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allergies: morphine / penicillins / ciprofloxacin hcl / warfarin / cozaar / norvasc / lisinopril / rosuvastatin attending: addendum: clarification: the patient had an acute exacerbation of his chronic chf. it is unlikely that he had pneumonia because he was afebrile. discharge disposition: home with service facility: vna md Procedure: Non-invasive mechanical ventilation Diagnoses: Other primary cardiomyopathies Acidosis Hyperpotassemia Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Long-term (current) use of steroids Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Obstructive chronic bronchitis with (acute) exacerbation Other specified forms of chronic ischemic heart disease Chronic kidney disease, Stage III (moderate) Acute respiratory failure Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Flatulence, eructation, and gas pain Other disorders of calcium metabolism Chondrocalcinosis, unspecified, site unspecified Hematuria, unspecified Examination of participant in clinical trial

allergies: morphine / penicillins / ciprofloxacin hcl / warfarin / cozaar / norvasc / lisinopril / rosuvastatin attending: chief complaint: dyspnea major surgical or invasive procedure: none history of present illness: 86 yo male h/o cad, chf, copd presents with dyspnea. reports cough x3 weeks, denies hemoptysis. noted dyspnea which awoke him from sleep on the night prior to presentation. patient denies chest pain, fevers and chills. patient endorses worsening orthopnea over past month, previously slept with 1-2 pillows now requires 3 pillows. has additionally experienced pnd. has not noted swelling of his lower extremities or increased weight. his weight on admission of 154 is down from his most recent clinic weight of 168. he has noted swelling of his abdomen starting on the morning of admission. he reports this swelling was present prior to presentation in the ed and states it is not a problem he has previously experienced. in ed patient's initial vs were t 98.6, hr 88, 154/96, resp 22 98% ra, patient then experienced decompensation of his respiratory status, desaturated to 92% on room air requiring placement on bipap. patient received a cxr which showed increased vascular congestion and questionable pneumonia. patient received azithro, ceftriaxone, nebs x3 and solumedrol. on arrival to the micu, patient was noted to be saturating well on bipap, experienced increased shortness of breath when taken off of bipap. past medical history: cad: cath w/ 90% lad, 90% ramus intermedius lesions, both stented w/ cypher des; om1 w/ 50-60% lesion; repeat cath and showed patent stents - combined ischemic/non-ischemic cardiomyopathy: lvef 30-40% - chf: 30-40% - htn - hypercholesterolemia - ckd: baseline creat 1.7- 2.0 - gerd - cataracts: bilateral, not repaired - sleep apnea - lower back pain - osteoarthritis - hemorrhoid repair 20 years ago - hernia repair (epigastric, ; inguinal ) - bph - restless leg syndrome social history: patient works as a minister at this point. denies etoh and illicit drug use. quit smoking many years ago. family history: + for multiple siblings with heart disease. sister with esrd. physical exam: admission exam: general appearance: well nourished eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: cervical wnl cardiovascular: normal s1 and s2 without murmurs/rubs/gallops peripheral vascular: well perfused peripherall with pulses in all extremities respiratory / chest: symmetric expansion, crackles at bases, mild wheezes abdominal: distended, tense abdominal wall, no tenderness to palpation, tympanitic to percussion extremities: no lower extremity edema skin: warm neurologic: responds to: verbal stimuli, movement: purposeful, tone: normal discharge exam: tc 98.0 tm 98.0 bp 120/75 hr 62 rr 18 o2 98%ra general appearance: lying comfortably in bed, breathing easily heent: perrl, eomi, mmm cardiovascular: normal s1 and s2 without murmurs/rubs/gallops respiratory / chest: good air movement, crackles at bases, mild wheezes abdominal: distended, tense, soft, nontender. hyperactive bowel sounds. extremities: no appreciable lower extremity edema, warm, peripheral pulses present bilaterally radial and pedal. pertinent results: admission labs: 11:20am blood wbc-8.3 rbc-4.72 hgb-14.5 hct-44.3 mcv-94 mch-30.7 mchc-32.7 rdw-13.4 plt ct-131* 11:20am blood neuts-80.9* lymphs-11.0* monos-4.8 eos-2.8 baso-0.5 12:07pm blood pt-10.7 ptt-26.5 inr(pt)-1.0 11:20am blood glucose-192* urean-34* creat-1.9* na-145 k-3.7 cl-108 hco3-28 angap-13 11:20am blood probnp-1275* 11:20am blood ctropnt-<0.01 07:31pm blood ctropnt-<0.01 07:29pm blood type-art po2-161* pco2-48* ph-7.35 caltco2-28 base xs-0 07:29pm blood lactate-2.6* 05:40pm urine color-yellow appear-clear sp -1.014 05:40pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg micro: blood culture - no growth urine cutlure - no growth urine legionella antigen - negative imaging: cxr impression: findings suggesting mild vascular congestion. in the appropriate clinical setting, atypical pneumonia could also be considered. also, although it is difficult to exclude focal pneumonia at the lung bases, patchy basilar opacities with low lung volumes could also be seen with atelectasis. cardiac echo conclusions 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 size is normal. overall left ventricular systolic function is mildly depressed (lvef= 35-40 %) with regional hypokinesis in basal-mid lateral hypo/akinesis and apical hypokinesis. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. moderate to severe (3+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the wall motion abnormalities and overall ejection fraction are similar. the degree of mitral regurgitation has increased but was probably underestimated on the prior study. impression: regional wall motion abnormalities in the inferior, lateral and apical territories with reduced ejection fraction to 30-35%. moderate to severe mitral regurgitation. mild aortic regurgitation. cxr comparison: . findings: as compared to the previous radiograph, the lung volumes have minimally increased, likely reflecting improved ventilation. otherwise, the radiograph is unchanged, including the pre-existing mild-to-moderate cardiomegaly. no pleural effusions are seen. no evidence of pneumonia. discharge labs: 09:00am blood wbc-12.2* rbc-4.70 hgb-14.3 hct-43.5 mcv-92 mch-30.4 mchc-32.8 rdw-13.5 plt ct-126* 09:00am blood glucose-127* urean-50* creat-2.0* na-143 k-4.3 cl-100 hco3-30 angap-17 09:00am blood calcium-8.6 phos-3.0 mg-3.2* brief hospital course: micu course: 87 year old male with productive cough x3 weeks and new onset of dyspnea on day prior to presentation who was admitted to the micu originally for bipap and quickly weaned off of it and transferred to the medical . # dyspnea: most likely represents chf exacerbation in setting of progressive orthopnea as well as contribution from concurrent copd exacerbation. likely exacerbated by abdominal wall tension with large amounts of bowel gas. abg on bipap shows mild respiratory acidosis. patient has previous spirometry results indicative of underlying restrictive pathology as well. his respiratory status improved after diuresis and he was weaned off fo bipap and stable on nc and transferred to the medical . on the floor he continued saturate comfortably on room air. in addition, he was placed on steroid burst and azithromycin x 5 days for copd flare. # chf: last echo shows lvef of 35-40%. patient received repeat echo on hospital day 2 with final report pending upon call out from icu. patient was continued on home chf medications of diovan, metoprolol and lasix. echo without marked interval change, ef 30-35%. # abdominal distension: kub shows diffuse bowel gas, no air fluid levels or signs of obstruction. abdominal exam currently without tenderness or rebound, not concerning for acute abdomen. distension preceded bipap initiation per the patient. patient endorses normal bms and continues passing some gas per rectum. patient received simethicone overnight with minimal improvement in bowel gas, also received aggressive bowel regimen. # ckd: cr noted to be at high end of patient's baseline, trended down. transitional issues: medication changes: increased prednisone to 40mg a day for and , then continue taking your home dose of 5mg daily started azithromycin (last day ) started advair twice daily and stopped flovent medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. acetaminophen w/codeine tab po q6h:prn pain 2. albuterol inhaler puff ih q6h:prn respiratory distress 3. allopurinol 100 mg po daily 4. lorazepam 0.5 mg po hs:prn restless legs 5. atorvastatin 20 mg po daily 6. calcitriol 0.25 mcg po 1x/week (tu) 7. zyrtec *nf* 10 mg oral daily 8. clopidogrel 75 mg po daily 9. clotrimazole cream 1 appl tp 10. cyclosporine *nf* 0.05 % ou 11. felodipine 5 mg po daily 12. fluticasone propionate 110mcg 1 puff ih 13. folic acid 1 mg po daily 14. furosemide 60 mg po daily 15. gabapentin 300 mg po bid 16. isosorbide mononitrate (extended release) 60 mg po daily 17. metoprolol succinate xl 25 mg po bid 18. nitroglycerin sl 0.4 mg sl prn chest pain 19. potassium chloride 8 meq po daily duration: 24 hours hold for k > 20. prednisone 5 mg po daily 21. valsartan 320 mg po daily 22. aspirin 81 mg po daily 23. docusate sodium 100 mg po bid constipation 24. multivitamins 1 tab po daily discharge medications: 1. allopurinol 100 mg po daily 2. aspirin 81 mg po daily 3. atorvastatin 20 mg po daily 4. calcitriol 0.25 mcg po 1x/week (tu) 5. clopidogrel 75 mg po daily 6. clotrimazole cream 1 appl tp 7. cyclosporine *nf* 0.05 % ou 8. docusate sodium 100 mg po bid constipation 9. felodipine 5 mg po daily 10. folic acid 1 mg po daily 11. furosemide 60 mg po daily 12. gabapentin 300 mg po bid 13. isosorbide mononitrate (extended release) 60 mg po daily 14. metoprolol succinate xl 25 mg po bid 15. albuterol inhaler puff ih q6h:prn respiratory distress 16. zyrtec *nf* 10 mg oral daily 17. potassium chloride 8 meq po daily duration: 24 hours hold for k > 18. nitroglycerin sl 0.4 mg sl prn chest pain 19. multivitamins 1 tab po daily 20. lorazepam 0.5 mg po hs:prn restless legs 21. acetaminophen w/codeine tab po q6h:prn pain 22. azithromycin 250 mg po q24h duration: 2 days last day rx *azithromycin 250 mg 1 tablet(s) by mouth daily disp #*2 tablet refills:*0 23. fluticasone-salmeterol diskus (100/50) 1 inh ih rx *fluticasone-salmeterol 100 mcg-50 mcg/dose 1 puff(s) inh twice a day disp #*1 unit refills:*0 24. simethicone 40-80 mg po qid:prn gas/bloating rx *simethicone 80 mg 1 tab by mouth every six (6) hours disp #*30 tablet refills:*0 25. valsartan 320 mg po daily 26. prednisone 40 mg po daily duration: 2 days after , resume 5mg daily rx *prednisone 20 mg 2 tablet(s) by mouth daily disp #*4 tablet refills:*0 discharge disposition: home with service facility: vna discharge diagnosis: chronic obstructive pulmonary disease exacerbation 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. , it was a pleasure participating in your care at . you were admitted to the hospital because you were short of breath due to a flare up of your chronic obstructive pulmonary disease. you were given inhalers and nebulizers, as well as steroids and antibiotics that both reduce inflammation and protect against potential infection. medication changes: increased prednisone to 40mg a day for and , then continue taking your home dose of 5mg daily started azithromycin (last day ) started advair twice daily and stopped flovent followup instructions: department: when: tuesday at 12:10 pm with: , m.d. building: sc clinical ctr north campus: east best parking: garage department: when: wednesday at 10:30 am with: , rnc building: sc clinical ctr none campus: east best parking: garage department: rheumatology when: friday at 9:30 am with: , md building: lm bldg () campus: west best parking: garage Procedure: Non-invasive mechanical ventilation Diagnoses: Other primary cardiomyopathies Acidosis Hyperpotassemia Obstructive sleep apnea (adult)(pediatric) Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Long-term (current) use of steroids Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Obstructive chronic bronchitis with (acute) exacerbation Other specified forms of chronic ischemic heart disease Chronic kidney disease, Stage III (moderate) Acute respiratory failure Hyperosmolality and/or hypernatremia Acute on chronic systolic heart failure Flatulence, eructation, and gas pain Other disorders of calcium metabolism Chondrocalcinosis, unspecified, site unspecified Hematuria, unspecified Examination of participant in clinical trial

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: none history of present illness: pt is a nursing home resident with dementia who presented with mental status changes, lower back pain, and fever. patient was found to have increased lower back pain at nh. on arrival to ed, patient had a fever to 104, hr in 130s. tachypneic to 30s-40s. bp was stable patient was given 2.5l ivf and became more tachypneic. she was also more agitated and requred 4 point restraints. uop remained > 30 cc/hr. in the ed, she received levofloxacin 500mg x1, vancomycin 1g x 1, tylenol 650mg x1, ativan 2mg x 1, haldol, 5mg x 2, and lidocaine. patient became more tachypneic and was breathing at 40-50 breaths per minute with hr in 140s. decreased initially with ivf to 120s, but then went back up to the 140s. spoke to patient's pcp who agreed that a central line, intubation or other invasive measures woudl not be in line with patient's wishes. states that bipap would be a reasonable option. on transfer to the icu, patient was on bipap with rr in the 50s. past medical history: 1. dementia 2. hypertension social history: pt lives at an facility in for the last 3-4 weeks, as she was recently hospitalized for 5-6 weeks at with a uti and worsening delirium. ms. was previously employed as a buyer for a clothing store. she has an artistic background. she has no history of tobacco abuse. she reports very rare alcohol intake on a rare holiday only. family history: she had her brother with diabetes and there is a family history of hypertension. otherwise, her two daughters are healthy. physical exam: t: 102.2 bp: 129/70 p: 132 rr: 41 o2: 100% on 15l nrb gen: minimally responsive, uncomfortable appearing female in respiratory distress heent: perrl mm dry op clear neck: supple cv: tachycardic, no rubs or murmurs pulm: tachyponeic, expiratory wheezes abd: soft, nt nd ext: no edema neuro; as above pertinent results: cxr: impression: interval development of perihilar pulmonary edema. persistent left lower lobe opacity. . ecg: supraventricular tachycardia. borderline low precordial lead voltage, new compared to the previous tracing of . in addition, there is st segment elevation in leads v2-v6 consistent with an acute anterolateral ischemic process. occasional ventricular ectopy. followup and clinical correlation are suggested. . ecg: sinus tachycardia. compared to the previous tracing of the rate has increased and there is intermittent abrupt change in axis. ventricular ectopy is no longer recorded. followup and clinical correlation are suggested. . 07:47pm blood wbc-16.5*# rbc-3.98* hgb-11.7* hct-34.2* mcv-86 mch-29.3 mchc-34.1 rdw-13.9 plt ct-341 07:47pm blood neuts-83* bands-8* lymphs-3* monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 07:47pm blood hypochr-2+ anisocy-1+ poiklo-normal macrocy-normal microcy-normal polychr-normal 07:47pm blood plt ct-341 07:47pm blood pt-13.5* ptt-22.8 inr(pt)-1.2* 07:47pm blood glucose-193* urean-20 creat-0.8 na-142 k-3.7 cl-103 hco3-24 angap-19 12:50am blood type-art po2-178* pco2-28* ph-7.42 calhco3-19* base xs--4 12:50am blood lactate-4.4* 07:49pm blood lactate-3.4* 12:50am blood freeca-1.09* brief hospital course: pt was transferred to the micu for respiratory distress in setting of chf exacerbation and worsening pleural effusions. pt was being positioned for central line for iv access. she was noted to be lethargic and unresponsive. she became bradycardic and immediately went into pea. cpr was initiated and continued for 15 min without success. pt expired after 20min. family aware throughout entire brief micu course. medications on admission: mvi tramadol 50mg tylenol 650mg tid asa 81mg daily depakote 500mg qhs seroquel 25mg qam, 12.5mg q4pm and qhs depakote: 250mg daily aricept: 5mg qhs metoprolol 25mg calcium 600mg discharge medications: none discharge disposition: expired facility: discharge diagnosis: -chf exacerbation -pea discharge condition: expired discharge instructions: none followup instructions: none Procedure: Non-invasive mechanical ventilation Diagnoses: Pneumonia, organism unspecified Urinary tract infection, site not specified Unspecified essential hypertension Unspecified septicemia Severe sepsis Other persistent mental disorders due to conditions classified elsewhere Septic shock Bipolar I disorder, most recent episode (or current) unspecified

history of present illness: baby girl , first name , was born at 36 and 2/7 weeks gestation to a 26 year- old, gravida i mother by cesarean section. this pregnancy was complicated by a diagnosis at 25 weeks gestation during an ultrasound of a pelvic mass in the fetus. further assessment at with ultrasound and fetal mri revealed pelvic lesions most consistent with sacrococcygeal teratoma, that was most pelvic in location with a combination of solid and mostly cystic components. blood supply was felt to not be robust. the mass was also noticed to displace the bladder anteriorly. no hydronephrosis or other evidence of urinary obstruction was noted at the time of imaging. mother had been referred to the advanced fetal care clinic by dr. of . the parents met with dr. who presented the plan for assessment after delivery including further mri imaging to plan the surgical approach for removal of the tumor. mother's prenatal screen: blood type 0 positive, antibody negative, hbsag negative. rpr nonreactive. rubella immune. gbs unknown. mother presented to the in the evening of with preterm labor. the delivery was performed by cesarean section at that time. the infant emerged vigorous with apgars of 8 and 9 and the baby was transferred to the nicu for further assessment and treatment. physical examination: physical examination on admission showed an alert, appropriate for gestational age size 36 week gestation infant. weight 2725 grams which is 50th percentile, length 47 cm which is 50th percentile, head circumference 33 cm which is 50th percentile. stable vital signs. heent: anterior fontanel soft and flat. normocephalic, non dysmorphic. respiratory: breath sounds clear and equal. cvs: normal s1 and s2, no murmur, well perfused. abdomen soft and full in appearance with a firm mass palpable in the lower abdomen. normal bowel sounds. anus normal with a positive anal wink. a five by six cm mass was palpable over the left buttocks. the mass was soft and completely covered with skin with a small tuft of hair present. the hips were noted to have increased laxity and range of motion with abduction, not clearly dislocatable. the right foot had a mild metatarsal adductus. neuro: strong suck, symmetrical exam. tone was good, alert and responsive. hospital course: 1. respiratory: the infant has remained on room air since birth with a normal respiratory rate and rhythm and normal oxygen saturation limits. 2. cardiovascular: the infant has maintained a normal cardiovascular exam; has had no murmurs, normal blood pressure, heart rate and normal s1 and s2. 3. fluids, electrolytes and nutrition: intravenous fluids were initiated on admission to the nicu. ad lib p.o. feedings were initiated within the first few hours of life. the infant was p.o. ad lib feeding and remained on iv fluids which weaned down by day 2 of life to 20 ml per kg per day. she received golytely bowel prep at approximately 10 a.m. on followed by a diet of pedialyte thereafter. she was made n.p.o. at midnight on . her most recent set of electrolytes was a sodium of 144; potassium of 4.4, chloride 110; carbon dioxide of 23 on . her most recent weight was 2600 grams on day of life 3, . 4. gastrointestinal: due to the diagnosis of sacrococcygeal teratoma, an abdominal ultrasound was done on which showed bilateral hydronephrosis with more hydronephrosis on the right versus the left and a probable hydroureter. the mass was measured to be approximately 5.2 cm by 2.4 cm in the abdomen and felt to be mostly cystic in nature with little mass to the teratoma. a mri was performed at on to evaluate the sacrococcygeal teratoma. an afp was sent on the infant and the afp result was 1,772,400. 5. hematology: no blood typing has been done on this infant. the hematocrit at birth was 42.8 with platelet count of 353. 6. infectious disease: cbc and blood culture were screened on admission due to the preterm labor at 36 and 2/7 weeks gestation. the cbc was benign with a white blood cell count of 9,000, 32 polys and 0 bands. the blood culture remained negative. due to the hydronephrosis on the ultrasound, prophylactic amoxicillin was started on . low dose ampicillin was initiated at 100 mg/kg q. 12 hours on in preparation for surgery and the amoxicillin was discontinued at that time. she has remained free of signs of infection. 7. neurology: the infant has maintained a normal neurologic exam, moves lower extremities very well with good tone and activity. 8. sensory: audiology: a hearing screen will need to be performed prior to discharge from the hospital. 9. psychosocial: a social worker has been in contact with the family. there is no ongoing social concerns at this time but if there are any questions or concerns, the social worker can be reached at . the infant's condition at discharge is stable. discharge disposition: transfer to in for surgical repair of a sacrococcygeal teratoma with admission to the nicu at after surgery. care recommendations: continued care for sacrococcygeal teratoma repair. medications: ampicillin 280 mg iv q. 12 hours. a state newborn screen was sent on . immunizations recommended: the first synagis rsv prophylaxis should be considered from through for infants who meet any of the following 3 criteria: (1) born at less than 32 weeks gestation; (2) born between 32 and 35 weeks gestation with two of the following: either day care during rsv season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or (3) with chronic lung disease. influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. pediatrician: dr. from pediatric associates of . obstetrician delivering: , md. pediatric surgery physician: , md. discharge diagnoses: sacrococcygeal teratoma. rule out sepsis. right foot mild metatarsal abductus. , m.d dictated by: medquist36 d: 19:44:46 t: 20:06:33 job#: Procedure: Parenteral infusion of concentrated nutritional substances Diagnoses: Single liveborn, born in hospital, delivered by cesarean section Other specified conditions originating in the perinatal period 35-36 completed weeks of gestation Other preterm infants, 2,500 grams and over Other benign neoplasm of connective and other soft tissue of pelvis Talipes, unspecified Other obstructive defects of renal pelvis and ureter

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: +ett as outpt, s/p cath major surgical or invasive procedure: - cardiac catheterizations, no complications history of present illness: 70 year old man with h/o htn, hyperlipidemia, 6 months of chest pain and an abnormal ett referred for cardiac catheterization. pt c/o approximately six months of exertional dyspnea and left sided chest tightness (non-radiating, "not very bad" but could not put on scale). he denies symptoms at rest but notes that he becomes acutely sob while shoveling/inc exercise which persistently resolves with rest. + occ diaphoresis. no nausea/dizziness. no peripheral edema. on he underwent an ett where he exercised 3 minutes on protocol, stopping d/t intense fatigue and shortness of breath (no chest pain). ekg revealed 2-2. depression in leads ii, iii, avf, and 1-1.5mm st depression in leads v4-v6. referred to for cardiac cath which showed: lad with 95% ostial stenosis, lmca with diffuse disease at 30% blockage, lca/rca with mild dz. given severity of lad, he is admitted awaiting cabg on monday. after cath, pt remained pain free and no complaints. * past medical history: hyperlipidemia mild diverticulosis appendectomy kidney stones gout social history: lives with his wife in . hx of smoking but quite 30yrs ago. family history: no family cardiac hx physical exam: s/p cath bp: 153/65 hr: 58 rr: 16 o2: 98% gen: mr is an eldery male, appears younger than stated age of 70, resting comfortably flat s/p cath, nad heent: perrl, eomi, sclerae anicteric, op - pink/clear - no lesions neck: supple - could not assess jvd as pt flat cardiac: rrr, nml s1/s2, no m/g/r lungs: ant lung exam - clear, no wheezes/crackles; nml work of breathing abd: obese, soft, nt/nd ext: no c/c/e; 2+ dp pulses; warm/dry neuro: alert and oriented x3, responding appropriately pertinent results: 12:00pm glucose-119* urea n-21* creat-1.0 sodium-139 potassium-4.9 chloride-105 total co2-27 anion gap-12 12:00pm alt(sgpt)-31 ast(sgot)-20 alk phos-66 amylase-46 tot bili-0.5 12:00pm albumin-4.2 12:00pm wbc-9.2 rbc-4.30* hgb-12.1* hct-36.4* mcv-85 mch-28.1 mchc-33.2 rdw-14.0 12:00pm neuts-68.4 lymphs-25.3 monos-3.2 eos-2.4 basos-0.6 12:00pm plt count-204 12:00pm pt-13.6 ptt-28.6 inr(pt)-1.2 brief hospital course: mr. is a 70 yo male with h/o htn, hyperlipidemia with +ett, s/p cath showing which demonstrated critical stenosis of the lad. he has initially admitted to the medical service, and subsequently underwent op cagbx1 on . his postoperative course was fairly routine. he was transferred from the csru to the cardiac floor on pod#1. he did develop post-op atrial fibrilation requiring amiodarone, which chemically cardioverted him to nsr. he recovered from that point on and his chest tubes were d/c'd on pod#2. he ambulated with physical therapy and was deemed ready to be discharged home on pod#6. medications on admission: lisinopril - 5mg lipitor - 10mg daily allopurinol - asa - 81mg daily folic acid discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 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. atorvastatin calcium 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(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. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily): take for three months post surgery. disp:*30 tablet(s)* refills:*2* 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. allopurinol 100 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. tamsulosin hcl 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* 10. pantoprazole sodium 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* 11. amiodarone hcl 200 mg tablet sig: two (2) tablet po tid (3 times a day): take 400mg po tid for 3 weeks after 3 weeks take 400 po bid. disp:*180 tablet(s)* refills:*0* 12. tylenol-codeine #3 300-30 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*40 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: cad s/p off pump coronary artery bypass graft x1 post-op atrial fibrilation hyperglcemia peri-op hyperlipidemia diverticulosis s/p appendectomy h/o nephrolithiasis discharge condition: excellent discharge instructions: call dr. office if you develop fever, chills, recurrent chest pain, increased drainage from your incision, or if your incision appears red around the edges. followup instructions: call dr. office for an appointment in 2 weeks follow-up with your cardiologist folow-up with dr. with dr. Procedure: Single internal mammary-coronary artery bypass Coronary arteriography using two catheters Angiocardiography of left heart structures Left heart cardiac catheterization Injection or infusion of other therapeutic or prophylactic substance Other conversion of cardiac rhythm Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Cardiac complications, not elsewhere classified Gout, unspecified Atrial fibrillation Personal history of tobacco use Other and unspecified hyperlipidemia Other and unspecified angina pectoris Personal history of urinary calculi

allergies: penicillins attending: chief complaint: s/p l mainstem bronchus stent removal major surgical or invasive procedure: bronchoscopy with stent removal intubation and extubation history of present illness: 71yo f with a history of stage iiia non-small lung transferred to the micu after rigid bronch for observation. the patient was diagnosed with lung cancer in 4/00 and is now s/p rul lobectomy, carboplatin tx, and radiation tx. since then, she has had multiple bronchoscopies, including placement of a stent into the l main bronchus in . on , she had a bronchoscopy which revealed significant narrowing of l main bronchus with formation of granulation tissue. she underwent rigid bronchoscopy on the day of admission () showing almost 95 percent obstruction of the left mainstem bronchus. she was treated with stent removal, debridement of a large amount of granulation tissue, and argon laser coagulation. the patient was felt to be at risk for airway collapse and bleeding after the procedure, and was not extubated. she was transferred to the micu from the pacu for further monitoring and evaluation. past medical history: 1. right upper lobe lung cancer (adenocarcinoma, stage iii). in , right wedge biopsy - adenocarcinoma. in 04/00, right upper lobe lobectomy. positive hilar/paratracheal node involvement. 2. hypothyroid. 3. hyperlipidemia 4. right arm surgery (? years ago, broken arm, unable to set, metal plates and screws, patient states that she has had numerous mris since the surgery) social history: the patient is married, graduated from . no ethanol use, denies any tobacco use. she has three children, former bookkeeper/accountant. supportive and involved husband. physical exam: hr 85 bp 145/90 o2 99% ventilated intubated, sedated, withdraws x4 to pain perrl, neck supple rrr, no murmurs, s1s2 nl bronchial bs, r>l, with bs greatly reduced throughout on l abd soft, nd, +bs extr with no edema and 2+ dp pulses no rashes no extremity edema pertinent results: 07:01pm wbc-11.1*# rbc-3.91* hgb-11.4* hct-33.7* mcv-86 mch-29.3 mchc-34.0 rdw-13.2 07:01pm wbc-11.1*# rbc-3.91* hgb-11.4* hct-33.7* mcv-86 mch-29.3 mchc-34.0 rdw-13.2 07:01pm pt-12.2 ptt-22.6 inr(pt)-1.0 07:01pm glucose-108* urea n-15 creat-0.7 sodium-143 potassium-4.0 chloride-107 total co2-25 anion gap-15 brief hospital course: plan: * 1. respiratory. the patient was maintained on a ventilator after the procedure for airway protection. the patient was kept sedated for comfort but was a+ox3 and communicative througout. on , the patient had a repeated flexible bronchoscopy showing l airway patency, at which time she was extubated without complication. * 2. id. sputum culture from +gpc in pairs and the patient received 1 dose of vancomycin. * 2. fen. an ngt was placed and tf's started while pt was intubated. * 4. hyperlipidemia. the patient was kept on lipitor. * 5. hypothyroidism. the patient was kept on synthroid. * 6. prophylaxis: - lanzoprazole - pneumoboots - heparin sc * 7. precautions - mrsa + from previous bronchial washings () * 7. access: peripheral iv r, radial left a-line * 8. fc * 9. communication: son at (t) and husband. * 10. discharge. the patient was discharged to home in good condition. medications on admission: lipitor 20qd synthroid 125qd protonix 40qd mytussin tessalon pearls ambien prn discharge medications: 1. levothyroxine sodium 125 mcg tablet sig: one (1) tablet po qd (once a day). 2. atorvastatin calcium 20 mg tablet sig: one (1) tablet po qd (once a day). 3. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. tessalon perles 100 mg capsule sig: one (1) capsule po every four (4) hours as needed for cough. 5. ambien 5 mg tablet sig: 1-2 tablets po at bedtime as needed for insomnia. 6. mytussin dm oral discharge disposition: home discharge diagnosis: s/p left main bronchus stent removal discharge condition: stable discharge instructions: please return to the er if you have difficulty breathing, chest pain, feel lightheaded or dizzy, or have bloody sputum or cough. please take all your medications as directed. followup instructions: please follow up with your pcp and pulmonary doctors as arranged. md Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Endoscopic excision or destruction of lesion or tissue of bronchus Removal of other device from thorax Diagnoses: Esophageal reflux Unspecified acquired hypothyroidism Personal history of malignant neoplasm of bronchus and lung Other and unspecified hyperlipidemia Acute respiratory failure Chronic and other pulmonary manifestations due to radiation Other complications due to other internal prosthetic device, implant, and graft

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: facial swelling major surgical or invasive procedure: :portacath removal from l chest by ir. :ir venogram of svc with direct clot lysis by tpa. :repeat venogram and additional clot lysis by tpa. :final venogram and placement of svc stent. history of present illness: mr. is a 61-year- old gentleman with a history of plasmacytoma/multiple myeloma. the patient is status post autologous bone marrow transplant on for treatment of his disease (done at with dr. . since then has been fairly well, without major signs/symptoms of his underlying disease. pt states that in the last 10 days he just has not felt like himself. he has been extremely fatigued with very little appetite. pt reports a weight loss of ~ 8 lbs and he states that it has been a chore to do his daily activities. at approximately 9:00 pm on pt's wife noticed that his appearance looked different, swollen. he thought it might be a bug bite and he went to sleep on the couch. he got up at 5:00 am and felt sob. his facial swelling was not improved and he went to the ed at . at , pt was noticed to have redness and veins bulging from neck and forehead. vs - 97.3 p 93 rr 16 bp 112/73. cxr did not show a mediastinal mass. due to concerns of svc thrombosis and pt s/p transplant w/ dr. , he was transferred to . at , pt taken to ir where he had a mechanical thrombectomy, clot lysis w/ tpa, and stenting of vessels. portacath was also removed. past medical history: mm diagnosed s/p autologous bmt multiple fracture of r. humerus with hardware (hinge). s/p removal of rod from r humerus social history: pt is a former truck driver, lives at home with his wife. family history: grandfather skin cancer mother skin cancer father cad physical exam: vs 98.3 155/74 81 15 97 ra gen lying in bed comfortable nad skin facial erythema heent peerl, eomi, mmm, prominent forehead and neck veins, neck supple cv rrr no m/r/g chest: l chest portacath site draining blood bandaged, cta b/l abd soft nt nd + bs - hsm ext warm no c/c/e neuro a & o x 3 pertinent results: svc gram 1) thrombosis of the superior vena cava and proximal portions of the right subclavian and internal jugular veins. the patient has received 10 mg of tpa directly into the thrombus at the time of the procedure and is now receiving 1 mg per hour of tpa via infusion catheter into the thrombosis. this will be stopped 12 hours from now and then normal saline will be infused through the catheter at a rate of 30 cc per hour to keep the catheter open. the patient is also on a heparin drip at 200 units per hour peripherally which will be continued. 2) the patient will be reevaluated with a venogram on to evaluate clot burden at that time. 3) status post removal of the patient's left portocath. --- ct impression: bypass of superior vena cava by intravenous contrast with filling of multiple venous collaterals consistent with svc thrombosis. no significant lymphadenopathy identified --- vq scan impression: no evidence of pulmonary embolism. --- echo conclusions: 1. the left atrium is mildly dilated. 2. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. 3. the aortic valve leaflets (3) are mildly thickened. 4. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. 5. no evidence of endocarditis seen. --- tagged wbc scan impression: 1) no definite evidence of an infectious source. 2) resolving small emboli of clumped tracer material --- ct abdomen/chest impression: 1. left anterior chest wall cystic lesion. this may be postoperative in nature, representing a hematoma/seroma. an infected collection cannot be ruled out. 2. small bilateral pleural effusions, new since the prior study. 3. left upper lobe pulmonary nodule, stable from . 4. stable osseous lytic/sclerotic lesion. 5. no hydronephrosis. --- cxr impression: bilateral pleural effusions again seen, with slight interval worsening. no other interval change. --- brief hospital course: a/p 61 yo male with multiple myeloma w/ fractures of humerus and vertebrae status post bmt admitted for svc thrombosis at portacath s/p thrombectomy and clot lysis w/ tpn. the following issues were addressed during this admission: 1. svc thrombosis: his portacath was thought to be the nydus for clot formation as a result of hypercoagulability secondary to underlying malignancy. he was initially taken for direct clot lysis with tissue plasminogen activator by ir. he was sent back to the icu with a tpa infusion and heparin. he also had his portacath removed. however, while receiving tpa, he began bleeding from the port removal site which was eventually controlled with a pressure dressing. he was brought back 2 days later for additional direct tpa to remaining clot. again, he was placed on a tpa infusion. finally, several days later, he was again taken for a venogram and had a stent place in his svc. he had a narrowed section that was felt to have contributed to his formation of clot. the stent was placed effectively. of note, he had residual clot seen in the left brachiocephalic vein and the right internal jugular vein. he was then sent out on heparin and continued on this. he was switched to lovenox and his heparin gtt was stopped. he was then started on coumadin and brought to therapeutic levels, at which point the lovenox was stopped. he remained stable, with no additional thrombus or signs of svc blockage. 2. multiple myeloma: patient presented with complaints of back pain, fatigue, and weight loss over the 2 weeks prior to admission. this was concerning for relapse of myeloma. total protein was also elevated on lab values. serum protein electropheresis sent on hospital day two demonstrated a single band with 20% of his total protein present, which represented an igg level of 2463mg/dl. likewise, urine protein electropheresis identified a band containing 70% of the total urine protein and revealed the presence of bence- proteins. repeat spep 10 days later demonstrated an increase in the representation of igg in total serum protein to 25%, 1968mg/dl, which was concerning for further evidence of relapse. 3. fuo: on the day before his svc stent was placed mr had a fever to 101. he then proceeded to have daily fevers of varying magnitude for much of the remainder of his course. on the day of his stent, he was 101 again, then had a 102.3 fever the following day. at this point, he was started on vancomycin, and defervessed for approx 72 hours. all of his blood cultures were negative, and the vancomycin was stopped. he proceeded to have a return of his fever 13 hours after his last dose. the fevers then recurred daily, and on some days occured for the majority of the day. they seemed to worsen in length and intensity as his course progressed. after 2 days of febrility, the vancomycin was restarted. however, he did not defervese. it was continued nonetheless to protect his stent and arm hardware from contamination. multiple blood cultures were obtained but were perpetually negative. at this point, he had a vq scan to rule out pe, as he did have clot remaining in his body, but it was negative. he then had a chest ct and abdominal ct which were unrevealing. an echo showed no endocarditis. he then had a tagged wbc scan which showed no source of infection. other possibilities included drug fever and tumor fever. myeloma is not known to cause fever, and especially not fevers to the 103s as he was exhibiting. his medication list was reviewed and nothing known to cause fever was found. vanco was considered, but he hadthe fevers before going on this drug. he did have one episode of itchy rash that resolved with benadryl and a 5% incidence of eos of his diff. this did not recur, and was unexplained. his portacath removal site was considered as a source and eventual i&d revealed no evidence of infection. during this process, id was consulted, and levaquin and ceftazidime were both added for broader coverage of possible pathogens. at this point, there was still no culture growth and no known source of infection, although patient did begin to have occasional episodes of diarrhea, which was ultimately found to be positive for clostridium difficile. patient was treated with metronidazole. therefore, given the absence of any obvious symptoms or signs of infection or morbidity as a result of the etiology of the fever, all antibiotics were stopped (except for metronidazole), and patient continued to do well with only acetaminophen for treatment of fever. patient was ultimately discharged with occasional episodes that were not otherwise symptomatic. 4. anemia: mr initially presented with a hct of 31 on admission. this slowly trended down, and he was transfused 2 units prbcs. he had a good response, but then drifted down again and was given another 2 units. a source of bleeding was not identified. his stools were initially guaiac negative, he had no hematuria, hemptysis, or obvious bleeding source. we also had an abdominal and chest ct which did not show bleeding. hemolysis labs were sent and negative. iron studies and b12/folate were also normal and unrevealing. despite these results, patient continued to require infrequent blood transfusions for support. given the lack of evidence for hemolysis or loss of red blood cells, the low blood count was concerning as further evidence of myeloma relapse with marrow infiltration. 5. renal failure: following initial procedures performed by interventional radiology, patient's serum creatinine began to trend upwards. despite aggressive hydration, serum creatinine continued to increase. therefore, it was thought that patient's renal insufficiency was likely a result of multiple rounds of contrast dye insult during initial hospital course. although urine output continued to be adequate, patient's serum creatinine stabilized at ~1.6 (baseline had been 0.7 on admission), which was concerning for an irreversible contrast nephropathy in the setting of likely relapse of myeloma and bence proteinuria. despite the above issues, at the time of discharge, mr. claimed that he felt "the best i've felt in years", and given the stabilization of acute issues, it was felt that patient was clinically stable for discharge. at the time of discharge, patient was continuing to have occasional fevers, but had no signs or symptoms of infection. patient was discharged with a course of metronidazole to eradiacte clostridium difficile. patient was to return to clinic for follow up of possible myeloma relapse. medications on admission: zometa discharge medications: 1. coumadin 5 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 2. epogen 10,000 unit/ml solution sig: one (1) injection sc injection every m/w/f. disp:*12 doses* refills:*2* 3. flagyl 500 mg tablet sig: one (1) tablet po three times a day for 10 days. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: clostridium difficile colitis svc syndrome plasmacytoma anemia s/p tpa lysis of svc clot discharge condition: good discharge instructions: the only medications you're going out on are coumadin and epo. you will also get 10 more days of flagyl. please call your the bmt doctor on call at (ask them to page the bmt doctor on call) or return to the hospital if you experience a fever above 100.4, or have abdominal pain, chest pain, shortness of breath, dizziness, or a recurrence of your face and neck swelling. followup instructions: please call dr. and make an appointment to followup within 7-10 days. Procedure: Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Angioplasty of other non-coronary vessel(s) Injection or infusion of thrombolytic agent Endoscopic polypectomy of large intestine Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Angiocardiography of venae cavae Diagnoses: Anemia, unspecified Acute kidney failure, unspecified Bone marrow replaced by transplant Compression of vein Other complications due to other vascular device, implant, and graft Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation Benign neoplasm of colon Multiple myeloma, in remission

history of present illness: this is a 46 year-old male admitted on from the emergency department after the patient was brought in by ems for being stabbed in the back three times. the patient does not recall how the event occurred entirely, but reportedly was attacked. the patient was alert, awake, without any respiratory distress in route to the hospital without any other complaints. past medical history: history of hepatitis c status post interferon and ribavirin treatment and a history of a prior stab wound in . status post ivdu and current alcoholism. past surgical history: none. allergies: no known drug allergies. medications: none. physical examination: pulse 97. heart rate of 115/71. respirations 24. 100% o2 saturations on nonrebreather. the patient was alert and oriented times three with a small abrasion to the right neck. heent was unremarkable. the neck had a c collar in place. there was no jvd. no midline shift. cardiac examination was a regular rate and rhythm without any murmurs. lungs were clear to auscultation on both sides. abdomen was soft, nontender with bowel sounds present. the back showed there was a 2 cm stab wound to the left paraspinal region at t6 and a 2 separate 1.5 cm stab wounds at the level of t5 t6 just medial to the scapula border. extremities were warm without any edema and well perfuse. all distal pulses were intact. there was no obvious deformity. the neurological examination was grossly intact to motor function and sensation bilaterally. initial laboratories: normal cbc, normal coags, lactate of 3.2, creatinine 0.9 and otherwise normal electrolytes and an alcohol level of 95. initial radiology: chest and pelvic x-rays were normal. head ct was negative. abdominal ct was within normal limits. chest ct showed a right pneumothorax. hospital course: the patient was diagnosed with a right pneumothorax by ct and admitted for placement of right sided chest tube, which was performed without complications and serial hematocrits were monitored. the c spine was cleared once the patient was sober. chest tube was removed without incident with a small residual less then 5% pneumothorax remaining. repeat chest x-ray the following day demonstrated the pneumothorax was decreasing in size. the patient is discharged home. final diagnoses: 1. status post stab wounds to the back. 2. right sided pneumothorax. 3. hepatitis c. 4. alcohol abuse. discharge medications: 1. methadone 5 mg po b.i.d. for five days only with ibuprofen 400 mg t.i.d. 2. cefalexin 500 mg b.i.d. times four days. 3. pantoprazole 40 mg po q.d. 4. dilaudid 2 mg po q 6 hours prn for five days. recommended follow up: the patient can follow up at the trauma clinic if there are any new developments with the wounds or problems relating to this injury. otherwise he is to obtain a primary care physician for long term healthcare. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Diagnoses: Chronic hepatitis C without mention of hepatic coma Opioid type dependence, continuous Assault by cutting and piercing instrument Traumatic pneumothorax without mention of open wound into thorax Other and unspecified alcohol dependence, unspecified Open wound of back, without mention of complication

changes to discharge medications: metoprolol 100 mg tid, amiodarone 400 mg tid times 7 days, then times 14 days, then q d times 14 days, then 200 mg q d. discharge condition: stable. discharge status: is to be transferred on to a rehabilitation facility. discharge diagnosis: 1. status post cabg times four. , m.d. dictated by: medquist36 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 Other esophagoscopy Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with intermittent claudication Atrial fibrillation Other and unspecified hyperlipidemia Other and unspecified angina pectoris Unspecified sleep apnea Subendocardial infarction, subsequent episode of care

history of present illness: ms. is a 67 year-old woman with a history of hypertension, diabetes mellitus, angina who initially presented to on with chest pain. cardiac catheterization performed on revealed normal left ventricular systolic function, lmca normal, left anterior descending coronary artery 80% at d2, 70% more distal mid left anterior descending coronary artery and d1 and d2 with severe proximal lesions, left circumflex 70% mid, multiple 80 to 90% lesions in branch and obtuse marginal two and right coronary artery long subtotal mid lesion collaterals from the right coronary artery. ms. now presents to the department of cardiac surgery for elective coronary artery bypass graft. past medical history: 1. noninsulin dependent diabetes mellitus. 2. claudication. 3. hypertension. 4. hyperlipidemia. 5. sleep apnea. 6. angina. 7. one episode of atrial fibrillation in the distant past. 8. gastroesophageal reflux disease. 9. knee and back arthritis. social history: ms. lives alone in . she does not smoke or consume tobacco. family history: her father died of an myocardial infarction when he was 64 years old. medications: atenolol 100 mg q.d., aspirin 325 mg q.d., glucophage 500 mg b.i.d., tiazac 360 mg q day, glyburide 10 mg b.i.d., pletal 100 mg q.d., lipitor 10 mg q.d., zantac 150 mg b.i.d., nitroglycerin prn. allergies: no known drug allergies. review of systems: negative unless otherwise stated above. physical examination: vital signs temperature 98.5. pulse 72. blood pressure 165/75. respirations 18. the patient is resting comfortably and in no acute distress. heent normocephalic, atraumatic. neck is supple with no bruits. heart is regular rate and rhythm with normal s1 and s2. lungs are clear to auscultation bilaterally. abdomen is soft, nontender, nondistended with normoactive bowel sounds. extremities are remarkable for trace edema. hospital course: ms. was taken to the operating room on for a coronary artery bypass graft times four. grafts included left internal mammary coronary artery to left anterior descending coronary artery, right saphenous vein graft to posterior descending coronary artery, right saphenous vein graft to ramus, right saphenous vein graft to diagonal. the operation was performed without complications and then ms. was transferred to the cardiac intensive care unit. she was weaned off drips and extubated. she was hemodynamically stabilized. her recovery in the intensive care unit was unremarkable and ms. was subsequently transferred to the floor. ms. continued to do well on the floor. she was tolerating an oral diet and her pain was under control with oral medications. she was ambulating with physical therapy. ms. hospital course was complicated by recurrent atrial fibrillation. these events were controlled with intravenous lopresor and amiodarone. she was also started on oral amiodarone and her lopresor doses were increased as tolerated. these episodes of atrial fibrillation seemed to have resolved and she has been without any further reports of atrial fibrillation over the last 48 hours. given her continued improvement ms. was felt stable for transfer to a rehabilitation facility. physical examination on discharge: temperature 98.2. pulse 77. blood pressure 142/80. pulse 20. respirations 93% on room air. examination heart was regular rate and rhythm. lungs were clear to auscultation bilaterally. abdomen was soft, nontender, nondistended with normoactive bowel sounds. extremities were remarkable for 1+ edema. incision was clean, dry and intact. discharge medications: lasix 20 mg b.i.d. times two weeks. k-ciel 20 milliequivalents b.i.d. times two weeks. docusate 100 mg b.i.d., zantac 150 mg b.i.d., aspirin 325 mg q.d., atorvastatin 10 mg q.d., amiodarone 400 mg t.i.d. times three days and then 400 mg b.i.d. times seven days and then 400 mg q.d. metoprolol 50 mg b.i.d., percocet one to two tabs q 4 to 6 hours as needed for pain, metformin 500 mg b.i.d., glyburide 10 mg b.i.d., pletal 100 mg q.d., insulin sliding scale, regular insulin for glucoses measured at breakfast, lunch, dinner and bedtime - for glucose 0 to 150 give 0 insulin at all times, for 151 to 200 3 units, 201 to 250 6 units, 251 to 300 9 units, 301 to 350 12 units, greater then 350 15 units and if glucose is less then 60 please give juice. follow up: ms. is to follow up with dr. in six weeks and she is also to follow up with dr. in three to four weeks. condition on discharge: the patient is stable. discharge status: ms. is to be discharged to a rehabilitation facility. discharge diagnosis: status post coronary artery bypass graft times four. , m.d. dictated by: medquist36 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 Other esophagoscopy Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atherosclerosis of native arteries of the extremities with intermittent claudication Atrial fibrillation Other and unspecified hyperlipidemia Other and unspecified angina pectoris Unspecified sleep apnea Subendocardial infarction, subsequent episode of care

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: mental status changes major surgical or invasive procedure: ffp and cryoprecipitate transfusions history of present illness: this 25 year old female with a history of bipolar disorder, cocaine use presented initially admitted to hospital on monday with jaundice/nausea and vomiting. she was diagnosed there with hepatitis b and discharged the day of presentation. shortly after discharge she experienced severe mental status changes. she presented to where she was found to be in fulminant liver failure. there she was having hallucinations, suicidal ideations and increased combativeness. there she was given zofran and ativan. she was also given mucomyst. the patient is unable to answer questions at this time, according to the family it is not known if she had an overdose of any kind, however it is possible given that she has a long history of substance abuse. her boyfriend was recently hospitalized for hepatitis b as well. of note she had a c-section 9 months ago followed by a d&c for retained placenta, she developed an infection in her uterus at the site of a stitch, she had a hysterectomy in . past medical history: 1. cocaine/heroine use 2. hepatitis b 3. bipolar disorder 4. c-section 9 months ago 5. s/p retained placenta -> d&c 6. hysterectomy social history: lives with boyfriend and two children 9 months and 2 years, smokes, excessive drug use, rare etoh family history: no history of liver disease physical exam: vitals 98.8 (rectal), pulse 89, bp 113/63, rr 16, 97% on ra gen moaning, unresponsive to questions heent: sclera icteric, pupils 8mm, equal reactive, mmm, unable to assess op due to poor cooperation lungs: clear to auscultation bilaterally cv: rrr, nl s1s2 abd: soft, non-tender, non-distended, positive bs ext: no edema rectal: guiaic negative skin: jaundice, no rashes, no spider angiomas neuro: moaning, responsive to pain but not to voice, moving all extremities pertinent results: labs at : alk phos 171, ast 1792, alt 7857, alb 2.9, t.prot 5.3, t. bili 13.9, d.bili 3.7, acetaminophen level <10.0, salicylate wnl, etoh neg, tcis neg, pt >50, ptt 66.3, ammonia 104 wbc 7.0, hct 41.7, 150 . labs here: see below 03:10am wbc-7.7 rbc-4.56 hgb-13.9 hct-40.4 mcv-89 mch-30.5 mchc-34.4 rdw-15.0 03:10am neuts-59.2 lymphs-32.8 monos-5.6 eos-1.8 basos-0.6 03:10am plt count-137* 03:10am pt-100.0* ptt-88.0* inr(pt)-88.8 03:10am fibrinoge-161 03:10am urine color-amber appear-clear sp -1.027 03:10am urine blood-neg nitrite-neg protein-neg glucose-250 ketone-150 bilirubin-sm urobilngn-1 ph-6.5 leuk-neg 03:10am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 03:10am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 03:10am glucose-62* urea n-2* creat-0.3* sodium-143 potassium-3.7 chloride-104 total co2-28 anion gap-15 03:10am alt(sgpt)-1647* ast(sgot)-1119* ld(ldh)-239 alk phos-150* amylase-49 tot bili-15.9* 03:10am lipase-33 03:10am albumin-3.7 calcium-8.3* phosphate-3.0 magnesium-1.7 03:22am lactate-3.2* 03:20am ammonia-78* : ct head - no bleed or increased pressure cxr - normal, abdominal ultrasound - the liver is of normal echogenicity. there is no intrahepatic bile duct dilatation. the main portal vein, hepatic arteries, and hepatic veins are patent. there is no free fluid around the liver. the gallbladder is normal without evidence of stones brief hospital course: 25 year old female with history of drug abuse, recent diagnosis of hepatitis b presenting with fulminant liver failure. . 1. fulminant liver failure: ms was in acute fulminant liver failure on admission. there was no report of an overdose however we considered toxicity given her history of substance abuse. we also considered acute hepatitis as a possibility, particularly since her boyfriend had been recently diagnosed with hepatitis c. serum and urine toxicity screens at the outside hospital and were negative. hepatitis testin grevealed that she had acute hepatitis c. liver transplant evaluated her on admission, and said she was not a liver transplant candidate at that time given her history of drug abuse. the liver team was consulted, and followed her and actively guided her liver treatment throughout her stay. she was intubated for decreased mental status/ airway protection, and an ng tube was placed. she was given lactulose for her encephalopathy, with dosing titrated to bowel movements. she was treated with adefovir for hepatitis c, and with n-acetylcysteine throughout her hospitalization. given her increased risk for gram postitive infection, she was treated prophylactically with levofloxacin. her inr was monitored every 6-8 hours, and she was given ffp to maintain inr < 4.0. her fibrinogen was monitored daily, and she was given cryoprecipitate prn to maintain fibrinogen >150. her fsbg was checked every 2 hours. over the course of her hospitalization her lfts steadily improved and normalized, but her total bilirubin remained elevated, suggesting that severe liver disfunction rather than improvement in disease. throughout this she showed no signs of improving mental status, even off all sedating medications. she was monitored closely for signs of increasing intra-cranial pressure, with frequent neuro exams with pupil and retina checks. seizure-like activity with clamped jaw and left lip twitching was then noted after several days of treatment. she was treated with ativan and mannitol was started. she was also noted to have decerebrate posturing of her upper extremities. neuroscurgery and neurology were consulted, but felt there was little else to do given her acute hepatitis c, and suggested continuing mannitol and ativan. despite these therapies, she failed to recover, and began to show further signs of increasing intracranial pressure with increasing seizure activity and posturing, and on the eighth hospital day the decision was made to make to make her comfort measures only. active care was withdrawn, and shortly thereafter she passed away. . 2. elevated inr: this was due to her acute hepatitis c. she was treated with vitamin k po for 3 days twice. her inr was followed every 6-8 hours, and she was given ffp as needed for proceedures or if bleeding, and to keep inr < 4.0. . 3. respiratory: ms. was intubated for mental status changes and airway protection. her fio2 was increased midway through her stay due to desaturation> it was felt that she may have a component of heart failure given that she was 13 liters positive for length of stay. treatment with lasix was minimally effective. ultimately it was felt that her respiratory status was largely due to her encephalopathy. . 4. fen: ms had an ng tube in place throughout her hospitalization. her electrolytes were repleted as needed. we started tube feeds per nutrition recommendations, but ms. had high residuals so her tube feeds were frequently held, and never ran at the goal rate. she was bolused prn for low urine output, and received free water flushes through her ng tube.she was also treated with a mvi, folate, and thiamine. . 5. ppx: ms. was not anticoagulated given her elevated inr. she was treated with pneumoboots and protonix. . 6. full code . 7. disp: ms. died of acute fulminant liver failure secondary to hepatitis c infection on . her family declined an autopsy. medications on admission: percocet - s/p surgery discharge medications: n/a discharge disposition: expired discharge diagnosis: liver failure discharge condition: deceased discharge instructions: n/a followup instructions: n/a 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 Arterial catheterization Insertion of other (naso-)gastric tube Transfusion of other serum Diagnoses: Abnormal coagulation profile Other convulsions Bipolar disorder, unspecified Viral hepatitis B with hepatic coma, acute or unspecified, without mention of hepatitis delta Cocaine abuse, continuous Opioid abuse, continuous Other specified anemias

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: s/p fall dizziness, headache major surgical or invasive procedure: none history of present illness: pt is a yo m s/p unwitnessed fall down 10 steps at home. was unattended for 2 hours, vomited x 3 at scene. awake on ems arrival, c/o headache, dizziness, taken by ems to osh, neurologically intact, found to have stable c2 fracture. was transferred to for further evaluation and stabilization and treatment. past medical history: angina aaa - 7cm - scheduled for endovascular repair in ~1-2 weeks. htn afib pvd aortic valve replacement - porcine - pacemaker rle bypass cataracts social history: married, lives with wife family history: noncontributory physical exam: 97.0 155/107 108 afib 18 97%ra in nad, gcs15 perrla, 3-->2 bilat, 4cm left parietal hematoma trachea midline, c-collar in place back, no deformity, no stepoff, no tenderness irreg rhythm, holosystolic murmur lungs cta bilat, normal expansion abdomen soft, nontender, nondistended, +bowel sounds extremities - weakly palpable dp bilaterally, +bilat venous statsis left elbow & l forearm abrasions pertinent results: 09:00pm urine rbc-0-2 wbc-0-2 bacteria-occ yeast-none epi-0 09:00pm urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 09:00pm urine color-straw appear-clear sp -1.011 09:00pm fibrinoge-275 09:00pm pt-20.2* ptt-35.1* inr(pt)-2.6 09:00pm plt count-153 09:00pm wbc-9.4 rbc-3.44* hgb-11.9* hct-35.4* mcv-103* mch-34.7* mchc-33.8 rdw-14.6 09:00pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 09:00pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 09:00pm amylase-64 09:00pm urea n-21* creat-0.8 09:10pm glucose-142* lactate-2.9* na+-138 k+-4.8 cl--100 tco2-30 findings: there is a type iii dense fracture which extends through the body of c2 into the right lateral mass. there is a fracture line that extends into the foramen transverse sarium on the right side. the fracture fragments are minimally displaced. there is no retropulsion into the cervical spinal canal. there are prominent degenerative changes in the mid cervical spine with degenerative disk disease of c3-c7. there is also prominent facet arthropathy at these levels as well. there is high attenuation in epidural space spanning from c1-c3. this abormality is consistent with a small epidural hematoma. there is csf attenuation remaining surrounding the cervical spinal cord. there is pronounced arterial vascular calcification and bilateral pleural effusions. there is no pneumothorax. impression: 1. type iii dens fracture with extent into the lateral mass of c2 and involves the right foramen transverse sarium. there is a small epidural hematoma spanning from c1-c3. 2. diffuse spondylytic changes in the mid to lower cervical spine. impression: 1. nondisplaced fracture through the anterior superior end plate of t2 and nondisplaced fracture of the left 8th rib. 2. no evidence of compression of the spinal cord in the thoracic spine. impression: 1) cholelithiasis without evidence of cholecystitis. there is no intra or extrahepatic ductal dilatation identified. however, the distal common bile duct and pancreas were not visualized due to overlying bowel gas. 2) small septated cyst and small granuloma in the left lobe of the liver. 3) small amount of fluid in the abdomen seen above the liver dome. brief hospital course: the patient was admitted on transferred from an osh with the fractures described above. he was admitted to the trauma sicu for stabilization and close monitoring. his ct head was negative for acute intercranial injury. he received ffp and vitamin k for his elevated inr (2.6). his scalp laceration was repaired with staples. he remained hemodynamically and neurologically stable in the sicu, and developed no new neurologic deficits. his motor and sensory exam was normal and remained so throughout his hospitalization. on hd4 he was transferred to the floor. on the floor, he had some episodes of agitation, mostly at night, that required haloperidol prn. on hd6 he was found to be dyspneic with decreased o2 sats to the low 90s. his chest xray showed slight fluid overload. he was given lasix 20, and nebulizer treatments, with an improvement in his respiratory status, to o2 sats in the high 90s. on hd7, he failed a swallow test, and on hd8 a picc line was placed to provide nutrition via tpn. on hd8, he was found to be slightly jaundiced, and lfts revealed a hyperbilirubinemia (50% direct, 50% indirect). liver fellow was consulted. ruq ultrasound showed cholelithiasis with no evidence of cholecystitis, normal ducts. he was started on ursodiol 300. on hd10 he self d/c'd his picc line. re-evaluation by the swallow consult showed that he passed for soft solids and thickened liquids. he was restarted on po feedings with assistance. throughout his stay on the floor, he had occasional tachycardia to the 140s, while in afib. these were treated with additional doses of iv metoprolol. he had no such tachycardia the 2 days prior to discharge, and required no additional beta-blocker. on hd12 he was started on po medications which he tolerated well. he was seen by pt/ot, which will be continued upon discharge. he was transferred to rehab on hd 13 with follow-up with neurosurgery, and a c-collar to stay on for 12 weeks. medications on admission: coumadin 5/7.5 dig 0.25 atenolol 50 qd zantac 150bid isosorbide 30 clonopin 0.5 qd hctz 25 qd altace 5qd norvasc 10qd ntg sl prn discharge medications: 1. isosorbide dinitrate 10 mg tablet sig: three (3) tablet po bid (2 times a day). 2. ramipril 5 mg capsule sig: one (1) capsule po qd (once a day). 3. amlodipine besylate 5 mg tablet sig: two (2) tablet po qd (once a day). 4. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 5. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 6. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). discharge disposition: extended care facility: - discharge diagnosis: type iii odontoid fracture nondisplaced fracture through the anterior superior end plate of t2 nondisplaced fracture of the left 8th rib hyperbilirubinemia - resolving atrial fibrillation s/p fall discharge condition: good discharge instructions: keep the cervical collar on at all times for 12 weeks. be briefly removed only for bathing and head must be immobilized while collar is off. activities as tolerated, with assitance. small frequent meals, with assistance - soft solids, advance as tolerated. please check lfts (ast, alt, alkphos, total bili, direct bili) in 1 week. please call the liver clinic at ( with the results. thank you. please check digoxin level in 1 day, and adjust dose as needed. followup instructions: with your primary care doctor (dr. as needed. with the neurosurgery clinic in 12 weeks for a follow-up visit and ct scan. please call ( as soon as possible to schedule an appointment. Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Closure of skin and subcutaneous tissue of other sites Transfusion of other serum Diagnoses: Congestive heart failure, unspecified Unspecified essential hypertension Atrial fibrillation Peripheral vascular disease, unspecified Open wound of scalp, without mention of complication Other and unspecified angina pectoris Accidental fall on or from other stairs or steps Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Cardiac pacemaker in situ Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Closed fracture of C1-C4 level with other specified spinal cord injury Heart valve replaced by transplant Closed fracture of one rib Abdominal aneurysm without mention of rupture

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: lethargy, hypoxia. major surgical or invasive procedure: intubation history of present illness: the pt. is a year-old gentleman with multiple medical problems, recently discharged from after a hospital stay for chf exacerbation and aspiration pneumonia, who presented from rehab with increasing lethargy. pt. was noted to be "obtunded" at rehab facility on day of admission and abg was performed which was consistent with hypercarbic and hypoxemic respiratory failure (7.25/96/26). intubation was attempted at rehab without success. pt. was also noted to be hypothermic (t=94f) and was given 1 gram of iv vancomycin and 1 gram of iv unasyn prior to transfer to the ed. he was also given 100mg of iv lasix before transfer. in the ed, the pt. was noted to be tachypneic with respiratory rate in the upper 20's and abg on presentation was 7.31/87/130. he was intubated and placed on mechanical ventilation shortly after presentation. he received a dose of levofloxacin and metronidazole for presumed aspiration pneumonia. he was also given a total of 2 liters of iv fluid and 40mg of iv lasix to which he put out approximately 800 cc of urine. according to the pt's. daughter, the pt. had been increasingly confused and lethargic for three to four days pta. she also noted that his lasix dose had been recently reduced as it was felt that the pt. was "dry." upon presentation to the micu, the pt. was intubated and sedated. past medical history: -cad s/p cabg x1 venous () -pvd w/ rle bypass -htn -chronic afib s/p pacemaker -avr (porcine ) -aaa (7cm), awaiting repair -diastolic chf; tte ( at osh) ef 55%, lae, severe lvh, global hk esp. rv, mr, tr, severe pulmonary htn -anemia of chronic inflammation -h/o aspiration pneumonia -s/p peg placement, -chronic subdural hematomas vs subdural hygromas of undeterminate age. -gastritis -type iii odontoid fx -cholelithiasis w/ hyperbilirubinemia -small septated cyst and granuloma in left liver lobe -cataracts meds: -toprol xl 75mg po daily -lasix 60mg po daily -isordil 10mg po bid -heparin 5000units sc tid -lisinopril 10mg po daily -asa 325mg po daily -digoxin 125mcg po daily -pantoprazole 40mg po daily -pramipexole 0.125mg po daily -docusate 100mg po bid -acetaminophen prn -albuterol prn -loperamide prn -senna prn social history: the pt. is a resident of . he is married. no use of tobacco or alcohol. family history: father (died of mi yo) mother unknown physical exam: vitals: t: 100.3f p: 84 r: 15 bp: 145/61 sao2: 97% on 70% fio2 vent: mode: ac vt: 500 rr: 16 peep: 5 fio2: 0.7 general: elderly, cachectic male, intubated and sedated heent: perrl, eomi, mmdry, ett in place neck: c-collar in place pulmonary: coarse breath sounds bilaterally cardiac: rrr, s1s2, v/vi (+parasternal heave) hsm at lsb to axilla abdomen: soft, nt/nd, hypoactive bowel sounds, no masses noted, peg tube insertion site without erythema or drainage extremities: warm, trace le pitting edema bilaterally, 1+ dp pulses bilaterally neurologic: sedated, moving all extremities. normal tone in all extremities. 1+ biceps and patellar dtrs bilaterally. mute plantar response bilaterally. skin: no rashes noted. right heel ulcer noted with scant serosanguinous drainage. pertinent results: labs on admission: ekg: nsr at 66bpm, lad, lbbb, no st-t changes noted cxr: bilateral pleural effusions, marked cardiomegaly, perihilar haziness, apparent worsening of chf in interval since brief hospital course: 1. respiratory failure: multifactorial and due to chf exacerbation with possible aspiration event. abg on admission c/w compensated chronic respiratory acidosis, improved with ventilatory support. 2. hypotension: differential includes sepsis vs. cardiogenic shock. the patient was maintained on pressors during his stay in the . 3. axis (c2) fx.: maintain hard collar at all times, pt. has f/u with orthopaedics in early . 4. cad: continue asa 5. comm: daughter , son dr. (internist, pg. ) 6. care plan: the paitne was clearly in pain and without a good prognosis given his aspiration risk and his c2 fracture. the family relied on the primary team and the ethics consult service for guidance in planning for mr. care. in addition, mr. had expressed to his wife the desire to not have his life prolonged by "machines". he was made cmo on and placed on a t-piece while still intubated. the patient passed away at 10:30 . post-mortum was declined. medications on admission: -toprol xl 75mg po daily -lasix 60mg po daily -isordil 10mg po bid -heparin 5000units sc tid -lisinopril 10mg po daily -asa 325mg po daily -digoxin 125mcg po daily -pantoprazole 40mg po daily -pramipexole 0.125mg po daily -docusate 100mg po bid -acetaminophen prn -albuterol prn -loperamide prn -senna prn discharge disposition: expired discharge diagnosis: congestive heart failure discharge condition: expired Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Infusion of vasopressor agent Diagnoses: Atrial fibrillation Aortocoronary bypass status Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other disorders of plasma protein metabolism Heart valve replaced by transplant Acute diastolic heart failure Pressure ulcer, heel Aftercare for healing traumatic fracture of vertebrae

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypotension major surgical or invasive procedure: 1) cardiac catheterization history of present illness: 78 year old man with multiple medical problems including cad s/p recent rca taxil stent , af and sick sinus syndrome s/p pacemaker in revised in , chf with ef 45% recently admitted from for atypical chest pain (no interventions) comes in this am for elective cardiac cath to evaluate for restrictive cardiomyopathy. during the procedure his pressures dropped from the 130s/80s to sbp of 70s, he also was somnolent (?due to versed and fentanyl). he was not responsive to atropine, or to low doses of dopamine, but responded to 15mcg/kg/min of dopamine. ekg not consistent with ischemia, no other s/s. the patient was admitted to the ccu for close monitoring. given his symmetric lvh, diseases such as sarcoid and amyloid were possible but pt has not wanted a biopsy to date. an echo earlier this month showed severe symmetric lvh, inferior and septal hypokinesis, an ef 45% as above, a small pericardial effusion, and an abnormally small lv cavity (which is not reported on a repeat echo this admission). the last two findings are new since . an exercise stress test as well as a persantine stress test earlier this month were both prematurely terminated after the patient dropped his pressures. he had a normal ett in ' and an ett with elevation in his bp with exercise in . past medical history: 1. sick sinus syndrome s/p pacemaker , revised as lead was disconnected and patient p/w hr in 190s 2. afib - on coumadin chronically (held 4d prior to cath), amiodarone (dc'd 1.5 weeks ago lft abnl), av paced 3. chf - ef 45%, on coreg, altace, digoxin, lasix and asa as outpatient 4. prostate ca s/p turp c/b bleeding ; last psa 0.8 in 5. gout - on allopurinol 6. cad s/p taxil to ostial rca 7. gerd - on protonix 8. anemia - baseline hct 30-33 but data only from ; per wife in high 30s >1 year ago. 9. hematuria - after turp, therefore not on plavix for stent . cri - baseline cr 1.2-1.6 but data only from social history: lives in with wife. in visitng his daughter. tobacco, occasional etoh. no illicits. family history: brother w/ father with mi physical exam: t nr bp pre cath: 135/80l; 129/80r post cath on dopamine drip: 115-134/62-70; post cath on dopamine dc'd: 110-112/59-60. hr 70-71 post cath rr 13-23 (post cath) post cath o2 sats 92-100%3l but then nc dc'd and patient was 96%ra i/o: wt: 170# * gen: pt in nad, lying flat in bed, eyes closed; on dopamine drip (subsequently dc'd at 2:45pm) heent: perrl, eomi, no jvd, no lad neck: no jvd cv: rrr, no m/r/g; paced chest: clear on anterior exam abd: soft nt/nd; arterial and venous access in right groin, no hematoma, no bruits, non tender, no bruising of flank. ext: warm, 1+ pitting edema to knees, 1+ dp pulses bilaterally, strength 5/5, sensation intact to light touch skin: dry neuro: alert and oriented x3; easily arousable pertinent results: chemistries 09:35am glucose-113* urea n-25* creat-1.2 sodium-140 potassium-3.8 chloride-101 total co2-29 anion gap-14 lfts 09:35am alt(sgpt)-42* ast(sgot)-32 alk phos-292* tot bili-0.9 coags 07:10am inr(pt)-1.5 abg (on 3l) 09:19am type-art po2-92 pco2-40 ph-7.51* total co2-33* base xs-7 intubated-not intuba 09:19am hgb-9.5* calchct-29 o2 sat-97 cardiac cath (): comments: 1. selective coronary angiography revealed two vessel coronary disease. the lmca had mild, diffuse plaquing. the lad was moderately calcified but contained no flow-limiting disease. a d1 branch contained a modest sized, long lower pole 80% stenosis. the lad wrapped around the apex. the lcx had mild luminal irregularities throughout but was otherwise without flow-limiting disease. the rca had an ostial 40% stenosis that resulted in pressure dampening on engagement of the vessel. this was somewhat attenuated with use of a jr5 catheter. the proximal rca stent was patent with a relative 50-60% stepdown afterwards. 2. resting hemodynamics revealed elevated mean ra pressure of 16mmhg. pcpw tracing was difficult to acquire and actual measurements probably represented a hybrid of pcpw and pa pressure. lvedp was elevated at 20mmhg. cardiac output via the fick method was 3.4 l/min with a cardiac index of 1.8 l/min/m2. 3. left ventriculography was not performed. 4. central aortic pressure was low immediately after obtaining arterial access. pressure was approximately 80/60. the patient had no symptoms of lightheadedness or back pain. administration of atropine and flumazenil (to reverse the versed given before the case) did not improve the blood pressure. the patient did not respond to infusions of dopamine at 5 or 10 mcg/kg/min. ultimately, at 15 mcg/kg/min, the blood pressure rose to 120/80 with a pulse in the 70s. cardiac output on 7.5mcg/kg/min dopamine was 3.7 l/min. 5. a stat echocardiogram done in the cath lab revealed "bradycardic" appearing heart with ef 40% and no evidence of effusion. final diagnosis: 1. two vessel coronary artery disease. 2. diastolic dysfunction. pressures ra 16 rv 43/15 pcw 24 pa 43/22 ao 83/57 lv 85/22 * sats svc 56% pa 49-51% ao 93-98% echo (): conclusions: 1. limited focused study. 2. the left atrium is moderately dilated. the left atrium is elongated. 3.the right atrium is moderately dilated. 4.there is severe symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50-55%). resting regional wall motion abnormalities include basal and mid septal hypokinesis. 5.the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. right ventricular systolic function is normal. 6.the aortic valve leaflets (3) are mildly thickened. no color doppler study was done to assess for the presence of mr . 7. the mitral valve leaflets are mildly thickened. 8.there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. the effusion appears circumferential. 9. an echogenic density in the right ventricle is present consistent with a pacemaker lead. compared with the findings of the prior study (tape reviewed) of , the pericardial effusion is much less. the overall function is unchanged. ct abd, non contrast () r/o retroperitoneal bleed impression: 1. no evidence of retroperitoneal or groin hemorrhage. 2. moderate size bilateral pleural effusion effusions and bilateral lower lobe atelectasis. 3. innumerable punctate low-attenuation liver lesions. these are likely benign but are too small to characterize. 4. irregular thickened bladder wall. this may be partially due to incomplete distention of the bladder. there is likely a small right bladder diverticulum. further evaluation of the bladder wall with direct visualization should be considered. 5. left hydrocele. ekg (): c/w lbbb as patient is paced; no evidence of acute stemi, no change on . ct chest (): small calcifications c/w granulomas in lll and rul, as well as in liver. pulmonary nodule in lul. small mediatstinal nodes. small b/l pleural effusions. small pericardial effusion. brief hospital course: 1. cardiovascular a. rate/rhythm - the patient had underlying af, sss with pacer in place. he came in on a beta blocker. these were held the day of catheterization but were added back the following day. while here he was well controlled on this regimen. coumadin still held in anticipation of biopsy. no anticoagnulation at present. b. pump - the patient came in on an acei, lasix, and digoxin. these meds were held the day of catheterization () but reinitiated the following day. he had an episode of hypotension requiring dopamine drip during catheterization but was weaned off the drip the same evening. his ef was 45%. he also received two additional iv doses of lasix on while he received 2 units of prbcs with good uop afterwards. c. cad - s/p rca stent in , and since has had the pump problems above. his asprin 81mg was continued during this admission. d. pericardial effusion - small, but new since . stable issue during this admission. e. symmetric lvh: seen on echo, and differential includes diseases such as amyloid and sarcoid. a cardiac biopsy for tissue dx was planned while the patient was admitted. however, his inr was somewhat evevated after having stopped coumadin and was 1.7 on . therefore he was given vitamin k with a decrease in his inr to 1.5 on . the interventional cardiologist felt that the inr should be lower, and that the patient should be placed on lovenox and return for the biopsy next week. this was scheduled for tuesday, . he was given another dose of vitamin k on and will get his inr checked on saturday. * 2. pulmonary - the patient maintained good sats with 2l nc. he had calcifications c/w granulomatous dz in liver and lung, possible sarcoid or tb. - ace level pending on discharge - ppd placed () - negative on * 3. renal - the patient had chronic renal insufficiency of unclear etiology. his creatinine was stable over the past one month, and during his hospitalization. * 4. id - during admission the patient remained afebrile, without a white count. * 5. gi - after his procedure, the patient was advanced to a cardiac diet. lft abnormalities on admission were lower than earlier this month. * 6. gu - s/p turp c/b hematuria in the past so was not on plavix for his stent. foley dc'd am. * 7. heme/onc - hct 36.7 after 2 units (), up from 28.6. inr 1.5 on after vitamin k given on , he was given another dose on . previously on coumadin - held on friday for procedure. the coumadin was held, and the patient was sent home on lovenox until procedure tuesday. * 8. endo - glucose stable in low 100s. hiss with qid fs. earlier this month ft4 was mildly elevated at 1.9 with normal tsh at 3.8. * 9. psych - no issues, wife supportive. * 10. proph - ppi, heparin sq, bowel regimen, tylenol. c/o constipation so increased bowel regimen. * 11. drains/tubes/lines - right groin arterial and venous access - dc'd at 2:45pm on ; now with l piv. * 12. dispo - sent home on to return for biopsy next tuesday . medications on admission: coreg 6.25mg altace 1.25mg digoxin 0.125mg lasix 40mg coumadin ld, held protonix 40mg allopurinol 100mg k dur 10meq mvi recently dc'd amiodarone lft abnl discharge medications: 1. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. allopurinol 100 mg tablet sig: one (1) tablet po qd (once a day). 3. multivitamin capsule sig: one (1) cap po qd (once a day). 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). 5. carvedilol 3.125 mg tablet sig: two (2) tablet po bid (2 times a day). 6. ramipril 1.25 mg capsule sig: one (1) capsule po qd (once a day). 7. outpatient lab work please come to the emergency department on saturday to have your inr drawn. you do not have to stay for the results. ordering physician . 8. medication vitamin k - take 10mg by mouth tomorrow 9. zocor 40 mg tablet sig: one (1) tablet po once a day. 10. lasix 20 mg tablet sig: one (1) tablet po every other day. discharge disposition: home discharge diagnosis: 1. hypotensive episodes since 2. sick sinus syndrome s/p pacemaker , revised as lead was disconnected and patient p/w hr in 190s 3. afib - on coumadin chronically (held 4d prior to cath), amiodarone (dc'd 1.5 weeks ago lft abnl), av paced 4. chf - ef 45%, on coreg, altace, digoxin, lasix and asa as outpatient 5. prostate ca s/p turp c/b bleeding ; last psa 0.8 in 6. gout - on allopurinol 7. cad s/p taxil to ostial rca 8. gerd - on protonix 9. anemia - baseline hct 30-33 but data only from ; per wife in high 30s >1 year ago. 10. hematuria - after turp, therefore not on plavix for stent . cri - baseline cr 1.2-1.6 but data only from discharge condition: stable, tolerating an oral diet, ambulatory, afebrile. discharge instructions: take all your regular medications take vitamin k 10mg tomorrow have your inr checked in the ed on sat am please return next week for your cardiac biopsy. weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet followup instructions: dr for biopsy next week dr per your routine Procedure: Injection or infusion of platelet inhibitor Left heart cardiac catheterization Coronary arteriography using a single catheter Angiocardiography of right heart structures Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Long-term (current) use of anticoagulants Cardiac pacemaker in situ Sinoatrial node dysfunction

