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Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillin G / Latex / peanuts Attending: ___ Chief Complaint: Hypoxemia, shortness of breath Major Surgical or Invasive Procedure: ___ line placement History of Present Illness: ___ orthopaedic surgeon with pmHx of CML-1, ILD, DM, CAD s/p CABG, and CHF transferred here from ___ for further pulmonary evaluation of hypoxia. Pt reports progressively worsing dyspnea with home oxygen requirements up to 6L NC with exertional desaturations to SaO2 <80% at home. He notes his SOB has been stable since his last admission. Recently hospitalized at ___ for WBC in ___ and diagnosed with CML at that time. During said hospitalization the patient had worsening hypoxia felt to be d/t drug effect (ATRA syndrome vs hydrea use initially given concern for AML) vs volume overload vs IPF flair. Pt treated with steroids and had much improvement radiographically and symptomatically with this tx following an abx course. Discharged home with oncology and pulmonolgy follow-up on long steroid taper. Pt notes that his pulmonary disease was worsened substantially following treatment with ATRA and hydrea and that he feels his respiratory status has been stable since then. Hospitalized at ___ on ___ for worsening hypoxia. Pt initially seeking transfer to ___ for further evaluation for possible reversible causes of worsening pulmonary function. At OSH, pt received BiPAP in the ICU initially then was transitioned to the floor where he was receiving 4L via NC. He was continued on home prednisone 40 mg daily (home dose) and given IV levofloxacin for possible PNA. WBC 57k at OSH. In the ED, VS: 97.6 77 157/83 24 91% 6L NC Notable labs: WBC 59.7, H/H 8.8/26.8, plt 78, Diff with 4% bands, 19% monocytes, RPI 0.9%, VBG 7.42/34, lactate 4.4, chemistry with bicarb of 20, BUN/cr 35/1.3, glucose 442 with anion gap of 18, uric acid 7.2, LDH 283, hapto 97, INR 1.4 Imaging: CXR read with bilateral hazy opacities in perihilar and lung bases; c/f mild pulmonary edema in the setting of ILD without large pleural effusion; CTPA pending at the time of transfer Given duonebs, 6U regular insulin, 2g cefepime and 1g vancomycin in the ED. On arrival to the ___, pt was speaking in full sentences and in NAD. States that he is here for further pulmonary evaluation and plans for palliative treatment of his IPF. Reports that he feels very thirsty, denies HA, CP, abd pain at this time. Notes that his thinking is clear, denies any problems with dysuria or hematuria. REVIEW OF SYSTEMS: Per HPI Past Medical History: CMML-1 Idiopathic pulmonary fibrosis Coronary artery disease status post CABG CHF PVD s/p toe amputation Diabetes mellitus, noted to be poorly controlled from outside provider's notes OSA Diverticulosis and occasional diverticulitis Anticardiolipin antibody positive Hepatitis B Social History: ___ Family History: Mother died at age ___ of CLL. No other malignancies. Physical Exam: ====================== EXAM ON ADMISSION ====================== Vitals: T:98.0 BP: 135/70 P: 76 R: 24 O2: 89% on 4L GENERAL: Well appearing male with NC in place, NAD, non-toxic appearing HEENT: PERRL, EOMI, MMM, oropharynx clear NECK: Thick neck, unable to assess JVP ___ body habitus, supple, no LAD LUNGS: Decreased at bases with soft crackles, no wheezing CV: RRR, no MRG ABD: obese, soft, nt, nd ecchymosis on LLQ EXT: 1+ pitting edema of BLE, no cyanosis or other ecchymosis noted ====================== EXAM ON DISCHARGE ====================== 97.5 133/65 76 98% high flow 80% Gen: Large, male on NC NAD Neck: JVP elevated HEENT: anicteric, oropharynx clear PULM: fine crackles at bases CV: rrr ABD: soft, nontender EXT: 3+ bilat pitting edema, bruises on arms R > L Pertinent Results: ========================== LABS ON ADMISSION ========================== ___ 08:30PM BLOOD WBC-59.7*# RBC-2.57* Hgb-8.8* Hct-26.8* MCV-104* MCH-34.2* MCHC-32.8 RDW-19.6* RDWSD-74.1* Plt Ct-78* ___ 08:30PM BLOOD Glucose-442* UreaN-35* Creat-1.3* Na-134 K-3.8 Cl-96 HCO3-20* AnGap-22* ___ 08:30PM BLOOD ALT-23 AST-17 LD(LDH)-283* AlkPhos-38* TotBili-0.9 ___ 06:49AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 ___ 10:25PM BLOOD ___ pO2-31* pCO2-34* pH-7.42 calTCO2-23 Base XS--2 ___ 08:36PM BLOOD Lactate-4.4 ========================== PERTINENT INTERVAL LABS ========================== ___ 03:27PM BLOOD B-GLUCAN-NEGATIVE ___ 06:10AM BLOOD QUANTIFERON-TB GOLD-INDETERMINATE ___ 09:42AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Not Detected ========================== LABS ON DISCHARGE ========================== ___ 03:12AM BLOOD WBC-111.1* RBC-2.58* Hgb-8.7* Hct-26.1* MCV-101* MCH-33.7* MCHC-33.3 RDW-19.3* RDWSD-71.1* Plt Ct-44* ___ 04:21AM BLOOD ___ PTT-37.7* ___ ___ 06:10AM BLOOD Ret Aut-3.8* Abs Ret-0.10 ___ 04:21AM BLOOD Fact II-50* Fact ___ FactVII-33* Fact X-61* ___ 03:12AM BLOOD Glucose-170* UreaN-34* Creat-1.2 Na-138 K-3.0* Cl-99 HCO3-27 AnGap-15 ========================== MICROBIOLOGY ========================== ___ 2:03 am Immunology (CMV) Source: Venipuncture. **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. ___ 12:16 am SPUTUM Source: Expectorated. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. ___ 2:45 pm SPUTUM Source: Induced. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT. Less than 2 ml received. PLEASE SUBMIT ANOTHER SPECIMEN. TEST CANCELLED, PATIENT CREDITED. Reported to and read back by ___ 15:38 ___. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. Time Taken Not Noted Log-In Date/Time: ___ 10:29 am URINE CHEM # ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. ========================== IMAGING ========================== ___ CXR - Bilateral hazy opacity involving the perihilar regions and lung bases, perhaps slightly worse in the left mid lung field compared to the prior study. Findings may reflect mild pulmonary edema superimposed on a background of chronic interstitial lung disease which was better assessed on the prior CT chest. No large pleural effusion. ___ Chest CT - 1. No evidence of pulmonary embolism or aortic abnormality. 2. Diffuse ground-glass opacities, improving in the right upper and left lower lobes but stable to mildly increased in the right lower lobe which could reflect drug reaction as previously stated. The ground-glass opacity especially in the rib lower lobe could be attributable to UIP and there has been mild worsening of interstitial lung disease. 3. Mild dilation of the main pulmonary artery measuring up to 3.2 cm suggestive of underlying pulmonary arterial hypertension. 4. Unchanged prominent mediastinal lymph nodes. 5. Splenomegaly. ___ Echo - No atrial septal defect is seen on color flow Doppler, but there is early appearance of agitated saline/microbubbles in the left atrium/ventricle at rest most consistent with an atrial septal defect or stretched patent foramen ovale (though a very proximal intrapulmonary shunt cannot be fully excluded). There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF = 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (indexed aortic valve area = 0.5 cm2/m2 BSA). The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___ aortic stenosis has progressed; bubble study suggests patent foramen ovale or small atrial septal defect. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Loratadine 10 mg PO DAILY:PRN allergies 2. Metoprolol Succinate XL 200 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia 5. Simvastatin 20 mg PO QPM 6. Potassium Chloride 20 mEq PO BID 7. PredniSONE 40 mg PO DAILY 8. Acetaminophen 650 mg PO Q6H 9. Acetaminophen w/Codeine 2 TAB PO Q6H:PRN pain 10. Aspirin 81 mg PO DAILY 11. Centrum (multivit & mins-ferrous glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg oral daily 12. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous use up to 4 x daily per sliding scale 13. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL) subcutaneous QAM 14. BD Ultra-Fine Nano Pen Needles (insulin needles (disposable)) 32 x ___ miscellaneous 5x/day 15. OneTouch FinePoint Lancets (lancets) 25 gauge miscellaneous as directed 16. OneTouch Ultra2 (blood-glucose meter) 1 meter miscellaneous as directed 17. OneTouch Ultra Test (blood sugar diagnostic) 1 strip miscellaneous as directed 18. Furosemide 40 mg PO BID 19. Lisinopril 5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Furosemide 40 mg PO BID 4. Loratadine 10 mg PO DAILY:PRN allergies 5. Potassium Chloride 20 mEq PO BID 6. PredniSONE 50 mg PO DAILY Please decrease by 10 mg weekly until down to 10 mg daily, which he should continue. 7. Sertraline 150 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, dyspnea 10. Allopurinol ___ mg PO DAILY 11. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 12. Atovaquone Suspension 750 mg PO BID Last day ___. Bisacodyl 10 mg PO DAILY:PRN constipation 14. CefePIME 2 g IV Q12H Duration: 2 Days end date ___. Docusate Sodium 100 mg PO BID 16. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 17. Glargine 45 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin 18. Ipratropium Bromide Neb 1 NEB IH Q6H 19. Lorazepam 0.5 mg PO Q8H:PRN anxiety 20. Metoprolol Tartrate 50 mg PO Q6H 21. Morphine SR (MS ___ 15 mg PO Q12H air hunger RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 22. Morphine Sulfate ___ mg IV Q1H:PRN air hunger RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) ___ mg IV every 1 hour Disp #*1 Bag Refills:*0 23. Mycophenolate Mofetil 1250 mg PO BID 24. QUEtiapine Fumarate 75 mg PO QHS 25. Senna 8.6 mg PO BID:PRN Constipation 26. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 27. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion 28. Thiamine 100 mg PO DAILY 29. Vancomycin 1000 mg IV Q 12H end date ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Interstitial lung disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with history of CHF, hypoxia TECHNIQUE: Portable upright AP view of the chest COMPARISON: CT chest ___, chest radiograph ___. FINDINGS: Patient is status post median sternotomy and CABG. Moderate to severe enlargement of the heart size is re- demonstrated, unchanged. Mediastinal contour is similar with central venous congestion again noted. Hazy opacities are noted involving the perihilar regions and lung bases bilaterally in a relatively symmetric fashion, perhaps slightly worse in the left mid lung field compared to the previous radiograph. No pneumothorax is present. No large pleural effusion is identified. There are no acute osseous abnormalities. IMPRESSION: Bilateral hazy opacity involving the perihilar regions and lung bases, perhaps slightly worse in the left mid lung field compared to the prior study. Findings may reflect mild pulmonary edema superimposed on a background of chronic interstitial lung disease which was better assessed on the prior CT chest. No large pleural effusion. Radiology Report INDICATION: ___ with new diagnosis CML ___, also with interstitial lung disease, transfer from OSH after ICU admission for progressive hypoxia with any exertion. Evaluate for PE. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 796 mGy-cm COMPARISON: CT chest from ___ FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. Moderate atherosclerotic disease of the coronary arteries are noted. There is also calcifications of the aortic valve. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main pulmonary artery measures 3.2 cm, mildly dilated and suggestive of underlying pulmonary arterial hypertension. There is no current evidence of right heart strain. The heart is moderately enlarged. No pericardial effusion is seen. The thyroid gland is unremarkable. There is no axillary, supraclavicular, or hilar lymphadenopathy. There are scattered prominent mediastinal lymph nodes with the largest measuring 11 mm in short axis in the right sub carinal station (2:74), unchanged since ___. The central airways are patent. There has been mild interval improvement in the diffuse ground-glass opacities in the right upper lobe and left lower lobe. In the right lower lobe, ground-glass opacities are stable to mildly increased. As before, there is a background subpleural reticulation, basilar subpleural honeycombing, and traction bronchiectasis consistent with interstitial lung disease. There is bibasilar atelectasis. Trace bilateral pleural effusions are noted. Limited images of the upper abdomen are remarkable for splenomegaly measuring 16.1 cm. No lytic or blastic osseous lesion suspicious for malignancy is identified. Median sternotomy wires are again identified. There are moderate degenerative changes of the thoracic spine. There are old left-sided rib fractures. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Diffuse ground-glass opacities, improving in the right upper and left lower lobes but stable to mildly increased in the right lower lobe which could reflect drug reaction as previously stated. The ground-glass opacity especially in the rib lower lobe could be attributable to UIP and there has been mild worsening of interstitial lung disease. 3. Mild dilation of the main pulmonary artery measuring up to 3.2 cm suggestive of underlying pulmonary arterial hypertension. 4. Unchanged prominent mediastinal lymph nodes. 5. Splenomegaly. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ILD with worsening hypoxia // Interval change COMPARISON: ___. IMPRESSION: Known interstitial lung disease. The extent and distribution of the bilateral basal and peripheral parenchymal opacities is constant. No pleural effusions. Moderate cardiomegaly persists. No pulmonary edema. Unchanged alignment of the sternal wires. Radiology Report INDICATION: ___ year old man with CML-1, ILD, T2DM, PFO, CAD s/p CABG, and CHF with hypoxia // R/o acute process COMPARISON: ___ FINDINGS: There is new airspace opacity involving the right upper lobe when compared to ___. This is superimposed on the bilateral basal and peripheral interstitial lung disease. In review of multiple prior radiographs, the patient appears to rapidly go in and out of congestive heart failure. Moderate cardiomegaly persists. No pneumothorax. Sternal wires remain intact and aligned IMPRESSION: Worsening asymmetric right-sided pulmonary edema superimposed on background interstitial lung disease. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ILLNESS: Briefly, this is a ___ y/o orthopaedic surgeon with PMH of CML-1, ILD, T2DM, PFO, CAD s/p CABG, and CHF transferred here from ___ ___ for further pulmonary evaluation of hypoxia likely d/t underlying IPF // ?interval changes TECHNIQUE: Portable chest ___. FINDINGS: Compared to the prior study there is no significant interval change. IMPRESSION: No change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with NSIP // concern for interval worsening COMPARISON: ___. IMPRESSION: As compared to the previous image, no relevant change is seen. Status post sternotomy. Known extensive right and basal left parenchymal opacities. The alignment of the sternal wires is constant. No new parenchymal opacities. The right PICC line is unchanged. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new R PICC // 48cm R basilic SL PICC ___ ___ Contact name: ___: ___ COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, the patient has received a right-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the lower SVC. No evidence of complications, notably no pneumothorax. Otherwise the radiographic appearance of the heart and the lungs is unchanged. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with HYPOXEMIA temperature: 97.6 heartrate: 77.0 resprate: 20.0 o2sat: nan sbp: 157.0 dbp: 83.0 level of pain: 0 level of acuity: 2.0

___ orthopaedic surgeon with pmHx of CML-1, ILD, DM, CAD s/p CABG, and CHF transferred here from ___ for further pulmonary evaluation of hypoxia likely d/t underlying IPF with additional component of pulmonary hypertension. #Hypoxia: Pt with known history of IPF/ILD on chronic corticosteroids presents with worsening home O2 requirement, transferred from OSH where he required BiPAP and stay in ICU for hypoxemia. Persistently hypoxic, requiring 6L via NC to maintain sats with desats to the 70's with any type of exertion. A CTPA was without evidence of acute PE, though noted pulmonary arterial dilation indicative of pulmonary arterial hypertension. A potential bronch was discussed with the patient and his outpatient pulmonologist, Dr. ___ was deferred given that it was unlikely to be revealing. The patient was started on a solumedrol burst for 3 days, with subjective improvement, but no change in O2 requirements. He was then transitioned to cellcept. The patient also underwent diuresis, with minimal improvement in his respiratory status. He required between ___ of O2, with desats upon movement. A TTE was done to assess for a cardiac cause of his worsening shortness of breath. It showed a possible pulmonary or cardiac shunt, pulmonary hypertension, as well as worsening aortic stenosis. Concern was that this may have caused a right to left shunt, causing worsening hypoxia. Cardiology was consulted, and the patient was transferred to ___ for a possible intracardiac echo and possible PFO closure. On AM of ___ patient triggered for hypoxia with O2 sats in the ___. He was started on high flow nasal oxygen. He was then taken to the cath lab for RHC and ICE (intra cardiac echo) which did not show evidence of shunt. Additionally it showed normal PCWP. Given lack of intervenable cardiac issue he was transferred back the Medical ICU service. In the ICU, the patient was kept on nonrebreather and high flow O2. He was continued on prednisone 50mg daily and cellcept, with no improvement in oxygen requirements. ID was consulted to assess for an infectious etiology. Though they thought the hypoxia was unlikely related to infection, the patient was started on atovaquone for PCP, and on vanc/cefepime, also with no improvement. A beta-glucan was negative The patient clearly stated that in the absence of any obvious reversible causes for respiratroy distress, he endorsed focusing on comfort as a priority. "I know I am going to die from my disease." Several extensive discussions were held with patienit and family members at the bedside, including wife, sons and ___. All in agreement with patients goals and values. The pateint and family were in suport of transition to Hospice care. The patient required increaing amounts of morphine for comfort and relief of dyspnea, and was transitioned to MS contin and PRN morphine. He was seen by palliative throughout his hospitalization and ultimately it was determined that he will be discharged to hospice. #Hyperglycemia: The patient's blood glucose in the past has been poorly controlled on chronic corticosteroids for ILD. He presented with a blood glc of 442 and anion gap of 18. He was initially placed on lantus 40U BID with an insulin sliding scale. However, following initiation of solumedrol on ___, the patietn had glucose levels in the 400s, which did not improve with SC insulin. He was placed on an insulin drip overnight. Per ___ recs, he was then transitioned back to basal and SC insulin the following day. He continued to be hyperglycemic throughout the remainder of his hospitalization. He was discharged on 45 units Lantus and SSI. ___: Presented with a Cr of 1.3, thought to be pre-renal from diuresis at OSH vs cardiorenal from poor forward flow. It improved to 1.0. However, following aggressive diuresis, it again increased to 1.4, which downtrended with PO intake and resumption of home diuretic dosing. His creatinine was 1.2 on discharge. #CMML- Pt reecently dx with CMML, previously treated with ATRA and hydrea. Dr. ___ manages as outpatient and has held off on decitabine tx for possible conversion to AML. On presentation, leukocytosis to 60, which then further increased to 85. Heme/onc was consulted on ___, and recommended no leukophoresis. The patient was found to have an elevated uric acid, and was started on allopurinol. There was no further treatment indicated by the oncology team for this condition. #Anxiety: The patient was found to be very anxious on arrival to the FICU. He required large doses of seroquel to sleep (75mg). His family was concerned about changes in his behavior. Geripsych and palliative care were consulted, who recommended first trying morphine to decrease anxiety around air hunger, and then a small benzo dose if there was no improvement. The patient was continued on nightly seroquel, PRN ativan, MS contin, and PRN morphine. #Anemia- Hgb baseline near 10, presents with H/H of 8.___.8. This remained stable during his stay in the FICU. #Thrombocytopenia- Stable at baseline ~70 while in FICU. #DM: hold metformin, insulin and hyperglycemia management as above #OSA: cont home CPAP at night #CAD: cont ASA and simvastatin. Lisinopril was stopped. Metoprolol was fractionated into 50 mg q6h. TRANSITIONAL ISSUES =================== # Patient to complete an additional 2 days of vancomycin and cefepime (last dose ___ for empiric HCAP treatment. # Patient to complete a 21 day course of atovaquone for empiric PCP ___ (last dose ___. # Please uptitrate MS ___ and IV morphine prn doses as tolerated for dypsnea. # Patient to continue to Cellcept 1250 mg BID per outpatient pulmonologist. Also patient to decrease prednisone by 10 mg weekly (currently at 50 mg) until he is at 10 mg daily. CODE STATUS: DNR/DNI

