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history of present illness: the patient is a 76-year-old male who had been hospitalized at the from through of after undergoing a left femoral-at bypass graft and was subsequently discharged to a rehabilitation facility. on , he presented again to the after being found to have a systolic blood pressure in the 70s and no urine output for 17 hours. a foley catheter placed at the rehabilitation facility yielded 100 cc of murky/brown urine. there may also have been purulent discharge at the penile meatus at this time. on presentation to the emergency department, the patient was without subjective complaints. in the emergency department, he was found to have systolic blood pressure of 85. he was given 6 liters of intravenous fluids and transiently started on dopamine for a systolic blood pressure in the 80.s past medical history: 1. coronary artery disease with diffuse 3-vessel disease; right-dominant, status post proximal left circumflex stent in with occlusion of the distal left circumflex; status post right coronary artery stent on (no percutaneous coronary intervention to 99% diagonal left circumflex, 80% small proximal left anterior descending artery, or 80% small distal left anterior descending artery). 2. congestive heart failure (with an ejection fraction of 15% to 20%). 3. type 2 diabetes with neuropathy. 4. hypertension. 5. diverticulosis (found on colonoscopy in ). 6. alzheimer's dementia. 7. history of gastrointestinal bleed (while the patient was taking eptifibatide). 8. cardiac risk factors (with a baseline creatinine of 1.4 to 1.6). 9. hypercholesterolemia. 10. history of methicillin-resistant staphylococcus aureus and pseudomonas growth in wound cultures. 11. severe peripheral vascular disease; status post left femoral-at bypass graft on . 12. chronic nonhealing foot ulcers. 13. recent right pedal cellulitis. allergies: the patient has no known drug allergies. medications on admission: 1. vancomycin 1 g intravenously q.24h. for a level of less than 15 (started on ). 2. levofloxacin 250 mg p.o. q.d. (started on ). 3. metronidazole 500 mg p.o. q.8h. (started on ). 4. heparin 5000 units subcutaneous b.i.d. 5. simvastatin 40 mg p.o. q.d. 6. lisinopril 5 mg p.o. q.d. 7. furosemide 40 mg p.o. q.d. 8. vitamin e 400 iu p.o. q.d. 9. atenolol 25 mg p.o. q.d. 10. pantoprazole 40 mg p.o. q.d. 11. ascorbic acid 500 mg p.o. b.i.d. 12. nph 17 units b.i.d. 13. regular insulin sliding-scale. 14. bisacodyl 10 mg p.o./p.r. as needed. 15. docusate 100 mg p.o. b.i.d. 16. percocet 5/325 mg one tablet p.o. q.4-6h. as needed for pain. 17. aspirin 81 mg p.o. q.d. 18. metoprolol 75 mg p.o. b.i.d. social history: the patient is retired and had been living at home with his wife prior to his admission to the hospital on ; he had been living at for the day prior to admission. he is a social drinker and has a 40-pack-year smoking history; although, he quit smoking 20 years ago. physical examination on presentation: initial physical examination revealed temperature was 96.1 degrees fahrenheit, heart rate was 83, blood pressure was 124/42 (following administration of 3 liters of normal saline), respiratory was 24, and his oxygen saturation was 100% on 2 liters nasal cannula. his heart had a regular rate and rhythm. there were normal first and second heart sounds. there was a 2/6 systolic ejection murmur, and there were no rubs or gallops. his lungs were clear to auscultation bilaterally. his abdomen was soft, nontender, and nondistended, and there were hypoactive bowel sounds. he had a palpable bypass graft pulse, dorsalis pedis and posterior tibialis pulses bilaterally; and his surgical incision was clean, dry, and intact. please note that the above examination was done by the vascular surgery team, which was the team that was initially planning to admit the patient to the hospital. pertinent laboratory data on presentation: on initial laboratory evaluation the patient had a white blood cell count of 12.7, hematocrit was 30.2, and platelets were 282,000. his pt was 13.5, ptt was 30.7, and inr was 1.3. his serum chemistries revealed sodium was 136, potassium was 5.4, chloride was 99, bicarbonate was 25, blood urea nitrogen was 53, creatinine was 3.2, and blood glucose was 91. his calcium was 8.2, magnesium was 2.4, and phosphate was 4.8. blood cultures drawn on admission were pending, but ultimately negative. a urine culture taken on admission was initially pending, but ultimately grew out yeast. a sputum culture taken on admission was also initially pending, but ultimately also grew out yeast. radiology/imaging: his admission chest x-ray demonstrated stable prominence of the right main pulmonary artery; no focal areas of consolidation; overall stable appearance of the chest compared with a study. no radiographic evidence of congestive heart failure or pneumonia. his admission electrocardiogram demonstrated a sinus rhythm, nonspecific inferior/lateral t wave changes, low qrs voltages in the limb leads, and t wave changes in v5 and v6 when compared with an electrocardiogram dated . an initial abdominal ct was a limited noncontrast examination that demonstrated diffuse vascular calcifications. no evidence of an abdominal aortic aneurysm or free fluid, incompletely imaged coronary artery calcification, a simple left renal cyst, sigmoid diverticulosis, and an enlarged and partially calcified prostate gland. hospital course by system: 1. cardiovascular: the patient was initially admitted to the vascular intensive care unit with hypotension, decreased urine output, and acute renal failure; most likely secondary to a presumed gram-negative urosepsis (although there were never any positive culture data to confirm this diagnosis). while boarding in the medical intensive care unit on the night of admission, the patient had a sudden cardiorespiratory arrest. he was resuscitated with epinephrine, lidocaine, and direct current cardioversion times four. he was also intubate for airway protection. following these measures, the patient returned to a sinus rhythm with a systolic blood pressure of approximately 100; the total time elapsed from the beginning of the arrest to the return of a pulse was approximately 16 minutes. he subsequently required double pressors to maintain his blood pressure. an echocardiogram performed at the bedside demonstrated a trivial pericardial effusion and a left ventricular ejection fraction of 20% to 25% in the setting of tachycardia and a hyperdynamic right ventricle; suggesting elevated right-sided filling pressures. although the definitive etiology of this arrest remained unknown, the most likely trigger was a non-q-wave myocardial infarction, as his troponin values were elevated to greater than 50 following his arrest. a repeat echocardiogram done on demonstrated mild left atrial dilation, an ejection fraction of 15% to 20%, resting regional wall motion abnormalities including inferior, mid, and apical left ventricular akinesis, depressed right ventricular systolic function, and moderate mitral regurgitation. compared with the prior study of ; the left ventricular function was unchanged. there was moderate mitral regurgitation, and the right ventricular function appeared worse. on , the patient was loaded with amiodarone and was subsequently started on oral amiodarone. the following day, he was started on heparin intravenously given his elevated serum troponin to greater than 50; this medication was continued for 72 hours. given his elevated troponins and non-q-wave myocardial infarction, the patient was a candidate for cardiac catheterization. after discussions between the medical intensive care unit team and the patient's family, however, the decision was made to not pursue further invasive procedures given that the patient had been made do not resuscitate/do not intubate following the resuscitation mentioned above, and his family no longer wished for aggressive resuscitating measures. by , he was off pressors and he was restarted on a beta blocker and ace inhibitor at low doses. on the evening of , the patient complained of substernal chest pain that was relieved by npg sl and morphine. he also had st segment depressions in v2 and v3 that reverted to baseline after the resolution of his pain. therefore, the patient was again started on heparin; although, this was discontinued on when the patient ruled out for a myocardial infarction by cardiac enzymes. he again had substernal chest pain on ; although, he had no electrocardiogram changes, and he again ruled out for a myocardial infarction by cardiac enzymes. by hospital day four, the patient began to develop evidence of congestive heart failure given his aggressive fluid resuscitation, and gentle diuresis with furosemide was begun. by the time of his transfer to the general medicine service on , the patient was still significantly volume overloaded following his aggressive fluid resuscitation in the medical intensive care unit. therefore, he was continued on the program of gentle diuresis given that he was having signs and symptoms of right-sided congestive heart failure. he achieved adequate diuresis by the time of his discharge to rehabilitation, as his oxygen saturation was greater than 95% on 2 liters nasal cannula. 2. infectious disease/sepsis: the patient was started on gentamicin and piperacillin/tazobactam in addition to the levofloxacin, metronidazole, and vancomycin he was already taking for right lower extremity cellulitis prior to admission for empiric coverage of a presumed gram-negative urosepsis, and he was aggressively hydrated with intravenous fluids. on , his levofloxacin and metronidazole was discontinued, and he was started on fluconazole given the growth of yeast on urine culture. he was taken off of gentamicin on hospital day three, and his fluconazole was discontinued on hospital day five (as per the infectious disease service). he was taken off of vancomycin on , and his piperacillin/tazobactam was discontinued on . despite the presumption of a gram-negative urosepsis precipitating this admission, the patient did not have any positive blood or urine cultures aside from the growth of yeast in two urine cultures noted above. he remained afebrile both before and after discontinuation of his antibiotics, and he was found to be clostridium difficile negative on . 3. pulmonary: as noted above, the patient was intubated and he was extubated on . he subsequently developed wheezing and mild hypoxia; most likely secondary to cardiac asthma and fluid overload in the setting of his aggressive fluid resuscitation. he was gently diuresed toward the end of his hospitalization, and by the time of his he was maintaining an oxygen saturation of greater than 95% on 2 liters nasal cannula, intermittent ipratropium nebulizers, and chest physical therapy for clearance of his respiratory secretions. 4. renal: the patient presented with acute renal failure and prerenal azotemia that rapidly resolved following fluid resuscitation. by the time of discharge, his serum creatinine was stable and at his preadmission baseline. 5. nutrition: the patient was found to be profoundly malnourished with a serum albumin of 1.8 on admission. once he was extubated and taking orals, he performed poorly on a modified barium swallowing study and was started on a thin liquid, ground-solid diet with whole medication tablets, small bites and sips, upright posture with meals, and aspiration precautions. he was also given promod shakes with and between meals for nutritional supplementation of his heart-healthy/diabetic diet. 6. vascular: the patient's operative incisions and foot ulcers continued to heal throughout this admission. he was started on an multivitamin, vitamin c, and zinc for improved wound healing. 7. hematology: the patient was transfused one unit of packed red blood cells on to maintain a hematocrit of greater than 30 given his history of severe coronary artery disease. his hematocrit subsequently remained stable. condition at discharge: condition on discharge was stable. discharge status: rehabilitation facility. discharge diagnoses: 1. cardiorespiratory arrest. 2. non-q-wave myocardial infarction. 3. acute renal failure. 4. coronary artery disease with diffuse 3-vessel disease; right-dominant, status post proximal left circumflex stent in with occlusion of distal left circumflex; status post right coronary artery stent on (no percutaneous coronary intervention to 99%, distal left circumflex, 80% small proximal left anterior descending artery, 80% small distal left anterior descending artery). 5. congestive heart failure (with an ejection fraction of 15% to 20%). 6. type 2 diabetes with neuropathy. 7. hypertension. 8. diverticulosis (found on colonoscopy in ). 9. alzheimer's dementia. 10. history of gastrointestinal bleed (while the patient was taking eptifibatide). 11. cardiac risk factors (with a baseline creatinine of 1.4 to 1.6). 12. history of methicillin-resistant staphylococcus aureus and pseudomonas growth in wound cultures. 13. severe peripheral vascular disease; status post left femoral-at bypass graft on . 14. chronic nonhealing foot ulcers. medications on discharge: 1. amiodarone 400 mg p.o. b.i.d. (through ), then 400 mg p.o. q.d. (times one week), then 200 mg p.o. q.d. 2. metoprolol 50 mg p.o. b.i.d. 3. captopril 6.25 mg p.o. t.i.d. 4. aspirin 325 mg p.o. q.d. 5. pantoprazole 40 mg p.o. q.d. 6. heparin 5000 units subcutaneously b.i.d. 7. multivitamin one tablet p.o. q.d. 8. zinc sulfate 220 mg p.o. q.d. 9. vitamin c 500 mg p.o. q.d. 10. ipratropium nebulizers q.4-6h. as needed (for wheezing). 11. acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed (for pain). 12. miconazole 2% powder to groin b.i.d. 13. santyl lotion to heels b.i.d. 14. regular insulin sliding-scale. code status: do not resuscitate/do not intubate. note: if applicable, an addendum to this discharge summary will be dictated to include follow-up appointments as well as any changes to the medication list noted above. , m.d. dictated by: medquist36 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 electric countershock of heart Pulmonary artery wedge monitoring Diagnoses: Other primary cardiomyopathies Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Cardiac arrest Other shock without mention of trauma Cellulitis and abscess of leg, except foot

history of present illness: the patient is a 47-year-old female with a history of human immunodeficiency virus (last cd4 count 42 and a viral load of 65,000), cirrhosis, diabetes, and hypothyroidism presented with eight days of fevers to 104, chills, shortness of breath, cough, dyspnea on exertion, and fatigue. the patient states she has become progressively dyspneic to the point where she is short of breath with speaking. she has also had night sweats for the past two days and whitish sputum. she complains of myalgias. no recent ill contacts. known tuberculosis exposure. in the emergency department, the patient was initially 96% on room air, with a respiratory rate of 20, and a heart rate of 117. a chest x-ray showed diffuse interstitial opacities. she received 3 liters of normal saline, clindamycin, and primaquine for likely pneumocystis carinii pneumonia. she spiked a temperature to 102.1 and became progressively dyspneic with her respiratory rate increasing to 40, and her oxygen saturations dropping to 89% on room air. she was placed on 6 liters by nasal cannula, and an arterial blood gas showed 7.47/28/74. the patient was given prednisone and aztreonam for possible cholangitis. past medical history: 1. human immunodeficiency virus diagnosed in ; acquired from her ex-husband (in , cd4 count was 42 and viral load was 65,000). 2. cirrhosis; status post liver biopsy in consistent with cytosis and sinusoidal fibrosis consistent with toxic metabolic disease possibly from highly active antiretroviral therapy. 3. insulin-dependent diabetes mellitus since . 4. hypothyroidism. 5. esophagogastroduodenoscopy in was normal with no varices. medications on admission: 1. viread 300 mg once per day. 2. epivir 150 mg twice per day. 3. acyclovir 400 mg twice per day. 4. diflucan 200 mg twice per day. 5. videx 400 mg once per day. 6. zantac 150 mg once per day. 7. klonopin as needed. 8. lantus 6 units subcutaneously in the morning; no sliding-scale. allergies: penicillin and sulfa drugs (cause a rash). dapsone (causes nausea). family history: family history was noncontributory. social history: the patient lives at home with her son. she quit tobacco five years ago. no alcohol. no illicit drugs. no intravenous drug use. no transfusions. physical examination on presentation: on admission, the patient had a temperature of 102.1, her heart rate was 118, her respiratory rate was 40, her blood pressure was 117/57, and her oxygen saturation was 89% on room air and 94% on 6 liters. in general, she was ill and toxic appearing. she was unable to speak in complete sentences. she was cachectic. head, eyes, ears, nose, and throat examination revealed anicteric. the mucous membranes were dry. the extraocular movements were intact. no thrush. the neck was supple. there was no jugular venous distention. thorax revealed bilateral basilar rales. no wheezes. cardiovascular examination revealed tachycardia. there were no murmurs. the abdomen revealed mild diffuse tenderness to percussion, hepatomegaly 6 cm below the costal margin, no spleen palpated, positive bowel sounds. there was no rebound or guarding. extremities revealed no lower extremity edema. pulses were 2+. neurologic examination revealed cranial nerves ii through xii were intact. strength was in all extremities. pertinent laboratory values on presentation: the patient had a white blood cell count of 9.7 (with 89% neutrophils and 7% lymphocytes), and her hematocrit was 34.2. chemistries were within normal limits with a blood urea nitrogen of 9 and a creatinine of 0.5. her aspartate aminotransferase was 69, her alanine-aminotransferase was 28, her alkaline phosphatase was 994, and her total bilirubin was 2.2, and her direct bilirubin was 1.5. her lactate was 2.1. urinalysis was negative for leukocyte esterase or nitrites. it was positive for 30 protein. pertinent radiology/imaging: an electrocardiogram revealed sinus tachycardia; unchanged from . a chest x-ray revealed bilateral interstitial opacities in the left mid lung; consistent with pneumocystis carinii pneumonia or viral pneumonia. a right upper quadrant ultrasound revealed no cholelithiasis. no gallbladder wall edema. common bile duct was 4 mm. brief summary of hospital course by issue/system: 1. pulmonary issues: from the emergency room, the patient was transferred to the intensive care unit secondary to respiratory distress. symptoms consistent with a respectively alkalosis. a chest x-ray was consistent with possible pneumocystis pneumonia versus a viral pneumonia. given her allergies to both sulfa and dapsone, she was started on empiric pneumocystis carinii pneumonia coverage with primaquine and clindamycin. she was also started on prednisone given her low oxygen saturations, and given her low pao2. in the intensive care unit, she requested noninvasive positive pressure ventilation. a bronchoscopy was performed with 1+ gram-positive cocci in pairs and positive pneumocystis carinii pneumonia. acid-fast bacillus smears were negative. the patient's respiratory status continued to improve on her medication regimen. she was weaned off of the noninvasive positive pressure ventilation and eventually was able to saturate 98% on room air. she was to be continued on primaquine and clindamycin for a total of a 21-day course of antibiotics as well as a 21-day steroid taper. 2. bacteremia issues: the patient's blood cultures from admission from and grew out methicillin-sensitive staphylococcus aureus ( blood cultures). at that time, the patient was started on vancomycin therapy with quick clearance of her blood cultures. a transthoracic echocardiogram was performed to rule out endocarditis, and it did not show any valvular abnormalities; although, the tricuspid valve was obscured by her peripherally inserted central catheter line. the subsequent surveillance blood cultures from on were negative, and the patient was to be continued on vancomycin intravenously for a 3-week course. after that time, blood cultures should be repeated for surveillance. the patient remained afebrile during the remainder of her hospital stay. 3. cirrhosis issues: the patient has child a class cirrhosis from a liver biopsy done in . her cirrhosis was thought to be secondary to her highly active antiretroviral therapy. she was to follow up with dr. in for a visit. a right upper quadrant ultrasound was performed as the patient's alanine-aminotransferase was slightly elevated and was within normal limits. 4. human immunodeficiency virus issues: the patient was restarted on her highly active antiretroviral therapy regimen on hospital day four. the patient tolerated these medications without any problems. she was also continued on acyclovir and fluconazole for prophylaxis. the patient was to follow up with dr. in clinic over the next two weeks. 5. diabetes mellitus issues: the patient was placed on original regimen of lantus without a sliding-scale secondary to her steroid taper. her blood sugars remained elevated while in house; ranging from the 200s to the 400s. her lantus was increased to 12 units subcutaneously in the morning, and her sliding-scale was increased as well with improved blood sugars. she was to be discharged on 12 units of lantus in the morning with a strict sliding-scale for the next three days until her prednisone is tapered; at which time her lantus will be decreased to 7 units in the morning, and her sliding-scale will be decreased as well. 6. hypothyroidism issues: the patient was continued on her levoxyl. 7. access issues: a peripherally inserted central catheter line was placed on for intravenous antibiotics. it was found to be in the right atrium on chest x-ray and was pulled back 6 cm with a repeat chest x-ray location in the superior vena cava. she will need the peripherally inserted central catheter line for 14 more days as she finishes her course of intravenous vancomycin. condition at discharge: condition on discharge was good. discharge status: the patient was discharged to home. discharge instructions/followup: the patient was instructed to follow up with dr. for cirrhosis and with dr. for her human immunodeficiency virus. she was to follow up with dr. and dr. next friday for primary care. medications on discharge: 1. prednisone 40 mg once per day times three days; then 20 mg once per day times 11 days. 2. acyclovir 200 mg by mouth twice per day. 3. fluconazole 200 mg by mouth twice per day. 4. primaquine 26.3 two tablets by mouth every day (times 14 days). 5. levoxyl 25 mcg by mouth once per day. 6. tenofovir disoproxil fumarate 300 mg by mouth once per day. 7. lamivudine 300 mg twice per day. 8. didanosine 400 mg by mouth once per day. 9. lantus 12 units subcutaneously in the morning times three days; and then 7 units subcutaneously in the morning. 10. regular insulin sliding-scale as directed (per sliding-scale). 11. clindamycin 300 mg by mouth four times per day (times 14 days). 12. vancomycin 750 mg intravenously twice per day (times 14 days). 13. codeine/guaifenesin syrup 5 cc to 10 cc by mouth q.6h. as needed. 14. klonopin 0.75 mg by mouth in the morning and 0.5 mg by mouth at hour of sleep. 15. multivitamin one tablet by mouth once per day. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Other bronchoscopy Diagnoses: Cirrhosis of liver without mention of alcohol Infection with microorganisms resistant to penicillins Human immunodeficiency virus [HIV] disease Pneumocystosis Cachexia Alkalosis Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Antiviral drugs causing adverse effects in therapeutic use

