and patient was shocked x1. received 1 dose epi, and 2 grams magnesium for prolonged qt and possible torsades. patient was intubated for airway protection and to allow for vascular access to be obtained as he was agitated. femoral line was placed. initial ecg post-code showed no st/t changes c/w ischemia. patient was transferred to icu for management. . ep was consulted and felt that his arrest was most likely secondary to underlying familial prolonged qt syndrome in setting of fluoroquinolone use, so ciprofloxacin was stopped. his antibiotic regimen was changed to vancomycin and meropenem. there were no deep tissue cultures to tailor therapy but tissue swabs grew diptheroids, citrobacter, staph, bacteroides. a urine culture from a foley also grew citrobacter. he was rapidly extubated without difficulty. cardiac markers remained negative. was initially bradycardic after resuscitation, although this normalized with discontinuation of propofol sedation and extubation. . his lower extremities did not improve substantially on antibiotics and he underwent right second toe amputation and left fourth toe amputation on . he also had debridement of bilateral venous stasis ulcerations. he was eventually called out of the icu and had an icd placed on . he was then transferred to the medicine service. past medical history: # avr , porcine # cri 1.3 baseline # afib on coumadin # pvd s/p left at pta # cad s/p rca stent , cath on "normal" # dm ii # left acoustic neuroma s/p resection # bcc s/p resection # melenoma s/p resection # s/p 2-toe amputation # s/p pulseless code blue # ? familial long qt syndrome social history: lifelong nonsmoker. no alcohol. retired school teacher. not married. has daughter. family history: no known history of sudden death physical exam: vitals: 98.0, 95, 113/66, 18, 97%ra gen: a+ox3, nad heent: perrl, eomi, op clear, mmm neck: no jvd, supple cv: irregularly irregular, no m/g/r pulm: ctab, no w/r/r abd: soft, nt, nd, +bs. ext: bilaterally pitting edema both legs up to groin. wrapped bilaterally in bandage. left 4th toe and right 2nd toe amputated. dressing c/d/i neuro: cn ii-xii intact. mobilizes all extremities. pertinent results: cxr : since , a left-sided single chamber pacemaker defibrillator was installed ending in the right ventricle. sternotomy for avr was performed. moderate pleural effusion and cardiomegaly persist. volume overload also persists. note that both bases were excluded on the frontal view. the technique is suboptimal, and it is hard to exclude a small right pneumothorax. repeat chest x-ray is recommended if of clinical concern. . echo: the atria are markedly dilated. the estimated right atrial pressure is 10-15mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. the ascending aorta is mildly dilated. a bioprosthetic aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is mild mitral valve prolapse. mild (1+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small circumferential pericardial effusion. impression: dilated right ventricle with mild systolic dysfunction. mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. normally-functioning aortic valve bioprosthesis. moderate tricuspid regurgitation. elevated right atrial pressure. . foot xr: impression: marked soft tissue swelling particularly of the left foot and ankle. there has been a progression of the erosive arthropathy at the second proximal interphalangeal joint. neither foot demonstrates findings suggestive of osteomyelitis. . micro: time taken not noted log-in date/time: 6:19 pm swab site: foot left foot. gram stain (final ): no polymorphonuclear leukocytes seen. 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs. wound culture (final ): 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.. corynebacterium species (diphtheroids). moderate growth. citrobacter koseri. moderate growth. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. staph aureus coag +. quantitation not available. sensitivities performed on culture # (). sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter koseri | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin---------- =>128 r tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r anaerobic culture (final ): mixed bacterial flora-culture screened for b. fragilis, c. perfringens, and c. septicum. bacteroides fragilis group. moderate growth. beta lactamase positive. time taken not noted log-in date/time: 6:19 pm swab site: foot right foot. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs. wound culture (final ): 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.. staph aureus coag +. sparse growth. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. 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. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ <=1 s 10:16 pm swab source: foot. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). wound culture (final ): 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.. staph aureus coag +. sensitivities performed on culture # 268-2432p . anaerobic culture (final ): bacteroides fragilis group. moderate growth. beta lactamase positive. 10:43 pm urine source: cvs. **final report ** urine culture (final ): citrobacter koseri. 10,000-100,000 organisms/ml.. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter koseri | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- =>128 r tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r 2:31 pm stool consistency: loose source: stool. **final report ** clostridium difficile toxin a & b test (final ): reported by phone to @ 5:15a . 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). . . 03:15pm blood wbc-7.9 rbc-2.91* hgb-9.8*# hct-28.5*# mcv-98 mch-33.8* mchc-34.5 rdw-16.6* plt ct-231 07:50am blood wbc-6.7 rbc-2.79* hgb-9.3* hct-27.5* mcv-98 mch-33.3* mchc-33.9 rdw-16.5* plt ct-197 04:40pm blood wbc-9.2 rbc-3.05* hgb-10.4* hct-30.4* mcv-100* mch-34.3* mchc-34.4 rdw-16.2* plt ct-218 04:05am blood wbc-6.7 rbc-2.85* hgb-9.7* hct-27.8* mcv-97 mch-33.9* mchc-34.8 rdw-16.8* plt ct-228 09:25am blood wbc-7.5 rbc-3.22* hgb-10.6* hct-32.2* mcv-100* mch-32.8* mchc-32.8 rdw-16.2* plt ct-252 08:15am blood wbc-9.2 rbc-2.79* hgb-9.4* hct-27.5* mcv-99* mch-33.8* mchc-34.2 rdw-16.1* plt ct-260 09:05am blood wbc-6.1 rbc-2.88* hgb-9.5* hct-28.0* mcv-97 mch-32.9* mchc-33.9 rdw-16.0* plt ct-291 07:40am blood wbc-5.9 rbc-2.86* hgb-9.7* hct-27.9* mcv-98 mch-33.8* mchc-34.7 rdw-15.7* plt ct-279 03:15pm blood neuts-84.0* lymphs-8.2* monos-5.6 eos-1.7 baso-0.5 09:05am blood neuts-69.4 lymphs-17.9* monos-5.5 eos-6.8* baso-0.4 09:25am blood neuts-68.3 lymphs-19.0 monos-5.1 eos-6.8* baso-0.8 03:15pm blood pt-20.4* ptt-36.7* inr(pt)-1.9* 07:50am blood pt-21.5* ptt-39.3* inr(pt)-2.0* 04:40pm blood pt-23.1* ptt-146.7* inr(pt)-2.2* 04:05am blood pt-20.6* ptt-39.5* inr(pt)-1.9* 09:25am blood pt-18.3* ptt-37.6* inr(pt)-1.7* 03:00am blood pt-17.3* ptt-93.1* inr(pt)-1.6* 09:05am blood pt-16.7* ptt-36.4* inr(pt)-1.5* 07:40am blood pt-17.5* ptt-37.5* inr(pt)-1.6* 03:15pm blood glucose-168* urean-45* creat-2.1* na-135 k-4.2 cl-95* hco3-32 angap-12 07:50am blood glucose-119* urean-35* creat-1.8* na-137 k-3.8 cl-98 hco3-34* angap-9 04:40pm blood glucose-180* urean-38* creat-1.9* na-134 k-4.3 cl-94* hco3-31 angap-13 04:05am blood glucose-194* urean-34* creat-1.6* na-134 k-4.3 cl-100 hco3-30 angap-8 09:25am blood glucose-142* urean-34* creat-1.5* na-135 k-4.5 cl-100 hco3-32 angap-8 04:15pm blood glucose-137* urean-32* creat-1.4* na-135 k-4.4 cl-99 hco3-29 angap-11 07:05am blood glucose-141* urean-42* creat-1.5* na-134 k-4.3 cl-99 hco3-26 angap-13 05:40am blood glucose-99 urean-44* creat-1.5* na-132* k-4.4 cl-99 hco3-28 angap-9 09:05am blood glucose-160* urean-41* creat-1.4* na-136 k-4.6 cl-101 hco3-29 angap-11 09:25am blood glucose-107* urean-39* creat-1.4* na-137 k-4.0 cl-101 hco3-31 angap-9 07:40am blood glucose-91 urean-40* creat-1.3* na-139 k-4.0 cl-101 hco3-31 angap-11 06:40am blood alt-24 ast-26 alkphos-182* totbili-1.2 12:32am blood alt-24 ast-45* ld(ldh)-183 ck(cpk)-28* alkphos-190* totbili-1.1 07:00am blood alt-18 ast-26 alkphos-171* totbili-0.9 04:40pm blood ck-mb-3 ctropnt-0.07* 12:32am blood ck-mb-notdone ctropnt-0.07* 04:16am blood ck-mb-notdone ctropnt-0.07* 04:40pm blood ck(cpk)-42 12:32am blood alt-24 ast-45* ld(ldh)-183 ck(cpk)-28* alkphos-190* totbili-1.1 04:16am blood ck(cpk)-28* 11:20am blood vanco-31.8* 09:05am blood vanco-29.1* 09:25am blood vanco-22.0* 07:40am blood vanco-15.7 brief hospital course: # s/p cardiac arrest: per ep, concerning for familial long qt syndrome. genotyping sent. awaiting results. he had a single lead icd placed without complication. he will need to follow up in device clinic and with his new electophysiologist to follow up his long qt genotyping. he will continue on metoprolol 25 mg . he will need electrolytes checked daily while receiving aggressive diuresis and should have his k repleted to >4 and his mg repleted to >2. . # toe gangrene/le ulcers: patient did not improve on antibiotics and therefore underwent debridement and toe amputation. no deep tissue cultures sent so covering broadly with meropenem and vancomycin for a 2 week course for soft tissue infection. he will complete his meropenem and vancomycin on . according to vascular surgery attending, patient did have bone involvement at the time of surgery but he felt that all of the involved bone was debrided so at this time he does not require treatment for osteomyelitis. he will need to follow up with his vascular surgeon dr. in 2 weeks to assess for appropriate granulation and need for further intervention. he will continue wet->dry dressing changes on his r foot and vac dressing on his left foot per vascular and wound care recommendations. he will also receive adaptic/ace on venous ulcers bilaterally. of note, patient had been receiving hyperbaric oxygen treatments as an outpatient and if possible, could continue as an outpatient. . # c diff: diagnosed on stool culture. diarrhea has improved on po flagyl. he has not had any significant fever, leukocytosis, or abdominal pain. he will require 2 weeks of flagyl after completion of his broad spectrum antibiotics. he will therefore complete his flagyl on . . # uti: diagnosed with citrobacter uti. sensitive to meropenem. complicated due to foley. as above, he will complete 2 weeks of meropenem which will treat his uti. unfortunately, his foley could not be removed due to penile and scrotal edema but as he continues to diurese (below) and his swelling improves, his foley should be removed. . # volume overload: patient notes several months of volume overload and weight gain following his avr. unclear cause. echo checked here showed preserved ef. potential contribution of recently decreased lasix prior to admission as well as acute renal failure on admission. he was initially diuresed with iv lasix, starting at 80 mg iv bid and then increased to 100 mg iv bid. he diuresed well (1-2 liters negative/day) and creatinine improved with diuresis. prior to discharge he was transitioned to torsemide 80 mg po bid with good response. he should continue this medication and should have his electrolytes monitored daily to ensure he does not go into renal failure or have significant electrolyte abnormalities. . # acute on chronic renal failure: prior baseline cr of 1.3. on admission, cr 2.1. slowly improved throughout hospitalization. potentially related to volume overload and poor forward flow. this improved with diuresis as above. . # af: history of paroxysmal af. on coumadin as an outpatient. his coumadin was held prior to his vascular surgery and his icd and was restarted at his home dose of 2.5. his inr remained subtherapeutic so his coumadin dose was increased to 5 mg on . he will need inrs checked 3-5 times a week until his inr is stable and therapeutic. . # dm: his glimeprimide was held on admission. he was treated with 8 units of lantus and insulin sliding scale. these were continued on discharge. his glimeprimide can likely be restarted as outpatient. . # cad: he was asymptomatic throughout admission. no evidence of ischemia at the time of his arrest. he was continued on aspirin, beta blocker, statin. medications on admission: klor-con 10meq 2 tabs qd lasix 80 coreg 3.125 vit c 500 vit d fish oil 1200 mvi simvastatin 20 oyster shell calcium 1 tab bactrim ds 1 tab levaquin 750 glimeprimide 1 singulair 1 tab warfarin 2.5 discharge medications: 1. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 4. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). 5. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 6. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 7. torsemide 20 mg tablet sig: four (4) tablet po bid (2 times a day). 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 11. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 12. senna 8.6 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 13. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 14. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 16 days: last day . 15. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 16. insulin glargine 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. 17. insulin aspart 100 unit/ml solution sig: one (1) injection subcutaneous qid per insulin sliding scale: give 6 units for bg 100-149, give 7 units for bg 150-199, give 8 units for bg 200-249, give 9 units for bg 250-299, give 10 units for bg 300-349, give 11 units for bg 350-400. 18. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 19. meropenem 500 mg recon soln sig: five hundred (500) mg intravenous q8h (every 8 hours) for 3 days: last day . 20. vancomycin in dextrose 1 gram/200 ml piggyback sig: 1000 (1000) mg intravenous q48h (every 48 hours) for 3 days: received dose on . next and final dose 3/14. . discharge disposition: extended care facility: - discharge diagnosis: primary: 1. toe gangrene s/p amputation 2. non-healing ulcers of lower extremities 3. cardiac arrest due to long qt syndrome (? familial) 4. acute on chronic diastolic heart failure 5. acute on chronic renal failure secondary: 1. atrial fibrillation 2. diabetes mellitus 3. hyperlipidemia 4. coronary artery disease 5. peripheral vascular disease discharge condition: hemodynamically stable. no sustained vt or icd shocks since icd placement. afebrile. no abdominal pain. diuresing well on po diuretics with stable cr. discharge instructions: you were admitted to the hospital for ulcers and infections of your legs and toes. you received antibiotics and surgery for this problem. during your hospitalization, you had a cardiac arrest. this may be due to an inherited abnormality in the electrical system of your heart. you had an defibrillator implanted to help treat this in case it happens again in the future. you were also diagnosed with an infection in your urine and in your stool. you will take iv antibiotics until and then you will need to continue to take an antibiotic by mouth until . . please follow up with your cardiologist and your vascular surgeon as below. you will need to have your defibrillator interrogated as below. please follow up with your pcp as needed after discharge from rehab. . please continue to take all medications as prescribed. please note the following changes to your regular medications: 1. your coreg has been changed to metoprolol 2. your lasix has been changed to torsemide 3. your glimeprimide has been stopped and you are receiving insulin glargine and insulin sliding scale 4. your warfarin dose has been increased. this will need to be adjusted as an outpatient. followup instructions: please follow up with your vascular surgeon dr. on at 12:15 on , . phone: (. . please follow up with dr. on at 3:20 pm in buidling on . phone: ( . please follow up to have your defibrillator checked: provider: clinic phone: date/time: 9:30 . please follow up with your pcp . after discharge from rehab. phone: . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arteriography of femoral and other lower extremity arteries Amputation of toe Excisional debridement of wound, infection, or burn Aortography Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Nonexcisional debridement of wound, infection or burn Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Paroxysmal ventricular tachycardia Ulcer of other part of foot Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Other specified cardiac dysrhythmias Cardiac arrest Cellulitis and abscess of leg, except foot Long-term (current) use of insulin Intestinal infection due to Clostridium difficile Long-term (current) use of anticoagulants Ventricular fibrillation Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Heart valve replaced by transplant Atherosclerosis of native arteries of the extremities with gangrene Personal history of malignant melanoma of skin Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Venous (peripheral) insufficiency, unspecified Long QT syndrome Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Other drugs and medicinal substances causing adverse effects in therapeutic use Other diuretics causing adverse effects in therapeutic use Ulcer of calf

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass grafting x3 with left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the distal right coronary artery and the obtuse marginal artery. history of present illness: 68 year old male with progressive, exertional chest discomfort over the past 6 months. he reports that he underwent a cardiac catheterization at hospital approximately 8-9 years ago. he is unclear on the specifics of why he had the procedure, but does not believe that he underwent pci.over the past six months he has been bothered by chest discomfort, dyspnea and fatigue. this can occur with walking about one block. in addition, he notices right calf pain with similar amounts of walking.denies edema, orthopnea, pnd, lightheadedness. cardiac workup with his pcp showed an abnormal ett and he was referred for an elective cardiac catheterization , which revealed three vessel coronary disease. cardiac surgery was consulted for evaluation of coronary revascularization. past medical history: hypertension hyperlipidemia diabetes ett: 5 minutes 30 seconds protocol, 89% max phr. + anginal discomfort with exercise. ekg with anterolateral st depression. imaging: moderate in size, severe in intensity territory of inferior reversibility. lvef 55%. chronic renal insufficiency, creatinine 2.4 left eye laser surgery approximately one month ago social history: lives with spouse : none etoh: none in 30 years family history: no family history of premature cad. father died when patient was 5 years old-unknown cause. physical exam: general:nad, alert and cooperative skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally few scattered rhonchi heart: rrr irregular no murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: +1 left:+1 dp right: +1 left:+1 pt : +1 left:+1 radial right: +1 left:+1 carotid bruit right: none left:none pertinent results: 05:10am blood wbc-7.3 rbc-3.67* hgb-10.3* hct-32.6* mcv-89 mch-28.1 mchc-31.7 rdw-14.4 plt ct-310 11:40am blood wbc-7.4 rbc-2.85*# hgb-8.4*# hct-24.8*# mcv-87 mch-29.5 mchc-33.9 rdw-14.6 plt ct-199# 11:40am blood neuts-75.3* lymphs-20.1 monos-2.7 eos-1.5 baso-0.3 05:10am blood plt ct-310 11:40am blood plt ct-199# 11:40am blood pt-14.2* ptt-30.5 inr(pt)-1.2* 11:40am blood fibrino-173 05:10am blood glucose-99 urean-22* creat-1.5* na-141 k-4.9 cl-103 hco3-31 angap-12 12:45pm blood urean-18 creat-1.3* cl-114* hco3-25 05:10am blood mg-2.2 05:59pm blood mg-2.3 radiology report chest (pa & lat) study date of 1:48 pm , fa6a 1:48 pm chest (pa & lat) clip # reason: please do in afternoon - eval for effusion medical condition: 68 year old man with s/p cabg reason for this examination: please do in afternoon - eval for effusion final report two view chest, comparison: . indication: status post coronary artery bypass surgery. pleural effusion assessment. findings: status post median sternotomy and coronary bypass surgery with similar postoperative appearance of cardiomediastinal contours. improving multifocal atelectasis with residual linear atelectasis in the mid and lower lungs. persistent small lateral left pneumothorax as well as bilateral small pleural effusions. retrosternal gas, probably postoperative considering recent surgery. impression: persistent small lateral left pneumothorax and small bilateral pleural effusions. improving multifocal atelectasis. dr. approved: mon 3:36 pm echocardiography report , (complete) done at 10:08:02 am preliminary referring physician information , - department of cardiac s , 2a , status: inpatient dob: age (years): 68 m hgt (in): 65 bp (mm hg): / wgt (lb): 160 hr (bpm): 65 bsa (m2): 1.80 m2 indication: intraop cabg evaluate wall motion, aortic contours, valves icd-9 codes: 424.0 test information date/time: at 10:08 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 #: 2010aw1-: machine: aw2 echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.5 cm <= 4.0 cm left atrium - four chamber length: *5.6 cm <= 5.2 cm left ventricle - septal wall thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.2 cm <= 5.6 cm left ventricle - systolic dimension: 3.6 cm left ventricle - fractional shortening: *0.14 >= 0.29 left ventricle - ejection fraction: 50% to 55% >= 55% left ventricle - stroke volume: 57 ml/beat left ventricle - cardiac output: 3.71 l/min left ventricle - cardiac index: 2.06 >= 2.0 l/min/m2 aorta - annulus: 2.2 cm <= 3.0 cm aorta - sinus level: 3.3 cm <= 3.6 cm aorta - sinotubular ridge: 3.0 cm <= 3.0 cm aorta - ascending: 3.0 cm <= 3.4 cm aortic valve - peak velocity: *2.7 m/sec <= 2.0 m/sec aortic valve - lvot pk vel: 0.80 m/sec aortic valve - lvot vti: 15 aortic valve - lvot diam: 2.2 cm aortic valve - valve area: *2.2 cm2 >= 3.0 cm2 mitral valve - mean gradient: 1 mm hg mitral valve - pressure half time: 84 ms mitral valve - mva (p t): 2.6 cm2 mitral valve - e wave: 0.6 m/sec mitral valve - a wave: 0.7 m/sec mitral valve - e/a ratio: 0.86 findings left atrium: normal la size. elongated la. no thrombus in the laa. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv wall thickness. normal lv cavity size. normal regional lv systolic function. low normal lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal ascending aorta diameter. focal calcifications in ascending aorta. normal aortic arch diameter. complex (>4mm) atheroma in the aortic arch. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no ms. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. physiologic (normal) pr. 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. no tee related complications. conclusions post bypass: left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. there are complex (>4mm) 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 mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post bypass: patient is a paced, on phenylepherine infusion. preserved biventricular function. lvef 55%. mr is now trace. aortic contours intact. remaining exam is unchanged. all findings discussed with surgeons at the time of the exam. i certify that i was present for this procedure in compliance with hcfa regulations. interpretation assigned to , md, interpreting physician cardiology report ecg study date of 2:08:28 pm sinus rhythm. low qrs voltage. non-diagnostic repolarization abnormalities. compared to the previous tracing of qrs voltage is diffusely reduced. read by: , intervals axes rate pr qrs qt/qtc p qrs t 69 162 104 372/387 84 0 -14 brief hospital course: admitted same day surgery and was brought to the operating room for coronary artery bypass graft surgery. see operative report for further details. he received cefazolin for perioperative antibiotics. post operatively he was transferred to the intensive care unit for management. in the first twenty four hours he was weaned from sedation, awoke, and was extubated without complications. he continued to do well and was transferred to the floor. his percocet was stopped due to confusion which resolved. physical therapy worked with him on strength and mobility. he was ready for discharge home with services on post operative day four. medications on admission: atorvastatin - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth every morning diltiazem hcl - (prescribed by other provider) - 300 mg capsule, sustained release - 1 capsule(s) by mouth every morning insulin glargine - (prescribed by other provider) - 100 unit/ml solution - 34 units at bedtime insulin lispro - (prescribed by other provider) - 100 unit/ml solution - 14 units before breakfast, 8 units before lunch, 14 units before dinner isosorbide mononitrate - (prescribed by other provider) - 60 mg tablet sustained release 24 hr - 1 tablet(s) by mouth every morning metformin - (prescribed by other provider) - 850 mg tablet - 1 tablet(s) by mouth twice a day metoprolol succinate - (prescribed by other provider) - 25 mg tablet sustained release 24 hr - 1 tablet(s) by mouth qam quinapril - (prescribed by other provider) - 40 mg tablet - 1 tablet(s) by mouth every morning aspirin - (prescribed by other provider) - 325 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth every morning olmesartan-hydrochlorothiazide - (prescribed by other provider; otc) - 20 mg-12.5 mg tablet - 1 tablet(s) by mouth daily every morning discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. 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* 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic (2 times a day): 1 drop in each eye twice a day . disp:*qs qs* refills:*0* 5. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 6. lopressor 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 7. quinapril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. lasix 20 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 9. insulin glargine 100 unit/ml solution sig: thirty four (34) units subcutaneous once a day. disp:*qs qs* refills:*0* 10. humalog 100 unit/ml solution sig: per scale subcutaneous before each meal : 14 units before breakfast, 8 units before lunch, 14 units before dinner. disp:*qs qs* refills:*0* discharge disposition: extended care facility: tba discharge diagnosis: coronary artery disease s/p cabg hypertension diabetes mellitus type 2 hyperlipidemia chronic renal insufficiency baseline cr 1.9 discharge condition: alert and oriented x2 nonfocal ambulating, gait steady sternal pain managed with tylenol 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: , md phone: date/time: 1:00 please call to schedule appointments primary care dr in weeks cardiologist dr in weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome 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 Other opiates and related narcotics causing adverse effects in therapeutic use Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Long-term (current) use of insulin Drug-induced delirium

allergies: penicillins attending: chief complaint: vt storm major surgical or invasive procedure: defibrillation during cardiac arrest history of present illness: 60 y/o f w/ h/o dilated cardiomyopathy ef 20%, cad and nstemi, s/p bms to lad in , dm, asthma, htn, pulmonary htn, h/o complete heart block, biv icd, who presents with vt storm. patient was recently hospitalized for syncope. during that stay she was found to have complete heart block and biv pacer and icd for primary prevention was placed. prior to this stay patient was in her usoh until this weekend when her icd discharged. patient was seen in device clinic on where her biv icd was interrogated. at that time the device reported two recent episodes of vf one that had been terminated by a 36 joule shock. her k+ was noted to be 3.2. she was given po potassium supplements, po amiodarone 200mg , but diuretics were continued. . over the next 3 days patient had several icd shocks. spoke with dr. who referred patient for admission. patient came to ed by ems. . in the ed, initial vitals: t97.8, bp96/58, hr 88, rr 16, o2 100%ra. patient was seen by ep who interrogated device. felt to have monomorphic vt at 220bpm with 7 shocks in last 3 days. impression was for over diuresis and hypokalemia triggering vt. she was admitted to the ccu for management. . on arrival to the ccu, patient was stable and without complaints. she was given 40meq k+, amiodarone 150mg ivx1. she subsequently had 7-10 episodes of recurrent vt over the next hours. . on review of systems, she 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. she 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: non ischemic cardiomyopathy ef 20-25% diagnosed 14 years ago asthma htn mitral valve regurgitation sleep apnea pulmonary htn hypothyroidism depression/anxiety . cardiac risk factors: -diabetes, dyslipidemia, hypertension . percutaneous coronary intervention, anatomy as follows: left main normal lad gives rise to mod diag, 50% prox and 50% mid lad stenosis left circ 30% ostial stenosis rca dominant. 70-80% stenosis distal rca. run off very good . pacemaker/icd: pt has refused in past social history: patient is single. works part time at library. social history is significant for the absence of current tobacco use. there is no history of alcohol abuse. family history: she has history of premature cad with father having mi in 50s. physical exam: gen: wdwn middle aged male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of *** cm. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: admission labs: 05:30pm blood wbc-10.5 rbc-5.40# hgb-13.0 hct-39.8 mcv-74*# mch-24.0* mchc-32.6 rdw-15.5 plt ct-308 05:30pm blood neuts-74.3* lymphs-15.2* monos-3.5 eos-6.1* baso-0.9 05:30pm blood pt-14.2* ptt-27.4 inr(pt)-1.2* 05:30pm blood glucose-272* urean-36* creat-1.3* na-130* k-3.2* cl-88* hco3-29 angap-16 05:30pm blood ck(cpk)-104 04:53am blood ck(cpk)-274* 05:30pm blood ctropnt-0.19* 04:53am blood ck-mb-7 ctropnt-0.39* 05:30pm blood calcium-10.1 phos-3.7 mg-2.5 05:30pm blood digoxin-3.2* . chest x-ray - report pending brief hospital course: patient is a 60 y/o f w/ dm, dilated non-ischemic cardiomyopathy, cad, p/w vt storm in setting of hypokalemia. her rhythm strips were consistent with torsades. she was admitted to the ccu on the electrophysiology service. she was started on an amiodarone infusion with initial bolus as well as lidocaine infusion. she was given magnesium infusion and her electrolytes were monitored with a goal of k>4 and mg>2.5. at approximately 4:50am, patient was noted to be pulseless and a code was called. pea algorithim was followed -- see code report for details -- and initial impression was for metabolic arrest to hyperkalemia/hypoglycemia or acidemia. she was given bicarbonate, glucose, insulin and calcium in addition to epinephrine/atropine/vasopressin. pulse was intermittently recovered and patient was given ivf's, dopamine and neosynephrine. femoral line was placed for iv access. intubation was complicated by significant amount of aspiration of stomach contents during the code. patient was difficult to oxygenate during the code, but after successful intubation there were no further apparent complications with her airway. bedside echo demonstrated no pericardial effusion/tamponade, and showed a hypocontractile left ventricle. she had symmetric breath sounds, and no apparent evidence of tension pneumothorax. she was shocked for vt x2 by external pacer pads during the code with successful return of underlying rhythm, but without sustained return of her pulse. ultimately, pulse could not be maintained in the face of substantial acidemia, and hypoxemia. lab work demonstrated profound respiratory acidemia with ph < 7.0. she was given bicarbonate acutely and bag ventilation was increased. after 45 minutes of the above the decision was made to terminate the code given prolonged hypoxemia and pulselessness. time of death: 5:37am. healthcare proxy, pcp, care team notified. medications on admission: aspirin 325 mg daily, plavix 75 mg daily, atorvastatin 80 mg daily, buspar 30 mg daily, digoxin 250 mcg daily, estradiol vaginal tablet 25 mcg on monday and thursday, advair diskus one puff every 12 hours, glipizide xl 2.5 mg daily, levothyroxine 50 mcg daily, cetirizine 5 mg daily, albuterol inhaler, metoprolol tartrate 12.5 mg twice daily, pantoprazole 40 mg twice daily, calcium citrate, vitamin d, potassium chloride 20 meq twice daily, prednisone 5 mg daily, spironolactone 25 mg daily, torsemide 20 mg twice daily, venlafaxine 300 mg daily, tylenol as needed, maalox as needed, colace as needed, valium as needed, temazepam as needed for sleep, ultram every four hours 50 mg as needed discharge medications: none, patient expired discharge disposition: expired discharge diagnosis: -non ischemic cardiomyopathy ef 20-25% -cad, h/o mi s/p bmsx2 to lad -complete heart block s/p biv pacer and icd -pulmonary htn -asthma -htn -mitral valve regurgitation -sleep apnea -hypothyroidism -depression/anxiety -recent r-clavicular fracture treated conservatively discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Venous catheterization, not elsewhere classified Insertion of endotracheal tube Insertion of endotracheal tube Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Other primary cardiomyopathies Acidosis Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Other chronic pulmonary heart diseases Hypopotassemia Paroxysmal ventricular tachycardia Dysthymic disorder Acute respiratory failure Old myocardial infarction Chronic systolic heart failure Automatic implantable cardiac defibrillator in situ Unspecified accident Closed fracture of clavicle, unspecified part Other diuretics causing adverse effects in therapeutic use Foreign body in trachea

allergies: penicillins attending: chief complaint: syncope major surgical or invasive procedure: rij placement and removal implantation of internal cardiac defibrillator and biventricular pacemaker history of present illness: 59 f with cad s/p lad bms x 2 on , chf (ef 20%), pulm htn and asthma recently discharged three days ago now presented with lightheadness and syncope. during her last hospitalization, she ruled in for an nstemi and had cath at nebh which showed rca clot. she was transferred to for asa desensitization and cath here showed resolution of the rca clot. there were 70% stenosis of the lad and 2 bms were placed. she also had sob from her asthma and chf and her diuretic regimen was increased from lasix to torsemide. her discharge weight was 137 pounds. . at home, she had been feeling weak and lightheaded for the past 3 days. she also had some mild small volume diarrhea. she took all her medication as prescribed including asa, plavix, torsemide and her antihypertensives. this morning, she felt dramatically lightheaded that she had to close her eyes and lay herself on the kitchen floor. she remembers trying to get up repeated but eventually lost consciousness. when she woke up, she discovered a bruise on her face and had pain in her r shoulder. she was still able to get up and finish her breakfast. she called her neighbors who came over and encouraged her to call her doctor. she took her bp and it was in the 70's. the covering physician encouraged her to come to the ed so she called an ambulance. . in the ed, her initial vitals at triage was listed as 96, 114/90, 88, 100% nc. the blood pressure was thought to be an error since her bp was in the 60s and 70's when she was evaluated. she was given about 2l ns. she was started on dopamine and then neo was added. she got 100 mg iv hydrocortisone. her sbp's were in the 90's. ekg had some deeper std laterally but cardiac markers were not significantly elevated. card's consult saw her in the ed and thought she may be overdiuresed. she had a central line placed and was admitted to the ccu. . she had chest burning consistent with her heart burn but no new chest pain. her right shoulder still has pain. she has sob but could not tell if it is her asthma. she reports that her weight was about 135 pounds at home. she denies palpitations. . ros: denies orthopnea, pnd, peripheral edema. denies abd pain, n/v. + dysuria since discharge. denies hematachezia or brbpr. . past medical history: non ischemic cardiomyopathy ef 20-25% diagnosed 14 years ago asthma htn mitral valve regurgitation sleep apnea pulmonary htn hypothyroidism depression/anxiety . cardiac risk factors: -diabetes, dyslipidemia, hypertension . percutaneous coronary intervention, anatomy as follows: left main normal lad gives rise to mod diag, 50% prox and 50% mid lad stenosis left circ 30% ostial stenosis rca dominant. 70-80% stenosis distal rca. run off very good . pacemaker/icd: pt has refused in past social history: patient is single. works part time at library. social history is significant for the absence of current tobacco use. there is no history of alcohol abuse. . family history: fhx: she has history of premature cad with father having mi in 50s. physical exam: gen: a+ox3, pleasant, nad heent: perrl, eomi, op clear, mmm/. r facial edema and ecchymoses neck: jvp about 10 cm on the left, r ij in neck cv: rrr, ii/vi holosystolic m at apex, no gallops, rubs pulm: ctab, no w/r/r abd: soft, mildly distended, nt, +bs ext: no peripheral edema. neuro: mentating normally, talkative. cn ii-xii intact. mobilizes all extremities. no focal weakness pertinent results: admission labs - 04:30pm blood wbc-15.4* rbc-3.94* hgb-11.1* hct-32.4* mcv-82 mch-28.3 mchc-34.3 rdw-15.2 plt ct-487* 04:30pm blood neuts-83.9* lymphs-7.5* monos-4.4 eos-3.8 baso-0.4 04:30pm blood pt-14.9* ptt-29.4 inr(pt)-1.3* 04:30pm blood glucose-135* urean-40* creat-1.7* na-125* k-7.1* cl-90* hco3-24 angap-18 12:14am blood alt-28 ast-19 ld(ldh)-245 ck(cpk)-62 alkphos-60 totbili-0.6 04:30pm blood ctropnt-0.13* 04:30pm blood albumin-3.9 calcium-9.3 phos-5.4* mg-2.8* 04:30pm blood digoxin-0.8* 04:44pm blood glucose-118* lactate-1.5 na-129* k-4.5 cl-91* calhco3-25 . discharge labs: 05:00am blood wbc-8.2 rbc-3.77* hgb-10.3* hct-31.7* mcv-84 mch-27.2 mchc-32.4 rdw-15.5 plt ct-338 05:00am blood neuts-51.9 lymphs-32.3 monos-5.4 eos-9.9* baso-0.6 04:30pm blood neuts-83.9* lymphs-7.5* monos-4.4 eos-3.8 baso-0.4 05:00am blood glucose-100 urean-21* creat-1.0 na-137 k-4.2 cl-98 hco3-31 angap-12 05:00am blood calcium-9.2 phos-3.1 mg-2.3 imaging ct head impression: 1. right facial soft tissue hematoma, without evidence of underlying fracture or intracranial injury. 2. moderate atrophy of the brain parenchyma is more than expected for the patient's age. 3. hypodensities in the right corona radiata are non-specific, but could be due to chronic small vessel ischemic disease. 4. chronic paranasal sinus mucosal disease, without air-fluid level. ct sinus impression: 1. right facial soft tissue hematoma, without evidence of underlying fracture. 2. mild chronic paranasal sinus mucosal disease again noted. 3. moderate brain atrophy redemonstrated. shoulder films impression: 1. probable distal right clavicular fracture, but evaluation is slightly limited due to overlying catheter. 2. no fracture or dislocation involving the glenohumeral joint. 3. displaced right lateral second rib fracture. cxr: impression: 1. acute fracture of the right second lateral rib. 2. decreased size of small-to-moderate-sized bilateral pleural effusions, left greater than right. 3. cardiomegaly without evidence of congestive heart failure. 4. possible fracture of the distal right clavicle for which clinical correlation is recommended. ct torso impression: 1. distal right clavicle fracture. 2. no evidence of pneumothorax, solid organ injury or extraluminal gas. 4. stable appearance of cardiomegaly. 5. tiny bilateral pleural effusions. 6. multiple calcified fibroids. 7. right renal hypodensity, which is incompletely characterized, but cystic. further imaging with renal ultrasound is recommended. tte: the left atrium is mildly dilated. the right atrial pressure is indeterminate. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated. there is severe regional left ventricular systolic dysfunction with akinesis of the entire septum and inferior wall, hypokinesis of the anterior wall and anterolateral wall, and hypokinesis of the distal inferolateral wall. the basal inferolateral wall contracts best. transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. the mitral valve leaflets do not fully coapt. moderate to severe (3+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the severity of mitral regurgitation is reduced. the other described abnormalities are unchanged. cxr impression: interval worsening of left pleural effusion with complete atelectasis of the left lower lobe. small right pleural effusion with adjacent atelectasis. cardiomegaly without frank volume overload. the study and the report were reviewed by the staff radiologist. renal u/s impression: 1.6-cm mid right renal cyst corresponds to hypodensity seen on ct. cxr findings: in comparison with the earlier study of this date, there has been placement of a new icd extending to the general area of the apex of the right ventricle. bilateral pleural effusions are seen with lower lung volumes. no evidence of pneumothorax. micro data 4:55 pm urine site: clean catch **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ 2 s blood cx x 2, ngtd brief hospital course: 59 f with cad s/p lad bms x 2 on , chf (ef 20%), pulm htn and asthma recently discharged three days ago now presents with syncope and hypotension. . 1. syncope and hypotension. hypotension most likely from combination of overdiuresis and antihypertensive medications as well as infection with leukocytosis and positive ua. she reports weight loss, feeling thirsty and lightheaded for the past three days. this was probably exacerbated by mild diarrhea prior to admission. hyponatremia and arf also consistent with volume depletion. not likely adrenally insufficient since she has been on stable prednisone. arrhythmia, seizure, stroke and hypoglycemia less likely. she was volume resuscitated with 2l ns fluid boluses. in the ed, rij was placed and she was initially on dopamine and neo but dopamine was rapidly weaned off. upon transfer to floor, she was only on low dose neo which was weaned off the following day. uti was treated as below. diuretics and heart failure medications initially held but then cautiously retsarted as below. baseline sbp 80s-90s. . 2. cad. pt had recent nstemi with 70-80% stenosis rca on cath at osh with likley recannulization. here had some lad stenosis last admission now s/p bmsx2. she has been compliant with asa + plavix. no sign of acute stent thrombosis. ekg on admission showed lateral std consistent with strain in setting of hypotension. cardiac markers were not significantly elevated and were flat. continued asa, plavix, statin, cautiously restarted beta blocker. . 3. chronic systolic chf: pt has severe systolic chf with ef 20% with severe lv dilation, severe mr, and pulm htn. upon admission, she was hypotensive and felt to be hypovolemic from possible overdiuresis. she was volume resuscitated with ns x 2l and her heart failure meds and diuretics were slowly reintroduced. she was continued on digoxin (level 0.8 on admission). torsemide was restarted at 20mg then uptitrated to 20mg , captopril started then changed to enalapril 2.5mg which was decreased from 20mg . spironolactone was also restarted. ep was consulted for consideration of icd for primary prevention given low ef. they initially recommended repeat echo in 3 months but then recommended icd as discussed below given development of complete heart block. . 4. complete heart block: pt developed complete heart block on with hypotension sbps 60s and hr 50s. ecg and telemetry c/w complete heart block with junctional escape. block likely infra-his. block resolved spontaneously after approximately 10-15 minutes and bp subsequently improved to sbps 90s. since ep was already consulted for biv icd for chf with low ef, they were asked to re-evaluate patient given new heart block. biv icd was placed without complications. she was continued on clinda x 72 hours post implantation. 5. uti: pt had complaints of dysuria with enteroccocus on urine cx sensitive to vanco and macrobid and ampicillin. she was treated with 5 days of vancomycin. she did not have any fevers in hospital. 6. arf: arf from hypovolemia as above. improved rapidly with volume resuscitation and holding antihypertensives. . 7. rib/clavicle fractures: pain controlled with tylenol prn. she was given sling for comfort and should follow up with dr. in 2 weeks. 8. asthma: currently no wheezing. continued prednisone 5mg daily, advair, inhalers prn. asthma tolerated readdition of beta blocker. . 9. pt had eosinophilia on day of discharge, 9.9%. repeat cbc with diff should be checked as outpatient and workup could be further pursued as outpt. be from asthma. full code medications on admission: 1. buspirone 30 mg tablet sig: one (1) tablet po twice a day. 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 3. venlafaxine 150 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po once a day. 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 6. torsemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 9. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 10. albuterol 90 mcg/actuation aerosol sig: two (2) puffs inhalation four times a day as needed for shortness of breath or wheezing. 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 14. temazepam 15 mg capsule sig: one (1) capsule po hs (at bedtime) as needed. 15. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 16. enalapril maleate 10 mg tablet sig: two (2) tablet po bid (2 times a day). 17. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 18. isosorbide dinitrate 30 mg tablet sig: one (1) tablet po once a day. 19. glipizide 2.5 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. . discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 5. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed. 6. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 7. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 8. buspirone 10 mg tablet sig: three (3) tablet po bid (2 times a day). 9. temazepam 15 mg capsule sig: one (1) capsule po hs (at bedtime) as needed. 10. venlafaxine 150 mg tab,sust rel osmotic push 24hr sig: two (2) tab,sust rel osmotic push 24hr po once a day. 11. levoxyl 25 mcg tablet sig: two (2) tablet po once a day. 12. vagifem 25 mcg tablet sig: one (1) intravaginally vaginal twice a week (). 13. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. disp:*40 tablet(s)* refills:*0* 14. diazepam 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 16. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp< 90. 17. glipizide 2.5 mg tab,sust rel osmotic push 24hr sig: two (2) tab,sust rel osmotic push 24hr po daily (daily). 18. torsemide 20 mg tablet sig: one (1) tablet po twice a day. 19. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 20. enalapril maleate 5 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp < 90. 21. zyrtec 5 mg tablet sig: one (1) tablet po once a day. 22. colace 100 mg capsule sig: one (1) capsule po twice a day. 23. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed. 24. digoxin 125 mcg tablet sig: one (1) tablet po once a day. 25. insulin lispro 100 unit/ml solution sig: sliding scale subcutaneous asdir (as directed) for 5 days: please d/c after 5 days if fs regularly < 150. 26. saline sensitive eyes drops sig: 1-2 drops miscellaneous five times a day. discharge disposition: extended care facility: for the aged - discharge diagnosis: complete heart block acute on chronic congestive heart failure acute renal failure distal right clavicle fracture right facial soft hematoma right second rib fracture discharge condition: stable. discharge instructions: you fell at home and fractured your right clavicle and right ribs. you were dehydrated and had complete heart block. a biventricular pacemaker, internal defibrillator was placed to regulate your heart rate. do not put your left arm over your head for 6 weeks. do not change the dressing over the pacemaker site or get the dressing wet. you can take a bath but no showers until after you are seen in the device clinic. no lifting more than 5 pounds with your left arm for 6 weeks. your blood pressure was low and your kidneys were dehydrated. we stopped your heart medicines and diuretics and your blood pressure and kidney function improved. we slowly restarted your heart medicines. medication changes: 1.tramadol: a medicine for pain to take for fractures 2. torsemide: diuretic. we have decreased this medication from 60mg twice a day to 20mg twice a day. 3. simethicone: a medicine for gas and heartburn 4. pantoprazole: a medicine for gas and heartburn. we have increased this dose from 20mg once a day to 40mg twice a day. 5. metoprolol tartrate: medication to protect your heart. we have discontinued your toprol xl and started this medication. please take 12.5mg twice a day. 6. glipizide: diabetes medication. we have increased this medication from 2.5mg once a day to 5mg once a daily. 7. enalapril: blood pressure medication. we have decreased this dose from 20mg twice a day to 2.5mg twice a day. . weigh yourself every morning, md if weight > 3 lbs in 1 day or 6 pounds in 3 days. adhere to 2 gm sodium diet no fluid restriction . please call dr. if you faint or feel dizzy, have any chest pain, increasing shortness of breath, increasing nausea, increasing redness of swelling around the pacer site, you get a shock from the defibrillator or any other concerning symptoms. followup instructions: electrophysiology: device clinic phone: date/time: 1:00 clinical center, , . . provider: , md phone: date/time: monday at 1:20pm. clinical center, , . cardiology: , md phone: date/time: date/time: 3:00 . primary care: please call dr. after you leave rehab to schedule an appt. . trauma surgery: dr. phone: ( date/time: tuesday at 2:00pm. please get a chest x-ray prior to this visit at clnical center , at 1:00pm. dr. is in the , . use the parking garage next to . . mammography: provider: phone: date/time: 3:15 Procedure: Venous catheterization, not elsewhere classified Application of splint Implantation of cardiac resynchronization defibrillator, total system [CRT-D] Diagnoses: Other primary cardiomyopathies Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Mitral valve disorders Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Long-term (current) use of steroids Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Other chronic pulmonary heart diseases Percutaneous transluminal coronary angioplasty status Dysthymic disorder Atrioventricular block, complete Unspecified sleep apnea Other antihypertensive agents causing adverse effects in therapeutic use Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Closed fracture of one rib Acute on chronic systolic heart failure Syncope and collapse Fall from other slipping, tripping, or stumbling Subendocardial infarction, subsequent episode of care Closed fracture of clavicle, unspecified part Contusion of face, scalp, and neck except eye(s) Other diuretics causing adverse effects in therapeutic use Eosinophilia