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: There were no major surgical or invasive procedures during hospitalization. History of Present Illness: Ms. ___ is a ___ with PMH of HCV cirrhosis (CP-C) s/p Harvoni with SVR c/b PVT (on warfarin), ascites, HE, and prior variceal bleed (s/p banding) who is being transferred from ___ ___ after presenting from home with AMS. By report from the daughter, Patient is AAOx3 at baseline. According to her husband, she had been complaining of abdominal pain the past two days attributed to GERD, but her mental status was clear as of the night prior to admission. The next morning, she was found significantly altered at home vomiting and she was brought to ___. She had a CT head/neck and CXR, which were both unremarkable. UA notable for only 5 WBCs. No cultures were obtained. Patient was given 2g CFTX and and lactulose via NGT, which was pulled out en route. In the Emergency Department at ___, initial vitals were: T97.6 HR 65 BP 134/96 RR 24 99% on RA. Labs were notable for Hg 11.2, plt 126, INR 2.3 (on AC), WBC 4.9, ALT 55, AST 65, tbili 1.2, Cr 1.1, negative troponin, lactate 1.9, and negative serum tox. Studies included US of liver and gallbladder which demonstrated cirrhosis with moderate volume ascites as well as persistent thrombosis of the main portal vein. An NGT was replaced in the ED and lactulose was given with some improvement in patient's mental status. However, patient still in four point restraints upon and thus diagnostic paracentesis was deferred at this time. Vitals on transfer: BP 125/66 HR 79 RR 19 100% RA. On arrival to the floor, Ms. ___ is in mitt restraints, confused, but not in significant distress. She is oriented to self and place and recognizes her daughter. She intermittently nods to questions and is able to state that she is not in any pain. Of note, Ms. ___ was recently hospitalized from ___ to ___ with progressive confusion and abdominal distension in the setting of holding enoxaparin after an episode of BRBPR 5 days. On that admission, she was found to have worsening PVT and her anticoagulation was transitioned to warfarin. She was also found to have an E.coli UTI and completed a 7 days course of nitrofurantoin on ___. EGD on that admission with grade I varices. Colonoscopy with grade I internal hemorrohoids. Past Medical History: HTN Hepatitis C c/b cirrhosis s/p cholecystectomy s/p appendectomy s/p incisional hernia Macular degeneration (treated with Avastin at ___) PTV diagnosed ___ on warfarin Recent T7 fracture ___ s/p fall managed conservatively Social History: ___ Family History: non-contributory, no FH of liver disease Physical Exam: ADMISSION: VS: T 97.4 137/50 HR 88 RR 18 100% on RA. GENERAL: lethargic, elderly lady sleeping in bed in NAD. HEENT - hematoma on right forehead with yellow discoloration, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP unable to assess. CARDIAC: RRR, normal S1/S2, ___ SEM best heard in RUSB. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender,mildly distended. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: oriented x2 (name and hospital), unable to obtain formal neuro but moving all four limbs spontaneously. DISCHARGE: VS: 97.6 afeb, 116/63 HR ___ RR 16 96% on RA. GENERAL: pleasant, elderly, walking about room in NAD. HEENT - no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. CARDIAC: RRR, normal S1/S2, ___ SEM best heard in RUSB. PULMONARY: Minimal crackles at bilateral bases, otherwise clear to auscultation bilaterally. ABDOMEN: Normal bowel sounds, soft, slightly distended, no rebound or guarding. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. NEUROLOGIC: spontaneously moving all four extremities, no facial droop/asymmetry. Pertinent Results: ADMISSION/SIGNIFICANT LABS ___ 01:30PM BLOOD WBC-4.9 RBC-3.96 Hgb-11.2 Hct-35.5 MCV-90 MCH-28.3 MCHC-31.5* RDW-15.7* RDWSD-51.4* Plt ___ ___ 01:30PM BLOOD Neuts-72.3* Lymphs-17.7* Monos-8.8 Eos-0.8* Baso-0.2 Im ___ AbsNeut-3.55 AbsLymp-0.87* AbsMono-0.43 AbsEos-0.04 AbsBaso-0.01 ___ 01:30PM BLOOD ___ PTT-30.0 ___ ___ 01:30PM BLOOD Glucose-126* UreaN-26* Creat-1.1 Na-135 K-4.6 Cl-104 HCO3-22 AnGap-14 ___ 01:30PM BLOOD ALT-55* AST-65* AlkPhos-118* TotBili-1.2 ___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICRO: ------- URINE CULTURE (Final ___: <10,000 organisms/ml. Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: --------- RUQ U/S ___ Cirrhosis with splenomegaly and moderate volume ascites. Persistent thrombosis of the main portal vein as well as central portal venous branches. CT Abdomen with contrast ___. Continued diffuse thrombosis of the intrahepatic portal venous system, main portal vein, and portion of superior mesenteric vein, unchanged compared to ___. There is evidence of cavernous transformation. 2. Small to moderate ascites is increased. Splenomegaly is stable. 3. Generalized bowel wall thickening within the colon and possibly the collapsed stomach, may relate to portal hypertensive changes. 4. Bilateral pleural effusions, right greater than left, increased. 5. Other incidental findings including right renal cyst, atherosclerotic disease, diverticulosis, are stable. LABS AT DISCHARGE: ___ 05:37AM BLOOD WBC-3.0* RBC-3.32* Hgb-9.4* Hct-30.0* MCV-90 MCH-28.3 MCHC-31.3* RDW-15.3 RDWSD-49.9* Plt Ct-86* ___ 05:37AM BLOOD Glucose-86 UreaN-22* Creat-0.9 Na-135 K-4.3 Cl-100 HCO3-26 AnGap-13 ___ 06:21AM BLOOD calTIBC-194* Ferritn-63 TRF-149* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rifaximin 550 mg PO BID 2. Ferrous Sulfate 325 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lactulose 30 mL PO QID:PRN confusion 5. Nadolol 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Spironolactone 100 mg PO DAILY 8. Tizanidine 2 mg PO QHS 9. TraMADOL (Ultram) 50 mg PO TID:PRN pain 10. Warfarin 3 mg PO DAILY16 11. Hemorrhoidal Suppository ___AILY Discharge Medications: 1. Furosemide 40 mg PO DAILY 2. Nadolol 20 mg PO DAILY 3. Rifaximin 550 mg PO BID 4. Spironolactone 100 mg PO DAILY 5. Hemorrhoidal Suppository ___AILY 6. Pantoprazole 40 mg PO Q24H 7. Ferrous Sulfate 325 mg PO DAILY 8. Lactulose 30 mL PO ___ PER DAY 9. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1.) Hepatic encephalopathy (with empiric treatment for SBP) 2.) HCV Cirrhosis 3.) Chronic Portal Vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with hepatic encephalopathy hx pvt on warfarin p/w ams TECHNIQUE: Right upper quadrant ultrasound COMPARISON: CT abdomen pelvis from ___ as well as a right upper quadrant ultrasound from ___. FINDINGS: The liver is coarse and heterogeneous compatible with known cirrhosis. Moderate volume ascites noted. Visualized portion of the IVC and aorta appear patent and normal. Common bile duct is 5 mm in maximal diameter. Limited views of the pancreas appear unremarkable. Gallbladder is surgically absent. Doppler: There is complete thrombosis of the main portal vein as well as central branches. Hepatic veins appear grossly patent. Hepatic arteries demonstrate normal waveforms. Spleen is enlarged measuring up to 14 cm. Limited views of both kidneys appear unremarkable. IMPRESSION: Cirrhosis with splenomegaly and moderate volume ascites. Persistent thrombosis of the main portal vein as well as central portal venous branches. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with NGT placement COMPARISON: ___ FINDINGS: AP portable upright view of the chest. There has been placement of an NG tube which courses inferiorly into the left upper abdomen. Clips in the right upper quadrant noted. Overlying EKG leads are present. Lungs are clear. Cardiomediastinal silhouette is stable. Left CP angle is excluded. Bony structures appear intact. IMPRESSION: NG tube positioned appropriately. Radiology Report INDICATION: ___ year old woman with cirrhosis, and history of portal venous thrombus, presenting with encephalopathy. // Please evaluate for progression of portal thrombus. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 3) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP = 16.2 mGy-cm. 4) Spiral Acquisition 13.0 s, 44.8 cm; CTDIvol = 7.1 mGy (Body) DLP = 309.1 mGy-cm. Total DLP (Body) = 340 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: Trace left and small right pleural effusions are new/ increased compared to prior study. Imaged portion of lung bases appear otherwise within normal limits except note mild bibasilar atelectasis. Imaged portion of heart and pericardium notable for coronary artery and aortic valvular calcifications. ABDOMEN: HEPATOBILIARY: Extensive thrombosis of the portal venous system, with thrombus involving the left, right anterior, and majority of right posterior portal venous system, as well as the main portal vein with extension to the proximal superior mesenteric vein, is unchanged in configuration compared to ___. The presence of multiple clips in the gallbladder fossa with associated streak artifact limits assessment of some segments. Some prominent vessels in the porta hepatis suggest that cavernous transformation is occurring. No discrete focal liver lesions are identified, noting the limitation of single phase post-contrast technique. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. Peripancreatic stranding is similar to that observed throughout the mesenteries and likely related third-spacing. SPLEEN: The spleen is enlarged, measuring 16.5 cm, unchanged. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. 6 mm hypodensity, interpolar region of right kidney, is unchanged and consistent with a cyst. There is no perinephric abnormality. GASTROINTESTINAL: The stomach contains a NG tube. No evidence of bowel obstruction. Mild gastric wall thickening as well as thickening of the cecum and colon, likely relate to portal hypertensive changes. Colonic diverticulosis is present without evidence of focal inflammatory changes. The rectum contains a rectal tube. . The appendix is not visualized. Small to moderate ascites is increased. PELVIS: The urinary bladder and distal ureters are unremarkable. There is small ascites in the pelvis. A dropped clip is seen in the region adjacent to the uterine fundus. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Postoperative changes from prior right inguinal hernia repair are noted. No recurrent hernias are identified. . IMPRESSION: 1. Continued diffuse thrombosis of the intrahepatic portal venous system, main portal vein, and portion of superior mesenteric vein, unchanged compared to ___. There is evidence of cavernous transformation. 2. Small to moderate ascites is increased. Splenomegaly is stable. 3. Generalized bowel wall thickening within the colon and possibly the collapsed stomach, may relate to portal hypertensive changes. 4. Bilateral pleural effusions, right greater than left, increased. 5. Other incidental findings including right renal cyst, atherosclerotic disease, diverticulosis, are stable. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with Hepatic failure, unspecified without coma temperature: 97.6 heartrate: 65.0 resprate: 24.0 o2sat: 99.0 sbp: 134.0 dbp: 96.0 level of pain: unable level of acuity: 2.0

Ms. ___ is a ___ with PMH of HCV cirrhosis (CP-C) s/p Harvoni with SVR c/b PVT (on warfarin), ascites, HE, and prior variceal bleed (s/p banding) who is being transferred from ___ ___ after presenting from home with AMS consistent with hepatic encephalopathy. # HEPATIC ENCEPHALOPATHY: Unclear etiology of precipitating cause. As per family, patient fully compliant with medications including lactulose and rifaximin. No evidence of bleed and abdominal imaging demonstrated stability of known portal vein thrombosis. CXR, blood culture, and urine were negative for infection. She was unable to receive a paracentesis given minimal perihepatic ascites and was treated empirically for SBP with five days of ceftriaxone and albumin on the first and third day of her hospitalization. She was also started on ciprofloxacin as presumptive SBP prophylaxis. For her hepatic encephalopathy, she initially required NGT for q2h lactulose and her mental status cleared by then next morning. She was transitioned to TID lactulose without any further episodes encephalopathy. #CHRONIC PVT: Previously on warfarin for chronic PVT. During this admission, she had a CT of the abdomen/pelvis to assess for progression of the portal venous thrombus as a cause of the encephalopathy. The portal venous thrombus was not increased in size and this was thought to not be the cause of the encephalopathy. Given her numerous episodes of hepatic encephalopathy and increased risk of falls, it was decided to stop her home coumadin after conversations with Dr. ___ outpatient ___. She had a head CT at the outside hospital which was negative for bleed. ## VARICES: Status post banding. Last EGD (___) showed Grade 1 varices. She was continued on nadolol. # ASCITES: No history of TIPS, currently managed with diuretics. Continued furosemide 40 mg daily/spironolactone 100 mg daily. # CIRRHOSIS: Secondary to hepatitis C, s/p Harvoni; CP-class C. Cirrhosis previously decompensated by ascites, HE, and variceal bleeding. HCV VL negative on ___. TRANSITIONAL ISSUES -Patient started on ciprofloxacin for SBP prophylaxis given recurrent episodes of HE -Warfarin was stopped in the setting of increased fall risk. Continue to reassess role for anticoagulation. -needs repeat UA as outpatient as patient had hematuria during hospitalization. -if gets constipated as outpatient, may consider iron infusion rather than iron pills, as her encephalopathy may be related to constipation. #Code Status: Full Code (confirmed) #Contact Information: -___ (husband): ___ -___ (daughter): ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Wellbutrin / Diltiazem / Verapamil / amiodarone Attending: ___ ___ Complaint: symptomatic afib Major Surgical or Invasive Procedure: none History of Present Illness: ___ PMH AF, ___ disease, who underwent a PVI on ___ without complications, and was discharged home the following day as per routine. At home today he noted some ecchymosis along his groin, as well as abdominal fullness and 8 lbs weight gain. He called the heart line, and was directed into the ED. In the ED, he denied severe symptoms, but noted that he felt that he had gone back into AF on the way in, and had associated dyspnea and dizziness as a result. He denies groin pain, and otherwise has been feeling well. He denied fever, chills or any other infectious symptoms On cardiac review of symptoms, the patient denies any chest pain or anginal equivalent, orthopnea, PND, palpitations, syncope or presyncope, or claudication-type symptoms. Past Medical History: HTN, HEP A, charcot ___ tooth, peripheral neuropathy, COPD(mild), hyperthyroidism, GERD, Colonic polyps, renal agenesis Social History: ___ Family History: Noncontributory for arrhythmias Physical Exam: Admission Exam: Vitals: BP: 147/73 mmHg supine, HR 100 bpm, RR 13 bpm, O2: 99 % on RA. CONSTITUTIONAL: Pleasant, No acute distress. EYES: No conjunctival pallor. No icterus. ENT/Mouth: MMM. OP clear. THYROID: No thyromegaly or thyroid nodules. CV: Nondisplaced PMI. Normal rate. irregular rhythm. nl S1, S2. No extra heart sounds. No appreciable murmurs. Mild JVD. Normal carotid upstroke without bruits. LUNGS: Breath sounds bilaterally. Basilar crackles. GI: NABS. Soft, NT. Mild fullness, dull to percussion. No HSM. No abdominal bruits. MUSCULO: Supple neck. Normal muscle tone. Full strength grossly. HEME/LYMPH: No palpable LAD. 1+ peripheral edema. Full distal pulses bilaterally. SKIN: Warm extremities. Ecchymosis along both groins, R>L, without palpable hemotoma or tenderness. NEURO: A&Ox3. Grossly normal without any significant focal deficits PSYCH: Mood and affect were appropriate. Discharge Exam: VS: 97.8 ___ 97-110/53-63 20 99%RA WT 101.4 GENERAL: WDWN male in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. NECK: Supple with JVP flat CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e Pertinent Results: Admission Labs: ___ 05:00PM BLOOD WBC-5.6 RBC-3.90* Hgb-12.6*# Hct-37.3* MCV-96 MCH-32.2* MCHC-33.7 RDW-12.7 Plt ___ ___ 02:49AM BLOOD ___ ___ 01:10PM BLOOD Glucose-103* UreaN-17 Creat-1.2 Na-134 K-4.1 Cl-97 HCO3-27 AnGap-14 Discharge Labs: ___ 07:35AM BLOOD WBC-4.6 RBC-4.14* Hgb-13.3* Hct-39.7* MCV-96 MCH-32.1* MCHC-33.5 RDW-12.7 Plt ___ ___ 07:35AM BLOOD ___ PTT-41.4* ___ ___ 07:35AM BLOOD Glucose-120* UreaN-27* Creat-1.3* Na-133 K-3.8 Cl-96 HCO3-26 AnGap-15 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob 2. Lisinopril 20 mg PO DAILY 3. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 4. Tamsulosin 0.8 mg PO HS 5. TraMADOL (Ultram) 100 mg PO QAM 6. TraMADOL (Ultram) 50 mg PO QPM:PRN pain 7. Warfarin 6 mg PO DAILY16 8. Aspirin 325 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Ibuprofen 400 mg PO Q8H:PRN chest pain 11. Atenolol 100 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN chest pain 3. Lisinopril 20 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Oxycodone SR (OxyconTIN) 30 mg PO Q12H 6. Tamsulosin 0.8 mg PO HS 7. TraMADOL (Ultram) 100 mg PO QAM 8. TraMADOL (Ultram) 50 mg PO QPM:PRN pain 9. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob 10. Atenolol 50 mg PO DAILY RX *atenolol 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 11. Dofetilide 500 mcg PO Q12H 12. Warfarin 6 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Recent cardiac ablation for AFib, now presents with shortness of breath for one day, question pulmonary edema. FINDINGS: PA and lateral views of the chest provided demonstrate plate-like left basal atelectasis. There is no consolidation or effusion. No signs of pulmonary edema. Cardiomediastinal silhouette is normal. Bony structures are intact. IMPRESSION: No signs of pulmonary edema or other acute intrathoracic process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DYSPNEA, DIZZINESS Diagnosed with ATRIAL FIBRILLATION temperature: 98.4 heartrate: 100.0 resprate: 16.0 o2sat: 97.0 sbp: 145.0 dbp: 107.0 level of pain: 0 level of acuity: 2.0

This is a ___ year old male with a past medical history of AFib, ___ disease, who underwent a PVI on ___ without complications, who unfortunately reverted back to symptomatic a-fib, then admitted for dofetilide initiation. #. Atrial fibrillation- The patient presented with symptomatic atrial fibrillation(e.g. lightheaded, dyspneic, and fluid overloaded). He was started on IV lasix, which resulted in -7 litters length of stay. He was initiated on dofetilide on the night of admission. He spontaneously converted to sinus rhythm just after the 3rd dose of dofetilide and remained in sinus throughout the remainder of his hospital course. His coumadin was uptitrated to 7.5mg daily since his INR dropped to 1.9 the day after admission, but was therapeutic at the time of discharge. He was given lovenox until his INR became therapeutic again. He remained on telemetry thoughout his hospital course, which was unremarkable. The atenolol dose was also halved to 50mg daily after initiating dofetilide and he was discharged on the lower dose. Overall, the patient tolerated dofetilide loading without complication.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Amiodarone Attending: ___. Chief Complaint: Right femoral neck fracture Major Surgical or Invasive Procedure: Right hip hemiarthroplasty History of Present Illness: ___ male with prior CVA, Afib (on Coumadin last taken day prior to admission yesterday), CAD s/p ICD placement, ___ disease and Alzheimer's dementia who sustained a mechanical fall at home. His wife witnessed he fall and said he lost his balance and fell. No prodrome. No LOC or HS. He managed to get himself to a chair and the wife called an ambulance. Patient interview was attempted with interpreter but is very limited to do dementia. Past Medical History: - ___ disease - Hyperlipidemia - Hypertension - Coronary artery disease s/p anterior MI, with DES to the mid LAD on ___ - PPM for complete heart block - Atrial fibrillation on coumadin - BPH - Hemorrhoids - History of adenomatous polyps - Polycythemia requiring intermittent phlebotomy - Thrombocytosis Social History: ___ Family History: No family history of malignancy. Physical Exam: AVSS NAD, A&Ox1 RLE: Incision well approximated. Fires FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP pulse, wwp distally. Pertinent Results: See OMR for all lab and imaging results Medications on Admission: ACYCLOVIR - acyclovir 5 % topical ointment. apply to affected area 5 times a day x 4 days CICLOPIROX - ciclopirox 8 % topical solution. Apply to affected nails daily Remove with alcohol every 7 days. CONDON CATHETER - Condon catheter . put on at bedtime, remove QAM DONEPEZIL - donepezil 10 mg tablet. 1 tablet(s) by mouth once a day ECONAZOLE - econazole 1 % topical cream. Apply to feet in red areas and between toes twice a day HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply to rash twice daily twice a day as needed for PRN for no more than 2 weeks per month HYDROXYUREA - hydroxyurea 500 mg capsule. 1 capsule(s) by mouth qday LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth once a day for blood pressure MEMANTINE - memantine 10 mg tablet. 1 tablet(s) by mouth twice a day OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 2 capsule(s) by mouth once a day QUETIAPINE - quetiapine 25 mg tablet. 1 tablet(s) by mouth once a day as needed for agitation SIMVASTATIN - simvastatin 40 mg tablet. one Tablet(s) by mouth daily for cholesterol TAMSULOSIN - tamsulosin 0.4 mg capsule. one capsule(s) by mouth nightly for prostate per Dr. ___ MALEATE - timolol maleate 0.5 % eye drops. 1 drop(s) both eyes twice a day WARFARIN - warfarin 2 mg tablet. 2 (Two) Tablet(s) by mouth once a day or as directed by ___ clinic Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. ___ Tablet(s) by mouth twice a day as needed for pain ASPIRIN - aspirin 81 mg tablet,delayed release. one tablet(s) by mouth daily DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QPM 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every Disp #*30 Tablet Refills:*0 5. Senna 17.2 mg PO HS 6. Donepezil 10 mg PO QHS 7. Memantine 10 mg PO BID 8. Omeprazole 40 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11. Warfarin 4 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Femoral neck fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS AP ___ VIEWS INDICATION: History: ___ s/p mechanical fall// R/o fx R/o fx R/o fx TECHNIQUE: Frontal radiograph of the pelvis, with frontal and lateral views of the right hip, proximal and distal femur COMPARISON: Concurrent CT abdomen and pelvis FINDINGS: There is shortening of the left femoral neck, consistent with previously seen right subcapital fracture. No additional fractures or dislocations are noted. There is severe degenerative changes of the partially visualized right knee, most notable in the patellofemoral compartment. There is at least moderate degenerative change of the bilateral hips, sacroiliac joints, and visualized lumbar spine. Contrast is noted in the bladder due to patient's recent CT. Radiodense substance overlying the patient's left pelvis and acetabulum is likely external. IMPRESSION: Shortening of the left femoral neck is consistent with previously seen right subcapital ___ stage IV fracture. No additional fractures or dislocations. Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ s/p mechanical fall and R femur fx// preop eval TECHNIQUE: Supine AP radiograph the chest COMPARISON: Multiple prior comparisons, most recent chest radiograph from ___ FINDINGS: Exam is mildly limited due to patient rotation. Again seen is left chest wall cardiac conduction device with leads terminating in the right atrium and right ventricle. Mildly enlarged and tortuous thoracic aorta and mild cardiomegaly are stable, allowing for patient rotation, AP and supine positioning. Reflective of tortuous thoracic aorta. Lung volumes are minimally low. There is no focal consolidation to suggest pneumonia. There is no pulmonary edema. Pleural spaces are normal. IMPRESSION: 1. No focal consolidation. 2. Unchanged cardiomediastinal silhouette com allowing for patient rotation, reflective of tortuous thoracic aorta. 3. Although no acute or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma or other soft tissue abnormality involving the chest wall is clinically warranted, the location of any referable focal findings should be clearly marked and imaged with either bone detail radiographs or Chest CT scanning. Radiology Report EXAMINATION: PELVIS PORTABLE INDICATION: RT HEMI, FX. TECHNIQUE: Cross-table portable view of the right hip COMPARISON: Pelvis radiographs from ___. CT abdomen and pelvis from ___ FINDINGS: The patient is status post right hip hemi arthroplasty, in overall anatomic alignment. No periarticular fracture is detected. There is no perihardware lucency or hardware failure. IMPRESSION: Status post hip prosthesis in overall anatomic alignment. No evidence of hardware complications. Gender: M Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: R Knee pain, s/p Fall Diagnosed with Pain in right knee, Unspecified fall, initial encounter temperature: 97.6 heartrate: 70.0 resprate: 18.0 o2sat: 95.0 sbp: 110.0 dbp: 77.0 level of pain: 6 level of acuity: 3.0

