Datasets:

Medilora

/

mimic_iii_diagnosis_anonymous

like 8

Follow

Medilora 5

allergies: iodine attending: chief complaint: lower extremity, belly swelling major surgical or invasive procedure: right internal jugular line history of present illness: 43yo male patient of dr. with severe dilated nonischemic cardiomyopathy, systolic chf, lvef 15%, massively dilated lv, morbid obesity with weight in excess of 415 lbs., s/p biv/icd with lbbb, osa who was directly admitted to ccu for increasing fluid overload, hypotension. . the patient was seen in cardiology clinic on and found to be markedly volume overloaded with large, distended abdomen with massive ascites, but refused hospital admission. patient agreed to direct admission to ccu today (). . pt reports being approx. 360 pounds prior to last . since that time he started to notice lower extremity edema. patient hospitalized in for increased lower extremity swelling. initially patient reports a good response with torsemide however in the past 2 months has noted decreased diuresis and weight gain. since that time patient has noticed increased swelling in the abdomen, now weighing approx. 415 pounds today. patient reports increased fatigue with activity. patient spends of his time sitting. with very little time up walking around. most patient walks is across one or two rooms. walking up 4 stairs greatly fatigues patient greatly. endorse pillow orthoponea. with nightly episodes of shortness of breath in the last 2 months. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. past medical history: non-ischemic dilated cardiomyopathy chf-lvef 20% gout hypertension obstructive sleep apnea (unable to use cpap) social history: he is single and lives alone. he does not smoke and very rarely drinks alcohol. he works in billing for sunny delight. family history: noncontributory physical exam: vs: t=98.5 bp=96/73 hr=77 rr=18 o2 sat= 95% ra general: aox3 nad. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. no cyanosis of the oral mucosa. no xanthalesma. neck: supple, with jvp of 18cm. cardiac: regular rate, normal s1, s2. no m/r/g. no thrills, lifts. possible s3 lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. scant crackles in b lower lobe, no wheezes or rhonchi. abdomen: impressive distention, obese, no tender. unable to appreciate any hsm given level of distention. bowel sounds present. extremities: 3+ lower extremity edema to level of knee. skin: stasis dermatitis in bilateral lower extremity. no other ulcers or skin breakdown appreciated on exam. no jaundice. pulses: lower extremity pulses difficult to palpate given edema, however feet are warm, well perfused, with good capillary refill. 2+ pulses in bilateral upper extremity. pertinent results: admission labs: 03:48pm blood wbc-6.9 rbc-5.28 hgb-14.9 hct-44.8 mcv-85 mch-28.3 mchc-33.3 rdw-17.4* plt ct-305 03:48pm blood neuts-74.8* lymphs-13.3* monos-8.7 eos-2.7 baso-0.6 03:48pm blood pt-13.6* ptt-23.5 inr(pt)-1.2* 03:48pm blood glucose-103 urean-46* creat-1.5* na-133 k-4.9 cl-96 hco3-27 angap-15 03:48pm blood alt-11 ast-19 ld(ldh)-206 ck(cpk)-36* alkphos-169* totbili-1.5 03:48pm blood ck-mb-notdone ctropnt-0.02* 03:48pm blood albumin-3.9 calcium-9.8 phos-3.7 mg-2.4 labs: 04:42am blood wbc-6.9 rbc-4.98 hgb-13.8* hct-41.5 mcv-83 mch-27.7 mchc-33.2 rdw-16.6* plt ct-317 04:03am blood wbc-8.0 rbc-5.02 hgb-14.1 hct-42.4 mcv-84 mch-28.0 mchc-33.2 rdw-15.6* plt ct-331 05:02am blood wbc-8.7 rbc-5.27 hgb-14.8 hct-45.3 mcv-86 mch-28.0 mchc-32.6 rdw-15.8* plt ct-355 02:55pm blood glucose-99 urean-73* creat-2.2* na-127* k-4.3 cl-80* hco3-33* angap-18 04:57am blood glucose-106* urean-79* creat-2.2* na-129* k-4.4 cl-79* hco3-35* angap-19 06:23pm blood glucose-109* urean-83* creat-2.2* na-129* k-4.3 cl-77* hco3-36* angap-20 12:45am blood glucose-113* urean-85* creat-2.2* na-132* k-4.2 cl-82* hco3-32 angap-22* 09:03pm blood calcium-10.6* phos-4.2 mg-2.3 04:14am blood calcium-10.5* phos-3.9 mg-2.2 02:55pm blood calcium-10.7* phos-3.9 mg-2.3 04:57am blood calcium-10.8* phos-4.4 mg-2.1 discharge labs: 04:45am blood wbc-5.4 rbc-5.25 hgb-14.9 hct-44.9 mcv-86 mch-28.3 mchc-33.1 rdw-16.5* plt ct-399 03:55am blood pt-14.4* ptt-25.1 inr(pt)-1.2* 04:45am blood glucose-108* urean-103* creat-2.1* na-127* k-4.7 cl-83* hco3-28 angap-21* 04:45am blood calcium-10.9* phos-4.2 mg-2.6 imaging: echo : the left atrium is markedly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated with severer global hypokinesis. no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. an eccentric, jet of moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular cavity size is minimally smaller and systolic function is minimally improved. right ventricular free wall hypokinesis appears more global, but of similar magnitude. cxr : the cardiac silhouette is markedly enlarged, accompanied by pulmonary vascular congestion and small bilateral pleural effusions. current examination is limited by exclusion of the extreme lung apices. repeat radiograph to include the entirety of the lungs is recommended. finally, icd remains in place with leads overlying right atrium and right ventricle. brief hospital course: 43yo male patient of dr. with severe dilated nonischemic cardiomyopathy, systolic chf, lvef 15%, massively dilated lv, morbid obesity with weight in excess of 415 lbs., s/p biv/icd with lbbb, osa who was directly admitted to ccu for decompensated systolic chf requiring iv milrinone and lasix for diuresis. . # pump/decompensated systolic heart failure: ef 15% during last echo in thought to be nonischemic cardiac myopathy, baseline weight prior to admission 400 pounds on diuretics (torsmide 60 mg ). however, patient was hypotensive with that regimen. upon admission patient was started on lasix drip up to 30 mg/hr. patient was very hypotensive and required neosynephrine drip and milrinone with beta-blocker to reduce tachycardia. patient was diuresing 5-10 l per day and requiring up to 300 meq potassium. electrolytes were monitored three time daily and as noted potassium was repleted agressively with a goal of 4.5 -5. patient was also started on metalazone, aldactone, and acetazolamide. diuresis was continued until patient's creatinine level peaked at 2.4. in total patient was diuresed 56 liters. on discharge patient was transitioned to oral medications including torsemide 40mg , aldactone 50mg daily, with potassium 40meq . patient will be followed closely as an outpatient by dr. . # rhythm: on admission patient had a v paced/av paced rhythm (with biv/icd). during the admission patient was monitored on telemetry for concern of increased ectopy given patient was being treated with milrinone and iv lasix. throughout the hospitalization patient had multiple episodes of non sustained ventricular tachycardia. patient was placed on metoprolol and uptitrated to toprol xl 300mg daily at discharge. of note patient had three episodes of sustained ventricular tachycardia which led to ventricular fibrillation and icd firing after failed anti tachycardic pacing. the first two episodes reguiring icd firing were in the setting of milrinone. the final episode of v fib reguiring icd firing occured after milrinone was stopped and was thought to be secondary to changes in intracellular electrolytes mainly potassium and digoxin. prior to discharge patient went three days without any episodes of non sustained ventricular tachycardia. patient will be followed as an outpatient by both electrophysiology and heart failure clinics. . # acute vs chronic renal failure: patient with unknown recent baseline. crt on admission was 1.5 and 1.3 in . most likely secondary to poor cardiac output. lisinopril was held. creatinine was followed during the hospitalization and slowly trended up, during the admission it was as high as 2.4 prior to iv lasix being held. at discharge patient crt decreased to 2.1. renal function will be followed by dr. in the outpatient clinic. . # coronaries: patient without history of coronary artery disease. however, no catheterization in the past. patient was continued on asa. . # gout: patient had an episode of gout during admission involving the left great toe. given colchicine which improved pain. developed diarrhea which resolved when colchicine was stopped. . # osa: stable during admission. not on cpap/bipap at home. _ _ _ ________________________________________________________________ medications on admission: colchicine 0.6 mg tablet 1 tablet(s) by mouth prn lisinopril 10 mg tablet 1 tablet(s) by mouth once a day metoprolol succinate 100 mg tablet sustained release 24 hr 1 tablet(s) by mouth daily spironolactone 25 mg tablet one-half tablet(s) by mouth twice a day torsemide 20 mg tablet 2 tablet(s) by mouth three times a day aspirin 325 mg tablet, delayed release (e.c.) 1 tablet(s) by mouth once a day maxair prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). tablet(s) 2. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain: take for gout pain. 3. colchicine 0.6 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for gout pain. 4. spironolactone 50 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. metoprolol succinate 100 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po daily (daily). disp:*60 tablet sustained release 24 hr(s)* refills:*2* 6. torsemide 20 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 7. potassium chloride 20 meq tab sust.rel. particle/crystal sig: two (2) tab sust.rel. particle/crystal po twice a day. disp:*120 tab sust.rel. particle/crystal(s)* refills:*2* discharge disposition: home discharge diagnosis: acute on chronic systolic heart failure ef 15% ventricular tachycardia discharge condition: stable. afebrile. sating normally on room air. discharge instructions: you have congestive heart failure and were admitted for intensive diuresis of extra fluid. you were on milrinone, lasix and phenylephrine drip in the ccu to remove fluid. during your stay you also had multiple episodes of ventricular tachycardia/fibrillation which resulted in your icd firing. all episodes were properly managed by your biv/icd. these episodes were secondary to changes in electrolytes and medications you were on while in the hospital. we changed all of the medicines to pill form and will send you home with the following medication changes: 1. torsemide: changed to 40 mg at 8:00am and 40 mg at 2:00pm 2. spironolactone was increased to 50 mg daily 3. your toprol was increased to 300mg daily 4. potassium chloride 40 meq was added twice daily 5. lisinopril was stopped . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1500cc per day. please avoid drinking plain water. . please call dr. or dr. if you have any trouble breathing, cough, chest pain, nausea, swelling or if your icd fires. followup instructions: cardiology ep: provider: phone: date/time: 1:00 . cardiology heart failure: dr. phone: date/time: at 2pm with practitioner how works with dr. . . cardiology: , md phone: (, please call to follow up in the next few weeks. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Other primary cardiomyopathies Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Morbid obesity Automatic implantable cardiac defibrillator in situ Acute on chronic systolic heart failure

allergies: no known allergies / adverse drug reactions attending: chief complaint: bowel obstruction and respiratory failure pod12 from emergent right hemicolectomy major surgical or invasive procedure: : tracheostomy and peg () : exlap right hemicolectomy () ] history of present illness: ms is a 50f with steroid-dependent copd known to the acs service from recent admission for free air & extensive pneumatosis now s/p ex-lap and r colectomy () who returns on transfer from osh for bowel obstruction and respiratory failure. pt was discharged in good condition with functioning bowels. hx obtained from daughter as pt is intubated: she has been increasingly distended and nauseated since discharge. she has been keeping her pills down but has been regurgitating into her mouth. this am at home she looked ill and her lips were blue. she was taken to where cxr and kub showed massive gastric dilatation and small bowel dilatation with stool/contrast in the rectum. an ngt was placed with hurricane spray and pt aspirated. she went into respiratory failure and was intubated prior to transfer. post intubation film confirmed the ngt well within the stomach, which was decompressed, and appropriate positioning of the ngt. past medical history: pmh: duodenal ulcers, copd on chronic steroids, asthma, tobacco dependence, hypothyroidism, chronic constipation, multiple t-spine compression fxs, depression w/hx suicidal ideation and suicide attempts/psych hospitalizations psh: open r hemicolectomy (), c-sxn, endoscopic "repair" of duodenal ulcers social history: lives with nephrew in , +tob 30 py, no etoh, no drugs family history: non-contributory physical exam: admission: vitals: hr 110's, bp 140's gen: intubated, no sedation since before transfer and pt is not moving or responding to stimuli, pt is cachectic, ill-appearing, w/skin changes c/w lonterm steroid use heent: no scleral icterus, mucus membranes moist cv: rrr, no m/g/r pulm: coarse b/l abd: soft, distended, retention sutures and surgical staples to midline abdominal wound, no erythema hypoactive bowel sounds, no palpable masses ext: no le edema, l calf ulcer, venous stasis changes to b/l les cbc: 2.5 > 36.7 < 279 140 / 92 / 46 chem: --------------< 134 ca: 8.7 mg: 7.8 p: 3.5 3.4 / 36 / 1.4 alt 21; ap 118; tbili 0.7; alb 3.4; ast 37; lip 42; trop-t: 0.02 pt: 11.0 ptt: 22.8 inr: 0.9 lactate:3.5 - ucg negative - ph 7.43/pco2 56/po2 423/hco3 38/basexs 11/methb 16/o2sat: 83 imaging: cxr (osh): massively dilated stomach, dilated loops of sb, no free air kub (osh): dilated sb, gastric distension, stool w/contrast in rectum pertinent results: 05:20pm blood wbc-2.5* rbc-3.71* hgb-11.7* hct-36.7 mcv-99* mch-31.4 mchc-31.8 rdw-18.1* plt ct-279 02:07am blood wbc-35.3* rbc-3.48* hgb-10.4* hct-32.1* mcv-92 mch-29.8 mchc-32.3 rdw-16.5* plt ct-534* 02:07am blood glucose-131* urean-20 creat-0.3* na-137 k-4.7 cl-94* hco3-32 angap-16 06:31am blood type-art temp-37.6 peep-5 po2-64* pco2-59* ph-7.42 caltco2-40* base xs-10 intubat-intubated 06:31am blood lactate-2.6* : ct torso: 1. increased number and confluence of cavitary lesions noted in the left lower lobe consolidation. other previously reported diffuse cavitary lesions and ground-glass opacities appear relatively stable. these findings are consistent with necrotizing pneumonia or septic emboli with superimposed necrotizing lobar pneumonia; fungal infection such as invasive aspergillosis is also considered. 2. interval resolution of pleural effusion. 3. stable ileocolic anastomosis without evidence of anastomotic leak or bowel obstruction. 4. minimal residual debris at site of prior pigtail drain without evidence of reaccumulated or new focal abscess. 5. stable thoracic spine compression fractures. 6. pancreatic calcifications consistent with chronic pancreatitis. brief hospital course: ms was admitted to the icu upon her arrival to the emergency department. she arrived from intubated/sedated on mechanical ventilation. during her 3 week icu stay, her primary issues were pulmonary and infectious. in brief, we were unable to wean her from the ventilator but her mental status normalized and her gut tolerated tube feeds. a detailed hospital course is below. neuro: ct head () was performed at presentation as neurologic status could not be adequately assessed and precipitating insult was not confirmed. this showed no acute intracranial pathology. cv: she had an intermittent pressor requirement. she underwent trans-thoracic echocardiogram on and , both studies showed good cardiac function (ef 65%). there was question of valve vegetation, but no tee was performed. pu: ct chest on admission showed left lower lobe consolidation and peribronchial ground glass opacities bilaterally, thought to be due to infection with possible aspiration. she remained ventilator dependent during the stay. on hd3, she self-extubated and soon became tachypnic and hypoxic so was re-intubated. repeated attempts to wean pressure support were limited by tachypnea, tachycardia and hypoxia. she underwent multiple bronchoscopies to remove secretions and mucous plugs. repeat chest ct on showed interval worsening of the large left lower lobe consolidation and interval increase of innumerable small cavitary lesions compatible with diffuse dissemination of infection. once apparent she would likely never wean from the vent, she underwent tracheostomy . repeat chest ct on was consistent with worsening necrotizing pneumonia. gi: she arrived with an ngt in place given her sedation and risk for aspiration. tube feeds were started . repeat ct abd/pelv on showed the anastamosis to be intact, no evidence of bowel obstruction and near-complete resolution of abdominal ascites and resolution of deep pelvic collection. percutaneous gastrostomy tube was placed on and feeds were begun the following day. gu: urine culture from showed >100k yeast. renal ultrasound on showed no evidence of fungal infection. foley was kept in place, and urine output remained adequate. fen: she required few iv boluses. she was started on tpn and continued until could tolerate tube feed nutrition. hem: she exhibited an initial rise then persistently elevated wbc. on admit, was 2.5, rose to 13.0 by hd6, peaked at 35.3 . she was transfused 2 units prbc on hd 4 and required pressors and was not responding sufficiently to crystalloid resuscitation. however, once adequately rescusitated, the patient was weaned off of pressors, and did not require additional blood transfusions. id: in summary of her infectious course, she had a pelvic abscess growing c. perfringens and that was treated. she then developed findings concerning for cavitary pneumonia with mucocutaneous candidiasis in bladder, esophagus and lungs. she never had fungemia. possible fungal reservoir include heart valves, which would require amphoteracin treatment. on hd2, she underwent ir-guided drain placement of the pelvic abscess. this drain was removed after 8 days and ct pelvis showed resolution of abscess. her antibiotic therapy changed frequently based on recommendations from the infectious disease consult team and her culture data. pip-tazo vanco cefepime metronidazole - meropenem gent fluc - micafungin levoflox - she had many microbiology studies performed. of note, all growths were fluconazole sensitive and klebsiella was pan-sensitive. there were no positive blood cultures. | pelvic abscess: c. perfringens, c. albicans | bal: yeast | urine: c. albicans | "peritoneal fluid" (abscess drainage): c. albicans | bal: c. albicans, c. dublinensis, klebsiella pna | urine: >100k yeast pending spp. | bal: yeast, gnr pending spp. (requested ) the patient overall was not improving clinically. her white count continued to rise, and she was unable to be weaned off of the vent. her necrotizing pneumonia continued to worsen and it was decided that recovery for her was unlikely. a family meeting was held on , and it was determined that patient should be made cmo. the patient expired on . medications on admission: duloxetine 60mg daily, albuterol nebs q4h, ipratropium nebs q6h, levothyroxine 50mcg daily, quetiapine 25mg qhs, pantoprazole 40mg daily, fluticasone 110mcg , latanoprost 0.005% qhs, montelukast 10mg qhs, clonazepam 1 mg tid, colace 100mg , prednisone 15mg daily, ferrex 150mg daily, symbicort 160-4.5mcg inh , bactrim ds 800-160mg 3x weekly, miralax 17g prn, oxycodone 5-10mg q6h, lactulose 20g prn constipation discharge medications: none discharge disposition: expired discharge diagnosis: - severe copd - right colon perforation leading to pelvic abscess - necrotizing pneumonia discharge condition: expired discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Diagnoses: Tobacco use disorder Long-term (current) use of steroids Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Severe sepsis Unspecified acquired hypothyroidism Candidiasis of mouth Pulmonary collapse Dysthymic disorder Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Septic shock Paralytic ileus Abscess of lung Disseminated candidiasis Encounter for palliative care Chronic obstructive asthma with (acute) exacerbation Do not resuscitate status Ventilator associated pneumonia Peritonitis (acute) generalized Mixed acid-base balance disorder Infected postoperative seroma Septic pulmonary embolism

allergies: no known allergies / adverse drug reactions attending: chief complaint: abdominal pain/distention major surgical or invasive procedure: exploratory laparotomy and right hemicolectomy - history of present illness: 50 f with c/o of increased abdominal distension and pain for 4 days with alternating constipation and diarrhea. she has a history of "bleeding ulcers" fixed endoscopically. past medical history: pmh: duodenal ulcers, copd on chronic steroids, asthma, tobacco dependence, hypothyroidism, chronic constipation, multiple t-spine compression fxs, depression w/hx suicidal ideation and suicide attempts/psych hospitalizations psh: c-sxn, endoscopic "repair" of duodenal ulcers social history: lives with nephrew in , +tob 30 py, no etoh, no drugs family history: non-contributory physical exam: (on admission) pe:97.8 88 114/65 18 97% aaox3 nad rrr ctab soft, distended, non-tender no edema, extrem warm physical examination upon discharge: vital signs: t=98.1, bp=110/60, hr=97, resp. rate 20, oxygen sat 97% on 2 liters general: sleepy, but awakens readily to voice cv: ns`1, s2, -s3, -s4 lungs: inspiratory/exp. wheezes bil. abdomen: soft, slightly distended, tender, stay-sutures intact, no erythema, no discharge ext: cool, no pedal edema bil.,+ dp bil. pertinent results: 04:38am blood wbc-8.2 rbc-3.11* hgb-9.8* hct-30.6* mcv-98 mch-31.5 mchc-32.0 rdw-17.8* plt ct-157 02:11am blood wbc-11.5* rbc-3.71* hgb-11.5* hct-36.3 mcv-98 mch-31.0 mchc-31.7 rdw-18.1* plt ct-190 09:41am blood wbc-9.6 rbc-3.91* hgb-12.3 hct-37.8 mcv-97 mch-31.5 mchc-32.6 rdw-18.0* plt ct-223 11:35pm blood neuts-77* bands-3 lymphs-14* monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 04:38am blood plt ct-157 02:11am blood plt ct-190 04:38am blood glucose-138* urean-7 creat-0.5 na-142 k-3.6 cl-108 hco3-27 angap-11 02:11am blood glucose-79 urean-9 creat-0.7 na-145 k-3.9 cl-110* hco3-26 angap-13 04:38am blood calcium-7.5* phos-2.2* mg-1.9 02:11am blood calcium-7.7* phos-3.6 mg-1.7 07:57pm blood glucose-91 06:59am blood glucose-118* lactate-1.9 na-134* k-3.4* cl-104 07:57pm blood freeca-1.12 : ekg: sinus rhythm. short p-r interval. no previous tracing available for comparison : chest x-ray: impression: 1. subdiaphragmatic gas implying gut perforation, per abdomen ct reported separately 2. possible small right upper lobe pneumonia. follow up is essential to exclude a lung nodule. 3. pronounced osseous demineralization and multilevel thoracic compression fracture deformities, unusual for age, could be traumatic given the present of many healed right rib fractures. 4. angulated kyphosis centered at t7 compression deformity. : cat scan of the abdomen: impression: 1. large amount of right-sided retroperitoneal air, in distribution suggestive of a posterior perforated duodenal ulcer. 2. no extraluminal contrast to indicate active leak. 3. bubbly appearance of cecum and ascending colon without significant symptomology or portal venous gas, favoring benign pneumatosis cystoides coli, less likely ischemic pneumatosis. 4. dilatation of transverse colon with tapering at the splenic flexure. 5. chronic pancreatitis with pseudocyst at the pancreatic tail. 6. compression deformities along superior endplates of t12-l3 vertebral bodies. 7. nonspecific thickening of sigmoid colon. : chest x-ray: findings: as compared to the previous radiograph, the patient has received a right internal jugular vein catheter. tip of the catheter projects over the mid svc. no pneumothorax or other complications. the patient has also received a nasogastric tube that is showing a correct course. the appearance of the lung parenchyma and the heart is unchanged. : urine: general urine information type color appear sp 00:40 straw clear 1.004 dipstick urinalysis blood nitrite protein glucose ketone bilirub urobiln ph leuks 00:40 neg neg neg neg neg neg neg 7.5 neg brief hospital course: the patient was taken emergently to the operating room for an exploratory laparotomy and right hemicolectomy (see operative report for full details). she was taken to the icu intubated afterwards but extubated shortly thereafter. she remained hemodynamically stable without a pressor requirement. she was treated with perioperative antibiotics (cipro and flagyl) for one day. her pain was controlled with a morphine pca. on pod1 she was stable for transfer to the floor. transferred to the surgical floor on pod #1. she was reported to have a decreased urine output for which she was given additional intravenous fluids. her urine output improved and the foley catheter was discontinued on pod #2. the nebulizers were continued for her chronic obstructive lung disease and she maintained her baseline oxygen saturation. the steroids which she was taking prior to her hospitalization were converted from intravenous to an oral . she will be discharged on daily predinisone with instructions to follow-up with her primary care provider. tube was discontinued on pod #3 and she began sips with progression to a regular diet. her incisional pain was controlled with morphine pca and she was transitioned to oral immediate release morphine. her vital signs are stable and she is afebrile. she is eating and has bm's. she is ambulating without assistance. her white blood cell count is normal. she is preparing for discharge home with vna assistance. she has instructions to follow-up with her primary care provider regarding her prednisone dosing and for further evaluation of a lung nodule. she will return to the acute care clinic in 1 week to have her wound sutures removed. medications on admission: duoneb 0.5mg-3mg qid, symbicort 160mcg-4.5mcg , bactrim ds 800mg-160mg 3x weekly, prednisone 1040mg chronically for copd, protonix 40mg daily, flovent hfa 110 mcg inh , colace 100mg tid, miralax 17g, lactulose 45ml prn, combivent 18mcg-103mcg q4h, ferrex 150mg daily, seroquel 100mg qhs, clonazepam 1mg prn, cymbalta 60mg daily, oxycodone tid discharge medications: 1. duloxetine 20 mg capsule, delayed release(e.c.) sig: three (3) capsule, delayed release(e.c.) po daily (daily). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inh inhalation q4h (every 4 hours). 3. ipratropium bromide 0.02 % solution sig: one (1) inh inhalation q6h (every 6 hours). 4. levothyroxine 25 mcg tablet sig: two (2) tablet po daily (daily). 5. quetiapine 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 8. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime): both eyes. 9. montelukast 10 mg tablet sig: one (1) tablet po hs (at bedtime). 10. clonazepam 1 mg tablet sig: one (1) tablet po tid (3 times a day). 11. colace 100 mg capsule sig: one (1) capsule po twice a day: hold for diarrheal stool. 12. prednisone 5 mg tablet sig: three (3) tablet po daily (daily): please take with food. 13. ferrex 150 150 mg capsule sig: one (1) capsule po once a day. 14. symbicort 160-4.5 mcg/actuation hfa aerosol inhaler sig: one (1) inh inhalation twice a day. 15. bactrim ds 800-160 mg tablet sig: one (1) tablet po three times a week. 16. miralax 17 gram/dose powder sig: one (1) packet po once a day: as needed for constipation. 17. oxycodone 5 mg tablet sig: 1-2 tablets po every six (6) hours: as needed for pain...may cause drowsiness. 18. lactulose 10 gram/15 ml solution sig: thirty (30) gm po prn as needed for constipation. discharge disposition: home with service facility: , discharge diagnosis: bowel perforation. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with abdominal distention and pain. your imaging showed free air in your abdomen. you were taken to the operating room where you had a segment of your bowel removed. you are now preparing for discharge home with the following instrucions: please call your doctor or nurse practitioner or return to the emergency department for any of the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon. avoid driving or operating heavy machinery while taking pain medications. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. *if you have staples, they will be removed at your follow-up appointment. *if you have steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. * please continue your steroids as ordered and follow-up with your primary care provider. sure to take your prednisone with food. please follow-up with your primary provider regarding your prednisone dosing and a follow-up chest x-ray. followup instructions: . please follow up with the acute care clinic next week to have your retention suturews removed. you can schedule this appointment by calling # . please follow up with your primary care provider in the next weeks regarding lung nodule finding on chest-x-ray. you will needto call for an appointment. Procedure: Open and other right hemicolectomy Diagnoses: Tobacco use disorder Long-term (current) use of steroids Unspecified acquired hypothyroidism Perforation of intestine Depressive disorder, not elsewhere classified Chronic obstructive asthma, unspecified Personal history of peptic ulcer disease Other specified disorders of intestine Megacolon, other than Hirschsprung's Body Mass Index less than 19, adult

allergies: levaquin attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization intraarterial tpa with merci procedure and penumbra device left frontal tooth extration () peg tube placement () history of present illness: 66 y/o m with hx of cad s/p cabg in , dm, chf, htn, and pvd presents with approximately a week long history of intermittent chest pain. the pain would come on consistently after dinner and be substernal and feel like burning. he would then get a "funny" feeling down the lateral aspects of his arms and also start to have some tingling in his gums. the pain would last for approx 40 minutes and then go away. he tried both tums and nitro and got no relief. . on he presented to with these complaints and was ruled out by ekgs and enzymes. he was worked up for atypical chest pain. a ct of chest without contrast was negative. he was started on prednisone for inflammation and doxycycline for possible lymes disease (sounds like he had a positive culture). he was discharged to home when two days ago he had the pain again. substernal, radiating to arms, no diaphoresis or shortness of breath. it was while he was driving and was now relieved by nitro (which was different than his other episodes). he went to bed that night and then woke up again with the pain. it again was relieved by nitro, so he decided to return to the hopsital. he had positive troponin rise, negative ck, and possible new ekg changes with st depressions. he was transferred to here at that time. . on ros he does endorse six months of increasing dyspnea on exertion, fatigue and inability to get very far without needing to sit down. is dizzy when standing still. has not fallen. no fevers or chills or changes in weight. past medical history: -cad s/p cabg in with svg->diagonal, rca, lad, and distal om-1; lima->distal branch of lad, s/p pci ami/vf arrest s/p ptca of the lad and ramus, imi s/p pci of the lcx and lad, s/p multivessel pci, s/p des to svg->lad -diastolic chf -diabetes mellitus -hyperlipidemia -hypertension -pvd s/p bilateral iliac stents with bilateral isrs s/p pta, moderated isr of left iliac stent -s/p cholecystectomy -cataract in right eye s/p lens implant -diverticulosis and diverticulitis, last colonoscopy -chronic renal failure (baseline cr 1.4) -arthritis -pleurisy -polycythemia -gerd -copd, pfts showed mild obstructive airway disease but not consistent with emphysema, vital capacity 3.15 liters which was 73% of predicted, fev1 was 2.60 liters which was 76% of predicted. -severe back pain/degenerative disc disease- followed by dr. hernia s/p repair -l5-s1 spondylyitis -pancytopenia -fatty liver social history: lives at home with wife, is independent, continues to smoke 1 ppd for 45 years, occasional etoh at social occasions, no illicit drugs. family history: father with leukemia, chf near the end of his life; mother still alive; one brother with hx of colon cancer, now in remission. physical exam: on admission: vs - t 98.2, 134/81, p66-79, r 16-20, 97% on ra gen - in bed, sitting up, nad heent - atnc, perrla, eomi, supple neck, no jvd, no bruits cv - rrr, no m,r,g lungs - cta b abd - soft, nt, nd, no hsm or masses, normoactive bowel sounds ext - cool, no hair growth from mid shin down, nonpalpable pulses, are dopplerable, sensation and motor grossly intact neuro - cn intact, moves all 4 extremities, no focal deficits physical exam at neurology unit admission: nih stroke scale score: 1a. loc: arousable to minor stimulation = 1 1b. loc questions: does not say month/age = 2 1c. commands: opens eyes on command, does not squeeze hands = 1 2. best gaze: left gaze deviation = 2 3. visual field: complete hemianopia = 2 4. facial palsy: flattening of left nlf = 2 5. motor arm: left-no movement = 4 right-no drift = 0 6. motor leg left-no movement = 4 right-no drift = 0 7. no ataxia = 0 8. sensory: unilateral sensory loss on the left = 1 9. best language: mild to moderate aphasia = 1 10. dysarthria: severe aphasia = 2 11. extinction/neglect: appears to neglect left side = 1 _______________________ total score: 23 physical exam upon discharge: patient remains with eyes closed most of the time, even when awake. at times he is able to say isolated words and 3 to 4 words sentences to express his feelings, and at times he just mumbles. he is able to follow simple commands such as show fingers, but he also shows perseverating. his eyes movements are impaired to vertical gaze deviation, and barely cross midline to left and slow to the right horizontal movements. he does not showed any voluntary movements from left upper and lower extremities. right extremities are normal in tone, strenght and reflexes. there was a time that he presented less movement at the right lower limb, but this was resolved. pertinent results: labs admission: 09:45pm ck(cpk)-154 09:45pm ck-mb-10 mb indx-6.5* ctropnt-0.12* 09:45pm pt-13.2 ptt-71.2* inr(pt)-1.1 01:05pm glucose-138* urea n-28* creat-1.4* sodium-138 potassium-4.6 chloride-103 total co2-23 anion gap-17 01:05pm ck(cpk)-168 01:05pm ctropnt-0.13* 01:05pm ck-mb-11* mb indx-6.5* 01:05pm calcium-9.4 phosphate-3.6 magnesium-2.0 01:05pm wbc-10.7 rbc-5.08 hgb-15.8 hct-44.8 mcv-88 mch-31.0 mchc-35.2* rdw-14.3 01:05pm neuts-64.1 lymphs-29.2 monos-4.4 eos-2.0 basos-0.3 01:05pm plt count-255 01:05pm pt-14.4* ptt-145.9* inr(pt)-1.3* labs from discharge: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:45am 14.3* 3.81* 11.6* 33.6* 88 30.5 34.6 14.5 544* differential neuts bands lymphs monos eos baso atyps metas 02:25am 68.8 21.8 4.0 5.1* 0.3 source: line-aline basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 10:30am 30.0 03:19am 57.0* chemistry renal & glucose glucose urean creat na k cl hco3 angap 06:45am 185* 20 0.9 136 4.4 102 23 15 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 10:55am 20 31 58 69 0.3 other enzymes & bilirubins lipase 10:55am 75* cpk isoenzymes ck-mb mb indx ctropnt 02:25am 3 0.10*1 chemistry totprot albumin globuln calcium phos mg uricacd iron cholest 06:45am 9.0 3.5 1.9 lipid/cholesterol cholest triglyc hdl chol/hd ldlcalc 05:50am 99 228*1 23 4.3 30 other studies: usg from lower extremities ():no evidence of deep vein thrombosis in either leg chest ct findings: equivocal subsegmental filling defects in pulmonary artery branches of left lower lobe that could represent flow artifact in this study with respiratory motion. if high clinical suspicious of pulmonary embolism, a repeat study is recommended. limited evaluation of lung parenchyma due to respiratory motion does not reveal lung nodules or consolidation. presence of dependent atelectasis. no pleural effusion. nasogastric tube can be seen in the esophagus. heart size is within normal limits. coronary stents and bypass graft is noted. atherosclerotic calcification in the aorta. no pericardial effusion. bilateral hilar lymph nodes are noted. limited evaluation of the abdominal organs is unremarkable. bone windows: status post sternotomy. degenerative changes seen of the thoracic spine. impression: equivocal findings of pulmonary embolism and left lower lobe, that could represent flow artifact. if high clinical suspicious of pulmonary embolism, a repeat study is recommended. repeat chest ct findings: equivocal subsegmental filling defects in pulmonary artery branches of left lower lobe that could represent flow artifact in this study with respiratory motion. if high clinical suspicious of pulmonary embolism, a repeat study is recommended. limited evaluation of lung parenchyma due to respiratory motion does not reveal lung nodules or consolidation. presence of dependent atelectasis. no pleural effusion. nasogastric tube can be seen in the esophagus. heart size is within normal limits. coronary stents and bypass graft is noted. atherosclerotic calcification in the aorta. no pericardial effusion. bilateral hilar lymph nodes are noted. limited evaluation of the abdominal organs is unremarkable. bone windows: status post sternotomy. degenerative changes seen of the thoracic spine. impression: equivocal findings of pulmonary embolism and left lower lobe, that could represent flow artifact. if high clinical suspicious of pulmonary embolism, a repeat study is recommended. neuroimaging: ct hyperdensity of the right caudate head and putamen, presumably reflecting hemorrhagic infarction, enhancement of infarcted tissue, or both. there is also gyriform hyperdensity with the same differential and a possiblity of a small amount of subarachnoid hemorrhage. with associated moderately extensive subarachnoid hemorrhage. brain mri/mra () 1. large acute infarction with extensive hemorrhagic transformation in the right middle cerebral artery territory. small acute infarction in the right anterior cerebral artery territory. 2. successful revascularization of the right internal carotid and middle cerebral arteries brief hospital course: he initially presented to with chest pain and diaphoresis which did not respond to sl nitro x3. he was seen by cardiology, and ces showed ck 123->116->94, ck-mb 1.5->1.8->1.2, tropt 0.02->0.04->0.03. he was instructed to quit smoking and follow up with his cardiologist. per the cardiology admission note, he was also "started on prednisone for inflammation and doxycycline for possible lyme disease." however, he continued to have substernal burning chest pain radiating into his bilateral arms over the past week. he returned to where ces showed ck 164, ck-mb 5.1, and tropt 0.1, and ekg per report showed old q in inferior leads, some 1mm elevations, lateral st depressions. he was continued on asa, loaded with plavix 300 mg, and started on heparin gtt. he was transferred to for further evaluation. he was admitted to cardiology on , continued on heparin gtt, asa 325 daily, plavix 75 mg daily, and crestor was changed to atorvastatin 80 mg daily. trop t peaked at 0.17, ck-mb at 11. he had a cardiac cathterization which showed known occlusions of svg-om1, svg-om3, svg-pda, lima-d1; and successful ptca and stenting of the proximal svg-lad graft with a cypher des. during the cath, he received bivalirudin bolus and gtt, fentanyl 200 mcg iv x1, nicardipine 200 mcg ic bolus, versed 1 mg iv x1, and sodium bicarbonate iv. he was to be discharged home on . at 10:20 am the nurse found him to be normal in his room. at approximately 11:10 am, the nurses noted that the nurse call button had been pulled out of the wall. he was found to have a dense left hemiplegia and decreased responsiveness. a code stroke was called. the patient was found to be awake but with decreased alertness, left facial droop, left hemiparesis, left eye deviation, and dysarthria. nihss 23. head cta and ctp showed complete occlusion of the cervical and intracranial right ica and of the right mca, the right aca is patent, likely supplied by the anterior communicating artery, subtle loss of -white matter differentiation and a large area of matched decreased cerebral blood volume and flow in the right middle cerebral artery territory, consistent with a large acute infarction, no evidence of hemorrhage. he was taken immediately to cerebral angiography, where he had ia tpa and merci to the right ica, and penumbra to the right mca, with ia ntg to right mca for spasm. he was intubated and transferred to the neuroicu. in the neurology icu, he was maintained on aspirin and plavix. mri/mra head showed a large acute infarction with extensive hemorrhagic transformation in the right mca territory, small acute infarction in the right aca territory, and successful revascularization of the right ica and mca. repeat head cts showed increased mass effect and right uncal herniation, and he was started on mannitol. he remained stable and mannitol was discontinued. tte showed lvef 40%, no thrombus/mass in the body of the lv, no asd or pfo. usg of the legs no evidence of venous thrombosis. eeg showed asymmetry with low voltage activity over the right side, and overall diffuse encephalopathy. he had some fluctuations in his mental status due to infection (see below) and remained significantly abulic. at times during his stay, he complained of chest pain, but cardiac enzymes were always unremarkable and ekg was unchanged. he was maintained on asa, plavix, and eventually heparin/coumadin (see below). he was treated with antihypertensives and cholesterol lowering medications. after extubation he was found to have persistent high respiratory rate (20-32). as this was concerning for pulmonary embolism, he underwent two consecutive chest cta; both revealed a small lesion in the lower segment of the left inferior lobe. heparin was started on , and warfarin 5mg daily was started (held prior to this for procedures). goal inr is . he was discharged on lovenox as a bridge to coumadin and will need to have inrs checked until the inr is therapeutic. he was noted to have a recent lyme titer positive at his pcp's office and was treated with doxycycline 100 mg po bid to complete a 14 day course; discontinued on . he had a fever and was diagnosed with a pseudomonas uti. he was initially started on cefazolin but this was changed to cefepime after persistent fever. he completed a 7 day course on . his diabetes was managed by , with lantus, humalog, and oral hypoglycemics. a1c was 13.7. he had a loose left front tooth, which was extracted on without complications. he passed his swallow study but he was waxing and wanning in his mental status and not holding well the po intake. he had peg placed on . medications on admission: asa 325 mg daily plavix 75 mg daily imdur 30 mg daily valsartan 80 mg daily atenolol 25 mg daily crestor 10 mg daily ezetimibe 10 mg qhs niaspan 1000 mg daily tricor 145 mg qhs metformin 1000 mg glyburide 5 mg januvia 100 mg daily nexium 40 mg daily percocet 1 tab q6 hr prn (usually takes ) discharge medications: 1. fenofibrate micronized 145 mg tablet sig: one (1) tablet po daily (). 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, fever. 6. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 7. niacin 100 mg tablet sig: five (5) tablet po bid (2 times a day). 8. docusate sodium 50 mg/5 ml liquid sig: two (2) po bid (2 times a day). 9. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 10. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 11. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 12. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). 13. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 14. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 15. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 16. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 17. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily). 18. enoxaparin 100 mg/ml syringe sig: ninety (90) units subcutaneous q12h (every 12 hours). 19. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 20. insulin glargine subcutaneous 21. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 22. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). discharge disposition: extended care facility: hospital - discharge diagnosis: primary diagnosis: 1. nstemi 2. coronary artery disease 3. hyperlipidemia 4. right mca stroke 5. left inferior pulmonary embolism 6. urinary tract infection 7. loose tooth status post extraction . secondary diagnosis: 1. diabetes 2. hypertension 3. positive lyme titer discharge condition: he was abulic, preferring to keep his eyes closed (even when awake), with decreased but appropriate speech output, ability to follow commands with his right side, left neglect, and a dense left hemiparesis. discharge instructions: you were admitted to the hospital for chest pain. it was determined to be related to your heart because we saw a rise in your cardiac enzymes. your pain was also relieved by nitro, again making us think it was related to your heart. we monitored you over the weekend while you were on a heparin drip through your iv. you did well and only had the recurrence of chest pain once. your cardiac enzymes also started to decrease. unfortunately before your discharge you presented subtle onset of left sided weakness, and code stroke was called. you underwent procedures to remove a clot from your left cerebral artery. during this acute phase you were intubated with mechanical ventilation. after your doctors noted that presented fast breathing, and you were found to have pulmonary embolism. to treat and prevent further episodes you need to take coumadin to make your blood thinner. you also had a broken tooth, which was removed during this admission. although you passed the swallow evaluation you had significant fluctuation of your mental status, which required a tube in your stomach, so you can receive your medications and feeds consistently. your diabetes was out of control and some adjustment of your medications was required. please call your doctor or return to the hospital for any new weakness, numbness, tingling, visual changes, loss of consciousness, chest pain, shortness of breath, lightheadedness, fainting, nausea, vomiting or any other conerns. call 911 if it is an emergency. please stop smoking. information was given to you on admission regarding smoking cessation. followup instructions: cardiology: please follow up with dr. . his phone number is if you need to change your appointment. neurology: , md phone: date/time: 2:00 endocrinology: please contact clinic to schedule a follow up appointment Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of thrombolytic agent Percutaneous [endoscopic] gastrostomy [PEG] Arteriography of cerebral arteries Insertion of (naso-)intestinal tube Other surgical extraction of tooth 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 Procedure on two vessels Procedure on vessel bifurcation Endovascular removal of obstruction from head and neck vessel(s) Diagnoses: End stage renal disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Tobacco use disorder Urinary tract infection, site not specified Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Coronary atherosclerosis of autologous vein bypass graft Other chronic pulmonary heart diseases Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Compression of brain Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Iatrogenic pulmonary embolism and infarction Accidents occurring in residential institution Atherosclerosis of native arteries of the extremities, unspecified Diastolic heart failure, unspecified Diverticulosis of colon (without mention of hemorrhage) Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Pseudomonas infection in conditions classified elsewhere and of unspecified site Iatrogenic cerebrovascular infarction or hemorrhage Lyme Disease Spondylosis of unspecified site, without mention of myelopathy Cerebral thrombosis with cerebral infarction Polycythemia vera Occlusion and stenosis of carotid artery with cerebral infarction Ankylosing spondylitis Cracked tooth Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: unresponsive, overdose major surgical or invasive procedure: endotracheal intubation and mechanical ventillation history of present illness: mrs. is a 37 year old female with an unknown past medical history who was found in her car on the side of the road unresponsive earlier today. per report she had vomited and was surrounded by little pink pills and had sent suicidal text messages on her cell phone (no damage to car). she was initially transported to hospital where she was initially noted to withdraw to painful stimuli and then had a seizure that lasted 1 minute and resolved with ativan 2 mg. she was intubated for decreased responsiveness and airway protection. she was tachycardic to the 120s. she had a ct head, c-spine, and torso that were reportedly negative. alcohol level was 166. utox was negative. she also received narcan without effect, activated charcoal, and protonix. . in the ed, initial vs were: p 94, bp 118/88, r 16, o2 sat 99% intubated. propofol was turned off and after five minutes she was noted to withdraw from pain and spontaneously move her right upper extremity. reflexes were normal. labs were notable for serum alcohol level of 15, utox + benzodiazepines and abg 7.46/32/429. ekg with qtc 465 and rate 80. toxicology was consulted and felt the ingestion may have been benadryl with anticholinergic intoxication syndrome although the patient was no longer tachycardic. they recommended supportive care and monitoring qrs interval. at time of sign-out patient was on propofol at a rate of 40 and noted to be following commands. vital signs were hr 86, bp 125/74, o2 sat 100% on fio2 40% 500x14, peep 5. . on the floor, patient was intubated and sedated. denies pain. past medical history: none social history: lives alone in . patient denies all tobacco, alcohol, and drug use other than last friday. she was sober x 6.5 years. prior to that she was a daily drinker. is not actively involved in aa. no h/o withdrawal symptoms/seizures. family history: patient does not speak or recall much about her family history physical exam: vitals: t: 37.5, bp: 132/68, p: 89, r: 9 o2: 100% cmv fio2 100%, 550x16, peep 5. general: overweight caucasian female, intubated, sedated, no acute distress heent: sclera anicteric, perrl 4->2, mmm neck: supple, jvp not elevated, no lad lungs: decreased bs at l base. no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, decreased bowel sounds. gu: + foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: moves all extremities, follows commands to wiggle toes and squeeze hands when sedation is lightened pertinent results: admission labs: 01:35pm blood wbc-11.0 rbc-4.48 hgb-13.4 hct-37.9 mcv-85 mch-29.9 mchc-35.3* rdw-12.0 plt ct-175 01:35pm blood neuts-75.8* lymphs-18.0 monos-5.4 eos-0.3 baso-0.5 01:35pm blood pt-12.1 ptt-24.3 inr(pt)-1.0 01:35pm blood glucose-88 urean-7 creat-0.7 na-137 k-3.5 cl-105 hco3-22 angap-14 01:35pm blood alt-19 ast-26 ld(ldh)-172 alkphos-46 totbili-0.6 01:35pm blood calcium-7.5* phos-2.4* mg-1.7 01:35pm blood asa-neg ethanol-15* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:07pm blood type-art po2-429* pco2-32* ph-7.46* caltco2-23 base xs-0 01:43pm blood lactate-3.0* k-3.5 02:07pm blood o2 sat-99 cohgb-0 10:39pm blood freeca-1.03* ct head without contrast : impression: no acute intracranial process. cxr : impression: retrocardiac opacity in the left lower lobe may represent atelectasis or sequelae of aspiration. ct spine () impression: no acute cervical fracture or malalignment. 03:13am blood wbc-15.1* rbc-4.13* hgb-12.4 hct-34.7* mcv-84 mch-30.1 mchc-35.9* rdw-11.8 plt ct-147* 03:30am blood wbc-18.5* rbc-4.28 hgb-12.8 hct-36.6 mcv-86 mch-29.8 mchc-34.9 rdw-11.7 plt ct-134* 06:30am blood wbc-10.8 rbc-4.30 hgb-12.4 hct-36.1 mcv-84 mch-28.9 mchc-34.5 rdw-11.9 plt ct-145* 09:15am blood wbc-5.5 rbc-4.50 hgb-13.5 hct-38.5 mcv-85 mch-30.0 mchc-35.1* rdw-12.1 plt ct-203 01:35pm blood neuts-75.8* lymphs-18.0 monos-5.4 eos-0.3 baso-0.5 03:13am blood neuts-88.6* lymphs-7.6* monos-3.4 eos-0.2 baso-0.1 01:35pm blood glucose-88 urean-7 creat-0.7 na-137 k-3.5 cl-105 hco3-22 angap-14 09:15am blood glucose-101* urean-8 creat-0.7 na-140 k-3.6 cl-104 hco3-28 angap-12 01:35pm blood alt-19 ast-26 ld(ldh)-172 alkphos-46 totbili-0.6 01:35pm blood lipase-35 06:30am blood calcium-8.3* phos-2.0* mg-2.0 10:39pm blood lactate-1.5 brief hospital course: this is a 37 year old female with an unknown past medical history found unresponsive in her car after vomiting surrounded by pills with concern for suicide attempt with overdose. # unresponsiveness - felt to be most likely secondary to anticholinergic toxicity from benedryl overdose and alcohol. she was intubated for airway protection at osh after seizure in the setting of unresponsiveness. she was extubated the next morning () without complications. lactate has normalized. although she complained of some visual hallucinations early in the day (likely secondary to benadryl overdose) she remained alert and oriented throughout the day. she was transferred to the medicine floor on and did very well. she remained aao x 3 with no other hallucinations. anxiety was managed with lorazepam .5-1mg po q4-6hrs prn. # overdose, suicide attempt, severe depression - felt to be a suicide attempt. received charcoal at the osh. evaluated by toxicology in the ed with concern for benadryl overdose and anticholinergic syndrome, though patient no longer tachycardic. utox and serum tox unrevealing except for alcohol (benzos likely secondary to ativan given for seizure at osh). noteably negative for acetaminophen and tricyclics. serial ekgs to monitor for qtc prolongation, remained stable, last check at 421. psych said she cannot leave ama and if wants to leave needs to be section 12. patient received 24hour 1:1 sitter while here. she was transferred to the medicine floor and was medically cleared to be discharged to a hospital for inpatient therapy. patient was sent to hospital on discharge. # pneumonia, aspiration: pt spiked a fever to 101.4 on . pan cultured and cxr performed. in setting of possible infiltrate, pt was started on augmentin for possible aspiration pna. the following morning, sputum gram stain was positive for coag positive staph, and the patient was switched to po clindamycin which was thought to cover community acquired mrsa and anaerobes. upon transfer to the medicine floor, she was switched to iv vanc given temp of 101.2 and white count of 18.5. no organism or sensitivites were available at that point. she remained afebrile after transfer to the medicine floor. cultures showed pan-sensitive staph aureus (coag +). she was transitioned back to po clindamycin (300mg q6hr) and did well. last day of antibiotics will be . fen: she initially received ivf boluses prn to maintain urine output (rec'd ivf at osh and 1l in ed). prophylaxis: subutaneous heparin, bowel regimen access: peripherals code: full medications on admission: none per patient discharge medications: 1. clindamycin hcl 300 mg capsule sig: one (1) capsule po every six (6) hours for 4 days. disp:*16 capsule(s)* refills:*0* discharge disposition: extended care facility: hospital unit discharge diagnosis: primary: benadryl overdose discharge condition: good. vital signs stable. ambulating without difficulty. discharge instructions: you were admitted to the hospital after being found unresponsive. you were admitted to the icu and intubated given your condition. you did well there and the breathing tube was removed. your mental status improved. the psychiatry team saw you and recommended that you be discharged to a psychiatric hospital for further stabilization. you were found to have a small pneumonia and are being treated with antibiotics. the last day of your antibiotics will be . upon discharge, you were stable. the following changes were made to your medications: 1. please take clindamycin 300mg- 1 tablet by mouth every 6 hours. the last day of this medication is . followup instructions: please follow-up with your primary care physician weeks Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Other convulsions Alcohol abuse, unspecified Pneumonitis due to inhalation of food or vomitus Suicide and self-inflicted poisoning by other specified drugs and medicinal substances Methicillin resistant pneumonia due to Staphylococcus aureus Poisoning by antiallergic and antiemetic drugs Unspecified episodic mood disorder Psychophysical visual disturbances Perpetrator of child and adult abuse, by father, stepfather, or boyfriend Adult emotional/psychological abuse

allergies: aspirin attending: chief complaint: chest pain, sob major surgical or invasive procedure: transesophageal echocardiogram endotracheal intubation s/p mv repair(28 cg ring)/cabgx1(svg-pda) history of present illness: 48 yom with pmh hiv, htn, hld presented to hospital with complaints of chest pain and sob and found to have stemi and new mitral regurgitation. according to the patient, he began feeling lower back pain and associated burning chest pain , he identified the symptoms as acid reflux and used tums for symptomatic relief with good effect. throughout the following week, he had daily symptoms with increasing severity and frequency until the day of admission when he developed burning chest pain radiating to the neck and arms. he became acutely short of breath and nauseated after taking baking soda for the burning chest pain he vomited 1x and called 911. throughout the duration of these symptoms, he notes that the pain was neither worsened by activity nor improved with rest. he denies chest pressure, palpatations, presyncope, changes in vision. on arrival to the hospital ed initial ekg showed afib with rvr, and st-e in iii and avf, st-d in i, avl, v2-5, he was anticoagulated with heparin, given anti-aggregation therapy with plavix and integrilin drip. he was given an amiodarone bolus for arrythmia prophylaxis. he was given atorvastatin 80mg for cad, diltiazem for afib with rvr. furosemide 20mg iv for pulmonary edema. he underwent emergent cardiac catheritization with bms to the rca. lv gram showed significant mr. was placed. he was transfered to for management of and evaluation for mitral valve repair. on arrival to ccu, his vs were bp95/71 p115 99% nrb. ekg showed sinus tachycardia at 112, std in i, avl, v3-5, ste iii, when compared to ekg from saints hospital, depressions and elevations appear less pronounced. he reported buring chest pain, sob and cough. cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: + dyslipidemia, + hypertension, 30 pack year hx smoking 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: - hiv: diagnosed , vl suppressed on truvada and viramune with nl cd4 counts - anal hpv with dysplasia s/p resection - anxiety - pericarditis social history: - tobacco history: 1 pack per day x 30 years, quit - etoh: denies - illicit drugs: denies family history: mother copd father htn family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: on admission: general: middle aged male, appearing anxious but in nad heent: mucous membs dry, conjuntiva pink. neck: jvp non elevatedcm. cardiac: ii/vi holosystolic blowing murmur at the apex. no thrills, lifts. no s3 or s4. lungs: right rales to the mid back, left basilar rales. no ronchi, no wheezes abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. aibp ascultated extremities: right aibp sheath in place with no ecchymosis or erythemia, no drainage. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 1+ pt 1+ left: dp 1+ pt 1+ pertinent results: tte: the left ventricular cavity size is normal. there is inferior/inferolateral and basal inferoseptal akinesis/hypokinesis with hyperdynamic motion elsewhere although views are suboptimal for assessment of regional wall. overall left ventricular systolic function is mildly depressed (lvef= 55 %). right ventricular chamber size is normal. right ventricular function is not well seen but may be depressed. the aortic valve is not well seen. there is posterior mitral leaflet flail with ruptured inferolateral papillary muscle. an eccentric medially directed jet of at least moderate mitral regurgitation is present but cannot be quantified to due suboptimal views. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. tee: no atrial septal defect is seen by 2d or color doppler. left ventricular systolic function is hyperdynamic (regional wall motino was not fully assessed). there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. there is flail of the posterior leaflet of the mitral valve with attached ruptured papillary muscle. eccentric anteromedially directed severe (4+) mitral regurgitation is seen. 04:55am blood wbc-7.3 rbc-3.17* hgb-9.9* hct-27.9* mcv-88 mch-31.3 mchc-35.5* rdw-14.5 plt ct-183 03:09am blood pt-13.9* ptt-24.9 inr(pt)-1.2* 04:55am blood glucose-110* urean-22* creat-1.1 na-139 k-3.9 cl-101 hco3-29 angap-13 , m 48 radiology report chest (portable ap) study date of 11:23 am , csru 11:23 am chest (portable ap) clip # reason: ? ptx after ct removal medical condition: 48 year old man with mv repair/cabg reason for this examination: ? ptx after ct removal final report chest radiograph indication: status post cabg, pneumothorax after chest tube removal. comparison: . findings: as compared to the previous radiograph, all monitoring and support devices, including the intra-aortic balloon pump, has been removed. given the positioning of the patient, the right hemithorax looks slightly denser than on the left, which might in part reflect pre-existing pulmonary edema that has decreased in severity. no evidence of pneumothorax. no pleural effusions. borderline size of the cardiac silhouette, no pulmonary edema. brief hospital course: 48m transferredfrom osh c/o cp and sob, found to have stemi and new mr. was in rapid a-fib, treated with amiodarone and diltiazem. he was given plavix and started on integrillin (asa allergy). he was diuresed for pulmonary edema. emergent cardiac cath was performed and he received a bms to rca. lv gram showed significant mr. was placed. he is transferred for surgical evaluation. tee revealed severe (4+) mitral regurgitation. on he was taken to the operating room and underwent coronary artery bypass grafting x1 with reverse saphenous vein graft to the posterior left ventricular branch artery and 2. mitral valve repair with a posterior p2 quadrangular resection and annuloplasty with a cg future annuloplasty ring, model #638r, size 28 mm. post operatively he was transferred to the icu intubated and sedated for hemodynamic care and monitoring. he awoke neuologically intact and was weaned from the vemtilator and extubated. on pod#1 his was removed. he was staretd back on plavix and asa was not started due to allergy to asa. his betablocker was titrated and he was diuresed toward his pre-operative weight. his chest tubes and pacing wires were removed per protocol. he was seen by physical therapy for strngth and conditioning. he was cleared for discharge to home on pod#4 by dr. . all appointments and discharge instructions were advised. medications on admission: - azelastine 137 mcg (0.1 %) ih nasally - chlorthalidone 25 mg po daily - citalopram 30 mg po daily - emtricitabine-tenofovir 200 mg-300 mg po daily - fenofibrate micronized 43 mg po daily - fluticasone 50 mcg ih nasally - nevirapine 400 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. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 3. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). disp:*45 tablet(s)* refills:*0* 6. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. nevirapine 200 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 8. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po q12h (every 12 hours) for 5 days. disp:*10 tab sust.rel. particle/crystal(s)* refills:*0* 9. lasix 20 mg tablet sig: one (1) tablet po twice a day for 5 days. disp:*10 tablet(s)* refills:*0* 10. lopressor 50 mg tablet sig: seventy five (75) mg po three times a day. disp:*90 tabs* refills:*2* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: hiv (dx ) htn hld anal hpv s/p resection anxiety pericarditis cad mr s/p mv repair/cabg discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema trace. 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. @ 1:15 pcp: . @ 9:30am ***please have dr. refer you to a cardiologist and make an appt 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 Injection or infusion of platelet inhibitor (Aorto)coronary bypass of one coronary artery Open heart valvuloplasty of mitral valve without replacement Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Other iatrogenic hypotension Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Tobacco use disorder Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Other pulmonary insufficiency, not elsewhere classified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Anxiety state, unspecified Unspecified disease of pericardium Other postprocedural status Acute systolic heart failure Asymptomatic human immunodeficiency virus [HIV] infection status Rupture of muscle, nontraumatic

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: severe nausea and vomiting. major surgical or invasive procedure: induction of hemodialysis plasmapheresis kidney transplant small bowel obstruction, ex lap with loa history of present illness: a 65 year-old woman with history of end-stage renal disease scheduled for lrrt presenting with uremic symptoms. she was admitted for induction of hemodialysis to prevent dialysis disequilibrium after receiving her transplant. . in the ed, her vital signs were 98.3, 118/62, 90, 13, and 98% ra. she received zofran 4 mg iv x1 and was sent directly to dialysis before arrival to the floor. at dialysis she had 0.5 kg removed via a right tunnelled line that had been placed one week ago for plasmapheresis (she underwent plasmaphereis to remove antibodies against daughter's antigens-- daughter will provide the donor kidney). upon arrival to the floor from hd, she feels much better. she denies nausea or vomiting, and is looking forward to eating dinner. she denies chest pain, shortness of breath, or lightheadedness. ros is positive for vertigo, worse with sitting and standing, that she says has been ongoing for three months. she says she was seen by ent yesterday for evaluation of the vertigo and was prescribed acyclovir for ?zoster infection, which she has not yet started. however, it appears the vertigo developed several weeks before she started immunosuppressants (which she started one week ago). she denies facial rash or burning. ros otherwise unremarkable. past medical history: - end-stage renal disease, likely due to lithium toxicity - questionable history of temporal arteritis versus polymyalgia rheumatica on prednisone - severe bipolar disorder, controlled with lamictal and celexa - hyperparathyroidism with hypercalcemia related to lithium - vertigo, on meclizine - gastroesophageal reflux disease - cholecystectomy in - right knee replacement in - left benign breast tumor resection 20 years ago - status post appendectomy - history of difficult intubation - living related renal transplant - ex lap, loa for sbo social history: she used to work as secretary at the company, and is retired since . she lives with her son and she has four children. the patient denies any history of tobacco smoking, alcohol abuse, or drug use. family history: her grandfather and one of her uncles suffered from bright disease. her mother's sister died of breast cancer. her uncle had a history of melanoma, which was metastatic. her father died at age of 84 from congestive heart failure. her mother died from a severe stroke. physical exam: on admission: vitals: 98.9, 144/78, 83, 18, 100% ra general: a middle-aged woman in no apparent distress, with appropriate affect, calm and cooperative heent: eomi, perrla, cnii-xii grossly intact neck: supple, no lad heart: rrr, normal s1/s2 lungs: cta bilaterally, no crackles at bases abdomen: overweight, non-tender, normal bowel sounds legs: no pitting edema; 2+ dp pulses skin: no rashes neuro: aaox3, moving all extremities pertinent results: 06:00am blood wbc-8.9 rbc-3.47* hgb-10.4* hct-30.1* mcv-87 mch-30.1 mchc-34.7 rdw-18.5* plt ct-546* 06:33am blood pt-12.8 ptt-23.9 inr(pt)-1.1 06:00am blood glucose-73 urean-25* creat-0.7 na-136 k-4.9 cl-104 hco3-23 angap-14 05:27am blood alt-64* ast-38 alkphos-162* totbili-0.4 06:44am blood calcium-9.9 phos-2.4* mg-1.6 05:30am blood tacrofk-6.9 06:44am blood tacrofk-6.7 06:00am blood tacrofk-6.4 brief hospital course: a 65 year-old woman with history of esrd scheduled for lrrt presenting with nausea and vomiting and emergent induction of hemodialysis. she underwent hd without complication and plasmapheresis to prevent transplant rejection. she received rituximab. her transplant was postponed to 4/9/9 because it seemed that she still had positive antibodies against her daughters kidney, this however, turned out to be not significant. she was continued on her immunosuppressant regimen (cellcept/tacrolimus. she had an episode of fevers/chills and was temporarily on vanc/zosyn, however, the sxs resumed and her cultures remained negative. on she underwent living related renal transplant from her daughter. it was noted that she had a very thin posterior fascia and peritoneum. therefore, the kidney was ultimately intraperitoneal in the retroperitoneal space. the iliac vessels were soft without significant plaque. the donor kidney had a single renal artery with an early bifurcation and a single renal vein and a single ureter. the kidney pinked up and produced urine. please refer to operative note. postop, she was sent to the sicu due to volume overload and respiratory difficulty. respiratory function improved. urine output was excellent. she received plasmapheresis postop transplant for hla desensitization related to transplant for 3 more treatments postop for a total of none treatments. a total of 3 doses of atg were given postop op. solumedrol was tapered. prograf was titrated to trough levels. cellcept continued at 1 gram . creatinine dropped to 0.6. luminex was sent on . urine output average 1.5 liters per day. bp was elevated to 180's/120s. lopressor was uptitrated and norvasc was started. bp improved. diet was advanced and tolerated. pt worked with her and recommended a walker. on postop day 4, she developed ecchymosis around incision with extension to right hip and lower abdomen. she also started to drain sero-sanguinous fluid from her incision. on , she fell in the bathroom after standing up from the toilet striking her nose against the wall. she denied passing out. she was alert and oriented. a stat head ct was done showing no acute intracranial process. a sinus//max ct showed questionable nondisplaced fracture of the nasal bone. she developed bruising over her nose with mild-mod swelling. a developed a frontal headache that was treated with tylenol and iv pain medication. she developed dizziness prompting a neurology consult on . it was felt that this was not a vestibular process, but rather findings were suggestive of cervical spondylosis with myelopathy with dorsal column involvement, with impaired functional position sensation given history of reduced range of motion of the neck, upper motor neuron weakness at the deltoids, triceps, and iliopsoas, reduced vibratory sensation, and brisk reflexes throughout. recommendations were for the her to wear a soft cervical collar at all times for two weeks (if tolerated), then at least at nightwhile sleeping thereafter. around postop day 6, her abdomen appeared distended and she complained of nausea. the incision started to oozed at the inferior edge. this was opened at the inferior edge. she continued to have diffuse bruising aroun the rlq. she developed nausea with vomiting that appeared bilious. lfts increased (alt 144, ast 148, alk phos 296, t.bili 6.8). lfts were monitored daily with continued rise. hepatitis screening was done. this was negative for hav, hbsag, hcv. hemolysis workup was negative. liver duplex was done twice noting a small amount of perihepatic fluid, no intra or extra-hepatic bile duct dilatation. ggt was elevated suggestive of liver/biliary source of increased alk phos that rose to 500 with t.bili of 4.9. a kub was done showing distended loops of small bowel. an ng tube was place. abd ct ()revealed distended small bowel with decompressed distal small bowel and relatively decompressed colon consistent with small bowel obstruction. there was a transition point in rlq. there was no evidence of perforation. normal liver without biliary abnormalities. small amount of perihepatic ascites. she was kept npo. lfts fluctuated daily. she received iv hydration. she started to have flatus and bowel movements. bowel movements increased in frequency. on , the ng tube was removed. kub revealed persistenly dilated loops of small bowel and air fluid levels. kubs continued to show distended loops with air fluid levels despite bms. nausea/vomiting and diarrhea continued. the ng was replaced. lfts improved. on , she was taken to the or by dr. for exploratory laparotomy and lysis of adhesions. postop diagnosis was small bowel obstruction. a wound vac was applied to the lower portion of the incision that was opened. despite the vac, the wound continued to drain serous fluid. the wound vac was discontinued and a gauze dressing was applied. drainage stopped and a topical dry gauze dressing was applied as the wound healed. she remained npo with an ng tube in place. given prolonged npo status, tpn was started. she developed watery diarrhea. stool cultures were negative. a cmv viral load was negative. cellept decreased to 500mg 3x/day. imodium was started. diarrhea resolved. ng was removed and diet slowly advanced and tolerated. tpn was discontinued. ensure supplements were tolerated tid. imodium was discontinued. on , hematocrit was 22.6. she was given 2 units of prbc with a hct increase to 28. she stabilized at 30. pt recommended rehab was recommended. she was screened and accepted at ne . prograf was increased to 6mg on for a trough level of 6.4. goal trough prograf level is 10. she was left on prednisone 20mg qd due to high sensitivity to her donor. she will require labs on for chem 7 and a trough prograf with results called to . labs should then be done every monday and thursday. medications on admission: lanthanum 1000 mg po tid w/meals lamotrigine 250 mg po daily calcitriol 0.25 mcg alternating with 0.5 mcg po every other day meclizine 25 mg po bid mycophenolate mofetil 500 mg po bid citalopram hydrobromide 40 mg po daily omeprazole 20 mg po bid colestid 1 gram oral daily prednisone 5 mg po daily ferrous sulfate 325 mg po daily tacrolimus 2 mg po q12h sodium bicarbonate 1 teaspoon po bid discharge medications: 1. lamotrigine 100 mg tablet sig: 2.5 tablets po daily (daily). 2. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 3. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 4. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 6. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po tid (3 times a day). 7. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed. 9. ipratropium bromide 0.02 % solution sig: one (1) neb neb inhalation q6h (every 6 hours) as needed for sob/cough. 10. prednisone 20 mg tablet sig: one (1) tablet po daily (daily). 11. insulin regular human 100 unit/ml solution sig: follow sliding scale injection four times a day. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. hydromorphone 2 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 14. tacrolimus 5 mg capsule sig: one (1) capsule po q12h (every 12 hours). 15. tacrolimus 1 mg capsule sig: one (1) capsule po twice a day. 16. outpatient lab work stat labs for chem 7 and trough prograf level am call results to discharge disposition: extended care facility: - discharge diagnosis: end-stage kidney disease secondary to lithium toxicity smal bowel obstruction diarrhea incision cellulitis fall . secondary diagnoses temporal arteritis versus polymyalgia rheumatica on prednisone severe bipolar disorder, controlled with lamictal and celexa vertigo gastroesophageal reflux disease discharge condition: stable discharge instructions: please call the transplant office if you experience fever, chills, nausea, vomiting, abdominal pain/distension, worsening diarrhea or decreased urine output labs every monday and thursday no heavy lifting followup instructions: provider: , transplant social work date/time: 10:30 provider: , md phone: date/time: 9:00 provider: , md phone: date/time: 10:00 provider: , . call to schedule appointment provider: , . call to schedule appointment provider: , . call to schedule appointment Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Other lysis of peritoneal adhesions Other kidney transplantation Therapeutic plasmapheresis Transfusion of packed cells Transfusion of other serum Injection or infusion of immunoglobulin Transfusion of other substance Transplant from live related donor Diagnoses: Other iatrogenic hypotension Anemia in chronic kidney disease End stage renal disease Polymyalgia rheumatica Esophageal reflux Other postoperative infection Cellulitis and abscess of trunk Unspecified essential hypertension Other specified intestinal obstruction Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Diarrhea Headache Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Bipolar disorder, unspecified Closed fracture of nasal bones Laparoscopic surgical procedure converted to open procedure Cervical spondylosis with myelopathy Giant cell arteritis Other hyperparathyroidism Other transfusion reaction Fall resulting in striking against other object

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath, hypoxia major surgical or invasive procedure: laparoscopic gastric pulldown and peg placement x2 picc placement history of present illness: pt is an 88 yo woman with pmhx sig. for dm2, dyslipidemia, and recent admission for l comminuted, intertrochanteric left femoral neck fracture, s/p open reduction internal fixation, and l proximal comminuted and displaced fracture of the left humeral neck fx treated with a sling () after fall was sent from rehab with respiratory distress. patient was found to be in respiratory distress this am with wheezing, using accessory muscles, poor air exachange, and tachypenia. her o2 sat was in the high 80s, improved to 100% on nrb. other vs were 140/90, 120, 30, temp 98.5. after a nebulizer treatment, her rr came down to 24. she also complained of diaphoresis. she denied any chest pain. . in the emergency department, initial vitals were: 98.5 110 140/90 34 98 on nrb. she had a cxr that showed bilateral pleural effusions, ?infiltrate. pt received levofloxacin 750 mg, vanc, and nebulizers. ucx and bcx were obtained. pt is currently feeling a little better, now satting 94% on 6l nc. . currently, she feels uncomfortable, but cannot specify why. she denies any sob and does not appear in respiratory distress while lying supine. she denies any cough, chest pain, nausea, vomiting, abdominal pain, dysuria, and fever/chills. she had some rhinorrhea about 2 weeks ago. . past medical history: - type 2 diabetes mellitus - dyslipidemia - anxiety - osteoporosis - hoh - diverticulosis - aortic insufficiency, 1+ - cystic lesion of pancreas felt to be benign - spinal stenosis - large hh into chest social history: patient was born in poland and grew up in . prior to her fall, she lived alone in a private apartment and visited the senior center for all 3 meals. she denies any tobacco/etoh. family history: mother with throat cancer. physical exam: general: pleasant, well appearing female in nad. heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. per/eomi. mm dry. op clear. neck: supple, no lad, no thyromegaly. + jvd. cardiac: occasionally irregular rhythm, tachycardic, normal s1, s2. systolic murmur best at llsb and apex. lungs: decreased breath sounds at the bases bilaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: no edema or calf pain, 1+ dorsalis pedis/ posterior tibial pulses. skin: no rashes, ecchymoses. stage ii heel ulcers bilaterally. surgical incision over l hip c/d/i. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout except proximal lle and lue secondary to pain. gait assessment deferred. psych: listens and responds to questions appropriately, pleasant . on dicharge vitals: 96.2 142/81 95 18 98%1l nc pain: l shoulder access: piv gen: elderly frail female, tired appearing, intermittent episodes with audible gurgling and accessory muscle use heent: mm dry neck: prominent neck veins cv: rrr, sm usb back: severe scoliosis resp: bs bases, +scattered crackles, no wheezing abd; nontender, +bs ext; 1+ b/l le edema, 1+ ue edema (new during this hospitalization) ms: l arm in sling neuro: a&ox3, grossly nonfocal, gait not assessed skin: scattered heel ulcers, l hip incision healing, sacral stage ii with dressing, l thigh bruising stable psych: calm, pleasant gu: foley back in place . pertinent results: 11:45am blood wbc-9.7 rbc-4.04*# hgb-11.8*# hct-37.1 mcv-92 mch-29.2 mchc-31.9 rdw-15.9* plt ct-423# 03:03am blood wbc-9.7 rbc-3.50* hgb-10.7* hct-32.2* mcv-92 mch-30.6 mchc-33.2 rdw-15.3 plt ct-419 07:50am blood wbc-9.9 rbc-3.34* hgb-10.3* hct-31.7* mcv-95 mch-30.9 mchc-32.6 rdw-15.8* plt ct-425 07:40am blood wbc-8.8 rbc-3.23* hgb-10.1* hct-30.6* mcv-95 mch-31.2 mchc-32.9 rdw-15.5 plt ct-482* 07:35am blood wbc-8.8 rbc-3.42* hgb-10.6* hct-32.8* mcv-96 mch-31.0 mchc-32.4 rdw-15.6* plt ct-451* 06:35am blood wbc-11.0 rbc-3.28* hgb-10.5* hct-31.8* mcv-97 mch-32.0 mchc-33.0 rdw-15.7* plt ct-430 07:42am blood wbc-12.2* rbc-3.60* hgb-11.3* hct-35.4* mcv-98 mch-31.3 mchc-31.8 rdw-15.4 plt ct-534* 07:17am blood wbc-13.0* rbc-3.21* hgb-10.4* hct-31.1* mcv-97 mch-32.4* mchc-33.5 rdw-15.6* plt ct-476* 08:00am blood wbc-12.4* rbc-3.40* hgb-10.3* hct-32.4* mcv-95 mch-30.4 mchc-31.9 rdw-15.7* plt ct-476* 06:55am blood wbc-10.3 rbc-3.30* hgb-10.2* hct-31.5* mcv-96 mch-30.9 mchc-32.4 rdw-16.0* plt ct-455* 04:05am blood wbc-12.3* rbc-3.23* hgb-10.1* hct-31.3* mcv-97 mch-31.3 mchc-32.4 rdw-15.9* plt ct-405 06:00am blood wbc-16.1* rbc-3.04* hgb-9.6* hct-29.0* mcv-95 mch-31.6 mchc-33.1 rdw-16.2* plt ct-395 05:39am blood wbc-21.6* rbc-2.55* hgb-8.1* hct-24.1* mcv-95 mch-31.7 mchc-33.6 rdw-16.4* plt ct-339 05:24am blood wbc-18.2* rbc-2.57* hgb-8.1* hct-25.1* mcv-98 mch-31.5 mchc-32.3 rdw-16.2* plt ct-328 05:23am blood wbc-13.7* rbc-2.65* hgb-8.5* hct-25.7* mcv-97 mch-32.0 mchc-33.0 rdw-16.1* plt ct-326 04:12am blood wbc-10.8 rbc-2.37* hgb-7.6* hct-23.0* mcv-97 mch-32.0 mchc-33.0 rdw-16.1* plt ct-342 05:08am blood wbc-7.8 rbc-2.81* hgb-8.6* hct-27.3* mcv-97 mch-30.6 mchc-31.5 rdw-15.8* plt ct-391 05:03am blood wbc-7.3 rbc-2.84* hgb-8.9* hct-27.6* mcv-97 mch-31.1 mchc-32.0 rdw-15.9* plt ct-386 05:45am blood wbc-7.8 rbc-2.68* hgb-8.3* hct-26.4* mcv-99* mch-31.2 mchc-31.6 rdw-15.7* plt ct-364 05:28am blood wbc-8.1 rbc-2.22* hgb-7.0* hct-21.9* mcv-99* mch-31.5 mchc-32.0 rdw-16.0* plt ct-376 05:33pm blood hct-30.8*# 10:58pm blood hct-29.3* 05:46am blood wbc-8.6 rbc-3.10*# hgb-9.7*# hct-29.8* mcv-96 mch-31.3 mchc-32.6 rdw-16.9* plt ct-323 06:00am blood wbc-8.6 rbc-3.25* hgb-10.3* hct-31.0* mcv-95 mch-31.8 mchc-33.3 rdw-16.4* plt ct-368 11:45am blood glucose-202* urean-46* creat-0.7 na-137 k-4.4 cl-101 hco3-27 angap-13 03:03am blood glucose-165* urean-41* creat-0.6 na-135 k-4.0 cl-98 hco3-28 angap-13 07:50am blood glucose-95 urean-29* creat-0.6 na-138 k-3.5 cl-101 hco3-31 angap-10 07:40am blood glucose-186* urean-25* creat-0.6 na-138 k-3.8 cl-103 hco3-28 angap-11 07:35am blood glucose-140* urean-21* creat-0.6 na-138 k-4.4 cl-103 hco3-30 angap-9 06:35am blood glucose-113* urean-19 creat-0.5 na-136 k-5.2* cl-101 hco3-24 angap-16 07:42am blood glucose-143* urean-15 creat-0.6 na-139 k-4.6 cl-101 hco3-30 angap-13 07:17am blood glucose-157* urean-15 creat-0.4 na-136 k-4.2 cl-97 hco3-31 angap-12 08:00am blood glucose-160* urean-13 creat-0.4 na-137 k-3.9 cl-98 hco3-32 angap-11 06:55am blood glucose-147* urean-11 creat-0.3* na-137 k-3.8 cl-98 hco3-30 angap-13 04:05am blood glucose-132* urean-12 creat-0.4 na-138 k-3.5 cl-98 hco3-31 angap-13 06:00am blood glucose-163* urean-17 creat-0.5 na-138 k-3.6 cl-99 hco3-33* angap-10 06:48pm blood glucose-725* urean-20 creat-0.5 na-132* k-6.3* cl-95* hco3-30 angap-13 09:35pm blood glucose-188* urean-21* creat-0.5 na-139 k-3.5 cl-99 hco3-33* angap-11 05:39am blood glucose-135* urean-23* creat-0.4 na-140 k-3.4 cl-102 hco3-32 angap-9 05:33pm blood na-139 k-3.4 cl-100 05:24am blood glucose-87 urean-29* creat-0.3* na-140 k-3.9 cl-101 hco3-33* angap-10 05:23am blood glucose-83 urean-32* creat-0.5 na-138 k-4.5 cl-103 hco3-32 angap-8 04:12am blood glucose-69* urean-33* creat-0.4 na-140 k-4.9 cl-105 hco3-31 angap-9 05:08am blood glucose-75 urean-37* creat-0.4 na-139 k-5.6* cl-104 hco3-29 angap-12 05:03am blood glucose-72 urean-37* creat-0.4 na-137 k-5.4* cl-103 hco3-29 angap-10 05:45am blood glucose-99 urean-36* creat-0.4 na-140 k-4.2 cl-111* hco3-25 angap-8 05:28am blood glucose-60* urean-44* creat-0.5 na-138 k-4.8 cl-105 hco3-31 angap-7* 05:46am blood glucose-121* urean-39* creat-0.4 na-139 k-4.6 cl-105 hco3-31 angap-8 06:00am blood glucose-160* urean-37* creat-0.4 na-138 k-4.8 cl-103 hco3-31 angap-9 as of wbc 8->12s 83%n hct 31-32 stable (up today to 35 may be concentrated) bun/creat 16/0.6 trop 0.01->0.02->0.02 bnp 3661 no prior albumin 2.8 lfts wnl lactate 1.6 urine legionella: neg . ua 0-2 wbc, +nitrite, many bacteria ucx >100k pseudomonas with intermediate sensitivity to cipro, to ceftaz . blood cx x2 ntd . . . imaging/results: cxr : large b/l pleural effusions not present on cxr . cxr pa/lat large, right greater than left bilateral pleural effusions associated with atelectasis and a very large hiatal hernia are unchanged. the visualized upper lungs are well aerated. cardiac size cannot be evaluated. . cxr : there is still evidence of a large hiatal hernia, and the stomach is still distended with air-fluid levels unchanged from prior. large bilateral pleural effusions are unchanged. new bilateral perihilar opacities are worrisome for aspiration. . cta 1. no evidence of pulmonary embolism or aortic dissection. 2. large bilateral pleural effusions, which in conjunction with large type iii hiatal hernia resultants in collapse of the right middle, right lower, and left lower lobe. the remaining aerated lung displays no focal opacity to suggest underlying pneumonia. 3. atherosclerotic disease involving the coronary tree and aorta with minimal dilatation of the ascending aorta. mass effect from the posterior hiatal hernia displaces the heart anteriorly with compression of the right atrium and right ventricle noted by the sternum. 4. thyroid goiter and probable benign simple right renal cyst and hyperdense left renal cyst. . ct chest -reviewed personally with radiologist large pleural effusions are present bilaterally, slightly larger on the right than the left. these effusions as well as a massive hiatal hernia result in extensive atelectasis of the lower lobes. compression of present. undigested food in stomach and now esophagus->high risk for aspiration. aerated parts of lungs w/o evidence of pna or pulm edema but difficult to exclude this underlying the areas of lung collapse. ct (c/a/p): 1. no definite evidence for active extravasation into the chest, abdomen, pelvis, or subcutaneous tissues. 2. large bilateral pleural effusions. 3. large right flank fluid collection which is incompletely assessed but may represent a hematoma. 4. interval decreased distention of large hiatal hernia. the distal stomach is fixated with two peg tubes. there is no evidence for active extravasation into the abdomen. 5. small volume of free intraperitoneal air likely related to recent post-operative status. 6. nonobstructed small bowel loops within bilateral inguinal hernias. 7. hypodense right renal lesions, compatible with cysts. 8. hypodense pancreatic head lesion, incompletely characterized, may represent cyst or dilated pancreatic duct side branch. 9. multilevel lumbar body vertebral compression fractures, age indeterminate. status post orif of a left intertrochanteric fracture with avulsion of the lesser trochanter. osteopenia. echo 70%ef, nl la/ra echo : 70%ef, extrinisic compression of la by hh echo : the left atrium is normal/small in size. the wall of the left atrium appears to be compressed by an external structure. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). compared with the prior study (images reviewed) of , there may be slightly less compression of the left atrium by an external structure. brief hospital course: ms. is an 88-year old woman with h/o dm and recent l humeral and l femur fracture s/p orif of her l femur (), who was admitted from rehab for for acute respiratory distress and hypoxia. she was found to have bilateral pleural effusions, as well as a large hiatal hernia which was compressing her left atrium and likely contributing to her pulmonary effusions. over her hospital course, ms. y developed aspiration pna, pseudomonal uti, and c. difficile colitis. each of these issues is addressed below. ##hypoxia the patient was admitted on from her rehab facility with increased rr and o2 saturations in the 80s. her o2 requirement on admission was 6l. cxr in the ed revealed bibasilar infiltrates, and chest ct revealed bibasilar effusions and collapse of the right middle, right lower, and left lower lung. her effusions were thought to be caused at least in part by compression of her left atrium by her hiatal hernia, leading to increased pressure in her pulmonary vasculature. empiric levofloxacin and vancomycin were started for pneumonia. no evidence of pulmonary embolism was seen on cta. on , 2x 20 mg iv lasix was given, leading to a diuresis of 1.5l and improvement in her hypoxia (o2 requirement from 6 to 3l). vancomycin and levofloxacin were discontinued on because no clear evidence of pna had been found. between and , iv lasix was used only intermittently because of concern for her preload limitations caused by the hiatal hernia compressing her left atrium (please see 'hiatal hernia' as separate issue below). on , cxr showed new perihilar opacities worrisome for aspiration. iv flagyl was added to her ceftazidime (which she was already taking for pseudomonas uti, discussed as separate issue below) for empiric coverage of aspiration pna. her iv flagyl and ceftazidime were continued for a 10 day course. on , the patient's o2 requirement increased from 2l to 3l. she received 2x 20 mg iv lasix, to which she diuresed 1.3 l. on , a thoracentesis was performed in her r pleural space, and 850 ml of straw-colored transudate was removed. pleural fluid analysis revealed a transudate, and cultures have not grown any organisms to date. diuresis with 1 or 2 20 mg doses of iv lasix per day was continued on (tbb goal -500 cc), and by , her oxygen requirement had been reduced to 0.5-1l. on , the patient underwent endoscopic gastric pulldown with double peg placement (see management of hiatal hernia as separate issue below), and her post-op o2 requirement was initially 4l. between and , she was diuresed with 20 mg doses of iv lasix to a tbb goal -500, and on , her o2 requirement was 0.5-1l. on , the patient was transitioned from iv lasix to 40 mg po lasix . the patient's daily tbb was -250 to -500 l on this dosage, and she was increased to 60 mg po lasix . for rehab planning, it is recommended that this dosage be weaned as necessary (based on her o2 requirement, daily tbb, and clinical volume status) so that she is not chronically using lasix for diuresis. ##hiatal hernia echocardiogram revealed a hiatal hernia compressing the l atrium. ejection fraction was 70%. on , ngt placement under fluoroscopy was attempted but unsuccessful. iv iv reglan was begun on in order to promote forward motility and gastric emptying. the patient was made npo with all non-essential po meds held, and on , a picc line was placed for tpn. tpn was started on and continued until . on , the patient underwent laparoscopic gastric pulldown and double peg placement in order to anchor her stomach and prevent reherniation/volvulus. on , she was transitioned to an oral diet of nectar thick liquids and pureed solids. on , she began getting tube feeds through one of her peg tubes (rate of 15 cc/hr to goal rate of 45 cc/hr). by , her tube feeds were at goal, and she was taking minimal po's (thick liquids, pureed solids, crushed pills). of note, her foley catheter was left in place because her mobility was still quite limited at the time of discharge. however, once she is able to progress in her rehabilitation and move more easily, foley should be discontinued. ##pseudomonal uti patient was diagnosed with uti on , and cultures grew pseudomonas sensitive to ceftazidime. a five day course of ceftazidime was started on . ceftazidime was continued past five days for concurrent empiric coverage of aspiration pna (see hypoxia section above). ##c. dificile colitis on , the patient's wbc rose from 12.3 to 16.1, and on , it rose further to 21.6. she was also having diarrhea ( episodes/day) during this time. stool specimen was newly positive for c. difficile toxin on , and this was thought to underlie her leukocytosis. po liquid vancomycin was started on . on , her wbc was reduced to 13.7, and by , it had decrased <10. ##anemia the patient had two episodes of hct drops during her admission. the first occurred on , when her hct dropped from 29.0 to 24.1. cbc was immediately rechecked, and hct rose back to 27.8 without intervention. this hct drop was thought most likely due to fluid shift, dilution from tpn, and/or lab error caused by drawing the blood from her picc line. the pt's hct stayed stable from to , when it dropped from 26.4 to 21.9 overnight. 1u of prbcs were given, and her post-transfusion hct was 30.8 because of her endoscopic surgery on , there was concern for internal bleeding. ct scans were taken of her abdomen, l thigh, and l humerus. there was no active extravasation, but fluid collections representing seromas vs. hematomas were seen in her r flank and l hip, likely caused by her fall and humeral/femoral fractures. in the absence of obvious extravasation, the differential for her hct drop was fluid shift from her surgery or lab abnormalities caused by her picc line. her large increase in hct (21.9 to 30.8) with only 1u of prbcs suggested that her hct drop was not caused by a true pathology. ##rehabilitation from open reduction internal fixation of l femur the patient was followed by the orthopedic trauma team throughout her stay, and per their recommendations, weight-bearing as tolerated/passive range of motion exercises were performed for her l femur and non-weight bearing/range of motion as tolerated exercises for her l humerus. a four-week course of lovenox was continued for dvt prophylaxis. lovenox was continued because of her high risk of dvt (immobile, s/p orthopedic and abdominal surgery, elderly). tylenol 1g tid was used for pain. iv morphine 0.25 mg was started on for pain as well. staples from her l thigh incision were removed on . there was no evidence of hemarthrosis during her admission. outpatient follow-up with dr. np has been scheduled. ##diabetes the patient's home metformin was held, and she was treated with insulin sliding scale, as well as supplemental insulin while receiving her tpn from to . once she transitioned from tpn to tube feeds, she was being controlled only on her insulin ss. she will be discharged on the sliding scale, while holding her home meformin. ##pressure ulcers the patient had a sacral ulcer and scattered bilateral heel ulcers on admission. she received daily wound care with elevation of both heels off the bed using boots. she was also brought ouf of bed as tolerated in order to relieve pressure on her ulcerated areas. #nutrition the patient was on tpn from . thereafter, she was taking limited po diet (nectar thick liquids/pureed solids) and tube feeds at a goal rate of 45 cc/hr. ##dvt prophylaxis lovenox 40 mg sc daily was used for dvt prophylaxis. medications on admission: enoxaparin 30 mg subcutaneous qd for 4 weeks. ascorbic acid 500 mg po daily b complex vitamins po daily calcium carbonate 500 mg po daily cholecalciferol (vitamin d3) 400 unit po daily famotidine 20 mg po bid docusate sodium 100 mg po bid senna 8.6 mg po hs acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, fever. omega-3 fatty acids po daily bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation: hold for loose stool. discharge medications: 1. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. b complex vitamins capsule sig: one (1) cap po daily (daily). 5. omega-3 fatty acids capsule sig: one (1) capsule po bid (2 times a day). 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 7. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 9. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 11. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous daily (daily). 12. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 13. oxycodone 5 mg/5 ml solution sig: 2.5 mg po bid (2 times a day). 14. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours): day 1 of 14 day course was . please continue until . . 15. famotidine 20 mg tablet sig: one (1) tablet po twice a day. 16. insulin lispro 100 unit/ml solution sig: please follow sliding scale subcutaneous asdir (as directed): please follow insulin sliding scale. 17. furosemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). discharge disposition: home with service facility: discharge diagnosis: large paraesophageal hernia causing left atrium compression s/p gastric pulldown and peg placement x2 bilateral pleural effusions hypoxia clostridium difficile colitis pseudomonas aeruginosa uti aspiration pneumonia discharge condition: stable on 0.5-1l oxygen. discharge instructions: you were admitted from your nursing home with shortness of breath and low oxygen. you were found to have fluid around your lungs which is new and was compressing your lungs. this is secondary to your large hernia that was displacing your stomach into your chest. we treated your low oxygen by giving you a medication that helps you urinate out excess body fluid. your oxygen improved steadily during your hospital stay. for your hernia, we initially stopped feeding you by mouth and started you on iv nutrition. you then underwent a surgery in which your stomach was pulled down closer to its original position and anchored to your abdominal wall using two tubes. following surgery, your iv nutrition was stopped, and you were fed both orally as well as through your stomach tube. in addition to your low oxygen level and your hernia, you also developed infection of your lungs, urinary tract, and gi tract (at different points during your admission). we treated each of these infections with the appropriate antibiotics. on admission, you were still recovering from your left arm and left femur fracture. the orthopedics team followed you during your admission, and we tried to get you out of bed as much as possible in order to do weight-bearing exercises. you had some pressure sores and were seen by wound care. please take all your medications as written. the following changes were made to your medications: new: 1) albuterol/ipratropium inhalors as needed for shortness of breath (you do not need to have this at home if it does not help you) 2) vancomycin 125mg orally four times a day (q6 hours) until 3) subcutaneous insulin for your diabetes 4) lasix 60 mg two times a day to prevent fluid in your lungs 5) oxycodone 2.5 mg twice a day as needed for pain. changes: please continue enoxaparin 40mg sub-cutaneous once a day until you talk to your orthopedist. calcium carbonate increased to 500mg three times a day vitamin d increased to 800 units daily we stopped your metformin during your admission and controlled your diabetes with insulin followup instructions: 1) primary care doctor: dr. , , 2:45 pm, 2) hernia surgery: dr. , md phone: date/time: 11:45 3) orthopedics: appointment with , np. , 9:20 am, bldg Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Laparoscopic repair of diaphragmatic hernia, abdominal approach Diagnoses: Anemia, unspecified Unspecified pleural effusion Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Pulmonary collapse Other and unspecified hyperlipidemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Osteoporosis, unspecified Intestinal infection due to Clostridium difficile Pressure ulcer, lower back Hypoxemia Pressure ulcer, heel Pseudomonas infection in conditions classified elsewhere and of unspecified site Pressure ulcer, stage II Spinal stenosis, lumbar region, without neurogenic claudication Diaphragmatic hernia with obstruction

allergies: penicillins / aspirin attending: chief complaint: s/ fall major surgical or invasive procedure: open reduction internal fixation with 7.3 mm cannulated screws. history of present illness: yo female with h/o of previous falls (5 in the past year) s/p fall while walking up a , fell forward, hit head on the ground. she does not recall tripping and states she probably lost her balance; denies any pre-fall symptoms and denies loc, vision changes and dizziness. she recalls all events. she was helped by passer-bys and ambulance was called. taken to an area hospital where found to have a small right sah and was then transferred to for further care. past medical history: htn, lipids, dm, urinary frequency, pacemaker 4 yrs ago, ?copd . family history: noncontributory physical exam: upon admission: o: t 97 hr 80 bp 120/80 rr 14 o2sats 93% on ra gen: wd/wn, comfortable, nad heent: r forehead abrasion w/ ecchymosis, pupils: r 2 to 3, l 3 to 4; eomi neck: supple. lungs: cta bilaterally. cardiac: regular 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. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, r: 2 to 3 mm; l: 3 to 4. 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 diminished at r hip secondary to pain). no pronator drift sensation: intact to light touch, pinprick bilaterally. reflexes: b t br pa ac right 2+ --------> left 2+ --------> toes downgoing bilaterally pertinent results: 05:20pm glucose-167* urea n-36* creat-1.6* sodium-121* potassium-3.3 chloride-84* total co2-24 anion gap-16 05:20pm ck(cpk)-189* 05:20pm ctropnt-<0.01 05:20pm wbc-16.3* rbc-4.14* hgb-12.3 hct-33.8* mcv-82 mch-29.7 mchc-36.4* rdw-12.7 05:20pm plt count-310 head ct scan impression: 1. right frontal cephalohematoma. 2. right parietal subarachnoid hemorrhage extending into the temporal lobe. 3. second area of subarachnoid hemorrhage in the right parietooccipital area. 4. right cerebellar intraparenchymal hemorrhage with no associated midline shift. this pattern of hemmorhage is consistent with trauma. ct cervical spine impression: 1. no acute fracture of the cervical spine. 2. severe degenerative changes predispose to spinal cord injury. the retrerolisthesis of c5 on c6 is liklely chronic given no prevertebral tissue swelling. however, actual chronicity cannot be definitively established without comparison studies. if there persists clincial concern for injury, consider mri for further characterization. cxr pacer is present with leads in standard positioning. heart size is normal. the aorta is mildly unfolded. there is questionable deviation of the trachea to the left above the thoracic inlet level, but note is made of absence of abnormality in this region on recently reported ct neck from earlier the same date. in the absence of intervention in this region, this could potentially be due to mild physiological bowing of the airway, but attention to this area on a standard pa and lateral radiograph may be helpful for initial further evaluation. lungs are slightly over expanded but grossly clear. right hip xray findings: there is an impacted valgus angulated fracture at the junction with the femoral head. the femoral head remains appropriately articulated. the more distal femur is intact. no fracture of the pelvis or sacrum is identified. the sacroiliac joints are unremarkable. impression: impacted valgus angulated fracture involving the femoral neck as detailed above. brief hospital course: she was admitted to the trauma service. neurosurgery and orthopedics were consulted given her injuries. her subarachnoid hemorrhage was managed nonoperative; serial neurological exams and repeat head ct scans were followed and remained stable. she will follow up in 1 month with dr. for repeat head ct scan. a medicine/geriatric consult was obtained for surgical clearance and she was given clearance. she was taken to the operating room by orthopedics for repair of her right femoral neck fracture. there were no intraoperative complications. postoperatively she has done well. her diet was adanced, her foley was removed. pain is being controlled with around the clock tylenol and prn percocet. she was started on calcium and vitamin d. physical and occupational therapy were consulted and have recommended rehab after her acute hospital stay. by discharge, she was tolerating a regular diet and was feeling well. she was discharged to rehab. medications on admission: levoxyl 100', toprol 200', lisinopril 20', caduet', glimepiride 2'', ditropan 5', furosemide 20', asa 81' discharge medications: 1. insulin regular human 100 unit/ml solution sig: one (1) dose injection four times a day as needed for per sliding scale. 2. metoprolol succinate 100 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po daily (daily): hold for hr<60; sbp<110. 3. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 4. enoxaparin 30 mg/0.3 ml syringe sig: thirty (30) mg subcutaneous (2 times a day). 5. acetaminophen 650 mg tablet sig: one (1) tablet po q 8h (every 8 hours). 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. senna 8.6 mg tablet sig: two (2) tablet po hs (at bedtime). 9. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 12. vitamin d 400 unit capsule sig: one (1) capsule po bid (2 times a day). discharge disposition: extended care facility: palm nursing home discharge diagnosis: s/p fall right subarachnoid hemorrhage right cerebellar intraparenchymal hemorrhage right femoral neck fracture discharge condition: hemodynamically stable, tolerating a regular diet, pain adequately controlled. discharge instructions: you were admitted to the hospital after you had a fall at home which caused you to break your right leg and have a small bleed in your head. your leg was operated on by orthopedics. at this time, you can touch down weight bear only on your right leg only. there are no restrictions for your left leg. you can eat a regular diet. also, some of your blood pressure medications were stopped. please do not take them unless restarted by a physician. return to the emergency room if you develop any fevers, chills, headaches, dizziness, chest pain, shortness of breath, redness/drainage from your incision, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. followup instructions: follow up in 2 weeks with dr. , orthopedics. call for an appointment. follow up in 4 weeks with dr. , neurosurgery. call for an appointment. inform the office that you will need a repeat non contrast head ct scan for this appointment. it is also very important that you follow up with your pcp, . , regarding your medication regimen. while in the hospital, several of your blood pressure medications were stopped. you were discharged on only your metoprolol. Procedure: Open reduction of fracture with internal fixation, femur Diagnoses: Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Unspecified fall Cardiac pacemaker in situ Closed fracture of unspecified part of neck of femur Contusion of face, scalp, and neck except eye(s) Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness

allergies: fluconazole / sulfa (sulfonamide antibiotics) attending: chief complaint: left flank pain major surgical or invasive procedure: chest tube placement x3 chest tube removal x2 intubation cvvh, hd central line placement in l ij hd line placement in r ij history of present illness: 52 year old woman with mpd/mds, ~ 1 year s/p sibling related allo sct with busulfan/cytoxan pre-conditioning therapy , hx of gvh of liver currently c1d20 of rituxan with nplate, she presents with left flank pain for several days and tachypnea. on she developed fevers treated with moxifloxicin qod. for the past several days she has c/o intermittent but persistent l. sided flank pain for several days. she was seen in clinic on and had a cta chest that showed no pe, increase in left effusion, trace right effusion, decreased bibasilar peribronchiolar opacities with slight increase in peripheral right upper lobe opacities and splenomegaly with incompletely visualized wedge shaped perfusion defect in spleen concerning for splenic infarct. she was referred to the ed for further evaluation. . in the ed, triage vs: 98.2 93 142/75 18 98% 4l nc. fast scan negative. she underwent ct abdomen that showed severe splenomegaly with some low attenuation geographic regions that may suggest early splenic infarctions, bilateral pleural effusions, left greater than right, with increased size of the left effusion since the examination earlier today. she was given cefepime, vancomycin, morphine, dilaudid and zofran. . on the floor, she was continued on vancomycin and cefepime for prseumed pneumonia. she undewent thoracentesis of the left pleural effusion with removal of 80-100cc exudative fluid with presence of fibrin clots in serosanguinous fluid and a chest tube was placed. there was a question on follow up cxr about chest tube position. she underwent limited chest ct following this that demonstrated supra-diaphragmatic placement on the chest tube. the chest tube has put out about 20cc of fluid since placement. she was placed on a morphine pca and ativan for pain/anxiety control with some improvement in her symptoms. she continues to be tachypnic to the thirties with oxygen saturations in the low 90s on 5l face mask (mouth breather)(mid 80s on room air), using accessory muscles. she is having increasing secretions. she triggered this morning for tachypnea and nursing concern. blood pressures 90s systolic on floor. past medical history: past oncologic history mpd/mds - large painless abdominal mass in luq found on physical exam in . ct abd/pelvis with enlarged spleen (24cm) with 3 hypodense nodules and no associated adenopathy. e/o marrow replacement. . she was admitted on for a sibling match allo transplant with bu/cy conditioning regimen. her transplant course was very complicated by: - pneumonia, pulmonary edema and respiratory failure requiring transfer to icu and intubation - acute renal failure requiring hemodialysis - neutropenic fever - confusion - fall with small head bleed on ct - rash from gvh - anemia requiring multiple transfusions - thrombocytopenia requiring multiple transfusions - multiple skin lesions - gvh of liver other past medical history: 1. history of reactive tb skin test in 3rd grade (age 8)- does not recall any known exposures or family members with disease. was treated for 1 year with 2 drugs. 2. history of anemia, on iron 3. precancerous polyp removed five years ago at a colonoscopy 4 benign lump in the right breast at the age of 22 5.enlarged nodes in the right neck after cat scratch at age 5. social history: married and lives in with her husband and 3 sons. she owns a medical transcription service. - tobacco: none - etoh: one glass at special occasions - drugs: none family history: - father, deceased at 73 of lung cancer - mother, deceased at 73 of unclear causes, had history of cardiac issues - paternal aunt with breast cancer - paternal grandmother with breast cancer - 3 brothers, 1 died in card accident, 1 died of brain aneurysm resulting from an accident, 1 alive and well with hypercholesterolemia - 4 sisters, all alive and well physical exam: admission pex: triage 9 (pain) 98.2 93 142/75 18 98% transfer vs99.5, 103, 122/74, 22, 98% 4lnp gen: aox3, nad heent: perrla. mmm. no lad. no jvd. neck supple. cards: rr s1/s2 normal. no murmurs/gallops/rubs. pulm: left basilar dullness to percussion, upper airway rhonchi, no wheezes or crackles bilaterally abd: bs+, soft, nt, no rebound/guarding, non tender massive splenomegaly, no sign extremities: wwp, no edema. dps, pts 2+. radial pulse 2+. skin: single, nonerythematous, crusted pseudo-vesicular lesion on dorsum surface of left thumb. neuro: strength and sensation grossly intact ================================== pex when discharge from icu: expired. pertinent results: labs on admission: 02:50pm blood wbc-1.1* rbc-2.90* hgb-8.9* hct-24.8* mcv-86 mch-30.8 mchc-36.0* rdw-16.8* plt ct-22* 02:50pm blood neuts-28* bands-2 lymphs-60* monos-3 eos-0 baso-0 atyps-1* metas-3* myelos-0 blasts-3* nrbc-1* 02:50pm blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-normal microcy-1+ polychr-occasional ovalocy-1+ tear dr 02:50pm blood pt-11.8 ptt-21.1* inr(pt)-1.0 05:45pm blood fibrino-512*# 02:50pm blood gran ct-373* 02:50pm blood urean-46* creat-1.4* na-140 k-4.7 cl-111* hco3-22 angap-12 02:50pm blood alt-66* ast-89* ld(ldh)-537* alkphos-599* totbili-0.9 02:50pm blood totprot-4.8* albumin-3.7 globuln-1.1* calcium-8.6 phos-3.7 mg-2.3 05:45pm blood hapto-174 04:04pm blood igg-229* 06:40am blood vanco-10.8 12:10pm blood hcv ab-pnd 12:10pm blood hbsag-pnd hbsab-pnd hbcab-pnd 11:08am blood type-art po2-79* pco2-37 ph-7.36 caltco2-22 base xs--3 10:22am blood type- temp-36.7 fio2-70 po2-81* pco2-39 ph-7.31* caltco2-21 base xs--6 intubat-not intuba 04:46am blood type-art temp-37.4 rates-16/ tidal v-450 peep-10 fio2-100 po2-137* pco2-54* ph-7.14* caltco2-19* base xs--11 aado2-522 req o2-87 intubat-intubated 11:08am blood lactate-1.1 11:08am blood hgb-10.7* calchct-32 o2 sat-94 02:24pm blood freeca-0.91* 10:17am blood b-glucan-test 10:17am blood aspergillus antibody-test 08:00pm blood ebv pcr, quantitative, whole blood- 08:00pm blood adenovirus pcr-test name 02:40pm blood engraftment/chimerism test, post-transplant-pnd 01:55pm blood francisella tularensis serology-test 01:55pm blood herpes 6 dna pcr, quantitative-pnd 03:55am urine color-straw appear-clear sp -1.021 03:55am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 03:55am urine rbc-3* wbc-1 bacteri-none yeast-none epi-1 03:55am urine castgr-2* 12:06pm pleural wbc-175* rbc-* polys-0 lymphs-93* monos-7* 08:05pm pleural wbc-325* rbc-* polys-78* lymphs-20* monos-2* 12:06pm pleural totprot-2.7 glucose-84 ld(ldh)-409 03:59pm pleural cholest-92 triglyc-173 12:27pm other body fluid polys-52* lymphs-3* monos-0 macro-31* other-14* 02:00pm other body fluid cd117-done cd45-done hla-dr cd10-done cd13-done cd15-done cd19-done cd20-done lamba-done cd5-done 02:00pm other body fluid cd34-done cd3-done 02:00pm other body fluid ipt-done 12:12pm other body fluid aspergillus galactomannan antigen-pnd 12:27pm other body fluid aspergillus galactomannan antigen- 04:23pm other body fluid adenosine deaminase, fluid-test . . . labs on discharge from icu: . . . . . . micro data: stool: c diff, cultures negative u/a: negative, cultures negative, neg for legionella ag. blood cultures: negative cmv viral load: pending respiratory viral cultures: negative 12:27 pm bronchoalveolar lavage source:bronchial lavage. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. legionella culture (final ): no legionella isolated. potassium hydroxide preparation (final ): this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). koh requested by dr.,karua () . no fungal elements seen. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (preliminary): no fungus isolated. nocardia culture (preliminary): no nocardia isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. viral culture: r/o cytomegalovirus (preliminary): no cytomegalovirus (cmv) isolated. bal cytology negative for malignant cells. 2:59 am sputum site: endotracheal source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). respiratory culture (preliminary): sparse growth commensal respiratory flora. stenotrophomonas (xanthomonas) maltophilia. moderate growth. identification and sensitivities performed on culture # (). imaging: cxr : interval removal of endotracheal tube and nasogastric tube. cardiomediastinal contours are unchanged. multifocal areas of consolidation are again demonstrated, most marked in the right lower lobe. although similar in appearance to the recent study, there has been improvement in the multilobar consolidations when compared to earlier radiographs such as . bilateral pleural effusions are unchanged, left greater than right. chest/abd/pelvis ct : 1. unchanged right superior mediastinal hematoma. 2. right upper lobe pneumonia with dense consolidations in both lower lobes and small nonhemorrhagic effusions. 3. splenomegaly. 4. no retroperitoneal hematoma. ekg : sinus tachycardia with atrial premature beats. borderline low voltage in the limb leads. since the previous tracing atrial premature beats are new. otherwise, findings are unchanged. echo (): the left atrium is mildly dilated. 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 normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the degree of mr seen is slightly less. the degree of tr seen has probably increased. if indicated, a tee would better exclude a small valve vegetation. cta (): 1. no evidence of pulmonary embolism. 2. marked splenomegaly, with an incompletely imaged wedge-shaped perfusion defect concerning for a splenic infarct. 3. slight increase in small-moderate left and small right pleural effusions. 4. decreased bibasilar peribronchiolar opacities, with increased opacities in the right upper lobe, which could represent an ongoing infectious/ inflammatory process. brief hospital course: 52 yo female with history of mpd/mds, s/p bmt 1 yr ago, who is admitted with fevers, neutropenia/pancytopenia and splenic infarct and splenomegaly, transferred to with acute respiratory distress, with rapidly expanding left pleural effusion. chest tube placed pm drained ~920 cc of blood-colored thin fluid. improved on abx, then developed rll presumed vap, found to be stenotrophomonas, to ceftaz (bactrim best but patient has sulfa allergy, resistant to levoflox). on broad spectrum antibiotics (vanc/voriconazole/ceftazidime/acyclovir ppx) id following, initially was on stress dose steroids, now weaned to daily iv 20mg dose for gvhd. . active issues: # hypoxic respiratory failure: initially due to white out of left lung likely due to pneumonia/rapidly expanding serosanguinous pleural effusion. her ct scan revealed pan lobar consolidation of lul/ lll and patchy involvement in the rll too with drainage of the pleural space with the chest tube. bronch showed very thick, purulent secretions, obtained samples. patient was continued on abx regimen since culture data nonspecific/pending (vanc//voriconazole/levoflox/acyclovir ppx). pna and effusions improved dramatically around the 7th, but since the 9-10th, cxr shows worsening rll process, likely infiltrate. patient was ct scanned which corroborated with infiltrate as opposed to edema and patient was bronch'ed on , minimal secretions noted, growing stenotrophomonas to ceftaz (bactrim best but patient has sulfa allergy; resistant to levoflox). patient continued on ceftaz(course length to be dictated by id, likely 2 wks), vancomycin(today is day , can stop afterwards), vori (can d/c, will need to f/u with id), & acyclovir ppx. chest tube has since been removed with no complications. patient initially headed to tracheostomy route but ended up responding beautifully to ceftaz and was extubated . she was transitioned back to the floor but on became acutely tachypneic and hypoxic and was transferred back to the icu. antifungal coverage had been changed to micafungin on . cxr showed worsening r sided pleural effusion and she underwent therapeutic thoracentesis with placement of a pigtail catheter with drainage of >1l serosanguinous fluid, exudative which was removed . she was started on vancomycin at time of icu transfer for possible worsening on chest ct of infectious process. sputum gs showed 3+ gpcs in pairs. induced sputum was sent. she was weaned to 3l nc with rr in 20s and was deemed stable for transfer back to floor on . she subsequently developed worsening tachypnea and hemoptysis on and was transferred back to the icu. she became increasingly hypoxic relatively rapidly and hct was noted to be falling. after a discussion with her, her husband, and the bmt team, the decision was made to intubate the patient for hypoxia and airway protection. she also required plt and prbc transfusion at this time. follow up chest imaging revealed a possible empyema vs complex loculated effusion with rind. thoracic surgery placed a new chest tube on the right while intubated with some effect. antibiotics were broadened to include tigecycline but the patient continued to require maximal ventilatory support. . # acute on chronic renal failure: etiology likely oliguric atn in setting of sepsis. baseline cr of 1.3-1.4, went as high as 3.3, with metabolic acidosis and electrolyte derrangements. at first tried to balance with respiratory alkalosis through ventilator settings but it became apparent after 1-2 days in the icu that she would benefit from dialysis. cvvh was initiated with great results, improvement in ph, electrolytes, & fluid balance. on , patient was started on hd, which she tolerated well. making small amounts of urine on . patient now recovering with increased uop with no acute indication for hd and will likely not require further. would trial diuretics if volume overload becomes an issue though currently is auto-diuresing. renally dose meds. renal following closely. hd line pulled . . # bp instability: patient hyper and hypotensive at times, likely to sepsis, anxiety, fluid overload at times. responded to boluses currently when hypotensive earlier in course. she became increasingly hypotensive during her last micu course, requiring 2 pressors at maximal dosage. after a discussion between the patient's husband and hcp and her outpatient , the decision was made to not escalate care further given overall prognosis. the patient expired with her family at the bedside on the evening of . postmortem exam was declined by the family. . # anemia: likely multifactorial, to blood loss from low platelets, hemolysis, and anemia of chronic disease. was guaiac pos but no evidence of active bleeding, on gi prophy. chest/abd ct from found no evidence of bleeding. have been following hcts and transfusing with goal of hct>24. . # thrombocytopenia: likely due to a combination of poor synthesis due to mds and sequestration. have been trending counts & transfusing with current goal >20 per bmt. . # mds s/p sct and pancytopenia: s/p transplant from sister . 85% donor on last evaluation. she remains neutropenic on gcsf g-csf and nplate, afebrile now. awaiting test of peripheral chimerism to see if current marrow mostly her own or if her donor marrow is still taking. concern for evolution into aml given peripheral circulating blasts. will continue folic acid, neupogen as per bmt team. ivig therapy was given on . pentamidine per bmt for pcp . . . inactive issues: . # gvhd: past gvh of skin and liver: have continued to monitor lfts, on baseline 20mg iv steroids daily, changed to 30mg iv methylprednisolone on . . # hsv lesions (perineal): continue acyclovir 5% cream for local lesion and acyclovir 400mg po bid for prophylaxis. medications on admission: home medications: (confirmed with patient) moxifloxicin 400 mg qod restated on with 15 tablets voriconazole 200 (started ) acyclovir 400 zovirax ointment folic acid 1 mg tablet sig: two (2) tablet po daily (daily). lorazepam 1-2 mg tablet qhs prn prednisone 40 mg daily (25 mg until ) albuterol sulfate inh dilaudid 2mg q4 prn oxycodone 5 mg q8 prn vitamin d 800 units daily multivitamin daily ??? bactrim ss tablet daily since discharge medications: n/a discharge disposition: expired discharge diagnosis: 1. hypoxemic respiratory failure 2. stenotrophomonas pneumonia 3. mds/mpd 4. sepsis 5. anemia discharge condition: expired discharge instructions: n/a followup instructions: n/a Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Injection or infusion of immunoglobulin Diagnoses: Pneumonia, organism unspecified Acidosis Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Unspecified septicemia Severe sepsis Hypopotassemia Myelodysplastic syndrome, unspecified Chronic kidney disease, Stage III (moderate) Acute respiratory failure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted bone marrow Herpes simplex without mention of complication Other diseases of spleen Other pancytopenia Chronic graft-versus-host disease

