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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: nitrofurantoin / Sulfa (Sulfonamide Antibiotics) / Cipro Attending: ___. Chief Complaint: Generalized tonic-clonic seizure Altered Mental Staatus Major Surgical or Invasive Procedure: Intubation (___) R IJ CVL NGT (discontinued ___ History of Present Illness: MS. ___ is a ___ woman with past medical history of hypertension, hyperlipidemia, pulmonary fibrosis, and recently diagnosed stage I lung cancer status post CyberKnife transfer to the ED intubated and sedated after a generalized tonic-clonic seizure lasting for minutes. Per report, patient was last seen well at around 4 ___ on date of admission. At 6 ___ she was home alone and her neighbor heard her yell, he arrived to find her on the floor, confused (said her age was ___ and told him an incorrect date). He immediately called ___. On EMS arrival she was able to speak but somewhat confused. At the time there were concerns of right upper extremity weakness. There was no evidence of facial droop. As they prepared to transport her she developed right gaze deviation followed by generalized tonic-clonic seizure lasting 4 minutes and resolving spontaneously. She was not given benzodiazepines. She was then taken to an OSH ED where noncontrast ___ CT and CT C-spine were unremarkable. She was given Keppra 1 g IV and lorazepam 1 mg IV. As her alteration in mental status persisted team became concerned that was unable to protect her airway so they proceeded with endotracheal intubation. Prior to intubation blood pressure was 220/102 so she was started on nicardipine drip which was shortly discontinued when she became hypotensive after intubation. She briefly required Neo-Synephrine prior to transport. On further discussion with the patient's family at the bedside they report at baseline she is able to walk with a cane, perform all activities of daily living, manage her finances, and drive. However, during the last ___ weeks she had experienced a persistent bout of diarrhea. She finally visited her PCP and was diagnosed with an intestinal parasite (family is unsure as to which). She was treated with an antiparasitic medication that she had difficulty tolerating per the family. During this time he had become dizzy, and orthostatic so her HCTZ had been held. They feel that in the last ___ weeks she had been somewhat deconditioned and difficulties with cognition have become more apparent. Past Medical History: Gout Left upper lobe adenocarcinoma Collagenous colitis Vitamin D deficiency Gouty arthropathy GERD Pulmonary fibrosis Hypertension Hyperlipidemia Osteoarthritis Cervical spine degenerative disc disease Social History: ___ Family History: Mother: Died of a stroke at age ___ Sister: Pulmonary fibrosis There is no family history of seizures Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 94.1, 57, 137/63, 20,100% Intubation General: Intubated HEENT: ET tube in place, hard cervical collar in place ___: RRR Pulmonary: Left lower lobe crackles Abdomen: Soft Extremities: Warm under Bair hugger Neurologic Examination: (Off propofol and fentanyl) Mental status: Opens eyes spontaneously, does not follow commands consistently. Cranial Nerves: Pupils equally round and sluggishly reactive to light at 1.5 mm. Blink to threat in all visual fields present. Corneals present bilaterally. Spontaneous cough and gag present. No facial asymmetry around ET tube. Motor: Vigorously moving bilateral upper and lower extremities with good strength. Unable to cooperate with confrontational exam. Sensory: Withdraws appropriately to noxious stimulation in all extremities DTRs: 2+ at the knees. Plantar downgoing on the right and brisk withdrawal on the left (patient become increasingly agitated at this point) DISCHARGE PHYSICAL EXAM VS: 97.4 123/73 88 18 99%RA GENERAL: Pleasant, cooperative, NAD. HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: Nontender supple neck, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: RLL>LLL crackles. Breathing comfortably without use of accessory muscles. No wheezes or rhonchi. ABDOMEN: nondistended, +BS, non-tender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes NEURO: Oriented to month, year, and location. CN II-XII intact. No focal neurological deficits. Pertinent Results: LABS ON ADMISSION: ___ 11:50PM BLOOD WBC-9.3 RBC-4.09 Hgb-11.5 Hct-37.6 MCV-92 MCH-28.1 MCHC-30.6* RDW-14.5 RDWSD-49.0* Plt ___ ___ 11:50PM BLOOD ___ PTT-28.8 ___ ___ 11:50PM BLOOD Plt ___ ___ 11:50PM BLOOD ___ 11:50PM BLOOD UreaN-13 Creat-0.7 ___ 11:50PM BLOOD Lipase-10 ___ 11:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:56PM BLOOD Rates-/___ Tidal V-400 O2 Flow-3 pO2-131* pCO2-28* pH-7.46* calTCO2-21 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED Comment-GREEN TOP ___ 04:13AM BLOOD Type-ART pO2-142* pCO2-36 pH-7.44 calTCO2-25 Base XS-1 ___ 11:56PM BLOOD Glucose-108* Lactate-1.9 Na-140 K-3.8 Cl-110* ___ 11:56PM BLOOD Hgb-12.9 calcHCT-39 O2 Sat-95 COHgb-4 MetHgb-0 ___ 11:56PM BLOOD freeCa-0.89* LABS ON DISCHARGE: ___ 07:35AM BLOOD WBC-7.9 RBC-4.08 Hgb-11.3 Hct-36.0 MCV-88 MCH-27.7 MCHC-31.4* RDW-14.2 RDWSD-45.7 Plt ___ ___ 07:35AM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-140 K-3.9 Cl-100 HCO3-25 AnGap-15 MICROBIOLOGY - Stool C. Diff (___) - negative - Urine legionella antigen (___) - negative - Blood culture (___) - negative - Urine culture (___) - negative - Blood culture (___) - negative IMAGING: CXR (___): Heart size and mediastinum are stable. Left perihilar opacity in left basal opacity is similar to previous examination consistent with provided history of pulmonary fibrosis. On the other hand the left perihilar opacity is more conspicuous in although might represent infectious process, it also might reflect the previous pulmonary nodule seen on chest CT from ___ and does assessment with chest CT is required. RECOMMENDATION(S): Chest CT for precise characterization of the left perihilar opacity. CXR (___): chest AP view when compared to prior done on ___ shows stable position of the NG tube. The right IJ line has been removed in the interim. Lungs continue to be low volume with a stable parenchymal opacity in the left lower lobe and left perihilar region and right lower lobe which could represent multifocal pneumonia. Lungs are low volume with stable interstitial prominence. Small left effusion is unchanged. No pneumothorax is seen EEG (___): This is an abnormal video EEG monitoring session due to the presence of diffuse background slowing, indicative of a moderate encephalopathy, nonspecific as to etiology. This finding is commonly caused by toxic metabolic, infections or medications effects. There are rare triphasic appearing sharp waves indicative of diffuse cortical irritability. This study captures no pushbutton activation, or electrographic seizures. Compared to yesterday's study, there is no significant change. Abdominal XR (___): Nonobstructive bowel gas pattern. No radiographic findings correlating to the reported history of new abdominal pain. L Upper Extremity US ___: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Diffuse subcutaneous edema. MR ___ W and ___ CONTRAST ___: 1. Moderately degraded exam due to motion artifact. 2. Small focus of subacute ischemia identified in the splenium of the corpus callosum detected in the DWI and FLAIR images (image 14, series 14, and series 18). There is no evidence of acute intracranial hemorrhage, or mass effect. No abnormal enhancement to suggest intracranial metastasis. 3. Old infarct within the left parietal lobe. CXR (___): Right IJ in place in the right atrium without pneumothorax. Ill-defined densities in the left lung, with some component representing scarring, though not well evaluated CTA ___ and Neck (___): 1. No acute intracranial process. 2. Mild to moderate atherosclerotic calcifications at the aortic arch, bilateral carotid bifurcations and bilateral cavernous carotid arteries, with 50% stenosis of the right ICA and 33% stenosis of the left ICA by NASCET criteria. 3. Partially visualized bilateral pleural effusions, left greater than right. 4. Partially visualized left upper lobe opacification, which may represent pneumonia in the appropriate clinical setting. CXR ___ endotracheal tube terminates 4.6 cm above the carina. Left mid to lower lung opacity obscures the left heart border. Findings concerning for aspiration versus an infectious process. Small left pleural effusion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 50 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Calcium Carbonate 500 mg PO BID 4. Simvastatin 20 mg PO QPM 5. Hydrochlorothiazide 25 mg PO DAILY 6. Ascorbic Acid ___ mg PO DAILY 7. Ranitidine 150 mg PO BID 8. Magnesium Oxide 400 mg PO DAILY 9. Hyoscyamine 0.125 mg SL QID:PRN pain 10. Lisinopril 40 mg PO DAILY 11. Aspirin 162 mg PO DAILY 12. Fluticasone Propionate NASAL 2 SPRY NU DAILY 13. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough Discharge Medications: 1. LevETIRAcetam Oral Solution 1000 mg PO Q12H 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 162 mg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Hyoscyamine 0.125 mg SL QID:PRN pain 9. Lisinopril 40 mg PO DAILY 10. Magnesium Oxide 400 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Ranitidine 150 mg PO BID 13. Simvastatin 20 mg PO QPM Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: PRIMARY DIAGNOSIS - GTC - Posterior Reversible Encephalopathy Syndrome (PRES) SECONDARY DIAGNOSIS - Aspiration Pneumonia - Hypertension - Diarrea - Pulmonary Fibrosis - Hyperlipidemia - L upper lobe adenocarcinoma s/p cyberknife - GERD - Gout - Swallowing Difficulty - Positive O&P Blastocystis homonis at PCP ___ 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: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ with altered mental status// ? ICH ? stroke 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 70 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 9.5 s, 0.5 cm; CTDIvol = 103.5 mGy (Head) DLP = 51.7 mGy-cm. 3) Spiral Acquisition 0.6 s, 4.9 cm; CTDIvol = 23.9 mGy (Head) DLP = 117.6 mGy-cm. 4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7 mGy-cm. 5) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP = 32.7 mGy-cm. 6) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.0 mGy (Head) DLP = 1,229.8 mGy-cm. Total DLP (Head) = 2,338 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are prominent, suggestive of volume loss. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are essentially clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Mild to moderate atherosclerotic calcifications are seen of the aortic arch, bilateral carotid bifurcations, and bilateral cavernous carotid arteries. 50% stenosis of the right ICA 33% stenosis of the left ICA by NASCET criteria. The vertebral arteries and their major branches appear otherwise normal with no evidence of stenosis or occlusion. OTHER: The visualized portion of the lungs are notable for bilateral pleural effusions, left greater than right, and partially visualized opacification at the left upper lobe, which may represent pneumonia in the appropriate clinical setting. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. No acute intracranial process. 2. Mild to moderate atherosclerotic calcifications at the aortic arch, bilateral carotid bifurcations and bilateral cavernous carotid arteries, with 50% stenosis of the right ICA and 33% stenosis of the left ICA by NASCET criteria. 3. Partially visualized bilateral pleural effusions, left greater than right. 4. Partially visualized left upper lobe opacification, which may represent pneumonia in the appropriate clinical setting. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with hx of HTN, pulmonary fibrosis and lung carcinoma presenting with new onset GTC. Please assess for metastatic disease vs stroke.// ___ year old woman with hx of HTN, pulmonary fibrosis and lung carcinoma presenting with new onset GTC. Please assess for metastatic disease vs stroke. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 8 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: None. FINDINGS: The exam is moderately degraded due to motion artifact. Focus of subacute ischemia is identified in the splenium of the corpus callosum (image 14, series 14 and 18), measuring approximately 2 x 3 mm in transverse dimension, there is no evidence of acute intracranial hemorrhage, or mass effect. No abnormal enhancement is identified. There is moderate global parenchymal volume loss. There is an area of encephalomalacia within the left superior and inferior parietal lobules, consistent with an old infarct. Small areas of hyperintense signal on T2/FLAIR within the subcortical periventricular white matter are nonspecific, but likely reflect the sequela of mild chronic small vessel disease. The major vascular flow voids are preserved. Fluid within the right sphenoid sinus and bilateral mastoid air cells may be related to endotracheal intubation. IMPRESSION: 1. Moderately degraded exam due to motion artifact. 2. Small focus of subacute ischemia identified in the splenium of the corpus callosum detected in the DWI and FLAIR images (image 14, series 14, and series 18). There is no evidence of acute intracranial hemorrhage, or mass effect. No abnormal enhancement to suggest intracranial metastasis. 3. Old infarct within the left parietal lobe. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with stroke// R IJ placement TECHNIQUE: Portable frontal view of the chest. COMPARISON: Chest radiograph ___. Whole-body PET-CT ___. FINDINGS: Lung volumes are low. Endotracheal tube is satisfactory. Right IJ catheter terminates in the right atrium. Upper enteric tube terminates in the stomach with tip outside of field-of-view. There is an area of left upper lobe consolidation, corresponding to that seen on previous PET-CT, though may have somewhat increased in prominence, with some component of this area likely reflecting post radiation change. There is probable right lung base bronchiectasis. There is no large effusion pneumothorax. IMPRESSION: Right IJ in place in the right atrium without pneumothorax. Ill-defined densities in the left lung, with some component representing scarring, though not well evaluated. All Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old woman with seizures, intubated. swelling of L AC and red// LUE U/S r/o DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. Diffuse subcutaneous edema is noted. IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Diffuse subcutaneous edema. Radiology Report INDICATION: ___ year old woman with PRES, presented with GTC// eval NG tube placement COMPARISON: Radiographs from ___ IMPRESSION: Support lines and tubes are unchanged in position. Heart size is upper limits of normal but stable. There is again seen a small left-sided pleural effusion. Bilateral opacities more confluent on the left side remain unchanged. There is minimal improvement of the pulmonary edema. There are no pneumothoraces. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with seizure likely s/t PRES, new NGT// NGT placement IMPRESSION: In comparison with the study of ___, the new nasogastric tube extends well into the stomach with the side port distal to the esophagogastric junction. The endotracheal tube is not seen. Right IJ catheter again extends to the upper right atrium. There is increasing bilateral pulmonary opacifications. Given the clinical history, this is worrisome for multifocal pneumonia with associated left effusion. Radiology Report INDICATION: ___ year old woman with a history of lung cancer presents with new onset abdominal pain// source of pain TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: PET-CT ___. Portable chest radiograph ___ FINDINGS: An enteric tube is seen projecting over the upper abdomen likely in the stomach. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Left total hip arthroplasty noted. Degenerative changes of the lumbar spine noted. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Nonobstructive bowel gas pattern. No radiographic findings correlating to the reported history of new abdominal pain. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with tachypnea, crackles on PE// Evaluate for fluid overload Evaluate for fluid overload IMPRESSION: Comparison to ___. The course of the feeding tube is unremarkable, stable position of the right internal jugular vein catheter. Minimal decrease in extent and severity of the bilateral parenchymal opacities, mild to moderate pulmonary edema continues to be present. No pneumothorax. Radiology Report EXAMINATION: Chest AP view INDICATION: ___ year old woman with new fever// interval change TECHNIQUE: Chest chest AP view COMPARISON: ___ IMPRESSION: chest AP view when compared to prior done on ___ shows stable position of the NG tube. The right IJ line has been removed in the interim. Lungs continue to be low volume with a stable parenchymal opacity in the left lower lobe and left perihilar region and right lower lobe which could represent multifocal pneumonia. Lungs are low volume with stable interstitial prominence. Small left effusion is unchanged. No pneumothorax is seen Radiology Report INDICATION: ___ year old woman with new NG tube replaced// NG tube placement eval Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the nasogastric tube projects over the stomach. Bilateral parenchymal opacities are again seen within the left mid and left lower lungs as well as the right perihilar region however the appear decreased since prior and may reflect decreasing multifocal pneumonia. Unchanged interstitial prominence and a small left pleural effusion. There is no pneumothorax. IMPRESSION: The tip of a nasogastric tube projects over the stomach. Interval decrease in extent of the parenchymal opacities presumed to reflect multifocal pneumonia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with history of pulmonary fibrosis, HTN, admitted after new onset seizures and AMS, found to have PRES, hospital course c/b aspiration PNA s/p 5 day course of unasyn, discontinued on ___, still with cough and productive white sputum and right lower lobe crackles greater than left lower lobe.// ?PNA ?PNA IMPRESSION: Heart size and mediastinum are stable. Left perihilar opacity in left basal opacity is similar to previous examination consistent with provided history of pulmonary fibrosis. On the other hand the left perihilar opacity is more conspicuous in although might represent infectious process, it also might reflect the previous pulmonary nodule seen on chest CT from ___ and does assessment with chest CT is required. RECOMMENDATION(S): Chest CT for precise characterization of the left perihilar opacity. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: Seizure, Transfer Diagnosed with Altered mental status, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: c level of acuity: 2.0

Ms. ___ is an ___ woman with a history of poorly differentiated adenocarcinoma of the lung diagnosed in ___, currently in remission s/p gamma knife therapy, as well as a history of htn, osteoarthritis who was brought to OSH after 2 GTCs requiring ICU admission for management of GTC with intubation for airway protection with hospital course including MRI Brain showing likely PRES syndrome. ============== ACUTE ISSUES ============== # GTC # Posterior Reversible Encephalopathy Syndrome - Initially found confused after witnessed 4 min GTC seizure and presented with 2 GTCs requiring ICU stay with intubation for airway protection. MRI Brain at OSH concerning for PRES. Etiology of seizure likely secondary to PRES, which was possibly in setting of HTN with SBP in 200s at OSH (she recently discontinued anti-hypertensives a few weeks prior because of dizziness). She was initially intubated for airway protection and admitted to the Neuro ICU. She was started on keppra and placed on cvEEG. Patient had no additional seizure activity and was successfully extubated on ___ and transferred to the floor. Patient was continued on Keppra 1G PO BID and will require indefinitely until she follows-up with neuro in ___ months. #HTN - Patient was initially hypertensive. Her home metoprolol 50mg BID was initially increased to 37.5 TID and home lisinopril 40mg was continued. After additional titration re-starting HCTZ, amlodipine, and adding lasix, patient became hypotensive to as low as SBPs 60-70s. Metoprolol was decreased to 25mg BID and other anti-hypertensives were stopped. Anti-hypertensives were additionally titrated to lisinopril 40mg QDaily and hydrochlorothiazide 25mg QDaily. #Aspiration Pneumonia - Found to have multifocal PNA, initially started on vancomycin and zosyn (___), however was de-escalated to unasyn (___). Speech and Swallow evaluated the patient. Was high aspiration risk, however eventually started on thin liquids and pureed solids and tolerated well. NGT was removed at time of discharge. CXR at discharge demonstrating left lower lobe opacity, could reflect pulmonary nodule identified on previous CT versus infectious process, however patient has remained afebrile without leukocytosis making infectious process at this time less likely. Recommending CT Chest to further characterize left lung opacity as outpatient. #Diarrhea - After starting vancomycin and zosyn patient started to have worsening diarrhea, possibly in setting of recent antibiosis. C. diff was negative. Given persistent diarrhea, tube feeds were stopped and stool cultures and O&P were sent given resent blastocystis hominis treatment. #Gout - was noted to have erythematous swollen right pinky finger on ___ and was given 1.2mg colchicine followed by 0.6mg daily. #Agitation - Became agitated after extubation requiring haldol PRN and standing seroquel. Improved over hospital course and end of hospital course was on seroquel 25mg QAM and 50mg QHS. ============== CHRONIC ISSUES ============== #Pulmonary Fibrosis - Continued home albuterol and fluticasone #HLD - Continued home simvastatin 20mg PO QD #LUL adenocarcinoma s/p cyberknife: Has f/up CT chest scheduled for ___ #GERD - continued ranitidine 150mg PO BID #Positive O&P for blastocystis hominis: S/p Rx with flagyl 500mg TID x 10d (___) per PCP ___ =================== TRANSITIONAL ISSUES =================== DISCHARGE/TRANSITIONAL ISSUES [ ] Continue levetiracetam 1000mg q12h on discharge [ ] CXR on ___ showing left pulmonary opacity, might reflect the previous pulmonary nodule seen on chest CT from ___ versus infectious process. Radiology recommending Chest CT for precise characterization of the left perihilar opacity. [ ] Plan for outpatient repeat MRI prior to follow up appointment with neurology. Please instruct patient to call ___ to schedule this for mid to late ___ or early ___. >30 minutes spent coordinating discharge

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: constipation Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is an ___ female with COPD, diastolic CHF, atrial fibrillation on warfarin recently admitted with respiratory failure who presented to the ___ ED on ___ with constipation and obstipation. Patient presented from ___ after not having a bowel movement or passing gas for 5 days (last BM ___. She had a KUB done today which showed mild colonic dilatation consistent with mild colonic ileus, moderate amount of rectal stool. She was recently admitted for acute hypoxic respiratory failure, secondary to COPD, CHF, and pneumonia ___ to ___. Treated in the ICU and intubated. During this admission she was given IV diuretics, treated with prednisone for COPD, and treated with vancomycin, azithromycin and bactrim for MRSA and stenotrophonas PNA. Discharged on 2 L nasal cannula. She also developed ogilvies/ileus and was found to have severe dilation on abdominal CT on ___. She was treated with enemas and anticholinergic meds were reduced. On ___, GI performed a colonoxcopy with decompression and placement of colonic tube which was in place for about 24 hours with improvement of sx. Antipsychotics were downtitrated and diltiazem was transitioned to metoprolol given concern for medication induced ileus. In the ED, initial vitals were: - Exam notable for: crackles and wheezes in lungs, soft non-distended abdomen with hypoactive bowel sounds, 2+ lower extremity edema -->Rectal: no impacted stool, guiaic neg - Labs notable for: Hb 6.9, Cr 1.2, INR 2.4, u/a with large leukocytes, negative nitrites, 21 WBC and few bacteria - Imaging was notable for: CT A/P showing prelim no acute intra-abdominal process. - Patient was given: 40mg pantoprazole IV x 1, 1 unit pRBCs - Vitals prior to transfer: 98.6 74 113/46 16 96% Nasal Cannula Upon arrival to the floor, patient reports that she is because of "bowel problems." Pt notes that her last BM was many days ago. She recalls that her BM pattern has not been normal since she was discharged to rehab from the hospital. She denies abdominal pain. She denies n/v. She has had no dysuria, urgency or urinary incontinence. She does endorse frequent burning reflux-like abdominal pain. Otherwise she is feeling well. Denies worsening ___ edema. Denies CP and SOB with activity. No orthopnea or PND. REVIEW OF SYSTEMS: (+) Per HPI (-) No fevers, chills, cough, congestion, rhinorrhea. No n/t of the extremities. Energy level is good. No change in hair/skin/nails. No dysphagia. Denies blood in her stools o rblack stools. Appetite has been very good. No myalgias. Past Medical History: -Diastolic heart failure -COPD -Pulmonary hypertension -CKD (chronic kidney disease), stage III -PAF (paroxysmal atrial fibrillation) -HLD -HTN -Breast cancer s/p chemoradiation in ___ Social History: ___ Family History: Per husband: History of cardiac disease in her father and brother. Otherwise no known family history. Physical Exam: ADMISSION PHYSICAL EXAM Vital Signs: 97.5 101 / 52 59 18 92 2L General: Elderly F, no acute distress, lying in hospital bed, alert and oriented to person, place, time (year and month, not date) HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. CV: Irregularly irregular, s1 and s2 heard, ___ murmur heard at RUSB, no extra heart sounds Lungs: Expiratory wheezing heard throughout, faint crackles at bases b/l Abdomen: Distended, soft, non-tender, bowel sounds present, non tender to palpation in all four quadrants, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pitting edema of the ___ DISCHARGE PHYSICAL EXAM Vital Signs: 97.5 101 / 52 59 18 92 2L General: Elderly F, no acute distress, lying in hospital bed, alert and oriented to person, place, time (year and month, not date) HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. CV: Irregularly irregular, s1 and s2 heard, ___ murmur heard at RUSB, no extra heart sounds Lungs: Expiratory wheezing heard throughout, faint crackles at bases b/l Abdomen: Distended, soft, non-tender, bowel sounds present, non tender to palpation in all four quadrants, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pitting edema of the ___ Pertinent Results: LABS ==== ___ 03:55PM BLOOD WBC-6.6 RBC-2.82* Hgb-6.9* Hct-22.6* MCV-80* MCH-24.5* MCHC-30.5* RDW-28.6* RDWSD-80.0* Plt ___ ___ 03:55PM BLOOD Neuts-71.1* Lymphs-15.7* Monos-9.8 Eos-2.6 Baso-0.3 Im ___ AbsNeut-4.72# AbsLymp-1.04* AbsMono-0.65 AbsEos-0.17 AbsBaso-0.02 ___ 05:05AM BLOOD WBC-5.3 RBC-3.12* Hgb-7.6* Hct-25.3* MCV-81* MCH-24.4* MCHC-30.0* RDW-27.1* RDWSD-78.0* Plt ___ ___ 03:55PM BLOOD Plt ___ ___ 05:25PM BLOOD ___ PTT-29.3 ___ ___ 05:05AM BLOOD ___ ___ 05:05AM BLOOD Plt ___ ___ 03:55PM BLOOD Glucose-130* UreaN-26* Creat-1.2* Na-135 K-3.4 Cl-94* HCO3-32 AnGap-12 ___ 05:05AM BLOOD Glucose-104* UreaN-24* Creat-1.2* Na-136 K-3.6 Cl-96 HCO3-36* AnGap-8 ___ 05:05AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.2 ___ 03:55PM BLOOD TSH-0.54 MICRO ===== ___ URINE CULTURE-PENDING IMAGING ======= ___ CT A/P: 1. Partially imaged left lower lobe consolidation may be due to atelectasis but underlying pneumonia is not excluded. Right base atelectasis and very trace right pleural effusion. 2. No evidence of bowel obstruction or bowel wall thickening. No free fluid. 3. Extensive atherosclerotic disease. 4. Severe narrowing of the central canal at L2/L3 with prominent posterior osteophyte causes severe narrowing. ___ Imaging CHEST (PA & LAT) In comparison with the study of ___, the cardiac silhouette remains enlarged, though not as prominent as on the previous study. Continued mild pulmonary vascular congestion with bibasilar atelectatic changes and small pleural effusions. The right subclavian PICC line extends to about the level of the cavoatrial junction. If there is any concern for it being the inciting factor for the arrhythmia, it could be pulled back about 2 cm to definitely be above the cavoatrial junction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 37.5 mg PO Q6H 2. Isosorbide Mononitrate 15 mg PO BID 3. Melatin (melatonin) 6 mg oral QHS 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 17.2 mg PO DAILY 6. Calcium Carbonate 500 mg PO QID:PRN reflux 7. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 8. Chloraseptic Throat Spray 1 SPRY PO Q2H:PRN sore throat 9. OLANZapine 5 mg PO BID:PRN agitation 10. Ondansetron 4 mg IV Q8H:PRN nausea 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Warfarin 3 mg PO DAILY16 14. Docusate Sodium 100 mg PO BID 15. Furosemide 60 mg IV DAILY 16. GuaiFENesin ER 1200 mg PO Q12H 17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 18. Multivitamins W/minerals 1 TAB PO DAILY 19. Pantoprazole 40 mg PO Q12H 20. QUEtiapine Fumarate 12.5 mg PO QHS 21. PARoxetine 20 mg PO DAILY 22. Simvastatin 20 mg PO QPM 23. Pulmicort (budesonide) 2.5/2 mcg/ml inhalation BID 24. Perforomist (formoterol fumarate) 20 mcg/2 mL inhalation BID Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY 2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 3. Lactulose 30 mL PO DAILY:PRN constipation 4. Metoprolol Succinate XL 150 mg PO DAILY 5. Potassium Chloride 20 mEq PO DAILY Hold for K >4.0 6. Tiotropium Bromide 1 CAP IH DAILY 7. Torsemide 80 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Senna 17.2 mg PO BID 10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 11. Calcium Carbonate 500 mg PO QID:PRN reflux 12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 13. Chloraseptic Throat Spray 1 SPRY PO Q2H:PRN sore throat 14. Docusate Sodium 100 mg PO BID 15. GuaiFENesin ER 1200 mg PO Q12H 16. Melatin (melatonin) 6 mg oral QHS 17. Multivitamins W/minerals 1 TAB PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. PARoxetine 20 mg PO DAILY 20. Perforomist (formoterol fumarate) 20 mcg/2 mL inhalation BID 21. Polyethylene Glycol 17 g PO DAILY 22. Pulmicort (budesonide) 2.5/2 mcg/ml inhalation BID 23. QUEtiapine Fumarate 12.5 mg PO QHS 24. Simvastatin 20 mg PO QPM 25. Warfarin 3 mg PO DAILY16 26.Outpatient Lab Work Date: ___ Dx: Chronic diastolic heart failure (I50.23) Labs: Na, Cl, K, HCO3, BUN, Cr, Mg Please send results to on call doctor at ___ in ___ Fax: ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: - constipation - Chronic diastolic heart failure SECONDARY: - Chronic renal failure - atrial fibrillation on warfarin - COPD 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 INDICATION: NO_PO contrast; History: ___ with obstipation x5 daysNO_PO contrast// Eval for evidence of bowel obstruction, oglive's syndrome 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 not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP = 10.8 mGy-cm. 2) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 15.6 mGy (Body) DLP = 819.1 mGy-cm. Total DLP (Body) = 830 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: Partially imaged left lower lobe consolidation is seen which may be due to atelectasis, but underlying infection is not excluded. There is also right base atelectasis. Very trace right pleural effusion is seen. No pericardial effusion is seen. Coronary calcification is seen. The heart is enlarged. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Spleen is not enlarged. The spleen is homogeneous without focal lesion seen. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are relatively atrophic but demonstrate symmetric nephrogram and excretion of contrast. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: Some is relatively collapsed. No bowel obstruction or bowel wall thickening is seen. The hepatic flexure is interposed above the right aspect of the liver. There is moderate colonic fecal loading. The appendix is not definitely seen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. 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 calcification is seen along the aorta and its branches.. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Multilevel degenerative changes are seen. There is severe narrowing of the central canal, L2/L3 where prominent posterior osteophyte causes severe narrowing of the central canal. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Partially imaged left lower lobe consolidation may be due to atelectasis, but underlying pneumonia is not excluded. Right base atelectasis and very trace right pleural effusion. 2. No evidence of bowel obstruction or bowel wall thickening. No free fluid. 3. Extensive atherosclerotic disease. 4. Severe narrowing of the central canal at L2/L3 with prominent posterior osteophyte causes severe narrowing. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with diastolic CHF, atrial fibrillation and recent admission for PNA with wheezing on exam// Please evaluate for pulm edema, PNA? Also please evaluate location of PICC IMPRESSION: In comparison with the study of ___, the cardiac silhouette remains enlarged, though not as prominent as on the previous study. Continued mild pulmonary vascular congestion with bibasilar atelectatic changes and small pleural effusions. The right subclavian PICC line extends to about the level of the cavoatrial junction. If there is any concern for it being the inciting factor for the arythmia, it could be pulled back about 2 cm to definitely be above the cavoatrial junction. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Constipation Diagnosed with Pneumonia, unspecified organism temperature: 97.9 heartrate: 64.0 resprate: 16.0 o2sat: 98.0 sbp: 111.0 dbp: 74.0 level of pain: 0 level of acuity: 3.0

___ female with COPD, diastolic CHF, atrial fibrillation on warfarin recently admitted with respiratory failure who presented to the ___ ED on ___ with constipation and obstipation. # Constipation: CT A/P on ___ during last admission showed severe colonic distention suggestive of primary ___ given absence of abdominal pain and nausea. Had colonoscopic decompression with colonic/rectal tube placement on ___ after there was no improvement with aggressive enemas, reduction of anticholinergic meds, lytes management, attempts to ambulate. Colonic tube was in place for 24hrs with significant improvement. Antipsychotics were also downtitrated and diliazem was transitioned to metoprolol given concern for medication induced ileus. On this admission, patient again reports having gone 5 days with constipation/obstipation without abdominal pain or nausea/vomiting. CT A/P now without ileus or obstruction/bowel wall thickening and significantly improved from prior. Patient received tap water enema this AM with large, well-formed BM shortly thereafter and patient feels significantly better. Per patient, she was not receiving enemas at the rehab, and does have a tendency to get constipated with prolonged ___ facility stay. TSH 0.54. Continue standing docusate and miralax. Change senna to standing. Added lactulose and tap water enemas prn if no BM for>48hrs. Discontinued Zofran. #Anemia Hb 6.9 upon admission. D/c Hb of 7.1 Has chronic anemia as outpatient. During previous admission, retic index high, hemolysis labs negative, iron studies showed low iron level and very low iron saturation (6%) c/w iron deficiency. She was started on PPI BID out of concern / high risk for gastritis/PUD. However, concern for gastritis low at this time. Heart burn likely secondary to deconditioning. Received one unit prbc on ___ in ED. Reduced PPI to 40 daily and added iron supplements daily to improve iron deficiency in setting of poor PO intake. We discussed that iron may make her stools dark and may make her constipated but that she should continue to make sure she has a good BM every day. #CT chest findings / Hypoxia Of note, during last admission, pt's sputum cultures grew MRSA and stenotrophonas. ID was consulted and patient completed a 7 day course of vancomycin (ended ___, 5 days azithro (ended ___, and bactrim (ended ___. CT chest on ___ did not show any significant consolidation, but patient had persistent hypoxia after completing abx course. Repeat CXR on ___ was suggestive of new retrocardiac opacity, but pt did not have clinical signs of infection and she did not receive further abx. On this admission, she is requiring 2L NC O2. CT A/P showed LLL consolidation and R basilar atelectasis but repeat CXR showed continued mild pulmonary vascular congestion with bibasilar atelectatic changes and small pleural effusions. Her symptoms are likely secondary to volume overload and she is afebrile, denies cough, congestion, or rhinorrhea. There is no leukocytosis. She was discharged on an increased dose of diuretic as below. #Asymptomatic pyuria: U/A on admission with large leukocytes, 21 WBC, few bacteria. Pt denies urinary sx. Will follow up culture and defer treatment of asymptomatic pyuria at this time. #COPD: Patient with diagnosis of COPD as an outpatient. Was recently treated for COPD exacerbation and s/p prednisone taper. Exam today with mild wheezing but no recent cough or increased sputum production. Her tioptropium was restarted and home advair was continued. She can continue albuterol nebulizers PRN upon discharge. #Diastolic heart failure (LVEF 56% on TTE ___: Dry weight is 185. Current weight is 183 lbs but given recent decrease in apatite likely there is some weight loss and dry weight is not accurate. Exam with wheezing and mild crackles. 2+ ___ edema present. Was receiving 60 mg IV Lasix at rehab, this was changed to torsemide 80mg daily and she should have repeat labs (Na, Cl, K, HCO2, BUN, Cr, Mg) on ___ to assess her renal function and potassium. Please adjust her diuretic and potassium supplementation as needed. Also changed isosorbide to long acting imdur once daily. #CKD: B/l Cr 1.2-1.5, currently at 1.2. #Atrial fibrillation. CHADS2-vasc 5. On warfarin 3mg daily at home and metoprolol. INR 2.2 on admission. Changed metoprolol to succinate once daily

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: doxycycline / Dilaudid Attending: ___. Chief Complaint: vomiting, abd pain, diarrhea Major Surgical or Invasive Procedure: ... History of Present Illness: HPI: Ms. ___ is a ___ year-old woman who began having loose stools around ___, around the time that she was started on new medications (lamotrigine, bupropion, and clonazepam). She generally had one loose bowel movement per day. In late ___ she had nausea, vomiting, abdominal cramps, and diarrhea ___ times per day. Her sister had similar symptoms at the time; the sister's symptoms improved, but the patient's did not. She was admitted to another hospital: C diff was negative, CT showed left-sided colitis. She was started on ciprofloxacin and metronidazole. She was transferred to ___. CRP, ESR, and TTG IgA were normal. CT showed mild improvement in colitis. Her symptoms ultimately improved and she was discharged to home on ___. . She was seen in GI clinic here on ___, and was doing better at that time, with no nausea, vomiting, or abdominal pain. She was still having ___ loose bowel movements per day. Differential included postinfectious IBS, medication effect, microscopic colitis, celiac disease, or IBD. Plan was made for colonoscopy. . On ___, she ate steamed vegetables and rice at a ___ restaurant and became ill 60-90 minutes thereafter. She had severe abdominal cramping as well as sharp pains, diarrhea, and vomiting (some blood in vomit). No one else who ate with her became ill. These symptoms have persisted since then, including at night, and regardless of whether she eats or not. ___ bowel movements per day, some soft, some watery. No melena or dark vomitus. No fever. She has lost about 15 pounds over the last few weeks. . -In the ED, initial VS: 99.5 96 119/88 16 100% RA -Exam notable for: diffusely tender abdomen, stool guaiac-negative -Labs notable for: leukocytosis -The pt received: Dilaudid and Zofran (developed rash), ketorolac . ROS: Denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, dysuria, hematuria. All other ROS negative. Past Medical History: Anorexia nervosa Anxiety Depression Social History: ___ Family History: No family history of IBD, celiac disease, or colon cancer. Physical Exam: VS: 98.9 51 116/74 16 100% RA GENERAL: appears fatigued, a bit uncomfortable, no distress, pleasant HEENT: PERRL, OP clear NECK: Supple, no LAD HEART: RRR, no murmur LUNGS: CTAB ABDOMEN: +BS, soft, ND, mild diffuse tenderness RECTAL: deferred (done in ED, stool guaiac-negative) EXTREMITIES: warm, no edema SKIN: rash on upper chest NEURO: Awake, alert, appropriate, normal sensation to light touch, ___ strength in bilateral UEs and ___ ___ Results: ___ 03:05PM URINE UCG-NEGATIVE ___ 11:42AM GLUCOSE-95 UREA N-9 CREAT-0.6 SODIUM-139 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-21* ANION GAP-20 ___ 11:42AM ALT(SGPT)-68* AST(SGOT)-28 ALK PHOS-88 TOT BILI-0.7 ___ 11:42AM LIPASE-28 ___ 11:42AM ALBUMIN-4.9 ___ 11:42AM WBC-15.3*# RBC-5.20 HGB-15.3 HCT-44.6 MCV-86 MCH-29.4 MCHC-34.3 RDW-12.4 ___ 11:42AM NEUTS-74.6* ___ MONOS-5.4 EOS-0.3 BASOS-0.4 ___ 11:42AM PLT COUNT-323 KUB IMPRESSION: No evidence of bowel obstruction or free air. EGD: Erythema in the gastroesophageal junction compatible with Mild esophagitis (biopsy) Normal mucosa in the stomach (biopsy) Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: Follow-up biopsy results Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. Prilosec 20mg BID Will proceed with Colonoscopy. Colonoscopy Terminal ileum mucosa looked normal. Cold forceps biopsies were performed for histology at the Terminal ileum. Impression: Normal mucosa in the colon (biopsy) Terminal ileum mucosa looked normal. (biopsy) Otherwise normal colonoscopy to cecum Recommendations: follow-up biopsy results Further management per inpatient GI team. Medications on Admission: Wellbutrin 100 mg daily Ativan prn anxiety Discharge Medications: 1. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for Pain. 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for abdominal pain for 7 days. Disp:*21 Tablet(s)* Refills:*0* 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Nausea and vomiting Diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Abdominal pain, nausea and vomiting. Evaluate for free air. COMPARISON: Chest radiograph, ___. FINDINGS: The lungs are clear without consolidation or edema. There is no pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal. There is no free air below the hemidiaphragms. IMPRESSION: 1. No acute cardiopulmonary process. 2. No evidence of free air below the hemidiaphragms. Radiology Report INDICATION: Nausea, vomiting and leukocytosis. Evaluate for free air or small bowel obstruction. COMPARISON: Abdominal radiograph ___. FINDINGS: There is no free air below the hemidiaphragms. The bowel gas pattern is normal without dilated loops of small bowel or air fluid levels. There is no evidence of obstruction or ileus. Air is seen extending to the rectum. The osseous structures are unremarkable. IMPRESSION: No evidence of bowel obstruction or free air. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABDOMINAL PIAN/DIARRHEA Diagnosed with ABDOMINAL PAIN GENERALIZED, NAUSEA WITH VOMITING temperature: 99.5 heartrate: 96.0 resprate: 16.0 o2sat: 100.0 sbp: 119.0 dbp: 88.0 level of pain: 7 level of acuity: 3.0

___ with anxiety, depression, several month history of diarrhea, recent admission for diarrhea, abd pain, and nausea/vomiting with evidence of colitis; improved and discharged on ___ now p/w 5 days of diarrhea, abd pain, and nausea and vomiting. Ddx includes gastroenteritis, infectious colitis, IBD, microscopic colitis. #Abdominal pain, Nausea and vomiting, Diarrhea She was treated with IVF. GI was consulted. She underwent EGD and colonoscopy on ___, which showed mild esophagitis but were otherwise unremarkable. Biopsy results are currently pending at time of discharge but there was no overt mucosal colitis on colonoscopy. Infectious stool studies were negative. She was advised to take PPI bid and to follow an anti-reflux regimen. The most likley cause of her symptoms was felt to be ongoing discomfort as a result of a viral gastroenteritis per the GI team. Even though her anti-TTG ab was previously negative biopsies should help further eliminate the possibility of celiac's disease. If she has ongoing symptoms GI ___ want to pursue a MRE to evaluate for small bowel inflammatory changes that could exist in the setting of crohn's limited to that region, however her inflammatory markers were normal this admission. #LEUKOCYTOSIS: WBC up to 15 on admission, improved without therapy . #ANXIETY AND DEPRESSION: continued home Wellbutrin. . #POSSIBLE ALLERGY: In the ED, she received Zofran and Dilaudid and subsequently developed a significant rash. She had received these medications previously without incident. exam on day of ___ 105 / 61 63 well appearing, but fatigued soft, non-distended abdomen, +BS, no guarding or rebound no peripheral edema

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: elevated d-dimer Major Surgical or Invasive Procedure: None History of Present Illness: ___ with DM2, HTN, tobacco use, and h/o PNA ___ years ago who was referred to the ED due to elevated D-dimer. She had a productive cough and fever to 101 for >1 week. She was started on Azithromycin 4 days prior to this presentation. Has been feeling much better, in fact is back to baseline, but outpatient provider called her at home due to elevated D-dimer (964) which was checked as an outpatient. . In the ED, initial VS: 98.2 80 ___ 98% RA. labs notable for WBC 3.2 (40% PMN, 47% lymphs). CTA did rule out PE but showed nodular opacities that could represent infection, malignancy, sarcoidosis. Patient felt fine but due to "diagnostic uncertainty" she was admitted to Medicine. Got levofloxacin prior to coming up. . Currently, she has no complaints except that she wants to go home. Notes that she feels back to baseline. Quit smoking ~1 week ago and says this may be contributing to her cough. Past Medical History: Type 2 Diabetes mellitus s/p C section (G2P2) Depression Asthma Social History: ___ Family History: -Diabetes in multiple members of family. -MGM ?ovarian ca, MGF colon ca -Mother died of ___ ca -Maternal aunts (4): with ovarian, breast, colon? unclear who has what. -Cousin with breast ca Physical Exam: ADMISSION EXAM VS - Temp 97.5F, BP 131/86, HR 75, R 18, O2-sat 99% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no thyromegaly, no JVD, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . (discharged within 12h of admission, no change in exam) Pertinent Results: ED LABS ___ 01:13PM BLOOD WBC-3.5*# RBC-4.10* Hgb-12.8 Hct-37.6 MCV-92 MCH-31.2 MCHC-34.0 RDW-12.4 Plt ___ ___ 01:13PM BLOOD Neuts-51.3 ___ Monos-7.4 Eos-1.6 Baso-0.4 ___ 01:13PM BLOOD D-Dimer-964* . ADMISSION LABS ___ 11:00PM BLOOD WBC-3.2* RBC-3.77* Hgb-12.3 Hct-35.0* MCV-93 MCH-32.7* MCHC-35.2* RDW-12.1 Plt ___ ___ 11:00PM WBC-3.2* RBC-3.77* HGB-12.3 HCT-35.0* MCV-93 MCH-32.7* MCHC-35.2* RDW-12.1 ___ 11:00PM NEUTS-39.9* LYMPHS-47.2* MONOS-5.8 EOS-4.2* BASOS-2.8* ___ 11:00PM GLUCOSE-142* UREA N-12 CREAT-0.7 SODIUM-139 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 ___ 11:00PM ___ PTT-30.7 ___ . DISCHARGE LABS none . PENDING LABS ___ 01:13PM BLOOD ___ . MICRO ___ BLOOD CULTURES PENDING X2 . IMAGING ___ CTA CHEST FINDINGS: The pulmonary arterial tree is well opacified and no filling defect to suggest pulmonary embolism is seen. There is no evidence of acute aortic syndrome. Within the lungs, there are multiple bilateral nodular opacities, predominantly peribronchovascular with predominance for the left lower lobe however also present in the lingula as well as the right middle and lower lobes. There is bilateral hilar adenopathy measuring up to 1 cm in short axis. Mediastinal lymph nodes do not meet CT criteria for pathologic enlargement. No axillary lymphadenopathy is seen. No evidence of endobronchial lesion is seen. The heart and great vessels appear grossly unremarkable. No pleural or pericardial effusion is seen. No pneumothorax is identified. No concerning osseous lesion is seen. Limited views of the upper abdomen are grossly unremarkable. IMPRESSION: Multiple bilateral, predominantly peribronchovascular nodular opacities greatest in the left lower lobe. The differential for this appearance is atypical infection, less commonly vasculitis such Goodpasture's syndrome or sarcoidosis. No pulmonary embolism. Radiology Report INDICATION: Cough with hemoptysis. TECHNIQUE: Multidetector helical CT scan of the chest was obtained after the administration of 100 cc IV Omnipaque contrast. Coronal, sagittal and oblique reformations were prepared. FINDINGS: The pulmonary arterial tree is well opacified and no filling defect to suggest pulmonary embolism is seen. There is no evidence of acute aortic syndrome. Within the lungs, there are multiple bilateral nodular opacities, predominantly peribronchovascular with predominance for the left lower lobe however also present in the lingula as well as the right middle and lower lobes. There is bilateral hilar adenopathy measuring up to 1 cm in short axis. Mediastinal lymph nodes do not meet CT criteria for pathologic enlargement. No axillary lymphadenopathy is seen. No evidence of endobronchial lesion is seen. The heart and great vessels appear grossly unremarkable. No pleural or pericardial effusion is seen. No pneumothorax is identified. No concerning osseous lesion is seen. Limited views of the upper abdomen are grossly unremarkable. IMPRESSION: Multiple bilateral, predominantly peribronchovascular nodular opacities greatest in the left lower lobe. The differential for this appearance is atypical infection, less commonly vasculitis such Goodpasture's syndrome or sarcoidosis. No pulmonary embolism. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: ELEVATED D-DIMER Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT temperature: 98.2 heartrate: 80.0 resprate: 16.0 o2sat: 98.0 sbp: 112.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

