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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

history of present illness: the patient is a 45-year-old male with a history of chronic obstructive pulmonary disease and obstructive sleep apnea who underwent uvulopalatotectomy in . this was complicated by hemorrhage and a tracheostomy for a period of two weeks. subsequently, he has had multiple dilatations for the tracheal stenosis. he is now here for tracheal reconstruction. past medical history: 1. obstructive sleep apnea, status post uvulopalatotectomy. 2. tracheostomy for two weeks in . 3. chronic obstructive pulmonary disease. 4. hypertension. 5. atrial fibrillation. the patient has failed several direct cardioversions. 6. alcohol abuse. 7. history of cardiac catheterization in with an ejection fraction of 69% and clean coronaries. 8. kidney stones. 9. umbilical hernia. 10. gastroesophageal reflux disease. medications on admission: flovent, atrovent, albuterol, guaifenesin 500 mg p.o. q.d., prednisone 60 mg p.o. q.d., protonix 40 mg p.o. q.d., diltiazem 120 mg p.o. b.i.d., zestril 10 mg p.o. q.d., amiodarone 200 mg p.o. q.d., lopressor 25 mg p.o. b.i.d., digoxin 0.25 mg p.o. q.d., colace 100 mg p.o. b.i.d., klonopin 0.5 mg p.o. t.i.d. p.r.n., trazodone 50 mg p.o. q.h.s. p.r.n., lipitor 10 mg p.o. q.d., coumadin (which has been held). allergies: penicillin. hospital course: the patient underwent a rigid bronchoscopy and direct laryngoscopy, tracheal resection and reconstruction on . his intraoperative course was uneventful. he was admitted to the intensive care unit postoperatively in an intubated condition. he remained intubated overnight and was in a stable condition. he was extubated on postoperative day one. he remained in atrial fibrillation at this time. he was started on a diltiazem drip for the atrial fibrillation with a rate of 150s. he underwent a bronchoscopy which showed mild anastomotic edema and was therefore continued on diuresis. he remained in the intensive care unit for the next few days slowly improving with aggressive respiratory treatment. his coumadin was restarted on postoperative day three. he was continued on antibiotics of vancomycin and flagyl which had been started in the initial postoperative period. on postoperative day six, he complained of some left lower extremity pain. he underwent a lower extremity noninvasive study which revealed a left lower extremity deep venous thrombosis. at this point, he was started on lovenox as he was not yet therapeutic on his coumadin. on , he underwent another bronchoscopy which again revealed mucosal edema at the anastomotic site. in the next few days in the intensive care unit were essentially uneventful as he slowly improved, and his respiratory function was slowly improving. he was deemed ready for transfer to the regular floor on postoperative day eight. he was stable on the floor over the next few days. his coumadin was continued until it reached a therapeutic level, and at that point the lovenox was stopped. he continued to have left leg pain secondary to the deep venous thrombosis and was treated with a morphine patient-controlled analgesia. he had aggressive respiratory toilet as well at this point. his clinical condition slowly improved, and he started ambulating, and his respiratory function improved as well. on postoperative day 16 (), he went back to the operating room for a bronchoscopy. at that time, his airways were clean, and there was no mucosal edema. he was now ready for discharge home on coumadin. medications on discharge: 1. diltiazem 120 mg p.o. b.i.d. 2. lisinopril 10 mg p.o. q.d. 3. amiodarone 20 mg p.o. q.d. 4. digoxin 0.25 mg p.o. q.d. 5. colace 100 mg p.o. b.i.d. 6. vitamin a 25,000 units q.d. 7. zinc 220 mg p.o. q.d. 8. atrovent inhaler 2 puffs q.i.d. 9. flovent 110 mcg 2 puffs b.i.d. 10. lopressor 25 mg p.o. b.i.d. 11. protonix 40 mg p.o. q.d. 12. vitamin c 500 mg p.o. q.d. 13. percocet one to two tablets p.o. q.4-6h. p.r.n. 14. lipitor 10 mg p.o. q.d. 15. coumadin 5 mg p.o. q.d. (inr is to be checked twice every week by primary care physician and then subsequently per primary care physician's recommendations). discharge followup: follow up with dr. in clinic in one week. , m.d. dictated by: medquist36 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

allergies: no known allergies / adverse drug reactions attending: chief complaint: bradycardia major surgical or invasive procedure: 1. intubation 2. permanent pacemaker placement history of present illness: mr. is an 89 year old gentleman with a history of atrial fibrillation on amiodarone and coumadin, cad with 3vd seen on cardiac cath in , chf with ef of 20%, who initially presented to last night complaining of a slow heart beat. per his wife at around midnight last night he came to bed complaining that his heart was beating very slowly, he felt weak and that he could "feel it in his chest." at that time he asked his wife to call 911 and he was taken to for further evaluation. per his wife he did not complain of any chest pain, shortness of breath or nausea. also, the family notes that he has been having some falls/syncope at home including one event that he did not remember in the past few weeks. . per ems report he was found to be pale, cool and diaphoretic on initial examination. there he experienced some nausea, vomited once, appropriate but lethargic, he was found to be bradycardic to the 20's to 30's and was taken to . en route to he was given atropine 0.5mg x 2 with no effect, he was put on external pacing with electrical but not mechanical capture. at he was still bradycardic initially to the 20's, was given atropine 1mg x 2, a right cordis was placed and pacing wires were floated but kinked and were unable to capture. his ck was 87, ck-mb was 2.1. he was then intubated for reported ams, external pacing was again attempted but there was no mechanical capture. throughout his course he was never hypotensive with his episodes of bradycardia. ekg's done at showed at times a junctional rhythm, ventricular escape and then bradycardia with his old lbbb. he was then transferred to for further management. . on arrival to the er his initial vs were: 96.8, 63, 113/60, 99% on 14x450, 5 peep, fio2 of 100%. his heart rate remained in the 50's, he was given fentanyl/versed for sedation, an ogt was placed and he was transferred to the ccu. vs on transfer were: 96, 51, 124/59, 97% on the above ventilator settings. his ck was 88, ck-mb was 4 with a troponin of 0.04. on arrival to the ccu his initial vs were: 97, 43, 130/57, 22, 100% on ac 14x450, peep of 5, fio2 of 60%. he is currently intubated and sedated, unable to respond to any questions, he is moving his extremities. . review of systems: unable to obtain, patient is intubated and sedated past medical history: 1. cardiac risk factors: -diabetes, -dyslipidemia, +hypertension 2. cardiac history: - cabg: none - percutaneous coronary interventions: 3 vd on cath in , no stenting or surgical options offered at that time - pacing/icd: none 3. other past medical history: - atrial fibrillation on amiodarone and coumadin - chf with ef of 20% - hypothyroidism - glaucoma social history: lives with his wife in - tobacco history: 31 pack year smoking history - etoh: none per records - illicit drugs: none per records family history: colorectal cancer, diabetes, and stroke physical exam: admission exam: general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic, endotracheal tube, ng tube cardiovascular: (s1: normal), (s2: normal), bradycardic, regular respiratory / chest: (expansion: symmetric), (breath sounds: clear : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: absent, left lower extremity edema: absent, pretibial erythema of the lle skin: warm right: carotid 2+ dp 1+ pt dopplerable left: carotid 2+ dp 1+ pt dopplerable pertinent results: echo the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef= 20-25 %) with global hypokinesis (and inferior akinesis). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. with mild global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the prior study (images reviewed) of , the lv appears more dysynchronous . cxr cardiomegaly with mild pulmonary edema. the widened mediastinum may represent an enlarged aneurysmal thoracic aorta or an aortic dissection. brief hospital course: hospital course: mr. is an 89 year old gentleman with a history of atrial fibrillation on amiodarone/coumadin, cad with 3vd, chf with ef of 20% who presented with symptomatic bradycardia. he was transferred to for permanenet pacemaker placement. hospital course complicated by brief intubation for altered mental status. . # rhythm / bradycardia: review of ekgs prior to admission reveal sinus arrest after a junctional rhythm and subsequent ventricular escape. when he returned into sinus rhythm he had a wider qrs interval and prolonged pr interval of 300 ms thank on prior ekgs. etiology unclear, may be secondary to conversion pause or a toxic or metabolic condition pre-empting sinus arrest with long pr and wide qrs. a free t4 was normal. the patient's home dose of amiodarone was held with concern for toxicity. a temporary pacemaker was placed and noted to be coiled in the ivc and was thus subsequently removed. coumadin was held in anticipation of pacemaker placement. a permanent pacemaker was placed on hd 2. although the patient is a given ef of 20% candidate for biventricular icd placement, dicussion with the patient and primary cardiologist prompted placement of pacemaker only, to place the simplest device that would address his bradycardia. coumadin was restarted post procedure at his home regimen, with follow-up at the coumadin clinic. . # coronary artery disease: the patient has a history of three vessel disease and was not on a statin or beta blocker as an outpatient. he was started on atorvastatin 80mg daily, aspirin 325 mg daily. his cardiac enzymes were cycled and flat. lipid panel revealed an ldl of 105, hdl of 33 and total cholesterol of 173, the atorvastatin was discontinued at the time of discharge. . # airway protection: the patient was intubated prior to admission to the intensive care unit due to altered mental status in the setting of symptomatic bradycardia. he was successfully extubated on admission to the ccu. . # systolic congestive heart failure: most recent echo prior to admission demonstrated ef of 20%. an echo on admission was similar demonstrating more dysynchronous lv function. the patient was continued on lisinopril at his outpatient dose of 5mg daily. . # hypertension: all antihypertensive medications were held given bradycardia, and then restarted after pacemaker placement, he was discharged on his home regimen. . # hypothyroid: the patient was continued on home synthroid at 225mcg daily. free t4 was normal with elevation of tsh. he was dischargard on his home dose with outpatient pcp follow up for further titration of his synthroid. . # glaucoma: continued on his outpatient eye drop regimen . transitional care: 1. code: full 2. follow-up: needs coumadin monitoring and pcp follow up for titration of his synthroid dose given elevated tsh. he will follow up with the ep device clinic and also with dr. for continued outpatient cardiology care. medications on admission: - amiodarone 300mg daily - synthroid 225mcg daily - lisinopril 2.5mg - asa 81mg daily - lasix 40mg daily - coumadin 5mg 5 days per week, 2.5mg on m and f - eye drops for glaucoma discharge medications: 1. cephalexin 500 mg capsule sig: one (1) capsule po q8h (every 8 hours) for 3 days. :*8 capsule(s)* refills:*0* 2. outpatient lab work please have your pt/inr checked on tuesday at the . please have this faxed to your pcp. 3. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 4. brimonidine 0.15 % drops sig: one (1) drop ophthalmic hs (at bedtime). 5. lisinopril 5 mg tablet sig: 0.5 tablet po twice a day. 6. furosemide 40 mg tablet sig: one (1) tablet po once a day. 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. warfarin 2.5 mg tablet sig: as directed tablet po once a day: take 1 tablet on monday and friday. 9. tramadol 50 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain: this medication can cause drowsiness. . :*15 tablet(s)* refills:*0* 10. synthroid 200 mcg tablet sig: one (1) tablet po once a day. 11. synthroid 25 mcg tablet sig: one (1) tablet po once a day. 12. amiodarone 200 mg tablet sig: 1.5 tablets po once a day. 13. warfarin 5 mg tablet sig: one (1) tablet po as directed: take 1 tablet tues, weds, thurs, sat, sun. discharge disposition: home with service facility: discharge diagnosis: symptomatic bradycardia permanent pacemaker placement chronic systolic congestive heart failure coronary artery disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , you were recently admitted to the cardiac intesive care unit for a low heart rate, which made you feel ill. you presented intubated (tube in your lungs helping you breathe), which was quickly taken out. you had a pacemaker placed to help keep your heart rate within a normal range. you tolerated this procedure well. . in the hospital we found that your thyroid is not working properly. for this reason your thyroid medication (synthroid) may need to be adjusted. please remember to take this medication daily and follow up with your primary care physician to address this. . we are making a few changes to your outpatient medications: -please start keflex 500mg by mouth every 8 hours for the next three days -please start tramadol 25mg by mouth every 6hrs as needed for pain ***this can cause drowsiness, do not take this medication when doing activity. -please continue to take your coumadin at the same dose (5mg every day except for 2.5mg on monday on friday). we spoke with the at . please have your labs drawn on tuesday for pt/inr. they will adjust your dose as needed. . -please continue to take your other medications as instructed weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please follow-up with the following appointments: name: ,perminder address: , , phone: appt: at 11:30am department: cardiac services when: monday at 3:00 pm with: device clinic building: sc clinical ctr campus: east best parking: garage name: , location: cardiology address: , , ma phone: appt: at 2:30pm Procedure: Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Artificial pacemaker rate check Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified acquired hypothyroidism Unspecified glaucoma Other specified cardiac dysrhythmias Other left bundle branch block Chronic systolic heart failure Long-term (current) use of anticoagulants

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: doe major surgical or invasive procedure: s/p avr(21mm aortic ce magna pericardial)/mvr(25mm metronic mosaic porcine)/cabgx2(lima->lad, svg->pda)/septal myomectomy history of present illness: 69 yo m with exertional sob, echo at osh showed severe as and cath showed 2vd. past medical history: htn, dm2, ^chol, hypothyroid, arthritis, hyst social history: stay at home mom 40 pack year tob no etoh family history: brothers with in their 50s physical exam: elderly female in nad full dentures lungs ctab rrr 4/6 sem ->carotids abd with well healed incisions, soft, nt/nd extrem warm, no edema brief hospital course: she was taken to the operating room on where she underwent an avr (21 mm ce magna pericardial)/cabg x 2 (lima->lad, svg->pda), mvr (25 mm mosaic porcine mitral) and spetal myomectomy. she was transferred to the csru in critical but stable condition paced with complete heart block. she was extubated and weaned form her vasoactive drips later that same day. she remained in complete heart block and was seen by electrophysiology. on she was reintubated and had a sigma dual chamber pacemaker placed. she was extubated on . a hit panel, which was sent for a platelet count of 63, was negative. she went into aflutter and was started on amiodarone and heparin and coumadin. she was transferred to the floor on pod #5. she converted to sinus rhythm. her amiodarone was decreased due to prolonged qtc. her activity was advanced with nursung and pt. she was ready for discharge home on pod 10. medications on admission: synthroid, kcl, lisinopril, lovastatin, metformin, atenolol. glyburide discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*50 tablet(s)* refills:*0* 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 5. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. lovastatin 40 mg tablet sig: one (1) tablet po once a day. 8. metformin 500 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 9. metformin 500 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 10. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily): 400mg qd x 1 week then 200mg qd. disp:*36 tablet(s)* refills:*2* 11. lisinopril 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 12. warfarin 2 mg tablet sig: as directed tablet po once a day: pt to take 2mg on then as directed by dr . disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: vna of greater / discharge diagnosis: aortic stenosis htn niddm ^chol hypothyroidism s/p avr/mvr/cabg/septal myomectomy s/p ppm discharge condition: good. discharge instructions: follow medications on discahrge instructions. do not drive for 4 weeks. do not lift more than 10 lbs. for 2 months. shower daily, let water flow over wounds, pat dry with towel. call our office for temp>101.5, sternal drainage. followup instructions: make an appointment with dr. for 1-2 weeks. make an appointment with dr. for 2-3 weeks. make an appointment with dr. for 4 weeks. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Excision or destruction of other lesion or tissue of heart, open approach (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Open and other replacement of mitral valve with tissue graft Transfusion of packed cells Transfusion of platelets Artificial pacemaker rate check Diagnoses: Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Atrial fibrillation Atrial flutter Atrioventricular block, complete Mitral valve insufficiency and aortic valve stenosis Osteoarthrosis, unspecified whether generalized or localized, site unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: sternal click major surgical or invasive procedure: sternal debridement with re-wiring emergency resternotomy for cardiac tamponade mediastinal washout/sternal plating/bil. pectoralis flaps picc line placement history of present illness: mr. is a 69 year old male who recently cabg on by dr. . his postoperative course was relatively uneventful. since discharge, he has been concerned about his chest incision. patient stated he felt a "click" when he coughed. he also noted a small amount of erythema and serous drainage. his temperature at home has been at most, 100 f. he has been short of breath with increasing fatigue and unable to do his daily chores. given the above complaints, he presented to the ed and was subsequently admitted for further evaluation and treatment. past medical history: coronary artery disease - s/p recent cabg on chronic obstructive pulmonary disease hypertension history of syncope depression benign prostatic hypertrophy gerd anxiety chronic back issues history of bladder cancer - s/p excision and bcg treatment social history: married, lives with his wife, 5 children. he is a retired truck driver and currently helps out in his son??????s restaurant. +tobacco 1ppd x 55 years. occasional etoh. family history: noncontributory physical exam: vitals: t 98.3, bp 128/74, hr 94, rr 22, sat 97 on 3l general: well developed male in no acute distress heent: oropharynx benign, neck: supple, no jvd, heart: regular rate, normal s1s2, no murmur or rub lungs: bibasilar crackles noted abdomen: soft, nontender, normoactive bowel sounds ext: warm, 1+ edema, pulses: palpable distally neuro: nonfocal sternum: positive click, no drainage, minimal erythema pertinent results: chest ct scan: sternal dehiscence with an extensive fluid collection extending along the entire length of the sternum. while this measures simple fluid density, infection cannot be excluded. bilateral pleural effusions measuring simple fluid density. echo: there is a moderate sized pericardial effusion. the effusion appears circumferential. there are no echocardiographic signs of tamponade. le u/s: 1. right lower extremity: extensive thrombosis of the right femoral vein along its entire length and no significant internal flow. 2. left lower extremity: no evidence for dvt. echo: the right atrium is moderately dilated. a mass/thrombus associated with a catheter/pacing wire is seen in the right atrium and/or right ventricle. this mass disappeared later in the exam. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. the left ventricular cavity is unusually small and hyperdynamic. there is mild lvh. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. right ventricular systolic function is borderline normal. there are simple atheroma in the aortic arch and the descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. moderate to severe tricuspid regurgitation is seen. all findings discussed with surgeons at the time of the exam. ue u/s: persistent areas of intraluminal thrombus in the left ij, and within the superficial veins of the left and right cephalic veins, and new thrombus in the superficial left basilic vein. 05:45pm blood wbc-12.8*# rbc-3.59* hgb-10.4* hct-30.1* mcv-84 mch-28.9 mchc-34.5 rdw-15.5 plt ct-578*# 01:06am blood wbc-20.1* rbc-2.50* hgb-7.1* hct-20.6* mcv-83 mch-28.6 mchc-34.7 rdw-16.0* plt ct-601* 03:02am blood wbc-30.5* rbc-3.08* hgb-9.6* hct-27.8* mcv-90 mch-31.2 mchc-34.6 rdw-16.2* plt ct-188 05:18am blood wbc-11.5* rbc-2.97* hgb-8.8* hct-26.3* mcv-89 mch-29.5 mchc-33.3 rdw-15.6* plt ct-446* 05:45pm blood pt-12.3 ptt-30.4 inr(pt)-1.1 10:56pm blood pt-28.1* ptt-80.3* inr(pt)-2.9* 05:18am blood pt-25.2* ptt-30.9 inr(pt)-2.5* 05:45pm blood glucose-102 urean-23* creat-1.5* na-133 k-4.9 cl-99 hco3-26 angap-13 03:20am blood glucose-115* urean-21* creat-1.4* na-136 k-4.0 cl-106 hco3-22 angap-12 05:18am blood glucose-103 urean-23* creat-1.3* na-136 k-3.5 cl-99 hco3-28 angap-13 06:00pm blood heparin dependent antibodies-negative brief hospital course: mr. was admitted with sternal instability and chest ct scan which confirmed sternal dehiscence. it was also notable for an extensive fluid collection extending along the entire length of the sternum. he was empirically started on antibiotics and taken to the operating room on for sternal re-wiring. there was no evidence of sternal wound infection. postoperatively, he was maintained on antibiotics and wound irrigation. on in the early am, he became acutely hypotensive and increased his chest tube drainage. transferred to the csru, swan placed, and transfused one unit. emergent echo revealed a moderate sized pericardial effusion that appeared circumferential. his chest was ultimately opened emergently in the unit for washout, and returned to the or for complete washout and a hole in the vein graft was sutured closed. please see op reports for surgical details. following surgery he was transferred to the with open chest and plastic surgery was consulted regarding sternal plating. the following day he was brought back to the operating room for chest closure. echo done at that time revealed an acute pulmonary embolism/thrombus in the ra/rv. this mass/thrombus disappeared later on exam. he then sternal plating closure/bil. pectoralis flaps done by plastic surgery. following surgery he was again transferred back to the csru for invasive monitoring. argatroban started for presumed hit (eventually came back negative) and hematology consulted. on he was weaned from sedation, awoke neurologically intact and extubated. following extubation a bedside swallow study was done, which he initially failed, but repeated with improvement. also on he was transferred to the sdu for further care. extremity u/s revealed thrombus in his right femoral vein, left ij, superficial veins of the left and right cephalic veins, and in the superficial left basilic vein. on a picc line was placed. although operative wound cultures were eventually negative, per id, he will receive 4 weeks of vancomycin for high risk of sternal contamination. he continued to improve and worked with physical therapy during his post-op course for strength and mobility. on he was discharged to rehab facility with the appropriate follow-up appointments. of note, he will remain on coumadin for dvt/pe for minimum of 6 months. medications on admission: lasix 20 aspirin 81 qd plavix 75 qd lipitor 20 qd lisinopril 5 qd lopressor 25 detrol 4 qd discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 2. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 9. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 11. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 13. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 14. zinc sulfate 220 (50) mg capsule sig: one (1) capsule po daily (daily). 15. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily). 16. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 17. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q12h (every 12 hours) for 1 months: via picc line. 18. haloperidol 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 19. furosemide 20 mg tablet sig: one (1) tablet po twice a day for 7 days. 20. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po twice a day for 7 days. 21. warfarin 1 mg tablet sig: one (1) tablet po daily (daily): please adjust for an inr (for dvt/pe). discharge disposition: extended care facility: - discharge diagnosis: sternal instability/dehiscence - s/p sternal re-wiring pulmonary embolism dvts of lij, right superficial femoral pmh: coronary artery disease - s/p recent cabg on , chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, anxiety, history of bladder cancer - s/p excision and bcg treatment discharge condition: good discharge instructions: patient may shower, no baths. please shower daily. 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: dr. in weeks, call for appt dr. in weeks, call for appt dr. in days, call for appt Procedure: Venous catheterization, not elsewhere classified Reopening of recent thoracotomy site Other repair of chest wall Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Local excision of lesion or tissue of bone, scapula, clavicle, and thorax [ribs and sternum] Attachment of pedicle or flap graft to other sites Suture of vein Transfusion of packed cells Internal fixation of bone without fracture reduction, scapula, clavicle, and thorax [ribs and sternum] Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Disruption of internal operation (surgical) wound Aortocoronary bypass status Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hemorrhage complicating a procedure Iatrogenic pulmonary embolism and infarction Other complications due to other cardiac device, implant, and graft Personal history of malignant neoplasm of bladder

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: recurrent ventral herniation with omentum up in the anterior chest major surgical or invasive procedure: ventral hernia repair, placement of surgimend and omentectomy. sternal plate removal. history of present illness: mr. is a 72 y.o. male with pmh significant for cad s/p cabg (), copd, htn who presents with recurrent ventral hernia. approximately three years ago (), the patient had a sternal repair done with plates. he had an omental transfer and at that time a ventral hernia repair to the anterior fascia at the bottom of sternotomy lead to a hernia. this was actually repaired primarily and reinforced with mesh. a separate new hole was made through the diaphragm for the omental transfer. over time omentum and bowel has protruded up through this hole in the diaphragm, as evidenced on a recent ct. he now comes in for repair of this defect. in addition was planning on removal of his plates as he was having some discomfort. he understood we could not guarantee success and further intervention may be required. past medical history: coronary artery disease s/p 5 vessel cabg bladder cancer bph anxiety copd history of dvt and pe (in treated with ? 6 months of coumadin) social history: he smoked one pack per day for over 59 years, active until , drinks alcohol socially ( 1 drink per month). no illicits. retired truck driver. lives with wife independent in adls. family history: father lung ca brother throat ca sister leukemia brother colon ca sister pancreatic ca physical exam: general: comfortable and in nad heent: ncat, sclerae anicteric. mmm. pulm: ctab, no rales/rhonchi/wheezes cvs: rrr with no murmur/gallop/rubs; s/p sternotomy. hardware palpable abd: soft/nt/nd ext: no c/c/e pertinent results: initial labs: 06:15am blood wbc-15.6*# rbc-5.01 hgb-14.4 hct-42.2 mcv-84 mch-28.7 mchc-34.1 rdw-14.6 plt ct-224 06:15am blood glucose-124* urean-19 creat-1.0 na-140 k-4.2 cl-106 hco3-25 angap-13 06:15am blood calcium-8.0* phos-3.4 mg-1.9 cardiac enzymes: 07:00pm blood ck(cpk)-342* ck-mb-6 ctropnt-0.03* 08:33am blood ck(cpk)-347* ck-mb-6 ctropnt-0.03* abg's: prior to intubation - 03:22pm blood type-art po2-70* pco2-75* ph-7.22* caltco2-32* base xs-0 after intubation - 06:48pm blood type-art po2-84* pco2-50* ph-7.36 caltco2-29 base xs-1 prior to icu call-out - 03:06pm blood type-art po2-64* pco2-41 ph-7.53* caltco2-35* base xs-10 12:35pm blood lactate-1.0 02:50pm blood lactate-1.7 blood and sputum cx - no growth to date. ecg () - sinus rhythm. normal tracing. since the previous tracing of sinus bradycardia is absent. cxr () - mild bibasilar atelectasis documented on the cta performed subsequently, 8:00 a.m. on and available at the time of this dictation, in combination with pulmonary embolism demonstrated on that study is sufficient to explain hypoxia. there is no pulmonary edema. heart size is probably normal and unchanged. there is no pulmonary edema. left pleural thickening is chronic. echo () - the left atrium is mildly dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is no ventricular septal defect. rv appears to have normal free wall contractility (poor image quality). there is abnormal septal motion/position. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. tricuspid regurgitation is present but cannot be quantified. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the rv funciton has probably improved. if indicated, a cardiac mri may better assess rv size and systolic function. cxr () - impression: asymmetric pulmonary edema, new since one day prior. cta chest () - impression: 1. left upper lobe lobar pulmonary embolism. 2. partial right lower lobe collapse due to a combination of dependent secretions and bronchial wall thickening, with associated surrounding peribronchial lymph nodes which are probably reactive; however, a followup ct is recommended in four to six weeks to ensure resolution. 3. diffuse ground-glass opacities superimposed on centrilobular emphysema are most likely infectious (such as viral in origin); aspiration and asymetrical edema are less likely. 4. large fatty lesion posterior to the left scapula contains internal septations; considering large size and septations, a dedicated mri with contrast is recommended for further evaluation to help distinguish a lipoma from a low grade liposarcoma. 5. new ventral hernia mesh with postoperative changes in the soft tissues of the anterior chest and upper abdomen. 6. diffuse coronary artery calcification with cabg. bilateral lenis () - impression: no evidence of dvt of bilateral lower extremities. brief hospital course: the patient was taken to the operating room for a joint procedure between dr. of plastic surgery and dr. of general surgery. he the following procedures: (1) repair of chest wall hernia (dr. (2) ventral hernia repair, placement of surgimend and omentectomy. sternal plate removal (dr. . the patient tolerated the procedure well and was transferred to the floor for routine post operate care. he initially had poor pain control and his pca was titrated up. he was kept strictly npo until return of bowel function. unfortunately, he developed acute respiratory distress during the early morning hours of that necessitated transfer to the medical intensive care unit. . # pulmonary: on pod 2, the patient was transferred to the icu for ongoing respiratory distress and hypoxia. he had been on 4l nc since he was in the or; however, he desaturated to the high 80's. also, he had had ongoing difficulty with deep breaths secondary to abdominal pain. cta during this decompensation showed pulmonary embolism. imaging was also concerning for underlying pneumonia as well as fluid overload. shortly after transfer to the icu, the patient was noted to have worsening hypercarbic respiratory failure and depressed mental status. ultimately, he was intubated on . the patient was started on antibiotics to cover for his pneumonia (see below). diuresis was intially limited hypotension; however, his blood pressures improved and he was ultimately diuresed. after a few days of antibiotics and diuresis, the patient's respiratory status improved. his sedating medications were weaned and he was ultimately extubated on . he was called out to the floor on the day following his extubation and remained stable from a pulmonary standpoint. . during the initial workup of his respiratory distress, a left upper lobe lobar pulmonary embolism was noted on cta. of note, patient does have a history of clots right femoral vein, left ij, superficial veins of the left and right cephalic veins, superficial left basilic vein, and pulmonary embolism in setting of surgery for cardiac tamponade s/p cabg . per hematology patient should have a minimum of 6 months of anticoagulation. in 2 months the patient will follow-up with hematology for additional work-up and determination of total length of anticoagulation. mr. was initially on a conservative heparin drip given he is recently post-operative. he was continued on heparin until his inr was therapeutic. . he continued on oxygen via nasal cannula at a rate of 4 lpm for the remainder of his admission and was maintaining an oxygen saturation > 94%. he continued pulmonary toilet with incentive spirometry. he responded well to intermittent doses of lasix and was started on standing lasix 20mg by mouth daily. . pneumonia - patient with likely pneumonia based on imaging and clinical history (reported approximately 1 week of cough during the week prior to surgery). large amount of secretions noted during intubation. pt started on levofloxacin on admission to icu. after intubation, ceftriaxone was added as double-coverage to treat for severe cap. sputum and blood cx were sent but had no growth to date at the time of transfer out of the icu. on transfer out of the icu, the patient was continued on levofloxacin / ceftriaxone with an end date of . . # neuro: post-operatively, the patient received dilaudid via pca initially with poor pain control that was then transitioned to po dilaudid with good effect and adequate pain control. . # cv: patient had troponin leak in setting pneumonia and pulmonary embolism felt to be demand. the patient was evaluated by the cardiology service during this admission. they recommended that the patient should discuss with his outpatient cardiologist the utility of continuing plavix, given the anticoagulation that will be started for his pe. plavix was restarted towards the end of the hospital admission. . multiple ekgs were performed throughout this hospitalization that did not detect any new st or t wave abnormalities or any other findings concerning for ischemia. . # gi/gu: post-operatively, the patient was given iv fluids until tolerating oral intake. his diet was advanced when appropriate, which was tolerated well. he was also started on a bowel regimen to encourage bowel movement. intake and output were closely monitored, and urine output was noted to be marginal on several occasions. the patient initially received boluses of ivf with improvement in his urine output. after these boluses, however, the patient was thought to be in fluid overload and received lasix. his urine output increased with lasix, as well. . the patient was continued on his home dose of finasteride for his bph. . id: the patient was started on antibiotics for hospital acquired pneumonia as above. the patient's temperature was closely watched for signs of infection. . # hematology: the patient's hematocrit did trend downwards slightly after his transfer to the icu. hematocrit was followed and remained stable thereafter. of note, when patient was intubated, og tube was placed and moderate amount of brown guaiac positive liquid was aspirated back; patient was kept on heparin gtt and started on iv ppi. when his plavix was restarted, his ppi was transitioned to an h2 blocker due to the interaction between these two medications. . # musculoskeletal: the patient had difficulty ambulating and getting out of bed. this was thought to be due to deconditioning. a pt consult was requested and the patient vigorous physical therapy. he will require continued physical therapy at rehab. . # prophylaxis: the patient was maintained on subcutaneous heparin after his operation. he was transitioned to heparin drip at the time of his pulmonary embolism, and eventually was started on coumadin. at the time of his discharge, his inr was 4.1 (). his inr from was still pending. medications on admission: albuterol aerosol 4 puffs daily amlodipine 10 mg po daily aspirin 81 mg daily atenolol 25 mg po daily atrovent 4 puffs daily citalopram 60 mg po daily lisinopril 40 mg po daily folic acid 1 mg po daily iron 65 mg po daily vytorin 10/80 mg po daily omeprazole 40 mg po daily oxycodone 5-10 mg po bid:prn plavix 75 mg daily finasteride 5 mg po daily discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. citalopram 20 mg tablet sig: three (3) tablet po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever: max 4000 mg tylenol/day. 7. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours). 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q2h (every 2 hours) as needed for sob, wheezing. 9. nicotine 7 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 10. potassium & sodium phosphates 280-160-250 mg powder in packet sig: two (2) powder in packet po tid (3 times a day). 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q4h (every 4 hours). 12. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 13. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 14. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 15. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 16. levofloxacin 750mg po daily: last dose friday . 17. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours): last dose friday . 18. warfarin 1 mg tablet sig: dose as necessary for inr tablets po once a day. discharge disposition: extended care facility: - discharge diagnosis: 1) recurrent ventral herniation with omentum up in the anterior chest 2) pulmonary embolism 3) hospital acquired pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: personal care: 1. leave your chest dressing in place until your follow up appointment with dr. . if your dressings get wet underneath, you may remove them. 2. clean around the drain site(s), where the tubing exits the skin, with hydrogen peroxide. 3. strip drain tubing, empty bulb(s), and record output(s) times per day. 4. a written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. you may shower daily. no baths until instructed to do so by dr. . . activity: 1. you may resume your regular diet. 2. do not lift anything heavier than 5 pounds or engage in strenuous activity until instructed by dr. . . medications: 1. resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. you may take your prescribed pain medication for moderate to severe pain. you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging. please note that percocet and vicodin have tylenol as an active ingredient so do not take these meds with additional tylenol. 4. take prescription pain medications for pain not relieved by tylenol. 5. take your antibiotic as prescribed. 6. take colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. you may use a different over-the-counter stool softerner if you wish. 7. do not drive or operate heavy machinery while taking any narcotic pain medication. you may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . call the office immediately if you have any of the following: 1. signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. a large amount of bleeding from the incision(s) or drain(s). 3. separation of the incision. 4. severe nausea and vomiting and lack of bowel movement or gas for several days. 5. fever greater than 101.5 of 6. severe pain not relieved by your medication. . return to the er if: * if you are vomiting and cannot keep in fluids or your medications. * if you have shaking chills, fever greater than 101.5 (f) degrees or 38 (c) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * any serious change in your symptoms, or any new symptoms that concern you. . drain discharge instructions you are being discharged with drains in place. drain care is a clean procedure. wash your hands thoroughly with soap and warm water before performing drain care. perform drainage care twice a day. try to empty the drain at the same time each day. pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. record the amount of drainage fluid on the record sheet. reestablish drain suction. followup instructions: please follow up with dr. on tuesday, at 9am at his office. . you are scheduled to see dr. , a hematologist, on at 10:30 am on , clinical center. dr. will determine how long you should remain on coumdin. phone: please follow-up with your primary care provider . - to follow-up on your recent hospitalization and to monitor your coumadin dose. your goal inr is . your first inr check out of the hospital will be on . please follow-up with your cardiologist dr. discuss your recent hospitalization and determine if you should re-start plavix. you should also call the pulmonary clinic as soon as possible for the next availabe appointment. their telephone number is (. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Other repair of chest wall Excision or destruction of peritoneal tissue Other open incisional hernia repair with graft or prosthesis Removal of implanted devices from bone, scapula, clavicle, and thorax [ribs and sternum] Application or administration of an adhesion barrier substance Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Coronary atherosclerosis of unspecified type of vessel, native or graft Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Pulmonary collapse Anxiety state, unspecified Incisional hernia without mention of obstruction or gangrene Iatrogenic pulmonary embolism and infarction Personal history of malignant neoplasm of bladder Other respiratory complications

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: positive stress test ; chest pain during hypertension to 220/110 major surgical or invasive procedure: cardiac catheterization cabgx5 (lima-lad,svg-diag,svg-om1,svg-om2,svg-pda) history of present illness: mr. is a 69 yo m w/ h/o htn and significant tobacco use, who had a severe headache on without associated symptoms (including weakness, visual changes), and was found to be hypertensive to 220/110. he was transferred via ambulence to hospital and in route complained of right sided chest discomfort, associated with dyspnea and diaphoreiss. by report he was administered sl ntg and nitro paste with improvement in bp and chest discomfort. he subsequently underwen ett with pmibi which demonstrated a perfusion deficit at rest and was referred to for cardiac catheterization and renal artery angiogram. . mr. also reports decreased exercise tolerance over the past several months - previously he would be able to climb several flights of stairs without difficulty; he currently gets extremely dypsneic after 10 steps (<1 flight); no associated cp, n, or diahphoresis. he denies orthopnea and pnd. . he denies history of angina or cad. . mr. cardiac catheterization today and was found to have 3vd, and a cabg is now planned. he took a dose of plavix this morning. . ros: denies recent illness, fevers, hematuria, melena, bloody stools, abdominal pain, le swelling. reports 8lb intentional weight loss (healthier diet) referred for cabg . past medical history: htn gerd bladder ca s/p excision x 2 and the bcg treatment syncopal episodes x 3 (episodes accompanied by diaphoresis and nausea) with the last episode many years ago h/o pneumonia x 3 depression chronic back problems including disc herniation, s/p disc surgery anxiety copd bph social history: married, lives with his wife, 5 children. he is a retired truck driver and currently helps out in his son??????s restaurant. +tobacco 1ppd x 55 years. occasional etoh. no illicits family history: noncontributory (h/o cancer) physical exam: 138/61 51 16 100% ra 5'" wt:220 lbs gen: nad, smiling heent: aniecteric, perrl, eomi, mmm, no jvd, no bruits cv: regular rhythm, ~60, no m/r/g chest: ctab abd: soft, nt/nd r groin: dressing c/d/i, no bruit or thrill ext: 2+ dp pulses bilaterally neuro: a&ox3, fluent speech, normal ambulation, mae pertinent results: 10:33am blood wbc-6.3 rbc-4.50* hgb-12.6* hct-35.9* mcv-80* mch-27.9 mchc-35.0 rdw-15.2 plt ct-193 10:33am blood glucose-98 urean-21* creat-1.0 na-137 k-4.1 cl-107 hco3-24 angap-10 10:33am blood alt-8 ast-12 alkphos-63 totbili-0.5 10:33am blood %hba1c-5.1 . recent testing: : echo showed a normal lv size and function. ef of 60-65%. the valves were all normal with trace tr. pulmonary systolic pressure was estimated to be 30-35%. : nuclear stress test where the patient exercised for 6 minutes 57 seconds on protocol stopping due to shortness of breath and leg pain. he achieved 68% of his predicted target heart rate. he did not develop any arrhythmias or chest pain. the nuclear images demonstrated a normal sized left ventricle. there was a moderate sized reversible perfusion abnormality involving the anteroapical and septal portion left ventricle. there was also a question of a small reversible abnormality involving the inferolateral portion left ventricle. the left ventricular wall motion was normal. the lvef was 62%. . cardiac catheterization comments: 1. coronary angiography of this right dominant system revealed severe three vessel coronary artery disease. the left main coronary artery had no angiographically apparent flow limiting stenoses. the lad was ectatic proximally and occluded in the mid segment after a small diagonal. the lcx had a 90% stenosis of the om1 proximally and a 50% followed by a 70% stenosis in the proximal and mid segment of the om2. the rca had a 90% stenosis in the mid pda. 2. limited resting hemodynamics revealed mildly to moderately elevated left sided filling pressures (lvedp was 18 mm hg). systemic arterial pressure was normal (aortic pressure was 121/73 mm hg). there was no significant gradient across the aortic valve upon pullback of the catheter from the left ventricle to the ascending aorta. 3. left ventriculography revealed a contrast calculated ejection fraction of 65%. no mitral regurgitation was noted. 4. bilateral selective renal angiography demonstrated widely patent renal arteries. final diagnosis: 1. three vessel coronary artery disease. 2. normal left ventricular systolic function. 3. mildly to moderately elevated left sided filling pressures. 4. no angiographically apparent renal artery stenosis. . pulmonary function tests: 06:25am blood wbc-7.3 rbc-3.17* hgb-9.1* hct-26.3* mcv-83 mch-28.7 mchc-34.6 rdw-15.5 plt ct-201# 06:25am blood plt ct-201# 06:25am blood glucose-101 urean-14 creat-1.3* k-5.1 cardiology report echo study date of patient/test information: indication: chest pain. coronary artery disease. hypertension. status: inpatient date/time: at 10:41 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2007aw2-: test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. measurements: left ventricle - septal wall thickness: *1.5 cm (nl 0.6 - 1.1 cm) left ventricle - ejection fraction: 45% to 50% (nl >=55%) aorta - ascending: *3.7 cm (nl <= 3.4 cm) aortic valve - peak velocity: 1.4 m/sec (nl <= 2.0 m/sec) interpretation: findings: left atrium: normal la size. no spontaneous echo contrast in the body of the la. no spontaneous echo contrast or thrombus in the body of the laa. right atrium/interatrial septum: normal ra size. a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: mild symmetric lvh with normal cavity size. mild symmetric lvh. normal lv cavity size. mild regional lv systolic dysfunction. no lv mass/thrombus. mildly depressed lvef. transmitral doppler and tvi c/w normal lv diastolic function. no resting lvot gradient. lv wall motion: regional lv wall motion abnormalities include: anterior apex - hypo; right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. normal aortic arch diameter. simple atheroma in aortic arch. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. mildly thickened aortic valve leaflets. no as. trace ar. mitral valve: normal mitral valve leaflets with trivial mr. mild mitral annular calcification. no ms. physiologic mr (within normal limits). tricuspid valve: normal tricuspid valve leaflets with trivial tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: trivial/physiologic pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient received antibiotic prophylaxis. the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope. the patient was under general anesthesia throughout the procedure. conclusions: pre-cpb: 1.the left atrium is normal in size. no spontaneous echo contrast is seen in the body of the left atrium. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. 2. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with apical anterior hypokinesis.. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is mildly depressed. transmitral doppler and tissue velocity imaging are consistent with normal lv diastolic function. 3. right ventricular chamber size and free wall motion are normal. 4. the ascending aorta is mildly dilated at a maximum of 3.7. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. 6. the mitral valve appears structurally normal with trivial mitral regurgitation. physiologic mitral regurgitation is seen (within normal limits). 7. there is a trivial/physiologic pericardial effusion. post-cpb: patient is on phenylephrine infusion. preserved biventricular systolic function with improvement of the anteroapical hypokinetic segment. lvef now 55%. trace mr. aortic contour is normal post decannulation. electronically signed by , md on 15:02. physician: () radiology final report chest (pa & lat) 11:20 am chest (pa & lat) reason: r/o ptx medical condition: 69 yom s/p cabg and ct removal reason for this examination: r/o ptx two view chest of . comparison: indication: chest tube removal. various lines and tubes have been removed since the prior radiograph, and a very small left apical pneumothorax has developed. cardiac and mediastinal contours are within normal limits for postoperative status of the patient. small pleural effusions and minor bibasilar atelectasis are noted. these findings are superimposed upon subtle likely more chronic peripheral and basilar interstitial lung disease. on the lateral view, small air-fluid level is present in the retrosternal region likely representing an anterior hydropneumothorax, and additional air is present in the retrosternal region, an expected postoperative finding given the time interval since surgery. impression: small left pneumothorax following tube removal. bibasilar atelectasis and small pleural effusions. dr. approved: mon 1:12 pm brief hospital course: a/p: this is a 69 yo m w/ h/o htn and significant tobacco use, who presents for cardiac catheterization after abnormal perfusion scan, which revealed 3vd, prompting cabg. . #cad: -medication regiment modified: continue asa, bb, imdur; minoxidil discontinued and acei started. . #htn: well controlled on bb, imdur, and acei . #bph: continue proscar . #bladder spasm s/p surgery and bcg tx: continue detrol . #gerd: continue ranitidine . #depression/anxiety: continue celexa . #h/o syncope: by report worked up extensively at w/o diagnosis -carotid u/s normal -no events on telemetry . #copd: per patient, recent diagnosis based on cxr at during last hospitalization, not on any active medications -no wheeze, no respiratory distress, good o2 sat -pfts performed and carotid u/s showed no significant stenoses. cabg x5 with dr. on . transferred to the csru in stable condition on titrated phenylephrine and propofol drips.extubated that evening and transferred to the floor on pod #1 to begin increasing his activity level. chest tubes and pacing wires removed on pod #3.nicotine patch continued. made good progress and cleared for discharge to home with vna on pod #4. pt. is to make all follow-up appts. as per discharge instructions. medications on admission: lasix 20 mg daily minoxidil 25 mg daily detrol 4 mg daily ranitidine 300 mg atenolol 25 mg pro-chlor 20 meq daily plavix 75 mg daily (pt started 2 weeks ago but stopped 4 days ago and will restart 4/20/070) celexa 40 mg daily endocet 5/325 mg prn asa 81 mg daily proscar 5 mg daily imdur 30 mg daily ntg 0.4 mg sl discharge medications: 1. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours): 20mg x7days then 20mg qd x10 days. disp:*24 tablet(s)* refills:*0* 2. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours): 20 meq x 7 days then 20meq qd x 10 days. disp:*48 capsule, sustained release(s)* refills:*0* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 7. atorvastatin 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily) for 2 weeks. disp:*14 patch 24 hr(s)* refills:*0* 9. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 11. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. citalopram 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 13. detrol 2 mg tablet sig: two (2) tablet po once a day. 14. lisinopril 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease, s/p cabgx5 pmh:hypertension,hyperlipidemia,gerd,bladder ca,depression,copd,bph 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 no driving for one month no lifting greater than 10 pounds for 10 weeks followup instructions: wound clinic in 2 weeks ( 2) dr in weeks dr in 4 weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Diagnostic ultrasound of heart (Aorto)coronary bypass of four or more coronary arteries Arteriography of renal arteries Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Intermediate coronary syndrome Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Personal history of malignant neoplasm of bladder