allergies: penicillins attending: chief complaint: nstemi; asa desensitization prior to cath major surgical or invasive procedure: cardiac catheterization history of present illness: this is a 59 year-old female with a history of non ischemic dilated cardiomyopathy ef 20-25% followed by clinic at who was admitted to nebh 3/309 with progressively worsening sob since , diaphoresis and chest pain. she was found to be in heart failure with elevated bnp and ruled in for nstemi with troponin i 5.97 peak, ck 212, ckmb 5.1 index 2.4. she was diuresed, started on nitro gtt and heparin gtt and underwent cardiac cath with 2vd with 50% proximal and 50% mid lad stenosis as well as 70-80% stenosis distal rca. heparin gtt d/c'd at 0800. due to reaction of anaphylaxis with asa she was transferred here for asa desensitization and pci. she report continued sob and diaphoresis which has been present since and was precipitaed by flu like illness. she denies any current chest pain buit has had intermittent epigastric discomfort typically relieved with maalox. she reports exertional dyspnea, pnd, orthopnea. symptoms have been progressive x months but acutely worsened 1 week prior to transfer one day after lasix dose decreased from 80 to daily ad dig stopped concern for dig toxicity. also has had dietary indiscretion with poor po intake but eating low sodium soup and saltines. . echo at osh: lv markedly dilated, severe global hk, ef 20-25%, dilated, rv mildly enlarged, rv fxn mildly impaired, ra mildly enlarged, moderate mr, mild-mod tr, small left pleural effusion. . on review of systems, report subjective fevers, diaphoresis, decreased po intake, nausea and vomiting. denies diarrhea, sob, cp, palpitations. past medical history: non ischemic cardiomyopathy ef 20-25% diagnosed 14 years ago asthma htn mitral valve regurgitation sleep apnea pulmonary htn hypothyroidism depression/anxiety . cardiac risk factors: -diabetes, dyslipidemia, hypertension . percutaneous coronary intervention, anatomy as follows: left main normal lad gives rise to mod diag, 50% prox and 50% mid lad stenosis left circ 30% ostial stenosis rca dominant. 70-80% stenosis distal rca. run off very good . pacemaker/icd: pt has refused in past social history: patient is single. works part time at library. social history is significant for the absence of current tobacco use. there is no history of alcohol abuse. family history: she has history of premature cad with father having mi in 50s. physical exam: vs - t 98.2, hr 105, bp 109/47, rr 22, 100% on 3l nc gen: wdwn middle aged female in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of cm. cv: pmi laterally displaced. tachy. reg. holosystolic blowing urmur radiating to apex. normal s1, s2. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. pt occasionally tachypneic with anxiety. crackles in bases anteriorly. abd: soft, nt. mildly distended with hepatomegaly 2-3cm below costal margin. no ruq tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. r femoral dsg cdi. ext slightly mottled 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: admission labs wbc-12.2* rbc-4.44 hgb-12.4 hct-37.6 mcv-85 mch-28.0 mchc-33.1 rdw-15.3 plt ct-335 pt-15.4* ptt-29.0 inr(pt)-1.4* glucose-167* urean-18 creat-1.0 na-134 k-4.9 cl-96 hco3-29 angap-14 alt-65* ast-40 ld(ldh)-311* ck(cpk)-120 alkphos-59 amylase-26 totbili-0.4 ck-mb-4 ctropnt-0.10* probnp-7323* albumin-4.0 calcium-8.9 phos-3.5 mg-2.7* cholest-137 %hba1c-7.8* triglyc-174* hdl-26 chol/hd-5.3 ldlcalc-76 miscellaneous labs tsh-2.1 ck-mb-6 ctropnt-0.06* glucose-149* urean-27* creat-0.9 na-132* k-3.9 cl-95* hco3-30 angap-11 pt-17.1* ptt-52.1* inr(pt)-1.5* wbc-10.5 rbc-3.97* hgb-11.4* hct-33.4* mcv-84 mch-28.7 mchc-34.1 rdw-15.5 plt ct-293 ck(cpk)-258* ck-mb-6 probnp-6482* ck-mb-4 ctropnt-0.10* probnp-7323* %hba1c-7.8* triglyc-174* hdl-26 chol/hd-5.3 ldlcalc-76 tsh-2.1 digoxin-0.6* 10:15pm urine rbc-24* wbc-10* bacteri-none yeast-none epi-0 10:15pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-lg 10:15pm urine color-yellow appear-clear sp -1.009 discharge labs wbc-11.8* rbc-4.05* hgb-11.5* hct-33.7* mcv-83 mch-28.4 mchc-34.2 rdw-15.7* plt ct-355 glucose-214* urean-24* creat-1.1 na-132* k-4.7 cl-92* hco3-26 angap-19 reports/imaging ecg : sinus tachycardia. left atrial enlargement. occasional ventricular ectopy. left ventricular hypertrophy. right axis deviation. downsloping st segment depression and t wave inversion in leads v4-v6 which may be left ventricular hypertrophy related. lateral ischemia cannot be excluded. no previous tracing available for comparison. clinical correlation of the right axis deviation and st-t wave changes is suggested. cxr : reason for exam: 59-year-old woman with chf admitted with shortness of breath and chest pain, please evaluate for infiltrate or effusion. since , moderate left and small right pleural effusions are new with bibasilar opacity, likely atelectasis. heart size is difficult to assess. there are no signs of edema. scoliosis is unchanged. . cardiac cath comments: 1. selective coronary angiography revealed two vessel cad. the lm was angiographically normal. the lcx was angiographically normal. the lad had a mid 70-80% hazy lesion and the mid-distal lad had a 70% lesion. the rca had moderate diffuse distal disease but the discrete lesion seen on friday was clearly no longer evident. there was evidence of distal embolization with slow flow in rpl. 2. limited hemodynamics with bp 83/55 with hr 83 in sinus. we gave 500cc ns bolus. right heart cath was deferred. 3. stenting of lad with vision 3x8 and 3x12mm bare metal stents. 4. groin closure with mynx device final diagnosis: 1. two vessel coronary artery disease. 2. severe cardiomyopathy with ef 20% and cardiac index 1.3 on friday 3. nstemi involving rca territory. 4. stenting of lad. echo the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated. overall left ventricular systolic function is severely depressed (lvef= 20 %) secondary to akinesis of the entire interventricular septum and inferior free wall and severe hypokinesis of the anterior free wall and apex. the posterior wall contracts normally and the lateral wall is only mildly hypokinetic. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the mitral valve leaflets do not fully coapt due to posterior and apical tethering of the leaflets. an eccentric, posteriorly directed jet of severe (4+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: severe, multifocal left ventricular contractile dysfunction with severe chamber enlargement, severe mitral regurgitation, preserved posterior wall contractile function, moderate pulmonary hypertension, and moderate-to-severe tricuspid regurgitation brief hospital course: patient is a 59f with non-ischemic dilated cardiomyopathy admitted with progressive sob and intermittent cp with borderline elevated biomarkers at osh transferred for asa desensitization and pci. . #. asa desensitization: patient completed asa desensitization per protocol with solumedrol, benadryl and singulair prior to desensitization. she was subsequently continued on asa 325 po daily which she tolerated. she did not have any adverse reactions to asa desensitization. . #. cad/chest pain: pt found to have 2vd on cardiac cath at osh. she had echo without focal wma so unclear if 2vd is true etiology of her current symptoms. ekg changes and elevated biomarkers may also be c/w strain. since it was felt that her symptoms may benefit from intervention, she was taken to cath lab on . her rca was not found to be occluded at the time and findings were consistent with recent lysis and embolization of an rca thrombus. the lad, however, was found to have approx 70%-80% stenosis. she had bms x 2 to lad. subsequently, she was continued on asa 325, plavix 75 daily, statin, imdur, beta blocker. . #. pump: pt has longstanding history of non-ischemic dilated cm of unknown etiology with ef 20-25% with severe global hk. symptoms over last several months most c/w decompensated systolic and diastolic heart failure. possible exacerbating factors include medication changes (lasix dose decreased by half), dietary indiscretion and recent viral illness with increased demand. from echo here, it is also possible that her longstanding history of cardiomyopathy may have been ischemic after all, although it is difficult to tell now. she was diuresed for net negative 1-2 liters per day, intially with iv lasix 40 iv bid then with 80 lasix iv bid. we considered titrated heart failure therapy with swan ganz catheter due to severity of elevated wedge and low ci at osh cath but did not feel it was neccessary since she was responding well to lasix iv and was comfortable on room air with sats in mid 90s. per notes, she is not candidate for heart transplant pulm htn and has refused icd in past. per osh records she had elevated dig level prior to admission. dig level 0.6 here. dig was restarted. she was continued on aldactone, beta blocker, ace. we attempted changing metoprolol to carvedilol but pt had increased wheezing with carvedilol so changed back to metoprolol. diuretic regimen changed from furosemide to torsemide atr discharge for improved heart failure management and diuresis. . #.leukocytosis: pt had mild leukocytosis with complaints of urinary dysuria and mildly dirty ua. foley catheter was d/c'd. urine culture grew enterococcus but u/a negative and pt without symptoms so antibiotics were not started at discharge. leukocytosis may have been partially related to steroids. . #. rhythm: sinus. continued beta blocker. . #. asthma: pt has h/o increased bronchospasm with asa in past. she tolerated asa well without exacerbation of asthma symptoms. continued outpatient regimen of advair, nebs, predisone 5mg po daily. . #. anxiety/depression: continued celexa, valium, buspar . #. hypothyrodism: continued synthroid. tsh wnl . #. code: full medications on admission: isosorbide 30mg po bid enalapril 20mg po bid spironolactone 25mg daily lasix 80mg toprol xl 12.5mg daily digoxin 0.125 mg daily buspar 30mg albuterol 2 puffs qid prn citracal d 2 tabs po bid prednisone 5mg daily levoxyl 50mcg daily lipitor 10mg daily effexor xr 300mg daily diazepam 5mg prn estradiol topical advair 250/50 prevacid 30mg daily colace 1 capsule temazepam 15mg qhs valium 5mg tid discharge medications: 1. buspirone 30 mg tablet sig: one (1) tablet po twice a day. 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 3. venlafaxine 150 mg capsule, sust. release 24 hr sig: two (2) capsule, sust. release 24 hr po once a day. 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. torsemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 9. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 10. albuterol 90 mcg/actuation aerosol sig: two (2) puffs inhalation four times a day as needed for shortness of breath or wheezing. 11. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 13. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 14. temazepam 15 mg capsule sig: one (1) capsule po hs (at bedtime) as needed. 15. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 16. enalapril maleate 10 mg tablet sig: two (2) tablet po bid (2 times a day). 17. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 18. isosorbide dinitrate 30 mg tablet sig: one (1) tablet po once a day. 19. glipizide 2.5 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*2* discharge disposition: home with service discharge diagnosis: acute on chronic systolic heart failure non st elevation myocardial infarction coronary artery disease severe mitral regurgitation hyperglycemia discharge condition: stable discharge instructions: you were admitted with a heart attack and had a catheterization at and was then transferred here for a stent and aspirin desensitization. you had another catheterization and 2 bare metal stents were placed in your left anterior descending artery. you will need to take plavix and aspirin every day for at least one month. do not miss or stop taking plavix unless dr. tells you to. we also changed some of your medicines for the heart failure. your weight at discharge is 137 pounds. medication changes: 1. stop taking furosemide, take torsemide 60 mg twice daily instead. 2. start taking digoxin again at 0.125 mg daily 3. start glipizide 2.5 mg daily 4. you were started on plavix to take every day for one month, do not miss or stop taking plavix unless dr. tells you to. 5. your atorvastatin was increased to 80 mg daily. you will need to get liver function tests checked in 6 weeks. 6. your nexium was changed to protonix. please speak to dr. about whether he wants you to continue with this medicine. weigh yourself every morning, md if weight > 3 lbs in one day or 6 pounds in 3 days. adhere to 2 gm sodium diet fluid restriction:1.5 liters or about 6 cups. . please call dr. if you develop increasing nausea, heartburn, trouble breathing, chest pain, diaphoresis or any other concerning symptoms. followup instructions: mammogram: provider: phone: date/time: 3:15 cardiology: dr. phone: clinical center, , . date/time: monday at 2:30 primary care: , r. phone: date/time: please call dr. after you get home and make an appt to see him after you see dr. . Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Left heart cardiac catheterization Immunization for allergy Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Other primary cardiomyopathies Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Long-term (current) use of steroids Adrenal cortical steroids causing adverse effects in therapeutic use Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Other chronic pulmonary heart diseases Dysthymic disorder Family history of ischemic heart disease Acute on chronic systolic heart failure Diseases of tricuspid valve Leukocytosis, unspecified Personal history of allergy to analgesic agent Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified

allergies: bactrim / dicloxacillin / levofloxacin attending: chief complaint: chronic, cough, fever major surgical or invasive procedure: bronchoscopy history of present illness: ms. is a 63 year-old female with burkitt's lymphoma (last chemo ) with recent parainfluenza pneumonia who presented on transfer with sepsis. over past three weeks has had cough. seen by dr. on and felt to be consistent with postviral irritative bronchitis; at that time had had no fever. she was given a brief course of steroids followed by inhaled steroids. then presented to an osh with continued cough and fever to 103. found to have a rll and rml pna on cxr and was given 2 l ns and azithromycin/ceftriaxone and transferred to as she receives all of her oncologic care here. enroute in the ambulance, she developed hypotension. in the ed, initial vitals included p 106 bp 78/45. she was fluid resusicated with 5 l ns, however remained hypotensive with sbps in the 80's-90's. she was treated with vancomycin and cefepime and admitted to the icu. a cta was done which showed no pe, but did show opacification in the rml concerning for infection. ros: (+) fever per hpi (+) 60 point weight loss since diagnosis (+) alopecia with chemo (-) chest pain, palpatations (+) cough per hpi (-) abdominal pain, diarrhea, constipation (-) rash (+) right shoulder pain (-) dysuria, frequency, hematuria (-) weakness past medical history: oncologic history: 1. burkitt's lymphoma - diagnosed in , s/p multiple chemo regimens. - most recent cycle (ivac) was on with complications of admission for profound neutropenia, fever, parainfluenza infection, and bacteremia. 2. hypothyroidism. 3. hyperlipidemia. 4. hx of pseudomonas bacteremia. 5. hx of coag-neg staph bacteremia. 6. hx of enterobacter bacteremia. 7. hx of parainfluenza and pneumonia social history: her husband has copd and has required frequent hospitalizations. one of her sons and daughter-in-law live downstairs with their three children. she worked as a system analysis at nhic, but is currently retired. denies tobacco or alcohol use. family history: there is no family history of lymphoma or other malignancies within the family. her sister has a history of cirrhosis. her brother has diabetes and anterograde amnesia. physical exam: vitals - general - well appearing, sitting in a chair at the bedside heent - no icterus; no pallor; no thrush cv - regular; split s2; no murmurs pulm - bilateral crackles without clear focus; no wheeze abd - soft; non-tender; lower abdominal scar from prior c-section ext - warm; 1+ edema neuro - alert; in good spirits; able to provide clear history pertinent results: wbc: 6.6 -> 6.1; 36% bands at discharge, wbc 2.3 hct: 32 -> 28 -> 30.2 plt: 129 -> 103 inr: 1.5 cr: 0.4 lactate: 1.2 ldh: 175 alt: 62 ast: 53 alb: 3.4 ua: negative cxr: impression: 1. right perihilar opacification is new since and may represent early infectious process versus nodule. correlate clinically. recommend follow up imaging post treatment or dedicated ct chest for further evaluation. 2. right-sided pleural effusion is resolved compared to the prior chest x-ray. 3. minimal right basilar atelectasis is noted. ctpa:impression: 1. no evidence of pulmonary embolism. 2. focal nodular opacity in the right middle lobe measuring up to 2.4 cm in cross-section with surrounding ground-glass halo, new from prior study from three weeks ago, likely represents pneumonia. 3. tree-in- micronodularity in the lower lobes most likely related to aspiration or pneumonia. please note the presence of mild bronchial wall thickening in the lower lobes and right middle lobe could also indicate chronic aspiration, though airways disease/bronchitis is also considered. brief hospital course: 1. pneumonia / septic shock: presented with fever and hypotension and imaging showing infiltrate. bronchoscopy with bal showed 1+ gnr, 1+ gpr and yeast. initially treated with vancomycin and cefepime with marked improvement. after 48+ hours afebrile and stable, transitioned to oral regimen. given no gpc on bal, did not cover staph auerus (mrsa). given allergy to levofloxacin, oral options were more limited; as there had been improvement without coverage for atypicals, switched to cefpodoxime alone. plan was for 14 days total with follow-up three days post-discharge. 2. burkitt's lymphoma: felt to be in remission; wbc trended down during stay with resolved bandemia; ldh was normal. medications on admission: levothyroxine 100 mcg tablet po daily acyclovir 400 mg tablet po q8h clonazepam 0.5 mg tablet po tid prn oxycodone 5 mg tablet po q4h prn lidocaine patch prn shoulder pain pyridoxine 50 mg tablet po daily sennosides 8.6 mg tablet 1-2 tablets prn docusate sodium 100 mg capsule po bid vancomycin 125 mg po qid discharge medications: 1. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 2. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 3. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. 4. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for prn shoulder pain. 6. pyridoxine 50 mg tablet sig: one (1) tablet po daily (daily). 7. sennosides 8.6 mg capsule sig: capsules po twice a day as needed for constipation. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours). 10. cefpodoxime 200 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: health care associated pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with pneumonia. please be sure to complete a course of antibiotics, as prescrubed. if you experience any fevers/chills, shortness of breath, worsening fatigue or have any concerns, please seek medical attention right away. followup instructions: department: hematology/ when: monday at 10:30 am with: , building: sc clinical ctr campus: east best parking: garage Procedure: Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Anemia of other chronic disease Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Septic shock Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites

allergies: bactrim / dicloxacillin / levofloxacin attending: chief complaint: hypotension major surgical or invasive procedure: subclavian cvl history of present illness: mrs. is a 63-year-old woman with a history of recurrent burkitt's lymphoma d +15 of , who was recently discharged from after her first treatment for recurrence (see pmh). she had been doing well at home until the morning of . she had awoken early to come to her outpatient appointment at 7 clinic, and on standing from bed, felt very lightheaded. she does not recall much after that point. her son found her in the kitchen, lying against the cabinets in a pool of feces. they called 911, and on transport to , her bp was found to be 58/38. she was given ivf on transport and in the ed at . . she was afebrile, and her blood pressure responded to fluid resuscitation to 90s/40s on transfer. she has been mentating the entire time. at the osh a chest x-ray and head ct were done. both of which were negative for any acute process. she was given a dose of vancomycin and cefepime at the outside hospital out of concern for infection given her neutropenia (wbc 0.2 at the osh) and hypotension. . on arrival to the floor, her vitals were t 99.4, bp 105/50, hr 99, rr 18 and o2 sat 100% on ra. she is mentating well and is currently asymptomatic. she denies any fever or chills, cough, chest pain, shortness of breath, dysuria, frequency, urgency, myalgias, or abdominal pain. she admits to diarrhea this am, lightheadedness, feeling "dry," and pain in her mouth. past medical history: interval history: burkitt's lymphoma: she was admitted with 6 weeks of persistent, progressive shoulder pain. on admission, there was a palpable mass on her right chest wall and axilla. a ct scan showed a large axillary mass that was cocerning for recurrence of disease. she had an ir guided biopsy which was inconclusive, and was then taken to the or for surgical excisional biopsy that showed recurrence of disease. on she had an echocardiogram and began treatment with . she had an lp done on , which was positive for disease. at that time she recieved intrathecal methotrexate and hydrocort. on her lp was repeated and she recieved intrathecal cytarabine. she was discharged with neupogen for one week with close follow-up. . 1. burkitt's lymphoma - diagnosed in , s/p multiple chemo regimens. - most recent cycle (ivac) was on with complications of admission for profound neutropenia, fever, parainfluenza infection, and bacteremia. 2. hypothyroidism. 3. hyperlipidemia. 4. hx of pseudomonas bacteremia. 5. hx of coag-neg staph bacteremia. 6. hx of enterobacter bacteremia. 7. hx of parainfluenza and pneumonia social history: (from omr, confirmed with patient) her husband has copd and has required frequent hospitalizations. one of her sons and daughter-in-law live downstairs with their three children. she worked as a system analysis at nhic, but is currently retired. denies tobacco or alcohol use. family history: (from omr, confirmed with patient) there is no family history of lymphoma or other malignancies within the family. her sister has a history of cirrhosis. her brother has diabetes and anterograde amnesia. physical exam: vitals: t: 99.4 bp: 105/50 hr: 99 rr: 18 o2 sat 100% on ra gen: well appearing woman heent: perrl, eomi, dry mm, no jvp, no lad, multiple areas of mucositis in her mouth cv: tahcycardic, regular rhythm, no m/r/g normal s1 and s2 chest: old ecchymosis on right breast lungs: ctab, no wheezes rales or rhonchi back: 3x5 cm contusion on her left midback, inferior to the scapula, no associated tenderness surrounding the lesion, also a 3x1.5 cm contusion along the top of the left scapula abdomen: soft, non-tender, mildly distended, nabs, palpable liver tip ext: no edema, cyanosis, clubbing. 2+ radial and dp pulses bilaterally skin: no abnormalities other than contusions noted above, warm, dry neuro: cnii-xii grossly intact, aaox3, strength 5/5 in upper and lower extremities pertinent results: admission labs: 03:45pm blood wbc-0.3*# rbc-2.20* hgb-7.7* hct-21.3* mcv-97 mch-35.0* mchc-36.2* rdw-14.5 plt ct-14*# 03:45pm blood neuts-11* bands-22* lymphs-7* monos-0* eos-1 baso-1 atyps-0 metas-1* myelos-1* other-56* 03:45pm blood pt-15.3* ptt-28.0 inr(pt)-1.3* 03:45pm blood plt smr-rare plt ct-14*# 03:45pm blood glucose-125* urean-24* creat-0.6 na-136 k-3.5 cl-104 hco3-24 angap-12 03:45pm blood alt-98* ast-39 ld(ldh)-169 alkphos-134* totbili-1.7* 03:45pm blood albumin-3.2* calcium-8.8 phos-3.5 mg-2.0 uricacd-2.9 06:45pm blood lactate-1.0 discharge labs: 12:00am blood wbc-2.1* rbc-2.92* hgb-8.7* hct-24.7* mcv-84 mch-29.9 mchc-35.5* rdw-13.4 plt ct-85* 12:00am blood neuts-67 bands-0 lymphs-14* monos-17* eos-0 baso-0 atyps-0 metas-0 myelos-2* nrbc-1* 12:00am blood gran ct-1449* 12:00am blood glucose-143* urean-15 creat-0.4 na-132* k-3.9 cl-99 hco3-25 angap-12 12:00am blood alt-75* ast-54* ld(ldh)-377* alkphos-135* totbili-0.4 12:00am blood calcium-8.9 phos-2.2* mg-2.0 uricacd-1.7* micro: 4:56 am blood culture source: line-tlcl. **final report ** blood culture, routine (final ): pseudomonas aeruginosa. of two colonial morphologies. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- 16 s tobramycin------------ <=1 s aerobic bottle gram stain (final ): gram negative rod(s). lp (#1) - no malignant cells lp (#2) - no malignant cells lp (#3) - no malignant cells lp (#4) - no malignant cells studies: ct abd/pelvis- 1. no infectious source identified in the chest, abdomen or pelvis. 2. interval decrease in size of confluent right axillary adenopathy compared to . 3. single stable left paraaortic lymph node. 4. sigmoid diverticulosis, without diverticulitis. 5. distention of the stomach, without evidence for mechanical obstruction. correlate clinically. ct chest: impression: 1. no acute pulmonary embolism or aortic pathology. 2. similar appearance of 1-cm ground-glass nodular opacity in the right upper lobe. recommend continued followup. 3. sub-4mm pulmonary nodules, with questionable interval increase in size, could be re-evaluated when followup for the ground-glass opacity. 4. slightly interval decrease in size of the right axillary lymph node conglomerate. echo: impression: mild global hypokinesis. mild mitral regurgitation. no evidence of endocarditis seen. if clinically suggested, the absence of a vegetation by 2d echocardiography does not exclude endocarditis. compared with the prior study (images reviewed) of , the findings are similar. abnormal septal motion was seen on the prior study also. mri shoulder: the lymphomatous mass in the right axilla, encasing the right brachial plexus has increased in size compared to prior imaging. u/s: no evidence of dvt in the right upper extremity. ct torso: read pending at time of discharge, will be followed up at outpatient appt on monday brief hospital course: assessment and plan: mrs. is a 63-year-old woman with recurrent burkitt's lymphoma who is d+15 of admitted from an osh with hypotension and neutropenia after a syncopal episode at home. . # hypotension/syncope: she was found to be hypotensive to 58/38 by ems, which responded to fluids. she was fluid resuscitated to sbp of 70s by ems and sbp of 90's by osh ed prior to transfer. blood cultures were drawn and she was given cefepime and vanco and transferred to 7 . on arrival she was given 2l of fluid, 1 unit of blood, and cefepime, vancomycin, and flagyl. her pressures responded. osh cultures came back as vre 1:4 bottles, sensitive to ampicillin, daptomycin, levofloxacin, and linezolid. she was switched to ampicillin on and her picc was pulled. she was switched to daptomycin on monday because she had begun receiving hyper cvad part b and amp interferes with clearance of methotrexate. she had a tte and tee which showed no vegetations. as she was being treated for the bacteremia, ms. again became hypotensive and febrile, requiring transfer to the where she required pressors. blood cultures were sent and ultimately returned positive with pseudomonas, believed to be associated with her central line. her line was pulled and her broad spectrum antibiotic coverage (started given her sepsis in the setting of neutropenia) was narrowed to cefepime, gentamicin, and linezolid. gentamicin was d/c-ed a few days after transfer to the floor and linezolid was transitioned to ampicillin as the patient was believed to have leukosuppression secondary to the linezolid. she completed a 10 day course of antibiotics (amp and cefepime) from the time her anc was greater than 1000 per id recommendations and remained afebrile and hemodynamically stable for the remainder of her hospital course. . # burkitt's lymphoma: she was admitted on day +15 of . an lp with intrathecal chemotherapy was performed on . a subclavian line was placed on and treatment with hyper cvad part b was started on . she tolerated her chemotherapy well, complicated by mild mucositis and the bacteremia discussed above. she had one more round of intrathecal chemotherapy with cytarabine on . lps on , and were negative for malignant cells. patient had significant right shoulder and arm pain as well as right hand weakness, believed secondary to brachial plexus involvement of her lymphoma. she underwent mri of her r shoulder which confirmed this finding and had 4 sessions of xrt as a palliative therapy. she had 4 lp's which were negative for malignant cells. had it cytarabine on prior to discharge which she tolerated well. pt had ct of torso to evaluate for progression of disease, read at the time of discharge was pending but will be followed up at follow-up appointment monday following discharge when pt will return for chemotherapy gemcitabine and vinorelbine. acyclovir and fluconazole were held given elevated lfts, will trend lfts as outpatient and do liver ultrasound if necessary. pt was given pentamidine prior to discharge for pcp . . # cardiomyopathy: patient became tachycardic at the time of her second episode of sepsis. this continued intermittently through her stay and subsequently on the floor. tachycardia was sinus in nature, up into the 140s with movement, and was attributed to an underlying cardiomyopathy (ef 45-50% on echo, last on ). cardiology was consulted for management and she was started on metoprolol 12.5mg which she tolerated well. . # dvt: found to have right upper extremity dvt last admission and was on lovenox for that until she had a drop in platelets (treatment related). she was thrombocytopenic during her admission and her lovenox was held. an ultrasound of the arm was repeated and was negative for clot. . # hypothyroidism: stable. continued levothyroxine 100mcg po daily . # depression: patient was frequently tearful and endorsed saddened mood and symptoms of depression. was started on citalopram 10 mg daily. medications on admission: 1. acyclovir 400 mg po q8 hours 2. clonazepam 0.5 mg po tid prn for anxiety. 3. levothyroxine 100 mcg po daily 4. pyridoxine 50 mg po daily 5. docusate sodium 100 mg po bid 6. nystatin 100,000 unit/ml suspension 5 ml po qid 7. senna 8.6 mg po qhs prn constipation 8. gabapentin 600 mg po tid 9. polyethylene glycol 17 gram/dose powder po daily prn constipation 10. ms contin 60 mg po q8h 11. hydromorphone 2-4 mg po q4h prn pain 12. saliva substitution 30ml qid 13. enoxaparin 60 mg/0.6 ml subcutaneous q12h 14. filgrastim 300 mcg/ml sc inj q24h for 5 days. 15. dexamethasone 2 mg po daily discharge medications: 1. clonazepam 0.5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed for insomnia. 2. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 3. pyridoxine 50 mg tablet sig: one (1) tablet po daily (daily). 4. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 5. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 7. gabapentin 300 mg capsule sig: two (2) capsule po q8h (every 8 hours). 8. oxycodone 30 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q12h (every 12 hours). disp:*60 tablet sustained release 12 hr(s)* refills:*0* 9. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 10. dexamethasone 4 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 11. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 12. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: burkitt's lymphoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , you were admitted to the hospital with an infection in your blood. you had a short stay in the icu and were treated with antibiotics and recovered. during your hospitalization you received chemotherapy and radiation therapy for your burkitt's lymphoma. you will be returning on monday for outpatient chemotherapy. please call if you have any symptoms or concerns before then. we have made the following changes to your medications: take metoprolol 12.5mg twice a day for blood pressure take celexa 10mg daily for depression take dexamethasone 4mg daily take oxycontin 30mg twice a day for long-acting pain control you can continue your home dilaudid 2-4mg every 6hrs as needed for breakthrough pain please do not take acyclovir or fluconazole until you follow-up as an outpatient because these medications can elevate liver labs it was a pleasure taking care of you. we wish you a speedy recovery. followup instructions: the following appointment has been scheduled for you: department: /oncology unit when: monday at 9:30 am building: fd building (/ complex) campus: east best parking: main garage Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Spinal tap Incision of lung Diagnostic ultrasound of heart Injection or infusion of cancer chemotherapeutic substance Injection or infusion of cancer chemotherapeutic substance Injection or infusion of cancer chemotherapeutic substance Other radiotherapeutic procedure Injection or infusion of oxazolidinone class of antibiotics Injection of other agent into spinal canal Injection of other agent into spinal canal Injection of other agent into spinal canal Central venous catheter placement with guidance Diagnoses: Severe sepsis Unspecified acquired hypothyroidism Sepsis 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 Infection with microorganisms without mention of resistance to multiple drugs Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Diarrhea Anticoagulants causing adverse effects in therapeutic use Other and unspecified infection due to central venous catheter Streptococcal septicemia Drug induced neutropenia Other specified antibiotics causing adverse effects in therapeutic use Syncope and collapse Fall from other slipping, tripping, or stumbling Precipitous drop in hematocrit Other specified hypotension Burkitt's tumor or lymphoma, lymph nodes of multiple sites Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Septicemia due to pseudomonas Neutropenia due to infection Other stomatitis and mucositis (ulcerative) Other secondary thrombocytopenia Secondary cardiomyopathy, unspecified Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity