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: myelodysplastic syndrome with myeloproliferative disease with myelofibrosis major surgical or invasive procedure: sibling allogenic stem cell transplant placement of venous central lines x 2 and removal intubation x12 days for hypoxic respiratory failure placement of femoral hemodialysis line history of present illness: 51 yo f with no significant pmh, with recent diagnosis of mds/mpd with myelofibrosis admitted for sibling allogenic sct. . patient reports that five years ago, she was found to be anemic by her pcp. colonoscopy and upper gi series were done to workup the source of anemia. there were colonic polyps which were removed. she was started on iron supplementation. however, the anemia did not resolve, and she eventually developed severe thrombocytopenia (plt <40). a ct of the abdomen showed splenemegaly. patient was referred by pcp to at osh, who then referred the patient to dr. . a bone marrow biopsy was done, which was equivocal. patient had a repeat biopsy which showed mds. her sister was found to be a matched donor, and so patient is admitted to subling allogenic sct. . of note, patient has had little symptoms associated with the anemia and thrombocytopenia. denied frequent bleeding, infections, or increased fatigue. the diagnosis of mds was very much a shock, and has been a significant stressor emotionally. . review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations. denies cough, shortness of breath, or wheezes. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rashes or skin breakdown. no numbness/tingling in extremities. no feelings of depression or anxiety. all other review of systems negative. past medical history: oncology history: recent diagnoses of mds with myelofibrosis features from two bone marrow biopsies. result: peripheral blood with leukoerythroblastic picture. markedly hypocellular marrow (10% cellularity) with dysmegakaryocytopoiesis, bony remodeling and background myelofibrosis. . past medical history: 1. history of reactive tb skin test in 3rd grade (age 8)- does not recall any known exposures or family members with disease. was treated for 1 year with 2 drugs. 2. history of anemia, on iron social history: married and lives in with her husband and 3 sons, ages 24, 22, and 20. eldest son has quit his job and will run her business which she is in the hospital. two sisters, both healthy, one of which will be the fonor for the transplant. she owns a medical transcription service. born in ma, grew up in except for 18 months when her family lived in for 18 months. she has never lived elsewhere in the us or outside of the us. she has travelled to (sisters live in and ); , aruba, and cancun. - tobacco: smokes only when out and having a glass of wine - etoh: glasses a month - drugs: none family history: - father, deceased at 73 of lung cancer - mother, deceased at 73 of unclear causes, had history of cardiac issues - paternal aunt with breast cancer - paternal grandmother with breast cancer - 3 brothers, 1 died in card accident, 1 died of brain aneurysm resulting from an accident, 1 alive and well with hypercholesterolemia - 4 sisters, all alive and well physical exam: physical exam on discharge: from icu: general: sleeping, arousable, nad heent: eyelid rim exudative and bruised, bilateral conjunctival injection, eomi, lungs: bilateral rhonchi cv: regular rate & rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: mildly distended, bs+, nt, splenomegaly ext: 1+ edema of the feet bilaterally, pneumoboots in place, 2+ dp pulses bilaterally neuro: obeys commands gu: trace blood on pad . exam on dishcarge: gen: nad heent: mmm, no op lesions, neck is supple cv: rrr, nl s1s2 pulm: ctab abd: bs+, soft, ntnd, ? spleenemegaly limbs: no le edema, no tremors or asterixis, no clubbing skin: no rashes or skin breakdown neuro: cnii-xii nonfocal, strength 5/5 of the upper and lower extremities, reflexes 2+ of the upper and lower extremities, toes down bilaterally pertinent results: 1. labs on admission: 09:42am blood wbc-7.1 rbc-3.90* hgb-9.9* hct-30.0* mcv-77* mch-25.4* mchc-33.1 rdw-17.8* plt ct-40* 09:42am blood neuts-67 bands-4 lymphs-14* monos-6 eos-0 baso-2 atyps-1* metas-5* myelos-1* 01:30pm blood pt-14.3* ptt-30.4 inr(pt)-1.2* 12:00am blood fibrino-256 12:00am blood gran ct-5103 09:42am blood urean-13 creat-0.8 na-141 k-4.4 cl-105 hco3-28 angap-12 09:42am blood alt-20 ast-18 ld(ldh)-196 alkphos-192* totbili-0.5 09:42am blood albumin-4.7 calcium-8.9 phos-4.4 mg-2.5 . labs on dishcarge: 10:57am blood wbc-2.2* rbc-3.03* hgb-8.8* hct-25.1* mcv-83 mch-29.0 mchc-35.0 rdw-15.7* plt ct-15* 12:00am blood wbc-1.5* rbc-2.79* hgb-8.4* hct-23.8* mcv-85 mch-29.9 mchc-35.2* rdw-16.8* plt ct-13* 10:57am blood neuts-85* bands-2 lymphs-10* monos-2 eos-0 baso-0 atyps-0 metas-1* myelos-0 12:00am blood neuts-83* bands-2 lymphs-8* monos-5 eos-1 baso-0 atyps-0 metas-1* myelos-0 10:57am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-1+ microcy-1+ polychr-1+ tear dr1+ 04:18pm blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-normal microcy-1+ polychr-occasional ovalocy-1+ tear dr1+ 10:57am blood plt smr-rare plt ct-15* 12:00am blood plt ct-13* 12:00am blood glucose-85 urean-86* creat-1.4* na-139 k-3.7 cl-107 hco3-20* angap-16 12:00am blood glucose-123* urean-99* creat-1.7* na-138 k-4.7 cl-107 hco3-22 angap-14 12:00am blood alt-13 ast-14 ld(ldh)-195 alkphos-143* totbili-3.2* 12:00am blood alt-9 ast-15 ld(ldh)-193 alkphos-164* totbili-3.1* 12:00am blood calcium-8.7 phos-4.2 mg-1.8 12:00am blood albumin-3.6 calcium-8.6 phos-4.5 mg-2.1 12:00am blood hapto-69 09:52am blood cyclspr-152 12:00pm blood anti-platelet antibody-test 11:24am blood anti-platelet antibody-test 11:30am blood herpes 6 dna pcr, quantitative-test name . 3. imaging/diagnostics: -abdomen u.s. (complete study) study date of 3:07 pm impression: 1. no evidence of biliary duct obstruction, as questioned. 2. gallbladder sludge, with no son features of acute cholecystitis. 3. stable splenomegaly. 4. stable 2.6 cm echogenic splenic lesion, benign. -ct chest w/o contrast study date of 9:26 am impression: 1. interval development of diffuse and symmetric perihilar ground glass opacities and septal thickening, most suggestive of diffuse pulmonary edema. pulmonary hemorrhage and diffuse infection are considered less likely given the symmetric findings. 2. increase in size of a right pleural effusion, which is now large in size. 3. minimal decrease in size of a left pleural effusion. 4. ascites and massive splenomegaly, partially imaged. 5. diffuse osseous sclerosis, compatible with changes relating to myelodysplastic syndrome. -tte (complete) done at 2:19:06 pm final conclusions the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the degrees of mitral and tricuspid regurgitation along with pulmonary hypertension have all increased. -ct torsow/o contrast study date of 1:41 pm impression: 1. increasing ascites and pelvic free fluid. no evidence of intraperitoneal abscess, hematoma, colitis, or renal abnormality. 2. stable splenomegaly and unchanged appearance of the hypodense inferior pole lesion. 3. increasing right pleural effusion, interstitial thickening within the lung parenchyma. 4. stable appearance of the calcified uterine fibroid. 5. diffusely dense bones, unchanged compared to prior. -ct chest w/o contrast study date of 3:32 pm impression: 1. bilateral effusions, right greater than left, are slightly increased from prior studies. there is associated relaxation atelectasis. 2. subtle peribronchovascular scattered ground-glass opacities in the right upper lobe, nonspecific, compatible with either infectious or inflammatory etiologies. the lungs are otherwise clear without consolidative opacities to suggest pneumonia. 3. splenomegaly. 4. increased ascites. 5. diffusely sclerotic bones, reflects underlying mds. - ct head w/o contrast study date of 4:58 pm impression: 1. unchanged small amount of bifrontal subarachnoid hemorrhage. no new foci of hemorrhage identified, however portions of the brain are incompletely evaluated in the presence of motion artifact despite second attempt. 2. no evidence of parenchymal hemorrhage or intra- or extra-axial hematoma within limitation of motion degraded study. 3. persistent opacification of mastoid air cells without osseous erosion. persistent mucosal thickening within paranasal sinuses. recommend clinical correlation to exclude the possibility of infection. -head ct w/o contrast 1. small amount of bifrontal subarachnoid hemorrhage. 2. 5 mm hyperdensity projecting over the right anterolateral temporal lobe likely represents a bone-related artifact 3. opacification of the mastoid air cells without osseous erosion, and possible fluid in the paranasal sinuses, new since the prior study. clinical correlation is advised regarding the possibility of an infection. -transvaginal u/s 1. heterogeneous uterus with thickening of the endometrial stripe measuring up to 1 cm, concerning in a postmenopausal patient. consider hysteroscopy/direct visualization for further evaluation. 2. normal appearance of both ovaries, without adnexal masses. 3. moderate-to-large amount of free fluid is seen within the pelvis, similar to recent prior ct exam. 4. although an exophytic partially calcified fibroid is suggested extending from the left lateral aspect of the fundus on recent prior ct, this is not visualized on ultrasound. - ct chest//pelvis w/o contrast () 1. bilateral pleural effusions consisting of simple or chylous fluid, with compressive atelectasis. 2. trace intraperitoneal free fluid, but no retroperitoneal or flank hematomas. 3. splenomegaly with incompletely-characterized but nonspecific inferior pole hypodensity. 4. prominent paratracheal lymph node. - liver or gallbladder u/s w/ doppler of portal system () 1. hepatic artery, hepatic veins, and portal veins are patent. 2. unchanged severe splenomegaly and small right pleural effusion. - renal u/s () no evidence of vasoocclusive disease at both kidneys. echogenic lesion in the spleen, suggestive of a hemangioma. although the echogenic appearance would be somewhat atypical, a focal lesion associated with the patient's underlying disease process cannot be excluded. - echocardiogram () the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). diastolic function could not be assessed. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. physiologic mitral regurgitation is seen (within normal limits). there is borderline pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. - brief hospital course: 52 yo f with recent diagnosis of mds/mpd, day d+59 sibling allogenic sct with ablative busulfan/cyclophosphamide therapy. noted anemic 5 years ago with polyps on colonoscopy but persisted and eventually deveoped severe pancytopenic and ct showed splenomegaly - 1 bmbx equivocal second showed mds. cough and febrile neutropenia post transplant d2 treated with iv cefepime, vanc, micafungin and cipro w acyclovir and had progressive resp decompensation requiring micu admission and intubation - intubated for 12 days and successfully extubated on . developed arf felt likely atn in the setting of hypotension and is on dialysis. was bronched on and was normal. persistent confusion since icu likely multifactorial in nature which resolved by . had deranged lfts max bili 11 in icu which have trended down ? drug effect ? gvhd and was treated with steroids. u/s was normal. she was still overloaded re volume status but urine output improved and fluid status improved with boluses of furosemide on advice of renal. her diet was advanced and was latterly able to eat normally and take oral meds by . she had no further fevers and antimicrobials rationalised . iv mp stopped on but restarted on cefepime stopped . and iv cefepime/ started due to new onset pain although scan negative ? gvhd. all antibiotics were stopped on . respiratory decompensation and ct showed pulmonary edema and responded to aggressive diuresis with considerable improvement in fluid status. she was found to have hlaii antibodies which do not necessitate hla matched platelets. due to deteriorating bili with tapering iv steroids, ivmp increased back to 30mg . symptomatically much improved so decreased steriods to 20mg on . although she was still requiring frequent transfusions of platelets and blood and needed to continue micafungin, it was felt that the pt was stable enough to be discharged to the apartments with daily monitoring at the clinic. . . # myelodysplastic syndrome/myeloproliferative disorder: allo sct . on acyclovir, and mica. patient underwnet pre-conditioning treatment with busulfan/cytoxan. she tolerated busulfan well, but started to experience nausea and abdominal discomfort with cytoxan. she was treated for nausea. she received stem cells from her sister without incident. required prbc and platelet transfusions during times. total bilirubin was elevated (direct bilirubin elevated) at one point, but abdominal ultasound was negative. she was started on tpn. she was transferred to the icu for febrile neutropenia and hypoxic respiratory failure. solumedrol was continued, but bactrim (for pcp ) was held secondary to profound neutropenia. acyclovir was also held as per bmt recommendations. in he icu, the patient had a baseline anemia bm suppression s/p transplant, but developed a falling hct and a small amount of vaginal bleeding in the context of low platelets (plts 7). ct chest/abdomen/pelvis did not identify any other source of bleed. no evidence of rp or thigh bleed was found on physical exam. therefore, the patient was tranfused prbc to a goal hct >21. platelets remained low in spite of platelet transfusions, presumably secondary to the patient's splenomegaly. gynecology recommended vaginal u/s that was done on . in the icu, the patient's neutropenia persisted throughout her icu stay, but her anc rose to 494 before she left the icu. she was put on neutropenic precautions and treated with filgrastim. she was treated with broad spectrum abx as discussed above under respiratory failure. abx will be continued until anc>500 as per id. the patient was thrombocytopenic throughout her icu course and has been refractory to platelet transfusions. after transfusion, her platelets briefly rise by points, but quickly drop back to her baseline of 7. this is presumed to be because of her significant splenomegaly. it was decided that she would be transfused plts only before procedures or in setting of active bleeding and transfusion goal was latterly set to aim for a hct>20 and plt>10 to reduce the transfusion burden due to high requirement of transfusions and lack of symptoms at this level. on transfer back to bmt floor from the micu, counts were increasing on gcsf. she remained on meropenem, vancomycin, ciprofloxacin, and micafungin until she was no longer neutropenic. thrombocytopenia was noted to be refractory to platelets, which were then only given when pt was showing signs of bleeding. pra was negative, so refractoriness was thought to be splenomegaly. after transfer to bmt floor from micu, patient was more responsive to platelets although this was again an issue by with little increase in her counts despite transfusions and having difficulty even attaining a platelet count of 20. due to absence of fevers, stopped mica, cefepime and vanc on . afebrile, no longer neutropenic. had ih pentamidine for prophylaxis. changed cipro to cefepime due to possible drug effect causing pancytopenia. started atovaquone for pcp and stopped cefepime . stopped atovaquone and started dapsone for pcp . bone marrow from was hypocellular but otherwise trilineage hematopoesis. cmv 1070 copies - started treatment dose iv gancyclovir . . #febrile neutropenia: patient was neutropenic during admission, and became febrile. initially was started on vancomycin, cefepime and micafungin, but she continued to have fevers and developed a cough that continued to worsen. ct scan on and showed no evidence of infiltrate. micafungin was changed to voriconazole on for coverage of aspergillus. pt triggered several times for tachycardia and tachypnea related to fever and was transferred to the icu for closer monitoring. the patient's neutropenia persisted throughout her icu stay, but her anc rose to 494 before she left the icu. she was put on neutropenic precautions and treated with filgrastim. she was treated with broad spectrum abx as discussed above under respiratory failure. abx were continued. on return to bmt floor from icu, patient remained on meropenem, vancomycin, ciprofloxacin, and micafungin while still neutropenic. she was planned to continued micafungin as an outpt at the clinic . #hypoxemic respiratory failure requiring icu transfer: in the icu the patient developed hypoxemic respiratory failure, initially secondary to volume overload with flash pulmonary edema in the context of a prbc transfusion. this was all likely complicated by a probable pneumonia (viral, bacterial or fungal). the patient was intubated for hypoxemic resp failure and ventilated for 12 days. the patient's pneumonia was treated w/ meropenem, cipro, vanc, micafungin as per id recs and her respiratory status improved. she was extubated successfully on . id recommended that micafungin/meropenem be continued until anc>500. her most recent granulocyte count is 494 on . the patient was given mucinex prn for cough. after starting hd, the patient's fluid balance became positive and she continues to respond poorly to lasix. her resp status nevertheless continues to be good and she remained clinically stable in this regard on ra until her episode of decompensated pulmonary edema on (see note on pulmonary edema for details). . #arf: no longer dialysis dependent. pt developed acutely worsening renal function after intubation and the cause was felt to be atn secondary to hypoperfusion during an episode of hypotension during intubation. she developed worsening hypervolemia, hyperkalemia up to 6.3 and a creatinine level of 4.1 in spite of intravenous fluids and treatment for hyperkalemia. the pt was treated w/ cvvh and volume was successfully removed over 8 days. however the pt's renal function continued to be poor and the patient was switched to intermittent hd when the patient was off pressors and relatively stable. she was transferred back to the floor once stable. while on the floor, she was dialysed with hd as needed for fluid removal and for uremia when renal function did not significantly improve. patient was noted to have altered mental status likely uremia as this improved after dialysis sessions. medications were renally dosed. she had a temporary dialysis line inserted on and it was felt that her uremia may be contributing to altered mental status although this was multi-factorial and resolved by early 11/. she had bilateral effusions and r effusion worse on ct . effusions improved with aggressive diuresis although by right effusion still present and small-moderate. she passed progressively higher volumes of urine and by passed 1000ml urine over 24 hrs as end of and this trended upwards. fluid status improved but she still had gross pitting edema to knees bilaterally. on advice of renal she was slowly started on iv furosemide boluses to help her fluid status. rby she no longer required dialysis. after an episode of acute pulmonary edema, she as aggressively diuresed from onwards with 80-100mg iv furosemide and her fluid status greatly improved. with diuresis, she was clinically improving and renal function was stable. dialysis line removed with platelet cover . kidney function has been stable and slowly improving. . # confusion: this was considered likely multifactorial given a high bili which improved, a high bun on dialysis and the possibility of infection. she was treated for infectious etiologies and /mica/vanc stopped . her lfts improved but did not resolve to the normal range and she was dialysed until her renal function recovered whereupon she no longer required dialysis. following discontinuation of antibiotics, she greatly improved in the matter of a few days to the extent that by she was gcs 15/15. . # subarachnoid hemorrhage: traumatic sah following fall out of bed on in the context of considerable thrombocytopenia and ct-head showed small bifrtontal sah with no itraparenchymal element. stable on rpt head ct. she was seen by the neurosurgery service who recommended rescanning only if she had a change in neuro exam and recommended transfusing platelets. she was rescanned on for concern for worsening altered mental status and bleed was unchanged. since she had been refractory to platelet transfusions, she was given doses of amicar and ddavp to avoid further bleed. her blood pressure was controlled initially with iv hydralazine and ;latterly has been transitioned to oral labetalol. neurologic status improved (she had been confused post-icu) and she had no sequelae clinically of her sah. a mild anisocoria was noted with the left pupil very marginally larger than the right. she otherwise had an unremarkable neuro exam other than mild jerky saccades. on overnight, fell out of bed and head ct showed bifrontal subarachnoid hemorrhage. she will need f/u with neurosurgery in 2 weeks. . # pancytopenia: ? cause ? viral ? drug effect ? failure of graft. stopped potential incriminating meds. d/w renal changed hydralazine to labetalol 100mg tid, stopped famotidine, stopped fluconazole and changed to mica iv, stopped metoclopramide and olanzapine prn. had bmbx - results awaited. transfused 2 units rcc hb 6.7/18.6 to 8.2/22.8. investigated dat -ve , hit ab pending, hapto normal, ldh normal smear -ve for schistocytes. started gcsf 300mcg qd. counts static. still requiring regular transfusions. bmbx . platelet count not increasing as of and labs sent for hla ab. ivig 0.4g/kg 25g one dose . gcsf was stopped on . . #gvhd: rash was present on back resolved. bili was high and decreased and remained stable. she initially had diarrhea initially which resolved. in the icu, cyclosporin levels were checked qam and cyclosporin was redosed if level <100 as per bmt recs. ivmp was continued in the icu. in the icu, the patient's t. bili and ap were initially elevated, but trended down during the patient's icu stay. likely the elevation was secondary to a medication effect vs gvhd. abdominal u/s found no biliary/gallbladder pathology. on her arrival in the icu, the patient was treated with voriconazole in the context of neutropenia and a possible pneumonia. this was stopped because of possible hepatotoxicity and micafungin was used instead. in the course post return rom the icu, we tapered iv methylpred and stopped on cyclosporin levels were taken daily and dose was adjusted accordingly. cyclosporin level aim was <100 in icu on renal advice and on transfer to the floor 100-150 but when renal function improved, this was increased to 150-200. restarted iv mp at 30mg qd. rash improving. changed to oral cyclosporin 11/4nd increased dose to 100mg and to 125mg on . level 263 on and reduced to 75mg . due to nausea, changed to cyclosporin iv 75mg . changed ivmp to oral prednisone 40mg qd and pred decreased to 20mg . changed tto cyclosporin 75/100 on . increased cyclopsorin to 100mg iv on and restarted ivmp 30mg . cyclosporin changed to 150mg and good level . increased to cyclosporin 175/150 on . . # pulmonary edema: respiratory decompensation dropped sats to 88% ra and now 94% on 2l o2 with initially high rr36 which also settled. bp maintained. but gradual over last 3 days - ct showed pulmonary edema and aggressively diuresed total 100mg iv furosemide . echo showed good lv function, mod mr/tr and pulmonary htn. further 100mg iv furosemide and to good effect and symptomatic improvement. isosorbide dinitrate 10mg tid started for decreasing afterload. if decompensates for further furosemide and trial of cpap +/- nitro iv infusion. her volume status improved and on , lasix was discontinued. . #cough and changing ggos on ct: persistent since admission ? cause ? reactive (asthma) ? secondary to fluid overload ? infectious started on regular albuterol nebs and incentive spirometer. pertussis -ve and ct-chest showed some change in ggos which have migrated. pulm consulteda dn felt wide differential. repeat ct chest 1 week and started cough suppressants with guaifensain/dextro qid regularly and added codeine prn which improved matters. f/u ct-chest - centrilobular ggo in lul suspicious for opportunistic infection - pulmonolary unimpressed and no current need for bronch. started oral levofloxacin and antibiotics changed to iv cefepime and given bowel concern. id reviewed and concerned re increased sob although not diuresed in past 2 days and found to have florid pulmonary edema by . she was initially continued on levofloxacin and then switched to cipro at discharge. diuresed sucessfully. . # acute pain: ? gvhd ? constipation. tender lower and voluntary guarding in rlq and r flank - eased by oxycodone. ct- /pelvis without contrast showed showed worsening ascites since prev film, no free air, fluid collection or abscess, no thickened bowel to suggest colitis (although no oral contrast) and no renal abnormalities or evidence of hematoma. antibiotics chaged to iv cefepime and metronidazoel (possible concern for c difficile given increased stool output) and negative. id recommended stopping iv cefepime and adding iv levofloxacin and keep iv metronidazole. generally resolved by with single episode . constipation was felt somewhat responsible. . # cmv reactivation: cmv vl 1070. started iv gancyclovir and increased to 2.5mg/kg on . no peripheral signs of cmv. given concerns for cmv with no other organ focus, seen by ophthalmology and evidence of retinal hemorrhage in supero-temporal field close to disc no evidence of cmv retinitis. will need repeat cmv levels on (one week from ). . # vaginal bleeding: noted to passing blood with clots through vagina while in icu stay in the setting of low platelets. she was evaluated by the gyn service who recommended vaginal u/s that showed thickened endometrial stripe concerning for endometrial neoplasm or other pathology. in the setting of her recent transplant and low platelets, no intervention at this time, but they recommended that she followup with a gynecologist after discharge. . #htn: given sah strict bp control was required. iv hydralazine to control. changed iv hydralazine 20mg to oral 50mg on . changed to oral labetalol and bp thus far controlled. medications on admission: 1. alprazolam 0.5 mg po qhs 2. butalbital-acetaminophen-caffein 50 mg-325 mg-40 mg tablet - 1 tablet po q4hr prn for headache (hasn't been using) 3. lorazepam 1-2 mg po qhs prn for insomnia 4. ferrous sulfate dose uncertain 5. folic acid dose uncertain discharge medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic qid (4 times a day). disp:*qs tube/bottle* refills:*2* 2. folic acid 1 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. labetalol 100 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. oxycodone 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain for 10 days. disp:*10 tablet(s)* refills:*0* 7. dapsone 25 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 8. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*30 tablet(s)* refills:*0* 9. cyclosporine modified 25 mg capsule sig: seven (7) capsule po qam: non-substitutable! please take 175mg (seven 25mg tablets) in the morning . disp:*210 capsule(s)* refills:*2* 10. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 11. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*10 tablet(s)* refills:*0* 12. ganciclovir 160 mg iv q12h 13. micafungin 100 mg recon soln sig: one (1) intravenous once a day. disp:*qs * refills:*2* 14. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. disp:*30 ml(s)* refills:*2* 15. cyclosporine modified 25 mg capsule sig: six (6) capsule po qpm: do not substitute. please take 150mg (six 25mg tablets) in the evening. disp:*180 capsule(s)* refills:*2* 16. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation prn as needed for shortness of breath or wheezing. disp:*1 * refills:*0* 17. multivitamin tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 18. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 19. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 20. prednisone 20 mg tablet sig: two (2) tablet po once a day for 4 days. disp:*8 tablet(s)* refills:*0* 21. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. disp:*14 tablet(s)* refills:*0* discharge disposition: extended care facility: - discharge diagnosis: primary: mds sibling allogenic stem cell transplant . secondary: pulmonary edema pneumonia respiratory failure require intubation acute renal failure requiring dialysis rash, granft versus host disease cmv infection treated with gancycolvir 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 sibling allogenic stem cell transplant. you received busulfan/cytoxan pre-conditioning therapy and your sister came in for collection of stem cells. . over the course of your transplant stay, you experienced some fevers and cough for which you received antiobiotics given that your white blood cell count was very low. you also received blood and platelets given your low red blood cell and low platelet counts. your course was complicated pulmonary edema and acute kidney injury for which you required transfer to the icu. you required intubated for respiratory failure in the setting of pulmonary edema (fluid in the lungs) and possible pneumonia. you also had fluid removed with dialysis given your acute kidney injury. you received supportive care and medications were given to help remove the excess fluid from your body in addition to dialysis. you symptoms improved, dialysis was able to be stopped and you were able to be transferred out of the icu and back to the regular bone marrow transplant floor. initially after coming out of the icu you experienced disorientation but this improved. you also had a fall out of your bed; ct scan was performed at that time which should a small amount of bleeding in your head. you were monitored and your symptoms improved. you also had a rash and abdominal pain concerning for rejection which improved with immunosuppressive medicatin. you received steriods and cyclosporin to prevent rejection of your transplant and will need to continue on these medications although they will likely need to be adjusted as you continue your recovery. you also received neupogen to help stimulate your bone marrow. . you also had post-menopausal vaginal bleeding. you were seen by gynecology and ultra sound showed thickened endometrial stripe that will need further gynecologic follow-up as an outpatient in the future. . the following changes were made to your medications: - please start taking prednisone 40 mg po daily - please start taking cyclosporine (neoral) 175 mg in the morning and 150mg in the evening. (ok for pharmacy to substitute with a generic form. - please start taking ganciclovir 160 mg iv every 12 hours. - please start taking dapsone 50 mg po/ng twice daily. - please start taking micafungin 100 mg iv daily. - please start taking ursodiol 300 mg twice a day. - please start taking omeprazole 40 mg daily. - please start taking multivitamins 1 tab daily. - please start taking cipro 500mg every 12 hrs for a total of 7 days (starting , last day ) - please continue to take all of your other home medications as prescribed please be sure to take all medication as prescribed. . please be sure to keep all follow-up appointments with your primary care phyisician, hematologist/oncologist and other healthcare providers. . it was a pleasure taking care of you and we wish you a speedy recovery. followup instructions: please be sure to keep all follow-up appointments with your primary care phyisician, hematologist/oncologist and other healthcare providers. . department: bmt/oncology unit when: sunday at 8:30 am building: fd building (/ complex) campus: east best parking: main garage . department: bmt chairs & rooms when: monday at 8:30 am . department: hematology/oncology when: monday at 8:30 am with: , rn building: sc clinical ctr campus: east best parking: garage md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Closed [endoscopic] biopsy of bronchus Injection or infusion of cancer chemotherapeutic substance Allogeneic hematopoietic stem cell transpant without purging Injection or infusion of biological response modifier [BRM] as an antineoplastic agent Transplant from live related donor Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Acute kidney failure with lesion of tubular necrosis Unspecified septicemia Severe sepsis Other specified forms of chronic ischemic heart disease Myelodysplastic syndrome, unspecified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Other shock without mention of trauma Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Paralytic ileus Other specified disorders of biliary tract Complications of transplanted bone marrow Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Drug induced neutropenia Other and unspecified coagulation defects Myelofibrosis Splenomegaly Other specified noninflammatory disorders of vagina Retinal hemorrhage Other specified erythematous conditions Acute graft-versus-host disease Fever presenting with conditions classified elsewhere Cough Other specified aplastic anemias Transfusion associated circulatory overload

allergies: no known allergies / adverse drug reactions attending: chief complaint: pancreatitis, diverticulitis major surgical or invasive procedure: none history of present illness: 60 yom with hld, history of etoh use admitted to for epigastric pain on , found to have pancreatitis by imaging and labs. initial labs at was notable for wbc of 16, hct of 43, plt of 265, alt/ast of 133/217, lipase of > 1000. prior to transfer, labs were notable for a wbc of 20 (11% band), downward trending lfts. ct/mrcp were performed at osh - ct showed pancreatitis and mild sigmoid diverticulitis. mrcp showed 2-3mm nonobstructing intrapancreatic common bile duct filling defect(approx 1.8cm proximal to the ampulla). egd was performed, showing gastroparesis with ? ileus secondary to panreatitis, no other lesions, noted pancreatitis. clinically, he had worsening pain control and require pca and micu admission at . he was transferred to for ercp. . on the floor, he appeared mild-moderate distress. report no bm/passing gas for the past few days. past medical history: hld asthema h/o dvt h/o factor v leiden deficiency h/o left knee surgery 1 yr ago social history: - tobacco: none - alcohol: drink alcohol moderately - illicits: none married with two children. former truck driver and has not worked for a year due to left knee surgery (injury at work) family history: non-contributory physical exam: vitals: t: 99 bp:147/80 p:114 r: 18 o2:98 4l general: alert, oriented, in moderate 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: tender, distended, bowel sounds present, + rebound tenderness and guarding, worse on the left side, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical: physical exam: vitals: 98.6 148/73 89 16 95ra general: alert, oriented, nad heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: mild bibasilar rales, -w/r cv: regular rate and rhythm, normal s1 + s2, -m/r/g abdomen: +bs, soft ntnd no rebound, tympanic to percussion throughout ext: + pitting edema bilaterally pertinent results: 11:58am blood wbc-17.0* rbc-3.88* hgb-12.1* hct-34.9* mcv-90 mch-31.1 mchc-34.5 rdw-13.0 plt ct-249 11:52pm blood wbc-15.6* rbc-3.94* hgb-12.3* hct-35.9* mcv-91 mch-31.3 mchc-34.3 rdw-13.1 plt ct-238 04:39am blood wbc-15.7* rbc-3.96* hgb-12.3* hct-35.9* mcv-91 mch-30.9 mchc-34.1 rdw-13.0 plt ct-267 03:45am blood wbc-16.4* rbc-3.92* hgb-11.9* hct-35.2* mcv-90 mch-30.5 mchc-33.9 rdw-13.0 plt ct-288 06:08am blood wbc-17.2* rbc-3.76* hgb-11.5* hct-33.3* mcv-89 mch-30.7 mchc-34.6 rdw-13.0 plt ct-288 05:45am blood wbc-19.1* rbc-4.03* hgb-12.3* hct-35.1* mcv-87 mch-30.5 mchc-35.1* rdw-13.2 plt ct-294 05:47am blood wbc-17.3* rbc-4.06* hgb-12.3* hct-35.4* mcv-87 mch-30.4 mchc-34.9 rdw-13.4 plt ct-279 05:55am blood wbc-16.2* rbc-4.12* hgb-12.7* hct-35.7* mcv-87 mch-30.9 mchc-35.6* rdw-13.7 plt ct-268 05:33am blood wbc-16.9* rbc-3.88* hgb-12.2* hct-33.8* mcv-87 mch-31.5 mchc-36.1* rdw-13.6 plt ct-260 06:08am blood wbc-19.6* rbc-3.94* hgb-11.9* hct-33.8* mcv-86 mch-30.3 mchc-35.2* rdw-14.0 plt ct-255 11:58am blood neuts-88.9* lymphs-3.8* monos-5.9 eos-1.3 baso-0.1 04:39am blood neuts-94.4* lymphs-2.6* monos-2.7 eos-0.2 baso-0 05:47am blood neuts-84* bands-1 lymphs-5* monos-5 eos-3 baso-1 atyps-0 metas-1* myelos-0 05:33am blood pt-14.2* ptt-37.0* inr(pt)-1.2* 06:08am blood pt-15.1* ptt-38.6* inr(pt)-1.3* 05:47am blood glucose-124* urean-8 creat-0.6 na-143 k-3.2* cl-104 hco3-32 angap-10 05:55am blood glucose-85 urean-10 creat-0.6 na-141 k-3.2* cl-101 hco3-32 angap-11 05:33am blood glucose-88 urean-9 creat-0.6 na-139 k-3.6 cl-100 hco3-32 angap-11 06:08am blood glucose-96 urean-6 creat-0.6 na-141 k-3.7 cl-103 hco3-30 angap-12 11:58am blood alt-46* ast-24 ld(ldh)-239 alkphos-73 amylase-151* totbili-0.7 04:39am blood alt-38 ast-23 alkphos-69 amylase-75 totbili-0.6 03:45am blood alt-35 ast-21 ld(ldh)-330* alkphos-66 totbili-0.4 06:08am blood alt-26 ast-15 ld(ldh)-226 alkphos-54 amylase-39 totbili-0.4 11:58am blood lipase-86* 04:39am blood lipase-42 06:08am blood lipase-27 06:08am blood calcium-8.2* phos-3.3 mg-2.1 05:57pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-10 bilirub-neg urobiln-neg ph-7.0 leuks-tr ruq u/s: 1. nodular irregularity of the gallbladder wall, incompletely evaluated. no mobile shadowing stones are identified. if the patient has not been fasting, repeat ultrasound after fasting may be obtained, otherwise further evaluation with mri to exclude polyposis or potential gallbladder malignancy is recommended. 2. echogenic liver compatible with fatty deposition. other forms of liver disease, including significant hepatic cirrhosis/fibrosis cannot be excluded on this examination. 3. extrahepatic cbd cannot be reliably identified. there is suggestion of central biliary dilation. ctpa: 1. pe involving the right lower lobe branch of the pulmonary artery without evidence right heart strain. 2. bilateral moderate pleural effusions with compressive atelectasis. 3. small right upper lobe opacity - inflammatory versus infectious etiologies may be considered. mrcp: 1. no significant change in pancreatic edema due to known pancreatitis. small acute fluid collections surrounding the pancreatic body and tail have increased from . no necrosis. 2. no wall nodularity or obvious filling defect in the gallbladder. 3. tapering of the common bile duct as it enters the pancreatic head is likely secondary to edema, with minimal central ductal dilatation. no peripheral intrahepatic biliary ductal dilatation. 4. fullness of the left renal collecting system is unchanged from . cxr (): semi-upright ap view of the chest: lung volumes are diminished. within this limitation, there is no new focal consolidation. there is no large pleural effusion although probable small left pleural effusion is present. there is no pneumothorax. cardiomediastinal silhouette is similar to prior. vascular congestion has decreased. right-sided picc follows normal course terminating in the lower svc. brief hospital course: 60 yom with hld, history of etoh use admitted to for epigastric pain on , found to have pancreatitis by imaging and labs, transferred for ercp. . # pancreatitis: etiology likely due to etoh due to history and lack of other causes. initially at had lipase >1000 and a ct scan with evidence of pancreatic edema and fat stranding. mrcp showed no cbd dilation or filling defect to suggest stone. ruq u/s without evidence of stone although the study was poor due to body habitus. triglycerides normal. not on medications that can cause pancreatitis. did not undergo ercp in house as his lfts normalized at admission and imaging did not suggest a retained stone. was treated symptomatically with dilaudid for pain control originally requiring a pca and eventually being weaned to minimal narcotics. there was also an ileus due to likely a combination of pancreatitis and narcotics; he began stooling after transfer from the micu. imaging did not show evidence of necrosis. he began taking clears on day 9 without pain, and was advanced to full diet without pain by the time of discharge. he was counseled regarding abstinence from alcohol as this was likely the cause of his pancreatitis. . # diverticulitis: on admission to pt had abdominal ct that showed some evidence of mild sigmoid diverticulitis and had a normal wbc count. by the time of transfer to 3 days later, he had severe llq pain with a wbc count of 20k and 22% bandemia. he was started on cipro/flagyl at osh and maintained for a 7 day course in house here (unclear when started cipro/flagyl at osh). his pain resolved relatively quickly in the micu here, and upon transfer to the floor a few days later had resolved. . # pulmonary embolism: on transfer to , the patient was noted to be tachycardic and hypoxic. initially due to his history of asthma, he was treated here with steroids and nebulizers. when his symptoms did not resolve, and due to his history of factor v leiden, a ctpa was ordered which showed a rll embolus. he was started on a heparin drip, changed to lovenox and eventually transitioned to coumadin. of note, 1 year prior he had a tka and a dvt. during that workup, he was found to be factor v leiden positive. he will likely need lifelong anticoagulation as this is his second event. he was discharged with lovenox to bridge to coumadin. . # electrolyte abnormalities: during his floor stay, he had multiple days of hypokalemia and hypophosphatemia requiring replacement, which resolved by the time of discharge. he will have a chem7 drawn as an outpatient 5 days after discharge to be faxed to his pcp to make sure he does not have any recurrant electrolyte abnormalities. . # leukocytosis: persistently elevated wbc count throughout admission. per osh records, pt presented with a normal wbc count that trended up to 20 with 22% bandemia prior to transfer secondary to diverticulitis. originally this was thought secondary to his asthma treatment with po steroids, however the wbc count did not resolve. at the time of discharge, he has continued to be afebrile and does not endorse any infectious symptoms. chest xray was negative for infiltrate. likely it is from a stress reaction to his admission diagnoses, however he will have a cbc in 5 days as an outpatient to reassess. medications on admission: liptor 10mg dialy advair 250/50 one puff albuterol discharge medications: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) puff inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. lipitor 10 mg tablet sig: one (1) tablet po once a day. 4. enoxaparin 120 mg/0.8 ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*14 * refills:*0* 5. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* 6. outpatient lab work please draw cbc, pt, ptt, inr, sodium, potassium, chloride, bicarbonate, bun, creatinine and glucose, and fax the results to to the attention of dr. . 7. vicodin 5-500 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. disp:*42 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: pancreatitis diverticulitis pulmonary embolism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at . you were transferred from another hospital for pancreatitis. it is unclear what caused your pancreatitis however it was likely due to alcohol consumption. you should not drink alcohol for at least 6 months if not longer. we looked for gallstones as a cause, however we did not see any. you were also found to have a pulmonary embolism, which is a blood clot in your lungs. you do have a history of a clotting disorder which makes you more susceptible to clots. you are being discharged on lovenox and coumadin, and you will need to follow-up with your primary care physician to discuss whether you should be on lifelong blood thinners. you will also need to follow-up with your primary care physician to make dosage changes to your coumadin. you also were found to have diverticulitis. it was found on a ct scan of your abdomen on your admission to . over the course of your stay at , it got progressively worse. we treated you with iv antibiotics for 7 days while you were here. you might need follow-up with a gastroenterologist to discuss your pancreatitis and diverticulitis, however we will leave it to the discretion of your primary care physician whether he feels you need follow-up. please make the following changes to your medications: please start: coumadin 5mg by mouth once per day lovenox 120mg injection twice per day vicodin 1-2 tabs by mouth every six hours as needed for pain otherwise take your medications as prescribed. please get bloodwork from your pcp's office either thursday or friday of this week to check for your white blood cell count elevation and your inr (a measure of your coumadin level). you will likely need changes to your coumadin dosing as an outpatient that your pcp will make. followup instructions: name: , b. location: internal medicine associates address: , , , phone: appt: at 11:15am Procedure: Central venous catheter placement with guidance Diagnoses: Unspecified essential hypertension Asthma, unspecified type, unspecified Other and unspecified hyperlipidemia Knee joint replacement Other pulmonary embolism and infarction Acute pancreatitis Diverticulitis of colon (without mention of hemorrhage) Congenital deficiency of other clotting factors

allergies: no known allergies / adverse drug reactions attending: chief complaint: severe abdominal pain nausea and vomiting major surgical or invasive procedure: : 1. ultrasound-guided puncture of right common femoral vein. 2. ipsilateral catheterization of right iliac vein. 3. inferior vena cavogram. 4. deployment of cook celect inferior vena cava filter at the mid body of l3. history of present illness: 60m discharged following 11 day admission for pancreatitis and concurrent uncomplicated diverticulitis now presenting with 1 day of severe abdominal pain, nausea and vomiting. patient s/p recent admission for pancreatitis thought to be related to etoh use given negative biliary workup. admission was also notable for 7 days of cipro/flagyl for uncomplicated diverticulitis and diagnosis of rll pe for which he was started on coumadin with lovenox bridge. discharged tolerating regular diet with minimal narcotic requirement for pain. now returns with onset of severe 8 to abdominal pain inferior to epigastrium. pain accompanied by nausea and two episodes of bilious, non-bloody emesis. passing flatus and bms per baseline. denies fever, chills, headache, chest pain, shortness of breath, constipation, diarrhea, dysuria. past medical history: hld asthema h/o dvt h/o factor v leiden deficiency h/o left knee surgery 1 yr ago social history: - tobacco: none - alcohol: drink alcohol moderately - illicits: none married with two children. former truck driver and has not worked for a year due to left knee surgery (injury at work) family history: non-contributory physical exam: on admission: vs: t: 98.4 p: 104 bp: 126/84 rr: 16 o2sat: 98ra gen: wd, obese m in nad heent: ncat, eomi, anicteric cv: rrr, +s1s2 w no m/r/g pulm: cta b/l, no respiratory distress abd: soft, +severe tenderness to light palpation in b/l lower abdomen, +distended, +periumbilical ecchymoses at sites lovenox injections pelvis: deferred ext: wwp, no cce, 2+ b/l dp neuro: a&ox3, no focal neurologic deficits on discharge: vs:.................. gen: obese, nad cv: rrr, no m/r/g pulm: diminished b/l on bases abd: soft, distended, tender on deep palpation extr: 2+ b/ pertinent results: 02:09am blood wbc-49.1*# rbc-3.34* hgb-10.4* hct-29.2* mcv-87 mch-31.0 mchc-35.5* rdw-13.9 plt ct-446* 06:00pm blood glucose-150* urean-30* creat-1.9* na-134 k-5.4* cl-106 hco3-20* angap-13 12:22pm blood alt-16 ast-26 alkphos-54 12:22pm blood calcium-8.0* phos-4.7* mg-2.7* 07:55am blood wbc-16.1* rbc-3.54* hgb-10.3* hct-30.8* mcv-87 mch-29.0 mchc-33.4 rdw-14.4 plt ct-534* 07:55am blood glucose-95 urean-13 creat-0.6 na-138 k-3.7 cl-99 hco3-31 angap-12 04:50am blood alt-17 ast-24 alkphos-50 amylase-36 totbili-1.0 07:55am blood calcium-8.2* phos-2.9 mg-1.9 8:32 pm mrsa screen source: nasal swab. **final report ** mrsa screen (final ): positive for methicillin resistant staph aureus. 8:30 am blood culture **final report ** blood culture, routine (final ): no growth. 3:10 pm urine source: catheter. **final report ** urine culture (final ): no growth. 3:50 pm stool consistency: not applicable **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 3:59 pm catheter tip-iv source: r. ij cvl. **final report ** wound culture (final ): no significant growth. abd ct: impression: 1. findings suggestive of hemoperitoneum with site of active contrast extravasation within a new hematoma within the left upper quadrant of the abdomen. recommend dedicated arterial and delayed contrast-enhanced ct images of the abdomen for further characterization. 2. worsened pancreatitis from most recent imaging by mrcp on with interval development of multiple peripancreatic fluid collections compatible with pseudocysts. there is no evidence of pancreatic necrosis and no pseudoaneurysms or thromboses are identified in the peripancreatic vasculature. 3. small bilateral pleural effusions unchanged from mrcp on but new from the ct on . 4. colonic and sigmoid diverticula with no evidence of diverticulitis. 5. no evidence of bowel obstruction. 6. hemoperitoneum with a site of active extravasation identified within a hematoma in the left upper quadrant. abd ct: impression: 1. increase in size of a component of a complex pseudocyst, with increased internal density, findings that are consistent with continued interval hemorrhage within a pseudocyst. however, the previously demonstrated active extravasation is no longer visualized. this finding discussed with dr. on via telephone at the time of dictation, approximately 4:30 pm. 2. findings consistent with post-pancreatitis change including multiple peripancreatic pseudocysts. no evidence of definitive pancreatic necrosis. 3. findings consistent with colitis, likely reactive. 4. ivc filter in place. phase of contrast administration limits assessment for patency of the ivc. 5. bilateral pleural effusions, slightly increased on the right. leni: impression: 1. non-occlusive thrombus the right superficial femoral and popliteal veins. 2. no dvt in the left leg. brief hospital course: the patient, who was recently discharge () after 11 days hospitalization secondary to acute pancreatitis and rrr pe, was readmitted to with recurrent abdominal pain, nausea and vomiting. the patient was started on coumadin/lovenox during last admission for pe treatment. on admission, patient's inr = 2.3, hct = 35.9, amylase 55 and lipase = 65. ct scan revealed hemoperitoneum with a site of active extravasation identified within a hematoma in the left upper quadrant, worsened pancreatitis and colonic and sigmoid diverticula with no evidence of diverticulitis. the patient's lovenox and coumadin was discontinued. on , the patient underwent ivc filter placement and placed in icu to continue care. on (hd # 2), the patient's hct fell down to 20.6, he received 3 units of prbc, post transfusion hct 27.6. inr was 2.7, patient was given 2 units of ffp and vit k, inr down to 2.0. on hd # 3 (), patient receive 2 u of rbc for hct 23.4 and 1 unit of ffp for inr 2.1, post transfusion hct 26.9, inr 1.8. nutrition consult was called and tpn was started on hd # 3 via r ij. on hd # 2, patient's wbc was 49.1, he was pan cultured and started on broad spectrum antibiotics (vancomycin, flagyl and ceftriaxone). on hd # 5, patient was stable (hct 26, inr 1.5, wbc 15.0), the patient was transferred on the floor npo, tpn, and antibiotics, with a foley catheter, and dilaudid iv for pain control. the patient was hemodynamically stable. neuro: the patient received dilaudid iv with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications. cv: the patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. pulmonary: chest radiograph revealed small bilateral pleural effusions on admission. good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. the patient remained stable from pulmonary standpoint. gi/gu: the patient was made npo with iv fluids on admission. tpn was started on hd # 3 and was continued to hd # 7. repeat abdominal ct scan on hd # 6, showed increased size of hemorrhagic pancreatic pseudocyst without active extravasation. the patient's diet was advanced to clears. diet was advanced when appropriate to low fat regular, which was well tolerated. patient's intake and output were closely monitored. electrolytes were routinely followed, and aggressively repleted. the patient had moderate diarrhea after admission, which though to be secondary to colon inflammation from direct contact with the pseudocyst. during hospitalization diarrhea improved, and prior discharge patient had normal bowel movements. the foley catheter was discontinued at midnight of pod# 6. the patient subsequently voided without problem. id: the patient's wbc was monitored daily, he picked wbc was 49.1 on hd # 2, and he was started on iv abx. blood, urine and ij tip cultures were negative. antibiotics were changed on hd # 4 to flagyl and ciprofloxacin with total course x 10 days. endocrine: the patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. hematology: the patient's complete blood count was examined routinely; no transfusions were required. prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: liptor 10', advair 250/50 1puff'', coumadin 5', lovenox 120'', vicodin q6h prn discharge medications: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) puffs inhalation (2 times a day). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 6. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 7. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 8. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 9. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 4 days: please stop after . disp:*12 tablet(s)* refills:*0* 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 6 days: stop after . disp:*12 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. recurrent pancreatitis. 2. hemorrhagic pancreatic pseudocyst 3. right lower extremity deep venous thrombosis with history of prior pulmonary embolism. 4. factor v leiden deficiency discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. please follow up with dr. (pcp) on monday between 8:30 and 9:30 am to check you pt/inr level and hct. followup instructions: provider: , md phone: date/time: 12:45 , . provider: scan phone: date/time: 9:30. please arrive to radiology department at 8:30. do not eat or drink 4 hours prior the scan. provider: , md phone: date/time: 10:15 3, . please follow up with dr. (pcp) on monday between 8:30 and 9:30 am to check you pt/inr level. Procedure: Parenteral infusion of concentrated nutritional substances Interruption of the vena cava Arterial catheterization Angiocardiography of venae cavae Central venous catheter placement with guidance Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Acute posthemorrhagic anemia Asthma, unspecified type, unspecified Other and unspecified hyperlipidemia Long-term (current) use of anticoagulants Primary hypercoagulable state Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Other pulmonary embolism and infarction Acute pancreatitis Cyst and pseudocyst of pancreas

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: mitral repair (28mm annuloplasty band), coronary artery bypass graft x 3(lima-lad,svg-pda,svg-om) history of present illness: 61 y/o female with increased dyspnea on exertion with recent echo concerning for moderate mitral regurgitation. underwent cardiac cath which revealed three vessel coronary artery disease. patient was then referred for surgery. past medical history: left arm cellulitis right shoulder injury, chronic right shoulder pain no known cad chronic systolic heart failure social history: patient is a psychologist. has a 13 year old son. notes 45 pack year history of smoking. trying to quit. notes etoh use of 3 glasses/evening. denies cocaine use. family history: family history of diabetes, stroke. denies any history of sudden cardiac death. physical exam: vs: 78 18 143/80 5'5" 188lbs gen: nad skin: unremarkable heent: eomi, perrl, ncat neck: supple, from -jvd chest: ctab -w/r/r heart: rrr -c/r/m/g abd: soft, nt/nd, +bs ext: warm, well-perfused, -edema neurp: a&o x 3, mae, non-focal pertinent results: echo: pre bypass: the left atrium is moderately dilated. overall left ventricular systolic function is mildly depressed (lvef= 30%). right ventricular chamber size and free wall motion are normal. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate to severe (3+) mitral regurgitation is seen with pressures 140 mm hg systolic. mr jet is central. vena contracta goes from 5 mm at sbp 110 mm hg to 7 mm at sbp 140 mm hg. reguritant volume by pisa 27 cc (hr 66, co 4.5 l/, regurgitant fractioni 40%) post bypass: the patient is a -paced and an infusion of epinephrine. biventricular function is preserved. there is a mitral valve ring in situ. it appears well seated and has mild residual regurgitation (vena contracta 3mm). the mean gradient was mmhg across the mitral valve. the aorta is intact. the remainder of the exam is unchanged. 06:25am blood wbc-6.9 rbc-2.57* hgb-8.2* hct-24.0* mcv-94 mch-31.8 mchc-33.9 rdw-13.7 plt ct-197 01:41pm blood pt-14.2* ptt-40.1* inr(pt)-1.2* 05:25am blood glucose-103 urean-45* creat-1.5* na-136 k-4.0 cl-90* hco3-38* angap-12 , f 61 radiology report chest (pa & lat) study date of 10:49 am , fa6a sched chest (pa & lat) clip # reason: f/u rll opacity final report history: 61-year-old woman with status post mitral valve replacement. followup right lower lobe opacity. technique: pa and lateral chest radiograph. comparison: compared to chest radiograph from . findings: the right lower lobe opacity has improved with almost complete resolution. there is a small remaining right discoid atelectasis at the right lung base. the discoid atelectasis in the left mid lung has improved in appearance and is now just remaining small streak of atelectasis. there is no pleural effusion. there are surgical changes from midline sternotomy with normal alignment of the sternal wire. the heart size is enlarged and unchanged. impression: interval improvement in the right lower lobe opacification, with almost complete resolution. small discoid atelectasis in the right lung base. tiny atelectasis in the left mid lung. no pleural effusion. the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 6:32 pm brief hospital course: ms. was a same day admit after undergoing all pre-operative work-up prior to day of surgery. on she was brought directly to the operating room where she underwent a mitral valve repair and coronary artery bypass graft x 3. please see operative report for surgical details. following surgery patient was transferred to the cvicu for invasive monitoring in stable condition. within 24 hours she was weaned from sedation and awoke neurologically intact. on post-op day one she was started on beta blockers and diuretics and transferred to the telemetry floor for further care. chest tubes and epicardial pacing wires were removed per protocol. she continued to progress very slowly with pt and was transfused 2uprbc on pod 6 for a hct of 22. she was discharged to home in stable condition on pod#8. her creat. was 1.9 and will be rechecked on fri. by the vna. medications on admission: aspirin 325mg qd, toprol xl 25mg , simvastatin 80mg qd, lasix 80mg qd, colace 100mg 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. 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. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 4. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 5. metoprolol succinate 50 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* 6. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: mitral regurgitation, coronary artery disease s/p mitral valve repair and coronary artery bypass graft x 3 diastolic heart failure systolic heart failure discharge condition: good discharge instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions report any fever greater than 100.5,redness of, or drainage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed no driving for 4 weeks and off all medications no lifting more than 10 pounds for 10 weeks followup instructions: dr. in 4 weeks () dr. in weeks () dr. in 2 weeks () please call for appointments Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnostic ultrasound of heart Open heart valvuloplasty of mitral valve without replacement Diagnoses: Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Chronic combined systolic and diastolic heart failure

allergies: penicillins / codeine / phenergan / pineapple / ibuprofen attending: chief complaint: back and abd pain, mrcp with biliary dilation and ? ipmn major surgical or invasive procedure: ercp with sphincteroromy history of present illness: 63f h/o severe copd on 4.5l 02 at home, insulin dependent diabetes type 2, obesity, afib on coumadin, hypertension, hyperlipidemia, presented to on with lower chest pain and epigastric pain and is transferred to for cosnideration of ercp. her hospital course is significant for mrcp with prominent intrahepatic dilatation, without change from and mild dilated pancreatid duct and transaminitis. she had a tte with ef 55 and mild mr , chest cta neg for pe but with compression fracture of thoracic spine. her coumadin was held but given yesterday so vit k po given this am with last inr of 1.42. currently she complains of severe pain diffusely, including mid-back. she is not more sob than her usual. she has new l leg swelling. she denies vomiting, or diarrhea. she does not relate abdominal pain to meals, food, or activity. she can walk slowly and prepare meals but is dyspnic with any stairs. she denies chest pressure. complete 13 point ros is negative except for the above items. past medical history: copd --4.5l home 02 and chronic home prednisone osa on nocturnal bipap afib on coumadin htn hl prior cath in with clean coronaries and per report neg stress in obesity gerd diabetes type 2 on insulin chronic pain, nos anxiety s/p ccy and appendectomy social history: former smoker lives with daughter etoh: unclear history family history: not relevant to current admission physical exam: admission physical exam: 98.3, 131/79 92, 94% 4l obese, multiple bruises on extremities speaking in full sentences, no resp distress heent: unremarkable neck supple irreg, soft systolic murmur at apex distant bs, no audible wheeze, prolong exp tender across mid back with heating packs applied abd soft non-tender +bs significant l>r leg edema with serous fluid weaping r chest port, appears clean and intact neuro exam non-focal, speech clear, did not assess gait mood: anxious discharge physical exam: gen: nad cv: rrr, nl s1 s2, no murmurs pulm: bronchial breath sounds at apices, otherwise ctab abd: soft, nt/nd, nabs extrem: 1+ pitting edema to mid-calf bilaterally skin: ~8-10cm area of warmth, blanching erythema on l anterior shin. pertinent results: osh studies significant for #chest cta no pe but with multiple chronic-appearing thoracic compression fractures --need f/u of l kidney masses? #ekg with afib, normal axis, inferior twi, #mrcp with prominent intra-hepatic and extrahepatic biliary ductal dilatation not significantly changed from , no choledocolithaisis, mildly dilated main pd, 2 cystic lesions, suggestive of ipmn, 16mm l hepatic cyst, bil renal cysts . admission labs: 07:50pm glucose-117* urea n-14 creat-0.7 sodium-140 potassium-3.8 chloride-93* total co2-43* anion gap-8 07:50pm alt(sgpt)-45* ast(sgot)-17 ld(ldh)-253* alk phos-159* tot bili-0.3 07:50pm ck-mb-2 ctropnt-<0.01 07:50pm albumin-3.8 calcium-8.9 phosphate-3.1 magnesium-2.4 07:50pm digoxin-0.6* 07:50pm wbc-12.4* rbc-3.81* hgb-12.5 hct-36.1 mcv-95 mch-32.9* mchc-34.8 rdw-13.5 07:50pm neuts-84.0* lymphs-12.2* monos-3.2 eos-0.4 basos-0.2 07:50pm pt-15.4* ptt-23.8 inr(pt)-1.3* . studies: cxr ()-impression: emphysema. subsegmental atelectasis in the left lung base. compression deformity of a mid thoracic vertebral body, likely chronic. . leni ()- no dvt in left lower extremity. . ercp (): procedures: a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. impression: severe biliary dilation with cbd measuring 20 mm, with findings consistent with severe sphincter stenosis. sphincterotomy was successfully performed otherwise normal ercp to third part of the duodenum ekgs: ekg at : afib, rate 120, normal axis, normal qrs and qt intervals. twi in ii, iii, avf. 1-2mm std in v2-v6. . ekg at during episode of cp: poor study. afib rate 96, na, normal qrs and qt intervals. ? twi in ii, iii, avf. qmm st depressiions in v2-v6. . ekg at when std seen on telemetry: a-fib rate 72, na, normal qrs and qt intervals. 1mm st depressions in ii, iii, avf, and v4-v5. brief hospital course: primary reason for hospitalization: 63f h/o severe copd on 4.5l 02 at home, insulin dependent diabetes type 2, obesity, afib on coumadin, hypertension, hyperlipidemia, presented to on with lower chest pain and epigastric pain and is transferred to for ercp. active diagnoses: #biliary ductal dilatation, sphincter stenosis: appeared stable per mrcp report compared with images from , but she has periods of transient elevation in lfts. ercp revealed both significant ductal dilation and sphincter stenosis. the latter was treated with sphincterotomy. lfts improved during hospitalization. patient was told she should follow-up on lfts as outpatient. #afib: currently rate controlled. anti-coagulation was held for the procedure and for 5 days thereafter per gi recommendations. (plan to restart coumadin on ) other cardiovascular medications were continued with no significant perturbation in hr or bp. #copd: the patient has a high o2 requirement at home (4.5l nc), and initial evaluation for procedure was concerning for respiratory function. following ercp, she remained intubated for roughly 18 hours. she was extubated the morning of with good results. home prednisone dose was continued. was told to f/u w/ pcp re need for pjp ppx given chronic steroids. #l lower extremity erythema: consistent with underlying venous stasis and superimposed cellulitis, given warm, blanching erythema. started on antibiotics (doxycycline) and told to f/u with pcp. #chest pain: on the evening of admission () she complained of chest pain that was different from her epigastric pain. notably, she has had a clean cath in and negative stress test in . ekg was largely stable from prior at , both of which showed diffuse downsloping st elevations consistent with digitalis effect. pain improved with nitro sl and she was given diltiazem for rate control. cardiac enzymes were negative x3. a f/u ekg on was again consistent with digitalis effect. #back pain: thoracic compression fx, likely secondary to chronic steroid use. home pain regimen continued. patient was told to follow-up with her pcp regarding her bone density and possible osteoperosis. she was continued on ca/vit d. chronic diagnoses: #osa: following extubation, nocturnal bipap was continued per home regimen. #diabetes type 2, complicated: home insulin regimen continued, with adjustment as appropriate while npo. #kidney masses: nos, found on cta of chest, but mrcp of abdomen only described bilateral simple renal cysts. the patient was told to follow-up on this issue with her pcp. transitional issues: code status: full (confirmed) patient was told to schedule an appointment with her pcp to lfts, her antibiotic course, bone density, and kidney masses found on cta. medications on admission: medications at home: - coumadin 5mg daily - simvastatin 20mg daily - budesonide - ipratroprium nebs qid - formoterol 1 inh - carisoprodol 350mg - digoxin 0.25mg daily - diltiazem 360mg daily - furosemide 40mg daily - glargine 30u qhs - humalog ss - prednisone 10mg daily - levothyroxine 25mcg daily - liododerm patch - calcium/vit d - omeprazole . prns: - diphenhydramine 25mg prn restlessness - apap - milk of magnesia - oxazepam 30mg prn insomnia - miralax - albuterol - oxycodone 5-10mg q4h prn pain - colace 100mg - guaifenesin - lorazepam 2mg tid - simethicone 150mg . medications on transfer from osh: - budesonide 0.5mg nebs - duonebs qid - formoterol 1 inh - albuterol nebs q2h prn - prednisone 20mg daily - calcium/vit d 1 tab - digoxin 0.125mg daily - diltiazem 360mg daily - furosemide 40mg daily - glargine 43u qhs - levothyroxine 25mcg daily - pantoprazole 40mg po daily - sucralfate 1 g po qac & qhs - simethicone 160mg - guaifenesin 600mg - lorazepam 2mg tid - oxazepam 30mg qhs prn insomnia - carisoprodol 350mg - oxycodone 15-20mg po q4h prn pain - 5% lidocaine patch-- two patches daily - colace 100mg - dulcolax 10mg prn - miralax 17g daily - milk of magnesia 10ml po daily discharge medications: 1. coumadin 5 mg tablet sig: one (1) tablet po once a day: please restart taking coumadin on . 2. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 3. budesonide 3 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po at bedtime. 4. ipratropium bromide 0.02 % solution sig: puff inhalation four times a day as needed for shortness of breath or wheezing. 5. digoxin 125 mcg tablet sig: two (2) tablet po daily (daily). 6. diltiazem hcl 90 mg tablet sig: four (4) tablet po once a day. 7. furosemide 40 mg tablet sig: one (1) tablet po once a day. 8. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain: do not exceed 4grams of acetaminophen daily. tablet(s) 9. insulin glargine 100 unit/ml solution sig: thirty (30) units subcutaneous at bedtime. 10. humalog 100 unit/ml solution sig: sliding scale subcutaneous with meals. 11. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 12. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 13. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: adhesive patch, medicateds topical daily (daily). 14. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po bid (2 times a day). 15. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 16. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 17. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) grams po daily (daily). 18. lorazepam 1 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for anxiety. 19. doxycycline hyclate 100 mg capsule sig: one (1) capsule po q12h (every 12 hours) for 10 days. 20. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 21. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 22. carisoprodol 350 mg tablet sig: one (1) tablet po bid () as needed for msk pain. 23. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: puff inhalation every four (4) hours as needed for wheezing. 24. ipratropium bromide 0.02 % solution sig: inh inhalation q6h (every 6 hours) as needed for wheezing. 25. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for flatulence. 26. mucinex 600 mg tablet extended release sig: one (1) tablet extended release po twice a day. 27. milk of magnesia 400 mg/5 ml suspension sig: ten (10) ml po once a day. 28. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po once a day as needed for restlessness. 29. formoterol fumarate 12 mcg capsule, w/inhalation device sig: one (1) inh inhalation twice a day. discharge disposition: home with service facility: vna assoc. of discharge diagnosis: copd spincter of oddi stenosis transaminitis dm2 atrial fibrillation cellulitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , it was a pleasure taking care of you at . you were transferred here from an outside hospital for a procedure called an ercp to evaluate your stomach pain, liver function test abnormalities, and a suspicion of ipmn seen on imaging. during the ercp procedure, sphincter stenosis (narrowing) was found, which was likely the cause of or liver function abnormalities. a sphincterotomy was performed to treat that narrowing, and your liver tests improved thereafter. when you were admitted, you also had a warm, red area on your left leg that was felt to be a skin infection called cellulitis. you were started on antibiotics for this infection. you also had chest pain while you were here, but were found not to have a heart attack. medication changes: - started doxycycline an antibiotic for your left leg cellulitis, which you should take for 10 days - restart your coumadin at your regular dose of 5mg daily on . this medication was not given to you in the hospital because we were afraid you might bleed after the spincterotomy. . please take all of your other medications as prescribed and follow up with the appointments below. followup instructions: please follow-up this hospitalization with your primary care doctor, dr. , by calling to make an appointment within 2 weeks. you should discuss the following with your primary care doctor: 1) resume coumadin for your atrial fibrillation on 2) have your primary care doctor look at your left leg to ensure the infection we are treating you for is improving, and that you do not need additional antibiotics. 3) discuss whether you need to be taking antibiotics to prevent pneumonia given that you have been on steroids as an outpatient (bactrim would be the most likely antibiotic). md Procedure: Endoscopic sphincterotomy and papillotomy Diagnoses: Unspecified essential hypertension Adrenal cortical steroids causing adverse effects in therapeutic use Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Atrial fibrillation Personal history of tobacco use Other and unspecified hyperlipidemia Anxiety state, unspecified Long-term (current) use of insulin Long-term (current) use of anticoagulants Other specified disorders of biliary tract Obesity, unspecified Hyperosmolality and/or hypernatremia Obstruction of bile duct Pathologic fracture of vertebrae Other dependence on machines, supplemental oxygen

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hcv here for orthotopic liver major surgical or invasive procedure: : orthotopic liver history of present illness: 50 yo male w/hx hcv (genotype 1) cirrhosis c/b hcc with 2.7 cm mass s/p rfa ablation in with recent admit for ruq pain concerning for cholecystits but with w/hida nl thus no operative rx performed being admitted tonight for liver . ros: pt denies any fever/chills/recent infections/ sore throat/ sinus infections/chest pain/palpitations/difficulty breathing/ dysuria/nausea/vomiting/changes in bowel habits (last bm this morning)/rashes/jt pain. does c/o long hx back pain, worse in am (w/recent bone scan and ct neg for mets), recent dull abd pain, similar to last admission, unchanged. past medical history: -hcv cirrhosis, genotype i. followed by dr. . - known grade 2 varices, last scope - hcc s/p rf ablation in -chronic abdominal pain -chronic back pain, negative bone scan . -depression -hemorrhoids -gerd social history: from . lives with wife in . quit tobacco and alcohol 12 years ago. denies drug use. family history: sister with breast cancer physical exam: a and o nad, well nourished 97.8 81 129/85 20 98% ra perrl, anicteric, no jvd, moist mucus membranes, no lad rrr no m/r/g ctab soft nd + bs no hsm + slight ttp ruq neg sign, no rebound tenderness no cva tenderness 2+ femoral pulses b/l no c/c/e 1+ dp b/l neuro 1+ patellar l, unable to elicit on r, 1+ br on r, unable to elicit on left, strength grossly intact psych slightly slow but otherwise nl affect, thought process, content derm: hyperpigmentation around back of arm, dorsal surfaces of arms, no petechiae slight ttp spine (lumbar), paraspinal pertinent results: on admission: wbc-2.7* rbc-3.83* hgb-13.0* hct-35.7* mcv-93 mch-34.0* mchc-36.5* rdw-14.2 plt ct-32* pt-17.5* ptt-40.3* inr(pt)-1.6* glucose-94 urean-13 creat-0.7 na-138 k-3.8 cl-104 hco3-27 angap-11 alt-52* ast-70* ld(ldh)-205 alkphos-109 totbili-2.1* albumin-3.6 calcium-8.7 phos-2.6* mg-1.6 at discharge: wbc-6.6 rbc-3.55* hgb-12.0* hct-30.9* mcv-87 mch-33.8* mchc-38.9* rdw-16.4* plt ct-65* 05:50am blood glucose-89 urean-17 creat-0.8 na-134 k-4.0 cl-99 hco3-27 angap-12 05:50am blood alt-94* ast-41* alkphos-57 totbili-1.2 05:50am blood calcium-8.2* phos-3.1 mg-1.9 05:50am blood tacrofk-10.8 brief hospital course: 50 y/o male with hcv who is deemed a suitable candidate for liver . he was taken to the or with dr . he received routine induction immunosuppression of cellcept, solumedrol 500 mg intra-op with standard solumedrol /pred taper and prograf initiated on the evening of pod 0. at the time of the surgery , he had a fibrotic hard nodular cirrhotic liver. he had moderate portal hypertension and moderate splenomegaly. he had no ascites. he had some omentum adherent to the anterior surface of the liver where the radiofrequency ablation was performed. he had normal anatomy. he received 4000 ml of crystalloid, 5 units of fresh frozen plasma, 4 units of platelets and urine output was 900 ml. ebl was ml. he was transferred to the sicu in stable condition, where he was extubated on pod 1. ultrasound pod 1 showed patent hepatic vasculature with no biliary ductal dilatation. he was transferred to 10 on pod 2 and followed the pathway in the post op period. his hct was noted to be slowly trending down and on pod 4 he received 2 units prbcs for a hct of 22.3%. his hct remained stable at 30% for the rest of the hospitalization. his lfts quickly normalized. prograf level was therapeutic at time of discharge. he was ambulating and tolerating diet. he received training with insulin/blood glucose management and was sent home with scripts for supplies. medications on admission: omeprazole 20', spironolactone 25", nadolol 20', prozac 10', clonopin 0.5" prn, colace 100", senna' hs, psyllium''' discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 2. prednisone 5 mg tablet sig: four (4) tablet po once a day. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. fluoxetine 10 mg capsule sig: one (1) capsule po daily (daily). 5. insulin nph human recomb 100 unit/ml suspension sig: twelve (12) units subcutaneous once a day: morning dose. disp:*1 bottle* refills:*0* 6. insulin nph human recomb 100 unit/ml suspension sig: five (5) units subcutaneous once a day: pm dose. 7. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 8. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 9. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 10. oxycodone 5 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 11. insulin syringe ultrafine ml 29 x syringe sig: one (1) syringe miscellaneous twice a day. disp:*1 box* refills:*2* 12. lancets,thin misc sig: one (1) miscellaneous twice a day. disp:*2 bottles* refills:*5* 13. one touch ultra system kit kit sig: one (1) kit miscellaneous once. disp:*1 kit* refills:*0* 14. one touch ultra test strip sig: one (1) in twice a day. disp:*2 bottles* refills:*5* 15. tacrolimus 1 mg capsule sig: three (3) capsule po twice a day. 16. alcohol prep pads pads, medicated sig: one (1) topical twice a day. disp:*1 box* refills:*5* 17. clonazepam 0.5 mg tablet sig: one (1) tablet po at bedtime as needed for anxiety. discharge disposition: home with service facility: homecare discharge diagnosis: hcv cirrhosis now s/p orthotopic liver discharge condition: stable/good discharge instructions: please call the clinic at for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications or other concerning symptoms. monitor the incision for redness, drainage or bleeding monitor the finger stick blood sugar twice daily and as needed for symptoms of low blood sugar to include sweating/weakness/irritability labwork every monday and thursday, fax results to the clinic at . when having labwork drawn, do not take your prograf before the lab test. bring prograf with you so you can take it as soon as labs have been drawn. no heavy lifting no driving if taking narcotic pain medications shower, pat incision dry, do not rub followup instructions: , social work date/time: 10:00 , md, phd: date/time: 10:40 , md, phd: date/time: 10:20 md, Procedure: Venous catheterization, not elsewhere classified Other transplant of liver Other operations on lacrimal gland Transplant from cadaver Diagnoses: Esophageal reflux Cirrhosis of liver without mention of alcohol Portal hypertension Unspecified viral hepatitis C without hepatic coma Depressive disorder, not elsewhere classified Malignant neoplasm of liver, primary Esophageal varices in diseases classified elsewhere, without mention of bleeding Backache, unspecified Abdominal pain, epigastric Other abnormal glucose Unspecified hemorrhoids without mention of complication

allergies: vancomycin attending: chief complaint: cough and tachycardia major surgical or invasive procedure: lymph node biopsy pleural drain history of present illness: this is a 45 year old male with no past medical history presenting with 3 - 4 weeks of cough. his symptoms began about a month ago when he noted the onset of a dry, paroxysmal, cough initially associated with one brief post-tussive syncope. no hemoptysis or sputum production. he also states he feels short of breath and "can't quite fill up his lungs with air." deep breaths tend to set off cough paroxysms. he has never experienced symptoms like these in the past, and denies prior history of asthma, allergies, or any other lung diseases. no history of gastroesophageal reflux. associated with cough and shortness of breath, he notes non-drenching night sweats and a lb weight loss. about 5 days prior to admission, he noted his shortness of breath got appreciably worse: while walking in his garden he noted significantly dyspnea. previously he has had normal exercise tolerance, able to play tennis, significant exercise. he saw his primary care doctor for these complaints on , who noted his heart rate to be in the 130s. his pcp sent him to the ed at for these complaints; he had a cxr there which showed left pleural effusion and widening of his mediastinum. cta showed no pe, but large pericardial effusion, left pleural effusion, and mediastinal adenopathy. vitals at this time were remarkable for hr in the 130s and tmax of 101.5. he had a bedside us done at which showed mild rv collapse at diastole but no hypotension was noted. pulsus unknown. at time of transfer to , his vitals were 113 114.89 20 100% on 2l nc. at , his vitals were 96.3 103 127/77 20 97. repeat bedside echo showed no echocardiographic evidence of tamponade physiology. there was no evidence of rv diastolic collapse. . ros: positive for non-drenching night sweats, recent weight loss of lbs, with no unusual bleeding/bruising, chest pain, palpitations, pnd, orthopnea. past medical history: none social history: just prior to current onset of symptoms, reports recent trip to st. / antilles, where he did explore a sea cave. he also spent some time in prior to the onset of these symptoms. no exposure to pets at home. no unusual work exposures; works in it for a pharmaceutical company. no known exposures to tb. no iv drug use, tobacco use. alcohol use 4 drinks / wk. lives with wife and 8 year old child; no sick contacts. than above travel history, no other recent travel. family history: no family history of malignancy, bleeding disorders, thyroid disease, autoimmune disease. physical exam: gen: sitting up in bed in nad neck: palpable left occiptal lymph node, no other adenopathy noted lymph: left occiptal lymph node, no other adenopathy noted cardiac: tachycardic, nl s1/s2, no distended neck veins noted, pulsus ~ 20 compared to pulsus ~ 6 noted in ed pulm: decreased breath sounds at left lung base abd: +bs, nontender, nondistended, no hepatosplenomegaly noted ext: no edema noted neuro: moving all extremities, alert + oriented x 3 pertinent results: admission labs: 02:45am blood wbc-7.5 rbc-4.77 hgb-13.5* hct-41.1 mcv-86 mch-28.2 mchc-32.8 rdw-13.0 plt ct-362 02:45am blood neuts-74.4* lymphs-14.1* monos-8.2 eos-2.9 baso-0.4 02:45am blood pt-14.7* ptt-26.8 inr(pt)-1.3* 02:45am blood glucose-110* urean-10 creat-0.8 na-138 k-4.3 cl-105 hco3-19* angap-18 02:45am blood alt-81* ast-68* ld(ldh)-791* alkphos-89 totbili-0.5 02:45am blood calcium-8.7 phos-3.7 mg-2.1 uricacd-5.9 02:45am blood tsh-4.3* 11:30am blood hcg-<5 11:30am blood afp-2.3 02:45am blood -negative 02:45am blood hiv ab-negative 02:45am blood brucella antibody, igg, igm-pnd . pericardial fluid: 04:30am other body fluid wbc-3456* hct,fl-4.5* polys-8* lymphs-69* monos-18* atyps-5* 04:30am other body fluid totprot-4.4 glucose-78 ld(ldh)-3000 amylase-25 albumin-2.9 . micro: blood culture: no growth to date pericardial fluid: propionobacterium acnes, bpcs. ebv and cmv pending 05:25pm blood coccidioides antibody, immunodiffusion-test 02:45am blood brucella antibody, igg, igm-test 05:00pm blood hcv ab-negative . discharge labs: 9:01 pm pleural fluid gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated brief hospital course: this is a 45 year old male with no significant past medical history presenting with 3 weeks of dry cough, tachycardia, and subjective dyspnea who was found to have cardiac tamponade and primary mediastinal b cell lymphoma. . # pericardial/pleural effusion - developed in the setting of 3 weeks of indolent symptoms of cough, non-drenching night sweats, fevers. he was found on lymph node biopsy to have a primary b cell lymphoma. tamponade was noted and patient had drain placed in the icu with subsequent removal once tamponade physiology resolved. pt was found to have propionum bacterium acnes infection of pericardial fluid as well as staph epidermidis and was started on vancomycin while sensitvities were being awaited from . echo prior to discharge showed resolution of pericardial fluid. he also had large pleural effusions which were successfully drained with chest tube removed prior to discharge. it is recommended that a repeat echo is conducted within 1 month of discharge. patient will follow up with oncology and i.d as outpatient. depending on the p.acnes sensitivities he may be switched by i.d to penicillin and ceftriaxone. labs as recommended by i.d will be followed whilst on antibiotics. . hypodense liver lesions.he also had hypodense liver lesions that had been noted on abdominal ct.liver mri was limited, and liver lesions could not be assessed. repeat imaging may be considered as an outpatient. . # tachycardia - likely in setting of underlying effusion, resulting in reduction in cardiac output with compensatory tachycardia. patient also has increased insensible water loss due to night sweats. patient was given several liters of fluid this admission. should continue to drink large amounts of fluid as outpatient. . # cough - likely secondary to underlying effusion as noted above. patient was managed symptomatically with cough supressants. . # lymphadenopathy: ct shows extensive mediastinal lymphadenopathy. patient also had lymph node in his neck and had excisional biopsy while in the hospital which showed primary mediastinal b cell lymphoma. . medications on admission: none discharge medications: 1. vancomycin 1,000 mg recon soln sig: 1500 (1500) mg intravenous every twelve (12) hours for 4 weeks. disp:*84 recon solns* refills:*0* 2. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. disp:*100 ml(s)* refills:*0* 3. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. disp:*90 capsule(s)* refills:*0* 4. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day) as needed for tinea corporis. disp:*1 tube* refills:*2* 5. zofran odt 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. disp:*30 tablet, rapid dissolve(s)* refills:*2* 6. outpatient lab work please check a cbc/diff, bmp, vancomycin trough, esr and crp every monday and fax results to (, attention dr 7. outpatient lab work please check cbc/diff twice a week and fax results to dr at 8. saline flush 0.9 % syringe sig: ml flush injection as needed : with administration of medications . disp:*84 doses * refills:*1* 9. heparin flush 10 unit/ml kit sig: five (5) ml flush intravenous as needed : with administration of medications. disp:*84 doses * refills:*1* discharge disposition: home with service facility: critical care systems discharge diagnosis: primary diagnosis: primary mediastinal b cell lymphoma. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with tachycardia and cough. you had fluid that had built up around your heart (pericardial fluid) that was drained. this fluid was found to be infected and you were started on antibiotics. ct showed several lymph nodes as well as pleural and pericardial fluids in your chest and a biopsy was performed. you were found to have a primary mediastinal lymphoma and you were treated with chemotherapy and you improved. . the following changes were made to your medications: we added clotrimazole topical cream. we added guafenesin as needed for cough we added benzonatate as needed for cough we added zofran as needed for nausea. . you were started on vancomycin. the infectious diseases doctors contact if there needs to be a change made in your antibiotics. . you will need to have another echo to determine if there is any fluid reaccumulating around your heart. you will be called by our radiology department with the date and time of your appointment. followup instructions: provider: 2-hem onc 7f hematology/oncology-7f date/time: 9:00 , tel . . dr : infectious disease clinic . tel:( you will be contact with the date and time of your appointment which will be in the last week of . if you do not hear from the clinic by wednesday next week, please call to determine the date of your appointment. . echo suite radiology department , tel you will be called by our radiology department with the date and time of your appointment. if you do not hear from them on monday next week, please call the number above to determine the date and time of your study. Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Pericardiocentesis Thoracentesis Thoracentesis Biopsy of bone marrow Biopsy of lymphatic structure Right heart cardiac catheterization Injection or infusion of cancer chemotherapeutic substance Diagnoses: Pneumonia, organism unspecified Other specified cardiac dysrhythmias Other abnormal blood chemistry Leukocytosis, unspecified Neutropenia, unspecified Cardiac tamponade Fever presenting with conditions classified elsewhere Other agents affecting blood constituents causing adverse effects in therapeutic use Malignant pleural effusion Other malignant lymphomas, intrathoracic lymph nodes

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p motor vehicle crash major surgical or invasive procedure: liver embolization history of present illness: 34 yo f passenger s/p high speed auto crash vs. embankment, restrained + airbag self extricated. + loc. she was transported to for further care. past medical history: denies family history: noncontributory pertinent results: 09:47pm glucose-104 urea n-16 creat-0.5 sodium-138 potassium-3.6 chloride-106 total co2-26 anion gap-10 09:47pm calcium-8.0* phosphate-2.7 magnesium-1.9 03:51am glucose-171* urea n-17 creat-0.8 sodium-136 potassium-3.5 chloride-99 total co2-28 anion gap-13 03:51am wbc-11.4* rbc-4.76 hgb-12.5 hct-36.9 mcv-78* mch-26.3* mchc-34.0 rdw-14.1 03:51am plt count-392 03:51am pt-12.3 ptt-22.7 inr(pt)-1.0 08:30am hct 24.3* ct abd/chest/pelvis impression: 1. grade iv liver laceration of the right lobe with active extravasation, subcapsular and perisplenic fluid. 2. right renal contusion without evidence of injury to the collecting system. 3. right posterior rib fractures 8 - 10. the above findings were discussed with dr. upon completion of the study. 4. large, heterogenous pelvic mass. further evaluation with pelvic ultrasound and/or mri is recommended. this was discussed with dr. at 1000am on . brief hospital course: she was admitted to the trauma service and transferred to the trauma icu for close observation. serial exams and hematocrits were followed. her hematocrit did drop to 23 and she was taken to interventional radiology for liver embolization; there were no procedural complications. post procedure she was taken to the pacu where she was monitored closely. once stabilized she was transferred to the regular nursing unit where she has remained stable. she did have pain control issues and was started on an aggressive pain regimen. she is being discharged on oxycodone prn. her diet was advanced and she is tolerating this. an incidental finding of a pelvic mass on pelvic ct imaging was noted. she was advised to follow up with her primary care doctor for this. medications on admission: none discharge medications: 1. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*80 tablet(s)* refills:*0* 2. tylenol extra strength 500 mg tablet sig: two (2) tablet po every six (6) hours. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 4. milk of magnesia 800 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 right renal laceration grade iv liver laceration - segment vi left subgaleal hematoma 9th posterior rib fracture discharge condition: hemodynamically stable, tolerating a regular diet, pain adequately controlled. discharge instructions: avoid any contact sports, activity or any activity that may cause injury to your abdominal area. no lifting objects greater than lbs. it is important that you walk several times throughout the day; cough, deep breathe and use the incentive spirometer every hour 10x while you are awake. take the stool softners and laxatives while on the narcotics t oavid constipation. go to the nearest emergency room if you become dizzy, feel lightheaded or as if you are going to pass out as these may be signs that you are bleeding from your liver injury. please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. followup instructions: follow up in clinic with dr. , trauma surgery in 2 weeks, call for an appointment. a pelvic mass was incidentally noted on your ct scan. further evaluation with pelvic ultrasound and/or mri is recommended. please follow up with your primary care physician to arrange this. Procedure: Injection or infusion of other therapeutic or prophylactic substance Diagnoses: Acute posthemorrhagic anemia Alcohol abuse, unspecified Closed fracture of one rib Closed fracture of three ribs Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Injury to kidney without mention of open wound into cavity, laceration Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle Leiomyoma of uterus, unspecified Injury to liver without mention of open wound into cavity, laceration, major Contusion of buttock

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue, anemia major surgical or invasive procedure: upper endoscopy with biopsies history of present illness: 83yo male with dementia, prostate ca (per son this has been stable, untreated for several months), utis who was noted at his nsg home to have malaise, poor po intake and low grade fevers (no note of fever in paperwork) for past 2d. they thought he might have a uti but were unable to get urine, so he was given a dose of cipro. the staff at his nursing home had difficulties managing him so he was sent to the ed for further work-up. when ems arrived, he was noted to be pale in color. he also became unresponsive for approximately 30 seconds when he was lifted onto the stretcher. in the ed, initial vs were: 96.7 89 111/63 18 98. on exam the patient was pale and lethargic. labs notable for hct 22, inr of 1.1. he had dark maroon colored stool. tried to ng lavage and didn't tolerate this. difficult match for , he did not receive any . patient was given vanco and levoquin for reports of fever at the nsg home. he has gotten 1.2l of ns. cxr unremarkable. bps 90-100 systolic (hypertensive baseline) and tachy 90s-110s. upon transfer, vitals: 97 91/62 rr 20 100% on ra. on the floor, the patient is pale appearing but baseline mental status according to his son (pleasant, no short term memory, likes to sing and hum). review of systems: (+) per hpi (-) denies pain currently otherwise unable to assess. past medical history: dementia utis prostate ca social history: lives at alf. has a son, , who serves as his health care proxy. - tobacco: denies - alcohol: denies - illicits:denies family history: no history of colon cancer physical exam: vitals: t: 96.4 bp: 116/68 p:93 r: 18 o2:96% on ra general: alert, oriented, no acute distress, singing to himself heent: sclera anicteric, mmm, oropharynx clear, pale neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs on admission: 08:14pm urine color-straw appear-clear sp -1.018 08:14pm urine -neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 08:12pm hct-24.4* 08:12pm pt-12.8 ptt-19.6* inr(pt)-1.1 03:30pm pt-13.3 ptt-21.1* inr(pt)-1.1 02:21pm comments-green top 02:21pm glucose-161* na+-143 k+-4.2 cl--108 tco2-21 02:21pm hgb-7.4* calchct-22 02:00pm glucose-165* urea n-65* creat-1.0 sodium-143 potassium-4.7 chloride-109* total co2-21* anion gap-18 02:00pm estgfr-using this 02:00pm ck(cpk)-47 02:00pm ctropnt-<0.01 02:00pm ck-mb-notdone 02:00pm wbc-8.6 rbc-2.56* hgb-7.3* hct-22.0* mcv-86 mch-28.6 mchc-33.2 rdw-12.9 02:00pm neuts-78.5* lymphs-17.3* monos-3.7 eos-0.4 basos-0.1 02:00pm plt count-256 labs on discharge: 08:35am wbc-6.8 rbc-3.16* hgb-9.7* hct-28.2* mcv-89 mch-30.7 mchc-34.4 rdw-14.9 plt ct-171 08:35am plt ct-171 08:35am glucose-102* urean-18 creat-0.6 na-145 k-3.5 cl-112* hco3-28 angap-9 studies: urinalysis: negative in detail images: cxr portable : there are low lung volumes. the cardiomediastinal contours are within normal limits. there is no focal consolidation, pleural effusion or pneumothorax. there is bibasilar atelectasis, right greater than left. degenerative changes of the thoracic spine are noted. upper endoscopy : normal esophagus. stomach: mucosa: thickened, edematous folds were noted in the body of the stomach suggestive of an infiltrating process. the mucosa was also friable. cold forceps biopsies were performed for histology at the stomach. duodenum: normal duodenum. impression: abnormal mucosa in the stomach (biopsy) otherwise normal egd to second part of the duodenum pathology: helicobacter pylori antibody test (final ): positive by eia. (reference range-negative). mrsa screen (final ): no mrsa isolated. urine culture (final ): no growth. brief hospital course: patient is a 83 year-old man with a history of hypertension and dementia who presented with an upper gasterointestinal bleed. for his upper gi bleeding, the patient received iv fluids and was transfused with . he received intravenous pantoprazole therapy. patient underwent an egd that showed edematous mucosa and thickened folds concerning for malignancy with no evidence of active. h. pylori testing was positive and he was started on lansoprazole amoxicillin, and clarithromycin. he had biopsies taken during endoscopy. the results will be communicated by dr. and appropriate followup will be arranged depending on results by gastroenterology. for his hypertension, home hydrocholrothiazide and lisinopril medications was held during this admission given concerns over his gi bleed. these were still held at the time of discharge and can be restarted as an outpatient. the patient did not have any active issues regarding his alzheimer's dementia. he was continued on his namenda and aricept during this admission. the patient did not have any active issues regarding his prostate cancer. he was continued on casodex. code : dnr but ok to intubate medications on admission: (per nsg home notes): acetaminophen 650 (standing) for wrist pain casodex 50mg po qam hctz 12.5mg po daily lipitor 10mg po daily lisinopril 10mg po daily namenda 5mg po daily aricept 5mg po qhs loperamide 2mg for loose stool discharge medications: 1. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day) as needed for h.pylori. disp:*60 tablet,rapid dissolve, dr(s)* refills:*2* 2. amoxicillin 500 mg tablet : two (2) tablet po twice a day for 12 days. disp:*48 tablet(s)* refills:*0* 3. clarithromycin 500 mg tablet : one (1) tablet po twice a day for 12 days. disp:*24 tablet(s)* refills:*0* 4. memantine 5 mg tablet : one (1) tablet po daily (). 5. donepezil 5 mg tablet : one (1) tablet po hs (at bedtime). 6. atorvastatin 10 mg tablet : one (1) tablet po daily (daily). 7. bicalutamide 50 mg tablet : one (1) tablet po daily (daily). 8. acetaminophen 325 mg tablet : two (2) tablet po twice a day. 9. loperamide 2 mg capsule : one (1) capsule po twice a day as needed for diarrhea. discharge disposition: extended care facility: house discharge diagnosis: primary: gastrointestinal bleeding h. pylori infection secondary: hypertension alzheimer's disease discharge condition: mental status: confused - always level of consciousness: alert and interactive activity status: ambulatory - requires assistance or aid (walker or cane) discharge instructions: you were admitted for fatigue. you were found to have low counts and received four transfusions. you were noted to have abnormalities in your stomach and biopsies were taken. the results of these biopsies were pending at the time of discharge. please take all your medications as prescribed. the following changes were made to your medication regimen. 1. please take lansoprazole 30 mg by mouth two times a day ongoing 2. please take amoxicillin 1000 mg two times a day for 12 more days 3. please take clarithromycin 500 mg by mouth twice a day for 12 more days 4. your lisinopril and hydrochlorothiazide were being held at the time of discharge and your pressures were stable. these can be restarted as an outpatient by your primary care physician. please keep all your follow up appointments as scheduled. followup instructions: please follow up with your primary care physician . within 2-3 days of discharge. your hematocrit should be rechecked at this time. dr. will contact you with the results of your stomach biopsies. after the results of the biopsies return a decision will be made as to appropriate referral. if you have not heard from dr. by tuesday please call her office at ( Procedure: Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Blood in stool Malignant neoplasm of prostate Fever, unspecified Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Helicobacter pylori [H. pylori] Personal history, urinary (tract) infection Malignant neoplasm of stomach, unspecified site

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hematemasis major surgical or invasive procedure: radiation therapy history of present illness: this is an 83 year old male with a history of dementia, prostate cancer and recent admission for hematemasis found to have likely gastric malignancy on endoscopy who presents from house four hours after discharge with recurrent hematemasis. during the patient's recent admission he presented with hematemasis and melena. he received four units prbcs and underwent endoscopy which revealed oozing mucosa with irregular contour concerning for malignancy. he was monitored for 72 hours with no recurrence of his bleeding and stabilization of his hematocrit. he was discharged to house on . 4 hours after discharge he had recurrent hematemasis. prior to arrival he had had four episodes of bloody emesis with associated nausea and mild abdominal pain. he was brought to ehe emergency room. . in the emergency room his initial vitals were t: 98.0, hr: 70, bp: 115/67, rr: 18, o2: 99% on ra. ng lavage showed bright red which did nto clear. he had an attempt at cordis placement but was not in the correct position and was rewired to a lij central line. hematocrit on arrival was 26.2 from 29.3 the day prior. he was admitted to the micu for further management. . in the micu he received four units of prbcs. he was started on erythromycin. on the night of admission he underwent emergent endoscopy which revealed in the stomach body with no clear site of bleeding. he underwent repeat endoscopy on which revealed no active bleeding. pathology from recent endoscopy with biopsy returned preliminarily with signet cell adenocarcinoma. he is transferred to the floor for further management. . on arrival to the floor he has no complaints. he denies fevers, chills, chest pain, difficulty breathing, nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria, hematuria, leg pain or swelling. all other review of sytems negative in detail. past medical history: dementia recurrent urinary tract infections prostate cancer social history: lives at alf. has a son, , who serves as his health care proxy. - tobacco: denies - alcohol: denies - illicits:denies family history: no history of colon cancer physical exam: admission: vitals: t: 98.0 bp: 134/79 p: 68 r: 18 o2: 98% on ra general: alert, oriented to person not time or place, no acute distress heent: sclera anicteric, conjunctiva pale, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs on admission: 09:35am wbc-5.8 rbc-2.96* hgb-8.9* hct-25.7* mcv-87 mch-30.1 mchc-34.8 rdw-15.0 plt ct-176 09:35am plt ct-176 09:35am glucose-95 urean-17 creat-0.6 na-143 k-3.8 cl-111* hco3-25 angap-11 labs on transfer from the icu: 04:00am wbc-10.0 rbc-3.78*# hgb-10.7* hct-31.0* mcv-82# mch-28.4 mchc-34.6 rdw-16.6* plt ct-159 04:00am pt-13.2 ptt-27.0 inr(pt)-1.1 04:00am plt ct-159 04:00am glucose-94 urean-34* creat-0.4* na-140 k-3.5 cl-112* hco3-25 angap-7* labs on discharge: \ 11.3 / 7.5/ 34.5 \ 353 142 | 110 | 6 / 96 3.8 | 23 | 0.5\ urine studies: 11:50am urine rbc-0-2 wbc-0-2 bacteri-few yeast-none epi-0 11:50am urine -neg nitrite-neg protein-tr glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg 11:50am urine color-yellow appear-clear sp -1.018 microbiology: mrsa screen (final ): no mrsa isolated. pathology: stomach, mucosal biopsy : poorly differentiated carcinoma with signet ring features. imaging: chest (portable ap) study date of 1:24 pm impression: nasogastric tube in standard position. left internal jugular approach central venous catheter, with tip terminating in the junction with the left brachiocephalic vein. small patchy focus in right lung base. represent atelectasis and vessel crowding, however small focus of aspiration and/or pneumonia not excluded. ct studies: ct chest w/ contrast : a small amount of oral secretions are seen dependently in the trachea (3:16). there are small bilateral pleural effusions with overlying consolidation, likely atelectatic. a calcific focus in the right lower lobe represents a calcified granuloma. the heart and great vessels are notable for coronary arterial calcification. there is no mediastinal or axillary lymphadenopathy. a left internal jugular central venous line terminates in the left brachiocephalic vein. incidental note is made of bilateral gynecomastia. ct abdomen with and without contrast : the spleen, pancreas, right adrenal gland, and gallbladder are unremarkable. a punctate calcific focus is present in the left adrenal gland. the kidneys enhance and excrete contrast in a symmetric fashion are notable for numerous bilateral hypodensities, some of which are too small to characterize, others of which are consistent with simple cysts. the liver also contains innumerable hypodensities. as was the case in the kidneys, many of these are simple cysts, others of which are too small to characterize. the left lobe is notably atrophic. a soft tissue mass is seen in the retroperitoneum, just posterior to the third portion of the duodenum difficult to precisely marginate, though measuring approximately 50 x 29 mm (3:76). this lesion extends along the anterior surface of the aorta, though does not constrict or deform the otherwise normally opacifying aorta. note is made of a 10-mm left paraaortic retroperitoneal lymph node (3:66). numerous mesenteric lymph nodes are visualized, none of which are enlarged by ct size criteria. ct pelvis with contrast : the urinary bladder contains a foley catheter. the prostate and seminal vesicles are unremarkable. note is made of a large amount of stool in the rectal vault. the remainder of the colon is unremarkable. there is no free gas in the pelvis. a small amount of free fluid is seen dependently in the pelvis. there is no pelvic sidewall or inguinal lymphadenopathy. impression: 1. retroperitoneal lymphadenopathy concerning for metastatic disease 2. bilateral pleural effusions. 3. trace ascites settling dependently in the pelvis. 4. numerous renal and hepatic cysts as well as other renal and hepatic hypodensities, too small to characterize, likely also cysts. ekg : sinus rhythm with ventriculr premature beats. prolonged qtc interval. modest st-t wave changes. findings are non-specific. clinical correlation is suggested for possible drug/electrolyte/metabolic effect. since the previous tracing of borderline sinus tachycardia is absent, ventricular ectopy is seen, the qtc interval appears prolonged and st-t wave abnormalities are decreased. brief hospital course: 83 yo m with recent admission for upper gastrointestinal bleed, found to be h.pylori positive and changes in gastric mucosa concerning for infiltrative process; now readmitted the day after discharge with hematemesis x 7 and ng lavage that returned bright red . . # adenocarcinoma: egd biopsy showed poorly differentiated carcinoma with signet ring features. ct abdomen with evidence of significant lymphadenopathy. surgery, oncology and radiation oncology were consulted. a trial of palliative radiation therepy was suggested to help decrease risk of recurrent gastrointestinal bleeding. patient received 5 of 5 doses of radiation therapy. . # hematemesis: patient with known gastric mucosa abnormality as seen on egd suspicious for infiltrating process with biopsy now showing adenocarcinoma. he was treated with transfusions (4 units on initial admission, 4 units on readmission to the icu from house) and iv ppi. after biopsy showed adenocarcinoma and ct scan of the abdomen showed retroperitoneal mass with associated lymphadenopathy concerning for metastatic disease, oncology was consulted and recommended palliative radiation for control of symptoms of hematemesis. surgery did not feel that the patient's disease could be cured with an operation. subsequently, a family meeting was held on in which it was decided to follow a palliative course of therapy rather than attempting to eradicate the patient's disease. his son and health-care proxy, , agreed to attempt palliate radiation therapy, and a decision was made to work with case management to find a facility where hospice-level care could be administered to the patient upon discharge. the patient was mapped and received his first course of palliative radiation therapy on . patient received 5 of 5 doses of radiation therapy. . # h pylori: h.pylori positive . patient was placed on triple therapy with pantoprazole, clarithromycin, and amoxicillin on . - continue with therapy for h.pylori infection for comfort for total 10 day course - recommend continuation of pantoprazole due to recent gi bleeding. . # ekg changes: patient with new twi in lateral leads compared to prior ekg. nonspecific and denies any localizing symptoms. - cardiac enzymes negative x 2 . #hypertension: the patient's pressure was elevated on arrival but with ongoing loss, decision was made to hold his hydrochlorothiazide and lisinopril. he was not restarted on these medications during his hospital stay; bp has remained stable despite being off of antihypertensives. . #alzheimer's dementia: stable. - held namenda and aricept initially in the setting of gi bleed, but were subsequently resumed. . # h/o metastatic prostate cancer: previously on bicalutamide. - discontinued due to changes in goals of care . # hyperlipidemia: patient's atorvastatin was discontinued due to changes in goals of care. . disp: discharge to hospice today, after last dose of xrt. ppx: at risk for dvt. pt received pneumoboots in setting of gi bleed. medications on admission: lansoprazole 30 mg po bid amoxicillin 1000 mg po bid clarithromycin 500 mg po bid memantine 5 mg po daily donepezil 5 mg po hs atorvastatin 10 mg po daily bicalutamide 50 mg po daily acetaminophen 325 mg po bid loperamide 2 mg po bid prn diarrhea discharge medications: 1. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 2. donepezil 5 mg tablet : one (1) tablet po hs (at bedtime) as needed for alzheimer's. 3. memantine 5 mg tablet : one (1) tablet po daily () as needed for alzheimer's. 4. amoxicillin 250 mg/5 ml suspension for reconstitution : 1000 (1000) mg po bid (2 times a day) for 6 days. 5. clarithromycin 250 mg tablet : two (2) tablet po bid (2 times a day) as needed for h.pylori therapy for 6 days. 6. pantoprazole 40 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. ondansetron 4 mg tablet, rapid dissolve : two (2) tablet, rapid dissolve po daily (daily) as needed for nausea. discharge disposition: extended care facility: house discharge diagnosis: # gastric adenocarcinoma # hematemesis # h. pylori infection # dementia, alzheimers # h/o metastatic prostate cancer discharge condition: mental status: confused - always level of consciousness: alert and interactive activity status: ambulatory - requires assistance or aid (walker or cane) discharge instructions: you were admitted for vomiting , and you were found to have an uncurable cancer in your stomach. to help control the bleeding, you have been receiving radiation therapy. you are being discharged to hospice care. followup instructions: please follow up with hospice care for ongoing care. Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Other endoscopy of small intestine Other radiotherapeutic procedure Diagnoses: Acute posthemorrhagic anemia Other and unspecified hyperlipidemia Malignant neoplasm of prostate Encounter for palliative care Hematemesis Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Helicobacter pylori [H. pylori] Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Benign essential hypertension Personal history, urinary (tract) infection Malignant neoplasm of body of stomach Malnutrition of mild degree

allergies: no known allergies / adverse drug reactions attending: chief complaint: left hip pain major surgical or invasive procedure: s/p l hip resection history of present illness: yo male with history of htn, gerd, etoh cirrhosis, crohn's s/p ileostomy, copd, depression, pancytopenia, avascular necrosis chronic prednisone use s/p l hip replacement presenting originally for planned l hip revision, but was found unable to be revised because of advanced osteolysis, and so is now s/p total resection arthroplasty. patient noted to be confused overnight. per ortho team, patient had also been confused on coming out of the or on , but his mental status cleared up overnight. had initially been transferred to icu post surgery because of hypotension, was on pressors with subsequent normalization of blood pressures and transferred to floor team on . he has been quite lucid until last night when he was again noted to be confused, trying to get out of bed, and seeing people in his room. . per prior report, patient himself says that he feels fatigued since his surgical procedure, finding that he falls asleep a lot. has been having nightmares and "distortions of reality" during his sleep. sees people in his dreams, is not quite sure if he sees them while he's awake. currently in a fair amount of pain in his left hip, . . during his stay on the floor, he has been afebrile with vitals stable. no psych history other than depression per patient and medical charts. . this am, pt alert and clear. he reports no hip pain at rest. he denies headache, cp/sob/palp, abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria. pt reports he is hungry past medical history: - htn - etoh cirrhosis c/v esophageal varices and bleeding - thrombocytopenia - crohn's disease s/p ileostomy - prostate cancer - copd - gerd - variceal bleeding - squamous cell carcinoma s/p resection - avascular necrosis of left hip secondary to prednisone - depression . psh: - squamous cell carcinoma excisions x 3 forehead () - l distal radius orif () - partial colectomy with transverse colostomy and mucous fistula - mucous fistula takedown - left wrist surgery - left hip replacement (20 years ago) . social history: he is retired from the department of social services, former widower, has a girlfriedn. he states he presently uses cigarettes, not currently. prior history of alcohol abuse, no longer drinking in 22 months per pt, family and pcp. family history: positive for hemophilia but not affecting this patient, although he does have thrombocytopenia. physical exam: discharge exam vs: tm:98.7 t:96 bp:108/68 hr:97 rr:18 o2 sats 100% on ra i/o:4220+2600/445+3225 ostomy. pain-denies gen:sitting upright in bed heent:ncat eomi anicteric mmm neck: supple, no lad cv: s1s2 rr no m/r/g resp: b/l ae no w/c/r decreased bs at bases abd: +bs, soft, nt, nd, no guarding or rebound, +ostomy back: non-tender gu: with foley extr: no c/c/e 2+pulses, l.leg in brace derm: no apparent rash neuro: aaox3, cn2-12 intact, motor x4 except for lle, sensation equal and intact to lt, +asterixis, follows commands. psych: cooperative. pertinent results: 06:25am blood wbc-6.7 rbc-3.83* hgb-12.7* hct-38.8* mcv-101* mch-33.2* mchc-32.8 rdw-22.1* plt ct-169 06:10am blood wbc-7.1 rbc-3.88* hgb-13.0* hct-39.0* mcv-101* mch-33.4* mchc-33.3 rdw-21.6* plt ct-166 06:15am blood wbc-7.5 rbc-3.74* hgb-12.5* hct-37.8* mcv-101* mch-33.6* mchc-33.2 rdw-21.6* plt ct-163 06:00am blood wbc-6.6 rbc-3.37* hgb-11.4* hct-33.7* mcv-100* mch-33.8* mchc-33.8 rdw-21.3* plt ct-143* 11:45am blood wbc-6.1 rbc-3.39* hgb-11.3* hct-33.4* mcv-99* mch-33.4* mchc-33.9 rdw-21.1* plt ct-125* 07:00am blood wbc-8.0 rbc-3.76* hgb-12.2* hct-36.0* mcv-96 mch-32.5* mchc-33.9 rdw-20.6* plt ct-142* 09:45am blood wbc-10.2# rbc-4.15* hgb-13.6* hct-39.7* mcv-96 mch-32.8* mchc-34.3 rdw-20.1* plt ct-148*# 06:10am blood wbc-5.5 rbc-3.61* hgb-11.8* hct-35.5* mcv-98 mch-32.6* mchc-33.3 rdw-20.5* plt ct-74*# 06:00am blood wbc-4.4# rbc-3.20* hgb-10.6* hct-30.7* mcv-96 mch-33.1* mchc-34.5 rdw-20.1* plt ct-45* 06:05am blood wbc-2.1* rbc-2.94* hgb-9.8* hct-28.5* mcv-97 mch-33.3* mchc-34.4 rdw-20.5* plt ct-34* 05:39am blood wbc-1.8* rbc-2.90* hgb-9.4* hct-27.5* mcv-95 mch-32.4* mchc-34.2 rdw-20.3* plt ct-32* 05:57am blood wbc-2.1* rbc-3.02* hgb-9.6* hct-27.9* mcv-92 mch-31.8 mchc-34.4 rdw-19.6* plt ct-34* 01:36am blood wbc-2.1* rbc-3.03* hgb-9.9* hct-27.1* mcv-90 mch-32.6* mchc-36.4* rdw-21.1* plt ct-35* 06:14pm blood wbc-1.8* rbc-2.95* hgb-9.7* hct-26.4* mcv-89 mch-32.7* mchc-36.6* rdw-20.6* plt ct-33* 12:28pm blood hct-26.2* 02:08am blood wbc-1.6* rbc-3.10* hgb-10.3* hct-27.0* mcv-87 mch-33.2* mchc-38.2* rdw-20.5* plt ct-34* 08:41pm blood wbc-1.6* rbc-3.20* hgb-10.3* hct-27.7* mcv-87 mch-32.1* mchc-37.1* rdw-20.4* plt ct-36* 03:17pm blood wbc-1.3* rbc-3.02* hgb-9.8* hct-26.1* mcv-87 mch-32.5* mchc-37.6* rdw-20.1* plt ct-39* 11:21am blood wbc-1.0* rbc-2.49* hgb-8.5* hct-22.4* mcv-90 mch-34.1* mchc-37.9* rdw-20.1* plt ct-29* 08:12am blood wbc-1.0*# rbc-2.76* hgb-9.0* hct-24.3* mcv-88 mch-32.5* mchc-36.9* rdw-20.5* plt ct-27*# 12:41pm blood wbc-5.5 rbc-2.74* hgb-9.8* hct-27.9* mcv-102*# mch-35.8* mchc-35.1* rdw-19.6* plt ct-121* 11:45am blood neuts-82.5* lymphs-6.5* monos-8.5 eos-2.0 baso-0.4 06:00am blood neuts-83.3* lymphs-7.7* monos-7.6 eos-1.0 baso-0.5 06:05am blood neuts-81.3* lymphs-8.0* monos-7.8 eos-2.7 baso-0.2 05:39am blood neuts-74* bands-0 lymphs-8* monos-13* eos-3 baso-2 atyps-0 metas-0 myelos-0 05:57am blood neuts-83.9* lymphs-6.3* monos-7.7 eos-1.6 baso-0.4 11:21am blood neuts-82.7* lymphs-9.5* monos-6.2 eos-1.3 baso-0.2 02:09am blood neuts-86.8* lymphs-5.5* monos-4.9 eos-2.7 baso-0.1 03:17pm blood ret aut-2.9 03:17pm blood fdp-0-10 11:21am blood fibrino-267 09:20am blood fibrino-328 01:50pm blood creat-pnd 06:25am blood glucose-107* urean-26* creat-1.4* na-141 k-4.3 cl-113* hco3-17* angap-15 06:10am blood glucose-99 urean-18 creat-1.2 na-146* k-4.5 cl-119* hco3-20* angap-12 06:15am blood glucose-118* urean-19 creat-1.1 na-148* k-4.0 cl-122* hco3-18* angap-12 06:00am blood glucose-94 urean-21* creat-1.0 na-146* k-3.8 cl-119* hco3-16* angap-15 11:45am blood glucose-100 urean-23* creat-1.0 na-144 k-4.0 cl-117* hco3-16* angap-15 09:45am blood glucose-104* urean-40* creat-2.2*# na-142 k-4.5 cl-108 hco3-16* angap-23* 06:10am blood glucose-88 urean-18 creat-0.9 na-139 k-3.6 cl-107 hco3-19* angap-17 05:57am blood glucose-100 urean-10 creat-0.6 na-138 k-3.7 cl-108 hco3-23 angap-11 01:36am blood glucose-107* urean-14 creat-0.8 na-140 k-3.5 cl-109* hco3-23 angap-12 02:08am blood glucose-106* urean-19 creat-0.8 na-141 k-3.5 cl-110* hco3-23 angap-12 03:17pm blood glucose-115* urean-22* creat-0.8 na-138 k-3.9 cl-108 hco3-23 angap-11 02:09am blood glucose-93 urean-20 creat-1.1 na-139 k-4.3 cl-111* hco3-21* angap-11 04:00pm blood glucose-97 urean-16 creat-1.0 na-138 k-5.1 cl-112* hco3-21* angap-10 12:41pm blood glucose-101* urean-11 creat-0.9 na-139 k-4.4 cl-112* hco3-25 angap-6* 06:10am blood alt-21 ast-30 alkphos-190* totbili-1.2 11:45am blood alt-18 ast-32 ck(cpk)-164 alkphos-124 totbili-1.9* 12:00pm blood alt-12 ast-34 ld(ldh)-296* alkphos-128 totbili-2.0* 12:41pm blood alt-9 ast-22 alkphos-68 11:45am blood lipase-34 11:45am blood ck-mb-7 ctropnt-<0.01 03:17pm blood hapto-18* 07:00am blood ammonia-30 12:40pm blood ammonia-17 06:05am blood tsh-2.9 12:50pm blood type-art temp-37.0 o2 flow-6 po2-202* pco2-35 ph-7.40 caltco2-22 base xs--1 intubat-not intuba comment-sfm . hip pathology-diagnosis: left hip femoral and acetabular components, removal: for gross examination only. left hip, granulation tissue, excision (a): coagulative necrosis and macrophage reaction to particles, consistent with wear debris. left acetabulum osteolysis, excision (b-c): - granulation tissue, coagulative necrosis and macrophage reaction to particles (consistent with wear debris). - degenerative bone. . hip -our views of the left hip: left total hip arthroplasty has been removed and there is significant osteolysis of the acetabulum and proximal femur with proximal migration of the femoral shaft. infection cannot be excluded. hemi-osteotomy is noted extending from the subtrochanteric region to the lateral cortex of the proximal femoral diaphysis secured by four cerclage wires. there are overlying surgical staples, soft tissue swelling and subcutaneous emphysema. prostatic seeds are noted. there is an ostomy in the right lower quadrant. it is noted that cultures were obtained at the time of surgery. . cxr -impression: 1. no evidence of pneumothorax after central venous catheter placement. 2. persistent right apical thickening, probably due to scarring, but in the absence of a more remote comparison, this could represent a small right apical lung cancer, which should be evaluated with chest ct. the study and the report were reviewed by the staff radiologist. . ct pelvis -impression: 1. status post removal of left total hip arthroplasty, resulting in girdlestone configuration, with superior position of the left femur and mutiple femoral cerclage wires. 2. nondisplaced linear lucency within the proximal femoral shaft new since the radiograph of -- ? osteotomy. 3. marked acetabular protrusio configuration. the inner surface of the left acetabulum is markedly thinned and, in areas, effaced. focal osteopenia also noted in lesser tuberosity. 4. apparent large fluid collection within and around the "joint", which may represent a post-operative seroma.a few small locules of air noted, which could relate to recent surgery. please note that the presence or absence of infection cannot be determined based on imaging. drains present. . head ct -impression: 1. no acute intracranial hemorrhage or mass effect. scattered hypodense areas in the white matter as described above, which are likely similar to the prior mr head study of . if there is continued clinical concern for abnormality, mr head can be considered if not contraindicated. 2. vascular calcifications in the cavernous carotid segments and in the left distal vertebral artery, patency not assessed on the present study. . cxr-reason for exam: status post left hip resection with increasing confusion. comparison is made to prior study and . compared to , there is new mild cardiomegaly. dilatation of the ascending aorta is more notorious than before and warrants further evaluation with either echo or ct. asymmetrical apical thickening is stable greater on the right. there is mild right apical scarring. there is no pneumothorax. there is a small left pleural effusion. . ruq u/s -findings: limited four-quadrant ultrasound of the abdomen was performed. no free fluid was identified. . ekg -sinus rhythm. early precordial qrs transition. borderline prolonged/upper limits of qtc interval. baseline artifact in the inferior leads makes assessment of those leads difficult. findings are non-specific. since the previous tracing of the qtc interval appears longer. . cxr-reason for exam: delirium, status post left hip hardware removal and fever. cardiomediastinal contours are unchanged with stable dilatation of the ascending aorta more conspicuous than in and . right greater than left apical pleural thickening is again noted with scarring in the right apex. as mentioned in prior studies, ct is recommended to assess the dilatation of the ascending aorta and the right upper lobe pleuroparenchymal abnormality. there is no pneumothorax or pleural effusion. there are no new lung abnormalities. . cta chest - 1. ascending thoracic aortic aneurysm,4.4 cm with dimensions as reported above. 2. coronary and aortic valvular calcifications. 3. severe emphysema. 4. consolidative and ground-glass opacity in the superior segments of the left lower lobe. this is likely infectious or inflammatory in etiology, though malignancy cannot be excluded, and a followup chest ct in three months is recommended. smaller nodules as detailed above can also be followed at that time. . hip xr- there has been removal of the hardware in the left hip since the radiographs of . compared to the most recent hip radiographs rom , there has been no significant change. there are again seen cerclage bands within the proximal femur. there is a perpendicular area of lucency in the proximal femur shaft that is stable. there has been removal of the surgical skin staples. the proximal femur is displaced superiorly in relation to the acetabulum. radiation seeds are seen projecting over the prostate. there are mild-to-moderate degenerative changes of the right hip. . blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient mrsa screen mrsa screen-final inpatient tissue gram stain-final; tissue-final; anaerobic culture-final inpatient tissue gram stain-final; tissue-final; anaerobic culture-final inpatient tissue gram stain-final; tissue-final; anaerobic culture-final inpatient discharge labs, wbc 2.3, plt 87 brief hospital course: this was written by your orthopedic team prior to transfer to medicine, patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. please see separately dictated operative report for details. the surgery was uncomplicated and the patient tolerated the procedure well. patient received perioperative iv antibiotics. . postoperative course was remarkable for the following: . 1. pod 0 - patient was sent to the icu from the pacu secondary to hypovolemia and hypotension 2. pancytopenia - worse from baseline. heme consulted, monitored with daily cbcs, temporarily (5 days) stopped azathioprine, and started on heparin 500units sc bid for dvt prophylaxis. otherwise, pain was initially controlled with a pca followed by a transition to oral pain medications on pod#1. the patient received lovenox for dvt prophylaxis starting on the morning of pod#1. the foley was removed on pod#2 and the patient was voiding independently thereafter. the surgical dressing was changed on pod#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. the patient was seen daily by physical therapy. labs were checked throughout the hospital course and repleted accordingly. at the time of discharge the patient was tolerating a regular diet and feeling well. the patient was afebrile with stable vital signs. the patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. the operative extremity was neurovascularly intact and the wound was benign. . the patient's weight-bearing status is non weight bearing at all times on the operative extremity with knee immobilizer on. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ . internal medicine course assessment/plan: 62 yo male with history of htn, gerd, etoh cirrhosis, crohn's s/p ileostomy, copd, depression, pancytopenia, avascular necrosis chronic prednisone use s/p l hip replacement presenting originally for planned l hip revision, but was found unable to be revised because of advanced osteolysis, and so is now s/p total resection arthroplasty. pt noted to be encephalopathic after or, initially medicine consulted for ams and arf then pt was transferred to medicine. . #toxic metabolic encephalopathy- pt with h.o etoh related cirrhosis. per report, no recent drinking in 2 years-pcp and family confirmed this. after procedure, pt had confusion, agitation, and hallucinations. pt had been ordered for higher doses of oxycodone, and benedryl, ativan, and flexeril were ordered prior to medicine transfer. labs were unrevealing, tsh normal, head ct without acute finding. likely etiology was medication effect from benzos, narcotics, flexeril in the setting of poor hepatic and transient poor renal clearance. pt also was not sleeping at night. pt with h.o etoh abuse but no recent drinking per report, etoh withdrawal/dt's could have been a consideration, but pt was without other signs of withdrawal including htn, tachycardia, diaphoresis. pt, pcp, pt's family denied that that been had been drinking for last 2 years. pt also developed delerium 8 days into stay and initially improved with lactulose, making etoh withdrawal less likely. another consideration would be adrenal insufficiency but no recent steroids, cortisol normal. abd u/s without ascites. pt was placed on the protocol, all narcotics and flexerill were dc'd as well as benzos and benedryl. pt's lactulose was uptitrated to 60mg qid. pt was given iv fluids in order to match ostomy outpt from lactulose. discussed case with patient's pcp who reported that pt has had prior hepatic encephalopathy during gi bleed. pcp suggested initiation of rifaximin and stopping nadolol to improve blood flow to liver. all in all, likely toxic encephalopathy due to medications, hepatic causes and transient arf. pt instructed rifaximin until pcp follow up. lactulose was discontinued prior to discharge as pt had remained with a clear mental status for days and had massive ostomy outpt causing metabolic acidosis. pt remained clear off lactulose. however, should confusion reoccur, would start lactulose 30ml tid. due to severe pain, pt was restarted on oxycodone prior to discharge. he did not have any confusion. . #acute renal failure-baseline cr 0.8-1.1. peaked at 2.2 and did have a metabolic acidosis, initially gap, then became non-gap. arf improved with ivf. however, arf transiently reoccurred with increased lactulose dosing and massive ostomy outpt. cr on discharge 0.9. acei was restarted. see above, lactulose and ivf stopped . #s/p l.hip hardware resection (h.o avn due to prednisone-s/p tha-now hardware resection)-no plans for or until mid-. pt will need rehab prior to or procedure and returning home. pt will f/u with ortho after discharge to determine final course/or plan. pain was controlled with standing tylenol (2grams maximum). in addition, pt was started on lidocaine patch. as he still had severe pain, and did have a clear mental status, low dose oxycodone was restarted. pt followed the patient and recommended rehab. . #hypernatremia-thought to be due to increased ostomy outpt and poor po intake while encephalopathic. pt received d51/2 ns with improvement. . #ascending thoracic aortic aneurysm - ascending aorta measuring up to 4.3 cm. root approx 3.8 cm. arch 2.8 cm. descending 2.6 cm. final measurements pending. no evidence of dissection or other acute aortic syndrome. this was discussed with cardiothoracic surgery who recommend appt with dr. and yearly ct scan for monitoring. . #incidental radiographic findings-" consolidative and ground-glass opacity in the superior segments of the left lower lobe. this is likely infectious or inflammatory in etiology, though malignancy cannot be excluded, and a followup chest ct in three months is recommended. smaller nodules as detailed above can also be followed at that time". . #h.o etoh cirrhosis-h.o varices and 1 prior episode of encephalopathy. abdominal ultrasound without ascites. see above. pt was given lactulose, started on rifaximin and nadolol held. lactulose was discontinued prior to discharge as above. rifaximin was continued and nadolol was restarted at 20mg daily given h.o varices. this may be uptitrated to 40mg daily if bp allows. in addition, would restart lactulose for an signs of encephalopathy/confusion . #metabolic acidosis-non-gap-from large ostomy output and ivf ns repletion. improved. chemistry panel should be followed after discharge. . #h.o crohns-ileostomy care. monitored ileostomy outpt. continued azathioprine. . #copd-nebs given prn. . #gerd-continued ppi . #pancytopenia-thought to be related to cirrhosis, portal sequestration, acute illness, and/or medication effect from amongst other things, azithioprine. counts improved. counts were monitored and actually improved during admission. however, wbc decreased to 2.3 and plt to 87 on day of discharge. labs gradually trended down to this over weekend. considered possibility of hit. however, pt with plt count of 30 earlier in course and had been on hep sc bid. plt count improved up to 160 while on heparin. however, counts gradually decreased to 87 on day of discharge. lovenox was started on instead of hep sc. in addition, as plt count trended down as did wbc. hit score was 3 for (>50% drop, but was >day 10 of admit). pt without any signs of thrombosis. pt will need to have wbc and platelet count closely monitoring in the outpatient setting while on lovenox and azathioprine. if continues to decrease will need eval for hit and/or medication effect from azithioprine. . #etoh abuse-pt did not display signs of withdrawal (but did have encephalopathy as above). family/pcp report no drinking in ~2years. pt denied recent etoh. unlikely to be withdrawal as delerium developed 8 days into stay. he was placed on thiamine and folate. . #htn, benign-continued acei, while monitoring renal function. (acei held during periods of arf) . #depression-continued duloxetine, no signs of si. . follow-up after discharge: ***patient requires a repeat chest ct in 3 months*** fen: regular diet, with ivf repletion to match ostomy outpt . dvt ppx: lovenox 40mg sc dailyh . precautions for: falls . code: full . - medications on admission: azathioprine 50 mg2-1/2 tablets daily, cymbalta 60 mg daily, folate 1 mg daily, lisinopril 10 mg daily, lorazepam 0.5 mg at bedtime, nadolol 40 mg daily, oxycontin 20 mg b.i.d., roxicet 5/325 mg one tablet q.4-6h. for breakthrough pain. he takes sodium chloride tablets, also calcium, vitamin b12, magnesium, mvi, and prilosec otc. discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. azathioprine 50 mg tablet sig: 2.5 tablets po daily (daily). 3. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 4. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 5. multivitamin tablet sig: one (1) cap po daily (daily). 6. sodium chloride 1 gram tablet sig: one (1) tablet po qid (4 times a day). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 8. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one (1) tablet po twice a day. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 10. acetaminophen 325 mg tablet sig: two (2) tablet po tid (3 times a day): maximum dose of tylenol 2gm daily. 11. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 12. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). 13. lactulose 10 gram/15 ml syrup sig: forty five (45) ml po qid (4 times a day). 14. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 15. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 16. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous daily (daily). 17. oxycodone 5 mg tablet sig: 0.5-1 tablet po every 6-8 hours as needed for severe pain: hold for any signs of confusion. disp:*10 tablet(s)* refills:*0* 18. outpatient lab work cbc, chem 7 . to monitor pancytopenia and recent arf. discharge wbc 2.3, plt 87, cr 0.9 discharge disposition: extended care facility: rehabilitation and nursing center - discharge diagnosis: failed l total hip replacement hepatic encephalopathy etoh cirrhosis toxic metabolic encephalopathy pancytopenia ascending thoracic aneurysm crohns disease copd discharge condition: level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. mental status: clear and coherent. discharge instructions: you were initially admitted to the orthopedic service for l.hip hardware removal. however, you then developed confusion which is likely due to your known liver impairment and medications for pain. you were given medications called lactulose and rifaximin to help with confusion. your nadolol was stopped to allow for better blood flow to your liver, however this was restarted at 1/2 dose (20mg daily). your pain medications were initially stopped and you were placed on tylenol and a lidocaine patch. your confusion improved on this regimen and your lactulose was able to be stopped and low dose oxycodone able to be restarted. in addition, you were evaluated by physical therapy who determined that you would benefit from a short stay in a rehab facility. . in addition, you were found to have an aneurysm in your thoracic aorta. this was discussed with you. the cardiothoracic team was made aware and have suggested that you be evaluated in clinic. then you will need yearly evaluations in clinic with a ct scan. . you were found to have a haziness on your l.lung. this is likely due to fluid. however, radiology has recommended that you have a repeat ct scan in 3 month's time for reevaluation. please discuss this with your pcp. . the orthopedic doctors be deciding when to replace your hip. please be sure to follow up in clinic for this issue. . medication changes: 1.start lactulose for recurrent confusion 2.start rifaximin for confusion-please discuss with your pcp/gastroenterologist on when to stop 3.start tylenol 650mg three times a day for pain 4.stop oxycontin 5.stop ativan 6.lovenox injections daily to prevent blood clots 7.start nadolol at 20mg daily (instead of 40mg) 8.start oxycodone 5mg every 6 hours as needed for pain. 9.start lidocaine patch for pain. these are instructions written below by the orthopedic team. 1. please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. please follow up with your primary physician regarding this admission and any new medications and refills. 3. resume your home medications unless otherwise instructed. 4. you may not drive a car until cleared to do so by your surgeon or your primary physician. 5. please keep your wounds clean. you may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. no dressing is needed if wound continues to be non-draining. any stitches or staples that need to be removed will be taken out by the visiting nurse (vna) or rehab facility two weeks after your surgery. 6. please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 7. please do not take any non-steroidal anti-inflammatory medications (nsaids such as celebrex, ibuprofen, advil, aleve, motrin, etc). 8. anticoagulation: please continue lovenox stockings x 6 weeks. 9. wound care: please keep your incision clean and dry. it is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. check wound regularly for signs of infection such as redness or thick yellow drainage. staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 10. vna (once at home): home pt/ot, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 11. activity: non weight bearing at all times on the operative extremity. posterior precautions. no strenuous exercise or heavy lifting until follow up appointment. followup instructions: please have your rehab facility call your pcp . at to schedule a follow up appointment after your discharge from rehab. provider: , : date/time: 11:00 orthopedics . department: cardiac surgery when: monday at 2:00 pm with: , md building: lm campus: west best parking: . garage Procedure: Arthrotomy for removal of prosthesis without replacement, hip Diagnoses: Thrombocytopenia, unspecified Esophageal reflux Toxic encephalopathy Long-term (current) use of steroids Alcoholic cirrhosis of liver Acute kidney failure, unspecified Thoracic aneurysm without mention of rupture Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Alcohol abuse, unspecified Regional enteritis of unspecified site Personal history of other malignant neoplasm of skin Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Hepatic encephalopathy Hyperosmolality and/or hypernatremia Aseptic necrosis of head and neck of femur Delirium due to conditions classified elsewhere Hip joint replacement Esophageal varices without mention of bleeding Benign essential hypertension Other colostomy and enterostomy complication Unspecified drug or medicinal substance causing adverse effects in therapeutic use Family history of other blood disorders Peri-prosthetic osteolysis