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hip hemiarthroplasty, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on Warfarin with lovenox bridge for DVT prophylaxis. The patient will need to follow up his INR in rehab and with his PCP regarding his warfarin/INR ___. ___. The patient will also follow up with Dr. ___ ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Oxacillin / Iodine Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ lady with ER(+) HER2(-) breast cancer which is metastatic to lung and medicastinal lymph nodes on Exemestane who presents with left back pain. She was seen in primary care clinic ___ (6 days ago) due to ___ days of left-sided pain. Per note, it is left-sided pain: "near a rib approximately in line with the posterior aspect of her external shoulder. It came on suddenly, felt like a knife cutting, and feels severe and deep. It does not radiate, and only bothers her when she ambulates. She also is unable to lay on her left side because of the pain unless she fully extends her legs. Does not worsen with inspiration, although with very deep breath she can feel the pain. Had a fall two months ago onto her back, no xray imaging obtained at that time, although she was noted to have a large flank hematoma that has since resolved. Otherwise, denies any recent trauma. No other symptoms: no SOB, chest pain, fever, chills, dysuria, hematuria, HA. She did have one episode." Rib x-ray was negative for fracture and CT chest did not reveal any etiology (though of note her RIGHT iliac bone seemed abnormal consistent with metastasis vs Paget's). She was given low-dose Oxycodone which did not help much, and then her regimen was changed to Vicodin with some effect. However the pain has been so bad that she cannot walk and can barely move at all so she came to the ED. In the ED, initial VS were: T98.2, BP 139/62, HR 77, RR 22, POx 98%RA. She was a difficult stick but basic electrolytes and LFTs were normal. UA normal with no blood. She did not receive any medications while in the ED. VS prior to transfer were: T 98.2, BP 154/84, HR 65, RR 18, POx 100%RA. On arrival to the floor, she feels OK. Prefers to lie on her left side because this helps her left back/flank pain. REVIEW OF SYSTEMS: (+) Per HPI. Also recently has been constipated but used bowel regimen and had a large bowel movement 3 days ago; none since then. (-) Denies chills, night sweats. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: [per OMR, confirmed with patient] - History of bilateral breast cancers age ___ initially treated at ___. Per review of Dr. ___: "She underwent bilateral mastectomies and on the left, she has stage III lymph node positive, ER positive disease. She completed axillary lymph node dissection followed by chemotherapy and adjuvant radiation therapy. She was then treated with tamoxifen for a total of ___ years. On the right, the patient reportedly had what she describes as "microscopic cancer." She is unaware of any lymph node evaluation on that side. She did not undergo any form of radiation therapy on the right side. The estrogen receptor status of the disease on the right is unknown to the patient." - In ___ she developed dry cough and ultimately underwent chest CT in ___ significant for left lower lung nodules and left hilar/subcarinal LAD. - ___ PET/CT with FDG avid mediastinal, hilar adenopathy and pulmonary nodules. A soft tissue attenuating area was also seen in a left renal mass measuring 3.5 cm in largest diameter with mild FDG avidity. This was overall felt to be nonspecific. - ___ bronch with US FNA of left hilar mass: malignant cells consistent with MBC, ER/PR pos, HER2 neg (FISH ratio 1.1) - ___ began ___ - ___ PD, switched to ___ OTHER PAST MEDICAL HISTORY: [per OMR, confirmed with patient] macular degeneration, is legally blind HTN DM2 HLD obesity h/o stroke h/o AFib s/p pacemaker placement CAD s/p MI ___ OSA on CPAP Hypothyroid s/p BTKR asthma Social History: ___ Family History: No family h/o breast cancer. Physical Exam: ADMISSION EXAM VS: T 98.8, BP 163/73, RR 18, POx 100%RA General: elderly lady in NAD, breathing comfortably but lying on her left side and avoids moving HEENT: MMM Neck: no cervical or cupraclavicular lymphadenopathy CV: S1 and S2, no murmur Lungs: CTA throughout Chest: chest wall with healed mastecomy sites; no superficial masses palpable Back: did not check ___ mild tendernedd to palpation over left flank near the midline Abdomen: (+)bowel sounds, soft, nontender, no masses GU: no foley Ext: no edema, warm Neuro: alert, oriented ___ hospital, year, and month; gait deferred Skin: no rash DISCHARGE EXAM Vitals: T: 98.3, BP:131/54 P:58 R:18 O2:99%RA General: elderly lady in NAD, breathing comfortably, lying on her right side HEENT: MMM Neck: no cervical or supraclavicular lymphadenopathy CV: RRR, normal S1 and S2, no murmur Lungs: CTA throughout Chest: chest wall with healed mastecomy sites; no superficial masses palpable Back: No CVA tenderness; very tender to palpation over left flank near the midline. Pt has large pannus. No obvious bowel herniations. Abdomen: (+)bowel sounds, soft, nontender, nondistended, no masses Ext: no edema, warm Neuro: alert, oriented ___ hospital, year, and month; gait deferred Skin: no rash Pertinent Results: ADMISSION LABS: ============== ___ 06:00AM BLOOD WBC-6.0 RBC-3.48* Hgb-10.1* Hct-30.5* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.8 Plt ___ ___ 08:54PM BLOOD Na-141 K-4.1 Cl-101 ___ 08:54PM BLOOD ALT-6 AST-17 AlkPhos-64 TotBili-0.3 ___ 08:54PM BLOOD Albumin-3.6 Calcium-9.4 Phos-2.9 Mg-1.6 ___ 08:54PM BLOOD freeCa-1.17 ___ 08:54PM BLOOD ___ pH-7.39 RELEVANT LABS: =============== ___ 06:00AM BLOOD CEA-1.9 ___ 06:00AM BLOOD CK(CPK)-46 DISCHARGE LABS: (labs not drawn on day of discharge as labs have been stable) =============== ___ 06:52AM BLOOD WBC-5.3 RBC-3.76* Hgb-10.9* Hct-32.6* MCV-87 MCH-29.0 MCHC-33.5 RDW-14.7 Plt ___ ___ 06:52AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-139 K-4.0 Cl-102 HCO3-30 AnGap-11 ___ 06:52AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.7 IMAGING: =============== Bone scan ___: IMPRESSION: 1. No definite evidence of osseous metastatic disease. Uptake in the right bony hemipelvis is more likely due to Paget's disease given the diffuse nature. 2. Nonspecific uptake in the L2 and L3 vertebral bodies may be degenerative. Uptake in the bilateral facets at L3/L4, left more than right, are likely degenerative. Correlate with symptoms to determine if this may be etiology of the left flank pain. US ___ IMPRESSION: No hernia seen in the left upper quadrant, left flank or left inguinal region. CT abd/pelvis ___: IMPRESSION: 1. No renal masses or intra-abdominal abscess. Nonobstructive right calyceal renal stone. Bilateral renal scarring. 2. Possibility of right iliac bone metastases, less likely to represent Paget's disease. 3. Early fibrotic changes at the lung bases, which may represent interstitial pneumonitis. 4. Stable focal pancreatic duct dilatation, common bile duct dilatation and central intrahepatic duct dilatation. 5. There is focal thinning of the left ventricular cardiac apex. Rib Xray ___: IMPRESSION: No displaced rib fracture is appreciated. MIRCO: ============ URINE CULTURE (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, wheeze 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze 3. Clopidogrel 75 mg PO DAILY 4. exemestane *NF* 25 mg Oral daily 5. Ezetimibe 10 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 11. Levothyroxine Sodium 88 mcg PO DAILY 12. Losartan Potassium 25 mg PO DAILY 13. MetFORMIN (Glucophage) 1000 mg PO BID 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Montelukast Sodium 10 mg PO DAILY 16. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain 17. Ranitidine 150 mg PO BID 18. Simvastatin 80 mg PO HS 19. Acetaminophen 1000 mg PO Q8H 20. Aspirin 81 mg PO DAILY 21. Cyanocobalamin 1000 mcg PO DAILY 22. Docusate Sodium 100 mg PO BID 23. melatonin *NF* 3 mg Oral QHS 24. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, wheeze 3. Aspirin 81 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 8. FoLIC Acid 1 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Gabapentin 300 mg PO TID 11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 12. Levothyroxine Sodium 88 mcg PO DAILY 13. Losartan Potassium 25 mg PO DAILY 14. Montelukast Sodium 10 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Ranitidine 150 mg PO BID 17. Simvastatin 40 mg PO HS 18. Milk of Magnesia 30 mL PO DAILY constipation 19. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain RX *morphine 15 mg 1 (One) tablet(s) by mouth every four (4) hours as needed Disp #*30 Tablet Refills:*0 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze 22. exemestane *NF* 25 mg Oral daily 23. Ezetimibe 10 mg PO DAILY 24. Ibuprofen 600 mg PO ___ X DAILY gout 25. melatonin *NF* 3 mg Oral QHS 26. MetFORMIN (Glucophage) 1000 mg PO BID 27. Metoprolol Succinate XL 50 mg PO DAILY 28. Nitroglycerin SL 0.6 mg SL PRN chest pain Discharge Disposition: Home Discharge Diagnosis: Primary: Left flank pain, unclear etiology Secondary: Breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance with arm holding. Followup Instructions: ___ Radiology Report HISTORY: ___ woman with ER+, HER2- breast cancer which is metastatic to lung and mediastinal lymph nodes presented with left flank pain, pain projects to inguinal ligament. Does she have an occult hernia on the left side that would be causing left flank pain radiating to the inguinal ligament of left? Would like to get ultrasound before scheduled bone scan. TECHNIQUE: Abdominal ultrasound limited, single organ. COMPARISON: This study is compared to previous CT abdomen/pelvis from ___. FINDINGS: The left flank was scanned from the left upper quadrant down to the inguinal region and no hernia was seen. No abnormal masses or nodules. IMPRESSION: No hernia seen in the left upper quadrant, left flank or left inguinal region. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: L SIDED ABD PAIN Diagnosed with NAUSEA WITH VOMITING, ABDOMINAL PAIN OTHER SPECIED, SECONDARY MALIG NEO LUNG, HX OF BREAST MALIGNANCY, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: nan heartrate: 77.0 resprate: 22.0 o2sat: 98.0 sbp: 139.0 dbp: 62.0 level of pain: 9 level of acuity: 3.0

Ms. ___ is a ___ lady with ER(+) HER2(-) breast cancer which is metastatic to lung and medicastinal lymph nodes on Exemestane who presents with left flank pain, unclear etiology.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Multiple medical complaints Major Surgical or Invasive Procedure: none History of Present Illness: Pt is an ___ yo female with a hx of DM type 1, HTN, HLD, GERD, hypothyroid, osteoporosis who presents from home with worsening fatigue and resolved dysarthria, dyshagia and altered mental status. The patient has been fatigued over the past few weeks and saw her PCP complaining of neuropathic pain keeping her awake at night, subsequently started on gabapentin 100 mg TID. She was also diagnosed with an UTI (urine cx grew E coli and Klebsiella) and started on Bactrim ___. She thinks these medications made her more fatigued, as they also impacted her walking (she was requiring more assistance than when she is well, but still getting around with walker in the house). Last night her caretaker noted her speech was slurred while the patient was speaking on the phone to her son. It is not clear if the speech was sensical or incoherent, but it was difficult to understand. She seemed disoriented. She had difficulty swallowing during dinner (unclear how this manifested, no facial weakness or choking noted). She was unable to stand to brush her teeth, and could not ambulate at all. She cannot describe what was wrong with her gait, but endorses generalized leg weakness and fatigue. In the ED, initial VS: afebrile 146/76, 83, 96RA, 18 Currently, pt is asmymptomatic asking to go home. Past Medical History: - DM TYPE 1- diagnosed at age ___ (last HbA1c ___ - Peripheral neuropathy - HTN - HLD - Osteopenia - Scoliosis - Congenital hip dysplasia - s/p multiple back surgeries L4/5 lami, L5-S1 fusion - Pelvic fractures - Hypothyroidism - CAD - s/p angioplasty ___. - Mild Aortic regurgitation - GERD (hiatal hernia) Social History: ___ Family History: No family hx of stroke Sister had CAD Physical Exam: Physical Exam on admission: VS - Temp 97.1 F, BP 167/68 , HR 62, R 18, 95 O2-sat % RA BS: 87 GENERAL - well-appearing female in NAD, comfortable, appropriate HEENT - EOMI, sclerae anicteric, dry mucous membranes, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), healing venous stasis ulcers bilaterally, hemosiderin deposits bilaterally NEURO - awake, A&Ox2 (person and place, unsure of exact date) CN II-XII grossly in tact, ___ strength in upper and lower extremeties Physical Exam on discharge: VS - Tmax 96.9 F BP 172/79 (134/53-198/96), HR 65 (64-66), R 18, 97 O2-sat % RA GENERAL - well-appearing female in NAD, comfortable, appropriate HEENT - EOMI, sclerae anicteric, dry mucous membranes, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox2 (person and place, unsure of exact date) CN II-XII grossly in tact, ___ strength in upper and lower extremeties Pertinent Results: Labs on admission: ___ 02:00PM BLOOD WBC-8.0 RBC-4.21 Hgb-12.1 Hct-37.3 MCV-89 MCH-28.8 MCHC-32.5 RDW-12.6 Plt ___ ___ 02:00PM BLOOD ___ PTT-23.2* ___ ___ 07:55AM BLOOD Glucose-127* UreaN-29* Creat-1.7* Na-142 K-5.9* Cl-104 HCO3-29 AnGap-15 ___ 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-778* ___ 07:00AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8 ___ 04:58PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04:58PM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 04:58PM URINE RBC-5* WBC-119* Bacteri-MOD Yeast-NONE Epi-13 TransE-1 ___ 12:55 pm URINE Source: ___. URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. Labs on discharge: ___ 07:55AM BLOOD WBC-9.6 RBC-4.08* Hgb-11.7* Hct-36.0 MCV-88 MCH-28.6 MCHC-32.4 RDW-12.9 Plt ___ ___ 07:00AM BLOOD Glucose-70 UreaN-20 Creat-1.4* Na-143 K-3.8 Cl-104 HCO3-27 AnGap-16 Imaging: MRI without contrast ___: IMPRESSION: No acute infarct seen. Ventriculomegaly out of proportion for sulci, which could be due to normal pressure hydrocephalus in proper clinical setting. CT Head without contrast ___: 1. No CT evidence of acute hemorrhage or major vascular territory infarction. Please note, MRI is more sensitive for acute ischemia, if indicated. 2. Global atrophy and remote occipital infarct, not significantly changed from the prior examination. CXR ___: IMPRESSION: No pneumonia or CHF. Large hiatal hernia. COPD Discharge Labs: ___ 07:55AM BLOOD WBC-9.6 RBC-4.08* Hgb-11.7* Hct-36.0 MCV-88 MCH-28.6 MCHC-32.4 RDW-12.9 Plt ___ ___ 07:00AM BLOOD Glucose-70 UreaN-20 Creat-1.4* Na-143 K-3.8 Cl-104 HCO3-27 AnGap-16 ___ 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-778* Studies pending at discharge: None Medications on Admission: ATENOLOL - 25 mg Tablet - one Tablet by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - 1 Capsule(s) by mouth once weekly GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth three times a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once a day HYDROCORTISONE - 2.5 % Cream - apply to skin daily INSULIN GLARGINE [LANTUS] - 100 unit/mL Cartridge - inject 16 units at bedtime as instructed INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - Take 20 units daily as directed LEVOTHYROXINE [SYNTHROID] - 88 mcg Tablet - 1 Tablet(s) by mouth once a day - No Substitution MOEXIPRIL [UNIVASC] - 15 mg Tablet - 1 Tablet(s) by mouth once a day PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day SIMVASTATIN - 20 mg Tablet - one Tablet(s) by mouth once a day SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1 Tablet(s) by mouth twice a day VALSARTAN [DIOVAN] - 40 mg Tablet - one Tablet(s) by mouth daily Medications - OTC BLOOD SUGAR DIAGNOSTIC ___ AVIVA] - Strip - test three times a day BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - test three times daily as directed CALCIUM CARBONATE [TUMS ULTRA] - (OTC) - 1,000 mg Tablet, Chewable - 1 Tablet(s) by mouth tid with food Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. hydrocortisone 2.5 % Cream Sig: One (1) Topical once a day. 5. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 6. insulin lispro 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: as directed. 7. levothyroxine 88 mcg 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. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. calcium carbonate Oral 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 13. moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Hyperkalemia Hypertension Acute kidney injury Secondary: Diabetes Mellitus Type 1 Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Hypertension, diabetes, GERD, dyspnea, weakness, question infection or fluid overload. FINDINGS: PA and lateral views of the chest were obtained. The lungs are hyperlucent with widened AP diameter of the chest, suggesting underlying COPD. There is a large retrocardiac opacity which is slightly increased in size compared with the prior study and likely represents a large hiatal hernia. There is no focal consolidation, effusion, or pneumothorax. No signs of CHF. Heart size appears stable. Mediastinal contour reflects an unfolded thoracic aorta. Bony structures are intact though demineralized. IMPRESSION: No pneumonia or CHF. Large hiatal hernia. COPD. Radiology Report INDICATION: New right-sided lower extremity weakness and facial droop. TECHNIQUE: Multidetector CT scan of the head was obtained without the administration of contrast. Coronal and sagittal reformations were prepared. COMPARISON: CT examination dated ___. FINDINGS: There is no CT evidence of acute hemorrhage, edema, mass effect or major vascular territory infarction. No significant change from the prior examination is seen. Diffuse prominence of the ventricles and sulci is consistent with global atrophy, unchanged. The configuration of the ventricles is stable from the exam of ___. A focal area of encephalomalacia in the left occipital lobe is consistent with a prior infarction, also unchanged. Areas of periventricular white matter hypodensity may reflect sequelae of chronic small vessel ischemic disease. There are calcifications of the carotid siphons. No concerning osseous lesion is seen. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No CT evidence of acute hemorrhage or major vascular territory infarction. Please note, MRI is more sensitive for acute ischemia, if indicated. 2. Global atrophy and remote occipital infarct, not significantly changed from the prior examination. ATTENDING NOTE: Ventriculomegaly, of proportion to the prominent cerebral sulci. Normal Pressure hydrocephalus can be considered, in the appropriate clinical setting. Radiology Report EXAM: MRI brain. CLINICAL INFORMATION: TIA, question of stroke. Patient with mental status changes, dysphagia, and dysarthria. TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial images of the brain were acquired. Comparison was made with the MRI examination of ___. FINDINGS: There is ventriculomegaly identified out of proportion for sulci, with prominence of sulci as well seen. Periventricular hyperintensities are identified. An area of encephalomalacia is seen in the left occipital lobe. Small areas of chronic microhemorrhage is seen in the left cerebellum and right temporal region. The ventriculomegaly has not significantly changed from prior study. No acute infarct is seen. IMPRESSION: No acute infarct seen. Ventriculomegaly out of proportion for sulci, which could be due to normal pressure hydrocephalus in proper clinical setting. Other findings as described above. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: WEAKNESS/SOB Diagnosed with URIN TRACT INFECTION NOS, OTHER MALAISE AND FATIGUE, RENAL & URETERAL DIS NOS, HYPOXEMIA temperature: 97.6 heartrate: 65.0 resprate: 20.0 o2sat: 95.0 sbp: 160.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

___ year old female with a history of type 1 diabetes, hypertension, hyperlipidemia, GERD, hypothyroidism, and osteoporosis admitted after transient dysarthria, dysphagia, and altered mental status and found to have hyperkalemia, acute renal fialure, urinary tract infection, and severe hypertension. #Transient altered mental status/dysphagia/Encephalopathy vs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L sided chest pressure Major Surgical or Invasive Procedure: ___- cardiac catheterization History of Present Illness: Patient is a ___ with history of HTN who presents to ___ with new left-sided chest pain. Patient says that after waking as usual this AM, around 9AM, he began to experience gradual onset, left-side chest pressure. The pain was present at rest and was soon associated with increased sweating and an overall sensation of being hot. No SOB, palpitations, or lightheadedness. He sat down in his chair and hoped that the pain would subside. There was a subsequent crescendo of discomfort, however, ultimately reaching ___ in intensity. After the pain began to radiate into his left shoulder and towards his left elbow, patient decided to present to his PCP who told him to come to the ED. In the ED initial vitals were: 98.4 80 162/95 18 98% RA EKG: NSR 64bmp, mild LAD, TWIs II/III/aVF, J-point elevation in precordial leads Labs/studies notable for: CBC 10.5>13.9/41.9<390 BMP 141/5.7(whole blood 5.1)/102/25/10/.9 CK 450 MB 6 Trop .02 INR 1.1 Patient was given: ___ 17:40 SL Nitroglycerin SL .4 mg ___ 17:40 PO Aspirin 324 mg ___ 18:15 SL Nitroglycerin SL .4 mg ___ 19:00 IV Heparin 4000 UNIT ___ 19:00 IV Heparin ___ 19:06 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min ordered) CXR FINDINGS: PA and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Vitals on transfer: 98.5 68 138/64 20 94% RA Upon arrival to ___, patient recounts the history as above. He says that after receiving SL NTG in the ED his chest pain soon subsided. There has been no recurrence of pain as he continues on a nitro gtt. He is currently comfortable at rest, no breathing difficulties. Patient has never experienced any chest pain in the past. He has been able to exert himself without difficulties, is fairly active with his work as a ___. Patient has never smoked tobacco, does smoke marijuana ~3x weekly. There is no history of cocaine use. 10-point ROS is otherwise NEGATIVE. Past Medical History: Hypertension Social History: ___ Family History: Brother (___) - has been hospitalized for cardiac problems, specifically stress-related tachycardia (no MI) No sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.6 110/67 58 18 96 RA GENERAL: Comfortable appearing obese male in NAD, breathing comfortably on RA HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: No JVP elevation. CARDIAC: Bradycardic, regular rhythm, normal S1, S2. No murmurs/rubs/gallops. LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.3 131/74 85 18 93 RA I/O= -56 (24hrs) (not recorded well) Weight: 123 kg Weight on admission: 124.8kg General: well-appearing, comfortably sitting upright in bed. NAD HEENT: PERRL Lungs: CTAB, no crackles, wheezes or rhonchi CV: RRR, normal S1 and S2, no murmurs, rubs or gallops Abdomen: Nondistended, nontender, normoactive bowel sounds, no rebound or guarding. Ext: No peripheral edema, +2 DP pulses, no clubbing or cyanosis. Pertinent Results: ADMISSION LABS ============== ___ 04:45PM BLOOD WBC-10.5* RBC-4.87 Hgb-13.9 Hct-41.9 MCV-86 MCH-28.5 MCHC-33.2 RDW-13.2 RDWSD-40.8 Plt ___ ___ 04:45PM BLOOD Neuts-69.4 ___ Monos-8.2 Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.32* AbsLymp-2.25 AbsMono-0.86* AbsEos-0.02* AbsBaso-0.03 ___ 04:45PM BLOOD ___ PTT-25.7 ___ ___ 04:45PM BLOOD Glucose-105* UreaN-10 Creat-0.9 Na-141 K-5.7* Cl-102 HCO3-25 AnGap-14 ___ 04:45PM BLOOD CK(CPK)-450* ___ 04:45PM BLOOD CK-MB-6 ___ 04:45PM BLOOD cTropnT-0.02* INTERVAL LABS ============= ___ 11:57PM BLOOD CK-MB-24* cTropnT-0.20* ___ 09:15AM BLOOD CK-MB-23* cTropnT-0.35* ___ 04:45PM BLOOD cTropnT-0.24___ 11:40PM BLOOD CK-MB-8 cTropnT-0.29* ___ 09:15AM BLOOD %HbA1c-5.8 eAG-120 ___ 09:15AM BLOOD Triglyc-81 HDL-32* CHOL/HD-4.9 LDLcalc-108 DISCHARGE LABS ============== ___ 04:40AM BLOOD WBC-9.1 RBC-4.46* Hgb-13.0* Hct-39.1* MCV-88 MCH-29.1 MCHC-33.2 RDW-13.3 RDWSD-42.5 Plt ___ ___ 04:40AM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-141 K-4.2 Cl-102 HCO3-26 AnGap-13 IMAGING STUDIES =============== ___ CHEST XRAY IMPRESSION: No acute intrathoracic process. ___ CATH REPORT IMPRESSION: 1. Minimal CAD in this right dominant coronary system 2. No identifiable culprit atherosclerotic lesion identified ___ TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF = 60%). However, there is focal hypokinesis of the inferior septum and inmferior free wall. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. DISCHARGE LABS ================== ___ 04:40AM BLOOD WBC-9.1 RBC-4.46* Hgb-13.0* Hct-39.1* MCV-88 MCH-29.1 MCHC-33.2 RDW-13.3 RDWSD-42.5 Plt ___ ___ 04:40AM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-141 K-4.2 Cl-102 HCO3-26 AnGap-13 ___ 10:52AM BLOOD CK-MB-5 cTropnT-0.26* ___ 04:40AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.2 ___ 10:52AM BLOOD ___ CRP-9.8* Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with L sided chest pain radiating to L arm// eval pneumothorax other acute process COMPARISON: None FINDINGS: PA and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Other chest pain temperature: 98.4 heartrate: 80.0 resprate: 18.0 o2sat: 98.0 sbp: 162.0 dbp: 95.0 level of pain: 5 level of acuity: 2.0

PATIENT SUMMARY Mr. ___ is a ___ old man with hypertension who presented ___ with left sided chest pressure, inferior TWIs on EKG and positive troponins, admitted for myocarditis s/p negative cardic cath. ACUTE ISSUES ADDRESSED #CHEST PAIN: Mr. ___ presented with L sided chest pressure at rest radiating down his left arm and associated with diaphoresis, TWIs in inferior ECG leads and troponin (0.02) that peaked to 0.35. His chest pressure resolved with nitro. Cardiac cath ___ was neg. Repeat ECG on ___ showed new TWIs in lateral leads not seen on admission. TTE ___ showed small area of hypokinetic in inferior wall although test nondefinitive due to large body habitus. Chest pain and elevated trops likely due to myocarditis (CRP 10.3) vs. stress-induced cardiomyopathy. Not likely ACS w/ distal occlusion, but could not be ruled out definitely. Lower on diff include: inflammatory or infiltrative cardiac processes (such as sarcoid), coronary vasospasm, drug-induced ischemia (neg urine cocaine). ESR, ___, ACE pending. Pt started on aspirin 81 PO QD, lisinopril 5 mg PO QD, metop 25 mg QD, statin 80 mg PO QD. D/c with activity modification to reduce cardiac stress pending outpt cardiology f/u. CHRONIC ISSUES ADDRESSED #Hypertension: hx of HTN not on meds. Started on ACEi, beta blocker per above TRANSITIONAL ISSUES

