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allergies: no known allergies / adverse drug reactions attending: chief complaint: right hemiparesis and aphasia major surgical or invasive procedure: endotracheal intubation history of present illness: mr. is a 49 year old right handed man with a history of high-grade, acth positive pituitary adenoma status post debulking surgeries in and with post-op radiotherapy treatments at , on ketoconazole suppressive treatment presented today to the ed with transient episodes of right sided weakness and aphasia. per his care home, health, mr. was in a "normal state of health" at 1130 hours at which time he took all his daily medications. at 1200 hours, he reportedly was witnessed by the staff slumped over to the right and aphasic. ems was activated who transported the patient to for further evaluation. upon arrival, he was assessed as having a nihss of 0. however, after non-contrast head ct was performed, mr. became right sided hemiparetic with right facial droop and was found to be aphasic. a repeat nihss was measured at 15. he was taken back to the scanner and a ct perfusion / angiogram were performed which identified patent vessels, but increased cerebral blood volume in the left hemisphere. after approximately 15-20 minutes, he returned back to his baseline. in the ed, he had more episodes with similar semiology; he was given 2 mg of ativan, and loaded with 1500 mg of keppra (19 mg /kg). past medical history: - pituitary adenoma diagnosed in , initially measuring 3.3 cm with extension into the left cavernous sinus with hypercortisolism and symmetric proximal muscle weakness status post resections in / and fractional radiotherapy - in (52.2 ), and (17 ); now medically managed on ketoconazole, - multiple episodes of pneumonia in - hypertension - hypokalemia - developmental disability v. highly functioning autism spectrum disorder social history: no recent tobacco, alcohol, or illicit drug use (distant tobacco and alcohol use). he lived independently with family for about eight years until his tumor five years ago, at which time he required more assistance for which he was placed into a group home for those with cognitive issues. he has been living at the center in since . family history: - father stroke at 75 - mother has esrd, alcohol / drug history (possibly while patient was in utero) physical exam: initial exam - both during event and in lucent period vitals: t: 97.6 p:80 r: 22 bp: 133/87 general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, no masses or organomegaly noted. extremities:warm and well perfused skin: no rashes or lesions noted. . neurologic: -mental status: initially on exam would tell me his name age and date and was oriented following both midline and appendicular commands, language was fluent and nondysarthric. however during these episodes he was very dysarthric, aphasic, and somnolent. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. blinks to threat bilaterally. iii, iv, vi: left gaze deviation during episodes, full conjugate duction of eye movements when first evaluated vii: during episodes has a right facial droop viii: hearing intact to voice ix, x: palate elevates symmetrically. xii: tongue protrudes in midline. - motor: normal bulk, tone throughout. no pronator drift bilaterally initially, then could not lift the right side antigravity - sensory: grimaces to noxious in all 4 extremities. - gait and coordination were not assessed ******************* examination on discharge vitals: t: 97.6 p:80 r: 22 bp: 133/87 general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, no masses or organomegaly noted. extremities:warm and well perfused skin: no rashes or lesions noted. . neurologic: -mental status: initially on exam would tell me his name age and date and was oriented following both midline and appendicular commands, language was fluent and nondysarthric. however during these episodes he was very dysarthric, aphasic, and somnolent. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. vff to confrontation. funduscopic exam revealed no papilledema, exudates, or hemorrhages. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: decreased bulk, tone throughout. no pronator drift bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 4+ 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: no deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. no extinction to dss. -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor bilaterally. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf or hks bilaterally. -gait: good initiation. narrow-based, normal stride and arm swing. able to walk in tandem without difficulty. romberg absent. pertinent results: 09:15pm cerebrospinal fluid (csf) protein-62* glucose-78 09:15pm cerebrospinal fluid (csf) wbc-0 rbc-4* polys-15 lymphs-79 monos-6 04:14pm glucose-97 urea n-23* creat-0.7 sodium-140 potassium-4.7 chloride-105 total co2-23 anion gap-17 04:14pm alt(sgpt)-24 ast(sgot)-20 ld(ldh)-284* ck(cpk)-34* alk phos-60 tot bili-0.5 04:14pm ck-mb-5 ctropnt-0.04* 04:14pm tsh-0.83 04:14pm crp-2.3 04:14pm wbc-10.6 rbc-4.19* hgb-13.6* hct-38.3* mcv-91 mch-32.5* mchc-35.6* rdw-15.2 04:14pm sed rate-28* 03:36pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 03:36pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg medications on admission: - vitamin b12 - tylenol 325mg - bisacodyl - senna - cepacol - fleet enema - androderm 4 mg /24 hour - ketoconazole 200 mg daily - lisinopril 30 mg daily - metoprolol xr 100 mg daily - potassium 20 meq discharge medications: - bisacodyl 10mg po qday - ketoconazole 200mg po qday - androderm 4mg patch apply td daily - asa 325mg po qday - synthroid 112mcg po qday - keppra 1000mg po bid - phenytoin 100mg po q8hrs - tylenol 325-650mg po q6h prn pain / fever - lisinopril 30mg qday - metoprolol xr 100mg qday - potassium 20meq qday - senna - cepacol - fleet enema discharge disposition: extended care facility: senior healthcare of discharge diagnosis: complex partial seizures discharge condition: improved, stable discharge instructions: you were admitted to the hospital in the setting of a recurrent episodes of speech difficulties with right sided weakness. you were found to be seizing on eeg and started on 2 medications (dilantin and keppra). your eeg improved and you were transferred out of the unit. an mri was performed that showed chronic changes likely secondary to radiation. you had no additional seizures on the floor and will be transferred back to health. you should follow up with neuro-endocrinologist and dr. at . please continue on you keppra and dilantin as an outpatient. followup instructions: - please follow up with dr. , on thursday, at 4:00pm. call us at ( if you need to reschedule. - please follow up with dr. on thursday, , at 11:00am. 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

allergies: no known allergies / adverse drug reactions attending: chief complaint: malaise, fevers, weight loss and weakness major surgical or invasive procedure: picc line insertion history of present illness: 64 yo m w/ no significant pmh presenting with 3 weeks of generalized weakness and found to have elevated lfts. he has been generally healthy, approx 3 wks ago he experienced the gradual onset of fatigued, decreased appetite, "bad" taste in mouth, and some fever/chills. he finally went to ed 2 days prior, cxr neg, was diagnosed with uti, discharged on levoquin at . symptoms persisted until today, so he returned to the ed at . ua was neg but he was found to have elevated lfts. us showed hypoechoic lesions in liver and spleen and he was transferred here for inpatient workup and mrcp/ercp. . this has never happened before and he denies any past hx. of jaundice, blood transfusions, iv drug abuse, or new sexual partners. has not been sexually active with his wife for at least 6 months. he drinks alcohol x per week at dinner with his wife. has been taking tylenol x per day since this past wed as instructed over the counter. he did travel to his summer home at 3 weeks ago, but denies any tick bites. he does have pet dogs and lives in semi wooded area outside . . in the ed initial vitals were:97 102 97/65 18 100% ns x 1 liter in ed and was transferred to the floor. heme/onc on board, he was ruled out for ttp and dic. id recommended started zosyn and doxy for tick borne or hepatobiliary causes. pt found to be tacycardic to the 160s while going to bathroom which resolves to the 100s. ekg with sinus tachycardia and rate related v3 st depressions. he was bolused 4l and hemodynamics improved to hr 110s, 115/67, but continued to be more work for nursing. on arrival to the micu,:103 bp:121/70 p:114 r:42 o2:87% on ra, returned to 98% on 4l nc. pt alert, confused, shaking with chills. no acute distress. review of systems: (+) per hpi the patient major complaints are fevers, chills, decreased appetite, and weight loss of 6-7lbs in last 3 wks. (-) he denies any abdominal pain, nausea,rashes,confusion, athralgias, myalgias, muscle weakness, sore throat,stiff neck, headache, vision changes, vomiting, gerd, nocturnal cough, cough, chest pain, dyspnea, melena. he usually passes one brown bm per day, over the past 3 weeks he has been passing yellow semi loose stools per day but denies frank watery diarrhea. he denies any recent travel outside the country or sick contacts. denies any dysuria,low back pain,nocturia, hematuria, penile lesions or penile discharge, flank pain. he denies dyspepsia, early satiety, or dysphagia. . past medical history: left hip replacement. depression social history: denies blood transfusion hx, no illicit drugs. drinks alcohol socially x per week with wife. use for "few years" last as teenager. last sexually active with wife at least 6 months ago. family history: no hx of liver or autoimmune disease physical exam: admission exam: vitals: t:103 bp:121/70 p:114 r:42 o2:87% on ra, returned to 98% on 4l nc. pt confused, mumbling, oriented x1. denied any pain. general: alert, oriented x1, stuttering, unable to construct coherent sentences. heent: sclera icteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 4+/5 strength symmetric upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact discharge exam: vitals: t:98.2 bp:130/82 p:70 r:18 o2:98% on ra, general: alert, oriented x3, nad lying comfortably in bed heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, 1+ edema le, no clubbing, cyanosis neuro: anisocoria l>r, cnii-xii intact, no focal neurologic deficits, 5/5 strength symmetric upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. pertinent results: 07:04pm urine hours-random creat-200 sodium-less than potassium-41 chloride-11 07:04pm urine osmolal-680 06:59pm urine hours-random 06:59pm urine gr hold-hold 06:59pm urine color-dkamb appear-hazy sp -1.021 06:59pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-mod urobilngn-4* ph-6.0 leuk-neg 06:59pm urine rbc-1 wbc-10* bacteria-few yeast-none epi-0 06:59pm urine hyaline-31* 06:59pm urine mucous-few 05:54pm pt-14.4* ptt-32.2 inr(pt)-1.3* 04:20pm glucose-117* urea n-32* creat-1.1 sodium-130* potassium-4.2 chloride-97 total co2-24 anion gap-13 04:20pm estgfr-using this 04:20pm alt(sgpt)-223* ast(sgot)-402* ld(ldh)-452* ck(cpk)-83 alk phos-284* tot bili-4.3* dir bili-3.5* indir bil-0.8 04:20pm lipase-13 04:20pm albumin-2.6* calcium-9.6 phosphate-3.1 magnesium-1.6 04:20pm hav ab-negative 04:20pm asa-neg ethanol-neg acetmnphn-8* bnzodzpn-neg barbitrt-neg tricyclic-neg 04:20pm wbc-4.1# rbc-4.34* hgb-12.2* hct-37.5* mcv-86 mch-28.1 mchc-32.5 rdw-12.9 04:20pm neuts-89.4* lymphs-7.1* monos-3.0 eos-0.4 basos-0.1 04:20pm plt count-120*# 04:20pm ret aut-0.5* abdomen ct: there is minimal bibasilar dependent atelectasis. the visualized portions of the lungs are otherwise clear. innumerable small hypodensities are seen throughout the liver, measuring up to 14 mm in the right hepatic lobe (2:28). there are also innumerable, similar-appearing hypodensities throughout the spleen. the spleen is moderately enlarged, measuring up to 15.8 cm in its craniocaudal dimension. the portal vein is patent. the gallbladder is unremarkable. there is a 7-mm hypodense lesion in the pancreatic body (2:22), possibly a cyst versus side-branch ipmn. the pancreas is otherwise normal. there is no dilation of the main pancreatic duct or common duct. there is no intrahepatic biliary duct dilatation. the adrenal glands are grossly normal. the kidneys excrete contrast symmetrically. no focal renal lesions are identified. there is no hydronephrosis. the stomach and small bowel are grossly unremarkable. there is extensive diverticulosis, predominantly involving the sigmoid colon, without definite evidence for diverticulitis. the appendix is not definitely identified. there is a small quantity of free fluid within the mesentery and dependent portion of the pelvis. there is no free air in the abdomen. multiple enlarged lymph nodes are seen along the retroperitoneum, specifically in the aortocaval region. the largest nodal conglomerate is in the left paraaortic region at the level of the left renal hilum, measuring 4.1 x 2.0 x 4.2 (ap x tv x cc). this lesion demonstrates central hypodensity, consistent with necrosis (2:31, 601b:26). an additional representative node within the aortocaval region measures 2.6 x 1.6 cm (2:34). an enlarged portacaval node measures 1.8 x 1.3 cm (2:26). pelvis ct: the bladder is unremarkable. the prostate is normal in size. there are no pathologically enlarged pelvic lymph nodes. bone window: no suspicious lytic or blastic lesions are identified. multilevel degenerative changes of the thoracolumbar spine are seen. note is made of a left total hip arthroplasty. impression: 1. innumerable hepatic and splenic small hypodensities, concerning for lymphoma versus metastases, although an infectious process cannot be entirely excluded. the presence of bulkly retroperitoneal lymphadenopathy would favor a neoplastic process. further evaluation with mri may provide additional information. 2. small volume ascites, predominantly within the dependent portion of the pelvis. 3. 7-mm hypodense lesion in the pancreatic body, possibly a cyst versus side-branch ipmn. further evaluation with mri is recommended. 4. extensive colonic diverticulosis, particularly involving the sigmoid colon, without evidence of diverticulitis. liver biopsy(): extensive necrosis(approximately 80%). viable areas demonstrate mild steatosis and a polymorphous lymphoid infiltrate, which focally effaces the liver parenchyma. cells are positive for cd30 with co-expression of cd45, cd20, cd79, pax5, -1 and -2 but are negative for cd5, cd15, and alk-1. cd30 positive cells far outnumber cd20 positive cells. liver biopsy results indicate a lymphoma with features intermediate between diffuse large b-cell lymphoma and classical hodgkin lymphoma (grey zone lymphoma). in this case, a hodgkin lymphoma is favored for the following reasons: 1) co-expression of cd30, .2, and pax5 with evidence of ebv-infection (lmp+) is more likely to be associated with hodgkin lymphoma. 2) cd30+ cells far outnumber cd20 positive cells, indicating loss of cd20 in the majority of cd30 positive cells. 3) the subsequent biopsy of the patient's bone marrow (s12-31075h) revealed patchy infiltration by a lymphoma containing classic -sternberg cells and an appropriate immunoreactive background. mr head w & w/o contrast (): impression: no evidence of intracranial lymphoma. no evidence of acute intracranial abnormalities. unilat up ext veins us left (): impression: no left upper extremity deep venous thrombosis. fdg tumor imaging (pet) (): report pending discharge labs: 12:10am blood wbc-2.4* rbc-2.97* hgb-8.5* hct-25.5* mcv-86 mch-28.5 mchc-33.3 rdw-15.7* plt ct-171 12:10am blood neuts-78.6* lymphs-19.2 monos-2.2 eos-0 baso-0 12:10am blood pt-11.4 ptt-23.4* inr(pt)-1.1 12:10am blood glucose-130* urean-22* creat-0.6 na-136 k-4.5 cl-105 hco3-27 angap-9 12:10am blood alt-109* ast-52* ld(ldh)-197 alkphos-418* totbili-2.3* 12:10am blood albumin-2.3* calcium-7.6* phos-2.4* mg-2.0 uricacd-2.0* brief hospital course: 64 y.o male w/ no significant pmhx presenting with 3 weeks of generalized weakness, fevers/chills decreased appetite found to have elevated lfts,anemia/thrombocytopenia and hepatic/splenic hypodensities on ct which was found to be stage iv hodgkins lymphoma with involvement of the liver, spleen, and bone marrow. micu course: #fever: he had a high fever in the setting of vague weakness, slight jaundice, and hepatic lesions. possible diagnoses included acute viral hepatitis vs. tick- illness (human ehrlichiosis and anaplasmosis and babesia) vs malignancy. less likely on the differential included autoimmune hepatitis, alcoholic hepatitis, and lower biliary process. acute hiv was also considered. he was started on vanc/zosyn/doxycycline for empiric coverage. hepatitis b/c serologies and pcr revealed him to be hcv negative. blood smear was unremarkable for parasites. anaplasma/ehrlichiosis/babesia serologies revealed: lyme was negative. ebv serologies revealed past infection. ct abdomen revealed innumerable hepatic and splenic small hypodensities, concerning for lymphoma versus metastases, w/ infection also possible. a 7-mm hypodense lesion in the pancreatic body, possibly a cyst versus side-branch ipmn, was also found. mri abdomen revealed an enlarged edematous liver with hepatomegaly and gallbladder wall edema, multiple focal hepatic lesions and innumerable focal lesions in the spleen. and retroperitoneal lymphadenopathy, suggestive of a lymphoproliferative disorder. sarcoidosis was also considered possible. two subcentimeter pancreatic cysts w/ 12-month mri f/u recommended were also seen. an us-guided biopsy of the liver was performed, with preliminary results concerning for lymphoma vs. hemophagocytic lymphohistiocytosis. cytology revealed atypical cells of undetermined significance. am cortisol was elevated to 35. ldh was elevated to the 500s-600s during throughout his micu stay. blood, fungal, and urine cultures were unremarkable. c. difficile was negative. id and heme/onc were consulted, and they recommended that empiric antibiotic therapy be discontinued given that liver biopsy was consistent with malignant process. heme/onc began allopurinol for uric acid production prophylaxis and dexamethasone was started with daily surveillance of tumor lysis labs. potassium increased significantly after initiation of steroids, without any ekg findings (no prolonged pr interval, peaked t waves, or widened qrs) at k of 5.6 and 7.3. #liver/splenic hypodensities: while in the micu, the liver and splenic hypodensities were most suspicious for malignancy of lymphoma or mets (likely primary would be from prostate/pancreas). also possible were small abscesses given fever and acute sx. ir-guided percutaneous biopsy revealed grey zone lymphoma of the liver. #altered mental status: pt exhibited acute confusion which seems to be far from his baseline. be due delerium febrile state. also question of acute intracranial process as he did have transient difficulty with language. no other localizing neurological symptoms. also possible ams is secondary to hyponatremia, however this level is not extremely low. tsh was within normal limits. #thrombocytopenia/anemia: no signs of bleeding or melena. in the setting of acute illness. no clinical splenomegaly. coags not concerning .likely related to infectious/malignancy process above. #hypotension and tachycardia: pt was febrile at the time and had gotten up to go to the bathroom and was syncopal. likely he was hypovolemic and also vasodilated in the setting of fever. improved when fever was treated and volume was repleted. on the floors medicine/bmt: # hodgkins lymphoma: pt was found to have stage iv hodgkins lymphoma with involvement of the liver, spleen, bone marrow, and likely subcarinal lymph nodes. both percutaneous biopsy of the liver and bm biopsies were obtained, which revealed lymphoma with characteristics intermediate between large b cell lymphoma and classical hodgkin lymphoma. given the prescence of -sternberg cells in the bone marrow this is most consistent with hodgkins lymphoma. due to his liver enzymes being elevated he was first started on dexamethasone for treatment of the lymphoma. after several days his lft's and bili began to trend down such that chemotherapy could be started. pt was informed about his options of chemo with dr. , dr. and dr. . beacopp was initated on , holding adriamycin and procarbazine due to persistently elevated lfts. pt received reduced dosage chemotherapy and on tbili was down to 2.6 so procarbazine and adriamycin were added at a reduced dosage. pt tolerated chemotherapy regimen well and will be discharged on procarbazine and prednisone to continue the beacopp regimen with the plan for him to get day 8 bleomycin and vincristine as an outpatient. he also had a staging pet scan on of which the is pending. # anisocoria: in addition on the floors pt experienced new onset anisocoria l pupil > r pupil which was concerning for cns lymphoma. pupils remain reactive to light and accommadation and eomi. pt remains alert and oriented. no change in mental status. a mri of the head with and without contrast did not reveal any intracranial lymphoma. in addition, pt does not have any other focal neurologic deficits. at this time it is unclear why the patient has anisocoria. per pt request an lp was deferred at this time. # liver/splenic hypodensities- pt presented to the hospital with fatigue and weakness. his labs revealed transaminitis and elevated bilirubin. follow-up ct scan of the abdomen revealed lesions on the liver and spleen along with retroperitoneal lad, which were concerning for either malignancy (lymphoma vs. mets) vs. infectious. he was started empirically on vancomycin, piperacillin-tazobactam, and doxycycline. once on the floor, he was sent for a biopsy of the livery lesion, the initial read of which revealed lymphocytic infiltration concerning for lymphoma vs. lymphophagocytic histiocytosis. it was later determined to be a grey zone lymphoma. hep b surface ag, surface ab, core ab negative. hav ab neg. bcv ab negative. cea 2.8 wnl. after liver and bm biopsy confirmed lymphoma, he was stopped on all antibiotics, and started on allopurinol for ppx against elevated uric acid, and 40mg iv dexamethasone qd with tumor lysis labs. his k trended upward to 5.6 and 7.3 s/p initiating steroids, with normal ekg. #pancytopenia-no signs of bleeding or melena. improving on steroids. anemia without thrombocytopenia. in the setting of acute illness. no clinical splenomegaly. coags are not concerning. likely related to malignancy process and secondary to chemotherapy. pt did not require transfusion suppport during in house chemotherapy. #fever: resolved. had high fever in the setting of vague weakness, slight jaundice, and hepatic lesions. this was likely secondary to malignancy as other etiologies on differential including autoimmune hepatitis, alcoholic hepatitis, and lower biliary process were ruled out. hepatitis labs were negative for hav, hbv, and hcv. also possible is acute hiv. however hiv ab was found to be negative. pt had received tylenol prn for fever, limit to 2g daily in light of liver dysfunction. on discharge pt is currently afebrile. #upper extremity swelling: on night of pt noticed swelling of left upper extremity where picc line is in place, not associated with pain or erythema. concern was for upper extremity dvt. duplex ultrasound showed no evidence of upper extremity dvt. currently no pain or erythema around picc line, and swelling decreased this am. picc site should be monitored for signs of infection, erythema, warmth. #transaminitis/hyperbilirubinemia: secondary to hepatocellular injury/cholestasis due to lymphoma involvement of the liver. ast/alt/alp decreased since admission, t bili is now down to 2.6. lft's should continue to be monitored as an outpatient. #hyperglycemia: blood glucose has been mildly elevated since starting steroids. -check bg before meals and bedtime. pt was on low dose iss for hyperglycemia (bg>150). pt did not require much insulin. pt will be discharged with 4 days of steroids and then tapered. no need for insulin at home given only mild elevation of glucose on steroids. chronic issues: # depression - on citalopram at home. he was initially started on paxil, but transitioned to citalopram, s/p confirmation of medications with pharmacy. mood improved until diagnosis of lymphoma was made. his low mood currently is appropriate given his new diagnosis of lymphoma. pt was instructed to not take citalopram while undergoing chemotherapy. transition issues: #pt will need to get day #8 chemo (vincristine and bleomycin on ). an appointment with dr. has been scheduled #pt will need to take neupogen after day #8 chemo. a prescription was called in his pharmacy. pt was instructed not to take neupogen until instructed by his oncologist. medications on admission: home medications: levofloxacin x 2 days citalopram 20mg qd discharge medications: 1. allopurinol 300 mg po daily rx *allopurinol 300 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 2. docusate sodium 100 mg po bid:prn constipation rx *docusate sodium 100 mg 1 capsule(s) by mouth :prn disp #*60 capsule refills:*0 3. omeprazole 20 mg po daily rx *omeprazole 20 mg 1 capsule(s) by mouth daily disp #*30 capsule refills:*0 4. procarbazine hcl 150 mg po days 1, 2, 3, 4, 5, 6 and 7. (, , , , , and ) (100 mg/m2 - dose reduced by 25% to 75 mg/m2) reason for dose reduction: lft abnormalities 5. prednisone 100 mg po daily days rx *prednisone 10 mg 10 tablet(s) by mouth daily disp #*40 tablet refills:*0 6. senna 1 tab po bid:prn constipation rx *senna 8.6 mg 1 capsule by mouth : prn disp #*30 capsule refills:*0 7. ondansetron 8 mg po q8h:prn nausea rx *ondansetron hcl 4 mg tablet(s) by mouth q8h: prn disp #*60 tablet refills:*0 8. filgrastim 300 mcg sc q24h duration: 10 doses please do not start until instructed to by oncologist. rx *neupogen 300 mcg/0.5 ml 1 subcutaneous injection daily once instructed to start by oncologist daily disp #*10 syringe refills:*2 9. nystatin oral suspension 10 ml po qid rx *nystatin 100,000 unit/ml 10 ml by mouth four times a day disp #*1 bottle refills:*2 10. sulfameth/trimethoprim ss 1 tab po daily rx *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*2 11. acyclovir 400 mg po q8h rx *acyclovir 400 mg 1 tablet(s) by mouth qh8 disp #*90 tablet refills:*0 discharge disposition: home with service facility: critical care systems discharge diagnosis: hodgkins lymphoma hepatitis/biliary obstruction secondary to lymphoma anisocoria left upper extremity swelling 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 caring for you on your recent hospitalization at . you came to the hospital because you were having fevers, weight loss, fatique, and jaundice. you were found to have liver dysfunction which was due to having a tumor in your liver. we then found that you had hodgkins lymphoma with involvement of your liver and spleen. you were given steroids after which your liver function improved. you were then started on chemotherapy for the hodgkins lymphoma which you tolerated very well. the chemotherapy you received was reduced dosage since your liver function was still decreased. we also found that your pupils were unequal in size and so we preformed a mri scan of your head which was normal. you also had a pet scan to determine the extent of the lymphoma. you also experienced swelling of your left arm around the site of your iv line. an ultrasound showed that you did not have any blood clot in or around the iv catheter. please follow up with the following appointments as listed below. please take the following medications: acyclovir 400mg po q8h bactrim ss 1 tab daily prednisone 100mg by mouth x 4 days procarbazine hcl 150 mg by mouth x 4 days allopurinol 300 mg by mouth daily docusate sodium 100 mg by mouth twice per day as needed for constipation omeprazole 20 mg by mouth daily ondansetron 8 mg by mouth every 8 hours as needed for nausea filgrastim 300 mcg subcutaneous injection once daily: please do not start taking filgrastim until instructed to by oncologist. followup instructions: department: bmt chairs & rooms when: friday at 9:00 am department: hematology/oncology when: friday at 9:00 am with: , bsn building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: friday at 9:30 am with: , md building: sc clinical ctr campus: east best parking: garage Procedure: Closed (percutaneous) [needle] biopsy of liver Biopsy of bone marrow Injection or infusion of cancer chemotherapeutic substance Central venous catheter placement with guidance Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Depressive disorder, not elsewhere classified Candidiasis of mouth Obstruction of bile duct Anisocoria Hodgkin's disease, unspecified type, lymph nodes of multiple sites Other pancytopenia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: stemi. major surgical or invasive procedure: cardiac catheterization with angioplasty and stenting (2 x des to om1), . history of present illness: ms. is a generally healthy 54-year-old woman who is admitted to the ccu following emergent cardiac catheterization. on the afternoon prior to admission, the patient had acute onset of a burning substernal cp with a pressure sensation radiating to her left shoulder. she did not have associated symptoms such as nausea, sob or diaphoresis. she thought this might have been indigestion or pain from her neck, and her symptoms did improve with antiacids. the discomfort then waxed and waned over the course of the day; the patient eventually felt well enough to go to sleep. around 1am she was awakened from sleep by an acute worsening of her symptoms. she presented to hospital where her ecg was notable for ste in i, avl, v5 and v6 as well as std in iii and v1 through v4. initial tropi was elevated at 0.51 (initial ck not available). the patient was treated with asa, iv heparin and iv ntg, which resulted in transient resolution of her pain. she was transferred to the ed, where she additionally received integrillin and 600mg plavix. as she was having recurrent discomfort in the ed, she was taken for urgent cardiac cath, performed with radial access, which demonstrated a tight om lesion. this lesion was treated with a des; a small proximal dissection was noted, and this was then treated with a second des. the was excellent flow post-procedure. on arrival to the ccu, the patient reports being pain free and feeling entirely well. on review of systems, she denies any recent fever, chills, change in weight, nausea, vomiting, abdominal pain, change to bowel or bladder habbits, arthalgia, myaglia, dizziness, numbness or weakness. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. upper back pain, s/p spinal fusion social history: the patient reports being under a moderate amount of psychosocial stress recently. she works in hr for the social security administration. -tobacco history: prior smoker, quit for 14 years, now smoking a few ciggarettes per day. -etoh: rare -illicit drugs: denies family history: the patient's mother suffered an mi in her early 40s, but is now in her 80s and doing well. the patient's father required multi-vessle cardiac bypass surgery in his late 60s. physical exam: gen: well appearing adult female, no acute distress. heent: perrl, eomi. mmm. op clear. conjunctiva well pigmented. neck: supple, without adenopathy or jvd. chest: lungs clear to auscultation with normal respiratory effort. cor: normal s1, s2. rrr. no murmurs appreciated. abdomen: soft, non-tender and non-distended. +bs, no hsm. extremity: small hematoma at right radial access cath site. otherwise warm, without edema. 2+ dp pulses bilaterally. neuro: alert and oriented. cn 2-12 intact. motor strength intact in all extremities. sensation intact grossly. on the day of discharge vital signs were 97.9 f (98.2 f maximum), 93/55 mmhg (range 92/62 to 106/56 mmhg), 56 bpm (range 55 to 72 bpm), rr of 18 and 100 % o2 sat. on room air. physical exam findings were unchanged from those above, except for some resolution of hematoma. pertinent results: laboratory data at admission: 04:45am blood wbc-11.5* rbc-4.55 hgb-14.7 hct-41.6 mcv-91 mch-32.3* mchc-35.4* rdw-12.4 plt ct-224 04:45am blood neuts-72.8* bands-0 lymphs-21.0 monos-3.7 eos-1.8 baso-0.8 04:45am blood hypochr-normal anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-normal 04:45am blood pt-12.3 ptt-150* inr(pt)-1.0 04:45am blood glucose-117* urean-17 creat-0.7 na-142 k-4.0 cl-108 hco3-23 angap-15 04:45am blood ck(cpk)-176 05:03pm blood ck(cpk)-1690* 04:22am blood ck(cpk)-1142* 04:45am blood ck-mb-15* mb indx-8.5* 04:45am blood ctropnt-0.12* 05:03pm blood ck-mb-166* mb indx-9.8* 04:22am blood ck-mb-65* mb indx-5.7 04:45am blood cholest-69 05:03pm blood %hba1c-5.7 eag-117 04:45am blood triglyc-53 hdl-45 chol/hd-1.5 ldlcalc-13 laboratory data at discharge: 06:40am blood wbc-7.8 rbc-4.49 hgb-14.0 hct-40.1 mcv-89 mch-31.2 mchc-35.0 rdw-13.7 plt ct-212 06:40am blood glucose-98 urean-16 creat-0.8 na-143 k-4.5 cl-105 hco3-29 angap-14 06:40am blood calcium-9.3 phos-3.9 mg-2.1 ekg sinus rhythm. st-t wave configuration consistent with acute ischemic injury (question posterolateral). clinical correlation is suggested. no previous tracing available for comparison. rate pr qrs qt/qtc p qrs t 77 162 84 30 cardiac catheterization (radial) brief history: this 54 year old female with a family history of premature coronary artery disease and current tobacco use presented to hospital with intermittent resting substernal chest pain that started the day prior. the patient awoke on the day of admission at 2am with recurrent chest discomfort and presented to the hospital where ecg revealed anterolateral st elevations and an elevated troponin of 0.52. she was treated with aspirin, heparin, and nitroglycerin with resolution of her pain and st changes. transfer was catheterization was initiated and following arrival to the ed she developed recurrent chest discomfort, was given integrilin and plavix, and taken urgently to the catheterization laboratory. indications for catheterization: stemi. procedure: left heart catheterization: was performed by percutaneous entry of the right radial artery, using a 5 french jacky radial catheter, advanced to the ascending aorta through a 6 french introducing sheath. coronary angiography: was performed in multiple projections using a 5 french jacky radial catheter, with manual contrast injections. percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). hemodynamics results body surface area: 1.84 m2 hemoglobin: 14.7 gms % rest **pressures left ventricle {s/ed} 154/25 aorta {s/d/m} 154/83/113 **cardiac output heart rate {beats/min} 72 rhythm sinus **arteriography results morphology % stenosis collat. from **right coronary 1) proximal rca diffusely diseased 70 2) mid rca diffusely diseased 70 2a) acute marginal normal 3) distal rca normal 4) r-pda normal 4a) r-post-lat normal **arteriography results morphology % stenosis collat. from **left coronary 5) left main normal 6) proximal lad normal 6a) septal-1 normal 7) mid-lad discrete 50 8) distal lad normal 9) diagonal-1 normal 12) proximal cx normal 13) mid cx normal 13a) distal cx normal 14) obtuse marginal-1 discrete 100 15) obtuse marginal-2 normal **ptca results cx ptca comments: initial angiography revealed a 100% occlusion in a large om branch. we planned to treat this with ptca and stenting. heparin and integrillin were given prophylactically. a 6f xb3.0 guide provided good support. a bmw wire crossed the stenosis without difficulty. we dottered with a 2.0x12mm sprinter balloon and then predilated at 12 and 14atm. a 2.5x23mm promus des was then deployed at 14atm and post-dilated with a 3.0x15mm quantum maverick at 20atm and a 3.25x12mm quantum maverick at 22atm (mid/distal) and 14atm (proximal). after the final balloon inflation there was a proximal cap dissection that was covered with a 2.5x8mm promus des, deployed at 16atm, and post-dilated to 3.25mm at 20atm. final angiography revealed no residual stenosis, timi 3 flow, and no apparent dissection. technical factors: total time (lidocaine to test complete) = 1 hour 13 minutes. arterial time = 1 hour 8 minutes. fluoro time = 26.6 minutes. contrast injected: non-ionic low osmolar (isovue, optiray...), vol 270 ml premedications: midazolam 1 mg iv fentanyl 25 mcg iv, 50 mcg iv asa 325 mg p.o. clopidogrel 600 mg po anesthesia: 1% lidocaine subq. anticoagulation: heparin 3000 units iv other medication: verapamil 2.5 mg ia integrilin (2mg/ml) 6.8 ml iv bolus, 11.7 ml/hr iv drip nitroglycerin 200 mcg ic x2 cardiac cath supplies used: .035in , magic torque 180cm .014in , bmw universal 300cm 2.0mm , sprinter 12mm 3.0mm , quantum maverick 15mm 3.25mm , quantum maverick 12mm 3.0mm , quantum maverick rx 12mm 3.25mm , quantum maverick rx 08mm 6fr cordis, xb 3.0 - allegiance, custom sterile pack - , left heart kit - , right heart kit 6fr arrow, transradial artery access kit - , priority pack 20/30 2.5mm , promus otw 23mm 2.5mm , promus otw 08mm - terumo, tr band large comments: 1. coronary angiography in this right dominant system demonstrated three vessel disease. the lmca was without angiographically apparent disease. the lad had 50% mid vessel stenosis. the lcx had a 100% occlusion of a large om1. the rca had diffuse disease 60-70% in the proximal and mid vessel and was a large caliber artery. 2. resting hemodynamics revealed mild systemic arterial systolic hypertension with sbp 154 mmhg. the left ventricular filling pressure was elevated at lvedp 25 mmhg. there was no significant pressure gradient across the aortic valve. 3. successful pci of the occluded om with overlapping 2.5x8mm (prox) and 2.5x23mm (distal) promus des. the entire length of stent was post-dilated to 3.25mm. final diagnosis: 1. three vessel coronary artery disease. 2. elevated left ventricular filling pressure. 3. successful pci of the lcx with des. attending physician: , . referring physician: , . cardiology fellow: , a. , m. echocardiography 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 low normal (lvef 50%) secondary to hypokinesis of the posterior and lateral walls. 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 appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. there is an anterior space which most likely represents a promient fat pad. cxr comparison: none. portable upright chest radiograph: there is no focal consolidation and no effusion or pneumothorax. the pleural surfaces are smooth. the hilar and cardiomediastinal contours are normal. cervical fixation hardware is incompletely visualized. there is no acute osseous abnormality, and the surrounding soft tissues and upper abdomen are normal. impression: no acute cardiopulmonary process. ekg sinus rhythm. right axis deviation. non-specific st-t wave changes, although ischemia or infarction cannot be excluded. low voltage in the limb leads. compared to the previous tracing st-t wave changes are more diffuse and more marked. rate pr qrs qt/qtc p qrs t 66 164 78 8 135 brief hospital course: coronary artery disease stemi, with ekg concerning enough for activation of the cath lab prior to large enzyme and myocardial damage. enzymes peaked late on the day of admission and were trending down by . pci with two drug-eluting stents placed in om1. posterolateral hypokinesis was noted on echo, resulting from the present event and associated with a mildly depressed left-ventricular ejection fraction of 50%. she was monitored with telemetry without any significant events, except for very occasional ectopy. ecg changes progressed slightly (see above). a1c was not indicative of diabetes as a potential risk factor, nor were lipids particularly abnormal. smoking is likely the primary indentified inciting factor for this patient. however, the patient's mother had early coronary disease, in her 40s, suggesting a genetic predisposition that is as yet unidentified in this pedigree, possibly polygenic. agressive lipid lowering is indicated, along with antiplatelet agents, particularly after drug-eluting stent placement. therefore, her medication regimen includes atorvastatin (80 mg po qd), plavix (75 mg po bid for one week then qd), aspirin (325 mg po qd). a beta-blocker, metoprolol succinate (25 mg po qd) was also added. hypertension mrs. was mildly hypertensive on the first day of admission, with blood pressure range up to 150/89 mmhg. lisinopril was commenced at an introductory dose (2.5 mg po qd). metoprolol, as above, likely also has a mildly anti-hypertensive effect. leukocytosis likely stress demargination in the context of acs. resolved spontaneously during the hospital stay. medications on admission: none. discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po twice a day for 7 days: after 7 days, switch to once daily in the morning. disp:*38 tablet(s)* refills:*5* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*5* 4. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*5* 5. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*5* discharge disposition: home discharge diagnosis: st elevation mi (heart attack) discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with chest pain which was found to be due to a heart attack. your blocked blood vessel was opened using agioplasty and with the placement of two drug coated stents. you are now safe for discharge home. it is very important that you take all of your medications as directed and keep your follow-up appointments. followup instructions: please call to schedule a follow-up appointment with a cardiologist. in the hospital, you have been cared for by dr. . dr. office number is (. Procedure: Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) 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: Coronary atherosclerosis of native coronary artery Tobacco use disorder Unspecified essential hypertension Hematoma complicating a procedure Accidental puncture or laceration during a procedure, not elsewhere classified Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Leukocytosis, unspecified Acute myocardial infarction of other lateral wall, initial episode of care

allergies: amoxicillin attending: chief complaint: s/p fall major surgical or invasive procedure: : right total hip replacement history of present illness: ms. is a 47 year old female who was involved in an mvc on . she suffered a right hip disloaction, a right acetabular fracture (which was stable), and a left distal radius fracture (which she underwent an orif on ). she was at rehab when she suffered a fall. she now presents for evaluation. past medical history: lumbar disc disease anxiety social history: lives with spouse family history: n/a physical exam: upon admission alert and oriented cardiac: regular rate rhythm chest: lungs clear bilaterally abdomen: soft non-tender non-distended extremities: rle shortened, externally rotated, silt, + pulses, sensation intact. lue +sensation /movement, + pulses pertinent results: 06:27am blood wbc-7.1 rbc-3.05* hgb-8.9* hct-26.3* mcv-86 mch-29.1 mchc-33.8 rdw-17.2* plt ct-319 12:50pm blood wbc-8.6 rbc-3.36* hgb-9.7* hct-28.1* mcv-84 mch-28.8 mchc-34.4 rdw-16.4* plt ct-284# 10:00pm blood hct-24.5* 10:30am blood hct-24.5* 06:15am blood hct-23.5* 03:20pm blood hct-24.3* 06:47am blood wbc-11.1* rbc-2.95* hgb-8.5* hct-24.4* mcv-83 mch-29.0 mchc-35.1* rdw-16.3* plt ct-188 08:00pm blood hct-25.5* 12:54am blood wbc-14.1* rbc-3.05* hgb-8.8* hct-25.0* mcv-82 mch-28.8 mchc-35.1* rdw-16.4* plt ct-151 01:36pm blood hct-23.4* 08:21am blood hct-24.6* 03:03am blood wbc-12.5* rbc-2.73* hgb-7.8* hct-22.9* mcv-84 mch-28.7 mchc-34.1 rdw-16.3* plt ct-199 09:15pm blood wbc-18.7*# rbc-2.75* hgb-8.0* hct-23.7* mcv-86 mch-29.1 mchc-33.7 rdw-16.8* plt ct-245 06:15am blood wbc-8.7 rbc-3.65* hgb-10.2* hct-30.7* mcv-84 mch-28.0 mchc-33.2 rdw-17.4* plt ct-230 01:51pm blood wbc-10.6 rbc-3.80* hgb-10.3* hct-31.7* mcv-83 mch-27.1 mchc-32.5 rdw-17.5* plt ct-241 12:50pm blood glucose-117* urean-3* creat-0.5 na-141 k-3.1* cl-105 hco3-24 angap-15 06:47am blood glucose-102 urean-4* creat-0.4 na-139 k-3.4 cl-107 hco3-26 angap-9 12:54am blood glucose-114* urean-4* creat-0.4 na-138 k-4.0 cl-109* hco3-24 angap-9 01:36pm blood glucose-150* urean-6 creat-0.5 na-135 k-3.9 cl-107 hco3-23 angap-9 03:03am blood glucose-122* urean-7 creat-0.5 na-140 k-4.5 cl-113* hco3-22 angap-10 06:15am blood glucose-97 urean-5* creat-0.5 na-135 k-3.9 cl-104 hco3-25 angap-10 01:51pm blood glucose-99 urean-7 creat-0.5 na-139 k-3.8 cl-108 hco3-23 angap-12 09:10am blood tsh-1.5 09:10am blood t4-7.2 brief hospital course: ms. presented to the on after a fall at her rehab. she was evaluated by the orthopaedic surgery service and found to have a right femoral neck fracture. she was admitted, consented, and prepped for surgery. on she was taken to the operating room and underwent a right hip replacement. intraoperatively she had an estimated blood loss of 1 liter and received 2 units of prbc and 4 liters of iv fluid. she was extubated and transferred to the recovery room. in the recovery room she was transfused with a total of 4 more units of packed red blood cells due to acute blood loss anemia. due to persistent tachycardia she was transferred to the sicu for further care. on she was transferred to the floor. she was seen by physical therapy to improve her strength and mobility. she underwent leni's and a cta which were all negative. the rest of her hospital stay was uneventful with her lab data and vitals signs within normal limits and her pain controlled. she is being discharged today in stable condition. medications on admission: neurontin 300mg qhs colace 100mg lovenox 30mg discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 2. senna 8.6 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). disp:*60 capsule(s)* refills:*2* 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 5. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 capsule(s)* refills:*2* 7. enoxaparin 30 mg/0.3 ml syringe sig: one (1) 30mg syringe subcutaneous q12h (every 12 hours) for 4 weeks. disp:*56 syringes* refills:*0* 8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 10. multivitamin tablet sig: one (1) cap po daily (daily). 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*90 tablet(s)* refills:*0* 12. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). discharge disposition: home with service facility: vna discharge diagnosis: right pipken ii femoral head fracture actue blood loss anemia discharge condition: stable discharge instructions: continue to be weight bearing as tolerated on your right leg with posterior precautions and passive abduction only. continue to be non-weight bearing on your left arm, you may use a platform crutch please take all medication as prescribed you were started on lopressor while in the hospital, please follow up with your pcp for monitoring your blood pressure and further refills of your lopressor. if you have any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergnecy department. physical therapy: activity: out of bed w/ assist right lower extremity: full weight bearing left upper extremity: non weight bearing, passive rom wbat rle with posterior precautions and passive abduction only. nwb lue (distal radius). treatment frequency: staples/sutures out of r hip 14 days after surgery followup instructions: please follow up with dr. in 2 weeks for your right hip, please call to schedule that appointment. please follow up with dr. in 3 weeks for your left arm, please call to schedule that appointment. please follow up with your pcp . for your tachycardia, the phone number to his office is . md Procedure: Transfusion of packed cells Total hip replacement Diagnoses: Acute posthemorrhagic anemia Unspecified fall Dehydration Tachycardia, unspecified Other closed transcervical fracture of neck of femur Degeneration of lumbar or lumbosacral intervertebral disc

allergies: lisinopril / amlodipine attending: chief complaint: dizziness with standing major surgical or invasive procedure: egd (upper endoscopy) history of present illness: 70 y/o m with h/o diverticulosis of the entire colon c/b lgib in the past, paf on coumadin c/b cva when off coumadin (no residual deficits), ckd (baseline cr 1.5) and htn presenting from clinic hypotensive with sbp 80s. previously, he required transfusion with 9u prbcs and colectomy was recommended; pt refused colectomy and his couamdin was held. he subsequently had an ischemic posterior cva and his coumadin was restarted. in clinic he endorsed lightheadedness and orthostasis and was sent to the ed. denies brbpr, hematemesis or melena. he states that he is orthostatic most mornings, which improves throughout the day, usually after eating breakfast. . in the ed, hct was 25 (baseline 27-35) inr 3.8. rectal exam was negative for brbpr, though stool was faintly guiac positive. he was given 2l ns and gi was consulted; felt egd could wait until monday. ng tube/lavage were not performed. 18g and 16g piv were placed at the pt was admitted to the micu. vs at time of micu transfer: t 98 bp 130/60 hr 77 rr 18 sat 99% ra. . micu vs: t 98 bp 121/66 hr 68 rr 18 o2 sat 100% ra states he feels back at baseline, no complaints. past medical history: diverticulosis, entire colon, c/b recurrent gib, last htn paf on coumadin bph ckd, stage ii renal cysts cva social history: works as cook at college. single, lives alone. has three grown children. quit smoking >40 years ago. prior history of alcohol abuse, but has been sober x13 years. family history: no significant cv disease including strokes in family. +htn and hld in several members. no notable dm2 history. physical exam: admission exam: t 98 bp 121/66 hr 68 rr 18 o2 sat 100% ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp 7cm above the ra at 45 degrees, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . discharge exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp 7cm above the ra at 45 degrees, no lad cv: iregular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities pertinent results: admission labs 03:00pm blood wbc-6.9 rbc-3.20* hgb-7.9* hct-25.7* mcv-80* mch-24.7* mchc-30.7* rdw-17.9* plt ct-261 03:00pm blood neuts-47.9* lymphs-38.5 monos-7.9 eos-1.0 baso-0.6 02:26pm blood pt-39.1* ptt-50.2* inr(pt)-3.8* 02:26pm blood glucose-87 urean-24* creat-1.5* na-140 k-3.8 cl-105 hco3-24 angap-15 02:26pm blood alt-24 ast-20 alkphos-84 totbili-0.4 02:26pm blood albumin-4.2 02:13am blood calcium-8.5 phos-2.5* mg-1.7 02:26pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:34pm blood lactate-1.0 . discharge labs: 07:05am blood wbc-8.3 rbc-3.59* hgb-8.8* hct-28.8* mcv-80* mch-24.6* mchc-30.7* rdw-18.2* plt ct-248 07:05am blood pt-23.9* ptt-42.0* inr(pt)-2.3* 07:05am blood glucose-105* urean-18 creat-1.3* na-139 k-3.9 cl-104 hco3-28 angap-11 07:05am blood calcium-9.1 phos-2.9 mg-1.7 . micro: 02:26pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg urine culture-neg . studies: egd: small hiatal hernia. schatzki's ring. normal mucosa in the third part of the duodenum (biopsy). otherwise normal egd to third part of the duodenum . path: duodenal bipsy: pending brief hospital course: 70 y/o m with h/o diverticulosis of the entire colon c/b lgib in the past, paf on coumadin c/b cva when off coumadin (no residual deficits), ckd (cr 1.5) and htn admitted to the micu for gib and hypotension. transfused 1u prbc and remained hd stable, so transferred to the floor. on the floor denied dizziness, lightheadedness, fatigue, or other pre-syncopal symptoms. had egd with normal appearing mucosa and no sign of stigmata of bleed. discharged with plan for capsule endoscopy. . active issues # gib: inr was supratherapeutic at 3.8 on admission. coumadin intially held. hd stable and hct stable following 1u prbc in ed. guiac positive, so thought this may represent slow gib. initially treated in micu, but quickly transferred to medicine floor. warfarin restarted at lower dose. denied any melena/brbpr during stay. has full colonic diverticula, but presentation not consistent with diverticular bleed. pt with iron deficiency anemia and no egd since , so egd performed to work up anemia. no signs of active bleed or stigmata of prior bleed. was discharged with plans for capsule endoscopy as an outpatient. continued on po omeprazole 20mg . . #paroxysmal a. fib: pt was in and out of a. fib during this admission. coumadin initially held with supratherapeutic inr, but was restarted when inr <3. the last time his inr was subtherapeutic, he had a cva. was rate controlled without medical intervention. . # hypotension: slightly hypotensive on presentation. resolved s/p 2l ns in the ed. normotensive during stay on floor. likely related to hypovolemia; possibilities include gib vs hypovolemia from diuretic use. no fevers or localizing s/sx to suggest sepsis. patient reports chronic problem with orthostasis. could be possible med side effect from anti-hypertensive medications vs. terazosin. . chronic issues: # hyperlipidemia: continued aspirin and statin . # ckd: cr 1.5 on admission, which is baseline. discharged with cr of 1.3 . # bph: continued finasteride and terazosin . transitional issues: #will need inr check on to determine if further adjustment is necessary #will need to follow-up duodenal biopsy results #will get capsule endoscopy with gi for further work-up of ?gib . medications on admission: 1. aspirin 325 mg po daily 2. simvastatin 20 mg po daily 3. finasteride 5 mg po daily 4. atenolol 100 mg po daily 5. warfarin 5 mg po daily16 6. terazosin 10 mg po hs 7. hydrochlorothiazide 12.5 mg po daily 8. vitamin d 1000 unit po daily 9. ferrous sulfate 325 mg po tid 10. cyclobenzaprine 5 mg po tid:prn msucle spasm . discharge medications: 1. atenolol 100 mg po daily hold for sbp < 100, hr < 55 2. finasteride 5 mg po daily 3. hydrochlorothiazide 12.5 mg po daily hold for sbp < 90, hr < 55 4. omeprazole 20 mg po bid 5. simvastatin 20 mg po daily 6. terazosin 10 mg po hs 7. vitamin d 50,000 unit po 1x/week (mo) 8. warfarin 5 mg po daily16 discharge disposition: home discharge diagnosis: primary: gastrointestinal bleed hypotension iron deficiency anemia secondary: diverticulosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you at . you were admitted for several days of weakness and fatigue, low blood pressure, and blood in your stool. your blood count (hematocrit) was very low and you were transfused 1 unit of red blood cells. because your blood pressure was low, you spent the night in the intensive care unit. you were then transferred to the medicine floor. we wanted to make sure there was no slow bleed in your stomach you we looked at it with a camera (endoscopy). this was normal and did not show any signs of bleeding. you had biopsies taken and will be contact with the results of the biopsy. you should follow up with the gi doctors as outpatient for further workup to determine what if you are bleeding. they will want you to swallow a capsule that can take pictures of the portion of your gi tract not seen with egd. medications to change: decrease warfarin from 6.25mg daily to 5mg daily (have inr checked on ) followup instructions: name: pa location: address: , , phone: appointment: monday 11:30am *this is a follow up appointment of your hospitalization. you will be reconnected with your primary care provider after this visit. please have your hematocrit (blood count) checked at this appointment. we are working on a follow up appointment for your hospitalization in gastroenterology with dr. . it is recommended you be seen within 1 month of discharge. the office will contact you at home with the appointment. if you have not heard within a few business days please contact the office at . department: neurology when: tuesday at 8:00 am with: , md building: campus: east best parking: garage Procedure: Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Abnormal coagulation profile Iron deficiency anemia secondary to blood loss (chronic) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hypopotassemia Other and unspecified hyperlipidemia Hypotension, unspecified Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Anticoagulants causing adverse effects in therapeutic use Hypovolemia Diverticulosis of colon (without mention of hemorrhage) Chronic kidney disease, Stage II (mild)

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: gsw major surgical or invasive procedure: 1. reoperation for intraperitoneal hemorrhage. 2. right nephrectomy. 3. cholecystectomy. 4. placement of common bile duct t tube. 5. exploratory laparotomy. 6. small intestinal resection x2. 7. control of hepatic injury. 8. right retroperitoneal dissection for hematoma. 9. exploratory laparotomy with removal of packs. 10. small intestinal anastomosis x2. 11. delayed abdominal closure with prosthetic mesh. 12. roux-en-y hepaticojejunostomy with intraoperative cholangiogram. 13. delayed closure of open abdominal cavity, staged procedure. 14. definitive closure of abdominal fascia. 15. ct guided drainage of intraabdominal fluid collection. 16. open repair of right common femoral av fistula history of present illness: 41yo m admitted on with multiple gsw to subxiphoid, suprapubic, l wrist. past medical history: previous exploratory laparotomy social history: hx ivdu pt. lives with mother and . unemployed family history: non-contributory physical exam: physical exam general: a/o, nad cor: rrr, no m/r/g pulm: ctab abd: s/nt/nd, wound incisions c/d/i; mild drainage from mid-epigastric wound, skin is intact ext: no c/c/e neuro: no focal deficits psych: appropriate mood and affect pertinent results: 03:40am wbc-27.9* rbc-3.63* hgb-11.4* hct-33.5* mcv-92 mch-31.4 mchc-34.0 rdw-14.4 03:40am plt count-117* 03:40am pt-19.1* ptt-70.6* inr(pt)-1.8* 03:40am alt(sgpt)-191* ast(sgot)-251* alk phos-46 tot bili-0.1 03:40am glucose-331* urea n-11 creat-1.3* sodium-141 potassium-4.2 chloride-113* total co2-13* anion gap-19 04:00am hgb-11.9* calchct-36 o2 sat-76 04:33am hgb-11.8* calchct-35 04:33am hgb-11.8* calchct-35 05:04am hgb-7.6* calchct-23 07:16am hct-21.6*# 08:51am hgb-6.0* calchct-18 09:19am hgb-6.8* calchct-20 09:58am hgb-7.8* calchct-23 o2 sat-97 11:17am wbc-1.6*# rbc-3.02*# hgb-9.3*# hct-25.6*# mcv-85 mch-30.8 mchc-36.3* rdw-14.5 12:22pm wbc-1.6* rbc-3.37* hgb-10.6* hct-27.8* mcv-82 mch-31.5 mchc-38.2* rdw-14.4 02:00pm wbc-2.0* rbc-3.18* hgb-9.8* hct-26.0* mcv-82 mch-30.9 mchc-37.7* rdw-14.4 03:16pm wbc-1.8* rbc-3.31* hgb-10.1* hct-26.9* mcv-81* mch-30.7 mchc-37.7* rdw-14.5 04:43pm wbc-2.4* rbc-unable to hgb-10.7* hct-30* mcv-unable to mch-unable to mchc-38.6* rdw-unable to 06:25pm wbc-2.8* rbc-unable to hgb-11.0* hct-29* mcv-unable to mch-unable to mchc-38.8* rdw-unable to 09:04pm wbc-3.8* rbc-unable to hgb-10.1* hct-29* mcv-unable to mch-unable to mchc-38.4* rdw-unable to brief hospital course: 41 yo m admitted c/ gsw to subxiphoid, superpubic, l wrist x2. bilateral chest tubes were placed @osh and blood products patient remained hd unstable and was transferred to and taken directly to the or for exploratory laparotomy hd 1 c/ liver packing, bowel stapled x2 no anastamosis, r nephrectomy, cholecystectomy, cbd reanastomosis w/ t-tube with the abdomen left open. he required large amounts of blood products including 48 u prbcs, 27 u ffp, 7 u platelets, 5 u cryo, and 1 u factor 7. on repeat exploratory laparotomy was performed with washout and reanastomosis of small bowel. on his b/l chest tubes were placed to water seal, with chest x-ray demonstrating no pneumothorax. patient was started on lasix gtt bowel edema. on ct were d/c'd. on pt returned to the or for hepatojejunostomy and his abdomen was again left open and lasix gtt was continued. on he was started on tpn. on pt returned to the or for partial closure of the abdomen. on the abdomen closure was completed. on the patient was extubated. he was weaned off fentanyl gtt methadone pca and transitioned to fentanyl patches and po methadone. a t-tube study/cholangiogram was performed and normal. on jp was d/c'd and pt was transferred to the floor. emg of l arm was obtained demonstrating decreased motor and sensory ulnar nerve function c/ evidence of some continuity. on a ngt was placed secondary to vomiting and increased abdominal distention c/ bilious return. methadone was transitioned back to iv as pt was npo. on a ct scan was obtained high ngt output showing a right pelvic collection, concerning for a right superior gluteal artery pseudo-aneurysm. vascular surgery was consulted and on patient underwent cta which showed a focus of organizing hematoma and/or thrombosed pseudoaneurysm with residual iv contrast from prior studies as well as findings suspicious for persistent bowel injury with at least barium outside small bowel and free fluid. on patient underwent ct guided ir drainage of fluid collection. - fluconazole was added to zosyn and vancomycin. bilious drainage continued to be followed from abdominal tube. vascular surgery was consulted regarding r cf avf, pelvic pseudoaneurysm. ng tube d/c'ed on . tpn d/c'ed . the patient's diet was slowly advanced. - right femoral vascular us performed. - ir performed embolization of pseudoaneurysm. pt. tolerated procedure well w/o complications. all abx d/c'ed on . fistula care tream was consulted regarding skin integrity of abdominal wounds. pt. continued to remain afebrile, vss, without n/v or abdominal pain. his bullet was removed from the right flank on . vascular surgery performed r femoral artery a-v fistula repair on . the procedure went well without any complications. the patient was discharged in a stable condition, with instructions on wound care, and follow-up appointments with the appropriate services. medications on admission: none discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 3. methadone 10 mg tablet sig: six (6) tablet po tid (3 times a day): dx: chronic pain syndrome. disp:*307 tablet(s)* refills:*0* ***patient does not have script for this, hospital has refilled his methadone bottles, final count is 307 tablets*** 4. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*142 tablet(s)* refills:*2* 5. terbinafine 1 % cream sig: one (1) appl topical daily (daily): apply to affected areas daily as directed. discharge disposition: home discharge diagnosis: 1. intraperitoneal hemorrhage with damage to cbd, sb 2. liver laceration 3. r ureter injury 4. r retroperitoneal hematoma 5. l wrist gsw 6. multiple enterotomies (from bullet) 7. right cf avf discharge condition: stable, improved. discharge instructions: you were admitted to the hospital tauma service on . you were emergently brought to the operating room for exploration of abdominal wounds. over the course of several operations, your condition stabilized, and you were later sent from the intensive care unit to the hospital floor. - please follow the instructions that were reviewed with you to flush your abdominal drain (two times per day). - you should change the ostomy bag every 3-4 days, or if it is full. -- your wounds should be cleaned once per day with the wound cleanser provided to you, replacing the dressings accordingly. please contact us immediately if you develop a fever 101.5 or greater, chills, nausea/vomiting, shortness of breath, chest pain, increased abdominal pain, bleeding, increased drainage from the abdominal wound, or any other concerns you may have. followup instructions: trauma - follow-up in one week with dr. . please call to schedule an appointment. transplant - follow-up with dr. in two weeks time. please call to schedule an appointment. plastic surgery - follow-up in plastic surgery clinic in two weeks. please call to schedule an appointment. vascular - follow-up in weeks with dr. in his clinic. please call to schedule an appointment at the clinic. md, Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other partial resection of small intestine Incision of abdominal wall Cholecystectomy Closed [endoscopic] biopsy of bronchus Nephroureterectomy Intraoperative cholangiogram Incision with removal of foreign body or device from skin and subcutaneous tissue Other laparotomy Delayed closure of granulating abdominal wound Delayed closure of granulating abdominal wound Small-to-small intestinal anastomosis Other suture of muscle or fascia Closure of laceration of liver Anastomosis of hepatic duct to gastrointestinal tract Repair of arteriovenous fistula Exploration of common duct Diagnoses: Arteriovenous fistula, acquired Other and unspecified coagulation defects Injury to liver without mention of open wound into cavity laceration, unspecified Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum Injury to other and multiple intra-abdominal organs, with open wound into cavity Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum Unspecified peritonitis Open wound of wrist, without mention of complication Other injury to small intestine, with open wound into cavity Injury to ureter, without mention of open wound into cavity Injury to other intra-abdominal organs without mention of open wound into cavity, bile duct and gallbladder Assault by handgun

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization - thrombectomy and bare metal stent placement to proximal lad history of present illness: mr. is an 85 y/o male with a history of cad s/p pci to prox lad(), sick sinus syndrome s/p ppm who presented to the night of with chest pain. patient states that he was having substernal chest pain most of the night with associated diaphoresis. he denies radiation to jaw or extremities, no nasuea/vomiting, no numbness/tingling, lightheadedness or dizziness. ekg at osh were remarkable for paced rhythm with lv bundle branch block. he was admitted to osh for monitoring, given aspirin, and his troponins trended 0.04-->5.59-->21.01, he was transferred here for catheterization. in the ed vitals were 98.4, 60, 185/88, 16, 99% 2l nc. labs were significant for troponin here was 4.08 and bun/cr: 37/1.9, h/h: 9.5/28.8. for bp control, he was started on a nitro drip at 1mcg/kg/min. his bp ranged from 160's-180's so he received hydral 5mg iv, and metoprolol 5mg iv with minimal effect. he was given nitro paste and morphine for chest pain. heparin drip was started, cardiology was consulted and he was taken emergently to the cath lab. in the cath lab for his nstemi he was underwent angiography and was found to have 3 vessel disease with a culprit lesion in the lad. thrombectomy was performed and a bare metal stent was placed in the proximal lad. he was started on eptifibatide for 18 hours, asa and plavix. transferred to the ccu cp free and stable, on nitro drip for pressures, will monitor overnight on review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis. he denies recent fevers, chills or rigors. . per chart, prior history of tia and retinal vein occlusion. all of the other review of systems were negative. . cardiac review of systems is notable for chest pain, and absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: diabetes dyslipidemia hypertension - not on lisonpril d/t hyperkalemia cad s/p percutaneous coronary interventions: lad and lcfx stents at complicated by contrast induced nephropathy pacing/icd for heart block, generator change at primary hyperparathyroidism treated with sensipar ckd iii vitamin d deficiency gastritis - endoscopy "mild erosive gastritis" and hiatal hernia carotid artery stenosis / occlusion tia retinal venous occlusion, branch hyperparathyroidism glaucoma assoc w vasc disorder, chronic angle closure and open angle cataracts diverticulitis meniere's disease and hearing loss (conductive and sensorineural) proteinuria anxiety disorder positive ppd bph s/p turp social history: speaks chinese, some english. mr. is a former movie star in . his wife reports she is sole caregiver to pt, and reports some fatigue and would like assistance for pt's personal care and respite. she states pt can not be left alone for more than brief periods due to his blindness. wife reports that couple live in a private home in , and her family live across the street. grandson assists with heavy chores such as yard maintenance, putting out trash barrels, etc. wife reports pt uses guide cane he learned to use himself at home, and manages in familiar environment. pt has an electric stair lift to bedroom/ bath on . wife manages pt's meds, meal prep and personal care. former smoker: no cig since (prev 3 ppd) family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death. father had a stroke. otherwise non-contributory. physical exam: on admission: ed vitals were 98.4, 60, 185/88, 16, 99% 2l nc general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple, jvp not assessed since lying flat. cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. coarse crackles on left. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. pulses: dopplerable dp and pt pulses bilaterally, 2+ radial pulses bilaterally on discharge: vitals 98.9 159/76 60 18 98%ra heent: ncat cv: rrr no m/r/g chest: compromised somewhat by poor patient cooperation but i was able to appreciate some l>r crackles at the bases abd: nt/nd, bs+ ext: wwp pertinent results: admission labs 02:10pm blood wbc-8.3 rbc-2.99* hgb-9.5* hct-28.8* mcv-96 mch-31.7 mchc-32.9 rdw-13.4 plt ct-169 02:10pm blood pt-11.5 ptt-150* inr(pt)-1.1 02:10pm blood glucose-108* urean-37* creat-1.9* na-136 k-4.2 cl-107 hco3-20* angap-13 09:43pm blood ck-mb-43* mb indx-6.0 02:10pm blood ctropnt-4.08* discharge labs: 06:00am blood wbc-6.8 rbc-3.03* hgb-9.4* hct-28.2* mcv-93 mch-30.9 mchc-33.3 rdw-14.2 plt ct-181 06:22am blood hct-27.2* 06:22am blood urean-30* creat-2.2* na-137 k-4.1 cl-107 studies: ekg on admission: v-paced rhythm with lbbb morphology, rate 60bpm cardiac cath : -assessment 1. nstemi with ongoing pain 2. three vessel coronary artery disease with culprit lesion in lad 3. successful bare metal stent in proximal lad -recommendations 1. aspirin 325 mg daily for one month 2. plavix 75 mg daily 3. iv eptifibatide for 18 hours cxr : lul infiltrate cxr : bibasilar atelectasis, with interval improvement in left mid lung airspace abnormality consistent with improved aspiration pneumonitis. echo : normal biventricular cavity sizes with preserved global biventricular systolic function with lv regional wall motion abnormalities as above. mild aortic regurgitation. mild mitral regurgitation. brief hospital course: mr. is an 85 y/o male with a history of cad s/p pci (), sss s/p ppm who presented an osh, transferred here for nstemi, taken to cath lab and had a stent placed to prox hospital course complicated by hematemesis and community acquired pneumonia. acute issues: # coronaries: patient is s/p drug-eluting stent placement to proximal lad with small dissection occuring during procedure. post cath he was chest pain free and on eptifibatide 1 mcg/kg/min for 18 hours. he was started on plavix 75mg po daily. continued on home aspirin, metoprolol, and nifedipine. his ace inhibitor was not resumed given his history of hyperkalemia. echo on which showed normal biventricular cavity sizes with preserved global biventricular systolic function with lv regional wall motion abnormalities as above with mild aortic regurgitation and mild mitral regurgitation. # gi bleed: patient with known erosive gastritis diagnosed on egd in on omeprazole 20mg po daily, but vomited bloody bilious fluid in setting of aspirin, plavix, heparin and integrilide drip. most likely this is from known gastritis. hemoglobin dropped from 9.5 to 8.1, he was transfused 1 unit packed rbc's with appropriate rise in hematocrit which remained stable during the rest of his admission. on patient complained of odynophagia, dysphagia for liquids, blood tinged sputum, and a "reflux" feeling in his throat. the reflux feeling improved with the addition of an h2 blocker and carafate to his ppi, and we have continued him on ranitidine prn in addition to his omeprazole, which he is tolerating. h. pylori antibody returned negative. endoscopy was recommended as an outpatient given his multiple risk factors (age, symptoms, history of gastritis, chinese ethnicity) for stomach/esophageal ca. # community acquired pneumonia: patient with lul opacification on initial cxr. no fevers or elevated wbc, but persistent cough. cxr initially concerning for pna vs. aspiration pneumonitis. tubular sounds and crackles l>r on exam and hemoptysis raised the suspicion for pna and patient started on ctx/azithro, switched to ctx only then cefpodoxime - to complete a total of 8 days antibiotics as an outpatient until sunday, . cxr on showed bibasilar atelectasis with interval improvement in aspiration pneumonitis. # anemia: likely some acute drop in hematocrit from gi bleed. baseline ~11.3. will need outpatient monitoring of cbc and egd follow up as above. chronic issues: # sick sinus syndrome s/p pacemaker insertion -stable, has pacemaker that was interrogated in house # htn: -nifedipine and metoprolol initially held for gi bleed, then gradually introduced them titrating up to 60mg qd nifedipine and 25mg metoprolol . # hld: - atorvastatin 80mg po qhs while in the hospital transitional issues: - will need outpatient gi consult with egd for further work up of his dysphagia, odynophagia, hemoptysis and hematemesis - outpatient follow up of his anemia and pneumonia with his pcp, repeat cxr 4-6 weeks after finishing his 8 day course of antibiotics (will finish cefpodoxime ) - follow up with his cardiologist () for his mi medications on admission: preadmission medications listed are correct and complete. information was obtained from patientfamily/caregiver. 1. nifedipine cr 60 mg po daily start: in am hold for sbp <100 2. brimonidine tartrate 0.15% ophth. 1 drop both eyes 3. simvastatin 20 mg po qhs start: in am 4. timolol maleate 0.5% 1 drop right eye qid start: in am 5. folic acid 2 mg po daily start: in am 6. cinacalcet 30 mg po daily start: in am 7. atropine sulfate ophth 1% 1 drop right eye start: in am 8. dorzolamide 2%/timolol 0.5% ophth. 1 drop both eyes start: in am 9. omeprazole 20 mg po bid 10. bimatoprost *nf* 0.03 % ou qhs 11. metoprolol tartrate 25 mg po daily:prn for sbp > 140 start: in am 12. vitamin d dose is unknown po daily start: in am 13. nitroglycerin sl 0.4 mg sl prn for chest pain 14. lorazepam 0.5 mg po bid:prn anxiety 15. ferrous sulfate 325 mg po 3x/week (,tu,th,sa) start: in am 16. aspirin 81 mg po daily 17. prednisolone acetate 1% ophth. susp. 1 drop right eye daily start: in am 18. vigamox *nf* (moxifloxacin) 0.5 % right eye qhs 19. erythromycin 0.5% ophth oint 0.5 in right eye start: in am discharge medications: 1. aspirin 81 mg po daily 2. bimatoprost *nf* 0.03 % ou qhs 3. brimonidine tartrate 0.15% ophth. 1 drop both eyes 4. cinacalcet 30 mg po daily 5. erythromycin 0.5% ophth oint 0.5 in right eye 6. ferrous sulfate 325 mg po 3x/week (,tu,th,sa) 7. folic acid 2 mg po daily 8. lorazepam 0.5 mg po bid:prn anxiety 9. nifedipine cr 60 mg po daily hold for sbp <100 10. cefpodoxime proxetil 400 mg po q24h rx *cefpodoxime 200 mg 2 tablet(s) by mouth dialy disp #*6 unit refills:*0 11. clopidogrel 75 mg po daily rx *clopidogrel 75 mg 1 tablet(s) by mouth daily disp #*28 unit refills:*3 12. prednisolone acetate 1% ophth. susp. 1 drop right eye daily 13. nitroglycerin sl 0.4 mg sl prn for chest pain 14. omeprazole 20 mg po bid 15. simvastatin 20 mg po qhs 16. vitamin d 800 unit po daily 17. dorzolamide 2%/timolol 0.5% ophth. 1 drop both eyes 18. metoprolol tartrate 50 mg po bid rx *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day disp #*56 unit refills:*3 19. atropine sulfate ophth 1% 1 drop right eye 20. polyethylene glycol 17 g po daily:prn constipation 21. ranitidine 150 mg po bid:prn reflux discharge disposition: extended care facility: life care center at discharge diagnosis: principal diagnosis: nstemi (heart attack) secondary diagnoses: coronary artery disease community acquired pneumonia gi bleed - hematemesis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital for treatment of your heart attack and pneumonia. during your stay you went to the cath lab and had a bare metal stent placed in your lad (a coronary artery that supplies your heart). after the procedure, your blood counts dropped a little and you were given one unit of blood cells. you will need to see a gastroenterologist after discharge, this appointment is being set up for you. you were also found to have a pneumonia and you were treated with antibiotics which you will continue after you are discharged. medications added: -plavix - this is a very important medication that you must take every day for your heart -cefpodoxime - this is for your pneumonia. please take this until sunday, . followup instructions: name: , b. location: - address: , , phone: appointment: friday 3:45pm cardiology: dr. 26 city mall office friday at 12:30pm we are also working on a follow up appointment in - gastroenterology. you need to be seen in 1 month of discharge. the office will contact you at the facility with an appointment. if you have not heard within a few business days please call the office at . md Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Acute posthemorrhagic anemia 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 Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Anxiety state, unspecified Fitting and adjustment of cardiac pacemaker Oliguria and anuria Unspecified vitamin D deficiency Dissection of coronary artery Other specified gastritis, with hemorrhage Primary hyperparathyroidism Glaucoma stage, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall with acute on chronic subdural hemorrhage major surgical or invasive procedure: emergent craniotomy history of present illness: m who slipped and fell while using his walker today - fell and hit the back of his head on his door. denies hitting head on ground or loc. c/o ha, otherwise no complaints. has had several falls over past week a nd as been feeling weak in his le. past medical history: colon ca, urinary incontinence social history: lives by himself in elderly community, no apparent close family family history: n/c physical exam: 97.9 80 113/71 19 100%ra aaox1 eyes open spontaneously follows commands x3 right 3->2mm smile symmetric, facial sensation intact, tongue midline, mucous membranes dry motor: extremities are antigravity and spontaneous movements wound c/d/i, dressing off pertinent results: 06:22am blood wbc-9.9 rbc-2.97* hgb-9.4* hct-27.6* mcv-93 mch-31.5 mchc-33.9 rdw-15.4 plt ct-178 06:55am blood wbc-10.7 rbc-3.10* hgb-9.6* hct-29.1* mcv-94 mch-30.9 mchc-33.0 rdw-15.3 plt ct-178 02:56am blood wbc-10.1# rbc-3.02* hgb-9.8* hct-27.9* mcv-92 mch-32.5* mchc-35.3* rdw-15.6* plt ct-163 03:15am blood wbc-6.0 rbc-3.29* hgb-10.1* hct-30.5* mcv-93 mch-30.8 mchc-33.3 rdw-15.7* plt ct-199 03:15am blood neuts-68.2 lymphs-21.0 monos-5.6 eos-4.4* baso-0.8 06:55am blood pt-14.1* ptt-33.2 inr(pt)-1.2* 09:02am blood pt-14.9* ptt-32.5 inr(pt)-1.3* 03:15am blood pt-13.6* ptt-30.3 inr(pt)-1.2* 06:22am blood glucose-141* urean-20 creat-0.9 na-135 k-3.8 cl-101 hco3-28 angap-10 06:55am blood glucose-120* urean-21* creat-1.0 na-138 k-4.4 cl-105 hco3-21* angap-16 02:56am blood glucose-126* urean-18 creat-1.1 na-140 k-4.6 cl-109* hco3-20* angap-16 03:15am blood glucose-98 urean-25* creat-1.1 na-141 k-3.6 cl-106 hco3-29 angap-10 03:15am blood ck(cpk)-121 03:15am blood ctropnt-0.01 03:15am blood ck-mb-5 06:22am blood calcium-8.1* phos-2.0* mg-2.0 06:55am blood calcium-8.1* phos-2.5* mg-1.7 02:56am blood calcium-8.3* phos-2.9 mg-1.6 02:56am blood calcium-8.3* phos-2.9 mg-1.6 03:15am blood vitb12-362 folate-16.8 03:15am blood tsh-0.93 06:22am blood phenyto-12.4 06:55am blood phenyto-12.7 02:56am blood phenyto-13.4 08:42am blood type-art po2-222* pco2-42 ph-7.36 caltco2-25 base xs--1 intubat-intubated 08:42am blood glucose-205* lactate-1.2 na-140 k-3.1* cl-106 08:42am blood hgb-11.2* calchct-34 08:42am blood freeca-1.13 brief hospital course: m s/p fall from standing and was admitted on and a ct head showed acute on chronic sdh with local mass effect and no herniation. pt was started on dilantin and continued during hospital stay. repeat head ct was ordered for a few hours later. the patient's mental status began to deteriorate and the patient had to have a stat ct of the head then emergently taking in to or for craniotomy and evacuation of hematoma. pt tolerated the procedure well for details of procedure, see operative note. pt was breifly aggitated in post-operativly and was given haldol. geriatric consult was requested and ct of the head was requested for pod1. systolic bp was maintained less than 160. pod1 pt's mental status seemed more lethargic and spiked a fever. blood cultures were sent. pt had positive ua and was treated with ciprofloxacin. ct head showed increase in extraaxial fluid collection over the right frontal lobe with small amount of sulcal effacement. pt remained aggitated and was treated with haldol. physical therapy and occupational therapy evaluated and treated patients. pod2 tube feeds were started. pt was made dnr/dni. pt continued to have aggitation. patient was started on sqh. pod3 more calm. swallow evaluation was performed and recommended initiating po intake, however to continue dobhoff. ct scan showed no new bleed. pt screened for rehab. medications on admission: none discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 2. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 3. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 4. lorazepam 0.5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 5. phenytoin 125 mg/5 ml suspension sig: one (1) po q8h (every 8 hours). 6. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 7. oxycodone 5 mg/5 ml solution sig: po q4h (every 4 hours) as needed. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours). 9. haloperidol 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days: currently day . 11. haloperidol 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for agitation. 12. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 13. morphine 2 mg/ml syringe sig: one (1) injection q2h (every 2 hours) as needed. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: acute on chronic sub-dural hemorrhage discharge condition: stable discharge instructions: ?????? please have your incision checked 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. ?????? you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? if you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. ?????? 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. follow-up appointment instructions ?????? please have your staples removed in 1 week at rehab. ?????? please call ( to schedule an appointment with dr. , to be seen in 4 weeks. followup instructions: please call dr. office regarding your follow up appointment. md Procedure: Incision of cerebral meninges Enteral infusion of concentrated nutritional substances Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Other chronic pulmonary heart diseases Chronic kidney disease, unspecified Personal history of malignant neoplasm of large intestine Gross hematuria Other disorders of plasma protein metabolism Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Fall from other slipping, tripping, or stumbling Delirium due to conditions classified elsewhere Colostomy status History of fall Body Mass Index less than 19, adult

allergies: penicillins / bactrim / sulfa (sulfonamide antibiotics) attending: chief complaint: dka osteomyelitis major surgical or invasive procedure: debridement of right heel x2 picc line placement history of present illness: 60 yo f with insulin dependent diabetes presented with fatigue, nausea, and vomiting, transferred from osh, admitted for dka requiring insulin gtt. . per report, she ran out of her insulin about 3 months ago because she did not have money to pay for it. she was out of work and husband was on disability. over the course of last week, she has been feeling more tired. she also noticed achy foot but did not recall any injury to it. since sunday, also has been having sternal discomfort that is pressure like, non-radiating. then, over the last 3 days, started to have nausea and non-bilious, non-bloody vomiting. . in the osh, she was given zofran, vanco, clindamycin, ns x 3l, insulin gtt. x ray of the foot showed swelling with specks of air in the soft tissue adjacent to the 5th metatarsal heads, ? infection or penetrating trauma. ekg was sinus tachycardia and left anterior fascicular block . in the ed, initial vitals 100f, hr 124, bp 138/72, rr 18, o2sat 96%. she was noted to have pus from her right foot and erythema. there is diminished sensation but has good pulse on the right foot. no evidence of nacrotizing fasciits per ed resident. blood and urine cultures were sent. she was given cefepime, morphine, and started on insulin gtt with ns/40meq kcl. her blood sugar improved from 303-> 273. per report, she has gotten about 4 l ns from osh & from ed. podiatry is informed of the patient and planning to see her. . on the floor, reports feeling sick to her stomach but otherwise no pain. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, weight gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies weakness. denies 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: per patient - t2dm - htn social history: - tobacco: never - alcohol: denies - illicits: denies - lives at home with husband - has grown children - works 15 hours a week as a duty aid family history: - 2 grandmother with dm - mother and father with mi at old age physical exam: admission physical exam on arrival to micu general: alert, oriented, uncomfortable heent: sclera anicteric, mucous membrane dry, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: 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, right foot wrapped in kerlex . discharge physical exam vs - tm/c 96.1, 159/81, 85, 16, 95%ra, fs 130 general - well-appearing woman in nad, comfortable, appropriate heent - nc/at, perrl, eomi, sclerae anicteric, mmm, op clear neck - supple, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, +bandage covering right heel and ankle c/d/i, dressing changes daily as per podiatry. l dp 2+. skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, pertinent results: osh: - wound swab: group b strep 01:29am blood wbc-10.8 rbc-4.27 hgb-13.1 hct-37.8 mcv-89 mch-30.7 mchc-34.7 rdw-12.4 plt ct-245 01:29am blood neuts-84.7* lymphs-9.8* monos-5.1 eos-0.1 baso-0.3 01:29am blood pt-12.0 ptt-25.3 inr(pt)-1.0 01:29am blood glucose-296* urean-13 creat-0.8 na-147* k-3.0* cl-110* hco3-12* angap-28* 04:35pm blood amylase-29 05:00am blood alt-15 ast-22 ld(ldh)-216 alkphos-97 totbili-0.2 01:29am blood ck(cpk)-22* 01:29am blood ctropnt-<0.01 01:29am blood ck-mb-2 05:00am blood ck(cpk)-29 05:00am blood ck-mb-1 ctropnt-<0.01 04:35pm blood ck-mb-2 ctropnt-<0.01 04:35pm blood ck(cpk)-20* 05:30am blood %hba1c-12.6* eag-315* 01:29am blood acetone-large 05:00am blood albumin-3.3* calcium-8.8 phos-0.6* mg-1.8 10:00pm blood lactate-1.3 04:28am blood beta-hydroxybutyrate-high 6.4 01:29am urine color-straw appear-clear sp -1.036* 01:29am urine blood-neg nitrite-neg protein-30 glucose-1000 ketone-150 bilirub-neg urobiln-neg ph-5.5 leuks-neg 01:29am urine rbc-2 wbc-<1 bacteri-few yeast-none epi-1 transe-<1 05:00am urine castgr-13* microbiology: stool clostridium difficile toxin a & b test-final-negative swab gram stain-final; wound culture-final {beta streptococcus group b}; anaerobic culture-preliminary blood culture, routine-final-no growth urine culture-final-no growth blood culture, routine-final-no growth tissue-final {beta streptococcus group b}; anaerobic culture-final swab wound culture-final {beta streptococcus group b, staph aureus coag +}; anaerobic culture-final mrsa screen-final blood culture, routine-final-no growth urine culture-final-no growth blood culture, routine-final-no growth r foot wound culture: gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): beta streptococcus group b. sparse growth. identification performed on culture # , . anaerobic culture (preliminary): no anaerobes isolated. 7:16 am swab source: right foot ulcer. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs, chains, and clusters. wound culture (final ): beta streptococcus group b. moderate growth. staph aureus coag +. sparse growth. | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- 0.25 s oxacillin------------- 0.5 s trimethoprim/sulfa---- <=0.5 s anaerobic culture (final ): no anaerobes isolated. imaging: foot x-ray findings: a cutaneous defect is noted at the lateral and inferior aspect of the fifth metatarsal head. there is subcutaneous emphysema tracking around the distal fifth metatarsal along with adjacent soft tissue swelling. there is no periosteal new bone formation or osseous destruction detected. no acute fracture or dislocation is detected. there are hallux valgus and metatarsus varus deformities with hyperostosis along the medial aspect of the distal first metatarsal. degenerative changes are noted at the first mtp joint with joint space narrowing and dorsal spurring. large inferior and posterior calcaneal spurs are also seen. there is a hammertoe deformity at the second digit. degenerative changes are seen in the mid foot at the talonavicular joint. an exaggerated arch is noted. there is patchy osteopenia. a linear radiopaque density is noted in the subcutaneous tissue of the right heel which may represent a foreign body. impression: 1. radiographic findings suggestive of osteomyelitis at the head of the fifth metatarsal. 2. possible foreign body in the right heel. 3. hallux valgus. hammertoe deformity of the second toe. cxr: low lung volumes with bibasilar atelectasis but no findings to suggest pneumonia. bone biopsy: pending brief hospital course: 60 yo f with insulin dependent diabetes presented with dka and right foot pain. # diabetic ketoacidosis. patient's initial anion gap found to be 25 on arrival to the ed. her presentation was most likely secondary to non-compliance and inability to pay for her insulin. she was started on an insulin gtt in the ed, which was continued upon her arrival in the micu. as her gap closed, her iv fluid hydration was adjusted and she was transitioned to glargine with a sliding scale as her consult recommendations. her hemoglobin a1c was found 12.6. she was transferred to the general medical floor on subcutaneous insulin and her blood sugars were primarily well controlled. # right foot osteomyelitis. the patient presented with pus at the plantar surface of her right foot. a deep tissue swab was taken, although after she had already received antibiotics, and blood cultures were sent. a foot x ray suggested osteomyelitis at the head of the 5th metatarsal and possible foreign body in the right heel. podiatry was consulted and she was taken to the or for debridement and wash out with a bone biopsy twice. she was originally started on vancomycin, cefepime and flagyl. the infectious disease team was consulted who recommended that she transition to ceftriaxone and flagyl as her cultures from the osh and in house grew group b strep and mssa. she will require 6 weeks of ceftriaxone from the date of her last debridement/wash out (). she was continued on flagyl due to loose stools, please see below. # htn. sbp was noted to be in the 170s upon arrival. she was initially treated with iv antihypertensives and transitioned to lisinopril in the micu. she continued to be hypertensive during the course of her stay. the patient noted a cough a few days into her course of lisinopril and she was transitioned to valsartan and later losartan for a generic antihypertensive. # loose stools upon arrival to the general medical floor, the patient began to report loose stools. cdiff studies were sent and were negative. the patient continued to report loose stools, although reported they were improving. as the patient was being treated with flagyl, it was not entirely clear if this improvement was due to the flagyl or resolving of her symptoms naturally. a cdiff pcr of the stool was sent and she is to be continued on flagyl po until the results return. . # substernal chest pressure as part of her presentation, the patient reported occasionally substernal chest pressure. she was ruled out for acs, but was noted to have ekg changes, most notably a lafb. while no former ekgs were within our system, this remained stable during her hospital course and her symptoms resolved and her condition improved. # medication noncompliance the patient reported that she had not taken her insulin in three months as she had lost her insurance and was unable to afford medications. she met with both the case management and social work teams who helped her procure insurance so she would be able to afford her medications in the future. # health insurance coverage: application for masshealth was completed, and should hopefully be improved by the time of discharge from rehab to cover home meds including insulin. ============================================================ ============================================================ transitions of care: -patient is to follow up with id for both her duration of flagyl and ceftriaxone -she is to receive ceftriaxone 2 gm iv qday -please monitor weekly labs: cbc, chem 7 (na, k, cl, hco3, bun, cr, glucose), lfts, crp, esr -hydrogel to dry daily dressing changes (wet to dry) to right foot with ace wrapping. -weight bearing as tolerated to right heel all laboratory results should be faxed to infectious disease r.ns. at ( all questions regarding outpatient antibiotics should be directed to the infectious disease r.ns. medications on admission: per patient: - asa 81 mg daily - vitamin c - calcium - mvi - stopped insulin, does not recall dosage . per osh record - metformin 250 mg - lisinopril 10 mg daily - multivitamin - vitamin c 1000 mg daily - caltrate 600 mg daily - asa 81 mg daily - glargin 45 units qpm - unclear dosage of discharge medications: 1. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours): until instructed to stop by infectious disease md. 2. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: two (2) grams intravenous q24h (every 24 hours): 6 week course, last day , unless otherwise directed. 3. senna 8.6 mg tablet sig: one (1) tablet po daily (daily) as needed for constipation. 4. losartan 50 mg tablet sig: two (2) tablet po daily (daily). 5. insulin glargine 100 unit/ml cartridge sig: fifty (50) units subcutaneous qam. 6. insulin lispro 100 unit/ml cartridge sig: as directed by sliding scale subcutaneous qachs. 7. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 8. outpatient lab work please check a weekly chem 7, cbc, crp/ esr, lfts, and fax results to the clinic rns at (. 9. multivitamin tablet sig: one (1) tablet po once a day. 10. vitamin c 1,000 mg tablet sig: one (1) tablet po once a day. 11. caltrate 600 600 mg (1,500 mg) tablet sig: one (1) tablet po once a day. 12. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: discharge diagnosis: primary: -diabetic ketoacidosis secondary: -right heel osteomyelitis -hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: ms. , it was a pleasure taking part in your care. we hope you continue to feel well. you were admitted because your blood sugars were found to be dangerously high and you were found to have a severe infection in your foot that involved your bone, called osteomyelitis. you were given insulin to decrease your blood sugars and antibiotics for your infection. you were seen by the podiatry team which cleaned your wound in the operating room twice. you were also see by the diabetes and infectious disease specialists. please review the following changes to your medications: diabetes- -insulin lantus (glargine) 50 units at night -insulin 3-16 units as directed by your sliding scale -stop taking metformin high blood pressure- -start losartan 100 mg daily -stop taking lisinopril because it caused a cough antibiotics- -ceftriaxone 2 gm intravenously daily for six weeks unless otherwise directed -metronidazole (flagyl) 500 mg three times a day until you are told to stop it is important to follow up with your primary care physician as well as with the infectious disease and podiatry teams as listed below. followup instructions: you will have regular followup with the infectious disease doctors ( ) to be sure your infection is resolving. your first appointment is on , though your facility will be called with the time and details. please keep the following appointment: department: podiatry when: tuesday at 8:00 am with: , dpm building: ba ( complex) campus: west best parking: garage md Procedure: Excision of lesion of other soft tissue Other partial ostectomy, tarsals and metatarsals Other tenonectomy Diagnoses: Unspecified essential hypertension Hypopotassemia Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Long-term (current) use of insulin Personal history of noncompliance with medical treatment, presenting hazards to health Diarrhea Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Other bone involvement in diseases classified elsewhere Unspecified osteomyelitis, ankle and foot Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Dermatophytosis of the body Precordial pain Inadequate material resources

allergies: codeine / prochlorperazine / remicade / demerol / morphine / dilaudid / darvocet-n 100 attending: chief complaint: hip pain/fracture major surgical or invasive procedure: open reduction internal fixation of the left hip history of present illness: 70 yo w w/ refractory crohn's disease s/p total colectomy/ileostomy, short gut syndrome, rheumatoid arthritis on prednisone, pes in (on coumadin), osteoporosis and falls who was admitted to medical service s/p fall on , found to have left intertrochanteric hip fracture and s/p intramedullary nailing with cephalomedullary system today, post op developed hypotension/resp. distress felt to be due to mucous plug, requiring reintubation, now re-extubated and admitted to micu for persistent tachycardia and hypoxia. . patient had a mechanical fall on in setting of increased sedating medications (gabapentin), initially evaluated at osh, where she was found to be in moderate pulmonary edema. on arrival to , was found to have a leukocytosis 12k (felt to be reactive) but was started on cipro/flagyl in case gi source and given 3mg of vitamin k. . has had progressively worsening dyspnea for months, attributed ild and chf? she is on coumadin for recurrent dvts. . post-op, post extubation, noted to be tachypneic w/ o2 sats in 80s, he in 140s and bp in 150s w/o significant improvement on nrb, thus was reintubated. bronch -> mucus plug, suctioned, vbg 7.18/57/49. after 2 hrs, noted to have improving ms and o2 sats, was thus extubated at 1300. weaned to 3l nc, however, remained tachycardic in 120-130 sinus with sbp 90/50s (pre-op bps in 110-130s) and oliguria. she was treated with 1u prbcs, 5.5 l ns total, uop improved to 30cc/hr (prior < 10cc/hr). in addition to above, pt. received 10mg of esmolol for nsvt on tele w/ sbp to 80s transiently, flagyl 250mg, prednisone 5mg, coumadin 5mg, dilaudid 0.6mg and apap 1g. given persistent tachycardia and hypotension, transferred to micu. . on arrival to the micu, vs 121 87/42, rr 22 95% 3l nc. c/o of hip pain and sob. past medical history: -cva with deficits in her right frontal lobe. -neuropathy -restless legs -h/o dvt in , denies any history of pes -small, subsegmental pe on cta -rheumatoid arthritis, dx in -crohn's dx in , c/b pyoderma gangrenosum developed recently at ostomy -asthma/chronic bronchitis -depression/anxiety -recent falls -osteoporosis with multilevel compression fracture t11-l3 . surgical history: -: laparotomy and extensive lysis of adhesions, excision of abdominal wall and en bloc resection of abdominal wall and small intestine, complex abdominal wall closure, permanent ileostomy, ventral hernia repair with placement of surgimend mesh. - - vac change and debridement - - wound opening and debridement of devitalized skin and subcutaneous tissues; irrigation of the wound; debridement of devitalized fascia and removal of some mesh and suture; placement of vac. -s/p multiple abd surgeries (13-14) ??????s procedure and reversal. -s/p colectomy/ileostomy social history: shows that she is a widow who has three daughters and a niece who is very close to her (, with her today). she likes doing crafts and likes cooking. she does not drink, smoked for 20 years, but quit in , denies tb exposure. family history: brothers and sister with heart disease, inc. sister with cabg. no family history of ibd. daughters healthy. physical exam: admission physical exam general: awake, slightly sleepy, but awakens to voice. heent: sclera anicteric, dmm, oropharynx clear neck: supple, jvp 12cm, no lad cv: rr, normal s1 + s2, no murmurs, rubs, gallops lungs: crackles bilaterally, laterally, unable to assess posteriorly, due to pain abdomen: soft, obese, nt, loose stool in stoma gu: foley ext: warm, well perfused, 2+ pulses, no edema. neuro: awake, sleepy, but responds to voice and follows commands. dowf but not backwards, intact naming, . did not test other cognitive functions. vff to confrontation. eomi, b/l 4->2mm, face symmetric, tongue midline, palate symmetric. ues antiresistance, unable to assess to hip pain. toes down discharge physical exam vs: t 98.5 bp 101/53 (101-110/50-60) p 88 (73-88) r 20 o2 95% ra general: awake, alert, interactive. heent: sclera anicteric, mmm, oropharynx clear cv: rr, normal s1 + s2, ii/vi sem at rusb no rubs, gallops lungs: bibasilar crackles but otherwise clear abdomen: soft, obese, minimally tender to palpation diffusely, loose stool in stoma ext: warm, well perfused, 2+ pulses, no edema. pertinent results: admission labs 09:15am blood wbc-11.7* rbc-3.34* hgb-9.1* hct-29.6* mcv-89 mch-27.2 mchc-30.7* rdw-22.7* plt ct-263 09:15am blood neuts-90.0* lymphs-4.8* monos-5.0 eos-0.1 baso-0.2 09:15am blood pt-31.7* ptt-35.3 inr(pt)-3.1* 09:15am blood glucose-120* urean-24* creat-0.6 na-139 k-3.5 cl-111* hco3-21* angap-11 09:15am blood alt-22 ast-23 ck(cpk)-74 alkphos-100 totbili-0.4 06:00am blood calcium-7.0* phos-1.2*# mg-1.6 relevant labs 10:10am blood wbc-20.5*# rbc-3.95* hgb-10.7* hct-36.3# mcv-92 mch-27.1 mchc-29.4* rdw-21.8* plt ct-245 04:07am blood pt-57.4* ptt-34.2 inr(pt)-5.7* 03:58am blood pt-72.7* ptt-34.2 inr(pt)-7.3* 01:12am blood ck-mb-7 ctropnt-0.35* 05:56am blood ck-mb-7 ctropnt-0.24* 04:14pm blood ck-mb-7 ctropnt-0.16* 01:37pm blood ck-mb-4 ctropnt-0.02* 04:03am blood ck-mb-3 ctropnt-0.02* 01:12am blood cortsol-20.5* 05:56am blood cortsol-11.5 06:48am blood cortsol-35.4* discharge labs 05:33am blood wbc-12.7* rbc-3.19* hgb-8.3* hct-29.2* mcv-92 mch-25.9* mchc-28.3* rdw-20.4* plt ct-518* 05:33am blood pt-26.2* ptt-35.2 inr(pt)-2.5* 05:33am blood glucose-85 urean-14 creat-0.6 na-137 k-4.0 cl-106 hco3-27 angap-8 05:33am blood calcium-7.9* phos-2.1* mg-1.8 microbiology blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. urine culture (final ): no growth. mrsa screen (final ): no mrsa isolated. clostridium difficile toxin a & b test (final ): feces negative for c. difficile toxin a & b by eia. sputum source: expectorated. gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. urine culture (final ): no growth. fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. clostridium difficile toxin a & b test (final ): feces negative for c. difficile toxin a & b by eia. (reference range-negative). cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. blood culture routine (pending): imaging ecg : sinus rhythm. within normal limits. no significant change compared to previous tracing of and that of . ecg : the rate is slightly slower with persistent sinus tachycardia. otherwise, no significant change compared to tracing #1. ecg : the rhythm appears to be supraventricular which could still be sinus tachycardia. however, this raises the possibility of a supraventricular tachycardia (atrial flutter or a-v re-entrant tachycardia) with low voltage compared to tracing #2. this could represent a pneumothorax or pericardial effusion, among other things. clinical correlation is suggested. tte : the left atrium is mildly dilated. the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50%). the right ventricular free wall thickness is normal. the right ventricular cavity is 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 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 tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen (may be underestimated). significant pulmonic regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , severe right ventricular contractile dysfunction and moderate-to-severe (possibly frankly severe) tricuspid regurgitation are now present. the pulmonary artery pressure is probably significantly elevated. cta : impression: 1. no acute aortic pathology. if there is a filling defect in the left lower lobe subsegmental artery, it is isolated and too small to be clinically significant. no other filling defect concerning for pulmonary embolism. 2. mild right heart failure with significant right atrial and right ventricular enlargement, exacerbated by interstitial lung disease and emphysema. 3. small perihepatic ascites. 4. lesion at the carina may be mucus or an endobronchial lesion covered with mucus. consider repeat ct for reassessment(preceded by vigorous coughing) after treatment of heart failure. ct abd : impression: 1. no evidence for abscess. 2. ileostomy in the right lower quadrant. 3. anterior abdominal wall hernia containing small bowel, no evidence of obstruction. cxr : findings: in comparison with study of , there is little overall change. substantial cardiomegaly with bilateral opacifications most likely reflecting pulmonary edema. the possibility of supervening pneumonia would have to be raised in the appropriate clinical setting. central catheter remains in place. slight impression on the lower cervical trachea on the right could possibly represent a small thyroid mass. cxr : comparison is made to prior study, . moderate-to-severe cardiomegaly is unchanged. there are low lung volumes. left port-a-cath tip is in the right atrium. there is no pneumothorax or pleural effusion. mild-to-moderate pulmonary edema is stable. tte : the left atrium is mildly dilated. the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). the right ventricular free wall thickness is normal. the right ventricular cavity is moderately dilated with mild 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. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is at least mild tricuspid regurgitation. there is mild-moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. moderately dilated and mildly hypokinetic right ventricle with at least mild tricuspid regurgitation and mild-moderate pulmonary hypertension. preserved left ventricular systolic function. cxr : as compared to the previous radiograph, there is unchanged evidence of moderate-to-severe pulmonary edema. however, the interstitial component of the edema is more prominent on the current image. the presence of a small pleural effusion cannot be excluded. unchanged mild cardiomegaly. unchanged position of the left pectoral port-a-cath. portable abdomen : there are dilated loops of presumably small bowel in the lower abdomen. although most likely reflecting adynamic ileus, the possibility of an obstruction cannot be unequivocally excluded. if this is a serious clinical concern, ct would be the next imaging procedure. brief hospital course: 70 yo w w/ refractory crohn's disease s/p total colectomy/ileostomy, short gut syndrome, rheumatoid arthritis on prednisone, pes in (on coumadin), osteoporosis and falls, admitted s/p l hip fracture, now s/p l orif w/ post op hypotension/resp. distress mucous plug, re-intubation/extubation, atrial tachycardia, called-out of the micu and is now doing well. acute issues # left hip fracture s/p orif - mechanical fall likely osteoporosis with chronic steroid use. stitches removed on and pt can weight-bear as tolerated. pt has been tolerating pt well. she will be discharged on her home oxycodone and acetaminophen prn for pain control. she has follow-up with np on . # hypotension. etiology remained elusive, however after extensive evaluation, most likely etiology initially was felt be a combination of sepsis from pulmonary source (hcap in setting of mucous plug), volume overload (right sided failure, confirmed by tte) in setting of aggressive volume resuscitation 8l and possible atrial tachycardia. cta showed no pe and ground glass opacities as well as findings consistent with interticial lung disease and emphysema. ct abdomen w/o iv contrast showed no evidence of large abcess or additional fistulae. adrenal insufficiency was ruled out with stim test. on multiple occasions, patient was found to have svt to 160s, felt to be consistent with atrial tachycardia with drop in bp by over 10mm hg. with svt to 130s, no appreciable change in bp was noted. pt. was weaned off pressors on . residual hypotension was noted in correlation to narcotic pain medication administration, though pt always mentated well. this was also in the setting of giving metoprolol for atrial tachycardia, which was then reduced to 12.5mg metoprolol in house with some improvement in hypotension. # fever. unclear in etiology. pt was treated with vancomycin/zosyn for hcap and on the day that they were supposed to be completed (), she developed sudden fever to 102.8 with severe wheezing and tachypnea. symptoms improved with apap. port was de-accessed and pt. was pancultured. she was restarted on vancomycin and meropenem. on port was re-accessed and cultures obtained w/o further incident. given negative cultures from , antibiotics were discontinued. pt remained afebrile through the rest of the hospitalization. # tachycardia. sinus during acute illness phase, however with runs of atrial tachycardia in setting of volume overload. with diuresis and completion of antibiotics, patient continued to have frequent runs of a-tach. she was started on metoprolol and loaded with digoxin. subsequent hrs were in 70-80 range with bps in 90s-100s. digoxin was then discontinued as pt was in sinus rhythm. cardiology was consulted who suggested rate control with toprol 25mg daily. # rv dysfunction. echo on showed the right ventricular cavity dilated with severe global free wall hypokinesis and abnormal septal motion/position consistent with right ventricular pressure/volume overload. moderate to severe tricuspid regurgitation was seen. it was recommended that pt be adequately diuresed and repeat echo obtained, which on showed the right ventricular cavity moderately dilated with mild global free wall hypokinesis and still abnormal septal motion/position consistent with right ventricular pressure/volume overload. however, it only showed at least mild tricuspid regurgitation. discussion was held with cardiology about possibility of performing a right heart catheterization, which was deferred to the outpatient setting. pt will be seen in cardiology as an outpatient for further follow-up. # acute on chronic diastolic dysfunction - tte w/ ef > 55% and evidence of rv dilatation and volume overload. pt was aggressively diuresed in the micu with repeat echo, though minimal change was seen, except for improvement in tricuspid regurgitation. pt is not on any diuretics at home and none were started upon discharge. pt will have f/u with cardiology as an outpatient. # pulmonary hypertension. pt w/ pasp of 35mm hg. could be due to ild or copd. pt has outpatient f/u with pulm for repeat pfts in . # recurrent dvts and hx of pe. coumadin temporarily held on admission in setting of hypotension. patient bridged at that time with lovenox. inr again increased in setting of meropenem initiation, coumadin temporarily held and restarted on . she has been on 3mg daily with therapeutic inrs. recommend checking inr level tomorrow and re-dosing as appropriate since pt is on acetaminophen and zoloft which can affect inr levels. # crohns disease. stable, pt. w/o c/o of abdominal pain/cramping (typical for her). no changes in stoma output. held mtx as above. steroids were restarted once patient was hd stable. gi was consulted to assess whether some of her infectious presentation could be due to an underlying fistula, which was not felt to be the case. her methotrexate was re-started upon discharge per her outpatient gastroenterologist. # rheumatoid arthritis dx. per discussion with op rheumatologist, all of her w/up has been negative (all serologies), and her arthralgias were felt to be more consistent with crohns related arthritis rather then ra. prednisone 5mg daily was restarted and continued throughout the hospitalization. # neuropathy. topamax was stopped in setting of lack of efficacy, persistent acidosis and family concerns re: aes (mental slowing). can consider re-starting as an outpatient if indicated. transitional issues # incidental finding f/u: cta chest showed a lesion at the carina may be mucus or an endobronchial lesion covered with mucus. consider repeat ct for reassessment(preceded by vigorous coughing) after treatment of heart failure. she is currently scheduled for ct chest w/o contrast on . # recommend discussion with dr. regarding utility for flagyl (on this previously, stopped during micu course) medications on admission: - lidocaine 5 %(700 mg/patch) adhesive patch - gabapentin 300 mg capsule sig: one (1) capsule po twice a day. - prednisone 5 mg tablet - ropinirole 1 mg tablet tid (confirmed with pt) - topiramate 25 mg po bid - sertraline 25 mg qhs - omeprazole 20 mg qd - methotrexate sodium 15 mg qd - warfarin 5 mg qd - lorazepam 0.5 mg qhs - promethazine 25 mg q6h prn for nausea. - folic acid 1 mg qd - oxycodone 5 mg q4-6 hours as needed for pain - mupirocin 2 % ointment tid - flagyl 250 mg qd (confirmed with pt - though pt reports not taking) . otc - magnesium oxide 500 mg qd - potassium chloride 99 mg 6 tablet - vitamin a 8000 units qd - cyanocobalamin (vitamin b-12) 1,000 mcg po qd - lysine 500 mg po bid - carbonyl iron sig: twenty seven (27) mg once a day (pt reports not taking) - brimonidine 0.2 % drops sig: one (1) drop each eye ophthalmic twice a day. - vitamin d 2,000 unit capsule qd discharge medications: 1. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 2. gabapentin 400 mg capsule sig: one (1) capsule po q8h (every 8 hours). 3. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 4. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*75 tablet(s)* refills:*0* 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. sertraline 25 mg tablet sig: one (1) tablet po at bedtime. 9. lorazepam 1 mg tablet sig: 0.5 tablet po at bedtime as needed for insomnia/anxiety. 10. ropinirole 1 mg tablet sig: two (2) tablet po bid (2 times a day). 11. ropinirole 1 mg tablet sig: one (1) tablet po q noon (). 12. acetaminophen 500 mg tablet sig: two (2) tablet po q 8h (every 8 hours) as needed for pain. 13. brimonidine 0.2 % drops sig: one (1) drop ophthalmic twice a day: please apply to both eyes. 14. vitamin a 8,000 unit capsule sig: one (1) capsule po once a day. 15. cholecalciferol (vitamin d3) 1,000 unit tablet sig: two (2) tablet po daily (daily). 16. lysine 500 mg capsule sig: one (1) capsule po twice a day. 17. magnesium oxide 500 mg capsule sig: one (1) capsule po once a day. 18. potassium 99 mg tablet sig: six (6) tablet po once a day. 19. cyanocobalamin (vitamin b-12) 1,000 mcg/15 ml liquid sig: fifteen (15) ml po once a day. 20. toprol xl 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 21. zofran odt 4 mg tablet, rapid dissolve sig: tablet, rapid dissolves po every eight (8) hours as needed for nausea. 22. heparin flush (10 units/ml) 5 ml iv prn line flush indwelling port (e.g. portacath), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 23. methotrexate sodium 15 mg tablet sig: one (1) tablet po once a week. 24. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every four (4) hours as needed for shortness of breath or wheezing. 25. symbicort 160-4.5 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation twice a day. discharge disposition: extended care facility: discharge diagnosis: primary diagnosis hip fracture secondary diagnosis atrial tachycardia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure taking care of you during your hospital stay at . you were admitted due to a hip fracture and you had this surgically repaired. however, you had a brief stay in the intensive care unit after surgery due to low blood pressures and fast heart rate. your low blood pressures were likely related to your pain medication. your fast heart rate is being managed by a new medication that you should take daily, called toprol. you will have follow-up with the cardiology clinic, at which time they will re-assess your heart. please note the following changes to your medications. please start taking: 1. toprol 25mg daily 2. acetaminophen as needed for pain 3. zofran as needed for nausea please change: 1. warfarin - take 3mg daily instead of 5mg 2. gabapentin - take 400mg three times daily please stop taking: 1. topiramate 2. promethazine otherwise, please continue taking your medications as prescribed. followup instructions: name: , a. location: -division of gastroenterology/ gi/west address: , ste 8e, , phone: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. department: radiology when: tuesday at 10:15 am with: cat scan building: gz building (/ complex) campus: east best parking: main garage department: west clinic when: tuesday at 11:30 am with: , md building: de building ( complex) campus: west best parking: garage department: orthopedics when: tuesday at 10:40 am with: , np building: campus: east best parking: garage department: cardiac services when: thursday at 11:40 am with: , md building: sc clinical ctr campus: east best parking: garage 10:30a ,tcc sc clinical ctr, pulmonary unit-cc7 (sb) 10:30a ,interpret w/lab no check-in intepretation billing 10:10a 7 - rm 1 , pulmonary lab Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other bronchoscopy Other lavage of bronchus and trachea Arterial catheterization Closed reduction of fracture with internal fixation, femur Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Acidosis Other postoperative infection Congestive heart failure, unspecified Unspecified septicemia Severe sepsis Cardiac complications, not elsewhere classified Atrial fibrillation Asthma, unspecified type, unspecified Other chronic pulmonary heart diseases Depressive disorder, not elsewhere classified Anxiety state, unspecified Regional enteritis of unspecified site Other specified cardiac dysrhythmias Cardiogenic shock Osteoporosis, unspecified Other late effects of cerebrovascular disease Septic shock Postinflammatory pulmonary fibrosis Rheumatoid arthritis Other diseases of lung, not elsewhere classified Fever, unspecified Personal history of venous thrombosis and embolism Urinary complications, not elsewhere classified Acute on chronic systolic heart failure Other and unspecified postsurgical nonabsorption Ileostomy status Mononeuritis of unspecified site Leukocytosis, unspecified Oliguria and anuria Tricuspid valve disorders, specified as nonrheumatic Restless legs syndrome (RLS) Closed fracture of intertrochanteric section of neck of femur Other acute and subacute forms of ischemic heart disease, other Foreign body in main bronchus Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Personal history of pulmonary embolism Acute respiratory failure following trauma and surgery Acquired absence of intestine (large) (small)

allergies: codeine / prochlorperazine / remicade / demerol / morphine / dilaudid attending: chief complaint: abnormal labs major surgical or invasive procedure: picc line placement history of present illness: 67 y.o. female with h.o. crohns disease (on prednisone, previously on mtx which has been d/c'd), recently completed course of cipro/flagyl for ostomy infection, multiple abdominal surgeries (last ) for ostomy revision referred to ed for abnormal lab values. she was discharged after a surgical admission for fistula at ostomy site, infection at site (d/c'd on cipro/flagyl), high ostomy output and electrolyte disturbances (hyponatremia and hco3 11). she was treated with ivfs, electroloyte repletion, antibiotics as above, and loperamide. on discharge she stated that she had some nausea that she attributed to the antibiotics. she denies vomiting and ostomy output has remained constant. she received a methotrexate treatment on and states that her nausea and fatigue worsened. no cp. chronic dyspnea on exertion. she drinks 10oz glasses of water daily, taking in very little solids. lost lbs in last few weeks. pt went to see dr. yesterday for follow up. she was started on coumadin for a dvt seen on ct scan . at that time she had labs drawn which were abnormal, specifically na 127, hco3 8, creatinine of 1.4. pt was called and instructed to come into the ed. in the ed initial vs were: t97.6, p100, bp 125/68, r 20, o2 sat 99%. she was noted to have abdominal pain (/which is chronic for her) and was given zofran 4,g x 1, oxycodone 10mg x 1 and empirically started on iv ciprofloxacin/flagyl. a ct abdomen/pelvis was obtained which showed no bowel obstruction or abscess, but was notable for filling defects of b/l common femoral veins, new on the l and worse on right. new right internal iliac vein. in the ed she also became transiently hypotensive to low 80s, was asymptomatic. at that time she had an ej placed in addition to piv and was given stress dose steroids with dexamethasone 10mg iv x 1, started on 2l of ns. she was also started on heparin gtt for her dvts. of note she was recently discharged on from surgical service for infection of her ostomy site. at that time, per d/c summary, she was noted to have high ostomy output; stool studies were negative and she was given ivf and imodium. she was discharged with 1 month of cipro/flagyl. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: -small, subsegmental pe found on hospital stay on cta -recent falls -diagnosis of ra made in -diagnosis of crohn's made in -pyoderma gangrenosum developed recently at ostomy site being treated with topical tacrolimus -asthma -depression/anxiety -: laparotomy and extensive lysis of adhesions, excision of abdominal wall and en bloc resection of abdominal wall and small intestine, complex abdominal wall closure, permanent ileostomy, ventral hernia repair with placement of surgimend mesh. - - vac change and debridement - - wound opening and debridement of devitalized skin and subcutaneous tissues; irrigation of the wound; debridement of devitalized fascia and removal of some mesh and suture; placement of vac. -s/p multiple abd surgeries (13-14) ??????s procedure and reversal. -s/p colectomy/ileostomy social history: social history: lives in with daughter; widowed. tobacco use for 30 pack-years until , no alcohol/drug use. family history: family history: brother has heart disease physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, thick yellowish plaque on tongue 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, +scar tissue throughout, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, ostomy site with dressing, there is a 1-2cm wound that is packed with clean gauze, borders are nonerythematous, no exudate, non-tender ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. tender thin veins over legs b/l pertinent results: labs on admission: 05:15am wbc-27.5* rbc-4.24 hgb-11.1* hct-36.1 mcv-85 mch-26.2* mchc-30.7* rdw-16.2* 05:15am neuts-88* bands-1 lymphs-3* monos-8 eos-0 basos-0 atyps-0 metas-0 myelos-0 05:15am hypochrom-1+ anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-normal ovalocyt-occasional schistocy-occasional 05:15am plt count-349 05:15am pt-14.8* ptt-26.9 inr(pt)-1.3* 05:15am albumin-3.2* calcium-8.5 phosphate-2.8 magnesium-1.4* 05:15am glucose-96 urea n-35* creat-1.1 sodium-128* potassium-5.1 chloride-108 total co2-11* anion gap-14 05:24am lactate-1.5 06:20am urine color-yellow appear-clear sp -1.013 06:20am urine -neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 06:20am urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-<1 06:20am urine granular-<1 hyaline-21-50* 06:20am urine mucous-few discharge labs: 06:00am wbc-13.5* rbc-3.56* hgb-9.1* hct-30.3* mcv-85 mch-25.4* mchc-29.9* rdw-16.4* plt ct-366 06:00am pt-22.3* ptt-24.0 inr(pt)-2.1* 06:00am glucose-79 urean-11 creat-0.6 na-138 k-4.5 cl-103 hco3-29 angap-11 06:00am calcium-8.4 phos-3.6 mg-1.7 05:24am lactate-1.5 microbiology: , urine c. diff cultures negative imaging: echo : the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with basal inferior and inferoseptal hypokinesis. overall left ventricular systolic function is low normal (lvef 50-55%). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: low normal left ventricular systolic function. mildly dilated right ventricle with mild global hypokinesis. mild pulmonary artery systolic hypertension. ekg : atrial fibrillation with uncontrolled ventricular response. right bundle branch block. non-specific inferolateral st-t wave changes. compared to the previous tracing of right bundle-branch block can be seen on the current tracing. the rhythm is now atrial fibrillation. the overall rate is increased. ct ab/pelvis : impression: 1. bilateral common femoral vein dvt with right sided extension to the deep pelvic veins. 2. post-surgical changes in the abdomen with no acute complications. prior enterocutaneous fistula appears closed. brief hospital course: a 67 year old lady admitted to the medical icu then medical floor for lab abnormalities from crohn's with short gut found to have a right iliac dvt. 1. dvt: the patient has a recent history of dvts of which the newest is the r iliac. she was started on heparin and 5mg of warfarin and quickly became therapeutic. her heparin drip was discontinued after 48 hours of inr>2.0. she will go home on 5mg of warfarin daily to be followed by dr. . 2. non-anion gap acidosis: the patient's non-anion gap acidosis was due to direct bicarb losses in copious/?malabsorptive stool. along with the acidosis was hyponatremia, hypokalemia and hypomagnesemia. these electrolytes were repleted throughout her stay. on discharge, she was not given any oral supplementation but will have triweekly hydration under the direction of dr. as an outpatient. 3. hypotension: the patient was transiently hypotensive and symptomatic. orthostasis and possible relative adrenal insufficiency were addressed with fluids, and stress dose steroids. she had no hypotension while admitted. 4. atrial tachycardia: the patient was found to have atrial tachycardia (occasional atrial fibrillation) to the 160s that was asymptomatic. she was started on metoprolol (25mg tid final dose) and seen by our electrophysiology service. they will follow her as an outpatient. 5. crohn's disease: the patient was continued on prednisone 10mg and cipro 250mg po bid under the direction of dr. . medications on admission: prednisone 10 mg daily metronidazole 500 mg q8h (completed) omeprazole 20 mg daily folic acid 1 mg daily ciprofloxacin 500 mg q12hr x 1month (plan to decrease to 250mg po daily today) sertraline 25mg daily ropinirole 1 mg qpm miconazole nitrate 2 % 1 appl topical tid x 1 week vitamin d 50,000 unit po qweek vitamin b-12 1,000 mcg qmonth oxycodone-acetaminophen 5-325 mg 1-2 tabs q4hrs prn x 2 weeks lorazepam 0.5-1 mg qhs prn anxiety loperamide 2 mg prn to keep ostomy output <1000-1500 ml/day. fluconazole 100 mg daily x 2 weeks (completed) lysine 500mg vitamin a 8000 iu daily iron 27 mg once daily ibuprofen 800 mg po bid prn coumadin started yesterday 8mgpo promethazine 25 mg qid prn methotrexate 25mg/1ml qwk (last dose 9/10) discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po qhs (once a day (at bedtime)). 2. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. sertraline 50 mg tablet sig: 0.5 tablet po hs (at bedtime). 5. ropinirole 1 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 6. cyanocobalamin 500 mcg tablet sig: one (1) tablet po daily (daily). 7. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 8. lorazepam 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for anxiety. 9. lysine 500 mg tablet sig: one (1) tablet po twice a day. 10. vitamin a 10,000 unit capsule sig: one (1) capsule po daily (daily). 11. iron 27 mg (iron) tablet sig: one (1) tablet po once a day. 12. alphagan p 0.1 % drops sig: one (1) ophthalmic (2 times a day). 13. normal saline please infuse 1l of normal saline over 2 hours monday wednesday and friday ongoing. this will be monitored by , a. location: -division of gastroenterology-gi/west address: , ste 8e, , phone: fax: email: 14. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 15. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h (every 12 hours). 16. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 17. alphagan p 0.1 % drops sig: one (1) drop ou ophthalmic (2 times a day). 18. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 19. outpatient lab work monday please draw na, k, cl, hco3, bun, cr, mg, k, phos, pt/inr and send results to , a. address: , ste 8e, , phone: fax: discharge disposition: home with service facility: vna and hospice discharge diagnosis: primary diagnosis: 1. iliac dvt 2. atrial tachycardia 3. hyponatremia 4. non-gap acidosis secondary diagnoses: 1. crohn's disease 2. s/p abdominal surgeries (colectomy, ilectomy) discharge condition: stable, afebrile, electrolytes stable discharge instructions: you have been admitted to the hospital because of lab abnormalities discovered by dr. at your recent clinic visit. while you were here, you spent a short time in the icu because of low pressure. however, you were quickly transferred to the medical floor after you did well in the icu. while on the floor, we worked to correct your fluids and electrolytes and have been successful. going home, you will received infusions at @ drum under monday/wednesday/friday under the direction of dr. and his associate dr. , phone: (. you were also found to have a clot in your leg "dvt" for which you will be on coumadin, a thinner for the next 6 months. in addition, you developed a fast heart rate called atrial tachycardia for which we have started metoprolol, a medicine to control your heart rate. if you feel lightheaded, please call dr. before continuing this medicine. please pay careful attention to your medications, the following have changed: - warfarin 5mg daily to be adjusted by dr. - continue ciprofloxacin 250mg by mouth twice daily - metoprolol 25mg by mouth three times a day - normal saline infusions per dr. : monday wednesday friday please call dr. or 911 if you experience any chest pain, difficulty breathing, lightheadedness or any other medical concern. followup instructions: provider: , md phone: date/time: 1:45 provider: , m.d. phone: date/time: 1:40 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acidosis Anemia of other chronic disease Long-term (current) use of steroids Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Asthma, unspecified type, unspecified Hypopotassemia Dysthymic disorder Regional enteritis of unspecified site Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Long-term (current) use of anticoagulants Rheumatoid arthritis Personal history of venous thrombosis and embolism Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Other and unspecified postsurgical nonabsorption Ileostomy status Disorders of magnesium metabolism Fistula of intestine, excluding rectum and anus Restless legs syndrome (RLS)