history of present illness: the patient is a 68-year-old gentleman with a significant cardiac history with coronary artery disease (status post coronary artery bypass graft), hypertension, congestive heart failure, hyperlipidemia, and diabetes mellitus who presented with worsening congestive heart failure of several months in duration with new onset chest pressure. the patient was in his usual state of health until three days prior to admission when he began to experience increasing shortness of breath at rest and with exertion. however, the patient was still able to walk his dog for approximately one half of a mile per day. no paroxysmal nocturnal dyspnea. no orthopnea. minimal bilateral lower extremity edema at baseline. the patient had one episode of chest pressure (his anginal equivalent) with exertion three days prior to admission which resolved after one hour. on the day prior to admission, the patient had a second episode of chest pressure, substernal, and without radiation. no associated nausea, vomiting, or palpitations. mild diaphoresis and lightheadedness. the patient took one sublingual nitroglycerin, and his pain score went down to 7/10, and he presented to the emergency department for evaluation. in the emergency department, the patient's chest pressure was relieved with aspirin, heparin, nitroglycerin, and integrilin. he also received metoprolol intravenously. he did continue to be short of breath despite receiving 80 mg of lasix intravenously on arrival. the initial electrocardiogram showed sinus tachycardia with a left bundle-branch block and left atrial abnormality, without any significant changed when compared to the previous tracing of . his initial creatine kinase was 326 with a troponin t of 0.31. of note, the patient denies fevers or chills. he has a slight cough with sputum. he is not on a low diet. no recent dietary indiscretion. past medical history: 1. coronary artery disease. (a) status post coronary artery bypass graft in ; left internal mammary artery to left anterior descending artery, saphenous vein graft to right coronary artery, and saphenous vein graft to diagonal. (b) persantine mibi on demonstrated a dilated left ventricle, partially reversible moderate perfusion defect in the anterior left ventricular wall, with moderate fixed deficits at the septal/inferior walls, global and left ventricular hypokinesis with an ejection fraction of 21%. 2. congestive heart failure; heart association class ii. an echocardiogram on with depressed left ventricular systolic function with an ejection fraction of 20%. 3. insulin-dependent diabetes mellitus. 4. hypertension. 5. hyperlipidemia. 6. onychomycosis. 7. status post appendectomy. 8. anemia with leukocytosis. 9. chronic obstructive pulmonary disease; last pulmonary function tests in with a mixed obstructive/restrictive deficit. medications on admission: 1. lisinopril 40 mg by mouth once per day. 2. lipitor 20 mg by mouth once per day. 3. cardura 2 mg by mouth q.h.s. 4. celexa 40 mg by mouth once per day. 5. coreg 12.5 mg by mouth q.a.m. 6. digoxin 0.25 mg by mouth every day. 7. lasix 80 mg by mouth once per day. 8. lumigan 0.03% drops q.h.s. 9. timoptic 0.25% drops both eyes q.a.m. 10. excedrin by mouth as needed. 11. nph insulin 95 units subcutaneously q.a.m. and 90 units subcutaneously at dinner. family history: family history was noncontributory for coronary artery disease. social history: the patient is a retired painter. he has been married times 44 years. he has a 60-pack-year history of tobacco; he quit 15 years ago. occasional alcohol use. no intravenous drug use. physical examination on presentation: physical examination on admission revealed his temperature was 98.4 degrees fahrenheit, blood pressure was 133/64, his heart rate was 107, his respiratory rate went from 40 to 24, and his oxygen saturation was 95% on 2 liters. in general, an elderly gentleman in no apparent distress. head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. pupils were equal, round, and reactive to light and accommodation. extraocular movements were intact. the neck was supple. no lymphadenopathy. no thyromegaly. cardiovascular examination revealed a regular rate. normal first heart sounds and second heart sounds. no murmurs, rubs, clicks, or gallops. pulmonary examination revealed decreased breath sounds at the bases bilaterally. no rales or wheezes. the abdomen was obese, soft, nontender, and nondistended. normal active bowel sounds. no hepatosplenomegaly or masses. extremity examination revealed 2+ pitting edema bilaterally to the knees. neurologic examination revealed alert and oriented times three. cranial nerves ii through xii were grossly intact. pertinent laboratory values on presentation: initial laboratories revealed creatine kinase was 326, ck/mb was 14, troponin t was 0.25, and mb index was 4.3. his white blood cell count was 7.8, his hematocrit was 33, and his platelets were 281. sodium was 135, potassium was 4.2, chloride was 99, bicarbonate was 28, blood urea nitrogen was 24, creatinine was 1.1, and blood glucose was 303. prothrombin time was 13.8, partial thromboplastin time was 25.2, and his inr was 1.3. pertinent radiology/imaging: a chest x-ray demonstrated cardiomegaly with pulmonary vasculature redistribution and a new lingular opacity (pneumonia versus asymmetric pulmonary edema), and a small calcified granuloma in the right upper lobe (as previously demonstrated). brief summary of hospital course by issue/system: the patient was admitted to the c-med service, placed on telemetry, and continued on his outpatient cardiac medications, as well as a nitroglycerin, heparin, and integrilin drips. 1. congestive heart failure issues: at baseline, the patient had been on 2 liters nasal cannula of home oxygen. his oxygen requirement remained stable while in house on 3 liters nasal cannula. he was saturating at 97%. an echocardiogram was performed on which demonstrated an ejection fraction of 20% with global hypokinesis; consistent with prior examination. the patient was continued on digoxin 0.25 mg by mouth once per day and lasix 80 mg intravenously once per day. daily weights and strict ins-and-outs were monitored. on the day of discharge, the patient no longer had edema of the lower extremities. he was saturating at 100% on 2 liters with his lungs clear to auscultation bilaterally. 2. coronary artery disease issues: the patient ruled in by enzyme criteria; however, his electrocardiogram continued to be unchanged with a left bundle-branch block at baseline. there was consideration of catheterization during this inpatient stay; however, given the patient's complications with gastrointestinal bleeds, as well as his reluctance to undergo this procedure, this was deferred. the patient underwent a chemical stress mibi on ; during which time he had no anginal symptoms or interpretable electrocardiogram changes. by verbal report, the nuclear portion of this study demonstrated fixed defects in the anterior/inferior walls with an ejection fraction of 20% and left ventricular cavity enlargement. 3. anemia/gastrointestinal bleed issues: the patient had an episode of melena on the morning of . he denied bright red blood per rectum, hematemesis, coffee-grounds emesis, nausea, vomiting, or abdominal pain. he had never had symptoms of gastrointestinal bleeding in the past. a nasogastric lavage demonstrated no active upper gastrointestinal bleed, and his vital signs remained stable with a stable hematocrit at 29.8. two large-bore intravenous lines were placed, and the patient was transfused a total of three units of packed red blood cells with 80 mg of intravenous lasix prior to this transfusion. he was also started on protonix 40 mg intravenously twice per day. the integrilin, heparin, and aspirin were held. a gastroenterology consultation was obtained, and an esophagogastroduodenoscopy was recommended and performed on the morning of . this demonstrated gastritis. nevertheless, due to the patient's gastrointestinal bleeding he was transferred to the medical intensive care unit because of concern over the initial hematocrit drop from 33 to 26 with a question of potential retroperitoneal bleed. on , when he was transferred to the medical intensive care unit, an abdominal and pelvic computed tomography without contrast was obtained which demonstrated some cholelithiasis without evidence for cholecystitis, and no evidence of retroperitoneal bleed. an anemia workup was continued, and iron studies demonstrated an elevated ferritin and decreased total iron-binding capacity suggesting likely anemia of chronic disease with acute anemia secondary to gastritis superimposed. the patient remained stable and was transferred back to the c-med service on the evening of . for the duration of his inpatient course, the patient's hematocrit remained stable at 32.7, and he did not experience subsequent episodes of melena or hematemesis. of note, the aspirin, heparin, and integrilin continued to be held (this contributed to the unwillingness to perform cardiac catheterization during this inpatient stay). 4. pneumonia issues: on admission chest x-ray, the patient was noted to have a lingular infiltrate that was felt to be new compared to prior studies. of note, the patient's white blood cell count was 7.8, but he did spike to 102.3 degrees fahrenheit on . thus, it was felt that the chest x-ray infiltrate was consistent with pneumonia, and he was started on levofloxacin 500 mg once per day for a 10-day course. the patient's chest x-ray gradually improved during his inpatient stay. on the day of discharge, his temperature was 99.6 with a white blood cell count of 13.3. of note, his maximum white blood cell count had been 13.9. the patient had been afebrile for 48 hours prior to discharge. 5. diabetes mellitus issues: the patient was placed on an insulin sliding-scale with four times per day fingersticks. his glucose remained within normal limits during this hospital course. 6. mental status change issues: the patient was minimally agitated during his medical intensive care unit stay. it was felt that this was likely baseline dementia with superimposed intensive care unit delirium. he did have a recent head computed tomography which showed no acute event. of note, his mental status was much improved upon transfer to the floor. discharge disposition: the patient was discharged on . his vital signs were stable. he was saturating at 100% on 2 liters nasal cannula. his creatine kinase levels had been dropping from 187 to 108 with a troponin of 0.31. he was asymptomatic. condition at discharge: condition on discharge was stable. discharge diagnoses: 1. acute non-st-segment myocardial infarction. 2. pneumonia. 3. coronary artery disease. 4. gastrointestinal bleed. medications on discharge: 1. lipitor 20 mg by mouth once per day. 2. celexa 20 mg by mouth by mouth twice per day. 3. doxazosin 2-mg tablets one tablet by mouth once per day. 4. timolol eyedrops 0.25% one both eyes q.a.m. 5. levofloxacin 500-mg tablets one tablet by mouth once per day (for a 10-day course with day one being on ). 6. lisinopril 40 mg by mouth once per day. 7. digoxin 250-mg tablets one tablet by mouth once per day. 8. carvedilol 12.5 mg by mouth twice per day. 9. protonix 40-mg tablets one tablet by mouth twice per day. discharge instructions/followup: 1. the patient was instructed to follow up with dr. in the medical building, suite b, on at 11 a.m. (telephone number ). 2. the patient was instructed to follow up with dr. in the building, on at 12:10 p.m. (telephone number ). 3. the patient was advised to call 911 or present to the nearest emergency department with symptoms of chest pressure, shortness of breath, jaw discomfort, palpitations, or diaphoresis. 4. the patient was advised to resume all outpatient medications; aside from aspirin. , m.d. dictated by: medquist36 d: 08:42 t: 14:08 job#: Procedure: Other endoscopy of small intestine Injection or infusion of platelet inhibitor Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic airway obstruction, not elsewhere classified Other specified cardiac dysrhythmias Unspecified gastritis and gastroduodenitis, with hemorrhage

allergies: inderal / bactrim / codeine / penicillins attending: chief complaint: epididymitis major surgical or invasive procedure: incision and drainage of fournier's gangrene history of present illness: the patient is a 75 year old male who was transferred from an outside hospital because of a suspected myocardial infarction on and possible need for cardiac catheterization. he was admitted to the cardiology service initially. his symproms actually began six days prior to admission with flu-like symptoms. then five days prior to admission, the patient began complaining of a painful lump in his left testicle. his symptoms gradually worsened, with increasing pain, erythema, and edema of his left testicle. in addition, he complained of difficulty urinating for two days prior to admission. he was admitted to an outside hospital four days prior to admission here, at which time a foley catheter was placed and he was started on iv levofloxacin and clindamycin (which was switched to levofloxacin and vancomycin the following day) for epididymitis diagnosed by ultrasound. the ultrasound also showed questionable air in the scrotum. the patient was seen by a urologist, dr. , as well as an infectious disease specialist. he denied any trauma to his scrotum. he has no significant urologic history. his prostate examination revealed a 20 to 25 gram nonfluctuent prostate. he is not diabetic and he is not immunocompromised. he reported that his pain has been improving on the antibiotics. however, on the night prior to admission he developed acute pulmonary edema, shortness of breath, hypotension and ekg changes suggestive of myocardial infarction (st elevation in leads v1- depression in v5-6). his peak troponin was 0.96. neo-synepherine was started upon admission because of hypotension, which was presumed to be secondary to sepsis. significant cardiac history includes a cabg in , hypertension, aortic stenosis, mitral regurgitation, high cholesterol, and congestive heart failure (ef of 40%). upon re-evaluation at this hospital, his ekg changes were thought to be secondary to demand ischemia, rather than a myocardial infarction. in addition, the patient was noted to be in acute renal failure, with a createnine of 1.8 on admission, likely due to prerenal causes. blood and urine cultures from the outside hospital were all negative. past medical history: as above. left femoral to popliteal bypass graft social history: none significant family history: none physical exam: general: no apparent distress heent: pupils equal, round and reactive to light, extraoccular muscles in tact neck: supple lungs: bibasilar crackles heart: irregularly irregular, 2/6 systolic ejection murmur diffusely gastrointestinal: soft, nontender, nondistended, bowel sounds positive genitourinary: enlarged (grapefruit sized) and edematous scrotum, can not palpate testicles due to edema, bilateral testicular tenderness (left greater than right), scrotal erythema extending faintly up the groin creases, penile edema, foley in place with dark yellow urine extremities: full range of motion and 5/5 strength in all four extremities neurologic: alert and oriented x 3, cranial nerves intact pertinent results: 01:17am blood wbc-18.2* rbc-3.82* hgb-12.5* hct-36.0* mcv-94 mch-32.6* mchc-34.6 rdw-14.0 plt ct-76* 03:48am blood wbc-14.0* rbc-4.01* hgb-12.5* hct-38.4* mcv-96 mch-31.2 mchc-32.6 rdw-14.6 plt ct-112* 08:02am blood wbc-14.0* rbc-3.32* hgb-10.5* hct-32.3* mcv-97 mch-31.6 mchc-32.5 rdw-14.6 plt ct-99* 01:20pm blood wbc-13.9* rbc-3.20* hgb-10.3* hct-30.2* mcv-95 mch-32.3* mchc-34.2 rdw-14.6 plt ct-99* 02:24am blood wbc-10.5 rbc-3.35* hgb-10.7* hct-31.9* mcv-95 mch-31.8 mchc-33.4 rdw-14.8 plt ct-121* 12:30pm blood hct-28.5* 01:53am blood wbc-9.3 rbc-2.91* hgb-9.5* hct-27.2* mcv-94 mch-32.7* mchc-35.0 rdw-14.7 plt ct-99* 02:30am blood wbc-8.8 rbc-2.90* hgb-9.2* hct-26.8* mcv-92 mch-31.6 mchc-34.3 rdw-14.6 plt ct-88* 01:29pm blood hct-26.1* plt ct-73* 11:43pm blood hct-28.8* 03:20am blood wbc-7.3 rbc-3.15* hgb-9.9* hct-29.1* mcv-92 mch-31.3 mchc-33.9 rdw-14.5 plt ct-53* 02:32pm blood wbc-8.8 rbc-3.07* hgb-9.6* hct-28.6* mcv-93 mch-31.4 mchc-33.7 rdw-14.7 plt ct-58* 02:39am blood wbc-7.7 rbc-2.81* hgb-9.0* hct-25.9* mcv-92 mch-31.9 mchc-34.5 rdw-14.6 plt ct-58* 02:15pm blood wbc-12.1*# rbc-3.18* hgb-10.1* hct-29.1* mcv-92 mch-31.8 mchc-34.6 rdw-14.5 plt ct-63* 02:38am blood wbc-7.6 rbc-3.16* hgb-10.0* hct-29.5* mcv-93 mch-31.6 mchc-33.9 rdw-14.6 plt ct-67* 03:46am blood wbc-7.4 rbc-3.22* hgb-10.1* hct-30.0* mcv-93 mch-31.3 mchc-33.6 rdw-14.7 plt ct-85* 01:15pm blood hct-25.7* 03:58pm blood hct-28.6* 02:34am blood wbc-8.4 rbc-3.20* hgb-10.0* hct-30.9* mcv-96 mch-31.2 mchc-32.4 rdw-14.5 plt ct-119* 02:03am blood wbc-5.6 rbc-3.00* hgb-9.4* hct-28.4* mcv-95 mch-31.3 mchc-33.1 rdw-14.5 plt ct-177 02:37am blood wbc-5.3 rbc-2.98* hgb-9.3* hct-28.2* mcv-95 mch-31.3 mchc-33.1 rdw-14.7 plt ct-183 02:14am blood wbc-5.2 rbc-3.20* hgb-10.0* hct-30.2* mcv-94 mch-31.1 mchc-33.0 rdw-15.5 plt ct-199 01:17am blood pt-14.4* ptt-28.2 inr(pt)-1.4 01:17am blood plt smr-very low plt ct-76* lplt-2+ 05:13pm blood pt-15.6* ptt-50.6* inr(pt)-1.7 02:30am blood ptt-53.2* 03:48am blood plt ct-112* lplt-2+ 08:02am blood pt-15.3* ptt-33.1 inr(pt)-1.6 08:02am blood plt ct-99* lplt-1+ 01:20pm blood pt-14.8* ptt-32.0 inr(pt)-1.5 02:34am blood plt ct-119* lplt-1+ 02:37am blood plt ct-183 02:14am blood plt smr-normal plt ct-199 lplt-1+ 01:17am blood glucose-94 urean-42* creat-1.8* na-140 k-4.4 cl-106 hco3-21* angap-17 05:13pm blood glucose-137* urean-55* creat-2.6* na-139 k-4.2 cl-107 hco3-20* angap-16 08:02am blood glucose-114* urean-52* creat-2.0* na-139 k-3.9 cl-111* hco3-19* angap-13 01:20pm blood glucose-156* urean-49* creat-1.9* na-138 k-4.2 cl-110* hco3-22 angap-10 02:24am blood glucose-92 urean-42* creat-1.7* na-138 k-4.8 cl-110* hco3-20* angap-13 12:30pm blood glucose-84 urean-35* creat-1.5* na-141 k-4.2 cl-112* hco3-22 angap-11 02:39am blood glucose-118* urean-17 creat-1.0 na-139 k-4.1 cl-106 hco3-29 angap-8 02:15pm blood glucose-115* urean-19 creat-1.0 na-137 k-3.7 cl-102 hco3-29 angap-10 02:38am blood glucose-111* urean-21* creat-1.0 na-137 k-4.2 cl-103 hco3-30 angap-8 10:16am blood glucose-113* urean-22* creat-1.0 na-138 k-4.1 cl-104 hco3-28 angap-10 03:58pm blood k-4.4 02:03am blood glucose-116* urean-21* creat-1.0 na-138 k-3.8 cl-110* hco3-23 angap-9 02:14am blood glucose-126* urean-25* creat-0.9 na-140 k-4.2 cl-112* hco3-23 angap-9 01:17am blood ck-mb-notdone ctropnt-0.15* 01:53am blood ck-mb-notdone ctropnt-0.22* 01:17am blood albumin-2.7* calcium-8.4 phos-3.0 mg-1.7 uricacd-6.4 02:24am blood albumin-2.2* calcium-8.4 phos-3.6 mg-2.3 uricacd-5.9 02:14am blood calcium-7.7* phos-3.2 mg-1.8 01:01am blood type- po2-38* pco2-43 ph-7.32* calhco3-23 base xs--3 01:36pm blood type-art po2-169* pco2-48* ph-7.29* calhco3-24 base xs--3 03:38am blood type-art po2-129* pco2-43 ph-7.42 calhco3-29 base xs-3 02:52am blood type-art temp-37.8 rates-/24 peep-5 fio2-40 po2-137* pco2-46* ph-7.46* calhco3-34* base xs-8 intubat-intubated 08:19pm blood type-art po2-114* pco2-40 ph-7.43 calhco3-27 base xs-2 04:14pm blood type-art po2-126* pco2-32* ph-7.47* calhco3-24 base xs-1 05:30pm blood type-art temp-36.9 rates-10/ tidal v-900 peep-5 fio2-40 po2-130* pco2-35 ph-7.48* calhco3-27 base xs-3 intubat-intubated brief hospital course: the patient was admitted to the cardiology service at on for presumed myocardial infarction on electrocardiogram, which was later attributed to demand ischemia due to sepsis. he was initially started on neo-synephrine for hypotension. he was continued on vancomycin and levofloxacin for his epididymitis. the urology team saw and evaluated the patient as a consult service under dr. . our suspicion of fournier's gangrene at that time was very low, considering his lack of risk factors and lack of significant groin erythema, however a ct scan of his abdomen and pelvis was ordered to rule out fournier's. that ct scan confirmed the diagnosis of fournier's gangrene on the morning of hospital day two (tracking of air around his left hemi scrotum tracking up the left spermatic cord. at that time, the patient was emergently rushed to the operating room for emergent surgical debridement by dr. and dr. , chief urology resident. during the operation, the patient had the majority of his left scrotum and all of his left testicle removed. he was then admitted to the trauma intensive care unit. he was sedated on propofol with fentanyl for pain. he was started on a levophed drip to maintain blood pressure. a central venous line was placed, as well as a swann ganz catheter. an oro-gastric tube was placed and put to gravity. his foley was continued from the operating room. dressing changes to his scrotum were scheduled for three times per day. on postoperative day two, his maximum temperature was 101.0. his levophed drip was weaned to a low level. tube feeds were started through his ng tube. on postoperative day three, the plastic surgery service began their evaluation of the patient for future closure of his wound. his propofol was discontinued. his levophed was discontinued. he vomited twice and his tube feeds were held for high residuals. he recieved one unit of red blood cells for a hematocrit under 30, and his hematocrit responded well. his acute renal appeared to have resolved, as his createnine dropped down to 1.0. on postoperative day four, his ventillator was weaned to pressure support, however he had some apneic spells. a hit panel was negative and his subcutaneous heparin was restarted. he had some bedside debridement by the urology team and his wound looked like it was healing well. he was transfused with another unit of red blood cells. the patient was noted to be roughly twenty liters positive and diuresis with a lasix drip was started as tolerated. on postoperative day seven, the patient required some propofol for sedation due to endotracheal tube and oro-gastric tube irritation. a sputum culture came back positive for mrsa sensative to vancomycin. his wound cultures were positive for mixed flora including bacteroides, provatella, and coagulase negative staphylococcus. a wound vac was placed by urology. on postoperative day eight, a post-pyloric feeding tube was placed by interventional radiology because the patient was not tolerating tube feeds via the oro-gastric tube. on postoperative day nine, dr. agreed to allow placement of a tracheostomy tube and a peg tube at a later date. the patient had been unable to tolerate a ventillator wean up to this point, most likely due to his fluid overload and his cardiac history. tube feeds were running at agoal of 90ml/ hour. on postoperative day ten, his flagyl and levofloxacin were discontinued. he was transfused one unit of blood for a hematocrit less than thirty. on postoperative day twelve, he recieved another unit of red blood cells. on pod 14, a #8 percutaneous trach was placed at the bedside. a perc peg was placed uner direct visualization, but the tube was pulled through the abdominal wall. the patient was subsequently taken to the or for an open gastrostomy tube which was placed without further complication. vancomycin was stopped on after a complete 14-day course. on , the wound was closed primarily at the bedside by the plastic surgery service. tf were restarted on and advanced as tolerated. a picc line was also placed on . propofol was d/c'd on . on , the patient spiked a temp to 102. cultures were drawn and the a-line tip sent for culture as well. tube feeds were held for high residuals, an ileus was found on imaginig. pt evaluation occured on . trach mask trials were started on and the vent weaned as tolerated, with the patient still requring vent assistance most of the day. vancomycin was restarted on for mrsa sputum; it will be continued for 7 days; the jp drain was removed on this day as well. tf were restarted on and brought to goal over the next day. the patient is now tolerating tf at goal with bowel movements. on , the patient was tolerating tf at goal, having bowel movements, tolerating trach mask trials daily, was working with pt, had good pain control with roxicet elixer, was alert and requring no sedation. he was subsequently transfered to rehab for physical therapy and vent weaning. medications on admission: lipitor 20', atenolol 25', asa 81', zestril 5', protonix 40' discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 4. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 5. insulin regular human 100 unit/ml solution sig: as directed injection asdir (as directed). 6. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 8. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q6h (every 6 hours) as needed. 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 10. phenol-phenolate sodium 1.4 % mouthwash sig: one (1) spray mucous membrane q4h (every 4 hours) as needed. 11. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). 12. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 13. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 14. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed. 15. morphine sulfate 1-2 mg iv q3-4h:prn prn breakthrough pain 16. metoclopramide 10 mg iv q6h 17. dolasetron mesylate 12.5 mg iv q8h:prn 18. vancomycin hcl 1000 mg iv q 12h 19. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 20. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 21. lorazepam 0.5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 22. midazolam hcl 0.5-1 mg iv q4h:prn anxiety discharge disposition: extended care facility: & rehab center - discharge diagnosis: fournier's gangrene discharge condition: stable discharge instructions: tube feeds: promote with fiber @ 90cc/hr md for: * fever * inability to tolerate tf * erythema/increased discharge from wound * uncontrolled pain followup instructions: abdominal staples to be removed on scrotal sutures to be removed 3 weeks after closure on vancomycin to be d/c'd Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other bronchoscopy Temporary tracheostomy Biopsy of parathyroid gland Excision or destruction of lesion or tissue of scrotum Other gastrostomy Unilateral orchiectomy Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Accidental puncture or laceration during a procedure, not elsewhere classified Vascular disorders of male genital organs Paralytic ileus Other inflammatory disorders of male genital organs Accidental cut, puncture, perforation or hemorrhage during other specified medical care

allergies: patient recorded as having no known allergies to drugs attending: addendum: a chief complaint: a major surgical or invasive procedure: a history of present illness: a past medical history: a social history: a family history: a physical exam: a pertinent results: a brief hospital course: a medications on admission: a discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 3. docusate sodium 150 mg/15 ml liquid sig: one hundred (100) mg po bid (2 times a day). 4. insulin regular human 100 unit/ml solution sig: one (1) injection injection asdir (as directed): standard insulin sliding scale, no standing insulin needed. 5. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 6. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 7. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 8. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 9. diltiazem hcl 30 mg tablet sig: 1.5 tablets po qid (4 times a day). 10. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 11. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 12. oxycodone 5 mg/5 ml solution sig: 5-10 mg po every four (4) hours as needed for pain. 13. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day). 14. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. 15. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day) as needed. 16. ferrous sulfate 300 mg/5 ml liquid sig: three hundred (300) mg po daily (daily). 17. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion. 18. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po daily (daily). 19. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 6 weeks: last date to give: . 20. dexamethasone sodium phosphate 4 mg/ml solution sig: one (1) mg injection qam (once a day (in the morning)) for 7 days: last date to give: . 21. dexamethasone sodium phosphate 4 mg/ml solution sig: two (2) mg injection qpm (once a day (in the evening)) for 7 days: last date to give: . 22. lorazepam 2 mg/ml syringe sig: 0.5-1 mg injection q6h (every 6 hours) as needed for anxiety. 23. sulfameth/trimethoprim 320 mg iv q8h duration: 3 days last date to give: 24. ceftriaxone 1 gm iv q24h duration: 4 weeks last date to give: 25. dexamethasone 1 mg iv qam duration: 7 days start: last date to give: 26. dexamethasone 1 mg iv qpm duration: 7 days start: last date to give: 27. dexamethasone 1 mg iv qd duration: 7 days start: last date to give: discharge disposition: extended care facility: discharge diagnosis: a discharge condition: a discharge instructions: a followup instructions: a md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of lung Transfusion of packed cells Closed [percutaneous] [needle] biopsy of brain Other craniotomy Diagnoses: Anemia, unspecified Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Cerebral edema Malignant neoplasm of brain stem Abscess of lung Methicillin susceptible pneumonia due to Staphylococcus aureus Pressure ulcer, buttock Candidiasis of lung Pneumonia due to escherichia coli [E. coli] Retention of urine, unspecified Pressure ulcer, lower back Personal history of malignant neoplasm of large intestine Personal history of malignant neoplasm of testis Unspecified disorder of skin and subcutaneous tissue

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: progressive signs of dizziness, visual difficulties, unsteady gait major surgical or invasive procedure: right-sided high frontal stereotactic biopsy, ct-guided target point, definition and mri-guided intraoperative imaging. history of present illness: the patient is a 56-year-old male with a history of colon cancer, as well as testicular cancer, who presents with progressive signs of dizziness, visual difficulties, unsteady gait for approximately 12 months. he was worked up including an mri scan that showed a brainstem lesion. he was referred to the brain tumor clinic for consideration of a biopsy. the patient has been followed at the at . he had been treated for a number of medical issues. he was examined by dr. whose physical exam reportedly showed bilateral facial numbness and swaying, and a mri of the head was preformed. this demonstrated expansion of the brainstem without significant contrast enhancement. the patient was thus considered to have a brainstem glioma and started on decadron. the patient now presents for a surgical opinion. in the office, the patient complains about dizziness, blurred vision, double vision, occasional headaches, and unsteady gait. he feels better with medications. he takes at baseline 2 tylenol a day. has a history of arthritis in the lower back, otherwise, he reports that the numbness in his hands has disappeared since starting the decadron. the patient has tapered his decadron to a dose of 2 mg p.o. b.i.d. the patient is otherwise feeling himself stable. he was told that he had a left lazy eye at baseline, but the patient is not quite sure about the symptoms. he denies otherwise any extreme fatigue, weight loss or other symptoms. past medical history: hypertension hypercholesterolemia sigmoid colon cancer testicular cancer s/p left orchiectomy and was found to be a germ cell tumor t1, n0.was treated with adjuvant chemotherapy no radiation. hemorrhoids recurrent bouts of thrush social history: he is a high school graduate. he is an electrician. he is divorced. he has no other people in the household. he has a 40-pack-year history of smoking. he drinks about three drinks a week, and he denies any recreational drug use. family history: his mother died at 63 of a heart attack. his father died at 44 after a mva. he has two sisters 58 and 54, the 54-year-old has gallbladder stones. other than that, they both are healthy. there are two brothers, one brother at 47 who has hypertension and two daughters that are in good health. physical exam: general: he is alert, pleasant, middle-aged man in no acute distress. weight was 170 pounds, height was 74 inches, blood pressure was 154/90, pulse of 96, respirations 20, temperature of 97.4. heent: the patient did have a head tilt to the left. cardiovascular: regular rate and rhythm. no murmurs, gallops or rubs. lungs: clear to auscultation. extremities: no clubbing, cyanosis or edema. neurologic: the patient is awake, alert and oriented. he has bilateral reactive pupils. eye movements are full and we cannot detect a clear deficit of a particular muscle, at current, the patient has no diplopia. visual fields seem to be fully intact. he has non-exhaustible end gaze nystagmus with rotatory component. face is symmetric. tongue is midline. no fasciculations. he has a hoarse voice. he has full strength bilaterally. he has intact sensation and symmetric reflexes. the patient does not have any memory problems, blackouts, nausea, concentration, or speech problems, as well as hearing problems. on motor examination, he was bilaterally, normal tone, no drift. i found no evidence of any weakness in his hands. upper sensory, he was intact to light touch throughout, and he was intact to pinprick over in the hands reflexes were 2+ throughout. cerebellar: he had bilateral intention tremor in the hands as well as finger tapping and rapid alternating movements were fine. foot tapping and heel-knee-shin was normal. gait: he had a wide based gait, he is unable to toe tandem or heel walk. pertinent results: 09:40am glucose-116* lactate-1.2 na+-132* k+-4.0 cl--95* 09:40am type-art po2-83* pco2-35 ph-7.50* total co2-28 base xs-3 intubated-intubated vent-spontaneou comments-rm air 09:48am pt-11.1* ptt-21.2* inr(pt)-0.8 09:48am plt count-241 09:48am wbc-17.9* rbc-4.30* hgb-12.2* hct-34.0* mcv-79* mch-28.4 mchc-35.9* rdw-17.9* 09:48am glucose-115* urea n-16 creat-0.5 sodium-133 potassium-3.9 chloride-95* total co2-26 anion gap-16 11:21am freeca-1.12 11:21am hgb-11.1* calchct-33 o2 sat-97 carboxyhb-1 11:21am glucose-129* lactate-1.7 na+-133* k+-3.9 cl--98* . pathology : middle cerebellar peduncle/pons stereotactic brain biopsy (including intraoperative smear): diffusely infiltrating fibrillary astrocytoma. who () grade ii out of iv. . brief hospital course: 56 m with pmh sigmoid and testicular ca in , htn, copd, admitted for new diagnosis pontine glioma s/p posterior fossa decompression and necrotizing pna. . # pontine glioma: 56 year-old man initially seen and discussed in brain tumor clinic. patient taken to or on for brainstem lesion biopsy under general anesthesia. postoperatively stayed in the pacu 6 hours then transferred to floor. on postop day one patient demonstrated difficulty of swallowing which he failed his speech and swallow evaluation. patient kept npo, started iv fluids. on patient taken back to or for a suboccipital chiari decompression. patient tranferred to neuro icu for hemodymanic and neurologic monitoring. due to postoperaive respiratory secretion extubated on after bronchcospy. . brain stem biopsy pathology result is significant for infiltrative astrocytoma. radiation oncology decided not to perform radiation mapping and to hold off for another several weeks before planning to start xrt, since patient has a slow growing glioma, and xrt could exacerbate pna. patient known by dr will follow up with him as scheduled. patient was transferred to step-down unit on . his speech continued to become more articulate and clear, and his mental status continued to become more clear. the patient stated that his dizziness has improved. . # necrotizing pneumonia: patient has a known pulmonary process that been followed in hospital in ma. in house repeat ct of the chest significant for left lower lobe, consolidative opacity, with central area of necrosis, an air-fluid level, and low-attenuation material. additionally, there are several areas within the right and left lungs peripherally, with patchy opacity and tree-in- opacities, concerning for multifocal opacity. there is also a wedge-shaped opacity in the right lower lung zone, some of which may represent atelectasis.there is a 3.3 x 2.6 cm nodule with multiple foci of calcification within the left lower lobe. attempt to obtain images from hospital regarding pulmonary lesions for comparison, with medical records to sent ua cd images. medicine and interventional pulmonary services recommended continue antibiotics, and follow up with chest ct with and with out contrast in 4 weeks in pulmonary clinic. in the mean time with dr at the hospital regarding tranfering him over to va regarding his known pulmonary process, and colon carcinoma for further work up which he was agreed with the transfer. . pleural fluid culture grew out positive to mssa, gnr, albicans, staph coag neg. bal culture grew out stenotrophomonas maltophila and klebsiella sensitive to almost all abx tested. id was consulted and created antibiotic regimen of clindamycin, bactrim, ceftriaxone, to be continued for 4-6 weeks. levo was completed for 2 weeks (last date ). patient should be reassessed to refine abx regimen within 2-4 weeks. the patient greatly improved on suctioning and chest pt, maintaining >95% ra on the floor. . the following labs will need to be followed up after discharge: lfts, mycolytic/fungal cx, cdiff x3, legionella urinary antigen . # urinary retention: patient had no urine output after foley was d/ced. straight cath released 980 ml of urine. after 2 days of straight caths, patient recovered normal urination, and does not have a foley upon discharge. . # skin lesions: dermatology consulted in reference to his left deltoid skin lesion, non-bleeding which is present for 5 year according to patient. dermotalogy recommended excision of the lesion to rule out melanoma once acute issues resolved with derm surgery (). . # anemia: patient's hct was around 25 during admission. . # htn: controlled. diltiazem and captopril were continued as per her outpt regimen. . # access: picc placed . medications on admission: the patient is a 56 y/ with a pmh significant for sigmoid and testicular cancer in ', htn, and copd who was admitted to the neurosurgery service on with a new diagnosis of a pontine mass after 1yr of progressive dizziness and ataxia. he underwent a stereotactic bx on showing a low grade glioma and received a palliative posterior fossa expansion on . . routine pre-op cxr revealed multiple opacities and a 3x3 cm well demarcated cavitary lesion with an air/fluid level in left posterior lung. following his surgery, he was extubated w/out event but required reintubation later that evening desaturation. on , a chest ct was done which showed a multifocal pneumonic process with lll necrotizing pna. he underwent a bronch on with bal revealing mssa and stenotrophamonas and was started on levofloxacin (now d10/14), vanco (since d/c), and clinda (d10/42) at this time. bactrim (d5/14) was added on when bal grew stenotrophamonas. . during this time, he has been intermittantly hypoxic with thick secretions requiring frequent suctioning. over the past 2d, he has been afebrile and his secretions have cleared appreciably. he has maintained his o2 sats on 4l nc. other than this, the patient has been intermittantly hypertensive requiring the addition of captopril to his outpatient regimen. he has also failed numerous speech and swallow evaluations requring ng tube feeds to maintain his nutritional status. from an oncologic standpoint, his pontine lesion is not amenable to resection and the plan is to initiate palliative radiation therapy. per neurosurgery, his prognosis is extremely poor. finally, the patient has requested transfer to the va system over the past several days as he has received much of his care at this hospital. discussions are still ongoing to facilitate this transfer. . pmh: 1. colon cancer 2. testicular cancer 3. hemorrhoids 4. hypertension. 5. thrush. 6. hypercholesterolemia. . transfer meds: acetaminophen albuterol bisacodyl captopril clindamycin dexamethasone diltiazem docusate hsq sulfameth/trimethoprim oxycodone nystatin nicotine patch levofloxacin lansoprazole ipratropium iss . pe: 97.0 (98.5), 124/72, 81, 21, 95% 4l nc gen: cachetic sitting up in a chair in nad heent: mmm, perrla, eomi, o/p clear w/ ngt in posterior oropharynx neck: no lad, no jvd cv: rrr, s1/s2 wnl, -m/r/g appreciated lungs: decreased breath sounds bilaterally l>r w/ coarse inspiratory sounds bilaterally and anteriorly, -wheezes appreciated, dullness to percussion at the l base abd: s/nt/nd, +bs ext: -c/c/e, 2+ peripheral pulses bilaterally neuro: cn 2-12 grossly intact, dysarthric, strength 5/5 in the rle, on the lle he has decreased dorsal flexion in the foot/flexion and extension at the knee/flexion at the hip, mildly decreased l grip strength compared to r hand ================ micro: - sputum : e. coli (pan-sensitive), coag + staph (pansensitive) - bal : stenotrophamonas (sensitive bactrim), coag + staph (mssa), sparse gnr - mrsa/vre swab: negative ================ cta : 1. some improvement in the consolidation in the left lower lobe, although the large 4-cm cavitary lesion with an air-fluid level persists, consistent with slight overall improvement in necrotizing pneumonia. 2. new small cavitary lesion in the left upper lobe, possibly related to aspiration. of note, the patient has a small hiatal hernia. 3. improvement in some of the ground-glass opacities in the right middle and upper lobes, with persistent 4-mm lung nodule. 4. similar slightly prominent right hilar and mediastinal lymph nodes. 6. no evidence of pulmonary embolism. 7. similar calcified lung mass, possibly a hamartoma, although metastatic colon cancer cannot be excluded. . ct head (): no definite change in the mass effect associated with the brainstem glioma. interval development of a small left frontal region subdural collection. . cxr : no interval change. persistent opacity at the left base. there is a 3.6-cm parenchymal opacity within the left base as well which is also unchanged. there is no evidence for overt pulmonary edema. the lines and tubes are stable in position. ================ a/p: 56 yo m admitted for dizziness/weakness. found to have a pontine glioma now s/p posterior fossa decompression complicated by necrotizing pna and multiple episodes of hypoxia requiring micu level care. called out to medicine service for further management of his infection and pulmonary status. . # hypoxia: he has been stable over the past few days w/ better maintained spo2. he has improved in the past w/with deep suctioning. chest ct c/w necrotizine pna. he is on levo ( -> 2 weeks), and clinda ( -> 6 weeks). bactrim was started on (x 2 weeks): bal + for stenotrophamonas. - wean o2 as tolerated on the floor - per thoracic staff () pt will need ct guided drain placement this week; ? if best to schedule peg at same time to minimize procedures - continue levaquin, clindamycin, and bactrim for full course - will need repeat ct in 1 month - continue nebs prn - continue aggressive pulmonary toilet - incentive spirometry on the floor . # lung nodule. chest ct from the va on demonstrated 2 lesions in lll (anterior and posterior) both of which were felt to be stable compared to prior ct . - await old films being mailed from the va - f/u ip/thoracic recs . # brainstem glioma. prognosis estimated at a couple of months per neurosurg. ? palliative radiation - continue decadron per neurosurgery - continue prn pain meds - neurosurg following - pt full code - monitor cn exam, mental status, and strength exams . # anemia. 4pt hct drop on , transfused on w/ appropriate hct elevation and has been stable overnight - repeat hct when called out to floor - guaiac stools x3 then d/c if negative - transfuse for hct < 25 - continue ppi while on decadron . # htn. bp well controlled on current regimen - continue diltiazem and captopril - monitor bp and titrate prn . # left deltoid lesion. - f/u in dermatologic surgery clinic on at 11am . # communication: va chief - . mrs. (aunt) is hcp. . # fen. tf's through ngt (failed video swallow again on ) - continue aspiration precautions - patient has decline peg placement x2 per notes in chart - will reevaluate patient's wishes once transferred to floor; would be best to place peg when placing drainage so as to minimize procedures - replete lytes prn . # access: picc line placed . # ppx. sc heparin, ppi, bowel regimen, iss while on decadron, replete lytes . # code: full . # dispo: patient would like to be transferred to va. aunt has a scheduled meeting today with dr. discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed: hold for lose stool. 3. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection (2 times a day). 5. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 6. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 7. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 8. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 9. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 10. hydromorphone 2 mg/ml syringe sig: one (1) injection q4-6h (every 4 to 6 hours) as needed. 11. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 12. lansoprazole 30 mg susp,delayed release for recon sig: one (1) po bid (2 times a day). 13. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed). 14. diltiazem hcl 60 mg tablet sig: one (1) tablet po qid (4 times a day). 15. levofloxacin in d5w 500 mg/100 ml piggyback sig: one (1) intravenous q24h (every 24 hours): started on total of 14 days then d/c. . discharge disposition: extended care facility: va discharge diagnosis: right brainstem lesion discharge condition: neurologically stable discharge instructions: monitor suboccipital staple sites for drainage, erthyma, swelling, fever greater than 101.5, seizure activity, visual changes, weakness, numbness or any other neurologic symptoms that may be concerning. keep your all appointments as sheduled. followup instructions: follow up with dr in 10 days from for wound check and staple removal or can be removed at the hospital. follow up with dr (neurooncology) and dr (radiation oncology) in brain tumor clinic on at 1300 building . follow up with pulmonary clinic in 4 weeks with a chest ct with and without contrast. follow up with dr , dermatologic surgery clinic(for left deltoid lesion on at 1100. follow up with va infectious disease for possible repeat ct chest in 4 weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [percutaneous] [needle] biopsy of lung Transfusion of packed cells Closed [percutaneous] [needle] biopsy of brain Other craniotomy Diagnoses: Anemia, unspecified Tobacco use disorder Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Pneumonitis due to inhalation of food or vomitus Iatrogenic pneumothorax Cerebral edema Malignant neoplasm of brain stem Abscess of lung Methicillin susceptible pneumonia due to Staphylococcus aureus Pressure ulcer, buttock Candidiasis of lung Pneumonia due to escherichia coli [E. coli] Retention of urine, unspecified Pressure ulcer, lower back Personal history of malignant neoplasm of large intestine Personal history of malignant neoplasm of testis Unspecified disorder of skin and subcutaneous tissue

history of present illness: the patient is a 61-year-old male whose chief complaint was shortness of breath. he has a history of cva, traumatic mi, and chf, who presented with shortness of breath times 5 days associated with anterior intermittent chest pain without diaphoresis, palpitation, pnd, orthopnea, or syncope. the patient had traumatic motorcycle accident with cva and right hemiparesis and slurred speech; and has a history of lv dysfunction diagnosed years ago at an outside hospital and was maintained on coreg and zestril. the patient's complaints prior to arrival to the was that he had shortness of breath and felt like an asthma attack. he was having increasing inhaler use with an intermittent left sided anterior chest pain. he also noticed increasing right lower extremity swelling, went to his pcp; ekg there was noted to have question of junctional tachycardia versus atrial flutter versus 2 to 1 block. the patient also had increased bnp at the outside hospital where he was referred to 3000. he was noted to be in 94 to 95 percent on room air. blood pressure was 110/76, heart rate 98. the patient was started on lovenox, amiodarone drip, iv nitroglycerine, lasix, and lopressor. he was ruled out for myocardial infarction and then noted to have primary av block with right bundle-branch block around the ventricular tachycardia. the patient was started on lidocaine and continued on diuresis and referred at the . allergies: the patient has no known drug allergies. medications on admission: 1. dilantin 400 mg once a day. 2. coumadin 3 mg once a day. 3. ventolin. 4. protonix 40 mg once a day. 5. coreg 12.5 mg twice a day. 6. zestril 30 mg once a day. 7. norvasc 5 mg once a day. 8. azmacort 2 puffs t.i.d. 9. lasix p.r.n., dose unspecified. 10. advair. 11. digoxin 0.25 mg once a day. 12. lovenox 40 mg subcutaneous q.12 hours. 13. lidocaine gtt. 14. amiodarone gtt. past medical history: significant for asthma, congestive heart failure, cerebrovascular accident /, status post mva 20 years ago, history of cholecystectomy, right bundle-branch block diagnosed in , melanoma on the right side of back, dysphagia, and gastroesophageal reflux disease. social history: he lives with his wife. does not work secondary to illness. no tobacco and he drinks only socially. family history: significant for cad in the mother. laboratory data: on admission, 1. ck 56, troponin less than 0.04. 2. ck 49, troponin 0.04. 3. ck 32, troponin 0.04 sodium 136, potassium 3.7, chloride 101, bicarbonate 28, bun 17, creatinine 0.9, glucose is 111, calcium is 7.9, magnesium 1.3, phosphorus 3.0, white count of 0.1, hematocrit 33.5, and platelet count is 213. physical examination: vitals: temperature is 98.2 degrees, heart rate 76, respiratory rate 16, and blood pressure 130/70. general: the patient is in no acute distress . heent: right pupil is fixed and left is minimally responsive. eomi. anicteric sclerae. moist mucous membranes. tongue deviates to the right. right facial droop is noted. jvp is 6 cm. heart: regular rate and rhythm with no murmurs. lungs: clear to auscultation bilaterally. abdomen: good bowel sounds, soft, nontender, nondistended. extremities: free of any clubbing, cyanosis, or edema. neurologic: exam is again significant for the right blown fixed pupil, left minimally responsive pupil, and tongue deviates to right. strength is 5 out of 5 and symmetric in the right upper and lower extremities. strength is 3 out of 5 in the left upper and left lower extremities. no resistance is noted. reflexes are 2 plus throughout. hospital course: 1. coronary artery disease: the patient was maintained on aspirin, coreg, and zestril. blood pressures were followed closely for ischemia. there was no active evidence of ischemia. cardiac enzymes confirmed this. echocardiogram from , revealed an ef of 25 percent, left atrium that is elongated, right atrium mildly dilated, left ventricular wall thickness that is normal. left ventricular cavity size mildly dilated. overall, left ventricular systolic function severely depressed. right ventricular systolic function appears depressed. aortic root has normal diameters and the aorta is mildly dilated; 2 plus mr is noted. physiologic tr is noted. 2. rhythm: the patient was noted to have runs as asymptomatic ventricular tachycardia. he was maintained on amiodarone gtt and lidocaine gtt. ep was consulted and the patient underwent vt ablation that was unsuccessful secondary to aneurysm. the patient subsequently had that was placed on . the patient had a max-mode dr placed via right cephalic access with no complications. otherwise, the patient was maintained on amiodarone 400 mg t.i.d. times 1 week, 400 mg q.d. times 3 weeks, and then 400 mg q.d. after that point. the patient was also maintained on coumadin and lasix with good effect. 3. hypertension: the patient was maintained on coreg and zestril for cva. the patient was maintained on dilantin. his dilantin dose was halved without patient's further management. 4. prophylaxis: the patient was maintained on subcutaneous heparin, bowel regimen, ppi, and the patient's bilateral knees were negative. the patient was a full code and was discharged on . medications at discharge: 1. amiodarone 400 mg 1 tablet 3 times a day for 5 days, then amiodarone 400 mg 1 tablet once a day for 3 weeks, and then amiodarone 200 mg tablets 1 by mouth once a day. 2. the patient was maintained on dilantin 200 mg once a day. 3. tylenol 1 to 2 tablets q.4 hours p.r.n., as needed for pain, not to exceed 4 gm a day. 4. fluticasone 110 mcg 2 puffs b.i.d. 5. lisinopril 5 mg 1 tablet once a day. 6. aspirin 325 mg 1 by mouth once a day. 7. atorvastatin 20 mg 1 tablet by mouth once a day. 8. metoprolol 12.5 mg 1 by mouth twice a day. 9. coumadin 5 mg tablets every night. 10. keflex 500 mg 1 capsule by mouth 3 times a day for 2 days. 11. lasix 20 mg once a day. follow up: he is to followup in the clinic on at 2 p.m. the patient is to see his primary care physician . on at 10:30 a.m., where he is to have his chem-10, pt, ptt, inr, and dilantin level checked. discharge diagnoses: 1. ventricular tachycardia, status post ventricular tachycardia ablation. 2. status post implantable cardioverter defibrillator placement. 3. history of cerebrovascular accident. 4. history of hypertension. 5. depressed ejection fraction. discharge status: he will be discharged to home. , md Procedure: Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] Cardiac mapping Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Coronary atherosclerosis of unspecified type of vessel, native or graft Old myocardial infarction Ventricular fibrillation Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Late effects of cerebrovascular disease, other speech and language deficits

allergies: lipitor attending: chief complaint: back pain major surgical or invasive procedure: thoracolumbar fusion t10-l3 history of present illness: 32 yo male s/p ejection off four after skidding on leaves now with back pain. past medical history: hyperlipidemia social history: denies family history: n/c physical exam: nad rrr cta b abd soft nt/nd bue- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis ble- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, /fhl; sensation intact distally; reflexes intact at quads and achilles; + pain to palpation midline lower back pertinent results: 09:40am blood hct-32.5* 08:30am blood wbc-12.0* rbc-3.38* hgb-10.3* hct-28.7* mcv-85 mch-30.5 mchc-35.8* rdw-15.5 plt ct-325 06:00am blood wbc-10.0 rbc-2.75* hgb-8.6* hct-23.7* mcv-86 mch-31.2 mchc-36.3* rdw-15.0 plt ct-247 04:19am blood wbc-10.9 rbc-3.23* hgb-10.0* hct-28.3* mcv-87 mch-30.9 mchc-35.6* rdw-15.2 plt ct-283 04:50pm blood wbc-9.3 rbc-3.15* hgb-9.6* hct-27.1* mcv-86 mch-30.5 mchc-35.5* rdw-13.8 plt ct-236 08:30am blood glucose-102 urean-9 creat-0.6 na-137 k-4.0 cl-100 hco3-29 angap-12 06:00am blood glucose-113* urean-14 creat-0.7 na-135 k-3.9 cl-99 hco3-31 angap-9 04:19am blood glucose-160* urean-13 creat-0.7 na-137 k-5.1 cl-102 hco3-30 angap-10 09:33pm blood glucose-176* urean-11 creat-0.9 na-133 k-5.2* cl-104 hco3-20* angap-14 03:26am blood glucose-89 urean-12 creat-0.7 na-142 k-3.2* cl-113* hco3-22 angap-10 brief hospital course: mr was admitted to the service of dr. for a thoracolumbar fusion for his t12 burst fracture. he was informed and consented for the procedure and elected to proceed. please see operative note for procedure in detail. post-operatively his chest tube and drain were removed. follow up x-ray showed atelectasis involving the right middle and lower lobes. incentive spirometer was encouraged. follow up films were taken which showed a stable atelectasis which began to show improvement after working with pt and is encouragement. post-operatively he was administered antibiotics and pain medication. his catheter and drain were removed pod 2 and he was able to take po's. his pain was well controlled and he remained afebrile throughout his hosptial course. he was able to work with physical therapy and made improvements in strength and balance. he will return to clinic in ten days. he was discharged in good condition. medications on admission: lipitor zetia discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed. 3. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po q6h (every 6 hours) as needed. 4. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 9. oxycodone 20 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po q12h (every 12 hours). 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 11. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 12. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: hospital - discharge diagnosis: t12 fracture discharge condition: good discharge instructions: please continue to take your pain medication with an over the counter laxative. call the clinic if you notice any redness or discharge from the incision site. call the clinic for any additional concerns. physical therapy: activity: activity as tolerated tlso for ambulation; may be out of bed to chair without. treatments frequency: please continue to change the dressing daily with dry, sterile gauze. followup instructions: please follow up in the spine clinic during your previously scheduled appointments. Procedure: Dorsal and dorsolumbar fusion of the anterior column, anterior technique Excision of intervertebral disc Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Other partial ostectomy, other bones Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 4-8 vertebrae Diagnoses: Pulmonary collapse Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Nontraffic accident involving other off-road motor vehicle injuring driver of motor vehicle other than motorcycle

allergies: lipitor--> leg cramping pmh- increased cholesterol tests: ct head-->neg ct of tl--> t12 fx ant/post fx frag. dural compression at this level ? need for surgery/brace mr of thoracic spine w/o contrast. ros: see carevue for exact data n: grossly intact. mae's with good equal strength. pupils equal and reactive at 3mm. follows commands appropriate, no dysfunction. sensory function intact. denies ha/nt/dizziness. morphine pca for pain . logroll precautions maintained, cspine clr'd by ho cv: hemodynamically stable. hr 70-80 sr, no ectopy. bp 120-130's sys via cuff pressure. positive pulses, sq heparin to start this a.m., venodynnes on. ns infusing at 100/hr. resp: lscta. pt remains on 2l o2 sats 94-97%. denies sob. rr 17-19. enc'd to take deep breaths. gi: abd soft, non tender. pos bs, denies n/v. pt npo gu: u/o adeq. skin: intact, no abrasions. pt c/o some soreness to right upper thigh. no abrasion or disfigurement, ho aware. coags: inr 1.2, pt 13.3, ptt 29.8 lytes: lytes all off. pt needs repletion this a.m. hem: stable soc: wife at bedside. appropriate. a: 32 yr old male s/p atv accident. stable with t12 fx await plan. Procedure: Dorsal and dorsolumbar fusion of the anterior column, anterior technique Excision of intervertebral disc Excision of bone for graft, other bones Dorsal and dorsolumbar fusion of the posterior column, posterior technique Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances Systemic to pulmonary artery shunt Other partial ostectomy, other bones Insertion of interbody spinal fusion device Fusion or refusion of 2-3 vertebrae Fusion or refusion of 4-8 vertebrae Diagnoses: Pulmonary collapse Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Nontraffic accident involving other off-road motor vehicle injuring driver of motor vehicle other than motorcycle