discharge medications: 1. colace 100 mg one po b.i.d. 2. aspirin 81 mg po q day. 3. robitussin syrup 5 mls po q 6 hours prn. 4. zoloft 25 mg po q day. 5. heparin flush for picc 100 units per ml give 2 ml intravenously q day prn with 10 ml of normal saline followed by 2 ml of heparin each lumen q day and prn. site is to be inspected each shift. 6. senna one tablet b.i.d. prn. 7. maalox 30 cc po q 6 hours prn. 8. neurontin 300 mg po q day. 9. captopril 12.5 mg po t.i.d. hold for systolic blood pressure less then 100. 10. ativan .5 to 2 mg intravenously q 4 hours prn. 11. amiodarone 200 mg po q day. 12. insulin sliding scale subcutaneous as directed. 13. atrovent meter dose inhaler six puffs q 6 hours. 14. metoprolol tartrate 12.5 mg po b.i.d. hold for systolic blood pressure less then 100 and for a pulse less then 60. 15. albuterol meter dose inhaler six puffs q six hours. 16. dulcolax suppository 10 mg q day. 17. lansoprazole 30 mg po q day (via g tube). 18. polyvinyl alcohol 1.4% drops one to two drops ophthalmic prn. 19. artificial tears .1% ointment prn. 20. heparin 5000 units subq q 8 hours. 21. percocet 5/325 mg in 5 ml solution give 5 ml po q 4 to 6 hours prn for peripheral neuropathy. 22. miconazole powder one application miscellaneous b.i.d. prn. 23. oxacillin 2 grams intravenously q 4 hours, this antibiotic should be given for the full day of . 24. lasix 40 mg intravenously q day. the dose of this medication may be adjusted according to the patient's urine output. goal diuresis is for a negative 500 to 1000 cc for the next several days. the patient does respond to the dose of 40 mg intravenously, however, this may need to be decreased or changed to po depending on rate of diuresis. treatments and frequency: the patient will need q four hour suctioning for thick bloody secretions that continue to improve in the management of his congestive heart failure. however, he does need to have suctioning every four hours regularly. his diet will be tube feeds. he will need physical therapy. you may refer the physical therapy recommendations for weight bearing status, however, the patient was wheel chair bound at baseline prior to hospital admission and now has multiple medical comorbidities in addition to icu polyneuropathy. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnostic ultrasound of heart Insertion of endotracheal tube Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Transfusion of packed cells Diagnoses: Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Methicillin susceptible Staphylococcus aureus septicemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other complications due to other cardiac device, implant, and graft Methicillin susceptible pneumonia due to Staphylococcus aureus

history of present illness: this is a 77-year-old male with complex cardiac history including coronary artery disease, status post coronary artery bypass graft in with multiple percutaneous interventions, instent stenosis as well as brachytherapy, congestive heart failure, ejection fraction of 42%, hypertension, hyperlipidemia, gastrointestinal bleed, cva, weakness, dementia. the patient originally presented to the hospital on with complaints of slow onset of left shoulder pain, about that radiated to the back associated with shortness of breath, but without nausea, vomiting or palpitations; somewhat similar to his past angina. patient was given aspirin at home and brought to the emergency room by ems. in the emergency room, he received nitropaste, lopressor, morphine, tramadol and had some improvement in his symptoms. review of systems: significant for a lack of fevers and chills, non-productive cough with a head cold without shortness of breath. positive peripheral burning neuropathy, no dysuria, no hematuria, no sick exposures, no lower extremity edema, no orthopnea. past medical history: 1. coronary artery disease, status post coronary artery bypass graft in (graft right saphenous vein graft to left anterior descending, saphenous vein graft to ramus to om and saphenous vein graft to posterior descending artery), complicated by instent restenoses of the saphenous vein graft to left anterior descending in , saphenous vein graft to ramus and om in with subsequent stent placement which was then further complicated by instent stenoses treated by percutaneous transluminal coronary angioplasty and brachytherapy in . last cardiac catheterization was which revealed significant native three vessel disease, with patent saphenous vein graft to left anterior descending with 40-50% instent restenoses, saphenous vein graft to ramus to om with ostial 70% instent restenoses and 80% instent restenoses and proximal stent, as well as 50% stenoses distally in the saphenous vein graft, saphenous vein graft to posterior descending artery totally occluded. patient underwent brachytherapy of instent restenoses and saphenous vein graft to ramus to om, as well as atherectomy and percutaneous transluminal coronary angioplasty of instent restenoses of saphenous vein graft ramus to om. 2. congestive heart failure. last echocardiogram during this admission, , ejection fraction 40-45% with anterolateral akinesis, posterior hypokinesis. 3. 1+ ai. 4. mitral regurgitation. 5. hypertension. 6. hyperlipidemia. 7. question of cva in . 8. right internal carotid disease. 9. history of gastrointestinal bleed with duodenal ulcer and esophageal erosion in , treated with embolization. 10. benign prostatic hypertrophy. 11. spastic bladder. 12. gait disorder, multifactorial, wheelchair bound status with progressive functional decline over the past one year. 13. urinary tract infection. 14. esophagitis. 15. question of buccal facial apraxia. new on this admission. 16. frontotemporal dementia, not parkinson's per neurology. 17. history of strangulated abdominal hernia and repair. 18. atrial fibrillation and atrial flutter during this admission. allergies: statin which causes hepatitis. medications at the time of admission: 1. zoloft 25 mg po q.d. 2. lopressor 25 mg po b.i.d. 3. prilosec 20 mg po q.d. 4. tramadol 50 mg po q.d. 5. oxycodone 1 tablet, po b.i.d. 6. aspirin 81 mg po q.d. physical examination at the time of admission: vital signs: pulse 75. blood pressure 149/63. respiratory rate 25. oxygen saturation 3 liters nasal cannula with 95% oxygen saturation. general: chronically ill-appearing elderly male. head, eyes, ears, nose and throat: pupils equal, round and reactive to light. extraocular movements intact. no conjunctival injection. oropharynx with thick white secretions posteriorly. mucous membranes are dry. neck: no lymphadenopathy, no jugular venous distention, no hepatojugular reflux, no carotid bruits. cardiovascular: no heave, no thrills, point of maximal impulses laterally displaced and diffuse, regular rate and rhythm with occasional premature ventricular contractions, 3+ holosystolic murmur at left upper sternal border. pulmonary: expiratory wheezes half way down bilaterally. crackles one third of the way up on the right, decreased breath sounds half way up on the left. abdomen: positive distention, positive bowel sounds, guaiac negative, nontender, no hepatosplenomegaly. extremities: 1+ edema bilateral lower extremities. neurological: 2+ reflexes throughout. laboratory data at the time of admission: white blood cell count 9.2, hematocrit 37.2, platelets 185,000. differential: neutrophils 84%, lymphocytes 11%, monocytes 4%, eosinophils .3%, basophils .2%. sodium 131, potassium 4.8, chloride 97, bicarbonate 29, bun 26, creatinine 0.6, ck 86, troponin of .02. chest x-ray: mild cardiomegaly compared to prior films, perihilar haziness, elevated left hemidiaphragmatic (old), small left pleural effusion consistent with mild congestive heart failure. electrocardiogram: normal sinus rhythm, left axis deviation, left ventricular hypertrophy, left anterior fascicular block, left atrial enlargement, down sloping st segments 1 mm in i, avl, v2, v3 with small st depressions in v5 and v6 less than a mm, t wave inversions in i, avl, biphasic t wave in ii. in comparison with an electrocardiogram dated , the patient's electrocardiogram at the time of admission appeared to be improved in terms of the st segment, t wave inversion were normalizing v2 to v6. in relation with an electrocardiogram done in , the st depressions are new. hospital course: by system: 1. cardiovascular: ischemia: the patient ruled out for myocardial infarction at the start of his admission. it was thought that his initial shoulder pain was more related to a pulmonary process versus a cardiac process. he subsequently was maintained on aspirin, beta-blocker and ace inhibitor, doses of which were variable throughout his hospital course based on his blood pressure and other ongoing medical issues. it was told to us that patient does not tolerate statins or plavix and he was not maintained on these medications. pump: patient had an echocardiogram on this admission that showed an ejection fraction of 40-45% consistent with systolic congestive heart failure. his hospital course was notable for increasing blood pressures 200/100s soon after his admission with associated shortness of breath and oxygen desaturations to 92% on a nonrebreather. this was thought to be consistent with flash pulmonary edema. patient was diuresed subsequently hypotensive requiring a dopamine drip and was transferred to the intensive care unit for closer monitoring, as well as a question aspiration event. patient was treated with a nitroglycerin drip and lasix and did have an electrocardiogram that showed st depressions in the anterior lateral leads thought to be secondary to demand ischemia. he was subsequently in the coronary care unit, however, his course was then complicated by persistent hypoxia from pneumonia and his blood cultures grew out 3-4 bottles of methicillin sensitive staph aureus. patient required intubation on and was subsequently transferred to the medical intensive care unit service after an episode of hypotension with systolic blood pressures down to the 60s. he was subsequently started on a neo drip, given fluid boluses, extubated on and transferred to the floor and then re-intubated on in the setting of an aspiration event, desaturations, when he was found unresponsive with a weak cough. at that time, the patient was then transferred to the intensive care unit. subsequent details will be elaborated in the various problems. rhythm: the patient remained in normal sinus rhythm with relative bradycardia during his intensive care unit stay which dates until the time of discharge anticipated to be during the week of . patient received amiodarone load and then followed by op amiodarone while he was in the coronary care unit and has subsequently remained out of atrial fibrillation and atrial flutter. the issue of anticoagulation was raised, however, given patient's multiple ongoing medical problems, bloody sputum and history of cva, as well as history of gastrointestinal bleed, which was severe, patient was not anticoagulated on this admission and that will need to be re-addressed when the patient is more stable. 2. pulmonary: patient has had multiple complex problems with his pulmonary status during this admission but to summarize, he initially had hypoxia secondary to congestive heart failure. subsequently, he was found to have difficulty with swallowing and probable persistent aspiration with a failed swallow evaluation on with subsequent positive blood cultures for methicillin sensitive staph aureus. he was on several antibiotic courses including initial levofloxacin and flagyl for aspiration pneumonia which was started on and discontinued on . subsequently he was empirically started on zosyn for potential pseudomonal nosocomial pneumonia, as well as vancomycin on the for gram positive cocci, however, when he had neck gene analysis for the infectious disease service and was found to have methicillin-sensitive staphylococcus aureus, he was changed to a course of four weeks of oxicillin and 14 days of levofloxacin per infectious disease recommendations. his course of oxicillin is due to end on . he will complete his levofloxacin at the same time. patient had multiple intubations and extubations during this admission. it is unclear what the precipitants of his worsening hypoxia were during all the various events, although, aspiration seemed to play a large role, as well as congestive heart failure and these are the two main issues for which he was treated while he was here. patient underwent bronchoscopy on where he was found to have a lingula with sputum plug. he had a repeat bronchoscopy on at which time he was found to have very thick secretions mixed with blood in the et tube. it was thought that the patient likely had a mucous plug and some aspiration which then led to pulmonary edema and congestive heart failure with bloody secretions. patient had difficulty weaning from the ventilator and ultimately had a trachea on . subsequently he was able to come off of the ventilator and is currently doing well from a respiratory prospective, however, he does require at least q. 4 hour suctioning of his thick bloody secretions which are thought to be due to congestive heart failure, as well as his pneumonia. patient also had a thoracentesis of about 800 cc of straw colored fluid on which improved his breathing parameters and culture data from that fluid was negative. 3. neurological: patient has had a chronic neurological condition over the past six months to one year over which time he has had a function decline and is wheelchair bound at home. he was seen and followed by neurology multiple times during this hospitalization. it is thought that he may have some sort of neurological degenerative disorder at baseline. he definitely has a sensory polyneuropathy and he had an emg during this hospitalization on consistent with icu polyneuropathy, as well as a mild myopathy. patient will need a neurology follow-up as an outpatient for further evaluation. there was some talk of myasthenia , however, this was then thought to be unlikely and further diagnostic work-up was not pursued along these lines. 4. gastrointestinal: patient did have an ileus during this hospital course and has been continued on an aggressive bowel regimen. he had no subsequent problems with this issue. he also had a g tube placed by gastrointestinal on and tolerates his tube feeds at goal at this point. 5. anemia: patient has a history of anemia, as well as a history of gastrointestinal bleed. he was transfused to maintain his hematocrit above 30 during his hospital course. 6. iv access: patient had multiple central lines and a lines during this hospitalization. he currently has a picc line in place that was placed on by interventional radiology. 7. prophylaxis: patient was maintained on subcutaneous heparin prophylaxis, protonix and a bowel regimen during his hospital course. 8. code: patient's code status is full code. 9. disposition: patient is being screened for rehabilitation at this time. dr , naimesh 12.acv dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnostic ultrasound of heart Insertion of endotracheal tube Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Transfusion of packed cells Diagnoses: Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Methicillin susceptible Staphylococcus aureus septicemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other complications due to other cardiac device, implant, and graft Methicillin susceptible pneumonia due to Staphylococcus aureus

discharge medications: locholest light 4 gm p.o.b.i.d. colace 100 mg p.o.b.i.d. dulcolax suppository p.r.n. protonix 40 mg p.o.q.12h. lopressor 37.5 mg p.o.b.i.d. aspirin 325 mg p.o.q.d., to be started on given the patient's recent gastrointestinal bleed. discharge status: the patient will ultimately be discharged to a skilled nursing facility, the name of which is not yet known. , m.d. dictated by: medquist36 Procedure: Other endoscopy of small intestine Injection or infusion of other therapeutic or prophylactic substance Arteriography of other intra-abdominal arteries Diagnoses: Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Hyposmolality and/or hyponatremia Atrial fibrillation Paralysis agitans Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of unspecified site, initial episode of care Esophagitis, unspecified

history of present illness: mr. is a 77-year-old man with a history of coronary artery disease, status post coronary artery bypass graft and multiple stents, history of after a fall related to a multi-factorial gait disorder. he was performed and the patient was rehydrated. the patient did well until he developed hyponatremia during his stay with the neurology service. his sodium was found to be at 122. he was thought to have hyponatremia secondary to the addition of hydrochlorothiazide to his medication regimen. the renal hyponatremia. throughout the course of his hospital stay, the hyponatremia resolved. on , he had an episode of coffee ground emesis with nausea. an nasogastric lavage was performed which demonstrated one liter of coffee grounds which did not clear with lavage. his hematocrit was also found to have decreased from 38 to 32. his systolic blood pressures also dropped from 130 to 90. the family noted about one month of nausea which the patient experienced at night after eating heavy meals and laying down to sleep. he has also complained of a decreased appetite over the past three to four weeks. his nausea was relieved by zantac over-the-counter. he has never had a previous episode of coffee ground emesis. he denies any other melena or bright red blood per rectum. he had a history of stomach problems in his late 20's with a question diagnosis of gastritis seen on a barium swallow. he has no known history of peptic ulcer disease or gastroesophageal reflux disease. on hospital day six, the patient was transferred to the medical intensive care unit for further evaluation. past medical history: 1. coronary artery disease status post coronary artery bypass graft and multiple stents. his primary cardiologist is from cardiology. 2. history of cerebrovascular accident in . 3. multi-factorial gait disorder secondary to polyneuropathy, cervical spondylosis, and cva. he is followed by from neurology. 4. hyperlipidemia (the patient did not tolerate statins). 5. hypertension. 6. benign prostatic hypertrophy. status post transurethral resection of prostate. 7. right carotid occlusion. 8. spastic bladder. allergies: no known drug allergies. outpatient medications: 1. lochol 4 grams twice a day. 2. toprol 50 mg p.o. q day. 3. norvasc 5 mg p.o.q day. 4. hydrochlorothiazide 25 mg p.o. q day. 5. aspirin 325 mg p.o. q day. 6. multivitamin. 7. zantac 75 mg p.o. b.i.d. 8. medication for spastic bladder which the patient could not recall. medications on transfer: 1. locholestlyte 4 grams b.i.d. 2. zofran p.r.n. 3. colace 100 mg p.o. b.i.d. 4. levofloxacin 500 mg intravenous every 24 hours. 5. protonix 40 mg intravenous twice a day. 6. lopressor 25 mg p.o. b.i.d. physical examination on presentation: vital signs temperature 98.1, blood pressure 118/62, heart rate 71, respirations 18, o2 saturation 99% on two liters. general: alert, comfortable. neck: right ij in place, noted to be clean, dry and intact without erythema. lungs: clear to auscultation bilaterally with the exception of decreased breath sounds at the basis. cardiovascular: regular rate and rhythm with a 4/6 systolic murmur at the right upper sternal border. abdomen: positive bowel sounds, soft, nontender, nondistended. extremities: notable for trace edema in bilateral fingers, no evidence of lower extremity edema. pertinent labs and studies: white blood count 5.8, hematocrit 28.9. platelets 133. sodium 139, potassium 3.7, chloride 106, bicarbonate 25, bun 22, creatinine 0.4. glucose 88. magnesium 1.8. h. pylori negative. urinalysis trace leukocyte esterase, occasional bacteria, 21 white blood cells. troponin which peaks at 20 and most recently on was 4.5. mr of the spine: limited examination though no definite evidence of cord compression. chest x-ray: no evidence of pneumonia. small bilateral pleural effusions and atelectasis with compression/collapse of the basilar left lung associated with an elevated left hemi-diaphragm. hospital course: 1. gastrointestinal. on hospital day six the patient developed coffee ground emesis. he was found to have a hematocrit drop from 36 to 32. he was also found to be slightly hypotensive. decision was made to transfer him to the medical intensive care unit for further care. while in the intensive care unit, the patient underwent an esophagogastroduodenoscopy which revealed grade i esophagitis in the middle third of the esophagus and lower third of the esophagus. blood was also noted in the proximal bulb and second part of the duodenum. epinephrine injection and electrocautery were attempted but hemostasis was unsuccessful. the decision was made to consult interventional radiology so that the patient could undergo a mesenteric angiogram. on the patient underwent a mesenteric angiogram which also involved coil embolization of the gastroduodenal artery. this was successfully completed. the patient tolerated the procedure well with no complications. in addition to the interventional radiology service, the general surgery service was consulted regarding the patient's upper gastrointestinal bleed. the decision was made to defer surgery given that the coil embolization of the patient's gastroduodenal artery was successful. on hospital day #9, the patient was continuing to have no evidence of further rebleeding. his hematocrit was otherwise stable. he did undergo and additional blood transfusion on since his hematocrit was less than 30 in the setting of known coronary artery disease. the post transfusion hematocrit bumped appropriately and was 32.5. in total, the patient received 6 units of packed red blood cells. the patient was continued on protonix 40 mg intravenous twice a day. he was also advanced to a cardiac diet without any difficulty. the patient subsequently was noted to have dysphagia, and bedside evalution was notable for aspiration of liquids. he underwent video swallowing study which was notable for recurrent aspiration felt to be neurological in nature. recommendations were made for thickening and chin tuck which will be included in his transfer orders. 2. cardiovascular. the patient was also noted to have a non-st elevation myocardial infarction which was thought secondary to demand ischemia in the setting of a gastrointestinal bleed. throughout his entire hospital stay, the patient did not complain of any chest pain or short of breath. his ck levels remained within normal limits, though his troponin levels did peak at 20 on . since this time, his troponin's have been trending downward. the patient was continued on a beta-blocker for management of his coronary artery disease. he was not given any aspirin in light of his gastrointestinal bleed. he will likely be restarted on an aspirin regimen in one to two weeks following discharge. the patient also developed paf w/ rvr which responded to prn iv lopressor. because of his recent ugib anti-coagulation will need to be deferred. the decision of when and if to initiate anticoagulation will need to be discussed with both gi and cardiology. 3. renal. the patient's hyponatremia resolved over the course of his hospital stay. he developed no neurological symptoms. his creatinine remained stable and on was 0.4. his potassium and magnesium levels were repleted as necessary. 4. pulmonary. the patient was eventually weaned off his o2 requirement. we encouraged him to use his incentive spirometer to prevent atelectasis. he did exhibit increased secretions in his upper airway. we instituted chest physical therapy to aid in the patient's respiratory status. 5. id: the patient was started on levofloxacin 500 mg q day for a urinary tract infection secondary to coag negative staphylococcus. he will be treated for a total of 7 days. 6. prophylaxis. the patient was administered protonix for ulcer prophylaxis. he was also placed on pneumatic boots for prevention of deep vein thrombosis. discharge diagnosis: 1. upper gastrointestinal bleed. status post coil embolization of the gastroduodenal artery. 2. urinary tract infection. 3. non-st segment elevation myocardial infarction. 4. multi-factorial gait disorder. 5. hyponatremia - now resolved. 6. coronary artery disease. 7. history of cerebrovascular accident. discharge medications: the patient's discharge medications will be found on his page one form as well as on the discharge addendum. discharge status: skilled nursing facility to be which he will be discharged will be mentioned in the discharge addendum. , m.d. dictated by: medquist36 d: 17:18 t: 16:29 job#: Procedure: Other endoscopy of small intestine Injection or infusion of other therapeutic or prophylactic substance Arteriography of other intra-abdominal arteries Diagnoses: Pure hypercholesterolemia Urinary tract infection, site not specified Unspecified essential hypertension Hyposmolality and/or hyponatremia Atrial fibrillation Paralysis agitans Hemorrhage of gastrointestinal tract, unspecified Acute myocardial infarction of unspecified site, initial episode of care Esophagitis, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: ventral hernia major surgical or invasive procedure: ventral hernia repair hematoma evacuation history of present illness: this is a 47 year old gentleman with ulcerative colitis status-post a j-pouch operation in ' with a reversal of ileostomy later that year who presents with recurrence of a ventral incisional hernia. he last had this operated on in and now presents with hernia repair with separation of components. he consented after it was explained that he might loose sensation in his abdominal wall and would lose his umbilicus. symptomatically he denies abdominal pain, nausea, vomitting, or constipation. past medical history: ulcerative colitis j-pouch ileostomy reversal ventral hernia repair atrial fibrillation mitral valve annuloplasty pace-maker social history: the patient is a rabbi and happily married with children. he does not smoke or drink alcohol. family history: negative for inflammatory bowel disease or colon cancer physical exam: on admission: v/s 96.5, 62, 97% room air, rr 18, 107/69 gen: no acute distress, well-nourished middle aged male heent: moist mucous membranes, perrla neuro: cn 2-12 grossly intact cv: irregular rhythm, v-paced, no murmurs appreciated abd: soft, palpable swelling at midline,prior laparotomy incisions well healed, non-tender, non-distended, normoactive bowel sounds extr: no edema,warm pertinent results: serologies 08:22am blood hgb-13.7* hct-38.4* plt ct-166 02:08am blood wbc-9.0# rbc-2.93*# hgb-9.0*# hct-25.7* mcv-88 mch-30.9 mchc-35.1* rdw-13.4 plt ct-91* 03:24am blood wbc-8.4 rbc-3.46* hgb-10.8* hct-30.6* mcv-88 mch-31.2 mchc-35.3* rdw-13.9 plt ct-85* 03:00am blood wbc-7.2 rbc-3.50* hgb-10.7* hct-30.9* mcv-88 mch-30.7 mchc-34.7 rdw-13.7 plt ct-94* 08:43am blood wbc-8.8 rbc-4.01* hgb-12.8* hct-35.3* mcv-88 mch-31.9 mchc-36.2* rdw-13.2 plt ct-149*# 05:15am blood wbc-7.9 rbc-3.53* hgb-10.9* hct-31.1* mcv-88 mch-30.9 mchc-35.1* rdw-13.3 plt ct-145* 05:25am blood wbc-7.0 rbc-3.37* hgb-10.5* hct-29.6* mcv-88 mch-31.1 mchc-35.4* rdw-13.0 plt ct-155 08:22am blood pt-15.7* ptt-36.0* inr(pt)-1.6 09:00pm blood pt-16.2* ptt-30.3 inr(pt)-1.7 05:42am blood pt-14.3* ptt-33.4 inr(pt)-1.3 03:24am blood pt-13.7* ptt-29.4 inr(pt)-1.2 03:00am blood pt-13.2 ptt-28.5 inr(pt)-1.1 05:25am blood pt-13.7* ptt-29.1 inr(pt)-1.2 05:55am blood pt-14.1* ptt-30.6 inr(pt)-1.3 06:50pm blood glucose-222* urean-14 creat-0.9 na-134 k-5.2* cl-100 hco3-26 angap-13 02:08am blood glucose-103 urean-13 creat-0.8 na-139 k-4.3 cl-108 hco3-22 angap-13 03:24am blood glucose-132* urean-6 creat-0.7 na-140 k-3.7 cl-105 hco3-31* angap-8 03:00am blood glucose-134* urean-5* creat-0.7 na-139 k-3.3 cl-102 hco3-31* angap-9 08:43am blood glucose-131* urean-9 creat-0.8 na-140 k-3.4 cl-99 hco3-33* angap-11 05:15am blood glucose-107* urean-11 creat-0.7 na-140 k-3.5 cl-105 hco3-26 angap-13 05:25am blood glucose-89 urean-12 creat-0.6 na-139 k-4.2 cl-104 hco3-27 angap-12 05:55am blood calcium-8.7 phos-3.8 mg-1.8 radiology: abdominal xray:1. mildly dilated loops of small bowel consistent with postoperative ileus. 2. no definite foreign body identified. microbiology mrsa, vre screen: negative brief hospital course: this is a 47 year old male who presented for operative management of a recurrent ventral hernia. he underwent ventral hernia repair with component separation on . both plastics surgery and gi surgery were involved in this procedure, which went well with no complications. anticoagulation was held in the perioperative period because of risk for bleeding. on the evening of post-operative day 0 he had an obvious abdominal wall hematoma and a drop in hematocrit from 35 to 25 and he was returned to the operating room for re-exploration . there he was found to have a rectus muscle bleed with was cauterized and -seal was added to improved hemostasis. he was given 4 units of prbc and 4 units of ffp. he was transferred to the icu post-operatively and extubated on post-op day 1. his hematocrit was stable for the next few days. he was transferred to the floor after a 2 day icu stay in stable condition. he was started on a clear liquids diet on post-operative day 4 but vomitted and an ngt was placed. this was clamped on pod 5 and removed and the patient was again started on a po diet with slow advancement. he tolerated this well with no further episodes of emesis and was on a regular diet by post-operative day 7; he had several bowel movements prior to discharge. his cardiologist was consulted and he was restarted on coumadin on post-operative day 5 with planned followup with cardiology and home inr checks at the clinic. he was discharged in fair condition on with planned followup with both gi and plastic surgery. his jp drains were removed on the day of his discharge. medications on admission: toprol 200mg oral daily immodium prn ciprofloxacin 500 mg oral zestril 10mg oral daily coumadin 10 mg oral x daily x 6 days and 7.5 mg oral daily x 1 day digoxin 0.375 oral daily folate fergon discharge medications: 1. coumadin 10 mg tablet sig: one (1) tablet po once/day for 6 days/weeks. 2. coumadin 7.5 mg tablet sig: one (1) tablet po one day/week. 3. digoxin oral 4. metoprolol succinate 100 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr po daily (daily). 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). 6. zestril 10 mg tablet sig: one (1) tablet po once a day. 7. loperamide hcl 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed. 8. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*100 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*40 capsule(s)* refills:*0* 10. fergon oral 11. folic acid oral 12. multi-vitamin oral discharge disposition: home discharge diagnosis: (1) ventral hernia (2) atrial fibrillation (3) ulcerative colitis (4) s/p mitral valve repair discharge condition: good discharge instructions: please contact the office or come to the emergency room with any worsening abdominal pain, nausea/vomitting, inability to tolerate a regular diet, or fever > 101.5. you may remove your dressings in 48 hours. followup instructions: please contact the office of dr. at to set-up a follow-up appointment within 2 weeks. please contact the office of dr. (plastics surgery) at to set up a follow-up appointment within 2 weeks. please see your cardiologist (dr. ) for follow-up within a month. he has been notified about your surgery and post-operative care. please follow-up in the clinic on monday to have your inr checked as per pre-op. Procedure: Incision of abdominal wall Insertion of other (naso-)gastric tube Other repair of abdominal wall Transfusion of packed cells Incisional hernia repair Dermal regenerative graft Diagnoses: Unspecified essential hypertension Acute posthemorrhagic anemia Atrial fibrillation Hematoma complicating a procedure Incisional hernia without mention of obstruction or gangrene Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Cardiac pacemaker in situ Ulcerative colitis, unspecified Other and unspecified mitral valve diseases

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: l chest pain, shortness of breath major surgical or invasive procedure: 1. l chest tube 2. endotracheal intubation history of present illness: 29m transferred from a referring faciltiy. patient reported getting kicked in the chest two weeks prior and c/o sob and chest pain throughout those two weeks. he as noted to have large pneumothorax at the referring hospital; a chest tube placed, he became hypotensive with sbp in the 50's. pressors were given and he was transferred to for continued trauma care. past medical history: none social history: social etoh. family history: nc. physical exam: at discharge: af vss ncat perrla eomi op clear neck supple, no subcut emphysema rrr no m/g/r ctab no w/r/c s/nt/nd +bs no c/c/e pertinent results: 03:09am fibrinoge-416* 03:09am pt-17.8* ptt-26.9 inr(pt)-1.7* 03:09am plt smr-normal plt count-150 03:09am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 03:09am neuts-80* bands-12* lymphs-5* monos-3 eos-0 basos-0 atyps-0 metas-0 myelos-0 03:09am wbc-19.1* rbc-5.30 hgb-17.4 hct-49.9 mcv-94 mch-32.8* mchc-34.8 rdw-12.7 03:09am albumin-2.5* calcium-6.6* phosphate-3.7 magnesium-1.4* 03:09am ck-mb-4 03:09am lipase-9 03:09am alt(sgpt)-14 ast(sgot)-18 ld(ldh)-233 ck(cpk)-200* alk phos-61 amylase-23 tot bili-0.3 03:09am glucose-145* urea n-17 creat-1.2 sodium-139 potassium-4.8 chloride-111* total co2-22 anion gap-11 03:23am freeca-1.19 03:23am lactate-1.7 04:32am urine rbc-* wbc-0 bacteria-none yeast-none epi-0-2 04:32am urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 04:32am urine color-yellow appear-clear sp -1.021 06:20am freeca-0.94* 06:20am glucose-101 06:20am type-art po2-93 pco2-41 ph-7.26* total co2-19* base xs--8 10:47am freeca-1.07* 10:47am type-art po2-117* pco2-43 ph-7.30* total co2-22 base xs--4 01:50pm type-art po2-80* pco2-47* ph-7.28* total co2-23 base xs--4 03:53pm calcium-8.2* phosphate-2.3* magnesium-1.7 03:53pm glucose-106* urea n-12 creat-1.0 sodium-139 potassium-4.2 chloride-108 total co2-24 anion gap-11 04:52pm type-art po2-90 pco2-45 ph-7.30* total co2-23 base xs--3 05:09pm pt-17.5* ptt-34.4 inr(pt)-1.6* -- please see omr radiology for numerous imaging studies of the chest. final cxr: chest (portable ap) 7:10 am findings: the left subclavian central venous line and left apical chest tube are stable. a tiny residual left apical pneumothorax persists. residual atelectasis is demonstrated in the left lung. the right lung remains clear. impression: residual left lower lobe atelectasis and tiny residual left apical pneumothorax. --- rue u/s: unilat up ext veins us right port 10:11 am indication: 29-year-old man with pneumothorax, intubated now with right upper extremity swelling. evaluate for dvt. right upper extremity ultrasound with doppler examination: scale, color flow, and doppler ultrasound of the right internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. a soft mobile clot was seen extending from the right cephalic vein into the mid subclavian vein. the right internal jugular, axillary, brachial and basilic veins were demonstrated normal flow, augmentation, compressibility and waveforms. impression: soft mobile clot arising from the right cephalic vein into the mid subclavian vein. --- lle u/s: unilat lower ext veins left 3:02 pm indication: 79-year-old male with a right upper extremity dvt. technique/findings: grayscale and doppler son of the left common femoral, superficial femoral, and popliteal veins were performed. there is no normal flow, compressibility, and augmentation of these vessels. no intraluminal thrombus was identified. there is no evidence of dvt. examination of area of ecchymosis in the thigh demonstrates a small hypoechoic area, which could represent a tiny hematoma, which measures 2.5 x 0.5 x 2.0 cm and is very small. impression: no evidence of dvt. brief hospital course: 29-year-old gentleman who has suffered trauma including a blunt blow to the chest. he presented with a large pneumothorax to an area hospital where a chest tube was placed. he was transferred to this institution with a pulmonary infiltrate, which was consistent partially with re expansion pulmonary edema and possibly a lower lobe pneumonia. after stabilized in the trauma bay he was admitted to the trauma icu under the care of the trauma service. on he developed acute right neck and shoulder pain with swelling; he underwent unilateral ultrasound which confirmed a thrombus in the subclavian region. he was started on heparin drip and later changed to lovenox and coumadin and was discharged to home with these medications. on he developed increasing subcutaneous emphysema and pneumothorax for which he received an additional chest tube; a flexible bronchoscopy was performed to rule out airway injury; there were no anatomic or mucosal abnormalities noted. his chest tubes were removed on , follow up chest xray with tiny residual pneumothorax. he was discharged to home with instructions to follow up in trauma clinic for repeat chest film and to have his blood drawn for inr. medications on admission: none. discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for 5 days. disp:*30 tablet(s)* refills:*0* 2. lovenox 120 mg/0.8 ml syringe sig: one (1) injection subcutaneous once a day. disp:*15 syringes* refills:*2* 3. warfarin 5 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 4. outpatient radiology pa/lat cxr discharge disposition: home with service facility: , discharge diagnosis: s/p assault 1. l ptx 2. reexpansion lung injury 3. l thigh hematoma 4. rue dvt discharge condition: good discharge instructions: please take all medication as prescribed. please schedule and attend all followup appointments. please seek medical attention for any chest pain, shortness of breath, fever, vomiting, worsening leg pain or swelling, or with other concerns. followup instructions: please followup with the trauma clinic on tuesday, . call to schedule this appointment. you should get a chest x-ray before hand (that same day). call ( to schedule your x-ray. Procedure: Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Other bronchoscopy Non-invasive mechanical ventilation Diagnoses: Other iatrogenic hypotension Acute respiratory failure Traumatic pneumothorax without mention of open wound into thorax Embolism and thrombosis of other specified artery Dehydration Emphysema (subcutaneous) (surgical) resulting from procedure Closed fracture of rib(s), unspecified Contusion of thigh Unarmed fight or brawl Pulmonary congestion and hypostasis

history of present illness: mr. is a 65 year old male who awoke from sleep at 4:00 a.m. on the morning of admission with crushing chest and back pain. he was triaged at his local emergency room and transferred to , where a ct scan was obtained, revealing dissection of his aorta starting at his aortic valve annulus and extending to his iliac bifurcation. he was emergently taken to the operating room for surgical repair. physical examination: on physical examination, the patient was alert and oriented. cardiovascular: regular rate and rhythm, no murmurs appreciated. lungs: clear. abdomen: scaphoid, soft, nontender. extremities: warm with palpable pulses throughout. neurologic: within normal limits. laboratory data: data were not available prior to patient's going to the operating room. hospital course: the patient was emergently taken to the operating room, where he had emergent repair of his dissection. his aortic valve was replaced and the ascending aorta was also replaced with a tube graft. post bypass, the patient suffered from primary cardiac failure. he was unable to be weaned from the cardiopulmonary bypass circuit and expired in the operating room. condition on discharge: dead. discharge status: death. discharge diagnoses: post cardiotomy syndrome, causing death. aortic dissection. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Intraoperative cardiac pacemaker Open and other replacement of aortic valve Cardioplegia Resection of vessel with replacement, thoracic vessels Diagnoses: Cardiac complications, not elsewhere classified Aortic valve disorders Thoracic aneurysm, ruptured Left heart failure Dissection of aorta, thoracoabdominal

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: symptomatic fibroid uterus major surgical or invasive procedure: multiple myomectomy with removal of 22 fibroids replacement of blood products history of present illness: 40yo f with history of recurrent fibroid, eczema, iron deficiency anemia and disease was admitted for elective myomectomy. she elected myomectomy over hytsterectomy for preservation of fertility. she voiced understanding of the increased operative risks secondary to the large size of her fibroid uterus. past medical history: 1.ob/gyn- status post a fibroid resection in at nyu several years ago. she had hemorrhoidal surgery at and she had an ovarian abscess that was drained several decades ago in . 2. eczema, no current problems. 3. remote heart murmur, with an echocardiogram done, hold no need to worry about predental antibiotics. 4. disease, treated with radioactive iodine, not taking any thyroid replacements. 5. g3, tab1 sab2. pap's negative. no sti's, would like to become pregnant hence part of the reason for this myomectomy, she has a history of a previous laminectomy as well. 6. iron deficiency anemia, secondary to heavy vaginal bleeding. social history: no tobacco, occasional alcohol, no regular exercise, married, monogamous relationship. she directs the diversity department of an hr division of an advertising firm. she has been married for five years, has no children, but would like to do so. family history: her family history is negative for thyroid disease or autoimmune diseases that she is aware of. no diabetes mellitus. father is 62-years-old and alive with prostate cancer treated by some mechanism and improved. mother is 62-years-old, alive with degenerative joint disease. no family history of sle. she has no siblings. physical exam: bp 138/78 p72 rr18 99%ra gen-nad cv-rrr, 2/6 sem resp-ctab abd- soft, nt, nd pelvic- large fibroid uterus; no adnexal masses; no cmt extr- no edema, no calf tenderness, 1+ pulses pertinent results: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 13.7* 2.48* 6.8* 20.6* 83 27.4 32.9 16.0* 156 brief hospital course: 40yo g3p0 admitted for elective myomectomy. intraoperatively she loss significant amount of blood requiring blood products and small amount of pressors. secondary to an estimated blood loss of 2500 - 3000 cc requiring transfusion of 4 units prbcs, 4 units ffp, and 1 unit of platelets intraoperatively, the patient was admitted to the sicu overnight secondary to concern for a consumptive coagulopathy. there, she received 2 more units of prbcs, with a goal of keeping the patient's hct > 25. she remained hemodynamically stable and was extubated without difficulty overnight. the patient was called out of the icu to the gyn service on post-operative day #1. her pain was treated w/ demerol and vistaril w/ good relief. on postoperative day #2, the patient started passing small amounts of flatus and her diet was advanced slowly. she was able to get out of bed and ambulate. the patient's hematocrit slowly fell over the course of postoperative day 1 and 2 to a nadir of 20.5. however, since the patient remained relatively asymptomatic w/ stable vital signs and a benign exam, transfusion was held per her request. on pod#3 she remained hemodynamically stable with a hct of 20.6 and no significant tachycardia, drop in bp or other signs suggestive of bleeding. she ambulated x3 but still did not eat adequately due to fear of becoming nauseated. she continued sips and her pain was in better control. on pod#4 she was advanced to house diet and ate without n/v, switched pain meds to tylenol#3 due to complaints of hallucination with percoct. she was discharged home on pod 5 in good condition. medications on admission: medroxyprogesterone acetate ten milligrams daily to reduce vaginal bleeding preoperative. levoxyl 100 mcg daily feso4 discharge medications: 1. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. disp:*15 tablet(s)* refills:*0* 2. colace 100 mg capsule sig: one (1) capsule po three times a day as needed for constipation. disp:*60 capsule(s)* refills:*2* discharge disposition: home discharge diagnosis: multiple myomectomy for symptomatic fibroids discharge condition: good. discharge instructions: please keep your follow-up appointments as detailed below do not drive while taking narcotics. please call your doctor if you experience fevers, chills, nausea, vomiting, redness around your incision, drainage from your incision, if your incision opens, if you have heavy vaginal bleeding or severe abdominal cramps. please call with any other questions or concerns followup instructions: please schedule an appt for tuesday for staple removal. where: ob/gyn pps cc8 (sb) date/time: 5:45 md Procedure: Transfusion of packed cells Transfusion of other serum Transfusion of platelets Other excision or destruction of lesion of uterus Diagnoses: Acute posthemorrhagic anemia Iron deficiency anemia secondary to blood loss (chronic) Intramural leiomyoma of uterus Toxic diffuse goiter without mention of thyrotoxic crisis or storm

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 51 y/ with closed head injury s/p mvc. major surgical or invasive procedure: intubation in er, left radial arterial line history of present illness: 51 y/ with closed head injury s/p mvc. on arrival to trauma bay pt with gcs of with waxing and of mental status. pt electively intubated. no other obvious injuries noted on primary survey. pt taken for emergent head, c-spine, chest/abd/pelvis ct. past medical history: struck by car in and pshx: fusion of distal tl spine, right femur rodding and right total knee replacement, partial right claviculectomy social history: occasional tobacco use (cigarettes) denies etoh use family history: ca mother-- physical exam: neuro: alert, mild distress, following commands, gcs heent: perrl, pupils 4->3 bilat, normocephalic cv: rrr, s1, s2 lungs: cta bilat, equal bs abd: soft, nt, nd, obese, no obvious injuries, no rebound/gaurding extremities: moving all 4 extremities, small hematoma/echymossis of right antero-medial arm, moderate hematoma/echymossis of right posterior mid thigh pertinent results: 02:45pm fibrinoge-350 02:45pm plt count-423 02:45pm pt-13.1 ptt-23.2 inr(pt)-1.1 02:45pm wbc-9.5 rbc-3.51* hgb-11.1* hct-34.0* mcv-97 mch-31.5 mchc-32.6 rdw-14.1 02:45pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-pos barbitrt-neg tricyclic-neg 02:45pm amylase-36 02:45pm urea n-15 creat-0.9 02:52pm glucose-109* na+-144 k+-3.8 cl--111 02:52pm type-art po2-76* pco2-56* ph-7.35 total co2-32* base xs-3 intubated-not intuba 02:58pm urine rbc-0-2 wbc-0-2 bacteria-few yeast-none epi-0-2 02:58pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 02:58pm urine color-straw appear-clear sp -1.016 02:58pm urine bnzodzpn-pos barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg 02:58pm urine gr hold-hold 02:58pm urine hours-random 02:58pm urine hours-random 08:25pm freeca-1.09* 08:25pm glucose-92 lactate-0.5 08:25pm type-art po2-458* pco2-39 ph-7.42 total co2-26 base xs-1 brief hospital course: pt found to have diffuse axonal injury and hemorrhagic shearing injuries with post-traumatic intraventricular and cisternal hemorrhagic foci on head ct, ct of c-spine, chest/abd/pelvis all negative. neurosurgery consulted and pt loaded on dilantin and started on dilantin 100 iv tid. pt admitted to ticu and had left radial a line placed for close bp monitoring and goal of keeping sbp < 140. pt did well overnight and on hd #2 had repeat head ct which showed no remarkable change from prior ct. pt then weaned on vent and extubated later that afternoon. foley, iv lines d/c'ed and pt transferred to floor. c-spine clearance, per neurosurgery recs, to be done with mri of c-spine since pt continued to have headache and generalized body pain-->therefore not able to be clinically cleared. mri of c-spine showed no fractures or ligamentous injuries. c-spine cleared and c-collar d/c'ed. pt deemed fit for d/c to home by neurosurg and physical therapy. medications on admission: percocet nortriptyline ibuprofen multivitamin valium ultram relafen discharge medications: percocet colace dilantin 100 mg tid x 7 days discharge disposition: home discharge diagnosis: closed head injury/diffuse axonal injury discharge condition: stable discharge instructions: return to emergency room if having severe headaches or headaches not controlled with pain meds, if having excessive sleepiness or changes in mental status, avoid any physical activity that may put you at risk for repeat head injury, no driving while taking percocet followup instructions: outpatient ct scan to be done in 2 weeks follow up in clinic in 2 weeks after ct scan is done no need to follow up in trauma clinic but you may call the clinic at with any questions md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Insertion of endotracheal tube Arterial catheterization Diagnoses: Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Head injury, unspecified Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle

history of present illness: this is a 56 year old former anesthesiologist, who has a history of anaplastic oligodendroglioma which was picked up in by screening mri of the head for an infertility workup. the initial abnormalities were in the right temporal and right insular cortices with later involvement of the corpus callosum. he had generalized tonic-clonic seizures shortly thereafter and was started on anticonvulsants. he was treated initially with antineoplaston in and finally had stereotactic brain biopsy in . he came to to see dr. in , and temozolomide chemotherapy was started in . because of lack of response to this, whole brain radiation was begun in and ended on . he appears to have been on chronic steroids since when starting the temozolomide. he was admitted to on for an intracranial hemorrhage seen on radioimaging that was probably radiation changes ultimately. he also was noted to have a leg abscess and hypotension and was seen by neurology and neurosurgery in consultation. to address the hypotension, steroid doses were increased and he was watched in the micu overnight. at that time, he was on lamictal but because a rash on the chest was noted, lamictal was stopped and depakote was increased because the level was subtherapeutic. he had a seizure and dilantin was added, and therefore he was discharged on keppra, dilantin, and depakote. he was seen on by dr. in neuro-oncology and his cell counts were low. for this, he was switched from dilantin to topamax. the plan at that visit was to eventually treat him again with adjuvant temozolomide. he was readmitted from to with encephalopathy from a urinary tract infection, pneumonia, narcotics, and also a few seizures, although i do not know which type these were. he was observed on long-term monitoring, during which he did have some subclinical brief electrographic seizures. this was questionable for muscle artifact at the same time, which was fairly atypical appearing. he was finally tapered off dilantin and sent home on increased keppra, topamax, and dilantin. he was then readmitted on for increased seizure activity. he was residing at rehab in and he was falling down and sent to hospital. a head ct showed no new changes and a chest x-ray showed a persistent right middle and right lower lobe infiltrate, thought to be due to aspiration pneumonia. a valproic acid level was low upon admission and it appears that it has not been therapeutic for a couple of months. past medical history: 1. oligodendroglioma, status post antineoplaston treatment with temozolomide and whole brain radiation. 2. generalized and complex partial seizures, requiring multiple anticonvulsants. 3. infertility. 4. history of a line infection, sepsis, in , related to chemotherapy. 5. adrenal insufficiency. 6. history of recent c-diff colitis and pneumonia. allergies: sulfa and lamictal. medications upon admission: 1. tylenol p.r.n. 2. dexamethasone 3 mg p.o. b.i.d. 3. depakote 700 mg p.o. b.i.d. 4. docusate 100 mg p.o. b.i.d. 5. ferrous sulfate 325 mg p.o. q.day. 6. florinef 0.1 mg p.o. q.day. 7. gabapentin 300 mg p.o. t.i.d. 8. heparin 5,000 units subcu t.i.d. 9. ibuprofen 600 mg p.o. q.6 hours p.r.n. 10. keppra 2,000 mg p.o. b.i.d. 11. flagyl 500 mg p.o. t.i.d. 12. protonix 40 mg p.o. q.day. social history: the patient formerly worked as an anesthesiologist in . his brother, dr. , is on staff at in the division of cardiology. he also has a wife by the name . family history: his parents are alive and well. his mother has a history of depression. his two brothers are healthy. examination upon admission: general: he is an ill-appearing man in no apparent distress. his temperature was 99.4, blood pressure was 120/74, heart rate 92, o2 sat 95 percent on room air. head & neck: normocephalic, atraumatic. he has alopecia. his neck is supple. his mucous membranes are moist. no carotid bruits. cardiovascular: regular rate and rhythm. chest: lungs revealed some decreased breath sounds at the right lower lobe. abdomen: soft and nontender. extremities: no edema or rashes. mental status: he was inattentive and extremely abulic. he did not easily follow commands. his language appeared to be intact in that he spoke in full sentences coherently, but his speech output was greatly reduced. he answered questions appropriately about biographical information and orientation to place. he was able to name a couple of objects and repeat. cranial nerves: he appeared to be neglecting the left hemi- field. the fundi appeared normal. the pupils reacted normally to light. extraocular movements were full without nystagmus initially. facial movement is symmetric. the tongue and the palate were midline. the patient spent most of his time with his gaze towards the right. motor: again, this was difficult due to the patient's inability to follow all commands. the bulk was normal. the tone was increased in the whole left hemi-body.; there initially was a left pronator drift and upon sustained extension of the arms, the left drops more rapidly than the right. there also appeared to be a component of neglect, during which leaving the limb in front of the patient's field of vision did not seem to help him sustain against gravity better than without making his arm more apparent to him. he spontaneously moves the right side much more than the left. coordination was thought to be somewhat more ataxic on the left. it was not clear whether this was due to motor weakness alone, however. reflexes were trace throughout and difficult to elicit. the plantar reflexes were flexor bilaterally. sensation was intact to noxious stimulus in all four extremities. gait and stance were deferred. hospital course by problems: 1. seizures: the patient was admitted to the neurology service with suspected increased seizure activity. his valproic acid level was 37 upon admission and, as mentioned before, had not really been therapeutic in the last several months. the previous recent medical illnesses including the c-diff colitis as well as the pneumonia were thought to be the exacerbating factors for those episodes of increased seizure activity, but it was not clear that these were acute issues upon this admission. although he was on neurontin and keppra, as well as depakote, he was having at least two to three clinical seizures a day on the neurology , which mainly consisted of right gaze deviation with some twitching of the right side of the face. there would also be tonic contracture of the right arm. during the brief episodes which lasted a couple minutes, the patient was not responsive to any commands. after these episodes, he would routinely seem more lethargic than prior. he remained fairly encephalopathic for the majority of the hospital course, which was thought to be multifactorial, in part due to poor seizure control, and potentially sedating effects of keppra. he did not have any significant metabolic or toxic abnormalities. he also did not have any significant systemic infections to account for this. around the fifth hospital day, it was decided to load the patient with phenobarbital orally as efforts to increase his depakote were still not making his frequency of clinical partial seizures reduced. he appeared to be again more sleepy initially with a question of the sedative effect from the phenobarbital, but an eeg done on the day of initiation of phenobarbital did show continuous 1 hz discharges in the right parietal or temporal regions. the extended eeg recording on this day also noted that there was a suspicion of a clinical seizure during the recording, and the eeg did not look changed and still had the persistent discharges, even with the presence of what was thought to be a twitching episode. in general, the rest of the background was very slow and low voltage. he had periodic lateralized epileptiform discharges throughout the recording at various times, which are fairly persistent. because it was felt that the patient was extremely encephalopathic and that the goal of the admission was to try to improve his encephalopathy, an attempt at aggressive seizure control was made and the patient was sent to the neuro icu for intubation and loading with i.v. phenobarbital to bring the level up quickly. he was monitored with extended eegs throughout this course and again showed the same persistent pattern of epileptiform activity at about 1 hz of spike and slow wave, which did not change whenever the patient had a clinical event that was thought to be a partial seizure, for example facial twitching on one-half of the face, usually the right side. the first day after starting i.v. phenobarbital, the patient did not appear to have any more twitching events, and his phenobarbital level was brought up to a range of between high 20s and mid-30's. his depakote level was also meant to be sustained at above a level of 50. meanwhile, he stayed on the same doses of keppra and neurontin. he was eventually sent back from the neuro icu after being successfully extubated. he was again transferred back to the general neurology floor, where he remained more responsive to questions, albeit answering in short phrases but usually appropriately in response to orientation questions to place. in terms of following simple motor commands, he was able to always squeeze his right hand. he would look towards his left after an extended delay, which we interpreted as abulia, in addition to a general slowing in terms of answering questions, which eventually were correct and showed clearly that he comprehended the questions. again, he had in general not much spontaneous motor activity, with the exception of the occasional movement of the right arm to move towards his nasogastric tube. he remained fairly slow, but usually with eyes opened, with not much activity during the day. it was decided at this point that the keppra should be tapered in the event that it was having a sedating effect on the patient. this was slowly tapered starting from 2 grams p.o. b.i.d. by 250 mg p.o. b.i.d. every two to three days. at this point, he is on keppra 1250 mg p.o. b.i.d. the patient did appear to have a better response to the decrease in the keppra while the phenobarbital and depakote were kept on board. on exam currently, he is able to answer appropriately questions regarding orientation. he is also able to appropriately indicate what type of foods he would like to eat. he is also able to appropriately answer questions that are rather insightful regarding his care. for example, with the upcoming placement of a gastrostomy tube, he was able to ask how long the procedure would take, and what type of anesthetic they would use. again, he is rather abulic and there appears not appear to be much increase by way of spontaneous motor activity. he does seem to be more awake at this time. 1. anemia: the patient had a baseline anemia with a hematocrit hovering in the 29 to 31 range. iron studies were checked and this was consistit with an anemia of chronic disease. 1. fluids/electrolytes/nutrition: the patient was fed predominantly through his nasogastric tube. however, on , the patient had a percutaneous endoscopically placed gastrostomy tube done by the gastroenterology service. instructions will be to restart tube feeds if necessary on the day after the gastrostomy tube placement. the patient was able to eat soft foods and required assistance with feeding, given that he appeared mainly to have a lack of motivation to perform the motor activity of eating himself. he was thought by the swallowing team to still be at some risk for aspiration, given that he pocketed foods in his mouth while he swallowed the majority of food items. they recommended a pureed diet with nectar-thickened liquids. it was felt that the patient could enjoy an oral diet, but that the gastrostomy tube would be there for backup nutrition needs, as well as a reliable means of administering critical medications such an anticonvulsants. 1. history of recent c-diff colitis: the patient did not appear to have any more issues with his c-diff colitis and has finished his course of flagyl. his liver function tests were normal throughout the hospital stay. his stool was checked for c-diff again on and this was negative. however, a rectal swab did show vancomycin- resistant enterococcus. 1. oligodendroglioma: the patient's neuro-oncologist was kept up to date during this hospital course, especially with regard to selection of anticonvulsants. he felt particularly that the dilantin should not be tried again because of the patient's history of a possible leukopenic reaction to the dilantin. he did agree with usage of phenobarbital, even though family initially expressed some reservations that that would be too sedating. it was felt that the main goal was seizure control and that although this did not appear to have a significant effect on the eeg recording, seemed to put a stop to what was thought to be clinical seizure activity, which was mainly complex partial in nature. with regard to neuro-imaging and the status of the oligodendroglioma, the most recent mri of compared with an mri in showed some considerable reduction in the diffuse flare hyperintensities present throughout the right temporal, frontal and occipital lobes. in , it was felt that the tumor was infiltrating even further and that there was extension of the tumor across the corpus callosum, both anteriorly and posteriorly. there was also thought to be infiltration of now the left hemisphere and the left medial temporal lobe. these changes still remained present on the mri, but again were thought to be less hyperintense than this mri in . of note, an mr spectroscopy was done in , which showed progressive infiltrative tumors centered in the right temporal lobe, but also involving the right frontal and parietal lobes. as mentioned a cat scan was done initially on admission at - , and this showed no changes consistent with hemorrhage. because the patient had appeared to be having a lot of clinical seizure activity during the first week of hospitalization, it was discussed with dr. and the decadron was increased from 3 mg p.o. b.i.d. to 6 mg p.o. b.i.d. to empirically treat for potentially any mass effect that would have been creating seizures that were difficult to control. the patient is now in the process of having the decadron tapered slowly and is currently at 4 mg p.o. b.i.d. disposition/plan: it was discussed extensively with the family, particularly his brother, dr. , that the patient would be going back to rehab in , and thereafter the family would consider whether the patient recovered enough to the point that he could return home, versus being placed in a nursing home, versus obtaining hospice services. discharge diagnoses: 1. epilepsy, partial seizures, with periodic lateralized epileptiform discharges. 2.. anemia of chronic disease. 1. right-sided anaplastic oligodendroglioma with infiltration widespread into the left hemisphere. 2. adrenal insufficiency. 3. history of c-diff colitis. 4. history of cre colonization. 5. history of recent pneumonia. discharge medications: 1. keppra 1250 mg p.o. b.i.d. to be decreased by 250 mg p.o. b.i.d. every three days, and therefore the next change should occur on . 2. divalproex sodium 1125 mg p.o. b.i.d. 3. dexamethasone 4 mg p.o. b.i.d. 4. lansoprazole 30 mg per g-tube q.day. 5. phenobarbital 130 mg per g-tube b.i.d. 6. artificial tears 1 to 2 drops o.u. p.r.n. 7. gabapentin 300 mg p.o. t.i.d. 8. fludrocortisone 0.1 mg p.o. q.day. 9. ferrous sulfate 325 mg p.o. q.day. 10. docusate 100 mg p.o. b.i.d. 11. bisacodyl 10 mg p.o. b.i.d. p.r.n. constipation. 12. tylenol p.r.n. 13. heparin subcu 5,000 units t.i.d. of note, the patient is receiving three doses of ancef 1 gram i.v. q.8 hours, which should be finished by the time he reaches rehab. follow up plans: the patient should follow up with his neuro- oncologist, dr. . also he should follow up with his primary care physician. . and have an appointment for . dr., 13-163 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Diagnoses: Pneumonia, organism unspecified Anemia, unspecified Other convulsions Malignant neoplasm of cerebellum nos Encephalopathy, unspecified

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hematemesis major surgical or invasive procedure: banding x 4 of esophageal varices history of present illness: pt is a 74yo woman with pmh of ms, autoimmune hepatitis, and niddm presenting with acute episode of hematemasis brought in by ems to ed and was vomiting large amounts of blood, history was not available from pt but pts family was able to relate some facts. husband relates several days of malaise, then in the evening of the night of admission the pt had nausea and subsequently vomited a large amount of blood, ems was called and pt brought to the ed. family denies former bouts of gi bleeds in the patient. pt does not take asa and is also on prednisone. family denies anticoagulation use. past medical history: ms, wheelchair bound, requiring self catherization hx of utis htn niddm hypercholesterolemia autoimmune hepatitis social history: greek speaking only, family members speak english, married no etoh hx as per family family history: non-contributory physical exam: t 98.9 bp 106/55 hr 82 rr 20 o2 99% gen: morbidly obese woman sitting on her chair, in nad lungs: coarse bs, bilaterally cardiac: rrr 3/6 systolic murmur abd: soft, nt, non-distended, +bs ext: no edema pertinent results: 11:50pm pt-14.3* ptt-23.7 inr(pt)-1.4 10:43pm glucose-384* urea n-43* creat-0.9 sodium-140 potassium-4.2 chloride-104 total co2-22 anion gap-18 10:43pm alt(sgpt)-23 ast(sgot)-17 ld(ldh)-210 ck(cpk)-42 alk phos-80 tot bili-0.4 10:43pm lipase-25 10:43pm ck-mb-notdone ctropnt-<0.01 10:43pm wbc-19.2*# rbc-3.10*# hgb-9.7*# hct-28.8*# mcv-93 mch-31.3 mchc-33.7 rdw-14.0 10:43pm neuts-63.0 lymphs-31.8 monos-3.6 eos-1.1 basos-0.6 10:43pm plt count-262 electrocardiogram performed on: normal sinus rhythm with atrial premature beats. left ventricular hypertrophy with repolarization changes. compared to the previous tracing of atrial premature beats are present and the axis is less leftward. ap chest 4:20 a.m. on history: gi bleed following intubation and right subclavian line repositioning. impression: ap chest compared to at 5:15 a.m.: lung volumes are low and mild pulmonary edema has worsened. perihilar opacification on the right could be asymmetric edema or developing pneumonia. et tube and right subclavian line are in standard placements. no pneumothorax or pleural effusion. heart size normal. portable ap chest radiograph clinical details: post repositioning of right subclavian line. findings: endotracheal tube at the precarinal level. the inferior tip of the right subclavian line lies at the inferior level of the svc. minor kink noted at its cutaneous entry. increased opacity at the left costophrenic angle likely due to a small pleural effusion. the lungs are otherwise clear. brief hospital course: in the ed on presentation pt was tachcardic at 118, had an o2 sat of 93% on ra up to 98%on 6l, and vomited 500cc of blood with clots, the decision was made to intubate the patient for airway protection, 2 liters of ns and 3 units prbcs were given while waiting for an abd ct scan in the ed her pressure dropped to low 80s/40s, nursing decided to transport pt to micu, bypassing ct scan, micu team and gi met pt in micu pts bp measure at 140s/80s, right subclavian was placed, gi performed gastric lavage and scoped pt in micu. discovered bleeding esophageal varices in the lower of the esophagus and banded x 4 as well as non-bleeding gastric varices in the cardia. . in the micu, pt was extubated on . she began to develop a non-productive cough. she denies any recent bleeding. she denies any nausea/vomiting/diarrhea. no chest pain/tightness. no lightheadedness. no fever/chills. she states she feels comfortable ros: + non-productive cough 1) upper gi bleed/esophageal varicies: unknown cause, ? secondary due history of autoimmune hepatitis, gi evaluated and banded times 4. she received 5 days of octreotide and hct was stable since banding. us shows normal flow in hepatic and portal veins and no ascites. - continue protonix 40 mg po bid - levoflox 500 mg po qd x 8d for sbp prophylaxis on discharge - nadolol 20 mg po qd - will see gi in 1-2wks/endoscope 4-5wks . 2)bp pt initially hypotensive most likely due to hypovolemia but normalized after fluid resuccitation. on transfer from the micu to the floor, she was slightly hypertensive with sbp in the 140s. according to her family, she has no history of hypertension and was on no hypertensive meds at home. we will leave her on nadolol and have her follow up with her pcp. nadolol 20 mg po qd . 3)respiratory distress: on admission, she was intubated for airway protection, also ? lung infiltrate: ? bloody aspirate vs. pna. she was started on levofloxacin/flagyl for aspiration pneumonia. on the floor, she was afebrile and her wbc count was normalized on discharge to 5.5. - continue levo/flagyl day for 8 more days on discharge for total of 11 days . 4) niddm: slightly high during this admission to low 200s - 70/30 insulin 25 qd, glypizide 10mg - will follow up with her pcp . 5) multiple sclerosis - no issues this admission - continue home dose of prednisone 5 mg po qd - evaluation for home services medications on admission: prednisone 5 mg po qd paxil 20 mg po qd trazodone glipizide 10 mg po bid cimetidine nystatin and miconazole powder medication for urinary yeast infection discharge medications: 1. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day). 2. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 3. glipizide 5 mg tablet sig: two (2) tablet po bid (2 times a day) for 10 days. disp:*40 tablet(s)* refills:*0* 4. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 6. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 8 days: for pneumonia. disp:*24 tablet(s)* refills:*0* 7. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 8 days: for pneumonia and prophylaxis against abdominal infection. disp:*8 tablet(s)* refills:*0* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 9. insulin 70/30 70-30 unit/ml suspension sig: twenty five (25) units subcutaneous once a day. 10. paxil 20 mg tablet sig: one (1) tablet po once a day: take your home dose of paxil. 11. prednisone 1 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: primary: 1. bleeding esophageal varices 2. nonbleeding gastric (stomach) varices 3. aspiration pneumonia secondary: 1. autoimmune hepatitis 2. diabetes mellitus type 2 3. hypertension 4. hypercholesterolemia 5. multiple sclerosis discharge condition: stable discharge instructions: 1. please take all medications as prescribed. 2. please attend all follow-up appointments. call dr. tomorrow at to schedule to have another endoscopy next week! tell the person making the appointment you were banded in the hospital for esophageal varices and need a follow up endoscopy in one week. 3. please seek medical attention or call 911 if you start to cough or vomit blood, for prolonged lightheadedness or weakness or for chest pain or shortness of breath. followup instructions: please call dr. at tomorrow to schedule an endoscopy for next week to follow up on your banded varices. you have a follow up thursday at 1 pm with dr. (). you also should follow up with gastroenterology, dr. () on at 8:20 am in medical building for a general appointment and ask if you should restart aspirin at that time. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Insertion of endotracheal tube Gastric lavage Endoscopic excision or destruction of lesion or tissue of esophagus Transfusion of packed cells Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute respiratory failure Hypotension, unspecified Pneumonitis due to inhalation of food or vomitus Other chronic hepatitis Esophageal varices with bleeding Multiple sclerosis Hypovolemia Varices of other sites

discharge status: to rehabilitation for intravenous antibiotics. discharge followup: 1. clinic with . 2. at 10:30 am at radiology repeat right upper extremity ultrasound. 3. neurosurgery followup. 4. primary care physician followup with dr. at 1:30 pm, 6 . medications in addition to previous discharge medications: 1. lisinopril 5 mg po bid. 2. motrin 600 mg po tid. 3. oxacillin 2 grams q4 hours through . dr., 12-adf dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Acidosis Subendocardial infarction, initial episode of care Chronic airway obstruction, not elsewhere classified Hypopotassemia Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Septicemia due to anaerobes Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of superficial veins of upper extremities

service: medicine the patient is a 66-year-old white female, poor historian with a past medical history significant for alzheimer's dementia, asthma, coronary artery disease, status post myocardial infarction, trigeminal neuralgia, status post recent trigeminal release requiring left craniotomy on of a two day history of short of breath and a cough and a one week history of malaise. in addition she had right arm tenderness and swelling at an old intravenous site. she denied short of breath, cough, chest pain, palpitations, nausea, vomiting, urinary symptoms, diarrhea, constipation or headache. she did complain of a decreased appetite and decreased p.o. intake at home. in the emergency department dropped from 190 to 60 and she was started on dopamine drip and intravenous fluids. initially levaquin and oxacillin were given to cover her for potential urine source and for cellulitis however, this medication was changed to vancomycin in the emergency room for broader coverage. in addition she was found to have electrocardiogram changes with significant st elevation in v1 through v6 of 1 mm and in leads 3 and avf. she had q-waves in lead v2 through v6 with loss of rs in comparison to electrocardiogram on . she was transferred to the intensive care unit for further stabilization. past medical history: 1. chronic obstructive pulmonary disease. 2. asthma. 3. hypertension. 4. coronary artery disease, status post anterior myocardial infarction in . 5. att, mibi in with greater than 55% ejection fraction. small fixed anterior defect. 6. trigeminal neuralgia status post release on . 7. alzheimer's dementia. social history: she lives alone and has supportive daughter. denies alcohol use although the patient has a drinking history. no current tobacco use. the patient with smoking history. medications on admission: 1. albuterol 2 puffs q.i.d. 2. aricept 10 mg p.o. q day. 3. aspirin 81 mg p.o. q day. 4. tums 500 mg p.o. b.i.d. 5. lasix 20 mg p.o. q day. 6. univasc 7.5 mg q day. 7. tegretol 300 mg p.o. b.i.d. 8. theophylline 200 mg p.o. three times a day 9. transinolone 6 puffs b.i.d. 10. vitamin e. allergies: 1. bactrim causes rash. 2. augmentin causes rash. physical examination: vital signs: t-max was 130.1, temperature 100.8, blood pressure 80 to 120's/50 to 70's. heart rate 100 to 110, respirations 22. she was alert and oriented times three in moderate distress. her head was normocephalic, atraumatic. pupils were equally reactive to light and accommodation. her neck was supple. no evidence of jugular venous distention. positive craniotomy site with scar, staples removed. her mucous membranes were moist. her heart was regular rate and rhythm with s1 and s2. she had a 2 to 3/6 systolic ejection murmur. her lungs were clear to auscultation bilaterally without wheezing, rhonchi or rales. abdomen soft, nontender, nondistended. normal active bowel sounds, obese. her right arm was warm and tender to palpation, edematous with erythema surrounding old intravenous site, antecubital and extended proximally over biceps. sensation was intact. pulses intact. no lower extremity edema. labs: white blood count 12.4, left shift with neutrophils 92.3, hematocrit 88.2, platelets 391, sodium 133, potassium 2.1, chloride 89, bicarbonate 28, bun 7, creatinine 4.6. glucose 129, calcium 8.5, magnesium 1.3, phosphorus 2.1, prothrombin time 13.2, ptt 26.8, inr 1.2. urinalysis was clear. no evidence of infection. chest x-ray showed a minimal opacity in her left lower lobe, no evidence of congestive heart failure. electrocardiogram is normal sinus rhythm at 98 beats per minute, left anterior descending, normal intervals, st elevation in 1 mm in v1 through v6 and lead 3 and avf. q-waves in v2 through v6 with loss of r-waves compared to . hospital course: 1. infectious disease. initial blood cultures grew gram positive cocci in clusters 4/4 bottles. she was continued on vancomycin until oxacillin sensitivities were acquired. she continued to spike fevers through , gentamicin was started for synergy. infectious disease was consulted to evaluate the patient, they recommended serial blood cultures as well as right upper extremity ultrasound. ultrasound revealed a right cephalic vein with thrombophlebitis, no evidence of an abscess or fluid collection. repeat blood cultures were negative. she was also evaluated with a transesophageal echocardiogram for endocarditis. she was discharged with a picc line to rehabilitation in order to receive outpatient oxacillin for a total of 4 weeks after the last negative blood culture. 2. cardiac. on she presented to the emergency department with electrocardiogram changes as noted and a troponin of 7.5 consistent with myocardial infarction. serial cardiac enzymes trended downward. an echocardiogram was done which revealed focal hypokinesis of the apical free wall of the right ventricle as well as a mild regional left ventricular systolic dysfunction, left hypokinesis of the distal septum, inferior and apical walls. her ejection fraction was noted to be 40% heparin was not started due to her recent intracranial surgery however, she was placed on a beta-blocker, ace inhibitor and aspirin. after three weeks from her postoperative date the plan is to consider anti-coagulation given the upper extremity clot. 3. pulmonary. the patient has a history of asthma, treated with theophylline and albuterol. she also has a history of chronic obstructive pulmonary disease with an fev 1/fvc ratio of 63% she will continue her theophylline and albuterol and start an atrovent inhaler. 4. fluids, electrolytes and nutrients: on admission she had a decrease k of 2.1, as well as decreased magnesium and phosphate. her electrolytes were repleted. she will need her electrolytes followed as an outpatient as she will be continued on lasix and theophylline. 5. vascular/heme: while in house she was evaluated by the vascular surgery team and they did not feel surgical removal of the septic thrombus would be necessary. they recommended treatment with warm compresses to her right arm and elevation of the arm. she was also worked up for normocytic anemia and iron studies are pending at the time of discharge. according to vascular surgery the cephalic vein clot is not proximal enough to require anticoagulation although this could still be considered. she should have a upper extrmity ultrasound in weeks to evaluate for progression of the clot. discharge status: to rehabilitation. discharge condition: stable. discharge diagnosis: 1. septic thrombophlebitis right cephalic vein. 2. recent myocardial infarction. 3. hypokalemia. 4. asthma discharge medications: 1. lasix 20 mg p.o. q day. 2. metoprolol 12.5 mg p.o. b.i.d. 3. protonix 40 mg p.o. q day. 4. dimazepo 10 mg p.o. q h.s. 5. carbamazepine 300 mg p.o. b.i.d. 6. vitamin e 400 mg units p.o. b.i.d. 7. albuterol inhaler one to two puffs q 6 hours p.r.n. 8. flovent 110 mcg two to four puffs b.i.d. 9. atrovent two puffs b.i.d. to q.i.d p.r.n 10. colace 100 mg p.o. b.i.d. 11. potassium chloride 40 meq p.o. q day. 12. theophylline capsule 200 mg p.o. b.i.d. 13. isosorbide dinitrate sa 40 mg p.o. b.i.d. at 8 am and 2 pm. 14. oxacillin 2 grams intravenous q 4 hours. 15. aspirin 325 mg p.o. q day. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Diagnoses: Acidosis Subendocardial infarction, initial episode of care Chronic airway obstruction, not elsewhere classified Hypopotassemia Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Septicemia due to anaerobes Other vascular complications of medical care, not elsewhere classified Phlebitis and thrombophlebitis of superficial veins of upper extremities

allergies: codeine / ambien / shellfish derived attending: chief complaint: altered mental status major surgical or invasive procedure: diagnostic paracentesis intubation, mechanical ventilation history of present illness: mr. is a 55 y.o m with hcv cirrhosis, hcc s/p rfa, s/p , now with recurrent hep c, htn, adrenal insufficiency, type ii dm who presented to osh on with ams. he was found to be hypoglycemic along with combative and altered. he was intubated, sedated and transfered to the for further evaluation. at the time of transfer, he was admitted to micu at which time he remained intubated but became more interactive. the micu team was alerted that cultures from the osh grew gpcs in pairs and chains which ended up being strep mitis. the patient was initially treated with vancomycin and then coverage was narrowed to cefazolin. he was extubated without difficulty and has been stable from a respiratory standpoint for 24 hours. his mental status was attributed to hepatic encephalopathy in the setting of sepsis and he has been treated with lactulose and rifaximin. . upon arrival to the floor vitals were 97.0 155/88 66 20 100ra glucose 188. the patient was able to respond to simple questions. he did not follow instructions. he was aox2 (date ). past medical history: - hepatitis c cirrhosis and hepatocellular carcinoma s/p radiofrequency ablation x 3, s/p liver transplantation , recurrent hep c after transpant, now with decompensated liver failure with ascites and encephalopathy, listed. last egd in showed 1 cords of grade i varices. - recurrent hep c after transpant- last viral load 69 on . - htn - hx of type ii dm - adrenal insufficiency: . after cortisal stimulation test. - s/p appendectomy - s/p tonsillectomy - s/p cervical laminectomy - s/p right forearm orif - s/p bone graft from right hip to elbow - s/p knee surgery social history: former fireman and barowner; positive tobacco history; 2 packs per day x 30 years, quit prior to liver . he is not using iv drugs. family history: his father has renal failure. his mother has hypothyroidism. physical exam: vitals: bp 167/78 hr 67 rr 16 sao2 100%ra general: somnolent male, nad heent: ng tube in place, mild scleral icterus, no oral lesions, dry mm neck: jvp not elevated lungs: clear to auscultation bilaterally on anterior exam, no wheezes or crackles cv: regular rhythm, normal rate, s1, s2, ii/vi systolic murmur llsb abdomen: soft, mild destension, nontender, +bs, scar from prior surgery inplace. gu/rectal: foley and flexiseal in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no splinter hemorrhages or lesions pertinent results: micro: osh culture: s. mitis peritoneal fluid: negative cultures: negative urine culture: pending . images: abdominal ultrasound: there is moderate amount of ascites in the perihepatic and perisplenic region. the macronodular liver is echogenic in echotexture but without focal lesions, compatible with cirrhosis. the right, mid and left portal veins are widely patent with normal hepatopetal flow. a 3-cm focal dilation of the main portal vein is similar in appearance compared to prior ct study. slight turbulent flow is noted around the focal dilation. the hepatic veins and arteries are patent and normal in doppler waveforms. the spleen measures 14.8 cm. the right kidney measures 11.3 cm. the left kidney measures 12.0 cm. there is no hydronephrosis, hydroureter or stone. impression: patent hepatic vasculature. cirrhotic liver with moderate ascites. normal kidneys. splenomegaly. cxr: findings: the ng tube has its tip projected over the stomach. there is blunting of the costophrenic angles bilaterally. the heart remains enlarged. there is no significant change in the bibasilar atelectasis. impression: 1. bibasal atelectasis and bibasal effusions along with cardiomegaly, overall appearances are suggestive of chf. 2. the nasogastric tube terminates in the proximal stomach, recommended advancing up to 5 cm brief hospital course: mr. is a 55-year old male with hcc s/p rfa, hcv cirrhosis, s/p olt , with hcv recurrence and cirrhosis complicated by encephalopathy, ascites, varices who was admitted with altered mental status and streptococcal bacteremia. 1. bacteremia- original cultures from showed strep mitis, but subsequent speciation showed strep sanguinus and salivarius species, all of which are consistent with oral flora, as patient has poor dentition. we obtained a panorex dental x-ray to better evaluate infectious foci in his oropharynx. he was treated with a 7-day course of cefazolin which was changed to iv ceftriaxone for ease of dosing upon discharge, for a total treatment duration of 14 days. infectious disease service was consulted regarding the treatment of this microorganism. a tte was obtained to rule out endocarditis, and there were no obvious vegetations. a tee was not pursued due to low clinical probability of endocarditis given lack of adequate duke's criteria. he was discharged with antibiotic course to be administered through picc line. 2. hepatic encephalopathy- mr. was quite encephalopathic on admission, and his mental status improved slowly each day on lactulose and rifaxamin. at the time of discharge, he was mentating at his baseline. 3. metabolic acidosis- chronic metabolic acidosis with partially compensated respiratory alkalosis as per gas and daily labs. could be partially due to volume depletion from greatly increased stool output from lactulose, as patient was hypokalemica and bicarb depleted. renal was consulted and recommended fluid challenge. he was also given albumin and bicarbonate with some improvement in lab values, but this derangement appears chronic. medications on admission: 1. hydrocortisone 10 mg po qam 2. hydrocortisone 5 mg po qpm 3. metoprolol tartrate 50 mg po bid 4. pantoprazole ec 40 mg po bid 5. paroxetine hcl 20 mg po daily 6. rifaximin 600 mg po tid 7. sucralfate oral 8. ferrous sulfate 325 mg po daily 9. magnesium oxide oral 10. doxazosin 1 mg po hs 11. trimethoprim-sulfamethoxazole 80-400 mg po mwf (-wednesday-friday). 12. ciprofloxacin 250 mg tablet po qsunday. 13. lactulose 60 gram po every 4-6 hours (titrate to 3bm) 14. lidocaine 5 %(700 mg/patch) adhesive patch daily prn 15. tacrolimus 0.5 mg po q12h 16. insulin nph & regular human 100 unit/ml (70-30) suspension subcutaneous discharge medications: 1. paroxetine hcl 20 mg tablet sig: two (2) tablet po daily (daily). 2. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 3. doxazosin 1 mg tablet sig: two (2) tablet po hs (at bedtime). 4. ceftriaxone 2 gram recon soln sig: two (2) grams intravenous once a day for 8 days: to end . disp:*16 grams* refills:*0* 5. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po mwf (-wednesday-friday). 6. hydrocortisone 5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 7. ciprofloxacin 500 mg tablet sig: 1.5 tablets po qsun (every ). 8. tacrolimus 0.5 mg capsule sig: capsule po q12h (every 12 hours). 9. lidocaine-prilocaine 2.5-2.5 % cream sig: one (1) appl topical prn (as needed) as needed for pain. 10. lactulose 10 gram/15 ml syrup sig: forty five (45) ml po qid (4 times a day). 11. propranolol 10 mg tablet sig: two (2) tablet po bid (2 times a day). 12. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for indigestion. 13. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). 14. hydrocortisone 5 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 15. bisacodyl 10 mg suppository sig: one (1) suppository rectal (2 times a day) as needed for constipation. 16. insulin nph & regular human 100 unit/ml (70-30) suspension sig: sixty (60) units subcutaneous twice a day: 60 units nph in am and 48 units in afternoon . discharge disposition: home with service facility: vna discharge diagnosis: primary: strep sanguis and strep salivarium bacteremia, hepatic encephalopathy secondary: hcc s/p rfa, hcv s/p olt ', c/b recurrence hcv w/ ascites, varices and pse discharge condition: activity status:ambulatory - requires assistance or aid (walker or cane) level of consciousness:alert and interactive mental status:clear and coherent discharge instructions: it was a pleasure being involved in your care, mr. . you were admitted to the hospital because of a bacterial infection in your , for which you were treated with antibiotics. the likely source of this bacteria is from your mouth, so it is important to follow-up with good dental care. you also were confused which is due to your hepatic encephalopathy. you cleared up with lactulose by the time you were sent home. your medications have changed as follows: 1. we added ceftriaxone 2g iv q24h (antibiotic) for a total 14 day course to end on the rest of your medications are the same, please continue to take them as you have been. please keep your follow-up appointments below. call your doctor or 911 you experience crushing chest pain, difficulty breathing, intractable nausea or vomiting, in your urine vomit or stool or any other concerning medical problem. followup instructions: 1. please see your liver doctor, , md phone: date/time: 8:00 2. please make an appointment to see your primary care doctor, dr. . phone for a post-hospital stay follow-up visit Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Diagnoses: Acidosis Cirrhosis of liver without mention of alcohol Chronic hepatitis C with hepatic coma Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Hypopotassemia Chronic kidney disease, unspecified Acute respiratory failure Alkalosis Bacteremia Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Other ascites Awaiting organ transplant status Complications of transplanted liver Glucocorticoid deficiency Hyperosmolality and/or hypernatremia Esophageal varices in diseases classified elsewhere, without mention of bleeding Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus Personal history of malignant neoplasm of liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