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall major surgical or invasive procedure: picc line placement history of present illness: 85m s/p fall down stair 14 steps with change in mental status. transported to for further care. he was noted to be briefly hypotensive to 70s in ed. past medical history: cervical spondylosis w/ mild myelopathy peripheral neuropathy hearing loss prostate ca s/p "surgery" depression cirrhosis (by radiographic appearance of liver on ct) cognition: no history of memory loss per son-in-law l cataract excision social history: widowed family history: noncontributory physical exam: vs: 97 112/62 64 16 93%/2l height: 69 in. weight: 87 kgs. (191.80 lbs) bmi: 28.3 gen: overweight older sleeping in bed; opens eyes briefly to name/sternal rub, then falls asleep heent: anicteric sclerae, op clear without e/e neck: no lad/tm, jvp 6 cv: rrr, s1/s2, no m/r/g appreciated resp: poorly assessed due to patient positioning; ctab anteriorly abd: +bs, s, nt/nd gu: foley in place ext: 2+ dps, no le edema skin: extensive confluent ecchymosis of r posterior thigh extending to mid back and to popliteal fossa and into groin; smaller ecchymoses of l posterior shoulder, posterior to r ear pertinent results: upon admission 10:30pm glucose-203* urea n-20 creat-1.1 sodium-140 potassium-4.6 chloride-103 total co2-28 anion gap-14 10:30pm ck(cpk)-515* 10:30pm ck-mb-11* mb indx-2.1 ctropnt-<0.01 10:30pm wbc-17.3* rbc-3.71* hgb-11.9* hct-35.2* mcv-95 mch-32.1* mchc-33.9 rdw-14.1 10:30pm plt count-187 10:30pm pt-13.3 ptt-28.1 inr(pt)-1.1 _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ wbc rbc hgb hct mcv mch mchc rdw plt ct 06:20am 9.2 2.58* 8.5* 25.5* 99* 32.9* 33.2 15.7* 221 02:09am 11.2* 2.75* 8.9* 26.9* 98 32.4* 33.1 15.6* 184 source: line-r forearm #20 angio 05:59pm 28.3* 02:05pm 27.4* 01:29am 12.6* 2.80* 8.9* 26.3* 94 31.7 33.7 16.3* 158 source: line-a-line 09:46pm 25.5* source: line-arterial 03:03pm 25.8* source: line-arterial 01:16am 13.9* 2.88* 9.3* 27.0* 94 32.5* 34.6 15.9* 147* source: line-aline 08:44pm 24.8* source: line-aline 04:56pm 25.1* source: line-arterial 01:05pm 27.1* _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ head ct impression: no intracranial hemorrhage. large subgaleal hematoma along the vertex. ct c-spine impression: 1. t1 spinous process fracture. 2. possible paget's disease involving c2-c3. 3. emphysema with 4-mm left apical nodule - f/u in 12 months. ct chest/abdomen/pelvis impression: 1. right buttock hematoma with evidence of active extravasation. findings were discussed with dr. at the time of initial review. 2. right and left adrenal nodules, incompletely characterized. recommend dedicated mri to further evaluate. 3. extensive atherosclerosis with notable coronary artery disease. 4. diffuse emphysema. 5. right eighth lateral rib fracture, t1 spinous process fracture. 6. left renal cyst. 7. shrunken liver, ? cirrhosis. _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ echocardiography report , portable tte (complete) done at 1:33:32 pm final echocardiographic measurements results measurements normal range left atrium - long axis dimension: 3.7 cm <= 4.0 cm left atrium - four chamber length: 4.9 cm <= 5.2 cm left atrium - peak pulm vein s: 0.5 m/s left atrium - peak pulm vein d: 0.2 m/s left atrium - peak pulm vein a: 0.3 m/s < 0.4 m/s right atrium - four chamber length: 4.8 cm <= 5.0 cm left ventricle - ejection fraction: >= 65% >= 55% left ventricle - peak inducible lvot gradient: 26 mm hg aorta - sinus level: *4.5 cm <= 3.6 cm aortic valve - peak velocity: 1.3 m/sec <= 2.0 m/sec aortic valve - lvot diam: 2.3 cm mitral valve - e wave: 0.6 m/sec mitral valve - a wave: 0.7 m/sec mitral valve - e/a ratio: 0.86 mitral valve - e wave deceleration time: 163 ms 140-250 ms tr gradient (+ ra = pasp): *28 mm hg <= 25 mm hg findings left atrium: normal la size. right atrium/interatrial septum: normal ra size. normal ivc diameter (<2.1cm) with >55% decrease during respiration (estimated ra pressure (0-5mmhg). left ventricle: suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. overall normal lvef (>55%). no resting lvot gradient. lvot gradient increases with valsalva. right ventricle: normal rv chamber size and free wall motion. aorta: moderately dilated aortic sinus. aortic valve: aortic valve not well seen. no as. trace ar. mitral valve: mitral valve leaflets not well seen. tricuspid valve: borderline pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. general comments: suboptimal image quality - poor echo windows. suboptimal image quality - poor parasternal views. suboptimal image quality as the patient was difficult to position. conclusions the left atrium is normal in size. the estimated right atrial pressure is 0-5 mmhg. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). there was no resting left ventricular outflow gradient, but the gradient increased to mild with the valsalva manuever. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated at the sinus level. the aortic valve is not well seen. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are not well seen. there is borderline pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: normal overall biventricular function. left ventricle is unusually small and underfilled. moderately dilated aortic sinus. _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ chest xray s/p picc line placment placement of picc line via the right brachial vein access with the tip of the catheter in svc, and the catheter is ready to use. brief hospital course: he was admitted to the trauma icu with following injuries parietal/occipital subgaleal hematoma, right post 7 rib fracture, t1 spinous process fracture as well as a right buttock hematoma with active extravasation. he was actively resuscitated in the icu with aggressive fluid therapy. a tte showed hypovolemia and for a low hematocrit of 23 he was given units of packed red cells on ; post transfusion hematocrit 26. his respiratory status was tenuous likely due to fluid overload and he was given 60mg iv lasix for pulmonary edema. on he was given another 20mg iv lasix; a deep sputum culture was obtained showing gpc and gnr and he was started on vancomycin and ceftriaxone. the antibiotics will continue for 2 weeks. he remained in the icu for several days becoming delirious. geriatrics was consulted and made several recommendations pertaining to his medications such as scheduling tylenol, minimizing narcotics, and use of small doses of anti-psychotic to manage behaviors. he was eventually transferred to the regular nursing unit where later in the evening had a desaturation episode. he was also at that time noted with low urine output and was given a fluid challenge with increase in his urine output. he has a 22 coud?????? catheter in placed which was inserted by urology during his icu stay because of problems with urinary retention. the catheter may removed at the discretion of the primary team once voiding adequately while at rehab. his oxygen saturations did improve and he is currently 97% with forehead probe on liters per minute. of note on ct imaging of his chest a small nodule was detected; it is being recommended that he have follow up ct of his chest in the next several months. he will require follow up with his primary care doctor for this as an outpatient. he was evaluated by physical and occupational therapy and is being recommended for acute care rehab. medications on admission: gapapentin 600"', asa 81', fluoxetine 20', tramadol 50"prn, mvi, urinary med? qhs (not flomax) discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5,000 units injection tid (3 times a day). 2. tylenol 325 mg tablet sig: two (2) tablet po every six (6) hours: give around the clock. 3. 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. 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold fro sbp <110; hr <60. 6. oxycodone 5 mg tablet sig: -1 tablet po every 4-6 hours as needed for pain. 7. colace 100 mg capsule sig: one (1) capsule po twice a day. 8. senna 8.6 mg tablet sig: 1-2 tablets po twice a day as needed for constipation. 9. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml's po twice a day as needed for constipation. 10. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gm intravenous q 12h (every 12 hours) for 2 weeks. 11. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) gm intravenous q24h (every 24 hours) for 2 weeks. 12. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per sliding scale. discharge disposition: extended care facility: & rehab center - discharge diagnosis: s/p fall parietal/occipital subgaleal hematoma right posterior 7th rib fracture pneumonia t1 transverse process fracture right buttock hematoma acute blood loss anemia oliguira discharge condition: hemodynamically stable, tolerating a regular diet, pain adequately controlled discharge instructions: wear the soft cervical collar for comfort; velcro may be placed in front. followup instructions: follow up in 2 weeks with dr. , trauma surgery for your rib fractures and evaluation of your right buttock hematoma. call for an appointment. an ap end expiratory chest xray will be needed for this appointment. follow up in 4 weeks with dr. =, ortho spine surgery for your t1 transverse process fracture. call for an appointment. please follow up with your primary care doctor from rehab for folow up ct imaging of your chest becasue of a nodule found in your lung. you or your family will need to call for an appointment. Procedure: Venous catheterization, not elsewhere classified Arterial catheterization Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Hypotension, unspecified Accidental fall on or from other stairs or steps Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Closed fracture of one rib Unspecified hereditary and idiopathic peripheral neuropathy Other alteration of consciousness Oliguria and anuria Contusion of face, scalp, and neck except eye(s) Cervical spondylosis with myelopathy Contusion of buttock

allergies: patient recorded as having no known allergies to drugs attending: addendum: hypernatremia: pt's serum sodium peaked at 155, thought to be due to hypotonic large volume urine loss due to autodiuresis. he was calculated to have a 6.5l free water deficit and was repleted aggressively with 250ml free water flushes via peg tube and 1l d5w. on discharge pt's na had improved to 147 and would expect continued improvement with aggressive repletion of free water deficit. pt will need continued close monitoring of sodium until stabilized urine output in balace with free water flushes. discharge disposition: extended care facility: - md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other gastroscopy Enteral infusion of concentrated nutritional substances Injection of steroid Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Injection of antibiotic Injection of antibiotic Bronchoscopy through artificial stoma Transfusion of packed cells Injection or infusion of oxazolidinone class of antibiotics Injection of insulin Infusion of drotrecogin alfa (activated) Diagnoses: Acidosis Hyperpotassemia Anemia in chronic kidney disease Subendocardial infarction, initial episode of care Pneumonia due to other gram-negative bacteria Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Acute posthemorrhagic anemia Unspecified protein-calorie malnutrition Severe sepsis Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Pulmonary collapse Hemorrhage complicating a procedure Acute respiratory failure Other specified septicemias Septic shock Other complications due to other vascular device, implant, and graft Hyperosmolality and/or hypernatremia Streptococcal septicemia Surgical or other procedure not carried out because of contraindication Acquired absence of kidney Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Paranoid type schizophrenia, chronic Other tracheostomy complications Methicillin resistant pneumonia due to Staphylococcus aureus Other adrenal hypofunction Benign neoplasm of stomach Hypothermia not associated with low environmental temperature Other specified diseases of the salivary glands

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from osh c severe sepsis major surgical or invasive procedure: -intubation -central venous line placement -arterial line placement history of present illness: this is a 74 y.o. male with history of adrenal insufficiency, hypothyroidism, paranoid schizophrenia, and dm ii presenting with sepsis of unclear etiology. on the day prior to admission the patient's family reports he had decreased po intake as well as congestion symptoms. last night his family noted that he was a little weak and put him to bed. although he did not complain of any fevers his family noted that he was extremely cold to the touch and gave him several blankets and heating blankets to help him stay warm. the next day they noted that he was awake but was not verbal. given this he was taken to ed. at he was noted to be very hypotensive to 40s-50s. he was given solumedrol 125mng x 1, he was also noted to be bradycardic to 40s and received atropine. azithromycin, zosyn were initiated and a headct was performed which was negative. he was also intubated and started on dopamine, levophed and neo. . in the , pt was given 2gm of vancomycin and 750mg of levofloxacin. he was also given stress dose steroids of hydrocortisone 100mg iv x 1, peep was increased to 10 and pt was set on ardsnet protocol. he also received a total of 8l of ns. his labs were notable for leukopenia, thrombocytopenia 116, creatinine 3.7, bun 93. troponin was noted to be 0.06 with a ck of 1836 and ck-mb that was pending. urine and serum tox were negative. abg obtained after intubation noted to be ph 7.28, pco2, 43, o2 60, hco3 21 on peep of 5 that was increased to 10. . review of systems: unable to obtain ros intubation past medical history: paranoid schizophrenia (unable to care for self at baseline) htn dm ii copd h.o. pna requiring hospitalization nephrectomy mild cri social history: pt lives with family at home. per pcp family is not able to care for pt adequately and home is in disrepair and has been investigated by department of health with consideration for condemning the property family history: noncontributory physical exam: general: elderly caucasian male intubated in nard. psych: localizes to pain, opens eyes to verbal stimuli heent: sclera anicteric, mmm neck: difficult to eval jvp given ij lungs: crackles noted diffusely on anterior exam with diminished crackles over left lung field. cv: borderline bradycardic (50), s1 + s2, no murmurs, rubs, gallops abdomen: no grimacing noted on abdominal palpation, non-distended, obese, + bowel sounds present, no rebound tenderness or guarding left groin: hematoma noted from femoral line placement, appears better rn from ed after warm compress ext: 2+ edema noted in all extremities. pertinent results: labs on admission: 06:50pm blood wbc-2.6* rbc-3.77* hgb-11.2* hct-35.7* mcv-95 mch-29.7 mchc-31.4 rdw-17.1* plt ct-116* 06:50pm blood neuts-37* bands-29* lymphs-27 monos-1* eos-0 baso-0 atyps-0 metas-4* myelos-2* 06:50pm blood hypochr-normal anisocy-1+ poiklo-occasional macrocy-1+ microcy-normal polychr-normal burr-occasional 06:50pm blood pt-12.8 ptt-32.7 inr(pt)-1.1 06:50pm blood fibrino-623* 06:50pm blood glucose-332* urean-93* creat-3.7* na-145 k-4.8 cl-107 hco3-22 angap-21* 06:50pm blood alt-74* ast-109* ck(cpk)-1836* alkphos-59 totbili-0.2 06:50pm blood ck-mb-230* mb indx-12.5* 06:50pm blood calcium-8.3* phos-4.5 mg-2.3 from osh: blood culture 2/4 bottles growing 2 species of coag neg staph urine cx growing >100,000 vre sensitive to ampicillin, daptomycin and linezolid gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): multiple organisms consistent with oropharyngeal flora. 2+ (1-5 per 1000x field): budding yeast with pseudohyphae. respiratory culture (preliminary): further incubation required to determine the presence or absence of commensal respiratory flora. yeast. moderate growth. acinetobacter baumannii complex. sparse growth. sensitivities: mic expressed in mcg/m _________________________________________________________ acinetobacter baumannii complex | ampicillin/sulbactam-- =>32 r cefepime-------------- 32 r ceftazidime----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ 8 i imipenem-------------- 2 s tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s linezolid------------- 2 s nitrofurantoin-------- <=16 s tetracycline---------- =>16 r vancomycin------------ =>32 r brief hospital course: this is a 74 y.o. male with h.o. hypothyroidism p/w septic shock, nstemi, hypothermia with suspected pulmonary versus urine source. ##. septic shock: pt noted to be in septic shock on admission to the ed on multiple pressors. per family pt has a history of pna versus aspiration pna, hospitalized three times over the past year and also had dirty ua and ?pna on cxr from ed. pt was initially started on zosyn, cipro and vancomycin for broad coverage in this frequently hospitalized pt in addition to pressors and xygris given pt's high apache score. stress dose steroids were also started as pt was on dexamethasone as outpt per his med list. influenza antigen and legionella antigen were sent and were negative. pressors able to be weaned and antibiotics switched to linezolid for vre in urine and meropenem for acinetobacter in sputum. antibiotic course was completed on . ##. respiratory failure: pt arrived intubated in ventilatory failure believed to be pna versus ards from urosepsis. this was complicated by fluid overload in the setting of volume repletion. pt's infections were treated and pt was diuresed aggressively with resolution of pulmonary edema at time of discharge. tracheostomy tube placed on . secretions continued to be a problem so t-tube kept in place. # : baseline cr of 1.8-2, which slowly rose to 4.6. etiology was believed to be atn secondary to hypotension in setting of septic shock. renal functions improved with creatinines trending towards baseline (baseline is 1.8-2.0, at time of discharge was 2.3). home lasix, glyburide, flomax, lubripristone, fenofexadine, verapamil held. ##. nstemi: pt showed no ischemic ekg changes in the ed but cardiac enzymes were noted to be positive with a ck of 1836, ckmb 230, ckmbi 12.5, troponin 0.06. twi in i, avl, q in lead iii, small r-wave and avf inferiorly. pt ruled in, likely ischemic from his prolonged episode of hypotension. aspirin was initially held as pt had been started on xygris, but asa was restarted once xygris course completed. in future could consider adding ace inhibitor as renal function resolves. did not start beta blocker given episodes of bradycardia. ##. bradycardia: pt noted to be bradycardic, requiring atropine in the field for hr in the 40s. bradycardia initially thought to likely be due to his hypothermia. however, had additional episodes of sinus bradycardia periodically, particularly in the evening. improved during hospital course, with patient maintaining normal sinus rhythm with regular rate at time of discharge. # anemia: pt??????s hematocrit trended down throughout first few days of admission. likely aggressive fluid hydration. pt does also have h/o peptic ulcers, and was on xygris which increases risk of gib, however, stool and ng aspirate both guiac negative, there was no evidence for rp bleed or intracranial bleed. pt was maintained on ppi and active type and screen maintained. pt was transfused one unit on and his hematocrit did bump appropriately. anemia thought to be secondary to renal failure. was not actively bleeding and hct was stable at time of discharge. #. hypothyroidism: continued on home levothyroxine . #schizophrenia: intially held clozaril and perphenazine while intubated and sedated. pt was then started on linezolid so clozaril and perphenazine were held for concern for seratonin syndrome. linezolid course was completed on . clozaril should be held another 2 weeks, at least, and could be restarted on as long as patient is not sedated. can be continued on perphenazine per home dose. . #copd: continue atrovent and albuterol prn, usually on nebs but switched to inh while intubated. . #? adrenal insufficiency: on dexamethasone 2mg at home, hydrocortisone was initially started at stress doses and then weaned down and eventually transitioned back to dexamethasone. pt can follow up c his pcp regarding whether he will need to continue dexamethasone (this diagnosis is very recent and did not seem definite based on osh records). . # dm: pt with known dm type 2. initially placed on insulin drip as it was felt that his skin was likely too edematous to get good absorption of sc insulin (target range for gtt was 150-200). after diuresis pt was placed on sc insulin. # sw: sw consulted for regarding safety of pt's living situation. they felt that placement at home would not be a good idea and should go to rehab and be further evaluated for placement at time of discharge from rehab. # prophylaxis: subcutaneous heparin , bowel reg # code: full pcp dr medications on admission: per pt list: lasix 40 levothyroxine 50 mcg daily glyburide 2.5 daily amitiza 24 mcg (lubiprostone) flomax 0.4 mg fexofenadine verapamil 120 perphenazine 4 clozaril 200 (recent dc summary says 100??) asa 81 centrum "cenna plus?" dexamethasone 2mg atrovent nebs albuterol nebs discharge medications: 1. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 2. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day). 3. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 4. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 5. perphenazine 2 mg tablet : two (2) tablet po bid (2 times a day). 6. levothyroxine 50 mcg tablet : one (1) tablet po daily (daily). 7. dexamethasone 2 mg tablet : one (1) tablet po daily (daily). 8. amlodipine 5 mg tablet : two (2) tablet po daily (daily). 9. chlorhexidine gluconate 0.12 % mouthwash : one (1) ml mucous membrane (2 times a day). 10. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 11. ipratropium bromide 17 mcg/actuation aerosol : six (6) puff inhalation qid (4 times a day). 12. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : six (6) puff inhalation q4h (every 4 hours) as needed for wheeze. discharge disposition: extended care facility: - discharge diagnosis: 1) uro/pneumo sepsis 2) ventilator acquired pneumonia 3) s/p tracheostomy and peg tube placement discharge condition: stable for discharge to rehab. good saturation on 60% fio2 via t-tube. discharge instructions: you were admitted to the icu because you had a severe infection in your urine and in your lungs that caused your blood pressure to fall. while in the icu, we treated you for this by giving you fluids and giving you antibiotics (linezolid and meropenem) for these infections, of which you completed the course. because you had trouble breathing, we started you on a breathing machine. over the course of several days, your infection began to clear, your fevers improved, and your blood pressure returned to normal. you were also getting better at breathing so we took you off the ventilator and put in a tracheostomy, which allows us to give you oxygen safely. when you go to rehab, they will assess you daily to see when your tracheostomy can be safely removed or whether your peg tube can come out once you can safely take food by mouth. . the following medication changes were made: (1) because of renal failure, we stopped your lasix. as your renal failure begins to clear, this can be restarted. (2) we stopped your glyburide because of your renal failure. (3) we stopped your home dose of flomax because of your renal failure. (4) we stopped your verapamil b/c of your renal failure. (5) we stopped your clozaril, because in combination with the linezolid, this can cause your white blood cell count to drop. you can restart clozaril on . (6) you should continue to take perphenazine 4 mg as at home; this can also be given prn for agitation. (7) you should start lansoprazole which protects your stomach from getting irritated. followup instructions: 1) monday, you should follow up with pulmonary with dr . his office is located on the in the building. (2) please follow up with renal on tues am with dr . this is located in the building on the . (2) you should follow up with your primary care physician and your outpatient psychiatrist within 1 month of discharge. you will need to have these appointments scheduled. md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other gastroscopy Enteral infusion of concentrated nutritional substances Injection of steroid Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Injection of antibiotic Injection of antibiotic Bronchoscopy through artificial stoma Transfusion of packed cells Injection or infusion of oxazolidinone class of antibiotics Injection of insulin Infusion of drotrecogin alfa (activated) Diagnoses: Acidosis Hyperpotassemia Anemia in chronic kidney disease Subendocardial infarction, initial episode of care Pneumonia due to other gram-negative bacteria Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Acute posthemorrhagic anemia Unspecified protein-calorie malnutrition Severe sepsis Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Pulmonary collapse Hemorrhage complicating a procedure Acute respiratory failure Other specified septicemias Septic shock Other complications due to other vascular device, implant, and graft Hyperosmolality and/or hypernatremia Streptococcal septicemia Surgical or other procedure not carried out because of contraindication Acquired absence of kidney Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Paranoid type schizophrenia, chronic Other tracheostomy complications Methicillin resistant pneumonia due to Staphylococcus aureus Other adrenal hypofunction Benign neoplasm of stomach Hypothermia not associated with low environmental temperature Other specified diseases of the salivary glands

allergies: no known allergies / adverse drug reactions attending: chief complaint: neck pain, right sided weakness major surgical or invasive procedure: : ivc filter insertion : ivc filter removal picc line placement arterial line placement intubation and mechanical ventilation surgery : 1. c6 corpectomy. 2. kyphectomy c7. 3. open biopsy, deep bone. 4. anterior body fusion c5-c6, c6-c7, c7-t1. 5. interbody reconstruction c5 through t1. 6. anterior cervical plate instrumentation c5 through t1. surgery : 1. deep bone biopsy. 2. open treatment cervical fracture/dislocation. 3. posterior cervical arthrodesis c5-c6, c6-c7. 4. posterior thoracic arthrodesis c7-t1. 5. posterior instrumentation c5-t1. 6. iliac crest bone graft harvest for fusion. 7. allograft for fusion. history of present illness: the patient is a 64 y/o m with pmhx significant for spinal stenosis with multiple discectomies ~4yrs ago c/b wound infection, afib on coumadin, chf ef 25-30%, htn, who presents from rehab and transfered from osh for neck pain, r sided weakness, and concern for osteomyelitis. pt states that he has had increasing neck pain for the last 1-2d, with increased weakness in his right arm and leg. he states that he is able to walk several steps at a time at baseline, but that he has been unable to walk at all. his outside hospital ct was concerning for osteomyelitis. . on arrival to the ed, the patient's vs were 98.4 84 96/70 16 98% ra. exam was significant for inability to lift right arm above 30' as well as weakness with right hip and knee flexion. osh ct was reread by radiology, who noted destructive process centered at the c6-c7 intervertebral disc space, concerning for disciitis / osteomyelitis. mri was ordered for further evaluation. the patient was seen by ortho spine, who recommended admission to medicine with plans for possible or early next week. vs prior to transfer were 97.7 97 18 117/94 96 with 4l nc. . currently, the patient reports pain in his neck, radiating into the bilateral arms. he endorses 2 days of worsening neck pain and weakness on the right side. he also reports occasional blurred vision. he endorses nausea and vomiting earlier today. he also endorses urinary incontinence, which is long-standing but has been slightly worse recently. he also endorses having a cough recently. denies fevers or chills. . review of systems: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, dysuria, hematuria. past medical history: atrial fibrillation on coumadin chf (systolic) ef 25-30% spinal stenosis htn ? osa pulmonary htn antiphospholipid syndrome prior pe depression social history: denies tobacco, alcohol, or illicit drug use. reports that he used to work as anesthesia rn. has not worked for 4 years due to back issues. family history: father died of pancreatitis. mother died of cva. 1 brother died of hepatitis/liver failure. 1 other brother who is healthy. physical exam: admission physical exam: vs - temp 96.8 f, bp 128/99, hr 98, rr 20, o2-sat 94% 2l general - obese male, cervical collar in place, lying in bed, nad heent - nc/at, perrla, eomi, sclerae anicteric, dry mm, op clear neck - cervical collar in place lungs - cta anteriorly, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - irregular rhythm, no mrg, nl s1-s2 abdomen - obese, nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - no significant edema, 2+ dp pulses skin - no rashes or lesions note lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, 4/5 strength in rue (shoulder extension, elbow flexion/extension) and rle (hip flexion, knee flexion/extension), in the lue and lle, strength on bilateral hand squeeze as well as bilateral foot dorsiflexion and plantarflexion, diminished sensation to lt in the rue and rle compared to the left, dtr's difficult to elicit discharge exam: vitals: 98.2 108/67 62 18 98% ra general: awake, alert, resting more comfortably, nad heent: sclera anicteric, mmm neck: -j collar in place, anterior cervical incision healing well, posterior cervical incision with overlying gauze c/d/i cv: irregularly irregular, no r/m/g lungs: ctab without wheezing/rales/rhonchi, good air movement bilaterally abdomen: obese, soft, non-tender, non-distended, bowel sounds present ext: warm, well perfused, 2+ pulses, trace lower extremity edema, chronic venous stasis changes neuro: strength 4+/5 in rue and rle, on left pertinent results: admission labs: 02:00pm blood wbc-7.2 rbc-3.80* hgb-11.1* hct-32.7* mcv-86 mch-29.3 mchc-34.0 rdw-16.9* plt ct-226 02:00pm blood neuts-79.4* lymphs-9.3* monos-5.8 eos-5.2* baso-0.2 02:00pm blood pt-46.7* ptt-51.3* inr(pt)-4.6* 02:00pm blood glucose-85 urean-31* creat-1.2 na-133 k-4.5 cl-99 hco3-26 angap-13 other pertinent labs: 12:04pm blood fibrino-682* 03:18am blood esr-69* 04:26am blood esr-126* 03:14pm blood esr-95* 04:25am blood esr-118* 06:15am blood esr-85* 03:18am blood crp-38.7* 04:26am blood crp-93.3* 02:02am blood crp-54.9* 04:25am blood crp-223.9* 06:15am blood crp-46.7* 06:15am blood ck(cpk)-201 06:15am blood ck-mb-3 ctropnt-<0.01 06:40pm blood ck(cpk)-60 06:40pm blood ck-mb-1 ctropnt-<0.01 probnp-4840* 02:00am blood alt-11 ast-18 ld(ldh)-175 ck(cpk)-41* alkphos-59 totbili-1.0 02:00am blood ck-mb-2 ctropnt-<0.01 04:26am blood alt-7 ast-14 ld(ldh)-128 alkphos-64 totbili-0.3 12:55am blood calcium-9.5 phos-4.0 mg-2.0 discharge labs: 05:23am blood wbc-4.8 rbc-3.14* hgb-8.9* hct-26.6* mcv-85 mch-28.5 mchc-33.6 rdw-16.9* plt ct-276 05:23am blood pt-35.5* ptt-96.9* inr(pt)-3.5* microbiology: blood cultures 2/11, , , : negative urine cultures 2/11, : negative c6 bone tissue culture : gram stain negative, culture negative, anaerobic culture negative, acid fast culture negative (prelim), acid fast smear negative, fungal culture negative (prelim), koh prep negative c6 bone biopsy tissue culture: gram stain negative, culture negative, anaerobic culture negative, fungal culture negative (prelim), koh prep negative universal pcr : bacterial pcr results: no bacterial dna detected with 16s rdna primer set. fungal pcr results: no fungal dna detected with 28s rdna and its primer sets. pathology: c6 vertebral body : 1. bone, c6 vertebral body, excision (a): fragments of viable and non-viable bone and cartilage. granulation tissue. no definitive evidence of osteomyelitis. 2. intervertebral disc, cervical, excision (b): fibrocartilage with degenerative change. see note. fragments of viable and non-viable bone and cartilage. note: in part 2, there is a detached cluster of neoplastic cells, favored to be neoplastic epithelial cells, present. as this cluster of cells is present on another level, it is present in the tissue block. given the apparent lack of a history of neoplasia, as well as the appearance of this cluster of cells on the slide, it is favored to be a contaminant from another case. (discussed with pathology and felt to be a contaminant from another sample). c6 vertebral body : results pending at time of discharge imaging: ct c-spine w/o contrast: laminectomy changes at c3-c6 with osseous destructive process centered around the c6-c7 intervertebral disc space concerning for vertebral osteomyelitis and discitis. mri c-spine is recommended for further evaluation. cxr : substantial cardiomegaly. no evidence of acute disease. mr w/ and w/o contrast : 1. no significant changes are demonstrated since the prior examinations, persistent abnormal signal identified at c6/c7 level, with moderate pattern of enhancement and retropulsion. 2. kyphotic deformity at c6/c7 level, causing anterior thecal sac deformity, these findings are concerning for discitis, osteomyelitis. epidural thickening with moderate pattern of enhancement, likely consistent with a combination of prominent epidural veins and dural thickening, no frank evidence of epidural collection is identified. unchanged prevertebral soft tissue swelling extending from c4 through c7 levels. 3. multilevel degenerative changes throughout the cervical spine as described above. there is no evidence of focal or diffuse lesions within the cervical spinal cord; however, the examination is limited due to patient motion. mri brain : 1. no acute intracranial process, specifically no evidence of intracranial infection or infarction. 2. mild chronic small vessel ischemic disease. 3. a lesion which lies superiorly to the right parotid is likely an enlarged lymph nodes, although a parotid tumor cannot be excluded. could correlate clinically and with prior imaging studies. 4. no stenosis, occlusion, or aneurysm visualized within the cerebral vasculature. tte : the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the lv ejection fraction appears depressed (? 35 percent). there is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm. the right ventricle also appears hypokinetic. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. bilateral lower extremity ulratsound : limited assessment of the peroneal veins bilaterally, otherwise no evidence of dvt in the bilateral lower extremities. cxr : as compared to the previous radiograph, the patient has received a cervical fusion. the endotracheal tube has been removed, the nasogastric tube is also removed, but the right picc line remains in unchanged position. unchanged moderate cardiomegaly with small areas of atelectasis but no evidence of pneumonia or other pathological changes. no pneumothorax. brief hospital course: 64m with afib on coumadin, chf with ef 35%, antiphospholipid antibody syndrome, multiple dvts and pes, htn, cervical spinal stenosis s/p c3-c7 laminectomies and c3-c4 fusion c/b mssa wound infection, who was transferred from with 1-2 days of increased neck pain, r sided weakness, with imaging evidence of c6-c7 discitis/osteomyelitis. # osteomyelitis: patient with history of cervical spinal stenosis s/p c3-c7 laminectomies and c3-c4 fusion c/b mssa wound infection that required prolonged antibiotics. he was admitted with increased neck pain, r sided weakness, and with imaging evidence on ct c-spine of c6-c7 discitis/osteomyelitis. was seen by ortho-spine in the ed and placed in a j cervical collar due to his unstable c-spine. he was afebrile, without leukocytosis, and numerous blood cultures were negative. antibiotics were initially held per id consult while awaiting cultures, and given the clinical stability of the patient from an infectious standpoint. mri with and without contrast was obtained on third attempt, requiring general anesthesia due to patient discomfort in the scanner and motion artifacts. mri/mra of the brain revealed no evidence of intracranial pathology, including septic emboli. tte showed no evidence of endocarditis, and tee was not obtained due to low suspicion of endocarditis. origin of the infection was not clear, possibly related to the prior mssa infection in . history, physical, and work-up revealed no other infectious source that could have led to the osteomyelitis. due to the proximity of the infection to the carotids, neuro ir decided they would not be able to obtain an ir-guided biopsy. thus, the patient needed an operative biopsy, which was delayed due to the patient's afib with rvr and antiphospholipid antibody syndrome (discussed below). . his first procedure was an anterior stabilization and operative biopsy, involving c6-7 corpectomies and anterior c5-t1 fusion on . the procedure went well. he was left intubated following the procedure, and required brief micu admission notable for hypotension and afib with rvr. his heparin gtt was restarted 48 hours after the surgery, and the patient was kept in the micu for the first day after restarting the heparin for frequent neuro checks, as there was concern for high risk of bleeding post-operatively. he did not develop any new neurologic deficits, and was stable for transfer back to the medicine floor. cultures from the biopsy were negative, and pathology from c6 vertebral body biopsy revealed no definitive evidence of osteomyelitis. the patient received cefazolin peri-operatively, and was continued on this antibiotic after the surgery. however, after cultures remained negative, id consult recommended again holding antibiotics and obtaining repeat cultures when the patient went back to the or on for posterior stabilization. the patient underwent deep bone biopsy, open treatment cervical fracture/dislocation, posterior cervical arthrodesis c5-c6, c6-c7, posterior thoracic arthrodesis c7-t1, posterior instrumentation c5-t1, iliac crest bone graft harvest for fusion, and allograft for fusion on . again, he tolerated the procedure well. was again briefly admitted to micu post-op, but stable for transfer to the floor the following day. patient was placed back on cefazolin perioperatively, though cultures from the repeat biopsy also remained negative. universal pcr for bacterial and fungal pathogens was sent, and was negative. given increasingly low suspicion for active infection, id recommended stopping all antibiotics on . they will see patient in follow-up in several weeks, and will monitor cbc, esr, and crp at the 2-week and 4-week marks. with regard to the patient's cervical spine stability, he will wear the j collar until ortho-spine follow-up in weeks. his pain was controlled during the admission with acetaminophen, gabapentin, tramadol, methadone, and oxycodone prn pain. he was placed on a dilaudid pca post-operatively. home tizanadine was used to help control muscle spasms. of note, his ecg was monitored for qtc prolongation with patient on both methadone and tizanadine. he worked with pt/ot, and acute rehab was recommended. # atrial fibrillation: the patient was on warfarin for anticoagulation, and carvedilol for rate control prior to admission. he had initial bursts of rvr on arrival to the floor, which improved with his home carvedilol. after mri obtained under general anesthesia, the patient was transferred to the micu in the setting of afib with rvr with rates in 120s-150s and sbps 90s-100. he received metoprolol 5mg x3 without response in the pacu. his cxr showed question of rml atelectasis; no signs of pulmonary edema or obvious infiltrate. ekg c/w afib with rvr but no signs of ischemia. in the micu, the patient was started on a diltiazem drip with good control of heart rate, and the patient was started on po metoprolol. he briefly required pressors. his carvedilol was d/c-ed in order to reduce alpha blockade in setting of relative hypotension. was weaned off dilt gtt with good control of heart rate on metoprolol 25 mg tid and sbp>100. after transfer back to the floor from the micu, he maintained good hr control on this dose of metoprolol. following his first surgery, c6-7 corpectomies and anterior c5-t1 fusion, the patient was again transferred to the micu for afib with rvr and hypotension with sbp in the 70s. he received fluids and dilt drip, resulting in good rate control. he was successfully extubated and rate control was transitioned to metoprolol 25 mg tid with sbp>100. after transfer back to the floor from the micu, he maintained good hr control on metoprolol, though dose was increased to 37.5mg tid prior to discharge. . # antiphospholipid antibody syndrome/anticoagulation management: patient has history of antiphospholipid antibody syndrome, rue dvt, and pex3. inr was supratherapeutic on arrival to the hospital. coumadin and aspirin were held given his supratherapeutic inr, and pending surgical procedures. heme/onc was for assistance with anticoagulation management peri-operatively. he was maintained on heparin drip initially. inr was reversed with vitamin k and ffp. due to the need to be off of anticoagulation peri-operatively for his spine surgeries, a temporary ivc filter was placed by ir on . heparin drip remained off 6 hours before and 48 hours after the surgery on . after the first procedure, the patient was monitored with frequent neurologic exam checks, especially after resuming therapeutic anticoagulation. heparin drip was continued with goal ptt 80-100 between his two c-spine surgeries. his inr trended up despite not receiving coumadin, and he received additional vitamin k prior to his second c-spine procedure. heparin drip was again discontinued before the second surgery, and restarted after the second procedure. after the second procedure, the patient was again monitored with neurologic exam checks, especially after resuming therapeutic anticoagulation. his ivc filter was removed on , and his warfarin was resumed that same day. he should continue on the heparin gtt until inr has been therapeutic at 2-3 for >48 hours. inr was 3.5 on day of discharge, and warfarin was held. if inr therapeutic on , heparin gtt can be discontinued. would recommend restarting warfarin at 3mg daily once inr <3. # chronic schf: prior ef documented as 25-30%; tee this admission revealed ef 35%. patient did not have any evidence of exacerbation this admission. he was initially continued on home medications, but later in his course his furosemide/lisinopril were held in the setting of hypotension due to afib with rvr and narcotics use. these medications can be restarted as bp will allow in the outpatient setting. at this time, will plan to restart furosemide on discharge. of note, as above his beta blocker was switched from carvedilol to metoprolol this admission for better hr control. . # htn: bp remained well controlled during admission, with occasional episodes of lower sbp in the 90s-100s. these lower pressures were attributed to narcotics use, and occasionally occurred in the setting of afib with rvr. patient was asymptomatic. in this setting, his home carvedilol was changed to metoprolol, which was uptitrated to a dose of 37.5mg tid prior to discharge. his home lisinopril can be started back following discharge if bp remains stable. furosemide will be restarted on discharge. . # depression: continued sertraline. . transitional issues: -given low suspicion for active infection, patient will not be discharged on antibiotics. -patient needs cbc, esr, and crp checked at 2 weeks and 4 weeks, with results sent to clinic. id follow-up scheduled for . -patient has ortho follow-up with dr. scheduled for , though this appointment may be moved. should wear j collar until that time. -patient restarted on warfarin . please monitor inr daily and adjust warfarin dose accordingly. please continue heparin gtt with goal ptt 80-100 until inr therapeutic () for >48 hours. if inr therapeutic on , can d/c heparin. as inr 3.5 on day of discharge, would recommend continuing to monitor inr and restarting at 3mg daily once inr <3. -please continue to reassess pain and increase/taper narcotic regimen as needed. patient may benefit from a pain consult after discharge if narcotics requirements continue to be an issue. -patient's lasix and lisinopril held this admission given relatively lower bp (90s-100s) and that patient appeared euvolemic. can be restarted in outpt setting as tolerated, and would recommend restarting lasix at this time. -mri during admission revealed enlarged lymph node superior to right parotid gland (though differential includes warthin's tumor or adenoma). should be compared to prior imaging and followed up after discharge. -on pathology report of c6 vertebral body biopsy, note was made of a detached cluster of neoplastic cells, favored to be neoplastic epithelial cells. this cluster of cells was favored to be a contaminant from another case (discussed with pathology). -pathology and finalized culture data from c6 biopsy still pending at time of discharge and will need to be followed-up. medications on admission: lisinopril 2.5 mg omeprazole 20 mg daily mvi daily aspirin 81 mg daily (per patient, not taking) colace 100 mg carvedilol 12.5 mg tid oxycodone 5-20 mg qid prn pain acetaminophen 650 mg q4h prn pain lasix 20 mg daily gabapentin 600 mg tid (per patient, dose was higher but causing confusion) sertraline 100 mg daily tizanidine 4 mg tid methadone 15 mg qid warfarin 5-7.5 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. gabapentin 300 mg capsule sig: two (2) capsule po q8h (every 8 hours). 3. methadone 10 mg tablet sig: two (2) tablet po three times a day. 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. sertraline 50 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 7. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 11. oxycodone 5 mg tablet sig: four (4) tablet po q4h (every 4 hours) as needed for pain. 12. heparin (porcine) in ns intravenous 13. heparin, porcine (pf) 10 unit/ml syringe sig: ten (10) ml intravenous prn (as needed) as needed for line flush. 14. tizanidine 2 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for muscle spasm. 15. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 16. furosemide 20 mg tablet sig: one (1) tablet po once a day. 17. anticoagulation please check inr and if <3 restart warfarin at 3mg daily, goal inr 18. oxycodone 5 mg tablet sig: five (5) tablet po twice a day as needed for breakthrough pain: may take extra 5 mg dose up to twice daily prior to working with pt for breakthrough pain. discharge disposition: extended care facility: - ( hospital of and islands) discharge diagnosis: primary diagnoses: c-spine osteomyelitis and instability antiphospholipid antibody syndrome atrial fibrillation with rapid ventricular response secondary diagnoses: chronic systolic congestive heart failure depression 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: dear mr. , you were admitted to the hospital for neck pain and right-sided weakness. ct and mri scans of your neck were obtained. there was concern for an infection in the bones in your neck (osteomyelitis), and the orthopedic-spine and infectious disease doctors . you underwent surgery two times (one procedure done from the front of the neck and one from the back of the neck) with the orthopedic doctors your neck and hopefully to prevent further pain and weakness. we did cultures of your blood and of the bone removed from your neck, which revealed no evidence of infection. you received iv antibiotics after the spine procedures, but the infectious disease doctors not feel you need to continue on antibiotics after you leave the hospital. you received pain medication, and you worked with physical therapy to start regaining your strength and mobility. because of your history of antiphospholipid antibody syndrome and multiple prior blood clots, we the hematology doctors to help manage your anticoagulation. your inr was high on admission and too high for surgery, so we stopped your coumadin and reversed your anticoagulation. you received heparin while the coumadin was stopped. you also had an inferior vena cava (ivc) filter placed prior to the spine procedures, due to the need to stop the heparin temporarily for the procedures. the inferior vena cava filter was removed after your two spine procedures. after all of these procedures, we re-started your coumadin. you will take coumadin after discharge. with regard to your atrial fibrillation, your heart rate was high on several occasions. this improved with changing your rate control medications, intravenous fluids, and better pain control. due to your lower blood pressure, we held your furosemide and lisinopril while you were here. you should discuss restarting these medications with your doctor after you leave the hospital, but it is reasonable to restart your furosemide (lasix) at this time. we made the following changes to your medications: - stopped carvedilol (coreg) - stopped lisinopril -changed gabapentin dose (neurontin) -changed methadone dosing -changed warfarin dosing -started metprolol (for heart rate control) -started senna and bisacodyl as needed for constipation -started miconazole powder as needed for skin irritation -started heparin (until your inr is at the right level) -started oxycodone 20mg every four hours as needed for pain (with an additional 5mg twice daily as needed for breakthrough pain when working with pt) we did not make any other changes to your medications. please continue to take them as you have been doing. please discuss with your doctor whether you should be taking aspirin (this medication was on your medication list, but you do not recall taking it recently). please keep follow-up appointments as below. followup instructions: name: , : internal medicine address: , , phone: **please discuss with the staff at the facility the need for a follow up appointment with your pcp when you are ready for discharge.** department: orthopedics when: wednesday at 9:10 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: spine center when: wednesday at 9:30 am with: , md building: campus: east best parking: garage ***it is recommended you follow up with dr in 3 weeks time, however this appt is 2 weeks out. the office may call you at home with an appt for a week later than above. Procedure: Interruption of the vena cava Other excision of joint, other specified sites Other cervical fusion of the anterior column, anterior technique Excision of bone for graft, other bones Repair of vertebral fracture Biopsy of bone, other bones Biopsy of bone, other bones Other cervical fusion of the posterior column, posterior technique Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 2-3 vertebrae Other operations on vessels Central venous catheter placement with guidance Diagnoses: Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Atrial fibrillation Other chronic pulmonary heart diseases Depressive disorder, not elsewhere classified Pulmonary collapse Acute respiratory failure Morbid obesity Chronic systolic heart failure Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Hypoxemia Primary hypercoagulable state Acute osteomyelitis, other specified sites Venous (peripheral) insufficiency, unspecified Pathologic fracture of vertebrae Benign essential hypertension Other and unspecified disc disorder, cervical region Personal history of pulmonary embolism Body Mass Index 40.0-44.9, adult Unspecified disease of spinal cord Kyphosis, postlaminectomy

allergies: ibuprofen / oxycodone hcl/acetaminophen / aspirin attending: chief complaint: brbpr major surgical or invasive procedure: colonoscopy history of present illness: mr. is a 87 yo m w/ h/o aortic disease, critical as, cad planned for cabg and avr the day after admission who presents with brbpr. of note, the pt had a cardiac cath which showed 80% lad and bifurcated diag with >70% stenosis in both poles. post op course was complicated by formation of a pseudoaneurysm. pt presented to the ed with complaints of increase in size of groin hematoma. at that time, us showed no flow into pseudoanaerysm which was thought to be thrombosed. pt was sent home by vasc surgery from the ed. . on sat , pt was constipated and took prune juice resulting in a bm. when he wiped, there was some blood on the toilet paper. in the evening , pt had bm, noted blood on the toilet paper and also around the mostly brown stool. in pt had a streaky brown marroon stool. initial vitals were t 98.5 p 82 bp 129/37 r 15 o2 sat 100 on ra. there, he was found to have hct 24.5 from 26.6 2 days prior. of note, pt had cauderization of cecal av malformation at an osh in . in the ed, the pt became hypotensive from bp 130/37 on arrival to a low of sbp 86. hr 80s rose from to 90s (pt is normally not on any beta blocker at home). at no time in his ed course was the pt symptomatic although he did admit to fleeting lightheadedness on the day prior to admission. gi was consulted from the ed and recommended ppi gtt which was started and transfusion of prbcs for goal hct>30. they stated they would talk to the icu team on arrival about possible egd on day of admission. 2 units of prbcs were ordered in the ed and the first hung just prior to transfer to the icu. pt was given about 2l ivf in the ed. 2 large bore ivs were placed in the ed. . in the ed, the pt refused ngt and when this was brought up, he began to c/o chest pain. ekg at that time showed st depressions in v2 and v4-6 which were worse from earlier in the day, new ste in avr and the pt was thought to be in an irregular rhythm ? multifocal atrial tachycardia. after the pt was told that an ngt would not be attempted since he had refused it, his cp resolved. cardiology was called from the ed who said, given the pt's bleeding, there was nothing more to do but that they would follow the pt in the icu. cardiac surgery was also made aware of his admission given his planned surgery on . . on the floor, pt is c/o left sided chest tightness with out lightheadedness, sob or palpitations. pt states he has had similar chest pain for several months. usually resolves with drinking cold water and rest. past medical history: 1. aortic stenosis (valve area 0.6cm2) 2. hypercholesterolemia (total 144, ldl 85, hdl 32 in ) 3. htn 4. l shoulder fx ~2wk ago 5. multiple large lymph nodes seen on ct social history: lives alone. two daughters. denies tobacco and etoh. family history: n/c physical exam: vitals: t: 97.3 bp: 109/37 p: 71 r: 18 o2: 96% ra general: nad, alert, oriented heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated lungs: clear to auscultation bilaterally, no wheezes or crackles cv: regular rhythm, normal rate, no s1 or s2 appreciated, ii/vi systolic murmur at base, no rubs or gallops appreciated abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, no clubbing, cyanosis or edema pulses: dp 1+ pulses pertinent results: 01:45am wbc-12.9* rbc-3.13* hgb-8.0* hct-24.5* mcv-80* mch-26.0* mchc-32.7 rdw-15.1 01:45am neuts-80.7* lymphs-11.6* monos-4.4 eos-2.9 basos-0.3 01:45am ctropnt-0.14* 01:45am ck(cpk)-42* 01:45am glucose-105* urea n-27* creat-1.3* sodium-132* potassium-4.5 chloride-100 total co2-23 anion gap-14 tte: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. 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). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , pulmonary artery pressures can be assessed on the current study and are mildly elevated. aortic stenosis remains crtical. brief hospital course: 87-year-old male with history of cad, critical as planned for cabg, avr presented with brbpr and demand ischemia. # bright red blood per rectum: the patient had a 3 point hct drop in 2 days and 1 maroon stool by report. the patient was transfused 3 units of packed rbcs to a hct over 30. stool guaiac was trace positive in the icu. gi was consulted and did a colonoscopy. they found evidence of hemorrhoids and diverticula and one rectal polyp without evidence of active bleeding. the patient was discharged with stable hematocrit. # chest pain: the patient developed chest pain. he had a planned cabg and avr. after blood transfusion the patient was asymptomatic. the patient was continued on his lipitor and anticoagulation was held. the patient had a slight cardiac enzyme elevation which is likely secondary to demand ischemia. the patient cardiac enzymes were trending down at the time of discharge. after the colonoscopy the patient was started on metoprolol succinate and diovan per outpatient regimen. # severe as: the patient also has significant cad. he was scheduled for a cabg/avr however developed the gi bleed. he remained chest pain free while he was an inpatient in the hospital. the patient was continued on the above cad medications. he was evaluated by csurg and scheduled for a cabg/avr in the near future. plavix and aspirin were held in anticipation of the surgery and the recent gi bleed. # hypertension: antihypertensives were held in setting of gi bleed. they were restarted at time of discharge. # dyslipidemia: continued statin. medications on admission: vitamin d 1,000 unit cap, 1 capsule(s) by mouth once a day saw 80 mg cap diovan 80 mg tab fish oil 1,000 mg cap, 1 capsule(s) by mouth once a day triamterene-hydrochlorothiazide 37.5 mg-25 mg cap, 1 capsule(s) by mouth daily omeprazole 40 mg cap, delayed release, 1 capsule(s) by mouth once a day centrum silver tab oral, 1 tablet(s) once daily lipitor 20 mg tab oral, 1.5 tablet(s) once daily discharge medications: 1. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day. 2. saw 80 mg capsule sig: one (1) capsule po once a day. 3. diovan 80 mg tablet sig: one (1) tablet po once a day. 4. fish oil 1,000 mg capsule sig: one (1) capsule po once a day. 5. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. centrum silver tablet sig: one (1) tablet po once a day. 7. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. metoprolol succinate 25 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:*0* 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*0* discharge disposition: home with service facility: home health care discharge diagnosis: primary diagnosis: 1. lower gi bleed 2. nstemi 3. hemorrhoids secondary diagnosis: 1. cad 2. htn 3. critical as 4. hld 5. pulmonary hyptertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with lower gi bleed. you also developed chest pain as well. you were transfused blood and your hematocrit (red blood cell count) remained stable. you had a slight increase in your cardiac enzymes suggesting a small heart attack. your chest pain has now resolved. you had a colonscopy to look for the bleed. they found hemorrhoids and no other obvious bleed. a polyp was found. you will need another colonoscopy to remove this polyp after your heart surgery. you were started on metoprolol tartrate, diovan and aspirin. you were discharged with a plan to return thrusday for cardiac surgery. the following changes were made to your medications: 1. start metoprolol succinate 25mg once daily 2. start aspirin 81mg once daily 3. increase your atorvastatin (liptor) to 80 mg daily followup instructions: you will have cardiac surgery on thursday. the surgery team will call you on wednesday to discuss when you should come in the following day. they will discuss the surgery further at this time. Procedure: Colonoscopy Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other chronic pulmonary heart diseases Other and unspecified hyperlipidemia Benign neoplasm of colon Diverticulosis of colon with hemorrhage Rheumatic aortic stenosis Internal hemorrhoids without mention of complication

allergies: ibuprofen / oxycodone hcl/acetaminophen / aspirin attending: chief complaint: exertional chest pain and dyspnea on exertion. major surgical or invasive procedure: aortic valve replacement(27-mm mosaic ultra aortic valve bioprosthesis) and coronary artery bypass grafting x3(lima-lad,svg-diag 1,svg-diag 2),patch bovine pericardial aortoplasty. history of present illness: this is a 87 year old male with known severe aortic stenosis and multivessel coronary artery disease orginally seen 3 years ago. she states over the last 5 months he has developed chest pain and dyspnea on exertion. he was referred for surgical evaluation and was admitted now for this. past medical history: aortic stenosis coronary artery disease h/o bleeding gastric ulcer h/o bleeding cecal arteriovenous malformation hypertension dyslipidemia diverticulosis rheumatic fever pulmonary hypertension axillary adenopathy cholelithiasis social history: lives alone. two daughters. denies tobacco and etoh. family history: non contributory physical exam: admission: pulse: 54 resp: 16 o2 sat: 99% b/p right: 146/51 left: 137/79 height: 5'8" weight: 179 general: well-developed obese elderly male in no acute distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular +murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema/varicosities: none neuro: grossly intact pulses: femoral right: 1+ left: 1+ dp right: 1+ left: 1+ pt : 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right/left: - pertinent results: 04:45am blood wbc-12.1* rbc-3.35* hgb-9.0* hct-27.9* mcv-83 mch-26.9* mchc-32.3 rdw-16.2* plt ct-314 03:40am blood wbc-14.6* rbc-3.23* hgb-9.4* hct-26.6* mcv-82 mch-29.0 mchc-35.2* rdw-16.6* plt ct-243 12:45pm blood wbc-25.5*# rbc-2.50*# hgb-6.7*# hct-21.0*# mcv-84 mch-26.7* mchc-31.8 rdw-16.2* plt ct-311 02:35pm blood pt-13.8* ptt-36.9* inr(pt)-1.2* 04:45am blood urean-20 creat-1.0 k-3.9 03:40am blood glucose-104* urean-22* creat-1.1 na-135 k-3.7 cl-101 hco3-27 angap-11 02:35pm blood urean-14 creat-0.8 cl-112* hco3-23 04:45am blood mg-2.1 brief hospital course: following admission he was taken to the operating room where revascularization was accomplished. see operative note for details. he weaned from bypass on epinephrine and propofol. he remained stable, weaned from pressors and the ventilator easily and was begun on beta blockers and diuretics as usual. he did have brief rapid atrial fibrillation which converted to sinus with amiodarone. ph6ysical therapy worked eith him for mobility and strength. he was felt to be an appropriate candidate for rehabilitation and arrangemnents were made for this. he was transferred to rehab on pod 4. wounds were clean and healing well. discharge instructions, medications and follow up were sent with the patient. medications on admission: lipitor 40mg qd hydrocodone-acetaminophen 5-500mg q6 prn omeprazole 40mg qd diovan 80mg qd colace 100mg fish oil vitamin d nystatin cream discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 7 days. 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain for 4 weeks. disp:*50 tablet(s)* refills:*0* 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 8. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 9. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 11. amiodarone 200 mg tablet sig: see below tablet po see below for 4 weeks: two tablets twice daily for two weeks, then one tablet twice daily for two weeks, then stop. 12. valsartan 80 mg tablet sig: one (1) tablet po daily (daily). 13. furosemide 40 mg tablet sig: one (1) tablet po once a day for 7 days. discharge disposition: extended care facility: skilled nursing and rehabilitation center - discharge diagnosis: aortic stenosis coronary artery disease h/o bleeding gastric ulcer h/o bleeding cecal arteriovenous malformation hypertension dyslipidemia diverticulosis rheumatic fever pulmonary hypertension axillary adenopathy-benign cholelithiasis discharge condition: incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema alert and oriented x3, nonfocal ambulating with steady gait incisional pain managed with percocet incisions: clean and dry sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month until follow up with surgeon 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: surgeon: dr. () on tuesday, at 1:30pm please call to schedule appointments with: primary care: dr. (in weeks cardiologist: dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Venous catheterization, not elsewhere classified Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Open and other replacement of aortic valve with tissue graft Repair of blood vessel with tissue patch graft Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other chronic pulmonary heart diseases Accidental puncture or laceration during a procedure, not elsewhere classified Other and unspecified hyperlipidemia Accidental cut, puncture, perforation or hemorrhage during other specified medical care Diverticulosis of colon (without mention of hemorrhage) Rheumatic aortic stenosis Chronic total occlusion of coronary artery Personal history of peptic ulcer disease Angiodysplasia of intestine (without mention of hemorrhage)

allergies: no known allergies / adverse drug reactions attending: chief complaint: colon cancer s/p jejunoileal bypass in major surgical or invasive procedure: : rt hemicolectomy, reversal of jejunoileal bypass, liver biopsy (tru-cut needle). : exploratory laparotomy with washout, repair of perforation in ileum, placement of vacuum-assisted closure dressing. history of present illness: 64-year-old man with a history of colonic polyps, who on screening colonoscopy () demonstrated an ulcerated, clamshell, nonobstructing mass in the cecum. the length was approximately 3 cm. biopsy confirmed invasive adenocarcinoma grade ii. otherwise, he has had no change in his health. no blood per rectum, no weight loss, no abdominal pain. he currently has formed bowel movements per day. he does experience loose bowel movements if he eats fatty foods or cheese. past medical history: past medical history: 1. myocardial infarction, . 2. right-sided nephrolithiasis. 3. morbid obesity (bmi 44.3 kg/m2). 4. hypertension. 5. history of colonic polyps. past surgical history: 1. jejunoileal bypass, (16 inches of jejunum anastomosis to the last 6 inches of ileum) appendectomy was performed at that time. 2. open cholecystectomy with choledochostomy tube and gastrostomy tube for acute gallstone pancreatitis, . 3. ureteroscopy with stenting, 05/. this was complicated by bradycardia into the 20s. 4. cardiac pacemaker placement, . 5. right flank incision with stone extraction, . 6. cystoscopic attempted stone extraction and stenting, . 7. surgical extraction of right renal stone, . 8. cardiac stents (drug-eluting), . 9. right shoulder surgery, , no metallic implants. social history: he does not smoke, drink excessively or use drugs. he manages an insurance firm. he is accompanied by his wife and daughter today. family history: significant for mother with disease, father with disease. physical exam: bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi: 44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99. physical examination: general: he is alert, oriented, in no acute distress. heent: pupils are equal, round and reactive to light. sclerae anicteric. oropharynx is clear. neck: supple without lymphadenopathy, jugular venous distention, bruits, thyromegaly or nodules. trachea is midline. lungs: clear to auscultation bilaterally. heart: regular. abdomen: obese. he has a right subcostal incision (cholecystectomy). he has a right lower abdominal transverse incision (intestinal bypass). he has a right flank incision (renal surgery). there are no obvious hernias. there is no tenderness. genitourinary: penis is circumcised. testicles are descended bilaterally. extremities: without edema. neurologic: grossly nonfocal. pertinent results: 04:50pm glucose-187* urea n-12 creat-1.0 sodium-141 potassium-4.1 chloride-104 total co2-27 anion gap-14 04:50pm estgfr-using this 04:50pm calcium-9.2 phosphate-3.9 magnesium-1.4* 04:50pm wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6* mcv-77* mch-23.8* mchc-30.8* rdw-15.5 04:50pm plt count-102* 12:44pm type-art rates-/12 tidal vol-700 po2-330* pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated vent-controlled 12:44pm glucose-153* lactate-2.1* na+-135 k+-3.8 cl--101 12:44pm hgb-10.7* calchct-32 o2 sat-97 12:44pm freeca-1.19 10:53am type-art rates-/12 tidal vol-700 po2-84* pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated vent-controlled 10:53am na+-135 10:53am hgb-10.3* calchct-31 o2 sat-94 brief hospital course: the patient presented to pre-op on . pt was evaluated by anaesthesia and taken to the operating room where a laparoscopic adjustable gastric band placement was performed. there were no adverse events in the operating room; please see the operative note for details. pt was extubated, taken to the pacu until stable, then transferred to the for observation. neuro: the patient was alert and oriented throughout the hospitalization; until her was intubated and sedated. pain was well controlled with iv pain medications. cv: vital signs were routinely monitored. the patient remained stable from a cardiovascular standpoint until he developed tachycardia and hypotension on . following that the patient was placed on multiple pressors by the icu team. cardiac enzymes were initially negative, a tee revealed a hyperdynamic myocardium. pulmonary: vital signs were routinely monitored. good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. the patient remained stable from a pulmonary standpoint until when he developed shortness of breath, new and increasing oxygen requirement and desaturation. cta of the chest revealed no evidence of pe, but the patient had evidence of worsening pulmonary function and ards. he was intubated and his peep was optimized using an intraesophageal balloon. he remained intubated until the decision of comfort measures only was executed terminally extubating the patient. gi/gu/fen: he was kept npo with ng tube to suction. the patient was initially putting out about 7-8 liters of bilious fluid a day. this was adequately replaced with iv fluids. the patient was later decreasing his ng tube outputs to 4 liters by day 6 post-operatively. the patient passed gas on the 5th day post-operatively, and bowel movements pod6. tpn was started due to the elevated ng outputs (dark green bile). patient's intake and output were closely monitored. pod#12, the patient decompensated with sudden onset chest and shoulder pain, shortness of breath, tachypnea, new oxygen requirement, ekg new right bundle branch block, and transient abdominal pain. the patient was taken to the or and exploration revealed a total of 5 liters of fluid non bilious. he was found to have one small hole at the proximal anastomosis and purulent pocket. 3 drains were placed. subsequently the patient developed multiple organ system failure, with acute renal failure requiring continuous venovenous hemodialysis. worsening refractory metabolic acidosis requiring multiple boluses and iv drip bicarbonate. acute liver failure was also noted with inr>3 and liver transaminases >. id: the patient's fever curves were closely watched for signs of infection. the patient developed sepsis as discussed above with multiple organisms (k. pneumonia, b. fragilis,...) the patient was placed on broad spectrum iv antibiotics. prophylaxis: the patient received subcutaneous heparin and dyne boots were used during this stay; he was encouraged to get up and ambulate as early as possible. the patient was showing signs of multiple organ system collapse with refractory hypotension and acidosis despite maximal medical therapy. a family meeting was conducted with the family deciding that the patient's wishes would be to withdraw care at that point. the patient was extubated terminally and the patient passed away shortly after on at 17:37. medications on admission: medications - prescription atorvastatin - (prescribed by other provider) - 40 mg tablet - 1 tablet(s) by mouth once a day hydrochlorothiazide - (prescribed by other provider) - 25 mg tablet - 1 tablet(s) by mouth once a day sildenafil - (prescribed by other provider) - dosage uncertain valsartan - (prescribed by other provider) - 80 mg tablet - 1 tablet(s) by mouth once a day medications - otc aspirin - (prescribed by other provider) - 81 mg tablet, chewable - 1 tablet(s) by mouth once a day cholecalciferol (vitamin d3) - (prescribed by other provider) - dosage uncertain discharge medications: none discharge disposition: expired discharge diagnosis: cecal cancer with positive lymph node reversal of jejunoileal bypass liver cirrhosis secondary to jejunoileal bypass acute respiratory distress syndrome acute liver failure acute renal failure intraabdominal severe septic shock discharge condition: dead discharge instructions: na followup instructions: na Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Hemodialysis Closed (percutaneous) [needle] biopsy of liver Arterial catheterization Closed [endoscopic] biopsy of bronchus Open and other right hemicolectomy Reopening of recent laparotomy site Suture of laceration of small intestine, except duodenum Peritoneal lavage Revision of anastomosis of small intestine Diagnoses: Acidosis Hypocalcemia Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute and subacute necrosis of liver Acute kidney failure, unspecified Severe sepsis Perforation of intestine Percutaneous transluminal coronary angioplasty status Right bundle branch block Other specified septicemias Septic shock Old myocardial infarction Morbid obesity Paralytic ileus Cardiac pacemaker in situ Personal history of urinary calculi Malignant neoplasm of cecum Do not resuscitate status Acute vascular insufficiency of intestine Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Personal history of colonic polyps Bariatric surgery status Accidental cut, puncture, perforation or hemorrhage during surgical operation Hypoglycemia, unspecified Dietary surveillance and counseling Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery Other digestive system complications Body Mass Index 45.0-49.9, adult

allergies: tetracycline / vancomycin attending: chief complaint: pancreatic lesion bleed major surgical or invasive procedure: splenic artery pseudoaneurysm embolization picc line placement x 2 history of present illness: 54 year old woman with history of chronic multiple sclerosis, osteomyelitis, mrsa wounds/esbl urinary tract infections, diverting colectomy w/ colostomy, sacral decub (stage 4), depression, hyperlipidemia who presents with pancreatic hemorrhaging. the patient initially presented to with altered mental status on . she was diagnosed with possible wound infection and started on iv vancomycin, in discussions with infectious disease. there was also some concern for cdifficile infection and so the patient was initially on po vancomycin but all stool cultures this admission were negative. the patient was also briefly on meropenem for unclear reasons. . the patient had reported abdominal pain on admission and ct abdomen revealed pancreatitis although lipase was 47. gi was consulted and egd documented a large duodenal ulcer without bleeding. ct abdomen subsequently showed portal and splenic vein thrombosis. heme/onc was consulted and diagnosed the patient with protein c and s deficiency; these may have been spurious diagnoses in the setting of having already started the patient on coumadin (confounder). thus, heme/onc felt strongly about anticoagulation (dalteparin) although gi at the osh was concerned regarding hemorrhaging into the pancreas given recent pancreatitis. the patient continued to have abdominal pain and had a hemoglobin/hematocrit drop with associated bright red blood in ostomy. hematocrit at its very lowest was 23.6. on repeat ct abdomen yesterday, she was found to have an actively hemorrhaging pancreatic lesion and non-acute pancreatitis. the lesion was 10.5 x 2.2 cm. the surgical team was consulted but had not seen her prior to transfer. the patient had been treated since admission with iron for presumed iron deficiency anemia. the patient was initially to be transferred to medicine floor but acutely dropped her bps to sbp90s at the osh. she was transfused two units of blood (baseline hct 26) with lasix in between, prior to transfer to . . the patient was found to severely malnutritioned, with albumin 1.6. . urology was also consulted for recurrent urinary tract infections, neurogenic bladder and recommended bladder neck closure and suprapubic catheter when more medically stable. . vital signs prior to transfer: t99.3, bp98/68-120/63, hr 80 (sinus), rr13-17, 98% o2 sat on 2l nasal cannula. . on arrival in the micu, vs were t 97.0, bp102/78, hr 82, rr 16, 98% on 2l nasal cannula. the patient was resting uncomfortably in bed. . ros: patient resting comfortably in bed, states she feels very tired. endorses pain in right hip and lower back, otherwise no complaints. breathing feels okay. past medical history: * chronic multiple sclerosis (nursing home bound) * osteomyelitis * stage 4 sacral decubitus ulcer * prior mrsa wound infections * esbl e. coli urinary tract infections * diverting colectomy, colostomy * hyperlipidemia * malnutrition * depression * ?congestive heart failure * ovarian cysts * cervical cancer, ?ovarian cancer * bilateral knee replacements * osteoarthritis social history: lives at wood mill care and rehabilitation center, in , ma. was a bartender several years ago. t - ppd "for a long time" quit in 1/. a - social. d - cocaine quit couple years ago. currently denies illicits. has two sons who live in . . family history: no known family history of coagulopathy, sudden cardiac death, cancers, pancreatitis/gallstones. physical exam: admission exam: vs: temp: 97.8 bp:102/73 hr: 80 rr: 20 o2sat 100% on 2l nc gen: pleasant, comfortable, nad, chronically ill appearing, pale heent: perrl, eomi, anicteric, pale conjunctiva, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, no m/r/g abd: non-tender, non-distended but obese with multiple well-healed surgical incision sites, +bs, colostomy bag w/ pink granulation tissue ext: no cyanosis, ecchymosis, edema skin: no rashes/no jaundice/no splinters; reportedly has left gluteal ulcer near ischial tuberosity (4.5x4.4), deep sacral ulcer 6.3x10x4 with wound vac removed neuro: aaox3. cn ii-xii intact. 3/5 strength throughout. sensation grossly intact. discharge: vs: 98.9, bp: 118/74, p: 85, rr: 20, 98% on room gen: friendly, chronically ill appearing female in nad, hospital cv: rrr, no m/r/g pulm: ctab abd: bs+, soft, nt, nd, ostomy in place in r mid abdomen- filled with gas and stool ext: no edema, good pulses skin: left gluteal ulcer- 4x4 cm covered in eschar- seen under bandage, stage 4 deep sacral ulcer neuro: cn ii-xii intact. 3/5 strength throughout. sensation grossly intact. pertinent results: 09:46pm glucose-80 urea n-14 creat-0.2* sodium-137 potassium-3.4 chloride-100 total co2-29 anion gap-11 09:46pm estgfr-using this 09:46pm alt(sgpt)-75* ast(sgot)-76* ld(ldh)-265* alk phos-405* tot bili-0.7 09:46pm lipase-41 09:46pm albumin-2.3* calcium-8.4 phosphate-3.8 magnesium-2.0 09:46pm triglycer-188* 09:46pm wbc-12.4* rbc-3.54* hgb-10.2* hct-30.4* mcv-86 mch-28.7 mchc-33.5 rdw-18.4* 09:46pm neuts-68 bands-0 lymphs-23 monos-5 eos-4 basos-0 atyps-0 metas-0 myelos-0 09:46pm hypochrom-1+ anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-1+ spherocyt-1+ ovalocyt-1+ target-1+ schistocy-1+ 09:46pm plt smr-normal plt count-387 09:46pm pt-15.5* ptt-32.6 inr(pt)-1.4* . discharge: 06:40am blood wbc-10.6 rbc-3.32* hgb-9.7* hct-29.7* mcv-90 mch-29.1 mchc-32.5 rdw-17.1* plt ct-600* 06:40am blood glucose-107* urean-19 creat-0.3* na-136 k-4.0 cl-103 hco3-23 angap-14 05:33am blood alt-26 ast-21 ld(ldh)-200 alkphos-325* amylase-47 totbili-0.2 06:40am blood calcium-9.8 phos-5.4* mg-2.0 . cxr: left picc terminates in the region of the cavoatrial junction. this finding was discussed with dr. at 2:30 a.m. by telephone by dr. . size is normal. patchy bibasilar opacities are present, which could be due to atelectasis, aspiration, or infectious pneumonia. small right pleural effusion is also noted. . abdominal ultrasound with dopplers: 1. no evidence for recurrent flow within the thrombosed splenic artery pseudoaneurysm. 2. reversal of flow within the splenic vein, the significance of this finding is uncertain. the splenic parenchyma was not evaluated on this examination which was targeted to assessment of the pseudoaneurysm. . cta: 1. no pulmonary embolism or acute aortic pathology. bilateral small pleural effusions and bibasal atelectasis. lue picc ends in the lower svc. 2. thrombosis of the main and right portal vein, likely chronic thrombosis of the left portal vein. enhancement is not appreciated within the narrowed splenic vein, likely thrombosed. patent hepatic veins. minimal perisplenic fluid, but no evidence of splenic infarcts. 3. s/p thrombin injection into the splenic artery pseudoaneurysm, with a 6mm focus of arterial enhancement in the region, suggesting minimal recanalization /residual flow. 4. fat stranding surrounding the pancreatic tail/pseudoaneurysm, with small phlegmon and fluid collection adjacent to the pancreatic tail, s/o pancreatitis. s/p diverting rlq loop colostomy. brief hospital course: 54 year old woman with history of chronic multiple sclerosis, osteomyelitis, diverting colectomy/colostomy, stage 4 sacral decubitus ulcer, prior mrsa wound infections and esbl e.coli urinary tract infections, hypertension, hyperlipidemia who presents with peripancreatic hemorrhage from where she was admitted for altered mental status, pancreatitis, possible wound infection and transferred to on . # peripancreatic hemorrhage: pseudoaneurysm suggested on this patient's ct abdomen between a pseudocyst and the splenic vein. it is possible, given the recent bright red blood in her colostomy (although not currently) that there has been some bleeding into the pancreatic duct as well (hemosuccus pancreaticus). consulted ir for mesenteric angiography with embolization vs. coiling for pseudoaneurysm. on , interventional radiology attempted stenting across the aneurysm but was unable due to toruosity of the splenic vein. instead, using ultrasound guidance, thrombin was injected and the patient's hematocrits remained stable. the patient underwent repeat abdominal ultrasound with dopplers which showed stable pseudoaneurysm after ir intervention. the patient's hematocrit remained stable and did not require any blood transfusions while at . # portal vein and splenic vein thrombosis: complications of pancreatitis due to peri-pancreatic inflammation and can actually cause gastric varices with portal hypertension. if patient's protein c and s levels were drawn while on coumadin, they were likely inaccurate. pt will need weeks off therapy before she can re-evaluated for coagulopathies. anticoagulation was held as an inpatient as she remained asymptomatic and it was discussed with hepatology who recommended no anticoagulation in the near future. pt will need outpt hematologic workup for protein c and s deficiency in the future. # pancreatitis: possibly due to gallstones seen on ct and abdominal ultrasound. patient's lipase was not elevated at the osh but had radiological findings and abdominal pain. the patient's abdominal pain gradually resolved, initially as npo with ivf/tpn and then advanced a regular diet. pt will need ongoing monitoring of nutrition intake given her low albumin. # esbl urinary tract infections: evaluated by urology at osh and felt to have neurogenic bladder and would benefit from suprapubic catheter. urine culture repeated on admission showed vre although urinalysis was bland. the patient catheter was changed and repeat ua showed possible infection. of note, on exam during foley catheter change, the patient's urethra appeared enlarged/stretched. urology was consulted and on evaluation, felt that the patient's urethra had likely been gradually dilated given multiple sclerosis and leaking around catheter. each time she leaked, the patient's catheters were likely upsized, resulting in dilation. the patient will likely benefit from suprapubic catheter placement in the future. patient grew enterococcus on repeat urine culture with a rising leukocytosis. linezolid was not used due to concern for serotonin syndrome. daptomycin allergy was actually "warmth" and so patient carefully monitored and treated with daptomycin which she tolerated without difficulty. patient was started on daptomycin 350 mg iv q24 on and should continue until for a 14 day total course. # stage 4 sacral decubitus ulcer and lateral gluteal ulcer: stable, previously with wound vac. patient has a history of mrsa wound infections. wound care consulted and daily wound care received while in house. she was continued on zinc and vitamin c to help with wound healing. # multiple sclerosis: stable, patient lives at a rehab/nursing facility at baseline. the patient was resumed on her home baclofen and neurontin. # picc line infection: blood culture from left sided picc line grew gpcs in clusters in bottles. decision was made to pull picc line given likelihood of line infection. at the time of discharge, the picc tip cx was negative for growth at 48hrs but pt had been getting daily infusions of daptomycin through this line. a picc line was resited in right antecubital fossa, and chest ap portable film confirmed placement in the mid svc, and is ready to use upon discharge. # diverting colectomy, colostomy: unclear original reason for colostomy possibly to prevent infection of decub. continue to monitor ostomy which was guaiac positive in the micu. serial hematocrits remained stable. patient has known esophageal ulcer on osh egd. she was continued on oral ppi daily. she is scheduled to follow up with gi for egd biopsy results. # hyperlipidemia: stable, held gemfibrozil given pancreatitis. . # malnutrition: albumin significantly low at 1.6 at osh and 2.3 here. nutrition was consulted for for tpn. continue multivitamin, calcium, vitamin d. the patient is at risk for infection on tpn, given past history. nevertheless, she was started on tpn with simultaneous encouragement for po intake. tpn was stopped on . she is not a candidate for g tube placement at this time due to esophageal ulcer but should be re-evaluated in weeks. . # depression: stable, continue wellbutrin sr, zyprexa and lamictal. . # osteoarthritis: s/p bilateral total knee replacements, pt requested vicodin for pain management, which was increased to q4h prn. her morphine liquid solution was stopped. . #code status: dnr/dni daptomycin allergy: the report of daptomycin allergy was not confirmed. patient was monitored carefully while getting daptomycin and did not have any reactions. recommended follow-up: follow-up: -please make sure patient sees a gastroenterologist within 2 weeks after discharge for management of pancreatitis/pancreatic hemorrhage. we have arranged for follow-up for a gastroenenterologist at but feel free to cancel this appointment and make arrangements with a different gastroenterologist. - patient will need mrcp to look for signs of liver malignancy or infiltrative disease. - she should be reevaluated for g-tube placement in weeks. - she should have repeat contrast ct of the abdomen to evaluate for residual pancreatic pseudoaneurysm medications on admission: * baclofen 10mg three times dialy * benadryl 25mg daily prn * calcium-vitamin d 500mg twice daily * multivitamin daily * neurontin 300mg qhs * omeprazole 20mg daily * potassium 20meq daily * simethicone 160mg three times daily prn * natural tears gtt * trazodone 500mg qhs * tums 1000mg three times daily prn * tylenol 1000mg every four hours for pain * valium 5mg three times daily * vicodin 5-500mg twice daily * vitamin c 500mg twice daily * zinc sulfate 220mg daily * colace 100mg twice daily prn * wellbutrin sr 100mg twice daily * zyprexa 5mg qhs * morphine 20mg/5ml 8 mg sublinguially prn pain (q4 hours) * lamictal 100mg qhs * dalteparin 5000 units daily * zofran 4mg every 6 hours prn nausea * zoloft 50mg daily * ketoconazole 2% cream to buttocks daily * esenex 2% powder topical twice daily prn itch * calazime topical lotion daily to red groin areas * selenium sulfide 2.5% lotion to eyebrows, scalp prn seborrhea * immodium 2mg daily prn * lopid 600mg qhs . meds on transfer: asked to fax over discharge medications: 1. baclofen 10 mg tablet sig: one (1) tablet po tid (3 times a day). 2. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one (1) tablet po twice a day. 3. multivitamin tablet sig: one (1) tablet po once a day. 4. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. simethicone 80 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day) as needed for gas, abdominal pain. 7. natural tears (pf) 0.1-0.3 % dropperette sig: one (1) drop to both eyes ophthalmic once a day. 8. trazodone 50 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 9. tums 200 mg calcium (500 mg) tablet, chewable sig: two (2) tablet, chewable po three times a day as needed for heartburn. 10. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: do not exceed 4 gm acetaminophen in 24 hours . 11. vitamin c 500 mg tablet sig: one (1) tablet po twice a day. 12. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 13. daptomycin 500 mg recon soln sig: 350 mg intravenous every twenty-four(24) hours for 4 days: until . 14. senna 8.6 mg capsule sig: one (1) tablet po bid (2 times a day) as needed for constipation. 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 16. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). 17. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs (once a day (at bedtime)). 18. bupropion hcl 100 mg tablet extended release sig: one (1) tablet extended release po bid (2 times a day). 19. lamotrigine 100 mg tablet sig: one (1) tablet po at bedtime. 20. insulin lispro 100 unit/ml solution sig: one (1) injection subcutaneous asdir (as directed): see sliding scale . 21. 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. 22. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 23. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every six (6) hours as needed for nausea. 24. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 25. ketoconazole 2 % cream sig: one (1) appl topical daily (daily). 26. esenex sig: one (1) application twice a day as needed for itching: 2% topical powder. 27. calamine lotion sig: one (1) application topical once a day as needed for itching: to red groin areas. 28. selenium sulfide 2.5 % suspension sig: one (1) application topical once a day as needed for seborrhea: to eyebrows, scalp. 29. imodium a-d 2 mg tablet sig: one (1) tablet po once a day as needed for diarrhea, excessive stools . discharge disposition: extended care facility: colonial heights care and rehabilitation center - discharge diagnosis: primary diagnosis: pancreatitis splenic artery pseudoaneurysm hemorrhage portal and splenic vein thrombosis urinary tract infection malnutrition . secondary diagnoses: multiple sclerosis stage 4 sacral decubitus ulcer hypertension hyperlipidemia colostomy discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: dear ms. , you were transferred to the because you were having a large bleed from your pancreas. we had to perform a procedure to stop the bleeding. you also developed blood clots in some of the veins in your abdomen. you developed an urinary tract infection and we gave you medications to treat that. you had very poor nutritional status and so we gave you nutrition through your veins. . the following changes were made to your medications: added: - started daptomycin 350 mg iv every 24 hours until for 14 day course - started pantoprazole 40 mg by mouth daily - remeron (mirtazapine) 7.5 mg by mouth at night changed: - increased frequency of vicodin from twice a day to every 6 hours as needed for pain removed: - stopped omeprazole (added pantprazole instead) - stopped morphine liquid suspension (increased frequency of vicodin) - stopped gemfibrozil - stopped valium - stopped benadryl followup instructions: please make an appointment and follow-up with your primary care doctor within 3 days after discharge. . department: div. of gastroenterology when: wednesday at 1 pm with: , md building: ra (/ complex) campus: east best parking: main garage Procedure: Parenteral infusion of concentrated nutritional substances Injection or infusion of other therapeutic or prophylactic substance Arteriography of other intra-abdominal arteries Diagnoses: Urinary tract infection, site not specified Depressive disorder, not elsewhere classified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Pressure ulcer, buttock Pressure ulcer, lower back Pain in joint, pelvic region and thigh Primary hypercoagulable state Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Do not resuscitate status Multiple sclerosis Other and unspecified infection due to central venous catheter Knee joint replacement Acute pancreatitis Cyst and pseudocyst of pancreas Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria Pressure ulcer, stage IV Ulcer of esophagus without bleeding Nutritional marasmus Other diseases of spleen Portal vein thrombosis Attention to colostomy Personal history of Methicillin resistant Staphylococcus aureus Neurogenic bladder NOS Aneurysm of other visceral artery

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: exertional chest discomfort major surgical or invasive procedure: s/p cabg history of present illness: 75 year old male with multiple risk factors for cad who presented to his cardiologist with several episodes of exertional chest discomfort. he underwent a stress test that was positive for symptoms and ekg changes. cardiac catheterization showed 50% left main, 100% lad, 100% lcx, and 100% pls. he was started on iv nitroglycerin and heparin and transferred for surgical management. past medical history: diabetes diabetic neuropathy hypertension dyslipidemia claudication social history: retired. quit smoking 25 years ago. family history: non-contributory physical exam: admission: general: alert and oriented times 3 neck: supple with full range of motion chest: lungs clear to auscultation bilaterally cor: regular rate and rhythm with no murmurs, rubs, gallops appreciated abdomen: soft and nontender extremities: warm and well perfused with no edema discharge: vitals: 98.5 148/75 74 sinus 20 95% ra general: pleasant, answers questions appropriately chest: lungs clear to auscultation bilaterally. sternal incision dry and intact without erythema. sternum stable. cor: distant heart sounds, regular without murmurs, rubs, gallops appreciated abdomen: soft, nontender without rebound or guarding extremities: warm with 1+ edema to ankles bilaterally pertinent results: 09:50pm blood wbc-12.5* rbc-4.07* hgb-11.9* hct-34.9* mcv-86 mch-29.2 mchc-34.0 rdw-12.8 plt ct-258 07:35am blood wbc-9.8 rbc-3.03* hgb-9.0* hct-26.0* mcv-86 mch-29.7 mchc-34.6 rdw-13.2 plt ct-193 07:35am blood pt-13.9* inr(pt)-1.2* 09:50pm blood pt-12.7 ptt-21.8* inr(pt)-1.1 06:47am blood glucose-96 urean-16 creat-1.0 na-133 k-4.6 cl-98 hco3-27 angap-13 09:50pm blood glucose-260* urean-18 creat-1.1 na-129* k-4.9 cl-98 hco3-24 angap-12 09:50pm blood %hba1c-7.0* echocardiography report , (complete) done at 9:36:59 am final referring physician information , , status: inpatient dob: age (years): 75 m hgt (in): 69 bp (mm hg): 130/80 wgt (lb): 190 hr (bpm): 50 bsa (m2): 2.02 m2 indication: chest pain. coronary artery disease. left ventricular function. right ventricular function. valvular heart disease. icd-9 codes: 440.0, 413.9, 414.8, 424.0 test information date/time: at 09:36 interpret md: , md test type: tee (complete) son: , md doppler: full doppler and color doppler test location: anesthesia west or cardiac contrast: none tech quality: adequate tape #: 2008aw1-: machine: aw1 echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.9 cm <= 5.6 cm left ventricle - ejection fraction: 50% to 60% >= 55% left ventricle - stroke volume: 53 ml/beat left ventricle - cardiac output: 2.67 l/min left ventricle - cardiac index: *1.32 >= 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: 2.6 cm <= 3.0 cm aorta - ascending: 2.8 cm <= 3.4 cm aorta - descending thoracic: 2.0 cm <= 2.5 cm aortic valve - peak velocity: 1.6 m/sec <= 2.0 m/sec aortic valve - lvot pk vel: 0.70 m/sec aortic valve - lvot vti: 17 aortic valve - lvot diam: 2.0 cm mitral valve - mva (p t): 4.0 cm2 mitral valve - e wave: 0.8 m/sec mitral valve - a wave: 0.4 m/sec mitral valve - e/a ratio: 2.00 findings left atrium: normal la and ra cavity sizes. right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness, cavity size, and global systolic function (lvef>55%). mild regional lv systolic dysfunction. right ventricle: normal rv chamber size and free wall motion. aorta: normal diameter of aorta at the sinus, ascending and arch levels. simple atheroma in aortic arch. normal descending aorta diameter. complex (>4mm) atheroma in the descending thoracic aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: normal mitral valve leaflets with trivial mr. s. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. 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. no tee related complications. resting bradycardia for the patient. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions pre-bypass: the left atrium and right atrium are normal in cavity size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). there is mild regional left ventricular systolic dysfunction with probable hypokinesis of the basal inferior wall.. 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 simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. post-bypass: biventricular function is preserved. the aorta is intact. the remainder of the study is unchanged. dr. was notified in person of the results at the time of the examination. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 11:47 ?????? caregroup is. all rights reserved. brief hospital course: mr was admitted from an outside hospital for surgical management of his cad and was worked up in the usual pre-operative manner. he was taken to the operating room on with dr and underwent three-vessel coronary artery bypass grafting surgery. please see operative note for full details. post-operatively he was admitted to the cvicu for invasive hemodynamic monitoring. he was weaned from his drips and was extubated by post-op day 1. he was transferred to the step down floor on post-op day 1. physical therapy was consulted to work on strength and conditioning. he had an episode of atrial fibrillation on pod 2 and was started on amiodarone and coumadin. the rest of his course was uncomplicated and he was ready for discharge on pod 4. medications on admission: norvasc 5mg daily tizanidine 2 mg po bid neurontin 800 mg po bid acarbose 75 mg po daily glipizide 10 mg po daily lisinopril 20 mg po daily amitriptyline 25 mg po qhs atenolol 25 mg po daily zocor 40 mg po daily isosorbide 30 mg po daily asa 162 mg po 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, chewable sig: two (2) tablet, delayed release (e.c.) po daily (daily). 3. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). tablet(s) 5. gabapentin 400 mg capsule sig: two (2) capsule po bid (2 times a day). 6. tizanidine 2 mg tablet sig: one (1) tablet po bid (2 times a day). 7. glipizide 10 mg tablet sig: one (1) tablet po daily (daily). 8. acarbose 50 mg tablet sig: 0.5 tablet po tid (3 times a day). disp:*45 tablet(s)* refills:*0* 9. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 10. lisinopril 20 mg tablet sig: 1.5 tablets po daily (daily). disp:*45 tablet(s)* refills:*0* 11. amiodarone 200 mg tablet sig: two (2) tablet po twice a day for 3 weeks: take 2 pills twice daily for one week, then one pill twice daily for one week, then one pill once daily. disp:*84 tablet(s)* refills:*0* 12. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). disp:*30 capsule, sust. release 24 hr(s)* refills:*0* 13. furosemide 20 mg tablet sig: one (1) tablet po once a day for 7 days. disp:*7 tablet(s)* refills:*0* 14. metoprolol tartrate 100 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*0* 15. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily) for 7 days. disp:*7 tab sust.rel. particle/crystal(s)* refills:*0* 16. warfarin 1 mg tablet sig: as directed tablet po once a day: please take 7.5 mg , vna will check your blood monday . dr office will call with appropriate dose to take. disp:*100 tablet(s)* refills:*2* 17. warfarin 2.5 mg tablet sig: as directed tablet po once a day: please take 7.5 mg , vna will check your blood monday . dr office will call with appropriate dose to take. disp:*100 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: cad s/p cabg diabetes hypertension dyslipidemia claudication 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 followup instructions: dr. (in lieu of dr in 4 weeks () please call for appointment dr. in 2 week () please call for appointment dr. in weeks please call for appointment needs inr checked monday (), wednesday, friday with results to coumadin clinic at the heart center of (. md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Arterial catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atherosclerosis of native arteries of the extremities with intermittent claudication Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Other and unspecified hyperlipidemia Iatrogenic pneumothorax Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Examination of participant in clinical trial Personal history of malignant neoplasm of larynx