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 80 year old white male with shortness of breath with exertion. major surgical or invasive procedure: cabg x 3 history of present illness: this 80 year old white male with a history of htn, hyperlipidemia, pvd, afib, and cva, was admitted for elective cardiac cath . he has complaints of shortness of breath with exertion and an ett during which time he had left arm pain which was relieved with sl ntg. past medical history: htn hyperlipidemia s/p cva , s/p bil. cea pvd bph afib diverticulitis sleep apnea s/p aaa repair s/p ventral hernia repair s/p aorto-bifem s/p turp social history: married, lives with wife. cigs: quit 13 years ago, 30 pk. yr. history etoh: rare family history: + cad physical exam: gen: elderly, white male, in nad avss heent: nc/at, perla, eomi, oropharynx benign neck: supple , from, no lymphadenopath or thyromegaly, carotids 2+= bilat w/ bruits. lungs: clear to a+p cv: rrr without m/g, 3/6 sem, rad to carotids and axilla abd: +bs, soft, nontender without masses or hepatosplenomegaly ext.: without clubbing, cyanosis, or edema, pulses 2+ radials, 2+ dp, 1+ pt bil. neuro: nonfocal. pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 07:45am 31.8* specimen not received in stat bag basic coagulation pt ptt plt ct inr(pt) 07:45am 18.3*1 2.1 specimen not received in stat bag 1 note new normal range as of 12a of chemistry renal & glucose glucose urean creat na k cl hco3 angap 07:45am 34* 1.4* 4.0 specimen not received in stat bag chemistry totprot albumin globuln calcium phos mg uricacd iron 06:30am 8.4 4.1# 2.1 brief hospital course: on the patient underwent cardiac cath which revealed: 70%lad, 80% d1, 60% lcx, 90% rca, mild as, av gradient of 15mmhg. he had a heavily calcified aorta and coronaries. dr. was consulted and on he underwent cabgx3 with lima->lad, svg->pda and om. cross clamp time was 63 minutes and total bypass time was 47 minutes. he required a urology consult intraoperatively and had to have a foley placed under cysto. he tolerated the procedure well and was transferred to the csru in stable condition on neo and propofol. he was extubated on his postoperative night and had his chest tubes d/c'd and was transferred to the floor on pod#2. on pod#4 he was in afib and was very hpotensive and was transferred back to the csru. he was started on amiodorone and converted to sr. he was transferred back to the fllor on pod#5 and had a few more episodes of controlled af. he was then anticoagulated with heparin and coumadin and was discharged to rehab on pod#7 in stable condition. medications on admission: pronestyl 750 mg po daily atenolol 25 mg po daily allopurinol 300 mg po daily minitron 2.5 mg po daily lasix 20 mg. po q mon., wed., fri. zocor 80 mg po daily asa 325 mg po daily cardura 2 mg po bid atacard 16 mg po daily discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 3. doxazosin mesylate 2 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 4. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. amiodarone hcl 200 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 8. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po bid (2 times a day) for 7 days. disp:*28 capsule, sustained release(s)* refills:*0* 9. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 7 days. 10. warfarin sodium 2 mg tablet sig: one (1) tablet po once a day: inr goal 2-2.5. 11. allopurinol 300 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: tcu discharge diagnosis: coronary artery disease htn hypercholesterolemia bph pvd discharge condition: good discharge instructions: no lifting > 10# or driving for 1 month no creams, lotions or powders to incision may shower, no bathing or swinning for 1 month followup instructions: make an appointment with you r uroligist for 1 week make an appointment with dr. in weeks make an appointment with dr. in weeks make an appointment with dr. in 1 month Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Left heart cardiac catheterization Transfusion of packed cells Dilation of bladder neck Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Peripheral vascular disease, unspecified Other and unspecified angina pectoris Unspecified sleep apnea Bladder neck obstruction Multiple involvement of mitral and aortic valves Family history of ischemic heart disease

history of present illness: mr. is a 42-year-old gentleman injured in a motorcycle versus car accident. the patient was the passenger of the motorcycle. past medical history: no prior medical problems. medications: no outpatient medications. summary of hospital course: the patient was brought to the trauma bay where he underwent full evaluation and resuscitation by the trauma team. the patient was found to have a left open comminuted fracture of the left lower extremity with a significant degloving injury. the patient was taken to the operating room for washout and external fixation of the patient's fracture by the orthopedic team. in addition, the patient received a consult from the vascular surgery team which determined that the patient was vascularly intact. following his initial washout, the patient was taken to the intensive care unit for close observation. on hospital day #2, the patient was transferred to the floor as he had been hemodynamically and neurologically stable. on hospital day #4, the patient was taken to the operating room again for a combined procedure with the orthopedic and plastic surgery team. orthopedic team placed an intramedullary nail into the patient's left tibia. a plastic surgery team then covered the patient's open defect with a rectus free flap. the patient tolerated the procedure well and there were no intraoperative complications. the patient was initially monitored in the stepdown intensive care unit for close observation of this flap. the patient also had a split thickness skin graft placed over the flap, as the patient had significant loss of skin tissue from his degloving injury. the patient did well after surgery and flap had no complications. throughout his stay, the patient continued to have a strong dopplerable signal both arterial and venous and a good take of his skin graft. on postoperative day #2, the patient was transferred to the floor as he no longer required hourly flap checks. beginning on postoperative day #5, the patient was allowed to begin dangling his left lower extremity which he tolerated without any problems. on postoperative day #7, the patient was seen by the physical therapist for instructions on non weight bearing of the left lower extremity transfers to chair. at this point, the patient was medically stable and ready for discharge to a rehabilitation facility. throughout his stay, the patient was also given aspirin q day and deep venous thrombosis prophylaxis with subcutaneous heparin. the patient was also on kefzol for the duration of his stay. discharge condition: the patient was stable during discharge. discharge disposition: the patient will be discharged to a rehabilitation facility, as the patient will have orthopedic ambulatory difficulties given his non weight bearing status on his left lower extremity. he will continue to be non weight bearing on the left lower extremity with dangling only, however the patient may transfer to a chair as long as his left lower extremity is elevated. discharge medications: 1. keflex 500 mg po qid 2. aspirin 81 mg po q day 3. lopressor 25 mg po bid 4. percocet 1 to 2 tablets po q 4 to 6 hours prn 5. colace 100 mg po bid 6. zolpidem 5 mg po q hs prn other instructions: the patient may begin showering or having a spray of water over his wound, however the patient is not to have any tub soaks. the patient should not progress on his weight bearing status until after his follow up with dr. in one week. , m.d. dictated by: medquist36 Procedure: Other skin graft to other sites Debridement of open fracture site, tibia and fibula Application of external fixator device, tibia and fibula Open reduction of fracture with internal fixation, tibia and fibula Closure of skin and subcutaneous tissue of other sites Removal of implanted devices from bone, tibia and fibula Diagnoses: Tobacco use disorder Open wound of scalp, without mention of complication Unspecified fracture of ankle, open Foreign body accidentally left during a procedure Open wound of jaw, without mention of complication Abrasion or friction burn of trunk, without mention of infection Abrasion or friction burn of elbow, forearm, and wrist, without mention of infection Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist

history of present illness: mr. is a pleasant 73-year-old gentleman with a past medical history significant for multiple myeloma, peptic ulcer disease, cholangitis, iron deficiency anemia, b12 deficiency anemia, status post cholecystectomy and appendectomy, who was transferred to the from for an ercp. the patient had an ercp that was done on , and had a stent placed with no significant findings except for mild dilatation, but no stones or strictures. the patient had developed gram-negative (klebsiella grown and e. coli) rod sepsis and jaundice prior to the first ercp. the patient did well for a few days, and then on , presented with a one day history of right upper quadrant pain, no nausea, vomiting, fever, or rigors. a mri that was done after showed abnormal tissue in the region of porta hepatis and some lymphadenopathy. so patient was transferred here for a repeat ercp. during the ercp procedure, the initial contrast revealed an amorphous intraductal mass. with further manipulation and extraction of the mass, there was an old blood clot and once the blood clot was removed, bright red blood began to drain from the biliary system. the gi fellow estimated about 1 unit of blood loss. the patient was stable and alert during and after the procedure, and was transferred to the intensive care unit for further management and eventually to interventional radiology for an a-gram. an a-gram was done that showed no active bleeding, however, the stent that was placed in the common bile duct was no longer there. the patient was then transferred to the floor after the hematocrit had been stable for greater than 24 hours and there was no evidence of any new acute bleed. past medical history: 1. multiple myeloma diagnosed in . 2. peptic ulcer disease. 3. cholangitis. 4. iron deficiency anemia. 5. b12 deficiency anemia. 6. status post cholecystectomy in . 7. status post appendectomy. medications on admission: 1. iron 325 mg po q day. 2. colace 100 mg po bid. 3. levaquin 500 mg po q day. 4. ambien 5 mg po q day. allergies: no known drug allergies. social history: the patient lives with his brother, , and the patient denies any alcohol, smoking, or iv drug abuse at this time. physical exam on admission to the unit: temperature of 97.0, blood pressure 130/55, heart rate of 105, respiratory rate 20, and o2 saturation 100% on room air. general: comfortable, in no acute distress. heent: moist mucosal membranes. extraocular movements are intact. pupils are equal, round, and reactive to light and accommodation. cardiovascular: s1, s2 slightly tachycardic, no murmurs, rubs, or gallops heard. lungs are clear to auscultation bilaterally. abdomen is soft, nondistended, mild tenderness in the epigastric area to deep palpation, decreased bowel sounds. extremities: no clubbing, cyanosis, or edema. skin: no evidence of any rash. neurologic: cranial nerves ii through xii tested grossly intact. laboratories on admission: white count 5.3, hematocrit 21.2, platelets of 301, sodium 133, potassium 3.1, chloride 106, bicarb 20, bun 13, creatinine 0.4, glucose 117, alt 303, ast 167, alkaline phosphatase 704, total bilirubin 1.2. hospital course: 1. gi: patient was admitted to the intensive care unit after an ercp because of a bleed. the patient's hematocrit at that time was 21.2 and the patient received 2 units and hematocrit was checked q6h for 24-48 hours. his hematocrit continued to remain stable between 25-27, however, one additional unit of blood was given when the patient was transferred to the floor and his hematocrit continued to remain stable in the range of 29-31. the patient also had a repeat ct angiogram for pancreatic protocol that was done on , and it was found that there was no evidence of any mass and patient had a dilated common bile duct with wall thickening and enhancement which is consistent with either hemobilia or cholangitis. however, patient's findings were most likely secondary to his hemobilia since he did have a bleed after his ercp. in addition, the ct angiogram did show extensive bony involvement of his multiple myeloma. also during the hospital course, the patient was started on broad antibiotic coverage consisting of ampicillin, flagyl, and levaquin for prophylaxis against developing cholangitis. during the hospital course, the patient did not seem to have any right upper quadrant tenderness or epigastric tenderness that would be concerned with cholangitis, and on the date of discharge, he was sent with levaquin 500 mg po q day for seven additional days. the patient's diet was also slowly advanced. he was made npo after his procedure for about two days and was started on a liquid diet and then eventually into a soft diet all of which the patient tolerated well. 2. oncology: the patient has a history of multiple myeloma, and as per the ct angiogram, it appears that there is extensive metastases to the bones. a brief discussion was brought up with the patient regarding further management, and if he wanted to see an oncologist at that time, he said that his care is provided by dr. in the area, and patient would want to talk to him before pursuing any further intervention. however, the patient would prefer to let it be as it is, and did not appear to be interested in any chemotherapy, or radiation therapy, or even talking to an oncologist during this hospital course. discharge diagnoses: 1. status post ercp bleed. 2. multiple myeloma. discharge condition: the patient is stable at time of discharge. discharge medications: 1. protonix 40 mg po q day. 2. levofloxacin 500 mg po q day x7 days. 3. the patient is to continue taking all of his outpatient medications. followup: the patient was asked to setup an appointment with his primary care physician, . in the next 3-4 days. the patient states that he would call and setup an appointment, according to his own time. , m.d. dictated by: medquist36 Procedure: Endoscopic sphincterotomy and papillotomy Arteriography of other intra-abdominal arteries Replacement of stent (tube) in biliary or pancreatic duct Removal of foreign body, not otherwise specified Diagnoses: Acute posthemorrhagic anemia Hemorrhage complicating a procedure Other specified disorders of biliary tract Multiple myeloma, without mention of having achieved remission Mechanical complication due to other implant and internal device, not elsewhere classified Iron deficiency anemia, unspecified Other vitamin B12 deficiency anemia Hemangioma of other sites

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue and dyspnea on exertion major surgical or invasive procedure: - avr 25mm st. porcine valve history of present illness: splendid 80 year old gentleman who has severe aortic stenosis. he sustained and inferior wall mi on followed by a ptca. he recently had a colonic tumor/polyp removed in and developed chest pain as well as dyspnea perioperatively. a cardiac catheterization was performed which revealed sever aortic stenosis and no flow limiting disease. his ejection fraction was preserved. past medical history: s/p colonic polyp removal left tkr ptca imi htn as hyperlipidemia copd cri depression erectile dysfunction social history: has not seen the dentist in 3 years. no tobacco, infrequent alcohol use. lives alone. wife in nursing home. family history: mother of endocarditis father died of accident physical exam: gen: nad, wdwn, 134/81 62 nsr heart: rrr, iv/vi systolic murmur lungs: clear abd: benign pulses: no carotid bruits, no edema pulses intact pertinent results: 06:10am blood hct-32.3* 06:05am blood wbc-7.0 rbc-3.50* hgb-10.9* hct-31.0* mcv-89 mch-31.1 mchc-35.0 rdw-15.4 plt ct-235 06:05am blood plt ct-235 06:10am blood urean-26* creat-1.3* k-5.0 cxr borderline cardiac enlargement has decreased, comparable to the preoperative appearance on . thickening of the right costal and apical pleural margin is probably due to fat deposition, not fluid, although a tiny volume of layering pleural fluid is present bilaterally. no pneumothorax. no pneumonia. ekg sinus rhythm consider left atrial abnormality probable inferior myocardial infarction, age indeterminate inferolateral st-t wave changes with slight st segment elevation - cannot exclude in part ischemia/injury clinical correlation is suggested since previous tracing of , first degree a-v delay absent and further lateral st-t wave changes seen ospital course: mr. was admitted to the on for elective surgical management of his aortic stenosis. he was taken directly to the operating room where he underwent an aortic valve replacement utilizing a 25mm st. porcine valve. postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. on postoperative day one, he awoke neurologically intact and was extubated. he was initially slightly confused requiring a sitter however his mental status slowly cleared. later on postoperative day one, he was transferred to the cardiac surgical step down unit for monitoring. he was gently diuresed towards his preoperative weight. beta blockade was discontinued for low blood pressure. the physical therapy service was consulted to help increase his postoperative strength and mobility. mr. developed atrial fibrillation which converted spontaneously back into normal sinus rhythm. mr. continued to make steady progress and was discharged to rehabilitation on postoperative day six. he will follow-up with dr. , his cardiologist and his primary care physician as an outpatient. beta blockade should be resumed as an outpatient when his blood pressure can tolerate. medications on admission: lopressor 25mg daily lasix 40mg daily celexa 20mg daily zocor 60mg daily aspirin 325mg daily discharge medications: 1. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 7 days. 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 4. simvastatin 20 mg tablet sig: three (3) tablet po daily (daily). 5. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days: take for three days then stop. 6. propoxyphene n-acetaminophen 100-650 mg tablet sig: tablets po q6h (every 6 hours) as needed for severe pain. 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) discharge disposition: extended care facility: health care discharge diagnosis: aortic stenosis hyperlipidemia paf htn copd imi ptca postop confusion left tkr colonic polyp removal cri depression erectile dysfunction discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. 2) report any fever greater then 100.5. 3) report any weight gain of greater then 2 pounds in 24 hours. 4) take lasix for 3 days until reach preop weight of 225 pounds and then stop or as insturcted by physician. potassium with lasix and stop when lasix stopped. 5) please resume lopressor and or an ace inhibitor when blood pressure can tolerate. 6) call with any questions or concerns. p instructions: follow-up with dr. in 4 weeks. ( follow-up with cardiologist dr. in 2 weeks. follow-up with primary care physician . in 2 weeks. ( Procedure: Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Transfusion of packed cells Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Aortic valve disorders Unspecified transient mental disorder in conditions classified elsewhere Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Other and unspecified hyperlipidemia Old myocardial infarction Other constipation

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bacteremia, sz major surgical or invasive procedure: paracentesis history of present illness: hpi : micu admission note reviewed. briefly, this is a 38 yo m h/o etoh cirrhosis, meld 27 on tx list initially presenting from osh with szs. admit to osh with abd pain/fevers to 103. bl cxs grew mssa in bottles , 1/4 . started on nafcillin. tte neg for veg. ct abd neg. started on flagyl for ? c diff though no cx data. afebrile since . has been pancytopenic at osh. on , pt had witnessed t-c sz x 2 min. givne iv ativan ct head neg. debate re: starting aed, given cirrhosis/tx status. pt continued to have t-c szs q hour x 5. dr. called and pt dilantin loaded. pt tx'd to micu for further management. . pt has remained afebrile and hd stable in the micu. no further szs. eeg and mri head negative. pt with ha on admission, but resolved shortly so team decided no lp. tee neg. abd us with nml doppler, mod ascites but no suitable spot for tap. . ros: pt currently denies ha/lh. denies cp/sob. +baseline mild abd pain. no melena/brbpr. past medical history: hepc cirrhosis; patient has never been treated with interferon/ribavirin alcoholic hepatitis in after a four month drinking binge anxiety s/p appendectomy social history: sh - lives in ri with his parents, currently unemployed. has a h/o ivdu, starting at age 17, ended in his early 20s when he spent several years in a residential drug rehab program he was previously on methadone to treat heroin addiction; stopped in he endorses only social alcohol use until , when he began binge drinking up to a fifth of vodka a day to cope with unemployment and methadone withdrawal; no alcohol since . smokes 1 ppd x 20 yrs. . family history: grandparents c diabetes. no history of cad or liver disease. physical exam: temp 99.2 bp 121/68 pulse 81 resp 21 o2 sat 98% ra gen - alert, no acute distress heent - extraocular motions intact, +icterus, mucous membranes moist neck - no jvd, no cervical lymphadenopathy chest - clear to auscultation bilaterally cv - normal s1/s2, rrr, no murmurs appreciated abd - soft, mild r and luq tenderness, distended, +bs extr -trace b/l le edema. 2+ dp pulses bilaterally neuro - no asterixis skin - spider angiomoas over chest pertinent results: 132 100 9 / 148 agap=13 3.1 22 1.0 \ ca: 7.8 mg: 1.8 p: 3.2 alt: 29 ap: 91 tbili: 8.6 alb: 3.1 ast: 55 ldh: 233 dbili: tprot: : 49 lip: 34 phenytoin: 5.2 . 108 3.7 \ 9.6 / 61 / 27.9 \ n:68.1 l:23.5 m:6.6 e:1.3 bas:0.6 anisocy: 1+ macrocy: 3+ gran-ct: 2490 pt: 24.7 ptt: 42.2 inr: 2.5 . micro: blood cultures negative . imaging: mri head: findings: there is no slow diffusion to indicate an acute infarct. there are no enhancing abnormalities. there is increased t1 signal within the basal ganglia prior to the administration of iv contrast. these findings are commonly seen in patients with liver failure. there is no midline shift, mass effect, or hydrocephalus. no areas of abnormal magnetic susceptibility are noted. normal vascular flow voids are present. impression: no evidence of an enhancing abnormality or mass. no acute infarct. increased t1 signal in the basal ganglia bilaterally consistent with the patient's history of hepatic failure. . tee: general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. the patient was sedated for the tee. medications and dosages are listed above (see test information section). the posterior pharynx was anesthetized with 2% viscous lidocaine. no tee related complications. 0.1 mg of iv glycopyrrolate was given as an antisialogogue prior to tee probe insertion. conclusions: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular systolic function is normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. impression: no echo evidence of endocarditis. . ruq ultrasound: impression: 1. successful ultrasound-guided diagnostic and therapeutic paracentesis. 2. hepatopetal flow of the main portal vein . renal ultrasound: the right kidney measures approximately 11.8 cm and the left kidney measures approximately 11.5 cm. there is no evidence of hydronephrosis or renal lithiasis bilaterally. areas of ascites are again demonstrated throughout the abdomen. no focal bladder wall masses are identified in the prostate appears slightly enlarged measuring approximately 5.1 x 4.3 x 4.3 cm. impression: 1. no evidence of hyrdronephrosis or renal lithiasis. 2. mild prostatic hypertrophy. 3. abdominal ascites . bone scan impression: 1) no definite evidence of osteomyelitis. 2) linear increased lower sacral uptake consistent with a fracture. 3) marked, diffuse bilateral increased renal uptake is non-specific and may be secondary to interstitial nephritis brief hospital course: 38 y/o m w/ alcohol/hepc cirrhosis with admitted with s. aureus bacteremia, and seizure. . 1) unclear source. patient did not have localizing signs or symptoms (other than chronic abdominal pain) and did not have a history c/w meningitis/meningoencephalitis. he underwent tte and tee while in the icu, both w/o evidence of vegetation. surveillance cultures remained negative (although all drawn on abx) and patient was w/o evidence of embolic or immunologic phenomena on examination. he remaineed afebrile in house. he also underwent bone scan to r/o occult osteomyelitis, which did not show evidence of infectious focus. lp was deferred per neuro recommendations- it was felt that the patient had been on antibiotics for approximately 5days on transfer from osh and his coagulopathy and thrombocytopenia would induce additional risk for the procedure. at the osh, the patient was initially started on vancomycin and ctx. when sensitivities returned as mssa the patient was switched to nafcillin. he completed 12 days of antibiotic therapy and subsequently developed arf (cr peaked at 3.5) but rapidly recovered. fena>1%, u/s neg, eos neg (including peripheral), sediment bland. bone scan did show evidence of increased renal uptake c/w intersitial nephritis. he completed the last two days of a total 14 day course with vancomycin. he was afebrile on discharge, w/ plan to obtain repeat blood cultures on monday . . 2) unclear etiology. patient w/o sz hx. interestingly, the patient seized at the osh on hospital d3. this course was concerning for etoh w/d but patient vehemently denies further alcohol use. he was initially loaded on dilantin and subsequently maintained on keppra. eeg did not show evidence of sz focus. plan for patient to f/u w/ dr. of neurology. . 3) acute hepatitis- patient admitted to osh with ast of approx 80, alt approx 40. these trended down following admission but the patient subsequently developed a cholestatic appearance on labs, with his bilirubin peaking at 15.7 and inr at 2.7. both were trending down on discharge. again, the patient denied alcohol use. . 4) arf- likely interstitial nephritis, as discussed above . 5) esld- on discharge, plan to start re-start diuretics pending evaluation of renal function on monday. patient was continued on lactulose in house. . 6) abdominal pain - chronic abdominal pain in house. minimal ascites but underwent ultrasound guided paracentesis that ruled out sbp. . 7) full code for this admission medications on admission: meds (home): 1. restoril 30mg qhs 2. alprazolam 1mg tid 3. furosemide 40mg qd 4. aldactone 100mg qd 5. lactulose 30cc tid discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 3. nicotine 21 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). disp:*30 patch 24hr(s)* refills:*2* 4. temazepam 15 mg capsule sig: two (2) capsule po hs (at bedtime). 5. hexavitamin tablet sig: one (1) cap po daily (daily). 6. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 7. labwork sig: one (1) once for 1 days: on monday you need to have the following labs drawn: cbc, chem 10, ast/alt/bili/inr, and blood cultures x2. please ask the lab to fax the results to . disp:*1 1* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: 1) esld 2) seizure 3) staph aureus bacteremia discharge condition: good, vss, afebrile, renal function normal discharge instructions: 1) please continue to take your medications as directed. 2) you have been given a prescription for labs to be performed on monday, . 3) please avoid taking nsaids (i.e. ibuprofen, naproxen, etc) until your pcp or dr. has verified that your renal function is ok. you should also avoid ultram (tramadol) followup instructions: please follow up with your pcp days. . please follow up with dr. in liver clinic as already scheduled. . provider: , md phone: date/time: 11:40 . please follow up with dr from neurology in weeks. ( Procedure: Diagnostic ultrasound of heart Percutaneous abdominal drainage Diagnoses: Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Acute kidney failure, unspecified Other convulsions Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Acute glomerulonephritis with other specified pathological lesion in kidney Other sequelae of chronic liver disease

history of present illness: the patient is a 45-year-old male with a history of gerd, standing with substernal chest pain while working at a construction site, which he thought was his gerd, then worsened in a few hours. after about 2 hours, he went to the emergency department. the pain was radiating down both arms with his chest pressure. no nausea, diaphoresis or shortness of breath. in the emergency department, he was found to have lateral st elevations in v4 through v6 and st elevations in 2 equal to 3 and avf. he went into ventricular fibrillation arrest. in the emergency department, he was shocked to normal sinus rhythm, given thrombolysis with tnk. at 4:52 a.m., he was transferred to for emergent catheterization. at the catheterization, they found right ventricular pressure of 38/14, pulmonary capillary wedge mean pressure at 25, and 98 percent thrombotic occlusion in om1. ptca and stent with heparin- coated stent was placed. st elevations resolved after catheterization and patient was pain free. patient then developed automated idioventricular rhythm after tnk at outside hospital. on arrival after catheterization here, he was pain free with small right groin hematoma. physical examination: stable vital signs and normal sinus rhythm. his temperature afebrile, heart rate 73, blood pressure 128/71, respirations 16, oxygen saturation 95 percent on 2 liters. generally, in no acute distress. alert and oriented x 3. no carotid bruits. heent: mucous membranes moist. jvp at 10 cm. cardiovascular: regular rate and rhythm. no murmurs, rubs or gallops. pulmonary: clear to auscultation bilaterally. abdomen: soft, nontender, nondistended, normoactive bowel sounds. extremities: no edema. trace dorsalis pedis pulses, 2 plus posterior pulses bilaterally. small right groin hematoma. laboratory data: white count 11.8, hematocrit 40.6, platelets 269, inr 1.3, sodium 137, potassium 4.6, chloride 104, bicarbonate 23, bun 19, creatinine 0.9, and glucose 108. hospital course: ischemia. patient had inferior st elevation mi. he was given thrombolysis at the outside hospital but was transferred for persistent pain and st elevations. his ptca here was a heparin coated stent to the om 1. he was given aspirin, plavix, lopressor, lipitor 80 mg, and started on ace inhibitor. ck is peaked at 3869. pump likely moderate-sized inferolateral mi. echocardiogram showed left atrial elongation, mild symmetric left ventricular hypertrophy, inferolateral hypokinesis/akinesis, mild dilated aortic root, trivial mr ejection fraction of 30 percent. he was started on coumadin and heparin for increased risk of thrombosis with no telemetry events. he will have a signal-average ekg and follow up with electrophysiology for t-wave alternans in 3 to 4 weeks. cocaine use. patient has been counseled regarding the risk of using cocaine including risk of mi and cva as well as sudden death. he was seen by and given phone numbers for several detoxification programs. discharge status: stable. discharge disposition: patient was discharged to home. followup plans: patient has to follow up with dr. , his new cardiologist and primary care provider. will arrange for the patient to begin a cardiac rehabilitation program. the patient can go to his office at 11:00 a.m. on . he has also to follow up with dr. regarding his signal-average ekg and t-wave alternans testing for risk of further arrhythmias. discharge medications: 1. plavix 75 mg p.o. q.d. 2. pantoprazole 40 mg p.o. q.d. 3. aspirin 325 mg p.o. q.d. 4. lipitor 80 mg p.o. q.d. 5. lisinopril 5 mg p.o. q.d. 6. metoprolol sustained release 50 mg p.o. q.d. 7. coumadin 7.5 mg p.o. h.s. 8. lovenox 80 mg subcutaneously b.i.d. until inr greater than 2. , Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Acute myocardial infarction of inferolateral wall, initial episode of care Cocaine abuse, episodic

see fhp for detailed hpi, pmh, and, allergies cath:upon arrival to cath, nitro and heparin stopped, lidocaine found not to be running so discontinued. pt pain free with stable vss. rhc opening pressures ra 9, rv 38/14, pa 38/20 and pcwp 24. lhc: lmca, lad, and rca normal. lcx with 90% disease mid and stented with taxol stent without complication with good flow and no residual. no lv gram performed. recieved 125mcgs of fent, 3mg of versed, 300mg of plavix and 2500u of heparin. no integrillin started secondary to lytics. rfa and rfv sheath dc'd in holding area. vss throughout procedure and denying chest heaviness or pain. s-"i feel like i could go back to work tommorow!" Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified essential hypertension Acute myocardial infarction of inferolateral wall, initial episode of care Cocaine abuse, episodic

allergies: bactrim / keflex / catapres / trazodone attending: chief complaint: admit for carotid angiography and possible intervention. major surgical or invasive procedure: s/p stenting of left carotid artery history of present illness: 64 year-old woman, patient of dr. , dr. , dr. , with an extensive history of cad, now s/p recent left upper lobectomy for lung cancer with an incidental finding of an old cva on head ct postoperatively prompting a workup that revealed 90% left internal carotid stenosis on duplex, vs 55% on cta of neck, now referred for left carotid angiography to more clearly define her carotid anatomy, and carotid intervention, if appropriate. events were as follows: imi - treated with stenting of the rca and lcx. found to have severe mr and was referred for surgical repair. mitral valve surgery aborted after tee at time of surgery revealed largely normal mitral valve with improvement of inferior hypokinesis compared to month prior. cardiac catheterization - total occlusion of rca stent and patent lcx stent, mild to mod mr pulmonary edema requiring intubation at an osh. transferred to and had a cardiac cath revealing t.o rca and 40% cx stenosis in prior stent. ef of 30% aicd placement cath d/t worsening chronic angina and doe and inferior ischemia on dobutamine viability study. angiography revealed 40% lad, 40% lcx isrs, rca totally occluded with distal filling via left to right collaterals. s/p unsuccesful recanalization of the rca. ffr of cx lesion demonstrated it to be a hemodynamically insignificant lesion. s/p vats, left upper lobectomy and mediastinal lymph node dissection d/t adenocarcinoma. patient d/c'd on and readmitted on d/t mental status changes and hypotension. a chest ct was done which was negative for a pe. a ct of the head was done revealing no evidence of intracranial hemorrhage, but a hypodensity at the right temporo-occipital junction. this could represent a late subacute to chronic infarct vs metastatic disease. a ct with contrast was done the following day revealing the same findings. a carotid series was therefore ordered and done on . this revealed an 80-99% stenosis of the left internal carotid artery and a <40% stenosis of the right internal carotid artery. a tte was done on . this revealed an ef of 40% with 1+mr, small to moderate sized pericardial effusion. mild symmetric lvh. hypokinesis noted in the infero-septum, inferior and infero-lateral walls. akinesis noted in the basal infero-septum and inferior wall. . the patient was subsequently referred to see dr as an outpatient who has recommended her for carotid angiography and intervention. the patient was then seen in clinic by dr. of neurology who is in agreement that the head ct scan abnormality is very likely an embolic stroke and feels that left carotid intervention is appropriate. the patient was also seen by dr. of neurosurgery who felt that it is exceedingly unlikely that the lesion on ct scan represents a malignancy vs. metastasis and cleared her to undergo a carotid procedure. he recommended repeat head ct in 3 months. . follow up studies have included: chest xray: normal post left upper lobectomy appearance. no evidence of any cardiopulmonary process. cta of neck: approximately 55% left sided carotid stenosis at the bifurcation ct of brain with and without contrast: no change of right posterior temporal-occipital region, likely represents a chronic infarct. noted to have tortuous basilar artery. basilary artery summit positioned to the left of the midline. just anterior to the summit is a 2-mm area of contrast enhancement--finding could represent very tortuous origin of left posterior cerebral artery or contigious tiny aneurysm. . in terms of symptoms, the patient denies any neurological deficits, confusion,or lightheadedness. she further denies any chest pain. she does report having dyspnea after climbing one flight of stairs. . on day of admission, she underwent carotid angiography with stent placement past medical history: s/p bronch/meds, 70 pck yr smoker, cad s/p mi x 2 and stenting x 2, s/p aicd implant, ef 33%, hypothyroid, dm< s/p hysterectomy, s/p appy, s/p varicose vein removal social history: married with two children who live close by. husband will drive her to the procedure.(+) cigarette smoking 80 ppy history, quit in , restarted in , quit again family history: (+) cad father had mi at 42yo and died. mother had cva 54yo. both sisters are healthy. physical exam: gen: wd female in nad heent: perrl, eomi neck: no bruits, no lad cv: rrr no m,r,g lung: cta bilat abd: soft, nt, nd bsna ext: no c/c/e neuro: cn ii-xii intact, a and o x 3, no focal defecits pertinent results: 09:22pm wbc-11.6* rbc-3.81* hgb-11.2* hct-32.4* mcv-85 mch-29.4 mchc-34.5 rdw-14.9 09:22pm plt count-343 . cardiac cath comments: 1. access was retrograde via the rcfa with catheter placemnt to the aortic arch and bilateral common carotid arteries. 2. the aortic arch was a type i arch with mild tortuosity of the great vessels and no angiographically significant lesions. 3. the right cca was angiographically normal. the had a mild 30% lesion at the bifurcation. the filled the ipsilateral aca and mca without cross-filling. there was mild tortuosity of the proximal intracerebral vessels. 4. the left cca was angiographically normal. the had a calcified eccentric 90% lesion at the bifurcation and filled the ipsilateral aca and mca. 5. successful stenting of the with a x 30 mm acculink stent (see pta comments). final diagnosis: 1. severe left internal carotid artery stenosis. 2. successful stenting of the left internal carotid artery. . ecg sinus rhythm with ventricular premature complexes low qrs voltages - clinical correlation is suggested brief hospital course: a/p: 64 year-old woman with question of significant carotid stenosis, referred for carotid angiography. . plan: . # s/p carotid angiography with stent placement: she had left ica stent placed on day of admission without event. developed reflex hypotension and was placed on a low dose of neo-synephrine. this was weaned and by hd #1, her bp was elevated and we resumed carvedilol and ace/lasix at home doses which were well tolerated. we continued continue asa, statin, plavix throughout admission. her mental status remained unchanged and her neuro exam was without focal defecits. she did report occasional headache which responded well to po meds. she was discharged to home on hd #2 without event. . # hypothyroidism: levothyroxine sodium 112 mcg po daily continued throughout admission. . #. dm: riss and fs qachs continued throughout admission. . # gerd: cont. ppi throughout admission. . # ppx: ppi, plavix, asa . # code: full . # comm: with pt . # disp: to home with planned follow up as outlined above. . medications on admission: ecasa 325mg daily lorazepam 0.5mg prn anxiety metformin 850mg tid prilosec 20mg daily coreg 12.5mg lipitor 60mg daily lisinopril 10mg daily celexa 60mg daily levoxyl .112mcg daily sprinolactone 25mg daily lasix 20mg daily discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 4. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. fioricet mg tablet sig: 1-2 tablets po every four (4) hours as needed for headache for 1 weeks: max dose 6 tablets in 24 hours. . disp:*48 tablet(s)* refills:*0* 6. spironolactone 25 mg tablet sig: one (1) tablet po once a day: to be restarted . 7. lasix 20 mg tablet sig: one (1) tablet po once a day: to be restarted . 8. metformin 850 mg tablet sig: one (1) tablet po three times a day: to be restarted . 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 10. lipitor 20 mg tablet sig: three (3) tablet po once a day. 11. citalopram 20 mg tablet sig: three (3) tablet po once a day. 12. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 13. levothyroxine 112 mcg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: primary diagnosis: s/p stenting of the left carotid artery secondary diagnosis: hypotension hypertension hypercholesterolemia hypothyroidism anxiety discharge condition: stable discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet please keep all follow up appointments. please take all medications as prescribed. you should restart you lasix and spironolactone tomorrow (friday), you should not restart your metformin until saturday . seek medical attention for fevers, chills, chest pain, shortness of breath, lightheadedness, or any other concerning symtpoms. followup instructions: 2. provider: , md phone: date/time: 9:30 3. provider: / phone: date/time: 4:30 4. provider: breathing tests phone: date/time: 2:40 Procedure: Percutaneous angioplasty of extracranial vessel(s) Percutaneous insertion of carotid artery stent(s) Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified acquired hypothyroidism Personal history of malignant neoplasm of bronchus and lung Coronary atherosclerosis of unspecified type of vessel, native or graft Percutaneous transluminal coronary angioplasty status Occlusion and stenosis of carotid artery without mention of cerebral infarction Automatic implantable cardiac defibrillator in situ

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fall major surgical or invasive procedure: n/a history of present illness: nf admit seen and appreciated. briefly this is a yo f w/ h/o lung ca w/ metastasis to brain on xrt, s/p fall at nh on sun eve. no loc. lethargy, n/v,l arm weakness, sent to where she was noted to havv 3x3cm r posterior parietal bleed. tx to nsicu, started on dilantin (load) and decadron. deemed not a surgical candidate -> dnr/dni. noted to be guiac pos, +hct drop, coffee grounds on ngl. gi recommended transfusing to maintain hct. past medical history: lung ca w/ mets to brain high cholesterol htn cad lopresser 25mg tid social history: lives at , at baseline walks w/ walker. speaks italian, some english physical exam: t 98.6, bp 120/68, p 88, r 20 97% ra elderly female, lying in bed, foam from mouth, responsive to voice, can squeeze r hand. r pupil 4mm, no reactive, l pupil reactive. no cervical/sm/sc la regular s1,s2. no m/r/g lca anteriorly. pertinent results: cbc: 8.9 8.6 229 27.1 electrolytes: 04:51pm sodium-137 04:51pm albumin-3.2* 09:45am sodium-131* potassium-4.1 chloride-95* total co2-30* anion gap-10 03:57am calcium-8.6 phosphate-3.9 magnesium-1.8 03:57am phenytoin-10.2 mri:on diffusion-weighted images there is a small area of restricted diffusion along the falx within the left occipitotemporal lobe. it is also bright on flair-weighted images and may represent a subacute infarct. clinical correlation is recommended. on gradient echo images there is a large area of intraparenchymal hemorrhage within the right parietal lobe and left thalamus which following administration of gadolinium reveals ring-enhancing lesions. these are suspicious for hemorrhagic metastases given the patient's history. additional ring-enhancing lesions throughout the supra- and infratentorial compartments are visualized. there is a moderate amount of peritumoral edema involving the right parietal lobe lesion in addition to a second right parietal lesion along the falx high in the vertex. the other areas of metastases reveal a minimal amount of peritumoral edema. . cxr: cardiomegaly and mild chf. nasogastric tube as described above. rounded opacity overlying the left hilum, which probably representing aspiration pneumonia; however, left hilar mass cannot be totally excluded. please confirm resolution by repeated chest x-ray after treatment, and if the lesion persists, please evaluate by ct scan. . ct: stable appearance of right parietal lobe and left thalamic hemorrhages, which are concerning for hemorrhagic metastasis in this patient with known metastatic lung carcinoma to the brain. brief hospital course: yo f s/p inh in r parietal region, evidence of transferred to medicine, w/ pupillary assymmetry but no evidence of neglect, responding to commands. . 1) altered ms- likely bleed into metastatic lesion, although unclear based on location of known lesions, vs component of fall. as per ns, not a surgical candidate. seems unlikely that pt will have dramatic cliical improvement given significant edema, mass lesions, and no ns intervention. -palliative xrt? family mtg tonite to discuss utility. -cont dilantin px, particularly since pt has ? of witnessed sz event. -cont high dose decadron, q6h w/ fs. -will clarify . 2) gib- drop in hct during admission and + ngl. gi input appreciated felt likely stress ulceration. enteral nutrition and ppi (usually oral) have been shown to reduce the risk of ongoing bleeding. -start tf's 10cc/h until nutrition recs -iv protonix (given recent h/o gib) . 3) cad/chf- previously some chf on cxr. oxygenating well. euvolemic on exam despite significant anasarca of hands/feet- minimal swelling of tibial surfaces so partially related to restraints. -cont lopresser -d/c lipitor, rx for hepatic dz. . 4) fen- ivf, tf's . 5) ppx- ppi, pneumoboots . 6) code- dnr/dni on a family meeting was held with oncology, social work, palliative care consult and primary medical team. at that time the family decided to place comfort as the main goal of her medical care. her status was changed to "cmo". medications on admission: -lipitor 20 -protonix -lopressor 25 tid discharge medications: morphine elixir scopolamine patch ativan discharge disposition: extended care facility: wayside discharge diagnosis: metastatic lung cancer intracerbral hemmorhage gi bleed discharge condition: critical discharge instructions: please keep patitent comfortable no blood draws, tubes or restraints followup instructions: n/a Procedure: Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Hyposmolality and/or hyponatremia Other convulsions Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of other parts of bronchus or lung Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction

allergies: morphine / shellfish attending: chief complaint: hypoglycemia and hypotension major surgical or invasive procedure: none history of present illness: 87 year old female with esrd on hd tu/th/sat, cad s/p pci lad, om1 ', nstemi , dm2, ras who presented to osh from nursing home with confusion and diaphoresis. glucose noted to be in the 30's and given d50 with improvement in mental status. at osh she had abdominal pain and a ct abd/pelvis without contrast was performed which showed no evidence of obstruction, free air, or aaa but had significant bandemia. she was given ceftriaxone and flagyl and transferred to . . on transfer to ed, sbp in 60's, hypoglycemic to 40's with abdominal pain. she was guaiac (+) with dark flecks of material on rectal. an ng lavage was done with bilious material which cleared with 700cc ns (no blood). surgery was consulted, reviewed her ct scans from osh and felt there was no acute surgical issue. she was given vanco x1. u/a was positive, and patient was given 2 l ns with sbp into 120s and hr 60's. blood sugars improved to 140's with 1 amp d50. blood and urine cultures drawn. patient was due for dialysis on the day of admission. renal was contact about missing her hd but felt no acute need for hd. on admission, patient was unable to recall preceding events. does not remember why she was sent in from nh. denied fevers, chills, nausea, vomiting, diarrhea. did complain of some left-sided abdominal pain. past medical history: cad pci lad, om1 ' nstemi esrd chronic hd dm2 htn dyslipidemia hypothyroidism ras dementia depression rbbb/lafb/bradycardia staph epidermis infection dialysis catheter oa social history: widowed. lives at pine manor nursing center. stm loss. has 2 grown sons. , is power of attorney and health care proxy for patient. nonsmoker. denies alcohol use. family history: nc physical exam: physical exam: vs: t: 98.0; hr: 70; bp: 130/87; rr 18; o2 95% ra gen: awake, alert, oriented to self and year. thought she was @ . heent: eomi. mmm. op clear. 3 cm diameter soft, mobile, nontender mass over r occiput (?lipoma). pt states has been present for x4mos. neck: supple, no jvd. cv: rrr. nl s1, s2. sys murmur at lusb. pulm: bibasilar crackles. abd: (+) bs. soft, nd. minimal epigastic tenderness. no rebound or guarding. back: no cva tenderness ext: lower extremities warm, well-perfused. 1+ dp pules bilat. no edema. pertinent results: 02:50pm pt-15.4* ptt-68.3* inr(pt)-1.4* 02:50pm plt smr-normal plt count-163 02:50pm hypochrom-1+ anisocyt-2+ poikilocy-1+ macrocyt-3+ microcyt-normal polychrom-occasional ovalocyt-occasional burr-1+ 02:50pm neuts-78.0* bands-0 lymphs-16.9* monos-3.9 eos-1.1 basos-0.1 02:50pm wbc-4.9# rbc-3.20* hgb-11.0* hct-33.6* mcv-105* mch-34.4* mchc-32.8 rdw-18.0* 02:50pm calcium-6.7* phosphate-7.1*# magnesium-1.4* 02:50pm ck-mb-notdone ctropnt-0.03* 02:50pm lipase-12 02:50pm alt(sgpt)-18 ast(sgot)-22 ck(cpk)-23* alk phos-91 tot bili-0.2 02:50pm glucose-42* urea n-60* creat-5.3*# sodium-139 potassium-3.8 chloride-100 total co2-19* anion gap-24* 09:30pm ck-mb-notdone ctropnt-0.05* 06:55am blood ck-mb-notdone ctropnt-0.21* 07:19pm blood ck-mb-notdone ctropnt-0.31* 06:55am blood ck-mb-notdone ctropnt-0.16* 06:55am blood wbc-5.1 rbc-3.76* hgb-12.7 hct-39.4 mcv-105* mch-33.9* mchc-32.3 rdw-17.5* plt ct-219 06:55am blood plt ct-219 06:55am blood glucose-73 urean-26* creat-5.1*# na-140 k-3.9 cl-100 hco3-28 angap-16 06:55am blood ck(cpk)-38 06:55am blood ck-mb-notdone ctropnt-0.16* 06:55am blood calcium-8.5 phos-3.3 mg-2.3 kub: impression: nonspecific bowel gas pattern without evidence of obstruction. brief hospital course: 87 year old female with esrd on hd, cad s/p mi and pci, dm2, ras presented from osh with hypoglycemia, hypotension, abdominal pain, uti, now normotensive with new epigastic pain and persistent intermittent hypoglycemia. --in the micu, patient treated for uti and question of urosepsis with cipro. pyelonephritis was considered possible source of abdominal pain. urine cultures came back positive for pansensitive e. coli and patient was continued on cipro. there was no growth in blood cultures. she was ruled out for mi with mild troponin elevation in the setting of renal failure but flat cks. patient was restarted on hd the day following admission. her labetolol, norvasc, clonidine, and isosorbide were held. she had no further hypotension following initial volume recessitation. however, she continued to be hypoglycemic at times, thought most likely secondary to persistent blood levels of glipizide in the setting of renal insufficiency as well as poor po intake. patient's po intake began to improve and prior to transfer to the floor, bgs had improved to 70-140 . micu stay also complicated by epigastric abdominal pain and emesis, bilious and non-bloody. pancreatic enzymes and lfts were normal. ptt and inr elevated in micu. heparin sc stopped. both trended down on repeat checks. . the morning after transfer, the patient was found to have increasing nausea and vomiting that was poorly responsive to anti-nausea meds. as there was concern for cardiac ischemia, an ekg was done that showed new t-wave inversions in the lateral leads. pt had significan troponin elevation and cardiology was consulted. though the patient was likely having mild episode of cardiac ischemia, given the patient's significant comorbidities and resolvation of symptoms as well as no hemodynamic compromise, the patient was treated medically with aspirin, plavix, beta blocker and oxygen. the patient was asymptomatic and had downtrending troponins. for the remainder of the hospital, the patient has stable vital signs and no other complaints of chest pressure. . # uti: urine culture positive for pansensitive e coli. was initially treated with cipro, but with the patient's nausea and vomiting, it was changed to levofloxacin qhd. pt now on day 6 of appropriate abx. currently afebrile. cva tenderness noted on admission now resolved. pyelonephritis possible cause of initial abdominal pain but no clear evidence of that on ct abdomen from osh. . # esrd on hd (tues/thurs/sat) pt now on mwf schedule, nephrology following. - next session due - monitor electrolytes - continue nephrocaps . # epigastric tenderness/vomiting: minimal epigastric tenderness on exam, +n/v. unclear etiology. lfts, pancreatic enzymes normal. be to gastroparesis given h/o dm and patient reports chronic n/v prior to admission. now asymptomatic, if persists, nay need gastric emptying study. . # dmii: patient p/w hypoglycemia, now resolved. was likely oral hypoglycemics in setting of worsened renal function due to infection. stable finger sticks on day of discharge, pt on insulin sliding scale - monitor qid finger sticks - cont to hold glyburide as was hypoglycemic - riss if needed . # htn: labetalol, clonidine, and norvasc held on admission to micu given hypotension. restarted prior to discharge. . # cad: stable, denies cp. slight troponin elevation likely renal failure, but slight elevation likely due to mild ischemic event, managed medically as pt has multiple comorbities. ck/mb negative. - continue asa, plavix, statin . # right hip pain- pt given history of falling prior to admission. x ray on admission showed no signs of occult fracture though small linear lucency on x ray. pt with large hematoma on hip that precludes anticoagulation. . # hypothyroidism: continue levothyroxine . # depression: continue sertraline . # code: dnr/dni confirmed with patient at the time of transfer medications on admission: asa 325 plavix labetalol 200 clonidine 0.3mg po bid sucralfate 1g qid nephrocaps feso4 325 qday glyburide 5mg qday isosorbide mononitrate 60 qday levothyroxine 100 qday lipitor 80 norvasc 10 qday sertraline 50 qday colace/senna/dulcolax protonix 40 qday razadyne 4mg qhs ativan 0.5mg qday prn prochlorperazine 25 mg pr prn nausea tylenol/benadryl prn sl ntg prn percocetq4 prn pain discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 6. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 7. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 14. levofloxacin in d5w 250 mg/50 ml piggyback sig: two hundred fifty (250) mg intravenous q48h (every 48 hours): please give at dialysis. 15. imdur 60 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. 16. razadyne 4 mg tablet sig: one (1) tablet po at bedtime. 17. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain, fever. 18. ativan 0.5 mg tablet sig: one (1) tablet po twice a day as needed for anxiety. 19. labetalol 100 mg tablet sig: 1.5 tablets po bid (2 times a day). 20. insulin regular human 100 unit/ml solution sig: see sliding scale injection asdir (as directed): check glucose qid, if < 70 give amp d 50 and md, if 70-150 no insulin, if 151-200 give 2 u, if 201-250 give 4 u, if 300-350 give 6 u, if 351-400 give 8 u, if >400, give 10 u and md. discharge disposition: extended care facility: manor - discharge diagnosis: urinary tract infection, hypoglycemia discharge condition: stable; tolerating po intake and afebrile discharge instructions: weigh yourself every morning, md if weight > 3 lbs. please take your medications as directed please keep your follow-up appointments followup instructions: please make an appointment with , for the next 7-10 days. please return to your normal hemodialysis schedule Procedure: Hemodialysis Insertion of other (naso-)gastric tube Diagnoses: Anemia of other chronic disease End stage renal disease Urinary tract infection, site not specified Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Other persistent mental disorders due to conditions classified elsewhere Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Nausea with vomiting Hypotension, unspecified Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Cardiac pacemaker in situ