allergies: codeine / ambien / shellfish derived / hydromorphone attending: chief complaint: back pain major surgical or invasive procedure: dobhoff tube placement (, , , , , ) tunneled hemodialysis catheter removal () temporary hemodialysis catheter placement (, , ) tunneled hemodialysis catheter placement () picc line placement () diagnostic and therapeutic paracentesis (, , , ) history of present illness: 56 year-old male with hepatitis c cirrhosis and hcc s/p liver transplant () with recurrent decompensated hepatitis c cirrhosis, esrd, diabetes mellitus type ii, and hypertension admitted with acute worsening of chronic low back pain. patient has had chronic lbp attributed to scoliosis of lumbosacral spine. he reports prior flares lasting 2-3 days. the current flare began approximately 3 days ago, following a scheduled weekly paracentesis (6l removed). the pain is localized to the lower back and does not radiate. he denies bowel or bladder retention or incontinence or difficulty with ambulation. he believes this may be related to increased physical activity over the past 1 week. in the past, he has received epidural steroid injections. narcotic use has been limited by encephalopathy. past medical history: pmh: -hepatitis c cirrhosis and hcc s/p rfa x3, liver transplantation () -recurrent hepatitis c cirrhosis, decompensated. ascites requiring weekly paracentesis, encephalopathy, grade i varices -esrd on hd (mwf) -hypertension -diabetes mellitus, type ii -levoscoliosis -adrenal insufficiency (diagnosed ) -urolithiasis, s/p stent placement and removal by urology -enterococcal bacteremia () -vre ( rectal swab) -b/l hearing loss due to noise during work as fireman psh: appendectomy, tonsillectomy, cervical laminectomy, r forearm orif, bone graft from hip to elbow, knee surgery, stent placement/removal for urolithiasis, liver transplant social history: former fireman and bar owner; positive tobacco history; 2 packs per day x 30 years, quit prior to liver transplant. he is not using iv drugs. lives with his wife. very involved family. family history: his father has renal failure. his mother has hypothyroidism. physical exam: physical exam on transfer: vs: t 99.2, bp 128/58, hr 93, rr 22, spo2 95% on ra general: sedated but awakens to calling his name. answers questions with 1-2 word answers. oriented to person, place, and year. heent: ncat. perrl, eomi, mild scleral icterus. mmm, op benign. neck: supple. jvp not elevated. no cervical lymphadenopathy. cv: rrr. normal s1, s2. blowing holosystolic murmur heard best at llsb with radiation to apex. chest: respiration unlabored. slightly decreased breath sounds at right base. few scattered crackles. abd: bs present. significant tense ascites. ext: wwp, no cyanosis or clubbing. no le edema. digital cap refill <2 sec. distal pulses radial 2+, dp 2+, pt 2+. neuro: moving all four limbs. unable to assess fully due to mental status. pertinent results: labs on admission: 08:50am blood wbc-8.3 rbc-3.32* hgb-9.8* hct-30.5* mcv-92 mch-29.6 mchc-32.3 rdw-21.4* plt ct-81* 08:50am blood neuts-82.9* lymphs-9.3* monos-6.0 eos-1.5 baso-0.3 08:50am blood pt-18.9* ptt-42.0* inr(pt)-1.7* 08:50am blood glucose-310* urean-25* creat-5.3* na-125* k-4.6 cl-89* hco3-22 angap-19 06:05am blood alt-15 ast-27 ld(ldh)-185 alkphos-210* totbili-3.9* 06:05am blood albumin-3.3* calcium-8.8 phos-4.5 mg-1.7 06:05am blood tacrofk-7.5 lumbo-sacral spine (ap & lat) essentially unchanged levoscoliosis of the lumbosacral spine with no evidence of new compression fracture. ct pelvis w/contrast study date of 6:00 pm impression: 1. stable appearance of the transplanted liver with markedly dilated portal veins. no thrombus is present. 2. stable splenomegaly, collaterals, and worsening intra-abdominal ascites. 3. mild-to-moderate layering right pleural effusion with compressive atelectasis. development of plate-like atelectasis left lower lobe. 4. kidneys without hydronephrosis and nonspecific stranding. at the lower pole of the left kidney, a single non-obstructive calculus is remaining measuring 5-6 mm. 5. segmental wall thickening and mural edema of the sigmoid colon, nonspecific in the setting of ascites. mild uncomplicated colitis cannot be excluded. no rim-enhancing lesions, pneumatosis or extraluminal air. no evidence of bowel obstruction. . mr l spine w/o contrast 1. increased intrinsic signal abnormality within the l2-3 disc with surrounding endplate signal changes since the previous mri of . subtle soft tissue prominence is also identified, but no definite fluid collection is seen. no evident paraspinal soft tissue prominence seen. these findings could be due to advancing degenerative change or due to low-grade infection. given the clinical suspicion of infection, further evaluation with repeat lumbar spine study with gadolinium is recommended. given patient's low egfr, a consent could be obtained and, clinically, it should be determined whether the study is important for any decision making. 2. multilevel degenerative changes are identified as above with spinal stenosis at l3-4 and l4-5 levels as well as at l2-3 level. . ct abdomen/pelvis impression: 1. right-sided pleural effusion, unchanged compared with the previous study. 2. moderate-to-large ascites, unchanged compared with previous study. 3. no reaccumulation of the retroperitoneal fluid collection which was previously drained. brief hospital course: the patient is an 56 year old male with hepatitis c cirrhosis/hcc s/p liver transplant () with recurrent decompensated hepatitis c cirrhosis, esrd on hd, diabetes mellitus type ii, who was admitted for acute on chronic low back pain and was found to have coag-negative staph bacteremia and l2-3 discitis / osteomyelitis. . initial - : . # gpc bactermia: he has had several prior episodes of bacteremia requiring removal of his hd catheter. blood culture from his hd line on grew coag negative staph. spinal plain films from his admission on were unrevealing. ct abdomen pelvis on showed no acute findings concerning for infection. his hd catheter was removed on after an early hd session. noncontrast mri on showed possible low grade discitis at l2-3. multiple consecutive blood cultures from to grew coagulase negative staph. his continued bacteremia was concerning for a persistent source of infection. tte and tee showed no evidence of endocarditis or paravalvular abscess. id was consulted and recommended an 8 week antibiotic course. he was treated with vancomycin following hd protocol from through without clearing the bacteremia, at which point he was switched to daptomycin. gallium and bone scans showed no evidence of infection except for the region of discitis at l2-3. his daptomycin dose was increased from 500 mg q48h to 650 mg q48h on per id recs for 8 week course to be completed with last dose on per id. a new tunneled hd catheter was placed on . he has subsequent clinical deterioration with new low grade fevers to 100.0 on and 100.1 on , blood culture positive for gpcs on , and worsening back pain with new radiation to the buttocks. lumbar spine plain film on showed progressive destructive changes. lumbar spine mri with contrast on showed increased collapse of the superior endplate of l3 and an epidural soft tissue mass spanning l2 and l3, which most likely reflects a phlegmon and causes moderate to severe canal encroachment. he received dialysis immediately after the mri study and again the next day. his picc line was pulled and the tip sent for culture. his hd line was pulled on after dialysis. ortho spine was consulted regarding the possible need for surgical debridement of the phlegmon. patient chose to pursue surgery. . # left flank erythema: he had significant leakage from a prior paracentesis site noted on with some flank swelling from subcutaneous fluid. it was sutured on and stopped leaking. a few days later on , his left flank was noted to have increased swelling, erythema, pruritis, and tenderness. he has continued to have symptoms in this area. the itching is fairly well controlled with sarna lotion. abdominal wall us on did not identify any drainable fluid collections. . # back pain: he has acute on chronic back pain, which was his initial reason for presenting to the ed. prior mri on showed lower lumbar levoscoliosis with severe spinal canal stenosis and severe degenerative disc, endplate, and facet joint disease. spine xray on admission did not show any acute fracture. ct abdomen and pelvis did not show any acute changes. a pain service consult was called and did not believe that a procedural intervention would be helpful, though tens may be useful as an outpatient. noncontrast mri on showed possible low grade discitis at l2-3. later gallium and bone scans were consistent with an infection at this location. his back pain on was significantly worse after walking to the bathroom and he required additional pain meds for the first time in many days. his oxycontin dose was increased to 20 mg po bid on . his back pain has worsened since then with new radiation to the buttocks. . # altered mental status: he was in grade iii encephalopathy on transfer to the liver service, stuporous and unable to give more than single word answers to questions. he has cleared significantly since admission, and was fairly clear even during his active bacteremia. his initial ms changes were most likely due to medication effects (received dilaudid 1 mg iv and lorazepam 3 mg iv total over 24 hours for back pain). infection was likely contributing, particularly given his associated leukocytosis with left shift and persistent gpc bacteremia. baseline hepatic encephalopathy from from decompensated liver disease was also a likely contributor. diagnostic paracentesis on admission showed no evidence of sbp, and subsequent therapeutic paracentesis has also showed no evidence of sbp. he has remained quite clear since his initial presentation. he was continued on his home regimen of lactulose and rifaximin for most of his stay. . # hyponatremia: he was hyponatremic on admission with na 125, which largely resolved after hd. it is likely due to his underlying cirrhosis, but siadh from severe pain may also have played a role. he has been mildly hyponatremic at various times during his admission. . # esld: he was transplanted in for hcv cirrhosis, with subsequent hcv recurrence and cirrhosis of the transplanted liver. his course has been complicated by esophageal varices, coagulopathy, encephalopathy, and refractory ascites. his meld was 33 on admission. it has improved to the high 20s during the course of his stay. he was continued on pantoprazole and propranolol per his home regimen. . # liver transplant history: he was previously on tacrolimus 0.5 mg po bid. this was decreased to 0.5 mg daily on , and further decreased to 0.5 mg every other day on . his goal level was set at <5 and his tactolimus doses were held briefly. his tacro level was 3.9 on and tacrolimus was restarted at 0.5 mg every other day. his levels have since dropped below 2. . # adrenal insufficiency: he has a history of adrenal insufficiency and is on chronic hydrocortisone 10 mg po qam and 5 mg po qhs. he did not require stress dose steroids during this admission, though it was considered initially. . # diabetes mellitus, type ii: he was previously well controlled on his home regimen of nph 55 units and humalog sliding scale. his glucose levels have been labile recently, likely due to the changes in his dialysis schedule, dietary changes, and the stress of infection. no changes were made to his insulin regimen. . # esrd: he is usually on a mwf hemodialysis schedule. he had an early session on prior to hd catheter removal and an hd holiday. his electrolytes were closely monitored and he had back to back sessions on and . he was started on calcitriol on based on his elevated pth level of 135 from . his phosphate levels have been mildly elevated, and he was started on sevelamer 800 mg po tid. he was also started on nephrocaps. a new tunneled hd catheter was placed on . he had dialysis three days in a row from through . he then returned to a mwf schedule. with his recurrent bacteremia on , his new tunneled catheter was pulled on . he has tolerated the disruptions in his dialysis schedule well, without any significant problems. to spine surgery, patient had temporary line placed on and received dialysis on and . . # depression: paroxetine was continued per his home regimen. . # nutrition: he was kept on a low sodium, diabetic diet. after his hd catheter was pulled, he was temporarily placed on a more restrictive diet. these restrictions were later lifted after it was clear he could tolerate a more regular diet despite his disrupted hd schedule. po intake was encouraged and he was provided ensure supplements and beneprotein with meals. he was seen by nutrition who recommended dobbhoff placement and initiation of tube feeds which he tolerated well. . sicu course: patient underwent spine surgery for debridement of l2-l3 osteomyelitis on . admitted to surgical icu afterwards, intubated. difficulty weaning off ventilator for one week due to fluid overload. received cvvh but eveually transitioned to hd. required pressors from - . post-pyloric dubhoff tube placed. treated empirically with zosyn for vap. post-pyloric dubhoff placed and tubefeeds initiated. wound culture from spine grew coagulase negative staphylococcus resistent to daptomycin, switched to linezolid at id recommendation. placed on hydrocortisone given known adrenal insufficiency. transferred to the floor on . . - course # 2: on the floor, patient was initially afebrile with no leukocytosis. he was continued on linezolid and ciprofloxacin was started empirically for sbp prophylaxis. therapeutic and diagnostic paracentesis were performed. negative for sbp. ct abdomen/pelvis with contrast was obtained to look for retroperitoneal bleed, which was negative. there was a pararenal collection of fluid which was drained and culture negative. multiple paracentesis were negative for infection, but given continual leukocytosis, fever, and mental status changes, patient was kept on linezolid, ceftriaxone, and po vancomycin for broad spectrum coverage. his continued to develop encephalopathy and lactulose doses had to be closely titrated. patient was continued on dialysis. he worked with physical therapy to regain strength and made minimal progress. . transplant surgery/sicu course patient was transferred again to the icu on under the transplant team for worsening lactic acidosis up to 12.6. he had a ct scan demonstrating no evidence of bowel ischemia and stable ascites. linezolid was d/c'd for possible association with lactic acidosis and was changed to tigecycline for sbp coverage. he was started on cvvh on after transfer and the lactate improved to 5.6. upon transfer to the icu pt had mild bloody emesis, so an ngt lavage was performed and was positive. an egd on demonstrated hypertensive gastropathy with friable mucosa, but no local site to intervene. his hct was stable after transfusing 3u prbc before the egd. he needed to be intubated for the egd and was kept intubated for aspiration risks given the amounts of blood in the stomach. on a postpyloric dobhoff feeding tube was placed. the cvvh filter was clogged and lactate went up to 11.2, but then decreased after resuming cvvh. on vancomycin/cefepime was started as wbc increased from 6.1 to 13.9. a decision was made to take him off the liver and the kidney transplantion lists, as patient seemed too ill to be a candidate. after long discussions with the family about his poor prognosis, patient was made dnr/dni on . cvvh continued. on patient was made , pt was extubated and died on at 5:49 am. autopsy was denied by the family. medications on admission: b complex-vitamin c-folic acid ciprofloxacin 750mg qsunday hydrocortisone 10mg in am, 5mg in pm humalog sliding scale insulin lactulose 60cc by mouth three times daily nph insulin 55 units sq in the am; 55 sq units in the pm pantoprazole 40mg po bid paroxetine 40mg po daily propranolol 10mg po daily rifaximin 600mg po bid bactrim 400 mg-80 mg tablet mwf tacrolimus 0.5mg po bid magnesium oxide 400mg po daily discharge medications: none discharge disposition: expired discharge diagnosis: cardiopulmonary arrest decompensated liver failure spontaneous bacteral peritonitis osteomyelitis/discitis at l2-3 status post partial vertebrectomy l2-3/debridement/fusion l2-3 coagulase negative staphylococcus bacteremia hepatic encephalopathy status post liver transplant hepatitis c cirrhosis end stage renal disease diabetes mellitus type 2 adrenal insufficiency levoscoliosis discharge condition: expired discharge instructions: patient expired followup instructions: patient expired Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Hemodialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Dorsal and dorsolumbar fusion of the anterior column, anterior technique Excision of intervertebral disc Other partial ostectomy, other bones Fusion or refusion of 2-3 vertebrae Insertion of recombinant bone morphogenetic protein Central venous catheter placement with guidance Diagnoses: Pneumonia, organism unspecified Acidosis Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Chronic hepatitis C with hepatic coma Acquired coagulation factor deficiency Hyposmolality and/or hyponatremia Portal hypertension Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Hemorrhage complicating a procedure Acute respiratory failure Bacteremia Other ascites Awaiting organ transplant status Hemorrhage of gastrointestinal tract, unspecified Complications of transplanted liver Glucocorticoid deficiency Personal history of malignant neoplasm of liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Intraspinal abscess Other and unspecified infection due to central venous catheter Acute osteomyelitis, other specified sites Other and unspecified disc disorder, lumbar region Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus Other extrapyramidal diseases and abnormal movement disorders Antidepressants causing adverse effects in therapeutic use Other specified disorders of stomach and duodenum Scoliosis [and kyphoscoliosis], idiopathic

history of present illness: this is a 52-year-old gentleman with hepatitis c cirrhosis, hepatocellular carcinoma who had an orthotopic liver transplant in . the patient has recurrent cirrhosis. had a liver biopsy done on the 12th. he developed abdominal pain and hypotension. he received demerol and xanax as premedication. his blood pressure prior to the procedure was 126/65. his heart rate was 60. the biopsy was done, and the patient was taken to the daycare area. he stated that he was sleeping in the recovery area; and he woke up about an hour and a half after the procedure with abdominal pain, stabbing in quality, primarily in the right upper quadrant and right mid abdomen. he developed some lightheadedness, some nausea and some diaphoresis. his blood pressure was rechecked and found to be 90/60 with a heart rate of 75. his oxygen saturation was 98% on room air. he had no vomiting, no chest pain, no shortness of breath. his labs demonstrated a hematocrit of 29.3, which was down from 35.5 on the day prior. two large-bore iv's were placed, and he was taken to the ct scanner and transferred to the medical icu for close monitoring. past medical history: consistent with cirrhosis, hepatitis c, hepatocellular carcinoma. he had rfa x 3. he had a liver transplant in . he has recurrent hepatitis c after transplant. he has steroid-induced diabetes which is now improving. he is status post appendectomy, status post tonsillectomy. he carries a diagnosis of hypertension. status post cervical laminectomy, a right forearm orif, a bone graft was taken from hip to the elbow for that surgery. status post knee surgery and chronic lower back pain. allergies: he has an allergy to codeine, for which he gets a rash. outpatient medications: he takes bactrim 1 pill daily, protonix 40 mg p.o. b.i.d., percocet p.r.n. for pain, prograf 0.5 mg p.o. b.i.d., ribavirin 200 mg p.o. b.i.d., interferon 135 mcg subcutaneously weekly (his last dose was on ), atenolol 50 mg daily, lasix 20 mg b.i.d., neupogen 300 mg subcutaneously each week (his last dose was ), procrit 40,000 units subcutaneously (his last dose was ). he also takes paxil 10 mg daily. social history: he is a __________ . he is currently not working. he is married. the patient's wife is very active in his care. he denies any alcohol. he has a positive tobacco history; 2 packs per day x 30 years, but he quit before his liver transplant. he is not using iv drugs. family history: his father has renal failure. his mother has hypothyroidism. physical examination: his vitals is 96.1 for a temperature, his heart rate is 65, his blood pressure is 115/67, his respiratory rate is 16, he is % on room air. he is lying in bed in no acute distress. his skin has multiple tattoos. there is no jaundice. his head, eyes, ears, nose, and throat are perrla. his sclerae are anicteric. his oropharynx is clear. his membranes are moist. he has no jugular venous distention. his chest is clear to auscultation but has poor respiratory effort. cardiovascular; he is regular rate and rhythm. his abdomen; he has a chevron scar. his bowel sounds are positive. he is nondistended. he has mild tenderness with percussion. he has diffuse tenderness with moderate palpation that is worse in the right upper quadrant with rebound and guarding. the patient neurologically is somnolent but easily arousable. he is awake, alert, and oriented x3. he has slight asterixis. his upper and lower extremities strength is grossly intact. imaging studies: his ct abdomen and pelvis showed new hemoperitoneum, new increased ascites, a stable fluid collection and hepatic fissure and porta hepatis. brief review of hospital course: the patient - as is mentioned before in the hpi - was transferred to the medical icu. he was transfused 2 packed red blood cells, platelets and fresh frozen plasma. he was to have his hematocrit checked q.6h., and he was also given ddavp. at approximately 6:15 on the night of , the transplant surgery service was consulted. the patient had some right upper quadrant tenderness without distention and without peritonitis. he was transferred to the transplant surgery service for serial hematocrit's, serial exams with platelets. at the time of transfer, the patient's hematocrit had gone from 27 to 29. he had already received 2 units of packed cells and 2 units of ffp. his hematocrit seemed to be stable. on hospital day #2, the patient reported he was doing better. he was generally without complaints. his hematocrit was stable; it was 30.2 that day. his inr was also stable at 3.1. the abdomen remained somewhat tender, especially in the right upper quadrant. the plan was to restart the patient's home doses of medications, to monitor his hematocrit and transfuse him liberally in the event that he needed transfusion. the hepatology service was also following the patient along with the medical team. on hospital day #3, the patient was transferred to the floor. his foley was discontinued. his oxygen was discontinued. all his home medications were restarted. his hemoglobin and hematocrit continued to be followed very closely. the transplant surgery team was managing the patient's immunosuppression medications. discharge disposition: on hospital day #4, the patient was discharged to home. condition on discharge: good. discharge diagnosis: bleed after liver biopsy. discharge medications: the patient was to restart his prior home medications. the patient was given percocet 5/325; he was dispensed 60 tablets. he was to take that medication q.4- 6h. for p.r.n. pain. he was also given atenolol 50 mg p.o. daily; he was dispensed 30 tablets and given 2 refills. he was also given tacrolimus 0.5 mg p.o. twice a day. discharge instructions: he was to follow up in the transplant surgery clinic for routine laboratory information. the patient was also to follow up with dr. in 1 to 2 weeks in order to have a follow-up appointment to evaluate him and make sure he was doing okay. , Procedure: Closed (percutaneous) [needle] biopsy of liver Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Hemorrhage complicating a procedure Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

history of present illness: the patient is a 41-year-old white male with chronic hep c complicated by hepatocellular carcinoma diagnosed approximately 4.5 years ago. the patient has chronic fatigue with recent 6 to 8 weeks of scleral icterus. the patient started on interferon and ribavirin cocktail without success. he has status post radiofrequency ablation for the hepatocellular carcinoma 2.5 months ago with second episode 4 weeks later. no interval change. he was noted to be jaundiced in the clinic with increased lfts. his hematocrit was 26. he denied any weight changes, headache. he denied shortness of breath, chest pain. no change in bowel movements or urine, urinary complaints. he did note positive bilateral leg swelling. past surgical history: significant for cervical laminectomy, right forearm orif, t and a, appendectomy, bone graft from the right hip to the elbow. past medical history: significant for hypertension. he denies diabetes, asthma or other ca. family history: father has renal failure, mother than hypothyroidism. social history: he is an active fireman. married with 2 girls, one boy. he is a smoker. positive social drinker prior to hep c being diagnosed. medications: 1. atenolol 25 once a day. 2. vicodin p.r.n.. 3. percocet p.r.n.. 4. hydrochlorothiazide 50 once a day. 5. quinine sulfate at bedtime. allergies: codeine and shellfish. admission laboratory data: admission labs on : white count of 4, hematocrit 32.5, creatinine of 0.8, ast 194, alt 138, alkaline phosphatase 144, total bilirubin 2.3. chest x-ray demonstrated no acute process. ekg on : he was in a sinus rhythm with ectopy, unchanged from . he is hepatitis b surface antibody positive, hep b core antibody negative, igm negative, afp was 18.3. hep c virus viral load 225,000 on . the patient was taken to the or on . he underwent a cadaveric liver transplant for hepatocellular carcinoma. surgeon was dr. . the patient underwent an orthotopic deceased donor liver transplant piggyback, portal vein to portal vein anastomosis, donor common hepatic artery with replaced right hepatic artery anastomosed to the sa stump to recipient right hepatic artery (arising from superior mesenteric artery), common bile duct to common bile duct anastomosis over an 8 french t-tube. surgeon was dr. and assistant was resident . the patient received general anesthesia. please see operative report for details. ebl was approximately 1300. iv fluid replaced 3 liters. 4 units of ffp, 4 units of packed red blood cells, two bags of platelets and cryo. the patient was intubated and admitted to the sicu where he was stable. he was on an insulin drip for elevated blood sugars. he was on propofol npo, placed on unasyn. he received induction of immunosuppression in the or of 1 gram of cellcept, 500 solu-medrol. he was extubated successfully without complications. he had 2 jps and t-tube to gravity drainage. an ng tube and a foley. he was in sicu for approximately 2 days during which time he was started on prograf 2 mg twice a day. he achieved prograf level of 12.8 on postoperative day 3. he continued on solu- medrol taper and maintenance cellcept of 1 gram b.i.d. his vital signs were stable. his hematocrit trended down to 29.6 on postoperative day 4. he was given iv lasix for fluid retention. his preoperative weight was 88.6. his weight on postoperative day 4 was 89.4. his lfts trended down nicely. he underwent a duplex ultrasound of the liver on postoperative day 1, hepatic veins, portal veins and hepatic arteries were all patent with appropriate direction of flow and normal wave forms. there was no biliary duct dilatation. no intraparenchymal focal lesions. there was trace of free fluid adjacent to the left lobe of the liver. chest x-ray demonstrated swan-ganz catheter with the tip in the main pulmonary artery with no evidence of pneumothorax. chest x- ray on postoperative day 2 demonstrated increased atelectasis within both lung bases with new small right pleural effusion. on postoperative day 5, he underwent a t-tube cholangiogram that demonstrated no evidence of contrast extravasation or bile leak. no evidence of biliary obstruction and mild irregularity at the expected region of the anastomosis, likely secondary to post surgical edema. his t-tube was capped. his ast was 191, alt 538, alkaline phosphatase 138, and total bilirubin 2. after his t-tube was capped for a day his ast was 114, alt 398, alkaline phosphatase 177, total bilirubin 1.5, with an albumin of 2.9. his creatinine remained stable throughout this hospital course at 0.8. hematocrit was 31.3, white count ranged between 8 to 8.5. blood pressure ranged from 115/67 to 133/89. his lasix was stopped as his weight had decreased to 84.2. preoperative it was 88.6. he did not have any edema in his legs. his steroid was tapered down to 20 mg of prednisone once daily. his prograf was increased to 2.5 mg on postoperative 7 for a level of 7.4. repeat level the next day was 11.3. his jps were removed without incident and his t-tube was capped. insertion sites were clean and dry. his ganciclovir was switched to valcyte. he had received a total of 8 days of ganciclovir. he was maintained on unasyn 1.5 grams iv q6 hours for 8 days. he was followed by hepatology while he was in hospital. his diet was advanced. he was tolerating a regular diet towards the end of his hospital stay. pain medication was adjusted. percocet was ineffective. he was given dilaudid 2 mg po p.r.n. q4 to 6 hours with good relief. he was out of bed with assistance initially and physical therapy felt that he was safe to be discharged home. during this hospital stay blood pressure range as previously noted. intermittent increases to 163/88. his lopressor was adjusted. transplant coordinator met with mr. and reviewed medications and transplant education information. he was discharged home on , in stable condition, alert and oriented, ambulatory. he resumed atenolol. lopressor was stopped. discharge medications: 1. 2.5 mg of prograf b.i.d. 2. cellcept 1 gram po b.i.d. 3. prednisone 20 mg po once daily. 4. bactrim single strength 1 tab po once daily. 5. fluconazole 400 mg po once daily. 6. protonix 40 mg po once daily. 7. dilaudid 2 mg one tab po q 4 to 6 hours p.r.n. as needed for pain. 8. valcyte 900 mg po once daily. 9. atenolol 25 mg po once daily. the patient was instructed in t-tube dressing care and scheduled to follow up with dr. on , at 11 o'clock. discharge diagnoses: 1. hepatitis c cirrhosis. 2. hepatocellular carcinoma. 3. status post radiofrequency ablation. 4. status post cadaveric liver transplant on . 5. hypertension. laboratory data on discharge: ast 114, alt 398, alkaline phosphatase 177, total bilirubin 1.5, creatinine 0.8, bun 15, white count 8.5, hematocrit 31.3, platelet count 123. prograf level 11.3. , Procedure: Diagnostic ultrasound of heart Other transplant of liver Transfusion of packed cells Transfusion of other serum Other cholangiogram Transfusion of platelets Transfusion of coagulation factors Other operations on lacrimal gland Transplant from cadaver Diagnoses: Chronic hepatitis C without mention of hepatic coma Acute and subacute necrosis of liver Portal hypertension Malignant neoplasm of liver, not specified as primary or secondary Chronic fatigue syndrome

allergies: codeine / ambien / shellfish derived attending: chief complaint: bleeding, anemia major surgical or invasive procedure: mechanical intubation and ventilation egd sigmoidoscopy central venous line placement therapuetic paracentesis hemodialysis catheter removal hemodialysis catheter placement history of present illness: this is a 56-year-old male four years five months status post liver for hepatitis c cirrhosis and hcc with recurrent hepatitis c with cirrhosis decompensated by ascites and encephalopathy presented with hematochezia and hematemesis. friday at dialysis patient noted feeling lethargic and unwell. initial thought was that this was related to hypoglycemia to 40 post-dialysis. friday night extensive teeth removal by dr. pager number with ffp prior. discharged from hospital after teeth removal on saturday. sunday mild increased oozing. monday onset of cherry colored stoools and general malaise. tuesday to dialysis with hct decrease slightly per sister who is present giving details. wednesday continued and to ed today with malaise, mild confusion, oozing from mouth and hematemesis with clots in addition to hematochezia. hct 14.5 at osh, given three units prbc and 1 ffp and transferred urgently to the . . bleeding from mouth and rectum on arrival to the ed. teeth pulled given recent gingival infection. ng lavage with serosanginous then clear. inr at osh 3.1, now 2.0. given 1 g ceftriaxone, octreotide bolus and gtt, pantoprazole bolus and gtt. cordis in right femoral vein. also with 16g x 2, 20g x 2. vs on transfer 109/63, 126, 26, 99 on unknown level of oxygen. mental status improving with blood transfusion. liver and surgery consulted in ed. 4 units prbc upon transfer. past medical history: - hepatitis c cirrhosis and hepatocellular carcinoma s/p radiofrequency ablation x 3, s/p liver transplantation , recurrent hep c after transpant, now with decompensated liver failure with ascites and encephalopathy, listed. last egd in showed 1 cords of grade i varices. - recurrent hep c after transpant- last viral load 69 on . - htn - hx of type ii dm - adrenal insufficiency: . after cortisol stimulation test. - s/p appendectomy - s/p tonsillectomy - s/p cervical laminectomy - s/p right forearm orif - s/p graft from right hip to elbow - s/p knee surgery - urolithiasis, s/p stent placement and removal by urology social history: former fireman and bar owner; positive tobacco history; 2 packs per day x 30 years, quit prior to liver . he is not using iv drugs. lives with his wife. family history: his father has renal failure. his mother has hypothyroidism. physical exam: vitals - 74 122/79 16 97/ra general: comfortable, alert. able to recount history. heent: mild scleral icteris, o/p with healing gingiva. no bleeding. small head bruise. cardiac: regular rate/rhythm with 2/6 systolic murmur at apex, not previously docmented. lung: decreased breath sounds and trace crackles on right. abdomen: mildly distended, bowel tones and without ttp ext: wwp, trace ankle edema, 2+ pt pulses. pertinent results: cbcs: 07:00pm blood wbc-9.9 rbc-1.11*# hgb-3.4*# hct-10.8*# mcv-98 mch-31.1 mchc-31.8 rdw-17.3* plt ct-168 09:40pm blood wbc-4.4# rbc-2.64*# hgb-8.0*# hct-23.6*# mcv-90# mch-30.4 mchc-33.9 rdw-16.5* plt ct-86* 11:57pm blood hct-27.0* plt ct-93* 04:03am blood wbc-6.5 rbc-2.95* hgb-9.0* hct-26.0* mcv-88 mch-30.6 mchc-34.6 rdw-16.6* plt ct-82* 12:01pm blood wbc-6.8 rbc-2.99* hgb-9.1* hct-26.4* mcv-89 mch-30.5 mchc-34.5 rdw-16.9* plt ct-98* 09:47pm blood wbc-5.8 rbc-2.92* hgb-9.0* hct-26.5* mcv-91 mch-31.0 mchc-34.1 rdw-17.2* plt ct-73* 01:57am blood wbc-7.3 rbc-3.38* hgb-10.4* hct-30.4* mcv-90 mch-30.7 mchc-34.1 rdw-17.2* plt ct-93* 05:35am blood wbc-9.5 rbc-3.52* hgb-10.7* hct-32.8* mcv-93 mch-30.5 mchc-32.7 rdw-16.8* plt ct-111* . coags: 07:00pm blood pt-21.3* ptt-42.4* inr(pt)-2.0* 04:03am blood pt-19.8* ptt-41.2* inr(pt)-1.8* 01:57am blood pt-18.2* ptt-37.6* inr(pt)-1.6* 05:35am blood pt-18.8* ptt-35.9* inr(pt)-1.7* . chemistries: 07:00pm blood glucose-35* urean-27* creat-3.2*# na-140 k-4.0 cl-100 hco3-23 angap-21* 03:45am blood glucose-190* urean-45* creat-4.1* na-138 k-3.8 cl-102 hco3-23 angap-17 05:35am blood glucose-165* urean-39* creat-5.1* na-136 k-3.2* cl-97 hco3-26 angap-16 . 03:45am blood tacrofk-3.8* 02:04am blood tacrofk-4.0* . 09:52am blood cortsol-17.6 . micro: no growth on any blood, urine, sputum, or peritoneal fluid cultures . imaging: cxr et tube is 5.5 cm above the carina. ng tube tip is out of view below the diaphragms. there are low lung volumes. there is mild-to-moderate cardiomegaly. there is mild pulmonary edema. right pleural effusion is small-to-moderate in amount. right central catheter tip is in the right atrium. there is evidence of pneumothorax. . cxr et tube tip is at the level of the carina and should be repositioned. ng tube tip is in the stomach. side port is distal to the eg junction. cardiomediastinal contours are unchanged. right supraclavicular catheter remains in place. no other interval changes. . cxr #2 et tube tip is 5.6 cm above the carina. ng tube tip is in the stomach. there are low lung volumes. there is mild cardiomegaly. right supraclavicular catheter tip is in the right atrium. moderate right pleural effusion has increased from . left lower lobe atelectasis has worsened. pulmonary edema has almost resolved. . cxr impression: 1. stable right pleural effusion and right lower lobe atelectasis. 2. stable left lower lobe airspace opacity. 3. stable mild pulmonary vascular congestion and cardiomegaly. . : rib films: 1. left anterolateral rib fractures without substantial displacement. 2. new right lower lobe opacity suggesting either atelectasis or pneumonia. 3. mildly prominent small bowel caliber with many air-fluid levels. the appearance is not fully characterized here. although suspected to represent an ileus, further clinical and radiographic evaluation may be helpful with small bowel obstruction not completely excluded. . : t and l spine by verbal report, no evidence of acute fracture. brief hospital course: this is a 56-year-old man with liver failure and recurrent admissions for hepatic encephalopathy who returns with hematochezia and hematemesis. . # gi bleed: source thought to be form teeth extraction as well as possible rectal varices/hemorrhoids. intubated for airway protection in setting of large volume ugib. egd did not show bleeding esophageal varices. kept on octreotide and pantoprazole gtt until these findings were available. presented with hct 10.8, so massive transfusion protocol initiated, received 13u prbc between both osh, ed and icu, plus plateletes and ffp. access was with piv 16g x 2, femoral cordis. hcts stayed stable without further transfusions. he was weaned off of pressors on . received ceftriaxone for post-gi bleeding ppx in a cirrhotic patient. omfs consulted and had no additional surgical recommendations for his gums/mouth. cordis removed . on the floor, patient bleeding stopped, and patient's hematocrit remained stable. # enterococcal bacteremia: confirmed with outside dialysis center that blood cultures positive for enterococci were drawn through dialysis line. enterococcos was vancomycin sensitive; initially on linezolid and then daptomycin, but switched to vancomycin one final sensitivities were available. patient was afebrile and without leukocytosis. a tte was negative for vegetations and infectious disease did not feel strongly about pursuing a tee. patient will remain on vancomycin, dosed at dialysis, through . his tunneled dialysis line was removed by ir on and replaced on without any complication. . ventilator associated pna: patient with evidence of vap after intubation. he finished an 8 day course of cefepime, levofloxacin, and vancomycin. his 02 sats remained normal and he was encouraged to use his incentive spirometer. . # liver failure: patient is currently listed for another liver with kidney. his lfts and coags remained at baseline. a diagnostic paracentesis showed no evidence of sbp. he received a therapeutic paracentesis (5l removed) on . patient was continued on tacrolimus, bactrim, lactulose, and rifaxamin. he was confused after extubation, but this was related to icu delirium and side-effect of multiple sedating medications. . # esrd: patient on hemodialysis as outpatient. awaiting dual liver/kidney . mr. was dialyzed monday, wednesday, and friday during this admission. . # adrenal insufficiency: mr. was continued on his home dose of hydrocortisone. . # thrombocytopenia: platelet count at baseline. likely due to splenomegaly and decreased thrombopoetin. patient's platelets were monitored throughout admission. . # dm2: patient's insulin was initially held while he was npo. his nph was slowly uptitrated, and he was discharged on 40 units . this can be uptitrated to his home dose as an outpatient. . # chronic back pain: patient with long-standing history of back pain. mr. reports that he has multiple slipped disks. lumbar and thoracic xrays showed no evidence of acute fractures. . # rib fracture: mr. fell out of bed in the icu in the setting of delirium and multiple sedating medications. he complained of left-sided pain, and xrays showed: "left anterolateral rib fractures without substantial displacement." he was treated symptomatically for pain, and symptoms had improved at time of discharge. medications on admission: iprofloxacin 750 mg q sun hydrocortisone 10 mg am /5 mg pm pantoprazole 40 qd propranolol -10 mg rifaximin 200 mg sulfamethoxazole-trimethoprim -400 3/wk tacrolimus - 0.5 mg capsule -. paroxetine hcl nph insulin 55 units discharge medications: 1. ciprofloxacin 750 mg tablet sig: one (1) tablet po once a week: weekly on sunday. 2. hydrocortisone 5 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 3. hydrocortisone 5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 4. lactulose 10 gram/15 ml syrup sig: sixty (60) ml po qid (4 times a day). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 6. paroxetine hcl 40 mg tablet sig: one (1) tablet po once a day. 7. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). 8. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). 9. tacrolimus 0.5 mg capsule sig: one (1) capsule po bid (2 times a day). 10. bisacodyl 5 mg tablet sig: two (2) tablet po once a day as needed for constipation. 11. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 12. nph insulin human recomb 100 unit/ml (3 ml) insulin pen sig: forty (40) units subcutaneous twice a day. disp:*1 1* refills:*2* 13. humalog kwikpen 100 unit/ml insulin pen sig: one (1) units subcutaneous four times a day: per sliding scale. 14. propranolol 10 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 15. outpatient lab work please draw labs every tuesday for cbc, pt/inr, na, cr, tbili, albumin, tacrolimums. please fax all labs to dr. , liver clinic 16. vancomycin in d5w 1.25 gram/250 ml solution sig: one (1) intravenous q hemodialysis for 3 doses: stop date . discharge disposition: home with service facility: so shore vna discharge diagnosis: primary: 1. acute blood loss anemia secondary to bleeding of mouth and gums 2. upper gastrointestinal bleed 3. enterococcal bacteremia 4. hcv cirrhosis 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. , it was a pleasure taking care of you on this admission. you came to the hospital because of bleeding in your mouth and from you rectum. you were initially admitted to the intensive care unit where you had a breathing tube placed and underwent an endoscopy. your bleeding was caused by your recent dental procedures. you were transfused blood with an improvement in your blood counts. . you were also found to have a blood stream infection caused by a bacteria called enterococcus. you had your hemodialysis line replaced as this was believed to be a source of your infection. you are continuing on a course of an antibiotic called vancomycin to treat this infection. you will complete your 14 day course of vancomycin on . . we did xrays of your spine, which showed chronic degenerative changes. there were no acute fractures seen on these films. you would benefit from physical therapy as an outpatient. you also suffered a small rib fracture on the left. your symptoms will improve with time, but please call your doctor if you have worsening pain on your left side. . the following changes to your medications have been made: 1. you have started vancomycin 1250mg iv at hemodialsys for 3 more sessions to complete a 14 day course on . 2. your medication propranolol has been decreased to 10mg twice daily. 3. your nph has been decreased to 40 units twice daily. please continue to check your fingersticks at least twice daily and call your pcp if you readings remain above 200 for further adjustment. . please maintain your scheduled follow up listed below. followup instructions: please maintain your scheduled follow up listed below: . 1. infectious disease - provider: , .d. phone: date/time: 3:00 . 2. spine - provider: , md date/time: 10:40 . 3. please follow up with dr. in weeks. please call the liver center at (. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Other endoscopy of small intestine Insertion of endotracheal tube Hemodialysis Venous catheterization for renal dialysis Percutaneous abdominal drainage Percutaneous abdominal drainage Flexible sigmoidoscopy Incision with removal of foreign body or device from skin and subcutaneous tissue Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hemorrhage complicating a procedure Bacteremia Long-term (current) use of insulin Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Awaiting organ transplant status Complications of transplanted liver Glucocorticoid deficiency Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Other and unspecified infection due to central venous catheter Other specified disorders of stomach and duodenum Internal hemorrhoids with other complication Ventilator associated pneumonia Closed fracture of two ribs External hemorrhoids with other complication Accidental fall from bed Accidents occurring in residential institution

allergies: codeine attending: chief complaint: hypotension and abdominal pain major surgical or invasive procedure: none history of present illness: pt is a 51y/o m with a hx of olt for hcv/hcc who p/w marked hypotension from home. he was in his usoh until 1 wk ptp when he started to exp epigastric pain. he then developed chills, and low grade fever that started the night before presentation. denies sob/cp, hematuria, brbpr, melena, cough or sore throat. pt has noticed ha, and recent runny nose. past medical history: hypertension hcc hcv psh: rfa appendectomy tonsillectomy & adenoidectomy social history: he is an active fireman. married with 2 girls, one boy. he is a smoker. positive social drinker prior to hep c being diagnosed. family history: father has renal failure, mother with hypothyroidism. physical exam: 96.9 80 66/44 20 100% on ra nad, +chills, anicteric, conversant eomi, oropharynx clear, neck supple lcta b/l, rrr abd: nd, soft, mild epigastric tenderness, mild ruq tenderness, no rebound, no guarding incision c/d/i, without erythema or fluctuance no edema of either lower extremity, palpable dp pulses b/l pertinent results: 08:10pm glucose-196* urea n-27* creat-1.4* sodium-134 potassium-5.9* chloride-108 total co2-16* anion gap-16 08:10pm alt(sgpt)-129* ast(sgot)-130* ld(ldh)-251* alk phos-137* tot bili-1.9* 08:10pm calcium-7.6* phosphate-3.8 magnesium-1.4* 08:10pm wbc-22.0* rbc-3.73* hgb-12.2* hct-33.8* mcv-91 mch-32.8* mchc-36.2* rdw-17.4* 08:10pm plt count-225 08:10pm pt-14.9* ptt-33.9 inr(pt)-1.3* 08:10pm urine blood-neg nitrite-neg protein-neg glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 01:41pm type-art po2-111* pco2-30* ph-7.34* total co2-17* base xs--8 brief hospital course: pt was diagnosed with a probable intra-abdominal process and was fluid resucitated and admitted to the sicu. a foley and cvl were placed and his hemodynamic status was closely monitored. his bp was maintained on a dopamine drip, and on hd2 this was changed to levofed. cultures were sent and the pt was started on vanco, zosyn, flagyl and fluconazole. on hd2 a ct of his sinuses showed no sinusitis, but his ct abdomen showed pancolitis with small ascites. he was afebrile, and his clinical status improved to the point that at the end of hd2 he was moved to the floor. he continued to improve and was d/ced home on hd4 to finish a course of levo and flagyl to treat his colitis. medications on admission: tacrolimus 0.5 mg capsule sig: one (1) capsule po bid (2 times a day). prednisone 10 mg tablet sig: one (1) tablet po daily (daily). trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). ursodiol 300 mg capsule sig: one (1) capsule po three times a day. atenolol 25 mg tablet sig: one (1) tablet po bid lasix 5mg po qday discharge medications: 1. tacrolimus 0.5 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 14 days. disp:*42 tablet(s)* refills:*0* 5. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 7 days. disp:*7 tablet(s)* refills:*0* 6. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 7. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). disp:*60 tablet(s)* refills:*2* 8. 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* 9. ursodiol 300 mg capsule sig: one (1) capsule po three times a day. disp:*90 capsule(s)* refills:*2* 10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: sepsis, pancolitis discharge condition: stable discharge instructions: go to an emergency room if you experience new and continuing nausea, vomiting, fevers (>101.5 f), chills, or shortness of breath. be sure to take your complete course of antibiotics. you may resume your regular diet as tolerated. please follow up on monday for lab work and to monitor your blood pressure. please call when you get home to arrange for the blood work per liver protocol. followup instructions: please follow up on monday for lab work, and with dr. as listed: provider: , md, phd: date/time: 10:00 md, Procedure: Venous catheterization, not elsewhere classified Infusion of vasopressor agent Diagnoses: Other and unspecified noninfectious gastroenteritis and colitis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified septicemia Liver replaced by transplant Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction

history of present illness: this is a 34 year old female with known history of bicuspid aortic valve who is preoperative right now for gastric bypass surgery. she was referred by her cardiologist for evaluation with chief complaints of palpitations, ankle edema, and dyspnea on exertion. an echo performed in , prior to admission showed dilated left ventricle, ejection fraction of 60%, severe aortic insufficiency, and dilated ascending aorta, 4.4 cm. magnetic resonance imaging performed in showed an ascending aorta 4.9 and arch of 3.2, descending 2.8, moderate ai and mild aortic stenosis. past surgical history: nil. past medical history: no past medial history other than obesity and unknown bicuspid aortic valve. medications: preoperatively she was on no medications. allergies: no known drug allergies, but erythromycin did cause gi upset. family history: noncontributory. she lives with her parents. she had a dental examination 2 years ago. social history: she is a physical therapy assistant. no smoking history or use of alcohol. review of symptoms: she has an increase in weight gain most recently with rare episodes of paroxysmal nocturnal dyspnea and positive palpitations, rare episodes of heartburn. she slept on 2 pillows. she had no other respiratory or cardiac history. no other gastrointestinal complaints, genitourinary or musculoskeletal issues. she has no peripheral vascular issues either. she did admit to seeing a counselor recently for stress as her brother had recently died. preoperative laboratory data: white blood cell count 7.5, hematocrit 34.0, platelet count 176,000, pt 12.3, ptt 23.8, inr 1.0. glucose 79, bun 12, creatinine 0.8, sodium 136, k 4.1, chloride 102, bicarb 25, anion gap 13, alt 13, ast 16, alkaline phosphatase 97, total bilirubin 0.3, total protein 10.1, albumin 4.2, globulin 2.9, hb aic 5.7%. mri of the chest performed on , showed dilating ascending aorta 4.2 x 4.7 cm at the level of pulmonary artery, ascending was 4.3 x 3.9, descending 2.5 x 2.75 with no evidence of dissection, intramural hematoma or penetrating ulcer with normal great vessels. please review the official report dated . preoperative ekg showed sinus rhythm but nonspecific st segment abnormalities with a rate of 89. physical examination: vital signs: heart rate of 74, respiratory rate 18, blood pressure on the right 142/74, on the left 140/70. she is 5 feet 8 inches tall, weighing 315 pounds. general: she is well appearing with a grade 4/6 systolic ejection murmur. lungs: clear bilaterally. neck: supple with full range of motion. skin: unremarkable. heent: unremarkable. abdomen: soft and obese with 2+ bilateral peripheral edema. no varicosities and was neurologically grossly intact. she also had 2+ bilateral femoral and 1+ bilateral dp and 1+ bilateral pt pulses with no carotid bruits. the plan was for her to be referred to dr. , for aortic valve replacement and possible ascending aortic replacement. the patient was admitted to the hospital on , and underwent aortic valve replacement with 25 mm magna pericardial bioprosthesis and replacement of ascending aorta utilizing 24 mm gelweave graft by dr. . she was transferred to cardiothoracic intensive care unit in stable condition on the phenylephrine and propofol drips titrated. on postoperative day 1, she had been extubated overnight and was in sinus rhythm at 86 with a blood pressure of 98/49, cardiac index of 2.9. she was started on toradol p.r.n. as well as percocet p.r.n. and continued on kefzol perioperative antibiotics. postoperative laboratory data: white blood cell count 14.4, hematocrit 20.9, platelet count 250,000, k 4.5, bun 14, creatinine 0.8 with blood sugar of 122. she was alert and oriented. heart was regular rate and rhythm. lungs were clear bilaterally. sternal incision was clean, dry and intact with positive bowel sounds and 1+ peripheral edema. she was doing very well. she began lasix diuresis and beta blockade with lopressor. she was transferred out to the floor where she was seen and evaluated by case management and physical therapy. on postoperative day 2, urinalysis was sent. she had a t-max at 99, with sinus rhythm at 80, blood pressure was 111/59. she was started back on her preoperative medications of lipitor, aspirin, and was on metoprolol 12.5 mg po twice a day. she had some serosanguineous drainage around her pleural tube. pacing wires remained in place. her chest tubes were removed later in the day. her oxygen wean was begun. she was encouraged to ambulate with physical therapy and increase her pulmonary toilet. she was started on vitamin c and iron for her anemia. her creatinine remained stable at 0.9. her white blood cell count came down to 12.8. on postoperative day 3, her chest tube was discontinued. chest x-ray showed 10% right apical pneumothorax. her urinalysis was negative, white blood cell count dropped further to 10.2, creatinine remained stable, hematocrit rose to 24.0. dressings were clean, dry and intact. she was alert and oriented with a nonfocal neurological examination. epicardial pacing wires were removed. she was continued with diuresis and discharge planning was begun. on postoperative day 4, she had no events overnight and was hemodynamically stable, with an unremarkable examination. her chest x-ray showed a stable tiny right apical pneumothorax. her lasix was switched over from iv to po in preparation for her being discharged the following day. she was discharged on , in stable condition on postoperative day 4, with instructions to follow up with dr. , in the office at 4 weeks postoperatively for surgical evaluation. dr. , her primary care physician 2 weeks and to see dr. , her cardiologist in 2 weeks. discharge medications: 1. potassium chloride 20 meq po twice a day x 1 week. 2. colace 100 mg po twice a day. 3. zantac 150 mg po twice a day. 4. enteric coated aspirin 81 mg po once a day. 5. percocet 5/325 one to two tablets po q4 hours p.r.n. for pain. 6. lipitor 10 mg po once daily. 7. ferrous gluconate 300 mg tablet po once daily. 8. vitamin c 500 mg po twice a day. 9. metoprolol 25 mg po twice a day. 10. lasix 40 mg po twice a day for one week. discharge diagnoses: 1. status post aortic valve replacement and ascending aortic repair with graft. 2. obesity. 3. hypertension. 4. bicuspid aortic valve. discharge disposition: the patient is discharged to home in stable condition on , with visiting nurse services. , m.d. dictated by: medquist36 d: 15:50:31 t: 03:31:59 job#: Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve with tissue graft Resection of vessel with replacement, thoracic vessels Diagnoses: Anemia, unspecified Thoracic aneurysm without mention of rupture Congenital insufficiency of aortic valve

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fever & chills major surgical or invasive procedure: intubation/extubation central line placement a-line placement midline placement history of present illness: mr. is a 73 year-old man with a history of recent turp () who presents with respiratory failure and uti. . per family, the patient was generally feeling well until one day prior to admission when he "wasn't feeling that great" and felt as though he was "coming down with something". a slight fever (100) was noted along with chills. took tylenol and dayquil. additionally noted a burning sensation and blood in urine. additionally noted a cough since last week with sputum, no blood. . regarding his breathing, the family felt that this was generally unchanged. he has had increasing doe, worsening over the last few months. he gets sob after one flight of stairs. he does not get chest pains. family has also noted significant weight over last few months, mostly in abdomen. . ems reports show an initial bp of 124/103 with a rr of 30 and o2 of 89% on room air. their notes indicate that the patient was "sitting in bed shaking violently. states he can't breath." . in the ed, bp was initially 224/91, hr 120, rr 35, 99% on unclear amount of oxygen. spiked to 104.8. blood pressures trended down (200s to 80s systolic). when an ekg showed inferior st-elevations, a code stemi was called. before taking the patient to the cath lab, it was noted that bps were unequal so a cta was obtained. this was negative for dissection and initially was thought to show a pe. soon thereafter, the patient was intubated with a propofol gtt started. was also given labetolol iv for hypertension. soon after, blood pressure fell to 118/56, then to 80s systolic. a total of 5+ liters of normal saline were given, along with the following medications: - aspirin 325mg - zofran - levaquin 750mg iv past medical history: 1. diabetes 2. dyslipidemia 3. hypertension 4. benign prostatic hypertrophy 5. arthritis 6. gout 7. bladder stone social history: previous history of smoking, quit 10 years ago. not currently drinking. worked as a cook. family history: non-contributory. physical exam: vitals - t 100.1, bp 138/48, hr 98, ac 600/16, peep 5, fio2 100% gen - intubated. does not respond to commands but is moving all extremities. heent - surgical pupil on the right; 3mm -> 2mm on left. cv - difficult to hear heart sounds. no obvious murmurs. pulm - no rales/wheeze. abd - soft. non-tender. guaiac + per ed. ext - warm. no edema. pertinent results: admission labs urine benzos, barbs, opiates, cocaine, amphet, mthdne negative serum asa, etoh, , , tricyc negative . ua: 1.017 / 6.5 leuk mod bld lg nitr pos prot 500 glu 250 ket neg . lactate:4.3 . : 56 lip: serum acetmnphn 8.5 . trop-t: <0.01 . pt: 13.7 ptt: 27.6 inr: 1.2 fibrinogen: 869 . wbc: 9.6 plt: 296 hct: 41.7 . ecg: sinus tachycardia with long pr interval. st-elevations in ii/ii/f with q-waves in same leads. q-waves are old. . cxr (): respiratory motion blurs the hemidiaphragms. grossly, no consolidation or edema is evident. a tortuous atherosclerotic aorta is identified. the cardiac silhouette is within normal limits for size. no definite effusion or pneumothorax is seen. the osseous structures demonstrate a relatively short segment levoconcave curvature of the mid and lower thoracic spine with associated osteophyte changes. . cta (): 1. no evidence of aortic dissection. 2. equivocal filling defect in a right upper lobe subsegmental branch of the pulmonary artery. no evidence of pulmonary embolism. 3. enlarged pulmonary artery may reflect an element of underlying pulmonary hypertension. 4. mild upper lobe centrilobular emphysematous changes. 5. markedly atrophic left kidney with associated dystrophic calcification and extensive cortical thinning and scar. correlation with prior surgical history and medical history recommended. 6. mild right renal hydronephrosis. 7. fatty infiltration of the liver. 8. air in the bladder is likely related to introduction of foley balloon catheter, but clinical correlation is recommended. brief hospital course: assessement/plan: 73 yo m s/p turp procedure c/b uti resistant to ciprofloxacin, developed urosepsis requiring intubation and icu stay, also developed atrial flutter this admission. . # urosepsis due to e. coli: urosepsis was felt to be secondary to recent procedure, which placed patient at high risk for uti. he received cipro post-procedure but on presentation had a markedly positive ua. urine & blood cultures grew e.coli. blood cultures with e.coli were sensitive to zosyn and ceftriaxone but resistant to cipro; ceftriaxone was given. changed antibiotics to ceftriaxone -> cefazolin iv -> keflex po, currently started on meropenem iv on day of discharge. changed from keflex to meropenem due to possibility of ain, rising creatinine as well as urine with eos. will need to complete 2 week course of antibiotics with 5 additional days of meropenem. . # atrial flutter: the patient had developed atrial flutter with poor rate control, without prior history. increased po metoprolol to 100 tid for rate control. the patient was started on heparin in the icu, then bridging with lovenox to coumadin. . ep consulted about treatment, after discussion with family, family wanted to pursue option of anticoagulation prior to cardioversion. they did not want tee and cardioversion during this hospitalization. inr 3.1 on day of discharge, decreased coumadin from 5 -> 4mg on day of discharge, holding tonight's dose. pt will need frequent inr checks until stabilized. pt will need to follow up with general cardiology 2weeks after discharge for managment of atrial flutter as well as cad. . # cad: pt without prior history of cad or mi, however ecg and echocardiogram revealed mild lvh with regional left ventricular systolic dysfunction consistent with cad. pt was initially started on low dose lisinopril, however holding due to worsening creatinine. would restart once creatinine at baseline 1.2-1.5. pt already on aspirin, simvastatin and metoprolol. he will need follow up with general cardiology for mangament of atrial flutter as well as cad. . # acute on chronic kidney disease: baseline creatinine is variable, though 1.7 in icu seemed somewhat elevated compared to when scr was 1.2. there are ct findings suggestive of mild hydro on the right though no stone was seen. also has an atrophic left kidney. increasing creatinine with +eos in urine, ?ain from antibiotics, changed keflex to meropenem iv. metformin also discontinued. would check daily creatinine levels to monitor for improvement. . # diabetes: oral hypoglycemics were intially held given the patient's acute renal failure, also with dye load from ct imaging. however, restarted with improvement in renal function. fingersticks well controlled on oral agents and sliding scale humalog. discontinued metformin due to worsening renal function. would need to restart once creatinine improved. . # hyperlipidemia: continued on home regimen of simvastatin . # hypoxia/resp failure (resolved): extubated o/n . unclear etiology of hypoxic failure. initially felt to be secondary to pe, though the second read is unclear. there is no infliltrate or failure on cxr. given recent admission, dfa for influenza was performed and was negative. there were some changes consistent with emphysema on ct, though there are no wheeze noted at this time. sputum culture was unremarkable. . pt is being discharged to rehab facility. he is to follow up with cardiology for management of cad as well as atrial flutter. medications on admission: 1. amlodipine 5 mg daily 2. hctz 25mg daily? 3. atenolol 50 mg daily 4. metformin 500mg daily 5. glyburide 5mg daily 6. simvastatin 40 mg daily discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. haloperidol 5 mg tablet sig: one (1) tablet po hs (at bedtime). 3. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 4. glyburide 2.5 mg tablet sig: two (2) tablet po daily (daily). 5. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime). 6. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*54 tablet(s)* refills:*2* 7. 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* 8. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q8h (every 8 hours) for 5 days: start stop . 9. warfarin 4 mg tablet sig: one (1) tablet po hs (at bedtime): please hold dose. 10. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po at bedtime as needed for agitation. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: urosepsis atrial flutter bph s/p turp hypertension discharge condition: hemodynamically stable, aferile discharge instructions: you were admitted with an infection of your bladder which was significant enough for you to be in the icu. we are treating you with antibiotics. you developed an atypical rhythm of your heart called atrial flutter . please continue meropenem iv x 5 days for the infection. we have also started you on coumadin because of the atrial flutter to decrease the risk of any clot formed to cause a stroke. . please follow up with a cardiologist at 2 weeks to evaluate your heart rhythm. he will discuss if & what further procedures need to be done. . please call your doctor or return to the emergency room if you have any of the following: chestpain, shortness of breath, palpitations or any other worrisome rhythm. followup instructions: urology: please follow up with dr. for post/op evaluation. s/p turp on at 1115am. . you will need to follow up with cardiology for your atypical heart rhythm in 2 weeks. you or your family will be contact with an appointment. please call , if you haven't been contact in 1 week. . pcp: , . please follow up within weeks of discharge. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Arterial catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Other postoperative infection Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial flutter Sepsis Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute respiratory failure Septic shock Septicemia due to escherichia coli [E. coli] Hydronephrosis

code: full allergies: nkda 73 year old male s/p turp admitted with sob and malaise, hypoxic. in ed febrile and hypertensive. intubated for cta, which was negative for dissection and pe. sent to micu for further management. neuro: pt alert but increasing confusion throughout shift, in early am pt yelling out, attempting to get out of bed, wrist restraints applied for safety. received haldol 2.5mg x 2 with no effect. pt disoriented, required frequent re-orientation. follows commands, mae. opacity over right pupil noted. pt denies pain. cv: hr aflutter 80-100s with occasional pvc, abp 160-170/80-90, md aware of hypertension, will address during am rounds. heparin gtt continues at 1450 units/hr, awaiting am , titrate per order. access includes right radial a-line and left midline. of note blue port on midline difficult to flush. resp: weaned to 2l nc, rr 18-24 with sats >97%, lungs clear to coarse, diminished in bases, productive cough. gi: bs x 4, multiple small stool smears this shift, unable to guiac. npo until speech/swallow eval, takes pills crushed in applesauce. gu: foley patent and draining pink and now more red urine with sediment. red urine likely caused by pt pulling on catheter, moving arouns in bed. md aware. endo: insulin per sliding scale. id: tmax 98.7 ax, continues on abx. Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Arterial catheterization Diagnoses: Coronary atherosclerosis of native coronary artery Other postoperative infection Urinary tract infection, site not specified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial flutter Sepsis Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Acute respiratory failure Septic shock Septicemia due to escherichia coli [E. coli] Hydronephrosis

past medical history: 1. hypertension. 2. diabetes. 3. oral hypoglycemia. 4. partial right kidney resection secondary to nephrolithiasis. 5. left renal mass, not worked up. 6. cad. 7. mibi with severe fixed perfusion defects at the inferolateral wall. moderate fixed defects at the inferior wall. ef 45%. 8. right eye surgery. 9. bph. 10. history of "ulcer". 11. nephrolithiasis. 12. cystoscopy in . social history: the patient has three children. the patient is a nonsmoker, nondrinker. the patient lives with wife. admission medications: 1. cipro. 2. tylenol. 3. atenolol. 4. cosopt one drop o.s. b.i.d. transfer from the icu medications: 1. insulin. 2. protonix 40 mg iv b.i.d. 3. nystatin p.r.n. 4. metoprolol 75 mg p.o. t.i.d. 5. ampicillin 500 mg p.o. t.i.d. 6. calcium acetate 667 t.i.d. 7. prednisolone 1 mg b.i.d. 8. dorzolamide one drop b.i.d. 9. levaquin 250 mg p.o. q.d. 10. ambien p.r.n. 11. morphine p.r.n. 12. atrovent. 13. albuterol q. four to six p.r.n. 14. ondansetron p.r.n. 15. trazodone. 16. tylenol p.r.n. physical examination on admission: vital signs out of micu: temperature maximum 99.8, temperature current 98.2, blood pressure 130s-180s systolic, diastolic 60s-90s, pulse 67-95, respirations 14-23, pulse oximetry 97-100% on room air. i&o even. general: the patient was a moderately obese chinese male, lying in bed, in no acute distress. heent: surgical pupil bilaterally. eomi. oropharynx clear. white membrane over tongue. cardiovascular: regular rate, no murmurs, rubs, or gallops. lungs: clear to auscultation. slight decrease in breath sounds at left base. abdomen: mild diffuse tenderness. no guarding, no hepatosplenomegaly. right nephrostomy tube in place, clean, dry, and intact. extremities: no clubbing, cyanosis or edema. jcd in place bilaterally. neurologic: the patient was alert and oriented times three, moving all four extremities appropriately. no cranial nerve deficits appreciated. laboratory/radiologic data: on transfer, hematocrit 40.1, white count 13.7, down from 14.9, platelets 313,000. the u/a revealed a few bacteria, white blood cells, trace leukocyte esterase, large blood. bun an creatinine on transfer 23, 1.4, glucose 108, inr 1.4. recent abg on , status post extubation, 7.35/38/94. culture date from influenzae a and b negative. on , urine culture pending. c. difficile pending. on sputum consistent with yeast. on h. pylori antibody positive. blood cultures two out of two negative. no growth to date. on , urine culture revealed three types of bacteria, enterococcus faecalis sensitive to ampicillin, levofloxacin, penicillin, and vancomycin on . the urine with e. faecalis with similar sensitivities. radiology x-rays on admission were negative. on , mild chf. on , et tube intubated at appropriate carinal height. on , chf, alveolar edema, left lower lobe collapse, consolidation of small effusion. on , lv prominence consistent with slight chf. renal ultrasound revealed right kidney pole 11.6, left kidney 9 cm, mild right hydronephrosis, stone in middle of right ureteropelvic duct, two stones in upper pole, left kidney up to 9 mm stone, mixed echo focus in midpole of left kidney, question of oxyphilic component. ct of the abdomen on revealed left renal mass 4 cm with scarring. similar findings on ultrasound. ct of the pelvis and abdomen were unchanged. hospital course: the patient was transferred from the micu to the floor status post urosepsis secondary to obstructive nephropathy, status post percutaneous nephrostomy drainage, urosepsis secondary to enterococcus, improving on ampicillin, stable gi bleed consistent with h. pylori infection, continued on ppi and levofloxacin. hematocrit stable. 1. genitourinary: the patient was hydrated, monitored urine output with continued u/a revealing a negative infection with appropriate antibiotic coverage. ir reevaluated nephrostomy tube on with efforts to internalize stent, although leaking at right nephrostomy percutaneous drain. on , reevaluation revealed normal flow pigtail catheter, evidence of extravasation of urine outside of old tract and was embolized successfully and without evidence of urine. the patient will follow-up with dr. in urology in two weeks. continued on urised-k 40 mg sustained release p.o. q.d. as well as amoxicillin 500 mg t.i.d. times two weeks and levofloxacin 250 mg for one day to complete his course. 2. infectious disease: the patient continues on amoxicillin and clarithromycin for appropriate enterococcus faecalis urosepsis as well as h. pylori eradication. finishes a ten day course of levofloxacin tomorrow. 3. hypertension: the patient was titrated on lisinopril as well as transitioned to appropriate beta blockade with metoprolol xl 225 mg p.o. q.d. the patient remained normotensive throughout and euvolemic. 4. gastrointestinal: the patient was continued on protonix as well as h. pylori eradication. hematocrit remained stable. no evidence of new bleed, gastritis on egd consistent with h. pylori infection. the patient is to continue clarithromycin times two weeks. 5. glaucoma: the patient will be continued on prednisolone 1% drop ophthalmic b.i.d. and dorzolamide 2/0.5% one drop b.i.d. 6. diabetes: the patient was continued on a regular insulin sliding scale throughout, transitioned to insulin regimen per home as well as glucovance for home regimen. discharge medications: 1. glucovance, prior dose. 2. dorzolamide one drop b.i.d. 3. prednisolone one drop b.i.d. 4. regular insulin sliding scale. 5. pantoprazole 40 mg p.o. q.d. the patient is to take b.i.d. for one month and then transition to q.d. dosing. 6. clarithromycin 500 mg p.o. b.i.d. 7. hyoscyamine 0.125 mg p.o. q.i.d. as needed. 8. lisinopril 2.5 mg p.o. q.d. 9. levofloxacin 250 mg p.o. q.d. 10. amoxicillin 500 mg p.o. t.i.d. times two weeks. 11. urised-k 40 mg p.o. q.d. 12. toprol xl 225 mg sustained release p.o. q.d. follow-up: 1. the patient was to follow-up with dr. on monday or tuesday. the patient was to call to confirm appointment date. 2. the patient is to follow-up with dr. in urology in two weeks. major surgical invasive procedures: 1. internalization of right nephrostomy with stent. 2. mri of the left kidney, showed no mass. condition on discharge: the patient was discharged home in fair condition with good urine output, evidence of patent ureteral stent. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other endoscopy of small intestine Percutaneous nephrostomy without fragmentation Injection or infusion of other therapeutic or prophylactic substance Ureteral catheterization Other irrigation of (naso-)gastric tube Percutaneous pyelogram Replacement of nephrostomy tube Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction Streptococcal septicemia Calculus of ureter Urinary complications, not elsewhere classified

history of present illness: this is a 64-year-old gentleman who began having episodes of dizziness starting four years ago. these symptoms led to a stress test and a cardiac catheterization four years ago. over the past year he has had increased fatigue and a positive stress test in . ejection fraction was measured to be 36% at this time. he was found to have an ischemic cardiomyopathy. the results of this work-up led to a cardiac catheterization on . the following occlusions were found: lad 100%, circumflex 90%, left posterior descending artery 80%, right coronary artery 90%, ejection fraction 35%. the patient is referred to dr. for coronary artery bypass graft surgery. past medical history: question of mi. the patient denies any nausea, myocardial infarction, coronary artery disease as described above. insulin dependent diabetes mellitus, hypercholesterolemia, rheumatoid arthritis, left carotid disease status post stenting, peripheral vascular disease. past surgical history: left carotid stent placed in . medications: on admission, humalog 8 units q a.m., humulin n 88 units q a.m., humalog 4 units, humulin n 16 units q p.m. ic-klor-con 10 meq , lipitor 40 mg po bid, digoxin 0.25 mg po q day, zestril 20 mg po q day, enteric coated aspirin 81 mg po q day, azulfidine 500 mg po q day, coreg 12.5 mg po bid, plavix 75 mg po q day (stopped ). allergies: no known drug allergies. family history: noncontributory. social history: tobacco abuse, quit 10 years ago, denies use or abuse of alcohol, denies any recreational drugs. physical examination: on admission, vital signs, pulse 67, blood pressure 182/85, height 5 feet, 10 inches, weight 186 lbs. general impression, well nourished, in no apparent distress. skin, good skin tone, dry patches on elbows and calves bilaterally, multiple skin tags. heent: darkened teeth, several missing, no lymphadenopathy. pupils equal, round and reactive to light. neck, no jugulovenous distension, no palpable lymph nodes, no thyromegaly. chest, decreased breath sounds at the right base, left is clear to auscultation. cardiac, regular rate and rhythm, s1 and s2, there is a 2/6 systolic murmur radiating to the left clavicular area. abdomen soft, nontender, non distended, positive bowel sounds, no hepatosplenomegaly. extremities, multiple scratch abrasions on both calves. no clubbing, cyanosis or edema is appreciated. legs are warm, well perfused, no ulcers or venous stasis disease. there are no varicosities. neuro, cranial nerves iii through xii grossly intact, non focal. motor strength 4/5 in the upper extremities and in the lower extremities. femoral pulse 2+ bilaterally, dp 2+ bilaterally, pt 1+ bilaterally, radial 2+ bilaterally. hospital course: the patient was admitted to on . on day of admission he had a coronary artery bypass graft of three vessels performed by dr. . he had left internal mammary artery anastomosis to the lad, saphenous vein graft to om and saphenous vein graft to pda. please see previously dictated operative note for more details. the patient tolerated the procedure well without problems and was discharged from the operating room to the cardiac surgery recovery unit. on leaving the operating room the patient was intubated and was on a neo-synephrine and propofol drip. the patient's postoperative course was uncomplicated and on the first postoperative day he was weaned off all vasoactive drips, was extubated and transferred to the patient care floor. on the floor the patient ambulated well and continued to make good progress. the only minor complication was a fever spike on the evening of postoperative day #1. for this, chest x-ray was obtained, urinalysis was obtained, cultures were sent of blood, sputum and urine and white count was checked. the white count was not elevated and all other investigations did not yield the source of the fever. the patient was afebrile for the duration of his hospital course. the patient's chest tubes were removed on postoperative day #2 as were his pacing wires. by postoperative day #4 the patient was ambulating level 5, all wires and tubes were removed and was ready to go home. on this day there was minimal erythema noted around the sternum for which he was started on a 10 day course of keflex. examination on discharge, temperature 99.3, pulse 86, blood pressure 138/64, respiratory rate 18, 94% on room air. the patient was comfortable. lungs were clear to auscultation bilaterally. heart regular. sternum stable. there was no drainage, minimal erythema around the staple line. his abdomen is soft, nontender, non distended with bowel sounds. his extremities have no edema. his saphenectomy wounds were well healed with no evidence of erythema or exudate. discharge disposition: to home. condition on discharge: stable. discharge medications: lasix 20 mg po bid times one week, potassium chloride 20 meq po bid while on lasix, percocet 1-2 tablets po q 4-6 hours prn, colace 100 mg po bid while taking percocet, aspirin 325 mg po q day, plavix 75 mg po q day, nph insulin 20 units subcu q a.m., lopressor 75 mg po bid, iron sulfate 325 mg po tid, keflex 500 mg qid times 10 days. fop: the patient will see his primary care physician, . in three weeks. the patient will see dr. in weeks. discharge diagnosis: 1. status post coronary artery bypass graft times three. , 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 Pure hypercholesterolemia Peripheral vascular disease, unspecified Other specified forms of chronic ischemic heart disease Rheumatoid arthritis Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled

history of present illness: this is a 47-year-old male with a history of two myocardial infarctions and two stents in his left circumflex who presented to the with chest pain and inferior st elevations on electrocardiogram. he received aspirin in the ambulance en route to the hospital as well as three nitroglycerin which improved his chest pain. he was started on heparin and aggrastat drips and transferred to for cardiac catheterization. in retrospect, the patient gave a history of one week of progressive intermittent chest pain as well as dyspnea on exertion. upon arrival to this hospital he was transferred to the catheterization laboratory where a left heart catheterization showed 100% discrete proximal circumflex in-stent restenosis. this received dotter, but angiography showed residual thrombus. the patient then became hypotensive requiring dopamine and then had ventricular tachycardia requiring cardioversion. an intra-aortic balloon pump was placed transiently and then removed after catheterization. a lidocaine bolus was given, and a drip was started. attention was again turned to the lesion in the circumflex artery. a percutaneous transluminal coronary angioplasty was performed, then a 3.5 mm x 15 mm stent was placed between the two existing stents. finally, a percutaneous transluminal coronary angioplasty was performed along the entire area and inside the distal stent. final angiography revealed no residual stenosis and normal flow. the patient was transferred to the coronary intensive care unit for further monitoring and care. past medical history: 1. coronary artery disease and myocardial infarction in . catheterization in showed a 40% proximal left circumflex lesion and a 90% middle left circumflex lesion that received a stent. a catheterization was again performed in for chest pain that revealed a 40% proximal left circumflex lesion without change and a patent stent to the middle circumflex. a stress test was performed in that provoked anginal symptoms as well as 1-mm st depressions in the lateral precordium, and there nonspecific st-t wave changes in the inferior leads. nuclear images showed moderate-to-severe lateral and inferior wall defects with an ejection fraction of 33%. this prompted another cardiac catheterization in that revealed that the proximal left circumflex lesion had progressed to 90%. this was stented. one month prior to admission (in ), the patient had another cardiac catheterization that showed a 40% to 50% lesion at the first diagonal, a 40% lesion in the distal circumflex, and a 60% lesion at the second obtuse marginal. both left circumflex stents showed mild (less than 30%) in-stent restenosis. 2. hypertension. 3. chronic pancreatitis induced by ethanol, status post pancreatic stone removal surgery at . 4. depression. 5. hypercholesterolemia. 6. anemia. medications on admission: bisoprolol 2.5 mg p.o. q.d., ramipril 2.5 mg p.o. q.d., lipitor 10 mg p.o. q.d., multivitamin 1 p.o. q.d., folate 1 mg p.o. q.d., oxycontin 40 mg p.o. b.i.d., oxycodone 5 mg p.o. t.i.d. p.r.n., fentanyl patch 100-mcg per hour transdermal patch q.72h., sublingual nitroglycerin p.r.n., colace 100 mg p.o. b.i.d., creon (pancrease) 40 mg p.o. t.i.d. with meals, zoloft 50 mg p.o. q.d., neurontin 300 mg p.o. t.i.d., trazodone 50 mg p.o. q.h.s. p.r.n., aspirin 325 mg p.o. q.d. allergies: no known drug allergies. family history: mother has coronary artery disease. father died in his middle 40s of a myocardial infarction. sister died of her second heart attack at the age of 45. social history: the patient lives in with his wife but is moving to this week. he smokes five to six cigarettes a day. he use to smoke 1.5 packs per day for 30 years. he is a former alcoholic, currently off ethanol but does have an occasional beer. he has a history of being in detoxification. no intravenous drug use. vital signs on admission revealed a temperature of 98.4, blood pressure of 120/66, heart rate of 80, respirations of 17, oxygen saturation of 100% on 2 liters nasal cannula. he was on a lidocaine drip at 2 mg per minute. physical examination on presentation: in general, alert and oriented times three. in no acute distress, lying in bed. head, eyes, ears, nose, and throat pupils were equal, round, and reactive to light. extraocular movements were intact. sclerae were anicteric. neck was supple. no jugular venous distention. no lymphadenopathy. pulmonary was clear to auscultation anteriorly. cardiovascular revealed a regular rate and rhythm. normal first heart sound and second heart sound. no murmurs, rubs or gallops. the abdomen was soft, nontender, and nondistended, positive bowel sounds. groin revealed no hematoma, no bruit. extremities revealed 2+ dorsalis pedis pulses. no clubbing, cyanosis or edema. neurologically, alert and oriented times three. cranial nerves ii through xii were intact. pertinent laboratory data on presentation: laboratories on admission revealed potassium was 4.1, the white blood cell count was 17.5, and the hematocrit was 29.6. at the hematocrit had been 37.4. arterial blood gas revealed a ph of 7.35, a pco2 of 45, and a po2 of 90. magnesium was 1.6. creatine kinase was 3418, with a mb of 365, with an index of 10.7. radiology/imaging: electrocardiogram showed st elevations in leads ii, iii, and avf with a t wave inversion in leads i and l as well as a 1-mm st elevation in lead avl. st depressions were also seen in v1 through v5, and the rhythm was atrial fibrillation. after catheterization, the st segment changes had resolved. there were st-t wave changes in leads i and l that had also resolved. there was persistent t wave inversions in the inferior leads. there were peaked t waves in leads v2 to v3. the st changes in the precordium had resolved. there were small q waves inferiorly. impression: this is a 47-year-old male with left circumflex disease, prior myocardial infarction, status post two stents to the left circumflex, who presents with an st elevation myocardial infarction. upon cardiac catheterization, there was in-stent restenosis seen at the proximal left circumflex stent. an angioplasty was performed and another stent was placed in between the two existing stents with final angiography revealing normal flow. the catheterization was complicated by cardiac arrest which was treated with cardioversion times three, resulting in a normal sinus rhythm. of note, the patient had been in atrial fibrillation prior to catheterization. he transiently required dopamine and intra-aortic balloon pump, which were both discontinued prior to transfer to the coronary care unit for continued care. hospital course by system: 1. cardiovascular: coronary artery disease: aggrastat was continued until 18 hours after catheterization. he was continued on aspirin, folate, multivitamin, beta blocker, and ace inhibitor. we recommend that he continue plavix for life given his recurrent thrombosis of his left circumflex stents. there is a strong possibility that he has a so-called "aspirin nonresponder." despite some post procedure chest pain, the patient's creatine kinases continued to trend downward, and relatively high creatine kinases were considered a function of his cardioversion. of note, the ck/mb index remained within the normal range after catheterization. electrocardiograms were unchanged after catheterization throughout this admission. the patient's lipid profile was checked, and this was extremely favorable. the total cholesterol was 82, with triglycerides of 39, a high-density lipoprotein of 43, and a low-density lipoprotein of 31. in terms of his left ventricular function, an echocardiogram was performed that revealed an ejection fraction of 40%. we recommend that he continue on ramipril. of note, the patient's blood pressure was approximately 90 to 110 systolic over 70 to 80 for the majority of his hospitalization. in terms of the patient's rate and rhythm, he was admitted with a rhythm of atrial fibrillation. after he was shocked out of his ventricular fibrillation arrest he was in normal sinus rhythm for the remainder of his hospitalization. a lidocaine drip was weaned off within 12 hours of his transfer to the coronary care unit. 2. fluids/electrolytes/nutrition: the patient was continued with a cardiac diet. electrolytes were followed and repleted as necessary. 3. renal: the patient had a normal blood urea nitrogen and creatinine during this hospitalization. 4. gastrointestinal: we continued the patient on protonix, pancrease, and his pain regimen for pancreatitis. 5. hematology: the patient had a hematocrit of 27.7 on the evening of admission, so he was transfused 1 unit of blood. his hematocrit continued to increase daily throughout the remainder of his hospitalization. medications on discharge: 1. aspirin 325 mg p.o. q.d. 2. bisoprolol 2.5 mg p.o. q.d. 3. ramipril 2.5 mg p.o. q.d. 4. lipitor 10 mg p.o. q.d. 5. zoloft 50 mg p.o. q.d. 6. neurontin 300 mg p.o. t.i.d. 7. trazodone 50 mg p.o. q.h.s. p.r.n. 8. creon 40 mg p.o. t.i.d. with meals. 9. duragesic patch 100-mc per hour patch q.72h. 10. oxycontin 40 mg p.o. b.i.d. 11. oxycodone 5 mg p.o. t.i.d. p.r.n. 12. sublingual nitroglycerin p.r.n. 13. multivitamin 1 p.o. q.d. 14. folate 1 mg p.o. q.d. 15. plavix 75 mg p.o. q.d. (for life). discharge followup: followup should be with his primary care physician, . , whom he should see within one month. an appointment was made for him with his cardiologist, dr. , at cardiology. condition at discharge: condition on discharge was good.. discharge status: he was discharged to home following clearance from physical therapy. discharge diagnoses: 1. myocardial infarction. 2. status post stent to the left circumflex artery. 3. hypertension. 4. atrial fibrillation; resolved. 5. chronic pancreatitis. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Injection or infusion of platelet inhibitor Left heart cardiac catheterization Insertion of temporary transvenous pacemaker system Atrial cardioversion Implant of pulsation balloon Hypothermia (central) (local) Diagnoses: Coronary atherosclerosis of native coronary artery Cardiac complications, not elsewhere classified Atrial fibrillation Paroxysmal ventricular tachycardia Cardiac arrest Acute myocardial infarction of other inferior wall, initial episode of care Other complications due to other cardiac device, implant, and graft Chronic pancreatitis

history of present illness: mrs. is a 74-year-old woman, with a several month history of shortness of breath leading to an echo which showed aortic stenosis as well as mitral regurgitation and tricuspid regurgitation. a cardiac cath done in showed minimal coronary artery disease. she had been admitted twice to the cardiothoracic service before, but was sent home for a yeast infection under her breast and an infection of the left forearm. she presented again on the day of admission, one day prior to her surgery for physical evaluation. past medical history: significant for rheumatic heart disease, obesity, aortic stenosis, mitral regurgitation, osteoarthritis, cataracts, atrial fibrillation, congestive heart failure, neuropathy, and rheumatoid arthritis. past surgical history: significant for tonsillectomy and hernia repair. she has no known drug allergies. meds at home: lasix 40 every day, diltiazem 30 q.i.d., potassium chloride 40 every day, coumadin 4 every day, and protonix 40 every day. social history: lives in with her son, still lives independently, remote tobacco history and rare alcohol use. family history: no significant history of cad. physical exam: weight 103.9 kg, temperature 95.6, heart rate 64 sinus rhythm, blood pressure 135/56, respiratory rate 18, o2 sat 97 percent on room air. in general no acute distress. neurological alert and oriented x3, nonfocal exam. cardiac showed regular rate and rhythm. respiratory was clear to auscultation bilaterally. abdomen was soft, nontender, nondistended with no hepatosplenomegaly. extremities warm and well perfused with bilateral lower extremity edema. laboratory data: pt 17.1, inr 1.9, sodium 142, potassium 4.1, chloride 106, co2 27, bun 26, creatinine 1.0, glucose 123, white count 9.2, hematocrit 39.2, platelets 301,000. chest x-ray showed mild cardiomegaly with no chf, consolidations or effusions. the patient was begun on a heparin infusion. she was typed and screened and was prepared for the operating room. due to her elevated inr the patient received subcutaneous vitamin k. on the patient was brought to the operating room. please see the or report for full details. in summary she underwent an avr, mvr and modified mays. avr was with a number 23 valve. the mvr was a number 25 valve. her bypass time was 196 minutes with a crossclamp time of 165 minutes. she tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer the patient was in sinus rhythm at 92 beats per minute, with a mean arterial pressure of 85 and a cvp of 18. she had epinephrine at 0.01 mcg per kilogram per minute, propofol at 40 mcg per kilogram per minute, and nipride at 0.2 mcg per kilogram per minute. the patient did well in the immediate postoperative period. propofol was discontinued. her anesthesia was reversed, however, she was slow to fully awaken from her anesthesia and she remained intubated throughout the day of her surgery. on postoperative day one the patient remained hemodynamically stable, requiring a nipride infusion to maintain blood pressure control. she was weaned from the ventilator and successfully extubated. by the end of the day the patient was begun on oral agents. her nipride infusion was discontinued. on postoperative day two she remained hemodynamically stable. she was begun on beta blockade as well as diuresis. her coumadin was restarted. swan ganz catheter was removed as were her chest tubes, however, the patient went back into atrial fibrillation and it was, therefore, decided to keep her in the intensive care unit for closer hemodynamic monitoring. on postoperative day three the patient continued to do well. the electrophysiology service was consulted regarding her atrial fibrillation following mays. she was begun on an amiodarone infusion and again she remained in the intensive care unit. she remained hemodynamically stable on postoperative day four. finally on postoperative day five the patient's temporary pacing wires were removed and she was transferred to the floor for continuing postoperative care and cardiac rehabilitation. once on the floor the patient was slowly progressing in her activity level. screening was begun for potential transfer to rehabilitation. on postoperative day seven the patient began to complain of increasing nausea as well as diarrhea. stools were sent at that time for c. diff and she was begun on empiric flagyl. the following morning the patient had a white count of 34,000. she was pan cultured and had abdominal films done at that time. general surgery was consulted. the general surgery service felt the patient had a toxic megacolon. she was brought to the operating room where she underwent a partial colectomy with ileostomy and as well as a cholecystectomy, following which the patient was transferred back to the cardiothoracic intensive care unit. throughout the remainder of the hospital course she was followed by both the hepatobiliary pancreatic surgery service as well as the cardiothoracic surgical service. she spent four days in the intensive care unit following her abdominal surgery, and was then transferred to the floor for continuing postoperative care. over the next week the patient was gradually transitioned from tpn to a p.o. diet. activity level was increased with the assistance of the nursing staff as well as physical therapy staff. her antibiotic coverage was tailored and on postoperative day 20 from her cardiac surgery, 11 from her abdominal surgery, it was decided the patient was stable and ready to be discharged to rehabilitation. at the time of this dictation the patient's physical exam is as follows: temperature 97.3, heart rate 66 atrial fibrillation, blood pressure 136/74, respiratory rate 20, o2 saturation 97 percent on room. laboratory data on showed pt 23.7, inr 3.5. medications on discharge: 1. amiodarone 200 mg b.i.d. 2. flagyl 500 mg t.i.d. 3. regular insulin sliding scale. 4. naprosyn 500 mg b.i.d. p.r.n. 5. percocet 5/325 one to two tablets q. six hours p.r.n. 6. prilosec 40 mg every day. 7. warfarin to maintain a target inr 2 to 2.5. physical exam shows in general she is in no acute distress. neurologically alert, oriented x3. moves all extremities. follows commands. nonfocal exam. pulmonary is clear to auscultation bilaterally. cardiac shows irregular rate and rhythm. sternum is stable. incision has steri-strips without erythema or drainage. abdomen is soft, nontender, with positive bowel sounds and ileostomy site with dark fluid drainage. abdominal incision with staples and minimal erythema at the staple line. no drainage. extremities are warm with trace edema. patient is to be discharged to rehabilitation. condition at time of discharge: good. discharge diagnoses.: 1. status post aortic valve replacement with number 23 tissue valve. 2. status post mitral valve replacement with number 25 tissue valve. 3. status post modified mays. 4. clostridium difficile colitis requiring partial colectomy with ileostomy as well as a cholecystectomy. 5. rheumatic heart disease. 6. obesity. 7. osteoarthritis. 8. cataracts. 9. atrial fibrillation. 10. congestive heart failure. 11. neuropathy. th is to have follow-up with dr. in his office in two weeks. the patient is to call the office to schedule an appointment and follow-up with dr. in four to six weeks. patient is also to call his office to schedule the appointment. discharge medications: 1. ketoconazole powder topically under the breast as needed. 2. amiodarone 200 mg b.i.d. times one week then 200 mg every day times two months. 3. percocet 5/325 one to two tablets q. four to six hours p.r.n. 4. prilosec 40 mg every day. 5. naprosyn 500 mg q.12 hours p.r.n. 6. flagyl 500 mg t.i.d. times two days. the patient's flagyl is to be discontinued on . 7. warfarin to maintain a target inr 2 to 2.5. the patient had been on 4 mg coumadin every day prior to admission. she has received 1 mg on the day prior to discharge, 5 mg two days prior to discharge, and 7.5 mg for the three days prior to that. , m.d. Procedure: Extracorporeal circulation auxiliary to open heart surgery Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Other electric countershock of heart Temporary ileostomy Excision or destruction of other lesion or tissue of heart, open approach Cholecystectomy 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 other serum Infusion of vasopressor agent Diagnoses: Severe sepsis Atrial fibrillation Rheumatic heart failure (congestive) Intestinal infection due to Clostridium difficile Long-term (current) use of anticoagulants Mitral valve insufficiency and aortic valve stenosis Rheumatoid arthritis Obesity, unspecified Septicemia due to anaerobes Acute vascular insufficiency of intestine Acute cholecystitis Unspecified hereditary and idiopathic peripheral neuropathy Other specified visual disturbances

allergies: vancomycin attending: chief complaint: nausea, vomiting and worsening abdominal pain major surgical or invasive procedure: exploratory laparotomy and resection of jejunum with jejunojejunostomy history of present illness: patient presents with nearly a 1 week course of nausea, vomiting and worsening abdominal pain, presented to the er. he received a cat scan that was consistent with a high-grade small bowel obstruction. the patient preoperatively underwent aggressive resuscitation with iv fluids and electrolyte corrections with potassium and magnesium. patient's creatinine improved from a creatinine of 3 to 1.7, and the potassium also corrected from 2.7 to 3.1. a central line was placed for resuscitation. the patient consented for exploratory laparotomy, possible bowel resection, possible ostomy. the past medical history: appendicitis age 8 social history: etoh 1 drink per day, no recreational drugs, tob 5 cig/week physical exam: 98.6 96.7 65 130/80 20 96%ra fs:83-136 gen: nad pulm: cta cv: rrr abd: +bs, soft, appropriately tender wound: c/d/i, resolved erythema, no soi or dehiscence, staples in place ext: no edema neuro: aaox3 pertinent results: 10:38pm glucose-81 lactate-1.2 na+-133* k+-3.1* cl--94* 10:38pm freeca-1.07* 08:57pm glucose-95 urea n-57* creat-1.9*# sodium-133 potassium-2.6* chloride-92* total co2-30 anion gap-14 08:56pm glucose-91 lactate-1.2 na+-132* k+-2.7* cl--92* 08:56pm freeca-0.96* 06:54pm lactate-1.4 01:20pm glucose-157* urea n-66* creat-3.0*# sodium-126* potassium-4.0 chloride-75* total co2-28 anion gap-27* 01:20pm alt(sgpt)-158* ast(sgot)-79* alk phos-108 amylase-26 tot bili-1.6* 01:20pm wbc-11.0# rbc-6.35*# hgb-21.6*# hct-58.7*# mcv-93 mch-34.0*# mchc-36.7* rdw-12.3 bcx(s): no growth ct scan: impression: 1. high-grade small-bowel obstruction with transition point identified in the right lower abdominal quadrant. no evidence of bowel wall thickening, free intraperitoneal air or fluid. 2. sub segmental atelectasis at the right base. upper extrem u/s: impression: no left upper extremity dvt identified final path report: small bowel (a-h): - segments of small bowel with mucosal hemorrhage, transmural acute and chronic inflammation, and serositis. - focal mesenteric hemorrhage. brief hospital course: patient presents with nearly a 1 week course of nausea, vomiting and worsening abdominal pain, and presented to the ed. he had copious amounts of ng output, and a cat scan consistent with a high-grade small bowel obstruction. the patient preoperatively underwent aggressive resuscitation with iv fluids and electrolyte corrections with potassium and magnesium. patient's creatinine improved from a creatinine of 3 to 1.7, and the potassium also corrected from 2.7 to 3.1. central line was placed for resuscitation. the patient consented for exploratory laparotomy, possible bowel resection, possible ostomy. the patient understood risks of procedure. following the procedure the pt was transfered to the sicu. pod#1 pt stayed in the sicu with ngt in place. he continued to receive fluids which helped lower his cr value from 3.0 -> 1.7. this value continued to improve during his hospital course. cardiology was consulted due to twi/st depression with borderline long qt. this was most likely due to low k value of 2.6 and low calcium. no ischemic causes were identified or suspected. aggressive repletion of electrolytes was continued. pt was npo, sedated and intubated, was on kefzol and flagyl. pt was extubated later in the day on pod #1. pod#2 extubated, ngt with no flatus, ue u/s showed no dvt pod#3 npo, d/c beta blockers, started ambulating, started course of kefzol due to erythema present at abdominal wound, no systemic signs of sepsis, no fevers pod#4 abx changed to levo and flagyl, npo, less erythema at wound site pod#5 npo, ngt until flatus, levo/flagyl stopped, changed back to kefzol, less erythema at wound site pod#6 ngt d/c, +flatus, abx continued, erythema at wound resolved, diet advanced to sips/clears pod#7 +flatus, experienced loose stools later that evening pod #8, diet continued to advance medications on admission: none discharge medications: 1. keflex 250 mg capsule sig: one (1) capsule po four times a day for 1 days. disp:*4 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:*40 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. small bowel obstruction 2. dehydration discharge condition: stable discharge instructions: please call your surgeon if you develop chest pain, shortness of breath,fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. no tub baths or swimming. you may shower. if there is clear drainage from your incisions, cover with a dry dressing. leave white strips above your incisions in place, allow them to fall off on their own. activity: no heavy lifting of items pounds until the follow up appointment with your doctor. medications: resume your home medications. you should take a stool softener, colace 100 mg twice daily as needed for constipation. you will be given pain medication which may make you drowsy. no driving while taking pain medicine. followup instructions: please call(617) 67-5101 to schedule an appointment to be seen in 2 weeks by dr. . please also call and schedule an appointment to be seen in the hand clinic in weeks. the number to call is: ( Procedure: Other partial resection of small intestine Diagnoses: Acute kidney failure, unspecified Dehydration Hernia of other specified sites, with obstruction

history of present illness: 71-year-old female with a sudden onset of a headache while in usual state of health at 3:45 p.m. on complained of meningeal signs and dizziness who was transferred to an outside hospital where a cat scan showed a subarachnoid hemorrhage with minimal blockage of the third ventricle. she was transferred to for further workup, was neurologically intact and then later transferred to . past medical history: 1. increased cholesterol. 2. hypertension. 3. femoral bypass surgery. 4. right breast biopsy. 5. multiple dilatations and curettages. admission medications: 1. univasc. 2. hydrochlorothiazide. 3. atenolol. 4. lipitor. social history: she is a 50-pack-year smoker. socially drinks alcohol. allergies: penicillin and cipro. physical examination: vital signs: 96.3, 125/56, pulse of 54, 13, 100%. she is intubated and sedated at time of exam. lungs: wheezes. cardiac: regular rate and rhythm. abdomen: soft, nontender, bowel sounds positive. extremities are warm; no edema. laboratory data: white count was 14.8, hematocrit 26.5, platelets 264, pt was 12.5, ptt 30.2, inr 1, sodium 141, potassium 4.2, 113 chloride, bicarbonate 19, bun 30, creatinine was 1.4, glucose is 143. ekg showed normal sinus rhythm. chest x-ray was pending. hospital course: patient was brought emergently to the neuro angio diagnostic suite on where she underwent gdc embolization and coiling for grade 1 acom aneurysm. postoperatively she had a decline in mental status post her procedure requiring reintubation. a stat head ct showed ventriculomegaly. a right frontal ventriculostomy. catheter was placed emergently, and the patient tolerated the procedure well. patient was admitted to the intensive care unit for q. one-hour neuro checks. she was started on kefzol for her drain prophylaxis. was kept npo. started on protonix and nimodipine. her blood pressure was kept less than 140. on her first postoperative day on temperature was 96.4, heart rate 64, blood pressure was 99 to 120s/upper 30s to 50s. ict was 6 to 8, cbp 54 to 76, dilantin was 4.9. patient was opening eyes to voice, following commands. pupils were 3.5 to 3 to ambient light. her right femoral site was intact with good distal pulses. postoperative hematocrit was 26.5. she was given one unit of blood and given a 500 mg bolus of dilantin. she was attempted to be weaned from the ventilator. she was extubated on without problems. she was awake, alert, and oriented to . pupils were 1.5 and trace reactive. ips were . on patient had a temperature of 101.2. blood pressures have been in the 150s to 180s, cbp 7 to 19, icp 3 to 9. she remained fluid negative, 1500 cc in 24-hour period. she remained awake, alert, and oriented times three. her upper and lower extremities motor strength was . her groin site was intact without a hematoma. she was given fluid boluses p.r.n. and albumin 25% q. 8 hours to keep her cbp 8 to 10. systolic blood pressure ranges 160 to 180, and nimodipine was decreased to 30 q. 4 hours. her drain was increased to 15 mm above her tragus, 50 mm of water above her tragus, and she was kept on triple h therapy. on her drain was increased to 20 mm above and she tolerated that well, remaining awake, alert, and oriented times three. her blood pressures were in the 180 range. on patient became short of breath and tachycardiac with hypertension and having difficulty breathing. she was awake, alert, had bilateral wheezing. ekg showed some changes in v1. gas was 7.39, 33, 69, -321. ck was 192. respiratory distress was improved with 100% non-rebreather. ativan was given for anxiety. the patient still seemed tachycardiac with sats in the 94%. chest x-ray was difficult to read. she was given some lopressor to help blockage her blood pressure, and she was ruled out for a myocardial infarction. she was given 10 mg of lasix, which helped, and gave her less shortness of breath. on her t-max was 101.8, blood pressure 160s to 180s, cbp 8 to 22, icp 3 to 11. she was awake, alert, oriented. no further respiratory problems. ventriculostomy drain was increased to 25 mm of water above the tragus. she had a chest x-ray which showed bibasilar atelectasis, bilateral pleural effusions. she also had an echocardiogram which showed ejection fraction of 50 to 55%, 3+ mitral valve regurgitation, and 1 to 2+ aortic insufficiency. tiny anterior pericardial infusion, no tamponade. on her drain was clamped. she was given two units of fresh frozen plasma and one unit of packed red blood cells for a hematocrit of 29 with an anr of 1.4. cultures had all been negative except for some yeast in her sputum for prior temperature workups. with her drain increased to 25 she had a severe headache and nauseated, so that was opened at 25 and her headache improved. on her inr was 1.7. she was given two units of fresh frozen plasma and she was given a dilantin bolus due to her dilantin level of 5.5. her icps were in 3 to 11 range. on she was started on salt tabs for a sodium of 131. icps were in the 7 to 10 range. drain was again attempted to be clamped on , and the drain was discontinued on . repeat head ct showed no increase in size of her ventricles. her culture workups were negative. on she was transferred to the regular surgical floor, where she remained awake, alert, and oriented, moving all of her extremities, continued on salt tabs. she was seen by physical therapy and occupational therapy, who worked with her for mobility, gait training, and safety evaluation. her central line was discontinued on . she was seen by social work on after complaining of feeling depressed. stated her spirits were down somewhat because of her long hospitalization. she was found to have no vegetative signs. her ability to keep up and initiate conversation and description of her family was supportive, and she is just eager to return home. social work followed her until discharge. each day she increased her ambulation and was walking well with physical therapy. she was discharged on . disposition: to home with services. discharge instructions: 1. she can resume her normal activities. 2. she needs to follow up with dr. in two weeks time. discharge medications: 1. colace 100 mg, one, p.o. b.i.d. 2. dilantin 100 mg, one, p.o. t.i.d. 3. sodium chloride 1 gram, one tablet, p.o. t.i.d. 4. flomax inhaler. 5. atorvastatin 20 mg, two tablets, p.o. q. day. 6. albuterol inhaler, one to two puffs, p.o. q. 4 hours as needed. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Arteriography of cerebral arteries Intravascular imaging of intrathoracic vessels Arterial catheterization Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Subarachnoid hemorrhage

history of present illness: the patient is a 72-year-old woman with previous aneurysm coiling who returned on and had an angiogram, which showed a 3 mm residual aneurysm at the neck of the previously coiled aneurysm. the patient was, therefore, admitted for diagnostic angiogram with coiling of the residual. allergies: the patient has got an allergy to penicillin, which causes rash; cipro, which causes rash; and dilantin, which causes a rash. past medical history: fem-fem bypass graft in . coiling of an acom aneurysm in . breast biopsy. dilatation and curettage. history of lymphoma with chemotherapy, which was diagnosed in . hypertension. medications: her medications at the time of admission, 1. atenolol 50 mg q.d. 2. univasc 15 mg q.d. 3. lipitor 40 mg q.d. physical examination: on physical exam, the patient was awake, alert, in no acute distress, cooperative. cardiovascular: regular rate and rhythm. she has a 1 to 2 out of 6 click and heart sounds. lungs: clear to auscultation. abdomen: soft, nontender, and nondistended. extremities: no edema. positive pedal pulses. she has got paresthesias of her fingertips and toes secondary to chemotherapy. her pupils are equal, round, and reactive to light. her tongue is midline. she has no lymphadenopathy, no thyromegaly. her neck is supple. her gait is steady. hospital course: she was admitted status post a coil embolization of residual acom aneurysm without intraprocedure complications. postoperatively, her vital signs were stable. she was afebrile. she was awake, alert, and oriented x3. eoms were full. face was symmetric. tongue was midline. her grasps and ips were . she had a right groin sheath in with no hematoma, no oozing, and positive pedal pulses. she was monitored in the icu overnight. she remained neurologically stable. her sheath was removed on postprocedure day number one. there was no evidence of hematoma, and she had positive pedal pulses. she was transferred to the regular floor on and discharged home on with followup with dr. on at 9:30 a.m. her condition was stable. discharge medications: her medications at the time of discharge include, 1. atenolol 50 mg q.d. 2. univasc 15 mg q.d. 3. lipitor 40 mg q.d. 4. percocet 1 to 2 tablets p.o. q.4 h. p.r.n. discharge condition: her condition was stable at the time of discharge. , Procedure: Arteriography of cerebral arteries Endovascular (total) embolization or occlusion of head and neck vessels Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Other malignant lymphomas, unspecified site, extranodal and solid organ sites Cerebral aneurysm, nonruptured

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest tightness, shortness of breath major surgical or invasive procedure: five vessel coronary artery bypass grafting utilizing the left internal mammary artery to left anterior descending artery, and saphenous vein grafts to second diagonal, first obtuse marginal, second obtuse marginal and posterior descending artery. bronchoscopy with bronchaveolar lavage. excision of right paratracheal lymph node. cardiac catherization history of present illness: 48 year old male with known coronary disease, who presented to outside hospital with chest tightness and shortness of breath. he ruled in for an nstemi with troponin 8.56. he was started on intravenous heparin and nitroglycerin and urgently transferred to the for further evaluation and treatment. past medical history: ischemic cardiomyopathy coronary artery disease, prior lad stent hypertension dyslipidemia diabetes mellitus type ii asthma obesity history of non-sustained ventricular tachycardia social history: retired paramedic. 20 pack year history of tobacco, quit 4 years ago. denies excessive etoh consumption. lives alone. family history: denies premature coronary artery disease. physical exam: bp 115/85, p 82, rr 16 ht 75 inches / wt 140.6 kg general: obese male in no acute distress heent: oropharynx benign neck: supple, no jvd chest: few crackles at bases heart: regular rate and rhythm, normal s1s2, no murmur or rub abd: obese, benign ext: warm, trace edema neuro: non-focal pulses: 1+ distally pertinent results: 06:48am blood wbc-8.8 11:00am blood wbc-11.3* rbc-4.24* hgb-12.4* hct-36.8* mcv-87 mch-29.2 mchc-33.7 rdw-13.7 plt ct-476* 03:55pm blood wbc-10.0 rbc-3.88* hgb-11.6*# hct-32.4*# mcv-84 mch-29.8 mchc-35.6* rdw-13.1 plt ct-206 11:00am blood neuts-70.2* lymphs-19.2 monos-5.5 eos-4.4* baso-0.6 03:55pm blood neuts-73.4* lymphs-21.4 monos-4.2 eos-0.8 baso-0.3 11:00am blood plt ct-476* 01:22am blood pt-15.0* ptt-31.3 inr(pt)-1.3* 03:55pm blood plt ct-206 03:55pm blood pt-17.2* ptt-142.9* inr(pt)-1.6* 01:54pm blood fibrino-470* 11:00am blood glucose-94 urean-26* creat-1.0 na-138 k-4.6 cl-99 hco3-29 angap-15 03:55pm blood urean-27* creat-1.1 na-134 k-4.4 cl-102 hco3-19* angap-17 01:22am blood alt-28 ast-30 alkphos-57 totbili-0.6 06:45am blood probnp-2083* 03:55pm blood ctropnt-2.09* 11:00am blood phos-2.9 mg-2.3 05:50am blood %hba1c-8.4* 05:50am blood triglyc-153* hdl-17 chol/hd-8.4 ldlcalc-95 05:52am blood vanco-11.1 pathology examination name birthdate age sex pathology # , 48 male report to: dr. . gross description by: dr. specimen submitted: immunophenotyping - 4r ln procedure date tissue received report date diagnosed by dr. /ttl previous biopsies: fs r 4 lymph node. diagnosis: flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, fmc-7, kappa, lambda, cd antigens 2, 3, 5, 7, 10, 19, 20, 23, 45. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. b cells comprise 50% of lymphoid gated events, are polyclonal, and do not express aberrant antigens. t cells comprise 39% of lymphoid gated events and express mature lineage antigens. interpretation non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by a t- or b-cell lymphoproliferative disorder are not seen in specimen. correlation with clinical findings and morphology (see s09-) is recommended. flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. radiology report chest (pa & lat) study date of 11:38 am , csurg fa6a 11:38 am chest (pa & lat) clip # reason: evaluate for effusion medical condition: 48 year old man with s/p cabg mv repair reason for this examination: evaluate for effusion final report reason for examination: followup of a patient after cabg and mitral valve repair. pa and lateral upright chest radiograph was compared to , . post-sternotomy wires appear to be intact. cardiomediastinal contour is stable. left linear opacities consistent with atelectasis, with overall slight improvement of the left base aeration. upper lungs are clear and there is no evidence of failure. impression: improved aeration of the left paramediastinal opacities consistent with improvement of atelectasis. dr. approved: mon 5:49 pm echocardiography report , (complete) done at 9:07:04 am final referring physician information , , status: inpatient dob: age (years): 48 m hgt (in): 74 bp (mm hg): / wgt (lb): 300 hr (bpm): bsa (m2): 2.58 m2 indication: intra-op tee for cabg, mv repair icd-9 codes: 428.0, 440.0, 414.8, 424.0 test information date/time: at 09:07 interpret md: , md, md test type: tee (complete) 3d imaging. son: , md doppler: full doppler and color doppler test location: anesthesia west or cardiac contrast: none tech quality: suboptimal tape #: 2009aw05-: machine: echocardiographic measurements results measurements normal range left atrium - long axis dimension: *6.6 cm <= 4.0 cm left ventricle - diastolic dimension: *7.5 cm <= 5.6 cm left ventricle - ejection fraction: 20% to 25% >= 55% aorta - ascending: 3.2 cm <= 3.4 cm aorta - arch: 2.2 cm <= 3.0 cm aorta - descending thoracic: 2.3 cm <= 2.5 cm aortic valve - peak velocity: 0.9 m/sec <= 2.0 m/sec mitral valve - peak velocity: 1.1 m/sec mitral valve - mean : 1 mm hg mitral valve - pressure half time: 36 ms mitral valve - mva (p t): 6.1 cm2 mitral valve - e wave: 1.0 m/sec mitral valve - a wave: 0.3 m/sec mitral valve - e/a ratio: 3.33 findings multiplanar reconstructions were generated and confirmed on an independent workstation. left atrium: marked la enlargement. mild spontaneous echo contrast in the body of the la. no mass/thrombus in the laa. depressed laa emptying velocity (<0.2m/s) right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. severely dilated lv cavity. severe regional lv systolic dysfunction. severely depressed lvef. right ventricle: normal rv chamber size. mild global rv free wall hypokinesis. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. normal aortic arch diameter. simple atheroma in aortic arch. normal descending aorta diameter. simple atheroma in descending aorta. aortic valve: three aortic valve leaflets. no as. no ar. mitral valve: mild mitral annular calcification. no ms. eccentric mr jet. moderate to severe (3+) mr. lv inflow pattern c/w impaired relaxation. tricuspid valve: physiologic tr. pulmonic valve/pulmonary artery: physiologic (normal) pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was under general anesthesia throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. results were personally reviewed with the md caring for the patient. see conclusions for post-bypass data the post-bypass study was performed while the patient was receiving vasoactive infusions (see conclusions for listing of medications). regional left ventricular wall motion: n = normal, h = hypokinetic, a = akinetic, d = dyskinetic conclusions pre-bypass: 1. the left atrium is markedly dilated. mild spontaneous echo contrast is seen in the body of the left atrium. no mass/thrombus is seen in the left atrium or left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). no atrial septal defect is seen by 2d or color doppler. 2. the left ventricular cavity is severely dilated. there is severe regional left ventricular systolic dysfunction of the apical, septal and anterolateral segments. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). 3. right ventricular chamber size is normal. with mild global free wall hypokinesis. 4. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. 5. there are three aortic valve leaflets. there is no aortic valve stenosis. no aortic regurgitation is seen. 6. an eccentric, posterior directed jet of moderate to severe (3+) mitral regurgitation is seen. t 7. he left ventricular inflow pattern suggests impaired relaxation. 8. there is no pericardial effusion. post-bypass: the patient is a-paced and on infusions of phenylephrine, epinephrine, and milrinone. 1. biventricular function is similar to pre-bypass. 2. a pfo is now visualized with color flow doppler. 3. the aorta appears intact post decannulation. 4. a mitral valve annuloplasty ring has been placed. there is no mr . is 3 mmhg at a cardiac output of 7 l/m. the swan-ganz catheter is in the proximal right pulmonary artery. 5. the remainder of the examination is unchanged. dr. was notified in person of the results in the operating room. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, md, interpreting physician 15:38 brief hospital course: mr. was admitted to the cardiology service with nstemi troponin 8 setting of known chronic systolic congestive heart failure. he remained stable on intravenous therapy. the following day he cardiac catheterization which revealed severe three vessel coronary artery disease - please see result section for details. given that his coronary anatomy was more suitable for surgical revascularization, cardiac surgery was consulted and further evaluation was performed. in anticipation for surgery, plavix was subseqently held. an echocardiogram was notable for moderate mitral regurgitation and an ejection fraction of 20% - see result section for further details. carotid ultrasound found normal internal carotid arteries while vein mapping revealed suitable saphenous vein. given chest x-ray findings revealed mediastinal lymphadenopathy, the pulmonary service was consulted and a chest ct scan was obtained which showed marked symmetric lymphadenopathy of the mediastinum and the hila. lymph node biopsy was recommended along with bronchoscopy/bronchoaveolar lavage. preoperative course was otherwise uneventful, and he remained stable on intravenous therapy. on , mr. coronary artery bypass grafting and mitral valve repair, along with excision of paratracheal lymph node and bronchoscopy with bronchoaveolar lavage. please see operative notes for details. given his inpatient stay was greater than 24 hours, vancomycin was given for perioperative antibiotic coverage. he was transferred in critical but stable condition to the surgical intensive care unit, on inotropes and vasoactive medications. a bilateral alveolar lavage was performed and a subsequent gram stain revealed gram negative rods and gram positive cocci, which he was placed on broad spectrum antibiotic coverage until the culture was finalized. the culture revealed oropharyngeal flora and antibiotics were discontinued. he was weaned off inotropes and vasoactive medications, started on lasix for diuresis, and was extubated on post operative day two. he remained in te intensive care unit for blood glucose management and was consulted. when blood glucose stable he was transferred to the floor were he received the remainder of his care. physical therapy worked with him on strength and mobilty. he was educated on diabetes and was ready for discharge home on post operative day seven with services. medications on admission: home meds: lipitor 60 qd, carvedilol 25 , lasix 40 prn, enalapril 10 am/20 pm, spironolactone 25 qd, metformin 850 discharge medications: 1. lipitor 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(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:*0* 5. hydromorphone 2 mg tablet sig: 1-2 tablets po q3h (every 3 hours) as needed. disp:*60 tablet(s)* refills:*0* 6. combivent 18-103 mcg/actuation aerosol sig: 2 puffs inhalation four times a day. disp:*qs qs* refills:*0* 7. albuterol 90 mcg/actuation aerosol sig: 2-4 puffs inhalation every four (4) hours as needed for shortness of breath or wheezing. disp:*qs qs* refills:*0* 8. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. furosemide 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 10. carvedilol 6.25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 11. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. disp:*60 tablet(s)* refills:*0* 12. enalapril maleate 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 13. humalog 100 unit/ml solution sig: sliding scale subcutaneous four times a day: please see sliding scale . disp:*qs qs* refills:*2* 14. lantus 100 unit/ml solution sig: fifty five (55) units subcutaneous once a day: please take in morning before breakfast . disp:*qs qs* refills:*2* 15. sliding scale humalog insulin sc sliding scale breakfast lunch dinner bedtime humalog humalog humalog humalog glucose insulin dose insulin dose insulin dose insulin dose 0-60 mg/dl 4 oz. juice 4 oz. juice 4 oz. juice 4 oz. juice 61-100 mg/dl 12 units 12 units 12 units 0 units 101-130 mg/dl 15 units 15 units 15 units 0 units 131-160 mg/dl 17 units 17 units 17 units 0 units 161-190 mg/dl 19 units 19 units 19 units 3 units 191-220 mg/dl 21 units 21 units 21 units 6 units 221-250 mg/dl 23 units 23 units 23 units 8 units 251-280 mg/dl 25 units 25 units 25 units 10 units 16. insulin needles (disposable) 29 x needle sig: five (5) syringe miscellaneous per day : for lantus once a day and humalog four times a day . disp:*150 syringes* refills:*2* 17. lancets misc sig: one (1) lancet miscellaneous four times a day. disp:*150 lancets* refills:*2* 18. blood glucose test strip sig: one (1) strip in four times a day. disp:*qs qs* refills:*2* discharge disposition: home with service facility: discharge diagnosis: ischemic cardiomyopathy non st elevation myocardial infarction acute on chronic systolic congestive heart failure mitral regurgitation coronary artery disease, prior lad stent hypertension dyslipidemia diabetes mellitus type ii mediastinal lymphadenopathy asthma discharge condition: good discharge instructions: 1) monitor wounds for signs of infection. these include redness, drainage or increased pain. in the event that you have drainage from your sternal wound, please contact the at (. 2) report any fever greater then 100.5. 3) report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) no lotions, creams or powders to incision until it has healed. you may shower and wash incision. gently pat the wound dry. please shower daily. no bathing or swimming for 1 month. use sunscreen on incision if exposed to sun. 5) no lifting greater then 10 pounds for 10 weeks from date of surgery. 6) no driving for 1 month or while taking narcotics for pain. 7) call with any questions or concerns 8) metformin was stopped due to heart failure, this medication should not be resumed, if any further questions please call 9) please monitor blood glucose at least prior to meals and bedtime, and with symptoms of hypoglycemia, goal bg < 150, please contact for questions in relation to blood glucose management followup instructions: please call to schedule appointments dr. in 4 week dr. , in days pa in 1 week dr. in 3 weeks wound check 6 - friday at 1200 for diabetes management friday with dr. at 1:30pm diabetes ( dr at 1:00pm (sleep clinic) bldg, neurology md 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 four or more coronary arteries Closed [endoscopic] biopsy of bronchus Biopsy of lymphatic structure Open heart valvuloplasty of mitral valve without replacement Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Asthma, unspecified type, unspecified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Paroxysmal ventricular tachycardia Other specified forms of chronic ischemic heart disease Obesity, unspecified Acute on chronic systolic heart failure Enlargement of lymph nodes Coal workers' pneumoconiosis

history of present illness: this is a 41-year-old male who presented with new shortness of breath in early of this year. an echocardiogram at an outside hospital showed new dilated cardiomyopathy. he first noted symptoms on approximately the day weekend. he described his symptoms as similar to asthmatic symptoms. this progressed to severe orthopnea, a symptom he had no previously had causing him to sit upright and gasp for breath at night. he used his friend's albuterol nebulizers with minimal improvement. he denies lower extremity edema. his shortness of breath at this point was severely limiting his activity, walking 20 to 30 feet with severe dyspnea. he felt better leaning forward. he also describes decreased appetite. at the beginning of he saw his primary care physician who felt he was having an asthma exacerbation and gave him intravenous solu-medrol, and the patient relayed a vague story of going into sinus tachycardia with a heart rate in the 120s, a fingerstick in the 500s, been sent to the emergency department and admitted to hospital. a chest x-ray showed a question of a left upper lobe pneumonia. he was given intravenous antibiotics; ceftriaxone and azithromycin. he was discharged from that hospital on . an echocardiogram during that admission showed global hypokinesis, 4-chamber dilatation, an ejection fraction of 10% to 15%. there were no previous echocardiograms. the patient denies antecedent upper respiratory infection or recent diarrheal illness. no rash. no joint pains. denies a history of exertional chest pain, previous orthopnea, or paroxysmal nocturnal dyspnea, or lower extremity edema. in the week between discharge from hospital and admission to he felt better with decreased dyspnea on exertion, increased exercise tolerance, and decreased lower extremity edema. his blood pressure previously had been 130s to 190s; he would take it at work. his cholesterol status is unknown. past medical history: 1. newly diagnosed dilated cardiomyopathy. 2. moderate mitral regurgitation. 3. global hypokinesis. 4. newly diagnosed type 2 diabetes. 5. elevated liver function tests. 6. asthma; no previous steroids. 7. pneumonia, status post ceftriaxone and azithromycin. medications on admission: azmacort, nph insulin 25 units q.a.m. and 10 units q.p.m., a course of ceftin (ended on ). social history: he lives in . he has a human immunodeficiency virus positive partner (female), positive tobacco history times 20 years, previous heavy drinker (now social), very remote cocaine use. family history: one uncle with coronary artery disease and a sister with grave's disease. physical examination on presentation: pulse of 114, blood pressure of 122/88, 98% on room air. in general, he was a large man, in no acute distress. head, eyes, ears, nose, and throat showed extraocular muscles were intact. pupils were equal, round, and reactive to light. the oropharynx was clear without lesions, 10 cm of jugular venous distention in the neck. lungs were clear to auscultation without crackles; however, decreased air movement was noted bilaterally. heart was fourth heart sound and first heart sound and second heart sound regular without murmurs. the abdomen was obese. sacral and abdominal wall edema. bowel sounds were present. it was soft. extremities showed 4+ edema, warm. neurologic examination was nonfocal. pertinent laboratory data on presentation: white blood cell count of 9.7, hematocrit of 39, mean cell volume of 88, platelets of 251. blood urea nitrogen of 16, creatinine of 0.8, glucose of 168. ast of 79, alt of 340, thyroid-stimulating hormone of 0.9, alkaline phosphatase of 186, albumin of 3.2, total bilirubin of 1.2. radiology/imaging: liver ultrasound from the outside hospital showed fatty infiltrate, no ascites, bilateral pleural effusions, normal portal flow. transthoracic echocardiogram at the outside hospital on showed dilated left atrium of 5.6 cm, dilated left ventricle with severe global hypokinesis, ejection fraction of 10% to 15%, moderate mitral regurgitation, dilated right ventricle with moderate global dysfunction, mild tricuspid regurgitation, pulmonary artery pressure in the 30s. hospital course by system: 1. cardiovascular: the patient was noted to be in severe heart failure with dilated cardiomyopathy based on the outside hospital records, the etiology of which was unclear. he was sent to the catheterization laboratory which revealed a middle left anterior descending artery lesion of 80%, status post stent. the right coronary artery was totally occluded. the left circumflex had a moderate ostial lesion which was not intervened upon. his pulmonary capillary wedge pressure was 35 mmhg to 40 mmhg. his cardiac index was 1.4 l/kg/min/m2. after catheterization, the patient was taken to the coronary care unit with an intra-aortic balloon pump and was diuresed approximately 15 liters in the coronary care unit with intravenous lasix. he was transferred back to the cardiology service for continued diuresis. he was started on a heart failure regimen of captopril 50 mg p.o. t.i.d., lasix 120 mg p.o. b.i.d., aldactone 25 mg p.o. q.d., carvedilol 3.125 mg p.o. b.i.d. he was also started on a statin, lipitor 10 mg p.o. q.d. he was seen by the electrophysiology service for the possibility of receiving a prophylactic automatic internal cardioverter-defibrillator. given the fact that this was not an ischemic cardiomyopathy, it was felt that it was not indicated at this point. 2. diabetes: he was continued on his diabetic regimen. 3. fluids/electrolytes/nutrition: electrolytes were repleted on a p.r.n. basis given his aggressive ongoing diuresis. 4. discharge disposition: the patient remained on the cardiology service as of . an addendum to this discharge summary will be dictated by the incoming intern. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Arterial catheterization Implant of pulsation balloon Pulmonary artery wedge monitoring Nonoperative removal of heart assist system Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Other specified cardiac dysrhythmias

under discharge condition, please add that the patient was discharged in stable condition to home with a holter monitor and an appointment to see dr. in two weeks and instructions to keep a diary of his daily urine output. his dental records were also requested to be faxed to dr. office concerning a tooth abscess. under medications on discharge, he was discharged on captopril 75 mg p.o. t.i.d., atorvastatin 10 mg p.o. q.d., carvedilol 6.25 mg p.o. b.i.d., lasix 120 mg p.o. b.i.d., insulin as directed, enteric-coated aspirin 325 mg p.o. q.d., plavix 75 mg p.o. q.d., spironolactone 25 mg p.o. q.d., amiodarone 400 mg p.o. q.d. also, under laboratories, also include human immunodeficiency virus antibody negative, hepatitis b surface antigen and hepatitis b surface antibody were negative. hepatitis c was negative. vcv titer was positive. cytomegalovirus was negative. toxo was negative. under physical examination, add that on discharge the patient's extremities had minimal edema in the left lower extremity and 1 to 2+ edema in the right lower extremity. , m.d. dictated by: medquist36 Procedure: Insertion of non-drug-eluting coronary artery stent(s) Combined right and left heart cardiac catheterization Angiocardiography of left heart structures Injection or infusion of platelet inhibitor Arterial catheterization Implant of pulsation balloon Pulmonary artery wedge monitoring Nonoperative removal of heart assist system Diagnoses: Other primary cardiomyopathies Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Other specified cardiac dysrhythmias

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: crush injury major surgical or invasive procedure: : fem- bypass graft repair of gastrocnemius + gracilis tear : rle fasciotomies : orif right patella history of present illness: the patient is a 24 year old male who presented to ed via the trauma service by medlfight. pt was involved in a construction accident at his work where he was pinned between a moving truck and a stationary truck. he was medflighted in secondary to a pulseless extremity past medical history: none social history: construction worker family history: nc physical exam: upon discharge: avss nad a+o cta rrr s/nt/nd/+bs rle: incisions c/d/i +/fhl/at/g/s silt 2+ dp/pt brisk cap refill brief hospital course: the patient was admitted to the trauma service. he was emergently taken to the operating room with the vascular service for repair of his popliteal artery injury. he tolerated the procedure well. he was extubated and brought to the tsicu for close monitoring. on pod#1 his compartments were closely monitored. he developed increased swelling and some diminished sensation over toes . vascular surgery then took him back to the operating room for rle fasciotomies. he tolerated the procedure well. he was extubated and brought to the recovery room in stable condition. post-operatively he was transferred to the vascular service. once stable in the pacu he was transferred to the floor. on the floor he did well. his pain was well controlled. he was seen by social work for emotional support. he was transfused 2 units prbc's on for post op anemia. on he was brought back to the operating room for orif of his right patella with orthopedics. he tolerated the procedure well. he was extubated and brought to the recovery room in stable condition. once stable in the pacu he was transferred to the floor. on the floor he did well. he was seen by physical therapy and progressed well. he was also seen by chronic pain service to help control his post-operative pain. his labs and vitals remained stable. his pain was well controlled. his hospital course was otherwise without incident. he is being discharged today to rehab in stable condition. discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day) as needed. 6. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 7. enoxaparin 30 mg/0.3 ml syringe sig: one (1) 30 mg syringe subcutaneous q12h (every 12 hours) for 4 weeks. 8. simethicone 80 mg tablet, chewable sig: 0.5-1 tablet, chewable po qid (4 times a day) as needed. 9. tizanidine 2 mg tablet sig: one (1) tablet po tid (3 times a day). 10. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). 11. hydromorphone 2 mg tablet sig: 1-2 tablets po q3-4h (every 3 to 4 hours) as needed. discharge disposition: extended care facility: - , me discharge diagnosis: right popliteal artery injury right patella fracture right lateral femoral condyle fracture right lateral tibial plateau fracture post operative anemia discharge condition: stable discharge instructions: please keep incision clean and dry. dry sterile dressing daily as needed. if you notice any increased redness, swelling, drainage, temperature >101.4, or shortness of breathe please md or report to the emergency room. please take all medications as prescribed. you need to take the lovenox shots to prevent blood clots. you may resume any normal home medication. please follow up as below. call with any questions. physical therapy: wbat rom as tol treatments frequency: dry sterile dressing daily followup instructions: please follow up with dr. at the orthopedic clinic clinic in 2 weeks. call to make that appointment. please follow up with dr. at the vascular clinic in 2 weeks. call to make that appointment. Procedure: Other (peripheral) vascular shunt or bypass Control of hemorrhage, not otherwise specified Open reduction of fracture with internal fixation, tibia and fibula Transfusion of packed cells Transfusion of other serum Other suture of muscle or fascia Transfusion of platelets Closed reduction of fracture without internal fixation, femur Other incision of soft tissue Transfusion of coagulation factors Suture of tendon sheath Diagnoses: Tobacco use disorder Acute posthemorrhagic anemia Closed fracture of patella Retention of urine, unspecified Injury to popliteal artery Crushing injury of knee Closed fracture of condyle, femoral Closed fracture of upper end of tibia alone Nontraffic accident involving other off-road motor vehicle injuring pedestrian Traumatic compartment syndrome of lower extremity Acute pain due to trauma

no known allergies. pt alert and oriented, describing accident, cooperative. morphine pca for pain in leg. afebrile. hr 90. bp 130/65. rr 18. ivf 125/hr. heparin sc. 2l np with sats 100%-lungs clear. taking clear liquids well. famotidine as ordered. foley draining clear urine. right leg with ace bandage-soaked through with blood-vascular team aware. jp drain with blood. left leg with dsd intact. bilateral pulses palpable. feet warm, pt can move toes and has sensation bilaterally. girlfriend at bedside-he states she is spokesperson. father visited. his employer has called. Procedure: Other (peripheral) vascular shunt or bypass Control of hemorrhage, not otherwise specified Open reduction of fracture with internal fixation, tibia and fibula Transfusion of packed cells Transfusion of other serum Other suture of muscle or fascia Transfusion of platelets Closed reduction of fracture without internal fixation, femur Other incision of soft tissue Transfusion of coagulation factors Suture of tendon sheath Diagnoses: Tobacco use disorder Acute posthemorrhagic anemia Closed fracture of patella Retention of urine, unspecified Injury to popliteal artery Crushing injury of knee Closed fracture of condyle, femoral Closed fracture of upper end of tibia alone Nontraffic accident involving other off-road motor vehicle injuring pedestrian Traumatic compartment syndrome of lower extremity Acute pain due to trauma

discharge medications: 1. prevacid 30 mg per j-tube q. day. 2. coumadin 3 mg per j-tube q. day, then as directed by the primary care physician for goal inr of 2.0 to 2.5. 3. flomax 0.4 mg per j-tube q. day. 4. aspirin 81 mg per j-tube q. day. 5. reglan 10 mg p.o. j-tube three times a day. 6. 20 meq, one tablet per j-tube q. day. 7. lasix 40 mg, one tablet per j-tube twice a day times one week, then every day as a maintenance dose. 8. calcium carbonate 500 mg, one tablet per j-tube three times a day. 9. zocor 20 mg tablet per j-tube q. day. 10. hytrin 5 mg tablet, one tablet per j-tube q. day. 11. flagyl 500 mg tablet, one tablet per j-tube three times a day times five days. 12. levaquin 500 mg per j-tube q. day times five days. 13. lopressor 100 mg tablets, one tablet per j-tube three times a day. 14. boost plus, 110 cc per hour per j-tube 10 p.m. to 10 a.m. q. day. discharge instructions: 1. the patient was going home with twice a day wet-to-dry normal dressing changes, pack the wound on the back and the abdomen. 2. he is to have a full liquid diet, less than 60 cc per hour. 3. his inr will be followed by dr. and dr. at his , telephone number . that office was contact and the medical staff was personally explained the disposition plan and understand his blood draws. a will forward the results of these draws to them. the nurse will draw such labs tomorrow and monday. today, he will receive 3 mg of coumadin. his inr today is therapeutic. condition at discharge: the patient, upon discharge, is in fair condition and understands the plan. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Total esophagectomy Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Paroxysmal ventricular tachycardia Cardiac arrest Malignant neoplasm of lower third of esophagus

history of present illness: the patient is a 71 year old retired medical doctor who had percutaneous transluminal coronary angioplasty , for coronary artery disease. on workup, it was discovered that he had advanced t2 no distal esophageal gastric cancer, esophageal adenocarcinoma. past medical history: 1. coronary artery disease, percutaneous transluminal coronary angioplasty times two, no history of myocardial infarction. 2. chronic atrial fibrillation. 3. hypertension. family history: noncontributory. social history: he is an ex-smoker of greater than twenty years. he denied ethanol abuse. allergies: questionable allergy to penicillin. physical examination: on admission, physical examination was unremarkable. hospital course: he was taken to the operating room on , for an esophagogastrectomy using approach by dr. and dr. , assistants dr. and dr. , general endotracheal anesthesia. please see the operative note for full details. postoperatively, the patient was doing well. he had an epidural and we were using lopressor for rate control and he was in the intensive care unit at that time. he was on vancomycin and flagyl postoperatively. on postoperative day one, the patient was transferred from the post anesthesia care unit to the floor. acute pain service was involved with reverse pain control. on , at 4:00 p.m. the patient's blood pressure dropped to 70/40 with the heart rate in the 100s. electrocardiogram showed atrial fibrillation. urine output had dropped to 15 ccs per hour since 7:00 a.m. that morning. he was bolused. at 2:00 a.m. on , the patient went to cardiac arrest and was resuscitated and was sent to the intensive care unit. central lines were placed and the patient was in grave condition. the patient's kidney function was slightly affected as he went into some degree of renal failure with a rising creatinine which resolved toward his discharge date. the patient was intubated and sedated in the unit. on the evening of , the patient was extubated and was alert and confused and was again in atrial fibrillation. the patient remained in the unit anticoagulated on heparin with chest tubes and nasogastric tube. the patient's creatinine at this point had decreased to 1.5 from a high of 2.2. the patient on postoperative day five, , had recovered well and was transferred to the floor where rate control was an issue. the patient was getting tube feeds and was npo. pca was discontinued. foley was discontinued and central line was discontinued on . on , it was noted that the patient's white count had increased and his back wound was dehiscing. the middle third was opened and drainage came out. he was packed with gauze. the patient was continued on vancomycin, levofloxacin and flagyl. the patient was confused and a code purple was declared on , and psychiatry was involved. his haldol was changed and adjusted. heparin was discontinued on the patient on , and coumadin was begun since his inr was now therapeutic. for the rest of the stay and postoperative day number nine, we continued the antibiotics. his chest tube was put to water seal. the patient's chest tube was removed. on , inferior aspect of the abdominal wound was showing some drainage and the patient's diet was being advanced and we continued wet to dry dressings at this point. however, the patient was then made npo. the patient's tube feeds continued. cat scan was done on the patient and showed question of a leak. on , the ct scan questioned a leak, however, no direct leak was seen as some retromediastinal and supradiaphragmatic air and debris was seen. the patient had a nasogastric tube placed by fluoroscopy on 0/25/02, and nutrition was once again involved as he was made npo as previously stated. electrolytes were repleted. the patient's inr was continuously adjusted to be 2.0 to 2.5 and lovenox was temporarily used for two days until for a moment when his inr dropped below 2.0. at the patient's behest, a medical consultation was called on , with regard to controlling his atrial fibrillation. an echocardiogram was done to check his left ventricular function and right ventricular function which came back normal. we continued vancomycin, levofloxacin and flagyl. barium swallow ct was done on , which showed the question of a leak as well. however, no direct leak was seen. the patient was transfused one unit of packed red blood cells to adjust for hematocrit which had fallen to 22.0 range and lopressor was changed to 50 mg p.o. t.i.d. in an attempt to control his atrial fibrillation. during this time of admission on , and onward, we were using lasix to help diurese the patient. the patient was complaining of edema and was noted to be puffy and likely fluid overloaded. the patient had an episode of ventricular tachycardia on , which was nonsustained and seven beats long and a cardiology electrophysiology consultation was called. they suggested increasing his lopressor and discontinuing the diltiazem which we did. they suggested a blood transfusion, discontinuing diltiazem and lopressor to be 100 mg t.i.d. which we did. the patient's nasogastric tube was discontinued on , had a ct scan which showed unlikely to be a current leak since no communication was seen between the collections and esophageal and gastric anastomosis. the patient was allowed to have a clear liquid diet which he tolerated. discharge summary addendum to follow. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Other enterostomy Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Total esophagectomy Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Percutaneous transluminal coronary angioplasty status Paroxysmal ventricular tachycardia Cardiac arrest Malignant neoplasm of lower third of esophagus

allergies: sulfa (sulfonamides) attending: chief complaint: left flank pain major surgical or invasive procedure: percutaneous nephrostomy tube placement history of present illness: 75 year old female with history of right staghorn calculi, colon cancer, and hyptertension, who presented to her pcp 2 days prior to admission with complaints of left flank pain, chills, and decreased urine output for 3 days. pt was started on cipro and flagyl for presumed diverticulitis. when wbc returned high, the patient was sent for outpatient ct scan which revealed new left 6mm obstructing stone at the urovesicular junction with mild hydronephrosis, ureteral dilation, and perinephric stranding. pt was subsequently sent to hospital where she was found to have wbc 27.8, creat 3.4, and ua with 100 wbc, + heme, +leuk esterases. at the time her bp was 88/43 after 3l of ivf and pt was started on dopamine and transferred to and urology team was consulted. past medical history: 1. r staghorn nephrolithiasis for 20years on ampicillin prophylaxis and now atrophic 2. colon ca s/p resection ' 3. tonsillectomy 4. htn 5. diverticulitis 6. h/o etoh abuse social history: pt lives with husband . pt has 2 children and 4 grand children. has a remote hx of smoking (20pack years but quit 20 years previous) and hx of etoh abuse. she quit drinking 9 years previous. family history: nc physical exam: physical exam: vs: tc: 98.8 hr: 88 bp: 115/60 rr: 12 sao2: 98% on 2l nc gen: pleasant female lying in bed in nad. conversing in full sentences and interacting appropriately. heent: perrl, eomi, mmm cv: rrr, s1, s2, no murmurs, rubs, gallops chest: cta bilaterally abd: soft, nt, nd, bs+ back: no cva tenderness ext: warm, well perfused, no clubbing, cyanosis, edema neuro: a+o x3. pertinent results: cxr 12:03 am: 1) cardiomegaly and minor left basilar atelectatic changes. 2) hiatal hernia. . 05:49am blood wbc-9.1 rbc-3.08* hgb-8.9* hct-27.3* mcv-89 mch-28.8 mchc-32.6 rdw-17.9* plt ct-184 10:32pm blood hct-26.3* 04:00am blood wbc-12.9* rbc-2.93* hgb-8.4* hct-26.2* mcv-89 mch-28.8 mchc-32.3 rdw-18.1* plt ct-177 05:38am blood wbc-19.7* rbc-3.35* hgb-9.7* hct-29.7* mcv-89 mch-28.9 mchc-32.6 rdw-17.6* plt ct-225 11:40pm blood wbc-25.7* rbc-3.55* hgb-10.3* hct-31.0* mcv-87 mch-29.1 mchc-33.3 rdw-16.6* plt ct-206 05:49am blood neuts-67.2 lymphs-25.0 monos-4.3 eos-2.8 baso-0.7 04:00am blood neuts-84.3* bands-0 lymphs-11.7* monos-2.3 eos-1.5 baso-0.3 05:38am blood neuts-91.1* bands-0 lymphs-6.6* monos-2.0 eos-0.2 baso-0.1 11:40pm blood neuts-84* bands-6* lymphs-7* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-0 05:38am blood pt-13.9* ptt-28.6 inr(pt)-1.2 11:40pm blood pt-14.4* ptt-23.5 inr(pt)-1.3 05:49am blood glucose-90 urean-17 creat-0.8 na-139 k-3.4 cl-109* hco3-25 angap-8 10:32pm blood glucose-90 urean-20 creat-0.8 na-139 k-3.5 cl-109* hco3-24 angap-10 04:00am blood glucose-87 urean-26* creat-1.0 na-142 k-3.1* cl-113* hco3-23 angap-9 05:38am blood glucose-108* urean-48* creat-1.6* na-142 k-3.5 cl-111* hco3-20* angap-15 11:40pm blood glucose-85 urean-54* creat-2.0* na-141 k-2.7* cl-109* hco3-15* angap-20 05:49am blood calcium-8.4 phos-2.1* mg-1.5* 10:32pm blood calcium-8.2* phos-1.7* mg-1.6 04:00am blood calcium-7.9* phos-2.0*# mg-1.5* iron-14* 05:38am blood calcium-7.6* phos-3.7 mg-1.8 11:40pm blood calcium-7.3* phos-3.6 mg-1.6 04:00am blood caltibc-183* ferritn-136 trf-141* clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. reference range: negative. urine culture (final ): no growth. aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. . intro cath or stent into urether 10:20 am reason: please place nephrostomy tube contrast: medical condition: 75 year old woman with l obstructive uvj stone, renal failure, and urosepisis reason for this examination: please place nephrostomy tube history: a 75-year-old female with urosepsis, ureteral stone, and need for decompression of the renal collecting system. procedure/findings: the procedure was performed by dr. and dr. . dr. , the staff radiologist, was present and supervising throughout. after the risks and benefits of the procedure were discussed with the patient and informed consent was obtained, the patient was placed prone on the angiography table. her left flank was prepped and draped in the standard sterile fashion. 400 mg of intravenous ciprofloxicin was administered. the skin and subcutaneous tissues in the left flank region were anesthetized with 10 cc of 1% lidocaine. using ultrasound guidance, attempts were made to advance a 22-gauge chiba needle into a posterior lower pole calyx. after several attempts, however, this proved unsuccessful. the patient was then given 40 cc of 60% optiray intravenously. using fluoroscopy, a new 22-gauge chiba needle was advanced through an anesthetized region in the left flank into an opacified middle pole calyx. after the stylet was removed, urine was aspirated confirming our position within the renal collecting system. the urine sample was sent for culture. an antegrade nephrostogram was then performed via hand injection of nonionic contrast. this revealed a mildly dilated collecting system with complete obstruction identified at the level of the distal ureter. a .018 guide wire was advanced through the chiba needle into the proximal ureter under fluoroscopic visualization. the skin entry site was incised with a #11 blade scalpel. the access needle was exchanged for a 6-french accustick sheath with inner dilator and metallic stiffener. upon entry into the renal parenchyma, the metallic stiffener was removed. the accustick sheath and inner dilator were advanced over the wire until the tip was positioned in the proximal ureter. the guide wire and inner dilator were removed. a .035 wire was then advanced through the accustick sheath into the distal ureter. the wire could not be advanced beyond the area of obstruction into the bladder. at this time, the accustick sheath was exchanged for a 6-french 23 cm bright-tip angiographic sheath. with the sheath tip positioned in the proximal ureter, a 5-french kumpe catheter was advanced through the angiographic sheath into the distal ureter. using the wire, attempts were made to traverse the area of obstruction. again, this was unsuccessful and the wire was exchanged for a .035 angled glidewire. using this wire, in combination with the 5-french kumpe catheter, the area of obstruction was successfully passed. with the glidewire positioned in the bladder, beyond the area of obstruction, the kumpe catheter was exchanged for a 5-french vertebral catheter. the glidewire was then exchanged for a .035 super-stiff amplatz wire. at this time, the vertebral catheter and 6-french angiographic sheath were removed. an 8-french 24 cm internal/external nephroureteral stent was then advanced over the amplatz wire into the bladder. the super-stiff amplatz wire was removed. the catheter pigtails were formed and locked in the bladder and in the right renal pelvis. a hand injection of nonionic contrast confirmed the appropriate positioning of the nephroureteral stent. the catheter was secured to the skin using a #0 silk suture. a stat- lock device was applied, followed by a dry sterile dressing. the catheter was placed to external bag drainage and may be capped in approximately 24 hours. complications: none. medications: 1% lidocaine. 400 mg intravenous ciprofloxicin. 2 mg of versed and 100 mcg of fentanyl were administered in intermittent doses with continuous monitoring of vital signs by the nursing staff. contrast: 90 cc of 60% optiray. impression: 1. antegrade nephrostogram revealed mild left hydronephrosis with a complete obstruction identified at the level of the distal ureter, secondary to stone presence. 2. successful placement of a 24 cm 8 french internal/external nephroureteral stent via a left posterior middle pole calyx. the catheter has side holes extending throughout its length and was placed to external bag drainage. the catheter may be capped for internal drainage in approximately 24 hours. brief hospital course: 75 year old female with right staghorn calculi for >20 years and new left obstructing calculi with hydronephrosis, ureteral dilation and perinephric stranding associated with increasedd wbc count, tachycardia, hypotension refractory to fluids and increased creatinine. . 1. sepsis: although pt has no fever and no tachypnea, pt does have an elevated white count, with tachycardia as well as a positive ua suggesting pylonephritis and urosepsis. . a). source was most likely urosepsis with positive ua, and obstructing stone by ct scan. she was treated with broad spectrum antibiotics with cefepime and cipro. urology was already consulted as was ir. a percutaneous nephrostomy tube was placed by ir with resultant good urine output. . b). hemodynamics: pt had hypotension temporarily requiring pressors and ivf to bring up cvp. pressors were successfully weaned. she had been mentating appropriately suggesting mental status would be an appropriate measure. . 2. acute renal failure: it was secondary to obstructive stone lesion (pt already with atrophic r kidney, now presenting with obstructive lesion in l kidney). no history of renal insufficiency as per patient. the percutaneous nephrostomy tube was placed and the patient's creatinine improved with fluid hydration. . 3. anemia of chronic decrease with decreased hematocrit over past 9 months (hct 36 in )plus possible blood loss from nephrostomy stent placement and ivf this admission. the patient has a history of colon cancer with a normal colonoscopy last year. iron studies were normal and the patient was guaiac negative. . 4. hypertension was controlled on metoprolol. . the patient was discharged in good condition with follow up in urology clinic with dr. . she was restarted on prophylactic amoxicillin as an outpatient. medications on admission: 1. asa 81mg once daily 2. atenolol 25mg once daily 3. amoxicillin 250mg once daily 4. mvi 5. recent cipro/flagyl . all: sulfa -> jaundice discharge medications: 1. multivitamin capsule sig: one (1) cap po daily (daily). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 3. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours for 6 days. disp:*20 tablet(s)* refills:*0* 5. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 10 days. disp:*20 tablet(s)* refills:*0* 6. atenolol 25 mg tablet sig: one (1) tablet po once a day. 7. amoxicillin 250 mg capsule sig: one (1) capsule po once a day: start amoxicillin after finished taking the final 10 days of the ciprofloxacin. 8. aspirin ec 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 9. iron 325 (65) mg tablet sig: one (1) tablet po three times a day for 2 weeks: start after completion of ciprofloxacin course. take 2 hours before or 2 hours after antacid therapy. disp:*42 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: nephrolithiasis with secondary hydronephrosis septic shock pyelonephritis iron deficiency anemia arf secondary: h/o r staghorn nephrolithiasis for 20 years on ampicillin prophylaxis and now atrophic colon ca s/p resection ' tonsillectomy htn diverticulitis h/o etoh abuse discharge condition: stable, tolerating oral diet, afebrile, ambulating without difficulty discharge instructions: continue with prior outpatient medications. continue with ciprofloxacin to complete a total of 14 days and then resume your regular dose of amoxicillin. notify your doctor in case of recurrent nausea, abdominal pain, blood in stools, diarrhea, fevers, back pain, or blood in your urine. call your doctor or return to the ed in case of recurrent fevers, increasing or decreasing urine output, change in color/quality/odor of the nephrostomy urine, or pain with urination. please call dr. tomorrow and arrange to go to the laboratory for follow up testing of your chemistry panel, calcium, magnesium, and blood counts and phosphorous in the next two days and see dr. this week. start iron supplementation for iron deficiency anemia after completion of ciprofloxacin course. followup instructions: schedule follow up with dr. in urology this week. call tomorrow to schedule an appointment. follow up with dr. this week. call tomorrow to arrange for laboratory testing: chemistry panel, calcium, magnesium, blood counts and phosphorous before your appointment. md, Procedure: Percutaneous nephrostomy without fragmentation Infusion of vasopressor agent Diagnoses: Acidosis Anemia, unspecified Urinary tract infection, site not specified Unspecified essential hypertension Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Hypopotassemia Septic shock Personal history of malignant neoplasm of large intestine Hydronephrosis Calculus of kidney

past medical history: rheumatic fever as a child. admission medications: lisinopril 20 mg q.d. allergies: the patient has no known drug allergies. social history: he lives at home with his wife and two children. occasional alcohol use. no tobacco use. physical examination: heart rate 59, blood pressure 159/74, respiratory rate 18, 02 saturation 99% on room air. neurologic: nonfocal examination. cardiovascular: regular rate and rhythm. harsh iv-v/vi systolic ejection murmur. respiratory: clear to auscultation bilaterally. gi: soft, nontender, nondistended, positive bowel sounds. extremities: warm and well perfuse with no edema. laboratory and radiologic data: white count 5.3, hematocrit 43, platelets 131,000. pt 12, ptt 32, inr 1. sodium 142, potassium 4.2, chloride 105, c02 31, bun 14, creatinine 0.7, glucose 73. alt 44, ast 36, alkaline phosphatase 144, total bilirubin 1.8, albumin 4.6. the u/a is negative. chest x-ray is without acute cardiopulmonary changes. hospital course: as stated previously, the patient was a direct admission to the operating room, at which time he underwent aortic valve replacement with a #23 st. regent mechanical valve, mitral valve replacement with #31 st. mechanical valve, and a saphenous vein graft to the pda. please see the or report for full details. in summary, the patient had an avr/mvr cabg times one. his bypass time was 181 minutes. his cross clamp time was 151 minutes. he tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient was in normal sinus rhythm at 76 beats per minute with a cvp of 9 and a mean arterial pressure of 74. he had propofol at 20 micrograms per kilogram per minute and levophed at 0.2 micrograms per kilogram per minute. the patient did well in the immediate postoperative period. the anesthesia was reversed. he was weaned from the ventilator and successfully extubated. the patient remained hemodynamically stable throughout the day of his surgery. he was gradually weaned from his levophed infusion. on postoperative day number one, the patient remained hemodynamically stable. the swan-ganz catheter was removed. he was begun on diuretics as well as beta blockade and was transferred to ii for continuing postoperative care and cardiac rehabilitation. on postoperative day number two, the patient continued to do well. he remained hemodynamically stable. his foley catheter, temporary pacing wires, and chest tube were all removed. his activity level was advanced with the assistance of the nursing staff and physical therapy. throughout the remainder of the patient's hospitalization, he had an uneventful course. his anticoagulation began on postoperative day number two with initial doses of 5 mg. by postoperative day number three, he was given 7.5 mg. the doses then fluctuated between 5 and 7.5 mg and finally on postoperative day number seven, the patient had an inr of 3.3 and it was felt that he was stable and ready to be discharged to home. at the time of discharge, the patient's physical examination is as follows: vital signs: temperature 98.3, heart rate 86, sinus rhythm, blood pressure 110/76, respiratory rate 18, 02 saturation 97% on room air. weight preoperatively 61 kilograms, at discharge 58.3 kilograms. neurologic: the patient was alert and oriented times three. moves all extremities. follows commands. respiratory: clear to auscultation bilaterally. cardiac: regular rate and rhythm. s1, s2, with mechanical click. sternum was stable. incision with steri-strips, open to air, clean and dry. abdomen: soft, nontender, nondistended with positive bowel sounds. extremities: warm and well perfuse with no edema. left lower extremity saphenous vein graft harvest site with steri-strips, open to air, clean, and dry. the laboratory data revealed a white count of 8.5, hematocrit 32.1, platelets 299,000. the inr on the day of discharge was 3.3. sodium 139, potassium 4.3, chloride 103, c02 28, bun 11, creatinine 0.6, glucose 125. discharge medications: 1. enteric coated aspirin 81 mg q.d. 2. captopril 12.5 mg t.i.d. 3. metoprolol 25 mg b.i.d. 4. coumadin as directed. on the day of discharge, the patient is to take 5 mg. his goal inr was 3 to 3.5. his inr is to be checked by visiting nurses on , the day following discharge, and the results are to be called into dr. office at . condition on discharge: good. discharge diagnosis: 1. history of rheumatic heart disease. 2. status post aortic valve replacement with a #23 st. mechanical valve. 3. status post mitral valve replacement with a #31 st. mechanical valve. 4. status post coronary artery bypass grafting with saphenous vein graft to the right coronary artery. diion: the patient is to be discharged to home with visiting nurses. he is to have follow-up in the clinic in two weeks. follow-up with dr. in two to three weeks and follow-up with dr. in four weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve (Aorto)coronary bypass of one coronary artery Open and other replacement of mitral valve Transfusion of other serum Transfusion of platelets Diagnoses: Coronary atherosclerosis of native coronary artery Multiple involvement of mitral and aortic valves Rheumatoid arthritis

allergies: patient recorded as having no known allergies to drugs attending: addendum: patient's condition was stable at the time of discharge his discharge was delayed until to allow inr to become therapeutic. his inr is currently 1.4 he should be between 2.0-2.5 he is currently on 7.5mg of coumadin. he should have weekly lft's checked. his last dose of vancomycin is . discharge disposition: extended care facility: - md Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Spinal tap Incision of lung Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Transfusion of packed cells Transfusion of other serum Other craniotomy Transfusion of coagulation factors Diagnoses: Unspecified essential hypertension Infection with microorganisms resistant to penicillins Aortocoronary bypass status Intracerebral hemorrhage Heart valve replaced by other means Acute and chronic respiratory failure Methicillin susceptible pneumonia due to Staphylococcus aureus Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Other and unspecified coagulation defects Hepatitis, unspecified Rheumatic heart disease, unspecified

history of present illness: patient is a 57-year-old man on coumadin for avr, mvr, valve replacement in who at 5 p.m. had an onset of speech difficulty and at 7:30 p.m., his wife found him on the floor with right-sided weakness, eyes open and nonverbal. he was brought to hospital via ems. vitals at 10:30 in the ed were 146/85, heart rate 64, respiratory rate 20, and saturations 94% on room air. he subsequently had a decompensation and was intubated. ct scan revealed a large left-sided intraparenchymal hemorrhage. labs were noted for an inr of 5.9. given 10 mg of vitamin k subcutaneously and 2 units of ffp. loaded with dilantin and transferred to for further management. past medical history: rheumatic heart disease status post avr, mvr, and cabg x1 vessel in on coumadin. allergies: no known allergies. vital signs on admission: bp 149/86, heart rate 72, respiratory rate 16, and saturations 100%, intubated on ventilator. intubated, young-appearing man attempting to pull at the et tube with his left hand. heent: nonicteric. neck: supple, no carotid bruits. chest was clear to auscultation. cardiovascular: regular rate and rhythm, harsh s1 and s2 sounds, no murmur. abdomen: soft, nontender, positive bowel sounds. extremities: no edema. neurologically: does not open eyes to voice or painful stimulation. cranial nerves: pupils 2 mm down to 1 bilaterally. eoms full. positive doll's eyes. corneal reflexes: absent bilaterally. facial symmetry: et restricts the lower face, but upper face appears wrinkling, symmetrically. gag reflex: gagging on the et. motor: increased tone in all four extremities. moves left side spontaneously, reaching and grabbing for the et tube with the left hand. no spontaneous movement of the right hemibody. decerebrate posturing of the right arm with pain and flexes knees and ankle with pain applied to both legs. purposely withdraws, localizes with the left arm. ct shows 5 x 7 cm large left frontal subcortical hemorrhage which stands 10 slices midline shift to the right, no hydrocephalus. patient was seen emergently in the ed and was taken to the or for a craniotomy. postop, patient had no eye opening. moves left upper and lower extremities spontaneously and purposefully with right-sided hemiparesis. pupils equal and brisk. not following commands. exam on 15 mg of propofol. patient was kept with a sbp of less than 120 and q.1h. neuro checks with repeat head ct in the morning. patient had a repeat head ct on that showed no change in the large left intraparenchymal hemorrhage with associated subfalcine herniation and minimal uncal herniation. on , the patient underwent tracheostomy and peg without complication. the patient remained in the icu until when he was transferred to the step-down unit. neurologically, he remained unchanged, occasionally opening his eyes. purposeful on the left side, hemiparesis on the right side. in the neuro step-down, he remained neurologically unchanged. he had a lp done on that showed an opening pressure of 27, closing pressure of 14. twenty cc of csf was sent. he had a repeat lp done the following day with an opening pressure of 32, closing pressure was not recorded. he was seen by the id service for a question of meningitis. he also had climbing lfts. general surgery was consulted. they recommended getting a right upper quadrant ultrasound which was done and was read as negative. gi was consulted for the elevated lfts. they felt they were maybe related to his ceftazidime that he was getting for his mrsa and urine infection. that was discontinued, and the patient was kept on vancomycin for mrsa in his sputum and blood. his lfts came down slowly. he should have them checked every week. he also will need to be restarted on coumadin for his heart valve. head ct is pending for . the results will decide when he will start on his coumadin. he was seen by physical therapy and occupational therapy, and he will require an acute rehab stay. he will remain on vancomycin for a total of 14 days. vancomycin should continue until . he is on 1000 mg iv q.8. other medications: metoprolol 25 mg p.o. b.i.d., hold for heart rate less than 60, sbp less than 110, nystatin swish and swallow 5 cc q.i.d., famotidine 20 mg p.o. b.i.d., heparin 5000 units subcutaneously t.i.d., keppra 500 mg p.o. b.i.d., insulin-sliding scale, senna 1 tablet p.o. b.i.d., ferrous sulfate 325 p.o. daily, colace 100 mg p.o. b.i.d. patient's condition was stable at the time of discharge. he will follow up with dr. in weeks with a repeat head ct. , Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Spinal tap Incision of lung Spinal tap Incision of lung Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Transfusion of packed cells Transfusion of other serum Other craniotomy Transfusion of coagulation factors Diagnoses: Unspecified essential hypertension Infection with microorganisms resistant to penicillins Aortocoronary bypass status Intracerebral hemorrhage Heart valve replaced by other means Acute and chronic respiratory failure Methicillin susceptible pneumonia due to Staphylococcus aureus Late effects of cerebrovascular disease, hemiplegia affecting unspecified side Other and unspecified coagulation defects Hepatitis, unspecified Rheumatic heart disease, unspecified

past medical history: hepatitis c. admission medications: 1. multivitamin. 2. aspirin. allergies: the patient has no known drug allergies. physical examination on admission: upon transfer to , the patient's blood pressure in the trauma bay was 142/palpable, heart rate 67. the patient was intubated, saturating 100% on his ventilator settings which were simv 700 by 14 with 100% fi02 and 5 of peep. on examination, he was intubated and sedated, moving all extremities. his pupils were reactive and equal. he was noted to have a right forehead lac just above the eyelid. the midface was stable without evidence of unstable fractures. he had a c-collar in place. the patient's tympanic membranes were free of blood. his chest was clear to auscultation bilaterally. he had obvious crepitus throughout his thorax. cardiac: regular rate and rhythm with a normal s1 and s2. abdomen: soft, nondistended, did not appear to be tender. back: the examination of the back showed no step-off or deformity. extremities: the left knee was somewhat swollen and his left foot was somewhat mottled in appearance. ankle brachial indexes were measured in the trauma bay and his abi was 1 on that left side. there were no other obvious deformities on examination. neurologic: somewhat limited by the fact that he was intubated and sedated; however, he was moving all extremities. laboratory/radiologic data: white count 23.3, hematocrit 37.2, platelets 264,000. the patient's coagulation studies were normal. his u/a showed trace blood with 0-2 rbcs on the microscopic examination. chemistries revealed a sodium of 140, potassium 4.5, chloride 101, bicarbonate 28, bun 19, creatinine 1.2, glucose 151. his amylase was 80. his tox screen was negative. his abg on arrival was 7.30, 53, 151, 27, and 0. he had a lactate of 1.8. the patient, as previously mentioned, from the outside hospital had a ct of the head which was negative for fracture or intracranial hemorrhage. ct of his chest showed multiple left-sided rib fractures and a left pulmonary contusion as well as a left-sided pneumothorax. ct of the abdomen was reportedly negative. the patient had a ct of the c-spine as well which was negative. at the , he had a left knee x-ray which was negative for fracture. however, there was a question of a right medial femoral condyle avulsion fracture. the patient did not have a chest tube placed at the outside hospital. he was noted on the chest x-ray in the trauma bay here, at , to have a pneumothorax. he had a left-sided chest tube placed in the trauma bay at . the patient was transferred to the intensive care unit for further treatment and monitoring. over the next several days the patient remained on the ventilator. during his hospital stay at , he was slowly weaned to minimal support on the ventilator. the patient's hematocrit was noted to trend down during the first several days of his hospital stay. the patient received a total of 4 units of packed cells and transfusion. he underwent ct angiogram of the chest as well as a ct of the abdomen and pelvis while at the which showed no active sites of bleeding in the chest. ct of the abdomen and pelvis was unremarkable. the patient also received a ct scan of the thoracic and lumbar spine which showed a transverse process fracture of the fourth lumbar vertebra. orthopedics was consulted during his hospital stay, both for his left medial femoral condyle avulsion fracture as well as to evaluate the left knee. they also saw the patient and consulted on this fourth lumbar vertebral fracture. the vertebral fracture was found to be amenable to nonoperative management and essentially required only symptomatic management with pain control. the left knee was placed in a knee immobilizer and they recommended toe-touch weightbearing when the patient was ambulating. the patient will ultimately require an mri of the left knee to further evaluate it but that was not obtained during this hospitalization. of note, on the patient's follow-up chest ct, it was noted that the patient had a persistent moderate size pneumothorax on the left side despite the presence of a chest tube. because of this, the patient had a second left chest tube placed in the icu and his lung was noted to be fully expanded after placement of that chest tube. both chest tubes remain in at the time of this dictation and they remain on suction. the remainder of the hospital course is fairly unremarkable. the patient did have several fevers during his hospital stay. multiple cultures of the blood, sputum, and urine were initially negative and remained essentially negative at the time of this dictation. the patient was started on tube feeds and the patient was receiving tube feeds at a goal rate of 90 via a ng tube at the time of this dictation. the patient was placed on vancomycin and levaquin. vancomycin was subsequently discontinued. at the time of this dictation, the patient remains on levaquin for prophylaxis of possible pneumonia; however, there is no culture date to support that. the patient also underwent follow-up ct of the head on the day of his discharge from this institution. the results of which are pending at the time of this dictation. discharge medications: 1. regular insulin sliding scale. 2. subcutaneous heparin. 3. pepcid. 4. p.r.n. morphine. 5. p.r.n. ativan. 6. levaquin. 7. tylenol. discharge diagnosis: 1. status post assault with left pneumothorax, status post left chest tube placement times two. 2. left medial femoral condyle fracture as well as a t4 transverse process fracture. disposition: the patient remains intubated on minimal ventilator support, most likely will be able to be weaned off the ventilator in the next several days. currently, the patient is on day number six of a course of levaquin and can be continued for a ten day course and then discontinue. dr., 02-239 dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Insertion of intercostal catheter for drainage Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Diagnoses: Pneumonia, organism unspecified Unspecified schizophrenia, unspecified Closed fracture of lumbar vertebra without mention of spinal cord injury Closed fracture of condyle, femoral Contusion of lung without mention of open wound into thorax Acute hepatitis C without mention of hepatic coma Concussion with loss of consciousness of unspecified duration Flail chest Assault by striking by blunt or thrown object