history of present illness: the patient is a 65 year-old woman with end stage renal disease, secondary to malignant hypertension. she was started on dialysis in . she currently was on peritoneal dialysis and appears to be doing well. she has a history of gastric angiectasia which she requires endoscopy. she was admitted on for a scheduled living donor kidney transplant by her son, who is the donor. she does have a donor specific antibody (b-51) and will have a final t & b cell class match prior to transplantation. past medical history: end stage renal disease, secondary to malignant hypertension on dialysis. history of anemia following gastric angiectasia. she has no known history for coronary artery disease for diabetes. allergies: no known drug allergies. medications: unknown. social history: married, lives with her husband. she has a history of a half pack of cigarettes per day for 20 years. occasional alcohol. physical examination: the patient was afebrile. vital signs were stable. blood pressure was 124/58; heart rate 76; weight 160 pounds. abdomen soft and nontender. she has a peritoneal dialysis catheter in the right lower quadrant. she has good femoral pulses bilaterally. mild pedal edema. hospital course: on , the patient went to the operating room for living donor kidney transplant, performed by dr. and assisting by dr. . please see details of this surgery in operating room note. also during her operating room time, the patient also had a right iliac artery thrombosis. it was noted that at the end of the completion of the procedure, that she had an ischemic appearing right foot and absence of a right femoral pulse. in the operation, there was some difficulty with arterial anastomosis, renal artery to the left iliac artery and dr. came to assist dr. . again, please see details of that operation in the operative report. postoperatively, the patient went to the intensive care unit. the patient had an a line, a central line, foley. she was placed on a heparin drip to keep ptt between 45 and 50. the patient's dressing was clean, dry and intact. the patient had 2 drains in place. good femoral pulse and good dorsalis pedis pulse. these pulses were palpable. the patient was making good urine output postoperatively. renal was consulted and made recommendations. postoperatively, the patient had a renal ultrasound demonstrating an unremarkable renal transplant ultrasound with normal size and appearance of the transplanted kidney and normal arterial wave forms and resistive disease, ranging from 0.63 to 0.75 throughout. on postoperative day number one, the patient had another ultrasound secondary to her hematocrit decreasing and they wanted to rule out hematoma. the ultrasound demonstrated that there was no hematoma seen adjacent to the transplanted kidney. the transplanted kidney is minimally changed from yesterday which was on with a small amount of pelvic ectasis. relatively unchanged resistive indices. the patient did get multiple transfusions for her low hematocrit. her heparin was discontinued on . the patient received 1/2 cc per cc of replacement and on , tacrolimus was started. on , the patient had some complaint of right foot numbness. lower extremity ultrasound was obtained to rule out deep venous thrombosis and this showed no evidence of right lower extremity deep venous thrombosis. on , wbc was 2.9, hematocrit of 35.2. also on , pt was 13.5, ptt was 36.7, inr of 1.2. sodium that day was 129 and 4.4, 100 bun, creatinine of 69 and 6.2 with a glucose of 96. vascular surgery continued to see the patient. it was decided that hematocrit was stable, that heparin could be continued. the patient was restarted on heparin. the patient still complained of right foot numbness but it was about the same and not worse. she was continued on all of her immunosuppressive medications, including tacrolimus, valcyte, cellcept, bactrim, solu-medrol. the patient was transitioned from heparin to coumadin. the patient was transferred to the floor, continued to make excellent urine output. the patient had another ultrasound on because there was blood in her drain and with the decreasing hematocrit. ultrasound demonstrated normal arterial and venous color, blood flow and wave form with normal residual indices. 7.6 by 3.5 cm fluid collection, likely simply fluid, anterior to the contrast. focal area of heterogeneity within the lateral aspect of the mid pole, probably which demonstrates normal blood flow and may represent artifact; however, attention to this area on a follow up scan is recommended to document interval change or resolution. on , the patient's right lower extremity was swollen. the patient complained of right hip and thigh pain, pitting edema of right lower extremity greater than left lower extremity so an ultrasound was performed which included the right iliac artery. this demonstrated acute deep venous thrombosis within the right common femoral and superficial femoral veins which had developed since . there is a right groin hematoma which was unchanged. the patient continued to be anticoagulated for dvt. one drain was eventually removed, continued on with drain output of 170, afebrile, vital signs stable. she went home with services on the following medications: valcyte 450 mg q. day, bactrim ss 1 tab q. day, protonix 40 mg q. day, nystatin 5 ml suspension, 5 ml four times a day, colace 100 mg twice a day, movlapine 10 mg q. day, percocet 22 tabs q. day, lopressor 100 mg twice a day, mmf 500 mg q.o.d. coumadin 2 mg q. day. this should be monitored to keep the inr between 2 and 3. reglan 10 mg four times a day before meals and at bedtime. tacrolimus 10 mg p.o. twice a day. potassium sodium phosphate, one packet q. day and compazine 10 mg q. 6 hours prn. the patient has a follow up appointment with dr. , please call for an appointment. the patient needs to change dressings on her wound twice a day located on her groin, place a dry gauze between the wound and her skin. no heavy lifting of greater than 10 pounds for the first 6 weeks after surgery. diagnoses: end stage renal disease, status post renal transplant. arterial thrombosis. deep venous thrombosis. resolving hypertension. , Procedure: Other kidney transplantation Transfusion of packed cells Repair of blood vessel with synthetic patch graft Incision of vessel, abdominal arteries Transplant from live related donor Diagnoses: Hyperpotassemia Anemia, unspecified Personal history of tobacco use Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Peripheral vascular complications, not elsewhere classified Disorders of phosphorus metabolism

past medical history: hypertension. admission medications: the patient was on no medications upon admission. allergies: the patient has no known drug allergies. family history: unknown. social history: the patient lives . physical examination on admission: during the five minute examination, the patient became progressively less responsive and then vomited requiring intubation and paralytics during the examination. vital signs: blood pressure 229/137, heart rate 85, respiratory rate 20, temperature 98.8. general: this was a well-developed african-american male. heent: the neck was supple without lymphadenopathy or thyromegaly. cardiovascular: regular rate and rhythm. no murmurs, rubs, or gallops noted. lungs: clear to auscultation bilaterally. abdomen: soft, nontender, nondistended with no hepatomegaly. extremities: no clubbing, cyanosis or edema noted. neurologic: on the mental status examination, the patient was alert but nonverbal. language was aphasic but can comprehend one-step commands. there was no evidence of neglect. the patient can follow one-step commands. on the cranial nerve examination, his optic disk margins were sharp. his extraocular eye movements were intact. his pupils were equal and reactive to light. his face was symmetrical at rest. motor: he had normal bulk and tone with no tremors. his power was 0/5 in the right arm and leg. his left arm and leg was apparently . sensory: he was reactive to noxious stimuli in all four extremities. his reflexes were minimal throughout. his toes were mute bilaterally. coordination and gait examination was not tested. laboratory/radiologic data: white count 7.5, hematocrit 45, platelets 258,000. pt 12.7, ptt 21.7, inr 1.1. the ekg was normal sinus rhythm at 99 with normal axis and intervals. lvh was noted. there were t wave inversions in i, ii, iii, avl, v1 through v3. serum and urine toxicology was negative. esr was 18. the urinalysis was negative. ct scan of the head showed 55 by 55 by 21 mm left putaminal bleed with a 5 mm midline shift to the right. chest x-ray showed cardiomegaly with chf. hospital course: 1. neurologic: left putaminal bleed secondary to presumed hypertension. the patient's blood pressure was initially controlled with a nipride drip to keep the cephalic pressure between 130-160. the nipride drip was then weaned as labetalol iv was added along with a nicardipine drip. the patient was also given dilantin load followed by a maintenance dose of 400 mg q.d. his level has been therapeutic around 20. considerations for a cta and angiogram for possible avm or aneurysm were considered but the patient's renal function and health status did not allow such studies to be done at the current time. repeated noncontrast ct of the head revealed no increase in the bleeding but showed subsequently increases in cerebral edema with some pressure onto the brain stem. the patient's neurological examination did deteriorate to the point that he only had reactive pupils that were equal and intact corneal reflexes. in addition, he had a gag reflex. however, he began to not move any extremities and not respond to any noxious stimuli in the four extremities. by 4:00 p.m. on , his neurological condition deteriorated to the point that his pupils were dilated and nonreactive. he lost gag and corneal reflex. calorics were done at this time which revealed no response. neurosurgery was reconsulted for a question of craniotomy but they felt that the patient would not be a candidate for the surgery in that it would not help him. mannitol was then started along with hyperventilation to keep the pc02 below 30 in an attempt to decrease the cerebral edema. despite clinical examination that the patient is clinically brain dead, the family wishes to continue aggressive treatment. the family requested that the patient be transferred to the . however, dr. at the stroke service said that the patient would not be accepted at the given that there would be no other intervention that would be done differently at . 2. cardiovascular: as mentioned above, the patient was initially started on a nipride drip to control the blood pressure between 130-160. however, he was slowly weaned off the nipride to be switched over to cardene drip. the cardene drip was then weaned to allow for the addition of p.o. labetalol. three serial cks and troponins were checked and found to be negative, thus, ruling the patient out for a myocardial infarction. 3. pulmonary: the patient was initially intubated when first seen down in the emergency room for airway protection since he vomited. he then showed a left lower lobe pneumonia on the chest x-ray. he was started on levofloxacin and flagyl since the day of admission for aspiration pneumonia. vancomycin was added on day number four of hospitalization due to sputum cultures showing staphylococcus aureus coagulase-positive organisms and gram-negative rods. susceptibilities are still pending. the patient did have one or two episodes of desaturation secondary to breathing trials and increased secretion in his nostrils. in an attempt to decongest him, saline nasal spray was started. 4. renal: acute renal failure secondary to dehydration. the patient's creatinine upon admission was 1.4 and continued to rise to 2 as he started third spacing his fluids. urine electrolytes were checked which showed a phena of less than 1 which is evidence of the patient being dehydrated and prerenal. he was subsequently given iv fluids and his creatinine improved to 1.6. a renal ultrasound was done which showed no evidence of hydronephrosis. 5. infectious disease: leukocytosis: given the aspiration pneumonia and elevated white count of 18.6, levofloxacin and flagyl were started on the day of admission. blood cultures were obtained. the first two sets showed one out of four blood cultures that grew staphylococcus coagulase-negative. since this was deemed a contaminent, no further antibiotics were given. however, on day number four of hospitalization, his sputum culture returned showing staphylococcus coagulase-positive organisms so vancomycin was added. more blood cultures were drawn but nothing has grown to date. 6. gastrointestinal: the patient was given and orogastric tube for tube feeds. he had some high residuals so the tube feeds were stopped. reglan was then administered to promote gi motility so that the tube feeds could be restarted. 7. fluids, electrolytes, and nutrition: hyponatremia: the patient's sodium slowly fell from 136 upon admission to 130 on the fourth day of hospitalization. it was felt that this was due to salt wasting from his cerebral problems so he was then fluid restricted. although he has acute renal failure secondary to dehydration and third spacing, it was felt that he needed to be fluid restricted given that the overall hyponatremia was more likely due to salt wasting. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Intracerebral hemorrhage Pneumonitis due to inhalation of food or vomitus

history of present illness: baby girl is a 1,385 gram, former 30 and week premature baby, born to an 18 year old, gravida i, para 0, now i, mother with prenatal serologies as follows: a positive, antibody negative, rpr nonreactive, hepatitis b surface antigen negative; gbs unknown. pregnancy was complicated by pprom on when the mother was transferred from hospital to . mother received betamethasone times two as well as ampicillin and erythromycin. she progressed to a spontaneous vaginal delivery on the morning of . the baby emerged vigorous with spontaneous cry; apgars of eight and nine. she was warm, dried and bulb suctioned in the delivery room and brought to the neonatal intensive care unit for further management for prematurity. physical examination: weight 1,385 grams (25th to 50th percentile); length 38 cms (10 to 25 percentile); head circumference 27.5 cms (10 to 25 percentile). she was an active, alert infant, pink, appropriate for gestational age of 31 weeks. anterior fontanel was open and flat with some molding and caput. no dysmorphism. lungs clear to auscultation. heart regular rate and rhythm without murmurs. abdomen was soft without hepatosplenomegaly or masses. hips were stable. premature female genitalia. extremities were well perfused. hospital course: 1.) respiratory: baby girl remained stable on room air throughout her neonatal intensive care unit stay at . she had one apnea and bradycardia episode on day of life five, requiring mild stimulation. 2.) cardiovascular: baby girl had seemed hemodynamically stable throughout her neonatal intensive care unit stay. she had no murmurs on examination. 3.) fluids, electrolytes and nutrition: baby girl had gradually been advanced to total fluids of 150 cc per kg per day; currently tolerating breast milk 22, maintaining good blood glucose. her admission weight was 1,385 grams; her weight on day of life seven prior to discharge was 1,445 grams. gastrointestinal: baby girl ' bilirubin level peaked on day of life three at 8.3, at which time phototherapy was initiated. subsequently, her bilirubin level was 4.2 on day of life six, at which time the phototherapy was discontinued. her rebound bili on day of life seven was 5.1. infectious disease: baby girl was initiated on ampicillin and gentamycin for rule out sepsis. her blood culture remained negative at 48 hours at which time the antibiotics were discontinued. hematology: the patient's initial hematocrit was 42.8 and required no transfusions during this admission. neurology: baby girl had a screening head ultrasound on day of life seven which was negative. condition at transfer: baby girl has been stable on room air and hemodynamically stable, tolerating full feeds of breast milk 22. discharge disposition: baby girl is being discharged to special care nursery. care and recommendations: feeds at discharge: total fluids of 150 cc per kg per day with breast milk 24. medications: none. state newborn screen: sent. follow-up appointment: recommended in two to three days after discharge from the neonatal intensive care unit. discharge diagnoses: prematurity at 31 weeks. rule out sepsis. , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Other phototherapy Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Neonatal jaundice associated with preterm delivery Other preterm infants, 1,250-1,499 grams 29-30 completed weeks of gestation

allergies: penicillins attending: chief complaint: cc: major surgical or invasive procedure: stereotactic brain biopsy, neuronavigation guided tumor resection. history of present illness: hpi: 50 year old female presents after having fallen in the bathtub 4 days ago and hitting the back of her head. since then she has had a "massive headache" which did not resolve with tylenol. she states that she has a high threshold for pain and did not realize how bad it was during the day while at work but then when she got home at night she noticed it. the patient noticed "silvery spects" in her vision and she had trouble with some simple tasks like finding the tags on the back of her clothing in the morning. she reported that she had to check several times to make sure she did not put her clothes on backwards. she has had some dizziness, but no nausea or vomiting. her speech has not been affected. past medical history: newly diagnosed gbm as above otherwise, none family history: physical exam: on admission: physical exam: t:98.4 bp:105/55 hr:95 rr:15 o2sats: 98% ra gen: wd/wn, comfortable, nad. heent: pupils: perrl eoms-intact neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. language: speech fluent with good comprehension and repetition. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 2 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift. when asked to rotate fists around each other, her right fist orbits the left, which may show slight lue weakness. sensation: intact to light touch bilaterally. reflexes: intact toes downgoing bilaterally coordination: normal on finger-nose-finger pertinent results: ct head w/o contrast 12:28 pm ct head w/o contrast reason: please evaluate for any new changes medical condition: 50 year old woman with brain mass. now has headache. reason for this examination: please evaluate for any new changes contraindications for iv contrast: none. non-contrast head ct scan history: brain mass. now has headache. evaluate for any changes. technique: non-contrast head ct scan. comparison study: ct scan of the head, reported by drs. and as revealing "unchanged mass effect and edema around large right parietal mass, without evidence of new intracranial hemorrhage following biopsy." findings: since the prior study, there is now mild linear hyperdensity within the basal cisterns of this could be hemorrhage, occasionally the tributaries of the circle of can be somewhat denser appearing, in the setting of increased intracranial pressure, which would mimic the presence of subarachnoid blood. no other new intracranial or extracranial abnormalities are discerned. conclusion: possible small amount of subarachnoid blood or relatively stagnant vascular flow, in the face of increased intracranial pressure, as noted above. we have telephoned (dr. with this report immediately after the conclusion of the study. addendum: there is a tiny residual gas collection superior to the biopsy site, definitely decreased in extent compared to the prior study of . dr. cardiology report ecg study date of 3:21:48 pm normal sinus rhythm. within normal limits. no previous tracing available for comparison. read by: , intervals axes rate pr qrs qt/qtc p qrs t 90 142 82 45 48 () mr head w & w/o contrast 5:01 am mr head w & w/o contrast reason: evaluate extent of ring enhancing brain mass w/ edema seen o contrast: magnevist medical condition: 50 year old woman with brain mass reason for this examination: evaluate extent of ring enhancing brain mass w/ edema seen on ct emergency mri scan of the brain. history: ring-enhancing brain mass with edema seen on ct scan. technique: multiplanar t1 and t2-weighted brain images with gadolinium enhancement. comparison studies: none available at this time. wet read report: dr. interpreted this study as revealing "bilateral parenchymal masses, suggesting metastatic disease. the largest mass in the right parietal lobe has a complex appearance, at least 5 cm in greatest dimension with at least 8 cm greatest dimension of surrounding edema and 7 mm leftward midline shift." dr. is a member of the "nighthawk" radiology group. findings: the study indeed reveals a large right parietal, irregularly thick ring enhancing mass, possibly with some tiny "daughter" cystic components extending towards the cortical surface. as mentioned in the wet , there is a substantial area of surrounding edema, with effacement of the right atrium and approximately 7 mm leftward subfalcine herniation. a smaller area of edema is seen within the white matter of the left occipital lobe, but i cannot delineate any specific area of enhancement associated with it. a third, very well circumscribed 18 x 26 mm area of elevated t2 signal is seen contiguous to the left temporal lobe, and it is difficult to determine whether the lesion is intra- or extra-axial in locale. again, there is no associated enhancement and no abnormal susceptibility is noted, either. on the coronal post-contrast images, there is a questionable area of enhancement, approximately 3 mm, immediately subjacent to the left temporal lesion- i am not certain that the two findings are necessarily related. the principal vascular flow patterns are identified. there is no overt extracranial abnormality noted. conclusion: large right parietal lobe mass, which may represent either a primary or metastatic brain neoplasm. the additional abnormalities within the left temporal lobe and left occipital lobe, while they may represent extremely unusual manifestations of metastatic disease, which would then render the right parietal lobe lesion more likely metastatic, could have alternative diagnoses, including hemorrhage or a calcified left temporal meningioma as an explanation for the left temporal lesion, and either an inflammatory or ischemic process to account for the left occipital lesion. i discussed this case this morning with dr. , it was decided that a non-contrast head ct scan would be a helpful followup diagnostic procedure to further characterize the left cerebral hemispheric lesions prior to brain biopsy of the right parietal lesion. dr. approved: 4:07 pm chest (portable ap) 3:50 pm chest (portable ap) reason: please evaluate preop medical condition: 50 year old woman with bilateral masses reason for this examination: please evaluate preop indication: bilateral brain masses for pre-op evaluation. portable chest: there are no priors for comparison. heart size is normal. mediastinal and hilar contours are normal. pulmonary vasculature is normal. lungs are clear, and there are no effusions or pneumothorax. impression: 1. no acute cardiopulmonary disease. 2. no evidence of a primary pulmonary neoplasm, but pa/lateral cxr or ct would be more sensitive than a portable study and may be helpful for more complete assessment, if not already recently obtained. the study and the report were reviewed by the staff radiologist. dr. dr. approved: fri 9:02 am **** ******* brief hospital course: a/p: 50 year-old woman without significant pmh who presented from osh with new dx of brain mass after fall, with biopsy that showed gbm, for which she had craniectomy/debulking and was started on xrt without event. . 1) glioblastoma multiforme: she was transferred to after fall and was noted to have a brain mass. she had a biopsy which showed glioblastoma, who grade iv. she was noted on to have headache, with 4/18 she had mental status changes and imaging c/w herniation. she was taken emergently to the or for craniotomy and subtotal tumor debulking. she was then transferred to omed for xrt and chemotherapy. she was maintained on keppra and decadron for seizure/cerebral edema prevention. she was maintained on seizure precautions with frequent neuro checks. she used a helmet with ambulation given s/p craniectomy. she was started on xrt with temador. she remained stable without signs of elevated intracranial pressure during this so was thought stable to go home and continue xrt as an outpatient. she was seen by pt and though stable to go home. she was continued on pantoprazole and sliding scale insulin while on dexamethasone. . medications on admission: none discharge medications: 1. diabetic.com starter kit kit sig: one (1) kit miscellaneous once a day. disp:*1 kit* refills:*0* 2. insulin lispro (human) 100 unit/ml solution sig: 0-15 units subcutaneous asdir (as directed): per sliding scale, check blood glucose 4 times daily. disp:*qs units* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(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. dexamethasone 4 mg tablet sig: two (2) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 7. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 8. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain. disp:*20 tablet(s)* refills:*0* 9. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. disp:*15 tablet(s)* refills:*2* 10. ondansetron 4 mg tablet, rapid dissolve sig: two (2) tablet, rapid dissolve po daily (daily): 2 pills 30 minutes prior to temodar (chemotherapy) or pills as needed every 8 hours for nausea. disp:*90 tablet, rapid dissolve(s)* refills:*2* 11. omega-3 fatty acids 550 mg capsule sig: one (1) capsule po bid (2 times a day). 12. melatonin oral discharge disposition: home with service facility: hospice and vna discharge diagnosis: glioblastoma discharge condition: stable discharge instructions: please take all medications as prescribed. please keep all follow-up appointments. you will be contact by dr. regarding your temodar prescription. . please call your primary care physician or dr. if you experience headaches, visual changes, nasea, vomitting, hiccups, change in strength, sensation, or coordination. these could be signs of elevated intercranial pressure and could require urgent treatment. * please limit exercise to walking; no lifting, straining, excessive bending. please continue to use your helmet with ambulation. you may wash your hair only after sutures and/or staples have been removed. you may shower before this time with assistance and use of a shower cap. increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation. unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, ibuprofen etc. call your surgeon immediately if you experience any of the following: ?????? new onset of tremors or seizures ?????? any confusion or change in mental status ?????? any numbness, tingling, weakness in your extremities ?????? pain or headache that is continually increasing or not relieved by pain medication ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f followup instructions: please continue with your daily radiation therapy treatments: to continue this as an outpatient you will need to call: ( first thing in the morning of . if you have any difficulty schduling these treatments or questions please call ( and ask for . . please follow-up with dr. on , . you should be contact with the time of this appointment but if you do not hear from her office please call . . please call to schedule follow-up with your primary care physician, . in the next 2 weeks. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Closed [percutaneous] [needle] biopsy of brain Closed [percutaneous] [needle] biopsy of brain Injection or infusion of cancer chemotherapeutic substance Other radiotherapeutic procedure Diagnoses: Malignant neoplasm of parietal lobe