___ with DM2, tobacco use, and recent PNA presented to the ED due to elevated D-dimer at ___'s office, was ruled out for PE and admitted for further evaluation of pulmonary nodules noted on CTA. . #. Pulmonary nodular opacities Differential included atypical infection, vaculitis, sarcoid, lymphoma/mets. Given that she is a smoker who had recent PNA (cough, fever) treated with Abx, noted CT abnormalities were thought to represent a resolving pneumonia. She was asymptomatic. She was discharged home with 4 days of levofloxacin for a total 5 day course, to treat any residual pulmonary infection. Recommended PCP ___ with ___ chest imaging. . #. DM2, Psych, Migraines Home medications were continued. No apparent symptoms. . TRANSITIONAL ISSUES 1. ___ clinical exam, chest imaging 2. ___ pending ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iron Attending: ___ Chief Complaint: PCP: ___. ___ - ___ -- ___ CC: weakness, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with no significant PMH who is presenting with weakness, diarrhea, numbness, and palpations. Patient reports multiple new symptoms over the past two weeks. She has had generalized weakness for around two weeks. She then reports that earlier today while walking home she suddenly developed a racing heart, and then a cold sensation that spread throughout her body - it first went down her legs, and then spread to her upper body. After this she became weak all over and was no longer able to walk. The weakness lasted around 2 hours and then has slowly gotten better, but has left behind numbness, which she now notes mostly in her fingertips. She currently reports no headache, though has stated that she has a "head heaviness". She has also had ongoing dizziness, which was not improved with meclizine. She has felt that her left eye has some pressure. She has also had some generalized abdominal pain and multiple stools with mucous. However, this improved, and her last bowel movement was dark "coffee-colored". She notes that she is being workup up for celiac disease. Regarding her palpitations, patient reports several episodes of feeling like her heart was racing, including the one noted above. She states that during one event she felt a tightness that went through her left arm, and then left her throat sore. Patient reports no chemical exposures, no sick contacts, and no family members who have experienced similar symptoms. She has not traveled recently, no recreational drugs. She reports a mosquito bite but otherwise no insect bites. In the ED: Initial vital signs were notable for: T 98.1, HR 112, BP 139/33, RR 20, 100% RA Exam notable for: CV: Tachy and rhythm, normal ___ and ___ heart sounds, no ___ heart sound, no JVD, no pedal edema, 2+ distal upper extremity and lower extremity pulses. Capillary refill less than 2 seconds. MSK: strength ___ in bilateral upper and lower extremities, unable to make fist or move fingers. Able to mildly wiggle toes on right, less on left,No cyanosis, clubbing or edema Neuro: Alert and following commands, not moving all extremities spontaneously, sensation intact to light touch in upper extremities, decreased in lower extremities, speech fluent Psych: Crying/AO X 3 Labs were notable for: - CBC: 6.7, hgb 11.2, plt 317 - Lytes: 142 / 106 / 9 AGap=14 -------------- 89 4.2 \ 22 \ 0.6 - lactate 2.1 - u/a negative - tox screen negative - trop <0.01 - ddimer 308 - coags normal Studies performed include: - CXR with no acute process Consults: Neuro was consulted, and felt like there was no clear unifying diagnosis. They have low suspicion for an infectious cause of symptoms. Do recommend MRI brain and MRA head and neck, as well and MRV to rule out sinus venous thrombosis Patient was given: ___ 01:09 PO Ondansetron ODT 4 mg ___ 03:28 IVF NS 1000 mL ___ ___ 07:31 PO Meclizine 25 mg Vitals on transfer: T 98.2, HR 96, BP 117/73, RR 13, 97% RA Upon arrival to the floor, patient recounts history as above. She currently denies headache, chest pain, or shortness of breath, though does note a new cough. States that she remains weak on the left side. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - iron deficiency anemia - history of panic Social History: ___ Family History: - mother - CHF - maternal grandmother - CHF - maternal aunt - diabetes - paternal grandmother - hypertension - sister - asthma Physical ___: VITALS: T 98.0, HR 89, BP 107/70, RR 18, 98% RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, Full str in all ext PSYCH: pleasant, appropriate affect Pertinent Results: ___ 06:35AM BLOOD WBC-4.1 RBC-3.84* Hgb-10.3* Hct-32.9* MCV-86 MCH-26.8 MCHC-31.3* RDW-14.2 RDWSD-44.5 Plt ___ ___ 06:35AM BLOOD Glucose-82 UreaN-13 Creat-0.7 Na-139 K-4.4 Cl-102 HCO3-24 AnGap-13 ___ 04:20PM BLOOD LD(LDH)-168 ___ 06:35AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.0 ___ 07:00AM BLOOD Hapto-109 ___ 06:40AM BLOOD T4-6.0 Free T4-1.2 ___ 06:40AM BLOOD Cortsol-12.8 ___ 06:40AM BLOOD ___ Titer-1:40* ___ 06:42AM BLOOD CRP-0.3 ___ 06:40AM BLOOD Lyme Ab-NEG ___ 03:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG MRI cervical and thoracic spine w/wo contrast: 1. No evidence of spinal canal or neural foraminal narrowing. No evidence of focal spinal cord lesion or abnormal enhancement. CT neck with contrast: Mildly prominent palatine tonsils and other lymphoid tissue in the pharynx. Proliferation of cervical lymph nodes, likely reactive although these could be followed by clinical examination or imaging if surveillance is felt necessary clinically. CT chest with contrast: Unremarkable study. # ___ CT a/p w/ contrast: IMPRESSION: 1. 3.8 cm cyst within the left adnexa, presumably physiologic in a patient of this age. In addition, there is small amount of intra-abdominal and intrapelvic free fluid, also likely physiologic. 2. No acute abnormality to account for the patient's left upper quadrant symptoms. No splenomegaly or evidence of diverticulitis. # ___ NCHCT (Atrius): IMPRESSION: Normal CT of the head without contrast # ___ CXR (pa and lat): IMPRESSION: No acute cardiopulmonary abnormality # Brain MRI/MRA (___): Normal MRI of the brain. No venous sinus thrombosis. Normal MRA of the head. # TTE (___): The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is 70%. There is no left ventricular outflow tract gradient at rest or with Valsalva. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). There is normal diastolic function. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. 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. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are normal. 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. IMPRESSION: No structural cardiac cause of syncope identified. Negative/normal labs: - AM cortisol 12.8 - Lyme Ab - Chromogranin A - 24 hour metanepherines (creatinine ordered for other test taken from same sample and was adequate) - 24 hour urine catecholamines - Calcitonin - ___ 1:40 - Urine Porphobilinogen Screen - ESR, CRP - Tryptase - VIP - Seratonin essentially normal - 5-HIAA - c diff negative - H pylori negative LP: ___ 05:50PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-2 Polys-0 ___ ___ 05:50PM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-55 LD(LDH)-16 ___ 05:50PM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-55 LD(LDH)-16 ___ 05:50PM CEREBROSPINAL FLUID (CSF) VDRL-Test ___ 5:50 pm CSF;SPINAL FLUID Source: LP #3. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills:*0 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild RX *ibuprofen 200 mg 3 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 4. Vitamin D 2000IU PO daily Discharge Disposition: Home Discharge Diagnosis: Tachycardia Weakness diarrhea Anemia Discharge Condition: Stable A/Ox3 self-ambulatory No activity restrictions Followup Instructions: ___ Radiology Report EXAMINATION: MRI AND MRA BRAIN INDICATION: ___ year old woman with c/o generalized ascending weakness, left upper motor neuron pattern weakness and sensory changes// Evaluate for VST, pleast perform post-contrast MPRAGE sequence TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T1-weighted, axial fast spin echo T2-weighted, axial flair, axial diffusion weighted with ADC map and axial gradient echo images. Post-contrast axial T1 weighted images as well as sagittal MPRAGE with axial and coronal reformats were performed. 3D time-of-flight MRA of the brain was also performed with 3D reformatted images COMPARISON: None. FINDINGS: MR: There is no intracranial mass, mass effect, or midline shift. There is no focal parenchymal signal abnormality. Ventricles and sulci are age-appropriate. There is no restricted diffusion to suggest acute infarct. No abnormal susceptibility artifact identified. Major intravascular flow voids are preserved including within the major dural venous sinuses which also have a normal postcontrast appearance. Visualized paranasal sinuses and mastoid air cells demonstrate no abnormal signal. Post-contrast images demonstrate no abnormal parenchymal or meningeal enhancement. MRA: Intracranial vascular structures are unremarkable without evidence of significant stenosis, aneurysm, or occlusion. IMPRESSION: Normal MRI of the brain. No venous sinus thrombosis. Normal MRA of the head. Radiology Report EXAMINATION: CT CHEST W/CONTRAST Q412 INDICATION: ___ year old woman with 2 weeks of cough, intermittent tachycardia, flushing, syncope. Concern for neuroendocrine tumor. Palpable neck nodes. // Eval for lymphadenopathy or abnormal lung paranchyma TECHNIQUE: Multidetector CT images of the chest were obtained with intravenous contrast. Sagittal and coronal reformations were also performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.2 s, 40.4 cm; CTDIvol = 8.5 mGy (Body) DLP = 337.8 mGy-cm. Total DLP (Body) = 338 mGy-cm. COMPARISON: CT of the abdomen and pelvis is available from ___. FINDINGS: The heart is normal in size. Great vessels are unremarkable. There is no pleural or pericardial effusion. No enlarged lymph nodes are found in the chest. Residual anterior thymic tissue is within normal limits for age. The lungs appear clear. Limited views of the upper abdomen are unremarkable. There are no suspicious bone lesions. Vertebral body heights and interspaces appear preserved in height. IMPRESSION: Unremarkable study. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 INDICATION: ___ year old woman with 2 weeks of cough, intermittent tachycardia, flushing, syncope. Concern for neuroendocrine tumor. Palpable neck nodes. // Eval for lymphadenopathy TECHNIQUE: Multidetector CT images of the neck were obtained with intravenous contrast. Sagittal and coronal reformations were also performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.6 s, 29.8 cm; CTDIvol = 10.7 mGy (Body) DLP = 312.4 mGy-cm. Total DLP (Body) = 312 mGy-cm. COMPARISON: No relevant prior study is available. FINDINGS: Visualized base of the brain is unremarkable. Partly visualized orbits also appear normal. Salivary glands appear within normal limits. Thyroid appears normal as well. There are a number of subcentimeter lymph nodes throughout the neck, especially along posterior cervical triangles and at level 2, but these do not appear enlarged by size criteria although somewhat striking by number.Major vascular structures appear widely patent. Partly imaged thymic tissue is probably normal for age. Visualized lung apices appear clear. Major airways appear widely patent. There is no prevertebral soft tissue thickening. Palatine tonsils are mildly enlarged with postinflammatory calcifications. Nasopharyngeal lymphoid tissue and lingular tonsillar tissue also are mildly prominent. Epiglottis is not thickened. Visualized paranasal sinuses and mastoid air cells appear clear. Bony structures are unremarkable. IMPRESSION: Mildly prominent palatine tonsils and other lymphoid tissue in the pharynx. Proliferation of cervical lymph nodes, likely reactive although these could be followed by clinical examination or imaging if surveillance is felt necessary clinically. Radiology Report EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE INDICATION: ___ year old woman with no PMH who has recurrent paralysis and numbness in all extremities // Recurrent episodes of whole-body paralysis Recurrent episodes of whole-body paralysis Recurrent episodes of whole-body paralysis TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: None. FINDINGS: CERVICAL: Minimal anterolisthesis of C3 on C4. Vertebral body and intervertebral disc signal intensity appear normal. The spinal cord appears normal in caliber and configuration. There is no evidence of spinal canal or neural foraminal narrowing. There is no evidence of infection or neoplasm. There is no abnormal enhancement after contrast administration. THORACIC: Alignment is normal. Vertebral body and intervertebral disc signal intensity appear normal. The spinal cord appears normal in caliber and configuration. There is no evidence of spinal canal or neural foraminal narrowing. There is no evidence of infection or neoplasm. There is no abnormal enhancement after contrast administration. OTHER: Incidentally noted Thornwaldt cyst versus inflammatory retention cyst within the nasopharynx (3:8). The partially visualized paraspinal muscles, lung parenchyma and abdominal organs are unremarkable. IMPRESSION: 1. No evidence of spinal canal or neural foraminal narrowing. No evidence of focal spinal cord lesion or abnormal enhancement. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with c/o generalized progressive ascendingweakness/paralysis// Chest pathology? TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: WHITE Arrive by WALK IN WALK IN Chief complaint: Anxiety, Dizziness, Palpitations Dizziness, Weakness Diagnosed with Weakness Dizziness and giddiness, Weakness temperature: 98.1 97.7 heartrate: 112.0 83.0 resprate: 20.0 14.0 o2sat: 100.0 99.0 sbp: 139.0 114.0 dbp: 33.0 73.0 level of pain: 0 1 level of acuity: 3.0 3.0

The pt was admitted for repeated episodes of weakness, flushing, and tachycardia in the setting of other non-specific complains including diarrhea. She continues to have these episodes inpatient. During the episodes, she will suddenly become tachycardic to 150s-170s with acute onset whole-body weakness and numbness. The symptoms last for about 2 hours as they slowly self-resolve. Workup so far has been unrevealing (see below) and the episodes continue to happen. The pt's syx seem to improve and be prevented by Ativan. On ___, the pt had a prolonged episode a/w lateral beating of the eyes. She reports that she was awake and aware during the episode but unable to communicate. However she may be remembering commotion right before the episode, as she cannot give any details about what she heard that align with what actually occurred. She received 0.5 mg IVP Ativan which was already at bedside. The episode broke before further Ativan could be given. She had a depressed respiratory rate and erratic breathing during the event, though her oxygen level stayed at 100% on RA and she protected her airway. She was loaded with Keppra. On ___, the pt had another episode while on EEG monitoring. There was no sign of seizure on EEG. Potassium, sodium, and magnesium were normal during the episode. MR cervical and thoracic spine showed no abnormalities. LP was unremarkable. Nephrology consulted for ?hypokalemic periodic paralysis, but no evidence of it as her K has always been normal. She interestingly had 2 more episodes both related to IV LR infusion, but quickly resolved after fluids were stopped. POTS disease related to recent viral infection is a possibility. We have recommended that she follows up with ___ neurology and ___ clinic for further testing. Functional neurologic disorder is also a possibility. Her Vit D is deficient and she will be placed on supplement. She developed post LP headache, which was conservatively managed. She is instructed to call pain clinic for blood patch if the headache remains severe after discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___ R craniotomy for tumor resection History of Present Illness: ___ who had a miscarriage 10 week prior presents to ED as transfer from OSH with c/o progressively worsening headaches since her miscarriage. She states the headaches began increasing in severity over the past month turning into migraines. She states the headaches come on randomly and wake her at night. Patient reports that on ___ the headaches became even worse, and she developed new onset sensitivities to smells, with nausea and two episodes of vomiting. She states that while trying to unbutton her pants her left hand went completely numb and she was unable to complete the task. Patient also notes episodes of left leg numbness and tingling and at one point that ___ her left leg stopped working, with an associated tingling sensation down the front of her leg and a "frozen foot". That ___ she presented to ___, where they gave her pain control and followed up with her PCP on ___. Upon review of systems she reports blurred vision and spinning, and yesterday had a new sensation of someone grabbing the back of her neck and sharp "zings" down her back. She denies any fevers, chills or recent illnesses. CT scan obtained at OSH which demonstrated a right parietal/temporal ring enhancing lesion with vasogenic edema, mass effect and MLS. Past Medical History: - Miscarriage 10 weeks prior to presentation Social History: ___ Family History: NC Physical Exam: ON ADMISSION ============ Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMI(patient becomes dizzy & headache worsens with lateral gaze) Neck: Supple. Lungs: RR normal, equal lung expansion visualized Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3-2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact. Slight left facial VIII: Hearing intact to voice. IX, X: Not tested XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch ON DISCHARGE ============ Pertinent Results: Please see OMR for pertinent imaging & labs Medications on Admission: - Loratidine - Prilosec - Amitriptyline Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Dexamethasone 4 mg PO Q12H This is the maintenance dose to follow the last tapered dose RX *dexamethasone 4 mg 1 tablet(s) by mouth every 12 hours Disp #*45 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth every 12 hours Disp #*45 Tablet Refills:*0 5. LevETIRAcetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth every 12 horus Disp #*60 Tablet Refills:*0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet Refills:*0 7. Senna 17.2 mg PO QHS 8.Outpatient Occupational Therapy ICD 9 code: ___ Please preform for home safety evaluation. S/p Brain tumor resection ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman s/p crany and R sided tumor excision// please perform 3 hrs post op at 6pm TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain window. DOSE: Total DLP (Head) = 934 mGy-cm. COMPARISON: MRI head ___ CT CTA head ___ MRI head ___ FINDINGS: Patient is status post right-sided craniotomy and excision of right frontotemporal lesion, previously characterized on MRI head ___. There is fluid density foci and foci of air within the resection bed. There is also surrounding edema with mass effect and effacement of the right lateral ventricle with 1 cm leftward midline shift (02:19), mildly increased in size from MRI ___, previously measuring up to 7 mm. Pneumocephalus and extra-axial fluid along the right frontotemporal convexity is within normal limits given recent surgery. There are ill-defined irregular linear hyperintense foci in the resection bed likely representing small foci of intraparenchymal hemorrhage. There is opacification of the left sphenoid sinus. Remaining paranasal sinuses clear. Mastoid air cells and middle ear cavities are well aerated. Right-sided post craniotomy changes are noted. IMPRESSION: 1. Status post right sided craniotomy and resection of frontotemporal lesion previously characterized on MRI ___. 2. Ill-defined irregular linear hyperintense foci in the resection bed could represent small foci of intraparenchymal hemorrhage. 3. Postoperative changes including fluid and foci of air within the resection bed with surrounding edema and 10 mm of rightward midline shift, previously 7 mm on MRI ___. 4. Right-sided pneumocephalus and right-sided extra-axial fluid are likely postoperative. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with right parieto-temporal brain mass// evaluate brain mass TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration 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: Outside hospital CT head ___ FINDINGS: Centered within the right frontotemporal operculum, there is a T1 isointense, T2 heterogeneously hyperintense, heterogeneously enhancing mass measuring approximately 5.2 x 3.3 x 3.6 cm (AP by TV by SI). The mass contains numerous small cystic components, areas of restricted diffusion, and areas of intralesional hemorrhage. There is extensive vasogenic edema seen within the surrounding white matter with extension into the right insular cortex, right basal ganglia, and right thalamus. There is resultant local mass effect, with effacement of the adjacent sulci. Additionally, there is approximately 9 mm of leftward midline shift. Uncal herniation is seen on the right, without evidence for downward herniation at this time. There is moderate effacement of the right lateral ventricle. The remainder of the ventricular system appears unremarkable. The basal cisterns are patent. The right M1/M2 segments appear pushed anteriorly from the resultant mass effect, but appear patent on this non angiographic phase study. Otherwise, there is gross preservation of the principal intracranial vascular flow voids. The dural venous sinuses appear patent on MP-RAGE imagine sequences. There is complete opacification of the left sphenoid sinus. The remainder of the visualized paranasal sinuses, middle ear cavities, and mastoid air cells are well aerated and clear. The orbits are within normal limits bilaterally. IMPRESSION: 1. 5.2 x 3.3 x 3.6 cm heterogeneous, enhancing mass centered within the right frontotemporal operculum containing areas of restricted diffusion, internal hemorrhage, and numerous cystic components. Findings are suggestive of a primary intra-axial neoplasm, such as a high-grade glioma. A lower grade glioma would be unlikely given the extent of enhancement. Metastatic disease along the differential is considered much less likely. 2. Associated mass effect, with 9 mm of leftward midline shift, moderate effacement of the right lateral ventricle, and moderate right uncal herniation. 3. Additional findings described above. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with right parieto-temporal brain mass // evaluate for metastatic disease TECHNIQUE: Abdomen and pelvis CT: Post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. 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 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP = 16.2 mGy-cm. 3) Spiral Acquisition 16.4 s, 63.1 cm; CTDIvol = 8.1 mGy (Body) DLP = 495.3 mGy-cm. Total DLP (Body) = 533 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Please refer to the separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, 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 stones, focal renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. Trace free fluid in pelvis is physiologic. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: No evidence of metastatic disease in the abdomen or pelvis. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD INDICATION: ___ year old woman with new R parietal ring enhancing brain lesion, with vasogenic edema, mass effect and MLS// Evaluate vascularity of R parietal lesion TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Next, rapid axial imaging was performed through the brain during the uneventful infusion of 70 mL of Omnipaque intravenous contrast material. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. 2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7 mGy-cm. 3) Stationary Acquisition 3.5 s, 1.0 cm; CTDIvol = 26.1 mGy (Head) DLP = 26.1 mGy-cm. 4) Spiral Acquisition 5.1 s, 19.7 cm; CTDIvol = 25.4 mGy (Head) DLP = 459.8 mGy-cm. Total DLP (Head) = 1,338 mGy-cm. COMPARISON: CT head and MR head ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is a large heterogeneous 4.7 x 3 cm temporoparietal mass with associated mass effect and surrounding vasogenic edema. There is moderate effacement of the right lateral ventricle. There is 9 mm of midline shift to the left. There is evidence of uncal herniation on the right. There is no evidence hemorrhage. There is a moderate-sized mucosal cyst in the right maxillary sinus. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The right M1 segment appears to be displaced anteriorly and superiorly. There is displacement and narrowing of multiple sylvian branches of the right MCA. There is a prominent vessel extending laterally within the area of the lesion which likely represents early venous filling. The remaining vessels of the circle of ___ and their principal intracranial branches appear normal with no evidence of stenosis, occlusion, or aneurysm. The dural venous sinuses are patent. IMPRESSION: 1. Large heterogeneous temporoparietal mass with associated mass effect, 9 mm of midline shift to the left, and surrounding vasogenic edema, unchanged compared to prior study. 2. There is displacement of the right M1 segment and displacement and narrowing of multiple right MCA sylvian branches. 3. Prominent ecstatic vessel extending laterally within the area lesion, likely demonstrating early venous filling. Radiology Report EXAMINATION: Functional MRI INDICATION: ___ year old woman with new R parietal ring enhancing brain lesion, with vasogenic edema, mass effect and MLS // Pre-op evaluation, please include DTI sequences TECHNIQUE: The examination was performed using a 3.0T MRI scanner. After the uneventful administration of 5 ml of Gadavist contrast agent, axial FSPGR, axial Arterial Spin Labeled (ASL), diffusion tensor images (DTI) using 36 directions and task based functional imaging paradigms were obtained. Functional imaging was performed using Echo Planar/BOLD (blood oxygen level dependent) technique using block design functional paradigms. The functional paradigms include analysis of the motor areas during the alternating movement of the left hand (motion =3 mm), right hand and feet (motion =less than 2 mm) and tongue (motion =less than 2 mm) and language areas during the mental process of generating words with different letters (motion =2.5 mm during native language, less than 2 mm during ___ language). Post processing of functional images, DTI fiber tractography and reference image skull stripping was performed using a dedicated workstation. All obtained and derived images were used to generate this report. COMPARISON: ___ contrast brain MRI. FINDINGS: Motion during left hand and native word generation tasks did exceed 2 mm which makes these images potentially nondiagnostic. Again is demonstrated a stable peripherally enhancing, centrally cystic/necrotic mass in the right frontotemporal operculum with surrounding vasogenic edema. The mass demonstrates slow diffusion in its periphery with surrounding vasogenic edema in the white matter, but no obvious restricted diffusion in this white matter. Mass effect with leftward midline shift and mild uncal herniation as previously described. The arterial spin labeled sequence is notable for increased perfusion peripherally in this mass. The tractography color maps demonstrate medial and anterior deviation of the major corticospinal tracts. In the immediate vicinity of the tumor there are multiple association and commissural tracks displaced inferiorly and medially. The functional MRI demonstrates BOLD activation areas during the movement of the hands, feet and tongue. Bold activation during right toe movement is a the expected position of the medial left motor cortex. Bold activation during left toe movement is poor. Bold activation during right hand movement is in the expected position of the left motor cortex. Bold activation during left hand movement is in the expected position of the right motor cortex away from the tumor, but please note that these images are potentially nondiagnostic due to motion. Bold activation during tongue movement is poor which makes placement of its bold topography difficult. Bold activation during native word generation is poor, but is seen predominantly in the left hemisphere, most likely related to dominance but please note that the images are potentially nondiagnostic due to motion. Bold activation during ___ language word generation is poor IMPRESSION: 1. Stable right frontotemporal opercular mass as described above, with increased peripheral perfusion, medial deviation of the major corticospinal tracts. 2. Inferior and medial displacement of the immediately adjacent association and commisural fibers suggest superolateral entry may be favorable. 3. Motion artifact degrades the diagnostic sensitivity of the left hand and native word generation tasks. Poor BOLD signal on many of the fMRI tasks of the left side of the body most likely secondary to impaired patient cooperation due to right frontotemporal mass with associated cerebral edema. 4. Native language paradigm demonstrates the propagation of activation in the convexity with the majority of the BOLD activity in the left cerebral hemisphere, likely related with dominance. Please take note of the decreased degree of certainty due to potential motion artifact. RECOMMENDATION(S): 1. Radiology Report EXAMINATION: MR HEAD W/ CONTRAST T___ MR HEAD INDICATION: ___ with new R parietal ring enhancing brain lesion, with vasogenic edema, mass effect and MLS.// Pre-operative planning, please perform prior to 6am ___ TECHNIQUE: After administration of 5 mL of Gadavist intravenous contrast, axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal orientation reformatted images of the MPRAGE acquisition was then produced. COMPARISON: MR head ___. FINDINGS: The patient's previously noted right frontotemporal heterogeneously enhancing lesion measuring 5 x 3 x 3.7 cm is again seen. There is a large area of ring enhancement with central hypointensities, likely representing necrosis. There is surrounding vasogenic edema with associated mass effect and moderate effacement of the right lateral ventricle. There is 6 mm of midline shift to the left. There is evidence of uncal herniation on the right. IMPRESSION: 1. Stable right frontotemporal heterogeneously enhancing lesion with associated mass effect, leftward midline shift, and uncal herniation on the right. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ woman with brain mass. Evaluate for metastatic disease. 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) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP = 16.2 mGy-cm. 3) Spiral Acquisition 16.4 s, 63.1 cm; CTDIvol = 8.1 mGy (Body) DLP = 495.3 mGy-cm. Total DLP (Body) = 533 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: None FINDINGS: HEART AND VASCULATURE: Main pulmonary artery and thoracic aorta are normal in caliber. Heart size is normal. No pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Central airways are patent. There is no pulmonary consolidation. There is mild pleural/parenchymal scarring at bilateral apices. There is a 2 mm nonspecific nodule, probably ground-glass in attenuation, in the anterior basal right lower lobe on image 7:172. A tiny linear pleural tag is incidentally noted in the left upper lobe on image 7:66. BASE OF NECK: Visualized thyroid is unremarkable. ABDOMEN: Concurrent abdominal/pelvic CT is reported separately. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 2 mm nonspecific, probably ground-glass nodule in the right lower lobe. RECOMMENDATION(S): For an incidentally detected single ground-glass nodule smaller than 6 mm, no CT follow-up is recommended. See the ___ ___ Society Guidelines for the Management of Pulmonary Nodules Incidentally Detected on CT" for comments and reference: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman s/p crany and R tumor excision// POD 1 TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 4.5 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: CT head without contrast ___, MR head with contrast ___ FINDINGS: There is evidence of right-sided craniotomy. The previously seen right frontotemporal lesion has been resected. There is evidence of pneumocephalus and an overlying extra-axial collection, consistent with postsurgical changes. On gradient and T1 precontrast images there is evidence of hemorrhage in the surgical bed. Surrounding edema with 9 mm of midline shift, and evidence of mass effect with partial effacement of the right lateral ventricle, is overall similar to prior exam. T2/FLAIR hyperintensities in the subcortical and periventricular white matter are nonspecific, but may represent sequela of chronic migraine headache, prior trauma, infectious/inflammatory etiology or small vessel ischemic disease in a patient of this age. There is postoperative mild dural thickening and enhancement, subjacent to the craniotomy site. There is no abnormal enhancement or definite nodular masslike enhancement after contrast administration. No acute infarct is identified. There is diffusion-weighted hyperintense signal along the margins of the resection bed, compatible with a combination of operative changes and hemorrhage product. There is a mucous retention cyst seen within the right maxillary sinus. There is opacification of the left sphenoid sinus. The remaining paranasal sinuses and mastoid air cells appear clear. The orbits are unremarkable. There is evidence of soft tissue swelling overlying the right frontal and temporal lobes which extends down over the zygoma. IMPRESSION: 1. Status post right-sided craniotomy and resection of previously seen frontotemporal lesion, with expected postsurgical changes of right-sided pneumocephalus and overlying extra-axial fluid collection. Mild expected dural thickening and enhancement underlying the craniotomy site is noted. 2. There is evidence of hemorrhage within the surgical bed and edema surrounding the surgical site with 9 mm of midline shift evidence of mass effect, similar to prior CT, but improved from preoperative MRI. 3. No definite evidence of masslike or nodular enhancement within the resection cavity. No acute infarct. 4. Additional findings as described above. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abnormal CT, Headache Diagnosed with Disorder of brain, unspecified temperature: 99.5 heartrate: 64.0 resprate: 18.0 o2sat: 100.0 sbp: 112.0 dbp: 75.0 level of pain: 1 level of acuity: 2.0

___ presenting with headaches, found to have new R parietal ring enhancing brain lesion with vasogenic edema, mass effect and MLS. #Neuro: Brain lesion The patient was admitted on ___ after outpatient ___ revealed a right parietal brain lesion during evaluation of headache. She underwent MRI which further demonstrated a right parietal ring enhancing lesion with vasogenic edema and mass effect. She was treated with dexamethasone for cerebral edema and keppra for seizure prophylaxis. Functional MRI and CTA for surgical planning were completed on ___. CT Torso was performed to evaluate for primary malignancy, which was negative. Patient underwent a right craniotomy for tumor resection with Dr. ___ on ___. Please see separately dictated operative report for complete details of procedure. Patient was extubated in the OR and transferred to the PACU for recovery. Post-op head CT showed expected post-operative changes and continued vasogenic edema. She was neurologically and hemodynamically stable and was transferred to the floor. Post-op MRI showed expected postsurgical changes and edema surrounding the surgical site with 9 mm of midline shift evidence of mass effect, similar to prior CT, but improved from preoperative MRI. Decadron was tapered to 4 bid. On POD#4 she remained neurologically intact, was tolerating PO diet, ambulating independent and pain remained well controlled. She was cleared for discharge home by OT with intermittent family supervision.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: none History of Present Illness: ___. is a ___ male who presents to ___ on ___ with a moderate TBI. The patient was originally brought to ___ by a friend and HCP after he woke up with a frontal headache and noted that he had a bump on the back of his head. The patient has no recollection of falling during the night and he awoke in his own bed. He called his cardiologist for recommendations given his Coumadin use and he was instructed to go to the ED. On arrival to ___, he had a NCHCT. After discovery of a subarachnoid/subdural hemorrhage, his INR of 3.4 was treated with Kentra and Vit K and he was medflighted to ___. Past Medical History: Cardiac ablation for atrial flutter ___ multiple DVTs that were unprovoked requiring lifelong Coumadin and IVC filter placement in ___. Hyperlipidemia Hypertension Social History: ___ Family History: Father: old age, early ___. Mother: pancreatic cancer age ___. Physical Exam: exam on admission and discharge: GCS ___ Eye Opening: [x]4 Opens eyes spontaneously Verbal: [x]5 Oriented Motor: [x]6 Obeys commands Gen: WD/WN, comfortable, NAD. Extrem: warm and well perfused Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Pertinent Results: please see OMR for pertinent results Medications on Admission: ACYCLOVIR [ZOVIRAX] - Zovirax 5 % topical ointment. apply as needed prm every 4 hours 60 grams FINASTERIDE - finasteride 5 mg tablet. 1 tablet(s) by mouth daily LISINOPRIL - lisinopril 5 mg tablet. 1 Tablet(s) by mouth once a day - (Prescribed by Other Provider) METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1 tablet(s) by mouth twice daily OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. one capsule(s) by mouth twice daily TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth once a day WARFARIN - warfarin 4 mg tablet. 1 tablet(s) by mouth one daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 3. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every 12 hours Disp #*12 Tablet Refills:*0 4. TraMADol 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours as needed Disp #*20 Tablet Refills:*0 5. Finasteride 5 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10.Outpatient Physical Therapy Evaluate and treat, s/p fall with subdural hematoma Discharge Disposition: Home Discharge Diagnosis: subdural hematoma h/o DVTs 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 Q16 CT NECK INDICATION: History: ___ with SAH, subdural eval for aneurismal bleed// SAH, subdural eval for aneurismal bleed 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) Sequenced Acquisition 2.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 200.7 mGy-cm. 3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 87.1 mGy (Head) DLP = 43.6 mGy-cm. 4) Spiral Acquisition 5.5 s, 43.5 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,351.0 mGy-cm. Total DLP (Head) = 2,498 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is right hemispheric acute subdural hematoma overlying right frontal, parietal, temporal occipital lobes, measuring 0.6 cm in maximum thickness. Midline shift is 0.4 cm to the left. There is acute tentorial subdural hemorrhage, measuring 1.2 cm maximum thickness focally, otherwise it is very thin at other levels. There is acute small volume subarachnoid hemorrhage overlying right temporal, parietal and occipital lobes.. Subarachnoid hemorrhage does not extend into the sylvian fissure or basal cisterns. Suggestion of trace intraventricular hemorrhage within left occipital horn. There are mild to moderate chronic small vessel ischemic changes. There is no evidence of acute infarct. Partial effacement right perimesencephalic cistern. Patent pre pontine cistern, foramen magnum. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. Suboptimal filling of the abdominal right transverse and sigmoid sinuses, may be related to mass effect from adjacent subdural hematoma. Recommend MR venogram to exclude thrombosis. Filling of the medial, central portion of jugular vein at the jugular foramen, suggesting of a filling defect more laterally.. Remainder venous sinuses are patent. CTA NECK: There is probably metal related artifact projecting at the same level within proximal subclavian arteries. Mild atherosclerotic narrowing of the proximal left V2 segment vertebral artery. The carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. 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. Bilateral submandibular glands are atrophic. IMPRESSION: 1. No evidence of aneurysm. 2. Acute subdural hematoma overlying right cerebral hemisphere, and layering along the tentorium. 0.4 cm midline shift to the left. Effaced right perimesencephalic cistern. 3. Right convexal mild volume subarachnoid hemorrhage, without extension into the basilar cisterns. 4. Suboptimal filling of a dominant right transverse, sigmoid sinus, may be related to adjacent tentorial hemorrhage, suggestion of a filling defect at the jugular foramen along the lateral wall, recommend MR ___ to exclude dural venous sinus thrombosis. RECOMMENDATION(S): MR ___ NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:49 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with R SDH// Eval for interval change; pls do ___ before 8am 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: Head CT dated ___. FINDINGS: Small acute right subdural hemorrhage along the right convexity currently measures 8.1 mm, previously 7 mm, although this is likely unchanged accounting for differences in technique and slice selection. There is mild effacement of the adjacent sulci along the right convexity. As before, hyperdensities in the right parietal, temporal, and occipital sulci are compatible with subarachnoid hemorrhage. Hyperdense hemorrhage layering along the tentorium bilaterally, right greater than left, is unchanged. There is a small foci of hemorrhage in the superior cerebellar cistern as before. There is approximately 3.5 mm of midline shift, unchanged. There is no evidence of fracture. 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. No significant change from prior. Acute small right subdural hemorrhage, diffuse subarachnoid hemorrhage in the right temporal, occipital and parietal lobes, as well as hyperdense hemorrhage along the tentorium bilaterally, right greater than left, are unchanged. 2. Approximately 3.5 mm of midline shift, unchanged. Gender: M Race: WHITE Arrive by HELICOPTER Chief complaint: s/p Fall, SAH, SDH, Transfer Diagnosed with Nontraumatic intracranial hemorrhage, unspecified, Personal history of other venous thrombosis and embolism, Long term (current) use of anticoagulants temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Mr. ___ is a ___ male on Coumadin for DVTs admitted from the ED with TBI. #Subdural hematoma CT head showed right side SDH, SAH and SDH along the tentorium. He was neurologically intact. INR at OSH was 3.4 and was reversed with K centra and Vitamin K. Repeat INR on arrival was 1.5. Repeat CT on ___ was stable. He was given a second dose of Vitamin K and INR was 1.3. He remained neurologically intact. He was evaluated by Physical Therapy, who recommended cleared him for discharge home with outpatient ___. He will follow up in 1 week with repeat head CT to discuss resuming Coumadin. #H/o DVTs on Coumadin Coumadin was held and reversed on admission. Patient has IVC ___ in place. There is still risk of stroke/DVT while holding Coumadin, and this was discussed with patient, however, this risk is outweighed by risk of bleeding with acute intracranial hemorrhage. Plan to hold for at least 1 week, until follow up with neurosurgery.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adhesive / codeine / ketorolac Attending: ___. Chief Complaint: Neck Abscess Major Surgical or Invasive Procedure: Intubation Extubation ___ aspiration of neck abscess History of Present Illness: ___ without significant past medical history who presented as a transfer from ___ due to enlarging neck abscess. Patient reported at presentation to the ___ ED that she had been unable to swallow water or pills after 2 days of throat swelling. Her pharyngitis had been previously felt to be viral ___ etiology. However, on presentation to the OSH, she was noted to be visibly short of breath with stridor. While ___ the OSH ED, she was found to have a WBC 15.4 with 88% PMNs. She was given a dose of clindamycin there and intubated. CT of the Neck showed a large rim-enhacing fluid collection that wrapped around the posterior aspect of the larynx. She also received racemic epinephrine, methylprednisolone, etomidate and succinylcholine as well as propofol, midazolam and fentanyl. She was then transferred to ___ ED for further management. ___ the ED, initial VS were as follows: 81 122/70 24 100% Intubation. Patient was then transferred to the MICU for further management. While ___ the ED, she received Unasyn 3g IV X 1, Dexamethasone 8mg X 1, Vancomycin 1mg X 1 ___s acetaminophen 1000mg IV X 1, fentanyl and propofol and NS at 125cc/hr. Vital signs at transfer were as follows: 59 117/61 15 98% Intubation. Past Medical History: Nephrolithiasis Social History: ___ Family History: None reported Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: intubated, sedated, ___ NAD HEENT: sclera anicteric LUNGS: clear to auscultation anteriorly, no wheezes CV: regular, no murmurs ABD: soft, non-tender, non-distended, no guarding or rebound EXT: warm, well perfused, no pedal edema SKIN: no rashes NEURO: sleepy but awakes to voice DISCHARGE PHYSICAL EXAM: Vitals: 98.0 135/82 42 16 97 Ra General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 09:08AM WBC-14.8* RBC-4.02 HGB-12.1 HCT-37.2 MCV-93 MCH-30.1 MCHC-32.5 RDW-12.4 RDWSD-42.3 ___ 09:08AM NEUTS-92.6* LYMPHS-2.5* MONOS-3.9* EOS-0.0* BASOS-0.1 IM ___ AbsNeut-13.65* AbsLymp-0.37* AbsMono-0.58 AbsEos-0.00* AbsBaso-0.02 ___ 09:08AM GLUCOSE-127* UREA N-11 CREAT-0.5 SODIUM-140 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-20* ANION GAP-16 ___ 09:24AM LACTATE-1.5 ___ 09:36AM ___ PO2-30* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS--1 INTUBATED-INTUBATED ___ 10:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG ___ 10:54AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 10:54AM URINE COLOR-Yellow APPEAR-Clear SP ___ DISCHARGE LABS: ___ 07:20AM BLOOD WBC-12.1* RBC-4.12 Hgb-12.2 Hct-40.1 MCV-97# MCH-29.6 MCHC-30.4* RDW-12.4 RDWSD-43.8 Plt ___ ___ 07:20AM BLOOD Glucose-75 UreaN-23* Creat-0.6 Na-142 K-4.2 Cl-109* HCO3-18* AnGap-19 ___ 07:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.3 MICRO: ___ 4:10 pm ABSCESS Source: neck abscess. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND ___ SHORT CHAINS. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Preliminary): RESULTS PENDING. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. IMAGING/REPORTS CT NECK ___ IMPRESSION: Large irregular crescent shaped faintly rim-enhancing intermediate density fluid collection immediately anterior to the hyoid bone and wrapping around the posterior aspect of the larynx on the left. Posterior C-spine fusion at C4-C5. Degenerative changes and facet hypertrophy seen at C5-C6 with slight grade 1 spondylolisthesis. Complex hypodense thyroid lesions arising from both inferior poles. CT NECK ___ IMPRESSION: 1. No significant change ___ the fluid collection extending from the left inferior margin of the hyoid bone inferiorly over bilateral thyroid cartilages. Rim enhancement is most pronounced along the left superior portion of the collection, similar to the prior study, and less conspicuous than on the prior study along the inferior bilateral portion of the collection. This is overall compatible with an abscess 2. Left greater than right strap muscle edema has improved. New trace fluid extending from the caudal portion of the above-described fluid collection ___ the midline to the level of the thyroid isthmus, without rim enhancement. 3. The above-described collection displaces the left thyrohyoid membrane medially and displaces the airway to the right. The patient is intubated. 4. Bilateral thyroid nodules measuring up to 1.6 cm. Medications on Admission: None Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*13 Tablet Refills:*0 2. Methylprednisolone 16 mg PO DAILY On ___ take 16mg, on ___ take 12mg, on ___ take 8mg, on ___ take 4mg Tapered dose - DOWN RX *methylprednisolone 4 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY - neck phlegmon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with abscess, intubated. ETT placement? TECHNIQUE: Frontal chest radiograph COMPARISON: None. FINDINGS: Patient is status post endotracheal tube placement with tip projecting over the mid thoracic trachea. The enteric tube is seen below the diaphragm with tip coiling and projecting over the expected location of the distal esophagus. The lungs are well inflated and clear. There is no pleural effusion or pneumothorax. The heart size is within normal limits. Mediastinal hilar contours are unremarkable. IMPRESSION: -Endotracheal tube in appropriate location. -Enteric tube tip coiling and projecting over the distal esophagus. Repositioning is recommended. -No acute intrathoracic abnormalities. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with neck abscess, intubated// confirm placement of ET tube confirm placement of ET tube IMPRESSION: Comparison to 11. ___. The endotracheal tube and the feeding tube remain in stable correct position. The feeding tube has been pulled back, the side hole is now at the level of the gastroesophageal junction. Stable normal size of the heart. No pulmonary edema, no pleural effusions. No pneumonia. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old woman with neck abscess. Please evaluate neck abscess, extent and any improvement. TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.5 s, 27.7 cm; CTDIvol = 4.6 mGy (Body) DLP = 126.9 mGy-cm. Total DLP (Body) = 127 mGy-cm. COMPARISON: CT neck from ___ FINDINGS: There is a fluid collection abutting the left inferior margin of the hyoid bone of which crosses the midline inferior to the hyoid bone, extending over or bilateral thyroid cartilages. While it is difficult to measure this collection due to its complex geometry, it does not appear significantly changed in size, for example measuring approximately 2.9 x 1.8 cm in the left neck (02:49), previously 2.9 x 1.6 cm. The thickness of the hypodense fluid anterior to the cricoid cartilage measures up to 8 mm, previously 9 mm (02:54). There is partial rim enhancement along the left superior part of the collection, similar to the prior study, with thinner and less avid rim enhancement of the lower bilateral portion of the collection. Thickening of left greater than right strap muscles caudal to the collection has decreased since the prior study. However, there is new trace fluid without rim enhancement tracking inferiorly in the midline to the level of the thyroid isthmus, image 602:27. The collection appears to displace the left thyrohyoid membrane medially, with rightward shift of the airway. The patient is status post endotracheal intubation and orogastric tube placement, with associated secretions along the pharyngeal courses of the tubes. Evaluation of the mucosal surfaces is limited. The salivary glands appear unremarkable. There are multiple bilateral thyroid nodules measuring up to 1.6 cm on the left, image 602:35. No pathologically enlarged cervical or supraclavicular lymph nodes are seen. Cervical carotid and vertebral arteries appear patent. Allowing for mixing artifact from the external circulation branches, internal jugular veins appear patent. There is mild pleural/parenchymal scarring at the included lung apices. There are no suspicious osseous lesions concerning for infection or malignancy. Patient is status post instrumented fusion of C4-5 spinous processes with cerclage wires. There is partial fusion of C4 and C5 vertebral bodies and facet joints, possibly congenital. 3 mm anterolisthesis of C5 on C6 is unchanged. Some of the bilateral anterior ethmoid air cells are opacified. There is trace fluid in the right sphenoid sinus, image 2:9, likely secondary to prolonged supine positioning and endotracheal intubation. Mastoid air cells appear clear. This exam is not technically optimized for evaluation of the included intracranial structures, but no concerning abnormalities are seen. IMPRESSION: 1. No significant change in the fluid collection extending from the left inferior margin of the hyoid bone inferiorly over bilateral thyroid cartilages. Rim enhancement is most pronounced along the left superior portion of the collection, similar to the prior study, and less conspicuous than on the prior study along the inferior bilateral portion of the collection. This is overall compatible with an abscess 2. Left greater than right strap muscle edema has improved. New trace fluid extending from the caudal portion of the above-described fluid collection in the midline to the level of the thyroid isthmus, without rim enhancement. 3. The above-described collection displaces the left thyrohyoid membrane medially and displaces the airway to the right. The patient is intubated. 4. Bilateral thyroid nodules measuring up to 1.6 cm. RECOMMENDATION(S): Outpatient thyroid ultrasound is recommended according to the ACR guidelines for nodules exceeding 1.5 cm. Radiology Report INDICATION: ___ year old woman with neck abscess// Please perform diagnostic/therapeutic drainage, would like cytology, gram stain and culture of aspirate COMPARISON: CT neck ___ PROCEDURE: Ultrasound-guided drainage of left neck collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the bed. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, a 16 gauge needle into the collection. Approximately 1 cc of purulent fluid was drained with a sample sent for microbiology evaluation. The needle was removed. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 1 mg Versed and 50 mcg fentanyl throughout the total intra-service time of 20 minutes during which patient's hemodynamic parameters were continuously monitored by the ICU nurse. FINDINGS: A small collection of fluid is seen measuring 2.6 x 1.7 x 1.1 cm. This was aspirated to completion. After aspiration of the fluid, the phlegmonous tissue is seen remaining in the neck but no remaining fluid. IMPRESSION: Successful US-guided complete aspiration of a left neck collection. Samples was sent for microbiology evaluation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abscess, Transfer Diagnosed with Cutaneous abscess of neck temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: uta level of acuity: 1.0