allergies: no known allergies / adverse drug reactions attending: addendum: patient was stable for discharge on sunday , but rehab was unable to admit secondary to power outage at facility. patient was discharged to rehab in stable condition on . pertinent results: 06:20am blood wbc-1.3* rbc-2.76* hgb-9.3* hct-27.0* mcv-98 mch-33.8* mchc-34.6 rdw-18.6* plt ct-46* 06:20am blood glucose-109* urean-13 creat-0.6 na-138 k-3.7 cl-108 hco3-24 angap-10 06:20am blood calcium-8.4 phos-2.9 mg-1.4* discharge disposition: extended care facility: rehabilitation and nursing center - md Procedure: Revision of hip replacement, both acetabular and femoral components Diagnoses: Thrombocytopenia, unspecified Esophageal reflux Unspecified essential hypertension Long-term (current) use of steroids Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Thoracic aneurysm without mention of rupture Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Regional enteritis of unspecified site Personal history of other malignant neoplasm of skin Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Congenital insufficiency of aortic valve Ileostomy status Hip joint replacement Esophageal varices without mention of bleeding Alcohol abuse, in remission Family history of other blood disorders Peri-prosthetic osteolysis

allergies: no known allergies / adverse drug reactions attending: chief complaint: r hip pain major surgical or invasive procedure: : s/p left total hip revision history of present illness: 62 year old man with cirrhosis c/b grade 1 esophageal varices and past gib's, crohn's s/p ileostomy, copd, htn, pancytopenia, gerd, depression, avascular necrosis chronic prednisone use s/p l hip replacement with massive osteolysis of pelvis/acetabulum and proximal femur, extended femoral osteotomy (clamshell) with multiple open reduction and internal fixations who is admitted to the icu for monitoring after 3rd attempt of total hip replacement. . the patient was previously discharged on s/p total resection arthroplasty on . post-operatively, the patient was noted to be confused coming out of the or and overnight. he was initially transferred to icu post surgery because of hypotension and was on pressors with subsequent normalization of blood pressures. post-op course was also complicated by hepatic/toxic-metabolic encephalopathy, cleared with rifaximin and lactulose, and by acute kidney injury. past medical history: past medical history: - htn - dyslipidemia - ascending aortic aneurysm, not involving the coronary vessels - bicuspid aortic valve - etoh cirrhosis c/b esophageal varices and bleeding: baseline liver enzymes alt 21, ast 30, alk 190, tbili 1.2 - pancytopenia: baseline wbc 1.7, hgb 12.3, hct 35.8, plt 54 - thrombocytopenia - crohn's disease s/p ileostomy - prostate cancer - kyphosis - copd - gerd - squamous cell carcinoma s/p resection - avascular necrosis of left hip secondary to prednisone - depression - baseline bun 15, cr 1.0 . past surgical history: - squamous cell carcinoma excisions x 3 forehead () - l distal radius orif () - partial colectomy with transverse colostomy and mucous fistula - mucous fistula takedown - left wrist surgery - left hip replacement (20 years ago) - avascular necrosis of left hip secondary to crohn's/prednisone, - complex complete resection arthroplasty of failed left total hip replacement; extended femoral osteotomy (clamshell) with multiple open reduction and internal fixation cerclage wires social history: he is retired from the department of social services, former widower, has a girlfriend. - tobacco: previous use - alcohol: prior history of alcohol abuse, no longer drinking in 22 months per pt, family and pcp. : denies family history: positive for hemophilia but not affecting this patient, although he does have thrombocytopenia. physical exam: well appearing in no acute distress afebrile with stable vital signs pain well-controlled respiratory: ctab cardiovascular: rrr gastrointestinal: nt/nd, ostomy rlq, hernia llq genitourinary: voiding independently neurologic: intact with no focal deficits psychiatric: pleasant, a&o x3 musculoskeletal lower extremity: * incision healing well with staples * scant serosanguinous drainage * thigh full but soft * no calf tenderness * 5/5 strength * silt, nvi distally * toes warm pertinent results: 11:30am blood hgb-12.5* hct-34.4* plt ct-53* 06:00pm blood hgb-9.7* hct-27.6* plt ct-85*# 08:43pm blood wbc-1.9* rbc-3.36* hgb-11.5* hct-33.2* mcv-99* mch-34.2* mchc-34.6 rdw-18.3* plt ct-62* 03:39am blood wbc-3.4*# rbc-3.01* hgb-10.6* hct-29.3* mcv-97 mch-35.2* mchc-36.2* rdw-19.2* plt ct-84* 04:07pm blood wbc-3.7* rbc-2.66* hgb-9.2* hct-25.5* mcv-96 mch-34.8* mchc-36.2* rdw-18.9* plt ct-83* 06:20am blood wbc-1.5*# rbc-2.15* hgb-7.5* hct-21.1* mcv-98 mch-35.0* mchc-35.6* rdw-19.3* plt ct-51* 12:30am blood wbc-1.8* rbc-2.68* hgb-9.0* hct-25.4* mcv-95 mch-33.7* mchc-35.5* rdw-18.6* plt ct-43* 06:25am blood wbc-1.2* rbc-2.71* hgb-9.2* hct-26.1* mcv-97 mch-33.9* mchc-35.1* rdw-18.6* plt ct-42* 07:20am blood wbc-1.3* rbc-2.79* hgb-9.6* hct-26.8* mcv-96 mch-34.3* mchc-35.7* rdw-18.3* plt ct-43* 07:20am blood wbc-1.3* rbc-2.79* hgb-9.6* hct-26.8* mcv-96 mch-34.3* mchc-35.7* rdw-18.3* plt ct-43* 06:05am blood wbc-1.3* rbc-2.79* hgb-9.7* hct-27.5* mcv-99* mch-34.9* mchc-35.4* rdw-18.8* plt ct-42* 08:43pm blood neuts-88.5* bands-0 lymphs-3.9* monos-7.0 eos-0.5 baso-0.1 03:39am blood neuts-89.0* bands-0 lymphs-4.2* monos-6.2 eos-0.1 baso-0.5 07:20am blood neuts-80.2* lymphs-9.1* monos-7.6 eos-2.5 baso-0.5 08:43pm blood glucose-140* urean-14 creat-0.7 na-138 k-4.6 cl-113* hco3-19* angap-11 03:39am blood glucose-119* urean-16 creat-0.8 na-138 k-4.4 cl-112* hco3-19* angap-11 06:20am blood glucose-135* urean-17 creat-0.9 na-140 k-3.6 cl-109* hco3-24 angap-11 06:25am blood glucose-94 urean-13 creat-0.7 na-141 k-3.3 cl-109* hco3-25 angap-10 07:20am blood glucose-98 urean-11 creat-0.7 na-142 k-3.4 cl-108 hco3-24 angap-13 06:05am blood glucose-134* urean-12 creat-0.9 na-140 k-3.6 cl-108 hco3-24 angap-12 brief hospital course: the patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. please see separately dictated operative report for details. the surgery was uncomplicated and the patient tolerated the procedure well. patient received perioperative iv antibiotics. postoperative course was remarkable for the following: 1. icu course: # s/p left hip replacement: patient tolerated the procedure well per ortho although he did have significant blood loss and fluid shifts. he had a rij placed in the or the postition of which was confirmed on presentation to the . post-op hct stable at 33.2. he received ancef for 24 hours after the procedure. was intubated on admission to unit. he was cautiously weaned from the vent and from propofol given his prior history of difficulty with extubation and altered mental status. opiods were avoided in management of the patient's pain. he was given small fentanyl boluses for pain through the night. he was extubated in the morning without difficulty. the jp drains contained serosanginous fluid, and on pod1 the patient was started on enoxaparin 40mg sc daily. pain management was an issue given the patient's underlying hepatic dysfunction. the acute pain and the chronic pain services were consulted regarding a lumbosacral block. it was decided that in place of a lumbosacral block, the patient's dilaudid pca would be increased to dose to .24/6m and his long-acting oxycontin po 10 mg q6h. the patient was successfully extubated upon leaving the . . # etoh cirrhosis - blood transfusions and insult of surgery would contribute to higher likelihood of post-op hepatic encephalopathy. patient does have history of grade 1 varices as well. mental status was monitored through course and the patient did not have hepatic encephalopathy on exam. lactulose was started after the patient was extubated. his home nadolol was initially held low bp, but this was restarted after extubation. . # pancytopenia - history of thrombocytopenia cirrhosis as well as pancytopenia, (which on previous workup by heme/onc was felt to medication, portal sequestration). macrocytic anemia consistent with history of alcohol and cirrhosis. cbc was monitored with a goal of keeping platelets > 10 or 50 if acute bleeding. through his course in the , the patient had an active type and screen. no transfusions were required post-operatively in the . . # crohn's disease - stable, not having diarrhea. continued with azathioprine when taking pos. . # htn - initially held lisinopril for now pending fluid shifts and post op hypotension. . # copd - documented h/o copd in omr but on no home medications. # ascending aortic aneurysm: stable on recent echo. vs were monitored. . # depression: home duloxitine was continued. 2. asymptomatic post-operative anemia - pod 2 hct 21.1 -> transfused 2 units prbcs 3. medicine consult for co-management otherwise, pain was initially controlled with a pca followed by a transition to oral pain medications on pod#2. the patient received lovenox for dvt prophylaxis starting on the morning of pod#1. the foley was removed on pod#2 and the patient was voiding independently thereafter. the surgical dressing was changed on pod#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. the patient was seen daily by physical therapy. labs were checked throughout the hospital course and repleted accordingly. at the time of discharge the patient was tolerating a regular diet and feeling well. the patient was afebrile with stable vital signs. the patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. the operative extremity was neurovascularly intact and the wound was benign. the patient's weight-bearing status is touchdown weight bearing on the operative extremity with posterior and trochanter off precautions. mr. is discharged to rehab in stable condition. medications on admission: medications at home: azathioprine - (prescribed by other provider) - 50 mg tablet - 2-1/2 tablet(s) by mouth once daily duloxetine - (prescribed by other provider) - 60 mg capsule, delayed release(e.c.) - one capsule(s) by mouth daily folic acid - (prescribed by other provider) - 1 mg tablet - 1 tablet(s) by mouth once daily lisinopril - (prescribed by other provider) - 10 mg tablet - one tablet(s) by mouth daily nadolol - (prescribed by other provider) - 40 mg tablet - one tablet(s) by mouth daily oxycodone - (prescribed by other provider) - 20 mg tablet extended release 12 hr - 1 tablet(s) by mouth twice daily oxycodone-acetaminophen - (prescribed by other provider) - 5 mg-325 mg tablet - 1 tablet(s) by mouth every 4-6 hours as needed for pain sodium chloride - (prescribed by other provider) - - 4 mg daily trazodone - (prescribed by other provider) - 50 mg tablet - 1 tablet(s) by mouth once a day . medications - otc calcium - (prescribed by other provider) - dosage uncertain cyanocobalamin (vitamin b-12) - (prescribed by other provider) - dosage uncertain magnesium oxide - (prescribed by other provider) - 400 mg tablet - 6 tablet(s) by mouth three times a day multivitamin - (prescribed by other provider) - dosage uncertain omeprazole magnesium - (prescribed by other provider) - 20 mg tablet, delayed release (e.c.) - two tablet(s) by mouth daily . medications on transfer to icu: -lisinopril 10 mg po/ng daily -acetaminophen 650 mg po q6h -milk of magnesia 30 ml po bid:prn constipation -bisacodyl 10 mg po/pr daily:prn constipation -multivitamins 1 cap po daily -cefazolin 2 g iv q8h (2 hrs post-op) -nadolol 40 mg po daily -calcium carbonate 500 mg po tid -oxycodone (immediate release) 5-10 mg po q4h:prn pain start: in am begin after pca has been d/c -docusate sodium 100 mg po bid -ondansetron 4 mg iv q8h:prn nausea/vomiting -duloxetine 60 mg po daily -omeprazole 20 mg po daily -enoxaparin sodium 40 mg sc daily start: in am begin on wednesday -senna 1 tab po bid -folic acid 1 mg po/ng daily -vitamin d 400 unit po daily order date: @ 1103 -hydromorphone (dilaudid) 0.12 mg ivpca lockout interval: 6 minutes basal rate: 0 mg(s)/hour 1-hr max limit: 1.2 mg(s) discharge medications: 1. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 2. multivitamin tablet sig: one (1) cap po daily (daily). 3. duloxetine 30 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 4. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 7. nadolol 20 mg tablet sig: two (2) tablet po daily (daily). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q8h (every 8 hours). 10. azathioprine 50 mg tablet sig: 2.5 tablets po daily (daily). 11. enoxaparin 40 mg/0.4 ml syringe sig: one (1) syringe subcutaneous daily (daily) for 3 weeks. disp:*21 syringe* refills:*0* 12. aspirin, buffered 325 mg tablet sig: one (1) tablet po twice a day for 3 weeks: after completing lovenox, take as directed with food. disp:*42 tablet(s)* refills:*0* 13. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): take while on strong pain medication. disp:*2700 ml(s)* refills:*2* 14. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: hold for confusion. disp:*50 tablet(s)* refills:*0* 15. outpatient lab work daily cbc with diff at rehab until his wbc counts increase. if he were to become neutropenic or show signs of infection, would recommend stopping azathioprine. would transfuse prn for goal plt >10 and hct > 21. discharge disposition: extended care facility: rehabilitation and nursing center - discharge diagnosis: failed left total hip replacement post-operative anemia due to blood loss chronic pancytopenia *anticipated length of stay < 30 days* 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: 1. please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. please follow up with your primary physician regarding this admission and any new medications and refills. 3. resume your home medications unless otherwise instructed. 4. you have been given medications for pain control. please do not drive, operate heavy machinery, or drink alcohol while taking these medications. as your pain decreases, take fewer tablets and increase the time between doses. this medication can cause constipation, so you should drink plenty of water daily to prevent this side effect. call your surgeons office 3 days before you are out of medication so that it can be refilled. these medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. please allow an extra 2 days if you would like your medication mailed to your home. 5. you may not drive a car until cleared to do so by your surgeon. 6. please keep your wounds clean. you may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. no dressing is needed if wound continues to be non-draining. any stitches or staples that need to be removed will be taken out by the visiting nurse (vna) or rehab facility two weeks after your surgery. 7. please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. please do not take any non-steroidal anti-inflammatory medications (nsaids such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. anticoagulation: please continue your lovenox for three (3) weeks to help prevent deep vein thrombosis (blood clots). after completing the lovenox, please take aspirin 325mg twice daily for three weeks. stockings x 6 weeks. 10. wound care: please keep your incision clean and dry. it is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. check wound regularly for signs of infection such as redness or thick yellow drainage. staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. vna (once at home): home pt/ot, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. activity: touchdown weight bearing on the operative extremity. posterior and trochanter off precautions. no strenuous exercise or heavy lifting until follow up appointment. physical therapy: lle touchdown weight bearing posterior and trochanter off precautions mobilize treatments frequency: dry sterile dressing daily as needed for drainage wound checks ice as tolerated staple removal pod 17 - replace with steristrips teds followup instructions: provider: , : date/time: 11:00 Procedure: Revision of hip replacement, both acetabular and femoral components Diagnoses: Thrombocytopenia, unspecified Esophageal reflux Unspecified essential hypertension Long-term (current) use of steroids Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Thoracic aneurysm without mention of rupture Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of prostate Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Regional enteritis of unspecified site Personal history of other malignant neoplasm of skin Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Congenital insufficiency of aortic valve Ileostomy status Hip joint replacement Esophageal varices without mention of bleeding Alcohol abuse, in remission Family history of other blood disorders Peri-prosthetic osteolysis

allergies: penicillins / cefazolin / clindamycin attending: chief complaint: abdominal pain major surgical or invasive procedure: none history of present illness: this is a 56 year old man who presented today with acute abdominal pain and nausea without actual vomiting. in ed, he underwent abdominal ultrasound followed by ct of the abdomen. the u/s was technically limited study due to body habitus but there was no evidence for cholelithiasis or cholecystitis. the ct woith contrast showed no acute intra-abdominal process. therefore, he was admitted for further work up after he received iv fluids and antibiotics for unclear reason. the patient was discharged on after 24 hour admission for chest pain with negative workup including cta of the chest (embolism protocol), ekg, cardiac enzymes, and nuclear stress test. he was also admitted between and for "near syncope". the discharge diagnosis was daytime somnolence related to obstructive sleep apnea. he had no orthostasis, hypoglycemia, events on telemetry, or seizure events on continuous eeg monitoring. during that admission, he had nonsignificant carotid ultrasounds and a transthoracic echocardiogram. in , he had admissions related to his diabetic foot and cellulitis. in regards to his current symptoms, he described diffuse mostly upper abdominal pain, sharp, nonradiating since :00 pm last night. no radiation to the back or to the groin. the pain was not related to food. he actually did not eat since last night. this was associated with only nausea and no actual vomiting (although ed m.d documents vomiting at home; nonbloody nonbilious) and no diarrhea. his last bowel movement was regular and nonbloody this morning. he had no fever, chills, chest pain, or shortness of breath. he has stable chronic doe. he denied previous similar abdominal pain. he never had gallstones or kidney stones. he denies hematuria. he denied alcoholism, pancreatitis, or drug seeking or abuse. ros: all remaining systems were reviwed and symptoms were negative. past medical history: - diabetes with neuropathy - right hallux amputation for osteomyelitis - morbid obesity - chronic venous stasis - possible pseudomonas bacteremia (referenced in the chart but not documented by microbiology) - hypertension - obstructive sleep apnea social history: on disability for hand neuropathy. he is married, no children, lives with wife. denies smoking at any time in his life. denies etoh or drugs. currently unemployed former machine assembly worker. family history: mother: copd, died of stroke father: copd, dm, chf, committed suicide physical exam: gen: middle aged male, morbidly obese, laying comfortably on bed heent: perrl, mmm, op clear, small airway neck: supple, difficult to assess for jvd obesity chest: cta bilaterally, no wheezes, rales, ronchi cv: rrr, nls1/s2, 2/6 systolic loudest at axilla abd: bs+, soft obese, diffuse non sepcific tendeness without gaurding or peritoneal signs, no hernia skin: slight erythema under abdominal pannus, dry, no discharge; bruising over abdomen c/w hsq injections ext: 1+ ble edema with signs chronic venous stasis bilaterally, 1+ dp/pt/radial pulses. no active cellulitis neuro: aox3, cn 2-12 intact, loss of fine sensation over hands/feet, motor , slow wide-based gait pertinent results: persantine perfusion stress no anginal symptoms or ischemic st segment changes. appropriate hemodynamic response to the persantine infusion. probably normal myocardial perfusion. fixed inferior wall defect most consistent with attenuation. normal left ventricular cavity size and systolic function. . cta chest 1. no evidence of pe. 2. coronary artery calcifications consistent with coronary artery disease. . echocardiogram the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. there is no aortic valve stenosis. no aortic regurgitation is seen. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion . carotid series: impression: right ica stenosis 40-59%. left ica stenosis 40-59%. . today: abdominal u/s was technically limited study due to body habitus but there was no evidence for cholelithiasis or cholecystitis. . today: the ct with contrast showed no acute intra-abdominal process brief hospital course: this is a 56 year old morbidly obese man who presented with acute diffuse abdominal pain and nausea without actual vomiting, diarrhea, or fever. the patient was admitted twice recently for unrelated symptoms (near syncope on one admission and a chest pain during a second admission). so far, including the 2 recent admissions, he had unremarkable cta of the chest (embolism protocol), ekg, cardiac enzymes, nuclear stress test, carotid ultrasound, transthoracic echocardiogram, abdominal ultrasound , and, finally, contrast ct of the abdomen. in regards to his current presentation, complete labs (cbc, chem 7, and lft's) and abdominal examination were normal and with only diffuse nonspecific tenderness. the ct of the abdomen was with contrast and did not support any diagnosis or any intraabdominal inflammatory process. the u/s also did not show any evidence of gallstones or cholecystitis. however, it was a technically limited examination. the patient was initially managed conservatively with npo, iv fluids, and pain medications. his pain worsened and became localized to the right side. in addition, he developed fever and leukocytosis the following day. therefore, surgery was consulted for the possibility of appendicitis. finally, a hida scan was done because of more localized pain to the ruq. the hida showed acute acalculous cholecystitis. the patient was then admitted to the micu because of new relative hypotension and for monitoring after percutaneous cholecystostomy with drain placed by ir for presumed acalculous cholecystitis. copious purulent drainage noted during procedure. there was concern for bacteremia and acute peritonitis post-procedure given his degree of pain and hypotension. he was started on ciprofloxacin, flagyl, and vancomycin. he was volume resuscitated with 1.5 l of ns post-procedure. he did not require additional ivf boluses but was kept on 150 ml ns continuous while npo per surgery recommendations. he was hemodynamically stable in icu: no additional hypotension, fever, or severe abdominal pain. foley catheter was discontinued. he was continued on the same antibiotics. bile cultures grew gpcs in pairs and chains (streptococcus; multiple growth). the biliary drain was productive of clear yellow fluid. he was sent to the floor only after a short micu course. he was seen by id regarding the optimal choice of antibiotics. they recommended moxifloxacin for total 14 days. surgery continued to follow him with a plan for potential lap cholecystectomy in 6 weeks. he remained clinically stable with only minimal symptoms post percutaneous cholecystostomy. specifically, he had no fever or gi symptoms. he was discharged home with vna and follow up with acute care surgery and bariatric surgery for cholecystectomy. medications on admission: smae as discharge medications: 1. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 2. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 3. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 4. lorazepam 1 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety. 5. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 6. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 7. aspirin 81 mg tablet sig: one (1) tablet po once a day. 8. multivitamin tablet sig: one (1) tablet po once a day. 9. insulin nph & regular human 100 unit/ml (70-30) insulin pen sig: thirty six (36) units subcutaneous twice a day. 10. humalog sliding scale humalog sliding scale . nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual once a day as needed for chest pain. 12. mupirocin calcium 2 % cream sig: one (1) appl topical daily (daily) as needed for to affected foot. 13. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion. disp:*50 tablet, chewable(s)* refills:*2* discharge medications: 1. gabapentin 300 mg capsule sig: one (1) capsule po q8h (every 8 hours). 2. lorazepam 1 mg tablet sig: one (1) tablet po bid prn () as needed for anxiety. 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 7. hydromorphone 2 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 8. moxifloxacin 400 mg tablet sig: one (1) tablet po daily () for 10 days. disp:*10 tablet(s)* refills:*0* 9. lasix 40 mg tablet sig: one (1) tablet po twice a day. 10. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 11. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 12. nph insulin human recomb 100 unit/ml (3 ml) insulin pen sig: thirty six (36) units subcutaneous twice a day. 13. humalog 100 unit/ml solution sig: one (1) home dose per sliding scale subcutaneous three times a day. discharge disposition: home with service facility: vna discharge diagnosis: acalculous cholecystitis obesity diabetes discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted because of inflammation in the gallbladder. we did place a tube in your gallbladder to drain the infected fluid. you need to follow up with dr. with bariatric surgery in few weeks to have your gallbladder removed. you will also follow up with acute surgery clinic regarding your gallbladder tube. followup instructions: department: podiatry when: friday at 9:15 am with: clinic (sb) building: ba ( complex) campus: west best parking: garage department: when: friday at 2:10 pm with: , md building: sc clinical ctr campus: east best parking: garage department: medical specialties when: wednesday at 9:20 am with: drs / building: sc clinical ctr campus: east best parking: garage department: surgical specialties when: wednesday at 3:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: general surgery/ when: thursday at 1:45 pm with: acute care clinic (dr. ) building: lm bldg () campus: west best parking: garage Procedure: Percutaneous aspiration of gallbladder Diagnoses: Obstructive sleep apnea (adult)(pediatric) Unspecified essential hypertension Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Polyneuropathy in diabetes Morbid obesity Acute cholecystitis Other toe(s) amputation status Venous (peripheral) insufficiency, unspecified Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Narcolepsy, without cataplexy

allergies: penicillins / cefazolin / clindamycin attending: addendum: pertinent results: ct pelvis: impression: 1. no acute process within the torso. 2. enlarged right external iliac lymph nodes. please correlate clinically. upon discussion with the resident, the patient has a right sided lower extremity cellulitis. these enlarged lymph nodes may be reactive and a follow up ct of the pelvis could be performed after treatment to assess for resolution. tib-fib xrays findings: there is evidence of prior amputation at the large portion of the first metatarsal bone and distally. in the remnant bone, there is some hypertrophic change but no evidence of lytic/destructive lesion or periosteal reaction. the joint spaces are normal. there is no fracture or dislocation. no gaseous density is appreciated within the visualized soft tissues. impression: no radiographic evidence for osteomyelitis. cxr findings: as compared to the previous radiograph, a new picc line has been inserted over the right upper extremity. the course of the line is unremarkable, the tip of the line projects over the mid svc. there is no evidence of complications, notably no pneumothorax. unchanged course and position of the pre-existing right central venous access line. unchanged appearance of the lung parenchyma, unchanged size of the cardiac silhouette. dvt findings: grayscale and color doppler son were performed of the left common femoral, superficial femoral, and popliteal veins, demonstrating normal compression, flow, and augmentation. normal color flow is also demonstrated in the left posterior tibial and peroneal veins. there is no intra-luminal thrombus. impression: no evidence of dvt in the left lower extremity. dvt findings: -scale and color doppler son were performed of the right common femoral, superficial femoral, and popliteal veins, demonstrating normal compression, color flow, and augmentation. color flow in the posterior tibial and peroneal veins are also demonstrated. impression: no evidence of dvt in the right lower extremity. discharge disposition: home with service facility: home solutions md Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acidosis Esophageal reflux Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Polyneuropathy in diabetes Ulcer of other part of foot Other and unspecified hyperlipidemia Cellulitis and abscess of leg, except foot Unspecified sleep apnea Septic shock Morbid obesity Diabetes with neurological manifestations, type II or unspecified type, uncontrolled

allergies: penicillins / cefazolin / clindamycin attending: chief complaint: fever, pre-syncope major surgical or invasive procedure: ij catheter placement picc line placement history of present illness: is a 55 yo male with a history of type ii dm, morbid obesity, history of cellulitis who presents to osh with pre-syncope. the patient reports that he has felt unwell, generally fatigued for a week. yesterday morning, he felt nauseated, confused, sweaty and lightheaded around 1 pm. he also noted a severe headache, right sided neck & jaw pain, nausea, diffuse abdominal pain and some transient chest pain. he was taken to an osh for evaluation and found to have a fever, bandemia and hypotension. his wife had also reported that he seemed forgetful and slow to respond to questions. ct head was negative for an acute process. an lp was attempted at the osh but unable to perform given morbid obesity. he was started on vancomycin and ceftriaxone to cover possible meningitis. patient was also give reglan and zofran for vomiting. his neck pain resolved in the ed with tylenol and motrin. the patient reports that his lower leg cellulitis has been stable, but his wife reports that the posterior reddness on the right leg and the warmth is new in the past 24 hours. he has a chronic non-healing ulceration on the right foot. . in the ed, initial vs were: 102.7 107 116/74 22 98% on 10l/nrb. patient was noted to be hypotensive, febrile with non-focal neuro exam. he was noted to have chronic bilat erythema of le. his headache and neck pain resolved by the time he reached our ed. a ct torso was performed to evaluate for potential eitologies of sepsis. patient was given meropenem 1000 mg iv, midazolam 4mg iv x1 for sedation for ct scan, acetaminophen 325mg x1, ibuprofen 600mg tablet x 1, fentanyl citrate 100mcg iv x1. in the ed, patient was hypotensive with sbp in 70s; he was given 3+l of ivf and was started on norepinephrine with improvement in sbp to 100. vs prior to transfer were 98.1 61 108/65 15 100% . on arrival to the icu, the patient reports that he feel much better. he reports mild diffuse abdominal pain and feeling thirsty. patient denies recent travel, surgery/medical procedures, recent sick contacts or exposure to pets/animals. . review of sytems: (+) per hpi and fever, slight cough (np), mild diffuse, diarrhea x1, joint and muscle pain which is at baseline related to arthritis and neuropathy. (-) denies chills, night sweats, recent weight loss or gain. denies sinus tenderness, rhinorrhea or congestion. denied shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation, brbpr. no recent change in bowel or bladder habits. no dysuria/hematuria. past medical history: diabetes c/b neuropathy and le ulceration. s/p right hallux amputation for osteomyelitis morbid obesity cellulitis associated with le ulcer pseudomonas bacteremia hypertension hyponatremia ? obstructive sleep apnea social history: married, no children, lives with his wife in . he is a nonsmoker, no alcohol, no drugs. he worked for diagnostics, but he recently lost his job. his wife lost her job approximately two years ago, so there have been recent financial stressors. family history: mother: copd, died of chf. father: copd, dm, chf physical exam: vitals: 70 108/58 18 93% wt 190 kg general: morbidly obese, alert, oriented x3, no acute distress heent: ncat, perrla, eomi, sclera anicteric, mmm, oropharynx clear neck: supple, unable to assess jvp, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: distant heart sounds, regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place. ext: 2+ radial pulses, pt & dp pulses were dop+ bilat, warm, well perfused, no clubbing, cyanosis or +3 pitting edema bilat. skin: right lower extremity, posterior calf with marked erythema, to mid-tibia, 4 cm skin tear/ulceration slightly proximal to achilles tendon, area warm compared to other leg. unable to unwrap bandage on right lower foot at this time. neuro: cn 2-12 intact, strength 5/5 in ue bilat, 4-/5 le bilat pertinent results: labs @ notable for wbc 18.8 with n:88% b:3% bun 21 cr 1.4 (baseline 1.2) ck & trop neg lactate 3.9 --> 1.9 lfts wnl lipase 99 u/a with trace ketones and glucose but neg for infection hosp labs: wbc 13 n: 82% b: 10% hct 45 cr 1.1 trop 0.02 ddimer 920 . micro: blood cx & urine culture pending . images: ct torso w/contrast 1. no acute process within the torso. 2. enlarged right external iliac lymph nodes. please correlate clinically. upon discussion with the resident, the patient has a right sided lower extremity cellulitis. these enlarged lymph nodes may be reactive and a follow up ct of the pelvis could be performed after treatment to assess for resolution. . cxr -- right ij in place, no infiltrates/effusions, no ptx. . ekg: st hr 103 nl axis, nl intervals, poor r wave progression, inferior q waves, twf in iii & avf, no st changes. no significant change from previous dated brief hospital course: 55 yo male with a history of type ii dm, morbid obesity, history of cellulitis who presents to osh with pre-syncope found to be hypotensive, with evidence of ongoing infection. * sepsis secondary to cellulitis: presented with hypotension, fevers and leukocytosis in the setting of a rle cellulitis. on admission with ct abd without obvious source, but with enlarged r external iliac ln. no evidence of uti, pneumonia on labs or imagin. his rle had a brawny, red cellulitis and this was thought to be the source of infection. he was started empirically on vancomycin and meropenam and while in the icu required levophed for his hypotension. pressors were weaned off during the first hospital day. he was transitioned to the floor and had continued improvement in his rle erythema. podiatry was also consulted given his history of toe amputation and chronic foot ulceration on the plantar aspect of his right foot. the podiatry service felt that this did not probe to bone and this was consistent with hypertrophic bone from his previous amputation. he is scheduled for follow up with podiatry after discharge to monitor this. initially recommended mri of the rle to rule out a deeper soft tissue infection, but given the rapid improvement with antibiotics, this was deferred. the surgical service was also consulted, who did not feel that his leg needed surgical exploration or debridement given the rapid improvement. a rle dvt study was negative for dvt. a wound swab was performed which ultimately grew strep b and diptheroids. he was transitioned to levofloxacin and flagyl for gnr and anaerobic coverage in addition to vancomycin, which will need to be continued until . his vancomycin dose on discharge was 1g tid down from 1.5g tid. his vancomycin trough will need to be checked on am and readjusted based on his value. of note, per ct report, his ct torso will need to be repeated to assess for resolution of his r external iliac lymphadenopathy. * acute kidney injury: cr 1.4 from 1.2. patient's labs consistent with pre-renal eitology. pt was treated with ivf and lisinopril was held. lisinopril was restarted prior to discharge. * metabolic acidosis: initially patient with ag of 14 and + lactate. this is secondary to hypoperfusion from septic shock. lactate improve with fluid resuscitation. * diabetes mellitus, type ii - was consulted for his diabetes management. nph was increased to 36 units in the morning and 26 units at bedtime. his humalog sliding scale was also changed. metformin was restarted at discharge. he will have follow up with after discharge. * hypertension - antihypertensives were held on admission, but where restarted on discharge. he was instructed to continue lisinopril 20mg daily * hyperlipidemia - continue statin * chest pain - per patient, has no history of cad. he developed chest pain in the hospital. it was relieved with nitro x 2. ekg was negative and troponins remained negative. this was also in the setting of removal of a guidewire from a picc line. cxr was negative for pneumothorax or malpositioned picc line. he had no further episode of pain. of note, an ekg was checked prior to discharge and his qtc was wnl (given that he was discharged on levofloxacin). * le edema - lasix was increased to 40mg . his le edema should be monitored as an outpatient and his creatinine should be followed regularly. * gerd - pt did not have a history of gerd on admission, but transitioned out of the icu with pantoprazole. pt was instructed to follow up with his pmd regarding this issue to determine if he should continue. * ? sleep apnea - per patient, he had been tried on bipap in the icu. he should follow up with his pmd regarding getting scheduled for a sleep study to determine if he should have this continued as an outpatient. medications on admission: # lasix 40 mg tab oral po daily # lisinopril 20 mg po daily # metformin 500 mg tab po bid # gabapentin 300 mg po bid # atenolol 25 mg tab oral po daily # ativan 1 mg po qhs # simvastatin 20 mg tab po qhs # nph insulin 28 units in am/22 units at bedtime sc # insulin regular human 15 units sc prior to meals discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po every twenty-four(24) hours. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 3. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 4. furosemide 40 mg tablet sig: one (1) tablet po every twelve (12) hours. 5. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 9 days. disp:*27 tablet(s)* refills:*0* 6. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 9 days. disp:*9 tablet(s)* refills:*0* 7. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 8. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual once a day as needed for chest pain. disp:*100 tablet, sublingual(s)* refills:*0* 9. nph insulin human recomb 100 unit/ml (3 ml) insulin pen sig: thirty six (36) subcutaneous twice a day: 36 units at breakfast and 26 units at bedtime. 10. humalog pen 100 unit/ml insulin pen sig: per sliding scale subcutaneous three times a day as needed for hyperglycemia. disp:*5 pens* refills:*0* 11. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 8h (every 8 hours) for 9 days. disp:*27 * refills:*0* 12. cortisone 1 % cream sig: one (1) appl topical daily (daily) as needed for erythema, pruritis: apply to infected area. disp:*1 packet* refills:*0* 13. metformin 500 mg tablet sig: one (1) tablet po twice a day. 14. insulin pen needle 29 x needle sig: one (1) miscellaneous three times a day. disp:*120 0* refills:*0* 15. outpatient lab work please check vancomycin trough on before 1st dose and fax results to ( (dr. ) 16. outpatient lab work please check cbc, chem 10 panel, lfts every wednesday while on vancomycin. please fax results to dr. at (. discharge disposition: home with service facility: home solutions discharge diagnosis: cellulitis septic shock diabetes mellitus hypertension hyperlipidemia obesity 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 with low blood pressure from your cellulitis. you were sent to the icu and started on antibiotics. you improved and transferred to the floor and continued to improve. you will need to continue antibiotics until . you were transitioned to 2 different oral antibiotics called levofloxacin and flagyl, which you will need to take until . please check you weights daily. if you gain more than 3 pounds in 24 hours please call your primary care provider. medication changes: 1. vancomycin (antibiotic) was added to 2. levofloxacin was started 3. flagyl was started 4. your insulin regimen was changed, please refer to the sliding scale that service gave you. 5. increase lasix to 40 mg twice daily followup instructions: please note that you have an appointment scheduled with dr. on at 11:45. please let her know if you would like to keep this appointment. department: podiatry when: tuesday at 3:30 pm with: , dpm building: ba ( complex) campus: west best parking: garage name: , md location: diabetes center address: one place, , phone: department: when: wednesday at 1:45 pm with: , md building: sc clinical ctr campus: east best parking: garage dr is your new physician in and dr works closely with dr , so both will be involved in your care. for insurance purposes please indicate dr as your primary care physician. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Acidosis Esophageal reflux Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Polyneuropathy in diabetes Ulcer of other part of foot Other and unspecified hyperlipidemia Cellulitis and abscess of leg, except foot Unspecified sleep apnea Septic shock Morbid obesity Diabetes with neurological manifestations, type II or unspecified type, uncontrolled

allergies: tylenol-codeine #3 / bactrim ds attending: chief complaint: st elevation mi major surgical or invasive procedure: coronary catheterization and angioplasty history of present illness: yof with h/o bioprosthetic valve replacement unclear as to which one at present time, htn who was transferred from out of concern for and inferior stemi. . she began having malaise/lethargy, anorexia, insomnia, indigestionfor the past week. last tuesday, there was initial concern for uti after she went to her pcp's and reportedly had a floridly positive ua, for which she was given a ten day course of ciprofloxacin started on . earlier in the week she started otc prilosec for gerd sx as well as frequent belching. . monday night while sitting in a chair she began having pressure-like tightness radiating to l arm; she has never had this pressure before and it was non-exertional. she thought it was related to her gerd sx and tried to go to sleep. the pressure never went away and the following day around noon the cp became worse and it was associated with nausea / vomiting and diaphoresis. her daughter-in-law called her cardiologist about the chest pressure and she was referred to . . at , ekg showed inferior ste and std in v2-3, new compared to 18 mos ago. she was noted to be hypertensive as well. labs there showed tropi 1.58 (normal 0-0.39), no ck's, cr 1.5, and wbc 17, hct 37. she received 325 asa, 600 mg po plavix, 5 mg iv metoprolol x2, bolus then gtt heparin, 80 mg atorvastatin. she was transferred to for further evaluation. . in the ed, initial vs: 150/76, p87 18. sbp's also noted to be 170. she was continued on heparin gtt. labs showed a subtherapeutic ptt, wbc 18.3, trop 0.35, and normal renal function. ekg showed improvement, but not full resolution, of the above noted st segment deviations. importantly, she was no longer having any pressure; because of this and resolving ekg changes, she was not taken to the cath, but admitted to ccu for medical management and close observation. . vitals before transfer: 91 151/77 23 97%ra . on arrival to the ccu she was denying cp, sob, n/v, diaphoresis. she was just tired and was requesting a sleeping pill to help her relax. on review of systems, she denies any prior history of stroke, tia, bleeding at the time of surgery. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: htn 2. cardiac history: - bioprosthetic valve replacement - pulmonary unclear the time frame, family unaware of this and pt cannot remember when it happened - cabg: none - percutaneous coronary interventions: states she had a prior cath at in , no records available at this time - pacing/icd: none 3. other past medical history: - h/o breast ca s/p l radical mastectomy - hip fx s/p fall - migraines - arthritis social history: widow, lives alone, takes care of self. has a chair that goes up her stairs, cooks her own dinner. - tobacco history: denies - etoh: 1 drink / month - illicit drugs: denies family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - mother: pt states passed away of "old age" unknown etiology - father: pt states passed away of "old age" unknown etiology physical exam: on admission: vs: bp= 156/58 hr= 90s rr=20 o2 sat=96% ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp not elevated, trachea midline cardiac: rrr, normal s1, s2. mechanical mr murmur appreciated best at axilla no thrills, lifts. 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+ dp 2+ left: carotid 2+ dp 2+ on discharge pertinent results: admission labs: 11:47pm ck(cpk)-326* 11:47pm ck-mb-60* mb indx-18.4* ctropnt-0.57* 11:47pm pt-12.9 ptt-42.1* inr(pt)-1.1 07:40pm glucose-128* urea n-19 creat-0.8 sodium-133 potassium-4.4 chloride-97 total co2-23 anion gap-17 07:40pm ck(cpk)-258* 07:40pm ctropnt-0.35* 07:40pm triglycer-52 hdl chol-58 chol/hdl-2.9 ldl(calc)-100 07:40pm %hba1c-5.9 eag-123 07:40pm wbc-18.3* rbc-4.80 hgb-14.6 hct-41.8 mcv-87 mch-30.5 mchc-35.0 rdw-13.3 admission ekg: moderate baseline artifact. normal sinus rhythm. st segment elevation in leads ii, iii, avf and v6. no previous tracing available for comparison. consider acute inferolateral ischemia. admission echo: due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. a bioprosthetic aortic valve prosthesis is present. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. impression: limited emergency study. grossly preserved biventricular systolic function. coronary cath: , f 91 cardiology report cardiac cath study date of *** not signed out *** brief history: this year old female with history of hypertension, hyperlipidemia and bioprosthetic aortic valve replacement is referred for cardiac catheterization secondary to ruling in for a myocardial infarcation. indications for catheterization: 1. mi 2. stemi procedure: percutaneous coronary revascularization was performed using balloon angioplasty. conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. hemodynamics results body surface area: 1.6 m2 hemoglobin: 14 gms % fick **pressures right atrium {a/v/m} 8/7/4 right ventricle {s/ed} 31/9 pulmonary artery {s/d/m} 31/10/19 pulmonary wedge {a/v/m} 10/9/8 aorta {s/d/m} 152/70/66 **cardiac output heart rate {beats/min} 84 rhythm nsr o2 cons. ind {ml/min/m2} 125 a-v o2 difference {ml/ltr} 50 card. op/ind fick {l/mn/m2} 4.0/2.5 **resistances systemic vasc. resistance 1240 pulmonary vasc. resistance 220 **% saturation data (nl) svc low 72 pa main 72 ao 98 other hemodynamic data: the oxygen consumption was assumed. **ptca results ptca comments: initial angiography revealed a complete occlusion in the distal r-pl branch of the rca which filled via right to right collaterals. we planned to treat this stenosis with ptca. bivalirudin was started prophylactically. a 5 french jr4 guiding catheter provided adequate support for the procedure. a prowater wire was used, however the wire was unable to cross the lesion despite multiple attempts at crossing. just proximal to the complete occlusion there was a point in the r-pl with a hazy appearance that suggested plaque rupture (likely cause of downstream embolization). we dilated this area with a a 1.5x15mm sprinter otw balloon at 8 atms. repeat angiography at this point showed minimal improvement in blood flow after the complete occlusion of the r-pl. due to the small size of the r-pl and the difficulty in corssing the lesion there was no further attempt made at intervention as the risks outweighed the benefits of opening up this small vessel which appeared to give blood supply to a small area of myocardium. final angiography showed the complete occlusion was still present, but no angiographically apparent dissection was noted. the patient left the lab free on angina and in stable condition. technical factors: total time (lidocaine to test complete) = 41 minutes. arterial time = 28 minutes. fluoro time = 8.7 minutes. irp dose = 400 mgy. contrast injected: non-ionic low osmolar (isovue, optiray...), vol 65 ml premedications: midazolam 0.25 mg iv fentanyl 12.5 mcg iv asa 325 mg p.o. anesthesia: 1% lidocaine subq. other medication: bivalirudin 40 mg bolus via iv bivalirudin 96 mg/ hr via iv cardiac cath supplies used: - , prowater 300cm 1.5mm , sprinter 15mm 5fr cordis, jr 4 sh - allegiance, custom sterile pack - merit, left heart kit - merit, right heart kit - , priority pack 20/30 5fr arrow, balloon wedge pressure catheter 110cm comments: 1. selective coronary asngiography demonstrated one vessel disease. the lmca had no angiographically apparent disease. the lad had no angiographically apparent disease. the cx had no angiographically apparent disease. the rca had a complete occlusion in a distal small (1.5mm in diameter) r-pl. prior to the complete occlusion there is point in the distal r-pl which appears to have a hazy area consistent with plaque. 2. limited resting hemodynamics revealed normal left and right sided filling pressures with an rvedp of 9 mmhg and a mean pcwp of 8 mmhg. the pulmonary pressures were 31/10 mmhg with a mean of 19 mmhg. the cardiac index was preserved at 2.5 l/min/m2. 3. unsuccessful attempt at crossing the distal r-pl. ptca of the point just proximal to the complete occlusion in the distal r-pl where there appeared to be a hazy area consistent with possible plaque rupture. final angiography revealed no apparent dissection and timi iii flow up to the level of the complete occlusion.' cxr: patient is status post median sternotomy with intact sternotomy sutures. both lungs are clear without lung consolidation. pleural effusion, if any, is minimal on the left side. heart size, mediastinal and hilar contours are normal. mild atherosclerotic calcification seen in the aortic arch. discharge labs: 04:12am blood wbc-10.1 rbc-3.94* hgb-11.9* hct-35.4* mcv-90 mch-30.3 mchc-33.7 rdw-12.7 plt ct-440 04:12am blood glucose-106* urean-12 creat-0.8 na-137 k-4.4 cl-106 hco3-26 angap-9 04:12am blood calcium-8.1* phos-3.3 mg-2.0 brief hospital course: assessment and plan yof with h/o bioprosthetic mitral valve replacement, htn who presented to found to have a inferior stemi and was transferred to for further evaluation and medical management. . # inferior stemi: patient presented with symptoms of chest pressure and abdominal discomfort which were felt to be anginal equivalents. the time frame of symptoms was unclear as patient was a poor historian, but likely occurred 24 hours prior to admission. right sided ekg and posterior ekg were performed and no rv infarct was noted. she was started on atorvastatin 80mg, aspirin 325mg, plavix 75mg, heparin gtt, metoprolol tartrate 12.5mg and lisinopril 5 mg. patient subsequently underwent cardiac cath which showed wedge of 8 ra of 6, rv:32/5 pa:31/10 ci=2.5 co=4, complete occlusion in the distal r-pl branch of the rca s/p balloon angioplasty with minimal improvement in flow. echo prior to cath showed a preserved ef and right ventricular chamber size and free wall motion that were normal. a bioprosthetic aortic valve prosthesis was present consistent with her pmh. the mitral valve leaflets were mildly thickened. trivial mitral regurgitation was seen. there was no pericardial effusion. she was discharged on aspirin 325mg, plavix 75mg, atorvastatin 80mg, metoprolol succinate 50mg and lisinopril 5mg. . # pt has chronic htn. she continued on her home metoprolol succinate 50mg and we stopped amlodipine and started lisinopril 5 mg daily. her blood pressures remained well controlled during admission. . # leukocytosis: patient had an elevated wbc at the time of presentation, likely as stress response to her mi. her leukocytosis had resolved prior to discharge. of note she was on ceftriaxone on admission due to a diagnosed uti as an out patient. her wbc trended down and she finished her 10 day course of ceftriaxone without incident. . # uti: patient was under treatment for a uti at the time of presentation and in the middle of a 10 day course of ceftriaxone. patient completed her course of antibiotics while in patient. she remained a symptomatic throughout this admission . # h/o breast ca s/p l radical mastectomy: stable, no change in treatment while inpatient. . #hip fx s/p fall: stable no change in treatment while inpatient. . # migraines: stable no change in treatment while inpatient. . # arthritis: table no change in treatment while inpatient. . transitional issues: pt has a follow up appointment with her cardiologist dr. on . medications on admission: metoprolol succinate 50mg simvastatin 40mg aspirin 81mg calcium 600mg vitamin d3 1000u daily tylenol 650mg q4hr prn pain amlodipine 2.5 mg daily ciprofloxacin 500mg daily 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 5. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. calcium oral 7. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day. 8. trazodone 50 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. disp:*5 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: myocardial infarcation hypertension urinary tract infection 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 mrs. , . it was a pleasure taking care of you. you were admitted to the hospital because you had a heart attack. this means that one of the arteries that supplies your heart with blood became occluded. we treated you with medication to thin your blood and performed a procedure call a cardiac catheterization. during the procedure we dilated a small artery in your heart with a balloon to allow the blood to flow to your heart effeciently. we believe that the occlusion in your blood vessel has resolved. we have made some changes to your medication regimen to optimally protect your heart. . we made the following changes to your medications: - increased aspirin from 81mg to 325mg daily - started clopidogrel (plavix) 75mg daily. **do not stop taking this medication unless instructed to by your cardiologist** - stopped simvastatin and started atorvastatin 80mg daily - stopped amlodipine and started lisinopril 5mg daily - stopped ciprofloxacin since you finished the course of antibiotics for your urinary tract infection followup instructions: name: , b. location: internal medicine associates address: , , , phone: appt: at 11:15am Procedure: Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Unspecified essential hypertension Personal history of malignant neoplasm of breast Other and unspecified hyperlipidemia Acute myocardial infarction of other inferior wall, initial episode of care Heart valve replaced by transplant Chronic total occlusion of coronary artery

allergies: amoxicillin attending: chief complaint: fatigue major surgical or invasive procedure: aortic valve replacement (21mm st. epic porcine) history of present illness: 74 year old woman was diagnosed with aortic stenosis in after being worked up for a progressive decline in her activity tolerance due to fatigue. echocardiogram in revealed moderate to severe aortic stenosis and mild to moderate aortic regurgitation. she was recently referred for stress testing where she was noted to have a progressive drop in systolic blood pressure with increasing workloads. she is now being referred for right and left heart catheterization to further evaluate. with regard to symptoms, she denies any chest pain or shortness of breath at rest or with exertion. she also denies lightheadedness, dizziness or syncope. until recently, she was walking from a half a mile to a mile per day at a slow pace but she feels that her general energy level has declined significantly. she is now being referred to cardiac surgery for aortic valve replacement. past medical history: aortic stenosis hyperlipidemia hx of shingles involving chest, neck and right shoulder copd depression osteoporosis arthritis d&c's benign breast biopsies right shoulder pain, ? rotator cuff sprain diverticulitis social history: lives with:son is currently living with her. occupation:retired tobacco:5-pack a day for approximately 50 years. she is attempting to quit, currently smoking 3 cigarettes per day etoh:denies family history: sister with a stroke in her early 70's. father with "heart trouble", died at age 74. mother died at age 70 with chf, sister with "valve problems". physical exam: pulse:70 resp:16 o2 sat: 100/ra b/p right:149/69 left:142/64 height:5'1" weight:135 lbs general: nad, wgwn, appears stated age, pleasant skin: dry intact no rash heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur 3/6 sem loudest at lsb abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema- none 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+ carotid bruit right: left: no bruit or radiation of murmur appreciated pertinent results: echo: prebypass: 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%). the estimated cardiac index is depressed (<2.0l/min/m2). right ventricular chamber size and free wall motion are normal. there are focal calcifications in the aortic arch. 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. postbypass: the patient is av-paced on a phenylephrine infusion. there is a new prosthetic valve which is well seated in the aortic position without evidence of regurgitation or paravalvular leak. peak/mean gradients are 18/10 mmhg with a cardiac output of 3.22 l/min. mitral regurgitation is now trace. tricuspid regurgitation has increased from trace to mild. left ventricular function continues to be normal. the thoracic aorta is intact. 06:25am blood wbc-11.0 rbc-4.30 hgb-12.6 hct-37.9 mcv-88 mch-29.4 mchc-33.3 rdw-15.0 plt ct-315 12:45pm blood wbc-7.4 rbc-2.76*# hgb-8.3*# hct-23.8*# mcv-86 mch-30.3 mchc-35.1* rdw-13.3 plt ct-183 06:25am blood plt ct-315 06:13am blood pt-12.7 inr(pt)-1.1 12:45pm blood plt ct-183 12:45pm blood pt-13.7* ptt-27.6 inr(pt)-1.2* 06:25am blood urean-21* creat-0.7 na-137 k-4.7 cl-96 02:39pm blood urean-14 creat-0.7 na-143 k-3.3 cl-109* hco3-23 angap-14 06:25am blood mg-2.0 07:24pm blood mg-2.9* brief hospital course: she was admited on and was brought to the operating room where she underwent an aortic valve replacement. please see operative report for surgical details. later this day she was weaned from sedation, awoke neurologically intact and extubated. on post-op day one beta-blockers and diuretics were initiated and she was gently diuresed towards her pre-op weight. later on post-op day one she was transferred to the step-down floor for further care. she went into atrial fibrillation which was treated with amiodarone and lopressor and she converted back to sinus rhythm. chest tubes and epicardial pacing wires were removed per protocol. she required very aggressive pulmonary toilet due to her copd history. she worked with physical therapy for strength and mobility. her pulmonary status slowly improved and she was ready for discharged home on post-op day six with appropriate medications and follow-up appointments. medications on admission: hydrocodone-acetaminophen - (prescribed by other provider) - 5 mg-500 mg tablet - 1 tablet(s) by mouth twice a day prn. do not drive, operate machinery, or drink alcohol while taking this medication. as your pain decreases, take fewer tablets and increase the time between doses. take a stool softener to prevent constipation. paroxetine hcl - 20 mg tablet - 1 (one) tablet(s) by mouth once a day simvastatin - 20 mg tablet - 1 tablet(s) by mouth at bedtime medications - otc aspirin - (otc) - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth daily calcium carbonate-vitamin d3 - (otc) - 500 mg (1,250 mg)-500 unit tablet - 1 tablet(s) by mouth twice a day multivitamin - (prescribed by other provider) - dosage uncertain discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. simvastatin 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 4. paroxetine hcl 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: two (2) tablet po every four (4) hours as needed for pain. tablet(s) 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): please take 400 mg twice a day until then decrease to 400 mg daily until then decrease to 200 mg daily until follow up with cardiologist . disp:*60 tablet(s)* refills:*0* 8. simvastatin 10 mg tablet sig: one (1) tablet po once a day: dose reduced due to amiodraone . disp:*30 tablet(s)* refills:*0* 9. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po tid (3 times a day): 75 mg three times a day . disp:*135 tablet(s)* refills:*0* 10. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). disp:*qs qs* refills:*0* 11. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation every four (4) hours as needed for shortness of breath or wheezing. disp:*qs qs* refills:*0* 12. lasix 40 mg tablet sig: one (1) tablet po once a day for 10 days. disp:*10 tablet(s)* refills:*0* 13. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day for 10 days. disp:*10 tablet, er particles/crystals(s)* refills:*0* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: aortic stenosis s/p aortic valve replacement post operative atrial fibrillation hyperlipidemia chronic obtructive pulmonary disease depression osteoporosis arthritis diverticulitis discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with tylenol incisions: sternal - healing well, no erythema or drainage edema trace lower extremities discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. at 1:15pm cardiologist: dr. on at 3:00pm wound check appointment 6 - wednesday at 11 am on 6 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 Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Anemia, unspecified Tobacco use disorder Unspecified pleural effusion Chronic airway obstruction, not elsewhere classified Cardiac complications, not elsewhere classified Atrial fibrillation Aortic valve disorders Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Osteoporosis, unspecified Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Diverticulosis of colon (without mention of hemorrhage) Arthropathy, unspecified, site unspecified

allergies: penicillins attending: chief complaint: hypotension, sepsis major surgical or invasive procedure: none history of present illness: 47m with chronic hepatitis b virus associated cirrhosis and delta hepatitis suprainfection on the liver transplant list (baseline meld 27). ems was called this morning at 4am for 3 days of worsening abdominal pain, double vision and weakness. upon arrival to his home: hr 100, bp 60/30's, o2 sats 84%, fs 46. oriented x 4. taken to hospital for stabilization, and the transplant center was notified. at , he was started on lactulose, neo-synephrine, octreotide, and midodrine, he was intubated, started on a d10w gtt. once a bed was available, he was transferred to the sicu. past medical history: - congenital hepatitis b - hep d positivity - cirrhosis, decompensated by ascites and jaundice - anemia - psoriasis - internal hemorrhoids . social history: married, 2 children 4,9, worked as social case manager in the past, now works as pca 8h per week. has not smoked or drank etoh since age of 15. no ivdu. . . family history: mother: hbv, dm physical exam: pe: neo 0.35, vaso 2.4, phenylephrine 1.5 112 91/44 cvp 17 27 96% cmv 100% +12 peep nad, unresponsive. on no sedation, but received iv ativan for transfer jaundiced and icteric diminished breath sounds on the right tachy abd distended, dull to percussion, +fluid shift. no response to deep palpation 1+ le edema pertinent results: 05:24pm wbc-1.7* rbc-2.29* hgb-9.1* hct-27.4* mcv-120* mch-39.6* mchc-33.1 rdw-14.6 05:24pm glucose-85 urea n-40* creat-2.8*# sodium-122* potassium-4.3 chloride-95* total co2-11* anion gap-20 05:24pm neuts-18* bands-14* lymphs-30 monos-3 eos-18* basos-0 atyps-0 metas-10* myelos-6* promyelo-1* nuc rbcs-10* 05:24pm hypochrom-1+ anisocyt-1+ poikilocy-1+ macrocyt-3+ microcyt-normal polychrom-2+ burr-2+ stippled-1+ 05:24pm plt smr-very low plt count-49* 05:24pm pt-38.7* ptt-54.8* inr(pt)-4.0* 05:24pm alt(sgpt)-52* ast(sgot)-78* ld(ldh)-191 alk phos-68 tot bili-17.7* 05:44pm type-art po2-87 pco2-32* ph-7.19* total co2-13* base xs--14 brief hospital course: patient was transferred from hospital after 3 days of worsening abdominal pain, severe hypotension and lactic acidosis. he was admitted to hospital on morning, was intubated, started on pressors and antibiotics and after notifying the transplant center, he was transferred in the afternoon and admitted to the surgical icu of . patient was started on neo-synephrine, norepinephrine and vasopressin, continued of broad spectrum antibiotics and attempted to correct his coagulopathy with blood products prior to perform a diagnostic paracentesis with hepatology. this showed 500 wbc and 25,500 rbc, but no microorganisms on the gram stain. a right chest thoracentesis for a large right pleural was also performed by the sicu to improve his ventilatory settings and improve his oxygenation, which drained 1,5 l of fluid. patient tolerated both procedures well initially, but was never stable enough to bring him to ct scan. at midnight he started with increasing pressure requirement and was maximized on neo-synephrine, levophed and vasopressin. his profound lactic acidosis with a worsening lactate up to 11.3 was attempted to be corrected with sodium bicarb, with no improvement on his ph of 7.10. his wife was , who decided to continue measures and after giving 5l of fluids including crystalloids, colloids, blood and at a maximum dose of 3 pressures, he was not able to hold his bp. patient expired on at 01:40 am, after his the pastor of his church arrived to the sicu. his wife was while she was on her way. the admitting office was notified and the medical examiner waived the case. his family consented for an autopsy which will be done at . medications on admission: : clobetasol clotrimazole 10mg 5x/day vit d 50,000 units weeks lactulose 15mg q4hrs viread 300mg daily mag oxide 400mg lasix 80mg rifaxamin 550mg spironolactome 200mg discharge medications: none discharge disposition: expired discharge diagnosis: cardiopulmonary arrest septic shock multiorgan failure (renal, liver, neurologic, cardiac) end-stage liver disease congenital hepatitis b discharge condition: expired discharge instructions: autopsy to be performed md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Thoracentesis Percutaneous abdominal drainage Closed [endoscopic] biopsy of bronchus Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Acidosis Anemia, unspecified Unspecified pleural effusion Cirrhosis of liver without mention of alcohol Unspecified septicemia Sepsis Cardiac arrest Other sequelae of chronic liver disease Other psoriasis Internal hemorrhoids without mention of complication Chronic viral hepatitis B without mention of hepatic coma with hepatitis delta

allergies: no known allergies / adverse drug reactions attending: chief complaint: altered mental status. major surgical or invasive procedure: cerebral angiogram history of present illness: mr. is a 42 y/o rh man with history of alcohol/tobacco use who was transported to via ambulance with altered mental status. he was found in his vomit and unresponsive by his roommate. he was reportedly last seen "normal" the evening prior although he was engaging in an evening of drinking. he complains of a right-sided headache at the time of presentation. his mental status upon arrival to the ed, was declining and the he was intubated for airway protection. he subsequently underwent a head cta and angio which were negative for aneurysms. after he was extubated, he related the history of drinking about "case and half" of beers the night of admission and knocking over his roommate's vases. he reports falling down, it is unclear whether he hit his head. past medical history: per sister: ?depression, bipolar ?dyslexia, learning disability heavy alcohol use x10-15 years, no known history of alcohol withdrawal seizures tobacco use per pcp's records: also history of auditory hallucinations, no known psychiatric diagnosis. denied current hallucinations. social history: never worked, on disability. sister thinks he's been drinking 10-15 years, no known history of withdrawal seizures. drinks ~30 beers daily. reports about ppd tobacco use. reports marijuana use, history of cocaine and ivdu in the past (reported last use changed throughout the hospitalization). family history: father with alcoholism, passed away from some kind of cancer, had liver problems. mother has hypertension but otherwise healthy. no strokes in the family. older brother passed away from brain tumor at age 33. older sisters and ) doing well. another brother in a group home due to "mental retardation." physical exam: physical exam on admission: vitals: 99.4 141/87 60 19 100% ra i/o: ivf 1606/foley 1665 general: extubated, awake but later falling asleep and arousable, lying in bed, nad. heent: nc/at, conjunctiva with icterus, mmm, no pharyngeal erythema, missing teeth neck: supple cv: rrr, normal s1 and s2, no murmurs pulm: ctab, no wheezes, rales or rhonchi abd: soft, nt/nd, active bowel sounds. extremities: clubbing in all fingers, no cyanosis, no edema. onychomycosis on all toes. lines and monitors on left. restrained left hand. foley in place. scd on left leg only. neurologic: mental status: alert, oriented to name, place (hospital and ), month, year but not to date. able to follow commands particularly if on the right side. garbled speech. able to name glove, chair and tree (instead of hammock) but not feather and cactus. repetition of "no ifs ands or buts" sounded muffled but could clearly say "lalala", "mamama" and "gagaga". left-sided neglect. no left-right confusion. able to recall 3 items at 5 min. cranial nerves: i: olfaction not tested. ii: perrl 4 to 3mm and brisk. left lateral visual field cut to confrontation. right gaze preference. iii, iv, vi: able to move eyes in all directions. no nystagmus. v: facial sensation intact vii: left facial droop; lower facial musculature asymmetric viii: hearing intact to finger rubbing bilaterally ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. motor: normal bulk, tone throughout. no pronator drift on right. no tremor. no asterixis noted. delt bic tri wre ffl fe ip quad ham ta l 3 4 3 3 4+ 3+ 4 5 4+ 4+ 5 4 r 5 5 5 5 5 5 5 5 5 5 5 5 sensory: left side extinction on simultaneous tactile stimuli dtrs: , tri, , , ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor on right and mute on left. coordination: no intention tremor. finger to nose : right side :no dysmetria, left side impaired weakness. did not follow instructions for heel-to-shin gait:deferred ========================================== physical examination on discharge: af vss general examination: thin male, all extremities with clubbing. unchanged from admission. soft collar in place. neurologic examination: mental status: alert/awake, oriented to self, place (), and to , thinks it is (when it's ). following commands. left-sided neglect but can attend to it with cuing/prompting. cranial nerves: i: olfaction not tested. ii: perrl 4 to 3mm and brisk. left hemianopsia to confrontation. iii, iv, vi: able to move eyes in all directions. no nystagmus. v: facial sensation intact vii: left facial droop viii: hearing intact to finger rubbing bilaterally ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm on r, weak on l. xii: tongue protrudes in midline. motor: normal bulk, tone throughout. no pronator drift on right. no tremor. no asterixis noted. l side with weakness in upper motor neuron pattern bic tri wre fe ip quad ham ta l 5 4 4 4 4 5 4+ 4 5 sensory: left side extinction on dss dtrs: tri ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor on right and upgoing on left. gait:deferred pertinent results: admission labs: 12:00pm blood wbc-10.2 rbc-5.00 hgb-15.4 hct-45.8 mcv-92 mch-30.8 mchc-33.6 rdw-14.8 plt ct-159 12:00pm blood pt-11.4 ptt-28.0 inr(pt)-1.1 12:00pm blood fibrino-239 05:08pm blood glucose-149* urean-11 creat-0.7 na-140 k-4.2 cl-104 hco3-25 angap-15 05:08pm blood calcium-8.0* phos-3.9 mg-1.6 serum/urine tox: 12:00pm blood asa-neg ethanol-56* acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 12:54pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg imaging: head ct 12:12pm: 5.9 x 4.2 cm right intraparenchymal hemorrhage with intraventricular and subarachnoid extension, causes 5 mm of leftward subfalcine herniation. cta head/neck 12:34pm: ct angiography shows no evidence of aneurysm or abnormal vascular structure. vascular displacement is seen in the distribution of right middle cerebral artery. the intracranial arteries in the anterior and posterior circulation demonstrates nonspecific decreased caliber, which could be secondary to increased intracranial pressure, such an appearance could also be seen in patients with reversible vasospasm. an endotracheal tube and nasogastric tubes are visualized. cxr : no acute cardiopulmonary process. oro-gastric tube side-port at the level around the ge junction and should be advanced so that it is well within the stomach. cerebral angiogram : eu critical underwent cerebral angiography which was normal and did not explain the right hemispheric hemorrhage. he was noted to have attenuated right middle cerebral artery secondary to the hematoma and possible compression from it. head ct 6:46pm: stable appearance of large right intraparenchymal hemorrhage with intraventricular and subarachnoid extension. head ct 1:05pm: stable appearance of large right basal ganglionic and temporal parenchymal hemorrhage, with similar intraventricular and subarachnoid extension. mri head: impression: 1. stable large right parenchymal hematoma with intraventricular extension. a small focus of contrast enhancement along the lateral margin of the hematoma may be reactive, but follow-up is recommended after resolution of blood products. no additional sites of intracranial blood products are identified to suggest multiple cavernous malformations or prior hypertensive hemorrhages. 2. signal abnormalities in the superior left frontal and parietal sulci suggest subacute subarachnoid hemorrhage. 3. no evidence of acute wernicke encephalopathy or chronic sequelae of alcohol abuse. echocardiogram: the left atrium is normal in size. no thrombus/mass is seen in the body of the left atrium. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no valve vegetations seen in a very good quality study. no intracardiac shunt or of embolism found. microbiology ucx : urine culture (final ): klebsiella pneumoniae. >100,000 organisms/ml.. cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _____________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 32 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: 1. dysphagia screening before any po intake? (x) yes - () no 2. dvt prophylaxis administered? (x) yes - () no 3. smoking cessation counseling given? (x) yes - () no (reason () non-smoker - () unable to participate) 4. stroke education given? (x) yes - () no 5. assessment for rehabilitation? (x) yes - () no transitional issues: wean off baclofen by 10 mg daily. currently on 10 mg tid, should transition to 10 mg and 10 mg daily and then off. complete 7 day course of antibiotics for pan-sensitive klebsiella, last day of treatment 42 yo rh man with history of alcohol and tobacco abuse who was found down. in the ed, found to have r intraparenchymal hemorrhage, cta and cerebral angiogram without clear etiology of bleed. hospital course complicated by alcohol withdrawal with intermittent tachycardia/hypertension and hallucinations. he was monitored on ciwa scale with baclofen and ativan/valium. his symptoms improved and he was able to be weaned off ciwa. # neuro: patient presented with drowsiness and left sided weakness, head ct in the ed showed a 5.9 x 4.2 cm right intraparenchymal hemorrhage with intraventricular and subarachnoid extension. he was intubated for airway protection and admitted to icu. no aneurysm or avm rupture found by cta or cerebral angiogram. he was extubated on hd #2 and transferred to step-down unit on hd#3. his neurologic status improved slightly during the hospitalization with improved attention to his left side and more spontaneous movement/strength on the left side. patient still has left hemianopsia and some left hemineglect, as well as left hemiparesis. his blood pressure was initially managed with prn hydralazine and labetalol in the icu, then started on amlodipine with goal bp <160 given his hemorrhage. as he remained tachycardic, he was started on propranolol instead for management of his blood pressure, tachycardia and to decreased likely increased sympathetic output from alcohol withdrawal. he was also started on phenytoin for seizure prophylaxis given his iph, and it was continued for 7 days (stopped prior to discharge). he passed speech/swallow evaluation in the icu and underwent pt/ot evaluation which recommended rehabilitation. # cv: patient with sinus tachycardia, likely related to increased sympathetic output with withdrawal. started on propranolol with good effect. tte without asd/pfo or other sources of cardiac embolus. # id: uti with pan sensitive klebsiella, started on iv ceftriaxone. will need treatment until , transitioned to po bactrim on discharge. bcx pending but negative to date, no leukocytosis. tte negative for thrombus/vegetations. # tox/metabolic: patient with significant alcohol use, reports drinking ~30 beers daily, last drink on . was intubated in icu initially, then started on ciwa protocol with evidence of active withdrawal. he was managed with baclofen and valium for his withdrawal. he was able to be weaned off ciwa scale, and should be weaned off baclofen. he was also started on multivitamin, thiamine and folate supplements. he was also started on nicotine patch daily for his tobacco use. # heme: thrombocytopenia, unclear baseline but could be related to myelosuppression from alcohol use. hct stable, no clear bleeding in other areas. his thrombocytopenia improved throughout this hospitalization and returned to range. # ppx: heparin sq tid, scds on both legs; bowel regimen with colace/senna. # code: full medications on admission: unknown discharge medications: 1. folic acid 1 mg po daily 2. multivitamins 1 tab po daily 3. thiamine 100 mg po daily 4. famotidine 20 mg po bid 5. acetaminophen 325-650 mg po q6h:prn fever/pain 6. baclofen 10 mg po tid 7. bisacodyl 10 mg po/pr daily:prn constipation 8. docusate sodium 100 mg po bid 9. heparin 5000 unit sc tid 10. nicotine patch 21 mg td daily 11. propranolol 10 mg po tid hold if hr< 60 or bp< 100 12. senna 1 tab po bid 13. sulfameth/trimethoprim ds 1 tab po bid duration: 2 days discharge disposition: extended care facility: hospital - discharge diagnosis: primary diagnosis: right intraparenchymal and intraventricular hemorrhage. secondary diagnosis: alcohol/tobacco use discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. neurological status: alert, oriented to and (occasionally gets the date wrong). l sided neglect and weakness. extinction to double simultaneous stimulation on l. discharge instructions: dear mr. , it was a pleasure to take care of you at . you were admitted to the hospital because of your weakness, and you were found to have bleeding in the right side of your brain. you were monitored in the icu and had cerebral angiogram which did not show any aneurysm or other causes of bleeding. mri also did not show a cause of bleeding. echocardiogram was done to see if there was an infection of the valves. it did not show any vegetations or other signs of infection. you are being discharged to rehab to strengthen the left side of your body. followup instructions: please call your primary care physician after you are discharged from rehab for a follow up appointment. department: neurology when: tuesday at 1 pm with: , md, phd building: sc clinical ctr campus: east best parking: garage md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Arteriography of cerebral arteries Computerized axial tomography of head Diagnoses: Thrombocytopenia, unspecified Tobacco use disorder Urinary tract infection, site not specified Unspecified essential hypertension Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site Intracerebral hemorrhage Other specified cardiac dysrhythmias Dysarthria Other and unspecified alcohol dependence, unspecified Hemiplegia, unspecified, affecting unspecified side Visual field defect, unspecified Alcohol withdrawal Facial weakness

allergies: lipitor / sotalol / amiodarone attending: chief complaint: lower gi bleed major surgical or invasive procedure: egd history of present illness: mr. is a 75 yo male with history of htn, hyperlipidemia, afib on coumadin, patient was in his normal state of health until the evening of sunday () when he rose from sitting and felt lightheaded /dizzy. later that evening he patient woke from sleep with an episode of dark black diarrhea, with specs of red mixed in. through the night and prior to presentation today the patient had, similar episodes. during this time patient notes some dizziness, lightheadness. patient notes no associated chest pain or shortness of breath. he reports no prior episode of dark black/bloody bowel movements/emesis in the past. he notes no history of liver disease and endorses only one drink a week. he notes no epigastric pain or indigestion in the past. notes no changes in bowel habits or weight loss. unable to have colonoscopy secondary to coumadin. he notes no change in diet and has not had undercooked/raw meet recently. . in the ed, initial vs were: afebrile p70-80s bp systolics 90-105. patient was given vitamin k 10mg iv. 2 units ffp. two 18 guage ivs placed. repeated labs two point hct drop 35 ->33. ng lavage 500cc totally clear. rectal with dark brown/reddish heme positive stool. 80mg protonix iv. 2 liters ns. vitals prior to transfer 89 117/72 15 97% ra. past medical history: 1)hyperthyroidism secondary to amiodarone use 2)atrial fibrillation: s/p cardioversion x 4 3)coronary artery disease: s/p cardiac cath 4)hyperlipidemia. 5)nephrolithiasis. 6)osteoarthritis. 7)status-post left hip replacement , successful. 8)"pinched nerve" resulting in right leg pain and numbness. social history: married. worked as a truck driver for 20years then for for 23 years. retired 13 years ago. four children. social history is significant for the absence of tobacco use for the last 35 years. there is no history of alcohol abuse. pt reports drinking alcoholic beverages per week. denies any illicit drug use. family history: brother: rectal 60s. mother: died in 60s secondary to father: medical hx unknown to patient. father died in 80s. physical exam: admission: vitals: bp: 124/43 p:85 r:19 o2: 99% general: very pleasant, talkative, alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, conjunctiva slightly pale. neck: supple, jvp not elevated, no anterior cervical or supraclavicular lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: irregular, normal s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs on admission: 05:00pm pt-25.2* ptt-26.1 inr(pt)-2.4* 05:00pm plt count-283 05:00pm neuts-77.3* lymphs-14.1* monos-4.0 eos-3.4 basos-1.2 05:00pm wbc-9.7# rbc-4.31* hgb-12.0*# hct-35.5* mcv-82 mch-27.8 mchc-33.7 rdw-14.6 05:00pm estgfr-using this 05:00pm glucose-156* urea n-27* creat-1.1 sodium-138 potassium-4.7 chloride-105 total co2-21* anion gap-17 10:13pm hgb-10.9* calchct-33 labs on discharge: 06:15am blood wbc-4.5 rbc-3.84* hgb-10.4* hct-32.1* mcv-84 mch-27.0 mchc-32.3 rdw-15.1 plt ct-147* 06:15am blood pt-12.9 ptt-22.1 inr(pt)-1.1 06:15am blood glucose-108* urean-17 creat-1.1 na-145 k-4.1 cl-107 hco3-31 angap-11 04:00am blood alt-14 ast-17 alkphos-36* totbili-1.0 reports: egd (): nonbleeding pyloric ulcer (no report in omr) (): findings: normal colon to cecum. recommendations: fair prep, need to have repeat colonoscopy in 3 yrs brief hospital course: 75 yo male with history of chronic atrial fibrillation on coumadin, hypertension, hyperlipidemia, cad, who presents with one day history of dark black/red stools and lightheadedness. . upper gi bleed pyloric ulcer: required total 2 units prbc, 2 ffp. remained hd stable throughout entire course of hospitalization. gi performed egd while patient in micu and noted non-bleeding ulcer. recommended continued high dose ppi and testing for h. pylori serologies, which returned negative. no history of liver disease or alcohol abuse. no previous gi bleeds. ng lavage negative in ed, however history consistent with upper gi bleed. colonoscopy was normal, though repeat colonoscopy should be done in 3 years. hematocrit stabilized x 48 hours prior to discharge. protonix 40mg should be continued and patient will f/u with gi as outpatient. advised to avoid all nsaids and to return to ed if melanotic/bloody stools. . hypotension: in ed patient reported to be slightly more hypotensive than during previous admission. in the micu blood pressure appears to be back to baseline. lisinopril and atenolol initially held, restarted when hematocrit stabilized. . thrombocytopenia: no clear etiology while inhouse, but platelets noted to trend down (see above lab values) prior to discharge. not on heparin while inhouse. repeat cbc will need to be followed up by pcp. hyperthyroidism secondary to amiodarone toxicity: previously on methimazole. stopped recently by dr. his outpatient endocrinologist when found to be euthyroid. . hyperlipidemia: continued zetia 10mg daily. has had myalgias with statin. . chronic atrial fibrillation: failed cardioversion x4. goal rate control to 80s while resting; coumadin/atenolol held while in micu given gib. was on metoprolol while on medical floor, and home atenolol restarted on discharge. coumadin held during entire hospitalization in anticipation for colonoscopy, though no biopsies were ultimately taken. coumadin restarted upon discharge starting at 5mg qhs, with inr to be followed up on by pcp. . cad: two vessel coronary artery disease (lcx and lad). no change in the coronary anatomy compared to the cath in . mild left ventricular diastolic dysfunction. normal systolic left ventricular function. . medications on admission: 1. allopurinol 300 mg tablet daily 2. ezetimibe 10 mg daily 3. atenolol 100 mg one tablet twice daily 4. lisinopril 20 mg once daily 5. coumadin 2.5 mg tablet one tablet, once a day: take 2.5mg every day for 4 days and 5mg on the fifth day. discharge medications: 1. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 2. allopurinol 100 mg tablet sig: three (3) tablet po daily (daily). 3. 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* 4. atenolol 100 mg tablet sig: one (1) tablet po twice a day. 5. coumadin 5 mg tablet sig: one (1) tablet po once a day. 6. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 7. outpatient lab work please have a cbc and inr checked on with results reported to , h. md. phone: fax: discharge disposition: home discharge diagnosis: primary diagnosis: 1. upper gi bleed secondary to ulcer 2. atrial fibrillation with rapid ventricular response secondary diagnosis: 1)hyperthyroidism secondary to amiodarone use 2)coronary artery disease 3)hyperlipidemia. 4)osteoarthritis. 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 on with a gi bleed. we did a colonoscopy and endoscopy, which showed that this bleed most likely came from an ulcer in your stomach. for this reason, you were started on a medicine called pantoprazole. take this medicine twice a day, and follow-up with the gastroenterologist as listed below. should you have any black or bloody stools, it is imperative that you call your doctor or come back into the hospital as your ulcer can bleed again. the following changes have been made to your medicines: 1. start taking protonix twice a day 2. start taking 5mg coumadin a day. it will take a few days for your inr to increase to the appropriate level. have bloodwork checked on monday morning and reported to your pcp, you can alter your coumadin dose as needed. followup instructions: please follow up with your pcp, . , on monday, at 10:30 am. have your bloodwork done on the morning of prior to your appointment, so dr. can have the results and adjust your coumadin as needed. provider: xray (scc 2) phone: date/time: 1:10 provider: , md phone: date/time: 1:30 Procedure: Other endoscopy of small intestine Colonoscopy Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Atrial fibrillation Other and unspecified hyperlipidemia Hypotension, unspecified Long-term (current) use of anticoagulants Osteoarthrosis, unspecified whether generalized or localized, site unspecified Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Cardiac rhythm regulators causing adverse effects in therapeutic use Thyrotoxicosis of other specified origin without mention of thyrotoxic crisis or storm

allergies: penicillins attending: chief complaint: s/p motorcycle crash vs car; 35mph; t-boned; +loc; major surgical or invasive procedure: 1. treatment of left intertrochanteric hip fracture with intramedullary nail. 2. treatment of left distal femur fracture with intramedullary nail. 3. washout and debridement, open tibia fracture, down to and inclusive of bone. 4. intramedullary nail, left tibia. 5. application of manual stress on radiography, left ankle. 6. open reduction and internal fixation, left intra- articular distal radius fracture. procedures: 1. open reduction internal fixation right acetabular fracture via ilioinguinal lateral window and stoppa window exposure. 2. open reduction internal fixation of left sacral fracture with percutaneous sacroiliac screw. history of present illness: 58-year-old male driver s/p motorcycle crash; helmeted with +loc. he wastransported to with liver laceration and multiple orthopedic injuries. past medical history: diverticulitis psh: sigmoid colectomy/colostomy, reversal of colostomy, exp-lap, appendectomy family history: noncontributory pertinent results: 09:25pm type-art po2-154* pco2-41 ph-7.36 total co2-24 base xs--1 09:13pm glucose-210* urea n-33* creat-1.4* sodium-139 potassium-4.8 chloride-109* total co2-20* anion gap-15 09:13pm wbc-20.5* rbc-3.69* hgb-10.1* hct-30.4* mcv-82 mch-27.4 mchc-33.2 rdw-14.8 09:13pm plt count-309 09:13pm pt-14.8* ptt-27.6 inr(pt)-1.3* 03:40pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:40pm wbc-23.1* rbc-4.45* hgb-11.9* hct-36.3* mcv-82 mch-26.7* mchc-32.8 rdw-14.2 03:40pm pt-13.8* ptt-27.7 inr(pt)-1.2* impression: no acute intracranial abnormality. impressions: 1. no acute traumatic injury seen in the cervical spine. 2. thyroid nodules may be further evaluated by ultrasound on a non-urgent basis. impression: 1. large (grade iv) liver laceration centered in the right hepatic lobe, with evidence for active arterial extravasation, and surrounding small hematoma. 2. small foci of right renal laceration, with small amount of surrounding hematoma. underlying chronic right upj obstruction. 3. multiple bilateral pelvic and left intertrochanteric femoral fractures as described above, with evidence for active extravasation along the right perineum, right gracilis, and right inguinal canal. no definite fluid or extravasation of contrast seen surrounding the urinary bladder, which is displaced by adjacent hematoma. to fully evaluate the bladder, a cystogram/ct cystogram is indicated. 4. multiple rib fractures as enumerated above with contusion/hematoma overlying the right anterior rib fractures, without evidence of pneumothorax. 5. right spigelian hernia containing fat, with mild surrounding stranding, probably traumatic in etiology. 6. incidentally noted heterogenous left renal mass, concerning for renal cell carcinoma. 7. multiple small pulmonary nodules measuring up to 5 mm. if patient has history of smoking or other risk factors for malignancy, recommend follow-up chest ct in months. if no risk factors or malignancy, recommend follow- up chest ct in 12 months. brief hospital course: he was admitted to the trauma service. he was taken to interventional radiology for angiogram and possible embolization=foliation because of concern for pelvic arterial bleed, none was identified and embolization was not required. orthopedics and urology consulted given his injuries. he was taken to the operating room by orthopedics on for : 1. treatment of left intertrochanteric hip fracture with intramedullary nail. 2. treatment of left distal femur fracture with intramedullary nail. 3. washout and debridement, open tibia fracture, down to and inclusive of bone. 4. intramedullary nail, left tibia. 5. application of manual stress on radiography, left ankle. 6. open reduction and internal fixation, left intra- articular distal radius fracture. there were no intraoperative complications; postoperatively he has remained stable. he was taken back to the operating room on by orthopedics for: 1. open reduction internal fixation right acetabular fracture via ilioinguinal lateral window and stoppa window exposure. 2. open reduction internal fixation of left sacral fracture with percutaneous sacroiliac screw. he is to remain non weight bearing on all extremities until follow up with orthopedics. urology was consulted for the renal laceration, scrotal ecchymosis and left renal mass. no urethral injury was noted as there was no hematuria. it was recommended that he follow up with urology in 1 month for repeat imaging of the renal mass. he was started on mini dose coumadin, 2mg daily, as dvt prophylaxis. the inr does not need to be monitored on this mini dose as it would if he were being treated therapeutically on coumadin. he was evaluated by physical and occupational therapy and is being recommended for short term rehab. medications on admission: denies 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). 3. senna 8.6 mg tablet sig: two (2) tablet po at bedtime. 4. milk of magnesia 800 mg/5 ml suspension sig: thirty (30) ml's po twice a day as needed for constipation. 5. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. famotidine 20 mg tablet sig: one (1) tablet po q 12h (every 12 hours). 8. oxycodone 10 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po q12h (every 12 hours). 9. oxycodone 5 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for breakthrough pain. 10. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm: mini dose coumadin for dvt prophylaxis. inr does not neeed to be monitored routinely. discharge disposition: extended care facility: house nursing & rehabilitation center - discharge diagnosis: bilateral acetabular fractures bilateral pubic rami fractures left intertroch femur fracture left mid shaft femur fracture left open tib/fib fracture grade i left distal radius/ulna fracture grade iv liver laceration, right renal bleeding, scrotal lac discharge condition: hemodynamically stable, tolerating a regular diet, pain adequately controlled. followup instructions: follow up in 2 weeks with orthopedics, call for an appointment. follow up in 2 weeks with dr. , trauma surgery for evaluation of your liver laceration and renal hemorrhage. call for an appointment. you were noted to have a left renal mass on ct scan for which urology saw you. you need to follow-up with the urology clinic in 1 month for a repeat ct scan to evaluate incidental left renal mass; call for an appointment. you may also choose to follow up with a urology provider recommended by your primary care doctor. Procedure: Venous catheterization, not elsewhere classified Interruption of the vena cava Arteriography of other intra-abdominal arteries Debridement of open fracture site, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Open reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, radius and ulna Open reduction of fracture with internal fixation, other specified bone Repair of vertebral fracture Open reduction of separated epiphysis, femur Diagnoses: Unspecified disorder of kidney and ureter Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist Closed fracture of sacrum and coccyx without mention of spinal cord injury Injury to kidney with open wound into cavity, laceration Street and highway accidents Other ventral hernia without mention of obstruction or gangrene Open fracture of shaft of fibula with tibia Closed fracture of three ribs Closed fracture of acetabulum Closed fracture of intertrochanteric section of neck of femur Injury to liver with open wound into cavity, laceration, unspecified Closed fracture of lower end of radius with ulna Closed fracture of epiphysis, lower (separation) of femur

allergies: nsaids (non-steroidal anti-inflammatory drug) / propoxyphene attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: 1. aortic valve replacement with a 21-mm st. regent mechanical valve. reference number . serial number . 2. mitral valve replacement with a 29-mm st. mechanical valve. reference number . serial number . 3. pericardial reconstruction with core matrix product. reference number . lot number history of present illness: 64 year old woman with known rheumatic heart disease. she has been more symptomatic lately, complaining of worsening dyspnea on exertion and fatigue. her most recent echocardiogram showed severe aortic stenosis and regurgitation, moderate mitral regurgitation with moderate to severe stenosis. she presents today for surgical evaluation. in addition to her progressive doe, she also admits to two pillow orthopnea, persistent pedal edema and intermittent palpitations. she denies chest pain, syncope, and pre-syncope. it appears she has marked limitation with routine adl's. past medical history: past medical history - rheumatic heart disease, chronic diastolic heart failure - hypertension - dyslipidemia - history of asthma - hypothyroidism - anxiety - morbid obesity - scattered pulmonary nodules on recent ct scan, ?sarcoidosis - eczema past surgical history - bariatric surgery, 4 years ago social history: race: caucasian last dental exam: more than 6 months ago lives with: sister occupation: retired cigarettes: denies etoh: rare illicit drug use: denies family history: family history: denies premature coronary artery disease. mother had valve surgery in her 70's. father had cabg in his 70's. physical exam: admission: pulse: 64 resp: 16 o2 sat: 99% room air b/p right: 154/55 left: 123/52 height: 64 inches weight: approx 230 lbs per patient general: obese female in no acute distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur - mixed diastolic and systolic murmurs noted throughout precordium abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: 1+ bilaterally varicosities: significant spider veins noted. bilateral gsv difficult to assess secondary to morbid obesity. no obvious varicosities 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 murmurs bilaterally discharge: 99.3 68 sr 132/86 18 94%-ra gen nad cv rrr, no murmur. sternum stable -incision cdi pulm diminished in bases otherwise cta abdm obese-soft, nt/nd/+bs ext warm 1+ bilat le pertinent results: admission: 07:40am hgb-12.0 calchct-36 12:32pm fibrinoge-188 12:32pm pt-14.5* ptt-27.3 inr(pt)-1.4* 12:32pm plt count-134* 12:32pm wbc-14.6*# rbc-3.10* hgb-9.0* hct-27.4* mcv-89 mch-28.9 mchc-32.6 rdw-14.2 02:43pm urea n-22* creat-1.0 sodium-142 potassium-3.6 chloride-111* total co2-25 anion gap-10 discharge: 05:06am blood wbc-10.4 rbc-3.70* hgb-10.7* hct-32.9* mcv-89 mch-28.9 mchc-32.6 rdw-14.4 plt ct-134* 04:54am blood pt-27.1* inr(pt)-2.6* 05:53am blood pt-54.2* inr(pt)-5.4* 04:18am blood pt-19.3* inr(pt)-1.8* 04:54am blood urean-29* creat-1.1 na-137 k-3.9 cl-103 04:54am blood mg-2.0 radiology report chest (pa & lat) study date of 3:47 pm final report findings: as compared to the previous radiograph, there is no relevant change. mild left pleural effusion, no noticeable right pleural effusion. low lung volumes, areas of bilateral atelectasis. status post cabg and valvular replacement. right internal jugular vein catheter. dr. echocardiography report echocardiographic measurements results measurements normal range left atrium - four chamber length: *5.3 cm <= 5.2 cm right atrium - four chamber length: 4.7 cm <= 5.0 cm left ventricle - septal wall thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.0 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *6.0 cm <= 5.6 cm left ventricle - ejection fraction: 55% to 60% >= 55% left ventricle - stroke volume: 104 ml/beat left ventricle - cardiac output: 5.63 l/min left ventricle - cardiac index: 2.75 >= 2.0 l/min/m2 aorta - annulus: 2.2 cm <= 3.0 cm aorta - sinus level: 2.7 cm <= 3.6 cm aorta - sinotubular ridge: 2.8 cm <= 3.0 cm aorta - ascending: *4.2 cm <= 3.4 cm aorta - arch: 2.5 cm <= 3.0 cm aorta - descending thoracic: 2.4 cm <= 2.5 cm aortic valve - peak velocity: *4.6 m/sec <= 2.0 m/sec aortic valve - peak gradient: *83 mm hg < 20 mm hg aortic valve - mean gradient: 40 mm hg aortic valve - lvot pk vel: 1.40 m/sec aortic valve - lvot vti: 41 aortic valve - lvot diam: 1.8 cm aortic valve - valve area: *0.7 cm2 >= 3.0 cm2 mitral valve - peak velocity: 2.2 m/sec mitral valve - mean gradient: 8 mm hg mitral valve - pressure half time: 186 ms mitral valve - mva (p t): 1.7 cm2 findings left atrium: no spontaneous echo contrast in the body of the laa. depressed laa emptying velocity (<0.2m/s) no thrombus in the laa. right atrium/interatrial septum: normal ra size. no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness. moderately dilated lv cavity. normal regional lv systolic function. overall normal lvef (>55%). right ventricle: borderline normal rv systolic function. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. no atheroma in ascending aorta. normal aortic arch diameter. no atheroma in aortic arch. normal descending aorta diameter. aortic valve: severely thickened/deformed aortic valve leaflets. critical as (area <0.8cm2). severe (4+) ar. mitral valve: severely thickened/deformed mitral valve leaflets. characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. severe mitral annular calcification. moderate valvular ms (mva 1.0-1.5cm2) moderate (2+) mr. tricuspid valve: moderate tr. pulmonic valve/pulmonary artery: mild 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. see conclusions for post-bypass data conclusions pre-bypass: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). 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 moderately dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). with borderline normal free wall function. the ascending aorta is mildly dilated. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). severe (4+) aortic regurgitation is seen. the mitral valve leaflets are severely thickened/deformed. the mitral valve shows characteristic rheumatic deformity. there is severe mitral annular calcification. there is moderate valvular mitral stenosis (area 1.0-1.5cm2). moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is no pericardial effusion. dr. was notified in person of the results at time of surgery. post-bypass: the patient is in sinus rhythm. the patient is on no inotropes. right ventricular function is unchanged. left ventricular function is mildly depressed, with hypokinesis of the basal inferior and inferoseptal walls. lvef = 45 - 50%. there is a well-seated, well-functioning mechanical valve in the mitral position. characteristic washing jets are seen. no mitral regurgitation is seen. there is a mean gradient of 3 mmhg through the valve at a cardiac output of 5.1 l/min. there is a well-seated, well-functioning mechanical valve in the aortic position. no aortic regurgitation is seen. there is a mean gradient of 8 mmhg across the aortic valve at a cardiac output of 5.5 l/min. the aorta is intact post-decannulation. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 14:04 brief hospital course: ms was a same day admission to the operating room for aortic and mitral valve surgery with dr on . please see operative report for details, in summmary she had: 1. aortic valve replacement with a 21-mm st. regent mechanical valve. reference number . serial number . 2. mitral valve replacement with a 29-mm st. mechanical valve. reference number . serial number . 3. pericardial reconstruction with core matrix product. reference number . lot number . her cardiopulmonary bypass time was 144 minutes, with a cross-clamp time of 112 minutes. she tolerated the operation well and post-operatively was transferred to the cardiac surgery icu in stable condition. in the immediate post-op period she was hemodynamically stable, she woke neurologically intact and was extubated. on pod1 she remained hemodynamically stable, she was started on bblockers and diuretics and was transferred to the stepdown floor. all tubes lines and drains were removed per cardiac surgery protocol. once on the floor the patient was noted to have atrial fibrillation which was treated with increased bblockers, amiodarone and she was started on anticoagulation. the remainder of her hospital course was uneventful. she worked with nursing and physical therapy to improve her strength and mobility. on pod4 she was cleared for discharge home with visiting nurses. she is to follow up w/dr in 1 month. medications on admission: simvastatin 10mg daily, lasix 40mg twice daily, levothyroxine 75mcg daily, atenolol 25mg daily, flovent 220mcg prn, lorazepam prn, vitamin d and vitamin b12, omega 3, fish oils discharge medications: 1. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po q12h (every 12 hours). disp:*120 tablet extended release(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 3. 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. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 7. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 8. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 9. cyanocobalamin (vitamin b-12) 250 mcg tablet sig: one (1) tablet po daily (daily). 10. omega-3 fatty acids capsule sig: one (1) capsule po daily (daily). 11. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 12. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for anxiety. 13. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 14. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 15. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 16. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg x 5days then 400mg daily x7days then 200mg daily. disp:*60 tablet(s)* refills:*1* 17. warfarin 2 mg tablet sig: as directed by dr tablet po once a day: target inr 2-2.5. disp:*75 tablet(s)* refills:*2* 18. lasix 40 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 19. warfarin 2 mg tablet sig: one (1) tablet po once a day for 2 doses: take 2 mg coumadin on and then as directed by dr . discharge disposition: home with service facility: discharge diagnosis: s/p regent avr/ mvr pmh: rheumatic heart disease, chronic diastolic heart failure hypertension dyslipidemia asthma hypothyroidism anxiety morbid obesity scattered pulmonary nodules on recent ct scan, ?sarcoidosis eczema, bariatric surgery 4 years ago discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with percocet incisions: sternal - healing well, no erythema or drainage edema 1+ bilat le discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr on @1pm cardiologist: dr office will call in 1 week wound check @10:15 please call to schedule appointments with your primary care dr., b. 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 atrial fibrillation goal inr 2-2.5 first draw results to phone , b. /atrius Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Open and other replacement of mitral valve Other repair of heart and pericardium Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Atrial fibrillation Asthma, unspecified type, unspecified Other and unspecified hyperlipidemia Anxiety state, unspecified Morbid obesity Multiple involvement of mitral and aortic valves Chronic diastolic heart failure Bariatric surgery status

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain, transfer for stemi major surgical or invasive procedure: cardiac cath coronary artery bypass grafting x4, with the left internal mammary artery to the left anterior descending artery and reversed saphenous vein grafts to the posterior descending artery and first and second diagonal arteries. history of present illness: 76 year old male who presented to osh for ed with sudden onset of chest pressure, similar to prior chest pain. attempted to fall asleep however could not and so called ems who brought him to . at osh, ekg revealed st elevations in anterior leads. pt was started heparin gtt and transferred to emergently for further evaluation. code stemi was called after ekg showed ~2mm st elevations in v3-v4. labs were significant for mild troponin of 0.09. he was found to have two vessel disease and he is now being referred to cardiac surgery for revascularization. past medical history: diabetes dyslipidemia hypertension 2 stents at in (not on plavix because of cva) atrial fibrillation not on coumadin because of cva mca stroke with hemorrhagic conversion s/p craniectomy in at southshore b12 deficiency bph s/p craniectomy in social history: race:caucasian last dental exam:>1 year ago lives with:wife, wheelchair bound. wife is primary caretaker contact: (wife) phone # occupation:retired business man cigarettes: smoked no yes hx:quit 20 years ago, has a greater than 20 pack year history of smoking other tobacco use:denies etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use:denies family history: no premature coronary artery disease- father had an mi at age 70 physical exam: pulse:97 resp:26 o2 sat:96/2l b/p 109/66 height:65" weight:83kgs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none contracted left knee neuro: grossly intact pulses: femoral right: palp left: palp dp right: palp left: palp pt : palp left: palp radial right: palp left: palp carotid bruit right: none left: none discharge exam: vs: t: 97.6 hr: 65-100 sr bp: 105-125/60-70 sats: 96% ra general: 76 year-old male in no apparent distress heent: normocephalic, mucus membranes moist neck: supple no lymphadenopathy card: rrr normal s1,.s2 no murmur resp: diminished breath sounds bilateral with fine crackles right 1/4 up, no wheezes gi: obese, bowel sounds positive, abdomen soft extr: warm no edema incision: sternal and left lower extremity clean, dry margins well approximated with no erythema skin: ecchymosis right hip, left papula rash left upper, lower and groin region. neuro: awake, alert, oriented to person, place and time. mild left facial droop strengths r 3-3/4, left 0-/4 (old cva) pertinent results: cardiac cath: 1. selective coronary angiography in this right dominant system demonstrated two vessel cad. the lmca was patent. the lad had diffuse plaquing throughout and tapers to 90% beyond the patent proximal to mid lad stent and the d2 takeoff. the d2 is diffusely diseased with 40% at ostium and 50% proximally. the d1 is a substantive bifricating vessel with 70% ostial stenosis (partially jailed by the lad stent). the lcx had mild plaquing throughout. the proximal om1 and mid om2 (both small vessels) have focal 70% stenosis with normal flow. the rca was subselectively engaged due to ostial stent and calcifications. the ostial stent was patent with instent restenosis (mild, nonflow-limiting). serial focal stenosis (1st 65-70%) just beyond the acute marginal takeoff and second (90%) about 2 cm downstream. the pl has 70-80% ostially but overall this is a small diffusely diseased vessel. the r-pda is patent. 2. limited resting hemodynamics revealed moderately elevated systemic arterial systolic pressures with an sbp of 150 mmhg. 3. abdominal aortography was performed using a pigtail catheter via power injection and showed diffuse plaquing in the infra-renal aorta, possible moderate l renal artery stenosis, calcific right common iliac artery stenosis (difficulty passing the wire through the common iliac into the aorta). . carotid u/s: right ica <40% stenosis. left ica no stenosis. . echo: pre-cpb: the patient is in a.fib. no spontaneous echo contrast is seen in the left atrial appendage. 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 ascending aorta is mildly dilated. there are complex (>4mm) atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). in the face of more modest peak and mean gradients across the valve, a discussion led to the decision to not replace it. dr. offered his opinion also. trace aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post-cpb: the patient is on an av-pacer, though there is no atrial response. no inotropes. preserved biventricular systolic fxn. 1+mr, trace ai. aorta intact. . wbc-10.4 rbc-3.14* hgb-9.3* hct-27.7* mcv-89 mch-29.6 mchc-33.5 rdw-13.9 plt ct-308 wbc-11.5* rbc-4.95 hgb-14.6 hct-43.0 mcv-87 mch-29.6 mchc-34.0 rdw-13.0 plt ct-205 glucose-136* urean-23* creat-1.0 na-140 k-4.5 cl-103 hco3-32 glucose-172* urean-21* creat-0.9 na-141 k-4.4 cl-106 hco3-22 alt-27 ast-29 ld(ldh)-260* alkphos-61 totbili-0.4 micro: urine culture (final ): <10,000 organisms/ml. mrsa screen nasal swab. mrsa screen (final ): no mrsa isolated picc line : right jugular line has been removed. tip of the new right pic line is in the right atrium. it should be withdrawn 3.5 cm to position it low in the svc. mild pulmonary edema has developed, most readily appreciated in the right lower lung. severe cardiomegaly is longstanding, but mediastinal and hilar vascular engorgements have worsened. there is greater consolidation at the left lung base, presumably atelectasis though pneumonia is not excluded, and an increase in small-to-moderate left pleural effusion. there is no pneumothorax. cxr: there is a questionable tiny left pneumothorax. the pulmonary edema has almost resolved. there are persistent low lung volumes with bibasilar atelectasis. cardiomediastinal silhouette is unchanged. right ij catheter remains low in the right atrium and can be withdrawn 3-4 cm for more standard position. if any there are small bilateral pleural effusions. the sternal wires are aligned. brief hospital course: as mentioned in the hpi, mr. was transferred from outside hospital with an st-elevation myocardial infarction. he underwent a cardiac cath on which revealed severe three vessel coronary artery disease. he then underwent appropriate surgical work-up while awaiting plavix to wash-out. on he was brought to the operating room where he underwent a coronary artery bypass graft x 4. please see operative note for surgical details. following surgery he was transferred to the civcu for invasive monitoring in stable condition. within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. on post-op day one he was started on beta-blockers and diuretics and diuresed towards his pre-op weight. on post-op day two he was transferred to the telemetry floor for further care. chest tubes and epicardial pacing wires were removed per protocol. on post-op day three he had episode of rapid atrial fibrillation iv/po amiodarone was started. he converted to sinus rhythm (pre-op history of af but not on coumadin d/t hemorrhagic stroke). a non-heparin picc line was placed for iv access. his foley was removed and a condom cath was placed for incontinence. he was bladder scanned for 300. he continued to make good progress while working with physical therapy. on post-op day 5 he was discharged to rehab with the appropriate medications and follow-up appointments. medications on admission: medications at home: metoprolol tartarte 50mg lisinopril 10mg daily simvastatin 20mg daily tamsulosin 0.4mg daily escitalopram 20mg daily finasteride 4mg senna-docunsate 1 tab tid nph/novolin 10 units sc daily nph 15 units sc at dinner ascorbic acid 500mg daily folic acid-vit b2-vit b6-vit b 1 tab ergocalciferol 1000 units daily trazodone 50mg daily aspirin 81mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 5. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 7. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 8. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 9. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: three (3) ml inhalation q6h (every 6 hours). 11. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q6h (every 6 hours). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 13. tramadol 50 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 14. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): 400mg x 7 days then 400 mg daily x 7 days then 200 mg daily. 15. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po daily (daily). 16. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash: apply to rash. 17. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/temp. 18. picc line non-heparin: flush with 10 ml of normal saline discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 4 past medical history: diabetes dyslipidemia hypertension 2 stents at in (not on plavix because of cva) atrial fibrillation not on coumadin because of cva mca stroke with hemorrhagic conversion s/p craniectomy in at southshore b12 deficiency bph s/p craniectomy in discharge condition: alert and oriented with left hemi-paresis ambulating with max assist incisional pain managed with tramadol incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. on at 1:15pm in the building cardiologist/pcp: . 12:00 **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Aortography Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atherosclerosis of aorta Atrial fibrillation Aortic valve disorders Percutaneous transluminal coronary angioplasty status Other B-complex deficiencies Acute myocardial infarction of anterolateral wall, initial episode of care Other and unspecified hyperlipidemia Gross hematuria Delirium due to conditions classified elsewhere Urinary incontinence, unspecified Atherosclerosis of other specified arteries Late effects of cerebrovascular disease, hemiplegia affecting nondominant side Wheelchair dependence

allergies: tetanus attending: chief complaint: asystolic cardiac arrest after dccv major surgical or invasive procedure: dccv on complicated by asystolic cardiac arrest history of present illness: mr. is a 57 yo m with history of paroxysmal atrial fibrillation s/p pvi x2 ( and ), atypical atrial flutter s/p ablation x2 ( and ), htn, tia () and depression who presents to the ccu due to pea after dccv. patient came in to the today for scheduled routine dccv for atrial fibrillation/flutter. after the procedure the patient had asystolic cardiac arrest for which he received atropine 1 mg, epinephrine 1 mg, peripheral dopamine and cpr (for ~2 minutes) then spontaneously woke up. after awaking he was kept on dopamine, and both epinephrine and phenylephrine drips started due to sbp in the 80-90's. he was breathing spontaneously and ao x3. subsequently his hemodynamics improved with hr nsr at 85 bpm, bp 121/31, o2 sat 100% on 6 l fm. he was then transfered to the cvicu. . in the cvicu the patient's epinephrine drip was stopped due to hypertension and both dopamine and phenylphrine drips minimized. he states he is feeling well and has no complaints. . all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, palpitations or presyncope. past medical history: afib dx'd but has been symptomatic for several years prior aflutter ablation fall s/p approximately 7 cardioversions, the first dating back to fall htn depression h/o tia in (brain mri was negative) with word finding difficulties social history: he has a girlfriend. works as a freelance journalist. he smoked for 9 months many years ago. he drinks occasional glass of wine, or shots of hard. he is eating healthy diet with 5 servings of fruits and vegetables every day. he exercises regularly. family history: mother had afib. physical exam: on admission: vs: t= 96.7 bp= 11/77 hr= 53 rr= 12 o2 sat= 100% 3l nc general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 6 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. nabs. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ no change in physical exam at discharge pertinent results: admission labs: 12:22pm blood wbc-13.6*# rbc-4.57* hgb-14.6 hct-43.7 mcv-96 mch-31.9 mchc-33.4 rdw-13.2 plt ct-320 07:15am blood pt-28.0* ptt-31.7 inr(pt)-2.7* 12:22pm blood glucose-133* urean-15 creat-1.1 na-140 k-4.4 cl-106 hco3-23 angap-15 12:22pm blood calcium-8.9 phos-3.2 mg-2.1 discharge labs: 04:50am blood wbc-7.9 rbc-3.63* hgb-11.8* hct-33.3*# mcv-92 mch-32.6* mchc-35.5* rdw-13.2 plt ct-240 09:46am blood hct-33.9* 04:50am blood pt-27.6* ptt-32.3 inr(pt)-2.7* 04:50am blood glucose-87 urean-15 creat-1.0 na-139 k-4.3 cl-108 hco3-26 angap-9 04:50am blood calcium-8.9 phos-3.8 mg-2.1 studies: . admisson ekg : atrial flutter with a rapid ventricular response. the axis is indeterminate. right bundle-branch block. compared to the previous tracing of atrial flutter is new. . discharge ekg : sinus bradycardia. right axis deviation. right bundle-branch block. compared to the previous tracing of atrial ectopy is no longer present. . pre dccv echo : this study was compared to the report of the prior study (images not available) of . left atrium: no spontaneous echo contrast in the body of the laa. no mass/thrombus in the laa. good (>20 cm/s) laa ejection velocity. right atrium/interatrial septum: mild spontaneous echo contrast in the body of the ra. mild spontaneous echo contrast in the raa. good raa ejection velocity (>20cm/s). no asd by 2d or color doppler. left ventricle: low normal lvef. aorta: normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. aortic valve: mildly thickened aortic valve leaflets (3). no as. filamentous strands on the aortic leaflets c/with lambl's excresences (normal variant). no ar. mitral valve: mildly thickened mitral valve leaflets. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. no 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 monitored by a nurse throughout the procedure. the patient was monitored by a nurse in throughout the procedure. local anesthesia was provided by benzocaine topical spray. the patient was sedated for the tee. medications and dosages are listed above (see test information section). the posterior pharynx was anesthetized with 2% viscous lidocaine. 0.1 mg of iv glycopyrrolate was given as an antisialogogue prior to tee probe insertion. no tee related complications. conclusions no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no mass/thrombus is seen in the left atrium or left atrial appendage. mild spontaneous echo contrast is seen in the body of the right atrium. mild spontaneous echo contrast is seen in the right atrial appendage. right atrial appendage ejection velocity is good (>20 cm/s). no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is low normal (lvef 50-55%). the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is no pericardial effusion. impression: no atrial thrombus seen. mild spontaneous echo contrast in the right atrium and right atrial appendage. low normal left ventricular systolic function. compared with the report of the prior study (images unavailable for review) of , left ventricular function is now low normal. brief hospital course: patient is a 57 yo m with history of af/flutter s/p multiple ablations and cardioversions who presented today for routine dccv and had a brief asystolic cardiac arrest after. . # asystolic cardiac arrest: pt initially presenting for routine dccv for afib/a flutter, and was found to have a brief episode of asystolic cardiac arrest post dccv requiring epinephrine, atropine and cpr for ~2 minutes. he spontaneously awoke without deficits but was hypotensive requiring pressors. likely cause of arrest was increased vagal tone and cardiac stunning also causing his persistent hypotension. dopamine and phenylepherine drips were able to be quickly weaned and he remained normotensive upon admission to the ccu and remained so overnight into the day of discharge. . # rhythm: pt came to the ccu in nsr after dccv. his rate remained 50s-60s overnight without major events on tele. his flecanide was continued in house. however, upon discharge the decision was made to discontinue his flecanide along with his home atenolol and quinapril given his borderline bradycardia and nsr. he has follow up with pcp and cardiology at which point restarting antiarrhytnmics can be discussed. he was discharged on his home coumadin regimen and should have inr checked per his normal regimen. he remained therapeutic on his coumadin in-house. . # hct drop: pt was noticed to have a hct drop from 43.7 on admission to 33.3. this was likely to be dilutional given his significant fluid resuscitation and comparable decrease in both his wbc and platelet counts. he was guaiac negative and denied any brbrp or dark stools. repeat hct on the day of discharge was stable at 33.9 so we did not feel there was any active bleed. his hct should be followed up as an outpatient to ensure normalization. . # depression: continued venlafaxine and lorazepam medications on admission: atenolol 25 mg daily breaker 45c 200 mg eod flecainide 100 mg folic acid 1 mg daily lorazepam 0.5 mg daily prn anxiety quinapril 10 mg daily ranitidine 300 mg daily prn dyspepsia sildenafil 50 mg prn venlafaxine xr 37.5 mg daily warfarin 2.5 mg x4 week, 5 mg x3 week aspirin 325 mg daily vitamin d 3,000 units daily during winter months coenzyme q10 100 mg daily niacin sr 300 mg daily omega 3 pufa's discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. ranitidine hcl 150 mg tablet sig: two (2) tablet po daily (daily) as needed for gerd. 3. sildenafil 50 mg tablet sig: one (1) tablet po as needed. 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. venlafaxine 37.5 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 6. warfarin 5 mg tablet sig: one (1) tablet po 3x/week (tu,th,sa). 7. niacin 250 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 8. cholecalciferol (vitamin d3) 400 unit tablet sig: 7.5 tablets po daily (daily). 9. omega-3 fatty acids capsule sig: one (1) capsule po daily (daily). 10. lorazepam 0.5 mg tablet sig: one (1) tablet po daily (daily) as needed for anxiety. 11. coenzyme q10 100 mg capsule sig: one (1) capsule po once a day. 12. warfarin 2.5 mg tablet sig: one (1) tablet po 4x per week: , mo, we, fr. discharge disposition: home discharge diagnosis: primary: asystolic cardiac arrest atrial fibrillation atrial flutter discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you came to the hospital for ablation of your atrial fibrillation/atrial flutter. after the procedure, you had a brief episode of cardiac arrest with dropping of your blood pressure, so you were admitted to the ccu. you did very well overnight with your blood pressures and heart rate remaining stable. you were also noted to have a drop in your blood count but on recheck it appeared to be stable. please note your appointments below. it is very important that you follow up with your pcp and cardiologist which have been scheduled for you. we have made the following changes to your medications: stopped quinapril stopped atenolol stopped flecainide you should continue all other medications as your were taking you should also have your inr (coumadin level) checked when you see your pcp followup instructions: department: when: monday at 10:40 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: cardiac services when: thursday at 11:00 am with: , np building: sc clinical ctr campus: east best parking: garage department: travel clinic when: friday at 1:30 pm Procedure: Diagnostic ultrasound of heart Cardiopulmonary resuscitation, not otherwise specified Diagnoses: Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Depressive disorder, not elsewhere classified Atrial flutter Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Cardiac arrest Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Precipitous drop in hematocrit