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: l carotid stenosis major surgical or invasive procedure: left carotid endarterectomy and dacron patch angioplasty carotid angioplasty and stenting history of present illness: this 77-year-old gentleman has been followed for some time with asymptomatic carotid stenosis and also intermittent claudication. his left carotid stenosis has progressed from the 70-80-99% range without associated symptoms. past medical history: htn, degenerative arthritis, hyperlipidemia social history: no etoh, no tobacco (quit 64') physical exam: gen: alert and oriented, patient comfortable, nad heent: atraumatic, normocephalic, eomi, sclera non-icteric, left carotid bruit cv: rrr, no murmurs, gallops, rubs s1s2+, no thrills/heaves resp: symmetric respiratory excursion, ctab, no wheezes/crackles/rubs abd: s/nt/nd; bs+ ext: no clubbing/cyanosis/edema, carotid pulses symmetric with good upstroke neuro: cnii-xii grossly intact pertinent results: 07:34pm hct-30.4*# 09:33am type-art rates-/9 tidal vol-660 o2-60 o2 flow-1.3 po2-188* pco2-36 ph-7.42 total co2-24 base xs-0 intubated-intubated vent-controlled 08:02am hgb-12.7* calchct-38 o2 sat-98 carboxyhb-1 met hgb-0 brief hospital course: pt admitted for elective l carotid endaretrectomy. while in pacu patient had episode of hypotension, bradycardia; atropine was administered, sbp120's, pt was noted to be aphasic with motor deficit of rue/rle. an emergent duplex was performed but technically difficult due to dacron patch. heparin was started and pt taken for stat ct angio which demonstrated a 1cm filling defect at or distal to anastomosis. returned to or emergently for exploration; dissection of the distal l ica was noted, re-patch angioplasty, angiogram w/stent placement were performed. pt was admitted to the icu. plavix, asa were started, nitroglycerin drip was used to control bp, iv morphine for pain, insulin drip for tight blood sugar control. no persistant neurologic deficits were noted. pt transfered to vicu on pod1, diet advanced, jp drain was d/c'd. patient was discharged on pod#2. 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. no persistent neurologic deficits were noted. instructions were given regarding f/u, care of surgical site, and contact information for any questions or concerns that should arise. medications on admission: amlodipine-benazepril 10 mg-20 mg capsule qd, lipitor 80 mg qd, plavix 75mg qd (stopped ) asa 81, atenolol 25' discharge medications: 1. lotrel 10-20 mg capsule sig: one (1) capsule po once a day. 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). 6. percocet 5-325 mg tablet sig: one (1) tablet po every hours as needed for pain for 30 doses. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: asymptomatic left carotid artery stenosis left internal artery carotid dissection discharge condition: stable discharge instructions: medications: ?????? take aspirin 325mg (enteric coated) once daily ?????? take plavix (clopidogrel) 75mg once daily ?????? 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: 1. surgical incision: ?????? it is normal to have some swelling and feel a firm ridge along the incision ?????? your incision may be slightly red and raised, it may feel irritated from the staples 2. you may have a sore throat and/or mild hoarseness ?????? try warm tea, throat lozenges or cool/cold beverages 3. you may have a mild headache, especially on the side of your surgery ?????? try ibuprofen, acetaminophen, or your discharge pain medication ?????? if headache worsens, is associated with visual changes or lasts longer than 2 hours- call surgeon??????s office 4. it is normal to feel tired, this will last for 4-6 weeks ?????? you should get up out of bed every day and gradually increase your activity each day ?????? you may walk and you may go up and down stairs ?????? increase your activities as you can tolerate- do not do too much right away! 5. it is normal to have a decreased appetite, your appetite will return with time ?????? you will probably lose your taste for food and lose some weight ?????? 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: ?????? no driving until post-op visit and you are no longer taking pain medications ?????? no excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? you may shower (no direct spray on incision, let the soapy water run over 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 over the area that is draining, as needed ?????? take all the medications you were taking before surgery, unless otherwise directed ?????? take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? 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 ?????? you should not have an mri scan within the first 4 weeks after carotid stenting ?????? call and schedule an appointment to be seen in 2 weeks for staple/suture removal what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? trouble swallowing, breathing, or talking ?????? temperature greater than 101.5f for 24 hours ?????? bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions ?????? numbness, coldness or pain in lower extremities ?????? bleeding from groin puncture site followup instructions: provider: () lmob (nhb) phone: date/time: 3:30 provider: , md phone: date/time: 4:00 Procedure: Arteriography of cerebral arteries Endarterectomy, other vessels of head and neck Endarterectomy, other vessels of head and neck Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Procedure on single vessel Procedure on vessel bifurcation Diagnoses: Other iatrogenic hypotension Unspecified essential hypertension Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Other specified cardiac dysrhythmias Dissection of carotid artery Osteoarthrosis, unspecified whether generalized or localized, site unspecified Aphasia Other musculoskeletal symptoms referable to limbs

allergies: ampicillin / ciprofloxacin attending: chief complaint: fever, chills, right sided flank pain major surgical or invasive procedure: none history of present illness: 45 y/o lady with recent history or 5.5 mm right mid ureteral stone w/ hydronephrosis and underwent cystoscopy and stent placement at osh on . during the procedure she was noted to have pyohydronephrosis. following procedure patient developed sepsis requiring icu admission. cultures were positive for e.coli. patient was discharged on in stable conditions with oral bactrim. she also had herpes vaginal eruption and was treated with 3 days of oral antiviral agents. at office follow up on pt complained of luts and was found to have 1700 ml residual in her bladder an indwelling foley was placed which subsequently fell out (?). she came to ed with abdominal pain and urinary retention on . her foley was replaced and drained 1000 mls following placement. labs showed a normal cr and wbc, ua pertinent for wbc, she was started on iv levaquin. she was continued on urecholin and flomax. she was discharged with oral bactrim. patient called her pcp yesterday with bilateral lower extremity calf pain/cramp and itching/rash. ble us was negative for dvt. her pain and rash resolved but overnight she started to develop fever and chills to 103.8 at home. she went to osh ed. she was diagnosed with suspected urosepsis and was transfered here per family request. . in the ed, initial vs were: t102 p112 bp94/54 r20 o2 sat100% ra. patient was given 1 gram of vancomycin and 1 gram of rocephin prior to transfer to . she also recieved 25 mg of iv benadryl prior to transfer. she recieved 2l ns in ed on top of ? 2 to 3 l of ns she recieved pta. central line was placed in ed. she was started on levophed. . on arrival to the icu, her vitals were, t:101 bp:114/99 p:102 r:19 o2: 100% on 4lnc. patient still has fevers and chills. mild diffuse abdominal discomfort. mild diffuse headache. she denies any neck stiffness, photophobia/phonophobia, change in vision/hearing, focal weakness, numbness, chest pain, shortness of breath, nausea, vomitting, diarrhea. no other complaints. past medical history: nephrolithiasis 5.5mm r s/p ureteral stent -complicated by urosepsis as above urinary retention as complication of above uterine fibroids s/p d&c c section x2 vagianal hsv social history: lives at home with boyfriend . she denies tobacco or street drugs. drinks per week. two children. . family history: mother and sister with kidney stones physical exam: vitals: tm 101.4 at 4am 98.5 70-80s 18 110-130/80s 98%ra pain: denies access: piv gen: nad heent: mm dry cv: rrr, sm resp: ctab, no crackles or wheezing abd; soft, nontender, no cvat, +bs ext; no edema neuro: a&ox3, nonfocal skin: no rash psych: appropriate . on discharge vitals: t 97.4 120/80 76 16 98%ra pain: denies access: piv gen: nad heent: mmm cv: rrr, sm resp: ctab, no crackles or wheezing abd; soft, nontender, no cvat, +bs ext; no edema neuro: a&ox3, nonfocal skin: no rash psych: tearful . pertinent results: wbc 6.7 93%n --> 3.3 66%n-->4.7 (wbc 9.4 with 13%bands osh on ) hgb 9-10s (was 10s recently at osh) mcv 79 plt 190 . inr 1.3 . chem panel: bun 8/0.6 (creat 1.0 on admission) k 4.6 mag 1.6 . lactate 1.8->0.8 . fe 13, tibc 200, ferritin 180 . ua here negative, ucx neg ua at osh +le, wbc, 1+ bacteria, cx pending . . blood cx x2 ntd blood cx x1 ntd . osh ucx on with ecoli osh ucx ntd (confirmed on ) osh blood cx x2 ntd (confirmed on ) . . imaging/results: ctu : impression: 1. appropriate position and function of the right ureteral stent. no evidence for obstruction. 2. abnormality in the right lower pole as described above is likely a sequela from prior percutaneous nephrostomy tube placement. please correlate with patient's history. there is no evidence for a renal abscess. 3. 4-mm stone in the distal ureter. 4. 2.1 cm mass in the endometrial cavity. this may represent a submucosal fibroid; however, differential diagnosis includes endometrial polyp or carcinoma. further evaluation with ultrasound is recommended. 5. findings consistent with hematocolpos. please correlate with menstrual status. . brief hospital course: briefly, 45year old female who is otherwise healthy was found to have obstructing kidney stone in , which was then complicated by uti and hydro requiring cystoscopy with stent placement , found pus, developed florid urosepsis (wbc 40, bandemia), ucx ecoli, rx iv abx in icu then d/c'd with bactrim, completed course. saw gu on , found to have urinary retention, foley placed, fell out at some point. seen again at osh er with new fever/abd pain, had urinary retention, mildly dirty ua, got iv levaquin x3days, then d/c on bactrim and foley. cultures negative at that time but pt did have bandemia. then on , had pain and le cramps, called pcp, neg, went to er because of low fevers, but d/c home. that night, developed fever 103.8, back to er, hypotensive, mildly dirty ua, got vanc/rocephin, transfered to for urosepsis, got 2l osh, 2l here, and levophed started in er and rij placed and t/f to icu. started vanc/meropenem. 2l more ivf given (total 6-7l) and pressors weaned off midday, then hds. last temp 101.4 on am, afebrile since. all cx ntd. vanc d/c'd on . kept on meropenem. ct nothing acute, stent in place, no perinephric abcess, etc. other infectious w/u with cxr, blood cx, flu, echo negative. pt transfered out of icu on . on transfer to floor, low grade temps, afebrile by next day. tolerated po and walking around. was emotional given her protracted illness. osh cultures from ucx and blood cx all negative. given her improvement with meropeneum and presumed failure with bactrim and allergy to fluroquinolones and pcn, decision made to complete 14days with ertapenum (day on discharge). picc placed prior to d/c. vna set up for teaching and monitoring and safety labs. discussed plan with patient and her current pcp (who is ob/gyne) dr who will follow up on labs. he will refer her to a pcp since her medical problems are a bit more complex than previous. she was also interested in f/u here with urology. appt made for with dr. . this will be after completion of her abx and the hope is that she can have more definitive treatment by removal of the stone and stent at that time. she also has had recent issues with urinary retention, likely complication of her illness and narcotics. she is told not to have any decath trials until her stone/stent issue has resolved given high risk for repeat infeciton in case of retention. thereafter she can have decath trials per gu or further w/u if fails. rest of her plan is outlined below. . . below is progress note from day of discharge: . 45year old female with complicated recent urological history with obstsructing stone s/p stent complicated by urosepsis, then urinary retention and recurrent transfered from osh with fevers/hypotension, presumed urosepsis. t/f out of icu on . . . sepsis, presumed urosepsis: ua mildly dirty (had been on bactrim) but has stent in place and stone which may be nidus, all in setting of urinary retention and foley. -continue meropenem for now, day -->will give a dose of ertepenum before d/c to make sure tolerates. plan is for 14day course. picc to be placed today (afebrile since am, cultures neg) and safety labs in one week -f/u osh urine cx from and blood cx are ntd -discussed with urology, made appt with dr. at 8am(once abx course completed), for removal of stone/stent for more definitive treatment -foley in place as below -reviewed lower pole findings with urology/radiology as pt did not have pcn-they are not concerned . . fever: as above, presumed urinary source. cxr neg. flu neg. no diarrhea. no other localizing complaints. possible related to bactrim but wouldnt have expected sepsis picture with drug fever. s/p vanc and , stopped. -plan is for two weeks ertapenem . . urinary retention: unclear cause but definately contributing to recurrent utis. may be due to narcotics patient was rx during 1st hospitalization in -keep foley in for now, will need close follow up with gu here for further management -flomax 0.4 . . leukopenia: from review of osh records, it appears pt mounted a white count as high as 40 when septic. recently she has been more leukopenic. suspect due to bactrim. -follow as outpt. will need safety labs on abx. . . constipation: no bm xseveral days, then had one on -add senna and dulcolax -abdominal exam benign . . anemia: microcytic, likely fe deficient based on fe studies. hgb currently , recently baseline was 10s from osh. likely has acute illness/acd component. no obvious bleeding or hemolysis. stable. -start fe supp with colace on discharge -needs outpt further w/u . . nephrolithiasis: complicated history as above. recurrent urosepsis. has 4mm stone and stent in place. -discussed with urology, appointment as above for definitive treatment . dispo/code: full code. will try to get picc today and arrange for home abx and teaching. f/u wtih dr. . pt to f/u with pcp in one week for labs. communication: patient. contact: boyfriend, , hcp is sister . medications on admission: tamsulosin-started bactrim-for uti percocet discharge medications: 1. ertapenem 1 gram recon soln sig: one (1) recon soln injection now () for 10 days. disp:*qs recon soln(s)* refills:*0* 2. picc line care per picc line care per home care. to be removed after antibiotics (approx 10days). 3. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for nasal dryness. 4. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). disp:*qs capsule, sust. release 24 hr(s)* refills:*0* 5. colace 100 mg capsule sig: one (1) capsule po twice a day. 6. ferrous sulfate 325 mg (65 mg iron) capsule, sustained release sig: one (1) capsule, sustained release po once a day. disp:*qs capsule, sustained release(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: urosepsis nephrolithiasis s/p stent and 4mm stone anemia, iron def discharge condition: stable discharge instructions: you were admitted for another infection of your urinary tract. you keep having these infections likely because of an infected stone. you were treated wtih a strong antibiotic with improvement (meropenem) and you will go home on a similar antibiotic (ertepenum) for 10more days (14days total). you have an appointment with dr. this on where he will discuss removal of the stone and stent to prevent further infections. you will have blood draw in one week while you are on the antibiotic. please make sure the results are forwarded to dr. and call him the next day to discuss please keep the foley catheter in until urology says it is okay to remove. your urinary retention may take some time to resolve. you are also started on iron supplements and stool softeners. your anemia shows that you are iron deficient. this may be due to your periods if they are heavy. however, if your periods are not heavy then you should ask your primary care doctor workup on other causes of anemia if your levels remain low. followup instructions: provider: , md phone: date/time: 8:00 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Urinary tract infection, site not specified Sepsis Constipation, unspecified Retention of urine, unspecified Iron deficiency anemia, unspecified Septicemia due to escherichia coli [E. coli] Calculus of kidney Leukocytopenia, unspecified Leiomyoma of uterus, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: pacer infection major surgical or invasive procedure: removal of icd generator removal of biventricular leads history of present illness: 51 y.o. with familial non ischemic cardiomyopathy , htn, af, with heart block s/p biv pacer with gen change on . by reports fromt he osh, his ef was initially 35% which improved to normal following biv. sent home with keflex post gen change. apparently the patient developed some loose stools and stopped takign the keflex. . presented back to ri on with fever, rigors, hypokalemia, creat of 1.8, and pacer pocket draining small amt of serous/sang from medial aspect of incision. . a tee was reportedly neg for veg. on evenign prior to transfer patient developed a fever to 102 and rigors. hr to 150 with telemetry showign widecomplex tachycardia. out of concern for vt he was lidocaine 100mg x2, amiodarone 300mg x2 and received a 125j dccv with premedication with versed with no effect. then they evaluated an old ekg which showed preexisting lbbb. his rhythm was then classified as svt with abberency. they gave him 6mg adenosine followed by another 12mg with no effect. they then gave him 5 mg lopressor which slowed the rhythm to 120's. he was started on vanc and zosyn. blood cultures from admission grew out gnrs in 2 out of 2 bottles and wound culture from his pacer site grew out gnr as well. . patient was also noted to have thrombocytopenia with platelets of 100 on admission trending down to 61 by hd #3. he received no heparin products while at the osh on this admission. prior heparin my have been given several weeks ago during his generator change. he also had reported anemia with hct down trending from 38.2 to 32.1 to 30.6. work up was notable for normal retic count, elevated ldh, elevated haptoglobin, negative direct coombs, elevated d-dimer, elevated fibrinogen adn normal coag panel. at time of transfer he was reportedly feeling well and hd stable. . on arrival to the icu he was febrile to 103 and rigoring with hr in the 150-180. he had two tenuous pivs. he became acutely delirious with severe agitation and combativness and refused placement of peripheral ivs. his hr remained elevated and was wide complex and regular/irregular with intermittent pacing consistent with svt with abberency. he was hd stable. patient was given 5mg iv lopressor x1 with correction of his hr to 160's, also received 1g iv tylenol through one remaining peripheral and 0.5mg of iv ativan. with the assistance of the cvic intensivist a 16 guage piv was placed in his left forearm and he was bolues 1l lr. his hr and mental status normalized significantly. he was given 1g iv vancomycin and 500mg meropenam iv. the ep fellow was contancted to discuss the possibility of emergency explantation for source control. given his improved clinical status and hd stability the explantation was scheduled for first thing in the morning. . central access was discussed with the patient but he adamently refused. we were able to obtain excellent peripheral access and clinical stabilization and improvement so no further access is being sought at this time. past medical history: 1. cardiac risk factors: hypertension 2. cardiac history: - pacing/icd: biv icd 3. other past medical history: - a fib - famililal cm social history: - tobacco history: unknown - etoh: yes occasionally - illicit drugs: marijunan occasionally family history: - no family history of early mi, arrhythmia, or sudden cardiac death; otherwise non-contributory. physical exam: on admission vs: 115 93% on 2l nc 121/64 general: middle agend gentleman diaphoretic with marked agitation and waxing and mental status. heent: ncat. dry mucous membranes. sclera anicteric neck: supple, difficult to assess jvp cardiac: tachycardic, irregular rate and rhythm lungs: cta bl abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: warm with 3+ pulses at all extremities skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: intermittent orientation with waxing and mental status. during brief periods of clarity he had no focal neurologic defects. his mental status complicated a through neurologic exam. on discharge: afebrile, bp 90-110s/70s, hr 90s-100s, tachycardic when ambulating, saturations >93% ra exam as above except for: mental status was cleared. alert and oriented x3, cn 2-12 intact, muscle tone normal, strength 5/5 in bilateral deltoids, biceps, triceps, and hand grip, 4/5 strength in bilateral hip flexors, in knee extension, plantar and dorsiflexion. sensation intact to light touch in bilateral c5-t1 and l4-s1. pertinent results: admission labs: 11:06pm blood wbc-6.4 rbc-3.46* hgb-11.3* hct-33.4* mcv-97 mch-32.7* mchc-33.9 rdw-13.0 plt ct-76* 11:06pm blood neuts-85.6* lymphs-10.7* monos-3.2 eos-0.2 baso-0.4 11:06pm blood pt-11.1 ptt-25.1 inr(pt)-1.0 11:06pm blood fibrino-642* 11:06pm blood glucose-105* urean-11 creat-1.1 na-138 k-3.2* cl-107 hco3-19* angap-15 11:06pm blood alt-57* ast-145* ld(ldh)-338* alkphos-105 totbili-0.7 11:06pm blood calcium-7.5* phos-0.4* mg-1.6 11:18pm blood lactate-2.4* urine: 11:32pm urine color-yellow appear-clear sp -1.012 11:32pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-40 bilirub-neg urobiln-neg ph-6.0 leuks-neg 11:32pm urine rbc-4* wbc-1 bacteri-none yeast-none epi-0 micro: enterobacter cloacae complex (amoxicillin r, cefazolin r, cefepime <=1 s, ceftriaxone <=1 s, ciprofloxacin <=0.25 s, gentamicin <=1, levofloxacin <=0.12 s, meropenem <=0.25 s, piperacillin-tazobactam 2 s, bactrim <=20 s pertinent reports: cxr: biventricular pacemaker is demonstrated with the leads terminating in right atrium, right ventricle and epicardial location of the left ventricle. no definitive interruption of the pacemaker leads is demonstrated, but proximal lead to the pacemaker battery, there is questionable irregularity in the defibrillator lead that should be further assessed with dedicated radiographs and lateral views as well. heart size and mediastinum are unremarkable. lungs are essentially clear except for minimal bibasilar atelectasis. mild degree of volume overload cannot be excluded. no appreciable pneumothorax is seen. echo: left ventricle - ejection fraction: 45% to 50% >= 55% findings left atrium: no spontaneous echo contrast in the body of the laa. good (>20 cm/s) laa ejection velocity. right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: normal lv wall thickness. normal lv cavity size. normal regional lv systolic function. mildly depressed lvef. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal aortic arch diameter. normal descending aorta diameter. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. moderate (2+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: physiologic (normal) pr. pericardium: no pericardial effusion. general comments: written informed consent was obtained from the patient. 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 tee performed for icd lead extraction. no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is mildly depressed (lvef= 45-50 %). 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 mildly thickened. moderate (2+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results at time of procedure. post lead extraction: no pericardial effusion is seen. tricuspid regurgitation is unchanged. cxr: as compared to the previous radiograph, there is no relevant change. status post lead extraction. no evidence of pneumothorax. borderline size of the cardiac silhouette. mild enlargement of the left ventricle. no pleural effusion. no parenchymal opacities brief hospital course: principle reason for admission mr. is a 51 year old male with history of non-ischemic cardiomyopathy status post biventricular pacemaker/icd (biv icd) and normalization of ejection fraction with recent generator change complicated by pocket infection with enterobacter bacteremia. he was transferred from osh for sepsis management as well as explantation of generator. active problems # icd pocket infection: patient presented to hospital on with pacer pocket infection. he was started on vancomycin and piperacillin/tazobactam and transferred to on for further management. on transfer, patient met sirs criteria (hr, fever, rr) with altered mental status. his ef was documented as normal by osh so received liberal fluid resuscitation. antibiotics were changed to vancomycin and meropenem on transfer. cultures from osh grew enterobacter and his antibiotics were narrowed to meropenem 500 mg q6h. infectious disease recommendations were for 4 week course of antibiotics from time of lead extraction on because this patient had bacteremia documented on and , ongoing fevers, and leukocytosis. because he was self-pay and unable to afford iv abntibiotics for the full course, he insisted on being switched to po antibiotics. the enterobacter was sensitive to ciprofloxacin so he was discharged to home with a script for ciprofloxacin 750mg po q12h for a 4 week course from . he should follow-up with infectious disease as well as his doctors in . # thrombocytopenia: there was concern at the outside hospital for hit and dic. however his pretest probability of hit was low given 4t score of 1 point for degree of thrombocytopenia. also dic unlikely given elevated fibrinogen, no evidence of hemolysis, and normal coags. no fever or evidence of hemolysis to raise concern for ttp/hus and his mental status resolved with control of fevers. likely his thrombocytopenia was secondary to sepsis. platelets trended from 76 on admission to 350 on discharge. # delirium: patient presented to with marked delirium in setting of fever and tachycardia. his agitation improved with control of fever. # dilated cardiomyopathy: patient with history of dilated non-ischemic cardiomyopathy. his metoprolol was changed to long acting metoprolol succinate 100 mg daily, and he was started on lisinopril 5 mg daily for heart failure. he was not started on aspirin or statin because his failure is non-ischemic. currently, he is not in biventricular synchrony because his biv pacer has been removed due to infection above. he will be expected to have worse ef now. he should be evaluated for placement of a new biv-icd when his infection has cleared. he did not have any symptoms of heart failure during this admission. # paroxsymal atrial fibrillation (paf): he had intermittent afib, which never persisted. he had no symptoms. his chads2 score was only 1 so he did not need anticoagulation. he could be considered for aspirin daily as an outpatient. transitional issues: - he should be evaluated for placement of a new biv-icd when his infection has cleared. - a standing order for labwork including cbc w/diff, bmp, and lfts qweek should be given to the patient so that he can have labwork done locally and then faxed to infectious disease at . - continue ciprofloxacin 750mg po q12h for a 4 week course from - he should be monitored for symptoms of heart failure and his medications should be adjusted as needed for fluid management until a biv-icd can be reimplanted. medications on admission: metoprolol tartate 50 mg omeprazole 20mg ecqd discharge medications: 1. outpatient lab work check cac with diff, chem-7, lft's every week starting . please fax results to infectious disease office at md 2. acetaminophen 650 mg po q6h:prn pain or fever 3. metoprolol succinate xl 100 mg po daily rx *metoprolol succinate 100 mg daily disp #*30 tablet refills:*2 4. omeprazole 20 mg po daily 5. lisinopril 5 mg po daily hold for sbp<100 rx *lisinopril 5 mg daily disp #*30 tablet refills:*2 6. ciprofloxacin hcl 750 mg po q12h duration: 4 weeks rx *ciprofloxacin 750 mg twice a day disp #*56 tablet refills:*0 discharge disposition: home discharge diagnosis: primary diagnosis icd pocket infection non-ischemic chronic systolic heart failure--ef 35% without biv pacer discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were admitted to the hospital because you were having fevers and your biventricular pacemaker/icd was infected. you had the device removed and you were treated with antibiotics which helped to make your fevers and infection clear. you were started on some heart failure medications. right now, your heart will not have the biventricular pacing which was helping it pump more effectively, you will need to have another device placed once you clear the infection. the following changes were made to your medications: - change your metoprolol to the long-acting formulation. you will now be taking metoprolol succinate 100 mg once a day for heart failure - start taking lisinopril 5 mg daily for heart failure - start ciprofloxacin twice daily until . . you will need to have labs checked every week. a prescription was given to you that you can bring to any lab and have the results faxed to the infectious disease doctor here at . you should keep all of the follow-up appointment listed below. you can postpone the appt with dr. if you wish. bring your medications to each appointment so your doctors update their records and adjust the doses as needed. it was a pleasure taking care of you in the hospital! followup instructions: department: infectious disease when: at 9:00 am with: , md building: lm campus: west best parking: garage department: infectious disease when: thursday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage pcp : , at 11am . with: ,md location: medical associates address: one st, , phone: department: cardiac services when: tuesday at 3:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage Procedure: Removal of lead(s) [electrode] without replacement Revision or relocation of cardiac device pocket Diagnoses: Other primary cardiomyopathies Thrombocytopenia, unspecified Esophageal reflux Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Sepsis Other specified septicemias Chronic systolic heart failure Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Lumbago Other alteration of consciousness Orthostatic hypotension Infection and inflammatory reaction due to cardiac device, implant, and graft

allergies: amiodarone / percocet / vicodin / gluten attending: chief complaint: fatigue major surgical or invasive procedure: 1.) thoracentesis 2.) percutaneous transhepatic biliary drainage history of present illness: hpi: mr. is a 69m w/ hx of metastatic prostate cancer, recently discharged from this service, who had a recent prolonged hospitalization for biliary obstruction, s/p biliary drain placement, who presented yesterday to an osh due to feeling tired. he was also found to be leaking from his biliary catheter. pt has no complaints, denies cp, abd pain, sob. received one unit of blood upon transfer. the patient has a chronic wet cough. please refer to discharge summary. ed course (labs, imaging, interventions, consults): - vitals upon transfer: 98.2 p 84 rr 20 sa 02 96% bp 133/64 - ekg: atrial fibrillation, normal axis, inverted t waves v1-v3 (v2-v3 which are new). rbbb osh labs: wbc 13.3 hgb 7.8 hct 23.8 na 131 k 3.7 cl 99 hco3 24 bun 9 cr 0.7 total bili 12.9 ast 38 alt 27 alk phos 247 alb 1.6 cxr (): large right effusion with associated atelectasis. superinfection cannot be excluded. left upper lobe peri-hilar opacity could represent pneumonia. past medical history: past oncologic history: : upper gi bleeding and painless obstructive jaundice egd: mucin producing adenocarcinoma in situ of the duodenal ampulla pancreaticoduodenectomy, partial pancreatectomy. pathology: ductal adenocarcinoma, moderately differentiated (g2) staging:t3n1mx (pt3: extends beyond pancreas-without involvement of vessels, pn1: regional lymph node metastasis, mx: distant metastasis cannot be determined) started on gemcitabine which was changed to flox due to disease progression based on ca19-9 and ct findings. : ventral hernia repair with hernia sac involved with pancreatic adenocarcinoma. : start on irinotecan due to disease progression : start on taxol past medical history: umbilical herniorrhaphy rt ear squamous cell carcinoma, htn gout osteoarthritis chronic lower extremity edema prostate ca s/p radiation erectile dysfunction urinary incontinence a.fib celiac disease borderline type 2 diabetes social history: denies smoking, endorses drinking 3 drinks per day, no other drug use. family history: father hx. of prostate ca at age physical exam: admission exam: general: alert, icteric and jaundiced, oriented, appears fatgued, but no acute distress heent: sclera icteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp difficult to appreciate, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: crackles at bases, moreso on right abdomen: obese, distended, ?fluid wave present, no tenderness to palpation, no rebound or guarding. ext: + edema b/l le to thighs neuro: cnii-xii intact, moving all extremities equially, grossly normal sensation. discharge exam: vitals deferred given cmo status general: alert, icteric and jaundiced, oriented, appears fatgued, but no acute distress. heent: sclera icteric, mmm, oropharynx clear, eomi, perrl. neck: supple, jvp difficult to appreciate, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: crackles at bases, moreso on right abdomen: obese, distended, no tenderness to palpation, no rebound or guarding. ext: + edema b/l le to thighs neuro: cnii-xii intact, moving all extremities equially, grossly normal sensation. pertinent results: pertinent labs: 03:52am blood wbc-14.0* rbc-2.94* hgb-8.8* hct-27.8* mcv-95 mch-30.0 mchc-31.8 rdw-24.3* plt ct-170 03:52am blood neuts-85.8* lymphs-7.4* monos-5.4 eos-1.3 baso-0.1 03:52am blood pt-14.4* ptt-33.1 inr(pt)-1.3* 03:52am blood glucose-108* urean-11 creat-0.7 na-130* k-5.8* cl-100 hco3-24 angap-12 06:20am blood wbc-8.6 rbc-2.52* hgb-7.6* hct-24.1* mcv-96 mch-30.2 mchc-31.6 rdw-23.6* plt ct-137* 05:43am blood wbc-15.3* rbc-2.72* hgb-8.2* hct-25.9* mcv-95 mch-30.2 mchc-31.7 rdw-23.6* plt ct-175 04:17am blood wbc-10.2 rbc-2.60* hgb-7.8* hct-24.7* mcv-95 mch-30.1 mchc-31.7 rdw-23.8* plt ct-121* 11:08am blood wbc-10.4 rbc-2.54* hgb-7.7* hct-23.8* mcv-97 mch-30.3 mchc-31.3 rdw-23.9* plt ct-152 06:00am blood wbc-10.3 rbc-2.61* hgb-7.9* hct-24.9* mcv-96 mch-30.2 mchc-31.7 rdw-24.0* plt ct-159 05:57am blood wbc-9.3 rbc-2.77* hgb-8.1* hct-26.3* mcv-95 mch-29.1 mchc-30.7* rdw-23.8* plt ct-172 06:01am blood wbc-8.6 rbc-2.36* hgb-7.2* hct-22.2* mcv-94 mch-30.4 mchc-32.2 rdw-24.5* plt ct-166 12:25pm blood wbc-9.9 rbc-2.53* hgb-7.6* hct-23.6* mcv-94 mch-30.0 mchc-32.1 rdw-24.4* plt ct-158 06:43am blood wbc-10.0 rbc-2.38* hgb-7.3* hct-22.2* mcv-94 mch-30.5 mchc-32.7 rdw-24.8* plt ct-157 04:17am blood neuts-89.3* lymphs-6.0* monos-3.5 eos-1.2 baso-0 11:08am blood neuts-90.3* lymphs-5.6* monos-3.3 eos-0.7 baso-0.1 06:01am blood neuts-85.7* lymphs-7.0* monos-4.3 eos-2.8 baso-0.1 11:08am blood hypochr-2+ anisocy-3+ poiklo-1+ macrocy-2+ microcy-normal polychr-normal target-occasional schisto-occasional burr-occasional 06:20am blood plt ct-137* 06:20am blood pt-12.0 ptt-66.5* inr(pt)-1.1 05:43am blood plt ct-175 05:43am blood pt-13.1* ptt-42.0* inr(pt)-1.2* 04:17am blood plt ct-121* 04:17am blood pt-29.9* ptt-54.3* inr(pt)-2.9* 11:08am blood plt ct-152 11:08am blood pt-24.1* ptt-43.7* inr(pt)-2.3* 06:00am blood plt ct-159 06:00am blood pt-21.6* ptt-43.0* inr(pt)-2.1* 05:57am blood plt ct-172 05:57am blood pt-15.8* ptt-35.9 inr(pt)-1.5* 06:01am blood plt ct-166 06:01am blood pt-17.2* ptt-37.3* inr(pt)-1.6* 12:25pm blood plt ct-158 06:43am blood plt ct-157 11:08am blood fdp-10-40* 11:08am blood fibrino-250 06:20am blood glucose-106* urean-41* creat-3.8* na-131* k-4.2 cl-99 hco3-20* angap-16 05:43am blood glucose-142* urean-37* creat-3.2* na-133 k-4.1 cl-100 hco3-20* angap-17 04:17am blood glucose-104* urean-29* creat-2.5* na-135 k-4.0 cl-104 hco3-21* angap-14 11:08am blood glucose-109* urean-25* creat-2.0* na-135 k-3.9 cl-103 hco3-22 angap-14 06:00am blood glucose-105* urean-25* creat-1.9* na-133 k-4.0 cl-100 hco3-25 angap-12 05:57am blood glucose-141* urean-16 creat-0.9 na-135 k-3.3 cl-101 hco3-23 angap-14 06:01am blood glucose-95 urean-14 creat-0.7 na-133 k-3.4 cl-102 hco3-24 angap-10 06:43am blood glucose-116* urean-10 creat-0.6 na-133 k-3.4 cl-102 hco3-25 angap-9 06:20am blood alt-19 ast-28 alkphos-128 totbili-11.2* 05:43am blood alt-19 ast-30 alkphos-133* totbili-12.9* 04:17am blood alt-18 ast-27 ld(ldh)-229 alkphos-132* totbili-13.9* 11:08am blood totbili-11.8* dirbili-8.8* indbili-3.0 06:00am blood alt-24 ast-38 totbili-12.7* 05:57am blood alt-25 ast-35 ld(ldh)-203 totbili-13.0* 06:01am blood alt-23 ast-40 ld(ldh)-202 alkphos-226* totbili-13.4* 06:43am blood totbili-14.0* 06:20am blood calcium-7.5* phos-6.0* mg-2.2 05:43am blood albumin-2.3* calcium-6.7* phos-5.7* mg-2.2 04:17am blood albumin-2.5* calcium-6.6* phos-4.6* mg-2.1 11:08am blood calcium-6.7* phos-4.1 mg-2.1 06:00am blood calcium-7.4* phos-4.1 mg-2.2 05:57am blood albumin-1.9* calcium-7.6* phos-3.0 mg-2.0 06:01am blood calcium-7.6* phos-3.0 mg-2.1 06:43am blood calcium-7.7* phos-2.5* mg-1.9 11:08am blood hapto-119 06:20am blood cortsol-22.9* 06:20am blood vanco-20.6* 05:43am blood vanco-17.1 04:17am blood vanco-20.4* 04:17am blood vanco-20.4* 07:32pm blood vanco-21.2* 05:57am blood vanco-15.0 11:08am blood type-central ve temp-36.7 po2-39* pco2-38 ph-7.34* caltco2-21 base xs--4 intubat-not intuba 06:32am blood lactate-1.4 09:55am blood lactate-1.7 02:13pm blood o2 sat-63 01:10pm blood ca -9 -test name 09:50am color-yellow appear-hazy sp -1.011 09:50am blood-sm nitrite-neg protein-30 glucose-70 ketone-neg bilirub-sm urobiln-neg ph-6.0 leuks-mod 09:50am rbc-4* wbc-44* bacteri-few yeast-none epi-1 transe-2 09:50am castwbc-9* 09:50am amorphx-rare 09:50am wbc clm-rare mucous-rare 09:50am eos-negative 09:50am hours-random urean-123 creat-41 na-91 k-26 cl-78 01:20pm pleural wbc-2500* rbc-* polys-57* lymphs-10* monos-0 eos-1* plasma-1* macro-31* 01:20pm pleural totprot-2.2 glucose-93 ld(ldh)-379 totbili-8.4 albumin-1.3 cholest-36 04:46pm ascites wbc-1400* rbc-* polys-30* lymphs-27* monos-1* mesothe-1* macroph-41* 04:46pm ascites totpro-1.3 albumin-less than 10:17am other body fluid totbili-114 : 03:20am color-dkamb appear-hazy sp -1.016 03:20am blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirub-lg urobiln-neg ph-5.5 leuks-tr 03:20am rbc-5* wbc-7* bacteri-mod yeast-none epi-<1 #microbiology/path: 9:15 am blood culture #1. **final report ** blood culture, routine (final ): staph aureus coag +. final sensitivities. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . consultations with id are recommended for all blood cultures positive for staphylococcus aureus, yeast or other fungi. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- r erythromycin---------- r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin-------------<=0.25 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s anaerobic bottle gram stain (final ): reported to and read back by dr. . on at 0130. gram positive cocci in pairs and clusters. 6:43 am blood culture source: line-poc. **final report ** blood culture, routine (final ): no growth. 1:16 pm pleural fluid **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. 5:58 am blood culture **final report ** blood culture, routine (final ): no growth. 6:00 am blood culture source: line-poc. **final report ** blood culture, routine (final ): no growth. 11:05 am mrsa screen source: nasal swab. **final report ** mrsa screen (final ): no mrsa isolated. 4:46 pm fluid received in blood culture bottles peritoneal fluid. **final report ** fluid culture in bottles (final ): no growth. time taken not noted log-in date/time: 1:03 pm site: not specified **final report ** culture (final ): yeast. >100,000 organisms/ml.. 10:17 am bile bile. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 1+ (<1 per 1000x field): budding yeast. fluid culture (final ): yeast, presumptively not c. albicans. sparse growth of two colonial morphologies. anaerobic culture (final ): no anaerobes isolated. #radiology cxr (): one view of the chest: the left lung is well expanded and shows a left perihilar opacity.. the right lung shows right lower lobe collapse associated with a large right effusion. a right-sided port-a-cath catheter terminates in the distal svc. impression: large right effusion with associated atelectasis. superinfection cannot be excluded. left upper lobe peri-hilar opacity could represent pneumonia. cta abd/pelvis : impression: 1. increased size of subcapsular hepatic collection containing both low-density and high-density material, most consistent with a hematoma. the external-internal hepatobiliary drain passes through this collection. there is no evidence of intravenous contrast material extravasation into this collection to suggest active hemorrhage. 2. multiple hepatic metastases, not significantly changed. 3. unchanged small left adrenal nodule. 4. moderate-to-large volume ascites. 5. unchanged large right and decreased small left pleural effusions with associated bilateral lower lobe atelectasis, right greater than left. echo: the left atrium is mildly dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 65%). the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. there are focal calcifications in the aortic arch. 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. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: suboptimal image quality. no vegetations seen cxr: as compared to the previous radiograph, there is no evidence of pneumothorax. bilateral areas of atelectasis, small right pleural effusion. moderate cardiomegaly. right pectoral port-a-cath. cxr: port-a-cath catheter tip terminates at the level of mid low svc. no appreciable change or may be potential slight increase in the right pleural effusion is demonstrated. cardiomediastinal silhouette is unchanged, and lungs are essentially clear except for right basal atelectasis. abd u/s: impression: no hydronephrosis. overall, there has been no change from the most recent ct scan. kub: one limited supine portable ap view of the abdomen demonstrates multiple dilated bowel loops, most likely of the small bowel up to 7 cm in diameter with no evidence of rectosigmoid air, concerning for obstruction. cxr: there is no change in right partially loculated pleural effusion and left pleural effusion. cardiomediastinal silhouette is unchanged. ng tube was inserted recently, with its tip most likely in the stomach, although not clearly seen. no pneumothorax is seen. right port-a-cath catheter tip is at the level of mid svc. ct abd/pelvis w/ oral contrast: impression: 1. contracting right perihepatic hematoma. 2. increasing ascites compared to the previous examination, now large in volume. 3. liver masses better seen on ct, as are changes from whipple's. brief hospital course: **patient was made comfort measures only during hospitalization brief clinical course: pt is a 69 yo pancreatic cancer (on paclitaxel, last dose 6/25) s/p whipple () originally presented with jaundice and biliary obsruction on . he failed ercp decompression and underwent ptbd on . despite apparently good drainage and multiple ir repositionings, his course has been complicated with persistent hyperbilirubinemia. he also developed mssa bacteremia on currently on nafcillin (tte negative). plan was for placement of metal biliary with ir today. however, overnight patient acutely developed anuria. bladder scan was remarkable for >700cc, although his foley was flushed and exchanged without return. coudet was placed given history of prostate cancer and previous radiation therapy, again without return. patient then became acutely hypotensive from sbp's 90's to sbp's low 70's this morning. urology was consulted given concern for acute obstruction causing ivc obstruction, however after evaluation, urology was confident the patient was actually anuric and bladder scan was eroneous given large abdomen. patient's antibiotics were expaneded to vancomycin and cefepime and patient was bolused 2l ns without improvement in bp. he was then transferred to the for presumed sepsis on . . on arrival to the micu, vs were 97.5, hr 87, bp 88/52, rr 14, o2 93%ra. patient complained of persistent fatigue, relatively unchanged over the last several weeks, but otherwise was without complaint. he denied , , cp, or sob. he denies abdominal pain or nausea. no diarrhea or obstipation. he does endorse mild cough during this hospitalization. review of systems was otherwise unremarkable. he was bolused with albumin and normal saline, but sbps were in the mid 80s, and he was started on low-dose levophed. he received a paracentesis. nephrology thought the etiology of his renal failure was either ain from nafcillin vs. atn from hypotension. his hospital course was also complicated by an ileus which caused significant nausea and relieved by an ng tube. on the evening of , a patient and family meeting was held to discuss goals of care, and he was made cmo. on the morning of , he experienced significant nausea with movement which was relieved with the ng tube. he otherwise had no complaints. . issues: # hypotension: patient with profound acute hypotension but relatively asymptomatic. presumed due to sepsis given mulitple possible sources. however, notably patient does not meet sirs criteria on transfer to icu, as he had no leukocytosis, was afebrile, and was not tachycardic. pt was started on vancomycin and cefepime. his pressure was supported with levophed. no source was found and after goals of care discussion with pt and family, the pt was made comfort measures only. # anuria/: patient with acute onset anuria. known urinary incontinence following radiation prostate cancer. urology evaluated patient and is confident he is not retaining beyond the level of the bladder. pt was seen by renal and felt this was likely ain possibly due to nafcillin. pt put out at best 10cc/hr . he was made cmo and additional work-up/treatment was stopped. #. biliary obstruction: likely due to hepatic mets. s/p ir guided ptbd and multiple revisions. also has had brb drainage previously in hospitalizaiton. drain was kept in place. # mssa bacteremia: have switched nafcillin to vancomycin and cefepime given hypotension. pt was made cmo and antibiotics were stopped. # elevated inr: elevated to 2.1 on transfer to micu, this reversed with vitamin k and therefore was thought to be nutritional. pt's coumadin was held due to bleeding risk. # cough: significant r sided pleural effusion s/p diagnostic thoracentesis on . exudative by light's criteria. likely related to underlying malignancy, although could consider pneumonic process as well given current hypotension. #. pancreatic cancer: patient is s/p whipple with known mets to regional lymph nodes. last chemo given . chronic issues: #. prostate cancer: s/p radiation, on dutasteride at home (not on formulary, so held) #. afib: home regimen includes carvedilol and warfarin. latest coumadin regimen is 2.5 mg one-half tab daily. these medications were held. #. gout: asymptomatic. allopurinol transitional issues: 1.) patient is cmo. medications on admission: 1. outpatient lab work cbc, lfts (ldh, ast, alt, alk phos, tbili), pt, ptt, inr for: biliary obstruction monitoring please fax results to: -division of hematology/oncology , 9 , phone: fax: 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 4. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). tablet(s) 5. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*15 tablet(s)* refills:*0* 6. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. disp:*qs qs* refills:*0* 7. oxybutynin chloride 5 mg tablet sig: two (2) tablet po bid (2 times a day). 8. 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* 9. diphenoxylate-atropine 2.5-0.025 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for diarrhea. 10. pantoprazole 40 mg tablet,delayed release (dr/ec) sig: one (1) tablet,delayed release (dr/ec) po q12h (every 12 hours). disp:*60 tablet,delayed release (dr/ec)(s)* refills:*0* 11. carvedilol 6.25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 12. dutasteride 0.5 mg capsule sig: one (1) capsule po once a day. discharge medications: 1. hydromorphone (dilaudid) 0.25-1 mg iv q1h:prn pain, dyspnea rx *hydromorphone (pf) 1 mg/ml 0.25-1mg q1h disp #*30 vial refills:*0 2. lorazepam 0.5-1 mg iv q1h:prn nausea, anxiety rx *lorazepam 2 mg/ml 0.5-1mg q1h disp #*30 vial refills:*0 3. olanzapine (disintegrating tablet) 5 mg po bid:prn nausea, insomnia rx *olanzapine 5 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 4. ondansetron 4 mg iv q8h:prn nausea rx *ondansetron hcl 4 mg/5 ml 4mg/5ml oral solution every eight (8) hours disp #*500 milliliter refills:*0 5. scopolamine patch 1 ptch tp q72h secretions rx *transderm-scop 1.5 mg/72 hour apply 1 patch q72h disp #*30 transdermal patch refills:*0 6. allopurinol 400 mg po daily rx *allopurinol 300 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 7. prochlorperazine 10 mg po q6h:prn nausea rx *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every six (6) hours disp #*60 tablet refills:*0 8. zolpidem tartrate 5 mg po hs rx *zolpidem 5 mg 1 tablet(s) by mouth at bedtime disp #*30 tablet refills:*0 9. hyoscyamine 0.125 mg sl qid:prn secretions rx *hyoscyamine sulfate 0.125 mg 1 tablet sublingually four times a day disp #*120 tablet refills:*0 10. heparin flush (10 units/ml) 5 ml iv prn line flush indwelling port (e.g. portacath), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 11. heparin flush (100 units/ml) 5 ml iv prn de-accessing port indwelling port (e.g. portacath), heparin dependent: when de-accessing port, flush with 10 ml normal saline followed by heparin as above per lumen. discharge disposition: extended care facility: livingcenter - discharge diagnosis: primary diagnosis: hyperbilirubinemia secondary diagnosis: metastatic pancreatic ampullary cancer discharge condition: mental status: waxing and level of consciousness: somnolent activity status: bed bound discharge instructions: dear mr. , it was a pleasure taking care of you. you were admitted to the for fatigue. you were found to have a complicated blockage within your biliary system and a revision of the drain placement was attempted. you were also found to have fluid in your lungs which was therapeutically removed to improve your breathing. you were transferred to the icu for low blood pressure and poor oxygenation of your blood. in the icu you were stabilized and put on medication to keep your blood pressure in the normal range. you and your family decided to proceed with comfort measures only and you were sent back to the regular inpatient . you and your family chose to transfer your care to . we wish you and your family the best. followup instructions: none Procedure: Thoracentesis Diagnoses: Pneumonia, organism unspecified Abnormal coagulation profile Anemia, unspecified Malignant neoplasm of liver, secondary Unspecified pleural effusion Unspecified essential hypertension Gout, unspecified Atrial fibrillation Methicillin susceptible Staphylococcus aureus septicemia Sepsis Hypotension, unspecified Malignant neoplasm of prostate Paralytic ileus Encounter for palliative care Obstruction of bile duct Personal history of irradiation, presenting hazards to health Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Acute kidney failure with other specified pathological lesion in kidney Malignant neoplasm of pancreas, part unspecified Cough Procedure not carried out for other reasons

allergies: no known allergies / adverse drug reactions attending: chief complaint: headache, nausea, slurred speech major surgical or invasive procedure: : left craniotomy and evacuation of sdh : diagnsotic cerebral angiogram history of present illness: 18m who graduated high school on friday and was at a party friday evening. he was in a inflatable bouncer where he was playing and knocked heads with another person. no loc. c/o headaches and took ibuprofen and asa. saturday evening () began c/o nausea and vomiting, becoming more lethargic and slurred speech. he was taken to where a head ct showed a large left sdh. he was loaded with dilantin and transferred to for further care. upon arrival in the er, patient was immediately evaluated by the neurosurgery service. dr spoke with the patient's father and surgical intervention was planned for. the patient was taken emergently from the er to the or for evacuation. past medical history: wisdom teeth extraction social history: lives with family, just graduated high school, plans to attend in the fall. family history: non-contributory physical exam: gen: lethargic but arouseable heent: no visible signs of trauma neuro: mental status: lethargic but arouses to voice, cooperative with exam, needs some prompting orientation: oriented to person and date. stating he was in a tv show. language: slurred speech, naming intact cranial nerves: i: not tested ii: pupils both reactive, r pupil larger than left iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact, r facial droop. 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. left side full motor, rue/rle slightly weaker than left. sensation: intact to light touch physical exam upon discharge: the patient is awake, alert, and oriented. he is resting comfortably in bed. scalp incision is clean, dry, and intact with no surrounding erythema or drainage. pupils are round and equally reactive to light. there is no facial asymmetry, and tongue is midline. upper extremity exam reveals full strength in the shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, and grip strength. lower extremity exam also shows full 5/5 strength in the hip flexors, knee flexors/extensors, and ankle plantarflexors/dorsiflexors. sensation is intact to light touch. pertinent results: cxr: indings: the et tube is 4.3 cm above the carina. the heart is upper limits normal in size. lungs are clear without infiltrate or effusion. the extreme left cp angle is off the film. ct head: impression: 1. post-operative changes after left craniotomy and evacuation of left subdural hematoma with post operative pneumocephalus. 2. small amount of residual subdural hematoma. 3. stable 8 mm of rightward shift of the normal midline structures with patent basal cisterns. 5. subcutaneous air and small subgaleal hematoma is an expected post-operative finding. cta head stable left frontoparietal subdural hematoma status post evacuation, likely related to arachnoid cyst in the left middle cranial fossa. no vascular occlusion or aneurysm is seen. however, engorged vein, cerebral vein coursing along the left frontoparietal convexity is likely secondary to mass effect from the subdural hematoma. if indicated an angiography can be performed to more definitively exclude aneurysm or vascular malformation. cta head stable postoperative fluid collection. no evidence of vasospasm. brief hospital course: pt was taken to the or and underwent an urgent craniotomy and evacuation. he was given 1 unit of platelets due to the recent aspirin consumption. surgery was without complication and he tolerated it well. he was extubated and transferred to the icu. post operatively he was lethargic but non-focal. post operative head ct revealed post op changes. on he underwent a cta of the head which showed alrge vbeins on the left andf plan was made to have a conventional cerebral angiogram. as the patient had consumed liquids the angio was postponed until . he remained stable in the icu and on went to the angio suite where the angiogram showed no evidence of vascular abnormality but did show some vasospasm. as a result he was placed on nimodipine. he remained stable overnight on into . on the morning of he was deemed fit for trasnfer to the step down unit. his exam was nonfocal and he continued on vasospasm watch with plans for a cta of the head on . on he was stable without deficit with his incision c/d/i with staples in place. he underwent repeat head cta on , which demonstrated a stable postoperative fluid collection and no evidence of vasospasm. he was discharged home in stable condition on with detailed precautionary instructions as well as instructions for follow-up. medications on admission: afrin prn, ibuprofen prn, mvi daily discharge medications: 1. nimodipine 30 mg capsule sig: two (2) capsule po q4h (every 4 hours) for 16 days. disp:*192 capsule(s)* refills:*0* 2. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 5. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po every six (6) hours as needed for pain. disp:*60 tablet(s)* refills:*0* 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 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. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: subdural hematoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: craniotomy for subdural/epidural hematoma dr. ?????? 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. ?????? your wound was closed with staples so you must wait until after they are removed to wash your hair. you may shower before this time using a shower cap to cover your head. ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? **you have been prescribed 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 . ?????? 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 a wound check. this appointment can be made with the physician assistant or practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????please call ( to schedule an appointment with dr. , to be seen in __4_weeks. ??????you will need a ct scan of the brain without contrast at that time. ??????we recommend you see dr in the traumatic brain injury (tbi) clinic the phone number is . if you have any problems booking this appointment please ask for . Procedure: Incision of cerebral meninges Arteriography of cerebral arteries Diagnoses: Compression of brain Unspecified transient cerebral ischemia Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Other accident caused by striking against or being struck accidentally by objects or persons

allergies: no known allergies / adverse drug reactions attending: addendum: addendum to reflect addition of glargine 35 units ongoing. major surgical or invasive procedure: cabg x4 (lima to lad, svg to diag, svg to om, svg to plv) 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:*1* 3. 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:*1* 4. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*1* 5. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 6. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 7. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*1* 8. levothyroxine 75 mcg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*1* 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): take 400mg for one week, then taper to 400mg daily, then 200mg daily ongoing. disp:*120 tablet(s)* refills:*2* 11. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 10 days: sternal erythema. disp:*80 capsule(s)* refills:*1* 12. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 13. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 14. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 14 days: adjust course per exam and creatinine. disp:*28 tablet(s)* refills:*1* 15. insulin glargine 100 unit/ml solution sig: thirty five (35) subcutaneous twice a day. disp:*qs * refills:*2* discharge disposition: extended care facility: hospital - 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 Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Personal history of tobacco use Ulcer of other part of foot Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Other and unspecified angina pectoris Personal history of other malignant neoplasm of skin Long-term (current) use of insulin Macular degeneration (senile), unspecified Morbid obesity Iron deficiency anemia, unspecified Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Arthropathy associated with neurological disorders Body Mass Index 40.0-44.9, adult

allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: cabg x4 (lima to lad, svg to diag, svg to om, svg to plv) history of present illness: 62 year old male with the onset of dyspnea two years ago. he complains of worsening dyspnea on exertion over the last 6 months but improves quickly with rest. this can be associated with lightheadedness at times. he saw dr. for this and was found to be anemic. he was started on iron and has noticed some improvement since then. he saw dr. who arranged a stress test for him. the persantine thallium stress test demonstrated a partially reversible, medium sized, severe perfusion defect involving the pda territory; increased left ventricular cavity size; and mild systolic dysfunction with mid and distal inferior hypokinesis. he was referred for a cardiac catheterization and was found to have three vessel disease. he is now being referred to cardiac surgery for revascularization. past medical history: diabetes hypertension hyperlipidemia chronic renal failure, stage 3 ( creat=1.1, creat=1.8) complicated foot disease: right charcot foot and foot ulcers (bilateral) hypothyroidism anemia: iron deficiency obstructed sleep apnea (uses cpap) macular degeneration retina detachment s/p removal of basal cell on face () s/p laser eye surgery for hemmorage social history: lives with:wife occupation:currently not working but previously worked in plumbing and heating cigarettes: smoked no yes quit smoking 18 years ago with a history of smoking 2 ppd x6 years other tobacco use:denies etoh: denies illicit drug use: denies family history: father had a cabg at the age of 81 physical exam: pulse:72 resp:18 o2 sat:99/ra b/p right:189/97 left:177/90 height:5'8" weight:280lbs general: no acute distress skin: red nonraised rash bilateral groins with slight skin opening left groin into perineum. ulceration plantar aspect left foot open no erythema no drainage - being treated with wound gel right foot intact but multiple calluses chest with red raised areas - occurred after shaving for stress test, right cheek surgical scar from basal cell removal heent: pupils equal non reactive to light, eomi, decreased peripheral vision left eye. neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + obese extremities: warm , edema right +1 left +2 pitting varicosities: none neuro: alert and oriented x3 mae r=l strength, visual deficits as noted above pulses: femoral right: +1 left: +1 dp right: +1 left: +1 pt : +1 left: +1 radial right: tr band in place left: +1 carotid bruit right: no bruit left: no bruit pertinent results: conclusions the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. global systolic function is good (?inferior hypokinesis). there is abnormal septal motion c/w post op or ivcd or paced rhythm. the right ventricular cavity is mildly dilated with free wall hypokinesis. the aortic valve is grossly normal in morphology. no aortic regurgitation is seen. the mitral valve is normal mild to moderate (+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. normal left ventricular cavity size and global systolic function. right ventricular cavity enlargement with free wall hypokinesis. pulmonary artery systolic hypertension. mild-moderate mitral regurgitation. moderate tricuspid regurgitation. compared with the pre-operative study of , the left ventricular cavity is smaller and the severity of mitral regurgitation, tricuspid regurgitation, and estimated pa systolic pressure are higher. electronically signed by , md, interpreting physician 08:21 05:06am blood wbc-9.4 rbc-3.37* hgb-10.3* hct-29.8* mcv-88 mch-30.5 mchc-34.5 rdw-14.3 plt ct-210 05:06am blood glucose-139* urean-66* creat-1.9* na-137 k-4.3 cl-103 hco3-26 angap-12 brief hospital course: admitted and underwent surgery with dr. . transferred to the cvicu in stable condition on titrrated phenylephrine and proofol drips. extubated the following morning and transferred to the floor to begin increasing his activity level. gently diuresed toward his preop weight. chest tubes and pacing wires removed per protocol. creatinine peaked at 3.2 and began to trend down until it reached his baseline of 2 at discharge. he experienced atrial fibrillation for which he was placed on amiodarone. he was placed on ultram for pain management as percocets caused him nausea. keflex was started for slight sternal erythema without drainage, leukocytosis, or a fever. by post-operative day six he was ready for discharge to rehab. all follow-up appointments were advised. medications on admission: insulin lispro protam & lispro (75-25) sixty (60) units levothyroxine 150 mcg tablet once a day. losartan 100 mg tablet once a day. metoprolol succinate 50 mg daily omeprazole 20 mg daily simvastatin 40 mg daily aspirin 81 mg once a day. cholecalciferol 1,000 unit once a day ferrous sulfate 300 mg daily omega-3 fatty acids 2 capsule daily multivitamin 1 tablet daily furosemide 40 mg daily nitroglycerin 0.4 mg sublingual prn nystatin 100,000 unit/g cream topical 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:*1* 3. 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:*1* 4. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*1* 5. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 6. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 7. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*1* 8. levothyroxine 75 mcg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*1* 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): take 400mg for one week, then taper to 400mg daily, then 200mg daily ongoing. disp:*120 tablet(s)* refills:*2* 11. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 10 days: sternal erythema. disp:*80 capsule(s)* refills:*1* 12. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 13. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 14. furosemide 40 mg tablet sig: one (1) tablet po daily (daily) for 14 days: adjust course per exam and creatinine. disp:*28 tablet(s)* refills:*1* discharge disposition: extended care facility: hospital - discharge diagnosis: coronary artery disease s/p cabg diabetes mellitus hypertension hyperlipidemia chronic renal failure, stage 3 ( creat=1.1, creat=1.8) complicated foot disease: right charcot foot and foot ulcers hypothyroidism anemia: iron deficiency obstructed sleep apnea (uses cpap) macular degeneration retina detachment discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, slight erythema but no drainage leg left - healing well, no erythema or drainage. edema 2+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr wed @ 1:15 pm 2a cardiologist: dr @ 11:10 am please call to schedule appointments with your primary care dr in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: 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 Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Personal history of tobacco use Ulcer of other part of foot Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Other and unspecified angina pectoris Personal history of other malignant neoplasm of skin Long-term (current) use of insulin Macular degeneration (senile), unspecified Morbid obesity Iron deficiency anemia, unspecified Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Arthropathy associated with neurological disorders Body Mass Index 40.0-44.9, adult

allergies: heparin agents attending: chief complaint: hepatocellular carcinoma and hepatitis c virus. major surgical or invasive procedure: : extended right hepatic lobectomy,intraoperative ultrasound, lysis of adhesions. : exploratory laparotomy, portal vein thrombectomy. : orthotopic deceased donor liver transplant (brain dead donor) piggyback, portal vein-to- portal vein anastomosis, common bile duct-to-common bile duct anastomosis with no t-tube, infrarenal iliac artery conduit to the common hepatic artery of the donor, and portal vein thrombectomy. : exploratory laparotomy, drainage of subphrenic abscess, liver biopsy and vicryl mesh closure of intra-abdominal wall. tracheostomy abdominal washout abdominal closure with mesh peritoneal drain placement tunnelled hd line placement nasointesintal feeding tube placement past medical history: hepatitis c (relapsed after pegylated interferon and ribavirin) cirrhosis prostate cancer depression overactive bladder insomnia cholecystectomy () social history: the patient works full time in the it division of market. he is single. he is a former polydrug abuser, mostly narcotics. he has not used alcohol or drugs in 29 years. family history: nc physical exam: post op liver resection: vs: 98.0, 90, 108/62, 18, 98% general: pain managed with intermittent iv morphine, in nad card: rrr, no m/r/g lungs: cta bilaterally abd: incision dressing c/d/i, abdomen appropriately tender, 1 jp drain in place extr: no c/c/e pertinent results: at time of initial surgery: wbc-10.5# rbc-4.67 hgb-15.0 hct-43.9 mcv-94 mch-32.2* mchc-34.2 rdw-15.1 plt ct-163 pt-18.5* ptt-38.6* inr(pt)-1.7* glucose-140* urean-9 creat-0.5 na-136 k-4.2 cl-105 hco3-25 angap-10 alt-75* ast-152* alkphos-119 totbili-3.8* calcium-8.6 phos-3.2 mg-2.2 at time of liver transplant: wbc-18.6* rbc-3.15* hgb-10.5* hct-29.3* mcv-93 mch-33.4* mchc-35.9* rdw-20.0* plt ct-53* pt-24.9* ptt-54.1* inr(pt)-2.4* fibrino-266 glucose-135* urean-35* creat-1.8* na-135 k-4.1 cl-102 hco3-23 angap-14 alt-20 ast-56* alkphos-91 amylase-126* totbili-36.0* albumin-3.1* calcium-9.0 phos-3.0 mg-2.1 hbsag-negative hbsab-positive hbcab-negative igm hbc-negative tsh-13* t4-3.0* at time of discharge: wbc-4.1 rbc-3.07* hgb-9.2* hct-27.9* mcv-91 mch-30.0 mchc-32.9 rdw-17.8* plt ct-134* pt-19.7* ptt-28.4 inr(pt)-1.8* glucose-140* urean-79* creat-2.8* na-139 k-4.4 cl-100 hco3-30 angap-13 alt-29 ast-22 alkphos-239* totbili-1.3 albumin-2.4* calcium-8.2* phos-3.9 mg-2.0 tacrofk-9.5 brief hospital course: on , he underwent extended right hepatic lobectomy,lysis of adhesions and intraoperative ultrasound for hepatocellular carcinoma and hepatitis c virus. surgeon was dr. . operative findings included extensive intra-abdominal adhesions from his prior cholecystectomy. he had increased venous collaterals but not obvious portal hypertension. the liver was large and cirrhotic with large regenerative nodules. there was a mass lesion in segment viii extending and pushing into segment with involvement of the peripheral branches of the middle hepatic vein but the proximal right hepatic vein was clear. there were no other lesions in the remainder of the liver demonstrated by intraoperative ultrasound. please refer to operative report for further details. initially, he did well, but was also having decreased urine output. a liver doppler ultrasound was performed showing patent flow in the left portal vein, left hepatic vein, and left hepatic artery. main portal vein was unable to be visualized and af luid collection adjacent to the surgical margin was noted. on pod 3 he was noted to have worsening encephalopathy and repeat liver doppler ultrasound was done showing new ascites. there was no flow within the main portal vein, though apparently forward flow was seen in the left portal vein. as the findings were concerning for portal vein thrombosis versus slow flow a ct was obtained showing thrombosis of the left portal vein and main portal vein, extending to the confluence of the smv, portal vein, and splenic vein. the splenic vein was occluded to approximately its mid segment. the common and left hepatic arteries were patent. the left hepatic vein appeared patent. the ivc was patent. hypoattenuation was noted in segment v/viii. given these findings, he was taken back to the or by dr for exploratory laparotomy, portal vein thrombectomy. due to difficult anatomy, the thrombectomy could not be done, and an attempt was made by interventional radiology with tpa. he had a portal venogram suggestive of acute expansile thrombus within the main portal vein. narrowing was seen at the junction of the main and left portal veins. a 5 french catheter was placed. on , focal contrast extravasation from the right portal vein stump into the region of the jp drain was seen. successful exclusion of the right portal vein stump with placement of covered stents in the main and left portal vein was done with no further extravasation, however there was still persistent thrombus in the main and left portal veins after mechanical thrombectomy (angioget). attempt was made at another thrombectomy with tpa and on there was interval improvement, but still some thrombus in the stent and the main portal vein. heparin drip was initiated and the patient was placed on empiric ceftriaxone. also due to his worsening mental status he was intubated. he was started on tpn for nutrition support. micafungin was started for moderate growth of yeast from a sputum specimen on . platelats dropped as low as 57 on , a hit panel was sent which returned as positive. serotonin release assay was sent and reported as borderline positive. the heparin was stopped and he was started on bivalarudin. wbc was elevated around pod 8 (), although he remained afebrile. he was pan-cultured. all cultures remained negative except pd fluid was positive for vre. lfts were notable for progressive increase of total bilirubin, worsening jaundice and worsening mental staus consistent with hepatic failure. lactulose and rifaximin were started. he remained intubated. overall, liver function continued to worsen and progressed to hepatorenal syndrome necessitating cvvhd. it was determined at this time that he should undergo liver transplant evaluation. he had all serologies and baseline exams completed. he was listed for liver transplant. on , a donor liver was available. the patient underwent orthotopic deceased donor liver transplant (brain dead donor)non- abo compatible liver transplant. plasmaphereis was performed prior to or. procedure consisted of piggyback, portal vein-to- portal vein anastomosis, common bile duct-to-common bile duct anastomosis with no t-tube, infrarenal iliac artery conduit to the common hepatic artery of the donor, and portal vein thrombectomy for portal vein/superior mesenteric vein/splenic vein thrombosis. this was a please see the operative report for full surgical detail, however it should be noted that the patient received 8000 ml of crystalloid, 69 units of fresh frozen plasma, 79 units of packed red cells, 12 units of platelets, 12 units of cryo, and took 7 liters of ccvh. he was left with an open abdomen, was transferrred back to the sicu intubated. on he was brought back to the or for abdominal washout, tru-cut biopsy of the liver, reclosure of silastic abdominal closure. he was unable to be closed and then on he was taken once again to the or with dr for exploratory laparotomy, drainage of subphrenic abscess, liver biopsy and vicryl mesh closure which was attached to the fascia for closure of the intra-abdominal wall. liver biopsy results from showed zone three hepatocyte apoptosis/necrosis with focal drop-out, consistent with preservation/reperfusion injury. mild to moderate, predominantly zone three cholestasis, with focal feathery degeneration of hepatocytes and rare bile plug formation. no acute rejection was seen. white count noted to once again be 21.5 (it had normalized previously) and blood cultures from came back positive for vre. because of the previous peritoneal fluid vre positive cultures the patient had been on daptomycin, had remained on the micafungin for the sputum yeast and had additionally been on zosyn. blood cultures were checked daily and did not clear until . during that interval the dapto was changed to linezolid. he received 19 days of linezolid and then per id recommendations he was switched to tigecycline because on he underwent a technically successful aspiration/drainage of a complex intraperitoneal fluid collection. 10 french catheter was placed and left to bag gravity drainage. cultures showed sparse growth of enterococcus. on he had drainage of a non-infected pleural effusion. given prolonged intubation, he underwent trache placement on by dr . he had been on cvvh throughout while intubated. lfts were notable for persistent bilirubin elevation. gi was consulted and performed an ercp on . cholangiogram revealed a tight curve/loop in the mid common bile duct, with possible evidence of a subtle stricture just above this curve with mild upstream biliary dilation, an 8cm by 10fr biliary stent was placed across the mid-cbd. the bilirubin was 21.9 at the time of the ercp. over the remainder of the hospital course and towards the end of the hospitalization the bilirubin decreased to normal value of 1.4 and all other lfts were wnl. a repeat ercp was scheduled for . coumadin was started on for h/o portal vein thrombus/hit+ and adjusted daily. in early it was determined he would be stable enough for intermittent hd. a post pyloric feeding tube was in place and he has been receiving tube feeds. the patient had multiple speech and swallow evaluations including video swallow that demonstrated aspiration. he remained npo with meds given as suspesions via the feeding tube. he was on strict aspiration precautions. he was not to even attempt swallowing pills. intensive speech therapy was recommended for rehab. trache was gradually transitioned to trache collar. mental status improved. with this improvement, the trache was decannulated which he tolerated. of note, with improved mental status, he was very anxious. psychiatry evaluated and recommended risperdal. this was started and proved to decreased anxiety. psychiatry continued to follow and recommended starting remeron. this was started on . mood and sleep improved. the patient was finally stable enough to be transferred to the regular surgical floor on . he has been evaluated throughout by pt noting severe deconditioning/weakness. pt recommended rehab. ot evaluated and worked with him also making recommendations for rehab. the patient has had a vac to the abdominal wound since the mesh was placed. the mesh was eventually removed at the bedside during a debridement, and the vac is still in place with a white sponge to the underlying structures. the wound is slowly closing although healing has been very slow. wound measures 22cm x 9cm x 2cm. vac change consists of white sponge first on top of bowel then black sponge changed every 72 hours. on thyroid function tests were sent (tsh 13, t4 3.0) , he was found to be hypothyroid and was started on levoxyl. tsh decreased to 8.8 on . intermittent hd was performed and on had successful uncomplicated placement of a 15.5 french x 23 cm tip-to-cuff tunneled hemodialysis catheter via right internal jugular venous access with the tip of the catheter terminating in the right atrium ready for use. no heparin was used during hd for line flushes (hit +). the xray done at the time of the line placement was concerning for increased bilateral pleural effusions. there was concern for aspiration. and the patient seemed increasing confused. the patient had a head ct which showed no evidence of acute intracranial pathological process. he was transferred back to the sicu for two days, but cleared and came back to the surgical floor. id followed throughout and recommended a 4-week course of therapy, which changed to tigecycline, from the day of the first negative blood culture for vre () and an indefinite course of fluconazole given his many anastomoses and high likelihood of recurrence. multiple c diffs were sent (all negative) for multiple loose stools. the cellcept has been changed several times due to its potential gi effects and is now 250 qid. imodium was started twice daily. prograf levels have been followed throughout with dosing based on levels. he is currently on a prednisone taper per transplant clinic guidelines. patient remains on coumadin therapy. medications on admission: enablex 7.5', mirtazapine 45 qhs, nadolol 20', risperidone 0.5' zolpidem 20', mag ox 400' discharge medications: 1. white petrolatum-mineral oil 56.8-42.5 % ointment : one (1) appl ophthalmic prn (as needed) as needed for dry eyes. 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 1-2 puffs inhalation q4h (every 4 hours) as needed for wheeze. 3. valganciclovir 50 mg/ml recon soln : four y (450) mg po 2x/week (mo,th). 4. insulin regular human 100 unit/ml solution : per sliding scale injection four times a day. 5. risperidone 1 mg/ml solution : 0.5 mg po bid (2 times a day). 6. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension : ten (10) ml po daily (daily). 7. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 8. fluconazole 40 mg/ml suspension for reconstitution : two hundred (200) mg po q24h (every 24 hours). 9. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 10. miconazole nitrate 2 % powder : one (1) appl topical prn (as needed) as needed for irritation. 11. acetaminophen 650 mg/20.3 ml solution : six y (650) mg po q6h (every 6 hours) as needed for pain: 2 gram maximum daily. 12. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day): via tube. 13. mycophenolate mofetil 200 mg/ml suspension for reconstitution : two y (250) mg po qid (4 times a day). 14. tigecycline 50 mg recon soln : fifty (50) recon soln intravenous q12h (every 12 hours) for 7 doses: through . 15. methylprednisolone sodium succ 40 mg recon soln : ten (10) mg injection q24h (every 24 hours): please decrease to 8 mg daily on friday . follow transplant clinic taper. 16. levothyroxine 200 mcg recon soln : fifty (50) mcg injection daily (daily). 17. outpatient lab work stat labs every monday and thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, pt/inr fax to attn: transplant rn coordinator 18. loperamide 1 mg/5 ml liquid : two (2) mg po twice a day: 8 am and 2 pm . 19. outpatient lab work trough prograf:every monday and thursday starting , tacrolimus; trough tacro to be drawn at and dropped off at lab , 304 before 9 am to be run same day. 20. warfarin 1 mg tablet : three (3) tablet po once a day: check pt/inr monday and thursday. goal inr . 21. tacrolimus 5 mg capsule : five (5) mg po bid (2 times a day): give as suspension via tube. discharge disposition: extended care facility: hospital transitional care unit - discharge diagnosis: hcc s/p right trisegmentectomy with postop liver failure malnutrition, severe hrs hit+ portal vein thrombus s/p abo incompatible liver transplant atn hypothyroid traumatic foley insertion vre, peritoneal fluid 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: the transplant office should be called if the patient develops fevers, chills, nausea, vomiting, increased diarrhea, jaundice, inability to take medications, increased abdominal pain/bloating, wound edges appear red or wound drainage increases or smells foul, malfunction of tube feeding, confusion or increased urine output. the patient has a tunneled dialysis line and should receive hemodialysis three times a week blood will be drawn twice weekly on monday and thursday with results faxed to the transplant clinic at : cbc, chem 10, ast, alt, t bili, alk phos, albumin, pt, inr trough prograf:every monday and thursday starting , tacrolimus; trough tacro to be drawn at and dropped off at lab , 305 before 9 am to be run same day. all medications must be given crushed or as suspensions via dobhoff. patient is to be kept completely npo until can pass swallow evaluation after completing speech therapy. please contact at with any questions. no medication changes are to be made without prior discussion with the transplant clinic followup instructions: , md, phd: date/time: 2:00 , md phone: date/time: 11:30 , md phone: date/time: 1:20 md, Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Hemodialysis Angioplasty of other non-coronary vessel(s) Closed (percutaneous) [needle] biopsy of liver Closed (percutaneous) [needle] biopsy of liver Venous catheterization for renal dialysis Thoracentesis Percutaneous abdominal drainage Incision of abdominal wall Temporary tracheostomy Aortography Endoscopic insertion of stent (tube) into bile duct Endoscopic excision or destruction of lesion or tissue of esophagus Other lysis of peritoneal adhesions Arteriography of other intra-abdominal arteries Other endovascular procedures on other vessels Other endovascular procedures on other vessels Delayed closure of granulating abdominal wound Lobectomy of liver Phlebography of the portal venous system using contrast material Incision of vessel, abdominal veins Other operations on lacrimal gland Transplant from cadaver Procedure on single vessel Auxiliary liver transplant Diagnoses: Acidosis Acute kidney failure with lesion of tubular necrosis Other postoperative infection Cirrhosis of liver without mention of alcohol Acute and subacute necrosis of liver Chronic hepatitis C with hepatic coma Hepatorenal syndrome Unspecified septicemia Severe sepsis Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Secondary malignant neoplasm of other specified sites Acute respiratory failure Defibrination syndrome Peritoneal adhesions (postoperative) (postinfection) Septic shock Infection with microorganisms without mention of resistance to multiple drugs Disseminated candidiasis Other ascites Malignant neoplasm of liver, primary Esophageal varices in diseases classified elsewhere, with bleeding Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other specified disorders of stomach and duodenum Obstruction of bile duct Peritoneal abscess Heparin-induced thrombocytopenia (HIT) Nutritional marasmus Other diseases of spleen Other suppurative peritonitis Portal vein thrombosis Vascular complications of other vessels

allergies: midazolam / lisinopril / naprosyn / indocin attending: chief complaint: aortic root to right atrial fistula major surgical or invasive procedure: pulmonary vein isolation: dr. on history of present illness: this 57 year old man has a long standing history of atrial arrhythmias s/p flutter ablation, pvi in and again in , and multiple cardioversions. he has been most recently managed on amiodarone. he was last here at on when he complained of dyspnea on exertion and fatigue for several weeks. he underwent successful cardioversion and had his coumadin switched to pradaxa due to difficulty maintaining adequate inr levels. plans were made for repeat attempt at ablation in . he developed recurrent atrial tachycardia shortly following his cardio version on . he underwent successful dccv of atrial tachycardia on with prompt return to sinus rhythm. . today, pt had planned repeat pvi attempt with ch, but 2nd transeptal went to aortic root above ncc. case stopped. tee color flow doppler revealed small fistula between the right atrium and aortic root with l to r flow. 1u platelets ordered but not yet given. , md surgery consulted and will patient shortly. patient was left intubated and sent to ccu for repeat tee ~1500 to re-evaluate fistula in hopes that it will have closed. last pradaxa am dose. . ros: unable to obtain. . please note that patient is intubated at time of admission and therefore details of history are obtained from his electronic medical record. past medical history: 1. cardiac risk factors: - diabetes, - dyslipidemia, + hypertension 2. cardiac history: 1. recurrent symptomatic atrial fibrillation 2. multiple recent dc cardioversions most recent was 3. pvis, last before admission was 4. recurrent symptomatic left atrial tachycardia following pvi - cabg: none - percutaneous coronary interventions: none 3. other past medical history: - hypertension - arthritis involving knees - anxiety - hepatitis c with elevate lft's: as of -> hepatitis c genotype is 1. hep c vl 2,200,000 international units/ml. hepascore is 1.00 with a 65% probability that the patient has cirrhosis. most recent abdominal ultrasound was obtained on , and did not demonstrate any hepatic lesions. the spleen was 15.5 cm and a recanalized paraumbilical vein. there was no ascites noted. social history: occupation: retired nurse from the va system. tobacco: denies etoh: he averages 6 drinks a day; he reports going a couple days at a time without any alcohol and denies any prior dt's. reports drinking "too much" in general and has considered detox before. home services: denies family history: fh: no family history of arrhythmias. no family history of liver or gi disease. physical exam: exam on admission: vs: t=95.8 bp= 127/59 hr=64 rr=14 o2 sat= 100% on 100% fio2 vent settings: cmv with tv 600, peep 5, rr 12, fio2 100% general: intubated and sedated. heent: ncat. sclera anicteric. pinpoint pupils, symmetric. neck: supple, unable to assess jvp. 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: clear anteriorly. abdomen: soft, ntnd. no hsm or tenderness. no abdominial bruits. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ . discharge exam: general: alert and orriented. heent: ncat. sclera anicteric. pupils reactive and symmetric. neck: supple, unable to assess jvp. 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: clear anteriorly. abdomen: soft, ntnd. no hsm or tenderness. no abdominial bruits. extremities: no c/c/e. 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-3.6* rbc-3.98* hgb-13.5* hct-38.2* mcv-96 mch-34.0* mchc-35.4* rdw-16.6* plt ct-58* pt-15.6* inr(pt)-1.4* glucose-118* urean-16 creat-1.1 na-136 k-3.5 cl-95* hco3-34* angap-11 . post-procedure initial tee : a mobile 0.3 x 0.3 cm structure consistent with probable thrombus (or other small mass) is seen in the the left atrium attached to left atrial wall to the left and posterior to the aortic root . a trans-septal catheter is seen and following withdrawal there is residual left-to-right shunt across the interatrial septum. left ventricular global systolic function is normal. there are simple atheroma in the aortic arch and descending thoracic aorta. no thoracic aortic dissection is seen. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. there is an echodense region along the posterior border of the aorta, adjacent to the non-coronary cusp consistent with a hemotoma that measures 1.8 cm at the widest. there is a 2mm wide jet of color doppler flow through the hematoma from the aortic root into the right atrium. the mitral valve leaflets are mildly thickened. there is a trivial/physiologic pericardial effusion. impression: aortic root to right atrial communication with associated hematoma. small left atrial mass as described above. . repeat 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. a small, approximately 1 x 3 mm mobile structure consistent with possible thrombus is seen attached to the wall of the left atrium (clip ), although independent motion is not appreciated. right atrial appendage ejection velocity is good (>20 cm/s). 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. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. no thoracic aortic dissection is seen. the aortic valve leaflets (3) are mildly thickened with good leaflet excursion. trace aortic regurgitation is seen. there is an echodense region along the posterior border of the aorta, adjacent to the non-coronary cusp consistent with a hematoma that measures 2.3 cm at the widest. there is a 3-5mm wide jet of color doppler flow from the aortic root into the right atrium. ] the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. impression: aortic root to right atrial communication with associated hematoma. very small left atrial mass suggestive of thrombus as described above. compared with the prior study (images reviewed) of the color doppler jet appears slightly wider and is now continous throughout the cardiac cycle. the left atrial mass is smaller in size. the previously appreciated interatrial shunt is no longer appreciated. repeat tte : the left atrium is mildly 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. right atrial appendage ejection velocity is good (>20 cm/s). a left-to-right color flow signal is seen across the interatrial septum at rest across the mid-interatrial septum consistent with a small secundum atrial septal defect. overall left ventricular systolic function is normal (lvef>55%). there are simple atheroma in the aortic arch and the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened with good leaflet excursion. mild (1+) aortic regurgitation is seen. there is an echodense region along the posterior border of the aorta, adjacent to the non-coronary cusp consistent with a hematoma that measures 1.3x1.5 cm. there is ~3 mm wide continuous jet of color doppler flow from the aortic root into the right atrium ]. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. impression: stable aortic root to right atrial communication with associated hematoma. small secundum-type asd with left to right flow at rest. mild to moderate mitral regurgitation. mild aortic regurgitation. compared with the prior study (images reviewed) of the left atrial mass is no longer seen and may have represented the tip of the "warfarin ridge.". the aortic root to right atrial communication and associated hematoma appear similar. the degree of mitral and aortic regurgitation are both increased. brief hospital course: primary reason for hospitalization: 57yom with h/o l atrial tachycardia/a-fibb, etoh, hcv, now s/p attempted pvi c/b transseptal puncture to aortic root with aortic root to ra fistula. active issues: # fistula: on admission to ccu he received 1u ffp and 3u platelets (platelet count >100). ct surgery was notified and began pre-op eval in the event that he would need open surgical repair of the fistula. his blood pressure was tightly controlled with sbp<100 to reduce pressure gradient between aortic root and right atrium. repeat tee on hd#2 showed slight enlargement of the fistula. he had a tte to determine if the fistula could be monitored with serial ttes, however it could not be visualized on tte. he was extubated on hd#2 and restarted on his home medications. on hd5, a repeat tee was performed which showed stable aortic root to right atrial communication with associated hematoma. small secundum-type asd with left to right flow at rest. mild to moderate mitral regurgitation. mild aortic regurgitation. . # rhythm: procedure was terminated fistula, so patient continued to be in atrial fibrillation. his pradaxa was held due to concern he may need open surgical repair of the fistula (last dose pradaxa am). he was restarted on his amiodarone on hd 1. pradaxa was held on discharge and will need to be restarted in 2 weeks. his rate was controlled in the 80s. . # h/o etoh: he was started on a ciwa scale after extubation and weaning of sedation due to concern for withdrawal given heavy reported etoh history. this was discontinued a day prior to discharge and the patient did well. . stable issues: # htn: stable. his home bp meds (lasix, losartan, hctz) were initially held while on propofol but restarted on hd#2 post-extubation. his hctz was increased to 25 mg and he was started on amlodipine 10 mg for better blood pressure control. . # gerd: stable. he was continued on his home omeprazole. . # anxiety: stable. he was continued on his home anxiety meds (alprazolam, sertraline). . # arthritis: continue home pain medications (vicodin, celebrex) as needed for arthritis pain. transitional issues: -patient maintained full code status throughout hospitalization. -patient will need to be restarted on anti-coagulation in 2 weeks. - follow up with dr. in 1 week medications on admission: alprazolam - 0.5 mg tablet - 1 by mouth up to 2 times a day as needed amiodarone - 200 mg tablet - 1 by mouth three times daily celecoxib - 50 mg - 1 capsule(s) by mouth daily prn dabigatran etexilate - 150 mg capsule - 1 po bid furosemide - 20 mg tablet - 1 tablet(s) by mouth once a day prn hydrocodone-acetaminophen - 7.5mg-750 mg tablet - 1- tablet(s) by mouth twice daily prn as needed for knee pain losartan-hydrochlorothiazide - 100 mg-12.5 mg tablet - 1 po qd omeprazole - 20 mg capsule, delayed release(e.c.) - 1 po qd sertraline - 50 mg tablet - 1tablet(s) by mouth once a day discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po tid (3 times a day). 2. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 3. sertraline 50 mg tablet sig: one (1) tablet po once a day. 4. celebrex 50 mg capsule sig: one (1) capsule po once a day as needed for pain. 5. alprazolam 0.5 mg tablet sig: one (1) tablet po twice a day as needed for anxiety. 6. hydrocodone-acetaminophen 7.5-750 mg tablet sig: one (1) tablet po twice a day as needed for pain. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. furosemide 20 mg tablet sig: one (1) tablet po once a day as needed for leg swelling. 9. pradaxa 150 mg capsule sig: one (1) capsule po twice a day. 10. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 11. losartan 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: aortic root- left atrial fistula high blood pressure gastroesophageal reflux disease arthritis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. it has been a pleasure participating in your care. you were admitted because there is a hole connecting your aorta with one of the of your heart. this connection does not seem to be enlarging so we do not think you need surgery to fix it at this time. you will need to follow-up with dr. who will continue to follow this issue. during your hospitalization we held your blood thinner, pradaxa. you can restart it now at your home dose. . we made the following changes to your medications 1. increase your hctz to 25 mg daily 2. added amlodipine 10 mg daily for blood pressure control followup instructions: name: , : internal medicine location: center address: , , phone: appointment: thursday at 2:10pm . department: cardiac services when: monday at 10:20 am with: , md building: sc clinical ctr campus: east best parking: garage Procedure: Left heart cardiac catheterization Diagnostic ultrasound of heart Other electric countershock of heart Diagnoses: Esophageal reflux Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Atrial fibrillation Hematoma complicating a procedure Alcohol abuse, unspecified Accidental puncture or laceration during a procedure, not elsewhere classified Anxiety state, unspecified Other specified cardiac dysrhythmias Long-term (current) use of anticoagulants Accidents occurring in residential institution Acquired cardiac septal defect Accidental cut, puncture, perforation or hemorrhage during heart catheterization

allergies: penicillins / ampicillin / vicodin es attending: chief complaint: fever s/p colectomy major surgical or invasive procedure: - ex lap, abdominal washout history of present illness: 81f transferred from today after undergoing subtotal colectomy on for diverticular bleeding. the patient had initially presented on for rectal bleeding which ultimately required icu admission and 10 units of prbcs in less than 24 hours. her inr was reportedly 3.0 at presentation and corrected with ffp. a colonoscopy revealed diffuse diverticular bleeding throughout the colon and she was taken on for subtotal colectomy. her postoperative course was complicated by hypotension and hypoxemia as well as a troponin leak to >10, which ultimately resolved. however, beginning 2 days ago the patient reportedly had fevers as high as 103. she was started on vancomycin, levaquin and flagyl and a ct scan was obtained on which demonstrated fluid in the pelvis. of note she was also started on tpn during this hospitalization. she also had elevated lfts which were attributed to large volume blood transfusion, and a ruq ultrasound on was negative for evidence of cholecystitis at . past medical history: pmh: - afib on coumadin - diverticulitis - htn - nephrolithiasis - macular degeneration / legal blindness - niddm - hyperlipidemia psh: hysterectomy (per family, unknown indication or year) social history: no history of tobacco, etoh or illicit drug use; lives at home with husband, daughter and son are nearby family history: n/c physical exam: on admission: vs 102.1 117af 98/45 31 952l gen somnolent but arousable, nad heent l ij triple lumen cvl, site clean cv irreg irreg chest ctab abd soft; vertical midline surgical incision clean/intact with staples and retention sutures; ostomy site pink with dark liquid output; nontender ext wwp, no edema rectal +external hemorrhoids, no gross blood pertinent results: abdominal us (per gi c/s note from ): free fluid in luq, moderately distended gb echo: the left atrium is markedly dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef ? 70%). the right ventricular cavity is dilated with grossly normal free wall contractility. the aortic valve is not well seen. the study is inadequate to exclude significant aortic valve stenosis. significant aortic regurgitation is present, but cannot be quantified. the mitral valve leaflets are mildly thickened. mitral regurgitation is present but cannot be quantified. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. there is no pericardial effusion. if clinically indicated, a transesophageal echocardiographic examination is recommended. ct chest/abd/pelvis: impression: compared to the outside study of : 1. bibasilar collapse and associated effusions, unchanged. no pulmonary parenchymal infiltrates, central pulmonary emboli, or other finding to explain this patient's sepsis. 2. increase in free fluid in the abdomen compared to the prior study, some areas demonstrating peripheral enhancement and thus peritonitis should be considered. no evidence of free air, no evidence of bowel ischemia. 3. collapse of the previously identified pelvic abscess, pigtail drain in appropriate location. residual collection demonstrating foci of air likely indicative of persistent communication with adjacent bowel. this finding is unchanged, however. 4. probable hyperdense cyst within the upper pole of the left kidney, ultrasound confirmation can be performed when the patient is clinically stable. 5. cholelithiasis. though there is pericholecystic fluid, this is felt to be just a portion of the overall free fluid within the abdomen rather than a sign of gallbladder inflammation. 6. an element of diffuse anasarca, increased compared to the prior outside study. 7. subcutaneous contrast within the region of the right wrist. no documentation of contrast extravasation during this current study, likely therefore the result of the outside ct scan. ruq u/s: no evidence of biliary obstruction. ascites loculated. tte: mildly dilated right ventricle with borderline focal apical hypokinesis and septal motion consistent with right ventricular pressure/volume overload. no clinically significant valvular regurgitation or stenosis. moderate pulmonary artery systolic pressure. trivial to very small pericardial effusion superimposed on a prominent anterior fat pad. compared with the prior study (images reviewed) of , the right ventricular systolic dysfunction is likely similar (poor image quality previously). a trivial to very small pericardial effusion is now seen without echocardiographic evidence of tamponade 04:30am blood wbc-16.7* rbc-3.48* hgb-10.6* hct-32.5* mcv-93 mch-30.6 mchc-32.7 rdw-16.8* plt ct-305 04:30am blood neuts-78* bands-1 lymphs-11* monos-8 eos-2 baso-0 atyps-0 metas-0 myelos-0 nrbc-1* 04:30am blood glucose-127* urean-17 creat-1.5* na-134 k-4.9 cl-103 hco3-12* angap-24* 04:30am blood alt-10 ast-43* alkphos-128* amylase-52 totbili-3.3* 04:30am blood albumin-3.5 calcium-8.3* phos-6.1* mg-2.1 iron-37 08:39am blood type-art temp-38.4 po2-80* pco2-23* ph-7.32* caltco2-12* base xs--12 08:39am blood lactate-6.5* brief hospital course: the patient was initially admitted to the , but was transferred to the trauma icu on hd1. on hd2 a ct guided drain was placed into the pelvic collection. she was started on digoxin, and her neo requirement had decreased. she clinically was starting to improve. her lactate levels were also trending down. however, patient had respiratory distress requiring intubation, and she was also transfused two units for low hct. on hd3, fluids were increased for rising lactate, neo was weaned off. she began to have septic physiology. patient was started on for coverage of abscess culture. patient continued to be septic with labile blood pressures, she received several intermittent boluses of albumin. on hd4, patient's hct was stable at 27, tube feeds were initiated with a goal of 65cc/hr. on hd5, a left sided abdominal cellulitis was noted and patient was started on vancomycin for this. her abscess cultures grew klebsiella sensitive to ciprofloxacin, so she was started on cipro. patient's urine output improved, but she still maintained pressor requirement with levophed. she was briefly on neo as well, but this was weaned off. on hd6, patient's lfts started to rise and patient appeared to have ruq tenderness. ruq ultrasound was performed that did not show signs of biliary obstruction. it was discussed whether the patient should have drainage of the gallbladder, but it was felt that she did not have acute cholecystitis warranting drainage. patient continued to require pressors and the ventilator for poor respiratory status. on hd7, patient had an episode of pulseless vtach, that responded to trendelenberg positioning. however, neo had to be restarted for labile blood pressures. amiodarone gtt was started as well. ultrasound guided aspiration of abdomen at bedside showed 400 wbc adn pmn, no organisms on gram stain. however, patient's abdominal pain worsened that evening and her pressor requirement increased with dropping urine output. as such, the patient was taken to the or emergently the night of for ex lap and washout with removal of > 400cc purulenet fluid. postoperatively, the patient began to deteriorate. she was hypotensive requring multiple pressors, and her urine output began to drop. she was having worsening sepsis, not responding to medical management and her lactate was rising. a discussion was held with the family on the morning of , and it was decided to make the patient cmo. she expired shortly thereafter on . medications on admission: meds on transfer: lopressor 25'', dilaudid 0.25 q4h prn, insulin sliding scale, digoxin 0.125mg iv daily, lopressor 5mg q4h prn, albuterol nebs prn, heparin 5000''', zofran prn, protonix 40', flagyl 500''', vancomycin 1000', lasix prn discharge medications: expired discharge disposition: expired discharge diagnosis: sepsis pelvic abscess 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 Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Arterial catheterization Arterial catheterization Arterial catheterization Reopening of recent laparotomy site Peritoneal lavage Diagnoses: Other postoperative infection Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Acute respiratory failure Cardiac arrest Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Long-term (current) use of anticoagulants Other septicemia due to gram-negative organisms Encounter for palliative care Personal history of urinary calculi Do not resuscitate status Peritoneal abscess Ileostomy status Legal blindness, as defined in U.S.A.

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: nippv history of present illness: 86f w/ pmh of copd on home o2 recent admission to for copd flare transferred from for respiratory distress. bibems tonight with increasing prod cough and sob, accidentally dislodged o2 at home. per her daughter, she has been more short of breath than usual even after being discharged from the hospital approximately a week ago on antibiotics. she was seen by a pulmonologist who started spiriva and a steroid taper (she took 40 mg yesterday). she was dyspneic but relatively comfortable last night prior to bed. at 3am, her daughter heard her calling from the bathroom where she was found gasping for breath w/ o2 supply not connected (unclear how long this had been the case). . on arrival to , hypoxic 60s% ra, tachycardic 120s-140s with 4-12 beat run of nsvt. sats improve to 92-95 on 5l. ekg with nsttw changes. cxr ? rml infiltrate. labs with wbc 24k, ck/trop 56/0.16. rec'd solumedrol 125mg iv, levaquin 750mg iv, amiodarone 150mg iv. transfer for elevated troponin, ?pe vs hypoxia vs other. they did not ct patient at b/c rad tech is ~ 45min to 1 hr from hospital. pt was documented as dnr/i. also gave 5mg sc fondiparanux (vte treatment - not prophylaxis dose) empirically pending ct, and asa. . in the ed, initial vs were: t 97.4 p 116 bp 151/82 r 18 o2 sat 97% on 6l. patient was given vanc, ceftriaxone, albuterol, ipratropium nebs, ntg ggt. ekg w/ st depressions laterally. v1-v2 st elevations. cp- l-sided. vitals prior to transfer. 116 (sinus), 182/96, 83% on bipap (). access: 1 piv, getting another. . on arrival, she was in respiratory extremis w/ tachypnea, pursed-lip breathing. c/o intermittent chest pressure that was l-sided. not pleuritic. no f/c. + productive cough (no blood). recent decrease in appetite. + very thirsty. past medical history: copd on 2l nc x 2 (continuously) w/ recent increase in the setting of copd exacerbation htn social history: has lived w/ daughter x 2 but relatively independent w/ adls until last week. former 1 ppd smoker (quit ago). no etoh. family history: nc physical exam: general appearance: no(t) no acute distress, thin, anxious eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: cervical wnl cardiovascular: (s1: normal), (s2: normal), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: wheezes : , diminished: ) abdominal: soft, non-tender, bowel sounds present extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing skin: warm, no(t) rash: neurologic: attentive, follows simple commands, responds to: not assessed, movement: not assessed, tone: not assessed pertinent results: echo : the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thicknesses and cavity size are normal. there is abnormal septal motion (?focal hypokinesis vs. ivcd). overall left ventricular systolic function is low normal (lvef 50%). right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. normal right ventricular cavity size with focal apical hypokinesis. moderate pulmonary artery systolic hypertension. abnormal interventricular septal motion. mild aortic valve stenosis. low normal global left ventricular systolic function. . cxr: there is emphysema. cardiac size is normal. right lower lobe ill-defined opacity is increasing as does opacity in the right upper lobe and engorgement of the vasculature. there is no pneumothorax or large pleural effusions. impression: interstitial pulmonary edema and emphysema. . cxr: no pneumonia or chf. irregular opacity in the left lung base may represent a summation of overlying structures, although it would be difficult to exclude nodule. recommend repeat pa and lateral radiograph with better inspiration and nipple markers. . ekg : sinus tach, 120s, ivcd with left bundle pattern, probable lvh, q-waves v1-3 with mild repolarization increased st segments, no other acute st-t changes 07:50am blood wbc-22.2* rbc-3.63* hgb-11.9* hct-36.1 mcv-100* mch-32.8* mchc-32.9 rdw-14.8 plt ct-294 03:31am blood wbc-18.1* rbc-3.57* hgb-11.6* hct-34.7* mcv-97 mch-32.4* mchc-33.3 rdw-15.1 plt ct-237 06:44am blood wbc-15.7* rbc-3.47* hgb-11.6* hct-33.9* mcv-98 mch-33.5* mchc-34.4 rdw-15.0 plt ct-270 03:48am blood wbc-18.8* rbc-2.98* hgb-10.0* hct-28.6* mcv-96 mch-33.5* mchc-34.8 rdw-15.2 plt ct-263 07:15am blood wbc-10.8 rbc-3.49* hgb-11.1* hct-33.8* mcv-97 mch-31.7 mchc-32.8 rdw-14.8 plt ct-345 07:50am blood neuts-91.8* lymphs-3.4* monos-4.5 eos-0 baso-0.3 03:31am blood neuts-95.0* lymphs-2.5* monos-2.3 eos-0.2 baso-0 07:15am blood neuts-90.9* lymphs-4.0* monos-4.9 eos-0.1 baso-0.2 03:31am blood pt-12.9 ptt-31.6 inr(pt)-1.1 06:44am blood pt-12.5 ptt-30.3 inr(pt)-1.1 03:48am blood pt-12.7 ptt-46.5* inr(pt)-1.1 07:15am blood pt-11.4 ptt-34.1 inr(pt)-0.9 07:50am blood glucose-164* urean-26* creat-0.9 na-137 k-4.6 cl-95* hco3-33* angap-14 03:31am blood glucose-148* urean-29* creat-1.1 na-133 k-4.5 cl-91* hco3-34* angap-13 06:44am blood glucose-124* urean-43* creat-1.3* na-138 k-4.5 cl-90* hco3-36* angap-17 03:48am blood glucose-119* urean-44* creat-0.9 na-138 k-3.9 cl-94* hco3-42* angap-6* 07:15am blood glucose-110* urean-33* creat-0.7 na-140 k-4.2 cl-96 hco3-40* angap-8 07:15am blood alt-42* ast-42* ld(ldh)-325* alkphos-61 totbili-0.6 07:50am blood ck(cpk)-151* 03:16pm blood ck(cpk)-303* 07:48pm blood ck(cpk)-333* 03:31am blood ck(cpk)-191* 07:15am blood lipase-71* 07:50am blood ck-mb-18* mb indx-11.9* probnp-1760* 07:50am blood ctropnt-0.31* 03:16pm blood ck-mb-36* mb indx-11.9* ctropnt-0.41* 07:48pm blood ck-mb-35* mb indx-10.5* ctropnt-0.29* 03:31am blood ck-mb-23* mb indx-12.0* ctropnt-0.26* 07:50am blood calcium-10.4* phos-3.1 mg-2.2 03:48am blood calcium-9.2 phos-2.5*# mg-2.5 07:15am blood albumin-3.1* calcium-9.1 phos-1.7* mg-2.6 iron-pnd cholest-pnd 07:15am blood vitb12-pnd folate-pnd ferritn-pnd trf-pnd 07:15am blood triglyc-pnd hdl-pnd ldlmeas-pnd 03:32pm blood type-art po2-89 pco2-78* ph-7.26* caltco2-37* base xs-4 03:45am blood type- po2-44* pco2-78* ph-7.31* caltco2-41* base xs-8 comment-peripheral blood cultures: + mrsa 6 bottles , . negative , , sensitivities: 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 stool studies: + c diff urine : u/a negative, u cx 10-100l colonies vre hematocrit: admission 36%, nadir 19%, discharge 29% received 4 u prbc total with last cxr: ap chest, 9:14 a.m., history: copd and pulmonary edema with increasing dyspnea. impression: ap chest compared to : lungs are hyperinflated consistent with severe emphysema, but clear of any focal abnormality. there is no pulmonary edema. minimal right pleural effusion unchanged. heart size normal. echo : conclusions the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>70%). there is a mild resting (18mmhg peak) left ventricular outflow tract obstruction with no valvular . right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is minimal valvular aortic stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is mild-moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: normal biventricular cavity sizes with hyperdynamic systolic function and mild resting dynamic lvot gradient. mild-moderate pulmonary artery systolic hypertension. compared with the prior study (images reviewed), of , left ventricular systolic function is now hyperdynamic without regional dysfunction and with a mild resting lvot dynamic gradient. ct torso: : impression: 1. no abdominal or pelvic fluid collections or abscesses. 2. 5-mm nodule in the right upper lobe of the lung. according to guideline criteria, if patient has known malignancy or smoking history would recommend followup in six months. otherwise, repeat imaging in 12 months. 3. additional foci of ground-glass opacity predominantly in the right lung likely represents areas of inflammatory or infectious changes. no abscesses in the lungs. 4. severe s-shaped scoliosis with extensive degenerative changes in the lumbar spine. there is preservation of the vertebral body endplates. if there is clinical concern for discitis, this study is of low sensitivity and would recommend mri for further evaluation. 5. air in the nondependent portion of the bladder and would recommend clinical correlation with recent foley catheterization or instrumentation. 6. severe diffuse atherosclerotic disease, without aneurysm. the study and the report were reviewed by the staff radiologist. brief hospital course: 86 yo female with copd on home o2 s/p recent copd flare admitted to with recurrent copd flare, flash pulmonary edema, and type ii nstemi. copd exacerbation/dyspnea: she was initially admitted to the micu and etiology of dyspnea was thought to be due to copd exacerbation and flash pulmonary edema in the setting of elevated blood pressures and no supplemental o2 at home. pna, acs and pe were all considered, however felt to be unlikely given improvement in symptoms and hypoxia with treatment of pulmonary edema and copd. elevated cardiac enzymes on admission felt to be demand mediated due to tachycardia and hypoxia, rather than acute thrombus. pe felt to be lower probability and no evidence dvt on exam. the patient did not have known chf and echo was obtained, which showed slightly depressed ef of 50% although the study was limited. she was treated with high dose iv steroids therapy which were converted to oral prednisone with a planned 2 week taper. her outpt advair and tiotropium were restarted. she was given frequent xopenex and ipratropium nebulizer treatments. she was initially started on a nitro drip for elevated blood pressures, and able to wean within the first 24 hours. flash pulmonary edema was treated with iv lasix. she was on nippv for approximately 12 hours and was eventually weaned to her baseline home o2. morphine was used for air hunger, however the patient developed hallucinations at higher doses and this was discontinued, it was restarted at lower doses and the patient tolerated it well. she was treated with vancomycin and zosyn initially which were changed to levofloxacin alone and completed a 5 day course for pneumonia vs bronchitis. throughout the hospital course her overall breathing improved. however, the patient continues to have intermittent episodes of mild dyspnea. multiple cxr, ecgs and abgs have been done in this setting which do not show clear abonormality. thus the episodes when mild are thought to be consistent with baseline copd and anxiety. slow breathing techniques work with occasionally needing neb treatments. pt should have pulmonary follow up as outpatient. she did have somewhat increased frequency in dyspnea episodes with lower hematocrits, however, she still had the episodes with hct >30. consideration should be made for repeat gi bleed if the frequency of the events increases. nstemi: elevated cardiac enzymes on admission in the setting of tachycardia and hypoxia. tnt peak of 0.41. ck peak 333. mbi 10-12%. ecg with nonspecific changes and patient was asymptomatic. likely type ii mi with increased demand from tachycardia and poor supply given hypoxia. there was no evidence to support acute plaque rupture physiology. she was continued on full dose aspirin. her imdur was restarted on the medical floor. she was not given beta blocker given significant copd. given her advanced age, she was not given a statin. lipids were checked and were under good control so statin was not started. during the patient's stay in the micu on , she developed chest pain radiating to neck and back. ekg was unchanged, and cardiac enzymes were lower than previous, 2 more sets were cycled and were pending on transfer to the floor. aspirin was stopped in the setting of an acute gi bleed. gi bleed: the patient was found to have large amounts of melena with a 10 point hematocrit drop on . for this she was briefly transferred to the icu and given 2 units of blood. however, given the patient's tenuous respiratory status, an egd was deferred. after several discussions with the family, it was decided to hold off on an egd unless the patient again became clinically unstable. the patient did have a total of 4 u prbc and had a stable hematocrit for >8 days. however, no egd was performed and the cause of the patient's bleeding is unknown. h pylori ab and stool antigen was negative. the patient did have hsv pharyngitis which could have caused esophageal ulceration and the gi bleeding. hsv pharyngitis: the patient had persistent dysphagia that was found to be hsv. she was treated with po valtrex for a 10 day course without issue. mrsa bacteremia: the patient was found to have a small pustule in the right antecubital fossa that was cultured to be positive for mrsa. 1 day later, the patient developed fevers and blood cultures positive for mrsa. high grade bacteremia was detected with mrsa with a total of 6 bottles positive. the patient had no signs of emboli including negative ct torso and transthoracic echo negative for endocarditis. however, given the patient's high grade bacteremia, the decision was made to treat empirically given systolic murmur and inability to perform tee (secondary to her respiratory status). thus the patient should finish her vancomycin on with id follow up the day prior. weekly cbc, lfts and chem 7's should be checked with the results faxed to the clinic at . acute systolic heart failure: developed acute pulmonary edema in the initial days of the hospitalization that occurred in the setting of slightly depressed ef on echo with evidence of elevated r sided filling pressures, likely due to underlying lung disease. less likely pe given rapid improvement in hypoxia as above. mild as. no priors for comparison. she was treated with aspirin and copd therapy to avoid hypoxia and worsened pulmonary htn. she did not receive beta blocker given her copd. in and outs as well as daily weights were monitored throughout. she required intermittent iv lasix in the setting of respiratory distress and tachycardia presumed to be flash pulmonary edema with good response. no lasix was needed for the last 1-2 weeks of hospitalization and bnp was lower than admission at ~700. leukocytosis: initially 22k on admission. declined to 15k and had risen but down to 10k after transfer to the floor. potentially due to pulmonary infection. no evidence of uti on u/a. could also be due to stress response as well as persistent steroid requirement. she was treated with a 5 day course of levofloxacin. repeat cxrs showed evolution of rll infiltrate but given that she remained afebrile and wbc resolved, antibiotics were not broadened beyond levofloxacin. htn: initially treated with nitro drip and then weaned and restarted on home amlodipine. per report, she also takes lisinopril as an outpatient but as bp was well controlled on amlodipine alone, lisinopril was not restarted. amlodipine was increased to 7.5 mg daily. transaminitis, elevated lipase: found on routine labs. tbili normal. abdominal exam benign. no fevers. normal lfts on discharge. pulmonary nodule: irregular l lower lobe density seen on cxr. stable on repeat cxrs. consider outpatient ct scan to further evaluate although unclear that patient would want any intervention. . # code: dnr/dni . # communication: patient, hcp daughter () . grandson is a resident at nyu (. medications on admission: spiriva (recently started) prednisone 40 mg daily (just decreased yesterday) combivent nebs prn advair imdur lisinopril norvasc 5 daily calcium vitamin d stool softeners mucinex remeron discharge medications: 1. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<110. 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). 4. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 5. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 6. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 7. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 8. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed. 9. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po daily (daily) as needed for constipation. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po every twelve (12) hours for until completion of steroid taper days. 12. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) neb inhalation q4h (every 4 hours). 13. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 14. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gram intravenous q 24h (every 24 hours): for 6 weeks (finish on ). 15. vancomycin 250 mg capsule sig: one (1) capsule po q6h (every 6 hours): for 7 weeks, finish on . 16. maalox 200-200-20 mg/5 ml suspension sig: five (5) ml po tid (3 times a day) as needed. 17. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: primary: - copd exacerbation - pneumonia - acute pulmonary edema secondary: - copd - hypertension discharge condition: normal o2 saturation on baseline home o2 2lnc. hemodynamically stable. discharge instructions: you were admitted to the hospital for shortness of breath due to your copd, a pneumonia, and some fluid in your lungs. you improved with steroids, antibiotics, and removal of fluid from your lungs with lasix. . please continue to take all medications as prescribed. please continue to take the antibiotics levofloxacin as prescribed. please continue to take the steroid prednisone as prescribed. . please call your doctor or return to the hospital if you experience any fevers, chills, worsening shortness of breath, chest pain, palpitations, abdominal pain, nausea, vomiting, or any other concerns. followup instructions: please follow up with your pcp . after discharge from rehab. please call to schedule an appointment. phone: . Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Long-term (current) use of steroids Acute posthemorrhagic anemia Acute kidney failure, unspecified Obstructive chronic bronchitis with (acute) exacerbation Other chronic pulmonary heart diseases Other opiates and related narcotics causing adverse effects in therapeutic use Constipation, unspecified Acute and chronic respiratory failure Other specified cardiac dysrhythmias Bacteremia Blood in stool Cellulitis and abscess of upper arm and forearm Intestinal infection due to Clostridium difficile Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Acute systolic heart failure Metabolic encephalopathy Delirium due to conditions classified elsewhere Hypercalcemia Neutropenia, unspecified Endocarditis, valve unspecified, unspecified cause Mixed acid-base balance disorder Acute pharyngitis Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Other dependence on machines, supplemental oxygen Herpes simplex with other specified complications Benign essential hypertension