allergies: gluten / betalactams / vancomycin hcl attending: chief complaint: 54 year-old male with an enteropathy associated t-cell lymphoma, status post hyper cvad therapy and 5 cycles of chop, and recently ice chemotherapy and collection, being admitted for auto-bmt. major surgical or invasive procedure: esophagogastroduodenoscopy () history of present illness: 54 year-old male with an enteropathy associated t-cell lymphoma diagnosed in , with known gastric and jejunal ulcers and history of small bowel resection for microperforation, admitted for auto-bmt on . he was previously treated with hyper-cvad (did not tolerate) and 5 cycles of chop. his course was complicated by a bout of hepatitis in which was felt to be chemical in etiology and led to weight loss, sprue exacerbation and relapse. following his bout of hepatitis, mr. was started back on tpn and has been doing well on it. he was recently teated with a cycle of ice chemotherapy and collected in preparation for auto-bmt. his bone marrow performed at the beginning of revealed some minimal involvement with his t-cell lymphoma. his liver biopsy performed on revealed numerous apoptotic hepatocytes, multiple small foci of sinusoidal mononuclear inflammation and enlarged kupffer cells consistent with acute hepatitis. no neoplastic cells. tissue egd performed on showed some involvement by enteropathy associated t-cell lymphoma in one biopsy section. past medical history: 1. sprue: diagnosis , which was refractory to gluten-free diet at which point prednisone therapy was initiated. further investigation led to biopsy of small bowel and the diagnosis of t cell lymphoma was made. 2. t cell lymphoma: as per hpi. 3. transaminitis: from (peak ast 198, alt 247, alk phos 1062, negative hav, hbv, hcv, hiv, cmv, toxo, vzv, hsv1, hsv2). thought to be secondary to chemo and/or tpn. liver bx revealed non-specific inflammation consistent with acute hepatitis. social history: mr. lives with his wife, a nurse. 1 pack of cigarettes per day, denies alcohol or illicit drug use. family history: mother with breast cancer. his father died of an unknown cardiac event at the age 34. mother, sister and grandmother have diabetes mellitus. physical exam: on admission: temperature 97.9, hr 80, rr 20, bp 86-98/50-64. general: cachectic man in nad. heent: perrla. clear oropharynx. neck: jvp not elevated. cvs: rrr. normal s1, s2. no murmur, rub or gallop. resp: cta bilaterally. abd: soft and non-tender. no hepatosplenomegaly. ext: no cyanosis, clubbing or edema. 1+ dorsalis pedis pulses bilaterally, 2+ peripheral pulses otherwise. neuro: cn ii-xii intact. strenght . reflexes 2+ throughout. sensation intact. pertinent results: pertinent laboratory results on admssion include wbc-9.3 (differential neuts-87, bands-0, lymphs-6*, monos-6, eos-0, basos-0, atyps-0, metas-0, myelos-1*), hgb-11.1, hct-33.7, plt count-521. chemistry reveals glucose-104 urea n-14 creat-0.4* sodium-140 potassium-4.6 chloride-107 total co2-23. mildly elevated alkaline phosphatase on admission at 124, transaminases within normal limits (alt-9, ast-15, tot bili-0.1). normal coagulation profile. urinalysis negative cmv igg and igm negative brief hospital course: his hospital course will be reviewed by problems: 1) enteropathy-associated t-cell lymphoma: he received ara-c and etoposide (day -6 to -3) and melphalan (day -2) as part of the beam protocol, followed by a rest day. reinfusion was done on , which was well tolerated. his period of neutropenia extended from to , at which time his anc was back up to 2230. he had evidence of only mild oropharyngeal mucositis which was treated with peridex and nystatin. on , mr. had an acute transfusion reaction to platelets, with hypotension, diffuse dermal edema and periorbital edema, currently under investigation. he received solumedrol iv and pepcid iv with symptomatic relief. premedication changed to hydrocortisone 100 mg iv, benadryl 50 mg iv, pecid 20 mg iv, tylenol 500-650 mg po. 2) id: mr had an isolated temperature spike on (day -3), at which time he was started on vancomycin and levoquin (latter to be started as part of the protocol on ). he quickly defervesced, but developed a diffuse maculopapular rash on , at which time vanco was d/c'd as it was felt to be a possible culprit. cultures from that time were negative. he became febrile again on , at which time vanco and cefepime were started, and levoquin was discontinued. he remained persistently febrile and an antifungal was added, along with flagyl for a history of diarrhea (eventually c. difficile negative). his rash persisted, and decision was taken to d/c cefepime (query contribution to persistent rash) and start aztreonam. given worsening of the rash with periorbital edema and query contribution to the fever, along with possibility of drug fever, all antibiotics were stopped on and he received 1 dose of solumedrol. he defervesced for 24 hours, then his temperature rose again. he was restarted on flagyl and levo on . ambisome was added on secondary to a finding of pulmonary nodules on ct scan, however pulmonary did not feel these were significant, and ambisome was d/c'ed on since the patient was not neutopenic. his temperature reached a peak to 104.6 on . ct chest on revealed multiple small non-specific nodules, felt by pulmonary to be non-significant. ct abdomen and pelvis negative on . aztreonam was added to the regimen on . id was consulted, and antibiotics were changed to meropenem and flagyl, and continue acyclovir. daptomycin was added on given persistent fever and desire to broaden gram positive coverage (vancomycin was felt to be a potential culprit in the rash). all cultures negative thus far except for a single bottle positive for corynebacterium on felt to be a contaminant. an mri of the liver done on was negative for hepatic candidiasis. stool cultures were negative. repeat cmv negative. he defervesced on the above regimen. his last temperature spike was on . on meropenem and flagyl were discontinued, with no further fever spikes. he will be discharged on acyclovir, and nystatin swish and swallow. 3) gi: on , mr. had a hct drop from 27 to 21 with frankly guaiac positive stools. the source was felt most likely to be upper gi. he was seen by gi, who was reluctant to perform a scope given the patient's low platelets and leukopenia, although anc > 500. decision was taken to treat conservatively, with blood product support. on , his hct dropped again from 29 to 21.8 with persistent melanotic stools and he was transferred to the icu. an egd was performed on , which revealed ulceration in d3 consistent with an area of ulcerative duodenitis without active bleeding. the egd was otherwise normal to d2. pill endoscopy was considered but cancelled given a prior history of small bowel stricture. the bleeding was also not significant enought for a tagged rbc scan. he received a total of 6 units prbcs in the icu, and 4 units of platelets. he was transferred back to the floor on . his hct has remained stable since transfer, without further melena. protonix iv changed to po bid on , which he will be discharged on. 4) rash: history as above in id section. he developed a diffuse maculopapular rash on , which changed to a diffuse blanching erythematous rash on and persisted. he also developped some periorbital edema on and received a dose of solumedrol. dermatology was consulted, with an impression of erythroderma. levoquin, cefepime and vancomycin considered potential culprits and to be avoided. he was treated symptomatically with triamcinolone, and the rash resolved. 5) fen: mr. was given tpn while he was here, in addition to being encouraged to eat. he will go home with tpn cycled over 10 hours at night, and encouraged to eat a gluten free diet. discharge medications: 1. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 2. nystatin mucous membrane 3. acyclovir 400 mg tablet sig: one (1) tablet po three times a day. discharge disposition: home with service facility: discharge diagnosis: malt s/p auto-sct . ugi bleed discharge condition: good, stable. discharge instructions: return to the hospital to have your blood drawn tomorrow. take all meds as directed. return if you experience any rectal bleeding or black stools, shortness of breath, chest pain. take your temperature everyday and call dr. if it's greater than 100.4. continue your tpn for 10 hours every night. followup instructions: return to the unit tomorrow for repeat blood work and to be seen by dr. . Procedure: Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Transfusion of packed cells Injection or infusion of cancer chemotherapeutic substance Transfusion of platelets Autologous hematopoietic stem cell transplant without purging Diagnoses: Thrombocytopenia, unspecified Acute posthemorrhagic anemia Unspecified protein-calorie malnutrition Other malignant lymphomas, unspecified site, extranodal and solid organ sites Blood in stool Celiac disease Dermatitis due to drugs and medicines taken internally

allergies: gluten / betalactams / vancomycin hcl attending: chief complaint: fevers neutropenia major surgical or invasive procedure: skin biopsy history of present illness: is a 55-year-old man with a history of enteropathy associated t-cell lymphoma dxed in , 190 days status post an autologous stem cell transplant. his post-transplant course has been complicated by an upper gi bleed with egd demonstrating pud, episode of bell??????s palsy, and pancytopenia. the suspicion is for bone marrow involvement of his t cell lymphoma, but this has not been out on bone marrow biopsy and flow cytometry. he presented to clinic today for platelet infusion, and his vitals were the following: t101.3 bp 92/62 pulse 120/min. he was given tylenol, 1l of ns over 2 hours, and blood cultures were obtained from peripheral site and picc line. also sent ua, urine cultures, and will have chest xray. he was given cefepime 2gm iv and neupogen 300mcg. past medical history: 1. sprue: diagnosis , which was refractory to gluten-free diet at which point prednisone therapy was initiated. further investigation led to biopsy of small bowel and the diagnosis of t cell lymphoma was made. 2. t cell lymphoma: as per hpi. 3. transaminitis: from (peak ast 198, alt 247, alk phos 1062, negative hav, hbv, hcv, hiv, cmv, toxo, vzv, hsv1, hsv2). thought to be secondary to chemo and/or tpn. liver bx revealed non-specific inflammation consistent with acute hepatitis. social history: mr. lives with his wife, a nurse. 1 pack of cigarettes per day, denies alcohol or illicit drug use. family history: mother with breast cancer. his father died of an unknown cardiac event at the age 34. mother, sister and grandmother have diabetes mellitus. physical exam: vitals: 98.6, 115, 86/57, 20, 100% ra gen: alert/oriented; no acute distress heent: significant for petechiae in sublingual area; no other oropharyngeal lesions. neck: supple, full range of motion; no lymphadnopathy; no jvd cv: rrr, no m/r/g resp: clear to auscultation bilaterally abd: soft,nt, nabs; no masses; no hsm extr: no c/c/e, 2+ dorsalis pedis pulses neuro: significant for strabismus; lateral deviation of right eye pertinent results: 12:00am blood wbc-0.2* rbc-3.17* hgb-9.1* hct-27.2* mcv-86 mch-28.9 mchc-33.7 rdw-16.3* plt ct-34* 07:30am blood neuts-60 bands-26* lymphs-10* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 07:30am blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-1+ microcy-normal polychr-normal ovalocy-occasional tear dr 09:33am blood plt ct-40* 12:00am blood fibrino-272# 12:16pm blood fdp-40-80 12:00am blood gran ct-160* 12:00am blood glucose-113* urean-18 creat-0.4* na-136 k-4.1 cl-103 hco3-26 angap-11 12:00am blood alt-83* ast-112* ld(ldh)-1358* totbili-1.9* dirbili-1.1* indbili-0.8 12:16pm blood alt-96* ast-97* ld(ldh)-1162* alkphos-382* amylase-188* totbili-1.6* dirbili-0.8* indbili-0.8 12:16pm blood lipase-27 ggt-602* 12:00am blood calcium-7.7* phos-3.6 mg-1.9 08:00am blood hapto-245* 07:26am blood lactate-3.4* 12:18am blood lactate-2.8* 05:28pm blood lactate-2.7* cultures: blood - persistently negative except a 1/2 bottles growing coag negative staph early in his hospitalization cmv vl - negative imaging: ct-abdomen: impression: 1. moderate amount of free air in the abdomen, as described above. there is abnormal thickening of small bowel loops with a moderate amount of free fluid in the abdomen and pelvis pet (): interpretation: an fdg-avid right adrenal mass is identified measuring approximately 2.3 x 1.1 cm, with a maximal suv value of 13.9. in retrospect,this right adrenal lesion was seen on the prior ct scans dating back to . additionally, there is mildly increased fdg activity demonstrated within the medial limb of the left adrenal gland with a small nodule seen measuring approximately 1.7 x 1.0 cm. the maximal suv value for this left adrenal lesion is 3.0. additionally, there has been interval development of new foci of abnormally increased fdg activity within the osseous structures including the right 1st rib, anterolateral portion of the right 2nd rib, posterior right 8th rib, posterior aspect of the right 10th rib, the left scapula, medial aspect of the left clavicle, and the t7 and l4 vertebral bodies. physiologic fdg uptake is seen in the myocardium, liver and gastrointestinal tract. brief hospital course: admitted with neutropenic fever with no clear source. he has a complicated past history of prolonged neutropenic fever, as well as unexplained pancytopenia. his primary oncologist has suspected recurrence of his t-cell lymphoma, but has been unable to conclude this based on several recent bone marrow biopsies. pet scans showed activity in multiple sites including the axial skeleton, lungs, and bilateral adrenal glands. ct-scan demonstrated bilateral enlargement of adrenal glands. he continued to spike high fevers and had several episodes of hypotension, confusion, hyponatremia, and hypokalemia which were felt to be related to adrenal insufficiency from either lymphomatous infiltration of his adrenals of cmv adrenalitis. he was placed on broad spectrum antibiotics including ganciclovir for presumptive treatement of cmv virmeia and high dose steroids. these antibiotics included daptomycin, voriconazole, caspofungin, cefepime, and aztreonam. daptomycin was continued for his presumed bartonella infection diagnosed earlier with a postivie igm titer and granulomas on a prior bone marrow bx. his cultures were persitently negative with the exception of a single bottle positive for coag negative staph felt to be a contaminant. cmv viral titiers also remained negative on at least 3 occasions and were checked weekly. his fevers resolved with steroids and were attributed to recurrence of his lymphoma. in the middle of his hospital course new skin lesions were noted. biopsy of a right chest lesion demonstrated anaplastic transformation of his t cell lymphoma with markers similar to those in his prior bone marrows. he was started on a single round of pentostatin and cytoxan. after a brief reduction in his ldh, his ldh started rising again. new skin lesions were observed. discussion was made to send him home on steroids and return for further treatment, however he developed acute abdominal pain, higher fevers, and peritonitis. ct abdomen demonstrated free air in the peritoneum and focal thickenings in several areas of his small bowel. in consultation with surgery, it was felt that exploratory laparotomy would have a near fatal outcome. regardless, the patient and his family wanted conservative management with antibiotics and pca morphine. the patient expired the next day. it is thought that his performation occured following tumor regression within his small bowel in the setting of chemotherapy and high dose steroids. medications on admission: - discharge medications: none discharge disposition: expired discharge diagnosis: anaplastic t cell lymphoma abdominal perforation with septic shock adrenal insufficiency discharge condition: deceased discharge instructions: none followup instructions: none Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Biopsy of bone marrow Arteriography of pulmonary arteries Transfusion of packed cells Closed biopsy of skin and subcutaneous tissue Injection or infusion of cancer chemotherapeutic substance Transfusion of platelets Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Acidosis Unspecified septicemia Atrial fibrillation Perforation of intestine Sepsis Candidiasis of mouth Other malignant lymphomas, unspecified site, extranodal and solid organ sites Hypotension, unspecified Cachexia Alkalosis Complications of transplanted bone marrow Bell's palsy Bartonellosis

allergies: sulfa (sulfonamides) attending: chief complaint: altered mental status, hypotension major surgical or invasive procedure: r ij central line history of present illness: 68 y/o m with sle who p/w 1d hx of dysuria, polyuria, chills, mental status changes. driving with wife and drove onto grass . states urine was "bright red" with increasing urgency, called pcp and was told to go to hospital. en route, had episodes of n/v, worsening mental status. denies pain. in ed, initially given asa, lopressor, then must protocol started. got 4.5l ivfs, started on levophed/vasopressin. lactate=4.4; given dose of levo/flagyl. t 101.3 hr 115 bp 129/63 rr 18 96% on ra. dirty urine. in micu, weaned off pressors. switched to gent for empiric coverage of gnr bacteremia. started on fluconazole emperically for yeast in the blood. hydrated with ivf and remained hemodynamically stable. transferred to medicine on . past medical history: sle- on plaquenil social history: doesn't smoke, glasses wine/night married, no children, retired writer family history: non-contributory physical exam: on admission vitals: t 101.3, bp 129/63, hr 115, rr 18, 96% ra gen: ashen appearing, cachectic, but nad heent: perrla/eomi; mmm; op clear pulm: cta b/l. no r/r/w cv: normal s1/s2. tachycardic. no m/r/g abd: bs present, soft, nt/nd ext: no edema, warm neuro: a&o x 3. downgoing toes b/l. 5/5 strength skin: no rash/lesions neck: r neck hematoma, rij in place * on transfer from micu vitals: 97.9, bp 122/70, hr 47, rr 20 , 95% on ra gen- well appearing, sitting up in bed, communicating appropriately heent- perrla/eomi. no scleral injection. op w/ mild posterior pharyngeal erythema. neck- supple. r ij central line in place pulm- cta b/l. no r/r/w cv- rrr. no m/r/g. normal s1/s2 abd- soft, nt/nd. nabs ext- 2+ pedal edema b/l. no joint swelling or redness. neuro- a&o x 3. cn ii-xii intact. skin- no diaphoresis, no rash medications on admission: home meds: plaquenil 200mg/400mg alternating days discharge medications: 1. hydroxychloroquine sulfate 200 mg tablet sig: one (1) tablet po every other day (every other day). 2. hydroxychloroquine sulfate 200 mg tablet sig: two (2) tablet po every other day (every other day): alternate days with 200mg dose. 3. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 10 days. disp:*10 tablet(s)* refills:*0* 4. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours) for 10 days. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: 1. enterobacter bacteremia (pan-sensitive) secondary diagnosis: 1. sle 2. rheumatoid arthritis discharge condition: good. hemodynamically stable. afebrile. discharge instructions: report fever, chills, lightheadedness, stomach pains or bleeding to your pcp. please complete your antibiotic regimen as prescribed below. stay well-hydrated. drink at least 8oz glasses of water each day. followup instructions: please follow-up with dr. in weeks at phone # . md, Procedure: Venous catheterization, not elsewhere classified Diagnoses: Systemic lupus erythematosus Anemia, unspecified Sepsis Disseminated candidiasis Other septicemia due to gram-negative organisms Rheumatoid arthritis

allergies: no drug allergy information on file attending: chief complaint: right hip pain, fall major surgical or invasive procedure: intubation history of present illness: this is a 88 year-old man with dementia, copd, chf, osteoarthritis s/p l hip replacement and h/o tia who presented to the ed after a fall. in the ed, he was initially stable, but he began to become increasingly agitated and aggressive. he received haloperidol and ativan, but remained combative. his o2 sats never dipped below 90% but he became even more agitated, diaphoretic and, after discussion with the pt's daughter, the decision was made to intubate him so a w/u of his fall could be undertaken. there was some concern about o2 sats in the low 90s, and after a d-dimer returned at 1000, a ctpa was done. it was negative. a head ct revealed no acute change. hip films revealed. he was admitted to the icu intubated. past medical history: dementia copd chf (ef unknown) osteoarthritis s/p l hip replacement h/o tia social history: lives at dementia facility family history: non-contributory physical exam: vs: temp: afebrile bp: 140/52 hr: 60 rr: 12 o2sat 93% general: sedated, intubated heent: perll, anicteric, mmm lungs: cta anteriorly heart: rr, s1 and s2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, soft, no masses or hepatosplenomegaly extremities: no cyanosis, clubbing or edema pertinent results: 08:45pm blood wbc-12.9* rbc-4.94 hgb-15.6 hct-44.5 mcv-90 mch-31.5 mchc-35.0 rdw-13.7 plt ct-195 08:45pm blood d-dimer-1009* 08:45pm blood glucose-129* urean-19 creat-1.2 na-140 k-4.2 cl-100 hco3-28 angap-16 08:45pm blood ck(cpk)-101 08:45pm blood ck-mb-3 ctropnt-<0.01 probnp-72 12:05am blood type-art po2-524* pco2-36 ph-7.44 caltco2-25 base xs-1 ct head: 1. no hemorrhage or mass effect. 2. the temporal horns are prominent but there is no hydrocephalus. 3. paranasal sinus mucosal disease. cta chest: 1. no pulmonary embolus. 2. mild chf. 3. gallstones. hip films: no acute fracture or dislocation of right hip. consider mri if symptoms persist. brief hospital course: this is a 88 year-old man with history of dementia, copd and chf (ef unknown) who presented from his nursing home after falling and having some right-sided weakness. in the ed, he became agitated and combative and was intubated for workup. ## agitation, intubation: cta revealed no avute pathology. he was extubated without difficulty. ## s/p fall: hip films and ct head were unremarkable. likely mechanical fall. no events on telemetry. ## copd: extent of copd unknown. takes no meds at baseline. reason for intubation was not hypoxia. ## cardiomyopathy: presumed ischemic in nature. unknown ef, but bnp <100 suggested no significant volume overload. he was continued on atorvastatin 10. medications on admission: furosemide 40 gm po qd atorvastatin 10 mg po qd quetiapine 25 mg po qd sertraline 100 mg po qd discharge medications: 1. sertraline 100 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. quetiapine 25 mg tablet sig: one (1) tablet po daily (daily). 4. furosemide 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: springhouse discharge diagnosis: primary: fall secondary: dementia copd chf (ef unknown) osteoarthritis s/p l hip replacement h/o tia discharge condition: stable discharge instructions: you were admitted because of a fall. you did not fracture any bones. please take all of your medications as prescribed. please follow-up with your primary care doctor. followup instructions: please follow up with your primary care doctor. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Unspecified fall Other persistent mental disorders due to conditions classified elsewhere Other specified forms of chronic ischemic heart disease Pain in joint, pelvic region and thigh Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Accidents occurring in other specified places Generalized hyperhidrosis Other and unspecified special symptoms or syndromes, not elsewhere classified

history of present illness: the patient is a 26-year-old woman with a history of iv drug abuse, who initially presented to an outside hospital on from a drug and detoxification facility with a chief complaint of headache, abdominal pain, and fever. at the outside hospital, the patient was found to be febrile to 104.6 degrees f, and she subsequently developed hypotension with a systolic blood pressure in the 80s. during this initial evaluation, the patient was confused and only intermittently answering questions. there was concern for possible headache, neck stiffness, and photophobia, so given the concern for meningitis, a spinal tap was done. this study demonstrated 50 white blood cells (84% neutrophils), 10 red blood cells, protein of 23, glucose of 86, and 0-5 yeast per high power field. given these findings and concern for meningitis, the patient received vancomycin, ceftriaxone, metronidazole, and gentamicin at the outside hospital. given the lack of intensive care unit beds at the outside hospital, the patient was therefore transferred to the for further evaluation. on arrival to the emergency department at the , the patient was found to have icteric sclerae, a 2/6 systolic ejection murmur, abdominal guarding, and right upper quadrant tenderness. given the concern for an abdominal process, the patient was given levofloxacin and metronidazole; she was also given ambisome given the finding of yeast in her csf at the outside hospital. in the emergency department, she had an abdominal ultrasound that was negative for the presence of gallbladder or ductal dilatation. also at this time, the patient began to deny the report that she was hiv positive; this report has been obtained only by report and not by documented laboratory testing from the outside hospital. past medical history: 1. intravenous drug abuse. 2. cholelithiasis. 3. cholecystectomy. 4. spontaneous abortion x2. 5. therapeutic abortion x1. allergies: no known drug allergies. medications on admission: none. social history: the patient is a single mother of three children ages 9, 8, and 2 years old. she is unemployed. she last used heroin 3-4 days prior to admission; she began using heroin one year prior to admission. the patient smokes a third of a pack of cigarettes a day and denies any history of alcohol abuse. she denies any history of providing sexual favors for drugs or money. she says her only lifetime partner is her husband. initial physical examination: temperature 97.6, heart rate 95, blood pressure 113/71, respiratory rate 20, and oxygen saturation 100% on room air. during this initial evaluation, the patient was not reliable as a historian. she appeared to be a well dressed well-nourished female in moderate distress from "not feeling well", lying in bed, and subsequently having emesis x1. heent exam: extraocular movements are intact. there was mild scleral icterus. mild conjunctival edema. pupils are equal, round, and reactive to light. there were small conjunctival hemorrhages on the right greater than on the left. her face was symmetric. her neck was stiff with pain with flexion half-way down towards the chest. the right ij central venous catheter was in place. a small posterior cervical lymph node is palpable. her oropharyngeal examination was remarkable for upper dentures with eroded mucosa and white plaques consistent with thrush underneath. her tongue was coated with a whitish film, and she had a few petechiae on her upper palate. her heart was regular, rate, and rhythm, and there was a holosystolic murmur throughout the precordium that radiated to the axilla. her lungs were clear to auscultation bilaterally. her abdomen was soft, there were normoactive bowel sounds, she had bilateral upper quadrant guarding, and mild abdominal distention. the patient notes that her abdominal discomfort has been present for the past five months. she had bilateral upper extremity tract marks in her right forearm and in her bilateral antecubital fossa that were clean. scattered dark macules were seen on her palms bilaterally. she had mild, but not true cmt on pelvic examination. she was moving all extremities freely and equally and had full strength on neurologic examination. her laboratories from the outside hospital included the following: urinalysis was essentially negative. one out of two blood culture bottles were growing gram-positive cocci in clusters initially. her csf demonstrated 0-4 neutrophils and 0-5 yeasts per high power field, 10 red blood cells, 50 white cells (80% neutrophils, 3% lymphocytes, 13% monocytes), 23 protein, and 86 glucose. her complete blood count showed a white count of 13.3, hematocrit 35.5, and platelets 110,000. differential for white count demonstrated 77 neutrophils, 14% bands, 2% lymphocytes, and 6% monocytes. her inr was 1.28 and her ptt was 49. serum chemistries demonstrated a sodium of 133, bicarbonate 21, bun 34, creatinine 2.0. of note, her creatinine was 0.5 in . her total bilirubin is 3, direct bilirubin 2.3, alt 967, ast 396, ggt 125, alkaline phosphatase 156; her lfts had been normal at baseline one month prior. her electrocardiogram at the outside hospital demonstrated sinus tachycardia at 112 beats per minute, normal axis, and normal intervals. her head ct scan from the outside hospital demonstrated motion artifact and normal volumes to the ventricles. an abdominal ultrasound demonstrated increased echotexture to the bilateral kidneys, and no evidence of hydronephrosis. at the , her laboratories demonstrated sodium 140, potassium 3.8, chloride 113, bicarbonate 16, bun 26, creatinine 1.5, and glucose of 204. her calcium was 5.8, magnesium 1.2, and phosphate 3. her white count was 12.2, hematocrit 29.7, and platelets of 60,000. differential of her white count demonstrated 68% neutrophils, 19% bands, 9% lymphocytes, and 4% monocytes. her fibrinogen was 477, fdp 10-40, and d dimer was pending. her alt was 529, ast 150, alkaline phosphatase 97, amylase 46, lipase 23, and albumin 2.3. her urinalysis had greater than 50 red blood cells, white blood cells, and leukocyte esterase and nitrate were negative. her ptt was 36.7 and her inr of 1.6. her abdominal ultrasound demonstrated minimal new intrahepatic ductal dilatation and small pneumobilia. a hiv test was done on admission to the and was pending. hospital course by systems: 1. infectious diseases: while the patient was reported to be hiv positive upon her arrival to the emergency department at the , her hiv test subsequently returned negative. she also informed her caretakers that she had multiple hiv tests in the past, all of which had been negative. the report of "yeast" found in her csf at the osh was also found to be false-positive. no yeast or fungal organisms grew out the culture of her csf, and a csf gram stain was repeated twice at the outside hospital and found to be negative both times. the patient received several doses of ambisome at the , but once it had been confirmed that the finding of yeast was a false-positive, her ambisome was discontinued. by hospital day three, the gram-positive cocci in clusters that ultimately grew out from blood culture bottles at the outside hospital had been speciated as methicillin-sensitive staphylococcus aureus (mssa). once this definitive speciation was made, the patient's antibiotic regimen was tailored to include oxacillin and gentamicin; the gentamicin was used for only four days in order to aid in the clearance of her bacteremia. given the finding of this bacteremia and her alarming concert of symptoms on admission, a transthoracic echocardiogram was performed on hospital day two. this study demonstrated a thickened posterior mitral leaflet with a question of prolapse and at least mild-to-moderate mitral regurgitation consistent with possible endocarditis. biventricular systolic function was preserved. pulmonary artery systolic hypertension was seen. given these findings, a transesophageal echocardiogram was performed on hospital day three. this study demonstrated a moderate sized mitral valve vegetation consistent with a diagnosis of bacterial endocarditis. given this finding, it was felt that all of the patient's initial signs and symptoms were consistent with bacterial endocarditis. given that the finding of yeast in the csf was found to be a false-positive, and given that all subsequent gram stain and culture data from the csf remained negative, the patient was not felt to have had bacterial meningitis at any point (of note, two colonies of gram-positive cocci in clusters were isolated from the patient's csf culture; however, these colonies were subsequently speciated as coag-negative staph, and were therefore thought to be a contaminate. given the patient's lfts abnormalities on admission, an abdominal ct scan was done on hospital day two. this study demonstrated a focal area of low attenuation in the contrast enhanced right kidney, that was ultimately attributed to a septic embolus to the right kidney. also seen were large bilateral pleural effusions with compressive atelectasis, ascites, and free abdominal fluid, and a large amount of pelvic fluid. these fluid collections were all thought to be secondary to a systemic inflammatory response syndrome secondary to the patient's underlying bacterial endocarditis. in order to rule out the possibility of an epidural abscess, a spinal mri was done on hospital day four. this study demonstrated no evidence of epidural abscess. also of note, a mri of the head had been done on hospital day two in order to further evaluate for the possibility of meningeal inflammation. this study did not demonstrate any definite evidence of a focal lesion in the third ventricle or a focal mass within the brain. following the initiation of the appropriate antibiotic therapy as noted above, the patient slowly began to improve clinically. she initially continued to spike high fevers, but she gradually defervesced. her white count also initially remained elevated, but this too gradually began to trend down while on appropriate antibiotics. she did develop reactive arthridities in both her left ankle and her left hand. the department of rheumatology was consulted given these reactive arthridities and recommended supportive care to the area. the patient's lfts abnormalities present on admission gradually normalized. of note, however, the patient did develop mild elevations in her alkaline phosphatase, amylase, and lipase following the initiation of oxacillin therapy. it was thought that these elevations may have been secondary to oxacillin, but the elevations did not persist and had begun to trend towards normal at the time of discharge. given these normalizations, and given that the patient's hematocrit had been remaining stable (thus indicating that there was no significant myelosuppression as a result of oxacillin therapy), the patient was discharged with a plan for six weeks of continued oxacillin therapy. in order to rule out the possibility of mycotic aneurysm in the brain, a mri of the head was obtained on hospital day seven. this study demonstrated no evidence of acute infarct from septic emboli, and a subtle increased signal in the right temporal region that could be within the sulcus. a similar, but less apparent abnormality was also seen along the sulcus of the left occipital region. these abnormalities were nonspecific in nature, but were thought to possibly have been due to a high protein content of the csf. given the patient's overall clinical stability, however, the decision was made to clinically follow the patient as an outpatient following her discharge from the hospital. also of note, the patient had a cervical chlamydia probe return positive during this hospitalization. she received azithromycin 1,000 mg once during her hospitalization for treatment of this chlamydia. 2. cardiovascular: given that the patient had significant endocarditis, a cardiology consult was obtained early in the patient's hospitalization for evaluation of whether or not the patient was a surgical candidate for her endocarditis. given that the patient did not have clinically significant congestive heart failure or valvular dysfunction with persistent infection after 7-10 days of appropriate antibiotics, the patient was deemed not to be a surgical candidate. she subsequently developed no significant congestive heart failure, and she had no further embolic phenomena following the septic embolus sheath to her right kidney. given her bilateral pleural effusions and mitral regurgitation, the patient was transiently on furosemide during this hospitalization, but had no signs or symptoms of congestive heart failure at the time of her discharge from the hospital. 3. rheumatology: as noted above, the patient initially developed a left ankle reactive arthritis on hospital day six. given the asymmetric edema in her left ankle, a rheumatology consult was obtained. the rheumatology service agreed that the swelling in her left ankle was reactive arthritis. the patient subsequently developed left hand swelling later in her hospitalization, at which point the rheumatology service was reconsulted. they again felt that the swelling in the patient's left hand was due to a reactive arthritis that would be best managed with supportive care. she was started on a 14 day course of naproxen for treatment of the inflammation and swelling in her hand. by the time of discharge, the patient's swelling in both her left hand and her left ankle had improved dramatically, and were nearly at their baseline. 4. hematology: soonafter admission, the patient manifested a significant anemia with a hematocrit in the low 20s. the etiology of this anemia was ultimately thought to be multifactorial due to a combination of anemia of chronic disease, recurrent phlebotomy, menstruation, and oxacillin induced myelosuppression. there was no evidence of hemolysis either by laboratory evaluation or by direct evaluation of the peripheral smear. given that the patient's hematocrit was low, she was started on iron supplementation during this hospitalization. at the time of discharge, however, the patient's hematocrit had been consistently stable for over one week, and the decision was made to continue her on oxacillin for the time being with twice weekly hematocrits following her discharge from the hospital. 5. psychiatry: by hospital day eight, the patient began threatening to leave the hospital against medical advice due to inadequate pain control. given the concern for the patient possibly leaving the hospital against medical advice without plans for continued intravenous antibiotics, a psychiatry consult was requested. the psychiatry service felt that the patient had poor coping mechanisms given the severity of her illness, and recommended initiation of an atypical antipsychotic. in addition, they recommended analgesia as necessary, including with narcotic medications if necessary, in order to adequately control the patient's pain. the patient was subsequently started on an atypical antipsychotic, and her narcotic medication dosing regimen was increased, with excellent therapeutic affect. discharge condition: good. discharge placement: hospital. discharge diagnoses: 1. methicillin-sensitive staphylococcus aureus endocarditis complicated by right renal septic embolus. 2. chlamydia. 3. systemic inflammatory response syndrome. 4. multifactorial anemia. 5. reactive arthritis. 6. intravenous drug abuse. discharge medications: 1. oxacillin 2 grams iv q4h through . 2. naproxen 500 mg po bid through . 3. pantoprazole 40 mg po q day. 4. ferrous sulfate 325 mg po q day. 5. quetiapine 25 mg po tid. 6. hydromorphone 1 mg iv q4h prn pain. followup: 1. the patient should have her hematocrit, alkaline phosphatase, amylase, and lipase all checked twice a week while at . the results of these blood tests should be faxed to dr. at fax # in the department of infectious diseases at . 2. the patient should arrange for a follow-up appointment with dr. by calling . she should arrange for this appointment during the week after she leaves . 3. the patient should call to arrange for a follow-up appointment with dr. during the week following her release from . 4. note that the patient should receive the hepatitis a and hepatitis b virus vaccines as an outpatient. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Methicillin susceptible Staphylococcus aureus septicemia Sepsis Opioid type dependence, unspecified Candidiasis of mouth Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis Pyogenic arthritis, ankle and foot Pyogenic arthritis, hand Acute and subacute bacterial endocarditis

allergies: nkda meds: none ros: neuro: very sleepy on arrival but arousable to voice, clearing over the course of the day. currently alert and oriented to self, date and year, confused to place and events of last night. attempting to sit up and get oob at times but able to redirect verbally. no further sedation given this shift. pt denies pain. maes, follows commands inconsistently. pupils 3mm bilat and briskly reactive. remains in c-collar. continues on dilantin, no seizure activity. cv: hr 80s at rest, up to 110, sinus tach. bp 155-160, started on lopressor and hydralazine. skin warm to touch, dry, (+)palpable distal pulses. resp: breath sounds clear in upper lobes, diminished in the bases bialt. sats 100% on ra gi: abdomen soft, hypoactive bowel sounds, remains npo. on pepcid gu: adequate urine output (see i & 0) heme: hct 45, coags from this afternoon pending id: t.max 100.1, continues on oxacillin skin: lac on occiput ota, staples intact, minimal serosang drainage. abrasions to left upper arm and right buttock. social: pt's parents, sister and girlfriend all in to visit, updated on pt's condition. pt has a 5 year old with girlfriend . was recently laid off from his job with the city of . per parents, pt does not drink during the week but on the weekends he drinks "alot" and "doesn't know when to stop". they are aware that patient had amphetamines in his system, according to the patient's mother, his friend told her that the patient was taking ecstasy last night. a: pedestrian struck, s/p skull fx, small epidural bleed and bilat frontal contusions p: continue q1h neuro checks, keep sbp < 150, continue with current plan. repeat head ct in am Procedure: Closure of skin and subcutaneous tissue of other sites Diagnoses: Closed fracture of vault of skull with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Alcohol abuse, unspecified Cocaine abuse, unspecified Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Open wound of scalp, without mention of complication Abnormality of gait Sixth or abducens nerve palsy Injury to other specified cranial nerves

discharge status: the patient was discharged to the clinic. , m.d. dictated by: medquist36 Procedure: Closure of skin and subcutaneous tissue of other sites Diagnoses: Closed fracture of vault of skull with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Alcohol abuse, unspecified Cocaine abuse, unspecified Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Open wound of scalp, without mention of complication Abnormality of gait Sixth or abducens nerve palsy Injury to other specified cranial nerves

history of present illness: patient is a 25-year-old male pedestrian struck by a car while walking across the street and thrown 10 feet. he was found unresponsive at the scene with a gcs of 8. he became combative in the ambulance and was taken to . he was hemodynamically stable. at , the patient was found to have a subarachnoid hemorrhage on head ct along with a large skull fracture. he was seen by neurosurgery at but his family requested transfer to . at the outside hospital, the patient received 2 mg of ativan and mannitol and a question of dilantin for his head injury. on arrival, the patient was hemodynamically stable with a gcs of 14, slightly agitated, but stable. past medical history: none. past surgical history: none. medications: none. allergies: none. social history: weekend use of alcohol. physical examination: vital signs: gcs 14. alert and oriented times one. vitals: temperature 97.2. heart rate 100. blood pressure 161/90. respiratory rate 14. oxygen saturation 100% on four liters. physical examination: pupils equal, round and reactive to light. extraocular movements intact. face was stable. tms were clear. neck: trachea was midline with no crepitus. mandible was stable. his heart was regular rate and rhythm. chest was clear to auscultation bilaterally with no crepitus. abdomen was soft, nontender, nondistended and his fast exam was negative. rectal was normal tone, no gross blood, guaiac was negative. extremities without deformities. patient was moving all four extremities. his strength was equal throughout, as well as his sensation and nonfocal neurological exam. there was a small laceration noted on the right occipital area of his head. laboratories: patient had a normal hematocrit of 45.0. he also had normal coagulations with a pt of 13, ptt of 23 and inr of 1.2. laboratories were also notable for an alcohol level of 112 and a toxicology screen that was positive for opiates and cocaine. radiology: chest x-ray and pelvis x-ray were negative. ct of the abdomen was negative. ct of the c spine was negative for fracture. plain films of the tls spine were also negative for fracture and stability. ct of the head showed orbital frontal contusions with subarachnoid hemorrhage. there was extra-atrial blood noted with a question of left epidural versus subdural hemorrhage and there was a large associated parasagittal skull fracture running along the midline of the cranium into the left orbital area. hospital course: the patient was admitted to the trauma surgical intensive care unit for q. 1 hour neurological checks, as well as for intravenous fluids. the patient was protecting his own airway, so intubation was not of concern. the patient had an immediate consultation from neurosurgery who recommended that operative management would not be necessary that it was sufficient to continue with the q. 1 hour neurological checks, as well as following the coags every 4 hours, as well as to try to limit the amount of sedation in order to not cloud the examination of medical status. the patient continued to remain agitative through the first three hospital days requiring occasional use of benzodiazepines and narcotics to relieve pain and agitation. on hospital day number two, he received a repeat head ct, which again demonstrated the parasagittal fracture, as well as slight increase in the size of a frontal epidural hemorrhage now with a right sided component. while in the trauma surgical intensive care unit, the patient was also started on dilantin for seizure prophylaxis, as well as on oxacillin for infectious prophylaxis of the open head wound. on hospital day number four, the patient's mental status had improved enough, to where his agitation had decreased slightly allowing him to be transferred from the trauma intensive care unit to the floor still under a 1:1 sitter due to occasional agitation. a neurobehavioral consult was obtained and per the recommendations of the neurobehavioral consult, the patient was removed from all sedating medications aside from occasional percocets for pain control and instead was added seroquel 25 q.p.m., as well as trazodone 25 q.p.m. to repeat times one for helping the patient sleep at night. on hospital day number five, the patient was slightly decreased in agitation in the morning, although, still getting up out of bed and walking, even with a 1:1 sitter, however, he continued to improve throughout the day clearing his mental status, becoming alert and oriented times three and becoming more aware of his surroundings. in an attempt to try to regulate his sleep cycles and decrease the morning agitation, the trazodone was discontinued, but the seroquel was continued. the morning of hospital day number six, the patient showed a marked decrease in his agitation in the morning, showing greater incite into his situation, not getting out of bed on his own and being fully alert and oriented. also, on hospital day number six, occupational therapy and physical therapy, as well as social work were consulted. occupational therapy and physical therapy had helped the patient work with his cognitive and functional deficits, principally, his gait, which was still mostly ataxic six days following his head injury. social work was consulted primarily for providing references for substance abuse programs to deal with the patient's noted alcohol abuse. the patient continued to deny any us of opiates or cocaine, although, did not remember if he had taken any substances the night the injury was sustained, so the patient was referred to substance abuse clinics for further follow-up for this. on hospital day number six, it was determined that the patient would be eligible for rehabilitation inpatient therapy, so that several facilities were contact and one facility determined that the patient would be suitable for a rehabilitation stay there. the patient was stable enough for discharge to the rehabilitation facility under constant 1:1 supervision to decrease any fall risk. thus, the patient was discharged to a neurological rehabilitation facility on hospital day number six. final discharge diagnoses: 1. pedestrian struck by car. 2. parasagittal skull fracture. 3. frontal lobe contusions. 4. bilateral epidural hemorrhages with result in cognitive and functional disabilities. 5. substance abuse. post discharge medications: 1. dulcolax 5 mg 2 tablets q.d. as needed for constipation. 2. tylenol 650 mg q. 4-6 hours as needed for pain. 3. hydromorphone 10 mg, 1-2 tablets every 4 hours as needed for pain. 4. seroquel 25 mg, 1 tablet q.p.m. times four weeks. 5. dicloxacillin 500 mg, 1 capsule po q. 6 hours times eight days. follow-up: 1. the patient will be followed up at the rehabilitation facility by a physician to take out the staples and evaluate the head wound in seven to ten days. 2. neurosurgery follow-up in three weeks with dr. with a repeat ct prior to the appointment. 3. trauma clinic in two weeks. 4. neurobehavioral follow-up with dr. in one month. 5. alcohol and other substance abuse. patient was provided referrals for follow-up at each of these places. , m.d. dictated by: medquist36 Procedure: Closure of skin and subcutaneous tissue of other sites Diagnoses: Closed fracture of vault of skull with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Alcohol abuse, unspecified Cocaine abuse, unspecified Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian Open wound of scalp, without mention of complication Abnormality of gait Sixth or abducens nerve palsy Injury to other specified cranial nerves

history of present illness: baby girl was the 3.115 kg product of a 35 and week gestation, born to a 27 year- old, gravida ii, para 0 now i. blood type a positive, antibody negative, hepatitis surface antigen negative, rubella immune, rpr nonreactive, gbs positive. mother followed at clinic for diabetes, diagnosed in . has a history of mild diabetic retinopathy. mother admitted to due to preterm rupture of membranes for clear fluid. given gestational age, mother's labor was induced with pitocin. labor progressed well. one hour prior to delivery, fetal tachycardia was noted. vaginal delivery required low forceps assistance. report of mild shoulder dystocia. initially, infant was floppy, dusky, no immediate spontaneous cry and then onset of crying within 30 seconds. on warmer, infant stimulated, continued crying, and received blow-by oxygen. left arm noted to have decreased spontaneous movements. perfusion and tone improved. apgars were 7 and 8. infant admitted to newborn icu. physical examination: weight 3.115 kg. length 50 cm. head circumference 31.5 cm. large for gestational age. significant molding with bruising on caput. no evidence of fullness in back of head or along neck. anterior fontanel soft and flat. mild bruising of left forehead and left cheek, due to forceps placement. eyes: no trauma of lids. external exam of eye appears within normal limits. no evidence of trauma. red reflexes bilaterally. nose within normal limits. ears within normal limits. mild asymmetry and cry with the mouth. palate within normal limits. clavicles within normal limits to palpation. chest clear and equal breath sounds, good air entry. cardiovascular: normal heart sounds. no murmur. regular rhythm. pulses 2+ to 4 extremities. abdomen soft, nondistended, nontender, no masses, no hepatosplenomegaly. genitourinary: normal preterm female. anus patent. extremities with symmetric spontaneous movement. hospital course by systems: respiratory: was admitted to the neonatal intensive care unit for management of prematurity. on admission, she had intermittent grunting which resolved within the first few hours of life. she has remained stable in room air throughout her hospital course. she was having occasional desaturations with feeding. last documented episode (with feeding) was on . cardiovascular: she has been stable throughout her hospital course with no cardiovascular concerns. fluids, electrolytes and nutrition: birth weight was 3.115 kg. discharge weight is 3000 grams. infant was initially started on 60 cc/kg/day of d-10-w. enteral feedings were initiated on day of life #1 and infant has been ad lib feeding since that time, taking in adequate amounts, demonstrating good weight gain. gastrointestinal: peak bilirubin was on day of life #7, 12.2. she has not required any intervention. hematology: hematocrit on admission was 48. she has not required any blood transfusions. infectious disease: cbc and blood culture were obtained on admission. cbc was benign with a white count of 16.9; platelet count of 143,000. 23 polys, 3 bands. infant received 48 hours of ampicillin and gentamycin at which time they were discontinued due to a negative blood culture. neuro: infant has been appropriate for gestational age. sensory: hearing screen was performed with automated auditory brain stem responses and the infant passed bilaterally. condition on discharge: stable. discharge disposition: to home. name of primary pediatrician: , , telephone number . feeds at discharge: continue ad lib breast feeding. medications: not applicable. car seat position screening: infant was placed in a car seat for a 90 minute screening and the infant passed. state newborn screens: have been sent per protocol and have been within normal limits. infant received hepatitis b vaccine on . discharge diagnoses: 1. prematurity born at 35 and week gestation. 2. transitional respiratory distress. 3. rule out sepsis with antibiotics. 4. mild hyperbilirubinemia. , Procedure: Parenteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Single liveborn, born in hospital, delivered without mention of cesarean section Neonatal jaundice associated with preterm delivery Other "heavy-for-dates" infants Observation for suspected genetic or metabolic condition 35-36 completed weeks of gestation Other preterm infants, 2,500 grams and over Other respiratory problems after birth Other specified birth trauma