history of present illness: mr. is a 72-year-old male with a past medical history significant for pancreatic cancer, ulcerative colitis, hypertension, status post endoscopic retrograde cholangiopancreatography, and status post total abdominal colectomy 20 years ago with an end-ileostomy. the patient underwent an endoscopic retrograde cholangiopancreatography recently, but a stent was unable to be placed. a computed tomography was performed which demonstrated a head of the pancreas mass with dilated intrahepatic duct along with vascular involvement of the gastroduodenal artery and superior mesenteric vein. he presented for exploratory laparotomy with possible pancreatic mass resection. past medical history: 1. ulcerative colitis. 2. hypertension. 3. benign prostatic hypertrophy. past surgical history: 1. total abdominal colectomy with end-ileostomy. 2. status post transurethral resection of prostate. medications on admission: 1. moexipril 15 mg by mouth once per day. 2. aspirin 81 mg by mouth once per day. 3. atenolol 25 mg by mouth once per day. 4. allopurinol 300 mg by mouth once per day. 5. multivitamin. allergies: the patient has no known drug allergies. physical examination on presentation: the patient is a thin, cachectic caucasian male who was alert and oriented times three. in no apparent distress. the sclerae were anicteric. the patient was jaundiced. the oropharynx was clear with moist mucous membranes. the neck was supple and without lymphadenopathy. the heart was regular in rate and rhythm. the lungs were clear to auscultation bilaterally. the abdomen was soft, nontender, and nondistended. there was a well-healed midline scar and ileostomy present. the extremities were warm without cyanosis, clubbing, or edema. pertinent laboratory values on presentation: his hematocrit was 43.2. his inr was 1.2. creatinine was 1.6. aspartate aminotransferase was 51, his alanine-aminotransferase was 89, his alkaline phosphatase was 395, and his total bilirubin was 12.5. brief summary of hospital course: on the day of admission, the patient was taken to the operating room where an exploratory laparotomy was performed. the patient had evidence of unresectable pancreatic cancer with biliary obstruction seen intraoperatively. adhesiolysis was therefore performed along with a roux-en-y hepaticojejunostomy, and open cholecystectomy, an open pancreatic biopsy, and a gastrojejunostomy. the estimated blood loss for the procedure was 250 cc. the patient was discharged to the regular hospital floor after being extubated in the postanesthesia care unit in good condition. in the evening on postoperative day one, the patient was taken back to the operating room emergently for likely mesenteric bleeding. this was controlled with suture ligation, and the patient was admitted to the surgical intensive care unit postoperatively for close monitoring. the patient remained intubated in the intensive care unit on pressor support and received total parenteral nutrition until postoperative day seven. at this time, the patient's mental status was extremely labile requiring haldol for agitation. the patient's hematocrit was stable at 35.8 at this time. tube feeds were initiated on postoperative day eight. on postoperative day nine, the patient was transferred to the regular hospital floor. at this time, tube feeds were held for elevated residuals and nausea. he was still receiving total parenteral nutrition at this time. the patient's mental status was still not completely improved. a computed tomography scan was performed on postoperative day ten which did not demonstrate any intra-abdominal pathology. the patient was started on sips on postoperative day eleven and was started on his home medications. at this time, he was seen by the physical therapy service and was being screened for rehabilitation placement. however, on the evening on postoperative day twelve the patient spiked a temperature to 101.5 degrees fahrenheit. a fever workup was done including a chest x-ray and blood cultures. early the next morning, the patient was found unresponsive without a pulse at approximately 2:45 a.m. at this time, a code blue was called and advanced cardiac life support protocol was initiated. however, the patient was asystolic without any respiratory effort at this time. he did receive multiple rounds of epinephrine along with attempts at ventilation. however, the patient never regained electrical activity and was pronounced deceased at 2:57 a.m. the patient's wife was notified at this time. however, a postmortem examination was declined. condition at discharge: the patient expired on . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Insertion of endotracheal tube Other lysis of peritoneal adhesions Reopening of recent laparotomy site Cardiopulmonary resuscitation, not otherwise specified Incisional hernia repair Anastomosis of hepatic duct to gastrointestinal tract Open biopsy of pancreas Diagnoses: Unspecified essential hypertension Cardiac complications, not elsewhere classified Hemorrhage complicating a procedure Cardiac arrest Malignant neoplasm of head of pancreas Calculus of gallbladder with other cholecystitis, without mention of obstruction Peritoneal adhesions (postoperative) (postinfection) Incisional hernia without mention of obstruction or gangrene 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

history of present illness: this is a 39-year-old woman with diabetes, hypertension, hyperlipidemia and obesity, with a one to two months of chest burning with exertion. for the past six months, she has been participating in a new vigorous exercise program to lose weight. her symptoms do gradually resolve with rest, but they have started to occur now with walking. she does acknowledge that there is associated nausea, diaphoresis and shortness of breath. now recently she started to get symptoms for the past two days while at rest. she was referred for an outpatient exercise tolerance test, where she had chest pain and significant ekg changes. she was referred to for cardiac catheterization today, which revealed significant left main artery disease. just prior to her transfer to , she did complain of chest pain and back pain at about 7/10 intensity and a nitroglycerin drip was started and she received 5 mg of iv lopressor and 2 mg of iv ativan, which did resolve her pain. while she was in the cath lab, she had an intraaortic balloon pump placed, and now she is not actively complaining of any pain. review of systems: she denies any orthopnea, lower extremity edema, but she does acknowledge that she does have dysmenorrhea. prior medical history: she has diabetes mellitus, type 2, diagnosed in . she has been able to control it with diet since ; hypertension and obesity; however, she has lost 40 pounds in the last six months. she has an allergy to shellfish. medications on transfers to : atenolol 50 mg a day, lisinopril 10 mg a day, lipitor 20 mg a day, aspirin 325 mg once a day, progesterone, nitroglycerin drip, lopressor, ativan. social history: she does not smoke. she does not use ethanol and she does not use cocaine. her father had a brain tumor. her brother did have coronary artery disease and a myocardial infarction in his late 30s. her mother has hypertension. she does have a strong family history for hyperlipidemia. physical examination: the patient is comfortable appearing, in no apparent distress. vital signs: temperature 99.1, pulse 72, blood pressure 144/87. pulse oximetry is 98% on room air. head and neck: perrla. eomi. anicteric. mucous membranes moist. neck supple, no lymphadenopathy, no jvd. cardiac: regular rate and rhythm. lungs clear to auscultation bilaterally. abdomen is soft, nontender, nondistended, but she is morbidly obese, positive bowel sounds. her extremities are warm, no edema. she has got 5/5 strength in all extremities. her laboratories prior to admission from were white count 7.4, hematocrit of 39.8, platelets 190,000. hemoglobin a1c was 7.1. sodium was 140, potassium 4.1, chloride 103, bicarbonate 28, bun 14, creatinine 0.6. total cholesterol was 307, triglycerides were 79, and hdl was 50. , which was at (it was not at ), showed diffuse left main and proximal left anterior descending artery stenosis, 60% to 70%, which was ulcerative; 50% mid lad stenosis; 50% left circumflex stenosis after om1; moderate right coronary artery stenosis; a normal ejection fraction of 78%; no mitral regurgitation. note that the right coronary artery stenosis that i am reported is different than what was actually reported on the initial catheterization results from . this was discussed between dr. and dr. , and was not actually considered to be 80% as previously reported. so this was a woman who was considered to have unstable angina but not actively ischemic. she was put on an intraaortic balloon pump, followed in the cardiac care unit, and was "preoped" and consented for a cabg on the next day because of her three-vessel disease. she was made n.p.o. after midnight and then in the morning she was taken to the operating room. on of , ms. went to the operating room with dr. for bypass surgery. please refer to the previously dictated operative note by dr. for the specifics of this surgery. in brief, three grafts were made. one was a left internal mammary to the left anterior descending artery and then two saphenous vein grafts were connected to the om1 and om2. she was on cardiopulmonary bypass for 76 minutes and the aorta was cross clamped for 53 of those minutes. she tolerated the surgery well and was transferred to the intensive care unit on propofol and neo-synephrine drips. postoperatively, ms. did extremely well. her intraaortic balloon pump and all of her intravenous drips were discontinued on postoperative day one. on postoperative day two she was extubated and on postoperative day three she was transferred to the floor. ms. major floor issues were as follows. ms. was followed by physical therapy, which cleared her to go home with home physical therapy to assist with mobility, strength and endurance. she was also actively diuresed with lasix and had her potassium repleted accordingly. finally, she was noted to have hyperglycemia while she resumed her regular diet. consultation was obtained and they recommended metformin 500 mg twice a day to maintain euglycemia. she would follow her sugar as an outpatient and report this back in an outpatient followup appointment. on the patient's central line was discontinued. she was scheduled to leave, but she developed chest pain; however, this chest pain was considered not to be cardiac, to be more gastrointestinal in nature, and she had ......... and an ekg, both of which confirmed a noncardiac source for this chest pain. she is, therefore, on , postoperative day six, being discharged home in good condition with home physical therapy scheduled. final diagnoses: 1. type 2 diabetes mellitus. 2. hypertension. 3. obesity. 4. hyperlipidemia. 5. unstable angina. 6. three-vessel coronary artery disease, status post coronary artery bypass grafting, status post intraaortic balloon pump. 7. hypokalemia. discharge medications: 1. metoprolol 100 mg t.i.d. 2. aspirin 325 mg p.o. q.d. 3. captopril 50 mg p.o. t.i.d. 4. lipitor 20 mg p.o. q.d. 5. lasix 20 mg p.o. b.i.d. for one week. 6. potassium chloride 10 meq p.o. b.i.d. for one week. 7. metformin 500 mg p.o. b.i.d.; follow your blood sugar levels and follow up with . 8. percocet one to two tablets every four hours as needed for pain. 9. colace 100 mg p.o. b.i.d. as needed for constipation. owup appointments are with dr. , her primary care physician, one to two weeks, dr. , her cardiologist, in two to three weeks, dr. from as directed, and dr. in one month. she is also recommended to follow up in wound care clinic in one to two weeks to remove her staples. , m.d. dictated by: medquist36 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 Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

see fhp for detailed pmh and allergies s-"how long will surgerry take?" o-a/o/x/3.very cooperative with care. anxious about surgery and asking many questions. anxious to go home soon. given ambien and sleeping well overnight. cv-hemodynamically stable. hr 60s to 80s, nsr with no vea, iabp 1:1 with map 70s to 110s. poor diastolic and systolic unloading, aumgmentataion good. arriving on nitro at 2.72mcgs/kg/min and heparin at 500u/hr for iabp protection where remains. ptt 44 with goal 50. no adjustment made. intial maps high 110s, and given bb and ace with maps currently, 80s to 90s. right groin site cdi with palpable pulses distal. ck remain flat. k and mg repleted resp:lscta, o2sats on ra 95-97%. denies sob. gu/gi:foley to gravity, draining adequate amounts of cyu, huo 30-120cc/hr. uo down with lower bps. abd soft with (+) bs. taking pos well. npo after mn. id: tm 99.1 and tc 97.6 po. wbc elevated at 16.6. continue to follow. soc: works and lives alone, sister primary contact, very supportive, number in chart. will be in prior to surgery. a/p: 2vd, to surgery 2nd case 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 Implant of pulsation balloon Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

allergies: bactrim / ampicillin / remeron attending: chief complaint: chest pressure/cardiac tamponade/ cardiogenic shock major surgical or invasive procedure: emergent sternotomy for pericardial window history of present illness: underwent min. inv. pfo closure in . had emergent admission on for hypotension, pericardial effusion , pleural effusion and chest pain for several days. did not resolve with pain med and had increasing sob. admitted to er for emergent eval. and bedside tte. started on dopamine drip for hypotension. past medical history: s/p min. inv. closure of patent foramen ovale ; history of stroke/tia; depression; anxiety; borderline hyperlipidemia; herniation of cervical discs; patella-femoral syndrome; s/p bunionectomies social history: denies tobacco. admits to occasional etoh. she is an employee of the in the neuro-pysch department. she is married with two children. she denies ivda and recreational drugs. family history: father underwent cabg at age 72. cousin died of an mi at age 46. physical exam: pt. in distress sbp 70- 80's lungs cta tachycardic, rr, no murmur or rubs palpable pedal pulses pertinent results: 08:40am blood wbc-11.3* rbc-3.62* hgb-9.9* hct-28.8* mcv-80* mch-27.3 mchc-34.3 rdw-14.4 plt ct-413 11:45am blood neuts-86.5* lymphs-7.0* monos-5.2 eos-1.2 baso-0.2 08:40am blood plt ct-413 08:40am blood glucose-118* urean-8 creat-0.6 na-136 k-3.7 cl-102 hco3-24 angap-14 11:45am blood ck(cpk)-26 11:45am blood ck-mb-notdone ctropnt-<0.01 brief hospital course: admitted through er as above and referred to ct for emergent pericardial window/pericardectomy via sternotomy, as the patient was hypotensive.this was performed by dr. on . transferred to csru in stable condition on phenylephrine and propofol drips. extubated and awoke neurologically intact. beta blockade started on pod #1 and transferred out to the floor to start increasing her activity level. mediastinal tubes removed on pod #1. crepitus was noted on anterior chest wall after pleural tubes removed on pod #2. beta blockade also titrated up. crepitus improved and cxr confirmed. she made good progress and was discharged to home with vna services on pod #4. medications on admission: asa 325 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. disp:*60 tablet(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. disp:*30 tablet(s)* refills:*0* 5. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 6. furosemide 20 mg tablet sig: one (1) tablet po once a day for 3 days. disp:*3 tablet(s)* refills:*0* 7. potassium chloride 20 meq packet sig: one (1) packet po once a day for 3 days. disp:*3 packet(s)* refills:*0* 8. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*1* discharge disposition: home with service facility: discharge diagnosis: s/p emergent pericardial window via sternotomy cardiogenic shock/tamponade s/p min inv. pfo closure s/p cva anxiety/depression cervical disc herniation patella-femoral syndrome borderline hyperlipidemia discharge condition: stable discharge instructions: may shower over incision and gently pat dry no lotions, creams or powders on incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness or drainage followup instructions: follow up with dr. (pcp) in weeks follow up with dr. (card)in weeks follow up with dr. in 4 weeks Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Pericardiectomy Diagnoses: Unspecified pleural effusion Depressive disorder, not elsewhere classified Other and unspecified hyperlipidemia Unspecified disease of pericardium Hypotension, unspecified Cardiogenic shock Displacement of cervical intervertebral disc without myelopathy Pain in joint, lower leg