allergies: bactrim attending: chief complaint: lymphoma major surgical or invasive procedure: dialysis catheter placement for cvvh central line placement history of present illness: 62 y.o. female w/ h.o. hl, hypothyroidism presented initially at osh w/ fatigue, insomnia found to be high grade lymphoma. transferred for further management from . admitted to the icu for cvvh for possible tumour lysis syndrome. pt states that 4 weeks ago she noted some jaw pain as well as total body weakness, malaise, "body burning sensation". she had also noted some decreased appetite to food and water, insomnia accompanied by a bloating sensation in her abdomen. she saw her pcp last for a check up and received bld work which was noted to be 'abnormal'. unfortunately she was not told what labs were abnormal, given her malaise she decided to come to the ed. in the ed she was noted to have a leukocytosis of 27.2, in addition to w/ creatinine of 2.2, plt 66, ldh 25, 348. she was initially given ceftriaxone for ?uti given appearance of her urine. 4+ bacteria, wbc were seen on a u/a that was notable for squamous cells. as part of her work up she underwent a ct torso which showed left subclavian node, retroperitoneal adenopathy, l hydronephrosis. she was then referred to the ed on day of admission. in the ed her initial vitals were noted to be t99.0, hr 110, bp 126/72, rr 14, sat 99%. her labs were notable for a leukocytosis of 28.4 with 29n, band 4, l 23, m14, e11, b1, meta5, myelos1, nrbcs5, other 12. bun/creatinine 38/2.4, glc 66. uric acid 26.3, ldh 26, 420, ast 211, alt 65, ca .4, k 3.8, ph 4.2, tb 1.6, alk phos 477. fibrinogen 266. oncology were consulted given the suspicion for lymphoma and obtained a bm bx, cytology was obtained from aspirate. review of systems: (+)ve: (-)ve: measured fevers, chest pain, palpitations, cough, nausea, vomiting, diarrhea, constipation past medical history: hypothyroidism hyperlipidemia social history: pt currently works as a system analyst at nhic. she denies any etoh, tobacco or ivdu history. family history: sister - cirrhosis, brother - dm, anterograde amnesia. denies any h.o. lymphoma or other malignancies physical exam: general: fatigued appearing caucasian female lying down in bned in nard heent: no scleral icterus, perrl, eomi. neck: no lad noted. cardiac: regular rhythm, tachy (110 bpm). normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. abdomen: soft, distended, tender in the epigastric region. no hsm extremities: no edema noted. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. psych: listens and responds to questions appropriately, pleasant pertinent results: labs on admission: fibrinoge-522* pt-14.9* ptt-24.4 inr(pt)-1.3* plt smr-low plt count-109* hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal neuts-29* bands-4 lymphs-23 monos-14* eos-11* basos-1 atyps-12* metas-5* myelos-1* nuc rbcs-5* other-0 wbc-28.4* rbc-3.67* hgb-10.9* hct-31.4* mcv-86 mch-29.8 mchc-34.8 rdw-14.5 haptoglob-7* calcium-11.4* phosphate-4.2 magnesium-2.1 uric acid-26.3* alt(sgpt)-65* ast(sgot)-211* ld(ldh)-* alk phos-477* tot bili-1.6* estgfr-using this glucose-66* urea n-38* creat-2.4* sodium-138 potassium-3.8 chloride-105 total co2-15* anion gap-22* bone marrow ipt-done bone marrow cd34-done cd3-done cd4-done cd8-done bone marrow -g-done cd33-done cd41-done cd56-done cd64-done cd71-done cd117-done cd45-done hla-dr a-done kappa-done cd2-done cd7-done cd10-done cd11c-done cd14-done cd15-done cd19-done cd20-done lambda-done cd5-done iron-done sed rate-62* fibrinoge-538* pt-15.5* ptt-23.1 inr(pt)-1.4* pep-no specifi crp-34.3* d-dimer-580* tot prot-5.0* calcium-10.6* phosphate-4.9* magnesium-2.2 ld(ldh)-* creat-2.9* potassium-3.4 hiv ab-negative calcium-10.6* phosphate-5.0* magnesium-2.1 ld(ldh)-* creat-2.8* sodium-134 potassium-3.5 chloride-93*flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, glycophorin a, kappa, lambda, and cd antigens 2, 3, 4, 5, 7, 8, 10, 11c, 14, 15, 19, 20, 33, 34, 41, 45, 56, 64, 71, 117. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. lymphoma cells comprise 20% of total gated events. t cells comprise 72% of lymphoid gated events, express mature lineage antigens, and have a helper-cytotoxic ratio of 1.6. no abnormal events are identified in the "blast gate." interpretation immunophenotypic findings consistent with involvement by a kappa restricted cd10 positive b-cell lymphoproliferative disorder. the immunophenotypic profile in concert with the morphologic features of the lymphoma on the bone marrow smear and core biopsy are consistent with burkitt's lymphoma. see s10- for correlation with morphology. specimen: bone marrow aspirate and core biopsy: diagnosis: hypercellular marrow entirely replaced by a high grade lymphoid tumor with morphologic and immunophenotypic features consistent with burkitt lymphoma (see note). microscopic description peripheral blood smear: erythrocytes appear decreased in number, and show mild anisocytosis. occasional polychromatophilic cells present. 13 nucleated rbcs per 100 wbcs present. the white blood cell count appears increased. there is absolute lymphocytosis. about 50% of the lymphocytes are medium to large, with an irregular nucleus with prominent one or more nucleoli. cytoplasm is deep basophilic and shows vacuoles. occasional neutrophil shows hypogranular cytoplasm with unsegmented nuclei. platelet count appears decreased. differential count shows 24% neutrophils, 1% bands, 2% monocytes, 52% lymphocytes, 17% eosinophils, 2% myelocytes, 2% metamyelocytes. aspirate smear: the aspirate material is adequate for evaluation. the m:e ratio cannot be reliably assessed since the marrow is replaced by a lymphoproliferative process. erythroid precursors are relatively reduced. myeloid precursors appear markedly decreased. megakaryocytes are present in decreased numbers. differential shows: <1% blasts, <1% promyelocytes, <1% myelocytes, <1% metamyelocytes, 4.2% bands/neutrophils, <!% plasma cells, 2.6% lymphocytes, 1.8% erythroid, 90% medium size blasts with basophilic cytoplasm with numerous vacuoles. clot section and biopsy slides: the biopsy material is adequate for evaluation, and consists of a core biopsy of paratrabecular bone measuring 2.2 cm. cellularity is 80%. the marrow is almost entirely replaced by a population of medium to large atypical lymphoid cells interspersed with tingible body macrophages. lymphoma cells exhibit nuclei with blastic chromatin with multiple nucleoli, and contain moderate amounts of amphophilic cytoplasm. normal hematopoietic elements greatly decreased. rare megakaryocytes are present. marrow clot section consists of bone marrow similar to biopsy and fibrocollagenous tissue. special stains: storage iron cannot be assessed due to absence of spicules and erythroblasts (marrow completely replaced by lymphoma cytogenetics pending as of cxr- impression: no acute cardiopulmonary process. low lung volumes tte: the left atrium is mildly dilated. 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. there is no aortic valve stenosis. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal biventricular systolic function. mild pulmonary hypertension. liver or gallbladder us (single organ) port 1. no intra- or extra-hepatic biliary dilatation. cbd 2-mm. no evidence of cholecystitis. 2. as seen on recent outside hospital ct, several subcentimeter non- obstructing right renal calculi, and mild left hydronephrosis without left renal calculi. hydronephrosis is likely related to extensive retroperitoneal soft tissue density mass (likely nodes), seen on the outside hospital ct. 3. mild splenomegaly 3. incidentally noted, enlarged uterus csf ()- negative for malignant cells. flow cytometry ()- cell marker analysis demonstrates a t cell dominant lymphoid profile and diagnostic immunophenotypic features of involvement by a non-hodgkin b-cell lymphoma are not seen in specimen. a small population of cd45 (moderate) positive cells is noted comprising 3% of total analyzed cells. review of corresponding blood smear showed occasional immature-appearing mononuclear cells, morphologically consistent with blasts. flow cytometry ()- non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. bm biopsy ()- - normocellular myeloid dominant marrow with myeloid left-shift, megakaryocytic hyperplasia and erythroid hypoplasia. - no diagnostic morphologic features of lymphoma seen. cytogenetics ()- no cytogenetic aberrations were identified in 20 metaphases analyzed from this unstimulated specimen. csf ()- negative for malignant cells. csf ()- negative for malignant cells. brief hospital course: ##. burkitt's lymphoma: pt was seen by heme/onc in ed, and bone marrow bx performed at that time. prelim read from heme-path suggesteded large cell lymphoma w/ vacuoles suggestive of possible burkitt's lymphoma. treatment was initiated with steroids. the patient began spontaneous tumor lysis prior to induction of chemotherapy. nephrology was consulted and patient was started on cvvh. pt received rasburicase for uric acid converion with good response as well as allopurinol. patient was then initiated on codox. received daily dexamethasone and cytoxan. she remained on cvvh with tumor lysis labs stable and ldh steadily trending down. dic labs remained wnl. ebv, cmv, hiv viral loads were negative. tte was done to evaluate baseline function prior to doxorubicin. doxorubicin and vincristine were administered on . methotrexate was given on , vincristine on and intrathecal cytarabine on . cytopathology-immunophenotyping from the csf fluid obtained on was positive for presence of lymphoma. she was started on acyclovir and received pentamidine for prophylaxis. she completed codox and was then started on ivac on . counts were slow to recover. ct scan showed bilateral pleural effusions (l>r). concern for methotraxate collecting in pleural fluid leading to persistent neutropenic and poor recovery of counts. interventional pulmonary team was consulted and drained 250cc of pleural fluid from left side on . no signs on infection were found in the fluid. patient's anc recovered almost immediately (- 0, - 129, - 594). repeat bm biopsy and csf studies showed no disease. while receiving ivac, she developed visual hallucinations, arm/leg tingling (no numbness) and increased anxiety. this was attributed to ifosphamide and, therefore, her 5th dose of the drug was not administered. her symptoms improved daily after ivac course was completed. she was on neupogen from . she received it methotrexate on and it-cytarabine on . her counts responded appropriately. plan after discharge is to begin codox-m therapy. she has an appointment scheduled with dr. (admitting physician) on / ##. rue thrombosis: the patient noted right upper extremity swelling. ultrasound was obtained, which demonstrated thrombosis in the right brachial and basilic veins. she was not anticoagulated given her significant thrombocytopenia. u/s repeated on which showed no progression of clot. picc line was kept in right arm but was eventually pulled due to vre-positive cultures (see below). ## c. difficile associated disease: she noted loose bowel movements, with c. diff antigen returning positive on . she was started on iv flagyl and po vanc. diarrhea eventually resolved. id was consulted re: duration of therapy. they recommended checking stool for c.diff antigen and if negative than to discontinue antibiotics. stool checked on was negative for c.diff so antibiotics were discontined on . she then developed recurrent diarrhea on and was empirically treated for c diff. she had 2 stool samples negative for c. diff at this time, but was treated with a course of oral vancomycin to be continued after discharge, at least until her next oncology appointment (scheduled for ). ## febrile neutropenia: she was noted to have a fever in the setting of neutropenia. she was started on vancomycin, cefepime, and micafungin. she developed a diffuse rash shortly after initiation of antibiotics. derm was consulted- performed biopsy which showed "intraepidermal vesicles and underlying linear track of ischemia with adjacent dermal inflammation with eosinophils". her rash was consistent with a drug eruption and cefepime was thought to be the culprit. cefepime was discontinued and patient was started on aztreonam (in addition to vancomycin). rash resolved shortly thereafter. the c. difficile antigen returned positive and she was started on flagyl. she was continued on antibiotics while neutropenic. antibiotics were discontinued as patient was afebrile and cultures remained negative. she again developed fevers on . cultures were drawn and grew back vre. patient was started on daptomycin and picc line was pulled. a central line (left ij) was placed after 48 hours. surveillance cultures were negative. daptomycin was continued until . upon discharge, she was no longer neutropenic and afebrile. ##. : likely due to uric acid stones and urate nephropathy, in additon to hydronephrosis due to external compression by retroperitoneal tumor. pt on cvvh during cytoxan treatment. renal function returned to baseline and remained stable off cvvh. ##. hematuria: patient began having hematuria after foley placement that worsened with initiation of cytoxan. she was also having bladder pain. she was started on continuous bladder irrigation for concern of hemorrhagic cystitis. hematuria eventually resolved as did pain. it seemed likely that patient passed uric acid stone. cbi was stopped and patient continued to make adequate urine. ##. tachycardia: on review of osh records pt has been persistently sinus tachycardic, likely related to her underlying lymphoma. she remained tachycardic (95-115) throughout her course here. she denied chest pain, palpitations, dizziness or syncope. ##. ?uti: pt was given iv ceftriaxone for ?uti however u/a was notable for several epi cells in addition to bacteria. no dysuria noted, urine appearance likely related to her . repeat urine cx neg x 2. pt was not further treated. ##. hypothyroidism: continued on home regimen of hypothyroidism. ##. anxiety- patient was quite anxious while here. it worsened after she received ifosphamide. standing clonazepam was added to her prn ativan ordered with good control of her anxiety. she was discharged on prn clonazepam but if anxiety is a problem in the future for her, she may need to be changed back to standing clonazepam. ##. fluid overload- patient received iv fluids with chemotherapy and became quite fluid-overloaded. weight was up to 210+ pounds with 3+ pitting edema in bilateral lower extremities. she received one-time doses of iv lasix and responded very well to them. she eventually began auto-diuresing and no longer required lasix. her weight on discharge was near 170 pounds with no signs of fluid overload on physical exam. medications on admission: levothyroxine 100mcg daily furosemide dose unknown daily lipitor unknown calcium vitamin d discharge medications: 1. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 2. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 3. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 4. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. disp:*90 tablet(s)* refills:*2* 5. vancomycin 125 mg capsule sig: one y five (125) mg po four times a day for 7 days. disp:*7 days* refills:*3* 6. 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* 7. bactrim 400-80 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 diagnosis: burkitt's lymphoma secondary diagnosis: diarrhea acute renal failure (resolved) discharge condition: good. vital signs stable. discharge instructions: you presented to the hospital with altered mental status and confusion. you initally were admitted to the intensive care unit given your condition. you underwent hemodialysis and once you were stable, you were transferred to the hematologic malignancy service for the remainder of your stay. you completed a round of chemotherapy while here and tolerated it very well. your kidney function returned to and your most recent bone marrow was free of disease. upon discharge, you were stable and doing well. the following changes were made to your medications: 1. start taking fluconzole 200mg by mouth daily 2. start taking acyclovir 400mg by mouth three times per day 3. start taking vancomycin 125mg by mouth four times per day 4. start taking potassium chloride 40milliequivalents/day 5. start taking bactrim 1 single strength tablet daily 6. start taking clonazepam 0.5mg three times daily as needed for anxiety followup instructions: please follow-up in clinic. you have the following appointment scheduled: provider: . date/time: monday, at 11:00am location: of building, phone: Procedure: Hemodialysis Venous catheterization for renal dialysis Thoracentesis Biopsy of bone marrow Closed biopsy of skin and subcutaneous tissue Injection or infusion of cancer chemotherapeutic substance Diagnoses: Acidosis Acute kidney failure, unspecified Unspecified acquired hypothyroidism Other and unspecified hyperlipidemia Anxiety state, unspecified Other specified cardiac dysrhythmias Bacteremia Intestinal infection due to Clostridium difficile Dermatitis due to drugs and medicines taken internally Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Other specified antibiotics causing adverse effects in therapeutic use Hematuria, unspecified Neutropenia, unspecified Fever presenting with conditions classified elsewhere Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites Acute venous embolism and thrombosis of deep veins of upper extremity

allergies: codeine / bactrim / zyban / flomax / iodine containing agents classifier / flexeril / doxazosin / lisinopril attending: chief complaint: abdominal pain major surgical or invasive procedure: emergent repair of ruptured thoracoabdominal aortic aneurysm with a 30-mm dacron tube graft from just beyond the left subclavian artery takeoff all the way down to the mid visceral bearing segment of the abdominal aorta using deep hypothermic circulatory arrest and a separate side branch to revascularize the celiac artery. the graft data is the following: vascutek gelweave graft, reference #, lot #, serial #. :tracheostomy/percutaneous gastrostomy :debridement of open wound left scapular region with debridement of muscle, subcutaneous tissue, and skin; latissimus flap reconstruction history of present illness: this 78 year old male has a known thoracoabdominal aneurysm and a two day history of abdominal pain. he presented to hospital and had a cta which revealed a contained thorocoabdominal rupture. he was transfered to for surgical evaluation. past medical history: bph diabetes hypercholesterolemia hypertension v tach lung nodules aaa pad nodular thyroid complex renal cyst tendon cyst cerebrovascular disease colitis impotence inguinal hernia insomnia rectal polyp right bundle branch block asbestos exposure h/o hyponatremia h/o tobacco abuse turp excision hydrocele excision spermatocele social history: former smoker x30+ years (quit ~ 7 years ago). no etoh. married with 4 adult children. retired. family history: non-contributory physical exam: pe on admission: vs: afebrile hr 70's bp: 140-170's / 60's rr: 16 gen: nad, aox3 neck: trachea midline, neck supple. palpable carotid pulses cvs: rrr, no m/r/g pulm: no resp distress abd: s/nd/min ttp to deep palpation. pulsatile mass upper abdomen consistent with known aaa le: no lle edema, warm, lack of hair distal le bilaterally pulse: rle: femoral palpable dp/pt: -/dop lle: femoral palpable dp/pt: p/dop pertinent results: 02:37am blood wbc-8.5 rbc-3.12* hgb-8.8* hct-28.8* mcv-92 mch-28.3 mchc-30.7* rdw-14.9 plt ct-341 07:00am blood wbc-9.7 rbc-3.78* hgb-11.7* hct-32.1* mcv-85 mch-31.1 mchc-36.6*# rdw-12.0 plt ct-317 02:37am blood pt-16.8* inr(pt)-1.6* 07:00am blood pt-13.8* ptt-30.2 inr(pt)-1.3* 02:37am blood glucose-107* urean-31* creat-0.7 na-135 k-3.7 cl-104 hco3-24 angap-11 07:00am blood glucose-162* urean-13 creat-1.0 na-129* k-4.7 cl-94* hco3-27 angap-13 12:37pm blood alt-32 ast-77* ld(ldh)-314* alkphos-63 amylase-56 totbili-0.9 03:01am blood alt-22 ast-86* ld(ldh)-286* alkphos-27* amylase-13 totbili-0.8 echocardiography report , (complete) done at 11:45:40 am final referring physician information , c. , status: inpatient dob: age (years): 78 m hgt (in): 74 bp (mm hg): 119/64 wgt (lb): 190 hr (bpm): 83 bsa (m2): 2.13 m2 indication: atrial fibrillation. endocarditis. mitral valve disease. source of embolism. icd-9 codes: 424.90, 427.31, 424.0 test information date/time: at 11:45 interpret md: , md test type: tee (complete) son: doppler: full doppler and color doppler test location: west echo lab contrast: none tech quality: adequate tape #: 2012w012-0:00 machine: vivid i-3 echocardiographic measurements results measurements normal range findings left atrium: 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: overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aortic valve: mildly thickened aortic valve leaflets (3). no masses or vegetations on aortic valve. trace ar. mitral valve: mildly thickened mitral valve leaflets. no mass or vegetation on mitral valve. trivial mr. tricuspid valve: normal tricuspid valve leaflets. no mass or vegetation on tricuspid valve. mild tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. no vegetation/mass on pulmonic valve. physiologic (normal) pr. pericardium: no pericardial effusion. general comments: informed consent was obtained. a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. local anesthesia was provided by benzocaine topical spray. echocardiographic results were reviewed with the houseofficer caring for the patient. conclusions 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. no atrial septal defect is seen by 2d or color doppler. the thoracoabdominal aortic graft is intact up to 45 cm from the incisors. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no evidence of intracardiac thrombus, pfo, or asd seen. no echocardiographic evidence of endocarditis seen. intact thoracoabdominal graft from the anastomosis site just below the left subclavian up to 45 cm from the incisors. was notified in person of the results. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 12:31 , m 78 radiology report cta head w&w/o c & recons study date of 9:43 am , csru 9:43 am cta head w&w/o c & recons; cta neck w&w/oc & recons clip # reason: r/o basilar infarct medical condition: 78 year old man with thorocoabdominal aneurysm repair reason for this examination: r/o basilar infarct contraindications for iv contrast: none. final report study: cta of the head and cta of the neck. clinical indication: 78-year-old man with history of thoracoabdominal aneurysm repair, rule out basilar infarct. comparison: prior mri of the head dated . technique: contiguous axial mdct images were obtained through the brain without contrast material. subsequently, rapid axial imaging was performed from the aortic arch through the brain during the infusion of omnipaque intravenous contrast material. images were then processed on a separate workstation with display of curved reformats, 3d volume-rendered images and maximum intensity projection images. findings: head ct: there is no evidence of acute intracranial hemorrhage, mass effect or shifting of the normally midline structures. vague areas of low attenuation are noted in the centrum semiovale, likely representing edema or areas of small vessel disease, previously demonstrated by mri of the brain on . the bone structures are grossly unremarkable. the patient is intubated. the orbits and mastoid air cells as well as the paranasal sinuses are grossly normal. head cta. there is vascular enhancement along the internal carotid arteries with no evidence of critical stenosis throughout the anterior, middle and posterior cerebral arteries. the basilar artery appears patent with codominance of the vertebral arteries. no aneurysms larger than 2 mm in size are seen. cta of the neck. the origin of the supra-aortic vessels appears normal with no evidence of critical stenosis including the cervical carotid bifurcations. the left carotid bifurcation demonstrates mild irregular contour at the posterior wall of the left internal carotid artery, consistent with soft plaque material. both vertebral arteries are patent. there is no evidence of dissection. the bony structures demonstrate multilevel degenerative changes throughout the cervical spine with anterior and posterior spondylosis, more severe at c3/c4, c4/c5 and c5/c6 levels. impression: 1. there is no evidence of acute or subacute intracranial hemorrhage or mass effect. vague areas of low attenuation are identified in the subcortical white matter, likely representing areas of small vessel disease and subacute ischemic changes, previously noted on mri of the head dated . 2. there is no evidence of flow stenotic lesions in the circle of . the basilar artery appears patent with codominance of the vertebral arteries. the neck vessels demonstrate mild irregular contour in the posterior wall of the left internal carotid artery at the cervical bifurcation, likely consistent with soft plaques, however, there is no evidence of significant stenosis. these findings were communicated to dr. in person by dr. on at 11:03 hours. dr. approved: tue 9:04 pm imaging lab there is no report history available for viewing. ?????? caregroup is. all rights reserved. brief hospital course: 78 year old male with abdominal pain and cta demonstrating thoracic aortic aneurysm descending to level of celiac artery with contained rupture into lateral wall at level of diaphragm. on he was taken to the or for an emergent repair of ruptured thoracoabdominal aortic aneurysm with a 30-mm dacron tube graft from just after the left subclavian artery takeoff all the way down to the mid visceral bearing segment of the abdominal aorta using deep hypothermic circulatory arrest and a separate side branch to revascularize the celiac artery. the graft data is the following: vascutek gelweave graft, reference #,lot #, serial #. co-surgeons: ,m.d. and , m.d. cardiopulmonary bypass time: 144 minutes. the visceral ischemic time was 28 minutes. circulatory arrest time: 32 minutes. please see operative report for further surgical details. he was transferred intubated and sedated to the cvicu requiring pressor support, in critical condition. in summary: he had a very complicated postoperative course due to cerebral and spinal infarcts with scans showing multiple areas of slow diffusion, predominantly in left parietal and occipital lobe concerning for sub-acute infarcts, paraplegia, s. marascens bacteremia with presumed graft infection, vap and post-op wound infection at the back of the thoracotomy site with coag negative staph. the patient had remained intubated until pod#1. rn, mr. never followed commands for her and noted a change with the lack of gross motor movement of his extremities. he was noted not to be moving the lower extremities, and had asymmetry in the exam of the arms, along with mental status changes after transient episode of hypotension/ atrial arrhythmia and shocks necessitated. he was reintubated. mri brain and spine performed. mri of brain showed no significant ischemic changes to explain such a poor mentation. neurology was consulted and felt imaging findings are consistent with multiple brain infarcts (left > right) and cord infarction; likely attributed to perioperative hypotension and aortic manipulations. eeg negative. anticoagulation was not initially started. however, after his continued paroxysmal afib, and neuro event, coumadin was ultimately initiated. the patient remains with afluent aphasia and paraplegic. mr. was taken to the operating room for trach and peg placement on with dr.. mr. postoperative course continued to get more complicated when he became bacteremic. id was consulted. broad spectrum antibiotics were initiated. cultures revealed e coli uti, serratia pna and s. marascens bacteremia. pod 15 from initial ta aaa repair now with ischemic eschar around the inferior portion of the wound. general surgery and plastics was consulted. it was suspected that the latissimus was perforated below the area of eschar. due to the perigraft and surrounding intrathoracic inflammatory changes and fluid evident, all teams agreed that debridement was required. on mr. debridement of open wound left scapular region with debridement of muscle, subcutaneous tissue, and skin; latissimus flap reconstruction. please see operative report for further details. the patient had a flexiseal in place for several days in the setting of his critical illness. hematochezia became evident. gi and acs was consulted. the patient was scoped by gi who visualized active rectal bleeding and was concerned for perforation on anoscopy likely secondary to flexi-seal s/p packing, seemingly with hemostasis.hematocrits remain stable. mr. began to slowly improve. id signed off after recommending: antibiotics for wound infection: would continue vanco/flagyl for 2 weeks from day of debridement (),for serratia aaa graft infection: plan to continue cipro iv for 4 weeks for presumed serratia endovascular infection (). and will require life long suppression with cipro po after this given presence of graft. speech and swallow had been consulted and following throughout mr. course. he remains npo with continued nutrition, hydration and medication via the peg in place. he was fitted for a passy muir valve. he weaned to trach collar and pmv during the day hours and is rested overnight on cpap. after a complicated course from his initial emergent repair of ruptured thoracoabdominal aortic aneurysm, mr. has made slow progress. on the day of his discharge to rehab on , he remains paraplegic, anticoagulated for paf/cva, with a jp drain and sutures intact s/p thoracoabdominal debridement. he is completing his antibiotics per id recs. all follow up apppointments were advised. medications on admission: hydrochlorothiazide 12.5 mg tab, lorazepam 0.5mg t tab hs prn, pindolol 5 mg tab qd, pravastatin 10 mg, aspirin 81 mg, mvi, psyllium powder 1 packet prv, ranitidine 75 mg discharge medications: 1. aspirin 81 mg , chewable : one (1) , chewable po daily (daily). 2. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 3. magnesium hydroxide 400 mg/5 ml suspension : thirty (30) ml po daily (daily) as needed for constipation. 4. pravastatin 20 mg : one (1) po daily (daily). 5. ipratropium-albuterol 18-103 mcg/actuation aerosol : six (6) puff inhalation q4h (every 4 hours). 6. white petrolatum-mineral oil 56.8-42.5 % ointment : one (1) appl ophthalmic prn (as needed) as needed for unresponsive and eyes open. 7. bisacodyl 10 mg suppository : one (1) suppository rectal hs (at bedtime) as needed for constipation. 8. insulin regular human 100 unit/ml solution : one (1) injection every six (6) hours: per riss. 9. acetaminophen 325 mg : two (2) po q6h (every 6 hours) as needed for pain/fevers. 10. chlorhexidine gluconate 0.12 % mouthwash : one (1) ml mucous membrane (2 times a day). 11. potassium chloride 20 meq packet : one (1) packet po prn (as needed). 12. lansoprazole 30 mg ,rapid dissolve, dr : one (1) ,rapid dissolve, dr daily (daily). 13. sertraline 25 mg : two (2) po daily (daily). 14. oxycodone 5 mg/5 ml solution : one (1) po q4h (every 4 hours) as needed for pain. 15. furosemide 40 mg : one (1) po three times a day. 16. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q6h (every 6 hours). 17. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours). 18. metoprolol tartrate 25 mg : three (3) po tid (3 times a day). 19. warfarin 1 mg : two (2) po once (once) for 1 doses. 20. heparin, porcine (pf) 10 unit/ml syringe : one (1) ml intravenous prn (as needed) as needed for line flush. 21. olanzapine 5 mg : one (1) po tid (3 times a day) as needed for delirium. 22. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback : one (1) intravenous q8h (every 8 hours): dc . 23. ciprofloxacin in d5w 400 mg/200 ml piggyback : one (1) intravenous q24h (every 24 hours): dc then convert to oral cipro for life. 24. vancomycin 500 mg recon soln : one (1) recon soln intravenous q 12h (every 12 hours): dc . 25. warfarin 1 mg : daily md once a day. discharge disposition: extended care facility: hospital for continuing medical care - ( center) discharge diagnosis: -ruptured thoracoabdominal aneurysm - s/p emergent repair -cerebral and spinal infarcts:scans showing multiple areas of slow diffusion, predominantly in l parietal and occipital lobe concerning for sub-acute infarcts, -paraplegia -s. marascens bacteremia with presumed graft infection, vap and post-op wound infection at the back of the thoracotomy site with coag negative staph. discharge condition: afluent aphasia, alert & oriented x1 intermittently, pt is paraplegic incisional pain managed with oral analgesia incisions: thoracotomy- jp/sutures intact, healing well, no erythema or drainage discharge instructions: -for wound infection: would continue vanco/flagyl for 2 weeks from day of debridement () -for serratia aaa graft infection: plan to continue cipro iv for 4 weeks for presumed serratia endovascular infection (). will require life long suppression with cipro po after this given presence of graft. *.**please check cbc with differential /bun/creatnine in 1 week and fax results to clinic, dr. :: 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: please schedule appointments when you are discharged from rehab with: cardiac surgeon: dr. # vascular surgeon:dr. office will contact you to arrange a follow up appointment. cardiologist:dr. neurology:please follow up in the stroke prevention clinic in about 3 months when stable. id:dr. at 9am at clinic.**please check cbc with differential /bun/creatnine in 1 week and fax results to :: plastics surgery follow up:dr. # suite #600 , ma date/time: , at 2:45pm please call to schedule appointments with your primary care dr. when discharged from rehab. **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; paroxysmal afib/cva goal inr :2-3.0 first draw: results to phone fax Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Enteral infusion of concentrated nutritional substances Other electric countershock of heart Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Resection of vessel with replacement, thoracic vessels Closed [endoscopic] biopsy of bronchus Graft of muscle or fascia Nonexcisional debridement of wound, infection or burn Resection of vessel with replacement, aorta, abdominal Other myectomy Other intra-abdominal vascular shunt or bypass Diagnoses: Pure hypercholesterolemia 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 Acute kidney failure, unspecified Atrial fibrillation Personal history of tobacco use Bacteremia 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 encephalopathy Infection and inflammatory reaction due to other vascular device, implant, and graft Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Ventilator associated pneumonia Cerebral artery occlusion, unspecified with cerebral infarction Aphasia Iatrogenic cerebrovascular infarction or hemorrhage Hemorrhage of rectum and anus Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Other and unspecified Escherichia coli [E. coli] Non-healing surgical wound Thoracoabdominal aneurysm, ruptured Vascular myelopathies Injury to rectum, without mention of open wound into cavity Flaccid hemiplegia and hemiparesis affecting unspecified side Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath (initial cc) transfer from osh for nstemi major surgical or invasive procedure: cardiac catheterization with thrombectomy and ptca of left circumflex artery history of present illness: 49 year old male with a history of diabetes mellitus, coronary artery disease with ?pci and stents, presenting from with shortness of breath and respiratory distress. initially, the patient presented called ems with a hx of shortness of breath x 2 hours. he told ems that he was unable to lie flat and he was thought to be pale and diaphoretic. the patient denied any chest pain or chest pressure; he was tachycardic to the 130s, htn to 245/128 and oxygen saturations of 75-85% on 2 l nc. he was started on nitropaste, sl ntg in the field. lopressor, ativan, solumedrol, lasix, levoquin and ctx, vanco were given, and was then bag ventilated given poor saturations and eventually placed on mechanical ventilation and transferred to for further management. upon arrival to on transfer from nashobe, bp still in 150s, slowly trended down to sbp 90s-110s, on a propofol drip for sedation. he received 4l ns with 3l uop. past medical history: past medical history (incomplete, awaiting pcp ): 1. cardiac risk factors: dm 2 2. cardiac history: - cad s/p pci with stent x2 to lcx (~2 years ago) 3. other past medical history: unknown social history: social history: on review of micu admission note, +etoh. family history: unknown physical exam: on admission: 98.6 108 120/71 24 100% on 100% fi02 ac, tv 550 rr 18 rr 15 gen: appropriately responsive on sedation heent: perrl, mmm heart: rrr, nl s1/2, no murmurs lungs: diminished at bases, upper lungs clear abd: benign extrem: no edema pertinent results: 11:35am ctropnt-0.27* 11:35am ck-mb-42* mb indx-3.5 probnp-869* 03:40pm ck-mb-95* mb indx-5.1 ctropnt-0.63* 03:40pm ck(cpk)-1860* 05:34pm lactate-3.4* 11:11pm ck-mb-117* mb indx-5.4 ctropnt-1.07* 11:11pm ck(cpk)-2156* 11:35am wbc-27.2* rbc-5.00 hgb-15.6 hct-46.4 mcv-93 mch-31.1 mchc-33.5 rdw-13.4 11:35am neuts-87* bands-0 lymphs-9* monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 other-1* 11:35am pt-12.8 ptt-24.1 inr(pt)-1.1 11:35am glucose-466* urea n-20 creat-1.3* sodium-142 potassium-4.7 chloride-102 total co2-18* anion gap-27* 11:47am lactate-5.7* 11:35am alt(sgpt)-72* ast(sgot)-106* ck(cpk)-1208* alk phos-116 tot bili-0.2 11:35am lipase-28 03:40pm ethanol-neg chest ct 1. no evidence of pulmonary embolism. 2. sequelae of massive aspiration with bilateral lower lobe consolidation and scattered centrilobular ground-glass opacities. 3. et and ng tubes positioned appropriately. tte the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with near akinesis of the basal inferolateral wall and mild global hypokinesis of the remaining segments (lvef = 40 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. 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 an anterior space which most likely represents a fat pad. impression: suboptimal image quality. mild regional and mild global left ventricular systolic function. no pathologic valvular flow identified. cardiac cath : final diagnosis: 1. one vessel coronary artery disease. 2. moderate diastolic ventricular dysfunction. 3. moderate systolic ventricular dysfunction. 4. moderate primary pulmonary hypertension. 5. acute posterior myocardial infarction, managed by acute ptca. 6. manual aspiration thrombectomy and ptca of the late stent thrombosis of the lcx. ct head impression: 1. technically limited study secondary to motion artifact without evidence of acute intracranial hemorrhage or mass effect. consider mr if there is concern for pres as the requisition. 2. layering secretions in the - and oropharynx. ct abdomen/pelvis impression: 1. bibasilar consolidations, right more than left. 2. no evidence of intra-abdominal source of fever. 3. fatty liver brief hospital course: 49 yo man with presumed cad, dm who presents w/ resp distress found to be profoundly hypertensive, evidence of aspiration on ct chest and rising ces. . 1) nstemi: pt presented with shortness of breath, rising troponins, and lbbb (unknown baseline), overall suspicious for acs, possibly in the setting of hypertensive emergency and flash pulmonary edema. troponin, cks rising since presentation to osh. pt denied any history of pain. he was started on iv heparin. he was continued on asa, plavix which he was taking his coronary stent. troponins were cycled x 3 with elevation in ck-mb and troponins. echo showed akinesis of the basal inferolateral wall and mild global hypokinesis of the remaining segments (lvef = 40 %). cardiology was consulted, and cath patient underwent cardiac cath, which showed in-stent restenosis of patient's prior lcx stent, and underwent thrombectomy and re-stenting. patient was also found to have moderate systolic and diastolic dysfunction, moderate pulmonary hypertension. . 2) acute on chronic heart failure: patient was found to have moderate systolic and diastolic dysfunction (ef 40%), and required lasix diuresis for fluid overload and pulmonary edema. he responded well to a lasix drip, with no supplemental o2 requirement on discharge. . 2) aspiration pna - febrile with wbc count elevated at 27 on initial labs, now trending down likely after fluid resuscitation. aspiration pna vs pneumonitis read based on appearance on ct chest. he was started on vancomycin, cefepime, and ciprofloxacin. sputum and blood cultures were obtained, but were negative. patient finished a course of treatment for aspiration pna and antibiotics were subsequently d/c'ed. . 3) persistent fevers - patient continued to be febrile despite broad antibiotic coverage, and was believed to be febrile dts vs. drug fever, as all cultures and infectious w/u was negative following the initial imaging of aspiration pna vs. pneumonitis. following the resolution of dts and d/c of ciwa, patient's antibiotics were discontinued after a full course of treatment for possible aspiration pneumonia. patient's fevers resolved shortly thereafter with all cultures negative. likely fevers dts or from antibiotics which were started to treat aspiration pna on intial presentation, and had completely resolved prior to discharge. . 4) acute renal failure - pt was admitted with elevated creatinine, which improved upon receiving ivf. likely poor perfusion in the setting of nstemi. . 5) mental status - patient was initially sedated on a vent, but was weaned off vent and sedation following cardiac catheterization. once off sedation, the patient went into dts from alcohol withdrawal, and ciwa scale was promptly initiated and patient was re-intubated with re-initiation of sedation. patient was gradually weaned off sedation and extubated, and ciwa scale was continued until patient's dts resolved. mental status returned to baseline prior to discharge. patient was seen by social work re: quitting alcohol use and was interested in quitting alcohol use on discharge. . 6) dm: patient required sliding scale insulin while in-house, and was discharged on insulin with f/u. medications on admission: home medications: asa 325 spironolactone 25 daily plavix 75 daily niaspan 500 glyburide 5 lisinopril 10 daily metoprolol 25 daily simvastatin 40 metformin 1000 medications on transfer: aspirin 325 mg po daily cefepime 2 g iv q12h chlorhexidine gluconate 0.12% oral rinse 15 ml oral ciprofloxacin 400 mg iv q12h clopidogrel 75 mg po daily famotidine 20 mg iv q12h fentanyl citrate 25-100 mcg/hr iv drip infusion heparin iv per weight-based dosing insulin sc (per insulin flowsheet)sliding scale & fixed dose midazolam 1-10 mg/hr iv drip titrate to sedation propofol 5-20 mcg/kg/min iv drip titrate simvastatin 80 mg po daily spironolactone 25 mg po daily vancomycin 1000 mg iv q 12h discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily): decrease to 162 mg (2 baby aspirin) in 1 month. 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. metoprolol succinate 100 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:*2* 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. insulin 75/25 sig: forty five (45) units injection twice a day. disp:*1 bottle* refills:*2* 7. one touch ultra test strip sig: one (1) bottle in four times a day. disp:*1 bottle* refills:*2* 8. niacin 500 mg capsule, sustained release sig: one (1) capsule, sustained release po at bedtime. 9. lisinopril 5 mg tablet sig: one (1) tablet po once a day. 10. multivitamin tablet sig: one (1) tablet po once a day. 11. clopidogrel 75 mg tablet sig: one (1) tablet po bid (2 times a day): decrease to 75mg, one pill, after 1 month. disp:*60 tablet(s)* refills:*2* 12. nitroglycerin 0.4 mg tablet, sublingual sig: 1-3 tablets sublingual take 1 tablet under tongue every 5 minutes for total 3 doses as needed for chest pain. disp:*1 bottle* refills:*0* 13. lancets misc sig: one (1) lancet miscellaneous four times a day: please check your blood sugar at breakfast, lunch, dinner, and before bedtime. disp:*120 lancets* refills:*2* discharge disposition: home with service facility: discharge diagnosis: non st elevation myocardial infarction delerium tremens acute renal failure diabetes mellitus type 2 acute respiratory failure discharge condition: stable. discharge instructions: you had a heart attack because a stent in your heart artery clotted off. this was opened by a balloon angioplasty and the blood flow was restored. you will need to take plavix and aspirin every day for at least one year and possibly indefinitely. for the next month, please take plavix twice daily. your kidneys had trouble working while you were so sick, they are now normal. you also had dt's from not drinking and was on valium that is now off. do not drink any more alcohol, you should seek intensive day therapy and aa after you go home. your diabetes medicine was also changed to insulin only to be taken before breakfast and dinner. check your fingersticks before meals and at bedtime, write down the results so you can show them to the np clinic at . . medication changes 1. stop taking metformin and glyburide 2. start insulin 75/25 45 units twice daily before breakfast and dinner. eat lunch about 5 hours after your insulin shot and eat a snack at bedtime. 3. decrease your lisinopril to 5 mg daily 5. increase your atorvastatin to 80 mg daily 6. increase your metoprolol to 150 mg daily . please call dr. if you have any recurrent chest pain, nausea, fevers, trouble breathing, or any other concerning symptoms. followup instructions: primary care: , : date/time: wed at 11:30am. diabetes: nurse phone: date/time: at 11:00am. , . cardiology: , md phone: date/time: tuesday at 10:00am. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Insertion of endotracheal tube Combined right and left heart angiocardiography Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Acidosis Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other complications due to other cardiac device, implant, and graft Acute systolic heart failure Alcohol withdrawal delirium