history of present illness: this is a 75-year-old male with a history of hypertension, stroke, dementia, and depression, some previous abdominal surgery, who is under full-time care of two caretakers, who noticed today that the patient was lethargic, and unable to get out of bed along with being aphasic. this was noted at approximately 7 p.m. the patient was reportedly globally weak. they also reported that his eyes looked differently than they normally did. no other history was able to be obtained at that time. upon further contact with the patient's sister, it was determined that the patient is under the full-time care of his caretakers and after his stroke four years ago in , she suffered from severe dementia along with inability to engage in activities of daily living. past medical history: 1. hypertension. 2. cva. 3. dvt in . 4. abdominal hernia. 5. dementia. 6. depression. past surgical history: multiple abdominal surgeries for ventral hernia and incisional hernias. medications: all antihypertensive medications. allergies: reactions unknown. 1. sulfa. 2. amoxicillin. 3. codeine. physical examination: afebrile, pulse 70, blood pressure 240/109, systolic ranging from 162-270, respirations 16, and o2 saturation is 100%. patient is alert and acknowledges the examiner. he speaks in short sentences. he has no right gaze in each eye. he does have intact upward, downward, and left gaze. questionable facial droop on the right. he follows commands in all four extremities. his strength is bilateral upper and lower extremities in the grip, biceps, triceps, iliopsoas, gastroc, and . his reflexes are 1+ in the biceps, triceps, and quads bilaterally. his toes are downgoing bilaterally. sensory examination was unable to be obtained. fine finger movements are decreased bilaterally. laboratories on admission: white blood cell count 9.3, hematocrit 54.1, platelets 183. coags were 13.2, 35.5, and 1.2. chemistry was sodium 137, potassium 5.1, chloride 100, bicarb 20, bun 24, creatinine 1.6, glucose 176. initial cardiac enzymes were negative. radiologic examination on admission: head ct shows a 4.5 x 4.5 cm cerebellar hemorrhage in the right cerebellar hemisphere, the fourth ventricle is effaced with blood tracking into it and into the third and lateral ventricles as well. there is periventricular edema indicating increased icp. assessment and plan: a 75-year-old male with hypertension now lethargic, aphasic with a left preferential gaze. now with large cerebellar bleed and blood in the third and fourth ventricles. brief hospital course: the patient was admitted to the trauma sicu. nipride drip was started. blood pressure was monitored with an arterial line. blood pressures initially were well controlled in the 130s systolic. we then placed a ventricular drain. the patient prior to the ventricular drain received 1 mg of midazolam and 1 mg of morphine. the patient tolerated the ventricular drain placement well. after the ventricular drain was placed, the patient was neurologically unchanged. the icp at the time of ventricular drain placement was approximately 8. the patient remained with stable vital signs until approximately one hour after the drain was placed at which time his blood pressure increased. this increase was to the point, where the blood pressure was in the low 200 systolic. nipride was pressed up and blood pressure was controlled down into the high 170s. the patient then became apneic. his systolic pressure dropped dramatically. he became unresponsive. neurologic examination at that time revealed pupils were blown bilaterally. patient was unresponsive. he had no corneal or gag reflex. patient's blood pressure then continued to drop and he became asystolic. time of death was 3:55 a.m. the patient's sister was . she did not wish to undergo autopsy. the medical examiner was and he did not wish to go ahead with examination. , m.d. dictated by: medquist36 Procedure: Intravascular imaging of intrathoracic vessels Diagnoses: Unspecified essential hypertension Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Intracerebral hemorrhage Other persistent mental disorders due to conditions classified elsewhere

service: general surgery history of present illness: mr. is a 70-year-old gentleman who, in the past, had multiple abdominal surgeries. as a consequence of his surgeries, he had developed very large hernias along his midline incision and at the site of his previous stoma in the left lower quadrant. he presented to the office comlaining of post-prandial pain at his incisional hernias. at that time, he had elected to undergo a ventral hernia repair which was performed laparoscopically on . postoperatively, the patient did well. he experienced some nausea with abdominal distention which eventually resolved. he was discharged uneventfully to the transitional care unit , he was tolerating a regular diet and passing flatus. two days after his discharge, he developed a fever up to 101.9??????, chills, nausea but with no vomiting with mild left upper quadrant and abdominal pain. pn evaluation, he had an elevated white count of 13,000 and his abdomen was very distended and tender on examination. a kub revealed a very large collection with an air fluid level in the mid abdomen. a follow up ct scan confirmed free intraperitoneal air and a large collection that appeared to be below the -tex mesh that was placed on the previous surgery. with the possibility of a bowel injury and perforation, the patient was readmitted to the and he was taken back to the operating room for an exploratory laparotomy. past medical history: 1. status post subtotal gastrectomy. 2. status post colectomy and colostomy for an unknown etiology. 3. status post colostomy takedown. 4. multiple incisional hernias, status post laparoscopic repair as stated above. 5. status post a stroke with residual poor memory and confusion. 6. hypertension. 7. hypothyroidism. 8. history of depression. admission medications: 1. levoxyl 0.112 mg po q day. 2. norvasc 5 mg po q day. 3. wellbutrin sr 250 mg po q day. 4. aspirin 81 mg po q day. 5. dulcolax. 6. milk of magnesia. 7. percocet prn. 8. multivitamins. 9. tylenol. 10. senokot. allergies: no known drug allergies. social history: no tobacco, no history of alcohol consumption. he lives at home alone with daily assistance from caregivers. admission physical examination: general: the patient was a 70-year-old male, mildly confused in moderate distress. he appeared mildly uncomfortable. vital signs: he had a temperature of 100.6??????, heart rate of 91, blood pressure 130/72, respiratory rate 18 with an o2 saturation of 96% on room air. head, ears, eyes, nose and throat: pupils equal, round and reactive to light and accommodation. extraocular movements intact. sclerae are anicteric. heart: regular rate and rhythm. normal s1 and s2. no murmurs, rubs or gallops. lungs: clear to auscultation bilaterally. abdomen: distended, tympanitic with protrusion of hernias. diffusely tender to palpation and light touch, but nevertheless, the patient remained with a soft abdomen. all hernia sites were reducible. there was no erythema, no drainage. rectal (as per the tcu): soft stool, low impaction, guaiac positive. extremities: warm, negative edema, hyperpigmented skin. significant labs: white count of 13,000, hematocrit of 30.5, platelet count of 328. differential showed 74% neutrophils, 5% basophils, 9% lymphocytes. the urinalysis was negative. urine culture was negative. electrolytes: sodium 135, potassium 3.9, chloride 99, co2 26, bun 26 with a creatinine of 1.3 which was the patient's baseline and a glucose of 148. hospital course: on at 7:30 p.m. mr. was taken back to the operating room. he underwent an exploratory laparotomy with oversewing of a left colonic perforation, excision of the -tex mesh, evacuation of a hematoma and placement of three - drains. the patient tolerated the procedure well and he was transferred under stable condition to the surgical intensive care unit for close monitoring. overnight, he remained hemodynamically stable and he was weaned successfully and uneventfully off the ventilator. he was started on vancomycin, ceftazidime and flagyl for broad antibiotic coverage. by postoperative day #2, the patient was doing well. he was spiking mild fevers to 100.6??????, but vital signs were stable. his abdomen remained soft, slightly tender to palpation, moderately distended. his white count came down to 8.8 with a hematocrit of 27.5 and a platelet count of 220. his electrolytes were within normal limits. his pain was well controlled on morphine and he was kept npo with a nasogastric tube suction. anticipating that the patient was going to be nutritionally deprived, tpn was started that same day. by postoperative day #3, the patient continued on vancomycin, ceftazidime and flagyl. his vital signs were stable. his temperature started to trend down. he was not complaining of significant pain and his nasogastric tube was discontinued. the patient remained on the tpn. the wound that was left open for closure was being packed with wet-to-dry gauzes and the dressings were changed . there was no evidence of infection or drainage and there was good granulating tissue. by postoperative day #6, mr. foley was discontinued and his diet was advanced to clear liquids. on postoperative day #7, he was tolerating clears well and his diet was advanced to regular diet as tolerated. a physical therapy consult was made and the patient was able to ambulate with the assistance of the physical therapist. two of his jp drains were discontinued and only one was left in place. his po medications were restarted. nutritional service was encouraging the patient to take his po supplements tid. on postoperative day #8, his antibiotics were discontinued. the patient remained afebrile and hemodynamically stable. his abdomen was soft, mildly distended and still tender to palpation. his wound was then packed and had good granulation tissue and no infection or drainage. the jp #3 was discontinued later that afternoon. by postoperative day #9, mr. was screened by the tcu and he was found to be stable to be transferred to this facility to continue his recovery. his temperature at that time was 98.9??????, blood pressure 110/60, heart rate of 60, respiratory rate of 20, 97% o2 saturation on room air with good urine output and his finger blood sugars below 190 currently on tpn. the patient was advanced to a regular diet and nutrition service was keeping a calorie count on him. according to the last calorie count, his intake was less than 300 calories, so it was decided to keep him on tpn. today, , mr. is being transferred to the transitional care unit to continue his recovery. he is being transferred on these medications: 1. levoxyl 0.112 mg po q day. 2. aspirin 81 mg po q day. 3. wellbutrin 250 mg po q day. 4. colace 100 mg po bid. 5. norvasc 7.5 mg po q day. discharge condition: stable. discharge diagnosis: 1. exploratory laparotomy and repair of descending colon perforation, status post laparoscopic loa and ventral hernia repair with mesh placement. , m.d. dictated by: medquist36 Procedure: Parenteral infusion of concentrated nutritional substances Suture of laceration of large intestine Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Unspecified acquired hypothyroidism Depressive disorder, not elsewhere classified Accidental puncture or laceration during a procedure, not elsewhere classified Hypopotassemia

allergies: nevirapine / abacavir / ampicillin / tylenol / zidovudine attending: addendum: after discussion with dr. , it was decided that the patient will not be discharged on mac prophylaxis (azithromycin) and digoxin. this was to prevent digoxin toxicity in light of declining renal function (pt will not have any lab testing done at hospice). also, the pt did not have any evidence of mac on discharge and will continue her 4 day course of antibiotics for pneumonia. her goals of care are comfort measures only discharge disposition: extended care facility: - md Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified

allergies: nevirapine / abacavir / ampicillin / tylenol / zidovudine attending: addendum: the patient was discharged with 600mg azithromycin (admission medication) for mac prophylaxis. discharge disposition: extended care facility: - md Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified

allergies: nevirapine / abacavir / ampicillin / tylenol / zidovudine attending: chief complaint: increased lower extremity swelling. concern about ability to care for self at home. major surgical or invasive procedure: l femoral central line, r internal jugular central line, cvvh history of present illness: 41f with advanced hiv/aids (last cd4 5 in , unknown viral load) and cardiomyopathy (ef 20%) who was recently hospitalized at for bibasilar pneumonia for which she completed a full 2 week course of levo and flagyl. she is a poor historian. she notes having leg swelling at that time and was discharged to home 2 days ago with stockings. she says she has been wearing her stockings since leaving the hospital. she returned to the ed last night with complaints of continued leg swelling and feeling week for the last two weeks. she denies sob, doe, orthopnea, pnd. she denies eating fast food or salty foods, but then states she has been eating chicken noodle soup from a can. she denies fever/chills. denies cough but has been spitting up clear fluid that looks like saliva. denies dysphagia. she has only got half of her prescriptions since discharge from hospital, and says she has taken bactrim, immodium, digoxin, and pain medication. she does not know the name, number, or type of haart drugs that she takes, and only identifies bactrim as her "hiv medicine." . in the er the patient received 10iv lasix, and a femoral line was placed (she has very difficult access and last picc just d/ced two days ago). . she denies feeling unsafe at home (although by report last night this is her reason for admission). states she has her daughter and to help her. she has occasional abdominal pain across the top of her abdomen nad occasional associated nausea, but none right now. no other complaints. past medical history: hiv/aids - h/o pcp x 2, mac, cervical dysplasia, hsv anal ulcers. cd4 ct 5 in , viral load unknown cardiomyopathy - ef 20% new renal insufficiency since with baseline cr mid 2s depression asthma social history: divorced. lives in apartment with 13 yo daughter. at home. pt reports feeling safe at home. ambulates with walker. denies tobacco, alcohol, or other drug use. family history: cad: mother died age 57 mi physical exam: vs 97.7 112/68 18 on room air (o2 sat not yet checked) gen: sitting up in bed, very quiet speaking, nad, pleasant heent: ncat neck: no lad, no jvd cor: s1s2, +s3, no r/g/m, tachy pulm: cta, decreased bs at b bases l>r, very mild crackle at r base abd: soft, ntnd, +bs, no hsm ext: stockings on, 2+pt pulses, 1+ pitting edema through, r femoral line line in place, sanguinous drainage on dressing, stockings to knees skin: no rashes gu: foley catheter wtih yellow urine in bag pertinent results: -bnp 64,499. digoxin 0.8. creatinine 2.1 (lower than new baseline since ). hct 27.5 ( above baseline). albumin 2.2. -cxr: persistant bibasilar pna with persistant bilateral effusions. -echo lvef 20%, small-mod pericardial effusion with no tamponade, global hypokinesis on brief hospital course: ms. is a 41 yo woman with end stage aids, hiv cardiomyopathy with last ef <20%, and hiv nephropathy with very low uop and nephrotic range proteinuria who was hospitalized in for 3 weeks with bibasilar pneumonia for which she was given a 2 week course of levo/flagyl. she was discharged with stable le edema and on an hiv salvage regimen consisting of 5 haart meds. she returned to the hospital one day after discharge complaining of possible increased le edema, which was found to be unchanged from prior on exam. she seemed to feel "unsafe" at home but was unable to elaborate on that. cultures from previous hospitalization returned at that time with in sputum and stool and she was started on treatment. . five days after admission, the patient was prepared for discharge to a with hiv specialty floor, when she complained of new onset sob, rr 30s-40s x hours, and eventual hypoxia. abg revealed lactic acidosis with lactate of 16 and ph of 7.19. fs at that time was 24. this was all believed to be lactic acidosis caused by hiv meds (zidovudine) interfering with mitochrondrial function. she recieved 1 amp nahco3, 1 amp d50 and 500 cc ns bolus. . she was transferred to the icu, where she required cvvh for lactic acidosis and d10 for hypoglycemia. she developed multi-system organ failure, including liver failure, increased oliguria, pancreatitis, and hemolysis. she responded well to cvvh and after family meeting cvvh was discontinued and decision was made not to restart dialysis of any sort even if her lactic acidosis were to recur. she was treated with aztreonam and vanco by levels for bilateral pneumonia. the patient expressed an interest in going to hospice. a palliative care consult was ordered and pt was transferred to floor. . the patient's 13 year old daughter is not aware of her mother's hiv status and the patient has not been forthcoming about her current prognosis. a family meeting with the patient, drs. and social worker , the patient's daughter , her daughter's cousin, and ms. sister-in-law. at this meeting the family was updated on the patient's generally poor prognosis. the pt decided that she would like to go to hospice, and understood the goals of hospice. the pt was seen by palliative care and she was placed in a hospice of her choice. the pt stated she would like to complete the course of po antibiotics which were started in the micu. her central line was pulled, uneventfully, on the day of discharge. the patient was discharged on cefpodoxime and azithromycin for 4 days to complete her course of antibiotics for pneumonia. the pt will be continued on her digoxin for heart failure, ipratropium nebulizer for shortness of breath, bactrim for pcp prophylaxis, for hyperphosphatemia secondary to renal failure and lasix for shortness of breath and painful lower extremity edema. . the pt reported that she will inform her family of the tranfer to the hospice facility. her brother was present for this conversation. medications on admission: (unclear which meds pt was taking for the 2 days between discharge from hospital and this admission but she reports not missing any bactrim doses) (haart meds are "salvage tx") bactrim megace 40 qday ritonavir 200 lamivudine 100 qday zidovudine 300 tipranavir 500 tenofovir 300qwed, sat loperamide 2mg qid prn diarrhea digoxin 125mcg qod azithromycin 600mg qwed bactrim ss qday oxycodone q6h prn pain protonix 40qday discharge medications: 1. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. sevelamer 400 mg tablet sig: two (2) tablet po tid (3 times a day). 3. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. lasix 40 mg tablet sig: one (1) tablet po qday prn as needed for shortness of breath or painful edema. 7. cefpodoxime 200 mg tablet sig: one (1) tablet po every twelve (12) hours for 4 days. 8. azithromycin 250 mg tablet sig: one (1) tablet po once a day for 4 days. discharge disposition: extended care facility: - discharge diagnosis: hiv/aids cardiomyopathy (ef 20%) new renal insufficiency (baseline cr 2s) gerd asthma depression discharge condition: stable discharge instructions: you are being transferred, at your request, to a hospice. goals of care are to continue meds by mouth that will help you feel better or prevent further infections, but no iv's, labs, or fingersticks will done. followup instructions: none md Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified

allergies:tylenol, ampicillin, bactrim, pcn, abacavir, nevirapine. neuro: pt a&ox3, calm cooperative woman,perrl,ue and le strength 5/5, mae.pt denies pain. cardiac:tmax:99.2 oral , hr:125-140 st, nbp mean:50-82, hco3 11: d5w bicarb bolus, with good effect. lactate @ 10am:17.4, post bicarb bolus lactate @ 1pm 14.6. hco3: increased to 14sodium bicarb cont @ 75 ml/hr. 4 units ffp admin.d/t inr of 2.7, post ffp inr was 2.7. dialysis line placed over wire on distal port of femoral mlc by renal. pedal pulses positive by doppler. hct @ 23 this am ..re-check @ 22 for 1uprbc resp: rr 28-40,tachypneic, team aware. 95% sat on 2l nc, ls clear to coarse with exp wheezes at bases. pleth wave form inconsistant d/t cold extremities.abg 7.36/23/36. ph improved with bicarb admin, ph 7.2 @ 10am, post bicarb ph 7.36. gi/gu:abd. firm, non tender,hypoactive bs,large guaiac positive stool via bedpan:dr notified. low output deteriorating renal function, clear amber urine via foley catheter;dr and dr. aware. renal team placed dialysis ports with chg.wire over fem line. nutrition consult ordered. endo:fs 41;d50 admin., hourly fs due to hx of hypoglycemia. id: antibx therapy, wbc 11.2,tmax 99.2 oral plan: blood products prn as ordered,replete lytes prn, monitor abg's, lactate, bicarb levels, hct, cvvh to begin this evening. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified

allergies:tylenol, ampicillin, bactrim, pcn,abacavir, nevirapine. code status:dnr/dni. neuro:a&ox3, mae, perrl, upper and lower extremity bilat strength 5/5. cardiac:sbp:88-106, sbp down to 83. dr notified and 250cc bolus of d5ns given with sbp up to 90. hr:130's, hct:27.7, lactate:15.5, pedal pulses doppler. temp low <96 ax, bear hugger placed on pt. resp:rr 28-40, sob, open face cool neb mask with sat's in the 90's. ls i/e wheezes bilat. pleth wave form inconsistant d/t cold extremities. abg 7.19/13/91/5 gi/gu:pt. npo except meds, nutrition consult ordered, abd. firm,nontender, hypoactive bs,low u/o clear amber urine via patent foley catheter; dr. notified, ho to be notified and no uo for 3 consecutive hours per dr . endo:fs hourly due to hypoglycemia patient had while on medsurg unit. , d50 admin for fs of 72. access:mlc left femoral id:hypothermic,wbc 6.7, vanco and iv antibx to be started today. social:brother hcp,supportive family in to visit. plan/dispo:plan to treat met. acidosis with bicarb per renal.,start iv antibiotics,monitor resp. status, labs, lytes, replete prn. monitor blood glucose closely, fs qhrly. bear hugger for low temperature and cold extremities. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified

code status: dnr/dni allergies:nevirapine,abacavir,amplicillin, tylenol 41 yo female transferred from cc7 with severe lactic acidosis, increased sob, tachypnea,ef 20% and hemodynamic instability. this condition is believed to be caused by hiv meds...cardiotoxic drugs. pmh includes endstage hiv/aids, asthma, etoh, chf. neuro:pt a&ox3, perrl, follows commands consistantly, attempts to move extremities however, pt "feels weak". pt denies pain. resp:pt on cool aerosol mask 60%. unable to maintain reliable sats; team aware. rr 17-30. ls insp wheezes at times to upper lobes, otherwise coarse and dim. at bases. expectorated thick, yellow sputum. per. venous abg @ 0400 7.41/47/22/31. lactate @ 0400 2.6 trending down. pt recieved neb tx; alb/atr q6hr by resp. team. cardiac:tmax 99.6 rectal,cvp monitor installed into the distal port of the rij. cvp 15-16,hr:114-120 st, nbp 110-130/50-70. mean > 65. pedal pulses positive with doppler. latest hct 22.6 (goal hct >21) ? d/t filter change of cvvh and blood loss. cvvhd : cvvhd clotted at 2300, filter chg.replacement @ 1500 ml/hr, dialysate @ 500 ml/hr. cvvh tolerated well.goal fluid balance negative 100. gi/gu: abd. firm and tender to touch at times.+bs. pt on tpn. pt did not have a bm this evening.pt on tpn @ 42 ml/hr.pt voiding amber colored urine via foley . access: pt has l fem. quintin catheter line, seeping serous fluid;dressing chg'd. also r sc triple lumen central line. no further bleeding. social: 13 yo daughter living with grand mother for now. plan: monitor resp status,ph, lactate, liver enzymes,hct q6hr, lytes, replete prn, montior fs hourly and blood sugar, continue antibx.,plan for fluid balance of -100 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Acidosis Thrombocytopenia, unspecified Anemia, unspecified Congestive heart failure, unspecified Acute and subacute necrosis of liver Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified

allergies: nevirapine / abacavir / ampicillin / tylenol / zidovudine attending: chief complaint: productive cough, fever major surgical or invasive procedure: none history of present illness: ms. is a 41yo f with aids, cardiomyopathy, asthma, crf who presents with two weeks of productive cough. two weeks ago, she developed a runny nose and a productive cough that was stable for one week. then, approximately one week ago, she began developing a worsening cough with increasing sputum. the sputum is green-yellow, without blood. she denies fevers, chills, night sweats, chest pain (pleuritic or constant), sob, doe, orthopnea, or pnd. she has a history of disseminated mac in and pcp and . she had been feeling well prior to this. she currently denies ha, uri sx, neck pain, chest pain, sob, abd pain, back pain, n/v/d/c, dysuria/hematuria, or rash. in the ed, she was hypothermic at 96.0 and hypotensive in the 60's, which improved to low 90's (her baseline per prior clinic notes) with one liter ns. she got asa, atovaquone, and levofloxacin. past medical history: -aids: dx . last cd4 5 and vl 70,500 on -disseminated mac -hiv nephropathy (fsgs) - baseline cr 1.1 -pcp and -chf with ef 20-25% on echo -childhood asthma -gerd -cervical dysplasia -hsv with subsequent anorectal ulcers . social history: born in , moved to the us as a teen. ms. lives with her 13yo daughter in an apartment in , ma. she worked as a word processor formerly, now is on disability. she never smoked and denies etoh or illicit drug use. has good social support system (brother, other family members live nearby). family history: cad: mother died at age 57 from an mi physical exam: t 96.0, bp 92/50, hr 92, rr 18, sat unobtainable (po2 127 on abg) gen - cachectic female, looks older than age, mildly uncomfortable, nad heent - anicteric, op clear with mmm neck - supple, no jvd/lad/thyromegaly cv - rrr, s1s2, ?s4, no m/r/g pul - no resp distress/acc muscle use, moves air well, bibasilar rales r>l, no wheeze abd - scaphoid, soft, nt, nd, nabs, no hepatosplenomegaly back - no cva/vert tenderness ext - no cyanosis/edema, warm/dry nails - no clubbing, no pitting/color changes/indentations neuro - a&ox3, no focal cn/motor deficits pertinent results: labs on admission: wbc 2.8, hct 26.7, mcv 81, plt 247 diff: 80n* 2b 10l* 6m 2e ddimer 1203, granulocyte count 1090 glu 83, bun 34*, cr 2.8*, na 134, k 5.5, cl 106, hco3 17, ag 17 alt 18, ast 55, ldh 446, alkphos 100, amyl 237, lip 133, tbili 0.3 ca 7.8, phos 4.5, mg 2.0 ua: staw yellow, clear, usg 1.008, lg blood, 500 prot, ph 6.0, 0 rbc, 0-2 wbc, occ bacteria, neg nitrites, neg le urine chem: cr 10, na 101, alb 55.1, prot/cr 5510.0* urine eos negative . other labs: tibc 152, ferritin >assay, trf 117* plasma osm 280 probnp tsh 2.5, pth 248 cosyntropin stim: random cortisol 19.7, 30 min cortisol 36.7, 60min 42.5 hbsag neg, hbsab neg, hbcab neg, hcv ab neg . labs on discharge: wbc 1.9, hct 24.7, mcv 94, plt 96 glu 66, bun 28, cr 2.1, na 135, k 3.6, cl 103, hco3 23, ag 13 ca 7.6, phos 3.1, mg 1.7 dig 0.5 albumin 2.2 . micro: : stool neg for c diff : stool cx no micro, cyclospora, crypto/giardia, o+p; few pmns : isolators pnd : cmv vl not detected : stool cx neg for microsp, cyclospora, o+p, crypto/giardia : stool cx for c diff toxin b pnd : stool cx neg for microspor, cyclospora, isospora, o+p, cdiff : stool cx neg for cdiff : blood cx x2 ngtd : stool cx afb pnd : blood cx x2 ngtd : induced sputum: neg for pcp, afb on direct smear, cx ngtd, afb cx + for afb (speciation pending at state lab) : urine cx ngtd : blood/ cx ngtd : urine legionella neg : rapid respiratory viral antigen test (final ): neg for adeno; parainfluenza 1,2,3; influenza a,b and rsv; viral cx pending : cryptococcal ag: neg : cmv vl: negative : induced sputum: neg for pcp, cx neg, afb smear neg : stool cx neg for salmonella, shigella, campylobacter, cdiff : blood cx/afb cx/ cx: ngtd : urine cx: ngtd . imaging: : echo - left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated with evere global hypokinesis. no left ventricular thrombus is seen. the right ventricular cavity is mildly dilated with moderate global wall hypokinesis. the aortic leaflets are normal with good excursion. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is a small to moderate sized circumferential pericardial effusion without evidence for tamponade physiology. compared with the prior study (images reviewed) of , the pericardial effusion is slightly larger (specifically around the right atrium). the estimated pulmonary artery systolic pressure is higher, right ventricular free wall motion may be slightly worse, and the severities of mitral and aortic regurgitation are slightly increased. . : portable abdominal film - no dilated loops of large or small bowel are seen to indicate obstruction. no definite free intraperitoneal air is seen. there are bilateral pleural effusions with lower lobe airspace opacities. . : ct a/p - 1. new, bilateral pleural effusions, right greater than left. ground-glass opacities at the left lung base may represent fluid overload. 2. cardiomegaly with interval marked enlargement of the cardiac from the previous ct. moderate pericardial effusion. 3. diffuse bowel wall thickening involving the right colon to a greater extent than the left. these findings may represent infectious colitis or possibly typhlitis. 4. anasarca. . : kub - non-specific bowel gas pattern. no air-fluid levels to suggest obstruction. . : cxr - 1. stable cardiomegaly. 2. improvement of the perihilar opacities with residual opacities at the bases. this may be secondary to resolving pulmonary edema or infectious process. . : echo - the left atrium is elongated. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed. right ventricular chamber size is normal. there is mild global right ventricular free wall hypokinesis. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a small pericardial effusion. lvef <= 20%. . : cxr - successful placement of 39 cm total length double lumen picc line with tip in the superior vena cava, ready for use. . : portable cxr - 1. enlarged cardiac silhouette suggesting cardiomegaly or pericardial effusion, which has increased compared to the prior examination. 2. bilateral perihilar opacities, likely due to pulmonary edema, increased compared to the prior examination. superimposed infection including pcp cannot be excluded. . : cxr - enlargement of the cardiac silhouette suggesting cardiomegaly or pericardial effusion that has progressed compared to . nonspecific bibasilar opacity suggests edema or consolidation. brief hospital course: # pneumonia: it was felt that ms. had a pneumonia on admission. with her history of disseminated mac and pcp in the past, she was treated empirically for community-acquired pneumonia (with 10 days of levaquin), mac (with clarithromycin and ethambutol), and pcp (with atovaquone originally, then clindamycin and primaquine due to nausea and vomiting associated with the atovaquone). id was consulted and helped guide her management throughout her hospital course. she was hypothermic and hypotensive on admission, which raised concerns for sepsis, but her bp responded to fluid boluses and her temperature came up slightly. induced sputum x3 was sent and were negative for pcp, afb culture came back positive for afb on (afb smears were negative x3). identification of the organism is still pending, but after confirming this with id, it was felt that this was most likely mac and the patient was being adequately treated with her current azithromycin dose (1200mg po 1x/week). . # hiv: ms. was not taking her haart medications or her prophylaxis upon admission, so her haart regimen was suspended until her acute pneumonia was treated and a discussion could be had between the patient and her pcp. team was concerned that many of her comorbidities, principally her cardiomyopathy and her renal failure, were related to her hiv and would only improve or remain stable with the administration of haart. dr. met with ms. on 11r and it was decided to restart antiretrovirals, with a 5 drug salvage regimen which id recommended based on her resistance profile. they also helped make recommendations for her prophylaxis, so her ethambutol and clarithromycin were changed to azithromycin 1x/week and her clindamycin and primaquine were changed to bactrim. she refused to take atovaquone because of nausea and vomiting. because of her history of a bactrim allergy, she was brought to the for bactrim desensitization. once she had begun prophylaxis and tolerated the regimen well, she was restarted on a haart regimen which included zidovudine, tipranavir, ritonavir, tenofovir, and lamivudine. she tolerated that regimen well with no change in her symptoms (diarrhea, abd pain were unchanged) and she was discharged on this regimen. prior to discharge, social work contact of the / aids cares network at () to set up outpatient services for ms. . . # cardiomyopathy: ms. was tachycardic and hypotensive in the er, with sbps in the 60s. a bnp was checked in the er and was 32,538. her sbp responded well to fluid boluses and came up to the 90s. her tachycardia persisted, however, ekgs showed it was a sinus tachycardia. on the floor, she was monitored on telemetry and she developed a hr of 170s overnight. she was given po and iv diltiazem which dropped her sbp and her hr to the 70s. she was asymptomatic during this episode, but was transferred to the for closer monitoring. an echo showed that her ef was < or =20% and she had severely depressed left ventricular systolic function and mild global right ventricular free wall hypokinesis. her sbp came back up to the 90s in the and she was felt to be hemodynamically stable, so she was transferred out the floor. her volume status remained difficult to assess as she appeared to be both total body overloaded (was grossly edematous, with bilateral le edema) and intravascularly dry (no appreciable jvd, hypotensive, tachycardic, with acute on chronic renal failure and oliguria). renal was consulted and after analyzing her urine sediment, felt that her picture was most consistent with prerenal azotemia (on top of underlying hiv nephropathy) and recommended ivf to correct her prerenal state. she was given multiple liters of ivf with minimal improvement in her uop, bp and tachycardia. she become more volume overloaded so she was given transfusions of prbc (as her hct was also in the low to mid 20s), again with minimal improvement. her cr remained elevated and her uop remained poor. she was tested for adrenal insufficiency given her persistently low bp, but she was not adrenally insufficient by cosyntropin stimulation test. a repeat echo was performed which again showed an ef of < or = 20%, dilated left and right ventricles, and moderate-severe global hypokinesis bilaterally. there was no tamponade physiology. cardiology was informally consulted to see if there would be utility to placing a line to measure cvp and then perhaps diuresing her (likely with the addition of a pressor), but it was felt that less invasive measures would be best in this patient. she was restarted on digoxin (no loading dose) and tolerated it well. her digoxin level prior to discharge was still subtherapeutic, but because of her renal function, it was decided to keep her on this dose and recheck a dig level as an outpatient. she was given metoprolol 12.5mg po x1 to attempt to slow down her hr, but dropped her sbp to the 70s. her bp responded to ivf boluses, but it was decided to not try any further medications that could potentially drop her bp. she was not able to be started on lasix, an ace or spironolactone for this reason. she was monitored on telemetry after starting the digoxin and had one run of nsvt (13 beats). . # arf: on admission, her cr was 2.8 which appeared to be an acute on chronic renal failure. her urine lytes were consistent with prerenal physiology and she was hydrated with ivf but with only minimal improvement in her uop. she maintained uop of 15cc/hr for most of her hospital stay. based on her urine studies, it was felt that she was prerenal and needed ivf. she was also given bicitra to attempt to correct the acidosis that was developing from her renal failure. however, the more ivf we gave, the more she seemed to third space and she developed anasarca and lower extremity edema which was very troublesome to her. her bp was so low that we were never able to safely give lasix to see if her uop and edema would improve. with administration of digoxin, her cr began to improve and came back down to her baseline of 2.1 by the time of discharge. she still had significant proteinuria (spot prot/cr of 5510, dipstick protein of 500) which was attributed to hiv nephropathy. her haart regimen was dosed according to her discharge cr, so her cr will have to be monitored closely as an outpatient and her medications will need to be adjusted according to her crcl. . # abdominal pain/diarrhea: her abdominal pain became a more prominent symptom once she developed anasarca. multiple stool studies were sent as she had frequent diarrhea, but all cultures, including o+p and cdiff, were negative. a ct scan of her abdomen showed a question of typhlitis. kub were negative for free air or for obstruction/toxic megacolon. ms. abdominal pain seemed to wax and wane, but became less severe once she began to autodiurese and her bloating and abdominal distension resolved. her greater concern was diarrhea. she felt that each time she stood up, she had to have a bowel movement and sometimes she would be incontinent because she could not control the urge to defecate. all stool studies were negative, including cdiff toxin b. she was given loperamide to help improve her diarrhea, which worked with some success. she was given a prescription for this upon discharge, with instructions to follow up on this symptom with her id doctors as it could be related to her medications (possibly the azithromycin or maybe even her haart regimen). . # anemia: ms. is anemic, with her baseline hct in the mid 20s. she is asymptomatic from her anemia, but was given several transfusions during her hospital stay in an attempt to increase her bp and intravascular volume without causing third spacing. however, her bp was minimally responsive to transfusions so they were held unless she became symptomatic. stools were guaiac negative. labs were most consistent with an anemia of chronic disease. on discharge, her hct was 24.5. . # fen: ivf were given originally, but had to be held due to anasarca. her electrolytes were checked daily and were repleted as necessary. her k and hco3 were often low and needed repletion. her na also trended down, and she was briefly put on a 1.5l/day fluid restriction to help bring her na back to normal. she was given a regular, low salt, heart healthy diet. she was continued on megace, though she frequently refused this medication. . # ppx: ms. was given heparin sc for dvt prophylaxis, but she soon developed thrombocytopenia and it had to be stopped. hit antibodies were never sent. she was then given stockings and pneumoboots for dvt prophylaxis. she was given a bowel regimen originally, but by the end of her stay, she was having frequent diarrhea and no stool softeners were needed. she was also given a ppi for gi ppx. . # access: she had a peripheral line originally, then a picc line was placed in her l arm due to poor iv access. the picc line worked well for her throughout her admission, without any evidence of infection or cellulitis. . # code: full. a discussion was had with the patient about her code status and the patient did not seem to understand what it meant to code someone or what it would mean for her as the patient. it was decided, however, that she would be cpr not indicated in case an event were to occur. . # dispo: to home with services. medications on admission: emtriva 200mg daily ethambutol 800mg daily (pt states not taking) famvir 250mg daily (pt states not taking) lisinoprol 10mg daily metoprolol 25mg rifabutin 300mg daily (pt states not taking) stavudine 30mg discharge medications: 1. megace oral 40 mg/ml suspension sig: ten (10) milliliters po once a day. disp:*1 bottle* refills:*2* 2. zidovudine 300 mg tablet sig: one (1) tablet po twice a day. disp:*180 tablet(s)* refills:*2* 3. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). disp:*45 tablet(s)* refills:*2* 4. azithromycin 600 mg tablet sig: two (2) tablet po 1x/week (we): please take once a week (every wednesday). disp:*30 tablet(s)* refills:*2* 5. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 6. tipranavir 250 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 7. ritonavir 100 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 8. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po 2x/week (we,sa). disp:*60 tablet(s)* refills:*2* 9. lamivudine 100 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 10. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. disp:*60 capsule(s)* refills:*2* 11. oxycodone 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: aids cardiomyopathy congestive heart failure (ef <20%) acute on chronic renal failure pneumonia anemia discharge condition: good. afebrile, bp 94/68, hr 108, rr 18, sats 96% on ra discharge instructions: 1. please call your pcp or go to the er if you develop any of the following symptoms: fever >101, cough, chills, shortness of breath, difficulty breathing, chest pain, palpitations, nausea, vomiting, persistent diarrhea, abdominal pain, weakness, swelling in your legs, or any other worrisome symptoms. 2. please take your medications as prescribed every day. it is very important that you take bactrim every day. if you miss even one or two doses, you may redevelop an allergy to it. 3. please follow up with dr. in the next few weeks. her office will call you with an appointment tomorrow. followup instructions: 1. please follow-up with dr. in weeks. her office will call you tomorrow with an appointment. 2. please call dr. office (cardiology) and set up an appointment with him in weeks. his office number is . Procedure: Venous catheterization, not elsewhere classified Injection or infusion of thrombolytic agent Transfusion of packed cells Immunization for allergy Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Anemia, unspecified Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Human immunodeficiency virus [HIV] disease Chronic kidney disease, unspecified Systolic heart failure, unspecified Personal history of allergy to other antibiotic agent Need for desensitization to allergens

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: clozaril overdose major surgical or invasive procedure: none history of present illness: pt is 36f h/o "schizophrenia" admitted for clozapine overdose. per report of her psychiatrist (per ed note) pt's mother was treating her daughter at home for schizophrenia. she kept her locked in the house during the days while she was at work believing that the pt may be denied a green card upon receiving the diagnosis of schizophrenia. starting in , pt began to express her desire to end her life, so mother sought medical attention. on day of admission pt was found at home on the floor, unconscious in a pool of vomit, surrounded by 5 empty bottles of clozapine (100 25mg tabs per bottle). ems was called, pt was thrashing, incoherent and agitated. taken to ed where she was intubated for airway protection. in ed received ativan 2 mg iv, activated charcoal, succ/etomidate and 3l ns. propofol gtt was ineffective in sedating her so pt was paralyzed with vecuronium, thinking that her lactate may improve if twitching stopped. her lactate did not improve and vecuronium d/c'd. past medical history: "schizophrenia" symptoms started 10 yrs ago, worse over past year, with si since mother reports that patient had "unknown" brain surgery for her schizophrenia in . social history: pt is a chinese citizen. she has an associate degree and speaks english. she lives with mother who is giving her psych meds from to prevent documentation of diagnosis. pt's psychiatrist's pager is . family history: no fh of psychiatric illness physical exam: 96.3 137 114/38 100% on 0.5 fi02 genl: well developed young woman, with intermittent jerking heent: intubated cv: rr no m pulm: ctab abd: s, nt ,nd ext: no edema neur: sedated, moving all 4 in intermittent asymmetrical jerks, reflexes 2+ and symmetrical pertinent results: labs on admission: type-art po2-533* pco2-37 ph-7.28* total co2-18* base xs--8 lactate-7.0* glucose-127* urea n-11 creat-0.6 sodium-141 potassium-3.8 chloride-112* total co2-17* anion gap-16 wbc-18.7* rbc-3.48* hgb-11.3* hct-31.1* mcv-89 mch-32.4* mchc-36.3* rdw-12.2 neuts-93.4* bands-0 lymphs-3.5* monos-3.0 eos-0 basos-0.1 hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal plt smr-normal plt count-221 type-art po2-298* pco2-30* ph-7.33* total co2-17* base xs--8 intubated-intubated lactate-8.3* urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg urine color-straw appear-clear sp -1.023 blood-neg nitrite-neg protein-30 glucose-100 ketone-50 bilirubin-neg urobilngn-neg ph-5.0 leuk-neg rbc-0-2 wbc-0-2 bacteria-none yeast-none epi-0-2 trans epi- hyaline-* glucose-163* urea n-16 creat-0.8 sodium-144 potassium-3.9 chloride-101 total co2-17* anion gap-30* alt(sgpt)-14 ast(sgot)-19 ld(ldh)-220 ck(cpk)-336* alk phos-86 tot bili-0.5 lipase-21 ck-mb-7 ctropnt-<0.01 albumin-4.7 calcium-9.6 phosphate-5.0* magnesium-1.5* lithium-<0.2 asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg wbc-27.0* rbc-4.11* hgb-13.1 hct-37.3 mcv-91 mch-31.8 mchc-35.0 rdw-12.3 07:20pm neuts-90.0* bands-0 lymphs-5.4* monos-4.4 eos-0 basos-0.2 hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal plt smr-normal plt count-295 studies: ct head w/o contrast 2:14 pm - no evidence of intracranial hemorrhage or mass effect. post- procedural changes of the frontal bones and overlying soft tissues, as well as presumable post-procedure changes of the frontal lobe resulting in unusual configuration of the frontal horns of the lateral ventricles. brief hospital course: 36 yo chinese speaking f with a 10 yr h/o schizophrenia s/p questionable surgical procedure of her brain in and si x3 months admitted with clozaril overdose. pt reportedly took 500 25 mg tabs in a suicide attempt. she received activated charcoal in ed. she was intubated for airway protection given obtundation. she was extubated on . 1. clozaril overdose/suicide attempt s/p activated charcoal and intubation for airway protection. she was successfully extubated on . now stable on ra. her lft's were initially elevated likely secondary to clozaril injestion, now wnl. pt is to go to psych unit today, now that medically stable. she was alert and oriented speaking softly in english prior to discharge. she was responding appropriately to questions. 2. altered mental status appears improved. etiology secondary to overdose. toxic/metabolic causes were initially considered, however pt improved without intervention. head ct shows no acute process. rpr and tsh normal. - b12 deficiency, she received a b12 injection during this admission. she will need to have a level checked in one month. 3. lactic acidosis, resolved. 4. leukocytosis - resolved. no evidence of infection. cxr and u/a negative, urine cx negative. blood cultures ngtd. 5. fen - tolerating house diet. 6. code - full 7. communication - mother, medications on admission: clozaril silpiride (selective dopamine d2 antagonist ) na deoxyribonucleotide tabs discharge medications: 1. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). discharge disposition: extended care facility: deacones 4 discharge diagnosis: clozaril overdose suicide attempt b12 deficiency discharge condition: good discharge instructions: please call your primary care physician if you experience shortness of breath or any other concerns. followup instructions: please follow up with your primary care physician weeks. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Diagnoses: Acidosis Anemia, unspecified Poisoning by other tranquilizers Unspecified schizophrenia, unspecified Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents Other B-complex deficiencies

history of present illness: ms. is a 57-year-old woman with no prior history of coronary artery disease; however, with a remote 15-pack-per year history of tobacco use and a family history positive for coronary artery disease who was in her usual state of health until two days prior to admission. at that time, the patient noticed intermittent epigastric discomfort and multiple episodes of chest pressure throughout the day. each episode lasted between 7 minutes and 15 minutes and occurred both with exertion and at rest. on the morning of admission, the patient had one episode of chest pressure and left-sided neck pain which lasted approximately 15 minutes. this pain resolved spontaneously. the patient was then well until 7 p.m. on the day of admission; at which point she noticed increasing chest pressure which prompted her to go to the emergency department at an outside hospital. en route to the emergency department, she developed worsening substernal chest pain without any radiation. however, this was associated with diaphoresis, nausea, vomiting, and the feeling of doom. in the emergency department, she developed further chest pain. an electrocardiogram showed st elevations in v2 through v6, and also in leads i and avl, with st depressions in leads ii, iii, and avf. the patient was given aspirin and retavase 10 mg intravenously times one; at which point, she had ventricular fibrillation at rest. the patient was shocked once at 200 joules and then 300 joules; after which she returned to a normal sinus rhythm. the patient became chest pain free after retavase. the st segment elevations returned to baseline. the patient was then started on heparin, integrilin, and amiodarone and was transferred to coronary care unit for cardiac catheterization. past medical history: status post total abdominal hysterectomy for endometrial cancer 30 years ago. medications on admission: premarin 0.625 mg p.o. q.d. (for one and a half years) and citracal. allergies: no known drug allergies. social history: she is a nursery teacher. she lives with her husband, her daughter, and her daughter's husband and child. she has four children. she has a remote history of tobacco use; 15-pack-per year history. she quit in . she denies any cocaine, heroin, or intravenous drug use. family history: her mother had a myocardial infarction at the age of 55 to 60. her brother had a myocardial infarction at the age of 59. they are both status post coronary artery bypass graft. physical examination on presentation: examination on arrival revealed temperature was 97.6, heart rate was 99, in a normal sinus rhythm, blood pressure was 102/64, respiratory rate was 26, oxygen saturation was 100% on 2 liters. general appearance revealed a middle-aged woman in no acute distress; moderately anxious, chest pain free. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. the oropharynx with bleeding. the neck revealed jugular venous pressure approximately 10 cm of water. no bruits. the chest was clear to auscultation bilaterally. heart revealed a regular rate and rhythm. no gallops and no murmurs. the abdomen was soft, nontender, and nondistended with active bowel sounds. extremities were warm and obese. dorsalis pedis pulses were palpable bilaterally. neurologically, alert and oriented times three. cranial nerves ii through xii were intact. pertinent laboratory data on presentation: laboratories revealed white blood cell count was 12.7, hematocrit was 41, and platelets were 417. chemistry-7 revealed sodium was 141, potassium was 3.5, chloride was 100, bicarbonate was 23, blood urea nitrogen was 20, creatinine was 0.9, and blood glucose was 113. ast was 16, alt was 12, albumin was 3.4. creatine kinase was 82. troponin was 0.15 at the outside hospital (where less than 0.2 is considered normal). pt was 10.6, inr was 0.8, ptt was 24. radiology/imaging: first electrocardiogram revealed a normal sinus rhythm with a heart rate of 63, st elevations in v2 through v6 in leads i and avl. st depressions in leads ii, iii, and avf. second electrocardiogram, status post retavase revealed a normal sinus rhythm with a heart rate of 64 with premature ventricular contractions. still with st depressions in leads iii and avf with resolution of st elevations in leads v2 through v6, i, and avl. third electrocardiogram, status post ventricular fibrillation arrest and cardioversion, revealed a normal sinus rhythm with a heart rate of 87. complete resolution of st depressions in avf and lead iii and complete resolution of all st elevations in leads v2 through v6, i, and avl. electrocardiogram at upon arrival revealed a normal sinus rhythm with a heart rate of 82, good r wave progression. no q waves. no st elevations. hospital course: ms. is a 57-year-old woman who presented status post anterolateral myocardial infarction; successfully treated with thrombolytics. ms. was continued on a heparin drip and integrilin drip from admission until monday, when she went to cardiac catheterization. during this time she was consistently chest pain free. the cardiac catheterization showed single vessel disease with 90% stenosis at the origin of the left anterior descending artery. the proximal left anterior descending artery lesion was stented with good flow. an echocardiogram showed severe focal hypokinesis of the anterolateral septum with an ejection fraction of 51%. after cardiac catheterization, she received integrilin infusion for another 18 hours. she was then loaded on plavix, and she was continued on plavix 75 mg p.o. q.d. her peak creatine kinase was 270. a fasting cholesterol panel was obtained which showed total cholesterol of 239, low-density lipoprotein of 140, and high-density lipoprotein of 61. therefore, she was started on atorvastatin 10 mg p.o. q.d. premarin was stopped. her heart rate remained in a normal sinus rhythm with a rate ranging between 80 to 105. she was started on lopressor which was titrated up as tolerated; up to 75 mg p.o. b.i.d. which was then converted to toprol-xl at discharge for patient convenience. however, her heart rate continued to be slightly elevated; ranging between the 80s and 90s. therefore, a thyroid-stimulating hormone was obtained to rule out hypothyroidism. condition at discharge: condition on discharge was good. discharge status: discharge status was to home. discharge diagnoses: aborted anterolateral myocardial infarction. medications on discharge: 1. plavix 75 mg p.o. q.d. (for one month). 2. aspirin 325 mg p.o. q.d. 3. lipitor 10 mg p.o. q.d. 4. toprol-xl 100 mg p.o. q.d. discharge instructions/followup: 1. the patient was to follow up with cardiac rehabilitation in . 2. the patient was also to follow up with her primary care physician within the next two weeks. 3. to follow up dr. if her insurance permits this within the next one month. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Personal history of tobacco use Accidental puncture or laceration during a procedure, not elsewhere classified Acute myocardial infarction of anterolateral wall, initial episode of care Personal history of malignant neoplasm of other parts of uterus