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: myocardial infarction major surgical or invasive procedure: -urgent coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and distal circumflex arteries. 2. endoscopic harvesting of the long saphenous vein. history of present illness: this 65 yo.male presented to the hospital ed with midsternal pressure radiating to arms with dyspnea after climbing stairs, described as pain on . this was present for 3 days prior with minimal exertion. troponin peaked at 0.95 and cardiolgy saw him, r/i for non-stemi. cath today to reveal 50% distal lm,80% osteal lad,prx 80%, small nondominant rca.nl lv with lvedp 20. referred here for surgery, having been painfree until early afternoon. pain with ecg changes led to heparin/ntg iv with resolution. past medical history: lumbar disc disease s/p laminectomy social history: occupation: machinist last dental exam:few months ago lives with: his wife :caucasian tobacco: 50 pack year history quit 4 days ago etoh: occassional family history: ? brother w/ mi age 55 physical exam: pulse: 70 sr resp: 13 o2 sat: 94 on nc b/p right: 121/67 left: height: 66 weight: 81 kg general:nad skin: dry intact right groin cath site, right leg calf skin venous stasis discoloration heent: perrla eomi neck: supple full rom chest: decreased right base, no crackles/rhonchi/wheezing heart: rrr irregular no murmur/rub/gallop abdomen: soft non-distended non-tender bowel sounds+ no masses extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: cath site left: +2 dp right: doppler left: doppler pt : +1 left: +1 radial right: +1 left: +1 carotid bruit right: no bruit left: no bruit pertinent results: 06:16pm wbc-11.3* rbc-4.81 hgb-15.1 hct-42.9 mcv-89 mch-31.4 mchc-35.2* rdw-13.1 06:16pm %hba1c-5.7 06:16pm alt(sgpt)-21 ast(sgot)-23 ld(ldh)-100 ck(cpk)-45 alk phos-67 amylase-120* tot bili-0.5 06:51pm urine rbc-* wbc-21-50* bacteria-mod yeast-none epi-0 06:51pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-sm 06:00am blood wbc-13.1* rbc-3.65* hgb-11.3* hct-33.5* mcv-92 mch-30.9 mchc-33.6 rdw-13.5 plt ct-280# 06:00am blood plt ct-280# 06:50am blood urean-13 creat-0.8 k-3.9 echo pre-bypass: no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. there is no aortic valve stenosis. no aortic regurgitation is seen. trivial mitral regurgitation is seen. there is a small pericardial effusion. post-bypass: sinus rhythm, no vasoactive infusions. 1. bi ventricular function is hyperdynamic and normal 2. aortic contours appear intact post decannulation. 3. other findings are unchanged. , m 65 radiology report chest (portable ap) study date of 7:12 am final report study: ap chest, . history: 65-year-old man status post cabg. evaluate right-sided pneumothorax. findings: comparison is made to previous study from . there is a tiny right apical pneumothorax which is unchanged since the previous study. there is some atelectasis at the lung bases, which is stable. there are no signs of focal consolidation or overt pulmonary edema. dr. brief hospital course: mr. was admitted via transfer from hospital for surgical management of his coronary artery disease. he was transferred on heparin and nitroglycerin because he had chest discomfort prior to leaving , he was admitted to the intensive care unit for close observation. he was worked-up in the usual preoperative manner. vein mapping showed no deep vein throbosis. there was a question of disruption to the right greater saphenous vein due to previous trauma. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. please see operative note for details. in summary he had: urgent coronary artery bypass graft x3, with left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and distal circumflex arteries. 2. endoscopic harvesting of the long saphenous vein. his bypass time was 86 minutes with a crossclamp of 71 minutes. he tolerated the operation well and was transferred to the cardiac surgery icu in stable condition. in the immediate post operative period he was hemodynamically stable, he awoke neurologically intact and was extubated. beta blockade, aspirin and a statin were resumed. an ace inhibitor will be started if his blood pressure and renal function tolerate given his preoperative myocardial infarction. after extubation he remained hemodynamically stable and 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 protocols. he was gently diuresed towards his preoperative weight. the remainder of his post operative stay was uneventful, physical therapy was consulted for assistance with his postoperative strength and mobility. he continued to progress and on pod5 he was discharged home with visiting nurses. medications on admission: tylenol prn started at hospital: asa 325', lopressor 25" discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*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:*2* 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. 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* 6. keflex 500 mg capsule sig: one (1) capsule po twice a day for 2 weeks. disp:*28 capsule(s)* refills:*0* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: cad/myocardial infarction s/p cabg x3 lumbar disc disease s/p lumbar laminectoy ' discharge condition: good discharge instructions: 1) monitor wounds for signs of infection(redness, drainage or increased pain). please report all wound issues to your surgeon at (. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) please shower daily. wash incision with soap and water. no lotions, creams or powders to incision for 6 weeks. 5) no lifting greater then 10 pounds for 6 weeks from date of surgery. 6) no driving for 6 weeks or while taking narcotics. 7) please call with any questions or concerns. followup instructions: wound clinic in 2 weeks-nurse appt before discharge please follow-up with dr. in 1 month. ( please follow-up with dr. in weeks. please follow-up with dr. in weeks. please call all providers for appointments. md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Thrombocytopenia, unspecified Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Degeneration of lumbar or lumbosacral intervertebral disc

allergies: patient recorded as having no known allergies to drugs attending: addendum: ms is a year old woman who was admitted for aortic valve replacement. prior to admission she had several episodes of pulmonary edema/congestive heart failure. her preoperative ejection fraction was 60% with an left ventricular end diastolic pressure was 17 millimeters of mercury. the ejection fraction was preserved post operatively. the preoperative pulmonary edema/heart failure is felt to represent acute on chronic diastolic heart failure. discharge disposition: extended care facility: lifecare of md Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Chronic diastolic heart failure Long-term (current) use of aspirin

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: aortic valve replacement ( tissue) history of present illness: is a year old woman with known aortic stenosis and coronary artery disease. she has had multiple recent admissions for pulmonary edema. she was admitted for cardiac surgery. past medical history: aortic stenosis s/p valvulopasty in coronary artery disease mrsa (left elbow cellulitis) hypertension pancreatitis gastric esophageal reflux disease hypercholesterolemia colovesical fistula repair s/p trach after valvuloplasty and pancreatitis in ' bilateral cataracts social history: she lives with her family and is widowed. she denies tobacco and alcohol use. family history: non-contributory physical exam: at the time of admission, ms. was in no acute distress. she is noted to use a cane for ambulation. her skin is intact. her neck is supple with no jvd. her lungs are clear to ausculation bilaterally. her heart is of regular rate and rhythm with a iii/vi systolic ejection fraction. her abdomen is soft, non-tender, and non-distended. her extremities are warm and well-perfused with trace edema. left lower extremity varicosities are noted. pertinent results: 05:00am blood wbc-9.2 rbc-2.99* hgb-9.3* hct-27.3* mcv-91 mch-31.0 mchc-33.9 rdw-15.0 plt ct-127* 05:00am blood plt ct-127* 05:00am blood glucose-97 urean-21* creat-0.9 na-138 k-4.5 cl-104 hco3-28 angap-11 05:15am blood wbc-7.5 rbc-2.80* hgb-9.2* hct-26.1* mcv-93 mch-32.7* mchc-35.1* rdw-14.3 plt ct-230# 05:15am blood glucose-97 urean-20 creat-0.9 na-141 k-4.5 cl-102 hco3-32 angap-12 echocardiography report , (complete) done at 10:19:25 am final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): f hgt (in): 65 bp (mm hg): 134/78 wgt (lb): 155 hr (bpm): 67 bsa (m2): 1.78 m2 indication: intraoperative tee for avr. aortic valve disease. chest pain. coronary artery disease. hypertension. left ventricular function. mitral valve disease. preoperative assessment. right ventricular function. shortness of breath. icd-9 codes: 745.5, 786.05, 786.51, 440.0, 424.1, 424.0 test information date/time: at 10:19 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 #: 2009aw5-: machine: aw5 echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: *1.4 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 3.6 cm <= 5.6 cm left ventricle - systolic dimension: 1.9 cm left ventricle - fractional shortening: 0.47 >= 0.29 left ventricle - ejection fraction: 60% >= 55% aorta - ascending: 3.4 cm <= 3.4 cm aortic valve - peak velocity: *3.9 m/sec <= 2.0 m/sec aortic valve - peak gradient: *59 mm hg < 20 mm hg aortic valve - mean gradient: 34 mm hg aortic valve - valve area: *0.4 cm2 >= 3.0 cm2 mitral valve - mva (p t): 1.6 cm2 mitral valve - e wave: 1.3 m/sec mitral valve - a wave: 1.7 m/sec mitral valve - e/a ratio: 0.76 findings left atrium: no spontaneous echo contrast in the body of the laa. right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. left-to-right shunt across the interatrial septum at rest. small secundum asd. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. mild symmetric lvh. normal lv cavity size. normal regional lv systolic function. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: simple atheroma in aortic root. normal ascending aorta diameter. simple atheroma in ascending aorta. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: severely thickened/deformed aortic valve leaflets. severe as (aova <0.8cm2). moderate to severe (3+) ar. mitral valve: severely thickened/deformed mitral valve leaflets. severe mitral annular calcification. mild valvular ms (mva 1.5-2.0cm2). moderate (2+) mr. tricuspid valve: mild tr. 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 prebypass 1. no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. a left-to-right shunt across the interatrial septum is seen at rest. a small secundum atrial septal defect is present. 2. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3.right ventricular chamber size and free wall motion are normal. 4.there are simple atheroma in the aortic root. there are simple atheroma in the ascending aorta. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis (area <0.8cm2). moderate to severe (3+) aortic regurgitation is seen. 5.the mitral valve leaflets are severely thickened/deformed. there is severe mitral annular calcification. there is mild valvular mitral stenosis (area 1.5-2.0cm2). moderate (2+) mitral regurgitation is seen. 6. dr. was notified in person of the results on at 845am. post bypass 1. patient is a paced and receiving an infusion of phenylephrine. 2. biventricular systolic function is unchanged. 3. bioprosthetic valve seen in the aortic position. the leaflets move well and the valve appears well seated. no aortic insufficiency seen. peak gradient across the aortic valve is 27 mm hg and the mean gradient is 11 mm hg. 4. mild mitral regurgitation is present. 5. aorta intact post decannulation. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 00:13 ?????? caregroup is. all rights reserved. brief hospital course: on ms. was taken to the operating room and underwent an aortic valve replacement with a st. tissue aortic valve. this procedure was performed by dr. . please see the operative note for details of the case. she tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. she was extubated on the following day and her pressors were weaned. she was drowsy but easy to arrouse. on post-operative day two her chest tubes were removed. she was gently diuresed. she experienced atrial fibrillation and converted to sinus rhythm on amiodarone and beta blockers. on the following day she was transferred to the surgical step down floor and her epicardial wires were removed. she was seen in consultation by physical therapy. her beta blockade was tirated upward as tolerated. her diuretic regimen was increased due to a wet chest radiograph. the patient developed atrial fibrillation again on pod 6. her blood pressure remained stable, and she was asymptomatic. beta blocker and amiodarone were adjusted accordingly. coumadin was started for a goal inr 2.0. she was discharged to rehab in good condition on pod 6. medications on admission: lasix 160mg daily lisinopril 5mg daily metoprolol 25mg zocor 10mg daily aspirin 325mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. simvastatin 10 mg tablet sig: one (1) tablet po once a day. 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. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours). 10. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed). 11. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day): hold for sbp<90, hr<60. 12. amiodarone 200 mg tablet sig: two (2) tablet po tid (3 times a day): 400mg 3x/day for 1 week, then 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then 200mg/day until further instructed. 13. warfarin 1 mg tablet sig: three (3) tablet po once a day: for atrial fibrillation, titrate daily for goal inr 2.0. 14. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 15. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po bid (2 times a day). discharge disposition: extended care facility: lifecare of discharge diagnosis: aortic stenosis 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 followup instructions: dr in 4 weeks () please call for appointment dr (pcp) in 1 week ( please call for appointment dr in weeks (cardiology) please call for appointment Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Chronic diastolic heart failure Long-term (current) use of aspirin

allergies: no known allergies / adverse drug reactions attending: chief complaint: trauma: moped accident left radial fracture very small falx sdh major surgical or invasive procedure: orif l distal radius fx history of present illness: history of presenting illness this patient is a 30 year old male who complains of mcc. helmeted driver of moped that t. boned taxi, patient reportedly ejected over the vehicle. repetitive questioning en route with left forearm deformity. hemodynamically stable prior to arrival past medical history: none social history: positive for alcohol and drugs family history: nc physical exam: physical examination upon admission: temp: 97.6 hr: 77 bp: 135/64 resp: 15 o(2)sat: 98 normal constitutional: repetitive questioning and no tenderness to heent: normocephalic, atraumatic, pupils equal, round and reactive to light, extraocular muscles intact dried blood in nares chest: clear to auscultation cardiovascular: regular rate and rhythm abdominal: soft, nontender, nondistended extr/back: no cyanosis, clubbing or edema skin: no rash neuro: speech fluent pertinent results: 04:55am blood hct-39.4* 03:22am blood wbc-14.1* rbc-4.14* hgb-13.1* hct-38.1* mcv-92 mch-31.6 mchc-34.3 rdw-13.6 plt ct-245 03:03pm blood hct-39.2* 04:11am blood wbc-11.6* rbc-4.57* hgb-14.3 hct-41.9 mcv-92 mch-31.2 mchc-34.1 rdw-13.5 plt ct-279 03:22am blood plt ct-245 04:11am blood pt-10.8 ptt-26.8 inr(pt)-1.0 04:11am blood fibrino-225 03:22am blood glucose-125* urean-13 creat-1.0 na-138 k-4.0 cl-103 hco3-24 angap-15 04:11am blood urean-18 creat-0.9 03:22am blood calcium-9.0 phos-2.8 mg-1.9 04:11am blood asa-neg ethanol-120* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:22am blood glucose-99 lactate-2.7* na-140 k-3.9 cl-103 calhco3-24 : chest x-ray: impression: normal limited chest radiograph. : cat scan of the head: impression: no acute intracranial injury. : cat scan of the c-spine: impression: no cervical spinal fractures or malalignment : cat scan of abdomen and pelvis: impression: 1. 4 x 2 cm retroperitoneal hematoma in between the psoas and abdominal aorta with a focus of contrast enhancement. given temporal stability, active arterial extravasation is unlikely. this most likely represents a venous bleed, but an arterial psuedoaneurysm is possible. 2. sequelae of prior trauma to the spleen and left kidney : left wrist x-ray: impression: distal third radius fracture. : left wrist x-ray: impression: 1. left radial diaphsysis fracture, with dorsal displacement, minimal overriding, and slight medial apex angulation. 2. high suspicion for disruption of the distal radioulnar joint. : cat scan of the head: no change in the thin falcine subdural hematoma. : x-ray of left fore-arm: pending ( informed by ortho. that pt could be discharged prior to final ) brief hospital course: 30 year old gentleman involved in a moped accident who was admitted to the acute care service. upon admission, he was made npo, given intravenous fluids, and underwent radiographic imaging. he was reported to have a left radial fracture, a small subdural hematoma, and a retroperitoneal hematoma. he was admitted to the intensive care unit for neurological monitoring, and serial hematocrits. on hd #1, he was taken to the operating room for a orif l distal radius fx. his operative course was stable with minimal blood loss. he was transferred to the surgical floor on hd #2 after his hematocrit stabilized. his hemodynamic and pulmonary status is stable. he is afebrile and tolerating a regular diet. his surgical pain is controlled with oral analgesia. his hematocrit has normalized at 39.0. he has been evaluated by physcial and occupational therapy and recommendations made for discharge home. he has also been evaulated by the social worker who provided him with additional support. he will follow-up with orthopedics, cognitive neurology, and the acute care service. medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for head ache. 2. phenytoin 50 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day) for 5 days: started ....complete course . disp:*30 tablet, chewable(s)* refills:*0* 3. colace 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stools. 4. oxycodone 5 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain: may cause increased sedation, drowsiness. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: trauma: moped collision r radial fracture very small falx sdh discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. sling to left arm discharge instructions: you were admitted to the hospital after you were involved in a moped collision. you sustained a fracture to your left arm and a small bleed into your head. you were taken to the operating for repair of the left radial fracture. your vital signs have been stable and your pain is well controlled with medication. you are preparing for discharge home with the following instructions: orthopedic: - continue to be non-weight bearing on your left arm - elevate left arm to reduce swelling and pain. - do not remove the splint an keep the splint dry. followup instructions: it is recommended that you establish care with a primary care physician 2 weeks. if you need assistance finding a pcp outside the area, your local hospital or healthcare center can be a resource.if you are looking for a pcp in the area or need further assistance please call the find-a-doc line at (. we are able to assist you between the hours of 8:30 am- 5:00 pm monday through friday. *** your insurance records are incomplete- please call our registration department at ( before your first appointment listed below to prevent you from getting , thank you.*** department: orthopedics when: tuesday at 2:00 pm with: , pa building: sc clinical ctr campus: east best parking: garage department: general surgery/ when: thursday at 3:30 pm with: acute care clinic building: lm bldg () campus: west best parking: garage cognitive neurology: pending with: dr. ??????we are working on a follow up appt with dr. in the neurology dept. for you to be seen with in a week from your discharge. you will be called at home with the appointment. if you have not heard with in 2 business days from your discharge or have questions, please .?????? delayed for e-signing until 11/. thus limits ability to further modify. accurate as best as i can recall. Procedure: Open reduction of fracture with internal fixation, radius and ulna Closed reduction of dislocation of wrist Diagnoses: Alcohol abuse, unspecified Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum Other closed fractures of distal end of radius (alone) Closed dislocation of radioulnar (joint), distal

allergies: sulfa (sulfonamides) / pentothal / codeine / wellbutrin / zosyn / meropenem attending: chief complaint: raw skin around ostomy major surgical or invasive procedure: takedown/reversal of ileostomy with ileorectal anastomosis. history of present illness: this is a 61 yo woman with h/o colostomy/ileostomy, copd, morbid obesity who presents with increased output from wound adjacent to ostomy. of note she went home from rehab at the end of (about 2 weeks ago) and things seem to be worse since. she notes the vna nurse told her about a week ago she had an open area adjacent to her ostomy that was draining. she has had such discomfort from the skin around her ostomy that she has been unable to keep an ostomy bag on it for the last week or so. she was seen by someone (? pcp) who started her on keflex to try to help the abdominal wall irritation improve (with no sign change-finished ) and also started her on macrobid for a uti (but ms. took it instead of qid so is still taking it even though it was to finish and took 1/2 dose). she states she couldnt take it at home anymore so came in. denies change in stool consistency, fevers or chills. she feels diffuse abdominal pain. no nausea or emesis but has been eating less intentionally so she could reduce her stool output for the last 3 days. . past medical history: hypertension diabetes obesity copd on home o2 2-3l at all times obstructive sleep apnea on home cpap: don't know settings obesity hypoventilation syndrome diastolic chf (by c.cath ) osteoarthritis s/p total colectomy for c.diff colitis with end ileostomy social history: quit smoking after 40-50 pack years. no etoh, or illicit drugs. recently moved home with her husband after long rehab stay. family history: there is family history of premature coronary artery disease- her father died in his 40s of an mi. physical exam: vs: t 98.4 hr 84 bp 126/74 rr 18 sat 99% 3l nc gen: chronically ill appearing woman in nad heent: eomi, perrl, conjunctiva clear, sclera anicteric, mmm, op clear neck: no jvd, no lad, no thyromegaly, no carotid bruits cardiovascular: rrr, nl s1/s2, no m/r/g respiratory: cta bilaterally, comfortable, no wheezing, no rhonchi, no rales gastrointestinal: soft, non tender, no rebound, obese, no hepatosplenomegaly, normal bowel sounds, g tube in place, left side with large (15cm x 10cm) pink ulceration and erythema musculoskeletal/extremities: no clubbing, no cyanosis, no joint swelling, trace edema in the bilateral extremities neurological: alert and oriented x3, fluent speech, sensation wnl, cnii-xii intact . at discharge: gen: a and o x3, nad v.s 99.1, 84, 134/66, 18, 100% ra. cv: rrr no m/r/g resp: lscta, sl decreased at bases. abd: soft, sl tender at incision site, obese, nd. incision: abd ota with staples, small open area with w-d dressing, old g-tube site with dressing. no s/s of infection at either site. ext: bilat le edema pertinent results: 06:20pm blood wbc-9.7 rbc-3.87* hgb-10.4*# hct-32.2*# mcv-83 mch-26.9* mchc-32.4 rdw-18.4* plt ct-413 08:28pm blood pt-13.2 ptt-21.5* inr(pt)-1.1 06:20pm blood glucose-113* urean-29* creat-1.7* na-138 k-4.9 cl-101 hco3-26 angap-16 06:20pm blood %hba1c-5.7 06:20pm blood tsh-2.5 06:30pm blood lactate-1.0 . ct abd ct abdomen with iv contrast: focal consolidation at the left lung base is unchanged, and likely represents atelectasis. there is no pleural effusion. the heart is normal in size without pericardial effusion. in the abdomen, the liver, gallbladder, pancreas, spleen, adrenal glands, stomach, and duodenum are unremarkable. the kidneys enhance and excrete contrast symmetrically. there is no free air or free fluid in the abdomen. the abdominal aorta demonstrates mild atherosclerotic calcification. scattered mesenteric and retroperitoneal lymph nodes do not meet ct criteria for pathologic enlargement. a percutaneous g-tube terminates in the stomach. ct pelvis with iv contrast: the patient is post colectomy. multiple loops of small bowel contain oral contrast, and are not distended. contrast extends through the small bowel to the ileostomy site in the anterior abdominal wall, and passes freely through the ileostomy. only a single channel of contrast passes through the abdominal wall. no contrast-filled enterocutaneous fistula is identified. a small focus of air within the deep subcutaneous/muscular layers adjacent to the ileostomy site is noted, decreased since the prior study. there is no associated fluid collection to suggest abscess. stranding is noted in the subcutaneous tissues. the urinary bladder, distal ureters, uterus, and adnexa are unremarkable. there is no free fluid in the pelvis. there is no pelvic or inguinal lymphadenopathy by size criteria. osseous structures: s-shaped curvature of the spine is unchanged. there is no fracture or worrisome bony lesion. soft tissues are unremarkable. impression: 1. no evidence of enterocutaneous fistula at this time. 2. interval decrease in size of subcutaneous air adjacent to the ostomy. no associated fluid collection to suggest abscess. . ct abd: dilated sb to ostomy, contrast in stomach be: normal hartmann pouch, no stricture/obstruction/oeak 10:00pm blood wbc-8.8 rbc-3.08* hgb-8.2* hct-26.8* mcv-87 mch-26.7* mchc-30.7* rdw-17.0* plt ct-291 10:00pm blood plt ct-291 04:42am blood pt-14.2* ptt-24.9 inr(pt)-1.2* 10:00pm blood glucose-138* urean-25* creat-1.9* na-138 k-3.7 cl-103 hco3-29 angap-10 05:59am blood calcium-7.8* phos-3.0 mg-2.2 07:25am blood albumin-3.6 calcium-9.4 phos-4.4 mg-2.3 iron-28* 07:25am blood caltibc-239* trf-184* 06:20pm blood %hba1c-5.7 brief hospital course: in short, ms is a 61 y/o f with hx of colostomy, copd, htn, dm and obesity who presented from home with inability to care for her ostomy and worsening skin breakdown around the site. . # ostomy wound and skin breakdown - patient was evaluated in the ed with a ct scan showing flow through the ostomy without any entero-cutaneous fistulas. wound care nurse at home told patient there was a fistula. surgery evaluated her in the ed and does not think there is a fistula as the wound adjacent to the ostomy was probed and could not be passed. the ostomy nurse examined the patient and recommended some various wound cleaning suggestions, as well as placing a bag over the ostomy. she continued to have pain around her wound throughout her admission and was treated with dilaudid po which controlled the pain to an acceptable level. the wound did not appear infected. . # nausea and vomitting - the two days prior to discharge, the patient developed some nausea and vomitting. it is unclear the etiology. she felt better with zofran. she thinks it was something in the food that she ate. she had the same level of abdominal pain that she had upon admission, and was tolerating pos and having appropriate output through her colostomy. surgery was following along and did serial exams that were not concerning for an acute abdomen. she can continue to be treated wtih antiemetics as needed as long as she has appropriate stool output and vomit remains non bilious and non bloody. . # uti - had positive ua but culture grew yeast and was likely a contaminant. had one day of cipro and then it was stopped when culture data returned. . # dm - patient takes metformin at home, sugars have been well controlled, was d/c'ed on lantus previously. we held the metformin because of her ckd and put her on insulin sliding scale. her hba1c was 5.7. she can stay on insulin for now but eventually go back on metformin (if her kidney function is ok) as she would be unlikely to be able to administer insulin to herself. . # neuropathy - patient with severe peripheral bilateral neuropathy today. at home takes celebrex and dilaudid for pain medicines. held celebrex for ckd and added gabapentin for neuropathy. per patient, gabapentin helped pain improve. . # ckd - seems to be at baseline, but creatinine has been variable past few months. received some ivfs the night prior to ct scan, and creatinine was not rechecked because she refused labs every time. . # copd - stable, did fine on room air . # osa - stable, do not know cpap settings . # depression - was tearful and obviously depressed throughout hospitalization, she was on venlafaxine per old disharge summaries, but she does think she's taking it anymore. she kept saying that she hoped she died, but always denied suicidal ideation. psych was consulted because depression was hindering her ability to get well from a medical standpoint. she was started on celexa. micu course () transferred to icu after failure to extubate. thought to be hypoventilation in the setting of narcotics for post-op pain and baseline disease (copd, obesity hypoventilation). tolerated ps trial in icu and was successfully extubated. started on a dilaudid pca. bolused w fluid for hypotension. transferred to floor. . the patient was transferred to the floor and was continued as npo, with foley, g-tube to gravity and iv meds/ivf. an ngt was placed secondary to n/v and decreased ostomy output. on the patient was taken to the or for takedown/reversal of ileostomy with ileorectal anastomosis. she returned to the floor and was made npo with ivf/foley/g-tube to gravity and iv meds. with the return of bowel function and flatus her diet was advanced from sips to regular. here g-tube was than removed, however it was noted that there was output from the g-tube site and a ct scan was done. see report. staples were removed from her incision and packed with w-d dressing . physical thearpy worked with patient daily and pt got oob to chair. the patient refused skin care, explained to patient the risks of this and she still refused. the patient will return to rehab for physical therapy and wound care. she will follow up with dr. in 1 week. medications on admission: meds: patient largely unable to verify duoneb 0.5-2.5 mg/3 ml q4h prn shortness of breath zantac 150mg daily (confirmed) dilaudid 2 mg po q3h prn as needed for pain - takes at least daily nystatin powder santyl ointment to ostomy macrobid as above metformin (does not know dose) celebrex 200mg daily . maybe: calcium acetate 667 po tid w/meals quetiapine 50 mg po at bedtime . no longer taking we think: arinesp 16mcg sc qwednesday venlafaxine 75 mg po daily insulin 7 units lantus sc qhs plus sliding scale lorazepam 0.5 mg po bid prn as needed for anxiety discharge disposition: extended care facility: center discharge diagnosis: primary diagnosis: 1. skin breakdown around ostomy 2. diabetes 3. depression 4. copd 5. nausea and vomitting discharge condition: stable. tolerating regular diet. pain well controlled with oral medications. discharge instructions: please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *avoid driving or operating heavy machinery while taking pain medications. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. . incision care: -your staples will be removed at your follow up appointment. -steri-strips will be applied and will fall off on their own. please remove any remaining strips 7-10 days after application. -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. . dressing: abd: please continue with wet-dry dressing changes . . g-tube was removed during your hospital stay. followup instructions: 1. please call dr. office, , to make a follow up appoinmtent in 1 week. 2. please follow up with your pcp at within one to two weeks after you are discharged from rehab. md, Procedure: Closure of stoma of small intestine Non-invasive mechanical ventilation Diagnoses: Acidosis Other iatrogenic hypotension Hypocalcemia Obstructive sleep apnea (adult)(pediatric) Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Nausea with vomiting Acute respiratory failure Right bundle branch block Morbid obesity Osteoarthrosis, unspecified whether generalized or localized, site unspecified Other chest pain Other postprocedural status Unspecified hereditary and idiopathic peripheral neuropathy Chronic diastolic heart failure Tracheostomy status Other colostomy and enterostomy complication Adjustment disorder with mixed anxiety and depressed mood Sleep related hypoventilation/hypoxemia in conditions classifiable elsewhere

allergies: sulfa (sulfonamides) / pentothal / codeine / wellbutrin / zosyn / meropenem attending: chief complaint: hypercarbic/hypoxic respiratory failure acute renal failure major surgical or invasive procedure: peg placement tracheostomy placement central venous catheter placement history of present illness: 61 y.o. female with dm, htn, dchf, copd, obesity hypoventilation syndrome, who was admitted to on , after being found unresponsive at home by her husband. unclear how long down (husband returned from work 4:30pm, pt last seen in am). she had hypercarbic and hypoxemic resp failure (initial sats 60s, ph 7.12, pco2 120s) and was intubated. her osh course by system: . respiratory: initially had total collapse of left lung, and underwent bronchoscopy upon admission, ? mucous plug. bal growing gpcs (no speciation reported or sent). treated with vanco/levo/zosyn from , but vanco stopped when mrsa screen negative. remains intubated, on assist control, 500, 18, (breathing 19-20), fio2 0.4, peep 5. abg: 7.16/52/98. sedation with propofol. cv: was intially hypotensive, placed on levophed. this was weaned within 48 hours admission. lactate borderline elevated initially, no repeat. has had to be placed back on levophed x last 2 days prior to tranfer for recurrent hypotension renal: initially normal renal fx. cr began to rise shortly after admission, and still rising (today 6.8). persistent hyperkalemia, acidemia. bicarb falling. receiving kayexalate and insulin gtt id: mrsa screen neg. sputum from admission growing gpcs, but no speciation reported. urine growing proteus. endo: h/o dm, currently on insulin gtt . gi: ngt. report of coffe ground material x 1 day past medical history: relative immobility, spends a lot of time in bed hypertension diabetes obesity copd on home o2 2-3l at all times currently tobacco use obstructive sleep apnea on home cpap obesity hypoventilation syndrome diastolic chf (by c.cath ) social history: social history is significant for the current tobacco use (40-50 pk yr). there is no history of alcohol abuse, only occasional wine she lives at home with her husband. family history: there is family history of premature coronary artery disease- her father died in his 40s of an mi. physical exam: tmax: 36.5 ??????c (97.7 ??????f) tcurrent: 36.5 ??????c (97.7 ??????f) hr: 78 (78 - 98) bpm bp: 136/68(88) {115/57(-6) - 136/68(88)} mmhg rr: 14 (14 - 21) insp/min spo2: 95% heart rhythm: sr (sinus rhythm) cvp: 41 (-11 - 41)mmhg o2 delivery device: endotracheal tube ventilator mode: vol/ac vt (set): 600 (550 - 600) ml vt (spontaneous): 533 (533 - 533) ml rr (set): 20 rr (spontaneous): 0 peep: 5 cmh2o fio2: 50% pip: 31 cmh2o plateau: 30 cmh2o spo2: 95% abg: 7.09/50/102/16/-14 ve: 9.9 l/min pao2 / fio2: 255 physical examination general appearance: overweight / obese eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic, endotracheal tube, og tube cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: clear : anteriorly, diminished: throughout) extremities: right: 1+, left: 1+ skin: not assessed neurologic: responds to: not assessed, movement: not assessed, sedated, tone: not assessed pertinent results: 10:15pm wbc-19.6*# rbc-3.94* hgb-11.1* hct-34.0* mcv-86 mch-28.3 mchc-32.8 rdw-16.9* 10:15pm neuts-90.7* lymphs-6.5* monos-2.3 eos-0.3 basos-0.2 10:15pm plt count-286 10:15pm pt-13.8* ptt-24.2 inr(pt)-1.2* 10:15pm glucose-104 urea n-115* creat-7.5*# sodium-139 potassium-6.3* chloride-96 total co2-16* anion gap-33* 10:15pm alt(sgpt)-66* ast(sgot)-51* ld(ldh)-363* ck(cpk)-202* alk phos-63 tot bili-0.5 10:15pm albumin-3.0* calcium-6.7* phosphate-14.4* magnesium-2.6 10:22pm lactate-0.6 . 03:22am blood wbc-6.0 rbc-2.76* hgb-7.9* hct-24.5* mcv-89 mch-28.8 mchc-32.5 rdw-16.7* plt ct-278 04:51am blood wbc-6.9 rbc-2.73* hgb-7.7* hct-24.3* mcv-89 mch-28.3 mchc-31.8 rdw-16.7* plt ct-286 03:55am blood wbc-6.1 rbc-2.71* hgb-7.5* hct-24.6* mcv-91 mch-27.7 mchc-30.5* rdw-16.1* plt ct-273 04:03am blood wbc-5.1 rbc-2.57* hgb-7.2* hct-23.5* mcv-91 mch-28.1 mchc-30.7* rdw-16.5* plt ct-296 03:22am blood neuts-75.5* lymphs-17.4* monos-1.9* eos-4.9* baso-0.3 04:51am blood neuts-75.3* lymphs-15.0* monos-2.5 eos-7.1* baso-0.2 03:55am blood neuts-64.1 lymphs-21.5 monos-3.3 eos-10.9* baso-0.1 04:03am blood neuts-64.0 lymphs-18.5 monos-5.1 eos-12.2* baso-0.1 04:51am blood glucose-189* urean-83* creat-5.6* na-149* k-3.6 cl-109* hco3-29 angap-15 03:55am blood glucose-168* urean-79* creat-5.2* na-148* k-4.0 cl-111* hco3-27 angap-14 02:48pm blood glucose-155* urean-69* creat-4.3* na-142 k-3.9 cl-107 hco3-24 angap-15 04:03am blood glucose-187* urean-76* creat-4.5* na-147* k-4.2 cl-110* hco3-27 angap-14 03:41am blood alt-10 ast-11 alkphos-55 totbili-0.5 04:51am blood alt-7 ast-11 alkphos-53 totbili-0.4 03:55am blood alt-9 ast-12 alkphos-52 totbili-0.3 05:53am blood caltibc-211* ferritn-330* trf-162* 07:13am blood type-art temp-37.8 rates-/14 peep-12 fio2-50 po2-155* pco2-52* ph-7.32* caltco2-28 base xs-0 intubat-intubated vent-spontaneou 11:33am blood type-mix temp-37.3 rates-/26 peep-10 fio2-40 po2-43* pco2-52* ph-7.34* caltco2-29 base xs-0 intubat-intubated vent-spontaneou 01:48pm blood type-central ve temp-38.9 rates-/20 tidal v-450 peep-8 fio2-40 po2-88 pco2-42 ph-7.41 caltco2-28 base xs-1 intubat-intubated vent-controlled 03:57pm blood type-central ve rates-/22 tidal v-450 peep-8 fio2-40 po2-87 pco2-39 ph-7.40 caltco2-25 base xs-0 vent-spontaneou 03:57pm blood lactate-0.9 . sputum cx: 12:36 am sputum site: endotracheal **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth oropharyngeal flora. yeast. sparse growth. . 9:08 pm urine source: catheter. **final report ** urine culture (f02/02/09 10:38 am stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). inal ): no growth. . 7:59 pm blood culture source: venipuncture. blood culture, routine (pending): . 12:37 pm bronchoalveolar lavage **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): 10,000-100,000 organisms/ml. oropharyngeal flora. . bilateral le us - bilateral lower extremity ultrasound: -scale and doppler son of the right and left common femoral, superficial femoral, and popliteal veins were performed. normal flow, augmentation, compressibility and waveforms are demonstrated in the common femoral, proximal and mid superficial femoral veins as well as in the popliteal veins. the distal superficial femoral veins (in the area above the knee) could not be evaluated due to habitus. no intraluminal thrombus is identified. impression: slightly limited exam as described in the distal superficial femoral vein just above the knee bilaterally. no intraluminal thrombus identified. . ct torso - chest without iv contrast: there is significant dependent atelectasis and widespread diffuse ground-glass opacity. the latter may be caused by expiratory phase imaging. the lingula demonstrates opacification, possibly due to atelectasis, but superimposed pneumonia cannnot be excluded. multiple subcentimeter pulmonary nodules are also noted. in the right upper lobe, two pulmonary nodules measure 10- mm and 9-mm (2:27, 2:31). the right lower lobe also demonstrates two pulmonary nodules, one along the fissure (2:37), measuring 5 mm, and one in the more inferior in the right lower lobe, measuring 11 mm (2:39). no comparison study is available to assess chronicity. an endotracheal tube is in satisfactory position, 4-cm above the carina. a nasogastric tube courses below the diaphragm and terminates in the gastric body. bilateral internal jugular lines are present, the left terminating in the superior vena cava and the right terminating in the right atrium. there is no supraclavicular, mediastinal, or axillary lymphadenopathy, within the limits of non-contrast technique. there is no pericardial effusion. coronary artery recalcifications are also identified. ct abdomen without iv contrast: the liver, pancreas, adrenal glands, large bowel, and small bowel appear unremarkable. multiple hypoattenuating renal lesions likely represent cysts, but evaluation is limited given non-contrast technique. there is mild splenomegaly, with the spleen measuring 13.5 cm. there is only trace abdominal fluid in the right paracolic gutter (2:86). no abdominal free air is identified. the aorta and its branches demonstrate calcifications. there is no mesenteric or retroperitoneal lymphadenopathy. the mesentery demonstrates a somewhat appearance, although evaluation is limited due to streak artifact and lack of iv contrast. slight thickening of the proximal ascending colon is present. ct pelvis without iv contrast: the rectum, sigmoid colon, and uterus appear unremarkable. the bladder demonstrates foley catheterization. osseous structures demonstrate an s-shaped scoliosis of the thoracolumbar spine, and degenerative change. impression: 1. dependent atelectasis bilaterally, and likely pneumonia involving the left lingula. 2. diffuse ground-glass opacity, which may expiratory nature, but for which infectious etiology should be considered. 3. multiple right upper and lower lobe pulmonary nodules, which require followup if no (outside) comparison study is available. 4. satisfactory position of tubes and lines. 5. mild splenomegaly. 6. thickened ascending colon suggesting mild colitis of uncertain etiology. findings verbally communicated to dr by dr . . tte - left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: moderate symmetric lvh. normal lv cavity size. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. estimated cardiac index is normal (>=2.5l/min/m2). no resting lvot gradient. right ventricle: normal rv chamber size. normal rv systolic function. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. aortic valve: ?# aortic valve leaflets. no masses or vegetations on aortic valve, but cannot be fully excluded due to suboptimal image quality. mild as (aova 1.2-1.9cm2). no ar. mitral valve: mildly thickened mitral valve leaflets. no masses or vegetations on mitral valve, but cannot be fully excluded due to suboptimal image quality. trivial mr. tricuspid valve: tricuspid valve not well visualized. pericardium: trivial/physiologic pericardial effusion. general comments: suboptimal image quality - body habitus. suboptimal image quality - ventilator. conclusions the left atrium is mildly dilated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size is normal. with normal free wall contractility. the ascending aorta is mildly dilated. the number of aortic valve leaflets cannot be determined. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. there is mild aortic valve stenosis (area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. trivial mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the biventricular systolic function is probably normal. no vegetations identified, but the study was suboptimal. if clinically indicated, a tee is recommended to assess endocarditis. brief hospital course: 61 y/o f with history of obesity hypoventilation syndrome, initially admitted to osh with hypercarbic and hypoxemic respiratory failure and hypotension, transferred here with arf, course c/b difficulty to wean, vap and drug rash/fever. # hypoxic/hypercarbic respiratory failure - the patient was intubated for > 2weeks and went for tracheostomy/peg placement on without complication. her difficulty to wean is related to initial vap, now off all antibiotics. also has history of co2 retention and underlying obesity/hypoventilation. she has been weaned to pressure support ventilation 0 and 8 of peep. she has intermittently tolerated trach mask and should continued to be weaned off vent and onto mask. she is treated with combivent mdis q6h. # ventilator associated pna ?????? pt has previously completed a course of vanc/zosyn for pna at osh. on admission here, she developed new infiltrates and fever and was transitioned to vanc/meropenem/cipro for a second 7 day course with improvement in her leukocystosis and infiltrates. sputum cultures, bal, blood cultures have remained negative for mrsa or gram ?????? organisms. she has persistent fevers and which were evaluated by id and worked up as below, not felt related to recurrent pna. ct chest shows multiple pulmonary nodules in right lung along with left lingular consolidation. she should have a repeat ct chest to look for resolution of her pulmonary nodules. # drug rash: the patient developed a maculopapular, blanching, coalescing rash, which spread from her back to her entire body. she was evaluated by dermatology who felt that the rash was consistent with a drug rash. she developed elevated serum eosinophils. rash most likely secondary to zosyn, however may also have worsened on meropenem. she continues on benadryl, sarna lotion and triamcinolone 0.1% lotion. patient should be told to never take zosyn or meropenem again as it may cause worsening rash and possibly anaphylaxis. # fever ?????? the pt had persistent daily fevers to 102 following the completion of her course of antibiotics for vap. she had no leukocytosis and culture data remained negative. at this point, most likely secondary to drug fever as patient has remained with a normal wbc count and cultures have remained negative. ct torso without clear source for fever. she had received initial course of zosyn/vanco for pneumonia, followed by a second course (7 days) of broad gnr/gpc/anaerobe coverage since , but remained persistently febrile, despite resolution of leukocytosis. id consult was obtained. she was initially started on flagyl for concern of c.diff based on ?colonic thickening seen on ct however cdiff toxin negative x 4 and flagyl was discontinued. there was no clear evidence of invasive fungal disease pt received brief course of fluconzale for yeast in urine and sputum. at the time of discharge the patient has an improving but severe drug rash, no mucus membrane involvement, normal wbc count and afebrile x 24 hours. # acute renal failure - evaluated by renal team, due to atn in setting of sepsis and hypotension. cr peaked at 7.6. she received hd followed by a lasix gtt with eventual return of excellent urine output. cr. continues to trend down, currently at 4.6. dialysis catheter has been removed. currently off lasix. continue to follow electrolytes. patient with mild hypernatremia today and she will be given 1.5l of free water via peg tube today. sodium should be monitored daily at rehab. hypernatremia likely in setting of diuresis. # dm: not on insulin at home. was maintained on insulin sliding scale . # fen: cont tf via peg tube. replete lytes with caution given renal failure, increase free water intake to 2l daily. # access: currently with picc line in place as she has difficult access. picc should be removed once deemed not medically necessary to prevent infection. medications on admission: home meds: metoprolol 25mg po bid foradil inhaler daily benzoate 100mg po qhs prn cough k-lor 10meq po daily zantac 75mg po bid metformin 500mg po bid diovan 80mg po daily torsemide 20mg po daily zanaflex 4mg po daily celebrex 20mg po bid xopenex ih prn nitro-dur 0.1 per patch daily macrodantin 100mg . meds on transfer: levophed gtt insulin gtt propofol gtt protonix 40mg iv daily zosyn 2.25mg iv q6h solumedrol 60mg iv q6h combivent mdi q6h vancomycin 1gm daily, last dose levofloxacin 250mg iv daily hep sc 5000 units tid lasix 120mg x 1 () kayexalate, several doses calcium gluconate discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed). 2. insulin humalog insulin sliding scale scale attached 3. acetaminophen 160 mg/5 ml solution sig: one (1) po q6h (every 6 hours) as needed. 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 6. calcium acetate 667 mg capsule sig: two (2) capsule po tid (3 times a day). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q6h (every 6 hours). 8. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q6h (every 6 hours). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 10. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching. 11. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed for itching. 12. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical tid (3 times a day). 13. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 14. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 15. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day). discharge disposition: extended care facility: - discharge diagnosis: pneumonia respiratory failure discharge condition: total body maculopapular rash which is slightly improved. on tracheal mask and looks comfortable. discharge instructions: you were admitted into the hospital for treatment of your pneumonia. you came intubated on a mechanical ventilator from an outside hospital. you were treated with antibiotics for your pneumonia. we were unable to take you off of the ventilator and a tracheostomy has now been placed. you are being transferred to a rehabilitation center for treatment of your respiratory failure and for physical therapy. you have also suffered from a drug rash secondary to zosyn and possibly meropenem. please do not take these medications in the future. please call your doctor o return to the ed if you experience worsening cough, chest pain, shortness of breath, nausea, vomiting, fevers > 101 or any other symptoms that are concerning to you. followup instructions: please follow up with your primary care doctor after you discharge from rehabilitation. md Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Diagnoses: Hyperpotassemia Obstructive sleep apnea (adult)(pediatric) Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Unspecified essential hypertension Unspecified septicemia Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Morbid obesity Dermatitis due to drugs and medicines taken internally Ventilator associated pneumonia Mixed acid-base balance disorder Shock, unspecified Penicillins causing adverse effects in therapeutic use

allergies: sulfa (sulfonamides) / pentothal / codeine / wellbutrin / zosyn / meropenem attending: chief complaint: abdominal pain major surgical or invasive procedure: total abdominal colectomy and end ileostomy history of present illness: 61 morbidly obese female with multiple medical problems including dm, htn, dchf, copd. was recently discharged on after admission for hypoxic and hypercarbic respiratory failure after being found unresponsive at home by her husband, treated for with vanco/levo/zosyn, s/p trach after prolonged wean, course c/b arf and drug fever, transferred to on . readmitted yesterday after she was complaining of diffuse abdominal pain and had low grade fevers to 100.9. at on the morning of , she had altered mental status, and was more difficult to arouse. on exam she seemed to have significant right sided abdominal/flank pain. she was started on levoflox 250mg q48h when she began to spike fevers to 103 with a dirty u/a no culture was sent. blood cx post for staph and vanco iv was started yesterday. flagyl iv started yesterday after ct abd/pelvis which showed diffuse colitis (unchanged from previous exam. c. diff cultures came back positive today and medical tem was concerend that abdominla exam had changed overnight to include rebound tenderness. the patient has remianed hemodynamically stable throughout this admission thus far. past medical history: past medical history: relative immobility, spends a lot of time in bed hypertension diabetes obesity copd on home o2 2-3l at all times currently tobacco use obstructive sleep apnea on home cpap obesity hypoventilation syndrome diastolic chf (by c.cath ) social history: social history is significant for the current tobacco use (40-50 pk yr). there is no history of alcohol abuse, only occasional wine she lives at home with her husband. family history: there is family history of premature coronary artery disease- her father died in his 40s of an mi. physical exam: pe: 103.7 104 136/55 25 95% ac 500x14 peep 5 fluids nacl 200/hr uop >100/hr abx iv vanc/levo/flagyl started last night obese female mod distress ncat trach in place mottled skin with drug rash diffuse bilateral ronchi tachycardia gastrostomy tube in place abd obese ttp diffusely r>l with no tap tenderness but with gaurding and rebound stool guiac neg pertinent results: 12.7>-----<294 28.4 149 112 57 ---i---i---<153 4.2 25 3.4 ct : interval worsening of colitis extending from the ascending colon to the splenic flexure, with new area of involvement within the sigmoid colon. stool cx c.diff pos brief hospital course: the patient was initially admitted to the micu service. general surgery consulted for c.diff colitis. she was treated conservatively. however, over the next 48 hours her abdominal become worrisome and she developed arf and essentially became anuric. a kub at this time demonstrated free air. the patient was then taken to the operating room where she underwent a total abdominal colectomy with end ileostomy. she was noted to have 2.5 liters of purulent material in the abdomen in the or. post-op: the patient was transferred to the sicu for further resuscitation. neuro: pain was controlled and sedation minimized . cv: at this point her hemodynamics had begun to improve. she was quickly weaned off of pressors and required minimal fluid resuscitation. . pulm: she was eventually able to wean to minimal vent settings, but only tolerated trach collar for a few hours at a time. this is likely due to her pre-existing condition as well as severe illness she was recovering from. . gi/fen: she was placed on trophic tube feeds and advanced to goal which she tolerated. her stoma was functioning well at the time of discharge. . renal: renal was consulted for her arf. she began cvvhd after a hd line was placed. this was continued for about a week until enought volume had been taken off to adequately wean her vent settings. the cvvhd was stopped and she began making more urine, about 50-100cc per hour. her electrolytes and creatinine remained stable. renal recommended holding off on further dialysis for now. she did receive a few doses of lasix and seems to respond well to this. . heme: her hct was stable but slowly drifted down to 22 by discharge, she received one unit of prbc for this. . id: she was initially treated with cipro/flagyl/vanco. the iv vanco was for a coag neg blood cx. the flagyl was for the c.diff, and the cipro was continued for 7 days for coverage due to gross abdominal contamination. . endo: blood sugars controlled with sliding scale insulin. medications on admission: benadryl 50mg iv q6,triamcinolone cream tid,sarna,insulin ss bisacodyl,colace,levofloxacin 250mg q48,vancomycin x 1,albuterol ipratropium,fluticasone,tf's discharge medications: 1. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 2. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical tid (3 times a day). 3. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 4. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 6-8 puffs inhalation q4h (every 4 hours). 6. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 7. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection (2 times a day). 8. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 9. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). 10. insulin regular human 100 unit/ml solution sig: insulin sliding scale injection asdir (as directed). 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. 12. famotidine(pf) in (iso-os) 20 mg/50 ml piggyback sig: one (1) dose intravenous q24h (every 24 hours). 13. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: one (1) intravenous q8h (every 8 hours). discharge disposition: extended care facility: - discharge diagnosis: clostridium difficile colitis sepsis acute renal failure respiratory failure discharge condition: hemodynamics stable, still requiring some vent support but tolerating periods of trach collar. acute renal failure appears to be resolving. tolerating tube feeds. wound healing well with wound vac dressing. discharge instructions: diet: patient should continue on tube feeds for now. try pos if passes swallow evaluation, off ventilator, and tolerating pmv activity: oob as much as possible, aggressive pt wound: abdominal wound with large wound vac. wound appears healthy, should be changed every 3-4 days. ostomy: stoma healthy, putting out adequate stool, continue current management. antibiotics: flagyl should continue for a total of 14 days from day of surgery (end on ) followup instructions: please follow up with dr. in 2 weeks md, Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Venous catheterization for renal dialysis Arterial catheterization Replacement of gastrostomy tube Injection or infusion of immunoglobulin Ileostomy, not otherwise specified Open total intra-abdominal colectomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Perforation of intestine Sepsis Chronic kidney disease, unspecified Intestinal infection due to Clostridium difficile Morbid obesity Dermatitis due to drugs and medicines taken internally Hyperosmolality and/or hypernatremia Chronic diastolic heart failure Chronic respiratory failure Tracheostomy status Attention to gastrostomy Other staphylococcal septicemia Penicillins causing adverse effects in therapeutic use

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: laparoscopic cholecystectomy history of present illness: pt is a 72f who presented to the ed today with acute left-sided abdominal pain. pain started last night about 10pm, and was associated with n/v x 4 times. prior to last night felt completely well, eating without difficulty. no previous episodes. no sick contacts, no travel. no aggravating or relieving factors. pain . last bm two days ago. + flatus. history obtained from son who has been translating for the ed. past medical history: 1. oa 2. renal stones 3. cataracts 4. s/p appendectomy as child 5. s/p uterine polyp removal social history: originally from , speaks somalian. lives here with son & helps care for his children. pretty active. no etoh, no tobacco. physical exam: af 62 143/68 18 100% 2l nad, resting. no jaundice or icterus cta b/l rrr abd obese, soft, ttp ruq>luq & epigastrium. no rebound or guarding. no le edema pertinent results: 06:20am blood wbc-7.9 rbc-3.88* hgb-11.6* hct-34.7* mcv-89 mch-29.9 mchc-33.5 rdw-14.0 plt ct-226 06:20am blood glucose-71 urean-10 creat-0.9 na-138 k-3.9 cl-107 hco3-22 angap-13 06:25am blood alt-86* ast-39 alkphos-66 amylase-180* totbili-0.6 06:25am blood lipase-243* 06:25am blood calcium-8.2* phos-2.9 mg-2.1 06:50am blood alt-294* ast-564* ld(ldh)-747* alkphos-110 amylase-3319* totbili-0.7 06:50am blood lipase-* . radiology report ct pelvis w&w/o c study date of 10:25 am impression: 1. mild peripancreatic fat stranding concerning for acute pancreatitis. 2. gallbladder wall edema, non specific. no definite gallstones or biliary dilatation identified on ct examination. 3. fatty infiltration of the liver. . radiology report liver or gallbladder us (single organ) study date of 10:31 am impression: 1. multiple gallstones with pericholecystic fluid and gallbladder wall edema. in the setting of acute pancreatitis, the gallbladder edema is non-specific. if concern for acute cholecystitis, a hida scan could be performed. 2. fatty infiltration of the liver. . radiology report chest (pa & lat) study date of 10:55 am impression: peribronchial cuffing and vascular prominence suggesting mild pulmonary edema. repeat after diuresis recommended to exclude underlying infection. brief hospital course: this is a 72f with acute cholecystitis and gallstone pancreatitis. the patient was admitted to surgery, npo and hydrated with ivf. closely monitor fluid status given pancreatitis and evidence of pre-existing pulmonary edema on cxr. foley & strict i/o's. iv abx for acute cholecystitis. she was stable, but given the potential morbidity/mortality of gallstone pancreatitis in the eldery, we will admit her to the sicu at least overnight. given her normal tb and lack of ductal dilation, no need to ercp at this point. serial exams were performed and we monitored her labs. amylase was as high as 3319 and lipase on admission. her tbili was 0.7. she went to the or on for a laparoscopic cholecystectomy. she recovered uneventfully and was discharged the next day tolerating a diet and pain was well controlled. medications on admission: tylenol for oa prn discharge medications: 1. oxycodone 5 mg tablet sig: one (1) tablet po q3h (every 3 hours) as needed. disp:*35 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. tylenol 325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. discharge disposition: home discharge diagnosis: abdominal pain acute cholecystitis and gallstone pancreatitis 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. . * take all new meds as ordered. * do not drive or operate heavy machinery while taking any narcotic pain medication. you may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * continue to increase activity daily * monitor your incision for signs of infection (redness, drainage). * no heavy lifting >10lbs for 4 weeks. followup instructions: please follow-up with dr. in 4 weeks, on at 9:45. call with questions or concerns. Procedure: Laparoscopic cholecystectomy Diagnoses: Calculus of gallbladder with other cholecystitis, without mention of obstruction Pulmonary congestion and hypostasis Acute pancreatitis

allergies: motrin / aspirin / codeine / erythromycin base / tetracycline / bactrim / penicillins / sulfa (sulfonamide antibiotics) attending: chief complaint: abdominal pain, fever, chest pain major surgical or invasive procedure: ercp history of present illness: ms. is a 53 year female with pmh of hcv, anxiety, colitis, s/p ccy in , 2 ercps & sphincterotomy in & for biliary pain & gallstone pancreatitis, who is now transferred from to for definitive treatment for cholangitis w/ ercp. pt was in her usual state of health until 1 week ago, when she experienced fatigue and general malaise. she then developed a fever to 103f 5d prior along with nausea, but no vomiting. pt has felt progressively worse w/ anorexia and "12"/10 abdominal pain, mainly epigastric, but radiating to ruq and r flank. pt has not been able to eat since 5 days ago, and has only been drinking ginger ale to keep hydrated. of note, she developed an isolated episode of r sided chest pain 4 days ago while she was in bed, which lasted 20 minutes and resolved on its own. pt has also had stomach cramps and loose diarrhea, not black or bloody. reports decreased urination. pt's symptoms did not improve, and she presented to , where she was found to have elevated lfts, bilit 6.5, wbc 4.1 -->5.1, plt 127 --> 86, inr 1.4. her ekg showed ischemic changes in the pericordial leads, but trops were negative x 2. by the pt's report, she was evaluated by cardiology there, who "told her that she was fine." pt had an mrcp at (no report is available) and was transferred to for ercp. . on arrival to the icu, pt's vitals were 98.6f, hr 69, bp 87/58, rr 14, sat 95% ra. . review of systems: (+) fever, chills, reports isolated chest pain as per hpi, reports nausea and loose stool, abdominal pain, and anorexia. (-) denies night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies , chest pressure, palpitations, or weakness. denies, vomiting, constipation. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - anxiety - colitis - depression - hcv dx - hbv dx in childhood - chronic back pain - neuropathy - recurrent small bowel obstructions - migraines - hypertension - meckel's diverticulum s/p repair . past surgical history: - lap cholecystectomy - hysterectomy - ? abdominal operation for ?volvulus (per patient description) social history: lives in with fiance. has 3 adult children. finished school for medical administration. - tobacco: 30 pack years, currently smoking 1 pack daily - alcohol: none - illicits: none family history: father - alcoholism mother - kidney cancer in 60s maternal uncle - kidney cancer physical exam: admission exam: vitals: 98.6f, hr 69, bp 87/58, rr 14, sat 95% ra. general: alert, oriented, no acute distress heent: eomi, perrl, sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: bilateral expiratory wheezes, no rales or rhonchi. somewhat reduced air movement on l lung. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-distended, bowel sounds present. marked tenderness to palpation in epigastric and ruq. gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema on discharge: abdomen: + distension, normal bowel sounds, +ruq tenderness, epigastric tenderness. no rebound or guarding. pertinent results: 05:40pm blood wbc-3.6* rbc-3.82* hgb-11.5* hct-32.4* mcv-85 mch-30.2 mchc-35.6* rdw-13.7 plt ct-76*# 08:35am blood wbc-4.3 rbc-3.83* hgb-11.3* hct-33.6* mcv-88 mch-29.5 mchc-33.5 rdw-14.9 plt ct-91* 08:35am blood glucose-98 urean-7 creat-0.7 na-143 k-3.5 cl-110* hco3-25 angap-12 05:40pm blood alt-813* ast-566* ld(ldh)-212 alkphos-204* totbili-5.1* dirbili-4.4* indbili-0.7 05:30am blood alt-663* ast-402* ld(ldh)-173 alkphos-224* totbili-8.3* dirbili-6.5* indbili-1.8 08:35am blood alt-363* ast-145* alkphos-326* totbili-5.3* ercp result: evidence of a previous sphincterotomy was noted in the major papilla. bile was draining from the major papilla, however a small stenosis was noted at the sphincterotomy. bile duct was successfully cannulated a mild diffuse dilation was seen at the main duct with the cbd measuring 10 mm. no filling defects were noted in the bile duct a sphincterotomy was performed. balloon sweeps were performed in the bile duct but they did not yield any debris. otherwise normal ercp to third part of the duodenum ultrasound: liver and gallbladder ultrasound: the liver appears without evidence of focal liver lesions. there is a right pleural effusion. there is trace ascites present. the patient is status post cholecystectomy with an echogenic structure just inferior to the gallbladder fossa measuring 5 mm, likely representing a dropped stone. the common bile duct measures 0.3 cm. the right kidney measures 10.6. the left kidney measures 9.8 cm. both kidneys show no evidence of hydronephrosis or renal calculi. the spleen measures 12.9 cm. upper abdominal aorta, and visualized portions of the ivc and hepatic veins are unremarkable. impression: 1. right pleural effusion. 2. ascites. 3. status post cholecystectomy with an echogenic focus just inferior to the gallbladder fossa, which likely represents a dropped stone. ct scan: impression: 1. findings suggest duodenitis and jejunitis with stranding in the surrounding mesentery. if clinically indicated, this could be reached by endoscopy. no evidence of colitis. 2. small bilateral pleural effusions, right larger than left, with adjacent compressive atelectasis. 2. diffuse body wall edema, intra-abdominal ascites and periportal edema may be related to liver disease and low albumin. 3. indeterminant pancreatic lesion. while it looks like fat, it does not clearly measure fat attenuation. follow up mrcp is recommended in 6 months. 4. no evidence of portal hypertension. brief hospital course: ms. is a 53 year female with pmh of hbv and hcv, anxiety, colitis, s/p ccy in , 2 ercps & sphincterotomy in & for biliary pain & gallstone pancreatitis, who presented to osh with ruq pain, fever and chills for the past 3 days, transferred to for ercp. . # abdominal pain: given history of biliary stones, gallstone pancreatitis, and two prior sphincterotomies as well as lfts suggesting obstruction, it was initially suspected that pt again has an obstructive biliary process due to cholelithiasis. however, ercp did not reveal any stone or sludge or cause of obstruction. her prior sphincterotomy was enlarged. it is possible that she had passed a gallstone by the time her ercp was done. the patient developed significant diarrhea while on three antibiotics for her cholangitis. her diarrhea improved when she was just on one antibiotic. c diff negative. patient complained of improved, but continued ruq and rlq pain after the ercp. on exam, she had diffuse abdominal distension with tenderness on exam. she had normal bowel sounds. although she was tender on exam and complained of persistant pain, she was seen ambulating the halls without difficulty and went out to smoke as well, despite advice from the rn not to do so. she also requested pain medicine despite appearing to be comfortable. because she did have abdominal distension and tenderness on exam, she went for ct scan of the abdomen. the findings showed possible duodenitis and jejunitis. she was advised to go for endoscopy with push enteroscopy, but she refused. she also had a lot of bowel wall edema not consistent with inflammation, but likely due to third spacing of fluids, as her albumin was 2.5. she was advised to finish a one week course of antibiotics for cholangitis # hepatitis c: seen by liver service. patient has outpatient hepatologist, but has never had a liver biopsy. she states that she became hepatitis c after a rape that occurred when she ws 15. her daughter is also hepatitis c positive, and is a heroin user. she was evaluated by the hepatology service here regarding her persistantly abnormal lfts after her ercp, and they felt that there was no acute hepatic process. she is interested in following up with them for possible treatment of her hepatitis. her lfts did start to improve by the course of her discharge, and should be followed up by her pcp. was no clear evidence of portal hypertension on imaging. # anxiety: patient continued on round the clock clonazepam. she became so worried about her medical condition, that she called a son that she put up for adoption at birth and told him that she was gravely ill, and asked that he request leave from his duties in to come and to see her. i explained to her that her hepatitis c is a chronic problem, and, that as she refused egd there was no further workup that could be done. medications on admission: clonazepam 1mg tid bentyl (dicyclomine) 20mg daily pantoprazole 40mg discharge medications: 1. clonazepam 1 mg tablet sig: one (1) tablet po tid (3 times a day). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 3. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days. disp:*6 tablet(s)* refills:*0* 4. dilaudid 2 mg tablet sig: 1-2 tablets po every 4-6 hours for 7 days: take only if needed for pain, and please minimize its use. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. cholangitis 2. chronic hepatitis c 3. anxiety discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were transferred to for treatment and evaluation of cholangitis. you had an ercp that was largely unremarkable. your pain and abnormal liver tests improved overall, but still persisted so you were seen by the liver specialists and you had a ct scan of your abdomen. the ct scan showed that your liver and spleen are normal sized, and that you may have some inflammation in your small bowel. we offered you the chance to have an endoscopy to better evaluate your small bowel, but you refused. please take antibiotics for an additional 3 days. you can take pain medicine for abdominal pain, but please do so sparingly. followup instructions: name: pa- address: , , phone: appointment: thursday 11:00am *this is a follow up appointment of your hospitalization. you will be reconnected with your primary care physician after this visit. department: liver center when: wednesday at 10:20 am with: , md building: lm campus: west best parking: garage Procedure: Endoscopic sphincterotomy and papillotomy Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Tobacco use disorder Unspecified essential hypertension Chronic hepatitis C without mention of hepatic coma Unspecified septicemia Sepsis Anxiety state, unspecified Diarrhea Duodenitis, without mention of hemorrhage Hypovolemia Cholangitis Obstruction of bile duct Unspecified antibiotic causing adverse effects in therapeutic use Other pancytopenia Retained cholelithiasis following cholecystectomy

allergies: iodine-iodine containing / optiray 320 attending: chief complaint: admission for mud allo-sct major surgical or invasive procedure: lumbar punctures central line placement stem cell transplant history of present illness: mrs. is a 53-year-old woman with a history of high-risk aml who is being admitted today for her matched unrelated allogeneic transplant. she was discharged home after a nine week admission on . she was seen for follow up on and as her counts had recovered, she had her left sided picc removed. the plan is to move forward with an allogeneic transplant from an unrelated donor. the donor would be able to collect stem cells, but we could not guarantee a backup bone marrow should her stem cell collections not be adequate, so the decision was made to cryo-preserve the stem cells and mrs. admission was delayed until today. she is admitted today for her allogeniec transplant with busulfan and cytoxan conditioning. past medical history: 1. aml s/p 7+3 induction and then 5+2 reinduction 2. hypertension 3. hypercholesterolemia 4. impaired glucose tolerance 5. diverticulitis 6. uterine polyps 7. renal calculi 8. recurrent c. difficile infection 9. hernia repair at time of c-section in with steel mesh placed; patient cannot have mri with abdomen in scanner. social history: patient worked at hospital as a microbiology lab technician. she is married and has three daughters. she lives in , ma. she is a nonsmoker and drinks alcohol on rare occasions. family history: non-contributory physical exam: admission exam: vitals: t 97.6, hr 100, r 24, bp 100/62, wt 252.4 lbs, 97% ra. general: well-appearing female in no acute distress. heent: perrl with anicteric sclerae. eomi. oropharynx is moist without erythema, lesions, or thrush. neck: supple, without adenopathy. lungs: diffuse expiratory wheezes, no rales or rhonchi heart: distant heart sounds, no m/r/g appreciated abdomen: soft, obese, nontender without hsm or other masses appreciated, although difficult to examine due to body habitus. no bowel sounds heard but pt reports bm this am. extremities: 2+ dp/pt pulses bilaterally, no c/c/e skin: without rashes or lesions back: no pain or cva tenderness. . discharge exam: pertinent results: admission labs: 12:03pm blood wbc-7.7 rbc-3.73* hgb-11.7* hct-33.5* mcv-90 mch-31.4 mchc-35.1* rdw-16.5* plt ct-310 12:03pm blood neuts-72.4* lymphs-15.6* monos-7.2 eos-4.2* baso-0.6 12:03pm blood pt-13.1 ptt-19.9* inr(pt)-1.1 12:03pm blood gran ct-5590 12:03pm blood glucose-104* urean-13 creat-0.6 na-139 k-4.3 cl-104 hco3-22 angap-17 12:03pm blood alt-44* ast-27 ld(ldh)-218 alkphos-92 totbili-0.4 dirbili-0.1 indbili-0.3 12:03pm blood totprot-7.0 albumin-4.3 globuln-2.7 calcium-10.1 phos-4.5 mg-1.9 . pertinent labs: serum: 12:11pm blood t4-4.4* 12:11pm blood tsh-3.1 10:00am blood cortsol-13.5 12:00am blood tsh-2.3 fsh-2.5 12:00am blood prolact-33* 12:00am blood negative 12:00am blood rheufac <3 02:20pm blood igg-542* iga-75 igm-31* 12:21pm blood adenovirus dna not detected 02:30pm blood abs b1, b2, b3 elevated 02:30pm blood abs b4, b5, b6 not detected 12:09pm blood igg-829 iga-79 igm-26* . serum hhv-6 dna pcr: : <500 : 1,540,881 : 119,409 : <500 : <500 : 15,230 : 41,945 : 19,975 : 32,297 : 14,355 . serum bk dna pcr: : not detected : not detected : not detected . urine bk dna pcr: : >500,000,000 : >500,000,000 : >500,000,000 . csf: totprot-88* glucose-109 wbc-2 rbc-1* polys-0 lymphs-87 monos-9 macroph-4 ebv-pcr-neg hsv-neg virus-neg toxo-neg hhv-6 pos totprot-66* glucose-67 wbc-2 rbc-2* polys-0 lymphs-93 monos-7 hsv-neg hhv-6 pos (799 copies) . discharge labs: ................................................................ microbiology: urine cx: coagulase negative staph urine cx: coagulase negative staph urine cx: coagulase negative staph 6:15 pm blood culture blood culture, routine (preliminary): burkholderia (pseudomonas) cepacia. ................................................................ pathology: right leg skin biopsy: vacuolar interface and mild superficial perivascular dermatitis with epidermal and follicular dyskeratosis. the finding of follicular dyskeratosis is suggestive of early gvhd. a viral exanthem cannot be excluded, however, the follicular dyskeratosis would be unusual. the lack of significant numbers of eosinophils makes a drug eruption less likely. pas and gram stains are negative. . csf immunophenotyping: there appears to be an atypical population of cells that are not clustered in the cd45 vs. ssc histogram and demonstrate variable reactivity for cd13, cd33, and cd34. the concurrent cytospin slides are negative for involvement by an acute leukemia. while the above immunophenotypic findings may be non-specific, they are atypical and warrant clinical follow-up. . left flank skin biopsy: the sections show focal/patchy parakeratosis with "squamous cell activation," multifocal dyskeratosis, and mild spongiosis. the dermal-epidermal junction is involved by marked vacuolar changes, and apoptotic and colloid bodies are present. there is mild papillary dermal fibrosis with marked endothelial cell activation. the inflammatory response is paucicellular and comprised of predominantly mononuclear inflammatory cells with rare eosinophils. red blood cell extravasation and pigment incontinence are noted. overall, the findings are suggestive of a hypersensitivity type reaction such as to drugs, if compatible with clinical presentation. given the histopathological features and the clinical history, graft versus host disease cannot be entirely excluded. . bone marrow biopsy: the aspirate material is aspicular, precluding adequate differential counts. however, the core biopsy has a focus of immature mononuclear cells which are morphologically suspicious for blasts. by immunohistochemical staining these are cd34(-), however with strong expression of cd117. they are weakly immunoreactive for myeloperoxidase, and are glycophorin negative. taken together, the findings are highly worrisome for disease relapse. . left ankle skin biopsy: the findings of multiple intraepidermal vesicles with foci of reticular degeneration are suggestive of a viral infection, including those in the picornavirus family including virus. no definitive viral inclusions are observed. the subepidermal cleft may be due to prior interface change. a few neutrophils are observed in the epidermis, however, well formed pustules are not observed. there is minimal dermal inflammation. the findings favor a viral infection, however, an unusual finding is the degree of dysmaturation. while this may be a viral effect, due to the dysmaturation an underlying component of graft versus host disease (with a superimposed viral infection) cannot be excluded. gvhd may show subepidermal blisters and dysmaturation, however, the degree of intraepidermal vesicles would be unusual for gvhd alone and this finding favors a component of a viral infection. special stains (pas and gram) are negative for fungus and bacteria. . bone marrow biopsy: pending ................................................................ imaging: ct chest/abd/pelvis w/o con: 1. near-complete resolution of previously noted right lower lobe consolidation with some residual scarring. 2. resolution of previously noted sigmoid diverticulitis. 3. status post cholecystectomy. . ruq u/s: normal doppler ultrasound of the liver. prior cholecystectomy with no focal liver lesion or evidence of biliary obstruction. . ct head w/o con: 1. no intracranial hemorrhage. 2. old infarct in the right aca-mca watershed region. 3. right maxillary sinus mucus-retention cyst. . ct chest/abd/pelvis w/o con: 1. limited study without iv or oral contrast. 2. trace left pleural effusion. no evidence of pneumonia. 3. no free air, free fluid, or fluid collection in the intra-abdominal cavity. 4. interval development of "" mesentery, nonspecific, could be seen in patients with lymphoma, or in the appropriate clinical context, could represent mesenteric panniculitis. . v/q scan: matched perfusion and ventilation defect in the medial left lung base. low likelihood ratio for recent pulmonary embolism. . ct chest/abd/pelvis w/ con: 1. no evidence of infection on this ct scan. 2. mesentery previously seen on is no longer visualized on this study. . ct head w/o con: no evidence of acute intracranial abnormalities. . mri head w/o con: multiple scattered foci of flair hyperintensity involving predominantly cortical matter of the bilateral hemispheres, some of which demonstrate slow diffusion without significant mass effect or hemorrhage. these may represent changes related to encephalitis, encephalopathy, inflammatory/infectious etiology, subacute infarcts, less likely neoplastic involvement or related to medications used. evaluation of these findings is somewhat limited without intravenous contrast. . gu ultrasound: 1. thickened bladder wall, though it is not fully distended and therefore not fully evaluated, with bilateral mild pelvocaliectasis which may be mildly increased on the right from the previous ultrasound of . 2. there are no stones. brief hospital course: mrs. is a 53 year old woman with aml who was admitted on for matched unrelated allogeneic stem cell transplant with busulfan/cytoxan conditioning. hospital course was complicated by graft failure + gvhd, hhv-6 encephalitis, thrombotic microangiopathy, and numerous electrolyte abnormalities accompanied by acute kidney injury, as well as intense allodynia and pruritus. # icu stay: ms. was transferred to the icu on for hypotension. gram negative rods grew from her blood on that same day. she was given a total of 17 liters of fluid overnight as well as 4 units of prbcs and maximum bp support with 4 pressors maxed out (neo, levo, vasopressin, and epinephrine) and despite these measures her pressures remained in the 60s-80s systolic. she had increased work of breathing and began to desaturate on non-rebreather. she was intubated for respiratory distress. multiple phone calls and meetings were held with her husband and her primary team (hematology/oncology) and it was decided to make her cmo after maximal attempts to support her through her septic shock. after withdrawal of pressors and extubation, she passed peacefully within a few minutes. much of the rest of the hospital course is described below. . # aml and mud allo-sct graft issues: patient received an mud allo sct on . after reaching anc of 0, she was engrafting well until around 25-30 days s/p transplant when her ancs began to drop. initial concern was with hhv-6 infection/marrow gvhd/cyclosporine causing graft failure. foscarnet was started for hhv-6, the cyclosporine was discontinued, and steroids were increased, and ancs started rising again. the cyclosprine was later restarted but ancs again dropped, so the cyclosporine was again discontinued. she developed skin gvhd, so she was started on a low dose of tacrolimus, uptitrated to therapeutic doses with subsequent downtitration of her steroids. she was given pentamidine for pcp (unable to give bactrim considering ). she also received weekly checks for cmv vl, b-glucan, galactomannan, and hhv-6 vl after her acute infection. around day +68 she was noted to have increased peripheral blasts. she reached a peak absolute blast count of xxxxx. a bone marrow biopsy on was consistent with relapsed leukemia (chimerism showed increase to 45% recipient, 55% donor) so the tacrolimus was tapered and then stopped. prednisone was tapered as well. the patient was treated with 5 days of dacogen. her blast count continued to rise. she was treated with a cycle of mec followed by donor lymphocyte infusion. . # hhv-6 viral encephalitis: patient was noted to have altered mental status, and hhv-6 pcr returned at >1,000,000 on with csf also positive for hhv-6. she completed a 17-day course of foscarnet from and her mental status gradually returned to baseline. however, peripheral blood from revealed 15,230 copies of hhv-6 dna. the foscarnet was restarted on but was stopped on due to worsening . she remained clinically asymptomatic so the foscarnet was not restarted. . # febrile neutropenia: hospital course was complicated by febrile neutropenia with temperatures up to 105f. infectious disease was consulted and her antibiotics were changed multiple times and included aztreonam, ciprofloxacin, metronidazole iv, vancomycin iv and po, and micafungin. due to concern for nephrotoxicity and after being afebrile for a prolonged period of time, her antibiotics were gradually discontinued, with the exception fungal prophylaxis. after mec therapy (in peri-dli period) she again developed febrile neutropenia. she was started on cefepime after which she defervesced. she was then noted to have a vre uti and daptomycin was started. she was afebrile for many days until she spiked once again with new abdominal pain . # rash: patient developed a diffuse erythematous rash after starting daptomycin, which did not resolve following discontinuation. a biopsy of her left leg on was suggestive of gvhd so she was started on systemic and topical steroids. the rash initially improved, but again worsened despite steroids and there was concern that it was virally mediated considering her hhv-6 viremia. however, a repeat skin biopsy on was again suggestive of gvhd vs. a drug reaction. she later developed vesicles on her palms and soles and a biopsy on was suggestive of gvhd with a superimposed viral infection, likely virus. the skin gvhd was managed with iv and then po steroid as well as topical clobetasol. her skin worsened again, so tacrolimus and prednisone were weaned out of concern for worsening viral infection, perhaps or hhv-6. this initially improved her rash. however, after dli her rash acutely worsened and became quite weepy with several areas of skin breakdown and the sensation of an acute burn, suggesting a gvh picture. . # hyperesthesias/pruritis/allodynia: the patient reported diffuse itching and burning with allodynia. ct spine was unremarkable. dermatology and neurology were consulted, but did not feel that her symptoms were related to the hhv-6 or gvhd. she was treated with various medications including benadryl, hydroxyzine, and olanzapine with some improvement in her symptoms. . # thrombotic microangiopathy and frank hemolysis: around the time that the hhv-6 infection was detected, she began to show evidence of hemolytic anemia with low haptoglobin, high direct bili, high ldh, and . considering the anemia, thrombocytopenia, , and mental status changes, it was felt that ttp-hus had developed, likely secondary to the hhv-6 infection. an adamts-13 evaluation was sent, which was normal. as the hhv-6 was treated, these abnormalities resolved. . # hematuria: it was believed to be due to both bk virus in the urine and thrombotic microangiopathy. resolved with tapering of immunosuppression. . # : believed to be multifactorial, including the foscarnet, zosyn, vancomycin, ttp-hus, and bk virus detected in the urine. the resolved with discontinuation of these medications and resolution of ttp-hus. however, after restarting the foscarnet her kidney function again declined so the foscarnet was again stopped. with gentle hydration her cr improved to 1.3. . # hypernatremia/hyperglycemia: secondary to partial di and free water deficit. the sodium concentration in her tpn was decreased and she was started on d5w to correct her water deficit, which exacerbated her hyperglycemia. an osmotic diuresis due to elevated glucose may have also been contributing to this hypernatremia, so aggressive control of glucose was made a priority with the addition of lantus and an iss. . # hypertension: with only metoprolol on board, she developed htn in the setting of thrombocytopenia. it was also believed to be exacerbated by the cyclosporine and steroids. nifedipine was added and the cyclosporine was discontinued, and her bp was well controlled. eventually her nifedipine was able to be stopped and blood pressure was well controlled prior to discharge. . # diarrhea: patient had ongoing diarrhea throughout this admission, though repeated stool cultures including c.diff were all negative. considering her numerous antibiotics, she was started on po vancomycin which was later changed to prophylactic dosing. the diarrhea eventually resolved and the po vancomycin was discontinued. . # nutrition: patient struggled with nausea throughout the entire admission and initally had poor po intake, so she was started on tpn on which was eventually stopped when she was able to tolerate po intake. medications on admission: 1. acyclovir 400 mg q8h 2. lorazepam 0.5 mg tablet; 1-2 tablets q4h prn 3. metoprolol tartrate 25 mg tid 4. vancomycin 125 mg capsule q12h 5. voriconazole 200 mg q12h 6. docusate 100 mg 7. senna 8.6 mg tablet; 1-2 tablets qhs prn constipation 8. lovenox (held since for picc placement) discharge medications: not applicable discharge disposition: home with service facility: all care vna of greater discharge diagnosis: expired acute myelogenous leukemia graft versus host disease of skin hhv-6 encephalitis acute kidney injury discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Spinal tap Incision of lung Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Biopsy of bone marrow Biopsy of bone marrow Closed biopsy of skin and subcutaneous tissue Closed biopsy of skin and subcutaneous tissue Closed biopsy of skin and subcutaneous tissue Injection or infusion of cancer chemotherapeutic substance Injection or infusion of immunoglobulin Allogeneic hematopoietic stem cell transpant without purging Transplant from live non-related donor Central venous catheter placement with guidance Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Acidosis Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Severe sepsis Acute respiratory failure Defibrination syndrome Septic shock Infection with microorganisms without mention of resistance to multiple drugs Complications of transplanted bone marrow Acquired hemolytic anemia, unspecified Diarrhea Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Hyperosmolality and/or hypernatremia Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other disorders of neurohypophysis Examination of participant in clinical trial Other specified disorders resulting from impaired renal function Diabetes insipidus Neutropenia, unspecified Septicemia due to gram-negative organism, unspecified Acute myeloid leukemia, in remission Unspecified pruritic disorder Acute graft-versus-host disease Fever presenting with conditions classified elsewhere Mucositis (ulcerative) due to antineoplastic therapy Other specified diseases due to viruses Human herpesvirus 6 encephalitis

allergies: patient recorded as having no known allergies to drugs attending: addendum: note: the team was paged with the following microbiology results s/p discarge: 6:42 pm fluid received in blood culture bottles gram stain (final ): test cancelled, patient credited. see fluid culture in bottles. fluid culture in bottles (preliminary): gram positive coccus(cocci). in pairs and clusters. fluid culture (final ): test cancelled, patient credited. see fluid culture in bottles. anaerobic culture (final ): test cancelled, patient credited. see fluid culture in bottles. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. aerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. reported by phone to 2:25pm. . . on discussion, it was felt that this was likely contaminant, especially given the abscence of signifigant white count noted in the fluid. attending aware. discharge disposition: home md 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 Other endoscopy of small intestine Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Arterial catheterization Transfusion of packed cells Transfusion of other serum Manual reduction of hernia Diagnoses: Acidosis Hyperpotassemia Urinary tract infection, site not specified Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute posthemorrhagic anemia Chronic hepatitis C with hepatic coma Alcoholic cirrhosis of liver Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Alcohol abuse, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other ascites Esophageal varices in diseases classified elsewhere, without mention of bleeding Other specified disorders of stomach and duodenum Other and unspecified coagulation defects Volume depletion, unspecified Ventral, unspecified, hernia without mention of obstruction or gangrene Acute duodenal ulcer with hemorrhage, without mention of obstruction Shock, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shock, respiratory failure, gi bleeding major surgical or invasive procedure: egd history of present illness: ms. is a 51 y/o woman with pmh notable for alcohol abuse with cirrhosis transferred to with shock, respiratory failure, and gi bleeding. history is sparse and patient now intubated so full history not able to be obtained. per discussion with patient's father, the patient was her usual self when speaking on the phone last night at about 7 or 8 pm. she planned to spend today with her father and when she did not show up, he called her without answer. he then went to her house at about 11 am at which point he found her unresponsive. he called ems and she was taken to ed. . at , the patient was noted to be unresponsive. temperature registered at 87.9 rectally. the ed staff found her to have agonal respirations so she was intubated with etomidate and succinylcholine. she also had an ng tube placed with return of dark blood. femoral cvl was placed for iv access. she was treated with iv narcan, thiamine, and iv normal saline. she received 2 u prbcs; due to persistent hypotension, she was placed on a levophed gtt. she reportedly received vitamin k there (not documented) and 1 u ffp (not documented) as well as was started on an octreotide gtt (not documented). . on arrival to the micu, the patient is intubated. she opens eyes to voice and responds to simple commands. further history is not able to be obtained. past medical history: alcohol abuse * cirrhosis, presumed alcohol abuse social history: drinks per her report 1 glass of wine per day, last use 2 days pta. reports never drinking more than that. lives with her 14 yo daughter. tobacco or smoking. no h/o stds. on disability for liver disease family history: no history of liver disease physical exam: t: 91.8 rectal bp: 118/70 hr: 98 rr: 27 o2 100% on a/c 400x16, peep 5, fio2 100% gen: intubated, opens eyes to voice, cachetic with tense ascites heent: + scleral edema, slight scleral icterus, pupils reactive bilaterally, lips dry neck: no jvp elevation, no lymphadenopathy cv: tachy but regular, no appreciable murmur, strong pmi lungs: grossly clear anteriorly with crackles at bilateral bases abd: tense ascites with multiple spider angiomas; umbilical hernia more reducible on left > right, midline supraumbilical hernia which is reducible. hypoactive bowel sounds. + fluid wave. no grimace to palpation. ext: cool, 1+ dp pulses bilaterally, 1+ pitting edema bilaterally skin: scattered ecchymoses neuro: perrl, + oculocephalic reflex, face symmetric, follows commands such as 'squeeze fingers' and 'wiggle toes' bilaterally, reflexes 1+ at biceps and patellae pertinent results: ========= labs ========= 06:00pm fibrinoge-123* 06:00pm pt-25.0* ptt-58.0* inr(pt)-2.5* 06:00pm plt count-230 06:00pm wbc-20.0* rbc-2.50* hgb-8.8* hct-26.4* mcv-105* mch-35.3* mchc-33.5 rdw-25.8* 06:00pm asa-neg ethanol-229* acetmnphn-8.1 bnzodzpn-neg barbitrt-neg tricyclic-neg 06:00pm lithium-0.2* 06:00pm ammonia-79* 06:00pm albumin-2.2* calcium-7.1* phosphate-5.8* magnesium-2.2 06:00pm alt(sgpt)-55* ast(sgot)-243* ld(ldh)-545* ck(cpk)-404* alk phos-141* tot bili-3.8* 06:00pm estgfr-using this 06:00pm glucose-180* urea n-29* creat-1.3* sodium-132* potassium-5.7* chloride-100 total co2-10* anion gap-28* 06:23pm glucose-157* lactate-12.4* na+-133* k+-5.8* cl--104 tco2-9* 08:38pm urine granular-0-2 08:38pm urine rbc-21-50* wbc-* bacteria-mod yeast-none epi-0-2 trans epi-0-2 08:38pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-sm urobilngn-1 ph-6.5 leuk-sm 08:38pm urine color-amber appear-hazy sp -1.015 08:38pm urine bnzodzpn-pos barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 08:38pm urine hours-random 08:39pm pt-21.5* ptt-53.5* inr(pt)-2.0* 08:39pm plt smr-normal plt count-221 08:39pm hypochrom-1+ anisocyt-2+ poikilocy-2+ macrocyt-2+ microcyt-2+ polychrom-occasional spherocyt-1+ target-1+ schistocy-1+ burr-2+ pappenhei-1+ 08:39pm neuts-89* bands-1 lymphs-4* monos-5 eos-0 basos-0 atyps-0 metas-1* myelos-0 08:39pm wbc-21.8* rbc-2.63* hgb-9.3* hct-27.6* mcv-105* mch-35.4* mchc-33.7 rdw-24.8* 08:39pm haptoglob-less than 08:39pm calcium-6.9* phosphate-5.3* magnesium-2.1 08:39pm ck-mb-24* ctropnt-0.05* 08:39pm lipase-11 08:39pm dir bili-2.6* 08:39pm glucose-152* urea n-27* creat-1.2* sodium-132* potassium-5.6* chloride-101 total co2-10* anion gap-27* 10:57pm type-art temp-33.4 rates-24/ tidal vol-500 o2-50 po2-100 pco2-20* ph-7.27* total co2-10* base xs--15 intubated-intubated vent-controlled 10:57pm lactate-12.0* 09:52pm lactate-13.2* 09:25pm ascites tot prot-1.1 glucose-189 albumin-less than 09:25pm ascites wbc-25* rbc-185* polys-4* lymphs-17* monos-77* mesotheli-2* brief hospital course: a/p: this is a 51 y/o woman with alcohol abuse and presumed alcoholic cirrhosis admitted with altered mental status, shock, and upper gi bleeding. . # shock: unclear etiology but most concerning for hypovolemic (due to blood loss) versus septic/infectious. patient has obvious gi blood loss with hct down to 21 on arrival at osh. hct here 26.4 (after 2 u prbcs at other hospital). receved a total of 4 u prbc in the icu. has clot in gastric fundus on egd but no apparent varices. for infection, patient has leukocytosis with bandemia. potential sources include abdomen (peritoneal fluid not indicative of sbp), ? stool (c diff given bandemia), and uti (wbcs on urinalysis). ? other ingestion (given lithium level 0.2 and tylenol in serum tox) but unclear how related. patient was treated with ciprofloxacin and ceftriaxone for a positive urine cx. . # upper gi bleeding: egd on arrival to the micu demonstrated large blood clot in the gastric fundus but no esophageal varices (difficult to discern due to hypotension). patient was on octreotide gtt that was d/cd and transferred to the hepat-renal service after hct was stable for 3 days. on the medical floor, hct remained stable and patient had no further episodes of gi bleed. ppi was transitioned to po formulation and patient's diet was advanced as tolerated. . # respiratory failure: intubated due to agonal respirations at osh. extubated in icu, and had no further respiratory distress on the medical floor. . # altered mental status: patient intermittently alert on arrival to micu and following commands. likely that unresponsiveness earlier related to hypotension, blood loss, ? infection. on the medical floor, patient had appropriate and clear mental status. . # acute renal failure: likely related to hypotension, volume depletion. continue to trend. improved with conservative treatment. . # coagulopathy: likely related to underlying liver disease (though platelets normal). inr 2.5 earlier down to 2.0 on arrival to micu. . # alcohol abuse with cirrhosis: patient arrived with tense ascites and is now s/p large volume tap (8 l removed). her alcohol level on arrival to was 229 at 1800 pm (patient's family not aware she continued to drink per their report). also, the patient had tylenol in her serum tox (? ingestion time but could have been up to 24 hours prior). . # code: full, confirmed with daughter . # comm: with patient and family. daughter . daughter . medications on admission: propanolol 10 mg qd kcl 20 meq x2 protonix 40 mg x2 folic acid 1 mg qd furosemide 40 mg x2 (unclear if this means or 80 mg) spirinolactone 100 mg x2 vitamin b qd multivatin qd 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. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). disp:*2700 ml(s)* refills:*2* 6. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. spironolactone 100 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 8. miconazole nitrate 200-2 mg-% (9 g) combo pack sig: one (1) combo pack vaginal hs (at bedtime) for 1 days. disp:*1 combo pack(s)* refills:*0* 9. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 10. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day). disp:*1 tube* refills:*2* 11. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. outpatient lab work please have cbc checked on . have results faxed to your hepatologist and gastroenterologist. discharge disposition: home discharge diagnosis: primary diagnosis etoh cirrhosis grade i varices gastric ulcer alcohol abuse discharge condition: hemodynamically stable. discharge instructions: you were admitted with an upper gi bleed and unresponsiveness. this was thought to be due to a bleeding ulcer. you had an endoscopy which did not show active bleeding and your blood counts have been stable. nutrition evaluated you and recommended drinking a nutritional supplement such as ensure or boost 3 times a day. you were also evaluated by social work. you had 2 abdominal paracenteses done, that showed no infection in your abdomen. please take all medications as directed. please follow-up with all outpatient appointments. please return to the ed if you experience any fever, chest pain, black or bloody stools, difficulty breathing, abdominal pain, confusion or any other concerning issues. followup instructions: please follow-up with a hepatologist in 1 week. the clinic number is . you can ask to make an appointment with dr. (who saw you during your hospitalization), or with any hepatologist who will be available in one week. you will need to have your hematocrit checked at that time. please follow-up with dr. in weeks. call for an appointment . 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 Other endoscopy of small intestine Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Arterial catheterization Transfusion of packed cells Transfusion of other serum Manual reduction of hernia Diagnoses: Acidosis Hyperpotassemia Urinary tract infection, site not specified Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute posthemorrhagic anemia Chronic hepatitis C with hepatic coma Alcoholic cirrhosis of liver Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Alcohol abuse, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other ascites Esophageal varices in diseases classified elsewhere, without mention of bleeding Other specified disorders of stomach and duodenum Other and unspecified coagulation defects Volume depletion, unspecified Ventral, unspecified, hernia without mention of obstruction or gangrene Acute duodenal ulcer with hemorrhage, without mention of obstruction Shock, unspecified

allergies: penicillins / lisinopril / shellfish / sulfa (sulfonamide antibiotics) / metal attending: chief complaint: worsening sob major surgical or invasive procedure: 1. aortic valve replacement with a 21-mm on-x mechanical valve. reference number , serial number . 2. replacement of ascending aorta and hemi arch with a 26- mm vascutek dacron tube graft using deep hypothermic circulatory arrest. graft data: catalog number , lot number , serialnumber . 3. reconstruction of pericardium with core matrix product. reference number , lot number . 4. epiaortic duplex scanning. history of present illness: history of present illness: this is a 65 year old female who complains of worsening exertional dyspnea and fatigue over the last several months. she underwent evaluation at outside institution, including echocardiography, that showed severe aortic stenosis. she recently saw dr. and underwent a repeat echocardiogram that confirmed severe as with 0.9cm2. she presents today for surgical evaluation. currently she denies chest pain, syncopce, pre-syncope, orthopnea, pnd and pedal edema. she has mild symptoms with routine adls. past medical history: - aortic stenosis, calcified ascending aorta - hypertension - hyperlipidemia - emphysema and pulmonary nodules found on recent ct scan - diabetes mellitus type ii - hiatal hernia with reflux - esophageal stricture s/p dilitaton - overactive bladder past surgical history - tonsillectomy - appendectomy - cesarean section x 3 social history: race: originally from last dental exam: 3 months ago lives with: husband occupation: retired cigarettes: 40+ pyh, quit 12 years ago etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use: denies family history: family history: denies premature coronary artery disease physical exam: physical exam pulse: 92 resp: 16 o2 sat: 99% room air b/p right: 135/89 left: 131/95 height: 58 inches weight: 130 lbs general: wdwn female in no acute distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade 4/6 sem abdomen: soft, non-distended, non-tender, bowel sounds + extremities: warm , well-perfused edema: none varicosities: bilateral gsv appears suitable. spider veins noted. neuro: grossly intact pulses: femoral right: 1 left: 1 dp right: 1 left: 1 pt : 1 left: 1 radial right: 2 left: 2 carotid bruit: transmitted murmur bilaterally pertinent results: 06:14am blood wbc-6.3 rbc-3.17* hgb-9.6* hct-28.2* mcv-89 mch-30.3 mchc-34.1 rdw-14.7 plt ct-225 05:51am blood pt-29.9* inr(pt)-2.9* 05:51am blood urean-19 creat-0.7 na-133 k-4.0 cl-101 05:51am blood mg-1.9 pa and lateral chest, impression: pa and lateral chest compared to through 10: severe left lower lobe atelectasis has improved slightly, and small left pleural effusion has decreased. less severe right lower lobe atelectasis and smaller right pleural effusion have remained relatively stable. there is no pneumothorax or pulmonary edema. enlargement of the postoperative cardiac silhouette is what one would expect given the preoperative size, and unchanged. right jugular line ends in the upper svc. ekg: sinus rhythm. cannot exclude a prior inferior myocardial infarction. poor r wave progression with precordial st segment elevation. cannot exclude myocardial injury. clinical correlation is suggested. compared to the previous tracing of there is loss of r wave in lead avf. precordial st segment elevation is new. brief hospital course: the patient was admitted to the hospital and brought to the operating room on where the patient underwent aortic valve replacement with a 21-mm on-x mechanical valve, replacement of ascending aorta and hemi arch with a 26- mm vascutek dacron tube graft using deep hypothermic circulatory arrest and reconstruction of pericardium with core matrix product. overall the patient tolerated the procedure well please see intraop note for further deatails. she 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 initially hypertensive but transitioned off nitro and nicardipine to beta blockers. she transferred to the floor on pod #2. she was gently diuresed and remained stable on the floor. chest tubes and pacing wires were discontinued without complication. the patient was evaluated by the physical therapy service for assistance with strength and mobility. she was started on anticoagulation and her inr was therapeutic at discharge.her pcp will manage her coumadin therapy. she was ambulating freely, her wounds were healing and pain was controlled with oral analgesics. the patient was discharged to home on pod#5 in good condition with appropriate follow up instructions. medications on admission: diovan 80 mg daily atorvastatin 40 mg daily aspirin 81 mg daily hctz 25mg daily metformin 500mg twice daily omeprazole 20mg twice daily oxybutynin 5mg twice daily multivitamin discharge medications: 1. oxybutynin chloride 5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). disp:*60 capsule, delayed release(e.c.)(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. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 7. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*60 tablet(s)* refills:*2* 8. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 9. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 10. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. lasix 40 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 12. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po twice a day for 10 days. disp:*20 tablet, er particles/crystals(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: 1. severe critical aortic stenosis. 2. severely calcified ascending aorta. discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics +lower extremity edema discharge instructions: 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 females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge followup instructions: *** ct scan in 6 months for f/u of lul pulm. nodules**** dr. @ 1:30 dr. @ 3:20pm dr. check @ 10:30 please call pcp for /u visit within 2 weeks coumadin therapy to be managed by pcp's office Procedure: Venous catheterization, not elsewhere classified Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Resection of vessel with replacement, thoracic vessels Other repair of heart and pericardium Diagnoses: Esophageal reflux Unspecified pleural effusion Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atherosclerosis of aorta Aortic valve disorders Diaphragmatic hernia without mention of obstruction or gangrene Other and unspecified hyperlipidemia Other emphysema

allergies: patient recorded as having no known allergies to drugs attending: addendum: per dr., follow up wound check with him has been changed to 4 weeks following discharge, unless other complications arise. discharge disposition: home with service facility: md 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 Unspecified essential hypertension Other and unspecified hyperlipidemia Anxiety state, unspecified Other and unspecified angina pectoris Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus

allergies: patient recorded as having no known allergies to drugs attending: addendum: please disregard initial addendum. made in error. discharge disposition: home with service facility: md 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 Unspecified essential hypertension Other and unspecified hyperlipidemia Anxiety state, unspecified Other and unspecified angina pectoris Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: angina major surgical or invasive procedure: cabg x 4 (lima to lad, svg to diag, svg "y" to pda and plv) history of present illness: 50 yo male with no regular medical care developed rest angina on , with midsternal chest pain. this recurred the next day twice, and he went to er at . ruled out for mi and cath showed lm and 3 v cad. referred for cabg. past medical history: coronary artery disease hyperlipidemia anxiety hypertension migraines gi bleed social history: lives with wife smoking one ppd for 30 years occasional etoh works in a warehouse family history: father mi at age 55 physical exam: 63" 76 kg hr 84 rr 16 132/90 right left 130/92 wdwn , nad dry scalp heent unremarkable neck with full rom and no carotid bruits appreciated ctab rrr no murmur appreciated abd soft nt, nd extrems warm, well-perfused, no edema or varicosities noted 2+ bil. fems/dps/pts/radials pertinent results: 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. 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%). right ventricular chamber size and free wall motion are normal. there are focal calcifications in the aortic arch. 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 leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results on mr. at 9:30am before incision. post-bypass: preserved biventricular systolic f unction. normal lvef 55%. trivial mr intact thoracic aorta i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 13:07 ?????? caregroup is. all rights reserved. 06:10am blood hct-26.9* 10:00pm blood wbc-9.7 rbc-4.59* hgb-14.0 hct-40.5 mcv-88 mch-30.5 mchc-34.5 rdw-14.2 plt ct-252 02:27pm blood pt-14.8* ptt-59.2* inr(pt)-1.3* 10:00pm blood pt-14.2* ptt-35.0 inr(pt)-1.2* 05:20am blood glucose-83 urean-12 creat-0.8 na-141 k-3.8 cl-106 hco3-29 angap-10 10:00pm blood glucose-127* urean-11 creat-0.9 na-142 k-3.4 cl-109* hco3-22 angap-14 brief hospital course: mr. was taken to the operating room and underwent coronary artery bypass grafting x4 with left internal mammary artery grafted to the left anterior artery, saphenous vein graft to the diagnal/saphenous vein y-grafted to pda/plv. please refer to dr operative note for further details. mr. the procedure well and was transferred to the cvicu in stable but critical condition. he awoke neurologically intact and was extubated that evening. all lines and drains were removed in a timely fashion. pod#1 he was transferred to the step down unit for further monitoring and progression. the remainder of his postoperative course was essentially uneventful. mr. continued to progress and on pod#4 he was ready for discharge to home with visiting nurse arrangement. all follow up appointments were advised. medications on admission: meds on trasnfer: trilafon 1 mg qhs inderal la 40 mg tid lipitor 80 mg daily xanax 0.5 mg tid protonix 40 mg daily asa 81 mg daily discharge disposition: home with service facility: discharge diagnosis: coronary artery disease s/p cabg x4 hyperlipidemia anxiety hypertension migraines gi bleed discharge condition: good discharge instructions: no lotions, creams or powders an any incision shower daily and pat incisions dry no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, drainage, or weight gain of 2 pounds in 2 days followup instructions: see dr. in weeks see dr. in weeks see dr. at in 3 weeks please call for all appts. 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 Unspecified essential hypertension Other and unspecified hyperlipidemia Anxiety state, unspecified Other and unspecified angina pectoris Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus

allergies: no known allergies / adverse drug reactions attending: chief complaint: syncopal episode, worsening shortness of breath major surgical or invasive procedure: percutaneous aortic valve placement history of present illness: mr is an 81-year-old gentleman status post cabg in with three grafts who has progressive lifestyle-limiting angina and class iii/iv congestive heart failure. he has severe aortic stenosis, a preserved ejection fraction and was turned down for a redo sternotomy in . he has significant copd with an fev1 of 0.96 on testing done in . he has atrial fibrillation and is not on coumadin because he has severe bruising, even on aspirin alone. he has had significant bleeding complications after both knee surgery and his initial cardiac surgery and thus was felt to be a very poor candidate for redo sternotomy. mr reports increasing fatigue and shortness of breath. he reports a constant chest discomfort with activity. he frequently has to rest. he is frustrated he can no longer mow his lawn. he denies any admissions, new events or problems, medications changes since last visit. he continues to report chest pressure with ambulation of about 100 feet. resolves with rest. nyha class: iii/iv past medical history: 1. aortic stenosis 2. cad - s/p cabg x 3 () 3. atrial fibrillation, rbbb 4. copd/asthma 5. cva 6. diabetes mellitus type 2 7. hypercholesterolemia 8. hypertension 9. sleep apnea 10. erectile dysfunction 11. s/p bilateral carotid endarterectomies 12. obesity 13. age related hearing loss 14. osteoarthritis 15. eczema 16. chronic low back pain lv diastolic dysfunction grade: none i ii iii iv chest wall deformity yes no history of ie yes no peripheral vascular disease yes no cirrhosis of liver yes no if yes, child score a b c history of anemia req transfusion yes no ulcer disease yes no connective tissue disease yes no hostile mediastinum yes no immunosuppressive therapy yes no previous cardiac surgery?: cabg x 3 () lima to lad, vein to ramus and pda previous balloon valvuloplasty?: no permanent pacemaker/icd in-situ?: no social history: retired. lives with wife in , ny (wife recovering from recent open heart surgery). supportive children in the area. likes to golf. (dtr-nurse) (son) average daily living: live independently yes no bathing independent dependent dressing independent dependent toileting independent dependent transferring independent dependent continence independent dependent feeding independent dependent race: caucasian last dental exam: two teeth upper, lower dentures - dental clearance obtained from dr (). lives with: wife occupation: retired from tobacco: never etoh: occasional family history: nc physical exam: admission exam pulse:57 b/p: left 137/60 resp: 20 o2 sat: 97 temp: 97.1 height: 170.1 cm weight: 100.4kg general: alert pleasant elderly male sitting upright. skin: tan, turgor fair. heent: normocephalic, anicteric. eyeglasses. oropharynx moist. neck: supple, trachea midline, bilat carotid bruits vs murmer chest: ls essentially cta. well healed sternal incision. heart: murmer throughout. abdomen: rotund, soft, (+)bs. nontender. extremities: no edema. no obvious deformities. neuro: a+o x 3, pleasant. gross from. gait steady. pulses: palpable peripheral pulses. discharge exam vs t 98.3 bp 150/67 hr 81 rr 18 97%ra rest of pe unchanged from admission pertinent results: pertinent labs 04:00pm wbc-6.3 rbc-4.37* hgb-13.4* hct-37.2* mcv-85 mch-30.6 mchc-36.0* rdw-14.5 04:00pm plt count-126* 04:00pm pt-13.4 ptt-31.5 inr(pt)-1.1 04:00pm digoxin-0.6* 04:00pm %hba1c-6.9* eag-151* 04:00pm ck-mb-2 probnp-687 04:00pm alt(sgpt)-16 ast(sgot)-18 ck(cpk)-63 alk phos-83 tot bili-0.5 04:00pm glucose-183* urea n-20 creat-1.0 sodium-139 potassium-4.1 chloride-97 total co2-36* anion gap-10 04:22pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-2* ph-6.0 leuk-neg 04:22pm urine color-straw appear-clear sp -1.010 . pre-procedure studies imaging: cardiac catheterization: ( iin vt) coronary angiographic findings: left main artery: the left main coronary artery was normal in size and had mild luminal irregularities. left anterior descending artery: the proximal lad artery has a 100% stenosis. the proximal portion of the 1st diagonal artery has a 90% stenosis. circumflex artery: the mid circumflex artey has a 50% stenosis (no graft to circumflex system). right coronary artery: the proximal rca has a 40% stenosis. the distal rca has a 90% stenosis. the proximal 1st rpl has a 90% stenosis. grafts: all anastomoses and grafts are widely patent. the mammary graft to the mid lad was without any significant lesions. the vein graft to the 1st diagonal was without any significant lesions. the vein graft to the 1st rpl was without any significant lesions. peripheral angiographic findings: aorta: the ingrarenal aorta is normal in size and has no significant angiographic lesions. iliac: the right and left common and external iliac arteries are normal in size and have no significant angiographic lesions. femoral/sfa/profunda: the right and left common femoral arteries are normal in size and have no significant angiogahic lesions. . tte (complete) done at 3:00:00 pm . findings patient experienced extreme transient lower back pain following definity administration. discomfort cleared within 10 minutes. intravenous administration of echo contrast was used due to poor native endocardial border definition. left atrium: elongated la. left ventricle: moderate symmetric lvh. normal lv cavity size. normal regional lv systolic function. overall normal lvef (>55%). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. aortic valve: severe as (area 0.8-1.0cm2). trace ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. mild pa systolic hypertension. pericardium: no pericardial effusion. conclusions the left atrium is elongated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. there is severe aortic valve stenosis (valve area 0.8-1.0cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: severe calcific aortic stenosis. symmetric lvh with normal global and regional biventricular systolic function. mild pulmonary hypertension. . ekg: () rate 59, atrial fibrillation, rbbb . cta chest: () impression: 1. diffusely atherosclerotic aorta without dilatation. the common iliac arteries measure 11mm diameter. 2. aortic valve stenosis. 3. patent coronary artery bypass grafts. 4. findings consistent with a few small airways disease. 5. moderate size left pleural effusion with associated compressive atelectasis of the left lower lobe. . ct pelvis w/contrast: impression: 1. calcifications present within the abdominal aorta, iliac and common femoral arteries. 2. there is focal narrowing of 6.4mm from calcifications in the right common femoral artery. there is focal narrowing in the right common iliac artery of 7.6mm. the left common femoral artery has focal narrowing of 6.4mm from calcifications. the left common iliac has focal narrowing of 7.7mm from calcifications. 3. prominent prostate gland. other diagnostics: . pft: () actual %predicted fvc 1.3 34% fev1 0.96 33% fev1/fvc 74% 97% fef 25% 1.811 28% fef 50% 0.873 28% fef 75% 0.159 17% fef 25-75% 0.68 27% fef 2.0 29% exp. time 4.783 v ext 0.047 imp: very severe restriction. . carotid dopplers: () (s/p lca , rca ) impression: 1. <50% rcea 2. <50% lcea 3. antegrade vertebrals 4. essentially no change from sts score: procedure name is risk of mortality 7.6% morbidity or mortality 31.3% long length of stay 19.3% short length of stay 16.1% permanent stroke 2.9% prolonged ventilation 25.3% dsw infection 0.4% renal failure 12.3% reoperation 9.9% . mmse-2 score: 27 grip strength test: right: left: . post-procedure studies: tte : the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is at least 15 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size is normal. with borderline normal free wall function. an aortic corevalve prosthesis is present. the transaortic gradient is normal for this prosthesis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is moderate to severe pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: normally functioning, well-seated aortic corevalve prosthesis. moderate to severe pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , a normally functioning, well-seated aortic corevalve prosthesis is seen. the severity of pulmonary artery systolic hypertension has increased and is now moderate to severe. a large left pleural effusion is now appreciated. . tte suboptimal image quality. the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 5-10 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. an aortic corevalve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . discharge labs 07:20am blood wbc-8.3 rbc-3.80* hgb-11.6* hct-32.6* mcv-86 mch-30.5 mchc-35.5* rdw-14.2 plt ct-158 04:00am blood pt-15.2* ptt-35.5* inr(pt)-1.3* 07:20am blood glucose-115* urean-20 creat-0.8 na-140 k-4.0 cl-99 hco3-37* angap-8 10:44pm blood ck(cpk)-70 07:20am blood probnp-568 04:00pm blood ck-mb-2 probnp-687 07:20am blood calcium-8.7 phos-4.5 mg-2.5 04:00pm blood %hba1c-6.9* eag-151* 04:00pm blood digoxin-0.6* 07:20am blood hemoglobin, free-pnd brief hospital course: primary reason for admission 81 yo male with severe aortic stenosis, h/o cabg, afib, symptomatic with chest discomfort with minimal exertion. evaluated to be prohibitively extreme risk surgical candidate. admitted for tavi/corevalve trial. . active issues: # critical as- patient with history of symptomatic severe aortic stenosis. on hd 1 he underwent percutaneous placement of a 29 mm corevalve percutaneous aortic valve. aortography demonstrated mild aortic regurgitation (1+), and trans-esophageal echocardiography showed mild (1+) paravalvular aortic regurgitation. he tolerated the procedure well and was successfully extubated shortly after transfer to the ccu. echocardiogram performed prior to discharge indicated that corevalve prosthesis was in place and well sealed with normal leaflet/disc motion and transvalvular gradients. no aortic regurgitation is seen. ef was <55%. all of the appropriate labs and studies for corevalve study were performed. . # rhythm- the patients pre-op ekg demonstrated a native rbbb, and given the risk of post procedure conduction abnormalities a temporary pacemaker was placed. he did not develop complete heart block and so temporary pacemaker was removed on hd3/pod2. telemetry noted pauses while patient was sleeping with appropriate chronotropic response while awake. additionally he was noted to have bradycardia to the low 30s with some dizziness and nausea. this was felt to be due to vagal response to nausea but the patient was transferred back to the ccu for further monitoring. ep evaluated the patient and felt that pt needed pacemaker. a single chamber pacemaker was placed on and pt tolerated procedure well. at time of discharge pt had ecg showing rate controlled afib and rbbb. his home propafenone, digoxin and beta blockage were discontinued and pt was started on dabigatran 75mg by mouth twice daily for anticoagulation. he was discharged on three days of keflex post pacemaker placement. . # chronic diastolic dysfunction: patient appeared euvolemic on admission. his weight was monitored throughout admission. he was diuresed with iv lasix as needed and discharged on oral lasix 100mg . . # af with pauses: patient had occasional pauses lasting secs noted on tele, always asymptomatic. dig level was low. his carvedilol was held post procedure. will need to restart beta-blockade after discharge. . stable issues: # copd: restrictive pattern on pft's, home o2 requirement. he was continued on his home advair, singulair and spiriva. . # htn: he was continued on his home enalapril. carvedilol held as above. . # cad: stable. grafts patent on cath in . he was continued on his home lipitor, and his asa was resumed post-procedure. # hld: he was continued on his home atorvastatin. transitional issues: - patient maintained full code status throughout hospitalization. - he should follow up with pcp in two weeks and primary cardiologist for wound check and to restart beta-blockade. medications on admission: aspirin 81mg daily - (stopped taking 6 days prior on his own) coreg 3.125mg po bid digitek 0.125mg daily vasotec 5mg daily rythmol 150mg po tid lasix 100mg po bid k-dur 40meq po bid lipitor 40mg daily advair diskus 250/50mg 1 puff singulair 10mg po qhs spiriva 18mcg inhaled daily discharge medications: 1. keflex 500 mg capsule sig: one (1) capsule po every six (6) hours for 2 days. disp:*8 capsule(s)* refills:*0* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. enalapril maleate 5 mg tablet sig: one (1) tablet po daily (daily). 4. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 5. montelukast 10 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 6. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 7. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) inhalation once a day. 10. dabigatran etexilate 75 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*3* 11. atorvastatin 40 mg tablet sig: one (1) tablet po at bedtime. 12. furosemide 20 mg tablet sig: five (5) tablet po twice a day. 13. potassium chloride 10 meq tablet, er particles/crystals sig: four (4) tablet, er particles/crystals po twice a day. discharge disposition: home with service facility: health ny discharge diagnosis: severe aortic stenosis s/p percutaneous corevalve placement coronary artery disease dyslipidemia diabetes mellitus type 2 hypertension atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you had severe aortic valve disease and had the valve replaced using a corevalve. this procedure went well and the echocardiogram shows that the valve is working well. your chest pain has improved. you have atrial fibrillation and some pauses while you are sleeping, so a pacemaker was placed. you were started on dabigatron to prevent blood clots, you should continue your aspirin as before. please let dr. know if you have any bleeding trouble on the dabigatron. . we made the following changes to your medicines: 1. start keflex 500mg every 6 hours for 2 days 2. start dabigatron 75mg twice a day 3. stop propafenone, digoxin, carvedilol followup instructions: department: cardiac services when: friday at 12:00 pm with: , md building: sc clinical ctr campus: east best parking: garage . department: cardiac services when: friday at 1 pm with: device clinic building: sc clinical ctr campus: east best parking: garage . department: cardiac services when: friday at 2:00 pm with: echocardiogram building: sc clinical ctr campus: east best parking: garage name: , specialty: family practice address: , , phone: appointment: wednesday at 10:50am Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Open and other replacement of aortic valve Aortography Arteriography of other intra-abdominal arteries Initial insertion of transvenous lead [electrode] into ventricle Percutaneous balloon valvuloplasty Initial insertion of single-chamber device, not specified as rate responsive Diagnoses: Other chronic pain Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Aortocoronary bypass status Aortic valve disorders Other and unspecified hyperlipidemia Other and unspecified angina pectoris Unspecified sleep apnea Right bundle branch block Unspecified hearing loss Obesity, unspecified Chronic obstructive asthma, unspecified Examination of participant in clinical trial Chronic diastolic heart failure