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: no urine output for over 2 days and abdominal distension major surgical or invasive procedure: transjugular liver biopsy history of present illness: 37 yo caucasian male with hx of hiv (, on haart since ) and recently diagnosed hl, s/p one dose of abvd on , presented to clinic for his neulasta injection today and reported no urination ssince thursday evening. over the past week, he reports frequent fevers up to 104f which he has been treating with naprosyn . he reports decreased po intake and increased concentration of urine. since he has felt increasing abdominal distension and loose bms. he stopped using the naprosyn on abdominal discomfort. his fevers are paroxysmal as are nightsweats. he has had theses since since and were the initial signs that lead to his dx of hl. in the clinic patient's labs were drawn and he was noted to be hyponatremic, hyperkalemic with bun/cr of 74/3.8 (bun/cr 19/1.0). he was admited for 3l of ns today. pt received 2u of blood and 1l of ns ( ) he denies any additional medication use prior to . he stopped using haart (atripla) in mid concern for causing these fevers. ros is remarkable as above and for fatigue, weight loss (40lbs), anorexia since of 08, . pt also increased frequency, no dysuria, hematuria. he denies melena, focal abdominal pain, hematochezia, mucous stools, n/v, changes in ms, weakness, cp, sob, lbp, incontinence of stool or urine, changes in skin/rashes, priritis. the remainder of the ros is negative in detail. ~ 1mo ago pt was seen by dr. , and was empirically started on prednisone 60 mg/day. he continued to have fevers unabated even with the steroids. stopped last week and restarted yesterday. onchx: . - bone marroww bx = hypercellular marrow (70-80%) with increased eosinophils and plasma cells, and no morphologic evidence for hodgkin's or non-hodgkin's lymphoma. flow cytometry = a non-specific t cell dominant lymphoid pro-file. - ct scan of the torso on notable for extensive retroperitoneal lymphadenopathy (up to 2.6 cm) and a single mediastinal lymph node (10 x 20 mm). - bx of a retroperitoneal showed a t-cell dominant lymphoid profile with scattered eosinophils and atypical cd30 positive cells, but no classical hodgkin or -sternberg cells. - laparoscopic procedure to remove 4 retroperitoneal lymph nodes. thickened capsule with sinus dilation histocytes and atypical spindle-shaped cells, and there were scattered areas of germinal center regression and areas of sinusoidal fibrosis, and areas of vascular proliferation. cd30 highlighted scattered immunopblasts, but no diagnostic -sternberg cells were seen, and cd15 was negative. hhv-8 stain was negative and highlighted scattered lymphoid cells. . bm aspiration from - hypercellular panhyperplastic myeloid dominant marrow focally infiltrated by classic hodgkin lymphoma . past medical history: dx with hiv ; his initial cd4 count (his nadir so far) was 247. starte on haart (efavirenz + emtricitabine + tenofovir) in 1/. by , his cd4 count = 411 by (21% of the lymphocytes and cd4/cd8 of 0.4), vl = undetectable. haart d/c in thought to be cause of fevers, with no effect. his platelet counts have ranged from 254-528,000 with his last on on at 303,000. his creatinine and electrolytes have been normal since . the alt, ast, ldh, alk phos and t.bili have been in the normal ranges since . his total protein has ranged from 7.8-9.0 grams/dl, and he had an spep that revealed no monoclonal gammopathy. his crp level has been 82.9-241.6 most recently. - chicken pox as a child social history: born and raised in central . he moved to in . he has a college education, and lives with his partner of 10 years. he works as an admissions officer at the architectural college. he has traveled to western europe, , and southern , and within the us has been to the southwest and midwest. family history: mother who is 61 and has sjogren's syndrome. his father is 70 and has hypertension. he has 1 brother who had nephrotic syndrome as a child, now recovered; he has 1 sister who is in good health. he is of descent and no other disorders that he is aware of run in his family. physical exam: gen - nad, amiable, anxious vs: 96.1f 100% ra, 71hr bp 98/55 rr18 heent: neck supple, no , rom intact, mild scleral icterus cor: s1s2 nl, no g/m/r pulm: cta b/l abd: + bs, tender throughout, mildly distended, negative extrem: no edema, dp 2+. skin: mild jaundice, no rashes neuro: a & o x3, cns grossly intact, nl gait, nl strength, dtrs 2+ at patella. rectal: deferred. pertinent results: 03:50pm blood wbc-12.7*# rbc-3.75* hgb-10.0* hct-29.0* mcv-77* mch-26.6* mchc-34.4 rdw-18.4* plt ct-41*# 07:40pm blood wbc-13.5* rbc-3.70* hgb-9.7* hct-28.7* mcv-78* mch-26.2* mchc-33.8 rdw-18.5* plt ct-29* 03:50pm blood neuts-94* bands-2 lymphs-2* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-0 07:40pm blood neuts-79* bands-18* lymphs-3* monos-0 eos-0 baso-0 atyps-0 metas-0 myelos-0 03:50pm blood hypochr-1+ anisocy-2+ poiklo-occasional macrocy-normal microcy-3+ polychr-normal ovalocy-occasional 07:40pm blood hypochr-normal anisocy-2+ poiklo-1+ macrocy-1+ microcy-2+ polychr-1+ ovalocy-1+ schisto-1+ 07:40pm blood pt-27.1* ptt-39.2* inr(pt)-2.7* 07:40pm blood plt ct-29* 11:45pm blood pt-27.1* ptt-38.9* inr(pt)-2.7* 11:45pm blood plt ct-29* 07:40pm blood fibrino-574* d-dimer-1442* 07:40pm blood fdp-0-10 03:50pm blood urean-74* creat-3.8*# na-129* k-5.2* cl-94* hco3-22 angap-18 07:40pm blood glucose-116* urean-76* creat-3.8* na-130* k-5.0 cl-96 hco3-21* angap-18 03:50pm blood alt-109* ast-69* ld(ldh)-313* alkphos-439* totbili-6.8* 07:40pm blood ld(ldh)-327* totbili-6.7* dirbili-6.1* indbili-0.6 03:50pm blood albumin-1.8* calcium-7.1* phos-5.1* mg-1.9 uricacd-7.4* 07:40pm blood calcium-6.8* phos-5.2* mg-1.9 uricacd-7.2* 07:40pm blood hapto-203* ct chest: heart size is within the upper limits of normal. there is no mediastinal adenopathy. the lungs demonstrate bilateral small pleural effusions with associated relaxation atelectasis. the lung apices demonstrate thickened interlobular septa, which may represent increased interstitial edema. patchy right upper lobe nodules (2:19) may represent an infectuous or inflammatory process. the airways are patent to the subsegmental level. ct abdomen: on this non-contrast examination, the liver, spleen, pancreas, adrenals, and kidneys are grossly unremarkable. there is moderate periportal edema noted. there is extensive bulky retroperitoneal and mesenteric lymphadenopathy that is grossly unchanged since five days ago. there is increased mesenteric free fluid. there is no evidence of free air. the intrabominal loops of large and small bowel are unremarkable. ct pelvis: there is a moderate amount of pelvic free fluid measuring water density (7 ). the rectum, sigmoid, and bladder are grossly unremarkable. there is no pelvic or inguinal lymphadenopathy. bone windows demonstrate no evidence of suspicious lytic or blastic lesion. there is diffuse mild stranding of the subcutaneous soft tissues that is consistent with anasarca. impression: 1. no evidence of hydronephrosis. 2. prominent lymphadenopathy that is unchanged since . 3. diffuse anasarca. 4. patchy right upper lobe nodular opaities may represent developing pneumonia or inflammatory process. brief hospital course: 1. acute renal failure: prerenal transformed to atn in the setting of high fevers, sweats and poor po intake prior to admission. he was anuric at admission, however, improved with iv fluid and time. he did have hyponatremia, hyperkalemia (mild, without ecg changes) and hyperphosphatemia which were treated until his creatinine normalized. his urine output and kidney function normalized prior to discharge. 2. cholestatic hepatitis: the patient had abnormal lfts with marked elevation in bilirubin. he underwent transjugular liver biopsy on . pathology demonstrated portal involvement of his hodgkin lymphoma with superimposed hepatitis, likely drug/chemotherapy related. he was treated with ursodiol 600 mg twice daily and his lfts improved. max bilirubin was 22, value at discharge was 3.3. he will continue ursodiol until his lfts normalize. there was no evidence of encephalopathy on this admission. 3. neutropenic sepsis: from e.coli and viridans streptococci bacteremia in the setting of mucositis/colitis and neutropenia from chemotherapy. ct abdomen without perforation or abscess. he was treated with cefepime/vancomycin and this was transitioned to augmentin as an outpatient to complete a 14 day course from negative blood cultures. 4. diarrhea: in the setting of neutropenia. he had a positive adenovirus in the stool. also probably related to mucositis vs. antibiotic associated vs. other. improved at discharge. 5. hodgkin lymphoma/pancytopenia: s/p cycle 1 of abvd. complicated by the above and pancytopenia requiring blood and platelet transfusion and granulocyte support with g-csf. he received g-csf until anc>1000 for two days. further therapy per outpatient providers. 6. volume overload: the patient had acute pulmonary edema in the setting of multiple blood product transfusions in preparation for liver biopsy. he was diuresed with 10 mg iv lasix with several liters response in uop. all attempts were made to minimize oxygen given his recent bleomycin exposure. 7. coagulopathy: in the setting of acute liver injury, poor po intake and antibiotic use. given several doses of vitamin k. inr 1.5 at discharge. 8. oral/tongue lesion: evaluated by infectious disease and dermatology. dfa and culture positive for hsv1. he was started on acyclovir 400 mg po 5 times per day to take for two weeks, then to be followed with 400 mg twice daily indefinitely. 9. hyponatremia: siadh, improvement on fluid restriction, he will continue this as an outpatient. 10. disposition: discharged home with close outpatient oncology follow up. he will continue on phosphorus repletion until instructed by his outpatient providers. it is likely this will improve with better po intake and time off the phosphate binders. he was full code. medications on admission: ondansetron hcl 8 mg tablet one tablet(s) by mouth two to three times per day prochlorperazine edisylate 10 mg tablet one tablet(s) by mouth three times a day as needed for nausea prednisone 60 mg po every am for nausea/night sweats benadryl 25 mg every night for sleep allopurinol 300 mg tablet one tablet(s) by mouth once daily discharge medications: 1. zofran 4 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. disp:*30 tablet(s)* refills:*0* 2. ursodiol 300 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 3. potassium & sodium phosphates mg powder in packet sig: two (2) powder in packet po once a day. disp:*40 powder in packet(s)* refills:*0* 4. compazine 10 mg tablet sig: one (1) tablet po every six (6) hours. disp:*120 tablet(s)* refills:*0* 5. acyclovir 400 mg tablet sig: one (1) tablet po five times a day: please take one tab 5 x day for 2 weeks, and decrease to one tab twice a day until instructed to stop. disp:*150 tablet(s)* refills:*1* 6. amoxicillin-pot clavulanate 875-125 mg tablet sig: one (1) tablet po bid (2 times a day): please take twice a day for 10 days. . disp:*20 tablet(s)* refills:*0* 7. clotrimazole 10 mg troche sig: one (1) troche mucous membrane four times a day as needed for oral thrush (fungal infection) . disp:*120 troche* refills:*0* discharge disposition: home discharge diagnosis: primary: acute renal failure, acute hepatic failure, bacteremia, hsv1 mucositis. secondary: hodgkins lymphoma, hiv discharge condition: stable, improving liver function, stable renal function, improving blood counts, afebrile discharge instructions: you were admitted to with abdominal distension, no urine output for over 2 days and acute renal failure. one day prior, you received chemotherapy for your hodgkins lymphoma. you were also found to have electrolyte abnormalities, impairment of your liver function and thinning of you blood. you were treated with supportive care for your kidneys, liver, heart and lungs. your kidney function returned to and your liver function continues to improve. because of the chemotherapy, you developed a low cell counts (pancytopenia) and required multiple blood product transfusions. also, because of poor immune function, you developed infection in your blood which were treated with antibiotics. you will need to take antibiotics for 10 days after discharge. in addition, because of your immune suppression, you developed an oral hsv1 infection. you will need to take acyclovir 400 mg 5x/day for 2 weeks and then twice a day until a doctor tells you to stop taking the medicine. the acyclovir will be taken chronically to suppress future hsv1 outbreaks. you were treated with fluid replacement and your electrolyte abnormalities are returning to normal. please restrict your free water intake to 1.5 l per day. you were discharged in a good condition. should you experience worsening fevers, chills, abdominal pain, inability to urinate, chest pain, shortness of breath, new pain or any other symptom concerning to you, please call you primary care doctor immediately or go to the nearest emergency room. followup instructions: please follow up with the following providers upon your discharge: provider: , rn phone: date/time: 9:00 provider: , md phone: date/time: 10:30 md, Procedure: Transjugular liver biopsy Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified Acute and subacute necrosis of liver Sepsis Candidiasis of mouth Disorders of phosphorus metabolism Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Dehydration Septicemia due to escherichia coli [E. coli] Streptococcal septicemia Other disorders of neurohypophysis Other and unspecified coagulation defects Herpes simplex without mention of complication Acute edema of lung, unspecified Other specified disorders of liver Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use Hodgkin's disease, unspecified type, lymph nodes of multiple sites Mucositis (ulcerative) due to antineoplastic therapy Other specified aplastic anemias Enteritis due to adenovirus

allergies: amiodarone / lopressor / aspirin / dofetilide attending: chief complaint: sepsis major surgical or invasive procedure: dc-cardioversion x 2 history of present illness: mrs is a pleasant 87f with hx of intermittent vertigo on meclizine, afib on coumadin, recent uti tx'd with bactrim, now presenting to the ed for vertigo. pt states that 4 days ago she noticed hematuria, which prompted her to go to her pcp, which point she was given bactrim for a uti. she never had dysuria or frequency. today she felt vertiginous and lightheaded and therefore presented to the ed. pt states that he vertigo comes on out of the blue, is not positional or worse with changing positions. she states that she feels thirsty but has had normal po intake over the last several days. of note, her ua from 4 d pta showed leuks, blood, few bacteria, creatinine was 0.87. urine cx showed mixed gram positive flora. in the ed inital vitals were 98.7 60 92/68 (b/l 120/80) 18 100% 10l non-rebreather, which was rapidly weaned. venous gas showed 7.26/48/51. triggered for hypotension (reportedly 50/30), central line placed, pt given 500 ccs ns, bedside echo showed adequate pump funx, no effusion. cvp reportedly 22. labs were notable for lactate of 5.3, creatinine 1.9, gap of 16. she was given zofran, levofloxacin for possible pna, and started on a norepi gtt for hypotension. cxr showed central venous catheter terminating at the cavoatrial junction, mild pulmonary vascular congestion, l-sided pleural effusion. line was pulled back. bps improved to 100s, no o2 requirement. vitals on transfer were 98.7 64 17 97/67 100% on 2l nc. on arrival to the icu, pt is comfortable. she states that her breathing is slightly labored however she denies sob, cough, cp. she does feel slightly nauseous and weak all over. she does not currently feel vertiginous, however states that it comes on suddenly and she was recently feeling nauseous. past medical history: - paroxysmal atrial fibrillation on coumadin. - echo in : lvef of 60-65%. - r septic knee: hospitalized from to during which she underwent arthrocentesis then i&d and washout on followed by 14 day-course of ceftriaxone - breast cancer status post lumpectomy in , also with six weeks of radiation therapy. - chronic low back pain followed at the pain clinic. - history of asthma: spirometry: mixed obstructive and restrictive ventilatory defect. since , there is no significant change in spirometry. since tlc has decreased 1.33l (28%). - exercise treadmill test echocardiogram in without evidence of angina or ischemia after four minutes, mild-to-moderate mitral regurgitation. - sick sinus syndrome with a ddi pacemaker placed. - herpes zoster in . - hypertension - ? alzheimer's dementia - recent rib fractures social history: pt lives at home with sister who was recently placed in rehab, has home health aids. ambulates with a walker. quit smoking 10 years ago after almost a decade of smoking, no etoh, no illicits. she has 6 children, she previously worked for the phone company and at . one of her daughters is a nurse. family history: father died of heart disease. mother died of cva. sister: died of emphysema at age 59. physical exam: admission exam: vitals: t:94.4 bp:152/57 p:65 r:20 o2: 98% on 2 l nc general: aaox3, no acute distress heent: sclera anicteric, mm dry, oropharynx clear neck: rij in place, fresh blood under dressing lungs: tachypnic, clear to auscultation bilaterally, mild crackles in l base cv: distant heart sounds, irregular rate, unable to appreciate any murmurs. abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: cool ext, thready pulses, no clubbing, cyanosis or edema skin: no rashes, l nipple scarred neuro: cns intact, moves all ext freely discharge examination: vs: tc 98.0 bp 107-128/49-57 hr 69-79 rr 18 o2 96% on ra. wt: 66.4<--69.4<--69.6<--70.4<--70.1<--69.1<--70.3 kg. gen: pleasant elderly woman, nad, aox3. looks a bit tired and described some dizziness cv: nl s1 + s2. systolic mumur, most loudly auscultated in lusb. resp: pt has poor air entry; otherwise ctab. some crackles in left base. extremities: 2+ pulses in all 4 extremities. no peripheral edema. pt has a grade 1 stress ulcer on her left ankle. complaining of pain in ankle. neuro: aox3, but does get confused intermittently. no neuro deficits. pertinent results: admission labs: 07:15pm blood wbc-11.1* rbc-3.89* hgb-11.6* hct-35.9* mcv-92 mch-29.8 mchc-32.3 rdw-13.8 plt ct-320 07:15pm blood neuts-84.9* lymphs-9.8* monos-3.9 eos-0.8 baso-0.5 07:15pm blood pt-36.3* ptt-37.6* inr(pt)-3.5* 07:10pm blood glucose-156* urean-31* creat-1.9*# na-131* k-5.9* cl-96 hco3-17* angap-24* 07:15pm blood ck(cpk)-116 07:15pm blood ck-mb-2 probnp-4420* 07:20pm blood ctropnt-<0.01 03:57am blood ck-mb-2 ctropnt-<0.01 03:57am blood calcium-8.0* phos-7.1*# mg-2.1 iron-44 08:21pm blood po2-51* pco2-48* ph-7.26* caltco2-23 base xs--5 comment-green top 07:26pm blood lactate-5.3* discharge labs: 06:35am blood wbc-8.4 rbc-2.96* hgb-8.5* hct-26.7* mcv-90 mch-28.6 mchc-31.6 rdw-14.5 plt ct-589* 06:35am blood pt-36.3* inr(pt)-3.5* 06:35am blood glucose-83 urean-13 creat-1.5* na-138 k-3.6 cl-94* hco3-36* angap-12 06:35am blood ck-mb-3 ctropnt-<0.01 02:06pm blood ck-mb-3 ctropnt-<0.01 06:35am blood calcium-8.1* phos-4.6* mg-1.6 10:00pm blood ret aut-2.6 10:00pm blood pep-no specifi micro: blood cultures: ngtd urine culture: ngtd stool: -ve imaging: cxr: persistent low lung volume. pulmonary edema has resolved. pacer leads are in standard position. right ij catheter tip is in the upper right atrium. there is no evident pneumothorax. bilateral pleural effusions are small. bibasilar atelectases have improved on the left. tte (focused views): impression: limited transthoracic echocardiography. unable to assess regional wall motion abnormalities due to limited study, but overall systolic function of the left ventricle is probably normal. severe tricuspid regurgitation with failure of tricuspid leaflet coaptation. mild mitral regurgitation. unable to fully assess aortic valve. compared with the findings of the prior report (images unavailable for review) of , the tricuspid regurgitation is now severe. if clinically indicated, a complete transthoracic examination with doppler is recommended. portable tte: compared with the prior study (images reviewed) of , estimated pulmonary artery systolic pressure is now higher. liver or gallbladder us (single organ) : 1. cholelithiasis without evidence of cholecystitis. 2. patent portal vein. prominent hepatic veins likely due to vascular congestion. 3. possible right renal fullness seen on partial views of right kidney. if indicated, this could be evaluated with renal ultrasound. renal u/s : somewhat limited study however both kidneys are within normal limits with good cortical thickness, no hydronephrosis or mass lesions identified. the bladder is fully decompressed around the foley catheter. cxr: central venous catheter and permanent pacemaker remain unchanged in position allowing for positional differences of the patient. cardiac silhouette is enlarged, accompanied by pulmonary vascular engorgement. previously reported multifocal pulmonary opacities have partially cleared with residual opacities mostly in the perihilar regions. this likely reflects improving pulmonary edema. more confluent opacity in left retrocardiac region has only slightly improved and is likely due to a combination of atelectasis and effusion. small right pleural effusion has decreased in size. ekg: atrial fibrillation with controlled ventricular response. intermittent pacer spikes which do not capture non-specific anterior and inferior st-t wave changes. modest q-t interval prolongation. compared to tracing #1 ventricular paced beats are absent. anterior st-t wave changes are more pronounced. clinical correlation is suggested. brief hospital course: hospital course: pleasant 87 yo female presenting with dizziness, hypotension concerning for sepsis initially requiring pressors in the icu, who was then called out to the cardiology service with volume overload, afib and severe tr w/ rv dilation. underwent dccv but continued to be in afib and had to be transferred to the ccu for respiratory distress where she was diuresed and then transferred back to the cardiology floor. she was discharged to (ltac). active issues: # septic shock: the pt was hypotensive on admission requiring pressors with signs of end organ damage including acute renal failure and shock liver. lactate was 5.3 on admission and rose rapidly throughout her first day in the icu peaking at 9. the pt had a recent hx of uti and there was a concern for urosepsis, so she was started on broad antibiotics with vancomycin and zosyn and receieved a 7 day course. on exam, however, she was cold and clamped down peripherally, more concerning for a cardiogenic process. additionally, ecg was showing only intermittent capture of pacemaker. cardiology/ep was consulted, and her pacemaker was interrogated and adjusted to improve cardiac output in setting of shock and acidosis (see atrial fibrillation below). echo was then obtained, which showed severe tricuspid regurgitation with complete lack of coaptation of tricuspid leaflets. it was thought that this was likely the cause of her shock, in addition to the infectious component that had instigated her acute presentation (although no infectious source was isolated during her hospital course). therefore she was gently diruresed with iv lasix back to her dry weight. she continued to have intermittent respiratory difficulty likely copd and fluid overload, which was alleviated with nebs and iv lasix. # atrial fibrillation: on coumadin, supratherapeutic inr on admission (see below). ekg initially showed intermittent pacing with evidence of pacer spikes on t-waves. cardiology/ep consult was obtained, and on pacemaker interrogation was noted to have elevated thresholds above programmed output of leads leading to intermittent capture. ppm was reprogrammed with higher output and higher hr to 80s with appropriate capture. hr was increased to improve cardiac output to more closely match physiologic demand in setting of shock. she was started on dofetilide, but this was discontinued due to qt prolongation. she was then started on amiodarone and metoprolol. in the icu, verapamil was increased to 60mg tid and metoprolol was maintained at 50mg . in this setting, home lisinopril was held to give blood pressure room. however, the pt has a hx of not tolerating amio which was dc/ed and the pt underwent dccv after transfer to the floor. however, pt reverted back to afib and had to go to the ccu for resp distress. qt prolongation prevented dofelitide from being continued, and metoprolol was dc/ed as it was thought to be worsening bronchospasm. at the time of discharge she was put on a higher dose of verapamil (280 ). dccv was performed again and she continued to be in afib. flecainide was dc/ed due to likely underlying cad and was switched to digoxin 0.125 every other day. however, dig was also dc/ed and the pt was dc/ed on verapamil alone with hr in 70s and 80s. the pacemaker was changed from ddir to vvi w/ a lower hr threshold of 50 bpm. # acute renal failure: creatinine elevated to 1.9 on presentation, up from previous baseline of 0.7-0.8 one year prior. etiology thought to be atn vs hypotension/shock. her initial course was complicated by hyperkalemia with associated widening of qrs and , she was given kayexalate, insulin + d50, and calcium gluconate. creatinine peaked at 2.9 with minimal urine output, however renal function improved with continued fluid resuscitation and support with pressors. towards the end of her stay she had another cr spike (1.8 from 1.1) which improved with gentle fluid resusciation. her cr at dc was 1.5. # dyspnea: patient became acutely dyspneic after cardioversion from afib. she was transferred to the ccu for closer monitoring. in the ccu, she was placed on a nitro gtt and diuresed with lasix boluses. her sob was however multifactorial but primarily d/t fluid overload vs copd vs severe thoracic kyphosis as she responded to both lasix and nebs. she was also started on fluticasone-salmeterol diskus (500/50). torsemide was started for po diuresis as she failed po lasix diuresis. lisinopril was restarted at 5mg. her 02 requirement went up to 3l but she was comfortable on ra on dc. at discharge she was stable on ra but patient prone to having acute episodes of dyspnea that were alleviated with duonebs and iv lasix 40mg (if the pt appeared overloaded on exam). # fluctuating inr: pt presented on coumadin for afib (inr goal ); inr 3.5 on presentation in the ed but rapidly rose to 6.2 upon arrival in the icu. peaked at 9.7. no signs of bleeding, so she was not given any reveral agents. etiology of acute rise presumed to be liver dysfunction in the setting of hypotension/shock. however, pt has a hx of labile inr. recieved vitamin k in the ccu and had hematuria which persisted a few days after resolution of supratherpeutic inr. she was bridged back to therapeutic range with lovenox. inr managment remained challenging throughout her stay. at the time of dc her inr was 3.5 so her coumadin of 0.5 mg was held. # hematuria: pt continued to have gross hematuria. unrelated to inr levels. was worked up in the past w/ cystoscopy showing bilateral diverticuli. she has been set up for follow up appt with urologist for cystoscopy. renal u/s done here was normal. # transaminitis: ast/alt in the 400s on presentation, likely due to acute injury from hypoperfusion (shock liver) vs. congestive hepatopathy. alkaline phosphatase and bili remained within normal limits, supports this hypothesis. transaminases rose to the thousands prior to coming down after resolution of sepsis. # anemia: normocytic, near recent baseline of 34.3 on presentation. despite high inr, no signs of acute bleedn other than known prior hematuria that continued intermittently througout her stay. likely chronic hematuria vs low marrow production. her retic count was normal, and spep was also normal. inactive issues: # dementia: stable; contined home meds mirtazepine and aricept # gerd: continue home ranitidine transitional issues: patient has a variety of specialist appts that need to be followed up with. in case that she develops dyspnea and does not respond to duonebs, iv lasix 40mg should be given. verapamil dose can be increased to 240 if rate control or blood pressure managment becomes problem. pt's inr on the day of dc was 3.5 so her warfarin dose of 0.5 mg was held. please restart warfarin at 1 mg after the inr is in therapuetic range. medications on admission: -sulfamethoxazole-trimethoprim 800-160 mg oral tablet take 1 tablet twice a day for 10 days -lorazepam 0.5 mg oral tablet take 1 tablet at bedtime -mirtazapine 15 mg oral tablet take 1 tablet at bedtime -verapamil sr 12 hr 240 mg oral tablet extended release po qam, and 1 po qpm -albuterol sulfate (ventolin hfa) 90 mcg/actuation inhalation hfa aerosol inhaler take 1 to 2 inhalations every 4 to 6 hours as needed; rinse mouthpiece at least once a week -donepezil (aricept) 10 mg oral tablet take 1 tablet daily at bedtime -lisinopril 40 mg oral tablet take 1 tablet daily -flecainide 100 mg oral tablet -metoprolol tartrate 50 mg oral tablet qd with one 25 mg tablet -metoprolol tartrate 25 mg oral tablet 1 tablet with 50 mg tablet -fluticasone (flovent hfa) 110 mcg/actuation inhalation aerosol use 1 inhalation by mouth twice daily and rinse your mouth thoroughly afterward -furosemide 20 mg oral tablet take one tablet daily -ranitidine hcl 75 mg oral tablet take 1 tablet twice daily; available over the counter -warfarin 1 mg oral tablet take 1.5 tablets daily or as directed -tramadol 50 mg oral tablet tab po qhs -loperamide (imodium a-d) 2 mg oral tablet take 1 tablet now, then 1 tablet each 4 hrsfter each unformed stool as needed; available over the counter -? meclizine, dosage unknown discharge disposition: extended care facility: - discharge diagnosis: atrial fibrillation acute on chronic diastolic heart failure hypertension discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). md, Procedure: Other electric countershock of heart Other electric countershock of heart Central venous catheter placement with guidance Diagnoses: Acidosis Hyperpotassemia Anemia, unspecified Esophageal reflux Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Unspecified essential hypertension Acute and subacute necrosis of liver Unspecified septicemia Hyposmolality and/or hyponatremia Severe sepsis Chronic airway obstruction, not elsewhere classified Atrial fibrillation Acute on chronic diastolic heart failure Personal history of malignant neoplasm of breast Personal history of tobacco use Acute respiratory failure Septic shock Long-term (current) use of anticoagulants Cardiac pacemaker in situ Do not resuscitate status Gross hematuria Other and unspecified coagulation defects Diseases of tricuspid valve Kyphosis (acquired) (postural) Dementia, unspecified, without behavioral disturbance

allergies: no known allergies / adverse drug reactions attending: chief complaint: l visual field loss major surgical or invasive procedure: none history of present illness: 66 rhm with parkinsons ds and afib not on coumadin was brought to the er for evaluation of visual changes. code stroke was called. he lives in and was visiting with his wife. they were at mfa next door to medical area this afternoon. while looking at the paintings, suddenly he noted that he had some difficulty in seeing things on the left side. this was especially of a problem, if he looked at things that were at the top and left side. he didnt have any other symptoms and immediatley told his wife. this happened at around 1 pm. 911 was called and he was brought to the ed for eval. past medical history: parkinson's a fib not on coumadin (afib diagnosed 10 years ago, was on coumadin for 1 month and then stopped, not on asa either) social history: lives with wife in , vt. no smoking, no alcohol or drugs. independent in adls, drives. family history: negative for parkinsons, positive for stroke in brother physical exam: admission exam: vitals: temp: 98.4 hr: 71 bp: 126/64 resp: 16 o(2)sat: 99 normal 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, mild llq tenderness, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. attentive. speech normal. able to read, intact repetition . able to follow both midline and appendicular commands. pt. was able to register 3 objects but recalls at 5 minutes. the pt. had good knowledge of current events. there was no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. vf show left superior field cut. funduscopic exam revealed no papilledema, exudates, or hemorrhages. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch and pain vii: symmetric viii: hearing intact. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, some ep rigidity and cogwheel tone throughout. no drift no adventitious movements, such as tremor, noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: intact to lt, pain, position and vibration -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was mute on both -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf or hks -gait: defd. discharge exam (pertinent): cv: irregular rate, no murmurs neuro: visual fields full to confrontation and with red pin examination. mild cogwheeling, stooped posture and turning en bloc, positive pull test. diminished l knee jerk. atrophy of r calf and edb. toes upgoing bilaterally. pertinent results: 02:25pm blood wbc-5.8 rbc-4.24* hgb-13.7* hct-39.7* mcv-94 mch-32.3* mchc-34.4 rdw-13.3 plt ct-160 03:59am blood neuts-75.7* lymphs-17.3* monos-4.4 eos-1.9 baso-0.7 02:25pm blood pt-15.3* ptt-27.1 inr(pt)-1.3* 02:25pm blood glucose-114* urean-20 creat-1.0 na-142 k-3.5 cl-108 hco3-26 angap-12 03:59am blood alt-8 ast-19 alkphos-61 totbili-0.9 04:12am blood calcium-8.5 phos-2.9 mg-2.0 03:59am blood %hba1c-5.8 eag-120 03:59am blood triglyc-58 hdl-44 chol/hd-3.3 ldlcalc-89 ct/cta code stroke protocol with perfusion 1. region of abnormally-increased mtt within the right pca territory, involving a large portion of the right occipital lobe with a smaller region of decreased rcbv in the same distribution is consistent with a small "core" of infarcted tissue surrounded by a penumbra of ischemic tissue. 2. there is an associated abrupt "cut-off" of the p2-p3 segment of the right pca, with "meniscus" appearance, suggestive of acute embolic occlusion. 3. no evidence of intracranial hemorrhage. 4. minimal calcified plaque at the origin of the right vertebral artery, without hemodynamically-significant stenosis. mri 1. small acute infarctions within the right pca territory, specifically within the right body/tail of the hippocampus, right temporal lobe, and right thalamus. 2. no evidence of intracranial hemorrhage. echo no cardiac source of embolism seen. normal global and regional biventricular systolic function. negative bubble study. brief hospital course: neuro: 1. r pca stroke the patient presented with a left superior quadrantanopsia. a code stroke was called and the ct/cta/ct perfusion showed a r p2 cut-off, with large penumbra in that vascular territory. given the visualized blockage, the large size of at risk brain tissue, and the potential for debilitating visual loss, the decision was made to give tpa. the patient received tpa in the ed, and was admitted to the neuro icu for monitoring. after the tpa infusion was complete, his visual deficit remained, but the following morning it had resolved. mri was done 24 hours after tpa, there was no bleed, and 3 small areas of infarction in the r medial temporal lobe and thalamus, consistent with pca stroke. the etiology was most likely atrial fibrillation. cta showed no other vascular abnormalities in the posterior circulation. transthoracic echo showed mild left atrial enlargement, but normal global systolic function, and bubble study was negative for asd/pfo. the patient was started on dabigatran (pradaxa) for stroke with atrial fibrillation. fasting lipid panel showed cholesterol 145, tg 58, hdl 44, ldl 89. he was started on 10 mg simvastatin for secondary stroke prevention. he was seen by pt/ot, and given a prescription for outpatient pt for his parkinsons. there are no restrictions on his daily activities, including driving. 2. ?radiculopathy the patient had a diminished l knee jerk compared to the right side. he then mentioned a concern about r calf atrophy over the past 1 year. his right calf and foot muscles did in fact look atrophied compared to the left side. strength and sensation was intact. he has a history of chronic low back pain, though denies any radiating pains down the legs. he likely has bilateral radiculopathy. he may warrant mri of the l-spine as an outpatient, however there is likely no treatment indicated given he is asymptomatic. atrial fibrillation: patient was in continuous af during his hospital course. he had 1 episode of rapid ventricular response at rest that resolved with 1 dose of iv metoprolol. of note, his verapamil had been held to allow his blood pressure to autoregulate post-stroke. the day of discharge, he ambulated and climbed stairs with pt. he did have tachycardia to 140-160s during this exercise, but remained asymptomatic. we will therefore restart his verapamil at discharge and have him follow up with his cardiologist in the next 2 weeks. medications on admission: sinement -0.5 amantidine 100 mirapex 1-1-0.5 verapamil 360 mg daily discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation: over the counter. 2. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day) as needed for constipation: over the counter. 3. outpatient physical therapy evaluate and treat diagnosis: parkinsons 4. amantadine 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for parkinson's disease. 5. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po qam and q noon () as needed for parkinson's disease. 6. carbidopa-levodopa 25-100 mg tablet sig: 0.5 tablet po qpm (once a day (in the evening)). 7. pramipexole 0.5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)) as needed for parkinson's disease. 8. pramipexole 1 mg tablet sig: one (1) tablet po noon (at noon) as needed for parkinson's disease. 9. pramipexole 1 mg tablet sig: one (1) tablet po qam (once a day (in the morning)) as needed for parkinson's disease. 10. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. dabigatran etexilate 150 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 12. verapamil 360 mg cap,ext release pellets 24 hr sig: one (1) cap,ext release pellets 24 hr po once a day. discharge disposition: home discharge diagnosis: r pca stroke atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with visual difficulties. you had a small stroke caused by a blocked blood vessel. you received a clot-busting medication called tpa to break up the clot. the stroke was caused by atrial fibrillation. you were started on a blood thinner called pradaxa. you were started on simvastatin for cholesterol and stroke prevention. followup instructions: you should follow up with your primary care doctor and your cardiologist within 2 weeks. md, Procedure: Injection or infusion of thrombolytic agent Diagnoses: Atrial fibrillation Paralysis agitans Cerebral embolism with cerebral infarction Lumbago Visual field defect, unspecified

allergies: haldol / penicillins attending: chief complaint: lethargy, ?pseudomonas pna, hypercarbic respiratory failure, and arf/hyperkalemia. major surgical or invasive procedure: : bal : bal : post pyloric feeding tube placement : midline catheter exchange : post pyloric feeding tube placement : removal of right groin tunneled hd catheter : midline replacement : exchange of left midline for new 30 cm 5 french single lumen catheter (with 4 cm out on the skin). the catheter tip is in the left axillary vein. the line is ready for use. history of present illness: 46 yo m s/p cadaveric renal transplant on recently discharged on now back from rehab with lethargy, ?pseudomonas pna, hypercarbic respiratory failure, and arf/hyperkalemia. the patient had been previously doing well at rehab and had been intermittently tolerated trach mask. he had been treated for his baseline anxiety/agitation w/ ms contin, ativan and seroquel, and had developed increasing lethargy two days prior to admission. he had an abg at that time on pcv 18/5 @45% that was 7.25/60/80 and was maintained on a vent since that time. sputum cx showed 2 species of psuedomonas, one resistent to carbapenems and the other resitant to fluoroquinolones and had been started on cipro/cefepime. additionally he was noted to have worsening creatinine, up from 1.47 to 2.04 today and a k in the 5s for the last few days. past medical history: past medical history: esrd of unclear etiology on hd x 3 years s/p kidney transplant mssa bacteremia , treated with 6 weeks iv vanco at hd mssa bacteremia at hospital htn s/p l nephrectomy late for stab wound to kidney hcv gt1 s/p 48 wks rbv/ifn ending with hcv vl undectable depression ocd obesity brachiocephalic stenosis psh: cadaveric renal transplant on ; s/p l nephrectomy late for stab wound to kidney social history: social history: + tobacco 1ppd x decades, no etoh, or ivdu. orginally from , here in us x 20 years. lives alone in . son involved. children in . unemployed. wife committed suicide family history: family history: no fh recurrent skin infections, cad, dm physical exam: on admit: vs: t: 101.5 hr: 96 bp: 165/142 cmv 100%/ 16x333 / 10 neuro: responds appropriately to command. pupils bilaterally heent: op clear. trach in place, well healed. card: rrr, no m/r/g lungs: decreased breath sounds throughout, scattered r sided wheezes abd: soft, ntnd extr: 1+ le edema, left femoral groin catheter in place pertinent results: on admission: wbc-6.6# rbc-2.92* hgb-9.1* hct-28.5* mcv-98 mch-31.1 mchc-31.8 rdw-17.5* plt ct-240 pt-25.2* ptt-35.9* inr(pt)-2.4* glucose-93 urean-55* creat-2.3* na-142 k-5.8* cl-108 hco3-28 angap-12 alt-7 ast-12 alkphos-86 totbili-0.3 calcium-9.3 phos-2.8 mg-2.4 albumin-3.8 at discharge: wbc-2.5* rbc-3.23* hgb-10.2* hct-31.4* mcv-97 mch-31.4 mchc-32.3 rdw-18.1* plt ct-112* pt-17.2* ptt-30.7 inr(pt)-1.5* glucose-105* urean-21* creat-1.4* na-140 k-6.2* cl-105 hco3-30 angap-11 alt-11 ast-12 alkphos-59 amylase-64 totbili-0.2 calcium-9.4 phos-2.7 mg-2.0 tacrofk-7.8 ******* : bal respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. of two colonial morphologies. : bal: no growth : cmv viral load: non-detectable brief hospital course: : directly admitted to sicu from for fever and white out of left lung. bronch here removed mucous plug on left. ms here more agitated and less alert than prior to discharge to rehab ~1wk before. has been on cipro & cefepime for pseudomonas lung infection at rehab. cr 2.3, uop minimal, foley placed : at 3am patient abruptly became hypotensive (after being hypertensive overnight) to sbp's in 70's map 40, developed rigors, chills. neo started, right axillary a-line place, piv (still has lue single lumen midline from prior admission). transfused 2 units rbcs for hct 24.9 (down from 28.5), bp stabilized, and neo weaned off. next hct 29.2. he had self-d/c'd dobhoff in rehab and this was replaced here by sicu and repositioned to approximately a post-pyloric position via ir. tf's restarted. agitation treated with seroquel, minimizing benzos per psychiatry. started vanco, cefepime, inhaled tobra, micafungin (had received dose of fluconazole immediatly upon arrrival). he was continued on cefepime (for psuedomonas isolated from rehab inhaled) and tobraycin inhaled started for pseudomonas aeruginosa (on sputum at sputum here ). cr 2.6 : hct 36.4. held coumadin due to supratherapeutic inr 3.2. patient desaturated, cxr w/ r lower lung atelectasis, labs sent, bronch done, mucus plug/pus material removed, tf's held. repeat bronchoscopy done over night for peak airway pressures in high 40's, thick secretions suctioned with improvement in peak pressures to low 30's. cr 2.7--->3.1; inr 4.0 : hct 32.3, cr 3.2 - ? intravascularly dry - fena sent, -stim test - did not respond appropriately, started hydrocortisone 100mg iv q8h started for 7 days - blood pressure and uop gradually improved, vanco d/c'd based on culture and clinical information, mmf decreased to 500 tid, echo - poor quality but lvef>55% (similar to last echo ), inr 5.1 (coumadin still held) : flagyl restarted for gnrs in anaerobic bcx bottle at osh. ivf changed to d5ns. foley d/c'd. emesis x1, ngt coiled in mouth, pulled back to stomach (by cxr). tfs held. : ivf down to 75, coumadin held, cmv overnight, unable to tolerate ps : cleared by speech and swallow for diet while on low dose cpap. given 80mg lasix. : received lasix 100 iv x2 doses. dosed coumadin 3mg for inr 1.8. discontinued flagyl and micafungin since there were no new cultured organisms from all cultures and no clinical evidence of bacteremia/fungemia. : lasix 40 po x 2 doses. coumadin 3 mg. tacro . cellcept to 1000 from 500 tid. hypertensive and agitated. clonidine 0.2 mg x 1, standing hydral. ativan given. small dose haldol ok with primary team, not given however. cefepime, valcyte, mmf dosing increased accordingly secondary to improvement of renal function w/ cr at 1.7 and uop ~4l the day before. tolerating regular soft po intake. having episodes of increased agitation w/ associated hypertension. these were treated medically w/ good response. : r groin hd cath removed without issue after obtaining consent from legal guardian and pt acknowledged and agreed to procedure. for the past two weeks kidney function has been stable, creatinine ranges from 1.1 - 1.4. immunosuppression has been followed by trough prograf levels with dosing based on levels. valcyte was discontinued due to neutropenia. the cmv viral load was non-detectable and patient and donor were cmv ab positive. in addition, he was dosed x 1 with neupogen with good response in his white count. the patient is continuing now solely on trach collar. he continues with thick secretions and requires suctioning and the use of around the clock nebulizers, but has remained off the vent > 1 week. he is tolerating tube feeds of novasource renal. pain management and agitation appear under much better control with current regimen. he is out of bed to chair and has begun working with pt on rehab, looks forward to engaging in rehabilitation process. medications on admission: 1. docusate sodium 50 mg/5 ml liquid : ten (10) ml po bid (2 times a day). 2. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day). 3. acetaminophen 650 mg/20.3 ml solution : one (1) dose po q6h (every 6 hours) as needed for pain. 4. glucagon (human recombinant) 1 mg recon soln : one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 5. fluoxetine 20 mg capsule : two (2) capsule po daily (daily). 6. famotidine 20 mg tablet : one (1) tablet po q12h (every 12 hours). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : six (6) puff inhalation q2 prn () as needed for sob/wheeze. 8. acetylcysteine 20 % (200 mg/ml) solution : 3-5 mls miscellaneous q4h (every 4 hours) as needed for thick secretions. 9. mycophenolate mofetil 200 mg/ml suspension for reconstitution : 1000 (1000) mg po bid (2 times a day). 10. insulin regular human 100 unit/ml solution : asdir asdir injection asdir (as directed). 11. oxycodone 5 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain. 12. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension : ten (10) ml po daily (daily). 13. quetiapine 50 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for agitation: hold for hypotension/oversedation. 14. clonidine 0.1 mg tablet : one (1) tablet po tid (3 times a day) as needed for agitation: hold for sbp<110. 15. epoetin alfa 10,000 unit/ml solution : one (1) sc injection injection qmowefr (monday -wednesday-friday). 16. tacrolimus 1 mg capsule : twelve (12) capsule po q12h (every 12 hours): tacrolimus level to be checked in am tomorrow and then 3 times a week, adjust dose accordingly. 17. lorazepam 0.5 mg tablet : one (1) tablet po qid (4 times a day) as needed for prn anxiety/agitation: hold for over-sedation. 18. warfarin 1 mg tablet : one (1) tablet po once (once) for 1 doses: please check inr in am tomorrow and then 3 times per week, adjust dose accordingly. 19. valganciclovir 50 mg/ml recon soln : four y (450) mg po 3x/week (,tu,th). 20. ondansetron 4 mg iv q8h:prn nausea/vomiting 21. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 22. vancomycin lock : one (1) vancomycin lock asdir: combine: 12,500 units heparin sodium & 12.5mg vancomycin in 5ml normal saline discharge medications: 1. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 2. gabapentin 100 mg capsule : one (1) capsule po tid (3 times a day). 3. bacitracin zinc 500 unit/g ointment : one (1) appl topical (2 times a day): to trach site. 4. collagenase clostridium hist. 250 unit/g ointment : one (1) appl topical (2 times a day) as needed for abd wound. 5. lorazepam 1 mg tablet : one (1) tablet po tid (3 times a day). 6. senna 8.6 mg tablet : two (2) tablet po hs (at bedtime). 7. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain. 8. lorazepam 0.5 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for anxiety. 9. polyethylene glycol 3350 17 gram/dose powder : seventeen (17) grams po daily (daily) as needed for constipation. 10. acetylcysteine 20 % (200 mg/ml) solution : one (1) ml miscellaneous q6h (every 6 hours) as needed for thick secretions. 11. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension : ten (10) ml po daily (daily). 12. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily). 13. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 14. fluoxetine 20 mg capsule : two (2) capsule po daily (daily). 15. clonidine 0.2 mg tablet : one (1) tablet po tid (3 times a day). 16. quetiapine 25 mg tablet : two (2) tablet po bid (2 times a day). 17. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : four (4) puff inhalation q4h (every 4 hours). 18. mycophenolate mofetil 500 mg tablet : two (2) tablet po bid (2 times a day). 19. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler : two (2) puff inhalation qid (4 times a day). 20. ondansetron hcl (pf) 4 mg/2 ml solution : two (2) ml injection q8h (every 8 hours) as needed for nausea. 21. hydromorphone 2 mg tablet : one (1) tablet po q4h (every 4 hours) as needed for pain. 22. furosemide 20 mg tablet : 0.5 tablet po daily (daily). 23. tacrolimus 5 mg capsule : one (1) capsule po q12h (every 12 hours). 24. tacrolimus 1 mg capsule : three (3) capsule po twice a day. 25. warfarin 5 mg tablet : one (1) tablet po once (once): dosage per transplant clinic. be adjusted based on inr. 26. insulin regular human 100 unit/ml solution : per sliding scale injection asdir (as directed). 27. kayexalate powder : seventeen (17) grams po for potassium > 6: per transplant clinic recommendations for hyperkalemia. discharge disposition: extended care facility: - - discharge diagnosis: recurrent psuedomonas pneumonia w/ sepsis esrd s/p cadaveric renal transplant with extended criteria complicated by vap sepsis s/p percutaneous tracheostomy acute on chronic renal failure: resolved 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: please call dr. / clinic at if any of the warning signs listed below or if you have any concerns or questions. no medication changes should be made without discussion with the transplant clinic. patient has a tracheostomy and is tolerating trach mask. ******** appointed guardian - o: ; c: *********** labwork thursday to include cbc, chem 7, trough prograf and pt/inr labwork friday to include chem 7, trough prograf and pt/inr then resume q monday and thursday schedule for labs. fax results to . cbc, chem 10, ast, t bili, trough prograf, pt/inr **** monitor for fever, chest pain, increased oxygen demand, change in sputum, increased pain over kidney graft, decreased urine output followup instructions: follow up apppointments will be scheduled with the transplant clinic. . coordinator is rn Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Arterial catheterization Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Incision with removal of foreign body or device from skin and subcutaneous tissue Bronchoscopy through artificial stoma Bronchoscopy through artificial stoma Central venous catheter placement with guidance Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Hyperpotassemia Abnormal coagulation profile Renal dialysis status Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Unspecified protein-calorie malnutrition Severe sepsis Pulmonary collapse Dysthymic disorder Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Pneumonia due to Pseudomonas Other diseases of lung, not elsewhere classified Obesity, unspecified Septicemia due to anaerobes 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 Ventilator associated pneumonia Acquired absence of kidney Delirium due to conditions classified elsewhere Complications of transplanted kidney Chronic respiratory failure Tracheostomy status Neutropenia, unspecified Other diseases of trachea and bronchus Mixed acid-base balance disorder Dependence on respirator, status Physical restraints status Obsessive-compulsive personality disorder Acquired absence of intestine (large) (small)

allergies: haldol attending: addendum: discharge medications: (revised) discharge medications/orders: mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). prednisone 10 mg tablet sig: one (1) tablet po daily (daily). bactrim 400-80 mg tablet sig: one (1) tablet po once a day. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*10 syringes* refills:*2* coumadin 3 mg tablet sig: one (1) tablet po at bedtime. tacrolimus 1 mg capsule sig: three (3) capsule po twice a day: followup transplant labs on thursday to adjust dosing. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po once a day: as you were taking. colace 100 mg capsule sig: one (1) capsule po twice a day. dilaudid 2 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. disp:*30 capsule(s)* refills:*0* discharge disposition: home with service facility: homecare md Procedure: Closed [endoscopic] biopsy of bronchus Other repair and plastic operations on trachea Local excision or destruction of lesion or tissue of trachea Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Unspecified essential hypertension Long-term (current) use of steroids Unspecified viral hepatitis C without hepatic coma Personal history of tobacco use Depressive disorder, not elsewhere classified Candidiasis of mouth Compression of vein Personal history of venous thrombosis and embolism Obesity, unspecified Acquired absence of kidney Delirium due to conditions classified elsewhere Kidney replaced by transplant Obsessive-compulsive disorders Mechanical complication of tracheostomy Body Mass Index 33.0-33.9, adult

allergies: haldol attending: chief complaint: tracheal stenosis major surgical or invasive procedure: : flexible bronchoscopy with bronchoalveolar lavage and cervical tracheal resection and reconstruction. : bronchoscopy history of present illness: the patient is a 47-year-old gentleman who has had a tracheostomy for some time and has been unable to be decannulated due to a peristomal stenosis. the total length of the abnormality in the trachea was 5 cm, but i thought the central portion of this, which was right at the stoma, was actually only about 2.5 to 3 cm. therefore, despite his ongoing immunosuppression for a kidney transplant, i recommended resection of the stenosis and reconstruction. after an abundant discussion preoperatively, the patient did understand that he is at increased risk for anastomotic complication, including dehiscence, necrosis, and incomplete alleviation of stenosis. most specifically, the immunosuppression prevents healing and he understood that this would potentially complicate his healing of the anastomosis. nevertheless, he did not want to continue with his tracheostomy tube in place and elected to go forward with surgery, despite understanding that the option would be to leave the tracheostomy tube as it was. past medical history: 1. hcv, genotype 1- completed 48 wks ifn () 2. esrd htn and traumatic nephrectomy due to stab wound, on hd (mwf) s/p nephrectomy. s/p cadeveric kidney transplant w/ multiple postop complications (vap, delayed graft function, ms changes) 3. hypertension 4. line sepsis due to left subclavian line with gram (+) cocci 5. central obstruction of venous flow from r and lue 6. multiple vascular admissions including thrombosed and stenosed b/l central veins. lead to hd catheters placed in femoral veins, but complicated by multiple line infx and sepsis. 7. mssa bacteremia of r fem line (removed thereafter). 8. hx leaving ama 9. svc occlusion of all central veins 10. depression 11. obsessive-compulsive disorder social history: + tobacco 1ppd x decades quit , no etoh, or ivdu. orginally from , here in us x 20 years. lives alone in . son involved. children in . unemployed. wife committed suicide. family history: nc physical exam: discharge physical exam: vs: t: 97.3 p: 100 bp: 123/74 rr: 19 o2sat: 98ra gen: wd, wn in nad heent: ncat, eomi, anicteric cv: rrr, +s1s2 w no m/r/g pulm: cta b/l w no w/r/r, normal excursion, no respiratory distress back: no vertebral tenderness, no cvat abd: soft, nt, nd, no mass, no hernia pelvis: deferred ext: wwp, no cce, no tenderness, 2+ b radial/dp/pt neuro: a&ox3, no focal neurologic deficits pertinent results: 06:22am blood wbc-7.5 rbc-3.53* hgb-10.6* hct-33.7* mcv-95 mch-29.9 mchc-31.4 rdw-14.6 plt ct-207 06:22am blood pt-16.8* ptt-32.5 inr(pt)-1.5* 05:00am blood pt-15.4* ptt-59.4* inr(pt)-1.3* 04:59am blood pt-14.1* ptt-48.9* inr(pt)-1.2* 03:15am blood pt-13.6* ptt-68.1* inr(pt)-1.2* 06:22am blood glucose-96 urean-14 creat-1.4* na-137 k-4.6 cl-104 hco3-23 angap-15 06:22am blood calcium-9.2 phos-1.9* mg-1.8 06:22am blood tacrofk-8.0 05:00am blood tacrofk-9.3 12:51pm blood type-art temp-37.3 fio2-50 po2-89 pco2-33* ph-7.40 caltco2-21 base xs--2 intubat-not intuba swallow f/u recommendations: 1. po diet: thin liquids, regular consistency solids. 2. meds whole with water. 3. oral care. 4. please call, page, or re-consult if there are any concerns on this diet. dc cxr on findings: as compared to the previous radiograph, there is no relevant change. left pleural effusions, slightly improved ventilation of the right lower lung. massive cardiomegaly with signs of moderate pulmonary edema. no evidence of newly appeared focal parenchymal opacities suggesting pneumonia. brief hospital course: date of icu admit: procedure/date: tracheal resection and reconstruction abx/date: vanc/cefepime (- ); fluconazole (-); cipro admit wt: cc: s/p tracheal resection and reconstruction hpi: 47m s/p cadaveric kidney transplant with post-tracheostomy stenosis s/p tracheal resection & reconstruction . patient had a complicated hospital course after his transplant about 1 year ago. he required tracheostomy which was complicated by tracheal stenosis. he underwent tracheal resection and reconstruction and is being admitted to the sicu. all: haldol pmh: hcv, esrd(htn/nephrectomy post-trauma)s/p cadaveric kidney transplant , hypertension; svc occlusion(all central veins), depression; ocd psh: cadaveric kidney transplant , mult thrombectomy, extremity veins : mycophenolate mofetil 1000'', prednisone 10, bactrim, tacrolimus 6'', warfarin 4, calcium carbonate, colace, senna micro: mrsa: negative sputum: contaminated imaging: cxr: no ptx cxr: there is a cardiac silhouette enlargement and prominence of the mediastinum; however, this may be due to mediastinal fat. study is very limited due to patient positioning and to the body habitus. cxr: as compared to the previous radiograph, there is no relevant change. left pleural effusions, slightly improved ventilation of the right lower lung. massive cardiomegaly with signs of moderate pulmonary edema. no evidence of newly appeared focal parenchymal opacities suggesting pneumonia. events: : to sicu post-op. called renal transplant recs: mmf 1000 iv bid, methylpred 8 iv daily (instead of prednisone 10'), hold bactrim. : failed swallow eval, video swallow performed- failed as well. pt to remain npo over the weekend. increasing agitation- rec'd ativan, zyprexa, started on dexmedetomedine gtt. creatinine bumped this am, urine lytes pending. : psych consult obtained. hep gtt started. : started vanc/cipro/cefepime for rll infiltrate. failed s&s : weaning dex, clonidine patch started. : passed s&s, started on prior oral meds. precedex stopped and started on seroquel and neurontin. developed tachycardia, started lopressor. foley d/c'd. : bronch in or: severe supraglottic edema, white plaque on vc ? (started fluc), granulation tissue at anastamosis, distal to anastamosis stenosis. ?ent consult. repeat bronch in 1 week +/- stent. d/c'ed cipro. d/c'd neck stitch. decreased coumadin to 2mg while on fluc. lovenox bridge and d/c'd heparin. : d/c vanc/cefepime. po meds. s&s re-eval say ok for reg diet no restriction. pt eval cleared for home w/ new cane. pt can't go to floor with r femoral cvl, midline unable to be placed : femoral cvl removed; discussed discharge instructions w pt regarding limited rom neck. assessment: 47m with post-tracheostomy stenosis s/p tracheal resection & reconstruction neurologic: - clonidine patch, seroquel, and neurontin for agitation cardiovascular: - hds - check daily ekg while getting seroquel pulmonary: - s/p tracheal resection and reconstruction - albuterol nebs prn - likely on vc - fluconazole (- ) - repeat bronch in ~1 week +/- stent. gastrointestinal / abdomen: - zofran prn nausea - famotidine for prophylaxis nutrition: - regular (low sodium) renal: - renal transplant recs: continue current immunosuppressants - baseline cr 1.1-1.7, monitor uop hematology: - coumadin for svc occlusion - lovenox 1mg/kg to bridge until coumadin therapeutic endocrine: - home immunosuppresion resumed: mmf 1000 iv''/pred 10', tacro (goal level ) - riss, goal bs<150 infectious disease: - fluc started for on vc; 200 mg po bid x 2 weeks - home bactrim resumed - discontinued vanc/cefepime for rll infiltrate - () tubes/lines/drains: l femoral cvl (-) d/c'd: r radial a-line ( - ) wounds: neck operative site imaging: - fluids: kvo consults: thoracic surgery, renal transplant, psych, s&s billing diagnosis: s/p tracheal reconstruction prophylaxis: - dvt: boots, lovenox, coumadin - stress ulcer: famotidine - vap bundle: n/a communication: icu consent: in chart code status: full disposition: icu medications on admission: : mycophenolate mofetil 1000'', prednisone 10, bactrim, tacrolimus 6'', warfarin 4, calcium carbonate, colace, senna, tacrolimus 6 mg po bid converted to 1.5 mg iv bid, 1000 mg mmf po bid converted to iv 1:1, 10 mg prednisone po daily converted to 8 mg iv methylprednisolone daily discharge medications: 1. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 2. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 3. bactrim 400-80 mg tablet sig: one (1) tablet po once a day. 4. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*10 syringes* refills:*2* 5. coumadin 3 mg tablet sig: one (1) tablet po at bedtime. 6. tacrolimus 1 mg capsule sig: three (3) capsule po twice a day: followup transplant labs on thursday to adjust dosing. 7. fluconazole 200 mg tablet sig: one (1) tablet po once a day. disp:*12 tablet(s)* refills:*0* 8. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po once a day: as you were taking. 9. colace 100 mg capsule sig: one (1) capsule po twice a day. 10. dilaudid 2 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: tracheal stenosis s/p tracheal resection and reconstruction esrd s/p kidney transplant ocd. obesity brachiocephalic stenosis 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: mr. , you were admitted for tracheal resection and reconstruction of your tracheal stenosis. please review the following home instructions: you will go home with vna services. call dr. office at if you have fevers greater than 101.5, chills, nightsweats, difficulty breathing, chest pain, decreased urine output, or if your neck incision develops redness, swelling or drainage. pain: take tylenol for pain activity: walk often, use the incentive spirometer. you may shower. medications changes take 3mg of coumadin each night and followup your inr on with dr. . please inject lovenox 100 mg sq twice a day until your inr is 2. tacrolimus: take only 3mg twice a day and followup labs on with kidney transplant clinic, on followup instructions: followup dr. your primary care doctor on at 245pm followup with , md phone: date/time: 1:30 get a chest xray 30 minutes prior to followup. provider: , md phone: date/time: 3:00 go to clinic for labs on thursday . Procedure: Closed [endoscopic] biopsy of bronchus Other repair and plastic operations on trachea Local excision or destruction of lesion or tissue of trachea Diagnoses: Pneumonia, organism unspecified Hyperpotassemia Unspecified essential hypertension Long-term (current) use of steroids Unspecified viral hepatitis C without hepatic coma Personal history of tobacco use Depressive disorder, not elsewhere classified Candidiasis of mouth Compression of vein Personal history of venous thrombosis and embolism Obesity, unspecified Acquired absence of kidney Delirium due to conditions classified elsewhere Kidney replaced by transplant Obsessive-compulsive disorders Mechanical complication of tracheostomy Body Mass Index 33.0-33.9, adult

allergies: haldol / penicillins attending: chief complaint: end stage renal disease major surgical or invasive procedure: cadaveric renal transplant central venous access arterial line hemodyalsis line kidney biopsy bronchoscopy tracheostomy history of present illness: 46 y/o male on hd at who has been called in for standard criteria cadaveric kidney transplant. the patient currently dialyzes t-th-s with last hd on . edw is reported as 100 kg, he states off weight yesterday was 102 kg. he often has hypotension during rx and have adjusted his bp meds recently. he reports he does not make urine. the patient denies fever, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath. he reports no recent hospitalizations and no sick contacts past medical history: past medical history: esrd of unclear etiology on hd x 3 years, on transplant list mssa bacteremia , treated with 6 weeks iv vanco at hd mssa bacteremia at hospital htn s/p l nephrectomy late for stab wound to kidney hcv gt1 s/p 48 wks rbv/ifn ending with hcv vl undectable depression ocd obesity brachiocephalic stenosis . social history: social history: + tobacco 1ppd x deacdes, no etoh, or ivdu. orginally from , here in us x 20 years. lives alone in . son involved. wife and children in . unemployed. family history: family history: no fh recurrent skin infections, cad, dm physical exam: vs: 98.9, 81, 126/81, 14, 96%ra wt: 103.7 kg heent: no oral infection or dental caries noted, no lad, sclera anicteric card: rrr, no m/r/g lungs: cta bilaterally abd: obese, multiple scars noted (s/p nephrectomy from stab wound 15 years ago) + bs, not taut or distended extr: 1+ le edema, left femoral groin catheter in place, arms with multiple access interventions neuro: a+o x 3, depressed somewhat flat affect skin: moist, multiple dry scaly areas especially lower legs pertinent results: 05:40pm urea n-78* creat-11.4*# sodium-137 potassium-4.3 chloride-96 total co2-20* anion gap-25* 05:40pm alt(sgpt)-8 ast(sgot)-13 05:40pm albumin-4.0 calcium-7.8* phosphate-8.5*# magnesium-2.1 05:40pm wbc-8.0# rbc-4.43*# hgb-13.6*# hct-41.9# mcv-95 mch-30.7 mchc-32.4 rdw-16.7* 05:40pm plt count-202 05:40pm pt-12.9 ptt-29.2 inr(pt)-1.1 11:19 am sputum gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. heavy growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- 8 s ciprofloxacin--------- =>4 r gentamicin------------ 8 i meropenem------------- =>16 r piperacillin/tazo----- 32 s tobramycin------------ <=1 s 6:59 am bronchial washings respiratory culture (final ): 10,000-100,000 organisms/ml. commensal respiratory flora. pseudomonas aeruginosa. >100,000 organisms/ml.. susceptibility to doripenem and colistin requested by dr (). sent to for colistin and doripenem sensitivities (). colistin <= 2 mcg/ml susceptible. doripenem > 2 mcg/ml not susceptible. colistin & doripenem sensitivities done by labs. pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. second morphology. susceptibility to doripenem and colistin requested by dr (). pseudomonas aeruginosa #2 combined with #1 for colistin & doripemem sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | cefepime-------------- 16 i 16 i ceftazidime----------- 16 i 16 i ciprofloxacin--------- =>4 r =>4 r gentamicin------------ 8 i 8 i meropenem------------- =>16 r =>16 r piperacillin/tazo----- 64 s 64 s tobramycin------------ <=1 s <=1 s fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. 7:59 pm immunology (cmv) source: line-art. cmv viral load (final ): cmv dna not detected. performed by pcr. detection range: 600 - 100,000 copies/ml. 2:48 pm blood culture blood culture, routine (final ): staphylococcus, coagulase negative. final sensitivities. _________________________________________________________ staphylococcus, coagulase negative | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ =>16 r levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- 2 i tetracycline---------- 2 s vancomycin------------ 1 s 11:40 am blood culture blood culture, routine (final ): staphylococcus, coagulase negative. _________________________________________________________ staphylococcus, coagulase negative | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ =>16 r levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- 2 s vancomycin------------ 1 s 4:30 pm sputum pseudomonas aeruginosa | pseudomonas aeruginosa | | cefepime-------------- 16 i 16 i ceftazidime----------- 16 i 16 i ciprofloxacin--------- =>4 r =>4 r gentamicin------------ =>16 r 8 i meropenem------------- =>16 r =>16 r piperacillin/tazo----- =>128 r =>128 r tobramycin------------ 2 s 2 s 12:58 am urine enterobacter cloacae. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | enterobacter cloacae | | cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- 64 i 64 i piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r 12:58 am urine _________________________________________________________ enterobacter cloacae | enterobacter cloacae | | cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- 64 i 64 i piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r brief hospital course: patient was admitted to dr. surgical service and underwent a cadaveric renal transplant on . prior to procedure, patient required re-positioning of his tunneled hd line as this is also his only vascular access. please refer to operative note for more details. he was taken directly to the intensvie care unit after his surgery. the remainder of his hospital course can be summarized by the following review of systems. neuro: patient's sedation and pain was appropriately controlled with fentanyl and versed while he remained intubated. the patient had multple episodes of agitation requiring increased boluses of fentanyl and versed. on pod 16, patient's fluoextine was restarted for concerns for ssri withdrawal. in addition, po zyprexa and ativan were also started. on , the patient was started on po methadone to improve pain control and anxiety. on , librium was started for a longer acting anxiolysis. fentanyl and versed were weaned off. by , methadone and ativan were being weaned. patient continued to have episodes of agitation. on , the patient had suicidal ideations and pyschiatry was reconsulted. the patient was started on cogentin for concern for akathisia and the zypexa was d/c'ed for suspected eps. the patient was started on prn seroquel for agitation. a 1:1 sitter was recommended. he received intermittent propofol at night to prevent deline/detubing. the patient's suicidal ideation improved with the start of eating and being in contact with his family in (via telephone). the patient's neuro status improved with an improvement in his suicidal ideations. the 1:1 sitter was d/c'ed. ativan and clonidine were weaned per psychiatry recommendations. patient is awake, alert, oriented and cooperative on discharge. pulm: the patient was transferred to the sicu intubated. esophageal balloon used to determine optimal peep. the patient was on an ards protocol. patient bronched on , cultures sent. cefepime and fluconazole started. patient was growing psuedomonas from sputum. tobramycin inh and cefepime started for vap. by pod15, peep decreased to 5 and started a cpap trial on pod16. since the patient has a history of tracheal stenosis (trach placed in ), thoracic surgery was consulted for trach placement. on pod 16, the patient was on cpap 5/5. on , the patient was brought to the or by thoracic surgery for trach placement, which was subequently exchanged for a longer size. the patient was weaned to ps with trach mask trials. on , speech and swallow was consulted. he did not tolerate a passy-muir valve. on , he tolerated trach collar all day with cpap overnight. the patient had episodes of tolerating trach collar and then required cpap support. on , ip assessed the patient for possible desizing trach to allow for a pmv. however, since he wasn't tolerating trach collar, it was decided to not manipuate the trach. on the evening of , the patient had a acute desaturation episode and became agitated. he had severe hypercarbia on abg and was restarted on cmv with gradual improvement. the patient was bronched during this event, which showed a normal exam: all airways patent, no mucus or erythema. since this, he is tolerating intermittent trach mask but still requiring vent support when tires. he has been oob to chair and has ambulated on his own from bed to chair. cardio: patient had massive fluid resuscitation immediately post-op and required levophed for hypotension. cardiac enzymes were negative x 3. tee on and showed hyperdynamic with evidence of low intravascular volume. patient was intermittently bolused with crystallioid,albumin, and prbcs for volume replacement. pressors were weaned, but needed to be restarted/increased for hypotension if too much fluid was removed via cvvhd or if the patient needed more sedation. patient continued volume resuscitation with albumin. the patient's bp stabilized and he was able to tolerate fluid removal via hd. he has been hemodynamically stable even while off hd for past few days. gi: dobhoff was placed by ir and novasource renal was started on and advanced. on , tf were held for increased abominal distention (noticeable at his known hernia site). on , relistor was given, which improved bowel function, and tf were restarted. on , the patient passed his swallowing evaulation. the patient was started on pureed solids and thin liquids with ensure supplements and has been tolerating them while on trach mask. renal: patient with delayted graft function. patient started on cvvhd post-op. renal u/s on showed patent vessels and good flow. patient received 2 doses of atg and tacorlimus was started pod3. on tpa was added to hd line clotting. hd line was replaced by ir on tacrolimus, cellcept, and solumedrol restarted on . right groin hd catheter was replaced on . renal biopsy on showed no acute rejection. by pod 14, the patient tolerated aggressive diuresis on cvhd, with daily diuresis up to 2- 3l daily. by, , the patient had a profound diuresis, and cvvhd was run even. however, since his bp was labile, intermittent hd was not recommended. on , the patient had a renal biopsy, which was negative for rejection. on pod 31 (), the patient tolerated hd. patient tolerated 1-2l negative on hd. on , 160mg lasix given, with no change in urine output. the patient has qdaily straight caths, with urine outputs upwards of 100-150cc/daily. on , the patient's ureteral stent was d/c'ed by urology. on , the patient was given 100mg iv lasix with an increase in urine output. overall, his urine output continued to improve up to 400-500cc/day. with the improvement in his urine output and return to pre-op weight, hd was held. given improving renal function (i.e. decreasing cr), he was not requiring hd from and was given intermittent lasix with good response. on , his urine output was ~100-200cc/hr without lasix. his last fk level on discharge was 10.2 (from 11.5) and he was sent on fk 12mg . he is to have his fk level checked at rehab and his medication dosed accordingly. heme: patient has been on heparin gtt post-op with a ptt goal 50-60 to protect the graft. on , the patient was started on coumadin. once the patient had a therapeutic inr, the hep gtt was stopped. the patient received intermittent prbcs transfusions with hd. he was transfused for low hct as needed with lasix after he was off hd. his hct at discharge was stable 29.5. his inr on discharge was 2.5 (from 1.8 on coumdain 7.5mg) and his coumadin dose was dropped to 1mg. he is to have his inr checked tomorrow am at rehab. id: vap sepsis, vancomycin/cipro/flagyl started on , improved and kept on cefepime and inhaled tobramycin. id was consulted on for pseudomonas aeruginoas pneuomia, plan to continue vanco, cefepime, d/c ciprofloxacin, cont micfungin, d/c fluconazole, start inh tobramycinpatient is on valgancyclovir and bactrim for post-transplant prophylaxis. on , blood cultures from r. femoral catheter grew gpc, coag negative staph. vancomycin was restarted, in addition to vanco lock in the hd line for a 14 day course. surveillance blood cultures were drawn, which were consistently negative. sputum culture on , positive for pseudomonas, treatment held since patient had normal wbc, afebrile, tolerating trach mask. hd line vanc lock continued. on , the patient was started on cipro for urine culture positive for enterobacter (). on , the cipro was stopped. his valcyte was increased to 450mg three times per week on date of discharge. endo: maintained on riss, random cortisol level was 30, confirming appropriate adrenal function. medications on admission: allergies: pcn - unknown. has never had a reaction but had a skin test decades ago in that was positive. haldol- cramps. meds prior to admission: fluoxetine 40mg po daily, renal cap daily, lisinopril 40mg po daily, renagel 1600mg po tid discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2 times a day). 2. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 3. acetaminophen 650 mg/20.3 ml solution sig: one (1) dose po q6h (every 6 hours) as needed for pain. 4. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 5. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 6. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q2 prn () as needed for sob/wheeze. 8. acetylcysteine 20 % (200 mg/ml) solution sig: 3-5 mls miscellaneous q4h (every 4 hours) as needed for thick secretions. 9. mycophenolate mofetil 200 mg/ml suspension for reconstitution sig: 1000 (1000) mg po bid (2 times a day). 10. insulin regular human 100 unit/ml solution sig: asdir asdir injection asdir (as directed). 11. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 12. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension sig: ten (10) ml po daily (daily). 13. quetiapine 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for agitation: hold for hypotension/oversedation. 14. clonidine 0.1 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for agitation: hold for sbp<110. 15. epoetin alfa 10,000 unit/ml solution sig: one (1) sc injection injection qmowefr (monday -wednesday-friday). 16. tacrolimus 1 mg capsule sig: twelve (12) capsule po q12h (every 12 hours): tacrolimus level to be checked in am tomorrow and then 3 times a week, adjust dose accordingly. 17. lorazepam 0.5 mg tablet sig: one (1) tablet po qid (4 times a day) as needed for prn anxiety/agitation: hold for over-sedation. 18. warfarin 1 mg tablet sig: one (1) tablet po once (once) for 1 doses: please check inr in am tomorrow and then 3 times per week, adjust dose accordingly. 19. valganciclovir 50 mg/ml recon soln sig: four y (450) mg po 3x/week (,tu,th). 20. ondansetron 4 mg iv q8h:prn nausea/vomiting 21. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 22. vancomycin lock sig: one (1) vancomycin lock asdir: combine: 12,500 units heparin sodium & 12.5mg vancomycin in 5ml normal saline -please administer via sterile syringe each time after using the femoral dialysis line -if any questions, please call for pharmacy. discharge disposition: extended care facility: hospital - discharge diagnosis: esrd s/p cadaveric renal transplant with extended criteria complicated by vap sepsis s/p percutaneous tracheostomy 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 going / rehab. please call dr. / clinic if any of the warning signs listed below appear or if you have any concerns/questions. you have a tracheostomy and are tolerating trach mask. followup instructions: please follow-up in 1 week at the transplant clinic with dr. - please call to schedule an appointment. Procedure: 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 Venous catheterization for renal dialysis Venous catheterization for renal dialysis Temporary tracheostomy Closed [percutaneous] [needle] biopsy of kidney Closed [percutaneous] [needle] biopsy of kidney Other kidney transplantation Bronchoscopy through artificial stoma Replacement of tracheostomy tube Local excision or destruction of lesion or tissue of trachea Diagnoses: End stage renal disease Acute kidney failure with lesion of tubular necrosis Other postoperative infection Urinary tract infection, site not specified Severe sepsis Unspecified viral hepatitis C without hepatic coma Other opiates and related narcotics causing adverse effects in therapeutic use Hypopotassemia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Pneumonia due to Pseudomonas 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 Infection and inflammatory reaction due to other vascular device, implant, and graft Obesity, unspecified Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Ventilator associated pneumonia Urinary complications, not elsewhere classified Drug-induced delirium Other complications due to renal dialysis device, implant, and graft Pseudomonas infection in conditions classified elsewhere and of unspecified site Other diseases of trachea and bronchus Personal history of Methicillin resistant Staphylococcus aureus Suicidal ideation Acute venous embolism and thrombosis of superficial veins of upper extremity

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: acute on chronic abdominal pain major surgical or invasive procedure: exploratory laparotomy; patch perforated duodenal ulcer. history of present illness: 88f s/p pelvic irradiation for stage ic endometrial cancer and two recent admissions for intractable diarrhea without true resolution presents to the ed after ~1d of acute on chronic abdominal pain. she is unable to describe the pain as anything but diffuse without laterality and having no mollifying factors. the patient presented to the ed due to these concerns and due to her recent discharge for the medical service with a diagnosis of continued inflammatory/infectious colitis. while i was reviewing other films, i noted that the patient had free air on abdominal ct with concern for freely perforated diverticulitis with a known history of radiation enteritis. upon assessment she has +rebound some minimal amount of voluntary guarding and requires exploratory laparotomy for definitive source control of perforated hollow viscus. past medical history: past medical history: endometrial ca -stage ic, grade 3 -s/p surgery followed by pelvic radiotherapy radiation proctitis diverticulosis hypertension hyperlipidemia h/o cellulitis l leg . surgical history: bso-tah cataract surgery hernia repair left groin 3/. social history: lives alone; thinks she wil have a hard time living alone again. smoked 1.5 packs/day for 30 years. denies alcohol and illicit drugs. family history: niece died of ovarian cancer at 76, father died of mi at 62, one sister with breast cancer. physical exam: upon presentation to : vs:97.0 110 122/97 24 97 a+ox 3, nad, lethargic, slightly anxious ctab rrr soft, distended, tender diffusely with +rebound and some involuntary guarding, not rigid mae anasarca present pertinent results: 11:30pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-sm urobilngn-neg ph-5.0 leuk-neg 07:40pm glucose-223* urea n-21* creat-1.1 sodium-138 potassium-3.5 chloride-101 total co2-23 anion gap-18 07:40pm wbc-11.1* rbc-4.58 hgb-12.0 hct-38.3# mcv-84 mch-26.2* mchc-31.3 rdw-17.6* 07:40pm plt smr-very high plt count-611* imaging: cxr: low lung volumes. bibasilar opacities=effusion and atelectasis, l>r, increased from prior. mild-to-moderate cardiomegaly. cxr: bibasilar opacities and blunting of costophrenic sulci. mediastinal structures unchanged. ct abdomen/pelvis: impression: 1. free air in the abdomen with free fluid and peritoneal enhancement compatible with peritonitis. site of bowel perforation is most likely sigmoid colon. 2. persistent colitis. 3. small bilateral pleural effusions, lower lobe compressive atelectasis, increased from prior. 4. large hiatal hernia. brief hospital course: on hd 1 the patient was taken to the or for an exploratory laparotomy and patch for a perforated duodenal ulcer. she was hypotensive and developed atrial fibrillation during the case and was started on levophed. on pod 1, her hypotension and atrial fibrillation continued and her levophed was changed to neo-synephrine; a diltiazem drip was started as well. her heart rate responded appropriately to the calcium channel blocker. of note she failed a vent wean on pod 2, a lasix drip was started in attempt to diurese to aid in ventilation. on pod 3, the lasix drip was continued and she was started on acetazolamide for metabolic alkalosis. the neo-synephrine was weaned off as she was hemodynamically stable. she was extubated. on pod 4 narcotics were discontinued and the lasix drip was changed to oral lasix with adequate diuresis. she was transferred to the regular nursing unit. she was transferred to the floor on and was stable from a respiratory standpoint on 4l o2 via nasal prongs. however, she had a possible aspiration event on with a brief desaturation to the 60s. o2 sats stabilized with 60% o2 via shovel mask and she was transferred to the sicu for continued care. her respiratory status improved and she was transferred back to the regular floor. while on the floor she was noted with marginal nutritional intake; calorie counts were initiated and were calculated at lower than required amounts. nutritional supplements were added to her diet and her diet has improved but stills bears watching. her foley catheter remains in place after a failed voiding trial; while at rehab and once ore ambulatory another voiding trial should be attempted. she was again noted with a desaturation episode on hospital day 10 and was given a mucomyst treatment as she was having difficulty coughing up sputum that was previously noted as thick; she did require nasal tracheal suctioning with improvement in her respiratory status. a cxr was done as well which showed in comparison with study of lower lung volumes, continued prominence of the cardiac silhouette with bilateral pleural effusions and bibasilar atelectatic change, more prominent on the left, with no acute pneumonia, vascular congestion, or pneumothorax. she was continued on her nebs. she was evaluated by physical therapy and is being recommended for rehab after her acute hospital stay. medications on admission: simvastatin 40', mesalamin 1600''', creon 4 caps w meals, loperamide 4''', bismuth prn, opium tincture 2ml''', hydrocort 100'' pr 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). 3. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 4. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 7. mesalamine 400 mg tablet, delayed release (e.c.) sig: four (4) tablet, delayed release (e.c.) po tid (3 times a day). 8. lipase-protease-amylase 12,000-38,000 -60,000 unit capsule, delayed release(e.c.) sig: one (1) cap po tid w/meals (3 times a day with meals). 9. hydrocortisone acetate 10 % (80 mg) foam sig: one (1) appl rectal daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). discharge disposition: extended care facility: re discharge diagnosis: perforated duodenal ulcer discharge condition: alert and oriented x2 activity status: out of bed with assistance to chair or wheelchair. discharge instructions: avoid heavy lifting, greater than 10 pounds. avoid tub baths; you may shower. no bending at waist. followup instructions: provider: , m.d. phone: date/time: 3:00 follow up with clinic in weeks; call for an appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Suture of duodenal ulcer site Diagnoses: Other iatrogenic hypotension Unspecified pleural effusion Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Personal history of tobacco use Personal history of malignant neoplasm of other parts of uterus Pulmonary collapse Other and unspecified hyperlipidemia Alkalosis Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Unspecified hearing loss Accidents occurring in residential institution Diverticulosis of colon (without mention of hemorrhage) Other specified diseases of pancreas Foreign body in larynx Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction

allergies: ancef / iodine; iodine containing attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: redo-sternotomy, aortic valve replacement (23mm st. tissue), ascending aorta and hemi-arch replacement (28mm gelweave), aortic endarterectomy temporary screw in lead permanent pacemaker insertion history of present illness: 57 year old female with history of bioprosthetic aortic valve replacement in with serial echocardiograms that have shown worsening aortic valve gradients. currently complaining of dyspnea on exertion with recent admission in for heart failure. past medical history: ascending aortic aneurysm, bicuspid aortic valve s/p aortic valve replacement , bilateral breast cancer s/p lumpectomy/xrt/chemotherapy, chronic lymphocytic leukemia s/p chemotherapy, h/o active tuberculosis , splenomegaly, cholelithiasis, s/p repair of cerebral avm social history: as rn on oncology unit lives with spouse quit 30 year ago etoh denies family history: mother and father both died of cardiac disease suddenly physical exam: vs: 90 16 90/70 5'3" 125# gen: no acute distress skin: unremarkable with well-healed sternotomy incision heent: unremarkable neck: supple, full range of motion chest: clear lungs bilat. heart: regular rate and rhythm with 2/6 systolic murmur radiating to carotids abd: soft, non-tender, non-distended +bowel sounds ext: warm, well-perfused, -edema neuro: grossly intact, alert and oriented x 3 pertinent results: 05:52am blood wbc-7.0 rbc-3.17* hgb-9.4* hct-27.4* mcv-87 mch-29.5 mchc-34.1 rdw-15.9* plt ct-278 01:12pm blood wbc-16.8*# rbc-2.16*# hgb-6.8*# hct-20.2*# mcv-93 mch-31.5 mchc-33.8 rdw-14.3 plt ct-103* 05:52am blood plt ct-278 05:52am blood pt-13.2 ptt-26.1 inr(pt)-1.1 04:45am blood pt-12.9 inr(pt)-1.1 01:12pm blood pt-16.3* ptt-53.7* inr(pt)-1.5* 03:45am blood fibrino-646*# 02:29am blood ret aut-3.9* 05:52am blood glucose-92 urean-20 creat-0.4 na-140 k-4.1 cl-101 hco3-31 angap-12 03:17pm blood urean-24* creat-0.8 cl-108 hco3-31 05:42am blood calcium-9.8 phos-4.7* mg-2.0 02:00am blood phos-3.6 mg-2.0 05:30am blood tsh-4.0 05:30am blood free t4-1.2 01:54am blood cortsol-17.6 , f 57 cardiology report ecg study date of 7:52:02 am sinus rhythm with atrial sensing and ventricular pacing. ventricular ectopy. compared to the previous tracing atrial fibrillation is no longer present and pacing is new. read by: , h. intervals axes rate pr qrs qt/qtc p qrs t 99 0 140 392/460 0 130 -51 chest, portable reason for exam: 57-year-old woman with chb status post avr. new pm implant. rule out pneumothorax, lead location. since , left-sided pacemaker was removed and right-sided pacemaker was installed, ending in the right atrium and right ventricle. there dobbhoff tube is still in place, ending below the diaphragm with its tip not imaged on today's study. a right-sided picc was also installed ending in the mid svc. small right pleural effusion, increased with basilar opacity. left lower lobe atelectasis improved. there is no pneumothorax. the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 5:52 pm provisional findings impression: jxrl tue 6:02 pm findings concerning for right frontal infarct with loss of -white matter differentiation (2:24-25). final report history: 57-year-old woman status post aortic valve replacement with left hemiparesis. assess for cva. comparison: non-contrast head ct from . technique: non-contrast head ct was obtained. findings: loss of -white differentiation associated with a subtle region of hypodensity within the right frontal lobe near the vertex (2:24-25), new in comparison to ct , is concerning for relatively acute infarction. there is no intracranial hemorrhage, mass effect or shift of normally midline structures. the ventricles and basal cisterns are normal and unchanged in size and configuration. post-operative changes of the right temporal lobe, with apparent right temporal resection and overlying right temporal bone craniotomy are unchanged. bones are otherwise unremarkable without lesions suspicious for metastases. paranasal sinuses and mastoid air cells are well aerated. impression: 1. findings concerning for relavtively acute right frontovertex infarct. 2. unchanged findings of right temporal lobe resection. comment: the findings were discussed with mr. (np, cardiothoracic surgery service) by dr. on , at approximately 6pm. findings can be further evaluated with mri if clinically indicated. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 9:00 am brief hospital course: mrs. was a same day admit after undergoing pre-operative work-up prior to her admission. she was taken directly to the operating room where she underwent a redo-sternotomy with an aortic valve replacement as well as an ascending aorta and hemi-arch replacement. please see operative report for surgical details. postoperatively she was taken to the intensive care unit for invasive monitoring. she was noted to be in complete heart block and was paced with epicardial pacing. she was quite slow to wean from sedation and focal facial seizures were noted. a neurology consult was obtained and a ct scan was performed. the ct scan was inconclusive and an mri was recommended but unable due to epicardial wires. extubation was delayed due to concern for airway protection. an eeg was performed which was abnormal suggesting a widespread encephalopathy or a metabolic anoxic or postictal etiology. a video eeg was performed which did not show any seizure activity but did show a markedly encephalopathic background. keppra was continued for control of seizure activity. the cardiology service was consulted for her complete heart block. she was taken to the electrophysiology where a temporary screw in pacemaker was placed. tube feed and intravenous vitamins were started for nutritional support. she slowly became more alert moving her right side and only responding to painful stimuli on her left side. the neurology service felt that all her symptoms were consistent with a brainstem infarct. on postoperative day five she was successfully extubated without incident. she continued with left sided weakness however physical and occupational therapy were consulted to work with her for range of motion activity. mrs. developed a fever and was pancultured. vancomycin and zosyn were started. her sputum culture revealed serratia marcescens and ceftriaxone was started. she continued to improve from a neurological standpoint however remained with no spontaneous left sided movement. she underwent repeat ct scan that had findings concerning for relavtively acute right frontovertex infarct. her mental status also improved where she could answer questions and respond to commands. mrs. was transferred from the icu on post operative day thirteen. a permanent pacemaker insertion and cardioversion on post operative day fourteen. she was started on coumadin and amiodarone for atrial fibrillation. she has continued to make slow progression, please see speech, occupational and physical therapy notes. sternal incision no erythema no drainage no edema weight preop 55 kg and discharge 52 kg medications on admission: lasix 40mg qd, toporol xl 25mg qd, femara 25mg qd, calcium and multiple vitamins discharge medications: 1. docusate sodium 50 mg/5 ml liquid : ten (10) ml po bid (2 times a day). ml 2. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 3. levetiracetam 500 mg tablet : one (1) tablet po bid (2 times a day): continue - if questions please contact dr (neurology). 4. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 5. furosemide 20 mg tablet : one (1) tablet po daily (daily). 6. amiodarone 200 mg tablet : two (2) tablet po bid (2 times a day): 400mg twice a day through then decrease to 400 mg once daily through , then decrease to 200mg and follow up with dr . 7. clindamycin hcl 150 mg capsule : two (2) capsule po q6h (every 6 hours) as needed for pm implant for 7 doses. 8. warfarin 3 mg tablet : one (1) tablet po once a day for 1 days: 3mg and recheck inr for further dosing - goal inr 2-2.5 for atrial fibrillation . 9. femara 2.5 mg tablet : one (1) tablet po once a day. 10. medications please consider starting betablocker when blood pressure will tolerate, then if stable start ace inhibitor, unable to start during hospitalization due to blood pressure 11. outpatient work pt/inr for coumadin dosing, goal inr 2-2.5 with first draw discharge disposition: extended care facility: hospital - discharge diagnosis: bioprosthetic aortic stenosis s/p aortic valve replacement ascending aortic aneurysm s/p replacement complete heart block s/p permanent pacemaker placement post operative atrial fibrillation right frontal infarction seizure acute on chronic systolic heart failure pmh: bicuspid aortic valve s/p aortic valve replacement , bilateral breast cancer s/p lumpectomy/xrt/chemotherapy, chronic lymphocytic leukemia s/p chemotherapy, h/o active tuberculosis , splenomegaly, cholelithiasis, s/p repair of cerebral avm discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the 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) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks from date of surgery. 6) no driving for 1 month or while taking narcotics for pain. 7) call with any questions or concerns. followup instructions: dr. in weeks dr. in weeks dr. after discharged from rehab dr. after discharged from rehab ( dr - clinic - at 11 am provider: clinic phone: date/time: 11:30 provider: , phone: date/time: 10:00 provider: , md phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Intraoperative cardiac pacemaker Diagnostic ultrasound of heart Enteral infusion of concentrated nutritional substances Thoracentesis Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Insertion of temporary transvenous pacemaker system Laryngoscopy and other tracheoscopy Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, aorta, abdominal Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Cardiac complications, not elsewhere classified Atrial fibrillation Aortic valve disorders Personal history of malignant neoplasm of breast Atrioventricular block, complete Mechanical complication due to heart valve prosthesis Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Abdominal aneurysm without mention of rupture Encephalopathy, unspecified Ventilator associated pneumonia Acute on chronic systolic heart failure Cerebral artery occlusion, unspecified with cerebral infarction Iatrogenic cerebrovascular infarction or hemorrhage Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms Chronic lymphoid leukemia, in remission Personal history of tuberculosis Unilateral paralysis of vocal cords or larynx, complete Flaccid hemiplegia and hemiparesis affecting unspecified side

allergies: augmentin attending: chief complaint: shortness of breath major surgical or invasive procedure: ultrasound guided right pigtail placement history of present illness: mr. is a 74 y/o m w/h/o ild, copd, chronic hydropneumothorax, initially diagnosed on , and avnrt, who presents on transfer from with pleural space infection. he had a spontaneous ptx on , treated intially with ct drainage, however he had a continued airleak requiring a vats pleurectomy and pleurodesis, with an oversewing of his airleak on by dr. . his air leak persisted requiring a repeat talc pleurodesis on . he was sent home initially but was readmitted to the osh from for an mssa wound infection and expanding ptx, he had his old chest tubes removed and a new one put in during this hospitalization that has remained in place since. he was readmitted from for fever and svt, during which his sputum tested positive for mac, but his pleural fluid did not grow any culture. due to his svt, his was changed from atenolol to sotalol then. he notes that he has been having a come to his house since his last hospitalization packing his old chest tube sites with wet to dry dressings since they are not healing well. for the previous 3-4 weeks he has noticed cloudy drainage from his chest tube, he returned to dr. 2 days pta who prescribed keflex. yesterday am he had a fever to 103, palpitations and shortness of breath and returned to where he was noted to be in avnrt, tachycardic to 171. he was administered adenosine causing this to break. in adition he was given vancomycin and zosyn. labs there revealed a wbc ct of 20.4. he was transfered here for further management of his pleural space infection, his chronic hydropneumothorax and his svt. on arrival here he notes no chest pain, sob or palpitations. +fevers/chills. + chronic cough, non productive. no hemoptysis. no ha/n/v. past medical history: chronic hydropneumothorax s/p vats pleurectomy/pleurodesis ; repeat pleurodesis interstitial lung disease chronic obstructive pulmonary disease rheumatoid arthitis supraventricular tachycardia (avnrt per osh report) hypothroidism chronic low blood pressure (states his normal sbps 80s-90s) ejection fraction 50% with global hypokinesis from tte cyst removal from back yrs prior tonsilectomy and adenoidectomy 65 yrs ago social history: married and lives with family, has two drinks per month and quit smoking 30 years ago after a 20 pack year history. he reports exposure to asbestos. family history: he has siblings with "liver and neurologic diseases." physical exam: vs: t: 97.8 hr: 79 sr bp: 108/60 sats: 94% ra wt: 66.2 kg general: 73 year-old male in no apparent distress heent:normocephalic, mucus membranes moist neck: supple no lymphadenopathy card: rrr resp: absent breath sound right apical and lateral border, left clear gi: benign extr: warm no edema chest tube site with suture, no sq air neuro: awake, alert oriented pertinent results: wbc-17.5* rbc-4.08* hgb-12.3* hct-37.2 plt ct-428 wbc-15.9* rbc-4.09* hgb-12.4* hct-37.2 plt ct-435 wbc-23.6*# rbc-4.11* hgb-12.5* hct-37.8 plt ct-421 wbc-19.2* rbc-3.54* hgb-10.8* hct-32.7 plt ct-361 neuts-71.0* lymphs-22.5 monos-4.0 eos-2.1 baso-0.5 glucose-111* urean-12 creat-0.8 na-139 k-4.2 cl-101 hco3-29 glucose-106* urean-16 creat-0.8 na-136 k-4.1 cl-106 hco3-23 calcium-9.0 phos-2.2* mg-1.9 caltibc-203* trf-156* pleural fluid culture (final ): acinetobacter baumannii complex. moderate growth. acinetobacter baumannii complex | ampicillin/sulbactam-- <=2 s cefepime-------------- 8 s ceftazidime----------- 8 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s imipenem-------------- <=1 s levofloxacin----------<=0.12 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s cxr: : large right-sided hydropneumothorax has not changed in size since exam performed about 24 hours ago. the left lung shows reticular opacity consistent with chronic interstitial disease. the left hemidiaphragm is obscured, probably secondary to left lower lobe atelectasis/interstitial disease. there is no evidence of pneumothorax or pleural effusion in the left hemithorax. the cardiomediastinal contour is stable compared with prior exam with no evidence of mediastinal deviation. a left-sided picc is observed in a stable position and ends in the upper superior vena cava. impression: right-sided hydropneumothorax and chronic interstitial lung disease without displacement of the mediastinum. brief hospital course: mr. presented to with shortness of breath. he was admitted to the icu as a transfer from an outside hospital. on arrival he was returned to svt requiring adenosine, pacer pads were placed and he was started on a diltiazem drip initially. cardiology was consulted and after patient became bradycardic on the diltiazem they recommended digoxin .5mg iv over 30 minutes once and then a second time after six hours. then digoxin 0.25mg iv once and then 0.25mg po daily from there on. his sotalol was held and he had was controlled on this regimen. he also had a right sided pleural pigtail placed on . # neuro- stable throughout hospitalization. required no pain medications, maintained airway and was oriented x3 throughout stay. # pulm- chronic pulmonary infection s/p vats pleurectomy/pleurodesis on and pleurodesis on who presented with apical chest tube in right chest placed , with purulent drainage and ongoing air leak. on a right basilar pigtail was placed at the bedside through ultrasound guidance. purulent drainage was noted but no air leak initially. serial chest x-rays revealed persistent loculation treated with tpa x 3 days with resolution of fluid collections confirmed by cct on . his respiratory status improved with oxygen saturations of 96-99% on room air from requiring 3-4lnc. a persistent leak remained. on he was taken to the or by interventional pulmonology and had bronchoscopy in an attempt to find the source of the leak with hopeful one way valve placement, but no source could be found. on he began having clamp trials of his chest tube. his respiratory status remained stable with oxygen saturations of 92-96% on room air at rest and 89-91% with ambulation. on his chest tube leak was noted to be reduced, although he had significant leak around chest tube insertion site. the basilar chest tube was removed and skin closed with 2.0 silk. the pigtail was removed . chest films: serial chest films showed stable large right pneumothorax. # cv- initially was transferred to unit after episode of supraventricular tachycardia that was thought to be avnrt, which patient had at outside hospital. he had a heart into the 200's, and was hypotensive (sbp 60-80s), was given adenosine x1 and then started on a diltiazem drip that was titrated up to 20mcg/hr. on this drip he became hypotensive and so per cardiology was taken off the diltiazem drip and started on digoxin iv 0.50mg q6 x2 then transition ed to digoxin 0.25mg po daily and had no further events. patient was kept on telemetry throughout. he did not have any additional episodes of significant ectopy through hospital stay. echocardiogram done global systolic function are normal (lvef 65%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is dilated with depressed free wall contractility. #gi- patient was kept on a regular diet and had ensure nutritional supplements added to boost caloric intake. he tolerated eating well. #gu- voiding on own throughout hospital stay # msk- deconditioned in appearance. was encouraged to get out of bed as tolerated. # id- infectious disease was following throughout and advising on antibiotic regimen as written in the pulmonary section. he grew out pan-sensitive acinetobacter and acid fast bacilli. he was initially placed in negative pressure room and was ruled out for tb with induced sputum x3. he was started on a 6 week course of meropenem . the cultures at grew . triple empiric treatment was started for 9-12 months. he will be followed by infectious disease. picc line: left basilic 53 cm single lumen terminates in the a left-sided picc line terminates in the distal svc appropriately. # dispo: he ambulated in the halls independently. continue to make steady progress and was discharged to home with fax and his wife and solutions fax . medications on admission: spiriva 18 mg, advair 250/50 ,, sotalol 80 mg qd, synthroid 100 mcg qd, leflunomide 20 mg every other day, feldene 20 mg every other day, mvi discharge medications: 1. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 3. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 4. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. azithromycin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*11* 6. rifampin 300 mg capsule sig: two (2) capsule po q24h (every 24 hours). disp:*60 capsule(s)* refills:*2* 7. ethambutol 400 mg tablet sig: two (2) tablet po once a day: total of 900 mg daily. disp:*60 tablet(s)* refills:*11* 8. ethambutol 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*11* 9. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 5 weeks: last day . disp:*126 recon soln(s)* refills:*0* 10. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush: flush with 10ml normal saline followed by heparin. 11. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 12. outpatient lab work weekly cbc, chem 7, lfts while on antibiotics. please fax results to infectious disease rn discharge disposition: home with service facility: hospice program discharge diagnosis: intersitial lung disease chronic obstructive pulmonary edema supraventricular tachycardia chronic right plerual effusion hypothyroidism rheumatoid arthritis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. Procedure: Venous catheterization, not elsewhere classified Injection or infusion of thrombolytic agent Other bronchoscopy Arterial catheterization Other incision of pleura Diagnoses: Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis Other specified cardiac dysrhythmias Postinflammatory pulmonary fibrosis Rheumatoid arthritis Empyema without mention of fistula Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: seizures, aphasia major surgical or invasive procedure: intubation/mechanical ventilation history of present illness: 66 yo m with a remote hx of eee resulting in a seizure disorder and etoh use, transferred to medicine from neurology for management of hypoxic respiratory distress. patient was initially presented to an osh on for evaluation of sudden onset aphasia that day, which was noted to occur in the past after seizures. on arrival to , he was noted to be in status epilepticus with subtherapeutic dilantin level, so he was intubated, loaded with dilantin, given iv valium, and transferred to neurology icu service. he was re-started on keppra, dilantin, and klonopin. no further episodes of status while in-house, although noted to have short episodes of seizures in lower extremities that would subside with ativan. hospital course complicated by nstemi with troponins to 0.9. cardiology was consulted and thought nstemi due to demand ischemia likely related to peri-intubation hypotension (transiently required neo gtt in icu). patient on heparin from and continued on cardioprotective medication. also noted to have a pna (fevers, leukocytosis, and rll consolidation), started on vancomycin and zosyn on at osh, which have been continued to date. patient self-extubated on , requiring bipap. resiratory status stabilized, and patient was called out to neuro floor on . called out to a negative pressure ?tb exposure (daughter's boyfriend died of tb). was ?receiving fluids when noted to be having difficulty with respiration. received 1 dose of solumedrol for wheezing on . med/ consult called for management of respiratory issues on , noted to be volume overloaded/with crackles on exam after getting maitenence fluids o/n. when evaluated by the primary team on the floor this afternoon, patient's breathing continued to be quite tachypneic/using accessory muscle to breathe despite being on 5 l o2 and 2 doses of lasix 40 mg iv, ipratroprium nebs, with -1 l diuresis in one hour. repeat abg shows increased hypoxia on same oxygen settings and worsening a-a gradient (570=>583, normal 19). patient also appeared slightly more confused, pulling off oxygen mask frequently during nebulizer treatment and insisting a 'cap' was on the floor, although nothing was noted on the floor. therefore, micu resident monitoring patient on the floor recommended immediate icu transfer. past medical history: seizure do s/p eee encephalitis # hx of etohism since # htn # hyperlipidemia # nstemi: echo with ef 20% to 25% (in setting of recent mi) social history: lives with daughter. daughter's boyfriend recently died of tb on . +etoh. denies illicit drug use or smoking hx. family history: noncontributory physical exam: vs: 97.6 110/80 76 28 95-97% on 5 l nc bs 105 ga: middle aged m lying in bed, labored breathing, aox2 (knows name and date) heent: perrla. mm dry. no lad. unable to assess jvd. neck supple. cards: distant hs heard. pulm: +expiratory wheezes scattered throughout all lung fields. +crackles at bases. abd: soft, obese, nt, +bs. no g/rt. neg hsm. neg sign. extremities: wwp, no edema. dps, pts 2+. skin: no rashes neuro/psych: cns ii-xii intact. 4/5 strength in u/l extremities. dtrs + bl (biceps, achilles). sensation grossly intact to lt. cerebellar fxn poor (unale to do ftn accurately). gait wnl. babinski upgoing bilaterally (r>l. spelled world backward "dlow". pertinent results: labs: 08:00am blood wbc-6.7 rbc-4.63 hgb-14.5 hct-39.6* mcv-86 mch-31.3 mchc-36.6* rdw-13.4 plt ct-362 07:20pm blood wbc-20.1* rbc-5.84 hgb-18.3* hct-48.4 mcv-83 mch-31.3 mchc-37.8* rdw-13.8 plt ct-339 07:20pm blood neuts-79.5* lymphs-14.6* monos-5.5 eos-0.1 baso-0.2 08:00am blood pt-13.8* ptt-22.4 inr(pt)-1.2* 08:00am blood glucose-114* urean-14 creat-1.0 na-141 k-3.9 cl-103 hco3-30 angap-12 07:20pm blood glucose-231* urean-14 creat-0.9 na-138 k-3.9 cl-101 hco3-23 angap-18 05:30am blood alt-18 ast-32 ld(ldh)-198 ck(cpk)-155 alkphos-101 totbili-0.3 12:20pm blood ck(cpk)-161 01:57pm blood ck(cpk)-118 10:47pm blood ck-mb-15* mb indx-12.4* ctropnt-0.91* 01:57pm blood ck-mb-3 ctropnt-0.14* 08:00am blood calcium-9.0 phos-3.1 mg-2.4 05:30am blood %hba1c-5.9 05:30am blood triglyc-452* hdl-21 chol/hd-7.1 05:30am blood tsh-5.3* 02:53am blood free t4-0.99 08:05am blood phenyto-20.8* 07:20pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg imaging: cxrs ~ : diffuse interstitial opacities are most likely due to pulmonary edema. repeat radiography following appropriate diuresis is recommended to assess for underlying infection. ~ : in comparison with the earlier study of this date, the endotracheal tube has been removed. there is opacification at the left base silhouetting the hemidiaphragm. this most likely represents atelectasis and pleural effusion, though the possibility of supervening pneumonia cannot be definitely excluded. pulmonary vascularity is now essentially within normal limits. ~ : moderate cardiomegaly is exaggerated by lordotic positioning, but has probably increased consistent with an enlarging heart, and/or pericardial effusion. azygos distention indicates worsening elevated central venous pressure. there is no pulmonary edema, but left lower lobe consolidation persists, either atelectasis or pneumonia. left subclavian line tip projects over the junction of brachiocephalic veins. there is no pneumothorax. ~ : since earlier today, lung volumes remain low. left lower lobe consolidation, right basilar atelectasis, and small bilateral pleural effusions slightly improved. effusion in the minor fissure is not present anymore. echo: ~: severe left ventricular systolic dysfunction consistent with multivessel coronary artery disease or stress cardiomyopathy. ~: moderate regional left ventricular systolic dysfunction. mild pulmonary hypertension. micro: afb smear neg x 3, cultures pending urine and blood cultures neg brief hospital course: brief hospital summary: 66 yo m with seizure disorder after eee infection and former etoh abuser who was transferred from an osh in status epilepticus. intubated and admitted to the neuro icu service. hospital course complicated by an nstemi resulting in depressed lv ejection fraction, ventilator associated pneumonia treated with 8 day course of vancomycin and zosyn, and hypoxic respiratory distress due to volume overload from depressed lv ejection fraction. patient was also ruled out for tb due to a possible exposure within his family members. during this hospital course, patient was transferred to the neurology icu to the neurology floor to the medicine floor to the medical icu and finally back to the medicine floor. he was discharged home with physical therapy. hospital course by problem: # status epilepticus: patient initially presented to the neuro icu intubated in status epilepticus, likely in setting of subtherapeutic dilantin level. mr. daughter reports that he typically has seizures every 4-6 months and that these occur in the context of low or high levels of dilantin. his level at the osh was subtherapeutic. unlikely meningitis given lack of nuchal rigidity. unlikely alcohol withdrawal as patient reported he had not had etoh use recently and his toxicology screen was negative for etoh. his head ct from the osh shows stable l frontal encephalomalacia. the patient while in the micu became acutely agitated, attempted to leave the unit without any clothes, and a code purple was called. he received on dose of iv haldol 2mg and improved. his mental status exam eventually improved, and his seizure medications were changed to keppra 1500 mg po bid, dilantin 300 mg po qhs (with therapeutic dilantin levels), and klonopin 1.5 mg po qhs on discharge. given prn ativan for seizures > 3min. no further seizure activity on discharge. # hypoxia: patient became acute hypoxic on the floor after being called out from the icu, presumably in the setting of continous ivfs and decreased lv ejection fraction of 30%. aspiration pneumonia may also have contributed to hypoxia. he was transferred to the micu after remaining on the floor for 6 hours due to concern for hypoxic respiratory distress and aggressively diuresed with iv lasix and treated with standing nebulizers. he improved gradually and was transferred back to the floor. transitioned to oral lasix. continued beta-blocker and ace-inhibitor. continued albuterol and ipratroprum nebs as needed. room air sats were 94% on ra at rest and xx% on ambulation. cxr showed stable l lobar opacities. he was discharged with home physical therapy. # ventilator associated pneumonia: patient noted to have leukocytosis and left lower lobe infiltrate on cxr, likely vap versus aspiration pna during seizures 9could not distinguish between the two). unable to obtain speciation on sputum culture, so treated with 8 day course of vancomycin and zosyn. kept on aspiration precautions and diet per speech and swallow recommendations. # tb exposure: recent exposure to family member who died of tb of . afb sputum negative x3. kept in negative pressure room until completely ruled out. # nstemi: patient suffered an nstemi likely due to demand ischemia (hypotensive and tachycardic in the neuro icu after intubation requiring transient neosynephrine gtt) versus takatsubo/stress cardiomyopathy. therefore, decision was made not to do cardiac catherization. cardiac enzymes were cycled and were downtrending on discharge. continued cardioprotective meds (asa, statin, beta-blocker, started low dose ace-inhibitor). patient will need a stress test as outpatient # pump: patient had pulmonary edema with poor ef% (20-25%) which improved to 30% on repeat tte, likely due to recent myocardial insult. patient was diuresed and treated with beta blocker and afterload reduced with ace-inhibitor. he will need a repeat tte in weeks as outpatient. # rhythm: no arrythmias noted on telemetry. continued telemetry # etoh use: no signs of withdrawal. continue mvi, thiamine, folate medications on admission: - atenolol 25mg po qd - folate 1 mg qd - mvi qd - simvastatin 40mg po qd - keppra 1500 mg po bid - klonopin 1mg qam and 1.5 qhs po - amlodipine 5mg po qd - dilantin 200mg po qhs discharge medications: 1. simvastatin 40 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. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). 6. phenytoin sodium extended 100 mg capsule sig: three (3) capsule po hs (at bedtime). 7. clonazepam 0.5 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). 8. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. multivitamin tablet sig: one (1) tablet po daily (daily). 10. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). 11. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 12. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation twice a day as needed for shortness of breath or wheezing. 13. amlodipine 5 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: vna discharge diagnosis: primary: status epilepticus non-st elevation myocardial infarction ventilator associated pneumonia acute systolic congestive heart failure discharge condition: satting well on room air on discharge discharge instructions: you were admitted initially with a diagnosis of seizures (status epilepticus). in the course of your hospital stay, you suffered a heart attack that damaged the pumping function of your heart, a pneumonia that was treated with antibiotics, and volume overload and difficulty breathing. due a possible tb exposure, you were also ruled out for tb with 3 sets of sputums that were negative for tb on special stains. you were satting well on room air off of oxygen on discharge. please take your medications as directed. you were started on oral lasix 40 mg by mouth daily. your seizure medications were increased to: dilantin 300 mg by mouth at night klonopin 1.5 mg by mouth at night keppra 1500 mg by mouth twice a day your atenolol was changed to metoprolol 37.5 mg by mouth twice a day. lisinopril 2.5 mg by mouth was added to your medications to help with heart remodeling. please weigh yourself daily and call your pcp if your weight gain is > 3 lbs in one day. fluid restrict to < 2 l daily. please return to the ed or call your pcp if you experience shortness of breath, chest pain, fevers > 101 f, swelling in your legs, weight gain greater than 3 lbs in one day, or any symptoms concerning enough to you to warrant physician . followup instructions: please schedule a follow up appointment with your pcp weeks after discharge. if you have no pcp, call to schedule an appt at . cardiology: dr @ 1:00pm, center . . you should have an echo repeated and stress test with dr . please also follow up with your neurologist within 1-2 weeks after discharge. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Non-invasive mechanical ventilation Diagnoses: Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Unspecified essential hypertension Other and unspecified hyperlipidemia Pneumonitis due to inhalation of food or vomitus Cardiogenic shock Grand mal status Ventilator associated pneumonia Acute on chronic systolic heart failure Aphasia Alcohol abuse, in remission Contact with or exposure to tuberculosis

allergies: no known allergies / adverse drug reactions attending: chief complaint: left sided chest discomfort major surgical or invasive procedure: 1. urgent coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal and posterior descending arteries. 2. endoscopic harvesting of the long saphenous vein. history of present illness: 50 year old male noted to have some vision problems. was also found to have elevated blood pressure readings. he was started on atenolol by his pcp. he reports three separate episodes of left sided chest discomfort, described slightly more than an ache. this occurred only with carrying furniture or moving furniture, lasted less than 30 seconds, and resolved spontaneously. four weeks ago he developed numbness in his hands and feet which persisted for a week. he sought medical attention and an a ekg demonstrated prior mi and t-wave abnormalities which were new since . he was referred to dr. who recommended a cardiac catheterization for further evaluation. upon cardiac catheterization he was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. past medical history: coronary artery disease hypercholesterolemia hypertension herpes simplex migraine ha allergic rhinitis type 2 diabetes shoulder arthralgias anxiety gerd past surgical history: bilateral eye surgery wisdom teeth extraction social history: lives with:wife contact: (wife) phone # occupation:real estate lawyer cigarettes: smoked no yes other tobacco use:denies etoh: up until 7 drinks a week, rare since that time illicit drug use:denies family history: premature coronary artery disease- father with mi x 2 (unclear age) and died of a cva at age 81 physical exam: pulse:45 resp:16 o2 sat:100/ra b/p right:131/70 left:135/73 height:6'2" weight:218 lbs general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema _____ varicosities: none neuro: grossly intact pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 1+ left: 1+ radial right: cath site left: 2+ carotid bruit right: no left: no pertinent results: intra-op tee conclusions prebypass no atrial septal defect is seen by 2d or color doppler. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. postbypass there is preserved biventricular systolic function. the study is otherwise unchanged from prebypass . cxr: : there is a right ij central line with distal lead tip in distal svc. there is stable cardiomegaly. there is no focal consolidation or signs for overt pulmonary edema. there is improved aeration at the left base. there is a small left-sided pleural effusion. within the right base, there is a 4-mm density, likely a granuloma. wbc-6.5 rbc-4.18* hgb-11.9* hct-35.8* mcv-86 mch-28.4 mchc-33.2 rdw-13.1 plt ct-221 glucose-149* urean-16 creat-0.9 na-139 k-4.3 cl-104 hco3-25 alt-45* ast-24 alkphos-36* amylase-40 totbili-0.5 mg-2.1 %hba1c-7.4* eag-166* triglyc-45 hdl-46 chol/hd-2.4 ldlcalc-54 mrsa screen (final ): no mrsa isolated. 04:54am blood wbc-7.9 rbc-4.20* hgb-11.7* hct-36.0* mcv-86 mch-27.9 mchc-32.6 rdw-13.0 plt ct-254 05:15am blood wbc-6.5 rbc-4.18* hgb-11.9* hct-35.8* mcv-86 mch-28.4 mchc-33.2 rdw-13.1 plt ct-221 05:58am blood wbc-7.9 rbc-4.26* hgb-12.2* hct-36.3* mcv-85 mch-28.7 mchc-33.7 rdw-13.2 plt ct-199 05:20am blood pt-12.5 inr(pt)-1.2* 05:20am blood urean-20 creat-1.0 na-136 k-4.6 cl-100 04:54am blood urean-24* creat-0.9 na-140 k-4.3 cl-102 05:15am blood glucose-149* urean-16 creat-0.9 na-139 k-4.3 cl-104 hco3-25 angap-14 brief hospital course: mr. was brought to the operating room on where the patient underwent cabg x 3 with dr. . overall the patient tolerated the procedure well and post-operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring. pod 1 found the patient extubated, alert and oriented and breathing comfortably. the patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. beta blocker 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. anti-hypertensives were titrated. anti-hyperglycemic regimen was slowly resumed. the patient was evaluated by the physical therapy service for assistance with strength and mobility. he had several brief bursts of rapid atrial fibrillation. amiodarone was initiated. he was in sinus rhythm at the time of discharge but had multiple episodes of atrial fibrillation and was started on coumadin. he was given 5 mg coumadin x 2 doses and his inr was 1.2 at the time of discharge. the next inr draw is scheduled for . by the time of discharge on pod 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. the patient was discharged to home with vna in good condition with appropriate follow up instructions. medications on admission: amlodipine 10 mg daily atenolol 50 mg daily butalbital-aspirin-caffeine 50 mg-325 mg-40 mg tablet - 1-2 tablets tid prn clonazepam 0.5 mg tablet - 1-2 tablets prn glipizide 5 mg tablet - 0.5-1 tablets daily/pm if blood sugar greater than 180 after pm meal. lantus 65 units daily hs lidocaine 5 % (700 mg/patch) adhesive patch, medicated - apply for 12 hours a day as needed for pain lisinopril 20 mg tablet metformin 850 mg tablet - 1 tablet am and 2 tablets pm nitroglycerin 0.4 mg tablet prn omeprazole 20 mg daily oxycodone-acetaminophen 5 mg-325 mg tablet - 1 tablet q4hrs prn crestor 40 mg daily valacyclovir 1,000 mg tid prn zolpidem 10 mg hs ascorbic acid 1,000 mg daily aspirin 81 mg daily multivitamin dosage uncertain cinnamon tablets garlic tablets discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): take while taking narcotics. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. acetaminophen 325 mg tablet sig: two (2) tablet po every six (6) hours as needed for pain/fever. 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 5. glipizide 5 mg tablet sig: one (1) tablet po daily (daily): take in pm if blood sugar greater than 180. 6. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 7. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 8. lisinopril 20 mg tablet sig: one (1) tablet po bid (2 times a day). 9. rosuvastatin 40 mg tablet sig: one (1) tablet po once a day. 10. ascorbic acid 1,000 mg tablet sig: one (1) tablet po once a day. 11. metformin 850 mg tablet sig: one (1) tablet po bid (2 times a day): increase pm dose to 2 tablets if blood sugars are consistenly high. 12. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 13. potassium chloride 10 meq tablet extended release sig: one (1) tablet extended release po once a day for 5 days. disp:*5 tablet extended release(s)* refills:*0* 14. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 15. clonazepam 0.5 mg tablet sig: 1-2 tablets po every twelve (12) hours as needed. 16. insulin glargine 100 unit/ml solution sig: sixty five (65) units subcutaneous at bedtime. 17. valacyclovir 500 mg tablet sig: two (2) tablet po three times a day. 18. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) topical once a day: take as previous. 19. coumadin 5 mg tablet sig: one (1) tablet po once a day: take as directed for inr goal 2.0-2.5. disp:*60 tablet(s)* refills:*0* 20. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): take 400 mg x 2 weeks then 200 mg x 2 weeks then 200 mg daily x 1 month then as directed by cardiologist. disp:*80 tablet(s)* refills:*0* 21. outpatient lab work inr check for afib, goal results to be sent to , rn at the anticoagulation management service phone ( fax ( plan confirmed with on discharge disposition: home with service facility: vna of discharge diagnosis: coronary artery disease hypercholesterolemia hypertension herpes simplex migraine ha allergic rhinitis type 2 diabetes shoulder arthralgias anxiety gerd past surgical history: bilateral eye surgery wisdom teeth extraction discharge condition: alert and oriented x3 nonfocal ambulating sternal pain managed with oral analgesics sternal incision - healing well, no erythema or drainage trace le edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: wound check at cardiac surgery office , 10:10 surgeon dr. , 1:00 cardiologist dr. , at 1:00p please call to schedule the following: primary care dr. ,hikaru in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Anxiety state, unspecified Examination of participant in clinical trial Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Herpes simplex without mention of complication

allergies: penicillins / bactrim ds attending: chief complaint: angina (transfer from for interventional cath) major surgical or invasive procedure: cardiac catheterization with drug eluting stent x1 and bare metal stents x2 to right coronary artery history of present illness: mrs. is a 66 year old woman with copd and pvd transfered from for interventional cath after worsening cp x 4 days. over the past 3-4 months, she endorses recurrent non-exertional substernal chest pressure. these last 4 days the chest pressure worsened, increasing in intensity and frequency. she called 911 and was taken to by ambulance. in the ed she reported same chest pain- ecg revealed no ischemic changes. sx were relieved with sl nitroglycerine. patient was admitted to where she received nitro and heparin gtt, asa, plavix, metoprolol, and lipitor. she had no cp since receving nitro in . troponin t peaked at 0.2. diagnostic cardiac catheterization at revealed: 1.severe single vessel cad, with a focal 90% stenosis of the distal rca involving the origin of the pda. diffuse calcification and mild-to-moderate disease of all three coronary arteries 2.normal lv systolic function. 3. mild lv diastolic dysfunction 4.no evidence of valvular disease. she was transferred to this am for interventional catheterization. . at , she underwent cardiac catheterization with identification of significant rca disease. she received a des to the distal rca and bms x 2 to the mid rca. the procedure was complicated by closure of the pda. the patient also experienced significant oozing with a drop in hematocrit from 29.8 to 22.9. . following the procedure, the patient was transfered from the cath lab to the ccu for close overnight monitoring. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: cad 2. cardiac history: - percutaneous coronary interventions: des to distal rca and bms x 2 to mid rca 3. other past medical history: copd, glaucoma, anemia social history: - tobacco history: 80 pack-years, now pack per day - etoh: history of etoh abuse, quit 15 years ago - illicit drugs: none family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. brother passed at age 58 from cad brother and sister with htn/hld brother and sister with arrhythmias sister with breast and colon cancer father and brother with alcoholism physical exam: admission exam: 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. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, loud p2. left 2nd intercostal 2/6 systolic murmur. no thrills, lifts. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. prolonged expiratory phase. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no edema. no femoral bruits. cath site without bruit or oozing. skin: no stasis dermatitis, ulcers, or xanthomas. pulses: right: carotid 2+ femoral 2+ pt 2+ left: carotid 2+ femoral 2+ pt 2+ . discharge exam: t 97.8 hr 74-78 rr 18 bp 112-145/61-68 o2 sat 100% ra wt 57.5kg general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, loud p2. 1/6 systolic murmur best heart at the l upper sternal border. no thrills, lifts. lungs: ctab, no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. prolonged expiratory phase. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no edema. no femoral bruits, cath site with moderately sized hematoma, not pulsatile, not expanding. pulses 2+ bilaterally. pertinent results: admission labs: 08:00pm blood hct-25.1* 12:56am blood glucose-110* urean-6 creat-0.5 na-137 k-3.6 cl-106 hco3-20* angap-15 12:56am blood ck-mb-7 ctropnt-0.11* 05:26am blood ck-mb-15* 06:00pm blood ck-mb-14* ctropnt-0.25* 12:56am blood calcium-8.3* phos-4.2 mg-1.5* . discharge labs: 06:35am blood wbc-7.6 rbc-3.72* hgb-11.1* hct-31.8* mcv-86 mch-30.0 mchc-35.0 rdw-15.9* plt ct-267 06:35am blood plt ct-267 06:35am blood glucose-106* urean-8 creat-0.7 na-144 k-4.1 cl-109* hco3-27 angap-12 06:35am blood ck-mb-8 06:35am blood calcium-9.1 phos-3.9 mg-2.0 . cardiac cath (): 1. limited coronary angiography in this right-dominant system demonstrated one-vessel disease. the rca had a 30% proximal stenosis, diffuse stenosis in the mid-rca to 60% with a question of thrombus and a distal rca 95% stenosis and an ostial rpda 99% stenosis. 2. successful ptca and stenting of the distal rca into the pl system with a 2.75 x 15 mm promus to 3.5 distally and 3.0 proximally complicated by loss of the rpda (see ptca comments). 3. successful ptca and stenting of the mid-rca with overlapping 2.75 x 12 mm (distally) and 3.0 x 26 mm integrity (proximally) stents postdilated to 3.0 (see ptca comments). . tte (): the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >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. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. brief hospital course: primary reason for admission: 66 year-old woman with copd and worsening cp/ transferred from osh for interventional cath now status post pci with stent x 3 to rca. . active diagnoses: . # cad: cardiac cath showed significant rca disease now s/p pci with stent x3. she had bms x2 placed to the mid rca (2.75 x 12 mm (distally) and 3.0 x 26 mm integrity (proximally) stents postdilated to 3.0) and des x1 to the distal rca (2.75 x 15 mm promus to 3.5 distally and 3.0 proximally). pci was c/b jailing of the rpda which resulted in cessation of flow to the pda that was confirmed by angiography. she had a slight bump in ckmb post procedure consistent with this finding, but ckmb was downtrending at the time of discharge. post-cath echo showed normal rv size and wall motion. . # post procedure hct drop: cardiac cath was c/b significant oozing at the femoral insertion site and the pt's hct dropped to 23 immediately post cath. she was transfused 2u prbcs with an appropriate response, and her hct at the time of discharge was stable at 32. she was admitted to the ccu for monitoring overnight and remained hemodynamically stable throughout her course. there was no evidence of femoral bruit or expaning hematoma at the femoral sheath site, but there was moderate superficial ecchymoses. . chronic diagnoses: . # copd: she has a ~80 year smoking history and was maintained on her home medications while hospatilized. a nicotine patch was provided. she was counseled on the importance of smoking cessation. pt was never sob after cardiac cath and never had any signs of symptoms of copd exacerbation. . # anxiety: pt was continued on her home citalopram and had no problems with anxiety during her course. . transitional issues: pt was discahrged home with asa 325, plavix 75, metoprolol, nitro, lipitor 80mg and nicotine patches as well as her existing copd meds. she was instructed on the importance of continuing asa/plavix and was counseled extensively on smoking cessation. she will follow up with cardiology and her pcp. medications on admission: ipratropium bromide 17- 2inh by mouth qid prn fluticasone 110 mcg/actuation- 2 inh budesonide-formoterol (symbicort)- 160-4.5- 2inh citalopram 10mg qam 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:*11* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 5. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation qid (4 times a day) as needed for shortness of breath or wheezing. 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. symbicort 160-4.5 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation twice a day. 8. citalopram 10 mg tablet sig: one (1) tablet po once a day. 9. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily) for 6 weeks. disp:*45 patch 24 hr(s)* refills:*0* 10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet sublingual as directed as needed for chest pain. disp:*25 tablets* refills:*0* 11. outpatient lab work please check labs at on friday discharge disposition: home discharge diagnosis: non st elevation myocardial infarction chronic obstructive pulmonary disease s/p bunion surgery 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 blockages were found in your right coronary artery at hospital. you were transferred to for a procedure to open the blocked artery and you had one drug eluting stent and two bare metal stents placed in your right coronary artery. it is crucially important that you take aspirin and plavix every day to prevent the stents from clotting off and causing another heart attack. do not miss or stop taking aspirin and plavix for any reason unless dr. tells you it is ok. you had some bleeding from the catheterization site and required two units of blood to replace the blood that was lost. you are recovering well and have had no further chest pain. during the catheterization, you received a lot of contrast (dye) and we will check your kidney blood tests on friday to make sure that your kidneys are functioning well. it is very important that you quit smoking in order to prevent the arteries from developing blockages and causing another heart attack. you have been given a prescription for a nicotine patch to help with the cravings. please get your blood checked on friday at in . . we made the following changes to your medicines: 1. start taking aspirin 325 mg and plavix 75 mg every day for at least one year to prevent the stents from clotting off. 2. start taking metoprolol to lower your heart rate and help your heart recover from the heart attack. 3. start taking a high dose of lipitor (atorvastatin) to lower your cholesterol and help your heart recover. 4. use nitroglycerin under your tongue as needed for chest pain. please take one pill, wait 5 minutes and you can take one more pill if the chest pain is still there. please call dr. if you have any chest pain and take nitroglycerin. 5. start nicotine patches daily to help you quit smoking. followup instructions: primary care: ,mahmooda . date/time: at 1:40pm. . cardiology: you will have an appt with dr. in about a month, her office will call you at home with an appt. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Insertion of drug-eluting coronary artery stent(s) Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Insertion of three vascular stents Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Chronic airway obstruction, not elsewhere classified Peripheral vascular disease, unspecified Unspecified glaucoma