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization cabg history of present illness: 65yo male with known cad (3vd with severe lv dysfunction cath with taxus stent to lad and lcx) , chf (ef >30%) and pvd who presents with intermittent sscp with radiation to back and associated with sob since 1pm on day of admission that is partially relieved by sl nitro. pt took the first sl nitro with improvements but sx returned within 30 mi., 2nd sl nitro taken at 5pm and 3rd sl nitro taken at 7pm. when pain did not resolve with 3rd sl nitro patient called ems. pt reports he has not taken his medications at ome for at least 2 days prior to admission (including plavis and aspirin). pt denies n/v, leg swelling, orthopnea, pnd. in pt received sl nitro x3, lopressor 5mg iv x5, morphine 2mg iv, asa and was eventually placed on nitro and heparin gtt. past medical history: 3v cad s/p cath with stent to lad and lcx on chf (ef <30%) per echo on with wall motion abnormalities - inferolateral hypokinesis and distal anteroseptal and apical akinesis, 1+mr and 1+tr pvd dm ii anemia s/p sfa and dp bypass s/p appendectomy s/p l 2nd toe amputation family history: non-contributory physical exam: pe: vs: t: 98.9 bp: 139/82 hr: 85 rr: 18 sao2: 95% on 2l gen: thin well appearing male in nad, greek speaking, pleasant heent: eomi, perrl, oral pharynx clear, mmm neck: no jvp appreciated chest: cta bilaterally cv: rrr, no murmurs, rubs, or gallops (loud in er) abd: soft, nt, nd, bs+ ext: no clubbing, cyanosis, edema neuro: cn ii-xii grossly intact, a+o x3 pertinent results: tte : the left atrium is normal in size. the left ventricular cavity size is normal. there is moderate to severe regional left ventricular systolic dysfunction. resting regional wall motion abnormalities include inferolateral hypokinesis and distal anteroseptal and apical akinesis. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (tape reviewed) of , left ventricular systolic function is now significantly impaired (in retrospect may have had mild hypokinesis on prior study). cardiac catheterization: "final diagnosis: 1. three vessel coronary artery disease. 2. mild mitral regurgitation. 3. severe systolic ventricular dysfunction with lvef 29%. 4. elevated right and left sided filling pressures. 5. low cardiac index of 1.8 l/min/m2 by fick. comments: 1. coronary angiography of this right dominant system demonstrated severe three vessel coronary artery disease. the lmca had no angiographically apparent, flow-limiting stenoses. the lad had severe serial lesions up to 90% in the proximal and midvessel. the lcx had severe in-stent restenosis and a totally occluded om2 branch. the rca had diffuse calcification and an 80% midvessel stenosis. 2. resting hemodynamics revealed pulmonary hypertension with a pa systolic pressure of 60 mmhg. mean pcwp was elevated at 30 mmhg. central hypertension was noted with blood pressure 158/80 mmhg. left sided filling pressures were elevated with lvedp 31 mmhg. no significant gradient was noted on catheter pullback from lv to central aorta. cardiac index was low at 1.8 l/min/m2 by fick. 3. left ventriculography demonstrated mild mitral regurgitation, global hypokinesis, and lvef 29%." venous vein mapping: "study: bilateral carotid series complete. reason: preop for cabg. study ii: venous duplex. reason: patient in need of cabg, evaluate for conduit. findings: duplex evaluation was performed on both carotid arteries. minimal plaque was identified. on the right peak systolic velocities are 82, 69, 99 in the ica, cca, eca respectively. the ica:cca ratio was 0.7. this is consistent with a less- than-40% stenosis. on the left peak systolic velocities are 82, 62, 178 in the ica, cca, eca respectively. the ica:cca ratio is 1.3. this is consistent with a less- than-40% stenosis. there is antegrade flow in both vertebral arteries. impression: minimal plaque with bilateral less-than-40% carotid stenosis. venous duplex was performed on the right greater saphenous vein. it was patent with diameters of 0.28, 0.37, 0.39, 0.40, 0.41 and 0.42 cm of the ankle, calf, knee, low thigh, high thigh and saphenofemoral junctions respectively. impression: patent right greater saphenous vein with diameters as noted. " : bilateral carotid us "study: bilateral carotid series complete. reason: preop for cabg. study ii: venous duplex. reason: patient in need of cabg, evaluate for conduit. findings: duplex evaluation was performed on both carotid arteries. minimal plaque was identified. on the right peak systolic velocities are 82, 69, 99 in the ica, cca, eca respectively. the ica:cca ratio was 0.7. this is consistent with a less- than-40% stenosis. on the left peak systolic velocities are 82, 62, 178 in the ica, cca, eca respectively. the ica:cca ratio is 1.3. this is consistent with a less- than-40% stenosis. there is antegrade flow in both vertebral arteries. impression: minimal plaque with bilateral less-than-40% carotid stenosis. venous duplex was performed on the right greater saphenous vein. it was patent with diameters of 0.28, 0.37, 0.39, 0.40, 0.41 and 0.42 cm of the ankle, calf, knee, low thigh, high thigh and saphenofemoral junctions respectively. impression: patent right greater saphenous vein with diameters as noted. " cxr: "study: bilateral carotid series complete. reason: preop for cabg. study ii: venous duplex. reason: patient in need of cabg, evaluate for conduit. findings: duplex evaluation was performed on both carotid arteries. minimal plaque was identified. on the right peak systolic velocities are 82, 69, 99 in the ica, cca, eca respectively. the ica:cca ratio was 0.7. this is consistent with a less- than-40% stenosis. on the left peak systolic velocities are 82, 62, 178 in the ica, cca, eca respectively. the ica:cca ratio is 1.3. this is consistent with a less- than-40% stenosis. there is antegrade flow in both vertebral arteries. impression: minimal plaque with bilateral less-than-40% carotid stenosis. venous duplex was performed on the right greater saphenous vein. it was patent with diameters of 0.28, 0.37, 0.39, 0.40, 0.41 and 0.42 cm of the ankle, calf, knee, low thigh, high thigh and saphenofemoral junctions respectively. impression: patent right greater saphenous vein with diameters as noted. " brief hospital course: a/p: 65yo male with known 3v cad s/p ptca with stent in lad and lcx in 4', pvd, and dm who presents with cp in setting of medical non-compliance. . 1. cad: the patient had undergone a cardiac catheterization which revealed diffuse 3v cad. at this time the cardiothoracic surgery team wa consulted for a possible cabg procddure. while awaiting cabg, the patient was medically optimized on asa 325mg once daily, plavix 75mg once daily, metoprolol, ace, statin, heparin gtt, and nitro gtt. the pre-op work up for cabg was undertaken including an ua, cxr, bilateral carotid us and bilateral le vein mapping. at this point, the cardiothoracic surgery team had taken over management of the patient. . 2. dm: the patient was maintained on his outpatient regimen of metformin and riss for coverage while awaiting cabg. . 3. anemia: the patient was consented for a possible transfusion and serial hct were monitored. . 4. fen: the patient was placed on a heart friendly, diabetic, low salt diet while awaiting cabg. . 5. prophylaxis: heparin sub q for dvt prophylaxis was unnecessary as patient was actively being anti-coagulated with heparin gtt. in addition, the patient was placed on colace and senna for a bowel regimen and started on a h2 blocker for gerd prophylaxis. . medications on admission: pt non-compliant with medications. meds not completely known discharge medications: 1. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 2. 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* 3. 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* 4. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 5. metformin hcl 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. lisinopril 10 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 9. glyburide 5 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 10. furosemide 20 mg tablet sig: one (1) tablet po qd (once a day) for 1 weeks. disp:*7 tablet(s)* refills:*0* 11. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po qd (once a day) for 1 weeks. disp:*14 capsule, sustained release(s)* refills:*0* 12. ferrous gluconate 325 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 13. vitamin c 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 14. multivitamin tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: tba discharge diagnosis: status post cabg x4(lima->lad,svg->pda,svg->ramus->om) status post ptca and lad stent peripheral vascular disease status post iliac stent, sfa-dp bypass status post appendectomy congestive heart failure anemia diabetes mellitus type 2 history of mrsa status post left toe amputation 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 of wounds followup instructions: dr in weeks dr in weeks dr in 3 months dr. in 6 weeks: Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Percutaneous transluminal coronary angioplasty status Other complications due to other cardiac device, implant, and graft

history of present illness: the patient is a 65-year-old man with known coronary artery disease, status post ptca and stenting of the lad and the circumflex in , at which time he was shown to have two-vessel disease. he refused coronary artery bypass graft at that time. the patient presented to an outside hospital earlier this week with a complaint of chest tightness and pain, not relieved by sublingual nitroglycerin, associated with shortness of breath. cath done on the revealed three- vessel disease with an 80 percent rca lesion, 90% lad lesion, 90% circumflex lesion with depressed ejection fraction of 30 percent. catheterization also revealed mild mitral regurgitation. past medical history: significant for cad status post stenting in ; also left iliac stent in ; congestive heart failure, anemia, diabetes mellitus type 2. past surgical history: significant for an sfa and an appendectomy. allergies: he has no known drug allergies. . medications given: 1. aspirin 325 every day. 2 lipitor 10 mg every day. 1. metformin 500 mg every day. 2. plavix 75 every day. 3. lisinopril 20 every day. 4. toprol xl 50 every day. 5. glyburide 2.5 every day. 6. lasix 40 every day. 7. zantac 150 every day. social history: he lives in by himself. he has a nephew who lives nearby. alcohol use is rare. tobacco use is current, greater than 50 years of use, one to three packs per day. family history: mother died of unknown causes. review of symptoms: general: weight is stable. good appetite. skin: no eczema, psoriasis, pruritus or open wounds. heent: positive glasses, positive cataracts, negative glaucoma, negative epistaxis. respiratory: positive shortness of breath. no asthma. history of pneumonia in the past and no history of copd. cardiovascular: positive angina, no palpitations, positive claudication, positive edema. gi: no nausea, vomiting, diarrhea or constipation. no abdominal pain, no melena. neuro: no seizures, cvas, tias, weakness. physical examination: height 5 feet 10 inches; weight 150 pounds. vital signs: temperature 96.3, heart rate 78, blood pressure 147/76, respiratory rate of 18. o2 sat 94% on 3 liters. general: lying flat in bed with no acute distress. neuro: alert, oriented x3. moves all extremities. follows commands. positive left carotid bruit. respiratory: coarse bilateral at the bases, nonproductive cough. cardiovascular: regular rate and rhythm, s1-s2. gi: soft, nondistended, nontender. positive bowel sounds. extremities: warm and well-perfused; well healed left leg bypass scar. pulses 2+ radial bilaterally, 2+ dorsalis pedis and 1+ posterior tibial bilaterally. laboratory data: white count 5.8, hematocrit 28.2, platelets 118, pt 13.6, ptt 58.4, inr 1.2, sodium 132, potassium 3.9, chloride 99, co2 22, bun 32, creatinine 0.9, glucose 182, alt 18, ast 16, alk phos 57, amylase 36, total bili 0.6. ua is negative. carotid ultrasound with less than 40 percent stenosis bilaterally. lower extremity vein mapping: patent right greater saphenous vein from the ankle to the upper thigh. following cardiac catheterization, ct surgery service was consulted. the patient was seen and accepted for coronary artery bypass grafting and on , the patient was brought to the operating room where he underwent cabbage x4. please see the or report for full details. in summary, the patient had a coronary artery bypass graft times four with lima to the left anterior descending; saphenous vein graft to the posterior descending artery, saphenous vein graft to the ramus with a jump to the obtuse marginal. his bypass time was 85 minutes with a cross clamp time of 55 minutes. he tolerated the operation and was transferred from the operating room to the cardiothoracic intensive care unit. at the time of transfer, the patient was a paced at 88 beats per minute with a mean arterial pressure of 85 and a pad of 12. he had milrinone at 0.5 mcg kilogram per minute, nitroglycerin at 1 mcg/kg minute; insulin drip, titrated to blood glucose and propofol at 28 mcg/kilogram per minute. the patient did well in the immediate postoperative period. his anesthesia was reversed. he was weaned from his ventilator and successfully extubated. he remained hemodynamically stable throughout the operative day. on postoperative day one, the patient continued to be hemodynamically stable. he was weaned from his milrinone and nitroglycerin infusions. his chest tubes were removed. he remained in the cardiothoracic icu because of his cardioactive intravenous medications. on postoperative day two, the patient was started on beta blockade. he was also begun on diuretics. an ace inhibitor was begun and he remained in the icu because it was noted overnight that he had short episodes of two to one heart block, during which he remained hemodynamically stable. on postoperative day 3, the patient remained hemodynamically stable. his central lines were discontinued. during this time, he was noted to have periods of increasing confusion and agitation, from which he was easily reoriented. an a wire trace done on postoperative day 3, showed that the patient did not have two to one heart block but was indeed in sinus rhythm with appropriate ventricular response. on postoperative day 4, the patient's temporary pacing wires were removed and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. throughout the next several days, the patient had an uneventful postoperative course. his activity level was increased with the assistance of the nursing staff and physical therapy. on postoperative day 7, he had a duplex of his femoral graft to assess patency. it was found to be patent and at that time, it was decided that the patient was stable and ready to be discharged to home on the following day. physical examination: at the time of this dictation, the patient's physical exam is as follows. vital signs temperature 98.4, heart rate 73. blood pressure 138/60; respiratory rate of 18. o2 sat 95 percent on room air. laboratory data: sodium 138, potassium 4.4, chloride 99, co2 31, bun 23, creatinine 1.0, glucose 138, white count 7.2; hematocrit of 34.6. platelets 355. physical examination: neurologic: alert and oriented times three. moves all extremities. follows commands. respiratory clear to auscultation bilaterally. cardiovascular regular rate and rhythm, s1-s2. sternum is stable. incision with steri-strips, open to air, clean and dry. abdomen is soft, nontender, nondistended with positive bowel sounds. extremities: cool with no edema. positive pulses bilaterally. right saphenous vein graft harvest site with steri-strips open to air, clean and dry. disposition: patient is to be discharged to home with visiting nurses. his condition at the time of discharge is good. discharge diagnoses: cad status post coronary artery bypass grafting times four with lima to the lad, saphenous vein graft to the pda, saphenous vein graft to the ramus with a jump to the om peripheral vascular disease. status post appendectomy. status post sfa bypass. diabetes mellitus. . discharge medications: 1. zantac 150 b.i.d. 2. aspirin 325 every day. 3. percocet 5/325 1-2 tablets every four to six hours p.r.n. 4. plavix 75 mg every day. 5. metformin 500 mg b.i.d. 6. atorvastatin 10 mg every day. 7. lopressor 25 mg b.i.d. 8. lisinopril 10 mg every day. 9. glyburide 5 mg every day. 10. lasix 20 mg every day times 7 days. 11. potassium chloride 20 meq. every day times 7 days. follow up: the patient is to have follow-up with dr. in two to three weeks. follow-up with dr. in weeks. follow-up with dr. in 3 months. follow-up with dr. in six weeks. , Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Transfusion of packed cells Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Percutaneous transluminal coronary angioplasty status Other complications due to other cardiac device, implant, and graft

allergies: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: 73yo m w/ hx of cad s/p 4v cabg ()and pci w/ lad stent, poorly controlled iddm, hld, copd, and ckd (baseline cr 3.5)presented to sunday am after being found unresponsive at home. ems fs at the scene was 63. in the ed was notable for bun 98, cr 5.0, troponin 1.85, ck-mb 25.9 and bnp>5000. ekg was notable for sinus tach, lvh with 1-2mm st depressions in the lateral leads. head ct was neg for intracranial pathology. he was started on a hep ggt and given rectal aspirin and transferred to the osh ccu. they could not plavix load or give beta blocker because not taking po. he was evaluated by the renal team and given his acute on chronic renal failure with hyperkalemia (peak 5.5) metabolic acidosis and volume overload, a right ij vas-cath was placed and he was emergently dialyzed with 1.2 kilos of fluid removed and creatinine fell to 3.7. his peak troponin i 23.9 and ck-mb 57.1 (mb peaked on ). he was maintained on heparin ggt. a cardiac echo was done which demonstarated an ef of 38% hypokinesis of mid inferoseptal, mid inferior, mid inferolateral, basal inferolateral, basal anteroseptal, basal inferoseptal and basal inferior segments. his blood sugars fell into the 30's while in the ccu and he was placed on d10 and maintained his blood glucose in the 70's-90's. he was transefered to ccu for further care. on arrival to the floor, patient remains altered. he is agitated and not oriented to person, place or time. he is unable to give any history at this time. his niece, his hcp, was and the situtation was discussed. she reports that his medication list is unchanged from his recent discharge from and that the patient is responsible for administration of his own medication. she reports that he has a history of hypoglycemia episodes, most recently an admission to from /12. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension 2. cardiac history: -cabg: 4 vessel in -percutaneous coronary interventions: cath with stent to lad and lcx on -pacing/icd: 3. other past medical history: chf (ef <30%) ckd with baseline cr (3.0-4.0) pvd s/p sfa and dp bypass left iliac stenting s/p appendectomy s/p l 2nd toe amputation social history: social history is significant for current tobacco use, thenpatient has smoked up to 2 and ppd for over 55 years, quit briefly for 6 months, now smoking again. there is no history of alcohol abuse. family history: there is no family history of premature coronary artery disease or sudden death. physical exam: admission physical exam: vs: t=97.5 bp=163/57 hr=78 rr=16 o2 sat=99% on ra general: wdwn male in nad. not oriented to person, place, or time. mildly agitated at times. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 8 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. 3/6 systolic ejection murmer best heard 2nd intercostal space. no r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ left: carotid 2+ femoral 2+ dp 1+ discharge physical exam: vs: t 98.0 bp 144/61 hr 57 rr 18 o2 96% general: awake, alert, oriented to , . struggles with days of the week in reverse heent: oral mucosa without erythema, dry mucous membranes heart: regular rate and rhythm, grade ii/vi systolic murmur, normal s1 and s2. pulm: soft bibasilar crackles that don't clear with cough. good air movement, no wheezes, rales, ronchi. abd: soft, nontender, nondistended, normoactive bowel sounds, no organomegaly. ext: right bka, good dorsalis pedis pulse. pertinent results: 03:33am blood wbc-5.6 rbc-3.14* hgb-10.2* hct-31.8* mcv-101* mch-32.5* mchc-32.1 rdw-14.7 plt ct-130* 09:26pm blood glucose-115* urean-64* creat-3.7* na-145 k-4.0 cl-108 hco3-21* angap-20 03:33am blood glucose-104* urean-65* creat-3.8* na-147* k-3.8 cl-109* hco3-20* angap-22* 08:37pm blood glucose-224* urean-73* creat-4.1* na-143 k-4.0 cl-105 hco3-21* angap-21* 08:37pm blood ck(cpk)-423* 03:33am blood alt-24 ast-47* ld(ldh)-379* alkphos-123 totbili-0.4 03:33am blood calcium-7.2* phos-6.2* mg-2.1 09:06pm blood type-mix po2-109* pco2-39 ph-7.33* caltco2-21 base xs--4 09:06pm blood lactate-0.9 03:33am blood tsh-1.6 ct head: no acute abnormalities. no hemorrhage. cxr: right hd line terminating at the low svc. no pneumothorax or effusion detected. discharge labs: 07:35am blood wbc-5.8 rbc-2.66* hgb-8.6* hct-27.5* mcv-104* mch-32.5* mchc-31.4 rdw-14.8 plt ct-108* 01:48am blood pt-12.2 ptt-29.9 inr(pt)-1.1 07:35am blood glucose-219* urean-96* creat-4.2* na-147* k-4.9 cl-111* hco3-24 angap-17 07:42am blood alt-23 ast-26 alkphos-115 totbili-0.3 07:42am blood ggt-69* 09:26pm blood ck-mb-19* mb indx-1.9 ctropnt-1.86* 07:35am blood calcium-8.2* phos-4.6* mg-1.7 iron-pnd 03:33am blood tsh-1.6 01:48am blood vitb12-566 09:06pm blood lactate-0.9 brief hospital course: 73 year old male with pmhx cad s/p 4v cabg ()and pci w/ lad stent, poorly controlled iddm, hld, copd, and ckd who presented to the hospital with altered mental status that was complicated by nstemi, hypoglycemia, and hypernatremia. #altered mental status: pt presented to the osh per report he was delirious and agitated, which seems to have been waxing and . on transfer to he continued to be altered, a&ox0. he recieved a workup that showed a clear head ct, normalized blood glucose, normal lfts without physical exam findings of encelpalopathy, and did not improve following urgent dialysis. his mental status gradually improved over hospital day 1. he gradually became more agitated and on hd 3 he required haldol 2.5mg x2 following the patient punching a member of the staff. he continued to be agitated and pyschiatry was consulted. they felt that this most likely was acute delerium and favored a standing dose of haldol with prn for breakthrough agitation. he had a workup of other causes of his ams including tsh, dosing with thiamine and folate, infection workup, head ct, lfts, b12. all of which were non-diagnostic. at transfer to the floor, he had no more episodes of agitation. his haldol and seroquel were tapered and he eventually became oriented to , . # renal failure: secondary to htn and dibetes, admitted with chronic kidney disease stage 4-5, baseline creatinine of ~3.5 with egfr ~15. he received dialysis due to heart failure and fluid overload as well as electrolyte control. during this admission, his cr continued to steadily rise into the mid 4's. he has been evaluated for vein mapping and planning on establishing he is currently euvolemic and making about 50cc of urine an hour. his electrolytes are medically controlled and he has no acute indications for dialysis, however he will likely need dialysis soon as an outpatient. he has had vein mapping here . # nstemi: the patient has a hx of extensive cad and is s/p 4v cabg and in the setting of his altered mental status he had elevated cardiac enzymes (mb peaked at 57) and echo with question of worsened wmas. ecg with st depressions in inferior and lateral leads, but unchanged compared to prior, consistent with abnormal repolarization. he recieved full dose asa rectally and was started on heparin ggt. due to his ams he was unable to take po medications and plavix was not able to be given. his biomarkers trended down on admission. he remained hemodynamically stable. he has had no complaints of chest pain. # hypernatremia: on admission to osh the patients na was 145. on transfer to his na rose to 147 and he was started on d5w. this was gradually corrected and normalized at 143. he was monitered off d5w and his sodium remained normal for the remainder of his hospitalization. he is hypernatremic at discharge, but is also dry and encouraged to increase po intake. # hypoglycemia: pt has been hypoglycemic on recent admission on to and was found to have a bs of on . per niece, he doses his own insulin and she is not sure if he is dosing it correctly. he required dextrose infusion at osh to maintain glucose levels, however on transfer to hisblood glucose remained stable in the 120s off of dextrose. he was placed on a sliding scale of insulin without and basal insulin and his blood glucose was maintained. it was felt that this initial hypoglycemia was to to overdosing of a long acting basal insulin. this appears to best fit the clinical picture as he had no further episodes since his inital hospitalization at the outside hospital. # dm2: as noted above the patient was admitted with concern for hypoglycemia and his home insulin was held. while recieving d5w to correct for hypernatremia his bllod glucose began to rise into the 200's. the patient was placed on a riss and his blood glucose was monitored during his hospitalization. # chronic systolic chf: baseline patient has ef 45%. he was found to have an estimated ef of 38% based on echo at osh on . no evidence of acute decompensation during hospitalization, with no rales, peripheral edema or elevated jvp. he maintained his volume status and had no episodes of sob or incraased o2 requirements. # hypertension: pt has a history of this and is controlled with metoprolol, hydralazine, and imdur at home. bps elevated on arrival with sbp into 170's. given the patients ams and inability to take po medications he was placed on iv metoprolol and iv hydrazine with sbps in the 120's. he was eventually transitioned to po hydralazine and metoprolol. his furosemide has been held, and his blood pressures have remained stable. transitional issues: - renal follow up medications on admission: preadmission medications listed are correct and complete. information was obtained from family/caregiver . 1. clopidogrel 75 mg po daily 2. hydralazine 25 mg po bid 3. isosorbide dinitrate 30 mg po tid 4. metoprolol tartrate 25 mg po bid 5. simvastatin 10 mg po qhs 6. tamsulosin 0.4 mg po hs 7. nephrocaps 1 cap po daily 8. calcium acetate 667 mg po tid w/meals 9. sodium bicarbonate 1300 mg po tid 10. furosemide 80 mg po daily 11. aspirin ec 81 mg po daily 12. glargine 6 units dinner insulin sc sliding scale using hum insulin discharge medications: 1. aspirin 325 mg po daily 2. calcium acetate 667 mg po tid w/meals 3. clopidogrel 75 mg po daily 4. hydralazine 25 mg po bid 5. glargine 6 units dinner insulin sc sliding scale using hum insulin 6. metoprolol tartrate 50 mg po bid 7. nephrocaps 1 cap po daily 8. sodium bicarbonate 1300 mg po tid 9. tamsulosin 0.4 mg po hs 10. heparin 5000 unit sc tid 11. lidocaine jelly 2% (urojet) 1 appl tp prn straight cath 12. nicotine patch 14 mg td daily 13. nitroglycerin patch 0.2 mg/hr td q24h please have patch on for 12 hours. 14. quetiapine fumarate 12.5 mg po daily please give at 5pm 15. senna 1 tab po bid:prn constipation 16. vitamin d 50,000 unit po 1x/week (sa) 17. atorvastatin 80 mg po daily 18. calcitriol 0.25 mcg po daily 19. docusate sodium 100 mg po bid:prn constipation 20. glucagon 1 mg im q15min:prn hypoglycemia protocol 21. folic acid 1 mg iv q24h 22. acetaminophen 1000 mg po q8h pain 23. simvastatin 10 mg po qhs discharge disposition: extended care facility: healthcare of discharge diagnosis: renal failure with altered mental status. discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking part in your care while at . you were transferred to this hospital from another hospital to which you were admitted when you were found down at home. the cause of your collapse is unclear, but you were found to have a very low blood sugar. you were also found to have heart failure and you had to have hemodialysis to remove the fluid that accumulated from low output from the heart. when you were transferred here, you were maintained in the intensive care unit until your renal and cardiac function stabilized. once they did, you were transferred to the regular hospital floor where your condition improved. your heart has been functioning well, and your blood sugars have been well controlled. unfortunately, your kidney function has not returned to what it was before this episode. while you do not currently need to be in the hospital to manage your kidneys, it is important that you see a nephrologist to continue managing. once again, it was a pleasure to meet you, and i wish you the best going forward. sincerely, md followup instructions: please see dr. on thursday at 3:30. greater assocs ( when discharged from rehab, please call regular pcp . , . Procedure: Hemodialysis Diagnoses: Hyperpotassemia Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Renal dialysis status Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Toxic encephalopathy Acute kidney failure, unspecified Chronic airway obstruction, not elsewhere classified Personal history of malignant neoplasm of bronchus and lung Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Other and unspecified hyperlipidemia Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Long-term (current) use of insulin Chronic systolic heart failure Other postprocedural status Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Below knee amputation status Other toe(s) amputation status

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: exertional chest discomfort major surgical or invasive procedure: two vessel coronary artery bypass grafting - left internal mammary to left anterior descending and vein graft to diagonal history of present illness: this is a 55 year old female with multiple cardiac risk factors and known coronary disease. she has undergone multiple percutaneous interventions to her left anterior descending artery in and . she was in her usoh until the end of when she began to experience exertional chest discomfort. she admitted to occasional rest symptoms. her angina does respond to nitro. she denies claudication, orthopnea, edema, pnd, syncope, presyncope and palpitations. given her history, she was admitted for cardiac catheterization. past medical history: coronary artery disease - s/p multiple lad pci/stenting, hypertension, diabetes mellitus, hyperlipidemia, gerd, obesity, hepatosplenomegaly, history of pancreatitis due to elevated triglycerides, s/p hysterectomy, s/p lumpectomy, s/p hemorrhoid surgery social history: married, lives in . she has one daughter. she is an office manager at building 19. prior light smoker, quit 5 years ago. family history: aunt diagnosed with cad in her 60's. physical exam: vitals: bp 140/74, p 75 general: well developed, obese female in nad heent: unremarkable neck: supple, no jvd lungs: clear bilaterally heart: rrr, normal s1s2, no murmur or rub abdomen: soft, nontender, nondistended, normoactive bowel sounds ext: warm, no edema pulses: 2+ distally, no carotid or femoral bruits noted neuro: nonfocal, mae pertinent results: 03:24am blood wbc-7.0 rbc-2.95* hgb-8.5* hct-24.8* mcv-84 mch-28.7 mchc-34.3 rdw-15.5 plt ct-212 03:24am blood glucose-152* urean-15 creat-0.6 na-139 k-3.6 cl-102 hco3-27 angap-14 03:58pm blood %hba1c-7.7* -done -done brief hospital course: mrs. was admitted and underwent cardiac catheterization. angiography was notable for 90% proximal and mid lad in-stent restenoses. the second diagonal also had a 80% lesion. the left main, circumflex and right coronary arteries had no significant disease. based on the above findings, cardiac surgery was consulted and further evaluation was performed as the patient preferred to proceed with surgical revascularization. a carotid ultrasound was normal. an echocardiogram revealed a lvef of 70% with only trivial mitral regurgitation. the ascending aorta was mildly dilated, measuring 3.9 centimeters. the rest of her evaluation was unremarkable and she was cleared for surgery. on , dr. performed two vessel coronary artery bypass grafting. the operation was complicated by a mild coagulopathy. a postoperative tee showed normal lv function and no mitral regurgitation. following surgery, she was brought to the csru. her coagulopathy improved with multiple blood products. no further intervention was required. within 24 hours she was extubated and awoke neurologically intact. she maintained stable hemodynamics and remained in a normal sinus rhythm. on pod#1, she transferred to the sdu. beta blockade was resumed and advanced as tolerated. she remained fluid overloaded and required further diuresis. she responded well to lasix and by discharge, had room air oxygen saturations of *******. she made steady progress and worked daily with pt. all tubes and wires were removed without incident. medical therapy was optimized and she was discharged to home on pod#4. medications on admission: asa 325 qd, plavix 75 qd, toprol xl 25 qd, lopid 600 , glucophage 1000 , imdur 30 qd, pravachol 20 qd, lisinopril 10 qd, actos 45 qd, glipizide 10 qd, ativan prn, omeprazole 20 qd discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. glipizide 10 mg tab, sust release osmotic push sig: one (1) tab, sust release osmotic push po daily (daily). 4. pioglitazone 45 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. gemfibrozil 600 mg tablet sig: one (1) tablet po bid (2 times a day). 7. pravastatin sodium 20 mg tablet sig: one (1) tablet po daily (daily). 8. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 9. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 10. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po bid (2 times a day). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 12. furosemide 20 mg tablet sig: one (1) tablet po once a day for 2 weeks. 13. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po once a day for 2 weeks. 14. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. discharge disposition: home with service facility: vna discharge diagnosis: coronary artery disease - s/p cabg x 2, hypertension, diabetes mellitus, hyperlipidemia, gerd, obesity, hepatosplenomegaly, history of pancreatitis discharge condition: good discharge instructions: patient may shower. no baths. no lotions or creams to incisions. no lifting no more than 10 lbs for 10 weeks. no driving for one month. monitor wounds for signs of infection. followup instructions: dr. in 4 weeks dr. (pcp) in weeks dr. (cardiologist) in weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Left heart cardiac catheterization Coronary arteriography using a single catheter (Aorto)coronary bypass of one coronary artery Angiocardiography of right heart structures Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux 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 Other complications due to other cardiac device, implant, and graft

allergies: ace inhibitors attending: chief complaint: cc: major surgical or invasive procedure: central line placement history of present illness: ms. is a 85 yo female with pmh of cad s/p cabg, chf who was in usoh until 1 week ago when she started experiencing cough and sob. she states that over the course of the week she experienced progressing shortness of breath and chills. she states that on the day pta, she lost her balance and fell and lay there as she was unable to make it to the phone for about 6 hours. her daughter found her. the next day, her daughter found her to be febrile to 103 and brought her to hospital. . initially, on admission to nwh, she was febrile but normotensive. cxr revealed both pna and fluid overload. bnp 1099. leni's of her lower extremities were performed due to complaint of calf pain with ambulation; both extremities negative for dvt. she was given lasix 40 mg iv, and her bp dropped to 60's and she was started on dopamine. she also was treated with vancomycin, ceftriaxone, and azithromycin. she was placed on nrb for her oxygentation and heparin gtt in the setting of elevated troponins (tropi to 0.9) and transferred to for further care. . on arrival to the er, she had a head ct and cxr and started on cpap prior to her transfer to the micu. at this time, she reported that her shortness of breath was improving. she denied chest pain, and ros revealed only one loose bm per day for the past 1 week. . in the micu, she required mask ventilatory support and levophed for bp support. a right subclavian cvl and left a-line were placed. levophed was quickly titrated off, and she was transferred to the general medicine service on 4l nc for further care. past medical history: 1. coronary artery disease s/p coronary artery bypass graft on 2. post-op atrial fibrillation requiring electrical cardioversion 3. chf 4. osteoarthritis 5. carpal tunnel syndrome 6. shingles right arm . psh: s/p pacemaker placement s/p left knee replacement in s/p thyroidectomy s/p cholecystectomy s/p hysterectomy for ?uterine cancer social history: she has two children, and currently resides with daughter. she quit smoking 40 yrs ago, previously smoked 1 ppd for 20 years. she admits to occasional etoh, denies illicit drug use. she ambulates without assistance at baseline. family history: father died of mi at age 69. physical exam: vs: t 96.9, 132/62, hr 66, rr 20, spo2 94% on 4l gen: elderly obese wf female reclining in bed, pleasant, hoh, nad. heent: moist mucous membranes, clear op chest: bilateral expiratory wheezes, exp>insp cvr: rrr, nl s1, s2; no jvd abdomen: soft, obese, nontender, nondistended ext: trace edema bilaterally, chronic venous insufficiency changes. neuro: a&o x 3, moves all ext, 5/5 strength upper and lower ext. mentating at baseline, per daughter. pertinent results: ekg - nsr, left axis, rbbb with lafb, no sig changes compared to previous. . - cxr: mild cardiomegaly. increased opacities in bilateral lower lobes, especially on the right with effusion and atelectasis. increased vascular markings in upper lobes. these findings can be explained worsening chf, however, there is a possibility of right lower lobe pneumonia. . head ct - chronic small vessel ischemia. no evidence of hemorrhage. . echo: 1. the left atrium is moderately dilated. the left atrium is elongated. the right atrium is markedly dilated. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). 3.the right ventricular cavity is markedly dilated. there is focal hypokinesis of the apical free wall of the right ventricle. right ventricular systolic function appears depressed. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 4.the ascending aorta is moderately dilated. 5.the aortic valve leaflets are mildly thickened. trace aortic regurgitation is seen. 6.the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the mitral regurgitation jet is eccentric. 7.moderate to severe tricuspid regurgitation is seen. 8.there is moderate pulmonary artery systolic hypertension. 9.there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. . cxr : 1. marked worsening of pulmonary edema. 2. worsening of bibasilar consolidation, which may be due to an infectious process or aspiration. . tte : there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. the right ventricular cavity is moderately dilated. there is mild global right ventricular free wall hypokinesis. there is abnormal septal motion/position. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the degree of tricuspid regurgitation and pulmonary hypertension are less. the rv is still dilated and hypokinetic. . cxr persistent pulmonary edema. bilateral pleural effusions. the slight interval increase in the left-sided pleural effusion may be attributable to differences in patient positioning. . cxr compared with , the posterior left pleural effusion appears grossly unchanged. no significant increase is seen involving the much smaller right pleural effusion. the right lower lobe atelectasis/infiltrate is grossly unchanged. brief hospital course: 85 year old woman with h/o chf, cad s/p cabg admitted with pneumonia & chf exacerbation. . 1. pneumonia: likely community acquired pna. she has been treated with azithromycin, vancomycin, and ceftriaxone; vancomycin d/c'd after 7 days as patient is low-risk for nosocomial mrsa pneumonia. gram stain and sputum cultures unrevealing. influenza dfa negative. she completed a 10d of cef/azithro. she required supplement o2 at discharge to maintain spo2>92% (she was down to 1.5l). this should continue to be titrated down. after completing her treatment, she remained afebrile. . 2. chf: patient with known h/o chf. echo performed during this hospital course show rv dysfunction and dilation (see echo reports). abnormal septal motion/position was felt to be consistent with rv pressure/volume overload. this pulm htn was not new as she had previously pa htn from prior to cabg in and in - per echo done by her primary cardiologist. lvef normal. it is possible that cause of rv failure is acute pulmonary disease; however, the differential diagnosis includes pe vs. ischemic disease. she had positive trops, but only mildly elevated without ekg changes and thus was felt to be demand related. at , our goal for her was for a negative fluid balance, particularly in the setting of worsened pulmonary edema on most recent cxr. after coming off pressors and transfer to floor, the patient was aggressively diuresed with 40mg iv of lasix. we diuresed her with a goal of -2l per day. she still required oxygen upon discharge, but with continued diuresis, this should be able to be weaned down. she was discharged on lasix 80mg po bid; once she is euvolemic and no longer requiring oxygen, she should be switched back to her home dose of lasix 40mg po daily. she should have repeat electrolytes on to ensure her kidney function is stable. she should follow up with her cardiologist in the next 1-2 weeks and have a repeat echocardiogram at that time once she is euvolemic. initially held bb & in the setting of hypotension and ?sepsis. these were restarted before discharge. continued amiodarone per prior regimen. weight on discharge was 236lb. she was maintained on a low sodium diet. . 3. cad: patient with known h/o cad, s/p cabg. patient presented with troponin leak (peaking at 0.15) but asymptomatic with no associated ekg changes. she was on a heparin gtt at outside hospital but this was discontinued once enzymes downward trending. troponin leak was likely secondary to demand ischemia in the setting of pneumonia. continued asa, zetia, lipitor and bb. . 4. acute renal failure: cr elevated to 2.3 on admission (baseline 1.1) with pre-renal etiology (fena <1%). creatinine did continue to increase with diuresis, and on discharge was 1.4. it is likely indicative of appropriate diuresis with relative hypovolemic state, necessary in this patient to keep her dry and prevent pulmonary edema. . 5. atrial fibrillation: rate controlled with beta blocker and amiodarone. in sinue rhythm during this hospitalization. not clear as to why the patient is not anticoagulated as she was anticoagulated in the past. this should be readressed with her cardiologist. . 6. pulmonary effusion: r sided effusion; ultrasound shows little layering of the fluid. followed by xrays. relatively stable on discharge. . 7. hypothyroidism: continue levothyroxine. . 8. code status: full code. . 9. communication with daughter (. pcp: . in . . 10. dispo: to extended care facility in good condition, on 1.5l of o2 by nc. medications on admission: 1. synthroid 200mcg 2. lipitor 40 3. zetia 10 4. prilosec 40 5. toprol xl 25 mg daily 6. lasix 40 daily 7. amdiodarone 200 mg daily 8. asa 81 mg daily 9. avapro 300 mg daily discharge medications: 1. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 5. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 6. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 7. lasix 80 mg tablet sig: one (1) tablet po twice a day. 8. prilosec 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 9. avapro 300 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: nursing home - discharge diagnosis: primary: pneumonia acute renal failure chf exacerbation . secondary: cad discharge condition: stable discharge instructions: you were admitted with pneumonia and a chf exacerbation. you should weigh yourself daily, and call your doctor if you gain more than three pounds in one day. please call your primary care doctor if you become short of breath, have chest pain, abdominal pain, nausea, vomiting, fever >101, chills, increase in swelling in your lower legs. . you should have a repeat electrolyte panel on , , to ensure that your kidney function is doing well. . you should continue to have your supplemental oxygen weaned off. . once you are off oxygen you should be switched back to your home dose of lasix, which is 40mg po daily. followup instructions: you have an appointment to follow up with your pcp, . , on thursday, @ 1:45. you can reach his office at . . you should make an appointment to follow up with your cardiologist, dr. within the next two weeks. you can reach his office at: (. you will need a repeat echocardiogram at that time. Procedure: Venous catheterization, not elsewhere classified Diagnoses: Pneumonia, organism unspecified Subendocardial infarction, initial episode of care Mitral valve disorders Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Severe sepsis Unspecified acquired hypothyroidism Atrial fibrillation Acute on chronic diastolic heart failure Aortocoronary bypass status Cardiac pacemaker in situ Diseases of tricuspid valve

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass graft 4. history of present illness: 83 year-old woman, patient of dr. , dr. , with increased sob with activity, left shoulder blade/back pain at rest, + mibi, referred for cardiac cath. this pleasant 83 year-old patient notes becoming sob when walking up hills or inclines about one year ago. this sob has progressively worsened and she is now sob when walking city block (flat surface). she also notes new sharp pain in left shoulder blade/back area. this pain occurs at rest and is not associated with activity or sob. adenosine mibi at osh showed +moderately reversible inferior defect, mild reversible anterior defect, nl lvef 70%. referred for cath here today which showed 80% lmca, 60% lad at origin of d1, rca diffusely diseased with 90% stenosis. past medical history: arthritis carpal tunnel shingles right arm needs right knee replacement left knee replacement in thyroidectomy cholecystectomy hysterectomy h/o lgib - after taking baby asa 81 social history: her husband died recently. she has two children. family history: father died of mi at age 69. physical exam: pe: t 97.6 bp 142/70 r arm, 150/70 p 42-64 r 16 sat 92% ra g: elderly female, nad heent: mmm, anicteric neck: jvd diff to assess lungs: +end exp rhonchi bilaterally upper lung zones cv: rrr, s1s2, distant heart sounds, +2/6 systolic murmur at apex abd: soft, nt, nd, bs+ ext: trace bilateral lower ext edema; r groin small hematoma, no bruits nails: no bed abnormalities, lunulas present, no splinters, pulses rectal: guiac neg pertinent results: cath: lmca had 80% eccentric distal stenosis; lad diffusely diseased with mid 60% stenosis at the origin of a large diagonal branch; lcx diffusely diseased; rca mid 90% stenosis; r-pda occluded; ef 60%. 06:10am blood wbc-7.4 rbc-3.53* hgb-10.7* hct-32.3* mcv-92 mch-30.3 mchc-33.1 rdw-14.4 plt ct-339 06:10am blood plt ct-339 09:59am blood pt-13.3 ptt-25.1 inr(pt)-1.1 06:10am blood glucose-124* urean-21* creat-1.0 na-141 k-4.5 cl-100 hco3-31* angap-15 brief hospital course: mrs. was admitted for cardiac cath showing 3vd. a cardiac surgery consult was obtained and after pre-operative testing, she proceeded top the operating room on with dr. . she had a cabg x 4 with lima to the lad, svg to the pda, svg to the plb, and svg to the om. please see op note for full details. she was transferred to teh csru post-op for hemodynamic monitoring. she was unsuccessfully weened on her operative evening and was kept on simv overnight ans successfully weened and extubated on pod one. pod three was significant for dropping oxygen saturation with increased pulmonary toilet. she also had a drop in her blood pressure for which she was a-paced with effect and her lopressor was discontinued. on pod five, she was in a rapid atrial flutter with pauses. she was started on amiodarone and woumadin for anticoaguation. pod six continued with bursts of atrial fibrillation. she was also transferred to the inpatient floor for ongoing recovery and rehabilitation. on pod seven it was decided that she would benefit from rehabilitation prior to discharge home and on pod eight she was discharged to rehab. medications on admission: levothyroxine 200 mcg daily. avalide 300/12.5 daily. norvasc 5 daily. ferrous sulfate . tylenol prn. discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 3. levothyroxine sodium 200 mcg tablet sig: one (1) tablet po daily (daily). 4. furosemide 20 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 5. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po twice a day for 10 days. disp:*40 capsule, sustained release(s)* refills:*0* 6. amiodarone hcl 200 mg tablet sig: two (2) tablet po daily (daily) for 2 weeks then decrease to 200mg po qd. disp:*60 tablet(s)* refills:*0* 7. coumadin as directed for goal inr 2.0-2.5 discharge disposition: extended care facility: manor - discharge diagnosis: coronary artery disease. s/p cabg post op atrial fibrillation discharge condition: stable. discharge instructions: shower daily and wash incisions with soap and water. rinse well. do not apply any creams, lotions, powders, or ointments. no tub bathing or swimming. no heavy lifting greater than 10 pounds. no driving for 6 weeks. check pt/inr qd and prn and dose coumadin for goal inr 2.0-2.5 followup instructions: follow-up with dr. in 4 weeks. follow-up with dr. in weeks. follow-up with dr. in weeks. Procedure: (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Angiocardiography of left heart structures Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Cardiac complications, not elsewhere classified Atrial fibrillation Other chronic pulmonary heart diseases

allergies: amiodarone / quinidine gluconate / pronestyl attending: chief complaint: ich major surgical or invasive procedure: mri/mra echo history of present illness: hpi: 62yo rh m h/o htn, afib on coumadin, cad s/p ptca x 2 in who was in usoh today when he began to have a mild right-sided headache around noon, a/w some photophobia and nausea. he was sitting at the computer half an hour later when he got up to go to and noticed that his l foot was numb and "wobbly". the foot felt weak, "like it was asleep". he walked but was tripping and went to get a banana, thinking that he needed to eat something. he took his pulse which was regular and went to drive to . while driving though, he felt confused and turned around. when he got home, he called his daughter and asked her if his speech was slurred, thinking he may be having a stroke. it was not and he had no difficulty speaking or comprehending what she was saying. she called 911 to get him checked out and he was brought to an osh. there, the family noticed an increasing left facial droop. his ankle felt better. head ct showed an ich and inr was 2.89 and the patient was given 3u ffp, vit k 5mg im, labetalol 10mg iv x 1 and dilantin 1g iv was started but d/c'd due to hypotension. the patient was then transferred here. at this point, the patient's only deficit, in addition to the persistent l facial droop, is some numbness in his left hand (all five "tingling"). he has had no palpitations (has been in nsr since ), no light-headedness. no neck pain. no diplopia or dysarthria or dysphagia. he no longer feels disoriented. he has had no loc or convulsions and has smelled no bad odors. no visual symptoms or anything else out of the ordinary. in our ed, he was seen by neurosurgery and neurosurgical intervention deferred. he received proplex x 2 vials and ffp 2u. past medical history: as above, plus prostate ca s/p resection in (no further rx) social history: works as plumber, quit smoking 30yrs ago after 15ppyr history, no other drugs. only occasional etoh. family history: father died of mi at age 50, mother alive and well 101 physical exam: 98.0 78 154/76 16 94%ra gen nad, lying in bed, pleasant cv rrr pulm ctab abd obese, nt/nd +bs ext no edema neuro ms awake, alert, fully oriented. backwards, dsf 6. language fluent no errors, naming intact, reads no errors and repeats. neglects the left side of the cookie jar picture, even to prompting. bisects a line on the right. no apraxia. no dysarthria. cn cn i: deferred cn ii: normal visual acuity, vff no extinction. pupils 4->2mm b/l and equal. cn iii,iv,vi: eom full in all directions, no diplopia. gaze conjugate no deviation cn v: intact to pp, lt both sides, no extinction cn vii: l lower face is asymmetrical, droops with smile as well. eye closure cn viii: hearing intact b/l, no nystagmus cn ix,x: palate rises symmetrically cn : shrug cn xii: tongue midline, agile motor no pronator drift, normal tone and bulk d b t we fe ff ip q h df pf l 5 5 5 5 5 5 5 5 4+ 5 5 sensory intact to lt, pp, jps, vibration b/l. +extinction to lt in le's, none in ues. graphesthesia intact in both hands. coordination: ftn intact b/l, hts as well gait: deferred reflexes: 2+ throughout, toes up on l, down on r pertinent results: labs wbc 9.1, hct 38.7, plt 145 inr 1.8 sma unremarkable (except for k 5.5 but hemolyzed) ekg sinus rhythm 11:19pm pt-14.1* inr(pt)-1.2* 05:59pm glucose-107* urea n-13 creat-1.1 sodium-136 potassium-5.5* chloride-101 total co2-24 anion gap-17 05:59pm wbc-9.1 rbc-4.44* hgb-14.2# hct-38.7* mcv-87 mch-32.0 mchc-36.8* rdw-14.1 nchct: there is a 2.7 x 1.6 cm focus of intraparenchymal hemorrhage within the right thalamus, with subjacent edema, and mass effect on the third ventricle. there is no shift of normally midline structures. no other foci of intracranial hemorrhage are identified. the ventricles are normal in caliber. the soft tissue and osseous structures are within normal limits. the basal and ambient cisterns are not effaced. repeat mchct: no significant change in right thalamic intraparenchymal hemorrhage compared to yesterday's study. brief hospital course: mr had no further events involving numbness/tingling while in the hospital. had a right thalamic intraparenchymal hemorrhage on ct. at the outside hospital received 3u ffp, vit k 5mg im, labetalol 10mg iv x 1. inr had corrected to 1.8 by the time of transfer to and was given additional ffp. coumadin held during admission. seen by neurosurgery but no surgical intervention recommended. was reevaluated with f/u ct the next day which showed no progression or sign of hydrocephalus. was at baseline at time of discharge and evaluated by pt/ot who felt the patient was safe to go home. was discharged home with instructions to f/u with pcp and neurology. coumadin to be restarted at a later date given risk of rehemorrhage. medications on admission: coumadin 3mg po qhs asa 81 zetia 10 toprol xl 100mg po daily mvi omega 3 discharge medications: 1. atenolol 50 mg tablet sig: two (2) tablet po daily (daily). 2. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. outpatient physical therapy 3 sessions per week. 6. outpatient occupational therapy 3 sessions per week discharge disposition: home discharge diagnosis: right thalamic cerebral hemorrhage atrial fibrillation high blood pressure discharge condition: stable, with mild sensory loss and weakness on left side discharge instructions: please take all medications as prescribed. you will need to start warfarin at some point in the near future (within a week or so but definately after the mri is performed). please keep all follow up appointments including: mri and neuro f/u. followup instructions: neurology follow-up: provider: , md, phd: date/time: 2:00 mri brain appointment: provider: radiology phone: date/time: 1:45 md, Procedure: Transfusion of other serum Diagnoses: Abnormal coagulation profile Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Atrial fibrillation Personal history of malignant neoplasm of prostate Percutaneous transluminal coronary angioplasty status Unspecified intracranial hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: exploratory laparotomy history of present illness: mr is a year old man s/p right nephrectomy, s/p left ureterostomy ileal conduit who was transferred from for sharp and worsening abdominal pain. the patient denied any bowel movement in the 2-3 days prior to presentation but had some flatus in the previous hour. a ct scan performed at was concerning for large bowel obstruction/cecal volvulus. past medical history: pmh: cad, mi, htn, djd, renal ca, a-fib psh: ccy, r nephrectomy, cystectomy/ileal conduit, aaa, pacemaker, ptca social history: no tobacco, occasional wine. family history: non-contributory physical exam: temp 97.2 72 170/76 24 gen: sitting up chest: ctab cvs: rrr abd: firm, mild-severe tenderness, severely distended, no rebound, no guarding, no local masses rectal: no masses, guiaic neg ext: warm pertinent results: ct abdomen 2//906 complete large bowel obstruction, possible cecal volvulus, possibly associated with ileal conduit brief hospital course: mr is a year old man s/p right nephrectomy, s/p left ureterostomy ileal conduit who presented with complete large bowel obstruction/cecal volvulus and who underwent ex lap, r colectomy, revision ileal conduit w/ urology on . in the or, the patient was found to have necrotic gut and underwent r colectomy and ileal conduit revision. please see operative report for full details of the procedure. in the or, the patient also underwent tee that revealed an ef of 45%. . post-operatively, the patient was transferred to the trauma sicu. the patient was initially thought to be coagulopathic, but this was eventually found to be secondary to 'propofol syndrome' and with suspension of the propofol on post-operative day #1, his lab values improved. otherwise, he remained on pressors until pod #4, was extubated on pod #7, completed a 7 day course of iv abx (levo/flagyl) and transferred to the floor on pod #9. on that same day, the patient was found obtunded with worsening o2 sats to the 80s. this did not improve with lasix or nebs. abg revealed pao2 of 39. pt was also found to be hypoglycemic (23) due to poor oral intake and nph administration. the patient was intubated and readmitted to the trauma sicu. he was started on levofloxacin prophylacticailly. on post-operative day #11, the patient was successfully extubated. on that day, a feeding tube was placed under fluoroscopy which was later pulled out by the patient. the patient was evaluated by speech and swallow who recommended that the patient reattempt oral feeds with pureed foods under supervision. given this, the patient was transferred to the floor. . on the floor, the patient recovered well. he was evaluated by nutrition who recommended supplementation to improve his nutritional status. he was seen by cardiology after one episode of asymptomatic vtach (18 beats) who recommended tight blood pressure control and resumption of anti-coagulation for afib. he was started on warfarin on with lovenox until inr is therapeutic at 2.0-2.5. at this point, lovenox should be discontinued. the patient was discharged to extended care facility for rehab on . medications on admission: : prednisone 7.5, coumadin 5/2.5, digoxin, lipitor, lisinopril, ativan, lopressor, tramadol discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*qs tablet(s)* refills:*0* 2. quetiapine 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 3. olanzapine 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4h (every 4 hours) as needed. disp:*250 ml(s)* refills:*0* 5. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 7. enoxaparin 60 mg/0.6 ml syringe sig: one (1) subcutaneous (2 times a day): please discontinue when inr therapeutic. disp:*qs * refills:*0* 8. warfarin 5 mg tablet sig: one (1) tablet po once (once): please adjust to reach therapeutic inr level of 2.0-2.5. disp:*qs tablet(s)* refills:*0* 9. digoxin 250 mcg tablet sig: one (1) tablet po once a day: except wednesday. disp:*30 tablet(s)* refills:*0* 10. lisinopril 30 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: ventral hernia discharge condition: stable discharge instructions: please call doctor greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain not controlled by pain medications or any other concerns. please resume taking all medications as taken prior to this surgery and pain medications as prescribed. please follow-up as directed. no heavy lifting for 4-6 weeks or until directed otherwise. wound care: shower (no bath or swimming) if no drainage from wound, if clear drainage cover with dry dressing followup instructions: provider: , md phone: date/time: 1:45, 3 clinical specialities Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Arterial catheterization Open and other right hemicolectomy Other small-to-large intestinal anastomosis Transfusion of other serum Artificial pacemaker rate check Infusion of vasopressor agent Revision of cutaneous uretero-ileostomy Diagnoses: Acidosis Coronary atherosclerosis of native coronary artery Acute posthemorrhagic anemia Acquired coagulation factor deficiency Unspecified septicemia Severe sepsis Atrial fibrillation Percutaneous transluminal coronary angioplasty status Paroxysmal ventricular tachycardia Hypotension, unspecified Old myocardial infarction Long-term (current) use of anticoagulants Urinary complications, not elsewhere classified Acute vascular insufficiency of intestine Volvulus Intravenous anesthetics causing adverse effects in therapeutic use Fitting and adjustment of cardiac pacemaker Attention to other artificial opening of urinary tract Other specified hypoglycemia

history of present illness: mr. is a 63 year old male with a history of hypertension who is status post a nine foot fall on his back on the when he fell off the cab of his truck. he was reportedly down for approximately two hours before help arrived and has had changes in his mental status since the fall. he was originally seen at where he was found to have a left scalp abrasion that was sutured, left clavicle fracture, left rib fractures, and a negative dictation ends. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Arterial catheterization Aortography Arteriography of renal arteries Diagnoses: Other iatrogenic hypotension Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Pneumonitis due to inhalation of food or vomitus Delirium due to conditions classified elsewhere Rhabdomyolysis

history of present illness: this is a 63 year old male with a history of hypertension and colon cancer status post hemicolectomy who is status post a nine foot fall from the cab of his truck on . the patient was reportedly down for about two hours before help arrived and has had changes in mental status since his fall. he was originally seen at the hospital where he was admitted and found to have a left scalp abrasion that was sutured, a left clavicle fracture, left rib fractures and a head ct scan that did not show any evidence of intracranial hemorrhage. his next ct scan was also negative for fracture. the pain was controlled there with percocet and he was cleared by physical therapy for discharge home with a creatinine of 2.4 at discharge. at home, however, he was unable to carry out his activities of daily living, became short of breath and was brought to an outside hospital emergency room where his ck was noted to be 2456 and he was noted to have a troponin t of 2.4, creatinine of 3.5, and had an o2 saturation of only 81% on five liters nasal cannula. an echocardiogram was carried out which showed an ejection fraction of 40 to 45% and an arterial blood gas at the outside hospital showed a ph of 7.32, with pco2 of 48 and a po2 of 50. a chest ct scan demonstrated right upper lobe and right lower lobe consolidation consistent with bronchopulmonary pneumonia thought to be secondary to aspiration pneumonia. no pneumothorax was seen. again, a head ct scan was negative. given the patient's white blood cell count elevation, infiltrate and hypoxia, he was given one gram of ceftriaxone, aspirin for positive cardiac enzymes and morphine sulfate for pain and was transferred to for further care. on admission to the , the patient was alert and intermittently oriented. the patient received in the emergency department aspirin, flagyl and further morphine sulfate for pain. the patient was noted to have unequal blood pressures in his arms and a transthoracic echocardiogram was carried out to rule out dissection. the transthoracic echocardiogram demonstrated no evidence of aortic or thoracic dissection and showed mile regional left ventricular systolic dysfunction with posterior and apical hypokinesis. past medical history: 1. hypertension times three years. 2. colon cancer status post hemicolectomy in . 3. prostate cancer status post prostatectomy. 4. remote history of hepatitis b approximately 25 years ago. medications on admission: 1. accupril 40 mg q. day. allergies: no known drug allergies. social history: the patient lives alone; he is separated from his wife. has two supportive daughters. has smoked approximately two to three packs per day times 50 years. has occasional ethanol. denies any intravenous drug use. he is a trucker and was independent before his fall. physical examination: on admission, vital signs with temperature of 98.0 f.; blood pressure 122/65; pulse 102; respiratory rate 20; o2 saturation 84% on room air and increased to 97 to 100% on a nonrebreather. in general, the patient was found lying in bed guarding his left side in mild distress. heent: pupils equally round and reactive to light. extraocular muscles are intact. oropharynx is clear. the patient wears dentures. neck with no lymphadenopathy. chest with diffuse rales and rhonchi on the right; clearer on the left but dullness is present at the left base. ecchymoses are present over the left anterior chest wall and he is tender to palpation on the left side of his chest. abdomen soft, nontender, slightly distended, positive bowel sounds. midline well healed scar. extremities with no edema, clubbing or cyanosis. two plus dorsalis pedis and radial pulses bilaterally. neurological examination: the patient is awake, oriented to person, occasionally to place, occasionally to time. cranial nerves ii through xii are intact. strength is five plus in all regions. laboratory: on admission, white blood cell count 22.1, hematocrit 40.5, platelets 298. sodium 138, potassium 5.2, chloride 103, bicarbonate 24, bun 41, creatinine 3.4 and glucose is 117. ck is 2427, with an mb of 133 and a troponin t of 3.41. ekg demonstrates normal sinus rhythm with normal axis and intervals and chamber size. there are no st or t wave changes. chest x-ray demonstrates minimally displaced rib fractures within the fifth, sixth and seventh left ribs posteriorly as well as a depressed fracture of the left clavicle which is displaced inferiorly by the width of the bone. there is no pneumothorax. mild congestive heart failure is evidenced by vascular engorgement. lungs are otherwise clear. hospital course: the patient was initially admitted to the medical intensive care unit. the patient was begun on antibiotics for presumed aspiration pneumonia and was placed on aspirin, beta blockers, given the elevated cardiac enzymes on admission. the patient's o2 saturations initially stabilized on therapy for presumed aspiration pneumonia and the patient was transferred to the floor. however, on the day of transfer, the patient had a further episode of hypoxia and hypotension with a drop in his systolic blood pressure to the 80s. the patient was bolused with a total of two liters of normal saline with improvement of his systolic blood pressure to 100 to 105 and the patient was transferred back to the medical intensive care unit for further management. on readmission to the medical intensive care unit, he had an o2 saturation of 80% on six liters via nasal cannula. he was transferred to a 50% face mask where his arterial blood gas was found to be 7.34/44/55. the patient demonstrated increasing agitation and required 50 mg of haldol for sedation. hospital course by systems: 1. pulmonary: the patient's hypoxia was most likely secondary to aspiration pneumonia as well as fluid overload. he was diuresed with intravenous lasix with improvement of his respiration. he was continued on a 14 day course of levofloxacin and flagyl for presumed aspiration pneumonia. the patient's respirations further improved with chest pt and he was transitioned back to nasal cannula and finally room air. the patient was able to maintain adequate room air o2 saturations. 2. cardiac: the patient was noted to have nonspecific inferior st depressions with t wave inversions, that were 1 mm in v4 through v6 in the setting of sinus tachycardia. on another occasion, the patient was noted to have t wave inversions in iii and avf with 1/ depressions in v4 and v5. on a further occasion, the patient was noted again in the setting of sinus tachycardia to have depressions in v4 through v6. the patient was monitored on telemetry and was noted to undergo atrial fibrillation at a rate of 140 on the with v4 through v6 st depressions of 1 mm. telemetry demonstrated further intermittent episodes of atrial fibrillation with rates up to 160 and a possible ten beat run of ventricular tachycardia. transesophageal echocardiogram demonstrated trace mitral regurgitation, trace tricuspid regurgitation, mildly depressed ejection fraction with posterior / apical hypokinesis and no evidence of dissection. furthermore, the transthoracic echocardiogram demonstrated left ventricular hypertrophy with mild global hypokinesis. the patient's ck was 2427 on admission and peaked at 2551 on the , after which point it trended downward to 575 on the . his ck mb was 133 on admission and declined consistently throughout his hospitalization. his ck mb was 5 on the . his troponin t was 3.41 on admission and increased to a maximum of 5.22 on the . his elevated cardiac enzymes were thought to be primarily due to renal failure in the setting of rhabdomyolysis as well as demand ischemia in the setting of tachycardia. the patient was begun on high dose beta blocker for rate control of his atrial fibrillation and nonsustained ventricular tachycardia. he was begun also on aspirin. he was anti-coagulated with heparin for prophylaxis of his atrial fibrillation. persantine mibi was carried out on the and did not demonstrate any significant ischemic st segment changes. there was no evidence of fixed or perfusion defects on nuclear study. diffuse hypokinesis and depressed ejection fraction of approximately 30% was noted. the patient was initially taken to the cardiac catheterization laboratory on the , but was unable to undergo the procedure at that time secondary to mental status changes and the cardiac catheterization was deferred to a later date. the patient was noted to have intermittent episodes of hypotension during subsequent hospitalization and his beta blockers and ace inhibitor doses were titrated. 3. renal: the patient was noted to have an elevated creatinine of 3.4 on admission. it was difficult to ascertain the patient's baseline creatinine level as he is not per report had blood work done recently prior to this admission; however, on admission to the hospital, shortly after his fall, he was noted to have an elevated creatinine of 2.6. his creatinine steadily declined during the course of his hospitalization from the maximum of 3.4 on admission to a baseline of between 2.2 and 2.4. renal ultrasound was carried out on the and revealed diffusely increased echogenicity of the renal parenchyma bilaterally consistent with chronic parenchymal disease. the left kidney is atrophied. overall, the study was consistent with arterial vascular disease. no hydronephrosis or proximal hydroureter was seen on the study. 4. psychiatric: the patient was noted to have intermittent episodes of delirium. a psychiatric consultation was obtained. a neurological consultation was also obtained. the patient's change in mental status were characterized by confusion that appeared to have a temporal component to it, with confusion occurring at its greatest at night time. at times, the patient was noted to have paranoid delusions. however, he never demonstrated any clear auditory or visual hallucinations. he required intermittent haldol for sedation. an ammonia level was checked and was found to be 27. a ct scan of the head was obtained and did not demonstrate any evidence of intracranial hemorrhage. the patient's mental status was significant improved on the and at the time of this dictation, the patient is alert and oriented times three and had a normal mini-mental status examination. 5. endocrine: the patient was found to be significantly hypothyroid. he had a tsh of 38 on the . repeat tsh on the 19th revealed a level of 45. the patient was begun on levothyroxine at 12.5 micrograms per day. his repeat tsh and thyroid studies will be carried out four weeks after this was initiated. , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Arterial catheterization Aortography Arteriography of renal arteries Diagnoses: Other iatrogenic hypotension Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Pneumonitis due to inhalation of food or vomitus Delirium due to conditions classified elsewhere Rhabdomyolysis

past medical history: as previously noted. 1. hypertension. 2. colon cancer status post hemicolectomy in . 3. prostate cancer status post prostatectomy. 4. remote history of hepatitis b. 5. severe three vessel coronary artery disease. 6. occluded severe bilateral iliac disease. 7. left renal artery stenosis. cardiac surgery consult was done by dr. team on , who noted his fall from a ladder earlier in the month with a fractured left clavicle and left rib fractures. his recovery was complicated by rhabdomyolysis. at home, he had desaturated, brought to an outside hospital emergency room and he had acute shortness of breath. he came in with pneumonia and a positive cpk. while in the hospital, the patient had paroxysmal atrial fibrillation. his carotid ultrasound also showed that his right internal carotid was occluded with a 40-60% left internal carotid stenosis. allergies: patient had no drug allergies. medications at time of consult: 1. thyroid medication 12.5 mcg p.o. q.d. 2. atorvastatin 20 mg p.o. q.d. 3. enteric coated aspirin 325 mg p.o. q.d. 4. lisinopril 2.5 mg p.o. q.d. 5. toprol xl 50 mg p.o. q.d. physical examination: on exam, he was awake, alert, and mentating well. his lungs were clear bilaterally. his heart was regular rate and rhythm. his abdomen was benign. his extremities were warm and well perfused. he was referred to dr. . he was also seen with a preoperative evaluation by physical therapy and continued to be followed by psychiatry for some confusion as noted in the previous discharge summary. he continued to be followed also by neurology given his risk with severe bilateral carotid disease. preoperative laboratory work as follows: on the 29th showed a white count of 14.6, hematocrit 30.8. pt 13.4, ptt 31.9. platelet count 424,000. inr of 1.2. bun 35, creatinine 2.2, glucose 108, sodium 136, potassium 4.4, chloride 105, bicarb 26, anion gap of 9.0, calcium 8.6, phosphate 2.9, magnesium 1.4. preoperative ekg on the 23rd showed inferior t-wave changes that were nonspecific. the patient was in sinus rhythm at the time with a rate of 67. on , he underwent coronary artery bypass grafting x2 with lima to the lad and a vein graft to the om by dr. . he was transferred to the cardiothoracic icu in stable condition. on postoperative day one, patient had no events overnight. he was extubated and was satting 96% on 3 liters. he had a cardiac index of 2.3. his white count rose to 30.7 with a hematocrit of 31 postoperatively. his bun was 20 and creatinine was 1.8, which was down from his baseline of 2.6. neurologically, he was intact. he continued to start his wean off oxygen. chest tubes remained in. his swan was pulled to begin wean of his neo-synephrine, which he was at at 0.1 mcg/kg/minute. he was also supported on an insulin drip. he finished his perioperative vancomycin and began lasix diuresis also. on postoperative day two, again he had no events overnight. he remained neurologically intact. his chest tubes were pulled. his lopressor was increased to 25 mg p.o. b.i.d. continued his lasix, and cultures had been sent off. no results at that time. his creatinine rose slightly to 20, and his white count dropped from the 30s to 18. on postoperative day three, he desatted very briefly to 88, but then improved with increased oxygen therapy. he was at 89 in sinus rhythm with a blood pressure of 114/56, increased his saturation to 98% on 2 liters nasal cannula. at the time his cultures did not return any significant information. his white count dropped to 14.5. his creatinine rose slightly to 2.2. he had decreased breath sounds at both bases, but otherwise his examination was unremarkable. his lopressor was increased to 50 b.i.d. and he was off all drips at that time. he also was restarted on his levothyroxine and atorvastatin. he was transferred from csru out to the floor on to begin his ambulation and physical therapy. he continued to be followed by case management and neurology. he had some periods of confusion and agitation. on postoperative day four, he had some bilateral rhonchi. his sternum was stable. his incisions were clean, dry, and intact. his white count remained stable at 13.6. his creatinine also remained stable at 2.1 with a hematocrit of 29.6. neurology recommended a head ct. patient continued to work with rehab, however, he did drop his blood pressure to the 70s and 80s supine throughout the day on the 4th, and so no ambulation was attempted at that time given the instability of his blood pressure. he was slightly somnolent when this happened on the 4th at 5:45 p.m., and this happened after he came back from his ct scan. a blood gas was drawn at that time. his blood pressure rose, but he was a little bit somnolent. eeg was ordered for the morning. his lopressor was decreased pending his blood pressure changes. neurology examined him again and with recommendations for the eeg, and the patient was transferred from 2 back to csru pending a full neurologic examination. on the 5th, patient has eeg in the morning. white count dropped to 10.7. he was in sinus rhythm in 80s with blood pressure of 99/54 and a planned mra in the afternoon. neurology examined him again and noted a homonomous inferior quadrant autopsia on the left, but results were being weighted both the eeg and the mra. patient was back on neo-synephrine drip at 1.5 in the unit for blood pressure support. he remained mildly confused on the 6th. his examination was otherwise unremarkable. his creatinine stabilized to 2.0, which is below his baseline. on postoperative day seven, patient's neo-synephrine had been weaned down to 0.25 mcg/kg/minute. with no final report from his eeg, the decision made to hold on his mri given that his confusion cleared for assessment by the neurology service. early in the morning on the 8th, he was alert and oriented, very cooperative. he remained afebrile. his incisions were clean, dry, and intact. he was satting 99% on room air, using incentive spirometer and coughing and deep breathing. he had no ectopy and his blood pressure was stable, and his incisions were clean, dry, and intact, and he was transferred back out to the floor on the 8th off all drips. his examination continued to be unremarkable. he had no further confusion. on postoperative day nine, he continued to do his rehab. his foley was discontinued. he appeared to be neurologically intact. his creatinine rose slightly to 2.9, which was above his baseline. on postoperative day 10, he had no events. remained in sinus rhythm with a blood pressure of 90/62 and a pulse of 85. he was satting 99% on room air, again and appeared alert and oriented. the patient was transferred back to 2 on the 10th. he was pushing his own wheelchair and ambulating independently. incisions were clean, dry, and intact. he was in sinus rhythm in the 90s. patient had a chest x-ray, results were not back at the time, and they were waiting for the patient's daughter to arrive so they could speak to her. they were not sure if the patient would qualify for rehab, and the patient wanted to go home. these issues were worked out with the case manager. on postoperative day 11, the , the patient was discharged to home in stable condition with a temperature of 98.4, sinus rhythm at 88, blood pressure 144/77, satting 96% on room air. his heart was regular rate and rhythm. his lungs were clear bilaterally. his incisions were clean, dry, and intact. his abdominal exam was benign. he had no complaints of pain and was oriented. discharge medications: 1. colace 100 mg p.o. b.i.d. 2. aspirin 325 mg enteric coated p.o. q.d. 3. levothyroxine 25 mcg p.o. q.d. 4. atorvastatin 20 mg p.o. q.d. 5. combivent 13-18 mcg aerosol 1-2 puffs inhalation q.6h. prn. 6. tylenol 650 mg p.o. prn q.4h. 7. magnesium hydroxide 7.75% suspension 30 cc p.o. h.s. as needed for constipation. 8. bisacodyl 10 mg suppository rectally q.d. as needed for constipation. 9. protonix 40 in delayed release enteric coated p.o. q.24h. final results for the ct of the head that was performed on showed no intracranial pathology including no signs of intracranial hemorrhage. discharge diagnoses: 1. status post coronary artery bypass grafting x2. 2. status post prostate cancer with prostatectomy. 3. status post colon cancer with colectomy. 4. remote hepatitis b. 5. hypertension. 6. hypothyroidism. 7. status post fractured left clavicle and left rib fractures. 8. status post rhabdomyolysis from fracture injuries. 9. bilateral severe carotid stenosis. 10. left renal artery stenosis. disposition: again the patient was discharged to home on . , m.d. dictated by: medquist36 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart (Aorto)coronary bypass of one coronary artery Arterial catheterization Aortography Arteriography of renal arteries Diagnoses: Other iatrogenic hypotension Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Pneumonitis due to inhalation of food or vomitus Delirium due to conditions classified elsewhere Rhabdomyolysis