allergies: codeine / morphine / pentothal / percodan / talwin attending: chief complaint: doe/ presyncopal events major surgical or invasive procedure: - avr with 21 mm ce pericardial valve history of present illness: 76 yo female with several episodes of pre-syncope while dancing . has doe and ett was positive. echo revealed as with normal ef. cath showed severe as with 0.6 cm2, minimal cad, av gradient 56 mm mean. referred to dr. for avr past medical history: as htn elev. chol. niddm diverticulosis hiatal hernia obesity pna x 3 psh: c-sections x3, right tkr, chole, bladder suspension with urethral sling,appy,coccygectomy, social history: lives with husband quit smoking 30 years ago rare etoh family history: brother had cabg at age 66 mother/brother/sister with chf physical exam: hr 88 rr 16 bp 106/60 5'3" 195# nad no jaundice eomi, carotid bruits versus transmitted as murmur ctab 3/6 sem radiates throughout precordium abdomen midline scar 2+ radial/dp/pt pulses rkr scar no varicosities neuro nonfocal pertinent results: 05:40am blood wbc-15.3* rbc-2.66* hgb-7.9* hct-23.5* mcv-88 mch-29.7 mchc-33.6 rdw-15.6* plt ct-126* 09:25am blood hct-30.9*# 05:40am blood plt ct-126* 05:49am blood urean-11 creat-0.6 k-4.0 09:25am blood mg-2.0 cxr small left-sided effusion. status post aortic valve replacement. no consolidation demonstrated. echo pre-cpb: no spontaneous echo contrast is seen in the left atrial appendage. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. mild to moderate (+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. moderate tricuspid regurgitation is seen. there is no pericardial effusion. insufficient time to measure mv or ao valve gradient/area before beginning cpb. lvot = 1.8. annulus = 2.2. post-cpb: well seated and functioning aortic valve prosthesis. no leak, no ai. other parameters remain as pre-bypass. intact aorta. good biventricular systolic function. ospital course: mrs. was admitted to the on for surgical management of her aortic valve disease. she was taken to the operating room where she underwent an aortic valve replacement utilizing a 21mm pericardial valve. postoperatively she was taken to the cardiac surgical intensive care unit. on postoperative day one, she awoke neurologically intact and was extubated. she was then transferred to the cardiac surgical step down unit for further recovery. mrs. was gently diuresed towards her preoperative weight. the physical therapy service was consulted for assistance with her postoperative strength and mobility. her pacing wires and drains were removed per protocol without incident. on postoperative day five, mrs. had a fever spike. she was pan cultured and empirically started on ciprofloxacin.her urine culture was positive for e.coli and ciprofloxacin was continued. she complained of numbness of her right lateral thigh which improved slowly. it was presumed that this was related to a right lateral femoral cutaneous nerve neuropathy likely from positioning. mrs continued to make steady progress and was discharged home on postoperative day six. she will follow-up with dr. , her cardiologist and her primary care physician as an outpatient. medications on admission: zocor 40 mg daily glucotrol 5 mg daily zestril 10 mg daily asa daily fish oil daily folic acid daily vit. c daily discharge medications: 1. glipizide 5 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) for 1 months. disp:*60 capsule(s)* refills:*0* 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. disp:*60 tablet(s)* refills:*0* 6. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day) for 5 days. disp:*10 tablet(s)* refills:*0* 7. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 8. metoprolol tartrate 100 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. disp:*60 tablet(s)* refills:*0* 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. ferrous gluconate 300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 13. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. disp:*10 tablet(s)* refills:*0* 14. potassium chloride 20 meq packet sig: one (1) po bid (2 times a day) for 5 days. disp:*10 * refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: s/p avr as elev. chol. htn uti niddm diverticulosis gerd hiatal hernia obesity s/p bladder suspension discharge condition: stable discharge instructions: 1) you may shower and pat wound dry 2) no lotions, creams or powders on incisions 3) no driving for one month 4) no lifting greater than 10 pounds for 10 weeks 5) call for fever, redness, or drainage 6) take lasix with potassium for five days then stop. 7) take ciprofloxacin for five days then stop. 8) take vitamin c and iron for 1 month and stop. 9) call with any questions or concerns. followup instructions: see dr. in the office in 4 weeks see dr. in weeks see dr. in weeks Procedure: Insertion of intercostal catheter for drainage Extracorporeal circulation auxiliary to open heart surgery Intraoperative cardiac pacemaker Diagnostic ultrasound of heart Open and other replacement of aortic valve with tissue graft Pulmonary artery wedge monitoring Transfusion of packed cells Diagnoses: Esophageal reflux Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Aortic valve disorders Personal history of tobacco use Pulmonary collapse Other nervous system complications Mononeuritis of lower limb, unspecified Diaphragmatic hernia without mention of obstruction or gangrene

service: ccu/medicine history of the present illness: mr. is a 45-year-old gentleman with a past medical history of hypercholesterolemia and hypertriglyceridemia and gout who was in his usual state of health until 2:00 a.m. on the day of admission. at that time, the patient was awakened by associated with diaphoresis. the pain resolved spontaneously after ten minutes but then recurred 20 minutes later, in intensity and again associated with diaphoresis. it was also associated this time with dizziness and the pain was radiating into his sternal area. there was no associated shortness of breath, nausea, vomiting, or palpitations. the emergency department by his wife who is a nurse practitioner. he was taken via ambulance. his pain at that time was after two sublingual nitroglycerin. at the outside hospital, the patient was found to have st depressions in leads ii, iii, and avf and he was hypertensive with a blood pressure of 200/110. he was given sublingual nitroglycerin, heparin drip, and beta blocked and subsequently experienced a witnessed v-fib arrest and required shocking with 200 joules. he returned to sinus bradycardia and then a normal sinus rhythm. he was started on a lidocaine drip and then transferred to the cath lab for persistent discomfort/chest pain. at cardiac catheterization, the patient had the following hemodynamics. cardiac output was 5.24 with a cardiac index of 2.48. the pulmonary capillary wedge pressure was elevated at 26 and his right atrial pressure was 13. on angiography he had a left dominant system with luminal irregularities in the lad, 30% stenosis of the left circumflex, and the patient's ramus was completely occluded. the ramus was angio-jetted and then stented with restoration of timi-iii flow. the patient was then transferred to the ccu. on review of systems in the ccu, the patient denied chest pain, shortness of breath. on review of systems, he states that he was noticing minimal bilateral lower extremity edema prior to admission but denied dyspnea on exertion, orthopnea, pnd, or palpitations. physical examination in the ccu: vitals: temperature 98, blood pressure 127/56, pulse 82, saturation 96% on 2 liters nasal cannula. the patient had a swan-ganz catheter in place. in general, the patient was lying in bed in no apparent distress. he was speaking in full sentences. heent: the pupils were equal, reactive, and round to light and accommodation. the oropharynx was clear and dry. he was anicteric. the neck was supple. no bruits. jvp could not be adequately assessed. his lungs were clear to auscultation anteriorly and laterally. his abdominal examination revealed a soft abdomen, nontender, nondistended, no masses. arterial and venous sheaths were in place in the right groin without hematoma or ooze. his pulses were full times four, warm and well perfuse. the neurological examination was grossly intact. laboratory data and other studies: the patient's ekg in the ccu was normal sinus at 93, axis within normal limits, intervals within normal limits. his ekg showed right atrial enlargement and t wave flattening in leads f and avl. he had a hematocrit of 39.7, white count 15.7, hemoglobin 13.3, platelet count 271,000. chemistries revealed a sodium of 138, potassium 4.4, chloride 101, bicarbonate 25, bun 19, creatinine 1.1, glucose 124. his magnesium was 1.5. his first ck was 1506 with an mb of 232. prior cks at the outside hospital included a ck of 169 with an mb of 2.2 and a troponin of 0.15. chest x-ray at the outside hospital showed clear lung fields and no cardiomegaly. past medical history: 1. gout. 2. hypertriglyceridemia and hypercholesterolemia; at last check total cholesterol 278 with a triglyceride level of 1,000. past surgical history: bilateral knee menisci repair. medications at home: 1. lipitor 20 q.d. 2. tums p.r.n. 3. indocin p.r.n. for gout. allergies: the patient has no known drug allergies. social history: the patient works in it for . he is married and lives with his wife and son. is a nonsmoker. he does not use intravenous drugs. he drinks 6-12 beers per week. family history: 1. mother with mi at age 42. 2. father with cva at age 68. the patient's father also suffered from gout. hospital course: 1. cardiac: from a cardiac standpoint, the patient is status post his first mi which was in the ramus distribution. he also had symptoms of chf with elevated wedge pressures and left-sided pressures. the patient was placed on metoprolol, captopril, and was given lasix 20 mg iv times one to mobilize the fluid from his elevated pulmonary capillary wedge pressure. the patient was also placed on aspirin 325 mg p.o. q.d. status post stenting of the ramus, he was placed on plavix 75 q.d. which to be continued for nine months status post stenting. the patient's ck peaked at 1,711 on the evening of and then on his ck was 1380, on , the day of discharge, his ck had fallen to 409. the patient's cholesterol panel came back with a total cholesterol of 209, hdl 42, calculated ldl of 90 and a triglyceride level of 386 with a cholesterol to hdl ratio of 5. realizing that these levels are not accurate during an acute event, the patient was continued on his outpatient regimen of lipitor 20 q.d. and was told to follow-up with his outpatient cardiologist for remeasurement of the cholesterol panel and appropriate adjustment of his lipitor dosage. the patient's lfts were also checked on as he was being continued on a statin. his alt was slightly elevated at 73. his ast was essentially within normal limits at 48, alkaline phosphatase and total bilirubin were normal at 94 and 0.7 respectively. the patient was old to follow-up with his primary cardiologist regarding appropriate dosage of the statin. rhythm: from a rhythm standpoint, the patient was status post v-fib arrest in the setting of an mi. he was placed on telemetry and monitored closely for recurrent episodes of v-tach. he had one episode on of a 14-beat run of v-tach that was asymptomatic. his electrolytes were within normal limits including his magnesium which had been repleted and was 2.2 at the time of the arrhythmia. the patient was kept on telemetry through and had no recurrent episodes of v-tach or nonsustained v-tach or pvcs for that matter. the patient had an echocardiogram to help risk stratify him. his echocardiogram showed a normal ef of 55%. the left atrium had a normal size. the left ventricle had normal wall thickness. cavity size and systolic function was within normal limits with no noted wall motion abnormalities. his right atrium was normal size as well as his right ventricle. his valves were all stated to be structurally normal. he had mild mitral annular calcification with trivial mr. it was felt that the patient would not require an ep study with this normal ef and with no recurrence of the ventricular arrhythmia. the patient had originally been on a lidocaine drip and this was discontinued 24 hours after his event. pump function: as stated, above this was completely normal on his echocardiogram with an ef of 55%. cardiac follow-up: the patient was to see his primary care physician few days after discharge, dr. , at . his primary care physician will refer him to a cardiologist at . of note, the patient's wife is a nurse practitioner and is very involved in the patient's care. she has already arranged for the patient to follow-up in cardiac rehabilitation at . the patient was advised to take a week off from work and attend cardiac rehabilitation. he was seen by physical therapy during his stay and was able to walk two flight of stairs without chest pain or shortness of breath. 2. rheumatology: the patient has a history of gout and did have a gouty flare of the arch of his right foot on the evening of . he was initially given percocet for pain management as it was felt that indocin should be avoided in the setting of acute mi. however, with the patient's normal ef and absence of ventricular scarring, his risks for wall rupture was extremely low. therefore, the patient was told that he could have a trial of colchicine and if this did not work he could resume his outpatient medication of indocin. he was started on colchicine on the day of discharge, given a trial dose of 0.5 mg p.o. and would be discharged on the following medications. discharge medications: 1. lisinopril 5 mg q.d. 2. atenolol 25 mg q.d. 3. atorvostatin 20 mg q.h.s. 4. aspirin 325 mg q.d. 5. plavix 75 mg q.d. 6. colchicine 0.5 to 1 mg q.i.d. for a maximum of 8 mg q.d., titrate to pain relief or development of side effects, nausea, vomiting, or diarrhea. these instructions were gone over thoroughly with the patient. disposition: the patient was discharged to home with his wife. , m.d. dictated by: medquist36 d: 12:16 t: 09:52 job#: Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Intraoperative cardiac pacemaker Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified True posterior wall infarction, initial episode of care Pure hyperglyceridemia

history of present illness: this is a 48-year-old hiv positive african-american male with a history of polysubstance abuse, hepatitis c, cirrhosis and hypertension who was admitted to hospital on , for detox following a recent binge using crack cocaine (about one gram per day), alcohol (one pint of wine per day) and xanax and klonopin while on methadone maintenance. on , he was noted to have fluctuating mental status (somnolence, disorientation) and after being found down beside his bed confused, with a bloody nose and a blood pressure of 170/130, he was presumed to have had a seizure. he was given 1 mg of ativan and was brought to the emergency department. following a negative head ct, no further seizures and stable vital signs, the patient was discharged back to bornwood on an ativan taper. on , the patient was reported to be lethargic and ataxic, with a blood pressure of 150/100. emt brought the patient back to emergency department, where his vital signs included a blood pressure of 190/90, pulse of 88 and a respiratory rate of 4, satting 94% on room air. the patient was barely responsive to sternal rub, with constricted pupils and was started on narcan, receiving a dose of 0.06 mg/hour with good effect. he was admitted to the micu in the early a.m. on . it was difficult to obtain additional history from the patient at this time. subsequently it was learned that the patient received some oxycontin 40 mg from a friend while at detox, and remembers taking it prior to admission to the hospital, although he is unclear as to what day he took it. past medical history: 1. hiv positive since . a cd4 count of 78 with an undetectable viral load was noted in as per the patient's primary care physician, . . the patient has a history of thrush as per previous dictation summaries. there is a question of a history of pcp in the past. the patient was on haart, but this was discontinued in the fall of last year because of decompensating liver disease in the setting of hepatitis c. 2. multisubstance abuse including intravenous drug abuse. the patient has a long-standing history of multisubstance abuse going back 25 years that includes intravenous heroin and cocaine abuse, benzodiazepine use including xanax and klonopin, and ethanol. the patient has been in and out of rehabilitation facilities in the past, stays on long term methadone maintenance. while the patient does admit to recent use of cocaine, ethanol, and benzodiazepines, he denies use of heroin for several months, stating that he does not crave heroin while he is on methadone. 3. hepatitis c positive. the patient has active hepatitis c disease with a high viral load and is not a candidate for therapy at this time considering his current treatment for depression. his albumin has been as low as 2.5 in the past but has improved since holding haart therapy. he has no history of ascites or gastrointestinal bleed. the patient falls between child class b and c cirrhosis. 4. pan cytopenia likely secondary to hiv and ethanol abuse. 5. hypertension. 6. depression. 7. history of tuberculosis exposure. 8. history of bacterial endocarditis, staph positive in the past ( and hospitalizations). 9. history of sternoclavicular septic arthritis in . 10. status post motor vehicle accident with head trauma. 11. bilateral leg pain and numbness secondary to peripheral neuropathy. 12. status post appendectomy. 13. status post inguinal hernia repair. 14. question of a distant history of seizure. medications prior to admission: 1. methadone 55 mg q. day. 2. prozac 20 mg q. day. 3. ativan 1 mg t.i.d. taper. 4. thiamine. 5. folate. 6. clonidine 0.2 t.i.d. p.r.n. 7. motrin 400 mg q. 4h. p.r.n. 8. mylanta 30 cc q. 4h. p.r.n. 9. ativan 1 mg p.o. q. 4h. p.r.n. social history: the patient lives with his wife in and has five children and several grandchildren. he is retired since after working for american airlines as a ramp worker. he now lives on ssi with mass health and veterans benefits that cover his medications. as previously mentioned, he has an extensive history of intravenous drug abuse that includes intravenous heroin and cocaine abuse that extends back for decades. his recent binge was attributed to increased depression of recent time because of his inability to stay clean, his cirrhosis and chronic illnesses, a recent fight with his wife, multiple deaths in the family, and an upcoming court date next week for a dui that he was arrested for in of this year. the patient has a one pack per day smoking history and, while he denies extensive abuse of alcohol, he does admit to recently drinking one pint or one bottle of wine per day. allergies: the patient has allergy to bactrim that causes him to have a rash. the patient has an allergy to nafcillin which has also given him exfoliative dermatitis of the palms and soles in the past. family history: the patient's mother is healthy at age 83. the patient's father is 82 years old, suffering from diabetes mellitus. the patient has two sisters who have died of cancer, one at the age of 58 and one who passed away in her 20's. there is no family history of substance abuse. there is a question of a history of depression in the patient's mother. review of systems: at admission the patient denied complaints of headache, chest pain, shortness of breath, nausea, vomiting, fevers or chills. he had no complaints of diarrhea, constipation or abdominal pain at the time. no dysuria or increased urinary frequency. physical examination at presentation: on physical examination at presentation to the intensive care unit floor the patient had the following vital signs: he was afebrile with a heart rate of 75, blood pressure of 139/101, a respiratory rate of 18 and he was saturating 100% on room air. general appearance: the patient was very somnolent, but responsive to questions and without tremulousness. on examination of the head, eyes, ears, nose and throat, the patient was normocephalic, atraumatic. mucus membranes were dry. pupils were 4 mm and reactive to light bilaterally. the patient's neck was supple without lymphadenopathy. on pulmonary examination the lungs were clear to auscultation bilaterally without wheezes or crackles. on cardiovascular examination, there was a normal rate and rhythm with normal s1, s2. a systolic murmur was appreciated at the apex. on abdominal examination normal bowel sounds were present. the abdomen was soft, non-tender and non-distended. the extremities were without edema or cyanosis. on neurological examination, the patient was alert and oriented times three. cranial nerves ii through xii were intact. no focal motor deficits were appreciated. pertinent laboratory data on presentation: the patient had the following laboratories on admission: a complete blood count revealed a white blood cell count of 1.9 with an anc of 700, hematocrit of 32.5 and a platelet count of 53,000. chem-7 (hemolyzed) showed a sodium of 137, potassium of 4.8, chloride of 103, bicarbonate of 31, bun of 13, creatinine of 0.8 and a glucose of 118. a serum tox screen for aspirin, ethanol, acetaminophen, benzodiazepines, barbiturates, tca was negative. radiology/studies at admission: 1. electrocardiogram: sinus rhythm, with left ventricular hypertrophy and left atrial abnormality. nonspecific st changes were observed. q2 prolongation that is new on this ekg was observed compared with previous ekg. 2. chest x-ray: mild to moderate cardiac enlargement with prominent left ventricle contour. wide thoracic aorta. no evidence of pulmonary congestion or infiltrates. 3. head ct: head ct from emergency department visit showed mild focal dilatation, with a normal ventricular system. no midline shift, mass, mass effect, hemorrhage was observed. chronic paranasal sinus disease was noted. impression at admission: this is a 45-year-old african-american male with a history of polysubstance abuse, hiv and hepatitis c who came to the emergency department with stuporous mental status changes from detox facility. this was felt to be most likely from an opiate overdose, as the patient appeared to respond to narcan while in the emergency department. infection as a possible etiology for mental status changes could not be completely ruled out in this hiv positive patient with his last cd4 count of 78. however, the patient does recall taking an extra 40 mg of oxycontin prior to admission on top of his maintenance methadone dose of 55 mg per day and benzodiazepine taper that he had been started on after his emergency department visit, making overdose more likely. hospital course in the intensive care unit: . neurological: patient's mental status changes which included increased lethargy to stuporousness, pinpoint pupils and decreased respiratory rate in the setting of methadone, benzodiazepine and opiate use make opiate overdose the most likely cause of this patient's presentation. the patient showed good response to naloxone throughout his stay in the intensive care unit which was continued as a drip until , with dramatic improvement in the patient's state of alertness. other causes for his change in mental status included withdrawal from benzodiazepines and alcohol, electrolyte abnormalities, infection, intracranial processes, as well as renal hepatic disease. for that reason, electrolytes were followed, calcium, magnesium, phosphate levels were sent. an lp was also performed. the patient was pan cultured, including cultures for blood, urine and cerebrospinal fluid. because of the patient's history of alcohol and benzodiazepine use with the last alcohol use likely on , there was a possibility of withdrawal in this patient, so a ciwa protocol with diazepam q. 4h. for a score greater than 10. clonidine p.r.n. was also continued for the possibility of developing opiate withdrawal. in this patient with depression, his prozac was held while he was in the intensive care unit. a neurology consult felt that the seizure on , was most likely secondary to a combination of withdrawal from both alcohol and benzodiazepines. as recent cocaine was evident in the urine tox screen, there was some concern of a cerebral infarct, but a negative ct and nonfocal neuro examination made this less likely. liver function tests and ammonia were also sent in this patient with a history of hepatitis c. patient's laboratory values while in the intensive care unit on , included a calcium of 8.0, magnesium of 1.4 and a phosphate of 3.1. the patient's pt was 13.7, inr was 1.2 and ptt was 37.7. the patient had an elevated ast of 101, an alt of 52, an alkaline phosphatase of 129, and a total bilirubin of 0.8. his albumin was 2.7 and was repeated that same day and found to be 3.1. amylase was 98 and lipase was 63. the patient had an ammonia elevated to 95 with no history of previous baseline ammonia recorded in the past. a urine tox screen was positive for cocaine and methadone and negative for benzodiazepines. an lp was performed on , which showed 0 white blood cells, 6 red blood cells, a protein of 37, and a glucose of 57. the gram stain was negative for pmns, no microorganisms were seen. cryptococcal antigen was not detected, and fluid, acid fast, viral, and fungal cultures were sent. 2. infectious disease: this patient is hiv positive and hepatitis c positive, and it is possible that infection could also be an underlying cause of his mental status changes. as mentioned he was pan cultured, including blood, urine, csf and stool cultures. tests for cd4 count and viral load were sent. the patient reported that he has not been on retrovirals since the fall of last year. liver function tests were ordered to follow up the status of his cirrhosis, and were elevated as previously mentioned in this dictation. throughout the patient's duration in the intensive care unit, he did not complain of fevers, shortness of breath or productive cough, dysuria, or other complaints suggestive of infectious process. 3. pulmonary: the patient's respiratory rate improved on narcan drip while in the intensive care unit and there was no need to intubate. 4. cardiac: the patient has a history of hypertension and has used beta blockers in the past. he has not been on his hypertensive medication during the past several days while at detox. his pressures remained elevated while in the intensive care unit. in the evening of , he was hypertensive to 206 and was given a dose of hydralazine for control of his pressure. subsequently, lisinopril 5 mg q. day and hydrochlorothiazide 25 mg q. day were begun to better control his pressure. the patient's ekg showed an increased qt prolongation from prior ekg, in the setting of a potassium of 3.4 upon repeat chem-7 on . it was unclear that any of the other medicines that the patient were taking should be associated with causing this qt prolongation. the patient's potassium was repleted. 5. hematology. the patient's pan cytopenia was noted on cbc. this was stable throughout his stay in the intensive care unit. 6. renal/fluids, electrolytes and nutrition. the patient was given maintenance fluids of one-half normal saline 100 cc per hour. these were maintained until the patient's mental status improved. he began tolerating p.o.'s on . because of the patient's elevated ammonia, he was placed on a low protein diet once he was able to tolerate p.o.'s. electrolytes were followed daily and were repleted as necessary, with potassium and magnesium requiring repletion. the patient was placed on thiamine, folate and a multivitamin considering the patient's history of alcohol abuse. 7. gastrointestinal: the patient has a history of cirrhosis in the setting of haart use that was discontinued in with a history of ethanol abuse. he has had elevated transaminases, pt and albumin of 3.1 and elevated ammonia. lactulose was started at 30 cc t.i.d., titrated to less than two stools per day to treat the elevated ammonia. hepatitis c serologies were not sent at this time and will likely be followed as an outpatient. 8. prophylaxis. the patient was placed on subcu heparin and pepcid iv q. day. summary of intensive care unit stay: the patient's mental status continued to improve on narcan drip which was weaned over 12 hours to a respiratory rate greater than 11. cultures remained negative during the icu stay. the patient was able to tolerate p.o.'s prior to transfer. vital signs were stable, although his blood pressures remained elevated prior to transfer. the patient was transferred to the service on . hospital course on the floor ( to ): 1. neurological: on arrival to the floor, the patient was breathing comfortably in no acute distress and was alert and oriented with some depressed mood. he did complain of some symptoms of nausea, chills, diaphoresis, aches and pains, diarrhea, that he thought were consistent with his typical withdrawal symptoms. he was continued on the ciwa protocol with p.r.n. diazepam, and clonidine was continued for his complaints of opiate withdrawal. his methadone was begun on the floor at a dose of 55 mg q. day. lactulose was also considered in light of his elevated ammonia, although encephalopathy appeared to be unlikely in this patient with no asterixis or additional changes in mental status. we continued to follow daily labs which showed a white blood cell count of 1.7, hematocrit of 32.6 and a platelet count of 47,000, with an anc of 740. electrolytes showed a sodium of 137, potassium 3.3, chloride 107, bicarbonate 22, bun 8, creatinine 0.5 and glucose 98. calcium was 7.5, magnesium 1.8 and phosphate was 3.0. while the pt and inr were now normal, ptt remained slightly elevated at 39. the patient was offered a nicotine patch for his nicotine addiction which he declined. the patient's mental status continued to be stable during his stay on the floor, with no signs of overt anxiety, hallucinations, instability, but the patient was somewhat depressed and nervous, which he admitted was primarily due to his worry about personal stressors. his symptoms of opiate withdrawal were also negligible during his second and third days on the floor. prozac was restarted on his last day of admission for depression. it appeared that the patient had very few symptoms of ethanol withdrawal, however, his blood pressure did remain elevated throughout his stay but without tachycardia. the patient's symptoms of opiate withdrawal seemed to be well controlled on his methadone maintenance dose although the patient did receive one to two doses of benzodiazepine per day, and requested clonidine on his final day of admission p.r.n. however, the patient does admit that he feels better than he has in years physically but admits that it is psychological problems and depression that make him feel most concerned at this time. we had several discussions with the patient regarding the seriousness of this hospital admission and the risk of poor outcome if he continues such risky behaviors, as this overdose might have been life threatening. the patient is actually quite thoughtful and clearly depressed with his current health situation, living environment ("my neighborhood is full of drugs"), and life stressors (several deaths in the recent past in his family). 2. infectious disease. the patient's cd4 count was found to be 48 during this admission and his viral load is still pending. the patient remained afebrile throughout his admission, without complaints of fever, productive cough, dysuria, abdominal pain, or other clinical signs concerning for infection. blood, stool and cerebrospinal fluid cultures have been negative to date. prophylaxis was begun for pcp with dapsone and fluconazole was also started in this patient with a history of thrush. however, fluconazole was discontinued prior to __________ as prophylaxis is not indicated routinely in hiv positive patients. as the patient's cd4 count is below 50, toxoplasmosis titers were also sent, and should be followed up for possible toxoplasmosis prophylaxis as well as prophylaxis as an outpatient. 3. cardiovascular. the patient's ekg was repeated on , and was found to be unchanged from admission ekg, with suddenly prolonged qt interval. potassium was also 3.2 on , and was repleted. the patient's blood pressure continued to be elevated throughout his stay on the floor, in the 150's to 180's over 90's to 100's. the dose of lisinopril was increased to 10 q. day, and it was decided prior to discharge to change the patient's blood pressure regimen to 10 mg lisinopril b.i.d., to discontinue the hydrochlorothiazide, and to begin norvasc 5 mg p.o. q. day. 4. pulmonary. the patient was breathing comfortably with normal respiratory rate and saturating well on room air throughout his stay on the floor. while the patient complained of some runny nose on transfer to the floor, he developed no other symptoms suggestive of a serious respiratory infection. this patient does have previous hospitalizations because of pneumonia with a question of pcp pneumonia in the past. 5. renal. the patient had normal creatinine throughout his hospital stay. his urinalysis was negative except for a negative urobilinogen in this patient with advanced liver disease. urine culture was positive for group b strep which was an endogenous organism not considered needing to be treated. 6. fluids, electrolytes and nutrition. the patient's lytes were followed and were repleted while he was on the floor. potassium remained slightly low throughout and was repleted with 40 meq of kcl during each of his stays on the floor and was increased to 60 meq on . he was maintained on a low protein diet in light of his elevated ammonia which was up to 148 on his day of discharge. he was continued on thiamine, folate and multivitamin and additional b12 and folate studies were sent and are still pending. he tolerated p.o. liquids and solids well throughout his stay on the floor. no complaints of nausea or vomiting. 7. gastrointestinal. in this patient with hepatitis c positive cirrhosis his albumin came back at 2.8 on . we continued to follow an ammonia which was 148 prior to discharge, and lactulose was poorly tolerated by the patient and was discontinued on his final day of admission. the patient was requesting therapy options for his liver disease and seemed most concern with this of his health issues. unfortunately, interferon therapy may be contraindicated in this patient on zoloft with clear symptoms of depression. as an outpatient it would be recommended that he receive vaccination such as hepatitis a in light of his liver disease. while this patient has no prior history of gastrointestinal bleed, we began imdur for gi prophylaxis, and it is recommended that he have an esophagogastroduodenoscopy as an outpatient. 8. hematology. the patient's pan cytopenia was stable while on the floor. the patient did complain of a nose bleed one morning in the setting of low platelet count that he described as robust, but which stopped easily and did not recur. in light of the patient's pan cytopenia which may be likely due to ethanol use, hiv, liver disease, it was thought that b12 and folate should also be checked. 9. prophylaxis. the patient remained on heparin subcu b.i.d. and ranitidine 150 mg p.o. b.i.d. throughout his stay on the floor. condition at discharge: the patient was in good condition at discharge. he was not complaining of symptoms of alcohol withdrawal, and was maintained on ciwa protocol greater than 8 during his last three days on the floor. methadone maintenance was restarted with good effect. he was primarily concerned with psychosocial issues of maintaining sobriety, a safe drug-free environment, his chronic health issues, family stressors, and tomorrow's pending court appearance. depression, for these reasons, is a concern in this patient who appears to have overdosed on narcotics leading to this admission. discharge status: the patient was discharged back to hospital, where he was first admitted last monday () to begin a detox program prior to this hospitalization. he wishes to return to bornwood to continue his detox in a safe environment where he can try to address his recurrent urges for polydrug abuse. hospital is located at in , . discharge medications: 1. thiamine 100 mg q. day. 2. folic acid 1 mg q. day. 3. multivitamin. 4. dapsone 100 mg q. day. 5. methadone 55 mg q. day. 6. fluoxetine 20 mg q. day. 7. _____ 10 mg b.i.d. 8. ativan 1 mg q. 4h. p.r.n. 9. clonidine 0.2 mg t.i.d. p.r.n. 10. potassium chloride 20 meq b.i.d. 11. norvasc 2.5 mg p.o. q. day. 12. magnesium oxide 400 mg p.o. q. day. 13. imdur 30 mg q. day. discharge instructions and follow up: 1. the patient was instructed to call his primary care physician, . , after discharge to set up a follow-up appointment in one week if he desired to continue having her involved in his care. 2. as the patient mentioned a desire to transfer his care from the v.a. hospital, as he has had some negative experiences there in the past, we have set up an appointment for him with dr. at associates, , for this thursday, , at 2:00 p.m., the building. at this appointment the patient will be able to follow up his pending laboratory studies which include pending cultures, his viral load, his toxoplasmosis cultures. also potassium and ammonia levels should be checked at this time. as the patient's blood pressures have been elevated during his hospital stay and his blood pressure control medications are still being optimized, his blood pressure should be checked during this visit and modification of his medical regimen should be considered. pending results of the toxoplasmosis titers, the patient should be considered for a toxo and prophylaxis, considering his cd4 count of 48. also consider a hepatitis a vaccine and confirm hepatitis b status in this patient. as this patient was noted to have a slightly prolonged qt interval on ekg, it would also be useful to recheck an ekg during this visit. while this patient has had no complaints of gastrointestinal bleed in the past, he should be sent for endoscopy to look for varices as an outpatient. the patient has also been requesting psychiatric and/or social work support as he has numerous psychosocial stressors and needs a support network to help him with his depression and with the numerous issues involving his drug abuse and health care problems. this patient should also be set up to be followed in the . 3. the patient was also scheduled to visit the pain clinic at this thursday with dr. on at 12:40 p.m. this visit is important in light of his chronic back pain and peripheral neuropathy, which the patient states have been a factor in his persistent drug use. 4. continue with methadone maintenance program as previous to admission. 5. consider contacting for acupuncture treatments as the patient has requested this therapy which has worked for him in the past. discharge diagnoses: 1. opioid and benzodiazepine intoxication. 2. polysubstance abuse. 3. hiv positive. 4. hepatitis c positive. 5. hypertension. 6. depression. , m.d. dictated by: medquist36 Procedure: Spinal tap Incision of lung Diagnoses: Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Human immunodeficiency virus [HIV] disease Poisoning by opium (alkaloids), unspecified Opioid type dependence, continuous Poisoning by benzodiazepine-based tranquilizers Accidental poisoning by other opiates and related narcotics Accidental poisoning by benzodiazepine-based tranquilizers

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain due to anterior mi. major surgical or invasive procedure: emergent cardiac catheterization. removal of thrombus from the lad coronary artery. placement of a drug-eluting stent in the proximal lad. pertinent results: echo on : left atrium - long axis dimension: 3.7 cm (nl <= 4.0 cm) left atrium - four chamber length: *5.8 cm (nl <= 5.2 cm) right atrium - four chamber length: 4.6 cm (nl <= 5.0 cm) left ventricle - diastolic dimension: 4.7 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 35% (nl >=55%) aorta - valve level: 3.0 cm (nl <= 3.6 cm) aorta - arch: 1.9 cm (nl <= 3.0 cm) mitral valve - e wave: 0.7 m/sec mitral valve - a wave: 0.8 m/sec mitral valve - e/a ratio: 0.88 mitral valve - e wave deceleration time: 200 msec tr gradient (+ ra = pasp): 21 mm hg (nl <= 25 mm hg) brief hospital course: no addendum. discharge disposition: home discharge diagnosis: anterior mi. discharge condition: good. discharge instructions: please return to the emergency department for re-evaluation if you experience chest pain, nausea, shortness of breath, dizziness, disorientation or any other symptoms that concern you. it is essential that you remember to take all your medications on time as prescribed. remember to keep your appointments. followup instructions: follow up with your primary care physician, . () to achieve appropriate coumadin levels. your appointment wiht dr. is scheduled for 11.30am on monday . follow-up cardiology care has been arranged with dr. (). you have an appointment to see him at 3.15pm on tuesday . dr practice is located at in , in the old shoe building. please remember to bring your card. md Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Implant of pulsation balloon Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Acute myocardial infarction of other anterior wall, initial episode of care Paroxysmal ventricular tachycardia Other specified conduction disorders

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, caused by anterior stemi. major surgical or invasive procedure: emergent cardiac catheterization. removal of thrombus from the lad coronary artery. placement of a drug-eluting stent in the proximal lad. history of present illness: 52m w/no signif pmh, developed left arm discomfort at 1pm today while in scout classes, , no sob, no lh/dizzyness, no diaphoresis, no n/v. paid no attention, discomfort started to move up along arm to shoulder and then lacw as day progressed. by 8pm patient had decided to rest, lay in bed to relieve discomfort but to no avail, pain at that time had increased to and very noticible in the chest area. called ems and taken to (arrived at 940pm). ecg there demonstrated ste in i,avl, v1 with hyperacute t waves in v2-v5, st depressions in ii, iii, f with twi iii, f, all consistent with anterior transmural infarction. he rec'd asa 325mg, plavix 300mg, iv heparin, and eptifibatide (single bolus and infusion). also rec'd nitroglycerin x1 which decreased pain from to . transferred to for emergent cath and continuing care. past medical history: anxiety, per pcp. social history: soh: neg x 3, good exercise and diet. family history: fm: father with mi in 70's, gf both paternal and maternal with mi in 60-70's. physical exam: gen: nad, comfortable, a/ox3. v/s: 98.8 (afeb) 64 96/44 20 98%ra heent: hncat cv pump: nl s1,s2. no m/r/g. cv rhythm: rrr with occasional rare infrequent pvcs. pulm: ctab. respirations comfortable. abd: s/nt/nd. vasc: hematoma at r femoral access site continues to resolve. pertinent results: cadiac cath: 100% occluded plad; cypher stent 3.5x13 placed by ptca. hemodynamics: ra mean 15/a wave 17/v wave 18/, rv 38/11/17, pcw mean 30/ v wave 37/ a wave 27, ao 102/76/89, pa sat 71%. peak cardiac enzymes: cpk 3169, ck-mb 494, troponin-t 8.23. lipid profile: hdl 41, ldl(calc) 101, tg 110 (all wnl). brief hospital course: 100% occluded plad found at emergent cath, cleared by thrombectomy. cypher stent 3.5x13 placed by ptca. patient noted to have aivr w/ mild hemodynamic intolerance during av dysyncrony. iabp was placed persistent borderline hypotension. patient's hemodynamics remained stable and the iabp was removed approximately 18 hours later. the patient was noted have brief runs of nsvt on telemetry, in the range of beats. these were likely secondary to reperfusion irritability, and have subsequently subsided without further intervention. echocardiogram revealed anterior wall hypokinesis and apical akinesis. patient was begun on tailored asa/plavix/lipitor/ace-inhibitor/metroprolol medication regimen, and also on coumadin for anticoagulation in the setting of wall hypokinesis. medications on admission: none. discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 3. atorvastatin calcium 40 mg tablet sig: two (2) tablet po qd (once a day). disp:*60 tablet(s)* refills:*2* 4. warfarin sodium 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 5. lisinopril 5 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 6. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po qd (once a day). disp:*30 tablet sustained release 24hr(s)* refills:*2* 7. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* 8. lovenox 80 mg/0.8 ml syringe sig: one (1) 80mg subcutaneous twice a day for 2 weeks. disp:*28 syringes* refills:*0* 9. outpatient lab work check hct% and inr on monday . please send results to dr. at . . 10. outpatient lab work check hct% and inr on thursday . please send results to dr. at . . discharge disposition: home discharge diagnosis: anterior mi. discharge condition: good. discharge instructions: please return to the emergency department for re-evaluation if you experience chest pain, nausea, shortness of breath, dizziness, disorientation or any other symptoms that concern you. it is essential that you remember to take all your medications on time as prescribed. remember to keep your appointments. followup instructions: follow up with your primary care physician, . () to achieve appropriate coumadin levels. your appointment wiht dr. is scheduled for 11.30am on monday . follow-up cardiology care has been arranged with dr. (). you have an appointment to see him at 3.15pm on tuesday . dr practice is located at in , in the old shoe building. please remember to bring your card. Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Implant of pulsation balloon Insertion of drug-eluting coronary artery stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Acute myocardial infarction of other anterior wall, initial episode of care Paroxysmal ventricular tachycardia Other specified conduction disorders

history of present illness: the patient is a 43 year-old male with no significant past medical history who was working on his welding job when a metal object came and hit him in the forehead. the patient lost his balance and fell back and hit the back of his head. no loss of consciousness at the scene by report. on transport to the patient had loss of consciousness. head ct at the outside hospital showed a frontal bone sinus fracture and pneumocephalus with a positive occipital fracture. there was a question of a contusion versus a bleed in that region. the patient had emesis times two. he was confused and agitated on arrival to the . past medical history: none. past surgical history: none. allergies: no known drug allergies. medications: none. social history: positive marijuana two times per day, occasional alcohol, occasional tobacco. physical examination: temperature 36.7. heart rate 80. blood pressure 127/67. respirations 18. o2 sat 98%. general no acute distress. pupils are equal, round and reactive to light. face was symmetric. tongue midline. laceration on the forehead, which was sutured. heart is regular rate and rhythm. lungs clear to auscultation bilaterally. abdomen soft, nontender, nondistended. pelvis is stable. extremities no gross deformities. palpable dorsalis pedis pulse and posterior tibial pulse bilaterally. laboratory data: hematocrit 40, white blood cell count 20, platelets 234, sodium 139, potassium 3.6, chloride 104, bicarbonate 23, bun 14, creatinine .9, glucose 196, blood gas on admission was 7.35/44/127/22/-1. head ct at the outside hospital showed a frontal bone sinus fracture with pneumocephalus and also an occipital fracture. at this institution c spine plain films were negative. chest x-ray was negative. pelvis x-ray was negative. hospital course: the patient was admitted to the trauma surgery service. he had a four vessel angiogram performed on , which showed no evidence of carotid dissection, no evidence of vertebral dissection and no evidence of intracranial vascular pathology. he was admitted for neurological checks and started on clindamycin. he was placed in the intensive care unit for neurological checks. a ct of his head was stable and ct c spine revealed no obvious pathology. a repeat ct on showed decrease in air in bifrontal areas and the patient's neurological examination was stable. he was tolerating a regular diet at the time of discharge. condition on discharge: stable. discharge status: to home with follow up with dr. from neurosurgery. discharge diagnoses: status post trauma with pneumocephalus and occipital bone fracture along with frontal bone sinus fracture. , m.d. dictated by: medquist36 Procedure: Closure of skin and subcutaneous tissue of other sites Diagnoses: Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with loss of consciousness of unspecified duration Open wound of forehead, without mention of complication Struck accidentally by falling object

history of the present illness: this is a 66-year-old female with a past medical history of coronary artery disease, status post cabg, ischemic cardiomyopathy with an ef of 20%, status post left parietal cva, and bilateral carotid aortic stenosis, status post left cea, who was transferred from an outside hospital for right carotid artery stenting. at the outside hospital, the patient was treated for chf exacerbation with successful diuresis. her hospital course at that time was complicated by nausea, vomiting, with elevated alkaline phosphatase and ggt status post right upper quadrant ultrasound without evidence of stones or ductal dilatation with trace ascites. gi was consulted with assessment of chf versus possible gastritis. a second complication included right mtp ulcers, status post debridement. no evidence of osteomyelitis. this was treated with keflex for a ten day course. the next issue included acute on chronic renal failure with creatinine peak at 2.8, bun 71. renal consult for this felt that it was believed to be due to worsened chf. on presentation, the patient reported minimal shortness of breath with significant fatigue and weakness. she denied chest pain, abdominal pain, orthopnea, pnd, or fever and chills. review of systems: pertinent for chronic nausea for weeks with intermittent vomiting. past medical history: 1. coronary artery disease, status post cabg in . 2. status post catheterization in with patent graft. 3. ischemic cardiomyopathy with an ef of 22% with basal mid inferior, posterior hypokinesis. 4. bilateral carotid artery stenosis, status post left cea. 5. left parietal cva. 6. type 2 diabetes mellitus. 7. chronic renal insufficiency. 8. hypercholesterolemia. 9. hypertension. 10. status post cholecystectomy and total abdominal hysterectomy. 11. gerd, positive h. pylori. allergies: question of an ace inhibitor causing rta. admission medications: 1. lasix 160 mg p.o. q.d. 2. zaroxolyn 5 mg p.o. q.d. 3. nitroglycerin paste two inches q. six hours. 4. coreg 12.5 mg b.i.d. 5. hydralazine 25 mg p.o. q.i.d. 6. plavix 75 mg p.o. q.d. 7. 20 meq p.o. b.i.d. 8. keflex 500 mg p.o. t.i.d. 9. glucotrol xl 5 mg q.d. 10. ecasa 81 mg p.o. q.d. 11. zoloft 25 mg p.o. q.d. 12. bactroban cream b.i.d. to feet. social history: the patient is married. she has a prior tobacco history of 40 plus years for one to two packs per day, quit a month ago. denied ethanol or illicit drug use. physical examination on admission: vital signs: temperature 98.0, bp 142/56, heart rate 50, respiratory rate 22, sp02 93% on 2 liters. general: the patient was in no acute distress, a pleasant female who appeared chronically ill. heent: normocephalic, atraumatic. surgical left pupil. extraocular movements intact. moist mucous membranes. clear oropharynx. neck: supple, no lymphadenopathy, positive jvp. pulmonary: decreased breath sounds one-fourth of the way up on the right. no wheeze. cardiovascular: regular rate and rhythm with s3 and a ii/vi systolic murmur at the left lower sternal border. abdomen: soft, obese, bowel sounds positive, positive hepatomegaly. extremities: no edema. the right mtp revealed a shallow-based ulcer, 1+ dp pulses on the right. the left mtp showed a healing ulcer, 1+ dp pulses on the left. neurological: the patient was awake, alert, and oriented. cranial nerves ii through xii were intact. the patient was noted to be diffusely weak, right upper extremity , deltoid, biceps, triceps, sensation diminished to light and pinprick, stocking glove distribution. admission laboratory data/studies: the ekg showed sinus bradycardia at 52 beats per minute with leftward axis. there were t wave inversions in the anterolateral leads and depression also in the anterolateral leads which were unchanged from . the admission laboratories were pertinent for a hematocrit of 32.4. sodium 140, potassium 3.6, chloride 87, bicarbonate 40, bun 60, creatinine 2.6, glucose 69. chest x-ray showed cardiomegaly and mild failure. hospital course: the patient was admitted to the cardiology service and ruled out for a myocardial infarction. she continued diuresis until her baseline weight. the day after admission, the patient underwent stenting and pta of the right ica with good results. post procedure, the patient had a hematocrit drop and was given 1 unit of packed red blood cells to return to greater than 30. also, postoperatively, the patient had episodes of bradycardia to the 40s. this was due to the procedure being near the carotid body. she was asymptomatic when this rate drops. also of note, the patient's creatinine increased to 3.4. the patient appeared intravascularly depleted and she was given iv fluid hydration. discharge diagnosis: 1. right internal carotid artery stenosis, status post stent. 2. chronic renal failure. disposition: the patient was discharged to home with vna services. of note, the patient refused rehabilitation. discharge medications: 1. isosorbide mononitrate 30 mg p.o. q.d. 2. plavix 75 mg p.o. q.d. 3. aspirin 81 mg p.o. q.d. 4. pyracin calcium 2% cream applied topically b.i.d. 5. fluoxetine 20 mg p.o. q.d. 6. prochlorperazine malleate 10 mg p.o. q. six hours p.r.n. nausea. 7. glucotrol xl 5 mg p.o. q.d. 8. hydralazine 25 mg p.o. q. six hours. 9. lasix 40 mg p.o. q.d. 10. carvedilol 3.125 mg p.o. b.i.d. 11. zantac 150 mg q.h.s. follow-up: the patient is to follow-up with dr. on wednesday on and follow-up with her primary care physician in one week. , md dictated by: medquist36 Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of cerebral arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Esophageal reflux Pure hypercholesterolemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Mitral valve insufficiency and aortic valve insufficiency Occlusion and stenosis of carotid artery without mention of cerebral infarction Rheumatic heart failure (congestive) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Ulcer of other part of foot Other specified forms of chronic ischemic heart disease