___ without significant past medical history who presented as a transfer from ___ due to enlarging neck phlegmon requiring intubation for airway protection # NECK PHLEGMON: Patient presents with evidence on imaging of large abscess ___ the neck. ENT consulted on patient ___ the ED and attempted aspiration but was unsuccessful. Patient was intubated due to respiratory distress/stridor. Follow up CT did not show improvement ___ abscess so she had ___ aspiration with only a small amount of fluid aspirated, consistent with phlegmon, rather than abscess. She subsequently developed a cuff leak and was able to be extubated. She was treated ___ the ICU with vancomycin, unasyn and dexamethasone 8 mg q8h per ENT recommendations. This was transitioned to Medrol Pak and Augmentin after extubation. She will follow up with ENT ___ weeks after discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Codeine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / morphine Attending: ___. Chief Complaint: odynophagia Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is a ___ year old female with multiple medical problems including distant gastric bypass with multiple complications and subsequent surgeries, chronic abdominal pain, substance abuse, and pulmonary embolism currently on lovenox who presents with 3 days of odynophagia and burning chest pain. She has chronic epigastric abdominal discomfort and nausea related to multiple surgeries. She was in her normal state of health until three days ago when she developed substernal burning chest discommfort and odynophagia. She states that these symkptoms are identical to a prior episode of ___ esophagitis in ___. She describes the pain as sharp and burning with swallowing - worse with solids than liquids. She can swallow pills. There is no radiation, no change with position, no shortness of breath. She also endorses low grade fever to 100.2 at home several days ago, as well as multiple episodes of diarrhea on ___ and ___ which have since resolved. No melana, BRBPR. She reports her weight has been stable at 138 pounds. The patient was admitted in ___ for odynophagia. She had an EGD on ___ that demonstrating esophageal candidiasis and longitudinal ulcerations at the gastroesophageal junction and the cardia. She was treated with a 3 week course of fluconazole. She was also given carafate QID, PPI, BID, and cholestyramine. An HIV test and H. pylori was negative. A dobhoff tube was placed during this admission and tube feeds were started for malnutrition. She was in rehab from ___ until ___. Per Dr. ___ G tube was attempted in ___ at ___ but she developed a hematoma so it was removed. In the ED, initial vs were: T98.6 87 134/78 16 96%RA. On exam patient was uncomfortable, complaining of ___ mid-sternal CP which she describes as "esophagus" pain. Exam is notable for dry mucus membranes, no appreciable oral lesions or evidence for candidiasis. [ ] CBC with diff, lytes: no leukocytosis [x] troponin: negative [x] IVF bolus, 1L NS [x] EKG: consistent with prior [ ] CXR [x] Nausea: IV zofran [x] pain control: IV dilaudid PRN, pt is on chronic methadone [x] GI: touched base with her GI Dr. ___ recs as he has not seen her as a pt before --> GI consult, per GI admit to medicine and they will see her as an inpatient Review of sytems: (+) Per HPI (-) Ten point review of systems is otherwise negative. Past Medical History: -Morbid obesity (max 448lbs) s/p gastric bypass & CCY at ___ and complete reversal -History of HTN, DM, asthma (prior to gastric bypass) -Opiate addiction: prior intranasal herion, oral dilaudid abuse, now on suboxone -Depression/Anxiety -Esophagitis: EGD ___ showed mild active esophagitis. -DJD -2 SBOs -Menopause completed Past Surgical History: -___- gastric bypass & CCY and subsequent complete reversal -7 surgeries on the abdomen. "stomach leak" hernia, 2 SBOs, attempted reverse of the gastric bypass, the most recent in ___ Social History: ___ Family History: -Mother with diabetes Physical Exam: General: appears older than stated age, comfortable HEENT: anicteric sclera, oropharynx clear Lungs: CTA bilaterally, unlabored CV: S1, S2 regular rhythm, normal rate Abdomen: healed surgical scars, soft, non-tender, non-distended Ext: warm, distal pulses intact Skin: no obvious rash Neuro: alert, speech fluent, tongue midline Pertinent Results: ___ 10:00AM BLOOD WBC-4.2 RBC-4.10*# Hgb-12.2# Hct-39.2# MCV-96 MCH-29.8 MCHC-31.2 RDW-14.0 Plt ___ ___ 06:35AM BLOOD Plt ___ ___ 10:00AM BLOOD Plt ___ ___ 10:00AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-141 K-3.5 Cl-97 HCO3-32 AnGap-16 ___ 06:35AM BLOOD Glucose-81 UreaN-8 Creat-0.7 Na-142 K-3.5 Cl-105 HCO3-32 AnGap-9 ___ 07:30AM BLOOD Glucose-72 UreaN-8 Creat-0.8 Na-139 K-3.5 Cl-101 HCO3-32 AnGap-10 ___ 10:00AM BLOOD ALT-10 AST-19 LD(LDH)-219 AlkPhos-112* TotBili-0.2 ___ 10:00AM BLOOD Lipase-10 ___ 10:00AM BLOOD cTropnT-<0.01 ___ 06:35AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 07:30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8 ___ 07:30AM BLOOD HIV Ab-NEGATIVE ___ 06:35AM BLOOD COPPER (SERUM)-117 . CXR: FINDINGS: AP upright and lateral views of the chest were provided. Lungs appear clear bilaterally without focal consolidation, effusion or pneumothorax. There is no free air below the right hemidiaphragm. The cardiomediastinal silhouette is normal. The bony structures are intact. IMPRESSION: No acute findings. . SMALL BOWEL FOLLOW THROUGH FINDINGS: Upon review of prior CT abdomen/pelvis, it was determined that the patient is status post gastric bypass with complete reversal of the bypass. The stomach appears slightly deformed with thickened and edematous gastric folds, likely secondary to surgical changes. Thin barium passes appropriately through the distal antrum into the duodenum, and then into the jejunum. There is no contrast filling of the Roux limb, which presumably was closed or excised. There is no extravasation of contrast to suggest fistula or leak. Small-bowel follow-through was limited due to patient fatigue and inability to tolerate swallowing much barium. Considerable portions of the distal small bowel are only minimally opacified and contrast opacification was not pursued to the terminal ileum. There is dilation of small bowel loops at the JJ anastomosis. Mild reflux of contrast past the GE junction into the distal ___ of the esophagus is noted. IMPRESSION: 1. Status post gastric bypass, with complete reversal. Contrast passes from the stomach into the duodenum and then jejunum as intended, without extravasation of contrast to suggest fistula or leak. 2. Thickened and edematous gastric folds, likely secondary to prior surgeries. 3. Mild reflux at the GE junction into the distal ___ of the esophagus. . . EGD: Findings: Esophagus: Mucosa:Erosive esophagitis with ulcerations and contact bleeding was seen extending up to 28cm. Cold forceps biopsies were performed for histology at the esophagus; biopsies were also sent for viral culture. Stomach: OtherAn end-end gastrojejunal anastomosis was seen, with a small remnant gastric pouch. There was also a suture with granulomatous tissue around it in the proximal gastric pouch. Bile was seen in the remnant gastric pouch as well. Jejunum:Normal jejunum. Impression:Esophagitis (biopsy) An end-end gastrojejunal anastomosis was seen, with a small remnant gastric pouch. There was also a suture with granulomatous tissue around it in the proximal gastric pouch. Bile was seen in the remnant gastric pouch as well. Otherwise normal EGD to jejunum Recommendations:F/u biopsies Further management per inpatient team . GI BIOPSY: PATHOLOGIC DIAGNOSIS: Esophageal mucosal biopsy: - Squamous mucosa, with rare eosinophils, spongiosis and increased basal zone regeneration, consistent with mildly active esophagitis. . GI BIOPSY: ime Taken Not Noted Log-In Date/Time: ___ 2:07 pm VIRAL CULTURE: R/O CYTOMEGALOVIRUS Site: ESOPHAGUS TEST VERIFIED BY ___ ___. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Herpes simplex (HSV) virus isolated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. ClonazePAM 1 mg PO TID 3. copper gluconate 2 mg oral daily 4. Doxepin HCl 75 mg PO HS 5. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 6. Furosemide 40 mg PO BID 7. Methadone 10 mg PO Q6H 8. Mirtazapine 22.5 mg PO HS 9. Omeprazole 20 mg PO BID 10. QUEtiapine Fumarate 100 mg PO QAM 11. QUEtiapine Fumarate 300 mg PO QHS 12. Sucralfate 1 gm PO QID 13. Vitamin D 1000 UNIT PO DAILY 14. Cyanocobalamin Dose is Unknown PO DAILY 15. Magnesium Oxide Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. ClonazePAM 1 mg PO TID 3. copper gluconate 2 mg oral daily 4. Doxepin HCl 75 mg PO HS 5. Methadone 10 mg PO Q6H 6. Mirtazapine 22.5 mg PO HS 7. QUEtiapine Fumarate 100 mg PO QAM 8. QUEtiapine Fumarate 300 mg PO QHS 9. Sucralfate 1 gm PO QID 10. Cholestyramine 4 gm PO TID RX *cholestyramine (with sugar) 4 gram 1 packet by mouth three times a day Disp #*90 Not Specified Refills:*0 11. Lidocaine Viscous 2% 15 mL PO TID RX ___ [FIRST-Mouthwash BLM] 400 mg-400 mg-40 mg-25 mg-200 mg/30 mL ___ teaspoons three times a day Disp #*450 Milliliter Refills:*0 12. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule,delayed ___ by mouth twice a day Disp #*60 Capsule Refills:*0 13. Furosemide 40 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN odynophagia 16. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q6 Disp #*35 Tablet Refills:*0 17. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Esophagitis 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 ___ COMPARISON: Prior chest CT from ___ as well as a chest radiograph from ___. CLINICAL HISTORY: Past medical history of gastric bypass and multiple abdominal surgeries with recent pneumonia, who presents with chest pain, assess for pneumonia or free air. FINDINGS: AP upright and lateral views of the chest were provided. Lungs appear clear bilaterally without focal consolidation, effusion or pneumothorax. There is no free air below the right hemidiaphragm. The cardiomediastinal silhouette is normal. The bony structures are intact. IMPRESSION: No acute findings. Radiology Report HISTORY: History of gastric bypass with a small remnant gastric pouch admitted with esophagectomy. Evaluate for emptying and fistula. COMPARISON: CT abdomen/pelvis from ___ and ___. FINDINGS: Upon review of prior CT abdomen/pelvis, it was determined that the patient is status post gastric bypass with complete reversal of the bypass. The stomach appears slightly deformed with thickened and edematous gastric folds, likely secondary to surgical changes. Thin barium passes appropriately through the distal antrum into the duodenum, and then into the jejunum. There is no contrast filling of the Roux limb, which presumably was closed or excised. There is no extravasation of contrast to suggest fistula or leak. Small-bowel follow-through was limited due to patient fatigue and inability to tolerate swallowing much barium. Considerable portions of the distal small bowel are only minimally opacified and contrast opacification was not pursued to the terminal ileum. There is dilation of small bowel loops at the JJ anastomosis. Mild reflux of contrast past the GE junction into the distal ___ of the esophagus is noted. IMPRESSION: 1. Status post gastric bypass, with complete reversal. Contrast passes from the stomach into the duodenum and then jejunum as intended, without extravasation of contrast to suggest fistula or leak. 2. Thickened and edematous gastric folds, likely secondary to prior surgeries. 3. Mild reflux at the GE junction into the distal ___ of the esophagus. These findings were communicated via telephone by Dr. ___ to Dr. ___ at 1547 on ___. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: CHEST PAIN/WEAKNESS Diagnosed with CHEST PAIN NOS, ESOPHAGITIS UNSPECIFIED temperature: 98.6 heartrate: 87.0 resprate: 16.0 o2sat: 96.0 sbp: 134.0 dbp: 78.0 level of pain: 10 level of acuity: 3.0

ASSESSMENT AND PLAN: ___ year old female with multiple medical problems including distant gastric bypass with multiple complications and subsequent surgeries, chronic abdominal pain on methadone, and pulmonary embolism now on lovenox who presents with 3 days of odynophagia and burning chest pain. . #ODYNOPHAGIA / ESOPHAGITIS: Her presentation was most consistent with esophagitis due to GERD. She underwent EGD that confirmed esophagitis (grossly and on biopsy). VIral culture was negative. She has a history of ___ esophagitis (___) but biopsy did not demonstrate fungus. HIV test was negative. She was started on PPI BID and sucrulfate (slurry) 1gram QID. She was given viscous lidocaine to take prior to meals and was able to tolerate a regular diet. EGD noted bile in the stomach so she was started on cholestyramine. Small bowel follow through did not demonstrate fistula between remnant and gastric pouch causing non acid bile reflux. She will continue PPI BID, sucrulfate, and cholestyramine until she follows up with GI in ___ weeks (scheduled). She was given a prescription for GI cocktail with lidocaine that she can take for one week. She was given a small number of PO dilaudid for pain control. CHRONIC: #History of Copper deficiency: Followed by neurology and felt that long standing weakness may be ___ copper deficiency so she was started on supplemental copper. A copper level was checked and was within normal limits. She was continued on copper gluconate 2mg daily #Hx of DVT: She was continued on lovenox 1mg BID for history of venous thromboembolism. #Chronic Pain: She was continued on her home of methadone #Depression/anxiety: She was continued on home Doxepin, clonazepam, Quetapin, and Mirtazapin # CODE: DNR per patient

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: acute onset headache and R eye vision loss Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ year-old left-handed man with history of HIV+ on HAART, former IVDU, who presents with acute onset ~1400 of R facial HA, R eye twitching, R eye blurry vision, and "black spot" in R eye visual field(inferior temporal quadrant). The HA is R temporal and periorbital, pain is nonspecific and improving. There was no specific inciting event, and he has not had these symptoms before. He has a history of sinus headaches which he says are different from this. He said that he also seemed to have more difficulty walking and tripped but did not fall. He denied any focal weakness or numbness. He has no prior history of stroke or blood clots. He has been having some R-sided neck pain in the last few weeks, but has not had any recent trauma or manipulation of his neck. Initial NIHSS at 1530 was 4 (R eye visual field cut, slight R nasolabial fold decreased activation, RLE drift, RUE decr sharp sensation), repeat NIHSS at 1545 by attending of 2 (R eye visual field cut, RLE drift). HCT negative. CTA did not show any evident occlusions or stenoses. On neuro ROS, the pt says that he has had poorer memory and concentration for the last ___ months (e.g. forgetting details about books he has read). He denies 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. On general review of systems, the pt endorses ___ months of SOB with exertion, intermittent central/left chest pain not associated with exertion or SOB, intermittent R-sided abdominal pain. He denies recent fever or chills. No night sweats or recent weight loss, has had some weight gain. Denies cough. Denies palpitations. Denies nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria, has had slow urine stream. Denies arthralgias or myalgias. Has rash on back (?eczema). Past Medical History: HIV dx ___ History of IV drug use, crystal meth, now sober ___ years Anal HPV, internal external condyloma s/p surgery ___ L hand 3rd degree burns R hand cellulitis Tonsillectomy R knee surgery Anxiety Social History: ___ Family History: Maternal GF died of cerebral aneurysm. Paternal grandmother and grandfather had strokes in old age. Mother HTN, HLD. Father died of lung cancer. Brother and sister healthy. Depression runs on paternal side, anxiety on maternal side. Physical Exam: ADMISSION EXAM: Vitals: per flowsheet General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, few white spots on tongue, no thrush in oropharynx. No ocular bruits. Mild TTP R temple. Neck: Supple, no carotid/vertebral bruits appreciated. No nuchal rigidity. Mild tenderness along R trapezius. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, ND, mild TTP RLQ, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Monocular R temporal inferior quadrantanopia to finger counting and wiggling. Funduscopic exam on R showed a possible tortuous or cut off vessel, no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch, slightly less on R. VII: Initially had slower activation of R lower face, now appears resolved, facial musculature symmetric. 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: Normal bulk, tone throughout. No pronator drift bilaterally. On holding up RLE, has some drift downward. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R 5- ___ ___ 5- 5 5- 5 5 5 5 -Sensory: Patchy decreased pinprick sensation all over body, not in any specific distribution, no sensory level. Decreased cold sensation RLE. Decreased vibration sense bilateral ___ R more than L at toe and metatarsal. Proprioception intact both toes. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 1 2 3 1 R 2 1 2 3 1 Crossed adductors bilaterally Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. R hand movements slightly slower than L. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem and on toes without difficulty. Romberg absent. DISCHARGE EXAM: Physical exam notable for no visual field cuts, normal fundoscopic exam, and patchy sensory deficits that may be attributed to HAART/HIV neuropathy, and mild givaway weakness in the right deltoid and right iliopsoa. Pertinent Results: ___ 03:29PM BLOOD WBC-6.8# RBC-5.32 Hgb-17.4 Hct-50.6# MCV-95# MCH-32.7* MCHC-34.4 RDW-13.1 Plt ___ ___ 03:29PM BLOOD Neuts-57.3 ___ Monos-4.9 Eos-2.3 Baso-2.2* ___ 03:29PM BLOOD Plt ___ ___ 03:29PM BLOOD ___ PTT-43.6* ___ ___ 03:39PM BLOOD Creat-1.0 ___ 03:29PM BLOOD UreaN-14 ___ 03:29PM BLOOD ALT-148* AST-92* AlkPhos-61 TotBili-0.5 ___ 03:29PM BLOOD Albumin-4.6 ___ 03:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:32PM BLOOD Glucose-113* Na-141 K-4.2 Cl-102 calHCO3-26 CT head ___ No acute intracranial abnormality. CTA head and neck ___ prelim No aneurysm or arteriovenous malformation. Patent ICA, vertebral arteries and its major branches bilaterally without significant stenosis. Pending reformats. ECHO ___ Patent foramen ovale. Mild symmetric LVH with normal global and regional biventricular systolic function. MRI/ MRA fat sat head and neck ___ 1. No evidence of acute intracranial process. 2. 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring approximately 3 mm, consistent with a small aneurysm. 3. No evidence of focal stenosis, occlusion, dissection or other aneurysm. There is no stenosis by NASCET criteria. ___ ___ No evidence of DVT. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. Raltegravir 800 mg PO DAILY 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. ValACYclovir 500 mg PO Q24H 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal congestion 6. Lorazepam 1 mg PO Q8H:PRN anxiety 7. Escitalopram Oxalate 20 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. ClonazePAM 0.5 mg PO BID 10. ZyrTEC (cetirizine) 10 mg oral daily:prn allergies 11. Multivitamins 1 TAB PO DAILY 12. Vitamin B Complex 1 CAP PO DAILY 13. TraZODone 25 mg PO HS:PRN insomnia 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash 15. ammonium lactate 12 % topical TID:PRN rash Discharge Medications: 1. BuPROPion (Sustained Release) 300 mg PO QAM 2. ClonazePAM 0.5 mg PO BID 3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 4. Escitalopram Oxalate 20 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal congestion 6. Lorazepam 1 mg PO Q8H:PRN anxiety 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Raltegravir 800 mg PO DAILY 10. TraZODone 25 mg PO HS:PRN insomnia 11. Vitamin B Complex 1 CAP PO DAILY 12. ammonium lactate 12 % topical TID:PRN rash 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash 14. ValACYclovir 500 mg PO Q24H 15. ZyrTEC (cetirizine) 10 mg oral daily:prn allergies 16. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: transient ischemic attack (TIA) Ocular migraine PFO Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro exam: non-focal Followup Instructions: ___ Radiology Report INDICATION: Right-sided weakness. Evaluate for hemorrhage or stroke. COMPARISONS: CT of the head from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Sagittal, coronal, and thin section bone reformatted images were obtained and reviewed. TOTAL DLP: 891.93 mGy-cm. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or large vascular territory infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. There is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses are clear. The left mastoid air cells are underpneumatized. There is a small amount of opacification in these left mastoid air cells and the left middle ear middle ear. This is unchanged from the prior exam. The right mastoid air cells and middle ear are clear. The soft tissues are unremarkable. IMPRESSION: No acute intracranial abnormality. MRI is more sensitive for the detection of acute infarction. Radiology Report HISTORY: ___ male with right-sided headache, right lower extremity weakness. Evaluate for aneurysm. TECHNIQUE: Using a multi detector CT scanner, volumetric data was acquired after intravenous administration of contrast through the head and neck and collimated at 1.25 mm slice thickness. Axial, sagittal and coronal multi maximum intensity projections were generated. Additional multiplanar reconstructions were performed on a separate workstation. COMPARISON: CT head without contrast ___. FINDINGS: CTA Head: There is a 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring approximately 3 mm (___). Otherwise, the internal carotid, anterior cerebral and middle cerebral arteries demonstrated normal opacification and branching pattern. The anterior communicating artery complex is visualized. The posterior circulation, including vertebral, basilar and posterior cerebral arteries also demonstrate normal opacification and branching pattern. The vertebral arteries are codominant. The posterior communicating arteries are diminutive. There is no evidence of significant stenosis, dissection or other aneurysm greater than 3 mm. CTA Neck: There is a left aortic arch with normal great vessel anatomy. There is normal opacification of the bilateral common carotid, internal carotid and vertebral arteries. There is mild atherosclerotic disease at the bilateral carotid bulbs and origins of the internal carotid. There is no evidence of stenosis at the origin or throughout the course of these vessels. There is no dissection or aneurysm/pseudoaneurysm. Right internal carotid artery (minimal diameter in mm): Proximal: 4.0 Distal: 4.0 Left internal carotid artery (minimal diameter in mm): Proximal: 5.0 Distal: 4.0 Additional findings: Note is made of hypoplasia of the left temporal bone with underpneumatization of the mastoid air cells. The oropharynx, nasopharynx, hypopharynx, larynx, oral and nasal cavities are otherwise normal. There is no lymphadenopathy by CT criteria. The parotid and submandibular glands and thyroid glands are normal. The soft tissues and osseous structures are normal. The visualized lung apices are clear. IMPRESSION: 1. 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring approximately 3 mm, consistent with a small aneurysm. 2. No evidence of focal stenosis, occlusion, dissection or other aneurysm. There is no stenosis by NASCET criteria. Dr. ___ these findings by phone with Dr. ___ at 5:20 pm on ___. Radiology Report HISTORY: ___ man with acute onset of right eye outer inferior field cut. Evaluate for infarct/dissection. TECHNIQUE: Multiplanar, multi sequence MRI of the head was performed without intravenous contrast administration. In addition, 3D time-of-flight MR angiography was performed of the intracranial vessels. The 2D time-of-flight angiography of the neck vasculature, as well as dynamic time resolved and 3D high-resolution contrast-enhanced MR angiography of the neck vasculature was also obtained after intravenous contrast administration. Maximum intensity projections of the head and neck were generated. COMPARISON: CTA head and neck ___,. FINDINGS: MRI Head: No evidence of acute infarct, hemorrhage, midline shift, mass effect or extra-axial fluid collections. The ventricles, sulci and basilar cisterns are within normal limits. The brain parenchyma demonstrates normal signal intensity on all sequences. The paranasal sinuses are clear. Again noted is underpneumatization of the left mastoid air cells. The right mastoid air cells are clear. The orbits and soft tissues are grossly unremarkable. MRA Head: There is a 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring approximately 3 mm, consistent with a small aneurysm. Otherwise, there is adequate flow related enhancement within the bilateral internal carotid, anterior cerebral, middle cerebral, vertebral, basilar and posterior cerebral arteries. From the anterior communicating artery is visualized. The the vertebral arteries are codominant. The posterior communicating arteries are diminutive and not clearly visualized. There is no evidence of significant stenosis, occlusion, dissection or other aneurysm. MRA Neck: There is a left-sided aortic arch with normal great vessel anatomy. There is normal flow related enhancement within the bilateral common carotid, internal carotid and vertebral arteries. There is no evidence of stenosis at the origin or throughout the course of these vessels. There is no evidence of dissection, aneurysm /pseudoaneurysm, focal stenosis or occlusion. No evidence of internal carotid artery stenosis by NASCET criteria. IMPRESSION: 1. No evidence of acute intracranial process. 2. 3 mm superiorly projecting outpouching in left supraclinoid ICA, measuring approximately 3 mm, consistent with a small aneurysm. 3. No evidence of focal stenosis, occlusion, dissection or other aneurysm. There is no stenosis by NASCET criteria. Dr. ___ these findings by phone with Dr. ___ at 5:20 pm on ___. Radiology Report HISTORY: Patent foramen ovale with transient vision loss. TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed of the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation in the bilateral common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal color flow is also demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. There is a small left-sided popliteal cyst. IMPRESSION: No evidence of DVT. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Headache, R Facial numbness, Vision changes Diagnosed with TRANS CEREB ISCHEMIA NOS temperature: 97.4 heartrate: 115.0 resprate: 20.0 o2sat: 97.0 sbp: 132.0 dbp: 85.0 level of pain: 10 level of acuity: 1.0

The pt is a ___ with history of HIV+ on HAART (CD4 456 and viral load < 75 on ___ per ___ Health and the only complication was oral thrush) who presents with acute onset R facial HA, R eye twitching, R eye blurry vision, and "black spot" in R eye visual field (inferior temporal quadrant). Symptoms are resolved by HOD2. Exam on HOD2 notable for absence of visual field cuts, normal fundoscopic exam. Diffuse patchy sensory changes remain and may be attributed to HAART and HIVn neuropathy. HCT was negative. CTA showed no evidence of occlusions or stenoses. Differential remains branch retinal artery occlusion either by vasospasm or embolus, with headache favoring the first. Retinal migraine is another consideration. CTA and MRA (fat sat) of the head and neck are unremarkable except for incidental finding of 3mm aneurysm of the left ICA Very unlikely termporal arteritis given his age but ESR/CRP sent. Opportunistic infectious due to HIV are important to consider although less likely given CD4 of 456 and viral load < 75. He was started on ASA 81mg to lower stroke risk. Risk factors eval: a1c 5.6. ECHO revealed PFO. Lower extremites doppler showed no DVT. D-dimer unremarkable. Ophthalmology also evaluated patient and found no intraocular abnormalities that would explain his clinical presentation. # Transitional issues [ ] follow up ESR/CRP [ ] follow up pending fasting lipid panel [ ] he was noted to have mild transaminitis (asymptomatic, ALT 127, AST75). Please recheck LFTs and consider further work up. [ ] 3mm aneurysm of the left ICA. Please monitor and consider ___ clinic referral.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fall from ladder Major Surgical or Invasive Procedure: ___ Embolization ___ Pelvic fixation History of Present Illness: ___ male presents with the above fracture s/p mechanical fall of ___ feet. Patient was at work, climbing a ladder, when he slipped and fell approximately 20 feet, landing on his buttocks. He endorses severe buttock and right hip pain, as well as lesser pain to injured hand and lower back. Otherwise no active complaints Past Medical History: Appendectomy Social History: ___ Family History: NC Physical Exam: General: Well-appearing, breathing comfortably, sitting up-right in the bed MSK: - Dressings c/d/I on abdomen and hip - Soft, non-tender thigh and leg - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Intact rectal tone, with mildly diminished, but improving ___ sensation. Hip Adduction, Knee extension, Knee Flexion are all with good strength. Pertinent Results: See OMR L Spine MRI 1. Status post interval placement of pelvic fixation hardware including a right sacroiliac screw. Although immediately adjacent structures are somewhat obscured by hardware artifact, within these confines there is no new spinal canal or neural foraminal narrowing or new cauda equina nerve root impingement. 2. Redemonstration of burst type fracture of L1 with moderate overall height loss and 4 mm posterior bony retropulsion without significant spinal canal narrowing or cauda equina impingement. 3. Redemonstration of disruption of the anterior longitudinal ligament at the site of the L1 fracture associated with prevertebral hematoma, unchanged. 4. Marrow edema in the upper sacrum, compatible with known sacral fractures. 5. Background moderate lumbar spondylosis, unchanged. Notably, spinal narrowing is worst (moderate) at L4-5, and multilevel neural foramina narrowing is worst (moderate to severe) on the left at L5-S1. Further details, as above. Medications on Admission: N/A Discharge Medications: 1. Acetaminophen 975 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QPM RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*25 Syringe Refills:*0 4. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as needed Disp #*30 Tablet Refills:*0 6. Senna 17.2 mg PO BID 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pelvis fracture, L1 burst fracture, left hand laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: Fall from 20 feet, pelvic injury TECHNIQUE: Supine AP view of the chest and supine AP view of the pelvis COMPARISON: None. Patient is currently listed as EU critical. FINDINGS: Within the chest, heart size is normal. Mediastinal and hilar contours are normal. Lungs are clear. Pulmonary vasculature is not engorged. Lungs appear clear of though the left costophrenic angle is excluded from the field of view. No large pleural effusion or pneumothorax, but assessment on the left is limited as the left costophrenic angle was excluded. No displaced fractures. In the pelvis, there is diastasis of the pubic symphysis. Mildly displaced fractures of the sacrum bilaterally are noted. Femoroacetabular joints are preserved without significant degenerative changes. No concerning lytic or sclerotic osseous abnormalities. Rounded calcifications project over the right superior pubic ramus, likely phleboliths. IMPRESSION: 1. Left costophrenic angle is excluded from the field of view. Otherwise, no acute cardiopulmonary abnormality within the chest. 2. Open book pelvic fracture with bilateral sacral fractures. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with fall ___ nfet, pelvis fr. on plain film,// trauma, fall ___ feet 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 20.0 s, 20.4 cm; CTDIvol = 49.1 mGy (Head) DLP = 1,003.4 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. There is mild thickening of the right anterior ethmoid air cells and mucous retention cysts in the right maxillary sinus. Otherwise, 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: No acute intracranial findings. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with, pelvis fr. on film// fall ___ feet fall ___ feet TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.4 s, 25.0 cm; CTDIvol = 22.8 mGy (Body) DLP = 571.7 mGy-cm. Total DLP (Body) = 572 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. No fractures are identified.Mild degenerative changes are seen with multilevel intervertebral disc space narrowing and small disc bulges, most pronounced C5-6 with mild flattening of the ventral thecal sac. There is no evidence of high-grade spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. The visualized lung apices demonstrate mild centrilobular emphysema. The thyroid is normal. There are aerosolized secretions within the esophagus. IMPRESSION: No acute fracture or traumatic subluxation. Radiology Report History: ___ with fall ___ nfet, pelvis fr. on plain film,// trauma, fall ___ feet FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. The heart, pericardium, and great vessels are within normal limits. Physiologic trace pericardial fluid is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. There are calcified hilar and paratracheal lymph nodes. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal opacification. A millimetric left upper lobe calcified granuloma is present. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesion or laceration. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, 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 lesion or laceration. There is a punctate splenic calcified granuloma. 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. The appendix is not visualized. There is no evidence of mesenteric injury. PELVIS: The urinary bladder and distal ureters are unremarkable. There is extraperitoneal hematoma at the anterior and right posterolateral pelvis and in the presacral region. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: No pathologically enlarged lymph nodes in the abdomen or pelvis. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is pubic symphysis diastasis by 1.8 cm (series 2, image 253). An extraperitoneal hematoma tracks along the anterior pelvic brim, with two areas of discrete contra extravasation, 1 near the superior pubic ramus (series 2, image 246), and 1 more inferior near the inferior pubic ramus (series 2, image 260). There is a comminuted right sacral ala fracture with multiple distracted fragments including a laterally angulated fragment along the course of the internal iliac artery (series 3 image 209). Multiple punctate areas of high attenuation adjacent to the fragment may represent smaller bone fragments with tiny foci of extravasation not excluded (series 2, image 208). The right sacral ala fracture extends posteriorly into the sacral foramina (series 3, image 209-241). There is a mildly displaced fracture of the S1 left lamina which extends inferiorly through the sacral foramina (series 3, image 193-216). The sacroiliac joints are intact bilaterally. Femoroacetabular joints appear within normal limits with mild degenerative changes demonstrated. Burst fracture of the L1 vertebral body with 2 mm of posterior translation with surrounding hypodensity measuring up to 4 mm off of the posteriorly distracted fragment is worrisome for hematoma (series 602, image 93). There is approximately 30% height loss. SOFT TISSUES: There is hematoma near the right inguinal canal. IMPRESSION: 1. Open book pelvic fracture with diastasis of the pubic symphysis of 1.8 cm. Extraperitoneal hematoma with active extravasation seen near the right superior and inferior pubic rami (series 2 image 246; series 2, image 260). Punctate foci hyperdensity posteriorly near the sacral ala (series 2, image 209) may represent additional sites of tiny active contrast extravasation versus bone fracture fragments. 2. Burst fracture of the L1 vertebral body with 2 mm of posterior translation and surrounding hypodensity measuring up to 4 mm off of the posteriorly distracted fragment, for which hematoma may be present (series 602, image 93). Correlate with neurological findings and consider MR for further evaluation. 3. Comminuted mildly distracted fracture of the right sacral ala with extension posteriorly into the neural foramina. 4. Mildly displaced fracture of the S1 left lamina extending inferiorly through the sacral foramina. 5. Calcified hilar and mediastinal lymph nodes with calcified left upper lobe pulmonary nodule and punctate calcification in the spleen compatible with the sequela of prior granulomatous disease. RECOMMENDATION(S): Burst fracture of the L1 vertebral body with 2 mm of posterior translation and surrounding hypodensity measuring up to 4 mm off of the posteriorly distracted fragment, for which hematoma may be present. Correlate with neurological findings and consider MR for further evaluation. Radiology Report INDICATION: History: ___ with finger laceration// eval fracture left ___ digit TECHNIQUE: Three views of the left ring finger COMPARISON: None. FINDINGS: Soft tissue swelling and laceration are seen involving the mid and distal aspects of the ring finger with punctate radiopaque foreign bodies along the radial aspect of the finger suggestive of foreign bodies. Additionally, mild cortical irregularity is seen involving the base of the radial aspect of the distal phalanx of the ring finger which may reflect a tiny fracture. No dislocation. Joint spaces are preserved without significant degenerative changes. IMPRESSION: 1. Soft tissue swelling and laceration involving the mid and distal aspect of the ring finger with radiopaque foreign bodies. 2. Mild cortical irregularity involving the base of the radial aspect of the distal phalanx of the ring finger suggestive of a tiny fracture. 3. No dislocation. Radiology Report EXAMINATION: MR ___ AND W/O CONTRAST ___ MR SPINE INDICATION: ___ year old man with L1 compression fracture// evaluate fracture evaluate fracture TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of Gadavist contrast agent. COMPARISON: CT torso with contrast dated ___ FINDINGS: Alignment is normal, with the conus ending at the T12-L1 level. STIR hyperintensity of the L1 vertebral body with a burst fracture morphology in the upper vertebral body only. There is associated 4 mm retropulsion of the superior fragment of the body (series 3, image 13). There is no compression of the spinal cord or nerve roots. The spinal cord signal intensity is normal. The anterior longitudinal ligament overlying the T12 vertebral body is disrupted with prevertebral hemorrhage (series 3, image 13). The posterior longitudinal ligament is normal. There is STIR hyperintensity at the left L1-L2 facet capsule (series 3, image 16), concerning for trauma. Additionally, there is STIR hyperintensity at the S2 vertebral body, most likely reflecting fracture. Again visualized is a comminuted fracture of the right sacral ala (series 101, image 81). T11-T12: No neural foraminal narrowing. No spinal cord compression. T12-L1: No neural foraminal narrowing. No spinal cord compression. L1-L2: No neural foraminal narrowing. Mild anterior spinal canal narrowing from retropulsion of the fractured L1 vertebral body without spinal cord compression. L2-L3: Mild bilateral lateral recess and neural foraminal narrowing and mild anterior spinal canal narrowing from intervertebral disc bulge. L3-L4: T2 hypodensity of the intervertebral disc, likely reflecting degenerative disease. No neural foraminal narrowing. No spinal cord compression. L4-L5: There is a midline disc protrusion, migrating inferiorly, with midline annular fissure (series 3, image 12). Along with thickened bilateral ligamentum flavum, this has led to severe spinal canal narrowing without cord compression (series 101, image 66). L5-S1: Minimal posterior disc bulge and bilateral facet osteophyte without spinal canal or neural foraminal compromise. Lastly, patchy multiple STIR hypodensity within the thecal sac dependent portion of the visualized sacral level, which could represent debris or blood products. There is narrowing of the thecal sac posterior due to the fractures demonstrated on the CT, poorly documented on the MR exam The spinal cord appears normal in caliber and configuration. There is no evidence of infection or neoplasm. IMPRESSION: 1. Burst fracture to the upper portion of the L1 vertebral body with 4 mm retropulsion without spinal cord or nerve root compression. 2. Disruption of the anterior longitudinal ligament at L1, with associated prevertebral hemorrhage. 3. STIR signal abnormality at the left L1-L2 facet capsule, concerning for trauma. 4. Severe spinal canal narrowing at the L4-L5 intervertebral level from disc protrusion and bilateral ligamentum flavum thickening. 5. STIR hyperintensity at S2 vertebral body, most likely reflecting fracture. 6. Comminuted fracture of the right sacral ala. 7. Multilevel degenerative disease, specified above. Radiology Report INDICATION: ___ y/o male s/p fall from ladder, pelvic fx with arterial extrav on imaging and dropping H H.// assess for arterial bleed COMPARISON: CT abdomen pelvis ___ TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ Interventional ___ and Dr. ___, interventional Radiology fellow performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 175mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 3 hours 10 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: CONTRAST: 170 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 36.5 minutes, 2299 mGy PROCEDURE: 1. Left radial artery access 2. Right internal iliac arteriogram. 3. Right external iliac arteriogram. 4. Right pudendal arteriogram 5. Gel-Foam embolization of the anterior division of the right internal iliac artery to near stasis. 6. Post embolization right internal iliac arteriogram. 7. Superior gluteal artery branch arteriogram. 8. Gel-Foam and coil embolization of a third order branch of the superior gluteal artery. 9. Post embolization right internal iliac arteriogram. 10. Post embolization distal aortic/iliac arteriogram. 11. Abdominal aortogram. PROCEDURE DETAILS: Following a discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. Left arm was prepped and draped in the usual sterile fashion. Using palpation, the left radial artery was identified. After injection of 1% subcutaneous lidocaine, a micropuncture needle was advanced into the radial artery until brisk blood return was identified. An 018 Nitinol wire was easily advanced into the radial artery. The micropuncture needle was exchanged for a 5 ___ Glide sheath. The sheath was flushed and 3000 units of intra-arterial heparin, 200 mcg of nitroglycerin and 2.5 mg of verapamil were injected into the radial artery. The sheath was connected to a pressurized bag of heparinized saline. A glidewire with ___ 125 cm ___ catheter was advanced easily under fluoroscopy into the aorta and then used to select the right common iliac artery and then internal iliac artery. Contrast injection was then performed confirming position. A right internal iliac arteriogram was performed which demonstrated irregularity of the pudendal artery though no active extravasation. The catheter was then retracted and advanced into the right external iliac artery. Contrast injection confirmed position. Right external iliac arteriogram was performed which did not demonstrate any areas of active extravasation. The catheter was retracted and the internal iliac artery was selected. An ___ microcatheter and double angled glide microwire were used to select the pudendal artery. Contrast injection confirmed position. A right pudendal arteriogram was performed which did not demonstrate any areas of active extravasation. The decision was made to Gel-Foam embolize the right anterior division. The microcatheter and microwire were retracted into the origin of the anterior division and Gel-Foam embolization was performed to prune peripheral vessels. A post embolization right internal iliac arteriogram was performed which demonstrated contrast pooling and possible extravasation arising from a branch of the superior gluteal artery. The superior gluteal artery was selected with the microcatheter and microwire. Contrast injection confirmed position. An exchange length Glidewire was introduced and the ___ catheter was exchanged over the wire for ___ F 110 cm pigtail flush catheter. A distal aortogram was performed to evaluate any additional areas of bleeding within the pelvis. An abdominal aortogram was performed to evaluate for any additional areas of bleeding arising from lumbar arteries. The Glidewire wire was used to remove the pigtail flush catheter. A TR band was placed over the patient's left wrist. After inflation of the band with 18 cc of air, the sheath was removed. The band was slowly deflated until bleeding was noted at the skin entry site. An additional 2 cc of air was introduced into the band. The total volume of air in the band is 12 cc. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Initial right internal iliac arteriogram demonstrated irregularity of the pudendal artery without definite active extravasation. 2. Selective pudendal arteriogram did not demonstrate active extravasation or pseudoaneurysm. 3. Post Gel-Foam embolization anterior division right internal iliac arteriogram demonstrated satisfactory pruning of the peripheral vasculature and a small area of contrast pooling arising from a branch of the superior gluteal artery. 4. Superior gluteal branch arteriogram confirmed active extravasation arising from a third order arterial branch. 5. Post Gel-Foam and coil embolization arteriogram demonstrated resolution of active bleeding without evidence of pseudoaneurysm. 6. Post embolization right internal iliac arteriogram not demonstrate any additional suspicious areas of active bleeding or pseudoaneurysm. 7. Abdominal aortic arteriogram did not demonstrate any additional areas of active extravasation or pseudoaneurysm arising from the lumbar arteries or pelvis. IMPRESSION: Left radial artery access pelvic arteriogram with Gel-Foam embolization of the anterior division of the right internal iliac artery and coil and Gel-Foam embolization of a third order branch of the right superior gluteal artery where active bleeding was noted. Radiology Report EXAMINATION: Intraoperative fluoroscopy of the pelvis. INDICATION: ORIF of pelvic injuries. TECHNIQUE: 14 intraoperative fluoroscopic spot views of the pelvis were obtained without presence of radiologist. DOSE: Fluoroscopy time 101.1 seconds, cumulative dose 4.33 rad. COMPARISON: ___. FINDINGS: Patient is status post open reduction internal fixation of the pubic symphysis and the right sacroiliac joint. IMPRESSION: ORIF of pelvic fractures. Please see the operative note for further details of needed. Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE INDICATION: ___ year old man with known L1 burst fracture and s/p ORIF APCII pelvis fx with new perianal numbness// assess for nerve compression potentially resulting in perianal numbness assess for nerve compression potentially resulting in perianal numbness TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. COMPARISON: 1. Pelvic radiographs ___. 2. MR lumbar spine ___. 3. CT torso ___. FINDINGS: New from prior studies hardware artifact in the upper sacrum from pelvic fixation hardware including a right sacroiliac transit trans-syndesmotic fixation screw. Artifact somewhat limits evaluation of immediately adjacent structures; within these confines: Again seen is an acute appearing compression fracture involving the full AP depth of the L1 vertebral body, with buckling and slight posterior retropulsion of the posterior cortex into the spinal canal, measuring approximately 4-5 mm, unchanged (03:13). Diffuse marrow edema seen in the vertebral body and extending into the pedicles bilaterally, unchanged. There is overall unchanged mild to moderate vertebral body height loss. Trace STIR hyperintense fluid, likely hematoma, is seen in the prevertebral space at this level, along with associated disruption of the anterior longitudinal ligament, as previously seen (see series 3, image 15). STIR hyperintense signal within the sacrum inferior to the hardware artifact is again noted, compatible with previously demonstrated sacral fracture. Marrow signal is otherwise within normal limits. Elsewhere, remaining vertebral body heights are preserved. Alignment is within normal limits. The distal spinal cord and conus medullaris is unremarkable and terminates at L1. The cauda equina nerve roots are normal. Intervertebral disc hypointense signal at L3-4 and L4-5 likely reflects degeneration. There is slight L1-L2 disc T2/STIR high signal, as seen previously, likely edema in the setting of adjacent fracture. T12-L1: Bony retropulsion of the buckled posterior L1 cortex at the level of the pedicles slightly effaces the anterior CSF space at this level, without overall spinal canal narrowing or cauda equina contact (2:46 and 101:4). No neural foraminal narrowing. L1-2: Unremarkable. L2-3: Posterior disc bulge, ligamentum flavum thickening, and facet osteophytes without significant spinal canal narrowing. There is very mild bilateral neural foraminal narrowing due to the disc bulge. L3-4: Broad-based posterior disc bulge is mild, along with ligamentum flavum thickening and facet osteophytes causing mild spinal canal narrowing. There is very mild bilateral neural foraminal narrowing. L4-5: Central disc protrusion associated with an annular fissure, ligamentum flavum thickening, and facet osteophytes cause moderate spinal canal narrowing with narrowing of the subarticular zones but no definite descending S1 nerve root impingement. There is mild bilateral neural foraminal narrowing. L5-S1: Partially obscured due to hardware artifact from right sacroiliac screw. No definite encroachment of the screw on the spinal canal or neural foramina. No definite spinal canal narrowing. Moderate to severe left and moderate right neural foraminal narrowing is unchanged. The remaining visualized prevertebral paraspinal soft tissues are unremarkable. Imaged portions of the abdomen retroperitoneum are without acute focal abnormality on limited evaluation. IMPRESSION: 1. Status post interval placement of pelvic fixation hardware including a right sacroiliac screw. Although immediately adjacent structures are somewhat obscured by hardware artifact, within these confines there is no new spinal canal or neural foraminal narrowing or new cauda equina nerve root impingement. 2. Redemonstration of burst type fracture of L1 with moderate overall height loss and 4 mm posterior bony retropulsion without significant spinal canal narrowing or cauda equina impingement. 3. Redemonstration of disruption of the anterior longitudinal ligament at the site of the L1 fracture associated with prevertebral hematoma, unchanged. 4. Marrow edema in the upper sacrum, compatible with known sacral fractures. 5. Background moderate lumbar spondylosis, unchanged. Notably, spinal narrowing is worst (moderate) at L4-5, and multilevel neural foramina narrowing is worst (moderate to severe) on the left at L5-S1. Further details, as above. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: s/p Fall Diagnosed with Stable burst fracture of first lumbar vertebra, init, Fall on and from ladder, initial encounter temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 6 level of acuity: 1.0

___ M fall from ladder at work - 20 feet, no LOC, w/ L1 compression fx, b/l sacral fx. Mr. ___ had his left finger lac repaired ___ Nylon. An MRI L-spine showed Burst fracture L1. His HCT continued to drift so ___ was consulted for embolization of the superior gluteal artery branch. The following day, he went to the operating room on ___ for surgical fixation of his pelvis, 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 and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. He was transfused 2 units of additional pRBCs for a low hematocrit, after which he stabilized. On HD 10, that patient noted some ___ numbness, but was without changing strength in the lower extremities or numbness/tingling elsewhere. He did not have any urinary or bowel incontinence or numbness/tingling in the legs. Rectal tone was intact. Given his L1 burst fracture and pelvic fixation, a repeat L Spine MRI was obtained to rule out cauda equina. The MRI demonstrated that there was no concerning neural compression. Repeat examination the following day continued to demonstrate good strength in the lower extremities distally and improving ___ sensation. The patient was informed about symptoms to look out for with regard to cauda equine syndrome and informed that he must emergently seek care if he developed any of those danger signs. He expressed full understanding and was in agreement. 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 partial weightbearing with bilateral upper extremity support in the right lower extremity, and will be discharged on enoxaparin 40mg sc for DVT prophylaxis. He should take this for one month's time since his operation - end date ___. The patient will 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: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: Primary PCI for STEMI of occluded RCA with DES ___ History of Present Illness: Mr. ___ is a ___ y/o man with PMH notable for HTN and CAD (DES x2 in RCA and POBA to LAD in ___, admitted after being found down with chest pain. Per information gathered from his son, the patient was in his usual state of health on day of presentation. He is a regular runner and went out for a run as per usual without any recent complaints of chest pain/pressure, DOE, SOB. Some time later, he was found down about a few blocks from his son's house (visiting from ___ for ___) by a passerby, who happened to be a ___. His son's neighbor was also around and called his son. The pediatrician who found the patient stated that he was able to endorse chest pain and remain conversant, however had a very slow pulse and perhaps looked pale. It is unclear how long the down time was and if there was any loss of consciousness. The patient's son arrived at the scene around the time EMS had come and the patient was brought to ___ for further care. Per patient's son, he does have a history of chest pain with STEMI in ___, treated with what son thinks was DES x2 to RCA and POBA of ?LAD. He was on aspirin 325mg PO daily and Plavix for many years until about ___ years ago. The Plavix was discontinued about ___ years ago as he was so many years removed from the STEMI. He has been on a baby aspirin since. He also has never had a history of GI bleed, intracranial bleed, or major bleed of any sort. His only medications at this point apart from baby aspirin include enalapril (2.5mg to 5mg daily - son is unclear which dosing) and simvastatin 80mg PO daily. He used to be on metoprolol, but this was recently discontinued because of intolerance to beta blockade (especially with exercise and running). In the ED initial vitals were: -P 40, 153/93 14, 100% RA -Subsequent recorded vitals include P48, 72/52, 12, 100% Non-Rebreather ECG per my read: atrial rate of ~55bpm, ventricular rate of 39 bpm; rhythm consistent with complete heart block; normal axis; probable left atrial abnormality, Q waves in inferior leads with sub-mm ST-elevations; 4-5mm ST depressions across V1-V4; 1mm ST elevations in V5-V6; no prior for comparison, consistent with likely postero-lateral STEMI (?evolving inferior as well) Labs/studies notable for: -Chem10 with K 3.3, Cr 1.2 (unclear baseline) -CBC with Hgb 13.3, Plt 147 Patient was given: -Dopamine gtt -Norepinephrine gtt -PO Ticagrelor 180mg x1 Patient was taken urgently to the cath lab where he was intubated on the table due to possible hypoxic respiratory failure and need to maintain airway protection prior to catheterization. He underwent successful aspiration thrombectomy and DES x1 placement to mid-total RCA occlusion. Given lack of enteral access, he received PR aspirin, IV heparin gtt (started in ED until cath), tirofiban gtt post-cath. He also had a pacer wire placed in the ED prior to transfer to cath lab, but quickly resumed native sinus conduction post-stenting without further need for pacing. He was subsequently transferred to the CCU intubated and sedated. At time of arrival he was agitated and initially not following commands. He also had repetitive myoclonic movements, concerning for seizure-like activity. However, these quickly resided and the patient was following commands, endorsing discomfort around the endotracheal tube. No future ROS could be collected i/s/o intubated/sedated status. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension 2. CARDIAC HISTORY - CAD s/p STEMI in ___ (DES x2 to RCA and POBA of LAD per son's report) 3. OTHER PAST MEDICAL HISTORY - None Social History: ___ Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: Well developed, well nourished in NAD. Intubated, sedated, but able to respond to simple questions and follow directions. HEENT: hematoma as below; EOMI, able to track with eyes, bilaterally; able to protrude tongue on command; ETT and OGT in mouth NECK: Supple. JVP unable to be assess with patient's temp wire and bandaging in place CARDIAC: RRR, normal S1, S2; no m/r/g LUNGS: CTAB with mechanical breath sounds over bilateral anterior and lateral lung fields ABDOMEN: Soft, unable to assess for tenderness, non-distended. No r/g, BS+ EXTREMITIES: Warm, well perfused. No pitting edema. SKIN: 5.5 x 4cm raised, soft, hematoma over left forehead; multiple abrasions over LLE PULSES: Distal pulses palpable and symmetric. NEURO: as above; moving all extremities spontaneously and intermittently to command DISCHARGE PHYSICAL EXAM: VS: Reviewed in POE GENERAL: Well developed, well nourished in NAD. HEENT: hematoma as below; EOMI, PERRLA CARDIAC: RRR, normal S1, S2; no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, non-distended. No r/g, BS+ EXTREMITIES: Warm, well perfused. No pitting edema. SKIN: 5.5 x 4cm raised, soft, hematoma over left forehead; multiple abrasions over LLE PULSES: Distal pulses palpable and symmetric. NEURO: as above; moving all extremities spontaneously and intermittently to command Pertinent Results: ADMISSION LABS: ___ 03:39PM BLOOD WBC-7.8 RBC-4.47* Hgb-13.3* Hct-41.9 MCV-94 MCH-29.8 MCHC-31.7* RDW-12.1 RDWSD-41.9 Plt ___ ___ 03:39PM BLOOD Neuts-36.5 Lymphs-53.4* Monos-5.4 Eos-4.0 Baso-0.4 Im ___ AbsNeut-2.84 AbsLymp-4.15* AbsMono-0.42 AbsEos-0.31 AbsBaso-0.03 ___ 03:39PM BLOOD ___ PTT-24.7* ___ ___ 03:39PM BLOOD Glucose-150* UreaN-16 Creat-1.2 Na-144 K-3.3 Cl-102 HCO3-22 AnGap-20* ___ 06:55PM BLOOD ALT-222* AST-934* LD(LDH)-1271* ___ AlkPhos-87 TotBili-0.7 ___ 06:55PM BLOOD Albumin-3.8 Calcium-7.3* Phos-3.3 Mg-1.8 Cholest-153 ___ 06:56PM BLOOD ___ pO2-251* pCO2-44 pH-7.26* calTCO2-21 Base XS--6 ___ 06:56PM BLOOD Lactate-3.2* MICRO: No relevant results IMAGING: CATH REPORT: Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is normal * Left Anterior Descending The LAD has no significant disease * Circumflex The Circumflex is a very small short vessel with severe proximal disease * Right Coronary Artery The RCA is a very large dominant vessel with mid total occlusion. Interventional Details The RCA was engaged with a ___ Fr JR4 guide. The mid occlusion was crossed with a Prowater wire restoring flow showing a severe lesion at the site of mid occlusion and a more distal mid lesion with the appearance of possible thrombus. The more proximal lesion was dilated with a 2.5 balloon. An Export catheter was then passed into the distal vesel with little change in the appearance of the more distal lesion. Both lesions were then covered with a 38 x 3.75 Onyx stent postdilated to 4.0 mm at 20 atm with no residual normal flow Tirofiban started at the beginning of the procedure to be continued until ticagrelor can be given. Initial rhythm was paced and he was hypotensive on dopamine and levophed. After opening of the RCA, rhythm was sinus and pressors were discontinued. A temporary pacemaker had been placed in the ED via the RIJ vein prior to PCI He was intubated on arrival to the room due to poor mental status and hypoxia. Impressions: Successful primary PCI for STEMI of occluded RCA with DES Normal LAD Severe disease of very small LCX Recommendations Continue aspirin uninterrupted indefinitely Continue ticagrelor minimal ___ year Continue tirofiban until ticagrelor begun Monitoring in CCU Head CT in view of developing forehead hematoma during procedure. CT HEAD W/O CONTRAST ___: 1. High density opacification of the ethmoid air cells and right maxillary sinus without clear air-fluid levels may represent fungal or atypical sinusitis. However, given history of trauma, hemosinus cannot be excluded. No definitive evidence of acute skullbase fracture despite right lamina papyracea deformity. 2. Right frontal subgaleal hematoma. 3. Minimally displaced right nasal bone fracture. CT C-SPINE W/O CONTRAST ___: IMPRESSION: No acute fracture or traumatic malalignment. ECHO ___: The left atrial volume index is normal. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the inferolateral wall and hypokinesis of the inferior, anterolateral and anterior walls. The remaining segments contract normally (Biplane LVEF = 35 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD. Mild mitral regurgitation. Increased PCWP. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or ___. RELEVANT LABS: ___ 06:55PM BLOOD CK-MB-GREATER TH cTropnT-10.84* ___ 11:13PM BLOOD CK-MB-575* MB Indx-6.2* cTropnT-14.20* ___ 04:15AM BLOOD CK-MB-327* MB Indx-4.4 cTropnT-18.54* DISCHARGE LABS: ___ 06:25AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.3* Hct-31.9* MCV-93 MCH-29.9 MCHC-32.3 RDW-12.9 RDWSD-43.9 Plt Ct-99* ___ 06:25AM BLOOD Neuts-77.3* Lymphs-14.0* Monos-7.6 Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.73# AbsLymp-1.04* AbsMono-0.56 AbsEos-0.02* AbsBaso-0.02 ___ 06:25AM BLOOD ___ PTT-32.4 ___ ___ 06:25AM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-143 K-4.2 Cl-109* HCO3-24 AnGap-10 ___ 03:54AM BLOOD ALT-117* AST-377* LD(LDH)-1172* CK(CPK)-2467* AlkPhos-51 TotBili-1.0 ___ 06:25AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Simvastatin 80 mg PO QPM Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 2. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. TiCAGRELOR 90 mg PO BID RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 4. Enalapril Maleate 2.5 mg PO DAILY RX *enalapril maleate 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 5. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================ Right coronary artery ST elevation myocardial infarction Newly reduced ejection fraction heart failure with reduced ejection fraction 35% Temporary complete heart block Acute Kidney Injury Right nasal bone fracture/subgaleal hematoma SECONDARY DIAGNOSIS =================== Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man found down, with facial hematoma s/p intubation and cath for RCA STEMI.// NCHCT, found down, facial hematoma TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 19.1 cm; CTDIvol = 47.3 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute infarction, intracranial hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is a moderate sized right frontal subgaleal hematoma (03:26). There is deformity of the right lamina papyracea (301:66), however the adjacent extraconal fat is preserved. The orbits are unremarkable. The orbital rim and maxillary walls are intact. There is no definitive underlying skullbase fracture within limitations of the study. There is high density material in the ethmoidal air cells and right maxillary sinus, without a clear air-fluid level, however given patient history hemosinus cannot excluded. The left maxillary sinus is clear. The mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. High density opacification of the ethmoid air cells and right maxillary sinus without clear air-fluid levels may represent fungal or atypical sinusitis. However, given history of trauma, hemosinus cannot be excluded. No definitive evidence of acute skullbase fracture despite right lamina papyracea deformity. 2. Right frontal subgaleal hematoma. 3. Minimally displaced right nasal bone fracture. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ year old man found down, with facial hematoma s/p intubation and cath for RCA STEMI.// found down, head hematoma; eval fro fracture TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 469.3 mGy-cm. Total DLP (Body) = 469 mGy-cm. COMPARISON: None. FINDINGS: There is minimal retrolisthesis of C4 on C5. Otherwise, alignment is normal. No acute fractures are identified.No severe spinal canal or neural foraminal stenosis.There is no prevertebral edema. The patient is intubated and an enteric tube partially imaged. The partially imaged thyroid gland is unremarkable. Lung apices are not imaged. Incidental note is made of partial nuchal ligament calcification. IMPRESSION: No acute fracture or traumatic malalignment. Radiology Report INDICATION: ___ year old man with RCA STEMI s/p intubation and cath.// eval for ETT and NGT placement TECHNIQUE: AP portable chest radiograph COMPARISON: None IMPRESSION: The tip of the endotracheal tube projects over the mid thoracic trachea and the tip of an enteric tube courses below the level the diaphragm but beyond the field of view of this radiograph. A single pacing lead projects over the right ventricle. Diffuse bilateral airspace opacities likely reflect moderate pulmonary edema. No pleural effusion or pneumothorax is identified. The size of the cardiac silhouette is within normal limits. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Chest pain Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: uta level of acuity: 1.0