allergies: bactrim / ampicillin / remeron attending: chief complaint: history of stroke major surgical or invasive procedure: minimally invasive closure of patent foramen ovale history of present illness: mrs. is a 47 year old female who suffered a cerebellar stroke in . workup at that time revealed a patent foramen ovale. she is currently followed by dr. (neurologist) from the . full hypercoagulability workup was unremarkable. since , she has had no other neurological events. in preperation for surgical intervention, she underwent cardiac catheterization in which showed normal coronary arteries and normal left ventricular function. past medical history: patent foramen ovale; history of stroke/tia; depression; anxiety; borderline hyperlipidemia; herniation of cervical discs; patella-femoral syndrome; s/p bunionectomies social history: denies tobacco. admits to occasional etoh. she is an employee of the in the neuro-pysch department. she is married with two children. she denies ivda and recreational drugs. family history: father underwent cabg at age 72. cousin died of an mi at age 46. physical exam: vitals: bp 114/68, hr 90, rr 14 general: well developed female in no acute distress heent: oropharynx benign, neck: supple, no jvd, no carotid bruits heart: regular rate, normal s1s2, no murmur or rub lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, no edema, no varicosities pulses: 2+ distally neuro: nonfocal pertinent results: 06:15am blood wbc-6.6# rbc-2.98* hgb-9.1* hct-26.1* mcv-88 mch-30.6 mchc-35.0 rdw-13.1 plt ct-192 06:19pm blood wbc-10.5 rbc-3.42*# hgb-10.5*# hct-30.0* mcv-88 mch-30.8 mchc-35.2* rdw-12.6 plt ct-138* 06:15am blood glucose-121* urean-12 creat-0.7 na-140 k-5.1 cl-106 hco3-28 angap-11 07:21pm blood urean-11 creat-0.8 cl-112* hco3-23 06:15am blood calcium-8.1* phos-3.2 mg-2.0 brief hospital course: mrs. was admitted and underwent surgical closure of her patent foramen ovale. the operation was performed minimally invasive and there were no complications. following the procedure, she was brought to the csru. she initially remained hypotensive, requiring volume and neosynephrine. within 24 hours, she awoke neurologically intact and was extubated without difficulty. by postoperative day two, she successfully weaned from inotropic support. she maintained stable hemodynamics and transferred to the floor. on telemetry, she remained mostly in a normal sinus rhythm with brief periods of accelerated junctional rhythm. she otherwise continued to make clinical improvements and was cleared for discharge on postoperative day four. she remained just on aspirin therapy. aggrenox was not resumed as her pfo was surgically repaired. at discharge, her systolic blood pressures were in the 100's with heart rate of 80-90. her room air saturations were 93% and she was ambulating without difficulty. she had good pain control with dilaudid and all wounds were clean, dry and intact. medications on admission: bupropion 150 , aggrenox qd, centrum, calcium, erythromycin eye gtts discharge medications: 1. bupropion 150 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). disp:*60 tablet sustained release(s)* refills:*2* 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. hydromorphone 2 mg tablet sig: 1-2 tablets po every 6-8 hours as needed. disp:*50 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: patent foramen ovale - s/p surgical closure; history of stroke/tia; depression; anxiety; borderline hyperlipidemia; herniation of cervical discs; patella-femoral syndrome; s/p bunionectomies discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks from the date of surgery. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: cardiac surgeon, dr. in weeks - call for appt, . local pcp, . in weeks - call for appt. local cardiologist, dr. in weeks - call for appt Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Other and unspecified repair of atrial septal defect Diagnoses: Other iatrogenic hypotension Other and unspecified hyperlipidemia Ostium secundum type atrial septal defect Personal history of other diseases of circulatory system

allergies: bactrim attending: addendum: medications on admission: klonopin 3mg po bid lexapro 20mg po daily nortriptyline 50mg po daily crestor 10mg po daily seroquel 50mg po tid trazodone 200mg po qhs:prn insulin, standing and ss medications on discharge: klonopin 3mg po bid lexapro 20mg po daily nortriptyline 50mg po daily crestor 10mg po daily seroquel 50mg po tid trazodone 200mg po qhs:prn ambien 10mg po qhs:prn insulin, standing and ss discharge disposition: extended care facility: md Procedure: Non-invasive mechanical ventilation Electroencephalogram Other psychiatric drug therapy Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Other convulsions Loss of weight Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior Long-term (current) use of insulin Insulins and antidiabetic agents causing adverse effects in therapeutic use Long-term (current) use of other medications Other diseases of pharynx, not elsewhere classified Unspecified sleep apnea Right bundle branch block Family history of psychiatric condition

allergies: bactrim attending: chief complaint: "i'm just so depressed, i can't do anything" major surgical or invasive procedure: none history of present illness: pt reports 3-4 weeks ago he noticed an increase of stress at work and at home at the same time that he was losing weight to gain better control over his diabetes (40lb in weeks). pt reports having increasingly frequent panic attacks which he controlled with klonopin and occassional xanax. he also noticed decrease in sleep, energy, concentration, interest and motivation, and an increase in anhedonia over the past weeks. his psychiatrist began zoloft which after 3-4 days made him jittery and this was switched to celexa which he seems to be tolerating better, although his neurovegetative sx seem to worsen. he denies si but reports fleeting, ego dystonic thoughts of hurting his wife, and has not acted on any of these thoughts. pt reports ruminations concerning whether he is schizophrenic, will have to stay in the hospital forever, or will be on meds forever. pt and wife also report guilt over allowing two children to develop bad sleeping habits such that now children and wife sleep in bed and pt sleeps in chair downstairs. past medical history: - iddm, type ii - osa - borderline htn - hypercholestremia - h/o rbbb past psychiatric history: panic d/o x 20yrs on klonopin x 12 yrs, occassional xanax outpt psychiatry intermittently, until 4 weeks ago when he began to see dr. with significant depression since . of this year pt and wife sought counseling for sleep issue with children x 2 sessions. no assaultive or suicidal behavior social history: substance abuse history: denies alcohol, tobacco or other street drugs. one episode of mj use in . social history: attorney for , division. married to for 11 yrs this children 4yo and 2 yo . denies physical or sexual abuse in past or currently. denies military or legal hx. family history: denies physical exam: mental status exam on admission appearance & facial expression: well-groomed, anxious posture: sitting up in chair behavior (note any abnormal movements): none noted attitude (e.g., cooperative, provocative): cooperative in conversation but somewhat guarded speech (e.g., pressured, slowed, dysarthric, aphasic, etc.): normal flow, articulation and prosody mood: anxious affect (note range, reactivity, appropriateness, etc.): blunted affect with moderate range/reactivity, congruent thought form (e.g., loosened associations, tangentiality, circumstantiality, flight of ideas, etc.): no loa/foi, , circ thought content (e.g., preoccupations, obsessions, delusions, etc.): fears he is schizophrenic because of the thoughts to hurt his wife, distorted thinking regarding work, somewhat paranoid about confidentiality issues and conditions of cv abnormal perceptions (e.g., hallucinations): denied neurovegetative symptoms (e.g., disturbances of sleep, appetite, energy, libido): poor sleep, energy, interest suicidality/homicidality (include ideation, intent, plan): fleeting thoughts as above to hurt wife, denies plan, si insight and judgment: limited cognitive assessment: sensorium (e.g., alert, drowsy, somnolent): alert orientation: x 3 attention (digit span, serial sevens, etc.): not tested memory (short- and long-term): registration and long term intact calculations: not tested fund of knowledge (estimate intelligence): above average proverb interpretation: not tested similarities/analogies: not tested physical exam on admission: vss, exam within normal limits pertinent results: 11:23am %hba1c-6.3*# -done -done 11:15am glucose-255* urea n-11 creat-0.9 sodium-137 potassium-4.1 chloride-100 total co2-28 anion gap-13 11:15am vit b12-271 folate-13.0 11:15am tsh-1.6 11:15am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 11:15am wbc-9.9 rbc-5.07 hgb-14.8 hct-42.0 mcv-83 mch-29.1 mchc-35.2* rdw-13.9 11:15am plt count-217 11:01am urine hours-random 11:01am urine gr hold-hold 11:01am urine color-straw appear-clear sp -1.010 11:01am urine rbc-0-2 wbc- bacteria-mod yeast-none epi-0-2 brief hospital course: somatic interventions: the patient was continued on his outpatient medication regimen of lexapro, nortriptyline, seroquel, klonopin and trazodone. he was also offerred ambien at hs as needed. the patient was admitted for ect and was cleared by medicine and anesthesia. of note, per ect consult, the patient's hs and a.m. doses of klonopin were held for procudure. overnight, prior to transfer, the doc was called in response to the patient being agitated and tremulous reporting "i'm going to die". fingerstick glucose was found to be over 300 - in response, the patient was given 10 units nph and received ativan 2mg im with fair effect. on the morning of transfer, the patient was again found to be tremulous and disoriented, repeating that he felt he was going to die. he was again given ativan 2mg im with minimal effect. fingerstick was checked and found to be 30. in the process of obtaining d50, the patient began to demonstrate myoclonic jerking of arms and legs. code was called when the patient became unresponsive. therapeutic interventions: the patient is followed as an outpatient by dr. who referred him to the inpatient unit for stabilization of his significant depression as well as for evaluation for ect. mr. admitted to significantly low mood since , and endorsed neurovegetative symptoms consistent with an agitated depression. behavioral: the patient remained in good behavioral control for the duration of his admission, requiring only 15 minute checks. legal: the patient signed in under conditional voluntary upon arrival. disposition: the patient was transfered to an icu bed after code was called for unresponsiveness and possible seizure activity. discharge disposition: extended care facility: discharge diagnosis: axis i: mdd axis ii: deferred axis iii: iddm, type ii; osa; borderline htn; h/o rbbb; seizure a/w hypoglycemia discharge condition: mental status exam on discharge: the patient is lying supine in bed, jerking arms and legs, with writhing movements in his trunk. the patient is unresponsive, will not attend to voice etc. unable to make eye contact. unable to assess mood, affect or thought process and content. insight and judgment n/a. discharge instructions: transfer to icu bed followup instructions: - transfer to icu bed - psychiatry c/l service will follow while on medicine Procedure: Non-invasive mechanical ventilation Electroencephalogram Other psychiatric drug therapy Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Other convulsions Loss of weight Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior Long-term (current) use of insulin Insulins and antidiabetic agents causing adverse effects in therapeutic use Long-term (current) use of other medications Other diseases of pharynx, not elsewhere classified Unspecified sleep apnea Right bundle branch block Family history of psychiatric condition

allergies: bactrim attending: chief complaint: depression major surgical or invasive procedure: none history of present illness: 50 yo m w/ type 2 dm, depression who was admitted to deaconness 4 for major depressive episode and possible . while on 4, the patient was given ativan 1 mg x 1. his klonopin was held. he was given normal dose of nph as npo for . the following am, the paitent was found to be shaking. he was given 2 mg ativan and became nonresponsive over the next 20 minutes and a code was called. the patient's fingerstick was 30 so he was given 1 amp of d50. he was also given 4 mg iv ativan. he stopped shaking and mental status cleared in 30 minutes. he was started on a dilantin load. he was seen by neuro who felt that in the setting of hypoglycemia (severe)and withdrawal of his klonopin, he was at risk to have a seizure. past medical history: - iddm, type ii - osa - borderline htn - hypercholestremia - h/o rbbb past psychiatric history: panic d/o x 20yrs on klonopin x 12 yrs, occassional xanax outpt psychiatry intermittently, until 4 weeks ago when he began to see dr. with significant depression since . of this year pt and wife sought counseling for sleep issue with children x 2 sessions. no assaultive or suicidal behavior social history: substance abuse history: denies alcohol, tobacco or other street drugs. one episode of mj use in . social history: attorney for , division. married to for 11 yrs this children 4yo and 2 yo . denies physical or sexual abuse in past or currently. denies military or legal hx. family history: denies physical exam: vs: tm 99.8 hr 87-133 (98) bp 117-166/75-97 rr 17-27 o2 sat - 95-100% ra 2740/2455 gen: nad, sitting in bed heent: perrl, eomi, sclera anicteric, mmm, no op lesions cv: normal s1/s2, rrr, no m/g/r. pul: cta b/l. abd: soft, nt, nd +bs. ext: no edema. neuro: a and ox3, cn 2-12 intact, m ue/le b/l, sensation grossly intact pertinent results: 07:30pm blood wbc-12.8* rbc-4.69 hgb-13.8* hct-39.7* mcv-85 mch-29.5 mchc-34.9 rdw-13.9 plt ct-217 07:30pm blood plt ct-217 07:45am blood glucose-186* urean-12 creat-1.0 na-139 k-3.9 cl-101 hco3-25 angap-17 07:30pm blood ck-mb-1 ctropnt-<0.01 06:14am blood ck-mb-1 ctropnt-<0.01 03:38pm blood phenyto-15.5 11:36am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:44am blood type-art po2-198* pco2-29* ph-7.54* calhco3-26 base xs-3 . eeg this is a normal eeg in the awake and drowsy states. note is incidentally made of a resting tachycardia. brief hospital course: a/p: 50m with history of hypertension, type ii diabetes, originally admitted to psychiatry for , made npo p mn for in am with 1/2 dose of insulin, who was found unresponsive and in apparent seizure state, who was found to have a blood glucose of 30. . 1)convulsions: a code was called and the patient was given ativan 2mg po x1, as well as an amp of d50, loaded with dilantin and transferred to the micu. the seizure was attributed to his hypoglycemic state, although psych thought there was an element of klonopin withdrawal and thus continued to give ativan 0.5mg po q4. pt had frequent bs checks in the micu and patient recovered from his initial event without any post-seizure sequelae. pt continued to be monitored and had no further events. neurology was consulted for his ? seizure event and after a negative exam and negative eeg, concluded that it was all due to hypoglycemia, and that further dilantin would not be necessary. dilantin was d/ced and patient continued to do well. he was eventually transferred to the floor. all home medications were continued and patient continued to express interest in his treatment on monday, although refused to be transferred back to 4. all home medications although his insulin dose (nph 20 qpm) was halved (--> nph 10 qpm) on the floor, and his sugars were running in the 150s-250s range. pt was sent home to return for on monday as an outpatient. explicit instructions were given to take all medications as normal the night before, including his klonopin, and only take dose of nph insulin the night before, npo p mn, no morning nph dose, and to cover his elevated morning sugars with humalog at a conservative sliding scale. goal sugars 150s-250s. 2) type 2 dm - follow sugars closely - continue normal dose insulin while taking pos, and when npo p mn for in am, pt was instructed to take nph dose the evening before, no nph in the am, and to cover with humalog prn according to conservative insulin ss to prevent hypoglycemic episodes. . 3) depression: pt with a h/o refractory depression that was originally admitted to the psych service for . psych consult remained aware as pt was admitted to the micu and then called out to the floors. recommended continuing his klonopin 3mg po bid for his anxiety, and added ativan 0.5mg po q4 for coverage of his anxiety and alleviation of ? withdrawal during periods when he is off the klonopin. continued his home doses of celexa, nortriptyline, seroquel and trazodone for sleep. pt was to be discharged to return on monday for treatments as an outpatient. . 4) f/e/n: -diabetic diet, replete lytes prn . 5) code: full . 6) dispo: medically cleared per micu team as well as pcp. to be discharged to follow up with outpatient on monday. medications on admission: nortriptylline 50mg qd (started a week pta) seroquel 50mg tid klonopin 3mg lexapro 20mg po qd trazadone 200mg qhs crestor 10mg po qd insulin ss + nph 20 qhs lisinopril 10mg po qd discharge medications: 1. nortriptyline 50 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 2. quetiapine 25 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 3. trazodone 100 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). disp:*60 tablet(s)* refills:*2* 4. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 5. rosuvastatin 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lisinopril 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. insulin nph human recomb 100 unit/ml suspension sig: twenty (20) units subcutaneous qam (in the morning) . disp:*qs units* refills:*2* 9. insulin nph human recomb 100 unit/ml suspension sig: five (5) units subcutaneous qhs (at bedtime) for 1 doses. disp:*qs units* refills:*0* 10. insulin nph human recomb 100 unit/ml suspension sig: twenty (20) units subcutaneous at bedtime: please start after treatments tomorrow night . do not use this dose when not eating. disp:*qs units* refills:*2* 11. klonopin 1 mg tablet sig: three (3) tablet po twice a day. disp:*180 tablet(s)* refills:*2* 12. ativan 0.5 mg tablet sig: one (1) tablet po every four (4) hours as needed for anxiety. disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: major depression hypoglycemic seizure . dmii htn discharge condition: afebrile, fs running in high normal range, stable to be discharged home. discharge instructions: 1. please return monday morning to receive your treatment with psychiatry as below. please call for your scheduled time. . 2. for preparations for tomorrow morning: (a) please take nph 5 units tonight, no regular insulin (b) do not take nph morning dose tomorrow. (c) nothing to eat past midnight. (d) take your klonopin 3mg dose tonight. (e) no morning medications prior to including klonopin. (f) have fingersticks checked in morning, and prior to , and give regular insulin based on sliding scale. . 3. please take your other medications as below. . 4. if develop lightheadedness, dizziness, sweating, chest pain, shortness of breath, confusion, or other symptoms, please call dr. (or dr. or report to the nearest er. followup instructions: provider: , clinic where: clinic date/time: 8:00 . provider: , md where: ra (/ complex) hmfp phone: date/time: 9:50 . provider: , md where: ra (/ complex) hmfp phone: date/time: 1:30 md Procedure: Non-invasive mechanical ventilation Electroencephalogram Other psychiatric drug therapy Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Other convulsions Loss of weight Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior Long-term (current) use of insulin Insulins and antidiabetic agents causing adverse effects in therapeutic use Long-term (current) use of other medications Other diseases of pharynx, not elsewhere classified Unspecified sleep apnea Right bundle branch block Family history of psychiatric condition

history of present illness: the patient is a 65-year-old woman status post coronary artery bypass grafting times three on and discharged home on , who the day prior to admission noted increasing redness of her right lower extremity at the saphenectomy site. she denied fevers, chills or leg pain. she had no shortness of breath and otherwise felt well. past medical history: coronary artery disease status post coronary artery bypass grafting. non-insulin-dependent diabetes mellitus. hypertension. arthritis. total abdominal hysterectomy. appendectomy. allergies: zestril. medications: lasix 20 b.i.d., potassium chloride 20 b.i.d., colace 100 b.i.d., aspirin 325 q.d., glipizide 5 q.d., lipitor 20 q.d., valsartan 60 q.d., lopressor 50 b.i.d., percocet p.r.n. physical examination: vital signs: temperature 98.4??????, heart rate 64 in sinus rhythm, blood pressure 156/43, respirations 20, oxygen saturation 98% on room air. general: well appearing in no acute distress. heent: pupils equal, round and reactive to light. extraocular movements intact. anicteric. noninjected. neck: supple. no lymphadenopathy. cardiovascular: regular, rate and rhythm. lungs: clear but with diminished breath sounds at the bases. abdomen: soft and nontender. positive bowel sounds. extremities: dopplerable pulses of both dorsalis pedis and posterior tibial bilaterally. right lower extremity with multiple areas of erythema and warmth. tender to touch along the saphenectomy site with scant serous drainage. laboratory data: white count 14.1, hematocrit 30.5, platelet count 494; sodium 136, potassium 4.9, chloride 101, co2 22, bun 21, creatinine 1.1, glucose 195. the patient at that time underwent a lower extremity ultrasound to rule out deep venous thrombosis. the exam showed no evidence of deep venous thrombosis. hospital course: the patient was admitted to ................... she was begun on vancomycin and levofloxacin for her lower extremity cellulitis. over the next two days, the patient's cellulitis improved. on hospital day #3, it was decided that she was stable and ready for discharge to home. at the time of discharge the patient's physical exam revealed her vitals signs to be stable, afebrile and alert and oriented times three. she moves all extremities. breath sounds were clear to auscultation bilaterally. heart sounds were regular, rate and rhythm. sternal incision is healing well with no erythema or purulence. abdomen soft, nontender and nondistended. extremities with no edema. right lower extremity saphenous vein graft site incision clean and dry with mild surrounding erythema decreased from the previous day with no drainage at this time. discharge medications: lasix 20 mg b.i.d., colace 100 mg b.i.d., aspirin 325 q.d., percocet tab q. p.r.n., glipizide 5 mg b.i.d., lipitor 20 mg q.d., valsartan 160 mg q.d., lopressor 50 mg b.i.d., ciprofloxacin 500 mg p.o. q.12 hours x 10 days. discharge diagnosis: 1. coronary artery disease status post coronary artery bypass grafting times three. 2. non-insulin-dependent diabetes mellitus. 3. hypertension. 4. arthritis. 5. total abdominal hysterectomy. 6. appendectomy. 7. cellulitis of the right lower extremity at saphenous vein graft site. disposition: she is to be discharged to home. follow-up: she is to have follow-up with her primary care physician in two weeks. she is to follow-up with dr. in his office four weeks from the date of her initial discharge from coronary artery bypass grafting; appointment to be made by the patient. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia

history of present illness: this is a 65 year old female with a 20 year history of hypertension and a ten year history of type 2 diabetes who demonstrated a positive exercise stress test in suggestive for possible coronary artery disease. the patient received a stress test as part of a risk stratification workup and at no point demonstrated any evidence of chest pain. a subsequent exercise mibi study performed revealed an exercise capacity of only 2 minutes 15 seconds on the protocol. there was no chest pain noted on the test and the peak exercise electrocardiogram showed 1.5 to 2 mm horizontal to upsloping st depression in the inferior leads and in v1 and v2. imaging studies revealed a large apical to a small anterior defect that was reversible. the patient's ejection fraction was noted to be 56% with normal wall motion. the patient subsequently underwent a cardiac catheterization on which demonstrated three vessel coronary artery disease and mild diastolic ventricular dysfunction. the patient was thereafter referred to dr. for surgical evaluation and was subsequently scheduled for a coronary artery bypass graft on . hospital course: on , the patient underwent a coronary artery bypass graft times three with grafts from the left internal mammary artery to the left anterior descending, saphenous vein graft to the right coronary artery and saphenous vein graft to the obtuse marginal. the patient tolerated the procedure well. the patient's pericardium was left open. lines were placed including an arterial line and a swan-ganz catheter ; both atrial and ventricular wires were placed; tubes placed included in a mediastinal and bilateral pleural tubes. the patient was subsequently transferred to the cardiac surgery recovery unit, intubated, for further evaluation and management. shortly after arriving in the cardiac surgery recovery unit, the patient was easily weaned and extubated without complication. on postoperative day #1, the patient was noted to be stable for transfer to the floor and was subsequently admitted to the cardiothoracic service under the direction of dr. . the patient's postoperative course was uneventful and she progressed well clinically. on postoperative day #1, the patient's chest tube and foley catheter were successfully removed without complications. follow up chest x-ray demonstrated no evidence of pneumothorax, and the patient was noted to be independently productive of adequate amounts of urine for the duration of her stay. physical therapy performed an initial evaluation with the patient and followed her progress for the duration of her stay. on postoperative day #3, the patient's pacer wires were removed without complications and her sternal incision was noted to be clean, dry and intact with steri-strips in place. the patient was successfully advanced to a regular diet, which she tolerated well and was noted to have adequate pain control via oral pain medications. the patient steadily advanced in her ability to ambulate freely and was subsequently cleared for discharge to home by physical therapy. the patient was subsequently cleared for discharge to home on postoperative day #4, , with instructions for follow up. condition on discharge: the patient is to be discharged to home with instructions for follow up. discharge status: stable. discharge medications: 1. lasix 20 mg p.o. q.12 hours times ten days 2. potassium chloride 20 meq p.o. q. 12 hours times ten days 3. colace 100 mg p.o. b.i.d. 4. enteric coated aspirin 325 mg p.o. q.d. 5. percocet 1 to 2 tablets p.o. q. 4-6 hours prn for pain 6. glipizide 5 mg p.o. q.d. 7. lipitor 20 mg p.o. q.d. 8. valsartan 160 mg p.o. q.d. 9. lopressor 50 mg p.o. b.i.d. discharge instructions: the patient is to maintain her incisions clean and dry at all times. the patient may shower but she is to pat dry the incisions afterwards; no bathing or swimming. the patient may resume a regular diet. the patient has been advised to limited physical activity; no heavy exertion. no driving while taking prescription pain medications. the patient has been advised to follow up with her primary care provider within one to two weeks following discharge. the patient is to follow up with dr. within four weeks following discharge; the patient is to call to schedule an appointment. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of two coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other and unspecified hyperlipidemia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, dyspnea major surgical or invasive procedure: cardiac catheterization with placement of three stents and iabp. swan catheter placement. history of present illness: history of present illness: 87 yo m with chronic kidney disease s/p av graft placement , stroke, hypertension, diabetes, and peripheral vascular disease presents with chest pain and shortness of breath. he reports that his chest pain began approximately one week ago. during the week it has gotten worse. it is substernal, radiating to left shoulder, especially with inspiration. it is associated with shortness of breath. he came to the hospital today because the pain was much worse, . in addition, he noted today black stools. he has been taking iron. he reports lightheadedness. denies nausea, vomiting, diaphoresis, arm paresthesias. he has also noticed a cough recently but has not been able to produce sputum (though he feels congested). . the pt was seen in geriatric urgent care clinic on for dyspnea. he noted worsening in the supine position. an cxr at the time to evaluate possible chf showed "no evidence of congestive heart failure or pneumonia. elevation of the right hemidiaphragm". . in the ed, the patient was given 80mg iv lasix x 2 with uop of 100-200cc. he received nitropaste, lopressor iv and , , and morphine, and was started on a nitro gtt. heparin was started as well, and 1 unit prbcs was transfused. he was given one dose of protonix, levofloxacin and . bps were in the 110s-120s/50s-60s, hr 70s-80s. renal, gi, and cardiology consults were called. the patient continued to report pain, eventually decreased to with titration of the nitro gtt. on arrival in the ccu, he still reported pain. he was on nitro at 120 mcg/min and heparin at 850 units/hr. . past medical history: past medical history: 1. esrd secondary to hypertensive nephrosclerosis s/p right upper extremity av graft 9'' in preparation for dialysis. graft placement was complicated by cellulitis, for which he was treated with keflex 2. dm, on glyburide and glipizide at home 3. htn, on clonidine, lisinopril, nifedipine 4. pvd s/p aortic bypass 5. cva, with residual weakness of his left side 6. r cea 7. secondary hyperparathyroidism 8. chronic anemia on procrit injections 9. prostate ca on lupron 10. gout social history: social history: lives at a senior facility in . has help with cleaning, other chores. denies alcohol and tobacco. family history: coronary artery disease physical exam: physical examination: vs: t 97.2, hr 75, bp 112/55, rr 28, sao2 97%/4l o2 nc heent: ncat, perrl, eomi, dry mucous membranes, op clear neck: jvp elevated approx 4cm above sternal notch cv: rrr, nl s1, s2, no murmurs, rubs, gallops pulm: diffusely decreased bs on r. bibasilar crackles. abd: soft, nontender, nondistended, bs+ ext: warm and dry, 1+ pitting edema, 1+ bilateral pulses in pt neuro: alert and oriented, cn iii-xii intact, moves all extremities (strength not tested) pertinent results: ekg: nsr at 80bpm, axis in nl quadrant, qrs borderline, q waves in v1-v3, st depressions in i, ii, avl, v4-6, ste in v1-3, biphasic tw in v4-6. . cxr : interval development of perihilar patchy opacities consistent with left ventricular heart failure. cxr 8pm: read pending . cath comments: 1. right heart catheterization revealed elevated right and left sided pressures. (pcwp = 25 mmhg). 2. left heart catheterization revealed no evidence of systolic hypertension. calculated cardiac output and index were 5.0/2.8. 3. selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. the left main coronary artery had a 40% mid-vessel stenosis. the left anterior descending artery had diffuse proximal disease with serial 70-80% stenosis. the left anterior descending had mild diffuse disease in the mid and distal segments. the large first diagonal had an 80% proximal lesion. the left circumflex coronary artery had mild diffuse disease in the proximal, mid, and distal segments. there was a subtotal occlusion of the om1. the right coronary artery was the dominant vessel. there was total occlusion of the right coronary artery in the proximal segment. the distal rca filled via collaterals from the lca septal branches. 4. no left ventriculography was undertaken given elevated cr. 5. successful predilation using 2.0 x 12 sprinter balloon and stenting using a minivision 2.5 x 23 stent of the proximal om1 with lesion reduction from 99 to 0% 6. successful predilaton using a 2.0 x 20 maverick balloon and stenting using 3.0 x 30 driver stent of the proximal lad with lesion reduction from 80% to 0%. 7. successful predilation using 2.0 x 12 sprinter balloon and stenting using a 2.25 x 15 minivision stent of the proximal d1 with lesion reduction from 80% to 0%. the final angiogram showed timi iii flow in the vessels intervened with no residual stenoses in any of the stents. thre was no distal embolisation or dissection noted in any vessel. 8. successful insertion of iabp via right femoral artery. ( see ptca comments for the above procdures from 5 through to 8) 9. at the request of the renal consultants, a 12 french dialysis central venous catheter was placed using the seldinger technique in the left common femoral vein. final diagnosis: 1. three vessel coronary artery disease. 2. elevated right and left sided pressures. 3. preserved cardiac output/cardiac index. 4. successful stenting of the om, lad and d1. 5. successful insertion of iabp via right femoral artery. 6. successful implantation of a central venous dialysis catheter in the left femoral vein. urine culture (final ): albicans, presumptive identification. >100,000 organisms/ml.. identification being performed on cult# 196-9912c as requested by dr. on .. brief hospital course: 1. rhythm: pt had 2 episodes of monomorphic vt accompanied by fall in bp, loc, terminated x 1 via precordial thumb. electrolytes were repeleted, pt was bolused with amiodarone x 2, and started on an amio gtt. amiodarone was then changed to po, with a dosing schedule of 400 mg for one week, followed by 400 mg daily for one week, then 200 mg per day. monomorphic vt thought to be likely due to a fixed area of scarring from previous mi. placement of an icd was discussed. however, given the pt's poor prognosis for non sudden cardiac death reasons, and given his increased infectious risk, it was decided to treat his arrhythmia medically. of note, the qt interval was prolonged (506), likely secondary to amiodarone. patient remained in sinus rhythm on amiodarone. 2. cad: pt with nstemi. cath on showed 3 vessel disease, subsequently underwent successful stenting of om, d1, lad and iabp placement. iabp was discontinued after the patient was able to maintain his own pressure. echo completed on , which showed apical akinesis, with severely depressed systolic function. patient was initially started on heparin and bridged to coumadin, however, he had another episode of guaiac positive stool, and given his history of melena and coffee ground emesis, the risk for gi bleed was thought to be high and anticoagulation was discontinued. the patient was continued on an aspirin, statin, beta blocker, and was started on an ace, all of which he will continue as an outpatient. his swan and sheath were discontinued without complications. 3.pump: chf: ef 20% by echo he was initially placed on imdur/hydral for afterload reduction and an ace was initially avoided in an attempt to salvage his kidneys. however, he was eventually started on low-dose lisinopril to be titrated up if necessary. patient also underwent hemodialysis on mon/wed/fri schedule. 4. renal: chronic renal disease, secondary to hypertensive nephrosclerosis, is status post graft placement with mature a-v graft. quentin catheter initially used, then discontinued once graft accessible. on , graft noted to be difficult to access per renal, patient underwent av fistulogram, and successful angioplasty was performed. 5. id: patient completed a seven day course of levofloxacin for suspected pneumonia, white blood count noted to be persistently elevated. patient was pan cultured, and a urine culture was positive for yeast. foley catheter was discontinued and a repeat culture was sent, also positive for . patient started on a 2 week course of fluconazole. blood cultures pending at time of discharge, no growth to date. 6. heme: anemia, likely anemia of chronic disease from chronic renal disease. patient also had an episode of melena and coffee ground emesis, guaiac positive stool. hematocrit was followed, and patient was transfused as necessary to keep hematocrit above 30. patient will need gi workup as an outpatient. oral iron supplementation was discontinued as patient receiving fe in addition to epo and procrit at hemodialysis 7. dm: patient was started on glargine for persistent hyperglycemia and covered with a regular insulin sliding scale with accu-check to monitor. 8. psych: patient was continued on his home dose of zoloft 100 mg once daily. patient tolerated a low na/cardiac healthy diet and was placed on a ppi for gi prophylaxis. patient was discharged to rehab facility with plan to follow up with cardiology and pcp within the next month. medications on admission: . nifedipine xl 60 mg daily 2. calcitriol 0.25 mcg dialy 3. lisinopril 2.5 mg once daily 4. aspirin 325 mg once daily 5. lasix 40 mg once daily 6. glyburide 10 once daily recently changed to glipizide 7. clonidine 0.2mg 8. zoloft 100mg daily 9. simvastatin 40mg daily 10. tums one tablet tid 11. procrit injections 16,000 units q. week. 12. lupron injections at heme/ clinic 13. niferex 150 mg daily (supplemental iron). discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. sertraline 100 mg tablet sig: one (1) tablet po daily (daily). 4. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 5. white petrolatum-mineral oil cream sig: one (1) appl topical (2 times a day) as needed. 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 30 days. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 9. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 10. amiodarone 200 mg tablet sig: two (2) tablet po bid (2 times a day): please continue to take twice a day for the next two days. please begin taking 400mg once a day on , and continue for one week. then please take 200mg once a day. 11. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 12. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 14 days. 13. lisinopril 2.5 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: acute coronary syndrome congestive heart failure chronic renal disease urinary tract infection discharge condition: good- patient hemodynamically stable and afebrile, heart rate and rhythm has been well controlled. discharge instructions: we have started you on a new medication to help control your heart rhythm, and a new medication to help control your blood pressure. in addition, we have started you on a medication to help treat a urinary tract infection. please take these and all of your medications as instructed. please maintain all of your follow-up appointments. please return to the hospital if you develop chest pain, shortness of breath, fevers, or chills. followup instructions: provider: , md phone: date/time: 2:30 provider: , m.d. date/time: 10:00 provider: , m.d. phone: date/time: 10:00 you have an appointment scheduled with dr. at the campus on at 10am. please arrive at 9:45am to register. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Hemodialysis Angioplasty of other non-coronary vessel(s) Venous catheterization for renal dialysis Implant of pulsation balloon Transfusion of packed cells Nonoperative removal of heart assist system Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Insertion of three vascular stents Destruction of cranial and peripheral nerves Procedure on three vessels Diagnoses: Anemia in chronic kidney disease Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Candidiasis of other urogenital sites Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Paroxysmal ventricular tachycardia Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Pneumonitis due to inhalation of food or vomitus Cardiogenic shock Blood in stool Compression of vein Other late effects of cerebrovascular disease

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from nursing home for fever and elevated white count major surgical or invasive procedure: none history of present illness: 87 yo m with pmh of dm, cad, esrd on hd who was transferred from rehab to ed for eval of fever. . per referal note, patient 2 days ago developed increase leukocytosis and delirim. apparently, he was started on iv vancomycin, flagyl and ceftazidime for pna. on day of admission patient developed a fever to 101.2, pulse 76 bp 102/68r 18 and sat 92%. blood cx and urine cx were drawn. . of note he was recently operated on by vascular for a r sup femoral and angioplasty and stenting along with left femoral patch angioplasty with bovine patch. he was discharged home on levoflox for probable rll pna . in the ed, vs 100.8 hr 85 bp 81/28 rr 20 sats 95%. a femoral line was placed and he was given 1000 cc ns. given pooor response, and after cvp measure 12, patient was started on levophed and transfer to . past medical history: past medical history: 1. esrd secondary to hypertensive nephrosclerosis s/p right upper extremity av graft 9'' in preparation for dialysis. graft placement was complicated by cellulitis, for which he was treated with keflex 2. dm, on glyburide and glipizide at home 3. htn, on clonidine, lisinopril, nifedipine 4. pvd s/p aortic bypass 5. cva, with residual weakness of his left side 6. r cea 7. secondary hyperparathyroidism 8. chronic anemia on procrit injections 9. prostate ca on lupron 10. gout social history: denies past or present tob, etoh, or illicit drug use. was living at a senior facility in with his wife prior to last admission. now at rehab. family history: nc physical exam: t 99.7 bp 114/60 hr 78 rr sats 98% 4 l nc general: patient in mild apparent distress, alert, responding to questions heent: dry oral mucose, no lad, jvd lungs: crackles bilaterally cv: regular heart sounds, soft holosystolic murmur rlsb back: sacral ulcers abdomen: bs +, soft, non tender non distended extremities: cold, distal pulses decreased, heel ulcers bilaterally, necrotic. 3-4th underneath nail toe right foot black. ru extremiti avf , no trhill, no erythema. left upper extremity- picc line right femoral line in place neuro: patient alert, oriented to person, movilizing grossly all extremities. pertinent results: 07:18pm lactate-1.6 07:05pm glucose-200* urea n-49* creat-4.2*# sodium-137 potassium-3.8 chloride-99 total co2-23 anion gap-19 07:05pm cortisol-19.5 07:05pm wbc-30.5*# rbc-3.05* hgb-9.1* hct-29.6* mcv-97 mch-29.8 mchc-30.7* rdw-16.9* 07:05pm neuts-89* bands-1 lymphs-5* monos-5 eos-0 basos-0 atyps-0 metas-0 myelos-0 07:05pm hypochrom-2+ anisocyt-1+ poikilocy-1+ macrocyt-normal microcyt-normal polychrom-1+ 07:05pm plt smr-normal plt count-275 07:05pm pt-18.1* ptt-31.7 inr(pt)-1.7* brief hospital course: assessment and plan: 87 yo m with mmp including dm, htn, cad, pvd on hd with l arm fistula presents with septic shock. . 1. sepsis: the pt was found to be hypotensive and febrile in the ed and admitted through sepsis protocol. he was infused with muliple boluses of normal saline, put on levophed for blood pressure support. he was covered with broad spectrum antibiotic empirically as culture data was sent. blood cultures were found to be positive for gram postive cocci which was ultimately shown to be vre. vancomycin was changed to linezolid. the pt remained hypotensive on pressors for the next several days and a work-up was initiated to determine the source of infection. mri of the foot was pursued to r/o osteomyelitis, and a ct of the abdomen was down to r/o an abdominal source of infection. the ct abdomen and pelvis showed possible abscess in liver and spleen. there was also pancolitis. gi and surgery were for assistance in the management of these problems. for the pancolitis, the pt was kept npo and he was treated for possible c. diff infection while c. diff cultures were sent and found to be positive. a ruq u/s was pursued which showed evidence of hypoechoic lesion could be flegmon or mass. it was unable to be confirmed on imaging whether these lesions on ct which were new compared with a previous scan in were abscesses vs possible mets from an unknown primary. ir was for possible drainage or biopsy, however option declined given localization of lesions and the pts significant bleeding risk. the gi team suggested an mri to further evaluate the liver lesions although this was unable to be pursued because the pt was too unstable requiring pressors for bp support. a tte echo was done to r/o endocarditis or abscess and was negative. head ct was negative for abscess as well. . 2. cmo: on the morning of , the icu team discussed with mr wife and daughter the different alternatives for mr care. it was explained that the feeling of the medical staff and nurse staff was that mr has been extremily uncomfortable with all the procedures that he undergoes during the day. despite giving pain medicines he has shown signs of a lot of discomfort. we explained to the family that we would need a ngt place in order to feed him and give him some of his medicines now that he is having trouble swallowing given his mental status. also we have explained that we still not have a clear dx on his liver lesions, and in order to obtained a dx he might need a surgical intervention for biopsy. it would be a long road ahead before he is able to go back to where he was previously. ms feels that her husband would not want to have all this procedures done along the road and that we should change the focus of care towards making him as comfortable as possible. the antibiotics and pressors were d/c'ed. the plan was to have no more dialysis. there were no more lab draws. a morphine drip was started for pain. the pt remained arousable though sleepy. his blood pressure was in the 80s-90s systolic off pressors and his extremities continued to show evidence of perfusion. on the evening of , he skin became more pale and his sensorium less alert. at 2:08 am he was found to have ceased respirations and was without a heart rate on the monitor. by 2:15 am he was pronounced deceased. . 2. cad: h/o mi. continued sinvastatin, aspirin until made cmo. bb and bp medications were held in the setting of hypotension . 3. peripheral vascular disease: continued plavix, aspirin until cmo the vascular team followed the pt. . 4. dm: insulin sliding scale was continued before the pt was made cmo. . #. esrd: the pt continued to recieve periodic dialysis sessions while in house until he was made cmo. . #. fen: he was kept npo given the colitis and sepsis. . # hypothyroidism: continued levothyroxine until cmo. . # ppx: pantoprazole, pneumoboots until cmo. . #code: dnr-dni was changed to cmo on . # communication: next of , wife, medications on admission: 1. clopidogrel 75 mg qday 2. docusate sodium 100 mg 3. epoetin alfa injection 4. sertraline 100 mg daily 5. fexofenadine 60 mg 6. amiodarone 200 mg qd 7. aspirin 325 mg qday 8. insulin glargine 10u/hs. 9. lisinopril 5 mg day 10. multivitamin daily. 11. oxycodone 5 mg q4h-6h 12. pantoprazole 40 mg /day 13. senna 8.6 mg 14. levothyroxine 50 mcg /daily 15. metoprolol succinate 25 mg sustain release 16. simvastatin 40 mg /daily discharge medications: none discharge disposition: expired discharge diagnosis: gram positive vre sepsis discharge condition: deceased discharge instructions: none followup instructions: none md Procedure: Hemodialysis Systemic arterial pressure monitoring Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Other postoperative infection Unspecified pleural effusion Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Severe sepsis Unspecified acquired hypothyroidism Gout, unspecified Atrial fibrillation Peripheral vascular disease, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other late effects of cerebrovascular disease Other specified septicemias Septic shock Pressure ulcer, other site Cellulitis and abscess of upper arm and forearm Intestinal infection due to Clostridium difficile Abscess of liver Infection with microorganisms without mention of resistance to multiple drugs Malignant neoplasm of prostate Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