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - cardiac cathterization - coronary artery bypass grafting x3. (left internal mammary to the left anterior descending artery, saphenous vein graft->diagonal artery, saphenous vein graft->obtuse marginal artery). history of present illness: 63 year old patient with a known history of cad, now with recurrent chest pain, referred for outpatient cardiac catheterization. past medical history: myocardial infarction hyperlipidemia hypertension previous stenting/angioplasty coronary artery disease social history: shx: 50 pyhx, quit 5 y ago. social etoh family history: + family history physical exam: on discharge vs: t: 97.7 hr: 91 sr bp: 112/68 sats: 92% ra bs 136 wt: 102.6 kg general: 63 year-old male in no apparent distress heent: normocephalic mucus membranes moist neck: supple no lymphadenopathy card: distant hs rrr normal s1,s2 murmur resp: bibasilar crackles otherwise clear gi; obese, bowel sounds positive, abdomen soft extr: warm no edema incision: sternal & rle clean, dry, intact with steri-strips, margins well approximated no erythema neuro: awake alert, oriented pertinent results: cardiac catheterization final diagnosis: 1. two vessel coronary artery disease. 2. unsuccessful ptca of ostial diag1 complicated by acute diag1 occlusion and perforation cxr: impression: 1. retrocardiac opacification most likely represents atelectasis; however, consolidative process cannot be completely excluded and should be considered in the correct clinical setting. trace left-sided pleural effusion. 2. removal of chest tubes and no evidence of pneumothorax. wbc-7.4 rbc-2.98* hgb-9.0* hct-25.6 plt ct-229 wbc-7.2 rbc-3.01* hgb-9.1* hct-25.6 plt ct-168 wbc-4.5 rbc-4.97 hgb-14.5 hct-43.0 plt ct-313 glucose-126* urean-20 creat-0.6 na-134 k-4.1 cl-97 hco3-28 urean-12 creat-0.9 na-138 k-4.6 cl-110* hco3-24 urean-15 creat-0.7 na-136 k-4.3 cl-100 hco3-24 brief hospital course: mr. was admitted to the on for a cardiac catheterization. an intervention was attempted to his diagonal artery which resulted in a dissection. cardiac surgery was consulted and he was taken emergently to the operating room where he underwent coronary artery bypass grafting to three vessels. please see operative note for details. postoperatively he was taken to the intensive care unit for monitoring. over the next 24 hours, he awoke neurologically intact and was extubated. respiratory: aggressive pulmonary toilet, nebs, incentive spirometer and ambulation he titrated off oxygen with saturation 92% on room air cardiac: sinus tachycardiac 110-130's beta-blockers titrated for better rate control. required low dose pressors for hypotension, transfused 2 units prbc for hct 27 wean off pressors with bp 110-130's hemodynamically stable gi: h2 blocker and bowel regime nutrition: tolerated a diabetic diet renal: renal function within normal range. good urine output. electrolytes replete as needed endocrine: under 200 covered with insulin sliding until taking po the metformin was restarted pain: well controlled with po narcotics. disposition: he was seen by physical therapy who deemed him safe for home. he was discharged on with his family and vna. he will follow-up with dr. , his cardiologist and his primary care physician as an outpatient. medications on admission: clopidogrel - (prescribed by other provider) - 75 mg tablet - one tablet(s) by mouth once a day gemfibrozil - (prescribed by other provider) - 600 mg tablet - one tablet(s) by mouth twice a day lisinopril - (prescribed by other provider) - 20 mg tablet - one tablet(s) by mouth once a day metformin - (prescribed by other provider) - 500 mg tablet - 1 tablet(s) by mouth daily metoprolol succinate - (prescribed by other provider) - 50 mg tablet sustained release 24 hr - 1 tablet(s) by mouth once a day simvastatin - (prescribed by other provider) - 80 mg tablet - 1 tablet(s) by mouth once a day aspirin ] - (prescribed by other provider) - 81 mg tablet, chewable - one tablet(s) by mouth once a day discharge medications: 1. aspirin 81 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. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 5. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 7. metformin 500 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 9. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day for 5 days: take with furosemide. disp:*5 tab sust.rel. particle/crystal(s)* refills:*0* 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 11. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. discharge disposition: home with service facility: nursing services discharge diagnosis: coronary artery disease hypertension hyperlipidemia myocardial infarction discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema or drainage leg right/left - healing well, no erythema or drainage. edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. ( date/time: 1:00 cardiologist: dr. phone: date/time: 10:20 please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Left heart cardiac catheterization Diagnoses: Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Personal history of tobacco use Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Percutaneous transluminal coronary angioplasty status Accidental puncture or laceration during a procedure, not elsewhere classified Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Other and unspecified angina pectoris Old myocardial infarction Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Obesity, unspecified

allergies: iodine/potassium iodide / amoxicillin / codeine / tetracycline / simvastatin / atorvastatin attending: chief complaint: nausea and vomiting major surgical or invasive procedure: - ercp - 1. laparoscopic cholecystectomy. 2. adhesiolysis over 60 minutes history of present illness: 82f with mvp, htn, h/o sbo s/p rsxn and vhr , who developed n/v x many starting last pm after custard pie and coke. thought was lactate insufficiency but diffuse abd pain this am and persistent nausea with light-headedness prompted ed visit today. was seen in clinic yesterday for palpitations (ekg apcs, echo and holter studies ordered). ekg here nsr. no f/c, no sob/cp. ct a/p obtained which showed gallstones, sig gb wall thickening, + pcf, cbd 8mm, no obvious cbd stones but internal echoes w/n gb suggestive of sludge vs gangrenous cholecystitis. given cipro/flagyl in ed. past medical history: cervical stenosis hypertension mitral valve prolapse anxiety hyupercholesterolemia osteoporosis hemorrhoids b12 deficciency s/p tah '50s s/p bilateral femoral hernia repair (', ') sbo s/p resection dr. , vhr social history: lives in apartment by herself, sister lives upstairs. denies tobacco, etoh, or ivdu. family history: noncontributory physical exam: upon discharge: vs:97.7, 76, 90/56, 18, 93% ra gen: nad, aaox3 heent: ncat cv: rrr, s1s2 lungs: ctab abd: soft, ntnd, old drain site in luq is c/d/i ext: no cyanosis, erythema, or edema are present. pertinent results: 04:25pm blood wbc-7.4 rbc-4.31 hgb-12.7 hct-37.3 mcv-87 mch-29.5 mchc-34.1 rdw-13.5 plt ct-242 11:40am blood wbc-14.9*# rbc-4.19* hgb-12.4 hct-34.0* mcv-81* mch-29.6 mchc-36.4* rdw-13.7 plt ct-212 06:05am blood wbc-7.8 rbc-3.46* hgb-10.1* hct-29.0* mcv-84 mch-29.3 mchc-34.9 rdw-13.8 plt ct-174 02:29am blood wbc-7.6 rbc-3.32* hgb-10.0* hct-28.1* mcv-85 mch-30.0 mchc-35.4* rdw-14.0 plt ct-173 01:49am blood wbc-4.4 rbc-3.26* hgb-9.8* hct-27.6* mcv-85 mch-30.0 mchc-35.4* rdw-13.9 plt ct-155 03:09am blood wbc-7.8# rbc-3.72* hgb-10.8* hct-31.3* mcv-84 mch-29.1 mchc-34.6 rdw-13.9 plt ct-247# 06:10am blood wbc-7.6 rbc-3.93* hgb-11.6* hct-32.6* mcv-83 mch-29.6 mchc-35.6* rdw-13.8 plt ct-265 11:40am blood neuts-93.4* lymphs-3.2* monos-2.9 eos-0.4 baso-0.1 04:54pm blood pt-13.4 ptt-30.3 inr(pt)-1.1 02:29am blood pt-16.7* ptt-49.9* inr(pt)-1.5* 04:25pm blood urean-10 creat-0.6 na-140 k-3.6 cl-101 hco3-29 angap-14 11:40am blood glucose-138* urean-7 creat-0.5 na-133 k-2.7* cl-95* hco3-26 angap-15 06:05am blood glucose-216* urean-5* creat-0.5 na-141 k-8.8* cl-116* hco3-21* angap-13 08:29am blood glucose-105 urean-5* creat-0.6 na-142 k-4.0 cl-110* hco3-24 angap-12 10:22pm blood glucose-112* urean-6 creat-0.5 na-138 k-3.4 cl-108 hco3-24 angap-9 02:29am blood glucose-86 urean-6 creat-0.5 na-138 k-3.5 cl-108 hco3-24 angap-10 01:49am blood glucose-76 urean-10 creat-0.4 na-139 k-3.9 cl-109* hco3-23 angap-11 03:09am blood glucose-102 urean-4* creat-0.5 na-137 k-3.5 cl-103 hco3-29 angap-9 06:10am blood glucose-147* urean-2* creat-0.5 na-138 k-3.6 cl-99 hco3-29 angap-14 06:00am blood glucose-107* urean-7 creat-0.6 na-137 k-3.7 cl-102 hco3-29 angap-10 04:25pm blood ck(cpk)-119 11:40am blood alt-22 ast-34 alkphos-73 totbili-3.1* 06:05am blood alt-276* ast-384* alkphos-198* amylase-15 totbili-5.0* dirbili-2.2* indbili-2.8 10:22pm blood ck(cpk)-121 02:29am blood alt-191* ast-159* alkphos-193* totbili-4.4* 06:03am blood ck(cpk)-96 01:49am blood alt-130* ast-67* ld(ldh)-140 alkphos-154* amylase-150* totbili-1.6* 03:09am blood alt-116* ast-95* ld(ldh)-222 alkphos-148* amylase-57 totbili-0.9 dirbili-0.4* indbili-0.5 06:00am blood alt-64* ast-34 alkphos-117 amylase-80 totbili-0.8 11:40am blood lipase-23 06:05am blood lipase-17 01:49am blood lipase-389* 03:09am blood lipase-119* 06:00am blood lipase-200* 10:22pm blood ck-mb-3 ctropnt-<0.01 06:03am blood ck-mb-notdone ctropnt-0.03* 04:25pm blood phos-3.2 mg-2.3 11:40am blood albumin-3.9 06:05am blood calcium-7.3* phos-1.6*# 10:22pm blood calcium-7.8* phos-1.7* mg-1.7 02:29am blood calcium-8.1* phos-1.6* mg-1.8 01:49am blood calcium-7.7* phos-1.7* mg-2.2 03:09am blood albumin-3.1* calcium-7.7* phos-2.5* mg-1.9 06:10am blood calcium-7.8* phos-2.1* mg-2.2 06:00am blood calcium-8.2* phos-2.2* mg-2.1 11:46am blood lactate-1.1 chest (portable ap) lungs now demonstrate pulmonary vascular congestion but no definite edema. small left pleural effusion suggests relative cardiac decompensation, as does interval increase in heart size, still within normal limits. no pneumothorax. ercp biliary&pancreas findings: 14 fluoroscopic images were performed by the gi service during ercp and are submitted for review. there is dilation of the common bile duct to 14 mm however there is smooth tapering at the distal margin on distal aspect of the cbd. no luminal filling defects are seen within the biliary system. a plastic stent catheter was placed at the end of the procedure. for full details please refer to the gi ercp note. ct abdomen w/contrast conclusion: 1. inflamed enhancing thick-walled gallbladder with pericholecystic fluid suggestive of acute cholecystitis. there are internal hyperdensities within the gallbladder, which may represent sludge versus sloughing of the gallbladder mucosa which could represent early gangrenous cholecystitis. 2. dilated cbd and intrahepatic ducts with the cbd measuring approximately 8 mm without evidence of a definite calculus in the cbd. 3. stable compression deformity of l1 vertebral body with approximately 50% loss of vertebral body height. chest (pa & lat) no acute cardiopulmonary process. stable compression fracture. brief hospital course: ms. was admitted to the surgical service on with a chief complaint of nausea and vomiting. a ct scan showed gallbaldder wall thickening, a dialted cbd and multiple gallstones. the pt was started on ciprofloxacin and flagyl. on the pt underwent an ercp with sphincterotomy and a stent was placed. on the evening of during routine vital sign checks the pt was noted to have a heart rate in the 130's though she was asymptomatic. her systolic blood pressures were low in the high 80's to 90's where she had previously been in the 120-130s range. a 12 lead ekg was done whcih revealed atrial fibrilation with a rapid ventricular response. the pt was placed on telemetry and given 10mg of diltiazem iv for rate control, however she remained in raf in the 110-120 range with persistently low pressures despite being asymptomatic. at that time the decision was made to transfer her to the icu for managment of her a-fib. the pt was placed on phenelelhrine in the icu for her hypotension. by the morning of she was back in sinus rhythm, off pressors and once again normotensive. she was monitored thoughout the day and cardiology was consulted. her abdominal pain, however, persisted. on the pt was taken to the operating room for a lararoscopic cholecystectomy. the pt did experience some episodes of atrial fibrilation intra-operatively but remained hemodynamically stable. the pt was transferred to the icu post-operatively, but did not require any inotropic support. on the morning on pod1 she was transferred back to the regular surgical floor in sinus rhythm and under beta blockade. she was started on diet and advanced as tolerated. the pt was discharged to a rehab facility on , tolerating a regular diet, ambulating without assistance, and pain well conrolled with oral pain medications. patient will be discharged to home with vna services. she will follow up with dr. in 2 weeks and with her primary care provider. medications on admission: hctz 25, ativan 0.5 qhs, zocor 10, cyanoalbumin 1gm qday discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 5. tylenol extra strength 500 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. discharge disposition: home with service facility: homecare discharge diagnosis: 1. cholangitis. 2. cholelithiasis. 3. chronic cholecystitis. 4. atrial fibrillation discharge condition: stable 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. * 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 lifting objects > 5lbs until your follow-up appointment with the surgeon. *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. incision care: -your steri-strips will fall off on their own. please remove any remaining strips 7-10 days after surgery. -you may shower, and wash surgical incisions. -avoid swimming and baths until your follow-up appointment. -please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. followup instructions: you have the following appointments: provider: , md phone: date/time: 3:15 provider: , m.d. date/time: 8:50 provider: , m.d. date/time: 11:30 Procedure: Endoscopic sphincterotomy and papillotomy Laparoscopic cholecystectomy Endoscopic insertion of stent (tube) into bile duct Laparoscopic lysis of peritoneal adhesions Other closed [endoscopic] biopsy of biliary duct or sphincter of Oddi Diagnoses: Mitral valve disorders Unspecified essential hypertension Atrial fibrillation Hypopotassemia Other B-complex deficiencies Anxiety state, unspecified Hypotension, unspecified Calculus of gallbladder with other cholecystitis, without mention of obstruction Peritoneal adhesions (postoperative) (postinfection) Osteoporosis, unspecified Cholangitis Calculus of gallbladder with acute cholecystitis, without mention of obstruction Spinal stenosis in cervical region

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bph major surgical or invasive procedure: turp - - dr. history of present illness: 57 m with bph and frequency/urgency was assessed to have prostatic obstruction of urine flow by dr. and was scheduled for turp. past medical history: 1. multiple sclerosis - affects left leg only 2. bph 3. hypertension social history: is a partner at a corporte law firm. no tob or etoh. physical exam: rrr ctab abd s, nt, nd urine light pink. pertinent results: 07:25am blood wbc-10.8 rbc-3.34* hgb-9.6* hct-27.8* mcv-83 mch-28.8 mchc-34.5 rdw-13.6 plt ct-195 brief hospital course: the patient was admitted to dr. ??????s urology service after transuretral resection of prostate. his operative course was complicated by a very rough wakeup from anesthesia involving significant valsalva that turned what was initially light pink urine into bloody urine. he was maintained on brisk continuous bladder irrigation for the next 24 hours, and bled significantly, requiring the foley to be placed on traction and for transfer to the icu for nursing purposes. he remained hemodynamically stable throughout his hospitalization and did not require blood transfusions despite a drop in hct from 41 to 28. he required multiple episodes of clot irrigation to clear his bladder of old clot after his bleeding stopped on pod 1. his foley catheter was removed on pod 2 but the patient failed to void so an 18 fr coude catheter was replaced with fruit punch colored drainage. the foley was hand irrigated with no evidence of clot. at discharge, patient's pain well controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and his foley was draining well. he was given oral pain medications on discharge as well as a 3-day course of abx. he was given explicit instructions to call dr. for follow-up and foley removal/void trial. medications on admission: 1. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). 2. glatiramer 20 mg kit sig: one (1) kit subcutaneous daily (). 3. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 4. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 5. terazosin 5 mg capsule sig: one (1) capsule po bid (2 times a day). 6. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). discharge medications: 1. hydromorphone 2 mg tablet sig: 0.5-1 tablet po q3h (every 3 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 2. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). 3. glatiramer 20 mg kit sig: one (1) kit subcutaneous daily (). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 5. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 6. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 7. terazosin 5 mg capsule sig: one (1) capsule po bid (2 times a day). 8. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 9. ciprofloxacin 250 mg tablet sig: one (1) tablet po twice a day for 5 days. disp:*10 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: bph discharge condition: stable discharge instructions: please call if your catheter stops draining or if your urine continues to get darker. the operation you have experienced is a "scraping" operation. bleeding was controlled with electrocautery which has produced a "scab" in the channel through which the urine passes (the urethra). about 1-2 weeks after the operation, pieces of the scab will fall off and come out with the urine. as this occurs, bleeding may be noted which is normal. you should not worry about this. simply lie down and increase your fluid intake for a few hours. in most cases, the urine will clear. if bleeding occurs or persists for more than 12 hours or if clots appear impairing your stream, call your surgeon. because of the potential for bleeding, aspirin (or advil) should be avoided for the first 3 weeks after surgery. you will be given a prescription for antibiotics to be taken for a few days after surgery. this is to help prevent infection. if you develop a fever over 101??????, chills, or pain in the testicles, call your surgeon. although not common, this may indicate infection that has developed beyond the control of the antibiotics that you have taken. it will take 6 weeks from the date of surgery to fully recovery from your operation. this can be divided into two parts -- the first 2 weeks and the last 4 weeks. during the first 2 weeks from the date of your surgery, it is important to be "a person of leisure". you should avoid lifting and straining, which also means that you should avoid constipation. this can be done by any of 3 ways: 1) modify your diet, 2) use stool softeners which have been prescribed for you, and 3) use gentle laxatives such as milk of magnesia which can be purchased at your local drug store. remember that the prostate is near the rectum, and therefore, it is important for you to be mindful of the way you sit. for example, sitting directly upright on a hard surface, such as an exercise bicycle , cause bleeding. reclining on a soft sea, or sitting on a "donut", is best. walking (not jogging) is okay. you should avoid sexual activity during this time. also, avoid driving an automobile. this is important, not because you are physically incapable of driving, but rather if you have an urge to urinate, it is important that you void and not let your bladder "stretch" too much, otherwise bleeding may occur. therefore, it is ok for you to be a passenger in an automobile (or even to drive for very short distances). during the second week period of your recovery, you may begin regular activity, but only on a graduated basis. for example, you may feel well enough to return to work, but you may find it easier to begin on a half-day basis. it is common to become quite tired in the afternoon, and if such occurs, it is best to take a nap! if you are a golfer, you may begin to swing a golf club at this time. sexual activity may be resumed during the second 3 week period, but only on a limited basis. remember that the ejaculate may be directed back into the bladder (rather than out), producing a "dry" orgasm which is a normal consequence of the operation. this should not change the quality of sex. in general, your overall activity may be escalated to normal as you progress through this second time period, such that by 6-8 weeks following the date of surgery, you should be back to normal activity. remember that your operation was a "scraping" operation and not all of the prostate was removed. therefore, you should still be monitored for prostate cancer (assuming age and general medical conditions dictate such). within one week of discharge, call our office for your return office visit appointment. followup instructions: please call dr. for a follow-up appointment and for foley removal Procedure: Dilation of urethra Other transurethral prostatectomy Endoscopic excision or destruction of lesion or tissue of urethra Diagnoses: Anemia, unspecified Unspecified essential hypertension Hypopotassemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Hemorrhage complicating a procedure Urinary frequency Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Multiple sclerosis Urgency of urination

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension, weakness major surgical or invasive procedure: cystoscopy, clot evacuation, fulguration - - dr. history of present illness: 57 m s/p turp on c/b post-op bleed requiring transfer to the icu for vigorous continuous bladder irrigation and foley traction. his bleeding slowed considerably on pod 1 and he was transferred to the floor and discharged on pod 2 with a discharge hct of 27.8 and fruit punch-colored urine in his 18 fr coude catheter. his urine had been clearing slowly since that time, but he did have one episode of clot retention, which required simple irrigation at an osh ed. he went to dr. clinic today for foley removal, but failed his voiding trial. cystoscopy by dr. demonstrated plentiful clot adhered to the bladder wall that could not be irrigated and removed. the patient subsequently had a presyncopal episode and transient hypotension to the 60s/40s. on further questioning, the pt does note that he has had milder but similar episodes while walking in the last few days. he was taken by ambulance to the ed. past medical history: 1. multiple sclerosis - affects left leg only 2. bph 3. hypertension social history: is a partner at a corporte law firm. no tob or etoh. physical exam: nad abd s/nt/nd urine pyridium colored with no clots pertinent results: 05:45am blood hct-35.6* 05:45am blood urean-12 creat-1.1 k-3.7 brief hospital course: pt was admitted to the urology service and transfused 2u prbcs. he was then taken to the or for cystoscopy, clot evacuation, fulguration. he was then transfused another 4u prbcs. he failed two voiding trials and was discharged with foley, in stable condition, pain minimal on po pain meds, ambulating without feeling dizzy. plan for voiding trial and possible cic teaching on wednesday with dr. . also bp meds held until tuesday, he will measure bp and hr at home. medications on admission: 1. hydromorphone 2 mg tablet sig: 0.5-1 tablet po q3h (every 3 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 2. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). 3. glatiramer 20 mg kit sig: one (1) kit subcutaneous daily (). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 5. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 6. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 7. terazosin 5 mg capsule sig: one (1) capsule po bid (2 times a day). 8. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 9. ciprofloxacin 250 mg tablet sig: one (1) tablet po twice a day for 5 days. disp:*10 tablet(s)* refills:*0* discharge medications: 1. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 2. hydromorphone 2 mg tablet sig: 0.5-1 tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 3. glatiramer 20 mg kit sig: one (1) subcutaneous once a day. 4. phenazopyridine 100 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for 5 days. disp:*15 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: benign prostatic hypertrophy, anemia discharge condition: stable discharge instructions: please hold your blood pressure medications until tuesday. record your blood pressure and heart rate at home three times a day and notify your primary care physician if systolic blood pressure >160 or heart rate >100 consistently. you may shower and bathe normally. do not drive or drink alcohol if taking narcotic pain medication. resume all of your home medications, but please avoid aspirin/advil for three weeks. call dr. office for 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. the operation you have experienced is a "scraping" operation. bleeding was controlled with electrocautery which has produced a "scab" in the channel through which the urine passes (the urethra). about 1-2 weeks after the operation, pieces of the scab will fall off and come out with the urine. as this occurs, bleeding may be noted which is normal. you should not worry about this. simply lie down and increase your fluid intake for a few hours. in most cases, the urine will clear. if bleeding occurs or persists for more than 12 hours or if clots appear impairing your stream, call your surgeon. because of the potential for bleeding, aspirin (or advil) should be avoided for the first 3 weeks after surgery. you will be given a prescription for antibiotics to be taken for a few days after surgery. this is to help prevent infection. if you develop a fever over 101??????, chills, or pain in the testicles, call your surgeon. although not common, this may indicate infection that has developed beyond the control of the antibiotics that you have taken. it will take 6 weeks from the date of surgery to fully recovery from your operation. this can be divided into two parts -- the first 2 weeks and the last 4 weeks. during the first 2 weeks from the date of your surgery, it is important to be "a person of leisure". you should avoid lifting and straining, which also means that you should avoid constipation. this can be done by any of 3 ways: 1) modify your diet, 2) use stool softeners which have been prescribed for you, and 3) use gentle laxatives such as milk of magnesia which can be purchased at your local drug store. remember that the prostate is near the rectum, and therefore, it is important for you to be mindful of the way you sit. for example, sitting directly upright on a hard surface, such as an exercise bicycle , cause bleeding. reclining on a soft sea, or sitting on a "donut", is best. walking (not jogging) is okay. you should avoid sexual activity during this time. also, avoid driving an automobile. this is important, not because you are physically incapable of driving, but rather if you have an urge to urinate, it is important that you void and not let your bladder "stretch" too much, otherwise bleeding may occur. therefore, it is ok for you to be a passenger in an automobile (or even to drive for very short distances). during the second week period of your recovery, you may begin regular activity, but only on a graduated basis. for example, you may feel well enough to return to work, but you may find it easier to begin on a half-day basis. it is common to become quite tired in the afternoon, and if such occurs, it is best to take a nap! if you are a golfer, you may begin to swing a golf club at this time. sexual activity may be resumed during the second 3 week period, but only on a limited basis. remember that the ejaculate may be directed back into the bladder (rather than out), producing a "dry" orgasm which is a normal consequence of the operation. this should not change the quality of sex. in general, your overall activity may be escalated to normal as you progress through this second time period, such that by 6-8 weeks following the date of surgery, you should be back to normal activity. remember that your operation was a "scraping" operation and not all of the prostate was removed. therefore, you should still be monitored for prostate cancer (assuming age and general medical conditions dictate such). within one week of discharge, call our office for your return office visit appointment which should already be scheduled. followup instructions: please call dr. office to arrange for a follow-up appointment, voiding trial, possible cic teaching in clinic wednesday. Procedure: Dilation of urethra Other transurethral prostatectomy Endoscopic excision or destruction of lesion or tissue of urethra Diagnoses: Anemia, unspecified Unspecified essential hypertension Hypopotassemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Hemorrhage complicating a procedure Urinary frequency Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Multiple sclerosis Urgency of urination

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: left sided weakness major surgical or invasive procedure: intubation for airway protection history of present illness: 73 year-old left-handed man with a history of hypertension, recurrent dvt on warfarin (also on daily baby aspirin), dyslipidemia who presents today with onset of left-sided weakness and language difficulties since ~10:30 am. he was reportedly in his usual state of health this morning, when his wife left to run errands. the patient reportedly had coffee with an acquaintance and returned home at ~10:30 am to go to his pt appointment at 11:00 am. his wife returned at 10:45 am, and found him awake, lying on the floor next to the bed. his speech was somewhat non-sensical and garbled. his left side appeared weak. there was no sign of trauma, and the patient had apparently lowered himself down to the floor. ems was called and arrived at 11:25 am. there was a discrepancy of blood pressure in each arm: 180/80 on right, 120/80 on left. pulse was 64, respiratory rate was 18, fingerstick reportedly normal. he received a 250 cc of normal saline en route to . in addition to the wife's description, he was also reported to have a left facial droop. he was noted to be bradycardic on ekg with no st-t changes. a code stroke was called on arrival to . the patient was in ct when the neurology team arrived, and scanning clearly showed a right thalamic hemorrhage with intraventricular extension, and the code stroke was cancelled. past medical history: -htn -recurrent lower extremity dvt on anti-coagulation, last reportedly (others in , ) -dyslipidemia -gerd -arthritis -gout -cervical disc disease, s/p surgery -knee surgery, unclear laterality -nephrolithiasis -glaucoma social history: retired office worker, living home with wife. rare alcohol use and reportedly a non-smoker. family history: -no stroke -mother and father died in 80s of an mi, no known thrombophilia physical exam: on admission: vitals: t 97.6 f bp 151/104 p 49 rr 15 sao2 99 ra general: nad, well nourished heent: nc/at, sclerae anicteric, mmm, no exudates in oropharynx neck: supple, no nuchal rigidity, no bruits lungs: clear to auscultation cv: bradycardic, regular rhythm, no mmrg abdomen: soft, non-tender, distended, bowel sounds present ext: warm, no edema, pedal pulses appreciated skin: no rashes neurologic examination: mental status: awake and initially alert, but then increasingly somnolent and inattentive over course of interaction, language deficits impair ability to relay history, but cooperative with exam where able, initially minimally fluent, with dysarthric speech, no paraphasic errors, simple comprehension and repetition initially intact; appears to have left-sided neglect cranial nerves: optic disc margins sharp; visual fields appear full to confrontation and blink to threat. pupils equally round and reactive to light, 3 to 2.5 mm bilaterally. right gaze deviation but can voluntarily get over to left. facial sensation intact bilaterally. perhaps mild left nlff, but facial movement normal and symmetric. hearing intact to finger rub bilaterally, though a bit reduced on left. palate elevates midline. tongue protrudes midline, no fasciculations. trapezii full strength bilaterally. motor: normal bulk , with perhaps increased tone in the left leg. + pronator drift. no tremor. d t b we fif ip q h ta edb right 5 5 5 5 5 5 5 5 5 5 5 5 5 left 4 4 5 4- 4- 4 4 5 4+ 5 5 5 5 *******please note that the patient evolved to a fairly dense left hemiplegia within the hour of presentation.**** sensation: patient has difficulty responding to questions regarding laterality of sensation; answers are non-sensical. on yes/no questioning, he seems to indicate that the left arm and leg have less sensation to light touch and pinprick. he withdraws the left-side less briskly to noxious. the other modalities of sensation are difficult to assess given language deficits and evolving somnolence. reflexes: b t br pa pl right 2 2 2 3 0 left 2 2 2 2 0 toes were upgoing bilaterally. coordination: unable to perform as patient's increasing somnolence interfered with his ability to participate. gait: deferred due to hemiplegia. in the day of discharge: pt fluctuates his mental status, remain with significant aphasia and poor comprehension, incapable to follow complex commands, however he can understand and follow simple commands. pt presents dense left hemiplegia. pertinent results: 12:24pm blood wbc-5.9 rbc-4.23* hgb-13.2* hct-37.4* mcv-89 mch-31.3 mchc-35.4* rdw-13.2 plt ct-212 02:15am blood glucose-109* urean-12 creat-0.7 na-139 k-3.6 cl-106 hco3-26 angap-11 12:24pm blood alt-22 ast-21 ld(ldh)-203 ck(cpk)-93 alkphos-95 totbili-0.4 12:24pm blood ctropnt-<0.01 05:30pm blood ctropnt-<0.01 02:15am blood ctropnt-<0.01 12:24pm blood albumin-4.0 02:15am blood calcium-8.5 phos-2.7 mg-1.8 cholest-147 02:15am blood triglyc-131 hdl-42 chol/hd-3.5 ldlcalc-79 12:24pm blood tsh-2.9 12:24pm blood pt-29.0* ptt-36.6* inr(pt)-2.9* 05:55am blood wbc-9.4 rbc-4.68 hgb-14.7 hct-41.8 mcv-90 mch-31.4 mchc-35.1* rdw-13.4 plt ct-313 07:00am blood wbc-10.3 rbc-4.66 hgb-14.3 hct-41.3 mcv-89 mch-30.7 mchc-34.7 rdw-13.4 plt ct-293 06:50am blood wbc-10.6 rbc-4.59* hgb-14.1 hct-40.6 mcv-88 mch-30.7 mchc-34.8 rdw-13.3 plt ct-292 07:15am blood wbc-9.0 rbc-4.39* hgb-13.5* hct-38.7* mcv-88 mch-30.8 mchc-34.9 rdw-13.3 plt ct-257 03:15pm blood wbc-8.6 rbc-4.22* hgb-13.5* hct-37.4* mcv-89 mch-32.0 mchc-36.1* rdw-13.4 plt ct-242 02:04am blood wbc-9.4 rbc-4.19* hgb-13.1* hct-37.0* mcv-88 mch-31.2 mchc-35.2* rdw-13.4 plt ct-247 05:55am blood neuts-67.6 lymphs-22.4 monos-7.5 eos-2.2 baso-0.4 06:50am blood neuts-72.1* lymphs-18.6 monos-7.8 eos-1.3 baso-0.2 05:55am blood plt ct-313 05:55am blood pt-14.9* ptt-30.2 inr(pt)-1.3* 07:00am blood plt ct-293 07:00am blood pt-15.1* ptt-30.0 inr(pt)-1.3* 06:50am blood pt-14.3* ptt-26.7 inr(pt)-1.2* 07:15am blood plt ct-257 05:55am blood glucose-111* urean-33* creat-0.7 na-138 k-4.3 cl-102 hco3-24 angap-16 07:00am blood glucose-113* urean-35* creat-0.8 na-140 k-4.5 cl-105 hco3-25 angap-15 06:50am blood glucose-116* urean-28* creat-0.7 na-137 k-4.6 cl-102 hco3-25 angap-15 07:15am blood glucose-152* urean-24* creat-0.7 na-139 k-4.2 cl-104 hco3-25 angap-14 03:15pm blood glucose-152* urean-24* creat-0.6 na-138 k-4.3 cl-104 hco3-26 angap-12 02:04am blood glucose-155* urean-23* creat-0.7 na-140 k-4.5 cl-106 hco3-23 angap-16 05:55am blood alt-53* ast-31 alkphos-93 totbili-0.7 06:50am blood alt-60* ast-39 totbili-0.5 02:15am blood ck(cpk)-43 02:15am blood ck(cpk)-73 05:30pm blood ck(cpk)-87 02:15am blood ck-mb-notdone ctropnt-<0.01 02:02pm blood ck-mb-notdone ctropnt-<0.01 11:00am blood ck-mb-notdone ctropnt-<0.01 05:55am blood calcium-9.1 phos-4.3 mg-2.2 07:00am blood calcium-9.3 phos-4.4 mg-2.3 06:50am blood calcium-9.2 phos-4.3 mg-2.1 07:15am blood calcium-9.0 phos-3.4 mg-2.1 02:15am blood %hba1c-6.4* 02:15am blood triglyc-131 hdl-42 chol/hd-3.5 ldlcalc-79 12:24pm blood tsh-2.9 02:49am blood type-art po2-112* pco2-37 ph-7.43 caltco2-25 base xs-0 08:26pm blood type-art po2-395* pco2-41 ph-7.42 caltco2-28 base xs-2 12:34pm blood glucose-98 na-141 k-4.4 cl-105 calhco3-24 ekg: sinus bradycardia. tracing is normal except for rate. nchct at noon: 4 x 2.3 cm parenchymal hemorrhage centered in the right thalamus with intraventricular extension. no hydrocephalus or evidence of herniation. repeat nchct at 2:30 for increased somnolence: 1. increased size of right thalamic hemorrhage. 2. increased amount of intraventricular hemorrhage with extension into the bilateral occipital horns and the fourth ventricle. 4. 4 mm leftward shift of normally midline structures. 5. no evidence for transtentorial herniation. head ct the right thalamic hemorrhage, with intraventricular extension is unchanged in comparison to yesterday's ct. associated edema and compression of the right lateral ventricle are stable. no areas of new hemorrhage are identified. small focus of high attenuation within the sulcus within the left parietal lobe is stable. opacification of the left sphenoid sinus and probable mucosal retention cysts are not significantly changed. impression: 1. unchanged right thalamic hemorrhage, with intraventricular extension and surrounding edema, and compression of the right lateral ventricle. 2. stable small focus of subarachnoid blood within the left parietal lobe, likely representing redistribution of blood. 3. no new hemorrhage identified. mri is more sensitive for the detection of acute stroke. brief hospital course: patient is 73 year-old left-handed man with a history of hypertension, recurrent dvt on warfarin (also on daily baby aspirin), dyslipidemia who presents today with onset of left-sided weakness and language difficulties since ~10:30 am. on general examination, he was hypertensive and bradycardic. his initial examination was notable for a fluent aphasia, left-sided neglect, and worsening left-sided weakness in an upper motor neuron pattern of distribution. he was initially anti-gravity on the left, but susequently became plegic. there is also evidence of loss of sensation to light touch and pinprick. inr is 2.9. ct head showed an acute right thalamic hemorrhage with extension into the ventricles, without hydrocephalus or shift. the location of the hemorrhage was suggestive of a non-traumatic etiology; the risk factors of hypertension and anti-coagulation are the most likely etiology. reversal treatment with vit k 10mg iv, profilnine 4 vials with 2 units ffp was done. given worsening exam, he was intubated for airway protection and head ct was repeated which showed increased hemorrhage with ~4mm leftward midline shift. neurosurgery was consulted and evd was considered but patient stabilized with repeat/3rd ct showing no significant changes hence no neurosurgical intervention was undertaken.patient was initially admitted to neuro icu and. he remained bradycardic with hr in 50's and occasionally requiring iv hydralazine to maintain sbp < 160~180. another head ct was performed in hd#2 which again had no significant changes to previous 2 ct's and his exam remained stable as well with l hemiplegia and neglect. he was successfully extubated on hd #3. on (hd#4) around 4~5am, patient developed afib with rvr which was refractory to metoprolol 5mg iv x4 hence dilatizem drip was started after bolus of 25mg iv. ekg showed afib rhythm without st changes and cardiac enzymes were negative including trop <0.01 x3. surface echo showed that he had preserved systolic function (lvef>55%) but both atria were dilated and he had mild pulmonary htn. no thrombus was seen. patient was not deemed to be a candidate for direct cardioversion given that he couldnot be anticoagulated after the intervention. he was started on asa 81mg daily and heparin sc 5000 tid for dvt ppx on and he was transferred to step down while still on diltiazem drip plus oral diltiazem for afib rate control. in the following days he remained stable. medications on admission: -warfarin 5 mg daily -asa 81 mg daily -lescol 80 mg daily -norvasc 10 mg daily -atenolol 50 mg daily -betimol 0.5% drip -protonix 40 mg daily -glucosamine -multivitamin -indocin, recently -lunesta discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 2. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic daily (daily) as needed for glaucaoma. 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed). 6. diltiazem hcl 60 mg tablet sig: one (1) tablet po q6h (every 6 hours). 7. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily). 11. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 12. nystatin 100,000 unit/ml suspension sig: five (5) ml po tid (3 times a day). discharge disposition: extended care facility: - discharge diagnosis: right thalamic hemorrhage secondary diagnosis: atrial fibrilation discharge condition: stable, fluctuating mental status and very dense left hemiplegia. discharge instructions: you were admitted to this hospital because you had subtle onset of left sided weakness and changes in your mental status. you underwent a headt ct and brain mri which showed signs of hemorrhage in the deep structure of the right side of the brain, called thalamus. you were treating deep venous thrombosis with anticoagulant therapy and you also have hypertension and this combination seems to be the cause of this hemorrhage. you received treatment to revert the anticoagulant therapy. during this admission you presented irregular cardiac rhythm called atrial fibrillation, and this condition is not new to you. you will need to follow up with your cardiology. please contact your primary care doctor or return to the emergency department if you have weakness, loss of consciousness, persistent headache, dizziness, change in vision or any concerning symptoms. followup instructions: provider: ,md (vascular ) provider: (cardiologist ) provider: , md phone: date/time: 3:00 please contact the office to update some of your information md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Esophageal reflux Unspecified essential hypertension Gout, unspecified Atrial fibrillation Intracerebral hemorrhage Other and unspecified hyperlipidemia Acute respiratory failure Cerebral edema Long-term (current) use of anticoagulants Personal history of venous thrombosis and embolism

allergies: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: emergent replacement of ascending aorta and hemiarch under deep hypothermic circulatory arrest. resuspension of aortic valve. history of present illness: this was a healthy 37 year old male who presented to outside hospital( ) with acute onset chest pain on the evening of admission. ekg revealed nonspecific st-t changes and troponins were negative. ct scan revealed type a aortic dissection. he was stabilized on intravenous esmolol and nitroglycerin, and emergently transferred to the for surgical interevention. past medical history: hypertension obesity social history: lives with family. denies tobacco. admits to occasional marijuana. family history: denies premature coronary disease. no history of aneurysms. physical exam: admission: bp:146/70 pulse:56 resp:18 o2 sat: 96 on ra height: 67 inches weight: 290 pounds general: obese white male, in no obvious distress skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular no murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema none varicosities: none neuro: grossly intact-patient moves all extremities, strength equal bilaterally,upper and lower extremities equal pulses: femoral right: decreased left: decreased dp right:2+ left:2+ pt :2+ left:2+ radial right:2+ left:2+ pertinent results: intraop tee: pre-bypass: the left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. left ventricular wall thicknesses and cavity size are normal. right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic root. the descending thoracic aorta is moderately dilated. a mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. a mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. a mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. the aortic wall is thickened consistent with an intramural hematoma. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. post cpb: 1. preserverd -ventricular systolic function 2. aortic valve unchanged from pre-cpb appearance and there is trace aortic insufficiency. 3. prosthetic tube graft visualized in aortic position. . head mri: 1. areas of acute infarction in the left mca, and a few tiny ones in the right mca territory, raising the possibility of an embolic etiology. patent intracranial carotid arteries with mild narrowing of the left m1 segment. 2. evidence of dissection in the left common carotid artery from its origin at the aortic arch, extending into the lower neck with luminal narrowing. grossly patent mid and distal portions of the left common carotid and cervical internal carotid arteries with limited assessment for details. 3. decreased signal in the distal vertebral and proximal basilar arteries with mild narrowing of the distal basilar artery. . renal ultrasound: limited exam due to portable technique, patient's intubated status, and body habitus. there is again maintenance of arterial and venous flow to both kidneys; however, the resistive indices are persistently slightly elevated bilaterally. abnormal waveforms in the left main renal artery may relate to its origination from the aortic false lumen. . chest and abd ct scan(without contrast): 1. status post aortic dissection repair with evidence of graft placement at the ascending aorta. small amount of hemorrhage within the mediastinum, presumably post-surgical. 2. bilateral opacities at the lung bases and in lingula, could be atelectasis, cannot exclude superinfection. 3. endotracheal tube too low with tip close to the carina. 4. the liver is normal in size. the gallbladder, spleen and bilateral adrenal glands are normal. there is no hydronephrosis. the pancreas and loops of small bowel appear normal. there is no free fluid or free air. 5. the appendix is normal. the rectum and sigmoid are collapsed. there is foley catheter in the urinary bladder. the prostate and seminal vesicles appear normal. there is no free fluid in the pelvis. . transesophogeal echocardiogram: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. a small patent foramen ovale is present with intermittent left-to-right shunt across the interatrial septum at rest. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. a mobile density is seen in the distal aortic arch extending to the descending aorta (to 45 cm) consistent with an intimal flap/aortic dissection. the true lumen is small and contains flow. the false lumen is larger and without flow, consistent with extensive intramural hematoma. the aortic branches are not visualized. the aortic valve leaflets (3) are mildly thickened without aortic stenosis or aortic regurgitation. no masses or vegetations on the aortic valve or aortic valve abscess are seen. prosthetic ascending aorta material is seen without abnormal vegetation or flow surrounding it. the mitral valve leaflets are structurally normal. no mitral valve mass or vegetation, or mitral valve abscess is seen. a mild (1+), centrally-directed jet of mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a very small circumferential pericardial effusion without echocardiographic evidence of tamponade. . labs: inr = 2.0 brief hospital course: mr. was admitted and underwent emergent surgical repair of his type a aortic dissection. for surgical details, please see operative note. following the operation, he was brought to the cvicu in critical condition. cardiac: remained hypertensive in the postoperative period intitially requiring intravenous nitroglycerin. he required multiple antihypertensive agents and was slowly transitioned to po regimen. throughout his hospital stay, he remained in a normal sinus rhythm. no atrial or ventricular arrhythmias were noted on telemetry. neuro: due to peristent hypertension, he required prolonged period of sedation and paralysis. as sedation and paralytics were weaned, he awoke confused and agitated. he remained oriented to place and appeared to be moving all four extremities. the day following extubation( pod#5), he was noted to have no movement on his right side, a right facial droop and expressive aphasia. neurology was consulted and imaging studies confirmed acute stroke(mostly left mca territory), likely embolic etiology. given no evidence of bleed, he was started on intravenous heparin. postoperative echcardiogram revealed a patent foramen ovale while lower extremity ultraound found no evidence of deep vein thrombosis. he was eventually started on warfarin anticoagulation and dosed for a goal inr between 2.0 - 3.0. he should followup with dr. as an outpatient. at discharge, he was alert and oriented. he continues to have right sided weakness and expressive aphasia. ambulatin gshort distances with assistance. pulmonary: initially remained hypoxic and required mechanical ventilation for prolonged period of time. with diuresis, hypoxia gradually improved. eventually extubated on postoperative day six. due to his acute stroke, he was reintubated for safety measures on postoperative day six given the need for imaging studies. he was eventually re-extubated several days later without difficulty. aspiration event on postoperative 11 requiring re-intubation. re-extubated on postoperative day 14. at discharge, he continues to require aggressive pulmonary toilet. his oxygen saturations were 98% on room air. id: initially started on bactrim for fevers in the early postoperative period. pan cultures at that time were unremarkable, and all lines were changed accordingly. diarrhea was c. diff negative. despite persistent fevers, empiric antibiotics were eventually discontinued given all cultures remained negative. following aspiration event on postoperative day 11, broad spectrum antibiotics were resumed. white count peaked to 28k on postoperative day 12. id service was consulted and continued to adjust antibiotic therapy. subsequent blood cultures showed coagulase negative staphylococcus, and tee showed no evidence of valvular vegetations. all antibiotics were discontinued on . at discharge, his wbc was normal and he remained afebrile. heme: initially transfused with prbc's in the early postoperative period. postoperative anemia remained stable, between 25 - 29%. renal: acute renal insufficiency with creatinine peaking to 2.6 on postoperative day five. by discharge, his creatinine normalized. renal ultrasound confirmed maintenance of arterial and venous flow to both kidneys. at discharge, he was making adequate urine. nutrition: following acute stroke, underwent speech and swallow evaluation which initially showed no evidence of aspiration on ground solid diet with nectar thick liquids. depsite supervision with meals, he experienced aspiration on postoperative day 11. tube feedings were therefore resumed. intermittently required free water for hypernatremia. on , he underwent percutaneous endoscopic gastrotomy tube placement. there were no complications and he tolerated the procedure well. repeat swallow evaluation on showed significant improvement in swallow function. po diet was therefore resumed. dispo: after complicated postoperative course, he was cleared for discharge to in on postoperative day 28. appointments advised. medications on admission: transfer meds: iv nitro, iv esmolol discharge medications: 1. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 2. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for dyspnea. 3. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for dyspnea. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever, pain. 7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 9. outpatient lab work check inr day every other day until stable. inr goal for ischemic cva 10. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. labetalol 200 mg tablet sig: four (4) tablet po tid (3 times a day). disp:*360 tablet(s)* refills:*2* 12. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 13. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qtues (every tuesday). disp:*4 patch weekly(s)* refills:*2* 14. warfarin 5 mg tablet sig: one (1) tablet po once a day: inr goal for ischemic cva. disp:*30 tablet(s)* refills:*2* discharge disposition: extended care facility: new rehabilitation hospital discharge diagnosis: type a aortic dissection s/p repair postoperative stroke hypertension postop acute renal insufficiency patent foramen ovale postoperative aspiration postoperative sepsis/septicemia(coagulase negative staphylococcus) discharge condition: alert and oriented. right sided weakness with expressive aphasia. incisional pain managed with incisions: sternal - 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 lifting more than 10 pounds for 10 weeks . labs: pt/inr for coumadin ?????? indication acute embolic stroke goal inr 2.0 - 3.0 first draw coumadin follow up will need to be arranged upon discharge from rehab. . **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr. on monday at 1:45 pm neurology: dr. - on at 5:30pm -rehab please call to confirm this appointment please obtain and see a cardiologist as soon as possible 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 acute embolic stroke goal inr 2.0 - 3.0 first draw coumadin follow up will need to be arranged upon discharge from rehab. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Diagnostic ultrasound of heart Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Resection of vessel with replacement, thoracic vessels Open heart valvuloplasty of aortic valve without replacement Diagnoses: Acidosis Toxic encephalopathy Unspecified essential hypertension Acute kidney failure, unspecified Severe sepsis Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Ostium secundum type atrial septal defect Septic shock Obesity, unspecified Cerebral embolism with cerebral infarction Hyperosmolality and/or hypernatremia Aphasia Dissection of aorta, thoracic Hemiplegia, unspecified, affecting unspecified side Iatrogenic cerebrovascular infarction or hemorrhage Methicillin resistant Staphylococcus aureus septicemia Body Mass Index 45.0-49.9, adult

allergies: sudafed attending: chief complaint: melena major surgical or invasive procedure: egd history of present illness: ms. is a 46 yo woman with history of asthma and occasional gerd now admitted to the icu with 5 day history of black tarry stool, lightheadedness, fatigue, pallor and hct 19 with guaiac positive stool in ed and negative ng lavage. mrs. reports initial complaint of nausea on associated with lightheadedness after teaching 2 yoga classes. symptoms improved with rest and she then had noted decreased appetite and had episode of diaphoresis with presyncope at dinner which resolved with cold packs. she noted ongoing fatigue and weakness on and had first black tarry stool x in am. stools prior to this had always been normal and regular. she attributed this to stress and possible viral infection. on she had black tarry stools but subsequently had normal bms on and so she did not seek medical evaluation. . this am, she had black stool x 1 and overall fatigue with doe climbing one flight of stairs so saw pcp who sent her to ed for further eval given pallor and concern for gib. orthostatics prior to transfer: supine: 118/58 88 upright 112/62 104. she denies any history of similar symptoms, denies abdominal pain, chest pain, vomiting, and brbpr but does have feeling of "hunger/cramping". she takes aleve prn menstrual cramping most recently took 2-3 tabs total and . lmp . she denies any other nsaid use but does not increased stress related to financial situation trying to support her family and run a business. also reports occasional gerd, most recently 1-1.5 weeks ago after eating indian food for which she took tums with good effect. . in the emergency department, initial vs:98.2 151/79 107 16 100%ra. she was mentating well but appeared pale with hct 19.6 and rectal exam was positive for guaiac positive black tarry stool. ng lavage was negative. she received 1l ns and was typed and crossed for 4 units and received 1 unit prbcs. piv x 2 18g were placed. gi was consulted who recommended bolusing and starting pantoprazole drip with plan to scope tomorrow. reason for micu admission was ppi drip. . upon arrival to , she reports she is feeling much better after 1 unit prbcs. . review of systems: (+)ve:recent sore throat x 1 day and, nasal congestion, cough and worsening of asthma over last 4-5 days. also reports ha, strain left leg related to yoga. (-)ve: fever, chills, night sweats, chest pain, sputum production, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, vomiting, diarrhea, constipation, hematochezia, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias past medical history: asthma seasonal allergies occasional gerd with spicy foods social history: married with two children (8 and 11 yo daughters). she owns her own business teaching yoga to children. denies tobacco. drinks 0.5-1 glass red wine per night. no drug use. exercises 4x/wk - walking, biking and yoga. increased stress related to financial concerns (unable to afford skating classes for 11 yo daughter) family history: no fh of bleeding disorder, colon or gi malignancy or ibd. mother - died young of . father primary hyperparathyroidism per omr, dm, htn, high chol, arrhythmia, pacemaker. grandparents lived to 90's. . physical exam: general: pleasant, well appearing woman in nad heent: normocephalic, atraumatic. + conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally, no wheezes with forced exhalation. abdomen: nabs. soft, nt, nd. no hsm. reports "cramping right side of abdomen" but no ttp extremities: no edema, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. gait assessment deferred psych: listens and responds to questions appropriately although occasionally tearful pertinent results: egd : schatzki's ring at distal esophagus. no stigmata of bleeding noted otherwise normal egd to third part of the duodenum brief hospital course: 46 year old woman with asthma who was admitted with gi bleed. she used nsaid for menstrual pain. she had an acute onset of melena consistent with upper gi bleed (although ng lavage reportedly negative in ed). however, upper endoscopy revealed no source of bleeding. the colonoscopy showed dry blood in the cecum which confirmed the suspicion of a higher bleed. at admission, the patient's hct was 19 but she remained hemodynamically stable with hr 90s-100s, normal bp, and normal mental status. she was initially treated with ppi drip but changed to po ppi after negative upper endoscopy. she was transfused 3 units prbcs and hct rose appropriately. she was monitored for additional 24 hours after her colonoscopy and 30 hours after her last transfusion with stable hct. her last bowel movement on the day of discharge was completely normal. she therefore requested discharge. of note she had leukocytosis related to stress reaction for gi bleed and had no other localizing symptoms/signs of infection. the patient was discharged on iron. she may need repeat egd or capsule endoscopy if she gets recurrent gi bleed. no nsaids. she will have a close follow up with pcp/gi to discuss the indications for capsule endoscopy. she was informed about symptoms/signs of bleeding. medications on admission: advair 250 atrovent qid tylenol prn aleve prn last dose 12/21 discharge medications: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. combivent 18-103 mcg/actuation aerosol sig: one (1) inhalation four times a day. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 4. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*3* discharge disposition: home discharge diagnosis: gastrointestinal bleeding discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you had gastrointestinal bleeding. avoid nsaids: ibuprofen, advil, indocin, indomethacin, diclofenac, meloxicam, naproxen, etc. if you have a recurrent bleeding you may need repeat egd or capsule endoscopy. you are going to discuss these options with your gi doctor during your close follow up appointment. you need to take iron with vit c/ juice and laxatives. iron treatment is for at least 3 months. followup instructions: appointment #1 md: specialty: internal medicine/ pcp date/ time: tuesday, , 3pm location: , phone number: appointment #2 md: specialty: gastroenterology date/ time: wednesday, , 9:15 location: , , phone number: provider: mammography phone: date/time: 10:00 provider: , md phone: date/time: 11:30 Procedure: Other endoscopy of small intestine Colonoscopy Diagnoses: Esophageal reflux Acute posthemorrhagic anemia Asthma, unspecified type, unspecified Anxiety state, unspecified Blood in stool Syncope and collapse Diverticulosis of colon (without mention of hemorrhage) Stricture and stenosis of esophagus Internal hemorrhoids without mention of complication Unspecified analgesic and antipyretic causing adverse effects in therapeutic use Other allergy, other than to medicinal agents

allergies: nsaids attending: chief complaint: gi bleeding major surgical or invasive procedure: exploratory laparotomy with small-bowel resection and primary anastomosis. history of present illness: 48 year old female with a history of recurrent gi bleeds felt to be secondary to nsaid induced ulceration who presents with increased fatigue and shortness of breath, found to be anemic. ms. was hospitalized in for melena and acute anemia with profound drop in hematocrit to 21 from unclear baseline. her presentation was in the setting of recent prescription of meloxicam for lateral epicondylitis. an egd performed during that admission did not reveal a source of bleeding, and a capsule study was attempted but terminated early secondary to equipment malfunction. she also had a gi bleed in , thought to be secondary to nsaids. egd/ at that time also did see a source of active bleeding, but noted a schatzki ring in distal esophagus and diverticuli in sigmoid colon. patient was discharged on protonix and iron supplementation. she has not had any nsaids since discharge. she drinks very little alcohol, rarely has an espresso, and usually drinks black tea. she reports that one week prior to admission, she was unable to get a refill of her lansoprazole as her pharmacy ran out of it. she also stopped her iron pills as she was concerned to take them without the ppi. she was able to get lansoprazole again two days prior to admission. she reports that on the thursday prior to admission, she "wasn't feeling good", reporting an upset stomach similar to discomfort with prior gi bleeds. she restarted her iron pills at this time. she notes that over the past two days she has become increasingly fatigued and short of breath with activity. she reports "feeling anemic," as she has in the past when her hematocrit is low. she reports pain in the center of her stomach which is , "small zaps" and like "champagne bubbles." pain is not associated with nausea or vomiting, and she has had a normal appetite. she reports hunger today. she has lost approximately 5lbs in the last several months, mostly during her last hospitalization. she has three bowel movements a day, which is her baseline. she notes dark/black stools since sunday, which are different than her dark stools with iron. she denies bright red blood per rectum. in the ed inital vitals were 99.4 100 123/70 14 97% ra. physical exam was significant for black guaiac positive stool. her labs were significant for hct 18 (discharge hct 31), wbc 11.3, creatinine 0.6. she refused an ng lavage. she was typed and crossed for 4 units. two 18 gauge pivs were placed. she was given 1l ns. gi was notified of her admission. she was started on a protonix gtt. vitals on transfer were significant for bp 132/75 hr 90s. on arrival to the icu, vital signs were t 100.4, hr 105, bp 124/78, rr 16, 100% on ra. patient was comfortable, reporting central stomach pain, no lightheadedness, no chest pain or shortness of breath. first unit of prbcs hanging on arrival. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, constipation. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: # recurrent gi bleed nsaids with no clear source identified (, )- diverticuli of sigmoid colon and descending colon, schatzki's ring in distal esophagus on egd/colonoscopy in # asthma # seasonal allergies # occasional gerd with spicy foods # dysmenorrhea . past surgical history # s/p breast biopsy in her 20s # s/p l knee synovectomy () social history: married with two children (8 and 11 yo daughters). lives in , ma. she teaches yoga to children and also works in a bakery. tobacco: none alcohol: occasional red wine illicits: negative exercise: 4x/day - walking, biking and yoga family history: no fh of bleeding disorder, colon or gi malignancy or ibd. mother - died young of . father - primary hyperparathyroidism, cardiomyopathy, dm, htn grandparents lived to 90's. siblings- one recently diagnosed with ra, one recently diagnosed with psoriatic arthritis physical exam: admission exam: vitals: t: 100.4 bp: 124/78 p: 105 r: 16 o2: 100% ra general: young female, awake and alert in nad heent: eomi, perrl, 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, grade ii/vi holosytolic murmur best heard at base abdomen: +bs, soft, nontender, nondistended, no hepatosplenomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no edema discharge exam: vitals - t 98.6, hr 69, bp 124/72, r 16, o2 99% general - no acute distress, alert oriented x 3 cardiac - rrr, no mrg, nl s1s2 lungs - cta b/l, no respiratory distress abd - soft, no rebound/guarding, mild paraincisional tenderness, mild distension wound - primary dressing in place over midline incision pertinent results: admission labs: 12:15pm blood wbc-11.3*# rbc-2.01*# hgb-6.1*# hct-18.2*# mcv-90 mch-30.5 mchc-33.7 rdw-13.0 plt ct-249 12:15pm blood neuts-82.3* lymphs-14.1* monos-3.2 eos-0.2 baso-0.2 12:15pm blood glucose-103* urean-22* creat-0.6 na-135 k-3.7 cl-105 hco3-21* angap-13 12:15pm blood ld(ldh)-236 totbili-0.1 12:15pm blood hapto-101 06:20am blood wbc-7.5 rbc-3.05* hgb-9.2* hct-27.6* mcv-91 mch-30.3 mchc-33.4 rdw-14.8 plt ct-382 05:10am blood wbc-13.8* rbc-2.97* hgb-9.0* hct-26.6* mcv-90 mch-30.4 mchc-33.9 rdw-16.4* plt ct-305 12:15pm blood neuts-82.3* lymphs-14.1* monos-3.2 eos-0.2 baso-0.2 06:20am blood plt ct-382 05:06am blood pt-11.3 ptt-24.9* inr(pt)-1.0 12:15pm blood ret aut-2.9 06:20am blood glucose-90 urean-9 creat-0.6 na-138 k-4.2 cl-104 hco3-29 angap-9 05:10am blood glucose-103* urean-8 creat-0.6 na-140 k-4.5 cl-106 hco3-31 angap-8 05:10am blood glucose-103* urean-8 creat-0.7 na-140 k-4.4 cl-107 hco3-28 angap-9 12:15pm blood ld(ldh)-236 totbili-0.1 05:10am blood calcium-8.1* phos-2.8 mg-2.1 10:18am blood calcium-7.5* phos-2.7 mg-1.9 12:15pm blood hapto-101 ct abd/pelvis : impression: 1. enhancing intraluminal and extraluminal bilobed mass within the mid to proximal jejunum, corresponding to the mass observed on endoscopy. no masses are present in the duodenum. numerous lymph nodes within the mesentery, but none are pathologically enlarged. 2. no active bleeding from this jejunal mass or elsewhere in the gi tract. 3. sigmoid diverticulosis without diverticulitis. 4. free fluid in the deep pelvis may be due to a ruptured hemorrhagic cyst in the right adnexa. 5. endoscopy capsule in the cecum. 6. small hiatal hernia. brief hospital course: 46 yo f with history of recurrent gi bleeds presenting with fatigue and anemia. # gib, sb mass: patient has not had any brbpr, hematochezia/coffee ground emesis, however, does report dark black stools (while on iron), which were guaiac positive in the er. high concern for gib. during last admission, no source was located in the upper gi system, however capsule study was not performed. as recent egd was negative and patient has no risk factors for ugib (no nsaid use, infrequent alcohol use), low suspicion for esophageal or gastric source. in addition, colonoscopy in showed only diverticuli, which may be source of bleed but unlikely as they were in sigmoid colon and patient denies any obviously bloody stool. initially planned repeat egd, but patient preferred less invasive study given recent negative egd. therefore, a tagged rbc scan was performed, which showed slow bleed in the distal jejunum/proximal ileum. ir , but felt that given the slow rate of bleed, angiography unlikely to be positive. patient was initially on a protonix drip which was changed to iv bid once the location of the bleed was localized to the small bowel. the acute care surgery service was consulted and she was found to have a bilobed 4.4 x 2.4 cm mass in her jejunum. she was taken to the or on and had an ex-lap and small bowel resection. she was transfused 2 uprbcs pre-operatively for a hct of 20.2. her post-op hematocrit was 27.5. over the next few days, her hct remained stable. her diet was slowly advanced as her bowel function was able to tolerate. she had no further bleeds and was able to be discharged home with appropriate follow-up instructions and warning signs # anemia: normocytic anemia, most likely due to acute/subacute blood loss. as below, source was identified. patient required 2uprbcs at the time of admission and hematocrit responded appropriately. hemolysis labs were negative and reticulocyte count was appropriate. gib workup as below. likely source of bleeding to be the sb mass as described above. post-operatively, she had no bleeding and her hematocrits were stable until discharge. # tachycardia: sinus in nature on ekg. most likely due to anemia. resolved with transfusions and fluid resuscitation. # leukocytosis: likely related to stress reaction and demargination from gib. resolved with time. # asthma: no shortness of breath or wheezing on admission. continued outpatient advair and atrovent. medications on admission: fluticasone-salmeterol 250/50 inh ipratropium 1 capsule inh qid lansoprazole (stopped one week pta) iron discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*25 tablet(s)* refills:*0* 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. ipratropium bromide inhalation 4. advair hfa inhalation discharge disposition: home discharge diagnosis: intestinal bleeding with identification of a 4-cm small bowel mass at the level of the jejunum. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you during your stay at . you were admitted to the hospital due to gi bleeding. you were taken to the or where a mass was seen at the level of the jejunum (a part of your small intestine). this mass and part of your small intestine was removed. you were then observed over the next few days to monitor your gi function and your pain. we feel comfortable sending you home at this time. please remember to take it easy over the next few weeks as you are recovering from a major operation and need time to recuperate. 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. 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. *avoid swimming and baths until cleared by your surgeon. *you may shower and wash 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. warning signs: 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. followup instructions: please call ( upon discharge to schedule an appointment in the acute care surgery clinic in 2 weeks, or with any questions/concerns. clinic is located in the medical office building, , . Procedure: Other partial resection of small intestine Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Esophageal reflux Acute posthemorrhagic anemia Asthma, unspecified type, unspecified Disorders of phosphorus metabolism Hemorrhage of gastrointestinal tract, unspecified Disorders of magnesium metabolism Neoplasm of uncertain behavior of connective and other soft tissue

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: lethargy major surgical or invasive procedure: medical icu stay ( - 9/13/ history of present illness: 79 year old man with a history of dementia, crohns, cad who was noted to be lethargic, unable to eat or walk by his caregiver and so was brought in from home by ems. per caregiver, no , fevers or other localizing symptoms other than decreased po intake x few days. . on arrival in the ed, the patient was in moderate distress, hypotensive to the 80s and tachycardic to the 130s. lactate was 11.0, wbc 39.3, sodium 158, creatinine 4.3. a central line was placed. he was given 4 liters of normal saline with improvement of his bp to 110s. cxr was notable for a lingular pna. he was given ctx/levoflox and tylenol in the er. past medical history: #. crohn's disease - history of pancolitis and ileitis - hx of rectal absces - dr. is gi doc #. coronary artery disease - s/p stent to right coronary artery - 20% stenosis of small diagonal artery noted, no intervention #. hypertension #. hypercholesterolemia #. lower extremity edema #. chronic anemia - iron deficiency #. hx of clostridium difficile enterocolitis #. chronic kidney disease - baseline from : bun of 25, creatinine of 1.2 #.depression #. vascular dementia #. hypothyroidism #. scarlet fever as a child . past surgical history: status post stent of right coronary artery. social history: lives with 24 hour caregiver. the patient has been widowed for seven years. he has three children. his daughter lives in , and is his healthcare proxy. another child lives in . past smoking history but quit 40 years ago. independent with feeding, dressing, and toileting prior to present decompensation. family history: the patient's mother had disease. his father abused alcohol and died of complications at a young age. the patient was one of six siblings. four are still living. he reports that one sister died secondary to severe obesity. other siblings have had cardiac issues. physical exam: vitals: 98.6 | 99-120/54-60 | 16-22 | 81-98 | sat 95-99% fm 5l humidified o2 general: confused appearing. alert/oriented x1; nad heent: ncat; perrla; eomi, anicteric; dry mm; very poor dentition neck: jvd 5cm; supple cardiac: rrr. s1, s2. sem rusb pulmonary: scattered course breath sounds bilaterally abdomen: soft;nt/nd, +bs no organomegaly; no mass palpated extremities: b/l 2+ edema calves; dp /pt 1+ bilat skin: bilateral heel eschars; sacral stage iii ulcer 7cm+ diffuse borders. neuro: +palmomental reflexes; grasp reflex; 4/5 strength legs; strenth arms. pertinent results: **admission labs wbc-39.5*# rbc-3.76* hgb-10.3* hct-34.6* mcv-92 mch-27.3 mchc-29.6* rdw-16.7* plt ct-776* neuts-90.3* lymphs-7.6* monos-1.9* eos-0.0 baso-0.2 glucose-146* urean-91* creat-4.3*# na-158* k-4.4 cl-108 hco3-26 angap-28* albumin-2.9* calcium-10.4* phos-5.1* mg-2.9* lactate-11.0* urine cx x 2 & blood cx x 2 from no growth- final . **subsequent labs/discharge labs wbc- steadily trending down to 12.5 at last check on diff steadily improving to neuts-76.6* lymphs-15.3* at last check on renal fxn steadily improving to urean-29* creat-1.0 on lactate resolved to 1.7 on . 07:37am blood probnp-4480* probnp elevated to >4000 after micu fluid resucitation . stool salm, shig, camp negative; c diff antigen not detected sputum gram stain/cx - 2+ gpc in clusters/sparse growth op flora blood cx x 2 - ngtd, pending blood cx x 2 - ngtd, pending ***********pertinent studies****************** ekg - sinus tachycardia at rate 133. right bundle-branch block with left anterior hemiblock. non-specific repolarization changes. overall similar to previous tracing cxr - new infiltrate within the lingular lobe which silhouettes the left heart border. no pleural effusion, pneumothorax, or pulmonary vascular congestion is detected cxr, pa & lat - heart size is enlarged. slight interval worsening in bilateral perihilar and lower lobe opacities is consistent with pulmonary edema. bilateral pleural effusion, left more than right, is present. chest ct- large pleural effusions (l>r) with associated atelectasis/collapse & consolidation bilaterally c/w pneumonia. no empyema, no abscess ct abdomen- 1. bilateral pleural effusion and adjacent atelectasis/consolidation; 2. right small bowel-containing spigelian hernia. there is no evidence of bowel obstruction; 3. colonic diverticulosis without evidence of diverticulitis; 4. diffuse atherosclerotic disease involving the aorta and branch vessels. again note is made of narrowing of the celiac artery origin, unchanged from ; 5. fracture of the sacral tip. new since prior ct from ; 6. small pericardial effusion. brief hospital course: mr. was evaluated in the ed and found to be in severe shock from presumed pulmonary infection. a central venous line was placed in the ed and antibiotic therapy and fluid resucitation were begun immediately. the patient was admitted to the medical intensive care unit where his hypotension and hypernatremia were treated with vigourous iv fluid rehydration without the use of pressors. his pneumonia continued to be treated with broad spectrum antibiotics with levofloxacin and vancomysin. an ng tube was placed to provide continued nutrition during this acute recovery phase of his illness. once he began showing signs of clinical improvement and stability, the patient was transferred to the floor for continued care. over the following days his renal fxn improved to better than baseline, his white count and left shift began resolving, his mental status started to clear, and he became afebrile. at the time of transfer to rehab macu, the patient was still in guarded but stable condition. he is not yet ambulating, not yet tolerating a po diet, and still experiencing episodic delerium. the patient is also still has an oxygen requirement and is undergoing gentle diuresis to improve the pulmonary edema and pleural effusions that developed secondary to his vigourous hydration in the macu. mr. has also been constipated is on a bowel regimen to help him move his stools. a spigelian (abdominal wall) hernia found on ct abdomen could also be explaining his episodic abdominal pain. he was seen and evaluated by the general surgery team who felt this could be handled later once the patient's general functional status was more improved. contact information for follow-up is given in the discharge follow-up instructions. the plan at the time of discharge is to continue antibiotic therapy and gentle diuresis at rehab with slow advances in diet and activity as tolerated. once the patient has improved, arrangements should also be made to see his pcp and the surgical specialists. medications on admission: lipitor 10 mg po qhs seroquel 25mg po qhs seroquel 12.5mg po bid (am and noon) nexium 40mg cap po daily lexapro 10mg po daily thiamine 100mg po daily hydrocholorthiazide 12.5 mg po daily lomotil 2.5mg-0.035mg po tid and prn lotrimin 1% topical cream to feet qhs lotrimin af 2% topical to feet levothyroxin 112mcg poo daily toprol xl 25mg po once daily discharge medications: 1. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 2. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 3. quetiapine 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 4. quetiapine 25 mg tablet sig: 0.5 tablet po bid (2 times a day): please give in am and at noon. 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. polysaccharide iron complex 150 mg capsule sig: one (1) capsule po daily (daily). 7. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. docusate sodium 50 mg/5 ml liquid sig: two (2) po bid (2 times a day). 11. papain-urea 830,000-10 unit/g-% ointment sig: one (1) appl topical daily (daily): apply to sacral decub. 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 13. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 14. polyethylene glycol 3350 100 % powder sig: one (1) po bid prn as needed for constipation: please titrate to soft bowel movements daily. 15. acetaminophen 325 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for fever. 16. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed. 17. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 18. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 19. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 20. furosemide 10 mg/ml solution sig: one (1) injection qam (once a day (in the morning)). 21. vancomycin 750 mg iv q 12h 22. thiamine hcl 100 mg tablet sig: one (1) tablet po once a day. 23. lotrimin 1 % cream sig: one (1) topical at bedtime: apply to feet at bedtime. 24. hydrochlorothiazide 12.5 mg tablet sig: one (1) tablet po once a day. . ****medical management please wean iv lasix as pulmonary, clinical presentation allows. . *****lab work 1. please check vanc trough at 9pm today . one hour prior to 10pm dose. due to change of dose yesterday. 2. follow cbcs daily until white count resolved and stable. then qod until discharged. 3. follow renal fxn with electrolytes daily vs. qod until discharged. . *****radiology per radiology- cxr should be followed to clearing. please cxr once weekly or as clinically indicated until resolved. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: **primary - community aquired pneumonia - hypovolemic shock ** secondary - crohn's disease - coronary artery disease - hypertension - hypercholesterolemia - chronic anemia - chronic kidney disease - depression - vascular dementia - hypothyroidism - aortic stenosis likely due to scarlet fever as a child discharge condition: fair. patient is getting tube feeds at 60ml/hr via ngt with gradual slow addition of honey thick liquids and pureed foods. he is being repositioned from bed to chair for one hour 2-3x daily with nursing assistance. he is not yet ambulatory. discharge instructions: you were admitted to the hospital because you have a community-aquired pneumonia that made you very sick and caused your blood pressure to be dangerously low. you were treated with supportive fluids and antibiotics in the medical intensive care unit for several days before being transfered to the floor. we feel that you are receiving the right treatment since you have been improving on the floor for the past few days. it will probably take you a while to recover from this severe infection so we are sending you rehab for further care. please follow these instructions: 1. please follow the recommended care provided for you at rehab. they will be responsible for making medical decisions/recommendations for you for the rest of your recovery period. 2. we have added two antibiotics to your regular medication regimen; levofloxacin and vancomycin. continue to take these antibiotics as prescribed up through tuesday . this will give you a total of 14 days of medical treatment. 3. we have temporarily switched you from toprol xl to metoprolol tartrate three times a day and added lasix 10mg iv once a day. the doctors rehab will help decide when it is safe for you to swtich back to your normal regimen. 4. we have stopped your lexapro and lomotil for now as these medications can worsen your mental status, especially when you are ill. you can restart these after visiting your primary care doctor once you are well. 5. please make an appointment with your primary care doctor within a week of being discharged from rehab. we have provided their name and contact number for you below. 6. please make an appointment to see dr. . he is a surgical specialist and will help you decide what needs to be done for the hernia that we found you have. **if you experience worsening , shortness of breath, swelling of your feet, severe abdominal pain, chest pain, nausea, vomiting, or any other worrisome symptoms, please talk to your primary care doctor or return to the emergency room.** followup instructions: please report to rehab macu for continued care. continue taking antibiotics as prescribed up through tuesday . this will give you a total of 14 days of medical treatment. please schedule/have rehab staff schedule follow-up with your primary care doctor for within one week of being discharged home. dr. - ( please schedule/have rehab staff schedule a follow-up appointmet with the surgical specialist to help you manage your spigelian (abdominal wall) hernia. dr. - ( Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Pneumonia, organism unspecified Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Aortic valve disorders Personal history of tobacco use Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Constipation, unspecified Regional enteritis of unspecified site Other shock without mention of trauma Septic shock Pressure ulcer, lower back Iron deficiency anemia, unspecified Acute diastolic heart failure Pressure ulcer, heel Hyperosmolality and/or hypernatremia Diverticulosis of colon (without mention of hemorrhage) Cerebral atherosclerosis Other ventral hernia without mention of obstruction or gangrene Mixed acid-base balance disorder Vascular dementia, with delirium

allergies: cephalosporins / penicillins / iodine / clindamycin attending: chief complaint: s/p stemi with cardiogenic shock major surgical or invasive procedure: cardiac catheterization with percutaneous coronary revascularization of left circumflex artery with drug eluding stent picc placement history of present illness: mr. is a 57 year-old man with esrd on hd who presented to on with an inferior stemi now s/p rca pci being transfered for further care. patient was scheduled to have an outpatient stress test the day prior to admission, but was unbale to participate in the study and returned to his nursing home. later the same evening he developed acute sob and was take to where he was found to be having an stemi. cardiac catheterization revealed severe three vessel disease with 100% occluded lad, 90% lcx lesion and severe rca disease requiring bms x3. he required intubation during cardiac catheterization for respiratory failure and subsequently required pressor support with peripheral dopamine for cardiogenic shock. he is now extubated but continues to require dopamine to maintain a sbp in the 80s-90s. . on arrival his vital signs were hr 114 with bp 94/71. he is breathing comfortably and has no complaints other than hearing loss. in particular, he denies chest and jaw pain. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension, pvd 2. cardiac history: - percutaneous coronary interventions: bms to rca x 3 3. other past medical history: - esrd to diabetic nephropathy on hd x7yrs mwf - osteomyelitis of the spine with resultant paraplegia - hyperparathyroidism - left bka to gangrene - right arm fistula social history: single male. has been on disability in his left bka. lives in a nursing home. - tobacco history: denies - etoh: denies - illicit drugs: denies family history: - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - significant for diabetes physical exam: admission exam: general: profoundly hard of hearing. 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 9 cm. cardiac: regular rhythm, soft s1 and s2. no m/r/g appreciated lungs: pronounced leftward chest deformity of unknown chronicity. symmetric air movement bilaterally. end expiratory crackles on exam, no wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: l bka, no femoral bruits. right heel ulcer 2x4cm with scant exudate and exposed bone and fat pulses: right: carotid 2+ femoral 2+ doplerable dp pulse left: carotid 2+ femoral 2+ discharge exam: pertinent results: admisson labs: 09:16pm wbc-8.3 rbc-3.35* hgb-10.7* hct-33.4* mcv-100* mch-32.0 mchc-32.2 rdw-14.0 09:16pm plt count-189 09:16pm glucose-404* urea n-30* creat-3.5* sodium-136 potassium-4.7 chloride-94* total co2-24 anion gap-23* 09:16pm calcium-7.7* phosphate-4.8* magnesium-2.1 09:16pm pt-15.0* ptt-30.6 inr(pt)-1.3* cardiac enzymes: 09:16pm ck(cpk)-146 09:16pm ck-mb-9 ctropnt-13.7* 04:50am blood ck-mb-8 ctropnt-13.99* other pertinent labs: 12:14pm blood lactate-2.4* studies micro: 4:50 am blood culture source: line-central lumen cath. blood culture, routine (preliminary): staph aureus coag +. consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. preliminary sensitivity. these preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. check for final susceptibility results in 24 hours. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | oxacillin------------- s aerobic bottle gram stain (final ): reported to and read back by @ 2232 on -. gram positive cocci. in pairs and clusters. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. imaging: cxr ap : central catheter projects over the lower superior vena cava. lung volumes are quite low, making evaluation of the lungs difficult. there are multiple bilateral rib fractures. i see no pneumothorax. tte : 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 is mildly dilated. overall left ventricular systolic function is severely depressed (lvef= 15-20 %) with global hypokinesis and distal lv/apical akinesis to dyskinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is dilated with severe 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. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. r foot x ray: large ulcer extending to the calcaneal tuberosity posteroinferiorly without gross cortical destruction. if the ulcer probes the bone this would be highly suspicious for osteomyelitis. brief hospital course: primary reason for hospitalization: 57m w/ htn, dm, hld, pvd and esrd on hd presented to osh with inferior stemi s/p pci to rca now transfered for further care. active issues: # cardiogenic shock: patient required pressor support with dopamine following pci at osh and was transferred to at a dose of 8mg/kg/min. on hd6 patient was successfully weaned from dopamine and was maintaining a stable blood pressure. he maintained pressures through dialysis as well. he was restarted on his home anti-hypertensives prior to discharge. # cad: patient did not have prior history of known cad, but recent tte from revealed anterolateral and apical defects consistent with cad. patient presented on with rca infarct that required bms x3. cardiac cath also revealed 90% lcx disease and completely occluded lad that was presumed chronic. lv gram revealed lvef of 20%. on hd3 patient was taken to the cath lab and had successful stenting of his left circumflex. he was continued on plavix and aspirin throughout admission. # esrd on hd: patient receives chronic hd on mwf schedule. patient's electrolytes were monitored closely throughout admission. patient was dialyzed on his normal schedule and pressures tolerated this without issue. he refused many of his medications throughout admission. #bacteremia: patient had one blood culture positive for gram positive cocci, mssa. he was treated with iv vancomycin given penicillin allergy. patient will be treated for 10 day course, last day . a picc line was placed for iv administration following discharge. patient was afebrile and hemodynamically stable at the time of discharge. he had two days of surveillance cultures with no growth to date at the time of discharge. #atrial fibrillation: patient had an episode of atrial fibrillation during his catheterization. he was given amiodarone, and spontaneously converted to sinus rhythm. he again had an episode of atrial fibrillation on hd5 and was started on an amiodarone drip. he spontaneously converted into sinus rhythm again, later the same day. he was started on oral amiodarone with a goal loading dose of 8g. at the time of discharge, his dose was 300mg po bid. he will continue this for 11 days, ending . at that time, he should be transitioned to amiodarone 200mg po daily. despite chads2 score of 3, patient was felt to be a poor candidate for anticoagulation given poor medication compliance and fall risk. patient was in sinus rhythm and hemodynamically stable at the time of discharge. # htn: patient was in cardiogenic shock at the time of admission, therefore his home anti-hypertensives were held. since bps were still lowish at discharge norvasc was discontinued and valsartan was continued but at a much lower dose (40mg ). # hld: patient is s/p stemi. he was changed to 40mg po atorvastatin daily as he is also on amiodarone, and therefore was felt to not necessitate 80mg daily. # right heel ulcer: patient had a 2x4 cm ulcer on right heel consistent with arterial insufficiency. per report, this has been followed by vascular surgery as an outpatient. patient was evaluated by both vascular surgery and podiatry. both teams agreed that the ulcer was not actively infected, and therefore there was no indication for antibiotics. the ulcer was cleaned daily with application of santil ointment. an xray of the heel was performed showing an ulcer but no cortical destruction. per vascular surgery, the patient should have an abi checked as an outpatient. # bilateral hearing loss: patient reported acute hearing deficit coinciding with his myocardial infarction. no obstructive cause was apparent on otoscopic examination. hearing loss appeared to be symmetric. he was not given otoxic drugs. ischemia in the setting of cardiogenic shock is also a possiblity. symptoms were not consistent with cva causing hearing loss, as he had no associated symptoms of nystagmus, nausea or dizziness as would be expected. patient's hearing improved spontaneously. he should have ent follow-up as an outpatient if he continues to have further issues. # compliance: patient refused many medications throughout admission, which made regulation of blood sugar and electrolytes difficult. he was made aware of the risks involved in refusing each medication. chronic issues: # dm: patient is on oral hypoglycemics and insulin at home. patient's blood sugars were controlled throughout admission on a diabetic diet and insulin sliding scale. transitional issues: - patient maintained full code status throughout hospitalization - patient will need abis performed as outpatient. dressing changes daily to heel. will also need to follow-up with his vascular surgeon. - follow-up with ent if hearing issues persist -follow- up with cardiology in approximately 2 weeks medications on admission: home medications: - norvasc 10mg on non-hd days - sensipar 120mg daily - trazodone 50mg qhs - zocor 20mg qpm - diovan 160mg - duoneb q4h prn - actos 30mg daily - glipizide 5mg daily - phoslo 3 tabs qac - reglan prn - atarax prn . medications on transfer: - acetaminophen 650 q6h prn - albuterol hfa 4 puff q2h prn - aspirin 325 daily - calcium acetate 2001mg tidqac - cinacalcet 120mg qhs - plavix 75mg daily - colace 100mg - dopamine gtt - epoetin 8000 unit iv qhd - glipizide 5mg qam - heparin 5000 units sq - hydroxyzine 50mg q6h prn - lidoderm patch qd - metoclopramide 10mg tidqac - metoprolol 6.25 q8h - morphine 2mg q5min - ntg 0.4mg sl - zofran 4mg iv q8h prn - pantoprazole 40mg qd - simvastatin 10mg qhs - trazodone 50mg qhs - valsartan 160mg - insulin sliding scale: 201-250:3 units 251-300:5 units 301-350:7 units 351-400:9 units >400: 11 units discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. duoneb 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) inhalation q4h prn sob, wheezing. 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. digoxin 125 mcg tablet sig: one (1) tablet po 1x/week (): last dose given , next dose . disp:*30 tablet(s)* refills:*2* 5. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metoclopramide 10 mg tablet sig: one (1) tablet po qid (4 times a day) as needed for nausea. 7. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. 8. amiodarone 200 mg tablet sig: 1.5 tablets po bid (2 times a day) for 11 days: then change to 200 daily. disp:*44 tablet(s)* refills:*2* 9. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous hd protocol (hd protochol) for 4 days: ending . disp:*4 units* refills:*0* 10. norvasc 10 mg tablet sig: one (1) tablet po on non-hd days: hold for sbp<90, hr<60. 11. sensipar 60 mg tablet sig: two (2) tablet po once a day. 12. diovan 40 mg tablet sig: one (1) tablet po twice a day: hold for sbp<90, hr<60. 13. glipizide 5 mg tablet sig: one (1) tablet po once a day. 14. actos 30 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: colonial heights care and rehabilitation center - discharge diagnosis: primary diagnosis: 1. cardiogenic shock 2. left circumflex stenosis secondary diagnosis: 1. coronary artery disease 2. end stage renal disease 3. diabetes mellitus type ii 4. peripheral vascular disease 5. chronic right heel ulcer 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 taking care of you during your recent admission to . you were admitted to our hospital because following heart your catheterization because you required iv medications to maintain your blood pressure. during this hospitalization, a previously noted blockage in your coronary arteries was stented open. after this, the iv medications were slowly weaned and your blood pressure was stable off of these medications at the time of discharge. you were dialyzed on your normal schedule throughout admission. in addition, you had an infection in your blood stream. one of your blood cultures grew a bacteria called staph aureus. we treated this with an iv antibiotic (vancomycin) as you are allergic to penicillin. you will need to continue this medication through . medication changes: you were continued on most of your home medications. but you should stop the following home medications: 1. norvasc the following home medications had their doses changed: 1. diovan dose decreased from 160mg to 40 mg you were started on the following new medications. these medications are very important. please be sure to take them every day as prescribed. 1. plavix 75 mg by mouth once each day 2. aspirin 325 mg by mouth once each day 3. atorvastatin 40mg by mouth once each day 4. digoxin 0.125mg by mouth once a week, next dose 5. amiodarone 300mg by mouth twice each day for 11 days. on you will change this does to 200mg by mouth once each day and continue this indefinitely. 6. vancomycin iv with dialysis each time dialyzed, ending . after you finish this medication your picc line can be safely removed. weigh yourself every morning, md if weight goes up more than 3 lbs. Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Hemodialysis 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 two vessels Central venous catheter placement with guidance Diagnoses: End stage renal disease Renal dialysis status Coronary atherosclerosis of native coronary artery Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Cardiogenic shock Unspecified hearing loss Acute myocardial infarction of other inferior wall, initial episode of care Secondary hyperparathyroidism (of renal origin) Below knee amputation status Paraplegia Atherosclerosis of native arteries of the extremities with ulceration Ulcer of heel and midfoot

allergies: penicillins attending: chief complaint: cardiac arrest major surgical or invasive procedure: none history of present illness: 78 yo female with h/o mi x2, right carotid endarterectomy, htn, prediabetes, dyslipidemia, stroke, cri who experienced a slow speed mva this morning (backed up into another car), and afterwards was pale and started vomiting. she was transported to the ed by her niece at 0825 with initial rhythm ventricular tachycardia (rate around 160bpm) with no palpable pulse/hypotension (88/50mmhg) and was found to be cool, clammy and diaphoretic. she was synchronized cardioverted x 3 at the osh. she underwent cpr and initially got bolus of amiodarone and then an infusion of it. patient was then intubated. patient continued in vt receiving 2 more synchronized cardioversion, a bolus of lidocaine and a new bolus of amiodarone. rhythm then converted to ventricular fibrillation (shocked once) and then pea; patient received 1 amp of epinephrine. rhythm converted to vfib again, receiving 2 amps of epi, 1 bolus of lidocaine and 2gm of magnesium. pulse was then found; patient was in vfib for at least 10 minutes. . ecg after the code blue was concerning for inferior stemi. patient had ice packs placed and she was then transported to . en route, patient became agitated, trying to pull her ett, and patient got fentanyl and versed for sedation. . in the ed ecg showed pattern compatible with vtach (multiple morphologies) patient has been stable with sbps 100s-110s even when she flips into vt, which she does intermittently. patient continued on amiodarone gtt (2 mg/min) and lidocaine gtt (2 mg/min). she was also started on iv heparin and given pr aspirin. patient moves all four extremities, but is not responding to commands. she got a bolus of midazolam at the time of her arrival; so it??????s difficult to assess the patient??????s neurologic status. she has underwent ct head, c-spine, chest, abdomen and pelvis, as well as a chest x-ray. cardiac catheterization was deferred because the patients neurologic was not intact, as well as the most likely cause of her monomorphic vt is a previous scar and not a current mi. right ij was placed before transfer. ng tube and foley were also placed. sedation was switched to propofol. . labs were significant for wbc count of 15k. creatinine was 1.8 from an unknown baseline. troponin was elevated to 0.21. vbg showed 7.05/50/52/15, with lactate 10.9, free calcium 1.08. glucose was elevated to 400s. rectal temperature on transfer is 35.3 c. p 76, bp 115/60, map 74, fio2 of 100, peep 5, rate 16, sat 100% on transfer. . on arrival to the ccu, patient was intubated and sedated. initial vs??????s: 94.1, 54 77/41 100 on ac 550x20 fio2 100%. also of note upon arrival to the ccu the patient??????s left lower limb was noted to be cold, mottled (progressing all the way to her hip at that time, but more prominent below the knee) and no distal pulses could be palpated. vascular surgery was called to evaluate the patient, the main diagnosis considered was an acute arterial thrombotic event so the patient was given an initial heparin bolus at 80u/kg iv and then a heparin infusion was started. anti-arrythmic gtts were d/cd without recurrence of vt. because of hypotension patient was started on a low dose of phenylephrine (other vasopressors were considered but due to risk of triggering arrhythmias phenylephrine was selected). an axillary line was placed. and arctic sun protocol was initiated. past medical history: diabetes hypertension hypothyroidism gerd gout tia status post right endarterectomy. degenerative joint disease in both hips. history of l4-l5 level of central spinal stenosis social history: social history; - - tobacco history: non-smoker - etoh: rare etoh - illicit drugs: - family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death physical exam: admission exam: gen: intubated, sedated heent: atraumatic, normocephalic. did not assess pupils neck: unable to appreciate jvp due to right ij cv: no m/r/g, soft heart sounds lungs: ctab bilaterally on anterior exam abd: depressed bowel sounds, no tenderness, non-firm, obese extremities: mottled on left side of lower extremities and cold, extends up to abdomen, no palpable or dopplerable pulses dp/pt on left, dopplerable pt on right pertinent results: labs: 11:26am blood wbc-15.0* rbc-3.45* hgb-11.5* hct-36.1 mcv-105* mch-33.2* mchc-31.8 rdw-15.7* plt ct-167 02:20pm blood neuts-87* bands-1 lymphs-10* monos-1* eos-0 baso-0 atyps-0 metas-1* myelos-0 08:55pm blood hypochr-normal anisocy-normal poiklo-2+ macrocy-normal microcy-normal polychr-normal burr-2+ 02:20pm blood hypochr-1+ anisocy-normal poiklo-normal macrocy-2+ microcy-normal polychr-normal 11:26am blood pt-11.5 ptt-45.9* inr(pt)-1.1 09:02pm blood pt-33.5* ptt->150 inr(pt)-3.3* 11:26am blood fibrino-232 09:58pm blood fibrino-105*# 09:58pm blood fdp-* 04:32am blood fibrino-172*# 04:32am blood fdp->1280* 02:20pm blood glucose-384* urean-39* creat-1.9* na-138 k-4.7 cl-106 hco3-14* angap-23* 04:32am blood glucose-264* urean-42* creat-2.2* na-135 k-4.8 cl-113* hco3-9* angap-18 04:32am blood alt-6255* ast-6553* alkphos-160* 11:26am blood ctropnt-0.21* 02:20pm blood ck-mb-24* mb indx-9.8* ctropnt-0.85* 02:20pm blood calcium-7.6* phos-5.0* mg-2.6 11:26am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:32am blood d-dimer-greater th 11:27am blood type- temp-35.1 po2-52* pco2-50* ph-7.05* caltco2-15* base xs--17 intubat-intubated 04:49am blood type-art po2-165* pco2-22* ph-7.13* caltco2-8* base xs--20 11:27am blood glucose-429* lactate-10.9* na-136 k-4.3 cl-108 04:49am blood lactate-13.1* echo : the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is severe regional left ventricular systolic dysfunction with focal thinning and akinesis of the inferior and inferolateral walls and hypokinesis of the inferior septum and apex. there is mild hypokinesis of the remaining segments (lvef = 25 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is moderate thickening of the mitral valve chordae. mild (1+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: suboptimal image quality. severe left ventricular regional dysfunction with thinning/akinesis of the inferior and inferolateral walls, and hypokinesis of the inferior septum and apex c/w multivessel cad. mild mitral regurgitation. mild aortic regurgitation. borderline pulmonary hypertension. ct head : 1. no evidence of intracranial hemorrhage. 2. focal hypodensity involving the left caudate head. the chronicity of this finding is indeterminate, due to lack of previous exams, and it likely represents remote infarction or sequela of small vessel ischemic disease. ct spine : no evidence of acute fracture or malalignment. extensive degenerative disc disease of the cervical spine, most pronounced at c5-c6 and c6-c7. in the setting of high clinical suspicion for ligamentous or cord injury, mr may be considered for further assessment. abdominal xray : 1. distal end of nasogastric tube is seen within the stomach. a minimal amount of gas is seen within non-distended bowel with no evidence of bowel obstruction. no large amount of free area is seen, although detection is limited on a supine film. calcification of the right upper quadrant likely represents a gallstone. degenerative changes in the lower lumbar spine. bilateral hip replacements. followup imaging should be considered given the limited evaluation on this study. cxr : right ij catheter tip is in the upper right atrium. et tube tip is in standard position, 3.8 cm above the carina. ng tube tip is out of view below the diaphragm. there are low lung volumes. there is no evident pneumothorax. there is moderate cardiomegaly. widened mediastinum is unchanged from one hour earlier. diffuse opacity is in the left hemithorax suggests the presence of layering pleural effusion. left lung opacities could be atelectasis, contusion and/or aspiration. brief hospital course: hospital course: 78 yo female with h/o cad, cva, chronic renal insufficiency presents with cardiac arrest at osh, transferred here for concern of stemi, who underwent therapeutic hypothermia complicated by ischemic lle, dic, gi bleeding, and shock. patient was intubated on transfer and was cooled per protocol. given the patient's very poor prognosis and in accordance with family's wishes, care was withdrawn and the patient passed away. . # post cardiac arrest: pt was pulseless at osh with vt, vfib, and pea and underwent acls with multiple rounds of cardioversion/defibrillation and multiple rounds of epi before recovery of pulse. pt was in a pulseless rhythm for at least 10 minutes. vt was treated with lidocaine and amiodraone. the pt was transferred here for concern of stemi post resuscitation. she was initated on cooling protocol approximately 8 hours after being found pulseless. her course was complicated by cold and pulseless left lower extremity, gi bleed, multiorgan failure, lactic acidosis, and dic. the family understood the grave prognosis of the patient. in the setting of continued hypotension with max dose phenylephrine, multiorgan failure, and bleeding despite rewarming and cryoprecipitate, care was withdrawn per family wishes. . # shock/shock liver/acute renal failure: most likely mix between distributive and cardiogenic as suggested by wide pulse pressure despite alpha agonist therapy and elevated cvp (cardiogenic) with ef 25% on echo. phenylephrine chosen due to it being less likely to reintroduce vt. pt had clear evidence of end organ damage including shock liver, severe metabolic acidosis with elevated lactate to 13, no urine output, cold ischemic left leg. pt was given intermittent fluid boluses, prbc, ffp, cryoprecipitate, bicarbonate, hyperventilated, and started on vanc and zosyn to attempt to restore intravascular volume, treat the bleeding, and remedy the acidosis without avail. given grave prognosis, the family decided to not escalate care. . # ventricular tachycardia: most likely a result of scar causing monomorphic vt. resolved with lidocaine and amiodarone drip. these were discontinued on arrival to the floor without recurrence of vt. . #. dic: during the evening, pt began oozing at iv sites had brb per ng tube and brbpr. the patient was found to be in dic. plt dropped from 167->64, inr rose from 1.1 to 3.3, fdp rose to above 1280, and fibrinogen dropped from 232->105. the patient was rewarmed and heparin was stopped. the patient was given 1 unit of prbcs and 2 units of cryo and 2 units of ffp with some reversal of labs. . # gi bleed: pt with 400cc of brb via ngt, cleared slowly on lavage, hct stable. rectal exam demonstrated brbpr. the patient was started on iv pantoprazole. most likely this was ischemia reperfusion injury and dic. gi was consulted and agreed that endoscopy would not be of assistance in this case. . # coronary artery disease/? stemi: pt with inferior st elevations with reciprocal depressions on osh ecg that resolved. unclear if this was true event vs related to shock vs transient ischemic event that resolved. given unclear neurologic prognosis due to prolonged resuscitation efforts, she did not go to the cardiac catheterization lab. trop elevation non specific in setting of shock and arrest . # ischemic right leg: on arrival to the floor, left leg with non dopplerable dp/pt/popliteal pulse, cold, with mottling from lower extremity to all the way up the thigh. most likely ischemic from arrest and shock in setting of bad pvd. vascular surgery was consutled. patient was started on heparin gtt, which was stopped after development of dic. . # s/p mva: patient was in slow-moving car accident. there was no evidence of acute fractures/injuries on radiographic imaging. . # leukocytosis: patient with wbc count 15k which escalated to . most likely from stress induced post arrest but cannot rule out infection. potential etiologies included pneumonia (chest x-ray with left-sided infiltrate), uti, gastroenteritis (given h/o vomiting). pt pan cultured and started on vanc and zosyn . # diabetes mellitus: pt's blood sugars were very high >400s in setting of cooling and stress. pt was placed in insulin drip. . medications on admission: 1) lasix 20mg po bid 2) metoprolol 50mg po bid 3) quinipril 10mg po daily 4) levothyroxine 125mcg po daily 5) allopurinol 300mg po daily 6) vitamin d 1 tab po daily 7) multivitamin 1 tab po daily 8) aspirin 81mg po daily 9) protonix 20mg po bid 10) simvastatin 40mg po daily 11) aldactone 25mg po daily 12) plavix stopped last month 13) imdur 30mg po daily discharge disposition: expired discharge diagnosis: cardiopulmonary arrest dic ischemic hepatitis acute renal failure cardiogenic shock distributive shock ischemic left leg lactic acidosis discharge condition: n/a discharge instructions: n/a followup instructions: n/a Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Arterial catheterization Central venous catheter placement with guidance Diagnoses: Acidosis Esophageal reflux Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute and subacute necrosis of liver Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Chronic kidney disease, unspecified Paroxysmal ventricular tachycardia Other and unspecified hyperlipidemia Defibrination syndrome Cardiogenic shock Old myocardial infarction Ventricular fibrillation Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Acute vascular insufficiency of intestine Arterial embolism and thrombosis of lower extremity Leukocytosis, unspecified Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh Personal history of sudden cardiac arrest

allergies: heparin agents attending: chief complaint: fevers, fatigue major surgical or invasive procedure: left and right heart catheterization, coronary angiogram multiple dental extractions placement of intra aortic balloon mitral valve replacement, maze,ligation of left atrial appendage history of present illness: this 78 year old white male has had essentially no medical for 20 plus years. he was told in the early summer he had dental abscesses but declined intervention then. he recalls fever at the time, despite a 10 day course of antibiotics. he eventually underwent dental surgery and received another 10 day course of antibiotics. he now presented to with fever and malaise and a murmur was appreciated. an echocardiogram was concerning for mitral vegetation and after being cultured was begun on vancomycin and unasyn. he was then transferred for further evaluation. echcardiography and cardiac catheterization were performed and a flail posterior mitral leaflet was seen. denatal extarctions were performed after an intra aortic balloon was placed for stabilization. infectious disease was consulted as well. . past medical history: dental abscess social history: lives alone in , family he performs all adls independently. works as a chaplain in a prison. smoked for approx 30 years, quit 35 years ago. remote h/o occasional etoh, none for the past 30 years. family history: no h/o premature coronary disease or stroke. father and mother both had heart disease, unsure what type. sister passed away from heart disease at 73. physical exam: admission exam general: pleasant, frail-appearing elderly man in nad. oriented x3. heent: ncat. mm dry. sclera anicteric. perrl, eomi. poor dentition. neck: jugular veins distended, jvp above earlobe. cardiac: irregularly irregular, normal s1, s2. harsh iv/vi holosystolic murmur heard best at lls border. +rv heave, +palpable thrill. lungs: pectus excavatum. no accessory muscle use. bibasilar crackles, r>l. diffuse rhonchi. abdomen: soft, ntnd. +bs. no abdominial bruits. extremities: cool. no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ . discharge exam pertinent results: tte (): dilated atria. mild symmetric left ventricular hypertrophy with normal cavity size and preserved global and regional systolic function. probable flail posterior mitral leaflet with at least moderate to severe mitral regurgitation. severe tricuspid regurgitation in the presence of a possible septal leaflet vegetation. at least moderate pulmonary artery systolic hypertension (ivc not visualized). tee ():flail posterior mitral valve with severe mitral regurgitation. no vegetation, mass, or thrombus seen. ruq ultrasound (): 1. extremely dilated hepatic veins and ivc, and pulsatile pv flow, findings suggestive of right heart failure, tricuspid insufficieny and congestive hepatopathy secondary to cardiac dysfunction. 2. no definite hepatic mass or abscess. 3. large right pleural effusion. 4. limited examination of the pancreas, biliary tree, and gallbladder. cardiac cath (): 1. selective coronary angiography of this right dominant system demonstrated no angiographically apparant coronary artery disease. 2. resting hemodynamics demonstrated significantly elevated right and left sided filling pressures, with a mean ra pressure of 22 mmhg, a rvedp of 22 mmhg, a mean pa prssure of 39 mmhg, and a mean pcwp of 22 mmhg. 3. the cardiac output/index were severely reduced to 1.9/1.0 4. svr and pvr were elevated 5. an iabp was inserted in the right femoral artery 6. a 8 french venous sheath was sutured in place. brief hospital course: following admission the infectious disease service was consulted. several tees failed to reveal mitral vegetations, but did demonstaret a flail posterior leaflet. antibiotics were continued. no coronary disease was found at catheterization and an intra aortic balloon was placed to stabilize hemodynamics and unload the ventricle. beta blockade was utilized to reduce his rapid ventricular rate in atrial fibrillation. multiple dental extaractions were completed as he was prepared for cardiac surgery. on he went to the operating room where valve replacement, maze and ligation of the left atrial appendage was performed. the tricuspid regurgitation was reduced to trace after mitral replacement. the balloon was retained and the right heart was severely impaired at the end of surgery, requiring milrinone, epinephrine and neo synephrine to wean from bypass. tissue culteres and ribosomal pcr samples were sent intraoperatively. vasopressin was added on the night of surgery. his iabp was removed on pod2 followed by worsening heart function- his pressor support was escalated and the intraortic balloon pump was reinserted. he stabalized mom but then developed a lactic acidosis and elevated liver function tests. he was seen by general surgery and brought to the operating room for an exploratory laparotomy and cholecysectomy. post-operatively he had acute renal failure requiring continuous venovenous hemodialysis. he also developed bilataterally cold lower extremity limbs and the iabp was removed. eventually, his toes became necrotic. he ultimately was found to have developed heparin antibodies and all heparin containing meds/catheters were stopped and he was started on argatroban. he continued to have an escalating pressor need and was hypothermic. blood cultures ultimately grew out albicans- he was started on antifungals at that time. a long discussion was carried out with family. given the fact that his prognosis was poor, and that his quality of life would be what the patient desired, even if he was to recover from the sepsis, the family decided to make this patient comfort measures only. his pressors were stopped and he expired shortly thereafter. he was pronounced at 15:40. medications on admission: started at : metoprolol tartrate 25mg po bid vancomycin 1000mg iv q18hours lovenox 60mg sc q12 hours furosemide 20mg iv daily levothyroxine 25mcg (unknown frequency) mgoh 10ml daily:prn constipation no meds at home discharge medications: expired discharge disposition: expired discharge diagnosis: heparin induced thrombocytyopenia mitral valve endocarditis mitral regurgitation tricuspid regurgitation atrial fibrillation acute renal failure hypothyroidism dental caries s/p mitral valve replacement,maze,ligation left atrial appendage s/p placement of intra aortic balloon s/p dental extractions s/p exploratory laparotomy and cholecystectomy fungal sepsis discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Hemodialysis Excision or destruction of other lesion or tissue of heart, open approach Cholecystectomy Closed [endoscopic] biopsy of bronchus Implant of pulsation balloon Implant of pulsation balloon Open and other replacement of mitral valve with tissue graft Extraction of other tooth Other surgical extraction of tooth Operations on chordae tendineae Diagnoses: Acidosis Hyperpotassemia Mitral valve disorders Acute kidney failure with lesion of tubular necrosis Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Acute posthemorrhagic anemia Acquired coagulation factor deficiency Unspecified acquired hypothyroidism Atrial fibrillation Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Loss of weight Cardiogenic shock Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Paralytic ileus Disseminated candidiasis Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Other ascites Ventilator associated pneumonia Examination of participant in clinical trial Dental caries, unspecified Gangrene Oliguria and anuria Heparin-induced thrombocytopenia (HIT) Tricuspid valve disorders, specified as nonrheumatic Chronic passive congestion of liver Rupture of chordae tendineae Hypothermia not associated with low environmental temperature Pectus excavatum