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain and wide complex tachycardia major surgical or invasive procedure: ep study internal cardiac defibrillator placed history of present illness: 51m with cad s/p pcix2 to the lcx (,), systolic chf (ef=40% in ) and t2dm, copd on home o2, who was transfered from osh after multiple shocks for wide-complex tachycardia. . patient was noted to have the onset of chest pain the night prior to admission, he subsequently called 911, ems found him in resp distress, diaphoretic, wct on monitor @ 180??????s, shocked biphasic sync 70 and 100 without effect and was brought to hospital. at ed he received amio 150mg iv x 2 , shocked biphasic sync 100, 100, 150, 200, calc chloride, insulin, bicarb adenosine 6 & 12. none of these interventions terminated his wct and he was then given a metoprolol iv with reported improvement in his heart rate to the 100s. of note, he has a known lbbb documented at prior admission to in . never lost peripheral pulses, remained responsive to voice throughout. patient had also recieved aspirin pr. at osh noted to be hypoxic to the 80s and cxr was consistent with pulmonary edema. nasal intubation was attempted x2 but patient did not tolerate, then intubated with etumidate, reportedly had copious secretions on intubation. bedside echo ?????? dilated lv,minimal septal/lateral contractility, hypok at apex. no pericardial effusion. bp's subsequently labile at 80's-100's. a right groin line was attempted which was found to be in the femoral artery and was subsequently removed, he reportedly received a dose of unasyn for this + suspected aspiration. . on admission to ed, patient was intubated/vented on fent/versed, cmv fio2: 100% peep: 18 rr: 24 vt:470, initial vitals were 129 97/70 81%. - cxr showed diffuse bil alveolar infiltrates consistent with florid pulmonary edema. - chem 7, cbc showed wbc 19.0, hyperglycemia to 433 but was otherwise unremarkable. wbc = 19.0 - ecg (my read) shows regular tachycardia 110 with leftish axis wnl and lbbb morphology which is consistent with his prior baseline and without precordial concordence. rythm looks like sinus tachycardia, as p waves identified consistent with prior tracing with pr = 0.16. - given 10units of iv insulin . . review of systems 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: diabetes, hypertension cad (s/p pci with stents to lcx in , s/p cardiac cath , which showed in-stent restenosis of patient's prior lcx stent, and underwent thrombectomy and re-stenting. ) sys+diast chf ( echo showed akinesis of the basal inferolateral wall and mild global hypokinesis of the remaining segments (lvef=40%). chronic lbbb hld social history: +etoh - per son, drinks fifth of vodka every few days family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: physical exam on admission: general: sedated, intubated, following commands heent: sclera anicteric. perrl. conjunctiva pink, no pallor or cyanosis. neck: supple, difficult to assess jvp but no ovious jvd. no carotid bruits. cardiac: distan regular heart sounds lungs: bil diffuse insp crackles on all lung fields abd: soft, ntnd, no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. ext: cool hands and feet, with mildly dusky bil fingertips. no c/c/e. no femoral bruits. right groin hematoma appears stable, s/p attempted femoral line in osh. skin: no stasis dermatitis, ulcers, scars pulses: therapy dp + radials palpable bilaterally physical exam on discharge: t 98.4, normotensive, not tachycardic, not tachypnic general - mr. is a well-appearing 51 y/o male found resting in bed in nad. heent - perrl, eomi, sclera anicteric, mmm neck - no jvd, no lymphadenopthy chest - upper left chest icd placed - dressing c/d/i, no warmth or erythema, mild tenderness to palpation cv - normal rrr, s1 and s2 audbile, no m/r/g resp - ctab, no wheezes, ronchi, rales gi - soft, ntnd, + bs ext - no c/c/e, 2+ dp pulses pertinent results: labs on admission: 06:50am blood wbc-19.5* rbc-4.83 hgb-15.9 hct-47.5 mcv-98 mch-32.9* mchc-33.5 rdw-12.7 plt ct-291 09:21am blood neuts-85.8* lymphs-7.2* monos-6.2 eos-0.6 baso-0.3 06:50am blood pt-11.4 ptt-30.4 inr(pt)-1.1 06:50am blood fibrino-295 09:21am blood glucose-396* urean-18 creat-1.1 na-144 k-4.7 cl-110* hco3-22 angap-17 09:21am blood alt-100* ast-171* ck(cpk)-526* alkphos-132* totbili-0.3 06:50am blood lipase-19 09:21am blood calcium-8.6 mg-2.1 09:21am blood vitb12-558 06:50am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 08:22am blood po2-104 pco2-54* ph-7.18* caltco2-21 base xs--8 03:15pm blood lactate-4.3* cardiac enzymes: 09:21am blood ck-mb-22* mb indx-4.2 ctropnt-0.09* 03:00pm blood ck-mb-28* mb indx-4.8 ctropnt-0.19* 11:10pm blood ck-mb-24* mb indx-4.7 ctropnt-0.28* 03:00pm blood ck(cpk)-582* 11:10pm blood ck(cpk)-506* cxr : 1. severe diffuse bilateral airspace opacities might represent pulmonary edema, pulmonary hemorrhage or widespread infection. further assessment with chest ct is recommended. 2. endotracheal tube ending 4.8 cm above the carina echo : the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef = 15 %) secondary to akinesis of the entire posterior wall, and hypokinesis (with regional variation) of the rest of the left ventricle - basal segments relatively well-preserved. no masses or thrombi are seen in the left ventricle. the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. with depressed free wall contractility. the aortic valve is not well seen. there is no aortic valve stenosis. trace aortic regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. cxr : impression: almost complete resolution of bilateral diffuse airspace opacifications consistent with diagnosis of pulmonary edema. cardiac mri : mildly enlarged left atrium and normal size right atrium. increased left ventricular cavity. thinned and akinetic antero-basal and mid-basal antero-lateral walls. moderately hypokinesis of the other ventricular segments with probable dyssynchrony also present. transmural late gadolinium enhancement of the antero-basal and mid-basal antero-lateral wall, consistent with fibrosis or scar, and low likelihood of contractile recovery after revascularization. no evidence of late gadolinium enhancement in the other, hypokinetic, left ventricular segments. normal right ventricular cavity size and function. the ascending aorta, descending aorta and main pulmonary artery were normal. no significant aortic or mitral regurgitation. no pericardial effusion. echo : the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size. overall left ventricular systolic function is severely depressed (lvef= 25 %). there is global hypokinesis with akinesis of the inferior wall. a left ventricular mass/thrombus cannot be excluded. 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) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: regional and global left ventricular systolic dysfunction. normal right ventricular systolic function. no pathologic valvular abnormalities identified. cxr : as compared to the previous radiograph, the patient has been extubated and the nasogastric tube has been removed. in the interval, the patient has received a pacemaker, the generator is in left pectoral position, the course of the leads is unremarkable, the tip of the lead projects over the right ventricle. there is no evidence of complications such as pneumothorax. no evidence of pulmonary edema. no pleural effusions. labs on discharge: 06:58am blood wbc-6.1 rbc-3.67* hgb-11.8* hct-34.0* mcv-93 mch-32.2* mchc-34.7 rdw-12.2 plt ct-188 06:58am blood glucose-158* urean-16 creat-0.9 na-136 k-4.2 cl-103 hco3-25 angap-12 06:58am blood mg-2.0 brief hospital course: 51m with cad s/p pcix2 to the lcx (, ), systolic chf (ef=40% in ) and t2dm, copd on home o2, who developed chest pain 1 day prior to admission was then treated by ems and osh ed with multiple shocks and meds for a stable wide-complex tachycardia which was not terminated, subsequently intubated for hypoxia and pulmonary edema and transferred to . patient now s/p icd placement. # wide-complex tachycardia: svt with abarrancy vs. sinus tachycardia. svt less likely given failure to convert with adenosine. ecg on admission consistent with sinus tachycrdia + lbbb. most likely this is tachycardia secondary to heart failure, pulmonary edema and possibly copd exacerbation. ischemia nevertheless should be ruled out given his history. cardiac enzymes were trended to peak, at third set when ck and ckmb reached plateau. an echo was obtained that showed overall left ventricular systolic function is severely depressed (lvef = 15 %) secondary to akinesis of the entire posterior wall, and hypokinesis (with regional variation) of the rest of the left ventricle - basal segments relatively well-preserved. the patient then had a cardiac mri to map out area of scar prior to ep study. he was then taken for an ep study where it became clear that this was indeed vt. however, there was difficulty finding focus with voltage map and was unable to induce vt. pt kept having pvcs and may be coming from an epicardial focus. therefore he was taken the next day to have an icd placed. he was then started on a 3 day course of antibiotics. cxr after procedure showed leads in correct place and without complication. he was discharged the day after icd placed. # resp distress: cxr on admission consistent with pulmonary edema. patient with known systolic chf with lvef = 40% per echo . unclear trigger for decompensation. ? of contributing underlying copd exacerbation +/- pneumonia (may have had aspiration during his dramatic intubation). the patient was intubated at osh prior to admission. the patient was diueresed with lasix. the patient was successfully extubated on hod 2. the patient's respiratory status remained well throughout the remainder of his hospitalization. # chf: the patient had an ef of 40% in . echo on admission showed ef of 15%, likely secondary to myocardial stunning. he was given iv furosamide 40mg x 2 on day of admission. diueresed for a goal -1.5 to 2 l net negative until euvolemic. we continued to diurese pt until he was euvolemic. he was discharged on a regimen of 40 mg po lasix. repeat echo the day before discharge showed ef of 25%. the patient was started on bb and ace-i. # coronaries: initially presented with cp, has history of lcx instent restenosis in . cardiac enzymes were initially trended and were initially elevated and trop up t 0.28 with elevated but flat ck and ckmb. however, the enzymes were hard to interpret given shocks. the patient was continued on home aspirin and started on metoprolol, lisinopril, and atorvastatin. # diabetes: the patient came in with a previous diagnosis of diabetes, however had not been taking his insulin for about 1 year. while in the hospital his glucose was trended and covered with iss and long acting insulin adjusted accordingly. he was discharged on a regimen of 20 units of glargine in the am. diabetic education was provided prior to discharge. # non-compliance: the patient has a h/o non-compliance and was only taking an aspirin prior to coming to the hospital. he reported insulin, but when re-evaluated he hadn't taken this in one year. diabetic education was provided as well as it was stressed the importance of his new medications and following up with the scheduled appointments as well as establishing care with primary care doctor. additionally social work met with the patient. he was set up with a home vna prior to discharge to provide medication teaching, diabetes teaching, and education. # alcohol abuse: the patient had no signs or symptoms of alcohol withdrawal throughout the hospitalization. education was provided and the patient was informed that it is strongly advised that he stop drinking. transitional issues: - the patient will need to establish with primary care doctor whom he reports he has never seen. he was instructed that it is very important for him to establish care. - patient will need diabetes management optimized - patient will follow up in device clinic and with cardiologist. medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. aspirin 325 mg po daily 2. humalog 75/25 45 units breakfast humalog 75/25 45 units dinner discharge medications: 1. aspirin 81 mg po daily rx *aspirin 81 mg one tablet(s) by mouth daily disp #*30 tablet refills:*2 2. atorvastatin 40 mg po hs rx *atorvastatin 40 mg one tablet(s) by mouth dailiy disp #*30 tablet refills:*2 3. furosemide 40 mg po daily rx *furosemide 40 mg one tablet(s) by mouth daily disp #*30 tablet refills:*2 4. lisinopril 5 mg po daily rx *lisinopril 5 mg one tablet(s) by mouth daily disp #*30 tablet refills:*2 5. metoprolol succinate xl 75 mg po daily hold for bp<100, hr<60 rx *metoprolol succinate 50 mg 1.5 tablet(s) by mouth daily disp #*45 tablet refills:*2 6. cephalexin 500 mg po q6h duration: 2 days rx *cephalexin 500 mg one capsule(s) by mouth four times a day disp #*8 capsule refills:*0 7. diabetes supplies glucose test strips needles disp: one month supply refil: 2 8. glargine 20 units breakfast rx *insulin glargine 100 unit/ml (3 ml) inject subcutaneously 20 units before breakfast disp #*2 each refills:*0 9. diabetes supplies glucometer discharge disposition: home with service facility: discharge diagnosis: acute on chronic systolic congestive heart failure coronary artery disease ventricular tachycardia diabetes chronic obstructive pulmonary disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you had a irregular looking tachycardia at and it was shocked multiple times. you needed a breathing tube to get enough oxygen and you were transferred to hospital for further management. you were admitted to the ccu. we do not feel that you had a heart attack. an electrophysiology study showed the rhythm was ventricular tachycardia. an internal cardiac defibrillator was placed that will shock you internally if this dangerous rhythm happens again. while you were here we worked to control your sugar level. we started you on a long acting insulin that you will take once a day. however, it is very important that you follow up with your primary care physician to get your diabetes under better control. your heart is weaker after the shocks and you are at risk for fluid accumulation in your legs and lungs. weigh yourself every morning, call your heart doctor if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. an icd (defibrilator) was placed. no baths or swimming for one week, no driving for one week until after you are seen in the device clinic. do not lift your left arm or lift more than 5 pounds with your left arm for 6 weeks. it is extremely important that you quit drinking alcohol. this makes your heart weaker and works against the medicines that you are taking. it was a pleasure caring for you, your doctors followup instructions: department: cardiac services when: thursday at 11:00 am with: device clinic building: sc clinical ctr campus: east best parking: garage department: cvi , when: monday at 2:00 pm with: building: (, ma) campus: off campus best parking: free parking on site it is recommended that you establish care with a primary care physician. call and schedule an appointment within the next week. name: venkat, md address: ., , phone: md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Cardiac mapping Diagnoses: Other primary cardiomyopathies Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Alcohol abuse, unspecified Paroxysmal ventricular tachycardia 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 Peripheral vascular complications, not elsewhere classified Cardiogenic shock Old myocardial infarction Other left bundle branch block Hypoxemia Personal history of noncompliance with medical treatment, presenting hazards to health Hypovolemia Phlebitis and thrombophlebitis of superficial veins of upper extremities Acute on chronic systolic heart failure Mixed acid-base balance disorder Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Other dependence on machines, supplemental oxygen

allergies: ibuprofen attending: chief complaint: sob, hypoxia major surgical or invasive procedure: mitral valvuloplasty history of present illness: 75 y/o f with hx of cad, severe recurrent ms valve from , afib, and diastolic chf presents with worsening hypoxia and shortness of breath as an inpatient pre-op for mitral valve replacement. patient had been admitted to from to for workup of sob. thought to be mostly due to chf, although has history of copd and sarcoidosis as well. . this admission, she was admitted sunday as scheduled admit for pre-op but had worsening shortness of breath and pedal edema. prior to admission at home she had been doing well. she was on home oxygen and had been monitoring her i/os and avoiding salts without any change in her breathing. then the morning of admission she noticed her legs were slightly more swollen than normal. while an inpatient, she continued to get more sob and have more swelling. she was hypoxic and treated for chf exaccerbation with lasix. . plan for surgery was was cancelled. she was transferred to team for further management of her hypoxia. . today she is feeling better than she was the last few days. she does complain of a cough. has had low grade fevers, but no sweats or chills. her cough is non-productive. she denies chest pain. she thinks her swelling has improved. . on review of systems, she 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. she denies recent fevers, chills or rigors. she 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, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. past medical history: # cardiac risk factors: (-) diabetes, (+) dyslipidemia, (+) hypertension . # cardiac history: -cabg: none -percutaneous coronary interventions: see below -pacing/icd: none, hx of afib . # other past medical history: atrial fibrillation chronic diastolic congestive heart failure mitral stenosis, s/p mitral valve replacement (tissue) recurrent mitral stenosis aortic stenosis chronic obstructive pulmonary disease sarcoidosis . # past surgical history: mitral valve replacement ovarian surgery s/p ectopic pregnancy total abdominal hysterectomy right lung biopsy left breast biopsy social history: widowed, lives with son; has son and daughter both supportive. she worked as a receptionist up until when her health worsened. -tobacco history: 40 pack/yr history, quit 15 years ago -etoh: one drink per day -illicit drugs: never family history: there is no family history of premature coronary artery disease or sudden death. mother had mi at 79. has sister with stroke. physical exam: vs: tm 99.9, tc98.5, bp 122/65 (99/55-122/65), p 80 (80-90), r 28 (26-26), 100% 3l (85-100 on 3l today) general: thin, cachectic f in mild respiratory distress, having hard time completing sentences. 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 elevated jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. 2/6 systolic murmur. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. bibasilar crackles halfway up lung fields, no 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. 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: 05:30pm blood wbc-10.6# rbc-3.61* hgb-9.7* hct-30.8* mcv-85 mch-26.7* mchc-31.4 rdw-19.3* 05:35am blood wbc-6.4 rbc-3.42* hgb-8.8* hct-28.2* mcv-82 mch-25.7* mchc-31.2 rdw-17.4* 01:25pm blood ptt-66.0* 05:35am blood pt-16.4* ptt-118.0* inr(pt)-1.5* 05:35am blood glucose-101 urean-27* creat-1.0 na-133 k-4.0 cl-98 hco3-22 angap-17 05:30pm blood glucose-113* urean-28* creat-0.9 na-134 k-4.2 cl-101 hco3-22 angap-15 05:30pm blood alt-23 ast-19 ld(ldh)-224 alkphos-47 totbili-0.5 01:35am blood ck(cpk)-17* 05:45am blood ck(cpk)-21* 09:20pm blood ck(cpk)-16* 05:49am blood ck(cpk)-11* 01:35am blood ck-mb-notdone ctropnt-<0.01 05:45am blood ck-mb-notdone ctropnt-<0.01 09:20pm blood ck-mb-notdone ctropnt-0.02* 05:49am blood ck-mb-notdone ctropnt-<0.01 03:43am blood caltibc-369 ferritn-103 trf-284 05:30pm blood %hba1c-5.2 03:31am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-2* ph-5.5 leuks-tr 03:31am urine rbc-1 wbc-16* bacteri-few yeast-none epi-6 urine culture negative blood cultures x2 negative. urine culture negative. blood culture negative. urine culture negative. sputum culture 1:21 am sputum site: expectorated **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast with pseudohyphae. 1+ (<1 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in clusters. respiratory culture (final ): moderate growth oropharyngeal flora. yeast. moderate growth. gram negative rod(s). rare growth. blood culture negative 05:30am blood wbc-8.0 rbc-3.37* hgb-8.8* hct-27.4* mcv-81* mch-26.0* mchc-32.1 rdw-16.8* 05:15am blood pt-15.0* ptt-47.4* inr(pt)-1.3* 05:30am blood glucose-87 urean-23* creat-1.2* na-131* k-4.5 cl-92* hco3-24 angap-20 c. 1. resting hemodynamics were performed. the right sided filling pressures were significantly elevated (mean ra pressure was 21mmhg). the pulmonary artery pressure was significantly elevated measuring 80/37mmhg. the left sided filling pressures were significantly elevated with mean pcw pressure at 36mmhg. the systemic arterial pressures were within normal range measuring 110/63mmhg. 2. intracardiac echocardiography was used throughout the procedure for identifcation of anatomic structure, placement of devices and assessment of valvular function. 3. successful balloon angioplasty of the prosthetic mitral valve using a inoue balloon inflated to 19mm. final diagnosis: 1. coronary arteries are normal. echo impression: severe stenosis of the bioprosthetic mitral valve due to restricted leaflet motion and probable pannus ingrowth. mild mitral regurgitation. right ventricular hypertrophy, dilation, and hypokinesis. moderate pulmonary hypertension. the left ventricular cavity is small in size with hyperdynamic function. brief hospital course: 75 year old f with hx of cad, diastolic chf and as/ms who presented for scheduled redo sternotomy and avr/mvr is transferred to for worsening sob and hypoxia thought to be secondary to chf exacerbation and pneumonia. . # sob - was transferred to from ct for worsening sob and hypoxia in the setting of chf exacerbation prior to her scheduled avr/mvr. she was tachpneic and had a respiratory acidosis that was worsening, so was transferred to the ccu for one day. with aggressive diuresis and treatment of a pna seen on ct scan, she started to improve. she was on ceftriaxone and vanco initially, then weaned to just ceftriaxone for a 10 day course for community acquired pneumonia. there were no positive cultures to guide treatment. of note, despite completing antibiotic course, patient continued to have crackles at lung bases, and required 4l oxygen to keep o2 sats over 90%. without supplemental oxygen, she would desaturate to 70s. pulmonary was consulted, who agreed that she was adequately diuresed, and there was no other obvious cause of hypoxia. patient was diuresed 500cc-1l daily. prior to valvuloplasty, she required 1l of supplemental oxygen to keep o2 sats > 95%. on discharge she was breathing comfortably o2 sats > 95% on room air. . # pump - has known diastolic chf, presented with worsening hypoxia and pedal edema most consistent with chf exacerbation. likely was exaccerbated by the underlying pneumonia causing an exacerbation. patient was agressively diuresed on admission. once down to dry weight, patient no longer had le edema. continued to have bibasliar crackles. we maintained her on lasix to keep her i/o's net even to negative 500cc. -please continue lasix with goal i/o's even to negative 500cc. . # fevers - patient was having low grade fevers until when she spiked to 101.4; ct scan was consistent with pneumonia, and she was treated with ceftriaxone. afebrile after completion of antibiotics. c diff x2 negative prior to discharge. . # valves - has as (ava1.2-1.9) and ms with plans for replacement of both valves this admission, although with new hypoxia and chf exacerbation, surgery was on hold indefinitely. was on heparin gtt while waiting for surgery. however, after further diuresis and treatment of pneumonia, patient continued to require 4l supplemental o2. on had mitral valvuloplasty, recovered well. continued on heparin gtt. prior to discharge heparin was stopped, and patient was discharged on lovenox. and started coumadin 4mg po daily. -please check inr and adjust coumadin accordingly to keep inr between 2.0 and 3.0 . # coronaries - had last month without coronary disease. continue asa 81 mg. . # anemia - chronic, stable. . # rhythm - has known afib in rate control. had 2 episodes of 4 and 8 beat nsvt. lytes have been ok with frequent k+ replacement while being diuresed. she was on heparin gtt and off coumadin because she was pre-op. patient was briefly transferred to ccu for 3rd degree av block in the setting of amiodarone, diltiazem, and carvedilol. nodal agents were held, and patient returned to sinus rhythm. . . # code - full; have been discussing with family and in ccu, plan was to remain full code. patient has expressed wishes not to be intubated indefinitely. . medications on admission: medications on transfer: furosemide 40 mg iv bid lorazepam 1 mg po q8h:prn anxiety bisacodyl 10 mg pr hs:prn constipation ipratropium bromide neb 1 neb ih q6h albuterol 0.083% neb soln 1 neb ih q4h ferrous sulfate 325 mg po daily docusate sodium 100 mg po bid fluticasone-salmeterol diskus (250/50) 1 inh ih vitamin d 400 unit po daily calcium carbonate 500 mg po bid cyanocobalamin 250 mcg po daily zolpidem tartrate 5-10 mg po hs:prn insomnia albuterol inhaler 2 puff ih q6h omeprazole 20 mg po daily amiodarone 50 mg po daily diltiazem extended-release 180 mg po daily montelukast sodium 10 mg po daily aspirin 81 mg po daily . . home meds: asa 81' lasix 20' coumadin 4' singulair 10' cartia 180' amiodarone ?50' omeprazole 20' vitamin b12 250' kcl 10' albuterol inh '' antibiotics prn- dental procedure discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 5. cyanocobalamin 250 mcg tablet sig: one (1) tablet po daily (daily). 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(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. outpatient lab work please have inr checked on and have results faxed to your primary care doctor 10. lovenox 60 mg/0.6 ml syringe sig: sixty (60) mg subcutaneous twice a day: please administer until inr > 2.0. disp:*10 syringes* refills:*2* discharge disposition: home with service facility: home care program discharge diagnosis: 1. acute diastolic congestive heart failure 2. community acquired pneumonia 3. mitral stenosis 4. aortic stenosis discharge condition: stable. breathing comfortably without supplemental oxygen discharge instructions: you were admitted with shortness of breath. you were found to have a pneumonia, and were treated with antibiotics. you also had fluid in your lungs, and were diuresed agressively to help with your breathing. despite this, you required 4l of supplemental oxygen to breathe comfortably. you had a mitral valvuloplasty performed on , and recovered well after this. you no longer required supplemental o2 after surgery. . we have started you on a medication called lovenox. please do not stop taking this medication until your primary care doctor tells you that it is safe to do so. it will be stopped once your inr level is above 2. we stopped your amiodarone and diltiazem. please do not restart these medications until your primary care doctor tells you to. . it is important that you improve your nutritional status and work with physical therapy in the next few weeks. you will need to be re-evaluated by cardiac surgeon after a few weeks for possible mitral valve repair. . please keep all of the follow up appointments. . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet . if you have worsening shortness of breath, chest pain, palpitations, lightheadedness, or any other symptoms that concern you, please call your primary care doctor or go to the emergency department. followup instructions: you have a follow up appointment with your primary care doctor, dr. , next monday at noon. it is very important that you keep this appointment. we have contact him over the phone to give an update. he agreed to check your inr levels and tell you when to stop lovenox. he also agreed to schedule an appointment with your cardiologist early next week during this visit. . cardiology follow up: please follow up with dr. in 2 weeks. the clinic phone number is . Procedure: Diagnostic ultrasound of heart Right heart cardiac catheterization Percutaneous balloon valvuloplasty Other operations on nervous system Intravascular pressure measurement of coronary arteries Diagnoses: Pneumonia, organism unspecified Acidosis Anemia of other chronic disease Unspecified essential hypertension Other pulmonary insufficiency, not elsewhere classified Chronic airway obstruction, not elsewhere classified Atrial fibrillation Other chronic pulmonary heart diseases Personal history of tobacco use Sarcoidosis Rheumatic heart failure (congestive) Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Atrioventricular block, complete Long-term (current) use of anticoagulants Heart valve replaced by transplant Lung involvement in other diseases classified elsewhere Cardiac rhythm regulators causing adverse effects in therapeutic use Mitral valve stenosis and aortic valve insufficiency

allergies: penicillins / cephalosporins / sulfa (sulfonamides) / aztreonam / clindamycin attending: chief complaint: abdominal pain duodenal perforation major surgical or invasive procedure: s/p duodenal perforation repair w/ patch history of present illness: 47 yo f transferred to ccu on from with hypotension requiring pressors, st elevation on ekg, and elevated troponins. initially the patient was admitted to the osh with a severe rash, nausea, vomiting, and hypotension on . prior to this she was being treated for a l toe infection, which ultimately was treated with a toe amputation by podiatry at the osh. the rash and other symptoms were thought to be due to antibiotics, presumably cephalosporins or penicillin. the patient was also noted to be in arf with a cr of 3. st changes were noted on ekg and her troponin was elevated following a run of af with rvr. she was then transferred to . on arrival here, she had pressures as low as 60/40. a pac was placed and showed a distributive shock-like picture with a low svr. she was treated with pressors, including neosynephrine and levophed. she was weaned off of these in the last 24 hours. she is now in sinus without recent af on bb's. an echo was performed on , which was positive for wma's and a lvef of 35%, however this appeared to be from an old infarct per the ccu team. her troponins peaked at .88 and have since been trending down, currently 0.4 on am labs. her arf is also resolving, with a cr of 1.3 this am. this morning the patient awoke around 8am with sharp, constant epigastric pain. she rated the pain as and has not increased throughout the day. the pain eventually migrated to her lower abdomen. she denies any nausea or vomiting. she has not eaten today. she denies any fevers or chills. she has never had pain like this before. the patient had a ruq us done earlier today, which was essentially unremarkable. a ct scan was obtained later in the day, at 6pm, which shows mild to moderate free air with a significant amount of inflammation around the duodenum. of note, she has been taking nsaid's recently for her toe pain. she also does not appear to have been on any gi prophylaxis while here in the ccu. her lactate has been normal throughout her hospitalization. she was being treated with vanc, cipro, and flagyl for her toe infection. all cultures were negative and these were stopped this morning. past medical history: pmh: newly diagnosed dm type ii, htn, ? hypercholesterolemia, rheumatic fever age 13 psh: podiatry surgeries (including recent toe amp), t&a, lithotripsy social history: lives with husband, 4 children and 1 grand-child. works as kindergraden teacher. tobacco history: quit 3 weeks ago. 1 ppd for > 25 years. etoh: denies. illicit drugs: denies. . family history: mother passed away lymphoma at 60s. father lung cancer at 60. father had a heart attack in age 60s. denies family history of early mi, dm or htn. physical exam: pe: 99.8 98.4 117/58 96 27 97%2l nad. a&ox3. somewhat labored breathing. obese. anicteric. tacky mucosal membranes. supple. mildly tachycardic and regular. diminished bases. limited inspiration secondary to abdominal pain. obese. nd. no bs. + guarding and mild rebound, both consistent with mild to moderate peritonitis. normal tone. no masses. no gross or occult blood. l foot bandaged. amp site c/d/i. no peripheral edema. pertinent results: 07:39pm blood wbc-5.2 rbc-3.34* hgb-9.4* hct-27.9* mcv-83 mch-28.2 mchc-33.8 rdw-15.7* plt ct-157 04:58am blood wbc-7.8 rbc-3.23* hgb-9.1* hct-27.0* mcv-84 mch-28.2 mchc-33.7 rdw-15.0 plt ct-151 04:58am blood glucose-125* urean-11 creat-1.2* na-136 k-3.9 cl-105 hco3-25 angap-10 09:43am blood alt-20 ast-19 ck(cpk)-47 alkphos-35* amylase-26 totbili-0.2 07:39pm blood ck-mb-notdone ctropnt-0.78* 05:05am blood ck-mb-notdone ctropnt-0.69* 09:43am blood ck-mb-notdone ctropnt-0.44* 04:58am blood calcium-7.8* phos-3.2 mg-1.8 07:56pm blood %hba1c-6.8* 04:13pm blood triglyc-235* hdl-25 chol/hd-5.0 ldlcalc-52 05:45am blood cortsol-21.4* 06:31am blood cortsol-33.5* 06:49am blood cortsol-37.4* 04:13pm blood -positive titer-1:40 . , f 47 normal sinus rhythm. q waves in leads v2-v5 aer consistent with anterior myocardial infaction. no previous tracing available for comparison. tracing #1 read by: , intervals axes rate pr qrs qt/qtc p qrs t 89 178 90 350/400 60 -22 57 . echocardiography report conclusions the left atrium and right atrium are normal in cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and anterior wall, distal inferior wall and apex. the remaining segments contract normally (lvef = 35 %). no masses or thrombi are seen in the left ventricle. there is a mild resting left ventricular outflow tract obstruction. 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 no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: mild symmetric left ventricular hypertrophy with mild resting lvot gradient and moderate regional systolic dysfunction c/w cad (mid-lad distribution). clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended . radiology report liver or gallbladder us (single organ) port study date of 10:17 am provisional findings impression: rsrc wed 1:11 pm pfi: study limited due to patient body habitus and increased hepatic echogenicity. pericholecystic, hyperechoic foci are most consistent with fat. however, if patient's symptoms continue or there is concern for emphysematous cholecystitis, ct scan would be more useful. right upper quadrant ultrasound: the liver is diffusely increased in echogenicity, a finding that is most often consistent with fatty infiltration of the liver due to obesity or other causes. however, fibrosis and/or cirrhosis cannot be excluded given this appearance. in this setting, sensitivity for focal liver lesion is markedly decreased. additionally, evaluation of the gallbladder is difficult due to poor beam penetration. the gallbladder measures 3.6 cm in maximal transverse dimension, which is at the upper limits of normal. a few foci of hyperechogenicity at the periphery of the gallbladder most likely represent pericholecystic fat. however, pericholecystic gas cannot be excluded. impression: markedly limited study. likely foci of fat at gallbladder periphery; however, air cannot be excluded. if the patient's symptoms continue and there is concern for emphysematous cholecystitis, ct examination would be more useful. . radiology report ct pelvis w&w/o c study date of 5:46 pm impression: 1. mild-to-moderate amount of pneumoperitoneum with wall edema and some surrounding inflammatory changes surrounding the region of the duodenal bulb most suggestive of a perforated duodenal ulcer. urgent surgical consultation is recommended. mild-to-moderate amount of simple free fluid within the abdominal and pelvic cavities. 2. probable fibroid uterus. this can be better defined with a dedicated pelvic ultrasound on a non-emergent basis. 3. nonobstructive right renal calculi as described above. 4. trace right pleural effusion. . brief hospital course: this is a 47 year old female who woke early this morning around 8am with sharp, constant epigastric pain. she rated the pain as and has not increased throughout the day. imaging: ct a/p: mild-to-moderate pneumoperitoneum with ct findings suggestive of probable perforated duodenal ulcer. she had mild to moderate peritonitis and free air on imaging, likely anterior perforation of duodenum secondary to stress ulceration vs nsaid use. she is currently hemodynamically stable and non-toxic appearing at this time. heparin gtt was stopped at 7pm, therefore we will take her to the operating room at approximately 10pm. she of moderate risk from a cardiac standpoint, although the ccu team does not feel her recent issues can be explained by an acute cardiac event, despite her troponin elevation and st changes. in the mean time, please add fluconazole to the current antibiotics regimen of vanc, cipro, flagyl. also, please start ppi gtt asap. she had a diagnoses: 1. perforated duodenal ulcer. 2. peritonitis. she went to the or on for: 1. exploratory laparotomy with suture duodenal ulcer closure of a single perforation. 2. modified patch overlay omental closure. she did well post-operatively and recovered without complications. pain: she had a pca for pain control. once her diet was advanced and she was tolerating, she was switched to po pain meds. gi/abd: she was npo with ivf and ngt. the ngt was d/c'd on pod 3. her diet was slowly advanced and at time of discharge was tolerating a regular diet. she was discharged home with protonix . cards: titrate home bp meds-->lopressor...if bp is a problem, lisinopril first, then hctz . cards: () heart rate was 140-160 with new-onset a fib and hypotension 60/40. the patient did not complain of chest pain or shortness of breath. she received iv fluid boluses and iv cardizem 5 mg x 3. ekg demonstrated st elevation v2, v3, i, ii. troponins 8.08, 8.19, 7.51. cpk 92, 104, 94. creatinine was 3.06 and on admission 1.7. c. diff negative for stool. patient was transferred to icu and started on neo-synephrine to maintain pressure support. echo reported as akinesis of mid-to-distal septum, apex, anterior wall and distal lateral wall with ef 35-40%. no valvular lesion. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. patient describes dizziness and light-headedness during hospital stay at which has since improved. shock: differential includes septic shock vs. cardiogenic shock. could be cardiogenic in setting of new st elevation, elevated troponins, localized akinesis on echo. however, ck was flat. in addition, co increased with decreased svr making septic shock more likely based on hemodynamics. septic shock supported by recent metatrasal infection as possible source. - patient transferred on neo for pressure support, switch to levophed to optimize septic shock therapy - source of infection dm cellulitis. patient with multiple allergies. started vancomycin, cipro and flagyl. discussed with id. - cvp goal > 12 . # acs: ekg demonstrates borderline st elevation, possible infarct to lad. troponins at outside hospital elevated (trop peak 8.19). echo demonstrated focal hypokinesis. however, co increased not decreased making cardiogenic shock less likely. patient asymptomatic throughout course. was plavix loaded and started on heparin drip. - cardiac enzymes c. trop elevated to 0.79 - continue conservative therapy of heparin drip, plavix and asa - cath currently not indicated in setting of infection and possible septic shock - ace and b-blocker on hold in setting of shock - start lipitor 80 mg qd - smoking cessation counselling (patient recently quit) . # a fib: patient with new onset a fib at . currently in sinus. b-blocker on hold in setting of shock. - monitor on tele . # acute renal failure: creatinine 3.0 which per osh records above baseline (on admission creatinine 1.7). differential includes prerenal vs. obstruction. obstruction unlikely as patient has foley. most likely pre-renal related to poor perfusion secondary to shock. - optimize cvp > 12, pressor support to increase renal perfusion. - send urine eosinophils to rule out allergic nephritis - send lytes, ua, urine culture . # hypersensitivity rash: blanching puritic rash with centralized clearing. most likely multiforme erythema secondary to antibiotics. - benadryl 50 mg q6 hr prn - hold steroids in setting of possible acute mi . # diabetes: recently diagnosed in . was on metformin as outpatient. hold as risk for lactic acidosis, and most likely will require contrast during admission. - insulin sliding scale - she was ordered to restart metformin at time of discharge. . # htn: hold outpatient htn meds in setting of shock. she was restarted on lopressor at time of discharge and lisinopril and hctz were held. . # left foot ulceration: full thickness ulceration extending from prior amp site dorsally and laterally to approximately the mid-shaft of 4th/5th metatarsal. the wound appears very clean with a beefy, granular base. there is no tracking or probing noted about the wound. there is no periwound erythema or any sign to suggest infection. there is no noted drainage from the wound. the wound is very sensitive for the patient. although it cannot be excluded, it seems unlikely at this point that the wound is the source for any sepsis, if indeed the patient is septic. cultures were taken of the wound but, unsure of the utility at this point given the patient's extensive antibiotic regimen for the last several weeks. she will follow-up with podiatry as an outpatient. medications on admission: metoprolol, hctz, lisinopril, metformin, aztreonam, clindamycin discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 3. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 4. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. disp:*25 tablet(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 6. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 8. metformin oral 9. ciprofloxacin 750 mg tablet sig: one (1) tablet po twice a day for 2 days. disp:*4 tablet(s)* refills:*0* discharge disposition: home with service facility: home health care discharge diagnosis: duodenal perforation shock: differential includes septic shock vs. cardiogenic shock acs a fib acute renal failure toe infection diabetes htn discharge condition: good 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 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 take all new meds as ordered. stop taking hctz and lisinopril. please see your pcp about continuing metformin as your blood sugars have been well controlled in the hospital. * continue with foot/toe dressing changes * monitor your incision for signs of infection (redness, drainage). * no heavy lifting (>10lbs) for 6 weeks. * no tub baths or swimming. it is ok to shower and wash. pat incision dry. . congratulations on quitting smoking. information was given to you on admission regarding smoking cessation and preventing relapses. followup instructions: please follow-up with your pcp weeks to review medications. . please follow-up with dr. in 3 weeks. call to schedule an appointment. . follow-up with gi for an egd on at 10:30. . call for questions or concerns. . podiatry recommends follow-up dr. . Procedure: Venous catheterization, not elsewhere classified Suture of duodenal ulcer site Diagnoses: Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Septic shock Other specified antibiotics causing adverse effects in therapeutic use Gangrene Ulcer of heel and midfoot Peritonitis (acute) generalized Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Peripheral angiopathy in diseases classified elsewhere Acute duodenal ulcer with perforation, without mention of obstruction Erythema multiforme, unspecified