history of present illness: the patient is a 64-year-old female with a history of hypertension, depression, prior suicide attempt by overdose, recently with exacerbated mood disorder status post the death of her husband in , now presented after being found unresponsive. the patient's daughters found her in the morning of the day of presentation, unresponsive with empty bottles of ambien and zyprexa at the bedside. pill count revealed that the patient had likely taken 26 ambien and 12 zyprexa. the patient has been unable to be alone secondary to depression with suicidal ideation, and has been living with her daughters. they note that the patient went to bed at 11 p.m. the night prior to admission and was found at 11 a.m. unresponsive with respiratory depression. the patient had seen her primary psychiatrist the day before. in the emergency department, the patient was charcoaled, gastric lavaged, and intubated for airway protection. she was hemodynamically stable. she was transferred to the intensive care unit. in the intensive care unit, the patient was able to open her eyes, and was moving all four extremities and responsive to command. past medical history: 1. hypertension 2. depression with suicide attempt ten years ago by overdose. the patient was hospitalized for two weeks at that point. the patient's outpatient psychiatrist is dr. . allergies: no known drug allergies. medications: zyprexa 2.5 mg by mouth daily at bedtime, zestril 20 mg by mouth once daily, ambien 10 mg by mouth daily at bedtime, estradiol 1 mg by mouth once daily, nortriptyline 25 mg by mouth daily at bedtime, klonopin 0.5 to 1 mg daily at bedtime, biotin and calcium supplementation. social history: the patient lives with her daughter. husband died in . the patient denied any tobacco, alcohol or drug use. family history: unknown. physical examination: the patient's temperature was 97.7, with a blood pressure of 130/65, pulse of 84, respiratory rate of 14, and oxygen saturation of 100%. the patient was ventilated on imv pressure support with a rate of 14, pressure support of 10, peep of 7.5, volume of 500, and 40% fio2. on general examination, the patient was a very ill-appearing female, in no apparent distress. she was intubated. head, eyes, ears, nose and throat examination revealed 1 to 2 mm nonreactive pupils. neck examination revealed no jugular venous distention and no bruits. cardiac examination revealed a regular rate and rhythm, normal s1 and s2, and no murmurs, gallops or rubs. pulmonary examination revealed that the lungs were clear to auscultation bilaterally. abdominal examination revealed a belly that was soft, nontender, nondistended, with normal bowel sounds. extremity examination revealed no edema, with 2+ dorsalis pedis pulses bilaterally. neurological examination revealed a patient that was moving all four extremities, opening eyes intermittently, withdrawing to pain. the patient had 2+ deep tendon reflexes, and downgoing plantar reflexes. laboratory data: the patient had a white blood cell count of 5.1, hematocrit of 35.9, platelets of 259. the patient had a sodium of 140, potassium of 4.4, chloride of 103, bicarbonate of 28, bun of 17, creatinine of 0.6, and glucose of 102. the patient's inr was 1.1. the patient had an alt of 19, an ast of 26. arterial blood gas was performed post-intubation and was found to be ph of 7.47, paco2 of 29, and pao2 of 287. electrocardiogram: normal sinus rhythm at 80, with normal axis, and intervals, and st elevations in v2 and lead i. other studies: urine toxicology was negative, serum toxicology was negative. urinalysis revealed negative nitrates, leukocytes, blood, no red blood cells, no white blood cells, occasional bacteria, and less than one epithelial cell. head ct: no signs of intracranial hemorrhage or mass effect. hospital course: the patient is a 64-year-old female with a history of hypertension and depression with suicidal ideation and previous history of overdose attempt, status post likely overdose on ambien and zyprexa, status post intubation and hemodynamically stable. 1. toxicology: patient with likely ambien overdose and zyprexa overdose. her symptoms of light coma, somnolence and respiratory compromise were consistent with ambien overdose. the patient also had evidence of myosis, which was consistent with zyprexa overdose. the patient had been gastric lavaged, charcoaled and supported in the emergency department. in the intensive care unit, the patient was supported with intravenous fluids and gradually weaned on the ventilator to the point where she was successfully extubated shortly after arriving to the intensive care unit. 2. psychiatric: patient with major depression, recently exacerbated by the loss of her husband, now with a second overdose attempt in her lifetime. likely zyprexa and ambien were the agents responsible. multiple attempts were made in the effort to contact the patient's outpatient psychiatrist, dr. . she was unable to be reached. psychiatry was consulted, who felt that the patient needed inpatient evaluation and treatment. they also recommended psychotropics be avoided, and that the patient have a one-to-one sitter. social work and case management were consulted. 3. cardiovascular: patient was hemodynamically stable with history of hypertension. her antihypertensives were held. her electrocardiogram was unremarkable, although there were no studies for comparison. 4. pulmonary: patient intubated secondary to decreased mental status without a primary lung process. post-extubation arterial blood gas did not suggest any obstructive lung process leading to hypercarbia or hypoxemia from other pulmonary process. the examination was unremarkable. a facile extubation was anticipated, and the patient was extubated within several hours of arriving in the intensive care unit. 5. psychosocial: communication was maintained with the patient's daughters, who also felt that the patient should receive inpatient evaluation and treatment. condition on discharge: stable. discharge status: the patient was discharged to an inpatient psychiatric bed. discharge medications: zestril 20 mg by mouth once daily, estradiol 1 mg by mouth once daily. discharge diagnosis: 1. major depression 2. ambien and zyprexa overdose 3. hypertension , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other irrigation of (naso-)gastric tube Diagnoses: Unspecified essential hypertension Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents Poisoning by other sedatives and hypnotics Poisoning by other antipsychotics, neuroleptics, and major tranquilizers Suicide and self-inflicted poisoning by other sedatives and hypnotics Major depressive affective disorder, single episode, unspecified

allergies: morphine attending: chief complaint: seizures major surgical or invasive procedure: : left craniotomy for mass resection history of present illness: mr. is a 75yo rhm with cad s/p cabg, as, htn, hyperlipidemia, now here for resection of parasagittal meningioma. pt first noted symptoms three years ago with dizziness, was evaluated in where a head ct revealed l frontal extraxial mass (~2cm per pt). seen by a neurosurgeon in and told watchful waiting was best. however 6 weeks ago the patient had an episode where his right lower extremity "gave way." occasionally "feels like wood." he underwent mri scan which revealed enlargement of the mass, with descriptions from records documenting 2.5x3.4x2cm l frontal lobe extraaxial mass, and also a much smaller 12mmx8mmx4mm mass in the r temporal lobe (per report). he was started on decadron 1mg . pt was scheduled for resection with dr. . however last night he was moving furniture, and upon moving a bureau back into his home he developed a sensation of numbness at his foot that travelled to his upper thigh over the course of only a few seconds. he then noted rhythmic low amplitude shaking of the limb that was not suppressable. his right arm then extended outwards beyond his volitional control. his wife took him to where he was given ativan iv, loaded with fosphenytoin 1,000mg iv. the movements subsided in about 15 minutes. no loss of consciousness. no speech/language deficits. no visual loss. he reports no further episodes since. currently feeling well. denies any headaches. he does still feel a loss of sensation in a stocking distribution of his right foot to his ankle. when he walks he feels like he does not have command over his right leg. no bowel or bladder dysfunction. past medical history: pmhx: cad- cabg x 4 () here at htn as- no syncopal symptoms. hypercholesterolemia past surgical hx: appendectomy bilateral inguinal hernia repair anal fissure repair cholecystectomy tonsillectomy and adenoidectomy social history: social hx: married, retired electrical equipment designer with three years of engineering training, korean war veteran, currently smokes pipe tobacco x last 55yrs, smoked cigarettes during the war but none since, rare social etoh use. no illicits. family history: family hx: mother- d. 93, cad father- d. 73, parkinson's disease, cad brother- d. 73, had hemo physical exam: on admission: physical exam: o: t: 97.3 bp: 118/70 hr: 71 r: 20 o2sats: 96% ra gen: wd/wn, comfortable, nad. heent: pupils: eoms neck: supple. lungs: cta bilaterally. cardiac: rrr. crescendo-decrescendo murmur best at rusb radiates throughout precordium and abdomen. 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. recall: objects at 5 minutes. 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, 5 to 3 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally with sustained nystagmus at lateral end-gaze. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power throughout. no pronator drift sensation: reduced to lt only on right foot in stocking distribution to the ankle. otherwise intact to light touch, propioception, pinprick and vibration bilaterally. reflexes: b t br pa ac right 2------> - left 2------> - toes mute bilaterally coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin gait: good initiation, wide based, discoordinated stride with right lower extremity, leans to the right. absent romberg. pertinent results: labs on admission: 04:55am blood wbc-10.9 rbc-4.29* hgb-13.4* hct-38.9* mcv-91 mch-31.3 mchc-34.6 rdw-14.4 plt ct-216 04:55am blood neuts-88.7* lymphs-7.0* monos-3.6 eos-0.3 baso-0.3 04:55am blood pt-11.9 ptt-26.6 inr(pt)-1.0 04:55am blood glucose-141* urean-16 creat-0.7 na-140 k-4.2 cl-104 hco3-27 angap-13 04:55am blood alt-26 ast-21 alkphos-68 totbili-0.8 04:55am blood albumin-4.1 calcium-8.9 phos-3.0 mg-2.1 ------------------- imaging: ------------------- mri head : findings: limited post-contrast mri of the brain demonstrates an enhancing left parafalcine lesion measuring approximately 2.1 x 3.3 x 3.5 cm. this lesion is in close proximity to the adjacent sagittal sinus although it does not appear to be involving the sinus. no other abnormal enhancing lesions are identified. there is minimal surrounding edema and no significant mass effect. impression: dural-based enhancing lesion arising from the left parafalcine region with minimal mass effect and small amount of surrounding edema. this likely represents a meningioma. mri head (post-op): findings: since the previous study, the patient has undergone resection of left parietal parafalcine extra-axial mass. blood products are seen in the region with edema. air is seen intracranially. bilateral small subdural collections are seen. these findings are indicative of post-operative change.no acute infarct seen. no midline shift or hydrocephalus identified. no residual nodular enhancement is identified. impression: 1. status post resection of left parietal parafalcine mass with expected post-surgical changes of blood products and air in the region and intracranial air and bilateral small subdural collections. no acute infarct, mass effect, or hydrocephalus. no residual nodular enhancement seen. eeg : background: a 9 hz posterior predominant rhythm was seen in the brief waking state. hyperventilation: could not be performed. intermittent photic stimulation: produced no activation of the record. sleep: the patient progressed from wakefulness to drowsiness but did not attain stage ii sleep. cardiac monitor: showed a generally regular rhythm with an average rate of 60 bpm. impression: this is a normal predominantly drowsy routine eeg in the waking and drowsy states. there were no focal lateralize or epileptiform features. brief hospital course: patient was admitted to the neurosurgical service on following an episode of seizure. the patient underwent resection of the left para-sagittal mass on . he tolerated this procedure well and remained neurologically unchanged post-resection. he was taken to the icu post-operatively for close monitoring on pod0. on pod#1, he was transferred to the neurosurgical floor. he was subsequently seen and evaluated by pt and ot and was cleared for discharge home. medications on admission: aspirin 81mg daily (currently held) tylenol prn decadron 1mg amlodipine 5mg daily lisinopril 40mg daily simvastatin 40mg daily synthroid 50mcg daily decadron 2mg q6hrs dilantin 100mg po tid nexium 40mg daily metoprolol 25mg discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 6. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 7. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*0* 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*30 capsule(s)* refills:*0* 9. dexamethasone 2 mg tablet sig: one (1) tablet po q6h (every 6 hours) for 3 days. disp:*12 tablet(s)* refills:*0* 10. dexamethasone 2 mg tablet sig: one (1) tablet po bid (2 times a day) for 3 days. disp:*6 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: left parasagital brain mass discharge condition: neurologically stable discharge instructions: general instructions wound care: ?????? you or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? keep your incision clean and dry, you may shower from the neck down. you will not need to have sutures removed, as dr. has used dissolvable sutures. ?????? do not apply any lotions, ointments or other products to your incision. ?????? do not drive until you are seen at the first follow up appointment. ?????? do not lift objects over 10 pounds until approved by your physician. diet usually no special diet is prescribed after a craniotomy. a normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. medications: ?????? take all of your medications as ordered. you do not have to take pain medication unless it is needed. it is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? do not use alcohol while taking pain medication. ?????? medications that may be prescribed include: -narcotic pain medication such as dilaudid (hydromorphone). -an over the counter stool softener for constipation (colace or docusate). if you become constipated, try products such as dulcolax, milk of magnesia, first, and then magnesium citrate or fleets enema if needed). often times, pain medication and anesthesia can cause constipation. ?????? you have been discharged on keppra (levetiracetam), you will not require blood work monitoring. ?????? you were on aspirin, prior to your surgery. you may restart this one week after your surgery. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc, as this can increase your chances of bleeding. ?????? you are being sent home on steroid medication taper, make sure you are taking a medication to protect your stomach (prilosec, protonix, or pepcid), as these medications can cause stomach irritation. make sure to take your steroid medication with meals, or a glass of milk. activity: the first few weeks after you are discharged you may feel tired or fatigued. this is normal. you should become a little stronger every day. activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. in general: ?????? follow the activity instructions given to you by your doctor and therapist. ?????? increase your activity slowly; do not do too much because you are feeling good. ?????? you may resume sexual activity as your tolerance allows. ?????? if you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? do not drive until you speak with your physician. ?????? do not lift objects over 10 pounds until approved by your physician. ?????? avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? do your breathing exercises every two hours. ?????? use your incentive spirometer 10 times every hour, that you are awake. when to call your surgeon: with any surgery there are risks of complications. although your surgery is over, there is the possibility of some of these complications developing. these complications include: infection, blood clots, or neurological changes. call your physician immediately if you experience: ?????? confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? double, or blurred vision. loss of vision, either partial or total. ?????? hallucinations ?????? numbness, tingling, or weakness in your extremities or face. ?????? stiff neck, and/or a fever of 101.5f or more. ?????? severe sensitivity to light. (photophobia) ?????? severe headache or change in headache. ?????? seizure ?????? problems controlling your bowels or bladder. ?????? productive cough with yellow or green sputum. ?????? swelling, redness, or tenderness in your calf or thigh. call 911 or go to the nearest emergency room if you experience: ?????? sudden difficulty in breathing. ?????? new onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? a seizure that lasts more than 5 minutes. important instructions regarding emergencies and after-hour calls ?????? if you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. followup instructions: follow up appointment instructions ??????please return to the office in days (from your date of surgery) a wound check(your sutures are dissolvable). this appointment can be made with the nurse practitioner. please make this appointment by calling . if you live quite a distance from our office, please make arrangements for the same, with your pcp. ??????you have an appointment in the brain clinic on at 10:30am. the brain clinic is located on the of , in the building, . their phone number is . please call if you need to change your appointment, or require additional directions. ??????you will / will not need an mri of the brain with/ or without gadolinium contrast. if you are required to have a mri, you may also require a blood test to measure your bun and cr within 30 days of your mri. this can be measured by your pcp, please make sure to have these results with you, when you come in for your appointment. Procedure: Excision of lesion or tissue of cerebral meninges Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Aortocoronary bypass status Aortic valve disorders Other convulsions Personal history of tobacco use Other and unspecified hyperlipidemia Benign neoplasm of cerebral meninges Cerebral edema Other acquired absence of organ