Mr. ___ is a ___ y/o man with PMH notable for HTN and CAD (DES x2 in RCA and POBA to LAD in ___, admitted after being found down i/s/o IPL STEMI c/b transient CHB s/p DES x1 to RCA and temp-wire placement and removal. Course complicated by aspiration of thin liquids for which he was seen by speech and swallow and put on nectar-thickened liquids. # CORONARIES: DES x1 to RCA on ___ # PUMP: EF 35% # RHYTHM: transient CHB; now sinus # RCA STEMI: # CAD Patient with known prior coronary disease with mid-RCA occlusion successfully treated with DES x1. Post-intervention TTE with EF 35% and akinesis of inferolateral wall and hypokinesis of the inferior, anterolateral and anterior walls. s/p full dose ASA load and tirofiban. Continued on aspirin daily, ticagrelor BID, atorvastatin daily. Started on metoprolol 6.25mg q6, and transitioned to metoprolol 25 XL. Reduced enalapril to 2.5 daily based on soft pressures (was on 6.25 captopril q8h and with soft pressures). Will not need life vest with EF 35%. Will need cardiac rehab. # CHB: patient presented with complete heart block in the setting of RCA ischemia and transient nature of CHB, likely due to heightened vagal tone. Temporary pacing wire initially placed but pulled on ___. Received 1g Vanc for possible contamination during placement. No further events on tele. # Intubation/hypoxic respiratory failure Patient was urgently intubated in the cath lab, in the setting of urgent need to proceed with catheterization as well as possible hypoxic event. He was on minimal vent settings ___ 50% on PSV) post-op and extubated rapidly ___. Possible residual edema with difficulty swallowing thin liquids. Speech and swallow recommended continuing regular solids with nectar thick liquids also recommend following up with PCP for further evaluation with a speech pathologist, including a video swallow study. # Rhabdomyolysis: # ___ Patient presented with Cr 1.2 from unclear but presumed normal baseline. Cr downtrended to 0.9 after cath, suggesting ischemia and transient hypotension to potentially be contributing. Additionally, the patient had elevated CK to >10,000 concerning for rhabdo and also received 110cc contrast intra-cath increasing risk for progressive ___. CK downtrended and Cr normalized. # Subgaleal hematoma: # Right nasal bone fracture: # s/p Fall: Patient collapsed without clear downtime. Appears to have sustained head strike but imaging notable only for superficial injuries (subgaleal hematoma) and minimally displaced right nasal fracture. Seen by plastics who recommend outpt follow up in one week. # HTN: decreased home enalapril to 2.5 daily TRANSITIONAL ISSUES ================== DISCHARGE WEIGHT: 154 lb

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ Laparoscopic appendectomy History of Present Illness: The patient is an otherwise healthy ___ y.o. man who presents with 1 day of RLQ abdominal pain. The pain started on waking the day prior to admission. It was focused in his RLQ and did not move or radiate. He has nausea and 1 episode of emesis that AM. He had subjective chills but no fever. He had no diarrhea. The pain gradually increased over the next ___ hours, which brought him to the ED. Past Medical History: None Social History: ___ Family History: Non-contributory Physical Exam: On admission: VS: 98.5 70 129/84 14 100% Gen: NAD CV: RRR S1 S2 Lungs: CTA B/L Abd: soft, ND, TTP focally in RLQ with localized rebound, no guarding, negative Rovsing and psoas signs. Extr: WWP On discharge: VS 97.9, 92, 118/63, 14, 98% on room air Pertinent Results: ___ 12:00PM BLOOD WBC-8.6 RBC-5.29 Hgb-16.6 Hct-48.7 MCV-92 MCH-31.5 MCHC-34.1 RDW-12.8 Plt ___ ___ 12:00PM BLOOD Neuts-59.8 ___ Monos-5.9 Eos-6.7* Baso-0.7 ___ 12:00PM BLOOD Plt ___ ___ 12:00PM BLOOD ___ PTT-33.2 ___ ___ 12:00PM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-140 K-4.4 Cl-102 HCO3-28 AnGap-14 ___ 12:00PM BLOOD ALT-15 AST-21 AlkPhos-85 TotBili-0.9 ___ 12:00PM BLOOD Albumin-5.2 IMAGING: ___ RUQ U/S Dilated hyperemic appendix with possible sliver of adjacent fluid compatible with acute appendicitis. ___ Appendix: Tissue pathology (pending) Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. 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 Discharge Disposition: Home Discharge Diagnosis: Acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Right lower quadrant pain. COMPARISON: None available. FINDINGS: Grayscale and Doppler ultrasound images of the right lower quadrant were obtained. FINDINGS: The appendix is dilated and hyperemic measuring 1.0 cm in diameter approximately and 0.5 cm in diameter distally. There is a possible sliver of adjacnet free fluid. The appendix is able to be traced from the cecum and the tip is blind ending and well visualized. The appendix is non-compressible, particularly proximally. IMPRESSION: Dilated hyperemic appendix with possible sliver of adjacent fluid compatible with acute appendicitis. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABDOMINAL PAIN Diagnosed with ACUTE APPENDICITIS NOS temperature: 98.6 heartrate: 69.0 resprate: 16.0 o2sat: 97.0 sbp: 123.0 dbp: 71.0 level of pain: 6 level of acuity: 3.0

Mr. ___ was admitted on ___ under the acute care surgery service for management of his acute appendicitis. He was taken to the operating room and underwent a laparoscopic appendectomy. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. The patient was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of ___ to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On the afternoon of ___, Mr. ___ was discharged home with scheduled follow up in ___ clinic. He was hemodynamically stable, afebrile and in no acute distress.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: latex / lactose Attending: ___. Chief Complaint: R arm pain Major Surgical or Invasive Procedure: Double Lumen Chest Port Placement ___ History of Present Illness: Mr. ___ is a ___ year-old gentleman with a history of HIV (undetectable VL, CD4>1200 per pt), depression and hypertension recently diagnosed with osteosarcoma of the right humerus with concern for LN, lung metastases presenting for pain control and initiation of chemotherapy. On ___ he was seen by Orthopaedic Oncology, a biopsy was made on ___ which resulted as osteosarcoma. His case was reviewed today in tumor board and he was asked to come to the ED. ED initial vitals were 97.6 94 119/72 18 98% RA Prior to transfer vitals were 98.5 77 107/67 18 99% RA Exam in the ED showed : "Palpable radial pulse, right upper extremity edema, paresthesias to digits 1 through 4 but sensation is intact. Very limited range of motion secondary to pain. " ED work-up significant for: -CBC: WBC: 16.2*. HGB: 13.7. Plt Count: 292. Neuts%: 63.4. -Chemistry: Na: 132* . K: 4.3 . Cl: 94*. CO2: 23. BUN: 16. Creat: 1.1. -UENI: "No UE DVT" ED management significant for: -Medications: oxycodone 5mg x2, nicotine lozenge 2mg x2 On arrival to the floor, patient reports he has been having progressively worse right upper extremity edema, pain and paresthesia. The pain barely lets him sleep in spite of frequent oxycodone 5mg. He has no other complaints. He has been constipated since he started the oxycodone. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: PAST ONCOLOGIC HISTORY (Per ___, reviewed): As per ortho-onc H&P ___: "He has been having some mild pain for about 6 months. He initially thought it was related to his work as a ___. Then in late ___, he was lifting an object and felt acutely worse pain. He was evaluated in the emergency department and told that he may have cancer. He subsequently had follow-up with his infectious disease doctor ___ at ___), who helped facilitate the workup. Most recently he saw Dr. ___ oncologist down in ___. Patient has also noticed a lump in his right armpit for the last several months. Denies any recent weight loss. Denies fevers or chills. He does feel a bit more tired in the last couple weeks. Denies any other lumps or bumps." Tumor board note ___ ___ has newly diagnosed right arm osteosarcoma, very large lesion with bone destruction of humerus. CT chest showed about 4 lung nodules, very small, though suspicious for metastatic disease. There are also adenopathy in the right axillary area, supraclavicular and pectoralis concerning for metastatic disease, though this degree of adenopathy is unusual for osteosarcoma." PAST MEDICAL HISTORY (Per ___, reviewed): -HTN -Asthma -Depression -Anxiety -HIV Social History: ___ Family History: Paternal grandmother with cancer, father with diabetes and heart disease, maternal grandfather with lung disease Physical Exam: ADMISSION PHYSICAL EXAM VS: ___ Temp: 98.4 PO BP: 117/68 HR: 89 RR: 20 O2 sat: 97% O2 delivery: RA GENERAL: Well-appearing gentleman lying on his back with pillow over abdomen seeking anthalgic position. HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. RUE with marked edema and erythema in right arm, and pitting edema without erythema in right forearm and hand. Limited right shoulder mobility ___ pain. NEURO: Alert and oriented, good attention, linear thought process. CN II-XII intact. Strength full throughout. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM VS: 24 HR Data (last updated ___ @ 004) Temp: 97.5 (Tm 97.7), BP: 100/60 (96-109/58-69), HR: 73 (73-82), RR: 16 (___), O2 sat: 93% (93-99), O2 delivery: RA, Wt: 234.3 lb/106.28 kg GENERAL: Well-appearing gentleman sitting in a chair, pleasant, in no acute distress HEENT: Anicteric, Mucous membranes moist, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. RUE with 4+ pitting edema in right arm, and pitting edema in right forearm and hand. Weakness of right shoulder (cannot lift to 90 degrees). Poor right hand mobility ___ swelling and possible weakness. NEURO: Alert and oriented, good attention, linear thought process. A&Ox3. Decreased sensation to light touch and temperature in entire RUE. SKIN: No significant rashes. ACCESS: Port Pertinent Results: ADMISSION LABS ___ 09:19AM WBC-16.2* RBC-4.48* HGB-13.7 HCT-40.8 MCV-91 MCH-30.6 MCHC-33.6 RDW-13.5 RDWSD-45.1 ___ 09:19AM NEUTS-63.4 ___ MONOS-13.9* EOS-0.2* BASOS-0.4 IM ___ AbsNeut-10.26* AbsLymp-3.46 AbsMono-2.24* AbsEos-0.04 AbsBaso-0.06 ___ 09:19AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 09:19AM GLUCOSE-110* UREA N-16 CREAT-1.1 SODIUM-132* POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-23 ANION GAP-15 ___ 09:19AM ALBUMIN-4.0 PERTINENT/DISCHARGE LABS ___ 05:15AM BLOOD WBC-11.0* RBC-3.17* Hgb-9.3* Hct-29.2* MCV-92 MCH-29.3 MCHC-31.8* RDW-13.5 RDWSD-45.9 Plt ___ ___ 05:15AM BLOOD Plt ___ ___ 05:15AM BLOOD ___ PTT-27.0 ___ ___ 05:15AM BLOOD Glucose-122* UreaN-20 Creat-0.7 Na-138 K-4.3 Cl-105 HCO3-22 AnGap-11 ___ 05:15AM BLOOD ALT-11 AST-17 LD(LDH)-238 AlkPhos-401* TotBili-0.3 ___ 05:15AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.3 IMAGING/STUDIES RUE U/S ___- 1. No evidence of deep venous thrombosis in the right upper extremity, however there is extremely slow venous flow along the brachial veins which puts the patient at risk for formation of deep venous thrombosis. 2. Right upper extremity subcutaneous edema. 3. Redemonstration of a node with calcification in the right axillary region, as demonstrated on prior CT. TTE ___- The left atrial volume index is normal. The right atrium is mildly enlarged. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 60 %. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Transmitral and tissue Doppler suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP less than 12mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. 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 pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: History: ___ with RUE swelling hx of osteosarcoma// r/o DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: CT pre-procedure right upper extremity, ___ FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian vein. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible but show extremely slow flow with normal augmentation. Marked subcutaneous edema is seen in the right upper extremity. Within the anterior chest wall and right axillary region, there is an ill-defined markedly anechoic structure with distal shadowing which correlates with the abnormal lymph node in the right axillary region containing calcifications. IMPRESSION: 1. No evidence of deep venous thrombosis in the right upper extremity, however there is extremely slow venous flow along the brachial veins which puts the patient at risk for formation of deep venous thrombosis. 2. Right upper extremity subcutaneous edema. 3. Redemonstration of a node with calcification in the right axillary region, as demonstrated on prior CT. Radiology Report INDICATION: ___ year old man with (likely metastatic) osteosarcoma. Plan for urgent initiation of MAP regimen tomorrow.// Please place DOUBLE LUMEN chest port leave both accessed. ___ aware. COMPARISON: None TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 100 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 20 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.4 min, 10.6 mGy PROCEDURE 1. Right internal jugular approach chest double lumen Port-a-cath placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The double lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The port was accessed using a non coring ___ needle and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with Other specified soft tissue disorders temperature: 97.6 heartrate: 94.0 resprate: 18.0 o2sat: 98.0 sbp: 119.0 dbp: 72.0 level of pain: 10 level of acuity: 3.0

Outpatient Providers: ___ year-old gentleman with a history of HIV on HAART (undetectable VL per pt and pending, CD4>1200), depression, and hypertension, recently diagnosed with osteosarcoma of the right humerus with concern for LN, lung metastases presenting for pain control and initiation of chemotherapy. Started chemo regimen of MAP on ___ and completed day 2 on ___. Pain regimen titrated to 10mg oxycodone ER PO TID and gabapentin 400mg PO TID. Lymph node biopsy and Neulasta shot planned for outpatient on ___. ==============

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Wound infection Major Surgical or Invasive Procedure: None History of Present Illness: ___ with longstanding history of IBD that required a colectomy with colostomy for obstruction (and SBR of 55 cm) in ___ and was restored to continuity in ___, then followed by an abscess that found in ___ and underwent a repeat colectomy and small bowel resection with end colostomy at ___. This was complicated by a GI bleed (in the setting of a supratherapeutic INR), holding her anticoagulation and insertion of a PICC line which resulted in PEs and a PICC-associated DVT. Her anticoagulation was resumed and she was discharged without incident. She has since been hospitalized again for altered mental status and an orthopedic procedure. She presents today from rehab where she was noted to be screaming in pain and found to have 300 cc of purulent drainage from the base of her midline incision. She was given a fluid bolus through her existing PICC line and sent here. In the ED, she notes persistent pain in her lower abdomen. Past Medical History: PMH: IBD (unclear UC vs. Crohns ___ years ago), DM2, Hypothyroid, HTN DVT LLE ___ PSH: ___ (OSH) - ___ for large bowel obstruction due to IBD ___ (OSH) - Reanastamosis (ostomy takedown) (OSH) ___ (___) - Sigmoid perforation with abscess, ___ Social History: ___ Family History: h/o colon ca Physical Exam: Admission Physical Exam: 97.8 129 148/67 18 94% RA Pleasant but not oriented, but appropriate in conversation relevance ("I do not want surgery") Reg rhythm Unlabored respirations Abdomen soft, protuberant but non-distended, midline incision healed (except see below), stoma to left abdomen with copious brown stool output, small <1 cm hole at base of midline incision approximately 5 cm superior to the pubic symphysis with copious purulent output on expression of lower abdomen, no erythema Discharge Physical Exam: GEN: alert, oriented CV: RRR, no murmur PULM: CTA bilat ABD: soft, NT, ND, clean wound EXT: warm, 2+ pulses Pertinent Results: IMAGING: ___: CXR: Low lung volumes. No focal consolidation to suggest pneumonia. ___: CT Abdomen/Pelvis: 1. 2.3 x 4.5 x 1.8 cm air and fluid containing collection compatible with and abscess in the lower anterior abdominal wall, just to the right of midline. No fistulous communication to bowel identified. 2. Status post partial colectomy with a colostomy in the left lower quadrant. No evidence of bowel obstruction. 3. Cholelithiasis. LABS: ___ 03:26AM GLUCOSE-118* UREA N-99* CREAT-1.3* SODIUM-144 POTASSIUM-5.4* CHLORIDE-114* TOTAL CO2-14* ANION GAP-21* ___ 03:26AM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-2.2 ___ 03:26AM WBC-18.6* RBC-3.11* HGB-8.1* HCT-26.3* MCV-85 MCH-26.0 MCHC-30.8* RDW-18.4* RDWSD-55.9* ___ 03:26AM PLT COUNT-355 ___ 03:26AM ___ PTT-58.2* ___ ___ 07:03PM K+-5.7* ___ 06:56PM GLUCOSE-193* UREA N-122* CREAT-1.8* SODIUM-135 POTASSIUM-5.9* CHLORIDE-104 TOTAL CO2-16* ANION GAP-21* ___ 04:21PM LACTATE-2.6* K+-8.6* ___ 04:21PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 04:21PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 04:21PM URINE RBC-5* WBC-169* BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-<1 ___ 04:21PM URINE HYALINE-5* ___ 04:21PM URINE WBCCLUMP-FEW MUCOUS-RARE ___ 04:00PM GLUCOSE-219* UREA N-133* CREAT-2.0*# SODIUM-138 POTASSIUM-6.8* CHLORIDE-109* TOTAL CO2-13* ANION GAP-22* ___ 04:00PM ALT(SGPT)-9 AST(SGOT)-25 ALK PHOS-105 TOT BILI-0.2 ___ 04:00PM LIPASE-67* ___ 04:00PM ALBUMIN-2.7* ___ 04:00PM WBC-22.9*# RBC-3.56* HGB-9.1* HCT-30.3* MCV-85 MCH-25.6* MCHC-30.0* RDW-18.7* RDWSD-58.5* ___ 04:00PM NEUTS-84* BANDS-0 LYMPHS-12* MONOS-4* EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-19.24* AbsLymp-2.75 AbsMono-0.92* AbsEos-0.00* AbsBaso-0.00* ___ 04:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-3+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ BURR-2+ ___ 04:00PM PLT SMR-HIGH PLT COUNT-409* ___ 04:00PM ___ PTT-58.9* ___ MICRO: ___ 11:12 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. ___ 10:34 am SWAB Source: Abdominal wound. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Time Taken Not Noted Log-In Date/Time: ___ 12:51 am BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 1 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ (___) ON ___ @ 11:09AM. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Furosemide 20 mg PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q12H 6. Warfarin 3 mg PO DAILY16 7. CefePIME 2 g IV Q24H 8. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain 9. GlipiZIDE 5 mg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Gabapentin 100 mg PO BID 12. Mirtazapine 15 mg PO QHS Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth once a day Disp #*6 Tablet Refills:*0 2. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp #*44 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7 Days 5. Miconazole Powder 2% 1 Appl TP BID:PRN groin rash 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Tamsulosin 0.4 mg PO QHS RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 9. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth once a day Disp #*6 Capsule Refills:*0 10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 11. ___ MD to order daily dose PO DAILY16 12. Furosemide 20 mg PO DAILY 13. Gabapentin 100 mg PO BID 14. GlipiZIDE 5 mg PO DAILY 15. Levothyroxine Sodium 100 mcg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD QAM 17. Lisinopril 20 mg PO DAILY 18. Mirtazapine 15 mg PO QHS 19. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*5 Tablet Refills:*0 20. Pantoprazole 40 mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Abdominal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Followup Instructions: ___ Radiology Report EXAMINATION: KNEE (2 VIEWS) RIGHT INDICATION: ___ year old woman with right knee pain// acute trauma acute trauma TECHNIQUE: Frontal and cross-table lateral radiographs of right knee COMPARISON: AP, cross-table lateral, and oblique views the left knee from ___ FINDINGS: No fracture or dislocation is detected. Tricompartmental degenerative changes with severe joint space loss of the medial compartment. There is degenerative spurring involving all 3 compartments of the knee most advanced in the medial compartment. There is subchondral sclerosis involving the medial femoral condyle and tibial plateau. There is slight chondrocalcinosis noted in the lateral compartment. No suspicious lytic or sclerotic lesion is identified. There is a small amount of fluid within the joint without a large joint effusion or fat fluid level identified. No soft tissue calcification or radio-opaque foreign body is detected. IMPRESSION: No fractures or dislocation is identified. Tricompartmental degenerative changes most advanced in the medial compartment. The medial compartment of the knee demonstrates severe joint space narrowing with subchondral sclerosis. There is degenerative spurring involving all 3 compartments of the knee, most advanced in the medial compartment. Radiology Report EXAMINATION: Pouchogram. INDICATION: ___ year old woman s/p ___ procedure in ___, now with wound infection. Note- only has rectal stump- please give gentle contrast enema to evaluate for fistula tract// Please evaluate for rectal stump collection or fistula TECHNIQUE: Pouchogram. DOSE: Acc air kerma: 0.9 mGy; Accum DAP: 33.7 uGym2; Fluoro time: 01:30 COMPARISON: CT abdomen and pelvis without contrast dated ___. FINDINGS: After scout images were obtained, a ___ Foley catheter was inserted into the rectum. 60 cc of water soluble contrast was gently hand injected. Due to limitations with patient positioning secondary to discomfort, only supine views were obtained. Contrast is seen filling the anus, though does not reach the level of the rectum. No leak or fistulous tract identified. IMPRESSION: Limited examination, due to lack of patient compliance with positioning, with only supine views obtained. Contrast with seen only to the level of the anus, therefore rectal stump was not fully evaluated. No definite leak or fistulous communication identified. MRI could be considered for better evaluation of the area of interest. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, Abnormal labs Diagnosed with Severe sepsis with septic shock temperature: 97.8 heartrate: 129.0 resprate: 18.0 o2sat: 94.0 sbp: 148.0 dbp: 67.0 level of pain: un level of acuity: 2.0

Ms. ___ is a ___ y/o F with history of ___ procedure in ___ who presented this admission with 300 cc of purulent drainage from the base of her midline incision. She was given a fluid bolus through her existing PICC line and was sent here. She underwent bedside I&D of the wound with packing, she notes persistent pain in her lower abdomen. The incision was packed with iodiform. Wound cultures were sent. She was started on IV vancomycin and was admitted to the Acute Care Surgery service for further medical care. The wound dressing was changed daily. WBC and fever curves were watched for signs of infection. Oxacillin resistant Staph resulted from the wound swab and nasal swab was positive for MRSA. The patient was started on a course of Bactrim, that was switched to Cephalexin few days before discharge and she would need another 11 days of treatment. Urine Cx grew yeast. the patient has a Foley cath. inserted for urinary retention and at this point this need to be further cultured and if persistent than can be treated as appropriate depending on Cx results. The remainder of the ___ hospital course is summarized by systems below: Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with acetaminophen and oxycodone. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet and early ambulation were encouraged throughout hospitalization. GI/GU/FEN: The patient tolerated a regular diet, intake and output were closely monitored. The patient was noted to have urinary retention >600 ml. She was straight catheterized twice. Flomax was started, but the patient still retained urine >600 ml, so a foley catheter was placed. On HD11, the patient was ordered for a barium enema to assess for any e/o fistula r/o leak or fistula HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received warfarin, INR was monitored. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: EtOH abuse, EtOH hepatitis Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female with history of heavy etOH use but no prior history of liver disease who presents as an admission from liver clinic. Patient was followed by her PCP and was referred to hepatology given abnl LFTs, jaundice, and significant etOH history. Patient has had a long history of heavy alcohol consumption for approx. ___ years. Over the summer, she had yellowing of her eyes and increasing abdominal girth. Also reports weight loss of 20 lbs. Denies confusion, hematemesis, melena, hematochezia, no recent illness including fevers and chills. Of note, last drink was approx. 1 week ago when she went to ___ for detox She was seen in hepatology for initial evaluation on ___. At that time it was felt that her presentation was consistent with a combination of alcoholic cirrhosis and alcoholic hepatitis. There was also some concern for less likely autoimmune liver disease or other infiltrative process given severe hepatosplenomegaly and elevated protein-albumin gap. She was also severely malnourished with sarcopenia. Labs were concerning for hepatitis with ___ 42; plt 124, Hgb 8.7, WBC 7.2. Past Medical History: H/o ?SBO: strangulated hernia vs strangulated bowel with sepsis ___ Sleeve gastrectomy ___ (BI-M) CCY ___ Multiple abdominal hernia repairs CSection x4 GERD Obesity Social History: ___ Family History: No family members with liver disease Sister has ___ lymphoma, autoimmune disease Physical Exam: ADMISSION: Vitals: T 99.7 BP 119/71 HR ___ RA General: Alert, oriented, mildly anxious appearing HEENT: Sclera icteric, MMM, sublingual jaundice noted, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: significant hepatosplenomegaly noted on exam with liver edge palpated approx. 11 cm from costal margin, mildly TTP; spleen approx. 7 cm from costal margin, abdominal scars noted; abdominal distension noted; unable to appreciate ascites. Ext: Warm, well perfused, 2+ ___ edema, no palmar erythema, +spider angiomas Neuro: A&Ox3. + asterixis DISCHARGE: Vitals: 98.1 99/64 89 18 94% RA General: Alert, oriented, NAD HEENT: Sclera icteric, MMM, (+) sublingual jaundice, oropharynx clear, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abd: (+) significant hepatosplenomegaly with mild TTP, abdominal distension noted; unable to appreciate ascites. Ext: Warm, well perfused, 2+ ___ edema, no palmar erythema, +spider angiomas Neuro: A&Ox3, no asterixis Pertinent Results: ADMISSION/PERTINENT: ___ 04:13PM WBC-7.2 RBC-2.50* HGB-8.7* HCT-26.3* MCV-105* MCH-34.8* MCHC-33.1 RDW-17.3* RDWSD-66.2* ___ 04:13PM ___ ___ 04:13PM UREA N-3* CREAT-0.5 SODIUM-134 POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-26 ANION GAP-12 ___ 04:13PM ALT(SGPT)-26 AST(SGOT)-115* ALK PHOS-93 TOT BILI-5.2* DIR BILI-2.2* INDIR BIL-3.0 ___ 04:13PM TOT PROT-7.9 ALBUMIN-2.7* GLOBULIN-5.2* ___ 04:13PM HBsAg-Negative HBs Ab-Negative HBc Ab-Negative ___ 04:13PM AMA-NEGATIVE Smooth-NEGATIVE ___ 04:13PM ___ ___ 04:13PM AFP-5.3 ___ 04:13PM IgG-2900* IgA-973* IgM-826* ___ 04:13PM HIV Ab-Negative ___ 04:13PM tTG-IgA-6 ___ 04:13PM HCV Ab-Negative DISCHARGE: ___ 05:03AM BLOOD WBC-7.5 RBC-2.25* Hgb-7.7* Hct-24.4* MCV-108* MCH-34.2* MCHC-31.6* RDW-17.7* RDWSD-69.8* Plt ___ ___ 05:03AM BLOOD ___ PTT-43.6* ___ ___ 05:03AM BLOOD Glucose-76 UreaN-6 Creat-0.4 Na-140 K-3.7 Cl-105 HCO3-25 AnGap-14 ___ 05:03AM BLOOD ALT-29 AST-115* AlkPhos-88 TotBili-3.7* IMAGING: -CXR (___): IMPRESSION: There are no prior chest radiographs available for review. Aside from linear atelectasis or scarring at one of the lung bases, as seen on the lateral view, lungs are clear. Nipple shadow should not be mistaken for lung nodules. Heart size top-normal. No pleural abnormality or evidence of central lymph node enlargement. -RUQ U/S (___): IMPRESSION: 1. Cirrhotic appearing liver without ascites. 2. Patent portal vein. 3. Massive splenomegaly, increased in size from ___. MICRO: ___ 5:10 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 12:47 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): __________________________________________________________ ___ 12:30 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Vitamin D ___ UNIT PO 1X/WEEK (___) 4. Cetirizine 10 mg PO DAILY 5. Cephalexin Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Potassium Chloride 20 mEq PO DAILY Hold for K >4 RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 2. PredniSONE 30 mg PO DAILY RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*42 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:*6 4. Cetirizine 10 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D ___ UNIT PO 1X/WEEK (___) 8.Outpatient Lab Work Please check CBC with diff, Na, K, Cl, HCO3, BUN, Cr, AST, ALT, Alk Phos, T Bili Dx: Alcoholic cirrhosis ICD-10: K70.31 Please fax results to Dr. ___ at ___ 9.Ensure Please provide patient with 120 Ensures/month with goal of having 4 Ensures/day Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Alcoholic hepatitis -Alcoholic cirrhosis -Malnutrition SECONDARY -Alcohol abuse 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: ___ year old woman with alcoholic hepatitis, possible cirrhosis, rule out PNA, pulmonary edema as etiology of decompensation // evidence of PNA, pulmonary edema as etiology of decompensation evidence of PNA, pulmonary edema as etiology of decompensation IMPRESSION: There are no prior chest radiographs available for review. Aside from linear atelectasis or scarring at one of the lung bases, as seen on the lateral view, lungs are clear. Nipple shadow should not be mistaken for lung nodules. Heart size top-normal. No pleural abnormality or evidence of central lymph node enlargement. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with etOH abuse, suspected cirrhosis, admitted for alc hepatitis // evidence of PVT, cirrhosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT of the abdomen pelvis from ___. FINDINGS: LIVER: The liver is heterogeneous in echotexture. The contour of the liver is nodular, consistent with cirrhosis. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. GALLBLADDER: Not visualized. SPLEEN: Normal echogenicity, measuring 20.8 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic appearing liver without ascites. 2. Patent portal vein. 3. Massive splenomegaly, increased in size from ___. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: UNKNOWN-CC Diagnosed with Encounter for examination and observation for unsp reason temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

___ F PMHx alcohol abuse, s/p sleeve gastrectomy presenting with alcoholic hepatitis/cirrhosis and malnutrition. #EtOH hepatitis/cirrhosis: Ms. ___ has a long history of EtOH abuse. Review of OMR was notable for hepatomegaly on CT A/P from ___, concerning for long-standing liver disease. She had been evaluated by Hepatology as an outpatient, and due to concern for EtOH hepatitis and malnutrition she was referred to ___ for admission. On admission she had a discriminant function of 42 and her total bilirubin peaked at 6.3. Infectious work-up, including CXR, urine culture, and blood cultures, was negative. RUQ U/S showed nodular liver with splenomegaly, negative for ascites. Her hepatitis serologies were negative. She was started on prednisone 40mg and her lab work was reassuring for a downtrend in her bilirubin; she was discharged on a course of x2 weeks of prednisone 30mg daily. She will need a screening EGD as an outpatient which will be coordinated by her outpatient Hepatologist's office. #Malnutrition: patient reported poor po intake and poor appetite, and her exam was concerning for temporal wasting. She was evaluated by Nutrition, who recommended supplemental Ensure QID. She was counseled extensively on keeping up with her calorie intake and received a prescription for Ensures. #EtOH abuse: Patient with longstanding EtOH history, with daily drinking for years. She had recently been admitted to ___. ___ for detox, and was sober for approximately x1 week prior to admission. She was monitored on CIWA with no signs of withdrawal. She should continue on MVI, thiamine, folate. She was seen by ___ and provided with resources regarding relapse prevention and was encouraged to reach out to the recommended services. #Anemia: patient was noted to have a macrocytic anemia on admission without evidence of active bleed. Etiology thought to be most likely due to a combination of nutritional deficiency vs ACD in setting of hepatitis vs marrow suppression with liver disease. Lab work notable for low folate. She was started on folate supplementation. She will get screening EGD for varices.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Prozac Attending: ___ Chief Complaint: fatigue Major Surgical or Invasive Procedure: Large Volume Paracentesis History of Present Illness: Ms. ___ is a ___ woman with a history of NASH/EtOH cirrhosis who was referred in for worsening abdominal distention and lab anormalities. Patient is follwed by PCP ___ in ___ and Hepatologist Dr. ___ with ___. She has a history of cirrhosis (never biopsied, thought to be due to NASH/EtOH, + HE, - EBV, - SBP) which has worsened rapidly over past few months. She reports she was hospitalized with confusion and poor PO intake (per ED call in, hospitalized with HE, worsening edema, ascites) in ___ at ___ x 2 weeks. She reports taking an extended prednisone taper after her admission, which she finished about 2 weeks ago, though she is unclear on exact timeline. She says the prednisone was for her liver. She reports drinking heavily before her hospitalization, saying "it used to be just ___ glasses of wine per night but for those few weeks it was more than that, more than 3, I wasn't taking in anything else." It is difficult to elicit more specific information on alcohol intake. She says many time that she has always been "only a social drinker." When asked about most recent drink, patient does not mention ___ episode and says, ___, but I'm telling people ___ She has seen Dr. ___ in outpatient setting. She reports having an extensive laboratory work-up and is awaiting results. She has discussed that she might need liver transplant and was told she needs 6 months of sobriety for eligibility. Patient reports that her confusion has improved since her hospitalization. She is taking lactulose and rifaximin and has several loose stools per day. She still feels confused when discussing health information and reports trouble keeping track of details. She has had abdominal pain for the past ___ months that is currently at baseline; her peritoneal fluid has been tested many times and she has never had SBP. She has had worsening abdominal distention. Over the past few months, she has required q2 week 8L paracenteses; most recent para was 1 week ago ___ (only 4L) but she reported full reaccumulation by the next day. She denies recent fevers, chills, nausea, vomiting, congestion, cough, sore throat. She has ___ loose, liquid stools per day, which has been her baseline since she started taking lactulose. No dysuria, frequency, urgency, hematuria, blood in stool, black stools. No hematemesis. No recent travel, unusual foods, or sick contacts. She is a ___ but had to take a leave of absence earlier this year due to her illness. In the ED initial vitals were: 2 97.8 113 108/67 20 100%. Labs were significant for AP 303, Tbili 2.3, albumin 2.1, AST 109, ALT 36. Serum tox (including EtOH) was negative. WBC 17.9 (83% PMN), plt 270, INR 1.7, Na 127. CXR showed atalectasis at R base but no evidence of pneumonia. A diagnostic paracentesis was negative for SBP. Vitals prior to transfer were: 98.8 ___ 100% RA On the floor, patient provides above history. Past Medical History: - HTN - Cirrhosis (thought to be due to NASH/EtOH) - Anxiety Social History: ___ Family History: - Father has alcoholism (currently sober x ___ years) and liver disease - Mother had valvular heart disease - No family history of cancer or MI Physical Exam: Admission physical exam: Vitals 98.1 93/54 93 20 100 RA GENERAL: Lying in bed, NAD HEENT: Ruddy face, AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, nontender supple neck, no LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: LCTAB, no w/r/r ABDOMEN: Distended, lagre ascites, + fluid wave, significant tenderness to palpation diffusely without r/g, NABS, cannot assess for HSM due to ascites EXTREMITIES: Moving all extremities, trace-1+ edema to knee bilaterally PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, mild tremor vs. asterixis, A+O x 3 but tangential, unclear on on many details of history SKIN: Warm and well perfused, petecchiae on bilateral arms, anterior chest, no palmar erythema DISCHARGE EXAM: VS: 98.3, 101/68, 107, 18, 97%RA GENERAL: Lying in bed, NAD HEENT: Ruddy face, sclera anicteric, clear conjuctiva. NECK: supple, no LAD or JVD CARDIAC: regular rhythm, no murmurs LUNG: clear bilaterally, no wheezes of crackles ABDOMEN: Distended, tight ascites, RUQ mildly TTP. EXTREMITIES: Moving all extremities, trace-1+ edema to distal shins bilaterally PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, mild asterixis, A+O x 3 SKIN: Warm and well perfused, spiders on chest Pertinent Results: Admission labs: ___ 12:10PM WBC-17.9* RBC-4.00* HGB-11.6* HCT-36.6 MCV-92 MCH-29.0 MCHC-31.7 RDW-14.7 ___ 12:10PM NEUTS-83* BANDS-0 LYMPHS-12* MONOS-4 EOS-1 BASOS-0 ___ MYELOS-0 ___ 12:10PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 12:10PM PLT SMR-NORMAL PLT COUNT-270 ___ 12:10PM ___ PTT-38.2* ___ ___ 12:10PM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-127* POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-20* ANION GAP-10 ___ 12:10PM ALT(SGPT)-36 AST(SGOT)-109* ALK PHOS-303* TOT BILI-2.3* ___ 12:10PM LIPASE-20 ___ 12:10PM ALBUMIN-2.1* ___ 12:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 05:20PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 05:20PM URINE UCG-NEGATIVE Discharge labs: ___ 07:00AM BLOOD WBC-17.2* RBC-4.02* Hgb-11.6* Hct-35.5* MCV-88 MCH-28.9 MCHC-32.7 RDW-14.8 Plt ___ ___ 07:00AM BLOOD ___ ___ 07:00AM BLOOD UreaN-8 Creat-0.7 Na-130* K-4.0 Cl-101 HCO3-18* AnGap-15 ___ 07:00AM BLOOD ALT-34 AST-107* AlkPhos-287* TotBili-2.5* ___ 07:00AM BLOOD Calcium-8.6 Phos-5.2* Mg-1.9 Micro: Blood cx negative Urine cx with 10,000-100,000 E coli Imaging: ___ CXR FINDINGS: The lungs are normally expanded. There are linear areas of opacity in the right base likely reflecting atelectasis. No focal airspace opacity is detected to suggest pneumonia. The heart is not enlarged. The mediastinal and hilar contours are normal. There is no pleural effusion or pneumothorax. IMPRESSION: Atelectasis at the right base but no evidence of pneumonia. ___ RUQ U/S 1. Coarsened echotexture and nodular contour of the liver in keeping with cirrhosis. No focal hepatic mass identified. 2. Mild splenomegaly and moderate ascites. 3. No detectable color Doppler flow in the main portal vein and right portal vein, which may relate to extremely slow flow, although thrombosis cannot be excluded. Color Doppler flow is identified in the left portal vein, however. Further evaluation with CT scan of the abdomen could be obtained, but initially, suggest repeat Doppler ultrasound with a radiology attending scanning the patient (this can be performed at no additional charge to the patient). 4. Normal directional flow and velocities of the main, right and left hepatic arteries. Normal directional flow of right, main and left hepatic veins. 5. Circumferential gallbladder wall thickening likely related to third spacing from underlying liver disease. ___ CT A/P 1. Main portal vein and its branches are patent. 2. Cirrhosis with sequelae of portal hypertension including mild splenomegaly, recanalized paraumbilical vein, esophageal varices, and large intra-abdominal ascites. 3. Area of hypoenhancement within the pancreatic body. This may be a complication of prior pancreatitis, but neoplasm cannot be excluded. Follow up with MRCP or short interval CT is recommended. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO DAILY 2. Klor-Con (potassium chloride) 40 mEq oral daily 3. FoLIC Acid 2 mg PO DAILY 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Magnesium Oxide 400 mg PO DAILY 6. Rifaximin 550 mg PO BID 7. Pantoprazole 40 mg PO Q24H 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2 puffs PRN sob 9. ZyrTEC (cetirizine) 10 mg oral daily as needed for allergy 10. flunisolide 25 mcg (0.025 %) nasal 1 whiff for allergies 11. Levothyroxine Sodium 25 mcg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Spironolactone 50 mg PO DAILY Discharge Medications: 1. FoLIC Acid 2 mg PO DAILY 2. Lactulose 30 mL PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Rifaximin 550 mg PO BID 5. flunisolide 25 mcg (0.025 %) nasal 1 whiff for allergies 6. Furosemide 20 mg PO DAILY 7. Klor-Con (potassium chloride) 40 mEq oral daily 8. Levothyroxine Sodium 25 mcg PO DAILY 9. Magnesium Oxide 400 mg PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2 puffs PRN sob 11. Spironolactone 50 mg PO DAILY 12. ZyrTEC (cetirizine) 10 mg oral daily as needed for allergy Discharge Disposition: Home Discharge Diagnosis: Cirrhosis, likely related to alcohol use. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Leukocytosis. Evaluate for infection. COMPARISON: None. TECHNIQUE: Upright PA and lateral radiographs of the chest. FINDINGS: The lungs are normally expanded. There are linear areas of opacity in the right base likely reflecting atelectasis. No focal airspace opacity is detected to suggest pneumonia. The heart is not enlarged. The mediastinal and hilar contours are normal. There is no pleural effusion or pneumothorax. IMPRESSION: Atelectasis at the right base but no evidence of pneumonia. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old woman with cirrhosis, abdominal pain. Please do Doppler study to assess hepatic vasculature/rule out PVT. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver demonstrates a coarsened echotexture and nodular contour in keeping with cirrhosis. There is no focal liver mass. Moderate amount of ascites is noted. VASCULATURE: The right, main and left hepatic vein demonstrate normal directional flow and waveforms. IVC demonstrates normal directional flow. No significant color Doppler flow is identified in the main portal vein and right portal vein. Normal directional color Doppler flow is noted in the left portal vein demonstrating velocities up to 10 cm/sec. The main hepatic artery, right hepatic artery and left hepatic artery demonstrate low resistance waveforms and normal directional flow. The peak systolic velocity of the main hepatic artery, right hepatic artery and left hepatic artery are 203, 127, and 110 cm/sec. The resistive indices of the main hepatic artery, right hepatic artery and left hepatic artery are 0.61, 0.64 and 0.65 respectively. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm. GALLBLADDER: Gallbladder wall appears thickened, likely related to third spacing from underlying liver disease. Minimal dependent sludge is seen within the gallbladder. PANCREAS: Pancreas is poorly visualized, with only pancreatic head identified which demonstrates no focal masses or pancreatic ductal dilatation. SPLEEN: Spleen is mildly enlarged measuring 14 cm. IMPRESSION: 1. Coarsened echotexture and nodular contour of the liver in keeping with cirrhosis. No focal hepatic mass identified. 2. Mild splenomegaly and moderate ascites. 3. No detectable color Doppler flow in the main portal vein and right portal vein, which may relate to extremely slow flow, although thrombosis cannot be excluded. Color Doppler flow is identified in the left portal vein, however. Further evaluation with CT scan of the abdomen could be obtained, but initially, suggest repeat Doppler ultrasound with a radiology attending scanning the patient (this can be performed at no additional charge to the patient). 4. Normal directional flow and velocities of the main, right and left hepatic arteries. Normal directional flow of right, main and left hepatic veins. 5. Circumferential gallbladder wall thickening likely related to third spacing from underlying liver disease. NOTIFICATION: This consultation was reviewed with Dr ___ telephone at 09:30 on ___. Radiology Report INDICATION: Alcoholic cirrhosis with concern for portal vein thrombus on ultrasound. COMPARISON: Ultrasound ___. TECHNIQUE: MDCT axial images from the lung bases to the iliac crest were obtained before and after the uneventful administration of contrast in the arterial, portal venous and three-minute delayed phases. Multiplanar reformation images were provided for review. DLP: 1244 mGy-cm. CT ABDOMEN WITH AND WITHOUT CONTRAST: The visualized lung bases demonstrate subsegmental linear atelectasis. There is no pleural or pericardial effusion. The liver is nodular with heterogeneous enhancement, compatible with provided history of cirrhosis. No suspicious liver lesion is identified. The gallbladder is decompressed. Gallbladder wall edema is nonspecific in the setting of ascites. The spleen is mildly enlarged measuring 13 cm. The pancreas is somewhat atrophic. An area of hypoenhancement within the pancreatic body (4:44), which persists on delayed images (8:45, 13:27) is nonspecific and although it does not appear mass-like, a neoplasm cannot be excluded. The bilateral adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. The imaged portions of the small and large bowel are not obstructed. There is large intra-abdominal ascites. No free air. The main portal vein, left portal vein and the right anterior and right posterior portal veins are patent. The paraumbilical vein is recanalized. Hepatic veins are patent. The splenic vein and SMV are patent. Small esophageal varices are noted. There is a replaced right hepatic artery, originating directly from the aorta. The abdominal aorta is of normal caliber. Small porta hepatic lymph nodes may be related to chronic liver disease. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. IMPRESSION: 1. Main portal vein and its branches are patent. 2. Cirrhosis with sequelae of portal hypertension including mild splenomegaly, recanalized paraumbilical vein, esophageal varices, and large intra-abdominal ascites. 3. Area of hypoenhancement within the pancreatic body. This may be a complication of prior pancreatitis, but neoplasm cannot be excluded. Follow up with MRCP or short interval CT is recommended. Findings and recommendations discussed with Dr. ___ by phone at 5:03pm ___. Radiology Report EXAMINATION: Abdominal MRI. MRCP. INDICATION: ___ year old woman with cirrhosis and ascites, finding of pancreatic hypodensity on CT // assess area of concern on abdominal CT TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired within a 1.5 Tesla magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 14 cc of Gadavist intravenous contrast. COMPARISON: CT and ultrasound available from ___. FINDINGS: MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Lung bases are clear. There is no pericardial or pleural effusion. The heart size is normal. There is moderate perihepatic and perisplenic ascites (series 3, image 27). The liver contour is nodular, compatible with cirrhosis. Reticular contrast enhancement, particularly throughout the posterior aspect of the right hepatic lobe on delayed sequences, denotes confluent fibrosis (series 15, image 25). There is heterogeneous signal drop-off of the hepatic parenchyma on T1 weighted out of phase images in comparison to in phase sequences, denoting steatosis (series 6, image 12). No focal hepatic mass is detected. There is conventional hepatic arterial anatomy. The portal and hepatic veins are patent. The spleen is mildly enlarged (series 2, image 13), measuring 13 cm. Perisplenic varices and a recannalized paraumbilical vein denotes chronic portal hypertension (series 13, image 50). The adrenal glands, kidneys, stomach, and intra-abdominal loops of small and large bowel are normal. There is no mesenteric or retroperitoneal lymphadenopathy. The pancreas demonstrates normal signal intensity on T1 and T2 weighted sequences. The main pancreatic duct is normal. An ill-defined area of hypoenhancement within the pancreatic tail seen on the ___ CT examination is again demonstrated on MRI on both early and delayed post-contrast dynamic series (series 12, image 51); however, no correlate is seen on T1 weighted precontrast images were T2 and diffusion weighted sequences. There is no atrophy. The abdominal aorta, celiac trunk, SMA, and renal arteries are patent and normal in caliber. A left accessory renal artery is present (series 12, image 46 52). There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. Ill-defined area of hypoenhancement within the pancreatic body has no DWI, T1 precontrast, or T2 correlates, and may reflect the sequela of prior pancreatits. No discrete mass. Normal-caliber pancreatic duct. This can be followed for stability on future hepatic screening imaging. 2. Cirrhotic liver with confluent fibrosis. Splenomegaly, perisplenic varices, recannalized paraumbilical vein, and moderate ascites reflecting chronic portal hypertension. No suspicious lesion. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN GENERALIZED, LEUKOCYTOSIS, UNSPECIFIED , CIRRHOSIS OF LIVER NOS temperature: 97.8 heartrate: 113.0 resprate: 20.0 o2sat: 100.0 sbp: 108.0 dbp: 67.0 level of pain: 2 level of acuity: 3.0