allergies: codeine / valsartan attending: chief complaint: feeling "lousy" major surgical or invasive procedure: craniotomy for evacuation of l sdh history of present illness: pt is a 86 yo m with pmhx sig. for afib on coumadin, cad, dm2 who presented to the ed on with weakness. he was recently admitted here from with pneumonia and was treated with 5 day course of levofloxacin. he was feeling pretty good for days. he still had a residual cough with clear phelgm. then, he started to feel lousy again. his cough got slightly worse, no worsening sob. he has become weaker, generalized, with poorer po intake. he states he just wasn't thirsty. no chest pain. he has occ. palpitations, which are not new. no n/v/abdominal pain/diarrhea/constipation. no fevers, chills, night sweats. . in the ed, initial vs were: 97 49 151/94 16 100. exam is sig. for bibasilar crackles. cxr is stable. labs were sig. for elevated cr to 1.3. he received 2l ivfs. . on the floor, he just feels tired. . further history in the morning revealed that he has some trouble describing his symptoms, but does say that he feels like he has been having trouble using his right hand to eat, pick up objects, etc for ~24 hours. he does say that he had a pcp but does note that he did not call his pcp last night when feeling poorly, and is not able to say why. yesterday, he started to feel lousy again. he told night float that his cough got slightly worse, but this morning he says that he thinks his cough is overall better. he denies worsening sob. he has become weaker, generalized to everywhere, with poorer po intake. when asked why, he states he just wasn't thirsty. denies chest pain. he has occasional palpitations, which are not new (known afib). no n/v/abdominal pain/diarrhea/constipation. no fevers, chills, night sweats. he does note that he feels more down lately, particularly with respect to an ongoing disagreement with his son whom he has not seen in 3 weeks . past medical history: 1. atrial fibrillation, on coumadin 2. coronary artery disease, s/p mi years ago 3. cerebral vascular accident 4. diabetes mellitus, type ii 5. hypertension 6. hypercholesterolemia 7. gastroesophageal reflux disease 8. osteoarthtritis 9. anemia 10. bilateral cataract surgeries 11. history of microscopic hematuria 12. erythrodermic ctcl (mycosis fungoides, mf) 13. prostate adenocarcinoma s/p xrt and lupron social history: pt lives in , housing. he has vna service that sets up his medications. he states that his children recently have "turned their backs" on the patient whent he (pt) refused to move to . he has a son in who he has not spoken to in 3 weeks. he does speak with his daughter in ca, who he thinks updates his daughter-in-law of his situation. he quit smoking and etoh 30 yrs ago, previously was a 1 pack q3 days. family history: mother died in her 30s and father at 89, but doesn't know what the cause was. no strokes or mi. physical exam: vitals: t: 96.2, bp: 133/74, p: 51 (51-76), r: 18, o2: 99 on ra general: no acute distress, alert, oriented heent: sclera anicteric, mm slightly dry, oropharynx clear neck: supple, jvp normal, no lad lungs: overall clear throughout, no wheezes. occasional coughing productive of white/clear sputum. cv: irregularly irregular, no murmurs abdomen: soft, non-tender, non-distended, bowel sounds present ext: warm, well perfused, 1+ pulses, no edema neuro: ms in bues and bles. cn ii-xii intact. does have intact sensation in both upper and lower extremities. intact finger to nose on l, impaired on r. impaired pincer grasp on r, but hand strength bilaterally. rapid alternating movements intact bilaterally. speech fluent but with frequent word-finding difficulties/substitutions (once/sentence). pertinent results: cbcs: 07:19pm blood wbc-6.4 rbc-3.93* hgb-10.3* hct-31.6* mcv-80* mch-26.3* mchc-32.7 rdw-19.6* plt ct-331 07:00am blood wbc-5.5 rbc-3.94* hgb-9.8* hct-31.3* mcv-79* mch-24.9* mchc-31.4 rdw-19.3* plt ct-281 07:30am blood wbc-6.1 rbc-4.10* hgb-10.2* hct-32.4* mcv-79* mch-25.0* mchc-31.6 rdw-18.9* plt ct-289 07:30am blood wbc-5.4 rbc-4.03* hgb-10.3* hct-32.4* mcv-81* mch-25.6* mchc-31.8 rdw-19.5* plt ct-321 coags: 08:28pm blood pt-31.3* ptt-36.5* inr(pt)-3.1* 07:30am blood pt-32.2* ptt-32.7 inr(pt)-3.2* 07:30am blood pt-29.3* ptt-31.3 inr(pt)-2.9* 02:55pm blood pt-21.4* ptt-28.0 inr(pt)-2.0* lytes: 07:19pm blood glucose-65* urean-23* creat-1.3* na-141 k-3.4 cl-105 hco3-26 angap-13 07:00am blood glucose-65* urean-17 creat-1.1 na-138 k-3.9 cl-105 hco3-28 angap-9 07:30am blood glucose-105* urean-15 creat-1.0 na-139 k-3.8 cl-104 hco3-29 angap-10 07:30am blood glucose-129* urean-13 creat-0.9 na-140 k-3.5 cl-104 hco3-29 angap-11 lfts: 07:00am blood alt-12 ast-20 ld(ldh)-214 alkphos-58 amylase-74 totbili-0.9 card enzymes: 07:19pm blood ck(cpk)-122 02:55pm blood ck(cpk)-81 07:19pm blood ctropnt-0.01 02:55pm blood ck-mb-notdone ctropnt-<0.01 tsh/b12: 07:00am blood tsh-0.83 07:00am blood vitb12-593 . ekg: : sinus rhythm with ventricular and supraventricular premature depolarizations. left axis deviation. possible left ventricular hypertrophy. possible left anterior fascicular block. diffuse non-diagnostic repolarization abnormalities. compared to the previous tracing of there is no diagnostic change. . imaging: cxr : ap erect and lateral views of the chest: little change in right basilar opacity at the cardiophrenic angle and left base is consistent with atelectasis. there is no pleural effusion or pneumothorax. the heart size is normal. aorta is slightly unfolded, but the mediastinal silhouette is otherwise unremarkable. hilar contours and pulmonary vasculature are unremarkable. impression: no acute intrathoracic abnormality. . mri head : findings: there is a very large left cerebral hemispheric mixed t1 and t2 signal intensity subdural hemorrhage effacing the left cerebral hemispheric sulci, but causing, at most only a mm of rightward subfalcine herniation. the signal pattern of the subdural hemorrhage suggests a prominent area of acute bleeding, located posterior to the coronal suture. on the axial flair images, there may be a very thin right frontal subdural hemorrhage, without overt mass effect. there are a few small areas of restricted diffusion within the left parietal lobe subcortical region, subjacent to the acute hemorrhagic component of the subdural hemorrhage. this finding could indicate acute brain ischemia. there are very extensive areas of high t2 signal within the white matter of both cerebral hemispheres, consistent with chronic small vessel infarction. the principal vascular flow patterns are identified. there is moderate bilateral maxillary and prominent bilateral ethmoid sinus, as well as mild frontal sinus and sphenoid sinus mucosal thickening, all consistent with an ongoing inflammatory process. conclusion: large left cerebral convexity subdural hemorrhage, which has developed since the prior head ct scan. dr. has already contact the requesting physician, her of these findings, as well as other is noted in the above report. dr. indicated that emergency neurosurgical consultation is mandated. please see above report for additional findings. . ct head : findings: there is confirmation of the presence of a large left cerebral convexity subdural hemorrhage, with verification of the acute components of this hemorrhage positioned posterior to the left coronal suture. there is negligible subfalcine herniation, but likely mild effacement of the left lateral ventricle. low-density zones within the left basal ganglia, and to a lesser extent the periventricular white matter of the cerebral hemispheres again reflect chronic small-vessel infarction. there is prominent atherosclerotic calcification of the cavernous internal carotid arteries, and to a lesser extent the distal left vertebral artery at the level of the foramen magnum. conclusion: large left cerebral convexity subdural hemorrhage, including some acute components. once again, emergency neurosurgical consultation is mandated. . ct head pm: prelim: no evidence of tonsillar (or any other) herniation . ct head w/o contrast status post left frontoparietal craniotomy and subdural hematoma evacuation, expected frontal pneumocephalus is visualized with a draining tube in place, persistent effacement of the sulci with no evidence of shifting or deviation of the midline structures. mild residual subdural blood is identified at the left parietal convexity, contiguous followup is recommended. brief hospital course: mr. is an 86 yo m with past medical history significant for afib on coumadin, cad, dm2, htn, h/o of cva and recent pneumonia who presents with feeling "lousy" and right-handed weakness. . #. generalized weakness: the onset of symptoms was initially unclear at patient's initial presentation. he appeared slightly volume-depleted, and was noted to have been taking in poor pos due to poor appetite. he was given iv fluids overnight after admission, and his cr improved. per information from caretakers at his facility, the right hand weakness was new but of uncertain onset. they stated that he had generally looked unwell since returning from the hospital on and had mostly stayed in his room. on exam, he had actually good strength, but difficulty with specific motor movements in the hand. pt and ot were consulted and saw the patient on . there was concern of delirium versus subacute stroke for the cause. tsh and b12 were normal. his blood sugars were controlled with an insulin sliding scale. the decision was made to do an mri of his head. this was completed by early morning of , and was significant for large l subdural hematoma (see below). . # subdural hematoma: found on mri . patient without history of falls or head trauma; had been on coumadin for some time given atrial fibrillation. inr on admission was elevated, so coumadin was initially held. it was re-started on , and held again on . after the finding of sdh, a stat ct head was performed which demonstrated both old and new areas of bleeding. a neurosurgery consult was called. he was given 10 mg vitamin k and 2 units of ffp. q 4 neuro checks and telemetry monitoring were initiated. he was started on keppra 500 and prednisone 40 mg daily. a final read of the mri was also notable for acute to subacute strokes in the l parietal lobe. a neurology consult was called as well, and their recommendations were similar. the patient was noted to have periodic bradycardic events to the 30s as well as bps to 130-140/90s, and given concern for worsened bleeding, a stat head ct was performed. this demonstrated no evidence of herniation. at this point the decision was made to transfer the patient to the neurosurgery service and the step-down unit on 11. . .. . . #. community-acquired pneumonia: the patient had completed a 5 day course of levofloxacin. his symptoms and cxr seemed to be improving, so he was not given any further antibiotics. he was given a cough suppressant as needed. . #. acute renal failure: on admission, the patient had a creatinine of 1.3 from a baseline creatinine of around 1.0. this was felt to be likely secondary to pre-renal causes. he was given iv fluids, and his creatinine gradually came back down to 1.0. his hctz was held and the decision to re-start can be re-considered as an outpatient. . #. atrial fibrillation: chads2 score 5. on admission, the patient was being treated with warfarin with an inr goal of .5 per records. warfarin was held, then restarted, then held again for supratherapeutic inrs. following the discovery of the subdural, it was stopped and his anticoagulation was reversed. aspirin was also stopped. . #. coronary artery disease: the patient is s/p mi in past. he did not have any ischemic signs or symptoms on admission or throughout his hospitalization. he was initially continued on aspirin, imdur, atorvastatin and hctz was stopped. later aspirin stopped. he had negative troponins and cks upon presentation. his ekg was at baseline. . #. diabetes mellitus type ii: given the concern that the patient had low blood sugars on his electrolyte panels in the ed, and may have been taking his home medications incorrectly, these were held on admission, and he was placed on an insulin sliding scale. . #. erythrodermic ctcl (mycosis fungoides): the patient is followed by hematology. as an outpatient, he is on methotrexate therapy. following discussion with the nurse practitioner working with his heme/onc doctor, his methotrexate was held during this admission given his other medical concerns. he should follow up with this provider as an outpatient. patient was readmitted s/p presenting feeling "lousy". he was found to have a l acute on chronic sdh. he has a history of a-fib and was on coumadin at presentation. patient was taken to the or for evacuation of l sdh on . post operatively patient appeared to have a r droop presumed to be from weakness and r side weakness. he was also observed to have episodes of bradycardia where cardiology was consulted. there recs were to continue care currently, restart coumadin when able, and follow up with cardiology as an out patient. on , patient was alert and oriented x2 and rue deltoid, biceps/triceps and full strength on l side. his subdural drain was removed and he was transferred to the floor. on , patient was accessed by pt was it was determined that he was safe to go to rehab. patient continues to be alert and oriented x 3 with prompting, moving all extremities, some r deltoid weakness 3/5. incision is clean, dry and intact with staples in place. medications on admission: atorvastatin 80 mg po hs fexofenadine 60 mg po bid as needed for rhinorrhea. folic acid 1 mg po daily lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for pain. aspirin 81 mg po daily hydrochlorothiazide 12.5 mg po daily benzonatate 100 mg po tid isosorbide mononitrate 60 mg tablet sustained release 24 hr po daily methotrexate docusate sodium 100 mg po bid zolpidem 5 mg po at bedtime. miralax 17 gram/dose powder sig: one (1) packet po once a day. tamsulosin 0.4 mg po at bedtime. hydroxyzine hcl 25 mg po four times a day as needed for itching. metformin 500 mg po twice a day. glipizide 10 mg po twice a day. fluticasone nasal spray twice a day. coumadin 7.5 mg tue-sun, 5 mg mon discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. isosorbide mononitrate 60 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 6. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 7. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous asdir (as directed). 8. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezes. 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for wheezes. 11. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 12. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 13. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for headache. 14. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 15. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 16. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 17. prednisone 10 mg tablet sig: one (1) tablet po daily () for 5 days. 18. prednisone 5 mg tablet sig: one (1) tablet po daily () for 5 days. discharge disposition: extended care facility: at for nursing & rehab discharge diagnosis: l sdh discharge condition: mental status: confused - sometimes level of consciousness: alert and interactive activity status: ambulatory - independent discharge 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, you may safely resume taking this after it has been discussed with dr. at your follow up visit. ?????? 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) for removal of your staples/sutures and/or a wound check. 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 a ct scan of the brain without contrast. Procedure: Incision of cerebral meninges Diagnoses: Anemia, unspecified Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Coronary atherosclerosis of unspecified type of vessel, native or graft Compression of brain Long-term (current) use of anticoagulants Subdural hemorrhage Cerebral artery occlusion, unspecified with cerebral infarction

allergies: bactrim attending: chief complaint: shortness of breath major surgical or invasive procedure: thoracentesis history of present illness: reason for micu admission: hypoxia respiratory distress . primary care physician: , . . cc: cough, shortness of breath . hpi: 83yo female russian with history of cll presenting with respiratory distress. . per patient she reports 6 days of productive cough and progressive dyspnea. she reports associated fevers up to 100.2 and sore throat. two days prior to admission prescribed bactrim by her son who is a physician. worsened and she presented to her pcp . there vital signs notable for o2 sat 89% ra, improved to 92% on 2l nc. cxr with right increased effusion and possible left sided infiltrate. she was referred to ed for further eval. . in the ed, initial vs: 99.3 81 118/46 20 96% nrb. labs notable for wbc of 33.2, 61% lymphocytes; k: 5.2, creatinine 2.7, lactate 1.3. blood cultures obtained. cxr performed which demonstrated interval increase in moderate - large right pleural effusion as well as opacity lateral to left hilum. patient received po tylenol 650mg x1, iv ceftriaxone and levofloxacin. the patient was attempted to be weaned to nc, but desated to 90%. she was placed back on a nrb and transferred to for further evaluation and management. . in the the patient states that her breathing has improved. . ros: +: as per hpi -: denies any chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, pnd, lower extremity edema, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. past medical history: past medical history: # oncologic history chronic lymphocytic leukemia - diagnosed in : rai stage 0 in - s/p 5 cycles of fludarabine ending in . - recurrent anemia and advancing peripheral blood lymphocytosis and lymphadenopathy, prompted 4 additional 3-day cycles of fludarabine from to . # pmh 1. macular degeneration; legally blind. 2. chronic renal failure: baseline creatinine 1.5 3. hypothyroidism secondary to hemithyroidectomy on 4. diabetes: last hga1c: 7.0 5. hypertension. 6. in , she was admitted to hospital with respiratory infection due to h1n1 influenza a. she received 6 days of tamiflu and levaquin with improvement in symptoms. myelosuppression during her viral illness improved. . surgical history: hysterectomy at age 43. appendectomy. right thyroidectomy social history: lives with her husband. two children. retired teacher. originally from tob: none etoh: none family history: father - h/o esophageal cancer mother - h/o skin cancer sister - h/o breast cancer physical exam: on admission: gen: well-appearing, well-nourished, no acute distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, mmm, op clear neck: no jvd, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline cor: rrr, ii/ vi sem, no m/g/r, normal s1 s2, radial pulses +2 pulm: diminished bs at the right base, otherwise no w/r/r abd: soft, nt, nd, +bs, no hsm, no masses ext: no c/c/e, 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. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymo pertinent results: 05:30pm wbc-33.2* rbc-4.31 hgb-12.5 hct-36.5 mcv-85 mch-29.1 mchc-34.3 rdw-15.9* 05:30pm plt smr-normal plt count-164 05:30pm neuts-34* bands-0 lymphs-61* monos-5 eos-0 basos-0 atyps-0 metas-0 myelos-0 05:30pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 05:30pm glucose-134* urea n-48* creat-2.7*# sodium-136 potassium-5.2* chloride-102 total co2-20* anion gap-19 10:28pm pt-13.6* ptt-28.0 inr(pt)-1.2* 05:30pm ck(cpk)-89 05:30pm ctropnt-<0.01 05:35pm lactate-1.3 10:28pm pt-13.6* ptt-28.0 inr(pt)-1.2* 05:30pm ck-mb-4 probnp-1345* 11:09pm urine hours-random urea n-390 creat-52 sodium-37 potassium-30 chloride-16 11:09pm urine osmolal-270 11:09pm urine color-yellow appear-clear sp -1.008 11:09pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 11:09pm urine rbc-<1 wbc-1 bacteria-none yeast-none epi-<1 11:09pm urine mucous-rare 11:09pm urine eos-negative . igg iga igm 05:57 963 52* 66 . micro: legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. 2:33 pm pleural fluid gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (final ): no growth. urine culture (final ): <10,000 organisms/ml pleural pathology: pending ct chest: findings: bulky lymphadenopathy is present in the imaged portion of the lower neck, superior mediastinum, throughout the intrathoracic mediastinum, bilateral hila, and to a lesser extent within the axillary regions. large right pleural effusion is dependent in location and measures simple fluid density. a small amount of loculated fluid is also present within the major fissure and in the anterolateral portion of the right lower chest. extensive consolidation is present within the right lower and right middle lobes. peribronchiolar abnormalities are present in both upper lobes with a combination of ground glass and consolidation accompanied by bronchial wall thickening and small peribronchial nodules. a dominant peribronchial nodule in the left upper lobe measures 2.2 cm and is surrounded by a halo of ground-glass opacity (26, series 3a). this corresponds to a rapidly growing focal opacity on serial chest x-rays between and . additional peribronchiolar abnormalities are present to a lesser extent within the left lower lobe. exam was not tailored to evaluate the subdiaphragmatic region, but note is made of retroperitoneal or intra-abdominal lymphadenopathy as well as incompletely imaged splenomegaly. lucent spine lesions within the lower thoracic spine (image 53, series 3a and image 48, series 3a) are probably hemangiomas. degenerative changes are also noted at multiple levels throughout the spine. impression: 1. multifocal lung abnormalities most suggestive of a widespread infectious process. nodular opacity with ground-glass halo in left upper lobe is nonspecific, but this appearance may be associated with angioinvasive aspergillus infection in the setting of neutropenic fever. 2. large simple right pleural effusion. 3. extensive lymphadenopathy, likely related to the provided history of cll. splenomegaly is also in keeping with this diagnosis. 4. two lucent thoracic vertebral body lesions in the lower thoracic spine which probably reflect hemangiomas. . tte the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (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 aortic valve leaflets are moderately thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. no clinically significant valvular regurgitation. borderline pulmonary artery systolic hypertension. an area of echodensity measuring 7.4 cm x 4.9 cm (clip ) is seen that appears to be contained within a small right pleural effusion. clinical correlation and consideration of a chest ct for further characterization suggested. . leni: findings: color and -scale son was performed on the bilateral 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. . brief hospital course: this is a 83 year-old female with a history of cll who presents with respiratory distress. . # respiratory distress. etiology likely secondary to worsening effusion as well as new infiltrates concerning for multifocal pneumonia. patient with known malignancy and therefore at risk for hypercoagulable state. score appears to be low -1 (+1 for malignancy, -2 for other cause of dyspnea). lenis negative. biomarkers flat. tte with normal systolic and diastolic function. patient underwent uncomplicated thoracentitis on , 500cc was removed. fluid largely transudative. gram stain with no growth. cytology pending. cxr with lul infiltrate. urine legionella negative. blood cx: ngtd. ct scan consistent with multifocal pneumonia; though question of fungal per radiology, clinical suspicion higher for pneumococcal pathogen. patient continued on ceftriaxone and levofloxacin with plan for 8-10day course. patient's respiratory status improved on these antibiotics and o2 was weaned as tolerated. at time of transfer to floor on , oxygen saturation was >94% on 3l nc. narrowed to levofloxacin alone prior to discharge . pending cytology needs follow up. also recommend ct chest after treatment completed. . # . patient with history of chronic renal insufficiency with baseline creatinine 1.5. creatinine on admission 2.7. etiology pre-renal, ain in setting of recent bactrim usage. ua and urine culture without sign of infection. urine eosinophils negative. fena: 1.3. creatinine slowly improved with ivf and was 2.3. at time of transfer to the medical floor. trending daily. it was lowered to 1.7 prior to discharge. . # cll. patient diagnosed in . patient last treated with fludarabine in . labs notable for elevated wbc >20 since 4/. patient without anemia or thrombocytopenia. igg levels checked. igg level wnl. dr followed patient closely. no plan for ivig infusion. . # diabetes. last hga1c: 9.0. patient states she does not take any meds for diabetes and her daughter said she eats whatever she wants. monitoring qid fs, iss. . # hypothyroid. continued synthroid . # fen: ivf, replete prn, diabetic/cardiac diet . # access: piv . # ppx: subq heparin, home ppi . medications on admission: see admission note discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po q12h (every 12 hours). 2. tramadol 50 mg tablet sig: one (1) tablet po daily (daily). 3. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 4. lipase-protease-amylase 12,000-38,000 -60,000 unit capsule, delayed release(e.c.) sig: one (1) cap po bid (2 times a day). 5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*0* 6. levofloxacin 750 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 2 doses. disp:*2 tablet(s)* refills:*0* 7. home oxygen 2 liters continuous pulse dose for portability. dx: pleural effusion 8. metformin 500 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. discharge disposition: home with service facility: family & services discharge diagnosis: community acquired pneumonia with parapneumonic effusion chronic kidney disease stage iii cll hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for treatment for severe pneumonia as well as fluid in the lung. the fluid in the lung was sampled. you were started on antibiotics with improvement in your symptoms. please continue your antibiotics to complete the full course. please take all other medications as prescribed. you need to see you pcp in close follow up. lung fluid cytology is pending at discharge and will need to be followed up. also, we recommend a follow up ct scan of the chest once your symptoms resolve. start: levofloxacin 750mg every 48 hours albuterol inhaler as needed followup instructions: please follow up with dr. as soon as possible department: center when: wednesday at 8:20 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 1:30 pm with: , rn building: campus: east best parking: garage department: medical specialties when: thursday at 9:30 am with: , m.d. building: sc clinical ctr campus: east best parking: garage Procedure: Thoracentesis Diagnoses: Pneumonia, organism unspecified Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hypopotassemia Chronic kidney disease, Stage III (moderate) Macular degeneration (senile), unspecified Personal history of antineoplastic chemotherapy Leukocytosis, unspecified Legal blindness, as defined in U.S.A. Chronic lymphoid leukemia, without mention of having achieved remission Acquired absence of both cervix and uterus Sulfonamides causing adverse effects in therapeutic use Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified Postsurgical hypothyroidism Other specified forms of effusion, except tuberculous

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: unresponsive, presumptive head trauma, unwitnessed major surgical or invasive procedure: : emergent left craniectomy for decompression of brain tracheostomy 11/12cranioplasty peg tube placement picc line placement history of present illness: patient is a 50m of unknown identity who was found unresponsive this morning by a walker-by on a bike trail in , who had apparently suffered trauma to his head, and possibly other areas of the body. her ems/ed records it is presumed he is a indigent individual. it is presently unknown who next of is. per ed report, he was unresponsive upon arrival and intubated. the ed pupillary exam was significant for aniscoria r>l with minimal light reflex. he did smell of alcohol, with labs pending at the time of examination. per ed he was also noted to have a fair amount of coffee ground emesis, and obvious trauma to the occiput of the head. past medical history: ivcf right burr holes /craniotomy brain aneurysm --> tx'd surgically (per pt has had sz's in / reportedly related to aneurysm) - seizures - etoh abuse - question hep c (pt thinks he has it) **pt has gotten care at & per his report. social history: homeless single, homeless, originally from . he smokes one ppd. he drinks several 40 oz beers per day. he occasionally uses marijuana and smokes cocaine/crack. family history: non-contributory physical exam: on admission: on neurosurgical examination(intubated at the time of exam): pupils are rt: 3mm lt: 2.5mm, minimally reactive, no response to commands, bilateral extensor posturing noted in the upper extremities. on discharge: upon dishcharge pt is non-verbal, pupils equal, round and flicker to light, does not open eyes to noxious, sporadically follows commands however could be possibly reflexive, does localize with rue to noxious, plegic lue and triple flexion to noxious with lowers. pertinent results: labs on admission: 08:50am blood wbc-10.1 rbc-4.44* hgb-12.1* hct-34.8* mcv-79* mch-27.2 mchc-34.7 rdw-15.9* plt ct-270 11:40pm blood neuts-84.6* lymphs-8.5* monos-6.4 eos-0.3 baso-0.2 08:50am blood pt-12.9 ptt-24.2 inr(pt)-1.1 12:14pm blood glucose-114* urean-16 creat-1.2 na-127* k-4.5 cl-83* hco3-33* angap-16 08:50am blood ck(cpk)-517* 11:40pm blood alt-431* ast-1164* alkphos-132* totbili-0.4 08:50am blood lipase-66* 08:50am blood ctropnt-0.12* 08:50am blood ck-mb-14* mb indx-2.7 12:14pm blood albumin-3.9 calcium-9.8 phos-5.9* mg-1.5* 08:50am blood asa-neg ethanol-26* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg labs on discharge: wbc:10.3 hgb/hct 9.5/27.9 plts 592 na-136 k-4.4 bun-13 creat-0.5 glu-125 ekg : sinus tachycardia possible right atrial abnormality borderline right axis deviation rsr' in lead v1 modest st-t wave changes findings are nonspecific - within normal limits for possible in part right ventricular overload since previous tracing of the same date, preocrdial lead t waves less prominent imaging: ct c-spine : conclusion: 1. deformity of the anteroinferior body of c2 with a well-corticated bony fragment projected anteriorly suggestive of an old injury. 2. there is apparent asymmetry in the distance between the odontoid and the lateral masses of c1 which may be due to rotatory subluxation versus positional and can be imaged further as per clinical need. 3. fracture through the right lateral transverse process of t1 which has the appearance of subacute/chronic injury. 4. multilevel degenerative changes in the cervical spine with most significant disc narrowing at c6-7. head ct : 18-mm left subdural hematoma with mass effect and midline shift towards the right of approximately 11 mm. acute hemorrhage is also seen in the left sylvian fissure as well as the right thalamus and fourth ventricle. there is subfalcine and subtentorial herniation with loss of -white matter differentiation suggesting raised intracranial pressure. ct chest, abdomen, pelvis : impression: 1. comminuted fracture of the distal right clavicle and would recommend dedicated films to further evaluate. multiple nondisplaced chronic-appearing rib fractures. 2. filling defect within the right portal vein, which could represent non- occlusive thrombus and would recommend ultrasound evaluation to further evaluate. there is an ivc filter present within the ivc, which is infrarenal. there are right-sided dependent lung consolidations which could represent aspiration or lung contusion. there is a small right apical pneumothorax and right apical blebs. 3. there is an endotracheal tube present in satisfactory position. 4. there is diffuse fatty liver. 5. the right testicle is high within the inguinal canal and could be related to patient's trauma. head ct (post-surgery): impression: 1. reduction in size of large left convexity subdural hematoma with decreased mass effect and decreased rightward subfalcine herniation as described. persistent rightward uncal herniation noted. 2. right thalamic and potential right midbrain small intraparenchymal hemorrhages. 3. persistent enlargement of the right lateral ventricle with transependymal resorption of csf noted. lenis :impression: non-occlusive thrombosis of the right common femoral vein. head ct : impression: 1. interval decrease in size of left subdural hematoma, associated midline shift and mass effect and resolution of left uncal herniation. 2. left temporal hypodensity may relate to evolving infarction. continued attention on followup studies is recommended. 3. thalamic and brainstem hemorrhages appear stable. ct head w/o contrast final report impression: 1. no new intracranial hemorrhage or significant changes since prior scan. 2. mild improvement in rightward midline shift from 3 mm to 2 mm. hypodensity seen within the right thalamus consistent with evolution of previously noted hemorrhage in this area. eeg impression: abnormal portable eeg due to the right fronto-central slowing and due to the relatively monotonous mildly slow background throughout. the first abnormality suggests a focal subcortical dysfunction in the left anterior quadrant. the tracing cannot specify the etiology. nevertheless, there were no clearly epileptiform features there or elsewhere. the widespread 7 hz rhythm suggests a widespread encephalopathy, with a regularity raising the possibility of medication effect. head ct impression: 1. patient is status post cranioplasty. hyperdense area adjacent to the left frontal lobe in subdural location that is likely secondary to post- operative changes, however, cannot exclude small amount of subdural hemorrhage. possible mild cerebrale dema without shift of midline structures, likely due to post-surgical changes. recommend close followup as clinically indicated. expected post- operative changes with pneumocephalus, extra-axial air, and soft tissue swelling. head ct impression: interval decrease in size of fluid collection, with decrease in mass effect upon left frontal hemisphere. associated decrease in left to right shift of midline structures. persistent edema and mass effect. hypodensities both occipital lobes are unchanged. head ct mpression: 1. stable appearance of a small left frontal epidural fluid collection with mild mass effect upon the left frontal hemisphere. no new foci of hemorrhage are identified. 2. low attenuation subgaleal fluid collection at the cranioplasty site which could relate to postoperative change, although its persistence raises the possibility of a csf leak. clinical correlation is recommended. 3. mild paranasal sinus mucosal thickening and mastoid air cell opacification. complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:58am 10.3 3.65* 9.5* 27.9* 76* 25.9* 33.9 16.4* 592* source: line-r picc differential neuts bands lymphs monos eos baso atyps metas 03:35am 90.5* 5.9* 3.2 0.3 0.1 source: line-picc red cell morphology hypochr anisocy poiklo macrocy microcy polychr ovalocy envelop bite 02:09am 3+ 1+ 1+ occasional 1+ normal occasional 1+ occasional basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 05:58am 592* source: line-r picc basic coagulation (fibrinogen, dd, tt, reptilase, bt) fibrino 08:50am 272 trauma hemolytic workup ret aut 04:49am 3.7* source: line-tlc chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:58am 125* 13 0.5 136 4.4 94* 32 14 source: line-r picc brief hospital course: pt was biba to the emergency department after being found unresponsive on a bicycle path - ct scan revealed that he had an left sided acute subdural with significant mid line shift and mass effect. on exam he was extensor posturing and had significant anisicoria. he was brought to the operating room for emergent decompression via left hemicraniectomy. he was maintained in a cervical collar during his stay. he was placed on dilantin for sz prophylaxis and later transitioned to keppra as his serum levels were difficult to keep in the therapeutic range. social work eval revealed that he is known to the system. there was no family available for consents. it was noted that the pt had an alcohol like odor on his breath on admission - he was placed on a ciwa scale. the legal department was contact for guardianship. inital eval revealed that 1. pt had ivcf (infrarenal)previously placed, 2. small right apical pneumothorax, 3. filling defect in right portal vein may represent non occlusive thrombus, 4. comminuted proximal right clavicular fracture, 5. right lung dependent consolidations could be aspiration or contusion injury, 6.right testicle high in canal could be result of trauma, 7.distended bladder. he remained intubated postoperatively and an oral-gastric tube was placed. a small amount of coffee ground drainage was noted that evolved to be bilious in nature without further concern. his hematocrit did drop during the hospitalization and the surgical icu determined that this was enamia of chronic disease. his serial exams showed some improvement, he was localizing with his right upper extremity, there was also some spontaneous movement on the right side. significant lue weakenss is noted. post operatvie ct scan was stable. he had a a subdural drain in place that was removed on day #1. a temp spike to 102.1 occurred on and fever workup was initiated - it revealed that he had citrobacter in the sputum and treated with cipro for this. x 2 weeks. urine and blood cultures at that time were negative. serial cxr's for the right apical pneumothorax showed spontaneous resolution of this-he did not require a chest tube. his incision remained clean and dry - his staples were removed on # 10. laboratory values on #13 revealed thrombocytosis (1,000) - aspirin was started for this. this has since resolved. a trial of extubation was initiated. he was re-intubated later that same day. cervical collar was cleared by dr. on . guardianship was obtained by the court and trach and peg were performed at the bedside that day. pt did have an episode of bradycardia after this procedure which was successfully treated with atropine. he was cleared for transferred out of the icu but did require neuro stepdown unit due to amount of suctioning needed. he went to the or for cranioplasty, he tolerated this procedure well and returned to step down. his neuro exam showed that he followed commands at times on the right upper and bilat lower extremities. he remained weak on the left upper and non-verbal. on pt developed a subgaleal collection on l side of head which was subsequently drained 4 times and head wrap most recently on with improvement. pt has moderate amounts of secretions, however has a strong cough and negative sputum samples. he is afebrile and remains hemodynamically stable. case manager assisted with long term placement. medications on admission: unknown discharge medications: 1. docusate sodium oral 2. insulin regular human 100 unit/ml solution : one (1) units injection asdir (as directed): sliding scale regular insulin sq. 3. levetiracetam 500 mg tablet : three (3) tablet po bid (2 times a day). 4. albuterol 90 mcg/actuation aerosol : two (2) puff inhalation q6h (every 6 hours) as needed. 5. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : one (1) po daily (daily). 6. folic acid 1 mg tablet : one (1) tablet po daily (daily). 7. acetaminophen 160 mg/5 ml solution : one (1) po q6h (every 6 hours) as needed. 8. heparin (porcine) 5,000 unit/ml solution : one (1) 5,000units injection tid (3 times a day). 9. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 10. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 11. modafinil 100 mg tablet : two (2) tablet po qd (). 12. miconazole nitrate 2 % cream : one (1) appl topical (2 times a day). 13. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). discharge disposition: extended care facility: hospital discharge diagnosis: traumatic acute sdh(left) hyponatremia respiratory failure peg tube placement tracheostomy anemia of chronic disease post operative fevers deep vein thrombosis / right common femoral vein pneumonia small pneumothorax right apical /traumatic comminuted proximal right clavicular fracture, thrombocytosis hemiparesis / left sided bradycardia discharge condition: neurologically stable 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, and ibuprofen etc. avoid asprin and any asprin containing products. ?????? you have been prescribed an anti-seizure medicine, take it as prescribed. 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 of any color. ?????? fever greater than or equal to 101?????? f. 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 for this appointment. ***you have been placed on keppra for seizure control (levetriactam) - do not stop taking medication unless instructed by a physician. md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Other lavage of bronchus and trachea Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Other cranial osteoplasty Bronchoscopy through artificial stoma Other craniotomy Injection or infusion of immunoglobulin Diagnoses: Pneumonia, organism unspecified Anemia of other chronic disease Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Acute respiratory failure Other specified cardiac dysrhythmias Other specified complications of procedures not elsewhere classified Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Traumatic pneumothorax without mention of open wound into thorax Assault by unspecified means Essential thrombocythemia Other specified hemiplegia and hemiparesis affecting nondominant side Closed fracture of sternal end of clavicle Postprocedural fever Subdural hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness and return to pre-existing conscious level

allergies: penicillins attending: chief complaint: sepsis major surgical or invasive procedure: ercp/stent placement history of present illness: this is a year old female with hx recent pe/dvt, atrial fibrillation, cad who is transfered from hospital for ercp. she has had multiple admissions to this past month, most recently on . in early , she presented with back pain and shortness of breath. she was found to have bilateral pe's and new afib and started on coumadin. her hct dropped slightly, requiring blood transfusion, with guaic positive stools. she was discharged and returned with abdominal cramping and black stools. she was found to have a hct drop from 32 to 21. she was given vit k, given a blood transfusion and started on protonix. she received an ivf filter and egd. egd showed a small gastric and duodenal ulcer (healing), esophageal stricture, no active bleeding. she also had an abdominal ct demonstrating a distended gallbladder with gallstones and biliary obstruction with several cbd stones. she was started on levo/flagyl and transfered here for ercp. per nursing, her bp had been low in 90's at osh and 80's enroute. in the ercp suite, she received vancomycin, ampicillin and gentamicin as well as fentanyl. a biliary stent was placed successfully in the upper third of the common bile duct. no sphincterotomy was done given elevated inr. in addition, a single cratered non-bleeding 20mm ulcer was found in the antrum. past medical history: recent pe/dvt afib htn hypotension hypothyroidism cad ? mild chf social history: lives with daughter and granddaughter, functional at home , non-smoker, no alcohol use family history: nc physical exam: gen: ill appearing, pale, awake but minimally responsive, well-nourished, no acute distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, mmm, op clear neck: no jvd, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: lungs ctab, no w/r/r abd: mildly tender abd diffusely w/o rebound or guarding, nd, hypoactive bowelsounds, diff to assess hsm, a soft large masses/protuberance in rlq ext: midly swollen left lower ext, no palpable cords neuro: awake, answering some basic questions but not conversant, unable to assess orientation skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses pertinent results: admission labs: 03:15pm wbc-11.4* rbc-3.61* hgb-11.3* hct-32.8* mcv-91 mch-31.3 mchc-34.5 rdw-17.9* 03:15pm neuts-76* bands-13* lymphs-6* monos-3 eos-0 basos-0 atyps-0 metas-2* myelos-0 03:15pm hypochrom-normal anisocyt-1+ poikilocy-occasional macrocyt-1+ microcyt-occasional polychrom-occasional ovalocyt-occasional schistocy-occasional burr-occasional 03:15pm plt smr-normal plt count-166 03:15pm pt-25.8* ptt-39.2* inr(pt)-2.5* 06:12pm alt(sgpt)-56* ast(sgot)-68* ld(ldh)-357* alk phos-100 tot bili-1.3 06:12pm glucose-128* urea n-85* creat-2.8* sodium-139 potassium-4.2 chloride-110* total co2-16* anion gap-17 other important labs: 03:35am blood wbc-14.8* rbc-3.15* hgb-10.0* hct-28.9* mcv-92 mch-31.9 mchc-34.8 rdw-17.8* plt ct-162 03:35am blood glucose-81 urean-85* creat-3.0* na-138 k-4.4 cl-107 hco3-15* angap-20 03:35am blood alt-50* ast-63* alkphos-87 03:35am blood calcium-7.5* phos-4.8* mg-1.8 10:14am blood type-art temp-36.7 o2 flow-4 po2-101 pco2-13* ph-7.20* caltco2-5* base xs--20 intubat-not intuba 10:14am blood lactate-10.5* kub: supine film shows gas-filled loops of large and small bowel with gas in the region of the rectum. the appearances are inconsistent with obstruction and do not suggest ileus cxr: no failure ruq ultrasound: report pending at time of death brief hospital course: septic from the time of transfer from the osh for ercp. required blood pressure support with levophed, which was changed to neosynephrine due to elevated hr. difficult to volume resuscitate given developement of crackles/increasing o2 requirement with fluid. treated with vanc/cipro/flagyl and changed to meropenem/vanc. had stent done by ercp, but sphincterotomy/stone removal not done due to elevated inr. most likely source of sepsis is biliary/ascending cholangitis. evaluated by general surgery team, who thought she was not a surgical candidate and would not recommend ir cholecystostomy tube. lactate rose to 10.5, last abg 7.2/13/101. the patient complained of significant pain, difficult to control with bolus morphine. bedside ultrasound was being done to evaluate for cholecystitis when the family decided to make the patient cmo and the study was stopped. preliminary report not available at the time of death. the patient was made cmo by her family and expired comfortably on a morphine gtt at 16:20 on . medical examiner declined the case, family declined autopsy. medications on admission: asa 325mg lopressor 25mg amiodarone 200mg coumadin 2.5mg daily isosorbide 60mg daily levothyroixine 50mcg daily discharge medications: expired discharge disposition: expired discharge diagnosis: septic shock due to ascending cholangitis choledocholithiasis atrial fibrillation with rapid ventricular response pulmonary emboli deep venous thrombosis upper gi bleed peptic ulcer disease discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Endoscopic insertion of stent (tube) into bile duct Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Chronic kidney disease, unspecified Septic shock Long-term (current) use of anticoagulants Pressure ulcer, lower back Personal history of venous thrombosis and embolism Hemorrhage of gastrointestinal tract, unspecified Cholangitis Calculus of bile duct without mention of cholecystitis, without mention of obstruction Pressure ulcer, stage II