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, sob, positive ett major surgical or invasive procedure: four vessel coronary artery bypass grafting(lima to lad, svg to diagonal, svg to om, svg to pda) history of present illness: this is a 71 year old male with known cad. he underwent ptca to lad and diagonal in . prior to hernia repair operation, an ett in was notable for ekg changes. an echo in was notable for mild mr as. the was estimated at 1.1 cm2 with peak/mean gradients of 34 and 22 mmhg. the was mild concentric lvh with an lvef of 60%. he was subsequently referred for cardiac catheterization. this was performed at the on . angiography showed a right dominant system with 80% ostial lad lesion; first diagonal had a 60% stenosis; the circumflex had a 60% lesion while the rca had a 40% stenosis. there was only mild as with of 1.8 cm2 and mean gradient of 18mmhg. left ventriculogram showed preserved lv function. based on the above results, he was referred for cabg. past medical history: cad - s/p ptca, htn, hypercholesterolemia, bph, hernia, decreased hearing, s/p l knee arthroscopy, s/p appy social history: 50 year history of pipe smoking. admits to etoh drinks per week. family history: no premature cad physical exam: temp 98.0, bp 126/74, hr 61, resp 18(sat 98% on ra) general: elderly male in nad neck: supple, no jvd heent: benign lungs: clear bilaterally heart: regular rate and rhythm, 4/6 sem radiating to carotids abdomen: benign ext: warm, no edema, no varicosities neuro: nonfocal pulses: 2+ distally, no femoral bruits pertinent results: 10:00am blood hct-26.1* 05:55am blood wbc-8.6 rbc-2.89* hgb-9.3* hct-25.7* mcv-89 mch-32.0 mchc-36.0* rdw-13.8 plt ct-113* 05:45am blood urean-20 creat-0.8 k-3.8 05:55am blood glucose-115* urean-20 creat-0.7 na-140 k-4.1 cl-107 hco3-27 angap-10 05:45am blood mg-1.9 brief hospital course: patient was admitted and underwent four vessel cabg on by dr. . surgery was uneventful - see op note for further details. following the operation, he was brought to the csru in stable condition. there he was weaned from inotropic support and was extubated without difficulty. he was noted to have some ventricular ectopy which improved after intravenous lidocaine and po beta blockade. k and mg levels were monitored closely and repleted per protocol. he otherwise maintained stable hemodynamics. units of prbcs were intermittently transfused to maintain hematocrit close to 30%. on pod 1, he transferred to the sdu. he remained in a normal sinus - no further ventricular ectopy was noted. beta blockade was slowly advanced as tolerated. over several days, he made clinical improvements. by discharge, he was near his preoperative weight with oxygen saturations over 96% on room air. he also worked daily with physical therapy and made steady progress. his hospital course was otherwise uneventful and he was cleared for discharge to home on pod 5. he is scheduled to follow up with dr. and his local cardiologist in approximately 4 weeks. medications on admission: isordil 20 , lescol 40 qd, accupril 40 qd, hytrin 5 qd, hctz 12.5 , 325 qd, cartia 80 qd, kcl 20 , tng prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. 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* 3. terazosin 5 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 capsule(s)* refills:*2* 4. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily) for 1 months. disp:*30 tablet(s)* refills:*0* 5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 10 days. disp:*10 tablet(s)* refills:*0* 7. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po daily (daily) for 10 days. disp:*10 tab sust.rel. particle/crystal(s)* refills:*0* 8. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours for 10 days. disp:*50 tablet(s)* refills:*0* 9. lescol 40 mg capsule sig: one (1) capsule po once a day. disp:*30 capsule(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: s/p cabgx4 (lima->lad, svg->diag, svg->om, svg->pda) pmh: cad s/p pci, htn, ^chol, bph, hernia repair discharge condition: good discharge instructions: keep wounds clean and dry. ok to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds followup instructions: clinic in 1 week dr in weeks dr in 4 weeks Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Aortic valve disorders Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Unspecified hearing loss

allergies: percocet attending: chief complaint: inferior mi major surgical or invasive procedure: cardiac catheterization with 4 overlapping stents to rca history of present illness: 39 yo male with history of gerd woke up w/ sob and lue discomfort 1 day pta. he presented to where he was ruled out for mi by enzymes. he underwent stress test the following day at . he developed sob and shoulder pain during the test. the stress test was discontinued and he reportedly had ste inferiorly and w/ inf wma on echo. he was transferred to for cath. at cath, he had 90% prox rca & 80-90% mid-distal rca lesions s/p 4 taxus stents w/ pcwp 17, hemodynamically stable throughout. . post-procedure he was doing well, no sob, no cp on arm discomfort and admitted to the ccu for monitoring. past medical history: gerd social history: works as police officer, lives alone, never married, no children; + tobacco 1p/week x 5 yrs, quit yesterday, occ etoh last drink 4 days ago, no ivdu; family history: father w/ mi's in 60's, + dmii; physical exam: 97.1 123/78 12 100% 2l nc gen: cauc m lying in bed flat in nad, alert, ox3. heent: anicteric neck: thick neck, no masses heart: rrr, s1, s2, no m/r/g lungs: ctbla, no rales, no wheezing abd: nabs/s/nt/nd/no masses, no hsm ext: no edema pertinent results: labs: @ na 137 k 4.1 cl 102 co2 27 bun 13 creat 1.0 glu 148 ca 9.1 alb 4.2 t.bili 0.6 /lip wnl alp phos 87 alt/ast 167/71 . # 1 ck 314 mb 1.2 tni <0.10 # 2 ck 273 mb 3.6 tni 1.0 # 3 235 3.5 0.9 # 4 210 2.3 0.8 . wbc 9 hct 43.5 plt 222 inr 1.0 ptt 22 chol 236 ldl 154 hdl 33 trig 244 . ekg: 9am tw flattening inferior and 1mm ste in iii; post cath: twi in iii, avf; q in iii, hyperacute t's. . cath: lmca 30%, distal lad diffuse 40%, mid 50% prox large d1 lcx nl, rca 99% prox w/ thrombus, timi 2 distal flow, diffuse 60-70% throughout mid-distal rca s/p 4 overlapping taxus stents to rca mean pcwp 17, ra mean 12 . echo 1. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). no abnormal regional left ventricular wall motion is seen. the inferior wall is not well seen. 2. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. . rad @ by report: cxr no acute disease ruq u/s cholelithiasis w/ gallstone possibly impacted in gb neck; abd aorta u/s no aneurism, max diameter 2.7cm; hida scan - no cystic or cbd obstruction, wnl; . 07:10am blood wbc-9.1 rbc-4.56* hgb-14.4 hct-41.2 mcv-90 mch-31.6 mchc-34.9 rdw-12.7 plt ct-213 07:10am blood plt ct-213 04:00am blood pt-12.4 ptt-22.5 inr(pt)-1.0 04:00am blood wbc-9.8 rbc-4.44* hgb-14.1 hct-40.4 mcv-91 mch-31.8 mchc-35.0 rdw-12.8 plt ct-203 06:54pm blood plt ct-215 07:10am blood glucose-114* urean-11 creat-1.0 na-141 k-4.0 cl-104 hco3-26 angap-15 06:54pm blood glucose-100 urean-13 creat-0.9 na-139 k-4.1 cl-105 hco3-24 angap-14 04:00am blood alt-166* ast-65* ck(cpk)-120 alkphos-93 totbili-0.5 04:00am blood ck-mb-3 ctropnt-0.04* 07:10am blood calcium-9.7 phos-3.2 mg-2.2 06:54pm blood %hba1c-6.5* -done -done brief hospital course: 39 yo male with history of gerd admitted with imi. . imi - his ekg and cardiac enzymes were consistent with imi. he has risk factors that included family history and hypercholesterolemia and tobacco use. he had a stent placed in the rca and was given aggrastat post cath for 18 hours. he was continued on asa, started on maximum dose statin, beta blocker and ace inhibitor, plavix. he should remain on plavix for at least 6 months. echo showed preserved ef. he was also counseled on smoking cessation and diet/nutrition. . hypercholesterolemia - he was started on maximum dose statin, 80mg atorvastatin. if his triglycerides remain elevated, gemfibrozil could be added as an outpatient. elevated glucose: he may have glucose intolerance. he was counseled on a low sugar diet and should have this followed up by his pcp. he can be managed with diet control only. transaminitis - he likely has nash given hypercholesterolemia and obesity; his hepatitis serologies were pending at time of discharge. his lft's should be followed up in 6 weeks with initiation of statin therapy. medications on admission: outpt meds: aciphex meds on transfer: asa, plavix, lopressor, aggrastat discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*6* 3. atorvastatin calcium 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*6* 4. aciphex 20 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:*6* 5. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*6* 6. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*6* discharge disposition: home discharge diagnosis: inferior mi hypertension hypercholesterolemia discharge condition: good discharge instructions: follow up with your cardiologist in , dr. , within 1 month. take your new medications as precribed. you must take plavix every day for at least 6 months or until told to stop by your cardiologist. you are encouraged to go to cardiac rehab. you should eat a low sugar diet as you are at risk for developing diabetes. followup instructions: follow up with your cardiologist in , dr. , within 1 month. follow up with your pcp with regards to possible early signs of diabetes. md Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Angiocardiography of right heart structures Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute myocardial infarction of other inferior wall, initial episode of care

allergies:percocet. social hx:single. police officer. etoh-occasional--last drink 4 days ago. wo drug use. crf:smoker-1pk/dat x5yrs. ?elevated cholesterol. +family hx-father w mi early 60's. family hx of dm. present hx:developed sob & lue discomfort/numbness. went to osh-ro w neg ekg/ck's. kept overnight. est-stopped due to sob & shoulder pain-ekg--interior ste. echo--inferior wma. transfered to -cath lab. cath-single vessel dz--rca--taxus stents x4 placed. admitted to ccu for observation. o:cv=pf. sheath dced-site c&d. pulses all >3+. hemody stable. started on lopressor & captopril (to ba chged to lisinopril in am). aggrastat 0.1mcg/kg/min x16hrs-dc 1230. ivf 1/2ns x2l-#2l up. gu=condom cath-adeq uo. labs=adm labs sent. social=family/friends updated. a:stable sp inferior mi requiring stenting x4. p:continue present manamgent. support as indicated. ?call-out in am. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Angiocardiography of right heart structures Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute myocardial infarction of other inferior wall, initial episode of care

allergies: motrin attending: chief complaint: transferred from osh for dka, r/o mi major surgical or invasive procedure: s/p cardiac catheterization with stenting of left circumflex artery history of present illness: 58 yo male with hx type 1 dm on insulin pump, ?vertigo, no known transferred to ccu for management of presumed dka in the setting of new ekg changes and borderline enzymes. no previous cad history althouth cath in ' reported to be negative with subsequent negative stress test. pt has history of vertigo with recent flare after fall from slipping on ice. otherwise, pt was in usoh until 1 day prior to admission when his insulin pump fell out at 2am. pt took some short acting insulin, but no lantus. pt developed worsening nausea followed by several episodes of emesis. denies chest pain, sob, diaphoresis. in osh , pt was afebrile, hemodynamically stable, but found to have blood sugar to 555, bicarb 18, anion gap 25, and abg 7.27/38/73. ekg was performed which showed diffuse st depressions in v3-v6, 1, 2, avf which were new from ekg from . cpk and tn were negative but given dm, he was started on iv heparin and integrillin and transfered to for cath. per osh report, head ct and cxr were negative. repeat ekg showed decreased st depressions with 2nd tn of 0.11 and cpk 153/mb 12. recent increased anion gap closed to 18. pt remained chest pain free on transfer to . . ros: negative for recent fever, chills, cough, uri symptoms, abdominal pain, diarrhea, constipation, dysuria, urinary symptoms. pt denies cp, sob, pnd, orthopnes, le edema past medical history: type i dm since , on insulin pump ?vertigo spinal fusion, r knee surgery social history: quit tobacco 20 years ago, smoked 6-7 years denies etoh; history of alcohol abuse denies drugs lives with wife works as plumbing/electrician family history: cad in father and grandfather physical exam: vs: p96.2, p60, 90/44, 18, 100% 2l, fs 393 pertinent results: 01:05am wbc-12.2* rbc-4.17* hgb-13.1* hct-37.9* mcv-91 mch-31.3 mchc-34.4 rdw-13.0 01:05am plt count-269 01:05am neuts-84.6* bands-0 lymphs-9.5* monos-5.2 eos-0.5 basos-0.2 01:05am pt-12.8 ptt-34.6 inr(pt)-1.0 01:05am glucose-378* urea n-50* creat-1.6* sodium-134 potassium-3.3 chloride-95* total co2-23 anion gap-19 01:05am ck(cpk)-153 01:05am ck-mb-12* mb indx-7.8* ctropnt-0.11* . ekg (osh): sr@80, nl axis/interval, borderline 1 degree avd, 26-mm st depressions in v3-v6, 2-3mm st depressions in 2,3,f; ?st elevation in v1, low limb voltage . old ekg (): sinus brady @80 with atrial ectopy, low limb voltage, nl axis/interval, no st changes brief hospital course: 1. cad: initial ekg showed marked depressions in v3-6. on admission to the ccu, art line was placed, after which pt was noted to be bradycardic to the 40s and hypotensive to 70s according to the art line. pt was bolused with ivf without significant increase in bp. dopamine was started. pt was asymptomatic. pt was taken emergently to the cath lab as we were concerned about acute ischemia. pt was found to have diffuse disease and 60-70% stenosis of lcx. in retrospect, pt's hypotensive episode was most likely spurious, as the arterial line bp and cuff pressures did not correlate. cuff pressures did not drop below 90s systolic during the entire time. pt may have some arterial stenosis which led to spurious bp. by cardiac enzymes, pt was found to have nstemi with peak ck of 573 and peak tn of 1.09. pt was started on aspirin, statin, plavix. bb and ace were initially held in setting of "hypotension", but then was started. later, decision was made to perform another cath and to stent the lcx lesion which was done successfully. 2. dm: pt was admitted in dka with ag 17. he was started on insulin drip and ivf and frequent electrolyte checks/repletions. gap was successfully closed. pt was transitioned to insulin pump. medications on admission: insulin pump neurontin isopril actos lasix 80 qd asa 325mg 2 tabs qhs alleve prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. atorvastatin calcium 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. pantoprazole sodium 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* 4. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. atenolol 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. calcium carbonate 1,250 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. insulin pump eng/french r1000 misc sig: one (1) miscell. once a day. 9. neurontin 300 mg capsule sig: three (3) capsule po three times a day. disp:*270 capsule(s)* refills:*2* 10. actos 30 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 11. glyset 25 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 12. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: s/p non-st elevation mi dka discharge condition: stable discharge instructions: if you develop chest pain or difficulty breathing, call your doctor or return to the emergency room followup instructions: follow up with your primary care doctor: , l. Procedure: Coronary arteriography using two catheters Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Injection or infusion of platelet inhibitor Left heart cardiac catheterization Left heart cardiac catheterization Insertion of drug-eluting coronary artery stent(s) Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled

history of present illness: patient is a 72-year-old male with coronary artery disease status post myocardial infarction, chf with an ejection fraction of 15% and icd for df/vt. here for possible icd malfunction after he was shocked three times at home the night before admission to an outside hospital. the first shock occurred on the morning prior to admission with no preceding symptoms. the second shock occurred while walking downstairs, and he reported reaching out his arm. third shock occurred shortly after this when he was reaching out with his left hand, and the final and fourth shock occurred when he was reaching out in bed with his left arm and received multiple shocks in a row. at the outside hospital, the patient had a magnet placed over his icd, and was given magnesium sulfate. he was hemodynamically stable, and had no complaints otherwise. on review of symptoms, the patient reported occasional orthostatic hypotension, but denied chest pain, shortness of breath, nausea, or vomiting. the patient denies fever or chills. denied bloody stools or black stools. the patient denied orthopnea, pnd, or dyspnea. past medical history: 1. coronary artery disease status post myocardial infarction and ischemic cardiomyopathy. 2. icd for vf with second svc coil because of high dfts with three-lead fracture in 03/99. 3. atrial fibrillation. 4. chronic renal insufficiency. 5. chf with an ef of 15%. 6. hypercholesterolemia. 7. obesity. 8. history of unsuccessful vt ablation. 9. osteoarthritis. 10. bph. 11. reactive airway disease. 12. diabetes mellitus type 2. medications: 1. toprol 50 b.i.d. 2. vasotec 10 b.i.d. 3. lasix 40 b.i.d. 4. imdur 60 q.d. 5. lanoxin 125 mcg. 6. levoxyl 125 mcg. 7. lipitor 40. 8. plavix 75. 9. spironolactone 25. 10. dofetilide 250 q.d. 11. coumadin 10 two days a week, 7.5 five days a week. social history: patient reports coronary artery disease in his father. also has a 50 pack year smoking history, but quit 34 years ago. he denies alcohol use. allergies: shellfish and iv dye, which causes hives, and amiodarone which caused edema. physical exam on admission: temperature 97.7, heart rate of 80, blood pressure 86/52, respiratory rate 16. saturating 97% on room air. patient was alert and oriented times three in no acute distress. neck was supple. pupils are equal, round, and reactive to light. clear oropharynx. there was no jvd and no carotid bruits. cardiovascular reveals regular, rate, and rhythm with occasional irregular beats. faint systolic ejection murmur at the left lower sternal border. respiratory: lungs are clear to auscultation bilaterally. the abdomen was soft, nontender, nondistended. extremities revealed trace bilateral lower extremity edema. summary of hospital course: 1. cardiac rhythm: patient is admitted with multiple shocks from his icd. the shocks had occurred when the patient was using his left arm predominantly. this is likely due to the fact that there was a device malfunction. the device was interrogated, and found to be oversensing noise from certain arm movements. the device was turned off and programmed ddd. the inr was 2.5, so the patient was given vitamin k with plan for future need revision. overnight the patient had a four-second pause on telemetry, although the patient was asymptomatic. the patient returned to the electrophysiology laboratory and had a pacing catheter placed. the patient was transferred to the ccu on for further monitoring in the setting of transvenous pacing. the patient remained comfortable and when his inr trended down, he returned to the ep laboratory for device revision and lead revision. patient tolerated the procedure well. after this, the patient returned to the floors and received multiple shocks on the morning, which were appropriate for ventricular tachycardia. the patient's pacemaker was interrogated and found to be functioning well. it was reprogrammed to over pace out of ventricular tachycardia prior to shocking. the patient had additional episodes of ventricular tachycardia, which were successfully paced out of by his pacemaker. patient was started on lidocaine drip given his significant ventricular tachycardia and the episodes of vt diminished significantly. the patient was transitioned to mexiletine on the next day, and tolerated this well. the patient had no further episodes of significant ventricular tachycardia. 2. coronary artery disease: the patient currently had no symptoms. he was continued on his plavix, statin, beta-blocker, and imdur. patient was not admitted on an aspirin, although he was given an aspirin during his hospitalization given the fact that was coumadin was held. plan for no aspirin on discharge with resuming his coumadin as per his prior home regimen. 3. congestive heart failure: patient has an ischemic cardiomyopathy with an ejection fraction of less than 20%. an echocardiogram on this hospitalization again revealed an ejection fraction of 15-20%. while the patient was npo during episodes of this hospitalization, his lasix and aldactone was held; however, he was continued on his lasix, aldactone, digoxin, and ace inhibitor. patient had no evidence of congestive heart failure during this hospitalization and he resumed his prior medications before discharge. 4. endocrine: patient with hypothyroidism: the patient was continued on his levoxyl. he was also maintained on a regular insulin-sliding scale. blood sugars remained in normal levels, and he did not require significant amounts of insulin. 5. renal: patient with chronic renal insufficiency. remained stable throughout this hospitalization. 6. heme: patient's inr was reversed with vitamin k, and the patient was instructed to resume coumadin dosing on the evening following discharge. the patient will follow up with his cardiologist or primary care physician for further monitoring of his inr and adjustment of his coumadin dose. 7. id: the patient had a temperature greater than 101.5 following his pacemaker placement, and therefore was continued on his cephalosporin, which was originally given for prophylaxis. the patient was transitioned to p.o. antibiotics, plan for seven-day course. condition on discharge: stable. discharge status: to home. discharge diagnoses: 1. icd firing. 2. icd revision. 3. ventricular tachycardia. discharge medications: 1. furosemide 40 b.i.d. 2. spironolactone 25 q.d. 3. plavix 75 q.d. 4. atorvastatin 40 q.d. 5. levothyroxine 125 mcg. 6. digoxin 125 mcg q.d. 7. mexiletine 150 p.o. b.i.d. 8. isosorbide mononitrate 30 q.d. 9. enalapril 2.5 q.d. 10. dofetilide 125 b.i.d. 11. ibuprofen prn. 12. metoprolol succinate 25 q.d. 13. keflex 500 t.i.d. for three days. 14. coumadin 7.5 mg p.o. q.d. follow-up plans: the patient will follow up with his primary care physician in the week following discharge. in addition to this, the patient will follow up with the electrophysiologist, dr. , on in addition to his appointment in device clinic on . , m.d. dictated by: medquist36 Procedure: Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Other nonoperative cardiac and vascular measurements Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Paroxysmal ventricular tachycardia Mechanical complication of automatic implantable cardiac defibrillator Old myocardial infarction Unspecified disorder of kidney and ureter