Ms. ___ is a ___ woman with a history of NASH/EtOH cirrhosis who was referred to the ___ ED for worsening liver function. Patient complains of subacute fatigue and poor appetite. ACUTE # Decompensated Cirrhosis ___ ETOH abuse: MELD 16 (unknown baseline). Currently decompensated with progressive ascites, ? mild encephalopathy. Last hospitalization ___ for alcoholic hepatitis s/p steroid tx, but currently transaminases low, bili much improved and tox screen negative for EtOH. Concern for PV thrombosis on RUQ u/s, but no e/o clot on CT A/P. Continued lactulose and rifaximin. Performed large volume paracentesis and restarted home diuretics on discharge. Will f/u with liver clinic as outpatient for further management and transplant evaluation. # Leukocytosis: No clear localizing symptoms of infection. Stable. Patient reports stool studies recently WNL at OSH. Could be secondary to recent steroid use (though unknown when she stopped), downtrended from high 30's last hospitalization. # Alcohol Abuse: By history, it sounds like patient was drinking as recently as ___ unclear last drink. # ? Hx of hypertension: BPs in the ___ here. Likely secondary to decompensated liver disease; however, patient's report that she actually has HTN (and takes diltiazem) does raise concern that hypotension is new and possibly due to another etiology such as infection/sepsis. As above, there are no clear localizing symptoms and patient is well-appearing, so will hold off on empiric antibiotics. Further infectious w/u was negative. Diltiazem was discontinued on discharge. TRANSITIONAL - liver f/u - titration of diuretics # Emergency Contact: Husband ___ ___ # ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ibuprofen / cefuroxime / ioversol Attending: ___. Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ history of HFrEF (EF 20%), cardiac arrest ___ now with LifeVest, PAD s/p L AKA and R BKA, AF, HTN, pancreatic ca s/p resection, without other records in ___ system, brought in with several day history of worsening confusion, somnolence, and productive cough, initially admitted to ___ transferred for further management. ___ records currently unavailable, following history obtained from patient with ___ interpreter and collateral from son. Per son, patient was in her usual state of health 3 days prior. For the last 3 days, he has noted she has had worsening confusion, somnolence, and sleeping more at home. She has also been having a productive cough with sputum with very poor PO intake. Also with chills. Patient was also complaining of dysuria prior to presenting to ___. Of records currently available, patient presented to her PCP ___ for current symptoms and was subsequently admitted to ___. At ___, noted to be hyponatremic to 122, lactate 1.0, was started on IV zosyn and vancomycin for UTI was >50WBCs in urine. ___ records unavailable however for my review. Per PCP note, was recently hospitalized at ___ however details of which are not documented, per son patient was hospitalized for UTI 2 weeks prior. In the ED here, initial VS were: T 97.5 HR 56, BP 126/71 RR 16, O2 96%2L Exam notable for: Gen: Ill-appearing woman mildly uncomfortable Pulm: Rhonchorous breath sounds heard throughout right greater than left CV: RRR HEENT: Dry mucous membranes Abdomen: Large epigastric ventral hernia, moderately distended mild tenderness to palpation no rebound tenderness Extremities: Right lower extremity with BKA left lower extremity with AKA no obvious skin breakdown Neuro: Patient awake and responsive however exam limited by language barrier Labs notable for: - WBC 12.5, Hb 9.6, HCT 30.2, PLT 273 - Na 122, Cl 89, bicarb 15, BUN 66, Cr 2.2, glucose 211 - Ca 7.2, phos 6.2 - ALT 329, AST 208, ALP 183, T. bili 0.6, albumin 2.7, lipase 130 - ___ 14.5, PTT 25.9, INR 1.3 - UA large leukocytes, small blood, neg nitrites, 72 WBC, moderate bactereia - Lactate 1.0 - Troponin 0.02 Imaging: CT Chest WO Contrast ___: 1. Mild-to-moderate centrilobular emphysema with mild superimposed pulmonary edema. 2. Patchy opacities in the left lower lobe may represent aspiration pneumonia in the setting of left main stem bronchus secretions. No evidence of bronchial occlusion. 3. Multiple prominent and borderline enlarged supraclavicular and mediastinal lymph nodes are nonspecific, but may be reactive. 4. Nodules measuring up to 5 cm in the left lung, one of which may be infectious or inflammatory, can be followed with optional CT in 12 months if the patient is high risk. CT A/P WO Contrast ___: 1. No clear acute findings to explain the patient's reported symptoms within the abdomen or pelvis. 2. Two large ventral bowel containing hernias. The more central hernia contains mildly distended loops of bowel without evidence of obstruction. The more lateral hernia on the right abdomen contains decompressed loops of bowel which enter and exit the hernia and a small amount of nonspecific free fluid which could be related to ascites, although ischemia cannot be excluded. No definite transition point identified. If there is clinical concern for obstruction, surgical consultation is recommended. 3. Cholelithiasis with mildly distended gallbladder. Trace pericholecystic fluid could be secondary to third spacing of fluids. If indicated, ultrasound may be obtained for further evaluation. 4. Small volume ascites. 5. Anasarca. 6. Nonvisualization of the pancreas and right kidney may be due to technical factors or suggest history of prior surgery. Clinical correlation recommended. 7. Compression deformity of the L1 vertebra is of indeterminate chronicity without prior studies for comparison. CXR ___: No definite acute cardiopulmonary process. EKG: Sinus, irregular, HR 57, normal PR, QRS widened 159, no acute ST changes, non-specific TWI II, III Administered: ___ 23:16 IV Morphine Sulfate 1 mg Subjective: On arrival to the floor, patient states that she is currently complaining of a headache. Also has total body pain, worse in her back. Currently without abdominal pain. Notably with significant cough, complaining she has copious sputum production. No nausea, vomiting, only with Foley in place, previously had dysuria. No diarrhea. Past Medical History: - HFrEF (EF 20%) - Cardiac arrest ___ and ___, now with LifeVest - PAD s/p L AKA and R BKA - AF - HTN - Pancreatic tumor s/p resection (~ ___ years ago per son) Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: ___ 0141 Temp: 98.3 PO BP: 144/81 R HR: 65 RR: 19 O2 sat: 100% O2 delivery: 3L General: Uncomfortable appearing due to total body pain, coughing HEENT: NC/AT, PERRLA, EOMI Lungs: Diffuse rhonchorous breath sounds throughout, no wheezes or rales appreciated CV: Rhythm, no murmurs, rubs, or gallops Abdomen: 2 large ventral hernia both nontender to palpation, no overlying erythema, reducible Back: Superficial sacral decubitus ulcers with no visible muscle/bone, no purulence GU: Bilateral inguinal erythema difficult to visualize, already with overlying lotion Ext: S/p L AKA and R BKA Neuro: CN II-XII intact. No focal neurological deficits. Moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM ========================= 24 HR Data (last updated ___ @ 1116) Temp: 97.3 (Tm 97.8), BP: 127/67 (96-127/59-80), HR: 60 (59-62), RR: 20 (___), O2 sat: 100%, O2 delivery: 2L Fluid Balance (last updated ___ @ 836) Last 8 hours Total cumulative -70ml IN: Total 580ml, PO Amt 580ml OUT: Total 650ml, Urine Amt 650ml Last 24 hours Total cumulative -575ml IN: Total 1750ml, PO Amt 1750ml OUT: Total 2325ml, Urine Amt 2325ml GEN: Laying in bed, in NAD HEENT: MMM, poor dentition CV: RRR, ___ systolic murmur LLSB, no r/g, JVP is difficult to appreciate but does not appear to be elevated on examation PULM: Diffuse course breath sounds anteriorly, less rhoncherous ABD: Large epigastric ventral hernieas, reducible, tender to palpation, no guarding or rebound. 8 cm linear area of ___ crusted papules on an erythematous base, tender to palpation on right side, ~T8 EXT: RLE BKA, LLE AKA, trace pitting edema right thigh MSK: Superficial sacral decubitus ulcers not visualized today GU: foley in place Pertinent Results: ADMISSION LABS: ============= ___ 09:51PM BLOOD WBC-12.5* RBC-3.50* Hgb-9.6* Hct-30.2* MCV-86 MCH-27.4 MCHC-31.8* RDW-20.5* RDWSD-64.4* Plt ___ ___ 09:51PM BLOOD Neuts-91.4* Lymphs-1.8* Monos-5.8 Eos-0.3* Baso-0.1 NRBC-0.4* Im ___ AbsNeut-11.44* AbsLymp-0.23* AbsMono-0.73 AbsEos-0.04 AbsBaso-0.01 ___ 09:13PM BLOOD ___ PTT-25.9 ___ ___ 09:13PM BLOOD Glucose-211* UreaN-66* Creat-2.2* Na-122* K-4.6 Cl-89* HCO3-15* AnGap-18 ___ 09:13PM BLOOD ALT-329* AST-208* CK(CPK)-257* AlkPhos-183* TotBili-0.6 ___ 09:13PM BLOOD Lipase-130* ___ 09:13PM BLOOD cTropnT-0.02* ___ 09:13PM BLOOD CK-MB-3 ___ ___ 09:13PM BLOOD Albumin-2.7* Calcium-7.2* Phos-6.2* Mg-1.7 ___ 09:18PM BLOOD Lactate-1.0 OTHER PERTINENT LABS: ================== ___ 06:19AM BLOOD calTIBC-307 ___ Folate->20 Ferritn-198* TRF-236 ___ 03:45AM BLOOD Ret Aut-4.9* Abs Ret-0.16* ___ 09:13PM BLOOD CK-MB-3 ___ ___ 09:13PM BLOOD cTropnT-0.02* ___ 05:26AM BLOOD CK-MB-3 cTropnT-0.03* DISCHARGE LABS: ============== ___ 08:28AM BLOOD WBC-7.9 RBC-2.95* Hgb-8.4* Hct-27.0* MCV-92 MCH-28.5 MCHC-31.1* RDW-22.7* RDWSD-75.7* Plt ___ ___ 08:28AM BLOOD Plt ___ ___ 08:28AM BLOOD Glucose-111* UreaN-101* Creat-2.2* Na-128* K-4.1 Cl-84* HCO3-27 AnGap-17 ___ 08:28AM BLOOD ALT-72* AST-68* AlkPhos-214* TotBili-0.3 ___ 08:28AM BLOOD Albumin-2.9* Calcium-8.1* Phos-6.0* Mg-3.1* IMAGING/STUDIES: ============== CT Chest WO Contrast ___: 1. Mild-to-moderate centrilobular emphysema with mild superimposed pulmonary edema. 2. Patchy opacities in the left lower lobe may represent aspiration pneumonia in the setting of left main stem bronchus secretions. No evidence of bronchial occlusion. 3. Multiple prominent and borderline enlarged supraclavicular and mediastinal lymph nodes are nonspecific, but may be reactive. 4. Nodules measuring up to 5 cm in the left lung, one of which may be infectious or inflammatory, can be followed with optional CT in 12 months if the patient is high risk. CT A/P WO Contrast ___: 1. No clear acute findings to explain the patient's reported symptoms within the abdomen or pelvis. 2. Two large ventral bowel containing hernias. The more central hernia contains mildly distended loops of bowel without evidence of obstruction. The more lateral hernia on the right abdomen contains decompressed loops of bowel which enter and exit the hernia and a small amount of nonspecific free fluid which could be related to ascites, although ischemia cannot be excluded. No definite transition point identified. If there is clinical concern for obstruction, surgical consultation is recommended. 3. Cholelithiasis with mildly distended gallbladder. Trace pericholecystic fluid could be secondary to third spacing of fluids. If indicated, ultrasound may be obtained for further evaluation. 4. Small volume ascites. 5. Anasarca. 6. Nonvisualization of the pancreas and right kidney may be due to technical factors or suggest history of prior surgery. Clinical correlation recommended. 7. Compression deformity of the L1 vertebra is of indeterminate chronicity without prior studies for comparison. CXR ___: No definite acute cardiopulmonary process. TTE ___ The left atrial volume index is moderately increased. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is a large anteroapical aneurysm. No thrombus or mass is seen in the left ventricle (on contrast-enhanced imaging) but cannot be excluded with certainty due to the technically suboptimal images. Overall left ventricular systolic function is severely depressed secondary to extensive apical akinesis with focal apical dyskinesis. The visually estimated left ventricular ejection fraction is 20%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with focal hypokinesis of the apical free wall. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (?#) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. The transmitral E-wave deceleration time is short (<140ms). There is mild to moderate [___] mitral regurgitation. There is significant pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate [2+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. RUQUS ___ IMPRESSION: No biliary dilatation is identified. No sonographic signs of cholecystitis are identified. A small amount of sludge and stones identified, however the gallbladder is not distended and there is no gallbladder wall thickening. RECOMMENDATION(S): If cholecystitis remains a consideration, liver MRI is more sensitive in the detection of acute on chronic cholecystitis RUQUS ___ IMPRESSION: Cholelithiasis without evidence of cholecystitis. No biliary duct dilatation is identified. There is trace ascites. Medications on Admission: 1. Multivitamins 1 TAB PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. FoLIC Acid 1 mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 100 mg PO DAILY 7. HydrALAZINE 10 mg PO Q8H 8. Gabapentin 100 mg PO BID 9. Furosemide 40 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Carvedilol 6.25 mg PO BID 12. Amiodarone 200 mg PO DAILY 13. Atorvastatin 40 mg PO QPM 14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN BREAKTHROUGH PAIN 15. Aspirin 81 mg PO DAILY 16. Levothyroxine Sodium 50 mcg PO DAILY 17. ClonazePAM 0.5 mg PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth Q8H PRN Disp #*60 Tablet Refills:*0 2. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Bisacodyl ___AILY:PRN Constipation - Second Line If no bowel movement on oral medications, can use this medication rectally RX *bisacodyl 10 mg 1 suppository(s) rectally daily PRN Disp #*30 Suppository Refills:*0 4. Bisacodyl 10 mg PO DAILY RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 6. Fentanyl Patch 12 mcg/h TD Q72H RX *fentanyl 12 mcg/hour Apply to skin Every 72 hours Disp #*10 Patch Refills:*0 7. GuaiFENesin ___ mL PO Q6H:PRN Cough RX *guaifenesin 100 mg/5 mL 5 mL by mouth Q6H prn Refills:*0 8. Isosorbide Dinitrate 10 mg PO TID RX *isosorbide dinitrate 10 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN right leg pain 10. Miconazole 2% Cream 1 Appl TP BID RX *miconazole nitrate 2 % Apply to red itchy areas of skin daily PRN Refills:*0 11. Sarna Lotion 1 Appl TP TID:PRN Itchiness RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to itchy skin daily PRN Refills:*0 12. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 13. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 14. ValACYclovir 1000 mg PO DAILY Duration: 7 Days RX *valacyclovir 1,000 mg 1 tablet(s) by mouth Daily Disp #*4 Tablet Refills:*0 15. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 16. Gabapentin 200 mg PO BID RX *gabapentin 100 mg 2 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 17. HydrALAZINE 25 mg PO Q8H RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 18. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL 30 units 30 Units before BED; Disp #*1 Vial Refills:*0 19. Amiodarone 200 mg PO DAILY 20. Aspirin 81 mg PO DAILY 21. Atorvastatin 40 mg PO QPM 22. Carvedilol 6.25 mg PO BID 23. ClonazePAM 0.5 mg PO TID 24. FoLIC Acid 1 mg PO DAILY 25. Levothyroxine Sodium 50 mcg PO DAILY 26. Multivitamins 1 TAB PO DAILY 27. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN BREAKTHROUGH PAIN 28. Pantoprazole 40 mg PO Q24H 29.___ LIFT Z89.611, I50.84 ___ LIFT ___: Lifetime, Ht: 48in Wt: 137lb Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Acute on chronic heart failure with reduced ejection fraction Hypoxemic respiratory failure Urinary tract infection Acute on chronic kidney disease SECONDARY DIAGNOSIS Herpes zoster (shingles) Chronic pain on opioids in setting of lower extremity amputations Coronary artery disease complicated by recent cardiac arrests Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with sepsis and rhonchorous breath sounds cough// Pneumonia? TECHNIQUE: Frontal lateral views the chest. COMPARISON: Chest x-ray from ___ performed at an outside institution. FINDINGS: There is moderate enlargement of cardiac silhouette. Right chest wall port is seen with tip in the right atrium. Electronic device with numerous component seen overlying/obscuring the chest and cardiac silhouette as seen on prior. Streaky right mid opacity is likely atelectasis. Opacity projecting over the right upper lung is felt to be due to external tubing. No large confluent consolidation or effusion. No overt edema. Orthopedic hardware projecting over the lower thoracic upper lumbar spine. IMPRESSION: No definite acute cardiopulmonary process. Radiology Report INDICATION: NO_PO contrast; History: ___ with transaminitis ventral hernia confusionNO_PO contrast// Evidence of intra-abdominal process TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 20.1 cm; CTDIvol = 26.7 mGy (Body) DLP = 534.8 mGy-cm. 2) Spiral Acquisition 4.1 s, 32.1 cm; CTDIvol = 23.3 mGy (Body) DLP = 746.6 mGy-cm. Total DLP (Body) = 1,281 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: Evaluation of the liver is limited due to streak artifact from overlying metallic device. The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is mildly distended and contains gallstones. No definite wall thickening or pericholecystic fluid. PANCREAS: The pancreas is not well seen due to anasarca and streak artifact. No gross fluid collections within its expected region. 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 right kidney is not visualized. The left kidney is slightly atrophic. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. There are large ventral bowel containing hernias in the midline and right abdomen. The more central hernia contains mildly distended loops of bowel on entry and exit. The right abdominal hernia contains decompressed loops of bowel and a small amount of nonspecific free fluid. No transition point identified. Elsewhere, the colon and rectum are unremarkable. There is small volume ascites. The appendix is not visualized. PELVIS: The urinary bladder is decompressed around a Foley catheter, limiting evaluation of its wall. The distal left ureter is unremarkable. The distal right ureter is not seen. There is small volume free fluid in the pelvis. REPRODUCTIVE ORGANS: There is a fibroid uterus. No adnexal abnormality is seen. 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. There is a femorofemoral bypass graft of which the patency cannot be assessed without contrast. BONES: The bones are diffusely osteopenic. A compression deformity of the L1 vertebra is of indeterminate chronicity without prior studies for comparison. There is no evidence of worrisome osseous lesions. Posterior spinal fusion hardware extends from the T10-L3 level. SOFT TISSUES: There is diffuse subcutaneous edema suggestive of anasarca. IMPRESSION: 1. No acute findings to explain the patient's reported symptoms within the abdomen or pelvis. 2. Two large ventral bowel containing hernias. No evidence of obstruction. 3. Anasarca. 4. Cholelithiasis with mildly distended gallbladder. Trace pericholecystic fluid is likely secondary to anasarca. 5. Nonvisualization of the pancreas and right kidney may be due to technical factors and anasarca or suggest history of prior surgery. Clinical correlation recommended. 6. Compression deformity of the L1 vertebra is of indeterminate chronicity without prior studies for comparison. Radiology Report INDICATION: ___ year old woman with hypoxia// PNA? TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: None FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. There are extensive atherosclerotic calcifications about the aortic arch, proximal arch vessels, and descending thoracic aorta. There are multiple coronary stents. The heart is moderately enlarged. No pericardial effusion. Calcific densities about the left ventricle are suggestive of prior infarct. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy by CT size criteria. There are innumerable prominent but subcentimeter supraclavicular and anterior mediastinal lymph nodes measuring up to 0.8 cm. A borderline enlarged 1.0 cm right lower paratracheal lymph node (4:80). No large mediastinal mass or hematoma. There are multiple right axillary venous varices. PLEURAL SPACES: No significant pleural effusion or pneumothorax. LUNGS/AIRWAYS: Mild to moderate centrilobular emphysema. Diffuse interlobular septal thickening and ground-glass opacification is suggestive of pulmonary edema. A 0.5 cm left lower lobe nodule is nonspecific, possibly infectious or inflammatory (4:135). There is a 0.5 cm nodule in the lingula (4:122). Few patchy opacities in the left lower lobe may represent aspiration in the setting of left main bronchus secretions. The airways are otherwise grossly patent to the level of the segmental bronchi bilaterally. BASE OF NECK: This mid esophagus is distended with debris. ABDOMEN: Findings will be reported on the same day CT of the abdomen and pelvis. BONES: Posterior spinal fusion hardware projects over the lower thoracic spine. No suspicious osseous abnormality is seen.? Apparent deformity of the T9 vertebra is likely a degenerative Schmorl's node. There is no acute fracture. IMPRESSION: 1. Mild-to-moderate centrilobular emphysema with mild superimposed pulmonary edema. 2. Patchy opacities in the left lower lobe may represent aspiration pneumonia in the setting of left main stem bronchus secretions. No evidence of bronchial occlusion. 3. Multiple prominent and borderline enlarged supraclavicular and mediastinal lymph nodes are nonspecific, but may be reactive. 4. Nodules measuring up to 0.5 cm in the left lung, one of which may be infectious or inflammatory, can be followed with optional CT in 12 months if the patient is high risk. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with HFrEF (EF 20%), cardiac arrest ___ now with LifeVest, PAD s/p L AKA and R BKA, AF, HTN, pancreatic ca s/p resection, with abnormal LFTs, CT A/P GB distention and some pericholecystic fluid// Eval for cholecystis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdomen CT ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 0.5 cm GALLBLADDER: At least 1 small stone is again seen in the neck of the gallbladder. There is no gallbladder wall edema and no pericholecystic fluid is seen. PANCREAS: The pancreas is not visualized due to overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 10.9 cm IMPRESSION: Cholelithiasis. No sonographic signs of cholecystitis. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with transaminitis, abdominal pain// eval for cholecystitis, biliary obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. A small right pleural effusion is incidentally noted. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 0.2 cm GALLBLADDER: The gallbladder is not distended. A small amount of sludge and a gallstone is visualized within the neck of the gallbladder. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 10.8 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: No biliary dilatation is identified. No sonographic signs of cholecystitis are identified. A small amount of sludge and stones identified, however the gallbladder is not distended and there is no gallbladder wall thickening. RECOMMENDATION(S): If cholecystitis remains a consideration, liver MRI is more sensitive in the detection of acute on chronic cholecystitis NOTIFICATION: The suggestion of Liver MRI was discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 11:12 am, Radiology Report EXAMINATION: Chest radiograph, portable AP upright INDICATION: Heart failure with productive cough and leukocytosis. Aspiration risk. COMPARISON: Prior radiographs from ___ and CT from ___. FINDINGS: Port-A-Cath terminates in the right atrium, as before. ___ rod again projects over the lower thoracic spine. Cardiac, mediastinal and hilar contours appear stable including mild to moderate cardiomegaly. Left ventricular apex is again calcified. Right hemidiaphragm is again mildly elevated. There is slight blunting of each costophrenic sulcus, possibly due to small pleural effusions. There is no pneumothorax. Decreased platelike opacities in the right midlung suggest improving atelectasis. However, persistent mild diffuse interstitial abnormality suggests mild pulmonary edema, similar to prior study. IMPRESSION: Similar mild interstitial process suggesting pulmonary edema. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old ___ woman with transaminitis and elevated WBC// ? signs of cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Ultrasound of the abdomen from ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 0.5 cm GALLBLADDER: There is cholelithiasis without evidence of cholecystitis. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 10.8 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Cholelithiasis without evidence of cholecystitis. No biliary duct dilatation is identified. There is trace ascites. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Abnormal sodium level, UTI, Transfer Diagnosed with Other fatigue temperature: 97.5 heartrate: 56.0 resprate: 16.0 o2sat: 96.0 sbp: 126.0 dbp: 71.0 level of pain: 3 level of acuity: 3.0

================== PATIENT SUMMARY ================== Ms. ___ is a ___ year old woman with a history of HFrEF (EF 20%), cardiac arrest ___ now with LifeVest as outpatient, PAD s/p L AKA and R BKA, AF on apixaban, HTN, pancreatic ca s/p resection, brought in with several day history of worsening confusion and productive cough found to have acute heart failure exacerbation and UTI. During her hospital course, she was diuresed with a Lasix drip then developed ___. She was transitioned to oral diuretics. The palliative care team was involved with her care and assisted with pain management.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Gadolinium-Containing Agents / Percocet / Tegretol / Beta-Blockers (Beta-Adrenergic Blocking Agts) / Verapamil / Shellfish Derived / Honey Bee Venom / gluten Attending: ___. Chief Complaint: Abdominal pain and diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old man with a history of celiac disease, developmental delay, NAFLD & c.diff colitis (___) who presents with abdominal pain, fever, and diarrhea. His symptoms began yesterday morning after eating ___. He had mild abdominal pain that progressed throughout the day and into today. Additionally, he had non-bloody, foul smelling and yellow diarrhea that stopped at around 2100 last night. This was all accompanied by poor oral intake. This was accompanied by fever, so his mother brought him to the hospital. After arrival to the ED he had improvement in his abdominal pain, nausea, and diarrhea. In the ED, initial VS were: T 101.4 HR 150 BP 104/60 RR 22 O2 98% RA Lowest BP in the ED was 96/44. He was given 3L NS, cefepime, vancomycin, and 40 mEq KCl Exam notable for: Gen: Feels somewhat pale, diaphoretic, awake and alert ___: NC/AT. EOMI. Neck: No swelling. Cor: Tachycardic. No m/r/g. Pulm: CTAB, Nonlabored respirations but with mild tachypnea Abd: Soft, mildly distended with mild tenderness to palpation in the epigastrium Ext: No edema, cyanosis, or clubbing. Skin: No rash. Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. Heme: No petechial Labs showed: 5.2> 13.2/39.1 <153 Na 140 K 3.4 BUN 14 Cr 1.1 Lactate 3.2 ---3L NS---> 0.9 CT A/P: 1. Prominent gas may simply be adherent to the dependent portion of the transverse colon, but there is suspicion of mild or early pneumatosis coli. Surgery was consulted due to hypotension and the CT findings. They felt that history and exam were not concerning for pneumatosis and recommended admission to medicine with surgery consult. Transfer VS were: T 99.2 HR 101 BP 100/52 RR 18 O2 98% RA On arrival to the floor, patient reports that his abdominal pain is mostly resolved. He is still having watery diarrhea. Mom is at bedside and states that he has not had any recent sick contacts, not eating raw ___ lettuce, and he has not had any reheated rice. Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: NAFLD - Hepatology: Dr. ___ ___ DELAY - Neurology: Dr. ___ - ___: insertional deletion of 5q: ___ SENSORINEURAL HEARING LOSS - Intermittently uses amplification HYPERTRIGLYCERIDEMIA SEASONAL ALLERGIES ___ SYNDROME - Cardiology: Dr. ___ - ___: EPS: could not ablate secondary to anatomy CELIAC DISEASE - GI: Dr. ___ ___ - Allergy: Dr. ___ H/O CLOSTRIDIUM DIFFICILE ENTEROCOLITIS H/O HERNIA H/O HELICOBACTER PYLORI - S/P treatment ___ Past Surgical History: s/p appendectomy ___ s/p hernia repair Social History: ___ Family History: The patient's mother provides history notable for mother with history of hypertension and intracranial aneurysm, father with history of CABG in his ___. Maternal grandparents with history of hypertension and diabetes. Maternal grandfather with history of Alzheimer's dementia. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 99.4 BP 97/54 HR 94RR 18O2 94%Ra GENERAL: NAD, mother at beside ___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, mucous membranes dry NECK: supple, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, very mildly tender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: T 98.0 BP 110/75 HR 94 RR20O2 sat 97 Ra General: Awake and alert, no acute distress ___: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Less distended, hyperactive BS, no TTP Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Pertinent Results: ADMISSION LABS: ___ 11:11PM BLOOD WBC-5.2 RBC-4.42* Hgb-13.2* Hct-39.1* MCV-89 MCH-29.9 MCHC-33.8 RDW-15.2 RDWSD-49.7* Plt ___ ___ 11:11PM BLOOD Neuts-77.1* Lymphs-18.4* Monos-3.3* Eos-0.4* Baso-0.4 Im ___ AbsNeut-3.98 AbsLymp-0.95* AbsMono-0.17* AbsEos-0.02* AbsBaso-0.02 ___ 11:11PM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-140 K-3.4* Cl-108 HCO3-19* AnGap-13 ___ 09:20AM BLOOD ALT-120* AST-129* LD(LDH)-202 AlkPhos-31* TotBili-0.6 ___ 09:20AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8 ___ 10:42AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* ___ 10:42AM BLOOD HCV Ab-NEG URINE: ___ 11:30PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 11:30PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 11:30PM URINE RBC-1 WBC-8* Bacteri-FEW* Yeast-NONE Epi-<1 ___ 11:30PM URINE CastHy-1* MICRO: ___ 4:30 am STOOL CONSISTENCY: WATERY FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: No E. coli O157:H7 found. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Pending): ___ 04:30 VIRAL MOLECULAR Norovirus Genogroup I NEGATIVE NEG GENOGROUP I - TEST PERFORMED BY PCR Norovirus Genogroup II POSITIVE* NEG GENOGROUP II - TEST PERFORMED BY PCR DISCHARGE LABS: ___ 05:55AM BLOOD WBC-10.5* RBC-4.42* Hgb-13.4* Hct-38.9* MCV-88 MCH-30.3 MCHC-34.4 RDW-15.7* RDWSD-50.7* Plt ___ ___ 05:55AM BLOOD Glucose-83 UreaN-7 Creat-0.8 Na-142 K-3.8 Cl-104 HCO3-19* AnGap-19* ___ 05:55AM BLOOD ALT-109* AST-70* AlkPhos-36* TotBili-0.6 ___ 03:40PM BLOOD Phos-3.3 ___ 05:55AM BLOOD Calcium-8.1* Phos-1.0* Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 2. Fish Oil (Omega 3) 1000 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Fenofibrate 200 mg PO DAILY 7. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild 8. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Cetirizine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO DAILY 3. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 4. Fenofibrate 200 mg PO DAILY 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild 8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Norovirus SECONDARY DIAGNOSES: Celiac disease and developmental delay Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: NO_PO contrast; History: ___ with abdominal pain, tachycardia, hypotensionNO_PO contrast// Evaluate for evidence of appendicitis versus other intra-abdominal infection 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 not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 7.3 s, 57.6 cm; CTDIvol = 11.6 mGy (Body) DLP = 666.4 mGy-cm. Total DLP (Body) = 674 mGy-cm. COMPARISON: CT abdomen ___, CT pelvis ___ FINDINGS: LOWER CHEST: There is mild scarring atelectasis at the lung bases, bilaterally. ABDOMEN: HEPATOBILIARY: A 1.4 cm hepatic hypodensity in the left lobe (series 2, image 19) may represent a hemangioma and is unchanged from ___. A 9 mm enhancing lesion at the dome of the liver (series 2, image 8) is also unchanged from ___ and compatible with a hemangioma. PANCREAS: The pancreas has normal attenuation throughout, 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. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Gas adherent to the wall within the transverse colon is noted. The appendix is surgically absent. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized 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. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute intra-abdominal abnormality. The appendix is surgically absent. Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with sepsis, abdominal distention// eval free air, pna TECHNIQUE: Single AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes are low, limiting assessment. The cardiomediastinal silhouette is within normal limits. Patchy opacities at the right lung base appear to represent prominent vessels, better seen on CT of the abdomen and pelvis from the same date. No evidence of free air below the diaphragm. IMPRESSION: No acute cardiopulmonary abnormality. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Abd pain, Fever Diagnosed with Sepsis, unspecified organism temperature: 101.4 heartrate: 150.0 resprate: 22.0 o2sat: 98.0 sbp: 104.0 dbp: 60.0 level of pain: 0 level of acuity: 1.0

SUMMARY: ======== ___ with a history of celiac disease, developmental delay, NAFLD & c.diff colitis (___) who presents with abdominal pain, diarrhea, poor PO intake and fever found to have norovirus.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Ibuprofen Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with PMH of HLD, diet-controlled DM2, and COPD who p/w sudden onset cramping left-sided chest pain. Patient reports that he woke up this morning feeling well. He exercised with some light weight lifting without difficulty or pain. While eating breakfast patient developed severe (___) left chest cramping pain with some radiation to back and neck. He has never had pain similar to this. There is no association with lightheadedness, shortness of breath, or pleuritic component. He denies fevers, chills, abdominal pain, nausea, vomiting, and diarrhea. Reports recent 4 lb. weight loss. Notably, patient smoked for ___ years before quitting ___ years ago. In the ED, initial vital signs were 97.9, 56, 144/82, 18, 100% RA. Patient was managed initially for ACS and given ASA and NTG. However, two sets of cardiac enzymes were negative and multiple EKGs were unremarkable. There was concern for aortic dissection given severity of pain for which CTA chest was performed. This revealed no evidence of dissection but did show a large LLL lung mass. This was communicated to his PCP who requested an admission for pain control and biopsy. On the floor, initial vital signs were 97.9, 88, 151/94, 20, 95% RA. Patient reports that chest pain has resolved. Does not believe this was due to pain medications. He is without complaints at this time with the exception of some bloating. Past Medical History: - Hyperlipidemia - Type II diabetes, diet-controlled - COPD - Melanoma in ___ - H. pylori gastritis - Osteoarthritis - Allergic rhinitis - Tobacco abuse Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION EXAM Vitals: 97.9, 88, 151/94, 20, 95% RA General: AAOx3, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD CV: Limited exam, RRR, nl S1/S2, no MRG Lungs: Decreased breath sounds and crackles at left base Abdomen: Soft, NTND, positive bowel sounds GU: No Foley Ext: Warm, well-perfused, no cyanosis/clubbing/edema Neuro: CN II-XII grossly intact DISCHARGE EXAM Vitals: 97.8, 69, 114/80, 18, 96% RA General: AAOx3, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD CV: Limited exam, RRR, nl S1/S2, no MRG Lungs: Decreased breath sounds and crackles at left base Abdomen: Soft, NTND, positive bowel sounds GU: No Foley Ext: Warm, well-perfused, no cyanosis/clubbing/edema Neuro: CN II-XII grossly intact Pertinent Results: ADMISSION LABS ___ 07:30AM BLOOD WBC-10.8 RBC-4.95 Hgb-15.5 Hct-46.2 MCV-93 MCH-31.3 MCHC-33.6 RDW-12.3 Plt ___ ___ 07:30AM BLOOD Neuts-67.9 ___ Monos-7.4 Eos-1.5 Baso-0.5 ___ 07:30AM BLOOD ___ PTT-28.5 ___ ___ 07:30AM BLOOD Glucose-167* UreaN-18 Creat-1.3* Na-136 K-4.6 Cl-101 HCO3-27 AnGap-13 ___ 07:30AM BLOOD ALT-19 AST-22 AlkPhos-80 TotBili-0.4 ___ 07:30AM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD Albumin-4.4 DISCHARGE LABS ___ 07:50AM BLOOD WBC-12.5* RBC-4.29* Hgb-13.4* Hct-40.4 MCV-94 MCH-31.3 MCHC-33.2 RDW-12.3 Plt ___ ___ 07:50AM BLOOD Glucose-103* UreaN-13 Creat-0.9 Na-137 K-3.9 Cl-103 HCO3-26 AnGap-12 ___ 07:50AM BLOOD CK(CPK)-28* ___ 07:50AM BLOOD CK-MB-6 cTropnT-<0.01 ___ 07:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0 IMAGING CTA chest (___): No pulmonary embolism or acute aortic syndrome. There is a large left lower lobe lung mass (?pleural based) measuring 4.1 x 2.3 cm. In addition, there is a large left adrenal mass of similar characteristics measuring 3.4 x 3.2 cm. These require outpatient oncologic workup and biopsy. CXR (___): No acute cardiopulmonary process. See subsequent CT for more complete evaluation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Fexofenadine 180 mg PO DAILY:PRN allergy symptoms 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID:PRN SOB 4. Montelukast Sodium 10 mg PO DAILY:PRN SOB 5. Pravastatin 40 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID:PRN SOB 3. Montelukast Sodium 10 mg PO DAILY:PRN SOB 4. Pravastatin 40 mg PO DAILY 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every four (4) hours Disp #*24 Tablet Refills:*0 7. Lorazepam 0.5 mg PO ONCE Duration: 1 Dose RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth twice a day Disp #*4 Tablet Refills:*0 8. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth DAILY Disp #*30 Tablet Refills:*0 9. Simethicone 80 mg PO QID:PRN bloating/gas pains RX *simethicone 80 mg 1 tablet by mouth four times a day Disp #*120 Tablet Refills:*0 10. Fexofenadine 180 mg PO DAILY:PRN allergy symptoms Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Lung mass, atypical chest pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Chest pain. COMPARISON: None available. FINDINGS: A portable AP radiograph of the chest demonstrates clear lungs and normal hilar and cardiomediastinal contours. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. Left lower lobe mass seen on subsequent CT is not visible on this study. IMPRESSION: No acute cardiopulmonary process. See subsequent CT for more complete evaluation. Radiology Report HISTORY: Chest and back pain. Evaluate for aortic dissection. COMPARISON: None available. TECHNIQUE: MDCT acquired axial images of the chest were obtained during the early arterial phase after the rapid administration of 100 cc Omnipaque intravenous contrast material. Multiplanar reformations consist of coronal and sagittal series. Additional pulmonary artery oblique maximal intensity projection images were also constructed. DLP: 692.55 mGy-cm. FINDINGS: CT ANGIOGRAM: There are no pulmonary arterial filling defects to suggest presence of pulmonary embolism. The thoracic aorta is normal in caliber, without dissection. The imaged portion of the aortic arch vessels is unremarkable. CHEST: The imaged portion of the thyroid gland is unremarkable. There is no supraclavicular, mediastinal, hilar, or axillary lymphadenopathy. The heart size is normal and there is no pericardial effusion. There are coronary arterial calcifications. The airways are patent to the subsegmental level bilaterally. Emphysema is noted. The lungs are clear. There is no pneumothorax or pleural effusion. Emphysema is noted with a 4.1 x 2.3 x 3.4 cm mass in the left lower lobe (2:94), concerning for malignancy. There is a 3.4 x 3.2 cm left adrenal mass (2:117), indeterminate though given pulmonary mass, metastasis is a concern. There is focal hyperenhancement in hepatic segment VII/VIII not fully characterized. A small hiatal hernia is present. BONES: There are no destructive osseous lesions concerning for malignancy or infection. IMPRESSION: 1. No pulmonary embolism or acute aortic syndrome. 2. Emphysema with a 4.1 x 2.3 x 3.4 cm left lower lobe lung mass, worrisome for primary malignancy. Also noted is a 3.4 x 3.2 cm left adrenal mass, concerning for metastasis. Oncologic workup and biopsy is recommended. 3. Foci of hyperenhancement in the dome of the liver, indeterminate, warrant further evaluation during oncologic workup. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CHEST PAIN Diagnosed with CHEST PAIN NOS temperature: 98.3 heartrate: 62.0 resprate: 24.0 o2sat: 99.0 sbp: 129.0 dbp: 77.0 level of pain: 3 level of acuity: 2.0

___ yo M with PMH of HLD, diet-controlled DM2, and COPD who p/w sudden onset cramping left-sided chest pain and found to have large LLL lung mass on CTA chest. ACTIVE ISSUES # Chest pain: There was no evidence of ACS or PE per cardiac enzymes, EKG, and a negative CTA chest. Pain was most likely related to large LLL lung mass appreciated on CTA chest. Most likely represents malignancy given patient's extensive smoking history. Consulted Interventional Pulmonology for biopsy but their impression was that mass was too peripheral to access via bronchoscopy. Called Interventional Radiology who will biopsy as an outpatient. Patient's pain had resolved by the time he was admitted and he developed no subsequent chest pain. Because biopsy in ___ could not be scheduled for several days patient was discharged home with a prescriptions for Dilaudid and as needed bowel regimen. CHRONIC ISSUES # Hyperlipidemia: Continued home pravastatin. # Type II diabetes: Diet-controlled at home. Did not start sliding scale. # COPD: Stable. Continued home inhaler regimen. TRANSITIONAL ISSUES - Patient discharged with Rx for oral Dilaudid - Biopsy of LLL lung and left adrenal mass to be scheduled ___ - Patient will follow-up with PCP early next week - Holding off on knee replacement pending lung cancer workup