allergies: no known allergies / adverse drug reactions attending: chief complaint: fever, tachycardia, hypotension, infected pancreatic necrosis with progressive multisystem organ failure major surgical or invasive procedure: ir drain placement ex-lap,open chole,necrosectomy,debridement of pancreas perc trach history of present illness: 76m who was recently admitted for gallstone pancreatitis (ct revealed necrotizing pancreatitis and multiple pancreatic pseudocysts) approximately 6 weeks prior, treated conservatively with npo and ivf. he had been placed on tpn (+lipids) via a rue picc line since last discharge due to poor po intake. he presented on with fevers and tachycardia and was sent to the er. after his previous discharge, he reported no problems with his picc and specifically denied chills after tpn infusion. he felt well until , when he had an abdominal ct with contrast. after the procedure, he developed shaking chills which he thought were due to low blood sugar. chills resolved with juice. on patient again developed shaking chills. he was seen in dr. office, where he was noted to be diaphoretic, tachycardic to 138, and febrile to 102.3. ros was significant for morning cough productive of scant white sputum x 1 month, rhinorrhea x 3 days, intermittent low back pain, and increased urinary frequency in the setting of tpn feeds. two loose bm's were documented on but patient reported they were soft only and denied diarrhea. past medical history: copd (hosp x2 for respiratory distress) htn hld left inguinal hernia necrotizing pancreatitis pancreatic pseuodcysts pulmonary nodule social history: heavy smoking history, 1 pk/d x 60 years, now stopped since . denies any etoh. has 2 daughtes and lives with one of them. family history: nc physical exam: on discharge: vitals - t 98.1 86 122/60 20 99% on fio2 35% gen - nad, resting in bed, responsive cv - rrr, s1s2 resp - wet sounding cough productive of thick secretions, harsh breath sounds throughout abd - soft, non-distended, non-tender, no massess; transverse incision dressed with wound vac. jp drain on left side, abdominal drain (more midline) draining to ostomy bag ext - wwp, non-edematous pertinent results: cxr (): the lungs are grossly clear with no focal opacities concerning for an infectious process. cardiomediastinal silhouette and hilar contours are unremarkable. no appreciable pleural effusion. no pneumothorax and no gross bony deformities. impression: no evidence of acute cardiopulmonary process. urine culture (): <10k organisms. urinalysis (): negative for nitrite/glu/ketones/bili/urobil/leuks, small blood, rbc 4, wbc 2, few bacteria, <1 epith, ph 5.5 blood cultures (): no growth ct abdomen/pelvis (): 1. interval progression of pancreatic pseudocyst which now extends to the hepatic capsule and exerts mass effect on the duodenum. no significant change in pancreatic necrosis with only a small remnant in the head, uncinate process and tail. 2. small left and trace right pleural effusions are new from comparison. 3. interval increase in ascitic fluid along the bilateral paracolic gutters, left greater than right. 4. stable non-obstructing left inguinal hernia containing colon. bal (): escherichia coli. 10,000-100,000 organisms/ml abscess culture (): citrobacter freundii complex placement of dobhoff tube (): successful placement - feeding tube into the second portion of the duodenum. tube is ready to use. ct abdomen/pelvis (): 1. interval increase in the amount of ascites and the bilateral pleural effusions as well as the consolidation/atelectasis at the lung bases. 2. the ng tube is coiled within the stomach multiple times. 3. there is infected walled off pancreatic necrosis. although decreasing in size, the collection is amenable to re-drainage. dr. discussed this finding with dr. at the time of reporting at 4:25 pm and it was agreed upon that drainage insertion would be performed on . ctap (): 1. subtle peribronchial ground-glass opacities seen in the right lung, predominantly in the right upper lobe, concerning for an infectious process. an additional nodular opacity in the right upper lobe likely represent additional site of infection. recommend follow-up after treatment. 2. moderate bilateral simple pleural effusions and compressive atelectasis of both lower lobes, stable since . 3. acute necrotizing pancreatitis, with slight decrease in the size of the walled-off pancreatic necrosis after placement of drainage catheter. stable pseudocyst in the uncinate process of the pancreas. 4. moderate amount of abdominal ascites, slightly larger since the prior study of . moderate anasarca. 5. severe gastroesophageal reflux. 6. attnuated but patent splenic vein. ctap 1. surgical intervention with almost complete resolution of lesser sac fluid collection, three drains within the peripancreatic/lesser sac region. residual small lenticular collection in the left colic gutter. 2. no change in amount of pelvic ascites, decrease in the amount of perihepatic ascites. 3. status post cholecystectomy. 4. study is otherwise unchanged which includes a right ij line with tip abutting the brachiocephalic vein at the brachiocephalic/svc junction. ctap impression: 1. right upper lobe nodular density now with slight central lucency, possibly indicating evolution of infectious nodule. 2. postsurgical change of pancreas with stable small uncinate process collection and no new collections identified allowing for limitations of noncontrast study. 3. otherwise, no change detected compared to four days prior. brief hospital course: the patient was admitted to the general surgical service for evaluation and treatment of his hypotension, tachycardia, and fever on . upon admission, a full set of laboratory tests including cbc, bmp, blood and urine cultures, lactate, arterial blood gas, and lfts were sent. a chest x-ray was also obtained. results of these studies may be found in the 'pertinent results' section above. the patient was started empirically on iv antibiotics (vancomycin and zosyn). he was given a clear liquid diet, and provided iv fluid rehydration as well. his picc line was not used, while evaluation for a source of bactermia was in progress. on hospital day #1 (), he no longer had any fevers. he tolerated a regular diet, and was having bowel movements. he was continued on vancomycin and zosyn. he ambulated regularly. he was urinating normally. he was not given tpn, and his picc line was used only for the administration of antibiotics. he was given tylenol and ibuprofen for his back pain. on hospital day #2 (), he continued to be afebrile, and tolerating diet. he continued to ambulate and have bowel movements. he was continued on vancomycin and zosyn. tpn continued to be held. on hospital day #3 (), the medical and infectious disease teams were consulted. due to sbp 110s and hr 60s-70s, his beta blockers were discontinued. he continued to be aggressively hydrated with iv fluids, and given vancomycin and zosyn. tpn continued to be held. on this day, he was returned to a clear liquid diet, which he tolerated well. on hospital day #4 (), a luq ultrasound was performed, which revealed a small increase in size of pseudocyst, and new intrahepatic and extrahepatic biliary ductal dilatation, with no choledocholithiasis, as well as known cholelithiasis. on this day, tpn was restarted. further evaluation led to the determination that surgery would likely be the optimal course of management for this patient. he was scheduled for an open cholecystectomy, drainage of pseudocyst, and pancreatic debridement the upcoming thursday. a ct scan without contrast was also obtained. on hospital day #5 (): a foley catheter was placed on this day for optimal input/output measurements. tpn was continued. due to an episode of questionable altered mental status, a full exam, full labs, including fingerstick, as well as immediate abg were performed, all of which were normal. the patient was continued on antibiotics (vancomycin and zosyn). an ngt was placed secondary to severe distension and bloating. on hospital day #6 (): the patient was taken to ir for percutaneous drainage of abdominal collection, and placement of a drainage catheter. antibiotics were changed to include only zosyn at this time. a drain was successfully placed by ir, and drained a large amount of brown liquid (see attached report in 'pertinent results' section). the patient tolerated the procedure well, but became increasingly agitated immediately thereafter. an abg was collected, which was normal, and due to persistent severe agitation, the patient was transferred to the sicu for further care. on hospital day #7 (): the patient was intubated and placed on a ventillator (cpap/ps setting) due to continued severe agitation and respiratory distress. foley was maintained, and antibiotics were continued, although changed from zosyn, to meropenem. the patient was continued on tpn, ivf, and remained otherwise npo. in the evening of this day, the patient's picc line was discontinued, and catheter tip was sent for culture. iv fluids were continued, and the patient remained intubated. foley catheter was maintained. -intestinal tube was placed by interventional radiology. vancomycin was added to the patient's antibiotic regimen, which including meropenem as well. on hospital day #8 (): the patient remained intubated/sedated, on ivf, with a foley catheter, with antibiotics (vancomycin and meropenem) running. on hospital day #9 (): the patient remained intubated/sedated, on ivf, with a foley cathter, and antibiotics running. an attempt was made at extubation, but the patient required re-intubation after only 2 hours due to respiratory distress and agitation. on this day, upon the return of bal cultures growing e.coli, and abscess cultures growing pan-sensitive citrobacter, the patient's antibiotics were changed to ceftriaxone and flagyl. on hospital day #10 (): the patient's abdominal drain was noted to be entirely outside the abdomen, not in appropriate position. a ct scan was obtained, results noted in the 'pertinent results' section. the patient was scheduled to have ir placement of a 12-french drain in his pseudocyst, and a second drain placed in his abdominal collections, as well as advancement of his nj tube by fluoroscopy, on . his antibiotics were continued, and he remained intubated/sedated, with a foley catheter, on ivf. the patient underwent the placement of the external percutaneous drainage catheter. he decompensated while in radiology department. patient developed confusion, altered mental status, was transferred to the icu where he was semi-electively intubated the same day for again altered mental status and tachypnea. he was found to have likely aspiration pneumonia. on hospital day #15 the patient continued to be edematous and anasarctic. he had a very firm abdomen on exam and elevated bladder pressures in the high 20's and a peep in the low 30's. due to concern for intra-abdominal hypertension, the patient was taken urgently for exploratory laparotomy, pancreatic debridement involving resection of pancreatic neck, body, and tail, with placement of large drains, and a cholecystectomy. post operatively, he required intensive supportive care in the icu. due to the continued need for ventilatory support, he had a percutaneously placed tracheostomy. throughout his stay in the icu, the patient required varying degrees of pressors and sedation. on , citrobacter freundii complex and enterococcus faecium were isolated from his peritoneal, on , klebsiella & pseudomonas were isolated in his sputum cultures, and on , yeast was isolated in his urine cultures. he was treated with a multitude of antibiotics: vancomycin micafungin (8-20-8/21) tigecycline,meropenem () the patient required aggressive suctioning for thick secretions. on 9/ 13, the patient was transferred to the floor after being stabilized in the icu. he was prepared for discharge on . medications on admission: lisinoprl/hctz 20-12.5' metoprolol 50'' xanax 0.5 prn albuterol nebs prn atrovent nebs prn pantoprazole 40' asa 325' advil prn discharge medications: 1. albuterol 0.083% neb soln 1 neb ih q4h:prn sob 2. ipratropium bromide neb 1 neb ih q6h:prn copd 3. pantoprazole 40 mg po q24h 4. alprazolam 0.5 mg po undefined as needed 5. aspirin 325 mg po daily 6. ibuprofen 400-600 mg po q6h:prn pain 7. acetaminophen (liquid) 650 mg po q6h:prn pain 8. bisacodyl 10 mg po/pr daily:prn constipation 9. docusate sodium (liquid) 100 mg po bid 10. insulin sc sliding scale fingerstick qachs insulin sc sliding scale using reg insulin 11. metoprolol tartrate 50 mg po tid 12. senna 1 tab po bid:prn constipation 13. pantoprazole 40 mg iv q24h discharge disposition: extended care facility: hospital - discharge diagnosis: fever, tachycardia and hypotension infected pancreatic necrosis with progressive multisystem organ failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the surgery service at for evaluation of your fever, tachycardia, and hypotension in the setting of recent pancreatitis approximately 6 weeks ago. you have done well in the during your stay, and are now safe to return home to complete your recovery with the following instructions: 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 driving or operating heavy machinery if taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. please call your doctor or nurse practitioner if you experience 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 is 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. followup instructions: , md phone: date/time: 3:00 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Drainage of pancreatic cyst by catheter Cholecystectomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Systemic arterial pressure monitoring Other excision or destruction of lesion or tissue of pancreas or pancreatic duct Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Acidosis Unspecified essential hypertension Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Severe sepsis Candidiasis of other urogenital sites Other specified intestinal obstruction Obstructive chronic bronchitis with (acute) exacerbation Personal history of tobacco use Candidiasis of mouth Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Long-term (current) use of insulin Other septicemia due to gram-negative organisms Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Metabolic encephalopathy Hypovolemia Acute pancreatitis Cyst and pseudocyst of pancreas Pseudomonas infection in conditions classified elsewhere and of unspecified site Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Nutritional marasmus

allergies: no known allergies / adverse drug reactions attending: chief complaint: left lung collapse major surgical or invasive procedure: bronchoscopy with aspiration of secretions bedside left sided chest tube placement history of present illness: mr. is a 76 m recently admitted for gallstone pancreatitis. he presented on with fevers and tachycardia and was sent to ir for percutaneous drainage of abdominal collection, and placement of a drainage catheter on . due to concern for intra-abdominal hypertension, the patient was taken urgently for exploratory laparotomy, pancreatic debridement involving resection of pancreatic neck, body, and tail, with placement of large drains, and a cholecystectomy. post operatively, he required intensive supportive care in the icu. due to the continued need for ventilatory support, he had a percutaneously placed tracheostomy. since his previous admission, he was doing well, his drains were discontinued, and his trach was decannulated. on he began to experience some dyspnea at rest. denies palpitations, fevers, chills, change in cough. he was found to have left lung collapse. several non-invasive measures to inflate left lung were attempted and failed. he was then admitted to the for bronchoscopy. past medical history: copd (hosp x2 for respiratory distress) htn hld left inguinal hernia necrotizing pancreatitis pancreatic pseuodcysts pulmonary nodule social history: heavy smoking history, 1 pk/d x 60 years, now stopped since . denies any etoh. has 2 daughtes and lives with one of them. physical exam: tmax: 98.8 ??????f 98.8 ??????f hr: 89 bp: 121/63(77) rr: 22 spo2: 97% general appearance: interactive, non-toxic appearing heent: eomi, sclera anicteric cardiovascular: (rhythm: regular), sinus tachycardia respiratory / chest: (breath sounds: rhonchorous : bilaterally), diminished breath sounds bilaterally, no crackles abdominal: soft, non-distended, ec fistula with scant serous fluid neurologic: (awake / alert / oriented: x 3, x 2), follows simple commands pertinent results: 09:20pm glucose-127* urea n-16 creat-0.4* sodium-137 potassium-4.1 chloride-98 total co2-34* anion gap-9 09:20pm estgfr-using this 09:20pm calcium-8.6 phosphate-2.8# magnesium-1.6 09:20pm wbc-5.5 rbc-3.37* hgb-9.1* hct-28.9* mcv-86 mch-26.9* mchc-31.5 rdw-15.6* 09:20pm plt count-449* 09:20pm pt-13.0* ptt-30.2 inr(pt)-1.2* brief hospital course: the patient was admitted to the hepatopancreaticobiliary surgical service for evaluation and treatment of his left lung collapse in the setting of his recent necrotizing pancreatitis. on the patient underwent a therapeutic bronchoscopy, with aspiration of secretions. the procedure revealed thick mucus plugging and (reader referred to the operative note for details). mr. was extubated in the or, but upon arrival to the pacu, the patient became unresponsive and apneic. intubation was attempted twice, resulting in minor laryngeal injury requiring the administration of dexamethasone. after a second attempted intubation, the third was successful. to evaluate the cause of his respiratory failure, a left chest ultrasound was performed. this ultrasound revealed a large left sided pleural effusion. the chest was prepped and draped and the patient received a chest tube placement at bedside. after he was stabilized, he was transferred to the surgical icu, on pressors still intubated. neuro: the patient was admitted to the icu intubated and sedated, he was started on a propofol drip for sedation. he was weaned to minimal sedation by pod 1 and was interactive and responsive. pod 3 the patient was extubated and no longer required sedation. he was given acetaminophen and oxycodone prn for pain control to good effect. cv: while in pacu the patient became hypotensive requiring multiple boluses of fluid and a neo gtt, he remained on that drip when transferred to the unit. he was succesfully weaned off of neo by pod 1. pulmonary: the patient required reintubation in the pacu he was started on cmv, but was weaned to cpap by pod 1. his chest tube put out greater than 2 l of pleural fluid immediately, it was left to waterseal. the pleural fluid was positive for pmns, and amylase, but no organisms. the patient had normal serum amylase so his elevated pleural fluid level was considered reactive. the patient was extubated successfully on . his sats were maintained on nasal cannula and he was given atrovent and albuterol nebulization treatments prn. gi/gu/fen: post-operatively, the patient was made npo with iv fluids. an ostomy applicance was placed to his midline fistula from his emergent exlap. a post pyloric dobhoff was placed pod 3 for nutrition supplementation. he was started on a thickened liquids/pureed solids diet pod 4 per recommendations of speech and swallow. he had a foley immediately post op for urine output monitoring which remained in place. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and repleted when necessary. id: the patient's white blood count and fever curves were closely watched for signs of infection, of which there were none. endocrine: the patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly on a regular insulin sliding scale. hematology: the patient has a known history of chronic anemia. patient's complete blood count was examined as required. no transfusions were needed. prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay; 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 thickened diet, at his baseline ambulatory status, still had a foley in place, and pain was well controlled. the patient and his proxy received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: lisinopril/hctz 20-12.5', metoprolol 50'', xanax 0.5 prn, albuterol nebs prn, atrovent nebs prn, pantoprazole 40', asa 325', advil prn discharge medications: 1. metoprolol tartrate 50 mg po bid 2. acetaminophen 325-650 mg po q6h:prn pain 3. albuterol 0.083% neb soln neb ih q6h wheezing/sob 4. pantoprazole 40 mg po q24h 5. docusate sodium (liquid) 100 mg po bid 6. ipratropium bromide neb 1 neb ih q6h wheezing/sob discharge disposition: extended care facility: hospital - discharge diagnosis: left sided pleural effusion, acute respiratory failure discharge condition: mental status: confused at baseline. level of consciousness: alert and interactive. activity status: ambulatory requires max assist discharge instructions: you were admitted for acute respiratory failure. you were extubated successfully in the icu and are now ready to continue your recovery in rehabiliation. 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. please follow-up with your surgeon and primary care provider (pcp) as advised. general drain care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *if the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or nurse if the amount increases significantly or changes in character. be sure to empty the drain frequently. record the daily output. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. for your left pleural effusion you had a pigtail catheter inserted. the pigtail catheter is to remain to waterseal. please flush the pigtail catheter twice daily with 10 cc of normal saline. please record the daily output of the pigtail catheter and output consistency. notify your pulmonologist when daily output is less than 150 cc per day. you have an enterocutaneous fistula with a red rubber catheter that was replaced on . be sure to place an ostomy appliance over the red rubber catheter. please empty the ostomy bag daily and record the output. for pulmonary care continue to take your inhalers for shortness of breath and wheezing. nutrition: continue taking peptamen 1.5 full strength at goal of 45 ml/hr. also take thickened liquids/pureed solids. no solids until evaluated by your surgeon followup instructions: you will have a follow up with intervention pulmonology. ip office will call rehab with the information about date/time of the follow up. if you have any questions, please call (. department: surgical specialties when: thursday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other intubation of respiratory tract Closed [endoscopic] biopsy of bronchus Diagnoses: Unspecified pleural effusion Unspecified essential hypertension Unspecified protein-calorie malnutrition Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Pulmonary collapse Other and unspecified hyperlipidemia Acute respiratory failure Pulmonary congestion and hypostasis Edema of larynx Unspecified local infection of skin and subcutaneous tissue

allergies: sulfa (sulfonamide antibiotics) / cefaclor / erythromycin attending: chief complaint: fevers, rigors, and abd pain major surgical or invasive procedure: none history of present illness: patient is a 27 year old male with history of polysubstance abuse who presented to the ed with fevers, chills, abdominal pain. on saturday, the patient was using oxycontin iv, on one occasion using toilet water to inject the drug. the next morning, woke up with a "tight" stomach. after drinking fluids, felt better and went out to a bar where he consumed ~16oz of rum. he felt weak, then was nauseous and had 4 episodes of vomiting, unsure if it was bloody or not. at this time, developed chills and abdominal pain radiating from the epigastrium to the back. . in the ed, initial vs were: t p 130 bp r o2 sat. he was noted to have a 1cm raised nonerythematous or fluctuant area in his right antecubital fossa with diffuse erythema. ecg was read as sinus tach. cbc with wbc 1. lactate 3.8. cxr normal. he received vanco/zosyn, 4l ns. spiked to 101.1 received motrin, 1g tylenol. has 18g piv x 2. 101.1 103 109/63 22 98%2l. . on the floor, patient still complains of abdominal pain, but no fevers or chills. of note, the patient does admit to a recent detox stay at hospital from heroin. he does admit to increased sleepiness and malaise prior to saturday. . review of systems: (+) per hpi - also positive for sob, difficulty urinating, drenching night sweats. (-) denies recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies shortness of breath, or wheezing. denies palpitations, or weakness. denies diarrhea, constipation, or changes in bowel habits. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: bipolar disorder hernia repair social history: - tobacco: 2ppd x 10 yrs - alcohol: 1 pint of rum/vodka per day - illicits: oxycontin - 7 30mg pills on saturday, prior history of cocaine and heroin iv. - sexual activity in past with men and women, no condom usage - denies jail time, has been homeless for 1 summer at age 18 family history: adopted pertinent results: 08:10pm blood wbc-1.0* rbc-5.39 hgb-16.0 hct-46.1 mcv-86 mch-29.7 mchc-34.7 rdw-13.4 plt ct-177 08:10pm blood neuts-68 bands-6* lymphs-25 monos-0 eos-1 baso-0 atyps-0 metas-0 myelos-0 03:00am blood wbc-11.4*# rbc-4.67 hgb-14.0 hct-39.6* mcv-85 mch-30.0 mchc-35.3* rdw-13.5 plt ct-119* 03:00am blood neuts-90* bands-4 lymphs-3* monos-1* eos-0 baso-0 atyps-0 metas-2* myelos-0 10:15am blood wbc-17.0* rbc-4.44* hgb-13.5* hct-37.3* mcv-84 mch-30.4 mchc-36.2* rdw-13.6 plt ct-111* 08:10pm blood hypochr-normal anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-normal 08:10pm blood pt-13.7* ptt-30.1 inr(pt)-1.2* 03:00am blood pt-15.1* ptt-36.5* inr(pt)-1.3* 08:10pm blood glucose-73 urean-16 creat-1.4* na-140 k-3.6 cl-101 hco3-24 angap-19 03:00am blood glucose-109* urean-15 creat-1.4* na-139 k-4.1 cl-110* hco3-21* angap-12 10:15am blood glucose-110* urean-13 creat-1.1 na-141 k-3.7 cl-109* hco3-20* angap-16 08:10pm blood alt-122* ast-326* ld(ldh)-413* ck(cpk)-157 alkphos-122 amylase-49 totbili-0.9 10:15am blood alt-99* ast-81* ld(ldh)-248 alkphos-92 totbili-0.9 08:10pm blood albumin-4.2 calcium-10.2 phos-1.6* mg-1.5* 03:00am blood calcium-8.6 phos-1.3* mg-1.3* 10:15am blood calcium-9.3 phos-2.2* mg-1.9 03:00am blood cortsol-20.6* 03:00am blood hbsag-negative hbsab-positive hbcab-negative igm hav-negative 03:00am blood hiv ab-negative 08:10pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:00am blood hcv ab-negative 08:57pm blood lactate-3.8* 10:55pm blood lactate-1.9 03:32am blood lactate-2.3* 11:45pm urine color-yellow appear-clear sp -1.012 11:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 11:45pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-pos . 8:10 pm blood culture left hand. blood culture, routine (pending): . 8:45 pm blood culture #2. blood culture, routine (pending): . 3:00 am immunology source: venipuncture. hiv-1 viral load/ultrasensitive (pending): . 2:56 am mrsa screen source: nasal swab. mrsa screen (pending): . 4:10 am urine n. **final report ** legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. . 3:00 am serology/blood chm s# s h/pylori added . helicobacter pylori antibody test (pending): . ecg: sinus tachycardia. no previous tracing available for comparison. . cxr (pa and lat): comparison: none. findings: there is increased opacity in the region of the right middle/lower lobe. the left lung is clear. no pneumothorax or pleural effusion is present. cardiac silhouette is top normal in size. hilar and mediastinal contours appear normal. impression: developing right middle/lower lobe opacity concerning for infection. . tte: the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). the right ventricular cavity is mildly dilated with borderline normal free wall function. 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 regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: low normal biventricular systolic function. mild right ventricular dilation. no vegetation seen. . cxr (portable): there is minimal interval progression of the interstitial prominence, findings that might be consistent with volume overload, especially given the distention of the azygos vein. the right lower lung opacity adjacent to the right cardiac border may be a part of the volume overload but it may represent focus of developing infection as well, and should be reevaluated after diuresis. the heart size is top normal which in part may be explained by the portable technique of the study. there is no pneumothorax. there is small amount of right pleural effusion present, better appreciated on the current study. impression: volume overload/mild interstitial pulmonary edema. those findings may potentially mask underlying infection and reevaluation of the patient after diuresis is highly recommended. . ct abd/pelvis w/contrast: ct abdomen: there are bilateral small nonhemorrhagic pleural effusions, with associated compressive atelectasis, right greater than left. interlobular septal thickening is also present, suggestive of volume overload. the heart is normal in size without pericardial effusion. the liver demonstrates no focal lesion. the gallbladder, spleen, a tiny splenule, pancreas, and adrenal glands appear unremarkable. bilateral kidneys enhance symmetrically without hydronephrosis or hydroureter. stomach, duodenum, small and large bowel loops are normal in caliber. there is no free air or free fluid. there is no mesenteric or retroperitoneal lymphadenopathy. great vessels are normal in caliber and patent. ct pelvis: the bladder is partially collapsed. the distal ureters, prostate gland, and rectum appear unremarkable. there is contrast progression into the transverse colon. there is no inguinal or pelvic lymphadenopathy. there is no free fluid within the pelvis. bone window: a bone island is noted in the right femoral head. no suspicious focal, lytic, or blastic lesions. impression: 1. pulmonary interlobular septal thickening and small bilateral pleural effusions with associated compressive atelectasis, right greater than left. these findings are suggestive of volume overload. 2. no evidence of acute process within the abdomen or pelvis. brief hospital course: micu course 27 y/o male with history of polysubstance abuse and msm who presents with fevers, chills, abdominal pain after shooting oxycontin with toilet water followed by a large amount of alcohol intake. # fevers, rigors, chest pain - the most concerning etiology was from infection after injection with toilet water, most likely bacteria include gnr and gpc, however, the timing of supposed injection of contaminated water and presentation of fever and chills was not consistent with ~24-36 hours in between events. the patient was started on vancomycin, zosyn, and levaquin to cover for gpc, gnr, atypicals, and anaerobes. his serum tox screen negative but urine tox screen positive for methadone. a tte was ordered to evaluate for any evidence of endocarditis, with a tee planned if the patient had positive blood cultures or was persistently febrile. the tte was negative, as was a ct abd/pelvis. the patient left ama with a rising white count. cultures were pending at the time the patient left ama. . # shortness of breath - this was thought to be secondary to bronchospasm from multiple possible etiologies including aspiration, asthma, septic emboli, pulmonary edema. a cxr showed evidence of pulmonary edema or early pneumonia. the patient was responsive to albuterol, which resolved his sob. he also auto-diuresed well and lasix was held for only if the patient became hypoxic or short of breath again. he left ama. . # leukopenia - the patient presented with a wbc of 1, which increased to 11 on repeat labs. the low wbc was concerning for hiv infection or sepsis. hiv serologies and viral load testing was sent (serologies negative and viral load pending). patient left with leukocytosis ama. . # abdominal pain - amylase and lipase were negative on admission. a ct a/p with po/iv contrast was obtained which did not show concerns for acute intraabdominal process. the patient's pain had resolved when he left ama. . # renal failure - unknown if this is acute or chronic as a baseline is unknown. the patient received n-ac and bicarb fluid hydration prior to his ct scan. cr had decreased to 1.1 from 1.4 at time of leaving ama. . # coagulopathy - patient has elevated inr. differential includes chronic liver disease, vitamin k deficiency. his lfts were trended and a hepatitis panel for a, b, and c was sent and returned without evidence of infection. . # alcohol abuse - patient reports intake of ~1 pint alchol daily, but denies history of withdrawal symptoms, including dts. he was started on valium for ciwa > 10. he left ama. . #opioid withdrawal - patient started on scale and given 10mg methadone for a score of 17. his symptoms improved and he was not given additional methadone in the micu. he received methadone on the floor and left ama. . # electrolytes - patient was hypophosphatemic and hypomagnesemic. differential included alcohol intake, poor po, chronic liver disease, legionella. he was repleted and his lytes were trended. . # the patient left ama despite being warned about rising white count while on broad-spectrum antibiotics raising concern for serious infection that may cause severe illness or death. he was able to understand and communicate these risks. he left ama. medications on admission: abilify 5mg trazodone 100mg clonidine 0.1 mg discharge medications: n/a discharge disposition: home discharge diagnosis: primary diagnosis: etoh and oxycontin abuse/withdrawal, right arm soft tissue infection, discharge condition: the patient left ama with a rising leukocytosis on broad spectrum antibiotics. he was instructed that by leaving ama he was placing himself at risk for severe illness and death. he communicated that he understood these risks and would leave ama regardless of the risk of death. discharge instructions: left ama. followup instructions: left ama. Procedure: Combined alcohol and drug detoxification Diagnoses: Abdominal pain, unspecified site Acute kidney failure, unspecified Opioid type dependence, continuous Bacteremia Disorders of phosphorus metabolism Cellulitis and abscess of upper arm and forearm Bipolar disorder, unspecified Other and unspecified coagulation defects Drug withdrawal Alcohol abuse, continuous Disorders of magnesium metabolism Alcohol withdrawal Leukocytopenia, unspecified Shortness of breath

allergies: penicillins attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization coronary artery bypass graft x4: left internal mammary artery to left anterior descending artery, and saphenous vein sequential grafting to obtuse marginal and the left posterior descending artery, and saphenous vein graft to diagonal artery. history of present illness: 72 year old male that started to experience chest pain with mild activity which usually resolved with 1 sl ntg. more recently he has been woken up with chest pain at night, which resolves with position changes. he denies any shortness of breath, but does complain of occasional lightheadnedness. he had an abnormal stress test on and presented for cardiac catherization which revealed coronary artery disease and intra aortic balloon pump was placed. cardiac surgery was consulted for coronary revascularization. past medical history: sciatica mi cad s/p stent to om (bms) htn hyperlipidemia skin cancer dental extractions claudication cataract surgery years ago left leg bypass 10 yrs ago had to be redone 4 months later (used bilateral legs for vein harvesting. left with first surgery right with second )c/b "staph infection" requiring picc line and 4 weeks antibiotics cholecystectomy social history: lives with:wife supportive children and grandchildren occupation:retired custodian tobacco:quit 10 years ago. 100 pack year history etoh:denies family history: mom died age 62 h/o pvd and hf physical exam: admission physical exam pulse:48 resp:18 o2 sat: 99 2l b/p right: 155/79 left: 143/42 height: 5ft 7in weight: 215lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur iabp sound abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema +1 varicosities: none incisions on both lower extermities neuro: grossly intact pulses: femoral right: left: +2 dp right: +1 left: +1 pt : +1 left: +1 radial right: +2 left: +2 carotid bruit right: 0 left: 0 pertinent results: 04:45am blood wbc-7.7 rbc-3.21* hgb-9.6* hct-28.5* mcv-89 mch-29.9 mchc-33.6 rdw-14.8 plt ct-205 03:05pm blood wbc-7.5 rbc-4.33* hgb-12.9* hct-36.5* mcv-84 mch-29.8 mchc-35.4* rdw-14.2 plt ct-182 04:38pm blood pt-14.4* ptt-36.5* inr(pt)-1.2* 03:05pm blood pt-12.7 ptt-28.7 inr(pt)-1.1 04:45am blood glucose-101* urean-19 creat-1.0 na-142 k-4.1 cl-103 hco3-32 angap-11 03:05pm blood urean-21* creat-1.0 na-136 k-4.1 cl-101 hco3-27 angap-12 03:05pm blood alt-21 ast-22 alkphos-77 totbili-0.4 echocardiography report , portable tte (complete) done at 11:25:41 am final referring physician information , division of cardiothoracic , status: inpatient dob: age (years): 72 m hgt (in): 67 bp (mm hg): 91/41 wgt (lb): 215 hr (bpm): 52 bsa (m2): 2.09 m2 indication: coronary artery disease. h/o cardiac surgery. mitral valve disease. icd-9 codes: 746.4, 424.0 test information date/time: at 11:25 interpret md: , md test type: portable tte (complete) son: bzymek, rdcs doppler: full doppler and color doppler test location: / 6 contrast: definity tech quality: suboptimal tape #: 2010w051-0:41 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.7 cm <= 4.0 cm left ventricle - ejection fraction: 65% >= 55% left ventricle - stroke volume: 118 ml/beat left ventricle - cardiac output: 6.12 l/min left ventricle - cardiac index: 2.93 >= 2.0 l/min/m2 aorta - sinus level: 2.9 cm <= 3.6 cm aortic valve - peak velocity: *2.6 m/sec <= 2.0 m/sec aortic valve - peak gradient: *27 mm hg < 20 mm hg aortic valve - mean gradient: 13 mm hg aortic valve - lvot pk vel: 1.50 m/sec aortic valve - lvot vti: 34 aortic valve - lvot diam: 2.1 cm aortic valve - valve area: *2.0 cm2 >= 3.0 cm2 mitral valve - e wave: 1.0 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 1.25 mitral valve - e wave deceleration time: 182 ms 140-250 ms tr gradient (+ ra = pasp): *29 to 31 mm hg <= 25 mm hg findings this study was compared to the prior study of . intravenous administration of echo contrast was used due to poor native endocardial border definition. left ventricle: normal lv wall thickness, cavity size, and global systolic function (lvef>55%). suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. overall normal lvef (>55%). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. paradoxic septal motion consistent with prior cardiac surgery. aortic valve: mildly thickened aortic valve leaflets. minimal as. mild to moderate (+) ar. mitral valve: normal mitral valve leaflets. no ms. eccentric mr jet. moderate (2+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. no ts. mild tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: no ps. pericardium: no pericardial effusion. general comments: suboptimal image quality - bandages, defibrillator pads or electrodes. suboptimal image quality as the patient was difficult to position. conclusions suboptimal image quality. echo contrast used. left ventricular wall thickness, cavity size, and global systolic function appear normal (lvef>55%). 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 appear normal. the aortic valve leaflets are mildly thickened (?#). there is a minimally increased gradient consistent with minimal aortic valve stenosis. mild to moderate (+) aortic regurgitation is suggested. the mitral valve leaflets are structurally normal. on post contrast images, an eccentric, posteriorly directed jet of at least moderate (2+) mitral regurgitation is suggested but not confirmed due to poor image quality. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the lvef appears improved. changes in mr are difficult to assess. a tee is therefore suggested. electronically signed by , md, interpreting physician 12:01 ?????? caregroup is. all rights reserved. brief hospital course: mr. presented for elective cardiac catheterization and was noted to have left main coronary artery disease. during catheterization, he had intractable anginal pain, so he underwent placement of intra-aortic balloon pump placement with resolution of chest pain. he underwent preoperative workup and in the cardiac care unit. the intra aortic balloon pump was weaned and removed. on he was brought to the operating room and underwent coronary artery bypass graft surgery x4: left internal mammary artery to left anterior descending artery, and saphenous vein sequential grafting to obtuse marginal and the left posterior descending artery, and saphenous vein graft to diagonal artery. see operative report for further details. he received vancomycin for perioperative antibiotics and was transfered to the intensive care unit for post operative management on epinephrine. in the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. all lines and drains were discontinued in a timely fashion. the epinephrine was weaned off and he was started on betablockers/statin/aspirin and diuresis. on pod#1 he continued to progress and was transferred to the floor for further monitoring. physical therapy worked with him on strength and mobility. the remainder of his postoperative course was essentially uneventful. on pod#5 he was cleared by dr. for discharge to home with vna. all follow up appointments were advised. medications on admission: furosemide 20 mg daily lisinopril dosage uncertain olmesartan 20 mg daily rosuvastatin 40 mg daily verapamil dosage uncertain aspirin 81 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. crestor 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 3. 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* 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. furosemide 20 mg tablet sig: two (2) tablet po once a day for 10 days: then resume preop dose of 20mg once daily. disp:*90 tablet(s)* refills:*0* 6. rosuvastatin 20 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). disp:*60 tablet(s)* refills:*2* 7. propoxyphene n-acetaminophen 100-650 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 8. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days: then decrease to 200 mg once daily. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p cabg sciatica myocardial infarction prvious coronary stent hypertension hyperlipidemia skin cancer claudication cataracts discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with vicodin incisions: sternal - healing well, no erythema or drainage leg right - healing well, no erythema or drainage. edema leg left calf - 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 phone: date/time: 1:15 cardiologist: dr - currently on vacation - cardiac surgery office will call you with 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** md Procedure: Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Implant of pulsation balloon Diagnoses: Other iatrogenic hypotension Anemia, unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atherosclerosis of native arteries of the extremities with intermittent claudication Atrial fibrillation Other and unspecified hyperlipidemia Other and unspecified angina pectoris Personal history of other malignant neoplasm of skin Chronic diastolic heart failure