allergies: no known allergies / adverse drug reactions attending: chief complaint: acute insult to head unknown cause major surgical or invasive procedure: none history of present illness: this is a 29 year old male who was found sitting on the curb bleeding per records. he was bleeding from a head laceration. at , a ct showed a subdural hematoma. the patient became combative and was restrained. he was transferred to and was intubated in the emergency room for agitation and combativeness. past medical history: none social history: unknown family history: unknown physical exam: on admission physical exam: o: t: 98 bp: 116/67 hr: 82 r 18 o2sats 100% gen: awake, agitated/combative, security at the bedside restraining patient. neuro: awake, alert, very agitated/combative, yelling/shouting, speech is clear, moves all 4 extremities spont/purposeful- appears full motor as he requires multiple personnel to hold him down. unable to fully assess neuro exam secondary to his level of agitation. on the day of discharge the patient is very aggitated but neurourologically intact. strength is full. sensation is intact. head laceration approximated with staples for closure (placed at ) no pronator drift patient is oriented to person/place/time pertinent results: 09:35am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-15 bilirubin-neg urobilngn-0.2 ph-5.0 leuk-neg 09:35am urine color-yellow appear-clear sp -1.025 09:35am pt-11.6 ptt-29.5 inr(pt)-1.1 09:35am plt count-371 09:35am wbc-24.2* rbc-5.14 hgb-15.3 hct-47.7 mcv-93 mch-29.8 mchc-32.1 rdw-12.5 09:35am urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg 09:35am asa-neg ethanol-112* acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 09:35am albumin-4.9 calcium-9.0 phosphate-4.1 magnesium-2.2 09:35am lipase-18 09:35am alt(sgpt)-37 ast(sgot)-45* alk phos-71 tot bili-0.5 radiology report ct c-spine w/o contrast study date of 9:32 am impression: no acute fracture or malalignment. ct head w/o contrast study date of 9:32 am impression: 1. small right frontotemporal subdural hematoma measuring up to 7 mm in diameter in the inferior frontal lobe. overall, the size appears similar compared to recent prior examination. 2. slight asymmetric thickening of the left tentorium possibly a minimal layering subdural hematoma. 3. no evidence of subfalcine or transtentorial herniation. 4. stable left occipital subgaleal hematoma with overlying stable at site of laceration. 5. stable left occipital skull fracture extending into the skull base trauma #2 (ap cxr & pelvis port) study date of 9:42 am impression: 1. no acute cardiopulmonary pathology. 2. no pelvic fractures. ct head w/o contrast study date of 12:36 am findings: again small subdural hematoma and hemorrhagic contusion with small amount of subarachnoid blood are identified. the overall size of the hemorrhage is less apparent and no new hemorrhage is seen. there is no midline shift or hydrocephalus. the basal cisterns are patent. impression: since the previous study, the multi-compartment hemorrhage is less apparent. no new hemorrhage is seen. no mass effect or hydrocephalus brief hospital course: this is a 29year old male who was found sitting on the curb bleeding per records. he was bleeding from a head laceration. at the , a ct of the head was consistent with a subdural hematoma, he became combative and was restrained. he was transferred to on and was intubated in the emergency department for agitation and combativeness. he was sdmitted to the neurosurgical service to the intensive care unit with every 1 hour neurological assessment. the patient required medication including ativan and precedex for aggitation. in the evening of the patient was electively extubated and was sedated overnight due to aggitation. on exam the patient was full stregth and sensation. his pupils were equal and reactive. he has a small head laceration on the back of his head that had been closed with staples at . the patient was kept in the icu due to aggitation overnight. on the patient was neuologically intact although aggitated. the patient was requesting to leave against medical advice. a psycological evaluation was obtained to evaluate the patient for competency which revealed that there was no current indication that he lacks capacity to leave the hospital. as the patients head ct was stable and the patient was neurologically intact, the patient was discharged to home. the patient was ambulating with a steady gait and tolerating a regular diet. he was able to void independently and there was family at his bedside to accompany him home. the patient was discharged with keppra tablets from the pharmacy as there was no keppra available at his pharmacy on the day of his discharge which was a sunday. medications on admission: none discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain for 2 weeks: hold for lethargy , do not drive while taking this medication. disp:*40 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. keppra 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 4. keppra 500 mg tablet sig: one (1) tablet po twice a day for 6 doses: please dispense from hospital pharmacy. disp:*6 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: small right frontotemporal subdural hematoma left occipital skull fracture extending into the skull base. discharge condition: aggitated but neurologically intact full strength and sensation pupils are equal and reactive no pronator drift noted 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 not on any medications such as coumadin (warfarin), or plavix (clopidogrel), or aspirin prior to your injury,do not begin taking these medications without discussing this with dr . ?????? you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. call your surgeon immediately if you experience any of the following ?????? new onset of tremors or seizures. ?????? any confusion, lethargy or change in mental status. ?????? any numbness, tingling, weakness in your extremities. ?????? pain or headache that is continually increasing, or not relieved by pain medication. ?????? new onset of the loss of function, or decrease of function on one whole side of your body. followup instructions: follow-up appointment instructions ??????please call ( to schedule an appointment with dr. , to be seen in four days on thursday of this week. ??????you will need a cta scan of the brain without contrast to evaluate left occipital skull fracture and subdural hematoma prior to your appointment. this can be scheduled when you call to make your office visit appointment. you have a scalp laceration that was repaired at and closed with staples. please return to in 7 days to have these staples removed. if there is any sign of infection at the site please present to the ed or your pcp . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Alcohol abuse, unspecified Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Open wound of knee, leg [except thigh], and ankle, without mention of complication Other alteration of consciousness Contusion of face, scalp, and neck except eye(s) Striking against or struck accidentally by other stationary object with subsequent fall Unemployment Narcissistic personality disorder

allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: bilateral thoracotomies, mini-maze with resection of left atrial appendage history of present illness: mr. is a 57 year old male with history of persistent atrial fibrillation since . he complained of intermittent shortness of breath. in addition he has intermittent palpitations, lightheadedness, dizziness and fatigue. he was on amiodarone in - and maintained a nsr but had to stop taking this medication due to photosensitivity. during this time he had two cardioversions. he is currently taking diltiazem and carvedilol. in addition is currently taking pradaxa instead of coumadin. due to his symptoms, and frequency of atrial fibrillation, he has been referred for maze procedure with left atrial appendectomy. past medical history: chronic paroxysmal atrial fibrillation colon/rectal cancer s/p surgery prostate cancer s/p surgery gerd bowel dysfunction osteoarthritis phlebitis claustrophobia s/p colectomy/ostomy(later reversed) s/p radical prostatectomy s/p right knee surgery s/p right shoulder surgery s/p left hip replacement s/p ventral hernia repair s/p vein stripping of right gsv social history: mr. lives with his wife and is a football coach. he is a non-smoker and drinks alcohol socially. family history: his father had a coronary artery bypass graft in his 70s. physical exam: physical exam pulse: 85 resp: 16 o2 sat: 98%ra b/p right: 117/78 left: 114/75 weight: 237lb general: nad, wgwn, appears stated age, slightly anxious skin: dry intact heent: perrla eomi op benign neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + well healed mid-line and rlq incisions extremities: warm , well-perfused edema varicosities: none neuro: grossly intact x pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ pertinent results: echocardiography report , (complete) done at 11:57:33 am preliminary referring physician information , c. , status: inpatient dob: age (years): 58 m hgt (in): 72 bp (mm hg): / wgt (lb): 225 hr (bpm): bsa (m2): 2.24 m2 indication: atrial fibrillation. icd-9 codes: 427.31 test information date/time: at 11:57 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 #: 2011aw-1: machine: us2 echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *5.8 cm <= 5.6 cm left ventricle - ejection fraction: 45% to 50% >= 55% left ventricle - lateral peak e': *0.01 m/s > 0.08 m/s aorta - annulus: 2.7 cm <= 3.0 cm aorta - sinus level: 3.2 cm <= 3.6 cm aorta - sinotubular ridge: 2.8 cm <= 3.0 cm aorta - ascending: 2.8 cm <= 3.4 cm aorta - descending thoracic: 2.3 cm <= 2.5 cm aortic valve - lvot diam: 2.5 cm findings left atrium: no spontaneous echo contrast in the body of the laa. good (>20 cm/s) laa ejection velocity. no thrombus in the laa. right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: normal lv wall thickness. mildly dilated lv cavity. mild regional lv systolic dysfunction. mildly depressed lvef. right ventricle: mildly dilated rv cavity. borderline normal rv systolic function. taspe depressed (<1.6cm) aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal aortic arch diameter. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: no ms. trivial mr. tricuspid valve: mild tr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no thrombus is seen in the left atrial appendage. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is mild regional left ventricular systolic dysfunction with apical hypokinesis. overall left ventricular systolic function is mildly depressed (lvef= 45-50 %). the right ventricular cavity is mildly dilated with borderline normal free wall function. tricuspid annular plane systolic excursion is depressed consistent with right ventricular systolic dysfunction. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. trivial mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results at time of surgery. post-ligation: the left atrial appendage is not seen. color flow doppler exam demonstrates no evidence of flow from the previous location of the left atrial appendage into the left atrium. brief hospital course: on mr. bilateral thoracotomies, mini-maze with resection of left atrial appendage performed by dr. . please see the operative note for details. he tolerated the procedure well and extubated in the operating room. he was transferred in critical but stable condition to the surgical intensive care unit. his chest tubes and temporary pacing wires were removed per protocol. he was started back on his , calcium channel blocker, and pradaxa. he was placed on indocin and motrin for 1 month post-operatively to reduce pericardial inflammation. he was evaluated by physical therapy for strength and conditioning and was cleared for discharge to home on pod#3. medications on admission: coreg 25mg pradaxa 150mg diltiazem 120mg daily benefiber lactobacillus lotrisone discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*28 tablet(s)* refills:*0* 3. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 5. dabigatran etexilate 150 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*75 tablet(s)* refills:*0* 7. diltiazem hcl 120 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po daily (daily). disp:*30 capsule, ext release 24 hr(s)* refills:*2* 8. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. indomethacin 25 mg capsule sig: one (1) capsule po tid (3 times a day) for 1 months. disp:*90 capsule(s)* refills:*0* discharge disposition: home with service facility: vna & hospice discharge diagnosis: atrial fibrillation chronic paroxysmal atrial fibrillation; colon/rectal cancer s/p colectomy; ventral hernia repair; prostate cancer s/p radical prostatectomy; gerd; bowel dysfunction; osteoarthritis; phlebitis; claustrophobia; l hip replacement discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesia incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema 1+ 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** recommended follow-up: followup instructions: you are scheduled for the following appointments surgeon: dr. on at 2:45pm in the medical office building , cardiologist: on at 1:40pm please call to schedule appointments with your primary care dr. , c. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: Excision or destruction of other lesion or tissue of heart, open approach Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Esophageal reflux Atrial fibrillation Personal history of malignant neoplasm of prostate Atrial flutter Other isolated or specific phobias Osteoarthrosis, unspecified whether generalized or localized, site unspecified Personal history of malignant neoplasm of large intestine

allergies: penicillins / effexor attending: chief complaint: diarrhea for 3 weeks major surgical or invasive procedure: picc line insertion, lumbar puncture attempt history of present illness: 49 y/o female with a history of seizure disorder, niddm, hypertension, alcohol abuse, presenting with persistent non-bloody diarrhea and dehydration for the past 10 days. patient reports that she was visiting , ate steak a ta cracker , and then began to have severe nausea, vomiting, and diarrhea. she reports associated chills, and overall weakness. she presented to duke with these symptoms and and was admitted for ivf hydration with negative blood and stool cultures per the husband's report. since returning, her symptoms have persisted and worsened to now 10 watery bowel movements per day. yesterday, she presented to her pcp's office with continued diarrhea, vomiting any po intake, tachycardia, and weak bp, and it was recommended she go to the ed. she deferred until this morning as she felt worse today. . in the ed, initial vs were: t 97 p 110 bp 86/47 r 18 o2 sat 100% ra. patient bolused 2 l ns with improvement in sbp to 115. k was found to be 2.6, mg was 1.6, both repleted. cxr was normal. ecg showed subtle flattenning of t waves in v2-v6, and patient was given asp 325. . on the floor, patient's initial vitals t 96.2 hr 100 bp 110/62 rr 16 96% ra. she was somewhat drowsy on interaction; however, stated she feels better after the ivfs. . review of sytems: (+) per hpi (-) denies fever, headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. no dysuria. denied arthralgias or myalgias or skin changes. past medical history: seizures diabetes mellitus hypertension schizophrenia alcohol abuse hepatitis c social history: she lives at home with her husband. she quit working 15 years ago, but was previously in sales and an administrator at a construction company. she quit smoking cigarettes 3 months ago, but previously smoked 1 ppd x >30 years. she has not had any etoh in 6 months, but has a history of etoh abuse. she denies a history of drug abuse, but per prior socialhistories there is a history of cocaine abuse in the past. family history: her maternal uncle had seizures. physical exam: admission physcial exam vitals: t 96.2 hr 100 bp 110/62 rr 16 96% ra general: patient drowsy and somewhat somnolent, oriented x 3, no acute distress heent: sclera anicteric, dry mm, 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: distended, somewhat firm, tender to deep palpation diffusely, hyperactive bowel sounds ext: 2+ pulses, no clubbing, cyanosis or edema skin: no rashes, bruises noted neuro: alert + oriented x 3, appropriate affect discharge physical exam vitals: t 98.1 hr 85 bp 100/53 rr 20 100 ra general: patient was comfortable in nad, aaox3 abd: soft, nontender, slightly distended ext: trace edema, no clubbing or cyanosis pertinent results: admission labs: . 10:30am blood wbc-10.9 rbc-4.74 hgb-12.0 hct-37.3 mcv-79* mch-25.4* mchc-32.2 rdw-19.6* plt ct-341# 10:30am blood glucose-242* urean-29* creat-1.4* na-130* k-2.6* cl-97 hco3-17* angap-19 01:20pm blood alt-11 ast-24 ld(ldh)-461* alkphos-106* totbili-0.1 10:30am blood ctropnt-<0.01 10:30am blood calcium-8.2* phos-4.8* mg-1.6 01:20pm blood valproa-81 01:20pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:37am blood lactate-2.0 . ecg : sinus tachycardia. there are small r waves in the anterior leads consistent with possible prior anterior myocardial infarction. non-specific st-t wave changes. compared to the previous tracing st-t wave changes are new. . eeg : continuous eeg: the background was slightly slow reaching a maximum of 7 hz. there were no clear epileptiform discharges or electrographic seizures noted. spike detection programs: there were 91 entries in these files. these represented electrical and muscle artifact. seizure detection programs: there were three entries in these files. these represented electrical and movement artifact. pushbutton activations: there were no entries in these files. sleep: there was no clear sleep architecture noted in the record. cardiac monitor: showed a generally regular rhythm with an average rate of 90 bpm. impression: this is an abnormal video eeg telemetry due to the presence of a slow background which reached a maximum of 7 hz. this represents a mild encephalopathy such as can be seen in toxic/metabolic, diffuse ischemic, or infectious etiologies. there were no clear epileptiform discharges or electrographic seizures noted. . eeg : continuous eeg: the background was slow reaching a maximum of 5.5 hz. of note, from 15:23 onward, the patient is not being recorded, as the leads appear to be off. spike detection programs: there were no entries in these files. seizure detection programs: there were no entries in these files. pushbutton activations: there were no entries in these files. sleep: there was no clear sleep architecture noted in the record. cardiac monitor: showed a generally regular rhythm with an average rate of 100 bpm. impression: this is an abnormal video eeg telemetry due to the presence of a slow background which reached a maximum of 5.5 hz. this represents a moderate to severe encephalopathy such as can be seen in diffuse ischemia, toxic/metabolic, infectious, or other diffuse etiologies. note is made of lack of readable recordings after 15:23. there were no clear epileptiform discharges or electrographic seizures noted. . ct head w/o contrast: impression: no evidence of definite acute abnormalities. the apparent thin left parietal extraaxial hyperdensity is likely an artifact, but could be reassessed by a follow-up ct or by mri. . mr head : findings: there is considerable motion artifact degrading image quality. the gradient echo images are nondiagnostic. there is no intracranial mass, mass effect or abnormal enhancement. no acute infarct is demonstrated. the ventricular dimensions and sulcal prominence are advanced for age. impression: no evidence of intracranial mass, acute infarct or abnormal enhancement. gradient echo images are degraded by motion artifact. mild degree of generalised cerebral atrophy advanced for age. . cxr : findings: in comparison with the study of and , there is some continued opacification in the retrocardiac region medially, concerning for pneumonia. the right picc line now extends to the region of the mid portion of the svc. . cxr : cardiac size is top normal. right picc tip is in the mid svc in unchanged position. retrocardiac opacity has improved consistent with improving atelectases. the right lower lobe opacity consistent with atelectases is unchanged. there is no pneumothorax or pleural effusion. . egd/colonoscopy biopsies: intestinal mucosal biopsies, three: a. duodenum: chronic active duodenitis with prominent increase in subepithelial collagen, surface epithelial damage, and subtotal villous shortening, see note. b. terminal ileum: small intestinal mucosa with largely denuded epithelium and increased subepithelial collagen, see note. c. random colon: 1. colonic mucosa with increased lamina propria chronic inflammation, surface epithelial damage, and increased intraepithelial lymphocytes, see note. 2. no appreciable increase in subepithelial collagen noted on h&e stained sections. note: in evaluable epithelium in the duodenal and terminal ileal biopsies, there is additionally a prominent increase in intraepithelial lymphocytes. the findings are consistent with a collagenous enteritis with concurrent microscopic (lymphocytic) colitis. these entities are known to co-exist in a rare subgroup of patients and show marked clinical response to steroid therapy. no microorganisms or viral cytopathic effect are seen. special stains to rule out possible co-existing infection and to confirm the presence of increased subepithelial collagen will be reported in an addendum. preliminary findings discussed with dr. on by dr. . addendum # 1: trichrome stain highlights a diffuse, markedly increased subepithelial collagen layer thickness in both the duodenal and ileal mucosal biopsies, while showing a patchy increase in the colonic mucosal biopsies. this supports a diagnosis of collagenous enterocolitis. red stain is negative for amyloid deposition in the duodenal biopsy with satisfactory control. giemsa stain reveals no microorganisms in the small intestinal biopsies with satisfactory control. brief hospital course: 49 y/o female with a history of seizure disorder, iddm, hypertension, alcohol abuse, initially presented with persistent, profuse, non-bloody diarrhea, biopsies consistent with collagenous colitis, course complicated by icu transfer for unresponsiveness and altered mental status, likely a post-ictal state from subclinical seizure. . #. collagenous enterocolitis: initially, etiology of patient's diarrhea was thought to be infectious and stool studies indicated a secretory process. she was started on cipro/flagyl and supported with ivfs for dehydration and electrolyte repletion as needed. initial stool studies were negative for infection and c. diff, and stool study results were obtained from duke, which were also negative. her diarrhea continued to be profuse, about 4-5 l/day. ciprofloxacin was discontinued during her icu course due to increase risk of seziures (see below). c. diff pcr and toxin were negative, although patient was continued on flagyl. gi was consulted, and recommended exploring other etiologies of secretory diarrhea, including sending tests for neuroendocrine tumors. (these tests were pending at the time of discharge). egd and colonoscopy was performed and showed no evidence of pseudomembranous colitis, thus flagyl was discontinued. biopsies showed findings consistent with microscopic colitis, and stains conformed the diagnosis of collagenous colitis. patient was started on budesonide 9 mg per day on andwill continue until her appointment with gastroenterology. patient's diarrhea began to decrease with the help of lomotil qid. . #. altered mental status/seizure: patient has a history of seziures controlled on depakote 1000 mg ; she had not been taking this med several days prior to admission due to poor po intake. patient's mental status began to change on hospital day #4. she became increasingly somnolent, was unresponsive. labs showed a worsening nag acidosis and an abg showed 7.33/23/100 with lactate of 1.1. she had no meningeal signs, was afebrile, serum tox negative. due to her history of seziures, and the fact that she had been off her po depakote, neurology recommended giving 1 mg ativan to treat possible seizure. she subsequently became more somnolent and was transferred to the micu. in the icu, 24 hour eeg only showed slow-wave activity, consistent with toxic/metabolic encephalopathy or post-ictal state. head ct and mri were both negative. vanc/ceftriaxone and acyclovir were started for emperic coverage of cns infection. lp was attempted but unsuccessful x 3. patient was transferred abck to the floor stable, but still somnolent. acyclovir was discontinued as viral encephalitis was unlikely. vanc/ceftriaxone was continued for treatment of hospital-acquired pneumonia (see below). her mental status began to clear and patient became more responsive over the next several days. she was maintained on iv depakote and dose was adjusted based on trough levels. once she able to tolerate pos, she was transitioned to po depakote at home dose without complications. she will have her valproate levels checked on with results faxed to dr. . her altered mental status was likely due to a prolonged post-ictal state after a subclinical seizure secondary to patient being off depakote for several days. by discharge, her mental status had cleared and she was interative and back to her baseline. . #. nutritional status: patient's albumin prior to discharge was 1.7, likely secondary to poor intake. the low albumin also caused diffuse edema and thrid spacing from massive ivf hydration over the past several weeks, which made the patient uncomfortable. nutrition was consulted and recommended that patient drink supplemetal formulas along with full po diet to increase protein intake to ultimately raise the albumin. as per gi she should be on a gluten free diet. . #. schizophrenia: on admission, patient had not been taking clozapine for several days. her dose was held through most of her admission as she was not able to tolerate pos. psych recommended starting at 12.5 mg once a day and slowly titrating up to patient's home dose. one 12.5 mg dose was administered; however, the patient became orthostatic, and subsequent doses were held. her clozaril was held prior to discharge and will discuss restarting during her follow up appointment with . . #. hypertension: lisinopril was held during patient's admission due to dehydration and labile blood pressures. she should discuss restarting lisinopril during her primary care appointment. . #. iddm: patinet's lantus was halved to 5 units qhs as she was not tolerating pos and sugars were maintained on an iss during admission. medications on admission: omeprazole 20 mg cap, delayed release 1 capsule(s) by mouth daily divalproex 500 mg tab, delayed release 2 tablet(s) by mouth twice daily clozapine 100 mg tab 3 tablet(s) by mouth daily at bedtime multivitamin tab 1 tablet(s) by mouth daily folic acid 1 mg tab 1 tablet(s) by mouth daily lantus 100 unit/ml subq cartridge subcutaneous 16-18 units cartridge(s) q pm glipizide 5 mg tab oral 1 tablet(s) once daily, in am lomotil 2.5 mg-0.025 mg tab oral 1 tablet(s) , as needed lisinopril 5 mg tab oral 1 tablet(s) once daily vitamin b-1 100 mg tab oral 1 tablet(s) once daily discharge medications: 1. divalproex 500 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 3. multivitamin tablet sig: one (1) tablet po once a day. 4. lantus 100 unit/ml cartridge sig: 16-18 units subcutaneous at bedtime. 5. glipizide 5 mg tablet sig: one (1) tablet po once a day. 6. outpatient lab work please check valproate level and fax results to dr. (phone: , fax: ). 7. budesonide 3 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po daily (daily). disp:*30 capsule, sust. release 24 hr(s)* refills:*0* 8. diphenoxylate-atropine 2.5-0.025 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*0* 9. outpatient lab work please check cbc have results faxed to , l . discharge disposition: home with service facility: vna discharge diagnosis: primary: microscopic colitis hypotension seizure disorder seconadary: schizophrenia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were seen in the hospital because of persistent diarrhea. this diarrhea was found to be due to an autoimmune process called microscopic colitis. this condition is treated with the steroid budesonide which you will continue until your appoinment on . you will be followed by the gastrointestinal doctors for this condition. you were also noted to have low blood pressures. this was most likley due to all the fluid you were losing with the diarrhea. your lisinopril was held and should continue to be held. you should discuss restarting this medication with your primary care doctor. you should have your blood count checked on when you have your valproate level checked. your clozapine was also held because of the concern that it was lowering your blood opressure further. you should discuss restarting when you meet with on . the neurologists visited you during your admission. you will have a follow up appointment with dr. . you will have your valproate levels checked and the results will be sent to dr. . you should start a gluten free diet after you are discharged. this was recommended by your gastroenterologists to prevents worsening diarrhea. medications changes during this admission hold lisinopril hold clozapine continue budesonide continue lomotil (stop when your diarrhea stops) followup instructions: gastrointestinal: thursday @ 8:20 am with dr. name: , l. location: community health center address: , , phone: appointment: monday, at 4:15pm name: , specialty: psychiatry location: , phone: appointment: wednesday, at 11:30am department: neurology when: tuesday at 7:30 pm with: , md building: sc clinical ctr campus: east best parking: garage nutrition services phone: ( appt: please contact nutrition services directly to set up nutrition counseling. discuss your doctors of a gluten free diet. Procedure: Venous catheterization, not elsewhere classified Esophagogastroduodenoscopy [EGD] with closed biopsy Closed [endoscopic] biopsy of large intestine Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Other and unspecified noninfectious gastroenteritis and colitis Anemia, unspecified Toxic encephalopathy Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Unspecified viral hepatitis C without hepatic coma Personal history of tobacco use Alcohol abuse, unspecified Hypopotassemia Unspecified schizophrenia, unspecified Diaphragmatic hernia without mention of obstruction or gangrene Hypotension, unspecified Epilepsy, unspecified, without mention of intractable epilepsy Duodenitis, without mention of hemorrhage Leukocytosis, unspecified Mixed acid-base balance disorder Malnutrition of mild degree

allergies: patient recorded as having no known allergies to drugs attending: addendum: - the patient had acute perfusion-related kidney injury. function recovered by discharge as evidenced by cr of 0.9. discharge disposition: extended care facility: for the aged - macu md Procedure: Parenteral infusion of concentrated nutritional substances Insertion of other (naso-)gastric tube Open reduction of fracture with internal fixation, femur Transfusion of packed cells Diagnoses: Acidosis Other iatrogenic hypotension Anemia in chronic kidney disease Esophageal reflux Urinary tract infection, site not specified Acute kidney failure, unspecified 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 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other persistent mental disorders due to conditions classified elsewhere Chronic kidney disease, unspecified Dysthymic disorder Paralytic ileus Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Alzheimer's disease Closed fracture of subtrochanteric section of neck of femur Fall from other slipping, tripping, or stumbling Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site Dementia in conditions classified elsewhere with behavioral disturbance

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: femur fracture s/p fall major surgical or invasive procedure: : s/p open reduction internal fixation, left hip. history of present illness: y.o. russian speaking m with htn, cri, dementia from rehab who was brought by ambulance to the ed s/p witnessed mechanical fall (backed into chair and fell after getting up without walker). reportedly did not strike his head strike and no loc. was noted to have left leg pain/deformity. per report, patient a & o x 0 at baseline. was seen by staff physician and given morphine. initial ed vs 96.9, 112 irregular, 118/82, 18, 100/ra. exam with left hip deformity, lle shortening and internal rotation, 1+ palpable distal pulses. baseline hct 35.8 (). given morpine 2mg iv, morphine 4mg x 1, ns 2l, haldol 5mg, 1u prbc. foley placed. fast negative per report but not in ed documentation. ortho consulted, consented patient for surgery and placed pin, currently in traction. given unclear source of bleeding and hypotension on arrival, patient admitted to micu for closer monitoring. vs on transfer 97.3, 100, 136/86, 22, 100/2l. upon admission to micu, patient appears in pain. . while in ed patient denied chest pain, pressure, fever, chills/rigors, sob, cough. past medical history: 1. hypertension. 2. chronic renal insufficiency. 3. benign prostate hypertrophy. 4. dementia 5. depression 6. peptic ulcer disease 7. s/p hernia repair social history: lives in behavioral unit at rehab. no tobacco, 'may have up to one glass of wine per day'. family history: non-contributory physical exam: on admission: vitals: 97.3, 100, 136/86, 22, 100/2l 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: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs: 12:00pm blood wbc-12.8*# rbc-3.62* hgb-11.4* hct-34.9* mcv-97 mch-31.5 mchc-32.6 rdw-12.8 plt ct-258 12:00pm blood neuts-86.3* lymphs-9.2* monos-3.9 eos-0.5 baso-0.1 02:32pm blood pt-13.8* ptt-22.0 inr(pt)-1.2* 03:00pm blood esr-16* 12:00pm blood glucose-205* urean-40* creat-1.9* na-140 k-4.6 cl-105 hco3-23 angap-17 12:00pm blood alt-25 ast-33 ck(cpk)-90 alkphos-105 totbili-0.5 12:00pm blood ctropnt-0.07* 12:00pm blood lipase-40 05:10am blood wbc-9.4 rbc-3.28* hgb-10.1* hct-30.5* mcv-93 mch-30.8 mchc-33.1 rdw-16.3* plt ct-208 05:10am blood pt-14.0* ptt-27.9 inr(pt)-1.2* 05:10am blood glucose-141* urean-37* creat-1.2 na-135 k-4.0 cl-105 hco3-28 angap-6* 04:23am blood ck-mb-9 ctropnt-0.08* 12:00pm blood alt-25 ast-33 ck(cpk)-90 alkphos-105 totbili-0.5 05:10am blood calcium-8.1* phos-3.8 mg-2.2 . admission imaging: hip x-ray impression: comminuted fracture proximal femur. . ct pelvis / pelvis w/o contrast -- ** preliminary ** comminuted left intertrochanteric femoral fracture. no acute intra-abdominal findings: no free air or fluid, no hematoma. no bowel obstruction, although rectum is distended with stool. 3mm nonobstructing renal calculus (versus vascular calcification). fluid-filled gallbladder without wall thickening, pericholecystic fluid or other evidence of cholecystitis. . ct c-spine w/o contrast -- ** preliminary ** no fracture. marked degenerative changes with reversal of lordosis in the mid c-spine resulting in moderate canal narrowing. . ct head w/o contrast -- ** preliminary ** no ich or acute abnormality . chest x-ray ** preliminary ** low lung volumes, marked deviation of trachea to the right, otherwise lungs are normally aerated. prior cxr with tracheal deviation. . ekg: 120 bpm, ?sinus tachy cardia but very poor baseline, slight lad, no clear st/tw changes but poor study. compared to , similar axis. abdomen, history: colonic pseudo-obstruction. please measure colonic diameter. impression: three views of the abdomen show no appreciable change in the diameter of the widest part of the colon, the ascending, 84 mm yesterday and 88 mm today. there is no appreciable wall thickening or intramural emphysema to suggest ischemia. generalized gaseous distention is moderate throughout the gi tract except for the stomach which is decompressed by a nasogastric tube. kub () 1. interval improvement in patient's colonic dilatation, with scattered air-filled loops of small and large bowel without evidence of significant dilatation. air-fluid levels are identified on the decubitus view. brief hospital course: yo m, russian speaking only, with dementia, ckd, bph presented after witnessed mechanical fall at rehab and found to have a comminuted left intertrochanteric femoral fracture . # left femur fracture: ortho was consulted in the ed and consented patient for surgery and placed pin for traction. the pt presented with hct 34 (baseline hct 35.8 ). he was given morpine 2mg iv, morphine 4mg x 1, ns 2l, haldol 5mg, and 1u prbc. his post transfusion hct dropped to 29 and he was transfused a second unit without appropriate bump (hct stayed at 29). foley was placed. given unclear source of bleeding and hypotension on arrival, the patient was admitted to micu for closer monitoring. vs on transfer were 97.3, 100, 136/86, 22, 100/2l. upon admission to micu, the patient appeared in pain. the patient's bp normalized after 2l. hypotension was thought secondary to morphine amdinistration in the ed. he was afebrile with negative cardiac enzymes. it was unclear where his source of bleeding was but the patient was guaiac negative. his thigh had been firm and it was suspected that he may a hematoma there. he remained hemodynamically stable and was thought appropriate for transfer to medicine. he was transferred to the medicine floor on and taken for surgery on , where he underwent orif of his left hip. he went to the sicu post-op to recover, as he was transiently hypotensive during the procedure. his sicu course included uti and post op ileus (see below). on he was called out to the medicine floor. he continued to have a large amount of serous fluid drain from the traction wounds in his knee. his hct remained stable in the low 30s. ortho recommendations were to continue weight beairng as tolerated, lovenox for dvt prophylaxis and tylenol for pain. he should follow up in two weeks in ortho clinic with , np. # abdominal distension/ileus: in the micu the patient was found to have a mildly distended abdomen that was soft and non tender, with an unclear baseline. it was noted in the records that the patient required agressive bowel regimen at rehab it was thought that he had chronic constipation and was given an aggressive bowel regimen. after the patient went to the or he developed a post op ileus confirmed by kub and had an ngt placed to suction. he had a rectal tube placed for decompression but this failed. on po d# 4 he was started on ppn for nutrition. gi was consulted and they felt this was a pseudoobstruction. they recommended continued ng suction, avoiding narcotics and anticholinergics, and changing his position every hour. he should have a daily kub and if his colon diameter is between 10-12 cm, surgery should be consulted because this is a surgical emergency. it was 8.8cm on , and unchanged on . ngt was taken off suction and patient had low residuals. ng was discontinued per general surgery recs on . receiving tpn. patient will need speech and swallow evaluation on admission to rehab. # uti: in the sicu the patient was found to have a proteus uti. his foley was changed and he was started on ceftriaxone on and should complete a 14 day course. # ckd: the patient presented with cr of 1.9. he had an unclear baseline. his most recent creatinine in omr was 2.1 on . the rest of his electrolytes were normal. urine lytes were consistent with pre-renal azotemia. over the course of hospitlaization the patient's creatinine improved to 1.2. it was 0.9 on discharge. # dementia with behavioural disturbances: the patient lives in the behavioural unit at rehab. he is oriented x 1 a baseline. prior to the surgery the patient was functioning below baseline per family members, taking to recognize them then normal. after the operation he remained verbally unresponsive to family members and would not follow commands. he was not given narcotics for worsening of his mental status. the patient was continued on his home dose quetiapine 150 mg . # depression / anxiety: unclear severity. the patient was continued on his citalopram 40 mg po daily. # elevated troponin: the patient was initially found to have an elevated troponin compared to his baseline, however it did not trend up and repeat ekg showed no changes so it was not thought to be from acs. # bph: the patient had a foley placed, his terazosin was initially held in the icu given concern for hypotension. # code status: dnr/dni (this was reversed temporarily for the operation then dnr/dni again) medications on admission: morphine 4mg po q4h prn acetaminophen 650 mg q4h prn milk of magnesia 30 ml po daily citalopram 40 mg po daily miralax 17gm po daily terazosin 2 mg po qpm quetiapine 150 mg po bid lorazepam 0.5 mg po bid prn eucerin 1 application daily ferrous sulfate 325 mg po daily cyanocobalamin 1000 mcg daily sodium fluoride 10 ml qhs swish bisacodyl suppository 10 mg daily senna 2 tabs mirtazapine 15 mg qhs omeprazole 20 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. quetiapine 50 mg tablet sig: three (3) tablet po bid (2 times a day). 4. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 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. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po daily (daily). 7. polyethylene glycol 3350 17 gram/dose powder sig: one (1) 17 grams/dose powder po daily (daily). 8. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 9. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 10. white petrolatum-mineral oil cream sig: one (1) appl topical daily (daily). 11. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 12. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 13. enoxaparin 40 mg/0.4 ml syringe sig: one (1) syringe subcutaneous daily (daily) for 4 weeks. 14. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 15. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nauesa. 16. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 17. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) gram intravenous q24h (every 24 hours) for 4 days: last dose . 18. white petrolatum-mineral oil cream sig: one (1) appl topical daily (daily). 19. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 20. regular insulin sliding scale 21. radiology supine abdomen daily. if colon is over 10cm contact surgery. 22. pantoprazole 40 mg recon soln sig: forty (40) mg intravenous once a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: 1. left hip fracture. 2. ileus/pseudopbstruction 3. urinary tract infection discharge condition: mental status:confused - always level of consciousness:lethargic but arousable activity status:ambulatory - requires assistance or aid (walker or cane) discharge instructions: you came to the hospital after you fell and were found to have a left hip fracture. you required several blood transfusions and went to the operating room to have your hip fixed. you remained in the surgical intensive care unit for 4 days after your operation. you developed a post operative ileus ( problem with your gut working) and you were not able to eat food for several days. we gave you iv fluids and nutrition through your vein. please go to your follow up appointment with the orthopedic doctors (see below). they have also provided the following special instructions after your surgery: wound care: -keep incision dry. -do not soak the incision in a bath or pool. activity: -continue to be full weight bearing on your left leg. -you should not lift anything greater than 5 pounds. other instructions - resume your regular diet. - avoid nicotine products to optimize healing. - resume your home medications. take all medications as instructed. - continue taking the lovenox to prevent blood clots. - narcotic pain medication may cause drowsiness. do not drink alcohol while taking narcotic medications. do not operate any motor vehicle or machinery while taking narcotic pain medications. taking more than recommended may cause serious breathing problems. if you have questions, concerns or experience any of the below danger signs then please call your doctor at or go to your local emergency room. followup instructions: 2 weeks (the week of ) in the clinic with , np. please call to make this appointment. Procedure: Parenteral infusion of concentrated nutritional substances Insertion of other (naso-)gastric tube Open reduction of fracture with internal fixation, femur Transfusion of packed cells Diagnoses: Acidosis Other iatrogenic hypotension Anemia in chronic kidney disease Esophageal reflux Urinary tract infection, site not specified Acute kidney failure, unspecified 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 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other persistent mental disorders due to conditions classified elsewhere Chronic kidney disease, unspecified Dysthymic disorder Paralytic ileus Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Alzheimer's disease Closed fracture of subtrochanteric section of neck of femur Fall from other slipping, tripping, or stumbling Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site Dementia in conditions classified elsewhere with behavioral disturbance

allergies: lactose attending: chief complaint: cough, sob, fevers major surgical or invasive procedure: placement of right ij central line history of present illness: 75 year old woman with mixed connective tissue disease with features of scleroderma (on chronic prednisone), ild, trigeminal neuralgia, esophageal dysmotility, htn, and diastolic chf, who presents with 2 days of fatigue, non-productive cough, and subjective fevers. has also been feeling more sob. denies headache, neck pain, chest pain, palpitations, abdominal pain, diarrhea, or dysuria. . in the ed initial vs were 102.8, 138, 141/60, 30, 93% on ra. exam notable for bibasilar rales, benign abdominal exam. labs notable for wbc 18.9 (90% pmns), lactate 6.1, trop 0.12 -> 0.14, ua neg. ekg with std laterally, though resolved with decreasing hr. cxr showed small right pleural effusion, mild pulmonary edema, possible pneumonia. patient was given vanc/zosyn for suspected pneumonia, asa 325mg, hydrocortisone 100mg, and 1l ns and repeat lactate was 2.6. she remained borderline hypotensive with maps 55-60 so a right ij was placed and patient was started on levophed. she received a total of 2.5l ns. ct abd/pelvis was performed and patient was transferred to the micu for further evaluation. . on arrival to the micu, the patient is comfortable and states that her breathing is improved and she is feeling more comfortable. past medical history: - mixed connective tissue disease with features of scleroderma (high-titer positive , 1:1280 in a speckled pattern, positive rnp antibodies,normal rf, neg anti-ccp antibody testing, neg ro/la, neg anti-scl-70 ab, neg ab, neg anticentromere ab) - interstitial lung disease - patulous esophagus - gerd - trigeminal neuralgia - raynaud's complicated by right index finger ischemic ulceration s/p surgical intervention one year ago - diastolic chf - htn - hyperlipidemia - rectal prolapse - bilateral knee osteoarthritis - chronic low back pain/lumbar stenosis - venous stasis, rle>lle - rle complicated fractures more than 20 years ago following mva - h/o right retinal vein occlusion greater than five years ago social history: the patient is originally from , lives with her son and daughter-in-law, both of whom are physicians, and with several grandchildren. she is widowed. denies alcohol, tobacco use, or other illicits. independent with adls, though less mobile recently due to rectal prolapse. family history: the patient's brother with diabetes and mi in his 50s. no other family history of any rheumatologic diseases or lung diseases. physical exam: admission exam: general: alert, oriented x3, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad, rij in place cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: decreased breath sounds and rales at both bases, no wheezing abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: + foley rectal: no prolapse ext: left leg > right leg (chronic), no pitting edema, warm and well perfused, 2+ dp/pt pulses, no evidence of raynaud's neuro: slightly dysarthric speech (unchanged and secondary to the trigeminal neuralgia), decreased sensation over right side of face, cns otherwise intact, strenth throughout, sensation in extremities grossly intact, gait not assessed. . discharge exam: vitals: 118/69 75 100%ra general: alert, oriented x3, 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: decreased breath sounds and mild course rhonchi at both bases, no wheezing abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly ext: left leg > right leg (chronic), no pitting edema, warm and well perfused, 2+ dp/pt pulses, no evidence of raynaud's neuro: slightly dysarthric speech (unchanged and secondary to the trigeminal neuralgia), decreased sensation over right side of face, cns otherwise intact, strenth throughout, sensation in extremities grossly intact, gait intact pertinent results: admission labs: 11:30am blood wbc-18.9* rbc-5.18 hgb-13.4 hct-41.9 mcv-81* mch-25.8* mchc-31.9 rdw-16.8* plt ct-293 11:30am blood neuts-90.8* lymphs-7.3* monos-1.2* eos-0.4 baso-0.3 02:20pm blood glucose-104* urean-18 creat-0.8 na-136 k-3.6 cl-98 hco3-22 angap-20 02:20pm blood alt-24 ast-28 alkphos-55 totbili-0.5 11:30am blood ctropnt-0.12* 02:20pm blood ctropnt-0.14* 08:00pm blood ctropnt-0.05* 02:20pm blood albumin-3.3* 11:45am blood lactate-6.1* 02:52pm blood lactate-2.6* . discharge labs: 06:10am blood wbc-9.4 rbc-4.51 hgb-11.1* hct-36.4 mcv-81* mch-24.6* mchc-30.4* rdw-16.6* plt ct-291 06:10am blood neuts-77.5* lymphs-19.6 monos-2.3 eos-0.2 baso-0.4 06:10am blood calcium-8.5 phos-3.5 mg-1.9 01:58pm urine color-straw appear-clear sp -1.009 01:58pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg . microbiology: blood culture x 2: pending urine culture: negative . imaging: cxr portable ap 11:00: mild pulmonary vascular congestion and small right pleural effusion, possibly exaggerated by low lung volumes or slightly worse compared to . right base consolidation/ infection cannot be excluded. . cxr portable ap 14:43: there are low lung volumes due to poor inspiratory effort. there is prominence of the pulmonary vascular markings suggestive of pulmonary edema. there is also a right-sided pleural effusion and a developing left retrocardiac opacity. heart size is upper limits of normal but stable. no pneumothoraces are seen. . cxr portable ap 16:25: there is a right ij central line with distal lead tip at the cavoatrial junction. heart size is again seen enlarged. there is prominence of the pulmonary vascular marking suggestive of moderate pulmonary edema. there is a right-sided pleural effusion. there is a wide vascular pedicle. no pneumothoraces are seen. . ct chest : 1. superimposed consolidation within the lower lobes bilaterally on a background of pulmonary fibrotic changes. this may represent superimposed pneumonia or aspiration. 2. bilateral atelectasis within the dependent portions of the upper lobes which along with the lower lobe consolidation limits identification of previously noted bilateral pulmonary nodules. 3. stable enlarged left supraclavicular lymph nodes. 4. coronary artery calcifications. 5. patulous esophagus with fluid within the upper esophagus which places the patient at risk for aspiration. 6. bilateral hypodense thyroid nodules which could be further evaluated with thyroid ultrasound on a nonurgent basis if not previously performed. . video swallow : essentially normal pharyngeal swallow with one episode of penetration with thin liquids. brief hospital course: 75 year old woman with mixed connective tissue disease with features of scleroderma (on chronic prednisone), ild, htn, and diastolic chf, admitted with bilateral pneumonia complicated by hypotension, now improving. . # pneumonia/sepsis: patient with bilateral infiltrates on ct, dyspnea and hypoxia on admission. she was found to be in sepsis on admission, and was briefly placed on levophed. with initiation of vancomycin and zosyn, respiratory symptoms improved and hypotension resolved. she was narrowed to ceftriaxone/azithro, and continued to have stable vital signs and breath comfortably. she was transferred to the medical floor. on the floor, she was transitioned to levofloxacin for a po outpatient regimen. she continued to saturate well on room air, and had no fevers. she underwent speech and swallow evaluation for possible aspiration as the source of her bilateral pneumonia, but was not found to aspirate. the patient was discharged on 5 remaining days of levofloxacin. she should follow up with her primary care physician at discharge. # mixed connective tissue disease: currently on prednisone 20 mg daily, which is being tapered in preparation for colorectal surgery. patient with patulous esophagus and evidence of food retention, likely due to scleroderma. the patient underwent speech and swallow bedside evaluation and video swallow. she was noted to have some oropharyngeal discoordination, without evidence of aspiration. the patient was also noted to have some mild food retention in the esophagus. swallowing difficulties discussed with outpatient rheumatologist ( ), who would like to start the patient on a promotility following her colorectal surgery. the patient was also started on bactrim prophylaxis, as she has been on prolonged high dose steroids. the patient will follow up with rheumatology as previously scheduled. . # rectal prolapse: new over past few weeks and associated with significant pain and decreased quality of life. has been evaluated by surgery who would like to wait to repair until after patient is off steroids. patient currently undergoing outpatient steroid taper in preparation for surgery. the patient was kept on current steroid dose of 20 mg prednisone daily throughout admission. she will decrease to 15 mg prednisone daily per rheumatology recommendations on . patient will follow up with surgery as an outpatient as previously scheduled. . # chronic, compensated, diastolic chf: patient was found to have a small pleural effusion and pulmonary edema on cxr, but overall appeared euvolemic on exam. she did not require diuresis during admission. she was continued on aspirin 81 mg daily throughout admission. losartan was held for hypotension, but was restarted with blood pressure stability and transition to the medical floor. . # htn: chronic. losartan held for hypotension on admission. once the patient's blood pressure stabilized and she was transferred to the medical floor, she was resumed on home losartan. . # hyperlipidemia: chronic. continued simvastatin. . # gerd: chronic. patient was continued on home omeprazole. . # ild: spirometry from with restrictive defect, though seems to be improving. followed by dr. . . # communication: son ( . # code: full (confirmed) ======================================== transitional issues: # patient to f/u with regarding prednisone taper and possible promotility for esophageal dysmotility # patient to f/u with colorectal surgery as previously scheduled medications on admission: 1. hydromorphine 2mg daily prn pain 2. losartan 25mg daily (for raynaud's) 3. omeprazole 20mg 4. prednisone 20mg daily (currently being tapered by rheum) 5. simvastatin 10mg daily 6. aspirin 81mg daily 7. calcium carbonate-vitamin d3 500mg(1,250 mg)-400 unit; 2 tabs daily 8. oxazepam 10mg qhs for insomnia discharge medications: 1. aspirin 81 mg po daily 2. calcium carbonate 500 mg po qid:prn heartburn 3. levofloxacin 750 mg po daily duration: 5 days rx *levofloxacin 750 mg daily disp #*5 tablet refills:*0 4. omeprazole 20 mg po bid 5. prednisone 20 mg po daily please continue this through , then decrease to 15 mg daily from , then decrease to 10 mg daily starting . tapered dose - down 6. oxazepam 10 mg po hs:prn insomnia hold for sedation or rr<10 7. simvastatin 10 mg po daily 8. sulfameth/trimethoprim ss 1 tab po daily rx *sulfamethoxazole-trimethoprim 400 mg-80 mg daily disp #*30 tablet refills:*0 9. hydromorphone (dilaudid) 1-2 mg po daily:prn back pain hold for sedation or rr<12. 10. losartan potassium 25 mg po daily discharge disposition: home with service facility: discharge diagnosis: primary diagnosis: pneumonia secondary diagnosis: mixed connective tissue disorder, dysphagia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , . you were admitted to the hospital with a severe pneumonia requring a short stay in the intensive care unit. you were started on antibiotics and your infection improved. you were transitioned to the medical floor. on the medical floor, you continued to feel better and were breathing comfortably on room air. you were transitioned to an oral antibiotic called levofloxacin. you should continue this for 5 days following discharge. . during your admission, you also complained of difficulty with swallowing. you underwent a swallow evaluation that showed you have some difficulty coordinating swallowing, but that you are still able to do so without causing danger to yourself. part of your difficulty swallowing may be caused by your mixed connective tissue disorder. you should follow up with dr. regarding this issue. in the mean time, eat multiple small meals daily and chew food finely before swallowing. . weigh yourself every morning, md if weight goes up more than 3 lbs. . medications changed this admission: start levofloxacin 750 mg by mouth daily for 5 days start bactrim single strength daily you should continue prednisone 20 mg daily through this week. next , you should decrease to 15 mg daily, then the following week starting you should decrease to 10 mg daily. . if your symptoms worsen with this slow taper, you should call dr. for further management. followup instructions: name:pearl ,md specialty: primary care location: center address: , , phone: when:tuesday, at 11:45am . department: rheumatology when: wednesday at 4:00 pm with: , md building: lm bldg () campus: west best parking: garage Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Esophageal reflux Unspecified essential hypertension Long-term (current) use of steroids Unspecified septicemia Severe sepsis Other and unspecified hyperlipidemia Septic shock Postinflammatory pulmonary fibrosis Raynaud's syndrome Chronic diastolic heart failure Venous (peripheral) insufficiency, unspecified Spinal stenosis, lumbar region, without neurogenic claudication Trigeminal neuralgia Rectal prolapse Other acute and subacute forms of ischemic heart disease, other Dyskinesia of esophagus Osteoarthrosis, localized, not specified whether primary or secondary, lower leg Nontoxic uninodular goiter Other specified diffuse diseases of connective tissue

allergies: morphine / codeine attending: chief complaint: nausea/vomiting, elevated liver enzymes, gram negative bacteremia and common bile duct dilation major surgical or invasive procedure: history of present illness: 68 f pod 12 from total proctocolectomy for uc presented to hospital yesterday with mild abdominal pain and nausea. she was found to have a uti, normal wbc, and was started on macrobid . she was called at home this am as she had gram (-) bacteremia from osh. she returned to the er and was found to have increased abdominal pain, jaundice, and was febrile to 103 f with diaphoresis. she was given ceftriaxone/flagyl and transferred to . she reports her ostomy has been functioning, she is tolerating a po diet, and continuing a prednisone taper (7.5 mg). she did have some nausea without vomiting. here she is having increased abdominal pain, is febrile to 103f and tachycardic to 130's, sinus. past medical history: *remicade treatment times three in the past but no longer being treated *cerebral aneurysm and hemorrhage requiring neurosurgery and shunt *chronic hepatitis c with large viral load *ulcerative colitis, 6-mercaptopurine toxicity in the past past procedures: *total proctocolectomy for uc *colonoscopy left-sided colitis *colonoscopy left-sided colitis done in *colonoscopy colitis *colonoscopy inactive colitis social history: married, has children. does not smoke, drink alcohol or coffee. she is a retired accountant. family history: negative for cancer and inflammatory bowel disease physical exam: on admission: 102.7 f 108 121/64 20 97% ra gen: a&o, nad heent: + scleral icterus, mucus membranes dry cv: rrr, no m/g/r pulm: clear to auscultation b/l, no w/r/r abd: soft, mildly distended, tender to percussion throughout, lower abdomen more than upper, no ruq tenderness, normoactive bowel sounds, no palpable masses ostomy: intact, pink, moist, with gas and bilious fluid in bag anal remanent: ext: no le edema, le warm and well perfused pertinent results: : preliminary read showed biliary dilitation but no purulent drainage, no stones, and a stent was placed. final read pending. 10:37pm pt-16.6* ptt-28.8 inr(pt)-1.5* 10:37pm plt count-287 10:37pm wbc-10.3 rbc-4.32 hgb-13.4 hct-39.4 mcv-91 mch-31.0 mchc-34.0 rdw-15.9* 10:37pm calcium-8.9 phosphate-4.0# magnesium-1.9 10:37pm ck-mb-2 ctropnt-less than 10:37pm lipase-12 10:37pm alt(sgpt)-104* ast(sgot)-92* ld(ldh)-210 ck(cpk)-17* alk phos-82 tot bili-3.2* dir bili-2.6* indir bil-0.6 10:37pm glucose-107* urea n-5* creat-0.7 sodium-138 potassium-4.3 chloride-103 total co2-27 anion gap-12 brief hospital course: patient was admitted to the icu from he emergency depratment, kept npo and broad-spectrum antibiotics were started (vancomycin, zosyn, flagyl). prednisone was continued at 7.5mg, tapering by 2.5mg every 5 days. the patient complained of chest tightness and an ekg was obtained which was unchanged and cardiac enzymes were negative. an was done, which showed biliary dilation but no purulent drainage or stones, and a stent was placed. blood cultures from hospital were reported to show pan-sensitive e.coli and morganella morganii sensitive to ciprofloxacin, gentamicin, levofloxacin, and meropenem, therefore her antibiotic regimen was tailored to oral ciprofloxacin. on hospital day 3 her diet was advanced, she remained afebrile and without nausea or vomiting, and she was transferred out of the icu to a regular floor. her foley was withdraw at midnight on hospital day 3, and she passed a voiding trial the next morning. she was discharged on hospital day 4 to a rehabilitation facility on recommendation from physical therapy and was eating a regular diet, voiding, without nausea, and her pain was well-controlled on oxycodone. her slow prednisone taper was continued as described in discharge instructions. the patient will follow-up with gastroenterology in weeks for the removal of her pancreatic stent. medications on admission: prednisone 7.5 taper oxycodone-acetaminophen 5-325 1-2 tablets po q4h prn pain aloe , vitamin b complex, calcium-vit-d, acidophilus, mvi discharge medications: 1. prednisone 5 mg tablet sig: one (1) tablet po daily () for 3 days: take 1 pill by mouth for 3 days to finish a 5 day course. . disp:*3 tablet(s)* refills:*0* 2. prednisone 2.5 mg tablet sig: one (1) tablet po daily () for 5 days: take 1 2.5 mg pill for 5 days. disp:*5 tablet(s)* refills:*0* 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever or pain. 4. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual qid (4 times a day) as needed for gi spasm/cramps. 5. oxycodone 5 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 6. simethicone 80 mg tablet, chewable sig: 1/2-1 tablet, chewable po qid (4 times a day) as needed for gas pain. 7. ciprofloxacin 250 mg tablet sig: three (3) tablet po q12h (every 12 hours) for 11 days. discharge disposition: extended care facility: center - discharge diagnosis: common bile duct dilation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the colorectal surgery service for elevated liver enzymes and a dilated common bile duct, with bacteria in your blood and signs of infection. you had and preformed by the gastroenterology service and a stent was placed in your biliary tree. you will need to call the gastroenterology service to scheduele an outpatient procedure to have the stent removed in weeks, this appointment has been made for you by the gastroenterology team and is listed below. you laboratory values have dramatically improved since your procedure and you are now ready to be discharged. you have becomed deconditioned and week and it has been recommended by physical therapy that you be discharged to a rehabilitation hospital. please monitor your bowel function closely. if you have <500cc or >1500cc of fluid from your ostomy please call dr. office. please seek medical attention if you develop nausea, vomiting, increased abdominal pain, increased abdominal distension, or inability to tolerate food or liquid call the office or if severe return to the emergency room. please call your doctor or go to the emergency department if: *you experience new chest pain, pressure, squeezing or tightness. *you develop new or worsening cough, shortness of breath, or wheeze. *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 an unusual discharge. *your pain is not improving within 12 hours or is not under control within 24 hours. *your pain worsens or changes location. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *you develop any concerning symptoms. general discharge instructions: please resume all regular home medications, unless specifically advised not to take a particular medication. please take any new medications as prescribed. please take the prescribed analgesic medications as needed. you may not drive or heavy machinery while taking narcotic analgesic medications. you may also take acetaminophen (tylenol) as directed, but do not exceed 4000 mg in one day. please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. please also follow-up with your primary care physician. monitoring ostomy output: *keep well hydrated. *replace fluid loss from ostomy daily. *avoid drinking only plain water. include gatorade and/or other vitamin drinks to replace fluid. *try to maintain ostomy output between 1000ml to 1500ml per day. you are being tapered from your prednisone very slowly. you are taking 5mg of prednisone currently and will take this for 3 more days to complete 5 days at 5 mg. then, you should decrease the dose by 2.5mg or five days and after this time you can stop this medication. followup instructions: please call dr. office for a follow-up visit in weeks. call ( to make an appointment. please call , phone: to scheduele a gastroenterology follow-up appointment. provider: 2 (st-4) gi rooms date/time: 1:00 provider: , md phone: date/time: 1:00 Procedure: Endoscopic insertion of stent (tube) into bile duct Diagnoses: Other iatrogenic hypotension Urinary tract infection, site not specified Chronic hepatitis C without mention of hepatic coma Sepsis Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Other specified disorders of biliary tract Septicemia due to escherichia coli [E. coli] Hydronephrosis Cholangitis Ileostomy status Acquired absence of intestine (large) (small)

allergies: lisinopril attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass graftx4(lima- lad,svg-dg,svg-om,svg-rca) left heart catheterization,coronary angiogram history of present illness: this 69 year old white male with a history of coronary stents x2 was admitted with substernal chest pain for 3 days. he described it as sharp with acute onset epigastric pain after dinner 3 days ago, worse on lying in bed, improved with sitting up and patient has thus been sleeping in a recliner. the pain resolved after 30 minutes and improved with tums. he has had 2 subsequent episodes of chest pain not clearly associated with eating, but denies any shortness of breath, or association with exercise.no nausea/vomiting, diaphoresis. shortly after arrival to the ed his pain resolved and he has been angina free since. on ros he complains of dyspnea deconditioning following fall between truck and dock 2 years ago with fracturing of l leg. he is able to walk mile or two flights of stairs before experiencing shortness of breath. he denies any orthopnea, pnd, syncope, or palpitations. he also reports left greater than right lower extremity edema since his leg fracture and surgery. the edema is worse in the evening and greatly improved in the am. he denies any claudication symptoms but has night time leg cramps. . on general review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors.he denies exertional buttock or calf pain. . in the ed: the patient was chest pain free. ekg revealed st depression ii, v-6, st elevation v-1, t wave inversion v2 v3, v4. the patient was discussed with the cardiology fellow who advised admission to , observation of symptoms and no treatment (no plavix or heparin) initially. however, ce then returned with trop 2.0, ck 1300; heparin gtt started. he was started on asa, metoprolol and high dose statin. he was noted to be in , received prehydration with mucomyst, bicarb for anticipated cath in future. on arrival to the floor he was also started on integrillin, reopro had been preferred given his ,however there were logistical limitations to administering reopro nursing/pharmacy comfort, and integrillin was started instead.in addition, plavix was not given as patient had known hx of 3 vessel disease, and it was unclear whether he would go to cath versus being triaged straight to cabg. past medical history: noninsulin dependent diabetes mellitus hyperlipidemia hypertension coronary artery disease s/p coronary stents chronic obstructive pulmonary disease obesity chronic renal insufficiency social history: the patient lives with his girlfriend. works in a wharehouse driving a fork-lift and moving chemical tanks. he smoked 2ppd x40yrs. notes significant past alcohol use, though none recently. denies drug use. family history: the patient's sister and brother died of mi in their late 50's. the patient's father died in his 50's of an unknown cause. physical exam: admission: vs: t=98.6 bp=104/64 hr=74 rr=20 o2 sat= 96% ra gfs:121 bm x1. npo. general: wdwn 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 7 cm. no carotid bruits 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: diffuse thick swelling of right lower leg. no femoral bruits. distal pulses palpable bilaterally 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: echocardiography report , portable tte (complete) done at 12:17:44 pm final referring physician information , - department of cardiac s , 2a , status: inpatient dob: age (years): 69 m hgt (in): 66 bp (mm hg): 102/52 wgt (lb): 216 hr (bpm): 98 bsa (m2): 2.07 m2 indication: tamponade. icd-9 codes: 410.91, 423.3, 413.9, 414.8 test information date/time: at 12:17 interpret md: , md test type: portable tte (complete) son: , rdcs doppler: full doppler and color doppler test location: west sicu/ctic/vicu contrast: none tech quality: adequate tape #: 2010w006-0:11 machine: vivid echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.1 cm <= 4.0 cm left atrium - four chamber length: *5.7 cm <= 5.2 cm right atrium - four chamber length: 4.8 cm <= 5.0 cm left ventricle - septal wall thickness: *1.3 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *5.7 cm <= 5.6 cm left ventricle - ejection fraction: 20% >= 55% left ventricle - lateral peak e': 0.13 m/s > 0.08 m/s left ventricle - septal peak e': 0.11 m/s > 0.08 m/s left ventricle - ratio e/e': 11 < 15 aorta - sinus level: 2.9 cm <= 3.6 cm aorta - ascending: 3.4 cm <= 3.4 cm aortic valve - peak velocity: 1.4 m/sec <= 2.0 m/sec aortic valve - lvot diam: 2.1 cm mitral valve - e wave: 1.3 m/sec mitral valve - e wave deceleration time: 172 ms 140-250 ms pericardium - effusion size: 0.6 cm findings this study was compared to the prior study of . left atrium: mild la enlargement. right atrium/interatrial septum: normal ra size. a catheter or pacing wire is seen in the ra and extending into the rv. left ventricle: mild symmetric lvh. top normal/borderline dilated lv cavity size. severe regional lv systolic dysfunction. right ventricle: rv not well seen. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. calcified tips of papillary muscles. tricuspid valve: tricuspid valve not well visualized. indeterminate pa systolic pressure. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: small pericardial effusion. effusion echo dense, c/w blood, inflammation or other cellular elements. effusion is loculated. general comments: the rhythm appears to be atrial fibrillation. conclusions the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is top normal/borderline dilated. there is severe regional left ventricular systolic dysfunction with severe hypokinesis of the entire ventricle with the exception of the basal inferior, inferolateral and anterolateral walls.. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. the effusion appears loculated. impression: suboptimal image quality. small loculated pericardial effusion adjacent to the inferolateral wall with no evidence of tamponade. severely depressed left ventricular function. compared with the prior study (images reviewed) of , left ventricular systolic function is similar. the pericardial effusion is slightly larger. the right ventricle is not well-visualized. brief hospital course: following admission he had recurrent angina and heparin was started. enzymes peaked, then fell and he remained stable. catheterization was performed, which revealed triple vessel disease, and elevated lvedp. no ventriculogram was performed given his renal dysfunction.he was referred for cardiac surgical evaluation. echocardiography demonstrated an ef of 20-25%, with mild pulmonary hypertension. on he went to the operating room where quadruple bypass grafts were performed. he had elevated pa pressures, with hyperexpanded lungs. he weaned from bypass on propofol, neosynephrine and milrinone with stable hemodynamics. he developed rapid atrial fibrillation associated with unstable hemodynamics the night after surgery and amiodarone was begun with restoration of sinus rhythm. he had a significant amount of peripheral edema and wheezing with fluid overload which was treated with bronchodilators and diuresis. captopril was begun on pod 3 for afterload reduction as his milrinone was discontinued. recurrent atrial fibrillation developed and amiodarone was reloaded and oral begun. he has an "allergy" to lisinopril noted, which was actually hyperkalemia, not a true allergy. potassium levels were monitored closely after the ace-i was begun. coumadin was started for atrial fibrillation. his chest tubes were removed on pod 1, and a lasix drip instituted on pod 3 to facilitate a gentle, consistent diuresis. his respiratory status improved considerably after a day of lasix infusion, despite worsening of the cxr. his oxygen requirement fell and his physical exam improved. on pod 3, he went into vf which required cpr and cardioversion. dr. was consulted. a cardiac cath was recommended which revealed all graft to be patent. an icd was subsequently placed. he was placed on keflex for serosanguinous sternal incision drainage which was minimal at the times of discharge. he had no sternal click and no sternal erythema on his discharge exam. on post-operative day thirteen he was discharged to rehab per dr. . all follow-up appointments were advised. medications on admission: actos 30 mg once daily atenolol 25 mg once daily flomax 0.4 mg once daily lasix 20 mg po twice daily lopid 600 mg po twice daily simvastatin 80 mg daily aspirin 325 mg daily vitamins discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). 4. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 5. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 7. actos 30 mg tablet sig: one (1) tablet po once a day. 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). disp:*30 capsule, sust. release 24 hr(s)* refills:*2* 10. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 11. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours): titrate as clinically indicated. disp:*60 tablet(s)* refills:*2* 12. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for sleep. disp:*30 tablet(s)* refills:*0* 14. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 15. hydralazine 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). disp:*120 tablet(s)* refills:*2* 16. keflex 500 mg capsule sig: one (1) capsule po four times a day for 10 days: for sternal incision drainage. disp:*40 capsule(s)* refills:*2* 17. warfarin 1 mg tablet sig: one (1) tablet po once (once) for 1 doses: titrate coumadin for atrial fibrillation for goal inr of . disp:*30 tablet(s)* refills:*0* discharge disposition: extended care facility: for the aged - macu discharge diagnosis: acute myocardial infarction s/p coronary artery bypass grafts hypertension hyperlipidemia chronic obstructive pulmonary disease noninsulin dependent diabetes mellitus benign prostatic hypertrophy s/p coronary artey angioplasty & stents chronic renal insufficiency discharge condition: good.ambulatory, neurologically intact, mentation normal. wounds healing well. 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: 8:30 , md phone: date/time: 4:40 dr. in 4 weeks () 6 wound clinic in 2 weeks (),your nurswill schedule the appointment dr. in weeks () Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Other and unspecified coronary arteriography Arterial catheterization Atrial cardioversion Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Tobacco use disorder Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Other chronic pulmonary heart diseases Atrial flutter Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other complications due to other cardiac device, implant, and graft Ventricular fibrillation Family history of ischemic heart disease Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Obesity, unspecified Acute on chronic combined systolic and diastolic heart failure Body Mass Index 34.0-34.9, adult

allergies: lisinopril attending: chief complaint: altered mental status major surgical or invasive procedure: percutaneous cholecystotomy history of present illness: 62m with stable known l parietal meningioma on keppra and dilantin, pulmonary embolism with rh strain dx with bilateral dvts s/p ivc filter on coumadin, wegeners granulomatosis, and no known active liver disease, admitted to ed with lethargy . patient was in usoh until 2 days ago found to have outpatient inr 11 on outpatient coumadin. no recheck yesterday as directed. husband noticed increased slowness of speech and lethargy x 1 day, then on day of admission was somnolent. also positive for recent back pain and diarrhea x 1 week, taking additional pain meds including tylenol #3 for this. . in the ed, initial vs were: 97.4 97 104/75 24 95 on ra. here jaundiced, confused, describing abd cramps with mild ttp. concern for new onset liver failure. + asterixis. ct abd showed air in biliary system and single large gallstone in gallbladder, dilated ducts, questional ileus. surgery seen patient in ed. labs significant for inr>20, k 6.6, na 129, cr 7.3, alt: 882 ap: 911 tbili: 8.1 ast: 1189, phenytoin level 3.2-3.7, tylenol level pending. ucx positive. tox consulted. patient was given calcium gluconate, na bicarb, d5 and 10 units insulin for hyperkalemia. received one loading dose of nac in ed. vitals on transfer were 97.7, hr 102, bp 103/59, rr 21, 97% on 2l. . on arrival to the micu, patient was only aox1, denied pain. multiple services saw patient at bedside upon arrival to floor, including liver, liver transplant, general surgery, and renal services. patient maintaining oxygenation on nc with abg 7.36/41/112. plan for elective intubation overnight, reversal of inr, and close monitoring of q2hr neuro exam, fs, and labwork. . review of systems: unable to obtain mental status past medical history: 1) l parietal meningioma stable in size for 2 years, initially presented with seizure 2) seizure disorder 3) wegeners granulomatosis - mild renal insufficiency - peripheral nephropathy - bilateral hearing loss - pulmonary embolism 4) pulmonary embolism with rh strain dx with bilateral dvts s/p ivc filter on coumadin 5) mild aortic valve stenosis: 1.07 cm2 on tte 6) iron deficiency anemia secondary to gi bleed 7) chronic renal insufficiency stage iii 8) htn 9) hyperlipidemia 10) alcoholic hepatitis in past (?one mention in one note) 11) gi bleeding 12) hypothyroidism 13) hyperparathyroidism due to renal failure 14) sickle cell trait 15) severe hearing deficit l>>r 16) gout 17) posterior tibial tendonitis 18) oa 19) subdural intracranial hemorrhage 20) myoclonal gammopathy . past surgical history 1) s/p appendectomy 2) s/p b/l carpal tunnel repair 3) s/p venous sclerotherapy on legs for venous ulcers 4) s/p hernia repair 5) s/p ivc filter placement social history: office assistant at , married with husband. - tobacco: positive - alcohol: social (as recent as 1-2weeks, glasses nightly) - illicits: no ivdu family history: mother and father deceased. history of seizures or autoimmune disease. physical exam: exam on micu admission vitals: t:97.4, bp93/63, hr107, rr19, 98% on 2l general: aox1, lethargic, arousable to loud voice, moving all extremities heent: sclera icterus neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: 3/6 sem at lusb abdomen: no organomegaly or ascites noted, +ttp in ruq with guarding neuro: +asterixis and upgoing toes pertinent results: 01:00pm wbc-8.6 rbc-3.63* hgb-11.4* hct-32.5* mcv-90 mch-31.4 mchc-35.1* rdw-14.4 01:00pm plt smr-high plt count-493* 01:00pm neuts-78* bands-2 lymphs-6* monos-12* eos-0 basos-0 atyps-0 metas-2* myelos-0 nuc rbcs-1* 01:00pm pt-150* ptt-89.4* inr(pt)->20.2* 01:00pm asa-neg acetmnphn-neg 01:00pm alt(sgpt)-882* ast(sgot)-1189* alk phos-911* tot bili-8.1* 01:00pm glucose-112* urea n-251* creat-7.3* sodium-129* potassium-6.3* chloride-83* total co2-17* anion gap-35* 01:25pm urine rbc-* wbc- bacteria-mod yeast-none epi-0-2 01:25pm urine blood-lg nitrite-neg protein-25 glucose-neg ketone-neg bilirubin-sm urobilngn-neg ph-5.0 leuk-neg 06:47pm hiv ab-negative f 06:47pm hcv ab-negative 06:47pm hbsag-negative hbs ab-negative hbc ab-negative 07:13pm -negative 07:13pm ama-negative 07:13pm igg-564* iga-203 igm-45 imaging ct abd 1. somewhat nodular in contour liver, suggesting underlying cirrhosis. nonspecific hypodensities at the dome of the right lobe are noted. given possible underlying cirrhosis, these should be evaluated with mri nonemergently to exclude malignancy. 2. large stone in the gallbladder, as well as air seen within the common duct and gallbladder neck. if there is no history of prior sphincterotomy, this is concerning for biliary-enteric fistula. possible fistulous connection is identified on coronal images (300b:22-23). 3. diffuse dilation of fluid-filled proximal small bowel measuring nearly 4 cm, with relative collapse of the terminal ileum and distal ileum. this is suggestive of early versus partial small-bowel obstruction, though no definite transition point is identified. 4. consolidation at the right lung base, likely atelectasis or aspiration. however, followup imaging following resolution of acute illness to exclude underlying lesion is recommended. 5. ivc filter is identified in adequate position. 6. delayed contrast excretion by the kidneys bilaterally, compatible with known renal failure. ct head 1. no evidence of global cerebral edema. 2. persistent 2 mm hyperdense focus in the left frontal lobe at the -white matter junction, which may represent a cavernoma, or a tiny focus of acute hemorrhage which could be related to a small mass. in the absence of associated focal edema, a septic embolus is less likely. consider further evaluation by mri with and without contrast. 3. large left parietal extraaxial mass, presumably a meningioma, with calvarial irregularity, as before. mri with and without contrast would be helpful to assess for osseous invasion and other aggressive features. tte the left atrium is normal in size. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity is small. left ventricular systolic function is hyperdynamic (ef 80%). 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 mild aortic valve stenosis (valve area 1.2-1.9cm2). the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. cholangiogram : impression: no evidence for fistulous communication between the biliary system and bowel. there is a large stone within the gallbladder. the cystic duct, and intrahepatic ducts are not dilated. there is an ivc filter in place. findings were discussed with dr. . egd 4/22 esophagus: normal esophagus. stomach: normal stomach. duodenum: normal duodenum. colonoscopy diverticulosis of the sigmoid colon internal hemorrhoids otherwise normal colonoscopy to cecum micro 2 of 6 blood cultures pan sensitive e coli bile culture pan sensitive e coli and serratia marcescens, also anerobic bottle with moderate clostridium perfringens and b fragilis discharge 144 113 41 -------------< 117 3.2 24 1.4 ca: 8.5 mg: 2.0 p: 3.6 alt: 80 ap: 272 tbili: 5.5 alb: 2.5 ast: 42 ldh: 206 90 12.2 > 8.9 / 25.9 < 176 phenytoin: 4.9 tsh:0.46 free-t4:1.5 t3: 86 other blood chemistry: ama: negative : negative hbsag: negative hbs-ab: negative hbc-ab: negative hav-ab: positive igm-hbc: negative igm-hav: negative igg: 564 iga: 203 igm: 45 hcv-ab: negative hiv-ab: negative for hiv-1 by trinity rapid hiv method brief hospital course: 62 yo m with history of wegeners, meningioma, prior pe, without known h/o active liver disease presenting to ed with altered mental status found to have encephalopathy, jaundice, transaminitis, acute renal failure. his initial presentation was concerning for fulminant hepatic failure and transplant workup was initiated. however, inr of 20 improved dramatically with vitamin k and was felt to be secondary to coumadin. he also had ct which showed acute calculous cholecystitis and is s/p percutaneous cholecystostomy. he grew pan sensitive e coli from his blood cultures and his bile grew ecoli, serratia, clostridium perfringens and bacterioides fragilis. he was treated with cipro and flagyl and will follow up with surgery with plan for cholecystectomy. # cholecystits with ecoli bacteremia he will continue cipro flagyl until surgery. percutaneous drain capped on at 8am. **if febrile, recommend uncapping drain.** # hyperbilirubinemia abscence of biliary dilation or obstruction and size of gallstone fits with mirizzi syndrome. he may also have had an element of cholestasis of sepsis. bilirubin trending down. **we have recommended to the surgeons a liver biopsy at time of cholecystectomy to rule out intrinsic disease.** # acute renal failure creatinine 7.3 on admission and bun 251. presumed atn secondary to sepsis/hypotension. trended down over hospital course. 1.4 on day prior to discharge. **we are holding his home lasix (160 qam and 80 qpm and hctz).** # acute blood loss anemia with reported melena on admission. egd and colonoscopy negative. likely was secondary to inr 20. continued home iron and folate on discharge. he was placed on ppi but this was dicontinued on discharge as no indication and was not on acid suppression at home. # paroxysmal afib with rapid ventricular rate this occurred while patient critically ill in icu and responded only to amiodarone. patient was on metoprolol at home but no reported history of atrial fibrillation. on the floor, amiodarone discontinued for concern for toxicity and suspicion that atrial fibrillation was provoked by illness, fluid status. has been in sinus rhythm with normal rate. # h/o pulmonary embolism with rh strain dx with bilateral dvts patient was on coumadin and with ivc filter. anticoagulation held. after endoscopy, we elected to restart anticoagulation with lovenox as will be going to surgery but felt to be high risk for embolism as sedentary and with wegeners. now also with afib. **recommend pcp to on long term need for/mode of anticoagulation. # altered mental status was likely uremia with bun 251 and not hepatic encephalopathy. was started on lactulose but this was discontinued. # meningioma and h/o seizures scans reviewed by neurosurgery, felt no bleeding or significant acute process. continued on keppra and dilantin. note that dilantin levels subtherapeutic but patient on two agents and therapeutic dose of keprra and has not had seizures on this regimen. # gout: flare likely in setting of uremia and dehydration. continued on 40 prednisone which had been started 2 days prior to presentation. slow taper initiated on discharge. home allopurinol renally dosed restarted on discharge and colchicine 0.6 every other day started on . # h/o wegeners: no evidence of white cell casts, acanthocytes, red cell casts that would suggest flare of wegeners medication changes and recommendations 1. ciprofloxacin and metronidazole until surgery 2. colchicine every other day for gout 3. lovenox until surgery then reevaluate 4. restart aspirin 81 when creatinine < 1.3 but hold one week prior to surgery 5. holding lasix and hctz as creatinine not at baseline and not hypertensive or edematous. consider lasix over hctz if need to resume diuretics 6. was on 50 mcg of synthroid. tfts normal off synthroid and ? whether contributing to afib so holding 7. was on 300 of toprol xl at home. discharging on 100mg. increase as needed 8. prednisone 40 continued and slow taper by 5mg 5 days intiated on discharge 9. irbesartan held. if hypertensive would consider adding back 10. restart simvastatin when lfts normalized medications on admission: tramadol-acetaminophen 37.5mg-325mg 1-2 tablets q12h prn (disp # 50 on ) prednisone 5mg increased to 40mg daily on phytonadione 5mg once diazepam 5mg prn (disp # 10 on ) cetirizine 10 mg daily asa 81 mg daily calcitriol 0.25 mcg po daily allopurinol 150 mg po daiily folic acid 1 mg po daily synthroid 50 mcg po qam lasix 160mg qam and 80 mg qam keppra 1 gram po bid toprol xl 300 mg po daily phenytoin 200 mg po bid simvastatin 40 mg po qhs ferrous sulfate 325 mg po daily coumadin 5 mg po daily (held starting ) irbesartan 150 mg po daily kcl 40 meq po bid hctz 25 mg po daily colchicine 0.6 mg po daily tramadol diphenhydramine multivitamin omega 3 fatty acids vitamin b 12 vitamin b6 coenzyme q nasonex discharge medications: 1. levetiracetam 1,000 mg tablet sig: one (1) tablet po twice a day. 2. phenytoin sodium extended 200 mg capsule sig: one (1) capsule po twice a day. 3. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). 4. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day). 5. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*1* 6. colchicine 0.6 mg tablet sig: one (1) tablet po every other day (every other day). disp:*15 tablet(s)* refills:*2* 7. enoxaparin 80 mg/0.8 ml syringe sig: seventy (70) mg subcutaneous q12h (every 12 hours). disp:*60 syringes* refills:*1* 8. prednisone 5 mg tablet sig: as directed for taper tablet po once a day: take 7 tablets (35 mg) daily for 5 days. every 5 days, decrease dose by one tablet. then take one-half tablet for 6 days. disp:*146 tablet(s)* refills:*0* 9. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*2* 10. allopurinol 300 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 12. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 13. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 14. omeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po bid (2 times a day). 15. cetirizine 10 mg tablet sig: one (1) tablet po once a day as needed for allergy symptoms. 16. nasonex 50 mcg/actuation spray, non-aerosol sig: one (1) spray nasal once a day. discharge disposition: extended care facility: - discharge diagnosis: primary: sepsis secondary to acute cholecystitis secondary: acute renal failure, cholestatic jaundice secondary to extrinsic compression of common bile duct, atrial fibrillation, history of pulmonary embolism, wegeners granulomatosis, gout 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: dear mr. , it was a pleasure caring for you here. you were admitted with a severe infection in your gall bladder. the surgeons places a plastic tube to drain the infected bile and we treated you with antibiotics. you improved. you will need to have your gallbladder and the large stone inside of it removed surgically when you are fully recovered. we made the following changes to your medications: start these: ciprofloxacin and metronidazole and continue until your surgery colchicine every other day for gout lovenox stop these: (your pcp may want to start these back as you continue to improve) coumadin synthroid (you don't need this and may be making your heart rate fast) furosemide aspirin simvastatin irbesartan note the changes in these toprol xl 100mg daily predisone will be slowly tapered allopurinol followup instructions: provider: , md phone: date/time: 10:30 please call dr. office and make an appointment to be seen by all of your regular doctors. please suggest that dr. schedule you to see a cardiologist for the abnormal heart rhythm called atrial fibrillation. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Insertion of endotracheal tube Colonoscopy Percutaneous aspiration of gallbladder Diagnostic ultrasound of digestive system Diagnoses: Hyperpotassemia Abnormal coagulation profile Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Acute posthemorrhagic anemia Acute and subacute necrosis of liver Severe sepsis Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortic valve disorders Hypopotassemia Other and unspecified hyperlipidemia Chronic kidney disease, Stage III (moderate) Benign neoplasm of cerebral meninges Unspecified hearing loss Long-term (current) use of anticoagulants Osteoarthrosis, unspecified whether generalized or localized, site unspecified Paralytic ileus Epilepsy, unspecified, without mention of intractable epilepsy Personal history of venous thrombosis and embolism Other postprocedural status Anticoagulants causing adverse effects in therapeutic use Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Septicemia due to escherichia coli [E. coli] Unspecified intestinal obstruction Diverticulosis of colon (without mention of hemorrhage) Calculus of gallbladder with acute cholecystitis, without mention of obstruction Internal hemorrhoids without mention of complication Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Sickle-cell trait Other specified bacterial infections in conditions classified elsewhere and of unspecified site, Clostridium perfringens Bacteroides fragilis Wegener's granulomatosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pea arrest, pneumonia major surgical or invasive procedure: cardiopulmonary resuscucitation x 45 minutes post-cardiac arrest cooling by the arctic sun protocol placement of right radial arterial line placement of left picc line history of present illness: 53f with amyotrophic lateral sclerosis with frontotemporal dementia who is chronically debilitated and dependent on a peg and tacheostomy who was found apneic and pulseless at her nursing home. cpr was initiated, and she underwent 45 minutes of chest compressions. at that point she was bolused with epinepherine 1mg iv and responded to a pulse of 140 and a blood pressure of 140/90. she was transfered emergently to ed for further evaluation. ems reported copious secretions in her trach tube during transfer including what appeared to be food or pills with tube feeds. . in the ed, initial vs were t 96.8 p 77 bp 94/55 r 12 o2 sat 100% on fio2 100% and intubated. initial ecg showed st elevations in ii, iii, v2-6. cardiology was consulted and felt she was not a candidate for pci. she was given aspirin 325mg po x 1 and started on a heparin drip. ct heat and torso showed pna and no acute intracranial process. she was fluid resusitated with 4 l ns iv, started on vancomycin levofloxacin for aspiration pna, and a femoral line was placed. she was initially on norepinepherine without adequate maps, and then improved once dopamine was added. she was admitted to the micu for further management. . upon initial presentation to the floor, she was intubated and sedated. past medical history: - amyotrophic lateral sclerosis with frontotemporal dementia - hypertension - depression - dysphagia - right upper extremity weakness - chronic respiratory failure, chronically trached - h/o shingles social history: social history: currently lives at a nursing home since her discharge . prior to that she had been living with her daughter since . she is dependent on nh staff for adls. per her family and nursing home, the pt not ambulatory and does not speak. she seems to have some cognition, i.e. will follow you with eyes, reach out her hand for glucose checks, listens and moves to music while lying in bed. her family reports that she can "communicate with her eyes." she is a former smoker. she worked as a cook at a hospital prior to her clinical medical decline last year. family history: no history of neurologic illness physical exam: on admission: gen: ill appearing woman, twitching, in distress heent: mmm, trach in place, neck is supple, no lad cv: rr, tachy, no mrg pulm: coarse rhonchi and crackles throughout the l lung fields, coarse breath sounds on the r abd: bs+ ndns, no masses or hsm limbs: r femoral line in place, no le edema, no clubbing, wasted limbs skin: no skin breakdown or rashes neuro: pupils minimally reactive, reflexes absent, occasional myoclonic jerks of arms and legs pertinent results: 146 106 27 agap=11 ------------< 174 3.9 33 0.3 . ck: 102 mb: 5 trop-t: 0.02 (cardiac enzymes negative x 2 add'l). . ca: 9.4 mg: 2.0 p: 3.5 alt: pnd ap: 157 tbili: 0.2 alb: 3.3 ast: 321 ldh: 662 . pt: 12.6 ptt: 99.3 inr: 1.1 mcv 84 wbc 22.7 &#8710; hgb 10.1 plts 322 hct 33.8 ph 7.27/83/56/40 . micro: sputum - mrsa blood cx - pending urine cx - negative legionella ab - negative . images: ct chest/ab/pelvis w/contrast - left lower lobe collapse and right lower lobe atelectasis with superimposed pneumonia and/or aspiration. fluid-filled loops of small and large bowel may relate to ileocolitis. . cheat head w/out - no acute process. . cxr - bilateral infiltrates . ekg: st elevations in ii, iii, v2-6 in initial tracings. improved subsequently . eeg: 24 hour video eeg telemtry was notable for the absence of any clear cerebral cortical activity. no focal or lateralizing epileptiform features were seen. there were no electrographic seizures captured during this recording. brief hospital course: 53f with amyotrohic lateral sclerosis with frontotemporal dementia admitted after 45 minutes of cpr for a pea arrest, completed artic sun cooling protocol and also had aspiration pna, treated with antibiotics. . # s/p pea arrest: the presumed etiology is aspiration pna, given the copious secretions in her trach tube during transfer. she completed artic sun protocol. although her initial ecg showed some st elevation, this resolved with subsequent ecgs and her cardiac enzymes, including troponin, never elevated. there was concern for anoxic brain injury, given her prolonged cpr. she underwent eeg monitoring, which showed no seizure activity by an absence of cortical activity. . # sinus tachycardia: during her hospitalization, the pt became intermittently tachycardic. the differential diagnosis included hypovolemia/bleed (but her hct stable), pe (but neg cta on admission, on ppx), pain/anxiety (but on fentanyl), seizure activity, fever (as pt w. low-grade temps around 101), and reflex tachycardia from discontinuation of sedatives/home beta blockers. it improved with tylenol and metoprolol. . # aspiration pna: the patient had infiltrates on cxr and frank aspiration in endotracheal suction. her sputum cultures grew mrsa. plan for a course of antibiotics with vancomycin 1g iv bid and zosyn 4.5g iv q8h for 7 days (from to ) and azithro 250mg iv q24h for 5 day course ( to ). on induced sputum cultures grew pseudomonas and patient was started on a 14 day course of cipro 400mg iv bid and zosyn 4.5g q8h for 14 day course. sensitivities were pending at the time of discharge. . # als with frontotemporal dementia: no acute interventions. neurology followed the patient while admitted. eeg with results as above. . # fen: ivf, replete electrolytes, npo for now, tfs . # prophylaxis: sc heparin, ppi, pneumoboots . # access: r aline, l picc currently . # communication: husband . # code: full (discussed with family) -> family open to changing status pending pt??????s ms is washed out (they are interested in the neuro perspective) ?????? today post-24 hours without aed??????s or , will monitor eeg, discuss with neuro, and discuss prognosis with family. medications on admission: combivent 4 puffs q6h desenex apply to affected area tid scopalamine patch 1.5mg q3d seroquel 25mg tid prilosec 20mg micatin apply to affected tissue lopressor 75mg imodium 2mg tid prn lidoderm daily heparin sc tid fentanyl 50mcg q3d vitamin d 800unit daily celexa 20mg daily peri-dex 10 cc tums 500mg daily tylenol 650mg q6h prn combivent 2 puffs tid discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for c. 3. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 6. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). 7. nystatin 100,000 unit/ml suspension sig: 5-10 mls po qid (4 times a day) as needed for thrush. 8. metoclopramide 5 mg/ml solution sig: one (1) injection q6h (every 6 hours). 9. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) intravenous q 12h (every 12 hours) for 7 days. 10. ciprofloxacin in d5w 400 mg/200 ml piggyback sig: one (1) intravenous q12h (every 12 hours) for 13 days. 11. piperacillin-tazobactam-dextrs 4.5 gram/100 ml piggyback sig: one (1) intravenous q8h (every 8 hours) for 13 days. 12. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours). 13. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 14. chlorhexidine gluconate 0.12 % mouthwash sig: one (1) ml mucous membrane (2 times a day). discharge disposition: extended care facility: hospital discharge diagnosis: primary - pneumonia - severe anoxic brain injury with loss of cortical activity secondary - als - frontal temporal dementia - hypertension discharge condition: patient with tracheostomy and peg tube at baseline, now unresponsive without cortical activity on 24 hour continuous eeg despite 72-96 hour washout of sedatives. brain stem reflexes including pupillary reflexes and oculovestibular reflex intact. discharge instructions: ms. was admitted to icu after suffering a pea arrest with extended down time and subsequent severe anoxic brain injury. patient was also diagnosed with a mrsa and pseudomonal pneumonia. a picc line was placed for prolonged antibiotic therapy. patient should be continued on vancomycin 1g iv q12 through , ciprofloxacin 400mg iv q12 through , zosyn 4.5g iv q8 through . sensitivities for the pseudomonas were pending at the time of discharge. cipro and zosyn antibiotic course may be tailored down pending the culture results. please call the microbiology lab on at for sensitivities. followup instructions: please follow up with your primary care doctor for further management. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Unspecified essential hypertension Amyotrophic lateral sclerosis Other specified cardiac dysrhythmias Pneumonitis due to inhalation of food or vomitus Anoxic brain damage Dementia in conditions classified elsewhere without behavioral disturbance Tracheostomy status Dependence on respirator, status Other frontotemporal dementia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: - endotracheal intubation and mechanical ventilation, tracheostomy - endoscopy, percutaneous endoscopy gastrostomy, duodenal biopsy - peripherally inserted central catheter insertion - bronchoscopy history of present illness: ms. is a 52 year-old woman who has a 6-month of history of neurologic deterioration and failure to thrive. she was completely functional and working as a cook until 11/. at that time her daugter became aware of worsening confusion and decreasing ability to communicate. she moved in with her daughter who has become her primary caretaker. intake has been declining gradually over this time, and she has lost ~80 pounds in 6 months. during the past 3 weeks she has also had worsening r arm weakness. she was admitted to . at that time an extensive work-up was undertaken. her dysphagia was thought to be secondary to bulbar weakness. she had a brain mri and mra showing extensive white matter changes that were nonspecific. she had a normal eeg and a csf negative for fungal, viral, or bacterial infection, and no oligoclonal bands. anticholinesterase and musk ab titers were checked to rule out myastehia and were pending a the time of discharge. als was thought to be possible (although cpk normal), but emg was planned as an outpatient. she also underwent evaluation for occult malignancy, including ct torso that was essentially normal and colonoscopy. hiv was checked and negative. she was discharged to rehab. . concominant with this decline in her functional status, her daugher noted that she coughs frequently after eating. this has worsened in recent weeks, and for the past 3 days she has been noticably short of breath and grunting with every expiration. she has been essentially unable to eat. she presented to on after a bout of coughing and desaturation to the low 80s after eating. she was admitted for one day. she was given ceftriaxone and metronidazole for possible aspiration pneumonia; however, given no cxr or clinical signs of pna, antibiotics were discontinued. she was seen by speech and swallow who recommended pureed solids and nectar thickened liquids in a supervised setting. she was discharged back to rehab on . . over the intervening three days, the patient has become increasingly visibly short of breath with grunting. she continues to have coughing fits after eating, and her daughter has essentially not been feeding her. she was transferred to for further evaluation. . in the ed, initial vital signs t 99.4, bp 126/76, hr 120, rr 22, o2 sat 100% on ra. t rose to 100.7, and she was persistnetly tachycardic. cxr showed bibasilar atelectasis. she received 3 l ns, tylenol 650 mg pr x 1 and levaquin 500 mg iv x 1. past medical history: - hypertension - depression - dysphagia - right upper extremity weakness - cognitive decline with past work-up as above social history: social history: currently lives at a nursing home since her discharge . prior to that she had been living with her daughter since . she is dependent on nh staff for adls but is ambulatory. she is a former smoker. she worked as a cook at a hospital prior to her clinical medical decline last year. family history: no history of neurologic illness physical exam: vitals: t 99.1, hr 110, rr 19, bp 132/76, o2 97% on 2l general: cachectic middle aged woman lying in bed, grunting with every expiration and using accessory muscles heent: extremely dry mm, lips chafed and bleeding, neck: supple, jvp not elevated card: regular, normal s1/s2 resp: grunting with each expiration, clear bilaterally with decreased sounds at bases abd: scaphoid, normoactive bowel sounds, nontender back: no spinal tenderness, no cva tenderness ext: no cyanosis or edema, strong distal pulses neuro: awake and alert, nonverbal but follows 1-step commans, cn ii-xii intact, strength 5/5 in lue, in rue, in distal muscle groups of le b/l, unable to assess proximal le strength difficulty communicating exam. sensation could not be adequately assessed. gait not tested. pertinent results: admission labs: 04:00pm blood wbc-10.3 rbc-4.42 hgb-11.5* hct-36.0 mcv-81* mch-26.0* mchc-32.0 rdw-14.4 plt ct-262 04:00pm blood neuts-84.0* lymphs-13.0* monos-2.7 eos-0.1 baso-0.2 04:04am blood pt-13.4 ptt-21.7* inr(pt)-1.1 04:00pm blood glucose-110* urean-13 creat-0.5 na-145 k-4.2 cl-103 hco3-33* angap-13 04:04am blood alt-29 ast-23 ld(ldh)-194 alkphos-56 totbili-0.6 04:00pm blood calcium-10.2 phos-4.0 mg-2.2 . neuro w/u: 04:17am blood esr-60* 04:17am blood crp-256.3* 04:17am blood tsh-0.76 05:14am blood anti-tg-less than antitpo-less than whipple's disease by pcr - negative 04:31pm cerebrospinal fluid (csf) wbc-1 rbc-0 polys-2 lymphs-84 monos-14 04:31pm cerebrospinal fluid (csf) totprot-16 glucose-66 04:31pm cerebrospinal fluid (csf) multiple sclerosis (ms) profile-test name 04:31pm cerebrospinal fluid (csf) 14-3-3-pnd . anemia w/u: 04:04am blood fe=23 caltibc-303 ferritn-207* trf-233 . urine: 04:45pm urine color-yellow appear-clear sp -1.016 04:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg . microbio: 04:17am blood htlv i and ii, with reflex to western blot-test blood cx - coag neg staph, otherwise all negative csf cx - negative rpr - negative sputum - yeast duodenal bx - no organisms vzv/hsv cx from oral lesion - positive for hsv-1 . eeg: impression: this is an abnormal portable eeg recording due to the slow background and the bursts of generalized slowing. this abnormality suggests cortical and subcortical encephalopathy. metabolic disturbances, medications, and infections are among the most common causes. if the patient's disease process progresses, a follow-up eeg for comparison would be of further diagnostic value. . emg (prelim): c/w motor neuron dz, likely amyotrophic lateral sclerosis . radiology: cxr on admission: impression: bibasilar linear opacities likely representing atelectasis. . cxr : findings: since interval examination from , there has been improvement in previously noted large pneumoperitoneum. no interval change in complete left lower lobe collapse with associated leftward mediastinal shift since . the right lung is clear with no new focal parenchymal opacities. no pleural effusions or pneumothorax. tracheostomy tube in stable standard position. cardiomediastinal silhouette is stable, demonstrating normal heart size. right picc line with tip terminating within the mid-to-lower svc. impression: stable left lower lobe collapse. improved pneumoperitoneum. . ct head: impression: no acute intracranial pathology. . mri head: impression: 1. multiple flair hyperintense lesions in the frontal and the parietal subcortical white matter without enhancement or restricted diffusion, some of the lesions, slightly more ill-defined compared to the prior study. the nature of these lesions is uncertain. the differential diagnosis includes post-inflammatory, post-infectious, demyelinating, vasculitis or slightly small vessel occlusive disease. however, given the patient's condition, clinical and lab correlation is recommended to exclude the possibilities as mentioned earlier. in addition, comparison with any remote imaging, is available remote mr imaging, if available, would be helpful. 2. interval development of bilateral mastoid air cells, mucosal thickening and/or fluid, moderate. . rue u/s: impression: no evidence for right upper extremity dvt. brief hospital course: in summary, ms is a 52f w 6-month h/o progressive neurological deterioration, right arm weakness and weight loss, who was admitted to the icu for respiratory failure. . # neurologic deterioration: likely amyotrophic lateral sclerosis w frontotemporal dementia. pt presented w progressive deterioration x 6-7 months and was found to have diffuse white matter disease of unknown etiology after exhaustive neurological evaluations at and . the infectious, serological and radiologic workup was non-revealing. the possibility of a brain bx was discussed repeatedly, but the decision was made not to do it, since no change in management was expected. given that steroids would be the treatment for the most likely reversable causes of pt's dz, the family decided to try a steroid course after a family meeting was held w neurology on . a 5-day methylprednisolone 1000mg iv daily course was began ( - ), but stopped early after an emg was done on , which revealed findings consistent w motor neuron disease, likely als. 14.3.3 protein was sent out to evaluate for neuronal degeneration/creutzfeld- dz and is negative. poor prognosis of als was discussed w family. treatment was riluzole was attempted but the drug is no longer available. pt to continue supportive measures. . # respiratory failure: this is likely neuromuscular weakness from progressive deterioration w overlying pna in the setting of aspiration, inability to clear secretions, and overlying infection (hap). on admission () was found to have increased work of breathing leading to acute respiratory acidosis. s/p intubation on , with subsequent poor rsbis, nif -1. s/p tracheostomy and peg tube on . complete collapse of lll mucous plug, reopened w bronchoscopy. remained strictly npo w supportive oral care. s/p zosyn x 8 days ( ?????? ). s/p vanc/cefepime/ciprofloxacin x for 8 days ( ?????? ). weaned off fentanyl drip and transitioned to fentanyl patch. attempts were made at decreasing patient's vent support and was tolerating ps at 10/5 with fio2 40% at the time of discharge. further attempts to wean ps to were not successful due to low tidal volumes, tachypnea, and decreased pao2 on abg. tracheostomy tube was placed. . # uti: on pt w slight fever, found to have +ua. completed course of ciprofloxacin. . # latent tb: pt was found to have a ppd of 18mm with cxrs negative for active tb. no prior treatment for tb was given per pt's daughter. she had two afb sputums sent for placement reasons at a ltac; however, this was determined to not be needed prior to d/c to ltac. thus, she was taken off of tb precautions. . # anemia: normocytic, possibly anemia of chronic disease and acute blood loss. hct 36 on admission, currently stable ~25. . # dysphagia: neuromuscular weakness, obvious aspiration. remained strictly npo w supportive oral care. s/p peg placement . maintained on tfs. . # tachycardia: unclear etiology, possibly related to neurological (? sympathetic) dysfunction. persistently in 110s-130s, sinus tachycardia on ekg. other vitals stable. did not appear to be hypovolemia, fever, infection, pain, thyroid function, or anemia. cta chest done to r/o pe. monitored on telemetry and stable. no need for further telemetry monitoring at ltac. . # right shoulder rash: likely shingles. treated w acyclovir x 14 days ( - ). pain controlled w increased fentanyl doses as well as gabapentin and lidocaine patch. no evidence for systemic dissemination. . # hypertension: home amlodipine and hctz held in the setting of low blood pressures. . the palliative care service assisted with discussions with the family. she is still a full code. hcp is daughter (cell) or (home). medications on admission: amlodipine 10 mg daily hctz 12.5 mg daily remeron 45 mg daily megace unknown dose discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. chlorhexidine gluconate 0.12 % mouthwash sig: one (1) ml mucous membrane (2 times a day). 3. acetaminophen 325 mg tablet sig: one (1) tablet po q6h:prn as needed for pain/fever. 4. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 5. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for fungal rash. 7. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): pls apply to back of r shoulder. 8. insulin regular human 100 unit/ml solution sig: 0-15 units injection asdir (as directed): pls see attached sliding scale. 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. loperamide 2 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for diarrhea. 12. fentanyl 50 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 13. quetiapine 25 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for agitation. 14. morphine 10 mg/5 ml solution sig: twenty (20) mg po q4h (every 4 hours) as needed for pain, agitation. 15. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 16. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. 17. haloperidol lactate 5 mg/ml solution sig: 0.5 mg injection tid (3 times a day) as needed for agitation. discharge disposition: extended care facility: hospital discharge diagnosis: primary: amyotrophic lateral sclerosis frontotemporal dementia ventilator-associated pneumonia . secondary: shingles depression/agitation discharge condition: vital signs stable. has a tracheostomy. current vent settings are ps 10/5 40%. discharge instructions: you were admitted to the hospital for decline in your mental status and general functioning. your muscles have been too weak for you to breathe and you needed assistance with the mechanical ventilation. you were diagnosed with amyotrophic lateral sclerosis (als) and frontotemporal dementia. . please take your medications as prescribed. followup instructions: you may follow-up with your pcp 2 weeks. no follow-up is needed with neurology. 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 Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Urinary tract infection, site not specified Unspecified essential hypertension Pulmonary collapse Acute respiratory failure Amyotrophic lateral sclerosis Pressure ulcer, lower back Dementia in conditions classified elsewhere without behavioral disturbance Ventilator associated pneumonia Tachycardia, unspecified Pressure ulcer, stage II Herpes zoster without mention of complication Other frontotemporal dementia