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness and lightheadedness with standing; transient loss of vision in right eye Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year old female with a past medical history notable for T2DM (last HA1c = 13.9 on ___, HTN, atrial fibrillation on Coumadin, severe three vessel CAD with ischemic cardiomyopathy and heart failure with reduced ejection fraction (EF25-30%), hypokinesis, thrombus in the left ventricle, and pulmonary hypertension who presented for dizziness, temporary loss of vision in her right eye, one episode of emesis, and several days of increased confusion. Notably, the patient was recently admitted 2 months prior for failure to thrive after moving to the ___ from ___ and had not had medical attention for the last ___ years. It was at this time that she was found to have the abovementioned chronic diseases, and it was decided to treat her CAD medically rather than surgically. As per Ms. ___ daughter, her mother was working with home physical therapy the morning of admission. During this session she stood up and felt extremely lightheaded, los vision in her right eye temporarily and had an episode of non-bloody, non-bilious emesis. The symptoms quickly resolved when she sat down; and she was referred to the ED by ___. In the ED, initial vitals were: 98.1 69 112/64 16 97%RA. Labs were significant for nitrite positive urinalysis. CTA head and neck showed no flow limiting stenosis. EKG showed atrial fibrillation with left axis deviation, left ventricular hypertrophy but no worrisome ST changes and relatively unchanged compared to prior. Neurology evaluated the patient and stated that the symptoms were likely explained by her known orthostatic hypotension and transient hypoperfusion through a stenosed right ophthalmic artery. She was given 2g cefepime and 1L NS before transfer to the floor. Upon arrival to the floor, Ms. ___ stated she was feeling better, and had no more nausea, vomiting, or abdominal pain. She denied urinary frequency, dysuria, chest pain, and shortness of breath. Further questioning of her daughter revealed that her mother has had some cognitive deterioration over the past few weeks/months; that she is more forgetful, intermittently more or less confused, occasionally incontinent, and incapable of performing activities of daily living on her own. Dementia has not been formally diagnosed. Her daughter stated that Ms. ___ had been acting more confused over the last few days, and that the confusion was waxing and waning. Past Medical History: Ischemic cardiomyopathy Heart failure with reduced ejection fraction (EF25-30%) 3 vessel CAD (medically managed) Atrial fibrillation T2DM (last HgbA1c of 13.9%) Hypertension Pulmonary Hypertension Social History: ___ Family History: No known family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.6 134/74 64 18 96%RA General: Alert, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM: Vitals: Temp 97.6-98.3 BP 110-136/48-78 HR ___ 96-99%RA 24H I/O: 880 PO 600 IV 700 GU BMx2 FSG ___, ___: 126,178,204,112 Current weight (bed scale): 54.5kg Orthostatic Measurements (AM): Supine: BP 130/60 HR 57 Sitting: 122/63 HR 61 Standing: BP 87/57 HR 90 General: Sitting up in chair. Had previously stood up with assistance and had been walking steadily with her walker to the bathroom. Alert; conversant in ___. No acute distress. HEENT: Anicteric sclerae; PERLL; MMM. JVP 8cm above the sternal angle. Lungs: Clear to auscultation bilaterally. No wheezes, rales, rhonchi. CV: Irregular rhythm, regular rate, normal S1, S2, soft II/VI apical holosystolic murmur. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: nontender, nonedematous, unable to appreciate pedal pulses. Neuro: Answering questions appropriately. No focal abnormalities; moving all 4 extremities spontaneously. Pertinent Results: ADMISSION LABS: ___ 03:40PM BLOOD WBC-7.5# RBC-4.63 Hgb-13.5 Hct-40.7 MCV-88 MCH-29.2 MCHC-33.2 RDW-15.4 RDWSD-49.4* Plt ___ ___ 03:40PM BLOOD Neuts-56.8 ___ Monos-7.1 Eos-1.3 Baso-0.4 Im ___ AbsNeut-4.27 AbsLymp-2.55 AbsMono-0.53 AbsEos-0.10 AbsBaso-0.03 ___ 04:42PM BLOOD ___ PTT-40.4* ___ ___ 03:40PM BLOOD Plt ___ ___ 03:40PM BLOOD Glucose-168* UreaN-19 Creat-0.9 Na-135 K-5.5* Cl-99 HCO3-25 AnGap-17 ___ 03:40PM BLOOD cTropnT-<0.01 ___ 03:40PM BLOOD Calcium-9.7 Phos-3.6 Mg-1.8 ___ 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:19PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:19PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 05:19PM URINE RBC-4* WBC-55* Bacteri-MOD Yeast-NONE Epi-1 ___ 05:19PM URINE CastHy-5* ___ 05:19PM URINE Mucous-RARE ___ 05:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS: ___ 08:20AM BLOOD WBC-6.0 RBC-4.13 Hgb-12.1 Hct-36.7 MCV-89 MCH-29.3 MCHC-33.0 RDW-15.5 RDWSD-49.7* Plt ___ ___ 08:20AM BLOOD Plt ___ ___ 08:20AM BLOOD ___ PTT-36.4 ___ ___ 08:20AM BLOOD Glucose-219* UreaN-14 Creat-0.7 Na-137 K-4.2 Cl-103 HCO3-25 AnGap-13 ___ 08:20AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.2 ___ 08:20AM BLOOD Digoxin-0.8* PERTINENT LABS: ___ 07:32AM BLOOD WBC-5.9 RBC-4.30 Hgb-12.3 Hct-38.0 MCV-88 MCH-28.6 MCHC-32.4 RDW-15.4 RDWSD-49.6* Plt ___ ___ 07:30AM BLOOD WBC-6.9 RBC-4.42 Hgb-12.8 Hct-39.2 MCV-89 MCH-29.0 MCHC-32.7 RDW-15.3 RDWSD-49.5* Plt ___ ___ 07:32AM BLOOD Plt ___ ___ 07:32AM BLOOD ___ PTT-34.5 ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD ___ PTT-38.4* ___ ___ 07:32AM BLOOD Glucose-138* UreaN-14 Creat-0.8 Na-139 K-4.3 Cl-102 HCO3-25 AnGap-16 ___ 07:30AM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-138 K-4.6 Cl-102 HCO3-26 AnGap-15 ___ 07:32AM BLOOD ALT-15 AST-24 AlkPhos-64 TotBili-0.8 ___ 07:32AM BLOOD Lipase-26 ___ 07:32AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.7 ___ 07:30AM BLOOD Calcium-9.6 Phos-3.6 Mg-1.7 ___ 07:32AM BLOOD VitB12-400 ___ 07:30AM BLOOD Digoxin-1.0 MICROBIOLOGY: ___ 5:19 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 7:32 am SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Pending): IMAGING AND STUDIES: IMAGING AND STUDIES: EKG (___): Atrial fibrillation with mean ventricular rate of 63. Compared to the previous tracing of ___ ventricular rate is reduced. Otherwise, no diagnostic change. CTA Head & CTA Neck (___): IMPRESSION: 1. Senescent volume loss and probable small vessel ischemic changes. Otherwise, no acute intracranial abnormality. 2. Beaded appearance of the bilateral distal cervical internal carotid arteries compatible with fibromuscular dysplasia. In addition, there is superimposed irregularity of the internal carotid artery and intracranial vasculature, likely secondary to atherosclerosis. No evidence of high-grade stenosis, occlusion or aneurysm. 3. Mild mediastinal lymphadenopathy and patchy ground-glass opacities which may be secondary to early pulmonary edema. 4. Enlarged, nodular left thyroid gland, which may represent multi nodular goiter. A thyroid ultrasound can be performed if clinically indicated. 5. A 0.6 cm right nasal skin lesion. Correlate with physical exam. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Digoxin 0.125 mg PO DAILY 4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Spironolactone 12.5 mg PO DAILY 8. Torsemide 10 mg PO 2X/WEEK (MO,TH) 9. Warfarin 4 mg PO 2X/WEEK (___) 10. Warfarin 3 mg PO 5X/WEEK (___) 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. GlipiZIDE 5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Digoxin 0.125 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Warfarin 4 mg PO 2X/WEEK (___) 7. Warfarin 3 mg PO 5X/WEEK (___) 8. GlipiZIDE 5 mg PO DAILY 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Spironolactone 12.5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Orthostatic hypotension Urinary tract infection Secondary Diagnosis: Heart failure with reduced ejection fraction (HFrEF) Atrial fibrillation Type II Diabetes Mellitus Coronary Artery Disease Right amaurosis fugax Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: ___ year old female with presyncope and unilateral visual changes. Evaluate for stroke. 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 70 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: This study involved 5 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 4) Stationary Acquisition 9.0 s, 0.5 cm; CTDIvol = 98.0 mGy (Head) DLP = 49.0 mGy-cm. 5) Spiral Acquisition 4.9 s, 38.8 cm; CTDIvol = 31.7 mGy (Head) DLP = 1,231.9 mGy-cm. Total DLP (Head) = 2,178 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, ormass effect. Prominent ventricles and sulci are compatible with age-related volume loss. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. There is a 9 mm calcification/ossification along the inner table of the right middle temporal fossa (series 4, image 10) which may represent dural calcification versus a calcified meningioma. Right frontal sinus disease is seen. Mucosal thickening of the ethmoid sinuses is noted. There is a retention cyst in the left maxillary sinus. The visualized portion of the mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is irregularity, with no high grade stenosis, of the basilar, vertebral, internal carotid and middle cerebral arteries, likely secondary to atherosclerosis. Otherwise, the vessels of the circle of ___ and their principal intracranial branches appear normal without occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is atherosclerotic calcification of the aortic arch. Atherosclerotic calcification of bilateral carotid bulbs is also seen with no stenosis by NASCET criteria. There is multifocal irregularity of the internal carotid and vertebral arteries, likely secondary to atherosclerosis. In addition, there are superimposed beaded appearance of the right and left cervical internal carotid arteries, most prominently seen in the right just proximal to the petrous segment (series ___, image 60). Carotid artery just proximal to the horizontal Otherwise, the carotid and vertebral arteries and their major branches are patent without evidence of occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: There are patchy regions of ground-glass opacity in the left upper lobe. The left thyroid gland is enlarged and nodular, which may represent multinodular goiter. There are multiple prominent AP window, prevascular and paratracheal lymph nodes, measuring up to 1 cm. There is a 0.6 cm right nasal skin lesion. Degenerative changes are noted throughout the cervical spine. IMPRESSION: 1. Senescent volume loss and probable small vessel ischemic changes. Otherwise, no acute intracranial abnormality. 2. Beaded appearance of the bilateral distal cervical internal carotid arteries compatible with fibromuscular dysplasia. In addition, there is superimposed irregularity of the internal carotid artery and intracranial vasculature, likely secondary to atherosclerosis. No evidence of high-grade stenosis, occlusion or aneurysm. 3. Mild mediastinal lymphadenopathy and patchy ground-glass opacities which may be secondary to early pulmonary edema. 4. Enlarged, nodular left thyroid gland, which may represent multinodular goiter. A thyroid ultrasound can be performed if clinically indicated. 5. A 0.6 cm right nasal skin lesion. Correlate with physical exam. RECOMMENDATION(S): The left thyroid gland is enlarged and nodular, which may represent multinodular goiter. Thyroid ultrasound if clinically indicated. Gender: F Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Dizziness, Vomiting Diagnosed with SYNCOPE AND COLLAPSE, URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS , HYPERTENSION NOS temperature: 98.1 heartrate: 69.0 resprate: 16.0 o2sat: 97.0 sbp: 112.0 dbp: 64.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is an ___ year old woman with a past medical history of T2DM, hypertension, atrial fibrillation on coumadin, three vessel disease CAD (medically managed), heart failure with EF ___, and pulmonary hypertension who presented with lightheadedness, right amarousis fugax, emesis and possible worsening confusion who was acutely treated for orthostatic hypotension and UTI. #Lightheadedness/Orthostasis: Ms. ___ presented because of dizziness, lightheadedness, and temporary loss of vision in her right eye with standing during a ___ session the morning of admission. Her symptoms were present upon sitting or standing, and had been present for the last few days prior to admission, but may have been going on more chronically, as her daughter reported that when Ms. ___ came back from ___ to live with her, she was already primarily wheel-chair bound because she had been having difficulty standing in ___ secondary to lightheadness. Differential included orthostasis, autonomic dysfunction because of longstanding uncontrolled diabetes, infection such as UTI causing systemic vasodilation, or basilar insufficiency, the last of which is less likely because initial evaluation in the ED with CTA head and neck imaging showed no flow-limiting stenosis. The Neurology team was consulted in the ED and concluded that her amaourosis fugax symptoms were likely explained by her known orthostatic hypotension and transient hypoperfusion through a stenosed right ophthalmic artery. The diagnosis of orthostatic hypotension was supported throughout her stay with positive orthostatic vital signs, which were most likely worsened by vasodilation in the setting of UTI (see below), CHF medications that she had been recently prescribed that caused systemic vasodilation, as well as decreased PO intake recently. She was treated conservatively at first by decreasing the dose of her isosorbide mononitrate from 120 mg PO daily to 90 mg PO daily, but she remained symptomatic. The medication was then stopped altogether, after which she was no longer symptomatic with dizziness or lightheadedness upon standing, but she remained positive on objective orthostatic measurements. She did not experience any chest pain after stopping the isosorbide mononitrate. She was also treated with several 500mL NS boluses to support her blood pressures, which the team felt comfortable proceeding with as Ms. ___ did not appear volume up on examination (non elevated JVP; no crackles on pulmonary examination; no lower extremity edema), and was still symptomatically dizzy upon standing. On the day of discharge, her torsemide was also discontinued given significant orthostasis and reported poor PO intake. She remained orthostatic by vital signs, but continued to have decreased symptoms. Her orthostasis will likely persist as it has been long standing, and there is likely a diabetic neuropathy component to her symptoms. Goal was to decrease her risk of falls, and that is why the above medications discontinued. Ms. ___ should continue to use her wheelchair at home as much as possible to minimize fall risk. She should have 24 hour care and should not ambulate without assistance. #UTI: Prior to presentation Ms. ___ had been experiencing worsening orthostasis, emesis 1x, and fluctuating changes in mental status, with initial workup in the ED showing positive urinalysis with nitrites. Urine culture showed mixed bacterial flora consistent with skin or genital contamination. She was given 1 dose of cefepime in the ED, then transitioned to 1 gm IV ceftriaxone q24h while inpatient, for a total of 3 days for uncomplicated UTI. As per her daughter, her mental status returned to baseline at the time of discharge. #HFrEF: Ms. ___ heart failure with reduced ejection fraction (EF ___ is a result of ischemic cardiomyopathy. She remained euvolemic throughout this admission, and did not acutely decompensate. She was being treated with high doses of vasodilatory agents, such as the isosorbide mononitrate, most likely contributing to her symptomatic orthostasis (see above). Her isosorbide mononitrate was first reduced in dosing, then discontinued, without any development of anginal symptoms. Torsemide was also discontinued on the day of discharge given persistently positive orthostatic measurements and reportedly decreased PO intake recently, with no evidence of volume overloaded state on exam (see above). Aspirin, atorvastatin, metoprolol, lisinopril and spironolactone were continued. Daily electrolytes, ins/outs, and weights were monitored throughout her admission. Given Ms. ___ multiple comorbidities and increased risk of arrhythmias, she was also monitored on telemetry throughout her admission with no worrisome changes or decompensations. #Atrial fibrillation: Ms. ___ has a history of atrial fibrillation with LV thrombus and cardiac areas of hypokinesis that is managed with digoxin and coumadin in the outpatient setting. She remained in atrial fibrillation throughout her hospitalization, as monitored both by telemetry and physical exam. Her INR remained therapeutic between ___ throughout her stay, and monitored daily. Her home dose digoxin was continued at 0.125mg PO daily, as was her home dose metoprolol succinate XL 25 mg PO daily. She was continued on her warfarin as scheduled, 4 mg PO 2X/WEEK ___ 3 mg PO 5X/WEEK ___, and monitored on telemetry throughout her admission with no worrisome changes or decompensations requiring further therapeutic intervention. #T2DM: Ms. ___ was only recently diagnosed with T2DM when she saw a doctor for the first time after over ___ years of no medical care in ___. Her T2DM is poorly controlled, with her last HgbA1c of 13.9 on ___. She is on metformin and glipizide at home, but was managed with insulin sliding scale, diabetic diet, and daily blood glucose level monitoring throughout her admission. She was restarted on her home medications at discharge. #CAD: Recent cardiac catheterization in ___ showed severe three vessel CAD (EF25-30%). The patient and her family opted for medical management of her severe coronary artery disease. She takes aspirin 81 mg PO daily and atorvastatin 80mg PO daily at home, and these medications were continued throughout her hospitalization. TRANSITIONAL ISSUES #Imdur discontinued. #Torsemide discontinued. No evidence of volume overload during this admission. Monitor for pulmonary or peripheral edema #Consider discontinuing spironolactone if orthostatic vital signs or symptoms persist. #F/u orthostasis, lightheadness and fall risk #Continue home ___ #F/u with cardiology for medication management #Consider outpatient neurocognitive work up for official diagnosis of dementia and possible treatment/management evaluation #F/u INR #Outpatient addressment of goals of care #CODE: FULL #CONTACT: Daughter (HCP); ___, ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors / ferrous sulfate Attending: ___ Chief Complaint: Feeling Unwell Major Surgical or Invasive Procedure: None History of Present Illness: ___ with sig CAD hx s/p recent MI this month, DM and ESRD s/p DDRT ___ who presents with feeling unwell with profuse diarrhea. He reports that has been doing well since discharge on ___ but developed general malaise and low grade fever with N/V/D over the past 2 days though the profuse, watery, brown diarrhea has been present for 5 days but he only started feeling otherwise unwell 2 days ago. No sick contacts. He also has been unable to tolerate PO intake since yesterday. Renal ___ was consulted in the ED and advised sending stool cultures, o/p, C. Diff, blood CMV and urine cx. Transplant surgery was consulted and recommended sending a flu swab which was negative. In the ED, initial vitals T 99, HR 100, BP 122/58, RR 18, 96%RA. No exam documented on ED Dash. Labs notable for leukocytosis to 21.2 with neutrophilic predominance, Hgb 8.2, Plt 82. Chem 7 with bicarb 13, BUN/Cr 39/3.2 (most recently 2.4 i/s/o delayed graft function), AG 21, glucose 235. Lactate 1.7. LFTs with AP elevation to 141. UA with 100 WBCs, + ___, + Nitrites, + ketones. Blood Cx and urine Cx obtained. Renal Tx US: Renal tx US with small amount of perinephric fluid and normal wafeforms. CXR without acute process. Patient was given 1gm Tylenol, 2gm Cefepime, 1L NS, 500mg Flagyl and Vancomycin. On arrival to the floor, pt reports that he feels better and confirms the above story. He has not had any further diarrhea. He tells me that he has not taking any of his short acting insulin as he has not eaten for 2 days. He did take his 22U of lantus yesterday evening. Past Medical History: 1. CARDIAC RISK FACTORS: +diabetes, HLD, HTN 2. CARDIAC HISTORY: - CABG: ___ - Urgent coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal and distal right coronary arteries. - PERCUTANEOUS CORONARY INTERVENTIONS: Hx of DES to LAD and LCx prior to CABG ___ - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Nephrolithiasis - ESRD s/p DDRT on ___ c/b Delayed Graft Function (previously on HD and PD) - CAD s/p CABG in ___ - left radiocephalic AVF (___) - laparoscopic cholecystectomy - "surgery for renal stones" x 3 Social History: ___ Family History: Father with CAD and CABG @ age ___. Mother with diabetes, died of MI at age ___. Physical Exam: ADMISSION PHYSICAL: Vitals: 98.8; 116/53; 88; 18; 99%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Incision line from recent transplant healing well with one area of ulceration but no erythema or concern for infection Ext: Warm, well perfused, no cyanosis or edema Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. DISCHARGE PHYSICAL: VS: 97.9 120-148/48-63 63-71 ___ RA Weight: 102.9 kg > 102.1 > 102.7 > 104.0 > 103.7 > 103.4 I/O: 8H ___, 24H 1760/1320 GENERAL: Alert, oriented in NAD. HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: CTAB 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 tenderness over graft site. EXT: Warm, well perfused, 2+ pulses, 2+ ___ edema to knees NEURO: AAOx3, grossly intact ACCESS: PIVs , pulses, no edema Neuro: grossly normal Pertinent Results: ================== ADMISSION LABS ================== ___ 07:28PM BLOOD WBC-21.2*# RBC-2.89* Hgb-8.5* Hct-27.4* MCV-95 MCH-29.4 MCHC-31.0* RDW-15.2 RDWSD-52.7* Plt Ct-82*# ___ 07:28PM BLOOD Neuts-92.7* Lymphs-0.2* Monos-6.1 Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.66*# AbsLymp-0.04* AbsMono-1.30* AbsEos-0.00* AbsBaso-0.02 ___ 07:28PM BLOOD ___ PTT-26.6 ___ ___ 07:28PM BLOOD Plt Smr-LOW Plt Ct-82*# ___ 07:28PM BLOOD Glucose-235* UreaN-39* Creat-3.2* Na-142 K-4.2 Cl-108 HCO3-13* AnGap-25* ___ 07:28PM BLOOD ALT-14 AST-24 AlkPhos-141* TotBili-0.6 ___ 07:28PM BLOOD Lipase-15 ___ 07:28PM BLOOD Albumin-3.6 ___ 07:35PM BLOOD tacroFK-12.2 ___ 03:20AM BLOOD ___ pO2-47* pCO2-35 pH-7.24* calTCO2-16* Base XS--11 Comment-GREEN ___ 07:34PM BLOOD Lactate-1.7 ================ DISCHARGE LABS ================ ================ MICRO ================ ___ 7:35 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 450-5257D, ___. ESCHERICHIA COLI. ___ MORPHOLOGY). IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 450-5257D, ___. Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ ___, @08:40 ON ___. Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S) ___ 7:28 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R ___ 2:50 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: ___ Reported to and read back by ___ @11:45 AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). ___ 8:41 am Immunology (CMV) **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. ___ 9:41 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ 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. FEW POLYMORPHONUCLEAR LEUKOCYTES. ================ IMAGING ================ ___ CXR: FINDINGS: Lung volumes are relatively low with bibasilar atelectasis, similar compared to prior. There is no effusion or consolidation worrisome for pneumonia. Probable calcified granulomas identified at the right lung base. The cardiomediastinal silhouette is within normal limits. Median sternotomy wires are again notable for fracture of the superior most wire. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. ___ RENAL TRANSPLANT U.S.: FINDINGS: There is a right iliac fossa renal transplant. The cortex is of normal thickness, but appears somewhat echogenic. There is no urothelial thickening and renal sinus fat is normal. There is no hydronephrosis. There is a small amount of perinephric fluid at the lower pole. There has been interval improvement of diastolic flow when compared to prior. The resistive index of intrarenal arteries no ranges from 0.71 to 0.82, previously approaching 1. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 133 cm/sec. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Somewhat echogenic transplant kidney and a small amount of perinephric fluid at the lower pole. 2. Improved diastolic flow since prior, with resistive indices ranging from 0.71 to 0.82. ___ TTE: Conclusions The left atrium is elongated. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with basal and mid-anterior septal hypokinesis, as well as mild hypokinesis of the distal inferior wall (consistent with post-CABG coronary anatomy). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate mitral regurgitation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 40 mg PO Q12H 2. Rosuvastatin Calcium 40 mg PO QPM 3. Acetaminophen 650 mg PO Q6H:PRN Pain 4. Aspirin 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. insulin lispro As directed unit/mL subcutaneous PER SLIDING SCALE WITH MEALS 7. Tacrolimus 6 mg PO Q12H 8. ValGANCIclovir 450 mg PO Q24H 9. Vitamin D ___ UNIT PO DAILY 10. TiCAGRELOR 90 mg PO BID 11. Mycophenolate Sodium ___ 360 mg PO QID 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Calcium Carbonate 500 mg PO QID:PRN nausea/indigestion 16. Lantus (insulin glargine) 22 units subcutaneous QHS 17. Dapsone 100 mg PO DAILY 18. Cinacalcet 45 mg PO DAILY 19. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Mirtazapine 15 mg PO QHS RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 2. Torsemide 80 mg PO DAILY RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet Refills:*0 3. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*56 Capsule Refills:*0 4. Calcium Carbonate 1000 mg PO NOON dyspepsia RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 5. Glargine 28 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Mycophenolate Sodium ___ 720 mg PO BID RX *mycophenolate sodium 360 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 7. Pantoprazole 40 mg PO Q12H 8. Tacrolimus 2 mg PO Q12H RX *tacrolimus 1 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*0 9. ValGANCIclovir 450 mg PO 2X/WEEK (WE,SA) 10. Acetaminophen 650 mg PO Q6H:PRN Pain 11. Aspirin 81 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. PredniSONE 5 mg PO DAILY 16. Rosuvastatin Calcium 40 mg PO QPM 17. TiCAGRELOR 90 mg PO BID 18. Vitamin D ___ UNIT PO DAILY 19. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until you see your cardiologist Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Sepsis due to urinary tract infection Acute c. diff colitis Diabetic ketoacidosis End stage renal disease Non-ST-elevation myocardial infarction SECONDARY DIAGNOSES: Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with DOE // r/o acute process TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___. FINDINGS: Lung volumes are relatively low with bibasilar atelectasis, similar compared to prior. There is no effusion or consolidation worrisome for pneumonia. Probable calcified granulomas identified at the right lung base. The cardiomediastinal silhouette is within normal limits. Median sternotomy wires are again notable for fracture of the superior most wire. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ with s/p renal transplant // eval for renal transplant TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: Renal transplant ultrasound ___ FINDINGS: There is a right iliac fossa renal transplant. The cortex is of normal thickness, but appears somewhat echogenic. There is no urothelial thickening and renal sinus fat is normal. There is no hydronephrosis. There is a small amount of perinephric fluid at the lower pole. There has been interval improvement of diastolic flow when compared to prior. The resistive index of intrarenal arteries no ranges from 0.71 to 0.82, previously approaching 1. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 133 cm/sec. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. Somewhat echogenic transplant kidney and a small amount of perinephric fluid at the lower pole. 2. Improved diastolic flow since prior, with resistive indices ranging from 0.71 to 0.82. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with recent MI, and new orthopnea and dyspnea // ? Pulm edema ? Pulm edema IMPRESSION: In comparison with the study of ___, there are lower lung volumes with bibasilar atelectasis most prominent on the left. No evidence of acute focal pneumonia. cardiomediastinal silhouette is stable, though there is some suggestion of increasing pulmonary vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with renal transplant, decompensated CHF // interval change interval change IMPRESSION: Comparison to ___. Decrease in severity of the pre-existing pulmonary edema. Elevation of the left hemidiaphragm and platelike atelectasis at the left lung bases persists. No pneumonia, no pleural effusions. Stable alignment of the sternal wires. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with pulm edema // interval change interval change IMPRESSION: In comparison with the study of ___, there is again increased opacification at the left base silhouetting the hemidiaphragm. Although this could merely represent atelectasis, in the appropriate clinical setting, superimposed pneumonia should be considered. Mild indistinctness of pulmonary vessels is consistent with the clinical diagnosis of elevated pulmonary venous pressure. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Weakness, Diarrhea Diagnosed with Sepsis, unspecified organism, Diarrhea, unspecified, Acute kidney failure, unspecified temperature: 99.0 heartrate: 100.0 resprate: 18.0 o2sat: 96.0 sbp: 122.0 dbp: 58.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ yom with a hisory DM and ESRD s/p DDRT ___ c/b delayed graft function and CAD s/p recent NSTEMI in early ___ treated medically, who presented with feeling unwell with profuse diarrhea found to have GNR bacteremia and c. diff colitis. He was also found to be in DKA ketones in his urine and an elevated glucose in the 400s. He was transferred to the MICU for insulin drip and started on PO vanc for his c. diff infection and ceftriaxone for his UTI/sepsis due to urinary tract infection. His DKA resolved, but he was then found to have acute renal failure in his transplanted kidney. He was eventually called out to the floor where he was stable but required intermittent HD due to impaired kidney function and poor UOP. He also was persistently anemic requiring several blood transfusions. He was otherwise asymptomatic. His UOP improved in the days prior to discharge with boluses of IV Lasix, and he will be discharged with close renal transplant and cardiac follow up. # DIABETIC KETOACIDOSIS: Pt admitted to the hospital and found to have DKA with glucose in 400s ketones in urine. First episode of DKA. Likely in the setting of not getting insulin with concomitant infection with c. diff, UTI, and E.coli bacteremia as triggers. Patient maintained on insulin gtt until gap closed. ___ consulted and provided recs on ongoing insulin regimen. # E. coli Bacteremia # UTI: GNR bacteremia with only clear source being urinary tract. Could potentially be in the setting of GI translocation ___ colitis and immunosuppression. Patient initially treated with cefepime, narrowed to ceftriaxone based on sensitivities. Patient finished 14 day course while in the hospital, from last clear blood culture (___). # Anuric Acute Renal Failure: #Acute Tubular Necrosis: Urine sediment confirmed muddy brown casts likely ___ to hypovolemia from C diff, tacrolimus toxicity. Should also consider rejection. Patient started on renal replacement therapy in the MICU due to escalating oxygen requirement and acidosis. Patient did have return of kidney function and UOP to Lasix and metolazone dosing by time of transfer back to the floor. His UOP was fairly poor for quite some time while on the floor but was finally responsive to boluses of IV lasix. UOP was > 1L in day prior to discharge. He will be discharged to have renal function monitored by ___ transplant nephrology. #C. diff colitis: Patient treated for severe C. diff colitis given underlying immunosuppression with PO vancomycin and IV metronidazole. Patient to continue PO vancomycin for 2 weeks after last dose of ceftriaxone (end date ___. # Anemia: Patient's Hb 7.5 on ___ (stable from ___ was in the 7s over the last couple days without evidence of bleeding or symtpoms. Anemia is likely ___ ACD, given recent ferritin >900. He required several units of blood throughout the course of the hospitalization. # NSTEMI: Elevated trop with flat MB with worsening TWI and ST-D on EKG., no clear trigger. Atrus cardiology consulted. Patient placed on heparin gtt for 48 hours. Patient optimized medical management (aspirin 81mg, ticagrelor 90mg BID, rosuvasatin, metoprolol). Repeat TTE similar to prior. Unable to continue lisinopril due to renal failure. Follow up with cardiology as outpatient #S/P Renal tx: Delayed graft function. Noted to have perinephric fluid collection which may represent post operative changes. # Supratherapeutic tacrolimus dosing: Patient noted to have high tacrolimus levels, likely secondary to diarrhea from C. Diff. Tacrolimus dosed daily, and decreased from 6mg to 1mg BID by time of transfer. - Immunosupression - patient continued on prednisone, mycophenolate, and - Proph: Valgancyclovir (q48 based on GFR), Dapsone 100mg qD CHRONIC ISSUES: #GERD - Patient on home dose pantroprazole 40mg q12H. Held in setting of C. Diff #Deficiency - Continued Vit. D, cinacalcet TRANSITIONAL ISSUES ===================== DISCHARGE WEIGHT: 103.4 kg DISCHARGE DIURETIC: Torsemide 80 mg PO daily DISCHARGE IMMUNOSUPPRESSION: Tacrolimus 2 mg PO BID, Pred 5mg qD, MMF 720 mg bid MEDICATIONS STARTED: Mirtazapine 15 mg PO/NG QHS, Vancomycin Oral Liquid ___ mg PO/NG Q6H MEDICATIONS CHANGED: Mycophenolate Sodium ___ 720 mg PO BID, Calcium Carbonate 1000 mg PO/NG NOON dyspepsia, Tacrolimus 2 mg PO Q12H ValGANCIclovir 450 mg PO 2X/WEEK (WE,SA) - Patient to continue PO vancomycin for 2 weeks after last dose of ceftriaxone (end date ___ - Patient to have repeat labs drawn on ___ in ___ and ___ have results faxed to ___ neprhology transplant ___. They will be in touch with him for further follow up. - Consider restarting isosorbide/hydral as tolerated - Consider referral to psychiatrist as an outpatient. Patient reported depressed mood and expressed desire to speak with a psychiatrist but decided to try starting mirtazapine as an inpatient first and potentially see psychiatry as an outpatient. - Insulin dosing adjusted per ___ recs. Discharged on Glargine 28 Units Breakfast and sliding scale which was provided to patient.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache, confusion Major Surgical or Invasive Procedure: ___: Left frontal craniotomy for tumor resection History of Present Illness: ___ year old male who does not routinely seek preventative care presents to OSH with headache, confusion, memory issues and word finding difficulty x 2 weeks. History obtained by wife at bedside due to patients altered mental status. She reports 2 weeks patient reported headache and she noticed progressively he would be forgetful, confused on planned events, and over the past week with word finding difficulty. She states he refused to go to seek medical care until his confusion worsened and she brought him to be evaluated. CT head showed left frontal brain lesion with vasogenic edema with 1.4 mm MLS. He was transferred to ___ ER for further evaluation. He is now s/p craniotomy for tumor resection. Past Medical History: None Social History: ___ Family History: Father deceased pancreatic cancer Physical Exam: ON ADMISSION: ************ T:99 BP:112/76 HR:82 RR:17 O2Sats:98%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3mm bilaterally EOMs Full Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert , confused disoriented to situation. Orientation: Oriented to person, year with choices. Language: Hypophonic, slow to respond to questions Speech fluent, with word finding difficulty Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Unable to test visual fields due to patients mental status and unable to understand task III, IV, VI: Extraocular movements intact bilaterally without nystagmus. Right ptosis V, VII: Right facial droop with normal sensation bilaterally. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius left stronger than RIGHT . XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch = = = = = = = = = ================================================================ ON DISCHARGE: ************* ___ ___ Temp: 97.9 PO BP: 102/73 HR: 63 RR: 18 O2 sat: 97% O2 delivery: RA FSBG: 117 Exam: Appears comfortable, eating breakfast in chair. Opens eyes: [x] Spontaneous [ ] To voice [ ] To noxious Orientation: [x] Person [x] Place [x] Time Follows commands: [ ] Simple [x] Complex [ ] None Pupils: PERRL 3-2mm bilaterally EOM: [x] Full [ ] Restricted Face Symmetric: [ ]Yes [x]No Has mild right NL flattening, activates symmetrically Tongue Midline: [x] Yes [ ] No Pronator Drift [ ] Yes [x] No Speech Fluent: [x] Yes [ ] No Comprehension intact [x] Yes [ ] No Motor: Moves all extremities symmetric, strength ___ throughout Sensation: Intact to light touch Wound: [x] Healing incision, well approximated [x] No drainage or signs of infection Pertinent Results: Please see OMR for pertinent lab and imaging results. Medications on Admission: Acetaminophen PRN Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 325 mg ___ tablet(s) by mouth Q6hr Disp #*90 Tablet Refills:*0 2. Dexamethasone 2 mg PO Q12H RX *dexamethasone 2 mg 1 tablet(s) by mouth Q12hr Disp #*60 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity RX *docusate sodium [Colace] 100 mg ___ capsule(s) by mouth daily Disp #*60 Capsule 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. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Nicotine Patch 21 mg/day TD DAILY RX *nicotine 21 ___ daily; remove used patch prior to new patch placement. Rotate sites. daily Disp #*28 Patch Refills:*0 7. Senna 17.2 mg PO QHS:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity RX *sennosides [senna] 8.6 mg ___ tablets by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left frontal brain metastasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with left brain lesion with vasogenic edema, chest xray concern for mass// Metastatic workup TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen was done with IV contrast. A single bolus of IV contrast was injected and the abdomen and pelvis was scanned in the portal venous phase, followed by 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 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.3 mGy-cm. 2) Spiral Acquisition 4.9 s, 64.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 536.9 mGy-cm. 3) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.8 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP = 20.1 mGy-cm. Total DLP (Body) = 962 mGy-cm. COMPARISON: None available. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, 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. No hydronephrosis in either kidney. There are bilateral hypoattenuating lesions, some of which are cysts while the others are too small to characterize. The largest cyst measures 4.2 cm (series 3, image 29). There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There are scattered colonic diverticula, without findings of acute diverticulitis. The colon and rectum are otherwise unremarkable. The appendix is unremarkable. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is not enlarged. LYMPH NODES: No enlarged mesenteric, retroperitoneal, pelvic, or inguinal lymph nodes. VASCULAR: There is no abdominal aortic aneurysm. Ectasia of the bilateral common iliac arteries are noted measuring up to 1.4 cm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There is moderate loss of disc height with vacuum disc phenomenon at L4-5. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of malignancy within the abdomen and pelvis. 2. Please see separate report performed on the same day for detailed evaluation of the chest. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old man with left frontal brain lesion with vasogenic edema; can be completed with MRI WAND study, please include MPRage sequence// Evaluate left frontal brain lesion; can be completed with MRI WAND study, please include MPRage sequence TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 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: CT of the head dated ___. FINDINGS: There is a left frontal lobe mass measuring 2.2 x 2.4 x 2.3 cm (AP x TV x SI). This demonstrates significant surrounding vasogenic edema, causing sulcal effacement of the left frontal lobe, a 1.2 cm rightward midline shift with a subfalcine herniation. The lesion enhances in homogeneously after contrast administration with areas of limited enhancement that suggest necrosis. These all only enhancing portion of the mass demonstrates slow diffusion, with fast diffusion in the area that appears necrotic. There is no evidence of hemorrhage or infarction. The intraorbital contents are normal. IMPRESSION: 1. In homogeneously enhancing left frontal lobe with extensive surrounding edema and a suggestion of necrosis. Differential considerations include metastatic disease or a primary neoplasm such as high-grade glioma. 2. Mass effect with 1.2 cm rightward midline shift. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with left brain lesion with vasogenic edema, chest xray concern for mass// Metastatic workup TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with intravenous infusion of nonionic, iodinated contrast agent, following oral administration of contrast agent for selected abdominal studies, and/or followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck will be reported separately. All images of the chest were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.3 mGy-cm. 2) Spiral Acquisition 4.9 s, 64.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 536.9 mGy-cm. 3) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 201.8 mGy-cm. 4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP = 20.1 mGy-cm. Total DLP (Body) = 962 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: None available. FINDINGS: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The thyroid is unremarkable. No enlarged lymph nodes in either axilla. No lymphadenopathy in the right supraclavicular station, the largest measuring approximately 2.0 x 2.5 cm. No abnormalities on the chest wall. Mild atherosclerotic calcifications in the head and neck arteries. HEART AND VASCULATURE: The heart is normal in size and shape. No pericardial effusion. Mild atherosclerotic calcifications in the coronary arteries and aorta, none in the cardiac valves. The pulmonary arteries and aorta are normal in caliber throughout. MEDIASTINUM AND HILA: The esophagus is unremarkable. Enlarged lymph nodes in the right paratracheal station, the largest history necrotic center measuring 4.7 x 3.9 cm (302:67) displaces and deforms the superior vena cava. Nodal tissue in the right hilum measuring 1.3 x 1.2 cm (302:74) invades the anterior branch pulmonary artery. No left hilar lymphadenopathy. PLEURA: No pleural effusions. No apical scarring bilaterally. LUNGS: Respiratory motion artifacts impair optimal parenchymal evaluation. The airways are patent to subsegmental levels. No bronchial thickening, bronchiectasis or mucus plugging. Lobulated mass in the posterior segment of the right upper lobe (302:62) measuring approximately 2.9 x 2.2 x 1.4 cm. CHEST CAGE: No acute fractures. No suspicious lytic or sclerotic lesions. UPPER ABDOMEN: Please refer to same day abdominal CT report for subdiaphragmatic findings. IMPRESSION: Lobulated lung mass in the right upper lobe suspicious for primary lung cancer. If clinically warranted, this lesion is assessable through CT-guided percutaneous biopsy. Lymphadenopathy in the right hilum, right paratracheal station and right supraclavicular station. No radiographically detected osseous lesions. Radiology Report EXAMINATION: Head CT. INDICATION: ___ year old man with left frontal brain lesion s/p resection// Evaluate for hemorrhage post craniotomy TECHNIQUE: Multidetector CT images of the head were obtained without intravenous contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.6 mGy-cm. Total DLP (Head) = 748 mGy-cm. COMPARISON: Recent MR from ___ and CT from ___. FINDINGS: Patient is status post interval resection of a ring-enhancing lesion in the left frontal lobe. An air-fluid cavity at the site measures 22 mm in diameter. More diffuse white matter abnormality in the left lobe frontal lobe persists. The degree of rightward shift, previously measuring up to 14 mm on CT, now measures 9 mm, so decreased. A more limited white matter abnormality involving the medial right frontal lobe also persists. Left ventricular system appears unchanged. There is no evidence of intracranial hemorrhage. Anticipated pneumocephalus is found deep to left frontal craniotomy site. Air is also expected in overlying soft tissues. Left frontal stable line is noted superficially. Paranasal sinuses and mastoid air cells remain clear. IMPRESSION: Anticipated postoperative findings after resection of left frontal lobe mass. Mild reduction in rightward mass effect. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with left frontal lesion s/p left craniotomy and resection// Evaluate for residual tumor post resection TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 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: MRI head with and without contrast ___. FINDINGS: Postsurgical changes are seen secondary to a left frontal craniotomy for resection of a left frontal lobe mass, including minimal scalp edema, a small epidural collection, focal dural thickening and blood products within the resection cavity. There is enhancement along the periphery of the resection cavity. The degree of surrounding T2 signal abnormality, left frontal horn effacement and midline shift are unchanged. The ventricles and sulci are normal in caliber and configuration. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. The intraorbital contents are normal. IMPRESSION: 1. Postsurgical changes secondary to a left frontal craniotomy for resection of a left frontal lobe mass. 2. Residual enhancement at the margin of surgical cavity identified posteromedially. 3. Unchanged degree of surrounding T2 signal abnormality in midline shift. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with rising leukocytosis; POD#7 from brain tumor resection// evaluate for infection TECHNIQUE: Chest PA and lateral COMPARISON: CT dated ___ FINDINGS: There is a bilobed opacity projecting over the right upper lobe, likely not significantly changed since the prior CT chest. No new focal consolidation is seen. No pleural effusion or pneumothorax. Prominence of the right upper mediastinum corresponds to known mediastinal lymphadenopathy. The size of the cardiac silhouette is within normal limits. IMPRESSION: No focal consolidation. Known right upper lobe pulmonary mass and mediastinal lymphadenopathy. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man POD# from craniotomy with rising leukocytosis. Evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow is 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 deep venous thrombosis in the right or left lower extremity veins. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status, Headache Diagnosed with Altered mental status, unspecified temperature: 99.0 heartrate: 82.0 resprate: 17.0 o2sat: 98.0 sbp: 112.0 dbp: 76.0 level of pain: 8 level of acuity: 2.0

#Brain Lesion Patient was found to have a left frontal brain lesion with surrounding edema on NCHCT. He was admitted to the ___ for close monitoring. MRI brain with and without contrast was obtained which showed a homogeneously enhancing left frontal lobe lesion with extensive surrounding edema, a suggestion of necrosis and 1.2 cm rightward midline shift. CT torso was obtained for malignancy workup which revealed a bilobed right upper lobe pulmonary mass measuring up to 2.9 x 1.4 cm concerning for primary lung cancer. Of note, CXR from OSH was concerning for 2.7cm density in right upper lobe, suspicious for mass. He went to the OR for left frontal craniotomy for resection of the lesion in ___ - please see Dr. ___ ___ operative report for further details. The resected tumor was sent for pathology. He underwent a ___ in the PACU that showed no significant hemorrhage. Following the procedure, he was transferred back up to the ___ for close monitoring. He underwent a post-operative MRI brain w/ and w/o that was pertinent for expected post-operative changes. He was started on decadron taper to 2 mg bid and keppra 1g bid. He was made floor status on ___ and his neurologic checks were liberalized to every 4 hours. Follow up was arranged with brain tumor clinic. #Leukocytosis WBC continued to rise. He remained afebrile and incision showed no signs of infection. Infectious workup was ordered which was unrevealing. Repeat CBC on ___ showed stable WBC at 20.1. #Right upper lobe lung mass Imaging revealed lung mass and thoracic oncology was consulted. He will follow up in thoracic ___ clinic. PET scan was scheduled as outpatient, and PET scan instructions were provided to the patient. #Speech, Language and Cognitive-linguistics evaluation The patient was evaluated by SLP on ___ who recommended services targeting language and cognitive-linguistic intervention in order to maximize functional outcomes and independence. Upon discharge, the patient was given outpatient prescription for theses services. At the time of discharge, the patient was tolerating a regular diet, ambulating independently and following ___ recommendations, he was discharged home. His significant other has agreed to assist the patient with minimal supervision and help with IADLs. He will follow up in brain tumor clinic for continued care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: simvastatin / Neomycin / hydralazine / Statins-Hmg-Coa Reductase Inhibitors Attending: ___ Chief Complaint: fall, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr ___ is a ___ yo M with h/o sCHF with EF ___ w/ICD, afib on eliquis s/p AVJ ablation with RV pacing, DM, recent admission to CCU for CHF now admitted with CHF exacerbation. Mr. ___ recent medical history is notable a hosptilization from ___ when he was admitted with GI bleed and required ICU stay. that was complciated with difficult to control afib with RVR preciptating cardiogenic shock and CCU transfer. His TTE showed LVEF of ___ with mild MR. ___ mixed venous was 27. He was diuresed with Lasix gtt 30 cc/hr and dopanine 3 mcg/kg/min for a total of 20 L. His course has been complicated by VT in the setting of hypokalemia requiring ICD therapies, currently on digoxin, amiodarone and mexiletene. DCCV was not performed given that it was thought it would be unsuccesful given permanent AF. Not good location of CS lead and CS thought not good candidate for epicardial lead at this time, so CRT-D was not pursued. He underwent AVJ ablation. He was discharged euvolemic on apixiban for stroke ppx and high risk of GI bleed. Discharged on ___, seen in ___ clinic on ___, at which time he was felt to be volume overloaded, for which patient's metolazone to 5 mg every other day. Then presented to the ED on ___ after feeling weak and falling at home, with headstrike. Initially seen in clinic, at which time he was noted to be hypotensive (81/52) and ?EKG changes (per note, ST-T elevation in anterior septal precordial leads V1), refered to the ED. Had trauma w/u for head strike, which was negative. Repeat EKG unchanged from prior, repeat SBP in ___, which was baseline during last admission. Given pip-tazo. Labs notable for lactate 2.3, Cr 2.2 (baseline), trop 0.05, new mildly elevated transaminases, BNP 1700 and Na 121 (chronic). Seen in ED by cardiology who recommended admission for decompensated heart failure, however patient left AMA. Today, ___ noted patient's systolics in ___. Patient's daughter brought him back to the hospital. In the ED intial vitals were: 97 90 108/69 18 99% RA EKG: Vpaced at 90bpm cwp CXR: some upper zone redistribution c/w volume overload Labs/studies notable for: Na 126, Cr 2.1, BNP 1700, lactate 2.1. Patient was given: nothing Vitals on transfer: 97.4 91 90/56 16 100% RA On the floor has no complaints, reports he feels fine, would rather not be here. Patient denies fever, chills, any infectious symptoms, SOB, ___ swelling (even though this is obvious on exam), CP, palpitations, orthopnea or PND. He denies lightheadedness Of note, patient was hospitalized ___, initially due to a GIB, followed by rapid atrial tachycardia, decompensated heart failure, right sided failure and VT. He ultimately failed rate control agents and underwent an AVJ ablation with underlying RV pacing. His anatomy and epicardium were unsuitable for BiV pacing. REVIEW OF SYSTEMS: On review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: -CAD: S/p CABG ___ -CHF: Most recent EF ___ s/p Implantable cardiac defibrillator -Atrial fibrillation, restarted on Coumadin recently (on hold after ___) -Diabetes II -CKD, ~1.5-2.0 -HTN -BPH -SDH s/p left craniotomy for ___ evacuation on ___ Social History: ___ Family History: Brother CAD/PVD - Early; Cancer - Prostate Father ___ - Type II Mother ___ Sister Cancer - Breast Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VS: 97.4 94/54 92 16 100RA WT: 91.4kg IO: 180/400 GENERAL: Tired appearing elderly gentlman, NAD, lying ___ in bed. Delayed responses. HEENT: NCAT. PERRL, EOMI. OP clear, MMM NECK: Supple with JVP of at angle of jaw 30 degrees. CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. LUNGS: unlabored. CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ ___ edema with shins bandaged from water blisters. SKIN: Blistering of ___ ___: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ======================= VS: 98.2, 85-94/50-54, 87-91, 20, 98% RA Ins/Outs: 660/100 (MN), 1476/1750+ (___) Weights: 91.4kg -> 90.9 -> 91.8 GENERAL: Tired appearing elderly gentlman, NAD, lying ___ in bed. Delayed responses. HEENT: NCAT. PERRL, EOMI. OP clear, MMM NECK: Supple with JVP of at angle of jaw 30 degrees. CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. LUNGS: unlabored. CTAB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ ___ edema with shins bandaged from water blisters. SKIN: Blistering of ___ ___: Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS ============== ___ 01:30PM BLOOD WBC-8.0 RBC-3.71* Hgb-8.7* Hct-27.8* MCV-75* MCH-23.5* MCHC-31.3 RDW-18.9* Plt ___ ___ 01:30PM BLOOD Neuts-76.4* Lymphs-11.8* Monos-9.2 Eos-2.2 Baso-0.3 ___ 01:30PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Burr-1+ Tear Dr-1+ Acantho-OCCASIONAL ___ 01:30PM BLOOD ___ PTT-31.7 ___ ___ 01:30PM BLOOD Glucose-143* UreaN-124* Creat-2.2* Na-121* K-3.2* Cl-83* HCO3-25 AnGap-16 ___ 01:30PM BLOOD ALT-49* AST-92* CK(CPK)-130 AlkPhos-52 TotBili-0.3 PERTINENT LABS ============== ___ 01:30PM BLOOD Lipase-49 ___ 11:46AM BLOOD proBNP-1760* ___ 01:30PM BLOOD cTropnT-0.05* ___ 01:30PM BLOOD CK-MB-8 ___ 01:30PM BLOOD Albumin-3.0* ___ 01:42PM BLOOD Lactate-2.3* ___ 11:37AM BLOOD Lactate-2.1* Na-123* K-4.4 ___ 12:09AM BLOOD Lactate-1.9 DISCHARGE LABS ============== ___ 06:20AM BLOOD WBC-10.4 RBC-4.18* Hgb-9.6* Hct-32.5* MCV-78* MCH-22.9* MCHC-29.4* RDW-20.4* Plt ___ ___ 11:46AM BLOOD Neuts-75.6* Lymphs-12.4* Monos-9.4 Eos-2.4 Baso-0.2 ___ 11:46AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-2+ ___ 06:20AM BLOOD ___ PTT-31.0 ___ ___ 06:20AM BLOOD Glucose-195* UreaN-106* Creat-2.4* Na-121* K-4.9 Cl-88* HCO3-28 AnGap-10 ___ 08:05AM BLOOD ALT-67* AST-72* AlkPhos-57 TotBili-0.6 ___ 06:20AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6 RELEVANT STUDIES ================ - CXR (___): Stable cardiomegaly with mild congestion and probable tiny bilateral pleural effusions. - CT HEAD W/O CONTRAST (___): Post-surgical changes with dural thickening from prior left subdural hematoma evacuation. No acute intracranial process. - CT C-SPINE W/O CONTRAST (___): 1. No definite acute fracture of the cervical spine. 2. Subacute or chronic appearing fractures of the C7 and T1 spinous processes. Correlate clinically for tenderness over this location. 3. Possible right thyroid nodule, nonemergent thyroid ultrasound could be performed if clinically indicated. - CXR (___): 1. COPD and cardiomegaly, with AICD type device, similar to the prior film. 2. There is upper zone redistribution, without other evidence of CHF. - CAROTID ULTRASOUND (___): Duplex evaluation was performed of bilateral carotid arteries. 1. On the right there is Mild heterogeneous plaque in the ICA. On the left there is mild heterogeneous plaque seen in the ICA. 2. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 41/11, 62/18, 52/14 cm/sec. CCA peak systolic velocity is 50 cm/sec. ECA peak systolic velocity is 31 cm/sec. The ICA/CCA ratio is 1.2. These findings are consistent with <40% stenosis. 3. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 51/10, 45/11, 65/23 cm/sec. CCA peak systolic velocity 61 cm/sec. ECA peak systolic velocity is 54 cm/sec. The ICA/CCA ratio is 1.1.These findings are consistent with <40% stenosis. 4. Right antegrade vertebral artery flow. 5. Left antegrade vertebral artery flow. Impression: Right ICA <40% stenosis. Left ICA <40% stenosis. - ARTERIAL DUPLEX UPPER EXTREMITIES (___): Widely patent bilateral upper extremity subclavian, axillary and brachial arteries without evidence of proximal or upper arm stenosis. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 500 mg PO BID:PRN pain 2. Amiodarone 400 mg PO DAILY 3. Bisacodyl ___ mg PO DAILY:PRN if no bowel movements. 4. Docusate Sodium 100 mg PO BID 5. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash 6. Aspirin 81 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY 10. Apixaban 2.5 mg PO BID 11. Bumetanide 5 mg PO BID 12. Mexiletine 150 mg PO Q8H 13. Pantoprazole 40 mg PO Q24H 14. Sertraline 25 mg PO DAILY 15. Spironolactone 37.5 mg PO DAILY 16. TraZODone 25 mg PO QHS:PRN insomnia 17. Cetirizine 10 mg PO DAILY:PRN allergies 18. Ferrous Sulfate 325 mg PO QOD 19. Multivitamins 1 TAB PO DAILY 20. pitavastatin 4 mg oral DAILY 21. Potassium Chloride 60 mEq PO DAILY 22. Vitamin D 4000 UNIT PO DAILY 23. Zolpidem Tartrate 5 mg PO QHS 24. Metolazone 2.5 mg PO QOD:PRN weight gain >2 lbs in 24 hours 25. Glargine 45 Units Breakfast Glargine 45 Units Bedtime Discharge Medications: 1. Amiodarone 400 mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Bisacodyl ___ mg PO DAILY:PRN if no bowel movements. 5. Bumetanide 5 mg PO BID 6. Cetirizine 10 mg PO DAILY:PRN allergies 7. Docusate Sodium 100 mg PO BID 8. Ferrous Sulfate 325 mg PO QOD 9. Fluocinonide 0.05% Cream 1 Appl TP BID:PRN rash 10. Glargine 45 Units Breakfast Glargine 45 Units Bedtime 11. Levothyroxine Sodium 50 mcg PO DAILY 12. Mexiletine 150 mg PO Q8H 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. pitavastatin 4 mg oral DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Sertraline 25 mg PO DAILY 18. Spironolactone 37.5 mg PO DAILY 19. TraZODone 25 mg PO QHS:PRN insomnia 20. Vitamin D 4000 UNIT PO DAILY 21. Zolpidem Tartrate 5 mg PO QHS 22. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*60 Capsule Refills:*0 23. Metolazone 2.5 mg PO QOD:PRN weight gain >2 lbs in 24 hours 24. Metoprolol Succinate XL 25 mg PO DAILY 25. Potassium Chloride 60 mEq PO DAILY Hold for K > 26. Acetaminophen 500 mg PO BID:PRN pain 27. Shower Chair Shower Chair ICD9: 428.0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Heart failure with reduced ejection fraction Asymptomatic hypotension 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: History: ___ with chf // eval for chf COMPARISON: ___ at 14 35 FINDINGS: Probable background hyperinflation/COPD. The patient is status post sternotomy. The cardiomediastinal silhouette is enlarged, but unchanged. Left-sided pacemaker/AICD type device is present, with lead tip unchanged. Multiple epicardial pacing wire is are present, similar to the prior film. There is upper zone redistribution, but no overt CHF. No focal infiltrate or effusion is identified. Minimal atelectasis versus slight thickening of the minor fissure is noted. Slight pleural thickening along lower chest walls bilaterally may relate to body habitus rather than frank pleural thickening. . IMPRESSION: 1. COPD and cardiomegaly, with AICD type device, similar to the prior film. 2. There is upper zone redistribution, without other evidence of CHF. Radiology Report EXAMINATION: ART DUP EXT UP BILAT COMP CLINICAL HISTORY ___ year old man with discrepant blood pressures, systolics with doppler 87 left upper extrem, 72 RUE, 135 right calf // please assess bilateral carotid, subclavian, and axillary arteries for stenosis please assess bilateral carotid, subclavian, and axillary ar FINDINGS: Bilateral upper extremity arterial duplex was performed from the subclavian through the brachial arteries. Right: The right subclavian artery waveform is bi/triphasic with normal velocities ranging from 88- 113 cm/ second. Similarly the axillary and brachial artery waveforms are triphasic with velocities ranging from 87-97cm/second. Left: The left subclavian artery waveforms are triphasic with velocities ranging from 60-85 cm/ second. The left axillary and brachial waveforms are also triphasic with velocities ranging from 60-80 cm/second. IMPRESSION: Widely patent bilateral upper extremity subclavian, axillary and brachial arteries without evidence of proximal or upper arm stenosis. Radiology Report FINDINGS: ___ Department of Radiology Standard Report Carotid US Study: Carotid Series Complete Reason: CHF, Asx hyotension Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is Mild heterogeneous plaque in the ICA. On the left there is mild heterogeneous plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 41/11, 62/18, 52/14 cm/sec. CCA peak systolic velocity is 50 cm/sec. ECA peak systolic velocity is 31 cm/sec. The ICA/CCA ratio is 1.2. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 51/10, 45/11, 65/23 cm/sec. CCA peak systolic velocity 61 cm/sec. ECA peak systolic velocity is 54 cm/sec. The ICA/CCA ratio is 1.1. These findings are consistent with <40% stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA <40% stenosis. Left ICA <40% stenosis. Gender: M Race: WHITE - RUSSIAN Arrive by WALK IN Chief complaint: Palpitations, Dizziness Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC temperature: 97.0 heartrate: 90.0 resprate: 18.0 o2sat: 99.0 sbp: 108.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Mr. ___ is a ___ yo M with h/o sCHF with EF ___ w/ICD, afib on eliquis s/p AVJ ablation with RV pacing, DM, recent admission to CCU for CHF. Last EF ___. BNP 1700 on admission (range ___. Recent admission complicated by patient's poor adherecene to fluid restrictions leading to worsened heart failure. Decompensated heart failure on last admission in setting of uncontrolled atrial fibrillation. He underwent AVJ ablation but was deemed not to be candidate for advanced therapies. On this admission, pt was optimized and sent home, as it appears he is compliant with regimen at home and had lost ___ since discharge on ___, and pt had attended clinic appts. Diuresis and home treatment limited by low measurements of SBP but pt has been asymptomatic. On reexamination, after being on bumex gtt for several hours, pt appears to be stable at SBP 85 in L arm, perfusing all organs and mentating well. Will be new threshold for normotension, with no need to use telemonitoring, and no need to check BPs or worry about measured BPs if pt is asymptomatic and LUE cuff pressure is above 70. Sent home with information for how to get shower chair and LifeAlert home monitoring. Set up old ___ per pt preference.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: stupor and involuntary movements Major Surgical or Invasive Procedure: spinal tap History of Present Illness: Mr. ___ is a ___ left-handed man presenting with Stupor and involuntary movements on a background of no other medical problems. Per ___, his friend: He has been doing well until this week. Since about ___ he has not slept well and this may have happened two weeks ago also. On that prior occasion, he was awake for two days straight and then slept for one whole day. He had been rejected two weeks ago by one college and became scarred. Now he stays awake waiting to hear about another school. This time, he has not slept since ___. He went to the gym last night and then took tablets of melatonin at 2 AM. He went to his room, closed the door. This morning, his friend ___, his room mate that has known and lived with him for one year, was going to go to class at 8:55 AM and ___ was still not awake. He went into the room to find him in bed, covered in blankets, breathing quickly and deep. ___ called him, shook and nothing happened. He put water on his face, then tickled his nose with a tissue and nothing happened. He called ___ and they instructed to turn him on his side. When he did this, he noted that ___ breathed even more quickly and was rigid with arms straight without any rhythmic movement. The heating system is old and seems to have been central. He usually closes his door. Nothing like this has happened before. Per the patient when more conversant later: He has lost 20 kg of weight in the last two months. He has been coughing recently, but there was no blood in his sputum. He had one episode of some bright red blood with stool a week or so ago. His vision and hearing have both been slightly worse over this period also. He saw an optometrist who seems to have found one eye myopic and the other presbiopic. Over the last two days he has had nucal pain and posterior headache that has been worsening. There have been no head injuries or other trauma, but he has been frequently going to the gym. He has been very stressed waiting to hear about his college applications. He also states not taking any other medications, but he did take melatonin twice yesterday. There is no double vision, but on looking to the extreme left, objects fatten slightly and blur. Further review of systems was negative except as above. Past Medical History: None Social History: ___ Family History: Older brother that "thinks like a ___ year old boy" Younger brother with "breathing problems" Physical Exam: ADMISSION: Vitals: 99.1 F, 90 BPM, 128/86 (180/94 on arrival) mmHg, 16 breaths, 100% RA He is lying still on the bed with an obvious right ptosis and irregular jerk of the right leg. He is slim, well groomed and looks otherwise healthy. His head and neck are of normal appearance. There is no meningismus and his neck is supple. Mouth is moist. Normal ears and nose without rash. Lungs are vescicular, heart sounds dual, near tachycardic. Abdomen is mildly tender to palpation. Skin appears normal. He is awake, but is mildly stuporous and complains that he feels sleepy. He can state his name, but earlier, when still showing irregular jerking of right leg, would sometimes show interuption to his speech, pause briefly then resume where he left off. He says that he has been recently forgetting things and feels that his memory is not right, but was able to register and recall three words. He is presently learning ___, but has excellent comprehension and spoken language and rarely does not know an uncommon word, which seems to be that this was not previously know - for example, he did not know the term for feces, but described urine as normal. Cranial Nerves: I: Not tested. II: Pupils symmetric, round and reactive to light, 5 to 3 mm bilaterally. Visual fields are full to confrontation. Fundi are normal. There is a right ptosis that is partial, but more than typical with Horner's syndrome, perhaps 3-4 mm. III, IV, VI: Extraocular movements full, conjugate and without nystagmus. V, VII: He has mild right facial weakness. Facial sensation intact. VIII: Hearing intact to voice, but dimished mildly on left compared to the right. IX, X: Palatal elevation symmetric. XI: Sternocleidomastoid and trapezius are of normal bulk and strength bilaterally. XII: Tongue slightly weaker on protusion to left. Tone and Bulk: Tone is normal throughout (arms, legs, neck). Muscle bulk is normal. Power is reduced in an upper motor neuron pattern on the right hemibody with slightly greater weakness in the right leg - initially the IP was just antigravity, then later was ___, as was the hamstring 3 to ___ on the right. On the right there was a no less than ___ pattern of upper motor neuron weakness and on the left there was very trace upper motor neuron weakness in the arm only. Reflexes were symmetrically brisk in the leg with bilateral cross-adductor, but down-going toes. Pinprick was diminished on the right hemibody, but not on the face. Coordination and Cerebellar Function: RAM's were slowed bilaterally. There was bilateral overshoot on finger-nose-finger, without intention tremor. Gait: Not tested. DISCHARGE: Fully oriented and able to converse. Pertinent Results: ___ 10:25AM PLT COUNT-180 ___ 10:25AM NEUTS-50.8 ___ MONOS-6.6 EOS-4.3* BASOS-0.9 ___ 10:25AM WBC-4.7 RBC-5.21 HGB-15.9 HCT-48.0 MCV-92 MCH-30.6 MCHC-33.2 RDW-12.8 ___ 10:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:25AM TSH-2.4 ___ 10:25AM GLUCOSE-107* UREA N-13 CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12 ___ 10:26AM GLUCOSE-97 LACTATE-1.2 ___ 12:18PM O2 SAT-77 CARBOXYHB-2 ___ 12:18PM ___ PO2-46* PCO2-50* PH-7.35 TOTAL CO2-29 BASE XS-0 COMMENTS-GREEN TOP ___ 01:15PM BLOOD ___ * Titer-1:80 ___ 01:15PM BLOOD CRP-0.5 ___ 01:15PM BLOOD HIV Ab-NEGATIVE, HIV RNA not detected RPR non reactive ___ VIRUS VCA-IgG AB (Final ___: NEGATIVE BY EIA. ___ VIRUS EBNA IgG AB (Final ___: POSITIVE BY EIA. ___ VIRUS VCA-IgM AB (Final ___: NEGATIVE <1:10 BY IFA. CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 50 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. ___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-25 RBC-3225* POLYS-49 ___ MONOS-11 EOS-1 ___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-83* POLYS-27 ___ ___ 01:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-24 GLUCOSE-73 ___ 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 01:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 01:45PM URINE HOURS-RANDOM CXR ___: No acute cardiopulmonary process. NCHCT ___: No acute intracranial process. EEG ___: This is a normal awake and sleep EEG. There are no epileptiform discharges, seizures, or focal slowing recorded. No note is made of abnormal movements during this study. MR head w/wo contrast ___: No intracranial abnormalities. MRA brain w/o contrast ___: No abnormalities. MRA neck w/wo contrast ___: No abnormalities. Medications on Admission: None Discharge Medications: 1. Lorazepam 1 mg IV Q6H:PRN anxiety 2. Acetaminophen 650 mg PO Q6H:PRN pain or fever Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Aseptic meningitis Depression with suicidal ideations Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with new onset dysmetria and dysarthria. COMPARISON: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were acquired. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. There are mucous retention cysts in the left maxillary maxillary and left sphenoid sinuses. Visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are intact. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: New onset seizure disorder. TECHNIQUE: AP upright portable view of the chest. COMPARISON: None. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: ___ man, with seizure and cranial neuropathy. Assess for basal meningitis, HSV encephalitis. COMPARISON: CT head without contrast on ___. TECHNIQUE: MRI HEAD: Multiplanar, multisequence T1- and T2-weighted images were acquired through the head before and after administration of IV gadolinium contrast. Diffusion-weighted images and ADC maps were also obtained for evaluation. MRA HEAD: Non-contrast 3D time-of-flight images were acquired through the head per standard MRA head protocol. Dedicated 3D rendering was performed to better visualize the underlying vessels. MRA NECK: Coronal images were acquired through the neck before and after administration of IV gadolinium contrast per standard MRA neck protocol. Dedicated 3D rendering was performed to better assess the underlying vessels. FINDINGS: MRI HEAD: The image quality is mildly motion-degraded. Postcontrast MPRAGE images are further limited by wrap-around and other artifacts, but postcontrast axial T1 weighted images are diagnostic. There is no abnormal enhancement in the brain parenchyma, along the cranial nerves or along the meninges. There is no edema, mass effect, abnormal diffusion, or evidence of blood products in the brain. The ventricles and sulci are normal in size and symmetric in configuration. There are small mucus-retention cysts in the left maxillary and sphenoid sinuses. The globes are unremarkable. MRA HEAD: The image quality is motion-degraded. Major intracranial vessels appear patent without evidence of hemodynamically significant stenoses. There is no evidence of an aneurysm. MRA NECK: There is a normal three-vessel aortic arch. The origin of the left vertebral artery is excluded from the imaged volume. Other major cervical vessels are patent without hemodynamically significant stenoses. IMPRESSION: 1. Unremarkable MRI head, allowing for motion artifacts. No evidence of abnormal enhancement to suggest basal meningitis. No evidence of HSV encephalitis. 2. Normal MRA of the neck. 3. Unremarkable MRA of the head, allowing for motion artifacts. Please note that the original report for this study was lost. This report is issued on ___. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: FOR EVAL Diagnosed with OTHER CONVULSIONS temperature: 98.0 heartrate: 97.0 resprate: 16.0 o2sat: 99.0 sbp: 180.0 dbp: 94.0 level of pain: 0 level of acuity: 3.0