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness, confusion Major Surgical or Invasive Procedure: ___ - Stereotactic ___ biopsy History of Present Illness: ___ presenting to the ER with a two week history of dizziness and confusion. A CT head shows a left occipital mass with surrounding vasogenic edema. Patient also reports a new rash along his right armpit for the last day. In the ER he has a temp of 100.7 and elevated BP. Patient denies any illness or any other symptoms. Past Medical History: HTN Old retinal injury Social History: ___ Family History: No known history of cancer or ___ tumors in his family. Physical Exam: Upon Discharge: ===================== VS: T 97.9, BP 147/77, HR 76, RR 16, O2 Sat 96%RA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Date Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL, anisocoric R>L EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip ___ IPQuadHamATEHLGast Right___ Left5 5 5 5 5 5 [x]Sensation intact to light touch Wound: [x]Staples in place, clean, dry, intact Pertinent Results: ___ 05:58AM BLOOD WBC-17.0* RBC-4.22* Hgb-13.7 Hct-39.5* MCV-94 MCH-32.5* MCHC-34.7 RDW-14.6 RDWSD-49.7* Plt ___ ___ 05:58AM BLOOD ___ PTT-24.0* ___ ___ 05:58AM BLOOD Glucose-136* UreaN-21* Creat-0.8 Na-143 K-4.1 Cl-105 HCO3-22 AnGap-16 ___ 05:58AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2 Medications on Admission: HCTZ 25mg QD Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN fever or pain Do not exceed 4000mg per day. 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Dexamethasone 4 mg PO Q8H RX *dexamethasone 4 mg 1 tablet(s) by mouth three times a day Disp #*240 Tablet Refills:*0 4. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Insulin SC Sliding Scale Fingerstick QACHS, HS Insulin SC Sliding Scale using HUM Insulin 6. Ketoconazole 2% 1 Appl TP BID RX *ketoconazole 2 % 1 appl twice a day Refills:*0 7. LevETIRAcetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H PRN pain Disp #*30 Tablet Refills:*0 9. Hydrochlorothiazide 25 mg PO DAILY 10.Outpatient Physical Therapy Please evaluate and treat Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left occipital ___ mass Cerebral edema Liver cirrhosis Rash Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with altered mental status, fever// Subdural Bleed, herniation TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5 mGy-cm. 3) Spiral Acquisition 5.3 s, 42.0 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,305.8 mGy-cm. Total DLP (Head) = 2,233 mGy-cm. COMPARISON: None. FINDINGS: Large infiltrative mass in the left parieto-occipital area measuring approximately 5.4 x 4 cm with extensive vasogenic edema and effacement of the posterior horn of the left lateral ventricle (series 2, image 19). Recommend MRI for further evaluation and characterization. 3.6 mm rightward midline shift is also appreciated. There is mild medialization of the left uncus, but no uncal herniation. There is no evidence of hemorrhage. There is effacement of the left lateral ventricle occipital horn, trigone and posterior temporal horn with mild enlargement of the anterior temporal horn suggestive mild entrapment. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Cerumen is visualized in the left external auditory canal. The visualized portion of the orbits are unremarkable. CTA HEAD: Moderate calcific atherosclerotic changes of the carotid siphons bilateral, but no significant stenosis. Mild calcific atherosclerotic changes of the left V4 segment, no significant stenosis. The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. Mild mass effect on the left MCA due to the vasogenic edema. Asymmetric filling of the transverse sinuses likely secondary to dominant right transverse sinus. The left parieto-occipital lobe mass demonstrates peripheral arterial enhancement. CTA NECK: Mild atherosclerotic disease of the bilateral internal carotid arteries, left greater than right, without stenosis by NASCET criteria. The bilateral common carotid, subclavian and vertebral arteries are unremarkable noting mild atherosclerotic disease. OTHER: The visualized portion of the lungs are clear. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Left occipital-parietal mass with surrounding vasogenic edema and mass effect as described above. Further evaluation with MRI advised. 2. Mild atherosclerotic disease of the carotid bulbs, without stenosis by NASCET criteria. 3. Moderate atherosclerotic disease of the carotid siphons bilateral, but no significant stenosis. 4. There is no intracranial aneurysms or acute occlusions. No intracranial hemorrhage. Radiology Report INDICATION: ___ with fever, cough// Pneumonia TECHNIQUE: Frontal lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: The lungs are clear without consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old man with L occipital brain mass// Better visualize L occipital mass and eval for other lesions TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 11 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CTA head and neck of ___. FINDINGS: Peripherally and heterogeneously enhancing left 4.8 x 3.4 x 3.1 cm (AP, TRV, SI) parieto-occipital mass with extension to the left lingual gyrus is identified with extensive geographic region of surrounding edema pattern involving the left parietal, occipital and temporal lobes. Small punctate foci gradient echo susceptibility hypointense signal within the lesion is compatible with microhemorrhage. There is associated effacement of the local sulci and of the left occipital horn, trigone and posterior temporal horn, with mild enlargement of the anterior aspect of the temporal horn, compatible with mild entrapment (series 7, image 9). 4 mm rightward midline shift is unchanged from recent CTA. While there remains mild effacement of the left perimesencephalic cistern, the basilar cisterns are otherwise patent. There is no uncal herniation. No other enhancing lesions are identified. There is no acute infarct. The major intracranial flow voids are preserved. The dural venous sinuses are patent. There is mild mucosal thickening of the ethmoid air cells. Both globes are slightly elongated in AP dimension, which may be seen in the setting of axial myopia/staphyloma. Otherwise, the orbits are unremarkable. Fluid signal is identified in the left mastoid air cells. IMPRESSION: 1. Peripherally and heterogeneously enhancing 4.8 cm left parieto-occipital mass, involving the left lingual gyrus, demonstrating small foci of micro hemorrhages is identified with geographic surrounding edema pattern involving the left parietal, occipital and temporal lobes with effacement of the left occipital horn, trigone and posterior temporal horn. Minimal enlargement of the anterior aspect of the left temporal horn is compatible with mild entrapment. 2. There is 4 mm rightward midline shift and minimal effacement of the left perimesencephalic cistern, unchanged from prior CTA. The basilar cisterns are patent. There is no uncal herniation. 3. No other enhancing lesions are identified. 4. Additional findings described above. Radiology Report EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: ___ year old man with left occipital brain mass// evaluate for any masses; metastatic workup TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was done as part of CT torso without and with IV contrast. Initially the abdomen was scanned without IV contrast. Subsequently a single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.6 mGy (Body) DLP = 678.4 mGy-cm. 2) Spiral Acquisition 4.7 s, 74.7 cm; CTDIvol = 19.6 mGy (Body) DLP = 1,462.0 mGy-cm. 3) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.8 mGy (Body) DLP = 686.4 mGy-cm. 4) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.8 mGy (Body) DLP = 1.4 mGy-cm. 5) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP = 18.2 mGy-cm. Total DLP (Body) = 2,846 mGy-cm. COMPARISON: None FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: Liver contours are nodular, suggestive of underlying cirrhosis. On the 3 minutes delayed sequence, there is suggestion of a 2.8 cm rounded hypodensity in the hepatic dome, with no definite correlate on the other sequences (series 4, image 5). There is a 3.0 cm simple cyst in segment ___ (03:52). Several additional subcentimeter hypodensities are too small to characterize, but may represent cysts or biliary hamartomas. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is not visualized. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Spleen is mildly enlarged measuring up to 15 cm. No focal lesions are identified. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. Normal appendix. No ascites. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate gland and seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. Circumaortic left renal vein, a normal variant. Portal venous system is patent. Note is made of a patent umbilical vein, with a small shunt connecting it to the left common femoral vein. Note is made of a prominent splenorenal shunt. BONES: There is a subcentimeter lucency in the right iliac bone, of unclear clinical significance. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Cirrhotic liver morphology. Suggestion of a 2.8 cm hepatic dome hypodensity seen only on delayed postcontrast imaging. Further evaluation with MRI is advised to exclude hepatocellular carcinoma. 2. Sequela of portal hypertension including mild splenomegaly and portosystemic shunts. No ascites. 3. Non-specific subcentimeter lucency in the right iliac bone, which may be further evaluated with a bone scan. 4. CT chest dictated separately. RECOMMENDATION(S): 1. Multiphasic liver MRI. 2. Bone scan. NOTIFICATION: The findings were discussed with ___ by ___ on the telephone on ___ at 1:49 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CT CHEST WITH CONTRAST INDICATION: History of left occipital brain mass. Please evaluate for pulmonary metastases. TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.6 mGy (Body) DLP = 678.4 mGy-cm. 2) Spiral Acquisition 4.7 s, 74.7 cm; CTDIvol = 19.6 mGy (Body) DLP = 1,462.0 mGy-cm. 3) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.8 mGy (Body) DLP = 686.4 mGy-cm. 4) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.8 mGy (Body) DLP = 1.4 mGy-cm. 5) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP = 18.2 mGy-cm. Total DLP (Body) = 2,846 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS) COMPARISON: None FINDINGS: The thyroid is normal. There is no supraclavicular lymphadenopathy. The heart size is normal. There is no evidence of a pericardial effusion. Valvular and coronary calcifications are seen. The esophagus is normal without evidence of wall thickening, or a hiatal hernia. Paraesophageal varices are noted. There is no evidence of axillary, hilar, or mediastinal lymphadenopathy. Mildly prominent hilar lymph nodes are seen measuring up to 0.5 cm in short axis. There is no pleural effusion or pneumothorax. The airways are patent to the subsegmental levels. Mild thickening along the proximal airways, may be secondary to bronchitis. Note is made of mild bibasilar atelectasis. No concerning pulmonary nodules are identified. For evaluation of the abdomen, please refer to dedicated CT of the abdomen pelvis performed on the same day. Osseous structures: No concerning lytic or blastic lesions are identified. IMPRESSION: No concerning intrathoracic pulmonary nodules identified. No evidence of intrathoracic malignancy. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: ___ year old man with newly diagnosed left occipital brain mass, cirrhosis of liver, ? liver mass// Eval for liver mass TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 11 mL Gadavist. COMPARISON: CT scan of the abdomen and pelvis dated ___. FINDINGS: Lower Thorax: The lung bases are clear. No pleural or pericardial effusion. Liver: Morphologic features of cirrhosis. There is confluent fibrosis delineating areas of nodules, likely regenerative nodules, which appears to account for the lesion identified on recent CT. No enhancing or suspicious nodule is identified. Multiple hepatic cysts, the largest measuring 3.3 cm in segment 8. Biliary: No biliary ductal dilatation. The gallbladder is not visualized. Pancreas: 5 mm cystic lesion within the pancreatic head (axial series 5, image 32), likely a small side branch IPMN. Suspected additional 3 mm cystic lesion in the pancreatic tail. Spleen: No splenomegaly. Adrenal Glands: Unremarkable. Kidneys: 4 mm cyst in the lower pole of the left kidney. Gastrointestinal Tract: The stomach, small bowel, and large bowel are unremarkable. 2 duodenal diverticula are noted along the third stage of the duodenum. Lymph Nodes: No retroperitoneal or mesenteric adenopathy. Vasculature: Extensive portosystemic collaterals, with large splenic and paraesophageal varices and recanalized paraumbilical vein. No abdominal aortic aneurysm. Incidental note is made of a retro aortic left renal vein. Osseous and Soft Tissue Structures: Unremarkable. IMPRESSION: 1. Morphologic features of cirrhosis with findings of portal hypertension. No suspicious liver lesion. 2. 5 mm cystic lesion in the pancreatic head, likely a small side branch IPMN. RECOMMENDATION(S): Follow-up MRI in ___ year is recommended for cystic pancreatic lesion. Radiology Report EXAMINATION: CT STEREOTAXIS W/ CONTRAST Q1218 CT HEADSUB INDICATION: ___ year old man with left occipital brain lesion; please perform with frame on just prior to surgery for brain biopsy. Surgery ___ around 1200// evaluate brain mass; Please perform with frame on just prior to surgery for brain biopsy. Surgery ___ around 1200 TECHNIQUE: Contiguous axial images of the brain were obtained after the uneventful administration of Omnipaque intravenous contrast. Thin bone-algorithm reconstructed images and coronal and sagittal reformatted images were then produced. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 25.2 mGy (Body) DLP = 452.7 mGy-cm. 2) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 25.2 mGy (Body) DLP = 452.7 mGy-cm. 3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 25.2 mGy (Body) DLP = 402.4 mGy-cm. Total DLP (Body) = 1,308 mGy-cm. COMPARISON: MRI from ___, CT from ___. FINDINGS: Evaluation is limited by streak artifacts caused by overlying external fixation device for stereotactic biopsy. The images were obtained for the purposes of localization of the target. Again seen is the known part cystic and part solid left parietooccipital lobe mass with rim enhancement measuring at least 3.0 x 3.4 cm, better characterized on the dedicated MRI from ___. Extensive vasogenic edema surrounding the mass affecting the left temporal, occipital and parietal lobe is grossly stable from prior exam. No significant midline shift is seen. There is persistent effacement of the occipital horn of the left lateral ventricle and narrowing of the frontal horn of the left lateral ventricle. There is no evidence of new territorial infarct or acute hemorrhage, though evaluation is limited due to presence of intravenous contrast and streak artifacts. The ventricles and sulci are stable in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: Re-demonstration of the known part cystic and part solid left parieto-occipital lobe mass, measuring at least 3.0 x 3.4 cm with extensive adjacent vasogenic edema, resulting in mild local mass-effect. No significant midline shift. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man s/p stereotactic biopsy for left occipital brain mass// post-op evaluation to be done at 4PM (as the patient is being taken from PACU to floor) TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.2 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: CT from ___ at 11:41. FINDINGS: Patient is status post biopsy of the known left parieto-occipital lobe mass. There is tiny foci gas along the expected tract of the biopsy as well as at the inner table of the left parieto-occipital calvarium, near the burr hole. The known mass demonstrate hyperdense rim, possibly representing retention of previously administered intravenous contrast during the exam obtained approximately 4 hours prior. However, superimposed hemorrhage is not entirely excluded in this region. Pre-existing extensive vasogenic edema surrounding the mass affecting the left temporal, parietal and occipital lobes is essentially unchanged from prior exam. The overall configuration of the ventricles and sulci remain unchanged. There is no evidence of new territorial infarct, though evaluation is mildly limited due to extensive vasogenic edema in the left hemisphere. Mild subgaleal stranding, subcutaneous emphysema and skin staples are noted in the surgical site. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Status post biopsy of the known left parieto-occipital lobe mass with postsurgical changes, including trace pneumocephalus and subcutaneous emphysema and skin staples. Due to prior administration of intravenous contrast, hyperdense appearance of the left parieto-occipital lobe mass could represent retained the intravenous contrast, with superimposed hemorrhage cannot be entirely excluded. Attention follow-up is recommended. 2. Stable extensive vasogenic edema in the left hemisphere. No evidence of large territory infarct. 3. Additional findings as described above. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Confusion, Lightheaded Diagnosed with Disorientation, unspecified temperature: 100.4 heartrate: 88.0 resprate: 18.0 o2sat: 99.0 sbp: 180.0 dbp: 94.0 level of pain: 0 level of acuity: 2.0

Mr. ___ was admitted to the neurosurgery service after imaging showed a left occipital ___ mass with vasogenic edema. #Left occipital ___ mass Patient underwent a ___ MRI that confirmed a left occipital ___ mass. Patient was started on Dexamethasone 4mg Q6. A CT torso was completed and showed liver cirrhosis and question of a liver mass. There was also a lucency at the right iliac crest thus radiology recommended a bone scan. Neuro-oncology was consulted and biopsy was recommended. He underwent MRI liver which was negative for evidence of HCC and bone scan was negative for osteoblastic metastatic disease. On ___, the patient underwent stereotactic ___ biopsy. The procedure was uncomplicated. For further procedure details, please see separately dictated operative report by Dr. ___. The patient was extubated in the operating room and transported to the PACU for recovery. Routine post-operative NCHCT showed expected post-operative changes. Once stable, he was transferred back to the floor. He was started on a 7 day course of Keppra for seizure prophylaxis. His Dexamethasone dose was adjusted to 4mg Q8 prior to discharge. He was on an ISS while an inpatient. Prior to discharge, he and his family received insulin teaching and instructions on signs and symptoms of hypoglycemia and how to respond. He was discharged with prescriptions for home insulin and instructions to follow up with his PCP in the week following discharge. #Liver Cirrhosis A liver MRI was ordered to better assess the liver and revealed findings consistent with cirrhosis and portal hypertension with no evidence of lesion. Labs were sent to assess liver function. #Rash Patient reported a rash below his right armpit down his flank. He denied any pain or itchiness. A dermatology consult was placed and it was recommended to start Ketoconazole 2% cream BID x 4 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: This ia ___ woman with a history of ___ syndrome complicated by multiple admissions for bleeding (predominantly menorrhagia) and treatments including steroids, rituxan, IVIG, and splenectomy (___), presenting with hemoptysis x1 day, found to be severely thrombocytopenic. The patient was most recently admitted for a flare of her ___ syndrome ___, placed on high dose prednisone taper over months. She self-tapered this off early in ___ as she didn't like the side effects of the steroids. She was due to see hematology oncology tomorrow for followup. Two days ago she awoke tired/fatigued, with sore throat with swallowing, coughing up small amount of blood with phlegm. No other bleeding. Then noted a petechial rash on her chest and arms so presented to ___. She has felt achy in her muscles but did Crossfit recently. One sick contact who had a cold. Her period is due soon. No diarrhea. Had HA in ED, ___, frontal, but this happens at baseline when she feels tired. Has been taking Nyquil, Dayquil. Sexually active with one partner without condoms, requests STD testing. At ___ were notable for a white count of 8.7, hematocrit 32.3, platelets of 7. Chest x-ray was negative. She received 10 mg dexamethasone. In the ED, initial vitals: 97.7 HR 68 BP 115/72 RR16 97RA - Exam notable for petechiae - Labs were notable for Hct 32, ___ 14.9/INR 1.4, Tbili 3.2, Bicarb 20, fibrinogen 251, UA no blood, small leuk, repeat plt <5 - Heme-onc recommended additional 30 mg decadron, IVIG, plts, ICU airway monitoring On arrival to the MICU, the patient notes ongoing sore throat and mild frontal HA but overall feels well. Review of systems: +/- per HPI Past Medical History: ___ syndrome/AIHA/ITP; s/p multiple steroid/IVIG courses, rituxan; s/p splenectomy) H. pylori + ___, reportedly treated with f/u serum Ag negative Iron-deficiency anemia Menorrhagia and fibroids Shingles ___ Ovarian cyst -___ Likely bone infarct in setting of high dose steroids in ___ PAST SURGICAL HISTORY: - Status post right meniscectomy ___ - Status post ACL repair ___ - Status post splenectomy ___ Social History: ___ Family History: Siblings: 3 sisters, no blood d/o's, no cancer, no autoimmune diseases. Grandmother with hypothyroidism, no other autoimmune disease (no RA, SLE). No history blood diseases Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, mild palatal erythema without exudate NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, coughing during the interview CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: scattered chest and R arm petechiae NEURO: A+Ox3, CN II-XII intact, moving all extremities ACCESS: PIVs ======================= DISCHARGE PHYSICAL EXAM ======================= VS: T: 98 HR: 54 BP: ___ RR: 16 100% RA Gen: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, OP clear, no cervical lymphadenopathy CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e MSK: full range of motion of bilateral hips and knees without pain, reports pain in right thigh improves with palpation Neuro: CN II-XII intact, ___ strength throughout Psych: normal affect Skin: warm, dry, fading petechial rash on chest and arms, mild bruising around IV sites and lab draw sites Pertinent Results: ============== ADMISSION LABS ============== ___ 12:42PM BLOOD WBC-10.5* RBC-3.66* Hgb-10.5* Hct-31.1* MCV-85 MCH-28.7 MCHC-33.8 RDW-16.9* RDWSD-50.9* Plt Ct-<5* ___ 12:42PM BLOOD Neuts-92.3* Lymphs-5.5* Monos-1.0* Eos-0.0* Baso-0.7 Im ___ AbsNeut-9.68* AbsLymp-0.58* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.07 ___ 12:42PM BLOOD ___ PTT-54.3* ___ ___ 12:42PM BLOOD Ret Aut-4.9* Abs Ret-0.18* ___ 05:38PM BLOOD FacVIII-299* ___ 12:42PM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-140 K-4.0 Cl-107 HCO3-20* AnGap-17 ___ 12:42PM BLOOD ALT-18 AST-28 AlkPhos-49 TotBili-3.2* ___ 12:42PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.1 Mg-1.7 ___ 01:27PM BLOOD calTIBC-239* VitB12-817 Hapto-31 Ferritn-326* TRF-184* ___ 01:27PM BLOOD TSH-0.15* ___ 03:02PM BLOOD Lactate-1.6 . ============== DISCHARGE LABS ============== ___ 06:51AM BLOOD WBC-21.8* RBC-2.75* Hgb-8.4* Hct-24.0* MCV-87 MCH-30.5 MCHC-35.0 RDW-18.3* RDWSD-49.5* Plt Ct-86* =============== IMAGING/STUDIES =============== None . ============ MICROBIOLOGY ============ __________________________________________________________ ___ 1:27 pm IMMUNOLOGY HIV-1 Viral Load/Ultrasensitive (Pending): __________________________________________________________ ___ 1:27 pm SEROLOGY/BLOOD **FINAL REPORT ___ MONOSPOT (Final ___: NEGATIVE by Latex Agglutination. (Reference Range-Negative). __________________________________________________________ ___ 1:27 pm SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Pending): __________________________________________________________ ___ 11:05 am URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. __________________________________________________________ ___ 7:45 am URINE Source: ___. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Pending): NEISSERIA GONORRHOEAE (___), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Pending): __________________________________________________________ ___ 5:00 am THROAT CULTURE Site: THROAT VIRAL CULTURE (Pending): __________________________________________________________ ___ 5:00 am THROAT CULTURE R/O Beta Strep Group A (Pending): Medications on Admission: The Preadmission Medication list is accurate and complete. 1. noreth-ethinyl estradiol-iron 1 mg-20 mcg (21)/75 mg (7) tablet oral DAILY Discharge Medications: 1. noreth-ethinyl estradiol-iron 1 mg-20 mcg (21)/75 mg (7) tablet oral DAILY 2. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ___ syndrome Hemoptysis Severe thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT INDICATION: ___ year old woman with thigh pain on steroids // AVN AVN IMPRESSION: No comparison. Normal bone density. Normal cortical contours. The width of the right hip joint as well as the round mass of the femoral head is preserved. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: Transfer, Hemoptysis, Rash Diagnosed with Hemoptysis temperature: 97.7 heartrate: 68.0 resprate: 16.0 o2sat: 97.0 sbp: 115.0 dbp: 72.0 level of pain: 0 level of acuity: 2.0

___ woman with a history of ___ syndrome complicated by multiple admissions for bleeding (predominantly menorrhagia) and treatments including steroids, rituxan, IVIG, and splenectomy (___), presenting with hemoptysis x1 day, found to be severely thrombocytopenic with undetectable platelets in setting of self-tapering steroids due to side effects. #Heme/onc: ___ syndrome, severe thrombocytopenia, hemolytic anemia, hemoptysis, petechial rash, possible bone infarct. She has self-tapered steroids as an outpatient due to numerous intolerable side effects. Currently appears to be responding to high dose dexamethasone and IVIG with improved platelet counts and resolution of clinical signs of bleeding. She had elevated ___ on first draw which normalized quickly, low suspicion for inhibitor or factor deficiency. Overnight on ___ she developed sudden onset of right thigh/hip pain similar to prior episode where she was diagnosed with bone infarct in setting of high dose steroids. Concern for recurrent infarct. -Received 3 doses of Dexamethasone 40 mg IV, held further due to concern for bone infarct -Received ___ planned doses of 80 mg IVIG -Follow-up heme/onc to discuss long term therapy, likely intermittent outpatient IVIG or Rituxan #ID: possible viral URI. Her symptoms appear to be triggered by a viral infection. Unable to do nasopharyngeal swab on admission due to severe thrombocytopenia. Given 5 day course of Tamiflu. Symptoms resolving. #FEN/PPX: regular, ambulatory Full code