she was born at 10:16pm this evening as the 3200 gram product of a 39+ week gestation pregnancy to a 34 y.o. g1 p0-1 mother. prenatal laboratory studies included bt o+/ab-, hbsag-, rpr nr, ri, and gbs+. pregnancy reportedly unremarkable. perinatal period was complicated by maternal fever to 102.5, with rom 14 hours ptd. mother did receive several doses of antibiotics, the first 13 hours ptd. infant was born via svd, requiring brief oxygen at delivery with apgars . infant brought to nicu. physical exam: weight 3200. vs: t 100.1r. hr 160s. rr 40s-60s. bp 68/35 (45). gen: wd infant, comfortable, active, no distress. heent: fontanelles soft and flat, ears/nares nl, palate intact. chest: clear, no g/f/r, well-aerated. cardiac: rrr, no m/g. abd: soft, no hsm, no mass, present bs. gu: normal female, anus patent. ext: warm, hips and back normal. neuro: appropriate tone and activity, intact moro/grasp/suck. dstik 101. impression: well-appearing term newborn at risk for sepsis given maternal gbs colonization and fever, despite maternal pretreatment with antibiotics. given height of maternal fever, will begin empiric antibiotic treatment pending clinical course and culture results. Procedure: Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Transitory tachypnea of newborn

history of present illness: mr. is a 74-year-old man with known cad, had an mi and 79 and ptca of his lad and rca and . he had a stent to his diagonal in , reports dyspnea on exertion over the past several months accompanied by leg cramps. denies any chest pain, nausea, vomiting, diuresis, syncope. stress echo done recently shows an ef of 25 percent with anterior septal akinesis, septal and anterior wall ischemia. a cath done at an outside hospital showed three-vessel disease. cath on done at showed an ef of 30 percent with anterior hypokinesis, left main 60 percent lad with a complex ostial lesion, left circumflex with 100 percent om-2 and rca with 100 percent proximal lesion. past medical history: cad status post mi, left bundle branch block, copd, hyperlipidemia, claustrophobia, diabetes mellitus type 2. past surgical history: none. allergies: states allergy to tetanus vaccine which causes hives. medications on admission: 1. pravachol 80 once daily. 2. plavix 75 once daily. 3. imdur 60 once daily. 4. lopressor 25 once daily. 5. ecotrin 325 once daily. 6. flomax 0.4 at bedtime. 7. amaryl 1 mg once daily. 8. lisinopril 5 mg once daily. 9. advair inhaler b.i.d. social history: lives with his wife and . retired police officer. tobacco: quit 3 years ago with etoh rare use. family history: has a brother with cad. physical examination: height 6 feet. weight 220. vital signs: heart rate 65 sinus rhythm, blood pressure 104/50, respiratory rate 12, o2 sat 96 percent on room air. general: lying flat in bed in no acute distress. neuro: alert and oriented times three. moves all extremities, nonfocal exam. respiratory: clear to auscultation. cardiovascular: regular rate and rhythm. s1-s2 with no murmurs, rubs or gallops. no carotid bruits and no edema. abdomen: soft, nontender, nondistended with normoactive bowel sounds. extremities are warm and well-perfused with no edema. no varicosities. left groin with dry sterile dressing and no hematoma. pulses: radial are two plus bilaterally. dorsalis pedis and posterior tibial both one plus bilaterally. laboratory data: white count 6.3, hematocrit 35.7, platelets 176, sodium 137, potassium 4.2, chloride 100, co2 19, bun 28, creatinine 1.3, glucose 123, alt 22, ast 14, alk phos 53, total bili 0.3, albumin 3.4, pt 14.4, ptt 110.6, inr 1.3. hospital course: on , the patient was a direct admission to the operating room. please see the or report for full details. in summary, he had a cabg times five with a lima to the lad, saphenous vein graft to the pda with a sequential graft to om-2, saphenous vein graft to the diagonal with a sequential graft to om-1. his bypass time was 101 minutes with a cross-clamp time of 67 minutes. he was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient was av paced at 86 beats per minute with a mean arterial pressure of 58 and pad of 17. he had propofol at 15 mcg/kg/min, epinephrine at 0.02 mcg/kg/min and insulin at 2 units per hour. the patient did well in the immediate postoperative period. his sedation was discontinued. his anesthesia was reversed. he was weaned from the ventilator and successfully extubated on postoperative day one. the patient continued to be hemodynamically stable. he was weaned from his epinephrine infusion. his chest tubes were discontinued. his pa catheter was removed and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. once on the floor, the patient had an uneventful postoperative course. his temporary pacing wires were removed on postoperative day three. his activity was slowly advanced with the assistance of the nursing staff as well as the physical therapy staff. on postoperative day four, it was decided that the patient will be ready and stable for discharge to home on the following day. physical examination: at this time the patient's physical exam is as follows. temperature 98.5, heart rate 83 sinus rhythm, blood pressure 124/54, respiratory rate 18, o2 sat 96 percent on room air. weight preoperatively was 100 kg, at discharge is 105.3. laboratory data: sodium 138, potassium 4.7, chloride 101, co2 29, bun 25, creatinine 1.1, glucose 156, magnesium 2.0, white count 8.5, hematocrit 31.2, platelets 119. physical examination: neurologic: alert and oriented times three. moves all extremities, nonfocal exam. pulmonary: clear to auscultation bilaterally. cardiac: regular rate and rhythm. s1-s2 with no murmur. abdomen is soft, nontender, nondistended with normoactive bowel sounds. extremities are warm and well-perfused with 1-2 plus edema bilaterally. sternal incision: sternum is stable. incision with dry sterile dressing, clean and dry. no erythema. leg incision on the left knee with steri-strips open to air. the left leg is somewhat ecchymotic. condition on discharge: the patient's condition at time of discharge is good. disposition: he is to be discharged to home with visiting nurses. discharge diagnoses: cad status post coronary artery bypass grafting times five with lima to lad, saphenous vein graft to the pda with a sequential graft to om-2, saphenous vein graft to diagonal with a sequential graft to om-1. copd. hypercholesterolemia. diabetes mellitus type 2. left bundle branch block. follow up: the patient is to have follow-up with dr. in weeks and follow-up with dr. or dr. in weeks and finally follow-up with dr. in 4 weeks. discharge medications: 1. colace 100 mg b.i.d. 2. aspirin 325 mg once daily. 3. percocet 5/325 1-2 tablets q. 4-6 hours p.r.n. 4. lisinopril 5 mg once daily. 5. flomax 0.4 mg at bedtime. 6. pravastatin 80 mg once daily. 7. advair inhaler, 2 puffs b.i.d. 8. amiodarone 400 mg once daily times one week then 200 mg once daily times 1 month. 9. metoprolol 25 mg b.i.d. 10. amaryl 2 mg once daily. 11. finally, the patient is to take potassium chloride 20 meq b.i.d. times 7 days then once daily times 2 weeks and lasix 20 mg b.i.d. times 7 days and then once daily times 2 weeks. , m.d. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified 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 Arterial catheterization Systemic arterial pressure monitoring Pulmonary artery wedge monitoring Transfusion of platelets Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Personal history of tobacco use Percutaneous transluminal coronary angioplasty status Old myocardial infarction Other left bundle branch block Other isolated or specific phobias

past medical history: 1. coronary artery disease: a) the patient had coronary artery bypass grafting with a saphenous vein graft to the left anterior descending artery, a saphenous vein graft to the first obtuse marginal artery, a saphenous vein graft to the third obtuse marginal artery and a saphenous vein graft to the right coronary artery. b) he had re-do coronary artery bypass grafting in with a saphenous vein graft to the left anterior descending artery with no bypass grafts to total occlusions of right coronary artery and obtuse marginal artery grafts. c) in , the patient had a stent of the saphenous vein graft to the left anterior descending artery with a cardiac catheterization showing a left ventricular end diastolic pressure of 17, an ejection fraction of 42% and mid inferior akinesis and anterolateral akinesis/hypokinesis. d) in , the patient had a percutaneous transluminal coronary angioplasty of a saphenous vein graft to the left anterior descending artery with a left ventricular end diastolic pressure of 19. 2. hypercholesterolemia. 3. hypertension. 4. chronic renal insufficiency with a baseline creatinine of 1.9. 5. hernia repair. medications on admission: aspirin 325 mg p.o. q.d. enalapril 10 mg p.o. b.i.d. metoprolol 25 mg p.o. b.i.d. lipitor 20 mg p.o. q.d. amlodipine 5 mg p.o. q.d. sublingual nitroglycerin p.r.n. allergies: there were no known drug allergies. history of present illness: the patient was doing well post percutaneous transluminal coronary angioplasty in . on , he developed back pain while sitting. this involved radiation to his left arm and also some retrosternal chest pain. he also described some slight shortness of breath with nausea and diaphoresis. this episode of chest pain was not initially relieved with sublingual nitroglycerin and the patient presented to . at , the patient was found to have no acute electrocardiogram changes and laboratory investigation showed a cbc with a white blood cell count of 10.7, a hematocrit of 36.6, a platelet count of 291 and a chem 7 which was within normal limits with a bun of 50 and a creatinine of 1.9. his ck, mb and troponin i were noted to be 64, 2.6 and 0.2. his second set of enzymes were also normal. the patient was admitted and his chest pain was treated with nitroglycerin and heparin drips. he was also noted to have an asymptomatic run of ventricular tachycardia of 27 beats without any hemodynamic compromise. the patient was started on a lidocaine infusion at that time. the patient was transferred to on and was taken straight to the cardiac catheterization laboratory. there, he was found to have a cardiac output and cardiac index of 3.1 and 1.8 respectively. his right ventricular end diastolic pressure was 16 and his pulmonary artery pressures were 48/28 with a mean of 39. his wedge pressure was noted to be 29 and his mixed venous oxygen saturation was 42. no left ventricular angiography was done. examination of the coronary arteries showed a right dominant system with a normal left main coronary artery. there was a 99% lesion at the first obtuse marginal artery and a 100% lesion at the second obtuse marginal artery. his posterolateral ventricular branch was noted to be occluded at 30%. the right coronary artery, which had a previous known occlusion, was not injected. the patient's saphenous vein graft to left anterior descending artery stent was found to be 98% occluded and the patient underwent balloon percutaneous transluminal coronary angioplasty and subsequent brachytherapy with a residual occlusion of 10%. social history: the patient denied any history of tobacco use. he consumed alcohol socially and currently lived alone without support. the patient was capable of doing his own shopping, cooking, cleaning and driving. he did have a health care proxy by the name of , who resided at 74 in . family history: the family history was noncontributory. physical examination: on examination, the patient was in no apparent distress with vital signs showing a temperature of 96.9??????f, a blood pressure of 138/63, a heart rate of 87, a respiratory rate of 20 and an oxygen saturation of 96% on a nonrebreather mask. the neurological examination was unremarkable. the patient was awake, alert and oriented times three. on head and neck examination, the pupils were equal and reactive to light. the extraocular movements were intact. the oropharynx was moist. on cardiovascular examination, the patient's jugular venous pressure was 8-10 cm above the sternal angle. he had a normal s1 and s2 with an s3 and s4. he did not have any audible murmurs. the respiratory examination showed diffuse crackles half way up his chest bilaterally with no wheezes. the abdominal examination was unremarkable. the extremities showed palpable bilateral dorsalis pedis pulses with no edema. he had a right groin pulmonary artery catheter line in place and his arterial sheath site was clean, dry and intact with no bruit or hematoma. laboratory data: the patient's cardiac care unit laboratory values showed a white blood cell count of 14,200, hematocrit of 27.6 and platelet count of 211,000. chem 7 showed a sodium of 129, potassium of 4.1, chloride of 97, bicarbonate of 18, bun of 46, creatinine of 2.1 and glucose of 217. ck was 555, calcium was 9.0 and magnesium was 1.6. arterial blood gases showed a ph of 7.33, a pco2 of 29 and a po2 of 90. electrocardiogram: the patient's electrocardiogram on showed him to be in sinus rhythm at 60 with a prolonged p-r interval, a normal p wave and a qrs axis of -60 to -90. he also had a right bundle branch block with a left anterior hemiblock. he had q waves noted in leads iii and avf. he also had some premature ventricular contractions. there were t wave inversions in leads v1 to v4, which appeared unchanged from his electrocardiogram from . radiology data: the patient's chest x-ray showed significant pulmonary vascular redistribution cephalad. hospital course: following cardiac catheterization, the patient was continued on plavix and received aggressive diuresis for his elevated pulmonary capillary wedge pressure. on , the patient was noted to have continued runs of nonsustained ventricular tachycardia and an echocardiogram was done, which showed the patient to have a moderately depressed left ventricular function with 1+ aortic insufficiency, 2+ mitral regurgitation and 1+ tricuspid regurgitation. he also was noted to have inferior and inferoseptal hypokinesis. the pulmonary artery catheter was removed along with the introducer on that day. on , the patient was noted to be in atrial bigeminy in the morning and also continued to have short runs of nonsustained ventricular tachycardia of three to four beats. the patient continued with his intravenous diuresis with 80 mg of lasix q.d. and was subsequently transferred to the floor. on , the electrophysiology department was informally consulted and the patient's metoprolol dose was increased. the patient's rhythm continued to be monitored. on , the patient was in stable condition with adequate diuresis. his nonsustained ventricular tachycardia continued to improve and the patient continued to show no further episodes of nonsustained ventricular tachycardia. the patient was discharged home on in stable condition. discharge medications: plavix 75 mg p.o. q.d. enteric coated aspirin 325 mg p.o. q.d. lipitor 20 mg p.o. q.d. metoprolol 37.5 mg p.o. q.d. enalapril 10 mg p.o. q.d. amlodipine 5 mg p.o. q.d. lasix 40 mg p.o. q.d. colace 100 mg p.o. b.i.d. nitroglycerin 0.4 mg sublingual every five minutes p.r.n. times three. protonix 40 mg p.o. q.d. follow up: the patient was instructed to follow up with his primary cardiologist, dr. , at in the upcoming week. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using a single catheter Implantation or insertion of radioactive elements Aspiration of skin and subcutaneous tissue Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Paroxysmal ventricular tachycardia Unspecified disorder of kidney and ureter Other complications due to other vascular device, implant, and graft Primary pulmonary hypertension Left heart failure

history of present illness: mr. is a 72-year-old gentleman with a history of hodgkin's disease was transferred here from hospital because of intractable seizures and decreased mental status. he was in his usual state of health, active and playing golf, until when he began to become "confused" and developed gait difficulties. according to the family, mr. was behaving in a way that was perceived to be nontypical by family members. was also having gait difficulties that were considered to be mild, according to the family members. because of these symptoms, he was evaluated at hospital on . at that time, a head computed tomography was reported as normal. he was give a diagnosis of transient ischemic attacks and was d/c home. over the next three days, mr. problems gradually worsened. on , he was at home when he developed a nonfocal onset of seizure which was later generalized. he was transferred to the nearest emergency department where he continued to have generalized seizures. he was given a dilantin load and phenobarbital. his systolic blood pressure at that time ranged between 120 and 200s. a repeat head ct was reported to be normal. despite the dilantin load and the phenobarbiltal, the patient continued to have clinical seizured. therefore, he was started on an ativan drip and was admitted to the intensive care unit. his dilantin was also continued on therapeutic levels. despite the ativan drip and dilantin therapeutic levels, mr. continued to be unresponsive and had intermittent seizures. the rate of the ativan iv infusion was increased and the patient was intubated. a lumbar puncture was performed on at hospital and showed normal values. a mri with diffusion- weighted imaging showed diffuse hyperintensity in the cerebral cortex (r > l) and both thalami. at this point, the patient remained intubated and unresponsive and was therefore transferred to for further evaluation and care. past medical history: 1. hodgkin's disease diagnosed in after developing a respiratory infection. this was diagnosed as nodular sclerosing hodgkin's disease; stage iii-b with positive -sternberg cells. a bone marrow biopsy was done in which showed no bone marrow involvement. 2. status post chemotherapy with bleomycin, cytoxan, vincristine, and procarbazine two years ago. this had to be discontinued after three cycles because of interstitial lung disease and because of myelosuppression with episodes of neutropenic fever. most recent surveillance computed tomography scan revealed gradual interval progression of hodgkin's disease with slightly large mediastinal lymph nodes. 3. borderline hypertension. 4. colonic polyps. 5. tuberculosis. 6. cataracts. 7. macular degeneration. medications on admission: aspirin, prevacid, and tylenol. ativan drip and dilantin were started at the outside hospital. allergies: ceftin (causes a rash). social history: the patient was a retired chemistry teacher and lived in . he was married with no alcohol or intravenous drug use. family history: family history was noncontributory. concise summary of hospital course: mr. was admitted to the intensive care unit of on . a repeat lp on admission showed normal cells, glucose and protein. a csf sample was also obtained for viral cultures and different viral and fungal ab titers (including west nile virus, arboviruses, hsv, hbvs). routine cultures for bacterial, tb and other infectious agents were also normal. cytology was normal. despite the therapeutic levels of ptn and the iv infusion of ativan, electroencephalogram (eeg) on admission showed epileptiform sharp spike activity suggestive of ongoing epileptict activity. therefore, a penotarbital infusion was started. the pentobarbital infusion was titrated to obtain a burst- suppression pattern on bedside 24 h, eeg monitoring. in particular, the eeg showed sharp waves complexes every 6 to 10 seconds. dilantin and depakote were continued as well. at this point, pressors were started to compensate to the pentobarbital- induced decreased cardiac function. mr condition did not improve and another magnetic resonance imaging examination () showed multicentric areas of t2 hyperintensity with more concentration in the right frontal as well as bilateral thalami. laboratory studies throughout mr. admission included several blood cultures, urine cultures and extensive toxic metabolic workup. another lp for cerebrospinal fluid analysis for infection, toxic metabolic and cytological analysis was also performed. in order to better elucidate the underlying pathology. a brain and meningeal biopsy was performed on in the right frontal lobe. in regards to empiric treatment, after the brain biopsy, the patient received iv solu- medrol and high doses of antibiotics with broad coverage. the infectious disease team was also involved in the care of mr. . all the tests performed on his tissues and fuids obtained under request of the id team, had thus far come back normal. brain and meningeal biopsy were remarkable for an meningitic eosinophilic infiltrates and extensive ischemic cortical neuronal damage (red neurons). there was no evidence of an infectious on traditional staining and/or on electronic microscopy. several attempts in decreasing the dose of pentobarbital resulted in an increased epileptiform activity on bedside eeg monitor. mr. condition deteriorated even further. he had developed ileus, and his abdomen was hyperextended. he had been intubated throughout his entire stay in the intensive care unit and was increasingly dependent on ventilatory support. at this point, the patient's poor clincal status and prognosis was thoroughly discussed with his closest family members. after a family meeting, it was decided that mr. would no longer benefit from aggressive support. therefore, he was extubated and expired briefly thereafter. , m.d. dictated by: medquist36 d: 15:05 t: 16:30 job#: Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Open biopsy of brain Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Grand mal status Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites Postinflammatory pulmonary fibrosis Macular degeneration (senile), unspecified Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Other generalized ischemic cerebrovascular disease

allergies: pcn (rash) ros/ neuro: pt awake, oriented x 3. percocet 2 tabs q 4-6 hrs for pain. pt c/o lt leg pain today - medicated w/ percocet with effect. cv: afib rate 80's, no ectopy. bp stable. lle noted to be edematous, painful, positive dopplerable pp ble. awaiting ultrasound lle to r/o dvt. heparin sc 5000u. coumadin for chronic afib. resp: lungs clear. bronchoscopy done this am. pt has strong productive cough. rr 20's labored at times, doe. o2 nc, mask prn. renal: u/o qs vis foley. lasix 40mg . kcl 40meq . gi: dat. + bs, lbm . heme: inr 1.2 coumadin qd id: afebrile skin: rt buttock duoderm d/t stage ii. social: pt brother called, will be in to visit patient this afternoon. Procedure: Laryngoscopy and other tracheoscopy Closed [endoscopic] biopsy of bronchus Other repair and plastic operations on trachea Other operations on trachea Local excision or destruction of lesion or tissue of trachea Diagnoses: Esophageal reflux Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Atrial fibrillation Unspecified sleep apnea Morbid obesity