This is a ___ yo left-handed male presenting with three nights of sleep deprivation found to be difficult to arouse, then with involuntary bilateral semi-rhythmic movements in the setting of multiple life stressors, 20 kg unintentional weight loss, and mildly impaired hearing and vision. # NEURO: In the emergency room, the patient was started on phenytoin and acyclovir for concern of meningitis. Lumbar puncture results were consistent with an inflammatory process with mild pleocytosis, though no clear lymphocytic or neutrophilic predominance, and negative gram stain consistent for aseptic meningitis. Preliminary infectious work-up was reassuring, with negative HSV, CMV, and HIV studies (EBV/lyme serologies, CSF/stool studies pending). Concern for systemtic inflammatory/autoimmune processes was low given ESR and CRP were both within normal limites. EEG results were also reassuring for no epileptiform discharges, seizures, or focal discharges. Acyclovir and phenytoin was discontinued on hospital day two. Clinical symptoms were significantly improved at that time with stable mental status, near full motor strength at the upper and lower extremities, and increased sensation at the right lower leg, which was initially absent on admission. # PSYCH: The patient endorsed depressive symptoms since childhood, acutely worsening over the past month with active suicidal ideations and plans. The psychiatry team evaluted the patient on hospital day two and found that the patient met ___ criteria. Medical work-up from a neurologic perspective appeared most consistent with clinically resolving aseptic meningitis. Patient was transferred to an inpatient psychiatry unit on ___ given that he remained at high risk for self-harm with concrete plans and no protective factors identified.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Triple Antibiotic Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an ___ with medical history of ESRD via LUE AVF (___), DMII, HTN, Hx DVT, who presented to the ED with chest pain occurring just PTA while at dialysis, got most of dialysis but did not finish. She initially reported a ___ sub-sternal chest pain that she described as pressure-like, no radiation, +dyspnea with pain, denies vomiting or diaphoresis, and lasted 45 minutes. Not pleuritic or positional. Pain gradually improved and was ___ in the ED but intermittently in the mild range. Denies fever or chills. She notes that she is on antibiotics for recent respiratory illness. Of note, she has a well-documented history of similar symptoms while getting dialysis with multiple ED visits. She does not have these symptoms at rest or with walking; only with dialysis. She had a normal myocardial perfusion study with preserved left ventricular systolic function in ___. DSE in ___ that showed: "Resting images were acquired at a heart rate of 91 bpm and a blood pressure of 120/60 mmHg. These demonstrated normal regional and global left ventricular systolic function. Right ventricular free wall motion is normal. There is no pericardial effusion. Doppler demonstrated no aortic stenosis, aortic regurgitation or significant mitral regurgitation or resting LVOT gradient." She was also was seen in ___ ED ___ for chest pain; seen by Cardiology attg on call who noted that she had similar presentations in the past, negative DSE as above. Per his note: "Transient CP in setting dialysis, likely reflecting volume shifts." In the ED initial vitals were: 97.8 76 146/76 20 98% RA. EKG: NSR, poor baseline, old inferior Q waves, similar morphology to prior Labs/studies notable for: Hgb 9.9, wbc 12.3, chemistries notable for K 6.2 (hemolyzed), repeat K 5.1, and Cr 2.5 (on HD). Troponin 0.03. MB 1. Coags WNL. Vitals on transfer: T 97.7, HR 74, BP 134/65, O2 95% RA. On the floor patient is a&ox3. She denies chest pain, chest pressure, and shortness of breath. She endorses muscle pain in both her arms as well as mild burning pain in her legs. She feels tired but otherwise well. Past Medical History: END STAGE RENAL DISEASE DIABETES, TYPE II ATRIAL FIBRILLATION LOW BACK PAIN GOUT HYPERTENSION OSTEOARTHRITIS SLEEP APNEA HYPERLIPIDEMIA ANEMIA SHOULDER PAIN SIALADENITIS NARCOTICS AGREEMENT Social History: ___ Family History: -Mother died at ___ of stroke, hypertension, acute renal failure. -Father died in his ___. She has no sisters. -She has two brothers. One died at ___ of diabetes and coronary artery disease. The other one is still alive and is in reasonably good health. -She has two daughters, ___ and ___, in good health. -She has two sons, the eldest one the ___ has liver cancer and the younger one, ___, is legally blind. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 97.7, HR 74, BP 134/65, O2 95% RA GENERAL: Obese female, lying in bed. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. No JVD CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. Slightly tender to palpation. Has LUE AVF SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: VS: T 98.7, HR 85, BP 108/51, O2 92% RA GENERAL: Alert and oriented, NAD. Breathing comfortably. HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. NECK: Supple. No JVD CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. Slightly tender to palpation. Has LUE AVF SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: LABS: Basic labs: ___ 12:00PM BLOOD WBC-12.3* RBC-3.23* Hgb-10.4* Hct-32.6* MCV-101* MCH-32.2* MCHC-31.9* RDW-17.0* RDWSD-61.2* Plt ___ ___ 06:55AM BLOOD WBC-9.5 RBC-2.96* Hgb-9.2* Hct-30.0* MCV-101* MCH-31.1 MCHC-30.7* RDW-17.3* RDWSD-61.5* Plt ___ ___ 12:00PM BLOOD ___ PTT-26.0 ___ ___ 12:00PM BLOOD Glucose-100 UreaN-12 Creat-2.5*# Na-137 K-6.2* Cl-95* HCO3-27 AnGap-21* Cardiac enzyme trend: ___ 12:00PM BLOOD CK-MB-1 ___ 12:00PM BLOOD cTropnT-0.03* ___ 11:38PM BLOOD CK-MB-<1 cTropnT-0.04* ___ 06:55AM BLOOD CK-MB-<1 cTropnT-0.04* MICRO: None STUDIES: ___ CXR: IMPRESSION: Heart size is prominent. There is tortuosity of the thoracic aorta. There are low lung volumes. There is atelectasis at the lung bases. No focal consolidation is seen. There is mild pulmonary edema. There is a rounded 15 mm density at the right base. This appears new since the previous study and may represent a parenchymal lung nodule. Nonemergent chest CT could be performed for further evaluation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Midodrine 10 mg PO TID 6. Nephrocaps 1 CAP PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 8. Senna 8.6 mg PO BID:PRN constipation 9. Sertraline 50 mg PO DAILY 10. sevelamer CARBONATE 1600 mg PO TID W/MEALS 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. B complex with C#20-folic acid 1 mg oral DAILY 13. Levocarnitine 330 mg PO TID 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Atorvastatin 20 mg PO QPM 16. Lidocaine 5% Patch 1 PTCH TD QAM pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. B complex with C#20-folic acid 1 mg oral DAILY 6. Docusate Sodium 100 mg PO BID 7. Levocarnitine 330 mg PO TID 8. Lidocaine 5% Patch 1 PTCH TD QAM pain 9. Midodrine 10 mg PO TID 10. Nephrocaps 1 CAP PO DAILY 11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Senna 8.6 mg PO BID:PRN constipation 15. Sertraline 50 mg PO DAILY 16. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: Chest pain 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 INDICATION: History: ___ with chest pain // Effusion, edema, infiltrate COMPARISON: Radiographs from ___. IMPRESSION: Heart size is prominent. There is tortuosity of the thoracic aorta. There are low lung volumes. There is atelectasis at the lung bases. No focal consolidation is seen. There is mild pulmonary edema. There is a rounded 15 mm density at the right base. This appears new since the previous study and may represent a parenchymal lung nodule. Nonemergent chest CT could be performed for further evaluation. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified, Localized edema, End stage renal disease temperature: 97.8 heartrate: 76.0 resprate: 20.0 o2sat: 98.0 sbp: 146.0 dbp: 76.0 level of pain: 4 level of acuity: 2.0

Ms. ___ is an ___ with ESRD via LUE AVF (___), DMII, HTN, Hx DVT and multiple ED visits and prior admission for chest pain in the setting of hemodialysis, admitted for chest pain in the setting of HD. # Chest pain: Patient has had several prior episodes of chest pain c/w typical angina i/s/o dialysis, likely caused by intravascular fluid shifts. No CAD history, but risk factors include ESRD, DM2, HTN, HLD, and age. Trop in ED to 0.03, and MB 1. Pharm MIBI in ___ was normal. Patient reports history of similar recent episodes that only happen during dialysis. Plan is for outpatient cardiac follow up with potential for outpatient stress testing. Chronic issues # Atrial fibrillation: not on OAC- after discussion with her nephrologist Dr. ___ year, the decision was made to not continue warfarin given the unclear net clinical benefit in the HD population with Afib. Continued home amiodarone and aspirin 81mg. # ESRD: Has LUE AVF for access, and gets HD ___. Completed most of session on day of admission prior to developing chest pain. She will continue to get # Orthostatic hypotension: - cont home midodrine # OA on chronic narcotics - Cont home oxycodone, acetaminophen, lidocaine and gabapentin # Depression: - cont home sertraline # T2DM: - qACHS fingersticks and ISS with Humalog while in house # HLD: - cont home atorvastatin.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with CAD c/b STEMI s/p DES x2 (___), DMII (diet-controlled), HLD, and recent admission (___) at ___ for NSAID-induced ___ with nephrotic syndrome, as well as admission at ___ (___) for basal ganglia ischemic stroke s/p tPA administration, with course c/b IPH secondary to right temporal lobe mass, presenting with dizziness and nausea. After his most recent admission he was discharged without residual deficits and has been living at home, doing well. The patient is an imperfect historian, but reports ___ days prior to this admission he began having intermittent dizziness, tinnitus, as well as nausea, vomiting, periumbilical abdominal pain, dyspnea, palpitations, and chills. The time course is somewhat unclear as to which symptoms came first. His symptoms have acutely worsened the morning of admission and he has been persistently dizzy since waking up this morning, unable to tolerate PO, and unable to walk secondary to dizziness. He denies fevers, chest pain, focal numbness/weakness/tingling of any extremity, or speech problems. Neurology was consulted in the ED. Impression: "Given positive orthostatics, positionally related dizziness, and some improvement noted since fluids started, his dizziness is most likely due to orthostasis. His exam appears mostly unchanged compared to previous, with the exception of bidirectional nonfatiguable nystagmus, which was not previously noted in notes. He did have a small vermal bleed in his last admission, which could potentially produce this finding. It would not be unreasonable to obtain a repeat MRI brain however, though the suspicion is lower. He does not have any EOM abnormalities however or other brainstem findings. His NCHCT does not show new bleed, old blood has been reabsorbed, his mass appears stable. The imaging being stable is reassuring that a new neurologic process is less likely to be involved in regards to his symptoms today. - consider medicine admission for treatment/workup of ___, elevated proBNP, abdominal pain - will follow on consult service - consider MRI head w/o contrast (preferably with contrast, but Cr 5.5) once admitted" In the ED, initial vitals: 99.6 74 182/104 20 99% RA - Labs notable for: BNP 37K (baseline unknown) WBC 11.2 Hb 9.6 Cr 5.5 (at baseline) Lactate 2.0 Trop 0.02 - Imaging notable for: NCHCT IMPRESSION: 1. There is known evolution of an approximately 3.3 x 1.7 cm right temporal hematoma since ___. 2. The previously described midline cerebellar hematoma is not well seen on today's exam, better seen on dedicated MR from ___. No new intracranial hemorrhage or large acute infarct. - Pt given: ___ 16:20 IV Ondansetron 4 mg ___ 16:20 IVF LR Started 150 mL/hr ___ 20:19 IV Ondansetron 4 mg - Vitals prior to transfer: 77 179/99 16 95% RA Upon arrival to the floor, the patient reports the story as above. As he was moved from the stretcher to the bed he vomiting some non-bloody vomitus and felt quite dizzy. States he feels quite dehydrated, and he felt better when he got fluids in the ED. Past Medical History: PMH/PSH: CAD c/b STEMI s/p DES x2 (___) DMII (diet-controlled) HLD Recent admission for NSAID-induced ___ with nephrotic syndrome Social History: ___ Family History: Notable for multiple family members with strokes on father's side, as well as ?CRAO in mother apparently treated with warfarin, c/b fatal ICH. Physical Exam: PHYSICAL EXAM: VITALS: 98.3 ___ 98Ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended GU: No Foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities DISCHARGE EXAM General: Alert, oriented, no acute distress CV: Normal rate, regular rhythm, normal S1 + S2, no murmurs, rubs, or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended GU: No Foley Ext: Warm, well perfused, no ___ edema Neuro: Alert and oriented x3. Right-beating end-gaze nystagmus with rightward gaze that does not extinguish, no vertical skew, positive head impulse test. No dysmetria with finger-nose or heel-shin. Pertinent Results: ADMISSION ___ 02:55PM BLOOD WBC-11.2* RBC-3.50* Hgb-9.6* Hct-31.2* MCV-89 MCH-27.4 MCHC-30.8* RDW-13.3 RDWSD-43.4 Plt ___ ___ 02:55PM BLOOD Neuts-87.2* Lymphs-6.1* Monos-4.5* Eos-0.5* Baso-0.6 Im ___ AbsNeut-9.78* AbsLymp-0.68* AbsMono-0.51 AbsEos-0.06 AbsBaso-0.07 ___ 03:36PM BLOOD ___ PTT-29.1 ___ ___ 02:55PM BLOOD Glucose-131* UreaN-54* Creat-5.5* Na-147 K-5.1 Cl-108 HCO3-19* AnGap-20* ___ 02:55PM BLOOD ALT-15 AST-28 AlkPhos-165* TotBili-0.5 ___ 02:55PM BLOOD cTropnT-0.02* ___ ___ 02:55PM BLOOD Albumin-2.4* ___ 06:50AM BLOOD Calcium-7.7* Phos-6.8* Mg-2.4 ___ 02:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 04:05PM BLOOD Lactate-2.0' DISCHARGE ___ 05:50AM BLOOD WBC-7.2 RBC-2.89* Hgb-7.8* Hct-25.5* MCV-88 MCH-27.0 MCHC-30.6* RDW-13.2 RDWSD-42.5 Plt ___ ___ 05:50AM BLOOD Glucose-83 UreaN-49* Creat-5.6* Na-144 K-3.6 Cl-109* HCO3-21* AnGap-14 ___ 05:50AM BLOOD Calcium-7.2* Phos-4.6* Mg-2.2 ___ 07:05AM BLOOD calTIBC-113* ___ TRF-87* ___ 06:50AM BLOOD ALT-25 AST-16 AlkPhos-160* TotBili-0.3 IMAGING ___ MRI HEAD 1. Unchanged findings consistent with a right temporal lobe subacute intraparenchymal hematoma. 2. No evidence of increased blood flow 3. Spectroscopic analysis is nondiagnostic due to field inhomogeneity caused by the hematoma. 4. No acute infarct. ___ RENAL ARTERY ULTRASOUND Unremarkable renal ultrasound. No evidence of significant renal artery stenosis. Mild stenosis would be better evaluated on MRA or CTA, if clinically applicable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sodium Bicarbonate ___ mg PO TID 2. Calcium Acetate 667 mg PO TID W/MEALS 3. HydrALAZINE 25 mg PO TID 4. Labetalol 200 mg PO BID 5. Furosemide 80 mg PO QAM Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. CARVedilol 25 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Meclizine 12.5 mg PO TID 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Sodium Bicarbonate 1300 mg PO TID 9. Calcium Acetate 667 mg PO TID W/MEALS 10. HELD- Furosemide 80 mg PO QAM This medication was held. Do not restart Furosemide until directed by nephrologist. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY ======= - Intracerebral hemorrhage - Vertigo SECONDARY ========= - Hypertension - Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with dizziness s/p stroke// ? stroke 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: Total DLP (Head) = 803 mGy-cm. COMPARISON: MR head from ___. CT head without contrast from ___. FINDINGS: Hypodensity in the right temporal lobe at the site of prior hematoma likely reflects developing encephalomalacia. Previously described midline cerebellar hematoma is less conspicuous. There is no new intracranial hemorrhage or large acute infarct. The ventricles and sulci are unchanged. There is stable appearance of chronic infarcts in the right caudate head and putamen. There is no evidence of fracture. 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. Developing encephalomalacia at the site of prior right temporal lobe hemorrhage. 2. Previously noted midline cerebellar hematoma not well seen on current exam. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: ___ year old man with dyspnea, dizziness, elevated BNP, ? pneumonia, pulm edema// ___ year old man with dyspnea, dizziness, elevated BNP, ? pneumonia, pulm edema TECHNIQUE: AP radiograph of the chest. COMPARISON: Outside reference chest radiograph ___. IMPRESSION: There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. There is no pulmonary edema. No acute osseous abnormalities are identified. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old man with R subcortical infarct with tPA administration c/b IPH in ___, now with vertigo and nausea, ? new infarct/bleed// ___ year old man with R subcortical infarct with tPA administration c/b IPH in ___, now with vertigo and nausea, ? new infarct/bleed TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair, axial diffusion weighted and axial gradient echo images . COMPARISON: MRI of ___ and CT of ___. FINDINGS: An area of restricted diffusion in the right temporal lobe indicate subacute hematoma with peripheral rim of hemosiderin. No other areas of restricted diffusion seen to indicate acute infarct. There is no mass effect midline shift or hydrocephalus. Chronic infarct in right parietal lobe with changes of small vessel disease are again seen. Vascular flow voids are maintained. IMPRESSION: 1. No acute infarcts are identified. 2. Subacute intra-axial hematoma is seen in the right temporal lobe with peripheral continuous rim of hemosiderin, evolved from the previous MRI and unchanged in size compared to the CT.. Radiology Report EXAMINATION: US RENAL ARTERY DOPPLER INDICATION: ___ year old man with CAD c/b STEMI s/p DES x2 (___), DMII (diet-controlled), HLD, basal ganglia stroke now with persistent hypertension. Working up for secondary causes of hypertension.// evaluate for renal artery stenosis TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the kidneys were obtained. COMPARISON: Noncontrast CT torso dated ___. FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 10.9 cm Left kidney: 11.7 cm Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic peaks and continuous antegrade diastolic flow. The resistive indices of the right intra renal arteries range from 0.7-0.8. The resistive indices on the left range from 0.73-0.85. Bilaterally, the main renal arteries are patent with normal waveforms. The peak systolic velocity on the right is 48 centimeters/second. The peak systolic velocity on the left is 50.5 centimeters/second. Main renal veins are patent bilaterally with normal waveforms. The bladder is moderately well distended and normal in appearance. IMPRESSION: Unremarkable renal ultrasound. No evidence of significant renal artery stenosis. Mild stenosis would be better evaluated on MRA or CTA, if clinically applicable. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with right temporal mass.// Eval right temporal mass vs hematoma **ASL and multivoxel MR spectroscopy** TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. Signal multi voxel spectroscopic analysis was also performed. COMPARISON MRI head without contrast ___ CT head without contrast ___. FINDINGS: An area of T2/FLAIR hyperintense signal and slow diffusion is re-demonstrated in the right temporal lobe with peripheral hemosiderin deposition, unchanged. Spectroscopic analysis is nondiagnostic due to field inhomogeneity from the hematoma. Perfusion imaging demonstrates no evidence of elevated blood flow associated with the hematoma. The ventricles and sulci are prominent, consistent with global cerebral volume loss. Old infarcts are seen in the right parietal lobe and right basal ganglia. Patchy T2 hyperintensities are seen in the periventricular white matter and bilateral dentate nuclei, right greater than left. These most likely are sequela of chronic microvascular angiopathy. IMPRESSION: 1. Unchanged findings consistent with a right temporal lobe subacute intraparenchymal hematoma. 2. No evidence of increased blood flow 3. Spectroscopic analysis is nondiagnostic due to field inhomogeneity caused by the hematoma. 4. No acute infarct. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: n/v/d, Weakness Diagnosed with Dizziness and giddiness temperature: 99.6 heartrate: 74.0 resprate: 20.0 o2sat: 99.0 sbp: 182.0 dbp: 104.0 level of pain: 0 level of acuity: 3.0

SUMMARY ======= Mr. ___ is a ___ with CAD c/b STEMI s/p DES x2 (___), DMII (diet-controlled), HLD, and recent admission (___) at ___ for ___ with nephrotic syndrome, as well as admission at ___ (___) for basal ganglia ischemic stroke s/p tPA administration, with course c/b ICH secondary to right temporal lobe mass. Currently presenting with dizziness and nausea. Course complicated by hypernatremia.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Pericardiocentesis (___) Pericardial Window (___) History of Present Illness: PCP: ___ does not know name CHIEF COMPLAINT: dyspnea REASON FOR TRANSFER: pericardial effusion ___ ___ nonsmoker with hyperlipidemia presenting from her PCPs office with 4 days of exertional dyspnea without pain. The ___ states that she first noticed her exertional dyspnea climbing stairs but over the last couple of days she has noticed it even walking on a flat surface even for short distances. She denies any fevers/chills, night sweats, or weight loss, but admits to a nonproductive cough one to 2 weeks ago which resolved spontaneously. Endorses mild orthopnea. Endorses mild bilateral peripheral edema, which is chronic. VS at ___: 97.8 F (36.6 C). Pulse: 72. Respiratory Rate: 24. Blood-pressure: 140/70. Oxygen Saturation: 98%. OSH electrolyte panel, trop, coags, BNP unremarkable. CBC with WBC 4.5, Hgb 11.0, plt 152. OSH EKG ___ showed: Sinus rhythm with low precordial ___. ESR: 30 Mm/Hr Interpretation: sinus rhythm, heart rate 72, no acute ischemia OSH CXR ___ showed: Significant cardiomegaly.? Possible pericardial effusion. Cardiac echo recommended. No significant CHF. No pleural fluid. OSH CTA ___ showed: No evidence of pulmonary embolus. Large pericardial effusion, with a 10.5 x 7.3 x 6 cm right superior mediastinal mass, presumed to be invading the pericardium. Suspicion of malignant thymoma, differential includes lymphoma, or teratoma. Left superior mediastinal prevascular pathologically enlarged 1.3 cm lymph node. Small right pleural effusion, mild cardiomegaly. Flattened appearing trachea, mainstem bronchi possibly incidental tracheobronchiomalacia, versus mechanical effect of cardiac enlargement and of pericardial fluid. Given ___ complexity she was transferred to ___ for further evaluation. In the ED, initial vitals were: 98.8 72 156/116 22 97%. She had a pulsus of 8 then 10. Labs notable for anemia H/H 10.9/34.3, thrombocytopenia 149, normal WBC of 4.3. UA/chem-7/lactate were normal. EKG showed sinus rhythm @ vent rate of 73. Q wave in lead III. Low voltages in precordial leads with T wave flattening/inversion. Bedside TTE revealed large pericardial effusion and possible diastolic collapse of RV suggestive of tamponade, prompting admission to the CCU for close monitoring. Vitals on transfer were 98.5 70 161/85 20 96% RA. In the ICU, she reports that she currently does not have dyspnea or chest pain. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: HLD ___ refused to start statin) Social History: ___ Family History: Brother with MI @ age ___. Does not know about family history of cancers. Physical Exam: ADMISSION PHYSICAL: ============================ VS: T=98.4 BP=123/72 HR=72 RR=30 O2 sat=94% RA Pulsus 6 Gen: Pleasant, obese HEENT: PERRL.EOMI. No lid lag. NECK: Soft, supple. JVP not elevated. No lymphadenopathy or thryoid masses appreciated CV: Muffled heart sounds. RRR. S1 and S2. No murmurs, rubs or gallops. LUNGS: Tachypneic but speaks in full sentences. Occasional expiratory wheeze but clear to auscultation bilaterally. ABD: + BS. Non-tender EXT: Warm, well-perfused. Trace pedal edema bilaterally PULSES: 2+ DP and ___ pulses bilat. SKIN: Linear excoriations on bilateral upper extremities NEURO: AAOx3. CN2-12 grossly intact. ___ upper and lower extremity strength. DISCHARGE PHYSICAL: ============================ VITALS: 98.4 119/57 ___ 18 99% General: well appearing, NAD sitting in bed conversational Neck: supple CV: RRR Lungs: CTAB. Abdomen: non-tender, non-distended, +BS, no hepatosplenomegaly, midline scar healing well, sight of chest tube removal with with dressing c/d/i. non eythematous Ext: trace ankle edema Neuro: CN II-XII grossly intact, symmetrical facial features Skin: WWP, no rashes apprecaited Pertinent Results: ADMISSION LABS: ===================== ___ 07:00PM BLOOD WBC-4.3 RBC-4.10* Hgb-10.6* Hct-34.3* MCV-84 MCH-25.9* MCHC-31.0 RDW-13.6 Plt ___ ___ 07:00PM BLOOD Neuts-60.2 ___ Monos-6.4 Eos-2.2 Baso-0.6 ___ 03:37AM BLOOD ___ PTT-34.2 ___ ___ 07:00PM BLOOD Ret Aut-1.7 ___ 07:00PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-139 K-3.7 Cl-104 HCO3-24 AnGap-15 ___ 07:00PM BLOOD ALT-25 AST-24 LD(LDH)-181 AlkPhos-114* TotBili-0.5 ___ 07:00PM BLOOD UricAcd-3.8 Iron-21* Cholest-139 ___ 07:00PM BLOOD calTIBC-404 Ferritn-35 TRF-311 ___ 07:00PM BLOOD Triglyc-103 HDL-49 CHOL/HD-2.8 LDLcalc-69 ___ 07:00PM BLOOD TSH-0.83 ___ 07:00PM BLOOD ___ ___ 07:11PM BLOOD Lactate-1.1 PERTINENT LABS: ===================== ECG (___): Sinus rhythm. There are non-diagnostic Q waves in the inferior leads. Non-specific ST-T wave changes. There is an early transition that is non-specific. Low voltage in the precordial leads. No previous tracing available for comparison. Read by: ___. ___ Axes Rate PR QRS QT/QTc P QRS T 73 158 96 ___ 32 ECHOCARDIOGRAM (___): Estimated left ventricular systolic function is normal (LVEF 55%). There is a large pericardial effusion with evidence of possbile mass adjacent to the pericardium in subxyphoid views. There is brief right atrial diastolic collapse. There is respiratory variation in mitral valve inflows, close to 30% variation in peak E wave variation, consistent with impaired ventricular filling. Findings may be consistent with early cardiac tamponade physiology by echo. CARDIAC CATHETERIZATION PROCEDURE (___): Successful pericardiocentesis with removal of 770 cc bloody fluid which is sent to Pathology for analysis. ECHOCARDIOGRAM ___, post pericardiocentesis) FOCUSED STUDY/LIMITED VIEWS: No atrial septal defect is seen by 2D or color Doppler. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is a very small pericardial effusion. The effusion appears loculated. No right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of ___, the majority of the pericardial effusion has been drained. There are no echocardiographic signs of tamponade. ECHOCARDIOGRAM (___): IMPRESSION: Some beats reveal evidence of brief diastolic right ventricular inward motion not collapse. The mitral inflow pattern shows respirophasic variation exceeding 25%. The RA and IVC could not be visualized. Compared to yesterday the pericardial effusion has increased and yesterday there was no mitral inflow variation. Taken together, the change in mitral inflow pattern together with the increase in pericardial effusion size is concerning for early tamponade physiology. MRI HEAD ___. Study is degraded by motion. 2. Within limits of study, no definite intracranial metastatic disease identified. 3. Probable small vessel ischemic changes. CTA ABD/PELV ___ IMPRESSION: 1. No evidence for malignancy in the abdomen and pelvis. 2. Incompletely imaged 7.8 cm heterogeneously enhancing mediastinal mass is better evaluated on recent chest CT. Differential diagnosis includes thymoma or teratoma. BONE SCAN ___ FINDINGS: The images show diffuse uptake in the paranasal region which may represent sinusitis. Foci of increased uptake around the knees and ankles bilaterally are most consistent with degenerative changes. There is no focus of increased uptake suspicious for malignancy. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. DISCHARGE LABS: ===================== ___ 06:03AM BLOOD WBC-4.1 RBC-3.90* Hgb-10.6* Hct-33.3* MCV-85 MCH-27.2 MCHC-31.8 RDW-13.6 Plt ___ ___ 06:03AM BLOOD Plt ___ ___ 06:03AM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-139 K-4.1 Cl-106 HCO3-21* AnGap-16 ___ 06:03AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4 PATHOLOGY: ====================== IMMUNOPHENOTYPING-MEDIASTINAL MASS Non-diagnostic study. Clonality could not be assessed in this case due to insufficient numbers of B cells. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells. Correlation with clinical findings and morphology is recommended. Cytospin preparations of the flow sample reveals cell clusters suggestive of a non-hematological neoplasm (see separate pathology report ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This ___ is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain 2. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Final diagnosis: Pericardial effusion Mediastinal Mass- Carcinoid tumor Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p pericardiocentesis ___ with new tachypnia, RR 34 // ? pneumothorax? ? pneumothorax? IMPRESSION: In comparison with the study of ___, there is little change in the huge enlargement of the cardiac silhouette, much of which could represent pericardial effusion. No definite pneumothorax or pneumopericardium. Pulmonary vascularity is essentially within normal limits. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pericardial effusion (suspected malignant), acculumating pleural effusion, not stable to go off floor // pre-op for pericardial window Surg: ___ (pericardial window) COMPARISON: Chest radiograph ___ and outside CT ___. IMPRESSION: Large right anterior mediastinal mass has been more fully characterized on the at outside CT and is associated with a known pericardial effusion resulting in enlargement of the cardiac silhouette. Pulmonary vascularity is normal, and lungs are grossly clear. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p pericardial window // ?PTX ?PTX COMPARISON: Chest radiographs ___ through ___. IMPRESSION: The change in right contour of the large cardiomediastinal silhouette has changed to reflect some drainage of the large pericardial effusion. Today there is no pneumothorax. Small left pleural effusion is presumed. Upper lungs clear. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST INDICATION: ___ female presenting with shortness of breath, found to have a large hemorrhagic pericardial effusion and mediastinal mass, for metastatic workup. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was administered. DOSE: DLP: 1218 mGy-cm (abdomen and pelvis). IV Contrast: 130 mL Omnipaque COMPARISON: Chest CT dated ___. FINDINGS: LOWER CHEST: Limited images of the lower chest demonstrate interval decompression of previously identified moderate pericardial effusion. A right pericardial drain is in place with scattered adjacent gas locules. There is an incompletely imaged 7.8 x 6.0 cm heterogeneous enhancing mediastinal mass resulting in mass effect on the distal superior vena cava and proximal right atrium. Minimal bibasilar atelectasis and trace effusions are present. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. Incidental note is made of cholelithiasis. No gallbladder wall thickening or pericholecystic fluid is present. PANCREAS: The pancreas has normal attenuation throughout, 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. Two well-circumscribed hypodense foci in the upper and mid poles of the right kidney measure water attenuation likely represent cysts. There is no evidence for renal calculus, hydroureteronephrosis, or perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder is unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits BONES AND SOFT TISSUES: Degenerative changes are seen in the lower thoracolumbar spine.. IMPRESSION: 1. No evidence for malignancy in the abdomen and pelvis. 2. Incompletely imaged 7.8 cm heterogeneously enhancing mediastinal mass is better evaluated on recent chest CT. Differential diagnosis includes thymoma or teratoma. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old woman with evidence of thymoma. Evaluate for intracranial metastatic disease. TECHNIQUE: Sagittal T1, axial T1, GRE, FLAIR, and T2 imaging was performed. Additional sagittal MPRAGE and axial T1 postcontrast imaging was obtained after the uneventful intravenous administration of 7 ml of Gadavist contrast agent. Multiplanar reformatted images of the MPRAGE acquisition was then produced. COMPARISON: None. FINDINGS: Please note the study is degraded by motion. There is no acute intracranial hemorrhage, abnormal extra-axial fluid collection, midline shift, or acute territorial infarction. The ventricles and sulci are preserved. The paranasal sinuses and mastoid air cells are preserved. There is no abnormal enhancement on post-contrast imaging. Periventricular and subcortical T2 and FLAIR hyperintensities are noted, which may represent small vessel ischemic changes. IMPRESSION: 1. Study is degraded by motion. 2. Within limits of study, no definite intracranial metastatic disease identified. 3. Probable small vessel ischemic changes. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with mediastinal mass and pericardial effusion, s/p pericardial window, chest tube pulled today. ***PLEASE DO AT 7:30PM*** // eval after chest tube pulled- please check at 730pm eval after chest tube pulled COMPARISON: Chest radiographs ___ through ___. IMPRESSION: Previous pulmonary vascular congestion has resolved. Large areas of lung are obscured by the very large cardiac silhouette, and although the frontal view suggests right infrahilar consolidation, there is no corresponding finding on the lateral. Right pleural effusion is tiny. The cardiac silhouette is comparable in its great size and shape to prior images, indicating large pericardial effusion persists. Deflection of the trachea the thoracic inlet is due to a large goiter. Gender: F Race: ASIAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with ACUTE PERICARDITIS NOS, CHEST SWELLING/MASS/LUMP temperature: 98.8 heartrate: 72.0 resprate: 22.0 o2sat: 97.0 sbp: 156.0 dbp: 116.0 level of pain: 0 level of acuity: 2.0

___ non-smoker with past medical history of untreated hyperlidiemia who presents with progressive dyspnea on exertion and was found to have pericardial effusion and mediastinal mass. #) PERICARDIAL EFFUSION/TAMPONADE: ___ initially had signs of tamponade on informal TTE, however, was hemodynamically stable with no pulsus. She had drainage of 770 cc of bloody fluid in the cath lab on ___. Post procedure echo showed normal cardiac function but on ___ had a repeat TTE that showed interval reaccumulation of fluid and signs of early tamponade. She went for a pericardial window on ___ by thoracic surgery which was successful. ___ had chest tube removed 2 days after procedure and remained symptom free. Pathology analanlysis of perocardial fluid was pending at discharge. #) MEDIASTINAL MASS - primary neuroendocrine carcinoma: Suspicious for malignant thymoma per radiology read of CTA, invading the pericardium. No weakness in history on exam to suggest myasthenia ___ from thymoma. She had no B-symptoms suggestive of lymphoma. Preliminary studies of the mediastinal mass indicated that it was a primary neuroendocrine carcinoma. Further workup including CT abdomen and pelvis, MRI head and a bone scan did not reveal any evidence of metastasis. #)ATRIAL FIBRILLATION: During placement of pericardial window ___ developed intraoperative atrial fibrillation. ___ was treated with metoprolol for rate controll and spontaneously converted to sinus rhythm. She had no further episodes of atrial fibrillation noted on telemetry during this hospitalization. She was discharged on metoprolol succinate. #) ANEMIA: Borderline normocytic. Unknown if acute or chronic. No active signs of bleeding. Concerning for BM involvement in setting of concurrent thrombocytopenia. #) THROMBOCYTOPENIA: No AMS, renal dysfunction to suggest TTP. She does not take any medications that could be contributing. Concerning for BM involvement in setting of concurrent anemia. No splenomegaly on exam. #) HYPERLIPIDEMIA: ___ reports she has high cholesterol but refused to start medicine. # CODE: presumed Full # CONTACT: ___ ___ ___ Issues: ___ needs to follow up with oncology to better characterize and evaluate the mediastinal mass Metoprolol was started due to atrial fibrillation induced in the perioperative setting. Please reconsider whether this is necessary in the outpatient setting.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: sulfa Attending: ___. Chief Complaint: Worsening headache, shuffling gait Major Surgical or Invasive Procedure: ___ Left craniotomy for subdural hematoma evacuation History of Present Illness: ___ yo M hx HTN followed by Dr. ___ small left SDH since ___ at ___ who developed worsening HA on ___. Family noticed that his gait was off and he was shuffling and that he was slow to respond. He went to OSH ED where head CT showed progression to acute on chronic left SDH with midline shift and entrapment of the right temporal horn. Pt was loaded with 1g Keppra IV and transferred to ___ for definitive care. Pt endorses HA and change in gait. Denies weakness, numbness, tingling. Past Medical History: HTN, HLD, left TKR Social History: ___ Family History: ___ Physical Exam: O: T: 97.7 HR:81 BP:125/79 RR:17 Sat:98% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Neck: Supple Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: speech slightly thick with good comprehension and repetition. Naming intact. No paraphasic errors. Cranial Nerves: I: Not tested II: Pupils anisocoria Right 4mm -3mm, left 3mm-2mm round and reactive to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Subtle right pronator drift. Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: dysmetric on right finger-nose-finger On Discharge: AAO x 3, PERRL, EOMs intact No facial droop, tongue midline No pronator drift Strength and sensation full throughout Left surgical incision CDI, closed with staples and sutures. Pertinent Results: CT head ___: 1. Status post left frontal craniotomy with evacuation of subdural hematoma with resultant pneumocephalus and mixed density subdural fluid collection consistent with evolving blood products. 2. Relative to prior study, degree of rightward shift and effacement of the left lateral ventricle and adjacent sulci is decreased. 3. No new hemorrhage is identified. 4. Moderate sinus disease as described above ___ 06:15AM BLOOD WBC-13.2* RBC-4.98 Hgb-14.2 Hct-41.4 MCV-83 MCH-28.5 MCHC-34.3 RDW-13.5 Plt ___ ___ 03:17AM BLOOD WBC-13.3*# RBC-4.81 Hgb-13.5* Hct-39.5* MCV-82 MCH-28.1 MCHC-34.2 RDW-13.4 Plt ___ ___ 04:16AM BLOOD WBC-8.5 RBC-4.51* Hgb-13.0* Hct-37.7* MCV-84 MCH-28.8 MCHC-34.5 RDW-13.6 Plt ___ ___ 06:15AM BLOOD ___ PTT-27.2 ___ ___ 06:15AM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-139 K-4.2 Cl-104 HCO3-23 AnGap-16 ___ 03:17AM BLOOD Glucose-131* UreaN-20 Creat-0.8 Na-138 K-3.3 Cl-101 HCO3-24 AnGap-16 ___ 04:16AM BLOOD Glucose-117* UreaN-27* Creat-1.0 Na-142 K-3.5 Cl-104 HCO3-24 AnGap-18 ___ 06:15AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2 ___ 03:17AM BLOOD Calcium-9.2 Phos-3.7# Mg-2.1 ___ 04:16AM BLOOD Calcium-8.8 Phos-6.4* Mg-2.0 Medications on Admission: Amlodipine, Losartan Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Amlodipine 10 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Losartan Potassium 50 mg PO DAILY 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*25 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ male status post left craniotomy for subdural hemorrhage evacuation. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 892 mGy-cm CTDI: 55 mGy COMPARISON: ___ outside head CT. FINDINGS: Patient is status post left frontal craniotomy and evacuation of subdural hematoma. There is resultant pneumocephalus. The remains extra-axial subdural fluid of mixed density consistent with evolving blood products. This measures 9 mm in maximum dimension along the left frontal convexity. This is associated with an 8 mm rightward shift of normally midline structures, previously 1.3 cm. There is effacement of adjacent sulci as well as effacement of the left lateral ventricle. Basal cisterns are clear. Gray-white matter differentiation appears preserved. No evidence a large territorial ischemia. Orbits are unremarkable. Near-complete opacification of right frontal sinus, anterior right ethmoidal air cells, and moderate mucosal thickening within the right maxillary and sphenoid sinuses is noted. Bilateral mastoid air cells and middle ear cavities are clear. Soft tissue postsurgical changes along the left craniotomy site are expected. IMPRESSION: 1. Status post left frontal craniotomy with evacuation of subdural hematoma with resultant pneumocephalus and mixed density subdural fluid collection consistent with evolving blood products. 2. Relative to prior study, degree of rightward shift and effacement of the left lateral ventricle and adjacent sulci is decreased. 3. No new hemorrhage is identified. 4. Moderate sinus disease as described above. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: Headache, Transfer Diagnosed with SUBDURAL HEMORRHAGE, HYPERTENSION NOS temperature: 97.8 heartrate: 80.0 resprate: 16.0 o2sat: 99.0 sbp: 140.0 dbp: 83.0 level of pain: 0 level of acuity: 2.0