allergies: no known allergies / adverse drug reactions attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp with common bile duct stone removal and sphincterotomy history of present illness: mrs. is an 83 year-old female with unknown past medical who comes with abdominal pain. she was in her prior state of health, until earier today when a neighbor found her with abdominal pain and brought her to emergency room. she had some nausea and vomiting and altered mental status. in the ed she had stable vs (per report) and labs significant for wbc 5, hct 13, plt 237, inr 1.1, ast 483, alt 349, tb 6.8, bun 15, cr 0.9, na 137, k 4, cl 100, co2 25, trop t <0.01, negative ua. she underwent a ruq us, which showed biliary duct dilation. she was admitted to the surgery team and received iv unasyn and gentamycin. she was stable and transfered to for ercp. past medical history: unknown. social history: she lives by herself with a friend checking on her in ri. she has history of smoking, but denies any current smoking. denies any alcohol or illegal substance use. normally independent with adls. family history: non-contributory. physical exam: vs: t: 96.5, bp: 125/61, hr: 83, rr: 16, spo2: 98%ra general: well-appearing woman in nad, comfortable, appropriate heent: nc/at, perrl, eomi, sclerae anicteric, mmm, op clear, poor dentition neck: supple, no thyromegaly, no jvd, no carotid bruits lungs: ctab, no wheezes, rales or rhonchi, good air movement, resp unlabored, no accessory muscle use heart: rrr, no mrg, nl s1, s2 abdomen: soft/nt/nd, +bs, no masses or hsm, no rebound/guarding. extremities: wwp, no c/c/e, 2+ peripheral pulses (radials, dps), l hallux with ingrown toenail s/p trimming by podiatry, resolved erythema skin: no rashes or lesions lymph: no cervical or supraclavicular lad neuro: awake, a&ox1 (person), cns ii-xii grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, dtrs 2+ and symmetric, gait not evaluated pertinent results: admission labs -------------- 03:08am blood wbc-7.5 rbc-3.68* hgb-12.0 hct-35.4* mcv-96 mch-32.6* mchc-33.8 rdw-13.4 plt ct-261 03:08am blood neuts-77.6* lymphs-13.9* monos-7.6 eos-0.4 baso-0.5 03:08am blood pt-13.6* ptt-26.2 inr(pt)-1.2* 03:08am blood alt-369* ast-379* alkphos-126* amylase-174* totbili-2.3* 03:08am blood lipase-349* 03:08am blood albumin-3.7 calcium-8.9 phos-2.6* mg-2.1 imaging ------- ercp impression: - severe iv esophagitis and moderate stricture was noted at the gej. - the duodenoscope was not able to traverse the lesion. - a gastroscope was used to balloon dilate the gej stricture to 12mm, 13.5mm and 15mm with positive heme noted. - the duodenoscope was then able to traverse the stricture with minimal resistance. - no mass was noted at cardia/gej. - normal major papilla - cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique - a moderate diffuse dilation was seen at the biliary tree with the cbd measuring 14 mm. - an approximately 5mm filling defect suggestive of a stone was noted in the distal cbd. - an approximately 3-4mm stone was noted in the cystic duct. - gallbladder was not visualized. - a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. - a balloon sphincteroplasty was performed to 10mm successfully to extend the sphincterotomy. - the 5mm stone and some sludge was extracted with a balloon catheter. - excellent drainage of bile and contrast was noted chest x-ray (portable ap): heart size is top normal. mediastinal contours are grossly unremarkable. questionable left hilar enlargement is present that might be further evaluated with bilateral ap shallow obliques to exclude the possibility of left hilar mass. lungs are essentially clear. there is no pleural effusion or pneumothorax. microbiology ------------ urine culture (final ): escherichia coli. 10,000-100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s blood culture : no growth blood culture : no growth mrsa screen (final ): no mrsa isolated. rapid plasma reagin test (final ): nonreactive. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. brief hospital course: # gallstone pancreatitis: patient had an unremarkable exam, with 2 criteria giving a 1% mortality. it is unclear if she has had episodes of pancreatitis before. she was given morphine for pain control and liberal iv fluids. she was made npo, and taken for ercp soon after admission, upon which a 3-4 mm common bile duct stone was noted. her lfts and amylase elevation resolved. her diet was advanced steadily and she was tolerating a soft mechanical diet on discharge. # cholangitis: patient had dilated common bile duct on ultrasound, and ruq pain, with labs suggestive of biliary obstruction. had choledocholithiasis on ercp. she was afebrile and with stable vital signs, but was placed on ampicillin/sulbactam for presumptive cholangitis for planned 7-day course. however, on work-up of her delirium she was found to have a uti that had intermediate resistance to unasyn, so her antibiotics were changed to ceftriaxone and metronidazole and later cefpodoxime and metronidazole. she received a total of 10 days of antibiotics. # toxic-metabolic encephalopathy: patient was noted to have hyperactive delirium following her ercp, most likely in the setting of infection. she was treated with ampicillin/sulbactam for presumed cholangitis. she was given intravenous fluids for hydration, re-oriented frequently, and sensory environment was optimized. patient required intermittent doses of haloperidol for agitation. she continued to have delirium and was transferred to the medicine service for further management. work up was positive for uti, constipation and vitamin b12 deficiency. she was treated for all 3, but her symptoms did not improve. initially she was not responsive to zyprexa during periods of agitation, so seroquel and trazadone were started qhs. she had two episodes of unresponsiveness after the first night (details described below), so these medications were discontinued. her mental status continued to wax and wane during admission, however, patient became more calm and less hyperactive overall and was not on any psychoactive medications at discharge. it is unclear what her baseline was prior to admission, however, it is likely that she had baseline dementia given her current mental status. # unresponsiveness: patient had an episode of unresponsiveness on . she was doing well early during pre-rounds and then around 10:30am she became more somnolent and was not responsive to sternal rub; only responded to nail bed pressure. fsbg was 121, ekg was unchanged, o2 sat was 97-99% on room air. she was sensitive to movements and retracted when her legs were flexed. she developed some rhythmic movements of her lower extremities. there was no bowel or bladder incontinence. it was thought that maybe this was a delayed reaction to the seroquel 12.5mg and trazadone 25mg po that she had received the previous night. there was also concern for a seizure. she recovered from this episode after 1.5 hours and then was back in her baseline delirious state. this occurred again later that afternoon. stat eeg was ordered and neurology was consulted. after the second event, there was increased concern for siezure, however, eeg did not reveal seizure activity and neurology did not think that this was consistent with seizure. all psychotropic medications were discontinued. these episodes did not recur. # urinary tract infection: patient was found to have a urinary tract infection, which likely contributed to her delirium. she was treated with a 7-day course of cefpodoxime. # ingrown toenail: patient had ingrown left hallux that was trimmed by podiatry. no evidence of infection. # guardianship: during this admission, patient's granddaughter, , was named her temporary guardian. # dvt prophylaxis: patient received heparin products during this admission. # code status: full code. this was discussed with her granddaughter. medications on admission: none. discharge medications: 1. b-12 dots 500 mcg tablet : two (2) tablet po once a day. 2. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 3. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 4. acetaminophen 325 mg tablet : two (2) tablet po every four (4) hours as needed for fever or pain. 5. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet : two (2) tablet po bid (2 times a day) as needed for constipation. 7. polyethylene glycol 3350 17 gram/dose powder : one (1) dose po daily (daily) as needed for constipation. discharge disposition: extended care facility: at discharge diagnosis: primary diagnoses: # choledocholithiasis # cholangitis # gallstone pancreatitis # urinary tract infection # acute toxic metabolic encephalopathy secondary diagnosis: # dementia discharge condition: mental status: confused - always. 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 abdominal pain and found to have a stone obstructing your common bile duct. you had a procedure known as an ercp and the stone was removed. you will likely need to have surgery to remove your gallbladder. # you were also found to have a urinary tract infection, which was treated with a 7-day course of cefpodoxime. # you had an ingrown toenail (left, 1st toe) that was trimmed by podiatry. you should see a podiatrist if you have recurrent pain. # we made the following changes to your medications: - started vitamin b12, thiamine & lansoprazole - started acetaminophen as needed for pain - started colace, senna & miralax as needed for constipation # it is important that you take all of your medications as prescribed and keep all of your follow up appointments. followup instructions: **please call dr. office (surgeon) to schedule an appointment in the next 7-10 days (tel: ).** Procedure: Other gastroscopy Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Dilation of esophagus Diagnoses: Urinary tract infection, site not specified Toxic encephalopathy Other persistent mental disorders due to conditions classified elsewhere Other B-complex deficiencies Constipation, unspecified Esophagitis, unspecified Antidepressants causing adverse effects in therapeutic use Cholangitis Acute pancreatitis Stricture and stenosis of esophagus Other alteration of consciousness Calculus of bile duct without mention of cholecystitis, with obstruction Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use Ingrowing nail

allergies: no known allergies / adverse drug reactions attending: chief complaint: seizures major surgical or invasive procedure: right internal carotid stent placement history of present illness: 68 female with a distant history of seizure disorder (on dilantin) who recently underwent a right at for questionable tias with left sided weakness. she was discharged from hospital on and was doing well untill the evening of . that evening she had a syncopal episode in the bathroom. in route to the hospital she had a 3 minute long seizure which resolved spontaenously. she had an additional seizure in the ed with dense left hemiparesis. she received ativan and dilantin for the seizures and was transferred to for further evaluation. on cta of neck, she was found to have focal moderate-to-severe narrowing of the distal right cca and ct/mri head did not demonstrate any obvious evidence of stroke. past medical history: seizure d/o (only had 2 grand mal seizures when 35 y/o; on dilantin) right ica stenosis hypertension rheumatoid arthritis migraines degenerative disc disease past surgical history: r l knee arthroscopic surgery x 2 plate and screws in r ankle social history: lives with her husband, retired nurse, does not smoke, drink etoh, no ivdu. family history: father and brother who have both had strokes and father had (? side) and brother had b/l physical exam: t: 98.4 hr: 83 bp: 134/50 rr: 14 spo2: 97% gen: alert and oriented x 3 neuro: cn ii-xii, no focal deficits cardiac: rrr, no mrg, + s1, s2 lungs: cta bilaterally, no resp distess abd: soft, nt. nd wound: right groin cdi, no hematoma or bleed pedal pulses palpable pertinent results: 08:40am blood wbc-12.4* rbc-3.24* hgb-10.4* hct-31.2* mcv-96 mch-32.0 mchc-33.2 rdw-13.5 plt ct-428 03:51am blood wbc-12.5* rbc-3.10* hgb-10.0* hct-29.3* mcv-95 mch-32.3* mchc-34.1 rdw-13.5 plt ct-411 03:45pm blood hct-26.9* 10:56am blood hct-25.0* 04:15am blood wbc-12.0* rbc-2.73* hgb-9.1* hct-25.9* mcv-95 mch-33.3* mchc-35.2* rdw-13.3 plt ct-355 08:40am blood plt ct-428 03:51am blood glucose-132* urean-5* creat-0.5 na-140 k-4.3 cl-102 hco3-31 angap-11 03:45pm blood na-136 k-4.1 cl-103 04:15am blood glucose-140* urean-5* creat-0.5 na-140 k-3.5 cl-102 hco3-31 angap-11 04:15am blood ck(cpk)-32 11:00pm blood ck(cpk)-23* 08:30am blood ck(cpk)-20* 09:30am blood calcium-9.2 phos-3.7 mg-1.8 03:51am blood calcium-9.2 phos-4.6* mg-1.9 02:30am blood phenyto-7.4* 09:23am blood phenyto-9.3* 11:00pm blood phenyto-11.3 chest xray findings: as compared to the previous radiograph, there is improved ventilation of both lungs. a minimal area of atelectasis at the right lung base has improved. the size of the cardiac silhouette is borderline, but there is no pulmonary edema. no pleural effusions. no pneumothorax. no evidence of pneumonia. brief hospital course: on the patient was transferred from for seizures after recent . she was alert and oriented x3 on exam. on heparin and nicardipine drip. a-line placed on admission and the patient was deemed icu level. an mri was ordered and dilantin level was checked. surgery was consulted for ica stenosis and possible intervention. the patient was placed on seizure precautions. blood pressure managed on labetalol and nicardipine drip. speech and swallow evaluation initiated. remained in the sicu for blood pressure management and seizure precautions. monitored in icu. continued on heparin drip. patient passed swallow evaluation. carotid duplex was obtained which showed significant stenosis of right cca and proximal ica. continued on aspirin and started on statin medication. neurological deficits resolving. the decision was made for the patient to undergo stent/angioplasty of previous . the patient was also enrolled in the sapphire trial. underwent right carotid stent without complications. bedrest overnight. npo. plavix for 30 days. frequent neurological checks in step down. required additional oral blood pressure agents for management of hypertension. neuro continued to follow and recommended weaning dilantin and treating the patient with keppra. stable and transferred to step down unit. continued on blood pressure agents and dilantin was continued to be weaned. started on ancef for right upper extremity thrombophlebitis. neurologically continues to do well. stable and cleared for home. will follow up with dr. and dr. as an outpatient. she was discharged on a course of keflex for r upper arm thrombophebitis on dc. medications on admission: abatacept ? dose/freq hydrochlorothiazide - 12.5 mg capsule daily methotrexate sodium ?dose phenytoin sodium extended - 300 mg daily prednisone ? dose propranolol - 120 mg capsule,extended release ramipril - 10 mg capsule aspirin - 81 mg tablet daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day): call pcp for refills , phone: fax: . disp:*180 tablet(s)* refills:*2* 3. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily): call pcp for refills phone: fax: . disp:*60 tablet(s)* refills:*2* 4. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): 30 days poststent. disp:*30 tablet(s)* refills:*0* 6. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for thrombophlebitis. 7. keflex 500 mg capsule sig: one (1) capsule po twice a day for 10 days. disp:*20 capsule(s)* refills:*0* 8. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 11. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po daily (daily): 5 days only then stop. disp:*5 capsule(s)* refills:*0* 12. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily): call pcp for refills. disp:*30 capsule(s)* refills:*2* 13. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 14. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 15. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). 16. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily): call pcp for refills. disp:*60 tablet(s)* refills:*2* 17. ramipril 5 mg capsule sig: two (2) capsule po bid (2 times a day). discharge disposition: home discharge diagnosis: 1. ultrasound-guided puncture of left common femoral vein. 2. ultrasound-guided puncture of right common femoral artery. 3. selective catheterization of the right carotid artery. 4. selective arteriogram of the right carotid artery. 5. primary stenting of the right carotid artery. 6. perclose closure of right common femoral arteriotomy. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. 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 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 ?????? you should not have an mri scan within the first 4 weeks after carotid stenting ?????? call and schedule an appointment to be seen in weeks for post procedure check and ultrasound 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 office. if bleeding does not stop, call 911 for transfer to closest emergency room. followup instructions: provider: , md phone: date/time: 9:00 provider: lab phone: date/time: 8:30 you should follow up with our neurology team in months. please call ( to make a follow up appointment with dr. Procedure: Arterial catheterization Percutaneous angioplasty of extracranial vessel(s) Percutaneous insertion of carotid artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Rheumatoid arthritis Examination of participant in clinical trial Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Phlebitis and thrombophlebitis of upper extremities, unspecified Hemiplegia, unspecified, affecting unspecified side Iatrogenic cerebrovascular infarction or hemorrhage Occlusion and stenosis of carotid artery with cerebral infarction Facial weakness Generalized convulsive epilepsy, without mention of intractable epilepsy Homonymous bilateral field defects

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: back pain with paraplegia major surgical or invasive procedure: fusion laminectomy t2-t10 l thoracotomy and l 5th rib excision, anterior fusion of t6-t8 peg and trach history of present illness: 28m s/p fall from unknown height on . circumstances surrounding fall unclear at this time; pt states he slipped on leaves and fell while walking, however extent of injuries suggest more severe mechanism. taken by ems to hospital where thoracic spinal fractures were identified on plain film, and patient was noted to have paresis of b/l les and parasthesias to the level of the xyphoid. medflighted to where ct scans confirmed t5/t6 burst fx w/bone fragmants in spinal canal. past medical history: anxiety, panic attacks jaw surgery after traumatic injury / assault; l arm surgery after traumatic injury / assault social history: lives in , works with his father. denies drug or alcohol use, smokes cigarettes. not married. unclear if finished high school/college. only child. family history: adopted physical exam: gen: nad. oriented x3. heent: ncat. sclera anicteric. perrl, eomi. op clear, no exudates or ulceration. neck: supple, jvp not elevated, neck veins pulsatile. cv: tachycardia, regular, normal s1, s2. no murmur. chest: on anterior exam, ctab. abd: soft. neuro: alert and oriented x 3. motor: bilateral upper extremitis, 0/5 bilateral lower extremities, sensation diminished throughout lower legs pertinent results: 02:30am blood wbc-7.1 rbc-3.40* hgb-9.7* hct-30.0* mcv-88 mch-28.5 mchc-32.3 rdw-15.0 plt ct-622* 02:21am blood wbc-7.4 rbc-3.12* hgb-8.7* hct-27.4* mcv-88 mch-28.0 mchc-31.9 rdw-14.6 plt ct-602* 01:25am blood wbc-10.5 rbc-2.85* hgb-8.2* hct-25.1* mcv-88 mch-28.8 mchc-32.7 rdw-14.5 plt ct-530* 12:22am blood wbc-9.1 rbc-2.89* hgb-8.3* hct-24.4* mcv-85 mch-28.9 mchc-34.2 rdw-13.4 plt ct-489* 12:24am blood wbc-17.6* rbc-3.11* hgb-9.2* hct-27.4* mcv-88 mch-29.7 mchc-33.7 rdw-14.4 plt ct-419 02:05am blood wbc-12.9* rbc-2.63* hgb-7.7* hct-22.8* mcv-87 mch-29.4 mchc-33.8 rdw-14.3 plt ct-305 11:00am blood wbc-11.8* rbc-2.96* hgb-8.9* hct-25.9* mcv-88 mch-30.0 mchc-34.3 rdw-14.5 plt ct-267 05:30pm blood wbc-16.0* rbc-4.39* hgb-12.8* hct-36.5* mcv-83 mch-29.2 mchc-35.1* rdw-13.3 plt ct-283 12:22am blood neuts-75.3* lymphs-13.7* monos-7.6 eos-3.1 baso-0.4 07:10am blood neuts-85.0* lymphs-9.6* monos-4.8 eos-0.6 baso-0 02:30am blood plt ct-622* 02:02am blood pt-19.6* ptt-76.4* inr(pt)-1.8* 09:12am blood pt-21.6* ptt-79.9* inr(pt)-2.0* 01:16am blood pt-15.5* ptt-58.8* inr(pt)-1.4* 12:24am blood pt-13.1 ptt-38.7* inr(pt)-1.1 08:45am blood pt-13.0 ptt-25.6 inr(pt)-1.1 02:30am blood glucose-93 urean-19 creat-0.7 na-141 k-4.1 cl-104 hco3-29 angap-12 02:51am blood glucose-103 urean-14 creat-0.7 na-139 k-3.9 cl-104 hco3-27 angap-12 12:22am blood glucose-105 urean-10 creat-0.8 na-138 k-3.8 cl-99 hco3-33* angap-10 02:05am blood glucose-120* urean-8 creat-0.7 na-140 k-3.8 cl-105 hco3-29 angap-10 07:10am blood glucose-97 urean-11 creat-0.8 na-138 k-3.7 cl-103 hco3-29 angap-10 10:56pm blood glucose-141* urean-11 creat-0.9 na-140 k-4.1 cl-108 hco3-23 angap-13 02:30am blood calcium-9.0 phos-4.3 mg-2.1 02:21am blood calcium-8.8 phos-2.8 mg-2.1 01:25am blood calcium-8.6 phos-4.2 mg-2.2 02:00am blood calcium-8.0* phos-3.1 mg-2.2 02:29am blood calcium-7.8* phos-2.7 mg-2.0 01:31pm blood tsh-1.6 07:12am blood vanco-22.7* 12:24am blood vanco-9.1* brief hospital course: initially evaluated in ew for - admitted postop following t2-t10 spinal fusion. no events overnight. - tx back to tsicu for desats to 70%s, tachypnea/tachycardia. o2 sats 98% with 100% face mask. tansitioned to nc during day. ketamine weaned. basal rate added to dilauded pca. patient persistantly with st@120-140, even sleeping. sbp 95-105 and map 58-65, but making good uop, 100-300/hour. repeat cxr showed no worsening ptx. spiked temp 103.4 in am. pan-cx and given tylenol. - sats in low 80's throughout am, failed to improve w/nrb mask. lenis neg for dvt. cta chest: b/l ptx, small pes in rul and lingula, collapsed lll, small areas of lul and rll consolidation. due to worsening respiratory status &o2, intubated. thoracic surgery called and ct placed on r, & l ct (pre-existing) placed to ws. bedside bronch w/copious secretions and bal sent. pt then started on abx for pna with vanc/zosyn/cipro. ivc filter placement in or. pt restarted on hep bolus -> gtt for pe (ptt goal 50-70). ogt placed & started on tube feeds. - 1 prbc given, l scv line placed, ct on ws w/incr ptx, back on sxn, bronch showing lll pna - extubated, small tv, no cough, requiring nt sxn - stable, ct to sxn - ct to ws, ptx worsened but thoracics felt ok, can remain on ws. ativan d/c, patient on haldol prn. seen by pt. started diet. ptt therapeutic. - ct back to sxn. during turning, pt dropped sats to 80's with no improvement with nrb. abg shows poor ventilation, cpap started with improvement of sats in high 90's/100. repeat abg shows hypercarbia worsening acidosis, pt then intubated. - bronch with cont thick secretions, decision to cont abx for vap. ok w/starting coumadin when ready. - coumadin started (5 mg), diamox x 4 doses. abg improved. psych recs minimizing benzos. - in am: inc fi02 o/n with pa o2 on abg, followed by worsened resp acidosis. sedated and incr rate. in pm, hypoxia resolved, fio2 weaned. r ct clamped and pulled, cxr unchanged r ptx. spiked temp 101.3, pancx. coumadin 5mg, haldol encouraged>bz per psych. sig abdl distention in am, ngt pulled back, air sxned from stomach. tf restarted w/high residuals (250cc) -> repeat cxr showed return of large gastric bubble. ngt to low sxn, tf held, ivf started. pt self-extubated at 2100, anesthesia stat-->re-intubated and sedation incr. left ct d/c. s/p tracheostomy. dobhoff placed. hep gtt restarted. 5 mg coumadin in pm. able to internally rotate ble : 5 mg coumadin. d/c'd haldol after bit rn w/1st dose 12/8-9. started zyprexa prn. : mycolytic bcx. abx d/c'd. tried to wean from vent for trach collar, but periodic desat's w/mvmt to chair & decreasing peep (tolerated ). rehab screen. : tolerated trach mask overnight. inr 1.8, ptt 76.4 so heparin held for 1 hour, re-started at lower rate. : lovenox started, hep gtt d/c, tolerated tm. : s&s - using pmv and passed for soft solids/nectar thick liquid diet. : coumadin continued; lovenox discontinued medications on admission: ativan prn, sertraline 50', venlaxafine 100' discharge medications: 1. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 2. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever/pain. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 5. venlafaxine 100 mg tablet sig: one (1) tablet po daily (daily). 6. gabapentin 400 mg capsule sig: three (3) capsule po tid (3 times a day). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. alprazolam 1 mg tablet sig: one (1) tablet po hs (at bedtime). 9. warfarin 1 mg tablet sig: five (5) tablet po once daily at 4 pm: goal inr . 10. methadone 10 mg tablet sig: two (2) tablet po tid (3 times a day). 11. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day) as needed for constipation. 12. alprazolam 1 mg tablet sig: one (1) tablet po three times a day. 13. oxycodone 5 mg/5 ml solution sig: two (2) po q6h (every 6 hours) as needed for pain. discharge disposition: extended care facility: - discharge diagnosis: t5/6 burst fracture paraplegia ventilatory pneumonia post-op blood loss anemia discharge condition: stable discharge instructions: you have undergone the following operation: fusion laminectomy t2-t10, l thoracotomy and l 5th rib excision, anterior fusion of t6-t8 immediately after the operation: -activity: you should not lift anything greater than 10 lbs for 2 weeks. please continue to shift side to side to avoid pressure sores. -rehabilitation/ physical therapy: o2-3 times a day you should participate in physical therapy. -diet: eat a normal healthy diet. you may have some constipation after surgery. you have been given medication to help with this issue. -brace: you have been given a brace. this brace is to be worn while in physical therapy. -wound care: remove the dressing in 2 days. if the incision is draining cover it with a new sterile dressing. if it is dry then you can leave the incision open to the air. once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. do not soak the incision in a bath or pool. if the incision starts draining at anytime after surgery, do not get the incision wet. cover it with a sterile dressing. call the office. -you should resume taking your normal home medications. no nsaids. -you have also been given additional medications to control your pain. please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. you can either have them mailed to your home or pick them up at the clinic located on 2. we are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. in addition, we are only allowed to write for pain medications for 90 days from the date of surgery. please call the office if you have a fever>101.5 degrees fahrenheit and/or drainage from your wound. physical therapy: activity: out of bed with assist. treatments frequency: please continue to change the dressings daily until dry. followup instructions: please follow up with dr. in his clinic in 10 days. call for an appointment. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Interruption of the vena cava Fiber-optic bronchoscopy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Incision of chest wall Dorsal and dorsolumbar fusion of the anterior column, anterior technique Other excision of joint, other specified sites Bronchoscopy through artificial stoma Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Repair of vertebral fracture Angiocardiography of venae cavae Insertion of interbody spinal fusion device Fusion or refusion of 4-8 vertebrae Excision of bone for graft, unspecified site Diagnoses: Acidosis Acute posthemorrhagic anemia Unspecified fall Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Iatrogenic pulmonary embolism and infarction Ventilator associated pneumonia Dependence on respirator, status Closed fracture of T1-T6 level with unspecified spinal cord injury

allergies: no known allergies / adverse drug reactions attending: chief complaint: complex left cystic adnexal mass, bilateral cystic adnexal masses, and left colon cancer. major surgical or invasive procedure: laparoscopic left colectomy laparoscopic bilateral salpingo-oophorectomy history of present illness: a -year-old woman who presented with symptoms of obstruction who was found to have descending colon cancer as well as ovarian cyst. the risks and benefits including but not limited to infection, bleeding, leak, the need for more procedures, hernia, pneumonia, death and heart attack were discussed. the patient consented and agreed. past medical history: pmh: hypertension hyperlipidemia postural dizziness social history: patient lives alone independently, daughter lives in and son in . daughter-in-law lives close by and frequently visits the patient. she is very active and frequently does yard work on her own. physical exam: general: appears well, ambulating the floor independently, toelrating a regular diet, +flatus, appropriate amount of pain. vs: tmac: 99.0 tcurrent: 97.7 hr: 59 bp: 129/71 rr:16 sao2:98 ra' general: a&ox3 cardiac: rrr lungs: cta bil abdominal: soft, nontender, nondistended, no rebound/gaurding wound: cd&i, all laparoscopic sites covered with staples pertinent results: 05:30am blood wbc-12.4* rbc-2.97* hgb-9.5* hct-29.4* mcv-99* mch-32.1* mchc-32.5 rdw-14.6 plt ct-216 04:06am blood wbc-14.6*# rbc-2.86* hgb-9.3* hct-27.7* mcv-97 mch-32.5* mchc-33.5 rdw-14.5 plt ct-228 10:06pm blood hct-27.6* 09:25am blood wbc-9.2# rbc-3.38* hgb-11.2* hct-32.7* mcv-97 mch-33.1* mchc-34.1 rdw-14.3 plt ct-307 04:06am blood plt ct-228 09:25am blood plt ct-307 09:25am blood pt-12.4 ptt-22.9 inr(pt)-1.0 05:30am blood glucose-121* urean-9 creat-0.6 na-136 k-3.8 cl-103 hco3-25 angap-12 04:06am blood glucose-132* urean-11 creat-0.6 na-140 k-4.4 cl-107 hco3-23 angap-14 10:06pm blood na-140 k-3.3 cl-104 09:25am blood glucose-104* urean-12 creat-0.8 na-140 k-3.8 cl-102 hco3-30 angap-12 05:30am blood phos-2.5*# mg-2.1 04:06am blood calcium-7.7* phos-4.3 mg-2.2 10:06pm blood mg-2.2 09:25am blood albumin-3.7 calcium-9.4 phos-3.7# mg-2.7* brief hospital course: : yo f was admitted to the 0 s/p laparoscopic left colectomy and b/l salpingooothecectomy complicated by subcutaneous emphysema. subcutaneous emphysema thought to be likely secondary to intraoperative co2 insulfation . on transfer she had hypercarbic respiratory failure. her respiratory acidosis improved with change of ventilator settings and respiratory alkalosis was induced; vent settings were changed again to correct this. sedation was weaned overnight and patient was extubated in the morning. patient was made dnr/dni in discussion with her daughter. from now on will be determined by general surgery and gyn/oncology. the patient was extubated on post-operative day one. she was transferred to the inpatient floor after extubation. . pending on transfer: blood cultures the patient was transferred to the inpatient unit from the in stable condition. she progressed well without any acute event. she was started on a clear liquid diet which she tolerated well and her foley catheter was removed. she was able to void spontaneously. the subcutaneous emphysema from the operating room continued to steadily improve. the patient was cleared by physical therapy to be discharged home with services. the patient has a supportive family and this discharge plan was realistic. the patient continued to ambulate independently and on passed flatus and tolerated a regular diet. the patient was discharged home on post-operative day four in stable condition. medications on admission: nicardipine 20 daily enteric coated aspirin 325 daily valsartan 320 daily atorvastatin 10 daily metoprolol xl 50 daily mvi stool softener qid discharge medications: 1. toprol xl 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 2. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. nicardipine 20 mg capsule sig: one (1) capsule po once a day. 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: two (2) tablet po tid (3 times a day) for 7 days: do not take more than 4000mg of tylenol daily, do not drink alcohol while taking tylenol. disp:*42 tablet(s)* refills:*0* 7. oxycodone 5 mg tablet sig: 0.5 tablet po q4h (every 4 hours) as needed for pain for 5 days: please call the office if you feel the need to take this medication. do not drink alcohol or drive a car while taking this medciation. disp:*10 tablet(s)* refills:*0* 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 10. miralax 17 gram powder in packet sig: one (1) packet po every other day as needed for constipation: please take if constipated. disp:*30 * refills:*0* discharge disposition: home with service facility: , discharge diagnosis: complex left cystic adnexal mass, bilateral cystic adnexal masses, and left colon cancer. 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 after a left laparoscopic colectomy and bilateral salpingo-oophrectomy for surgical management of your adnexal masses and left colon cancer. you have recovered from this procedure well and you are now ready to return home. samples from your colon were taken and this tissue has been sent to the pathology department for analysis. you will receive these pathology results at your follow-up appointment. if there is an urgent need for the surgeon to contact you these results they will contact you before this time. you have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. you may return home to finish your recovery. please monitor your bowel function closely. you may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next 2-3 days. after anesthesia it is not uncommon for patient??????s to have some decrease in bowel function but your should not have prolonged constipation. some loose stool and passing of small amounts of dark, old appearing blood are explected however, if you notice that you are passing bright red blood with bowel movments or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. if you are taking narcotic pain medications there is a risk that you will have some constipation. please take an over the counter stool softener such as colace, and if the symptoms does not improve call the office. please follow the bowel regimen prescribed for you, you have been prescribed the medication miralax which is a powder that you may take every other day as needed for constipation. if you notice that you are developing loose stools you make take away one bowel medication at a time. if you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. you have laparoscopic surgical incisions on your abdomen which are closed with internal surtures and staples. these are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/gree/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. please call the office if you develop any of these symptoms or a fever. youmay go to the emergency room if your symptoms are severe. you may shower, pat the incisions dry with a towel do not rub. the small incisions may be left open to the air. your staples will be removed at your post-operative appointment with dr. . please no baths or swimming for 6 weeks after surgery unless told otherwise by dr. . you may continue to take tylenol for pain. please do not take more than 4000mg of tylenol , not drink alcohol while taking tylenol. you will be given a small amount of the medication oxycodone for pain, please take only as needed as you have not taken this medication in the hospital. you should take a half tablet only if needed. if you find thta you are having abdominal pain requiring you to use pain medications please call dr. office. do not drink a car or drink alcohol if taking narcotic pain medicaitons. no heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. please no strenuous activity until this time unless instructed otherwise by dr. or dr. . 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. for a short time you will have visiting nurses check on you at home. good luck! followup instructions: please call the colorectal surgery office at to make an appointment for your first post-operative check with dr. 3 weeks after your discharge from the hospital. please call and make an appointment with your primary care provider to have you staples removed in 7 days. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Laparoscopic removal of both ovaries and tubes at same operative episode Laparoscopic left hemicolectomy Diagnoses: Acidosis Pure hypercholesterolemia Unspecified essential hypertension Other specified intestinal obstruction Alkalosis Emphysema (subcutaneous) (surgical) resulting from procedure Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Dizziness and giddiness Benign neoplasm of ovary Malignant neoplasm of descending colon

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: c1 fracture after fall major surgical or invasive procedure: tracheostomy percutaneous endoscopic gastrostomy history of present illness: patient is a 70 yo male who fell one step, suffering an axial load of his c-spine leading to a bilateral lateral mass fracture and fracture of right posterior arch of his c1 vertebrae. he suffered no other injuried other than mild ecchymosis. past medical history: patient is a confirmed alcoholic. he has a history of prostate cancer. he has a history of hypertension. he is status post appendectomy. social history: alcoholic. lives with wife and family. family history: non contributory physical exam: aao x 3, nad neck is in cervical collar. tracheostomy in place, functioning on trach-mask. rrr no mrg cta b/l no rrw abdomen is soft, nt, nd, with a peg in place and without erythema or drainage. +1 edema bilaterally pertinent results: imaging: ct: collapsed lung b/l mid and lower lungs with sm bl pl eff. cxr: intubated, rll atelectasis has increased. right pleural effusion is increasing. ct c cpine osh: fracture of bilateral lateral masses of c1 and posterior arch of c1. ct head osh: neg cxr: no acute process c-spine: narrowing of pre-dens space unchanged. severe degenerative changes involving mid and lower cervical spine without compression deformities. cxr: improved. c-spine xray: the minimally displaced fracture involving the body of c1, no change in spinal canal. : high stir signal within the t2 vertebral body, may suggest an acute/subacute fracture. complex c1 fracture. extensive multilevel degenerative changes, most severe at the levels from c4 through c7 as detailed above, with moderate canal stenosis. cxr: consolidation rml ?loculated pleural fluid. l retrocardiac opacity. bl pl eff, left > right. brief hospital course: patient was admitted overnight for assessment of his cervical spine. the patient was alert and oriented and was planned to be discharged the following day with rehab services. overnight on hd 1 to hd 2, he became acutely tachypneic, and had respiratory stridor. he was emergentyl intubated via laryngeal mask airway intubation with a 6.5 size tracheal tube, after failing nasal airway intubation. he had a significant cuff leak post intubation and suffered from bilateral lower lobar collapse - for which he was cultured and began broad spectrum antibiotics. due to the need for continued respiratory ventilator requirement, he underwent a tracheostomy on hd 3, which was successful and uneventful, under direct bronchoscopy. furthermore, a percutaneous endoscopic gastrostomy was placed for nutrition as he was unable to tolerate feeding orally. he was chaged to nafcillin after cultures grew mssa. his neurologic status was slow to recover, and some proximal weakness was seen on physical exam, but an mri of his c-spine revealed no central cord injury, but moderate conal stenosis. over the next several days he cleared mentally, he was weaned from the ventilator appropriately, and he was cleared for discharge to a rehab facility on hd 14 / pod 10 and 7. medications on admission: lamotrigine 100'; aderral 10 mg ; folic acid; avadart 0.5mg'; metoprolol 100'; gabapentine 800 three tabs q hs; crestor 5 mg'; casodex 50mg'; naltrexone 50mg q am; lisinipril 10 mg '; toffrinil 100mgq hs; benztropine 1mg daily; discharge medications: 1. lamotrigine 100 mg tablet : one (1) tablet po daily (daily). 2. rosuvastatin 5 mg tablet : one (1) tablet po daily (daily). 3. bicalutamide 50 mg tablet : one (1) tablet po daily (daily). 4. benztropine 1 mg tablet : one (1) tablet po daily (daily). 5. imipramine hcl 25 mg tablet : four (4) tablet po hs (at bedtime). 6. cyanocobalamin 100 mcg tablet : 0.5 tablet po daily (daily). 7. folic acid 1 mg tablet : one (1) tablet po daily (daily). 8. lisinopril 20 mg tablet : two (2) tablet po daily (daily). 9. insulin regular human 100 unit/ml solution : one (1) injection asdir (as directed). 10. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 11. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 12. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 13. white petrolatum-mineral oil 42.5-56.8 % ointment : one (1) appl ophthalmic qid (4 times a day) as needed. 14. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 15. bisacodyl 10 mg suppository : suppositorys rectal hs (at bedtime) as needed for constipation. 16. metoprolol tartrate 25 mg tablet : one (1) tablet po tid (3 times a day). 18. acetaminophen 325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for fever/pain. 19. oxycodone-acetaminophen 5-325 mg/5 ml solution : 5-10 mls po q6h (every 6 hours) as needed for pain. 20. ipratropium bromide 17 mcg/actuation aerosol : two (2) puff inhalation q6h (every 6 hours) as needed. 21. albuterol 90 mcg/actuation aerosol : two (2) puff inhalation q6h (every 6 hours) as needed. discharge disposition: extended care facility: discharge diagnosis: c1 fracture discharge condition: stable discharge instructions: return to er if: - persistent temperature > 101.4 - severe abdominal pain, nausea or vomiting - difficulty breathing, chest pain or shortness of breath - bleeding or drainage from wounds - changes in mental status, consciousness or vision followup instructions: dr. - orthospine - - call for an appointment 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 Other bronchoscopy Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Other intubation of respiratory tract Temporary tracheostomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Unspecified essential hypertension Personal history of malignant neoplasm of prostate Pulmonary collapse Acute respiratory failure Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Accidental fall on or from other stairs or steps Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection Hypovolemia Ventilator associated pneumonia Other and unspecified alcohol dependence, unspecified Barrett's esophagus Closed fracture of first cervical vertebra Alcohol withdrawal Cervical spondylosis without myelopathy Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection

allergies: sulfa (sulfonamide antibiotics) / compazine / penicillins / cipro cystitis / zostrix / prednisone / bactrim attending: chief complaint: pancreatitis, ? ugib, abdominal pain, dka major surgical or invasive procedure: none history of present illness: 39 y/o female with history of chronic regional pain syndrome due to reflex sympathetic dystrophy, intractable migraines (followed at the management service), and pud who presents with report of retching and one day of blood in her vomit, after 4 days of nausea, vomiting, and diffuse abdominal pain. these symptoms have all super imposed on intractable migraine for several months. she also reports severe abdominal pain. . she reports being in her usoh until thursday, after visiting the zoo. she reports developing nausea and retching without emesis. she denies other sick contacts. she denies fevers and diarrhea. she started to develop abdominal pain on saturday, in the middle of her abdomen, which moved to the back. it was , sharp, crampy. outside of the nausea, there were no other associated symptoms. her pain was not positional. she reports that she has not been eating much since thursday, due to lack of appetite. today, she wonders if there was an episode of blood in her vomiting. she presented to the ed given lack of improvement. . in the ed, initial vs - 10, 96.5, 118, 147/115, 18, 97% ra. exam notable for severe abdominal pain. labs notable for wbc 28.7 with left shift, hct 50.5, plt 463, na 131, k 3.0, agma of 21, lipase 1415. ucg was negative. multiple peripheral attempts, including us and ej unsuccessful, and left ij was placed. ng lavage was clear, no blood or coffee grounds seen. ekg not performed. cxr without acute infiltrate. . patient was given four doses of dilauded and zofran for pain. she also received iv pantoprazole, flagyl and ceftriaxone given her allergies, 10 units regular insulin. abdominal ct showed possible necrotizing pancreatitis. surgery was consulted re: possible focus of necrosis of the pancreatic head as well as whether this could represent gall-stone pancreatitis. they felt that no acute surgical interventions were needed and gall-stone pancreatitis was unlikely. past medical history: 1. intractable migraines with muscle spasm and neuralgia, and status migrainous, currently treated with trigger point injections, plans to try botox if approved -first headaches 2. chronic pain due to reflex sympathetic dystrophy secondary to being hit by a car at age 15 3. type 2 diabetes mellitus 4. hypertension 5. obesity 6. complex regional pain syndrome of the right face and right upper extremity on methadone 7. right eye blindness 8. left pupil dysfunction - adie 9. pud 10. rheumatoid arthritis 11. vitamin d deficiency 12. abnormal lft's - no response to hep b vaccines x3 social history: occasional social alcohol use, denies any other substance use history. lives with boyfriend and rabbit. previously divorced at age 30. college educated. she exercises /week. previously worked as pool manager of health club until 6 months ago. currently on disability but wants to work. she has 4 sisters and her family is very close and supportive. parents split time in and . one sister is an er nurse, another is a teacher. family history: father and sister with htn. family history of cad. no family history of cva or headache. physical exam: exam on admission: vs - 97.4, 94, 170/110, 16, 94 ra general: alert, oriented, mild distress but distractible, sitting on edge of bed, sunglasses on heent: sclera anicteric, right eye fixed at 5mm, left eye fixed at 8mm, mm dry, oropharynx clear 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, obese, soft, tender to palpation diffusely, without rebound or guarding, non-distended ext: warm, well perfused, 2+ pulses, 2+ le edema bilaterally, right arm extremely sensitive to touch neuro: cns2-12 intact, motor function grossly normal exam at discharge: vs: tm 98.3, tc 97.4, bp 102/78 (102-107/73-88), hr 93 (88-93), rr 18 (18-20), 96%ra (94-96%ra), fs: 272, 143, 301, 331 gen: middle aged female with central adiposity. oriented x3. lying in bed. pleasant and appropriate. heent: ncat. sclera anicteric. mmm, op benign. neck: jvp not elevated. no cervical lymphadenopathy. cv: rrr with normal s1, s2. no m/r/g. chest: respiration unlabored. ctab without crackles, wheezes or rhonchi. abd: bowel sounds present. mildly distended, obese. mildly ttp in epigastric area and across mid-abdomen. no organomegaly or masses. ext: wwp. digital cap refill <2 sec. no c/c/e. distal pulses intact radial 2+, dp 2+, pt 2+. skin: few scattered healing ecchymoses. neuro: moving all four limbs. normal speech. pertinent results: on admission: 03:00pm blood wbc-28.7*# rbc-5.45*# hgb-17.5*# hct-50.5*# mcv-93 mch-32.2* mchc-34.7 rdw-12.0 plt ct-463* 03:00pm blood neuts-93.4* lymphs-3.1* monos-2.8 eos-0.1 baso-0.6 03:00pm blood glucose-445* urean-25* creat-1.1 na-131* k-3.0* cl-83* hco3-27 angap-24* 03:00pm blood alt-20 ast-20 alkphos-83 totbili-0.9 11:47pm blood ck(cpk)-33 03:00pm blood lipase-1415* 11:47pm blood ck-mb-2 ctropnt-<0.01 11:47pm blood calcium-11.1* phos-2.6*# mg-1.7 11:47pm blood triglyc-198* 11:47pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg ct abdomen : pancreas is fatty infiltrated, with extensive fat stranding and some adjacent fluid concentrated around the pancreatic head but also seen around the remainder of the pancreas, and tracking inferiorly along the paracolic gutters, right greater than left. there is questionable of the pancreatic head, which could represent fatty infiltration, but early necrosis is not excluded. inflammatory changes extend along the c-sweep of the duodenum and hepatic flexure, without definite evidence of fistulization. multiple prominent celiac axis nodes measure up to 9 mm. the portal, splenic, superior mesenteric, hepatic veins, and ivc remain patent. there is no free intraperitoneal air, and no evidence of portal or mesenteric venous gas. there is mild diffuse fatty infiltration of the liver. the gallbladder is partially collapsed. there is no intra- or extra-hepatic biliary ductal dilatation. the spleen is normal in size. the adrenals are normal. the kidneys enhance and excrete contrast promptly and symmetrically, without masses or hydronephrosis. bilateral renal hypodensities were previously characterized as cysts on mr. the stomach is relatively collapsed. no bowel obstruction seen. pelvis: there is a moderate amount of retained fecal material throughout the ascending colon and proximal transverse colon. the distal transverse, descending, and sigmoid colon are relatively decompressed. the uterus and ovaries are unremarkable, with a small corpus luteum cyst noted on the left. there is a physiologic amount of free fluid in the pelvis. the bladder and distal ureters are unremarkable. no suspicious lytic or sclerotic osseous lesions are identified. there is a moderate diffuse disc bulge at l4-5, which abuts the thecal sac outline. please note that ct cannot visualize intrathecal detail. mild degenerative changes are also noted surrounding the bilateral sacroiliac joints. impression: acute pancreatitis, with possible of the pancreatic head which could represent early necrosis. no evidence of venous thrombosis or drainable fluid collections. . ruq u/s : impression: 1. diffusely echogenic liver suggesting fatty infiltration. other forms of more advanced liver disease such as cirrhosis or fibrosis cannot be excluded on this study. 2. no evidence of cholelithiasis. top normal to minimally prominent common bile duct without definite intraluminal stone seen. correlation with lfts and consider mrcp as clinically warranted. . ct abdomen : impression: 1. worsening diffuse acute pancreatitis. no complications of collections or pancreatic ductal dilatation. mild relative of pancreatic head is likely due to fat replacement and is unchanged. increased perihepatic and perisplenic free fluid, with fluid extending along both gutters. regional reactive lymph nodes have increased in size and number. 3. focal filling defect in the mid splenic vein is likely nonocclusive thrombus, new from previous exam. 4. development of bilateral layering pleural effusions with bibasilar atelectasis and/or consolidation. . cxr : there is worsening of the opacification of the right lower lung that might represent interval development of atelectasis and/or infectious process. the left lung base is also involved by atelectasis but to a lesser extent. a left picc line tip is at the level of cavoatrial junction. the apices of the lungs are unremarkable. no pneumothorax is seen. small amount of pleural effusion cannot be excluded. surgical clips projecting over the right upper mediastinum are unchanged. . no labs at discharge. brief hospital course: # necrotizing pancreatitis: presented with abdominal pain and an elevated lipase, with ct consistent with necrotizing pancreatitis (<30% necrosis). etiology was unclear, but possibly alcohol related. she reports drinking alcoholic beverages daily, but likely drinks significantly more based on information from her family. no new medications, but does appear to be on crestor which has been noted to be a rare cause of pancreatitis. no gallstones were seen on liver/gallbladder ultrasound and ct imaging did not suggest gall-stone pancreatitis. igg4 sent and was wnl. patient was made npo and treated with aggressive ivf, her electrolytes were repleted. given she had <30% necrosis antibiotics were not given. her pain was treated with dilauded pca. on hd#2 the patient was noted to have a worsening abdominal exam so ct was repeated and did not show any new findings, just ongoing pancreatitis. surgery was consulted and did not see indication for urgent intervention. gi was also consulted and felt the pancreatitis could be due to viral etiology, medication, or alcohol. on hd# 2 the patient's mother called to say that per patient's boyfriend she has been having about 3 drinks a night (mostly hard lemonade/cider) which could have been contributing. her lipase trended down rapidly from 1415 on admission to 18 on . her wbc count also trended down from 28.7 on admission to 9.0 on . she has continued to have abdominal pain and nausea, but was clearly improving. her diet was advanced to sips/clears on . she was transferred out of the icu after further improvement. however, she was having nausea and vomiting when attempting to eat her clears. -jejunal tube was placed and enteral tube feeds were started on , but she then vomited up her ngt. on , a repeat post-pyloric ngt was placed and tube feeds were again started, but at a much slower rate. she tolerated the tube feeds at 80cc/hr x16 hours a day well. the goal is to have her only need the ngt for ~2weeks, and hopefully she can have it removed as an outpatient at her gi f/u appt. she went home with the ngt and a donated pump and instructions on how to give tf's, as she doesn't have health insurance so could not afford a visiting nurse. . # coffee ground emesis: per history, patient had bloody emesis x 4 days in the setting of nausea and retching. she remained hemodynamically stable, with hct 50.5 down to 39.5 with ivf (which is her baseline) in the icu. ng lavage in ed was clear, and so this was felt likely due to tear. patient was initially on protonix iv which was continued due to her ongoing abdominal pain, but later converted to po. she will follow up with gi to determine the duration of this medication. . # hypoxia: patient required 2-3 l 02 to keep sats >90 after the second day of admission. this was multifactorial: fluid, pancreatic inflammation, atelectasis from lying in bed. she showed no signs of pneumonia, and oxygen was quickly weaned off by the time of transfer to the floor. she was continued on ra throughout the rest of her admission. . # dka/agma: bg 445 with glucosuria and ketonuria on admission. likely related to her nausea and pancreatitis. metformin held and patient put on ssi. her glucose improved and her gap closed with ivf only. . # leukocytosis with left shift: afebrile without localizing signs and symptoms outside of abdomen. ddx includes pancreatitis versus infection with superimposed hemoconcentration. u/a without evidence for infection, no evidence for colitis or pancreatic fluid collection on ct imaging. patient did receive one dose of ceftriaxone and flagyl in the ed but this was not continued. patient remained afebrile and leukocytosis resolved while treating pancreatitis as above. . # sinus tachycardia: resolved with aggressive ivf and pain control. . # chronic regional pain syndrome: at home patient is on gabapentin, percocet, and tizanidine. when patient came in she was strictly npo and pain was not controlled with iv dilaudid boluses so she was transitioned to dilaudid pca. her pain control was improved and although the patient still reported ongoing pain she appeared calm, sleepy, and abdominal exam was benign. there was concern for narcotic seeking behavior. her gabapentin and tizanadine were restarted. she was weaned of her dilaudid pca shortly after transfer to the floor and switched to diludid iv. she was switched to dilaudid po on after losing iv access. her dilaudid dose was decreased after an episode of possible over sedation on . she was switched to percocet on with good effect, and was sent home with a 1 week course of percocet, enough to get to her outpt f/u appts. . # htn: she intially had sbp 100 off all her anti-hypertensives likely due to third spacing from pancreatitis. with ivf only, her sbp was 130s by the time she was transferred to the floor. her hypotension resolved, and she was restarted on lisinopril 10 mg po daily (home dose 20 mg) on . clonidine 0.2 mg po bid (home dose 0.6 mg ) was started later that night, and increased to 0.4 mg po bid on . amlodipine 10 mg po daily was also restarted on . it was felt she should not go back on hctz due to potential to cause pancreatitis, but her lisinopril was increased back to home dose of 20mg prior to dispo. . # fatty liver on us: patient will need follow up as an outpatient. . pending labs: none . transitional care issues: patient will need her ngt and po intake assessed at her gi follow-up appointment, and hopefully it can be removed at this time. in addition, she will need her fatty liver seen on u/s to be followed up as an outpatient. we encouraged pt to stop drinking both for her pancreatitis and liver. if she is unable to, she may need outpatient alcohol counselling treatment. . medications on admission: rosuvastatin 40 mg po qhs amlodipine 10 mg po qhs carvedilol 12.5 mg po qam lisinopril 20 mg po bid clonidine 0.6 mg po bid hydrochlorothiazide 25 mg po daily metformin sr 750 mg po bid gabapentin 1100 mg qam, 1100 mg qpm, 1600 mg qhs tizanidine 8-16 mg po qhs doxepin 75 mg po qhs 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. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 3. doxepin 25 mg capsule sig: three (3) capsule po hs (at bedtime). 4. gabapentin 800 mg tablet sig: 1-2 tablets po three times a day: take 1100mg qam (1x800mg and 1x300mg), take 1100mg qpm and take 1600mg qhs (2x800mg). 5. gabapentin 300 mg capsule sig: one (1) capsule po twice a day: take 1100mg qam (1x800mg and 1x300mg) and take 1100mg qpm. 6. tizanidine 4 mg tablet sig: 2-4 tablets po at bedtime as needed for headache. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 8. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 9. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for bloating, gas pain. disp:*112 tablet, chewable(s)* refills:*0* 10. clonidine 0.2 mg tablet sig: one (1) tablet po bid (2 times a day). 11. amlodipine 5 mg tablet sig: two (2) tablet po hs (at bedtime). 12. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. disp:*30 doses* refills:*0* 13. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*30 tablet(s)* refills:*0* 14. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). 15. metformin 750 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po twice a day. discharge disposition: home with service facility: home solutions discharge diagnosis: primary: necrotizing pancreatitis secondary: type ii diabetes, chronic regional pain syndrome discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , you were seen in the hospital for necrotizing pancreatitis. you went to the intensive care unit initially where you were monitored, and when you improved enough you were sent to the general medicine floor. there, your abdominal pain slowly improved, and we tried to start you on clear liquids. you had worsened pain and vomiting with food, so we treated you with intravenous nutrition for 1 day and then placed a feeding tube. we made the following changes to your medications: 1) we stopped your hydrochlorothiazide. your doctor may tell you to restart this at some point in the future. 2) we stopped your rosuvastatin. your doctor may tell you to restart this at some point in the future. 3) we stopped your carvedilol. your doctor may tell you to restart this at some point in the future. 4) we started you on bisacodyl 10mg once a day as needed for constipation. 5) we started you on senna 1 tablet twice a day as needed for constipation. 6) we started you on docusate 100mg twice a day. this is a stool softener, so don't take it if you're having loose stools. 7) we started you on omeprazole 40mg once a day. 8) we started you on simethicone 80mg four times a day as needed for gas pains. 9) we started you on polythylene glycol 1 dose once a day as needed for constipation. 10) we started you on percocet 1 tab every 4-6 hours as needed for pain. 11) we decreased your clonidine to 0.4mg twice a day. your doctor may end up increasing this medication back to the original dose. if you experience any of the below listed danger signs, please call your doctor or go to the nearest emergency room. it was a pleasure taking care of you on this hospitalization. followup instructions: department: hmfp headache center when: thursday at 4:30 pm with: , md building: one place (, ma) campus: off campus best parking: parking on site department: when: thursday at 10:45 am with: , md building: (, ma) campus: off campus best parking: on street parking please speak to your pcp about referring you to an outpatient nutritionist if this is possible. department: gastroenterology when: tuesday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Diagnoses: Unspecified essential hypertension Long-term (current) use of insulin Long-term (current) use of other medications Rheumatoid arthritis Mononeuritis of unspecified site Acute pancreatitis Other chronic nonalcoholic liver disease Unspecified vitamin D deficiency Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Malnutrition of moderate degree Reflex sympathetic dystrophy of the upper limb

allergies: sulfa (sulfonamide antibiotics) / compazine / penicillins / cipro cystitis / zostrix / prednisone / bactrim attending: chief complaint: n/v, abdominal pain major surgical or invasive procedure: right ij cvl placement ir guided picc history of present illness: ms. is a 39yo f w/hx of necrotizing pancreatitis, dm2, chronic regional pain syndrome due to reflex sympathetic dystrophy, intractable migraines (followed at the management service) and pud who presents with nausea, vomitting and epigastric abdominal pain radiating to the back for the past 2 days. she was recently admitted from for necrotizing pancreatitis thought to be possibly alcohol related vs. viral. she also had dka during this admission. she was treated with a dilaudid and bowel rest. a post-pyloric dobhoff was placed due to inability to tolerate pos and she did tolerate tfs. she was discharged with instructions to continue tfs for 2 weeks. she has been using the tf at night but had to stop on friday night due to abdominal pain and bloating. she has been eating broth and crackers for the majority of the week. reports nausea which started 2 days prior to admission (friday) and countless episodes of vomitting starting yesterday. emesis was initially clear liquid and food, then became greenish and bilious. no hematemesis. abdominal pain is described as sharp epigastric pain radiating to the back, similar to prior episode of pancreatitis. since her discharge this was intermittent in nature, and 2 days ago became severe and constant. it is not brought on by eating but tfs make it worse. she has been taking perocet 1 tab at bedtime and does wake up in the middle of the night with pain and takes a 2nd pill. . she was seen by her pcp and amlodipine and lisinopril were stopped due to hypotension. she reports that her clonidine was increased to 0.6mg which she takes for pain. . in the ed, initial vs were: t97.3 hr134 bp154/122 16 94%. a ct scan of the abdomen showed resolving pancreatitis, with extensive early pseudocyst formation in tail. surgery was called and recommended no surgical intervention. she was given zofran 8mg odt, reglan 10mg iv, dilaudid 4mg iv in the course of 6 hours, vanc 1gm iv, ceftaz 2gm iv and flagyl 500mg iv due to leukocytosis and abdominal pain. she had a ua with ketones and an ag of 28 and was given 3l ns. an insulin gtt was started at 7 units/hr. a lij cvl was placed. repeat lytes showed and ag of 18. . on the floor, she reports epigastric pain and nausea. she is shaking. denies fevers at home. denies chest pain. no dysuria. . review of sytems: (+) per hpi; also for constipation which has been present her entire life, last bm was friday and soft. + for chronic right sided pain, chronic headaches. (-) 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. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: 1. intractable migraines with muscle spasm and neuralgia, and status migrainous, currently treated with trigger point injections, plans to try botox if approved -first headaches 2. chronic pain due to reflex sympathetic dystrophy secondary to being hit by a car at age 15 3. type 2 diabetes mellitus 4. hypertension 5. obesity 6. complex regional pain syndrome of the right face and right upper extremity on methadone 7. right eye blindness 8. left pupil dysfunction - adie 9. pud 10. rheumatoid arthritis 11. vitamin d deficiency 12. abnormal lft's - no response to hep b vaccines x3 social history: denies tobacco, previously drank socially (3 drinks per night per some reports but per her report she drank no more than one drink per day for many years, no alcohol since last admission which was one alcoholic drink at . denies drug use. lives with boyfriend, unemployed since but before then she is an aquatics instructor and teaches children swimming in addition to lifeguarding. she longs to return to aquatics and teaching. family history: father and sister with htn. family history of cad. no family history of cva or headache. physical exam: general: alert, oriented, uncomfortable appearing in pain. heent: sclera anicteric, mm slightly dry, oropharynx clear neck: supple, jvp not elevated, no lad, l ij in place lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, normoactive bowel sounds, tender on palpation diffusely, mostly in epigastric area but also rlq, llq, ruq gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: pupil are fixed with r at 2mm and l at 4mm . discharge physical exam: vss. bp 90s/50s. picc in right arm. abdomen soft, with epigastric tenderness. ext without edema. pertinent results: 06:15pm wbc-19.3*# rbc-4.33# hgb-14.2# hct-40.6# mcv-94 mch-32.9* mchc-35.1* rdw-13.3 06:15pm neuts-87.2* lymphs-9.7* monos-2.3 eos-0.3 basos-0.5 06:15pm plt count-744*# 06:15pm glucose-551* urea n-9 creat-1.0 sodium-132* potassium-6.2* chloride-89* total co2-15* anion gap-34* 06:15pm alt(sgpt)-24 ast(sgot)-60* ld(ldh)-818* alk phos-118* tot bili-0.4 06:15pm lipase-25 06:15pm albumin-4.6 06:21pm lactate-3.2* 11:55pm urine color-straw appear-hazy sp -1.029 11:55pm urine blood-neg nitrite-neg protein-30 glucose-1000 ketone-150 bilirubin-neg urobilngn-neg ph-5.5 leuk-lg 11:55pm urine rbc-14* wbc-16* bacteria-few yeast-none epi-10 11:55pm urine granular-1*. . . ct abdomen: lung bases: the lung bases are clear without pleural or pericardial effusion. abdomen: the liver, spleen, gallbladder, and adrenals are normal in appearance. the kidneys demonstrate symmetric contrast enhancement and brisk bilateral excretion without hydronephrosis. hypodensity in the right mid kidney is too small to characterize. the pancreas is enlarged, and in the interim there are new fluid collections with lobulations and slight rim enhancement about much of the pancreas suggesting regions of necrosis and mild liquefaction, possibly with extraparenchymal fat necrosis as well. fatty regions are seen within areas of necrosis which spares the neck and body and involves mostly parts of the head and tail. representative of necrosis in the tail is a fat and fluid containing collection measuring 5.8 x 4.7 cm, in the body measuring 3.4 x 6.2 cm, and in the inferior portion of the head measuring 4.0 x 3.6 cm. the pancreatic duct is not well seen. there is no intra- or extra-hepatic biliary ductal dilatation. there is no intraperitoneal free fluid or free air. there is minimal thickening of the gerota fascia around the left kidney, improving compared with priors. loops of small bowel are decompressed but enhance normally. pelvis: the bladder is distended. pelvic organs appear normal. the rectum and colon is unremarkable. there is no pathologic lymphadenopathy. bones: no concerning lytic or blastic osseous lesions. impression: findings suggesting evolving necrotizing pancreatitis, with areas of liquifactive necrosis. . . cxr: upright ap view of the chest: left internal jugular central venous catheter has been repositioned, with the tip now in the low svc. no pneumothorax is present. the remainder of the chest is unchanged. . discharge labs: 05:06am blood glucose-226* urean-9 creat-0.4 na-139 k-4.0 cl-105 hco3-28 angap-10 05:06am blood calcium-8.7 phos-4.6* mg-1.6 09:31am blood triglyc-201* brief hospital course: ms. is a 39 yo f w/hx of necrotizing pancreatitis who presents to the ed with recurrent n/v, abdominal pain and is found to be in dka. . necrotizing pancreatitis: the underlying cause of her decompensation. lfts were normal. ct showed evolving necrosis and pancreatitis. gi and surgery were consulted. they did not feel antibiotics or surgery were indicated at this time. previous work up suggested alcohol or medications as the possible cause. her metformin and ace-i were stopped. she was treated with supportive care, including narcotic medication. given her intolerance to tube feedings, tpn was initiated (see below). - will need close gi and surgery follow up - will need mrcp once pancreatic inflammation improves to rule out anatomic/malignant process - aggressive nutritional support dka/type2 diabetes mellitus: dka developed as a result of severe pancreatic injury. she was initially on an insulin drip. her metformin was stopped due to her pancreatitis. she was transitioned to insulin in her tpn, plus lantus with hiss. was consulted and assisted with glucose management. - will need to go home with nph and hiss, with teaching - insulin in tpn - follow up malnutrition, severe: caused by her severe pancreatitis. she could not tolerate tube feedings in the outpatient setting. the possibility was discussed for gj tube placement, but was deferred in the setting of her pancreatic inflammation. thus tpn was initiated. tpn was cycled once sugars were better controlled. - continue tpn for the next weeks post discharge until follow up with gi and surgery. once pancreatic inflammation improves, should transition back to full orals. . hypertension: be due to pain but patient has underlying essential hypertension and several medication changes have been made recently. hctz and carvedilol were stopped during her last admission due to concerns about causing her pancreatitis. her pcp instructed her to stop her lisinopril and amlodipine on due to hypotension, likely in the setting of dehydration and decreased po intake. - held ace-i, also d/ced amlodipine. - continued clonidine (for pain) . acute and chronic pain, migraines: followed at center. takes tizanidine, gabapentin and doxapin at home. had previously been on methadone but not currently taking this. recently was discharged on percocet. continued tizanidine, gabapentin, doxasin, clonidine. opiates will be needed for significant pancreatitis pain. initiated on fentanyl patch 50mcg->75mcg then 100 mcg. also started oxycodone q4-6 prn, transitioned to po dilaudid 8 mg q 4 hours prn. . access issues: patient and family requested port-a-cath placement given difficult access and need for blood draws in the future. a cvl was placed in the icu. at first the patient was hesitant to have a picc placed. was consulted. we explained the risk of placing a port at this time (infection), and that ports are used as a last result. she agreed to ir guided picc placement. - picc will be temporary until tpn is finished - consider port placement going forward given difficult access issues. has gi and surgery follow up. . transitional issues: 1. nutritional: discharged on tpn, with lab results to . hopefully will wean off of tpn over next several weeks. 2. necrotizing pancreatitis: still with severe abdominal pain, will need surgery/gi follow up, and mrcp to evaluate for pseudocysts. 3. diabetes: sugars elevated, but better on current regimen. she has follow up, and was given insulin teaching and all testing equipment. . outstanding tests: none medications on admission: bisacodyl 10mg po daily prn constipation senna 1 tab po bid prn constipation doxepin 75mg po qhs gabapentin 1100mg qam, 160mg qhs tizandidine 4-8mg po qhs prn headache colace 100mg po bid omeprazole 40mg po daily simethicone 80mg po qid prn bloating, gas clonidine 0.6mg po bid (recently increased by pcp) amlodpine 10mg po qhs - stopped by pcp due to low bp miralax 17gm po daily prn constipation percocet 1-2 tabs po q4-6h prn pain lisinopril 20mg po daily - stopped by pcp due to low bp metformin 750mg po bid discharge medications: 1. heparin lock flush 100 unit/ml solution sig: five (5) ml intravenous once a day: after tpn infusion, and saline flush. disp:*30 day supply* refills:*1* 2. saline flush 0.9 % syringe sig: five (5) ml injection once a day: before and after tpn, and as needed. disp:*30 day supply* refills:*1* 3. doxepin 75 mg capsule sig: one (1) capsule po once a day. 4. gabapentin 800 mg tablet sig: two (2) tablet po at bedtime. 5. tizanidine 2 mg tablet sig: 2-4 tablets po qhs (once a day (at bedtime)). 6. clonidine 0.3 mg tablet sig: two (2) tablet po twice a day. 7. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). disp:*10 patch 72 hr(s)* refills:*0* 8. hydromorphone 4 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. disp:*120 tablet(s)* refills:*0* 9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 10. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) mg po daily (daily) as needed for constipation. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 13. senna 8.6 mg tablet sig: two (2) tablet po hs (at bedtime). 14. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. disp:*15 tablet, rapid dissolve(s)* refills:*0* 15. test strips sig: one (1) teststrip twice a day: use as directed. disp:*60 teststrips* refills:*1* 16. lancets,thin misc sig: one (1) lancet miscellaneous twice a day: use as directed. disp:*1 month's supply* refills:*0* 17. insulin syringe-needle,dispos. 0.5 ml 30 x syringe sig: use as directed miscellaneous twice a day. disp:*1 month's supply* refills:*0* 18. lantus 100 unit/ml solution sig: eight (8) units subcutaneous at bedtime. disp:*1 month's supply* refills:*0* 19. humalog 100 unit/ml solution sig: sliding scale units subcutaneous every six (6) hours. disp:*1 month's supply* refills:*0* 20. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po twice a day. 21. outpatient lab work bmp, ca, mg, phos, triglycerides weekly on tuesdays, first on results to - phone, fax discharge disposition: home with service facility: discharge diagnosis: necrotizing pancreatitis dka, type 2 diabetes mellitus, poorly controlled chronic pain, complex regional pain syndrome hypertension chronic headaches discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with abdominal pain and high blood sugars. you were found to have a recurrence of your pancreatitis with acid in the blood from your diabetes. with supportive care and insulin your symptoms have improved. we have transitioned you to a transdermal/oral pain regimen. as your pancreas recovers, we will need to taper you off this medication. you should eat very minimally until the pain improves, you can discuss this with dr. and dr. . . for nutrition, you will require tpn for the time being. over the next few weeks, we hope to resume your diet and stop your tpn. a picc was placed for this reason. . you will need to come to the pheresis unit to have your dressing changed every week. . you will need to follow up closely with your pcp, , and surgery to discuss next steps. consideration for a port-a-cath can be made with the assistance of . . new medications: dilaudid 4 mg tablets for pain, 1-2 tablets every 4 hours ondansetron 4 mg po q 8 hours as needed for nausea insulin - lantus 8 units at night humalog 4 times a day, according to the sliding scale. fentanyl patch 100mcg/hour, every 72 hours. followup instructions: endocrinology appointment: clinic when: tuesday, at 8:30am with: ,np (she works closely with your doctor @ the clinic, dr. ) where: clinic,, , phone: ** if you need to discuss payment of the appointment please call the financial conselor office @ the @ you will be responsibile for paying for this appointment, so should call them before to discuss this. department: when: wednesday at 9:30 am with: , md building: (, ma) campus: off campus best parking: on street parking department: gastroenterology when: tuesday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage department: surgical specialties when: wednesday at 12:00 pm with: , md building: (, ma) campus: off campus best parking: parking on site Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Unspecified essential hypertension Long-term (current) use of insulin Long-term (current) use of other medications Rheumatoid arthritis Chronic pancreatitis Mononeuritis of unspecified site Acute pancreatitis Cyst and pseudocyst of pancreas Profound impairment, both eyes, impairment level not further specified Unspecified vitamin D deficiency Nutritional marasmus Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Contact dermatitis and other eczema, unspecified cause Reflex sympathetic dystrophy, unspecified Migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus

allergies: sulfa (sulfonamide antibiotics) / compazine / penicillins / cipro cystitis / zostrix / prednisone / bactrim / picc dressing / lisinopril attending: chief complaint: chronic pancreatitis major surgical or invasive procedure: : distal pancreatectomy/splenectomy/cholecystectomy/j-tube placement history of present illness: ms. is a 39 year old female with a history of chronic pancreatitis complicated by necrotizing pancreatitis and multiple pseudocysts requiring placement of multiple drains. she presents with abdominal pain on long term tpn for distal pancreatectomy with splenectomy, cholecystectomy, and j-tube placement for tube feeds. past medical history: 1. intractable migraines with muscle spasm and neuralgia, and status migrainous, currently treated with trigger point injections, plans to try botox if approved -first headaches 2. chronic pain due to reflex sympathetic dystrophy secondary to being hit by a car at age 15 3. type 2 diabetes mellitus 4. hypertension 5. obesity 6. complex regional pain syndrome of the right face and right upper extremity on methadone 7. right eye blindness 8. left pupil dysfunction - adie 9. pud 10. rheumatoid arthritis 11. vitamin d deficiency 12. abnormal lft's - no response to hep b vaccines x3 . pancreatitis: complicated by necrotizing pancratitis w/ multiple admissions for abdominal pain social history: denies tobacco, previously drank socially (3 drinks per night per some reports but per her report she drank no more than one drink per day for many years, no alcohol since last admission which was one alcoholic drink at . denies drug use. lives with boyfriend, unemployed since but before then she is an aquatics instructor and teaches children swimming in addition to lifeguarding. she longs to return to aquatics and teaching family history: father and sister with htn. family history of cad. no family history of cva or headache. physical exam: vs: 98.7 71 100/60 12 98 ra gen: aox3 nad cor: rrr res: ctab abd: soft, nt/nd. j-tube site appears clean without erythema or discharge. wound: appears c/d/i with steri-strips in place, minimal irritation at staple site but no erythema at wound. ext: warm and well perfused. pertinent results: 04:58pm blood wbc-15.7*# rbc-3.20* hgb-7.4* hct-23.2* mcv-73* mch-23.0* mchc-31.7 rdw-16.7* plt ct-453* 06:28am blood wbc-15.1* rbc-3.01* hgb-6.7* hct-22.1* mcv-74* mch-22.4* mchc-30.4* rdw-16.7* plt ct-504* 04:53am blood wbc-25.5*# rbc-3.37* hgb-8.2* hct-26.0* mcv-77* mch-24.3* mchc-31.5 rdw-18.2* plt ct-565* 02:41pm blood wbc-26.55* rbc-3.68* hgb-8.8* hct-27.8* mcv-76* mch-23.8* mchc-31.6 rdw-19.0* plt ct-716* 06:49am blood wbc-54.7*# rbc-2.98* hgb-7.2* hct-22.9* mcv-77* mch-24.2* mchc-31.5 rdw-19.6* plt ct-561* 06:05am blood wbc-19.7*# rbc-2.69* hgb-6.3* hct-21.6* mcv-80* mch-23.2* mchc-29.0* rdw-19.0* plt ct-595* 12:05am blood wbc-18.8* rbc-3.03* hgb-7.3* hct-23.4* mcv-77* mch-24.0* mchc-31.1 rdw-18.9* plt ct-1118*# 04:58pm blood glucose-126* urean-14 creat-0.6 na-138 k-3.7 cl-102 hco3-26 angap-14 06:28am blood glucose-196* urean-11 creat-0.7 na-137 k-4.0 cl-102 hco3-28 angap-11 04:53am blood glucose-139* urean-5* creat-0.5 na-143 k-3.6 cl-103 hco3-30 angap-14 04:30am blood glucose-172* urean-7 creat-0.4 na-140 k-3.3 cl-104 hco3-27 angap-12 04:16am blood glucose-203* urean-8 creat-0.5 na-138 k-3.7 cl-101 hco3-27 angap-14 06:49am blood glucose-214* urean-14 creat-0.6 na-138 k-4.0 cl-104 hco3-24 angap-14 06:05am blood glucose-276* urean-9 creat-0.5 na-137 k-4.4 cl-102 hco3-25 angap-14 12:05am blood glucose-194* urean-10 creat-0.5 na-138 k-4.5 cl-98 hco3-33* angap-12 06:05am blood vanco-10.3 12:05am blood vanco-13.7 12:16pm blood type-art po2-88 pco2-50* ph-7.41 caltco2-33* base xs-5 intubat-intubated vent-controlled 02:19pm blood type-art po2-180* pco2-42 ph-7.46* caltco2-31* base xs-6 intubat-intubated vent-controlled brief hospital course: ms. was admitted to the pancreatobiliary surgery service and underwent distal pancreatectomy, splenectomy, choelcystectomy and j-tube placement on . please see the dictated operative note for further details of the operation. she tolerated the procedure well and was brought to the floor postoperatively. initially she had poor pain control and was started on a ketamine drip by the chronic pain service. she had a hematocrit of 22 on pod1 and hence was transfused x1 unit. on pod3 she she began to be weaned from the ketamine drip. her epidural was discontinued and her foley was discontinued. on pod4 she was started on clear liquids, her ketamine drip had been stopped, and chronic pain was consulted for management recommendations. she was vaccinated for meningococcus, pneumococcus, and hemophilus influenza b. overnight from pod4 to pod5 she began to become mildly febrile and tachycardic. she was treated with iv lopressor, which had only a modest effect. urine and blood cultures x 2 were sent, and a chest x-ray was performed which demonstrated no intrapulmonary source of infection. her temperature continued to rise to a maximum of 104, and she became hypotensive, at which point she was transferred to the intensive care unit. in the intensive care unit her picc line and her central line were discontinued as possible sources of infection. she was empirically started on vancomycin, ceftriaxone, and fluconazole, given her history of yeast infection in the past. blood cultures drawn from the floor returned positive for gram positive cocci in clusters. her ceftriaxone was discontinued and she was continued on vancomycin and fluconazole. she was started on tube feeds and was slowly advanced towards her goal of 90cc/hour. she became afebrile and was transferred back to the floor on . her foley catheter was discontinued. on she continued to have intermittent hypotension and was bolused with good effect. she was started on an oral pain medication regimen. on the next hospital day, her jp amylase returned at 178. her vancomycin trough was therapeutic. her platelet count was 1118, hence she was started on antiplatelet therapy with asa 325. on her vancomycin dose was adjusted to dosing. she was toelrating her tube feeds at goal of 90cc/hour, cycled over 16 hours. on she had a picc line placed. placement was confirmed by chest x-ray. she was discharged home with visiting services for vancomycin administration, which will continue for a total of 10 days from her first day of therapeutic vancomycin levels. she also will continue on her tube feeds for the time being. medications on admission: clonidine .2'', doxepin dose uncertain, fentanyl patch, gabapentin 300 in am in noon, dilaudid 6 tid, needed for prn, insulin dose uncertain, naratriptan 2.5', zofran 4'''', promethazine 12.5'''', scopolamine patch, tizanidine 4 2-4 tabs qhs discharge medications: 1. clonidine 0.2 mg tablet sig: two (2) tablet po twice a day. disp:*120 tablet(s)* refills:*2* 2. gabapentin 600 mg tablet sig: two (2) tablet po bid (2 times a day): am and noon. disp:*120 tablet(s)* refills:*2* 3. gabapentin 400 mg capsule sig: four (4) capsule po qhs (once a day (at bedtime)). disp:*160 capsule(s)* refills:*2* 4. doxepin 25 mg capsule sig: three (3) capsule po hs (at bedtime). disp:*90 capsule(s)* refills:*2* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 7. vancomycin 500 mg recon soln sig: one (1) recon soln intravenous q 12h (every 12 hours): for 10 days. 8. hydromorphone 2 mg tablet sig: (two to three) tablets po q3h (every 3 hours) as needed for pain for 2 weeks. disp:*240 tablet(s)* refills:*0* 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 10. lorazepam 0.5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for anxiety or insomnia. 11. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours) for 2 weeks. disp:*5 patch 72 hr(s)* refills:*0* 12. insulin glargine 100 unit/ml solution sig: twenty five (25) units subcutaneous once a day. 13. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous four times a day. 14. glucerna liquid sig: one (1) po once a day: please give 90ml/hour over 16 hours beginning at 1600 daily. disp:*qs sufficient* refills:*15* discharge disposition: home with service facility: discharge diagnosis: s/p distal pancreatectomy/splenectomy/cholecystectomy/j-tube placement discharge condition: mental status clear and coherent. ambulating. voiding. tolerating po and tube feeds. normal bowel function. discharge instructions: activity: do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. you may climb stairs. you may go outside, but avoid traveling long distances until you see your at your next visit. don't lift more than 20-25 lbs for 6 weeks. (this is about the weight of a briefcase or a bag of groceries.) this applies to lifting children, but they may sit on your lap.) you may start some light exercise when you feel comfortable. you will need to stay out of bathtubs or swimming pools for a time while your incision is healing. ask your doctor when you can resume tub baths or swimming. heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. you may resume sexual activity unless your doctor has told you otherwise. how you feel: you may feel weak or "washed out" for 6 weeks. you might want to nap often. simple tasks may exhaust you. you may have a sore throat because of a tube that was in your throat during surgery. you might have trouble concentrating or difficulty sleeping. you might feel somewhat depressed. you could have a poor appetite for a while. food may seem unappealing. all of these feelings and reactions are normal and should go away in a short time. if they do not, tell your . your incision: your incision may be slightly red around the stitches. this is normal. you may gently wash away dried material around your incision. do not remove steri-strips for 2 weeks. (these are the thin paper strips that might be on your incision.) but if they fall off before that that's okay). it is normal to feel a firm ridge along the incision. this will go away. avoid direct sun exposure to the incision area. do not use any ointments on the incision unless you were told otherwise. you may see a small amount of clear or light red fluid staining your dressing or clothes. if the staining is severe, please call your . you may shower. as noted above, ask your doctor when you may resume tub baths or swimming. ove the next 6-12 months, your incision will fade and become less prominent. your bowels: constipation is a common side effect of narcotic pain medication. if needed, you may take a stool softener (such as colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. you can get both of these medicines without a prescription. pain management: it is normal to feel some discomfort/pain following abdominal surgery. this pain is often described as "soreness". your pain should get better day by day. if you find the pain is getting worse instead of better, please contact your . you will receive a prescription from your for pain medicine to take by mouth. it is important to take this medicine as directied. do not take it more frequently than prescribed. do not take more medicine at one time than prescribed. your pain medicine will work better if you take it before your pain gets too severe. talk with your about how long you will need to take prescription pain medicine. please don't take any other pain medicine, including non-prescription pain medicine, unless your has said its okay. if you are experiencing no pain, it is okay to skip a dose of pain medicine. remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. if you experience any of the folloiwng, please contact your : - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain medications: take all the medicines you were on before the operation just as you did before, unless you have been told differently. if you have any questions about what medicine to take or not to take, please call your . followup instructions: please call dr. office to make an appointment to be seen in days. please call your primary care physician's office to make an appointment to be seen in weeks. ****please note**** you have been discharged with a 2-week supply of narcotic pain medications. you will need to arrange follow up with your primary care physician or chronic pain physician 2 weeks to arrange for ongoing pain medicine. because you are under a pain management contract elsewhere, your cannot give you more than 2 weeks of pain medication for treatment of your acute pain. you have been discharged with fentanyl patch for long-acting pain relief and dilaudid tablets for breakthrough pain. you have been discharged with 240 dilaudid tablets. Procedure: Parenteral infusion of concentrated nutritional substances Other enterostomy Enteral infusion of concentrated nutritional substances Cholecystectomy Total splenectomy Other partial pancreatectomy Central venous catheter placement with guidance Diagnoses: Unspecified essential hypertension Unspecified septicemia Sepsis Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Rheumatoid arthritis Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Chronic pancreatitis Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus Cyst and pseudocyst of pancreas Unspecified vitamin D deficiency Bloodstream infection due to central venous catheter Reflex sympathetic dystrophy of other specified site Other acute postoperative pain

allergies: sulfa (sulfonamide antibiotics) / compazine / penicillins / cipro cystitis / zostrix / prednisone / bactrim / picc dressing / lisinopril attending: chief complaint: nausea/vomiting major surgical or invasive procedure: left femoral central line placement history of present illness: 40yo f with history of distal pancreatectomy on , on chronic tube feeds,type 2 dm, who presents with 3 days of nausea, bilious vomiting and abdominal pain. her abdominal pain is minimal, located diffusely, present for 3 days, constant , worsened with food intake. her vomitus is green with few specks of red in her last vomiting episode earlier today , she denies any frank hematemesis, melena, hematochezia, diarrhea.last bm was normal yesterday, brown and formed. she at times feels sleepy, but denies confusion. in the ed, initial vs were: 96.1 128 136/92 16 . she was found to have elevated blood glucose and in dka. started on insulin drip and iv fluids.she also recieved 4 mg iv dilaudid, 8 mg iv morphine for abdominal pain and iv/p.o zofran, compazine, for nausea.for her leukocytosis she was given vancomycin and meropenem.she recieved 4 liters of ns and one liter of 1/2ns. she was given calcium gluconate for questionable t waves. on arrival to the micu, her vitals are pulse 122, 99% ra, bp-120/95. the above hx was obtained and she was oriented x 3. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: 1. intractable migraines with muscle spasm and neuralgia, and status migrainous, currently treated with trigger point injections, plans to try botox if approved -first headaches 2. chronic pain due to reflex sympathetic dystrophy secondary to being hit by a car at age 15 3. type 2 diabetes mellitus 4. hypertension 5. obesity 6. complex regional pain syndrome of the right face and right upper extremity on methadone 7. right eye blindness 8. left pupil dysfunction - adie 9. pud 10. rheumatoid arthritis 11. vitamin d deficiency 12. abnormal lft's - no response to hep b vaccines x3 . pancreatitis: complicated by necrotizing pancratitis w/ multiple admissions for abdominal pain social history: denies tobacco, previously drank socially (3 drinks per night per some reports but per her report she drank no more than one drink per day for many years, no alcohol for months.) denies drug use. lives with boyfriend, unemployed since . family history: father and sister with htn. family history of cad. no family history of cva or headache. physical exam: admission exam: vitals:pulse 122, 99% ra, bp-120/95. general: alert, oriented, no acute distress, sleepy at times but wakes up to verbal stimuli 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, diffusley tender, no rebound, no guarding, bs +, non-distended, bowel sounds present, no organomegaly gu: foley placed 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. oriented x 3, with poor attention not able to say days of week backward. discharge exam: t 97.5, 98/50, 78, 18, 98% on ra general: alert, oriented, covering her eyes with her arm, but in no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: very soft, diffuse mild tenderness, no rebound, no guarding, bs +, non-distended, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: left pupil dysfunction (at baseline), cniii-xii intact, 5/5 strength upper/lower extremities pertinent results: urine culture: gram positive bacteria. 10,000-100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. urine culture: no growth. ct abdomen/pelvis: impression: 1. omental infarct along the left lateral aspect of the abdomen. clinically correlate with the patient's pain. 2. the patient is status post distal pancreatectomy, splenectomy, and cholecystectomy. 3. at least three walled off collections are again seen in the pancreas which probably represent chronic hematomas and are slightly smaller. no evidence for chronic pancreatitis. 4. mild dilation of the common bile duct. mrcp may be performed to further evaluate. admission : 01:30pm blood wbc-34.0*# rbc-5.05 hgb-11.0* hct-40.9# mcv-81*# mch-21.8* mchc-27.0* rdw-17.5* plt ct-634* 01:30pm blood glucose-965* urean-34* creat-1.5* na-140 k-5.6* cl-101 hco3-8* angap-37* 01:30pm blood alt-26 ast-33 alkphos-216* 01:30pm blood lipase-913* 01:30pm blood albumin-4.9 calcium-9.6 phos-5.5* mg-2.6 04:25pm blood triglyc-189* 04:25pm blood osmolal-359* 09:04pm blood type- po2-68* pco2-47* ph-7.30* caltco2-24 base xs--3 01:54pm blood lactate-1.9 discharge : 09:06am blood wbc-13.7* rbc-4.03* hgb-8.7* hct-30.0* mcv-75* mch-21.6* mchc-29.0* rdw-17.6* plt ct-385 09:06am blood glucose-351* urean-13 creat-0.5 na-139 k-4.4 cl-103 hco3-26 angap-14 09:06am blood calcium-9.2 phos-5.1* mg-1.8 brief hospital course: ms. is a 40yo f with history of distal pancreatectomy on , on chronic tube feeds, who presented with 1 day of nausea, blilious vomiting and abdominal pain. patient was found to have pancreatitis and diabetic ketoacidosis. active issues: 1. diabetic ketoacidosis: in the ed, she was found to have elevated blood glucose to 900s and to be in dka. her anion gap was 31. she was started on an insulin drip and iv fluids. in the icu she was continued on the insulin drip and her anion gap closed within 12 hours. she was ruled out for mi. no infectious etiology of hyperglycemia was found (had urine culture with 10,000-100,000 colonies of gram positive alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp). pt was not treated for uti as it was felt that this was a contaminant. she denied insulin noncompliance or recent drug abuse. mental status was stable and not obtunded anion gap closed with insulin drip and iv fluids (8-10 liters). on hospital day # 2 tolerated orals and was transitioned to sc insulin. 2. pancreatitis: patient was found to have elevated lipase to 913 on admission and diffuse abdominal tenderness. surgery was consulted and recommended ct scan, which did not any changes except for omental infarct in the left upper abdomen (nothing to do for this as per surgery). no surgical intervention was recommended. surgery followed patient throughout hospitalization. she was able to tolerate a regular diet in addition to her tube feeds. patient was controlled with iv morphine in the icu. when patient tolerated po, her pain medication was changed to oxycodone. patient was discharged with several days of oxycodone as she continued to have some abdominal pain at discharge. 3. hyperglycemia: when tube feeds were restarted, hyperglycemia was a problem for patient. consulted. glargine insulin was increased from 12 to 34 at discharge. given tube feeding, patient was changed from humalog insulin sliding scale to regular insulin sliding scale. 4. leukocytosis: likely secondary to pancreatitis. no other localizing symptoms of infection. improved throughout admission and was 13 at last check prior to discharge. patient should have her cbc checked next week at visit with her pcp. chronic inactive issues: 1. hypertension: normotensive. continued clonidine. 2. chronic pain: worse than typical pain in setting of acute pancreatitis. continued fentanyl patch, gabpentin, tizanidine. patient received oxycodone prn for breakthrough pain. transitional issues: 1. repeat cbc in one week as patient had elevated wbc count throughout hospitalization. 2. patient instructed to track finger stick glucose and insulin requirement. she will bring this information to next appointment. medications on admission: fentanyl patch 75 mcg q72 hours tizanidine 4 mg qhs naratriptan 2.5 mg prn migraine lantus/humalog, clonidine 0.4 lorazepam 0.5 mg qhs, promethazine 12.5 q6h prn nausea, doxepim 50 mg qhs gabapentin 800 , 1600 qhs, zofran 4 mg daily discharge medications: 1. fentanyl 75 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 2. clonidine 0.2 mg tablet sig: two (2) tablet po bid (2 times a day). 3. tizanidine 2 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 4. naratriptan 2.5 mg tablet sig: one (1) tablet po as needed as needed for migraine headache. 5. gabapentin 400 mg capsule sig: four (4) capsule po hs (at bedtime). 6. lantus 100 unit/ml solution sig: thirty four (34) units subcutaneous twice a day. disp:*20 ml* refills:*2* 7. lorazepam 0.5 mg tablet sig: one (1) tablet po at bedtime. 8. doxepin 25 mg capsule sig: three (3) capsule po hs (at bedtime). 9. gabapentin 800 mg tablet sig: as directed tablet po three times a day: take 1100 mg in am and afternoon, 1600 mg at bedtime. 10. naratriptan 2.5 mg tablet sig: one (1) tablet po as needed as needed for headache. 11. ondansetron 4 mg film sig: one (1) po every eight (8) hours as needed for nausea. 12. promethazine 12.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. 13. tizanidine 4 mg tablet sig: two (2) tablet po at bedtime: please take as directed by your pcp. . 14. multivitamin oral 15. tube feeds nutritional supplement - fiber - liquid - 90 cc via tube feed per hour x 16 hours please give 90cc/hr via j-tube with a pump for 16 hours daily. 16. insulin regular human 100 unit/ml solution sig: as directed units injection qachs: please take subcutaneously as directed by sliding scale. pt will use 14 - 26 units four times per day. disp:*30 ml* refills:*2* 17. oxycodone 10 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain: do not drive while taking this medication. . disp:*15 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: diabetic ketoacidosis, pancreatitis, hyperglycemai secondary: chronic abdominal pain, hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure to participate in your care ms. . you were admitted to the hospital with pancreatitis and diabetic ketoacidosis. you were initially in the icu and received an insulin drip. the diabetic ketoacidosis improved. you were seen by the surgeons. the pancreatitis improved. you were transferred to the medical floor and restarted tube feeds. your blood surgar was high so we increased your insulin. please check your fingerstick four times per day. please record this information and bring it to your next appointment with your doctor. please make the following changes to your medications: 1. increase lantus insulin to 34 units twice a day 2. stop humalog insulin 3. start oxycodone 10 mg every 6 hours as needed for pain. this medication may make you drowsy. do not drive while taking this medication. 4. start regular insulin as per sliding scale breakfast lunch dinner bedtime regular regular regular regular glucose breakfast lunch dinner bedtime 71-80 mg/dl 2 units 2 units 2 units 2 units 81-120 mg/dl 14 units 14 units 14 units 14 units 121-160 mg/dl 18 units 18 units 18 units 18 units 161-200 mg/dl 20 units 20 units 20 units 20 units 201-240 mg/dl 22 units 22 units 22 units 22 units 241-350 mg/dl 26 units 26 units 26 units 26 units followup instructions: department: when: wednesday at 10:45 am with: , md building: (, ma) campus: off campus best parking: on street parking name: , k. md location: diabetes center address: one place, , phone: appointment: tuesday at 9am Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Diagnoses: Other chronic pain Abdominal pain, unspecified site Unspecified essential hypertension Acute kidney failure, unspecified Long-term (current) use of insulin Hyperosmolality and/or hypernatremia Acute pancreatitis Profound impairment, both eyes, impairment level not further specified Unspecified vitamin D deficiency Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Malnutrition of moderate degree Reflex sympathetic dystrophy, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea major surgical or invasive procedure: bronchoscopy history of present illness: 57 yo f with pmhx of htn who presents with shortness of breath x 7 days, worsening over the last 3 days. patient reports that she has been feeling weak over the last 3 weeks with an unintentional 10 lb weight loss (of note over the last 2 months she has lost 20lbs). 1 week ago she started feeling sob with exertion, and "hot and cold" but no fevers chills. then 3 days ago she began to have a non-productive cough that left her "gasping for air", worse at night, with "belly racing", (which appears to be belly breathing when pt demonstrates this). patient denies nausea, vomiting, chest pain, night sweats, but does endorse a poor appetite. she reports that food has been tasting bland over the last week and that she will only eat food that's "really tasty" like market, but most of the time she just has soup at home. of note, patient also reports that 2 weeks ago she had burning on urination for 7 days that went away spontaneously. she also reports that over the last 3 days she has been having more watery stools than normal, but no more frequent bm's than usual. patient attributed the loose stools to her being ill "it's what happens when i get sick." today was seen by np, found to have decreased breath sounds throughout, hr of 120, o2 sat of 70%, increased to 84% on 2l, so was sent to the ed. . in the ed, initial vs were: 110 120/80 28 86% 6l (to 100% on nrb). on exam, shallow breathing and tachypneic but mild degree of respiratory distress. flu swab ordered. ekg showed ***. cxr showed atypical pneumonia vs pcp. , ordered for azithromycin, but unclear if given. got 1 liter ivf on way out of ed. access is 18g and 20g piv. temp 97.6 96 120/70 37 99,nrb. . on the floor, patient reported feeling "much better", and when asked what had caused her improvement she reported that it was "the oxygen, definitely". . review of systems: (+) per hpi; otherwise she reports a small flat skin discoloration in spots on her l upper extremity (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies wheezing. denies chest pain, chest pressure, palpitations. denies nausea, vomiting, constipation, abdominal pain. denies frequency, or urgency. denies arthralgias or myalgias. past medical history: -htn -vitiligo -uterine fibroids social history: she works for the , currently as a ticket collector. she lives with her 2 daughters and her boyfriend of 4 years sleeps over often. for the last 1.5 years patient has been drinking a pint of - (cognac) and a 6 pack of corona over the course of 2 days, every day. while she was drinking she would smoke 3 cigarettes per day. she abruptly quit both drinking and smoking 6 weeks pta, and reports that " finally gave me the strength to do it". family history: mother had , died at 74 from cancer. father died at 62 of cad. 1 sister with hypertension and thyroid disease. 2 brothers and 1 sister alive and healthy. her daughters are healthy. physical exam: vitals: t:98.8 bp:105/66 p: 91 r: 28 o2: 94% on 100% nrb general: aaox3, no acute distress heent: sclera anicteric, mmm, oropharynx with some mild thrush noted at base of tongue neck: supple, jvp not elevated, no lad lungs: poor air movement, coarse crackles at the bases bilaterally 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, vitiligonous changes on the shins bilaterally pertinent results: admission labs: 10:40am blood wbc-10.2# rbc-3.93* hgb-12.5 hct-35.9* mcv-92# mch-31.8 mchc-34.8 rdw-12.9 plt ct-527*# 10:40am blood neuts-91.5* lymphs-5.3* monos-2.0 eos-0.6 baso-0.5 10:40am blood glucose-113* urean-13 creat-0.7 na-136 k-3.4 cl-94* hco3-27 angap-18 10:40am blood albumin-3.1* immuno: 05:30am blood wbc-14.0* lymph-4* abs -560 cd3%-32 abs cd3-179* cd4%-1 abs cd4-8* cd8%-29 abs cd8-165* cd4/cd8-0.1* hiv-1 viral load/ultrasensitive (final ): 114,000 copies/ml. micro: immunoflourescent test for pneumocystis jirovecii (carinii) (final ): positive for pneumocystis jirovecii (carinii). chest (portable ap) study date of 10:44 am impression: diffuse hazy opacities within both lungs, without evidence for volume overload. findings are most concerning for a diffuse infectious process, likely with atypical organisms. if the patient is immunocompromised, pcp should be considered. brief hospital course: on admission there was high index of suspicion for pcp given the appearance on chest x-ray and a significant amount of oropharyngeal thrush. bronchoscopy with bal on was positive for pcp. was presumptively started on bactrim and prednisone treatment in the emergency department. she was consented for hiv testing and it came back positive with a viral load (vl) of 114,000 and a cd4 of 8. her oxygenation was tenuous initially requiring face mask with desaturation to the high 70 with movement to the commode but she did not require intubation. over the course of her treatment she was transition ed to face tent and eventually to 4-5 l of oxygen via nasal cannula. her overall oxygenation minimally improved very slowly despite bactrim with a prolonged steroid taper. she was finally discharged home with o2 supplementation of l to keep o2 sat at 94 % at rest. her hypoxia was related to the pcp . for confirmation, she underwent cta of the lung which was negative for pulmonary embolism. the ct did show diffuse ground glass opacities as well as lymphadenopathy without effusions consistent with the diagnosis of pcp. her exertional hypoxia, she remained well with minimal symptoms (only mild dyspnea with activity but no significant cough and no fever or chest pain). patient remained in the hospital for several extra days hoping that her hypoxia will improve. it did remain stable at the above level without any additional symptoms (4-5 l at rest with o2 sat at 94 with decrease to 87-85 with activity. without oxygen, her o2 sat will decrease to 76 with activity). in regards to the new diagnosis of aids(aids defining illness and cd4 of 8), her toxoplasma igg was positive. she was started on azithromycin for prophylaxis. id was consulted and will follow her closely as an outpatient ( 3 days after discharge). hiv genotyping was sent and was pending at the time of discharge. the patient has a history of hypertension and was continued on home dose of atenolol 50 mg daily. bp was well controlled despite holding amlodipine/chlorthalidone and these were not restarted on discharge. she did have elevation of her liver function tests on presentation. work up included negative hepatitis serologies and ruq ultrasound (mild fatty infiltration). lfts abnormalities were related to pcp pneumonia, fatty liver, or both. blood afb culture and hcv viral loads are pending and will be followed by her id. she was discharged home without vna, the latter would offer little help as she had no to minimal symptoms. total discharge time 56 minutes. medications on admission: amlodipine 10 mg daily atenolol-chlorthalidone 100 mg-25 mg 0.5 tablet daily calcium carbonate-vitamin d3 500 mg (1,250 mg)-400 unit discharge medications: 1. home oxygen 4-5 l continuous oxygen for portability pulse dose system. pcp . 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. azithromycin 600 mg tablet sig: one (1) tablet po 2x/week (tu,fr). disp:*60 tablet(s)* refills:*2* 5. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: two (2) tablet po tid (3 times a day) for 17 days. disp:*102 tablet(s)* refills:*0* 6. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 7. prednisone 20 mg tablet sig: one (1) tablet po daily (daily) for 14 days: take 1 tablet for 10 days followed by tablet for 4 days. disp:*12 tablet(s)* refills:*0* 8. combivent 18-103 mcg/actuation aerosol sig: one (1) inhalation four times a day. disp:*2 mdi* refills:*2* discharge disposition: home discharge diagnosis: primary: pcp pneumonia hiv/aids discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. (requiring supplemental o2) discharge instructions: you were admitted with shortness of breath and were found to have a severe pneumonia from an organism called pcp. have been treated with antibiotics and prednisone. your immune system is suppressed by hiv/aids and you will need to be followed closely by the infectious disease team. you have a very low oxygen in your blood from the severe inflammation related to the pcp . this may take several days to weeks to improve. please increase your activity as much as possible to avoid clots formation in legs or lung. you requested discharge home. . please note the following changes to your medication regimen: followup instructions: department: when: wednesday at 10:20 am with: , md building: campus: east best parking: garage department: infectious disease when: friday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage Procedure: Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Unspecified essential hypertension Hyposmolality and/or hyponatremia Candidiasis of mouth Human immunodeficiency virus [HIV] disease Pneumocystosis Candidal esophagitis Leiomyoma of uterus, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: wound drainage, right sided weakness major surgical or invasive procedure: wound washout picc placement history of present illness: 55 y/o male with history of hep c cirosis who is s/p c3 to c7 decompression with on by dr. . this patient presented this evening to complaining of drainage from his operative wound. during his evaluation he started to also complain of right arm weakness. received a call from the ed physician at with these findings, he was transferred here to for evaluation and treatment. upon arrival to our ed and evaluation by ed resident he is stated that he was unable to move any of his extremities. he states that he has transient loss of strenth in all extremities that resolves after a period of time, patient states that he got into an altercation with the police last evening and was assaulted and that is when the bleeding from his surgical incision started. past medical history: pmh: -hcv cirrhosis - genotype 1 (dx secondary to ivda) with known grade i varices, hx ascites, on copilot study getting peg intron in the past, d/ced progression of liver dx. patient was briefly on the tranplant list but was taken off when per notes he was found to have alcohol in his blood stream in /06. -thrombocytopenia -gout -hx hyponatremia and hypernatremia -history of arf -anemia -cervical neck pain. . psh: -s/p anterior and posterior laminectomy and fusion l4-s1 -s/p l inguinal repair -s/p c3-7 laminectomies for decompression on with dr. social history: recently moved out of his parents' home. denies smoking, + recent etoh. denies ivda in past 20 years. not currently working. family history: breast ca in mother. family hx of liver disease, hemachromatosis. physical exam: on admission: o: t:97.1 bp:122 /67 hr: 80 r 18 o2sats: 98% 2l gen: wd/wn, comfortable, nad. heent: pupils: reactive eoms: full neck: blood draning from upper and lower portion, staples intact. abd: soft extrem: warm and well-perfused. neuro: mental status: awake and alert, agitated, has to be redirected for exam multiple times. orientation: oriented to person, place, and date. motor: d b t we wf ip q h at g r 3 0 0 0 0 3 4- 4- 0 0 0 l 4+ 4- 4- 4- 4- 5 5 5 5 5 5 sensation: intact to light touch reflexes: b t br pa ac right 0 0 0 1 1 left 0 0 0 1 1 babinski: mute rectal exam normal sphincter control upon discharge: aox3. awake and alert. rue 4/5 strength. lue 5/5 strength. ble . pertinent results: : ctcervical spine: post operative changes, no clear evidence of a hematoma ct head noncontrast: no acute findings, no fractures : mri cervical spine :abnormal stir signal in cord not significantly changed fromprior examination. multilevel severe spinal canal narrowing spanning c3/c4-c7/t1. c3/c4 and c4/c5 may be slightly progressed from . post-op soft tissue changes and epiduralenhancement. in posterior soft tissues, t2 heterogeneity and t1 hyperintense areas likely indicate blood products/evolving hematoma. 11:10pm pt-20.9* ptt-38.7* inr(pt)-1.9* 11:10pm plt count-40* 11:10pm wbc-4.7# rbc-2.85* hgb-9.9* hct-29.3* mcv-103* mch-34.7* mchc-33.8 rdw-15.9* 11:10pm asa-neg ethanol-neg acetmnphn-19 bnzodzpn-neg barbitrt-neg tricyclic-neg 11:10pm alt(sgpt)-54* ast(sgot)-75* alk phos-96 11:10pm glucose-152* urea n-16 creat-0.7 sodium-138 potassium-4.2 chloride-110* total co2-22 anion gap-10 rue venous doppler:no right upper extremity dvt. wound culture taken (final ): staph aureus coag +. moderate growth. cervical mri : impression: since the most recent examination, there has been interval decrease in size of posterior rim-enhancing collection emanating from the laminectomy at c4 through c7. there is also less mass effect on the posterior aspect of the thecal sac from c4 through c6. stable enhancement in the epidural space could represent post-operative changes or granulation tissue, although superimposed infection cannot be excluded. brain mri : impression: motion-degraded study, no acute changes seen. eeg : impression: this is an abnormal routine eeg due to the presence of a mixed-frequency background that was mostly in the delta range, with some theta and beta activity intermixed. this suggests the presence of a moderate encephalopathy, which represents diffuse cerebral dysfunction of nonspecific cause. there were no clear focal or epileptiform features seen. cxr: there has been interval removal of the ng tube with a new dobbhoff catheter passed, the tip of which is seen to lie within the stomach. again, a left picc is in adequate position. there has been an interval improvement in the pulmonary edema compared to the study obtained earlier on the same date. abdominal u/s: impression: 1. mild-to-moderate amount of ascites. 2. nodular hepatic architecture consistent with the patient's known cirrhosis. no focal liver lesion identified. 3. cholelithiasis. 4. splenomegaly. brief hospital course: patient was admitted to a stepdown unit for neuro checks and infectious workup. blood cultures and urine cultures were sent. urine cultures were negative. the patient was started on vitamin k 10mg iv for 3 days in the setting of elevated inr and in preparation of the o.r for cervical wound washout. he was started on ancef 1g q8 for wound infection prior to to his procedure. he was kept npo on the evening of and given 2 units of ffp for elevated inr. his inr on the morning of was 1.6 and his platelet count was 97 after 1 unit transfusion. he was taken to the or for cervical wound washout and a vac dressing was applied post operatively with the plan to continue for 3 days. he tolerated his procedure very well with no complications and post operatively he was transferred to the icu for continued care due to confusion. his mental status continued to be altered and he was only following commands intermittently. the hepatology team was consulted for help in treating his hepatic encephalopathy. per recommendations he was started on lactulose and rifaximin. the infectious disease team was consulted post operatively and they felt a more appropriate abx coverage would be vancomycin to treat his infection with gpc and the ancef was discontinued. cultures grew mrsa and he continued on vancomycin. he was started on tube feeds. his mental status slowly improved. he was transferred to step down unit . he was evaluated by speech and swallow and cleared for po diet. his mental status continued to improve and he became more awake and alert and he continued lactulose and rifaximin per hepatology recommendations. his wound was monitored and was noted to be draining small amount serosanginous drainage. this will continue to be monitored. on he was cleared for discharge to rehab. he will cont vancomycin and follow up with the id team. he will also follow up with neurosurgery in 1 week for a wound check and with the liver center. medications on admission: vicoden cialis prn 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 hs (at bedtime). 3. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 4. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 5. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): goal bm's per day. 6. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day): goal bm's per day. 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. vancomycin in d5w 1 gram/200 ml piggyback sig: 1000 (1000) mg intravenous q 12h (every 12 hours): weekly cbc /c diff, crp, esr, bun/cr & vancomycin trough. all laboratory results should be faxed to infectious disease r.ns. at ( . discharge disposition: extended care facility: radius specialty discharge diagnosis: cervical wound infection hepatitis c hepatic encephalopathy thrombocytopenia 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: ?????? do not smoke. ?????? keep your wound clean/ do not immerse incision but take daily showers including getting incision wet/clean. ?????? have your incision checked daily for signs of infection. ?????? 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. for 3 months post op to promote fusion of bone. ?????? 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. followup instructions: ?????? please have your sutures removed at rehab on . ?????? please call ( to schedule an appointment with dr. to be seen in 1 week for a wound check. ?????? you do not need any imaging prior to this appointment. ?????? you need to follow up with dr. at the liver center in weeks. this appointment can be made by calling . ?????? you have a follow up with infectious disease on @ 8:50am. ** you need weekly cbc /c diff, crp, esr, bun/cr & vancomycin trough. 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. at ( or to on md in when clinic is closed. Procedure: Enteral infusion of concentrated nutritional substances Reopening of laminectomy site Central venous catheter placement with guidance Diagnoses: Thrombocytopenia, unspecified Other postoperative infection Cirrhosis of liver without mention of alcohol Chronic hepatitis C with hepatic coma Gout, unspecified Hematoma complicating a procedure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Other ascites Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site

allergies: no known allergies / adverse drug reactions attending: chief complaint: abdominal distention abdominal pain major surgical or invasive procedure: diagnostic paracentesis therapeutic paracentesis history of present illness: 56m with history of hepatitis c cirrhosis with recent hospitalization for encephalopathy and bacteremia on iv vanc through picc line presenting with worsening ascites. pt states he was "finally doing better" until a week ago when he began to develop abdominal distension. per pt, his abd girth increased from "112 to 224" in one week. he then developed pain in his llq which was sharp and similar to the pain he developed the last time he required therapeutic paracentesis. he denies recent medication or dietary changes. no fevers, chills, sweats, cp, n/v, change in bowel frequency (having 3 per day), dysuria, or blood in stool. admits to sob. brought in from rehab where he was discharged after his last hospitalization. in the ed, initial vitals/trigger: 10 97.6 102 116/79 20 100% 2l. labs significant for wbc 11.1 with 78% pmn, hct 34.5, inr 1.8, ast/alt 68/49, tbili 2.6, alb 2.7, ap 123, lipase 74, creatinine 1.4, k 3.0, na 128, lactate 1.8. got kcl 40meq x 1, morphine 5mg iv x 1. liver c/s - ruq u/s w/duplex, no need for diagnostic tap unless spike in cr or wbc --> pt had diagnostic paracentesis which showed wbc 153, 34% pmn, protein 0.4, glucose 196, rbc 350. ruq u/s final pending but prelim shows ascites, cirrhosis, patent portal vein. vs on transfer 97.6 102 116/79 20 100% 2l. on the floor 97.7, 140/80, 110, 18, 96% ra. he c/o abd pain. past medical history: -hcv cirrhosis - genotype 1 (dx secondary to ivda) with known grade i varices, hx ascites and encephalopathy, on copilot study getting peg intron in the past, d/c'ed progression of liver dx. patient was briefly on the tranplant list but was taken off when per notes he was found to have alcohol in his blood stream in /06. -thrombocytopenia -gout -hx hyponatremia and hypernatremia -history of arf -anemia -cervical neck pain s/p c3-7 laminectomies -s/p anterior and posterior laminectomy and fusion l4-s1 -s/p left inguinal repair - s/p c3-7 laminectomies social history: he is of russian descent. he currently lives with his significant other. does not smoke. he consumes approximately 6 beers weekly, but unable to obtain current alchol consumption from the pt. denies ivda in past 20 years. on disability but by report is working as a contractor. family history: mother with breast cancer. no family hx of liver disease or hemachromatosis. physical exam: admission physical examination: vitals: 97.7, 140/80, 110, 18, 96% ra general: pleasant male, appears uncomfortable but not acutely distressed. marked jaundice. aaox3 heent: perrl, eomi lungs: diffuse coarse crackles bilaterally with decreased bs at left lung base heart: rrr, normal s1 s2, no mrg abdomen: soft, markedly distended, ttp diffusely but worst over epigastrium, nabs extremities: 2+ edema in le bilat extending to thighs neurologic: a+ox3, no asterixis, 4+/5 strentgh in the lue and lle, 4/5 strength in the rle, 3+/5 strength in the rue discharge physical examination: expired @ 14:10. pertinent results: admission labs: 10:20pm blood wbc-11.1* rbc-3.13*# hgb-11.4* hct-34.5* mcv-110*# mch-36.5* mchc-33.1 rdw-16.0* plt ct-82* 10:20pm blood neuts-78.5* lymphs-13.6* monos-7.3 eos-0.3 baso-0.2 10:20pm blood pt-18.6* ptt-44.8* inr(pt)-1.8* 10:20pm blood glucose-174* urean-17 creat-1.4* na-128* k-3.0* cl-100 hco3-19* angap-12 10:20pm blood alt-49* ast-68* alkphos-123 totbili-2.6* 10:20pm blood albumin-2.7* 10:46pm blood lactate-1.8 11:40pm ascites wbc-153* rbc-350* polys-34* lymphs-18* monos-35* nrbc-1* mesothe-12* 11:40pm ascites totpro-0.4 glucose-196 urine studies: 10:00pm urine color-yellow appear-hazy sp -1.009 10:00pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 10:00pm urine rbc-<1 wbc-3 bacteri-few yeast-none epi-<1 10:48am urine hours-random creat-108 na-10 k-23 cl-15 10:48am urine osmolal-340 12:36pm urine hours-random creat-110 na-less than k-25 cl-12 12:36pm urine osmolal-344 labs on transfer to icu: 07:30am blood wbc-13.0* rbc-3.27* hgb-11.8* hct-36.4* mcv-111* mch-36.1* mchc-32.4 rdw-16.1* plt ct-77* 07:30am blood glucose-166* urean-20 creat-1.5* na-134 k-3.6 cl-102 hco3-16* angap-20 07:30am blood alt-35 ast-42* alkphos-95 totbili-2.7* 07:30am blood calcium-9.2 phos-2.7 mg-2.0 05:59am blood vanco-32.0* 05:41pm blood type-art po2-134* pco2-16* ph-7.43 caltco2-11* base xs--10 intubat-not intuba 05:41pm blood lactate-8.6* radiology ct abdomen 1. significant small bowel pneumatosis, mesenteric gas, and portal venous gas, consistent with small bowel ischemia and/or necrosis. most likely secondary to high grade small bowel obstruction with transition point in the central right lower abdomen, although entire picture may be secondary to ischemia alone. urgent surgical consultation is recommended. 2. persistent cirrhotic liver with mildly prominent periportal and retroperitoneal lymph nodes, with large volume ascites with possible layering hemorrhagic component. 3. bowel wall thickening of the ascending and descending colon, may represent ischemia, secondary inflammation, or portal enteropathy. . ruqus : 1. large amount of ascites. 2. shrunken cirrhotic liver. splenomegaly. 3. patent portal veins. brief hospital course: mr. is a 56m with a history of hepatitis c cirrhosis with recent hospitalization for encephalopathy and bacteremia who presented from rehab with 1 week of acutely worsening ascietes. his micu course is summarized below. # acute abdomen, high grade small bowel obstruction: likely secondary to cirrhosis; patient denied recent medication changes and had been eating a stable, presumably healthy diet at rehab prior to admission. there was no evidence of sbp on diagnostic paracentesis done in the ed, but it did total protein. the patient underwent a 3l therapeutic paracentesis on . he tolerated the procedure well, but shortly thereafter started complaining of nausea. over the course of 24 hours, the fluid re-accumulated, and he became increasingly nauseated, confused, and somnolent. his nausea was treated with iv onsansetron q8h and iv promethazine without relief, and his pain was treated with iv dilaudid q6h, also without relief. 24 hours after the therapeutic paracentesis, the patient spiked a fever >101, became tachycardic to the 160's, hypotensive to the 110s systolic (baseline is 140s), and so was transferred to the icu and started on iv zosyn to cover for aspiration and bacterial perotinitis secondary to the therapeutic para. pt's nausea persisted as well as constipation refractory to lactulose. ngt drained almost a liter. diagnostic tap was done which was not consistent with sbp. ct scan revealed high grade sbo and signs of small bowel pneumatosis, mesenteric gas, and portal venous gas, consistent with small bowel ischemia and/or necrosis. patient underwent urgent ex-lap. # : volume depletion vs. hepatorenal syndrome vs. post-renal failure. while on the floor, the patient was found to have a urine na<10. we gave 75g albumin infusion, without improvement, and gave a second 100g albumin the next day. the patient was transferred to the icu before we could gauge his response to the second infusion. his lasix and spironolactone were held throughout his admission. a renal ultrasound was obtained the day of icu transfer and showed no hydronephrosis. liver team recommended midodrine and octreotide as hepatorenal was most likely. this was held as patient was taken to the or for ex-lap. # confusion: hepatic encephalopathy vs. underlying infection vs. overmedication from dilaudid. the patient was continued on his home rifaximin dose; his lactulose was increased from qid to q2h when his confusion worsened post therapeutic para. his oxycodone, initially written q3h was spaced out to q6h. blood and urine cultures were drawn and showed... # bacteremia: patient had a recent hospitalization for mrsa bacteremia, and was admitted from rehab with a picc in place for iv vancomycin treatment (last dose is ). a trough was checked on hd#2 and was found to be supratherapeutic at 38. his dose that day was held with the plan to titrate the dose to levels moving forwards. blood and urine cultures were drawn and showed... # hcv cirrhosis: chronic issue. patient was continued on his home folic acid, thiamine and mvi. he was continued on his home dose of rifaximin and had his lactulose uptitrated as described above. his hospital course by systems, after surgical consultation is outlined below. in brief, he was taken emergently to the operating room for an exploratory laparotomy for an acute abdomen on . ct scan demonstrated pneumatosis intestinalis, portal venous gas and a potential bowel obstruction. please refer to dr. operative summary for additional details but in the or, he was found to have scattered intermittent hemorrhagic small bowel that all appeared viable and was not resected. there was no perforation or frankly necrotic bowel. 7l of ascitic fluid was drained. he was transferred to the surgical icu for further management. his initial course was characterized by close monitoring of his abdominal exam to assess need for takeback to the or; he improved gradually but was slow to wean from the vent and on pod 5 had escalating ventilator requirements. he was diagnosed with a pneumonia and his antibiotic coverage was broadened. he gradually improved but required multiple repeat large-volume paracentesis to keep his abdominal distention at a minimum and optimize his respiratory status. he self extubated on pod 11 but did well and remained extubated; he was transferred to the floor on pod 13. unfortunately, he had a gi bleed on pod 17 requiring significant product transfusion, an egd and colonoscopy. a particular source of bleed was not identified but he did demonstrate a pretty significant coagulopathy which was an on-going issue throughout his hospitalization as his liver function continued to worsen. he was transfused ffp and cryoprecipitate multiple times daily to support his coagulation parameters and receiving near daily paracentesis until, in the light of a worsening clinical situation and worsening lfts that both the hepatology team and transplant surgery team did not believe would improve without liver transplantation (for which he did not, unfortunately, qualify as a candidate) a family meeting was convened to discuss goals of care on . mr. was clear in mental status and was able to participate in the meeting. he expressed clear wishes that he did not wish to receive care if he did not have a changes to recover. he was made dnr/dni and one day later, made comfort measures only, with only a dilaudid gtt and ivf left running with intermittent pain meds and haldol for breakthrough pain/agitation. his pain regimen was optimized and he appeared comfortable on , and he was transferred to the floor that day. on he qualified for inpatient hospice care, and on the advice of his hospice team, his medications were gradually titrated up over then next few days to keep him comfortable. finally, during the afternoon of , he was noted to have shallow and irregular respirations, and he ceased breathing entirely shortly thereafter. he was pronounced dead at 14:10. his family was notified. neuro: he was intubated and sedated post-op until when he self-extubated. post-extubation, his mental status waxed and waned, with encephalopathic confusion interchanged with brief but real moments of clarity. he was treated with propofol, fentanyl and versed initially and these were weaned with a preference to fentanyl to minimize the cardiovascular effects of propofol and the liver clearance associated with benzodiazepines. he was alert after his second surgical icu stay and took part in the discussions to withdraw aggressive care in favor of comfort measures only. cv: he was initially on multiple vasopressors post-operatively but these were weaned relatively quickly. he remained hemodynamically stable in the large part and this was not an active issue. respiratory: he remained intubated post-operatively with the potential to take him back to the or and in light of the fluid and product resuscitation he received in and out of the or. his respiratory status was improving with plans to extubate but worsened acutely on pod 5 and he was believed to potentially have an aspiration event despite the ett. he was noted to have a worsening rll consolidation on cxr and was started on broad spectrum antibiotics -- meropenem to treat a multidrug resistant klebsiella pneumonia (see id section for more details). gastrointestinal: he was initially improving post-operatively but by pod 5 had a recurrently distended abdomen. kub demonstrated ileus but repeat imaging with bedside ultrasound demonstrated worsening ascities; he was ultimately tapped on pod 9 and thereafter received frequent large-volume paracentesis through his hospitalization. unfortunately his liver function enzymes continued to worsen and he was not a transplant candidate due to his prior history. he was briefly transferred to the floor on , relatively stable. he returned to the sicu on with an ugi bleed (hematemesis on the floor, transferred to the intensive care until febrile with a total of 8u prbc, 5u ffp, and 1u platelets. colonoscopy and egd did not demonstrate an obvious source. his hct eventually normalized with correction of his coagulopathy (his fibrinogen level was noted to be in the 60s). however, he required frequent repeated cryoprecipitate and ffp transfusions to maintain his fibrinogen level and inr in acceptable ranges (as was being done initially in his hospitalization). he was hemodynamically stable in the latter days of his hospitalization but his coagulation parameters continued to worsen without product transfusion. nutrition: he was npo initially, then transitioned to tube feeds and ultimately these were dc'd after fear of aspiration (worsening vent requirements on pod 5) in favor of tpn. he was ultimately transitioned back to tube feeds and after extubation tolerated a regular diet while he was on the floor. gu: he was in acute renal injury on admission and initially post-operatively. he recovered to a normal cr which then worsened again on his repeat admission to the icu. id: he was initially on vanc/zosyn, this was transitioned to vanc//micafungin. he was on the vancomycin for gpcs in his blood cultures (believed to potentially be from a spinal source as he was treated for this in the past). the vancomycin was to continue indefinitely until reimaging of his spine. his meropenem and micafungin were in relation to his pneumonia treatment and were scheduled to stop after a full two week course to end on . these were dc'd at that time, which also happened to coincide with the family meeting and the decision to transition him to comfort measures only -- at which point all antibiotics were dc'd. medications on admission: amlodipine 5 mg po daily hold for sbp <100 fluticasone propionate nasal 2 spry nu daily folic acid 1 mg po daily furosemide 40 mg po daily lactulose 30 ml po qid hold for >6 bms per day lidocaine 5% patch 1 ptch td daily 12h on, 12h off multivitamins 1 tab po daily omeprazole 20 mg po daily rifaximin 550 mg po bid spironolactone 50 mg po daily vancomycin 500mg iv q12h thiamine 100 mg po daily acetaminophen 500 mg po q8h:prn pain do not exceed 2g in 24 hours bisacodyl 10mg pr prn constipation milk of mag 30ml po prn bedtime albuterol inhaler puff ih q6h:prn sob/wheezing tramadol (ultram) 50 mg po q6h:prn pain discharge medications: expired @ 14:10 discharge disposition: extended care discharge diagnosis: hcv cirrhosis ascites discharge condition: expired @ 14:10 discharge instructions: expired @ 14:10 followup instructions: expired @ 14:10 md, Procedure: Venous catheterization, not elsewhere classified 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 Percutaneous abdominal drainage Percutaneous abdominal drainage Exploratory laparotomy Arteriography of other intra-abdominal arteries Flexible sigmoidoscopy Dilation of intestine Injection or infusion of oxazolidinone class of antibiotics Diagnostic ultrasound of abdomen and retroperitoneum Diagnoses: Acidosis Thrombocytopenia, unspecified Anemia of other chronic disease Cirrhosis of liver without mention of alcohol Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hepatorenal syndrome Severe sepsis Portal hypertension Acute respiratory failure Defibrination syndrome Pneumonitis due to inhalation of food or vomitus Septic shock Other ascites Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Encounter for palliative care Do not resuscitate status Hematemesis Hemorrhage of gastrointestinal tract, unspecified Esophageal varices in diseases classified elsewhere, without mention of bleeding Unspecified intestinal obstruction Pneumonia due to Klebsiella pneumoniae Methicillin resistant Staphylococcus aureus septicemia Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft Nontraumatic compartment syndrome of abdomen Acute hepatitis C with hepatic coma Other and unspecified alcohol dependence, episodic