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: NSAIDS ___ Drug) / iodine Attending: ___. Chief Complaint: Requesting medical clearance for psychiatric placement Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of depression with previous suicide attempt, rheumatoid arthritis, IBS and recent C. difficile colitis who presents to the emergency department with suicidal ideation and requesting for help with her eating disorder. She was previously on Enbrel for control of her RA which wasa stopped two months prior to admission because of recent upper respiratory infections and fevers, viral gastroenteritis, and C. difficile colitis. She was recently admitted from ___ with C. difficile colitis with her course complicated by a rheumatoid arthritis flare. She was treated with oral vancomycin from ___ and a prednisone taper of 15mg x3d, 10mg x3d, and 5mg x3d. She was seen in ___ clinic on ___ with labs that were significant for WBC 10.4 with 7.1% eos, normal Ig quantification with borderline low IgG2, borderline low C3 and normal C4, and normal CRP and ESR 2. In the ED she reported that she began to feel sweats the night prior to presentation and was found to have a fever to 100.6. She reports decreased PO intake and reports 5 loose bowel movements starting today, though these are less watery than previously with her cdiff. She is feeling more anxious than her baseline and is taking more clonazepam. She has a history of IBS, alternating diarrhea and constipation, and thinks her current episodes of diarrhea might be related to this. Of note, she has longstanding difficulties with depression and an eating disorder. She presents seeking residential treatment. ROS otherwise negative except as noted in HPI. Denies cough. In the ED, initial vital signs were: 100.6 90 117/83 16 98% RA - Exam notable for: Sitting up, pleasant, NAD. + Mask, RRR no MRG, CTAB, diffusely minimally tender without localization, no rebound/guarding. Nondistended. - Labs were notable for: CBC: 7.1>14.5/44.6<271 Na 138 K 3.7 Cr 0.7 UA unremarkable. Serum/urine tox negative. - Studies performed include: CXR: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Note is made of bilateral breast implants. No acute osseous abnormality. Mild ___ thoracic scoliosis is noted. Partial fusion of the anterior left first and second ribs is noted. EKG: normal sinus rhythm, t wave inversion in V2 appear stable from previous in ___ - Patient was given: IVF ___ ( 1000 mL ordered) Started 200 mL/hr PO/NG ClonazePAM 1 mg - Vitals on transfer: 98.5 61 105/59 18 100% RA Upon arrival to the floor, the patient feeling anxious about her ability to be placed into a treatment program, as she feels her eating disorder (which consists of restricting, eats ~500 calories per day) is not under control. Patient estimates she has lost ___ in previous months. Describes frustration at not being able to get help she needs and states this frustration has driven her to be "impulsive" in the past, and attempt suicide, usually by overdose. Currently she is very committed to getting help and has no plans to try and hurt herself. With regards to her possible infection, she completed antibiotic treatment last ___ and just developed recurrent watery diarrhea today. She also reports nausea, no vomiting. No recent cough, chest pain, abdominal pain, sob, joint pain, dysuria or rash. Past Medical History: - RA - anxiety - depression - asthma - migraines - IBS Social History: ___ Family History: colon cancer in younger brother. Mother and father both have RA. Father also with DM Physical Exam: ADMISSION EXAM: Vitals: 98.5, 116 / 74 64 18 97 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated, no LAD. Lungs: coarse with some crackles in LLL. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. DISCHARGE EXAM: Physical Exam: Limited by patient cooperation Vitals- 98.1 | 102/62 | 71 | 16 | 97% RA General- Alert, oriented, anxious; sitting up in bed comfortably. HEENT- Normocephalic, atraumatic. Lungs- Breathing normally on room air GU- no foley Ext- Moves all extremities with purpos Neuro- NO facial droop, motor function grossly normal Pertinent Results: ADMISSION LABS: ================= ___ 12:22PM BLOOD ___ ___ 12:35PM BLOOD ___ ___ ___ 12:22PM BLOOD ___ ___ 12:35PM BLOOD ___ ___ Plt ___ ___ 02:35PM BLOOD HIV ___ ___ 12:35PM URINE ___ ___ 12:22PM URINE ___ Sp ___ ___ 12:35PM URINE ___ ___ ___ 12:22PM URINE ___ ___ 12:35PM URINE ___ ___ DISCHARGE LABS: ================ ___ 08:15AM BLOOD ___ ___ Plt ___ ___ 08:15AM BLOOD ___ ___ Im ___ ___ ___ 07:29PM BLOOD ___ ___ MICRO: ___ 5:50 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference ___. ___ 9:18 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. MANY POLYMORPHONUCLEAR LEUKOCYTES. FEW RBC'S. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. IMAGING: ___ CXR: FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Note is made of bilateral breast implants. No acute osseous abnormality. Mild ___ thoracic scoliosis is noted. Partial fusion of the anterior left first and second ribs is noted. IMPRESSION: No acute cardiopulmonary process. ___ F ___ Cardiovascular Report ECG Study Date of ___ 12:14:17 ___ Sinus rhythm. RSR' pattern in leads ___, probably a normal variant. Compared to the previous tracing of ___ the heart rate is faster but other findings are similar. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 74 139 69 ___ 4 52 30 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5 mg PO TID anxiety 2. ClonazePAM 1 mg PO QHS:PRN insomnia 3. DULoxetine 60 mg PO DAILY 4. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK 5. Hydroxychloroquine Sulfate 300 mg PO DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Multivitamins W/minerals 1 TAB PO DAILY RX ___ 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. ClonazePAM 0.5 mg PO TID anxiety 5. ClonazePAM 1 mg PO QHS:PRN insomnia 6. DULoxetine 60 mg PO DAILY 7. Hydroxychloroquine Sulfate 300 mg PO DAILY 8. HELD- etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK This medication was held. Do not restart etanercept until talk to your rheumatologist about restarting this med Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Anorexia Nervosa Secondary Diagnoses: Irritable Bowel Syndrome Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: ___ with eating disorder, fever // Eval for PNA TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest radiograph on ___ FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Note is made of bilateral breast implants. No acute osseous abnormality. Mild S-shaped thoracic scoliosis is noted. Partial fusion of the anterior left first and second ribs is noted. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: SI, Abnormal labs Diagnosed with Fever, unspecified temperature: 100.6 heartrate: 90.0 resprate: 16.0 o2sat: 98.0 sbp: 117.0 dbp: 83.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a ___ year old woman with a history of depression with previous suicide attempts, rheumatoid arthritis, IBS and recent C. difficile colitis who presented to the emergency department on ___ with suicidal ideation and requesting help with her eating disorder, found to have fever to 100.6 and reported recent diarrhea, so admitted for concern for C. diff. #FEVER/#Diarrhea: Patient presented w/out localizing symptoms or leukocytosis, but new low grade fever to 100.7 in ED and reports of recurrent diarrhea, initially concerned for c. diff so started on PO vanc, but subsequently found to be c. diff neg. No episodes since admission. Patient had completed course of PO Vancomycin on ___ for recent c. diff. CXR, UA, and blood cultures negative for infection, HIV negative. Resolved prior to discharge. Fever was likely from rheumatoid arthritis and the patients fevers resolved. She was restarted on her hydroxychloroquine and her symptoms improved. #SUICIDAL IDEATION #DEPRESSION #ANXIETY - Pt reports problems with depression and eating disorder and presented seeking residential treatment but needs medical clearance. Has a long history of anxiety and depression with multiple hospitalizations for suicidal ideation/attempts. Says that she has been struggling with increasing anxiety and depression recently in the context of stress at work and recent hospitalizations for infection. She was initially safe from a psychiatric perspective. However when she was refused from the initial facility she was acutely suicidal and was placed on a ___. She code purpled (called security and psychiatry) for agitation and required chemical restraints. Psychiatry reevaluated the patient on ___ and Dr. ___ removed the ___. Spoke with patients outpatient therapist. The patient felt safe to go home with her partner and would not harm herself. #EATING DISORDER: patient reports longstanding history of eating disorder for which she has received inpatient care in the past. Describes mainly restrictive symptoms, currently eating "less than one meal per day". She estimates ___ weight loss in recent months, although her weight is stable from admission ___. BMI 20 on admission. Reports remote history of purging, but not recently. Her work up was negative. She had no hemodynamic instability, electrolyte issues or signs of dehydration. Social work was consulted and attempted to place her at ___ however she was declined. She became acutely suicidal. This resolved prior to her discharge. Her restricted intake resulted in hypoglycemia to 48 treated with glucose. Soon after she resumed eating. She was cleared by psychiatry as documented above. She was eating and drinking prior to her discharge. She requested her information be sent to ___ ___ to set up intake phone session on ___. She also had referrals made to ___ but she declined. The patient and partner felt like she had a safe disposition. She will need residential placement. Started on thiamine, MVI and folate. #RHEUMATOID ARTHRITIS: Previously in remission prior to recent flare during hospital admission. She presented s/p prednisone taper since her last flare. She had a low fever on admission, but no signs of active flare on joint exam on admission. She has been off immunosuppressive medications for several months due to her recent infections. Was seen by her rheumatologist on ___ who recommended restarting hydroxychloroquine, but she has not yet taken it due to GI issues (has caused her significant diarrhea in past). Hydroxychloroquine restarted during hospital stay. Etanercept held and should be restarted as per rheumatology discretions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: daughter is unsure about allergies Attending: ___ Chief Complaint: Recurrent Episodes of Right Facial Droop and Speech Changes Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ year-old right-handed woman with HTN, DM who presents with recurrent episodes of right facial droop and speech changes. The patient had been feeling well this morning, in her usual state of health. At baseline she is mostly bedbound due to deconditioning and requires daily ___ services for most ADLs including showering and dressing herself. She lives in an apartment 1 floor below her daughter who assists as well. Despite her age and deconditioning, she has reasonably good cognitive function, somewhat forgetful but has no problems with speech or following commands. Today a ___ was in her home and around 3PM she noted sudden onset R facial droop while the patient was watching TV. The patient does not clearly recall the details of the event but seems to understand that her face was drooping. Her ___ attempted to ask her questions, but the patient only mumbled single words like "yes". The ___ called the patient's granddaughter around the time of the episode and apparently she seemed to understand what her granddaughter was saying but was attempting to reply with moaning/ grunting. By report, this episode lasting between ___ minutes and then resolved spontaneously. The daughter does not endorse that the patient had a period of post-event confusion, urinary incontinence or convulsions. Of note she has a history of 4 similar prior events since ___, each with right facial droop and speech changes lasting less than 30 minutes. She never sought medical attention for them previously. There does not appear to be a clear trigger for the event today. Although the patient has a history of recurrent UTI, she is not febrile or reporting urinary symptoms. She denies falls or head trauma. Recently she was taken of HCTZ and metoprolol for BP management but these are the only medication changes. ED VS notable for BP to 180, NIHSS-0 with resolution in facial droop on Neurology arrival. CT showed extensive atrophy and white matter disease. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - HTN - CHF - DM - OSA - Hypothyroid - Recurrent presumed TIAs: facial droop and speech changes - Vasovagal syncope spells - Chronic constipation Social History: ___ Family History: No family history of stroke. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 54 184/64 18 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x self, hospital, year, Obama. Slow at ___ backward. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II: PERRL surgical, reactive 2mm bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: slightly diminished R nasolabial fold at rest but symmetric upon activation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Reduced bulk, generalized effort-dependent weakness throughout. No pronator drift bilaterally. No tremor. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4+ 4+ ___ ___ ___- 5 5 R 4+ 4+ ___ ___- ___ 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3 2 3 1 0 R 3 2 3 1 0 Plantar response was equivocal bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred due to chronic weakness ================================= DISCHARGE PHYSICAL EXAM: General: Awake, cooperative, NAD. HEENT: NCAT and moist mucus membranes. Neck: Supple. No nuchal rigidity. Pulmonary: CTAB without rales, rhonchi and wheezes. Cardiac: RRR. S1S2, no murmurs, rubs or gallops. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No clubbing, cyanosis or edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x self, hospital and year. Able to maintain a conversation. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II: PERRL surgical, reactive 2mm bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: slightly diminished R nasolabial fold at rest but symmetric upon activation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Reduced bulk, generalized effort-dependent weakness throughout. No pronator drift bilaterally. No tremor. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4+ 4+ ___ ___ ___- 5 5 R 4+ 4+ ___ ___- ___ 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3 2 3 1 0 R 3 2 3 1 0 Plantar response was equivocal bilaterally. -Coordination: No intention tremor. No dysmetria on FNF. Pertinent Results: ___ 06:52AM BLOOD WBC-5.9 RBC-3.34* Hgb-10.5* Hct-32.9* MCV-99* MCH-31.5 MCHC-32.0 RDW-12.7 Plt ___ ___ 04:00PM BLOOD Neuts-58.2 ___ Monos-6.1 Eos-1.8 Baso-0.7 ___ 06:52AM BLOOD Plt ___ ___ 04:00PM BLOOD ___ PTT-25.4 ___ ___ 04:54AM BLOOD Glucose-146* UreaN-26* Creat-0.8 Na-140 K-4.6 Cl-105 HCO3-27 AnGap-13 ___ 04:00PM BLOOD ALT-13 AST-29 AlkPhos-94 TotBili-0.3 ___ 04:00PM BLOOD Lipase-25 ___ 04:00PM BLOOD cTropnT-<0.01 ___ 04:54AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8 ___ 06:52AM BLOOD %HbA1c-6.8* eAG-148* ___ 06:52AM BLOOD Triglyc-150* HDL-33 CHOL/HD-5.5 LDLcalc-119 ___ 06:52AM BLOOD TSH-0.46 ___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:13PM BLOOD Lactate-1.5 EEG: Normal in the awake and drowsy states. Echo: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Increased PCWP. No valvular pathology or pathologic flow identified. No definite structural cardiac source of embolism identified. CXR: No acute cardiopulmonary process. CT Head: There is no acute intracranial hemorrhage, acute infarction or midline shift. There is no edema. Global atrophy is noted with increase in the size of the ventricles as well as sulci. Scattered white-matter hypodensities are most likely the sequelae of chronic small vessel ischemic disease. Dense atherosclerotic calcifications are noted within the intracranial ICAs bilaterally. Scleral calcifications are noted. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Senna 8.6 mg PO BID:PRN constipation 4. Pantoprazole 40 mg PO Q24H 5. Losartan Potassium 25 mg PO DAILY 6. Aspirin 325 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Transient Ischemic Attack 2. Hypertension 3. Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with ?R facial droop // stroke? pna? TECHNIQUE: Chest PA and Lateral COMPARISON: None FINDINGS: There is elevation of the right hemidiaphragm. There are no focal consolidations concerning for pneumonia. No pleural effusion. No pneumothorax. Normal heart size. Abdominal surgical clips are noted. Calcification of the abdominal aorta is seen. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with ?R facial droop // stroke? pna? TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 891 mGy-cm; CTDI: 54mGy COMPARISON: None. FINDINGS: There is no acute intracranial hemorrhage, acute infarction or midline shift. There is no edema. Global atrophy is noted with increase in the size of the ventricles as well as sulci. Scattered white-matter hypodensities are most likely the sequelae of chronic small vessel ischemic disease. Dense atherosclerotic calcifications are noted within the intracranial ICAs bilaterally. Scleral calcifications are noted. Visualized paranasal sinuses and mastoid air cells are clear.There is no fracture. IMPRESSION: No acute intracranial process. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Altered mental status, FACIAL DROOP Diagnosed with FACIAL WEAKNESS, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS temperature: 98.2 heartrate: 54.0 resprate: 18.0 o2sat: 100.0 sbp: 184.0 dbp: 64.0 level of pain: 13 level of acuity: 1.0

___ is a ___ year old female with vascular risk factors including hypertension and diabetes presenting with multiple episodes over the last 4 months of transient R facial droop with speech changes. Her neurological exam is nonfocal and her cognition is baseline per daughter. She has generalized diffuse weakness although right upper and lower extremities are subltly weaker. CT shows extensive atrophy and chronic white matter disease indicative of long-standing small vessel disease. EEG was normal in the awake and drowsy states. Thus, the etiology of episodes likely TIA secondary to small vessel disease. # Neuro: Ms. ___ neurological exam is nonfocal and her cognition is baseline per daughter. She has generalized diffuse weakness although right upper and lower extremities are subltly weaker. CT shows extensive atrophy and chronic white matter disease indicative of long-standing small vessel disease. No MRI was done due to the risk vs benefits of possible sedation. Vascular risk factors were further evaluated. LDL 119, ___ 150 and HBA1c 6.8. Although her LDL is elevated, a statin was not started due to age. EEG was normal in the awake and drowsy states. Thus, the etiology of episodes likely TIA secondary to small vessel disease. Her aspirin was increased from 81mg to 325mg. She has no indication for anticoagulation. # CV: Throughout the hospitalization, Ms. ___ was monitor by telemetry. We allowed her BP to autoregulate with goal SBP < 180 (goal SBP 140-180s). She was restarted on her home antihypertensives. Her blood pressure was well controlled during the hospitalization. Echo was normal. # ENDO: Ms. ___ was continued on her home Synthroid. Her TSH was 0.46. # TOX/METAB: Ms. ___ LFTs are within normal limits. Her urine is negative for infection. Urine tox was negative. CXR shows no acute cardiopulmonary process # FEN/GI: Ms. ___ passed her bedside swallow. Throughout the hospitalization her PO intake was noted to be poor especially in regards to fluid. Daughter reports that she drinks a very specific water and orange juice at home and will not drink much other anything else. She did require some IV NS boluses due to her poor PO intake.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ibuprofen Attending: ___. Chief Complaint: AMS, urinary retention Major Surgical or Invasive Procedure: None History of Present Illness: HOSPITALIST ADMISSION H&P HPI: ___ with poorly-controlled DMII, CAD s/p stent on Plavix, CVA with R hemiparesis, wheelchair bound at baseline, s/p R hip fracture with chronic R hip pain, who presents from home with altered mental status, urinary retention, and renal failure. History is obtained from the patient's daughter, as the patient has difficulty speaking from her h/o L sided stroke. For the last week, the patient has been complaining of difficulty urinating. She endorses a desire to urinate but then cannot make any urine. During this time she has also endorsed lack of appetite and has not eaten or drank her usual amount. Then the day of presentation, the patient woke up screaming in pain on the left side of her body. Per her family, the pain is usually on the right side due to contractures from her stroke and her recent R hip fracture, so this was unusual. In addition to the pain, she also appeared to be sleepier than usual and less responsive. Per the family, when she had her stroke many years ago, she had a similar presentation, so they were concerned and brought her to the ED. In the ED, her VS were notable for HTN 194/74 which improved to 140s systolic. Other VSS. Exam notable for baseline R hemiplegia and facial droop. Labs showed wBC 14, ___ with Cr 1.5 from baseline normal, negative UA, negative NCHCT and CXR. She complained of having an urge to urinate but difficulty voiding. A foley was placed for urinary retention with good output. Upon arrival to the floor, the patient is sleepy. The patient is able to follow commands and answer yes or no questions. She endorses difficulty urinating but no dysuria. She endorses R sided leg pain when asked but otherwise no complaints. No cough, chest pain, SOB, abd pain, n/v/d. ROS: As per HPI. Remainder of 10 point ROS is otherwise negative. Past Medical History: Stroke ___ left posterior limb of internal capsular and left anterior temporal infarct Seizure ___ CAD- ___ at ___) presented with chest pain, stent to her mid right coronary artery and found to have unilateral severe left renal artery stenosis which is s/p stent. Hypertension Type 2 DM - insulin dependent for many years Hypercholesterolemia L renal artery stenosis- ? s/p stent as above. Asthma Gastritis Chronic LBP s/p L5 lami with "failed back surgery syndrome" Tobacco abuse Depression s/p Appendectomy R Intratrochanteric Fracture s/p ORIF w/ cephalomedullary nail (___) Social History: ___ Family History: no history of neurological diseases Physical Exam: Admission physical exam: 97.9, 178/86, 91, 18, 98% on RA GEN: well nourished appearing elderly female in NAD HENT: NCAT, OP clear, MMM Eyes: EOMI, sclera anicteric, PERRL Neck: supple CV: RRR, ___ SEJM at ___, no gallops or rubs Resp: CTAB, no w/r/r, breathing comfortably GI: soft, nondistended, nontender, BS hyperactive GU: foley in place draining CYU Extr: R sided muscular atrophy and contractures. No edema. Neuro: AAOx2 (baseline knows person and place, not date). R facial droop. R sided hemiplegia. Moves L arm and leg on command. Dysphasia (limited assessment due to ___ speaking) Skin: no skin breakdown, rash, or jaundice Psych: unable to assess due to dysphasia Pertinent Results: Admission labs ___ 02:00PM BLOOD WBC-14.4* RBC-4.32 Hgb-10.3* Hct-34.1 MCV-79* MCH-23.8* MCHC-30.2* RDW-15.2 RDWSD-43.8 Plt ___ ___ 02:00PM BLOOD Neuts-63.1 ___ Monos-6.6 Eos-4.8 Baso-0.6 Im ___ AbsNeut-9.11* AbsLymp-3.50 AbsMono-0.95* AbsEos-0.69* AbsBaso-0.08 ___ 02:00PM BLOOD ___ PTT-29.7 ___ ___ 02:00PM BLOOD Glucose-186* UreaN-32* Creat-1.5* Na-137 K-3.7 Cl-101 HCO3-27 AnGap-13 ___ 02:00PM BLOOD ALT-12 AST-16 AlkPhos-115* TotBili-0.1 ___ 02:00PM BLOOD Lipase-92* ___ 02:00PM BLOOD Albumin-3.3* Calcium-9.7 Phos-3.6 Mg-2.0 UA ___ 02:00PM URINE HOURS-RANDOM ___ 02:00PM URINE HOURS-RANDOM ___ 02:00PM URINE UHOLD-HOLD ___ 02:00PM URINE GR HOLD-HOLD ___ 02:00PM WBC-14.4* RBC-4.32 HGB-10.3* HCT-34.1 MCV-79* MCH-23.8* MCHC-30.2* RDW-15.2 RDWSD-43.8 ___ 02:00PM NEUTS-63.1 ___ MONOS-6.6 EOS-4.8 BASOS-0.6 IM ___ AbsNeut-9.11* AbsLymp-3.50 AbsMono-0.95* AbsEos-0.69* AbsBaso-0.08 ___ 02:00PM PLT COUNT-445* ___ 02:00PM ___ PTT-29.7 ___ ___ 02:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 02:00PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 02:00PM URINE HYALINE-7* Micro: none Imaging: CXR ___ There is no focal consolidation, sizeable pleural effusion or pneumothorax. No overt pulmonary edema. Mild cardiomegaly is stable. No acute osseous abnormalities identified. IMPRESSION: No acute cardiopulmonary process. NCHCT ___ Images are mildly limited by streak artifact. No acute intracranial hemorrhage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Gabapentin 300 mg PO QHS 3. TraZODone 50 mg PO QHS:PRN insomnia 4. GlipiZIDE XL 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Bisacodyl 10 mg PO BID 8. Tizanidine 4 mg PO BID 9. Labetalol 300 mg PO DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. Clopidogrel 75 mg PO DAILY 12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 13. Glargine 48 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Bisacodyl 10 mg PO BID 3. Citalopram 20 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Glargine 48 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Labetalol 300 mg PO DAILY 7. Acetaminophen 650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg 2 tablet(s) by mouth q6h prn Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ female with altered mental status and headache. Evaluate for acute intracranial hemorrhage or large territorial infarct. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.0 s, 14.5 cm; CTDIvol = 48.5 mGy (Head) DLP = 702.4 mGy-cm. Total DLP (Head) = 702 mGy-cm. COMPARISON: ___ noncontrast head CT. FINDINGS: Images are limited by streak artifact. There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular, subcortical, and deep white matter hypodensities are again seen, consistent with chronic small vessel ischemic disease. Chronic infarctions within the left frontal lobe are unchanged from the prior study. There is no evidence of fracture. The visualized portion of the paranasal sinuses, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Small nonspecific right mastoid tip fluid is noted. IMPRESSION: 1. Images are mildly limited by streak artifact. 2. Within limits of study, no acute intracranial hemorrhage. 3. Please note MRI of the brain is more sensitive for the detection of acute infarct. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: History: ___ with confusion // PNA? TECHNIQUE: Frontal chest radiograph COMPARISON: Chest radiograph ___ FINDINGS: There is no focal consolidation, sizeable pleural effusion or pneumothorax. No overt pulmonary edema. Mild cardiomegaly is stable. No acute osseous abnormalities identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with ___, urinary retention // assess for obstruction or hydronephrosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Contrast-enhanced CT abdomen pelvis CT from ___. FINDINGS: The right kidney measures 9.9 cm. The left kidney measures 11.7 cm. There is no hydronephrosis, stones, or suspicious masses bilaterally. A 1.1 x 1.0 x 1.2 anechoic lesion in the lower pole of the right kidney with a central thin echogenic band may represent two adjacent simple cysts or a cyst with a thin septation, minimally large compared to the CT from ___. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is collapsed around a Foley catheter and difficult to evaluate. IMPRESSION: No hydronephrosis. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by UNKNOWN Chief complaint: Body pain, Altered mental status Diagnosed with Altered mental status, unspecified, Acute kidney failure, unspecified temperature: 97.8 heartrate: 81.0 resprate: 16.0 o2sat: 97.0 sbp: 194.0 dbp: 74.0 level of pain: unable level of acuity: 1.0

ASSESSMENT/PLAN: ___ with poorly-controlled DMII, CAD s/p stent on Plavix, CVA with R hemiparesis, wheelchair bound at baseline, s/p R hip fracture with chronic R hip pain, who presented from home with altered mental status, urinary retention, and renal failure. #Acute encephalopathy The patient presented with 1 day of increased drowsiness, decreased responsiveness compared to her baseline. No s/s infection. Neg CXR, UA. Most likely metabolic from ___ in addition to sedating medications and decreased clearance of gabapentin. ___ negative for CVA and neurologic exam appeared to be at baseline. During the hospitalization pt was noted to be significantly more somnolent when given tizanidine, so this was stopped as well. She was advised to hold her home gabapentin, oxycodone, tizanidine and trazodone pending further evaluation with her PCP. #Acute renal failure #Urinary retention Cr elevated to 1.5 on admission from normal baseline. DDx either prerenal from reported poor po intake recently versus acute urinary retention. S/p 500cc NS in the ED. Urinary retention have been caused by medication (Percocet) or constipation. She was able to urinate spontaneously once her constipation resolved and oxycodone was held. She was advised to hold hctz and lisinopril on discharge. #Leukocytosis No s/s infection as above. There may have been an aspiration event in the setting of somnolence, but no pna symptoms developed. #Acute left leg pain #H/o L sided stroke with residual R hemiplegia, facial droop, and dysphasia Physical exam appears at baseline per prior records and family report. Fell well on Tylenol alone. #IDDM -continued home lantus and ISS -held home glipizide #CAD, HTN -continued home labetolol; held hctz and lisinopril as above -continued home ASA, Plavix #Anxiety -continued home citalopram and trazodone # Code status: full # PPX: sc heparin