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall major surgical or invasive procedure: : bedside placement of peg history of present illness: this is a 70 y/o man who had a fall from a ladder after presumed syncopal episode. per osh reports, mr. was working on a ladder, complained of light headedness and fell approximately feet. he was alert and oriented initially, but vomited three times en route to osh, where he had a gcs of 10. he was then intubated for airway protection, and prepared for to . upon arrival here, head ct was performed revealing a significant right sdh and basilar skull fracture. past medical history: hypertension, dyslipidemia social history: married, resides at home. family history: non-contributory physical exam: on admission: o: bp:148/108 hr:97 rr:18 o2sats:100%cmv gen: wd/wn, comfortable, nad. heent: periorbital ecchymosis, there are air bubbles appreciated behind the left ear; right tm appears to be intact pupils: perrl eoms: uta motor: minimal spontaneous movement of the upper extremities, withdrawal of the lower extremities to noxious nail bed pressure. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 2mm to 1.5mm bilaterally. iii, iv, vi-xii: uta. reflexes: +gag, +corneals toes upgoing bilaterally exam on discharge: a&ox self, month, and year perrl 4-2mm bilaterally eoms: intact follows commands intermittently face symmetrical tongue midline rue: biceps and triceps, grip lue: biceps and triceps, grip ble: antigravity peg incision: c/d/i pertinent results: ct c-spine 1. no fracture or malalignment involving the cervical spine. 2. multilevel degenerative change most prominent at the level of c6-c7 with loss of intervertebral disc height, posterior disc-osteophyte complex, facet arthrosis and uncovertebral hypertrophy resulting in mild-to-moderate central canal stenosis and neural foraminal narrowing. this predisposes the patient to spinal cord injury with minimal trauma, and mri of the cervical spine should be considered for further evaluation of cord injury if clinically indicated. 3. basilar skull fracture involving the left occipital bone extending to involve the left occipital condyle and the left internal carotid canal within the petrous portion of the left temporal bone. recommend cta for further evaluation. 4. partially imaged is pneumocephalus involving the right temporal region as seen on concurrent ct examination. ct head : 1. extensive intracranial hemorrhage as detailed above with right cerebral convexity subdural hemorrhage measuring up to 11 mm, a small left frontal subdural hemorrhage measuring up to 4 mm, extensive right-sided cerebral subarachnoid hemorrhage, and likely component of intraparenchymal right frontal contusion. 2. multiple scalp hematomas involving the left occipital region, the right frontal region, and likely near the right frontal convexity. 3. left basilar skull fracture involving the left occipital bone with extension into the left occipital condyle and petrous portion of the left temporal bone, with involvement of the left internal carotid canal. recommend cta for further evaluation. 4. sinus opacification likely related to recent intubation ankle x-ray minimally displaced lateral malleolar fracture. small well corticated ossific density inferior to medial malleolus could represent sequelae of old trauma. cta neck : no evidence of vascular injury, thrombosis or aneurysm. the left basilar skull fracture involving the left occipital bone and extending into the left carotid canal is redomenstrated. the left carotid artery is suboptimally opacified in this region, however given symmteric appearance a focal intimal dissection is felt unlikely. ( ) echo the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is no ventricular septal defect. 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) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. ct head 1. increase in the right inferior frontal intraparenchymal hemorrhage with mild increase in the leftward shift of the midline structures. 2. increase in the conspicuity of the subarachnoid hemorrhage in the left frontal and parietal lobes. persistent mass effect on the right lateral ventricle with mild increase in the leftward shift of the midline structures. 3. other details as above. please see the prior ct head study for details regarding the osseous structures. 4. unchanged appearance of the scalp soft tissue swelling, on the left side. mri c-spine : impression: 1. multilevel neural foramen narrowing as above. 2. posterior disc bulge at c6-c7 and c7-t1 levels without impingement on the cord or central canal stenosis. 3. incidental note is made of blood within the left cerebellar cistern. ct head : impression: re-demonstration of multifocal intracranial subdural, intraparenchymal, and subarachnoid hemorrhage. there is no new hemorrhage identified. right subarachnoid hemorrhage is somewhat less conspicuous than on prior study. there is continued mass effect upon the right lateral ventricle, and associated rightward shift of midline structures, again measuring approximately 1 cm. small amount of intraventricular blood is again identified in the occipital of the left lateral ventricle. there is no new hemorrhage or increased mass effect identified. lenis : conclusion: no evidence of dvt in the right or left lower extremity. cta chest : impression: 1. right upper lobe pneumonia. 2. no central pulmonary embolism. limited distal branch evaluation due to respiratory motion artifact. in a single posterior segment right upper lobe pulmonary artery, there is suggestion of a filling defect, although this opacity overlaps with adjacent airspace disease, and may be artifactual. brief hospital course: mr. was admitted to on . he was intubated and taken to the icu with q1hr neuro checks. ct imaging showed worsening hemorrhage. platelets were goiven for history of aspirin use. e was on dilantin for seizure prophylaxis. mri c-spine was performed on . he was see by orthopedics who recommended an air cast for his ankle. serial ct's remained stable. dr. cleared his cervical collar on . he was weaned toward extubation. repeat head ct on was stable. his mannitol was held due to na/osm parameters. he failed speech and swallow evaluation at the bedside and a dobhoff was placed. on his mannitol was discontinued. his foley was discontinued. he was transferred to the step down unit. his dilantin dose was increased for a corrected level of 6.1. the patient had tachypnea overnight but his oxygen saturation remained within normal limits. his neuro exam remained stable. during the day on his tachypnea became worse and his abg showed respiratory alkalosis. he continued to oxygenate well. lenis were negative for dvt. his rr went up to the 40s and he became more lethargic and stopped following commands. the repeat head ct was stable. he also spiked a fever of 102. due to suspicion of a pe and the tachypnea, he was transferred to the icu and had a chest cta on the way there. the cta was equivocal. the patient's head of bed was kept elevated and he had nasotracheal suctioning and he several mucus plugs were removed. he also had chest pt and his rr came down to the 20s. by his mental status improved and he was following commands again with the right side. additionally id was consulted to guide antibiotic managment for his pneumonia. a repeat speach and swallow evaluation was performed and unfortunately, he did not pass. therefore a general surgery consult was obtained. he was also transferred to the stepdown unit, where vancomycin increased to q8h. urine culture was negative from . sputum culture found to have normal flora. his dobhoff was replaced to restart tube feeds. peg was performed on to bridge his nutrition during his recovery. post-operatively, he was tachypneic and reintubated for respiratory managment. he was then transferred back to the icu. after being placed on cpap, his respiratory status improved, as it was thought his tachypnea was due to atelactasis and/or mucous plugs. a nchct was again performed; revealing persistant right acute on chronic sdh and evolving right frontal contusion. it was decided to take him to the operating room on to evacuate the right sdh to optimize his recovery. however, it was noted on morning rounds on , that he has much improved clinically(following commands, moving all extremities); so the or case was cancelled. the patient's mental status remained stable and he was successfully extubated on . he continued to do well neurologically and he was breathing on room air with no difficulty. therefore he was transferred back to the neuro step down unit. he continued to work with pt and ot and was screened for rehab. he is stable neurosurgically and respiratory wise and will be discharged to rehab on . medications on admission: lopid magnesium calcium asa discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever. 2. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: inhalation q6h (every 6 hours) as needed for wheezing. 6. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 7. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 11. hydralazine 10 mg iv q4h:prn sbp>160 , hr<100 hold for sbp<100 12. metoclopramide 10 mg iv q6h:prn nausea discharge disposition: extended care facility: discharge diagnosis: subdural hematoma subarachnoid hemorrhage skull fracture cerebral contusion minimally displaced lateral malleolar fracture hospital acquired pneumonia respiratory failure dysphagia hyponatremia discharge condition: neurologically stable 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, advil, and ibuprofen etc. you have however, already been restarted on your home dose of aspirin. ?????? you have been prescribed an anti-seizure medicine,keppra. you will not require any bloodwork to monitor this. you will continue to take this until you are seen in follow up ?????? 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. 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 this appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Diagnoses: Acidosis Unspecified essential hypertension Hyposmolality and/or hyponatremia Pulmonary collapse Compression of brain Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Alkalosis Accidental fall from ladder Pneumonia due to Klebsiella pneumoniae Fracture of lateral malleolus, closed Foreign body in respiratory tree, unspecified Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall, change in mental status, headache, syncopal major surgical or invasive procedure: none history of present illness: 55 y/o female on coumadin for a-fib s/p fall x 2 days ago presents to osh hospital after syncopal episode. went to osh 2 days ago for headache, head ct was negative and was sent home. presented to pcp today for change in mental status and headache. while at pcp's office, syncopized and was transferred to . inr was 5.2, one unit of ffp administered and head ct showed r sdh with mid line shift. her mental status began to decline so she was then intubated for airway safety and transferred to for further neurosurgical workup. patient received 10mg of vitamin k and profiline in emergency department. past medical history: 1. hcv (genotype iib) cirrhosis s/p pegylated interferon and ribavirin with clearance of hepatitis virus in , c/b portal hypertension, ascites, and variceal bleed 2. fibromyalgia 3. granuloma annulare 4. hypothyroidism 5. disc disease in the cervical and lumbar spine 6. b12 and iron deficiencies social history: currently on disability. she lives with her sister. she never married and does not have any children. no tobacco,etoh or ivdu. unclear etiology of hep c- believes it may have been surgery w/blood transfusion as a child. family history: her brother has a history of polio and disease who is deceassed. her father had a history of breast carcinoma and her mother has disease. she has one brother who has hep (uncertain on type), and her mother also had hepatitis physical exam: on admission: t: unable to obtain bp:119/77 hr: 84 r :15 o2sats: 100% on cmv gen: patient off sedation for exam, intubated, following commands heent: bilateral orbital edema, normocephalic pupils: r 6-5mm, l 5-4mm eoms: intact neuro: mental status: intubated, awake and alert to person, place and time, nods head appropriately to questions orientation: oriented to person, place, and date. cranial nerves: i: not tested ii: pupils equally round and reactive to light, r 6-5mm l 5-4mm. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. motor: moves all extremities spontaneously, r>l. ecchymosis on r hip, thigh, knee, and shin. sensation: intact to light touch toes downgoing bilaterally exam on discharge: awake and alert, oriented to self and hospital, strength full pertinent results: 02:18am blood wbc-3.4* rbc-2.93* hgb-9.2* hct-26.6* mcv-91 mch-31.2 mchc-34.4 rdw-15.0 plt ct-38* 02:05pm blood neuts-87.2* lymphs-8.5* monos-3.7 eos-0.5 baso-0.1 02:18am blood pt-15.5* ptt-31.1 inr(pt)-1.4* 02:18am blood glucose-144* urean-9 creat-0.7 na-135 k-3.5 cl-105 hco3-24 angap-10 03:33am blood alt-25 ast-35 alkphos-40 totbili-2.2* 02:18am blood calcium-8.1* phos-1.4* mg-1.6 10:00pm blood osmolal-281 03:12am blood phenyto-15.3 ct head 1. extra-axial hemorrhage layering over the right cerebral convexity extending into that middle cranial fossa and layering along the right leaflet of the tentorium, as above, appears significantly improved, overall, since the admission studies of . 2. persistent subarachnoid hemorrhage in right frontoparietal sulci, with no new hemorrhage. ct head 1. no significant change in extensive right-sided subdural hematoma. increased subdural hematoma along the falx. stable right greater than left bilateral tentorial hematoma. 2. stable extensive right-sided subarachnoid hemorrhage. 3. stable right to left midline shift of approximately 6 mm. 4. stable small left frontal subdural hematoma. 5. probable new area of subarachnoid hemorrhage in the left frontotemporal area. brief hospital course: patient presented to osh on and was found to have a right sdh with midline shift and a traumatic right sah and was transferred to for further care. she was admitted to the icu with plans to wean to extubation, and was successfully extubated on the morning of after am rounds were completed. she was found to have thrombocytopenia and as such was administered platelets. her follow up platelet count after the administration actually dropped. her coagulation status was complicated by her liver disease and as such parameters were put in place of keeping her platelet count greater than 80 and her inr <1.5. also on this date she developed a fever to 101.4 and was pancultured by the icu team. her exam improved steadily with her only deficit being slight confusion at times. on she was evaluated by physical therapy for discharge planning and was deemed able to go home with home pt. medications on admission: b12 injection - im monthly clonazepam - 1 mg tablet - 1 tablet(s) by mouth prn clotrimazole - 10 mg troche - dissolve one in mouth five times a day do not drink or eat for 15 minutes after taking furosemide - 20 mg tablet - 1 (one) tablet(s) by mouth once a day lactulose - (prescribed by other provider) - 10 gram/15 ml solution - 30cc solution(s) by mouth three times a day as needed for constipation levothyroxine - (prescribed by other provider; dose adjustment - no new rx) - 125 mcg tablet - 1 tablet(s) by mouth once a day lipase-protease-amylase - (prescribed by other provider) - 249 mg (33,200 unit-,000 unit-,500 unit) capsule, delayed release(e.c.) - 1 capsule(s) by mouth prn before or after meals nadolol - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth once a day oxycodone - (prescribed by other provider) - 5 mg tablet - 1 tablet(s) by mouth prn spironolactone - 50 mg tablet - one tablet(s) by mouth daily warfarin - 5 mg tablet - 1 tablet(s) by mouth once a day start 5 today and check inr tomorrow zolpidem - (prescribed by other provider) - 5 mg tablet - 1 tablet(s) by mouth qhs prn medications - otc acetaminophen - (otc) - 500 mg tablet - 1 tablet(s) by mouth prn cholecalciferol (vitamin d3) - (otc) - 400 unit capsule - 1 capsule(s) by mouth once daily multivitamin - (otc) - tablet - 1 (one) tablet(s) by mouth once a day omega-3 fatty acids - (otc) - 1,000 mg capsule - 1 (one) capsule(s) by mouth once a day probiotic - (otc) - dosage uncertain discharge medications: 1. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 2. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 3. omega-3 fatty acids capsule sig: one (1) capsule po daily (daily). 4. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 7. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day) for 10 days. disp:*30 capsule(s)* refills:*0* 8. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): use while on oxycodone. disp:*60 capsule(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: right sdh with temporal accumulation and traumatic sah discharge condition: level of consciousness: alert and interactive activity status: out of bed with assistance to chair or wheelchair mental status: confused - sometimes 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 were on coumadin prior to your injury, you may safely resume taking this in 2 weeks 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 Diagnoses: Thrombocytopenia, unspecified Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Acquired coagulation factor deficiency Hyposmolality and/or hyponatremia Portal hypertension Unspecified acquired hypothyroidism Atrial fibrillation Accidental fall on or from other stairs or steps Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Other ascites Subdural hemorrhage Syncope and collapse Myalgia and myositis, unspecified Portal vein thrombosis History of fall Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness

allergies: lisinopril attending: chief complaint: chest pain major surgical or invasive procedure: cardiac cath : urgent coronary artery bypass graft x3: left internal mammary artery to left anterior descending artery; saphenous vein grafts to diagonal and obtuse marginal arteries. 2. endoscopic harvesting of the long saphenous vein. history of present illness: mr. is a 73 m with a history of cvd s/p left carotid stent placement on , htn, hl, dm2 who presents following an episode of dizziness followed by n/v/d and associated chest pain. he reports that he has been feeling well since his prior hospitalization with no recurrence of neurologic symptoms (initially had some right hand numbness/weakness which came and went). he felt well when he went to bed last night. on awakening this morning and turning over in bed, he felt extremely dizzy and like the room was spinning around. he turned back and his symptoms resolved after about 10 seconds. he then got out of bed and walked toward his kitchen to take his medications, but felt the sudedn onset of nausea and rushed to the bathroom where he proceeded to vomit for ~ one hour. he also had several episodes of "soft stool" during this period though stool was not liquidy. no blood in emesis or stool. he was diaphoretic during this time, and after about an hour of dry heaving began to develop chest pain located just above the manubrium to a severity of ~6.5/10. he also had an exacerbation of chronic left biceps pain radiating to his hand to severity and throbbing in quality. at this time, his wife called ems. he was ultimately able to take his morning medications and reports that though he had some dry heaving afterward he did not vomit his pills. the chest pain began to resolve on its own and was down to 1/10 prior to ems arrival. en route to the ed, he received a second 325 mg of aspirin and sublingual ng spray, following which the cp fully resolved. he did have persistence of the left arm pain, though less severe. . in the ed, initial vs were t 98.0, hr 130, bp 186/102 18 100% 4l nasal cannula. his arm pain improved with one dose of 4 mg iv morphine. labwork was significant for wbc of 17.8 with neutrophilic predominance on differential. cxr was notable for possible early rll pneumonia, for which he received 1 g iv vanco and 750 mg levofloxacin for hap given his recent hospitalization. ekg was unremarkable. vitals on transfer to the floor were hr 122, bp 179/85, rr 18, o2 sat 97% on 2l. he was admitted to medicine for treatment of pneumonia. . upon transfer to the floor, he reported feeling significantly improved. he has had no further vertigo, nausea, vomiting, or diarrhea/loose stool since arriving in the ed. he does not feel sob and denies fever, chills, night sweats, shortness of breath, cough, pleuritic chest pain or sputum production. no current cp or arm pain. past medical history: - hypertension (per record of home bps, generally runs sbp 130s-140s, hr 80s-90s) - hypercholesterolemia - diabetes mellitus type ii - hypothyroidism - cerebral disease s/p stent placement to left carotid - vertigo (likely bppv) x several months (last episode > 1 month ago) - lung cancer s/p surgical excision (left sided), no chemo/radiation - left inguinal hernia repair - partial gastrectomy for ulcer ~40 years ago - multiple (~4) back surgeries for bone spurs (? additional indications), no active back problems, ? hardware in place - accidental amputation of right thumb - rotator cuff surgery social history: married (second marriage) and lives with his wife. has one stepson who lives nearby and two biological grown children who live out of state. he was previously a heavy smoker (up to 4 packs per day) but quit 40 years ago. he drinks occasional beer but keeps this to a minimum, because he continues to work as a bus driver (cross-country charter buses) and takes jobs as they come. family history: raised in an orphanage - does not know his biological family. physical exam: admission physical exam: general - well-appearing elderly gentleman in nad, comfortable, appropriate, speaking in full sentences heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear, upper and lower dentures in place, nc in place neck - supple, no thyromegaly, no jvd, soft carotid bruits appreciable bilaterally lungs - no wheeze, rales, rhonchi. however, patient has increased vocal fremitus at right base, as well as increased sound transmission on assessment for egophony. no significant dullness to percussion appreciated. heart - pmi non-displaced, rrr, no mrg, nl s1-s2 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 signifcant rashes or lesions. sebhorrheic keratoses on the back neuro - awake, a&ox3, cns ii-xii grossly intact, strength/gait not assessed pertinent results: chest (portable ap): 1. suboptimal study, as the left costophrenic angle is not fully included and a small left pleural effusion cannot be excluded. slightly increased right lower lobe opacity, early consolidation not excluded. suggest dedicated pa and lateral views for better evaluation when patient able. tte: : pre-bypass: 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 mildly depressed (lvef= 45 %). there is mild basal and mid-inferoseptal wall hypokinesis. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. the aortic valve leaflets are moderately 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. dr. was notified in person of the results at time of surgery. post-bypass: the patient is av paced, on no inotropes. there is moderate hypokinesis of the basal and mid-inferoseptal and inferior wall of the left ventricle. left ventricular systolic function is unchanged. right ventricular function is unchanged. mild aortic stenosis is unchanged. mild (1+) aortic regurgitation is unchanged. moderate (2+) mitral regurgitation is seen. the ascending aorta, aortic arch, and descending aorta are intact. . cardiac catheterization : 1) coronary angiography of this right-dominant system demonstrated significant left main and functional three vessel coronary artery disease. the lmca had 70% stenosis with severe damping. the lad had 60% distal stenosis with a d1 with 70% proximal stenosis. the lcx had 70% stenosis at the origin. the dominant rca had 99% proximal stenosis, 99% mid stenosis, and 99% distal stenosis with left to right collaterals. 2) limited resting hemodynamics revealed systemic arterial hypertension (161/72/113). 3) left ventriculography was deferred. . non-contrast chest ct : 1. moderate calcifications of the ascending aorta, the aortic arch, the descending aorta and the supra-aortic branches. moderate-to-severe coronary calcifications. 2. multiple non-characteristic, partly calcified and partly non-calcified pulmonary nodules. several sub 5-mm ground-glass nodules. 3. part solid and part non-solid pulmonary nodule in the anterior aspects of the right lower lobe, with retractile behavior with regard to the major fissure. this nodule needs to be followed by ct in approximately six months from now. 4. minimal bilateral basal scarring, left more than right, with a minimal left pleural effusion. cxr : upright pa and lateral views of the chest show a decrease in the left pleural effusion. the abnormal contour is likely due to pleuralthickening seen on previous examinations. unchanged small right pleural effusion. heart size is large but unchanged. decrease in mediastinal size with no evidence for active bleeding. again seen are small calcified granulomas within the right mid lung. no pneumothorax. brief hospital course: as mentioned in the hpi, mr. presented to the ed with dizziness and chest pain. he was admitted and worked up. a repeat troponin on the evening of the day of admission () was elevated at 0.34 and ck-mb was 39. the patient was placed on oxygen and administered a second dose of aspirin 325 mg. a cardiology consult was called. he was placed on telemetry and then transferred to the cardiology floor for cardiac catheterization. catheterization on demonstrated left main and functional three vessel disease. he was continued on a heparin drip, aspirin, clopidogrel, beta blocker, and statin in preparation for cabg. he was brought to the operating room on where he underwent an urgent coronary artery bypass graft x 3. overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. he was intubated on propofol and neo. he had increase bloody ct drainage required multiple blood products, he ended up returning to the or for exploration. venous bleed was found and repaired. he returned to the icu and was hemodynamically stable. he was extubated that evening and was found to be alert and oriented and breathing comfortably. the patient remained neurologically intact and hemodynamically stable he weaned from vasopressor support. beta blocker was initiated and the patient was gently diuresed. the patient was transferred to the telemetry floor on pod#1, his ct remained for continued drainage. his wires were removed in timely fashion and wihtout difficulty. the patient was evaluated by the physical therapy service for assistance with strength and mobility. patient has a history of vertigo (likely bppv), in the post-op period he was acutely dizzy and very unsteady gait as a result, he was restarted on his meclizine. he has a hx of carotid stenosis and was restarted on plavix. due to his continued dizziness, he had carotid studies done which showed 60-69% stenosis in right and patent left carotid stent. he was evaluated by the neurology service who felt that his dizziness was related his vertigo that has been aggravated by his recent surgery and that it will improve with time. he has remained hemodynamcically stable and remains in sr. the wound was healing and his pain was controlled with oral analgesics. in lgiht of his dizziness, unsteady gait and safety concerns he was discharged to neuro rehab - rehab on pod# 8. follow up instructions arranged medications on admission: ergocalciferol (vitamin d2) 50,000 unit cap po every other week simvastatin 80 mg po mouth daily losartan 100 mg by mouth daily meclizine 25 mg po up to three times per day for dizziness levoxyl 50 mcg po daily enteric coated aspirin 325 mg tab (e.c.) po daily plavix 75 mg po daily metformin 850 mg po bid 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. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. metformin 850 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 8. losartan 25 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 9. meclizine 12.5 mg tablet sig: two (2) tablet po qid (4 times a day). 10. ibuprofen 400 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. 11. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 12. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po daily (daily) for 4 days. 13. metoprolol tartrate 50 mg tablet sig: 2.5 tablets po bid (2 times a day). 14. lasix 20 mg tablet sig: one (1) tablet po once a day for 5 days. discharge disposition: extended care facility: hospital - discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 3 past medical history: - hypertension - hypercholesterolemia - diabetes mellitus type ii - hypothyroidism - cerebral disease s/p stent placement to left carotid - vertigo (likely bppv) x several months (last episode > 1 month ago) - lung cancer s/p surgical excision (left sided), no chemo/radiation - left inguinal hernia repair - partial gastrectomy for ulcer ~40 years ago - multiple (~4) back surgeries for bone spurs (? additional indications), no active back problems, ? hardware in place - accidental amputation of right thumb - rotator cuff surgery 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** followup instructions: you are scheduled for the following appointments: surgeon: dr. on at date/time: 1:00 cardiologist: dr. on @ 11am please call to schedule the following: primary care: , md phone: date/time: 8:30 **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Left heart cardiac catheterization Reopening of recent thoracotomy site Diagnoses: Pneumonia, organism unspecified Other and unspecified noninfectious gastroenteritis and colitis Subendocardial infarction, initial episode of care 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 Unspecified acquired hypothyroidism Personal history of malignant neoplasm of bronchus and lung Personal history of tobacco use Abnormality of gait Other and unspecified hyperlipidemia Hemorrhage complicating a procedure 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 and unspecified coagulation defects Examination of participant in clinical trial Benign paroxysmal positional vertigo Unspecified vitamin D deficiency Unspecified cerebrovascular disease

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension major surgical or invasive procedure: central venous line placement arterial line placement history of present illness: ms. is a y.o. f with esrd on hd t/th/sat, htn, cad, and new type 2 dm, who was admitted on for hypotension in the setting of hd. normally, she is a&o x 3 but developed hypotension to the 50s with ams while at hd. day prior to admission, she had angioplasty of her left av fistula which increased flow rate from 195 to 450 cc/min. in the ed, initial vs: t 98.0 bp 95/50 hr 88 rr 13 100% on 3 l nc. received 1 l ns with improvement of sbp to 120s. fs 69 and amp d50 given with repeat fs 90. o2 sat stable. exam with pinpoint pupils and depressed mental status. she was also given narcan with some improvement in mental status given recent percocet use. she was then admitted to medicine for further evaluation of her hypotension and altered mental status. on the medical service, her hypotension was attributed to hypovolemia in the setting of hd. she continued to have altered mental status that was thought to be due to delirium due to pain, narcotics, and hospitalization. narcotics were held, and tylenol and lidocaine patch were instituted. renal followed patient, and she continued to have hd. she had leukocytosis and was cultured, although never mounted fever. patient cultured as foci of infection could be necrotic toes of l foot. vascular surgery was consulted for ? superinfection of necrotic toes on l foot. also found to have new rue dvt. had episode of coffee ground emesis on . hct was stable at 40. patients meds were held until mental status was improved to prevent aspiration. patient was triggered on at 20:57 for o2<90% in spite of oxygen and marked nursing concern. per trigger note, ra o2 sat 68-80% on ra. with 2 l nc, o2 sat 100%. at that time, thought to be due to hypoventilation due to ams, but concerned for pe vs infection. heparin gtt was started as pt guiaic negative, but then not resumed due to loss of iv access. on day of transfer to micu, pt had hd with no ultrafiltration. per resident, she was noted to be slightly more tachycardic in low 100s with bps in 90s (usually 140s), but not documented in chart. she was also noted to be hypotermic to 93 axillary. around 8 pm on evening of transfer, pt bp 67/palp in thigh and repeat in wrist was 98/60s. ej was attempted but not successful. she was unresponsive to sternal rub or pain. l sided facial droop was notably worse, and per floor resident, the family had noted that earlier also. she is being transferred to the icu for urgent iv access and her hypotension. per medicine resident, family continues with dnr/dni, but allows a-lines, cvls and pressors. of note, patient admitted 2 weeks agos with new l 1st and 2nd toe ischemia and gangrene severe pad. started on pletal and discharged to rehab on pain medications. past medical history: 1. esrd on hd, tues, thurs, sat. started in . has left av fistula for which she had a fistulogram and angioplasty on 2. htn 3. cad: tte : ef of >55%, moderate as, mild mr, mild tr. exercise stress test from that showed no evidence of redistribution. 4. djd 5. osteoporosis 6. iron deficiency anemia 7. colonic polyps, hemorrhoids 8. duodenal bulb ulcer, 9. shatski ring, hiatal hernia 10. glaucoma 11. right kidney cysts, slightly complex, first noted in , increased in size on 12. seasonal allergies 13. pancreatic tumor resection in 14. s/p appy 15. s/p oopherectomy for cyts 16. s/p cholecystectomy . s/p bilateral cataract surgery . proctitis in 19. left lower ext gangrene w dx angiography on with no suitable intervention possible 20. new dm type 2 social history: from notes and daughter - was living alone in independent living in until recent hospitalization after which she was sent to epic in . her husband passed away in and she has 2 adopted children. she has a sister who lives close by. she denies tobacco, etoh, recreational drug use. family history: from notes - mother who died from a stroke at yo. father who died from a stroke at yo. sister who is healthy. 2 brothers who passed fairly young, one from alcohol abuse. 3rd brother with prostate problems. family h/o kidney disease. physical exam: vitals - t: 95.5 ax bp: 45/33 --> 110/35 hr: 96 rr: 13 02 sat: 96% ra fs 35 --> 137 general: unresponsive initially on floor to sternal rub or pain, but after d50 x 2, able to open eyes and garble words heent: perrl, anicteric, op - mmm, no cervical lad, noticeable l sided facial droop that improved with glucose cardiac: ii/vi sem at rusb, no r/g lung: difficult exam, but no wheezes or rales abdomen: diffuse ttp with grimacing of face, hypoactive bs ext: 3+ pitting edema to knees neuro: a&o x 0, unable to follow commands rectal: guiaic positive brown stool with brb pertinent results: 03:44am blood wbc-15.6* rbc-2.97* hgb-8.8* hct-28.4* mcv-95 mch-29.8 mchc-31.2 rdw-19.9* plt ct-88* 08:35am blood wbc-11.1*# rbc-3.94* hgb-11.7* hct-37.1 mcv-94 mch-29.8 mchc-31.6 rdw-18.2* plt ct-162 08:35am blood neuts-92.8* lymphs-4.7* monos-2.0 eos-0.5 baso-0 03:44am blood neuts-93.5* lymphs-3.7* monos-2.5 eos-0.2 baso-0.1 05:11am blood pt-19.2* ptt-150* inr(pt)-1.8* 08:35am blood pt-14.0* ptt-38.6* inr(pt)-1.2* 11:30am blood fibrino-165 08:44pm blood ret aut-2.2 03:44am blood glucose-102 urean-14 creat-2.1* na-143 k-3.4 cl-106 hco3-26 angap-14 08:35am blood glucose-71 urean-24* creat-3.0*# na-140 k-5.5* cl-102 hco3-26 angap-18 03:44am blood alt-51* ast-151* ld(ldh)-408* ck(cpk)-2552* alkphos-122* totbili-0.3 08:44pm blood alt-29 ast-69* ld(ldh)-324* ck(cpk)-756* alkphos-127* totbili-0.3 12:45pm blood alt-26 ast-29 ld(ldh)-283* alkphos-151* totbili-0.2 08:35am blood ck(cpk)-148* 03:44am blood ck-mb-40* mb indx-1.6 ctropnt-0.26* 08:44pm blood ck-mb-16* mb indx-2.1 ctropnt-0.17* 08:35am blood ctropnt-0.14* 03:44am blood albumin-1.8* calcium-7.3* phos-2.9 mg-2.0 12:45pm blood albumin-2.3* calcium-8.2* phos-3.5 mg-1.5* 04:04am blood lactate-4.2* 08:57pm blood lactate-3.3* 08:49am blood lactate-1.4 08:57pm blood type-art po2-134* pco2-33* ph-7.52* caltco2-28 base xs-4 comment-greentop : echo, tte: the left atrium is normal in size. the estimated right atrial pressure is 0-5 mmhg. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. left ventricular systolic function is hyperdynamic (ef>75%). a mid-cavitary gradient is identified. right ventricular chamber size and free wall motion are normal. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is severe aortic valve stenosis (valve area 0.9 cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a small pericardial effusion. no right atrial or right ventricular diastolic collapse is seen. compared with the prior study (images reviewed) of , the heart rate has doubled and the left ventricular size is smaller with mid-cavitary obstruction, suggesting underfilling of the left ventricle. the severity of aortic stenosis may be slightly worsened. upper extremity ultrasound: acute deep venous thrombosis involving the right subclavian, axillary, basilic, and brachial veins. cxr: previous severe atelectasis in the right middle and lower lobes has improved. persistent air bronchograms in the right lower lung could represent consolidation due either to atelectasis or pneumonia, but much of the relative increase in radiodensity of the right lower chest is due to a moderate right pleural effusion. pulmonary vasculature is generally engorged. mild-to-moderate cardiomegaly is stable. brief hospital course: the patient was admitted with hypotension at the time of dialysis. she had a leukocytosis and had no source for infection. she was cultured and monitored. her leukocytosis persisted and her hypotension returned on hospital day 2, she was transferred to the icu for hypotension. she was started on broad spectrum antibiotics, no source for infection was found. the patient had coagulation studies consistent with worsening dic, a discussion with the family was held to discuss the poor prognosis associted with the likely diagnosis of severe septic shock complicated by dic. a decision was made to make the patient "cmo" (comfort measures only). medications on admission: lidocaine patch 5% transdermal daily zofran 4 mg iv q8 hours prn nausea heparin 5000 sq qid pantoprazole 40 mg iv q24 hours acetaminophen 1 g po/pr tid warfarin 5 mg po daily discharge medications: deceased discharge disposition: expired discharge diagnosis: severe septic shock disseminated intravascular coagulation discharge condition: deceased discharge instructions: deceased followup instructions: deceased Procedure: Venous catheterization, not elsewhere classified Hemodialysis Diagnoses: End stage renal disease Renal dialysis status Coronary atherosclerosis of native coronary artery Unspecified septicemia Severe sepsis Aortic valve disorders Unspecified glaucoma Diaphragmatic hernia without mention of obstruction or gangrene Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Defibrination syndrome Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Osteoporosis, unspecified Septic shock Osteoarthrosis, unspecified whether generalized or localized, site unspecified Iron deficiency anemia, unspecified Hemorrhage of gastrointestinal tract, unspecified Hypovolemia Atherosclerosis of native arteries of the extremities with gangrene Drug-induced delirium Unspecified sedatives and hypnotics causing adverse effects in therapeutic use Cyst of kidney, acquired

allergies: patient recorded as having no known allergies to drugs attending: addendum: medications were amended to increase his lasix to his home dose. he was also advised to follow-up with a local gastroenterologist given his pre-operative gastrointestinal bleeding. discharge medications: 1. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. digoxin 125 mcg 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. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 6. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days: last dose 6/14 pm. 7. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 9. ipratropium bromide 0.02 % solution sig: inhalation q6h (every 6 hours). 10. furosemide 20 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: extended care facility: long term health - md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Intraoperative cardiac pacemaker (Aorto)coronary bypass of four or more coronary arteries Transfusion of packed cells Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Congestive heart failure, unspecified Adrenal cortical steroids causing adverse effects in therapeutic use Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Other chronic pulmonary heart diseases Alcohol abuse, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction 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 Long-term (current) use of anticoagulants Other respiratory complications Hemorrhage of gastrointestinal tract, unspecified Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Examination of participant in clinical trial Pneumonia due to Hemophilus influenzae [H. influenzae] Other abnormal glucose Tricuspid valve disorders, specified as nonrheumatic Secondary cardiomyopathy, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - coronary bypass grafting x5: left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the second obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery; as well as reverse saphenous vein graft from the second obtuse marginal vein graft to the first diagonal as a y-graft from the proximal portion of the graft just after the proximal anastomosis. resection of left atrial appendage. history of present illness: mr. is a 67 yo m h/o afib on coumadin, copd, systolic hf with ef 30%, who presented to an osh on with c/o wks worsening sob , increasing lower extremity edema and orthopnea and a reported 20 lb weight gain. notably, patient reports taking sl nitro daily for chest pain for the past few weeks. . on osh admission, he was initially felt to be having a chf exacerbation with concurrent copd exacerbation and was treated with diuresis and iv steroids/nebs. on patient complained of chest tightness and ecg showed diffuse st depressions. cardiac enzymes flat at the time. he was started on heparin, integrillin gtt and cont on asa. plavix was not given in case surgery needed. on hct noted to drop from 38 at admission to 25. stool was guiac positive. he was transfused two units of prbcs. pt was seen by gi who felt that bleeding likely related to anticoagulation thus asa, heparin and integrillin were all held. ct abdomen to rule out intraperitoneal or retroperitoneal bleed was considered but deferred until transfer. . patient underwent cardiac cath on which severe multivessel disease including 90% focal mid-l main, 60% mid- lad, 80% mid left cx, 80% proximal rca stenosis. given severity of coronary disease he was transferred to the for further management. notably, prior to transfer patient had cp requiring 1 sl nitro despite being on nitro gtt at 40 mcg. . on arrival, patient chest pain free on nitro gtt though developed 4/10 chest pain. ecg cont to show diffuse st depressions which is unchanged previous ecgs over past 24 hours. past medical history: hyperlipidemia chronic obstructive pulmonary disease gi bleed severe pulmonary hypertension atrial fibrillation tobacco abuse-80 pack yr etoh abuse social history: sister: ca mother: dm no hx heart disease or sudden death family history: occupation: retired janitor drugs: none tobacco: 80 pack yr hx alcohol: drinks vodka tonic /night physical exam: vitals: t 98.3 hr 87 bp 127/61 rr 17 o2 96% on 2l nc gen: elderly male, sitting in bed, speaking comfortably, nad heent: nc/at, perrl, eomi, op clear, poor denitition neck: supple, no lad, jvp not elevated heart: irreg, irreg s1/s2 present, +iii/vi diastolic murmur heard best at lusb ctab: diffuse wheezes, exp>insp abd: +bs, soft, nt, nd ext: 1+ le pitting edema, peripheral pulses dopplerable, lower ext skin shiny and hairless neuro: aox3, cn ii-xii, light touch sensation grossly intact, motor strength bilaterally pertinent results: echo () the left atrium is mildly dilated. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with basal to mid anterior wall hypokinesis. overall left ventricular systolic function is 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 to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: mild regional left ventricular systolic dysfunction and overall normal global function. mild to moderate mitral regurgitation. mild aortic regurgitation. moderate pulmonary artery systolic hypertension with borderline normal right ventricular systolic function. . carotid duplex () 1. 60-69% left ica stenosis. 2. 40-59% right ica stenosis. . chest x-ray () the post-cabg appearance of the chest is unremarkable including the sternal wires and surgical clips. the right internal jugular line tip is at the cavoatrial junction. the bilateral pleural effusions are small potentially slightly increased since the prior study, although it may be explained by currently upright position of the patient. there is questionable new left perihilar opacity that might be worrisome for a developing infectious process and close attention to this area is recommended. multiple calcified pulmonary nodules are unchanged. . 07:17pm blood wbc-9.6 rbc-3.07* hgb-9.7* hct-28.3* mcv-92 mch-31.6 mchc-34.2 rdw-15.5 plt ct-243 05:53am blood wbc-14.8* rbc-2.72* hgb-8.5* hct-25.3* mcv-93 mch-31.4 mchc-33.8 rdw-15.9* plt ct-305 07:17pm blood pt-14.4* ptt-20.9* inr(pt)-1.3* 05:49am blood pt-14.7* inr(pt)-1.3* 07:17pm blood glucose-216* urean-39* creat-0.9 na-140 k-3.3 cl-92* hco3-37* angap-14 05:53am blood glucose-84 urean-19 creat-0.6 na-133 k-4.6 cl-99 hco3-31 angap-8 05:53am blood mg-1.7 brief hospital course: mr. was admitted to the on via transfer from for further management of his coronary artery disease. he was worked-up in the usual preoperative manner by the cardiac surgery service including a carotid duplex ultrasound which showed a 60-69% left internal carotid artery stenosis and a 40-59% right internal carotid artery stenosis. he required a transfusion of packed red blood cells for a low hematocrit in the setting of his recent gi bleed. on , he was taken to the operating room where he underwent coronary artery bypass grafting to five vessels and resection of his left atrial appendage(given history of atrial fibrillation). postoperatively he was taken to the intensive care unit for monitoring. within 24 hours, he awoke neurologically intact and was extubated without incident. ciprofloxacin was empirically started for chest x-ray findings concerning for worsening left retrocardiac opacity. he required aggressive pulmonary toilet but otherwise maintained stable hemodynamics and transferred to the sdu on postoperative day two. amiodarone was initiated and beta blockade was advanced for better rate control of his atrial fibrillation. given his recent gi bleed, warfarin was not resumed until gi workup was performed. he underwent endoscopy and colonoscopy which revealed...? ciprofloxacin was continued for a sputum culture that grew out haemophilus influenzae. over several days, he continued to make clinical improvements with diuresis. he was eventually cleared for discharge to rehab on postoperative day six. medications on admission: lasix 20mg , dig 0.25mg/d, lopressor 100mg , lipitor 40mg/d, asa 81mg/d, coumadin? dose discharge disposition: extended care facility: long term health - discharge diagnosis: coronary artery disease s/p coronary artery bypas graft x 5 postoperative pneumonia hyperlipidemia chronic obstructive pulmonary disease gi bleed severe pulmonary hypertension atrial fibrillation congestive heart failure discharge condition: good discharge instructions: 1)no driving for one month 2)no lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)please shower daily. wash surgical incisions with soap and water only. 4)do not apply lotions, creams or ointments to any surgical incision. 5)please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). office number is . 6)call with any additional questions or concerns. followup instructions: dr. in weeks ( dr. in weeks follow-up with dr. in 2 weeks. please call all providers for appointments. Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Intraoperative cardiac pacemaker (Aorto)coronary bypass of four or more coronary arteries Transfusion of packed cells Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Congestive heart failure, unspecified Adrenal cortical steroids causing adverse effects in therapeutic use Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Other chronic pulmonary heart diseases Alcohol abuse, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction 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 Long-term (current) use of anticoagulants Other respiratory complications Hemorrhage of gastrointestinal tract, unspecified Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Examination of participant in clinical trial Pneumonia due to Hemophilus influenzae [H. influenzae] Other abnormal glucose Tricuspid valve disorders, specified as nonrheumatic Secondary cardiomyopathy, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: alcohol detox and palpitations major surgical or invasive procedure: none. history of present illness: 48 y/o female with hx bipolar, alcoholism presents with desire for alcohol detox. patient reports last drink pm, alcohol level negative today. patient reports sober for 3 months, and went on a drinking binge this past week 1 large bottle of wine per day and several shots of vodka. patient reports increased stress in her life at the time of her birthday and split from verbally abusive husband. presented today because this am had episode of severe anxiety and palpitations that she was scared for her life and called 911. . in the ed, initial vs were: t 97 p 103 bp 158/90 r 23 o2 sat 99% ra. vomited *1. patient got valium 10 mg and hr improved to 80s. exam unremarkable except for tremor and mildly try. a*o*3. patient was noted to have na of 118, and wbc 15.6. got total 30 mg iv valium total in ed over 3 hours. got 3 l ns. bp 126/60 hr 84 rr 20 o2sat: 95% ra. . upon arrival to icu, patient alert and oriented, c/o tremors and headache. patient reports near constant ha worse in am, with photo and phonophobia, bilateral temporal r>l, blurry vision. patient denies double vision. . review of systems:(+) per hpi. (+) hot flashes, chills, night sweats (worse when she is on drinking binges), congestion, cough, constipation *1 wk, dysuria w/o increased urinary frequency. vomit *1, no nausea, diarrhea, abdominal pain. (+) weight gain. no rhinorrhea, shortness of breath, chest pain. past medical history: bipolar/depression/anxiety hyperlipidemia ptsd - from a rape several yrs ago etoh abuse: hx of withdrawal seizure and dts in past menopause: lmp 1.5 yrs ago social history: long etoh use since age 20. 1 large bottle of wine per day, denies iv drug, 1ppd smoker. verbally abusive husband (unclear if he left recently or she left him, but this is very distressing to her). reports no food in the home and lost money recently. patient reports longest period of sobriety 4 yrs. on disability for mental illness. patient with pet cats, currently being taken care of by a neighbor. . psychiatrist (dr. at medical records there , fax ) and weekly counselor ms. at house. family history: non contributory physical exam: vitals: t: bp: p: r: 18 o2: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs at admission: images: cxr : minimal atelectasis left base. no acute pulmonary process otherwise identified. no radiographic evidence for pulmonary nodule or mass. ct head : no acute intracranial hemorrhage or mass effect. ekg: nsr, no acute abnormalities 11:08am blood wbc-15.6*# rbc-3.60* hgb-11.0* hct-32.1* mcv-89# mch-30.6# mchc-34.2 rdw-14.8 plt ct-276 11:08am blood neuts-84.3* lymphs-11.4* monos-2.9 eos-1.1 baso-0.2 11:08am blood glucose-120* urean-4* creat-0.6 na-118* k-3.9 cl-81* hco3-19* angap-22* (sodium increased to 125 after 3l ns) 11:08am blood alt-22 ast-40 alkphos-69 totbili-0.7 02:22pm blood calcium-7.2* phos-2.4* mg-1.5* iron-pnd 11:08am blood hcg-<5 01:39pm blood type- po2-96 pco2-38 ph-7.43 caltco2-26 base xs-0 comment-green top 12:57pm urine color-straw appear-clear sp -1.004 12:57pm urine blood-mod nitrite-neg protein-neg glucose-neg ketone-50 bilirub-neg urobiln-neg ph-7.0 leuks-neg 12:57pm urine rbc-0-2 wbc-0-2 bacteri-mod yeast-none epi-0-2 12:57pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg brief hospital course: 1. etoh withdrawal - the pt received iv thiamine, folate with fluids in the icu. she continued to receive vitamins and fluids upon transfer to the floor and was placed on a ciwa scale for management of withdrawal. the patient's home medication of klonopin was held. the patient experiened fine tremors and night sweats but experienced no hallucination or frank delirium and received several doses of valium, remaining in the hospital approximately 72 hours since her last drink. social work was consulted to speak with the patient; the patient stated that she would be able to go home and that a friend would stay with her and that they could go to aa meetings together. 2. headache - an intracranial process was ruled out with ct head. 3. hyponatremia - corrected after ivf administration. psychiatry was consulted and felt that hyponatremia could have been secondary to trileptal use; this was therefore discontinued. 4. leukocytosis - thought uti. patient was started on cipro 500 mg po bid x 3d. 5. bipolar d/o - patient is on topamax (part of ongoing trial at ). no adjustments of home medication were needed. medications on admission: medications: per patient lipitor 10mg daily mvi 1 tab daily trazodone 300mg qhs - on med list effexor - dose unknown - 75 mg - on med list trileptal - dose unknown - 600mg - on med list geodon - dose unknown - 40 mg - on med list hydroxyzine 100 mg qhs - on med list klonopin 0.5 mg tid -- not in her psychiatric record from . patient identified as her pharmacy. called . date last filled, drug, dosage trazodone 300 mg qhs effexor 75 mg (immediate release, ) trileptal 300mg geodon 40 mg hydroxyzine 100 mg daily klonopin 0.5 mg tid (dr. lipitor 10 mg daily discharge medications: 1. ziprasidone hcl 20 mg capsule sig: one (1) capsule po bid (2 times a day). 2. venlafaxine 37.5 mg tablet sig: one (1) tablet po bid (2 times a day). 3. topiramate 100 mg tablet sig: 1.5 tablets po bid (2 times a day). 4. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety. disp:*30 tablet(s)* refills:*0* 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 doses. disp:*3 tablet(s)* refills:*0* 6. trazodone 100 mg tablet sig: three (3) tablet po hs (at bedtime) as needed for insomnia. 7. thiamine hcl 100 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis: hyponatremia, alcohol withdrawal secondary diagnoses: uti, bipolar disorder discharge condition: alert, ambulatory, and oriented x 3. in good condition. discharge instructions: you were seen in with alcohol withdrawal and significantly low sodium. you were given iv fluids with normal saline in order to replete your sodium levels, and you were given medication to treat your alcohol withdrawal. the following medication changes were made during your hospital stay: stopped klonopin (clonazepam), as it interacts with alcohol, and is not the benzodiazepine of choice in treatment for alcohol withdrawal. stopped trileptal (oxcarbazepine), as it may have been responsible for your low sodium levels. started cipro (ciprofloxacin), as you were found to have a uti (urinary tract infection) during your hospitalization. the bacteria responsible was e. coli, and in our testing it should be sensitive to the antibiotic you were prescribed. please contact your pcp if you suffer from symptoms including hallucinations, tremors, night sweats, fevers, chills, chest pain, shortness of breath, or any other symptoms that concern you. please take all medications as prescribed. followup instructions: please make and keep scheduled appointments with your pcp and psychiatrist as soon as is convenient following your release from the hospital. md, Procedure: Alcohol detoxification Diagnoses: Anemia, unspecified Tobacco use disorder Urinary tract infection, site not specified Hyposmolality and/or hyponatremia Dysthymic disorder Other and unspecified hyperlipidemia Headache Bipolar disorder, unspecified Disorders of magnesium metabolism Other and unspecified alcohol dependence, continuous Alcohol withdrawal Posttraumatic stress disorder Other and unspecified anticonvulsants causing adverse effects in therapeutic use Malnutrition of mild degree