history of present illness: this is a 44-year-old right-handed white female who presents with a history of seven to eight days with global headache and new onset of nausea with vomiting times one on the morning of admission on . she called her primary care physician and was seen and evaluated at the hospital with a workup including a head ct and magnetic resonance imaging scan positive for a 2.5-inch tumor in the left parietal region with moderate surrounding edema. the patient came to the emergency room at the at that time and was admitted overnight for further evaluation and was subsequently discharged home with 24 hours, and is now readmitted on for definitive surgical treatment of this lesion. she reports that in retrospect she has felt occasional vague weakness, and vague occasional dizziness, and "just not right" for the past three to five weeks. she also noted that it would take her longer to calculate and balance her checkbook or to do simple mathematics. she denies any visual changes or impairments to vision or hearing. she denies any weakness, numbness or paresthesias of the arms or legs. past medical history: (previous medical history includes) 1. a tubal ligation. 2. she is gravida 2, para 2 with both pregnancies completing normal spontaneous vaginal deliveries. medications on admission: she is on no current medications. allergies: reports an allergic reaction to tetanus in the past. review of systems: review of systems was unremarkable and noncontributory. social history: she is a nonsmoker with a negative alcohol history. she is a married woman with a supportive family. she works part time at a local restaurant. family history: mother had epilepsy and breast cancer. father had a history of cancer. physical examination on presentation: on physical examination she was afebrile with stable vital signs, and oxygen saturation was 99% on room air. she was a well-developed, well-nourished white female in no acute distress. the examination of the head, ears, nose, eyes and throat, heart, lungs, and abdomen were essentially unremarkable. there was no clubbing, cyanosis or edema of the extremities. the neurologic examination showed the patient to be awake, alert, and conversant, and oriented times three with speech fluent and no dysnomia or paraphrasic errors. pupils were equal, round, and reactive to light and accommodation. extraocular movements were intact. visual fields were full to confrontation. the tongue was midline. the smile was equal. the face was symmetric, and there was no drift. strength showed full 5/5 strength in all muscle groups of the bilateral upper and lower extremities. sensory examination was intact to light touch, pinprick and proprioception. the deep tendon reflexes were 2+ throughout with plantar responses downgoing bilaterally. there was no ankle clonus, and finger-to-nose test was intact without any dysmetric movements. radiology/imaging: the ct from the outside hospital and the magnetic resonance imaging done at the confirmed the presence of a 4-cm x 5-cm irregular shaped enhancing lesion with central necrosis and surrounding edema located in the medial left posterior parietal area with some lateral deviation and compression of the posterior of the ventricle. hospital course: the impression was that of a 44-year-old right-handed white female with headaches times seven to eight days, and studies positive for a lesion in the posterior and medial parietal area, and she was therefore admitted on for craniotomy and excision of this lesion. she was taken to the operating room on the morning of admission where under general endotracheal anesthesia the patient underwent a left parietal craniotomy with resection of lesion. the patient tolerated the procedure well. the tumor specimen was given to the pathologist with frozen section showing a high-grade astrocytoma. the patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition. she spent the first night in the postanesthesia care unit with postoperative check showing the patient to be neurologically stable and was subsequently discharged to the hospital floor on the first postoperative day, and subsequently to that was noted to be ambulating with minimal discomfort and minimal headache. she was taking solid food and liquids by mouth without difficulty. her intake and output was considered quite adequate. then she was subsequently discharged to home with arrangements to be followed up in the brain clinic in approximately two weeks' time. condition at discharge: condition on discharge was stable and improved. discharge diagnoses: a left parietal brain tumor. medications on discharge: medications on discharge included decadron and zantac, and she was given a prescription for percocet for relief of mild headache. discharge followup: she was given an appointment for followup in the brain clinic in early with plans for probable radiotherapy to the tumor bed. , m.d. dictated by: medquist36 Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Malignant neoplasm of brain, unspecified

allergies: no known allergies / adverse drug reactions attending: chief complaint: weakness/fever major surgical or invasive procedure: none history of present illness: 76 yo male with hx of avr, cad s/p cabg, mds- pancyopenia, non-hodgkins lymphoma, and parkinson's who was relaeased from the hospital 2 months ago for a pneumonia. he brought in from his ecf because of fever to 105 and new weakness, and sob. he says he has had a cough and sob for the last few weeks. today he was unable to get up and go to the bathroom. he denies any fevers prior to today. he denies any pains including chest and abdominal pain. in the ed a cxr showed possible rll pna versus atelectasis. his ua was neg, he got 3 sets of blood cultures. he was given vanc/zosyn/azithro in the ed for emperic coverage of a hcap, tylenol 325 after 650 earlier in the day for his fever and 4l of ivf. his ekg showed sinus tachycardia in the ed. on arrival to the micu, in rigors, not febrile at this time, has cough, no pain. review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: 1. as s/p porcine aortic valve replacement () 2. cad s/p cabg x 2 (lima to lad, svg to om ) 3. ckd 4. depression / anxiety, currently treated only with diazepam qhs. previously on effexor and benzo and seroquel (stopped in due to eps/?pd) 5. hyperlipidemia on crestor 6. hypothyrodism 7. tremor 8. gait disorder, thought by dr. to be primarily due to posterior column dysfunction 9. bph s/p turp, no longer on flomax; nocturia x hourly 10. non-hodgkin's lymphoma s/p chemo/bmt @osh was in remission until current thrombocytonia 11. osa on prior sleep study; pt refuses cpap; wife says no snoring. m-iii to m-iv airway, with extra neck soft tissues. social history: married, kids in ca (just visited, as above), lives with wife. retired from cigarette sales ~15y ago.chronic/progressive health problems as above. smoked heavily in military ~50y ago, but quit cigs and now smokes occasional cigars "do not inhale" for many years. says 1-2 beers per night, but formerly drank heavily (up to ~15 years ago when he retired). denies any h/o illicit drug use or supplements. family history: non-contributory physical exam: admission exam: vitals: t: 98.6 bp: 166/87 p: 136 r: 39 o2: 99 general: alert, rigors heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, no lad cv: tachycardic, crisp s1, s2, no rubs, gallops lungs: scattered wheezes abdomen: soft, non-tender, non-distended, bowel sounds present gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation discharge exam: pertinent results: 04:50pm wbc-6.9# rbc-3.59* hgb-10.4* hct-32.3* mcv-90# mch-29.1# mchc-32.2 rdw-22.5* 04:50pm neuts-57 bands-4 lymphs-23 monos-11 eos-0 basos-0 atyps-4* metas-0 myelos-0 blasts-1* nuc rbcs-1* 04:50pm hypochrom-1+ anisocyt-3+ poikilocy-occasional macrocyt-2+ microcyt-1+ polychrom-normal ovalocyt-occasional 04:50pm plt smr-very low plt count-31* 04:50pm pt-13.6* ptt-28.1 inr(pt)-1.3* 04:50pm calcium-8.7 phosphate-1.2*# magnesium-1.8 04:50pm ck-mb-1 ctropnt-<0.01 04:50pm ck(cpk)-71 04:50pm glucose-113* urea n-22* creat-1.4* sodium-133 potassium-4.1 chloride-100 total co2-23 anion gap-14 05:04pm lactate-0.9 06:30pm urine rbc-1 wbc-<1 bacteria-few yeast-none epi-<1 06:30pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 06:30pm urine color-yellow appear-clear sp -1.012 06:30pm urine uhold-hold 06:30pm urine hours-random cxr pa and lateral the patient is status post median sternotomy for cabg. heart remains mildly enlarged with left ventricular predominance. the patient is status post aortic valve replacement. the mediastinal contours are unchanged, with mild calcification of the aortic knob again demonstrated as well as a mildly tortuous course of the thoracic aorta. the pulmonary vascularity is not engorged. streaky opacities in the lung bases are nonspecific, possibly reflecting atelectasis though infection cannot be excluded. no pleural effusion or pneumothorax is visualized. there are no acute osseous abnormalities. impression: streaky bibasilar opacities, which could reflect atelectasis though infection cannot be completely excluded. brief hospital course: 76 yo male with hx of avr, cad s/p cabg, mds- pancyopenia, non-hodgkins lymphoma, and parkinson's who was relaeased from the hospital 2 months ago for a pneumonia who returns with a hcap and new a. fib w/ rvr. was treated in the icu and transferred to the floor to complete 10 day course of antibiotics. 1) hcap pneumonia/sepsis- pt initially sirs criteria, and presented with dry cough x2 weeks, new weakness, and his cxr was concerning for a new rll inflitate. with the pt's history of parkinson's disease, was at risk for aspiration due to dysphagia, and thus cause recurrent pneumonia. pt's fever curve improved with vancomycin, cefepime and azithromycin for a 10 day course (through ). blood cultures were negative. pt's dry cough did not improve with cough syrup, tessalon perles and nebulizer treatments and thus had an ent consult which found mild irritation of vocal cords most likely related to acid reflux or viral infection. laryngoscopy did not show vocal cord paralysis and structurally normal. cough mildly improved while on the floor, but still with significant cough at discharge. he was started on prednisone 40 mg po daily for a 4 day total course to end on . 2) new atrial fib w/ rvr in 120s likely due to stress of increasing cardic output in septic picture. other concerns included his thyroid medicine and new ischemia but tsh normal and cardiac enzymes were negative. pt was rate controlled with metoprolol 50mg tid and was successfully converted to ns rhythm. echo was done which showed lvef>55%, no thrombus. pt's chads2 score at 1. aspirin was held due to thrombocytopenia. metoprolol was discontinued given his reactive airways and wheezing. on stopping, patient tended to be borderline tachyardia with intermittent atrial fibrillation and bigeminal pacs. when his pulmonary symptoms resolve, metoprolol should be considered if his tachycardia/afib persists at rehab. 3) parkinson's disease: was continued on home pramipexole during course and was evaluated by speech and swallow for dysphagia; pt was cleared for regular solid po intake. 4) mds/non-hodgkin's lymphoma: s/p chemo and bmt, chronic thrombocytopenia. pt had no bleeding issues. patient required transfusion of 1 unit of platelets prior to picc line placement but otherwised remained above transfusion threshold without evidence of bleeding. 5) hyperlipidemia: rosuvastatin was continued throughout course. 6) bph: tamsulosin was continued throughout course. 7) depression/anxiety: stable, prn diazepam. was requiring approximately one additional dose of diazepam daily. 8) hypothyroid: continue home levothyroxine sodium 50 mcg po daily. tsh normal. 9) left ear ceurmen: stable. 10) constipation: continued lactulose, polyethylene glycol, docusate sodium 100 mg po bid, and senna 1 tab po bid. # transitional issues: - consider starting patient on metoprolol for new atrial fibrillation, was started in house, then discontinued given reactive airways. should be restarted if he continues to have tachycardia/afib once pulm symptoms resolve. - patient should continue full treatment for hcap with vancomycin 1g iv q12 and cefepime 2 g iv q12h through is picc line, both through . - picc line okay to use by nursing staff at rehab. cxr confirmed placement on and has been used here. - patient started on prednisone 40 mg po daily for reactive airways, which should continue through . - patient started on high dose ppi while in house given ent evaluation of laryngeal inflammation from possible reflux. this should be discussed with pcp and in 2 weeks. continued high dose ppi has multiple risks and these should be weighed. medications on admission: preadmission medications listed are correct and complete. information was obtained from record. 1. diazepam 5 mg po daily:prn anxiety 2. lactulose 15 ml po daily constipation 3. polyethylene glycol 17 g po daily:prn constipation 4. ondansetron 4 mg po q8h:prn nausea 5. acetaminophen 325-650 mg po q4h:prn pain/fever 6. codeine sulfate 15-30 mg po q4h cough 7. guaifenesin-dextromethorphan 15 ml po q4h:prn cough 8. benzonatate 200 mg po tid:prn cough 9. docusate sodium 100 mg po bid 10. senna 1 tab po bid 11. pramipexole *nf* 0.5 mg oral tid parkinson's 12. albuterol 0.083% neb soln 1 neb ih q4h:prn sob 13. levofloxacin 500 mg po q24h pna duration: 13 days 14. levothyroxine sodium 50 mcg po daily 15. tamsulosin 0.4 mg po hs bph 16. carbamide peroxide 6.5% 5 drop ad qhs duration: 4 days left ear at bedtime 17. rosuvastatin calcium 10 mg po daily discharge medications: 1. carbamide peroxide 6.5% 5 drop ad qhs duration: 4 days left ear at bedtime 2. acetaminophen 325-650 mg po q4h:prn pain/fever 3. albuterol 0.083% neb soln 1 neb ih q4h:prn sob 4. benzonatate 200 mg po tid:prn cough 5. codeine sulfate 15-30 mg po q4h cough 6. diazepam 5 mg po daily:prn anxiety 7. docusate sodium 100 mg po bid 8. guaifenesin-dextromethorphan 15 ml po q4h:prn cough 9. lactulose 15 ml po daily constipation 10. levothyroxine sodium 50 mcg po daily 11. ondansetron 4 mg po q8h:prn nausea 12. polyethylene glycol 17 g po daily:prn constipation 13. pramipexole *nf* 0.5 mg oral tid parkinson's 14. rosuvastatin calcium 10 mg po daily 15. senna 1 tab po bid 16. tamsulosin 0.4 mg po hs bph 17. cefepime 2 g iv q12h continue through . 18. vancomycin 1000 mg iv q 12h continue through . 19. prednisone 40 mg po daily duration: 3 days continue through . discharge disposition: extended care facility: for living discharge diagnosis: primary: health care associated pneumonia new atrial fibrillation secondary: myelodysplastic syndrome thrombocytopenia discharge condition: patient is afebrile with stable vitals. satting mid 90s on ra. he is in and out of a fib and borderline tachycardic in the 90s-100s. lung exam with inspiratory and expiratory wheezing and transmitted upper airway sounds, breathing is nonlabored. mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - with walker or aid. discharge instructions: dear mr. , you were admitted to the for symptoms concerning for pneumonia. we treated your pneumonia with antibiotics and your fevers resolved. you will need to continue taking antibiotics at the rehab facility. a picc line was placed in your left arm and it's placement was confirmed with an x-ray, so your antibiotics can be given at rehab. you were also started on steroids (prednisone) for a total of 5 days to help with your breathing. it was a pleasure taking care of you at the . followup instructions: department: cardiac services when: thursday at 3:20 pm with: , md building: sc clinical ctr campus: east best parking: garage we are working on a follow up appt with dr. at . you will be called at home/rehab with the appointment. if you have not heard or have questions, please call (. department: dermatology when: monday at 9:30 am with: building: sc clinical ctr campus: east best parking: garage department: cardiac services when: thursday at 2:20 pm with: , md building: sc clinical ctr campus: east best parking: garage department: when: wednesday at 9:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage md Procedure: Laryngoscopy and other tracheoscopy Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Obstructive sleep apnea (adult)(pediatric) Tobacco use disorder Unspecified septicemia Unspecified acquired hypothyroidism Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Sepsis Bone marrow replaced by transplant Myelodysplastic syndrome, unspecified Dysthymic disorder Other and unspecified hyperlipidemia Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Nocturia Paralysis agitans Personal history of other lymphatic and hematopoietic neoplasms Heart valve replaced by other means Chronic kidney disease, Stage III (moderate)

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea on exertion major surgical or invasive procedure: cardiac catheterization aortic valve replacement (29mm ce pericardial valve), ascending aorta replacement (28mm gelweave graft), coronary artery bypass graft x 2 (lima to lad, svg to om) history of present illness: 71 y/o male who has been followed by cardiologist for years for asymptomatic aortic stenosis. stress test to determine his functional capacity, d/t cardiologist concerned if his parkinson's could be masking symptoms of aortic stenosis. no ekg changes, but after 46 seconds his bp dropped from 110/70 to 98/70 and the test was stopped. echo did reveal severe aortic stenosis with a bicuspid valve. in terms of symptoms he does feel fatigued with dyspnea on exertion occuring after block. referred for cardiac cath to further evaluate. past medical history: aortic stenosis, parkinson's disease, non-hodgkin's lymphoma s/p chemo and stem cell transplant (in remission), anxiety, gastroesophageal reflux disease, benign prostatic hypertrophy s/p turp social history: married, does not work. denies etoh or tobacco use. family history: non-contributory physical exam: vs: 92 16 104/71 6'2" 180# gen: nad skin: unremarkable heent: eomi, peerl, nc/at neck: supple, from, -jvd, -bruits chest: ctab -w/r/r heart: rrr 2/6 sem abd: soft, nt/nd, +bs ext: warm, well-perfused, -edema, -varicosities neuro: a&o x 3, mae discharge neuro alert, oriented x3, mae r=l strength no tremors pulm cta decreased at bases bilat cardiac rrr no m/r/g abd soft, nt, nd +bs sternal inc midline healing no drainage/erythema steris sternum stable leg inc left evh steris no erythema/drainage ext warm +1 edema, pulses palpable pertinent results: cnis: on the right, peak velocities are 65, 60, and 53 cm/sec in the ica, cca, and eca respectively. this is consistent with no stenosis. on the left, peak velocities are 50, 71, and 40 cm/sec in the ica, cca, and eca respectively. this is consistent with no stenosis. cardiac cath: 1. selective coronary angiography of this right dominant system demonstrated a two vessel cad. the lmca was patent. the lad had a 70% proximal and a 90% mid vessel stenoses. the lcx was patent but there was an 80% stenosis in the om1. the rca had mild nonflow limiting disease. 2. resting hemodynamics revealed normal right and left sided filling pressures with an rvedp of 8 mm hg and a mean pcwp of 10 mm hg. the cardiac index was preserved at 2.33 l/min/m2. 3. left ventriculography was deferred. 4. there was a severe aortic stenosis with a peak to peak gradient of 45.89 mm hg and a calculated of 0.62 cm2. 5. peripheral angiography demonstrated no right iliac disease. 6. short run of svt during the case that terminated spontaneously. echo: pre-bypass: 1. the left atrium is normal in size. no spontaneous echo contrast is seen in the left atrial appendage. no atrial septal defect is seen by 2d or color doppler. 2. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal (lvef>55%). 3. right ventricular chamber size and free wall motion are normal. 4. the aortic root is mildly dilated at the sinus level. the sino-tubular junction is preserved. the ascending aorta is moderately dilated. the aortic arch is mildly dilated. there are complex (>4mm) atheroma in the aortic arch. the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. 5. the aortic valve is bicuspid. the aortic valve leaflets are severely thickened/deformed and extremely calcified. there is severe aortic valve stenosis (area <0.8cm2). trace aortic regurgitation is seen. 6. the mitral valve leaflets are mildly thickened. trace to mild (1+)mitral regurgitation is seen. post-bypass: pt is being atrially paced and is on an infusion of phenylephrine 1. av bioprosthesis well seated in good position. no significant perivalvular gradient. trace central valvular ai is noted, no perivalvular leak seen. aortic graft noted in ascending aorta. 2. no wall motion abn noted, maintained lv and rv function 3. aortic contours unchanged 4. remaining exam unchanged ue u/s: grayscale and doppler images of the left ij, subclavian, axillary, brachial, basilic, and cephalic veins were performed. normal flow, augmentation, compressibility, and waveforms are demonstrated. intraluminal thrombus is not identified. 07:40am blood wbc-5.4# rbc-4.23* hgb-12.8* hct-35.8* mcv-85 mch-30.2 mchc-35.6* rdw-15.0 plt ct-133* 03:34pm blood wbc-6.4 rbc-2.24* hgb-6.8* hct-19.9* mcv-89 mch-30.2 mchc-34.0 rdw-14.8 plt ct-172# 05:45am blood wbc-6.2 rbc-4.08* hgb-12.0* hct-35.6* mcv-87 mch-29.5 mchc-33.8 rdw-15.0 plt ct-133* 07:40am blood pt-12.7 inr(pt)-1.1 03:08am blood pt-12.8 ptt-32.0 inr(pt)-1.1 07:40am blood glucose-104 urean-27* creat-1.2 na-139 k-4.0 cl-105 hco3-23 angap-15 05:45am blood glucose-90 urean-28* creat-1.2 na-136 k-4.0 cl-101 hco3-28 angap-11 brief hospital course: as mentioned in the hpi, mr. a cardiac cath on . cardiac cath revealed severe aortic stenosis along with 2 vessel coronary artery disease and a dilated ascending aorta. he was then referred for surgical evaluation. all pre-operative testing and was brought to the operating room on . he an aortic valve replacement, asc. aorta replacement, and coronary artery bypass graft x 2. please see operative report for surgical details. he did have significant amount of post-op bleeding that required multiple blood products. following surgery he was transferred to the csru for invasive monitoring in stable condition. within 24 hours he was weaned from sedation awoke neurologically intact and extubated. on post-op day one there appeared to be left arm edema with bluish discoloration and left-sided neck bulge. all left arm peripheral iv's and arterial line were removed, vascular surgery was consulted and an upper extremity ultrasound was performed. ultrasound was negative for dvt. his chest tubes and epicardial pacing wires were removed per protocol. diuretics and beta-blockers were initiated and he was gently diuresed towards his pre-op weight. on post-op day two he was transferred to the telemetry floor. he continued to improve post-operatively and worked with pt for strength and mobility. left arm swelling and neck bulge has resolved. clinically he appeared to be doing well but needed additional pt and was discharged to rehab facility on post-op day seven. medications on admission: primidone 150mg qhs, mirapex 0.5mg tid, diazepam 4mg , zyprexa 5mg qhs, omeprazole 20mg prn discharge disposition: extended care facility: nursing home - discharge diagnosis: aortic stenosis, asc. aortic aneurysm, coronary artery disease s/p aortic valve replacement, asc. aorta replacement, coronary artery bypass graft x 2 pmh: parkinson's disease, non-hodgkin's lymphoma s/p chemo and stem cell transplant (in remission), anxiety, gastroesophageal reflux disease, benign prostatic hypertrophy s/p turp discharge condition: good discharge instructions: shower, no baths or swimming monitor wounds for infection - redness, drainage, or increased pain report any fever greater than 101 report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week no creams, lotions, powders, or ointments to incisions no driving for approximately one month no lifting more than 10 pounds for 10 weeks please call with any questions or concerns p instructions: dr. in 4 weeks dr. after discharge from rehab dr. after discharge from rehab please call to schedule all appointments Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization (Aorto)coronary bypass of one coronary artery Reopening of recent thoracotomy site Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Thoracic aneurysm without mention of rupture Aortic valve disorders Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Paralysis agitans Other malignant lymphomas, unspecified site, extranodal and solid organ sites Peripheral stem cells replaced by transplant Hemorrhage complicating a procedure Anxiety state, unspecified Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure

allergies: latex attending: chief complaint: dyspnea on exerion and intermittent palpitations major surgical or invasive procedure: mitral valve repair with 30mm ring and closure of asd with pericardial patch history of present illness: this 45 year old patient with a known heart murmur as a child recently developed shortness of breath and palpitation and was investigated and was found to have primum atrial septal defect with a cleft mitral valve leaflet with a mild mitral regurgitation and mild tricuspid regurgitation with right ventricular dilation. in view of this finding, she was electively admitted for surgical repair. past medical history: h/o r breast cancer s/p lumpectomy and xrt with breast reconstruction left breast reduction social history: denies tobacco or etoh use. family history: non-contributory physical exam: vs: 135/85 70 98%ra general: wd/wn female in nad skin: warm, pink, well-perfused heent: eomi, perrl, nc/at neck: supple, from, -jvd or thyromegaly lungs: ctab -w/r/r heart: rrr +s1s2 w/ 2/6 sem abd: soft, nt/nd, +bs ext: warm, -c/c/e, 2+ pulses pertinent results: echo : the left atrium is markedly dilated. the right atrium is moderately dilated. a left-to-right shunt across the interatrial septum is seen at rest. a primum atrial septal defect is present. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is moderately dilated. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. post cpb: a prosthetic patch is visualized on the ias, at the position of the primum defect with no residual shunt on cfd. an annuloplasty ring is seen in the mitral annular position, which is well seated and mecahnically stable. peak gradient across the mitral valve = 16 mm. hg. mean gradient 7 mm hg. mitral valve area by continuity equation was consistently obtained to be 2-2.4 sq.cms. mitral valve area by planimetry of the mitral leaflets was 3 sq. cms. preserved bivertricular systolic function. cxr : 1. decreasing right apical pneumothorax. 2. worsening bibasilar opacities, likely due to atelectasis, although differential includes aspiration and infectious pneumonia. 03:23pm blood wbc-13.0*# rbc-2.73*# hgb-8.0*# hct-23.3*# mcv-85 mch-29.3 mchc-34.4 rdw-13.2 plt ct-191 07:25am blood wbc-7.3 rbc-2.44* hgb-7.0* hct-20.7* mcv-85 mch-28.9 mchc-34.0 rdw-13.9 plt ct-156 04:45am blood hct-19.3* 05:20pm blood pt-14.2* ptt-25.1 inr(pt)-1.3* 03:45am blood pt-13.8* ptt-25.5 inr(pt)-1.2* 05:20pm blood urean-9 creat-0.6 cl-110* hco3-21* 07:25am blood glucose-112* urean-12 creat-0.7 na-135 k-3.8 cl-103 hco3-26 angap-10 04:45am blood urean-8 creat-0.6 na-135 k-4.2 brief hospital course: as mentioned in the hpi, ms. was electively admitted for surgery following out-patient pre-operative work-up. she was brought to the operating room on where she underwent a repair of her mitral valve and closure of a asd y dr. . please see operative report for surgical details. she was then transferred to the csru on minimal bp support for invasive monitoring. later on op day she was weaned from sedation, awoke neurologically intact and extubated. on post-op day tow her chest tubes were removed and she was weaned off neo-synephrine. she was then transferred to the cardiac surgery step down floor. both beta blockers and diuretics were started and she was gently diuresed towards her pre-operative weight. both vitamin c and iron were started secondary to patient being anemic (although asymptomatic so wasn't transfused). epicardial pacing wires were removed on post-op day three. physical therapy followed patient during post-op course for strength and mobility. she continued to improved post-operative with stable labs, vital signs and physical exam on day of discharge. she was discharged home on post-op day 4 with vna services and the appropriated follow-up appointments. medications on admission: aspirin, lisinopril discharge medications: 1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 2. furosemide 20 mg tablet sig: one (1) tablet po every twelve (12) hours for 10 days. disp:*20 tablet(s)* refills:*0* 3. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 10 days. disp:*40 capsule, sustained release(s)* refills:*0* 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 5. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. 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* 7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 8. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: capitol vna discharge diagnosis: mitral regurgitation/atrial septal defect (asd) s/p mitral valve repair and closure of asd repair h/o r breast cancer s/p lumpectomy and xrt with breast reconstruction left breast reduction discharge condition: good discharge instructions: shower, wash incisions with mild soap and water and pat dry. no lotions, creams or powders to incisions. call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. no lifting more than 10 pounds for 10 weeks. no driving until follow up with surgeon. followup instructions: dr. in four weeks dr. in two weeks dr. in two weeks Procedure: Extracorporeal circulation auxiliary to open heart surgery Other and unspecified repair of atrial septal defect Open heart valvuloplasty of mitral valve without replacement Diagnoses: Mitral valve disorders Ostium primum defect

history of present illness: patient is a 23-year-old gentleman who was in his usual state of health when in the early on the day of admission was reportedly stabbed in the chest. it is unknown the actual sequence of events. it is reported that the patient had been stabbed, entered his vehicle, began to drive and subsequently crashed into some parked cars. patient was taken from his car and brought to the with initial heart rate in the 90s, blood pressure in the 90s and saturation of 98%. the patient, upon entering the trauma room, had a heart rate of 78, blood pressure of 98/66, respiratory rate of 24 and saturating at 100% on room air. the patient underwent a dpo which was negative and vats exam which showed a pericardial effusion. he was resuscitated with four liters of lactated ringers and a unit of blood in the trauma room. the patient was then moved to the operating room for emergent exploration of the wound. past medical history: none. past surgical history: none. medications on admission: none. allergies: none. social history: patient is an information technology worker at a computer firm at . physical examination: head and neck are within normal limits. chest had bilateral breath sounds. abdomen soft, nontender, nondistended. he had positive extremity pulses. patient had a 3 cm stab wound of the fifth intercostal space on the left. laboratory: on admission white count was 9.8, hematocrit 36.6, platelets 161,000. pt was 14.5, ptt 28.5, inr 1.5. urinalysis was negative. sodium 145, potassium 3.6, chloride 112, bicarbonate 19, bun 10, creatinine 0.9. glucose 151. amylase 54, calcium 7.4, magnesium 1.5, phosphorus 2.4. etoh was 245. other tox screen was negative. arterial blood gas drawn once he was intubated initially was 7.33, 37, 205, 20. chest x-ray showed an enlarged cardiac silhouette and slight widening of mediastinum. a subsequent head ct scan was negative. subsequent c spine ct scan was negative for injury. ct scan of the abdomen was also negative. ap pelvis was negative. hospital course: upon being transferred to the operating room for emergent exploration, the patient lost blood pressure and in the operating room underwent an emergent thoracotomy and exploration. injury to the right ventricle was found and repaired. the patient was resuscitated successfully and was transferred to the intensive care unit in stable conditions on no pressors. patient's postoperative course is as follows. in the intensive care unit the patient was weaned and extubated on postoperative day #1 without any incident. the patient had a postoperative echo which was within normal limits. postoperative day #2, the patient was transferred to the floor for the remainder of his recovery. the patient had a right chest tube discontinued and his diet was advanced. he was evaluated by physical therapy and began to ambulate. on postoperative day #3 the patient had a temperature spike to 102.7 f. blood cultures were sent which have only been only significant for one bottle out of four with staph coagulase negative. he was started on vancomycin. he subsequently defervesced. his white count went to a high of 10.6 and more recently is 7.7. the left chest tubes were discontinued without incident. the wound was examined. it has been clean, dry and intact. the patient had a second echo was for evaluation of the valves which showed no vegetations. on postoperative #5 his antibiotics were discontinued. the patient was ambulating, tolerating diet and is now stable and ready to go home. discharge diagnoses: 1. stab wound to the right ventricle status post emergent thoracotomy and surgical repair. discharge medications: 1. percocet one to two p.o. q. four hours p.r.n. 2. colace 100 mg p.o. b.i.d. condition on discharge: stable. discharge instructions: patient will follow up in trauma clinic in one week to have staples removed. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Diagnoses: Unspecified pleural effusion Laceration of heart with penetration of heart chambers with open wound into thorax Unspecified disease of pericardium Assault by cutting and piercing instrument

discharge condition: expired , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Insertion of endotracheal tube Biopsy of bone marrow Arterial catheterization Endoscopic control of gastric or duodenal bleeding Closed biopsy of skin and subcutaneous tissue Diagnoses: Acute gastric ulcer with hemorrhage, without mention of obstruction Hematoma complicating a procedure Sarcoidosis Reticulosarcoma, lymph nodes of multiple sites Regional enteritis of unspecified site Acute respiratory failure Arteriovenous fistula, acquired Defibrination syndrome

history of present illness: ms. is an 81-year-old female with a complicated past medical history who presented with several months of fevers as well as rash of approximately three weeks duration. the patient's past medical history dates back to , at which time she had a medical workup for abdominal pain, weight loss, and anorexia. she had a cat scan done on that showed significant abdominal adenopathy, extensive adenopathy displacing the bowel in the periaortic, aorta cava, and mesenteric area. she had a bone marrow biopsy done on that showed no evidence of malignancy. in , the patient then had a retroperitoneal node biopsy done via a mini-laparotomy procedure which showed granulomatous lymphadenitis with noncaseating granulomas. this was acid-fast bacillus negative as well as gms negative and pas negative. at this time, the patient obtained the diagnosis of sarcoidosis. also in , the patient had the onset of low-grade temperatures as well as some early satiety, and she continued to have abdominal pain. she had an abnormal xylose test done in . at this point, again, the working diagnosis on this patient was sarcoidosis. her blood was tested and was negative for histoplasmosis, coccidioidomycosis, blastomycosis. as well, she had a purified protein derivative placed which was negative. no steroids were started at this time. approximately one year ago, in , the patient was diagnosed with crohn's disease. it is my understanding that this was a clinical diagnosis, as there was no documented colonoscopy. the patient was followed by dr. as well as by a gastroenterologist at an outside facility. the medications used to treat her crohn's disease included prednisone, 6-mp, methotrexate, as well as remicade. her cycles of remicade were in , , and . it is not entirely clear to me at this time what the sequence of medical therapy was for her crohn's disease. she also had approximately a 6-month course of high-dose steroids for the crohn's disease with a taper prior to starting her first remicade cycle. the patient then had an admission to the from to ; at which time she was admitted for diarrhea, fever, chills, sweats, as well as bloating. she was thought at that time to have a crohn's flare (plus or minus gastroenteritis). she was treated with ciprofloxacin, flagyl, and stress-dose steroids. at that time, she improved and her fevers stopped. it should be mentioned at this time that the patient had intermittent fevers occurring weekly and spiking up to 103 for approximately four to five months prior to her admission to the hospital in . cultures were done during her admission, and they were negative. after she finished a 10-day course of antibiotics, her fevers recurred. on , she had a remicade infusion and felt well for a few weeks following that; and then, on , she was seen by dr. in the clinic. at that time she looked tired and exhausted, although her crohn's disease was quiescent. she then experienced recurrent fevers in late and was treated with ciprofloxacin and flagyl from to . at that time, her fevers remitted and she felt somewhat better. on , the patient's fevers returned, and she was spiking to 103 at home, continued to have night sweats (which was essentially her baseline with these fevers). she also has episodes where she becomes somewhat lethargic and nearly unresponsive during the hour or so before she is going to have a temperature spike. she also experiences rigors. all of this history is obtained from family members as well as from the patient herself. review of systems: review of systems was also positive for weight loss and lethargy (as mentioned) during the temperature spikes and drenching night sweats. otherwise, negative for headache and visual changes. no sinus congestion. no dysphagia. no cough. no shortness of breath. no nausea or vomiting. no abdominal pain. no joint pain. no other localizing symptoms to correlate with these fevers. approximately three weeks prior to admission, the patient mentioned that she noted a nodule in her right axilla. over time, the patient developed significant/enumerable nodules and papules covering her sternum, her breasts, her abdomen, her upper extremities, her upper back, and the back of her neck, as well as her scalp. these nodules spared her palms, and spared her left extremities, and also spared her face. she was seen by a dermatologist at an outside facility, and a biopsy was done. when she was admitted to the hospital on , she was carrying the presumptive diagnosis of a cutaneous lymphoproliferative disorder, but that had not been further characterized when she was admitted to the hospital. the patient was scheduled to have an appointment with dr. of hematology/oncology on . however, she came to the emergency department (brought by her husband) in the setting of having a temperature spike and her usual rigors, sweats, and lethargy. she was noted to have what the husband felt was mild respiratory distress with deep inspiration, and what he characterized as respiratory difficulty. in the emergency department the patient was treated with ampicillin, levofloxacin, and flagyl as well as intravenous fluids. she was admitted for further workup. past medical history: her past medical history has been detailed above. also significant for uterine suspension in , as well as total abdominal hysterectomy/bilateral salpingo-oophorectomy in . she also does carry the diagnosis of crohn's disease and sarcoidosis (as mentioned). medications on admission: her medications on admission to the hospital included prednisone 15 mg p.o. q.d., 6-mp 75 mg p.o. q.d., multivitamin p.o. q.d., premarin, fosamax, omega -3 fatty acids. she is status post remicade cycle on . she takes folic acid and an iron supplement as well. allergies: the patient has no known drug allergies; however, it is noted in her history that in the past she has been treated with pentasa and methotrexate without good effect on her crohn's disease. it is not believed that she actually has a frank allergy to pentasa or to methotrexate. family history: family history is significant for diabetes mellitus. mother died of stomach cancer and a pulmonary embolism, and a daughter who has survived breast cancer. social history: no history of tobacco. occasional alcohol one to two times per week. no history of intravenous drug use. she works as an artist. she was born in . her first husband was in the military, and she has lived in , , ., as well as . she is currently married to her second husband. family is very supportive of her and has been giving her tremendous support during the past year and a half when she has been suffering from these recurrent fevers and an ongoing workup for them. physical examination on presentation: on physical examination her temperature maximum was 104.2, in the emergency department temperature was 101. on admission heart rate was 102, blood pressure of 122/59, oxygen saturation of 100% on room air, respiratory rate of 16. examination of her skin revealed multiple welts, circumscribed, round, nontender, firm, nonulcerative papular lesions/nodules ranging from 2 mm to 5 mm over her arms, chest, back, abdomen, breast, scalp, and neck; sparing her face, palms lower legs and feet. head, eyes, ears, nose, and throat examination was normocephalic and atraumatic. pupils were equal, round, and reactive to light. extraocular movements were intact. she had a left cataract. there was no oropharyngeal erythema. no exudate. no oral lesions. the appearance of her face was somewhat cushingoid. the neck was supple. there was no lymphadenopathy. lungs were clear to auscultation bilaterally. cardiovascular examination revealed carotids with normal volume with brisk upstroke, no bruits. jugular venous pulse at 4 cm. a regular rate and rhythm. normal first heart sound and second heart sound. no third heart sound. no fourth heart sound. a holosystolic murmur. the abdomen was soft, nontender, and nondistended, normal active bowel sounds. extremities were without cyanosis, clubbing or edema. pertinent laboratory data on presentation: initial laboratory data included a white blood cell count of 11.7 (with 55% polys, 15% bands, 11% lymphocytes, 9% monocytes, 1 metamyelocytes, 1 myelocyte, 1 promyelocyte. hematocrit of 37.9, platelet count of 402, mean cell volume of 81. urinalysis with a specific gravity of 1.035, 0 to 2 red blood cells, 6 to 10 white blood cells, few bacteria. her chem-7 was sodium of 132, potassium of 6.6 (hemolyzed, repeated at 5.7), chloride of 97, bicarbonate of 22, blood urea nitrogen of 23, creatinine of 0.8, glucose of 103. alt of 33, ast of 124, alkaline phosphatase of 184, total bilirubin of 0.5. inr of 1.7. radiology/imaging: electrocardiogram with sinus tachycardia at 106, flat t waves in avl and iii. ct scan showed bilateral atelectasis at the lung bases, small stone in the gallbladder, as well as perihepatic ascites, and a small amount of pelvic ascites. hospital course: in summary, then, ms. is an 81-year-old female with a history of sarcoid and crohn's disease who has had recurrent temperature spikes times approximately six months as well as an approximate year and a half history of low-grade fevers prior to these temperature spikes. she also presents with a progressive skin eruption consisting of papules and nodules over the past three weeks. she is admitted with fever, dehydration, and a further evaluation of this rash. the hospital course while she was on the medicine service is as follows: the patient had a consultation by hematology/oncology on the day following admission, at which time a bone marrow biopsy was done, and the slide from the outside facility was read of her cutaneous lesions. she was found to have cd30 positive and cd68 positive anaplastic large cell lymphoma. subsequent studies of her bone marrow and her peripheral blood showed that she had large cell anaplastic lymphoma in the peripheral blood as well as in the bone marrow. additional biopsies of the skin were done in the clinic. the patient also had a gastrointestinal consultation for further evaluation of her question of crohn's disease. in terms of management of that, however, when the patient presented during this hospital admission, her crohn's disease did not seem to be an active issue, as she was not complaining of any diarrhea or abdominal pain. the patient was doing well on and ; however, on , her hospital course took a much different course. it was noted that her platelet count was 360 on and dropped to 169 on . following that through, from the to the , she continued to have a rapid decline in her platelets; such that, on , her platelets were 18. similarly, her inr continued to climb. her fibrinogen continued to fall, and the patient appeared to be flora dic. she had a lactate level drawn which was 15.5 (consistent with a metabolic acidosis). her bicarbonate fell to a low of 7 on . she was subsequently started on bicarbonate. the patient had a hematocrit drop from 39 to 29, and she was transfused with 2 units of packed red blood cells. the patient had a head ct done to further evaluation the lethargy and dramatic change in her mental status in her peri-febrile states. her head ct was negative for any bleed, any evidence of a regional infarction, or any mass lesions. she was transferred to the intensive care unit for approximately a 12-hour period of time for further management of her dic; however, she was then returned to the floor because it was the feeling that the care she was getting on the floor was not significantly different from that which would be done in the intensive care unit. at the time the patient was transferred from the medicine service to the oncology service, she was in flora dic. she had received bicarbonate; and at the time of transfer, her bicarbonate was back within the normal range. her platelets, inr, and fibrinogen continued to be followed daily. prior to transfer to the oncology team she was started on methotrexate p.o. she received three doses of that as well as aggressive hydration. she was also started on allopurinol and folic acid. it was felt that the patient's dic as well as metabolic acidosis was perhaps due to tumor burden versus tumor lysis. the question of tumor lysis seemed less likely given that the patient started to decompensate prior to receiving the methotrexate. a discussion was had with the family on multiple occasions, and ultimately the family decided that the patient's code status would do not resuscitate/do not intubate; however, they chose a course of therapy that would include oral methotrexate. they were unwilling to make the patient comfort measures only; and, similarly, they were unwilling to pursue a more aggressive chemotherapy regimen such as chop with methotrexate. the patient was able to participate in all of these discussions regarding her code status and regarding her treatment of her large cell anaplastic lymphoma. the remainder of her hospital course, while she is on the oncology service, will be dictated in a subsequent discharge summary. she had not been , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Spinal tap Incision of lung Insertion of endotracheal tube Biopsy of bone marrow Arterial catheterization Endoscopic control of gastric or duodenal bleeding Closed biopsy of skin and subcutaneous tissue Diagnoses: Acute gastric ulcer with hemorrhage, without mention of obstruction Hematoma complicating a procedure Sarcoidosis Reticulosarcoma, lymph nodes of multiple sites Regional enteritis of unspecified site Acute respiratory failure Arteriovenous fistula, acquired Defibrination syndrome

history of present illness: is a 775-gram product of a 26-week gestation born to a 30-year-old g1/p0 (to 1) woman whose pregnancy was notable for an admission to with cervical shortening on . she was treated with bed rest and betamethasone. mother's history is notable for insulin-dependent diabetes and a seizure disorder (for which she is being treated with trileptal). antibiotics were begun this afternoon. there was no fever or other sepsis risk factors noted. maternal prenatal screens: gbs unknown, o positive, antibody negative, hepatitis b surface antigen negative, rpr nonreactive, rubella immune. rupture of membranes occurred on the day of delivery. labor progressed steadily leading to spontaneous vaginal delivery. the baby required intubation for respiratory distress in the delivery room. apgar's were 7 at one minute and 9 at five minutes. the infant was brought to the nicu after visiting with the family. physical examination on admission: birth weight was 775 grams. she is patent nondysmorphic infant with a foul smell noted. skin with bruising noted about the trunk. heent exam was within normal limits. cardiovascular exam revealed s1 and s2 without murmur. lungs revealed coarse breath sounds bilaterally. the abdomen was benign. neurologic exam was nonfocal. tone was slightly decreased throughout. the patient was moving all 4 extremities. hips were normal. anus was patent. the spine was intact. summary of hospital course by system: 1. respiratory: the patient was intubated in the delivery room. received 2 doses of surfactant and is currently in simv at settings of 16/5 at a rate of 18. fio2 is room air. 2. cardiovascular: the patient has had no murmur. she has received 2 normal saline boluses for hypotension. blood pressure currently is within normal limits. 3. fluids, electrolytes and nutrition: the patient was initially on enteral feedings at 100 cc/kg/day. a uvc and uac were placed. electrolytes yesterday evening revealed a slightly high sodium, and therefore fluids were increased to 120 cc/kg/day. 4. gastrointestinal: the patient was started on phototherapy for an 8-hour bilirubin level of 3.5/4/0.2. 5. infectious disease: the patient was started on ampicillin and gentamicin. blood culture and cbc were obtained. due to the thick green and yellow secretions that were noted as well as foul smelling fluids, the decision was made to treat with 7 days of antibiotics. condition on discharge: fair. name of primary care pediatrician: unknown. care recommendations: 1. feedings: the patient is currently n.p.o. 2. medications: the patient is currently on ampicillin and gentamicin. 3. state newborn screen status: has not been sent. 4. immunizations: the patient has not received any immunizations. discharge diagnoses: 1. respiratory distress syndrome. 2. hypotension - resolved. 3. presumed sepsis. 4. hyperbilirubinemia. 5. prematurity at 26 and 1/7 weeks. , Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Non-invasive mechanical ventilation Other phototherapy Transfusion of packed cells Other surgical occlusion of vessels, thoracic vessels Diagnoses: Single liveborn, born in hospital, delivered without mention of cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Neonatal bradycardia Patent ductus arteriosus Anemia of prematurity Retrolental fibroplasia Septicemia [sepsis] of newborn 25-26 completed weeks of gestation Other disturbances of straight-chain amino-acid metabolism

history of present illness: remains the same as previously dictated by dr. on . physical examination on admission: remains the same as previously dictated by dr. on . interim summary of hospital course by system during this period: 1. respiratory: she was weaned from the ventilator and extubated to cpap on day of life 26. she had been loaded with caffeine prior to extubation and currently is on cpap +5 at 20% to 30% oxygen. she had upwards of 3 spells which usually self resolved in any 24-hour period. her caffeine was discontinued on the secondary to tachycardia. 1. cardiovascular: she was treated during the first week of her life with 1 course of betamethasone, and on day of life 8 had an echocardiogram that revealed a tiny pda, and she was without murmur at that time. she was stable until day of life 16 when a loud murmur was noted, and an echocardiogram revealed a moderate pda with continuous left-to-right shunting. arrangements were made, and she was transported over to where she had a pda ligation on the . she did well both before and after this procedure with no inotropic support needed. she has been cardiovascularly stable with normal blood pressures and perfusion since surgery. 1. fluids, electrolytes, and nutrition: just prior to her pda ligation she had reached full feedings. she was made n.p.o. around the time of her surgery, and feedings were reinitiated on day of life 22; which was postoperative day 4. her feedings were slowly advanced, and she reached full enteral volume by postoperative day 7. she is currently on similac special care 30 calories; plus promod, vitamin e, and iron. her most recent weight is 980 grams. 1. gi: she was initially on phototherapy, but this was discontinued on day of life 7 for a bilirubin of 1.9. she was restarted when her bilirubin went up to 3.2 on day of life 9. it peaked at 4.1 on day of life 11, and it was discontinued when it went down to 2.5. her rebound bilirubin on day of life 16 was 2.3. 1. hematology: she was transfused with 20 cc/kg of packed red blood cells on day of life 12 for a hematocrit that was 26%. she was transfused another 20 cc/kg on day of life 20 for a hematocrit of 31.6%. her most recent hematocrit is 42% from the . she is on iron. 1. infectious disease: she initially completed a 7-day course of vancomycin and gentamicin. prior to her antibiotics being discontinued, she had a lumbar puncture performed that had 42 red blood cells and 2 white blood cells. she received 3 doses of kefzol perioperatively around the time of her pda ligation. she has had no other infectious disease issues throughout this interim summary. 1. neurology: she had a normal head ultrasound on day of life 5, on day of life 14, and also on day of life 30. she has her first eye exam scheduled for the . she has not yet had a urine screening, nor has she received a hepatitis b vaccination. discharge diagnoses: prematurity at 26 weeks, respiratory distress syndrome, presumed sepsis (resolved), hyperbilirubinemia, patent ductus arteriosus, status post indomethacin 1 course patent ductus arteriosus, status post ligation surgically, anemia of prematurity requiring packed red blood cell transfusion x 2. , Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Non-invasive mechanical ventilation Other phototherapy Transfusion of packed cells Other surgical occlusion of vessels, thoracic vessels Diagnoses: Single liveborn, born in hospital, delivered without mention of cesarean section Extreme immaturity, 750-999 grams Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Primary apnea of newborn Neonatal bradycardia Patent ductus arteriosus Anemia of prematurity Retrolental fibroplasia Septicemia [sepsis] of newborn 25-26 completed weeks of gestation Other disturbances of straight-chain amino-acid metabolism