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: delirium major surgical or invasive procedure: removal of left tibial hardware left tibial washout with wound vac placement history of present illness: history limited by patient's decreased mental status, with collateral obtained from orthopedic floor team and chart. this is a 42 yo male with a history of dm, osa, seizure disorder, bipolar disorder who was admitted to orthopedics on for removal of external fixator and orif of his left tibial plateau fracture. this am (pod #2), he was found to be somnolent and oriented times one, from a baseline of full orientation. his chem 7 revealed an am glucose of 28, with fs of 44. he was given juice with added sugar, briefly increased to 97, but then fs decreased to 41. he then received amp of d50 and repeat fingerstick was 98. merit was called for medicine consultation given hypoglycemia and altered mental status, in addition to new renal failure in the setting of oliguria. at the time of merit resident assessment, the patient was somnolent and would arouse to voice, able to state his name and that he was in a hospital, date was "friday," but would fall asleep quickly. he was noted to have occasional jerks of his extremities suggestive of asterixis. also, he was on 4l of o2 by nc given hypoxia to 88% on ra, which is new. his most recent vs were: 100/48 90 18 95%,3l. an abg was obtained and only showed mild co2 retention. the micu resident was notified of his issues and it was agreed to transfer to the icu for closer monitoring. regarding his recent hospitalization, he was admitted to from after a motorcycle accident and underwent external fixation of a left tibial plateau fracture, left proximal fibula fracture, with fasciotomies for compartment syndrome on the left lower extremity. this was notable for development of post-op agitated delirium, which was comanaged with psychiatry. upon arrival to the icu, the patient was minimally responsive and quite sleepy, however was following commands. past medical history: htn dm seizure disorder ptsd and bipolar disorder osa, reportedly noncompliant with cpap in hospital social history: denies etoh or substance use to me. per omr, h/o incarceration for shooting his wife in the context of a drinking binge. family history: nc physical exam: micu admission physical: vs: temp: 98.9 bp:140/53 hr:95 rr:10 o2sat 97% 2 l gen: pleasant, comfortable, nad heent: pupils constricted and minimally responsive, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, soft systolic murmur heard throughout precordium, no gallops/rubs abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: warm, well perfused; no cyanosis, no edema; bandage on left leg is c/d/i; skin: no rashes/no jaundice/no splinters neuro: aaox3. moving extremities and following commands. no sensory deficits to light touch appreciated. pertinent results: 11:28am glucose-164* urea n-17 creat-1.0 sodium-137 potassium-5.0 chloride-104 total co2-25 anion gap-13 11:28am estgfr-using this 11:28am wbc-24.2*# rbc-3.17* hgb-8.7* hct-27.1* mcv-85 mch-27.5 mchc-32.3 rdw-13.9 11:28am plt count-643*# 11:28am pt-15.1* ptt-28.6 inr(pt)-1.3* 05:36am blood ck(cpk)-546* 07:20am blood asa-negative ethanol-negative acetmnp-10 bnzodzp-negative barbitr-negative tricycl-negative 07:20am blood lithium-1.0 07:20am blood tsh-1.5 11:13am urine color-amber appear-clear sp -1.017 11:13am urine blood-neg nitrite-pos protein-75 glucose-neg ketone-tr bilirub-sm urobiln-12* ph-7.0 leuks-sm 11:13am urine rbc-0 wbc-* bacteri-many yeast-none epi-0 01:02pm urine osmolal-236 01:02pm urine hours-random urean-257 creat-152 na-11 k-25 cl-14 . cxr there are low lung volumes. mild cardiomegaly is accentuated by the low lung volumes. the lungs are grossly clear. there is no pneumothorax or pleural effusion. . other labs: 06:25am blood ck(cpk)-266 06:25am blood lithium-1.0 . discharge labs: 06:55am blood wbc-12.5* rbc-3.27* hgb-9.3* hct-28.0* mcv-86 mch-28.3 mchc-33.1 rdw-14.6 plt ct-418 06:55am blood glucose-128* urean-7 creat-0.9 na-138 k-4.1 cl-103 hco3-29 angap-10 06:55am blood calcium-9.2 phos-3.2 mg-1.6 brief hospital course: 42yo m with bipolar d/o, type ii dm, and osa originally admitted to orthopedics for hardware removal who was transferred to the micu for hypoglycemia and delerium. when sugars and metal status had improved, he was tranfered to the medical floor. . # left tibial fracture s/p orif: initially admitted to the hospital from rehab for removal of external fixator on . postoperative pain was managed with tylenol atc and low dose oxycodone prn. he went back to the or for a washout on . pt saw patient and recommended home with home pt. . #. altered mental status: likely multifactorial including hypoglycemia, infection, and medication build up from arf causing decreased elimination. notably, seroquel, ativan, lithium, duloxetine, dilaudid, and gabapentin build up in setting of arf. psych was consulted who recommended putting patient on a bzd taper, which he finished on the day of discharge. he was also started on haloperidol 5mg tid. over, time, the patient's delirium improved, and haloperidol was d/c prior to discharge. his qtc was monitored while on haloperidol and did not prolong. he was found to have a urinary tract infection (see below). #. hypoglycemia: patient transferred to micu in setting of ams with hypoglycemia in 40s. etiology of hypoglycemia likely caused by medication error as patient was started on glyburide 10mg following surgery. furthermore, clearance of glyburide was reduced given acute kidney injury (see below). hypoglycemia was corrected with d10 and d5 gtt which were weaned off once blood sugar had normalized, and patient was called out to the medical floor. he was maintained on sliding scale humalog on the floor and will be discharged home with his outpatient dose of metformin. . # uti: urine culture from grew pseudomonas. patient was initially treated with zosyn, and when the organism was found to be fairly pan-sensitive, he was switched to po ciprofloxacin to complete a 14 day course for a complicated uti as patient had a foley in the micu which was d/c upon transfer to the floor. . # low grade fever, leukocytosis: improved with initiation of treatment for uti, but source was unclear initially. lateral leg incision was draining serosanguinous fluid, and orthopedics took pt back to or for a washout . he was put on ancef initially then switched to vanco for gram (+) coverage. wound gram stain showed pmns but no organisms, and cultures were negative. per ortho recs, pt will be d/c with a 2 week course of keflex. . #. acute renal failure: oliguric on admission. fena 0.2% that was consistent with pre-renal etiology and resolved with fluids. his home enalapril was initially held but re-started when arf resolved. pt was prophylaxed with sq heparin initially, then switched back to lovenox when arf resolved. he should continue lovenox as an outpatient as laid out by ortho. . #. hypoxia: on admission to micu, abg c/w hypercapnia likely hypoventilation given patient's ams. resolved with resolution of delirium. . # anemia: hct down to low 20's from baseline of high 20's. had 700 cc of ebl in or, anemia most likely from or blood loss. received 2units rbc's and hct bumped appropriately and was stable throughout the rest of the admission . #. bipolar disorder/ptsd: initially held home seroquel, clonazepam, ativan, trazodone, duloxetine, lithium in setting of arf and ams. slowly restarted meds and renal doses which were changed back to home doses once renal function returns. however, pt was tapered of bzds as noted above and will be discharged without any lorezapam or clonazepam. . #. osa: reportedly noncompliant with cpap in micu, but did not showing evidence of apnea on monitor. however, on the medical floor, pt was using his cpap and tolerating it well. . #. seizure disorder: held gabapentin/bzds in setting of arf and slowly restarted and titrated back to home dose when arf resolved. . #. htn: given low dose of diltiazem, in preparation for discharge, dilz was d/c and enalapril was increased to 20mg daily. pt will follow up with pcp upon /c. . #. hyperlipidemia: held gemfibrozil in setting of arf and elevated ck. continued pravastatin upon discharge. medications on admission: home medications 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. enoxaparin 40 mg/0.4 ml syringe sig: one (1) syringe subcutaneous daily (daily) for 4 weeks. 4. lithium carbonate 300 mg tablet sustained release sig: two (2) tablet sustained release po bid (2 times a day). 5. clonazepam 0.5 mg tablet sig: four (4) tablet po daily (daily) as needed for prn anxiety. 6. gabapentin 300 mg capsule sig: three (3) capsule po q8h (every 8 hours). 7. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h:prn as needed for pain. 8. quetiapine 300 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 9. enalapril maleate 10 mg tablet sig: one (1) tablet po daily (daily). 10. glucophage 1,000 mg tablet sig: one (1) tablet po twice a day. 11. pravastatin 80 mg tablet sig: one (1) tablet po once a day. 12. cymbalta 60 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po once a day. 13. diltiazem hcl 30 mg tablet sig: one (1) tablet po once a day. 14. trazodone 100 mg tablet sig: two (2) tablet po at bedtime. 15. ativan 0.5 mg tablet sig: 1-2 tablets po tid: prn. discharge medications: 1. lithium carbonate 300 mg tablet sustained release sig: two (2) tablet sustained release po bid (2 times a day). 2. enoxaparin 40 mg/0.4 ml syringe sig: one (1) injection subcutaneous daily (daily). 3. enalapril maleate 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 4. gabapentin 300 mg capsule sig: three (3) capsule po tid (3 times a day). 5. quetiapine 300 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po qhs (once a day (at bedtime)). 6. trazodone 100 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for sleep. 7. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours). disp:*240 tablet(s)* refills:*2* 8. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain not relieved by tyenol. disp:*10 tablet(s)* refills:*0* 9. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. disp:*14 tablet(s)* refills:*0* 10. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 11. pravastatin 80 mg tablet sig: one (1) tablet po once a day. 12. docusate sodium 100 mg capsule sig: one (1) capsule po once a day: hold for loose stools or more than 2 bowels movements per day. 13. senna 8.6 mg tablet sig: two (2) tablet po at bedtime: hold for loose stools or more than 2 bowels movements per day. disp:*60 tablet(s)* refills:*2* 14. keflex 500 mg capsule sig: one (1) capsule po twice a day for 2 weeks. disp:*28 capsule(s)* refills:*0* 15. duloxetine 60 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po once a day. discharge disposition: home with service facility: all care vna of greater discharge diagnosis: primary: s/p hardware removal and washout left tibia urinary tract infection . secondary: diabetes sleep apnea 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: mr. , . thank you for coming to for your medical care. you were admitted to the hopital so the orthopedic surgeons could remove the hardware from your left leg. your blood sugar got low, so you were transfered to the medical intensive care unit (micu). you were also confused in the micu. when your sugars were stable, you came to the regular medical floor. the surgeons took you back to the or to clean the operation site. you were started on antibiotics for a urinary tract infection. you should continue to take ciprofloxacin for 7 more days to finish your course. . we made the following changes to your medications: - please stop taking ativan (lorezapam) and klonapin (clonazepam). the psychiatrists thought these medicines contributed to your confusion. - please stop taking glyburide. we think this is responsible for your low sugars. - please start taking ciprofloxacin 500mg twice a day for the next 7 days. - please start taking keflex (cephalexin) 500mg twice a day - please stop taking diltiazem. - please increase your enalapril to 20mg daily - you may take tylenol (acetaminophen) 1000mg every 6 hours for pain. you may take 5mg of oxycodone every 4 hours for pain not relieved by tylenol. we have given you a small supply of pain medicine. you should discuss the amount of pain you are having when you see your primary care doctor later this week. - while on the oxycodone, please take docusate and senna regularly to prevent constipation. stop taking these medications if you have loose stools or more than 2 bowel movements in one day. - please continue taking enoxaparin injections twice a day for at least 2 more weeks. you should discuss the need for this medication when you see the orthopedic surgeons. followup instructions: you should call your psychiatrist to make an appointment. . name: thavaseelan, s. location: internists address: , , , phone: appointment: thursday 11:30am . department: orthopedics when: thursday at 12:00 pm with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage . department: orthopedics when: thursday at 12:20 pm with: , np building: campus: east best parking: garage Procedure: Other incision with drainage of skin and subcutaneous tissue Open reduction of fracture with internal fixation, tibia and fibula Closed reduction of fracture without internal fixation, tibia and fibula Removal of implanted devices from bone, tibia and fibula Diagnoses: Acidosis Obstructive sleep apnea (adult)(pediatric) Other postoperative infection Urinary tract infection, site not specified Acute posthemorrhagic anemia Acute kidney failure, unspecified Other and unspecified hyperlipidemia Cellulitis and abscess of leg, except foot Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Epilepsy, unspecified, without mention of intractable epilepsy Hypoxemia Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Bipolar disorder, unspecified Delirium due to conditions classified elsewhere Closed fracture of upper end of fibula with tibia Pseudomonas infection in conditions classified elsewhere and of unspecified site Posttraumatic stress disorder Other noncollision motor vehicle traffic accident injuring motorcyclist

allergies: penicillins / quinidine attending: chief complaint: fatigue major surgical or invasive procedure: none history of present illness: mr is an 84 yo m with a history of biventricular heart failure, atrial fibrillation, icd and cad s/p cabg who presented today to dr. clinic for his usual follow up. on evaluation the patient was found to be fluid overloaded and was directly admitted to the ccu. . the patient reports that over the last 1.5 months he has had progressive fatigue and weakness. during this time he has also noted an increase in his weight from a baseline of 151 lb to a peak weight of 171 lbs. approximately a month ago the patient's lasix was changed to torsamide which improved his weight by a few pounds. however, the patient has continued to feel unwell. he notes that prior to these changes, the patent had a decrease in his digoxin from 1 tab daily to tab every other day, secondary to "toxicity". he notes not other acute issue preceeding his decline including no chest pain, no acute dyspnea, no change in his diet or other symptoms. he has had persistent dyspnea on exertion for two months with 200 yards walking, though he does not think that it has worsened. . on review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, myalgias, joint pains, 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, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: cardiac history: - mi x2 -cabg: 4 vessel -percutaneous coronary interventions: -pacing/icd: - pacemaker placed for sick sinus syndrome - upgrade to -v icd in - generator change , pocket revision (lead protruding from skin) - s/p vt ablation - atrial fibrillation - systolic, diastolic chf last ef: other past medical history: ischemic cardiomyopathy-lvef 30% hypertension hyperlipidemia prior tia??????s with aphasia (none in the past 4 years) orchiectomy due to a gunshot wound sustained in the service central retinal vein occlusion social history: -tobacco history: quit smoking approx 25 years ago, did have heavy pipe/cigar smoking for approx 8-10 years -etoh: rare glass of wine -illicit drugs: none served in the army family history: no family history of early mi, otherwise non-contributory. physical exam: height: 66 inch, 168 cm weight: 161.5 kg t 97 bp 105/63 rr 19 02 96% ra eyes: (conjunctiva and lids: wnl) ears, nose, mouth and throat: (oral mucosa: wnl), (teeth, gums and palette: wnl) neck: (right carotid artery: bruit present), (left carotid artery: no bruit), (jugular veins: jvp, ~20 cm), (thyroid: wnl) back / musculoskeletal: (chest wall structure: wnl) respiratory: (effort: wnl), (auscultation: abnormal, crackles in lower of posterior lung fields) cardiac: (rhythm: regular), (palpation / pmi: abnormal, laterally displaced pmi), (auscultation: s1: wnl, systolic murmur loudest at the llsb ) abdominal / gastrointestinal: (bowel sounds: wnl), (bruits: no), (pulsatile mass: no), (hepatosplenomegaly: no) genitourinary: (wnl) extremities / musculoskeletal: (dorsalis pedis artery: right: 1+, left: 1+), (edema: right: 2+, left: 2+), (extremity details: to kneew) skin: (abnormal, multiple ecchymoses) pertinent results: basic admission labs: 08:17pm wbc-4.7 rbc-3.71* hgb-12.0* hct-34.5* mcv-93 mch-32.3* mchc-34.7 rdw-15.6* 08:17pm neuts-68.2 lymphs-22.3 monos-8.1 eos-1.2 basos-0.2 08:17pm glucose-120* urea n-93* creat-3.1*# sodium-134 potassium-5.1 chloride-97 total co2-23 anion gap-19 cardiac labs: 08:17pm blood probnp-* 04:58am blood digoxin-0.9 tfts 08:17pm blood tsh-6.9* 03:39pm blood t4-8.0 calctbg-0.87 tuptake-1.15 t4index-9.2 echo: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50%) secondary to hypokinesis of the inferior and posterior walls; the other walls are hyperdynamic. there is no ventricular septal defect. the right ventricular cavity is dilated with severe global free wall hypokinesis. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (area 1.2-1.9cm2). mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. brief hospital course: 84 yo m with history of diastolic and systolic heart failure who presents with significant volume overload. . # acute on chronic systolic congestive heart failure: there was likely a large contribution from tricuspid regurgitation. on admission, patient noted to have 15-20 lb weight gain and significantly elevated jvp. the precipitating event was unclear, but possibly related to recent medication changes. he was started on a dopamine gtt and lasix gtt with good response in terms of blood pressure and urine output. he diuresed ~1 l daily for 4 days, after which lasix drip was slowly weaned and outpatient diuretic-torsemide-was restarted. dopamine drip was also weaned, and blood pressure fell back to baseline sbp 80s. he was stabilized on a regimen of torsemide 50 mg in the morning and 25 mg in the evening. he will need electrolyte and creatinine follow-up by his pcp. addition, his digoxin dose was increased to .0625 mg daily, and aminophylline (theophylline) was started. he will need levels checked on both of these medications at his visit on . . # atrial fibrillation: patient was anticoagulated on admission for a history of atrial fibrillation. he remained in av paced rhythm and anticoagulated throughout his stay. inr on discharge was 2.3. inr follow-up will be with visiting nurse. . # acute on chronic renal failure: creatinine on admission was elevated from baseline 1.5-2.0 to 3.1. this was most likely prerenal in the setting of poor forward flow from heart failure. creatinine improved to baseline with diuresis. creatinine on discharge was 2.0. . # hematuria: patient was noted to have clots in his foley catheter that were unable to be manually irrigated. a triple lumen 22-french catheter was placed, and continuous bladder irrigation was started, with resolution of clots. urology was consulted and recommended work-up of hematuria to include abdominal ct, urine cytology, and outpatient follow-up for cystoscopy. ct did not show any stone or other clear inciting abnormality. an appointment was made with urology for outpatient follow-up of the cytology and possible cystoscopy. # hypothyroid: the patient was found to be hypothyroid with tsh 6.9. this was likely attributable to amiodarone treatment. low dose levothyroxine (25 mcg daily) was started. he will need tsh checked again in 6 weeks by his pcp. . # pyuria: the patient had wbc on urinalysis the day prior to discharge. culture was not growing. he will need to have a repeat urinalysis at his appointment with his pcp 2 days. medications on admission: amiodarone 100 mg daily aggrenox 25/200 mg daily torsemide 50 mg twice daily carvedilol 3.125mg coumadin 2.5 mg daily except 5 mg on mwf zocor 10 mg daily digoxin 0.0625 mg every other day (decreased from his last visit). discharge medications: 1. dipyridamole-aspirin 200-25 mg cap, multiphasic release 12 hr sig: one (1) cap po daily (daily). 2. amiodarone 100 mg tablet sig: one (1) tablet po once a day. 3. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 5. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. warfarin 5 mg tablet sig: one (1) tablet po days (mo,we,fr). 7. warfarin 2.5 mg tablet sig: one (1) tablet po days (,tu,th,sa). 8. aminophylline 100 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 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. torsemide 20 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). tablet(s) 11. torsemide 5 mg tablet sig: one (1) tablet po qpm. disp:*30 tablet(s)* refills:*2* 12. torsemide 100 mg tablet sig: .5 tablet po qam (once a day (in the morning)). disp:*15 tablet(s)* refills:*2* 13. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 14. digoxin 125 mcg tablet sig: .5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: primary: acute exacerbation of chronic diastolic congestive heart failure secondary: atrical fibrillation, hypertension, hyperliidemia discharge condition: hemodynamically stable, euvolemic discharge instructions: you were admitted to due to worsening heart failure. you were treated with iv medications to remove extra fluid. you also had some blood in your urine. this may have been from the catheter palcement, but you should see a urologist after discharge to see if other studies are needed. changes were made to your home medications: digoxin was increased torsemide was changed to 50 mg in the morning and 25 mg in the evening levothyroxine was added aminophylline was added please keep your follow up appointments as below. please call your doctor if your weight increases by more than 3 pounds. please return to the emergency department if you have chest pain, shortness of breath, high fevers and chills, or other symptoms that are concerning to you. adhere to a 2 gm sodium diet. fluid restriction: 1.5 liters of fluid intake per day. followup instructions: you have an appointment this , , at 10 a.m. to see pat () at your pcps office. we spoke with their office and they are aware of the tests that are needed as well as medication changes that were made. a summary of your hospitalization will be faxed to that office prior to the appointment. you also have the following appointments: urology: phone: date/time: 2:45 cardiologist: dr. on at 2 pm. cardiologist: , m.d. phone: at 3:20 pm. Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Other genitourinary instillation Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortocoronary bypass status Personal history of tobacco use Chronic kidney disease, unspecified Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Old myocardial infarction Long-term (current) use of anticoagulants Pressure ulcer, buttock Automatic implantable cardiac defibrillator in situ Hematuria, unspecified Other specified retention of urine Tricuspid valve disorders, specified as nonrheumatic Pressure ulcer, stage I Acute on chronic combined systolic and diastolic heart failure Cardiac rhythm regulators causing adverse effects in therapeutic use Other specified acquired hypothyroidism Abnormal weight gain Urinary obstruction, unspecified

allergies: penicillins / quinidine attending: chief complaint: fatigue major surgical or invasive procedure: dccv history of present illness: 84 yo male with a history of biventricular heart failure, atrial fibrillation, icd and cad s/p cabg who was directly admitted to the ccu today from dr. clinic for medical treatment of volume overload. according to the patient's daughter, his primary complaint is fatigue. he feels "whole body" fatigue with minimal exertion. he was able to walk approximately 5 minutes without fatigue in the past, however recently has required resting for minimal movement including going from sitting to standing position. the patient reports improvement of bl le edema, however increased amount of ascites. the daughter also reports decreased appetite. on review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, myalgias, joint pains, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. past medical history: cardiac history: - mi x2 - cabg: 4 vessel - percutaneous coronary interventions: - pacing/icd: - pacemaker placed for sick sinus syndrome - upgrade to -v icd in - generator change , pocket revision (lead protruding from skin) - s/p vt ablation - atrial fibrillation - systolic, diastolic chf last ef: 50% with lv hypertrophy and severe global rv free wall hypokinesis and 4+ tr other past medical history: hypertension hyperlipidemia prior tia??????s with aphasia (none in the past 4 years) orchiectomy due to a gunshot wound sustained in the service central retinal vein occlusion cardiac risk factors: htn, hyperlipidemia, former smoker social history: -tobacco history: quit smoking approx 25 years ago, did have heavy pipe/cigar smoking for approx 8-10 years -etoh: rare glass of wine -illicit drugs: none served in the army family history: no family history of early mi, otherwise non-contributory physical exam: vs: hr 77 bp 120/75 rr 15 o2 99% general: elderly man in nad heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink. hematoma on left anterior forehead with surrounding ecchymoses. neck: supple with jvp of anterior ear cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. holosystolic murmur at llsb. 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, ascites present, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: 2+ pitting edema to the thigh bl le. no femoral bruits. skin: no stasis dermatitis, ulcers, scars. pulses: right: carotid 2+ femoral 2+ dp 1 pt 1 left: carotid 2+ femoral 2+ dp 1 pt 1 pertinent results: ecg: v paced rhythm at 75, with possible atrial flutter at a rate of 150bpm. telemetry: v paced rhythm at 75 bpm admission labs: 07:52pm glucose-113* urea n-63* creat-2.0* sodium-137 potassium-4.1 chloride-99 total co2-26 anion gap-16 07:52pm probnp-6409* 07:52pm calcium-8.9 phosphate-3.3 magnesium-2.0 07:52pm tsh-7.2* 07:52pm digoxin-0.4* 07:52pm wbc-4.5 rbc-3.17* hgb-10.0* hct-29.4* mcv-93 mch-31.4 mchc-33.9 rdw-17.5* 07:52pm plt count-153 07:52pm pt-36.6* ptt-38.9* inr(pt)-3.9* brief hospital course: 1. chf exacerbation: biventricular failure secondary to ischemic cardiomyopathy, right sided failure secondary to left sided failure. the patient has severe tricuspid regurgitation, moderate mitral and aortic regurgitation on recent tte. the patient does not have typical chf symptoms considering his severe tr. his symptomatic equivalent is fatigue and whole body weakness. it seems that he has progressed over the past few months from stage 3 nyha classification to stage 4, with symptoms with minimal exertion/rest. on admission, the patient was very volume overloaded. he was treated with iv lasix drip with good diuresis. diuresis with lasix drip was initiated, with weaning and placement on torsemide 80mg po daily he did not have adequate urine output and was thus placed back on the lasix gtt until discharge. as his bps were low with the lasix gtt a picc line was placed and dopamine was initiated to maintain adequate blood pressures while aggressive diuresis. he was continued on digoxin. held carvedilol initially given attempt at diuresis and risk of hypotension, however then this medication were reinitiated to help control af. held midodrine and aminophylline given dopamine treatment and risk of tachyarrhytmias initially, then once weaned off dopamine, these medications were restarted. aminophylline was increased to 100mg . his torsemide was increased to 100mg for discharge. he also was instructed to take metolazone daily prior to his am dose of torsemide. lasix drip was continued untill discharge when he was sent home on metolazone and torsemide. 2. atrial flutter: the patient has been in atrial fibrillation regardless of attempts at chemical cardioversion with amiodarone in the past. it appeared on 12 lead from admission that the patient is in atrial flutter at a rate of 150bpm. continued amiodarone. continued carvedilol. continued coumadin, monitored inr daily. 3. cad s/p cabg: continued simvastatin, aggrenox. coreg was held given hypotension initially and then re-started. 4. history of tias: continued aggrenox. 5. bph: continued flomax, with holding parameters. 6. cataracts: continued opthalmic treatments including predfort, acular, zymar, and cosopt. 7. gout: continued colchicine 8. hypothyroidism: the patient's daughter reports that they did not initiate levothyroxine therapy given unclear results. tsh elevated but t4 and free t3 within normal limits. did not make any changes to medications. 9. long term goal: palliative care was involved and discussion with patient and family took place re: long term goals of care. the decision to eventually go home with home care, and think about hospice care in the future. medications on admission: midodrine 5mg 1 po qam, then 6 hours later colchicine 0.6mg torsemide 50mg metolazone 5mg (1 or tablet) prior to torsemide dosing flomax 0.4mg qd aminophylline 50mg qd kcl 10 meq qd amiodarone 100mg qd carvedilol 3.125mg digoxin 125mcg tab qd aggrenox 1 cap qd simvastatin 10mg qd coumadin 5mg qd predfort opthalmic cosopt opthalmic zymar opthalmic acular opthalmic discharge medications: 1. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). 2. dipyridamole-aspirin 200-25 mg cap, multiphasic release 12 hr sig: one (1) cap po bid (2 times a day). 3. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 4. digoxin 125 mcg tablet sig: 0.5 tablet po daily (daily). 5. amiodarone 200 mg tablet sig: 0.5 tablet po daily (daily). 6. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic qid (4 times a day). 7. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 8. ketorolac tromethamine 0.5 % drops sig: one (1) ophthalmic qid (4 times a day). 9. ciprofloxacin 0.3 % drops sig: 1-2 drops ophthalmic q6h (every 6 hours). 10. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 11. aminophylline 100 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 12. warfarin 2 mg tablet sig: 1.5 tablets po once daily at 4 pm. disp:*60 tablet(s)* refills:*2* 13. potassium chloride 10 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day. 14. torsemide 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 15. metolazone 5 mg tablet sig: one (1) tablet po once a day: please take 1 hour prior to torsemide dosing, if weight is increased by 2lbs. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnoses: biventricular congestive heart failure atrial fibrillation/atrial flutter . secondary diagnoses: hypertension hyperlipidemia prior tia??????s with aphasia (none in the past 4 years) orchiectomy due to a gunshot wound sustained in the service central retinal vein occlusion discharge condition: the patient was hemodynamically stable at discharge. discharge instructions: you were admitted to for evaluation and treatment of your heart failure. you were treated with iv medications to help remove excess fluid. you were changed back to most of your home medications prior to discharge, the changes are below. . these medications were changed: - aminophylline increased to 100mg - torsemide increased to 100mg - metolazone to be taken one hour prior to dose of torsemide in the event that your weight is 2lbs higher than the previous day - coumadin decreased to 3mg qd, please check your inr in 2 days and adjust the coumadin dose accordingly . these medications were discontinued: - midodrine . you should continue to weigh yourself every morning, your md if your weight increases by 2 lbs. if your weight is elevated, please take 5mg of metolazone 1 hour prior to your torsemide dose. please attempt to restrict your fluid intake to 1l per day. please decrease the amount of salt intake to 2gm per day. . if you experience worsening fatigue, whole body weakness, shortness of breath, chest pain, fever, chills or any other worrisome symptoms please seek medical attention. followup instructions: please follow up with your primary cardiologist, dr. , in 2 weeks regarding your treatment. . please follow up with your primary care physician, . , in weeks. . please have your labs drawn, specifically your inr in 2 days following discharge. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Gout, unspecified Atrial fibrillation Aortocoronary bypass status Atrial flutter Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Automatic implantable cardiac defibrillator in situ Acute on chronic combined systolic and diastolic heart failure

allergies: no known allergies / adverse drug reactions attending: chief complaint: abnormal hida major surgical or invasive procedure: ercp history of present illness: mr is a 41 year od male with history of als activity limited to his upper face and ventilator dependent who was admitted to osh hospital five days ago with acute gangenous calculous choecystitis s/p cholecystectomy on . he had an intraoperative cholangiogram with no flow into the duodenum, however the glide wire passed without a problem. this was thought to be secondary to inflammation vs retained cbd stone. follow up hida on showed no biliary flow. on day of transfer lfts were slightly improved, but alk phos still elevated over 1000. he was transferred to for ercp. he was admitted to the as patient is ventilator dependent. past medical history: (+) fed through g tube without difficulty, chronic difficulites moving bowels. otherwise difficult to obtain social history: continues a close relationship with his wife and family who are dedicated to his care. vent dependent and livign at home. no etoh or tobacco. family history: factor v leiden physical exam: general appearance: no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: endotracheal 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: bronchial: , no(t) wheezes : ) abdominal: soft, bowel sounds present extremities: right lower extremity edema: absent, left lower extremity edema: absent, no(t) cyanosis, no(t) clubbing musculoskeletal: muscle wasting, unable to stand skin: warm pertinent results: from records wbc 7.5 hct 26.1 plt 329 na 140 k 3.4 cl 111 co2 25 cr 0.3 ca 7.6 tbili 2.5 tprot 5.1 alb 1.7 ast 343 alt 487 phos 2.1 mg 1.7 \ 05:32am blood wbc-8.4 rbc-2.67* hgb-8.0* hct-24.1* mcv-90 mch-29.9 mchc-33.2 rdw-14.4 plt ct-277 05:32am blood glucose-114* urean-6 creat-0.0* na-139 k-3.5 cl-109* hco3-25 angap-9 05:32am blood alt-298* ast-97* alkphos-748* totbili-1.7* ercp: impression: the major papilla was normal. cannulation of the biliary duct was successful and deep with a sphincterotome. a straight tip .035in guidewire was placed. there was filling defects that appeared like stones in the distal cbd. cbd measured 6-7 mm and intrahepatic ducts were normal. a sphincterotomy was performed using a sphincterotome over an existing guidewire. two small stones were extracted successfully using a 8.5 mm rx balloon. the final balloon-occlusion cholangiogram showed no additional filling defect. otherwise normal ercp to third part of the duodenum. brief hospital course: pt was admitted to micu in anticipation of ercp. went directly to ercp shortly following transfer. ercp was successful and unevently with balloon dilatation, spincterotomy and removal of two stones. balloon was removed. post procedure patient was well. needs to be monitored for further complications include bleeding and post ercp pancreatitis, but none were evident at time of transfer. pt was ready for discharge and getting set up for the ambulance transfer on in the evening but had difficulty with the transport ventilator, despite same settings. he started to develop non purposeful repetetive facial movements and pt was unable to communicate. symptoms did not improve with morphine or ativan, which were given due to concern of agitation/pain or possibly seizure like activity. neurology was consulted who felt symptoms were unlikely to be related to seizure, and more likley to be related to his als and resultant of a positive feed back loop activating his facial muscles. and that patient was unable to break feed back loop due to lack of strength. in the am, follow up labs showed improvement of lfts, mildly elevated amylase/lipase were thought to be related to ercp. repetetive movements were resolved, pt was back to baseline mental status, smiling and responding appropriately to yes/no questions. he continued to have few fasiculations of the face as is his basline. he also has a stable anemia post cholecystectomy. pt was otherwise continued on levofloxacin and flagyl to be completed for 14 day course for treatment of cholangitis with no changes made to medications. pt was maintained npo during his hospitalization, but diet can be advanced to clears then full tube feeds as tolerated. medications on admission: medications on transfer: duonebs q2h prn scopolamine 1.5mg daily loratidine 10mg daily methylcellulose drops both eyes q1h prn robinul acidophilus 250mg lorazepam 1mg prn heparin for picc levofloxin 750mg q24h iv sucralfate 1000mg qid prn zolpidem 5mg qhs prn zofran 4mg iv q6h prn flagyl 500mg iv q8h protonix 40mg iv daily isss discharge medications: duonebs q2h prn scopolamine 1.5mg daily loratidine 10mg daily methylcellulose drops both eyes q1h prn robinul acidophilus 250mg lorazepam 1mg prn heparin for picc levofloxin 750mg q24h iv sucralfate 1000mg qid prn zolpidem 5mg qhs prn zofran 4mg iv q6h prn flagyl 500mg iv q8h protonix 40mg iv daily isss discharge disposition: extended care discharge diagnosis: cbd obstruction discharge condition: stable, afebrile, vent dependent discharge instructions: pt transfer back to for continuity of care. pt underwent successful ercp and needs to be monitored for complications. followup instructions: n/a md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Diagnoses: Amyotrophic lateral sclerosis Cholangitis Gastrostomy status Chronic respiratory failure Tracheostomy status Dependence on respirator, status Calculus of bile duct with acute cholecystitis, with obstruction

allergies: percocet / penicillins / adhesive tape attending: chief complaint: left arm numbness major surgical or invasive procedure: coronary artery bypass x4(lima-lad,svg-om1,svg-om2,svg-pda) history of present illness: 65m with history of hypertension. he has developed left arm numbness with exertion over the previous months. this has progressed recently, coming on nocturnally and associated with shortness of breath. stress test was markedly positive for ischemia and terminated at 3.5 minutes of the standard protocol. cardiac cath revealed multi-vessel cad, including 60% left main stenosis. he is referred for surgical myocardial revascularization. past medical history: past medical history: coronary artery disease, hypertension, obesity, hyperlipidemia past surgical history: cholecystectomy, right total knee replacement, left knee arthroscopy, left shoulder arthroscopy social history: lives with: wife (ill, requiring transfusions), mother-in-law in nsg home, son- suicide last year occupation: accounting cigarettes: smoked no yes hx: other tobacco use:never etoh: < 1 drink/week drinks/week >8 drinks/week illicit drug use: denies family history: family history: no premature coronary artery disease father mi < 55 mother < 65 physical exam: physical exam pulse: resp: o2 sat: 94% ra b/p right:150/78 left:154/84 height: weight:278 general:wdwn in nad skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur grade ______ abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema no varicosities: none neuro: grossly intact pulses: femoral right: left: dp right:2 left:2 pt :2 left:2 radial right:2 left: 2 carotid bruit right:n left:n pertinent results: 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 (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 a very small pericardial effusion. dr. was notified in person of the results before surgical incision. post_bypass: preserved biventricular systolic function. lvef 55%. intact thoracic aorta. no new wall motion abnormalities. 05:50am blood wbc-10.6 rbc-2.83* hgb-10.6* hct-30.3* mcv-107* mch-37.3* mchc-34.8 rdw-13.6 plt ct-187 04:39am blood wbc-11.5* rbc-3.03* hgb-11.1* hct-32.8* mcv-108* mch-36.7* mchc-33.9 rdw-14.0 plt ct-155 05:50am blood glucose-137* urean-16 creat-1.3* na-131* k-4.3 cl-99 hco3-24 angap-12 04:39am blood glucose-131* urean-14 creat-1.4* na-132* k-4.2 cl-101 hco3-25 angap-10 brief hospital course: the patient was brought to the operating room on where the patient underwent cabg x4(lima-lad,svg-om1,svg-om2,svg-pda). 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. the patient was evaluated by the physical therapy service for assistance with strength and mobility. he was placed on free water restriction for hyponatremia. 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: atenolol 50mg daily,ecasa81mg daily,pravastitn 40mg daily discharge medications: 1. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). disp:*30 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. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 5. furosemide 20 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 6. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po once a day for 5 days. disp:*10 tablet extended release(s)* refills:*0* discharge disposition: home with service facility: all care vna of greater discharge diagnosis: coronary artery disease, s/p cabg pmh: hypertension obesity hyperlipidemia past surgical history: cholecystectomy, right total knee replacement, left knee arthroscopy, left shoulder arthroscopy 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 edema: trace 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 care, phone: date/time: 10:15 surgeon dr. , 1:00 please call to schedule the following: cardiologist dr. 2 weeks primary care in weeks , **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Hyposmolality and/or hyponatremia Other and unspecified hyperlipidemia Obesity, unspecified Knee joint replacement Balanitis xerotica obliterans

allergies: dogs / seasonal allergies attending: chief complaint: epigastric pain major surgical or invasive procedure: : diagnostic laparoscopy, open cholecystectomy with shaved liver margin. : ultrasound-guided drainage catheter placements (two catheters placed) to a perihepatic and subhepatic fluid collection compatible with biloma. : extravasation of the contrast was noted at the cystic duct stump. otherwise normal post cholecystectomy cholangiogram. a sphincterotomy was performed. a biliary stent was placed successfully : egd: a clot was seen at the sphincterotomy site, which could not be dislodged. no active bleeding was seen and epinephrine was injected for hemostasis. history of present illness: 64m admitted to 2 days ago for epigastric pain () which was relieved with morphine. he notes that he had a similar episode that last 2 hours 6 days prior to his admission. his pain lasted for 12 hours. he notes that he has felt fatigued over the past several months and has had an intentiona weight loss of 15lbs. he denies fevers, chills, nausea, vomiting and diarrhea. his last bowel movement was this am and was of normal quality. ct and us performed at demonstrated heterogenous gb suggestive of malignancy. no evidence of metastasis were seen on ct. prior us here in showed normal gb and was consistent with fatty liver. past medical history: past medical history: hypertension, coronary artery disease, prostate cancer, asthma past surgical history: cabg x 4 in , radical prostatectomy, right shoulder surgery, skin grafts to back following burn injury as a child social history: patient works as a rubber and plastic manufacturer. he is married. he has 2 children. he does not regularly exercise. his wife works with him at work. he was born originally in and now lives in . he was a former smoker, but he quit in . he also drinks an occasional glass of wine with dinner. he reports that he did have a blood transfusion in the 's after a burn. family history: his father is alive and well. his mother died of breast cancer. he has 2 brothers, one of whom has high bp. he has a sister who is alive and well. he has 2 sons, one of whom has high bp. physical exam: on discharge: vs: 98.4, 88, 113/64, 16, 93% 2l n/c gen; nad, comfortable heent: no conjunctival pallor. no icterus. mmm. op clear cv: rrr, no m/r/g resp: diminished bs, r>l abd: right subcostal incision open to air with steri strips and c/d/i. periumbilical incision ota with steri strips and c/d/i. intraperitoneal biloma drain in place, draining bilious fluid. extr: warm ,no c/c/e pertinent results: 09:25am blood wbc-15.5*# rbc-5.09 hgb-15.2 hct-46.0 mcv-90 mch-29.9 mchc-33.0 rdw-13.5 plt ct-242 09:25am blood glucose-172* urean-14 creat-1.1 na-130* k-4.8 cl-91* hco3-33* angap-11 09:25am blood calcium-9.2 phos-2.7 mg-1.9 pathology: pending chest portable: findings: portable ap semi-upright radiograph is obtained. the lungs are low in volumes resulting in crowding of bronchovascular structures. left basal opacity is likely a combination of atelectasis and small effusion. abd portable: impression: likely small amount of free air in this patient who is preliminary reportpostoperative day 2. no obstruction or ileus. 11:45am blood wbc-15.9* rbc-4.14* hgb-12.6* hct-37.6* mcv-91 mch-30.3 mchc-33.4 rdw-13.9 plt ct-340 pa/lat: findings: in comparison with the study of , there is slightly better inspiration. little change in the appearance of the somewhat enlarged cardiac silhouette without evidence of vascular congestion. blunting of the lower right costophrenic angle with lateral displacement of the dome of the hemidiaphragms suggests some subpulmonic pleural effusion. the degree of gas beneath the hemidiaphragm on the left has substantially decreased. on the lateral view, there is a small amount of gas in this region, consistent with a small amount of postoperative residual pneumoperitoneum. generalized ileus pattern is noted. ercp: extravasation of the contrast was noted at the cystic duct stump. otherwise normal post cholecystectomy cholangiogram. a sphincterotomy was performed. a biliary stent was placed successfully egd: a large adherent clot was noted at the sphincterotomy site. a biliary stent was seen in placed. despite multiple washes and suction, clot could not be dislodged. no fresh blood was noted at the site or in the stomach or duodenum. (injection) otherwise normal egd to third part of the duodenum brief hospital course: the patient with acute cholecystitis vs. gb malignancy was admitted to the general surgical service for elective open cholecystectomy. on , the patient underwent open cholecystectomy with shaved liver margin, which went well without complication (reader referred to the operative note for details). patient's foley was discontinued post op, he wasn't able to void and was straight cath in the pacu. the patient arrived on the floor on clears, on iv fluids and antibiotics, and dilaudid pca for pain control. the patient was hemodynamically stable. neuro: the patient received dilaudid pca with good effect and adequate pain control. when tolerating oral intake, the patient was transitioned to oral pain medications. cv: the patient has a history of cad, s/p cabg . immediately post op he was started on telemetry for continuous o2 sats monitoring. on pod # 2, patient was noticed to have irregular rate and rhythm, patient was asymptomatic. ekg was obtained and revealed a-fib. cardiology was consulted and their recommendations were followed. the patient spontaneously returned back to rrr within in hour after onset of a-fib. cardiac enzymes were cycled and were negative. he received 20 mg iv lasix for small left pulmonary effusion with good response. patient again went into a-fib while undergoing ercp. cardiology was consulted again and they recommended no echo as an inpatient. they recommended a regimen of toprol xl 75mg , continue with full dose aspirin, and follow up with his outpatient cardiologist to discuss the possibility of long-term anticoagulation. on pod#10, the patient experienced shoulder and jaw pain. ecg and cardiac enzymes were negative for cardiac ischemia and the pain was not relieved by morphine or nitroglycerin. the pain resolved over the course of the early morning. the patient remained stable from a cardiovascular standpoint; he remained on telemetry for cardiac monitoring. pulmonary: the patient was required supplemental o2 post op, and his o2 sats were monitored with continuous pulse sats. on pod# 1, patient started to wean off supplemental o2. he wasn't able to take a deep breath secondary to post op pain. chest x-ray was obtained and demonstrated left atelectasis and small effusion. patient received 20 mg lasix and his respiratory quality improved. he periodically required supplemental o2 prior to discharge; 1 l in rest and 3l via n/c during ambulation. pulmonology was consulted and their recommendations were followed. the patient was able to be weaned off of oxygen, with sats above 93% on room air on ambulation and at rest. gi: post-operatively, the patient was made npo with iv fluids. diet was advanced when appropriate, which was well tolerated. patient's intake and output were closely monitored, and iv fluid was adjusted when necessary. electrolytes were routinely followed, and repleted when necessary. an elevated wbc on pod#7 prompted a ct scan of the torso, which revealed a subcapsular fluid collection, at which point he was taken to interventional radiology and the fluid collection was drained. two drains were placed in the fluid collection, one in the subcapsular space and another in the gall bladder fossa. the drained fluid appeared billous and was sent for gram stain and culture, which were negative. ercp revealed a leak at the cystic duct stump. a biliary stent was successfully placed, and a sphincterotomy was performed. on pod #12, patient reported that he had melena, subsequent workup revealed guaic-positive stool and a hct of 19.7. this hct was confirmed, and patient was transfused with 2 units of prbc. patient was taken by ercp for an upper endoscopy, to evaluate for potential sources of bleeding. a large clot at the site of his sphincterotomy was seen on ercp, but no active bleeding was appreciated. his post-transfusion appropriately responded to 26.4. he was transferred to the icu as a precautionary measure. he remained stable and subsequently returned to the floor on pod #13. on the morning of pod #14, he was discovered to have a hct of 21.3 from 25.3 the previous day. the patient's vitals remained stable, and he was asymptomatic yet again. the patient was transfused with 2 units of prbc. follow-up hct following the transfusion revealed an appropriate response to the 2 unit transfusion, with a hct of 28.8. he will follow-up to have his hct monitored by his pcp, . , as an outpatient, and will follow-up with dr. as an outpatient on . gu: patient s/p prostatectomy and history of urinary retention post cabg. foley catheter was removed on pod # 0, patient failed to void and bladder scan revealed > 800 cc of urine. the patient was straight catheterized and started on flomax, he failed second trial and foley catheter was replaced on pod # 1. the foley was removed on pod # 2 and patient subsequently voided this time. upon admission to the icu, the patient had a foley placed. this was subsequently removed the following morning, and the patient successfully voided x2. id: the patient's white blood count and fever curves were closely watched for signs of infection. wound looked c/d/i and was not erythematous or tender throughout the hospital stay. he will go home on a 5-day course of augmentin as prophylaxis following endoscopy/ercp. endocrine: no issues hematology: the patient's complete blood count was examined routinely. the patient received 2 units of prbc for hct of 19.7 on pod #12 (please refer to "gi" above). the patient received another 2 units of prbc for hct of 21.3 on pod#14 (please refer to "gi" above). prophylaxis: the patient received subcutaneous heparin and venodyne boots were used during this stay, however the subcutaneous heparin was held starting pod #12 due to his decreased hematocrit and bleed from the sphincterotomy site; was encouraged to get up and ambulate as early as possible. at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing amlodipine - 5 mg tablet - 1 tablet(s) by mouth once a day atorvastatin - 80 mg tablet - 1 tablet(s) by mouth once a day fluocinolone - 0.01 % solution - at bedtime as needed for itchy scalp apply to scalp at night and wash off in the morning fluticasone - 50 mcg spray, suspension - 1 to 2 sprays in each nostril once a day fluticasone - 220 mcg aerosol - 1 inhalation(s) by mouth twice a day rinse mouth after use lisinopril - 40 mg tablet - 1 tablet(s) by mouth once a day metoprolol succinate - 100 mg tablet extended release 24 hr - 1 tablet(s) by mouth once a day nitroglycerin - 0.3 mg tablet, sublingual - 1 tablet(s) sublingually as needed for chest pain omeprazole - 20 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth once a day aspirin - (otc) - 81 mg tablet, chewable - 1 tablet(s) by mouth once a day discharge medications: 1. amlodipine 5 mg po daily rx *amlodipine 5 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 2. atorvastatin 80 mg po daily rx *atorvastatin 80 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 3. docusate sodium 100 mg po bid rx *docusate sodium 100 mg 1 capsule(s) by mouth twice a day disp #*60 capsule refills:*1 4. omeprazole 20 mg po daily rx *omeprazole 20 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 5. senna 1 tab po bid rx *senna 8.6 mg 1 cap by mouth twice a day disp #*60 capsule refills:*1 6. tamsulosin 0.4 mg po daily rx *tamsulosin 0.4 mg 1 capsule(s) by mouth q24h disp #*30 capsule refills:*0 7. tramadol (ultram) 50 mg po qid rx *tramadol 50 mg 1 tablet(s) by mouth four times a day disp #*80 tablet refills:*0 8. albuterol inhaler puff ih q6h:prn sob, wheezing rx *albuterol sulfate 90 mcg 2 puffs oral every four (4) hours disp #*1 inhaler refills:*1 9. aspirin 325 mg po daily rx *aspirin 325 mg 1 tablet(s) by mouth once a day disp #*30 tablet refills:*0 10. metoprolol succinate xl 75 mg po bid rx *metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*1 rx *metoprolol succinate 25 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*1 11. amoxicillin-clavulanic acid 500 mg po q8h duration: 3 days rx *augmentin 500 mg-125 mg 1 tablet(s) by mouth every eight (8) hours disp #*15 tablet refills:*0 12. fluticasone propionate 110mcg 2 puff ih rx *flovent hfa 110 mcg/actuation 2 puffs oral twice a day disp #*1 inhaler refills:*0 discharge disposition: home with service facility: vna, discharge diagnosis: 1. acute, chronic and xanthogranulomatous cholecystitis 2. atrial fibrillation 3. urinary retention 4. right pleural effusion with atelectasis 5. large subcapsular fluid collection 6. anemia due to bleed from sphincterotomy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the surgery service at for surgical resection of your gallbladder. you have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid 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. drain care: *please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *note color, consistency, and amount of fluid in the drain. call the doctor, nurse practitioner, or vna nurse if the amount increases significantly or changes in character. *be sure to empty the drain frequently. record the output, if instructed to do so. *you may shower; wash the area gently with warm, soapy water. *keep the insertion site clean and dry otherwise. *avoid swimming, baths, hot tubs; do not submerge yourself in water. *make sure to keep the drain attached securely to your body to prevent pulling or dislocation. followup instructions: department: surgical specialties when: friday at 3:15 pm with: , md building: sc clinical ctr campus: east best parking: garage . lab draw:cbc when: friday campus: east **please report to have labs drawn prior to your clinic visit with dr. ** . department: surgical specialties when: friday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage . department: when: wednesday at 8:40 am with: , m.d. building: sc clinical ctr campus: east best parking: garage . department: cardiac services when: monday at 10:20 am with: , md building: campus: east best parking: garage Procedure: Percutaneous abdominal drainage Endoscopic sphincterotomy and papillotomy Cholecystectomy Endoscopic control of gastric or duodenal bleeding Endoscopic insertion of stent (tube) into bile duct Diagnoses: Obstructive sleep apnea (adult)(pediatric) Unspecified pleural effusion Unspecified essential hypertension Acute posthemorrhagic anemia Atrial fibrillation Personal history of malignant neoplasm of prostate Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Asthma, unspecified type, unspecified Personal history of tobacco use Pulmonary collapse Hemorrhage complicating a procedure Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Blood in stool Old myocardial infarction Retention of urine, unspecified Other specified disorders of biliary tract Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Laparoscopic surgical procedure converted to open procedure Acute and chronic cholecystitis Other digestive system complications

allergies: no known allergies / adverse drug reactions attending: chief complaint: angina major surgical or invasive procedure: urgent coronary artery bypass grafting x4 on intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to first diagonal coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery left heart catheterization, coronary angio gram, placement of intaaortic balloon pump history of present illness: this 62 year old male complains of chest pain. he reports that he has had pain in his lower sternal region, bilateral jaw and frontal region of his fore head which he describes as a punching sensation since last night. he denies previous similar pain and has never had a heart attack or any type of cardiac evaluation. he went to bed last night with pain and awoke this morning with the same pain. past medical history: hypertension hypercholesterolemia prostate ca s/p radical prostatectomy childhood asthma right rotator cuff surgery skin graft to back after burn injury social history: manufacturer of iv tubings; quit smoking over 22 years ago, drinks 2 caffeinated products per day; married with good family support. family history: non-contributory physical exam: pulse:69 resp: 13 o2 sat:99% b/p right: 127/77 left: height: 67" weight:86 kg general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm x, well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: sheath left: +2 dp right: +1 left: +1 pt : +1 left: +1 radial right: +2 left: +2 carotid bruit right/left: 0 pertinent results: carotid u/s: there is less than 40% stenosis within internal carotid arteries bilaterally. echo: prebypass: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is borderline low (2.0-2.5l/min/m2). 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. there is no pericardial effusion. an intra-aortic balloon is in situ. its tip is 1 cm below the distal arch. postbypass: the patient is in sinus rhythm. there is normal biventricular systolic function. valvular function is unchanged. the thoracic aorta appears intact after decannulation. the intra-aortic ballon has been withdrawn and is now 3 to 4 cm below the distal arch. 10:00am blood wbc-11.8* rbc-3.86* hgb-11.7* hct-33.7* mcv-87 mch-30.3 mchc-34.7 rdw-13.7 plt ct-221 10:20am blood wbc-12.9* rbc-4.97 hgb-15.0 hct-42.8 mcv-86 mch-30.1 mchc-34.9 rdw-13.6 plt ct-309 10:00am blood urean-21* creat-1.0 na-134 k-3.9 cl-97 10:20am blood glucose-131* urean-23* creat-1.1 na-141 k-3.9 cl-101 hco3-32 angap-12 04:33am blood ck-mb-38* mb indx-3.6 ctropnt-2.09* 10:20am blood ctropnt-0.47* brief hospital course: mr. was admitted from the er with angina and elevated troponins. he was taken emergently to the cath lab and found to have three vessel coronary artery disease, with occluded om 1 which was angioplastied open and iabp placed. on he was taken to operating room and underwent coronary artery bypass x 4. please see operative note for surgical details. following surgery he was transferred to the cvicu for invasive monitoring in stable condition. on post-op day 1 his iabp was removed. later on this day he was weaned from sedation, awoke neurologically intact and extubated. beta-blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. on post-op day two he was transferred to the step-down floor for further care. chest tubes and epicardial pacing wires were removed per protocol. he continued to make good progress and worked with physical therapy during his post-op course for strength and mobility. he developed atrial fibrillation and received amiodarone with conversion to sinus rhythm on post-op day 5 he was discharged home with vna services and the appropriate medications and follow-up appointments. medications on admission: acetaminophen-codeine - 300 mg-30 mg tablet - 1 (one) tablet(s) by mouth every six (6) hours as needed for pain albuterol sulfate - 90 mcg hfa aerosol inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing anaprox - 550 mg tablet - one tablet , as needed atenolol - 25 mg tablet - 1 tablet(s) by mouth once a day fluticasone - 50 mcg spray, suspension - 1 to 2 sprays in each nostril once a day hydrochlorothiazide - 25 mg tablet - 1 tablet(s) by mouth once a day lisinopril - 20 mg tablet - 1 tablet(s) by mouth once a day pravastatin - 40 mg tablet - 1 tablet(s) by mouth once a day sildenafil - 100 mg tablet - to one tablet(s) by mouth one hour prior to sexual contact triamcinolone acetonide - 55 mcg aerosol, spray - 1 spray intranasally daily discharge medications: 1. influenza vaccine tr-s 10 (pf) 45 mcg (15 mcg x 3)/0.5 ml syringe sig: one (1) ml intramuscular now x1 (now times one dose). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 3. amiodarone 200 mg tablet sig: as directed tablet po bid (2 times a day): 2 tablets(400mg) for 2 weeks, then 1 tablets (200mg) for two weeks, then 1tablet (200mg) daily. disp:*100 tablet(s)* refills:*2* 4. metoprolol tartrate 75 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*120 tablet(s)* refills:*2* 5. 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* 6. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal (2 times a day). 7. pravastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 9. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). discharge disposition: home with service facility: area vna discharge diagnosis: coronary artery disease s/p coronary artery bypass s/p myocardial infarction hypertension hypercholesterolemia s/p radical prostatectomy for carcinoma 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 left - healing well, no erythema or drainage. edema .none discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 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: provider: fern, rnc phone: date/time: 9:00 provider: , md phone: date/time: 4:00 provider: , md phone: date/time: 2:30 please call to schedule appointments with your primary care dr. in weeks **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Implant of pulsation balloon Nonoperative removal of heart assist system Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Acute posthemorrhagic anemia Atrial fibrillation Personal history of malignant neoplasm of prostate Personal history of tobacco use Family history of ischemic heart disease Internal hemorrhoids without mention of complication Acquired absence of organ, genital organs

allergies: no known allergies / adverse drug reactions attending: chief complaint: metastatic papillary carcinoma of the thyroid major surgical or invasive procedure: bilateral neck dissection of levels ii-iv and l ij removal. history of present illness: reason for micu transfer: monitor for airway obstruction history of present illness: 69 year old female with history of htn, hep b, pulmonary sarcoid, and metastatic papillary thyroid cancer to the supraclavicaular lymph nodes, now s/p bilateral modified radical neck dissection (in which they removed lymph nodes and the l ij) on , now pod2. she has had continued oozing from superficial b/l wound sites on neck since the surgery. on , five stitches were placed in the r neck incision for oozing, on two sutures were placed in the l neck incision. on scope on , unilateral laryngeal edema was seen in the morning, which was treated with decadron 10 and sch was dced. repeat afternoon scope showed worsening edema b/l with significant epiglottic, ae fold, and post-cricoid edema with epiglottic ecchymosis. heme was consulted for concern that edema and oozing were coagluopathy. the patient was transfered to the icu for closer management of airway. a ct neck was done to r/o fluid collection. per wet read, ct scan showed laryngeal edema but no fluid collection. a subsuquent scope was planned for 9 pm to follow up edema and assess for need for possible elective intubation. review of systems: (+) per hpi (-) denies blood in the stool, change in stool, abdominal pain, thigh pain, joint pains. past medical history: metastatic papillary carcinoma of the thyroid: diagnosed with papillary thyroid cancer in , when she was found to have a thyroid nodule. she was treated with left thyroidectomy at that time. in , she was found to have enlarged l neck lymph nodes that was attributed to a local recurrence and underwent completion right thyroidectomy, followed by radioactive iodine treatment. in , she developed new lymphadenopathy in the thyroid bed and received additional radioactive iodine treatment. in , she was again found to have multiple enlarged lymph nodes in the thyroidectomy bed and a biopsy-proven metastasis in a left supraclavicular node. in , she had an ultrasound that revealed interval enlargement of the metastasis along the left cervical chain and a stable left supraclavicular node. in , she had a left neck dissection with an excision of 27 lymph nodes with one being positive for metastatic papillary carcinoma of the thyroid. one left cervical lymph node that contained thyroid carcinoma on biopsy was unable to be removed due to its proximity to the carotid artery and jugular vein. in , she underwent further radioactive iodine treatment. more recently, she has had further enlargement of the left neck lymphadenopathy and left paratracheal mass. ct of the neck with contrast on , revealed a 2.9 x 2.5 x 2.8 cm paratracheal mass at the site of the thyroid gland, which was in close contact with the vertebral artery posteriorly and the left common carotid artery anteromedially. there were also multiple enlarged lymph nodes in levels 1b, 2a, 2b, and 3 in the supraclavicular region on the left side, the largest measuring 2 x 1.6 cm at the level 1b on the left. there are also enlarged lymph nodes in level 2a on the right. the larynx and trachea appeared normal despite the paratracheal mass, which was deemed inoperable. - hepatitis b - heart murmur - hypertension - pulmonary sarcoid social history: she is originally from the and immigrated to the us in . she lives with one of her daughters. she is a never smoker and does not currently drink any alcohol (rare use in past). she used to work in a solar panel plant on an assembly line, but the solar panel company has recently closed last year and she has not worked since that time. family history: her brother had thyroid carcinoma and died at age 49. no family history of bleeding disroders. her daughter has dm. physical exam: admission exam general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi neck: b/l neck incision with clean dressings, wound is clean, no current oozing 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, no organomegaly, no tenderness to palpation, no rebound or guarding ext: warm, well perfused, 2+ pulses, trace pedal edema which the patient states is her baseline neuro: grossly intact pertinent results: 04:04am blood wbc-8.2 rbc-3.38* hgb-10.9* hct-32.2* mcv-95 mch-32.2* mchc-33.7 rdw-13.6 plt ct-136* brief hospital course: : 69 year-old with pmh of htn, hepatitis b, pulmonary sarcoid, and metastatic papillary thyroid cancer to the supraclavicaular lymph nodes, now s/p bilateral modified radical neck dissection pod2. she has been oozing from the surgical site b/l for the last 2 days, and developed laryngeal edema seen on scope that worsened during the day, prompting transfer to for close airway monitoring. acute issues: ------------- # laryngeal edema: during her admission the patient was monitored closely for signs of airway obstruction or labored breathing labored breathing. she was given one dose of amicar. she underwent a repeat scope by ent which showed improvement from the day of admission. she did not require repeat intubation and was stable at the time of transfer. her laryngeal edema continued to improve on steroids until the date of discharge (). # metastatic papillary thyroid cancer: the patient was continued on her home dose of levothyroxine and will follow up with ent regarding treatment of her cancer. chronic issues: --------------- #hypertension: the patient was continued on lisinopril, atenolol and furosemide at her home dose. transitional issues: ------------------- will need follow-up with ent regarding treatment of metastatic papillary thyroid cancer. medications on admission: lisinopril 40 mg po daily - already got today levothyroxine 137 mcg po daily - already got today furosemide 60 mg daily - already got today atenolol 50 mg daily - already got today dexamethasone 10 mg iv q8h aminocaproic acid 4 gm iv once -- per heme onc recs discharge medications: 1. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 2. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 3. furosemide 20 mg tablet sig: three (3) tablet po daily (daily). 4. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 5. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: tablet, chewables po qid (4 times a day) as needed for heartburn. discharge disposition: home discharge diagnosis: metastatic papillary carcinoma of the thyroid discharge condition: in good condition. mental status is intact, and patient is ambulatory independently. discharge instructions: -please refrain from any strenuous activity for one week. -you may change your dressings daily. followup instructions: -you have a follow up appointment with dr. in clinic on at 3:15 pm. Procedure: Laryngoscopy and other tracheoscopy Other surgical occlusion of vessels, other vessels of head and neck Radical neck dissection, bilateral Diagnoses: Unspecified essential hypertension Sarcoidosis Hemorrhage complicating a procedure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Lung involvement in other diseases classified elsewhere Personal history of malignant neoplasm of thyroid Edema of larynx Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery

allergies: penicillins attending: chief complaint: pcp: . chief complaint: visual changes reason for micu admission: pcn desensitization. major surgical or invasive procedure: pcn desensitization history of present illness: pt is a 42 y.o male with h.o hiv (last cd4 479, vl 13,700), not on haart who was started on doxycycline (pcn allergy) 5 days ago for secondary syphilis (titer 1:64). he reported to his pcp that he had been having visual problems for the past month. he was sent urgently to ophthal where b/l anterior uveitis and b/l disc edema was seen. he was sent to the ed for imaging, lp with thoughts of pcn desensitization. pt was referred for infectious w/u. . pt states that since , he developed chills, skin rash (purple/pink spots on torso/arms/face/neck/penis, joint pains, swollen cervical lymph nodes, abdominal bloating (constipation), as well as visual changes (white lights in periphery, white circles and lines). pt denies fever, eye pain, photophobia, neck stiffness, cp/sob/palp, abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria/parestheisas or weight loss. +uri symptoms since the weekend. magnesium for constipation. he then was using a friend's bactrim, which he reports some improvement in symptoms. he decided to return to his doctor down . there, hiv labs as well as rpr were drawn and pt was started on doxycycline for secondary sphyllis. pt returned yesterday and reported the eye symptoms(which he did not before) and was sent for urgent optho eval, then eval. . in the ed, vital signs were initially: 21:07 4 97.2 92 125/83 16 98 68, 127/93, rr 16, sat 99% on ra. no ekg. pt denies fever or headache, reports fatigue. head ct performed, plaque found on arm (pt states there for 2 months) past medical history: hiv-last cd4 479, vl 13,700 dx 10yrs ago, on haart for 1 yr in beginning. recent dx of sphyllis- titer 1:64, started on doxycycline x5 days. admission for seizures -started on dilantin, no longer taking tobacco and amphetamine abuse asthma anxiety and depression . social history: pt lives on , formerly had long term partner. unemployed. smokes 1/2-1ppd. h.o crystal meth use, last use 3 months ago. denies ivda. denies etoh. family history: unknown, pt reports he was adopted physical exam: physical examination: vs:t. 98.5, bp 141/92, hr 76, rr 19, sat 96% on ra gen:the patient is in no distress and appears comfortable skin:+fading maculopapular rash on torso/arms, ankles. heent:perrla, eomi, anicteric, mmm, no op lesions. neck: no discrete lymphadenopathy. chest:lungs are clear without wheeze, rales, or rhonchi. cardiac: regular rhythm; no murmurs, rubs, or gallops. abdomen: no apparent scars. non-distended, and soft without tenderness, +bs extremities:no peripheral edema, warm without cyanosis neurologic: alert and appropriate. cn ii-xii grossly intact. bue , and ble both proximally and distally. sensation intact to lt. pertinent results: 03:19pm cerebrospinal fluid (csf) protein-104* glucose-50 03:19pm cerebrospinal fluid (csf) wbc-112 rbc-64* polys-1 lymphs-93 monos-0 macrophag-6 03:19pm cerebrospinal fluid (csf) wbc-154 rbc-159* polys-1 lymphs-95 monos-0 macrophag-4 05:38am glucose-101* urea n-11 creat-0.8 sodium-136 potassium-3.7 chloride-102 total co2-27 anion gap-11 05:38am alt(sgpt)-25 ast(sgot)-27 ld(ldh)-231 alk phos-81 tot bili-0.3 05:38am albumin-3.5 calcium-8.8 phosphate-3.5 magnesium-1.9 05:38am tsh-1.1 05:38am wbc-6.3 rbc-4.27* hgb-12.4* hct-35.1* mcv-82 mch-29.0 mchc-35.3* rdw-14.5 05:38am neuts-44* bands-2 lymphs-44* monos-5 eos-3 basos-1 atyps-0 metas-1* myelos-0 05:38am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-occasional 05:38am plt smr-normal plt count-153 05:38am pt-13.7* ptt-30.5 inr(pt)-1.2* 05:38am pt-13.7* ptt-30.5 inr(pt)-1.2* 12:51am pt-12.4 ptt-30.2 inr(pt)-1.0 11:55pm glucose-124* urea n-13 creat-0.9 sodium-138 potassium-4.0 chloride-100 total co2-28 anion gap-14 11:55pm estgfr-using this 11:55pm estgfr-using this 11:55pm calcium-9.1 phosphate-2.8 magnesium-1.9 11:55pm urine hours-random 11:55pm urine gr hold-hold 11:55pm wbc-7.9 rbc-4.53* hgb-13.0* hct-37.5* mcv-83 mch-28.6 mchc-34.5 rdw-14.5 11:55pm neuts-31.2* lymphs-59.9* monos-6.5 eos-1.7 basos-0.7 11:55pm plt count-169 11:55pm urine color-straw appear-clear sp -1.013 11:55pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg . head ct- impression: no acute intracranial hemorrhage or mass effect. the study and the report were reviewed by the staff radiologist. . cxr-, j m 42 pa and lateral view, chest: the lungs are clear and the cardiomediastinal and hilar contours and pleural surfaces are normal. impression: no acute cardiopulmonary process. the study and the report were reviewed by the staff radiologist. 05:38am blood tsh-1.1 05:38am blood fluorescent treponemal antibody (fta-abs)-pnd brief hospital course: assessment & plan: pt is a 42 y.o male with hiv, not on haart, who presents with positive rpr and visual disturbances. . #rash/visual disturbances/joint pain-pt with hiv,not on haart (last cd4 479). pt reporting visual disturbances for some time now. pt with recent rpr 1:64. reportedly optho visit demonstrating anterior uveitis and b/l disc edema. differential is broad, but most likely is related to neurosphyllis. -lp to eval for opening pressure, cell count/diff, glucose/protein, and csf for spirochetes was all done an normal. he had an opening pressure of 18. 6cc of clear fluid sent for evaluation wbc 112, lymphs 93, prot 104, gluc 50. -pcn desensitization was done an pcn started for 2 week course. -head ct normal -csf vdrl and treponemal testing all pending at discharge. -optho was called and recommended therapy for anterior uveitis. they did not evaluate the patient, stating this needed to be done as an outpatient. close f/u was arranged. . #hiv-pt not on haart . #abdominal bloating-no pain on exam. will add on lfts. will consider abdominal imaging if persistant. . #htn-will continue home dose atenolol for now . #joint pains-no erythema, swelling, to suggest septic joint. likely related to above process. -tx for sphyllis as above medications on admission: atenolol 25 mg tab oral daily doxycycline 100 mg tab oral discharge medications: 1. penicillin g potassium 20,000,000 unit recon soln sig: four (4) million units q4h injection q4h (every 4 hours) for 2 weeks. disp:*336 million units q4h* refills:*0* 2. epipen 0.3 mg/0.3 ml pen injector sig: two (2) pens intramuscular once as needed for allergic reaction. disp:*2 pens* refills:*2* 3. outpatient lab work cbc, bun/cr, and lft's on . fax to , md at clinic, . 4. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic q4h (every 4 hours). disp:*1 month supply* refills:*0* 5. tobramycin-dexamethasone 0.3-0.1 % ointment sig: one (1) appl ophthalmic qhs (once a day (at bedtime)). disp:*1 months supply* refills:*2* 6. cyclopentolate 1 % drops sig: one (1) drop ophthalmic q 8h (every 8 hours). disp:*1 months supply* refills:*2* 7. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis: 094.9 neurosyphilis nos secondary diagnosis: 401.1 hypertension, benign secondary diagnosis: v08 hiv, asymptomatic secondary diagnosis: 360.12 uveitis discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: as we discussed, you were admitted for an infection of your central nervous system. you will need 2 weeks of iv antibiotics for this. we have arranged f/u for you in both opthomology and infectious disease clinic. please keep these follow up appointments and make sure you take the eye drops as directed. followup instructions: appointment #1 md: dr. specialty: opthalmology date/ time: 3:15pm location: , ma phone number: special instructions for patient: appointment #2 md: pa specialty: infectious disease date/ time: location: 49 way, ma phone number: special instructions for patient: the office will call with an appointment. if you do not here from them in 2 business days please call and book an appointment. Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Diagnoses: Tobacco use disorder Asthma, unspecified type, unspecified Nausea alone Asymptomatic human immunodeficiency virus [HIV] infection status Benign essential hypertension Amphetamine or related acting sympathomimetic abuse, continuous Syphilis, unspecified Syphilitic iridocyclitis (secondary)

allergies: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: coronary artery bypass graft x5, left internal mammary artery to left anterior descending artery, saphenous vein graft to distal left anterior descending artery and right coronary artery, and sequential saphenous vein grafts to obtuse marginal 1 and 2. endoscopic harvesting of the long saphenous vein. history of present illness: 60 year old man has a history of type ii diabetes and hyperlipidemia. he reports that around late summer he had at least 24 hours of persistent chest burning or "heartburn". he recalls at the time that he was involved in heavy exertion. in addition to these symptoms, he also noticed bilateral shoulder discomfort and shortness of breath that would resolve with rest. since that time he has noticed continued fatigue and shortness of breath with exertion, although he has remained fairly sedentary over the past months. upon evaluation in , he was found to have new ekg changes as compared to his ekg from . he has since undergone both echo and stress testing as noted below and cardiac catheterization that revealed coronary artery disease. past medical history: hypertension hyperlipidemia type ii dm hyperthyroidism s/p radioactive iodine depression remote knee surgery t&a (remote) social history: lives with: spouse occupation: is employed as a manager for a racetrack. tobacco:quit in etoh:several beers every nights family history: mother died from an mi at age 73 physical exam: pulse: 63 resp: 14 o2 sat: 99 b/p right: 149/71 height: 5'6" weight:171 pounds general: skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular murmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: none neuro: grossly intact pulses: femoral right: 1+ left: 1+ dp right: 1+ left: 1+ pt : 1+ left: 1+ radial right: 1+ left: 1+ carotid bruit right: - left:- discharge exam: vs: t: 99.2 hr bp: sats: 96% ra general: 60 year-old male in no apparent distress heent: normocephalic, muscus membranes moist neck: supple, card: rrr normal s1,s2 no murmur resp: gi: benign extr: warm 1+ edema incision: sternal clean, dry intact, neuro: awake, alert moves all extremities pertinent results: wbc-9.9 rbc-3.11* hgb-9.5* hct-26.9* mcv-86 mch-30.5 mchc-35.2* rdw-13.4 plt ct-156 wbc-19.6*# rbc-3.16* hgb-9.8*# hct-28.3* mcv-90 mch-31.0 mchc-34.7 rdw-13.2 plt ct-176 glucose-144* urean-12 creat-0.9 na-138 k-3.9 cl-101 hco3-32 urean-14 creat-0.8 na-144 k-4.0 cl-116* hco3-23 angap-9 mg-2.0 cxr: : small posterior pleural effusions which may not have been visible on the previous ap chest x-ray. evaluation of the right hemidiaphragm unchanged. subsegmental atelectasis or scarring, unchanged. : the et tube tip is 4 cm above the carina. the left chest tube, the right internal jugular line, and the ng tube are in expected location as well as the mediastinal drain. cardiomediastinal silhouette is unremarkable in the patient immediately after surgery as well as there is no abnormality seen with sternal wires. left mid lung linear opacity is most likely consistent with atelectasis as well as the opacity in the right upper lung. there is no evidence of pneumothorax or appreciable pleural effusion seen. echo : prebypass no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. there is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the lateral, anterolateral and anteroseptal walls. overall left ventricular systolic function is mildly depressed (lvef= 40 %). 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. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. post bypass patient is a paced and receiving an infusion of phenylephrine. biventricular systolic function is unchanged. mild mitral regurgitation persists. aorta is intact post decannulation. i brief hospital course: admitted same day surgery and was brought to the operating room for coronary artery bypass graft surgery. see operative report for further details. he received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for postoperative management. in first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. on post operative day one he was started on beta blockers and diuretics. he continued to do well and was transferred to the floor hemodynamically stable. respiratory: aggressive incentive spirometer, nebs and ambulation he titrated off oxygen with room oxygen saturations of 96% chest tubes: 2 mediastinal and left pleural chest tubes were removed on pod2 cardiac: beta-blockers were started pod1 and titrated for sinus tachycardia. blood pressure was stable. gi: benign. h2 blockers and bowel regime were given nutrition: diabetic diet was started on pod1 and he tolerated renal: gentle diuresis was titrated as needed. foley was removed and he voided. electrolytes were repleted. renal function remained within normal limits cre 0.9 endocrine: bs 96-200's. while in the sicu he was on an insulin drip and transitioned to insulin ss and his home dose of glyburide and metformin. neuro: awake, alert and oriented. pain was control with opioids and nsaids with good control. disposition: he was seen by physical therapy and deemed safe for home. he was discharged on xxx. medications on admission: glyburide 10 mg twice a day levothyroxine 75 mcg daily metformin 1,000 mg twice a day metoprolol tartrate 25 mg twice a day pioglitazone 30 mg daily sertraline 50 mg daily sildenafil prn simvastatin 20 mg daily aspirin 81 mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for fever/pain. 3. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 4. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 6. glyburide 5 mg tablet sig: two (2) tablet po bid (2 times a day). 7. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day): take early am & 3pm until weight < 170 pounds. disp:*60 tablet(s)* refills:*2* 10. potassium chloride 8 meq tablet sustained release sig: one (1) tablet sustained release po once a day: take in am with lasix. disp:*30 tablet sustained release(s)* refills:*2* 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 12. sennalax-s 8.6-50 mg tablet sig: one (1) tablet po twice a day: take while taking narcotics. disp:*60 tablet(s)* refills:*2* 13. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease s/p cabg hypertension hyperlipidemia diabetes mellitus type 2 hyperthyroidism depression discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with incisions: sternal - healing well, no erythema or drainage leg left - healing well, no erythema or drainage. edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments surgeon: dr monday at 2:30 pm cardiologist: dr monday at 11:15 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** md Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries 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 Depressive disorder, not elsewhere classified Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm Other and unspecified hyperlipidemia Chronic total occlusion of coronary artery

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: squamous cell carcinoma major surgical or invasive procedure: : 1. right thoracotomy and right middle and lower lobectomy. 2. harvesting of intercostal muscle and buttressing of bronchial staple line with intercostal muscle. history of present illness: 50y f initially presenting in w/ a single episode of hemoptysis, bronchoscopy was performed that demonstrated no gross lesions but cytology showed some atypical cells. upon subsequent follow-up in a repeat bronchocsopy was performed, cytology consistent w/ non-small cell carcinoma. a biopsy was then done which demonstrated poorly differentiated squamous carcinoma. she has no current complaints of cough, hemoptysis, or weight loss, but does relay some recent hx of night sweats. her history is significant for hodgkins lymphoma s/p staging laparotomy, splenectomy w/ no evidence of infradiaphgramatic disease, s/p radiation as well as a short course of chemotherapy. there has been no evidence of recurrent lymphoma to date. past medical history: hodgkins lymphoma (s/p chemo/xrt), hypothyroid (secondary to radiation) social history: 20 pack-year history of smoking, reportedly quit just prior to surgery; social etoh use, no recreational drug use. has boyfriend, supportive and teenage daughter. therapeutic radiation exposure xrt. family history: lymphoma in a cousin; otherwise unremarkable physical exam: discharge day exam: vs 98.5 98.2 92 110/76 18 97ra gen: awake, alert, nad cv: rrr chest: ctab, incision sites clean/dry; chest tube site with moderate serosanguinous drainage, non-erythematous skin abd: soft, nontender, nondistended ext: wwp, no edema or cyanosis pertinent results: - chest x-ray: in comparison with study of , there are now two right chest tubes in place following surgery. although difficult to visualize, there appears to be a pleural line on the right, consistent with a mild pneumothorax. no evidence of collapse or consolidation. left lung remains clear. 05:40am blood wbc-12.1* rbc-3.24* hgb-10.4* hct-31.5* mcv-97 mch-32.2* mchc-33.1 rdw-12.8 plt ct-464* 05:40am blood glucose-98 urean-10 creat-0.5 na-141 k-3.6 cl-98 hco3-34* angap-13 05:40am blood calcium-8.8 phos-3.8# mg-1.8 brief hospital course: ms. was admitted to the tsicu following her operation on . the following information covers dates - : neuro: pain controlled initially with morphine / bupivacaine epidural per aps with inadequate pain control per patient. epidural was split to contain only bupivacaine and the patient was started on a dilaudid pca for pain, which improved her pain control somewhat. due to her persistent hypotension, however, the epidural was d/c'd on pod 2 and she was transitioned to a dilaudid pca with po percocet, tizanidine, toradol, and gabapentin. her pain control did improve each subsequent hospital day with adjustments to the doses and frequency of these medications. cv: blood pressure augmented with phenylephrine gtt postoperatively. attempts to wean the pressor on pod 1 were unsuccessful, likely related to high-dose bupivacaine epidural. ivf maintained at maintenance rate and gentle albumin bolus given. she was weaned from phenylephrine succesfully on pod 2 and remained hemodynamically stable thereafter. resp: extubated early morning of pod 1, maintaining o2 saturations > 95% on 2l nasal cannula / face tent, then room air. incentive spirometry and pulmonary toilet encouraged. chest tubes x2 to right chest were maintained to suction for the first 24 hours postoperatively and then transitioned to waterseal. a cxr on pod 1 demonstrated small right pneumothorax and the chest tubes were placed back to suction. on pod 2 the chest tubes were again placed to waterseal and did demonstrate a persistent but stable small air leak. chest tubes:on pod 2 the chest tubes remained on water. the apical chest tube was removed. the cxr showed slight increase in apical pneumothorax and a hydropneumothorax. she remained on water-seal. followed by serial chest films. on pod8 the basilar chest-tube was clamped x 24 hrs, cxr showed stable pneumothorax. on pod9 the basilar chest-tube was removed follow-up cxr showed a stable ptx. gi: diet started with clear liquids and advanced to regular on pod 1. gu: foley catheter remained in place while epidural was needed. once removed she voided without difficulty heme: hematocrit remained stable postoperatively, no need for blood product transfusions. id: perioperative ancef given x3 doses total, then d/c'd. endo: no issues disposition: she was discharged to home on pod 9 and will follow-up with dr. as an outpatient. medications on admission: percocet prn discharge medications: 1. bupropion hcl 75 mg tablet sig: two (2) tablet po bid (2 times a day). 2. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 3. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 4. fluconazole 100 mg tablet sig: one (1) tablet po once a day for 5 days. disp:*5 tablet(s)* refills:*0* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for no bm. 7. tizanidine 2 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed. disp:*5 tablet(s)* refills:*1* 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 9. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day). disp:*120 troche(s)* refills:*2* 10. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 11. motrin 600 mg tablet sig: one (1) tablet po every 6-8 hours as needed for pain: take with food and water. disp:*90 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: right middle lobe and lower lobe nodule discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: call dr. office if you experience: -fever > 101 or chills -increased shortness of breath, cough or sputum production -chest pain -incision develops drainage -chest tube site remove dressing sunday and cover site with a bandaid -you shower. no tub bathing or swimming -no driving while taking narcotics. take stool softners with narcotics. followup instructions: follow-up with dr. phone: date/time: 10:30 on the clincal center . chest x-ray 10:00am on the radiology deparmtent Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for less than 96 consecutive hours Other repair and plastic operations on bronchus Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Other lobectomy of lung Diagnoses: Other iatrogenic hypotension Personal history of tobacco use Iatrogenic pneumothorax Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Malignant neoplasm of other parts of bronchus or lung Intravenous anesthetics causing adverse effects in therapeutic use Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Personal history of hodgkin's disease Other postablative hypothyroidism Other specified forms of effusion, except tuberculous Acute post-thoracotomy pain Other specified adverse effects, not elsewhere classified

allergies: tetanus antitoxin / aspirin attending: chief complaint: gi bleed and decreased po intake major surgical or invasive procedure: percutaneous g- tube placement history of present illness: 85 yo m w/ hx ad, diverticulosis, recently diagnosed colon ca, status post hemicolectomy on presents with dark stools. hcts have trended down from 30 at nh --> 26--> 23. in the ed, vs: t 99.2 hr 67 bp 146/69 rr 18 99% ra. ng lavage was negative. patient was transferred to for further monitoring with plan for egd in am. past medical history: 1) colon ca s/p r colectomy - mucinous adenocarcinoma with 1 out of three lymph nodes positive 2) diverticulosis 3) right knee and shoulder surgery 4) benign prostatic hypertrophy s/p turp with history of arf attributed to post-obstructive uropathy, requiring transient indwelling foley 5) nephrolithiasis 6) alzheimer's 7) chronic anemia 8) depression social history: lives in nursing house. no smoking. minimal alcohol use. formerly in the navy, worked as a tailgunner during ww2. family history: 2 brothers died of lung cancer, one brother died of colon cancer physical exam: vs: afebrile, hr 70, bp 140/76, 98%ra gen: elderly man, pleasant, in nad heent: eomi, perrl neck: supple, jvp at clavicle cv: rrr, s1s2, no m/r/g abd: soft/ nt/ nd, +bs ext: warm, no cyanosis or edema skin: no rashes neuro: aao x 2: hospital (); cn ii-xii intact pertinent results: 10:30am blood wbc-9.0 rbc-4.12* hgb-10.6* hct-33.4* mcv-81* mch-25.8* mchc-31.7 rdw-17.1* plt ct-474* 10:30am blood glucose-115* urean-6 creat-0.8 na-144 k-4.0 cl-112* hco3-24 angap-12 12:15am blood alt-8 ast-19 alkphos-73 amylase-81 totbili-0.5 10:30am blood tsh-1.5 <b> ct abdomen<b/> indication: recent percutaneous gastrostomy placement. evaluate placement. <br> comparison: ct torso of and abdomen radiograph of . <br> technique: contiguous axial images from the mid chest through the abdomen were obtained without iv contrast. coronal and sagittal reformatted images were generated. <br> preliminary report: gastrostomy tube terminates in the esophagus, repositioning is recommended. filling defect in the mid esophagus. bilateral pleural effusions, right greater than left. small right lung base consolidation. large bilateral renal cysts. . <br> ct abdomen without iv contrast: there is a moderate right pleural effusion and small left pleural effusion, simple in attenuation. there is adjacent atelectasis and/or consolidation within a portion of the posterior right lung base. there is a small pericardial effusion. all effusions are increased since . there are coarse coronary artery calcifications, particularly involving the lad. <br> in the epigastric region, a percutaneous gastrostomy has been placed into the gastric antrum. the tube courses cephalad through the body of the stomach, through the gastroesophageal junction, and with the tip into the lowermost esophagus. oral contrast has been administered via the gastrostomy tube, which opacifies the lower esophagus. within the lumen of the uppermost imaged esophagus (at the level of the carina), there is a round soft tissue attenuation structure with air, which may represent retained food. small amounts of oral contrast are seen within the gastric lumen. <br> the non-contrast appearance of the liver is unremarkable except for the occasional calcified granuloma. minimal high-density material is seen dependently within the gallbladder, possibly representing layering stones. multiple calcified granulomas are seen in the spleen. a splenule is noted. the non-contrast appearance of the pancreas is unremarkable. the adrenal glands are minimally bulky, without a focal mass lesion, unchanged. there is no hydronephrosis of the kidneys. bilateral renal cysts are noted, which are unchanged in appearance. the previously described hyperenhancing focus in the lower pole of the right kidney is not apparent on non-contrast imaging. <br> the abdominal aorta is normal in caliber, with moderately-severe atherosclerotic calcification, particularly involving the origin of the sma. <br> the patient is post-right hemicolectomy. oral contrast opacifies the remaining portion of the colon, or several diverticula are seen. visualized small bowel loops also contains some oral contrast, but are otherwise unremarkable. there is no free air in the abdomen. there is no free fluid. small retroperitoneal nodes are seen adjacent to the ivc measuring up to about 7 cm size (2:36). these are not markedly changed from the prior examination. <br> no concerning osseous lesions are seen. <br> impression: 1. the gastrostomy tube has been placed percutaneously into the gastric antrum, but the tube is oriented cephalad, with the tip in the lowermost esophagus. oral contrast is seen within the lower half of the esophagus, and a rounded structure within the lumen of the mid esophagus at the level of the carina likely represents retained food. 2. increased size of bilateral pleural effusions, right greater than left, and there is a small pericardial effusion. 3. diffuse atherosclerotic disease as described. findings reviewed with the gi fellow on . the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 2:44 am <br> <br> <b>egd from admission:<b/> findings: esophagus: normal esophagus. stomach: mucosa: atrophy of the mucosa was noted in the antrum. duodenum: protruding lesions there was a question of a small sub-mucosal mass of benign appearance at the duodenal bulb. excavated lesions a few ulcers were found in the duodenal bulb as well as duodenitis. these were considered low risk for bleeding. other procedures: as ulcers and duodenitis were considered low risk, decision was made to proceed with peg placement. a 20fr percutaneous gastrostomy tube (peg) was placed successfully using standard techniques at the stomach body. <br> impression: atrophy in the antrum low risk ulcers and duodenitis in the duodenal bulb successful peg placement (peg) question of small submucosal mass in duodenal bulb. otherwise normal egd to third part of the duodenum recommendations: high dose protonix 40 mg twice a day please check h. pylori serology and treat if positive no further intervention for now for question of submucosal mass unless symptomatic or further bleeding. use tube for essential meds if needed tonight. can start tube feeding tomorrow. duodenitis and ulcer may have accounted for slow hct decline. <br> brief hospital course: mr. is a 85 year old man with a history of alzheimer's, diverticulosis, recently diagnosed colon ca, status post hemicolectomy on presented with dark stools and acute blood loss anemia and malnutrition from the . in the , ng lavage was negative by report. he was initially admitted to the medical icu, and given 2 units of prbcs. he was hemodynamically stable and underwent egd, revealing: "atrophy in the antrum, low risk ulcers and duodenitis in the duodenal bulb, successful peg placement (peg), question of small submucosal mass in duodenal bulb, otherwise normal egd to third part of the duodenum." it was felt these ulcers were likely accounting for the blood loss and occult blood positive stools. h. pylori ab was positive and he was started on antimicrobial therapy as well as twice daily ppi treatment. <br> mr. was called out of the unit to the general medical floor. once on the general medical floor, he had trouble tolerating his tfs initially with emesis and nausea. ct scan revealed the g tube curled up proximally into the esophagus. the gi fellow pulled the tube back and abdominal x-ray showed it no longer in the esophagus. tfs were resumed and the patient had no difficuties thereafter. <br> alzheimer's dementia and depression: pt oriented to self, but not place or time. he was continued on namenda and aricept per home regimen. he was continued on his mirtazapine and his tsh was normal. <br> submucosal mass seen on egd: unclear if this requires follow-up. see egd report attached. <br> remaining open surgical wound: minimal opening, excellent granulation tissue, no evidence for infection, appears to be healing well. continue conservative care as directed. <br> mucinous adenocarcinoma with 1/3 positive lymph nodes, adenopathy seen on ct scan: consider outpatient follow up with gi oncology if patient/family desire. i personally discussed the above findings and recommendations with the patient's hcp and son and his questions were answered to his apparent satisfaction. <br> during the patient's admission, he was a full code. you may consider readdressing this in the future. <br> please note, the patient may have some dark stools given his recent gi bleed, but this should resolve over time. you may consider checking a hct if you are concerned that he is bleeding again, though the suspicion that his duodenal ulcers will bleed any more is small as he is on treatment for h. pylori and a high dose ppi. medications on admission: remeron 15mg qhs omeprazole 20 mg po bid celexa 20mg daily aricept 10mg daily namenda 10mg daily senna ferrous sulfate discharge medications: 1. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 2. memantine 5 mg tablet sig: two (2) tablet po daily (). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed: hold for loose stools. 4. acetaminophen 500 mg capsule sig: capsules po q 8 hours as needed. 5. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 6. amoxicillin 250 mg capsule sig: four (4) capsule po q12h (every 12 hours) for 10 days. 7. clarithromycin 250 mg tablet sig: two (2) tablet po bid (2 times a day) for 10 days. 8. protonix 40 mg susp,delayed release for recon sig: forty (40) mg po twice a day. 9. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: three hundred (300) mg po daily (daily). discharge disposition: extended care facility: - discharge diagnosis: primary: 1) acute blood loss anemia - likely secondary to duodenal ulcerations, h. pylori ab positive 2) malnutrition, s/p g tube placement secondary: --adenocarcinoma s/p hemicolectomy in , metastatic to 1 out of three lymph nodes, ct report from this admission, showed "small retroperitoneal nodes are seen adjacent to the ivc measuring up to about 7 cm size (2:36). these are not markedly changed from the prior examination." --alzheimer's dementia --possible depression --history of renal failure secondary to obstructive uropathy discharge condition: good discharge instructions: please md if mr. is unable to tolerate his tube feeds, develops respiratory distress, pain, fever, or other concerning symptoms. followup instructions: please ensure patient has transporation to see his urologist, dr. phone: date/time: 10:30 please ensure patient has transportation to see his colonic surgeon , md phone: date/time: 11:15 consider oncologic evaluation for adjuvant therapy for his advanced mucinous adenocarcinoma Procedure: Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Transfusion of packed cells Diagnoses: Acute posthemorrhagic anemia Unspecified protein-calorie malnutrition Chronic kidney disease, unspecified Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Diverticulosis of colon (without mention of hemorrhage) Helicobacter pylori [H. pylori] Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes Malignant neoplasm of rectosigmoid junction Body Mass Index between 19-24, adult

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: exertional dyspnea major surgical or invasive procedure: aortic valve replacement (#23mm st. tissue valve) history of present illness: mr. is a 73 year old gentleman with known history of severe aortic stenosis with complaints of progressive exertional dyspnea. most recent echocardiogram showed mean gradient of 65 mmhg, aortic valve area of 0.6cm2, and an ejection fraction of 45%. preoperative cardiac catheterization revealed minimal coronary artery disease and was notable for post-stenotic dilatation of aortic root and ascending aorta. he was admitted for aortic valve replacement. past medical history: severe aortic stenosis dilated aortic root inferior myocardial infarction s/p rca stent diabetes mellitus hypertension hyperlipidemia prostate cancer s/p seen implant bladder cancer s/p bcg injections gastroesophageal reflux disease varicose veins social history: occupation: retired truck driver, currently horse trainer/rider lives with: wife : caucasian tobacco: quit 12 yrs ago after 40 pk yr hx etoh: denies family history: mother died of mi at age 64. brother had at age 71 physical exam: pulse: 80 resp: 16 b/p right: 116/70 height: 5'9.5" weight: 170lbs general: wd/wn male in nad skin: dry intact heent: perrla eomi neck: supple full rom no jvd chest: lungs clear bilaterally heart: rrr irregular murmur 3/6 sem abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema: 1+lle and trace rle varicosities: severe bilateral (l>r) neuro: grossly intact, alert and oriented x 3 pulses: femoral right: 2+ left: 2+ dp right: 2+ left: 2+ pt : 2+ left: 2+ radial right: 2+ left: 2+ carotid bruit right/left: trans murmer pertinent results: 02:54am blood wbc-12.2* rbc-3.84* hgb-11.1* hct-32.6* mcv-85 mch-28.8 mchc-33.9 rdw-14.7 plt ct-115* 10:51am blood wbc-10.0# rbc-2.78*# hgb-8.3*# hct-23.8*# mcv-85 mch-29.9 mchc-35.1* rdw-14.2 plt ct-124* 12:08pm blood pt-13.7* ptt-38.9* inr(pt)-1.2* 10:51am blood pt-14.5* ptt-35.3* inr(pt)-1.3* 02:54am blood urean-12 creat-0.7 na-136 cl-110* hco3-22 12:08pm blood urean-14 creat-0.6 cl-116* hco3-25 echocardiography report , (complete) tape #: 2009aw2-: machine: echocardiographic measurements results measurements normal range left ventricle - septal wall thickness: *2.0 cm 0.6 - 1.1 cm left ventricle - ejection fraction: 50% >= 55% aorta - sinus level: *4.0 cm <= 3.6 cm aorta - ascending: *4.8 cm <= 3.4 cm aortic valve - peak velocity: *4.1 m/sec <= 2.0 m/sec aortic valve - peak gradient: *67 mm hg < 20 mm hg aortic valve - mean gradient: 41 mm hg aortic valve - valve area: *0.7 cm2 >= 3.0 cm2 findings right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: severe symmetric lvh. normal regional lv systolic function. low normal lvef. right ventricle: borderline normal rv systolic function. aorta: moderately dilated aortic sinus. moderately dilated ascending aorta. simple atheroma in ascending aorta. simple atheroma in aortic arch. simple atheroma in descending aorta. aortic valve: severely thickened/deformed aortic valve leaflets. critical as (area <0.8cm2). mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. mild to moderate (+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial 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. conclusions prebypass no atrial septal defect is seen by 2d or color doppler. there is severe symmetric left ventricular hypertrophy. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). with borderline normal rv free wall function. the aortic root is moderately dilated at the sinus level. the ascending aorta is moderately dilated. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) 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 830am post bypass patient is av paced and receiving an infusion of phenylephrine. biventricular systolic function is unchanged. bioprosthetic valve seen in the aortic position. leaflets move well and the valve appears well seated. the peak gradient across the valve is 22 mmhg. aorta is intact post decannulation. the tricuspid regurgitation is now mild. mild mitral regurgitation persists. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 16:06 , m 73 radiology report chest (portable ap) study date of 11:34 am provisional findings impression: sp tue 3:23 pm final report type of examination: chest ap portable single view. indication: status post and ct removal. evaluate for possible pneumothorax. findings: ap single view of the chest obtained with patient sitting upright position is analyzed in direct comparison with the next preceding similar study of . during the one-day examination interval, the patient has been extubated, the ng tube has been removed. the same holds for the previously present swan-ganz pulmonary catheter and right-sided internal jugular sheath. left-sided chest tube has been withdrawn. no pneumothorax can be identified in the apical area. comparison of the chest findings demonstrates that the diaphragms are somewhat in higher position indicating shallow breathing mechanism but no evidence of new pulmonary parenchymal infiltrates or vascular congestion is seen. the lateral pleural sinuses remain free. impression: unremarkable postoperative findings. dr. brief hospital course: mr. went to the operating room and underwent aortic valve replacement (#23mm st. tissue valve) with dr.. cross clamp time= 65 minutes, cardiopulmonary bypass time= 87 minutes. please refer to dr operative report for further details. he was intubated, sedated, and on pressors to optimize hemodynamics when transported in critical but stable condition to cvicu. he awoke neurologically intact and was extubated without difficulty on the day of surgery. beta-blocker, aspirin, statin, and diuretics were initiated. all lines and drains were discontinued in a timely fashion. he continued to progress and was transferred to the step down unit for further monitoring on pod#1. physical therapy consulted for evaluation of increase in strength and mobility. the remainder of his postoperative course was essentially uneventful. he continued to progress and on pod# 6 he was cleared by dr. for discharge to home. all follow up appointments were advised. medications on admission: lantus insulin asa 81 mg daily metformin 1000mg glucotrol xl 10 mg lipitor 10 mg daily metoprolol 25 mg prilosec 20 mg daily flomax 0.4 mg daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. glipizide 10 mg tablet sig: one (1) tablet po bid (2 times a day). 5. metformin 500 mg tablet sig: two (2) tablet po bid (2 times a day). 6. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*65 tablet(s)* refills:*0* 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. lasix 20 mg tablet sig: one (1) tablet po twice a day for 7 days. disp:*14 tablet(s)* refills:*0* 10. potassium chloride 20 meq packet sig: one (1) po q12h (every 12 hours) for 7 days. disp:*14 * refills:*0* 11. lantus 60 units of lantus at breakfast daily discharge disposition: home with service facility: community nurse care,inc discharge diagnosis: severe aortic stenosis, s/p dilated aortic root/ascending aortic aneurysm history of inferior myocardial infarction , s/p rca stent diabetes mellitus hypertension hyperlipidemia discharge condition: good discharge instructions: 1)no driving for one month and off all narcotics 2)no lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)please shower daily. wash surgical incisions with soap and water only. 4)do not apply lotions, creams or ointments to any surgical incision. 5)please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). office number is . 6)call with any additional questions or concerns. followup instructions: dr. in weeks, call for appt dr. in weeks, call for appt dr. in weeks, call for appt dr. in 3 months with chest ct, call for appt ( Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Thoracic aneurysm without mention of rupture Personal history of malignant neoplasm of prostate Aortic valve disorders Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Long-term (current) use of insulin Old myocardial infarction Personal history of malignant neoplasm of bladder Asymptomatic varicose veins

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral lower extremity dvts major surgical or invasive procedure: ivc filter placement history of present illness: 58 year old man s/p liver transplant on found to have dvt on duplex ultrasound. the patient was recently discharged on after a liver transplant complicated by bleeding which required two take-backs to the or and bilateral occipital stroke with residual left field visual defect. he has been doing very well since his discharge, working with pt with minimal pain, eating well and regaining his strength. his only complaint is his eyesight which has been stable since his discharge. he was seen today for scheduled bilateral lower extremity ultrasounds to evaluate for embolic source for his stroke. these revealed a dvt and the patient was directly admitted to the floor for management. he has no specific complaints at this time. past medical history: pmh: cirrhosis, htn, gi bleeding, gerd, history of basal and squamous cell carcinomas treated topically and surgically psh: significant for an appendectomy as well as knee and shoulder arthroscopies social history: married and lives with his wife, who is in good health. he is employed as a telecommunications technician. he has no children. he reports that he smoked cigarettes for about 10 years but quit approximately 30 years ago. he has no history of use of intravenous or illicit drugs. family history: significant for colon cancer in his father as well as seizures in his brother physical exam: physical exam: afebrile, vss no distress, alert and oriented x 3 perla, eomi, anicteric rrr, no murmurs lungs clear abdomen soft, nontender, nondistended, well healed incision ext: no edema, palpable pulses pertinent results: discharge labs: 04:30am blood wbc-6.5 rbc-3.98* hgb-11.8* hct-36.0* mcv-91 mch-29.7 mchc-32.8 rdw-16.0* plt ct-109* 05:35am blood pt-14.8* ptt-25.5 inr(pt)-1.3* 04:30am blood glucose-103* urean-18 creat-0.8 na-141 k-4.1 cl-106 hco3-28 angap-11 04:30am blood alt-32 ast-24 alkphos-70 totbili-0.4 04:30am blood albumin-3.0* calcium-8.4 phos-4.4 mg-1.5* 04:30am blood tacrofk-12.4 . ct head prior to starting heparin: - 1. small gyriform foci of hyperdensity in the right occipital lobe at the area of prior infarct may represent areas of hyperperfusion-petechial hemorrhage-laminar necrosis or residual blood from prior hemorrhage, age-indeterminate. no large intracranial hemorrhage is seen. 2. bilateral occipital lobe hypodensity, right larger than left, unchanged left caudate head hypodensity likely consistent with chronic ischemic changes. . ct head after the administration of heparin: - areas of subacute infarction in the occipital lobes bilaterally, unchanged since . evolving hemorrhage within the infarctions. close interval followup is suggested. . ct head : - bilateral subacute occipital infarction/hemorrhage. no acute changes. . duplex: 1. right superficial femoral and peroneal vein thrombus. 2. left posterior tibial vein thrombus. brief hospital course: mr. was admitted on after routine duplex scanning of his legs revealed right superficial and peroneal vein dvt and left posterior tibial dvts. due to his recent occipital strokes a ct scan was obtained prior to the administration of heparin. the ct scan showed bilateral occipital lobe hypodensities, right larger than left, unchanged from prior studies. neurology was consulted and a heparin gtt was started at a low rate. a few hours after the heparin was started he began to complain of new visual hallucinations that he did not have before. due to concerns for hemorrhagic conversion of his prior cva he was transferred to the icu for monitoring and a head ct was obtained that showed areas of subacute infarction in the occipital lobes bilaterally, unchanged since with evolving hemorrhage within the infarctions. his heparin gtt was immediately stopped and 2 more follow up head cts showed no change. an eeg was obtained and this show signs of encephalopathy but no seizure activity. his hallucinations continued and keppra was started. a 24hour eeg was obtained, an initial interpretation showed no seizure activity, but the final read is still pending as of his discharge. he was transferred back to the floor. his diet was advanced and he is having bowel function. his labarotory work is stable. his visual hallucinations are vastly improving and his main complaints are blurry vision in his left visual fields. he is discharged on keppra with transplant as well as neurology follow up. a cardiology consult was obtained to evaluate for closure of his asd as an appropriate date. his tacro dose was decreased to 1.5mg based on his level. his prednisone was decreased to 15mg daily. medications on admission: mmf 1000mg , protonix 40mg daily, fluconazole 400mg daily, valcyte 900mg daily, plavix 75mg daily, asa 325mg daily, bactrim ss daily, metoprolol 25mg tid, colace 100mg , prednisone 17.5mg daily, prograf 2mg discharge medications: 1. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 2. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 3. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 4. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. prednisone 5 mg tablet sig: three (3) tablet po daily (daily). 8. tacrolimus 1 mg capsule sig: 1 and capsule po q12h (every 12 hours). 9. insulin lispro 100 unit/ml solution sig: per sliding scale per scale subcutaneous asdir (as directed). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. levetiracetam 250 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: bilateral leg dvts discharge condition: good alert and oriented x 3 ambulating independently discharge instructions: please call the clinic at if you experience any of the following: fever, chills, nausea, vomiting, inability to eat or drink, abdominal pain, diarrhea, chest pain, shortness of breath, a change in your visual symptoms, weakness or numbness on one side of your body, or any other concerns you may have. . resume all of your medications. your prednisone dose was decreased to 15mg daily. you were started on keppra due to concerns for seizures. your eeg was tentatively read as negative. you should continue the keppra and follow up with neurology. followup instructions: provider: , md phone: date/time: 9:30 provider: , md phone: date/time: 10:00 provider: , md phone: date/time: 10:00 . follow up with dr. (neurology). his office number is (. you have an appointment on but he may want to see you sooner. call his office on monday. Procedure: Interruption of the vena cava Diagnoses: Esophageal reflux Unspecified essential hypertension Intracerebral hemorrhage Ostium secundum type atrial septal defect Other late effects of cerebrovascular disease Anticoagulants causing adverse effects in therapeutic use Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Other specified visual disturbances Acute venous embolism and thrombosis of deep vessels of distal lower extremity Late effects of cerebrovascular disease, disturbances of vision