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ yo woman with a history of dementia, HTN, HLD and recent hospitalization for SOB treated as CHF who is admitted from rehab with recurrence of SOB. Per daughter, pt has been doing well since hospital discharge on ___. Her breathing status has been stable, though daughter does report increased lower extremity edema. Pt developed fairly sudden onset SOB yesterday afternoon at rehab, with sats reportedly to the ___. She received 40mg PO lasix and SL morphine, though was still SOB when presented to ED. . In the ED, pt was initially placed on BiPAP for low oxygen saturation. She received lasix 40mg IV x2. Her BNP was elevated to ___ with troponin of 0.05 and lactate of 3.1. Her CXR was concerning for mild pulm edema and moderate bilateral pleural effusions. She was also started on a nitro drip. Foley placement was attempted x 5 but failed. . Pt began making urine once on the floor, though she is incontinent and wearing a diaper so accurate I/O monitoring will be difficult. She has no recollection of the events leading up to her hospitalization and states that she feels well. She is A&O x 1. Past Medical History: - HTN - HLD - ? CAD - systolic murmur: mild MR and mod TR - advanced dementia - anxiety - GERD - constipation - OA - h/o temporal arteritis, s/p prednisone - bilateral cataracts - arrythmia, ? a fib, prevoiusly on coumadin but stopped several years ago Social History: ___ Family History: Her mother died from complications of diabetes. Father died from complications of a stroke. She has 4 brothers and 1 sister all of whom have passed, 2 died from motor vehicle accidents, one died from complications of pancreatic cancer, and the other died from complications of polio; he also suffered from end-stage renal disease. Physical Exam: ADMISSION EXAM: VS- Temp 97.6 F, BP 127/62, HR 88, R 20, O2-sat 91% 2L-> 96% 3L GENERAL- well-appearing in NAD, comfortable, appropriate HEENT- NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK- supple, no JVD LUNGS- diminished breath sounds bilat, bibasilar crackles, resp unlabored, no accessory muscle use HEART- PMI non-displaced, RRR, holosystolic mumur ___ best at ___ ABDOMEN- NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES- WWP, 2+ DP pulses bilaterally, 2+ edema to the legs bilat SKIN- chronic venous stasis change , as well as skin breakdown on coccyx area. NEURO - awake, A&Ox3 . DISCHARGE EXAM: VS- Tm 97.7, BP 92/61 (92-154/61-121), HR 87(64-89), RR 21, O2-sat 98% 4L wt 57.1 kg (from 57.4 on admission) GENERAL- elderly woman in NAD, breathing comfortably, unable to straighten neck fully. HEENT- NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK- supple, no JVD though difficult to appreciate as pt is unable/unwilling to straighten neck fully LUNGS- diminished breath sounds bilat, poor respiratory effort, resp unlabored, no accessory muscle use HEART- irregular, holosystolic mumur ___ best at ___ ABDOMEN- NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES- WWP, 2+ DP pulses bilaterally, trace edema to the knees bilat SKIN- chronic venous stasis change on legs with bilateral errythema and flaky skin, as well as skin breakdown on coccyx area. NEURO - awake, A&Ox1 Pertinent Results: ADMISSION LABS: ___ 05:55PM BLOOD WBC-9.0 RBC-3.69* Hgb-11.5* Hct-36.7 MCV-99* MCH-31.1 MCHC-31.4 RDW-12.8 Plt ___ ___ 05:55PM BLOOD Neuts-90.2* Lymphs-5.3* Monos-3.7 Eos-0.5 Baso-0.3 ___ 05:55PM BLOOD ___ PTT-25.1 ___ ___ 05:55PM BLOOD Glucose-209* UreaN-30* Creat-1.3* Na-139 K-4.9 Cl-96 HCO3-32 AnGap-16 ___ 05:55PM BLOOD CK-MB-3 ___ ___ 06:10AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.2 ___ 06:10AM BLOOD TSH-2.1 ___ 06:10PM BLOOD Lactate-3.1* ___ 05:10PM BLOOD Lactate-1.5 . DISCHARGE LABS: ___ 06:05AM BLOOD WBC-9.1 RBC-3.54* Hgb-11.3* Hct-35.7* MCV-101* MCH-31.9 MCHC-31.6 RDW-12.8 Plt ___ ___ 06:05AM BLOOD Glucose-137* UreaN-32* Creat-1.3* Na-143 K-4.1 Cl-97 HCO3-39* AnGap-11 ___ 06:05AM BLOOD Calcium-9.8 Phos-3.6 Mg-2.4 . IMAGING: CXR ___: SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette size is difficult to assess given the presence of bilateral pleural effusions, moderate on the left and small on the right. Heart size is likely mildly enlarged. The aortic knob is calcified. There is evidence of mild pulmonary edema. Bibasilar airspace opacities likely reflect compressive atelectasis. No large pneumothorax is identified. IMPRESSION: Mild pulmonary edema with moderate left and small right pleural effusions and bibasilar atelectasis. . CXR ___ FINDINGS: Compared to the previous radiograph, there is a slight increase in extent of the pre-existing bilateral pleural effusions. The pre-existing signs of moderate pulmonary edema are present in unchanged manner. Moderate cardiomegaly. No other change is detected on this technically limited radiograph. . TTE ___: The left atrium is elongated. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy with overall normal left ventricular systolic function (LVEF 55-60%) and relatively small cavity size. The estimated cardiac index is borderline low (2.0-2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed with moderate to severe aortic valve stenosis (valve area 1.0 cm2 by planimetry). Mild (1+) central aortic regurgitation is seen. The mitral valve leaflets are moderately thickened with severe mitral annular calcification. Mild to moderate (___) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are moderately thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate symmetric left ventricular hypertrophy with small cavity size, normal global systolic function, and suggestion of significant diastolic dysfunction. Moderate to severe aortic stenosis. Mild aortic regurgitation. Mild mitral regurgitation. Moderate pulmonary hypertension. . ECG: atrial fibrillation with rate in ___, left bundle branch block Medications on Admission: tylenol ___ PO PRN aspirin 81 mg daily lorazepam 0.25mg TID PRN for anxiety or agitation omeprazole 20mg daily senna 8.6 mg daily Saline nasal spray BID furosemide 40mg PO daily ergocalciferol ___ units q3 weeks Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal twice a day. 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution Sig: Forty (40) mg Intravenous PRN as needed for shortness of breath or wheezing: shortness of breath. 8. morphine 4 mg/mL Syringe Sig: ___ mg Injection PRN as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: diastolic CHF exacerbation atrial fibrillation . SECONDARY: hypertension dyslipidemia anxiety Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: Dyspnea. COMPARISON: Chest radiograph ___. SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette size is difficult to assess given the presence of bilateral pleural effusions, moderate on the left and small on the right. Heart size is likely mildly enlarged. The aortic knob is calcified. There is evidence of mild pulmonary edema. Bibasilar airspace opacities likely reflect compressive atelectasis. No large pneumothorax is identified. IMPRESSION: Mild pulmonary edema with moderate left and small right pleural effusions and bibasilar atelectasis. Radiology Report CHEST RADIOGRAPH INDICATION: Chronic heart failure, exacerbation, question of pulmonary edema. COMPARISON: ___. FINDINGS: Compared to the previous radiograph, there is a slight increase in extent of the pre-existing bilateral pleural effusions. The pre-existing signs of moderate pulmonary edema are present in unchanged manner. Moderate cardiomegaly. No other change is detected on this technically limited radiograph. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: SOB Diagnosed with ACUTE LUNG EDEMA NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE III (MODERATE), HYPERLIPIDEMIA NEC/NOS temperature: 96.0 heartrate: 91.0 resprate: 30.0 o2sat: 100.0 sbp: 138.0 dbp: 86.0 level of pain: 13 level of acuity: 1.0

___ yo F with h/o HTN, HLD, ? CAD admitted for volume overload, increased work of breathing and lower extremity edema, and volume overload evidence on CXR. Pt continued to decline throughout her hospitalization and required intermittent IV lasix for flash pulmonary edema and acute respiratory decompensation. Several conversations were held with the daughter and the palliative care team, with transition to comfort care. . # Hypoxia/acute on chronic diastolic CHF: Pt was admitted with hypoxic respiratory failure secondary to volume overload, initially requiring BiPAP. She was treated with boluses of IV lasix with improvement in her respiratory status. However, she continued to have intermittent declines in her respiratory status, requiring additional doses of lasix PRN. She has reached end stage heart failure and medical options are limited. After discussion with her daughter and the palliative care team, the decision was made to transition her to comfort focused care. She should continue to be treated with IV lasix PRN for respiratory distress. She has been responding well to lasix 40mg IV, but she may require increasing doses as her disease progresses. The daughter is also amenable to morphine PRN as needed for increasing shortness of breath or anxiety. . # atrial fibrillation: Per daughter, pt has history of an arrhythmia in the past, for which she was on atenolol and Coumadin. Daughter does not know why but both of these medications were stopped within the past ___ years. Pt is currently in atrial fibrillation, which is a change from her previous admission 2 weeks ago. This may have been a precipitating factor for her CHF exacerbation. She was initiated on metoprolol for heart rate control, with the hope that this will make her less likely to develop flash pulmonary edema, thereby keeping her more comfortable. . # ___: Likely pre-renal secondary to poor forward flow from CHF exacerbation. We have been unable to obtain a urine sample to evaluate further. . # Anxiety/dementia: Pt was noted to be very anxious throughout her hospitalization and would request constant companionship. This is likely due in part to her progressive dementia along with anxiety associated with increasing shortness of breath. Her daughter is agreeable to morphine PRN for increasing shortness of breath or anxiety, which will hopefully keep the patient more comfortable. . # GERD: Pt was continued on her omeprazole. .

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Compazine / Sulfur / Vicodin / Morphine / Penicillins / Macrodantin / Iodine / Clindamycin / azithromycin / Cipro / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending: ___. Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ year old female with dCHF, CKD stage 4, LLE DVT ___ complicated by BRBPR now off coumadin, multiple episodes of previous syncope attributed to dehydration who presents one day after fall at home. Patient was in her usual state of health when she got up from a recliner and decided to go to the bathroom using her walker. She reportedly took ___ wide steps and began to fall forward on her left leg. She did not hit her head during the fall. Afterwards, she began to complain of lower mid back pain that radiated to the coccyx. She also scrpaed her left arm and complained of left knee pain. She initially refused to go the ED. She was given 650 mg of tylenol and was able to sleep throughout the night. She was brought to the ED after she was unable to ambulate this am ___ pain. In the ED she complained of low back and left knee pain. Her low back pain was made better by lying supine. Her knee pain was brought on by flexion/extension of the knee. Per daughter ___ there was no LOC, chest pain, SOB, or pain radiating to legs. She denies any weakness in her extremities. Of note patient was on coumadin (for left thigh DVT) previously but discontinued in ___ lower GI bleed. She is on prednisone for polymyalgia rhuematica and has severe osteoporosis. In the ED, initial VS were: T 99.1 HR 90 BP 162/77 RR 14. Labs were notable for BUN/Cr of 35/1.5 (baseline Cr of 1.7-1.8). U/A showed 2 WBC, positive nitrite, negative leukocyte esterasae. VS prior to transfer were: 98.4 74 129/78 16 96%. On arrival to the floor, pt is comfortable, complaining of low back pain. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ___: EF 75-80% LLE DVT (___), now off comuadin secondary to BRBPR Hyperlipidemia Hyperparathyroidism Hypothyroidism PMR (on chronic prednisone) CRI Osteoporosis Venous insufficiency Bowel/bladder incontinence Multiple episodes of syncope attributed to dehydration hx aspiration pna Social History: ___ Family History: Mother deceased of stroke. Husband deceased of stroke. No other known family hx of clot Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Tm 98.5, Tc 98.1, BP 160 (112-188)/70(62-75), p (___) rr 91-93% on RA GENERAL: Patient somnolent but arousable to voice, in NAD. HEENT: PERRL, EOMI NECK: No carotid bruits, JVD LUNGS: Bibasilar crackles, good air entry bilaterally HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NABS, mild distention, diffuse tenderness to palpation, no guarding/rebound tenderness EXTREMITIES: Small inter-digitary ulceration on R hand between ___ and ___ fingers with denuded skin and dried yellow exudate. NEUROLOGIC: A+OX3, full strength grossly, good range of motion, spinal tenderness difficult to assess given patient's mental status MSK: knee pain on flexion, presence of effusion and hematoma on R patella DERMATOLOGIC: thin, flacky skin with abrasions on L arm DISCHARGE PHYSICAL EXAM: GENERAL: Calm, comfortable, in NAD HEENT: PERRL, EOMI NECK: No carotid bruits, flat JVP LUNGS: CTAB with no wheezes, rales, rhonchi. Good aeration. HEART: RRR, normal S1/S2, no M/R/G ABDOMEN: NABS, soft, ND, mildly tender diffusely to palpation, no guarding/rebound tenderness EXTREMITIES: small inter-digitary ulceration on R hand between ___ and ___ fingers with denuded skin and dried yellow exudate. NEUROLOGIC: A+OX2, full strength grossly, good ROM MSK: L knee without pain on flexion/extension, improved effusion and hematoma on L patella. DERMATOLOGIC: thin, flacky skin with abrasions on L arm, bilateral lower extremities Pertinent Results: ADMISSION LABS: ___ 02:45PM BLOOD WBC-10.6 RBC-4.19* Hgb-12.6# Hct-38.1 MCV-91 MCH-30.0 MCHC-32.9 RDW-15.8* Plt ___ ___ 02:45PM BLOOD Neuts-75.6* ___ Monos-3.9 Eos-2.2 Baso-0.3 ___ 02:45PM BLOOD ___ PTT-21.2* ___ ___ 02:45PM BLOOD Glucose-75 UreaN-35* Creat-1.5* Na-143 K-3.9 Cl-108 HCO3-23 AnGap-16 ___ 03:41PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:41PM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 09:33AM URINE Blood-TR Nitrite-POS Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 03:41PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 ___ 09:33AM URINE RBC-4* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 DISCHARGE LABS: ___ 07:20AM BLOOD WBC-10.5 RBC-4.11* Hgb-12.4 Hct-37.8 MCV-92 MCH-30.2 MCHC-32.8 RDW-15.8* Plt ___ ___ 07:20AM BLOOD Glucose-64* UreaN-33* Creat-1.7* Na-140 K-3.7 Cl-107 HCO3-20* AnGap-17 ___ 07:20AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9 MICROBIOLOGY: URINE CULTURE (Final ___: ___. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ___ | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S URINE CULTURE (Final ___: ___. >100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. IMAGING STUDIES: PLAIN FILM L KNEE (___): Tricompartment degenerative disease, most prominent in the medial compartment. Calcification is noted within medial and lateral menisci concerning for CPPD arthropathy. PLAIN FILM LUMBAR SPINE (___): Stable grade 1 anterolisthesis of L5 on S1 and L4 on L5 unchanged compared to the prior CT abdomen and pelvis ___. CXR (___): No definite evidence for acute disease. Peripheral interstitial changes suggestive of underlying interstitial disease. KUB (___): Nonspecific bowel gas pattern with no evidence of bowel obstruction. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Acetaminophen 650 mg PO TID:PRN pain 2. Amlodipine 2.5 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Carvedilol 3.125 mg PO DAILY 5. Cetirizine *NF* 10 mg Oral daily 6. Vitamin D 1000 UNIT PO DAILY 7. Ferrous Sulfate 300 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD DAILY to shoulder 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. PredniSONE 15 mg PO DAILY 14. Senna 1 TAB PO BID 15. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum, hydrophilic;<br>white petrolatum) 2 % Topical BID 16. Aspirin 81 mg PO DAILY Discharge Medications: 1. ___ Lift Diagnosis: Polymyalgia rheumatica 2. Acetaminophen 650 mg PO TID:PRN pain 3. Amlodipine 2.5 mg PO DAILY 4. Ascorbic Acid ___ mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Carvedilol 3.125 mg PO DAILY 7. Ferrous Sulfate 300 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Lidocaine 5% Patch 2 PTCH TD DAILY apply to back and left shoulder daily RX *lidocaine 5 % (700 mg/patch) 1 patches daily Disp #*60 Transdermal Patch Refills:*0 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. PredniSONE 15 mg PO DAILY 14. Senna 1 TAB PO BID 15. Vitamin D 1000 UNIT PO DAILY 16. wound care for right hand interdigitary wound Soak in saline for 20 minutes followed by zinc ointment application 17. Bisacodyl ___AILY:PRN constipation RX *bisacodyl 10 mg 1 Suppository(s) rectally daily PRN Disp #*10 Suppository Refills:*0 18. Ciprofloxacin HCl 500 mg PO Q24H Duration: 7 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 19. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth BID PRN Disp #*60 Tablet Refills:*0 20. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum, hydrophilic;<br>white petrolatum) 2 % Topical BID 21. Cetirizine *NF* 10 mg Oral daily 1. Hoyer Lift Diagnosis: Polymyalgia rheumatica 2. Acetaminophen 650 mg PO TID:PRN pain 3. Amlodipine 2.5 mg PO DAILY 4. Ascorbic Acid ___ mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Carvedilol 3.125 mg PO DAILY 7. Ferrous Sulfate 300 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Lidocaine 5% Patch 2 PTCH TD DAILY apply to back and left shoulder daily RX *lidocaine 5 % (700 mg/patch) 1 patches daily Disp #*60 Transdermal Patch Refills:*0 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. PredniSONE 15 mg PO DAILY 14. Senna 1 TAB PO BID 15. Vitamin D 1000 UNIT PO DAILY 16. wound care for right hand interdigitary wound Soak in saline for 20 minutes followed by zinc ointment application 17. Bisacodyl ___AILY:PRN constipation RX *bisacodyl 10 mg 1 Suppository(s) rectally daily PRN Disp #*10 Suppository Refills:*0 18. Ciprofloxacin HCl 500 mg PO Q24H Duration: 7 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 19. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth BID PRN Disp #*60 Tablet Refills:*0 20. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum, hydrophilic;<br>white petrolatum) 2 % Topical BID 21. Cetirizine *NF* 10 mg Oral daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Mechanical fall Urinary tract infection Delerium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH HISTORY: Status post fall. History of aspiration. Right lower lobe crackles on physical examination found. COMPARISONS: ___. TECHNIQUE: Chest, AP supine. FINDINGS: A dual-lead pacemaker/ICD device appears unchanged with leads again terminating in the right atrium and ventricle, respectively. The heart is mildly enlarged. The mediastinal and hilar contours appear unchanged. The lungs appear clear aside from similar interstitial changes predominating in the lower lungs which suggest mild interstitial disease. There is no pleural effusion or pneumothorax. The right glenohumeral joint is severely narrowed. IMPRESSION: No definite evidence for acute disease. Peripheral interstitial changes suggestive of underlying interstitial disease. Radiology Report INDICATION: ___ woman with complicated medical history with lower back pain radiating to coccyx. COMPARISON: Comparison made to CT abdomen and pelvis without contrast ___. TECHNIQUE: AP and lateral lumbar spine. FINDINGS: There are five non-rib-bearing lumbar vertebrae. The vertebral body and heights are maintained. There is no evidence of compression fracture. There is grade 1 anterolisthesis of L5 on S1 and L4 on L5 unchanged compared to the prior CT abdomen and pelvis ___. IMPRESSION: Stable grade 1 anterolisthesis of L5 on S1 and L4 on L5 unchanged compared to the prior CT abdomen and pelvis ___. Radiology Report INDICATION: ___ woman with complicated medical history status post fall in the ED. Patient reports back pain radiating to coccyx and point tenderness. Assess for acute fracture of the left knee. THREE VIEWS OF THE LEFT KNEE: Three views of the left knee demonstrate no acute fractures or traumatic dislocation. Tricompartment degenerative changes are noted, most prominent in the medial compartment. Spurring is noted within both medial and lateral compartments as well as along the tibial spines. Calcification is noted within medial and lateral menisci concerning for CPPD arthropathy. An enthesophyte is noted arising from superior pole of the patella. Vascular calcifications are noted. No significant joint effusion is noted. IMPRESSION: 1. Tricompartment degenerative disease, most prominent in the medial compartment. 2. Calcification is noted within medial and lateral menisci concerning for CPPD arthropathy. Radiology Report INDICATION: ___ female with left lower quadrant pain. COMPARISON: Comparison is made with abdominal radiograph from ___. FINDINGS: Supine and left lateral decubitus images of the abdomen show a nonspecific bowel gas pattern with no evidence of bowel obstruction. There is a general paucity of bowel gas. There is no free air at the liver edge on the left lateral decubitus image. There is small amount of stool in the distal colon. There are no air-fluid levels. Prominent atherosclerotic calcification of the abdominal arteries is seen. Pacemaker leads are noted in the chest. IMPRESSION: Nonspecific bowel gas pattern with no evidence of bowel obstruction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with BACKACHE NOS, DIFFICULTY WALKING, HYPERTENSION NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE, HX VENOUS THROMBOSIS/EMBOLISM temperature: 99.1 heartrate: 90.0 resprate: 14.0 o2sat: 99.0 sbp: 162.0 dbp: 77.0 level of pain: 7 level of acuity: 3.0