allergies: all allergies / adverse drug reactions previously recorded have been deleted attending: addendum: procedures: right frontoparietal craniotomy and right frontoparietal craniectomy. discharge disposition: expired md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Arteriography of femoral and other lower extremity arteries Arteriography of cerebral arteries Arteriography of cerebral arteries Arterial catheterization Other craniotomy Computerized axial tomography of head Computerized axial tomography of head Unilateral thyroid lobectomy Percutaneous angioplasty of intracranial vessel(s) Procedure on single vessel Insertion or replacement of external ventricular drain [EVD] Temporary (partial) therapeutic endovascular occlusion of vessel Diagnoses: Acidosis Anemia, unspecified Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Subarachnoid hemorrhage Intracerebral hemorrhage Compression of brain Acute respiratory failure Hypotension, unspecified Encephalopathy, unspecified Aphasia Electrolyte and fluid disorders not elsewhere classified Cerebral atherosclerosis

allergies: all allergies / adverse drug reactions previously recorded have been deleted attending: addendum: procedures: right evd placement cerebral angiogram with coiling cerebral angiogram with angioplasty patient did not undergo a hemicraniectomy. discharge disposition: expired md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Arteriography of femoral and other lower extremity arteries Arteriography of cerebral arteries Arteriography of cerebral arteries Arterial catheterization Other craniotomy Computerized axial tomography of head Computerized axial tomography of head Unilateral thyroid lobectomy Percutaneous angioplasty of intracranial vessel(s) Procedure on single vessel Insertion or replacement of external ventricular drain [EVD] Temporary (partial) therapeutic endovascular occlusion of vessel Diagnoses: Acidosis Anemia, unspecified Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Subarachnoid hemorrhage Intracerebral hemorrhage Compression of brain Acute respiratory failure Hypotension, unspecified Encephalopathy, unspecified Aphasia Electrolyte and fluid disorders not elsewhere classified Cerebral atherosclerosis

allergies: all allergies / adverse drug reactions previously recorded have been deleted attending: chief complaint: sah major surgical or invasive procedure: cerebral angiogram with coiling of left mca aneurysm left hemicraniotomy r frontal evd cerebral angiogram with angioplasty history of present illness: 74f who was diagnosed with l mca aneurysm one week ago. today had complaints of headache and became aphasic. taken to osh where her ms decreased and she was intubated. ct head showed sah and she was transferred to for further evaluation. on transport her left pupil became fixed and dilated. she received 3% nacl. her sbp was labile and noted to be 200 on transport. past medical history: htn, copd social history: positive tobacco use, unknown amount family history: nc physical exam: physical exam: hunt and : 5 : iv gcs 3 e: 1 v: 1 motor 1 t: 99.0 bp: 164/88 hr: 56 r 15 o2sats 100% gen: intubated. not sedated. no eye opening. no commands. no movement in upper or lower extremities to noxious. heent: pupils: on arrival l 8mm nr r 3mm reactive. 2nd exam after mannitol both pupils 3mm and reactive patient passed at 1o:04 am on pertinent results: cxr: impression: 1. endotracheal tube in proper position. 2. nasogastric tube with side port at the gastroesophageal junction. could be advanced several centimeters for proper positioning. cta head: impression: 1. bilobed 11 x 7 mm aneurysm arising from the left m1/m2 junction, the likely source of the large left frontal intraparenchymal hematoma with extensive neighboring subarachnoid and subdural blood products. 2. moderate right word subfalcine herniation. 3. moderate suprasellar and mild quadrigeminal cistern effacement, concerning for early uncal/transtentorial herniation. 4. right frontal approach ventriculostomy catheter terminating in the approximate region of the third ventricle. cerebral angiogram: impression: underwent cerebral angiography, which revealed an aneurysm of the left middle cerebral artery that was coiled subtotally. since her exam was poor, at some point, she will be brought back to finish this if she makes a satisfactory recovery. cxr: an ng tube is present, the tip extends beneath the diaphragm and overlies the lower mid abdomen, question within distended stomach. the lung bases are grossly clear. the sideport lies in the left mid abdomen, again, likely in a distended stomach. right upper quadrant surgical clips noted. ct head: impression: 1. interval left frontal craniectomy with improved but persistent rightward shift of normally midline structures and mild effacement of the basal cisterns on the left. 2. increased density of large left parenchymal and extensive bilateral subarachnoid hemorrhage, likely secondary to interval administration of contrast and additional extravasation. 3. external ventricular drain catheter terminates below the left lateral ventricle, with tip possibly outside the ventricular system. eeg: *** pending ct head: impression: status post left frontal craniectomy and ventriculostomy drain retraction, stable appearance of left intraparenchymal and bilateral subarachnoid hemorrhage with mild improvement of midline shift, but persisting sulcal and ventricular effacement. eeg: ***pending cxr: findings: endotracheal tube has been advanced slightly, now terminating about 2.5 cm above the carina. central venous catheter has apparently been slightly withdrawn since previous study with tip now at or just below the cavoatrial junction. cardiomediastinal contours are within normal limits. appearance of the lungs is essentially unchanged except for slight obscuration of a small portion of the peripheral right hemidiaphragm. it is uncertain whether this represents a focal area of right basilar atelectasis or consolidation, or if it reflects a newly developed small right pleural effusion. attention to this area on followup radiograph may be helpful in this regard. ct head: impression: status post left frontal craniectomy and ventriculostomy with persistent large parenchymal and subarachnoid hemorrhage causing increased hmass effect. the tip of the evd in the frontal of the left lateral ventricle, which is being compressed by adjacent mass effect. eeg: ***pending echo: the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). doppler parameters are indeterminate for left ventricular diastolic function. 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. the mitral valve leaflets are elongated. trivial mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal regional and global biventricular systolic function. indeterminate diastolic function. no pathologic valvular abnormalities. cxr: findings: as compared to the previous radiograph, there is no relevant change. monitoring and support devices are constant. no change in appearance of the lung parenchyma and the cardiac silhouette. a previously seen blunting of the lateral aspect of the right diaphragmatic contour is no longer present. eeg: impression: this is an abnormal continuous icu monitoring study because of severe diffuse encephalopathy and interhemispheric asymmetry suggesting greater left hemisphere pathology and particularly greater left mid to posterior temporal pathology. there continues to be multifocal independent interictal epileptic activity predominantly over the right central and temporal regions with rare discharges over the left hemisphere. compared to the prior day's recording, there is worsening encephalopathy and worsening left temporal cerebral dysfunction noted in this recording. cxr: findings: in comparison with study of , there is poor definition of the hemidiaphragms, especially on the right, consistent with small layering effusions and compressive atelectasis at the bases. no evidence of vascular congestion. the tip of the endotracheal tube measures approximately 4.8 cm above the carina. nasogastric tube and left central catheter are unchanged in position. cta: impression: 1. minimal vasospasm of the m1 segment of the left mca proximal to the coil. the distal opercular branches are patent. there is no vascular occlusion. 2. stable intraparenchymal and subarachnoid hemorrhage involving the left temporal and frontal lobes with no change in the mass effect from the prior study. no evidence of herniation. eeg: impression: this is an abnormal continuous icu monitoring study because of a severe diffuse encephalopathy with a burst and burst suppressive pattern and asymmetric attenuation of voltage over the left temporal region and, to a lesser degree, left central region. there were no clear electrographic seizures and only a few potential interictal discharges identified. cxr: the et tube tip is 4.3 cm above the carina. the ng tube tip is in the stomach. heart size and mediastinum are unremarkable. there is small amount of bilateral pleural effusion, unchanged since the prior study with no evidence of interval development of pneumothorax or pulmonary edema. right midline tip is at the level of mid portion of right subclavian artery. ct head: little change in comparison to prior study from the day before with stable appearance of large left fronto-temporal intraparenchymal hemorrhage and foci of subarachnoid hemorrhage with continued rightward mass effect. continued followup is recommended. cxr: as compared to the previous radiograph, there is no relevant change. the monitoring and support devices are constant. normal size of the cardiac silhouette. no overt pulmonary edema. no larger pleural effusions. no evidence of pneumonia. no pneumothorax. ct/cta head: 1. unchanged intraparenchymal and subarachnoid hemorrhage involving the left temporal and frontal lobes as described in detail above, with similar pattern of mass effect and edema. there is no evidence of herniation or new areas of hemorrhage. 2. interval improvement in the vasospasm involving the m1 segment of the left middle cerebral artery as described in detail above, there is no vascular occlusion, the examination is partially limited due to streak artifact and coiled material, obscuring the vascular anatomical details, however, the distal opercular branches are patent. brief hospital course: this is a 74 year old female who was diagnosed with a left mca aneurysm one week ago. the patient presented with complaints of headache and became aphasic.she initially presented to an outside hospital where her mental statuss decreased and she was intubated. a ct head showed subarachnoid hemorhage and she was transferred to for further evaluation. on transport her left pupil became fixed and dilated. she received 3% nacl. her sbp was labile and noted to be 200 on transport. the patient was admitted on to the intensive care unit. gram mannitol was given a external ventricular drain placed in emergency department.\ on , the external ventricular drain pulled back 1cm and the evd was patent and still draining. the patient was given a 500cc iv bolus for hypotension. following the iv bolus the sbp in 90s. on , the external ventricualr drain dropped to 10 to increase cerebral perfusion. intercranial pressures were elevated at 22-24. teh drain was not draining. a nchct was performed which was consistent with increase in mass effect, ventricular compression and midline shift. on , the evd was open at 10 icp 8-12. the patient was paralyzed and cooled to decrease icps.the patient's pupils were reactive- there was no movement in the extremities given sedation and parylytic medication. in the afternoon the patient was rewarmed given the normal icps. a family meeting was held with the two daughters to review images and update the family on the patients status. on , patient remained on paralyzed overnight into the am. pupils were 2 and reactive. cta of her head was done which showed mild narrowing of the m1, but all vessels were patent. tcds also show no vasospasm. her icps were stable at 15. eeg read shows worsening encephalopathy, but no further seizure activity. on her neurological exam was stable. upon further review of her cta and in comparison with her tcd's, it was decided to undergo cerebral angiography for closer assessment for vasospasm. there was vessel narrowing noted in the left mca therefore angioplasty was performed without complication. ivf's were increased and she was given 2 units of prbc's for a hct of 23. on patient started developing increased intracranial pressures, her icps were in the high 20s. her sedation was increased and she was cooled and placed on paralytics. tcds revealed mild to moderated spasm in the right mca; to counter pervent further spasm she was started on a presser to elevate her blood pressure to the 150s. head ct was performed and stable. she was noted to have a likely cushings response when her heart rate began dropping into the 40's. she also had increased urine output which was concerning for d.i. at about 9pm neurosurgery was called to the patient's bedside per the families request. a discussion was held and questions regarding the patient's current medical status and outcome were asked. the patient's 2 daughters and son were present and decided to make her cmo at this time. this was discussed with dr. and dr. . it was decided that we would rewarm her to 35 degrees and then shut off the paralytics. when the paralytics wore off and she was >36 degrees she was extubated. patient passed at 10:04 am on . medications on admission: unknown discharge medications: n/a discharge disposition: expired discharge diagnosis: l mca aneurysm subarachnoid hemorrhae intraventricular hemorrhage cerebral vasospasm anemia requiring transfusion respiratory failure dysphagia discharge condition: n/a discharge instructions: n/a followup instructions: n/a Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Arteriography of femoral and other lower extremity arteries Arteriography of cerebral arteries Arteriography of cerebral arteries Arterial catheterization Other craniotomy Computerized axial tomography of head Computerized axial tomography of head Unilateral thyroid lobectomy Percutaneous angioplasty of intracranial vessel(s) Procedure on single vessel Insertion or replacement of external ventricular drain [EVD] Temporary (partial) therapeutic endovascular occlusion of vessel Diagnoses: Acidosis Anemia, unspecified Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Subarachnoid hemorrhage Intracerebral hemorrhage Compression of brain Acute respiratory failure Hypotension, unspecified Encephalopathy, unspecified Aphasia Electrolyte and fluid disorders not elsewhere classified Cerebral atherosclerosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: orif ulnar and femur fractures history of present illness: 78 y.o. male driver s/p motor vehicle crash vs. large flat bed diesel truck with extensive damage to vehicle. per ems report, patient without memory of the event. past medical history: htn, bronchitis family history: noncontributory physical exam: upon admission- 96.3 bp: 124/55 hr:64 r 18 o2sats100% nrb gen: wd/wn, comfortable, nad. heent: cercal collar in place. no c/o posterior neck pain. unable to elicit several large scalp and left facial lacerations. pupils:3mm to 2mm bilat eoms full. no nystagmus neck: supple. no carotid upstrokes lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light,3mm to 2mm 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.+eccymosis. no oral blood noted. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power bil. ue. right le. unable to move the left leg at all due to pain. wiggles toes. sensation in the le's normal to light touch. no pronator drift (left rad. aline present). sensation: intact to light touch, propioception toes downgoing bilaterally coordination: normal on finger-nose-finger, unable to do heel to shin. pertinent results: 08:00pm glucose-160* urea n-32* creat-1.4* sodium-140 potassium-4.7 chloride-106 total co2-23 anion gap-16 08:00pm calcium-7.7* phosphate-3.3 magnesium-1.5* 08:00pm wbc-25.3*# rbc-3.36* hgb-10.6* hct-31.7* mcv-94 mch-31.6 mchc-33.5 rdw-13.2 08:00pm plt count-225 01:08pm ph-7.31* comments-green top 01:08pm glucose-129* lactate-2.8* na+-142 k+-3.8 cl--103 tco2-24 01:05pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg ct head impression: 1. multiple small foci of subarachnoid hemorrhage in the bifrontal cortices. 2. small left subdural hematoma along the falx without evidence of mass effect. 3. irregularity of the distal right carotid artery and probable branch of the left mca may represent atraumatic calcified aneurysms which can be evaluated on a non- emergent basis if clinically indicated. ct chest/abdomen/pelvis impression: 1. comminuted intertrochanteric left femoral fracture. 2. no evidence of posttraumatic solid organ injury in the chest, abdomen, or pelvis. 3. atherosclerotic disease of the descending and abdominal aorta, coronary arteries. 4. diverticulosis without diverticulitis. 5. enlarged prostate with probable associated bladder wall thickening. 6. multiple hypodense lesions in the kidneys likely represent simple cysts but some of which are too small to characterize. repeat ct head impression: 1. small regions of bilateral subarachnoid hemorrhage and small acute subdural hemorrhage noted along the posterior falx as described above. overall amount of hemmorhage is evolving and fainter compared to the prior. 2. hypoattenuating extra-axial collection noted along the left cerebral convexity which may represent a chronic subdural hematoma or hygroma. 3. soft tissue injury as described above. no skull fractures. brief hospital course: he was admitted to the trauma service. he was evaluated by plastics in the emergency room for his multiple facial lacerations. they were irrigated and sutured. the facial sutures will need to be removed on . neurosurgery and orthopedics were consulted. his subarachnoid hemorrhage was managed non operatively, serial head ct scans were followed and remained stable. per neurosurgery he does not require further follow up for this. his mental status is awake, alert and oriented x3. he was taken to the operating room by orthopaedics for open reduction internal fixation of left intertrochanteric hip fracture, open reduction internal fixation left femoral shaft fracture, irrigation and debridement open ulnar shaft fracture, open reduction internal fixation ulnar shaft fracture and complex lacerations of dorsum of hand and forearm. there were no intraoperative complications. postoperatively he was transferred to the regular nursing unit. he did have some pain control issues and was started on tylenol around the clock and prn oxycodone which has appeared to help. a bowel regimen was initiated as well. he was evaluated by physical therapy and is being recommended for rehab after his acute hospital stay. medications on admission: unknown discharge medications: 1. enoxaparin 30 mg/0.3 ml syringe sig: thirty (30) mg subcutaneous q12h (every 12 hours). 2. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po at bedtime. 3. acetaminophen 650 mg tablet sig: one (1) tablet po q6h (every 6 hours). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: two (2) tablet po hs (at bedtime). 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 7. oxycodone 5 mg/5 ml solution sig: 5-10 mg po q4h (every 4 hours) as needed for pain. 8. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per sliding scale. discharge disposition: extended care facility: rehab unit at - discharge diagnosis: s/p motor vehicle crash subarachnoid hemorrhage open left ulnar fracture left femur fracture discharge condition: hemodynamically stable, tolerating oral diet, pain adequately contolled discharge instructions: do not bear any weight on your left arm. you may touch down weight bear on your left leg. the lovenox injections for preventing blood clots will need to continue for at least 4-8 weeks, possibly longer based on recommendation from orthopedics. followup instructions: follow up next week in clinic for suture removal from your scalp. call for an appointment. follow up in 2 weeks with dr. , orthopedics, call for an appointment. follow up with your primary care doctor in 2 weeks after discharge from rehab. you or your family will need to call for an appointment. Procedure: Open reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, radius and ulna Debridement of open fracture site, radius and ulna Other repair and reconstruction of skin and subcutaneous tissue Diagnoses: Unspecified essential hypertension Open wound of scalp, without mention of complication Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Closed fracture of shaft of femur Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Closed fracture of intertrochanteric section of neck of femur Open wound of hand except finger(s) alone, without mention of complication Open wound of forearm, without mention of complication Open fracture of shaft of ulna (alone)

allergies: no known allergies / adverse drug reactions attending: chief complaint: right substernal goiter. major surgical or invasive procedure: resection substernal goiter, cervical approach,right thyroidectomy. history of present illness: this patient was on the medical intensive care unit suffering from an asthma exacerbation when imaging study showed a significant compressive goiter. it was the opinion of the medical service that this was the major cause of her respiratory distress and surgical options were discussed with patient who agreed to proceed with removal of goiter. past medical history: pmh: htn - newly diagnosed , migraines, possible history of exercise induced asthma psh: resection substernal goiter, cervical approach,right thyroidectomy social history: she is from and her parents are from . she went to and then went to sulfolk law school. currently practicing in her own private practice and focuses on family law and juvenile justice. does not smoke. rare alcohol. no illicits. married in . no kids. family history: mother with diabetes and obesity. father hypertension, dyslipidemia. she has three brothers, one of whom has hypertension. she has two sisters, one of whom has hypertension. no h/o cancer. physical exam: vitals:98.2, 66, 116/72, 16, 98 % room air. general:alert,oriented, no acute distress, voice clear,no respiratory distress heent:sclera anicteric, mmm, oropharynx clear neck:supple, jvp not elevated, no lad, bil non tender smooth enlarged thyroid pulmonary:clear to auscultation bilaterally, no wheezes,rales,ronchi cardiovascular: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 incision:neck soft, steri-strips c/d/i extremities: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neurological: grossly normal exam pertinent results: pathology substernal goiter pending at discharge. cxr : mediastinal and right hilar prominence/widening -- concerning for lymphadenopathy-- with ct chest. ct chest : large bilobed thyroid mass (arising from rt lobe) extending inferiorly into the anterior/superior mediastinum with upper and lower masses connected by a narrow waist - overall dimensions of upper and lower segments of this bilobed mass are approx 6.4 (tr) x 4.4 (cc) x 4.2 (ap) cm and 5.1 (tr) x 5.8 (cc) 4.0 (ap) respectively. ++ mass effect on the mid trachea at the level of the t1-2 with >50% loss of ap diameter of the trachea. additional small left thyroid nodule. no lymphadenopathy. thyroid ultrasound a large heterogeneous, hypervascular mass arising from the inferior pole of the right thyroid lobe and isthmus, extending inferiorly into the mediastinum. the lesion is further characterized on the ct chest exam of . ekg: sinus tach rate 102, normal axis, normal intervals, some non specific st-t changes, no signs of ischemia, pericarditis, lvh. brief hospital course: ms. is a 32-year-old female who has a history of htn, migraines, and no known diagnosis of asthma but requiring ventolin with previous uri's, who presented to the ed with sob and was found to have thyroid mass with > 50% obstruction of mid trachea. she was admitted to the micu for observation. high dose steroids were given initially for possible tracheal edema exacerbating her tracheal narrowing and causing her current symptoms. she was initially given iv solu-medrol 80mg tid and then switched to prednisone 60mg daily which was discontinued after her last dose on . she was also on standing robitussin+codeine for her cough and sq heparin for dvt ppx. during her micu stay she continued to have episodes of sob/stridor/cough/nausea which were attributed to her tracheal obstruction and responded to ventolin and lidocaine inhalation, antiemetics and reassurance. she remained afebrile and hemodynamically stable throughout her stay. patient had history of recently diagnosed htn but her bp's in the micu were largely wnl. leukocytosis was noted and thought to be steroid treatment. patient was followed by endocrine, general surgery and thoracic surgery teams. on she was taken to the or and is status post resection substernal goiter, cervical approach, right thyroidectomy.the procedure was tolerated well and she was transferred to the recovery room and admitted to the sicu overnight where she was hemodynamically stable.she was later transferred to the inpatient general surgery unit pod 1 and her postoperative course was stable. neurological: the patient received iv pain medication with good effect and adequate pain control. when tolerating oral intake, the patient was transition to oral pain medications. cardiovascular: the patient was monitored on telemetry and vital signs were routinely monitored which were stable. pulmonary: the patient received nebulizer treatment appropriately and was monitored closely. she had no dyspnea and had adequate o2 sats on room air. gi/gu: post-operatively, the patient was given iv fluids until tolerating oral intake. the diet was advanced from clears to regular which was tolerated well. intake and output were closely monitored. id: the patient's temperature was closely watched for signs of infection, and the incision remained clean, dry, intact,and without erythema or hematoma. endocrine: the patient's calcium prior to discharge was normal. prophylaxis: the patient wore pneumatic compression boots, and was encouraged to get up and ambulate as early as possible. at the time of discharge, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. disposition:the patient was discharged home in good condition and will follow-up with dr. and endocrinologist. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs inhaled every six (6) hours as needed for cough and shortness of breath hydrochlorothiazide - stopped this on her own ibuprofen - 800 mg tablet - 1 tablet(s) by mouth three times a day with meals sumatriptan succinate - 25 mg tablet - 1 tablet(s) by mouth x1 as needed for headache may repeat in 2hrs x1. max dose 200mg/24 hrs allergies: nkda bees -> fainted with swelling at site of sting and bannana-> vomiting and diarrhea. discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) inhalation twice a day as needed for shortness of breath or wheezing: . 2. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. disp:*30 tablet(s)* refills:*0* 3. oxycodone 5 mg/5 ml solution sig: 5 mg/5 ml po q3h (every 3 hours) as needed for pain. disp:*40 5 mg/5 ml* refills:*0* 4. acetaminophen 650 mg/20.3 ml solution sig: one (1) po q6h (every 6 hours) as needed for pain/fever. 5. diphenhydramine hcl 25 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pruritus. 6. colace 100 mg capsule sig: one (1) capsule po twice a day. discharge disposition: home discharge diagnosis: right substernal goiter. 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 inpatient general surgery unit after your thyroid surgery. you have adequate pain control and have tolerated a regular diet and may return home to continue your recovery. please resume all regular home medications, unless specifically advised not to take a particular medication and take any new medications as prescribed. you will be given a prescription for narcotic pain medication, take as prescribed. it is recommended that you take a stool softner such as colace while taking oral narcotic pain medication to prevent constipation. you may also take acetaminophen (tylenol) as directed, but do not exceed 4000 mg in one day. please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. incision care: please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site.you may shower and wash incisions with a mild soap and warm water.avoid swimming and baths until cleared by your surgeon.gently pat the area dry.you have a neck incision with steri-strips in place, do not remove, they will fall off on their own. thank you for allowing us to participate in your care! our hope is that you will have a quick return to your life and usual activities. good luck! followup instructions: please call and schedule follow-up appointment with dr. in 1 month . follow-up with dr. (endocrinologist) 3:30 pm . building please call and schedule follow-up with your primary care provider. Procedure: Application or administration of an adhesion barrier substance Unilateral thyroid lobectomy Percutaneous angioplasty of intracranial vessel(s) Diagnoses: Unspecified essential hypertension Other pulmonary insufficiency, not elsewhere classified Anxiety state, unspecified Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Leukocytosis, unspecified Asthma, unspecified type, with (acute) exacerbation Other diseases of trachea and bronchus Acute upper respiratory infections of unspecified site Unspecified nontoxic nodular goiter

allergies: no known allergies / adverse drug reactions attending: chief complaint: post operative bleeding. major surgical or invasive procedure: sinus washout. reexploration of the sinuses with anterior and posterior packing. history of present illness: 55 yo male with history of hepatitis c cirrhosis, dm, sleep apnea, and chronic sinusitis here for sinus clean out prior to an experimental hep c trial. his ct guided sinus surgery was complete when the surgeons noticed oozing at diffuse mucosal surfaces which did not appear to be from any specific vessels. they placed packing in the anterior nares with some resolution of his bleeding. he was about to be woken up and extubated, when there was an accidental extubation while the patient was still under sedation. an airway emergency was called. his oral cavity was suctioned with continued oozing noticed in the oropharynx. there was concern for aspiration. it took multiple attempts but he was successfully reintubated. blood was noted in the ett. once more alert, he was extubated, and was doing well satting 99% on shovel mask. however, he had continued oozing at the front of his packing, pacu. he was given a unit of platelet with better control of his bleeding for the next hour. cxr was clear and ekg was normal. he was hemodynamically stable during this time with pacu vitals of 143/76 71 19 98% ra. labs revealed an inr of 1.4 so he was given 1 unit of ffp. in the pacu, the patient noted intermittent dizzy spells while sitting up so he was given 1 unit of prbc's. in addition, he received 1700cc crystalloid, with 400cc of uop. he denied cp, sob, palpitations, nausea, vomiting, or abdominal pain at that time. . ent came to reevaluate the patient and brought him back to the or to look for the site of bleeding. he underwent bilateral sinus exploration which did not identify source of bleeding, but rather only oozing from his nasal mucosa. anterior and posterior packing with foley catheters was performed. the catheters were inserted, balloon inflated, and then pulled forward with tension. his anterior nasal cavity was packed with anterioform gauze that was covered with vaseline. clamps were placed to hold the foleys in place. during the procedure, he was noted to have high pip's, and was subsequently given an extra large dose of a paralytic . as a result, he was kept intubated overnight, with a plan to extubate in the morning. . on the floor, patient was intubated and sedated. . review of systems: unable to report while sedated. past medical history: hepatitis c cirrhosis diabetes mellitus chronic sinusitis sleep apnea hypertension depression cervical spondylosis with chronic neck pain djd social history: lives at home with his wife. ivdu--80s. family history: mother-breast ca ca great uncle-diabetes physical exam: upon admission: vitals: 97.4 74 100/53 10 99% on 50% fio2 general: sedated, restrained, no acute distress heent: sclera anicteric, mmm, two foley catheters with nasal packing, held in place by clamps neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: rrr, normal s1 + s2, no murmurs, rubs, gallops abdomen: +bs, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly, no ascites gu: +foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema at discharge: avss heent: no nasal packing. neuro: aox3. no asterxis. pertinent results: labs upon admission: 01:44pm blood wbc-4.4 rbc-4.19* hgb-13.4* hct-36.3* mcv-87 mch-32.0 mchc-36.8* rdw-13.9 plt ct-132* 01:44pm blood pt-15.5* ptt-33.9 inr(pt)-1.4* 08:12pm blood fibrino-136* 11:49pm blood fdp-10-40* 01:44pm blood glucose-229* urean-13 creat-0.9 na-140 k-3.5 cl-105 hco3-22 angap-17 08:12pm blood alt-56* ast-54* alkphos-84 totbili-1.7* 01:44pm blood calcium-8.2* 08:12pm blood albumin-2.9* calcium-7.6* phos-4.5 mg-1.8 11:49pm blood hapto-<5* 08:14am blood type-art temp-36.2 rates-/9 peep-5 fio2-40 po2-113* pco2-56* ph-7.35 caltco2-32* base xs-4 intubat-intubated vent-spontaneou micro: serology/blood rapid plasma reagin test-final blood culture blood culture, routine-pending urine urine culture-final sputum gram stain-final; respiratory culture-final {staph aureus coag +} swab respiratory culture-final {staph aureus coag +}; anaerobic culture-final; fungal culture-preliminary; gram stain-final swab respiratory culture-final {staph aureus coag +}; anaerobic culture-final; fungal culture-preliminary; gram stain-final imaging: cxr: heart size top normal. lungs clear. no pleural abnormality or evidence of central adenopathy. cxr: new et tube is in standard position. the tip is 5.4 cm above the carina. there are low lung volumes. cardiomediastinal contours are unchanged with mild cardiomegaly. new right lower lobe opacity is consistent with aspiration. there is no pneumothorax or pleural effusion. cxr: rotated positioning. at present, the tip of the et tube lies approximately 6.9 cm above the carina, above the level of the medial clavicular heads and should be advanced. there are low inspiratory volumes. the cardiac silhouette is grossly stable. there is upper zone re-distribution, without gross chf. there is patchy opacity at the left base -- although likely accentuated by low inspiratory volumes, this appears to have progressed compared to one day earlier. no focal infiltrate is seen on the right. no gross effusion. cxr: the lungs are low in volume, but clear. the cardiac silhouette is enlarged. the mediastinal silhouette and hilar contours are normal. no pleural effusion or pneumothorax is present. discharge labs: 04:23am blood wbc-3.6* rbc-3.26* hgb-10.3* hct-29.4* mcv-90 mch-31.5 mchc-35.0 rdw-14.8 plt ct-105* 04:20am blood glucose-125* urean-7 creat-0.7 na-143 k-3.3 cl-108 hco3-27 angap-11 04:23am blood alt-41* ast-66* alkphos-72 totbili-2.0* 12:25am blood albumin-2.8* calcium-7.4* phos-3.1 mg-1.6 brief hospital course: 55m hcv cirrhosis, diabetes, htn, and chronic sinusitis that underwent s/p sinus wash out with post operative bleeding from the nasal mucosa. hospital course complicated by prolonged course of delirium that resolved. active issues: # post operative bleeding: likely a result of bleeding from his posterior nasopharynx in a patient with a coagulopathy from hepatic dysfunction. his bleeding was stabilized with anterior and posterior packing. he was hemodynamically stable in the icu. no further bleeding once brought out to the floor. # acute toxic metabolic encephalopathy: following extubation, the patient had a prolonged (~2 days) period of delirium with marked obtundation and episodes of significant agitation, requiring chemical and physical restraints. his delirium was felt secondary to either delayed clearance of his anesthetics vs fever. he was seen by psychiatry, who did not feel that the delirium was due to venlafaxine withdrawal. he was placed on a precedex infusion with subsequent clearing. he was awake, alert and interactive on , his day of transfer to the medical floor. the patients mental status improved through discharge and was at his baseline on . # fever likely from aspiration pna/pneumonitis: the patient had fevers around the time of his extubation, and was started on broad spectrum antibiotics to treat hcap, due to his high aspiration risk and small lower lobe opacities on chest x-ray. the pt was treated empirically with vanc/zosyn for 4 days and was transitioned to bactrim ds . this was continued for a planned 13 more days to cover both mrsa aspiration pna (per sputum cx on ) and for mrsa chronic sinusitis. # hepatitis c cirrhosis: history of grade varices on beta blockade. wife unsure if patient currently taking peg interferon, ribavirin, and boceprevir for hepatitis c treatment. npo without feeding tube, so will hold on nadolol and eplerenone in the setting of bleeding. he had a likely -- tachycardia, and nadolol was resumed on the day of transfer from the micu. # depression: his venlafaxine was held while npo, but was restarted during admission. # diabetes: his metformin was held while inpatient. he was maintained on a humalog sliding scale for coverage. restarted metformin on dc. medications on admission: per omr: boceprevir 200 mg capsule 4 capsule(s) by mouth q8h eplerenone 50 mg tablet by mouth daily metformin 850 mg tablet by mouth twice a day nadolol 40 mg tablet by mouth once daily peginterferon alfa-2a 180 mcg/0.5 ml kit inject 180mcg/0.5ml sq once weekly ribavirin 200 mg capsule 7 capsule(s) by mouth 4 capsules in am and 3 capsules in pm sulfamethoxazole-trimethoprim 800 mg-160 mg tablet by mouth venlafaxine 75 mg capsule, ext release 24 hr by mouth twice a day multivitamin tablet by mouth once daily discharge medications: 1. eplerenone 50 mg tablet sig: one (1) tablet po once a day. 2. nadolol 20 mg tablet sig: two (2) tablet po daily (daily). 3. venlafaxine 75 mg tablet sig: one (1) tablet po twice a day. 4. metformin 850 mg tablet sig: one (1) tablet po twice a day. 5. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day) for 13 days. disp:*26 tablet(s)* refills:*0* 6. outpatient lab work please have a complete blood count and basic metablic panel checked and sent to dr. office next week. office: ( fax: ( 7. sodium chloride 0.65 % aerosol, spray sig: sprays nasal twice a day. disp:*2 tubes* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis - ct guided sinus surgery for chronic sinusitis - acute toxic metabolic encephalopathy - aspiration pna 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 a sinus surgery. following surgery you may have developed an aspiration in the setting of a nose bleed. in addition you had episodes of confusion which resolved. . we have made one change to your medication: 1) please start taking bactrim double strength 1 tab twice daily for 13 more days followup instructions: department: otolaryngology (ent) when: wednesday at 2:30 pm with: , m.d. building: lm campus: west best parking: . garage department: when: thursday at 9:30 am with: , md building: (, ma) campus: off campus best parking: on street parking department: liver center when: thursday at 8:45 am with: , md building: lm campus: west best parking: garage Procedure: Intracranial ventricular shunt or anastomosis Intranasal antrotomy Ethmoidectomy Frontal sinusotomy Other diagnostic procedures on nasal sinuses Control of epistaxis by posterior (and anterior) packing Sphenoidotomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Toxic encephalopathy 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 Acquired coagulation factor deficiency Depressive disorder, not elsewhere classified Hemorrhage complicating a procedure Pneumonitis due to inhalation of food or vomitus Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Osteoarthrosis, unspecified whether generalized or localized, site unspecified Examination of participant in clinical trial Delirium due to conditions classified elsewhere Epistaxis Unspecified sinusitis (chronic) Cervical spondylosis without myelopathy Esophageal varices without mention of bleeding

allergies: shellfish / lisinopril / neosporin / sulfa(sulfonamide antibiotics) / ativan / glucophage / morphine / statins-hmg-coa reductase inhibitors / benadryl attending: chief complaint: hematochezia, chest pain, shortness of breath major surgical or invasive procedure: egd colonoscopy history of present illness: 66f with hx of copd, htn, and dm who presents with with 3 days of dark stools. she noticed red blood in her toilet today. over the past week she has had intermittent chest pain and shortness of breath. chest pain is substernal and radiates to jaw, associated with sob, and is exertional. no abdominal pain. nausea, no vomting. she went to osh ( ), where hct was found to be 13.3 (baseline 34), trop i 0.31 (thought to be due to demand ischemia). vitals at osh were reportedly stable with hr 95 and bp 105/43. she was transfused 3 units prbcs, given 2 l ns, protonix, and levaquin (for unclear reasons). they consulted cards, surgery, and finally, gi, who wanted the patient transferred to for for further management. she states that for the past 3 days, she has noticed loose, dark stools mixed with brbpr that comes out in a "gush" before her bm. she thought this was secondary to hemorrhoids, and therefore didn't immediately present for care. however, given exertional chest pain in a bandlike distribution across her chest, assoc w/ nausea/sob in addition to extreme fatigue and lightheadedness, she went to osh ed. very occassional sharp pains in stomach over past month when taking ice cubes. otherewise none. some fatigue and muscle pain over past 3 days. some loss of appetite past 3 days. she has never had an endoscopic procedure in the past, including colonoscopy. she denies any history of melena or brbpr. she does have lactose intolerance and ibs, so her bowel habits are variable, but states that she is currently having frequent stools. she notes recent "heartburn" symptoms for the past days as well, for which she has been taking tums prn. also of note, she takes ibuprofen 600mg 1-2 times per day x several months for lbp. in the ed, initial vitals were: 98.6 91 97/54 20 100% on ra. ng lavage showed a scant amount of red blood that cleared quickly, and the patient reportedly had a small amount of brbpr. gi and cardiology were consulted, large-bore iv access x 3 obtained, and blood was sent for crossmatch. hct was 23.3. gi recommended admitting to micu, 2 additional units of prbcs to be given in ed, egd/colonoscopy in the morning, and cta and call fellow if hemodynamically unstable overnight. vitals stable here. bp 120s/53. no fluids or red cells given in the ed. on arrival to the micu, patient feels well and has no pain. past medical history: chronic obstructive pulmonary disease htn osteoporosis, treated with yearly reclast spinal stenosis djd diabetes mellitus with recent hga1c 6.4% social history: retired legal secretary. lives w/ grandson and sister is upstairs in two story house. previous tobacco (quit 17 yrs ago, previously smoking 1 ppd x 34 yrs), drinks one glass of wine every 3-4 months, denies drugs. family history: no gi malignancies or ibd. gm with breast ca that metastasized to colon. physical exam: admission: vitals: t: 100.2 bp: p: r: 18 o2: general: alert, oriented, no acute distress, lying in bed. + pallor heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly rectal: brbpr mixed in with stool, +external hemorrhoids gu: no foley ext: no edema, +pallor, cap refill; access: 3 18g pivs neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact discharge afebrile, hypertensive to the 140s systolic, not tachycardic, no oxygen requirement general: alert, oriented, no acute distress, heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: no edema, 2+ pulses neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact pertinent results: admission labs 01:13pm blood wbc-11.3* rbc-3.04* hgb-7.6* hct-23.3* mcv-77* mch-25.1* mchc-32.7 rdw-19.2* plt ct-435 01:13pm blood neuts-81.2* lymphs-13.7* monos-2.7 eos-2.0 baso-0.4 01:13pm blood hypochr-3+ anisocy-1+ poiklo-2+ macrocy-1+ microcy-normal polychr-1+ ovalocy-1+ burr-1+ 01:13pm blood pt-11.2 ptt-25.3 inr(pt)-1.0 01:13pm blood glucose-115* urean-19 creat-0.8 na-134 k-3.6 cl-99 hco3-21* angap-18 01:13pm blood alt-24 ast-27 ck(cpk)-176 alkphos-46 totbili-0.6 01:13pm blood ck-mb-8 01:13pm blood albumin-3.7 01:18pm blood glucose-112* lactate-1.9 k-3.4 01:18pm blood hgb-7.8* calchct-23 01:13pm ctropnt-0.04* 01:13pm ck-mb-8 10:59pm ctropnt-0.11* discharge labs 07:15am blood wbc-6.3 rbc-4.16* hgb-10.9* hct-33.8* mcv-81* mch-26.1* mchc-32.2 rdw-19.1* plt ct-514* 07:15am blood glucose-96 urean-13 creat-0.9 na-141 k-4.5 cl-103 hco3-27 angap-16 07:15am blood calcium-9.4 phos-4.8* mg-2.0 cxr the lung volumes are normal. borderline size of the cardiac silhouette without pulmonary edema. the patient has received a nasogastric tube. the course of the tube is unremarkable, the tip of the tube projects over the middle parts of the stomach. no complications, notably no pneumothorax. no pleural effusions, no pneumonia. . ekg st depressions in v3-v6 . ct c/a/p 1. focal cecal wall thickening near the ileocecal valve, likely corresponding to primary lesion. local lymphadenopathy measures up to 10 x 7 mm. 2. small bilateral pleural effusions and bilateral lower lobe atelectasis versus consolidation. 3. multiple peripheral ground-glass nodules in the lungs may be of infectious origin although metastatic disease is not excluded. close interval followup is recommended. borderline mediastinal lymph nodes may also be re-evaluated at this time. 4. thyroid nodule in the left lobe should be correlated with prior imaging or further evaluated with routine thyroid ultrasound. 5. 8-mm focus of enhancement within segment 7 of the liver may represent an fnh or hemangioma. recommend continued attention on follow up. . endoscopy colonoscopy findings: protruding lesions a broad-based 5 cm mass with overlying exudate was found in the cecum. cold forceps biopsies were performed for histology. grade 1 internal hemorrhoids were noted. excavated lesions a single non-bleeding diverticulum was seen. impression: grade 1 internal hemorrhoids diverticulum in the colon mass in the cecum (biopsy) otherwise normal colonoscopy to cecum egd findings: esophagus: lumen: a partial, nonobstructing schatzki's ring was found. a small size hiatal hernia was seen. stomach: normal stomach. duodenum: normal duodenum. impression: small hiatal hernia schatzki's ring . pathology cecal mass biopsies: focal adenomatous mucosa with at least high grade dysplasia. no definitive invasive carcinoma is identified. additional levels examined. the biopsies may not be representative of the entire "mass" described. clinical correlation is needed. brief hospital course: 66f with pmh of copd and dm presented with gi bleed and chest pain, found to have hct of 13 out osh. active # gastroinstestinal bleed: the patient was admitted to the micu from outside hospital with a hct of 13. at that time she was hypotensive. she received 3 units of prbcs and ivns at the osh and was started on a protonix drip. upon transfer to she was transfused another 2 units prbcs. her hct was 31 and she remained hemodynamically stable. an egd was performed which was unremarkable for a cause of her gi bleed. she was prepped for colonoscopy and transfused another unit of prbcs to maintain her hct greater than 30. colonoscopy performed the next day revealed hemorrhoids and a 5cm mass in the cecum concerning for malignancy. surgery was consulted and she was discharged with scheduled resection of the mass on after being evaluated by cardiology, pulmonology, and anesthesia. her hct was stable at ~30 and she remained hemodynamically stable during the remainder of her stay with no evidence of gi bleed. # nstemi: the patient presented with chest pain and shortness of breath at the osh, which improved with transfusion of prbcs and ivns in addition, her troponin was elevated, and peaked at 0.16. her ekg demonstrated st depression in the lateral leads which improved with administration of prbcs, which were felt to be due to demand ischemia. her hct was maintained at > 28 in the setting of her troponin leak and symptoms. after egd and colonscopy, she was evaluated by cardiology prior to discharge for or planning. she was started on metoprolol that was uptitrated to 25 to a goal heart rate of 60. she was also then started on asa 81 and pravastatin. her losartan was held while uptitrating metoprolol and then restarted prior to discharge. she will need cardiology evaluation after surgery with stress testing and possible catheterization is performed. chronic # htn: pt's home medications hctz and losartan were held initially. losartan was restarted prior to discharge and the patient was instructed to restart her hctz only after consulting with her pcp for blood pressure check. # copd: the pt was on albuterol nebs and advair while in hospital. she was instructed to restart her home nebs on discharge. she underwent pre-operative pulmonary evaluation prior to discharge. # osteoporosis: on yearly reclast. she was continued on her calcium and vitamin d supplementation. # dm: the patient was placed on an insulin sliding scale while in the hospital. transitional # f/u pulmonary nodules # f/u thyroid nodule # cardiology to cath after surgery medications on admission: hydrochlorothiazide 37.5mg daily losartan 25mg daily spiriva neb 1x daily brovana neb 2x daily pulmicort neb 1x daily albuterol neb prn reclast once yearly ca/vit d daily ibuprofen 600mg 1-2x/day trichromium/cinnamon daily for dm discharge medications: 1. brovana *nf* (arformoterol) 15 mcg/2 ml inhalation 2. cal-citrate *nf* (calcium citrate-vitamin d2) 250-100 mg-unit oral daily 3. losartan potassium 25 mg po daily 4. pulmicort *nf* (budesonide) 0.5 mg/2 ml inhalation daily 5. reclast *nf* (zoledronic acid-mannitol&water) 5 mg/100 ml injection yearly 6. tiotropium bromide 1 cap ih daily 7. aspirin 81 mg po daily rx *aspirin 81 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 8. metoprolol tartrate 25 mg po bid rx *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 9. pravastatin 20 mg po daily rx *pravastatin 20 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 10. albuterol 0.083% neb soln 1 neb ih q6h:prn wheezing, shortness of breath discharge disposition: home discharge diagnosis: primary: lower gastrointestinal bleed, colon neoplasm secondary: type ii diabetes, hypertension, demand ischemia, 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 caring for you during your recent admission to . you were admitted because of bleed from your gastrointestinal tract. you had become quite symptomatic from this, as evidenced by your worsened shortness of breath. we believe that your low blood counts caused some strain on your heart. you were given several units of red blood cells to improve your symptoms. a colonoscopy and esophagogastroduodenoscopy (egd) were performed. egd showed no cause for your bleeding. however, the colonoscopy showed a 5 centimeter mass in the right side of your colon as well as hemorrhoids, both of which were likely to have contributed to your bleeding. it is felt that resection of this mass would be an appropriate means of treatment. we still do not have the pathology results from the biopsy taken from the colon mass. however, these will be followed up in the outpatient setting with gastroenterology and colorectal surgery. plans for your future management will be made at that time. because of the strain caused on your heart, you will also be started on three new medications, a statin for your cholesterol, aspirin, and metoprolol to control your heart rate. all of your other medications should remain the same. followup instructions: name:, g. address: , , phone: fax: md Procedure: Other endoscopy of small intestine Closed [endoscopic] biopsy of large intestine Other irrigation of (naso-)gastric tube Diagnoses: Subendocardial infarction, initial episode of care Unspecified essential hypertension Acute posthemorrhagic anemia 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 Diaphragmatic hernia without mention of obstruction or gangrene Osteoporosis, unspecified Osteoarthrosis, unspecified whether generalized or localized, site unspecified Other diseases of lung, not elsewhere classified Malignant neoplasm of cecum Hemorrhage of gastrointestinal tract, unspecified Spinal stenosis, unspecified region Leukocytosis, unspecified Stricture and stenosis of esophagus Intestinal disaccharidase deficiencies and disaccharide malabsorption Internal hemorrhoids without mention of complication

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sepsis major surgical or invasive procedure: none history of present illness: 45m h/o remote mrsa abscess transferred here with sepsis after suffering complications of perforated appy. initially presented to presented to on with perforated appendicitis where he underwent lap appendectomy complicated by abscess which was later drained by ir on at . he was also treated with antibiotics. . two weeks ago, he was rescanned with evidence of a 6 x 3.3 cm abscess in the rlq. a residual collection was identified and drained again. he was admitted for sepsis and treated with another course of antibiotics, discharged on 2 weeks of augmentin. he had been feeling well, tolerating pos, and without nausea, vomiting, or abdominal pain. . yesterday at 1pm, he was scheduled for a repeat interval ct scan which was apparently reassuring but was not officially read. he returned home, however, and began having chills, mild transient chest pain, nausea and anxiety for which he returned to hospital. . at the outside hospital, he was found to be hypotensive to sbp of 70s and tachycardic to 160s. he was started on a norepinephrine drip with improvement in sbp to 110s. transported by helicopter to ed. . in the ed, vitals tm/tc 104/101 rectally, 115/68, 88, 12, 95% ra. labs notable for wbc 24.7 with 23% bands, lactate 1.8, hco3 19, normal lfts, inr 1.4, ck 133, ckmb 13 (index 9.8), tnt 0.29. u/a negative, blood and urine cultures sent. ecg with twf ii, twi iii. ct abd/pelvis with inflammation about appy site but no drainable fluid collection and no free air. central venous line placed, continued on levophed. given vanco, levoflox, ceftriaxone, flagyl. surgery consulted and based on imaging and benign abdomen, recommended non-surgical management at present. cardiology was called and thought this was demand ischemia. he was admitted to micu for sepsis. . ros: denies pain. he denies fever, and has had diarrhea (2-3x/day) which he relates to being on antibiotics. while he was off antibiotics, his diarrhea resolved. denies dyspnea, orthopnea, pnd. able to walk independently. past medical history: h/o mrsa abscess on arm () s/p appy c/b abscess, s/p ir drainage x 2 social history: works for furniture warehouse. ppd smoker from age 18-present. denies etoh. family history: father died of a "blood clot" after a traumatic injury, mother healthy, 3 sibs healthy, 3 children healthy. no family history of ibd. physical exam: on admission to the micu, exam: t 98.4 hr 88 bp 129/67 rr 21 sao2 98% ra general: ill appearing, speaks in full sentences, tearful at times, breathing comfortably on ra heent: perrl, eomi, anicteric sclera, conjunctivae pink, very dry mucous membranes neck: supple, trachea midline, no thyromegaly or masses, no lad, right ij in place c/d/i cardiac: rrr, s1s2 normal, no m/r/g, no jvd pulmonary: ctab anterior back: patient declines back exam abdomen: +bs, soft, nontender, nondistended, no hsm, well-healed laproscopic scars extremities: warm, 1+ dp pulses bilaterally, no edema neuro: a&ox3, speech clear and logical, cnii-xii intact, moves all extremities rectal: guaiac negative in the ed . on discharge: vs t 98.3, bp 128/76, hr 84, rr 20, 94% ra pt was well-appearing, mmm, abdomen benign, otherwise unchanged. pertinent results: labs : 10:20pm blood wbc-24.7* rbc-4.21* hgb-11.5* hct-33.9* mcv-81* mch-27.4 mchc-34.0 rdw-16.4* plt ct-644* 10:20pm blood neuts-70 bands-23* lymphs-2* monos-3 eos-0 baso-0 atyps-0 metas-2* myelos-0 10:20pm blood pt-16.0* ptt-33.5 inr(pt)-1.4* 10:20pm blood glucose-193* urean-9 creat-1.2 na-135 k-4.2 cl-108 hco3-19* angap-12 10:20pm blood alt-11 ast-14 ck(cpk)-133 alkphos-61 totbili-0.5 10:20pm blood lipase-20 10:20pm blood ck-mb-13* mb indx-9.8* 10:20pm blood ctropnt-0.29* 10:20pm blood cortsol-27.9* 11:01pm blood lactate-1.8 10:20pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 10:20pm urine color-yellow appear-clear sp -1.036* . labs : 05:45am blood wbc-22.6* rbc-4.18* hgb-11.2* hct-34.4* mcv-82 mch-26.7* mchc-32.4 rdw-15.4 plt ct-596* 05:45am blood ck-mb-14* mb indx-13.3* ctropnt-0.27* 11:41am blood ck-mb-notdone ctropnt-0.18* 05:45am blood albumin-2.1* calcium-7.0* phos-2.6* mg-2.6 cholest-73 05:45am blood triglyc-93 hdl-11 chol/hd-6.6 ldlcalc-43 12:14am blood lactate-1.8 11:41am blood crp-120.1* . labs : 04:10am blood wbc-11.5* rbc-4.03* hgb-10.8* hct-32.5* mcv-81* mch-26.8* mchc-33.2 rdw-15.0 plt ct-391 04:10am blood neuts-51 bands-3 lymphs-8* monos-5 eos-32* baso-1 atyps-0 metas-0 myelos-0 04:10am blood glucose-84 urean-5* creat-1.0 na-139 k-4.1 cl-109* hco3-24 angap-10 . labs : 05:31am blood wbc-11.3* rbc-4.15* hgb-10.9* hct-34.0* mcv-82 mch-26.3* mchc-32.1 rdw-15.3 plt ct-409 05:31am blood neuts-31* bands-1 lymphs-26 monos-4 eos-38* baso-0 atyps-0 metas-0 myelos-0 07:50am blood wbc-11.8* rbc-4.39* hgb-11.5* hct-35.6* mcv-81* mch-26.2* mchc-32.3 rdw-15.4 plt ct-428 07:50am blood neuts-44.6* bands-0 lymphs-17.1* monos-2.1 eos-36.0* baso-0.2 . cultures: blood cultures: no growth to date urine cultures: final no growth stool: c. diff negative stool: c. diff negative stool: c. diff negative ct abdomen and pelvis (iv contrast): there are small bilateral pleural effusions with associated atelectasis. atelectasis within the lingula is additionally noted. an amorphous area low attenuation is identified within segment ivb of the liver. the liver is otherwise unremarkable. the gallbladder, spleen, pancreas, adrenal glands, and left kidney appear within normal limits. the kidneys enhance symmetrically and excrete contrast normally. a 3-cm low- attenuation lesion at the lower pole of the right kidney is consistent with a simple cyst. diffuse atherosclerotic disease of the infrarenal abdominal aorta is evident. there is thickening of the cecum and significant pericecal stranding of mesenteric fat. surgical clips at the site of appendectomy are noted. no evidence of abscess or loculated fluid. a small amount of free fluid in this area, which also tracks down into the pelvis is seen. although the distal ileum is not well distended with oral contrast, there is a suggestion of bowel wall thickening/edema and stranding of the surrounding mesenteric fat. no organized fluid collection is evident, however. there is no evidence of bowel obstruction as contrast has passed through to the rectum. there is no free air within the abdomen. although the colon is not distended, there is a suggestion of diffuse colonic wall thickening. . ct of the pelvis with iv contrast: the rectum, sigmoid colon, intrapelvic loops of small bowel are unremarkable. a foley balloon is present within a decompressed bladder. a small amount of free fluid is evident within the pelvis. small, bilateral fat-containing inguinal hernias are evident. osseous structures: there are no suspicious lytic or blastic lesions. impression: 1. inflammatory process appears to be centered in the ileocecal area at the site of recent appendectomy. no organized or drainable intra-abdominal fluid collection. assessment is somewhat limited by lack of distal ileal distention with oral contrast. a small amount of free fluid and scattered subjacent lymph nodes are additionally evident. 2. equivocal diffuse colonic wall thickening. this finding raises the possibility of colitis and and infectious process such as c. difficile should be considered. 3. small bilateral pleural effusions with associated atelectasis. . echocardiogram : the left atrium and right atrium are normal in cavity size. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with focal akinesis of the basal inferolateral wall and hypokinesis of the basal half of the inferior wall. there is minimal hypokinesis of the remaining segments (lvef = 45 %). the estimated cardiac index is normal (>=2.5l/min/m2). 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: mild regional left ventricular systolic dysfunction c/w ischemia. left pleural effusion. . ecg : normal sinus rhythm with t-wave inversions in leads iii, avf . pending studies at time of discharge: final blood cultures from (no growth to date) stool cultures, o&p from brief hospital course: 1. sepsis: mr. was transferred from an outside hospital with hypotension, on levophed with an elevated wbc count of 22.6 on admission. the source of infection was not clear on admission and differential included infection from recurrent abscesses at appendectomy site or c. diff colitis. other etiology considered was reaction to ct contrast. was started on vanocmycin, zosyn and flagyl in the micu. he remained hemodynamically stable and afebrile and levophed was stopped on the day of transfer for map>65, svo2 72, cvp 6 and good urine output. ct showed inflammation prior appendectomy site without fluid collection. surgery was consulted and did not recommend surgery. gastroenterology was consulted and recommended 48 hours of iv antibiotics for presumed gi infection, then 3 weeks of po antibiotics. cultures were obtained on from hospital and showed no growth to date of blood or urine cultures. blood and urine cultures collected at showed no growth to date. c. diff x 3 were negative. the patient continued to do well and was trasnferred to the general medical floor on . he was continued on iv antibiotics and then changed to po antibiotics on . he was put on ciprofloxacin 500mg po bid and metronidazole 500mg po tid and was discharged with 16 more days of antibiotics. he will follow-up with his pcp 1 week. another possible etiology for his symptoms that was considered was anaphylaxis from po contrast from the ct scan, although this was less likely given that he has had po contrast in the past without problems. we recommended that he see an allergist as an outpatient to assess the possibility of an allergic reaction to po contrast. . 2. nstemi the patient was found to have elevated cardiac enzymes with a ck of 133, ckmb 19, troponin t 0.29 and t-wave inversions in leads iii and avl. cardiology was called and thought this was likely rate-related demand ischemia in the setting of tachycardia due to sepsis physiology. cardiac enzymes trended down and follow-up ecgs showed no change. the patient's tachycardia improved with iv fluids and antibiotics. he was asymptomatic during his admission. he was put on telemetry and had no events or arrythmias. an echocardiogram showed global reduced function, ef 45% and focal akinesis of basal inferior wall. aspirin 325mg po qday and metoprolol 12.5mg po bid were started for nstemi. cardiology did not recommend heparin or anti-platelet agents. cardiology recommended a follow-up echo and cardiologist appointment within 4 weeks after his acute illness had resolved. the patient will have this scheduled with his primary care doctor. he remained asymptomatic with no chest pain or signs of clinical heart failure. . 3. eosinophilia the patient's wbcs trended down from admission from 22.6 to 11.8. he had 23% bands on admission which resolved by discharge. his eosinophil count was 0 on admission, however on he had 32% eosinophils, on had 38% eosinophils, and on had 36% eosinophils. this corresponds to an absolute eosinophil count of 3680 on , 4294 on , and 4248 on . he had no signs of drug reaction, no fevers, skin rashes or other symptoms. his diarrhea had improved over the course of admission but was still having bowel movements per day. his stool was checked for c. diff and was negative x 3. ova and parasites and fecal stool cultures were pending at the time of discharge. it was recommended that he see an allergist for discussion and testing for reaction to po contrast from the ct scan. . 4. diarrhea most likely etiology is antibiotic-associated as the patient has been on antibiotics off and on for the past several weeks. his diarrhea was at times watery, but improved through admission and was described as loose stool at the time of discharge. clostridium difficile was checked x 3 and was negative. he was discharged with cipro and flagyl for his antibiotic regimen. he will follow-up with his pcp with any further problems. his final stool cultures are still pending at the time of discharge. . 5. anxiety the patient was anxious during his hospitalization regarding his medical condition and etiology of his sepsis. he was given ativan 0.5mg prn for anxiety symptoms. he was given trazodone 25mg po qhs to help with sleep. . 6. prophylaxis mr. was given sc heparin for dvt prophylaxis. he was able to tolerate a regular diet on . . his symptoms improved and he was discharged with close pcp and instructions to follow-up with cardiology as arranged by his pcp. was also recommended to see an allergist on discharge for follow-up of this episode as a potential reaction to po contrast from the ct scan. medications on admission: augmentin x 2 weeks (approx day 7) discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 2. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 16 days. disp:*48 tablet(s)* refills:*0* 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 16 days. disp:*32 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: 1. sepsis secondary diagnosis: 2. non-st elevation mycardial infarction 3. eosinophilia discharge condition: afebrile, hemodynamically stable, good condition discharge instructions: you were admitted to the hospital with low blood pressure and septic shock after having a perforated appendicitis several weeks ago. all your blood cultures were negative. you were admitted to the intensive care unit and improved dramatically on antibiotics. you were initially put on intravenous antibiotics and these were changed to oral antibiotics after 72 hours. you experienced some chest pain and blood tests showed that was some damange to your heart which was likely from the low blood pressure. you had an echocardiogram which showed some reduced function of the heart. you should see a cardiologist as an outpatient as arranged by your primary care doctor and have another echocardiogram in 1 month to reassess your heart. you had a rise in your white blood cell count associated with the sepsis. your eosinophils, a type of white blood cell, was still elevated on discharge. you should have your blood checked in 1 week to assess your white blood count and differential. this will be arranged by your primary care doctor. you should continue to take the antibiotics ciprofloxacin and metronidazole as prescribed for the next 16 days, even if you are feeling well. you were started on metoprolol 12.5mg by mouth twice a day to help your heart. you should continue to take aspirin. you should follow-up with your primary care doctor next week. your primary care doctor will arrange for you to see a cardiologist and have a repeat echocardiogram within 1 month. you should call your doctor or come to the emergency room for any fevers > 100, chills, night sweats, cough, shortness of breath, chest pain or pressure, numbness in the arm or jaw, abdominal pain or bloating, nausea or vomiting, swelling in the legs, skin rashes, or any other symptoms that concern you. followup instructions: primary care doctor: dr. at , , ma appointment: wednesday, at 10:10 am please have your labs drawn at this visit to check your cbc and differential. please follow-up with a cardiologist and repeat echocardiogram in 1 month as arranged by your primary care doctor. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Subendocardial infarction, initial episode of care Tobacco use disorder Unspecified pleural effusion Severe sepsis Pulmonary collapse Anxiety state, unspecified Septic shock Diarrhea Accidents occurring in residential institution Methicillin resistant Staphylococcus aureus septicemia Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) Unspecified antibiotic causing adverse effects in therapeutic use

allergies: no known allergies / adverse drug reactions attending: chief complaint: hypotension major surgical or invasive procedure: none history of present illness: 53f with a history of gastric bypass and metastatic carcinosarcoma of the uterus s/p chemotherapy with /taxol, most recent treatment six weeks ago, who presented to about one month ago and was diagnosed with spontaneous splenic rupture. she is now s/p exploratory laparotomy and splenectomy. she was reviewing the pathology slides today with her oncologist in clinic and was told that there was evidence of metastatic disease in the spleen. they checked her blood pressure and noted systolics in the 80's so transported her to the ed. in the ed she complained of mild luq pain. fast was performed and noted to be positive so surgery was consulted. past medical history: oncologic history: mrs. is a 53-year-old woman who noted some vaginal discharge and followed up with her gynecologist when the discharge became bloody. she underwent endometrial biopsy, which revealed high-grade malignant tumor concerning for carcinosarcoma and a pelvic ultrasound revealing an echogenic area within the cavity measuring 4 x 4 x 4 cm. she was referred to dr. . -- on , she underwent robotic assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy, bilateral pelvic and paraaortic lymph node dissection and washing. pathology revealed carcinosarcoma (malignant mixed mullerian tumor) and cervix with squamous metaplasia. tumor 5.5 x 3.5 x 2.5 cm grade 3. cytology of washings negative. pt1a (stage ia) 10% myometrial invasion, cervix negative, ovaries and fallopian tubes negative, tn0, 0 out of 9 pelvic lymph nodes, and 0 out of 4 paraaortic lymph nodes positive for metastasis. no definitive foci of lymphovascular invasion identified. - on , started carboplatin auc 5 and taxol 175 for cycle 1 which was complicated by taxol-associated myalgias and orthostatic hypotension (brief hospitalization, without loc). - on seen by dr. regarding vaginal spotting, thought to be secondary to healing at suture site. - on , continued auc 5 and decrease taxol to 150mg/m2 for cycle 2 for c1d15, anc 730 - on received cycle 3 4 and taxol to 135mg/m2 with neulasta on day 3 after deferred 4 week due to persistent neutropenia - c4d1 taxol/ - c5d1 /taxol past medical history: hypertension, osteoarthritis, history of urate and calcium stones, status post multiple lithotripsy, thyroid cancer in with recurrence status post radical neck dissection (of note, she had an mssa surgical wound infection in the setting of her radical neck dissection) and complicated by thoracic duct injury status post clip placement, negative colonoscopy (history of polypectomy in ). past surgical history: gastric bypass in at with 135-pound weight loss (a 40-pound weight gain since menopause), thyroidectomy (), radical neck dissection for recurrent disease (), left total knee replacement in complicated by bacteremia and joint infection with recurrence after six weeks of antibiotics resulting in spacer placement and replacement of the joint again in , tonsillectomy at age 5, carpal tunnel bilaterally in , cholecystectomy, umbilical hernia repair social history: denies tobacco and drug use. married and lives with her husband. she works in retail and has 6 grandchildren family history: noncontributory physical exam: on admission: vitals: 98.1 74 94/64 16 97 ra gen: a&o, nad heent: no scleral icterus, mucus membranes moist cv: rrr, no m/g/r pulm: clear to auscultation b/l, no w/r/r abd: soft, mildly tender to palpation in the luq, no hernias or masses, well-healed midline incision ext: no le edema, le warm and well perfused pertinent results: cxr : new left-sided effusion with possible underlying atelectasis or airspace disease ct abd/pel : enlarging complex ascites, hemorrhage without clear source of bleed; rapid progressive metastatic disease in pelvis, liver, splenectomy bed, stomach, mesentery, peritoneum cta : no active extravasation, loculated fluid, large complex masses in splenectomy bed, pelvis, omentum, peritoneum abdominal xr : no e/o obstruction, contrast in colon, pleural effusion cxr : substantial l pleural effusion, compressive atelectasis, low lung volumes cxr : no ptx, substantial decrease in l pleural effusion gib study : no evidence of active bleeding within the splenic resection bed cta : acute pulmonary emboli in rll and rul, new nodular opacity in r apex concerning for early pna. extensive metastatic dz in abd, perihepatic ascites cxr : picc in place, l effusion returned cxr : l effusion brief hospital course: ms. is a 53yo woman with a history of metastatic uterine carcinosarcoma who was admitted from the emergency room to the icu for hypotension secondary to hemorrhage into splenectomy bed lesion. she was then transferred to the gynecologic oncology service on hospital day 2. she was discharged on home hospice on hospital day 10. her hospital course was as follows: # code status: ms. was initially full code and all the measures below were taken. however after two family meetings, her daughter, was named as her healthcare proxy and her code status was changed to comfort measures only on . she was evaluated by hospice and admitted into inpatient hospice. it was decided that she would be receive a fentanyl patch daily and oxycodone as needed for breakthrough pain. her picc line and foley catheter were left in place. her family received teaching about managing her indwelling catheter prior to discharge. # hemoperitoneum: in the icu, she was transfused a total of 3 units of prbcs with hct increase from 25.1 to 32.4. due to concern for bleeding from her splenectomy bed, interventional radiology was consulted and recommended a repeat ct scan in arterial phase to identify potential vessels to embolize. on hospital day 2, after receiving renal-protective bicarb infusion given her cr 1.5, a cta abdomen showed no active extravasation. since a repeat hct was stable at 32.4 and 34.1, she was then transferred to the gynecologic oncology service where hct trended downwards overnight from 34.1 to 30.4 to a nadir of 27. as she was also tachycardic in the 100s and oliguric (10-20cc/hr), she was transfused 2 additional units of prbcs on hospital day 3. during transfusion, her tachycardia improved to the 90s and her urine output improved. her post-transfusion hct was appropriate at 32. however, her hematocrit still continued to trend downwards and per acs recommendations, we did order a tagged red cell scan, which showed no evidence of an acute bleed. we therefore transfused her 2 more units of blood for a hct of 25.7. her hct did not show an appropriate rise and was 27.8 and she received another unit of blood. labs were discontinued after her code status changed. # acute kidney injury: given her creatinine of 1.5 on admission, she received renal-protective bicarb infusion prior to her cta abdomen. after her cta abdomen, her creatinine increased from 1.1 to 1.8, and she was oliguric. a fena was 0.3% consistent with pre-renal acute kidney injury, likely caused by a combination of iv contrast and anemia. her urine output improved slightly and her creatinine decreased to 1.7 after her blood transfusion on hospital day 3. however, she continued to be oliguric (10-15cc/hr) on hospital day 4 with creatinine of 1.8, so she was bolused 500cc crystalloid and her urine output improved slightly. her urine output continued to average 10-20cc during the course of her stay. however, we stopped giving her boluses because there was concern that the fluids were adding to her left lung pleural effusion. urine output monitoring was stopped and her foley discontinued after her code status was changed. # pleural effusion: chest x-ray in the emergency room showed a new left-sided pleural effusion. she was maintained on nasal canula oxygen with acceptable oxygen saturations. given the inability to wean her from oxygen and dyspnea on exertion on hospital day 4, a repeat chest x-ray was performed which demonstrated a substantial l pleural effusion, compressive atelectasis, and low lung volumes. given her symptoms, interventional pulmonology was consulted. on hospital day 5, she underwent an uncomplicated left thoracentesis by interventional pulmonology, with 300cc of fluid removed. post-procedure chest x-ray desmonstrated no evidence of pneumothorax. after the thoracentesis, we attempted to wean her off the oxygen on hospital day 6. however, she had a desaturation to 85%/ra prompting an evaluation with ct scan to rule out a pulmonary embolism. given her poor kidney function and creatinine of 1.8, we pre-hydrated her with sodium bicarbonate to prevent worsening nephropathy. her cta showed acute pulmonary emboli in the right lung vasculature, new nodular opacity in righ apex concerning for early pneumonia. extensive metastatic disease in her abdomen and perihepatic ascites. she continued to require oxygen and was continued on this for comfort. # pulmonary embolism: lovenox 80mg sc daily was started after diagnosis of pulmonary embolism. it was discontinued after her code status was changed. # right apex pneumonia: given the fact that ms. was newly diagnosed with this while in house, it was treated as a hospital acquired infection with intravenous vancomycin, cefepime and levofloxacin. she did have a picc line placed because of her antibiotic requirement and for blood draws. the antibiotics were discontinued per her code status. # nausea: on hospital day 3, she had persistent nausea, for which she received iv zofran, phenergan, and ativan. her nausea then improved and she was able to tolerate small amounts of a regular diet. # e. coli uti: in the icu, she was started on bactrim due to a urinalysis with positive nitrites. on hospital day 4, her final urine culture returned showing e.coli resistant to bactrim. she was then started on ceftriaxone for her urinary tract infection. her final blood cultures were negative and her ceftriaxone was discontinued on # metastatic uterine carcinosarcoma: in the emergency room a ct abdomen/pelvis demonstrated enlarging complex ascites, hemorrhage without a clear source of bleeding, and rapid progression of metastic disease in pelvis, liver, splenectomy bed, stomach, mesentery, and peritoneum compared to a ct scan performed a week prior. she was seen by the atrius palliative care consult on hospital day 2, who provided recommendations for pain control. on hospital day 5, a team meeting with representatives from the gynecologic oncology, medical oncology, and palliative care teams met with the patient and her family and we discussed the plan of care for her. patient wishes to remain full code. she was told that the prognosis of her disease was not good and palliative chemotherapy with doxil outpatient was discussed once the patient becomes stable and is discharged from the hospital. however, after the 2nd family meeting, it became apparent to the patient and her family that she would not get better and wold not be a candidate for palliative chemotherapy. her code status was therefore changed to comfort measures only. # 1st degree heart block: while in the icu, her troponin increased from 0.05 to 0.18. ekg showed 1st degree av block without any st changes. serial troponins decreased to 0.06 and 0.03 and cpks were within normal limits. she was maintained on telemetry on the floor with no events. telemetry was therefore discontinued. # prophylaxis: given her bleed risk, she did not receive subcutaneous heparin dvt prophylaxis. she did have sequential compression devices and received intravenous pepcide for stress ulcer prophylaxis. she also received an aggressive bowel regimen for constipation and this has continued for comfort measures. medications on admission: allopurinol 100mg daily, levothyroxine 62.5mg daily, ativan 0.5 q8 prn, paxil 80mg daily, mvi, vitamin b6 discharge medications: 1. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 2. paroxetine hcl 30 mg tablet sig: two (2) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 4. senna 8.6 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for constipation. disp:*30 tablet(s)* refills:*0* 5. oxycodone 5 mg/5 ml solution sig: one (1) po q3h (every 3 hours) as needed for pain. disp:*10 bottle* refills:*0* 6. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. disp:*20 tablet(s)* refills:*0* 7. fentanyl 75 mcg/hr patch 72 hr sig: one (1) transdermal q72h (every 72 hours). disp:*20 * refills:*0* 8. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for oral discomfort. 9. oxygen please provide oxygen with flow of 2l 10. prochlorperazine 25 mg suppository sig: one (1) suppository rectal q12h (every 12 hours) as needed for nausea. disp:*30 suppository(s)* refills:*1* 11. lorazepam 2 mg/ml concentrate sig: 0.5-1 mg po every six (6) hours. disp:*30 ml* refills:*2* discharge disposition: home with service facility: hospice and palliative care discharge diagnosis: metastatic uterine carcinosarcoma pulmonary hospital acquired pneumonia coagulopathy urinary tract infection concern for intraabdominal bleed. acute renal failure. discharge condition: level of consciousness: lethargic but arousable. mental status: clear and coherent. activity status: bedbound. discharge instructions: you were admitted to the gynecology oncology service for concern for bleeding from your splenectomy bed and you were found to have metastatic uterine carcinosarcoma. *) please take your pain medication as scheduled. *) please continue your bowel regimen *) please continue oxygen for comfort followup instructions: none do 16-adl Procedure: Venous catheterization, not elsewhere classified Thoracentesis Diagnoses: Pneumonia, organism unspecified Malignant neoplasm of liver, secondary Unspecified pleural effusion Urinary tract infection, site not specified Unspecified essential hypertension Acute posthemorrhagic anemia Acute kidney failure, unspecified Depressive disorder, not elsewhere classified Candidiasis of mouth Pulmonary collapse Hemorrhage complicating a procedure Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified coagulation defects Knee joint replacement Other pulmonary embolism and infarction Personal history of antineoplastic chemotherapy Hemoperitoneum (nontraumatic) First degree atrioventricular block Secondary malignant neoplasm of other digestive organs and spleen Secondary malignant neoplasm of retroperitoneum and peritoneum Bariatric surgery status Postsurgical hypothyroidism Personal history of malignant neoplasm of thyroid Other and unspecified Escherichia coli [E. coli] Malignant neoplasm of uterus, part unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: respiratory distress major surgical or invasive procedure: endoscopic retrograde cholangiopancreatography endotracheal intubation peripherally inserted central catheter placement on history of present illness: ms. is a 64yo f with history of atrial fibrillation on warfarin, mild mental retardation and history of cva with left sided paralysis who was transferred to for urgent in setting of elevated liver enzymes and concern for cholangitis. patient was tachypneic to 20-30s while awaiting and intubated to protect her airway for the procedure. she became hypoxic to 70s% during induction and remained intubated after the procedure. per records, patient presented to on with epigastric pain. she was found to have elevated lfts (initially only mildly elevated, see below for details) and had an abdominal ultrasound and ct which showed possible stones in the gallbladder without common bile duct dilation. she also was diagnosed with a uti but had a negative urine culture. while at the osh, she had a cxr on that showed cardiomegaly without pulmonary edema and questionable left lower lung atelectasis. she also had a nuclear medicine cardiology scan with ef noted to be 90% and "technically it was not ideal" but no evidence of ischemia. there is also an echo report that comments on normal ef, moderately dilated la, evidence of asd repair although "not clear if patch is still intact or not", moderate mr, moderate tr and rvsp is 51mmhg. patient received two doses of 5mg vitamin k the day prior to transfer to . she was transferred to for before a possible cholcystectomy. at , she underwent with biliary stenting (no sphincteromy given inr 2.0) that was unremarkable without evidence of cholangitis or biliary obstruction. she received ceftriaxone 1g iv and ampicillin 2g iv during . patient remained intubated after the procedure and was transferred to the for further management. in the , she is intubated and sedated. she squeezes right hand to command but does not squeeze on left. she does not open eyes to command. past medical history: mental retardation history of embolic cva, now with left hemiplegia hypertension depression chronic chf of unknown etiology h/o alcohol abuse, sober since s/p asd repair social history: she lives in a nursing home. patient quit smoking years ago and quit drinking alcohol in . no illicit drug use. she is wheelchair bound at home. family history: unable to obtain. physical exam: admission: vs: 99.2 65 105/55 16 94%psv fio2 0.4 general: intubated and sedated heent: sclera anicteric, mmm, et in mouth neck: supple, jvp elevated to angle of mandible, no lad lungs: clear to auscultation bilaterally anteriorly with coarse vent sounds, no wheezes, rales, rhonchi appreciated cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, no grimace to palpation, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: squeezes hand on right to command, not on left; will not open eyes or follow other commands discharge: vs: tmax 98.1, tcurrent 97.9, bp 154/97, hr 63, rr 25, o2 sat 94% ra gen: a+ox3 heent: sclerae anicteric, perrl, eomi neck: supple, jvd not appreciated no lad lungs: bibasilar rales, no wheezes or rhonchi cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops abd: soft, non-tender, non-distended, bowel sounds present ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. trace peripheral edema neuro: limited by cognitive impairment (mild mr), moving ble, lue contracted (stable), moving rue, face symmetric, cn ii-xii w/o focal deficit pertinent results: admission labs: 01:12pm blood wbc-7.0 rbc-3.68* hgb-11.6* hct-34.1* mcv-93 mch-31.6 mchc-34.0 rdw-14.2 plt ct-185 04:15am blood pt-18.1* ptt-29.6 inr(pt)-1.6* 01:12pm blood glucose-140* urean-17 creat-0.8 na-143 k-3.3 cl-104 hco3-26 01:12pm blood alt-165* ast-85* alkphos-222* amylase-49 totbili-1.9* 01:12pm blood lipase-40 01:12pm blood probnp-3344* 01:12pm blood calcium-8.9 phos-2.9 mg-1.7 12:43pm blood type-art po2-158* pco2-43 ph-7.39 caltco2-27 base xs-1 12:43pm blood lactate-1.2 11:06pm blood o2 sat-99 discharge labs: 04:02am blood wbc-5.4 rbc-3.60* hgb-11.2* hct-33.9* mcv-94 mch-31.2 mchc-33.1 rdw-14.2 plt ct-179 04:02am blood pt-16.4* ptt-29.1 inr(pt)-1.5* 04:02am blood glucose-142* urean-11 creat-0.7 na-139 k-3.5 cl-103 hco3-31 angap-9 04:02am blood calcium-9.0 phos-2.5* mg-2.0 microbiology: 4:16 am sputum (source: endotracheal) gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): no growth. 4:15 am urine (source: catheter) urine culture (final ): no growth. 4:16 am blood culture (source: venipuncture) blood culture, routine (pending): 1:12 pm mrsa screen (source: nasal swab) mrsa screen (final ): no mrsa isolated. imaging: transthoracic echocardiogram (tte) impression: surgical repair of a probable ostium secundum asd with residual left-to-right interatrial shunting. dilated right ventricle with preserved systolic function and mild pulmonary hypertension. normal left ventricular systolic function. recommend a cardiac mri for more precise definition of congenital anatomic abnormalities and quantification of intracardiac shunting. findings discussed with dr. at 1410 hours on the day of the study. images impression: placement of common bile duct stent. normal appearing bile ducts. brief hospital course: ms. is a 64yo f with history of mental retardation, atrial fibrillation and cva with left hemiplegia who was transferred to for and intubated for respiratory distress likely secondary to volume overload & pneumonia; successfully extubated on . # respiratory distress: patient was tachypneic to 20-30s while awaiting and intubated to protect her airway for the procedure. she became hypoxic to 70s% during induction and remained intubated after the procedure. respiratory distress likely caused by chf exacerbation secondary to volume overload, in addition to healthcare-associated pneumonia (bnp 3344). cxr was concerning for infiltrate or pulmonary edema. echo with ef >55% with mild pulmonary hypertension. treated with vancomycin and cefepime for hcap with a planned 8-day course (d1=, last day ). she was treated with iv lasix for her volume overload. lasix was held on due to agressive diuresis, but redosed on the morning of discharge based on exam and repeat chest x-ray. she should resume her usual home dose of oral lasix on . # lft abnormalities: her was unremarkable and did not show any frank pus from the biliary system s/p stent placement. will need repeat for stent removal in 2 months (appointment has already been scheduled). lfts trended down during admission. # atrial fibrillation and h/o cva: coumadin was restarted when it was clear that the patient would not be undergoing any other procedure during this admission. there had been a question of whether she would be having a cholecystectomy but per the osh this was not planned or necessary. increased dose to 5mg from 2.5mg for subtherapeutic inr. she will need close monitoring of her inr and adjustments of coumadin dosing until it stabilizes. # hypertension: lisinopril was initially held as patient was being diuresed with iv lasix. after diuresis was stopped, lisinopril was restarted at home dose. # urinary tract infection: final urine culture negative. osh records report uti. continued her on cefepime for biliary tract infection which was adequate treatment for an uncomplicated uti. # prophylaxis: patient received heparin products during this admission. # code status: presumed full code. medications on admission: acetaminophen 650mg qhs acetaminophen 650mg q4-6 prn dulcolax suppository 10mg pr daily prn refresh tear 1 gtt ou 4xd celexa 40mg daily colace 100mg flonase 2 sprays each nostril daily lasix 40mg daily lisinopril 10mg qdaily milk of magnesia 30 ml daily prn constipation mvi mylanta 30 ml q6 prn gastric upset coumadin 2.5mg daily lorazepam 1mg q6 prn anxiety discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever: do not exceed 4 grams/day. 2. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 3. refresh tears 0.5 % drops sig: one (1) drop in each eye ophthalmic four times a day. 4. flonase 50 mcg/actuation spray, suspension sig: two (2) sprays in each nostril nasal once a day. 5. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day: hold for loose stools. 6. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: adjust dose based on inr checks every other day. 7. 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. 8. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 9. cefepime 2 gram recon soln sig: two (2) grams injection q12h (every 12 hours) for 3 days. disp:*12 grams* refills:*0* 10. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 11. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 3 days. disp:*6 grams* refills:*0* 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal once a day: hold for loose stools. 13. furosemide 40 mg tablet sig: one (1) tablet po once a day. 14. milk of magnesia 400 mg/5 ml suspension sig: five (5) ml po once a day as needed for constipation. 15. mylanta 200-200-20 mg/5 ml suspension sig: ml po every six (6) hours as needed for gastric upset. 16. lorazepam 1 mg tablet sig: one (1) tablet po every six (6) hours as needed for anxiety: this medication can make you sleepy. do no drink alcohol, drive or operate machinery after taking this medication. 17. acetaminophen 325 mg tablet sig: two (2) tablet po at bedtime. 18. outpatient lab work please check inr every other day until level is stable between on three checks and patient has completed antibiotic course. please fax results to dr. . 19. outpatient lab work chem7 on . please fax results to dr. . discharge disposition: extended care facility: manor extended care facility - discharge diagnosis: primary diagnoses: 1. hypoxic respiratory failure secondary to healthcare-associated pneumonia 2. pulmonary edema 3. liver function test elevations secondary to presumed cholangitis with biliary stent placement secondary diagnoses: hypertension mental retardation chronic congestive heart failure urinary tract infection discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: 1. you were transfered from to have a procedure called an . you had a biliary stent placed during this procedure and will need a repeat in 2 months as below. your inr should be less than 1.5 at that time if possible. 2. you were admitted to the intensive care unit after your for difficulty breathing. you required a breathing tube, also known as intubation. we removed the tube on . you were treated for healthcare-associated pneumonia with antibiotics and we gave you medicine to help remove fluid from your body. you will need to continue taking antibiotics through . 3. you urine cultures were negative, but we had received a report that they were positive at . we treated this with the same antibiotics that we used to treat your pneumonia. 4. we restarted your coumadin at a higher dose because your inr was too low. you will need to have your inr checked every other day and you coumadin dose adjusted as needed. the antibiotics may be affecting your coumadin dosing. 5. we made the following changes to your medications: started cefepime (last dose on ) started vancomycin (last dose on ) increased warfarin dose to 5mg (adjust as necessary based on inr) started heparin flush (10 units/ml) 2 ml iv prn line flush picc 6. it is important that you take all of your medications as prescribed. 7. it is important that you follow up with your primary care doctor. followup instructions: date/time: at 12:00pm provider: 2 (st-4) gi rooms provider: , md phone: it is important that you follow up with your primary doctor (dr. ) at nursing home (tel: ). Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Endoscopic insertion of stent (tube) into bile duct Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Other chronic pulmonary heart diseases Acute respiratory failure Long-term (current) use of anticoagulants Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Acute systolic heart failure Cholangitis Mild intellectual disabilities

allergies: ceftin attending: chief complaint: stemi major surgical or invasive procedure: cardiac catheterization with drug eluting stent to mid left anterior descending artery history of present illness: this is a 58 year old male physician with past medical history significant for prostatic intraepithelial neoplasia as well as known cad who presents today with anterior stemi. the patient was walking on the treadmill today when he suddently had onset of burning substernal chest pain with radiation down his left arm and to his jaw. onset of this pain was around 14:30 on the day of admission. this pain was extremely severe, unrelenting, constant, and not relieved by anything he tried. this was associated with dyspnea and diaphoresis. the patient was concerned he was having a heart attack so he had ems called from his health club and was taken to where ekg was consistent with stemi. therefore, he received asa, clopidogrel, heparin, and epifibatide. he also had a brief episode of nsvt and thus received lidocaine drip prior to transfer here for further management. . on presentation to the the patient went immediately for cardiac catheterization, which showed a 99% occlusion of the mid lad at the point of diversion of the diag. initial balloon was inflated at 4:42 pm. he had ptca, thrombectomy, and stenting with a des followed by a right heart cath that revealed essentially normal pressures. post-cath ekg had essentially normalized. . on arrival to the ccu he reports minimal chest pain, no shortness of breath, fevers, chills, or other complaints. aside from fatigue and generally feeling unwell, he denies any complaints. . cardiac review of systems is notable for chest pain, dyspnea, and diaphoresis during the event but he denies any doe, pnd, orthopnea, ankle edema, palpitations, syncope, or presyncope prior to today. past medical history: 1. cardiac risk factors: - diabetes, +dyslipidemia, + hypertension 2. cardiac history: *cabg: none *percutaneous coronary interventions: ---angiography in with sequential 20 and 30% lad lesions *pacing/icd: none 3. other past medical history: -bph -dysautonomia -partial complex seizures social history: -tobacco history: no tobacco since -etoh: social -illicit drugs: none he is an oncologist who practices on . he is married and lives with his wife. family history: notable for early coronary artery disease in his father and uncles. on uncle died in his 50's of cad. physical exam: t 97, hr 57, bp 132/71, rr 13, spo2 100% on 2l general appearance: well nourished, no acute distress, no(t) overweight / obese, no(t) thin, no(t) anxious, no(t) diaphoretic eyes / conjunctiva: perrl, no(t) pupils dilated, no(t) conjunctiva pale, no(t) sclera edema head, ears, nose, throat: normocephalic, no(t) poor dentition lymphatic: cervical wnl cardiovascular: (pmi normal), (s1: normal), (s2: normal), no(t) s3, no(t) s4, no(t) rub, jvp visible just above clavicle while patient lying flat peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: clear : anteriorly, no(t) crackles : , no(t) wheezes : ) abdominal: soft, non-tender, bowel sounds present, no(t) distended, no(t) tender: extremities: right lower extremity edema: absent, left lower extremity edema: absent, no(t) cyanosis, no(t) clubbing musculoskeletal: muscle wasting skin: cool, no(t) rash: , no(t) jaundice neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person, place, time, situation, movement: purposeful, no(t) sedated, no(t) paralyzed, tone: normal pertinent results: admission labs: 05:15pm blood wbc-11.1*# rbc-4.24* hgb-12.0* hct-36.7* mcv-87 mch-28.3 mchc-32.8 rdw-13.2 plt ct-233 05:15pm blood neuts-88.3* lymphs-7.4* monos-3.7 eos-0.5 baso-0.1 05:15pm blood pt-15.6* ptt-150* inr(pt)-1.4* 05:15pm blood glucose-108* urean-20 creat-0.2* na-140 k-3.4 cl-107 hco3-16* angap-20 05:15pm blood ck(cpk)-52 10:24pm blood ck(cpk)-202 04:15am blood ck(cpk)-310 06:17pm blood ck(cpk)-230 05:20am blood ck(cpk)-151 05:15pm blood ctropnt-0.06* 10:24pm blood ck-mb-20* mb indx-9.9* ctropnt-0.48* 04:15am blood ck-mb-30* mb indx-9.7* ctropnt-0.69* 06:17pm blood ck-mb-17* mb indx-7.4* 05:20am blood ck-mb-8 05:15pm blood calcium-8.4 phos-2.7 mg-1.7 04:15am blood triglyc-36 hdl-52 chol/hd-2.0 ldlcalc-47 -------------------- discharge labs: 06:35am blood wbc-4.1 rbc-4.24* hgb-12.1* hct-35.7* mcv-84 mch-28.6 mchc-33.9 rdw-12.5 plt ct-182 07:18am blood pt-13.1 ptt-32.9 inr(pt)-1.1 06:35am blood glucose-97 urean-19 creat-1.0 na-139 k-4.2 cl-102 hco3-30 angap-11 -------------------- studies: ekg: 15:21: nsr at 75. normal axis. diffuse st elevations in i, avl, v2, v3, v4, and v5 consistent with anterior stemi. . 17:33: sinus rhythm at 65. normal axis and intervals. no acute st or t wave abnormalities. compared to previous st elevations have resolved. . telemetry: nsr at 61. . cardiac cath : 1. coronary angiography in this right dominant system revealed single vessel coronary artery disease. the lmca was normal. the lad had a 99% thrombotic occlusion of the mid-portion involving the diagonal branch. the lcx had mild disease. the rca was normal. 2. resting hemodynamics revealed mildly elevated left-sided filling pressures with mean pcwp of 15 mmhg. the right sided pressures were normal, and the cardiac output was normal. 3. successful pci of the lad with a 3.0x28mm promus des, post-dilated to 3.5mm. 4. successful ptca of the jailed diagonal branch with a 2.25mm balloon with perserved timi 3 flow throughout the procedure. final diagnosis: 1. one vessel coronary artery disease. 2. mildly elevated left-sided filling pressures. 3. successful pci of the lad with des. . hemodynamics: **pressures right atrium {a/v/m} 13/12/10 right ventricle {s/ed} 36/13 pulmonary artery {s/d/m} 36/17/25 pulmonary wedge {a/v/m} 18/16/15 aorta {s/d/m} 117/68/90 **cardiac output heart rate {beats/min} 65 rhythm sinus o2 cons. ind {ml/min/m2} 125 a-v o2 difference {ml/ltr} 28 card. op/ind fick {l/mn/m2} 8.4/4.5 **resistances systemic vasc. resistance 762 pulmonary vasc. resistance 95 . cxr : no active disease in the chest. . tte : the left atrium is mildly dilated. the interatrial septum is aneurysmal. no atrial septal defect is seen by 2d or color doppler, but cannot be fully excluded. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). transmitral and tissue doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (pcwp<12mmhg). the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: normal biventricular cavity sizes with preserved global and regional biventricular systolic function. mild mitral regurgitation with normal valve morphology. interatrial septal aneurysm. brief hospital course: this is a 58 year old male with past medical history significant for known cad but no mi who presents with anterior stemi. # stemi/cad: the patient had a large anterior stemi, and on cardiac catheterization, he was found to have a 99% thrombotic occlusion of the mid-portion of lad involving the diagonal branch. successful pci of the lad with a 3.0x28mm promus des was performed. successful ptca of the jailed diagonal branch was accomplished with a 2.25mm balloon with perserved timi 3 flow throughout the procedure. patient had one episode of chest pain on the night after cath, relieved by nitro gtt. nitro gtt and heparin gtt were weaned off the next morning. patient was put on aspirin, plavix, high dose atorvastatin, and beta-blocker. tte showed normal lvef. because of concern of relative resistance to plavix, patient was on plavix 150mg daily, and he will continue 150mg daily for one month, followed by 75mg daily afterwards. . # pump: despite large anterior wall stemi the patient had no signs/symptoms of left ventricular systolic dysfunction, and his ef was normal. he had no hypotension or signs of cardiogenic shock. he tolerated beta-blocker, and his acei was held given concern for hypotension if acei is restarted. . # rhythm: patient had very short run of nsvt at osh but was in nsr during his stay at . his heart rate was in the 40s-50s at rest, which increased appropriately to 70s with activity. therefore, beta-blocker was re-initiated one day after cath, and he tolerated it well. . # dysautonomia/partial complex seizures: patient has been relatively stable on home regimen of phenobarbitol and lamotrigine. these two medications were continued, and he had no seizure activities during this hospital stay. . # hypertension: he tolerated beta-blocker after cath while in the hospital. his acei was held given concern for hypotension if acei is restarted. patient was discharged home with metoprolol 12.5mg . . # hyperlipidemia: patient was on simvastatin at baseline. his lipid profile showed chol-106 triglyc-36 hdl-52 chol/hd-2.0 ldlcalc-47. he was on 80mg atorvastatin and niacin in context of acute mi in the hospital. he was discharged with simvastatin and niacin. . # bph: home dose doxasosin was continued. . # contact: wife (h) ; (c) medications on admission: -lamotrigine 150 mg po bid -phenobarbitol 60 mg po -ramipril 2.5 mg qhs -simvastatin 20 mg po daily -asa 81 mg po daily (not taking) -doxasosin 1 mg po qhs discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. lamotrigine 100 mg tablet sig: 1.5 tablets po bid (2 times a day). 3. phenobarbital 60 mg tablet sig: one (1) tablet po at bedtime. 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 5. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. doxazosin 1 mg tablet sig: one (1) tablet po hs (at bedtime). 7. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: take up to 3 pills, if you still have chest pain after 3 pills, call 911. disp:*25 tablet, sublingual(s)* refills:*0* 8. clopidogrel 75 mg tablet sig: two (2) tablet po daily (daily): take 2 tablets for one full month. disp:*60 tablet(s)* refills:*1* 9. clopidogrel 75 mg tablet sig: one (1) tablet po once a day: start after 150 mg clopidogrel is finished. disp:*30 tablet(s)* refills:*2* 10. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 11. ambien 10 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 12. niacin 500 mg tablet sig: two (2) capsule, sustained release po at bedtime. discharge disposition: home discharge diagnosis: st elevation myocardial infarction hypertension partial complex seizures prostatic neoplasia discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you had a very small anterior mi with positive troponins and mb index. an echo showed no wall motion abnormalities and normal ejection fraction of > 55%. a cardiac catheterization showed a large clot burden in the mid lad with 99% occlusion. this was treated with a thrombectomy and a promus drug eluting stent with good results. successful ptca of the jailed diagonal branch with a 2.25mm balloon with perserved timi 3 flow throughout the procedure. the remaining coronary arteries were read as normal. you will need to take plavix 150 mg daily for one month and then 75 my daily for at least one year. don't stop taking plavix or miss s unless dr. tells you to. you will need a stress test in one month prior to seeing dr. . please follow activity restrictions outlined by pt. . medication changes: 1. start metopolol at 12.5 mg , check hr and bp daily at home 2. change simvastatin to 80 mg daily 3. increase aspirin to 325 mg daily 4. hold ramepril for now, your np should restart this if bp allows. 5. start ambien as needed for sleep 6. start clopidogrel 150 mg for one month, then 75 mg daily for at least one year. followup instructions: cardiology: dr. phone: date/time: friday at 2:40pm. clinical center, . stress test: treadmill on 301 (down the from your room) phone: date/time: at 8:00am. npo for one hour before test. take all meds in am. . primary care: , : date/time: at 2pm neurology: provider: . & phone: date/time: 2:00 urology: provider: , m.d. phone: date/time: 9:30 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on two vessels Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Acute myocardial infarction of other anterior wall, initial episode of care Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other and unspecified hyperlipidemia Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy Unspecified disorder of autonomic nervous system

allergies: sulfa (sulfonamide antibiotics) / percocet / codeine attending: chief complaint: chest pain; transfer from for possible stemi major surgical or invasive procedure: cardiac catheterization with bare metal stent to distal left anterior coronary artery history of present illness: ms. is an 89 y/o f with h/o htn and dm who was transferred to for concern of possible stemi. . she woke up this morning feeling well until she went down and saw that her basement had flooded. approx. 30 minutes later, when she was addressing the flooding, she developed substernal chest pain. she described this pain as squeezing, located in the center of her chest and radiating to her left breast. she denied shortness of breath, diaphoresis, or palpitations. . she initially presented to , where ekg was concerning for st elevations in v3-v5. she was given a sl ntg and then started on a nitro gtt. she also received 1 dose of 5mg iv lopressor, asa, lipitor 80mg. she also was started on plavix 600mg and a heparin gtt (4000unit bolus followed by gtt at 850 units/hr). transfer to for cardiac cath was arranged. . in the cath lab at , she was noted to have diffuse calcification in the proximal and mid lad with a 70-80% stenosis in the distal lad that was stented with minivision bms. she was also noted to have 70% stenosis in the origin of the left circumflex but given the distribution of her ekg changes, this was not felt to be the culprit lesion and was not intervened on. she had only moderate luminal irregularities of her rca. . on arrival to the ccu, the patient's vs were t= 97.7 bp= 127/64 hr= 60 rr= 18 o2 sat= 97%. she complained of some slight discomfort in her chest 0.5/10, which she felt could be due to having to lay flat for an extended period of time. she denied any other complaints at that time. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. she does admit to excessing bleeding during a hysterectomy many years ago, chronic joint pains oa, foot pains and hand numbness diabetic neuropathy, chronic back pain, and vision loss related to macular degeneration. she also reports chornic overactive bladder symptoms for the past 3 years. all of the other review of systems were negative. . cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, or syncope. of note, the patient does report some intermittent chest discomfort at home, which she describes as indigestion and has treated with antacids. she does report some chronic lightheadedness. past medical history: 1. cardiac risk factors: +diabetes, +hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: none . pmh: htn niddm s/p c section x 4 s/p tah h/o l knee surgery, neck/back surgery, and l shoulder surgery and l wrist surgery trauma social history: -tobacco history: smoked for 40 years from ages 14 to 55. -etoh: rare -illicit drugs: denies lives alone. has a son who is a firefighter. used to work in a hospital as an aid on a neuro floor. family history: 2 sisters died on in their 70's. pt is unsure of any other cardiac history. physical exam: vs: t= 97.7 bp= 127/64 hr= 60 rr= 18 o2 sat= 97% general: wdwn 89 y/o f in nad. oriented x3. mood, affect appropriate. heent: nc/at. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma noted. neck: supple with no obvious jvd noted. cardiac: 2/6 systolic ejection murmur most noted at the rusb. no r/g noted. no s3 or s4 appreciated. lungs: resp were unlabored, no accessory muscle use. ctab anteriorly. abdomen: obese. soft, ntnd. no hsm or tenderness. bowel sounds present. no abdominial bruits. extremities: no c/c/e. pulses: right: dp dopplerable pt dopplerable left: dp dopplerable pt dopplerable pertinent results: 06:20am blood wbc-8.2 rbc-4.16* hgb-13.1 hct-37.7 mcv-91 mch-31.5 mchc-34.7 rdw-12.8 plt ct-201 06:20am blood glucose-148* urean-18 creat-0.6 na-140 k-4.0 cl-104 hco3-26 angap-14 06:20am blood ck(cpk)-67 08:42pm blood ck(cpk)-103 03:29pm blood ck(cpk)-96 06:20am blood ck-mb-notdone ctropnt-0.32* 08:42pm blood ck-mb-14* mb indx-13.6* 03:29pm blood ck-mb-17* mb indx-17.7* ctropnt-0.62* 06:20am blood calcium-9.1 phos-3.3 mg-1.6 06:20am blood triglyc-130 hdl-44 chol/hd-3.4 ldlcalc-79 . persantine stress : interpretation: left ventricular cavity size is normal. rest and stress perfusion images reveal a fixed, moderate reduction in photon counts involving the mid and distal anterior wall, distal septum,distal inferior wall and the apex. there is also a reversible, mild reduction in photon counts involving the mid and basal inferolateral walls. gated images reveal akinesis of the apex, distal anterior wall, distal septum, distal inferior wall and the mid anterior wall. the calculated left ventricular ejection fraction is 48% with an edv of 94 ml. impression: 1. fixed, large, moderate severity perfusion defect involving the lad territory. 2. reversible, small, mild perfusion defect involving the lcx territory. 3. normal left ventricular cavity size. mild systolic dysfunction with akinesis of the apex, distal anterior wall, distal septum, distal inferior wall and the mid anterior wall. . echo : the left atrium is normal in size. there is moderate regional left ventricular systolic dysfunction with focal severe hypokinesis to akinesis of the distal of the left ventricle. the remaining segments contract normally (lvef = 35-40 %). the estimated cardiac index is borderline low (2.0-2.5l/min/m2). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the remaining left ventricular segments contract normally. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened (?#). there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. focal regional left ventricular dysfunction which may be consistent with stress cardiomyopathy (takotsubo) or mid/distal wrapaound lad infarction. moderate pulmonary hypertension. minimal aortic stenosis. . cardiac catheterization : comments: 1. coronary angiography in this right dominant system demonstrated two vessel disease. the lmca had no angiographically apparent disease. the lad had diffuse calcification in the proximal and mid vessel with 70-80% stenosis distally. there was a 70% stenosis in the origin diagonal branch. the lcx had a retroflexed 70% ostial stenosis that appeared most severe on the initial injections but improved with ic nitroglycerin. the rca had moderate luminal irregularities. 2. limited resting hemodynamics revealed mild systemic arterial systolic hypertension with sbp 145 mmhg. 3. successful ptca and stenting of the distal lad with a 2.25x12 mm minivision bms with excellent results (see ptca comments). 4. successful closure of the r common femoral arteriotomy with a 6f perclose proglide device. final diagnosis: 1. two vessel coronary artery disease. 2. successful stenting of the dfistal lad with a minivision bms 3. successful closure of the r-cf arteriotomy with perclose proglide brief hospital course: # stemi: the patient developed sudden onset of sscp on the morning of admission in the setting of seeing her basement flooded. ecg did show findings concerning for stemi, with st elevations in the lateral leads. she was taken to the cath lab, where she had stenting of the distal lad performed. there was some concern about additional disease in the left circumflex so, in the days following catheterization, the patient underwent stress testing. nuclear stress did show a small reversible defect in the left circumflex territory as well as a large fixed defect in the lad territory. she was discharged with cardiology follow-up. she was discharged on full-dose asa, plavix, metoprolol, and a statin. # htn: was normotensive on arrival to ccu. at discharge, was continued on her hyzaar. was also started on metoprolol as above. # dm: sliding scale insulin while in-house. restarted on oral hypoglycemics at discharge. medications on admission: losartan-hydrochlorothiazide 50-12.5mg one (1) tablet po once a day metformin 500mg glipizide 2.5mg centrum multivitamin daily caltrate fish oil b12 discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol succinate 25 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* 5. losartan-hydrochlorothiazide 50-12.5 mg tablet sig: one (1) tablet po once a day. 6. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual once a day: every 5 minutes for a total of 3 . if you still have chest pain after 3 , call 911. . disp:*25 tablets* refills:*0* 7. metformin 500 mg tablet sig: one (1) tablet po twice a day. 8. glipizide 2.5 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po twice a day. 9. fish oil oral 10. multivitamin capsule sig: one (1) capsule po once a day. 11. caltrate 600 600 mg (1,500 mg) tablet oral 12. ranitidine hcl 150 mg capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: st elevation myocardial infarction hypertention diabetes mellitus type 2 discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you had a heart attack and your heart is weak. you will need to be on new medicines to keep the chest pain from coming back and to help your heart heal. activity restrictions: please follow the exercise program that physical therapy discussed with you. no lifting more than 10 pounds for one week. no driving for 2 days. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. medication changes: 1. restart your metformin, glypizide and your losartan/hctz 2. continue with caltrate, fish oil, b12 and your multivitamin 3. start taking a full aspirin, 325 mg daily, and plavix 75 mg daily for at least one month and possibly longer. these medicines keep the stent open and prevent another heart attack. do not miss or stop taking plavix and aspirin for any reason unless dr. tells you to. 4. start taking atorvastatin to lower your cholesterol and help the heart recover. 5. start taking metoprolol to keep your heart rate low and help your heart recover. 6. take nitroglycerin under your tongue if you have the chest pressure/heartburn again. take each tablet 5 minutes apart while sitting down. if you still have the symptoms after 3 , call 911. 7. start ranitidine to protect your stomach from the plavix and aspirin. . please call dr. if you have any chest pain or heartburn at home. followup instructions: dr. phone: date/time: tuesday at 12;00pm . dr. phone: date/time: at 10:40am. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters 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 Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia Acute myocardial infarction of unspecified site, initial episode of care