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: etoh cirrhosis and hcc admitted for liver transplant major surgical or invasive procedure: : cadaveric liver transplant with roux-en-y biliary reconstruction. : abdominal washout and control of bleeding : re-opening of recent laparotomy with control of hemorrhage. history of present illness: 58m with etoh cirrhosis and hcc called in for liver transplant. a donor liver has become available and mr. is the back-up recipient. he is status post cyberknife treatment on for hcc. the patient's last alcohol use was on , and he is participating in relapse prevention. past medical history: cirrhosis, htn, gi bleeding, gerd, history of basal and squamous cell carcinomas treated topically and surgically psh: significant for an appendectomy as well as knee and shoulder arthroscopies social history: married and lives with his wife, who is in good health. he is employed as a telecommunications technician. he has no children. he reports that he smoked cigarettes for about 10 years but quit approximately 30 years ago. he has no history of use of intravenous or illicit drugs. family history: significant for colon cancer in his father as well as seizures in his brother physical exam: 97.6 72 108/66 18 100%ra wt72 kg gen: alert and oriented cv: rrr, no murmurs/rubs/gallops resp: clear to auscultation abd: soft, non-tender, non-distended, reducible umbilical hernia, well-healed appendectomy incision ext: warm and well-perfused, no edema pertinent results: on admission wbc-3.9* rbc-3.57* hgb-11.8* hct-35.4* mcv-99* mch-33.2* mchc-33.5 rdw-14.7 plt ct-54* pt-17.1* ptt-37.6* inr(pt)-1.5* glucose-115* urean-8 creat-0.7 na-141 k-3.7 cl-107 hco3-27 angap-11 alt-19 ast-38 alkphos-192* totbili-3.3* albumin-3.4* calcium-8.7 phos-3.5 mg-2.0 at discharge wbc-6.8 rbc-3.62* hgb-10.8* hct-33.7* mcv-93 mch-29.8 mchc-32.0 rdw-18.0* plt ct-101* pt-14.0* ptt-26.3 inr(pt)-1.2* glucose-100 urean-11 creat-0.6 na-137 k-4.2 cl-102 hco3-33* angap-6* alt-45* ast-31 alkphos-81 totbili-1.0 calcium-7.8* phos-3.0 mg-1.5* albumin-2.6* tacrofk-3.8* brief hospital course: 58 y/o male who is admitted from home as backup for liver transplant. the liver was from a 67-year-old woman with normal liver function but who had a liver with 30% macrosteatosis and microsteatosis. the patient was taken to the or with dr after a careful discussion with the patient. the patient received routine immunosuppression induction to include cellcept, solumedrol intra-op with taper and started prograf on the evening of pod 1. per the operative report during the transplant after the portal vein was clamped and tied, a few minutes later, the bowels began to swell and the patient began to bleed significantly , due to the increased portal hypertension with clamping the portal vein. despite clamping as much bleeding as possible, there was significant oozing everywhere. the donor bile duct was approximately 2 cm, and per dr note did not feel a duct to duct anastomosis would be done safely, so a roux-en-y was performed. the bleeding remained significant but after approximately 3 hours of controlling the bleeding the patient was deemed stable and he was transferred to the sicu. on the patient was noted to have falling hcts despite multiple transfusions and he was taken back to the or with dr for intra-abdominal hemorrhage s/p liver transplant. at the time of surgery, when the old incision was opened there was a significant amount of blood in the abdomen. this was washed out, and although there were no areas of overt bleeding, there was a constant retroperitoneal ooze. the area was argon beamed and the patient was closed once sites looked satisfactory. in thre ensuing 24 hours, he continued to have transfusion requirement and was also receiving , he was taken back once again with dr . after opening the old incsision, a significant amount of clotting was encountered> again the abdomen was washed out all anastomoses inspected and it was again determined the bleeding was from the retroperitoneum and diaphragm. following this third surgery the hematocrit was more stable and he required no more intervention. he received 5 days of unasyn due to multiple intrabdominal excursions. in the post operative period, the patient reported visual changes. he was seen by the neurology/stroke consult team who recount the patient report that although he was initially "out of it" while intubated and sedated following the procedures, he recalled visual difficulty on around or . he noticed that he could only see clearly out of the right visual fields. per the neuro note, the patient gave as an example that he could see his nurse enter from the right before apparently disappearing and reappearing across the room. he also recounts seeing the right half of other peoples' faces; the left half appears blurry if not absent. he was unable to identify a clear trigger for the visual change. a head ct was done showing: confluent low attenuation in bilateral occipital lobes as well as left caudate head. mri of the head showed multiple areas of signal abnormality predominantly in the bilateral posterior cerebral artery distribution involving the occipital lobes bilaterally, with an additional area of involvement in the left caudate head and a couple of punctate foci in the left basal ganglia and internal capsule. an echo was performed showing mid interatrial septum c/w a small secundum asd. no clot was identified. head and neck cta demonstrated that the carotid and vertebral arteries and their major branches appear patent, with no evidence of stenoses, aneurysm, dissection, or thrombus. the patient was started on aspirin and plavix and will have outpatient neurology and opthamology follow up. the liver transplant did very well in the post op period. lfts declined daily and t bili settled out at 1.0. drains were removed once the majority of old blood and clot dissipated. his blood pressure was well maintained on metoprolol and he is discharged to home on this new med, although the dosing was dropped to on discharge. the patient was followed by ot and pt and he will require home services with both specialties, but he was deemed safe for home. prograf dosing was monitored and adjusted, cellcept and pred taper were continued. the patient will go home on short term lasix. medications on admission: clotrimazole 10mg troche 5x daily, nadolol 20 mg daily, pantoprazole 20mg daily discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 2. prednisone 5 mg tablet sig: four (4) tablet po once a day. 3. docusate sodium 100 mg tablet sig: one (1) tablet po bid (2 times a day). 4. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 8. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for incision pain. disp:*40 tablet(s)* refills:*0* 12. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*2 tablet(s)* refills:*0* 13. one touch ultra system kit kit sig: one (1) kit miscellaneous twice a day: check blood sugars twice daily, bring record to clinic. 14. tacrolimus 1 mg capsule sig: four (4) capsule po twice a day. discharge disposition: home with service facility: vna discharge diagnosis: s/p orthotopic liver transplant hematoma evacuation x 2 (or takebacks) post transplant subacute infarcts involving both occipital lobes with visual changes discharge condition: stable a+ox3: s/p subacute infarcts involving both occipital lobes during this admission, resulting in blurred vision ambulatory with walker discharge instructions: please call the transplant clinic at for fever, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications or noted increase in visual changes you will have labs drawn every monday and thursday at the office building lab. this will continue until further notice. please come to the lab on friday to have labs drawn for this week only. come to lab in the morning, do not take prograf prior to lab draw but bring it with you and take the prograf once blood is drawn. take your night time prograf dose approximately 12 hours before you plan to have labs drawn the following day. take all meds as directed monitor the incision for redness, drainage or bleeding no heavy lifting no driving if taking narcotic pain medications you may shower, no tub baths or swimming call the transplant clinic at for blood sugars over 200 on two consecutive days. check blood sugars twice daily (fasting and 4pm, and avoid concentrated sweets in your diet please purchase over the counter aspirin and colace (stool softener) monitor for signs of bleeding such as nose bleed, rectal bleeding or easy bruising since you are now on aspirin and plavix followup instructions: , md phone: date/time: 8:00 , transplant social work date/time: 9:00 , md (ophthamology) - phone: date/time: 9:15. , md phone: date/time: 10:00 (neurology) at 2pm. please call ( for details regarding that appointment. you may also choose to schedule follow up with an ophthamologist closer to home instead if that is more convenient. Procedure: Diagnostic ultrasound of heart Cholecystectomy Other transplant of liver Other laparotomy Other laparotomy Excision or destruction of lesion or tissue of abdominal wall or umbilicus Excision or destruction of lesion or tissue of abdominal wall or umbilicus Choledochoenterostomy Other operations on lacrimal gland Transplant from cadaver Diagnoses: Esophageal reflux Unspecified essential hypertension Alcoholic cirrhosis of liver Portal hypertension Pulmonary collapse Hemorrhage complicating a procedure Personal history of other malignant neoplasm of skin Calculus of gallbladder with other cholecystitis, without mention of obstruction Ostium secundum type atrial septal defect Other sequelae of chronic liver disease Malignant neoplasm of liver, primary Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Accidents occurring in residential institution Cerebral artery occlusion, unspecified with cerebral infarction Other and unspecified alcohol dependence, unspecified Iatrogenic cerebrovascular infarction or hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: addendum: cardiology: patient had attempted asd closure but aborted secondary to right ij/cephalic thrombus and ivc filter thrombus. there were no complications following attempt. tee : left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. a patent foramen ovale is present. a left-to-right shunt across the interatrial septum is seen at rest. left ventricular wall thicknesses and cavity size are normal. the right ventricular cavity is mildly dilated with borderline normal free wall function. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no pericardial effusion. discharge disposition: home with service facility: vna md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Angiocardiography of venae cavae Electroencephalogram Diagnoses: Esophageal reflux Other and unspecified alcohol dependence, in remission Other convulsions Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Ostium secundum type atrial septal defect Other complications due to other vascular device, implant, and graft Accidents occurring in other specified places Personal history of malignant neoplasm of liver Liver replaced by transplant Surgical or other procedure not carried out because of contraindication Other venous embolism and thrombosis of inferior vena cava

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: confusion major surgical or invasive procedure: ivc filter removal and asd closure() attempted but not completed history of present illness: is a 58 year-old man with a complex past medical history including hypertension, hepatocellular carcinoma, alcoholic cirrhosis, status post liver transplant, dvts, previous stroke who was brought to the ed after episode of change in mental status. he was in his usual state of health until 3pm this afternoon, when he was talking in the phone with one of his co-workers, his wife noticed that he stopped speaking and looked confused. she approached him and started to ask question. in two occasions he seemed appropriate, but in the begining he was repeating what she was asking him. she tested his face symmetry and asked him to put his arms up, which he did without problems. his wife decided to call 911 and when the team arrived he was sitting in a chair and talking to he was adequately talking and provide information. they decided to transport him to , and in the ambulance he developed decerebrate posturing. concerning for new stroke, he was intubated to protect airway and sedated. ct scan was done in the osh and patient was transferred to continue his care. upon arrival he had another head ct. in comparision with previous studies no changes were observed. ros: he denies fevers, chills, nausea, sob, cp, cough, abdominal pain, bowel or bladder problems, rash past medical history: pmh: cirrhosis, htn, gi bleeding, gerd, history of basal and squamous cell carcinomas treated topically and surgically social history: married and lives with his wife, who is in good health. he is employed as a telecommunications technician. he has no children. he reports that he smoked cigarettes for about 10 years but quit approximately 30 years ago. he has no history of use of intravenous or illicit drugs. family history: significant for colon cancer in his father as well as seizures in his brother physical exam: vs: 102x68mmhg hr 70bpm genl: intubated and sedated with versed and fentanyl heent: sclerae anicteric, no conjunctival injection, oropharynx clear cv: regular rate, nl s1, s2, no murmurs, rubs, or gallops ext: no lower extremity edema bilaterally neurologic examination: mental status: intubated sedated. not folowing commands. eyes in the midline. responding well to noxious stimulation, localizing source of dyscomfort cranial nerves: pupils equally round and sluggish reactive to light. extraocular movements seemed intact. no nystagmus. facial movement symmetric. tongue midline. motor: no observed myoclonus, asterixis, or tremor. no pronator drift. moving all extremities anti-gravity. sensation: withdraw of the four limbs with noxious stim. reflexes: 2+ and symmetric throughout. toe upgoing in the left side. coordination: no tremor. gait: not tested. pertinent results: 07:08pm glucose-189* urea n-13 creat-0.7 sodium-141 potassium-4.7 chloride-105 total co2-26 anion gap-15 07:08pm estgfr-using this 07:08pm alt(sgpt)-19 ast(sgot)-22 alk phos-67 tot bili-0.7 dir bili-0.3 indir bil-0.4 07:08pm albumin-3.6 07:08pm wbc-5.4 rbc-3.91* hgb-12.3* hct-36.0* mcv-92 mch-31.5 mchc-34.3 rdw-15.7* 07:08pm neuts-81.8* lymphs-13.9* monos-3.5 eos-0.3 basos-0.6 07:08pm pt-14.3* ptt-24.1 inr(pt)-1.2* 07:08pm plt count-109* 11:00am glucose-120* 11:00am urea n-11 creat-0.7 sodium-138 potassium-3.9 chloride-100 total co2-28 anion gap-14 11:00am estgfr-using this 11:00am calcium-9.1 11:00am afp-3.7 11:00am wbc-6.8 rbc-4.21* hgb-13.0* hct-40.0 mcv-95 mch-30.9 mchc-32.5 rdw-15.5 11:00am plt count-123* 11:00am pt-13.4 inr(pt)-1.1 04:25am blood wbc-5.0 rbc-3.84* hgb-12.1* hct-35.4* mcv-92 mch-31.5 mchc-34.2 rdw-15.6* plt ct-95* 04:20am blood wbc-4.9 rbc-3.84* hgb-11.6* hct-34.7* mcv-90 mch-30.2 mchc-33.4 rdw-15.5 plt ct-96* 03:46am blood wbc-5.9 rbc-3.37* hgb-10.5* hct-31.1* mcv-92 mch-31.2 mchc-33.8 rdw-15.7* plt ct-90* 07:08pm blood wbc-5.4 rbc-3.91* hgb-12.3* hct-36.0* mcv-92 mch-31.5 mchc-34.3 rdw-15.7* plt ct-109* 03:46am blood neuts-70.2* lymphs-22.8 monos-4.7 eos-1.9 baso-0.5 08:15pm blood pt-14.2* ptt-51.5* inr(pt)-1.2* 01:30pm blood pt-14.2* ptt-62.5* inr(pt)-1.2* 04:25am blood plt ct-95* 04:25am blood pt-13.8* ptt-118.4* inr(pt)-1.2* 09:15pm blood pt-13.4 ptt-108.5* inr(pt)-1.1 04:20am blood plt ct-96* 03:46am blood plt smr-low plt ct-90* 03:46am blood pt-15.3* ptt-30.5 inr(pt)-1.3* 07:08pm blood pt-14.3* ptt-24.1 inr(pt)-1.2* 07:08pm blood plt ct-109* 11:00am blood plt ct-123* 11:00am blood pt-13.4 inr(pt)-1.1 04:25am blood glucose-89 urean-12 creat-0.6 na-138 k-3.8 cl-103 hco3-28 angap-11 04:20am blood glucose-92 urean-10 creat-0.7 na-139 k-3.9 cl-103 hco3-29 angap-11 06:41pm blood urean-6 creat-0.7 na-136 k-5.0 03:46am blood glucose-102* urean-9 creat-0.6 na-140 k-3.2* cl-109* hco3-26 angap-8 03:46am blood alt-17 ast-17 ck(cpk)-45* alkphos-54 totbili-0.6 03:46am blood ck-mb-notdone ctropnt-<0.01 04:25am blood calcium-8.8 phos-3.6 mg-1.6 04:20am blood calcium-8.3* phos-4.3 mg-2.0 06:41pm blood mg-1.7 03:46am blood calcium-7.6* phos-3.0 mg-1.5* 03:46am blood %hba1c-5.2 eag-103 03:46am blood tsh-2.8 11:00am blood afp-3.7 04:25am blood tacrofk-6.2 04:20am blood tacrofk-5.2 09:12am blood tacrofk-5.2 : cxray: impression: 1. endotracheal and nasogastric tubes in appropriate position. 2. right costophrenic angle not included on the image, 3. elevation of the left hemidiaphragm with overlying left mid to lower lung atelectasis. trace left pleural effusion not excluded. 4. prominent ectatic appearing ascending aorta, particularly given patient age. retrospective review of the patient's prior chest ct shows mildly dilated ascending aorta (3.6 cm). ct head: findings: there is bilateral hypodensity in the occipital lobes, right greater than left. again noted is an area of increased hyperdensity measuring approximately 1.6 x 3.3 cm (2, 16) in the right occipital lobe in the area of prior infarction. there is an old lacunar infarct in left basal ganglia. there is prominence of the ventricles and sulci consistent with age-related atrophy. there is no evidence of hydrocephalus. there is no intraventricular hemorrhage or subarachnoid hemorrhage identified. there is no shift of normally midline structures. there is otherwise normal -white matter differentiation. the basilar cisterns are preserved. the visualized paranasal sinuses are clear. extensive secretions are seen in the posterior nasopharynx. mucosal thickening in the ethmoid air cells is noted. impression: no significant change in hemorrhagic right occipital lobe infarct. no change in left occipital lobe infarct. eeg: impression: this is a normal routine eeg in the waking and sleeping states. there were no focal, lateralized, or epileptiform abnormalities noted. mri brain: impression: 1. findings consistent with subacute infarction within the bilateral posterior cerebral artery distributions involving the occipital lobes as well as within the anterior circulation involving the left caudate head and internal capsule. there is no evidence of acute infarction. 2. central and cortical involutional changes slightly advanced for the patient's age of 58 years. 3. microangiopathic ischemic white matter disease. brief hospital course: brief hospital course: neurologic: he was admitted to the icu intubated. he was quickly extubated and neurologic exam improved. he was transferred to the floor. mri brain did not show evidence of new infarction. clinical history most consistant with seizure. eeg did not show seizures. keppra increased from 750 mg to 1000mg po bid. patient was started on anticoagulation with ptt goal (50-70)given history of dvt. patient also started on coumadin and dose kept low given interaction with fluconazole/bactrim. inr was 1.5 at discharge. he was trained to administer himself lovenox and instructed to use it q 12 hours until inr therapuetic between . aspirin and plavix discontinued. cv: ekg showed: nsr. evaluated by cardiovascular surgery and taken to cath lab for closure of asd and also removal of ivc filter. rt ij and ivc showed clotting and procedure was aborted to avoid showering of emboli. plan was to anticoagualte for another month before attempting procedure again. he will have venous duplex imaging in 3 weeks. hypercoaguable workup will be sent as an outpatient. metoprolol changed to propranolol because of improved control of tremor with the later medication. gi: transplant team followed the patient since he is s/p liver transplant . tacrolimus level monitored and dosing adjusted daily. he was discharged with a level of 6.7 and a dose of 3mg at 6pm and 6am. he is on antifungals and antibiotics that interfere with coumadin and therfore recommendation was to keep coumadin dose at 2 mg daily. he will have his standing order of labs drawn on . discharge plan discussed with transplant and cardiology teams. medical assistant also informed of plan and follow up scheduled in pcp's office and stroke clinic on . home pt and vna services arranged. medications on admission: outpatient medications: kayelaxate as needed metoprolol 25mg furosemide 20mg clopidogrel 75mg daily asa 325mg daily keppra 750mg tacrolimus 1.5mg cellcept 1000mg prednisone 5mg valganciclovir 900mg daily bactrim 1 tablet daily fluconazole 400mg daily pantoprazole 40mg qam colace 100mg discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 2. propranolol 40 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 3. lovenox 80 mg/0.8 ml syringe sig: one (1) subcutaneous every twelve (12) hours. disp:*8 * refills:*0* 4. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 5. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 8. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 10. prednisone 5 mg tablet sig: 2.5 tablets po daily (daily). 11. tacrolimus 1 mg capsule sig: three (3) capsule po bid (2 times a day) for 2 doses: at 6pm and 6 am. 12. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: seizure history of occipital and caudate infarction with hemorrhagic transformation s/p liver transplant history of dvt history of cirrhosis hypertension gerd discharge condition: ms: awake alert cn: dense left field cut (inferior quadrant) motor: throughout gait: wide based steady gait discharge instructions: you were admitted to the hospital for an episode concerning for seizure. given your recent history of stroke, you had an mri that did not show a new stroke or bleed. you were felt to have had a seizure and your keppra medication has been increased to 1000mg twice a day. your eeg was normal. since you had a dvt, you were started on heparin and coumadin. you were taken to the cath lab for removal of the ivc filter recently placed and closure of your asd, but the procedure was not completed because of clotting found and we wanted to avoid further complications. you will need to stay anticoagulated and then followup for repeat imaging in 3 weeks (a venous duplex will be scheduled and we will call you with the date) to consider removal of the ivc in one month. another appointment in the cath lab will be scheduled in one month. we will need additional labs drawn for a hypercoaguable workup and you have been given a lab slip to have these drawn. you tacrolimus medication was adjusted in the hospital and you were followed by the transplant team. you should have your tacrolimus levels drawn as typically scheduled on monday and thursday. current dose is 3 mg at 6pm and 6 am. you should go to all follow up appointments. it is important to take all of your medications and make all follow up appointments. changes to your medications include an increase in the dose of keppra, a switch from metoprolol to propranolol, and you have been started on coumadin. you do not need to take aspirin or plavix any longer. your tacrolimus dose is 3 mg at 6pm and 6 am. you will be administered subcutaneous heparin for the next several days until your inr becomes therapuetic. you should have your inr drawn in days at your pcp's office. inr goal is () and you should not stop lovenox injections until coumadin is therapuetic. you have been given a list of foods to avoid while on coumadin. your cardiologist would like you to have a hypercoaguable workup and you have been given a lab slip to have this drawn as an outpatient as well as your pt/ptt/inr and tacrolimus level on . all lab results should be sent to . followup instructions: 02:20p -cc7 -cc7 sc clinical ctr, cc7 cardiology (sb) provider: , md phone: date/time: 2:00. (case management) stated it is ok to attend this appointment in stroke clinic. we have spoken to the medical assistant of dr. who will follow inr monday . you also have follow up with dr. at 10:00 am on . will also be made aware so that she can follow inr while on ocumadin. provider: , md phone: date/time: 10:00 provider: field screening phone: date/time: 10:00 md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnostic ultrasound of heart Angiocardiography of venae cavae Electroencephalogram Diagnoses: Esophageal reflux Other and unspecified alcohol dependence, in remission Other convulsions Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Acute respiratory failure Ostium secundum type atrial septal defect Other complications due to other vascular device, implant, and graft Accidents occurring in other specified places Personal history of malignant neoplasm of liver Liver replaced by transplant Surgical or other procedure not carried out because of contraindication Other venous embolism and thrombosis of inferior vena cava

allergies: no known allergies / adverse drug reactions attending: chief complaint: left leg pain major surgical or invasive procedure: peripheral catheterization- abdominal aorta and bilateral distal extremity run-offf, bilateral limb angiography, pta/stent left iliac history of present illness: patient is a 52yo male with history of pvd, copd, dm and hyperlipidemia admitted to the ccu after undergoing left iliac stent placement x 2 for total occlusion of said vessel. post-procedure saturations were noted to be in the mid-80s so he was sent to the ccu for further care. . the patient reported a recent history of worsened left lower extremity claudication. per recent cardiology note, he states after walking his son to the bus stop which is yards from home he has to stop and rest in the middle of the walk due to left leg pain. he states both of legs hurt, left > right and after resting for 10 minutes the pain will go away. patient states he has to stop multiple times on his way to his son's bus stop every morning. this pain has been occurring for the past ten years. . he underwent a ct angio of his abdomen and bilateral lower extremities on , which demonstrated "lower abdominal aorta irregularity and vascular consultation. left side of the common iliac artery 4-cm total occlusion with the distal portion reconstitution. right sided common iliac artery distal portion calcification with mild narrowing mid-portion of right sided superficial femoral artery focal calcification with 50% focal narrowing is also noted." . the patient has copd most likely secondary to extensive tobacco history. per his wife, he has a poor baseline secondary to dyspnea and leg claudication. his baseline oxygen saturations are in the high 80s/low 90s at rest. he uses 2l nc oxygen during exertion. he also has a history of osa but did not complete sleep study. . after the procedure this evening, he oxygen saturations were noted to be in the mid-80s. patient denied shortness of breath/chest pain/dizziness/light-headedness. he was otherwise hemodynamically stable. there were no post-procedure complications. given his low saturations, he was sent to the ccu for closer monitoring and possible positive pressure ventilation. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. positive for exertional buttock and calf pain. all of the other review of systems were negative. . he denies chest pain, worsened dyspnea, edema, orthopnea, pnd, lightheadedness, or syncope. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: (+)diabetes, (+)dyslipidemia, (+)hypertension 2. cardiac history: -cabg: - -percutaneous coronary interventions: - -pacing/icd: - 3. other past medical history: copd sleep apnea has not done sleep study restless leg syndrome prostate cancer s/p radiation treatment carpal tunnel syndrome s/p left hand operation obesity arthritis s/p broken jaw in mva at the age of 17 small benign tumor removal from right jaw tobacco abuse social history: lives with his wife and six year old son. -tobacco history: 1/2ppd x 40 years -etoh: denies -illicit drugs: denies family history: mother and sister had cancer. father died of cad s/p cabg and had diabetes, mother has htn, older brother has dm and cabg. physical exam: vitals on discharge: 98.7, 98, 108/91, rr 20, 92% on 2l general: 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 with normal jvp. cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. no abdominial bruits. extremities: no c/c/e. no femoral bruits. cath sites are clean, dry and dressed. no bruits heard. dt/pt- 2+ bilaterally. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ dp 2+ pt 2+ pertinent results: 07:25pm blood type-art o2 flow-2 po2-60* pco2-80* ph-7.27* caltco2-38* base xs-6 intubat-not intuba comment-nasal 08:03pm blood o2 flow-1 po2-51* pco2-67* ph-7.30* caltco2-34* base xs-3 comment-nasal 08:03pm blood o2 sat-79 cohgb-8.3* 11:41pm glucose-231* urea n-14 creat-0.9 sodium-137 potassium-4.4 chloride-97 total co2-29 anion gap-15 11:41pm ck-mb-5 ctropnt-<0.01 11:41pm ck(cpk)-123 11:41pm pt-12.6 ptt-23.6 inr(pt)-1.1 cxr : the lungs are clear. heart size is within normal limits. the slight fullness of the right mediastinum is likely vascular as there is prservation of the right paratracheal stripe. no concerning bone findings. iliac stent placement : angio showed l cia occlusion. bilateral access and stenting with 2 stents. perclose to both groins. brief hospital course: # hypoxia- patient with known copd (baseline sats in the mid-high 80s/low 90s) who was found to have sat of 85% post-procedure. he denies shortness of breath, chest pain, or lightheadedness. etiology seems to be copd. given body habitus, he most likely has some degree of osa also but is not on cpap at home. most recent abg consistent with co2 retaining- 7.30/67/51, consistent with chronic respiratory acidosis. patient sat'ed in low 90s on 2l nc throughout admission; prior to discharge his o2 sat at rest was 85% off o2 but the patient was completely asymptomatic and said that he felt like he was at his baseline. of note the patient has home o2 2l which he will continue using prn at home. patient was continued on home inhalers. . # coronaries: patient with known dm, hyperlipidemia, and hypertension. he denies chest pain or shortness of breath at this time and ekg was normal. given his risk factors and known pvd, patient most likely has some degree of cad but is currently asymptomatic. remained hemodynamically stable throughout hospitalization. patient started on plavix 75mg daily for iliac stent placement and continued on home aspirin and simvastatin. . # pump: patient had ett in demonstrating ef of 70%. patient is not showing signs of fluid overload on exam- normal jvd, no peripheral edema, chest clear to ausculatation bilaterally. cxr was normal. . # rhythm: patient in normal sinus rhythm throughout admission. . # left iliac occlusion s/p stent- site was clean and dry with no signs of bleed. patient started on plavix 75mg daily, continued on aspirin 325 mg daily. . # dm- patient instructed to hold metformin and re-start 48 hours after procedure. medications on admission: budesonide-formoterol 160 mcg-4.5 mcg/actuation hfa aerosol inhaler - 2 puffs twice daily glyburide 5 mg tablet qd lisinopril 40 mg tablet qd metformin 1,000 mg tablet po bid pramipexole 0.5 mg tablet qd simvastatin 20 mg tablet qd tiotropium bromide 18 mcg capsule, w/inhalation device one daily verapamil 180 mg cap sr qd aspirin - (prescribed by other provider) - 325 mg tablet - one tablet(s) by mouth daily famotidine - (prescribed by other provider) - 10 mg tablet - one tablet(s) by mouth daily as needed discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*5* 2. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. disp:*12 tablet(s)* refills:*0* 3. famotidine 10 mg tablet sig: one (1) tablet po daily (daily) as needed for indigestion. 4. verapamil 180 mg tablet sustained release sig: one (1) tablet sustained release po q24h (every 24 hours). 5. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 6. aspirin 325 mg tablet sig: one (1) tablet po once a day. 7. simvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. pramipexole 0.5 mg tablet sig: one (1) tablet po daily (). 9. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 10. glyburide 5 mg tablet sig: one (1) tablet po daily (daily). 11. symbicort 160-4.5 mcg/actuation hfa aerosol inhaler sig: one (1) puff inhalation twice a day. 12. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home discharge diagnosis: primary: peripheral vascular disease (left iliac artery occlusion s/p stent placement), copd. secondary: hyperlipidemia, hypertension. diabetes mellitus, discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with leg pain. while here, you had a stent placed in your left leg artery for the occlusion there. you had relatively low oxygen saturations after the procedure so you were sent to the ccu for close monitoring. while here, you did very well and remained at your baseline oxygen requirement. you are being discharged home. the following changes were made to your medications: 1. start taking plavix 75mg daily. 2. continue taking aspirin 325mg daily. you should continue taking these medications until you followup with dr. . resume your other home medications as your had been taking them. followup instructions: please follow-up with your cardiologist, dr. , at 8:40 am. () please follow-up with your primary care physician, . in one week () please return to the ed if you have any pain in your groin, numbness or tingling in your legs, chest pain, increasing shortness of breath or any other concerning symptoms. Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Insertion of drug-eluting stent(s) of other peripheral vessel(s) Transposition of cranial and peripheral nerves Insertion of two vascular stents Procedure on single vessel Diagnoses: Pure hypercholesterolemia Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atherosclerosis of native arteries of the extremities with intermittent claudication Personal history of malignant neoplasm of prostate Obesity, unspecified Personal history of irradiation, presenting hazards to health Insomnia, unspecified Restless legs syndrome (RLS) Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Arthropathy, unspecified, site unspecified Chronic total occlusion of artery of the extremities Atherosclerosis of other specified arteries

allergies: sulfa (sulfonamide antibiotics) / levaquin / allopurinol / rituxan / droperidol / doxycycline / bacitracin attending: chief complaint: hypotension major surgical or invasive procedure: sinus debridment history of present illness: 69 yo m w/ cll, h/o parkinson's disease, recurrent pulmonary infections and chronic sinusitis who is s/p endoscopic sinus surgery (sinusectomy) on to prevent recurrence of mrsa pneumonia. on he started to develop fevers, was seen by ent on and given inhaled vancomycin and betamethason as or cultures were positive for mrsa. he was then admitted from and started on vancomycin with goal trough of 10. during that admission his anc dropped to 0 and was started on neuopgen by his oncologist, dr. . on he underwent debridment by dr. with minumal purulent discharge. on he began to develop fevers to 103 with rigors and fatigue. he was admitted on . in the ed, labs were notable for wbc 51.9 hct 25 plts 104, sodium 132 (was 27 on ). cxr without infiltrate. his floor course was c/b several runs of afib with rvr to the 150s with systolic blood pressures as low as the 80s. he was started on cefepime to converage grown on nasal swab for pseudomonas on . since then his fever curve has declined. today at 7am he was in afib wtih rvr to 150 blood prssure briefly at 70/52. he was given 3l ns followed by 0.25mg of digoxin. ekg was similar to above. pt remained asympomatic throughout without chest pain, palpitations, shortness of breath, or light headedness. shortly after digoxin, hr reduced to 80s-100, bp improved to 90s. he was transferred to the micu for monitoring and for increased nursing requirements. past medical history: past medical history: -cll (dx ) s/p rituximab, fludarabine in . -hypogammaglobulinemia (iga, igm) treated with iv ig 2x/month (last ) -recurrent pna with mrsa, pseudomonas, m. gordonae (likely contaminant) -bronchiectasis -recurrent sinusitis -rectal ca in s/p resection, radiation, 5-fu -parkinson's dz dx -htn social history: the patient is married, lives with his wife in . he has two daughters, both healthy. he is a retired phd in economics, still working minimally as a professor. . no tobacco. no ivdu or illicits. family history: stroke and parkinson's disease, congestive heart failure, prostate cancer, glaucoma. physical exam: admission physical exam: vitals: t:98.2 bp:95/69 p:101 r:20 o2:94% ra general: alert, oriented, no acute distress heent: sclera anicteric, perrl, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: few basilar rales. otherwise clear, good airmovement. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, enlarged spleen gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: perrl, no facial assymmetry, + cogwheel rigitidity, alert and oriented, responds appropriately to questions. pertinent results: 11:55am gran ct-355* 11:55am plt smr-low plt count-86* 11:55am hypochrom-1+ anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 11:55am neuts-1* bands-0 lymphs-98* monos-1* eos-0 basos-0 atyps-0 metas-0 myelos-0 11:55am wbc-35.5* rbc-2.76* hgb-8.4* hct-25.1* mcv-91 mch-30.5 mchc-33.5 rdw-15.3 12:45pm pt-13.3 ptt-25.8 inr(pt)-1.1 12:45pm plt smr-low plt count-104* 12:45pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 12:45pm neuts-1* bands-0 lymphs-99* monos-0 eos-0 basos-0 atyps-0 metas-0 myelos-0 12:45pm wbc-51.9* rbc-2.74* hgb-8.4* hct-25.1* mcv-91 mch-30.7 mchc-33.6 rdw-15.9* 12:45pm lactate-0.9 12:45pm estgfr-using this 12:45pm glucose-123* urea n-17 creat-1.0 sodium-132* potassium-4.1 chloride-98 total co2-24 anion gap-14 01:30pm urine rbc-0 wbc-0 bacteria-mod yeast-none epi-0 01:30pm urine blood-neg nitrite-neg protein-25 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 01:30pm urine color-yellow appear-clear sp -1.021 08:25pm plt smr-low plt count-84* 08:25pm wbc-39.3* rbc-2.54* hgb-7.7* hct-22.9* mcv-90 mch-30.5 mchc-33.8 rdw-15.9* 08:25pm vanco-9.5* 08:25pm ck-mb-1 ctropnt-<0.01 08:25pm ld(ldh)-135 ck(cpk)-18* 08:25pm glucose-155* urea n-17 creat-1.1 sodium-132* potassium-3.5 chloride-97 total co2-25 anion gap-14 02:52am blood gran ct-1780* 04:00am blood gran ct-720* 11:55am blood gran ct-355* 12:03pm blood tsh-2.5 05:47am blood wbc-34.3* rbc-2.44* hgb-7.4* hct-22.5* mcv-92 mch-30.4 mchc-33.1 rdw-17.3* plt ct-54* 05:47am blood glucose-91 urean-16 creat-1.1 na-140 k-4.2 cl-103 hco3-32 angap-9 11:30 am swab site: sinus **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. heavy growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml ______________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ 4 s meropenem------------- 0.5 s piperacillin/tazo----- 8 s tobramycin------------ <=1 s 12:10 pm tissue source: middle meatus. **final report ** gram stain (final ): reported by phone to @ 630pm . 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). tissue (final ): pseudomonas aeruginosa. heavy growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ 2 s meropenem-------------<=0.25 s piperacillin/tazo----- 8 s tobramycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. potassium hydroxide preparation (final ): no fungal elements seen. fungal culture (final ): no fungus isolated. blood culture, routine (final ): no growth. urine culture (final ): no growth. blood culture, routine (final ): no growth. urine culture (final ): no growth. blood culture, routine (final ): no growth. urine culture (final ): no growth. blood culture, routine (final ): no growth. .........................imaging................... echo the left atrium is moderately dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with borderline normal free wall function. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: normal global and regional left ventricular systolic function. borderline dilated and hypokinetic rv. mild mitral regurgitation. moderate pulmonary artery systolic hypertension. ct chest here is no evidence of pulmonary embolism. small bilateral pleural effusionsand associated bibasilar atelectasis are new. bronchiectasis and bronchialwall thickening involving the anterior segment of the right upper lobe (2:28)is unchanged since . allowing for the limitation of significant respiratory motion artifact, multiple poorly defined nodules in the left upper lobe: a 5-mm perifissural nodule (2:17) in the apical posterior segment, and two other ground-glass opacities in the anterior segment of the left upper lobe measure 5 mm each (2:18 and 20). a 3-mm noncalcified left apical posterior segment nodule on act of is now calcified (2, 19), suggesting that it is a granuloma. a 5-mm noncalcified superior segment of right lower lobe nodule is stable since (2:25). extensive adenopathy in the superior mediastinum, bilateral axillae, anterior mediastinum, tracheobronchial stations and the para-aortic space are again present: the largest right hilar node measures 18 x 26 mm compared to 13 x 21 mm on the prior study (3:46). confluent prevascular adenopathy has also increased in size and number (3:31). conversely enlarged axillary and periaortic lymph nodes have decreased in size: a right axillary node measures 20 x 24 mm (2:20) compared to 22 x 32 mm on the prior study, the largest paraaortic posterior mediastinal node now measures 41 x 42 mm compared to 41 x 45 mm on the prior study (2:45). a left upper extremity peripherally inserted central venous catheter tip terminates in the distal left brachiocephalic vein. the cardiac size is normal without pericardial effusion. the airways are patent to the subsegmental level. the proximal esophagus is mildly dilated and contains food debris, possibly a mechanical effect of the extensive posterior mediastinal adenopathy. the study is not tailored for subdiaphragmatic evaluation, only to confirm extensive para-aortic and retroperitoneal soft tissue masses which are incompletely visualized and stable perinephiric fat stranding. upper and lower thoracic spine osteophytosis are moderately severe. impression: 1. no evidence of pulmonary embolism. 2. new small bilateral pleural effusions with associated atelectasis. 3. mixed interval change in size of extensive axillary, hilar, superior and posterior mediastinal adenopathy. there is enlargement of the mediastinal and hilar adenopathy with slight interval reduction or stability of the axillary and posterior mediastinal masses. 4. three new left upper lobe poorly defined nodules, in the setting of recent surgery could represent aspiration or infection. 5. stable mild right middle lobe bronchiectasis and bronchial wall thickening. brief hospital course: assessment & plan: a 69 yom with pmh paroxsymal afib, cll, parkinson's disease, chronic sinusitis and mrsa pneumonia admitted for pseudomonas sinusitis and called out of micu after 4 day stay for afib with rvr. #. sinusitis: on admission, was febrile to 103, most likely source was sinuses given recent debridment. blood cultures and urine cultures were negtaive. he was empirically treated with cefipime while pseudomonas cultures were speciated. culture data showed sensitivity to cipro and cefipime, however patient is allergic to fluroquinolones. he was treated with cefipime and vancomycin, given history of mrsa sinusitis. ent followed the patient in house and performed repeated debridments of sinuses. he was discharged with a picc line and a plan for outpatient iv cefipime and vancomycin to complete a total of 14 days of antibiotic therapy. followup with ent and pcp was arranged. #: micu course: on hd 4, he developed a fib with rvr and hypotension to sbp 70, he was transfered to the micu where he was treated with fluid resussication and rate controlled with amiodarone and digoxin, he converted to sinus rhythm and both were discontinued and metoprolol 12.5mg was started. cta chest was performed which was negative for pe, echo showed borderline hypokenetic rv and normal lv systolic function. moderate pulmonary artery systolic hypertension was noted. # afib: following transfer from micu, patient remained in sinus rhythm and was continued on metoprolol 12.5 mg tid. # cll: patient has not been treated since as there have been no acute indications to do so. he is followed by dr. as outpt. on admission his neutrophil count was 790 and he received one dose of neuopgen to correct this. he was given an appointment for follow up with dr. on discharge. # parkinson disease: patient has slow scanning speech and a shuffling gait, no resting tremor appreciated on exam. throughout admission, patient was maintained on home regimen of carbidopa/levodopa, rasagiline 0.5 mg daily and ropinirole 3 mg qid. medications on admission: -rasagiline 1 mg tablet sig: one (1) tablet po daily () as needed for parkinsons. - ropinirole 1 mg tablet sig: three (3) tablet po qid (4 times a day). -amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). -alprazolam 0.25 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). -nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day) as needed for groin rash. -guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po bid (). -psyllium packet sig: one (1) packet po tid (3 times a day) as needed for constipation. -vancomycin inhaled treatment (pt to take home medication) -betamethasone oral -acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain or fever. -carbidopa-levodopa 25-100 mg tablet sig: two (2) tablet po qam (once a day (in the morning)) as needed for at 7 am. - carbidopa-levodopa 25-100 mg tablet sig: 1.5 tablets po daily (daily) as needed for 10:30 am. 16. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)) as needed for 2 pm. -carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)) as needed for 5:30 pm. -vancomycin in d5w 1 gram/200 ml piggyback sig: 250 ml intravenous q 12h (every 12 hours) for 16 days. disp:*80 grams* refills:*0* -carbidopa-levodopa 25-100 mg tablet sig: 1.5 tablets po daily (daily) as needed for 10:30 am. disp:*45 tablet(s)* refills:*0* - neupogen sig: three hundred (300) mcg subcutaneous once a day. discharge medications: 1. cefepime 2 gram recon soln sig: one (1) recon soln injection q8h (every 8 hours) for 22 doses: final full day of abx: . disp:*22 recon soln(s)* refills:*0* 2. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) gram intravenous q 12h (every 12 hours) for 6 doses: final full day of abx . disp:*6 gram* refills:*0* 3. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for fever: do not exceed 4000mg in 24hrs 4. ropinirole 1 mg tablet sig: three (3) tablet po qid (4 times a day). 5. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 6. alprazolam 0.25 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). tablet(s) 7. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day): groin rash. 8. guaifenesin 600 mg tablet sustained release sig: two (2) tablet sustained release po twice a day. 9. psyllium packet sig: one (1) packet po tid (3 times a day) as needed for constipation. 10. carbidopa-levodopa 25-100 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 11. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po daily 2pm (). 12. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po daily 17:30. 13. carbidopa-levodopa 25-100 mg tablet sig: 1.5 tablets po daily 10:30. 14. betamethasone 0.6 mg/5 ml solution oral 15. rasagiline 0.5 mg tablet sig: one (1) tablet po daily (daily). 16. mupirocin 2 % ointment sig: one (1) appl topical every hours: 3 inches of mupirocin mixed in saltaire bottle (420ml), use 2 squirts in each nostril . 17. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). disp:*45 tablet(s)* refills:*2* 18. outpatient lab work please check cbc with differential and fax to dr. at , and dr. at discharge disposition: home with service facility: northeast home care discharge diagnosis: primary diagnosis pseudomonas sinusitis secondary diagnoses: paroxsymal atrial fibrillation cll (dx ) s/p rituximab, fludarabine in . hypogammaglobulinemia (iga, igm) treated with iv ig 2x/month (last ) recurrent pna with mrsa, pseudomonas, m. gordonae (likely contaminant) bronchiectasis recurrent sinusitis rectal ca in s/p resection, radiation, 5-fu parkinson's dz dx discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , it was a pleasure taking care of your in your hospitalization at . as you know, you were admitted for pseudomonas sinusitis. you were seen by ear nose and throat who performed debridments of your and flushings of sinuses. you were treated with iv antibiotics with good result. you are being discharged with visiting nurse service to help administer your antibiotics. in your hospital stay, you developed atrial fibrillation and were admitted to the intensive care unit for low blood pressure related to atrial fibrillation. your heart rhythm returned to and you were started on metoprolol to prevent return of atrial fibrillation. we recommend that you follow up with your primary care doctor to discuss the length of treatment with metoprolol. we noted that you are anemic (low blood), although not in a dangerous range, we recommend that you have your blood checked in one week and follow up with dr. to discuss your red blood cell level. we have arranged for the visiting nurse to draw your blood. we made the following changes to your medications: - start metoprolol 12.5mg three times per day - start iv cefipime three times per day - start iv vancomycin twice per day followup instructions: please call dr. from ear nose and throat to arrange follow up for this thursday () or friday (). dr. friday at 11:20am ipswitch department: hematology/bmt when: wednesday at 2:00 pm with: , md and dr. building: sc clinical ctr campus: east best parking: garage Procedure: Sinusectomy, not otherwise specified Sinusectomy, not otherwise specified Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Unspecified septicemia Hyposmolality and/or hyponatremia Atrial fibrillation Sepsis Paralysis agitans Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site Bronchiectasis without acute exacerbation Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Splenomegaly Chronic lymphoid leukemia, without mention of having achieved remission Insomnia, unspecified Pseudomonas infection in conditions classified elsewhere and of unspecified site Chronic maxillary sinusitis Neutropenia, unspecified Acute sinusitis, unspecified Hypogammaglobulinemia, unspecified Personal history of Methicillin resistant Staphylococcus aureus Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus

allergies: sulfa (sulfonamide antibiotics) / levaquin / allopurinol and derivatives / rituxan / droperidol / doxycycline / bacitracin attending: chief complaint: fever major surgical or invasive procedure: bronchoscopy history of present illness: mr. is a 69 yo male with a history of cll, hypogammaglobulinemia, parkinson's disease, and recurrent pna who was admitted to on with cough and fever, now transferred to the micu due to tachypnea. he presented with fever, cough, and fatigue in the setting of undergoing bowel prep for colonoscopy (for workup of chronic diarrhea). of note he had a recent mrsa pna and pseudomonas sinus infection (as well a thrush and intertiginous ) and had been on vanc and cefepime. cxr in the ed was concerning for an opacity. he was cultured and started on vanc, cefepime, and ivf for possible pna. . on the floor he was continued on vanc and cefepime (since ). she was started on oseltamivir on on the floor due to concern for flu (he was uptodate with his flu shot). he has had some issues with a.fib with rvr during this hospitalization and his home metoprolol was changed to diltiazem and uptitrated. azithromycin was started on due to concern for atypical pna. id was consulted and recommended starting gentamicin if he worsened (which was started early prior to transfer). ivig was recommended, but not given due to concern for administration during fevers. . the afternoon and evening prior to transfer he was noted to be tahypneic to the 30's on a high flow shovel mask. an abg was 7.49/34/63 on 3.5 l. he was using an acapella valve to help clear secretions. nightfloat was called to see him due to worsening tachypnea in the 40's and initiated transfer to the micu. . currently he denies pain. he feels like his breathing is getting worse and he is tired. . on ros he admits to loose bowel movements. ros was limited due to respiratory distress. past medical history: - cll (dx ) s/p rituximab, fludarabine in . - hypogammaglobulinemia (iga, igm), last given ivig x1 in -recurrent sinusitis, last treated for mrsa and pseudomonal sinusitis in - recurrent pna with mrsa, pseudomonas, m. gordonae (likely contaminant) - bronchiectasis - htn - parkinson's dz dx - rectal cancer in s/p resection, radiation, 5-fu social history: (per admit note) the patient is married, lives with his wife in . he has two daughters, both healthy. he is a retired phd in economics, still working minimally as a professor. . no tobacco. no ivdu or illicits. family history: (per admit note) stroke and parkinson's disease, congestive heart failure, prostate cancer, glaucoma. physical exam: gen: middle-aged male laying in bed, tired-appearing and very tachpneic with a shovel mask on. heent: perrl, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: paradoxical abdominal movements, accessory muscle use, patient speaking in short sentences. appears very tired. diffusely wheezy and coarse throughout. cv: rrr, no mrg. abd: +bs, soft ntnd ext: no c/c/e neuro: sleepy, but arousable. oriented to person, place, and time. grossly nonfocal. . pertinent results: admission labs: na 134 k 4.7 cl 101 bicarb 26 bun 19 cr 1.1 glu 126 ca 8.3 mg 2.0 phos 2.5 . wbc 80.7 hct 29.5 plt 100 . vanc level - 7.3 (he got an extra 250 mg iv dose the afternoon of ) . abg (1:50 pm) 7.49/34/63 lactate 0.9 micro: , bcx: negative , bcx: pending at time of death , , ucx: negative ulegionella: negative sputum: negative sputum: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): yeast(s). 2+ (1-5 per 1000x field): gram positive rod(s). respiratory culture (final ): moderate growth commensal respiratory flora. yeast. moderate growth. pseudomonas aeruginosa. rare growth. futher work-up per dr (). mold. 1 colony on 1 plate. pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ 4 s meropenem-------------<=0.25 s piperacillin/tazo----- 8 s tobramycin------------ <=1 s sputum: aspergillus species. 1 colony on 1 plate. , resp viral culture: negative influenza: negative stool microsporidia, cyclospora, o&p, cryptosporidium, c.diff: negative cryptococcus serology: negative bal: resp culture, legionella, koh prep, pcp, fast smear, negative (final). fungal culture, fast culture, viral culture, negative (prelim). sinus swab: gram negative rod(s). ~1000/ml. stool o&p: pending at time of death c. diff: pending at time of death . imaging: ecg: baseline artifact. the rhythm is likely atrial flutter/coarse atrial fibrillation with rapid ventricular response. probable left ventricular hypertrophy. compared to the previous tracing of the findings are similar. cxr: findings: as compared to the previous radiograph, the right upper lobe opacity is not relevantly changed. the left lower lobe opacity is slightly more extensive than on the previous examination and is today accompanied by a small left pleural effusion. no evidence of newly appeared focal parenchymal opacities. unchanged calcified granuloma in the left upper lobe. unchanged heart size, unchanged mild tortuosity of the thoracic aorta. lenis: no deep venous thrombosis in either lower extremity. . cytology: bronchial washings: negative for malignant cells. brief hospital course: initial differential for his tachypnea and hypoxia included worsening pna, pe, or acute chf. patient was intubated emergently on arrival to micu for respiratory distress. microbiology studies were as above; sputum grew pseudomonas and aspergillus. id was consulted for antimicrobial management; the patient was treated with vancomycin, meropenem, and voriconazole. his respiratory status continued to worsen, and he required increasing levels of ventilatory support. ip was consulted for possible u/s guided thoracentesis of left pleural effusion but were unable to locate a big enough pocket of fluid. blood pressures were initially stable but the patient eventually developed likely septic shock, and became vasopressor dependent. he was not given his rate control agents for atrial fibrillation, given his hypotension. his renal function worsened acutely the day after transfer to the micu, and bun/creatinine continued to worsen through the rest of his hospitalization. his cll was evident with leukocytosis beyond his baseline wbc levels. his hypogammaglobulinemia was demonstrated with low igg, igm, and iga levels. ivig was considered, but ultimately not given in his state of acute critical illness and fevers. he was also continued on his chronic parkinson's medications. the patient's family had been kept aware of his worsening condition. on , after further discussions with the family, the decision was made to transition the patient's care to comfort measures only. his vasopressors were stopped, and he passed away with his family at his side, several hours thereafter. medications on admission: alprazolam 0.75mg qhs amitriptyline 25mg qhs carbidopa-levodopa 25mg-100mg 2 tabs 7am, 1.5 tabs 10:30am, 1 tab 2pm, 1 tab 5:30pm diphenhydramine 50mg prn metoprolol succinate 25mg daily rasagiline 0.5mg daily ropinirole 3mg at 7am, 10:30m, 2pm, 5:30pm ascorbic b complex vitamins 1 tab daily calcium 1000mg daily coenzyme q10 400mg daily docusate calcium 240mg daily guaifenesin 1200mg omega 3 fatty acids psyllium hydrocortisone 0.5% lotion daily prn mupirocin wash 2-3x/day discharge medications: expired discharge disposition: expired discharge diagnosis: primary: septic shock pneumonia secondary: chronic lymphocytic leukemia hypogammaglobulinemia parkinson's disease discharge condition: expired discharge instructions: n/a followup instructions: n/a 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 Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Hyperpotassemia Unspecified pleural effusion Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Paralysis agitans Acute respiratory failure Pneumonia due to Pseudomonas Septic shock Dermatitis due to drugs and medicines taken internally Diarrhea Do not resuscitate status Other specified antibiotics causing adverse effects in therapeutic use Bronchiectasis without acute exacerbation Personal history of antineoplastic chemotherapy Personal history of irradiation, presenting hazards to health Aspergillosis Pneumonia in aspergillosis Chronic lymphoid leukemia, without mention of having achieved remission Personal history of Methicillin resistant Staphylococcus aureus Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus Other specified erythematous conditions Antifungal antibiotics causing adverse effects in therapeutic use Body Mass Index between 19-24, adult Common variable immunodeficiency

allergies: no known allergies / adverse drug reactions attending: chief complaint: cc: major surgical or invasive procedure: egd with injection and thermal therapy history of present illness: 57yom with h/o cva in (thought to be pfo, on coumadin) presenting with 24-48 hours of dark black tarry stools. was in usoh last week however over weekend developed change in bowels with associated with light headedness and fatigue. denies any brbpr, nausea or vomiting however endorses "gas-like" pain in mid epigastric area. no recent use of nsaids (other than daily aspirin) or excessive etoh use (drinks 1 glass of red wine/day). also endorses feeling very thirsty. denies cp, sob, palpitations, le edema, headache, or uri symptoms. given symptoms, patient presented to ed. . in the ed, initial vs: 98.4 110 126/83 16 100%. evaluation was significant for supratherapeutic inr to 3.9, bun 34 and hct 32 (no baseline). pt received 1 unit of ffp and vitamin k (5mg) for inr. gi was consulted who recommended ppi gtt and egd in am. vitals prior to transfer were 98.3po 119/81 87 16 98% ra. . currently, patient stated that he was feeling very well however noted that he was significant less active today. denied any pain. . following this initial presentation, he was sent to the west procedural suite for egd where he was found to have a fairly large, high-risk ulcer in his pre-pyloric channel as well as a precipitous hematocrit drop over a period of a few days from a prior baseline crit in the 40's to 26 and requiring 1 unit of prbc's. he underwent injection and thermal therapy and was transferred to the unit for close monitoring overnight. patient describes head ache that feels similar to his usual migraine pain but denies cp, sob, abd pain, n/v, or bloody bm's since the procedure. he otherwise feels well but is upset that he will be missing out on a business trip this upcoming weekend. . review of systems: (+) per hpi, otherwise negative. past medical history: - cva ( pfo, on coumadin) social history: lives with partner in . law professor. no tobacco or illicit drug use. 1 glass of wine per night. family history: no family history of gi issues or bleeding problems. physical exam: admission physical exam: vs - temp 98.6f, bp 100/70, hr 116 (90s on telemetry), r 16, o2-sat 100% ra general - alert, interactive, well-appearing in nad heent - perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no carotid bruits heart - pmi non-displaced, tachycardic, nl s1-s2, no mrg lungs - ctab, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use abdomen - nabs, soft/nt/nd, no masses or hsm rectal - empty vault extremities - wwp, no c/c/e, 2+ peripheral pulses skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout . discharge physical exam: vs - temp 98.3 f, bp 115/60, hr 97, r 16, o2-sat 96% ra general - alert, interactive, well-appearing in nad heent - mmm, op clear neck - supple heart - rrr, nl s1-s2, no mrg lungs - ctab, no r/rh/wh abdomen - soft/nt/nd extremities - wwp, no c/c/e, 2+ peripheral pulses neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout pertinent results: admission labs: . 05:40pm blood wbc-7.4 rbc-3.61* hgb-10.8* hct-32.2* mcv-89 mch-30.0 mchc-33.6 rdw-13.0 plt ct-237 05:40pm blood neuts-61.8 lymphs-31.5 monos-5.0 eos-0.8 baso-0.8 05:40pm blood pt-39.8* ptt-43.5* inr(pt)-3.9* 05:40pm blood glucose-103* urean-34* creat-1.0 na-141 k-3.9 cl-104 hco3-24 angap-17 . pertinent labs: . 12:50pm blood wbc-4.8 rbc-2.72* hgb-8.0* hct-24.2* mcv-89 mch-29.5 mchc-33.1 rdw-13.2 plt ct-169 06:50am blood wbc-5.3 rbc-2.78* hgb-8.1* hct-24.9* mcv-90 mch-29.2 mchc-32.6 rdw-13.7 plt ct-190 . discharge labs: . 01:43pm blood wbc-8.8# rbc-3.00* hgb-9.0* hct-28.0* mcv-93 mch-30.1 mchc-32.3 rdw-14.1 plt ct-183 serology/blood helicobacter pylori antibody test: negative . inpatient . endoscopy: : small prepyloric ulcer with large visible vessel and active bleeding was noted - this was successfully treated with epinephrine and cautery. : the site of the prior ulcer along the prepyloric channel appears to be healing well. there was no visible vessel and the site appears to be healing well. brief hospital course: upper gastrointestinal bleed: the patient underwent endoscopy in the gi suite that demonstrated a small ulcer in the prepyloric channel that was treated with epinephrine injection and thermal therapy. he received one unit of prbcs prior to be transferred to the micu where he was maintained on a pantoprazole drip overnight with serial hematocrits that remained stable. he was then called out to the floor, where his vital signs and hematocrits were also stable. he underwent repeat endoscopy which showed no evidence of further bleeding. gastroenterology recommened changing to omeprazole po bid. his post-procedure hematocrit was stable. he will follow up in clinic in four weeks. . stroke prophylaxis: the patient has a history of stroke/tia for which he was on warfarin prophylaxis prior to admission. anticoagulation was held as an inpatient given his upper gi bleed. in consultation with his neurologist dr. , he will start clopidogrel 75 mg daily one week after discharge and follow up in clinic. medications on admission: - warfarin - atrovastatin 5mg daily - diazepam 5mg prn discharge medications: 1. atorvastatin 10 mg tablet sig: 0.5 tablet po daily (daily). 2. diazepam 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed for insomnia. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). disp:*120 capsule, delayed release(e.c.)(s)* refills:*1* 4. clopidogrel 75 mg tablet sig: one (1) tablet po once a day: start taking on . disp:*30 tablet(s)* refills:*2* 5. fish oil 1,000 mg capsule sig: one (1) capsule po once a day. disp:*30 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: upper gastrointestinal bleeding prepyloric ulcer 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 to the hospital for an upper gastrointestinal bleed from an ulcer in your stomach that was seen on endoscopy. the gastroenterologists were able to stop the bleeding at the site, and the repeat endoscopy showed that the site was healing well. you will need to take omeprazole twice a day as prescribed until seen by the gastroenterologists in their clinic. in discussion with dr. , we would like you to start taking clopidogrel for stroke prophylaxis in a week. you also received intravenous iron to help your body build new red blood cells. medication changes: stop warfarin start omeprazole 40 mg by mouth twice daily start fish oil start clopidogrel 75 mg by mouth daily on followup instructions: dr. clinic (gastroenterology) will contact you about an appointment in four weeks, and plans for a repeat endoscopy in eight to twelve weeks. if you have not heard from them by , please call the office at . other appointments: name: , l. location: health services address: , 3 east, , phone: appt: at 2:20pm name: , location: , cardiology-bach address: , 2, , phone: appt: at 11:30am name: , location: -neurology address: , , phone: ***the office is working on an appt for you and will call you at home with the appt. if you dont hear from them by tuesday, please call the office to book an appt. Procedure: Other endoscopy of small intestine Endoscopic control of gastric or duodenal bleeding Diagnoses: Abnormal coagulation profile Acute gastric ulcer with hemorrhage, without mention of obstruction Anemia, unspecified Ostium secundum type atrial septal defect Long-term (current) use of anticoagulants Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Anticoagulants causing adverse effects in therapeutic use Long-term (current) use of aspirin

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall - ich/ivh major surgical or invasive procedure: . history of present illness: this is an 84 y/o female with an extensive history of htn,who was found down by a friend (actively heard her fall), + consciousness, lucid on the scene, became lethargic at osh and intubated for airway protection. ct at osh was consistent with cerebellar ich and ivh involving the 3rd and 4th ventricle. the patient became hypertensive and bradycardic en route and was found to be in decerebrate posturing. the patient received 400 mcg fentanyl, 4mg ativan en route, and received another 2mg versed 30 minutes before neuro exam. past medical history: hypertension social history: lives independently family history: 2 sons with hemorrhagic stroke physical exam: physical exam on admission: o: t: 97.4 bp: 95/36 hr: 44 r 14 o2sats 100% cmv 400x16 peep 5 gen: intubated, prior sedation, no paralytics heent: pupils: l 4mm r 3mm eoms non-responsive neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: intubated, non-responsive cranial nerves: i: not tested ii: pupils l. 4mm r. 3mm and not reactive to light iii, iv, vi: no extraocular movements. v, vii: non responsive. viii: non responsive. ix, x: non responsive. : non responsive. xii: non responsive. motor: decerebrate posturing to sternal rub and finger pinch toes downgoing bilaterally discharge exam: death. death exam confirmed by icu resident at 1700 on pertinent results: ct/mri: ct head (wet read): intraventricular hemorrhage involving bilateral lateral ventricles, third ventricle and fourth ventricle, there is also a left cerebellar intraparenchymal component. no mass effect or herniation is present. overall slightly worse than prior outside hospital study. cta head (wet read): no definitive evidence of aneurysm within the circle of with mild focal prominence at the right carotid terminus. ct head: redistributed hemorrhage, more in occ horns. slightly larger ventricles. evolving l pca infarct. r cerebellar infarct indet age. 08:40pm wbc-13.4* rbc-4.35 hgb-13.2 hct-41.0 mcv-94 mch-30.3 mchc-32.1 rdw-13.5 brief hospital course: the patient was admitted to the icu for q1 neurochecks. it was initially decided by the family that should the patient require intervention with an evd or operative intervention, then that was against their wishes. her neuro exam remained unchanged, and a repeat head ct demonstrated no hydrocephalus, no increase in her ich, but an increasing pca infarct. a lenghtly discussion was had with the patient's family and nsurg team, and the decision was made to no perform any interventions to improve the patient's condition, as the prognosis for this type of brain injury was grave. the patient was extubated, kept comfortable, and passed away with her family present at 1630 on medications on admission: atenolol 100mg benicar discharge medications: . discharge disposition: expired discharge diagnosis: sdh, l pca infarct discharge condition: death discharge instructions: expired followup instructions: . md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Diagnoses: Unspecified essential hypertension Intracerebral hemorrhage Compression of brain Cerebral artery occlusion, unspecified with cerebral infarction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass grafting to four vessels. (left internal mammary artery->left anterior descending artery, saphenous vein graft(svg)->diagonal artery, svg->obtuse marginal artery, svg->posterior descending artery.); left atrial appendage ligation. history of present illness: mr. is a 76 year old male with chest pain, called ems which found st elevations in leads ii, iii, avf and diffuse depressions in other leads. he was transported directly to the catherization lab at gsmc with ongoing chest pain and st elevations. past medical history: atrial fibrillation (on coumadin) chronic obstructive pulmonary disease hypertension hyperlipidemia obesity glaucoma bronchitis myocardial infarction 30 y ago cholethiasis (by ct scan) right pericardial cyst (noted on ct ) peripheral artery disease social history: occupation: retired lives with wife : 2pks x 30y etoh: occasional family history: non-contributory physical exam: pulse: 81 sr resp: 14 o2 sat: 98% 4 l nc b/p right: 112/66 left: height: 5'8'' weight: 220 lbs general: skin: dry intact edema 2 + pitting in : perrla eomi neck: supple full rom short neck chest: lungs clear bilaterally heart: rrr irregular murmur - abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema varicosities: cannot assess neuro: grossly intact/ moves 4 ext pulses: femoral right: + left: + dp right: dop left: dop pt : left: radial right: + left: + carotid bruit right: - left: - pertinent results: carotid ultrasound 1. mild heterogeneous plaque in the right internal carotid artery with less than 40% stenosis. 2. significant heterogeneous plaque in the left internal carotid artery with 70-79% stenosis. this is a baseline examination at the . ===================================== echo pre-cpb:1. the left atrium is markedly dilated. moderate to severe spontaneous echo contrast is seen in the body of the left atrium. moderate to severe spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). a left atrial appendage thrombus cannot be excluded. 2. the right atrium is markedly dilated. mild spontaneous echo contrast is seen in the right atrial appendage. no atrial septal defect is seen by 2d or color doppler. 3. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. overall left ventricular systolic function is moderately depressed (lvef= 35-40 %). there is calcification of the inferior midventricular segment. 4. the right ventricular free wall is hypertrophied. the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. there is abnormal systolic septal motion/position consistent with right ventricular pressure overload. 5. there are simple atheroma in the ascending aorta. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. 6. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 7. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. post-cpb: on infusions of phenylephrine and epinephrine, av pacing, preserved biventricular systlic function compared with pre-bypass, lvef = 35-40%, mr remains mild, aortic contour normal post decannulation, no evidence of hematoma or dissection of aortic wall. ========================================= head ct scan: there is no intra- or extra-axial hemorrhage, shift of normally midline structures, edema, mass effect, or evidence of acute infarct. there is periventricular and subcortical white matter change as well as there is an old left basal ganglia infarct noted. there is no evidence of acute vascular territorial infarct. the mastoid air cells are hypoplastic bilaterally. the right maxillary sinus is opacified. ethmoid and sphenoid sinus opacification is also noted. the bony calvarium is intact. ======================================== , m 76 radiology report chest (pa & lat) study date of 5:30 pm , fa6a 5:30 pm chest (pa & lat) clip # reason: evaluate pulm edema final report pa and lateral chest on history: evaluate pulmonary edema after cabg. impression: mild pulmonary edema is almost resolved. moderate cardiomegaly and small bilateral pleural effusions persist. the study and the report were reviewed by the staff radiologist. dr. dr. approved: fri 2:57 pm =========================================== 08:56pm urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-tr 08:56pm urine rbc->50 wbc-* bacteria-few yeast-none epi-0-2 07:34pm glucose-103 urea n-23* creat-1.5* sodium-139 potassium-3.3 chloride-99 total co2-31 anion gap-12 07:34pm alt(sgpt)-14 ast(sgot)-16 ld(ldh)-269* ck(cpk)-51 alk phos-72 amylase-40 tot bili-0.7 07:34pm lipase-34 07:34pm ck-mb-notdone ctropnt-0.04* 07:34pm albumin-3.5 calcium-8.5 phosphate-3.2 magnesium-1.9 07:34pm %hba1c-6.6* 07:34pm tsh-2.6 07:34pm wbc-5.3 rbc-3.05* hgb-9.7* hct-29.5* mcv-97 mch-31.7 mchc-32.9 rdw-16.7* 07:34pm pt-25.1* ptt-56.2* inr(pt)-2.5* 07:34pm plt count-226 08:55am blood wbc-8.5 rbc-3.25* hgb-9.8* hct-30.2* mcv-93 mch-30.2 mchc-32.5 rdw-18.2* plt ct-224 08:55am blood pt-18.7* inr(pt)-1.7* 08:55am blood glucose-179* urean-30* creat-1.6* na-140 k-5.1 cl-99 hco3-30 angap-16 ======================================== 11:06 am urine source: catheter. **final report ** urine culture (final ): citrobacter freundii complex. ~/ml. identification and sensitivities requested per dr. # . this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. piperacillin available on request. sensitivities: mic expressed in mcg/ml citrobacter freundii complex | cefepime-------------- <=1 s ceftazidime----------- =>64 r ceftriaxone----------- 16 i ciprofloxacin--------- 2 i gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s ============================================== brief hospital course: mr. was admitted to the on for surgical management of his coronary artery disease. he was worked-up in the usual preoperative manner including a carotid ultrasound which showed mild heterogeneous plaque in the right internal carotid artery with less than 40% stenosis and significant heterogeneous plaque in the left internal carotid artery with 70-79% stenosis. plavix was allowed to washout of his system. the sleep service was consulted regarding his sleep apnea and cpap was recommended. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to four vessels with ligation of his left atrial appendage. please see dr operative note for further details. postoperatively he was taken to the intensive care unit for monitoring. he remained on pressors and intubated overnight. pressors were slowly weaned over the next few days. he remained intubated for a prolonged postoperative period due to hemodynamic instability as well as thick secretions impairing his ventilation/oxygenation status. by pod#7 mr. was weaned off all pressors and inotropes. he was treated with antibiotics for positive staph sputum culture and he was aggressively diuresed to optimize his potential for extubation. pod#13 ventilator weaning continued until an episode of flash pulmonary edema which required increased ventilatory support. during this postoperative period mr. was slow to wake up from sedation. his mental status improved enough, along with hemodynamic and ventilatory stability that he was successfully extubated. all lines and drains were removed in a timely fashion. over the next several days mr. remained in the cvicu due to his state of confusion, refusing medications and nutrition, requiring haldol and need for pulmonary management. sleep consult was called and cpap was initiated for obstructive sleep apnea. full anticoagulation was attained with coumadin for his rate controlled, chronic atrial fibrillation. beta-blocker, digoxin, aspirin and statin were initiated once blood pressure and heart rate would tolerate. nutrition was consulted due to poor intake and aspiration risk. speech and swallow evaluated oral and pharyngeal dysphagia with recommendations for nectar thickened/ground solid advancement of po intake and tube feeds over night. wound care was also consulted for skin impairments and heel ulcerations. by pod# 24 mr. continued to progress and was transferrd to the step down unit for further monitoring. the remainder of his postoperative course was slow but steady. given his flucuating waxing and mental status with visual hallucinations and agitation, the psychiatry service was consulted prior to discharge. eeg ruled out epileptiform activity and head ct scan showed no evidence of acute infarct. the head ct scan did reveal a chronic left basal ganglia lacunar infarct. given his delirium, it was recommended to continue haldol twice daily and prn, optimize non-psychopharm measures(frequent reorientation, emphasize sleep wake cycle, dimming lights at night) and minimize benozodiazepines, opiates and anti-cholinergics. a u/a was also check which was positive and the patient was started on bactrim. by pod# 35 he continued to progress and he was cleared for discharge to rehab for further increase in strength, endurance and conditioning. all follow up appointments were advised medications on admission: lasix 40 mg daily xalatan eye drops timoptic 0.5% one drop each eye prilosec 20 mg daily zocor 80 mg daily plavix 75mg daily cardizem cd 120 mg daily aspirin 81 mg daily lopressor 50 mg twice a day fluorouracil 5% cream every 8 hours topical combivent inhaler 2 puffs qid discharge medications: 1. carvedilol 12.5 mg tablet : one (1) tablet po bid (2 times a day). 2. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours) as needed for wheezing. 3. digoxin 125 mcg tablet : one (1) tablet po daily (daily). 4. simvastatin 40 mg tablet : one (1) tablet po daily (daily). 5. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 6. latanoprost 0.005 % drops : one (1) drop ophthalmic hs (at bedtime). 7. timolol maleate 0.5 % drops : one (1) drop ophthalmic daily (daily). 8. bisacodyl 10 mg suppository : one (1) suppository rectal daily (daily) as needed for constipation. 9. acetaminophen 325 mg tablet : two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 10. magnesium hydroxide 400 mg/5 ml suspension : thirty (30) ml po hs (at bedtime) as needed for constipation. 11. aspirin 81 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po daily (daily). 12. lidocaine hcl 2 % gel : one (1) appl mucous membrane prn (as needed) as needed for pain. 13. warfarin 1 mg tablet : as directed to keep inr 2-2.5 tablets po daily (daily): target inr 2-2.5 patient to recieve 2mg on then as directed to keep inr 2-2.5. 14. insulin regular human 100 unit/ml solution : sliding scale injection qac&hs. 15. potassium chloride 20 meq tab sust.rel. particle/crystal : one (1) tab sust.rel. particle/crystal po bid (2 times a day): hold for k>4.5. 16. haloperidol 2 mg tablet : one (1) tablet po tid (3 times a day). 17. trimethoprim-sulfamethoxazole 160-800 mg tablet : one (1) tablet po bid (2 times a day) for 10 days. 18. furosemide 10 mg/ml solution : sixty (60) mg injection (2 times a day). 19. heparin, porcine (pf) 10 unit/ml syringe : as outlined below ml intravenous prn (as needed) as needed for line flush: heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. . discharge disposition: extended care facility: - discharge diagnosis: coronary artery disease s/p cabg postop delirium atrial fibrillation chronic obstructive pulmonary disease hypertension hyperlipidemia obesity glaucoma bronchitis myocardial infarction cholelithiasis peripheral artery disease cellulitis mrsa (nasal swab) discharge condition: good. discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the 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) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks from date of surgery. 6) no driving for 1 month or while taking narcotics for pain. 7) call with any questions or concerns. 8)adjust warfarin for goal inr between 2.0 - 3.0. please arrange pt/inr followup with pcp prior to discharge from rehab. followup instructions: please follow-up with dr. in 1 month. ( please follow-up with dr. in 2 weeks. please call all providers for appointments. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Insertion of endotracheal tube (Aorto)coronary bypass of four or more coronary arteries Excision, destruction, or exclusion of left atrial appendage (LAA) Diagnoses: Obstructive sleep apnea (adult)(pediatric) Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Other chronic pulmonary heart diseases Peripheral vascular disease, unspecified Unspecified glaucoma Other and unspecified hyperlipidemia Acute respiratory failure Long-term (current) use of insulin Old myocardial infarction Long-term (current) use of anticoagulants Other respiratory complications Obesity, unspecified Chronic obstructive asthma, unspecified Pressure ulcer, heel Delirium due to conditions classified elsewhere Long-term (current) use of aspirin Tricuspid valve disorders, specified as nonrheumatic Pressure ulcer, unstageable Unspecified congenital anomaly of heart

allergies: no known allergies / adverse drug reactions attending: chief complaint: dyspnea on exertion, fatigue major surgical or invasive procedure: resection of the ascending aortic aneurysm and the ascending aortic replacement with 32 mm gelweave tube graft under deep hypothermic circulatory arrest on . history of present illness: 89yo woman with 6.4 cm ascending aortic aneurysm. cardiac surgery consulted back in . cath at that time showed clean coronaries. on warfarin for atrial fibrillation and probable thrombus in the left atrial appendage. given this finding, cardioversion was declined. since that time, she has been medically managed with beta blockade. she was seen again in and plan was made to proceed with ascending aortic replacement. past medical history: asc. ao aneurysm 6.4cm x 6.9cm-prox desc ao 4.1cm, s/p ascending aortic replacement on hypertension diverticulosis cataracts osteoporosis-osteoarthritis compression fx rt rotator cuff injury wandering atrial pacemeaker social history: race:caucasian last dental exam: lives with: alone in senior housing occupation: retired banker tobacco: none etoh: social family history: non contributory physical exam: admission physical exam pulse:94 af resp: 16 o2 sat: 97%-ra b/p right: 134/78 left: height: 5'3" weight: 130 lbs general:nad, alert and cooperative skin: dry intact heent: perrla eomi neck: supple full rom chest: lungs clear bilaterally heart: rrr irregular nomurmur abdomen: soft non-distended non-tender bowel sounds + extremities: warm , well-perfused edema 1+ pedal edema varicosities: none prominent veins without varicosities neuro: grossly intact x pulses: femoral right: +2 left:+2 dp right: +1 left:+1 pt :+1 left:+1 radial right: +2 left:+2 carotid bruit right: none left:none pertinent results: left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 3.4 cm <= 5.6 cm left ventricle - ejection fraction: 70% to 75% >= 55% aortic valve - peak velocity: 0.7 m/sec <= 2.0 m/sec aortic valve - lvot vti: 13 mitral valve - e wave: 1.0 m/sec mitral valve - e wave deceleration time: *112 ms 140-250 ms findings right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. left ventricle: normal lv wall thickness. small lv cavity. normal regional lv systolic function. hyperdynamic lvef >75%. no resting lvot gradient. no vsd. right ventricle: dilated rv cavity. cannot assess regional rv systolic function. aortic valve: mildly thickened aortic valve leaflets. no as. mild (1+) ar. mitral valve: no ms. mild (1+) mr. tricuspid valve: moderate to severe tr. indeterminate pa systolic pressure. pericardium: no pericardial effusion. no echocardiographic signs of tamponade. conclusions left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is no ventricular septal defect. the right ventricular cavity is dilated the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. mild (1+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. there are no echocardiographic signs of tamponade. 04:42am blood wbc-8.7 rbc-4.45 hgb-14.0 hct-42.1 mcv-95 mch-31.5 mchc-33.3 rdw-15.9* plt ct-140* 02:09am blood wbc-8.2 rbc-4.11* hgb-13.1 hct-38.2 mcv-93 mch-31.9 mchc-34.3 rdw-15.7* plt ct-137* 04:42am blood pt-16.9* ptt-28.9 inr(pt)-1.5* 02:33pm blood pt-16.6* inr(pt)-1.4* 02:09am blood pt-16.8* ptt-30.2 inr(pt)-1.5* 04:42am blood glucose-104* urean-44* creat-1.1 na-147* k-4.1 cl-109* hco3-25 angap-17 01:46pm blood na-146* k-4.3 cl-109* 02:09am blood glucose-113* urean-40* creat-1.0 na-143 k-4.4 cl-108 hco3-23 angap-16 05:45am blood wbc-8.6 rbc-3.96* hgb-12.7 hct-37.0 mcv-94 mch-32.0 mchc-34.2 rdw-15.9* plt ct-170 05:45am blood pt-17.7* inr(pt)-1.6* brief hospital course: mrs. was admitted to for preoperative surgical workup and heparin bridge while off coumadin for her atrial fibrillation. prior to her admission dental clearance was obtained. on she was taken to the operating room and underwent replacement of her ascending aorta with dr. . circulatory arrest time=15 minutes. please refer to operative report for further surgical details. she tolerated the procedure well and was transferred to the cvicu intubated and sedated, requiring inotropy and pressor support. she was kept intubated overnight. pod#1 she awoke neurologically intact and was extubated. she was confused and had worsening respiratory status and a low mixed venous despite inotropes which required reintubation. initially she weaned off milrinone. poor cardiac output/mixed venous results warranted an echocardiogram which showed the heart to be underfilled and volume was administered. milrinone was resumed. ep was consulted in the setting of afib with rapid ventricular rate. per ep, mrs. likely has significant diastolic dysfunction given her lvh and would benefit from rate control and restoration of sinus rhythm. she is high risk for embolus given history of laa thrombus and was not yet back on anticoagulation. per ep recommendations, an esmolol drip was initiated to allow more diastolic filling time, she was placed on digoxin and anticoagulation was resumed with coumadin. she again weaned off inotropic support. on hit panel was sent secondary to postoperative thrombocytopenia, which resulted negative. she was placed on a lasix gtt for worsening pulmonary edema and diuresed. her pulmonary status improved and on she was weaned to extubation. all lines and drains were discontinued per protocol. she remains in a rate controlled atrial fibrillation on beta-blocker, digoxin, and anticoagulated with coumadin. her thrombocytopenia has been consistently improving. pod# 6 she was placed on antibiotics for a urinary tract infection. she remained in the cvicu until pod 8 when she was transferred to the step down unit for further monitoring and increased physical activity. physical therapy was consulted for evaluation of strength and mobility. the patient was discharged to ***** bay****** on pod 9. medications on admission: alendronate - (prescribed by other provider) - 70 mg tablet - 1 tablet(s) by mouth q weekly/wednesday metoprolol succinate - 100 mg po a am, 50 mg po q pm mupirocin calcium - 2 % ointment - 0.5 (one half) tube(s) nares twice a day please insert tube into each nares and then gently massage for 1 minute warfarin - 2 mg tablet - tablet(s) by mouth once a day take 2 and 1/2 tabs today and tomorrow then 1 tab daily, last dose medications - otc aspirin - (otc) - 81 mg tablet, chewable - 4 tablet(s) by mouth once a day chlorhexidine gluconate - 4 % liquid - 1 bottle daily please shower daily for the five days prior to surgery and the morning of surgery loperamide - (prescribed by other provider) - 2 mg tablet - 1 (one) tablet(s) by mouth as meeded prn discharge medications: 1. outpatient lab work labs: pt/inr for coumadin ?????? indication afib goal inr 2.0-2.5 first draw please set up coumadin follow up with dr prior to discharge from rehab 2. metoprolol succinate 50 mg tablet extended release 24 hr sig: two (2) tablet extended release 24 hr po once a day: 100mg qam, 50mg qpm. 3. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po qhs: 100mg qam, 50mg qpm. 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. alendronate 70 mg tablet sig: one (1) tablet po qwed (every wednesday). 8. warfarin 2 mg tablet sig: one (1) tablet po once a day: dose to change daily for goal inr 2-2.5. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezes. 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 11. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain/fever. 12. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 13. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 14. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 15. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 16. furosemide 40 mg tablet sig: one (1) tablet po once a day for 1 weeks. 17. potassium chloride 10 meq tablet extended release sig: two (2) tablet extended release po once a day for 1 weeks. discharge disposition: extended care facility: bay skilled nursing & rehabilitation center - discharge diagnosis: hypertension, diverticulosis, cataracts, osteoporosis-osteoarthritis, compression fx, rt rotator cuff injury, wandering atrial pacemaker psh: cataract removal, tonsillectomy discharge condition: alert and oriented x3 nonfocal ambulating with assistance incisional pain managed with tylenol incisions: sternal - healing well, no erythema or drainage 1+ le edema discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns . answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointment surgeon: dr. on at 2:00, phone# in the medical office building please call to schedule appointments with your cardiologist: dr. in weeks 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 afib goal inr 2.0-2.5 first draw please set up coumadin follow up with dr prior to discharge from rehab Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Extracorporeal circulation auxiliary to open heart surgery Enteral infusion of concentrated nutritional substances Resection of vessel with replacement, thoracic vessels Diagnoses: Thrombocytopenia, unspecified Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified essential hypertension Acute posthemorrhagic anemia Thoracic aneurysm without mention of rupture Chronic airway obstruction, not elsewhere classified Atrial fibrillation Aortic valve disorders 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 Osteoporosis, unspecified Long-term (current) use of anticoagulants Osteoarthrosis, unspecified whether generalized or localized, site unspecified Acute diastolic heart failure Pseudomonas infection in conditions classified elsewhere and of unspecified site Other abnormal glucose Other ill-defined heart diseases

allergies: lisinopril / penicillins / zocor / tetracycline / theophylline / macrolide antibiotics attending: chief complaint: acute renal failure major surgical or invasive procedure: none history of present illness: this is a 60 year-old female with a history of alcoholic cirrhosis who is transferred from with spontaneous bacterial peritonitis, renal failure, and small bowel obstruction. of note, the provided information on transfer is incomplete. the patient was initially seen with acute renal failure after a paracentesis of 5.7 l - the patient was given 2l ns, renal us was negative, and the patient signed out ama. she then represented for abdominal pain of unclear duration and and worsening ascites. peripheral wbc 19.4 with 3% bands. paracentesis of 6 l per the patient (amount not documented) revealed > 10,000 wbc with 83% pmn, and the patient was started on levofloxacin and flagyl presumably . the patient states she received albumin after this paracentesis. ct abdomen at this time was negative for perforation per notes - report not included. repeat diagnostic paracentesis of 10 cc fluid showed wbc 4,422. she was started on tigecycline at some point for broader gram negative coverage, however, she developed significant nausea and vomiting and this was discontinued. she was then started on aztreonam at some point. the id consult note mentions a single temperature of 100.4, however, it appears as if the patient was otherwise afebrile. her wbc count continued to climb, however, apparently reaching the 30s. . her creatinine on admission was 4.2 from baseline 1.4. her lasix and aldactone were discontinued after discussion with renal consult, presumably . she was given some amount of intravenous fluids for treatment. . the patient developed nausea the day prior to transfer. ct abdomen showed a large amount of ascites, liver consistent with cirrhosis, and "dilated loops of small bowel in the left mid- to upper abdomen with normal caliber of the terminal ileum, consistent with small bowel obstruction." an ng tube was placed with 400 cc bilious return. last bowel movement was the day prior to transfer per the patient. . ros: on transfer, the patient complains of mild generalized abdominal discomfort and shortness of breath due to distention but denies pain. she also complains of mild nausea. she denies any fevers, chills, melena, hematochezia, chest pain, shortness of breath, orthopnea, pnd, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. past medical history: - alcoholic cirrhosis, complicated by portal hypertension and ascites, abstinent from alcohol for over a year per patient - chronic kidney disease, baseline creatinine 1.4 - history of hypertension - new recent baseline systolic blood pressures in the 80s over the past three months off antihypertensives per patient - hyperlipidemia - pernicious anemia - osteoarthritis - irritable bowel syndrome - bilateral knee replacements social history: retired nurse. history of alcohol abuse, none in over a year. denies smoking or other drug use. family history: non-contributory. physical exam: general appearance: overweight / obese eyes / conjunctiva: perrl, sclera anicteric cardiovascular: (s1: normal), (s2: normal), no murmurs, rubs, or gallops peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (expansion: symmetric), (breath sounds: clear : anteriorly) abdomen: tense, distended, diffusely tender to palpation, no rebound or guarding extremities: right: 2+, left: 2+ skin: not assessed neurologic: attentive, follows simple commands, responds to: not assessed, oriented (to): person, place, time - history inconsistent at times, movement: not assessed, tone: not assessed, no asterixis pertinent results: 09:13pm wbc-27.7* rbc-3.26* hgb-10.4* hct-29.7* mcv-91 mch-31.9 mchc-34.9 rdw-15.5 09:13pm neuts-84* bands-0 lymphs-7* monos-4 eos-0 basos-0 atyps-0 metas-0 myelos-5* nuc rbcs-1* 09:13pm plt count-191 09:13pm pt-20.5* ptt-41.1* inr(pt)-1.9* 09:13pm alt(sgpt)-8 ast(sgot)-24 alk phos-194* tot bili-0.9 09:13pm tot prot-4.9* albumin-2.7* globulin-2.2 calcium-8.5 phosphate-5.3* magnesium-1.7 09:13pm glucose-107* urea n-45* creat-4.4* sodium-132* potassium-3.5 chloride-99 total co2-16* anion gap-21* 09:47pm lactate-1.9 brief hospital course: this is a 60 year-old female with a history of alcoholic cirrhosis who presented from with renal failure and small bowel obstruction. she had a lengthy hospital course from until when she died after having chosen comfort care only as her goal of care. prior to that she was first admitted to the micu and then the hepatorenal service hospital floor with a question of spontaneous bacterial peritonitis for which she was treated with levofloxacin, flagyl and aztreonam. she initially had spontaneous bacterial peritonitis, renal failure, and ileus. on the floor, the patient was followed by the renal service. octreotide and midodrine were titrated to maximal doses and the patient was administered albumin without effect on creatinine or urine output. the decision was made to initiate cvvh given that the patient was becoming symptomatic from fluid overload and was unable to obtain various studies for liver transplant evaluation. the patient underwent paracentesis x 3 with 3l fluid removed. the first showed wbc 838 with 76% pmn, showed wbc 870 with 81% pmn, and the last was wbc 233 with 78% pmn. there have been no positive peritoneal or blood cultures. she continues with an ng tube on intermittent suction for ileus, however, she states she is passing stool. the patient has been continued on aztreonam, levofloxacin, and flagyl. her leukocytosis has continued to trend down. she was informed that in order to best treat her and improve the possibility of survival she should undergo a combined liver kidney transplant, with that information she decided that her illness was compromising her comfort and she chose not to undergo the surgery and also to withdraw any care that would not be directed towards comfort. medications on admission: protonix 40 mg daily aldactone 40 mg daily lasix 20 mg daily mvi b12 os-cal discharge medications: none discharge disposition: expired discharge diagnosis: spontaneous bacterial peritonitis hepato renal syndrome discharge condition: expired discharge instructions: expired followup instructions: expired Procedure: Venous catheterization, not elsewhere classified Hemodialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Arterial catheterization Transfusion of packed cells Transfusion of other serum Diagnoses: Acidosis Anemia in chronic kidney disease Pure hypercholesterolemia Alcoholic cirrhosis of liver Acute kidney failure, unspecified Hepatorenal syndrome Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Candidiasis of other urogenital sites Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Alkalosis Paralytic ileus Spontaneous bacterial peritonitis Chronic kidney disease, Stage II (mild)

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp with common bile duct stent placement mechanical ventilation picc placement history of present illness: admission date/time: cc: abdominal pain hpi: 48m with history of alcohol-induced pancreatitis who presented to on with abdominal pain consistant with prior episodes. patient was still drinking alcohol. on admission, lipase was 713, along with elevated ast/alt. ct showed evidence of pancreatitis along with pancreatic duct dilation and an enlarged common bile duct. his labs were improving with lft's including lipase were falling, however his bilirubin was rising from 2.7 to 9.9. his pain continued to worsen. mrcp was then performed that showed large heterogeneous head of the pancreas most likely secondary to pancreatitis, likely choledochocyst, and pancreatic pseudocyst or less likely dillated wirsung duct with pancreatitc divisum. in addition prior to transfer after approx 48 hrs in the hospital the patient began to get tremulous and agitated and he was suspected to be in etoh w/d and was placed on ciwa and required restraints. at the time of admission the patient is still quite confused, attempting to punch staff and requiring restraints. ros: on ros the patient denies any symptoms including abd pain. past medical history: etoh pancreatitis asthma right eye blindness history of pneumonitis in the past l5 disk surgery social history: patient states he drinks 2 bottles of wine a day. currently married for 21 months. denies any drug use and is a current smoker. currently working as a manager at sporting goods in , nh. has 2 children family history: mother died of colon cancer at 66 an father died of brain aneurysm at 57. he has 1 brother who is alive and 5 sisters who have no medical problems(one died in ). physical exam: vs: 97.2 154/98 78 26 97ra gen: tremulous, but falling asleep during the exam. aao x 1, but answering some questions skin: warm to touch, no apparent rashes. heent: no conjunctival pallor, no scleral jaundice, op clear . blind in right eye. cv: rrr no audible m/r/g lungs: clear to auscultation abd: soft, tender in epigastrim to deep palpation only, normal bs ext: no c/c/e neuro: not complaint with neuro exam pertinent results: labs on admission: 09:05pm wbc-9.4 rbc-4.12* hgb-14.2 hct-41.1 mcv-100* mch-34.4* mchc-34.6 rdw-13.6 09:05pm neuts-86.6* lymphs-7.2* monos-5.6 eos-0.5 basos-0.1 09:05pm plt count-185 09:05pm glucose-96 urea n-7 creat-0.5 sodium-134 potassium-3.4 chloride-101 total co2-23 anion gap-13 09:05pm calcium-8.5 magnesium-1.5* 09:05pm alt(sgpt)-307* ast(sgot)-244* alk phos-68 amylase-83 tot bili-11.2* dir bili-8.1* indir bil-3.1 09:05pm lipase-116* 09:05pm pt-17.1* ptt-29.7 inr(pt)-1.5* . labs on discharge: 06:00am blood wbc-9.4 rbc-3.77* hgb-12.6* hct-36.8* mcv-98 mch-33.4* mchc-34.3 rdw-13.2 plt ct-409 05:32am blood pt-13.8* ptt-33.2 inr(pt)-1.2* 05:34am blood glucose-107* urean-11 creat-0.9 na-134 k-3.9 cl-99 hco3-28 angap-11 05:34am blood alt-62* ast-31 alkphos-142* totbili-2.2* 06:00am blood lipase-220* 05:34am blood calcium-9.0 phos-5.2* mg-1.8 05:32am blood caltibc-308 ferritn-303 trf-237 05:34am blood vitb12-984* folate-10.7 05:34am blood tsh-2.7 05:34am blood hbsag-negative hbsab-negative hbcab-negative 05:32am blood ama-negative smooth-positive 05:32am blood -negative 05:34am blood hcv ab-negative . osh imaging: ct abd cbd(1.7cm) and pancreatitic duct(1.1 cm) dilatation and edematous changes in the head of the pancreas and in the 2nd portion of the duodenum with mass effect. . mri enlarged heterogenous head of the pancreas most likely due to pancreatitis, although a pancreatiic neoplasm cannot be excluded. also a likely choledochal cyst. right poleural effusion with possible infiltrate in rll. . imaging: ercp findings: esophagus: limited exam of the esophagus was normal stomach: limited exam of the stomach was normal mucosa: severe diffuse congestion and erythema of the mucosa with contact bleeding were noted in the duodenal bulb and second part of the duodenum. major papilla: normal major papilla cannulation: cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. contrast medium was injected resulting in complete opacification. the procedure was moderately difficult. biliary tree: a single smooth stricture that was 20 mm long was seen at the lower third of the common bile duct. there was moderate post-obstructive dilation. the rest of the biliary tree was normal. procedures: a 7cm by 10mm cotton- biliary stent was placed successfully in the lower third of the common bile duct using a oasis system stent introducer kit. impression: severe edema and inflammation of the duodenum, consistent with pancreatitis. (cannulation) biliary stricture was noted in the lower third of the cbd, otherwise normal biliary tree. a biliary stent was placed. . non-contrast chest ct findings: moderate right and small left pleural effusions, both of which measure simple fluid in attenuation. they appear to layer dependently, with no evidence for loculation based on morphology. there is no pneumothorax. in the right lung, there is dense consolidation of the lower and middle lobe, with complete opacification of the lung parenchyma and multiple air bronchograms. in the right upper lobe, there are additional patchy ground-glass opacities with associated bronchial wall thickening. similar patchy ground-glass opacities are seen throughout the left lung, most prominent in the lower lobe and lingula, with relative sparing of the left upper lobe. there is again bronchial wall thickening. superimposed interstitial thickening suggests a component of volume overload. there are no definite nodules or masses, although evaluation for small lesions is limited given the underlying consolidation and low volumes. impression: 1. moderate right and small left pleural effusions, simple fluid attenuation. 2. dense opacification of the right lower and middle lobes, with air bronchograms. additional patchy opacities throughout the right upper lobe, and left lung, predominantly in the lower lobe and lingula, compatible with multifocal pneumonia. there is associated bronchial wall thickening, and narrowing of the right main stem and lower lobe bronchi, as desctibed above. 3. interstitial thickening compatible with volume overload. 4. cardiomegaly. 5. anterior pararenal spacefat stranding, compatible with history of pancreatitis. though evaluation is limited without intravenous contrast, there is also suggestion of pancreatic ductal dilatation in the visualized body and tail of the pancreas. . right upper extremity ultrasound : complete thrombosis of the right cephalic vein, however, no evidence of deep vein thrombosis of the right upper extremity. . non-contrast head ct : findings: there is no acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major or minor vascular territorial infarction. the density values of the brain parenchyma are maintained. the sulci are slightly prominent for the stated age. a tiny focal calcification is noted within the pons. the soft tissues and osseous structures are unremarkable. a small mucus retention cyst is noted within the left maxillary sinus. otherwise, the visualized paranasal sinuses and mastoid air cells are clear. dense vascular calcifications are noted of the cavernous portions of the carotid arteries. impression: 1. no acute intracranial hemorrhage or other intracranial process. 2. calcifications involving the cavernous internal carotid arteries. 3. mild cerebral atrophy. 4. focal calcification in the pons of uncertain etiology. . liver/gallbladder us : findings: the liver appears normal in echotexture without focal masses or lesions. there is no intrahepatic biliary ductal dilation. the chd measures 2.4 mm. the cbd, however, contains a stent and is dilated up to 1 cm. the stent extends into the pancreatic duct, which also appears dilated. the pancreatic parenchyma appears unremarkable. there is no abdominal ascites. the spleen appears normal in echotexture measuring 11.5 cm. there is a small amount of pleural fluid. impression: biliary stent in place with a dilated cbd to 1 cm. no intrahepatic biliary ductal dilation. trace pleural fluid, but no ascites. . left upper extremity ultrasound : impressions: the left basilic picc in place. no left upper extremity dvt, nor thrombosis of the left basilic vein seen. brief hospital course: 48m with a history of recurrent alcoholic pancreatitis admitted for ercp with common bile duct stricture, now s/p cbd stent placement. hospital course complicated by icu stay for hypoxic respiratory failure, hospital-acquired pneumonia, alcohol withdrawal, right upper extremity superficial vein thrombus, and altered mental status. . # common bile duct stricture: patient had increasing direct hyperbilirubinemia at outside hospital despite falling ast, alt, and lipase. ercp here revealed a cbd stricture, which was stented. his total bilirubin trended down following this intervention but increased slightly after a trial of clears. abdominal ultrasound showed no stent obstruction. patient was started on ursodiol to treat possible biliary sludge. his bilirubin trended down to 2.2 on discharge, with patient tolerating full diet. he has been instructed to continue taking ursodiol and will have his stent removed by ercp on . . # acute alcoholic pancreatitis: lipase had been improving with iv fluids on the floor, then increased transiently with ercp. his lipase gradually trended down with a slight bump concurrent with his initial trial of clears, thought to be due to biliary sludge or exacerbation of his underlying pancreatitis. at discharge, his lipase had trended down to 220. the patient remained asymptomatic without abdominal pain, nausea, or vomiting. . # hospital-acquired pneumonia: initially, patient was intubated for ercp and remained intubated afterwards for agitation from alcohol withdrawal. however, he subsequently failed extubation due to purulent copious secretions and aspirated. he was initially treated with vancomycin and cefepime. chest imaging was consistent with right-sided pneumonia, possibly with an aspiration component, as well as ipsilateral pleural effusion. sputum cx grew strep pneumo. in this setting, patient developed increased white count from his leukopenic baseline. there was concern for parapneumonic effusion vs. empyema. abx were tailored to vancomycin and ceftriaxone. chest ct showed multifocal pna with right greater than left sided pleural effusions. bedside thoracentesis on the right was done , with drainage of 300 cc serous fluid that was significant for uncomplicated parapneumonic effusions. patient was extubated without any complications and called out to the floor on . vancomycin and ceftriaxone were discontinued on the floor given that the patient had completed a full course for hap and he has improved breathing and pulmonary exam. . # alcohol withdrawal/ alcohol abuse: . pt was increasingly tachycardic, agitated, and tremuluous on the floor, where he was receiving lorazepam by ciwa scale. he was initially maintained in the on a propofol gtt, but was changed to fent/versed which were weaned off for extubation. he received mvi/folate/thiamine. patient was seen by social work during admission and appeared motivated to seek additional inpatient or outpatient rehab. he has been given a list of rehab facilities to call for availability . # altered mental status: pt was confused and sometimes agitated during his icu stay. his altered mental status was thought to be multifactorial, likely icu psychosis and possible hepatic encephalopathy. correctable causes of altered mental status were ruled out with normal b12, tsh, and rpr. a head ct showed no acute intracranial processes. patient was started on lactulose and rifaximin to treat possible hepatic encephlopathy, and patient became increasingly attentive and oriented. he was instructed to continue lactulose (titrated to 3 bm/day) and rifaximin on discharge and will follow up with hepatology. . # hepatitis: pt had persistently elevated lfts as well as hepatomegaly, low albumin, and elevated inr on admission, which were thought to be due in part to alcoholic liver disease in the setting of acute pancreatitis/cbd obstruction. hepatology was consulted on the patient. a diagnostic work-up for other etiologies of hepatitis were negative, including negative hbv and hcv serologies, normal iron studies (transferrin, ferritin, tibc), negative anti-mitochondrial antibody, negative , slightly positive anti-smooth muscle antibody (1:20). alpha1-antitrypsin and ceruloplasmin levels were pending at discharge. his inr trended down with vitamin k. abdominal ultrasound showed normal liver without ascites. he is scheduled for outpatient follow-up with hepatology. . # right upper extremity superficial vein thrombus: patient developed a thrombus in his right cephalic vein in the setting of an indwelling picc. the picc was removed and patient was treated with lovenox for one week. . # tobacco abuse: patient was placed on a nicotine patch during admission and was instructed to continue on discharge. smoking cessation was performed. medications on admission: medications on transfer: mvi/folate/thiamine dilaudid nicotine patch valium ciwa b12 discharge medications: 1. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*2* 2. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). disp:*2700 ml(s)* refills:*2* 3. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 7. ursodiol 250 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 8. ursodiol 250 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)): in addition to 2 tablets twice a day. disp:*30 tablet(s)* refills:*2* 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis: common bile duct obstruction causing hepatitis alcohol induced pancreatitis hospital acquired pneumonia causing acute respiratory failure catheter associated dvt delirium alcohol withdrawal hepatic encephalopathy tobacco and alcohol abuse discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you were admitted to for alcohol-induced pancreatitis and obstruction of your bile duct. you had a procedure to place a stent in your bile duct and your pancreatitis improved. you also had alcohol withdrawal and were admitted to the intensive care unit. in the icu, you had pneumonia, which we treated with antibiotics. you also had a blood clot in your right arm, which we treated with blood thinners. you were found to have alcohol-related liver disease with confusion. you were given medications to clear your confusion. . you should abstain from alcohol. you should eat low-fat meals with vitamin supplements. . you should also continue taking your medications for confusion and liver disease as follows ... start lactulose 30mg three times a day (if you develop freq loose stools, cut back your dose to have 3 bowel movements per day) start rifaxamin 400mg three times a day start pantoprazole 40mg once a day start ursodiol 500mg twice a day plus 250mg at night start multivitamin, thiamine, and folic acid daily start nicotine patch - abstain from smoking followup instructions: please keep the following appointments: appointment #1 md: dr. specialty: pcp / time: tuesday, @ 10:30am location: , *** phone number: special instructions for patient: ***patient needs to be aware that dr. moved her office 2 weeks ago to the new address above address above . appointment #2 md: dr. specialty: gi/ ercp date/ time: thursday, @12 noon for procedure, patient needs to be there for 11am arrival location: 4, endoscopy suite phone number: special instructions for patient: . appointment #3 md: dr. specialty: hepatology/liver center date/ time: wednesday, @ 3:20pm location: ,, office medical building , suite 8e phone number: special instructions for patient: Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Thoracentesis Endoscopic insertion of stent (tube) into bile duct Diagnoses: Tobacco use disorder Unspecified pleural effusion Alcoholic cirrhosis of liver Asthma, unspecified type, unspecified Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other complications due to other vascular device, implant, and graft Other ascites Hepatic encephalopathy Chronic pancreatitis Obstruction of bile duct Pneumonia due to Streptococcus, unspecified Acute pancreatitis Cyst and pseudocyst of pancreas Acute alcoholic hepatitis Alcohol withdrawal delirium Other and unspecified manifestations of thiamine deficiency Acute venous embolism and thrombosis of superficial veins of upper extremity

allergies: no known allergies / adverse drug reactions attending: chief complaint: abdominal pain major surgical or invasive procedure: endoscopic retrograde cholangiopancreatography (ercp) history of present illness: -year-old male with history of dementia, cad s/p cabg, recent common bile duct stent () for pancreatitic head mass c/b obstructive jaundice, presented with fevers, abd pain, nausea and vomiting. he was initially transferred from his skilled facility to lgh for evaluation of abdominal pain. at lgh, he had a white count of 20.4 with 22% bands, t. bili of 3.1, alt of 100, ast 173, alkaline phosphatase of 273. amylase of 255. patient had a ct scan without contrast showing evidence of a mildly distended gallbladder with numerous stones, the bile stent is in place. he was also noted to have 4.3 cm solid mass exophytic from the left upper renal pole. as well as chronic pleural plaque suggestive of prior asbestos exposure. he was given levaquin and flagyl and transferred here. in the ed, initial vs were: t 97.2, hr 80, bp 98/52, rr 16, svo2 98%. he is nonverbal, guarding noted on exam, lactate of 2.1. he recieved 2l of ivf, surgery saw him in ed recommended ruq us; ercp is to scope tomorrow but will do overnight if unstable. access: 20g r, 18g l on arrival to the micu, patient's vs stable. past medical history: ckd prostate ca cad s/p cabgx3 chf af (no coumadin) htn iddm pancreatic mass s/p palliative stenting vascular dementia scc prostate ca hypothyroidism ckd vte (unk source/location) social history: lives in health and rehab center, currently on hospice. his wife died several months ago code dnr/dni no smoke/drink/drug use daughter and son are and are involved. family history: non-contributory. physical exam: on arrival to micu vitals: 97.6 77 114/58 70 15 98%ra general: non-verbal, mildly distress heent: sclera anicteric, dmm, 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, moaning more when pressing on the belly esp. ruq, + guarding. gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: on admission to : ======================== 09:30pm blood wbc-14.4* rbc-3.71* hgb-10.3* hct-33.2* mcv-90 mch-27.9 mchc-31.2 rdw-15.2 plt ct-199 09:30pm blood neuts-94.5* lymphs-2.5* monos-2.4 eos-0.1 baso-0.5 09:30pm blood pt-19.5* ptt-29.8 inr(pt)-1.8* 09:30pm blood glucose-201* urean-27* creat-1.4* na-138 k-4.3 cl-104 hco3-27 angap-11 09:30pm blood alt-97* ast-164* alkphos-284* totbili-2.9* 09:30pm blood albumin-2.8* 09:41pm blood lactate-2.1* ercp: impression: the previously placed plastic stent was identified at the major papilla. the stent was removed with a snare and sent for cytology. the major papilla was very edematous. there was no evidence of prior sphincterotomy. successful biliary cannulation was achieved with the sphincterotome. a moderate diffuse dilation was seen at the biliary tree. there were subtle filling defects suggestive of sludge or stones. no definitive stricture was seen, although there was a very subtle area of irregularity in the lower/mid cbd. contrast opacification was intentionally limited due to clinical suspicion of cholangitis and the cystic duct was not opacified. sludge and pus was extracted successfully using a balloon a 7cm by 10fr biliary stent was placed successfully in the bile duct. sphincterotomy was not performed because of the patient's abnormal inr. otherwise normal ercp to 3rd portion of duodenum. recommendations: juices when awake and alert, then advance diet as tolerated. continue antibiotics. prior imaging (with contrast) needs to be reviewed. there is no definitive evidence of malignant stricture on today's exam. if there is definitive mass, then could consider metal stent placement at next ercp. otherwise, would consider ercp with sphincterotomy for definitive treatment of biliary stones/debris. repeat ercp in 8 weeks. needs inr checked 4 days before, goal <1.5. ongoing discussion with family re: care goals. there is risk of recurrent plastic stent obstruction/cholangitis if repeat ercp is not performed. blood cultures: escherichia coli | amikacin-------------- <=2 s ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s piperacillin/tazo----- s tobramycin------------ 8 i trimethoprim/sulfa---- =>16 r brief hospital course: -year-old male with history of dementia, cad s/p cabg, recent common bile duct stent () for pancreatitic head mass c/b obstructive jaundice, who presented with fevers, abd pain, nausea and vomiting concerning for ascending cholangitis # ascending cholangitis # e. coli bacteremia patient presented with fever, ruq pain, and elevated bilirubin all suggestive of ascending cholangitis but in addition had some ct features of cholecystitis. he was started on iv zosyn and taken for ercp. ercp revealed sludge and pus in the common bile duct. the old plastic stent was removed and a new plastic one was placed. a metal stent was not placed because of active cholangitis (more risk of bacterial translocation). because plastic stents are only good for short term, he would ordinarily need a repeat ercp in 8 weeks to switch to a metal stent for long term. there is risk of recurrent plastic stent obstruction/cholangitis if repeat ercp is not performed. however, he was previously on hospice due to failure to thrive and pancreatic head mass, so this plan may or may not be relevant his clinical status should be reassessed in the next 1-2 months and if he is still stable, recommend that a repeat ercp be arranged with gi (dr. ). he would need an inr checked 4 days prior to the procedure, with goal <1.5. - radiology reviewed (non-contrast) ct from from osh: notable for 1.2x1.8cm cystic mass in pancreas (best seen in series 2 image 36). patient will need multiphasic ct to fully evaluate the pancreatic mass. formal read to follow. his antibiotics have been switched from zosyn to ceftriaxone, based on e. coli sensitivities. he should complete a total course of 14 days antibiotics, to be completed . he has a picc line in place (placed ). # rll infiltrate with rhoncherous bs- possibly aspiration pna, but at this point his respiratory status is stable with no clinical signs of pna. adequately tx with zosyn, now ceftriaxone. no role for swallow study at this point (goals are primarily comfort/quality of life), aspiration precautions, pt can resume his prior diet #) agitation, delirium/metab encephalopathy in the setting of active infection, hospitalization, and underlying dementia. - treated with frequent reorientation, fall precautions - he did require low dose haldol while in-house for periods of agitation and for procedures. - continued namenda #) coagulopathy - elevated inr, suspect some underlying liver dysfunction, now improved from 2.1 --> 1.5. no signs of bleeding, hgb stable, monitor .. #) hypothyroid: continue synthroid #) type 2 dm, insulin dependent: continue insulin # stage 2 coccyx ulcer - daughter reports this was present on admission. please clean with commerical wound cleanser with each mepilex change (change q3 days). # coronary artery disease, s/p cabg, hx htn, - stable. appears many of these maintenance meds have been trimmed off due to his overall poor prognosis and goals of care # pancreatic mass and overall goals of care - pt has recently been on hospice due to declining status after wife's death several months ago and recnet diagnosis of pancreatic head mass. iv antibiotics and hospital level care are within goals of care for now for reversible new conditions (like cholangitis). hospice can be reinitiated at after iv antibiotics are completed. note: his daughter reports that the pt may have a propensity to pull at lines. if he does pull his picc line out, would recommend a discussion with pt's family to determine best approach to care. overall the focus has been on quality of life and comfort. if his family feels that it would be best in the future not to re-hospitalize and the pt accidentally pulls the picc line out, then could consider a course of oral antibiotics instead. although this is not the recommended course from a purely infectious disease standpoint, it seems a reasonable compromise if his goals of care are consistent with hospice. his e. coli is sensitive to cephalosporins, including 1st generation and 3rd generation. could consider keflex or cefpodoxime in this instance. code: dnr/dni medications on admission: bactrim ss 1 tab daily levemir 10 units sc qhs with insulin sliding scale cipro 250 mg po daily x 7 days mom 30 cc po daily prn constipation levothyroxine 100 mcg po daily namenda 10 mg po bid haldol 1 mg topically q6h and q4h prn visine eye drops discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed for constipation. 4. memantine 10 mg tablet sig: one (1) tablet po bid (2 times a day). 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. 7. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 8. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) gram intravenous q24h (every 24 hours) for 10 days: continue until . 9. insulin glargine 100 unit/ml solution sig: ten (10) units subcutaneous at bedtime. 10. insulin sliding scale please see accompanying humalog sliding scale. discharge disposition: extended care facility: health and rehab center discharge diagnosis: ascending cholangitis e. coli bacteremia delirium, metabolic encephalopathy secondary: type 2 diabetes pancreatic mass coronary artery disease s/p cabg hypertension hypothyroidism discharge condition: condition: stable mental status: alert but disoriented, oriented to self only ambulatory status: ambulates with assistance discharge instructions: you were admitted for a biliary tract infection called cholangitis which required treatment with a procedure (ercp) and antibiotics. you were also found to have e. coli bacteria in your bloodstream and are being treated with antibiotics for this. followup instructions: his clinical status should be reassessed in the next 1-2 months and if he is still stable at that point, recommend that a repeat ercp be arranged with gi (dr. ( for 8 weeks from now. if his status is declining on hospice, then this can be deferred in favor of comfort-focused care. md Procedure: Endoscopic retrograde cholangiopancreatography [ERCP] Replacement of stent (tube) in biliary or pancreatic duct Central venous catheter placement with guidance Diagnoses: Coronary atherosclerosis of native coronary artery Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Aortocoronary bypass status Chronic kidney disease, unspecified Bacteremia Pressure ulcer, lower back Do not resuscitate status Metabolic encephalopathy Cholangitis Other specified diseases of pancreas Vascular dementia, uncomplicated Cerebral atherosclerosis Pressure ulcer, stage II Other and unspecified Escherichia coli [E. coli]

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall and left sided inability to move. major surgical or invasive procedure: none history of present illness: 72 y/o male with pmhx significant for colon, prostate and stomach cancer who presents with concerns of a stroke. patient was at in his current state of health this morning talking about an interesting job. he then went upstairs to the bathroom when 5 minutes later his wife heard him fall (~09:30). she then found him on the floor, in the fetal position. when spoken to, he was only able to moan. his wife was concerned about a stroke and contact ems where he was brought to at ~09:50. here he was noted to have a right gaze preference, word finding difficulties and right gaze preference. a head ct was obtained and showed a right pareital stroke as well as 3 old subcortical strokes. cta also showed blockage in the right distal m1 segement. patient did meet time criteria for tpa and was given the bolus of iv tpa, however then the infusion was stopped as the circumstances that the patient had old cortical stroke came out. tpa was stopped because of the potential for intraparenchymal bleeding due to history of stroke in early . of note, during his last admission neurology was consulted for concerns with difficulties with complex spatial tasks and a recent fall. his exam was notable for mild inattention, difficulty with calculations, mildly unsteady tandem gain, left neglect with spatial tasks and signs of apraxia. mri showed bilateral parietal gyriform enhancing lesions of unclear etiology with etiologies ranging from subacute stroke to leptomeningeal metastasis to cerebritis. an lp to rule out infection (wbc 1, rbc 90 with 0 polys, 57 lymphs and 43 monos, protein 67 and glucose 60) and cytology to rule out malignant cells in csf was recommended. asa 325mg daily was also initiated with further stroke evaluation (carotid dopplers mr angiogram) to be completed. past medical history: 1. clinically-localized prostate cancer - s/p xrt + adjuvant hormone therapy 2. stage iiic colon cancer - s/p folfox adjuvant chemo 3. metastatic ampullary carcinoma. social history: currently employed electrician - runs his own business. married. lives with extended family in a two-family home. one son and his family lives upstaris. he is in the midst of turning over the business to this son. denies recreational drug use or etoh. he smoked cigarettes in the past, quit family history: colon cancer physical exam: nihss: 22 nih ss: 1a. level of consciousness: 1 1b. loc questions: 0 1c. loc commands: 0 2. best gaze: 2 3. visual: 2 4. facial palsy: 2 5a. motor arm, left: 4 5b. motor arm, right: 0 6a. motor leg, left: 4 6b. motor leg, right: 0 7. limb ataxia: 0 8. sensory: 2 9. best language: 2 10. dysarthria: 1 11. extinction and inattention: 2 bp-120/42 hr-67 rr-21 o2sat 100% gen: lying in bed, intermittent retching, awake heent: nc/at, moist oral mucosa neck: no tenderness to palpation, supple, no carotid or vertebral bruit cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: +bs soft, nontender ext: no edema neurologic examination: mental status: general: awake, answers questions with latency orientation: oriented to person and month, not situation executive function: *follows simple axial and appendicular commands: closes and opens his eyes, opens mouth, smiles. able to releases a grip at command on right. speech/language: dysarthric with waxing ability to understand speech cranial nerves: ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. blinks to visual threat on right, none on left. eyes deviated to right. iii, iv, vi: able to follow commands on right visual gaze only. unable to cross midline. vii: facial movement asymmetric with left faical droop. motor: normal bulk bilaterally. tone normal. no drint on left. unable to move lue to commands. moves lle minimally spontaneously but not to gravity. delt; c5 bic:c6 tri:c7 wr ext:c6 fing ext:c7 left 5 5 5 5 5 right 5 5 5 5 5 . ip: quad: hamst: dorsiflex: :pl.flex left 5 5 5 5 5 5 right 5 5 5 5 5 5 . deep tendon reflexes: . sensation: intact to noxious stimulation on right, none on lue, minimally on lle. reflexes: +2 and symmetric throughout. toes downgoing bilaterally coordination: finger-nose-finger normal on right pertinent results: laboratory studies: admission ct /cta/ ctp: there is subacute-to-chronic-appearing right parietal lobe infarct identified. there is no loss of -white matter differentiation seen. no hemorrhage identified. there is no evidence of dense middle cerebral artery. ct perfusion head: ct perfusion of the head demonstrates a large defect within the right middle cerebral artery territory on mean transit time with a corresponding blood volume abnormality indicative of a large area of evolving infarct. ct angiography head: ct angiography of the head demonstrates complete occlusion of the right middle cerebral artery at the m1 region with subtle distal flow in the sylvian branches. the remaining arteries of anterior and the posterior circulation are patent. impression: 1. ct angiography of the head demonstrates subacute infarct in the right parietal lobe seen on the previous mri of . 2. large perfusion defect in the middle cerebral artery region indicative of an evolving infarct. 3. ct angiography of the head demonstrates near complete occlusion of the right middle cerebral artery at m1 region with minimal distal flow as described above mri/a: there is an acute right middle cerebral artery territorial infarct identified as seen on recent cta examination. the infarct is evolving and involves the basal ganglia as well as the parietal and frontal and temporal cortices. there is no evidence of hemorrhage seen in this region. there are linear areas of susceptibility abnormalities identified in the right parietal cortex at the site of previously seen infarct on the mri of . in addition, signal abnormalities are seen in the left parietal lobe and also along the medial aspect of the left parietal lobe on diffusion images, some of which were present on the previous mri and could be subacute infarcts. however, the abnormalities in the medial aspect of the left parietal lobe on diffusion were not clearly seen on the previous study and could be interval infarcts but they are difficult to assess on adc map secondary to motion. there is no midline shift or hydrocephalus identified. mra head: the head mra demonstrates non-visualization of the right middle cerebral artery beyond its proximal m1 portion. there are no vascular structures identified in the sylvian region. the remaining arteries are unremarkable. impression: 1. acute right middle cerebral artery infarct without evidence of a hemorrhage with minimal mass effect. 2. evolving subacute infarcts in both parietal lobes with new diffusion abnormality in the medial left parietal lobe could be also due to subacute infarcts but were not clearly visible on the prior mri. laminar necrosis with susceptibility abnormalities are seen in both parietal lobes at the site of previous infarcts. 3. mra shows complete occlusion of the right middle cerebral artery in the m1 region without visualization of the distal branches. tte: the left atrium is normal in size. a patent foramen ovale is present. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal biventricular systolic function. patent foramen ovale. ct abdomen and pelvis: 1. the previously noted multiple liver metastases are not well visualized on this current late urographic phase study, but heterogeneity of the liver parenchyma suggests progression. 2. no source of gastrointestinal bleeding demonstrated. carotid ultrasound: bilateral ica simple calcific plaque, no appreciable associated stenosis however (graded as less than 40% bilaterally). brief hospital course: neuro: at the time of presentation, his nihss was 22. he received iv tpa but it was stopped after several minutes once it became known that he had a prior stroke during early . there was no remarkable improvement in his examination. patient was monitored in the icu and there was no complications, with stable head ct at 24 hours. patient was then transferred to floor. he still has a dense l-sided neglect with anosognosia and with his eyes not crossing the midline. fluent. he was not opening his eyes till he received a direct command (and then did so with difficulty: ocular apraxia). however, he has clearly improved in this regard. he does have a pfo. his carotids show a plaque (<40%). ct brain on did not show evidence of hemorrhagic transformation. on , asa 81 qd was started. he was also given simvastatin 10 mg daily. there were no af runs in his telemetry monitoring. id: patient was treated for uti with 10 day course of ceftriaxone. goals of care: we had extensive discussions with his family discussion about goals of care. the palliative care team was most helpful in this regard. he does not want a peg placed. the speech and swallow evaluation determined he could have po feeds under 1 to 1 supervision. he will need to work with nutrition in the rehab setting, and be evaluated if he can maintain sufficient nutrition on his own. if this is not improving in the following weeks, the family may want to readdress the peg tube issue, depending on his overall level of function at that time. hospice care was also discussed with the family, and there will be a possibility for transition to hospice care from . code status: dnr/dni (confimed with family and hcp) medications on admission: asa 81 mg tabs, 4 tabs daily ascorbic acid vitamin d3 ibuprofen omega-3 discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 4. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po tid (3 times a day) as needed for contipation. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) 5000 injection every eight (8) hours. 6. bacitracin zinc 500 unit/g ointment sig: one (1) appl topical qid (4 times a day). 7. pantoprazole 40 mg iv q24h gib 8. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nausea. 9. prochlorperazine 5-10 mg iv q6h:prn nausea 10. morphine sulfate 0.25 mg iv q2h:prn pain 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 12. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 13. famotidine 20 mg tablet sig: one (1) tablet po twice a day. 14. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: complete right mca stroke. discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. neurologic status: left hemiplegia and neglect, no blink to threat and eyes cannot cross midline to the left discharge instructions: you have had a large right mca stroke. you have developed left sided weakness and neglect that will require rehabilitation. you were started on aspirin and simvastatin, which help prevent strokes. followup instructions: provider: , md phone: date/time: 9:00 provider: , m.d. phone: date/time: 11:00 clinical center Procedure: Injection or infusion of thrombolytic agent Diagnoses: Malignant neoplasm of liver, secondary Urinary tract infection, site not specified Ostium secundum type atrial septal defect Malignant neoplasm of prostate Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Primary hypercoagulable state Cerebral embolism with cerebral infarction Do not resuscitate status Aphasia Personal history of irradiation, presenting hazards to health Hemiplegia, unspecified, affecting unspecified side Secondary malignant neoplasm of other digestive organs and spleen Personal history of malignant neoplasm of stomach Other speech disturbance