___ year old female with dCHF, CKD stage 4, LLE DVT off coumadin due to GI bleed, multiple episodes of previous syncope secondary to dehydration, and chronic dementia, who was admitted one day after a witnessed mechanical fall at home. Hospital course was complicated by acute delirium caused by narcotic administration for pain and UTI. Urine culture grew pansensitive Morganella. She was treated with ciprofloxacin and mental status improved to baseline. She was treated with an aggressive bowel regimen for constipation, which she will need to continue at home to maintain regular movements. She was seen by ___ and per patient and family preference, she was discharged to home with ongoing nursing and ___ services with addition of a Hoyer lift. She had plain films of her lumbar spine and left knee which were without fracture. For all other chronic issues, including R hand ulceration (SCC), hypertension, hypothyroidism, CKD, GERD, PMR, home medications were continued as prescribed. Patient was DNR/DNI throughout admission.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right upper quadrant pain. Major Surgical or Invasive Procedure: ___ Laparoscopic converted to open cholecystectomy History of Present Illness: Ms. ___ is a ___ yo woman with a h/o grade III infiltrating ductal right breast cancer, who presents to the ED after an episode of RUQ pain in the setting of recent hospitalization for acute cholecystitis. On ___, the pt presented to ___ with excruciating abdominal pain. US showed distended gallbladder and gallstones without evidence of mural edema, pericholecystic fluid collections, or dilated ducts. CT abdomen and pelvis confirmed gallbladder distention and showed mild pericholecystic stranding. She was admitted for nonsurgical management of biliary colic. She received IV abx and was discharged on ___ with a 5-day course of augmentin 875 mg BID. She had an appt with Dr. ___ on ___. She remained pain-free throughout the week. On ___, she felt "off" and had T 100.8F, which resolved. On ___, she had a 30 minute episode of colicky RUQ pain that radiated to her flanks and fluctuated between ___ to ___. She treated with 2 oxycodone and it resolved. She spoke with her PCP her asked her to go to the ED if the pain returned. Today, she ate a ___ sandwich and M&M's (last meal) at 12:30pm. Within a half hour, she had another episode of colicky pain that resolved within 15 min and treated with 0.5 tab oxycodone. All episodes are accompanied with nausea. Denies any emesis, diarrhea, constipation, chills. Past Medical History: PMH: - 2.6 cm grade III infiltrating ductal cancer of the right breast, clean lymph nodes, negative LVI, ER/PR positive, HER-2 negative - Hypertension - Hypothyroidism - GERD - depression - anxiety PSH: - At age ___, laparotomy for intussusception - At age ___, tonsillectomy - ___ right breast lumpectomy with sentinel node biopsy - ___ left ankle repair - ___ Right temporal artery bx to r/o giant cell arteritis (negative) Social History: ___ Family History: Significant for a mother who never had cancer, a maternal aunt who died of bladder cancer in her ___, another maternal aunt who died in her ___ of some cancer. The aunt with bladder cancer had a daughter who had breast cancer in her ___. Her maternal uncle died without cancer but his son had some kind of cancer and died in his ___. This would be ___ first cousin. The family is ___. All of her maternal aunts and uncles share the same maternal grandfather but have a different maternal grandmother. She is not aware of any cancer in either her maternal grandmother or grandfather. On her father's side of the family, her father smoked and died of lung cancer. He had a brother who died at ___ of a brain tumor. Her father had two sisters who died in their ___ without cancer. Physical Exam: On admission: Overweight woman sitting up in bed appearing uncomfortable. HEENT: Right incision wound in temporal region; no scleral icterus; no oral lesions. CV: RRR; no m/r/g. Resp: CTAB Abdomen: +BS; diffuse mild tenderness in all four quadrants; mod tenderness in RUQ; no rebound or guarding. Soft. Ext: +pedal pulses; no edema; L>R ankle asymmetry. On discharge: VS: 98.2, 94, 110/52, 14, 95% on room air. Pertinent Results: ___ 05:45AM BLOOD WBC-7.3 RBC-3.82* Hgb-11.6* Hct-34.8* MCV-91 MCH-30.5 MCHC-33.4 RDW-12.8 Plt ___ ___ 04:45PM BLOOD WBC-12.6* RBC-4.47 Hgb-13.7 Hct-41.9 MCV-94 MCH-30.5 MCHC-32.6 RDW-12.9 Plt ___ ___ 04:45PM BLOOD Neuts-62 Bands-0 ___ Monos-7 Eos-1 Baso-1 Atyps-2* ___ Myelos-0 NRBC-1* ___ 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 04:45PM BLOOD ___ PTT-38.4* ___ ___ 04:45PM BLOOD Glucose-108* UreaN-23* Creat-0.7 Na-140 K-4.1 Cl-101 HCO3-29 AnGap-14 ___ 05:45AM BLOOD Glucose-107* UreaN-6 Creat-0.5 Na-138 K-4.5 Cl-104 HCO3-28 AnGap-11 ___ 05:42AM BLOOD ALT-43* AST-40 AlkPhos-122* TotBili-0.3 DirBili-0.1 IndBili-0.2 ___ 04:45PM BLOOD ALT-45* AST-56* AlkPhos-125* TotBili-0.2 ___ 05:42AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8 ___ 05:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0 IMAGING: ___ Liver/Gallbladder U/S Gallbladder stone/sludge and mild gallbladder wall edema. No pericholecystic fluid. Negative sonographic ___ sign. Acute cholecystitis is not excluded in the appropriate clinical setting. Questionable intrahepatic biliary dilatation in the left lobe of the liver versus artifact. Correlate with recent prior imaging and with LFTs. Consider MRCP if clinically warranted. ___ ERCP 1. Acute cholecystitis with a probable small localized & contained perforation of the gallbladder. No associated abscess. 2. No intra or extrahepatic duct dilatation. No stones within the common bile duct. 3. Pancreas divisum. 4. Colonic diverticulosis. 5. Chronic anterior wedge compression fracture at L1. ___ Liver/gallbladder U/S Status post cholecystectomy with a small amount of fluid collection, roughly 3 cm at the gallbladder fossa, adjacent to the distal tip of the surgical drain which contains foci of gas. There is no biliary obstruction. ___ CT abdomen/pelvis with contrast (wet read) 1. 3.5 x 3.9 cm cavity in the gallbladder fossa. Soft tissue density and air loculations within the cavity are compatible with Surgicel. In addition there is an air-fluid level in this cavity which could represent biloma, seroma, or abscess. The JP drain tip terminates in this collection, and analysis of the drain output should be helpful to discriminate. 2. Appropriate position of the right anterior bile duct to CBD stent. 3. Pneumobilia. 4. Bibasilar atelectasis. 5. Tiny 5 millimeter posterior segment 7 biliary hamartoma 6. Moderate fecal loading of the ascending and transverse colon 7. Extensive bilateral adnexal enhancement may represent extensive varices or enhancing mass. Pelvic ultrasound is suggested for evaluation. 8. Small volume of free pelvic fluid. Medications on Admission: - anastrozole 1 mg PO daily - celecoxib 200 mg PO twice daily - hydrochlorothiazide 25 mg PO daily - Levoxyl 100 mcg PO daily - lorazepam 1 mg ___ tabs QHS prn for anxiety - omeprazole 20 mg - venlafaxine 150 mg PO daily - oxycodone 5 mg ___ tabs Q4 hours for pain (new medication as of ___ for RUQ pain) Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Lorazepam 1 mg PO Q8H:PRN anxiety 5. Omeprazole 20 mg PO DAILY 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 7. Senna 1 TAB PO BID:PRN constipation 8. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Recent cholecystitis diagnosed at outside institution. COMPARISON: None. FINDINGS: The liver demonstrates normal, homogeneous echotexture without focal intrahepatic lesion seen. There is questionable mild intrahepatic biliary dilatation in the left lobe of the liver. The common bile duct is normal in caliber, measuring 0.4 cm in diameter. The gallbladder contains sludge/stone. There is mild gallbladder wall edema. There is no pericholecystic fluid. Sonographic ___ sign was absent. The main portal vein is patent with hepatopetal flow. No pancreatic ductal dilatation is seen. While dedicated imaging of the right kidney was not performed, there is no evidence of right-sided hydronephrosis. IMPRESSION: Gallbladder stone/sludge and mild gallbladder wall edema. No pericholecystic fluid. Negative sonographic ___ sign. Acute cholecystitis is not excluded in the appropriate clinical setting. Questionable intrahepatic biliary dilatation in the left lobe of the liver versus artifact. Correlate with recent prior imaging and with LFTs. Consider MRCP if clinically warranted. Radiology Report HISTORY: Cholelithiasis. Assess for intra/extrahepatic biliary ductal dilatation. COMPARISON: Ultrasound dated ___. TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during and after the uneventful intravenous administration of 7 mL of Gadavist. The patient also received 2.5 mL of Gadavist diluted with 75 mL of water P.O. FINDINGS: The gallbladder wall is thickened and there is pericholecystic fat stranding (3:9). Post-contrast, the gallbladder wall demonstrates hyperenhancement (1102:76). On the delayed phase, there appears to be a small defect/irregularity within the medial aspect of the wall of the body of the gallbladder (1103:81) which leads into a small tract in the pericholecystic fat (1103:82-85). This likely represent a small localized/contained perforation without evidence of associated abscess formation. There is layered nonenhancing sludge with tiny gallstones noted within the gallbladder (4:21). No intra or extrahepatic duct dilatation. No filling defects within the biliary tree. There is arterial phase enhancement surrounding the gallbladder within the gallbladder fossa of the liver (1101:68). Multiple subcentimeter T2 hyperintense cystic lesions are noted within both lobes of the liver and likely represent biliary hamartomas. The portal and hepatic veins are patent. The hepatic artery is patent with conventional hepatic arterial anatomy. The pancreas is within normal limits. Note is made of pancreas divisum. The pancreatic duct is of normal caliber. There are subcentimeter T2 hyperintense cystic lesions within both kidneys which do not enhance and are consistent with simple cysts. The kidneys are otherwise unremarkable. The adrenals and spleen are within normal limits. Colonic diverticulosis is noted. The visualized small and large bowel is otherwise unremarkable. No retroperitoneal or mesenteric adenopathy. Linear atelectasis is noted within both lung bases. There is a chronic anterior wedge compression fracture at L1 with approximately 50% loss of vertebral body height (1:9). No destructive osseous lesions. IMPRESSION: 1. Acute cholecystitis with a probable small localized & contained perforation of the gallbladder. No associated abscess. 2. No intra or extrahepatic duct dilatation. No stones within the common bile duct. 3. Pancreas divisum. 4. Colonic diverticulosis. 5. Chronic anterior wedge compression fracture at L1. Verbal report issued to surgical team [Dr. ___ (pager ___ at time of discovery at 9.55, ___. Dr ___, Body MRI fellow. Radiology Report TYPE OF EXAMINATION: Chest PA and lateral. INDICATION: ___ female patient with fever and leukocytosis. Post-operative day 5 from laparotomy converted to open cholecystectomy, evaluate for consolidation. FINDINGS: PA and lateral chest views were obtained with patient in upright position. Analysis is performed in direct comparison with the next preceding available chest examination ___. High-positioned diaphragms indicate poor inspirational effort probably related to patient's post-operative status. Heart size has not changed significantly and there is no evidence of pulmonary vascular congestion. There exist bilateral linear appearing densities on the lung bases mostly occupying the posterior depending lung segments indicative of poor inspirational mechanics and bilateral atelectasis. There is no significant amount of pleural effusion as the posterior pleural sinuses are free on the lateral view. In the lung mid fields and the upper portions, there is no evidence of any acute pulmonary parenchymal infiltrate and no pneumothorax is identified in the apical area on the frontal view. When comparison is made with the previous examination of ___, the patient had already at that time minor basal atelectasis. These changes have increased dramatically and are most likely the result of poor post-operative breathing dynamics. Parenchymal densities typical for post-operative aspiration pneumonias or inflammatory processes cannot be identified on this PA and lateral chest examination. Radiology Report HISTORY: Status post open cholecystectomy; biliary leak ; collection/biloma was questioned. TECHNIQUE: Multiple grayscale and Doppler images of the right upper quadrant were obtained with a multifrequency probe in portable setting. COMPARISON: Prior ultrasound pre-surgery, dated ___ and MRI dated ___. FINDINGS: There is a small collection in the gallbladder fossa, adjacent to the tip of the JP drain measuring approximately 3 cm with internal foci of gas. The liver otherwise demonstrates no evidence of focal lesions or intrahepatic biliary dilatation. Common bile duct is normal in caliber, measuring 3 mm. There is no intrahepatic biliary dilatation. Main portal vein is patent demonstrates hepatopetal flow. Spleen measures 10 cm and contains small granulomas. There is small amount of dependent fluid in the lower pelvis anterior to the urinary bladder. IMPRESSION: Status post cholecystectomy with a small amount of fluid collection, roughly 3 cm at the gallbladder fossa, adjacent to the distal tip of the surgical drain which contains foci of gas. There is no biliary obstruction. Radiology Report CT ABDOMEN AND PELVIS WITH CONTRAST COMPARISON: Liver ultrasound from ___ and MRCP from ___. Chest radiograph from ___. The lung bases demonstrate bibasilar subsegmental atelectasis. The heart is prominent without pericardial effusion. The liver is normal in size. Pneumobilia is noted with a stent in place. Status post cholecystectomy with Surgicel material and mild amount of post-operative fluid noted. JP catheter courses out of the right flank from the subhepatic region. Expected pneumobilia in the left hepatic lobe. Spleen, pancreas, and bilateral adrenal glands are normal. Both kidneys demonstrate symmetric enhancement. Tiny hypodense foci within both kidneys are too small to characterize. Few calcified granulomas are noted within the spleen. The pancreas is otherwise normal. The bowel is normal. CT PELVIS: Urinary bladder is well distended without wall thickening. Uterus is grossly normal. However, the adnexa are not well seen. There is a mild amount of presacral fluid noted with high-attenuation material within the fluid, which may represent blood product. Underlying adnexal enlargement cannot be excluded. Pelvic ultrasound may be helpful for further evaluation. BONES: Degenerative disc disease in the lumbar spine. Superior endplate compression deformity is noted at the L1 vertebral body. Minimal retrolisthesis of L5 on S1. This was seen on ___ MRCP, but was not appreciated on the lateral radiograph from ___. IMPRESSION: 1. Post-surgical changes of cholecystectomy with Surgicel, post-operative fluid and JP drain in place. Expected pneumobilia with two common bile duct stents noted. 2. Nonspecific pelvic free fluid with mixed areas of high-attenuation areas, which could represent underlying adnexa vs mild blood product. The adnexa are not otherwise well seen. An underlying adnexal enlargement is not definitively excluded. Pelvic ultrasound may be helpful for further evaluation. 3. Few small hypodense lesions scattered throughout both kidneys may represent renal cysts; however, some are too small to characterize. 4. Superior endplate compression deformity of the L1 vertebral body is stable since ___, however, is new since ___. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with CHOLELITH W AC CHOLECYST, HYPERTENSION NOS, HX OF BREAST MALIGNANCY temperature: 98.4 heartrate: 94.0 resprate: 16.0 o2sat: 95.0 sbp: 139.0 dbp: 74.0 level of pain: 1 level of acuity: 3.0

Mrs. ___ was admitted the Acute Care Surgery service on ___ after she presented to ___ with complaints of right upper quadrant pain. A liver/gallbladder ultrasound showed gallbladder sludge and stones with possible intrahepatic biliary dilatation in the left lobe of the liver. Her LFTs were only mildly elevated, with an AST and ALT of 56 and 45, respectively. She subsequently had a MRCP on ___ which revealed acute cholecystitis with a probable small localized and contained perforation of the gallbladder. There was no associated abscess nor any intra- or extrahepatic duct dilatation. No stones were discovered in the common bile duct. While on the inpatient ward, Mrs. ___ was kept NPO and IV fluids. Her electrolytes were checked daily and repleted as necessary. She was given parenteral narcotic and non-narcotic analgesics for pain control. On ___, Mrs. ___ was taken to the operating room and underwent a laparoscopic cholecystectomy which was converted to an open cholecystectomy due to surgical complexity. A drain was left in place. Please see the operative report for further details. She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. She was initially given IV fluids postoperatively, which were discontinued when she was tolerating PO's. Her diet was advanced on the morning of ___ to regular, which she tolerated without abdominal pain, nausea, or vomiting. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. On approximately hospital day 9, Mrs. ___ developed a fever (one-time tmax of 102) and an elevated white count of 19. Due to concerns of a local abscess or fluid collection, she underwent a RUQ ultrasound, which showed a small fluid collection adjacent to the current drain. On the same day, a CT of the abdomen and pelvis was ordered to better define the fluid collection. Those results showed that the current drain was placed appropriately in the identified fluid collection. Because the drain had very little output in a 24 hour period (approximately 8 mls), the drain was removed on the day of discharge. She was afebrile, hemodynamically stable and in no acute distress. She was tolerating an oral diet, voiding without issue and ambulating independently. Her WBC continued to trend downwards. On the afternoon of ___, Mrs. ___ was discharged home with scheduled follow up in ___ clinic. At that time, her surgical staples will be removed. The patient requested that ___ services make one to two visits to her home for wound checks and a safety evaluation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left leg swelling, pain, and redness Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with PMH of HTN, HLD, DM2, and CHF with LVEF of 15% who presents with a 3 day history of LLE pain, swelling, and redness. This occured in the setting of a small ulceration on left shin. Denies fever, chills, chest pain, SOB different from baseline, cough, abdominal pain, nausea, vomiting, and diarrhea. She has no recent history of surgery, immobilization, or air travel. She is a ___ with no history of cellulitis. In the ED, initial vital signs were 96.3, 72, 109/63, 16, 99% RA. Labs notable for WBC 3.7, Plt 124, glucose 254, and an INR of 3.4. Patient was given vancomycin 1000 mg and admitted to Medicine given her complicated past medical history. Past Medical History: - Severe dilated cardiomyopathy - Chronic systolic heart failure with LVEF of 15% - ___ MR and TR - ___ 2 diabetes requiring insulin - Hypertension - Hyperlipidemia - H. pylori - hx CVA on Coumadin - Thrombocytopenia Social History: ___ Family History: No family history of CHF Physical Exam: ADMISSION EXAM Vitals: 97.6, 75, 119/77, 18, 99% RA General: Elderly female in no distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP at 10 cm at 30 degrees, no LAD CV: RRR, nl S1/S2, ___ systolic murmur heard best at RUSB Lungs: Crackles to apices bilaterally R > L Abdomen: Soft, NTND, normoactive bowel sounds GU: No Foley Ext: Chronic venous stasis changes bilaterally L > R Neuro: CN ___ grossly intact, moving all four extremities Skin: Healing ulceration on left shin with erythema. Marked. DISCHARGE EXAM Vitals: 99.1, 80, 103/62, 16, 97% RA General: Elderly female in no distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP at 8 cm at 30 degrees CV: RRR, nl S1/S2, ___ systolic murmur heard best at RUSB Lungs: Crackles to apices bilaterally R > L Abdomen: Soft, NTND, normoactive bowel sounds GU: No Foley Ext: Chronic venous stasis changes bilaterally L > R Neuro: CN ___ grossly intact, moving all four extremities Skin: Interval improvement in LLE cellulitis Pertinent Results: ADMISSION LABS ___ 05:45PM BLOOD ___ ___ Plt ___ ___ 05:45PM BLOOD ___ ___ ___ 05:45PM BLOOD ___ ___ ___ 05:45PM BLOOD ___ ___ ___ 06:09PM BLOOD ___ DISCHARGE LABS ___ 08:00AM BLOOD ___ ___ Plt ___ ___ 08:00AM BLOOD ___ ___ ___ 08:00AM BLOOD ___ ___ ___ 08:00AM BLOOD ___ MICROBIOLOGY: Blood cultures pending IMAGING CXR (___): In comparison with study of ___, there is again substantial enlargement of the cardiac silhouette in a patient with a ___ pacer device with leads in position. No appreciable pulmonary vascular congestion or acute focal pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 20 mg PO DAILY 2. Carvedilol 25 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Warfarin 2 mg PO DAILY16 5. Simvastatin 20 mg PO EVERY OTHER DAY 6. Glargine 10 Units Bedtime 7. Torsemide 20 mg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Carvedilol 25 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. Enalapril Maleate 20 mg PO DAILY 4. Glargine 10 Units Bedtime 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 20 mg PO EVERY OTHER DAY 7. Torsemide 20 mg PO DAILY 8. Warfarin 2 mg PO DAILY16 Please DO NOT take today. Restart tomorrow, ___. 9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days RX ___ [Bactrim DS] 800 ___ mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: LLE Cellulitis Secondary diagnosis: - Hypertension - Hyperlipidemia - Type 2 diabetes - Coronary artery disease - ___ cardiomyopathy - chronic systolic CHF with LVEF 15% Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report HISTORY: CHF. FINDINGS: In comparison with study of ___, there is again substantial enlargement of the cardiac silhouette in a patient with a triple-channel pacer device with leads in position. No appreciable pulmonary vascular congestion or acute focal pneumonia. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: LLE CELLULITIS Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF LEG temperature: 96.3 heartrate: 72.0 resprate: 16.0 o2sat: 99.0 sbp: 109.0 dbp: 63.0 level of pain: 8 level of acuity: 3.0