allergies: epinephrine / amiodarone / ambien attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with drug eluting stent to left circumflex artery, balloon catheterization to om branch history of present illness: mr. is an 89 year old gentleman with a pmh significant for cad s/p multiple pcis most recently in , ischemic cardiomyopathy with an lvef 25-30%, paf, and cva transferred from an osh for cardiac catheterization after vf arrest. the patient initially presented to osh on with chest pain. per review of records, the chest pain woke him from sleep at 2 am described as epigastric pain and did not improve with sl ntg. he then was taken to an osh ed, where he was found to be in atrial fibrillation with rvr with lateral std. while in the osh ed, he developed left-sided chest pain different from intial chest pain that resolved with ntg and morphine. his labs at that time were notable for elevated cardiac biomarkers to ck 42, mb 3.1, tnt 0.22. cardiology was consulted with recommendation for cardiac catheterization. prior to catheterization, however, the patient had vf arrest on with rosc after defibrillation x2, cpr, calcium, and amiodarone. at that point, the patient was started on heparin gtt, integrillin gtt, and taken to cardiac catheterization. cardiac catheterization demonstrated 60% proximal and mid-lad, 80-90% lcx, 100% proximal rca, some in-stent resteonsis of om with iabp placed. ct surgery was consulted for possible cabg, which the family deferred pending transfer to for further evaluation and repeat cardiac catheterization. of note, the patient received 4 units prbcs at osh for a hct of 28.7. in addition, the patient was also admitted to on for chest pain that resolved without intervention. . currently, the patient is resting comfortably without complaints. denies cp/sob, f/c/s, n/v/d, abd pain, ha, palpitations, pain radiating to jaw, arms, or back. . ros: as above, he denies change in weight or bowel habit, cough, fever, arthralgias or myalgias. all other review of systems negative. past medical history: 1. cardiac risk factors: +dyslipidemia, +hypertension 2. cardiac history: - cad: pci history * ptca om & ptca/des to lcx * bms lcx * ptca lad * ptca/stenting proximal and mid-lad . - ischemic cardiomyopathy ef 25-30% - aortic regurg (2+ by tte) - atrial fibrillation - lbbb . 3. other past medical history: l cva w/o residual deficit microcytic anemia b/l hct ~34% hypothyroidism depression gerd social history: retired chemist and inventor. married, four children. able to ambulate independently and accomplish all adls without difficulty. quit smoking in . has a glass of wine each day. no illicit substances. family history: htn in mother, died of mi at 49; , polycythemia in father (may have been related to benzine exposure in shoe industry), died of stroke at 72; sister with cad. physical exam: vs: 98.3 61 135/65 11 98%ra gen: age appropriate male supine in bed heent: perrl, eomi, sclerae anicteric. mmm, op clear without lesions, exudate, or erythema. neck supple. cv: regular s1+s2, audible iabp pulm: faint early inspiratory crackles bilaterally abd: s/nt/nd, audible iabp ext: no c/c/e 1+ dp bilaterally pertinent results: osh resistance 280/18% plt inhibition . in-house . cardiac biomarker peak tnt 2.21 ck mb 14 ck 449 . 01:33pm glucose-108* urea n-15 creat-1.0 sodium-132* potassium-4.1 chloride-100 total co2-27 anion gap-9 01:33pm alt(sgpt)-43* ast(sgot)-27 ld(ldh)-315* alk phos-74 tot bili-0.9 01:33pm albumin-3.2* calcium-8.4 phosphate-3.3 magnesium-2.2 01:33pm wbc-9.1 rbc-4.44* hgb-12.1* hct-37.4* mcv-84 mch-27.4 mchc-32.5 rdw-16.5* 01:33pm neuts-79.0* lymphs-11.7* monos-6.5 eos-2.4 basos-0.4 01:33pm plt count-177 01:33pm pt-14.9* ptt-45.4* inr(pt)-1.3* 06:54pm urine eos-negative 06:54pm urine rbc-0-2 wbc-<1 bacteria-occ yeast-none epi-0 06:54pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-tr bilirubin-neg urobilngn-4* ph-6.5 leuk-neg 06:54pm urine osmolal-532 06:54pm urine hours-random urea n-436 creat-60 sodium-76studies: ecg: sinus with 1:1 conduction. na, ivcd. laa. lbbb, 1-2 mm std v4-v6, std i. . cxr : cardiomegaly, mild cephalization. no effusions or consolidations. . cardiac cath ptca comments: initial angiography showed severe diffsue disease throughout the lcx system with new tight lesion just proximal to the stent placed in . the om branch (was treated with poba in ) was also diffusely and severely diseased throughout. we planned to treat this with ptca and stenting, if feasible. a 6 french 4.0 xb guide provided adequate support. heparin was commenced prophylactically. the patient also was receiving ntg gtt and the iabp was set on 1:1 with augmented bp of 140 mmhg and mean of 65 mmhg. a choice pt extra support wire crossed the lesion with minimal manipulation and positioned into the distal av groove lacx. the proximal lcx stent was predilated with a 2.5x12 mm quantum maverick rx at 12 atm x2 followed by deployment of a 2.5x15 mm promus rx des at 12 atm, postdilated with a 2.75x8 mm quantum maverick balloon at 22 atm. we then advanced the wire into the jailed om branch and performed several pobas starting with a 2.0x12 mm voyager rx at 6-12 atm followed by 2.76x15 mm quantum maverick balloon (at 6-8 atm), each left up for 30-45 seconds. final angiography showed excellent flow into the lcx system with 0% residual stenosis within the stent and 40% residual stenosis in the om branch (due to rapid recoil). no apparent dissection or distal emboli. the iabp was then adjusted under flouroscopy 9advande 3 cm). the patient left the cath lab free from angina and in stable condition. brief hospital course: mr. is an 89 year old gentleman with a pmh significant for cad s/p cabg and multiple pcis most recently in , ischemic cardiomyopathy with an lvef 25%, paf, and transferred from an osh for cardiac catheterization after vf arrest. underwent cardiac cath with des to lcx proximal to prior stent, but etiology of vf arrest unclear, possible ischemic vs. prolonged qt from citalopram. . # coronaries: patient with severe cad s/p cabg with osh diagnostic cardiac catheterization demonstrating possible in-stent restenosis of om 1 after recent pci with in-hospital vf arrest at osh concerning for ischemic event. underwent cardiac cath here with des to lcx proximal to prior stent, 60% lad and 100% rca not intervened on. unclear if lcx lesion led to arrhythmias. had iabp which was removed following cath. being discharged on , , bb, statin, moexipril (home acei). . # pump: patient with known chronic systolic chf with lvef 25-30%. was euvolemic with minimal pulmonary vascular congestion on cxr and minimal signs of volume overload on exam. continued on home metoprolol, lasix with goal -500-even in-house and discharged on home lasix dose. discharged on bb, digoxin, moexipril. . # rhythm: patient with a history of paf with report of af with rvr on initial presentation although available ecgs demonstrate sinus rhythmn. patient also with vf cardiac arrest at osh, with longest qtc recorded as 511 msecs prior to vf, 0.48 now in-house. possible etiologies to vf arrest include acs versus r on t with prolonged qtc. celexa discontinued for ?qtc prolongation and possible precipitant of vf. des to lcx as above for possible ischemic component of vf. did not receive amiodarone as history of pulmonary toxicity. pt has outpatient f/u with outpatient cardiologist dr. to assess need for icd with low ef and s/p vf arrest. d/c'ed on low dose bb. . # hyponatremia: baseline serum sodium of mid-130s, likely secondary to chf, remained stable in-house. . # anemia: baseline hct in 30s and at baseline throughout hospitalization. . # cva: continued and . . # hypothyroid: continued levothyroxine. . # depression: citalopram discontinued as above. . # gerd: zantac prn . code: full (confirmed) communication: , (wife) medications on admission: atorvastatin 80 mg daily citalopram 30 mg daily 75 mg daily digoxin 125 mcg daily 60 mg daily folate 1 mg daily lasix 20 mg daily isosorbide mononitrate 30 mg po bid ketoconazole cream prn levothyroxine 75 mcg daily toprol xl 25 mg daily moexipril 7.5 mg daily ntg sl prn zantac - dose unknown coumadin 2 mg mwf 81 mg daily discharge medications: 1. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): do not stop taking unless dr. tells you to. . disp:*30 tablet(s)* refills:*11* 4. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 6. fexofenadine 60 mg tablet sig: one (1) tablet po once a day as needed for allergies. 7. moexipril 7.5 mg tablet sig: one (1) tablet po daily (daily). 8. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 9. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 11. nitroglycerin 0.4 mg tablet, sublingual sig: 1-2 tablets sublingual every 5 minutes x2 as needed for chest pain. 12. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 13. outpatient lab work please check inr on and call results to dr. at 14. imdur 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po twice a day. 15. warfarin 1 mg tablet sig: two (2) tablet po every mon/wed/fri: please take on sat as well. 16. ketoconazole 2 % cream sig: one (1) topical as needed. discharge disposition: home with service facility: homecare discharge diagnosis: ischemic cardiomyopathy with chronic systolic dysfunction: ef 30% ventricular fibrillation cardiac arrest acute blood loss anemia paroxysmal atrial fibrillation stroke discharge condition: medically stable, vitals stable. discharge instructions: you were transferred here for a catheterization because of a dangerous heart rhythm and chest pain. you received a drug eluting stent to your left circumflex artery. you will need to be on and aspirin daily for at least one year, do not stop taking unless dr. tells you to. weigh yourself every morning, call dr. if weight > 3 lbs in 1 day or 6 pounds in 3 days. adhere to 2 gm sodium diet fluid restriction: no more than 6 cups per day. medication changes: 1. stop taking your celexa, this may have contributed to your dangerous heart rhythm. 2. check your inr on monday . this can be done by the vna. . please call dr. if you have any trouble breathing, chest pain, abdominal pain, vomiting, fevers, swelling in your legs or any ohter concerning symptom. followup instructions: cardiology: provider: , md phone: date/time: 2:30. please call office when you get home to see if you need an earlier appt. primary care: , j. phone: date/time: wednesday at 10:45am. Procedure: Coronary arteriography using two catheters Nonoperative removal of heart assist system Insertion of drug-eluting coronary artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Congestive heart failure, unspecified Acute posthemorrhagic anemia Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Atrial fibrillation Aortocoronary bypass status Depressive disorder, not elsewhere classified Other specified forms of chronic ischemic heart disease Other left bundle branch block Chronic systolic heart failure

allergies: no known allergies / adverse drug reactions attending: chief complaint: fall with tetraparesis major surgical or invasive procedure: : c5 corpectomy, acdf c4-6 history of present illness: 32yom fall from foot high fence onto head with immediate loss of sensation all 4 extremities and inability to move legs with weakness in arms, able to shrug shoulders. placed in collar and to ed. endorses neck pain. denies n/v, stool/urinary incontinence. states had been drinking this morning, drinks half liter alcohol daily. past medical history: none social history: half liter etoh per day, denies illicits, works as sheet metal worker family history: nc physical exam: on admission: o: t: afeb bp: 143/64 hr: 72 r: 18 100% on ra o2sats gen: nad, anxious but calm heent: pupils: equal, round, 5 to 3mm b/l eoms intact neck: midline tenderness. abd: soft, nt extrem: warm and well-perfused. no deformity neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. motor: d b t we wf ip q h at g r 4 4 3- 1 1 1 1 1 2 2 2 l 5- 5- 4 2 2 2 3 3 3 3 2 sensation: back - level at t8 chest - level at umbilicus b/l ue sensation intact with distal non-descript numbness/tingling b/l le medial thigh numbness, otherwise diminished but intact to light touch, propioception, nociception. reflexes: b t br pa ac right 1 0 2 1 1 left 2 0 1 1 1 toes mute bilaterally rectal exam low tone no clonus no physical exam upon discharge: motor: d t b t g ip q h at r 3 5 4 0 2 1 0 0 4- 1 1 l 4 5 5 1 1 3 5 5 5 5 4- sensation- below t4, + sensation but decreased. +numb/tingling/burning. no clonus/hoffmans. r toe mute, left down. incision: c/d/i pertinent results: 02:36pm blood wbc-8.4 rbc-4.96 hgb-15.5 hct-45.0 mcv-91 mch-31.3 mchc-34.5 rdw-13.0 plt ct-196 02:36pm blood pt-11.7 ptt-29.0 inr(pt)-1.1 02:36pm blood asa-neg ethanol-145* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:36pm blood calcium-8.1* phos-3.7 mg-1.8 ______________________________________________________ radiology report trauma #3 (port chest only) study date of 2:18 pm impression: low lung volumes, without acute traumatic injury identified within the chest. radiology report ct head w/o contrast study date of 2:21 pm no acute intracranial process radiology report ct c-spine w/o contrast study date of 2:22 pm impression: 1)comminuted, displaced fracture of the c5 vertebra extends through the transverse foramen on the right. slight retropulsion of the c5 posterior vertebral fragment into the spinal canal with mild canal narrowing at c5/6. 2)c6 vertebral body fracture involves the lamina on the right as well as the right aspect of the vertebral body. fracture fragment seen within the spinal canal at the c5/c6 level. 3)associated prevertebral soft tissue swelling is seen at c5/c6 level. mr cervical spine w/o contrast study date of 4:11 pm radiology impression: 1. burst fracture of c5 with retropulsion of vertebral body and traumatic c5-c6 disc herniation, compromising the spinal canal. 2. disruption of the anterior longitudinal ligament at c4-c5 level and likely focal disruption of the posterior longitudinal ligament at c5 level, as described above. 3. abnormal cord signal intensity at c5 level likely represents cord contusion/edema. 4. increased signal intensity involving the vertebral body of c6 and posterior elements on the right, correspond to the laminal fracture seen on the prompting ct of the cervical spine. 5. vertebral arterial flow-voids preserved. radiology report cta neck w&w/oc & recons study date of 3:02 pm radiology impression: allowing for limitation by motion degredation, no dissection or obvious vascular injury. c5 fracture is as detailed on preceding c-sp ct. radiology report study date of 2:38 pm ct with contrast chest/abdomen/pelvis: impression: 1. no acute traumatic injury within the torso. 2. bibasilar atelectasis. 2. fatty deposition of the liver. radiology report mr cervical spine w/o contrast study date of 4:11 pm impression: 1. burst fracture of c5 with retropulsion of vertebral body and traumatic c5-c6 disc herniation, compromising the spinal canal. 2. disruption of the anterior longitudinal ligament at c4-c5 level and likely focal disruption of the posterior longitudinal ligament at c5 level. 3. abnormal cord signal intensity at c5 level likely represents cord contusion/edema. 4. increased signal intensity involving the vertebral body of c6 and posterior elements on the right, correspond to the laminal fracture seen on the prompting ct of the cervical spine. 5. vertebral arterial flow-voids preserved. mri thoracic and lumbar spine: radiology impression of the thoracic spine: there is no evidence of acute traumatic injury throughout the thoracic spine, schmorl's nodes are noted at the level of t5, t6 and inferior endplate of t11 as described above. there is no evidence of ligamentous injury. radiology impression of the lumbar spine: essentially normal mri of the lumbar spine, with no evidence of acute traumatic injury. chest (portable ap) study date of 7:40 am radiology impression: ap radiograph of the chest was reviewed in comparison to . heart size and mediastinum appear unchanged. mediastinal widening seen on the prior radiograph is corresponding to fat deposition as demonstrated on the ct torso from . lungs are essentially clear. no pleural effusion or pneumothorax is seen. c-spine xray: expected postoperative changes. nonfixated right c5 transverse process and c6 vertebral fractures. assessment of thecal sac contents is limited on the present study. lenis: no dvt brief hospital course: mr. was admitted to the trauma icu on to the neurosurgery service with an incomplete cervical cord injury after a fall from a foort fence. trauma work-up was negative for trauma outside of the c5-6 fracture and cervical cord contusion. he was placed in a hard cervical collar for immobilization. he was maintained on full spine logroll precautions until a total spine mri could be done to rule out cord injury in the thoracic and lumbar spine given his patchy sensory deficits. mri revealed a burst fracture of c5 with retropulsion of vertebral body and traumatic c5-c6 disc herniation,compromising the spinal canal. disruption of the anterior longitudinal ligament at c4-c5 level and likely focal disruption of the posterior longitudinal ligament at c5 level, as described above. abnormal cord signal intensity at c5 level likely represents cord contusion/edema. cta of the neck was performed which was consistent with no dissection or obvious vascular injury.the patient was febrile overnight. due to his unstable cervical fracture the plan was developed for surgical fixation. on , mri of the lumbar and thoracic spine were performed and showed no ligamentous injury or evidence of acute injury. the thoracic and lumbar spine was cleared. the patient was transferred to floor. subcutaneous heparin was started. on , a pre-operative chest xray was performed which was consistent with clear lungs no pleural effusion or pneumothorax seen. on , a preliminary urine culture was consistent with staphylococcus, coagulase negative. 10,000-100,000 organisms/ml and vancomycin was initiated until final culture results are available given the patient had a planned or case for . on , there was an overnight fever of 101.4. is was encouraged. consent was obtained for surgery. the patient underwent a c5 corpectomy, c4-6 acdf without complication. he was extubated and transferred to the pacu/floor. post op ct-cspine revealed adequate hardware placement. on his neurological exam was improving. pain was well controlled but he complained of neck muscle spasms so he was started on robaxin. pt and ot were consulted for assistance with discharge planning. he was started on asa & sqh for dvt prophylaxsis. on he was again neurologically stable, he was however found to be febrile. cultures were sent and lenis were ordered. u/a was negative. on the morning of he was afebrile and was offered a bed at spaudling which was accepted and he was discharged in the early afternoon with instructions for follow-up medications on admission: none discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qfri (every friday). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, t>38.5. 5. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for dryness. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 9. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for dyspepsia. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) unit injection tid (3 times a day). 12. methocarbamol 500 mg tablet sig: two (2) tablet po qid (4 times a day). 13. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 14. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. 15. ondansetron 8 mg iv q8h:prn nausea.emesis 16. hydromorphone (dilaudid) 0.5-2 mg iv q2h: prn pain hold for somnolence; hold for rr < 10 17. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. discharge disposition: extended care facility: - discharge diagnosis: c5-6 fractures cervical ligamentous injury cervical spinal cord contusion discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: ?????? do not smoke. ?????? keep your wound(s) clean and dry / no tub baths or pool swimming for two weeks from your date of surgery. ?????? if you have steri-strips in place, you must keep them dry for 72 hours. do not pull them off. they will fall off on their own or be taken off in the office. you may trim the edges if they begin to curl. ?????? no pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? limit your use of stairs to 2-3 times per day. ?????? have a friend or family member check your incision daily for signs of infection. ?????? wear your cervical collar at all times. ?????? you may shower but the collar must be left on. let soap/water run over incision and pat dry. do not submerge in tub or pool. ?????? take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, and ibuprofen etc. unless directed by your doctor. ?????? increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. we recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine. ?????? any weakness, numbness, tingling in your extremities. ?????? any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? fever greater than or equal to 101?????? f. ?????? any change in your bowel or bladder habits (such as loss of bowl or urine control). followup instructions: follow up instructions/appointments ??????please call ( to schedule an appointment with dr. to be seen in 6 weeks. ??????you will need a ct-scan of your c-spine prior to your appointment. Procedure: Other excision of joint, other specified sites Other cervical fusion of the anterior column, anterior technique Spinal traction using skull device Fusion or refusion of 2-3 vertebrae Diagnoses: Cocaine abuse, unspecified Fever, unspecified Obesity, unspecified Accidents occurring in unspecified place Alcohol abuse, continuous Sprain of neck Other chronic nonalcoholic liver disease Other accidental fall from one level to another Spasm of muscle Body Mass Index 40.0-44.9, adult Closed fracture of C5-C7 level with other specified spinal cord injury

allergies: no known allergies / adverse drug reactions attending: chief complaint: bradycardia major surgical or invasive procedure: aai pacer electrical cardioversion history of present illness: yo woman with past history of hypertension and urinary incontinence presents with syncope and bradycardia. per report patient was recieving physical therapy when she became diaphoretic and unresponsive. physical therapist took patient's bp which was 70s/?? with a pulse in the 30s. ems was called and patient's bp was 70-80s/40s with a pulse of 30-40 bpm. patient was given atropine with no change in pulse. upon arrival to the ed patient was aox3 and mentating well, but was persistantly hypotensive to the 70s systolic with pulses in the 30s. patient was given calcium and glucagon without response as well as 1 l of fluid with no change in her systolic pressures. patient was then started on dopamine drip at 20 mg/min with no change in her systolics. ekg showed a junctional rhythm. upon arrival to the ccu patient was 78/39 hr 49, mentating normally. she denied any dizziness, sob or chest pain. denied any exposure to ticks or new rashes in the preceeding weeks. . 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. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. hypothyroidism 2. hypertension 3. osteoarthritis 4. djd 5. psoriasis 6. depression/anxiety 7. urinary incontinence 8. fall risk social history: patient lives alone in an adult independent living community. patient is widowed and has one adult daughter, son-in-law, and adult granddaughter. occupation: retired salesperson tobacco: denies etoh: denies drugs: denies family history: non-contributory physical exam: on addmisison: vs: t=96.5 bp=78/39 hr=44 rr=6 o2 sat= 100% general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 5 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. 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: 11:09pm glucose-177* urea n-33* creat-1.5* sodium-132* potassium-5.3* chloride-98 total co2-23 anion gap-16 11:09pm calcium-8.8 phosphate-5.1* magnesium-2.0 11:09pm tsh-3.4 11:09pm wbc-15.8*# rbc-4.60 hgb-14.7 hct-42.5 mcv-92 mch-31.9 mchc-34.5 rdw-13.8 07:15pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-lg ekg : fairly regular rhythm with one or two early beats of the same morphology. left ventricular hypertrophy by voltage in lead avl. p waves are not well seen. st-t wave abnormalities including j point and st segment elevationin leads v1-v2. since the previous tracing of the rate is slower. p waves are now not apparent. voltage and st-t wave abnormalities are probably more prominent including qtc interval prolongation. junctional rhythm versus atrial fibrillation and high grade a-v block. clinical correlation is suggested. cxr : findings: accounting for differences in positioning, there is likely little significant interval change in moderate to severe pulmonary edema. bilateral pleural effusions and bibasilar atelectasis are present and appear slightly improved on the right. no pneumothorax is seen. the cardiomediastinal silhouette is unchanged. left-sided pacemaker with single lead is unchanged in position. urine cx: escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 8 s cefazolin------------- 8 r cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i tobramycin------------ <=1 s trimethoprim/sulfa---- =>16 r brief hospital course: yo woman w/ a hx of htn and no previous cardiac history who presents with persistant hypotension and bradycardia. . # bradycardia: patient presented with bradycardia and hypotension which was not repsonsive to atropine or fluid administration. ekg showed a narrow complex w/ no p waves and regular rhythm on tele. diagnosis of a high junctional escape with intact av node was made and the patient had an atrial pacer placed. post procedure patient was stable with an improvement in her bps to the 130s systolic. . # atrial fibrillation. on hd 3 pt went into atrial fibrillation with rvr. she was hemodynamically stable with heart rates in 130s-140s. she was given a total of 15mg iv diltiazem and started on 90mg po diltiazem q6hrs. patient remained stable, but did not to sinus rhythm with medical management. paitnet was then successfully electrically cardioverted out of concern that her preload dependence from hypertensive diastolic heart failure and lack of atrial kick placed her at risk for flash pulmonary edema. she was started on lovenox 60mg sc daily (renally dosed) for prophylaxis and will need a total of one month treatment as long as she remains in sinus rhythm. . # hypotension: patient initially presented hypotensive to the 80s and received in excess of 3 l of fluid while in the ed with no improvment in systolic pressure. patient was stablized on a dopamine drip and went for atrial pacer placement. post-procedure patient was normotensive and no longer required pressor support. . # hypertension: post-pacer placement patient became hypertensive to the 160s in the setting of holding her home antihypertensives. she was then started on po hydralazine, imdor and metoprolol succinate for afterload reduction. patient was discharged on hydralazine 50 mg po q8h, issosorbide mononitrate 90 mg qam, metoprolol succinate 50 mg qd, valsartan 80 mg qhs. . # uti: patient had a positive ua in the ed and urine cultures which grew out a bactrim/cipro resistant e coli. patient was treated with a 5 day course of ceftriaxone. # hypothyroidism: tsh and t4 were sent to rule out involvement in patient's bradycardia and patient was continued on home levothyroxine regiment. transitional issues: -on presentation patient stated that she was dnr/dni, at the time of transfer patient was reconsidering her code status, but wanted to speak with her daugher who could not be reached. this will need to be readdressed. her daughter and name is (h), (c). -patient will need a ua to confirm celerance of uti (incontinent while at , unable to provide repeat specimin). medications on admission: - diltiazem hcl 360 mg po daily - nadolol 20 mg qd - valsartan 80 mg qhs - levothyroxine 75 mcg qd - mvi discharge medications: 1. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 2. senna plus 8.6-50 mg tablet sig: one (1) tablet po twice a day as needed for constipation. tablet(s) 3. bisacodyl 5 mg tablet sig: two (2) tablet po once a day as needed for constipation. 4. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for wheeze. 5. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: three (3) tablet extended release 24 hr po daily (daily). 6. hydralazine 50 mg tablet sig: one (1) tablet po q8h (every 8 hours). tablet(s) 7. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 8. valsartan 80 mg tablet sig: one (1) tablet po hs (at bedtime). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: - brady arrythmia with junctional escape - atrial pace maker placement - e coli urinary tract infection - paroxsymal atrial fibrulation - hypertension - hypothyroidism - spinal stenosis - low back pain - osteoporosis - urinary incontinence - depression - lung nodule - cataracts 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 taking care of you while you were in the hospital. you were admitted to the hospital for a slow heart rate and low blood pressures. you had a pace maker placed which fixed these problems. were also treated for a urinary tract infection. you will need to follow up with your primary care doctor and your cardiologist, these appointments have been made for you. the following changes have been made to your medications: - stop diltiazem hcl 360 mg po daily - stop nadolol 20 mg qd - continue valsartan 80 mg qhs - continue levothyroxine 75 mcg qd - continue multivitamin once daily - start hydralazine 50 mg every 8 hours - start isosorbide mononitrate 90 mg daily - start metoprolol succinate 50 mg daily followup instructions: department: cardiac services when: monday at 9:30 am with: device clinic building: sc clinical ctr campus: east best parking: garage at 9:30 am. md Procedure: Other electric countershock of heart Initial insertion of single-chamber device, rate responsive Initial insertion of transvenous lead [electrode] into atrium Diagnoses: Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified acquired hypothyroidism Atrial fibrillation Acute on chronic diastolic heart failure Hypotension, unspecified Osteoarthrosis, unspecified whether generalized or localized, site unspecified Sinoatrial node dysfunction Syncope and collapse Other psoriasis Delirium due to conditions classified elsewhere Unspecified hypertensive heart disease with heart failure

allergies: sulfa (sulfonamide antibiotics) attending: addendum: discharge pe: sbp low 100's general: aaox3, in nad cv: rrr, no rmg lungs: ctab, no wrr extremities: lue picc in place, cdi, no pain on palpation, ue slightly cool but able to move all fingers, pulses 2+ and equal, rue limited rom in shoulder due to surgery and presence of sling, lue is wnl discharge disposition: extended care facility: hospital - md Procedure: Arthrocentesis Revision of joint replacement of upper extremity Central venous catheter placement with guidance Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Severe sepsis Unspecified acquired hypothyroidism Acute on chronic diastolic heart failure Hematoma complicating a procedure Sarcoidosis Chronic kidney disease, unspecified Constipation, unspecified Other and unspecified hyperlipidemia Septic shock Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified Other staphylococcal septicemia Infection and inflammatory reaction due to internal joint prosthesis

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: r shoulder erythema/swelling major surgical or invasive procedure: r shoulder 1. aspiration right shoulder. 2. irrigation and debridement right shoulder. 3. exchange of polyethylene liner right reverse total shoulder. history of present illness: is an 84f with chf and longstanding history of worsening back and bilateral shoulder pain. she underwent elective r reverse total shoulder replacement on and was discharged to rehab on . that evening she felt unwell, experienced increased back and r shoulder pain, and was found to have fever to 102. she presented to the ed this morning. initial vs in ed: hr 104, rr 22, bp 54/37, o2sat 93 on ra in the ed, her rue was erythematous distal to incision, not crossing elbow. ueni was negative. she received 3lns and had a rij placed. bps improved on levophed 0.12. she was mentating well throughout. wbc 7.0, hct 23.6 down from 37.4 ten days ago. received 1g vanco in ed, also morphine for pain control. initial vs in micu: t 97.6 hr 125 bp 149/62 rr 25 sao2 96% on 2l nc she complains of pain in bilateral shoulders, r>l, across her upper back, and in her neck. it is difficult to ascertain whether or not the pain is worse than it was pre-operatively. she denies ha, uri sx, sob, cp, abd pain, diarrhea, melena, hematochezia, dysuria. ros otherwise negative. past medical history: -dchf (lvef>55%) -renal insufficiency (baseline cr 1.0) -anemia -hypothyroidism -sarcoidosis -chronic pain -s/p breast ca -alcoholism -cervical myelopathy and radiculopathy social history: the patient had lived in , ma with her husband and granddaughter until her recent discharge to rehab. she has 6 living children (2 passed), previously employed as a waitress tobacco: quit , prior use: 1 ppd x 40 years etoh: history of alcoholism. sober since although per omr, she had recently restarted drinking 1 vodka drink daily. illicits: history of codeine abuse previously per omr family history: nc physical exam: admission to floor pe: 97.8 130/70 88p 20 96%ra appearance: alert, nad, obese eyes: eomi, perrl, anicteric ent: op clear s lesions, mmd, no jvd, neck supple, rij c/d/i cv: +s1, s2 -m/r/g, 2+ ue edema, 1+ le edema, 2+ dp/pt bilaterally pulm: clear bilaterally - anteriorly abd: soft, nt, nd, +bs msk: right arm in sling, jp drain with ss drainage, able to move right fingers with handgrip neuro: cn 2-12 grossly intact, no focal deficits skin: no rashes psych: appropriate, pleasant gu: foley . discharge pe???? pertinent results: . joint aspiration 3:30 pm joint fluid site: shoulder right shoulder. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. . swab right shoulder 3:30 pm swab site: shoulder right shoulder wound. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): no growth. anaerobic culture (preliminary): no growth. ... 12:17 pm blood culture blood culture, routine (preliminary): staphylococcus epidermidis. isolated from only one set in the previous five days. sensitivity requested by dr. , including sulfa x trimeth , ciprofloxacin and rifampin. final sensitivities. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sulfa x trimeth sensitivity testing performed by . abiotrophia/granulicatella species. isolated from only one set in the previous five days. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus epidermidis | ciprofloxacin--------- <=0.5 s clindamycin-----------<=0.25 s erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin-------------<=0.25 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- s . ue doppler impression: limited exam but no evidence of right upper extremity dvt. . tte impression: no valvular vegetations or clinically-significant regurgitant valvular disease seen. normal global and regional biventricular systolic function. mild pulmonary hypertension. . last labs : white blood cells 7.2 4.0 - 11.0 k/ul red blood cells 3.24* 4.2 - 5.4 m/ul hemoglobin 9.7* 12.0 - 16.0 g/dl hematocrit 30.3* 36 - 48 % platelet count 282 150 - 440 k/ul glucose 89 70 - 100 mg/dl urea nitrogen 23* 6 - 20 mg/dl creatinine 1.0 0.4 - 1.1 mg/dl sodium 143 133 - 145 meq/l potassium 3.5 3.3 - 5.1 meq/l chloride 103 96 - 108 meq/l bicarbonate 30 22 - 32 meq/l anion gap 14 8 - 20 meq/l calcium, total 8.5 8.4 - 10.3 mg/dl phosphate 3.9 2.7 - 4.5 mg/dl magnesium 1.7 1.6 - 2.6 mg/dl brief hospital course: 84f with chf and cri p/w fever to 102 and hypotension following a r shoulder arthroplasty on # septic shock: blood cx from admission grew gp cocci and clusters speciated to be coagulase negative staph. the most likely source is post-operative shoulder infection / septic joint given clinical exam of erythema of effected shoulder. she transiently required levophed, but was weaned off as she was aggressively fluid resuscitated. she underwent i&d of r shoulder with replacement of joing liner on . cultures were sent. infectious disease was consulted and recommended vancomycin and ceftriaxone while awaiting sensitivities; culture returned on with staph epi. she will continue on ceftriaxone monotherapy, 2 grams daily, for at least 2 weeks (course to be determined by outpatient id team). she may require oral suppressive therapy thereafter. outpatient id and ortho follow up arranged. . # s/p r shoulder surgery: most likely source of sepsis. went to or for i&d and replacement of joint capsule on . she is discharged in sling; non weight bearing, ortho follow up in place. . # hypoxemia in setting of h/o dchf: likely due to atelectasis and effusion demonstrated on cxr. low suspicion for pna as clinically did not have cough. when she returned from or, had flash pulmonary edema and responded well to lasix. she was extubated morning after wash out and required another dose of lasix. she was then maintained on her home lasix dose. . # anemia: upon admission, her hct down 14 points since . per prior heme/onc workup, possible etiologies include chronic disease, b12 deficiency, sarcoid (marrow involvement). increased in response to first unit prbcs, subsequently received total of 2 units in transfusion. haptoglobin, lactate did not indicate hemolysis; hct subsequently remained stable. . # acute on chronic renal failure: cr up to 1.7 at admission from baseline 1.0, back to 1.0 with fluid resuscitation. . # dchf: upon admission to the icu, she was hypotensive. her home dose of furosemide and metoprolol were held. she had flash pulmonary edema most likely to fluids during or and responded well to furosemide. she medications were slowly resumed with the exception of amlodipine which can be re-started if her blood pressure tolerates it. . # altered mental status at 11pm on , pt had abrupt onset ams and difficulty speaking shortly after receiving oxycodone and zofran. she was able to comprehend questions and was oriented to place, but nearly unable to produce speech. no other focal neurologic deficits. pupils reactive. no change in vs. ecg obtained -> no e/o ischemia. vbg, cardiac enzymes were unremarkable. spiked to 102 shortly afterwards. recultured and given 1000mg iv acetaminophen with improvement. . # transitional issues: -follow up with id and ortho as indicated, d/w id 1-3 days prior to follow up if they want routine labs for monitoring medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. amlodipine 10 mg po daily hold if sbp<110 or hr<60 2. aspirin ec 325 mg po daily 3. cyanocobalamin 1000 mcg po daily 4. docusate sodium 100 mg po bid 5. folic acid 1 mg po daily 6. furosemide 80 mg po daily hold if sbp<110 7. latanoprost 0.005% ophth. soln. 1 drop left eye hs 8. levothyroxine sodium 75 mcg po daily 9. metoprolol tartrate 25 mg po bid hold if sbp<110 or hr<60 10. oxycodone (immediate release) 5-15 mg po q3h:prn pain hold if sedated, rr<12, or confused 11. simvastatin 5 mg po daily 12. timolol maleate 0.5% 1 drop left eye daily 13. morphine sr (ms contin) 15 mg po q12h as needed for pain 14. hydrocodone-acetaminophen *nf* 7.5-500 mg oral 1 tab qid pain discharge medications: 1. cyanocobalamin 1000 mcg po daily 2. docusate sodium 100 mg po bid 3. aspirin ec 325 mg po daily 4. folic acid 1 mg po daily 5. furosemide 80 mg po daily hold if sbp<110 6. latanoprost 0.005% ophth. soln. 1 drop left eye hs 7. levothyroxine sodium 75 mcg po daily 8. metoprolol tartrate 25 mg po bid hold if sbp<110 or hr<60 9. oxycodone (immediate release) 5-15 mg po q3h:prn pain hold if sedated, rr<12, or confused 10. simvastatin 5 mg po daily 11. timolol maleate 0.5% 1 drop left eye daily 12. acetaminophen 650 mg po tid 13. ceftriaxone 2 gm iv q24h 14. polyethylene glycol 17 g po daily constipation hold for loose stools 15. senna 1 tab po bid:prn constipation 16. morphine sr (ms contin) 15 mg po q12h as needed for pain discharge disposition: extended care facility: hospital - discharge diagnosis: septic shock from joint infection of right shoulder prosthesis normocytic anemia heart failure with preserved ejection fraction discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to with complaints of right shoulder pain, fevers and low blood pressure. you were intially admitted to the icu, were treated with surgical washout of your shoulder and placed on broad spectrum antibiotics. one of your blood cultures grew out bacteria which was felt to be responsible for your illness. you will require at least two weeks of antibiotics for this infection via the intravenous route. the final course of these antibiotics will be determined when you follow up with the infectious disease physicians. you will be sent to rehab. . medication changes: -please see medication list below followup instructions: department: orthopedics when: thursday at 8:45 am with: , md building: (, ma) campus: off campus best parking: none department: infectious disease when: friday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage please follow up with: primary md (call for an appointment following discharge from rehab and see below) department: surgical specialties when: monday at 1 pm with: , md building: campus: east best parking: garage department: center when: tuesday at 10:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: when: tuesday at 11:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage Procedure: Arthrocentesis Revision of joint replacement of upper extremity Central venous catheter placement with guidance Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Severe sepsis Unspecified acquired hypothyroidism Acute on chronic diastolic heart failure Hematoma complicating a procedure Sarcoidosis Chronic kidney disease, unspecified Constipation, unspecified Other and unspecified hyperlipidemia Septic shock Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified Other staphylococcal septicemia Infection and inflammatory reaction due to internal joint prosthesis

allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: three vessel coronary artery bypass grafting(left internal mammary artery to left anterior descending with saphenous vein grafts to obtuse marginal and posterior descending artery) history of present illness: 72m with history of dmii,htn and hyperlipidemia presented to his pcp with progressive chest pain and sob with exertion. he previously was able to exercise for more than 30 minutes before sob or chest discomfort set in. this has been progressing, and on the day of presentation, could tolerate only about 5 minutes of exercise prior to feeling chest tightness and throat pressure. his pcp admitted him to an osh and cardiac workup ensued. cardiac cath revealed multi-vessel cad. he is transferred for cabg evaluation. past medical history: coronary artery disease hypertension diabetes mellitus type ii chronic kidney disease hyperlipidemia retinopathy diabetic neuropathy obesity osteoarthritis stasis dermatitis anemia s/p cholecystectomy s/p tonsillectomy s/p lens implant, right social history: occupation: retired school principal cigarettes: quit 40rs ago hx: 2ppd etoh: less than two per week illicit drug use: denies family history: father died @ 59yo from mi physical exam: pulse: 46 resp: 20 o2 sat: 99%ra bp left: 150/60 height: 5'7" weight: 261lb general: nad, obese male skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + obese extremities: warm , well-perfused edema 2+ varicosities: none - chronic stasis dermatitis of lower extremities with some associated erythema neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 1+ left: 1+ radial right: 2+ left: 2+ carotid bruit right: none left: none pertinent results: wbc-4.5 rbc-3.63* hgb-11.1* hct-30.8* plt ct-324 pt-13.2 ptt-35.1* inr(pt)-1.1 glucose-167* urean-38* creat-1.6* na-135 k-4.3 cl-99 hco3-25 alt-15 ast-58* ld(ldh)-239 alkphos-76 amylase-56 totbili-0.8 lipase-18 albumin-3.9 calcium-9.4 phos-4.1 mg-2.0 %hba1c-5.2 eag-103 conclusions prebypass no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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 no pericardial effusion. dr. was notified in person of the results on at 11:00 am. post bypass patient is av paced and receiving an infusion of phenylephrine. lvef= 45%. mild mitral regurgitation persists. aorta is intact post decannulation. poor transgastric views. i certify that i was present for this procedure in compliance with hcfa regulations. interpretation assigned to , md, interpreting physician 06:20am blood wbc-7.3 rbc-3.07* hgb-9.3* hct-26.0* mcv-85 mch-30.3 mchc-35.6* rdw-15.1 plt ct-340 06:30am blood wbc-5.6 rbc-3.25* hgb-9.6* hct-28.0* mcv-86 mch-29.6 mchc-34.4 rdw-15.1 plt ct-306 06:20am blood pt-14.6* inr(pt)-1.3* 06:30am blood pt-12.2 ptt-25.1 inr(pt)-1.0 06:20am blood glucose-140* urean-37* creat-1.5* na-137 k-4.3 cl-99 hco3-28 angap-14 06:30am blood glucose-171* urean-35* creat-1.3* na-133 k-4.4 cl-97 hco3-26 angap-14 07:55am blood glucose-201* urean-36* creat-1.3* na-129* k-4.8 cl-94* hco3-27 angap-13 brief hospital course: mr. was admitted under cardiac surgery and underwent routine preoperative evaluation. he remained pain free on medical therapy. workup was unremarkable and he was cleared for surgery. on , dr. performed coronary artery bypass grafting surgery. for surgical details, please see operative note. following surgery, he was brought to the cvicu for invasive monitoring. within 24 hours, he awoke neurologically intact and was extubated without incident. he was transfused with prbc for a postoperative anemia. his cvicu course was otherwise uneventful and he transferred to the sdu on postoperative day one. beta blockade was initially held for bradycardia. he was also noted to have a rise in creatinine associated with hyperkalemia which prompted treatment with kayexalate. his creatinine peaked to 2.1 but by discharge, his creatinine returned to baseline. potassium levels also normalized.he went into a fib and was started on amiodarone as well as coumadin.he continued to work on strength and mobility with pt. insulin adjusted for tighter bs management. chest tubes and pacing wires removed per protocol. minor erythema developed at the inferior pole of the sternal incision. there was no drainage, and the sternum was stable. he is started on levaquin. the patient is discharged home on pod 4 with appropriate follow-up instructions. medications on admission: medications at home: procrit 10,000 units qoweek lipitor 20mg daily aspirin 325mg daily feso4 325mg daily atenolol 100mg daily amlodipine 10mg daily lasix 40mg daily irbesartan 300mg daily hctz 25mg daily metformin 1000mg insulin- humalog 75/25, 30 units at dinner magnesium 500mg daily fish oil 4g daily chromium 1600mcg daily glucosamine chondroitin coenzyme q10 120mg daily meds on transfer: amlodipine 10mg daily, aspirin 325mg daily, atenolol 100mg daily, lipitor 20mg daily, coenzyme q10 100mg daily, lovenox 120mg q12h, feso4 325 daily, lasix 40mg daily, riss, nitropaste, fish oil 1000mg daily, spironolactone 12.5mg daily, valsartan 160mg , apap prn 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. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 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:*1* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. disp:*40 tablet(s)* refills:*0* 5. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 6. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 7. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* 8. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. disp:*30 tablet(s)* refills:*0* 9. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400 mg through , then 200 mg ; then 200 mg daily ongoing. disp:*120 tablet(s)* refills:*1* 10. outpatient lab work labs: pt/inr for coumadin ?????? indication a fib goal inr 2.0-2.5 first draw results to dr. , 11. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 12. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 13. warfarin 2.5 mg tablet sig: one (1) tablet po once a day: dr. to manage for goal inr 2-2.5, dx: afib. disp:*30 tablet(s)* refills:*2* 14. humalog mix 75-25 100 unit/ml (75-25) suspension sig: one (1) subcutaneous twice a day: 33 units at dinner, 30 units at breakfast. disp:*qs * refills:*2* 15. furosemide 40 mg tablet sig: one (1) tablet po twice a day for 2 weeks: 40mg x 2 weeks, then resume 40mg daily . disp:*28 tablet(s)* refills:*2* 16. levofloxacin 500 mg tablet sig: one (1) tablet po once a day for 1 weeks. disp:*7 tablet(s)* refills:*0* 17. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: coronary artery disease, s/p cabg postop atrial fibrillation hypertension type ii diabetes mellitus chronic renal insufficiency dyslipidemia retinopathy neuropathy obesity osteoarthritis stasis dermatitis anemia discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema 2+ discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments wound check , 2a, 10:15 surgeon:dr on at 1:00pm cardiologist: (dr. dr at 27 , (dr seen him before, and is booked out much farther so they want him to see this doctor sooner) on at 10:30am please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** labs: pt/inr for coumadin ?????? indication a fib goal inr 2.0-2.5 first draw results to dr. , Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Hyperpotassemia Anemia, unspecified Coronary atherosclerosis of native coronary artery Cardiac complications, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Other and unspecified angina pectoris Osteoarthrosis, unspecified whether generalized or localized, site unspecified Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Venous (peripheral) insufficiency, unspecified Contact dermatitis and other eczema due to other chemical products

allergies: ciprofloxacin / quinolones attending: chief complaint: fevers, abd pain major surgical or invasive procedure: right percutaneous nephrostomy tube placement, . history of present illness: 57 y/o female with hx of nephrolithiasis who missed her planned right ureteroscopy, laser lithotripsy because she felt too sick to come to the hospital. she deferred going to the ed for further work up despite recommendation. she was nauseated on , had bilious emesis on , had malaise , and was febrile to 102 today. due to the fever, she called and ambulance to bring her to the . she was being transferred to when she had to be diverted to due to tachycardia and hypotension. she now complains of rlq pain. no nausea/vomiting/chest pain/dyspnea. past medical history: pmh: sbo pe dvt depression psh: gastric bypass open cholecystectomy ventral hernia repair laser lithotripsy, right ureteral stent () social history: non contributory family history: non contributory physical exam: on admission: pe: vs: 98.1 92 90/52 18 98%ra nad, a&ox3 rrr, no respiratory distress abd: soft, obese, nondistended, tender to palpation in ruq, rlq, guarding in rlq, no rebound tenderness no cva tenderness ext: 1+ edema bilaterally. pertinent results: 04:32am blood wbc-12.1* rbc-3.31* hgb-9.9* hct-31.3* mcv-95 mch-30.0 mchc-31.7 rdw-15.4 plt ct-393 05:55am blood wbc-12.8* rbc-3.29* hgb-9.9* hct-31.3* mcv-95 mch-30.0 mchc-31.5 rdw-15.7* plt ct-334 03:22am blood wbc-13.3* rbc-3.18* hgb-9.6* hct-29.8* mcv-94 mch-30.3 mchc-32.2 rdw-15.1 plt ct-288 08:51pm blood wbc-11.7* rbc-3.03* hgb-8.9* hct-28.8* mcv-95 mch-29.5 mchc-30.9* rdw-15.4 plt ct-262 05:37am blood wbc-13.3* rbc-3.33* hgb-9.9* hct-31.4* mcv-94 mch-29.7 mchc-31.5 rdw-15.2 plt ct-303 07:00pm blood wbc-16.8* rbc-3.79* hgb-11.1* hct-35.8* mcv-94 mch-29.4 mchc-31.1 rdw-15.8* plt ct-292# 05:37am blood neuts-90.2* lymphs-6.7* monos-2.7 eos-0.4 baso-0.1 07:00pm blood neuts-88.9* lymphs-7.4* monos-3.3 eos-0.3 baso-0.2 04:32am blood plt ct-393 04:32am blood pt-25.4* ptt-37.4* inr(pt)-2.5* 05:55am blood plt ct-334 05:55am blood pt-27.5* ptt-37.9* inr(pt)-2.7* 03:22am blood plt ct-288 03:22am blood pt-23.4* ptt-35.4* inr(pt)-2.2* 08:51pm blood plt ct-262 08:51pm blood pt-22.2* ptt-33.2 inr(pt)-2.1* 10:10am blood pt-19.4* ptt-33.1 inr(pt)-1.8* 06:14am blood pt-21.1* inr(pt)-2.0* 05:37am blood plt ct-303 05:37am blood pt-24.5* ptt-35.6* inr(pt)-2.3* 02:15am blood pt-33.9* ptt-39.9* inr(pt)-3.4* 07:00pm blood plt ct-292# 04:32am blood glucose-76 urean-4* creat-0.8 na-141 k-3.0* cl-106 hco3-27 angap-11 05:55am blood glucose-76 urean-5* creat-0.5 na-142 k-3.5 cl-110* hco3-28 angap-8 03:22am blood glucose-72 urean-9 creat-0.7 na-145 k-3.8 cl-113* hco3-25 angap-11 08:51pm blood glucose-54* urean-10 creat-0.7 na-144 k-3.5 cl-114* hco3-24 angap-10 07:00pm blood glucose-64* urean-21* creat-0.9 na-138 k-3.4 cl-108 hco3-20* angap-13 brief hospital course: patient admitted to dr. urology service for management urosepsis, resultant from obstructive right renal stone. the patient has a hx of nephrolithiasis wit previous stent placement on the right side. she was scheduled for a right ureteroscopy and laser lithotripsy on the friday prior to admission. she cancelled her procedure due to feeling ill. her symptoms at home escalated and she requested ambulance transport to the . during her transport to the she had to be diverted to due to tachycardia and hypotension. on admission she was afebrile and hypotensive, she was placed empirically on ampicillin and gentamicin, hydrated and cultures were drawn. she was scheduled for placement of a percutaneous nephrostomy tube by ir in the am. a ct scan revealed that the right ureteral stent was in place, with evidence of striated right nephrogram and perinephric stranding concerning for pyelonephritis. areas of more confluent hypodensity may represent areas of more focal infection; and a developing abscess could not be excluded. two separate tiny calcific densities along the right mid ureter adjacent to the stent could represent calculi measuring 6 and 5 mm long. mild right hydronephrosis, particularly of the lower pole. a right sided neprhostomy tube was placed on . a urine culture from returned as esbl e coli > 100k (sensitiveimipenem, ertapenem, nitrofurantoin, amikacin) and klebsiella pneumoniae > 100k (sensitive to ertapenem (other carbapenems not listed) cefazolin, ciprofloxacin, gent, nitrofurantoin, pip-tazo)and her antibiotic was changed to meropenem 8:40 am on . a 48 cm picc placed to facilitate outpatient delivery of iv abx, the meropenem was changed to ertapenem for ease of dosing in out patient setting. urine and blood cultures collected in house are pending. on the day of discharge she complained of diarrhea although questioning revealed that she has persistant diarrhea that she treats with imodium, to r/o a possible hosptial aquired infection a c-diff test was ordered results if pertinent will be reported to the patient and pcp following discharge. she was discharged to home on hd5 in stable condition afebrile, wbc in normal range, picc in place, with a therapeutic inr of 2.5, she was advised to contact her clinic and pcp immediately upon discharge for the continued management of her coumadin. her pcp's ( office as well as the clinic () she visits were contact and informed of her hospitalization and our recommendations. she is scheduled with ambulatory care clinic for daily administration of her antibiotic and follow up labs that are to be faxed to dr. of infectious disease. she was given explicit instructions to contact dr. office upon discharge to arrange for a follow up appointment with in two weeks. medications on admission: meds: coumadin (being held for planned or ) cymbalta 90 qam, 30 qhs neurontin 600 tid cartia 300 qhs ambien 5 qhs vicodin prn vit b12 vit d vit b6 vitamin d discharge medications: 1. warfarin 1 mg tablet sig: tablet tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 3. gabapentin 300 mg capsule sig: one (1) capsule po q8h (every 8 hours) as needed for chronic pain. 4. duloxetine 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po qhs (once a day (at bedtime)). 5. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po qam (once a day (in the morning)). 6. tylenol-codeine #3 300-30 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain: for breakthrough pain >4. disp:*30 tablet(s)* refills:*0* 7. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*60 capsule(s)* refills:*0* 8. ertapenem 1 gram recon soln sig: one (1) 1 gm intravenous once a day for 3 weeks: administer daily as prescribed. disp:*21 21* refills:*0* discharge disposition: home discharge diagnosis: right renal stones with nonfunctional ureteral stent in place, urosepsis status post right percutaneous nephrostomy tube placement discharge condition: stable discharge instructions: -you may shower but do not bathe, swim or otherwise immerse your nephrostomy site for 4 weeks. -do not lift anything heavier than a phone book for 2 weeks. -tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. replace tylenol with narcotic pain medication. max daily tylenol dose is 4gm, note that narcotic pain medication also contains tylenol (acetaminophen) -do not drive or drink alcohol while taking narcotics -colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -resume all of your home medications -we have reduced your daily coumadin dosage to 0.5 mgs daily, please continue with this dosage until you contact your pcp. contact your pcp or clinic immediately upon discharge to inform them of your recent hospital stay, discontinuance and restart of your coumadin and for follow up inr checks. -you have been prescribed an iv antibiotic that must be given by intravenous daily, please visit your pcp's office for daily administration of this medication. -if you have fevers > 101.5 f, or increased redness, swelling, or discharge from your nephrostomy tube site, call your doctor or go to the nearest emergency room. -call dr. office () on the day of discharge to schedule a follow-up appointment and if you have any urological questions. followup instructions: call dr. office () on the day of discharge to schedule a follow-up appointment and if you have any urological questions. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Percutaneous nephrostomy without fragmentation Diagnoses: Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Depressive disorder, not elsewhere classified Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Other postprocedural status Hydronephrosis Calculus of kidney Hip joint replacement Bariatric surgery status Acute pyelonephritis without lesion of renal medullary necrosis Hypoglycemia, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: ureteroileal anastomotic strictures, hypotension, a. fib with rvr. major surgical or invasive procedure: removal of neobladder (cystectomy), excision of lymphocele wall, creation of ileal conduit urinary diversion (conversion of chimney to an ileal conduit with a new double barrel ureteral ileal anastomosis), dr. , history of present illness: 69 y.o. male w/ h.o. high grade invasive transitional call carcinoma of the bladder s/p lap cystectomy, neobladder formation , a. fib w/ rvr in the or today for removal of neobladder, creation of ileal conduit urinary diversion. transfer to icu for a. fib with rvr, hypotension. . pt removal of his neobladder with excision of ileal conduit urinary diversion. prior to the surgery he was noted to be hypotensive in the 90s after receiving diltiazem po. during the surgery he was estimated to have a 500cc bld loss. he was noted intra-operatively to go into a. fib with rvr with a rate 100-110s and sbp in the 80s. he received a total of 9l of fluid with minimal response to hypotension. he was also given po diltiazem with no resulting effect. he was thus started on a dilt gtt and transferred to dilt gtt. in addition to fluid he also received 2u prbcs given his pre-op hct was 28. . upon arrival to the floor his vitals were noted to be t 97.4, hr 110, bp 103/50. pt denied any chest pain, chest palpitations, sob, lightheadedness, recent fevers, chills. . on review of his prior hospitalizations it appears his microdata is significant for vre as well as pan sensitive e.coli. during his neobladder construction he was noted to be hypotensive that was thought to be due to sepsis from vre. at that time he was on a regimen of linezolid and zosyn. . review of systems: (+)ve: (-)ve: fever, chills, chest pain, palpitations, dyspnea, nausea, vomiting, diarrhea. past medical history: 1. h/o mi - 17 yrs ago, treated at hospital, per patient treated with a "clot busting medication" (possibly tpa), hospitalized x 6 days and discharged. as noted previously, he did not take medications after discharge and did not follow up with any physicians 2.paroxysmal atrial fibrillation, discovered at time of cancer diagnosis , difficult to control post-operatively . has recurrences of af/rvr during last hospitalization. 3.high-grade invasive transitional cell carcinoma 4.osteoarthritis of ankles 5.c. difficle colitis 6. klebsiella bacteremia (last ) with klebsiella uti 7. gastritis/duodenitis 8.left percutaneous nephrostomy tube for presumed obstructive uropathy. 9.right percutaneous nephrostomy tube, emergent, for obstructed pyelonephritis. 10. vre septic shock s/p neobladder construction () social history: -married and lives with wife in . retired, worked as a construction worker. -smoking: 30+ py, quit before -etoh: denies -drugs: denies family history: -mother died at yrs. -father died in early 70's from asbestosis physical exam: t=97.4. bp=103/50 hr=110 rr=16 o2= 98% . . physical exam general: pleasant, well appearing caucasian male in nad heent: no scleral icterus. eomi. mmm. cardiac: irregularly, irregular, s1, s2, borderline tachy (110s)lungs: ctab, good air movement biaterally. abdomen: rlq ostomy noted with drain in place. b/l quadrants have jp drains. abd dressing c/d/i. extremities: no edema neuro: a&ox3. appropriate. cn 2-12 grossly intact. psych: listens and responds to questions appropriately, pleasant pertinent results: 06:00am blood wbc-6.8 rbc-3.19* hgb-9.0* hct-27.2* mcv-85 mch-28.1 mchc-33.1 rdw-15.8* plt ct-245 05:34pm blood neuts-86.6* lymphs-8.4* monos-3.3 eos-1.4 baso-0.4 06:15am blood pt-19.4* inr(pt)-1.8* 07:40am blood pt-17.8* inr(pt)-1.6* 06:00am blood pt-17.0* inr(pt)-1.5* 07:50am blood glucose-84 urean-7 creat-1.3* na-138 k-4.3 cl-103 hco3-28 angap-11 07:50am blood calcium-8.0* mg-1.9 brief hospital course: icu course (by problem): ##. hypotension: patient was admitted to icu rather than floor post-op due to hypotension. hypotension was thought to be related to a. fib with rvr with rates ranging from 110-120s. pt received a total of 7l ns in the pacu over 7 hours but was still noted to have a bp in the mid 70s, asymptomatic. differential included a. fib with rvr given his prior history, however would expect a more impressive rate to give such hypotension. other differentials to consider included possible sepsis that could have occured peri-op, he was also noted to have leukocytosis prior to his operation. on review of his record he has had septic shock after gu procedures as well as a history of vre, pan sensitive e.coli. pt's bp also noted to decrease after diltiazem 120mg was given. for possible sepsis patient was bolused with 500cc lr to check bp response, pt mentating well currently. changed antiobiotics of vanc and ceftriaxone to zosyn (for broad gram positive, negative coverage) and linezolid (vre coverage). pt received diltiazem and is on morphine pca which could also explain the hypotension. blood cultures were sent. antibiotics were then discontinued on post-op day 2 per urology, given no evidence of infection, and resolution of hypotension. . ##. a. fib with rvr: pt has history of a. fib with rvr post-op following a prior gu surgery performed in . on review of anaesthesia records it appears his a. fib was in the 100-120 range, he received a total of 9l ns as mentioned above as well as 2u packed red blood cells. he received diltiazem 120mg sr with his rate responding 85-103. on review it appeared he required amiodarone 150mg bolus and drip during prior episodes. amiodarone was started on post-op day 1. this was discontinued per cardiology consult, and the patient's rate was subsequently controlled with diltiazem iv boluses, follow by a diltiazem drip. he was on warfarin at home given his atrial fibrillation, despite having a chads2 score of zero, and warfarin was continued during his hospital course. the diltiazem drip was discontinued and transitioned to oral. initial dose was diltiazem 90 mg po qid, increased to 120 mg qid for rate control. bradycardia to 40s followed first 120 mg dose, and patient was converted back to diltiazem 90 mg po qid. adequate rate control was achieved with this dose, and the patient was subsequently transferred out of the icu. . ##. s/p ileal conduit urinary diversion: pt ileal conduit urinary diversion in addition to neobladder. urology currently following pt, who is npo per their recommendations. patient remained npo on post-op day 2, with slow transition to clears on pod 4. ileus remained. . ##. leukocytosis: pt noted to have leukocytosis of 16.4 on admission. unclear as to the etiology, pt does have h.o. of vre colonization within his gu system, multiple infections. no fevers reported. leukocyte count trended down. . ##. renal insufficiency: pt currently sees a nephrologist in for his insufficiency. prior to admission baseline creatinine has ranged from 1.9-2.0. prior creatinine level of was thought to be due to atn from hypovolemia. renal insufficiency is thought to be obstruction from transitional bladder cell cancer with obstruction. creatinine was improved from baseline on pod #2. . ##. hyperchloremic acidosis: likely related to large volume resuscitation from ns. trended during course . ##. fen: keep npo for now per urology. replete lytes prn . ##. ppx: dvt ppx with pneumoboots, pain management with morphine pca. . ##. access: 2 piv's . ##. code status: full code confirmed . ##. emergency contact: (wife and hcp) . ##. disposition: pending resolution of symptoms. floor hospital course: mr. conversion of ileal neobladder to an ileal conduit on and was transferred to the (as detailed above) for close monitoring due to afib and hypotension. no concerning intraoperative events occurred; please see dictated operative note for details. once his acute cardiac issues stabilized, he was deemed stable for transfer out of the to dr. urology service. patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with . his inr was noted to be supratherapeutic after two doses of and subsequent doses were held until his inr dropped in the therapeutic range. with the passage of flatus, patient's diet was advanced. the patient was ambulating and pain was controlled on oral medications by this time. physical therapy worked with the patient and cleared him for discharge home once stable from a medical standpoint. the ostomy nurse saw the patient for ostomy teaching. at the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. the ostomy was perfused and patent. patient is scheduled to follow up in one week's time in clinic for wound check. additionally his pcp's office was regarding mr. discharge dosages of and diltiazem. dr. nurse has arranged follow up in 2 days. medications on admission: metoprolol 25mg xl daily diltiazem sr 120mg daily mvi 1tab daily colace 100mg daily warfarin 3mg daily 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. tylenol-codeine #3 300-30 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. disp:*40 tablet(s)* refills:*0* 3. diltiazem hcl 180 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). disp:*30 capsule, sustained release(s)* refills:*2* 4. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: bladder cancer discharge condition: stable discharge instructions: -please resume all home meds -tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. replace tylenol with narcotic pain medication. max daily tylenol dose is 4gm, note that narcotic pain medication also contains tylenol (acetaminophen). -do not drive while taking narcotic pain medication -colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops -you may shower, but do not immerse incision, no tub baths/swimming -small white steri-strips bandages will fall off in days, you may remove at that time if irritating, if staples are present they will be removed by dr. at a follow up appointment in days --if you have fevers > 101.5 f, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest er -please refer to visiting nurses (vna) for management of the ileal conduit. -please make an appointment to see your cardiologist, pcp, whoever manages your and blood pressure/heart medications within the next 2 days. followup instructions: please contact dr. office upon discharge to arrange follow up appointment. please contact your pcp . upon discharge to arrange for management of your inr, dosage and hypertension medications. Procedure: Ureteral catheterization Other operations on lymphatic structures Revision of ureterointestinal anastomosis Diagnoses: Acidosis Other iatrogenic hypotension Atrial fibrillation Urinary complications, not elsewhere classified Personal history of malignant neoplasm of kidney Other noninfectious disorders of lymphatic channels

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral ureteral obstruction major surgical or invasive procedure: bilateral stent removal (complicated), bilateral stent placement and bilateral retrograde pyelogram readings, cystolitholapaxy. dr. . . history of present illness: 69 year old male with a history of high grade invasive transitional call carcinoma of the bladder s/p lap cystectomy and neobladder formation and multiple complications including atrial fibrillation with rapid ventricular response and bacteremia presenting for elective bilateral ureteral stent change. he has had bilateral nephrostomy placements in the past few months for obstructive pyelonephritis and sepsis. since then, the pcn's were internalized to jj ureteral stents. he has also undergone ureteral balloon dilation by interventional radiology. past medical history: 1. h/o mi - 17 yrs ago, treated at hospital, per patient treated with a "clot busting medication" (possibly tpa), hospitalized x 6 days and discharged. as noted previously, he did not take medications after discharge and did not follow up with any physicians 2.paroxysmal atrial fibrillation, discovered at time of cancer diagnosis , difficult to control post-operatively . has recurrences of af/rvr during last hospitalization. 3.high-grade invasive transitional cell carcinoma 4.osteoarthritis of ankles 5.c. difficle colitis 6. klebsiella bacteremia (last ) with klebsiella uti 7. gastritis/duodenitis 8.left percutaneous nephrostomy tube for presumed obstructive uropathy. 9.right percutaneous nephrostomy tube, emergent, for obstructed pyelonephritis. social history: -married and lives with wife in . retired, worked as a construction worker. -smoking: 30+ py, quit before -etoh: denies -drugs: denies family history: -mother died at yrs. -father died in early 70's from asbestosis pertinent results: 07:10am blood wbc-7.6 rbc-3.51* hgb-10.0* hct-29.8* mcv-85 mch-28.4 mchc-33.6 rdw-18.1* plt ct-76*# 12:19pm blood wbc-32.0* rbc-3.61* hgb-10.4* hct-31.7* mcv-88 mch-28.8 mchc-32.9 rdw-18.1* plt ct-73* 07:10am blood glucose-76 urean-101* creat-4.7* na-142 k-4.0 cl-111* hco3-21* angap-14 03:44pm blood glucose-99 urean-103* creat-5.8* na-133 k-4.1 cl-93* hco3-20* angap-24* 06:40am blood wbc-7.9 rbc-3.61* hgb-10.2* hct-31.6* mcv-87 mch-28.2 mchc-32.2 rdw-18.7* plt ct-165# 06:02am blood wbc-6.6 rbc-3.46* hgb-9.9* hct-29.0* mcv-84 mch-28.6 mchc-34.1 rdw-17.8* plt ct-96* brief hospital course: pt was admitted to dr. urology service after undergoing bilateral stent change. the patient was scheduled for day surgery, but became hypotensive, tachycardic in the day surgery pacu, requiring pressors. the patient was transferred from the pacu to the icu. icu course was significant for: # sepsis mr. was admitted to the icu in septic shock after bilateral ureteral stent change. he had an elevated lactate, rising white blood cell count, fevers and hypotension not responsive to fluids. he has a history of chronic infection in the gu tract, in addition to vre colonization. he has been admitted for severe sepsis after gu procedures on multiple occasions since his neobladder surgery in . on admission to the icu, the patient was requiring multiple pressors and was started on treatment with linezolid and zosyn. he was slowly weaned off pressors and transferred back to the urology service when hemodynamically stable. # atrial fibrillation the patient presented to the icu from the pacu with heart rates in the 130s-150s, which appeared consistent with prior post-op course and contributing to his hypotension. triggers, likely multifactorial, likely included post-op stress, hypovolemia, and infection. he was started on an amiodarone drip, which controlled his rhythm. prior to transfer back to the urology service, he was started on low-dose beta-blocker, which is to be increased back to his home dose of metoprolol prior to discharge from the hospital. an echo showed that his left atrium is mildly dilated, and there is mild symmetric left ventricular hypertrophy with normal cavity size. he has some mild regional left ventricular systolic dysfunction with inferior hypokinesis. # acute renal failure mr. was in rapidly worsening acute renal failure post-operatively with oliguria and hyperkalemia, most likely from acute tubular necrosis secondary to hypotension. a renal ultrasound showed no concern for obstructive post-renal etiology. lasix boluses were used to increase his urine output and keep his potassium in check. prior to transfer from the icu, the patient started autodiuresing, and his kidney function began to slowly improve. # diarrhea the patient presented with stool incontinence. due to history of severe c. difficile infection, he was treated empirically with metronidazole and per oral vancomycin. his stool was negative for c difficile during this hospitalization. on pod 7, the patient was transferred to the floor in stable condition. on pod 8, the foley catheter was removed and the patient continued to be incontinent as he was prior to admission. he was discharged in stable condition on pod 10, creatinie trending down, wbc normal, with a picc line in place for 13 more doses of zosyn and oral vancomycin to be taken for two days following zosyn. vna services were arranged for the administration of antibiotics and subsequent removal of picc line and in home physical therapy. he was instructed to follow up with renal on and provided a lab order slip (per renal recs) for a chem 10 to be drawn on at the clinical center. he was instructed to contact dr. office upon discharge to arrange/confirm follow up appointment. medications on admission: metoprolol 100 mg po daily warfarin 2 mg po daily vit d2 800 units daily oxycodone-acetaminohpen 5mg-325mg one tab q6h prn discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day). 3. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. piperacillin-tazobactam 2.25 gram recon soln sig: one (1) recon soln intravenous q8h (every 8 hours) for 5 days: administer daily iv antibiotics as prescribed until finished. disp:*13 recon soln(s)* refills:*0* 7. vancomycin 250 mg capsule sig: two (2) capsule po q8h (every 8 hours) for 7 days: take as prescribed until finished. disp:*42 capsule(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: bilateral ureteral stricture status post bilateral stent removal, bilateral stent placement. discharge condition: stable discharge instructions: -you may shower and bathe normally. -tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. replace tylenol with narcotic pain medication. max daily tylenol dose is 4gm, note that narcotic pain medication also contains tylenol (acetaminophen) -do not drive or drink alcohol while taking narcotics -colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -resume all of your home medications, no changes. -take the antibiotics as prescribed for the full course (vancomycin and zosyn). dosing is scheduled at midnight, 8am and 4 pm, if at all possible please continue with this schedule. -please do clean intermittent catheterization daily with flushing as instructed. -please return to clinical center next week to have labs drawn to evaluate your renal function -please follow up with renal as scheduled (see below) -call dr. office to schedule a follow-up appointment and if you have any urological questions, . -if you have fevers > 101.5 f, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. definitions: ureter: the duct that transports urine from the kidney to the bladder: stent: a plastic hollow tube that is placed into the ureter, from the kidney to the bladder to prevent the ureter from swelling shut. despite the fact that no skin incisions were used, the area around the ureter and bladder is irritated. the stent is required in order keep the ureter open and urine flowing from the kidney to the bladder. because one end of the ureter is in the bladder, it can cause irritation to the bladder. therefore, it is normal to feel that you need the urge to urinate frequently when the stent is in place. although the stent can be uncomfortable, it is important to have the stent to avoid damaging the kidney and ureter after your procedure. you may see some blood in your urine while the stent is in place and a few days afterward. drink lots of fluid - this will help clear up your urine. diet: you may return to your normal diet immediately. because of the raw surface of your bladder, alcohol, spicy foods, acidy foods and drinks with caffeine may cause irritation or frequency and should be used in moderation. to keep your urine flowing freely and to avoid constipation, drink plenty of fluids during the day (8 - 10 glasses) activity: your physical activity doesn't need to be restricted. however, if you are very active, you may see some blood in the urine. we would suggest to cut down your activity under these circumstances until the bleeding has stopped bowels-it is important to keep your bowels regular during the postoperative period. straining with bowel movements can cause bleeding. a bowel movement every other day is reasonable. use a mild laxative if needed, such as milk of magnesia tablespoons, or 2 dulcolax tablets. call if you continue to have problems. if you had been taking narcotics for pain, before, during or after your surgery, you may be constipated. take a laxative if necessary medication-you should resume your pre-surgery medications unless told not to. in addition you will often be given an antibiotic to prevent infection. these should be taken as prescribed until the bottles are finished unless you are having an unusual reaction to one of the drugs. problems should report to urology service a. fevers over 100.5 fahrenheit b. heavy bleeding, or clots (see notes above about blood in urine). c. inability to urinate. d. drug reactions (hives, rash, nausea, vomiting, diarrhea). e. severe burning or pain with urination that is not improving. f. you have and internal stent and it is important to have a follow-up appointment to remove your stent. call your doctor for this appointment when you get home followup instructions: call dr. office to schedule a follow-up appointment and if you have any urological questions, . renal follow up- provider: , md phone: date/time: 12:45 Procedure: Venous catheterization, not elsewhere classified Ureteral catheterization Retrograde pyelogram Transurethral clearance of bladder Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acidosis Thrombocytopenia, unspecified Other postoperative infection Urinary tract infection, site not specified Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Atrial fibrillation Septic shock Personal history of malignant neoplasm of bladder Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Other and unspecified coagulation defects Diastolic heart failure, unspecified Stricture or kinking of ureter

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: atrial fibrillation with rvr, hypotensive, distended abdomen, likely uti major surgical or invasive procedure: none history of present illness: this is a 69 year old male, who is admitted with atrial fibrillation with rvr. . patient was recently admitted one month ago for a radical cystectomy for transitional cell carcinoma of the bladder and neobladder creation. post-operatively, his hospital course was complicated by new atrial fibrillation with rvr when he was npo following surgery, at which time he was in the requiring an esmolol gtt. he also developed an ileus, with recurrent rvr. he was stabalized and discharged on metoprolol 100 mg . . today he presented to urology clinic after his daughter prompted him to come in. he was noted to have a distended abdomen, that improved after a bowel movement while at clinic. a kub demonstrated question of ilieus or partial small bowel obstruction. he was also noted to be tachycardic with a heart rate in the 130's. finally, he reported foul smelling urine from his neobladder. he denied chest pain, shortness of breath, chills, rashes, bleeding, pnd, orthopnea, or leg swelling. he does endorse possible fevers. . he was initially admitted to the urology service, however his heart rate remained 120-140 on the floor, with a systolic blood pressure in the low 90's. cardiology was contact and amiodarone load and drip was recommended. given tachycardia, hypotension, and inability to do an amiodarone drip on the floor, patient was transferred to for further management. . upon arrival to the , patient reported he was doing well and had no complaints. specifically he denied chest pain, shortness of breath, or other symptoms. he did report that his abdomen has been more full and somewhat distended after "eating too much--a steak and cheese sub" over the weekend. he denied any nausea, vomiting, diarrhea, or constipation. he has been passing gas and reports his abdomen is much better. past medical history: - myocardial infarction - 17 yrs ago, treated at hospital, per patient treated with a "clot busting medication" (possibly tpa), hospitalized x 6 days and discharged. as noted previously, he did not take medications after discharge and did not follow up with any physicians - paroxysmal atrial fibrillation, discovered at time of cancer diagnosis , difficult to control post-operatively - high-grade invasive transitional cell carcinoma - osteoarthritis of ankles social history: as noted in the chart, patient is married and lives with wife in . he has a 30+ pack year history of tobacco and quit 10+ years ago. he denies etoh. no history of illicit drugs. he worked as construction worker. family history: mother died at 92. father died in early 70's from asbestosis physical exam: on admission to : gen: well-appearing, well-nourished, no acute distress, appearing slightly uncomfortable, moving around in bed heent: eomi, perrl, sclera anicteric, no conjunctival pallor, slightly dry mucous membranes, op clear neck: no jvd, no cervical lymphadenopathy, trachea midline cor: irregularly irregular tachycardic, no m/g/r, normal s1 s2, radial pulses +2 pulm: lungs ctab anteriorly, no w/r/r abd: soft but mild to moderately distended. no tenderness, +bs. no fluid wave or shifting dullness. well healed surgical incisions over lower abdomen in suprapubic region. no guarding or rebound tenderness. ext: warm, no clubbing/cyanosis/edema. radial, dp/pt 2+ bilatearally. full rom of ankles, no erythema. neuro: alert, oriented to person, place, and time. cn ii ?????? xii grossly intact. moves all 4 extremities. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: 10:29pm urine hours-random urea n-475 creat-67 sodium-38 09:46pm type- temp-37.6 rates-/25 po2-32* pco2-39 ph-7.39 total co2-24 base xs--1 intubated-not intuba 09:46pm glucose-105 lactate-2.0 na+-136 k+-4.3 cl--101 09:46pm hgb-11.3* calchct-34 09:46pm freeca-1.09* 02:40pm urine color-yellow appear-cloudy sp -1.016 02:40pm urine blood-mod nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-lg 02:40pm urine rbc-80* wbc-467* bacteria-mod yeast-none epi-0 02:39pm glucose-120* 02:39pm urea n-28* creat-1.6* sodium-135 potassium-4.7 chloride-99 total co2-23 anion gap-18 02:39pm estgfr-using this 02:39pm alt(sgpt)-22 ast(sgot)-27 alk phos-81 tot bili-2.5* 02:39pm calcium-8.5 phosphate-3.3 magnesium-1.5* 02:39pm wbc-16.7*# rbc-3.85* hgb-11.4* hct-33.7* mcv-88 mch-29.6 mchc-33.8 rdw-14.7 02:39pm neuts-89.9* lymphs-4.8* monos-5.0 eos-0.1 basos-0.1 02:39pm plt count-224 culture data: klebsiella pneumoniae. >100,000 organisms/ml.. 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 nitrofurantoin-------- 32 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s : clostridium difficile. feces positive for c. difficile toxin by eia. imaging: abdomen x-ray: impression: findings concerning for small bowel obstruction . renal ultrasound: findings: the right kidney measures 12.2 cm. the left kidney measures 13.4 cm. there is moderate hydronephrosis, bilaterally. there is no evidence of renal calculi or cortical masses. within the upper pole of the left kidney, there is a hypoechoic lesion with increased through transmission consistent with a simple cyst measuring 1.5 x 1.1 cm. this is unchanged when compared to prior exam. impression: moderate hydronephrosis bilaterally, new when compared to prior exam. stable-appearing left upper pole renal cyst. no evidence of renal calculi. brief hospital course: this is a 69 year old male with a history of atrial fibrillation and recent radical cystectomy and neobladder who was initially transferred to the icu from the floor for atrial fibrillation with rapid ventricular response, hypotension, fevers, leukocytosis, abdominal discomfort, and acute renal failure. the following is his course by problem. . # atrial fibrillation with rapid rate: since his surgery last month, his rate has been very hard to control, but he was discharged on 100 mg metoprolol . tsh was 3.4. last echo was demonstrated lvh and dilated left atrium with low normal ef. he had not been anticoagulated, and reports taking an aspirin; he states he was supposed to follow up with his pcp to discuss after his surgery, but had not made it to that appointment yet. he reported he was aware of the risks of stroke secondary to atrial fibrillation. at time of arrival to icu, his blood pressure was stable, so he was given iv beta-blocker and loaded with digoxin, as wished to avoid potentially chemically cardioverting. cardiology had been consulted and followed along. he was started on anticoagulation, and inr will need to be followed by his pcp. was increased to 5 mg daily on , but inr trended up to 4.1 quickly. was held for 2 days and inr was 3.1 on day of discharge (). pt was asked to started taking 2.5 mg of daily after discharge and will need inr checked at least twice weekly while on antibiotics. metoprolol was increased to 100 mg tid. given hr increasing to 130s-140s with activity once transferred to the floor (not orthostatic), pt was given iv digoxin again given concern for poor po absorption in the setting of his colitis. digoxin oral was then restarted at 0.125 mg daily with level of 0.6. because of continued poor rate control with activity, diltiazem 30 mg qid was started. pt then had 2 second pauses digoxin was stopped per cardiology recs (in addition, pts bp was higher so did not required digoxin anymore). prior to discharge, pt was having several 2 second pauses while sleeping (this could be due to sleep apnea, increased vagal tone), but heart rate would still go up into the 130s with little activity. he was completely asymptomatic, hemodynamically stable, and refused to stay in the hospital any longer for titration of his medications. he was discharged on 100 mg of metoprolol tid and 120 of diltiazem daily. he should follow up with cardiology after discharge. he prefers to see his home cardiologist. pcp aware of inr monitoring while pt is on antibiotics. . # uti/bladder transitional cell carcinoma: patient well known to the urology service. his surgical incisions appear to be healing well. after discussion with urology, it was felt he likely had a soft tissue infection of his neobladder based on description of his urine, urine analysis, and fevers. imaging of his abdomen and pelvis to look for abscess was deferred given that urology reported that soft tissue infections of the neobladder may be slower to resolve. he was initially on ceftriaxone, however changed over to ciprofloxacin after sensitivies returned on his urine. will continue cipro to complete a 10 day course. his neobladder was irrigated every 8 hours. cystogram was performed and pts foley was removed by urology. pt was instructed on straight intermittent catheterization. per urology, no further treatment is needed at this time. he should follow up with urology after discharge. . # hypotension: it was felt that the patient's hypotension was secondary to atrial fibrillation with rvr and poor forward flow. in addition patient appeared volume depleted at time of admission. there was also concern for developing sepsis given leukocytosis, fevers, foul smelling urine and urine analysis consistent with infection. no chest pain or ekg changes to suggest ischemia. his lactate was within normal limits, and his blood pressure normalized within several hours of admission after his rate control improved and he was given fluids. . # c diff colitis/ distended abdomen: initially there was concern for possibly developing partial small bowel obstruction or ilieus, however he continued to have flatus and move his bowels. he refused a nasogastric tube on admission. he began to develop loose stools and a c. difficile toxin assay was positive. he continued to have abdominal cramping and then nausea. he was started on flagyl on for this and should complete a 2 week course (1 week after cipro has been completed for uti). his abdominal examination remained benign, although he continued to have gas cramps and loose stools. kub appeared benigin on , and he was given antiemetics for his nausea (likely due to flagyl). will discharge with compazine as needed while pt is completing his course of flagyl. . # fever: pt continued to spike temps after cipro was started for uti and flagyl started for c diff. his antibiotics were changed back to iv in the case of poor gi absorption and once afebrile for 48 hrs, po antibiotics were resumed. will continue cipro for uti and flagyl for c diff . # cad: no active symptoms, no acute ekg changes. continued asa, statin, and beta-blocker . # acute renal failure: patient's baseline creatinine 0.8-1.0. on admission, his creatinine was up to 1.6. he was not on any nephrotoxic medications. although his bun was not as high as would be expected for pre-renal etiology, suspect that volume depletion and poor forward flow while in af with rvr, with possible development of some atn in that setting. his creatinine eventually decreased to 1.1-1.2 after fluids and improvement in his blood pressure. a renal ultrasound demonstrated mild hydronephrosis, which per discussion with urology is expected after neobladder formation, although a bump in creatinine is not typically expected. . # ankle pain: patient reports this is chronic secondary to arthritis. he was treated initially with narcotics for this (vicodin), but pt did not want to take any more. . # anemia: stable hct since last admission (32.8), suspect secondary to losses from prior urologic surgery, chronic disease state with concurrent malignancy. . # elevated total bilirubin: noted on admission, however returned to baseline. medications on admission: medications at home: - omeprazole 20 mg daily. - simvastatin 10 mg daily - metoprolol tartrate 100 mg - asa 325 mg ("most days") discharge medications: 1. metoprolol tartrate 100 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours): this is tylenol and is over the counter. you can take this for your arthritis. 5. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 9 days. disp:*27 tablet(s)* refills:*0* 6. cipro 250 mg tablet sig: one (1) tablet po twice a day for 2 days. disp:*4 tablet(s)* refills:*0* 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation: this is a stool softener and can be purchased over the counter. 8. senna 8.6 mg tablet sig: two (2) tablet po hs (at bedtime): this is a stool softener and can be purchased over the counter. 9. 2.5 mg tablet sig: two (2) tablet po once a day. disp:*60 tablet(s)* refills:*2* 10. 1 mg tablet sig: one (1) tablet po as directed. disp:*100 tablet(s)* refills:*2* 11. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for arthritis pain. disp:*30 tablet(s)* refills:*0* 12. compazine 10 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. disp:*30 tablet(s)* refills:*0* 13. compazine 25 mg suppository sig: one (1) suppository rectal every six (6) hours as needed for nausea. disp:*20 suppositories* refills:*0* 14. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 15. diltiazem hcl 120 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. 16. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed. disp:*20 tablet, rapid dissolve(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: atrial fibrillation with rapid ventricular rate hypotension acute renal failure c difficile colitis klebsiella uti discharge condition: stable discharge instructions: you were admitted with abdominal pain and found to have both a urinary tract infection and gi infection (c diff colitis). you were treated with antibiotics for this and you should complete both of them (ciprofloxacin and flagyl). you also were transferred to the icu for poorly controlled heart rates and low blood pressure. you were started on diltiazem to help control your heart rate and your metoprolol was increased. . medication changes: metoprolol was increased to 100 mg three times a day. diltiazem was started to help control heart rate. ciprofloxacin and flagyl are antibiotics and they should be completed. you were started on (a blood thinner). you should take 2.5 mg a day to start. you have been provided with 2 different doses of in case your doctor needs to adjust your dosage. you will need your blood levels checked twice a week initially by dr. . please call his office to arrange to have your inr's checked after discharge. you also were given vicodin to be taken if your arthritis pain is severe. this can make you sleepy and constipated. you should not drive while taking this medication. . you will need to see a cardiologist in the very near future to evaluate your heart rate/atrial fibrillation. . call your doctor or return to the er for any fevers, worsening abdominal pain, diarrhea, dehydration, palpitations, shortness of breath, chest pain, or any other concerning symptoms. followup instructions: please call dr. and let them know that you were discharged and need your inr checked (your level) twice a week now. you should have it repeated this friday. . primary care follow up: name: , f address: , ste 2b, , phone: thursday, , 3:00pm . please call dr. office to arrange for follow up after your discharge Procedure: Other cystogram Diagnoses: Anemia, unspecified Urinary tract infection, site not specified Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute kidney failure, unspecified Atrial fibrillation Intestinal infection due to Clostridium difficile Personal history of malignant neoplasm of bladder Dehydration Arthropathy, unspecified, ankle and foot

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: urosepsis major surgical or invasive procedure: placement of right percutaneous nephrostomy tube, removal of left percutaneous nephrostomy tube and placement of left uretal stent history of present illness: the patient is a 69 year old man with a history of high grade invasive transitional cell carcinoma s/p laparoscopic cystectomy and neobladder formation whose course since then has been complicated by rapid atrial fibrillation, bacteremia, c.diff colitis, renal failure likely secondary to partial bilateral ureteral obstruction who was admitted with sepsis. the patient was recently discahrged from the gu service on . he had been admitted that time with nausea/vomiting, 50lb weight loss, and arf with a cr up to 3.6 from baseline of 0.9. during that hospitalization, the patinet was started on tpn for nutritional support, and an egd demonstrated gastritis/duodenitis. his creatinine only improved to 2.0 with rehydration, and nephrology believed that the renal failure was secondary to obstructed uropathy despite the mag3 lasix renogram. he underwent placement of a left percutaneous nephrostomy tube without complication. . the patinet had done well since discharge, but began to feel unwell the days prior to presentation, with complaints of fevers and chills. he denies any cough, shortness of breath, headache, blurred vision, neck stiffness, focal neurolgoic deficis, diahrea, abdominal pain, or joint swelling. he presented to the clinic today for foley removal, and was evaluated by dr., who noted the pt's poor clinical appearance. he was reffered to the ed for further evaluation. a ct of the abdomen and pelvis showed increased right perinephric stranding since prior study, unchanged fluid collection in left pelvis may be lymphocele with possible small hemorrhagic componenet. new left neprhrostomy tube with improved left hydronephrosis. the patient deteriorated in the ed requiring pressors, he was transfered to the micu for management of probable sepsis. past medical history: - myocardial infarction - 17 yrs ago, treated at hospital, per patient treated with a "clot busting medication" (possibly tpa), hospitalized x 6 days and discharged. as noted previously, he did not take medications after discharge and did not follow up with any physicians - paroxysmal atrial fibrillation, discovered at time of cancer diagnosis , difficult to control post-operatively - high-grade invasive transitional cell carcinoma - osteoarthritis of ankles social history: as noted in the chart, patient is married and lives with wife in . he has a 30+ pack year history of tobacco and quit 10+ years ago. he denies etoh. no history of illicit drugs. he worked as construction worker. family history: mother died at 92. father died in early 70's from asbestosis pertinent results: 01:00pm blood wbc-8.5 rbc-3.60* hgb-10.7* hct-29.9* mcv-83 mch-29.6 mchc-35.7* rdw-18.0* plt ct-291# 01:00pm blood plt ct-291# 01:00pm blood glucose-126* urean-22* creat-1.6* na-147* k-3.7 cl-111* hco3-29 angap-11 01:00pm blood estgfr-using this 01:00pm blood calcium-8.2* mg-2.0 brief hospital course: pt was admitted to the urology service after being transferred from clinic to the ed febrile with uncontrolled atrial fibrillation and hypotension. he underwent fluid resusication in the ed, and a ct scan was performed, which demonstrated worsened right hydroureteronephrosis with significant stranding around the r kidney. the diagnosis of obstructed pyelonephritis was made, and interventional radiology was called for emergent r percutaneous nephrostomy tube placement. the patient was brought to the micu and intubated in preparation for the procedure given his relative hemodynamic instability. r pcn was uncomplicated. cultures from the nephrostomy tube and blood were obtained, and his infection was empirically treated with with vancomycin and zosyn. the patient was kept in the micu for one full day for aggressive fluid resuscitation for sepsis from r obstructed pyelonephritis. he was extubated on hd 3 and was transferred to the floor in stable condition. the remainder of his hospital course was uncomplicated. he remained afebrile. his left percutaneous nephrostomy tube was internalized to a jj ureteral stent on after balloon dilation of a left uretero-iliac anastamotic stricture. a right antegrade nephrostogram was also performed, which demonstrated a a r ureteroiliac anastamotic stricture. his antibiotics were switched grew pan-sensitive klebsiella, and his antibiotics were switched to po ciprofloxacin, on which he was discharged. although the klebsiella was sensitive to bactrim, ciprofloxacin 500 mgs was chosen as his antibiotic at the advice of the id team becausae of its efficacy for treating soft tissue infections. he will remain on cipro until his remaining nephrostomy tube is removed, which will occur in weeks. medicine was consulted for rate control of atrial fibrillation, and he was maintained on a regimen of metoprolol 125 mg po tid. he was given explicit instructions to f/u with his primary care physician, was and updated on the patient's current condition before discharge. medications on admission: 1. ensure liquid sig: one (1) can po three times a day. 2. gabapentin 300 mg capsule sig: one (1) capsule po hs 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid 4. simvastatin 10 mg tablet sig: one (1) tablet po daily 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h ( 6. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. 7. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid 8. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po every six (6) hours discharge medications: 1. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 14 days: continue antibiotic prescription until next appt. w/ dr. . disp:*28 tablet(s)* refills:*1* 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: second line pain medication, if tylenol alone ineffective, do not exceed 4 gms of tylenol daily. disp:*30 tablet(s)* refills:*0* 4. metoprolol tartrate 100 mg tablet sig: one (1) tablet po q 8h (every 8 hours). disp:*30 tablet(s)* refills:*1* 5. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for oral thrush: use as needed for oral thrush. disp:*100 ml(s)* refills:*1* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po every eight (8) hours: to be taken in conjuction with 100 mg tablet of same to equal prescribed dosage. disp:*30 tablet(s)* refills:*1* 7. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 8. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: urosepsis discharge condition: stable discharge instructions: vna: 1. please help patient with physical therapy at home. no weight-bearing restrictions. 2. please help patient with management of right percutaneous nephrostomy tube, including dressing changes and supplies 3. please teach patient to perform daily foley catheter flushes with sterile saline to avoid mucus plugging. patient instructions: -please take your metoprolol 125 mgs three times daily as instructed on the prescriptions. -continue to take the prescribed antibiotics until your return for you next scheduled procedure. -do not take any aspirin or blood thinning medications (ie. ) before your next scheduled appointment with dr. , be certain to discuss restart of these medications with dr. . -please contact your pcp with in the next week to discuss long term management of atrial fibrilation, blood pressure and gerd. providing him with a copy of your discharge instructions will be helpful. -please drink an ensure with each meal -please call if you experience fevers > 101.5 -please call if you are unable to tolerate food and are unable to hydrate yourself -please call if you experience significant dizziness that prevents you from walking -please follow-up with dr. with in next week regarding rescheduling of right percutaneous nephrostomy tube removal, foley removal and self-catheterization teaching. followup instructions: dr. phone: followup instructions: please contact dr. office upon discharge to arrange a follow up appointment. Procedure: Venous catheterization, not elsewhere classified Percutaneous nephrostomy without fragmentation Ureteral catheterization Removal of pyelostomy and nephrostomy tube Diagnoses: Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Acute kidney failure, unspecified Severe sepsis Atrial fibrillation Candidiasis of mouth Personal history of malignant neoplasm of bladder Other septicemia due to gram-negative organisms Hyperosmolality and/or hypernatremia Hydronephrosis Pyelonephritis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bladder ca major surgical or invasive procedure: lap cystectomy, open neobladder history of present illness: 69m invasive bladder ca elected to proceed w/ lap cystectomy per dr. and open neobladder w/ dr. . past medical history: 1) myocardial infarction - 17 yrs ago, treated at hospital. patient reports receiving a "clot busting medication" ? tpa, hospitalized x 6 days and discharged. did not take medications after discharge nor did he see a physician . no history of other hospitalizations or illnesses . patient does report multiple abrasions, minor lacerations etc that have occurred during his work as a self-employed contractor. social history: married, lives with wife in . 30+ pack year history of tobacco, quit 10+ years ago. does not and never has drunk alcohol (confirmed with family). no history of illicit drugs. works as construction worker. family history: mother died at 92. father died in early 70's from asbestosis physical exam: avss nad s/nt/nd brief hospital course: patient post-operative course complicated by ileus requiring ngt and tpn which pt eventually had return bowel funnction and tolerating po upon discharge. in addition, pt had wound erythema which responded to vancomycin abx with complete resolution of wound erythema. post-operative afib, non-rate controlled w/ cardiology consult/recs cont lopressor 20mg iv q4hrs with transition to lopressor 100mg po bid with return bowel function and pt rate controlled. during this time due to afib not rate controlled pt transferred to icu twice for further management. upon discharge, all wd drains removed except foley catheter, pt tolerating regular diet, no wound erythema w/ staples removed and afib rate controlled tol lopressor 100 . cardiology confirmed to f/u outside cardiologist dr. or cardiology and to continue lopressor, statin and aspirin. patient will f/u w/ dr. / for postoperative f/u. patient will cont keflex x 1wk for wd. medications on admission: simvastatin 10 lopressor 100 doxazosin 4 discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). discharge disposition: home discharge diagnosis: bladder ca discharge condition: stable. discharge instructions: please call if nausea/vomiting/fever/chills, decreased foley output. please flush foley 30cc tid. if chest pain, sob please call and/or visit nearest ed and contact cardiologist dr or cardiology by calling . followup instructions: please call dr. for follow-up appt. please f/u pcp . within 1 wk of d/c home. please f/u outside cardiologist, dr or cardiology and make appt by calling . Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Radical cystectomy Urinary diversion to intestine Reconstruction of urinary bladder Division or crushing of other cranial and peripheral nerves Regional lymph node excision Radical prostatectomy Isolation of segment of small intestine Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Cardiac complications, not elsewhere classified Gout, unspecified Atrial fibrillation Pain in joint, lower leg Old myocardial infarction Paralytic ileus Retention of urine, unspecified Obesity, unspecified Hypovolemia Malignant neoplasm of other specified sites of bladder Arthropathy, unspecified, lower leg Other acute postoperative pain Body Mass Index 33.0-33.9, adult

allergies: sulfa (sulfonamides) / zestril attending: chief complaint: syncope melena major surgical or invasive procedure: upper endoscopy () history of present illness: ms. is a 65-year-old female with past medical history significant for pe about 4 years ago(on coumadin), htn, left sided breast cancer ( dcis, s/p left lumpectomy with atypical ductal breast hyperplasia now) who presented to ed after syncope episode this morning while in the shower. patient fell and sustained small laceration to the bridge of her nose during this fall. head ct in ed was negative. she has also been having black tarry stools over the past 24 hours and additional c/o ongoing lightheadedness since yesturday. she denies any overt abdominal pains. no history of gi bleed. denies nausea, vomiting, diarrhea, constipation. she is also taking occasional home ibuprofen as well. in ed, initial vital signs were: t 97.7f, bp 117/67, hr 100, rr 18, 100% ra. she was given 1l ivf, 1 unit prbcs, 80mg iv protonix and 20meq po potassium in ed. 2 large bore pivs were placed. gi consult called after notable hct drop to 27 (from older baseline 41). additional labs notable for k 3.2. wbc slight elevated at 12 and inr 3.6. she had positive guaiac in ed. ekg showed rate 103, sinus, and was also remarkable for st depressions v3-v6 although she denied any chest pains, palpitations, shortness of breath. initial set of cardiac markers negative. gi was consulted and wants to do egd but won't do it until inr < 2.0. currently 3.6 on arrival to icu so patient was given po vitamin k and additional 1 unit ffp. on arrival to the icu, patient appeared to be mentating well and was in nad. initial vitals were t 98.4f, bp 124/81, hr 106, rr 13 and o2 sat 99% ra. patient admitted to icu for additional monitoring in setting of active gib and large hct drop with syncope. past medical history: 1. pulmonary emboli 2. atypical ductal hyperplasia of left breast, dx (s/p 5 years of tamoxifen) 3. hypertension 4. chronic low back pain 5. mild insomnia 6. ibs 7. migraines social history: patient works as librarian at . she is divorced and has no children. - tobacco: never - alcohol: drinks 3 glasses wine per week - illicits: never family history: patient was adopted and does not know family history. physical exam: 1. coumadin 10 mg daily 2. hctz 25 mg daily 3. ibuprofen 1-2 tablets few days per week as needed 4. fioricet/butabarbital - as needed for migraines 5. ativan 1mg qhs prn 6. imitrex 50 mg tablet as needed for migraine 7. venlafaxine 37.5 mg pertinent results: upper endoscopy : 1. ulcer in the antrum 2. small erosions in the antrum 3. normal mucosa in the duodenum hct on admission: 27.4 hct at discharge: 31.8 h.pylori serology pending at discharge brief hospital course: 1. peptic ulcer: endoscopy showed an ulcer in the antrum which was the likely culprit lesion in the setting of warfarin and nsaids. will be discharged on ppi with plan for repeat egd in weeks. also will be discharged off warfarin and nsaids. h.pyolori is pending at discharge. 2. acute blood loss anemia: hct 27.4 on admission and 31.8 on discharge. recieved a total of 4 units of prbcs during stay. 3. syncope: likely result of blood loss. patient had negative head ct in ed. at time of discharge, ambulating without difficulty. 4. history of pulmonary emboli: discussed wtih patient the cost and benefit of continuing warfarin. certainly, in the setting of an acute gib, plan is to stop warfarin. it is her desire to continue to remain off warfarin indefinitely. 5. hypertension: hctz held during stay with plan to continuing holding until seen by pcp in . pending at discharge: - h.pylori serology medications on admission: ibuprofen - 1-2 tablets few days per week fioricet/butabarbital - as needed for migraines hctz - 25 mg tablet by mouth once a day ativan 1mg tablet hs prn imitrex 50 mg tablet as needed for migraine venlafaxine -37.5 mg coumadin - 10 mg tablet once a day 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. venlafaxine 37.5 mg tablet sig: one (1) tablet po bid (2 times a day). 3. sumatriptan succinate 50 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for migraine. 4. lorazepam 1 mg tablet sig: one (1) tablet po qhs as needed for anxiety. 5. fioricet oral discharge disposition: home discharge diagnosis: peptic ulcer disease acute blood loss anemia syncope history of pulmonary embolism discharge condition: stable with stabilized hemotocrit discharge instructions: you were admitted and found to have an ulcer in your stomach. as a result of this ulcer, you had significant bleeding which likely contributed to the dizziness prompting your hospital stay. please stop both warfarin (coumadin) and all nsaids (e.g. ibuprofen, motrin) until discussing their use with your doctors in the future. also, please stop your hctz until being seen by your pcp. followup instructions: please be sure to call your pcp to schedule an appointment within one week of discharge. Procedure: Other endoscopy of small intestine Transfusion of packed cells Transfusion of other serum Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Personal history of malignant neoplasm of breast Blood in stool Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction Anticoagulants causing adverse effects in therapeutic use Other and unspecified coagulation defects Syncope and collapse Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Unspecified analgesic and antipyretic causing adverse effects in therapeutic use