history of present illness: the patient is a 68-year-old male with no prior cardiac history who originally presented to his primary care physician because of an upper respiratory infection. during the examination, he was noted to have a murmur and was referred to a cardiologist for further evaluation. an echocardiogram was done in . the echocardiogram revealed preserved lv function with left ventricular hypertrophy, severe aortic stenosis with a p-gradient of 90, aortic valve area of 0.8. there was pulmonary hypertension with pulmonary systolic pressure of 40, moderate mitral regurgitation and left atrial enlargement. the patient denied any chest pain, shortness of breath or dizziness. however, according to his wife, she did notice him to be short of breath with moderate level of activity. the patient was consequently referred to cardiac catheterization for further evaluation. the patient denied any claudication, orthopnea, edema, paroxysmal nocturnal dyspnea or lightheadedness. past medical history: recent upper respiratory infection treated with antibiotic. allergies: no known drug allergies. medications: 1. aspirin 325 mg po q day 2. multivitamins 1 tablet q day admission laboratories: hematocrit 39.7, white blood cell count 9.9, platelets 212. inr 1.2, glucose 132, potassium 4.6. summary of hospital course: prior to admission, the patient had a cardiac catheterization performed. cardiac catheterization showed left ventricular ejection fraction of 49%. it also revealed mild pulmonary hypertension, severe central aortic hypertension with moderately increased ventricular filling pressure and mild mitral regurgitation. the patient was admitted to cardiac surgery for a possible surgical intervention. on , the patient underwent aortic valve replacement (minimally invasive) for his aortic stenosis. postoperative echocardiogram showed a left ventricular ejection fraction of more than 55%. the patient tolerated the procedure well. there were no complications. please see the full operative note for additional detail. the patient was transferred to the intensive care unit in stable condition. the patient remained intubated. the patient was in sinus rhythm while in the intensive care unit. he remained afebrile with stable blood pressures and heart rate. he was maintained on lasix, aspirin and lopressor. he was extubated on postoperative day 1. the patient was then transferred to the floor in stable condition. while on the floor, the patient was thought to be slightly confused. given a history of alcohol use, his symptoms and signs were carefully monitored. on postoperative day 2, the patient experienced atrial fibrillation with heart rate in the 140s. the patient was treated with iv lopressor. in addition, the patient was maintained on po lopressor dose. the patient converted to sinus rhythm on the next postoperative day, remained in sinus rhythm up until his discharge. his pacer wires were removed on postoperative day 2. physical therapy was following the patient throughout his hospitalization. he was cleared to go home without any additional services needed. discharge condition: stable discharge disposition: home discharge diagnoses: 1. aortic stenosis, status post aortic valve replacement 2. atrial fibrillation converted to sinus rhythm discharge medications: 1. lopressor 50 mg po bid 2. amiodarone 400 mg po tid 3. ibuprofen 400 mg po q6h prn 4. percocet 1 to 2 tablets po q 4 to 6 hours prn pain 5. aspirin ec 325 mg po q day 6. colace 100 mg po bid prn 7. lasix 20 mg po bid x7 days 8. potassium chloride 20 milliequivalents po bid x7 days 9. multivitamins 1 tablet q day discharge instructions: 1. the patient is to follow up with his cardiac surgeon, dr. , in approximately four weeks. 2. the patient is to follow up with his cardiologist, dr. , in approximately three to four weeks. 3. the patient is to follow up with his primary care physician, . in approximately one to two weeks. , m.d. dictated by: medquist36 Procedure: Extracorporeal circulation auxiliary to open heart surgery Open and other replacement of aortic valve Diagnoses: Atrial fibrillation Other chronic pulmonary heart diseases Mitral valve insufficiency and aortic valve stenosis

allergies: sulfa (sulfonamides) / codeine attending: chief complaint: cc: major surgical or invasive procedure: femoral catheterization and successful recanalization, pta, cryoplasty and stenting of the left sfa history of present illness: hpi: 71 yo f with h/o porcine avr, cabg (lima->lad), pvd presenting for elective angioplasty of left sfa lesion. previously, she was found by her cardiologist, to have a r abi of 0.59 and a left abi of 0.5 after complaining of bl claudication. she presented for elective angiography and pci of the left and was to return in 2 weeks for treatment of the r. this am, angiography revealed a left distal sfa lesion with diffuse disease to the proximal popliteal and proximal occlusion of the at and pt with reconstitution distally from collaterals. she received angioplasty, cryoplasty and stenting of the left sfa lesion from right femoral artery access. her sheath was subsequently removed at 11 am with minor oozing at the site of the wound. an act at the time was found to be 220, an ekg showed nsr with frequent pacs but no acute changes from prior to procedure. pressure was held for 30 minutes by the interventional fellow with attainment of hemostasis. 30 minutes later, the patient felt wet, and noticed bleeding at the site of the wound. pressure was again held at the site of the wound for 30 minutes. while holding pressure, she became persistently hypotensive hr 40s, sbp 60s. 1 amp of atropine was given and dopamine was given transiently. she became tachycardic to the 130s and developed sharp pain below her breasts r>l without radiation associated with nausea (no sob, diaphoresis). she denied having felt this pain before. she was given wide open fluids x 2 l, a hct was checked and found to be 33 (from her baseline of 40), and she was given a bolus of 1 unit of blood. her bp stabilized at 103/49 and her hr decreased to 104. her temp was 94, likely due to the ivf, and she was given warm blankets. her ruq abdominal/chest pain gradually resolved and she was subsequently transferred to the ccu. in the ccu, she reported resolution of her cp. no back pain. past medical history: avr porcine, lima-lad colon ca remote high cholesterol right hernia social history: widowed 2 years ago, lives alone. has no help at home. her son-in-law and daughter are close. remote occasional smoking history (40 years ago). no etoh. family history: no hx of cad physical exam: pe:t 97.3 hr 79 rr 19 100% ra bp 108/52 gen: wdwn woman lying flat in nad heent: perrl, op clear, mm dry neck: no carotid bruits cv: rrr, nl s1, s2, 2/6 systolic murmur best heard at lusb without radiation to apex or carotids lungs: ctab from chest abd: bs+, soft, nt, nd, no organomegaly ext: r femoral hematoma within marked space (~10x10 cm), 1+ r femoral pulse, dressing c/d/i, no bruit, l femoral pulse 2+, dopplerable dp and pt pulses bilaterally, dp>pt, no edema, warmth or swelling pertinent results: tte lvef 60%, la mild dilation, bioprosthetic aortic valve with normal function and mean gradient of 15 mm hg and peak of 27 mm hg with 1+ ar, severe mitral annular calcification with 2+ mr, 2+ tr , estimated pap of 29 mm hg. doppler evidence of diastolic dysfunction. . ekg pre-cath 0731 sr with pacs at 72, left anterior fascicular block, lvh, twi in i and avl, borderline lbbb with qrs 118 . ekg 14:22 nsr at 76, lafb, lvh, twi in i and avl, borderline lbbb with qrs 116 femoral cath report procedure: peripheral catheter placement was performed. peripheral imaging was performed. peripheral pta was performed. peripheral stenting was performed. conscious sedation: was provided with appropriate monitoring performed by a member of the nursing staff. hemodynamics results body surface area: m2 hemoglobin: gms % fick **pressures aorta {s/d/m} 144/60/90 **ptca results ptca comments: initial angiography showed a distally occluded left sfa. we planned to recanalize the vessel. heparin was used for anticoagulation. a 7 french sheath was advanced around the into the left sfa. the lesion was crossed with an angled glidewire which was then exchanged for a filterwire. the lesion was dilated with a 4.0x80 mm amphirion balloon at 2-4 atm. next, the lesion was treated with cryoplasty using a 5.0x60 mm polar catheter for multiple inflations. angiography showed a residual dissection which was covered with a 6.0x56 mm dynalink stent, post-dilated with a 5.0x40 mm submarine balloon at 8 atm. final angiography showed a 20% residual stenosis, no dissection and normal flow. the patient left the lab in stable condition. technical factors: total time (lidocaine to test complete) = 1 hour 31 minutes. arterial time = 1 hour 31 minutes. fluoro time = 20 minutes. contrast: non-ionic low osmolar (isovue, optiray...), vol 175 ml, indications - hemodynamic anesthesia: 1% lidocaine subq. anticoagulation: heparin 2500 units iv other medication: benadryl 25 mg iv fentanyl 25 mcg iv midazolam 0.5 mg iv cardiac cath supplies used: 7f cook, , 55 200cc mallincrodt, optiray 200cc 150cc mallincrodt, optiray 150cc 4 ev3, amphirion, 80 5 ev3, submarine plus, 40 6 guidant, dynalink .018, 100 - , filter wire ez 300 cm 5 , polarcath balloon .014, 20 - , polarcath inflation unit comments: 1. access was obtained via the right cfa in a retrograde fashion. 2. resting hemodynamics showed mild central aortic hypertension. 3. abdominal aorta: diffuse moderate disease. 4. renal arteries: single bilaterally without lesions. 5. right lower extremity: the cia, eia, iia and cfa were widely patent. 6. left lower extremity: the cia, eia, iia and cfa were widely patent. the distal sfa had diffuse disease and was occluded at canal up to the proximal popliteal. the pa was the principle vessel to the foot with the at and pt proximally occluded and reconstitution distally via collaterals. 7. successful recanalization, pta, cryoplasty and stenting of the left sfa with a 6.0 mm dynalink stent, post-dilated to 5.0 mm. femoral vascular ultrasound report: there is normal flow on color flow from the right common femoral vein and artery. no evidence of hematoma, pseudoaneurysm or av fistula is identified. brief hospital course: 71 yo f with h/o porcine avr, cabg (lima->lad), pvd s/p pci of left distal sfa lesion complicated by r groin bleed/hematoma with hct drop of 7. . #. hct drop with groin bleed - patient with rapid hct drop of 7 from 40 to 33 in the setting of r groin bleed and development of hematoma. received 2 l of ns and 2 units of blood, and was hemodynamically stable on transfer to the micu. her metoprolol and digoxin were held. no evidence of rp bleed. a right femoral ultrasound showed no evidence of hematoma, pseudoaneurysm or av fistula. her hematocrit remained stable and there was no evidence of repeat bleeding with serial exams. she was restarted on her metoprolol xl 25 mg qd and tolerated it well. her digoxin was held as her heart rate was well controlled and she had no evidence of heart failure. . #. chest/ruq and epigastric abdominal pain (burning) with nausea- this was in the setting of the dopamine drip and hct drop and may have been demand ischemia, though her cardiac enzymes were flat x 3 and there were no ekg changes. she was given protonix, maalox, anzemet and tums, and the pain resolved. - start on omeprazole 40 qd . #. pvd - following her intervention, her distal pulses remained dopplerable bilaterally. she is scheduled to return in weeks for angiography and possible intervention in her rle. - continue asa and plavix indefinitely . #. ischemia - patient s/p cabg (lima-> lad 10 years ago). no recent cath. no ekg changes with her chest/abdominal pain. her cardiac enzymes were cycled and were flat x 3. - continue asa and plavix indefinitely - restart metoprolol xl 25 mg qd . #. pump - last tte in showed lvef 60%, 1+ ar with porcine valve, 2+ mr and 2+ tr, and evidence of diastolic dysfunction. - continue metoprolol 25 mg po qd - hold digoxin with no evidence of failure and well-controlled heart rate . #. rhythm - sr, occasional pacs on telemetry medications on admission: admission meds: metoprolol xl 25 mg qd digoxin 125 mcg qd ecasa 325 mg qd mvi lipitor 10 mg qd plavix 75 mg qd . transfer meds: toprol xl 25 qd dig 125 mcg qd ecasa 325 mg qd plavix 75 mg qd mvi lipitor 10 mg qd tylenol prn ntg sl prn simethicone prn discharge medications: 1. aspirin 325 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*0 tablet(s)* refills:*0* 4. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. 5. multi-vitamin tablet sig: one (1) tablet po once a day. 6. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: peripheral vascular disease s/p revascularization and stenting of left sfa/popliteal lesion right femoral bleed discharge condition: patient is doing well, hemodynamically stable, no chest pain, ambulating without difficulty discharge instructions: 1. please take all medications as prescribed. you must take your aspirin and plavix every day. 2. please keep all follow-up appointments. 3. please seek medical attention if you develop chest pain, shortness of breath, abdominal pain, recurrent or worsened claudication of the left foot, a larger hematoma, bleeding, lightheadedness or have any other concerning symptoms. 4. please refrain from heavy lifting or vigorous activity for 2 weeks. 5. please refrain from driving until at least 3 days after discharge from the hospital (after wednesday, ). followup instructions: return in weeks for angiography and intervention on the right leg. please follow-up with dr. at ( in weeks. please follow-up with dr. at ( in weeks. Procedure: Angioplasty of other non-coronary vessel(s) Arteriography of femoral and other lower extremity arteries Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transfusion of packed cells Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Other iatrogenic hypotension Coronary atherosclerosis of native coronary artery Atherosclerosis of native arteries of the extremities with intermittent claudication Aortocoronary bypass status Accidental puncture or laceration during a procedure, not elsewhere classified Other and unspecified hyperlipidemia Personal history of malignant neoplasm of large intestine Heart valve replaced by transplant Emphysema (subcutaneous) (surgical) resulting from procedure Chest pain, unspecified

history of present illness: this is the discharge summary covering the entire hospitalization of , baby boy on at 34 weeks gestation. ii, para 0,2,2 mom. pregnancy was complicated by preterm labor and cervical shortening. cerclage was placed at 19 weeks. mom was admitted to labor and delivery at 23 and 1/2 weeks gestation in preterm labor. she was treated with betamethasone and magnesium sulfate. she was on the antepartum floor since and 1/2 weeks gestation, up to the time of the infant's birth. prenatal screens were blood type a positive, antibody negative, hepatitis b surface antigen negative, rpr nonreactive and rubella immune. delivery room course was remarkable for an infant who emerged with some spontaneous effort but minimal respiratory effort. the infant was given bag mask ventilation for five to ten breaths, with a good response, and was transported to the neonatal intensive care unit. the apgars were six and eight respectively. the infant was transferred to the neonatal intensive care unit due to prematurity. in the neonatal intensive care unit, the infant was found to be grunting, flaring and retracting with an oxygen requirement and a clinical picture consistent with surfactant deficiency. hospital course will be outlined below following the physical examination. physical examination: at the time of admission, the infant was a normal appearing 34 week infant with tone and maturity and activity consistent with gestational age. the skin was pink and clear, without rashes or petechiae. the anterior fontanel was open, flat and soft. there were bilateral red reflexes. the palate was intact. the thorax was within normal limits. the chest examination revealed grunting, flaring, retracting infant with moderate degree of respiratory distress and inspiratory crackles noted. cardiac examination revealed normal s1 and s2, without murmurs, regular rate and rhythm and 2+ distal pulses bilaterally abdomen examination was soft, nontender, nondistended without any hepatosplenomegaly. genitourinary examination revealed normal male infant with descended testicles. the anus was patent. the trunk and spine were straight without evidence of defect. extremities were well perfused and there was no evidence of a click on hip distraction. the infant had normal tone and reflexes for gestational age. the birth weight was 2,765 grams which is around the 75th percentile for gestational age. length was 45 cms which is the 50th percentile for the gestational age. head circumference is 33.5 cms which is around the 95th percentile for gestational age. hospital course: the infant's hospital course was significant for the following, by problem: 1.) respiratory. initial impression was surfactant deficiency. the infant received one dose of surfactant, was intubated and placed on synchronized mechanical ventilation. this lasted for less than 24 hours, after which he was subsequently taken to room air with minimal difficulty and he has been on room air since that time. there is no evidence of chronic lung disease and no supplemental oxygen requirement currently. in terms of respiratory drive, has exhibited no signs of apnea of prematurity and has never been on any methylxanthines. 2.) cardiovascular. the infant had no indication of murmur. he has had a normal cardiac examination throughout his hospital course. 3.) fluid, electrolytes and nutrition. the infant had initial electrolytes of sodium of 135; potassium of 5.2; chloride 103, bicarbonate 20. he has not had repeat electrolytes since he has remained stable. he was started on d-10-w and kept n.p.o. initially for respiratory distress. his feedings were slowly advanced over the course of his first week of life. he has been on full feeds for over a week and has been tolerating these without problems. is taking all of his feedings p.o. he has been having very acceptable weight gain, taking either mother's milk or enfamil 20. he is getting .2 cc of fer-in- daily. 4.) gastrointestinal. the infant had peak bilirubin of 9.9 on the . he never required phototherapy. he is voiding and stooling without difficulty. 5.) hematology. the infant had a hematocrit of 49.4 on admission and a platelet count of 234. this has not been repeated. he remains on iron as mentioned above. 6.) infectious disease. the infant had initial white blood cell count of 20.8; 25% neutrophils, 1% bands, 18.5 lymphocytes. there was minimal concern for sepsis. he did receive two days of ampicillin and gentamycin empirically for possible sepsis, but cuture remained negative. 7.) neurologic. he was above the age necessary for screening ultrasound. he has been appropriate from a neurologic standpoint, exhibiting mature sensory respiratory drive right from birth. he has a flat fontanel and normal tone for gestational age. 8.) sensory. a.) audiology. a hearing screen was performed with automated auditory brain stem responses. the infant had normal results from this. b.) ophthalmology. this infant did require an examination for prematurity since he was above 34 weeks gestation and had a good weight. condition at discharge: good. discharge disposition: home. primary pediatrician: dr. , pediatrics. care recommendations: a.) feedings at discharge: this infant should be taking mother's milk or enfamil 20 calories per ounce, four to five with iron, on an ad lib basis. b.) medications: fer-in- 0.2 cc p.o. daily. c.) car seat position screening was done and there were no concerns noted. d.) this infant received one dose of synagis and also his hepatitis b vaccine. e.) immunizations recommended: synagis rsv prophylaxis, this should be considered from through for infant's who meet any of the following three criteria: (1) at less than 32 weeks. (2) between 32 and 35 weeks with plans for day care during rsv season, with a smoker in the household or with preschool siblings. (3) chronic lung disease. influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease, once they reach six months of age. before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. f.) follow-up appointment scheduled and recommended. this infant has a follow-up appointment tomorrow morning with dr. at pediatrics. phone number is . fax # is . discharge diagnoses: 1. 34 week premature infant, now corrected to about 36 weeks gestation. 2. history of respiratory distress, now resolved. 3. history of sepsis evaluation, now resolved. , m.d. dictated by: medquist36 d: 06:08 t: 18:05 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Prophylactic administration of vaccine against other diseases Circumcision Diagnoses: Need for prophylactic vaccination and inoculation against viral hepatitis Observation for suspected infectious condition Twin birth, mate liveborn, born in hospital, delivered by cesarean section Other preterm infants, 2,500 grams and over Other respiratory problems after birth Routine or ritual circumcision

history of present illness: a 34-year-old male status post high speed motor vehicle crash unrestrained driver. there was some loss of consciousness. he was verbal at the scene with altered mental status. he was intubated at the scene and brought to the . he was hemodynamically stable upon arrival. past medical history: noncontributory. allergies: no known drug allergies. medications: none. physical examination: temperature 98.8, heart rate 88, blood pressure 150/palp, 99% with an endotracheal tube in place. coma score of 3. heent: pupils are equal, round, and reactive to light 3 mm bilaterally. two cm laceration in the right forehead, tympanic membrane clear. lungs: decreased breath sounds on the left side. cor: regular, rate, and rhythm. rectal: guaiac negative. pelvis: stable. extremities: no deformities. palpable pulses. laboratory data: hematocrit 40, white blood cell count 25, platelets 312, inr 1.1. electrolytes were within normal limits. chest x-ray revealed a wide mediastinum and a collapsed right lower lobe and a left pneumothorax. pelvis x-ray was negative. head ct scan showed a left frontal subarachnoid hemorrhage. c spine film showed a very slight c4-c5 anterolisthesis with no fractures. chest ct scan showed a right lower lobe collapse, aorta was okay. abdominal ct scan was negative. the patient was admitted to the intensive care unit for critical care and had bilateral chest tubes placed. neurosurgery consult was obtained for the subarachnoid hemorrhage. they repeated a head ct scan in 24 hours which showed no expansion. .................... cardiology consult was obtained. echocardiogram was done which revealed no evidence of tamponade. the patient had multiple bronchoscopies performed with significant suctioning of mucus. neurosurgery had initially placed an intracranial pressure monitor for the subarachnoid hemorrhage. due to icps well controlled, the monitor was removed. the patient was extremely difficult to wean off the ventilator. it was thought that he had an aspiration event. per neurosurgery recommendation, subq heparin was started on , based on the head ct scan readings. patient had an evolving ards picture which required prolonged intubation. patient was agitated and difficult to extubate. he was finally extubated on . he was transferred to the surgical floor on . nutrition consult was obtained. tube feedings were started. after the modified barium swallow test was passed, the patient was started on regular diet. patient was worked with aggressively with occupational and physical therapy services. patient was stable at the time of discharge. the condition on discharge was stable. discharge medications: aspirin 81 mg q day, subq heparin 5,000 units . discharge status: rehabilitation facility. followup: the patient is to followup .................... in two weeks. discharge diagnoses: status post motor vehicle crash with left subarachnoid hemorrhage found with thoraces, prolonged intubation aspiration. , m.d. 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 Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Closed [endoscopic] biopsy of bronchus Gastric lavage Pulmonary artery wedge monitoring Suture of laceration of lip Linear repair of laceration of eyelid or eyebrow Other diagnostic procedures on brain and cerebral meninges Diagnoses: Pneumonitis due to inhalation of food or vomitus Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Contusion of lung without mention of open wound into thorax Cerebellar or brain stem contusion without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Traumatic shock Pneumonia due to Streptococcus, unspecified Laceration of skin of eyelid and periocular area Open wound of lip, without mention of complication

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: cold numb rt. leg below knee major surgical or invasive procedure: laser thrombectomy to atheromatous debris of both vessels balloon angioplasty cardiac cath past medical history: 67 y/o with hx. cad s/p cabg (all grafts occluded), lad stenting , pvd s/p lt. carotid stenting , pmr, htn, hcl, who presented with acute onset of n/v/d while at a casino last evening. this was her anginal equivalent in the past, so she became concerned for new mi. shortly thereafter, she noted that her legs felt weak, that her rt. foot was numb, white, and she couldnt move it. she presented to the ed and was found to have a cold, white, pulseless foot. sx. was consulted and felt that she should go emergently to catheterization. heparin gtt was started. on evaluation by the intverventionalist fellow in the ed, she had already regained some color of the foot, with some blanching, and return of sensation to normal. rt. dp and pt were faintly dopplerable at this time. . in the cath lab (retro lfa to the coronaries and contralateral pt and dp) she was found to have: . ao: 70% ulcerated vessels at the bifurcation renals: bilateral single vessels with rt. 90% lesion rt le: cia and eia normal, cfa and sfa normal. popliteal free of disease. rt. at occluded mid vessel with pt occluded proximally (both from the patent pa). she underwent laser thrombectomy catheter to atheromatous debris of both vessels, and then balloon angioplasty to the same with return of flow. . coronary anatomy as follows: lmca normal lad previous stent patent, mid segment 70% lesion with bifurcation d2 lcx: non-dominant without critical lesion; om2 60% lesion after bifurcation rca dominant with proximal occlusion; distal l to r collaterals remain , optiray 312 ml. she got a dose of mucomyst prior to prodcedure and normal saline gtt was started for planned total 2 l social history: social history is significant for the absence of current tobacco use. family history: there is no family history of premature coronary artery disease or sudden death. physical exam: blood pressure was 143/90 mm hg while supine. pulse was 73 beats/min and regular, respiratory rate was 12 breaths/min. generally the patient was well developed, well nourished and well groomed. the patient was oriented to person, place and time. the patient's mood and affect were not inappropriate. . there was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. the neck was supple with jvp of 6 cm. the carotid waveform was normal. there was no thyromegaly. the were no chest wall deformities, scoliosis or kyphosis. the respirations were not labored and there were no use of accessory muscles. the lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . palpation of the heart revealed the pmi to be located in the 5th intercostal space, mid clavicular line. there were no thrills, lifts or palpable s3 or s4. the heart sounds revealed a normal s1 and the s2 was normal. there were no rubs, murmurs, clicks or gallops. . the abdominal aorta was not enlarged by palpation. there was no hepatosplenomegaly or tenderness. the abdomen was soft nontender and nondistended. the extremities had no pallor, cyanosis, clubbing or edema. there were no abdominal, femoral or carotid bruits. inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ brief hospital course: 67 y/o with hx. cad and pvd s/p cabg and carotid stenting p/w cold rt. foot. her active issues during this hospital course includes: . ## acute thromboembolic occlusion of right and left le: pt s/p thrombectomy/atherectomy and balloon angioplasty. initially, pt. had significant bleeding at sheath post procedure requiring advancement of sheath to hub and pressure dressings, manual pressure; heparin stopped, but integrilin continued. she was able to amubulate well. the next day, she then underwent thrombectomy/atherectomy of left with good results bilaterally. she was discharged on asa, plavix and lovenox bridge to coumadin. . . outpatient follow-up: pt was instructed to have her inr checked by vna and faxed to dr. office, who will be managing her coumadin. dr. was notified. . appointments were made for additional imaging as per dr. . medications on admission: asa plavix metoprolol 50 allopurinol colchicine hctz discharge medications: 1. enoxaparin 80 mg/0.8 ml syringe sig: one (1) subcutaneous q12h (every 12 hours) for 4 days. disp:*8 syringes* refills:*2* 2. aspirin 325 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. allopurinol 300 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 7. colchicine 0.6 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). disp:*30 tablet(s)* refills:*2* 8. warfarin 5 mg tablet sig: one (1) tablet po hs (at bedtime) for 3 doses: please take on evening of and . disp:*2 tablet(s)* refills:*0* 9. warfarin 2 mg tablet sig: one (1) tablet po hs (at bedtime): please start on evening of . disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary: peripheral disease coronary artery disease . secondary: hypertension dyslipidemia discharge condition: stable, ambulating, pain free discharge instructions: you had clots in the arteries in your leg which required urgent intervention and thrombectomy. . please call 911 or go to the emergency room if you have any symptoms of foot/leg pain, coolness, numbness in your extremities, chest pain, shortness of breath, palpatations, or any other concerning symptoms. . please take all medications as prescribed. . in addition, you will need to take blood thinners. there are two medications. 1) coumadin is the oral blood thinner and you will need to have your blood levels checked regularly to ensure that the level is within range. too high or too low levels can be dangerous. please have your coumadin levels checked by the visiting nurses. make sure that they fax the results to dr. office. he wil adjust the dose for you. 2) while your coumadin levels become therapeutic, you will need to take injections of an immediate acting blood thinner called lovenox. once your coumadin level is within range, you will not need to take lovenox any more. followup instructions: please attend all follow-up appointments as noted below: provider: phone: date/time: 9:30 provider: study phone: date/time: 1:30 provider: , m.d. phone: date/time: 4:00 Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Angioplasty of other non-coronary vessel(s) Angioplasty of other non-coronary vessel(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transfusion of packed cells Insertion of three vascular stents Procedure on two vessels Destruction of cranial and peripheral nerves Procedure on three vessels Procedure on vessel bifurcation Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Polymyalgia rheumatica Unspecified essential hypertension Coronary atherosclerosis of autologous vein bypass graft Atherosclerosis of aorta Gout, unspecified Other and unspecified hyperlipidemia Hemorrhage complicating a procedure Old myocardial infarction Arterial embolism and thrombosis of lower extremity Atherosclerosis of native arteries of the extremities with rest pain

allergies: lipitor / zocor attending: addendum: see discharge summary chief complaint: the patient is a 69-year-old woman who had undergone an x-ray for shoulder pain that had disclosed bilateral lung abnormalities. a ct scan was performed and confirmed a solid nodule in the superior segment of her left lower lobe highly suspicious for malignancy as well as a bulla in the right lower lobe with a thickened cyst wall also concerning for malignancy. a pet scan was performed subsequent to the ct scan. this showed that the left lower lobe nodule showed an suv of 16.4 as well as a left hilar node with an uptake of 9.6. the lesion in the right lower lobe showed an suv of 7.5, also suspicious for malignancy. there was no other site of fdg avidity on the study. she also underwent an mri scan on , that was negative for metastatic disease. in addition, a pft was performed in disclosing fev1 of 133% of predicted and a diffusion capacity of 82% of predicted. dr. performed a mediastinoscopy as well as bronchial brushing on . the mediastinoscopy was negative for carcinoma. the bronchial brushing of the left lower lobe superior segment was also negative. the lesions in her right lower and left lower lobe are likely to represent synchronous primary lung cancers rather than stage iv disease based upon a negative mediastinoscopy and no signs of metastatic disease on her pet/ct scan. as a result, on , a left vats converted to a left anterior thoracotomy, a resection of superior segment of the left lower lobe, and a mediastinal lymph node dissection were all performed. a right lower lobectomy is actively being considered as a future treatment option. major surgical or invasive procedure: : left vats converted to left anterior thoracotomy, resection of superior segment of the left lower lobe, mediastinal lymph node dissection history of present illness: the patient is a 69-year-old woman who had undergone an x-ray for shoulder pain that had disclosed bilateral lung abnormalities. a ct scan was performed and confirmed a solid nodule in the superior segment of her left lower lobe highly suspicious for malignancy as well as a bulla in the right lower lobe with a thickened cyst wall also concerning for malignancy. a pet scan was performed subsequent to the ct scan. this showed that the left lower lobe nodule showed an suv of 16.4 as well as a left hilar node with an uptake of 9.6. the lesion in the right lower lobe showed an suv of 7.5, also suspicious for malignancy. there was no other site of fdg avidity on the study. she also underwent an mri scan on , that was negative for metastatic disease. in addition, a pft was performed in disclosing fev1 of 133% of predicted and a diffusion capacity of 82% of predicted. dr. performed a mediastinoscopy as well as bronchial brushing on . the mediastinoscopy was negative for carcinoma. the bronchial brushing of the left lower lobe superior segment was also negative. the lesions in her right lower and left lower lobe are likely to represent synchronous primary lung cancers rather than stage iv disease based upon a negative mediastinoscopy and no signs of metastatic disease on her pet/ct scan. as a result, on , a left vats converted to a left anterior thoracotomy, a resection of superior segment of the left lower lobe, and a mediastinal lymph node dissection were all performed. a right lower lobectomy is actively being considered as a future treatment option. past medical history: 1. coronary artery disease - mi x3 with her first mi at age 34. the patient underwent a cabg in . status post lad drug-eluting stent in . she is followed by dr. . 2. peripheral vascular disease status post angioplasty of the right leg - 3. chronic kidney disease 4. renal artery stenosis status post right renal artery stent- 5. carotid stenosis status post left internal carotid stent- 08/. 6. gout 7. polymyalgia rheumatica 8. hypertension 9. hypercholesterolemia 10. osteoarthritis 11. endometrial polyps- the patient has been followed by dr. . 12. gi bleed secondary to diverticulosis 13. urinary incontinence social history: the patient is married and lives with her husband in . she is retired from doing secretarial work, but in this setting was exposed to both tobacco smoke and diesel fumes. she smoked two packs per day for 20 years, but quit in . no alcohol. she does not use an assistive device. she walks for exercise. family history: the patient's father died of cad as did her mother. two brothers have cad. a sister has had multiple tias. physical exam: general: well-appearing anxious appearing elderly lady in no apparent distress. alert. engaged in conversation. moves steadily without the aid of an assistive device. heent: normocephalic, atraumatic. pupils equal, round and reactive to light. extraocular motion intact. anicteric sclerae. moist mucous membranes. no lesions in the oropharynx. clear tympanic membranes bilaterally with normal light reflex. minimal cerumen. neck: supple. no cervical or supraclavicular lymphadenopathy. no appreciable thyromegaly or thyroid nodules. cardiac: regular rate and rhythm. s1, s2. no murmurs, rubs, or gallops. no carotid bruits. pulmonary: good effort. clear to auscultation bilaterally. no wheezes, rales, or rhonchi. abdomen: obese. soft. nontender. nondistended. positive bowel sounds. no appreciable masses or hepatosplenomegaly. extremities: warm. no clubbing, cyanosis, or edema. 1+ dorsalis pedis pedal pulses bilaterally. neurologic: cranial nerves ii through xii intact. able to perform the get up and go test without difficulty. negative romberg. breasts: without dimpling or puckering of the skin. no appreciable masses. no nipple discharge. no axillary lymphadenopathy. pertinent results: wbc-8.0 rbc-3.15* hgb-9.2* hct-27.9* plt ct-352# wbc-8.3 rbc-2.74* hgb-8.1* hct-24.4* plt ct-230 wbc-13.2* rbc-3.97* hgb-12.0 hct-36.1 plt ct-365 glucose-91 urean-27* creat-1.1 na-140 k-4.1 cl-106 hco3-25 glucose-172* urean-37* creat-1.5* na-137 k-4.0 cl-108 hco3-15* inr 2.8 inr 3.8 inr 1.9 inr 1.3 cxr impression: 1. status post left chest tube removal, with no pneumothorax. 2. improved right lung aeration with persistent left basilar atelectasis or consolidation. echocardiogram: the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with basal to mid inferior and infero-lateral hypokinesis. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: the patient is a 68 year old female who on had a left vats converted to left anterior thoracotomy, a resection of superior segment of the left lower lobe, and a mediastinal lymph node dissection. she developed postoperative atrial fibrillation with a rapid ventricular rate soon afterwards and her blood pressure was initially 80/40, leading to a transfer to the intensive care unit. by , the patient had rate stabilized at around 110-120 and her pressures was around 109/47. amiodarone had begun being loaded as per cardiology recommendations and so it was felt, ms. could be transferred to the floor. after coming to the floor, ms. gradually improved clinically though with persistence of her atrial fibrillation. as per cardiology recommendations, on an initial dose of warfarin was given along with heparin anticoagulation. on , she developed rapid a fib into the 130s. her lopressor was increased to 37.5 which she converted to sinus rhythm. cardiology was reconsulted and felt she had tachy-brady syndrome, and recommended she be discharged home with of hearts monitor which was arranged. on her inr was 3.8 the coumadin was held and a repeat inr on was 2.8. she was discharged to home with coumadin 1 mg and to follow-up with dr. her pcp for further coumadin dosing, follow-up with cardiology dr.. and dr. as an outpatient. medications on admission: atacand hct 16-12.5 mg daily, clopidogrel 75 mg daily, imdur 15 mg daily, prednisone 10 mg daily, allopurinol 300 mg qpm, lopressor 50 mg , simvastatin 10 mg daily, tng 0.3 prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po once a day. 2. atacand hct 16-12.5 mg tablet sig: one (1) tablet po once a day. 3. clopidogrel 75 mg tablet sig: one (1) tablet po once a day. 4. imdur 30 mg tablet sustained release 24 hr sig: tablet sustained release 24 hr po once a day. 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual q5min as needed for chest pain. disp:*30 units* refills:*2* 6. prednisone 10 mg tablet sig: one (1) tablet po once a day. 7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 8. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 9. metoprolol tartrate 25 mg tablet sig: tablet po bid (2 times a day). disp:*75 tablet(s)* refills:*2* 10. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* 11. outpatient lab work ---please check inr twice a week. goal inr is between 2 and 3. please call pcp with results. 12. allopurinol 100 mg tablet sig: one (1) tablet po once a day. 13. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily) for 7 days: please take starting for exactly 1 week. disp:*14 tablet(s)* refills:*0* 14. amiodarone 200 mg tablet sig: one (1) tablet po once a day for 18 days: please talk to your primary care provider about getting refill after this course of medication complete. disp:*18 tablet(s)* refills:*0* 15. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 1. atacand hct 16-12.5 mg tablet sig: one (1) tablet po once a day. 2. clopidogrel 75 mg tablet sig: one (1) tablet po once a day. 3. imdur 30 mg tablet sustained release 24 hr sig: tablet sustained release 24 hr po once a day. 4. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual q5min as needed for chest pain. disp:*30 units* refills:*2* 5. prednisone 10 mg tablet sig: one (1) tablet po once a day. 6. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* 7. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 8. metoprolol tartrate 25 mg tablet sig: tablet po bid (2 times a day). disp:*75 tablet(s)* refills:*2* 9. outpatient lab work ---please check inr twice a week. goal inr is between 2.0-2.5 please call pcp with results. 10. allopurinol 100 mg tablet sig: one (1) tablet po once a day. 11. amiodarone 200 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 12. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 13. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 14. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 15. coumadin 1 mg tablet sig: one (1) tablet po as directed to maintain inr 2.0-2.5. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: left lower lobe lung nodule. coronary artery disase s/p mi x 3 perpheral vascular disease hypertension/hyperlipidemia, gout, polymyalgia rheumatica psh: pci x several, l carotid stent, aortic stent, renal stents, s/p ccy discharge condition: good discharge instructions: call dr. office if experience: -fever > 101 or chills -increased shortness of breath, or cough -chest pain -incision develops redness or drainage -or if you have any symptoms that concern you. coumadin for atrial fibrillation: inr goal 2.0-2.5 call dr. office for coumadin dosing. blood draw on at the coumadin clinic. followup instructions: follow-up with dr. on at 11:30am on the clinical center, . follow-up with dr. on at 2:30pm clinical center. follow-up with dr. on at 3:30pm clinical center report to the 4th radiology department for a chest x-ray 45 minutes before your appointment. follow-up with dr. for further coumadin dosing. (the office has been notified). also please call at for an appointment on wednesday to have your inr checked and coumadin assessed. call dr. office (cardiology) for follow-up appointment. md Procedure: Division or crushing of other cranial and peripheral nerves Regional lymph node excision Other and unspecified segmental resection of lung Diagnoses: Polymyalgia rheumatica Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Old myocardial infarction Sinoatrial node dysfunction Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Malignant neoplasm of lower lobe, bronchus or lung Thoracoscopic surgical procedure converted to open procedure

allergies: lipitor / zocor attending: chief complaint: left lower lobe nodule major surgical or invasive procedure: : left vats converted to left anterior thoracotomy, resection of superior segment of the left lower lobe, mediastinal lymph node dissection history of present illness: the patient is a 69-year-old woman who had undergone an x-ray for shoulder pain that had disclosed bilateral lung abnormalities. a ct scan was performed and confirmed a solid nodule in the superior segment of her left lower lobe highly suspicious for malignancy as well as a bulla in the right lower lobe with a thickened cyst wall also concerning for malignancy. a pet scan was performed subsequent to the ct scan. this showed that the left lower lobe nodule showed an suv of 16.4 as well as a left hilar node with an uptake of 9.6. the lesion in the right lower lobe showed an suv of 7.5, also suspicious for malignancy. there was no other site of fdg avidity on the study. she also underwent an scan on , that was negative for metastatic disease. in addition, a pft was performed in disclosing fev1 of 133% of predicted and a diffusion capacity of 82% of predicted. dr. performed a mediastinoscopy as well as bronchial brushing on . the mediastinoscopy was negative for carcinoma. the bronchial brushing of the left lower lobe superior segment was also negative. the lesions in her right lower and left lower lobe are likely to represent synchronous primary lung cancers rather than stage iv disease based upon a negative mediastinoscopy and no signs of metastatic disease on her pet/ct scan. as a result, on , a left vats converted to a left anterior thoracotomy, a resection of superior segment of the left lower lobe, and a mediastinal lymph node dissection were all performed. a right lower lobectomy is actively being considered as a future treatment option. past medical history: 1. coronary artery disease - mi x3 with her first mi at age 34. the patient underwent a cabg in . status post lad drug-eluting stent in . she is followed by dr. . 2. peripheral disease status post angioplasty of the right leg - 3. chronic kidney disease 4. renal artery stenosis status post right renal artery stent- 5. carotid stenosis status post left internal carotid stent- 08/. 6. gout 7. polymyalgia rheumatica 8. hypertension 9. hypercholesterolemia 10. osteoarthritis 11. endometrial polyps- the patient has been followed by dr. . 12. gi bleed secondary to diverticulosis 13. urinary incontinence social history: the patient is married and lives with her husband in . she is retired from doing secretarial work, but in this setting was exposed to both tobacco smoke and diesel fumes. she smoked two packs per day for 20 years, but quit in . no alcohol. she does not use an assistive device. she walks for exercise. family history: the patient's father died of cad as did her mother. two brothers have cad. a sister has had multiple tias. physical exam: general: well-appearing anxious appearing elderly lady in no apparent distress. alert. engaged in conversation. moves steadily without the aid of an assistive device. heent: normocephalic, atraumatic. pupils equal, round and reactive to light. extraocular motion intact. anicteric sclerae. moist mucous membranes. no lesions in the oropharynx. clear tympanic membranes bilaterally with normal light reflex. minimal cerumen. neck: supple. no cervical or supraclavicular lymphadenopathy. no appreciable thyromegaly or thyroid nodules. cardiac: regular rate and rhythm. s1, s2. no murmurs, rubs, or gallops. no carotid bruits. pulmonary: good effort. clear to auscultation bilaterally. no wheezes, rales, or rhonchi. abdomen: obese. soft. nontender. nondistended. positive bowel sounds. no appreciable masses or hepatosplenomegaly. extremities: warm. no clubbing, cyanosis, or edema. 1+ dorsalis pedis pedal pulses bilaterally. neurologic: cranial nerves ii through xii intact. able to perform the get up and go test without difficulty. negative romberg. breasts: without dimpling or puckering of the skin. no appreciable masses. no nipple discharge. no axillary lymphadenopathy. pertinent results: 09:31pm urine hours-random creat-114 sodium-57 08:36pm type-art po2-84* pco2-45 ph-7.26* total co2-21 base xs--6 08:36pm lactate-3.7* 08:36pm o2 sat-94 08:36pm freeca-1.24 08:09pm glucose-167* urea n-38* creat-1.7* sodium-137 potassium-4.3 chloride-107 total co2-18* anion gap-16 08:09pm ck(cpk)-865* 08:09pm ck-mb-10 mb indx-1.2 ctropnt-0.06* 08:09pm calcium-9.4 phosphate-4.7* magnesium-2.3 08:09pm wbc-12.3* rbc-3.45* hgb-10.5* hct-31.6* mcv-92 mch-30.4 mchc-33.2 rdw-15.8* 08:09pm plt count-367 02:32pm type-art po2-78* pco2-41 ph-7.27* total co2-20* base xs--7 02:32pm glucose-165* 02:32pm freeca-1.35* 02:17pm glucose-172* urea n-37* creat-1.5* sodium-137 potassium-4.0 chloride-108 total co2-15* anion gap-18 02:17pm estgfr-using this 02:17pm ck(cpk)-416* 02:17pm ck-mb-6 ctropnt-0.04* 02:17pm calcium-10.5* phosphate-4.4 magnesium-2.6 02:17pm wbc-13.2* rbc-3.97* hgb-12.0 hct-36.1 mcv-91 mch-30.2 mchc-33.2 rdw-15.4 02:17pm plt count-365 12:07pm type-art po2-274* pco2-33* ph-7.38 total co2-20* base xs--4 intubated-intubated 12:07pm glucose-173* lactate-3.8* na+-137 k+-3.9 cl--107 12:07pm hgb-12.4 calchct-37 o2 sat-99 12:07pm freeca-1.09* 10:40am type-art po2-233* pco2-36 ph-7.42 total co2-24 base xs-0 10:40am glucose-143* lactate-2.2* na+-138 k+-3.6 cl--104 10:40am hgb-12.1 calchct-36 o2 sat-99 10:40am freeca-1.19 09:23am type-art po2-78* pco2-46* ph-7.34* total co2-26 base xs--1 intubated-intubated 09:23am glucose-122* lactate-1.2 na+-139 k+-3.7 cl--104 09:23am hgb-12.3 calchct-37 o2 sat-93 09:23am freeca-1.21 brief hospital course: the patient is a 68 year old female who on had a left vats converted to left anterior thoracotomy, a resection of superior segment of the left lower lobe, and a mediastinal lymph node dissection. she developed postoperative atrial fibrillation with a rapid ventricular rate soon afterwards and her blood pressure was initially 80/40, leading to a transfer to the intensive care unit. by , the patient had rate stabilized at around 110-120 and her pressures was around 109/47. amiodarone had begun being loaded as per cardiology recommendations and so it was felt, ms. could be transferred to the floor. after coming to the floor, ms. gradually improved clinically though with persistence of her atrial fibrillation. as per cardiology recommendations, on an initial dose of warfarin was given along with heparin anticoagulation. the patient remained within the target aptt and ptt ranges and so therapy continued. by , the patient had converted to normal sinus rhythm, was rate controlled and had improved clinically to the point where she could follow up on an outpatient basis with her coumadin and amiodarone medications. the patient was informed and agreed to the mandatory scheduled inr checks in the coumadin clinics. discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po once a day. 2. atacand hct 16-12.5 mg tablet sig: one (1) tablet po once a day. 3. clopidogrel 75 mg tablet sig: one (1) tablet po once a day. 4. imdur 30 mg tablet sustained release 24 hr sig: tablet sustained release 24 hr po once a day. 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual q5min as needed for chest pain. disp:*30 units* refills:*2* 6. prednisone 10 mg tablet sig: one (1) tablet po once a day. 7. medication please take all other medications as directed by your pcp. 8. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*50 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(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. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* 12. outpatient lab work ---please check inr twice a week. goal inr is between 2 and 3. please call pcp with results. 13. allopurinol 100 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: vna discharge diagnosis: left lower lobe lung nodule. coronary artery disase s/p mi x 3 perpheral disease hypertension/hyperlipidemia, gout, polymyalgia rheumatica psh: pci x several, l carotid stent, aortic stent, renal stents, s/p ccy discharge condition: stable discharge instructions: call dr. office if experience: -fever > 101 or chills -increased shortness of breath, or cough -chest pain -incision develops drainage chest-tube site cover with a bandaid coumadin for atrial fibrillation: inr goal 2.0-2.5 call dr. office for coumadin dosing. blood draw on xxx followup instructions: follow-up with dr. (office phone number is ) on the clinical center, . report to the 4th department for a chest x-ray 45 minutes before your appointment. follow-up with dr. for further coumadin dosing. (the office has been notified). also please call at for an appointment on tuesday to have your inr checked and coumadin assessed. Procedure: Division or crushing of other cranial and peripheral nerves Regional lymph node excision Other and unspecified segmental resection of lung Diagnoses: Polymyalgia rheumatica Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Peripheral vascular disease, unspecified Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Old myocardial infarction Sinoatrial node dysfunction Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Malignant neoplasm of lower lobe, bronchus or lung Thoracoscopic surgical procedure converted to open procedure

history of present illness: this is a 63 year old female with coronary artery disease status post catheterization with stent of the mid left anterior descending on , who presented on , for elective carotid catheterization. in the past, the patient has had a series of flashing lights in her left and right eyes which were possibly attributed to carotid disease. a duplex of the carotids was obtained on , which showed significant plaque of 80 to 99% in the left. a stenosis of 40 to 59% was identified in the right. the lesion in the left internal carotid artery was stented this morning. the final residual was 20% with normal flow. the patient did have some mid segment spasm of the internal carotid artery that improved with tng through the sheath. the patient was neurologically intact throughout the case. she was admitted to the coronary care unit for postoperative care. past medical history: 1. coronary artery disease status post stent on , of the mid left anterior descending. 2. status post coronary artery bypass graft times four in . 3. status post myocardial infarction times three in , and . 4. hypertension. 5. hypercholesterolemia. 6. diverticulosis status post gastrointestinal bleed. 7. carpal tunnel syndrome. 8. trochanteric bursitis. 9. status post cholecystectomy. allergies: no known drug allergies. home medications: 1. aspirin 325 mg p.o. q. day. 2. metoprolol 15 mg p.o. q. day. 3. atorvastatin 10 mg p.o. q. day. 4. plavix 75 mg p.o. q. day. 5. multivitamin. 6. folic acid. family history: early coronary artery disease. physical examination: blood pressure 110 to 120 over 50 to 53; heart rate 45 to 50; saturation 99% on room air. in general, alert and oriented in no acute distress. cardiac: regular rate and rhythm, normal s1, s2. no murmurs, rubs or gallops. pulmonary: clear to auscultation bilaterally. abdomen soft, nontender, nondistended, positive bowel sounds. groin: right groin site without hematoma or bruit. extremities with no cyanosis, clubbing or edema. one plus dorsalis pedis pulses bilaterally. neurological: pupils are equal, round and reactive to light, 3 millimeters to 2 millimeters. extraocular movements intact without nystagmus. symmetric but normal sensation in all three branches of the trigeminal nerve. tongue: midline, clear phonation, elevation of palate is symmetrical. laboratory: on admission, white blood cell count 7.9, hemoglobin 11.2, hematocrit 31.6, mcv 87, mch 30.9, mchc 35.5, platelets 177. sodium 139, potassium 3.3, chloride 103, bicarbonate 29, bun 16, creatinine 0.7. summary of hospital course: 1. status post left internal carotid catheterization. the patient was neurologically intact and doing well following the procedure. all blood pressure medications were held with a target blood pressure goal of 120 to 170. the patient required a neo-synephrine drip to maintain her blood pressure near 120. on the evening of , and during the day on , multiple attempts were made to wean the patient off the neo-synephrine drip. when this was done, her systolic blood pressures would drop to around 100. she was also given multiple boluses of normal saline in an attempt to bring up her blood pressure. throughout this time, the patient was asymptomatic without dizziness or lightheadedness. she was up in a chair and walking around her hospital room. the neo-synephrine was successfully weaned off at 01:00 a.m. on . the patient's blood pressure once weaned off the drip remained between 110 and 115. the patient was continued on aspirin and plavix throughout the admission. 2. possible sleep apnea: when asleep, the patient has episodes when she pauses in her breathing and her saturations drop. saturations return immediately when she takes a deep breath and resumes her normal breathing pattern. will have her follow-up for this with her primary care physician. condition on discharge: stable. discharge status: the patient was discharged to home. discharge diagnoses: 1. status post left internal carotid artery catheterization. 2. coronary artery disease status post stent on , and mid left anterior descending. 3. status post coronary artery bypass graft times four vessels in . 4. status post myocardial infarction times three. 5. hypertension. 6. hypercholesterolemia. 7. diverticulitis status post gastrointestinal bleed. discharge medications: 1. aspirin 325 mg p.o. q. day. 2. plavix 75 mg p.o. q. day. discharge instructions: 1. the patient will follow-up with dr. on , for a blood pressure check. 2. dr. , on , at 04:00 o'clock. 3. vascular study at the cc clinical center for radiology on , at 03:00 o'clock. 4. dr. , on , at 04:00 o'clock. , m.d. dictated by: medquist36 Procedure: Angioplasty of other non-coronary vessel(s) Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Percutaneous transluminal coronary angioplasty status Occlusion and stenosis of carotid artery without mention of cerebral infarction Unspecified sleep apnea Old myocardial infarction Family history of ischemic heart disease

allergies: lipitor / zocor attending: chief complaint: lower gastrointestinal bleed major surgical or invasive procedure: picc line placement colonoscopy history of present illness: ms is a 68 year old woman with multiple medical problems, including cad s/p cabg in 85' and lad des in 03', recent diagnosis of lung cancer s/p partial lobectomy, newly diagnosed atrial fibrillation, presenting to the hospital with hematochezia. patient was given 2u prbc and was closely monitored on the wards, when she was noted to have a large bloody bowel movement accompanied by onset of afib with rvr and hypotension. patient was bolused with 500ml of ns and transfered to the micu for further management. last colonoscopy in with severe diverticulosis, patient has had two prior episodes of gib which required several transfusions. in the floor prior to transfer, temp 97.4 bp 74/57, hr 77, rr 20 o2 sat 98% currently, she denies any lightheadedness, dizziness, chest pain, palpitations, shortness of breath, nausea or vomiting, but does report some "chest pressure" which is rated and is different from her angina. not worsened with inspiration. past medical history: 1. coronary artery disease -- mi x3 with her first mi at age 34 -- 3v cabg in (lima to lad and svgs to om, rca and d1.) -- all vein grafts 100% occluded -- mid lad drug-eluting stent in . 2. peripheral disease -- s/p angioplasty of the right leg - -- pta and stenting to distal aorta and ostial iliac arteries 3. chronic kidney disease: baseline cr 1.2-1.4 4. renal artery stenosis status post right renal artery stent- 5. carotid stenosis status post left internal carotid stent- 08/. 6. gout 7. polymyalgia rheumatica 8. hypertension 9. hypercholesterolemia 10. osteoarthritis 11. endometrial polyps- the patient has been followed by dr. . 12. gi bleed secondary to diverticulosis 13. urinary incontinence 14. squamous cell carcinoma of lung- synchronous right and left lower lobe nodules found in now s/p left lobectomy. has not had xrt or chemo yet. social history: married. smoked in the past but quit 25 years ago, denies alcohol or illicit drug use. family history: the patient's father died of cad as did her mother. two brothers have cad. a sister has had multiple tias. physical exam: vitals: t 97.8, bp 117/54, hr 71, rr 19, o2sat 100% ra gen: nad, lying in bed, pale heent: perrl, eomi, pale conjuctiva cv: regular rate, no murmurs, rubs or gallops. normal s1 and s2. resp: ctab no w/r/r, slightly diminished bs on left base. scar well healed. abd: ntnd, hyperactive bowel sounds ext: no edema, dp pulses palpable symmetrically. well healed scar from grafts. brief hospital course: ms. is a 68yo female with cad and pvd with multiple coronary and peripheral artery stents and recent left lobectomy for lung cancer complicated by atrial fibrillation on coumadin now presenting with lgib. # lgib: upon admission, patient was given 2u prbc and was closely monitored on the wards, when she was noted to have a large bloody bowel movement accompanied by onset of afib with rvr and hypotension. patient was bolused with 500ml of ns and transfered to the micu for further management. in the micu, patient continued to pass brbpr and received an additional 10 units of prbc. inr was measured at 2.2. asa and coumadin were discontinued, while plavix was continued. colonoscopy was performed on , showing old and new blood throughout the colon, with more active bleeding present in the descending colon when compared to ascending colon. moderate to severe diverticulosis was also noted. per gi recs, tagged red blood cell scan was performed on and showed no evidence of gi bleed. by , the patient had received a total of 10 units of blood and was no longer passing brbpr, though she continued to pass clots. hct stabilized in the upper 20s and inr was 1.1. after transfer to the general medical service on , patient continued to pass clots, but her hct remained stable in the 28-30 range. towards the end of her stay (), plavix was discontinued and she was started on asa 81mg. given history of diverticular disease () and severe diverticulosis observed on colonoscopy, this episode of lgib is most consistent with diverticular bleeding. she will follow up with her cardiologist next week to discuss reinitiation of plavix and coumadin. . # atrial fibrillation: patient had an episode of atrial fibrillation on initial presentation associated with hypotension, resulting in micu transfer. she converted to sinus and remained there while in the micu. patient was transferred to the general medical service where she was monitored on telemetry and had a recurrence of atrial fibrillation with rvr to the 140s, though mostly resting in the low 100s. she remained hemodynamically stable with palpitations as her only symptom. she spontaneously converted to sinus with a rate in the 60s the following morning. she remained in sinus rhythm for the rest of her hospital stay. per recommendations of her outpatient cardiologist dr. , she was continued on her home dose of amiodarone. her coumadin was discontinued in the setting of her gi bleed. oral metoprolol was restarted at increased dose of 25mg tid. . # cad: patient remained chest pain free during her hospitalization. cardiology was contact on admission to discuss risks of being on asa and plavix. given significant cardiac history, they recommneded that she be continued on both. nitrate and beta-blocker were initially held in the setting of gi bleed. in the latter part of her hospitalization given that she was still having small amount of bleeding even on plavix alone, dr. was contact and he recommended discontinuing the plavix given that her last bare metal stent was placed in (renal artery stent), and her last drug-eluting stent was placed in . she was instead put on asa 81mg daily. as above, her metoprolol was restarted at a higher dose given her a. fib with rvr. she was, however, normotensive at time of discharge so her imdur was held pending follow up and repeat blood pressure check this upcoming week. . # pvd: patient has several stents to renal and carotid arteries. as above, her plavix was ultimately held and asa was continued at 81mg daily. this will be addressed further upon outpatient follow up with her pcp and cardiologist. . # cri: creatinine remained within her baseline throughout this admission. . # lung cancer: s/p lobectomy. her respiratory status remained stable during her hospital stay. she has outpatient follow up appointments scheduled with her oncologists next week. . # pmr: patient on prednisone 10mg as outpatient; she was continued on this dose during her hospitalization. . # access: due to poor peripheral access, picc line was placed prior to transfer to the floor. this was removed prior to discharge. medications on admission: atacand hct 16-12.5mg po daily clopidogrel 75mg po daily imdur 15mg po daily prednisone 10mg po daily oxycodone-acetaminophen 5-325mg po q4-6h prn docusate sodium 100mg po tid metoprolol tartrate 12.5mg po bid allopurinol 100mg po daily amiodarone 200mg po daily aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. coumadin 1 mg tablet sig: one (1) tablet po discharge medications: 1. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. allopurinol 100 mg tablet sig: one (1) tablet po once a day: take in the evening. disp:*30 tablet(s)* refills:*0* 4. metoprolol tartrate 25 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*0* 5. calcium 500+d 500 (1,250)-200 mg-unit tablet sig: one (1) tablet po three times a day. 6. aspirin 81 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:*0* 7. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain: 1) do not drive while on the medication 2) do not exceed 12 tablets in any 24 hour period . 8. docusate sodium 100 mg capsule sig: one (1) capsule po every twelve (12) hours as needed for constipation: take as long as taking narcotics stop if stools become loose . 9. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual every 5 minutes as needed for pain: one under the tongue every 5 minutes as needed for pain. 10. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. discharge disposition: home discharge diagnosis: lower gi bleed, probable diverticular bleed atrial fibrillation squamous cell lung cancer discharge condition: stable, in normal sinus rhythm with stable hematocrit. discharge instructions: you were admitted to the hospital for lower gastrointestinal bleeding, that is most likely due to diverticulosis. while you were in the hospital, you went into atrial fibrillation and your blood pressure decreased. you were sent to the intensive care unit to manage your blood pressure and were transfused with 10 units of blood. your home medications, aspirin and coumadin, were stopped while you were in the hospital in order to help control the bleeding. you underwent a colonoscopy which showed blood and diverticula in your colon. a tagged red blood cell scan to localize the source of bleeding was then done, and did not show any active bleeding. after leaving the icu, you were transfered to the general medical floor where your heart rate, rhythm, and blood pressure were monitored. you experienced another episode of atrial fibrillation which resolved on its own overnight. you were discharged when these became stable and you were no longer bleeding. while you were in the hospital we stopped your plavix and coumadin, and changed your dose of aspirin from 325mg to 81mg. when you go home please continue the aspirin 81mg but do not restart the plavix or coumadin until following up with dr. . we also increased your dose of metoprolol from 25 mg twice a day to 25 mg three times a day. please continue taking the metoprolol 25 mg three times per day when you go home. we stopped your imdur while you were in the hospital and suggest that you do not take anymore until you see dr. and he re-evaluates you. please follow up with your primary care physician . , your cardiologist dr. , and your oncologist dr. as detailed below. please call your doctor or return to the emergency room if you develop shortness of breath, lightheadedness, dizziness, chest pain, blood in your stools or any other symptoms that concern you. followup instructions: provider: , md (heme/onc) phone: date/time: 2:30 provider: , md (thoracic surgery) phone: date/time: 2:30 provider: , md phone: date/time: 11:30 provider: . phone: date/time: at 10:30am provider: , md phone: date/time: 9:00am Procedure: Venous catheterization, not elsewhere classified Colonoscopy Diagnoses: Hypocalcemia Polymyalgia rheumatica Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Coronary atherosclerosis of autologous vein bypass graft Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Percutaneous transluminal coronary angioplasty status Chronic kidney disease, unspecified Other and unspecified hyperlipidemia Hypotension, unspecified Malignant neoplasm of bronchus and lung, unspecified Old myocardial infarction Long-term (current) use of anticoagulants Diverticulosis of colon with hemorrhage

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: 67m with fever and cough major surgical or invasive procedure: cabg x 4 (lad, pda, , ) cardiac cath history of present illness: pt is a 67yo homeless man with pmh sig for "enlarged heart" who presents to the ed by ems complaining of fever/chills and productive cough with progressively worsening sob over the past 3-4 days. denies palp/n/v. has had diaphoresis. no orthopnea/pnd. in the pt had increased o2 requirements to 100% nrb, given solumedrol, ceftriaxone, azithromycin. given elevated cardiac enzymes, ekg changes pt started on heparin drip. past medical history: ?cardiomegaly knee pain social history: +smoker former golf pro homeless + former alcohol use - quit 7 yrs ago no ivda family history: unable to obtain physical exam: t 96.9 hr 98 bp 70/50 ac 500x18 fio2 100% rr 20 gen: using accessory muscles to breath, diaphoretic neck: jvd to mandible card: tachycardia, no mrg, no s3s4 lungs: b/l soft exp wheeze, no rales, decreased bs on left lower lung field abd: soft nt nd nabs ext: cool, no edema neuro: aao x 3, mae rectal guiac neg pertinent results: 02:16am blood wbc-6.3 rbc-3.31* hgb-10.1* hct-28.9* mcv-87 mch-30.7 mchc-35.1* rdw-16.4* plt ct-110* 05:45am blood pt-11.0 ptt-23.8 inr(pt)-0.9 05:45am blood glucose-91 urean-17 creat-0.8 na-137 k-4.4 cl-101 hco3-25 angap-15 radiology preliminary report chest (pa & lat) 1:27 pm chest (pa & lat) reason: pleural effusion medical condition: 67 yo m s/p cabgx4, avr reason for this examination: pleural effusion reason for the study: assessment for pleural effusion in a patient after cabg. technique: pa and lateral views of the chest, and the study is compared to the previous one done on . findings: heart, mediastinal and hilar contours are normal. lungs are clear. there are no pleural effusions or pneumothorax. impression:normal study. no evidence of pleural effusion. dr. dr. . cardiology report echo study date of patient/test information: indication: intraoperative tee for avr/cabg height: (in) 67 weight (lb): 145 bsa (m2): 1.77 m2 bp (mm hg): 109/67 hr (bpm): 65 status: inpatient date/time: at 11:20 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2006aw1-: test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. measurements: left ventricle - septal wall thickness: 1.0 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 0.9 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 5.5 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 50% (nl >=55%) aorta - ascending: 3.1 cm (nl <= 3.4 cm) aorta - descending thoracic: 2.5 cm (nl <= 2.5 cm) aortic valve - peak velocity: *3.0 m/sec (nl <= 2.0 m/sec) aortic valve - peak gradient: 36 mm hg aortic valve - lvot diam: 2.0 cm aortic valve - valve area: *0.8 cm2 (nl >= 3.0 cm2) interpretation: findings: right atrium/interatrial septum: no asd by 2d or color doppler. left ventricle: wall thickness and cavity dimensions were obtained from 2d images. normal lv wall thickness. normal lv cavity size. mild global lv hypokinesis. mildly depressed lvef. lv wall motion: regional lv wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; right ventricle: borderline normal rv systolic function. aorta: focal calcifications in aortic root. focal calcifications in ascending aorta. normal descending aorta diameter. simple atheroma in descending aorta. focal calcifications in descending aorta. aortic valve: three aortic valve leaflets. severely thickened/deformed aortic valve leaflets. moderate as. mild to moderate (+) ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. mild 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 was under general anesthesia throughout the for the patient. conclusions: pre-cpb no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild global left ventricular hypokinesis. overall left ventricular systolic function is mildly depressed. right ventricular systolic function is borderline normal. there are simple atheroma in the descending thoracic aorta. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. post-cpb patient is receiving epinephrine by infusion. normal right ventricular systolic function. left ventricle with septal "bounce" consistent with ventricular pacing. overall systolic function is slightly improved from pre-cpb. bioprosthesis in aortic valve position is well seated and displays normal leaflet function. there is trace valvular ai. no other changes from pre-cpb. electronically signed by , md on 15:52. physician: () brief hospital course: the pt. was admitted on to the micu and intubated for respiratory distress and profound acidosis. he was on levophed for hypotension and had bacteremia and sepsis. his pneumonia was treated with ceftriaxone and azythromycin and was on levo for quite some time. he had an echo on admission which revealed an ef of 55% and no wall motion abnormality. he eventually had a nstemi and refused cardiac cath. he eventually agreed and underwent cardiac cath on which revealed: 70%lm stenosis, prox 80%lad, 50% 1, 80% 2, 90% prox lcx, 100% l pda, mod. as with of 0.9 cm2 and a peak gradient of 30mmhg, and +mr. cardiac surgery was consulted and he needed to wait for surgery until he was off plavix for 5 days, and he had 2 teeth extracted. on he had a cabgx4(lima->lad, svg->pda, , and om)/avr w/ 23mm magna pericardial valve. the cross clamp time was 136 mins. and total bypass time was 166 mins. he tolerated the procedure well and was transferred to the csru on epi, nitro, and propofol. he was agitated and followed by psychiatry who recommended haldol. he was extubated on pod#1 and had his chest tubes d/c'd on pod#3. his epicardial pacing wires were d/c'd on pod#3 and he was weaned off levophed. he was transferred to the floor on pod#4 and continued to progress. he remained in the hospital for the next 3 weeks to have his sternum heal as he will be released to a homeless shelter and will need to be completely independent. he completed an application for the and will hopefully get a bed and agree to live there in the next month. he was discharged in pod#30 in stable condition. medications on admission: none discharge medications: 1. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: tba discharge diagnosis: cad pneumonia sepsis nstemi discharge condition: good. discharge instructions: call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. no heavy lifting or driving. shower, no baths, no lotions, creams or powders to incisions. followup instructions: dr. (pcp at va) 1-2 weeks make an appointment with dr. for 4 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more (Aorto)coronary bypass of three coronary arteries Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnostic ultrasound of heart Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Open and other replacement of aortic valve with tissue graft Transfusion of packed cells Other surgical extraction of tooth Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Other primary cardiomyopathies Thrombocytopenia, unspecified Coronary atherosclerosis of native coronary artery Tobacco use disorder Acute posthemorrhagic anemia Unspecified septicemia Severe sepsis Rheumatic heart failure (congestive) Acute respiratory failure Septic shock Mitral valve insufficiency and aortic valve stenosis Acute myocardial infarction of inferolateral wall, initial episode of care Delirium due to conditions classified elsewhere Lack of housing Dental caries, unspecified Paranoid personality disorder

history of present illness: the patient is a 30 year old male with a past medical history of pulmonic stenosis (now thought to be secondary to an anterior mediastinal mass), who presented with five weeks of progressive nonproductive cough, fever, and night sweats to an outside hospital on , where a chest x-ray revealed an anterior mediastinal mass and a cat scan showed the mass measuring at 11.3 by 14.4 by 12.0 centimeters, as well as small effusions. the patient was sent home with follow-up but over the weekend, he developed pleuritic left sided chest pain with mild shortness of breath. again, he was evaluated at the outside hospital where the pericardial effusion now appeared large. he was therefore transferred to where an echocardiogram revealed a 3.5 centimeter effusion with inferior vena cava inspiratory collapse and mitral inflow variability without increased jugular venous pressure or a pulsus. the patient was transferred to the ccu for close monitoring. past medical history: 1. hernia repair at eight years old. 2. lyme disease at ten years old. 3. pulmonic stenosis diagnosed in , after a murmur and diagnosed by echocardiogram. 4. shingles. medications on admission: none. allergies: no known drug allergies. social history: the patient lives alone. negative tobacco. three drinks of alcohol per month. the patient works as industrial designer, physically active. family history: mother passed seven years ago from breast cancer. grandfather with prostate carcinoma. physical examination: on admission, temperature 101.8, heart rate 105, blood pressure 130/70, respiratory rate 27 to 32, oxygen saturation 98% in room air. the patient is a well developed male who is thin and diaphoretic, anxious, in mild respiratory distress. the pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. cranial nerves ii through xii are intact. the oropharynx is clear. negative anterior posterior lymphadenopathy. neck is supple, negative axillary nodes. lungs are clear to auscultation bilaterally. the heart was tachycardia, regular s1 and s2 with ii to iii/vi murmur at the left sternal border. the abdomen was soft, nontender, positive bowel sounds, no hepatosplenomegaly. extremities were no cyanosis, clubbing or edema. no rashes. strength was in all four extremities. laboratory data: on admission, white blood cell count was 10.9, hematocrit 37.2, platelet count 381,000. inr 1.5. chem7 was within normal limits. echocardiogram revealed normal systolic function, 3.5 effusion at the largest diameter, inferior vena cava collapse with inspiration, question of pericardial studding, mild respiratory variation in mitral inflow consistent with some early signs of tamponade. cat scan from , heterogeneous mass in the left midline compressing the left pulmonary artery, right upper lobe pleural nodules, left pleural effusion, pericardial effusion. hospital course: 1. pericardial effusion at admission - the patient had signs for early tamponade physiology but was hemodynamically stable and was admitted to the ccu for close monitoring. repeat echocardiogram showed increasing size of the effusion. the patient therefore underwent pericardial drain and 600cc of grossly hemorrhagic fluid were removed. following the procedure overnight, there was no further drainage from the pericardial drain. repeat echocardiogram showed decreasing pericardial fluid. therefore on , the pericardial drain was pulled. the patient had one further follow-up echocardiogram on . this revealed no effusion and it was felt the patient was stable from a cardiac standpoint. 2. hematology/oncology - the patient underwent a mediastinal biopsy to diagnose the large anterior mediastinal mass. the biopsy revealed nonseminomatous germ cell yoke sac tumor. the patient underwent two treatments of radiation therapy as well as a round of five days of chemotherapy with etoposide and cisplatin. staging workup included a head magnetic resonance scan which revealed no lesions, as well as an ultrasound of the scrotum which was within normal limits. fluid drained from the pericardial and pleural effusions were negative for malignant cells. the patient tolerated chemotherapy well suffering from nausea, relieved by ativan. he was pretreated with allopurinol and intravenous fluids to prevent tumor lysis. the patient completed his five days of chemotherapy. he will follow-up with dr. in one week for continuation of his therapy with the possible addition of bleomycin following pulmonary function tests. 3. infection - during the hospital course, he continued to have shortness of breath as well as a cough with mild hemoptysis. on , the patient spiked a fever. this was thought most likely secondary to the tumor burden, however, the patient was started on vancomycin, levofloxacin and clindamycin as broad spectrum therapy with a question of postobstructive pneumonia. subsequently, the patient did well with no further fevers. vancomycin and clindamycin were stopped and the patient will complete a ten day course of levofloxacin. 4. pleural effusion - the patient had a left sided chest tube placed for drainage of pleural fluid. following the removal of the chest tube, the patient had continued drainage from the site of the tube. after a number of days, this slowly resolved. the patient's site was closed by ct surgery with a suture. the suture is to be removed in seven to ten days at a follow-up appointment with dr. . condition on discharge: stable. discharge status: discharged to home with vna services for dressing changes. follow-up: the patient will follow-up on , with dr. , as well as , with dr. of cardiology. medications on discharge: 1. ativan 0.5 to 1 mg p.o. q3-4hours p.r.n. nausea. 2. levofloxacin 500 mg p.o. once daily times three days. 3. robitussin with codeine p.r.n. final diagnoses: 1, nonseminomatous germ cell anterior mediastinal tumor. 2. pericardial effusion, status post drainage. 3. left pleural effusion, status post drainage. 4. postobstructive pneumonia. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Pericardiocentesis Pericardiocentesis Right heart cardiac catheterization Injection or infusion of cancer chemotherapeutic substance Other radiotherapeutic procedure Closed [percutaneous] [needle] biopsy of mediastinum Diagnoses: Pneumonia, organism unspecified Unspecified pleural effusion Malignant neoplasm of anterior mediastinum Secondary malignant neoplasm of mediastinum Hemopericardium

allergies: bactrim / dilaudid attending: chief complaint: abdominal pain major surgical or invasive procedure: lumbar puncture history of present illness: ms. is a 27yo woman with h/o hcv, liver transplant x 2 in (rejected first liver), (?wilson's disease per records) and 3rd olt in who was in her usoh until yesterday afternoon when she began to have ruq pain that radiated like a band across her stomach. she had chills and diaphoresis at that time, and a headache (which she frequently gets per records), n but no v. noted that she "just din't feel good" and was sleeping a lot yesterday. she also noted a few hours later she had some chest pain, not pleuritic, sharp pain "like needles", no cough, +sob along with abd and cp. yesterday, she presented to hospital in , ma, where she had an abdominal ct scan that was unremarkable. she was found to have an elevated bilirubin over 4 (baseline 2.0). she remained there overnight and went home today, when she went to see dr. . in his office she was febrile to >101. he sent her immediately to be admitted to the hospital. . ros: ha as above (per records complained of this over last few weeks), facial tingling "all over in a circle." otherwise unremarkable. past medical history: liver transplant x 2 in at (rejected first liver); ?3rd transplant in - does not recall cmv infections, but did have hsv esophagitis in 2/87 - possible cholangitis - recurrent utis - hcv: past interferon treatment suppressed vl from 6mill to 79,000 but had to stop depression/disorientation. recently restarted ribaviron and pegylated interferon on . - incarcerated hernia repair - s/p ccy with liver transplantation . meds: prednisone 10mg po qother day (took today) cyclosporin 125 mg po qday ribavirin 400mg po bid interferon 120mcg (0.3ml) sq qfri trazodone 10mg po qhs prn . all: bactrim --> hives; dilaudid social history: lives at home with her daughter and her brother's family (his wife and 4 children). does not work. denies tobacco, alcohol, or other drugs including intravenous drugs. family history: mother with dm, htn, breast ca. physical exam: hr 96, bp 95/59 rr 19 o2 98% ra gen: sleepy but answers questions with poor concentration heent: ncat, perrl, sclerae mildly icteric, op not injected, mm dry, no sinus tenderness, no photophobia neck: supple, no jvd, no lad cor: rrr, ii/vi systolic flow murmur heard throughout precordium non radiating, s1s2 pulm: ctab abd: well-healed transverse surgical scar, ruq tenderness, + sign, + rebound tenderness over upper but not lower abdomen, + diffuse abdominal tenderness to moderate palpation, +bs, soft, nd ext: no c/c/e, w/w/p, pulses 2+ radial and pt pulses bilat neuro: moves all four to command, strength 4/5 bilateral quads, bilateral hands and feet at ankles, rest of neuro exam not performed given sleepiness of pt pertinent results: ct abd from osh : film reviewed by trauma here with radiology and was basically negative (pneumobilia only, with mild intrahepatic dilation, no free air or abscesses) . ruq u/s:normal hepatic vessels in this patient post transplant. no other commentary. . cxr: no acute cp process. ct abd : impression: 1. decrease pneumobilia status post hepaticojejunostomy. 2. splenomegaly. 3. increasing bibasilar atelectasis compared to same day study from outside hospital. possible consolidation cannot be excluded. . mrcp: negative for obstruction . cmv/ebv negative bld cx + pan- e coli; + urine cx from osh + for e coli repeat bld cx neg . hsv dfa + . lumbar puncture: 0 rbc, 0 wbc . 04:04am blood wbc-5.7 rbc-3.16* hgb-9.7* hct-27.5* mcv-87 mch-30.8 mchc-35.4* rdw-15.7* plt ct-74* 04:50am blood wbc-4.3 rbc-3.66* hgb-11.6* hct-31.3* mcv-86 mch-31.8 mchc-37.2* rdw-15.9* plt ct-184 02:30pm blood glucose-78 urean-12 creat-0.8 na-139 k-3.9 cl-108 hco3-22 angap-13 02:30pm blood alt-29 ast-27 ld(ldh)-244 alkphos-145* amylase-42 totbili-4.2* dirbili-0.8* indbili-3.4 04:50am blood alt-27 ast-27 totbili-1.1 09:21pm blood hbsag-negative hbsab-negative hbcab-negative igm hbc-negative igm hav-negative . bld cx + for e coli brief hospital course: ms is a 27f with h/o liver transplant x 3 (last in ) who presented with fever and abdominal pain and direct hyperbilirubinemia who was presumed to have cholangitis but was subsuquently found to have e coli urosepsis. . upon admission to the floor ms was found to be tachycardic to the 120s, hypotensive with sbp in the 90s fever to 104. she was given 3lns boluses, started on zosyn and flagyl to empirically cover for cholangitis, and was transferred to the icu for further management. she received another 2lns boluses in the icu and did not need pressors for bp support. ms had a stat ct abdomen and abdominal ultrasound which did not reveal any signs of cholangitis. she was subsuquently found to have e coli bacteremia and urine culture from an outside hospital revealed e. coli uti. she was changed to iv ciprofloxacin when sensitivities returned and was discharged with a 14 day course of oral cipro. her fevers gradually resolved as did her hypotension and her abdominal pain was completely resolved by discharge. repeat blood cultures were negative. ua and urine cultures repeated at were negative and ct-abdomen showed no evidence of pyelonephritis. . # immunosuppression: ms post transplant immunosuppressive regimen was cyclosporine 150bid + prednisone 10 qod. she was admitted with supra-therapeutic cyclosporine levels above 300. her csa doses were adjusted with wide fluctuation in her level. her dose was decreased to 100mg po bid prior to discharged because the concern is her sepsis was likely induced by her overimmunosuppression. her csa level on the morning of discharge was 344, but this was not reported until after the patient's discharge. she was contact via telephone to have another level drawn the next day. . during ms. stay she developed oral lesions that were + for herpes virus by direct antigen testing. she had also been reporting headache and photophobia so a lumbar puncture was performed that showed no rbc or wbc. she was treated briefly with iv acyclovir and then transitioned to a 10-day course of valacyclovir 500mg po bid. she has been instructed to cover her lesions when she interacts with her 18month-old daughter. she also had signs of bacterial superinfection of one of the lesions for which she is being treated with bactroban. . #. hyperbilirubinemia: there was concern on admission that ms tbili was 4.4 and she had ruq pain. abd us and ct abdomen were negative for obstruction. she had an mrcp that was negative for obstruction. the hyperbilirubinemia resolved with antibiotic treatment making sepsis the likely source. . # hcv: ms received her 4th treatment of pegylated ifn + ribaviring several days pta. her interferon was held x 1 dose due to her sepsis and her ribavirin was briefly held due to concern over her anemia. her last viral load had shown good response to ifn/ribavirin so the ribavirin was restarted with plans to resume ifn in 1 week. . # anemia/thrombocytopenia: ms presented with anemia and thrombocytopenia that improved with treatment of her sepsis. hemolysis labs were negative making ribavirin a less likely culprit. her hct on discharge was 30, which does not merit epo treatment. . # immunization: ms was found to be negative for hav and hbv antibodies. she was therefore vaccinated with #1 of the hav and hbv series. these series should be completed in liver clinic. she also received pneumococcal vaccine and influenza vaccine. medications on admission: prednisone 10mg po qother day (took today) cyclosporin 125 mg po qday ribavirin 400mg po bid interferon 120mcg (0.3ml) sq qfri trazodone 10mg po qhs prn discharge medications: 1. prednisone 10 mg tablet sig: one (1) tablet po qother day (). 2. ribavirin 200 mg capsule sig: three (3) capsule po daily (daily). 3. mupirocin calcium 2 % cream sig: one (1) appl topical (2 times a day): apply to lesions on upper lip until resolved. disp:*1 tube* refills:*2* 4. cipro 750 mg tablet sig: one (1) tablet po twice a day for 8 days. disp:*16 tablet(s)* refills:*0* 5. valtrex 500 mg tablet sig: one (1) tablet po twice a day for 9 days. disp:*18 tablet(s)* refills:*0* 6. cyclosporine 100 mg capsule sig: one (1) capsule po q12h (every 12 hours). disp:*60 capsule(s)* refills:*2* 7. peg-intron 120 mcg/0.5 ml kit sig: 0.3 ml subcutaneous once a week. 8. outpatient lab work cyclosporine trough please draw in approximately 1 week discharge disposition: home discharge diagnosis: e coli bacteremia urosepsis hepatitis c s/p orthotopic liver transplantation herpes labalis discharge condition: good: afebrile, vss discharge instructions: you should continue to take all medications as prescribed. you were admitted with a blood infection and need to finish a 14-day course of an antibiotic called ciprofloxacin (you have 9 more days to take this). we are also giving you a medicine called valtrex for your mouth sores to take for 8 days. until the lesions on your lips are crusted over, they are potentially ifectious. you need to be careful around your daughter and not her. you should continue to take your interferon and ribavirin as scheduled. . dr wants you to decrease your cyclosporine dose to 100mg twice per day. you should have your trough level drawn in about a week (it should be drawn 1 hour before your next dose is due). . you should follow-up in clinic with as below. . please seek immediate medical attention if you have abdominal pain, fevers, chills, jaundice, eye pain, worsening headache, or for any other concerns. . you were also given a hepatitis a vaccine, influenza vaccine, pneumonia vaccine, and the first in the hepatitis b vaccine series. you will need to finish the hepatitis b vaccine series with 2 other shots. we will convey this to . followup instructions: provider: , : date/time: 2:20 Procedure: Spinal tap Incision of lung Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Urinary tract infection, site not specified Chronic hepatitis C without mention of hepatic coma Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Septicemia due to escherichia coli [E. coli] Herpes simplex without mention of complication