allergies: lipitor / zetia attending: chief complaint: necrotizing/hemorrhagic pancreatitis major surgical or invasive procedure: 1. pancreatic necrosectomy and debridement. 2. placement of a j-tube for infected necrosis. 3. placement of a feeding jejunostomy tube. history of present illness: the patient is a 78-year-old male who is well-known to the gold service. he presented to the ed with complaints of fever to 102f and chills that started 5 days pta while he was visiting friends in . he also complained of fatigue and malaise, and dyspnea occasionally. he said that he wanted to sleep all the time. he denied nausea and vomiting. he does have diarrhea that has been going on for months since his episode of hemorrhagic necrotizing pancreatitis in 9/. he takes creon for this but, he believes, perhaps not enough. he had lost 4 pounds in the past 2 weeks. he denies pain. past medical history: 1. crf (cr ~3) 2. cabg x 3 ' 3. s/p appy as a child 4. gallstone pancreatitis with complicated, hemorrhagic pancreatitis in late 5. ccy on social history: reitred engineer. lives in , alone. no etoh, no tobacco family history: nc physical exam: vital signs stable, afebrile gen: elderly male, nad, no icterus heent: nc/at, eomi, perrla bilat., mmm, without cervical lad on my exam cor: rrr without m/g/r, no jvd, no bruits lungs: cta bilat. : +bs, soft, nd, nt, no masses ext: warm feet, no edema pertinent results: 07:05pm glucose-107* urea n-44* creat-3.2* sodium-136 potassium-3.5 chloride-108 total co2-17* anion gap-15 07:05pm alt(sgpt)-9 ast(sgot)-17 alk phos-94 amylase-28 tot bili-0.6 07:05pm lipase-17 07:05pm albumin-2.8* calcium-7.5* phosphate-2.5* magnesium-1.5* 07:05pm wbc-8.6 rbc-3.46* hgb-8.6* hct-26.6* mcv-77* mch-25.0* mchc-32.5 rdw-15.9* 07:05pm plt count-202 07:05pm pt-16.5* ptt-33.5 inr(pt)-1.5* 07:05pm fibrinoge-591* 11:51am lactate-1.9 : ct abd: large peripanc fluid collection w/ nondependent gas -> ?abscess, borderline splenic enlargement w/ extensive venous collaterals -> ?splenic vein thrombosis brief hospital course: :admitted to west 2 service with suspected hemorrhagic/necrotizing pancreatitis :no significant events : to or for ex-lap, pancreatic specimen growing multiple species. continued jp drainage x2. got 2 u prbc, 2 units ffp perioperatively. : no overnight events. transferred out of icu to floor. : foley d'ced. pt consult requested. : pt. begun on sips and trophic tube feeds. : diet advanced to full liquids. tube feeds advanced to goal. telemetry d'ced. : advanced to regular diet. : pt. discharged to , stable. jps in place. tube feeds to continue. ambulatory. voiding and stooling. tolerating po intake. medications on admission: creon 10 249mg capsules w/meals, cardura 2', toprol 75', omeprazole 20', asa 81", magnesium discharge medications: 1. doxazosin 1 mg tablet sig: two (2) tablet po hs (at bedtime). 2. amylase-lipase-protease 33,200-10,000- 37,500 unit capsule, delayed release(e.c.) sig: caps po qidwmhs (4 times a day (with meals and at bedtime)). 3. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 weeks. disp:*28 tablet(s)* refills:*0* 4. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 weeks. disp:*14 tablet(s)* refills:*0* 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 7. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day: in addition to toprol xl 50mg for total dose 75mg daily. tablet sustained release 24 hr(s) 8. aspirin 81 mg tablet sig: one (1) tablet po once a day. 9. magnesium oral 10. hydromorphone 2 mg tablet sig: one (1) tablet po 3-4 hours as needed for pain. 11. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. capsule(s) discharge disposition: extended care facility: - discharge diagnosis: primary: 1. infected pancreatic necrosis with peri-pancreatic abscess. secondary: 1. chronic pancreatitis 2. chronic renal failure discharge condition: good 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. . incision care: -your steri-strips will fall off on their own. please remove any remaining strips 7-10 days after surgery. -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. . jp drain care: -please look at the site every day for signs of infection (increased redness, swelling, odor, yellow or bloody discharge, fever). -maintain the bulb deflated to provide adequate suction. -note color, consistency, and amount of fluid in drain. call doctor if amount increases significantly or changes in character. -be sure to empty the drain frequently. -you may shower, wash area gently with warm, soapy water. -maintain the site clean, dry, and intact. -avoid swimming, baths, hot tubs-do not submerge yourself in water. -keep drain attached safely to body to prevent pulling followup instructions: you will be contact by dr. office regarding the date and times of your follow-up abdominal ct scan and subsequent office appointment, which will be scheduled in 2weeks. provider: , m.d. phone: date/time: 1:00 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Excisional debridement of wound, infection, or burn Transfusion of packed cells Percutaneous (endoscopic) jejunostomy [PEJ] Diagnoses: Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Chronic kidney disease, unspecified Chronic pancreatitis Cyst and pseudocyst of pancreas

allergies: no known allergies / adverse drug reactions attending: chief complaint: hypotension, fever, respiratory distress major surgical or invasive procedure: intubation with mechanical ventilation right ij central venous line placement foley catheter insertion history of present illness: ms. is a 59 year-old female with htn, type 2 dm on insulin, seizure disorder on dilantin, multiple sclerosis who is nonverbal at baseline who presents from nursing home with acute respiratory distress. she was reported to be "agonally breathing" at her nursing home with o2sat 91% on 2l; p 154-170, sbp 100/60, rr 30. unable to obtain a temperature . she was taken emergently to the ed. . in the ed, initial vs were: rectal temp 104, p 145-150, sbp 120-140, rr 20s, o2sat 99% breathing on her own with 100% bag mask on. pt was documented to be dnr without comment on dni status. the ed was unable to contact her family members on multiple attempts, so she was emergently intubated. labs notable for wbc 19.3 (92.1% n, 0% bands); na 150, bicarb 13, anion gap 13 with lactate 3, glucose 561, and cr 1.6 (baseline unknown). u/a showed 43 wbc and many bacteria, leuks large, nitrite negative; no ketones. her abdomen was distended, and she had 2l drained with foley placement. cxr with question of rul infiltrate vs. scarring. sbps declined to 90s, and patient was given 2liters of ns ivf. she was started on zosyn and ordered for vancomycin. she was given tylenol for her fever. initial access was intraosseous, but a right ij cvl was subsequently placed. of note, after line placement, patient was felt to have seizure-like movements of her eyes and given ativan 2mg iv with resolution. on transfer, vs were: p 120s, bp 92/66, vent set to rr 12 but overbreathing vent, o2sat 100% with abg 7.35/24/290/14 on ac. . on the floor, she is intubated, not opening eyes or responding to any commands. past medical history: multiple sclerosis, nonverbal at baseline seizure disorder type 2 diabetes mellitus on insulin dementia htn gerd dry eyes h/o paronoia, delusional ?h/o cva social history: resides in nursing home, reportedly in a persistant vegetative state. she is dnr. hcp is father, (), who is currently in rehab. her brother () is the secondary hcp in the interim. family history: unknown. physical exam: admission physical exam: general: intubated, non-responsive, not following any commands heent: sclera anicteric, dry mm neck: supple, jvp not elevated, r ij line lungs: no use access mm, coarse rhonchorous breath sounds anteriorly, no wheezes cv: rrr, difficult to appreciate heart sounds over coarse bs, but no appreciable murmurs abdomen: +bs, distended, non-tender, tympanic to percussion, no rebound tenderness or guarding, no organomegaly. peg tube present. gu: foley ext: dry, cool at distal extremities, faint pulses, no edema, no cyanosis; left tibial io line neuro: non-responsive, r eye deviated to right, pupils ~1mm, mimimally reactive, not moving any extremities, lower extremities with muscle wasting, no clonus, unable to elicit dtr's, does not withdrawal to pain discharge physical exam: t 97.9, p 78, bp 97/58, rr 20, o2sat 100% on 40% face tent general: extubated, non-responsive, not following any commands heent: sclera anicteric, dry mm neck: supple, jvp not elevated, r ij line lungs: basilar crackles cv: rrr, difficult to appreciate heart sounds over coarse bs, but no appreciable murmurs abdomen: +bs, distended, non-tender, tympanic to percussion, no rebound tenderness or guarding, no organomegaly. peg tube present. gu: foley ext: dry, cool at distal extremities, faint pulses, no edema, no cyanosis neuro: opens eyes to loud stimulus, perrl, ?tracking subjects, not moving any extremities, lower extremities with muscle wasting, no clonus, hyperreflexic, does not withdrawal to pain access: right ij central venous line pertinent results: 01:00am blood wbc-19.3* rbc-3.95* hgb-12.6 hct-37.9 mcv-96 mch-31.9 mchc-33.2 rdw-14.6 plt ct-516* 01:00am blood neuts-92.1* lymphs-4.2* monos-2.4 eos-0.5 baso-0.8 01:00am blood glucose-561* urean-95* creat-1.6* na-150* k-4.0 cl-124* hco3-13* angap-17 calcium-8.0* phos-3.5 mg-1.9 04:26am blood alt-51* ast-47* ld(ldh)-283* alkphos-98 totbili-0.6 04:26am blood osmolal-367* 04:26am blood05/01/11 01:08am blood lactate-3.0* 04:26am blood phenyto-7.8* 02:41am blood wbc-10.9 rbc-2.84* hgb-8.9* hct-26.5* mcv-94 mch-31.5 mchc-33.7 rdw-14.0 plt ct-226 02:41am blood pt-12.3 ptt-29.9 inr(pt)-1.0 02:41am blood glucose-186* urean-22* creat-0.5 na-140 k-4.1 cl-115* hco3-16* angap-13 02:41am blood alt-32 ast-22 alkphos-76 totbili-0.3 02:41am blood albumin-2.4* calcium-7.8* phos-2.0* mg-2.1 10:41pm blood osmolal-298 02:48am blood lactate-1.9 02:41am blood phenyto-11.3 1:28 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive rod(s). consistent with corynebacterium or propionibacterium species. respiratory culture (final ): moderate growth commensal respiratory flora. gram negative rod(s). rare growth. c. diff toxin a & b: neg. ecg: sinus tach, rate 142, left axis deviation, no st changes cxr: scattered subsegmental atelectasis, without acute cardiopulmonary process. the endotracheal tube should be withdrawn for optimal positioning. rij line extends into the right atrium. cxr: since extubation, there is little interval change, right lower lobe atelectasis is stable. the right internal jugular central venous catheter tip is projected over the expected location of the lower svc. the nasogastric tube has been removed. linear densities in the retrocardiac space at the left lower lobe are consistent with atelectasis, unchanged since . the cardiac size is normal. pulmonary venous congestion is stable. impression: bilateral subsegmental atelectasis, stable since . **pending results: - blood cultures: pending, no growth to date. - urine culture: preliminarily growing >100,000 enterococcus; sensitivities pending *** - urine culture: pending. brief hospital course: pt is a 59 year-old female with iddm, seizure disorder, and multiple sclerosis transferred from nursing home for acute respiratory distress and found to be in septic shock. # septic shock: patient borderline hypotensive with fever to 104, tachycardia, tachypnea, and leukocytosis. right ij cvl placed for cvp monitoring as well as for iv antibiotics. she responded to volume resuscitation and did not require pressors. infectious source likely uti based on ucx from now growing enterococcus, sensitivities pending. plan to complete a 14-day course of vancomycin and zosyn for urosepsis - to be continued until ; may be able to narrow down antibiotics based on sensitivities. blood cultures are also pending at time of discharge but negative to date. her sbps have ranged from 85 to 105 with patient requiring and responding to occasional 500cc lr ivf boluses; urine output maintained throughout. . # urinary retention: foley placed with urine output of 2l on presentation. likely related to uti. have component from ms as well although per nursing home, had not required consistent straight cathing. foley in place at time of discharge. rehab physician to change out foley in setting of uti. also recommend removing foley for voiding trial as soon as able and routine straight cathing as indicated, especially given multiple recent utis. . # seizure disorder: question of observed seizure in ed. pt was treated with one dose of ativan in ed. most likely due to lowered seizure threshold in setting of sepsis, fevers. possible also that significant leukocytosis due to seizure. pt having no movements on arrival to floors and did not have any during icu course. given phenytoin bolus and increased phenytoin regimen to 50 mg qam, 75 mg qpm, and 100 mg qhs) with therapeutic level on discharge. outpatient keppra dosing maintained. she was maintained on seizure precautions. . # hypoxic respiratory failure: pt was tachypneic with reported o2sat 89-91% on 2l at osh, but question of poor pleth in setting of peripheral vasoconstriction. she was intubated for airway protection here. abg not done until after intubated, which demonstrated pao2 290. cxr without clear pneumonia, and patient was extubated without complication. she was maintained on 40% face mask without any further oxygen desaturations. . # acute renal failure: bun 95 with cr 1.6; baseline cr appears to be 0.7. most likely pre-renal. this resolved with iv fluid resuscitation; cr 0.5 on discharge. . # metabolic acidosis: anion gap 13 and lactate 3, rising to 3.6 on presentation. glucose markedly elevated but no urinary ketones suggestive of dka in this patient with type 2 dm. the patient's metabolic acidosis and lactic acidosis improved with fluid resuscitation. . # hyperglycemia: pt with type 2 dm, on lantus 14 units qhs with gentle iss. most likely elevated infectious process as above. no e/o dka. the patient was initially started on an insulin gtt but weaned off this as better glycemic control attained. the patient was restarted on home lantus dose with regular insulin sliding scale after tube feeds restarted. . # hypernatremia: na corrected for hyperglycemia is 157. likely secondary to dehydration from infection and osmotic diuresis in setting hyperglycemia. treated with combination of ns for fluid resuscitation d5w ivf with slow correction of this over several days. she was continued on free water flushes 200 cc q4h. . # ms: lives in nursing home, and is nonverbal at baseline, reportedly for years. nursing home records note persistent vegetative state. we tried to obtain medical records from regarding prior neurologic evaluation to better ascertain her cognition (?locked-in syndrome) but did not receive any information prior to her discharge. would recommend further neurologic evaluation as outpatient if no previous work-up has been done. . # ppx: heparin sc tid started and recommended to be continued for dvt ppx. . # access: right ij central venous line placed for access. . # code status: patient confirmed to be dnr but ok to intubate and hospitalize per brother # 2). would recommend further discussion of goals of care as an outpatient. medications on admission: ranitiine 10 ml qhs dilantin infatab 50 mg 9am, 50 mg 5pm, 100 mg 9pm levetiracetam 100 mg lactulose 30 ml bisacodyl 10mg pr daily refresh eye drops os daily refresh ointment os qhs mvi 15 ml daily vitamin c 500 mg cranmax drink mix daily prosource protein liquid 30 ml glucerna 1.0 cal 240 ml 5x/day 150 cc h2o flush 5x/day guaituss 15 ml q4h prn acetaminophen 650 mg q4h prn prochlorperazine 25 mg daily prn ipratropium-albuterol 1 neb q4h prn discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. levetiracetam 100 mg/ml solution sig: five (5) ml po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 5. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic hs (at bedtime): in left eye. 6. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic every four (4) hours as needed for dry eye: in both eyes. 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 8. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid. 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 10. phenytoin 50 mg tablet, chewable sig: as directed tablet, chewable po three times a day: one tablet in am, one and one-half tablet in pm, two tablets at bedtime. 11. insulin glargine 100 unit/ml solution sig: fourteen (14) units subcutaneous at bedtime. 12. piperacillin-tazobactam-dextrs 4.5 gram/100 ml piggyback sig: 4.5 gram intravenous q8h (every 8 hours): to be continued until . 13. vancomycin 500 mg recon soln sig: seven y (750) mg recon soln intravenous q 12h (every 12 hours): to be continued until . 14. ranitidine hcl 15 mg/ml suspension for reconstitution sig: ten (10) ml po at bedtime. 15. bisacodyl 10 mg suppository sig: one (1) supp rectal once a day. 16. multi-vitamin w/minerals capsule sig: one (1) capsule po once a day. 17. vitamin c 500 mg tablet sig: one (1) tablet po twice a day. 18. -max 500 mg capsule sig: one (1) capsule po once a day. 19. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) neb inhalation every four (4) hours as needed for shortness of breath or wheezing. 20. prochlorperazine 25 mg suppository sig: one (1) supp rectal once a day as needed for nausea. 21. guiatuss 100 mg/5 ml liquid sig: fifteen (15) ml po every four (4) hours as needed for cough. 22. guiatuss 100 mg/5 ml liquid sig: fifteen (15) ml po every four (4) hours as needed for cough. 23. regular insulin sig: as directed subcutaneous every six (6) hours: per sliding scale. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary: septic shock urinary tract infection secondary: acute kidney injury multiple sclerosis seizure disorder discharge condition: level of consciousness: lethargic and not arousable. activity status: bedbound. discharge instructions: you were admitted to the hospital with fevers and low blood pressure indicating a severe infection. this infection was likely a urinary tract infection. you are currently being treated with broad spectrum antibiotics. we are waiting for the bacteria to grow so we know which antibiotic will be best for you. it is likely that your urinary tract infection was a result of urinary retention. we are discharging you with a foley catheter and would like for you to be assessed for urinary retention in the future. medication changes: started vancomycin and zosyn for total 14 days (until ) increased dilantin to 50 mg in am / *75 mg in pm* / 100 mg at bedtime started subcutaneous heparin injections for dvt prophylaxis. followup instructions: with rehab physician md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Diagnoses: Acidosis Esophageal reflux Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Acute respiratory failure Long-term (current) use of insulin Long-term (current) use of other medications Septic shock Epilepsy, unspecified, without mention of intractable epilepsy Multiple sclerosis Hyperosmolality and/or hypernatremia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p vf arrest major surgical or invasive procedure: cardiac catherization icd placement history of present illness: mr is a 78m with pmh of pvd, htn, cad s/p remote mi and aaa repair transfered from after witnessed vf arrest. per ed notes and pt's wife, he was out shopping with her this am, in usoh when collapsed. immediate cpr administered. ems arrived within ~4 minutes, initial rhythm vf, was defibrillated to asystole, received epi x 3, atropine with conversion from pea to pulsatile st. brought to hosp, intubated, lidocaine gtt initiated, pt transfered to . . in ed, noted to have guaiac + stool, brbpr as well as coffee ground aspirate in ngt with 1 episode brb from ngt which cleared with lavage, then return of coffee grounds. hct stable from osh. per report ct scan head/neck wnl and abd/pelvis without aorto-enteric fistula; both done non-contrast at osh. gi called in ed, plan to scope in am. lfts noted to be elevated. wife unaware of liver disease. inr 1.2. transaminases in 200s. trop 0.23, was 0.05 at osh. ecg st, 111. similar to osh, no priors here. started on esmolol gtt. plts 77, ordered for plts. typed and screened. vasc consulted given aaa. ? aorto-enteric fistula. they assisted with obtaining osh op records and recommended cta. while in ed developed af with rvr, esmolol gtt initiated. noted to be intubated, sedated, withdrawing to painful stimuli. cooling was initiated with arctic sun protocol. . initial ed vs 110 121/67 24 100% on vent. at time of transfer vs: 96.0 92 109/67 16 100% on fi02 100% cmv peep 5 vt 600 . pt intubated, sedated, unable to obtain ros. per wife had occasional cp, took nitro. sob with exertion, stable since , able to climb 1 flight stairs slowly. unable to walk 1 block. no known h/o gibs. past medical history: past medical history: 1. cardiac risk factors:dyslipidemia, hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: unknown -pacing/icd: none . 3. other past medical history: cad, mi , no intervention (?) pvd, aaa s/p repair at diverticulitis hyperlipidemia copd djd s/p r hip arthroplasty s/p sigmoid colectomy social history: lives in with wife and son. this is second marriage. retired civil engineer. -tobacco history: active tobacco abuser per wife, unclear how much -etoh: no etoh x decades, ? of etoh abuse in past -illicit drugs: none family history: no family history of early mi, son with dm physical exam: vs: hr 93 110/79 18 96% 100% fi02, cmv general: elderly man, intubated, sedated. heent: ncat. ogt/ett in place. maroon ngt aspirate. pupils constrict equally. neck: c-collar in place cardiac: distant heart sounds, no murmurs ascultated. irregularly irregular. lungs: intubated, mechanical bs, ctab in all lung fields anterolaterally. abdomen: soft. extremities: no c/c/e. no femoral bruits. cool, mottled extremities. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: labs on admission: . 03:01pm blood wbc-6.9 rbc-3.25* hgb-11.7* hct-33.8* mcv-104* mch-35.9* mchc-34.5 rdw-15.0 plt ct-73* 03:01pm blood neuts-86.0* lymphs-8.5* monos-3.6 eos-1.8 baso-0.1 03:01pm blood pt-13.8* ptt-31.2 inr(pt)-1.2* 03:01pm blood glucose-132* urean-27* creat-1.5* na-142 k-4.7 cl-108 hco3-28 angap-11 03:01pm blood alt-251* ast-213* ck(cpk)-249* alkphos-65 totbili-0.8 03:01pm blood albumin-4.0 calcium-9.1 phos-3.5 mg-1.8 . cardiac enzymes: 03:01pm blood ck-mb-9 04:08pm blood ctropnt-0.23* 09:11pm blood ck-mb-64* mb indx-3.1 ctropnt-0.26* 04:36am blood ck-mb-66* mb indx-3.5 ctropnt-0.28* 05:09am blood ck-mb-21* mb indx-3.4 ctropnt-0.28* 03:01pm blood alt-251* ast-213* ck(cpk)-249* alkphos-65 totbili-0.8 09:11pm blood ck(cpk)-2037* 04:36am blood alt-192* ast-165* ld(ldh)-329* ck(cpk)-1875* alkphos-54 totbili-0.9 09:34pm blood ck(cpk)-961* 05:09am blood ck(cpk)-622* . labs on discharge complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:35am 6.7 2.70* 9.7* 28.5* 106* 36.0* 34.1 14.2 83* basic coagulation pt ptt inr(pt) 10:05am 17.1* 32.8 1.5* renal & glucose glucose urean creat na k cl hco3 angap 05:35am 109* 45* 1.5* 144 3.9 100 37* 11 %hba1c 02:36am 5.51 lipid/cholesterol cholest triglyc hdl chol/hd ldlcalc 02:36am 151 224*1 34 4.4 72 urine: 03:01pm urine color-yellow appear-clear sp -1.048* 03:01pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg . microbiology: blood culture, routine (final ): viridans streptococci. isolated from one set only. of two colonial morphologies. staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. aerobic bottle gram stain (final ): reported by phone to @ 11:50 am. gram positive cocci in pairs and chains. - all other blood cultures negative urine culture (final ): gram positive coccus(cocci). ~1000/ml. mrsa screen: no mrsa isolated . . cardiology: . tte (): conclusions the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). the right ventricular cavity is moderately dilated with severe global free wall hypokinesis. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. impression: suboptimal image quality. severely depressed biventricular systolic function. . cardiac cath (): comments: 1. coronary angiography of this right dominant system revealed three vessel coronary artery disease. the lmca did not have significant coronary artery disease. the lad was calcified with a mid-vessel 80% stenosis involving d1. the d1 had a proximal 50% and a mid-vessel 80% stenosis. the lcx had a proximal 50-60% lesion and was calcified in the mid-segment. the om1 was large and bifurcating. the rca was subtotally occluded in the mid vessel and distally filled via left to right collaterals. 2. limited resting hemodynamics demonstrated mildly elevated left ventricular filling pressure (lvedp 15 mm hg) and normal systemic arterial blood pressure (sbp 125 mm hg). there was no gradient upon pullback of the catheter from the left ventricle to the aorta. 3. left ventriculography was deferred due to renal dysfunction. final diagnosis: 1. three vessel coronary artery disease. 2. mildly elevated left ventricular filling pressure. . ekg : irregular rhythm but with well seen p waves in some leads suggesting sinus tachycardia with atrial premature beats. borderline intraventricular conduction delay. st-t wave abnormalities. no previous tracing available for comparison. rate pr qrs qt/qtc p qrs t 111 0 100 316/405 0 45 172 ekg : atrial fibrillation with rapid ventricular response. compared to the previous tracing of no diagnostic interim change. rate pr qrs qt/qtc p qrs t 85 0 106 358/401 0 82 -72 . radiology: . cta torso w contrast (): impression: 1. infrarenal abdominal aortic aneurysm measuring up to 42 mm and extends into the proximal left common iliac artery. there is no evidence of aortoenteric fistula. 2. left perinephric and retroperitoneal stranding. 3. small amount of fluid in the left paracolic gutter. 4. left psoas collection measuring 40 , 6 cm x 3.6 cm x 2.1 cm 5. several lung nodules as described in the text, the largest one measuring 8.5 mm. if patient has history of smoking or known risk factors, a followup in six months is suggested. 6. bibasilar consolidations probably represent atelectasis, but could represent aspiration. . cxr : impression: 1. satisfactory position of og tube. 2. small bilateral pleural effusions and associated atelectasis. . cxr : comparison is made with prior study performed a day earlier. cardiac size is top normal. ng tube tip is in the stomach. et tube tip is in standard position. left lower lobe retrocardiac opacity has worsened as is right lower lobe opacity consistent with atelectasis. there is no pneumothorax. impression: worsened bibasilar atelectasis. . cxr : findings: newly inserted left pectoral pacemaker. correct lead position, no pneumothorax. the pre-existing right basal opacity has completely resolved, the nasogastric tube and endotracheal tube have been removed. brief hospital course: mr is a 78m with cad, htn, hl, pvd presenting s/p vf arrest, with coffee ground emesis and guaiac+ stool. #. v fib arrest: the etiology was unclear on admission. has known history of cad. cardiac enzymes were slightly elevated after defibrillation, and not suggestive of primary coronary ishemic event. also be scar mediated from prior mi. he underwent arctic sun cooling protocol. one day after warming, sedation was weaned and he was following commands. he was extubated 3 days after the arrest but required bipap shortly thereafter. he was evaluated by cardiac cath and subsequently by ep for icd placement. cath showed 3 vessel disease with mildly elevated lv filling pressure. icd was placed on without complication. he did not have any subsequent events. pt is completing a 3-day post-operative course of keflex (last day .he will be discharged to rehab with follow-up for his icd with dr. . . # coronaries: given the possibility that cardiomyopathy was ischemic in origin, he was placed on a statin, beta blocker, and asa. he underwent diagnostic cardiac cath which showed 3-vessel disease. he will be discharged on low-dose lisinopril, metoprolol, simvastatin, and aspirin 81. he will be following up with dr. for general cardiology. he will be evaluated for possible surgical intervention with cardiothoracic surgery as outpt, but he is likely not a good candidate. . # pump: patient had known cardiomyopathy, with tte showed ef 20% with both systolic and diastolic chf. despite this, he did not initially appear overloaded and was oxygenating well. after resuscitation, he was overloaded and was diuresed with lasix. acei was not started initially given concern for gi bleed. he required several doses of prn lasix 60mg iv during his stay for tachypnea. he required a dose of lasix 40mg iv x 1 during his icd placement for tachypnea to the 30s. he has also responded to nebs given his underlying copd. he has been satting in the mid to upper 90s on 2l, and upper 80s-low 90s on ra (according to physical therapy.) he was not previously on home o2. he will be discharged on standing lasix 20mg po daily, and o2 will be weaned as tolerated to maintain o2sats >92%. . # atrial fibrillation: after initially presenting with vf, he was in and out of atrial fibrillation. metoprolol was uptitrated for rate control. he will be discharged on metoprolol 75mg po tid. hr was stable in the 60s on day of discharge. he was also maintained on a heparin gtt during his hospital stay. this was held in preparation for his icd placement. the morning after the procedure, he was started on coumadin 5mg po daily for anti-coagulation in the setting of afib (so does not require heparin bridge.) dosing should be adjusted to maintain an inr of . . # gi bleed: patient initially had coffee-ground emesis and guiac positive stool. his hematocrit fell from 33 to 27, but he did not require transfusion. ct was negative for aorto-enteric fistula. the gi team did an egd and found gastritis and duodenitis without source of bleed. he was given proton pump inhibitor initially, and this was transitioned to 40mg po daily. he did not have any recurrent signs of bleed. on day of discharge, his crit was stable at 28.5. his anemia should be followed up as outpt with his pcp. . # transaminitis: on admission, patient had macrocytosis, transaminitis, thrombocytopenia. per conversation with pcp, was new. he has no prior history of liver disease. the most likely cause of transaminitis was underperfusion in the setting of shock. inr/albumin were normal on admit. transaminases continued to trend down toward normal throughout his stay. lfts should be re-checked as outpt with pcp. . # thrombocytopenia: platelets were low but stable during stay. levels fluctuated between 60s-low 100s. pt did not require any transfusions, and did not show new signs of bleeding. platelet levels should be followed up further as outpatient to evaluate for underlying hematologic derangement. . # copd: pt had episodes of tachypnea during his stay which was thought to be related to both fluid overload following resuscitation and his underlying copd. he was maintained on nebs as needed (which he responded well to) and resumed on advair at discharge. he required supplemental o2, and was satting in the mid-upper 90s on 2l on day of discharge. he was also started on standing lasix 20mg po daily to address the component of fluid overload. . # fen: heart healthy, replete lytes prn, no ivf for now . # access: piv . # ppx: bowel reg prn, coumadin, ambulate as tolerated with pt . # code: full, discussed wiht wife . # dispo: to rehab for continued physical therapy, weaning of o2 requirement. pt to follow-up with electrophysiology, general cardiology, and pcp. medications on admission: atenolol 100mg daily combivent advair 250/50 simvastatin 40mg qhs nifedipine 60mg er daily flomax 0.4mg daily omeprazole 20mg daily folic acid 1mg daily discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: nebs inhalation q6h (every 6 hours) as needed. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. ipratropium bromide 0.02 % solution sig: nebs inhalation q6h (every 6 hours) as needed. 8. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 9. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). 10. nystatin 100,000 unit/g ointment sig: one (1) appl topical qid (4 times a day) as needed. 11. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours): complete 3-days total. last day . 12. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 13. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 14. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: inr goal . 15. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 16. 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. 17. flomax 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po at bedtime. 18. folic acid 1 mg tablet sig: one (1) tablet po once a day. 19. advair diskus 250-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. discharge disposition: extended care facility: - discharge diagnosis: primary: ventricular fibrillation, with icd placement chronic systolic and diastolic heart failure (ef 20%) secondary: hypertension atrial fibrillation copd discharge condition: good, hemodynamically stable, atrial fibrillation with hr in 60s, afebrile, aox3 discharge instructions: you were admitted after you had ventricular fibrillation. you were resuscitated, and underwent diagnostic catheterization which showed 3-vessel disease in your heart. you also had an icd placed to help prevent further ventricular fibrillation. you will be following up with dr. for your icd, and dr. for further management of your heart disease. you will likely be seeing a cardiac surgeon to be evaluated for vessel surgery as outpatient. . you were found to have low platelet counts while you were here. this should be followed up with your pcp to evaluate for bone marrow abnormalities. you did not require any blood or platelet transfusions. . the following significant changes were made to your medications: stop atenolol start metoprolol 75mg po three times daily stop nifedipine start lisinopril 2.5mg po daily increase omeprazole 20mg po daily start aspirin 81mg po daily start lasix 20mg po daily start coumadin 5mg po daily . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1500ml . please stop smoking. information was given to you on admission regarding smoking cessation. . if you experience any chest pain, sob, nausea, vomiting, increased dyspnea with exertion, or have any other concerns please call your pcp or return to the ed. followup instructions: cardiology (icd): dr. 1:20pm . cardiology (general, eval for cardiac surgery): dr. 9:40pm . please see your pcp, . , k. in follow-up 1-2 weeks after discharge from rehab. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Coronary arteriography using two catheters Other endoscopy of small intestine Arterial catheterization Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Other primary cardiomyopathies Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Chronic airway obstruction, not elsewhere classified Atrial fibrillation Acute respiratory failure Duodenitis, without mention of hemorrhage Hemorrhage of gastrointestinal tract, unspecified Unspecified gastritis and gastroduodenitis, without mention of hemorrhage Chronic combined systolic and diastolic heart failure

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: septic shock major surgical or invasive procedure: intubation central line placement picc line placement history of present illness: ms. is an 87 year old female who presented from her nursing home with diarrhea, hypotension, and lethargy. she was recently discharged from for gastric ulcer and uti. she was discharged on with clarithromycin and amoxicillin. on the morning of this admission, patient was complaining of increased thirst. she had large foul smelling bowel movements x 2 without abdominal pain. she was febrile to 100.5 and so was sent to the - ed. . at -, she was found to be in renal failure with an elevated troponin. her ekg showed twi in v3-v6 and lateral st depressions. she was given vanco/flagyl/ceftriaxone. a ct abd/pelvis was performed which showed colitis. . she was intitially taken to - where her vitals were t 100.1 rectal, hr 87, bp 70/30, rr 18-20, 83% on ra. she was given 4l of ivf. she became more tachypneic, so was intubated. her stool was found to be c. diff positive. she was given iv vanco/flagyl/ceftriaxone. a ct abd/pelvis showed pancolitis. a right ij was placed and she was transferred to . . upon arrival to , her vitals were t 97.8, bp 108/47, hr 78, rr 18, 100%, intubated. her blood pressure fell to 78/34, so she was given ?3l of ivf. she was started on levophed and dopamine. her bp then rose to 200 , dopamine drip was stopped. upon arrival to the floor, her dopamine drip had been titrated off. in the ed, she had a loose brown stool with trace bright red blood. past medical history: type 2 diabetes asthma dementia gastric ulcer (h. pylori positive) h/o aspiration pneumonia legally blind h/o tb (treated at age 20) glaucoma social history: she currently lives in a nursing home. she is widowed. denies alcohol, drug, or tobacco use. family history: no family history of heart disease or dementia. physical exam: gen: intubated, sedated heent: perrl, sclera anicteric, no epistaxis or rhinorrhea, mmm, op clear neck: no jvd, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: coarse breath sounds anteriorly, no w/r/r abd: soft, nt, nd, +bs, no hsm, no masses ext: no c/c/e, no palpable cords neuro: sedated. moves all 4 extremities. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: labwork on admission: 03:45pm wbc-13.8*# rbc-2.74*# hgb-8.8* hct-25.6* mcv-93 mch-32.1* mchc-34.5 rdw-15.4 03:45pm neuts-47* bands-40* lymphs-2* monos-1* eos-0 basos-0 atyps-4* metas-6* myelos-0 03:45pm pt-13.2 ptt-38.2* inr(pt)-1.1 03:45pm glucose-177* urea n-49* creat-1.4* sodium-132* potassium-3.5 chloride-100 total co2-23 anion gap-13 03:45pm alt(sgpt)-16 ast(sgot)-38 ck(cpk)-64 alk phos-65 tot bili-0.3 03:45pm lipase-45 brief hospital course: 87 year-old female with history of type 2 diabetes and dementia transferred from an outside hospital with sepsis from c. difficile colitis initially requiring pressors. she was treated with flagyl iv and vancomycin po. she developed hypoxic respiratory failure in the setting of aggressive fluid rescucitation and was intubated prior to transfer. her course was complicated by nstemi in the setting of demand ischemia, acute renal failure, and ventilator-associated pneumonia. extubation was attempted , however, the patient developed hypercarbic respiratory failure after one and a half hours. she was reintubated at that time. her respiratory failure was thought due to muscle weakness. she continued to require pressure support ventilation. after discussion with her son, the decision was made not to pursue tracheostomy. the patient was terminally intubated and expired 22:13. autopsy was declined. medications on admission: calcium and vitamin d aspirin 81 daily metformin 500 mg prilosec 40 mg daily mirtazeipne 22.5 qhs celexa 20 mg daily toprol xl 50 mg daily lisinopril 2.5 mg daily lipitor 80 mg daily clarithromycin 500 mg amoxicillin 1000 mg sugar free supplement daily collace seena artificial tears 1 drop tid discharge medications: none discharge disposition: expired discharge diagnosis: primary: septic shock from c. difficile colitis respiratory failure . secondary: type 2 diabetes dementia gastric ulcer history of aspiration pneumonia legally blind history of tuberculosis (treated at age 20) glaucoma discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Arterial catheterization Transfusion of packed cells Diagnoses: Anemia of other chronic disease Subendocardial infarction, initial episode of care Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Severe sepsis Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Acute respiratory failure Alkalosis Other specified septicemias Septic shock Intestinal infection due to Clostridium difficile Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Encounter for palliative care Ventilator associated pneumonia Legal blindness, as defined in U.S.A. Personal history of tuberculosis

allergies: no known allergies / adverse drug reactions attending: addendum: patient was intubated for respiratory failure, as noted in the brief hospital course: "upon arrival to the icu at 1500, mr. had another prolonged episode of somnolence along with right sided weakness and aphasia. he was also noted to be apneic as evidenced by an elevated respiratory rate, and loud snoring. both neurology and anesthesiology agreed securing the patient's airway was necessary and intubation was successfully accomplished with propofol started for sedation." discharge disposition: extended care facility: senior healthcare of md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Diagnoses: Hyperpotassemia Esophageal reflux Unspecified essential hypertension Acute respiratory failure Hypotension, unspecified Other specified hemiplegia and hemiparesis affecting unspecified side Aphasia Cushing's syndrome Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy Redundant prepuce and phimosis Apnea Facial weakness Benign neoplasm of pituitary gland and craniopharyngeal duct Autistic disorder, current or active state