___ yo F with PMH of HTN, HLD, DM2, and CHF with LVEF of 15% who presents with LLE cellulitis. ACTIVE ISSUES # Cellulitis: Exam was consistent with cellulitis, most likely exacerbated by her venous stasis disease. Patient had no evidence of SIRS on admission or during hospitalization. However, given diabetes and an association with a recently open wound, she was started on vancomycin to cover for MRSA. Blood cultures were sent which were pending on discharge. By HD#2, erythema was receding and patient reported improvement in her pain. Because of this, she was switched to Bactrim which she will continue as an outpatient for 7 days. CHRONIC ISSUES # Congestive heart failure: LVEF of 15%. ___ AICD in place. She did not tolerate spironolactone in the past given worsening renal function. Patient with elevated JVP and crackles on admission. This was initially concerning for an exacerbation of CHF; however, patient was satting well on room air and CXR was unchanged from prior. Elevated JVP most likely due to severe TR and crackles may represent ILD. Patient at dry weight in hospital. Patient was continued on home enalapril, carvedilol, and torsemide. Coumadin was held for a supratherapeutic INR of 3.4. Discussed indication for ___ with PCP. Per review of records, patient is on Coumadin due to CVA thought to be in the setting of depressed LVEF. Patient should continue on Coumadin. She is being followed by ___. # Hyperlipidemia: Continued home statin. # Type 2 diabetes: Poorly controlled with HbA1C ___. Continued home Lantus and also used Humalog sliding scale while in hospital. # Question of CVA: Held Coumadin and discussed with PCP as above. Per discussion, decision was made to continue Coumadin given history of CVA thought by a Neurology consult to be due to depressed LVEF. # Thrombocytopenia: At baseline. TRANSITIONAL ISSUES - Bactrim DS 1 tab BID for 7 days for cellulitis - Continue Coumadin - Patient to ___ with ___. Next INR on ___. - ___ services arranged for LLE monitoring - ___ with PCP scheduled - ___ - Code status: Full (confirmed) - Emergency contacts: * ___ (daughter) ___ * ___ (daughter) ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ F with a history of COPD on home O2, prior PE, HFpEF, HTN, CKD, and DMII who presented with SOB. She uses 1 L O2 at baseline. Over the past two weeks she has noted increased dyspnea on exertion to the point that she is winded crossing the room to go to the bathroom. She has also noted nonproductive cough and some orthopnea. She lived in ___ until recently and would come to ___ to visit her sister and family. She is now planning to stay in ___. She has been to ___ before (last in ___ with a similar CC), and has begun to establish care here. She was going to wait until she could go see her PCP but her symptoms acutely worsened in the past two days so she came to the hospital. In the ED, initial vitals were: 97.6, 66, 225/115, 20, 100% RA -ED Exam notable for: Gen: on O2, not in acute distress Pulm: some mild wheezing Ext: Trace edema in the lower extremities. No asymmetric lower extremity edema -Labs notable for: Cr 2.8, BUN 57, BNP 944. CBC wnl. A1C 5.4%. pH 7.31, pCO2 47, PO2 43. -Imaging was notable for: ___ duplex dopplers with no evidence of acute or chronicdeep venous ~thrombosis in the left lower extremity veins. ~CXR with mild cardiomegaly without pulmonary edema. Mild bibasilar atelectasis. In the ED the patient was given: duonebs, 40mg prednisone. Upon arrival to the floor, patient corroborates the above HPI. She reports feeling short of breath at this time on ___. She denies chest pain. Has had urinary frequency over the past month or so but denies dysuria. Past Medical History: depression gout HFpEF (TTE nl EF% ___ hypothyroidism CKD ___ HTN & DM ? COPD on home O2 Obstructive Sleep Apnea T2DM (A1c 5.4% not on meds ___ Social History: ___ Family History: Notable for extensive heart disease and diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 24 HR Data (last updated ___ @ 1332) Temp: 98.5 (Tm 98.5), BP: 182/117 (___), HR: 71, RR: 22, O2 sat: 98%, O2 delivery: 3L, Wt: 335.76 lb/152.3 kg GENERAL: Obese woman lying in bed in NAD HEENT: Difficult to assess JVD, PERRL, MMM CARDIAC: Distant, RRR, S1S2 normal. soft systolic murmur. RESPIRATORY: Mildly increase RR, but overall comfortable appearing. Diminished breath sounds especially on L but clear w/o wheezing or crackles. ABDOMEN: Obese, soft, NT, +BS. EXTREMITIES: Warm, bilateral pitting edema NEUROLOGIC: Mentating well, no focal neurological deficits. DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 643) Temp: 98.8 (Tm 98.8), BP: 158/87 (137-158/80-103), HR: 64 (63-66), RR: 20 (___), O2 sat: 98% (95-98), O2 delivery: RA, Wt: 323.19 lb/146.6 kg GENERAL: woman sitting upright at bedside in NAD NEUROLOGIC: AAOx3. Mentating well, no focal neurological deficits. HEENT: Difficult to assess JVD, PERRL, MMM CARDIAC: NR, RR, S1S2 normal. soft systolic murmur. RESPIRATORY: Overall comfortable appearing, no increased WOB. Diminished breath sounds at bases, no wheezes or crackles. ABDOMEN: Obese, soft, NT, +BS. EXTREMITIES: ttp L ___ metatarsal, swelling of forefoot (w/o pitting). L forefoot warmer than right. 1+ pitting edema legs bilaterally. Pertinent Results: ADMISSION LABS: ============= ___ 07:40AM WBC-9.8 RBC-3.62* HGB-11.6 HCT-35.3 MCV-98 MCH-32.0 MCHC-32.9 RDW-14.3 RDWSD-51.2* ___ 07:40AM NEUTS-66.5 LYMPHS-17.9* MONOS-9.4 EOS-4.7 BASOS-0.6 IM ___ AbsNeut-6.53* AbsLymp-1.76 AbsMono-0.92* AbsEos-0.46 AbsBaso-0.06 ___ 07:40AM GLUCOSE-106* UREA N-57* CREAT-2.8* SODIUM-142 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15 ___ 07:49AM ___ PO2-43* PCO2-47* PH-7.31* TOTAL CO2-25 BASE XS--2 ___ 07:40AM %HbA1c-5.4 eAG-108 DISCHARGE LABS: ============= ___ 06:28AM BLOOD WBC-8.6 RBC-3.73* Hgb-11.7 Hct-36.4 MCV-98 MCH-31.4 MCHC-32.1 RDW-14.1 RDWSD-50.7* Plt ___ ___ 06:28AM BLOOD Plt ___ ___ 06:28AM BLOOD Glucose-82 UreaN-67* Creat-3.0* Na-139 K-5.9* Cl-103 HCO3-19* AnGap-17 ___ 06:28AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.3 MICROBIO: ======== N/A IMAGING: ======= TTE ___ 13:15 The left atrial volume index is normal. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 76 %. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). There is Grade II diastolic dysfunction. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. FOOT AP,LAT & OBL LEFTStudy Date of ___ 6:44 ___ FINDINGS: Joint spaces appear preserved in with. Scalloped appearance to the dorsal navicular suggests a corticated erosion associated with gout. There is possibly a shallow erosion along the margin of the first tarsometatarsal joint which may reflect the history of gout, in addition to slight degenerative changes better appreciated on the lateral view. There are also very small suspected erosions at the first interphalangeal joint, although not at the first metacarpophalangeal joint. There is no evidence of fracture or dislocation. IMPRESSION: Few erosions which may reflect the history of gout. No definite active process. OTHER SELECTED RESULTS: ===================== ___ 04:53 TSH 0.14* ___ 04:53 T4 6.2 ___ 07:16 PTH 170* ___ 04:53 AM Cortisol 1.5* ___ 07:16 25-OH Vit D 14* ___ ___ Metanephrines (Plasma) Test Result Reference Range/Units METANEPHRINE, FREE <25 <=57 pg/mL Test Result Reference Range/Units NORMETANEPHRINE, FREE 32 <=148 pg/mL Test Result Reference Range/Units TOTAL, FREE (MN+NMN) 32 <=205 pg/mL METANEPHRINES, FRACTIONATED, 24HR URINE Test Result Reference Range/Units 24 HR URINE VOLUME 3500 mL METANEPHRINE 135 90-315 mcg/24 h Test Result Reference Range/Units NORMETANEPHRINE ___ mcg/24 h Test Result Reference Range/Units METANEPHRINES, TOTAL ___ mcg/24 h Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole 2 mg PO DAILY 2. Valsartan 320 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Calcium Carbonate 500 mg PO BID 5. TraZODone 200 mg PO QHS:PRN insomnia 6. Doxazosin 16 mg PO HS 7. Escitalopram Oxalate 40 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Moderate 10. Baclofen 10 mg PO TID 11. Colchicine 0.6 mg PO DAILY:PRN gout flare 12. Diltiazem Extended-Release 420 mg PO DAILY 13. Levothyroxine Sodium 450 mcg PO DAILY 14. CloNIDine 0.2 mg PO TID Discharge Medications: 1. Allopurinol 50 mg PO DAILY RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 2. Chlorthalidone 12.5 mg PO DAILY RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 3. Levothyroxine Sodium 25 mcg PO DAILY RX *levothyroxine 25 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. NIFEdipine (Extended Release) 60 mg PO QPM RX *nifedipine 60 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 5. PredniSONE 10 mg PO ASDIR gout flare Duration: 5 Days Take 3 pills on the first day. Then take 2 pills for two days. Then take 1 pill for 2 days. Tapered dose - DOWN RX *prednisone 10 mg 0 tablet(s) by mouth daily in the morning Disp #*9 Tablet Refills:*0 6. Colchicine 0.3 mg PO DAILY:PRN gout flare RX *colchicine 0.6 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*15 Tablet Refills:*0 7. Doxazosin 8 mg PO HS RX *doxazosin 8 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 8. Levothyroxine Sodium 325 mcg PO DAILY RX *levothyroxine 300 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Moderate 10. ARIPiprazole 2 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Baclofen 10 mg PO TID 13. CloNIDine 0.2 mg PO TID 14. Escitalopram Oxalate 40 mg PO DAILY 15. Ferrous Sulfate 325 mg PO DAILY 16. TraZODone 200 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Uncontrolled Hypertension Diastolic heart failure exacerbation Acute kidney injury SECONDARY DIAGNOSES: hypothyroidism gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with hx HFpEF// Cardiomegaly? Pulm Edema? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ FINDINGS: Cardiac silhouette size remains mildly enlarged. The mediastinal and hilar contours are unremarkable. The pulmonary vasculature is not engorged. There are mild streaky atelectasis in the lung bases without focal consolidation. No pleural effusion or pneumothorax. No acute osseous abnormality. Multilevel degenerative changes within the thoracic spine are present. IMPRESSION: Mild cardiomegaly without pulmonary edema. Mild bibasilar atelectasis. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: History: ___ with left leg swelling, dyspnea,// dyspnea TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of acute or chronicdeep venous thrombosis in the left lower extremity veins. Radiology Report EXAMINATION: US RENAL ARTERY DOPPLER INDICATION: ___ year old woman with treatment resistant hypertension// renal artery stenosis? Please obtain bilateral study TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: A 1.8 cm echogenic focus which deforms the renal contour in the upper pole of the right kidney may represent an angiomyolipoma. Otherwise, there is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 10.7 cm Left kidney: 10.6 cm Renal Doppler: Right intrarenal arteries show normal waveforms with sharp systolic peaks and continuous antegrade diastolic flow, although waveforms within the left kidney are slightly delayed and less sharp. The resistive indices of the right intra renal arteries range from 0.65-0.75. The resistive indices on the left range from 0.63-0.70. Bilaterally, the main renal arteries are patent with normal waveforms. The peak systolic velocity on the right is 103 centimeters/second. The peak systolic velocity on the left is 42.3 centimeters/second. Main renal veins are patent bilaterally with normal waveforms. The bladder is moderately well distended and normal in appearance. IMPRESSION: 1. Discrepancy in peak systolic velocity between the kidneys may suggest renal artery stenosis on the left. CTA with 3D lab reconstructions may be considered for further evaluation. 2. 1.8 cm echogenic focus in the upper pole of the right kidney may represent an angiomyolipoma. Non urgent MR without and with contrast may be obtained for further evaluation. Radiology Report EXAMINATION: Left foot radiographs, three views. INDICATION: Gout, hypertension and obesity. Now with left lateral foot pain. COMPARISON: None available. FINDINGS: Joint spaces appear preserved in with. Scalloped appearance to the dorsal navicular suggests a corticated erosion associated with gout. There is possibly a shallow erosion along the margin of the first tarsometatarsal joint which may reflect the history of gout, in addition to slight degenerative changes better appreciated on the lateral view. There are also very small suspected erosions at the first interphalangeal joint, although not at the first metacarpophalangeal joint. There is no evidence of fracture or dislocation. IMPRESSION: Few erosions which may reflect the history of gout. No definite active process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, Hypertension Diagnosed with Dyspnea, unspecified, Chest pain, unspecified temperature: 97.6 heartrate: 66.0 resprate: 20.0 o2sat: 100.0 sbp: 225.0 dbp: 115.0 level of pain: 3 level of acuity: 2.0

Ms. ___ is a ___ F with a history of COPD on home O2, prior PE, HFpEF, HTN, CKD, and DMII who presented with SOB, DOE, and HTN to the 200s systolic.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ HLD, Arrythmia (Unknown type) presents s/p mechanical fall c/o back pain. Pt was in shower and slipped in tub, causing her to fall backwards onto the lip of the tub, may have heard a "cracking" sound, and felt sharp pain in her whole lumbar area and left buttock without radiation. She denied head strike or LOC. She did not lose bowel/bladder function but has not gone since then. She was concerned about the degree of pain and called EMS for evaluation. In the ED, initial vital signs were: 97.7 77 138/66 14 98% RA Studies performed include plain films, CT T-L spine Patient was given percocet x4 over 24 hours, atenolol 25 mg, pneumovax Plain films followed by CT T+L spine show acute mild compression fracture of L2. No red flag sx or neurologic findings. Evaluated by spine who stated no restrictions, outpatient f/u. Overnight unable to even sit up in bed because of pain, can't work with ___ currently b/c of pain, despite percocet. Vitals on transfer: 98.0 56 135/80 16 95% RA Upon arrival to the floor, the patient is lying flat in bed, NAD, with daughter-in-law at bedside translating. Pt verifies history, ROS, PMH/FHx/Social/Meds/Allergies. Review of Systems: (+) nausea, left chest pain with inspiration (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Arrhythmia HLD GERD osteoporosis Medications: Pt knows names of the four meds she takes but does not recall dosages or schedules Atenolol Aledronate Statin PPI Social History: ___ Family History: No family history of strokes, seizures, congenital/developmental neurological conditions Physical Exam: ADMISSION PHYSICAL EXAM Vitals- 98.6 139/79 87 20 100/RA General: NAD, appears stated age, lying comfortably in bed HEENT: PERRL, EOMI, MMM CV: RRR, normal S1, S2, no m/g/r Lungs: CTAB, pain on palpation of left lower ribs Abdomen: Soft, NT, ND +BS Back: Tenderness over lumbar spine, left buttock Ext: Pulses 2+, no edema Neuro: Strength, sensation intact in bilateral ___. Reflexes 2+ Skin: Warm, well perfused, no bruising DISCHARGE PHYSICAL EXAM Vitals: Tm 98.5 BP 123/80 (110s-150/80s-100) P 63 (60s-70s) RR ___ Sat 97% RA General: NAD, appears stated age, sitting up on side of bed on phone HEENT: PERRL, EOMI, MMM CV: RRR, normal S1, S2, no m/g/r Lungs: CTAB, pain on palpation of left lower ribs- less so than previous Abdomen: Soft, NT, ND +BS Back: No tenderness over lumbar spine Ext: Pulses 2+, no edema Neuro: Strength, sensation intact in bilateral ___. Skin: Warm, well perfused, no bruising Pertinent Results: Imaging: -Rib Films IMPRESSION: No displaced rib fracture identified. -CT L-Spine IMPRESSION: 1. Mild compression fracture of L2 which appears acute with no retropulsion or posterior element involvement. 2. Mild degenerative changes. 3. Demineralization. 4. Bilateral adnexal cysts, 21 mm on the right and at least 34 mm on the left; ___ ultrasound recommended when clinically appropriate to characterize further. -Pelvis ap xray FINDINGS: No fracture or dislocation. Mild degenerative changes of the bilateral femoroacetabular joints. No concerning lytic or sclerotic lesions. Phleboliths project over the pelvis. IMPRESSION: No fracture or dislocation. -LumboSacral Spine xray IMPRESSION: Vertebral body height loss involving L2, with a distinct step-off of the anterior cortex of this vertebral body, which is concerning for compression fracture of uncertain chronicity. - T-spine plain films IMPRESSION: Vertebral body height loss involving L2, with a distinct step-off of the anterior cortex of this vertebral body, which is concerning for compression fracture of uncertain chronicity. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Alendronate Sodium 70 mg PO QFRI 3. Simvastatin 20 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Calcium Carbonate 500 mg PO DAILY 6. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Calcium Carbonate 500 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. Vitamin D 400 UNIT PO DAILY 6. Acetaminophen 650 mg PO Q6H 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills:*0 8. Alendronate Sodium 70 mg PO 1X/WEEK (FR) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Acute L2 Compression Fracture SECONDARY DIAGNOSES Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS (AP ONLY) INDICATION: History: ___ with mechanical fall c/o lumbar and left buttock pain, no abnormaliies on examination // fracture? fracture? TECHNIQUE: Frontal view of the pelvis COMPARISON: Radiographs of the pelvis dated ___. FINDINGS: No fracture or dislocation. Mild degenerative changes of the bilateral femoroacetabular joints. No concerning lytic or sclerotic lesions. Phleboliths project over the pelvis. IMPRESSION: No fracture or dislocation. Radiology Report EXAMINATION: DX THORACIC AND LUMBAR SPINES INDICATION: History: ___ with mechanical fall c/o lumbar and left buttock pain, no abnormaliies on examination // fracture? fracture? TECHNIQUE: Frontal and lateral radiographs of the thoracic and lumbar spine. COMPARISON: New as lumbar spine dated ___. FINDINGS: THORACIC SPINE: There appears to be a wedge shape deformity of a mid thoracic vertebral body, otherwise, Vertebral body and disc heights are maintained throughout the thoracic spine. Moderate degenerative changes are present with anterior osteophytosis. LUMBAR SPINE: There are 5 non rib-bearing lumbar vertebral bodies. There is vertebral body height loss involving L2 with a step-off in the anterior cortex of this vertebral body, which is concerning for compression fracture of uncertain chronicity. Multilevel degenerative changes are seen throughout the lumbar spine, with disc height loss at multiple levels. There is calcification of the abdominal aorta. IMPRESSION: Vertebral body height loss involving L2, with a distinct step-off of the anterior cortex of this vertebral body, which is concerning for compression fracture of uncertain chronicity. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ ___ telephone at 12:53pm on ___, 5 min after discovery. Radiology Report CT OF THE LUMBAR SPINE HISTORY: Status post mechanical fall with L2 compression fracture. COMPARISONS: Radiographs from earlier on the same day; no prior relevant imaging available. TECHNIQUE: Multidetector CT images of the lumbar spine were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. FINDINGS: There is a mild compression fracture that appears acute, including visible but non-displaced fracture lines, involving the mid body and superior endplate of the L2 vertebral body. Although fracture lines may meet the posterior cortical margin, there is no evidence for retropulsion. Throughout all levels of the lumbar spine, there are mild degenerative changes at all facet joints of the lumbar spine and also at T11-T12. Small anterior osteophytes are present at L3-L4 and L4-L5. At L4-L5, the interspace is also very mildly narrowed. The bones appear demineralized. There is a right adnexal cyst measuring up to 22 x 21 mm in axial ___ of uniform low density. Inferior axial images show a partly visualized left adnexal cyst measuring at least 35 x 26 mm in axial ___ (3:101). Again, the visualized parts are of uniform low density. In addition to patchy vascular calcifications, the common iliac arteries are mildly tortuous. Parapelvic cysts are noted along each kidney. Patchy vascular calcifications are present. There is mild sigmoid diverticulosis. IMPRESSION: 1. Mild compression fracture of L2 which appears acute with no retropulsion or posterior element involvement. 2. Mild degenerative changes. 3. Demineralization. 4. Bilateral adnexal cysts, 21 mm on the right and at least 34 mm on the left; follow-up ultrasound recommended when clinically appropriate to characterize further. Radiology Report INDICATION: Left rib pain, status post fall. TECHNIQUE: AP chest and left ribs, 5 images total. COMPARISON: Chest radiograph from ___. FINDINGS: A skin marker is noted along the lower lateral aspect of the left chest wall. No displaced rib fractures identified. The lungs are clear. The heart is normal in size. Aortic calcifications are noted. IMPRESSION: No displaced rib fracture identified. Gender: F Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL temperature: 97.7 heartrate: 77.0 resprate: 14.0 o2sat: 98.0 sbp: 138.0 dbp: 66.0 level of pain: 13 level of acuity: 3.0

___ speaking only ___ who was brought to ___ via EMS after experiencing a mechanical fall at home while taking a shower. No focal deficits on exam including no evidence of saddle anesthesia and no point tenderness. Neurologically intact. T-L spine Xray was concerning for L2 compression fracture. L-T CT showed acute mild compression fracture of L2 with no retropulsion or posterior element involvement. Evaluated by neurosurgery who recommended outpatient management. Overnight unable to even sit up in bed because of pain, difficulty working with ___ b/c of pain. Reviewed with case management, admitted for continued eval of pain, ___ when able, probable rehab placement. Pt's pain well controlled with improvement of symptoms but continued difficulty with movement. ___ recommended rehab. Patient with stable vitals, deemed safe for discharge to rehab with scheduled outpatient neurosurgical ___. # L2 fracture: No focal deficits. Cleared by neurosurgery. Pain control and ___ with possible rehab placement today. Screening for ___ at this point. ___ has seen and recommended rehab stay. RTC Tylenol for pain control with oxycodone 5 mg PO Q6h prn breakthrough pain. Continue ___ at rehab center. Pt has 2 week f/u with Neurosurgery spine service as outpatient. Given fracture, agree with continue patient on alendronate as well as calcium and vitamin D. # Rib pain: Inspiratory pain and tenderness on palpation of left lower rib cage. No visible bruise. Rib films without any evidence of fracture. Continue using inspiration spirometer. CHRONIC ISSUES # Osteoporosis: Now with fracture as above. Continue alendronate, calcium, vitamin D # Unspecified arrythmia: continued atenolol # GERD: Continue omeprazole Transitional Issues: # L2 Compression Fx: outpatient f/u with repeat XR L spine in 2 weeks # Cysts: On CT, pt found to have b/l adnexal cysts, 21 mm on the right and at least 34 mm on the left seen on CT, will need to be followed up by PCP with ___ ultrasound recommended when clinically appropriate.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: oxycodone Attending: ___. Chief Complaint: fevers,wound infection Major Surgical or Invasive Procedure: s/p left radical orchiectomy, liposarcoma resection, and inguinal hernia repair (___) History of Present Illness: Mr. ___ is a ___ year-old retired psychiatrist who is s/p resection of left groin liposarcoma w/ radical orchiectomy and inguinal hernia repair w/ mesh who presents with fevers and rigors. The patient has been recovering well without symptoms and was recently evaluated in clinic. His scrotal drain remains in place. The night prior to presentation the patient developed rigors and subjective fevers. He reports became very weak and could barely get out of bed and therefore his wife called an ambulance and he was taken to the ___ ED. The surgical team was present in the ED upon the patient's arrival. He continues to feel febrile with rigors. He also reports pain and warmth at his surgical site. He denies other symptoms such as cough, chest pain/trouble breathing, abdominal symptoms, and dysuria, though he had some urinary frequency overnight. ROS: positive as per HPI, otherwise complete review of systems is negative Past Medical History: Atrial Fibrillation on Coumadin dysthymia BPH obstructive sleep apnea, uses CPAP machine spinal stenosis polyneuropathy h/o urinary retention with oxycodone depression obesity pulmonary nodule seasonal allergies left groin lipsarcoma s/p Lap cholecystectomy s/p R Inguinal Hernia repair, umbilical hernia repair s/p Left knee arthroscopy with partial knee meniscectomy s/p bilateral cataract surgery s/p BCC excision from left side of nose Social History: ___ Family History: colon cancer (mother, father, both in ___, ___ syndrome (sister), DM2 (father) Physical Exam: General: overall uncomfortably appearing, feels warm HEENT: NC/AT, EOMI, no scleral icterus CV: irregularly irregular Pulm:clear Abd: soft, non-tender/non-distended Wound: Ext: well-perfused, no edema Neuro: AAOx3, no focal deficits Pertinent Results: ___ 02:18PM BLOOD Lactate-1.7 ___ 02:05PM BLOOD Glucose-131* UreaN-23* Creat-1.1 Na-138 K-4.2 Cl-102 HCO3-23 AnGap-17 ___ 02:05PM BLOOD Calcium-9.2 Phos-2.3* Mg-2.1 ___ 02:05PM BLOOD WBC-12.9* RBC-3.66* Hgb-12.1* Hct-34.2* MCV-93 MCH-33.1* MCHC-35.4 RDW-13.5 RDWSD-45.9 Plt ___ ___ 02:05PM BLOOD ___ PTT-37.1* ___ ___ 05:20AM BLOOD WBC-6.4 RBC-3.28* Hgb-10.4* Hct-30.4* MCV-93 MCH-31.7 MCHC-34.2 RDW-13.5 RDWSD-46.4* Plt ___ ___ 07:40AM BLOOD ___ PTT-42.3* ___ ___ 07:20AM BLOOD ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO TID 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. Diltiazem Extended-Release 120 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Finasteride 5 mg PO DAILY 6. Gabapentin 300 mg PO QHS 7. Tamsulosin 0.4 mg PO BID 8. Warfarin 6 mg PO 4X/WEEK (___) afib 9. Warfarin 8 mg PO 3X/WEEK (___) afib 10. Senna 17.2 mg PO HS 11. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Hydrocortisone Cream 1% 1 Appl TP QID Right hand 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 5. Senna 17.2 mg PO HS 6. Sulfameth/Trimethoprim DS 2 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 7. BuPROPion XL (Once Daily) 300 mg PO DAILY 8. Diltiazem Extended-Release 120 mg PO DAILY 9. Finasteride 5 mg PO DAILY 10. Gabapentin 300 mg PO QHS 11. Tamsulosin 0.4 mg PO BID 12. Warfarin 6 mg PO 4X/WEEK (___) afib 13. Warfarin 8 mg PO 3X/WEEK (___) afib Discharge Disposition: Home Discharge Diagnosis: left inguinal wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with h/o sarcoma resection w/ orchiectomy, please perform scan through mid-thighNO_PO contrast// ? abscess or other acute intraabdo process, please perform scan through mid thigh, pt with drain present with ongoing signs of infx TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Delayed imaging through the lower pelvis and superior portion of lower extremities was performed. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,549 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits besides dependent atelectasis. There is no evidence of pleural or pericardial effusion. There is mild cardiomegaly. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. Calcifications seen posterior to the right lobe of the liver, potentially a pseudo lipoma. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas is diffusely fatty replaced without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. Bilateral renal hypodensities are too small to characterized but likely cysts GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Postoperative changes are centered at the left groin. Postoperative changes of left orchiectomy are also noted. Superficial drain is in place within a oblong fluid collection at most 3.7 x 2.4 cm across and tracks along the course of the drain. LYMPH NODES: Postoperative changes seen in close association with the external iliac vasculature (2:68). There is mixed stranding and soft tissue density overlying the vessels measuring up to 3.0 x 1.9 cm. This may be postoperative however followup will be necessary given excision of underlying liposarcoma. There several adjacent enhancing but not enlarged lymph nodes. A right external iliac lymph node prominent size measuring up to 1.0 cm in short axis (2:73). Prominent right-sided inguinal nodes are also seen, enlarged since prior. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. Excess Re right renal artery is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. L4 and L5 laminectomy changes are noted. SOFT TISSUES: Patient is status post interval abdominal wall herniorrhaphy with mesh in place. Postoperative changes in the left grain groin are as detailed above. Subcutaneous stranding seen extending superiorly the to lateral chest wall. No other peripherally enhancing discrete fluid collection identified to suggest abscess. IMPRESSION: 1. Postoperative changes of left sarcoma resection. Peripherally enhancing fluid collection surrounding the JP drain. This could be postoperative in nature, clinical correlation regarding infection will be necessary. Superficial subcutaneous stranding along the right lateral abdominal wall extending superiorly. 2. Mixed soft tissue and stranding in the postoperative bed overlying the external iliac vasculature. This could be postoperative however residual mass cannot be excluded and continued followup will be necessary for both this and adjacent hyperenhancing lymph nodes. 3. Prominent right external iliac and inguinal lymph nodes, enlarged since ___, nonspecific. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Wound eval Diagnosed with Fever, unspecified temperature: 103.3 heartrate: 120.0 resprate: 22.0 o2sat: 97.0 sbp: 171.0 dbp: 54.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ year-old retired psychiatrist who is s/p resection of left groin liposarcoma with radical orchiectomy and inguinal hernia repair w/mesh who presents with fevers and rigors to the ED. In ED, patient was tachycardic and febrile to 103 with significant erythema over the surgical site and murky output in his JP drain. Labs were significant for a normal lactate and WBC of 12.9. CT scan was obtained which demonstrated a small amount of fluid in the scrotum with drain and good position and some stranding of the subcutaneous tissue. He was admitted to the surgical service for IV antibiotics(vancomycin and zoysn).JP drain was discontinued and sent for culture which grew out MRSA on GPC speciated, GNRs not speciated. Wound erythema continued to improve on IV antibiotics. Neuro: His pain was well controlled with acetaminophen and tramadol as needed. CV: He continued on Coumadin for his atrial fibrillation.He was monitored appropriately on telemetry during his hospitalization. Pulm: The patient had no pulmonary issues. GI: The patient was advanced to and was tolerating a regular diet,passing flatus, and had normal bowel movements. GU: The patient voided and had good urine output. He was maintained on his home medications of finasteride and tamsulosin BID. ID: patient was febrile on admit, fever curves were monitored closley. He continued on IV ABX vancomycin and zosyn. Drain culture grew out MRSA,GPC speciated, GNRs not speciated.He was switched to oral antibiotics Bactrim DS BID on ___. His wound was monitored closely and erythema gradually improved. Heme: The patient Hct was stable. He was monitored for signs of bleeding or hypovolemia. At time of discharge, patient was afebrile, denied pain and was tolerating a regular diet and voiding.