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: exertional chest pain major surgical or invasive procedure: off-pump coronary artey bypass grafts x 2 (lima-lad, sv-om) history of present illness: this 82 year old male with multiple risk factors for coronary artery disease had been experiencing exertional chest pain when walking up an incline or stairs for several months. he had a nuclear stress test in that was positive for ekg changes, symptoms as well as perfusion defects. he saw a cardiologist in consult who sent him for an outpatient catheterization on . this revealed severe coronary artery disease and he was referred for surgical revascularization. past medical history: hypertension dyslipidemia s/p stroke with some residual memory deficits s/p laser eye surgery hypothyroidism gastric reflux social history: divorced and lives alone. retired. denies alcohol or tobacco. family history: non-contributory physical exam: discharge: vitals: 98.5 145/76 62 sinus 18 98% ra general: pleasant, answers questions appropriately chest: lungs clear to auscultation bilaterally, sternum stable. sternal incision without drainage or erythema cor: regular, normal s1 s2, no murmurs, rubs, gallops appreciated abdomen: soft without tenderness, normoactive bowel sounds extremities: warm with trace edema pertinent results: 07:05am blood wbc-11.5* rbc-3.56* hgb-10.9* hct-31.2* mcv-88 mch-30.6 mchc-35.0 rdw-13.4 plt ct-135* 03:04am blood wbc-13.4* rbc-3.49* hgb-10.6* hct-30.4* mcv-87 mch-30.4 mchc-34.8 rdw-13.6 plt ct-195 11:12am blood wbc-8.4 rbc-3.68* hgb-11.3* hct-32.3* mcv-88 mch-30.7 mchc-34.9 rdw-13.5 plt ct-162 07:00am blood na-135 k-4.0 07:30am blood urean-14 creat-1.2 na-134 k-3.7 cl-101 hco3-25 angap-12 03:04am blood glucose-63* urean-16 creat-0.9 na-134 k-4.2 cl-105 hco3-24 angap-9 03:04am blood tsh-12* echocardiography report , (complete) done at 12:20:24 pm final referring physician information , r. , division of cardiothorac , status: inpatient dob: age (years): 82 m hgt (in): bp (mm hg): / wgt (lb): hr (bpm): bsa (m2): indication: intraoperative tee for off-pump cabg icd-9 codes: 440.0, 424.1, 424.0 test information date/time: at 12:20 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: aw2 echocardiographic measurements results measurements normal range left atrium - long axis dimension: *6.3 cm <= 4.0 cm left atrium - four chamber length: *6.2 cm <= 5.2 cm left ventricle - septal wall thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - ejection fraction: 55% >= 55% aorta - sinus level: 3.2 cm <= 3.6 cm aorta - sinotubular ridge: 2.6 cm <= 3.0 cm aorta - ascending: *3.5 cm <= 3.4 cm aorta - descending thoracic: *2.7 cm <= 2.5 cm aortic valve - lvot diam: 1.8 cm findings left atrium: marked la enlargement. elongated la. no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. good (>20 cm/s) laa ejection velocity. right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness, cavity size, and global systolic function (lvef>55%). right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. mildly dilated ascending aorta. complex (>4mm) atheroma in the ascending aorta. complex (mobile) atheroma in the ascending aorta. complex (>4mm) atheroma in the descending thoracic aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. trace ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild (1+) mr. tricuspid valve: tricuspid valve not well visualized. mild tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. conclusions the left atrium is markedly dilated. the left atrium is elongated. 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. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. there are complex (>4mm) atheroma in the ascending aorta. there are complex (mobile) atheroma in the very proximal ascending aorta. there are complex (>4mm) 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 leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. there were no changes noted in the post grafting setting. dr. was notified in person of the results in the operating room at the time of the procedure. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 12:35 ?????? caregroup is. all rights reserved. brief hospital course: mr had his pre-operative work up done as an outpatient and was admitted same day for cabg with dr on . please see operative note for complete details. post-operatively he was admitted to the cvicu for invasive hemodynamic monitoring. his iv meds were weaned and he was extubated on pod 1. later that day he was transferred to the step down unit. once on the step down unit physical therapy was consulted to work on strength and balance. his medicines were advanced to optimum levels and he continued to progress. physical therapy cleared him for discharge on pos-op day 3. by post-op day 5 he was discharged to rehab. medications on admission: lisinopril 40 mg daily aspirin 81 mg daily hctz 25 mg daily aricept 5 mg hs pravachol 20 mg daily imdur 30 mg daily percocet tab prn atenolol 25 mg 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 3 months. disp:*90 tablet(s)* refills:*0* 4. donepezil 5 mg tablet sig: one (1) tablet po hs (at bedtime). 5. 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* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. metoclopramide 10 mg tablet sig: one (1) tablet po tid (3 times a day) for 5 days. disp:*15 tablet(s)* refills:*0* 8. lisinopril 40 mg tablet sig: tablet po once a day. disp:*15 tablet(s)* refills:*0* 9. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. disp:*60 tablet(s)* refills:*0* 10. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. disp:*qs qs* refills:*0* 11. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. disp:*10 suppository(s)* refills:*0* 12. pravachol 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: extended care facility: house nursing & rehabilitation center - discharge diagnosis: cad s/p cabg hypothyroidism s/p cva gerd 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 followup instructions: dr. in 4 weeks () dr. in 1 week dr. in weeks () wound check appointment 6 as instructed by nurse () please call for appointments Procedure: Single internal mammary-coronary artery bypass (Aorto)coronary bypass of one coronary artery Insertion of indwelling urinary catheter Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Peripheral vascular disease, unspecified Chronic kidney disease, unspecified Occlusion and stenosis of carotid artery without mention of cerebral infarction Other and unspecified hyperlipidemia Other late effects of cerebrovascular disease Osteoarthrosis, unspecified whether generalized or localized, site unspecified Redundant prepuce and phimosis Occlusion and stenosis of basilar artery without mention of cerebral infarction Memory loss Vitiligo

allergies: macrodantin / augmentin attending: chief complaint: back and neck pain major surgical or invasive procedure: cystoscopy - transvaginal biopsy - cytoscopy with clot evacuation - history of present illness: 77 year old woman with history of hypertension, hypothyroidism, significant vascular disease requiring multiple vascular surgeries including aorto-r carotid bypass for subclavian steal syndrome, and remote aortobifemoral bypass, seizure disorder, and subacute onset of atraumatic chest, back and neck pain, who was referred to ed from pcp's office today for worsening upper and lower back pain. her pain is primarily over her upper back and neck, as well as some bilateral anterior chest pain, all of which are worsened with movement. . these symptoms have been accompanied by worsening fatigue, anorexia and decreased functional status over the past several weeks. she typically is active, plays tennis and is totally independent in her adls. she currently has great difficulty with walking up stairs, lifting laundry, and exerting herself in other ways. she has lost 15 lbs over the past 1-2 months. she denies fevers, chills, or drenching sweats. denies tingling, numbness, paresthesias, bowel incontinence, or urinary retention. her pcp has recently considered the diagnosis of pmr as an explanation for her symptoms; the patient's pain did not respond to steroid therapy, and she completed a taper to off, this morning. . in the ed, initial vs: 97.6. 151/77. 78. 18. 97% ra. neuro exam was nonfocal, and pt had no focal or midline spinal tenderness. labs notable for leukocytosis with left shift, anemia (hct 34) and hyponatremia (129). u/a demonstrated pyuria, bacteriuria, and hematuria. cta of torso revealed obstructing bladder mass with hydronephrosis and hydroureter, lytic t6 lesions extending posteriorly into spinal canal, l3 compression fracture, and other mottled appearing cervical vertebrae concerning for metastatic disease. pt was given normal saline, 5 mg diazepam po, morphine 4 mg iv x2, and ceftriaxone 1g. spine was consulted and recommended mri for further characterization of vertebral lesions and spinal cord pathology. mri was ordered but pt was transferred to floor prior to mri, given delay. vs prior to transfer were 89 174/80 18 97%ra. . currently, she is accompanied by her daughter; both women are quiet and intermittently tearful, expressing concern about pt's life expectancy. she continues to have significant back and neck pain with movement, but feels more comfortable when she is still. denies any paresthesias or numbness. denies urinary symptoms, although may be having the urge to urinate more frequently than usual. she can pass urine easily when she needs to. past medical history: retinal ischemia w neovascular glaucoma hypothyroidism elevated homocysteine branch retinal artery occlusion (r) atherosclerosis, aortofemoral s/p ascending aorta to r common carotid bypass - s/p bypass graft, aortobifemoral hx of carotid artery occlusion (l) s/p carotid endarterectomy (l) hx of tobacco use (50 pack years discontinued ) macrocytic anemia hypertension osteopenia mitral regurgitation chronic kidney disease stage ii hx of seizure disorder hx of pasteurella infection (arm) urinary tract infection, chronic hx of pelvic fracture social history: lives at home with husband, who has prostate cancer. +50 pack-year tobacco history, quit in . daughter and family are close by and involved. family history: "heart disease" in parents and siblings. sister had breast cancer. no other cancer history. physical exam: admission exam: . vs - temp 98.0f, bp 190/92, hr 93, r 19, o2-sat 95% ra, pain, 48.7 kg general - thin elderly woman appears alert and interactive but depressed, nad heent - anisocoria with r > l pupillary dilation. eomi, sclerae anicteric, mmm, op clear neck - supple, decreased lateral rotational rom due to pain, no jvd, no carotid bruits heart - pmi non-displaced, rrr, nl s1-s2, no mrg lungs - ctab, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use back - no abnormal contours or trauma. no midline tenderness, scoliosis or kyphosis abdomen - nabs, soft/nt/nd, no masses or hsm rectal - normal sphincter tone extremities - thin, wwp, no c/c/e, 2+ peripheral pulses skin - no rashes or lesions neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, patellar and achilles dtrs are 2+ and symmetric, cerebellar exam intact, gait assessment deferred due to pain . discharge exam: patient unresponsive to noxious stimuli in 4 extremities. pupils fixed and dilated to light. no heart sounds or breathing while listening over precordium for 1 minute. no pulses palpated in radial pulses or carotids bilaterally. pertinent results: admission labs: 05:34pm blood wbc-14.8*# rbc-3.27* hgb-12.1 hct-34.1* mcv-104*# mch-37.1* mchc-35.6* rdw-15.8* plt ct-278# 07:19pm blood pt-13.2* ptt-34.1 inr(pt)-1.2* 05:34pm blood glucose-113* urean-17 creat-0.9 na-129* k-3.5 cl-89* hco3-25 angap-19 05:34pm blood alt-12 ast-29 alkphos-210* totbili-0.3 05:34pm blood totprot-7.3 albumin-4.3 globuln-3.0 calcium-10.4* phos-3.9 mg-1.4* . microbiologic data: urine culture - coagulase negative staphylococcus blood culture (x 2) - no growth urine culture - no growth mrsa screening - negative blood culture (x 2) ?????? no growth blood culture ?????? no growth blood culture x2 - ngtd . imaging studies: mr cervical, thoracic, lumbar spine w/o c - extensive bone marrow changes of the cervical, thoracic, and lumbar spine as detailed above, representing osseous metastatic disease. compression fractures are identified at t3 and t6, the latter with mild retropulsion and indentation on the spinal cord. multilevel degenerative changes of the cervical spine with spinal canal stenosis. . liver or gallbladder us - distended gallbladder without stones or other sign of acute cholecystitis. mild intrahepatic biliary duct dilatation. severe right hydronephrosis, fully discussed on the recent cta torso from , likely secondary to bladder cancer. trace perihepatic ascites. . mr pelvis w&w/o contras - urinary catheter is noted within the bladder with thrombus identified in relation to the right ureteric orifice. abnormal region enhancing mass noted in the right distal ureter causing proximal right hydronephrosis and hydroureter concerning for either a transitional carcinoma of the right distal ureter versus a bladder mass invading the right ureteric orifice. diffuse osseous metastatic disease noted of the axial pelvic skeleton. . ct head w/ & w/o contra - no evidence of metastatic lesions to the brain or bones. mri would be more accurate in identifying metastatic lesions if not contraindicated. . ct abd & pelvis w/o con - right hydroureter and hydronephrosis, with hyperdense material distending the right renal pelvis, ureter and the bladder, compatible with hemorrhage. the biopsied periureteral mass likely responsible for the hemorrhage is not appreciated by non contrast ct. new low-density ascites, with small hyperdense component in the cul-de-sac. given the clnical history, this likely reflects bladder rupture, with the low-density fluid representing urine. the small hyperdense component in the cul-de-sac is attributable to the blood products seen within the bladder. left greater than right pleural effusions, with associated atelectasis. . 2d-echo - the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is at least 15 mmhg. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with fical mid anterior/anteroseptal hypokinesis, the remaining segments are hyperdynamic and thus the overall lvef is preserved. there is no ventricular septal defect. the right ventricular cavity is dilated with normal free wall contractility. there is abnormal septal motion/position. 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 severe mitral annular calcification. there is mild functional mitral stenosis (mean gradient 9 mmhg) due to mitral annular calcification. an eccentric jet of moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . chest (portable ap) - as compared to the previous radiograph, there is an increase in severity of the pre-existing pulmonary edema. this is reflected by increased interstitial markings, widening of the right aspect of the mediastinum, increase in diameter of the cardiac silhouette and, potentially, a small left pleural effusion. no other abnormalities are noted. the right venous introduction sheath is in unchanged position. . cxr: the left picc line can be seen to the level of the mid portion of left brachiocephalic vein. advancement by at least 6 cm is recommended to bring the tip of the picc line into the svc. the dobbhoff tube tip is below the inferior margin of the film, most likely in the stomach. the heart size and mediastinum are unchanged. widespread parenchymal opacities and bilateral pleural effusion is unchanged. brief hospital course: 77 y/o woman with significant vasculopathy, seizure history, hypothyroidism, chronic uti presenting with back pain found to be spinal mets from an obstructing periureteral mass. underwent transvaginal biopsy which showed urothelial carcinoma. hospital course complicated by perforation of the bladder and significant hematuria requiring 4 units of rbcs and transfer to micu. she also required emergent cystoscopy and had hypoxic respiratory distress. patient was transferred to the oncology floor when her respiratory distress improved with diuresis, however, returned to the icu after iv fluid administration for hypercalcemia worsened her respiratory status. as patient was not deemed to be a candidate for a radiation or chemotherapy for her primary cancer given her poor functional status, multiple discussions with the family, icu/medical team and palliative care team were had and patient was made comfort measures only. she was started on aggressive comfort measures to control her pain from osseous metastases and also to ease her breathing and died on . . # acute hypoxic respiratory failure: patient presented following her repeat cystoscopy with worsening oxygen requirement and she has acute hypoxia with 2d-echo showing systolic dysfunction with a prior anterolateral injury and evidence of hypokinesia that likely resulted in volume overload and flash pulmonary edema. she responded to lasix diuresis and her oxygenation improved. she was also given nebulizer treatments. her initial oxygen requirement was a non-rebreather and she quickly weaned to nasal cannula. she required a short return to the icu given some fluid administration needs and with diuresis and anti-hypertensive therapy her respiratory status stabilized. . # delirium: the patient developed delirium concerns this admission which was considered multifactoral in origin. her infection concerns were treated, her metabolic derangements were addressed and we felt her pain control and icu delirium was most likely contributing. we optimized her medication regimen, controlled her pain with dilaudid and optimized her sleep cycles. . # ureteral mass/urothelial carcinoma: she was initially sent to the ed for back pain. a ct of the torso revealed an obstructing bladder mass with mets throughout the lumbar, thoracic and cervical spine. urology was consulted and she underwent a cystoscopy on which showed an extravesicular mass, pushing into the right ureter and bladder. she was started on continuous bladder irrigation for hematuria. an mri showed that the mass was actually periureteral. she underwent a transvaginal ultrasound guided ir biopsy on . on , her hct dropped from 28->18 and her stomach became tense and distended. she was transfused 4 units of packed red cells and transferred to the micu. urology repeated her cystoscopy and noted a bladder tear which was conservatively managed with continuous bladder irrigation. . # hypercalcemia: transient elevation in serum calcium to 10-11 range in the setting of malignancy which improved with bisphosphonate administration, calcitonin and diuretic therapy; given her volume concern issues, fluids were deferred for calcium management. . # spinal mets: her back pain was initially concerning for pmr and was treated by pcp with steroids. she was discovered on ct torso to have diffuse mets to the spine. palliative care was called for assistance with pain management. she was given morphine and ms contin, as well as dexamethasone and gabapentin. dilaudid was switched to morphine due to confusion. neuro spine was consulted and recommened a tlso brace at all times when out of bed. radiation oncology was consulted for palliative radiation options. she initiated palliative spine radiation this admission. . # acute kidney injury: creatinine bumped on from baseline 0.9 up to 1.6. this was initially concerning for obstruction from clots in the bladder. she was given iv fluids initially and her creatinine improved to baseline. following resuscitation, her creatinine remained stable in the setting of diuresis needs. . # hypertension: hctz was stopped early on in hospital stay due to electrolyte abnormalities. metoprolol was restarted and uptitrated for hypertension and tachycardia given her episode of flash pulmonary edema and ongoing respiratory distress. her 2d-echo demonstrated cardiac dysfunction with a diastolic component which was treated with acei and beta-blocker therapy. . # pvd: status post aorto-carotid and aorto-bifemoral bypasses. on aggrenox at home. this was held in preparation for biopsy and remained off in the setting of bleeding. it was restarted after discussion with urology team, when bleeding from her bladder perforation stabilized . # hypothyroidism: has been high per pcp for unclear reasons. continued home levothyroxine . # seizure history: we continued phenytoin, vitamin b6 supplementation. . # uti: she has chronic utis per her pcp. was asymptomatic but was treated for 7 days with ceftriaxone then dicloxacillin for urine culture showing staph epi. medications on admission: aggrenox 25-200 lipitor 20 mg tab daily dilantin cap 100mg qam, 200mg qpm (phenytoin sodium extended) dilantin 60 mg caps (phenytoin sodium extended) qhs synthroid 300 mcg daily sertraline hcl 200 mg daily metoprolol succinate 25 mg xr 24h-tab (metoprolol succinate) hydrochlorothiazide 12.5 mg daily folgard rx 2.2 tabs 0.5-2.2-25 mg (folate-vit b6-vit b12) cipro 500 mg tabs (ciprofloxacin hcl) 1 po hs discharge medications: none. discharge disposition: expired discharge diagnosis: urothelial carcinoma discharge condition: expired discharge instructions: none followup instructions: none md Procedure: Enteral infusion of concentrated nutritional substances Other cystoscopy Other cystoscopy Closed [transurethral] biopsy of bladder Transurethral clearance of bladder Transurethral clearance of bladder Diagnoses: End stage renal disease Malignant neoplasm of liver, secondary Congestive heart failure, unspecified Acute posthemorrhagic anemia Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Hyposmolality and/or hyponatremia Other chronic pulmonary heart diseases Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Epilepsy, unspecified, without mention of intractable epilepsy Gross hematuria Secondary malignant neoplasm of lung Acute diastolic heart failure Hydronephrosis Delirium due to conditions classified elsewhere Secondary malignant neoplasm of bone and bone marrow Hypercalcemia Hemoperitoneum (nontraumatic) Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Neoplasm related pain (acute) (chronic) Pathologic fracture of vertebrae Hemorrhage into bladder wall Malignant neoplasm of other specified sites of bladder Body Mass Index less than 19, adult Chronic lymphocytic thyroiditis Rupture of bladder, nontraumatic Chronic pyelonephritis without lesion of renal medullary necrosis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: headache major surgical or invasive procedure: : suboccipital craniotomy for chiari decompression history of present illness: patient is a 30m electively admitted for chiari type i decompression. past medical history: osa chiari malformation(type i) social history: non-contributory family history: non-contributory physical exam: exam on discharge: neurologically intact pertinent results: 06:05am blood wbc-8.2 rbc-4.07* hgb-12.4* hct-35.7* mcv-88 mch-30.4 mchc-34.6 rdw-12.4 plt ct-284 06:05am blood plt ct-284 06:05am blood glucose-106* urean-13 creat-0.8 na-136 k-4.1 cl-98 hco3-26 angap-16 06:05am blood calcium-9.6 phos-4.3 mg-2.1 06:05am blood glucose-106* urean-13 creat-0.8 na-136 k-4.1 cl-98 hco3-26 angap-16 06:05am blood calcium-9.6 phos-4.3 mg-2.1 brief hospital course: patient is a 30m electively admitted for suboccipital craniotomy for chiari type i malformation. operative course was uneventful, and he was taken to the icu post-operatively for close neuromonitoring overnight. post-op head ct showed no hemorrhage. there were no adverse events overnight. he was transfered to the floor on , his pca was discontinued and given po medications. he continued with normal expected headaches throughout his hospitalization. his incision was clean and dry. on discharge he was voiding, tolerating a regular and had a normal neurological exam. medications on admission: ambien prn, motrin prn, fluocinonide prn 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. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 3. methocarbamol 500 mg tablet sig: 1.5 tablets po qid (4 times a day). disp:*180 tablet(s)* refills:*2* 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. discharge disposition: home discharge diagnosis: chiari type i malformation discharge condition: neurologically stable discharge instructions: general instructions wound care ?????? you or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? keep your incision clean and dry. ?????? you may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? do not apply any lotions, ointments or other products to your incision. ?????? do not drive until you are seen at the first follow up appointment. ?????? do not lift objects over 10 pounds until approved by your physician. usually no special is prescribed after a craniotomy. a normal well balanced is recommended for recovery, and you should resume any specially prescribed you were eating before your surgery. medications: ?????? take all of your medications as ordered. you do not have to take pain medication unless it is needed. it is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? do not use alcohol while taking pain medication. ?????? medications that may be prescribed include: -narcotic pain medication such as dilaudid (hydromorphone). -an over the counter stool softener for constipation (colace or docusate). if you become constipated, try products such as dulcolax, milk of magnesia, first, and then magnesium citrate or fleets enema if needed). often times, pain medication and anesthesia can cause constipation. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc, as this can increase your chances of bleeding. activity: the first few weeks after you are discharged you may feel tired or fatigued. this is normal. you should become a little stronger every day. activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. in general: ?????? follow the activity instructions given to you by your doctor and therapist. ?????? increase your activity slowly; do not do too much because you are feeling good. ?????? you may resume sexual activity as your tolerance allows. ?????? if you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? do not drive until you speak with your physician. ?????? do not lift objects over 10 pounds until approved by your physician. ?????? avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? do your breathing exercises every two hours. ?????? use your incentive spirometer 10 times every hour that you are awake. when to call your surgeon: with any surgery there are risks of complications. although your surgery is over, there is the possibility of some of these complications developing. these complications include: infection, blood clots, or neurological changes. call your physician immediately if you experience: ?????? confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? double, or blurred vision. loss of vision, either partial or total. ?????? hallucinations ?????? numbness, tingling, or weakness in your extremities or face. ?????? stiff neck, and/or a fever of 101.5f or more. ?????? severe sensitivity to light. (photophobia) ?????? severe headache or change in headache. ?????? seizure ?????? problems controlling your bowels or bladder. ?????? productive cough with yellow or green sputum. ?????? swelling, redness, or tenderness in your calf or thigh. call 911 or go to the nearest emergency room if you experience: ?????? sudden difficulty in breathing. ?????? new onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? a seizure that lasts more than 5 minutes. important instructions regarding emergencies and after-hour calls ?????? if you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. . followup instructions: follow-up appointment instructions ??????please return to the office in days (from your date of surgery) for removal of your sutures and 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 2 weeks. ??????you will not need a ct scan of the brain. Procedure: Other exploration and decompression of spinal canal Other repair of cerebral meninges Diagnoses: Compression of brain

allergies: iv dye, iodine containing contrast media attending: chief complaint: s/p fall - wrist fracture, visual deficit major surgical or invasive procedure: angio with coiling pcomm / amgioseal history of present illness: this is a 69 year old female on 81 mg aspirin daily with known right pcom aneurysm 7 mm as seen on mri in of this year was transferred from following a 5 minute episode of "triple vision" , blurred vision. she describes this as when she looked at the receptionist at she saw three heads stacked upon each other instead of one. the patient was about to be discharge from with a left sprain wrist. after she experienced the triple vision a head ct was performed which was found to be negative. given the patient's known right pcom aneurysm , she was transferred here for further evaluation and treatment by this neurosurgery service. the patient originally had the mri in due to an episode of slurred, non sensical speech. she states that she was at an appointment and her words became garbled. she notified her pcp who ordered an mri. the patient was to see neurology to discuss the mri findings later this week on tuesday. currently, the patient has no neurological complaints. she denies diplopia, speech difficulty, weakness other than at the location of her sprained left wrist. the patient denies weakness, numbness, tingling sensation. she denies bowel or bladder dysfunction or hearing deficit. past medical history: right lens implant, asthma, htn, hypothyroidism, hyperactive bladder, renal ca with partial nephrectomy 5 years ago- treated. social history: nc family history: nc physical exam: o: t:98.4 bp: 109/96 hr: 90 r: 16 o2sats:98% ra gen: comfortable, nad. heent: pupils: pupils are bilaterally reactive . right eye is irregular surgical pupil 5mm and left pupil is 5-4mm eoms: intact neck: supple. extrem: left wrist sprain neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils are bilaterally reactive . right eye is irregular surgical pupil 5mm and left pupil is 5-4mm.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 except left wrist was not challenged due to sprain.. no pronator drift sensation: intact to light touch, proprioception bilaterally. toes downgoing bilaterally coordination: normal on finger-nose-finger, rapid alternating movements upon discharge: alert, oriented x3, r pupil surgical, l pupil reactive, mae full motor pertinent results: nchct at impression: 1. no evidence of acute large vessel territorial infarct or intracranial hemorrhage. 2. nonspecific periventricular and subcortical white matter hypoattenuation, likely the sequelae of microangiopathic disease. mri brain :impression: 1. right posterior communicating artery aneurysm measuring 7 mm,directed posteriorly and slightly laterally.2. fetal origin of the right posterior communicating artery withnonvisualization of the right p1 segment.3. stenosis of the proximal right internal carotid artery of approximately 55%.4. mild nonspecific periventricular and subcortical white matter disease, likely the sequela of small vessel ischemic change in a patient this age. brief hospital course: patient was admitted to neurosurgery on to the neurosurgery service - icu. on , she underwent the above stated procedure. please review dictated operative report for details. she was transferred back to icu in stable condition. she did well overnight and was transferred to the sdu on . on , she remained nonfocal, afebrile, tolerating a regular diet and ambulating without difficulty. medications on admission: synthroid, amlodipine, vesicare, lisinopril, singulair, mvi, calcium+d, asa 81, benefiber 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. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 3. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 4. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 6. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 7. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days: began . disp:*5 tablet(s)* refills:*0* 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. acetaminophen extra strength 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 10. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. vesicare 10 mg tablet sig: one (1) tablet po daily (daily). 12. plavix 75 mg tablet sig: one (1) tablet po once a day: begin 5 days prior to your angiogram. disp:*35 tablet(s)* refills:*0* 13. prednisone 20 mg tablet sig: two (2) tablet po 16 hrs, 8 hrs, & 2 hrs prior to your angiogram for 3 doses. disp:*6 tablet(s)* refills:*0* 14. zantac 150 mg tablet sig: one (1) tablet po twice a day for 3 doses: begin with steroids. disp:*3 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: right posterior communicating artery aneurysm discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: angiogram with embolization medications: ?????? take aspirin 325mg (enteric coated) once daily. ?????? take plavix (clopidogrel) 75mg once daily starting 5 days prior to your scheduled angiogram in one month. we will provide you with a rx for 35 tablets as you will continue plavix one month post-coiling. ?????? continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs. ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? after 1 week, you may resume sexual activity. ?????? after 1 week, gradually increase your activities and distance walked as you can tolerate. you may return to work when you feel ready as long as you are able to maintain the above restrictions for 7 days. ?????? no driving until you are no longer taking pain medications what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? trouble swallowing, breathing, or talking ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site *sudden, severe bleeding or swelling (groin puncture site) lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call our office. if bleeding does not stop, call 911 for transfer to closest emergency room! ****** pre-op meds for angio in one month ****** plavix 75 mg daily - begin 5 days prior to your angio prednisone 20 mg tablets (for dye allergy) take 2 tablets (40 mg) by mouth 16 hours prior to the procedure or test, 8 hours prior, and 2 hours prior. zantac (ranitidine) 150 mg tablets take 1 tablet by mouth twice daily along with the prednisone. please be sure to take 1 dose one hour prior to your procedure or testing. (will be given in the hospital) benadryl 25 mg capsules take 2 capsules (50 mg) by mouth one hour prior to your procedure or testing. followup instructions: please call to schedule a cerebral angiogram with completion of coil with stent assist in one month. you will need to take steroids prior for your allergy to dye. also take plavix 75mg for 5 days prior. Procedure: Arteriography of femoral and other lower extremity arteries Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Cerebral aneurysm, nonruptured Personal history of malignant neoplasm of kidney Hypertonicity of bladder

allergies: iv dye, iodine containing contrast media attending: chief complaint: elective admit for coiling of pcomm aneurysm major surgical or invasive procedure: coiling of r pcomm aneurysm history of present illness: pt is a 69f with previously coiled r pcomm aneurysm who presents for elective admission for re-coiling procedure. past medical history: right lens implant, asthma, htn, hypothyroidism, hyperactive bladder, renal ca with partial nephrectomy 5 years ago- treated. social history: nc family history: nc physical exam: non focal brief hospital course: pt was admitted to the neurosurgery service and underwent elective coiling of r pcomm aneurysm. she tolerated the procedure well with no complications. post operatively she was transferred to the icu for further care including sbp control and a heparin gtt for 24 hours. her post op exam remained stable and she had no issues. she was transferred to the floor in stable condition on . she was oob and had no difficulty voiding on her own or tolerating a po diet. she was dc'd home in stable condition on and will follow up accordingly. medications on admission: levothyroxine, norvasc, asa 325 discharge medications: 1. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*75 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: r pcomm aneurysm discharge condition: aox3. activity as tolerated. no lifting greater than 10 pounds. discharge instructions: medications: ?????? take aspirin as you have been prescribed and continue this until further discussion with dr. in clinc. continue all other medications you were taking before surgery, unless otherwise directed ?????? you make take tylenol or prescribed pain medications for any post procedure pain or discomfort. what activities you can and cannot do: ?????? when you go home, you may walk and go up and down stairs. ?????? you may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? no heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? 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 what to report to office: ?????? changes in vision (loss of vision, blurring, double vision, half vision) ?????? slurring of speech or difficulty finding correct words to use ?????? severe headache or worsening headache not controlled by pain medication ?????? a sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? trouble swallowing, breathing, or talking ?????? numbness, coldness or pain in lower extremities ?????? temperature greater than 101.5f for 24 hours ?????? new or increased drainage from incision or white, yellow or green drainage from incisions ?????? bleeding from groin puncture site *sudden, severe bleeding or swelling (groin puncture site) lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. if bleeding stops, call our office. if bleeding does not stop, call 911 for transfer to closest emergency room. followup instructions: please follow up in 1 month with dr. with an mri/mra of the head. call for an appt. Procedure: Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Cerebral aneurysm, nonruptured Personal history of malignant neoplasm of kidney Hypertonicity of bladder

allergies: somatostatin / compazine / dilaudid / meperidine / percocet / bactrim / fentanyl / oxycontin / paxil / demerol / droperidol / lactose / barium sulfate / iodine-iodine containing / pantoprazole / omeprazole / codeine / sulfa (sulfonamide antibiotics) / tramadol / iv dye, iodine containing contrast media / lovenox attending: chief complaint: dehydration major surgical or invasive procedure: none history of present illness: ms. is a 50yo f with complicated pmh including sclerosing mesenteritis who presents from home with dizziness and decreased uop x 1 day. she initially came to today to be seen by the iv access team due to redness and swelling in the r groin after exchange of her cvl a few days ago. she made herself npo at 630 this am in case she required any intervention for her line. of note, multiple recent admissions, most recently for ?sbo. ultimately, it was felt that her increased pain was "multifactorial from both physical and emotional pain." her g-tube and fem line for tpn were both re-placed that admission. for insurance/financial reasons, pt was unable to get home fluid boluses, although did continue her usual tpn. she is able to take a small amount of po at baseline. in the ed, initial vs were: t97, hr 83, bp 83/50, rr 18, 98% ra in the ed, she was given 3.5l ns and pressures were in the 80s-low 90s. baseline pressure per omr 110s. fsg 60 in ed, but came up with d5w. on arrival to the micu, patient's vs bp 122/89, hr 76, rr 18, 100% ra. past medical history: -sclerosing mesenteritis (dx'd in , s/p multiple abdominal surgeries, including placement of decompressive g-tube) -recurrent sbo -chronic gi dysmotility -ibs -nsaid-related gastritis and ugi bleed -hep c (transmitted via transfusion in ) -recurrent dvts (most recently in the r subclavian vein , not on lovenox at the time) -anemia -mitral valve prolapse -migraine has w/ visual aura -asthma -nocturnal benign myoclonus -chronic tachycardia (hr in the 120s) -depression -osteopenia -gerd -esophagitis -recurrent utis -sebaceous cysts . past surgical history: 23 abdominal surgeries -including multiple loas -colonic decompressions -sbrs - parts of duodenum, entire ileum -repair of incisional hernias -appendectomy -open ccy -g-tube placement -extraction of duodenal bezoar -multiple port-a-cath placements and removals -l hemi-thyroidectomy -breast reduction and multiple breast lumpectomies -tooth extractions -b/l knee arthroscopies -b/l ankle reconstructions -c-section social history: lives in with husband, has two sons and a cat. no smoking history, no alcohol use. previously worked as a computer programmer but has been on disability since . her husband is also chronically ill. family history: - mother with myelofibrosis, , breast ca age 30, died at 61 - father with , htn, mi s/p cabg, aortic aneurysm died at 75 - brother with glioblastoma multiformans, died 46 - sister lupus, bowel obstruction, breast cancer mets to brain - two sons w/ celiac, one with jra physical exam: physical exam on admission general: alert, oriented, no acute distress heent: sclera anicteric, dry mucous membranes cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-distended, hypoactive bowel sounds. g-tube with brown-green output, site dressed. diffuse tenderness to light touch. ext: warm, well perfused skin: r groin cvl insertion site clean, intact. there is some erythema and induration medial to the line that is tender to light palpation. pertinent results: cxr: spinal stimulator device is redemonstrated in unchanged position. the heart size is normal. the mediastinal and hilar contours are unremarkable. the pulmonary vascularity is within normal limits. there is minimal atelectasis in the left lung base. no focal consolidation, pleural effusion or pneumothorax is visualized. impression: minimal atelectasis in the left lung base. 05:00am blood wbc-3.0* rbc-3.18* hgb-9.0* hct-28.0* mcv-88 mch-28.4 mchc-32.3 rdw-16.3* plt ct-135* 03:00pm blood wbc-5.6# rbc-3.94*# hgb-10.9* hct-34.5* mcv-88 mch-27.7 mchc-31.7 rdw-16.6* plt ct-195 12:18pm blood na-141 k-4.0 cl-111* 05:00am blood glucose-84 urean-17 creat-0.6 na-142 k-3.2* cl-111* hco3-21* angap-13 03:00pm blood albumin-3.8 brief hospital course: ms. is a 50yo f with complicated pmh including sclerosing mesenteritis who presents from home with dizziness and decreased uop x 1 day found to have systolic bp in the 80s in the setting of being unable to recieve ivf boluses as prescribed and no po intake for > 12 hours. # hypovolemic hypotension: the patient has not used her home iv fluids for some time because of insurance issues. on day of admission she held her po intake in case she needed a procedure for r femoral venous catheter. these 2 events led to her hypotension. she was admitted to the icu and quickly recovered w/ aggressive ivf. infection on differential but less likely; blood and urine cultures were negative, no empiric abx were given. # r groin pain: has a femoral venous catheter for home tpn. given pain from tunnelled site the patient had the catheter re-tunnelled during this hospitalization. # chronic pain: on morphine suppositories, increased on recent admission from 20mg q6h to 25mg q6h. patient reports no relief with this increase. she states honestly that if she continues to uptitrate it without relief, she may discontinue altogether because she sees no purpose in taking higher doses of an ineffective opioid. she was treated with iv dilaudid 1mg doses while in house for additional pain control; it was noted that she was not admitted for any acute pain issues and therefore her home narcotics are not to be changed for discharge. we would recommend she continue outpatient pain mgmt and have an established narcotics contract. patient was discharged with a script for morphine suppositories as the script that her pain management doctor had sent was lost in the mail. inactive issues: # abdominal pain, sclerosing mesenteritis: pt followed by dr. as well as pain mangement. - continued home regimen: gabapentin, morphine pr - gets monthly lupron injections # depression/anxiety: likely contributing to chonic pain per medical and sw assesment last admission. pt endorsing worsening of her depression and frustration with multiple hospitalizations. - con't home meds: lamotrigine, abilify, trazodone, lorazepam - clonidine patch held - seen by psychiatry and social work # migraines: continude home butorphanol and sumatriptan. # anemia: pt currently above baseline hct (29-32). - continued home ferrous sulfate. # hypothroidsim: continued home levothyroxine # code: dnr dni(confirmed) medications on admission: meds (per d/c summary ): 1. aripiprazole *nf* 2 mg oral daily reason for ordering: wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. please dispense liquid form! thanks 2. docusate sodium 100 mg po bid 3. gabapentin 900 mg po q8h 4. clonidine patch 0.2 mg/24 hr 1 ptch td qtues 5. ferrous sulfate (liquid) 300 mg po daily 6. lamotrigine 75 mg po daily 7. lansoprazole oral disintegrating tab 30 mg po daily 8. levothyroxine sodium 88 mcg po daily 9. misoprostol 200 mcg po qidpchs 10. octreotide acetate 100 mcg sc q8h 11. pilocarpine hcl *nf* 10 mg oral reason for ordering: wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 12. senna 1 tab po bid 13. vitamin d 1000 unit po daily 14. trazodone 150 mg po hs:prn insomnia 15. sumatriptan succinate 6 mg sc q4h:prn migraine headache please give first injection at onset of headache. can give second injection 4 hours later. no more than 2 injections per day 16. butorphanol tartrate *nf* 10 mg/ml nu qid:prn headache * patient taking own meds * 17. lorazepam 1 mg po hs:prn sleep 18. diphenhydramine 12.5 mg po q6h:prn itching 19. leuprolide acetate 3.75 mg im qmonth duration: 1 doses 20. promethazine 25 mg pr q6h:prn nausea 21. polyethylene glycol 17 g po daily 22. enoxaparin sodium 40 mg sc daily 23. morphine sulfate 25 mg pr q6h hold for sedation, rr<12 discharge medications: 1. aripiprazole 1 mg/ml solution : two (2) po daily (daily). 2. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 3. gabapentin 300 mg capsule : three (3) capsule po q8h (every 8 hours). 4. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : one (1) po daily (daily). 5. lamotrigine 25 mg tablet : three (3) tablet po daily (daily). 6. levothyroxine 88 mcg tablet : one (1) tablet po daily (daily). 7. misoprostol 200 mcg tablet : one (1) tablet po qidpchs (4 times a day (after meals and at bedtime)). 8. octreotide acetate 100 mcg/ml solution : one (1) injection q8h (every 8 hours). 9. pilocarpine hcl 5 mg tablet : two (2) tablet po bid (2 times a day). 10. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day). 11. cholecalciferol (vitamin d3) 1,000 unit tablet : one (1) tablet po daily (daily). 12. trazodone 150 mg tablet : one (1) tablet po hs (at bedtime) as needed for insomnia. 13. sumatriptan succinate 6 mg/0.5 ml solution : one (1) subcutaneous x2 prn as needed for migraine. 14. diphenhydramine hcl 25 mg capsule : 0.5 capsule po q6h (every 6 hours) as needed for itching. 15. polyethylene glycol 3350 17 gram powder in packet : one (1) powder in packet po daily (daily). 16. butorphanol tartrate 10 mg/ml spray, non-aerosol : one (1) spray nasal q4h (every 4 hours) as needed. 17. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 18. ethanol (ethyl alcohol) 98 % solution : one (1) ml injection daily (daily). 19. morphine 20 mg suppository : one (1) rectal every six (6) hours as needed for pain. disp:*40 tabs* refills:*0* 20. morphine 5 mg suppository : one (1) rectal every six (6) hours. disp:*40 tabs* refills:*2* 21. zolpidem 5 mg tablet : one (1) tablet po hs (at bedtime). disp:*10 tablet(s)* refills:*0* 22. enoxaparin 40 mg/0.4 ml syringe : one (1) subcutaneous daily (daily). 23. tpn see attached order discharge disposition: home with service facility: vna discharge diagnosis: hypotension depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted because you developed low blood pressure after not eating in preparation for a procedure. your blood pressure improved with iv fluids. during this admission your iv catheter in the femoral vein was re-tunnelled. during this admission you were seen by social work and psychiatry. your home medications remain the same. followup instructions: department: pain management center when: monday at 11:10 am with: ,md building: one place (, ma) campus: off campus best parking: parking on site department: div. of gastroenterology when: tuesday at 9:40 am with: , md building: ra (/ complex) campus: east best parking: main garage department: when: wednesday at 10:10 am with: post clinic building: sc clinical ctr campus: east best parking: garage Procedure: Parenteral infusion of concentrated nutritional substances Central venous catheter placement with guidance Diagnoses: Other chronic pain Anemia, unspecified Esophageal reflux Mitral valve disorders Chronic hepatitis C without mention of hepatic coma Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Anxiety state, unspecified Hypotension, unspecified Other postprocedural status Do not resuscitate status Dehydration Gastrostomy status Sclerosing mesenteritis Myoclonus Irritable bowel syndrome Migraine with aura, without mention of intractable migraine without mention of status migrainosus

allergies: cipro attending: chief complaint: acute renal failure major surgical or invasive procedure: bilateral nephrostomy tube placement by ir history of present illness: the patient is a 53 year old female with no significant past medical history who presents with increasing nausea/vomiting and malaise. two weeks prior to presentation, the patient had symptoms of a uti with increased urinary frequency and lower abdominal pressure. she has no history of prior utis and did not note any blood in her stool she was not experiencing any fevers/chills, but did have some lower left flank discomfort. the patient was started on ciprofloxacin, but had immediate gi distress, and was switched to bactrim. she continued bactrim to complete the course. her urinary symptoms did improve, but she continued to have gi symptoms. she had been constipated over the last 2 weeks, had an inability to tolerate pos, and had nausea/vomiting. she denies bruising, easy infections, or fatigue. she had ? fevers with chills for the last 2 days, decreased uop, and worsening flank discomfort. the patient decided to come to the ed for evaluation. . the patient presented to hospital. she was found to have arf with a cr of 29.2, and a k of 6.3. she was given 1l of ns, kayexalate, glucose, insulin, calcium. the patient was transfered to for further evaluation. . on arrival to , vitas were 97.3, bp of 168/103, hr 97, 97% on ra. repeat k was 6.0 without ekg changes. she was given d5 with an mp of bicarb, calcium gluconate, and 20ml of aluminum hydroxide. urology was consulted, and the patient was admitted to the micu for close monitoring past medical history: patient had a prior csxn social history: the patient is a housewife, with 2 teenage children. she is a social drinker, and denies tobacco/ivdu. family history: no family history of kidney stones, renal carcinoma, or other kidney problems. physical exam: vitals: t:97.7 bp:150/88 p:91 r:20 18 o2:94%ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, 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 back: b/l nephrotomy tubes in place and draining. dressing c/i/d. pt with b/l cva tenderness ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: 07:00pm blood wbc-10.5 rbc-3.22* hgb-9.5* hct-27.8* mcv-86 mch-29.6 mchc-34.3 rdw-12.7 plt ct-477* 08:25pm blood pt-14.3* ptt-34.9 inr(pt)-1.2* 07:00pm blood glucose-65* urean-143* creat-27.5* na-123* k-6.0* cl-84* hco3-10* angap-35* 01:48am blood alt-3 ast-12 ld(ldh)-225 totbili-0.2 05:30am blood ck-mb-notdone ctropnt-<0.01 01:48am blood calcium-8.2* phos-13.2* mg-2.4 uricacd-11.8* 05:55am blood caltibc-186* ferritn-732* trf-143* 05:03pm blood pth-174* 10:08am urine color-red appear-cloudy sp -1.005 10:08am urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-mod 10:08am urine rbc->50 wbc-* bacteri-none yeast-none epi-0 02:40pm urine hours-random urean-148 creat-25 na-71 k-17 cl-71 02:40pm urine osmolal-239 11:15 am urine,kidney site: kidney rt. kidney. **final report ** fluid culture (final ): staphylococcus, coagulase negative. rare growth. ct-abd/pelvis impression: bilateral mild-to-moderate hydronephroureter with mild bilateral perinephric stranding. no obstructing stones or extrinsic masses identified, however, evaluation is limited without iv contrast administration; a non- contrast mru or retrograde study can be performed for further evaluation. renal u/s impression: mild-to-moderate bilateral hydronephrosis. no stone or mass is noted within the kidneys. both kidneys have normal echogenicity. cxr: impression: no evidence of chf, no acute parenchymal infiltrates but a plate atelectasis on the left base is present. brief hospital course: # obstructive uropathy: the patient reports that approx two weeks prior to admission she developed uti symptoms. she was started on cipro and took it for ~4days. her urinary symptoms improved after 2-3 days; however, the patient developed nausea/vomiting and was thought to be intolerant to cipro. she was switched to bactrim, but only took 2-3 days because of worsening nausea/vomiting. he denied initial fevers/chills, but did have some lower left flank discomfort. she had chills and felt extremely cold the last 2 days, but no fevers. she also did noticed decreased uop, and worsening flank discomfort. the patient decided to come to the ed for evaluation. the patient presented to hospital on . she was found to have arf with a cr of 29.2, and a k of 6.3. she was given 1l of ns, kayexalate, glucose, insulin, calcium. the patient was transfered to for further evaluation. on arrival to , vitas were 97.3, bp of 168/103, hr 97, 97% on ra. repeat k was 6.0 without ekg changes. she was given d5 with an mp of bicarb, calcium gluconate, and 20ml of aluminum hydroxide. urology was consulted, and the patient was admitted to the micu for close monitoring. the patient was also treated with ceftriaxone over concern for infection. the patient underwent urgent b/l ir placement of pcn on . the patient had increased urine output with 500-1000cc/hr urine output. her electrolytes were serially checked and repelete. her fluids were replaced 0.5cc per 1cc of output. a ct-scan at the osh did not show a clear cause of her obstruction. urology plans to take the patient to or on for cystogram and further evaluation. it is recommended that the patient have outpatient colonoscopy and pap/smear for malignancy workup as a cause of her obstruction. schisto labs were negative. she will follow-up with urology prior to cystoscopy, as well as primary care for other evaluation. she completed a course of antibiotics prior to discharge. medications on admission: none discharge medications: none discharge disposition: home with service facility: vna of southeastern mass. discharge diagnosis: primary: acute renal failure bilateral hydronephrosis pyelonephritis discharge condition: stable discharge instructions: it was a pleasure taking care of you while you were in the hospital. you were admitted to because of an obstruction in your urinary tract causing renal failure. you underwent bilateral placement of tubes to help your kidneys drain urine and your kidney function improved. you were also treated for an infection in your urine. you will need to follow-up with dr. in clinic. please continue taking your outpatient medications as before. you have completed your antibiotic course. please follow up with the appointments below. please call your pcp or go to the ed if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. followup instructions: pcp: , . fax: a colonoscopy has been scheduled for you below: provider: , md phone: date/time: 9:15 provider: (st-3) gi rooms date/time: 9:15 please call your pcp to schedule pap smear. dr office will call you with the date/time of your appointment within the next couple of days. you also have a scheduled cystoscopy on . Procedure: Percutaneous nephrostomy without fragmentation Percutaneous nephrostomy without fragmentation Diagnoses: Acute kidney failure, unspecified Pulmonary collapse Hydronephrosis Acute pyelonephritis without lesion of renal medullary necrosis Urinary obstruction, unspecified

allergies: bactrim / tetanus toxoid attending: chief complaint: acute abdominal pain major surgical or invasive procedure: exploratory laparotomy; subtotal colectomy with end ileostomy history of present illness: history of presenting illness this patient is a 80 year old female with a history of chf and copd who complains of severe abd pain radiating ot her back. patient reports constipation for the past 5 days, blood in stool, and left leg numbness. patient comes from , where a ct scan ruled out aaa but shows evidence for ischemic colitis. the patient was hypotensive at the outside hospital and was started on neo. she was not given antibiotics. her last bowel movement was about an hour ago which consisted of diarrhea. timing: gradual severity: severe duration: hours location: abdomen context/circumstances: pain past medical history: past medical history: chf, osteoporosis, pacer, , cad, copd social history: lives at home. family history: nc physical exam: physical examination upon admission: temp: 98.5 hr: 110 bp: 115/28 resp: 18 o(2)sat: 100 normal constitutional: uncomfortable heent: normocephalic, atraumatic oropharynx within normal limits chest: clear to auscultation cardiovascular: paced. no murmur abdominal: soft, diffusely tender. rectal: heme positive gu/flank: no costovertebral angle tenderness extr/back: no cyanosis, clubbing or edema skin: warm and dry neuro: speech fluent psych: normal mood heme//: no petechiae pertinent results: 05:17am blood wbc-8.3 rbc-3.59* hgb-11.5* hct-36.2 mcv-101* mch-32.0 mchc-31.7 rdw-16.0* plt ct-309 10:15am blood wbc-8.4 rbc-4.02* hgb-12.8 hct-40.7 mcv-101*# mch-31.9 mchc-31.4 rdw-15.5 plt ct-391# pathology: tissue: colon: ileum and colon, exploratory laparotomy: 1. ischemic colitis with diffuse mucosal damage and focal submucosal edema and transmural acute inflammation; distal end demonstrates mucosal ischemia only. 2. proximal ileal resection margin, within normal limits. 3. five adenomata, measuring from 0.3 to 1.1 cm in greatest dimension; no high grade dysplasia or carcinoma seen. 4. regional lymph nodes, within normal limits. 5. medial calcification and atherosclerosis of arteries of mesocolon 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. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). 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. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. chest (portable ap): the et tube tip is 5.5 cm above the carina. the pacemaker leads terminate in right atrium and right ventricle. cardiomegaly is unchanged. there is interval improvement of pulmonary edema, currently minimal. there is no substantial pleural effusion and there is no pneumothorax. right internal jugular line tip is at the level of mid low svc. linear opacities projecting over the pacemaker are new and most likely represents overlying findings , and unlikely to represent discontinued pacemaker leads but repeated radiograph to clarify this point is recommended. chest (portable ap): comparison is made to prior study from the chest radiograph from . there is a right-sided pacemaker distally tips in the right atrium and right ventricle, appropriately sited. there is a right ij central venous line whose tip is in the distal svc. endotracheal tube and nasogastric tube are appropriately sited. there is persistent cardiomegaly. there has been interval worsening of the left retrocardiac opacity. no significant pulmonary edema is seen. there are no pneumothoraces. ecg: sinus rhythm with ventricular premature beats. left axis deviation. first degree a-v block. intraventricular conduction defect with atypical left bundle-branch block. probable old anterolateral myocardial infarction. no previous tracing available for comparison. chest (portable ap): impression: 1. the patient is markedly rotated on the current examination. the endotracheal tube has its tip 4.4 cm above the carina. a nasogastric tube is seen coursing below the diaphragm with the tip not identified. a right internal jugular central line is unchanged in position with its tip in the proximal to mid svc. 2. there is worsening bilateral airspace process, likely pulmonary edema with increasing consolidation at the left base likely reflecting compressive atelectasis in the setting of a pleural effusion. a smaller right effusion is also likely evident. a right-sided dual-lead pacer remains in place with its leads terminating over the expected location of the right atrium and right ventricle respectively. no pneumothorax appreciated. heart remains enlarged. portable ap chest radiograph: a right dual-lead pacemaker device is noted with leads terminating in the right atrium and right ventricle. a nasogastric tube is noted with tip not clearly visualized in the field of view. a right ij catheter appears kinked as before; however, the tip projects over the upper svc in unchanged position from the prior examination. moderate cardiomegaly is stable. there is no pneumothorax. mild pulmonary edema is unchanged from the prior examination. stable left lower lobe opacity may represent pleural effusion with adjacent atelectasis; however, infectious process such as pneumonia cannot be completely excluded in the correct clinical setting. minimal opacification at the right lung base may also represent atelectasis versus aspiration pneumonitis or pneumonia chest(portable ap): impression: ap chest compared to : mild pulmonary edema and bibasilar atelectasis have both improved since . transvenous right atrial and right ventricular pacer leads follow their expected courses. pleural effusions are small if any. no pneumothorax brief hospital course: the pt initially presented to an osh with acute onset abdominal pain which began suddenly earlier that morning that was associated with non-bloody diarrhea. at the osh she was hypotensive to the 70's so was bolused with crystalloid fluids and started on pressors. a ct scan at the time showed diffuse non-specific colitis and she was transferred to for further care. on arrival in the ed she was noted to be hypotensive to the 90s with escalating doses of neo-synephrine. troponin' were negative, and patient's abdominal exam was consistent with peritonitis with mental status changes. after a discussion with the family and patient she consented to an exploratory laparotomy. she was given vancomycin, cipro and flagyl preoperatively. please see operative note for further details. at laparotomy patient was noted to have ischemic splenic flexure through sigmoid colon. her right colon was dilated and thin with a cecal bascule, a subtotal colectomy and end ileostomy was performed. a jp drain was left above her . post operatively she was transferred to the icu, intubated on dual pressors. a right femoral a-line placed. a tte was performed and her pacer was interrogated. cardiac enzymes were cycled without evidence for myocardial injury. by pod 1 she was off pressors with stable vital signs. she was started on intermittent lopressor for intermittent tachycardia that extended into pod 2. these episodes of atrial tach with nonsustained v-tach delayed extubation. cardiology and ep were re consulted. pod : patient was extubated, cardiology stated that no intervention should be performed for her atrial tachycardia aside from beta blockade. she was diuresed with intermittent lasix. ngt was continued. pod 5 tf started at 20ml/hr via ngt. pod 6 ngt was discontinued with flatus. patient was restarted on her home macrobid. ciprofloxacin and flagyl were discontinued after a 7 day course. speech and swallow was consulted and recommended thin liquids, pureed solids. jp drain d/c'ed. pt worked with her throughout her icu stay. nursing care helped with patient teaching. pathology returned ischemic colitis. on pod 7 patient was transferred to the floor where she remained stable with stable vital signs. the patient's outpatient cardiologist was contact and felt it was appropriate to initiate 3 mg warfarin daily with adjustment per inr due to new onset atrial fibrillation. she received her first dosage of 3 mg on and will require daily inr checks; most recent inr 1.1 . of note, the patient complained of left leg pain on pod9. no erythema or edema was noted at that time, but will require monitoring. additionally, she continued to tolerate a diet, which was advanced to soft solids, thin liquids and whole pills with thin liquids as tolerated following re-evaluation by speech and swallow on pod9. her ostomy continued to function well and was draining moderate amounts of semi-formed stool; stoma was beefy red. the ostomy rn assisted with care and teaching, but would require additional teaching for ongoing management. the patient was subsequently discharged to rehab on . medications on admission: neurontin 300 qam, 600 qpm, tramadol 100 qid, vicodin 5/500 q4h prn, trazadone 50 qhs, tylenol 1000 prn, spiriva inh, xopenex 0.63', lasix 20', baclofen 10', omeprazole 20', lidoderm 5% td, lisinopril 5', nitrofurantoin 100', simvastatin 20', mom 30', dulcolax 10', klor-con 10', fleets enema' discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob/wheeze. 3. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 4. tylenol 325 mg tablet sig: two (2) tablet po every 4-6 hours as needed for pain. 5. nitrofurantoin monohyd/m-cryst 100 mg capsule sig: one (1) capsule po daily (daily). 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 8. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 9. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 10. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for to affected area: apply to affected breast & groin folds as directed. 11. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for to affected area. 12. warfarin 1 mg tablet sig: three (3) tablet po once (once) for 1 doses: goal inr for afib. dose daily based on reaching inr goal. 13. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per sliding scale. discharge disposition: extended care facility: house nursing home - discharge diagnosis: ischemic colitis atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital with with an acute condition of your intestines where blood flow was compromised requiring an operation to repair this condition. as a result you have a colostomy bag where stool can collect into a pouch. after your operation you also had another condition where your heart rate was too fast prompting that cardiology evaluate you. several recommedations for medication management of this were made and put into place. followup instructions: department: general surgery/ when: tuesday at 3:00 pm with: acute care clinic with dr phone: building: lm bldg () campus: west best parking: garage name: , np specialty: cardiology location: medical associates address: , , phone: when: at 11:40am name: i.,md specialty: primary care location: medical and walk- in center address: , 3rd fl, , phone: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Open and other right hemicolectomy Exteriorization of small intestine Artificial pacemaker rate check Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Unspecified septicemia Severe sepsis Chronic airway obstruction, not elsewhere classified Atrial fibrillation Acute respiratory failure Osteoporosis, unspecified Septic shock Cardiac pacemaker in situ Barrett's esophagus Restless legs syndrome (RLS) Unspecified vascular insufficiency of intestine Postprocedural fever Paroxysmal tachycardia, unspecified

allergies: penicillins / cefuroxime / cephalosporins attending: chief complaint: right knee pain/swelling and general fatigue/malaise major surgical or invasive procedure: : arthroscopic right knee washout : open knee i&d : open knee i&d : picc line placement history of present illness: mr. is a 53 year old man who had a right knee acl repair in . he presents to the with sudden onset right knee pain and swelling + shaking chills. he had been seen the previous day in the clinic of dr. who was concerned for an infected joint and requested that the patient come back the following day for further treatment. the pain, however, became unbearable and the patient came back to the ed later that night. of note, the patient also came in with a rash which was possibly due to a dose of cefuroxime that he had received the day prior but the origin of the allergy was not clear, as he had also just taken a dose of vicodin for the first time. past medical history: acl repair recent sore throat htn hocm appy tonsillectomy social history: lives with wife no , drinks 4-5x/week, works as artist family history: n/a physical exam: upon admission 97.5, 94, 118/79, 20, 100% alert and oriented cardiac: regular rate rhythm chest: lungs clear bilaterally abdomen: soft non-tender non-distended extremities: r knee pain with a/prom, +effusion, no erythmia, +pulses pertinent results: 04:22pm glucose-96 urea n-40* creat-2.1* sodium-129* potassium-5.3* chloride-95* total co2-21* anion gap-18 04:22pm ld(ldh)-245 ck(cpk)-215* 04:22pm calcium-7.8* phosphate-4.6* magnesium-1.3* 04:30am urine color-yellow appear-clear sp -1.017 04:30am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-sm 04:30am urine rbc-0-2 wbc-* bacteria-few yeast-none epi-0-2 02:00am joint fluid protein-6.0 glucose-3 02:00am joint fluid wbc-* rbc-* polys-67* lymphs-4 monos-2 eos-3* macrophag-24 01:40am pt-15.9* ptt-29.1 inr(pt)-1.4* 12:37am lactate-3.3* 12:30am glucose-117* urea n-31* creat-2.1* sodium-132* potassium-4.7 chloride-94* total co2-24 anion gap-19 12:30am wbc-25.4* rbc-4.58* hgb-13.7* hct-39.9* mcv-87 mch-29.9 mchc-34.2 rdw-13.9 12:30am neuts-73* bands-17* lymphs-1* monos-6 eos-2 basos-0 atyps-0 metas-1* myelos-0 12:30am plt count-195 12:30am sed rate-21* 06:01am blood wbc-8.6 rbc-3.45* hgb-9.9* hct-30.3* mcv-88 mch-28.8 mchc-32.8 rdw-14.5 plt ct-347 06:01am blood neuts-72.5* lymphs-21.3 monos-3.7 eos-2.2 baso-0.3 06:01am blood plt ct-347 06:01am blood glucose-104 urean-10 creat-0.8 na-133 k-3.9 cl-99 hco3-29 angap-9 03:45am blood alt-16 ast-17 ck(cpk)-28* 06:01am blood calcium-7.4* phos-3.7 mg-2.1 06:01am blood vanco-13.1 chest port. line placement study date of 9:25 am right picc line tip in the superior cavoatrial junction brief hospital course: mr. presented to the on with a right knee that was swollen and painful. in the ed, the patient's knee was tapped revealing purulent fluid. due to the appearance of the fluid, there was concern for lyme vs. septic joint. due to some hypotension and tachycardia in the ed, the patient was admitted to the icu for monitoring. later on the , the patient was taken to the operating room and underwent an arthroscopic right knee washout. he tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. on the floor he was seen by disease and was started on iv vancomycin and clindamycin (cephalosporins were avoided due to a potential cephalosporin allergy). on he was noted to be tachycardiac and hypotensive. he was given 3 liters of fluid bolus due to fluid volume deficit. a tte was done and was normal. he was transferred to the sicu for further care and closer monitoring of his blood pressures. at this point, the cultures had grown out group a strep and there was a high suspicion for toxic shock syndrome. on he returned to the operating room and underwent an open right knee i&d/washout. he tolerated the procedure well and was transferred back to the sicu because he continued to be hypotensive and tachycardic. due to lack of substantial clinical improvement, on he returned to the operating room and underwent another open i&d of his right knee. he tolerated the procedure well was extubated, transferred to the recovery room and then to the floor where he remained hemodynamically stable. on he had a picc line placed for long term antibiotics. his hemovac drain was removed from his knee. on , his clindamycin was discontinued and his vanc dose was adjusted so he could go home on dosing - and his vanc trough was 13 at this dose. he was seen by physical therapy to improve his strength and mobility/range of motion. the rest of his hospital stay was uneventful with his data and vital signs within normal limits and his pain controlled. he is being discharged today in stable condition. medications on admission: lisinopril, couple doses of vicodin/cefuroxime discharge medications: 1. outpatient work pt needs weekly blood draws: cbc with diff, bun/cr, lft's, vanc trough (1 hour prior to next dose) fax results to (id rn) 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. enoxaparin 40 mg/0.4 ml syringe sig: forty (40) mg subcutaneous daily (daily) for 4 weeks. disp:*28 doses* refills:*0* 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. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*90 tablet(s)* refills:*0* 7. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours). 8. senna 8.6 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for constipation. 9. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. 10. zofran 4 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: right knee infection fluid volume deficit acute blood loss anemia toxic shock syndrome discharge condition: stable/improved discharge instructions: continue to be weight bearing as tolerated on your right leg continue your antibiotics as instructed 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. * 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. other: *avoid driving or operating heavy machinery while taking pain medications. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. physical therapy: activity as tolerated weight bearing as tolerated rle treatments frequency: staples/sutures out 14 days after surgery (at follow up appointment) dry dressing as needed followup instructions: please follow up with , np in orthopaedics in 1 week, please call to schedule that appointment. please follow up with , md disease. phone: date/time: 11:00 Procedure: Venous catheterization, not elsewhere classified Other local excision or destruction of lesion of joint, knee Synovectomy, knee Synovectomy, knee Diagnoses: Acute posthemorrhagic anemia Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Personal history of tobacco use Chronic kidney disease, unspecified Dermatitis due to drugs and medicines taken internally Cephalosporin group causing adverse effects in therapeutic use Pyogenic arthritis, lower leg Toxic shock syndrome Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group A

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: aortic stenosis, doe major surgical or invasive procedure: aortic valve replacement (21 stjude epic/porcine) history of present illness: 78 year old male with a life long history of heart murmur. he claims this was never really followed. he recently underwent a urologic procedure and developed urosepsis with mrsa bactermia. an echocardiogram was performed while an inpatient due to the presence of his systolic murmr and he was noted to have severe aortic stenosis. he currently complains of very mild dyspnea on exertion. he has now been referred for surgical evaluation. past medical history: aortic stenosis, s/p avr pmh: recent urosepsis with mrsa bactermia glaucoma prostate and bladder cancer diagnosed 14 years ago s/p turp, prostate biopsies, recent dilation and ureter stenting social history: race: caucasian last dental exam: years ago lives with: wife in occupation: insurance broker cigarettes: smoked no yes last cigarette 30 years ago hx: 4-5 packs per day for 20 years other tobacco use: etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use family history: family history: mother with valve issues and died at 80, father with cad and died at 83. brother with cad and died at 56. physical exam: physical exam pulse: 67 sr resp: 16 o2 sat: 100% b/p right: 112/64 left: 108/67 height: 66" weight: 163 general: wdwn in nad skin: warm, dry and intact. no c/c/e heent: ncat perrla eomi sclera anicteric, op benign. neck: supple full rom chest: lungs clear bilaterally heart: rrr, iv/vi sem abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused no edema varicosities: anterior venous dilation below knee, gsv appears suitable bilaterally. 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 tranmsitted vs. bruit pertinent results: chest (pa & lat) clip # reason: eval for effusion final report history: avr. findings: in comparison with study of , there is less opacification at the right base. however, this most likely reflects primarily the change in patient position, as there is continued large effusion with compressive atelectasis. the right ij sheath has been removed. lower lung volumes and some atelectatic changes are also seen at the left base. dr. approved: mon 2:29 tee 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 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%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results before surgical incision. post-bypass: preserved biventricular systolic function. lvef 50% the aortic bioprosthesis is stable and functioning well with a mean residual gradient of 15mm of hg. intact thoracic aorta. no new valvular findings. 05:50am blood wbc-10.4 rbc-3.06* hgb-9.5* hct-28.7* mcv-94 mch-31.1 mchc-33.0 rdw-14.4 plt ct-195 05:30am blood urean-35* creat-1.6* na-138 k-4.3 cl-101 05:50am blood glucose-124* urean-31* creat-1.4* na-138 k-4.2 cl-104 hco3-26 angap-12 brief hospital course: brief hospital course: the patient was brought to the operating room on where the patient underwent avr(21 stjude epic/porcine). 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 developed junctional rhythm, beta blocker was decreased and sinus rhythm returned. the patient was evaluated by the physical therapy service for assistance with strength and mobility. by the time of discharge on pod 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged home with vna in good condition with appropriate follow up instructions. medications on admission: dorzolamide-timolol 2 %-0.5 % drops - 1 gtt in each eye , sulfamethoxazole-trimethoprim 800 mg-160 mg , travoprost 0.004 % drops - 1 gtt ou daily discharge medications: 1. 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* 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). disp:*qs * refills:*2* 5. travoprost 0.004 % drops sig: one (1) drop ophthalmic daily (daily). 6. metoprolol tartrate 25 mg tablet sig: 0.25 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 7. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 10 days. disp:*10 tablet(s)* refills:*0* 8. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po daily (daily) for 10 days. disp:*20 tablet extended release(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: aortic stenosis, s/p avr pmh: recent urosepsis with mrsa bactermia glaucoma prostate and bladder cancer diagnosed 14 years ago s/p turp, prostate biopsies, recent dilation and ureter stenting discharge condition: discharge condition: alert and oriented x3 nonfocal ambulating, gait steady sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage trace discharge instructions: 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: wound check: date/time: 10:00 surgeon dr. , r. , 1:00 please call to schedule the following: cardiologist dr. , 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 Open and other replacement of aortic valve with tissue graft Diagnoses: Personal history of malignant neoplasm of prostate Aortic valve disorders Unspecified glaucoma Personal history of malignant neoplasm of bladder Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus

allergies: penicillins / sulfa(sulfonamide antibiotics) attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: facial suturing history of present illness: 19 y/o female involved in a rollover motor vehicle collision. per ed report it is unclear whether she was restrained. she was extricated from the vehicle. according to she had a gcs of 11, but had some deteriorating somnolence and was intubated prior to transfer. she had obvious significant injury to her face and head. she was hemodynamically stable on transport aside from tachycardia. she was intubated, given versed, and given pancuronium for paralysis secondary to some agitation and trying to pull out the tube. past medical history: denies family history: noncontributory physical exam: upon presentation to : hr: 120 o(2)sat: 100 normal constitutional: comfortable; intubated heent: pupils are equal, there is gross blood and soft tissue damage the left side of the face and the left orbital area, but no proptosis or firmness of the globe. there is an upper eyelid laceration. no obvious skull step-off cervical collar is in place chest: clear to auscultation cardiovascular: tachycardic abdominal: soft, nondistended; fast exam is negative rectal: normal rectal tone extr/back: no obvious extremity deformity skin: multiple abrasions and soft tissue damage to the left side of the face neuro: gcs is 3t pertinent results: 10:40pm glucose-64* urea n-5* creat-0.3* sodium-142 potassium-3.3 chloride-124* total co2-15* anion gap-6* 10:40pm calcium-4.6* phosphate-1.9* magnesium-1.0* 10:40pm wbc-15.1*# rbc-3.15*# hgb-10.1*# hct-29.3*# mcv-93 mch-32.1* mchc-34.5 rdw-12.7 10:40pm plt count-151 10:40pm pt-14.3* ptt-28.7 inr(pt)-1.3* 08:00pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-pos barbitrt-neg tricyclic-neg ct head: impression: 1. no acute intracranial hemorrhage. 2. radiopaque densities within the laceration overlying the left frontal scalp extending over the left maxillary region. 3. fluid in the left mastoid, may represent sequela of intubation, but cannot exclude occult temporal bone fracture in this patient with trauma. 4. fracture of the floor of the left orbit extending medially. ct sinus/mandible: impression: laceration extending from the forehead down to the left maxillary region with presence of foreign bodies. fracture of the inferior wall of the orbit as well as the medial wall of the orbit. ct c-spine: impression: no evidence of acute fracture or subluxation. there is mild rotation of the atlas within respect to the axis likely due to patient positioning. ct chest/abd/pelvis: impression: 1. et tube tip is at the level of the carina just above the margin of the right main bronchus and needs to be repositioned. 2. right upper and left lower lobe collapse. 3. distended bladder. findings discussed with dr. and the trauma team at 8:20 p.m. on in person. findings were also rediscussed with dr. at 10 p.m. to confirm that et tube was repositioned. 4. a 4 cm right adnexal hypodensity, likely ovarian cyst is identified. recommend pelvic us on a nonemergent basis for further evaluation which can be performed in months brief hospital course: she was admitted to the acute care surgery team and evaluated by plastics for her facial injuries. her lacerations were irrigated and sutured. plastics recommended a course of antibiotics for the lacerations which will continue at least until her outpatient follow up in a few days. incidentally on ct imaging of her pelvis a 4 cm right adnexal hypodensity, likely ovarian cyst was identified. it is being recommended that she have pelvic ultrasound on a non emergent basis for further evaluation in months. this information was communicated to the patient. at time of discharge she is ambulating independently and tolerating a regular diet. her pain is well controlled with oral pain medications. she will follow up in clinic in the next few days for suture removal. follow up with her pcp /or ob/gyn for the likely ovarian cyst is also being recommended. medications on admission: denies discharge medications: 1. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 2. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) 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. clindamycin hcl 150 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 5 days. disp:*40 capsule(s)* refills:*0* 6. milk of magnesia 400 mg/5 ml suspension sig: thirty (30) ml's po twice a day as needed for constipation. discharge disposition: home discharge diagnosis: s/p motor vehicle crash injuries: comminuted maxillary laceration/avulsion orbital floor fracture 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 following a motor vehicle crash where you sustained extensive facial lacerations and facial fractures. sutures were placed to the lacerations which will be removed in the next few days. -continue to apply bacitracin ointment to forehead suture line and areas of abrasion twice/day. do not get bacitracin in eyes. -apply 'xeroform' dressing to left face once/day. -sleep with head of bed elevated to help with swelling -please take pain medication 1 hour prior to your plastic surgery appointment on friday in preparation for exam and suture removal. a 4 cm right likely ovarian cyst was found noted on cat scan imaging of your pelvis. it is being recommended that you have a pelvic ultrasound on a nonemergent basis for further evaluation which can be performed in months. you will need to contact your pcp or ob/gyn doctor to have this arranged as an outpatient. followup instructions: plastic surgery follow up appointment: provider: , md , md phone: date/time: friday 2:15 ***the plastic surgery clinic is located on the , , , . please contact your primary care doctor in the next 1-2 weeks for a general physical and for follow up of the likely right ovarian cyst that was found on your cat scan. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Suture of laceration of lip Linear repair of laceration of eyelid or eyebrow Closure of skin and subcutaneous tissue of other sites Diagnoses: Acute posthemorrhagic anemia Closed fracture of other facial bones Open wound of lip, without mention of complication Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle Open wound of cheek, without mention of complication Open wound of forehead, complicated Other and unspecified ovarian cyst Laceration of eyelid, full-thickness, not involving lacrimal passages

allergies: no allergies/adrs on file attending: chief complaint: sah major surgical or invasive procedure: none history of present illness: per neurosurgery note. 83-year-old female transferred from osh with sah. . of note, the patient contact ems for flank pain. enroute to osh with ems she suddently complained of a severe headache and then became unresponsive. upon presentation to the osh she was unresponsive to any stimuli. she was found to have sah. she received dilantin, decadron, mannitol and dopamine and then transferred to . . upon arrival to ew, initial vitals were: bp 110/72, hr 55, rr 15-20, sao2 100%. neurosurgery evaluated the patient and ct findings. they found devastating sah hunt grade 5, grade 4, no withdrawal to pain, no corneals, gag or cough. the neurosurgery team discussed with her son who stated that her mother would not want to be resuscitated or live with the complications of this. the decision was to make the patient comfort measures only. past medical history: - htn - cad with cardiac stents social history: lives in cares for mentally retarded daughter, husband deceased has son making decisions today family history: unknown physical exam: per neurosurg report hunt and : 5 : 4 gcs3 e: 1 v: 1 motor 1 no eye opening no response to pain in any extremity pupils on right 7 surgical left 5 non reactive no gag, cough or corneal breathes over the vent no response in any extemity to pain pertinent results: 05:30pm wbc-30.3* rbc-5.03 hgb-14.8 hct-42.2 mcv-84 mch-29.4 mchc-35.0 rdw-14.1 05:41pm lactate-3.5* 05:30pm fibrinoge-320 05:30pm pt-11.8 ptt-23.7 inr(pt)-1.0 05:30pm plt count-271 osh ct: sah around circle of brief hospital course: # goals of care: the neurosurgery team had a discussion with son who decided that his mother would not want to live like this and be dependent on others. neurosurgery had nothing to offer. the patient was made comfort measures only. she was extubated and dopamine was stopped. started on morphine, ativan and scopolamine. she passed away with family at bedside. # subarachnoid hemorrhage: the patient has a massive sah with no neurologic signs suggestive of recovery. neurosurgery evaluated the patient and felt that surgical intervent or medical therapy would be futile at this point. she was made cmo. medications on admission: unknown discharge medications: n/a discharge disposition: expired discharge diagnosis: sah discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Subarachnoid hemorrhage Encounter for palliative care

allergies: pollen extracts attending: chief complaint: sigmoid diverticulitis kidney mass major surgical or invasive procedure: 1. partial colectomy with anastomosis. 2. appendectomy. 3. robotic assisted laparoscopic left radical nephrectomy. history of present illness: is a very pleasant 42-year-old gentleman with an episode of diverticulitis in . ct scan then revealed a left pelvic kidney with a 6 cm mass at the central point. he denies any gross hematuria, incontinence, frequency, urgency. he has no nocturia. his aua score is 7/35. no recent weight changes, no back pain, bone pain. he has had three to four diverticulitis flare-ups over the last five years. he has lost about 70 pounds over the last 13 weeks through diet and exercise, mostly walking. he was seeing dr. and is considering gastric bypass in the future. past medical history: lap chole in 06, tonsillectomy as a child, diverticulitis, lower back pain secondary to weight social history: lives with wife, , in . he has two children aged 3 and 6. he works night shifts at farms in . no tobacco, occasional alcohol, no drug use. family history: family history of prostate cancer in his uncle who was diagnosed at 70, he underwent radical prostatectomy. no bladder or kidney cancer. physical exam: discharge day exam: vs: 98.2 73 101/73 20 98%ra gen: awake, alert, nad cv: rrr chest: ctab abd: obese, soft, nontender; well-healing incisions with staples present, mild reactive erythema around staples; midline incision with inferior portion open, granulating; wet-to-dry dressing in place ext: wwp pertinent results: 11:11pm urine hours-random creat-139 sodium-21 11:11pm urine color-yellow appear-clear sp -1.022 11:11pm urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 11:11pm urine rbc-39* wbc-1 bacteria-few yeast-none epi-0 11:11pm urine hyaline-3* 11:11pm urine mucous-rare 09:21pm type-art temp-38.1 rates-18/ tidal vol-600 peep-12 o2-70 po2-117* pco2-55* ph-7.25* total co2-25 base xs--3 intubated-intubated 09:21pm lactate-2.7* 08:57pm glucose-131* urea n-21* creat-1.3* sodium-137 potassium-5.7* chloride-105 total co2-23 anion gap-15 08:57pm estgfr-using this 08:57pm alt(sgpt)-40 ast(sgot)-67* ld(ldh)-291* alk phos-73 tot bili-0.3 08:57pm probnp-130* 08:57pm albumin-3.7 calcium-8.1* phosphate-5.0* magnesium-2.2 08:57pm wbc-17.5*# rbc-4.72 hgb-13.6* hct-40.1 mcv-85 mch-28.9 mchc-34.0 rdw-14.9 08:57pm neuts-86.6* lymphs-7.2* monos-5.7 eos-0.3 basos-0.2 08:57pm plt count-273 08:57pm pt-12.6 ptt-21.8* inr(pt)-1.1 07:12pm type-art temp-37.3 rates-18/3 tidal vol-600 peep-12 o2-70 po2-85 pco2-52* ph-7.26* total co2-24 base xs--4 05:43pm potassium-5.6* 05:43pm magnesium-2.1 05:43pm hct-40.5 03:40pm type-art rates-/16 po2-99 pco2-38 ph-7.35 total co2-22 base xs--3 intubated-intubated vent-controlled 03:40pm glucose-138* lactate-4.1* na+-137 k+-5.2 cl--106 03:40pm hgb-14.1 calchct-42 03:40pm freeca-1.03* 10:54am type-art tidal vol-700 o2-80 po2-108* pco2-53* ph-7.29* total co2-27 base xs--1 aado2-422 req o2-72 intubated-intubated vent-controlled 10:54am glucose-123* lactate-2.2* na+-138 k+-4.3 cl--103 10:54am hgb-14.3 calchct-43 10:54am freeca-1.08* brief hospital course: course : . # hypoxia: most likely due to pulmonary edema as pt appeared volume overloaded on admission to . received 10mg iv lasix with good urine output and negative 800cc (counting fluids received in or). appears less hypervolemic today. there may also be a component of atelectasis given pt??????s body habitus and he is post op. abg demonstrates chronic respiratory acidosis. o2 was titrated to maintain o2 sats 90-92% to allow us to have warning if hypoventilation develops superimposed on chronic hypercapnia. is encouraged for atelectasis. . # tachycardia: pt was tachycardic to 110s prior to extubation, which increased to 120s beginning with extubation; pt denied chest pain or palpitations. hr pre-op was 89-95. ekg unchanged from prior except for increased sinus tachycardia. it was attributed to pain although pt on morphine pca. he received extra 2mg iv morphine with no effect. given that pt had diruresed to a small dose of lasix, there was concern for intravascular volume depletion and cxr showed decreased fluid overload. pt given 250cc fluid bolus x2 with slight decrease in hr to 115-120. hr decreased to 99-110 as fever decreased and may be related to his fever. score (at least 4)??????moderate risk for pe. leni's were ordered to evaluate for dvt. hr was monitored with temperature. . # fever: most likely post-op fever as it has decreased over night. per surgery, no antibiotics needed at this time. be due to atelectasis given pt??????s body habitus and prolonged time in bed. is and oob to chair encouraged. . # arf: have been due to surgery. resolved and cr at transfer to surgery was 0.9. nephrotoxic meds were held. . # elevated lactate: pt was hemodynamically stable. lactate improved with hydrate and assess for improvement. . general surgery: -admitted to 12 once stable. hr in 100's, sats >95% on liters, other vitals stable. -pain initially controlled with pca. switched to po percocet once tolerating diet. pain well controlled with oral percocet. -continued to drop o2 sats during sleep to high to mid 80's. has h/o osa. refused to wear cpap offered per hospital. ra sats over 95% with and without activity. -hr gradually decreased from 100's to 70-80's. started on lopressor during this admission for heart rate control. patient advised to follow-up with pcp for full cardiac & pulmonary re-assessment in weeks post-discharge. -abdominal incision intact with staples, cdi. erythema/cellulitis noted distal incision. started on iv kefzol with minimal improvement. switched to iv vanco / unasyn on and wound erythema greatly improved. discharged home on po augmentin. -diet advanced gradually from sips to regular food as bowel function and abdominal distention improved. reported flatus, and eventual loose stools. iv fluid discontinued. medications switched to oral. foley removed, failed voiding trial x1. foley re-inserted. voided without issue. -activity below baseline due to deconditioned state post-op. physical therapy consulted, and worked with patient multiple times in-patients. ambulated up & down stairs prior to discharge. activity progressed to safe level for discharge back to home. medications on admission: paroxetine 40mg daily, levotyroxine 150mcg daily, alprazolam 1mg hs sleep discharge medications: 1. paroxetine hcl 20 mg tablet sig: two (2) tablet po daily (daily). 2. alprazolam 1 mg tablet sig: 1-2 tablets po qhs (once a day (at bedtime)) as needed for insomnia. 3. levothyroxine 75 mcg tablet sig: two (2) tablet po daily (daily). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain for 2 weeks: maximum of 4gm of apap daily. disp:*45 tablet(s)* refills:*0* 5. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation for 2 weeks. disp:*60 capsule(s)* refills:*0* 6. augmentin 500-125 mg tablet sig: one (1) tablet po every twelve (12) hours for 7 days. disp:*14 tablet(s)* refills:*0* 7. aquacel-ag 1.2-6 x 6 %- bandage sig: one (1) topical once a day for 14 days. disp:*14 bandages* refills:*0* discharge disposition: home with service facility: southern vna discharge diagnosis: 1. left pelvic kidney with mass. 2. redundant sigmoid colon with an active phlegmon adherent to small bowel and appendix discharge condition: stable tolerating a regular diet pain well controlled with oral medication discharge instructions: please call your doctor or return to the er for any of the following: * 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 staples will be removed at your follow-up appointment. steri strips will be applied. -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. . wound: please continue to change abd dressing daily or as needed. the vna will assist you with this. followup instructions: 1. follow-up with dr. in weeks for staple removal . 2. provider: . phone: date/time: 7:45 Procedure: Other incidental appendectomy Nephroureterectomy Open and other sigmoidectomy Large-to-large intestinal anastomosis Laparoscopic robotic assisted procedure Diagnoses: Acidosis Hyperpotassemia Other postoperative infection Cellulitis and abscess of trunk Acute kidney failure, unspecified Malignant neoplasm of kidney, except pelvis Pulmonary collapse Acute respiratory failure Morbid obesity Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Peritoneal abscess Volume depletion, unspecified Other specified anomalies of kidney Acute edema of lung, unspecified Diverticulitis of colon (without mention of hemorrhage)

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall major surgical or invasive procedure: none history of present illness: 50 yo female s/p fall down stairs w/ +etoh, +loc, combative and intubated upon arrival in the ed. past medical history: etoh abuse depression social history: married; resides with husband family history: noncontributory pertinent results: ct head/facial - r frontal sah, small sdh over l frontal lobe, ?ivh, l lateral orbital wall, maxillary, and l nasal fx, large periorbital hematoma,bony frag adj to post l lr-?entrapment, l zygomatic arch fx ct c-spine - changes in c-spine, severe facet jt dz-->neural foraminal narrowing @ l c3-4, r c6-7 ct torso - flank hematoma, no traumatic injury ct-chest/cta - sup mediastinal soft tissue density, ? hematoma vs. edema 2o spinal cord injury. mri recommended 2. fatty liver. mri: findings indicative of injury to the anterior longitudinal ligament at c6-7 level with focal anterior spinal hematoma and soft tissue changes. no evidence of intraspinal hematoma, spinal cord compression or intrinsic signal within the spinal cord. no evidence of disruption of the posterior longitudinal ligament or ligamentum flavum. mild soft tissue injury of the spinous processes of c5 and c6 with increased signal. ct head : increased left extra-axial/subdural fluid overlying the left frontal lobe. punctate hyperdense focus in a left parietal sulcus, with an identical appearance seen on the ct scan of . this could represent a new focus of subarachnoid hemorrhage in the exact location of a previous hemorrhage, or alternatively could suggest hemosiderin staining from previous bleed. cxr : of incidental note is an old healed rib fracture-right. ct head : 1. increased left extra-axial/subdural fluid overlying the left frontal lobe. 2. punctate hyperdense focus in a left parietal sulcus, with an identical appearance seen on the ct scan of . this could represent a new focus of subarachnoid hemorrhage in the exact location of a previous hemorrhage, or alternatively could suggest hemosiderin staining from previous bleed. flex ex: on the neutral view, c7 is not adequately seen and the possibility of a fracture in this region cannot be excluded. similar attempt at a flexion study also fails to show c7. on both the images, there is a minimal anterior listhesis of c5 with respect to c6. however, the vertebrae and intervertebral disc spaces are well maintenance and there is no evidence of prevertebral soft tissue swelling. mri : resolution of previously seen prevertebral hematoma at the c6/7 level. normal alignment of the cervical spine, and no cord signal abnormalities with widely patent spinal canal. micro: sputum cx: 1+ gnrs urine cx: >100k e. coli 12:10am blood wbc-11.5* rbc-3.09* hgb-11.1* hct-32.9* mcv-106* mch-35.8* mchc-33.7 rdw-14.4 plt ct-272 06:13am blood wbc-8.8 rbc-2.84* hgb-9.9* hct-29.3* mcv-103* mch-35.0* mchc-34.0 rdw-14.6 plt ct-182 05:50am blood wbc-14.6* rbc-2.65* hgb-9.3* hct-28.3* mcv-107* mch-35.1* mchc-32.9 rdw-15.5 plt ct-264 01:25pm blood wbc-11.6* rbc-2.70* hgb-9.4* hct-28.8* mcv-107* mch-34.9* mchc-32.8 rdw-15.5 plt ct-307 02:02am blood pt-14.4* ptt-34.6 inr(pt)-1.3* 01:25pm blood glucose-139* urean-11 creat-0.6 na-141 k-3.7 cl-106 hco3-24 angap-15 09:05am blood alt-76* ast-126* ld(ldh)-300* alkphos-310* amylase-109* totbili-1.8* 01:25pm blood alt-65* ast-96* ld(ldh)-282* alkphos-280* amylase-87 totbili-1.3 01:25pm blood lipase-279* 09:51am blood lipase-563* 06:13am blood lipase-31 01:52am blood lipase-19 02:33am blood phenyto-8.5* 05:50am blood vitb12-800 09:05am blood ammonia-45 01:25pm blood tsh-2.9 12:10am blood asa-neg ethanol-279* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg brief hospital course: she was admitted to the trauma service and transferred to the trauma icu. because of her injuries plastic surgery, orthopedic surgery, neurosurgery, and orthopedic spine surgery were initially consulted. neuro/heent: clindamycin was started initially for her facial fractures. these fractures were later noted to be nonoperative, and she was monitored closely. she also had a sah, sdh, and an ivh, which was closely monitored with neuro checks, dilantin for seven days, and serial ct scans which remained stable. she will follow up with neurosurgery 6 weeks from date of her injury. she also had a cervical spine fracture, which was nonoperative. she is to remain in a hard cervical collar until follow up with spine surgery in 2 weeks from discharge. she did experience delirium tremors because of her alcohol abuse history; she was placed on valium per ciwa scale and initially also required clonidine and precedex. these were eventually weaned. psychiatry and neurology were also consulted because of her brain injuries. she was started on olanzapine.it was thought that she had wernicke's encephalopathy; thiamine and folate were started. lactulose was started as well for the encephalopathy. cv: she initially was tachycardic, thought to be secondary to alcohol withdrawal. this did eventually resolve. resp: she was eventually extubated. she did have some inspiratory stridor and wheezing post extubation for which she received nebulizer treatments and decadron. she recovered well, and has had no further issues. gi/gu: she initially received tube feeds. the tube feeds were stopped and she was started on an oral diet, which she is tolerating without difficulty. she also developed a urinary tract infection, for which she was treated with a course of ciprofloxacin. she also developed hemorrhoids which are being treated with prn suppositories and tuck's pads. she is on a bowel regimine. endo: her blood sugars were elevated and she was started on standing nph insulin twice daily and sliding scale regular insulin. she was changed to a diabetic diet. she was also treated for what appeared to be a left ankle gout flare, with a 3 day course of indocin. id: treated for a uti as above. no further issues. heme: her hematocrit was closely monitored and remained stable throughout her hospital stay. prophylaxis: she was placed on heparin for dvt prophylaxis and ppi for gi prophylaxis. medications on admission: zyprexa, omeprazole, wellbutrin, b-12 discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever or pain. 2. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day) as needed for constipation. 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. hexavitamin tablet sig: one (1) cap po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stools. 9. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day). 10. olanzapine 5 mg tablet sig: two (2) tablet po hs (at bedtime). 11. olanzapine 5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for agitation, insomnia. 12. propranolol 10 mg tablet sig: two (2) tablet po tid (3 times a day): hold for sbp <110; hr <60. 13. insulin nph human recomb 100 unit/ml suspension sig: fifteen (15) units subcutaneous qam. 14. insulin nph human recomb 100 unit/ml suspension sig: seventeen (17) units subcutaneous at bedtime. 15. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per insulin sliding scale: see attached sliding scale. 16. hemorrhoidal suppository 0.25 % suppository sig: one (1) rectal twice a day as needed for hemorrhoids. 17. pramoxine-mineral oil-zinc 1-12.5 % ointment sig: one (1) appl rectal prn (as needed). discharge disposition: extended care facility: care center discharge diagnosis: s/p fall right frontal subarachnoid hemorhage left frontal subdural hematoma c5 anterolisthesis gout discharge condition: good discharge instructions: continue to wear the cervical collar for 2 more weeks. followup instructions: please follow up with ortho-spine in 2 weeks; call to make an appointment with dr. . follow up with dr. , neurosurgery, in 2 weeks. call for an appointment. follow up with your primary care doctor within 1-2 weeks after discharge from rehab, dr. ge, . Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Urinary tract infection, site not specified Gout, unspecified Accidental fall on or from other stairs or steps Alcohol abuse, continuous Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Closed fracture of malar and maxillary bones Closed fracture of other facial bones Closed fracture of nasal bones Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness

allergies: no known allergies / adverse drug reactions attending: chief complaint: mechanical fall major surgical or invasive procedure: none history of present illness: 65f s/p mechanical fall down stairs while intoxicated with brief loc. she was first seen at hospital, then transferred to for further evaluation. she has a history of alcohol-related falls and traumatic sah and sdh in and . evaluation at the outside hospital and revealed a parafalcine sdh and nasal bone fractures. patient was transferred to for management. she was initially admitted to the trauma surgical service where she was found to have l1 compression fracture and bilateral maxillary sinus fractures and a nasal fracture. ct head showed parafalcine subdural hematoma. she was seen by neurosurgery who recommended serial ct scans which showed stable size of sdh with blood products seen within the right ventricle (neurosurg thought this was breakdown blood products and nothing to address at this point). during admission she became increasingly agitated with altered mental status. she fell out of bed and had ct c-t-l spine and ct head which did not show significant change from original films. she was treated initially with zyprexa, then transitioned to ativan with ciwa due to concern for alcohol withdrawl. agitation continued prompting initiation of precedex on . she was transferred from the sicu service to the micu service on for management of delerium. in the micu, haldol was initiated and patient improved. a urinalysis was also obtained and was concerning for uti. therapy with ceftriaxone was initiated on . she is being transferred to medicine for further management. . the patient has minimal recollection of the events that led to her hospitalization. the patient's husband reports that he found the patient on the floor at the bottom of a flight of stairs and gathered that she fell because she was intoxicated. he states that she had tried to call him by phone about 15 min prior to his finding her, but unfortunately he did not have his phone. at the time that he found her, he states that she was breathing but was not responding to him. by the time ems arrived, she was responsive. she was taken to an osh where she was found to have ich and was transferred to for further management. the patient's husband further details that she has had a long struggle with etoh abuse and has been to detox many times. he states that at one point he filed a section 35 in order for her to enter women's rehab center in , however, her progress was hindered by the facility's inability to handle her delirium, per husband. states that the patient has a tendency to become delirious and confused when she is hospitalized. in addition, he states that she has had increasing problems with memory, especially short term memory since her first fall . past medical history: -etoh abuse ---s/p multiple falls, h/o sdh in past ---h/o dt's ---possible korsakoff dementia ( neuro eval) -depression (per husband refused to see psychiatry) - right trochanteric hip fracture s/p orif w/ tfn - l1 compression fracture - peptic ulcer disease social history: married; resides with husband. suffers from etoh abuse. has four children and many grandchildren. denies alcohol and illicit drug use. family history: noncontributory physical exam: admission: vitals: 98.6 122/75 104 18 99ra general: oriented to person, place not time, poor attention, heent: facial ecchymoses maxilla bilaterally, dry mm, oropharynx clear, eomi, left pupil slightly larger than right but rrl bilaterally neck: supple cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation discharge: vitals t98.6 tm 98.6 bp 108/78 (120-160/60-80) hr 93 (70-140) rr18 96% on ra general: non-toxic looking, nad heent: facial ecchymoses maxilla bilaterally, mmm, oropharynx clear, eomi, l pupil 6mm and r pupil 3mm baseline, rrl neck: supple, no lad cv: tachycardic, rr, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: ecchymoses diffusely, rash on r lower arm extensor surface neuro: a&o x (not to date, but knows tomorrow is day), cnii-xii grossly intact, 5/5 strength grossly, grossly normal sensation. attention intact, can follow multi-step commands, clock drawing accurate pertinent results: admission 05:10pm blood wbc-11.4*# rbc-4.26# hgb-13.7# hct-41.4# mcv-97# mch-32.1*# mchc-33.0 rdw-14.2 plt ct-174 05:10pm blood glucose-109* urean-10 creat-0.7 na-143 k-4.5 cl-108 hco3-21* angap-19 03:53am blood alt-32 ast-34 ld(ldh)-290* alkphos-47 totbili-0.3 10:33pm blood calcium-7.8* phos-3.3 mg-1.6 . pertinent 01:51am blood pt-11.8 ptt-33.1 inr(pt)-1.1 03:53am blood acetone-positive osmolal-286 03:53am blood tsh-1.1 05:10pm blood asa-neg ethanol-111* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 05:47am blood lactate-0.9 9:50 pm urine source: catheter. **final report ** urine culture (final ): escherichia coli. >100,000 organisms/ml.. presumptive identification. 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 _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 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 . discharge 04:09pm blood hct-31.6* 09:53am blood glucose-148* urean-8 creat-0.6 na-135 k-3.6 cl-100 hco3-24 angap-15 10:02am blood alt-38 ast-32 ld(ldh)-318* ck(cpk)-72 alkphos-103 totbili-0.6 09:53am blood calcium-9.1 phos-3.1 mg-2.0 . cta chest w&w/o c&recons, impression: 1. no acute intrathoracic process. 2. motion artifact and slightly suboptimal contrast bolus timing limits evaluation of the distal subsegmental pulmonary arteries, however, no pulmonary embolus is seen. cxr findings: a right sided picc line has been retracted to the low svc after initial low position on . the lungs are well inflated and clear. no focal consolidation, effusion, or pneumothorax is present. the cardiac and mediastinal contours are normal. impression: picc line tip in the low svc. no acute cardiopulmonary process to explain tachycardia. . echo the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. 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%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal left ventricular cavity size and wall thickness with low normal global left ventricular systolic function. normal pulmonary artery systolic pressure. ct head : impression: 1. stable appearance of subdural hematoma. 2. newly apparent intraventricular blood products within the occipital of the right lateral ventricle. there is no associated ventriculomegaly. 3. no interval change to explain patient's pupillary findings. . ct cspine : impression: no fractures. severe degenerative changes. . ct lspine : stable appearance of severe l1 compression fracture as seen previously with no new acute fractures or dislocations. . ct tspine : 1. compression wedge deformity involving the l1 vertebral body with no evidence of acute fractures or dislocations involving the thoracic spine. 2. this study is not tailored for evaluation of intrathoracic or intra-abdominal structures. however, there is mild bibasilar atelectasis in the lungs, greater on the right than the left. ct head : unchanged subdural hematoma layering along the falx measuring up to 10 mm. ct face : 1. acute comminuted nasal bone and frontal process of maxilla fractures as above. no other visualized facial bone fracture. 2. hyperdense fluid seen layering within the maxillary sinus and right sphenoid sinus raises the possibility of occult fractures. 3. subdural hematoma along the falx and on the tentorium on the right, similar to prior head ct. ct t & l spine: 1. compression wedge deformity involving the l1 vertebral body with no evidence of acute fractures or dislocations involving the thoracic spine. 2. this study is not tailored for evaluation of intrathoracic or intra-abdominal structures. however, there is mild bibasilar atelectasis in the lungs, greater on the right than the left. ct cspine: no fractures. severe degenerative changes. brief hospital course: 65 year old woman with alcohol abuse and depression presented after a mechanical fall while intoxicated, found to have maxillary and nasal fractures, sdh and transferred to for further management. ms. was admitted to the trauma icu on for neuro monitoring. her gcs remained 15 throughout, though she was intermittently agitated. tertiary survey revealed right elbow pain and a film was obtained with no evidence of fracture. patients' spine was cleared with ct and clinical exam. on , patient fell out of bed and hit her head again. a repeat ct of the head and cspine were peformed with no new injuries seen. overnight, she was more agitated and required lorazepam for ciwa scale. on , her agitation persisted though her neuro exam was normal and ct unchanged. she was started on a precedex drip with significant improvement. on the morning of , a repeat head ct was performed due to concern for anisocoria. ct showed a small amount of new intraventricular blood but nothing significant and neurosurgery felt not clinically significant. on patient was transferred from tsicu to micu for ongoing management of delerium. during admission she became increasingly agitated with altered mental status. prior to transfer to micu, patient was treated initially with zyprexa, then transitioned to ativan with ciwa due to concern for alcohol withdrawl. she was transferred from the sicu service to the micu service on for management of delirium. on transfer to the micu service, infectious work-up revealed uti for which patient was started on ceftriaxone. patient lose iv access and precedex was stopped on . patient's delirium improved with treatment of uti. patient was started on diazepam ciwa scale for alcohol withdrawal, although it was felt alcohol withdrawal was less likely source of delirium. patient also had metabolic acidosis, was found to have ketones in urine, which is likely starvation ketosis as patient had not been fed from - . patient's delirium improved and she was called out to medicine floor on . toxic-metabolic encephalopathy: multiple contributing factors, including previous h/o delirium during hospitalization as reported by husband, etoh abuse, dementia, uti, and sdh.the patient remained at baseline confused and was oriented to person, but only intermittently oriented to place and time. the patient was maintained on minimal doses of oral haldol as needed for agitation, but within the last few days of her hospitalization required no haldol. the patient was aao x person, place (), and time (, day before day) on the day of discharge. cognitive assessment performed by occupational therapy revealed that patient cognitive impairments in insight, orientation, visual spatial skills, attention, abstraction, language and memory. she was felt to be unsafe to return home without 24 hr care out of concerns for her safety following this acute hospitalization. the patient would benefit from follow up with cognitive neurology in the outpatient setting for further assessment. . sinus tachycardia patient with asymptomatic tachycardia in 120s with episodes of tachycardia to 140s with exertion. patient has remained hemodynamically stable and asymptomatic throughout these episodes. ekg not concerning for ischemic pattern. echocardiogram for evaluation of cardiomyopathy revealed mildly depressed ef, no pericardial effusion or significant valvular disease. no chest pain, hd stable, stable hct, no fevers, no leukocytosis, le swelling, or dyspnea. cta of the chest was negative for pulmonary embolism. possibly related to some component of volume depletion with some response to volume expansion. likely also related to generalized deconditioning, for which patient will benefit from pt. etoh abuse patient with long h/o etoh abuse with multiple hospital admissions for falls. per husband patient has failed multiple attempts at rehabilitation. patient with likely korsakoff syndrome per neurology assessment in and has declining ability to care for self. continued on folate, thiamine, multivitamin, calcium and vitamin d. patient would benefit from substance abuse program. patient should follow up with neurology and pcp to determine when it is safe to resume bupropion, acamprosate, naltrexone, and trazodone. simvastatin was held in the setting of active alcohol abuse, however, this may be reconsidered in the outpatient setting as the patient's ast/alt were wnl. . uti complicated cystitis in setting of indwelling foley catheter. treated initially with ceftriaxone, then transitioned to bactrim based on culture sensitivities to complete seven day course. . subdural hematoma stable in size on repeat head ct , no interventions deemed necessary. completed seven days of seizure prophylaxis with keppra. remained neurologically stable throughout remainder of her course, with only notable finding of pupillary asymmetry without other findings. neurosurgery was aware. she will follow up in 4 weeks with repeat ct head with dr. . anisocoria new finding during this admission. left pupil 6 mm right pupil 3mm, both round and reactive to light. could be related to small hemorrhage in right occipital cell. multiple fractures facial, nasal and l1 compression fracture. seen by plastic surgery during admission. patient evaluated by plastic surgery who sutured facial lacerations. patient to follow up for suture removal and evaluation upon discharge. patient evaluated by pt who was concerned about safety and recommended rehab. electrolyte abnormalities likely nutritionally depleted in setting of etoh. required repletion of potassium magnesium and phosphorus. anemia likely multifactorial with b-12/folate deficiency in setting of etoh and possibly some iron deficiency from poor nutrition and potential gi loss from gastritis. remained stable throughout her course. gerd continued omeprazole per home regimen. transition of care -patient should f/u with neurosurgery (with repeat head ct) and neurology and noted above -patient should f/u with plastic surgery -patient should f/u with pcp for coordination of care medications on admission: home medications: (confirmed by husband) -bupropion 150mg xr twice daily -vitamin b1/thiamine 100mg daily -folic acid 400mg daily -vitamin d 11000iu daily -citalopram 40mg q am -namenda 5mg q am -campral (acamprosate) 333mg 2tabs tid -omeprazole 20mg daily @ 2pm -naltrexone 50mg @ 2pm -multivitamin with iron @ 2pm -trazodone 100mg qhs -simvastatin 10mg qhs -asa 325mg daily discharge medications: 1. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po twice a day. 4. vitamin d3 1,000 unit capsule sig: one (1) capsule po once a day. 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. memantine 5 mg tablet sig: one (1) tablet po daily (). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. colace 100 mg capsule sig: one (1) capsule po twice a day. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 11. citalopram 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: rehabilitation and skilled nursing center - discharge diagnosis: primary diagnoses: fall, intracranial hemorrhage, facial fractures secondary diagnoses: substance abuse, urinary tract infection discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires supervision discharge instructions: dear ms , you were admitted to the hospital because you had a fall and unfortunately suffered some fractures of your facial bones and had some bleeding around your brain. while you were here, we monitored you closely to make sure that the bleeding around your brain remained stable, and it did. you will need to follow up with the plastic surgeons in about one week to have your sutures removed. you will also need to follow up with the neurosurgeons in four weeks to make sure that the blood around your brain is stable. you will need to get another ct scan of your head before your follow up appointment. you were also a little confused and anxious sometimes, so we gave you some medication to help with this. it is very important for you to follow up with a neurologist for further evaluation and to determine what medications can best help you with this. we also found that you had a urinary tract infection, so you completed a course of antibiotics. you are now being transferred to a rehabilitation facility where you will get physical therapy to work on getting stronger. it is very important that you follow up with your primary care doctor after you leave rehab. it is also important for you to discuss ways to help you refrain from alcohol use and prevent injuries in the future. medication changes stop the following medications until you follow up with your doctors to determine when it is safe to restart: - bupropion - acamprosate - naltrexone - simvastatin - aspirin - trazodone followup instructions: follow up with your primary care doctor within 1-2 weeks after discharge from rehab, dr. ge, . department: div of plastic surgery when: friday at 1:30 pm with: , md building: lm bldg () campus: west best parking: garage department: neurology when: thursday at 1 pm with: drs. / building: sc clinical ctr campus: east best parking: garage department: radiology when: thursday at 10:00 am with: cat scan building: cc campus: west best parking: garage department: neurosurgery when: thursday at 11:00 am with: , md building: lm campus: west best parking: garage Procedure: Closure of skin and subcutaneous tissue of other sites Central venous catheter placement with guidance Diagnoses: Acidosis Thrombocytopenia, unspecified Toxic encephalopathy Depressive disorder, not elsewhere classified Other specified cardiac dysrhythmias Disorders of phosphorus metabolism Accidental fall on or from other stairs or steps Open wound of jaw, without mention of complication Iron deficiency anemia, unspecified Other vitamin B12 deficiency anemia Diarrhea Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Accidental fall from bed Closed fracture of lumbar vertebra without mention of spinal cord injury Delirium due to conditions classified elsewhere Unspecified intestinal malabsorption Volume depletion, unspecified Alcohol withdrawal Infection and inflammatory reaction due to indwelling urinary catheter Closed fracture of nasal bones Contusion of face, scalp, and neck except eye(s) Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Personal history of peptic ulcer disease Anisocoria History of fall Alcohol-induced persisting amnestic disorder Other and unspecified Escherichia coli [E. coli] Bacterial infection, unspecified, in conditions classified elsewhere and of unspecified site Pain in joint, forearm Folate-deficiency anemia Vaginitis and vulvovaginitis, unspecified Other and unspecified alcohol dependence, episodic Dementia, unspecified, without behavioral disturbance Cystitis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bleeding from rectum major surgical or invasive procedure: : superior mesenteric and inferior mesenteric arteriogram. : left upper extremity picc placement. : superior mesenteric artery and a selective ileocolic artery arteriogram. : ileocecectomy. : right internal jugular vein central line placement. history of present illness: ms. is a 62yo female with a pmh significant for crohn's disease who is transferred from an osh for management of a gi bleed. per patient, she was in her usual state of health until . she typically wakes up at 4am to move her bowels. she woke up that morning and passed brbpr. it apparently filled up the toilet bowel. ten minutes later, she passed more brb. there was no associated pain, nausea, or vomiting. she presented to the osh and hct was 36.8 (last hct in was 43.3). the next day she underwent a colonoscopy which showed the following: left sided diverticulosis, tortuous redundant colon with excessive looping. blood throughout the colon but no active bleeding seen. fresh blood from the rectum to the anastomosis. per the osh gastroenterologist, she also had an egd which was completely normal. she continued to pass brb and proceeded to have several bleeding scans over the course of her hospitalization. two of the three bleeding scans showed questionable activity in the left side of the gi tract and one study was completely normal. she proceeded to have a mesenteric angiogram which was negative. per osh records, she received a total of 17 units prbcs. given the persistent bleeding, she was transferred to for further work-up. on admission hct was 28.5. past medical history: 1. crohn's disease 2. copd 3. hypothyroidism 4. osteoporosis social history: quit smoking 1 week ago, smoked since age of 17 1 ppd, 45 pk year. no etoh. no illicit drug use. family history: mother w/ dm, 88 years old. father w/ mi at age 54. twin sister with brain tumor physical exam: on admission: vital signs:t: 98.7 bp: 97/57 hr: 123 rr: 19 02 sat: 97% on ra general: no acute distress lungs: clear to auscultation bilaterally cardiac: regular rate and rhythm, s1/s2 abdomen: soft, nontender, nondistended rectal: normal tone, burgudany stool, guaiac positive extrem: warm, well-perfused, palpable distal pulses in all distal extremities. on discharge: vs: t 97.1, hr 90, bp 110/60, rr 18, o2 sat 96% ra general: calm, appropriate, nad cardiac: rrr, no m/r/g lungs: ctab abdomen: midline incision, open to air with staples. soft, non distended. ext: warm, distal pulses 2+. neuro: aaox3, perrl. pertinent results: 05:58pm wbc-9.8 rbc-2.83* hgb-8.4* hct-24.5* mcv-86 mch-29.6 mchc-34.3 rdw-17.6* 05:58pm plt count-132* 05:58pm pt-15.6* ptt-30.6 inr(pt)-1.4* 05:58pm glucose-73 urea n-20 creat-0.6 sodium-141 potassium-4.2 chloride-114* total co2-17* anion gap-14 05:58pm alt(sgpt)-7 ast(sgot)-15 alk phos-30* tot bili-0.6 05:58pm calcium-7.3* phosphate-3.9 magnesium-1.6 : ct abdomen w/o contrast impression: 1. no evidence of retroperitoneal hematoma or bleeding. 2. multiple liver lesions, most of which represent simple cysts, but the largest lesion is ill-defined and incompletely characterized. dedicated mri is recommended for further characterization of this lesion. 3. left adrenal adenoma. : gi bleeding study: impression: no evidence of active gi bleeding over 104 minutes. : mesenteric angiography and possible embolization. impression: superior mesenteric and inferior mesenteric arteriograms showing no active contrast extravasation suggestive of active bleeding at the time of angiography. therefore, no further intervention was required. : left upper extremity veins us: impression: 1. partially occlusive deep vein thrombus in the left subclavian vein, with occlusive superficial vein thrombus in the left basilic vein from the elbow to the shoulder. 2. patent left internal jugular, axillary, brachial and cephalic veins. 3. normal respiratory variability in the right subclavian vein, indicating central patency. : cta abd w&w/o c & reconstruction: impression: 1. abnormal progressive enhancement in the lateral wall of the ileum could represent bleeding in the wall of the ileum. differential diagnosis includes a vascular malformation. 2. hemangioma and multiple cysts within the liver. 3. distended gallbladder with pericholecystic fluid. clinical correlation is recommended. : mesenteric angiography to possibly embolization. impression: 1. sma and a selective ileocolic artery arteriograms demonstrating no evidence of active extravasation or vascular malformation. therefore, no embolization was performed. 02:21am blood wbc-9.4 rbc-3.54* hgb-10.1* hct-31.3* mcv-88 mch-28.6 mchc-32.3 rdw-15.6* plt ct-576* 10:31am blood glucose-132* urean-17 creat-0.5 na-138 k-4.1 cl-102 hco3-29 angap-11 10:31am blood calcium-7.7* phos-4.5 mg-2.1 04:35am blood caltibc-131* ferritn-376* trf-101* 06:55am blood hct-27.9* brief hospital course: general brief hospital course: the patient was admitted to the general surgical service for evaluation and treatment. on patient underwent mesenteric angiography and possible embolization, which showed no active contrast extravasation suggestive of active bleeding at the time of angiography. on patient underwent repeat mesenteric and iliac artery angiogram, which was negative for acute bleeding. on patient underwent abdominal cta which showed abnormal progressive enhancement in the lateral wall of the ileum could represent bleeding in the wall of the ileum. on , the patient underwent ileocecectomy which went well without complication (reader referred to the operative note for details). after a brief, uneventful stay in the pacu, the patient arrived on the floor npo, on iv fluids and antibiotics, with a foley catheter, and morphine pca for pain control. the patient was hemodynamically stable. neuro: the patient received morphine pca with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications (percocet) with adequate pain control. cv: on admission patient was hypotensive and tachycardic secondary to active bleeding. patient was placed on telemetry monitoring while in icu. after receiving fluid resuscitation and blood transfusions, patient's cardiovascular status improved. the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. ekg was obtained on and was grossly normal. pulmonary: patient was intubated on for respiratory compromise. patient was extubated on and started on supplemental o2 via face mask. when respiratory status stabilized, patient was weaned off from o2. the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. gi/gu/fen: pre-operatively, the patient was made npo with iv fluids. post-operatively patient nutrition consult was obtained and patient was started on tpn. diet was advanced to clear liquids on , which was well tolerated. on diet was advanced to regular, patient tolerated well. tpn was discontinued on . during hospitalization patient underwent multiple blood/ffps and aggressive fluid resuscitation. patient developed signs of fluid overload including bilateral lower extremities edema. chest x-ray was obtained and was normal (no pulmonary edema was revealed). patient was started on iv lasix daily for diureses, her iv fluid intake was adjusted accordantly. patient's intake and output were closely monitored via foley catheter. foley was discharged on . electrolytes were routinely followed, and repleted when necessary. hematology: the patient was admitted with hct 24.5 and active rectal bleeding. on (day of admission), patient received 4 units of prbc. on hct was 26.1, patient received 7 units of prbc and 3 units of ffp, 2 units of cryo, and 1 unit of platelets total. hct improved to 47.3. on patient re-bleed, hct was 33.8, patient received 2 units of prbcs. on prior or patient's hct was 24. post surgery patient's hct was stable low, ranging between 27-33. no further transfusion were required. dvt: on / patient developed low grade fever and her left arm was swollen. picc line was removed, and left arm ultrasound was obtained , showed left subclavian vein dvt. patient was started on heparin gtt. her ptt was routinely monitored and kept within therapeutic level, heparin drip was adjusted. prior discharge patient was started on coumadin po. patient's heparin was discontinued, and she was started on sc lovenox on discharge. lovenox teaching was done, patient demonstrated well injection technique. patient was discharged with vna services, which will continue to tech/monitor lovenox administration, and will follow inr results. inr results will be reported to patient's pcp, pcp will manage patient's inr. id: the patient's white blood count and fever curves were closely watched for signs of infection. patient's blood cultures were monitored and were negative. wound care was required dressing change post surgery. currently, patient's wound open to air with staples. incision clear, dry and intact. staples will be removed during follow up appointment. endocrine: the patient's blood sugar was monitored throughout his stay and was within normal limits. patient continue to receive levothyroxine for hypothyroidism during hospitalization. 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: 1. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 2. warfarin 3 mg tablet sig: one (1) tablet po daily in the evening. disp:*30 tablet(s)* refills:*0* 3. mesalamine 400 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qid (4 times a day). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* 5. imuran 50 mg tablet sig: one (1) tablet po qam and 0.5 tablet po qpm. 6. choleystyramine sig: one (1) packet once a day. 7. calcium carbonate-vitamin d3 oral 8. vitamin b-12 injection 9. raloxifene 60 mg tablet sig: one (1) tablet po once a day. discharge medications: 1. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 2. warfarin 3 mg tablet sig: one (1) tablet po daily in the evening. disp:*30 tablet(s)* refills:*0* 3. mesalamine 400 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qid (4 times a day). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* 5. imuran 50 mg tablet sig: one (1) tablet po qam and 0.5 tablet po qpm. 6. choleystyramine sig: one (1) packet once a day. 7. calcium carbonate-vitamin d3 oral 8. vitamin b-12 injection 9. raloxifene 60 mg tablet sig: one (1) tablet po once a day. 10. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*60 capsule(s)* refills:*0* 11. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation: over-the-counter. 12. enoxaparin 80 mg/0.8 ml syringe sig: 0.8 ml (80mg) subcutaneous q12h (every 12 hours) for 7 days. disp:*14 pre-filled syringes* refills:*1* 13. alcohol pads pads, medicated sig: one (1) pad topical as directed. disp:*1 box* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: 1. crohn's disease 2. gastrointestinal bleed at ileocolonic anastomosis. 3. left upper extremity dvt. 4. acute blood loss anemia 5. respiratory failure 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 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. coumadin (warfarin): what is this medicine used for? this medicine is used to thin the blood so that clots will not form. how does it work? warfarin changes the body's clotting system. it thins the blood to prevent clots from forming. what you should contact your healthcare provider : signs of a life-threatening reaction. these include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. call your doctor if you are unable to eat for several days, for whatever reason. also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. these problems could affect your coumadin??????/warfarin dosage. coumadin (warfarin) and diet: certain foods and beverages can impair the effect of warfarin. for this reason, it's important to pay attention to what you eat while taking this medication. until recently, doctors advised taking warfarin to avoid foods high in vitamin k. this is because large amounts of vitamin k can counteract the benefits of warfarin. however, recent research shows that rather than eliminating vitamin k from your diet, it is more important to be consistent in your dietary vitamin k intake. these foods contain vitamin k: fruits and vegetables, such as: kiwi, blueberries, broccoli, cabbage, sprouts, green onions, asparagus, cauliflower, peas, lettuce, spinach, turnip, collard, and mustard greens, parsley, kale, endive. meats, such as: beef liver, pork liver. other: mayonnaise, margarine, canola oil, soybean oil, vitamins, soybeans and cashews. limit alcohol. alcohol can affect your coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. serious problems can occur with alcohol and coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. binge drinking is not good for you. be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. monitoring: the doctor decides how much coumadin??????/warfarin you need by testing your blood. the test measures how fast your blood is clotting and lets the doctor know if your dosage should change. if your blood test is too high, you might be at risk for bleeding problems. if it is too low, you might be at risk for forming clots. your doctor has decided on a range on the blood test that is right for you. the blood test used for monitoring is called an inr. use of other medications: when coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. other medicines can also change the way coumadin??????/warfarin works. it is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. followup instructions: please call ( to schedule a follow-up appointment with dr. , md (surgery) in 2 weeks. . please call ( to arrange a follow-up appointment with dr. (pcp) in weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Arterial catheterization Arteriography of other intra-abdominal arteries Arteriography of other intra-abdominal arteries Open and other right hemicolectomy Other small-to-large intestinal anastomosis Endoscopic destruction of other lesion or tissue of large intestine Endoscopic destruction of other lesion or tissue of large intestine Diagnoses: Other iatrogenic hypotension Abnormal coagulation profile Tobacco use disorder Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Acute respiratory failure Osteoporosis, unspecified Blood in stool Altered mental status Diverticulosis of colon (without mention of hemorrhage) Regional enteritis of small intestine with large intestine Edema Ulceration of intestine Acute venous embolism and thrombosis of subclavian veins