allergies: bactrim/dilaudid neuro: she is a/ox3. c/o facila numbness, chest pain, and abd pain. all pain 4(). pupils are 3mm and brisk. she is able to mae. no pain meds are to be given per liver team. icu team aware of fical numbness. icu team did assess the facial numbness. most of the numbness is at the left upper side of her forehead. cv: st up the the 110's with pac noted. ekg was done, when she c/o of chest pain. the pain was note with deep breath (per pt). no change on ekg( icu team states). b/p 72/23. total 1.5l of fluid was givne. b/p up the 108/81. hr 88-90's w/ pac noted. resp: ls clear bilat. o2 sat >96% on ra rr 20's. gi/gu: npo except meds. +bs c/o ruq pain 4(). she had a abd ct without contrast results pending. voiding ua sent. skin: intact. Procedure: Spinal tap Incision of lung Diagnoses: Thrombocytopenia, unspecified Anemia, unspecified Urinary tract infection, site not specified Chronic hepatitis C without mention of hepatic coma Complications of transplanted liver Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Septicemia due to escherichia coli [E. coli] Herpes simplex without mention of complication

discharge medications: 1. furosemide 20 mg po q day. 2. latanoprost 0.005% drops one drop ophthalmic at h.s. 3. docusate 100 mg po b.i.d. 4. senna one tablet po b.i.d. 5. bisacodyl 10 mg po q.d. 6. atorvastatin 10 mg po q.d. 7. oxycodone 5 mg half tablet po q 4 to 6 hours as needed. 8. lovenox 40 mg subcutaneous q 24 hours times six weeks. 9. sliding scale regular humulin recombinant insulin. 10. ativan 1 mg. 11. pantoprazole 40 mg po q.d. 12. tylenol 500 mg po q.i.d. prn pain. 13. metoprolol 50 mg half tablet po b.i.d. the patient had occasional episodes of hyponatremia with sodium at discharge of 130. recheck sodium later today. please check sodium level as well as other laboratories. all the electrolytes, calcium, phos and magnesium were within normal limits. hematocrit was 33.1, white blood cell 6.7 on the day of discharge. the patient will need to follow up with dr. in two weeks, please call to schedule an appointment. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of endotracheal tube Open reduction of fracture with internal fixation, femur Percutaneous balloon valvuloplasty Closed reduction of fracture without internal fixation, femur Application of external fixator device, femur Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cardiac complications, not elsewhere classified Aortic valve disorders Unspecified fall Atrial flutter Closed supracondylar fracture of femur

history of present illness: the patient is a 79 year old female with a history of severe aortic stenosis, hypertension, coronary artery disease, who presented to outside hospital emergency after a mechanical fall. according to the patient she was walking to the television to turn it on when she slipped and fell on her left side. the patient denied chest pain, shortness of breath, and dizziness. there was no loss of consciousness. they presented to the outside hospital emergency where radiographs revealed a comminuted fracture of the distal left femur extending into the joint surface. the patient was transferred to . the patient was admitted for surgical fixation of her fracture. past medical history: the patient reports having had myocardial infarction and had a normal exercise stress test at a year and a half ago. she never had cardiac catheterization. she has been followed by primary care physician for cardiac problems. obtained from the outside hospital, , echocardiogram was done on with an ejection fraction of 30%, severe aortic stenosis with the aortic valve area of 0.7 cm squared. the patient denied a history of hypertension, diabetes, hypercholesterolemia, tobacco use, congestive heart failure, chest pain or syncopal episodes. medications on admission: lasix, metoprolol, -ciel and acetaminophen. allergies: no known drug allergies. social history: the patient lives alone at home and is independent with all activities of daily living. she ambulates one flight of stairs in-house. echocardiogram, normal sinus rhythm, left ventricular hypertrophy, 1 to elevations in v1 to v3, no change compared to echocardiogram from . physical examination: physical examination on presentation reveals the patient is a white female in no distress. head atraumatic, normocephalic. eyes, extraocular movements intact. chest clear to auscultation bilaterally. heart regular rate and rhythm. left lower extremity with flexion deformity. no ulcerations, no abrasions. extensor hallucis longus, flexor hallucis longus, anterior tibialis , normal sensation to light touch in l1-s1. dorsalis pedis and posterior tibial pulses 2+. hospital course: due to severity of aortic stenosis, the patient was transferred to the medical service. the case was discussed with anesthesia. they feel that it was not safe for the patient to proceed without further workup. the patient went to the cardiac catheterization laboratory on where the patient underwent valvuloplasty of the aortic valve. as a result, gradient across the aortic valve was decreased from 87 to 33 mm of mercury, e to a increased from baseline of 0.36 cm square to 0.65 square. after angioplasty the patient had episode of bleeding on and had developed a large groin hematoma. hematocrit fell down to 21 with blood pressure as low as 56 to 20. the patient was resuscitated with fluids and started on dopamine. the patient was intubated and transferred to the cardiac care unit. pressures throughout the stay in the cardiac unit the patient has been noted to be arousable and followed commands on request. left ej line, the patient received blood transfusions with 5 units of red blood cells and 2 units of fresh frozen plasma. hematocrit, blood pressure and heartrate stabilized in acceptable range. the patient had several episodes of tachycardia and atrial flutter which normalized with amiodarone. on , the patient was taken to the operating room where she underwent open reduction and internal fixation with plate placement. she was operated on by dr. . she tolerated the procedure well and went back to the cardiac care unit. it was noted that the patient had a lack of cough lead and could not be extubated immediately. she was started on dexamethasone to decrease the swelling prior to orthopedic surgery. she was extubated on . it was noted that the patient had a somewhat slowness of speech. neurology consult was requested. dr. saw the patient and did not believe the patient had aphasia and the reason for slowed speech was secondary to coming off of intubation along with fentanyl therapy. neurological examination was entirely nonlocalized. at the time of this dictation, , the patient is alert and has no problems talking to her providers and family. the patient was mobilized by physical therapy who notes she is nonweightbearing on the left lower extremity. the patient has immobilizer block in extension. the patient needs prolonged course of rehabilitation. the patient was screened by rehabilitation facility and will be tentatively discharged there on , and addendum will be dictated. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Insertion of endotracheal tube Open reduction of fracture with internal fixation, femur Percutaneous balloon valvuloplasty Closed reduction of fracture without internal fixation, femur Application of external fixator device, femur Diagnoses: Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Unspecified essential hypertension Cardiac complications, not elsewhere classified Aortic valve disorders Unspecified fall Atrial flutter Closed supracondylar fracture of femur

allergies: indinavir / ritonavir / stavudine / lamivudine attending: chief complaint: increased cough x1 week and fevers major surgical or invasive procedure: 1.) intubated secondary to hypoxic respiratory failure. successfully extubated. 2.) lumbar puncture 3.) central line placement 4.) transfused 2 units prbc history of present illness: 38 yo male with hx of hiv/aids (diagnosed in ; had cd4=5, viral load = 100k ),disseminated , candidal esophagitis, recurrent pcp, started on haart (had been held prior lft abnormalities while on clarithromycin and ethambutol for disseminated ), who presents w/ increased dry cough x 5 days, fever, l-sided abdominal pain and ruq pain. pt noted began having fevers approximately 1 week ago associated with this worsening dry cough. day after onset of symptoms he had an outpt appointment with his primary care physician at which time they got a cxr which was normal. pt noted worsening of these symptoms throughout the week until presentation. states this is similar to the symptoms he has had in the past when he was diagnosed with pcp. note, pt had been on bactrim prophylaxis for pcp which was /ced lft abnormalities (as mentioned above). he was then started on pentamadine inh pcp prophylaxis which he recieved his first dose of 5 weeks pta - was scheduled to get his 2nd pentamadine prophylaxis the week pta but did not make appointment. pt also noted onset of l-sided abdominal pain and ruq pain day pta. he does report diarrhea, which he describes as "loose stools" approximately 5 times/day, but he has had this ever since restarting the haart therapy in . denies any blood in the stool. denies nausea. ros otherwise negative for chest pain/pressure, sick contacts, sob, dysuria, weight changes. past medical history: 1. hiv/aids, cd4 nadir 5. 2. history of recurrent pcp. 3. eczema. 4. hsv. social history: mr. was diagnosed around with hiv and has been on haart intermittently since then. he lives with his partner, , who is hiv negative, in w/ one roommate. he was recently laid off from his job in an accounting firm and is currently unemployed and w/o insurance or a way to pay for medications. a case manager is looking into his options. he has had problems w/ noncompliance w/ his meds, though he expresses the desire to start taking them again. his parents and 3 of 5 siblings live in the area, with whom he states he has a good relationship. he started smoking cigarettes 6 yrs ago and smokes 1 ppd. he has used crystal meth for 2 yr when he goes clubbing, but denies other drug use, though cocaine and ecstasy use are recorded in some records. he does not drink etoh. family history: - father mi , living - paternal grandomother- mi - maternal grandmother- dm physical exam: vitals - t 98.7, hr 78, bp 127/68, rr 20, o2 98% 2l general - awake, alert, nad heent - perrl, eomi, op clear w/out thrush/lesions, neck - no cervical lad heart - rrr +s1, s2, no m/r/g lungs - scattered rhonci at bases b/l, otherwise cta abd - tender to palpation in luq, lll, ruq - difficult to assess as patient was voluntary guarding, although no noted involuntary guarding, rebound. + bs x 4 q ext - no edema in le b/l skin - no noted rashes neuro - a+ox3 pertinent results: labs on admission: 11:49pm blood type-art po2-66* pco2-28* ph-7.47* calhco3-21 base xs--1 intubat-not intuba 02:15pm blood wbc-7.1 rbc-3.31* hgb-9.3* hct-27.4* mcv-83 mch-28.0 mchc-33.8 rdw-19.7* plt ct-220 02:15pm blood neuts-77* bands-3 lymphs-10* monos-5 eos-0 baso-0 atyps-5* metas-0 myelos-0 02:15pm blood glucose-102 urean-15 creat-0.6 na-127* k-4.1 cl-94* hco3-24 angap-13 02:15pm blood alt-19 ast-39 ld(ldh)-247 alkphos-548* amylase-33 totbili-3.7* dirbili-2.5* indbili-1.2 02:15pm blood albumin-2.5* calcium-7.8* phos-2.9 mg-2.0 on tranfer to micu: 06:43pm blood type-art po2-347* pco2-23* ph-7.17* calhco3-9* base xs--18 06:51pm blood type-art po2-132* pco2-33* ph-7.10* calhco3-11* base xs--18 07:40pm blood type- po2-61* pco2-28* ph-7.24* calhco3-13* base xs--13 07:44pm blood type-art po2-484* pco2-25* ph-7.32* calhco3-13* base xs--11 11:01pm blood type-art temp-34.4 rates-16/ tidal v-650 peep-5 fio2-50 po2-224* pco2-28* ph-7.42 calhco3-19* base xs--4 intubat-intubated vent-controlled 01:35am blood type-art temp-36.2 rates-/20 tidal v-600 peep-5 fio2-40 po2-179* pco2-29* ph-7.42 calhco3-19* base xs--3 intubat-intubated on discharge: 05:33am blood wbc-3.4* rbc-3.60* hgb-10.3*# hct-30.6* mcv-85 mch-28.8 mchc-33.9 rdw-19.2* plt ct-292 05:33am blood glucose-152* urean-16 creat-0.6 na-132* k-3.8 cl-104 hco3-20* angap-12 03:19am blood alt-27 ast-40 ck(cpk)-20* alkphos-491* totbili-1.4 05:33am blood calcium-7.9* phos-2.8 mg-2.0 micro data: urine cx - negative blood cx - ngtd blood cx - ngtd fungal blood cx - ngtd urine cx - negative csf fluid - cryptococcal ag negative, lp unimpressive, cx ngtd blood cx - ngtd fungal blood cx - ngtd cmv viral load - pending blood cx - ngtd cmv viral load ngtd imaging: cxr: no focal consolidation appreciated. questionable diffuse and symmetric haziness could relate to technique, but infection such as pcp cannot be excluded. ct thorax: 1. prominent interstitial markings in both lungs, more pronounced in the lower lobes consistent with given history of pcp . 2. free fluid in the pelvis. 3. apparent thickening of the sigmoid bowel wall. this could be secondary to under distension. however, inflammatory/infectious process can give similar appearance. c-spine study: no fracture identified ruq u/s: normal son appearance of the liver. there is no biliary dilatation as clinically questioned. there is mild dilatation of the common duct, which is likely secondary to the patient's status of cholecystectomy. dilated splenic vein raises possibility of portal hypertension mri head: mild age inappropriate prominence of sulci and ventricles and subtle increased periventricular hyperintensities could be secondary to hiv encephalopathy. there is no enhancing lesion or acute infarct seen. brief hospital course: the patient is a 38yo man with hiv/aids (last cd4 count = 5 and last viral load = 100k in when off of haart, currently back on haart), history of recurrent pcp infections, not on pcp prophylaxis on admission who presented with increased cough and fevers x 5 days. was febrile on admission to 101-102, with cxr on admission c/w pcp infection, had abg with pao2 = 66 also c/w pcp. was started on bactrim and 40 mg prednisone given pao2. on night of admission, pt was found down and seizing at the bedside and code was initiated for hypoxic respiratory failure and patient was intubated and transferred to icu. pt's seizure was thought to be secondary hypoxia in the setting of the pt's likely pcp infection coupled with ambulation off of oxygen. pt. was admitted to the micu on s/p respiratory failure and seizure. bp was low initially in the micu, requiring pressors and concerning for sepsis vs secondary to medications used for intubation. therefore he was initially started on vancomycin and zosyn which were subsequently d/ced after no further signs of infection, and was maintained throughout micu stay on bactrim and steroids. he received an lp in the micu that was notable for no wbcs or rbcs. micu course significant for cxr which showing diffuse haziness with no consolidation, ct showing prominent interstial markings in lungs, free fluid in the pelvis and thickening of the sigmoid wall (?concerning for infectious colitis), c-spine was negative for fractures. blood cultures, fungal blood cultures, cryptococcal antigen (in serum and csf), cmv viral load were all sent and were negative or no growth to date on discharge. pt was quickly weaned off levophed and extubated, and returned to regular medicine floor. on medicine floor, patient maintained on bactrim and steroids. oxygenation was measured at > 96% on ra. prior to discharge, patient had ambulatory oxygenation which was > 96%. patient was discharged with instructions to complete 21 day course of bactrim and prednisone taper (40mg x 5 days, 40mg qd x 5 days, 20mg qd x 5 days) and with instructions to follow up with dr. in clinic. in terms of the abdominal ct that demonstrated ? sigmoiditis, pt had complained of abdominal pain on admission with ruq u/s that ruled out any biliary process, and abdominal pain quickly resolved on admission, without complaints of worsening diarrhea from baseline. therefore no further work up was performed as an inpatient with plans to address as an outpatient as needed. pt was also anemic on admission, with hct = 27, dropping to 25 during hospital course. etiologies thought to include marrow suppression vs. anemia of chronic disease. pt was transufed 2 units of packed red blood cells with appropriate bump of hct and was discharged with hct = 30.6. patient also with hyponatremia to 127 on admission (baseline na = 133-138). as patient appeared euvolemic on exam, this was thought secondary to siadh likely to pcp . hyponatremia resolved during hospitalization and treatment of pcp and patient was discharged with na = 132. in terms of pt's hiv/aids, maintained on haart therapy throughout hospital course, lfts monitored and showed elevated t. bili and alk phos (c/w immune reconstitution syndrome per dr. but flat transaminases. of note, pt with mri prior to discharge which showed some changes that could be c/w hiv encephalopathy. patient was agitated prior to d/c, but at baseline per previous caregivers. remained alert and oriented x 3 without mental status changes throughout hospital course. medications on admission: clarithromycin 500mg ethambutol 500mg qd kaletra 3 tabs zerit 30mg truvada 1tab qd amphotericin b swish and swallow folic acid 1mg qd cyanocobalamin 100mcg qd discharge medications: 1. clarithromycin 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. lopinavir-ritonavir 133.3-33.3 mg capsule sig: three (3) cap po bid (2 times a day). 3. stavudine 30 mg capsule sig: one (1) capsule po q12h (every 12 hours). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. cyanocobalamin 100 mcg tablet sig: 0.5 tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. ethambutol 400 mg tablet sig: one (1) tablet po daily (daily). 8. ethambutol 100 mg tablet sig: one (1) tablet po once a day. 9. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: two (2) tablet po tid (3 times a day) for 21 days: complete 21 day course, through (began course on ). disp:*qs tablet(s)* refills:*0* 10. amphotericin b 100 mg/ml suspension sig: twenty (20) mg po qid (4 times a day): 5 ml wash, 4 times/day. 11. prednisone 20 mg tablet sig: two (2) tablet po see other instructions for 21 days: 40mg 40mg qd 20mg qd . disp:*qs tablet(s)* refills:*0* 12. truvada 200-300 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: 1.) pcp 2.) hypoxic respiratory failure discharge condition: stable. patient oxygenating well on room air at rest. ambulating oxygenation is good. on bactrim and prednisone. discharge instructions: 1.) please contact physician if increased cough, shortness of breath, fevers > 100.4, change in mental status, any other questions or concerns 2.) please take medications as directed 3.) please follow up with appointments as instructed followup instructions: 1.) provider: , md where: phone: date/time: 1:30 2.) provider: , m.d. where: center phone: date/time: 9:00 md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Spinal tap Incision of lung Insertion of endotracheal tube Diagnoses: Other convulsions Human immunodeficiency virus [HIV] disease Acute respiratory failure Pneumocystosis Other disorders of neurohypophysis

history of present illness: this is a 36 year old male with hiv who presented on , with intermittent fevers, chills and diaphoresis times five weeks, progressive shortness of breath and cough times two to three weeks. the cough was productive of white sputum. the patient also reports a sore throat, nausea and vomiting times one. he was seen in clinic on , and given a short course of bactrim, which improved his symptoms temporarily. review of systems: the patient denies headache, neck stiffness, chest pain, orthopnea, edema, abdominal pain, diarrhea, dysuria, erectile or penile discharge, blood in urine or stool. he reports a ten pound weight loss in the last five weeks. he has a new rash over his chest which is non-pruritic and nontender. past medical history: 1. human immunodeficiency virus diagnosed in . on , cd4 264; viral load greater than 100,000. the patient has been on various haart regimens in the past. treatment was complicated by skin reactions. the patient self discontinued his last regimen about a year ago secondary to skin rashes. he denies prior opportunistic infections. 2. status post cholecystectomy. medications on admission: 1. tylenol p.r.n. allergies: unspecified hiv medications cause a skin rash. social history: the patient with smoking history of pack per day times ten years. no smoking in the last five weeks prior to admission. the patient reports social ethanol use and occasional cocaine use. the patient is a homosexual in a monogamous relationship times five years. he is an accountant. physical examination: on admission, vital signs are temperature 98.4 f.; pulse 87; blood pressure 117/60; respiratory rate 24; saturation of 95% on room air. in general, a thin male, tachypneic, no accessory muscle use, speaking in complete sentences. heent: pupils are equal, round and reactive to light. sclerae anicteric. oropharynx and tongue with white plaques. neck: no lymphadenopathy, jugular venous distention or thyromegaly. cardiac: regular rate and rhythm; normal s1 and s2. no murmurs, rubs or gallops. lungs: bibasilar crackles, rare inspiratory rhonchi, right base, no egophony. abdomen: soft, nondistended, nontender. no hepatosplenomegaly. normoactive bowel sounds. extremities warm, no edema. two plus distal pulses. skin: erythematous macular rash over chest and back. no lesions over extremities, palms or soles. laboratory: on admission, hematocrit 36.4, platelets 208, glucose 141, bun 12, creatinine 0.7. sodium 129, potassium 4.3, chloride 93, bicarbonate 24, ld 712. chest x-ray with bilateral diffuse pulmonary interstitial opacities; finding compatible with pneumocystis carinii pneumonia. hospital course: 1. pulmonary: the patient was admitted to , due to respiratory decompensation. he was treated empirically with bactrim and high dose of steroids for pcp . the patient initially responded well to treatment and was transferred to the floor . on , sputum culture was positive for pcp. patient's respiratory status decompensated , requiring intensive care unit transfer and intubation. the patient was started on ganciclovir, levofloxacin, flagyl and ampicillin, to treat possible co-infection. ganciclovir was discontinued on , as cmv viral load 812 copies felt to be not a significant contributor to respiratory decompensation. on , levofloxacin, flagyl and ampicillin was discontinued and vancomycin started to cover possible methicillin resistant staphylococcus aureus, ventilator associated pneumonia as the patient grew gram positive cocci in sputum. respiratory status improved and the patient was extubated on , and vancomycin discontinued. on , the patient with tachypnea and hypoxia with oxygen saturation 88 to 91% on non-rebreather following possible aspiration. the chest x-ray with bilateral fluffy infiltrates. the patient was transferred to the intensive care unit and started on ceftazidine and vancomycin. he was re-intubated on , for respiratory distress. he was extubated , and ceftazidine and vancomycin discontinued as decompensation was felt secondary to chemical pneumonitis from aspiration rather than super infection. on , left subclavian line was removed. the patient had a right picc line placed. after removal of the left subclavian line, the patient desaturated to 40% on non-rebreather, and the patient was reintubated. a ct angiogram confirmed right lower lobe subsubmental thrombus and heparin drip on weight based protocol was started. the patient's respiratory status improved and the patient was extubated . coumadin was started on , and the patient was transferred to the floor on . following transfer to the floor, the patient's respiratory status remained good. oxygen saturation 96% on room air at rest, decreasing to 92% with moderate exertion. on the day of discharge, the patient had completed a 21 day course of bactrim for pcp and had begun a steroid taper. at the time of discharge, the patient was on a heparin drip and coumadin 7.5 mg p.o. q. h.s. for goal inr of 2.0 to 3.0. at the time of discharge, inr was 1.2. the patient will continue coumadin for six months. 2. myocardial infarction: following pulmonary embolism , ekg with new q in iii and avf with st elevations in iii, avf, v1, v2. cardiac enzymes were ck 273, troponin 0.53. as the patient was already on heparin, no further cardiac treatment was started. cardiac enzymes continued to normalize throughout the remainder of his hospital stay. the patient will follow-up with cardiologist as an outpatient. on , an echocardiogram showed a normal left atrium, no atrial septal defect, left ventricular ejection fraction of 70%; dilated right ventricle with decrease in function, trivial mitral regurgitation, no pericardial effusion. for cardiac function, the patient was started on metoprolol and lisinopril. 3. human immunodeficiency virus: the patient was started on azithromycin for mac prophylaxis. the patient received a ten day course of acyclovir for crusting on nares felt to be likely herpes. the infectious disease team decided to wait to start haart regimen until the patient had been extubated for at least a week. the patient is to follow-up with dr. as an outpatient who will start an haart regimen. as mentioned above, ganciclovir had been discontinued on , due to low viral load. on , cmv 6690. infectious disease service recommended holding adding ganciclovir for now. the patient to follow-up with dr. an outpatient. the patient will have cmv viral titer drawn in one week post discharge and dr. will decide if ganciclovir is warranted. the patient received an ophthalmology consultation on , to rule out cmv retinitis and cmv retinitis was felt unlikely. given increase in cmv viral load at time of discharge, ophthalmology reconsulted. recommendations were pending at time of discharge. 4. hyponatremia: the patient with low sodium throughout admission, reaching a nadir on , at 125. renal studies were consistent with syndrome of inappropriate diuretic hormone. this was felt secondary to a pulmonary process. the patient's sodium stabilized at 131 and as the patient was asymptomatic, no further treatment was pursued. 5. anemia: the patient was noted to have an anemia ranging at 26 to 34 during current admission. iron studies were consistent with anemia of chronic disease. hematocrit stabilized at the time of discharge to 34.7. 6. pancreatitis: the patient noted to have elevated amylase and lipase on ; amylase was 204 and lipase 172. the patient was asymptomatic and pancreatitis was felt secondary to bactrim. although bactrim was continued, amylase and lipase normalized to lipase of 53 and lipase was 76 at time of discharge. condition on discharge: stable. discharge status: to acute rehabilitation facility. discharge diagnoses: 1. acute respiratory failure. 2. pneumocystis carinii pneumonia. 3. myocardial infarction. 4. pulmonary embolism. 5. human immunodeficiency virus. discharge medications: 1. heparin drip on weight based protocol. 2. guaifenesin 5 to 10 ml p.o. q. six hours. 3. nystatin 100 per ml oral suspension, 5 ml four times a day. 4. albuterol and atrovent mdi, two puffs q. six hours p.r.n. shortness of breath or wheezing. 5. zolpidem 5 mg p.o. q. h.s. p.r.n. insomnia. 6. docusate sodium 100 mg p.o. twice a day. 7. prednisone 40 mg p.o. q. day times five days; until . 8. prednisone 20 mg p.o. q. day times five days; until . 9. prednisone 10 mg p.o. q. day times five days; until . 10. warfarin 5 mg p.o. q. h.s. 11. lantoprazol 30 mg p.o. q. day. 12. azithromycin 1200 mg p.o. q. week. 13. lisinopril 2.5 mg p.o. q. day. 14. metoprolol 12.5 mg twice a day. 15. asa 325 mg p.o. q. day. discharge instructions: 1. the patient to be discharged to acute rehabilitation facility. 2. the patient is to follow-up with primary care physician. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Subendocardial infarction, initial episode of care Human immunodeficiency virus [HIV] disease Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pneumocystosis Methicillin susceptible pneumonia due to Staphylococcus aureus Other disorders of neurohypophysis Cytomegaloviral disease Acute pancreatitis

history of present illness: a 36-year-old male with hiv, cd4 count 264, viral load 100,000 on , presented , with intermittent fevers, chills, diaphoresis times five weeks, progressive shortness of breath and cough times two to three weeks. cough is occasionally productive of white sputum. he also complains of a sore throat, nausea and vomiting. he was seen at clinic , and given a short course of bactrim which improved his symptoms temporarily. review of systems: the patient denies headache, neck stiffness, chest pain, orthopnea, edema, abdominal pain, diarrhea, dysuria, rectal or penile discharge, or blood in urine or stool. he reports ten pound weight loss. he has new rash over his chest which is non-pruritic, non-tender. past medical history: 1. hiv since approximately . on , cd4 264, viral load greater than 100,000. patient has been on a variety of haart regimens in the past complicated by skin reactions. he self discontinued his last regimen about a year ago. he denies any opportunistic infections. 2. status post cholecystectomy. medications on admission: tylenol p.r.n. allergies: hiv medications unspecified. reaction is a skin rash. social history: smoking one-half pack per day times ten years. none in the past five weeks. patient reports social alcohol use. he also reports occasional cocaine use. he is a homosexual in a monogamous relationship for the last five years. he works as an accountant. physical examination on admission: vital signs: temperature 98.4, pulse 87, blood pressure 117/60, respirations 24, oxygen saturation 95% on room air. general: tachypneic, no accessory muscle use. speaking in complete sentences, no acute distress, thin male. heent: pupils equal, round and reactive to light, sclerae anicteric, oropharynx and tongue with white plaques. neck: no lymphadenopathy, jugular venous distention or thyromegaly. cardiac: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops. lungs: bibasilar crackles, rare inspiratory rhonchi right base, no egophony. abdomen: soft, non-distended, non-tender, no hepatosplenomegaly. normoactive bowel sounds. extremities: warm, no edema, 2+ distal pulses. skin: erythematous macular rash over chest and back, no lesions in extremities, palms or soles. laboratory on admission: white blood cell count 10.2, hematocrit 36.4, platelet count 208,000, glucose 141, bun 12, creatinine 0.7, sodium 129, potassium 4.3, chloride 93, bicarbonate 24, ldh 712. radiology: chest x-ray with bilateral interstitial infiltrates greater on the right than on the left, no cardiomegaly, no pleural effusions. summary of hospital course: 1. pulmonary: the patient admitted to , for increased respiratory distress. patient started empirically on bactrim and high dose steroids for pcp pneumonia to which he responded well and was transferred to the floor . sputum culture at that time positive for pcp and patient was continued on bactrim and steroids. his respiratory status decompensated , and he required intensive care unit transfer and intubation. the patient was started on ganciclovir to cover positive cmv antibody, levofloxacin, flagyl and ambazone to treat possible co-infection. cmv viral load from , 812 ______. ganciclovir discontinued as given low cmv viral load, cmv was not considered to be a significant contributor to respiratory function. levofloxacin, flagyl and ambazone discontinued , and vancomycin started to cover possible methicillin-resistant staphylococcus aureus ventilator acquired pneumonia as sputum was positive for gram positive cocci. respiratory status improved and patient was extubated , and vancomycin discontinued. on , patient presented with increased tachypnea and hypoxia. oxygen saturation 88-91% on nrb following possible aspiration. chest x-ray with bilateral fluffy infiltrates. patient transferred to intensive care unit and started on ceftazidime and vancomycin. reintubated , for respiratory distress. patient extubated , and ceftazidime and vancomycin discontinued as decompensation felt due to chemical pneumonitis rather than super infection. on , left subclavian central line was removed as patient had right picc, after which patient suddenly desaturated to 40% on nrb. patient was reintubated. ct angiogram confirmed right lower lobe subsegmental thrombus and heparin weight based protocol was started. patient was extubated , which he tolerated well. coumadin started . at time of discharge, patient had completed a 21 day course of bactrim, and status improved. scheduled for gradual prednisone taper. oxygen saturation 96% decreasing to 92% with mild activity. 2. cardiac: following pe patient's electrocardiogram showed new acute q-waves in iii and avf with st elevations in iii, avf, v1, v2. cardiac enzymes revealed ck 273, troponin 0.53. patient was already on heparin drip for pe. myocardial infarction felt secondary to heart strain in setting of pe with history of cocaine use. cardiac enzymes continued to normalize through hospital stay. patient to follow up with cardiology as outpatient. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Subendocardial infarction, initial episode of care Human immunodeficiency virus [HIV] disease Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pneumocystosis Methicillin susceptible pneumonia due to Staphylococcus aureus Other disorders of neurohypophysis Cytomegaloviral disease Acute pancreatitis

history of present illness: this is a 36 year old male with hiv, presents with intermittent fever, chills, diaphoresis times five weeks, progressive shortness of breath and cough times two to three weeks. cough is productive of white sputum. he also complains of sore throat, nausea and vomiting times one. the patient was seen at clinic on and given short course of bactrim which improved symptoms only temporarily. review of systems: no headache, neck stiffness, chest pain, orthopnea, edema, abdominal pain, diarrhea, dysuria, rectal or penile discharge, or blood in urine or stool. the patient reports ten pound weight loss over the last five weeks. the patient notes new rash on chest which is non pruritic and nontender. past medical history: 1.) hiv diagnosed in . cd-4 count was 264. viral load greater than 100,000. the patient has been on various haart regimens in the past, complicated by skin reactions. the patient self-discontinued his last regimen about a year ago. the patient denies prior opportunistic infections. 2.) status post cholecystectomy. medications on admission: tylenol prn. allergies: hiv medications, unspecified. reaction is a skin rash. social history: the patient reports smoking one-half pack per day times ten years, none in the past five weeks. he reports social alcohol consumption and occasional cocaine use. the patient is homosexual in a monogamous relationship times five years. the patient is an accountant. physical examination: on admission, temperature is 98.4; pulse 87; blood pressure 117/60; respiratory rate 24; saturation 95% on room air. general: thin male, appearing fatigued, tachypneic, no accessory muscle use. the patient is able to speak incomplete sentences. head, eyes, ears, nose and throat: pupils are equal, round, and reactive to light and accommodation. sclera anicteric. oropharynx and tongue with white plaques. neck: no lymphadenopathy, jugular venous distention or thyromegaly. cardiac: regular rate and rhythm, normal s1 and s2, no murmurs, rubs or gallops. lungs: bibasilar crackles, rare inspiratory rhonchi, right base. no egophony. abdomen: soft, nontender, nondistended, no hepatosplenomegaly, normoactive bowel sounds. extremities: warm with no edema and 2+ distal pulses. skin: erythematous macular rash over chest and back. no lesions over extremities, palms and soles. laboratory data: white blood cell count of 10.2; hemoglobin of 12.8; hematocrit of 36.4; platelets 208. glucose 141; bun 12; creatinine 0.7; sodium of 129; potassium of 4.3; chloride 93; bicarbonate 24; ldh 712. chest x-ray with diffuse bilateral increased pulmonary parenchymal opacity. no evidence of pneumothorax or pleural effusion. soft tissue and osseous structures unremarkable. hospital course: 1.) pulmonary: the patient was admitted to on for respiratory decompensation. started on empiric bactrim and high dose steroids for pcp. patient responded well to treatment and was transferred to medical floor on . on , sputum cultures were positive for pcp. patient's respiratory status decompensated on and the patient required transfer to intensive care unit and intubation. he was started empirically on ganciclovir, levofloxacin, flagyl and ambazone to treat possible coinfection. cmv viral load, 812. ganciclovir was discontinued as low viral count of cmv was felt unlikely to contribute to respiratory status. on , levofloxacin, flagyl and ambazone were discontinued and vancomycin was begun to cover possible methicillin resistant staphylococcus aureus ventilator associated pneumonia as the patient grew gram positive cocci in sputum. respiratory status improved and the patient was extubated on and vancomycin was discontinued. on , the patient with tachypnea and hypoxia with oxygen saturations 88 to 91% on nrb, following possible aspiration. chest x-ray at that time showed bilateral and fluffy infiltrates. the patient was transferred to intensive care unit and empirically treated with ceftazidime and vancomycin. the patient was reintubated on for respiratory distress. his respiratory status improved and he was extubated on and ceftazidime and vancomycin were discontinued at that time as decompensation was felt secondary to a chemical pneumonitis from aspiration rather than super infection. on , the patient's left subclavian line was removed as the patient had right picc line placed, after which the patient desaturated to 40% non rebreather and required reintubation. ct angiogram confirmed right lower lobe subsections thrombus and heparin drip was started. the patient's respiratory status improved and the patient was extubated on and started on coumadin on . the patient was transferred to the floor on where respiratory status has remained good with oxygen saturation 96% on room air at rest, decreasing to 92% on room air with ambulation. at the time of the discharge, the patient remains on heparin as coumadin is not yet therapeutic. goal inr of two to three. inr at the time of discharge is 1.2. the patient will be discharged off heparin when coumadin is therapeutic. at the time of discharge, the patient had completed a 21 day course of bactrim for pcp pneumonia and had begun prednisone taper. 2.) cardiac: following pulmonary embolism on , electrocardiogram showed new q waves in iii and avf with st elevations in iii, avf, v1, v2. cardiac enzymes showed ck of 273 and troponin of 0.53. the patient likely had a myocardial infarction in the setting of strain due to a pulmonary embolism, in the setting of prior use of cocaine. of note, pulmonary embolism occurred while the patient was on subcutaneous heparin. the patient is to follow-up with cardiologist as an outpatient. 3.) hiv: the patient is currently markedly immunocompromised secondary to hiv. the patient was placed on azithromycin mac prophylaxis. the patient received a seven day course of acyclovir for crusty nasal lesions felt consistent with hsv. as mentioned above, low cmv viral load at 812 copies, felt noncontributory to pulmonary status. at that time, ophthalmology was consulted and performed dilated funduscopy. at that time, findings were not consistent with cmv retinitis and the patient was taken off ganciclovir. however, follow-up cmv viral load on was 6,690. infectious disease service felt that ganciclovir was not warranted at this time and scheduled outpatient follow-up with dr. . the patient received repeat cmv viral titers on to have results forwarded to dr. . dr. will determine whether ganciclovir should be instituted. the patient received a repeat ophthalmology evaluation on which noted normal eye examination, no evidence of cmv retinitis. at this time, the patient remains off any haart regimens. dr. will institute appropriate regimen as an outpatient. 4.) fluids, electrolytes and nutrition: the patient noted to have hyponatremia on admission. sodium remained low throughout admission, reaching nadir at of 125. hyponatremia was thought likely to be due to ciadh based on renal studies as patient had significant pulmonary process. the patient's sodium stabilized at 131 at the time of discharge. the patient will require further follow-up but, as the patient is asymptomatic with stable sodium, no treatment was undertaken at this time. 5.) gastrointestinal: the patient was noted to have increased amylase and lipase on with amylase 703 and lipase of 172. this was felt likely due to bactrim. the patient remained on bactrim and amylase and lipase returned to levels at the time of discharge, with amylase of 76 and lipase of 53. at the time of transfer to floor , the patient was noted to have a four cm, mildly tender right mid abdomen mass. potential causes include hernia as patient has a history of distant cholecystectomy. however, lymphoma needs to be considered given the patient's immunocompromised status. the patient will be worked up for this mass as an outpatient. 6.) hematology: the patient was noted to have anemia on admission with hematocrit reaching nadir of 29.8 on . however, hematocrit stabilized at 34.7 at the time of discharge. prior work-up for anemia on consistent with anemia of chronic disease. the patient will require further evaluation of anemia as an outpatient with primary care physician. condition on discharge: stable. discharge status: to acute rehabilitation facility. discharge diagnoses: respiratory failure. pneumocystis carinii pneumonia. pulmonary embolism. myocardial infarction. hiv. discharge medications: heparin drip on weight base protocol. guaifenesin 5 to 10 mls p.o. every six hours. nystatin swish and swallow four times a day. wolfram 7.5 mg p.o. q h.s. lansoprazole 30 mg p.o. q. day. azithromycin 1,200 mg p.o. q. week. lisinopril 2.5 mg p.o. q. day. metoprolol 12.5 mg twice a day. asa 325 mg p.o. q. day. prednisone 40 mg p.o. q. day times five days, to . prednisone 20 mg p.o. q. day times five days, to . prednisone 10 mg p.o. q. day times five days, to . dulcosate sodium 100 mg p.o. twice a day. senna 15 mls p.o. q. day. zolpidem 2.5 mg p.o. q h.s. albuterol and atrovent mdi q. six hours prn p.o. q h.s. prn. follow-up: the patient is to follow-up with on at 11:00 a.m. at vi at . the patient is to follow-up with dr. from cardiology on a.m. the patient is to follow-up with primary care physician, on at 1:15 p.m. the patient will be discharged to rehabilitation facility. the patient will require cmv viral titer on with results sent to dr. . , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Subendocardial infarction, initial episode of care Human immunodeficiency virus [HIV] disease Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pneumocystosis Methicillin susceptible pneumonia due to Staphylococcus aureus Other disorders of neurohypophysis Cytomegaloviral disease Acute pancreatitis

phm: hiv s/p ccy, allergies: antiviral meds ...rash, social: significant other with patient on transfer and went home for the night. Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for less than 96 consecutive hours Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Subendocardial infarction, initial episode of care Human immunodeficiency virus [HIV] disease Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Pneumocystosis Methicillin susceptible pneumonia due to Staphylococcus aureus Other disorders of neurohypophysis Cytomegaloviral disease Acute pancreatitis

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: - cardiac catheterization with iabp placement - cabgx3(svg->lad, svg->om1, svg->pda), avr(23mm magna pericardial valve) re- exploration of mediastinum and picc line placement history of present illness: 52yo male w/ mmp who presented to osh after the onset of cp at rest. described cp as pressure in the center of his chest that radiated across the base of his chest bilaterally and up to his throat. it was not associated w/ sob, n/v or diaphoresis. it lasted for about 15 mins, but he had no nitro in the house, so he called ems. was given 4 baby asa by ems and nitro x1 in the er before his cp resolved. first set ce at osh were negative. had repeat episode of cp at 5am, resolved on its own. again, had another episode of cp while boarding the helicopter for transport here. was given fentanyl w/ resolution of his pain. . last episode of cp was at hospital. was there for l subclavian vein stenting and in pacu, developed cp similar in character to what he felt last night. was kept in the hospital for 1 week and underwent a chemical stress test which he says revealed "abnormalities" but nothing that had to be dealt with immediately. on discharge, he was told to resume taking asa daily. he had not been taking asa or plavix since when he underwent surgery for his decubitus ulcers. . last evening, at osh, he was given asa 325 + sl ntg w/ relief of his cp. ekg on admission showed st depression in v5-6, with ? twi i, ii. q waves in iii, avf. overnight, he did well until 5am when he developed chest heaviness. it resolved on its own, but his ekg showed worsening st depressions in v5 and v6 and his tropi increased from <0.1 to 1.6 (ck 45 -> 54). the decision was made to transfer him to for emergent cath. he was set for ground transport when he began to develop cp again. he was instead medflighted here as his bp was also tenous (sbps in 80s-90s). he was started on reopro, heparin, and plavix (600mg x1) and was transferred straight to the cath lab. in the cath lab, it was found that he has in-stent restenosis and needs surgical intervention. plan is to take him to cabg once vascular imaging performed to identify suitable grafts. iabp placed in cath lab and referred to dr. for urgent cabg. past medical history: 1. cad s/p des in lad and cx 2. dm - on riss for fs >200, mostly diet controlled 3. htn 4. esrd, s/p lrrt in on chronic immunosuppression, but transplant failed , now on hd tu/th/sat 5. copd/asthma 6. h/o recurrent uti's w/ vre and resistant proteus (s/p kidney/bladder removal with neobladder formation and urostomy) 7. h/o mrsa in sputum 8. spina bifida (wheel chair dependent) 9. stage iii/iv sacral decubitus ulcers 10. anemia, h/o guaiac positive stools and hemmorrhoids 11. possible newly dx hcv 12. possible h/o calciphalaxis(?) 13. nstemi social history: lives alone at home. no tob currently, no etoh, no ivdu. smoked 1.5 packs/day x 5 years, quit 30 yrs ago. thinks received hep c from blood tx or kidney transplant. family history: brother died of mi in 50s; sister w/ angioplasty in her 50s; m and mgm w/ cad, died of mis in 50s. physical exam: vs: t 96.2, hr 86-96, bp 85-100/47-60, rr 19, sats 97% on 2l iabp: ass systole 82, diastole 84, baedp 60, iabp mean 79, sys unloading 18, diastolic unloading 1 gen: obese male, lying in bed, in nad. heent: ncat, sclera anicteric, mmm. neck: neck obese, jvp not appreciated. cv: rr, normal s1, s2. iii/vi systolic murmur, best heard at lusb, does not radiate to apex. lungs: cta anteriorly. no crackles/wheezes/rhonchi. abd: soft, protuberant abdomen. multiple scars, large post-surgical hernia. urostomy bag in llq, site clean, no erythema or tenderness. mild tenderness in rlq, but no ecchymosis. ext: wwp. r groin w/ balloon pump in place. no c/c/e. 1+ pt and dp pulses bilaterally. 2+ radial pulses bilaterally. l forearm avf w/ palpable thrill. skin: no rashes. neuro: cn ii-xii grossly intact. pertinent results: labs on admission: 10:30am blood wbc-5.6# rbc-3.30* hgb-10.8* hct-32.1* mcv-97 mch-32.8* mchc-33.6 rdw-17.3* plt ct-155 10:00am blood pt-13.1 ptt-45.5* inr(pt)-1.1 10:30am blood glucose-93 urean-58* creat-5.6* na-139 k-4.6 cl-98 hco3-25 angap-21* 10:30am blood alt-7 ast-14 ck(cpk)-49 alkphos-145* dirbili-0.1 10:30am blood ck-mb-notdone ctropnt-0.29* 10:30am blood albumin-3.5 calcium-9.2 phos-7.6*# mg-1.6 cholest-96 : na 138 k 5.4 chloride 96 bicarb 26 bun 53 creat 5 c. diff. negative wbc 8.2 hct 30.8 plts 116 gluc 103 micro: . imaging: cath : lmca 80% discrete lad 80% discrete lcx proximal 80% rca 100% . 1. selective coronary angiography in this right dominant circulation demonstrated severe three vessel coronary artery disease. the lmca stents had moderate distal instent restenosis. the proximal lad had an 80-90% instent restenosis. the distal lad had only mild luminal irregularities. the d1 was a small vessel, but d2 was large and had no flow limiting disease. the lcx also had an 80-90% instent restenosis. the mid lcx was widely patent. the om1 was a moderate size vessel and om2 was a large vessel. neither had any flow limiting disease. the rca had a proximal total occlusion. there were left to right, as well as, some right to right bridging collaterals noted. 2. non-selective angiograms of the rima and lima demonstrated patent vessels. there was a left subclavian vein stent noted. 3. opening central aortic pressure was 89/59mmhg. 4. an 8fr 40cc iabp was placed successfully from the right common femoral artery. . final diagnosis: 1. three vessel coronary artery disease. 2. severe instent restenosis of lm into lad and lcx stents. 3. iabp placement. 4. patent rima and lima. . cxr : (my read) - mild perihilar haziness, r costophrenic angle slightly blurred, no evidence of infiltrate, heart regular size 05:32am blood wbc-9.8 rbc-3.06* hgb-9.7* hct-30.2* mcv-99* mch-31.6 mchc-32.0 rdw-17.4* plt ct-214 05:32am blood plt ct-214 05:32am blood glucose-107* urean-36* creat-4.8*# na-141 k-4.3 cl-101 hco3-27 angap-17 echo the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular systolic function is normal. the ascending aorta is mildly dilated. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is moderate thickening of the mitral valve chordae. there is mild mitral stenosis. 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. echo prebypass: no atrial septal defect is seen by 2d or color doppler. there is mild global right ventricular free wall hypokinesis. lv is mildly hypokinetic with lvef 50%. lv is moderately dilated with borderline lvh. there are three aortic valve leaflets. the aortic valve leaflets are severely thickened/deformed. there is severe aortic valve stenosis. the mitral valve leaflets are moderately thickened. mild (1+) mitral regurgitation and mild mitral stenosis is seen. nonmobile atheroma seen in arch. iabp in descending aorta. post bypass: preserved biventricular function lvef 45-50% with no change in wall motion. bioprosthetic #23 aortic valve instiu. no as (peak gradient 8, mean 4), no ai, no perivalvular leaks. ms remains mild (mean gradient 4), mr +. aortic contours preserved. iabp position unchanged in descending aorta. remaining exam unchanged. results discussed with surgical team at time of study. brief hospital course: mr. was admitted to the on for further management of his myocardial infarction. a cardiac catheterization was performed which revealed severe three vessel disease and a intra-aortic balloon pump was placed. heparin was continued for anticoagulation and he remained pain free. given his history of end stage renal disease on hemodialysis, the renal service was consulted for assistance with his management. given the severity of his disease, the cardiac surgical service was consulted for surgical management and mr. was worked-up in the usual preoperative manner. he underwent hemodialysis on in preparation for surgery without complication. an echocardiogram was performed which showed an ejection fraction of 55%, + mitral regurgitation and moderate aortic valve stenosis with a valve area of 0.9cm2. the plastic surgery service was consulted for evaluation of his sacral decubitus ulcer and no surgical intervention was recommended at this time. the wound care nurse was asked to assist in his care throughoout his hospital stay. the infectious disease service was consulted given his history of mutiple infectious disease issues and vancomycin and zosyn were recommened perioperatively for prophylaxis. on , mr. was taken to the operating room where he underwent coronary artery bypass grafting to three vessels as well as an aortic valve replacement utilizing a 23mm magna valve. afterward he was transferred to the cardiac surgery recovery unit in stable condition and awakened neurologically intake. he required post op iabp and pressor support due to low cardiac output which was successfully weaned. on pod 2 he was transfused 2u prbc for a low hct during hd. he was aggressively diuresed toward his preoperative weight with hd, aspirin therapy was resumed, and physical therapy service was consulted to assist with his postoperative strength and mobility. electrolytes were repleted as needed. on pod 3 he had a picc line placed for continued perioperative iv vancomycin and zosyn given his history of uti, sacral decubitis infection, and intramuscular abscess. his epicardial pacing wires were removed. he subsequently became hypotensive, arrested and cpr was started. tee showed hemopericardium for which he had his sternotomy opened. an avulsed side branch of the svg->rca graft was isolated and ligated with 7-0 prolene at the bedside. mr. regained pulses and his hemodynamics stabilized. he continued to require pressor support and diuresis was accomplished using cvvhd at the bedside. on pod his chest tubes were removed without complication. on pod his pressor support was weaned and cvvhd was discontinued. he was transferred to the cardiac step down unit for further recovery. he was initially requiring daily hd until pod . at which time he resumed his qod schedule. given his need for sternal precautions his activity level was oob to chair via lift. plastic surgery was consulted for decubitus evaluation, and wound care team continued to follow him. he had some nausea on pod 14/11, amylase was 258, kub was unremarkable. repeat amylase was 124. hd continued per renal service. pain meds were changed and nausea was relieved. ot evaluation also done. hd done on and pt. cleared for discharge to rehab on pod 17/14. please see discharge plan for required follow- up instructions. medications on admission: prednisone 5mg qd toprol xl 50mg tizanidine 4mg qd lisinopril 5mg qd lipitor 80mg qd imdur 30mg qd nephrocaps lanthanum 500mg tid neurontin 100mg discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po hs (at bedtime) as needed for constipation. 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 7. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 8. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed. 10. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 11. lanthanum 250 mg tablet, chewable sig: two (2) tablet, chewable po tid (3 times a day). 12. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 13. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation q6h (every 6 hours). 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 15. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 16. acetaminophen-codeine 300-30 mg tablet sig: 1-2 tablets po every 4-6 hours as needed. 17. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed: 10 ml ns followed by 2 ml (200 units) heparin each lumen daily and prn. 18. dolasetron 12.5 mg/0.625 ml solution sig: 12.5 mg intravenous q8h (every 8 hours) as needed. discharge disposition: extended care facility: - discharge diagnosis: s/p avr/cabg x3 anemia tamponade with re-exploration of mediastinum sacral decubitus ulcer hstory of mrsa hstory of recurrent urinary tract infections with vre and resistant proteus. s/p bladder and kidney removal cad diabetes htn esrd on hd (last hd today ) copd asthma spina bifida nstemi discharge condition: stable 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 2 pounds in 24 hours or 5 pounds in 1 week. 4) adhere to 2 gm sodium diet, low fat, low cholesterol. 5) no creams, powders or lotions to wounds until they have healed. 6) no lifting greater then 10 pounds for 10 weeks. 7) no driving for 1 month. p instructions: follow-up with dr. in 4 weeks. follow-up with cardiologist follow-up with primary care physician . in 2 weeks. follow-up with nephrologist as instructed. call all providers for appointments. Procedure: Venous catheterization, not elsewhere classified (Aorto)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Coronary arteriography using two catheters Left heart cardiac catheterization Hemodialysis Incision of mediastinum Open and other replacement of aortic valve with tissue graft Implant of pulsation balloon Diagnoses: End stage renal disease Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Cardiac complications, not elsewhere classified Aortic valve disorders Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Unspecified disease of pericardium Other complications due to other cardiac device, implant, and graft Pressure ulcer, lower back Chronic obstructive asthma, unspecified Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Spina bifida without mention of hydrocephalus, unspecified region Paraplegia

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain, fever, chills major surgical or invasive procedure: cardiac catheterization debridement of sacral ulcers history of present illness: this is a 52 yo male with multiple medical problems including esrd s/p failed renal transplant on hd, dm, htn, recurrent utis with vre and resistant proteus who presented to osh with fevers, myalgias, and fatigue. he was found to be hypotensive with presumed urosepsis and was started on vanc/gent/linezolid/ceftaz and on neo. during the hospitalization, he developed cp radiating to the jaw with ecg changes and elevated ck (600) and trop i (28). pt was started on heparin but cardiac catheterization was deferred pending stabilization from urosepsis. pt experienced a second episode of cp which was relieved with ntg, but with new lateral st depressions. at this time, a combination of cardiogenic and septic shock was suspected and a tte was done, showing new global hk w/ ef 30%, ant//apical hk, worsening as, severe pa htn, dilated rv, and severe tr. pt was started on dopamine instead of neo, placed on heparin, asa, plavix, and transferred to for cardiac catheterization. past medical history: 1. dm 2. htn 3. esrd, s/p renal transplant , transplant failed , now on hd 3. copd 4. asthma 5. hx recurrent uti's w/ vre and resistant proteus (s/p kidney/bladder removal with neobladder formation and urostomy) 6. hx mrsa in sputum 7. spina bifida (wheel chair dependent) social history: lived independently, no cigarette smoking, no alcohol use family history: brother died of mi in 50s physical exam: on admission to ccu: -vs: tc 98.0 bp 90/70 hr 90s rr 20 93%ra -gen: no acute distress -neck: without jvd -cv: regular rate and rhythm, normal s1s2, no mrg -chest: lungs with slight inspiratory wheeze in left upper lung field -abdomen: soft nt nd nabs, ostomy site at llq -extremities: warm and well perfused, trace edema -back: stage 3 ulcer on buttocks . . on admission to the floor: -vs: afebrile, 110/60, hr: 80s, rr: 12, sao2: 96% ra -gen: obese caucasian male lying in bed getting sacral decubiti cleaned by rn. nad -heent: eomi, anicteric -cv: rrr, s1, s2, ii/vi systolic murmur at lusb -chest: cta bilaterally -abd: obese, soft, bs+ -ext: w/w/p, 1+ lue edema -buttocks: 2 large sacral decubitis on buttocks both class iii with serous/faintly bloody fluid on packing, some odor (not particularly foul) . pertinent results: 02:31pm wbc-19.1* rbc-4.02* hgb-11.9* hct-38.0* mcv-95 mch-29.7 mchc-31.4 rdw-17.6* 02:31pm plt count-263 02:31pm pt-15.4* ptt-37.6* inr(pt)-1.5 02:31pm ret aut-1.7 02:31pm glucose-110* urea n-65* creat-6.2* sodium-134 potassium-4.4 chloride-93* total co2-23 anion gap-22* 02:31pm alt(sgpt)-22 ast(sgot)-16 ld(ldh)-329* alk phos-103 tot bili-0.3 02:31pm albumin-2.8* calcium-8.3* phosphate-7.1* magnesium-1.9 iron-34* 02:31pm caltibc-195* ferritin-greater th trf-150* 02:31pm tsh-0.47 05:00pm urine color-straw appear-cloudy sp -1.010 05:00pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-mod 05:00pm urine rbc-* wbc-* bacteria-many yeast-many epi- . . cardiac catheterization : **pressures right atrium {a/v/m} 14/11/12 right ventricle {s/ed} 45/14 pulmonary artery {s/d/m} 45/28/35 pulmonary wedge {a/v/m} 20/23/22 aorta {s/d/m} 85/57/68 **cardiac output heart rate {beats/min} 96 card. op/ind fick {l/mn/m2} 7.7/3.7 **resistances systemic vasc. resistance 582 pulmonary vasc. resistance 135 . **% saturation data (nl) svc low 76 pa main 76 ao 97 . 1. selective coronary angiography demonstrated a right dominant system with left main and three vessel cad. the distal left main tapered to a 80% stenosis. the lad had a 90% ostial lesion. the remainder of the lad had mild luminal irregularities. the lcx had a 80% ostial lesion. a major om2 branch had a 70% lesion in the mid vessel. the rca was occluded proximally. the distal vessel filled via collaterals from the left coronary artery and bridging collaterals. 2. resting hemodynamics demonstrated mildly elevated right sided filling pressures with a mean ra pressure of 12 mm hg and moderately elevated left sided filling pressures with a mean pcw pressure of 22 mm hg. moderate pulmonary hypertension was present. cardiac index was near the upper limits of normal (based on an assumed oxygemn consumption index) with a reduced system vascular resistance. 3. left ventriculography was not performed. 4. a 7 french 30 cc intra-aortic balloon pump was successfully placed via the right common femoral artery. this provided diastolic augmentation of blood pressure and systolic unloading of the ventricle. . final diagnosis: 1. left main and three vessel coronary artery disease. 2. elevated left sided filling pressures. 3. low systemic vascular resistance. 4. successful placement of a 7 french 30 cc intra-aortic balloon pump. . . . cardiac catheterization : **pressures aorta {s/d/m} 102/67/88 **cardiac output heart rate {beats/min} 104 rhythm sr . comments: 1. coronary angiography of this right-dominant circulation showed severe 3-vessel cad. the lmca had a distal 90% stenosis. the lad had an ostial 90% stenosis. the lcx had an ostial 90% lesion and a 90% mid vessel stenosis. the rca was totally occluded proximally. 2. resting hemodynamics showed normal central aortic blood pressure. 3. unsuccessful pci of the rca. 4. successful ptca and stenting of the lmca into the lad and lcx ostium with two double-barrel 3.0 mm cypher drug-eluting stent, which were post-dilated to 3.5 mm. final angiography showed no residual stenosis, no dissection and normal flow. 5. successful stenting of the mid lcx with a 3.0 mm cypher drug-eluting stent. final angiography showed no residual stenosis, no dissection and normal flow (see ptca comments). 6. the left common femoral arteriotomy site was closed with an 8 french angioseal with good hemostasis. . final diagnosis: 1. three vessel coronary artery disease. 2. unsuccessful pci to the rca. 3. successful stenting of the lmca into the lad and lcx. 4. successful lcx stenting. . . us: " medical condition: 52 year old man with esrd and left upper extremity fistula, now with lue edema. reason for this examination: please assess for vascular flow in lue, and flow through fistula. indication: left upper extremity edema. known history of end-stage renal disease, and left upper extremity fistula. comparison: none. left upper extremity dvt study: scale and doppler son of the left internal jugular vein, subclavian vein, brachial vein, and basilic veins were obtained. normal flow, augmentation and compressibility and wave forms are demonstrated. the left basilic vein is not well-visualized but appears patent without any evidence of thrombus. no intraluminal thrombus is identified. the left upper extremity av fistula was patent." . . urine culture (final ): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. yeast. >100,000 organisms/ml.. enterococcus res to vancomycin . 2:36 pm swab source: right buttock wound. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram negative rod(s). wound culture (preliminary): this is a corrected report (). due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for pseudomonas aeruginosa, staphylococcus aureus and beta streptococcus). previously reported as also positive for gram positive bacteria (). reported by phone to dr at 12:30pm. gram negative rod #1. sparse growth. proteus species. quantitation not available. pseudomonas aeruginosa. sparse growth. . . blood cultures , all negative to date. . . brief hospital course: a/p: 52yo male with multiple medical problems including left main and 3vd s/p ptca, esrd s/p failed cadaveric renal transplant on hd, recurrent uti with vre and proteus s/p kidney/bladder remal with neobladder formation and urostomy. . 1. cv: pt was admitted to the ccu directly from the osh and continued on linezolid, and started on gentamycin for uti. he was hemodynamically stable, requiring no pressors, and had no chest pain on arrival. on the morning after admission he developed chest pain and was started on heparin and taken to the catheterization lab where he was found to have lma, lcx, and lad disease with rca occlusion. a iabp was placed to increase perfusion. after extensive discussion with the ct surgery team, who felt that the surical mortality risk was 20%, it was decided that the pt would be taken for pci. at the second cardiac catheterization, pt received kissing stents to lad and lcx. it was recommended that he have a relook catheterization in 3 then 7 months. he tolerated the procedure well and was taken off thye balloon pump shortly after catheterization. the patient's cardiovascular medications were titrated to give him the maximum medical benefit. he was placed on asa, clopidogrel, atorvastatin, metoprolol, and lisinopril. he tolerated these medications well. he had only one more episode of chest pain, rated , which occurred during dialysis, and resolved within minutes on its own. he had no ekg changes at that time. because he has drug-eluting stents, he should remained on plavix for at least 9 months. his ef at the osh was reportedly 30%. in approximately three weeks, the patient will need a repeat tte to evaluate for interval change in his ef. his volume status was maintained at hemodialysis. he remained in sinus rhythm throughout his stay, but was often tachycardic. we were unable to decrease his beta-blocker any more, because his blood pressure was often around 100/60. his tachycardia may also have been due to pain his sacral ulcers. . 2. id: in regards to the uti, the pt has had a history of recurrent utis which in the past required the removal of his bladder, and placement of a neobladder and urostomy. from the osh, he had cultures of his urine which grew vre and proteus. the proteus was sensitive only to gentamicin and cefuroxime. he was treated with gentamicin for the proteus, and linezolid for the vre (14/14 day course completed). he remained afebrile throughout his hospital course at osh. pt complained of pain at the site of ulcers at his buttocks. plastic surgery was consulted, and his ulcers were debrided and treated with enzyme based dressings. plastic surgery felt that these ulcers were unlikely to be the source of his sepsis at osh. they recommend continuation of tid dressing changes and to consider a rectal tube to protect the dressing/tube. he will need re-evaluation by plastic surgery for a possible flap in the future. . 3. sacral decubitis ulcers: the patient has 2 stage 3 ulcers on his r and l buttocks. these were debrided at the bedside several times by plastic surgery. they felt that a flap may be necessary in the future, but was not indicated during this hospitalization. he also developed an intramuscular abscess next to his ulcer, which was incised and drained by plastics. this fluid grew proteus (not enough for sensitivities) and pseudomonas. because the patient remained afebrile, it was decided to not treat him for these, as he is likely to be colonized. . 4. renal: the patient was kept on his mon, wed, fri hemodialysis schedule. he was also kept on nephrocaps, and his phos-lo was changed to renagel as he has a history of calciphylaxis with phos-lo. he takes prednisone at home for his failed renal graft, with the thought being that it should prevent him from developing an immune response to alloantigens that would subsequently prevent him from tolerating another transplant. he was tapered to a home dose of 5 mg prednisone. . 5. anemia: as the patient was admitted with acs and significant cad, the transfusion criteria remained >30. as the patient remained on asa and plavix for his cardiac stents he remained at high risk for bleeding and was monitored closely with transfusions prn to maintain hct >30. a). the patient had 3 episodes of hemoptysis on . these consisted of coughing up small (1 cm) blood clots. he did not cough up any bright red blood. on further questioning, the patient reported having a nosebleed earlier that day. in terms of his respiratory status, he was kept on his outpatient inhalers. his oxygen saturation remained greater than 92%. on further questioning the patient admitted to having had previous nose bleeds, usually in the setting of dry/cold weather. the patient was taken off the nc as his oxygen saturation remained >92% on ra and was given a nasal spray with good effect. he remained without further episodes of hemoptysis or nose bleeds for >4 days. b). the patient was also noted to have guaiac positive stool/brbpr (little flecks of blood) on . on rectal exam he was noted to have some external hemorrhoids, although none were found to be bleeding at the time. however, as the patient had just had a cardiac catheterization in the setting of acute coronary syndrome, a colonoscopy was deferred. as he remained hemodynamically stable and hct was mostly steady, it was decided that the risk of colonoscopy outweighed the benefits in the immediate setting. recommend outpatient colonoscopy to better evaluate his source of brbpr. . 6. endocrine: the patient was kept on an insulin sliding scale for his diabetes. he was transferred from an osh on stress-dose steroids, which were weaned down to his home dose of prednisone of 5mg once daily. the finger sticks remained within normal limits. . 7. lue edema: the patient was found to have some moderate lue edema. u/s shows patent av fistula and no lue dvt. pt was treated with ice and elevation with good resolution. . 8. fen: the patient was maintained on a renal/cardiac diet . 9. ppx: the patient was maintained on h2 blolcker, bowel regimen consisting of colace and senna, and sq heparin for dvt prophylaxis. . 10. code: dnr/dni confirmed on multiple occasions with patient. . medications on admission: asa heparin doapmine plavix lopressor ceftazadime vancomycin hydrocortisone pepcid advair renagel nephrocaps feso4 nebs insulin discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 2. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. atorvastatin calcium 40 mg tablet sig: two (2) tablet po daily (daily). 9. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 10. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). 11. papain-urea unit-mg/g ointment sig: one (1) application topical twice a day. 12. oxycodone hcl 5 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 13. sevelamer hcl 800 mg tablet sig: one (1) tablet po tid (3 times a day). 14. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 15. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 16. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 17. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 18. sodium chloride 0.65 % aerosol, spray sig: sprays nasal tid (3 times a day) as needed. 19. miconazole nitrate 2 % powder sig: appls topical tid (3 times a day) as needed. 20. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 21. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). discharge disposition: extended care facility: - discharge diagnosis: primary: acute coronary syndrome, coronary artery disease secondary: end stage renal disease, uti, stage 3 ulcer on buttocks discharge condition: stable discharge instructions: please take all of your medications. please follow up with all of your doctors. please maintain your three times a week dialysis schedule - mon, fri, fri. please return to the emergency department or call your doctor if you develop chest pain or difficulty breathing. followup instructions: pcp . (within 1 week) cardiology: please follow up with your cardiologist dr. within 2 weeks. please call for an appointment at 1- . renal: dialysis dr. plastic surgery: please call for an appointment within two weeks of discharge at phone: Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Coronary arteriography using two catheters Left heart cardiac catheterization Hemodialysis Implant of pulsation balloon Arthrocentesis Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Insertion of drug-eluting coronary artery stent(s) Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Subendocardial infarction, initial episode of care Anemia, unspecified Coronary atherosclerosis of native coronary artery Urinary tract infection, site not specified Congestive heart failure, unspecified Unspecified septicemia Severe sepsis Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Cardiogenic shock Septic shock Pressure ulcer, lower back Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Spina bifida without mention of hydrocephalus, unspecified region Paraplegia Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site Epistaxis

allergies: ibuprofen attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization history of present illness: 77y/o m with dm2, cad s/p 3v cabg, htn, hypercholesterolemia, chf, developed chest pain at around 7pm while watching the begining of the red sox game. his pain was across his chest, , non radiating, no shortness of breath, did have some associated lightheadedness/dizziness and weakness, no diaphoresis, no n/v. he took 1 old without relief then went to his neighbors house who then gave him two from hers but did not help with the chest pain either. there he was having visual blurriness/double vision. she took his blood pressure which was 112/66, his pain at that time had increased to . his friend then convinced him to let her call 911, ems arrived by 9pm. they transported him to hospital, upon arrival his cp was ecg was read at stemi by ed, he was given 3 additional with min relief, decreasing his pain to . they then gave him lopressor 5mg iv x one, heparin 4000u x one, placed him on oxygen and then med flighted him to for emergent cath. here he was started on heparin iv, integrellin iv and was taken up to cardiac cath. cath showed: hd: ao 150/66, right dominant system lmca: mod disease lad: diffusely diseased w/ serial 60% and 70% stenosis, d1 is a large vessel w/ 90% stenosis. lcx: to px, a large om fills via l-l collaterals rca: to px, the pda and pl fill via l-r collaterals svg-rca: atritic and occluded svg-om: to px lima-lad: atritic w/o flow into lad. past medical history: 1. dm2 for 6 years 2. cad s/p 3v cabg 3. htn 4. hypercholesterolemia 5. chf social history: tob: 2 packs for 40yrs, quit in etoh: quit in 80's. lives by self, does adls by self, drives. walks with cane. family history: father died 66 from heart failure mother died 59 from cervical cancer. diabetes in fathers family as well as heart disease. physical exam: t: 93.1 axillary, bp: 131/63, hr: 59, 98% 2l nc gen: axox3, nad, pleasant male with family in room heent: eomi, perrl, mmdry, o/p clear neck: no jvp appreciated, no bruits appreciated cv: rrr, no m/r/g, normal s1/s2 pulm: cta b/l, no w/r/r abd: large, bowel sounds present, obese, nt/nd ext: no c/c, edema present to mid legs 1+ b/l. dp/pt palpated 1+ b/l neuro: cn ii-xii grossly intact. groin: right groin w/o hematoma, non tender, no bruit appreciated, gauze and dressing in place with minimal blood staining. pertinent results: ecg: sinus 68, inferior q waves, 1mm st depression i, avl. ******************* cath 1. severe three vessel native coronary artery disease. 2. all three bypass grafts occluded. carotid series + venous duplex 1. findings consistent with 40%-59% stenosis of the right internal carotid artery secondary to atherosclerotic plaque. 2. occlusion of the left internal carotid artery. 3. nonvisualization and query occlusion of the right vertebral artery. 4. patent left greater saphenous vein with dimensions provided above. ******************* echo the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is very mildly depressed with focal basal inferior and infero-lateral thinning and akinesis the remaining lv segments appear hyperdynamic. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated. 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. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. ******************* p-mibi moderate inferior and inferolateral partially reversible perfusion defect. mild global hypokinesis that is worse in the region of the patient's perfusion defects. ef 45% ******************** stress no angina and no ekg changes suggestive of ischemia. nuclear report sent separately. ******************** 01:25pm blood ck-mb-13* mb indx-10.2* ctropnt-0.13* 11:30pm blood ck-mb-4 ctropnt-0.01 01:25pm blood ck(cpk)-128 11:30pm blood ck(cpk)-87 brief hospital course: a/p: 77y/o m with dm2, cad s/p 3v cabg, htn, hypercholesterolemia, transferred from hospital for stemi and found to have severe 3vd w/ occluded grafts on cath, no stemi. had cardiac cath w/ no intervenable lesions but with severe 3vd and occluded grafts. ecg reread and no evidence of stemi though sent over for emergent intervention. start metoprolol 25mg , aspirin 325mg once a day, atorvastatin 80mg once a day, no lisinopril given arf, c/w integrellin, heparin o/n. patient did not want to undergo any further surgical intervention and so patient was managed medically. medications on admission: 1. lisinopril 2. amaryl 3. bumetanide 4. avandia 5. simvastatin 6. atenolol 7. asa discharge medications: 1. nitroglycerin 2.5 mg capsule, sustained release sig: one (1) capsule, sustained release po twice a day. disp:*60 capsule, sustained release(s)* refills:*5* 2. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual prn as needed for pain. disp:*60 * refills:*5* 3. aspirin 325 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: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. simvastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. hydralazine 10 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 8. metoprolol tartrate 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 9. isosorbide dinitrate 10 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: cad htn dm type 2 chf hypercholesterolemia cad htn dm type 2 chf hypercholesterolemia cad htn dm type 2 chf hypercholesterolemia discharge condition: pt is chest pain free, with stable vital signs discharge instructions: if you experience any chest pain, lightheadedness, passing out, shortness of breath, palpitations you should seek medical attention immediately. you have appointments set up for you to see a kidney doctor and heart doctor. you should also follow up with your pcp at the va in the next 1-2 weeks. followup instructions: provider: , m.d. where: cardiac services phone: date/time: 11:00 provider: , m.d. where: medical specialties phone: date/time: 11:00 Procedure: Coronary arteriography using two catheters Left heart cardiac catheterization Diagnoses: Sciatica Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Coronary atherosclerosis of autologous vein bypass graft Unspecified disorder of kidney and ureter