allergies: zosyn attending: chief complaint: weakness and shortness of breath major surgical or invasive procedure: endotracheal intubation and extubation arterial line placement placed on assist controlled ventilation history of present illness: 74 yo m with history of bph, htn, s/p recent cervical laminectomy fusion for cervical stenosis who presented to the ed from rehabilitation facility when he was noted to be febrile to 102.2, tachycardic and diaphoretic on routine vital check. . the patient was discharged from orthopedic service to rehab on . he was discharged in cervical collar and on ciprofloxacin for treatment of uti. per family, the patient was feeling well until 3 days prior to admission, when he complained of trouble sleeping at night. the next day he started feeling lightheaded. he has been feeling weak and was complaining of sob for several days. they also report that he has not been able to eat due to shortness of breath. family reports minimal po intake. per family, he also has been more listless over the last several days. per nursing home notes, the patient has not had adequate pain relief despite percocet standing q6 hrs and prn q 4hrs. per family, the patient's upper extremity weakness initially improved following the surgery, but lately he has not been able to lift his arms off the bed to wave. . in the ed, vs t 98.7 (then spiked to 101.6), hr 78, bp 160/96, 97% ra. cxr showed rll and rml opacities interpreted as pna vs. atelectasis. the pateint received metronidazole 500mg iv, levofloxacin 500mg iv, acetaminophen (liquid) 650mg, morphine 2mg iv, lorazepam 2mg iv, metoprolol 5mg iv x 2, vancomycin 1000 mg iv once, zosyn 4.5 mg iv once. shortly after receiving morphine and ativan, he was noted to be lethargic. abg was checked and was 7.33/85/100 on 2l nc (previous abg 7.41/pco2 39/po2 49 in ). he was placed on bipap 15/5 fio2 0.5 in the ed for hypercapnea. narcan was not given. . while in the ed, the patient was also evaluated by orthopedics. the wound was examined and cleared. orthopedics recommended c spine films. currently, he denies any chest pain and is asking for a sleep medication. past medical history: 1. spinal stenosis s/p cervical laminectomy c3,4,5 and fusion on by dr. 2. neurogenic bladder 3. bph 4. htn social history: no tobacco, no etoh. for approximately a month prior to his surgery , he was bed bound. prior to that, he was getting around in a wheelchair secondary to lower back pain. he lives with his wife and his son. is unable to perform any of his adls, his son does these for him. his is a former car mechanic. family history: non-contributory physical exam: upon presentation to : vs: af; hr 115; bp 138/75; 99% on 2l nc general: thin chronically ill appearing elderly man lying bed, breathing using accessory muscles neck: hard cervical collar in place heent: nc, at, perrl, no scleral icterus, op clear cv: regular, nls1/s2 no m/r/g pulm: decreased breath sounds on right abd: soft, nt, nd +bs, no rebound or guarding extr: no c/c/e; hands and feet cool to touch; dp and radial pulses are 2+ bilaterally neuro: eom intact, bilateral 4/5 weakness in upper extremities; able to move hands/fingers, but unable to lift up arms off the bed; babinski equivocal pertinent results: upon presentation: 11:00am glucose-77 urea n-13 creat-0.2* sodium-133 potassium-4.6 chloride-86* total co2-45* anion gap-7* 11:00am wbc-10.6# rbc-3.80* hgb-12.7* hct-37.3* mcv-98 mch-33.5* mchc-34.1 rdw-15.4 11:00am plt count-401# 02:01pm lactate-2.3* 03:47pm type-art po2-100 pco2-85* ph-7.33* total co2-47* base xs-14 . : mri c-spine: postsurgical changes of c3-c5 decompressive laminectomies without evidence for recurrent spinal stenosis, abnormal fluid collection or pathological enhancement. however, assessment of hemorrhage is limited. . : emg abnormal study. the electrophysiologic findings are most consistent with a generalized, severe, chronic and ongoing disorder of motor neurons or their axons, affecting the cervical, lumbar, and thoracic regions; however, severe, chronic and ongoing cervical, thoracic, and lumbosacral polyradiculopathies could also give rise to these electrophysiologic findings. there is no evidence for a generalized polyneuropathy, for a generalized myopathy, or for a pre- or post-synaptic disorder of neuromuscular transmission. brief hospital course: # hypercapnic respiratory failure: this was felt to be a combination of neuromuscular failure c-spine disease and als. he completed a course of antibiotics (vancomycin and zosyn) for pneumonia. s/p trach and peg, stable on ventilatory settings. vent settings at discharge: ac vt 450, 0.4 fio2, rr 10 peep 5. he was discharged to rehab and will further work on means to regain some of his voice while at rehab. . # als: recent diagnosis during this admission, he was started on rilutek per neuro recs. . # labile bp: the patient's bp was initially very difficult to manage, ranging from 60s/30s to sbp 200s. he was originally treated with ivfs and pressors. the patient was able to mentate with sbp in the 60s and bp improved upon awakening and with decreased sedation. the patient's bp has been stable on stimulation and midodrine. on the day of discharge, bp ranged from 70-150; however, patient asymptomatic. . # pain: adequate control with lidocaine patch, fentanyl patch, gabapentin. prn morphine and prn ibuprofen. gabapentin dose at discharge increased to 1200 tid. . # s/p cervical laminectomy. patient with pain and weakness. was originally wearing a hard cervical collar at all times, and changed to j collar which should be worn when out off bed/changing position. per recs, may be taken off while lying in bed. continue pain medications as needed. . # fever. the patient was originally febrile with cxr showing rml and rll infiltrate vs atelectasis. he was originally started on antibiotics and found to have an eosinophilia which was attributed to zosyn. all cultures including bal were negative (except for yeast from likley colonization). antibiotics were eventually discontinued and the patient remained afebrile. . # ppx. heparin sq and ppi while npo. . # fen. s/p peg, continue tube feeds. # code. full. . # access. piv . # communication. (son/hcp) ; (granddaughter) . # outstanding issues at discharge: 1. per orthopedics, he will need repeat films of c-spine (ap and lat) once he is at rehab. 2. as he is transferring care to , he will need neurology follow-up for his als. medications on admission: 1. gabapentin 600 mg po tid 2. tamsulosin 0.4 mg po hs 3. lisinopril 10 mg po daily 4. timolol maleate 0.5 % 5. latanoprost 0.005 % hs 6. tolterodine 2 mg po bid 7. bisacodyl 10 mg tablet daily prn 8. docusate sodium 100 mg po bid 9. metoprolol tartrate 25 mg po bid 10. trazodone 50 mg po hs prn 11. oxycodone-acetaminophen 5-325 q 6 hrs standing and tab q4 prn 12. ciprofloxacin 500 mg po q12h for 7 days 13. senna 2 tabs qhs 14. ativan 1 mg po qhs prn 15. maalox 30 cc po qid prn 16. apap 650 mg po q 4hrs prn discharge medications: 1. docusate sodium 150 mg/15 ml liquid : one (1) po bid (2 times a day). 2. senna 8.8 mg/5 ml syrup : one (1) tablet po hs (at bedtime). 3. timolol maleate 0.5 % drops : one (1) drop ophthalmic daily (daily). 4. latanoprost 0.005 % drops : one (1) drop ophthalmic hs (at bedtime). 5. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 6. acetaminophen 325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 7. heparin (porcine) 5,000 unit/ml solution : one (1) injection (2 times a day). 8. ferrous sulfate 325 (65) mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po daily (daily). 9. zolpidem 5 mg tablet : one (1) tablet po hs (at bedtime) as needed. 10. mirtazapine 15 mg tablet : one (1) tablet po hs (at bedtime). 11. albuterol 90 mcg/actuation aerosol : 6-10 puffs inhalation q4-6h (every 4 to 6 hours) as needed. 12. riluzole 50 mg tablet : one (1) tablet po bid (2 times a day). 13. trazodone 50 mg tablet : 0.5 tablet po hs (at bedtime) as needed for insomnia. 14. midodrine 5 mg tablet : 1.5 tablets po q 8h (every 8 hours). 15. fentanyl 75 mcg/hr patch 72hr : one (1) patch 72hr transdermal q72h (every 72 hours). 16. ketoconazole 2 % cream : one (1) appl topical (2 times a day). 17. ibuprofen 100 mg/5 ml suspension : one (1) po q6h (every 6 hours) as needed for pain. 18. gabapentin 400 mg capsule : three (3) capsule po tid (3 times a day). 19. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 20. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). discharge disposition: extended care facility: discharge diagnosis: primary: amyotrophic lateral sclerosis s/p cervical laminectomy labile hypertension secondary: benign prostatic hypertrophy discharge condition: stable discharge instructions: you were diagnosed with amyotrophic lateral sclerosis. please continue all medications as prescribed. please attend all follow-up appointments. md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Non-invasive mechanical ventilation Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Unspecified essential hypertension Atrial fibrillation Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Amyotrophic lateral sclerosis Acute and chronic respiratory failure Other specified cardiac dysrhythmias

allergies: no drug allergy information on file attending: chief complaint: weakness major surgical or invasive procedure: 1. endotracheal intubation 2. central venous catheter placement history of present illness: 74 y/o m w/past hx of htn and cervical radiculopathy, who presented today c/o weakness. he stated that he thought he had the flu over the past few days, with a nonproductive cough, headache, and general weakness. very poor po intake. he was recently prescribed effexor, and took his first dose this am. approximately one hour after that, he felt much weaker. ems was called and on arrival his bp was 80/60. he received 1 l ns and his bp responded to 120s. on arrival to the ed, his bp was 110s-120s/60s with a pulse in the 60s. he was awake, alert, and answering questions. his only complaints were of a headache, and he felt like he had to urinate but was unable to. he denied any chest pain, shortness of breath, abdominal pain. mild nausea but no vomiting. while examining him, he became bradycardic to 42 and hypotensive to 60/40. he was febrile to 101.2 and diaphoretic. he received 2l ns wide open with a mild response in his bp to 70s/50s. he was put on peripheral dopamine. bedside echo revealed no pericardial effusion, possibly depressed ef, no visible aortic aneurysm, and a dilated ivc. he was taken urgently to ct scan to r/o pe and dissection. in the ct scanner, he vomited. no aspiration observed and cxr no infiltrate. no blood in vomit. he then became tachycardic to the 130s (narrow complex) which appeared to be svt per ed resident no ecg confirmation in ct. dopamine stopped with normalization of hr. he then again became tachycardic in the 130s, and this time broke with carotid massage back down to 70. still hypotensive in 70s and so started on neo. ct showed no pe or dissection. when he returned, intubated for airway protection given vomiting and hemodynamic instability. never hypoxic or with resp distress. good mentation per family. vanc/levoflox/flagyl and decadron. lactate was 1.6 and he had 1600 cc uop. his sbp came back up to the 160s and the neo was weaned off. multiple attempts at right subclavian caused 2 arterial sticks. cxr showed no pneumo/hemothorax. subsequently became hypotensive again, and placed back on neo and dopa. right ij placed. sent to ccu. given total of 3 liters ns. recently had epidural steroid inject ion . no worsening of back pain since that time. past medical history: 1. htn 2. cervical radiculopathy 3. low back pain s/p lumbar epidural steroid injection social history: never smoked, no alcohol. lives with son. uses at baseline. has normal mental status. has home pt. family history: non-contributory physical exam: tm 101.2, tm 99.8, bp 114/63, map 80, p 80 nsr vent: ac 600/5/r12/40%, rr (obs) 17, pip 15 abg: 7.34/44/371 i/o: uop>30cc/hr drips: neo 0.19, dopa 3 gen: well, nontoxic lungs: ctab cv: s1/s2, rrr abd: soft, nttp, nabs, nd ext: no edema, warm, dry, dp2+ neuro: pupils 3mm equal, mae, cantonese speaking only, intubated. skin: no rash or skin breakdown anteriorly pertinent results: laboratory: labs at discharge: wbc 4.7, hct 41.2, plt 148 na 134, k 3.6, cl 110, hco3 22, bun 11, cr 0.8, glucose 95, ca 8.6, mg 1.8, ph 2.9. . microbiology: blood culture: pending. urine culuture: negative. dfa for influenza: negative. . imaging: cxr: clear lungs. ct chest/abdomen/pelvis: 1. no evidence for pulmonary embolus or aortic dissection. 2. focal mesenteric region of increased attenuation which most likely represents inflammation secondary to mesenteric panniculitis, or less likely trauma, edema, or tumor (lymphoma). there is no evidence of mesenteric vasculature or bowel compromise. a biopsy or ct scan in the future may provide further diagnostic information. 3. fluid within the esophagus which increases this patient's risk of aspiration. 4. multiple low-attenuation lesions throughout the liver which most likely represent simple liver cysts; however, an ultrasound examination could be performed for confirmation when the patient is clinically stabilized. tte: conclusions: the left atrium is normal in size. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: mild mitral regurgitation with normal valve morphology. preserved global and regional biventricular systolic function. brief hospital course: 74 m with fever and hypotension intubated electively for airway protection. . # hypotension: he was hypotensive in the emergency department which was of unclear etiology. this was thought most likely to be due to hypovolemia due to dehydration as his blood pressure normalized with iv fluids. by the end of his hospitalization he had actually started to become hypertensive and was started on lisinopril 10 mg daily. his hctz was not restarted as it was thought this may have been contributing to his hyponatremia. . fever: this was of unclear etiology and was attributed to a likely viral syndrome. he had no localizing signs or symptoms of infection. a test for influenza was negative as was a urine culture. blood cultures were pending at discharge. he was initially treated with broad spectrum antibiotics including vancomycin, levofloxacin, and metronidazole. once his culture data was negative he was switched to po levofloxacin and he was discharged to complete a seven day course. . # resp failure: he was intubated in the ed for airway protection but he was successfully extubated shortly after arriving to the micu and maintained a normal o2 saturation throughout the rest of his hospital course. . # hyponatremia: on admission he was initially hyponatremic with a sodium of 129. this was thought to be due to a combination of hypovolemia from dehydration as well as hctx effect. with hydration and stopping his hctz his sodium normalized and at discharge it was 134. . # cervical radiculopathy: he has a history of this and was last seen in neurology clinic in . he intermittently complained of neck pain during his admission and was set up with a follow-up appointment in neurology with dr. on at 3:00. . # lower back pain: he has a history of chronic lower back pain and spinal stenosis and has been followed in the pain management center. he was kept on his gabapentin and has a follow-up appointment with the pain clinic. . # urinary hesitancy: this is also a chronic issue for him and he was started on tamsulosin during his hospitalization with some effect. he has a follow-up appointment in the urology clinic. . # focal mesenteric thickening on ct scan: his abdominal exam was benign and he did not complain of abdominal pain. the general surgery service was consulted and did not recommend any intervention. . # dispo: he was discharged to home with plans for home physical therapy as he had previously had. he was also set up for appointments with his pcp, pain clinic, urology, and neurology. medications on admission: gabapentin 300 mg qd spectravite senior super b-complex omega3/omega6 fish oil hctz 25 mg qd xalatan 0.005% eye drop timolol 0.5% opthalmic solution effexor - started day of admission. discharge medications: 1. gabapentin 600 mg tablet sig: one (1) tablet po three times a day. 2. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 3. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 4. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 3 days. disp:*3 tablet(s)* refills:*0* 5. tamsulosin 0.4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po hs (at bedtime). disp:*30 capsule, sust. release 24hr(s)* refills:*2* 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lorazepam 1 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. discharge disposition: home with service facility: , discharge diagnosis: 1. viral syndrome. discharge condition: stable. discharge instructions: 1. you are being discharged to home. 2. please take your medications as prescribed. --we started lisinopril for your blood pressure. please take this until you see dr. next week and you can have your blood pressure checked. --we started tamsulosin for your urinary frequency. --you should continue to take levofloxacin (an antibiotic) for three more days. 3. please come to your follow-up appointments (see below). 4. if you experience any fevers, chills, sweats, dizziness, or other concerning symptoms, please seek medical attention. followup instructions: 1. you have an appointemnt with dr. on wednesday at 2:00 pm. please call his office at if you need to reschedule this appointment. 2. provider: ,(a) pain management center date/time: 1:30 3. provider: , md phone: date/time: 3:30 - urology appointment. 4. provider: , md, phd: date/time: 3:00 - neurology appointment. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Insertion of endotracheal tube Diagnoses: Mitral valve disorders Unspecified essential hypertension Hyposmolality and/or hyponatremia Other specified cardiac dysrhythmias Brachial neuritis or radiculitis NOS Hypotension, unspecified Unspecified viral infection Urinary frequency

history of present illness: this is a 39-year-old gentleman, who sustained a 30-foot fall, hitting a porch prior to landing on the ground. there was no loss of consciousness, and the patient arrived in the trauma bay complaining of a chest pain on arrival. he was noted to have a massive bleeding from his oropharynx and became hypotensive to the 60s. he was emergently intubated, and a right femoral cordis was placed. his blood pressure improved with a fluid resuscitation, and his chest x-ray was clear. he had good saturations after intubation. a dpl was performed given his hypotension as an unknown source that was positive after instillation of 1 l of saline. he was also noted to have a left upper extremity open fracture. he was taken emergently to the operating room for exploration. past medical history: unknown. past surgical history: unknown. allergies: no known drug allergies. medications: none known. social history: unknown. physical examination: initial physical exam: heart rate was 88, blood pressure 82/palpations, and 02 saturation 90 percent. the patient had an unstable face with a lip laceration and blood in his oropharynx. gcs of 15. pupils equal, round, and reactive with tms clear. heart: regular rate and rhythm. s1 and s2. chest: clear to auscultation bilaterally. sternum stable with no crepitus. abdomen is soft, nontender, and nondistended. rectal was guaiac negative with a normal prostate and normal tone. back showed no step-offs or lacerations. pelvis was stable. left forearm with an open fracture unstable with a 2 plus radial pulse. right arm question dislocation, and left and right lower extremities are without deformities. laboratory data: white blood cell count 8.1, hematocrit 38.9, and platelets 244,000. chemistry-7: sodium 143, potassium 4, chloride 104, and bicarbonate 29. pt was 12.2, ptt 19.4, inr 1.0, fibrinogen 199, and lactate was 3.5. abg: ph was 7.38, pco2 43, po2 232, bicarbonate 26, and base deficit minus 2. ua was moderate blood and urine tox negative. initial films: chest x-ray negative and pelvis negative. left forearm showed an ulnar fracture with radial head displacement. left shoulder was negative. left wrist was negative. right shoulder, a nondisplaced fracture of the greater tuberosity. a right humeral neck fracture that was nondisplaced and impacted. ct of the head: frontal contusion, small temporal bleed, frontal sinus fracture of the anterior and posterior table, and le fracture. ct of the c-spine was negative. ct of the chest showed bilateral pneumothoraces, right greater than left, with a right upper lobe collapse and a sternal fracture. brief hospital course: as per hpi, mr. was taken emergently to the operating room for exploration. on entering the abdomen, they found a laceration of the transverse mesocolon, splenic decapsulation, liver laceration, and multiple colonic deserosalizations. the splenic decapsulation was repaired, as were the serosal injuries to the colon. the transverse mesocolon was repaired, as was the liver laceration. the orthopedic surgery team then came into the operating room for washout and closed reduction of his left monteggia fracture of the radial head without long-arm splinting. he remained hemodynamically stable throughout the procedure without hypothermia. of note, prior to this, because of the known intracranial hemorrhage with hemodynamic instability, neurosurgery was called for bolt placement. icp monitor was placed with pressures in the 10 to 13 range. he was also placed on iv ancef perioperatively. he was then taken to the trauma icu where several consults were obtained, including an ophthalmology consult regarding his orbital wall fractures. they did not identify any entrapment on ct and recommended outpatient followup. he had subsequent bilateral chest tubes placed and a subclavian line placed on return to the icu. he was seen by oromaxillofacial surgery regarding his facial fractures and was taken to the operating room on for open reduction and internal fixation of his mid face fractures. of note, he had a large laceration of his eyebrow/nasal region that had been closed on the day of admission. of note, because of his multiple facial injuries and his deteriorating respiratory status over the course of his icu stay, he ended up developing pseudomonas in his urine. a tracheostomy was performed on . he also had an ivc filter placed on after bilateral lower extremity ultrasound revealed a right common femoral vein nonocclusive thrombus. a cta of the chest to evaluate for pulmonary embolus was negative, but was a poor quality study. he was subsequently additionally started on a heparin drip. however, there was difficulty in making him therapeutic, and a hematology consult was obtained. however, he was deemed to have no identifiable hematologic problem and was eventually maintained on goal ptt. coumadin was subsequently started. he was maintained on antibiotics for the pseudomonas in his sputum. he did continue to spike temperatures during his icu stay and required frequent suctioning and aggressive pulmonary toilet to manage his copious secretions. after recovering from his last operation, which was the orif of his facial fractures, he was finally transferred to the floor on . due to the fact that he was now a candidate for anticoagulation, vascular surgery was re-consulted and his ivc filter was removed. he was then placed on lovenox for anticoagulation purposes. he was able then to ambulate with physical therapy. however, he continued to have a very poor p.o. intake. we strongly encouraged p.o., and he stabilized his intake and was cleared by speech and swallow and was deemed stable for discharge to home from that standpoint. he was also placed on a passy-muir valve, which he tolerated well. he defervesced, and his antibiotics were stopped, and he remained without any further infectious issues. his mental status improved, and he was able to follow commands, and he was oriented x 3. once his mental status had improved, his c-spine was clinically cleared and his c-collar was removed. he was followed up by orthopedic surgery, who revised his cast after doing repeat films of his left upper extremity. he continued to progress well, and he was deemed stable for discharge to home on postoperative day numbers 29 and 17, which was also hospital day number 30. discharge diagnoses: status post fall with multiple injuries, including: mesocolic laceration. splenic laceration. liver laceration. colonic deserosalization x 3. le fracture with fractures of the anterior and posterior table of the frontal sinus. open left ulnar fracture with radial head dislocation. dislocated right shoulder reduced with greater tuberosity fracture nondisplaced. status post exploratory laparotomy. status post open reduction and internal fixation of the left ulna. status post tracheostomy placement. respiratory failure with ventilator-associated pneumonia, resolved. right common femoral vein deep vein thrombosis. status post inferior vena cava filter placement and removal. status post bronchoscopy. discharge medications: 1. lovenox 90 mg subcutaneously q.12h. 2. percocet 1 to 2 p.o. q.4-6h. p.r.n. 3. peridex mouthwash p.r.n. 4. colace 100 mg p.o. b.i.d. condition on discharge: improved. discharge status: the patient will be discharged to home with services. discharge instructions: the patient should keep his left arm cast on and leave tracheostomy capped, right arm, to have a full range of motion and weightbearing as tolerated. keep left arm elevated and use saline drops in both eyes p.r.n. followup: follow up with the trauma clinic in 2 weeks, with associate, dr. , in 2 weeks, with center in 2 weeks, and with dr. from orthopedic surgery in 2 weeks, and with oromaxillofacial surgery on . , dictated by: medquist36 d: 08:21:01 t: 13:45:06 job#: Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Interruption of the vena cava Other permanent tracheostomy Suture of laceration of large intestine Suture of laceration of large intestine Open reduction of maxillary fracture Insertion of synthetic implant in facial bone Open reduction of fracture with internal fixation, radius and ulna Debridement of open fracture site, radius and ulna Closure of laceration of liver Other diagnostic procedures on brain and cerebral meninges Other diagnostic procedures on brain and cerebral meninges Repair and plastic operations on spleen Diagnoses: Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness Closed fracture of sternum Injury to liver without mention of open wound into cavity, laceration, minor Other injury into spleen without mention of open wound into cavity Pneumonia due to Pseudomonas Traumatic pneumohemothorax without mention of open wound into thorax

history of present illness: the patient is a 73-year-old male with known coronary artery disease. he is status post coronary artery bypass grafting in , ptca to the right coronary artery in , and ptca of the saphenous vein graft in . he has had recent increase in frequency of chest pain. catheterization on the day of admission revealed diffuse coronary artery disease. the team consulted ct surgery for a coronary artery bypass grafting. past medical history: coronary artery bypass grafting in with saphenous vein graft to left anterior descending. stenting in of the right coronary artery and stenting in of his saphenous graft. the patient had a right renal artery stent in . hypertension. hypercholesterolemia. tobacco abuse. back surgery. hernia repair. appendectomy. medications on admission: aspirin 325 p.o. q.d., nitroglycerin patch, lisinopril 40 p.o. q.d., nadolol 10 mg p.o. q.d., hydrochlorothiazide 25 mg p.o. q.d., nifedipine 90 mg p.o. q.d., pravachol 10 mg p.o. q.d., vitamin e, prilosec 20 mg p.o. q.d. allergies: intravenous dye which causes hives. family history: noncontributory. social history: noncontributory. physical examination: general: the patient was in no acute distress. he was alert and oriented times three. lungs: clear to auscultation bilaterally. cardiovascular: regular, rate and rhythm. normal s1 and s2. there was a grade 3/6 systolic ejection murmur. abdomen: soft, nontender, nondistended. no organomegaly. extremities: he had +2 pulses throughout with no peripheral edema. neurological: grossly intact. laboratory data: white count 5.2, hematocrit 37.3, platelet count 176; inr 1.1; urinalysis was negative; chemistry showed a sodium of 138, potassium 4.0, chloride 104, bicarb 28, bun 27, creatinine 0.8, glucose 127; lfts were all within normal limits. chest x-ray showed no acute cardiopulmonary disease. assessment and plan: this was a 73-year-old male with recurrent diffuse coronary artery disease and coronary artery bypass grafting in the past, now requiring coronary artery bypass grafting of diffuse coronary artery disease. the patient will be brought to the operating room with dr. for coronary artery bypass grafting. hospital course: on , the patient was brought to the operating room for a redo coronary artery bypass grafting times two and aortic valve replacement. the patient tolerated the procedure well and was transported intubated to the pacu in stable condition on a levophed drip, milrinone drip, and a propofol drip. the patient had atrial wires and a chest tube. on postoperative day #1, the patient was continued on his levophed drip and milrinone drip over night. the patient was extubated over night and was on a nasal cannula of 4 lungs:, oxygen saturation 95% on room air. the patient's vital signs were otherwise stable. the patient had a postoperative hematocrit of 26.8; otherwise laboratory values were all within normal limits. the patient was encouraged to be out of bed. drips were weaned. the patient was started on his plavix. on postoperative day #2, the patient was off all drips, was started on aspirin 325 per day and captopril 6.25 t.i.d. the patient was afebrile in sinus rhythm. the patient had an oxygen saturation of 96% on 2 l nasal cannula. the patient had minimal output from the chest tubes. the patient's white count was 9.7, hematocrit 25.4, otherwise other labs were all within normal limits. the patient's chest tubes were removed, and the patient was transferred to the floor. on postoperative day #2, the patient was also seen by physical therapy. on postoperative day #3, the patient was still in the intensive care unit. the patient was kept in the intensive care unit due to bed availability. the patient was afebrile with a t-max of 99.7??????. the patient developed atrial fibrillation over night; however, the patient was rate controlled. the patient had an oxygen saturation of 96% on 2 l nasal cannula. the patient's hematocrit on postoperative day #3 was 23.9. other lab values were all within normal limits. the patient was started on lopressor 12.5, heparin drip at 600. the patient's wires were removed. the patient self-converted to normal sinus rhythm with occasional premature atrial contractions. the patient remained in normal sinus rhythm, and his heparin drip was held. the patient was continued on lopressor and captopril, and tolerating it well. on postoperative day #4, the patient's hematocrit was 22.3. the patient was transfused 2 u packed red blood cells. the patient's lopressor was increased. the patient was continued on captopril. the patient was transferred to the floor. on postoperative day #5, the patient was on aspirin, lasix, and metoprolol 25 b.i.d. the patient was in sinus rhythm. the patient had an oxygen saturation of 94% on room air. the patient was out of bed with physical therapy. follow-up hematocrit revealed a hematocrit of 29.8, which was up from 22.3. the patient was ambulating at a physical therapy level of 5. the patient's metoprolol was increased to 25 t.i.d. the patient tolerated this well. on postoperative day #6,the patient was at a physical therapy level of 5. the patient was tolerating a regular diet, and the patient was in stable condition, and it was felt that the patient could be discharged home with vna services. the patient was therefore discharged home with vna services in stable condition. discharge planning: the patient will follow-up with dr. in six weeks. the patient will follow-up with dr. ; the patient will call the office for an appointment in two weeks. discharge medications: darvocet 1 tab p.o. q.6 hours p.r.n. pain, metoprolol 25 mg p.o. t.i.d., pravastatin 20 mg p.o. q.d., lasix 20 mg p.o. b.i.d. for 10 days, colace 100 mg p.o. b.i.d., zantac 150 mg p.o. b.i.d., aspirin 325 mg p.o. q.d., ibuprofen 600 mg p.o. q.8 hours. discharge diagnosis: 1. status post redo coronary artery bypass grafting times two and aortic valve replacement. 2. coronary artery disease. 3. hypercholesterolemia. 4. renal artery stenosis. discharge status: the patient is discharged to home in stable condition with vna care for wound evaluation and hemodynamic monitoring. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Angiocardiography of left heart structures Left heart cardiac catheterization Coronary arteriography using a single catheter (Aorto)coronary bypass of one coronary artery Open and other replacement of aortic valve with tissue graft Transfusion of packed cells Transfusion of platelets Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Pure hypercholesterolemia Unspecified essential hypertension Atrial fibrillation Aortic valve disorders Atherosclerosis of renal artery

history of present illness: the patient is a 40-year-old female with complaints of headache and dizziness. in , the patient had headache with neck stiffness and was unable to walk for 45 minutes. the patient also had a similar episode a year and a half ago where she had inability to walk without pain. she had a headache at that time which was relieved with tylenol. past medical history: hypothyroidism. allergies: penicillin and bactrim which causes a rash. medications: levoxyl 1.75 mg. physical examination: on physical examination, her blood pressure was 104/73, pulse 79. in general, she was a woman in no acute distress. heent: nonicteric. pupils are equal, round, and reactive to light. extraocular movements are full. pharynx is benign. tongue midline. neck is supple. chest was clear to auscultation. cardiac: s1, s2, regular, rate, and rhythm. abdomen is soft, nontender, nondistended, negative bruits. extremities: no clubbing, cyanosis, or edema. palpable pulses. gait was steady. the patient is being admitted status post cerebral aneurysm with clipping. the patient underwent right mca and a right a-comm aneurysm clipping via a right pterional craniotomy without intraoperative complication. postoperative vital signs are stable. patient was afebrile. she was awake, alert. pupils are equal, round, and reactive to light. eoms are full. no facial droop, no drift. strength down the legs was . on postoperative day #1, the patient was taken to arteriogram, where she underwent a cerebral angiogram to evaluate clipping of the aneurysm. it was found at that time that the patient had a third aneurysm and that the mca aneurysm which was clipped was at the origin of the anterior temporal artery and not the one at the mca bifurcation. the patient was therefore taken back to the operating room for a clipping of the second mca aneurysm without intraoperative complication. the patient was monitored in the surgical intensive care unit. she was alert, awake, oriented, complaining of severe headache, moving all extremities. eoms full, negative drift, a smile was symmetric, ip is . the patient was then discharged to the floor on . she has been out of bed and ambulating with physical therapy, tolerating a regular diet, and voiding spontaneously. she has been seen by physical therapy, and was found to be safe to discharge to home with home physical therapy on . her incision is clean, dry, and intact and she is neurologically stable. discharge medications: 1. hydromorphone 2-6 mg po q4h prn. 2. synthroid 175 mcg po q day. 3. colace 100 mg po bid. condition on discharge: stable. follow-up instructions: she will follow up in 10 days for staple removal with dr. . , m.d. dictated by: medquist36 Procedure: Clipping of aneurysm Clipping of aneurysm Clipping of aneurysm Arteriography of cerebral arteries Diagnoses: Unspecified acquired hypothyroidism Cerebral aneurysm, nonruptured

history of present illness: the patient is a 73-year-old male admitted to due to new onset of angina and a positive stress test. he was fine until approximately two weeks prior to presentation when he started developing exertional chest pain. the pain resolved with rest. he had a stress test which showed inferolateral st changes. an echocardiogram was negative for ischemia. ejection fraction was 60%. the patient had a catheterization which showed 3-vessel disease. he was referred to cardiothoracic surgery. past medical history: 1. hypertension. 2. basal squamous cell skin cancer. 3. hemorrhoids. past surgical history: 1. status post hemorrhoidectomy 2. status post tonsillectomy and adenoidectomy. 3. status post knee arthroscopy. allergies: sulfa, shell fish, and dye. medications on admission: aspirin 81 mg p.o. q.d., lopressor 25 mg p.o. b.i.d., zestril 10 mg p.o. q.d., centrum p.o. q.d. physical examination on presentation: blood pressure was 155/76, heart rate was 48. chest was clear to auscultation bilaterally. cardiovascular revealed a regular rate and rhythm. extremities were well perfused, no edema. the abdomen was soft, nontender, and nondistended. pertinent laboratory data on presentation: laboratories on admission revealed white blood cell count was 13.3, hematocrit was 46.2, platelets were 230. sodium was 138, potassium was 4.7, chloride was 101, bicarbonate was 26, blood urea nitrogen was 19, creatinine was 1.2. inr was 0.9. hospital course: the patient was taken to the operating room on where he had a coronary artery bypass graft times three with left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, saphenous vein graft to ramus. the operation was without complications. pacing wires as well as chest tube were placed intraoperatively. the patient was transferred to the surgical intensive care unit in stable condition. on postoperative day one, the patient was afebrile. vital signs were stable. he was extubated without complications. his chest tube was removed successfully. on postoperative day two, the patient remained afebrile. vital signs were stable. his intravenous line and foley were removed. the patient was transferred to the floor. on postoperative day three, the patient remained afebrile. vital signs were stable. he started working with physical therapy. he complained about pain and weakness in his left arm. the patient reported it was worse immediately postoperatively and slowly improved with time. on serial examinations which were performed, the patient's strength had improved over the preceding two days. on postoperative day four, an occupational therapy consultation was obtained who found that the patient did not need immediate occupational therapy treatment at this time. their recommendation was to follow up on an outpatient basis in two to three weeks if he did not recover significantly at this time. the patient remained afebrile. vital signs were stable. he was exercising with physical therapy. no concerns. no active issues. condition at discharge: condition on discharge was stable. discharge status: the patient was discharged to home without . die followup: the patient was to follow up with dr. in four weeks for a postoperative check. the patient was to follow up with his primary care physician in two to three weeks for his left arm numbness and weakness; if symptoms do not improve at that time, he may request referral to the outpatient occupational therapy. medications on discharge: 1. lasix 20 mg p.o. b.i.d. (times seven days). 2. potassium chloride 20 meq p.o. b.i.d. (times seven days). 3. zantac 150 mg p.o. b.i.d. 4. enteric-coated aspirin 325 mg p.o. q.d. 5. percocet one to two tablets p.o. q.4h. as needed. 6. tylenol 650 mg p.o. q.4-6h. as needed. 7. lopressor 25 mg p.o. b.i.d. discharge diagnoses: 1. coronary artery disease; stabilized. 2. status post coronary artery bypass graft times three. 3. hypercholesterolemia. 4. hypertension. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters (Aorto)coronary bypass of two coronary arteries Angiocardiography of left heart structures Left heart cardiac catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Other and unspecified angina pectoris Disturbance of skin sensation Personal history of other malignant neoplasm of skin

allergies: sulfa. medications: hydrochlorothiazide 25 mg q d. past medical history: aortic insufficiency. past surgical history: status post avr. history of present illness: the patient is a 71-year-old female who is status post avr in for aortic stenosis with prosthetic valve, symptomatic, during routine echo which showed severe aortic insufficiency and poorly functioning valve, although patient remained asymptomatic. the patient also underwent cardiac catheterization which showed again significant valvular dysfunction with insignificant coronary artery disease. physical examination: pulse 77 and regular, blood pressure 154/66. heent: no lymphadenopathy. neck, no jvd, bruits. chest, clear to auscultation bilaterally. heart, regular rate and rhythm, 4/6 systolic ejection murmur at second intercostal space, radiating up to the neck. extremities, warm, well perfused, no edema. pulses strong and equal bilaterally. ekg, pvcs, no ischemia. hospital course: the patient was taken to the operating room on . during placement of monitoring lines by anesthesia team, the patient became asystolic for a brief period of time and came back after chest compressions, atropine and epinephrine. intraoperatively the patient had supracoronary aortic rupture which required large graft placement. she also had aortic valve successfully replaced with 21 mm pericardial valve. pacing wires as well as mediastinal and pleural tubes were placed intraoperatively. the patient was transferred to icu in stable condition. on postoperative day #1 the patient had a few episodes of asystolic which resolved spontaneously and did not require any treatment. patient was afebrile, vital signs were stable. postoperative day #2 the patient was extubated without complications and episodes of atrial fibrillation responded to two amiodarone boluses. she was also started on lasix. she was transferred to the regular floor in stable condition. on postoperative day #3, overnight, patient had an episode of atrial fibrillation. she again responded really well to amiodarone boluses, was started on oral amiodarone. her chest tube was discontinued without complications. foley was discontinued. postoperative day #5 wires were taken out without complication, patient again had an episode of atrial fibrillation responding really well to amiodarone and remained afebrile, vital signs stable, ambulating well with pt. no concerns, no active issues. discharge medications: enteric coated aspirin 325 mg po q d, tylenol 325 mg 1-2 tabs po q 6 hours prn, percocet 1-2 tabs q 4-6 hours prn, amiodarone 400 mg tid for 7 days, then 400 mg for 7 days, then 400 mg q d, lasix 20 mg po bid for 7 days, potassium chloride 20 meq one tablet po bid for 7 days. condition on discharge: good. die status: the patient is discharged home. the patient should follow-up with dr. in four weeks for postoperative follow-up. discharge diagnosis: 1. non functioning avr, status post avr re-do. 2. aortic rupture, status post supracoronary aortic graft placement. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Open and other replacement of aortic valve Resection of vessel with replacement, aorta, abdominal Diagnoses: Atrial fibrillation Aortic valve disorders Atrioventricular block, complete Mechanical complication due to heart valve prosthesis Thoracic aneurysm, ruptured

discharge medications; 1. aspirin enteric coated 325 mg po qd 2. tylenol 325 mg 1 to 2 tablets po q6h 3. percocet 1 to 2 tablets po q 4 to 6 hours prn 4. amiodarone 400 mg for four days, then 400 mg po qd for four weeks, then 200 mg qd 5. lasix 20 mg po bid x7 days 6. potassium chloride 20 milliequivalents 1 tablet po bid for seven days 7. coumadin 2 mg po qd 8. docusate sodium 100 mg po bid discharge condition: good die status: the patient is discharged home. the patient should have her inr checked in the next 48 hours and call her primary care doctor with the results and coumadin dose adjustment. the patient should follow up with dr. in four weeks for postoperative check. the patient should follow up in pacemaker clinic in one week. discharge diagnoses: 1. aortic insufficiency, status post avr repair 2. status post aortic rupture, super coronary aortic graft 3. complete heart block with permanent pacemaker placement 4. atrial fibrillation , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Initial insertion of dual-chamber device Initial insertion of transvenous leads [electrodes] into atrium and ventricle Open and other replacement of aortic valve Resection of vessel with replacement, aorta, abdominal Diagnoses: Atrial fibrillation Aortic valve disorders Atrioventricular block, complete Mechanical complication due to heart valve prosthesis Thoracic aneurysm, ruptured

history of present illness: mr. is an 82 year-old asian male with a history of dementia, who was transferred from the micu to the floor following a long stay for respiratory failure, complicated by fevers and complicated by bilateral iatrogenic pneumothoraces requiring chest tube placement. briefly the patient was admitted on following a respiratory and cardiac arrest after choking on food. the patient was resuscitated and intubated in the field by ems. estimated total time of arrest (cardiac and respiratory) was 5 to 15 minutes including 5 to 10 minutes of cpr. in the emergency department the patient received a left pneumothorax following an attempted left subclavian line placement. this left pneumothorax required a chest tube. the emergency department course is also notable for hypotension requiring levophed, as well as witnessed aspiration event. upon arrival to the complications of the left chest tube resulted in a left tented pneumothorax as well as a right sided pneumothorax presumed secondary to high pips in the 90s. the cardiac surgery was consulted and bilateral chest tubes were placed. the patient was initially begun on levofloxacin/flagyl for presumed aspiration pneumonia with bilateral infiltrates on chest x-ray. the patient intermittently spiked fevers in the for which vancomycin was added on . in addition, the patient had episodes of supraventricular tachycardia, which was responsive to adenosine and vagal maneuvers. a neurology consult was obtained who felt that anoxic brain injury was highly unlikely and his prognosis for recovery was poor. after an extensive discussion with the patient's family the patient's code status was changed to dnr/dni. on the patient was extubated and bilateral chest tubes were discontinued. since the patient remained hemodynamically stable and the patient was transferred to the floor on . past medical history: 1. dementia of alzheimer's type. 2. prior ceas. allergies: bacitracin and neosporin. medications at home: 1. aricept 10 mg po q.d. 2. zyprexa 25 mg po q.d. 3. prevacid 30 mg po q.d. 4. tube feeds. antibiotics while inpatient: 1. levofloxacin 500 mg q.d. 2. vancomycin 500 mg q 24. 3. flagyl 500 mg q 8 hours. 4. subcutaneous heparin. social history: the patient is a resident of the facility). the patient's son is health care proxy. the patient's daughter is power of attorney. the patient's wife is living in she lives at home in . the patient has five children, four of whom who live locally and one who is in route to the hospital. physical examination on transfer: temperature 97.3. temperature max 99.6. heart rate 57. blood pressure 95 to 130/35 to 60. respiratory rate 12 to 14. o2 saturation 100%. in general, the patient is unresponsive to verbal stimuli, but responsive to pain. coarse upper airway sounds are audible. cardiovascular distal heart sounds without murmurs. lungs very coarse breath sounds, positive upper airway noise, positive rhonchi. abdomen soft, nontender, nondistended. no masses, bowel sounds are positive. extremities bilateral upper extremities and bilateral lower extremities with marked edema. laboratory data on : white blood cell count 10.4, hematocrit 28.3, sodium 141, potassium 4, chloride 106, bicarb 27, bun 22, creatinine 0.5, albumin 2.3, calcium 7.6, magnesium 1.9. radiology: chest x-ray on bilateral basilar lower lobe opacities right greater then left increasing over the past few days. microbiology: blood cultures times two, sputum is negative. urine is negative. blood cultures times two are negative. urine is with positive coag negative staph. electrocardiogram on normal sinus rhythm at 94 beats per minute, right bundle branch block, low limb voltage. impression: the patient is an 82 year-old asian male with baseline dementia who is initially admitted after a prolonged cardiac/respiratory arrest. he was admitted to the medical intensive care unit with anoxic brain injury secondary to prolonged cardiac and respiratory arrest. in addition his hospital course was complicated by pneumothoraces as well as continued aspiration. a neurology consult was obtained to evaluate the patient and their overall consensus was that this patient's prognosis was very poor. upon transfer to the floor the patient was currently aspirating with worsening bilateral lower lobe infiltrates, and the risk of recurrent arrest or decompensation was high. hospital course: 1. pulmonary: the patient continued aspirating. he remained on high oxygen flow by shovel mask. the was continued with supplemental oxygen with suctioning prn. 2. cardiovascular: the patient is hemodynamically stable, blood pressure in the 90 to 120 range. 3. infectious disease: afebrile times 48 hours with negative culture workup thus far. his fevers are likely secondary to aspiration pneumonitis/pneumonia versus central in origin. because of worsening infiltrates the patient was continued on aspiration coverage with levofloxacin/flagyl. 4. renal: the patient's bun to creatinine ratio was steadily increasing. this increasing ratio is likely indicated of a prerenal insufficiency. intravenous fluids were given to the patient to assist with the prerenal condition. 5. neurology: as per the neurological evaluation significant neurological recovery was very unlikely and the and patient's prognosis was poor. 6. fen: the patient's tube feeds were continued initially. 7. prophylaxis: the patient was kept on a ppi and subcutaneous heparin. 8. code status: a family meeting was carried out with the health care proxy, son and power of attorney daughter . the medical condition was discussed and at the patient's current state he was at extremely high risk of decompensation and another cardiopulmonary arrest. the patient on transfer to the floor was dnr/dni. a family meeting on with the son and daughter to represent the family. the medical condition and treatment were discussed in depth regarding dnr/dni, intravenous fluids, antibiotics, deep oropharyngeal suction, laboratory draws, chest x-rays and blood cultures. stated that the family had already made peace with their father's health condition and he voiced the preference that the patient be kept comfortable. also stated that he wished that his father would "go peacefully" with no intervention. and stated that they did not want any intravenous fluids or any pressors. it was decided by the family to discontinue all lines, intravenous fluids, with prn morphine given for comfort. in addition, the family declined deep oropharyngeal suctioning and laboratory draws. regarding feedings, daughter felt that the nasogastric tube feedings "would not change anything" and they opted to have the nasogastric tube feeds discontinued as well. the patient's family stressed that the primary role is that the patient is to be kept comfortable and peaceful. a plan was made that the patient would be kept on supplemental oxygen for comfort, given prn morphine, oral suctioning as needed for comfort, as well as scopolamine patches to decrease secretions. from through the patient was kept comfortable with oxygen, morphine and prn tylenol. throughout his course the patient remained unresponsive, though the patient did once open his eyes to touch. the patient's course continued to decline from through and he was without spontaneous movement. on the patient began having increased secretions, increased gurgling and his respiratory status became more labored. in addition, the patient began to have increased work of breathing. supplemental oxygen, scopolamine patches to decrease secretions and morphine gtt were continued for comfort. on at 12:17 p.m. the patient expired. discharge diagnoses: 1. dementia secondary to alzheimer's disease. 2. aspiration of food causing cardiac arrest. 3. anoxic brain damage secondary to prolonged cardiopulmonary resuscitation. 4. continued aspiration pneumonitis/pneumonia. 5. iatrogenic pneumothorax status post subclavian line attempt. 6. left tension pneumothorax, secondary to displacement of left sided chest tube, which also resulted in a small right pneumothorax. 7. status post placement of bilateral chest tubes and removal of bilateral chest tubes. 8. acute respiratory failure, requiring ventilator support while in the medical intensive care unit. dr., 12-aad dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Arterial catheterization Diagnoses: Acidosis Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pneumonia due to Staphylococcus, unspecified Iatrogenic pneumothorax Cardiac arrest Anoxic brain damage Persistent vegetative state

history of present illness: was born at at 32-1/7 weeks gestation to a 34-year-old gravida 3 para 0 now one b+ female whose remaining prenatal screens were noncontributory. pregnancy was conceived via in- fertilization. a uterine hematoma was noted at seven weeks with a normal fetal survey. she was admitted at 25 weeks in preterm labor and was treated with a course of betamethasone at that time. she has remained hospitalized at bed rest and magnesium sulfate. preterm premature rupture of membranes occurred 11 hours prior to delivery. she received intrapartum antibiotics and induction began. she had a normal spontaneous vaginal delivery and the infant's apgars were 4 6,7 at 1, 5, and 10 minutes. infant had a cry, but became apneic soon thereafter. he received positive pressure ventilation for 1-2 minutes. he was brought to the nicu at hospital with blow-by oxygen without incident. his admission examination was remarkable for a hypospadias with chordae and a meatus at the base of the phallus with testes high in the scrotum. on admission, the baby weighed , length 45 cm, head circumference 32 cm, all appropriate for gestational age. problems during hospital stay: 1. respiratory: infant was intubated on admission to the nicu. received one dose of surfactant with a x-ray consistent with hyaline membrane disease. he remained intubated from until when he went to continue his positive airway pressure briefly and then oxygen via nasal cannula, and by later that evening was in room air. he remained in room air throughout the remainder of his hospital course. there were no episodes of apnea or bradycardia of prematurity. 2. cardiac: he had no murmurs present, and had stable blood pressures throughout. 3. infectious disease: patient had an initial sepsis rule out. was on ampicillin and gentamicin for 48 hours once blood cultures were negative. 4. feeding and nutrition: infant currently is feeding adlib demand and being put to breast for no more than 1x/day. he is currently on mother's milk 24 calories per ounce and his weight prior to discharge was 2490 . 5. hematology: mother is b+. baby had a peak bilirubin of 11.8 for which he underwent several days of phototherapy. 6. genitourinary: patient was noted on admission to have a significant hypospadias and chordee with a cleft-like area and the meatus appears to be somewhere along the shaft of the penis. he has two testes high in the scrotal sac. this was discussed at length with the parents, and as an outpatient, he will be referred by his primary care physician, . to urology, and this will be anticipatory of surgery at some later date around the first year of life. on his initial state screen, we were notified that the 17-hydroxyprogesterone was elevated. two further state screens were sent following the initial abnormal on . repeats were and . both of these were within normal limits. he also had electrolytes drawn that were normal. there was some question as to whether this could have been a virilized female, however, the physician staff and agree that there are definitely two testes high in the scrotum with normal electrolytes and followup state screen normal for 17-hydroxyprogesterone that this patient was indeed a male. hearing screening performed on and was normal. hepatitis b immunization #1 given on . discharge medications: 1. poly-vi- 1 cc daily. 2. fer-in- 0.2 cc daily. follow-up plan: the patient is to be followed at vangard, center with dr. ,on and at a future date, urology appointment to be made by dr. . vna is to come to home the day post discharge to check infant's weight and see how mother/baby are doing. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Other phototherapy Prophylactic administration of vaccine against other diseases Diagnoses: Observation for suspected infectious condition Single liveborn, born in hospital, delivered without mention of cesarean section Respiratory distress syndrome in newborn Neonatal jaundice associated with preterm delivery Other preterm infants, 1,750-1,999 grams 31-32 completed weeks of gestation Hypospadias Congenital chordee

allergies: nkda meds: asa; univasc; thiamine; mvi; levoquin; atenolol; norvasc; folate; tylenol; magnesium pt. went to the or on to have debulking of cerebellar tumor and evacuation of hematoma. pt. has been stable here post op. she has had an mri last nite of her head. she is awaiting a bronchoscopy for further w/u of her pulmonary stautus. brief ros: pt. mae with gd strength, in bed. she is cooperative and calm this afternoon. on the night shift she had become slightly restless and confused a couple of times. her speech is clear today, not garbled. she remains sleepy and slightly slow to respond. pt. got oob today to the chair. she stated, "oh no, i can't, i'll fall again". she did well with a 2 person assist. her head halls forward, pulling her wt all forward but her legs are strong enough to bear wt easily. she recognized all her family members, but does get more anxious when they're here, "please don't leave me" or "take me home" she repeats often. her incision on the rt is dry and intact. see care vue for neauro assessment. pt. has reletively clear breath sounds. sats on rm air are 95-97%. weak, non-prod. cough. cv- stable bp. maintaining bp lower than 160, using hydralazine with gd effect. switched to po hydralazine today. lopressor has been held today and yesterday with hr in the 50's-60's, sinus. skin is warm and dry with gd periph pulses. gu- adequate u/o via foley. gi- started clear liqs today. tolerated diet well, she's hungry. abd soft and non-tender. no bm's today. pt. has recieved tylenol for pain today, with some relief. she also rcv'd ativan .5mg iv for anxiety before family left, sleepy now. iv's- she has a new #20 gauge placed on nite shift and an older iv in left hand. a-pt. has been stable today. her neuro status is unchanged, she was wakeful earlier in shift, improved speech today. she continues to require neuro checks for changes. p- transfer when bed available. Procedure: Other operations on extraocular muscles and tendons Other excision or destruction of lesion or tissue of brain Diagnoses: Pneumonia, organism unspecified Unspecified essential hypertension Personal history of tobacco use Intracerebral hemorrhage Secondary malignant neoplasm of brain and spinal cord Malignant neoplasm of upper lobe, bronchus or lung Loss of weight Unspecified disorder of adrenal glands