allergies: sulfa (sulfonamides) attending: chief complaint: admitted for orthotopic liver transplant secondary to hep c cirrhosis with hcc treated in past with rf ablation. major surgical or invasive procedure: olt takeback for biliary leak requiring biliary reconstruction with roux-en-y hepaticojejunostomy history of present illness: admitted for olt in the setting of hep c, hcc with rfa in . feeling well recently. meld score 25 for hcc exception past medical history: hep c positive (bx proven 4 years ago) hcc with rfa in for lesions in segment v and viii dvt cryoglobulinemia kidney stones depression lumbar spine laminectomy left partial orchiectomy social history: lives with wife and 1 son in single family home smokes cigarettes no etoh since remote hx iv heroin use family history: non-contributory physical exam: on admission: vs: 97.4, 74, 127/81, 20, 100% ra gen: in nad lungs: cta bilaterally card: rrr, s1, s2, no m/r/g abd: soft, nt, minimally distended, hepatomegaly with palpable liver extr: warm, 2 + pulses bilaterally pertinent results: on admission: 02:10am glucose-92 urea n-12 creat-0.8 sodium-138 potassium-4.1 chloride-103 total co2-26 anion gap-13 02:10am alt(sgpt)-28 ast(sgot)-42* alk phos-150* tot bili-0.6 02:10am calcium-8.5 phosphate-3.2 magnesium-1.9 02:10am wbc-4.9 rbc-3.82* hgb-11.8* hct-34.0* mcv-89 mch-30.9 mchc-34.8 rdw-18.8* 02:10am plt count-91* 02:10am pt-13.0 ptt-30.5 inr(pt)-1.1 02:10am fibrinoge-187 01:35am urine color-yellow appear-clear sp -1.015 01:35am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-1 ph-6.5 leuk-neg brief hospital course: patient admitted for olt from brain dead donor. surgical procedure: deceased donor liver transplant with piggyback portal vein-to-portal vein anastomosis, celiac axis to gastroduodenal artery, common hepatic artery branch patch,and common bile duct-to-common bile duct anastomosis. patient was stable and transferred, extubated to sicu. on the morning of postoperative day 1, his drain began putting out approximately 50 cc per hour of bile. patient returned to the or on pod 1 for surgical correction of a biliary leak with biliary reconstruction with roux-en-y hepaticojejunostomy. patient was stable post surgery and returned to the sicu. liver u/s done on pod 1 showing liver transplant with patent vessels, no biliary dilatation or intrahepatic collections, a very small subhepatic fluid collection, and a small right pleural effusion. patient was started on a solumedrol taper. pod2: patient extubated. prograf started and diuresis performed. on pod3 patient transferred out of sicu to transplant surgery floor. cellcept was started. on pod4 (), physical exam suggested patient had a swollen right arm. duplex doppler showed no evidence of dvt within the right upper extremity. : lfts rose and liver us was performed, demonstrating increased velocity at distal main portal vein of uncertain significance. based on patient's lack of abdominal pain and no new symptoms, conservative management was chosen. solumedrol taper completed; patient started on prednisone taper. on , lfts continued to rise. roux study was performed and demonstrated a widely patent anastomosis. hida scan was performed, showing 1) good uptake, but very slow clearance of tracer by the liver; concerning for impaired hepatic function. 2) some activity in a tubular structure consistent with jejunum. 3) two foci of tracer collection inferior to the left lobe of the liver in the region of an indwelling drain, which could represent a leak. delayed images recommended to further assess the possibility of leak. us was done to mark liver for biopsy location. patient was given pre-procedure zosyn. on , cholangiogram through existing ptc showed no biliary leak and no portal vein stenosis, and no portal vein pressure gradient was observed. liver biopsy was performed and was indeterminate for acute rejection but showed no evidence of acute biliary tract obstruction. patient was given mucomyst and bicarb prior to procedures. on lfts began down-trending and continued to do so until discharge. on day of discharge, patient was ambulating, eating a regular diet, having regular bowel movements. his pain was well-controlled, and all jp drains had been d/c'd. blood sugars will continue to be monitored at home, teaching done, this will be followed in clinic. medications on admission: nexium 40', lactulose 30 cc's b.i.d., aldactone 150', lasix 40', quinine 325 hs cipro 750 mg once a week, nadolol 20' feso4 325', folic acid 1 mg' discharge medications: 1. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 2. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). disp:*60 tablet(s)* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: ten (10) ml po daily (daily). disp:*qs ml(s)* refills:*2* 5. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 6. tacrolimus 1 mg capsule sig: one (1) capsule po once (once). disp:*60 capsule(s)* refills:*2* 7. colace 100 mg capsule sig: one (1) capsule po twice a day: take as long as you are taking narcotics. continue as needed. disp:*60 capsule(s)* refills:*2* 8. prednisone 5 mg tablet sig: four (4) tablet po once a day: taper prednisone per transplant recommendations. 9. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours: taper dose as pain level improves. disp:*30 tablet(s)* refills:*0* 10. furosemide 20 mg tablet sig: two (2) tablet po twice a day: md will review continued use at transplant office visit. disp:*30 tablet(s)* refills:*0* 11. one touch test strips dispense 2 bottles refills 5 12. lancets dispense 2 bottles refills 5 discharge disposition: home with service facility: vna of r.i. discharge diagnosis: s/p liver transplant for hcc takeback for biliary leak requiring biliary reconstruction with roux-en-y hepaticojejunostomy discharge condition: stable discharge instructions: call if you experience any of the following symptoms: fever,chills, nausea, vomiting, diarrhea or inability to eat. also report pain over the incision site or liver, jaundice, an increase in abdominal girth or any other symptoms concerning to you. monitor incision site for redness or drainage and report to transplant office. have labs drawn every monday and thursday and have them faxed to transplant office at . cbc, chem 10, ast,alt, alk phos, albumin, t bili and trough prograf level do not drive if you are taking narcotics. check blood sugar 4 times daily for the first week and record. bring record to transplant office visit followup instructions: provider: , md phone: date/time: 3:20 provider: , md phone: date/time: 1:20 provider: , transplant social work date/time: 1:20 Procedure: Venous catheterization, not elsewhere classified Closed (percutaneous) [needle] biopsy of liver Injection or infusion of other therapeutic or prophylactic substance Other transplant of liver Other cholangiogram Other cholangiogram Transfusion of platelets Anastomosis of hepatic duct to gastrointestinal tract Phlebography of the portal venous system using contrast material Other operations on lacrimal gland Transplant from cadaver Diagnoses: Tobacco use disorder Unspecified essential hypertension Acute and subacute necrosis of liver Unspecified viral hepatitis C without hepatic coma Other specified disorders of biliary tract Personal history of venous thrombosis and embolism Personal history of urinary calculi Malignant neoplasm of liver, not specified as primary or secondary Other paraproteinemias

allergies: sulfa (sulfonamides) attending: chief complaint: 52m s/p olt and revision portal vein admitted after perc liver bx for observation and hct check with prbc transfusion major surgical or invasive procedure: s/p perc liver biopsy past medical history: hep c positive (bx proven 4 years ago) hcc with rfa in for lesions in segment v and viii dvt cryoglobulinemia kidney stones depression lumbar spine laminectomy left partial orchiectomy social history: lives with wife and 1 son in single family home smokes cigarettes no etoh since remote hx iv heroin use family history: non-contributory physical exam: ms/neuro: a/ox3 heent: perrla, eomi cvs: rrr resp: cta-b abd: s/nt/nd/+bs ext: no. p. edema inc: c/d/i pertinent results: 10:15pm wbc-10.2 rbc-3.85* hgb-11.2* hct-33.1* mcv-86 mch-29.1 mchc-33.9 rdw-18.3* 10:15pm plt count-134* 04:20pm wbc-11.1* rbc-3.81* hgb-11.3* hct-32.6* mcv-85 mch-29.7 mchc-34.7 rdw-18.2* 04:20pm plt count-139* 02:37pm wbc-12.6* rbc-3.63* hgb-10.6* hct-31.0* mcv-85 mch-29.1 mchc-34.1 rdw-18.6* 02:37pm plt count-165 11:00am wbc-15.1* rbc-3.82* hgb-11.0* hct-32.2* mcv-85 mch-28.7 mchc-34.0 rdw-19.2* 11:00am plt count-205# 07:35am glucose-91 urea n-21* creat-0.8 sodium-138 potassium-4.3 chloride-105 total co2-23 anion gap-14 07:35am alt(sgpt)-212* ast(sgot)-186* alk phos-233* tot bili-0.6 07:35am rapamycin-10.9 07:35am wbc-10.1 rbc-4.74 hgb-13.4* hct-39.9* mcv-84 mch-28.2 mchc-33.6 rdw-19.2* 07:35am plt count-95*# 07:35am pt-10.9 inr(pt)-0.9 brief hospital course: 53 male s/p perc liver biopsy s/p hypotensive episode (sbp 60s), drop hct (39->32) after liver bx. pt was dmitted to sicu on for observation and monitoring. he was given 2u prbcs. his follow-up hct were stable at 33. on u/s liver: (post-procedure) that showed no evidence of hematoma. he was tranferred back to the floor on . pt was stable and dicharged home on with a htc of 33. medications on admission: metoprolol 50", bactrim 80-400, feso4 325", riss, mmf 1000", sirolimus 3', calcium 500''', vit d 400', zolpidem 5', valganciclovir 450', prednisone taper, omeprazole 20' discharge medications: 1. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 2. mycophenolate mofetil 250 mg capsule sig: four (4) capsule po bid (2 times a day). 3. sirolimus 1 mg tablet sig: three (3) tablet po daily (daily). 4. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 5. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po bid (2 times a day). 6. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day). 7. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. prednisone 5 mg tablet sig: 3.5 tablets po daily (daily). 10. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: home discharge diagnosis: s/p perc liver biopsy for olt discharge condition: stable discharge instructions: pt to call or return to ed if he has any hypotensive episodes, fever, lightheadedness followup instructions: transplant coordinator to arrange follow-up Procedure: Closed (percutaneous) [needle] biopsy of liver Transfusion of packed cells Diagnoses: Other iatrogenic hypotension Anemia, unspecified Chronic hepatitis C without mention of hepatic coma Personal history of venous thrombosis and embolism Liver replaced by transplant Other paraproteinemias

allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: admission from clinic for cap major surgical or invasive procedure: egd flexible sigmoidoscopy colonoscopy bronchoscopy history of present illness: this is a 57 yo male with h/o for hepatitis c and hcc 4 yrs ago, h/o rfa in , cryoglobulinemia, itp s/p splenectomy, htn, and dvt who presented to liver clinic today with fever and cough. a cxr was done and he was found to have a multifocal pneumonia. . he reports that he was feeling well until 3 days ago. at that time he developed a cough productive of yellow phlegm. he denies blood in the sputum. he gets pain in his chest only when he coughs. he has developed a mildly sore throat secondary to cough. he started developing chills yesterday and had a temp of 100.9 which he took 2 tylenol for. he always feels somewhat sob at baseline although this does not limit his activity and has felt mildly more sob since sunday. he feels that he is breathing with more effort. he's has a runny nose all winter in the cold but it is normally of clear discharge and is now is of yellow discharge. he has had a mild left sided headache that comes and goes since sunday. he reports very mild body soreness. he denies sick contact and did get his flu shot this year. . on the floor, he was noted to have sob with exertion. he had some mild back pain. . review of systems: (+) per hpi , + 13 lb weight loss slowly over the last yr, + back pain after he threw it out a few weeks ago. + bruising on knees and left arm (from window slamming into his arm) from work as a carpenter (-) denies night sweats denies sinus tenderness, denied chest tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. no depression/anxiety. past medical history: hepatitis c (vl 55,000,000 in ) cirrhosis s/p liver hemothorax with complicated pleural effusion hcc with rfa in for lesions in segment v and viii htn (since ) h/o dvt () cryoglobulinemia kidney stones () lumbar spine laminectomy left partial orchiectomy itp s/p splenectomy recurrent hcv social history: lives at home with his wife. worked as a carpenter. smokes 1 ppd x since yo and quit a few weeks ago. denies alcohol or drugs. used iv drugs >30 years whichh is how he contracted hep c. family history: m with alzheimer's. half sister with diabetes mellitus physical exam: his vss t 101.3, bp 136/72, hr 92 rr 20 90% on ra general: alert, answering questions appropriately, intermittent coughing heent: sclera anicteric, mmm, oropharynx clear neck: supple, no lad lungs: + mild rhonci and decreased air movement on right compared to left, no wheezes. no accessory muscle use. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: + surgical scar, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, liver edge at the edge of rib cage. ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. pink distal toes bilaterally (chronic per pt). exam at discharge: vs: t 98.4, bp 120/60, p 97, r 20, o2 92% on ra (84% with ambulation) gen: well appearing man in nad heent: erythematous oropharynx, moist mucous membranes cardiac: holosystolic murmur resp: diffuse rhonchi and expiratory wheezes bilaterally abd: distended, non-tender, soft ext: 1+ edema in lle pertinent results: admission labs: wbc-69.2, hgb-11.6* hct-36.8* plt ct-40* pt-15.0* inr(pt)-1.3* urean-36* creat-1.5* na-137 k-4.1 cl-96 hco3-22 angap-23* alt-32 ast-43* alkphos-90 totbili-1.2 albumin-4.5 calcium-9.2 . pertinent labs/studies: . wbc: 69.2 -> 31.9 () -> 58.4 () platelets: ranged from 24k to 40k troponin: 0.01 -> 0.08 () bnp: () -> 9625 () total protein: 5.4 tibc: 204, b12 872, folate 5.9, ferritin 541, hapto 138, trf 157 hba1c: 5.6% total cholesterol: 80, ldl 48, hdl 13 tsh 5.0 anca: negative afp : < 1 bcr/abl: negative . microbiology: beta glucan: negative galactomannan: negative strongyloides ag: negative sputum : >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): moderate growth commensal respiratory flora. haemophilus influenzae, beta-lactamase negative. heavy growth. . sputum culture (): pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. smear reviewed; results confirmed. respiratory culture (final ): moderate growth commensal respiratory flora. klebsiella pneumoniae. moderate growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- =>32 r cefazolin------------- 16 i cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . cxr (): heterogeneous opacification in the lower lungs, particularly in the middle lobe, is new since . elevation of the right lung base laterally could be due to a small subpulmonic pleural effusion. there is no left pleural effusion, heart size is normal and there is no indication of central adenopathy. overall, findings are consistent with pneumonia, including nonbacterial causes such as viral infection or even pneumocystis. dr. and i discussed these findings by telephone at the time of dictation. . ct chest with contrast (): 1. extensive multifocal parenchymal consolidations, ground-glass and tree-in- opacities predominantly in a peribronchial distribution, most severe within the right lower lobe. these findings are consistent with multifocal pneumonia. small right pleural effusion and mediastinal lymphadenopathy is likely reactive in nature. 2. mild left hydronephrosis, new compared to prior study of . 3. post-surgical changes within the upper abdomen status post splenectomy and liver . . mri l-spine with gad (): 1. no evidence of osteomyelitis, discitis or other spinal infection. 2. chronic post-operative changes at l4-l5 with underlying degenerative disease and congenital stenosis. this is most prominent at l4-l5 and l5-s1, where there is probable impingement upon the left-sided traversing nerve roots in those subarticular zones. 3. diffusely t1- and t2-hypointense vertebral bone marrow signal may relate to the immunosuppressive medications for hepatic patient's and/or chronic hematologic abnormality (history of itp, s/p splenectomy); correlate with clinical and laboratory data. 4. mild paraortic lymphadenopathy and urinary bladder distention with diverticulum, unchanged from ct. . cta chest (): 1. progression of multifocal opacities suggesting pneumonia with consolidative opacities within the right upper, lower, and left lower lobes. overall similar to slightly worsened appearance of axillary and mediastinal lymphadenopathy, probably reactive in etiology, although not specific. 2. new left pleural effusion and progressed right pleural effusion. 3. smooth septal thickening suggesting fluid overload or pulmonary vascular congestion. 4. unchanged vascular including coronary artery calcifications. 5. unchanged appearance to post- liver and splenectomy, only partly visualized. . tte (): the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is low normal (lvef 50%) secondary to severe hypokinesis/akinesis of the basal inferior, posterior, and lateral walls. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is a minimally increased gradient consistent with minimal aortic valve stenosis. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. severe posteriorly directed (4+) mitral regurgitation is seen. the mitral regurgitation is due to centripetal remodelling of the inferior posterior walls with consequent functional tethering of the posterior mitral leaflet. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , intercurrent inferoposterolateral infarct is evident with consequent severe mitral regurgitation. . cardiac catheterization (): 1. selective coronary angiography in this right dominant system revealed two vessel disease. the lmca was normal. the lad has minimal disease. the lcx had tubular mid disease to 95%. the rca is dominant but very small vessel with mid disease to 90%. 2. limited resting hemodynamics revealed normal systemic arterial pressure with central aortic pressure 119/66 with a mean of 75 mmhg. 3. severe lcx lesion probably culprit for new lateral wall motion abnormality and increased mr - stented successfully. 4. severe rca disease suboptimal for pci in view of long lesion and small caliber - would consider pci if producing ischemia. 5. monitor in ccu and follow mr. 6. aspirin indefinitely, plavix 75mg daily for a minimum of one month final diagnosis: 1. two vessel coronary artery disease. 2. successful bare metal stenting of lcx. . . tte (): the left atrium and right atrium are normal in cavity size. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate to severe (3+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the findings are similar. . ct chest (): ct chest (): 1. improving, though still extensive, multifocal pneumonia. 2. improved pulmonary edema which is now mild, including decreased pleural effusions. 3. extensive coronary artery calcifications. 4. retention of iv contrast in the renal cortices, likely from cardiac catheterization two days prior, compatible with renal dysfunction. . ct chest (): 1. persistent multifocal right-sided patchy airspace consolidations, compatible with persistent multifocal pneumonia. however, there is slight improvement of aeration since . near-complete resolution of left-sided pneumonia with only small patchy focal airspace consolidations in the left base. no cavitary lesion. the constellation of findings is compatible with continued improvement without acute complication. 2. likely reactive mediastinal and bihilar lymph nodes. 3. status post liver transplantation and splenectomy. egd (): varices at the lower third of the esophagus. food in the stomach. angioectasias in the antrum (thermal therapy). duodenal bezoar otherwise normal egd to third part of the duodenum . colonoscopy (): 1. estimated blood loss: none. 2. specimens: none 3. final diagnosis: small punctate lesions in rectum, without active bleeding, consistent with proctitis. otherwise normal colonoscopy to cecum. brief hospital course: the patient is a 57 yo male with h/o hcv cirrhosis c/b hcc s/p distant olt, itp s/p splenectomy and myelofibrosis admitted with h. flu pna. his hospital course was complicated by klebsiella pneumonia, worsening mitral regurgitation s/p cardiac catheterization with bms x2 to the lcx, lower gi bleed and recurrent epistaxis, now clinically stable. . #. community acquired pneumonia: the patient presented with productive cough and fever on . he was initially treated with ceftriaxone/azithromycin/vanc for presumed hcap, and he was also started on tamiflu for presumed influenza. his sputum eventually grew out h. flu, so he completed a course of ceftriaxone/azithromycin. he continued to have a leukocytosis and productive cough and was found to have klebsiella pna on . he was then started on ciprofloxacin, for which he completed the course of antibiotics. he had a repeat chest ct on , which demonstrated improvement of the multifocal pneumonia and he had a bronchoscopy on , from which the cultures were negative. his cxr prior to discharge remained consistent with multifocal pneumonia. he has a follow-up appointment with his outpatient pulmonologist, dr. , on . he should have a repeat ct chest performed in weeks to assess for radiographic improvement. . #. gatrointestinal bleeding: the patient developed a lower gi bleed on . he had an egd, which demonstrated grade i varcies and avm and flexible sigmoidoscopy showed fresh blood in colon without source of bleeding. he received 5 during his hospital stay, and he remained hemodynamically stable without evidence of bleeding for one week prior to discharge. he will be followed in the liver center after discharge. . # mitral regurgiation: the patient developed worsening shortness of breath and chest pain on . he had a tte performed, which demonstrated worsening mitral regurgitation, and there was concern for inferolateral hypokinesis, thought to be secondary to ischemia. he was taken to the cath lab on , where he had the two bare metal stents placed to the left circumflex artery. after the cath lab he was transferred to the ccu due to hypoxia post procedure. during his stay in the ccu he was aggressively diuresed with improvement in his oxygen saturations. cardiology recommended not repairing valve now, and there is also no indication for pci in rca at this time. a repeat echo was done on which showed improvement in his mr and wall hypokinesis, somewhat unclear if this was related to the intervention in the cath lab or to improvement in cardiac function with diuresis. he was started on metoprolol, which was uptitrated to 37.5 mg tid by the time of discharge. he was also started on plavix 75 mg daily and aspirin 325 mg daily, which should be decreased to 81 mg daily on . he was not started on a statin given his history of hcc. he should have a repeat tte performed in weeks. he will follow up with dr. at hospital on for management of his mr. # epistaxis: the patient developed a nose bleed on . packing was placed in his nostril to tamponade the bleeding, and this was removed on . he also completed a 5-day course of keflex for the bleeding. he was started on afrin nasal spray on for a three day course, which was completed at the time of discharge. . # myelofibrosis, itp w/ residual splenule: he was seen by hematology who confirmed that he had myelofibrosis. his peripheral smear was notable for eosinophils and hematology was concerned that he could have chronic eosinophilic pneumonia. flow cytometry, bcr-abl, and fish for pdgfr-alpha and rar-alpha were sent. the patient's transfusion goals were set at: hct < 30 and platelets < 15k. he did not receive any platelets during his hospital course, but he was given 5 for his lower gi bleed. of note, his baseline wbc is in the 30s and his baseline platelet count is in the 40s. he will follow-up with his outpatient hematologist on discharge. . # hcc s/p olt: the patient was continued on tacrolimus and his levels were checked daily with a goal of . . # chronic lbp: the patient has a history of low back pain, for which he takes tylenol at home. during this hospital stay, his pain was controlled with oxycodone, morphine, tylenol, gabapentin, and a lidocaine patch. . # bph: no active issues. he was continued on his home dose of tamsulosin 0.4mg daily . #. hydronephrosis on ct chest: his creatinine was 1.6 on arrival and improved to 1.2. it was later elevated to 1.5. the wet read of his renal ultrasound showed no hydronephrosis or stone. . #. hepatitis c: he had a history of hcc with rfa in for lesions in segment v and viii. he is s/p liver 4 yrs ago and on prograf. his hep c viral load was high during this admission and his ct scan in showed no evidence of local recurrence or metastatic disease. his ct of the chest did reveal multiple perigarstric varices. he was continued on his home prograf dose and home nadolol. . #. hyponatremia: his home hctz was held in the setting of his hyponatremia. . #. h.o dvt: he had a dvt in but given his low platelet count he remained on pneumoboots during his hospitalization. . # code: full . # communication: wife medications on admission: tricor 48 mg. 1x daily hydrochlorothiazide 12.5 mg. 1x daily nadolol 40 mg. 1x daily omeprazole 40 mg. daily (2, 20mg caps) prograf 1 mg. b.i.d., level 3.8 calcium 500 mg. 2x daily vitamin d 400 units 2x daily tylenol yesterday discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 2. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po bid (2 times a day). 4. oxygen sig: two (2) liters per minute nasal continuous: pulse dose for portability dx: pneumonia. disp:*1 unit* refills:*0* 5. tricor 48 mg tablet sig: one (1) tablet po once a day. 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day) for 2 months. disp:*1 inhaler* refills:*2* 7. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) for 1 months. disp:*1 bottle* refills:*0* 8. gabapentin 300 mg capsule sig: one (1) capsule po q8h (every 8 hours). disp:*90 capsule(s)* refills:*2* 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for to area of back pain. disp:*30 adhesive patch, medicated(s)* refills:*1* 10. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). disp:*30 capsule, ext release 24 hr(s)* refills:*2* 11. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing for 2 months. disp:*1 inhaler* refills:*1* 12. aspirin 325 mg tablet sig: one (1) tablet po once a day for 9 days: please take daily until . disp:*9 tablet(s)* refills:*0* 13. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 14. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day). disp:*1 vial* refills:*2* 15. tylenol 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 16. tacrolimus 0.5 mg capsule sig: one (1) capsule po q12h (every 12 hours). disp:*60 capsule(s)* refills:*2* 17. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*2* 18. phenol 1.4 % aerosol, spray sig: one (1) spray mucous membrane q4h (every 4 hours) as needed for sore throat. disp:*1 bottle* refills:*0* 19. oxycodone 10 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain for 1 weeks. disp:*36 tablet(s)* refills:*0* discharge disposition: home with service facility: vns of ri discharge diagnosis: primary diagnosis: community acquired pneumonia acute renal failure myelofibrosis back pain with nerve compression hyponatremia secondary diagnosis: hepatitis c cirrhosis hepatocellular carcinoma hypertension itp discharge condition: alert and oriented x3 ambulates independently discharge instructions: you were admitted to the hospital on with a productive cough and fever, and you were found to have a pneumonia. you were treated with antibiotics for this pneumonia, but when your clinical picture did not improve, you were found to have another bacteria causing an infection in your lungs. during the course of this treatment, you had worsening shortness of breath, and a cardiac ultrasound demonstrated that your mitral valve was no longer functioning as well as it once had. you had a cardiac catheterization performed, during which two metal stents were placed into one of the blood vessels around your heart. after this procedure, you had an episode of bleeding from your gi tract, for which you underwent a sigmoidoscopy and egd. you received 5 units of blood during this hospital stay, and your hematocrit has remained stable for the past week. finally, you had a nose bleed while you were here, for which our ent doctors saw . your nose was packed and you were given antibiotics and a nasal spray. . while you were here, the following changes were made to your medications: 1. we stopped your hctz 2. we started you on home o2 3. we started you on aspirin 325 mg daily. you should take this until , at which time you should decrease your aspirin dose to 81 mg daily. you should take plavix every day, and please follow-up with your cardiologist regarding this medication. 4. we started you on fluticasone and albuterol inhalers 5. we started you on a lidocaine patch, neurontin and oyxcodone for pain 6. we started you on metoprolol for your blood pressure and heart 7. we started you on tamsulosin for your benign prostatic hypertrphy 8. we started you on a cough syrup for your cough 9. we started you on a saline nasal spray, given your nose bleed 10. we decreased your tacrolimus to 0.5 mg twice daily 11. we stopped your nadolol please take all medications as prescribed and please keep all follow-up appointments. it was pleasure taking care of you during this hospital stay. followup instructions: please call your hematologist's office to make a follow up appointment. department: when: wednesday at 2:20 pm with: clinic building: lm campus: west best parking: garage name: , md specialty: internal medicine when: monday at 9:30am location: medical address: , , phone: name: , md specialty: pulmonary when: thursday at 2:30pm address: 1407 trail bldg 4 ste a, , phone: name: , md specialty: cardiology when: wednesday at 9:20am address: 1377 trail, , phone: fax: this appointment is in dr. office in . you will need to get all of your medical records sent to dr. for this appointment so that dr. is aware of your medical history. you also must get a copy of your cardiac catheterization done here at on a disc and bring that disc to dr. at this appointment. Procedure: Insertion of non-drug-eluting coronary artery stent(s) Coronary arteriography using two catheters Left heart cardiac catheterization Closed [endoscopic] biopsy of bronchus Colonoscopy Endoscopic control of gastric or duodenal bleeding Control of epistaxis by anterior nasal packing Transposition of cranial and peripheral nerves Insertion of two vascular stents Excision of lingual thyroid Percutaneous transluminal coronary angioplasty [PTCA] Procedure on single vessel Diagnoses: Hyperpotassemia Other chronic pain Coronary atherosclerosis of native coronary artery Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Hyposmolality and/or hyponatremia Unspecified viral hepatitis C without hepatic coma Personal history of tobacco use Other acquired absence of organ Retention of urine, unspecified Personal history of venous thrombosis and embolism Acute diastolic heart failure Hemorrhage of gastrointestinal tract, unspecified Complications of transplanted liver Personal history of malignant neoplasm of liver Lumbago Hydronephrosis Epistaxis Pneumonia due to Hemophilus influenzae [H. influenzae] Myelofibrosis Immune thrombocytopenic purpura Pneumonia due to Klebsiella pneumoniae Leukocytosis, unspecified Angiodysplasia of stomach and duodenum without mention of hemorrhage Other specified disorders of rectum and anus

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: chest pain major surgical or invasive procedure: coronary artery bypass graft x 5 (lima->lad, svgs ->om1, d1, d2, pda) history of present illness: 57 y/o male with recurrent syptoms of chest pain and dyspnea on exertion post diag stenting in . again underwent cardiac cath which revealed severe three vessel disease. then referred for surgical intervention. past medical history: coronary artery disease s/p diag stenting, s/p laser eye surgery, partial herniated disc, s/p l knee hematoma, hyperlipidemia, s/p r tear duct surgery social history: denies tobacco or etoh. prosecutor for district attorney. family history: mother died of mi at age 55. physical exam: vs: 55 158 130/74 5'7" 70.3kg general: 57y/o male in nad heent: eomi, perrl, ncat neck: supple, from -jvd chest: ctab -w/r/r heart: rrr -c/r/m/g abd: soft, nt/nd, +bs ext: warm, well-perfused -edema, -varicosities, good pulses throughout neuro: mae, non-focal, a&ox3 pertinent results: echo : prebypass: left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is normal(lvef>55%). there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. postbypass: preserved biventicular systolic function. study is otherwise unchanged from prebypass. cxr :single portable chest radiograph demonstrates interval removal of mediastinal drains, left-sided chest tube, and swan-ganz catheter when compared to . the lungs are clear. no effusion. cardiomediastinal contours are normal. the patient is seen to be status post cabg. no pneumothorax. 11:47am blood wbc-16.6*# rbc-3.09*# hgb-8.9*# hct-26.1*# mcv-85 mch-28.6 mchc-33.9 rdw-13.9 plt ct-215 01:28am blood wbc-9.8 rbc-3.39* hgb-10.1* hct-28.0* mcv-83 mch-29.9 mchc-36.1* rdw-14.3 plt ct-269 04:40am blood wbc-11.2* rbc-3.14* hgb-9.5* hct-26.6* mcv-85 mch-30.1 mchc-35.6* rdw-14.5 plt ct-174 12:45pm blood pt-16.9* ptt-39.5* inr(pt)-1.6* 03:14am blood pt-11.3 ptt-25.0 inr(pt)-0.9 12:45pm blood urean-13 creat-0.6 cl-109* hco3-21* 04:40am blood glucose-109* urean-15 creat-0.9 na-136 k-4.3 cl-99 hco3-30 angap-11 05:40am blood urean-14 creat-0.7 k-4.3 brief hospital course: admitted and underwent cabg x5 with dr. . transferred to the csru in stable condition on phenylephrine and propofol drips. extubated successfully and had a syncopal /vagal episode on pod #1. his chest tube output remained high and he received platelets and prbcs. this improved, swan removed, and he was transferred to the floor on pod #2 to begin to increase his activity level. pacing wires removed on pod #3. he made excellent progress with clear cxr on . cleared for discharge to home with vna on pod #4. pt. to follow up per discharge instructions. medications on admission: atenolol 50mg qd, aspirin 325mg qd, plavix 75mg qd, zocor 80mg qd, drixoril prn, ciprofloxacin discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*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. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 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:*50 tablet(s)* refills:*0* 6. zocor 80 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*0* 7. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 8. furosemide 20 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 weeks. disp:*14 tablet(s)* refills:*0* 9. potassium chloride 10 meq capsule, sustained release sig: two (2) capsule, sustained release po q12h (every 12 hours) for 1 weeks. disp:*28 capsule, sustained release(s)* refills:*0* discharge disposition: home with service facility: southeastern ma vna discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 5 pmh: s/p diag stenting, s/p laser eye surgery, partial herniated disc, s/p l knee hematoma, hyperlipidemia, s/p r tear duct surgery discharge condition: good discharge instructions: call with fever, redness or drainage from incisions, or weight gain more than 2 pounds in one day or five in one week. no heavy lifting or driving until follow up with surgeon. shower, no baths, no lotions, creams or powders to incisions. followup instructions: dr. 2 weeks dr. 2 weeks dr. 4 weeks the following appoinments were already scheduled: , m.d. phone: date/time: 8:20 , m.d. phone: date/time: 11:40 Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery (Aorto)coronary bypass of four or more coronary arteries Diagnoses: Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome

allergies: gentamicin attending: chief complaint: increasing chest pain major surgical or invasive procedure: two vessel coronary artery bypass grafting utilzing the left internal mammary to left anterior descending artery and vein graft to obtuse marginal. history of present illness: mr. is a 77 year old male with extensive history of coronary artery disease undergoing multiple angioplasties and stents in the past. over the last six months, he admits to experiencing increasing anginal symptoms. his chest pain improves with nitroglycerin and rest. cardiac catheterization at the on revealed a 70% stenosis in the left main coronary artery, and an 80% lesion in the left anterior descending artery. the rca and circumflex had only 40% stenoses. his lvef was estimated at 49%. his aortic and mitral valves were normal and without significant gradients. based on the above results, he was referred for future cardiac surgical intervention. he denied orthopnea, pnd, pedal edema, syncope, presyncope and palpitations. he was subsequently admitted for coronary revascularization. past medical history: coronary artery disease with history of multiple stents and angioplasties, hypertension, type 2 diabetes mellitus, mild renal insufficiency, history of tia, chronic anemia, history of bladder carcinoma s/p cystectomy and ileostomy, history of gi bleed social history: 40 pack year history of tobacco, quit smoking in . admits to 1-2 drinks per day family history: mother and sister with "heart problems" ?? age physical exam: vitals: bp 160/80, hr 63, rr 16, sat 96% on room air general: elderly male in no acute distress heent: oropharynx benign neck: supple, no jvd, no carotid brutis heart: regular rate, normal s1s2, 3/6 systolic ejection murmur lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds, ielostomy pink ext: warm, no edema, no varicosities pulses: 1+ distally neuro: nonfocal brief hospital course: mr. was admitted on and underwent two vessel coronary artery bypass grafting by dr. . the operation was uneventful and he was brought to the csru on minimal inotropic support. within 24 hours, he awoke neurologically intact and was extubated without difficulty. he weaned from intravenous therapy and maintained stable hemodynamics. on postoperative day one, he transferred to the sdu. beta blockade was resumed and advanced as tolerated. most of his other preoperative medications were also resumed. he experienced bouts of paroxysmal atrial fibrillation for which warfarin anticogulation was eventually initiated.amiodarone was also started. this was then stopped when the patient went into sr. the center was consulted to assist in the management of his diabetes mellitus.he continued to have intermittent bursts of rapid afib and a flutter over the next several days.ep consult was obtained. they recommended possible follow-up ablation and coumadin was restarted . patient underwent an atrial focus ablation on without complication. he was started on coumadin that day and after 2 doses of 5mg of coumadin, his inr rose to 7.8. he was given 5mg vitamin k and on pod# 15 his inr was down to 3.0 and he was cleared for discharge to home. medications on admission: isosorbide 20 , lopressor 50 , tricor 145 qd, diovan 160 qd, plavix 75 qd, glipizide 2.5 qd, aspirin 325 qd, xalantan eye gtts 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 twice a day. disp:*60 tablet(s)* refills:*2* 3. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 4. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every 4-6 hours as needed for pain. disp:*20 tablet(s)* refills:*0* 5. aspirin 325 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. glipizide 2.5 mg tab, sust release osmotic push sig: three (3) tab, sust release osmotic push po daily (daily). disp:*90 tab, sust release osmotic push(s)* refills:*2* 7. amiodarone 200 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 8. metoprolol tartrate 100 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 9. coumadin 1 mg tablet sig: one (1) tablet po once a day: no coumadin and 1mg , then per dr. . disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: coronary artery disease with history of multiple stents and angioplasties, hypertension, type 2 diabetes mellitus, mild renal insufficiency, history of tia, chronic anemia, history of bladder carcinoma s/p cystectomy, history of gi bleed, postoperative atrial fibrillation 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 4 weeks dr. in weeks dr. in weeks Procedure: Single internal mammary-coronary artery bypass Extracorporeal circulation auxiliary to open heart surgery Diagnostic ultrasound of heart Catheter based invasive electrophysiologic testing Excision or destruction of other lesion or tissue of heart, endovascular approach (Aorto)coronary bypass of one coronary artery Diagnoses: Coronary atherosclerosis of native coronary artery Pure hypercholesterolemia Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Cardiac complications, not elsewhere classified Atrial fibrillation Chronic kidney disease, unspecified Personal history of malignant neoplasm of bladder Unspecified procedure as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure

allergies: sulfa (sulfonamides) / epinephrine attending: chief complaint: shortness of breath major surgical or invasive procedure: -v/icd left lead placement adjustment history of present illness: 56f h/o htn, lbbb, card cath wnl (), post-viral cardiomyopathy (of 10 yrs; ef=20%) s/p -v/icd pacer () and surgical lv lead placement, rv lead revision on . reportedly tolearted procedure well and was extubated on . placed on keflex for periprocedural ppx. after extubation, pt complained of pleuritic substernal chest pain rad to right lower chest, sob, doe, occ cough, and one episode of hemoptysis (<1tsp bld w/ mucous). of note, there was reported laryngeal injury during intubation. she reported subjective fevers (but had been on ibuprofen/percocet; no objective fevers) and malaise. ros: "hot flashes," had mild epigastric pain, had mild nausea w/o vomiting. last bm prior. had gas. past medical history: 1) post-viral cardiomyopathy (of 10 yrs; ef=20%) 2) s/p -v/icd pacer () and l lead adjustment on . 2) htn 3) lbbb 4) osa on cpap 5) fibromyalgia 6) depression 7) recurrent utis 8) tonsillectomy cardiac cath (): no cad. social history: works as dental office manager. lives with parents, of whom she takes care of her father. divorced. illegal drugs or tobacco. rare etoh. family history: mom81 - s/p cabg/avr. dad88 - esrd/hd, dm. physical exam: t98.4 bp94/50 hr79 rr20 os96%3l gen - nad heent - op clear, anicteric. pulm - decr bs at l>r; bases with faint bibas crackles. cv - rrr, no m/g/r. abd - s/nt/nd, no hsm. ext - no pitting edema, but l>r asymmetry and swollen appearance of both legs. 1+ dps. neuro - a&ox3. perrl. eomi. pertinent results: 06:59pm type-art rates-10/0 tidal vol-600 peep-5 o2-50 po2-150* pco2-51* ph-7.39 total co2-32* base xs-5 intubated-intubated vent-imv 06:59pm glucose-116* k+-4.1 06:59pm hgb-10.7* calchct-32 o2 sat-99 01:07pm type-art po2-295* pco2-46* ph-7.43 total co2-32* base xs-5 01:07pm glucose-127* na+-138 k+-3.3* cl--103 01:07pm freeca-1.18 12:47pm glucose-122* urea n-24* creat-0.8 sodium-143 potassium-3.3 chloride-104 total co2-27 anion gap-15 12:47pm wbc-10.6# rbc-3.14* hgb-10.1* hct-27.5* mcv-87 mch-32.0 mchc-36.6* rdw-14.2 12:47pm plt count-177 12:47pm pt-13.8* ptt-28.3 inr(pt)-1.2 09:22am type-art rates-8/ tidal vol-800 po2-342* pco2-49* ph-7.39 total co2-31* base xs-4 intubated-intubated vent-controlled 09:22am glucose-90 na+-140 k+-4.0 09:22am hgb-10.1* calchct-30 09:22am freeca-1.15 06:30am blood wbc-8.7 rbc-3.99* hgb-12.6 hct-36.1 mcv-91 mch-31.5 mchc-34.8 rdw-13.9 plt ct-314 09:10pm blood urean-46* creat-1.8* 06:30am blood glucose-96 urean-35* creat-1.3* na-144 k-4.5 cl-98 hco3-35* angap-16 09:40pm blood urean-33* creat-1.4* na-145 k-4.5 06:20am blood glucose-103 urean-29* creat-1.1 na-146* k-4.2 cl-97 hco3-34* angap-19 09:26am blood type-art po2-92 pco2-52* ph-7.36 calhco3-31* base xs-2 10:29am blood type-art po2-95 pco2-49* ph-7.38 calhco3-30 base xs-2 brief hospital course: mrs. was admitted to s/p -v/icd pacer placement () and l lead adjustment on to evaluate her sob/decr os and pleuritic chest pain/chest tenderness which were deemed likely related to chf/l pleural effusion (vs atelectasis) and with pain from surgery, respectively. 1. doe/chf. upon transfer to , the patient had sob, which was mainly exertion (comfortable at rest, but was very fatigued). initialy, her o2 requirement was 3-4l to maintain os>93: likely chf-related along with possible left pleural effusion (vs. atelectasis). cxr was read as 'large left pleural effusion.' of note, the loudness of her voice was diminished upon transfer, presumed seconday to laryngeal injury during intubation. over the course of her hospital stay, her exercise tolerance, dyspnea, and energy level improved with diuresis (lasix po and iv) along with incentive spirometry and physical therapy. her voice quality was drastically improved by discharge. the procedure team saw the patient on to eval for possible therapeutic thoracentesis, but felt the cxr along with u/s + exam findings were more consistent with atelectasis and not effusion. thus, there was no intervention. pt had mild o2 requirement on dc and was sent home with vna and home o2 (93-94% on 1-2l; 89%-93% on ra). her chf drug regimen included carvedilol 12.5 mg po bid, digoxin 0.125 mg po qd, losartan potassium 75 mg po qd, along with lasix 60-80mg daily and spironolactone 25 mg po qd, which were both held on her day of dc secondary to rising creatinine (1.8 from 1.3). the patient was encouraged to ambulate as well as to use her is. she was seen by pt. 2. acute renal insufficiency. likely prerenal after diuresis. held meds as above and rechecked cr: trended down to 1.1 on day of dc. 3. chest tenderness/pain. pt was tender near incision site and initially had chest pain with breathing. chest tenderness was secondary to ct surgical procedure. it was well controlled with ibuprofen 400-600 mg q6-8h. she was also on oxycodone prn and cyclobenzaprine hcl 5 mg po qd and again, encouraged ambulation, is, and pt. her pleurisy and chest pain/tenderness all had drastically improved upon dc. 4. htn. sbps 90s-110s. appeared to be normotensive to hypervolemic, yet had somewhat low sbps, but stable. we continued carvedilol 12.5 mg po bid, digoxin 0.125 mg po qd, losartan potassium 50 mg po qd, and spironolactone 25 mg po qd. 5. anemia. hct was 28.6-28.7 upon transfer; pt was transfused 1u prbc on to allievate her symptoms in face of chf. her hct then rose to >35 and remained at that level for the remainder of her hospital course. the etiology of the anemia was unclear, although it may have been peri-operative. fe studies showed low iron, high ferritin and nml tibc (low end of nml): thus, likely inflammation in setting of fe-deficiency anemia. 6. depression/anxiety. continued escitalopram oxalate 20 mg po qd. 7. fen. low salt/heart healthy diet. 8. ppx. colace, senna, lactulose. sq heparin. pantoprazole 40 mg po q24h (used ppi because of ibuprofen use and recent epigastric pain). 9. code. full. 10. dispo. dced to home with vna and home o2. medications on admission: transfer meds: losartan 50mg , carvedilol 12.5 mg , sq heparin 5000 units , spironolactone 25mg , escitalopram 20mg daily, digoxin 12.5mg daily, cyclobenzaprine 5mg daily, tylenol pm, percocet prn, ranitidine 150mg , ibuprofen 400 q6h discharge medications: 1. spironolactone 25 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*0* 2. escitalopram oxalate 10 mg tablet sig: two (2) tablet po qd (once a day). disp:*60 tablet(s)* refills:*2* 3. cyclobenzaprine hcl 10 mg tablet sig: 0.5 tablet po qd (once a day). disp:*15 tablet(s)* refills:*2* 4. digoxin 125 mcg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 5. pantoprazole sodium 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* 6. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*50 tablet(s)* refills:*0* 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 9. oxycodone hcl 5 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*30 tablet(s)* refills:*0* 10. losartan potassium 25 mg tablet sig: three (3) tablet po qd (once a day). disp:*90 tablet(s)* refills:*0* 11. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 12. ibuprofen 400 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. disp:*50 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: 1) post-viral cardiomyopathy (of 10 yrs; ef=20%) 2) s/p -v/icd pacer () and l lead adjustment on . 2) htn 3) lbbb 4) osa on cpap 5) fibromyalgia 6) depression 7) recurrent utis 8) tonsillectomy discharge condition: good discharge instructions: please take all your medications as prescribed. furosemide (lasix) has been added to your regimen. your losartan (cozaar) dose has been changed to 75 mg po qd. please weigh yourself daily. if you gain more than 3 lbs, call your cardiologist. pleasy notify your physician if you have any worsening chest pain, shortness of breath, fevers, chills, or any other concerning symptoms. followup instructions: 1) primary care: please see your primary care physician (, ) within the next 1-2 weeks. 2) please call to schedule an appointment with your cardiologist dr. () or dr. () to be seen within 1 week following discharge. your electrolytes (k/na) and renal function (bun/cr) should be checked at this visit to ensure that they are stable. at time of discharge, your creatinine was 1.1. Procedure: Thoracentesis Other bronchoscopy Implantation of cardiac resynchronization defibrillator, total system [CRT-D] Diagnoses: Other primary cardiomyopathies Anemia, unspecified Mitral valve disorders Congestive heart failure, unspecified Unspecified essential hypertension Unspecified disorder of kidney and ureter Supraglottitis unspecified, with obstruction

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: increasing sob and le edema major surgical or invasive procedure: tvrepair (#30 ce annuloplasty band) history of present illness: 83 yo f with seere tr and increasing pulmonary . past medical history: mi, , lipids, severe tr, pulm , oa, hoh, s/p r thr, tkr social history: lives with son retired no tobacco no etoh family history: premature cad - son with mi at 52 physical exam: elderly women in nad lungs ctab rrr no m/r/g abdomen benign extrem warm with 2+ le edema, ble erythematous edema dp/pt pulses non-palp, femoral 2+, radial 2+ discharge vitals 98.0, 64 sr, 141/77, 22, sat 97% on 3l nc wt 60.2kg neuro a/o x3 mae r=l strength but generalized weakness cardiac rrr, sternal inc healing no erythema/drainage, sternum stable pulm crackles right base, decreased left base abd soft, nt, nd last bm ext warm +2 edema right calf with erythema - cellulitis resolving, pulses palpable pertinent results: 03:00pm blood wbc-10.6 rbc-3.54* hgb-10.1* hct-30.9* mcv-87 mch-28.6 mchc-32.9 rdw-19.1* plt ct-191 04:15am blood wbc-13.9* rbc-3.63* hgb-10.4* hct-31.3* mcv-86 mch-28.7 mchc-33.3 rdw-19.0* plt ct-156 09:53am blood wbc-14.2* rbc-3.66* hgb-10.3* hct-31.3* mcv-86 mch-28.3 mchc-33.1 rdw-19.0* plt ct-223 03:00pm blood plt ct-191 03:46am blood pt-13.2* ptt-30.6 inr(pt)-1.2* 09:53am blood plt ct-223 09:53am blood pt-13.6* ptt-54.8* inr(pt)-1.2* 09:53am blood fibrino-268 09:50am blood glucose-111* urean-15 creat-0.8 na-145 k-3.6 cl-105 hco3-32 angap-12 10:46am blood urean-25* creat-0.8 cl-108 hco3-25 09:50am blood calcium-8.1* phos-3.3 mg-1.9 03:13am blood calcium-9.0 phos-2.5* mg-2.2 ekg normal sinus rhythm. left axis deviation. probable left anterior fascicular block. delayed r wave transition. possible prior anteroseptal myocardial infarction. no change st-t wave abnormalities. compared to the previous tracing of no diagnostic interim change. read by: , intervals axes rate pr qrs qt/qtc p qrs t 63 160 104 -54 23 cxr chest (pa & lat) 10:25 am chest (pa & lat) reason: evaluate effusions medical condition: 83 year old woman with tr reason for this examination: evaluate effusions chest two views on history: triscuspid regurg, check effusions. reference exam: . findings: there is moderate cardiomegaly with moderate bilateral pleural effusions and pulmonary vascular redistribution consistent with chf. there is fluid and azygos fissure. an incomplete ring of a valve replacement is seen overlying the spine on the frontal film and overlying the mid heart on the lateral film. the appearance of this incomplete ring was discussed with the cardiac surgeon on call (dr. . impression: increased chf. dr. approved: sun 12:28 pm\ echo preliminary report patient/test information: indication: tricuspid valve repair- intra-op tee height: (in) 61 weight (lb): 118 bsa (m2): 1.51 m2 bp (mm hg): 112/54 hr (bpm): 42 status: inpatient date/time: at 12:09 test: tee (complete) doppler: full doppler and color doppler contrast: none tape number: 2007aw000-: test location: anesthesia west or cardiac technical quality: adequate referring doctor: dr. measurements: left ventricle - ejection fraction: 55% (nl >=55%) interpretation: findings: left atrium: marked la enlargement. right atrium/interatrial septum: markedly dilated ra. normal interatrial septum. no asd by 2d or color doppler. cilated ivc (>2.5cm) with no change with respiration (estimated rap >20 mmhg). left ventricle: normal lv wall thickness. normal lv cavity size. normal regional lv systolic function. overall normal lvef (>55%). right ventricle: moderately dilated rv cavity. mild global rv free wall hypokinesis. aortic valve: three aortic valve leaflets. no as. no ar. mitral valve: mildly thickened mitral valve leaflets. severe mitral annular calcification. no ms. mild (1+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. no ts. severe tr. eccentric tr jet. severe pa systolic hypertension. pulmonic valve/pulmonary artery: physiologic (normal) pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. no tee related complications. the patient was under general anesthesia throughout the procedure. the patient appears to be in sinus rhythm. results were personally post-bypass data conclusions: pre-bypass: the left atrium is markedly dilated. the right atrium is markedly dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is >20 mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is moderately dilated. there is mild global right ventricular free wall hypokinesis. there are three aortic valve leaflets. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is severe mitral annular calcification. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. the tricuspid regurgitation jet is eccentric and may be underestimated. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. post-bypass: physician: brief hospital course: ms. came in for scheduled surgery on however had eaten breakfast that morning. she was admitted to the floor and then taken to the operating room on where she underwent a tv repair with a #30 ce annuloplasty ring. she was transferred to the icu in critical but stable condition. she was seen by pulmonology post op for pulmonary . recommendations included outpatient w/u, as well as treatment for her diastolic dysfunction - diuresis, rate control and afterload reduction. her vasoactive drips were weaned to off and she was extubated by pod #2. she was transferred to the floor on pod #2. she was seen by physical therapy and continued to progress. she was ready for discharge to rehab on pod 5. medications on admission: atenolol, imdur, ditropan, norvasc, lasix, prilosec, xocor, colace, mvi, k-dur, diovan, asa, oxygen prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). capsule(s) 2. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 3. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). tablet, delayed release (e.c.)(s) 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 8. potassium chloride 20 meq packet sig: two (2) packet po q12h (every 12 hours). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 10. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 11. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 2 weeks: for right leg cellulitis. tablet(s) 12. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: extended care facility: discharge diagnosis: severe tr s/p tv repair mi lipids pulmonary oa hoh s/p r thr, tkr discharge condition: good. discharge instructions: call with fever, redness or drainage from incisions, or weight gain more than 2 pounds in one day or five in one week. shower, no baths, no lotions, creams or powders to incisions. no heavy lifting or driving until follow up with surgeon. p instructions: dr. 4 weeks dr. (pcp) discharge from rehab dr. (cardiology) 2 weeks dr. (pulmonology) 1-2 months for pulmonary hypertension workup Procedure: Extracorporeal circulation auxiliary to open heart surgery Open heart valvuloplasty of tricuspid valve without replacement Diagnoses: Mitral valve disorders Other postoperative infection Cellulitis and abscess of trunk Congestive heart failure, unspecified Unspecified essential hypertension Primary pulmonary hypertension Diseases of tricuspid valve

allergies: bactrim / lipitor attending: chief complaint: elevated creatinine from 0.9 () to 2.5 ()s/p cadaver kidney transplant major surgical or invasive procedure: kidney biopsy history of present illness: 42 y.o. male with hiv s/p cadaver kidney transplant presents with two day h/o fever of 101.8, nausea, diarrhea and gi discomfort after eating restaurant meal. evaluated in outpatient clinic by dr. . complained of nausea, decreased urine output and orthopnea. denied fever,vomiting and abdominal pain. diarrhea was resolving. past medical history: esrd hiv hiv nephropathy htn hyperlipidemia social history: lives with roommate. works in group home smokes 3 cigarettes per day rarely drinks etoh physical exam: a&o, very pleasant, sitting up in bed, nad vs: t 100.4-78-18, 172/88 o2 93% ra, wt: 84.4 heent: at, nl, proptosis od, perrla, eomi, full, decreased va od, no icterus of sclerae, mouth/tongue midline, moist bm, no exudate neck: supple, no palpable nodes, no tm, no carotid bruits lungs: clear a&p bilaterally, no decreased breath sounds cor: s1s2reg, no murmur/regurgitation abd: full, hyperactive bowel sounds, soft, to palpation, non-tender, well healed rlq scar ext-no cce vasc: lue avf, no sign of infection. 2+ dp/at on l. 1+ dp/at on right pertinent results: 01:15pm urine hours-random 01:15pm urine hours-random creat-215 tot prot-546 prot/crea-2.5* 01:15pm wbc-8.8 rbc-3.46* hgb-10.4* hct-31.7* mcv-92 mch-30.2 mchc-32.9 rdw-15.2 01:15pm plt count-187 01:15pm urine color-ltamb appear-clear sp -1.020 01:15pm urine blood-mod nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 01:15pm urine rbc-25* wbc-35* bacteria-few yeast-none epi-<1 01:15pm urine granular-1* 01:15pm blood glucose-137* 01:15pm blood urean-30* creat-2.5*# na-134 k-3.3 cl-103 hco3-16* angap-18 01:15pm blood alt-33 ast-27 totbili-0.9 01:15pm blood albumin-4.1 calcium-9.7 phos-2.1* 01:15pm blood rapamycin-test brief hospital course: admitted on with nausea, vomiting, diarrhea, fever and decreased urine output. noted to have shortness of breath with o2 sat of 88% which responded to o2 2 liters nc with repeat o2 of 94%. foley cath placed to check urine output. urine output 15-30 ml/hr and u/a positive. ultrasound of the transplanted kidney revealed increased resistive indices, and decreased diastolic flow in conjunction with cortical edema and swelling. no hydronephrosis was noted. shortness of breath increased with respiratory rate of 38,decreased breath sounds, bp of 170/88 and temperature of 100.6. 100% non-rebreather was placed on patient with o2 sat increased to 96%. transfered to sicu for worsening abgs. cxr revealed interstitial markings/edema. labs revealed wbc of 8.4, hct 27.4, creatinine of 3.3, bun 51, potassium 3, sodium 133 and bicarb 14. iv bicarb was started. sputum was sent for pcp as well as a cmv viral load and bk pcr. dapsone was changed to bactrim and valcyte was decreased to qod.empiric zosyn and levaquin were started with zosyn later changed to iv vancomycin. nephrology was consulted for increased creatinine and decreased urine output. on a transplant kidney biopsy was performed by nephrology without complications. on a pulmonary consult was obtained. diuresis was recommended for dyspnea/hypoxia consistent with fluid overload given cxr changes and low urine output. pcp was less likely dianosis, but induced sputum was ordered for viral pathogens and pcp. infectious disease consult was also obtained. nasal aspirate for viral cultures, sputum, and cultures were recommended as well as changing stavudine to 20mg q 24 hours for creatinine clearance of 10-25cc/min. on he received 2 units of prbc for a hematocrit of 22.3. on a steroid pulse was given pending renal biopsy results. consequently hyperglycemia occurred necessitating an insulin drip. iv vancomycin was stopped on per id recommendations as urine and blood cultures were negative. on the renal biopsy results were postive for acute cellular rejection (acr)/endothelitis. atg was initiated. on he was transfered out of sicu to the medical-surgical unit with improved respiratory status. pulmonary signed off as patient improved with diuresis and treatment of acr. cmv vl, pcp, cultures, for c. diff and rapid repiratory viral cultures were negative. urine culture from revealed >100k gram + bacteria. a blood culture from revealed coag neg staph felt to be a contaminant. gradually renal function improved with five doses of atg and solumedrol. creatinine improved to 1.5 on hd 6. rapamune was converted to prograf. per id recommendation repeat blood cultures were obtained and subsequently negative. given temperature spike on hd 6, diarrhea and fevers of 101.8 suspicious for c. difficile despite c. diff and e.coli negative cultures, patient was empirically started on po flagyl. flagyl was later switched to po vancomycin qid per dr. , id. fevers were felt to be secondary to atg, but repeat cultures of blood, urine and were sent on . mmf was changed to 500mg qid as mmf can cause gi disturbance, and iv bicarb was given for acidosis secondary to diarrhea. a total of 7 doses of atg were given for acr. diarrhea improved with vancomycin po. valcyte was increased to qd and needs to continue indefinately based upon cd4 count. azithromycin 1200mg po q week was initiated for no cd4 count. patient was discharged to home with vital signs wnl, decreased nausea and diarrhea feeling better. urine output improved and creatinine decreaed to 1.5. he was tolerating a regular diet. patient will monitor his glucose qid as he had steroid induced hyperglycemia and was instructed to call transplant office if glucoses were greater then 200mg/dl. labs on discharge were as follows: creatinine 1.4, plt 214, hct 28.1, and wbc 5.2. he will complete a three week course of po vancomycin. medications on admission: efavirenz 600mg po qhs ritonavir 100mg po bid norvasc 10mg po qd atenolol 100mg po qd dapsone 100mg po qd cellcept 1000mg po bid protonix 40mg po qd valcyte 450mg po qd ziagen 300mg po bid agenerase 600mg po bid stavudine 40mg po bid clonidine 0.3mg po tid clonidine patch 3mg tp q wk oscal +d 500mg po qd lipitor 40mg po qhs prednisone 7.5mg po qd rapamune 0.5mg po q wk discharge medications: 1. efavirenz 200 mg capsule sig: three (3) capsule po hs (at bedtime). 2. amlodipine besylate 5 mg tablet sig: two (2) tablet po daily (daily). 3. dapsone 100 mg tablet sig: one (1) tablet po daily (daily). 4. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. abacavir sulfate 300 mg tablet sig: one (1) tablet po bid (2 times a day). 7. atorvastatin calcium 40 mg tablet sig: one (1) tablet po pm (). 8. ritonavir 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. fosamprenavir calcium 700 mg tablet sig: one (1) tablet po q12h (every 12 hours). 10. clonidine hcl 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsat (every saturday). 11. zolpidem tartrate 5 mg tablet sig: one (1) tablet po hs (at bedtime). 12. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). disp:*1 * refills:*2* 13. sodium citrate-citric acid 500-334 mg/5 ml solution sig: twenty (20) ml po tid (3 times a day). 14. prednisone 2.5 mg tablet sig: three (3) tablet po daily (daily). 15. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 16. stavudine 20 mg capsule sig: two (2) capsule po q12h (every 12 hours). 17. vancomycin hcl 10 g recon soln sig: one (1) recon soln intravenous q6h (every 6 hours). disp:*120 recon soln(s)* refills:*2* 18. valganciclovir hcl 450 mg tablet sig: one (1) tablet po daily (daily). 19. azithromycin 600 mg tablet sig: two (2) tablet po once (once) for weekly weeks: take every thursday follow up with dr. from infectious disease. disp:*8 tablet(s)* refills:*2* 20. atenolol 50 mg tablet sig: three (3) tablet po daily (daily). 21. insulin syringes 22. syringes 1 box insulin syringes 23. syringe storage bin misc sig: one (1) miscell. once a day. 24. insulin syringes (disposable) syringe sig: one (1) miscell. four times a day: low dose insulin syringes for sliding scale insulin. disp:*1 box* refills:*0* discharge disposition: home discharge diagnosis: acute cellular rejection s/p cadaver kidney transplant pulmonary edema renal insufficiency hiv diarrhea, c.difficile steroid induced hyperglycemia mac discharge condition: stable/good discharge instructions: call transplant office if fevers, chills, nausea, vomiting, inability to take medications, decreased urine output. lab draw on monday for cbc, chem 7, calcium, phosphorus, ast, t. bili, and tacrolimus trough level. check accuchecks twice a day, record followup instructions: provider: , md where: lm center phone: date/time: 2:20 provider: , md where: lm center phone: date/time: 2:40 provider: , (transplant) transplant center-medicine where: lm center phone: date/time: 1:30 provider: , call to schedule appointment Procedure: Closed [percutaneous] [needle] biopsy of kidney Diagnoses: Unspecified essential hypertension Acute kidney failure, unspecified Human immunodeficiency virus [HIV] disease Intestinal infection due to Clostridium difficile Complications of transplanted kidney

history of present illness: the patient is a 75-year-old gentleman who is a patient of dr. who was transferred in from status post a myocardial infarction for cardiac catheterization. he was seen by cardiology on admission. he was referred to dr. and was seen on . past medical history: 1. hypertension. 2. myocardial infarction. 3. hypercholesterolemia. 4. myocardial infarction in . 5. status post cancer and radiation therapy to the mouth. 6. grave's disease with right eye diplopia. 7. transient ischemic attack in . 8. syncope. 9. glaucoma. 10. left carotid endarterectomy in . 11. transurethral resection of prostate. medications on admission: (medications on admission were as follows) 1. plavix 75 mg p.o. once per day 2. aspirin 325 mg p.o. once per day. 3. lopressor 25 mg p.o. twice per day. 4. lisinopril 5 mg p.o. once per day. 6. synthroid 0.025 mg p.o. once per day 7. lipitor 10 mg p.o. once per day. 8. flonase 2 puffs as needed. 9. xalatan eyedrops once per day. 10. trusopt one drop three times per day to both eyes. pertinent radiology/imaging: cardiac catheterization showed left vein and 3-vessel disease with an ejection fraction of 45%. cardiac catheterization today just showed left vein 60% left anterior descending artery, 60% to 80% first diagonal, 100% left circumflex, and 90% ostial right coronary artery. his preoperative chest x-ray showed no acute cardiopulmonary disease. on , he had ultrasounds done which showed a right internal carotid stenosis of 60% to 69%, a left internal carotid stenosis of less than 40%. please refer to the final dictated report. physical examination on presentation: on examination, blood pressure was 166/77, oxygen saturation was 100% on room air, respiratory rate was 18, and heart rate was 55. his left eye pupil appeared larger but both were reactive. sclerae were anicteric. he had well-healed scars bilaterally on his neck. his lungs were clear. his heart was regular in rate and rhythm. normal first heart sounds and second heart sounds. no murmurs. his abdominal examination was benign with good bowel sounds and no hepatosplenomegaly. his extremities were warm and well perfused with no cyanosis, clubbing, or edema, or varicosities. he had good peripheral pulses throughout. pertinent laboratory values on presentation: his creatine kinase peaked at at 384 with a troponin of 8.35. he had q waves in his inferior leads. his preoperative laboratories were as follows; white blood cell count was 5.8, hematocrit was 36.5, and platelet count was 162,000. prothrombin time was 13.1, partial thromboplastin time was 40.9, and inr was 1.1. sodium was 134, potassium was 3.9, chloride was 104, bicarbonate was 22, blood urea nitrogen was 22, creatinine was 0.9, and blood glucose was 87. alt was 22, ast was 28, alkaline phosphatase was 64, total bilirubin was 0.5, and albumin was 3.7. creatine kinase was 270 followed by 320. troponin was 8.3. hospital course: plavix was placed on hold. on , he underwent coronary artery bypass graft times four with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to posterior descending artery, saphenous vein graft from obtuse marginal to diagonal. coming off bypass, the patient experienced right ventricular failure and went back on bypass with drug manipulations. additional echocardiography showed an ejection fraction still approximately 35% to 40% with moderate mitral regurgitation, moderate aortic insufficiency, and moderate tricuspid regurgitation and aortic regurgitation. intra-aortic balloon pump was still in good position which had been placed. the patient went back on bypass a third time for increased right ventricular failure and increasingly unstable vital signs. the patient was placed on right heart bypass with cannulas in the right atrium and pulmonary artery going into the left pulmonary artery. this was confirmed by an echocardiogram. the patient was brought to the cardiothoracic intensive care unit with a right heart bypass cannulation in place. the patient was profoundly hypoxic and acidotic. he was unresponsive on examination and was successfully sedated. he was on the following drips: amiodarone at 1, dobutamine at 2.5, epinephrine at 0.3, and levophed at 0.8, lidocaine at 2, and pitressin at 0.2. his heart rate was 98. he was atrially paced with a blood pressure of 93/41. intra-aortic balloon pump was at 1:1. he was fully supported by the ventilator with a blood gas of 7.27/35/41/17/-9. temperature maximum was 93.9. hematocrit was 20.8. he was on an insulin drip also. he remained fully on swan-ganz catheter and monitored with maximum pressors and inotropic support. he was critically hypoxic with instructions to do no cardiopulmonary resuscitation but to defibrillate only. the patient was seen by a renal fellow on . please note to refer to the patient's operative note. in the operating room, the patient coded and was asystolic on the way out of the operating room and then went back to the operating room on bypass times three. that was when the intra-aortic balloon pump was placed and the right ventricular assist device was placed, as the right ventricular wall was not moving. in addition, to the saphenous vein graft to the right coronary artery. please refer to dr. operative report. it was the impression of the renal consultation that the patient's urine output had slowly resumed. his blood pressure had increased to a mean arterial pressure of greater than 70, but the prognosis was very poor. they recommended continuous venovenous hemofiltration for fluid removal and oxygenation to help improve it, but the patient was clearly hypoxic and had cardiogenic shock. he also had lactic acidosis and congestive heart failure. the hypernatremia was likely secondary to multiple ampules of bicarbonate given during the operation. the left femoral venous dialysis was placed under sterile conditions in the intensive care unit on in preparation for continuous venovenous hemofiltration. the patient was seen again the next morning by the renal service with the right ventricular assist device still in place and massive volume overload after dor noted on maximal ventilatory support with acute renal failure secondary to the prolong hypertension. the right ventricular assist device remained in place at that time. blood pressure dropped with the fluid removal. on postoperative day two, the pressors were slowly weaned. the patient received two units of packed red blood cells, and his positive end-expiratory pressure was increased. the patient was unresponsive with no movement. the patient was on a levophed drip, amiodarone drip, epinephrine drip, and milrinone, as well as dobutamine drip, lidocaine drip, as well as pitressin drip. heart rate was 76, a-paced. blood pressure was 118/48. blood gas that morning was 7.47/26/63/19/-2 with a temperature maximum of 99.5. white blood cell count was 16.7. hematocrit was 45. platelet count was 121. sodium was 132, potassium was 4.6, blood urea nitrogen was 22, creatinine was 2.3, chloride was 97, bicarbonate was 18, and blood glucose was 104. the patient was continued on propofol sedation. lidocaine was decreased to 1. the patient was continued on perioperative vancomycin. levofloxacin was also added in. the patient remained critically ill in the intensive care unit. the patient continued to have low-flows and low blood pressures on his right ventricular assist device with coarse breath sounds. he was sedated and intubated with massive anasarca. his extremities appeared to have anasarca emboli and were warm. his blood urea nitrogen was 27 with a creatinine of 2.6. his hematocrit dropped from 48 to 32.2. he remained on amiodarone drip at 0.5, lidocaine drip at 1, dobutamine drip at 2.5, epinephrine drip at 0.3, levophed drip at 0.27, and milrinone drip at 0.25, vasopressin drip at 0.08, neo-synephrine drip at 1.4, propofol drip at 20, insulin drip at 1, as well as perioperative antibiotics. he was continued on his right ventricular assist device and his intra-aortic balloon pump with acute tubular necrosis and was requiring vasopressors and on inotropic support. he had a poor potassium clearance, by renal service, suggesting extreme/extensive recirculation of fluid. he continued with continuous venovenous hemofiltration. the te showed some right ventricular function remaining. a pericardial clot was evacuated at the bedside, and his pressure dropped slightly. he remained on all of his inotropic and vasopressor support. he was fully sedated, intubated, and paralyzed. he was continued on perioperative antibiotics. the plan was to try and wean his sedation, and try weaning his right ventricular assist device, and transfuse him as needed, with orders to defibrillate only. he was seen by clinical nutrition service for a discussion of starting some parenteral nutrition, but the patient continued to decline and stopped responding to his drugs with any full measure. on , at approximately 7:30 p.m., the family had made the decision to stop all pressors and withdraw support. at 7 p.m., all infusions were stopped. the patient developed profound hypotension, his rhythm deteriorated to asystole. at 7:25 p.m., the pupils were fixed and dilated. there was no cardiac activity or spontaneous respirations. the patient was pronounced dead. the family was present. dr. was notified. postmortem was declined by the family. please refer to the death note by dr. . the patient expired in the cardiothoracic intensive care unit on at 7:30 p.m. please refer to dr. operative report. , m.d. dictated by: medquist36 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 Hemodialysis (Aorto)coronary bypass of four or more coronary arteries Other electric countershock of heart Implant of pulsation balloon Removal of external heart assist system(s) or device(s) Insertion of implantable heart assist system Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Acute kidney failure, unspecified Cardiac complications, not elsewhere classified Mitral valve insufficiency and aortic valve insufficiency Paroxysmal ventricular tachycardia Cardiogenic shock Encounter for palliative care

allergies: codeine / meperidine / iodine containing agents classifier attending: chief complaint: autoimmune hepatitis hcc major surgical or invasive procedure: left hepatic lobectomy, caudate lobe resection, cholecystectomy, intraoperative ultrasound. history of present illness: the patient is a 68-year-old male with a history of auto-immune hepatitis and cirrhosis who developed right upper quadrant abdominal pain. an ultrasound demonstrated a large mass in the right lobe of the liver that on biopsy was consistent with hepatocellular carcinoma. his afp was 336. a ct scan of the chest and abdomen demonstrated no evidence of pulmonary metastases. the patient had a large mass lesion measuring 12.7 x 9.2 x 11.2 cm arising primarily in the medial segment of the left lobe. the middle hepatic vein was not visualized but the right hepatic vein and the left lateral segment hepatic veins were identified. the mass lesion superiorly appears to abut not invade the right lobe of the liver. the patient does not have evidence of portal hypertension. the patient after informed consent is now brought to the operating room for left hepatic lobectomy, possible left trisegmentectomy, caudate lobe resection and cholecystectomy. past medical history: hyperchol, htn, cad s/p cabg (echo --> ef 50%), niddm social history: he has no history of alcohol use, smoking, iv drug use, tattoos, or marijuana use. bs degree. retired in . he was an accountant for over 48 years with . he has seven children and 20 grandchildren. family history: diabetes, hypertension, prostate cancer, colon cancer. his mother is alive at age 88. his father died at age 88 of prostate cancer. physical exam: discharge pe: vitals: 98.9 82 133/74 20 96% room air nad rrr ctab soft, nd, appropriately tender incision: c/d/i no c/c/e pertinent results: admission labs: 06:27pm blood wbc-8.5# rbc-3.37* hgb-10.7* hct-32.4* mcv-96 mch-31.7 mchc-33.0 rdw-15.2 plt ct-334 06:27pm blood glucose-173* urean-21* creat-1.2 na-136 k-5.2* cl-103 hco3-22 angap-16 06:27pm blood alt-486* ast-788* alkphos-208* totbili-2.4* 06:27pm blood calcium-9.3 phos-5.6* mg-1.5* . discharge labs: 05:07am blood wbc-4.7 rbc-3.16* hgb-10.1* hct-30.7* mcv-97 mch-32.1* mchc-33.0 rdw-14.9 plt ct-282 04:55am blood pt-11.8 ptt-23.2 inr(pt)-1.0 05:07am blood glucose-140* urean-18 creat-1.3* na-136 k-4.7 cl-100 hco3-35* angap-6* 05:07am blood alt-171* ast-56* alkphos-194* amylase-66 totbili-0.8 05:07am blood lipase-123* 05:07am blood albumin-2.6* calcium-8.7 phos-3.4 mg-1.9 brief hospital course: the patient was admitted to dr. hepatobiliary surgery service at the on . he underwent a left hepatic lobectomy, caudate lobe resection, cholecystectomy, intraoperative ultrasound. for details of the operation, please refer to the operative report. his postoperative course was uncomplicated. immediately post-operatively, he was transferred to the sicu. he remained stable in the sicu on pod 1. his pain control was increased and was deemed stable for transfer to the floor. on pod 2, he remained afebrile and had good urine output. his foley catheter was discontinued without difficulty voiding and he was advanced to a clear liquid diet, which he tolerated well. on pod 3, was consulted for his uncontrolled diabetes. his central line was discontinued. he remained afebrile and toelrating a clear liquid diet. he reported no flatus or bowel movements. on pod 4, he continued to remain afebrile. he continued to not have signs of return of bowel fuction and he was given a dulcolax suppository without a bowel movement. his drain continued to have minimal output and it was discontinued. on pod 5, he remained afebrile and tolerating a diabetic diet. he had a fleets enema with a resultant bowel movement and he was started on milk of magnesia. his pain continued to be well-controlled. he was deemed stable for discharge on pod 6, afebrile, tolerating a diabetic diet, ambulating well with good pain control. he will follow-up with dr. and . medications on admission: metoprolol 25mg lisinopril 5mg daily hctz 12.5mg daily pravachol 40mg daily prilosec 20mg daiy iss discharge medications: 1. oxycodone 5 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*2* 3. home medications please resume all your previous home medications except for a change in your insulin dosages. you are on glargine 30 units at bedtime. please resume your previous humalog sliding scale. 4. insulin glargine 100 unit/ml solution sig: thirty (30) units (0.3ml) subcutaneous at bedtime. disp:*qs qs* refills:*2* discharge disposition: home discharge diagnosis: autoimmune hepatitis hcc discharge condition: stable discharge instructions: please call your physician or go to the emergency room for the following: - chest pain - shortness-of-breath - increased redness or drainage from your wounds - temperature > 101.5 - inability to tolerate food - or other concerns . please take your pain medication and stool softener as prescribed. . no heavy activity or lifting (anything that makes you strain) for 4-6 weeks. continue to ambulate. you may shower, but no baths for 4-6 weeks. . please keep a journal of your blood sugars to bring to your follow-up appointment with dr. . followup instructions: please call dr. at ( to schedule a follow-up appointment. . please follow-up with your primary care physician 1 week from your date of discharge. . please call dr. () at for a follow-up appointment. md, Procedure: Cholecystectomy Other lysis of peritoneal adhesions Biopsy of lymphatic structure Division or crushing of other cranial and peripheral nerves Regional lymph node excision Lobectomy of liver Diagnoses: Obstructive sleep apnea (adult)(pediatric) Pure hypercholesterolemia Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Coronary atherosclerosis of unspecified type of vessel, native or graft Aortocoronary bypass status Peritoneal adhesions (postoperative) (postinfection) Long-term (current) use of insulin Other chronic hepatitis Malignant neoplasm of liver, primary Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Obesity, unspecified Personal history of urinary calculi

history of present illness: this is a 58-year-old male with coronary artery disease, who presents with a 3-week history of chest pain at bed rest, who presented to an outside hospital on after having an episode of severe chest pain. he was already scheduled for an exercise stress test by his primary care physician for this date. he had been chest pain free since his stent five years ago. however, three weeks ago he had started having jaw pain (which may be his anginal equivalent) while lying in bed. the patient was unable to get a cardiac catheterization done at the outside hospital secondary to insurance noncoverage. he was given lovenox, integrilin, lopressor, intravenous nitroglycerin and then transferred to for further workup; however, chest pain free. past medical history: (this is a 58-year-old male with a past medical history significant for) 1. coronary artery disease, status post right coronary artery stent five years ago. 2. type 2 diabetes for 20 years. 3. high cholesterol. 4. hypertension. 5. depression since . medications on admission: the patient's medications prior to admission were lipitor, tiazac, aspirin, toprol-xl, glucotrol, glucophage, and prozac. allergies: the patient has allergies to penicillin and amoxicillin. hospital course: a cardiac catheterization was performed on at which revealed severe 3-vessel coronary artery disease with preserved left ventricular function. the patient underwent a coronary artery bypass grafting times three on ; with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the posterior descending artery, saphenous vein graft to the obtuse marginal. the patient was transferred in stable condition to the cardiothoracic surgery recovery unit on propofol at 10 mcg/kg per minute as well as a nitroglycerin drip. the patient was weaned an extubated at 6 p.m. on the day of surgery. he had a labile blood pressure which was titrated with nitroglycerin, neo-synephrine, intravenous fluids, and 2 units of packed red blood cells. his blood pressure remained stable after the volume and transfusion as well as low-dose neo-synephrine, and the patient's anxiety was relieved with pain medication and verbal support. on postoperative day one, the patient remained afebrile. vital signs were stable, in sinus rhythm. white blood cell count was 5.3, hematocrit was 26.5, platelet count was 169. sodium was 138, potassium was 4.5, blood urea nitrogen was 13, creatinine was 0.9, and blood glucose was 123 on no drips with a plan to start his beta blocker later on that day as well as the lasix, and to transfer the patient to the floor. the patient was transferred to the floor on postoperative day one. however, on the morning of postoperative day two, the patient went into a sinus tachycardia with rates above 150s. he was given 5 mg of intravenous lopressor times two, and his p.o. lopressor was increased to 25 mg p.o. b.i.d. his blood pressure was stable, and the patient was asymptomatic. also on postoperative day two, the patient was complaining of a headache which he had reportedly had all night. the patient vital signs were stable. the patient with a low-grade fever of 99.3; however, he was still tachycardic. the patient was found to be in atrial fibrillation/atrial flutter which started at around 6 a.m. that morning. initially in sinus tachycardia, but in atrial flutter when slowed. he was given intravenous amiodarone 150 mg bolus as well as amiodarone 400 mg p.o. t.i.d. the plan was to get a neurology consultation for the headache. neurology came to consult with the patient for this headache, and they felt that given the recent history of coronary artery bypass graft and sudden onset of headache, and its severity in developing after falling back to bed yesterday, it was important to rule out a cerebral hemorrhage. they felt that although the patient had photophobia associated with this headache, a migraine was unlikely because of the nature of the headache. the plan was to get a head ct without contrast, to transfuse 2 units of packed red blood cells (because of his low hematocrit), and to administer fioricet one tablet p.o. q.6h. for 24 hours, then q.4h. as needed for pain, as well as to volume replete with intravenous fluids given the increased creatinine which would exacerbate his headache, to consider transfusion, to keep hematocrit greater than 30. on postoperative day three, the patient remained with a low-grade fever with a temperature maximum of 100.9 and temperature current of 98.9. heart rate was 76. in sinus rhythm. the plan was to continue the fioricet. the patient was responding well to this medication, and he continued the amiodarone. it was decided to hold off on the head ct at that time. on postoperative day four, the patient had no complaints overnight. the patient remained afebrile. vital signs were stable with a heart rate of 75 and in sinus rhythm. the plan was to keep ambulating, and if at level v today the patient would be able to be discharged home with an expected discharge date of . the patient's laboratories included a white blood cell count of 4.5, a hematocrit of 22.2, platelet count was 169. sodium was 139, potassium was 4.5, blood urea nitrogen was 22, creatinine was 1.2, and blood glucose was 169. physical examination on the patient's probable day of discharge revealed the patient was stable, afebrile, in sinus rhythm. the patient was awake and alert times three. moved all of his extremities. his lungs were clear to auscultation bilaterally. his heart was regular in rate and rhythm with no murmurs. his sternum was stable. his incision was with steri-strips, clean and dry. his abdomen was benign. his extremities were warm and well perfused with a right saphenous vein graft site clean and dry; no edema. medications on discharge: (his discharge medications were) 1. aspirin 325 mg p.o. q.d. 2. metoprolol 25 mg p.o. b.i.d. 3. amiodarone 400 mg p.o. q.d. 4. lasix 20 mg p.o. q.d. (times seven days). 5. potassium chloride 20 meq p.o. q.d. (times seven days). 6. metformin 1000 mg p.o. b.i.d. 7. glyburide 5 mg p.o. b.i.d. 8. percocet one to two tablets p.o. q.4h. as needed for pain. 9. ibuprofen 400 mg to 600 mg p.o. q.4-6h. as needed for pain. discharge status: the patient was discharged to home. condition at discharge: in stable condition. discharge followup: the patient to follow up with dr. in four weeks and with his primary care physician in three to four weeks. discharge diagnoses: 1. coronary artery disease. 2. hypertension. 3. hypercholesterolemia. 4. type 2 diabetes. 5. depression. , 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 Cardiac complications, not elsewhere classified Atrial fibrillation Depressive disorder, not elsewhere classified Percutaneous transluminal coronary angioplasty status Other and unspecified angina pectoris