Patient was admitted directly to the OR for evacuation of a left sided SDH. He tolerated the procedure well, was extubated in the operating room, and transferred to the ICU post-operatively for further management and care. Post op imaging was done that showed evacuation of the hematoma and expected post-op changes. He remained stable into ___ and worked with ___ who felt he did not require further ___ assessment and was safe to discharge home once medically ready. He remained stable overnight into ___. On ___ he was seen and evalauted and deemed fit for transfer to the floor. Orders for transfer were written in the morning. Mr. ___ was seen and evaluated by Physical Therapy and Occupational Therapy and it was decided that can be discharged home with outpatient ___ services. Mr ___ is neurologically intact. He will continue on Levetiracetam for anticonvulsant prophylaxis. His pain is being controlled with Oxycodone ___. He has been ambulating and taking a regular diet without any complications. Mr. ___ was offered home ___ services at the time of discharge but felt he didn't need them. He said he'd be staying with his son and his daughter is a ___. At the time of discharge, Mr. ___ was afebrile, hemodynamically and neurologically stable.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Fatigue Shortness of breath Major Surgical or Invasive Procedure: left chest tube placement (___) History of Present Illness: Ms. ___ is a ___ female with history of pulmonary embolism on xarelto, hypertension, hyperlipidemia, type II diabetes, and metastatic mucinous adenocarcinoma of unknown primary with peritoneal carcinomatosis and malignant ascites currently on palliative ___ who presents with shortness of breath. Patient reports shortness of breath for the past couple weeks. This has worsened over the past three days and she notified her daughter. She has been unable to catch her breath. She notices the shortness of breath particularly with exertion. She also notes tightness under her bilateral breasts. She notes decreased appetite. She also reports nausea with vomiting related to chemotherapy. She does note that her abdomen is more distended recently, but denies abdominal pain. She notes her chemotherapy was held ___ for generalized weakness. She initially presented to ___ Urgent Care. Labs were notable for WBC 7.1, H/H 8.2/25.3, Plt 345, INR 2.3, Na 132, K 4.3, BUN/Cr ___, LFTs wnl, BNP 349, trop < 0.01, and UA with moderate leuks, pyuria, and bacteruria. She had a CTA chest which showed massive left pleural effusion and no PE. She was transferred to ___ ED for further evaluation. Past Medical History: - ___: Port placed - ___: C1 D1 ___ (AUC2) Taxol (60mg/m2) - ___: C1 D8 " - ___: C1 D15" " - ___: C2 D1, ___ ___ 15% to AUC 1.7, Taxol 60mg/m2, Procrit - ___: C2 D8 - HOLD treatment for diarrhea, nausea/vomiting; support with IVF - ___: IVF - ___: C2 D15 - ___: 1 unit of PRBC - ___: US guided paracentesis, removed 3.6L - ___: C3 D1 - ___: C3 D8 - ___: C3 D15 - treat as planned; tachycardic, defer to PCP - ___: Imaging; improved carcinomatosis; decrease in size of L pleural effusion; incidental R LL PE --> continue treatment - ___: C4 D1 ___, Dr15%; taxol, 60mg/m2 - ___ C4 D8 " - ___: C4 D15 " - ___: US guided paracentesis; removed 0.3L - ___: C5 D1, ___ DR15%; taxol, 60mg/m2 - treat 1, 8,15 - ___: C6 D1 " - ___: C7 Day 1 ___ and Taxol. - ___: C8 D1 Carboplatin and Taxol. PAST MEDICAL HISTORY: - Pulmonary Embolism on Xarelto - Hypertension - Hyperlipidemia - Type II Diabetes - Stage III Chronic Kidney Disease - Arthritis - Glaucoma - Gallstones Social History: ___ Family History: Father with alcohol abuse. Physical Exam: ADMISSION EXAM ============================= VS: Temp 97.4, BP 105/72, HR 104, RR 18, O2 sat 97% RA. GENERAL: Pleasant woman, slow to respond, in no distress, sitting in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g. LUNG: Decreased breath sounds on left lung. ABD: Soft, non-tender, mildly distended, positive bowel sounds. EXT: Warm, well perfused, trace bilateral lower extremity edema. NEURO: A&Ox2-3 (initially thought ___ and unknown month but was able to answer correctly with prompting). CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. DISCHARGE EXAM ============================= VS: 97.9 103/62 112 18 94 RA GENERAL: No acute distress HEENT: Moist mucous membranes CV: Regular rate & rhythm, no murmurs LUNGS: Bilateral breath sounds at apex, R > L at bases. ABD: Soft, non-tender, non-distended. EXT: Warm, well perfused, no edema. NEURO: AAOx3. Moving all four extremities with purpose. Pertinent Results: ADMISSION LABS ============================== ___ 02:10PM BLOOD WBC-7.1 RBC-2.60* Hgb-8.2* Hct-25.3* MCV-97 MCH-31.5 MCHC-32.4 RDW-17.2* RDWSD-61.5* Plt ___ ___ 02:10PM BLOOD Neuts-65.5 Lymphs-18.1* Monos-14.0* Eos-1.3 Baso-0.4 Im ___ AbsNeut-4.65 AbsLymp-1.28 AbsMono-0.99* AbsEos-0.09 AbsBaso-0.03 ___ 02:10PM BLOOD Plt ___ ___ 02:23PM BLOOD ___ PTT-35.4 ___ ___ 02:10PM BLOOD Glucose-117* UreaN-25* Creat-1.0 Na-132* K-4.3 Cl-99 HCO3-23 AnGap-10 ___ 02:10PM BLOOD ALT-7 AST-15 AlkPhos-73 TotBili-0.2 ___ 02:10PM BLOOD Lipase-58 ___ 02:10PM BLOOD cTropnT-<0.01 proBNP-349 ___ 02:10PM BLOOD Albumin-2.6* ___ 09:29PM BLOOD ___ pO2-33* pCO2-41 pH-7.41 calTCO2-27 Base XS-0 ___ 09:29PM BLOOD Lactate-1.0 ___ 09:24PM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:35PM URINE Type-RANDOM Color-Yellow Appear-Slcldy* Sp ___ ___ 09:24PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD* ___ 02:35PM URINE Blood-TR* Nitrite-POS* Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-MOD* ___ 09:24PM URINE RBC-6* WBC-17* Bacteri-FEW* Yeast-NONE Epi-1 ___ 02:35PM URINE ___ WBC->50 Bacteri-MANY* Yeast-NONE ___ 09:24PM URINE Mucous-OCC* PERTINENT LABS ============================== ___ 04:53AM BLOOD WBC-7.5 RBC-3.38* Hgb-10.1* Hct-31.1* MCV-92 MCH-29.9 MCHC-32.5 RDW-18.2* RDWSD-61.1* Plt ___ ___ 04:53AM BLOOD ___ PTT-26.7 ___ ___ 04:53AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-132* K-4.0 Cl-97 HCO3-22 AnGap-13 ___ 10:39AM BLOOD Na-137 ___ 04:53AM BLOOD ALT-10 AST-14 AlkPhos-83 TotBili-0.3 ___ 02:10PM BLOOD cTropnT-<0.01 proBNP-349 ___ 02:10PM BLOOD Lipase-58 ___ 09:29PM BLOOD Lactate-1.0 PERTINENT STUDIES ============================== CTA CHEST (___) 1. Massive left pleural effusion, grown since ___, loculated and heterogeneous which may suggest malignant involvement. Near complete collapse of the left lower lobe and substantial atelectasis in the left upper lobe. 2. No evidence of pulmonary embolism or acute aortic abnormality. 3. Small right pleural effusion and small volume loculated ascites. 4. 2.4 x 1.6 cm hypodense structure in the medial border of the inferior vena cava may represent loculated fluid or otherwise be related to the patients underlying malignancy 5. 8 mm right thyroid nodule, could be assessed by dedicated thyroid US if clinically indicated. 6. Cholelithiasis. PLEURAL FLUID (___) DIAGNOSIS: PLEURAL FLUID: POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma. ECHO (___) Suboptimal image quality. Normal biventricular cavity sizes with preserved global systolic function. Due to suboptimal image quality, a focal wall motion abnormality cannot be fully excluded. No pathologic valvular flow identified. CT CHEST (___) Loculated left hydro pneumothorax. Left-sided chest tube in place. Small right pleural effusion. Several scattered pulmonary nodules ranging in size from 2-4 mm throughout the right lung concerning for metastasis. High-density ascites, consistent with known peritoneal carcinomatosis. Right-sided Port-A-Cath with its tip in the SVC. Gallstones CXR (___) Right Port-A-Cath catheter tip is at the level of lower SVC. Left pleural effusion is moderate. Minimal left basal pneumothorax is unchanged. Interval slight increase in left pleural effusion is suspected. Small right pleural effusion is unchanged. MICRO ============================== UCx (___) URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 8:00 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Radiology Report INDICATION: ___ year old woman s/p chest tube w/ persistent tachycardia// infection/ pleural effusion improvement? TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ FINDINGS: There is a stable moderate left loculated hydropneumothorax with adjacent atelectasis. There is atelectasis at the right lung base and likely small right pleural effusion. There is no acute focal consolidation. The cardiomediastinal silhouette and pulmonary vascular congestion are stable. A right Port-A-Cath terminates at the cavoatrial junction. Left chest tube in unchanged position. IMPRESSION: There is a stable moderate left loculated hydropneumothorax with adjacent atelectasis. There is atelectasis at the right lung base and likely small right pleural effusion. There is no acute focal consolidation. The cardiomediastinal silhouette and pulmonary vascular congestion are stable. A right Port-A-Cath terminates at the cavoatrial junction. Left chest tube in unchanged position. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p chest tube placement// tube positioning, interval improvement in effusion? tube positioning, interval improvement in effusion? IMPRESSION: Comparison to ___. Stable position of the left chest tube. Stable extent of the left fluid or pneumothorax. No change in appearance of the heart and of the right lung. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman s/p chest tube// tube positioning/ interval improvement in effusion? tube positioning/ interval improvement in effusion? IMPRESSION: Compared to chest radiographs ___ through ___. Persistent moderate left hydropneumothorax, with a relatively small fluid component, not appreciably changed over the past several days, despite the indwelling left pigtail pleural drainage catheter entering the lower chest laterally and sitting in the posterior hemithorax. Moderate right basal atelectasis and small right pleural effusion are unchanged. Heart size top-normal. Pulmonary vasculature is engorged but there is no pulmonary edema. Right transjugular central venous infusion catheter ends close to the superior cavoatrial junction. Radiology Report EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman s/p chest tube with new dyspnea// chest tube placement, effusion interval change? TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ FINDINGS: There is a stable loculated left hydropneumothorax with left lung base atelectasis. Stable appearance of the right lung. The cardiomediastinal silhouette is unchanged. A right Port-A-Cath terminates at the cavoatrial junction. Left chest tube is in stable position. IMPRESSION: No significant interval change. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman h/o PE on xarelto and metastaticmucinous adenocarcinoma of unknown primary with peritonealcarcinomatosis and malignant ascites currently on palliativecarbo/taxol admitted for massive, loculated left-sided pleural. s/p chest tubeeffusion.// please evaluate pleural effusion, ?trapped lung TECHNIQUE: multi detector CT of the chest was performed without the administration of intravenous contrast. Axial, coronal, sagittal and maximum intensity reconstructions were acquired. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 37.4 cm; CTDIvol = 12.5 mGy (Body) DLP = 459.0 mGy-cm. Total DLP (Body) = 459 mGy-cm. COMPARISON: no prior CT chest is available for comparisons. FINDINGS: The thyroid is unremarkable. There are no enlarged axillary lymph nodes. Right-sided Port-A-Cath tip projects to the SVC. Heart size is normal. There is no pericardial effusion. There is a small pericardial effusion. There is a small to moderate loculated left pleural effusion with the larger component loculated anteriorly of a from the tip of the pigtail catheter. There is a small left-sided pneumothorax. There is also mild associated pleural thickening and subsegmental atelectasis in the lingula and left lower lobe. Pockets of air extend along the fissure. There is also of small right pleural effusion with subsegmental atelectasis in the right lung base. There are several ___ concerning for metastasis. Mm scattered pulmonary nodules throughout the right lung she Review of bones shows degenerative changes involving the thoracic spine. Limited sections through the upper abdomen shows gallstones. There is high-density ascites. IMPRESSION: Loculated left hydro pneumothorax. Left-sided chest tube in place. Small right pleural effusion. Several scattered pulmonary nodules ranging in size from 2-4 mm throughout the right lung concerning for metastasis. High-density ascites, consistent with known peritoneal carcinomatosis. Right-sided Port-A-Cath with its tip in the SVC. Gallstones Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with massive pleural effusion, now s/p chest tube removal// effusion interval change effusion interval change IMPRESSION: Right Port-A-Cath catheter tip is at the level of lower SVC. Small bilateral pleural effusions are unchanged. Left pigtail catheter has been removed. Minimal 80 basal loculated most likely pneumothorax and small left apical pneumothorax are unchanged as well as left basal opacification. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman w/malignant effusion s/p CT removal// please eval interval change please eval interval change IMPRESSION: Right Port-A-Cath catheter tip is at the level of lower SVC. Left pleural effusion is moderate. Minimal left basal pneumothorax is unchanged. Interval slight increase in left pleural effusion is suspected. Small right pleural effusion is unchanged. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with sob hx metastain malignany and PE// ? recurrent PE 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: Total DLP (Body) = 409 mGy-cm. COMPARISON: Chest CT from ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus except in the right lung base where assessment of the subsegmental pulmonary arteries is limited due to respiratory motion. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma.. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. The mediastinum is shifted rightward by the large left pleural effusion. PLEURAL SPACES: Small nonhemorrhagic right pleural effusion. Massive left pleural effusion, grown from ___, is likely low-density in nonhemorrhagic although somewhat heterogeneous and loculated. LUNGS/AIRWAYS: There is near complete collapse of the left lower lobe substantial atelectasis in the left upper lobe adjacent to the pleural effusion. Mild atelectasis in the right lung base adjacent to the pleural effusion. The airways are patent to the subsegmental level bilaterally. BASE OF NECK: In the right lobe of the thyroid, an 8 mm hypodensities compatible with a thyroid nodule. ABDOMEN: A hiatal hernia is small. Cholelithiasis are present in the gallbladder without evidence of cholecystitis. A 2.4 x 1.6 cm hypodense structure along the medial border of the inferior vena cava may be related to the patients underlying malignancy (2:96, 601:31). Small volume nonhemorrhagic ascites is loculated. The remaining included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. Degenerative changes are present in the spine. IMPRESSION: 1. Massive left pleural effusion, grown since ___, loculated and heterogeneous which may suggest malignant involvement. Near complete collapse of the left lower lobe and substantial atelectasis in the left upper lobe. 2. No evidence of pulmonary embolism or acute aortic abnormality. 3. Small right pleural effusion and small volume loculated ascites. 4. 2.4 x 1.6 cm hypodense structure in the medial border of the inferior vena cava may represent loculated fluid or otherwise be related to the patients underlying malignancy 5. 8 mm right thyroid nodule, could be assessed by dedicated thyroid US if clinically indicated. 6. Cholelithiasis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:42 pm, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with left pleueral effusion// s/p chest tube placement IMPRESSION: In comparison with the study ___, there is a substantial increase in the degree of left pleural effusion with a chest tube in place. Gas density above the effusion laterally suggests that this may represent a loculated hydropneumothorax. If clinically possible, a lateral view would be most helpful for further evaluation. Right IJ central catheter extends to about the cavoatrial junction. Continued enlargement of the cardiac silhouette with mild vascular congestion and possible small right effusion. Radiology Report EXAMINATION: Portable AP chest radiograph. INDICATION: ___ year old woman w/ left pleural effusion s/p chest tube placement on ___// chest tube positioning. TECHNIQUE: AP chest x-ray COMPARISON: Prior chest radiograph dated ___. FINDINGS: Right-sided Port-A-Cath remains in place in the cavoatrial junction. Left chest tube remains position in the left lower lung. There has been a moderate reduction in size of the left loculated hydro pneumothorax, with residual air tracking to the left apex, which is improved from previous. The pulmonary vascular congestion and cardiomediastinal silhouette appears mildly improved. IMPRESSION: Moderate reduction in the size of left loculated hydro pneumothorax. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Pleural effusion, not elsewhere classified temperature: 98.2 heartrate: 107.0 resprate: nan o2sat: 95.0 sbp: 103.0 dbp: 52.0 level of pain: 0 level of acuity: 2.0

___ woman with PMH of pulmonary embolism on rivaroxaban, hypertension, hyperlipidemia, type II diabetes, and metastatic mucinous adenocarcinoma of unknown primary with peritoneal carcinomatosis and malignant ascites currently on palliative ___ who presented for worsening fatigue and dyspnea and discovered to have massive left pleural effusion. Underwent chest tube drainage with unsuccessful conversion to tunneled catheter. Pathology consistent with known adenocarcinoma. Plan for outpatient follow up with interventional pulmonary to re-attempt PleurX in ___ weeks. # MASSIVE LEFT PLEURAL EFFUSION Presented for chief complaint of worsening fatigue and dyspnea. Underwent CTA chest notable for massive left pleural effusion with near collapse of the left lower lobe. No PE visualized. Underwent chest tube placement ___ with bloody, exudative effusion and cytology notable for malignant cells. Remained in place for three days with interval improvement in pleural effusion size. Chest tube later removed with intent for tunneled catheter placement however this was unsuccessful due to complexity of the space and concern for trapped lung. Underwent repeat CT chest that demonstrated persistent loculated hydropneumothorax, improved in size. Remained completely asymptomatic from respiratory standpoint with good O2 saturation over course of hospitalization. Discharged with plan for interventional pulmonary outpatient follow up for consideration of PleurX at that time. # SINUS TACHYCARDIA: Noted to have persistent sinus tachycardia to 100-130s, up to 150s on occasion with exertion. Review of records suggests this has been ongoing issue. No response to fluid bolus, pRBC transfusion (s/p 1U pRBCs ___. CXR stable. CT chest without pericardial effusion and pulsus normal. Echo reassuring. Minimal pain. Possibly rebound from holding home atenolol (in setting of borderline hypotension) however this would likely have dissipated over length of admission. Trialed low-dose fractionated metoprolol however this caused worsening orthostasis and was discontinued. Remained hemodynamically stable other than persistent tachycardia. Did not resume atenolol at discharge given SBP 100s. Overall possibly due to widely metastatic disease though no clear diagnosis. # METASTATIC MUCINOUS ADENOCARCINOMA OF UNKNOWN PRIMARY History of peritoneal carcinomatosis and malignant ascites. On palliative ___ (last dose C1, W3, ___. # ASYMPTOMATIC BACTERURIA: UA with bacteria but patient asymptomatic. Given CTX in the ED but discontinued given absence of symptoms. Repeat UA negative. # HX PULMONARY EMBOLISM: History of multiple LLL PEs in ___. Rivaroxaban held for chest tube procedure with heparin bridge. Resumed at discharge. # ANEMIA: Stable. On Procrit as outpatient. No evidence of active bleeding. s/p 1U pRBCs on ___ for tachycardia in case this was evidence of symptomatic anemia. Appropriate rise in Hgb. # HYPERTENSION: Held home atenolol and lisinopril given borderline hypotension during admission. # CKD STAGE 3: Baseline Cr 0.9-1.1. # HYPERLIPIDEMIA: - simvastatin # PSYCH: - duloxetine TRANSITIONAL ISSUES =========================== [ ] Attempted PleurX catheter placement at bedside was unsuccessful due to complex anatomy and concern for trapped lung. Will follow up with interventional pulmonary in ___ weeks to re-consider. IP office will contact patient. [ ] Persistent sinus tachycardia to 100-130s. Extensive workup (discussed above) was unremarkable. Most likely due to widely metastatic disease; otherwise hemodynamically stable. Discontinued atenolol given SBP 100-110s. [ ] Consider discontinuing omeprazole unless strong patient preference. Notable that patient is requiring magnesium supplements. [ ] Held lisinopril at discharge for SBPs in 100-110s. [ ] CTA notable for incidental 8 mm right thyroid nodule, could be assessed by dedicated thyroid US if clinically indicated. #CODE: full (confirmed) #CONTACT: ___ (daughter/HCP) ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: latex / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: L pilon fracture Major Surgical or Invasive Procedure: ___: ORIF L pilon fracture History of Present Illness: ___ with PMH CAD, DM on insulin, who tripped over her dog earlier this afternoon, sustaining a twisting moment to her left ankle. Denies syncopal episode, LOC or headstrike. Was taken to ___ where she was found to have an ankle fracture and was transferred here for further care. Reports no pain anywhere other than left ankle. Otherwise has been in her normal state of health, no active medical problems. Past Medical History: CABG (3-vessel) in ___, chronic back pain (occasional oxycodone PRN), IDDM Social History: ___ Family History: Non-contributory Physical Exam: No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended Splint in place, clean, dry, and intact Left lower extremity fires ___ Left lower extremity SILT sural, saphenous, superficial peroneal, deep peroneal and tibial distributions Left lower extremity dorsalis pedis pulse 2+ with distal digits warm and well perfused Pertinent Results: Xray ankle ___: Intraoperative fluoroscopic spot films are submitted is documentation of procedure performed under imaging guidance with our radiologist in attendance. Xray ankle ___: Distal tibial and fibular fractures with posterior subluxation of the talus. CT ___ ___: 1. Comminuted distal fibular fragment with large butterfly fragment displaced anteriorly. 2. Comminuted intraarticular fracture of the distal tibia and tibial plafond with distraction of the posterior malleolus creating a gap in the articular surface. There is severe posterior subluxation of the talus in relation to the largest tibial plafond fracture fragment. 3. There is a transverse component of the tibial fracture through the medial malleolus with mild widening of the anterior aspect of the medial ankle joint. 4. Equivocal small avulsion or impaction fracture of the posterior lateral body of the talus and lucency in the posterior medial aspect of the talus may be artifact versus nondisplaced fracture. 5. Incidental small focus of chondroid matrix and distal medial femur, likely enchondroma. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: ___ with tib/fib pilon fracture. TECHNIQUE: Frontal and lateral views of the tibia/fibula and frontal, lateral, and oblique views of the ankle COMPARISON: Outside ankle radiographs from earlier the same day FINDINGS: Overlying cast somewhat limits evaluation. Compared with earlier today, no significant changes detected. Again seen are the intra-articular, longitudinally oriented fracture of the distal tibia and the comminuted fracture of the distal fibular diaphysis. The talus is posteriorly subluxed with regards to the tibia. IMPRESSION: Distal tibial and fibular fractures with posterior subluxation of the talus. Radiology Report EXAMINATION: CT LOW EXT W/O C LEFT INDICATION: ___ with tib/fib pilon fracture. Evaluate tibia, fibula, foot, and ankle joint space. No need for femur evaluation. // ___ with tib/fib pilon fracture. Evaluate tibia, fibula, foot, and ankle joint space. No need for femur evaluation. ___ with tib/fib pilon fracture. Evaluate tibia, fibula, foot, and ankle joint space. No need for femur evaluation. TECHNIQUE: 2.5 mm axial images were obtained through the left lower extremity without intravenous contrast. Coronal and sagittal reformats. DOSE: DLP: 696.19mGy/cm COMPARISON: Tibia and fibula radiograph ___ and left ankle and foot radiograph from outside hospital ___ FINDINGS: There is a comminuted fracture of the distal fibular diaphysis extending to the anterior aspect of the lateral malleolus with a large butterfly fragment seen displaced anteriorly and mildly angulated. There is a comminuted predominantly vertically oriented fracture of the distal tibia extending from the mid diaphysis to the tibial plafond with distraction of the fracture fragments (posterior malleolus) at the articular surface. There is a gap in the articular surface measuring up 9 mm in AP dimension (series 2, and 0.60). In addition, there is a transverse fracture through the medial malleolus. There is severe posterior subluxation of the talus in relation to the larger fracture fragment of the tibial plafond. The lateral and medial aspect of the ankle mortise remains in articulation with mild widening of the anterior aspect of the medial ankle joint space (series 2, image 173). There is a predominantly vertically oriented lucency in the posterior medial aspect of the talus which may represent artifact versus nondisplaced fracture (series 400bH, image 25). In addition, there is minimal irregularity of the posterior lateral talar cortex, may represent small impaction or avulsion injury (series 400bH, series 32 and 401bG, series 38-39). The subtalar joints are preserved. Small osseous fragments along the medial aspect of the navicular bone, likely small ossicles (series 2K, image 183). There is a small foci of air in the syndesmosis interval (series 3, image 152). There is mild soft tissue edema most prominent along the lateral aspect of the ankle. The anterior extensor tendons, medial long flexor tendons, and peroneal tendons are grossly intact without evidence of entrapment. The Achilles tendon is intact. Incidental note is made of a rounded area of chondroid matrix in the distal medial femoral metaphysis, measuring 9 x 7 x 13 mm. IMPRESSION: 1. Comminuted distal fibular fragment with large butterfly fragment displaced anteriorly. 2. Comminuted intraarticular fracture of the distal tibia and tibial plafond with distraction of the posterior malleolus creating a gap in the articular surface. There is severe posterior subluxation of the talus in relation to the largest tibial plafond fracture fragment. 3. There is a transverse component of the tibial fracture through the medial malleolus with mild widening of the anterior aspect of the medial ankle joint. 4. Equivocal small avulsion or impaction fracture of the posterior lateral body of the talus and lucency in the posterior medial aspect of the talus may be artifact versus nondisplaced fracture. 5. Incidental small focus of chondroid matrix and distal medial femur, likely enchondroma. Radiology Report EXAMINATION: CHEST (PRE-OP PA AND LAT) INDICATION: Preop Surg: ___ (orif) COMPARISON: None available FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. Heart size is top-normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. Sternal wires are intact. IMPRESSION: No acute intrathoracic process. Radiology Report INDICATION: Intraoperative radiograph for surgical guidance. COMPARISON: None relevant FINDINGS: 60 Views of the left ankle obtained fluoroscopically. Fixation hardware is seen placed about the left ankle. Please refer to full operative note for further details. IMPRESSION: Intraoperative fluoroscopic spot films are submitted is documentation of invasive procedure performed under imaging guidance with our radiologist in attendance. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Tib/Fib Fracture Diagnosed with Displaced pilon fracture of left tibia, init for clos fx, Fall same lev from slip/trip w/o strike against object, init temperature: 98.1 heartrate: 77.0 resprate: 16.0 o2sat: 94.0 sbp: 166.0 dbp: 55.0 level of pain: 4 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 L pilon fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF L pilon fracture, 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 and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home 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 NWB in the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will 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: M Service: SURGERY Allergies: wheat / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: post-operative chills, nausea, shortness of breath Major Surgical or Invasive Procedure: None this admission. POD#3 ___ myotomy with partial fundoplication for type II achalasia History of Present Illness: Mr. ___ is a ___, who presented to the ED for subjective chills, nausea, and shortness of breath on POD#2 of ___ myotomy with partial fundoplication. He was discharged from ___ in stable condition the day prior, with adequate pain control, independent ambulation, voiding well, and tolerating regular diet with no nausea or vomiting. His discharge vitals were within normal limits. He received anticipatory guidance to return to the hospital if experiencing chills or nausea, and came to the ED. Past Medical History: ___ esophagus Colonic adenoma Sleep apnea w/home CPAP HTN Dysthymic disorder Varicose veins Obesity Cancer of bladder wall s/p surgery+chemo PSH: Right shoulder surgery Right axillary vein pseudoaneurysm repair Umbillical hernia repair Transurethral bladder tumor excision Social History: ___ Family History: Father - cancer Mother - breast cancer, HTN, phlebitis Sister - ___ esophagus Maternal grandfather - cancer Physical ___: Gen: AAOx3, NAD, appears comfortable HEENT: MMM, no scleral icterus Resp: nl effort, CTABL, no wheezes/rales/rhonchi CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops Abd: +BS, soft, obese, ND, appropriately tender to palpation Port site incisions C/D/I with steristrips Ext: no edema, 2+ DP Pertinent Results: ___ 10:43AM WBC-8.6 RBC-4.83 HGB-14.1 HCT-41.8 MCV-87 MCH-29.2 MCHC-33.7 RDW-12.5 RDWSD-39.7 ___ 12:35AM GLUCOSE-109* UREA N-15 CREAT-0.9 SODIUM-136 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15 Medications on Admission: Sucralfate 100 mg/mL - 1gm bid Ranitidine 300 mg qhs Triamterene-HCTZ 37.5 mg / 25 mg qd Lisinopril 20 mg qd pantoprazole 40 mg bid escitalopram oxalate (LEXAPRO) 20 mg qd Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Docusate Sodium 100 mg PO BID 4. Escitalopram Oxalate 20 mg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Nicotine Patch 21 mg TD DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. Pantoprazole 40 mg PO Q24H 9. Ranitidine 300 mg PO QHS 10. Senna 8.6 mg PO BID 11. Sucralfate 1 gm PO DAILY 12. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Home Discharge Diagnosis: Post-operative chills, nausea, shortness of breath Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with weakness s/p ___ // eval for acute process TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: Bilateral pleural effusion is small. There is no pneumothorax. Linear opacity is identified in the left lower lobe. There is bilateral increased perihilar interstitial markings. Cardiac silhouette is mildly enlarged. IMPRESSION: Linear opacity in the left lower lobe is probably atelectasis. Small bilateral pleural effusions. Radiology Report INDICATION: ___ year old man with s/p lap ___ myotomy and Dor fundoplication // please perform water-soluble swallow study to eval for leak TECHNIQUE: Single contrast upper GI. DOSE: Acc air kerma: 101 mGy; Accum DAP: 1446 uGym2; Fluoro time: 1 min 13 seconds COMPARISON: Chest radiograph ___ FINDINGS: Water-soluble contrast (Optiray) was administered. No evidence of leak is identified. Small amount of contrast passed into the stomach from the esophagus with the majority of contrast held up at the distal esophagus. IMPRESSION: No evidence of leak .Small amount of contrast passed into the stomach from the esophagus with the majority of contrast held up at the distal esophagus. Radiology Report INDICATION: ___ man status post esophagram. Evaluate for interval passage of contrast. TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Esophagram from ___. FINDINGS: There are no abnormally dilated loops of large or small bowel. Radiodense contrast is seen in the distal small bowel, ascending colon, and hepatic flexure. There is no contrast in the distal colon or rectum. There is no free intraperitoneal air. Degenerative changes throughout the spine. Osseous structures are otherwise unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Interval passage of contrast into the distal small bowel and proximal colon. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 98.3 heartrate: 65.0 resprate: 20.0 o2sat: 95.0 sbp: 132.0 dbp: 89.0 level of pain: 6 level of acuity: 2.0

Mr. ___ was admitted to the General Surgical Service on ___ for evaluation and treatment of post-operative chills, nausea, and shortness of breath. He is POD#2 of ___ myotomy with partial fundoplication and was discharge from the hospital in stable condition on POD#1. Testing in the ED with an UGI and KUB revealed that he did not have a leak at the myotomy, and that contrast was passing reasonably well into the small bowel and proximal colon. He was afebrile, with a WBC wnl. His nausea and shortness of breath resolved spontaneously, although he had Zofran and albuterol ordered PRN for symptomatic relief. Throughout his stay, Mr. ___ remained nutritionally supported with regular diet without bread. He was able to tolerate oral pain medication oxycodone. At the time of discharge his diet included regular diet without bread. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin during this stay. At the time of discharge, Mr. ___ was doing well, afebrile with stable vital signs. He was tolerating diet as above per oral, ambulating, voiding without assistance, and pain was well controlled. He was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Tylenol / acetaminophen Attending: ___. Chief Complaint: hemoptysis/right pneumothorax Major Surgical or Invasive Procedure: removal of chest tube History of Present Illness: This is a case of ___ year old male patient presenting to ___ as transfer from ___ Family with R pneumothorax s/p chest tube placement at ___. Pt had CT guided right upper lobe biopsy 4 days ago for lung nodules. Since then pt has been having intermittent hemoptysis with cough (measuring as tea spoon) and SOB with DOE. The blood has been increasing in amount over the last 2 days until he went to OSH today where he was found to have 50% ptx thus he got the chest tube placed. He denies any nausea/vomiting, chest pain, fever/chills, weight loss, and no other complaints. Past Medical History: BRAIN ANEURYSM TOBACCO ABUSE BACK PAIN NECK PAIN R HEAD PAIN R FACIAL NUMBNES FACIAL PAIN FATIGUE LUNG NODULES PSH: ___: R Craniotomy for clipping of ACOMM aneurysm ___: Diagnostic cerebral angiogram corrective foot surgery at ___ yrs old Social History: ___ Family History: NC Physical Exam: Admit PE: Temp:98.4 HR:86 BP:120/76 RR:18 O2 Sat:96%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: Right Chest Tube in place CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: Discharge PE: Vitals: Temp 99.2 PO, BP 109/46, HR 94, RR 20, O2sat 96% RA Gen: A&O, NAD, resting comfortable in bed, ambulatory for several days including previously with chest tube now removed CV: RRR Pulm: no increased WOB, CTAB, chest tube site on right upper lateral chest is clean and dry, closed, no drainage, erythema, or induration Abd: soft, NT/ND Ext: WWP, no CCE Pertinent Results: CHEST (PA & LAT) Study Date of ___ 9:22 AM: The tiny right apical pneumothorax seen previously has resolved. Cardiomediastinal silhouette is within normal limits. There has been improved aeration at the left base however there remains some atelectasis. No definite consolidation are seen. Medications on Admission: BACLOFEN - baclofen 10 mg tablet. 1 tablet(s) by mouth one in the am, one at 2P and 2 at bedtime - (Prescribed by Other Provider) GABAPENTIN [NEURONTIN] - Neurontin 600 mg tablet. 1 tablet(s) by mouth three times per day - (Prescribed by Other Provider) OXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth three times a day as needed for pain - (Prescribed by Other Provider) PREGABALIN [LYRICA] - Lyrica 150 mg capsule. capsule(s) by mouth twice a day - (Prescribed by Other Provider) (Not Taking as Prescribed: pt states no longer taking) Discharge Medications: 1. Baclofen 10 mg PO TID 2. Docusate Sodium 100 mg PO TID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. Gabapentin 600 mg PO TID 4. Pregabalin 150 mg PO BID 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: right pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph. . INDICATION: ___ with 50% pneumothorax s/p lung biopsy, s/p CT placed at OSH TECHNIQUE: AP upright view of the chest. COMPARISON: Chest radiograph ___. PET-CT ___. CT interventional procedure images ___. FINDINGS: The cardiomediastinal contours are normal. There is no large pleural effusion. A right chest tube is present, terminating at the right lung apex. There is no definite residual pneumothorax. The lungs are well-expanded. Increased haziness at the right lower lobe and left hilum may represent postprocedural changes and underlying nodule. There is no focal consolidation concerning for pneumonia. Soft tissue gas along the right upper lateral chest wall is second to chest tube placement. IMPRESSION: 1. Right chest tube with tip terminating in the right apex. No definite residual pneumothorax. 2. Haziness in the right lower lung and left hilum may be post procedural and underlying nodule. Attention on follow-up is recommended. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with pnx // follow on right pnx, morning date of ___ IMPRESSION: In comparison to prior radiograph of 1 day earlier, a right chest tube remains in place, with a probable tiny right apical pneumothorax. Exam is otherwise similar to the recent study except for worsening atelectasis the left lung base and development of a small left pleural effusion. Radiology Report INDICATION: ___ M w/ hx of RLL/RML lung mass c/f lung cancer with 1 wk hx dyspnea, hemoptysis after CT guided lung biopsy, 50% ptx s/p CT placement at OSH ED. // Please eval for pneumothorax, Chest tube clamp trial COMPARISON: Radiographs from ___ at 09:04. IMPRESSION: There is a right-sided chest tube with distal tip is at the apex. No definite pneumothorax is seen. There is some atelectasis at the lung bases, unchanged. Heart size is within normal limits. Radiology Report INDICATION: ___ M w/ hx of RLL/RML lung mass c/f lung cancer with 1 wk hx dyspnea, hemoptysis after CT guided lung biopsy, 50% ptx s/p CT placement at OSH ED // Please eval for interval change COMPARISON: Radiographs from ___ IMPRESSION: The tiny right apical pneumothorax seen previously has resolved. Cardiomediastinal silhouette is within normal limits. There has been improved aeration at the left base however there remains some atelectasis. No definite consolidation are seen. Radiology Report INDICATION: ___ year old man with chest tube removal // ?pneumothorax COMPARISON: Radiographs from ___ at 18:37. IMPRESSION: There has been removal of the right-sided chest tube. There is a very tiny right apical pneumothorax. There has been improvement of the subcutaneous emphysema along the right lateral chest wall. There is atelectasis at the left base with elevation of left hemidiaphragm. Heart size is within normal limits. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Pneumothorax Diagnosed with Pneumothorax, unspecified temperature: 99.0 heartrate: 74.0 resprate: 18.0 o2sat: 100.0 sbp: 124.0 dbp: 76.0 level of pain: 3 level of acuity: 2.0

Mr. ___ is a ___ year-old male who underwent CT guided right upper lobe biopsy on ___ for lung nodules (RUL, 18G core, per procedural note - parenchymal bleeding noted). He subsequently had persistent intermittent hemoptysis (non-massive - 35-50cc per day) and gradual worsening of SOB and DOE. He initially presented to OSH ED and was found to have a right pneumothorax. A right chest tube was placed and the patient as transferred to ___ for further management ___. IP was consulted for bronchoscopy given the patient's hemoptysis. However, flexible bronchoscopy was deferred given rapid improvement/resolution of hemoptysis without intervention. The patients chest tube was initially kept to WS and chest films reveal interval resolution of his small apical pneumothorax. His chest tube was clamped for 6 hours without interval development of expanding pneumothorax. His chest tube was removed ___ and post-up films demonstrated tiny right apical pneumothorax with subsequent resolution the morning of ___. The patient was discharged home in stable condition with clinic follow-up and CXR scheduled for ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: V Tach arrest Major Surgical or Invasive Procedure: ___: cardiac cath for ICD lead extraction History of Present Illness: Mr. ___ is a ___ male with cardiac history significant for CAD (anteroseptal MI s/p LAD ___, s/p stent left posterior descending and OM in ___, systolic heart failure (EF ___, inducible sustained VT s/p ICD ___. Today, patient was in his usual state of health until he was shocked ten times by his device before becoming unresponsive. EMS was called and found him in pulseless ventricular tachcyardia. He was subsequently defibrillated into normal sinus rhythm with normal mental status and brought to ___ ED where he was given amiodarone 150mg IV x1 and then started on a 1mg/min amiodarone drip. He was then transferred to ___ for EP evaluation. On arrival to ___ ED, he was in stable in sinus rhythm. In the ED, initial vitals were 97.8 68 106/57 18 98% 4LNC. He was continued on amiodarone drip. Labs significant for K 4.5, Mg 2.2 and INR of 3.1 and trop 0.01. EP evaluation/interrogation of device revealed lead fracture. Patient was not in VT and had inappropriate shocks, which put him into VT, at which point he was found pulseless by EMS and shocked externally. ICD was turned off in the ED. EP team advised admission and stopping coumadin. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: 1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CAD s/p anteroseptal MI ___ LAD stenting ___ LPDA/OM stenting ___ - PACING/ICD: DDD-ICD (placed ___, generator changed ___ - LV dysfunction: EF ___ - Apical aneurysm - Paroxysmal atrial fibrillation, on coumadin 3. OTHER PAST MEDICAL HISTORY: Right inguinal hernia repair Left inguinal hernia repair Tendon laceration-hand GI bleed -in records, pt's wife denies ___ arthritis Social History: ___ Family History: Mother had cancer. Father died from ALS. Sister, brother and nephew have all died from ALS. Physical Exam: ADMISSION EXAM: =============== VS: T=97.8 BP=119/77 HR=60 RR=18 O2 sat= 98%RA Weight: 71.4 kg General: NAD, A&Ox3, comfortable HEENT: NCAT, EOMi Neck: Supple, no JVD CV: RRR, normal S1 S2, no murmurs Lungs: bibasilar crackles Abdomen: soft, NTND Ext: no lower extremity edema Neuro: CN grossly intact. Moves all extremities PULSES: 2+ DP bilaterally DISCHARGE EXAM: =============== VS: Temp=98 HR=110 (afib) BP=103/69 RR=22 O2 sat=96% RA General: NAD, A&Ox3, comfortable HEENT: NCAT, EOMI, pupils equal and reactive to light, no facial droop Neck: Supple, no JVD CV: RRR, normal S1 S2, no murmurs Lungs: faint bibasilar crackles Abdomen: soft, NTND Ext: no lower extremity edema Neuro: CN II-12 intact. ___ strenght grossly in all extremeties PULSES: 2+ DP bilaterally Pertinent Results: ADMISSION LABS: ================ ___ 05:45PM BLOOD WBC-9.3 RBC-3.92* Hgb-12.5* Hct-38.1* MCV-97 MCH-32.0 MCHC-32.9 RDW-11.7 Plt ___ ___ 05:45PM BLOOD Neuts-87.0* Lymphs-6.9* Monos-5.3 Eos-0.3 Baso-0.5 ___ 05:45PM BLOOD ___ PTT-32.7 ___ ___ 05:45PM BLOOD Glucose-129* UreaN-18 Creat-0.9 Na-140 K-4.5 Cl-103 HCO3-25 AnGap-17 ___ 05:45PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2 IMAGING AND STUDIES: ===================== PPM Interrogation ___: Elevated threshold for RV pacing at 3.0 V at 0.5 ms. ___ voltage lead impedance revealed recent jump from ~40 ohms to > 200 ohms since ___. RV pace impedance appears to have also oscillated over the past 12 months. Interrogation episode log reveals ___ frequency, non-physiology signals in the RV lead beginning on ___. On ___ the patient had a series ofhigh frequency activity leading to triggering of ATP. On ___ the patient had numerous episodes of ___ frequency, non physiologic activity in the RV lead. On one occasion (presumably time of arrest) ___ frequency activity falling in the VF zone resulted in triggering of ICD discharge. Following this shock there appears to be induction of monomorphic VT or VF, however, subsequent shocks from the device fail to terminate ventricular arrhythmia. Since ICD discharge there have been further episodes of ___ frequency activity, though they have not resulted in tachy therapies. TTE Echocardiogram ___: Conclusions The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with akinesis of the distal segments and an aneurysmal apex with mild dyskinesis. There is mild hypokinesis of the remaining segments (LVEF = 25 %). [Intrinsice left ventricular systolic function may be more depressed given the severity of mitral regurgitation.] No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Left ventricular cavity dilation with extensive regional and global systolic dysfunction c/w multivessel CAD or other diffuse process. Moderate mitral regurgitation. Pulmonary artery hypertension. Right ventricular cavity dilation with free wall hypokinesis. Increased PCWP. CT head, CTA head and neck, CT perfusion ___: IMPRESSION: Noncontrast head CT demonstrates subtle hyperdensity in the left parietal region suggestive of an acute infarct. No intracranial hemorrhage. CT perfusion demonstrates increase in mean transit time and decrease in cerebral blood flow in the left parietal region without decrease in cerebralblood volume. Findings are indicative of ischemia in this region, butambiguous in regards to completed infarction. However, given the hypodensityon the noncontrast head CT favor infarction. There is moderate stenosis at the origin of the left vertebral artery. The head and neck CTA is otherwise unremarkable without evidence of significant stenosis, aneurysm or dissection. ___ ECHO: Focused exam: The left atrium is mildly dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. The left atrial appendage emptying velocity is depressed (<0.2m/s). A definite thrombus is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is moderately depressed. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a very small pericardial effusion. Thrombus in RA from ICD lead noted - not mobile, not indicative of vegetation echocardiographically. Post procedure: left and right heart structure and function remain unchanged. No tamponade or worsening of pericardial effusion seen. New leads seen in situ. No rigth ventricular perforation noted. ___ CXR: In comparison with study of ___, the pacer leads extend to the region of the right atrium and apex of the right ventricle. Continued enlargement of the cardiac silhouette without definite vascular congestion. Atelectatic changes are seen at the left base. MICROBIOLOGY: ============= Urine ___: mixed bacteria c/w skin flora DISCHARGE LABS: =============== ___ 09:14AM BLOOD Hct-33.5* ___ 04:46AM BLOOD Hct-30.0* ___ 03:52AM BLOOD WBC-9.5 RBC-3.13* Hgb-9.5* Hct-30.8* MCV-98 MCH-30.4 MCHC-31.0 RDW-12.4 Plt ___ ___ 03:52AM BLOOD Plt ___ ___ 03:52AM BLOOD Glucose-98 UreaN-20 Creat-0.8 Na-138 K-3.6 Cl-107 HCO3-24 AnGap-11 ___ 03:52AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Amlodipine 2.5 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Hydroxychloroquine Sulfate 200 mg PO BID 8. Metoprolol Succinate XL 12.5 mg PO BID 9. Warfarin 2.5 mg PO 3X/WEEK (___) 10. Warfarin 1.25 mg PO 4X/WEEK (___) 11. Pravastatin 40 mg PO HS 12. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral daily 13. Amoxicillin 500 mg PO Q8H Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Hydroxychloroquine Sulfate 200 mg PO BID 3. Pravastatin 40 mg PO HS 4. PredniSONE 5 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral daily 6. Furosemide 20 mg PO EVERY OTHER DAY 7. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg One tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Rivaroxaban 20 mg PO DINNER RX *rivaroxaban [Xarelto] 20 mg One tablet(s) by mouth QHS with dinner Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: # Primary: Ventricular tachycardia arrest, Stroke # Secondary: Paroxysmal atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Ventricular tachycardia, AICD defibrillation. TECHNIQUE: Portable upright AP view of the chest. COMPARISON: ___. FINDINGS: Left-sided AICD device is re- demonstrated with leads in the right atrium and right ventricle, unchanged. Heart size is mildly enlarged. Mediastinal and hilar contours are unremarkable. Lung volumes are low with minimal retrocardiac atelectasis noted. No pleural effusion, pulmonary edema or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Unchanged position of the AICD leads. Radiology Report EXAMINATION: CTA HEAD AND NECK WITH PERFUSION INDICATION: ___ year old man with sCHF and LV aneurysm now with word finding difficultiesand right sided deficits // Code Stroke, please complete CT head non-con, CTA head and CTA neck TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial images were obtained through the head and neck using CTA protocol after the uneventful administration of 110 cc of Omnipaque intravenous contrast. Curve reformats, volume rendered reformations and maximum intensity projection images were generated on an independent workstation. In addition, CT perfusion was performed with blood flow, blood volume and mean transit time maps created on an independent workstation. DOSE: DLP: 3739.61 mGy-cm COMPARISON: None. FINDINGS: CT HEAD: There is subtle hypodensity in the left parietal region suggestive of an acute infarct. There is no hemorrhage or mass effect. The ventricles and sulci are normal in caliber and configuration. There are nonspecific periventricular and subcortical white matter hypodensities, likely sequela of chronic small vessel ischemic disease. The orbits, and paranasal sinuses are unremarkable. There is a small amount of fluid within the left mastoid air cells. CT PEFUSION: There is mild decrease in cerebral blood flow and increase in mean transit time in the left parietal region. The cerebral blood volume is preserved in this area. HEAD AND NECK CTA: There is minimal calcified atherosclerotic disease of the intracranial ICAs, but without significant stenosis. The anterior, and middle cerebral arteries are unremarkable. The posterior communicating arteries are not identified. The posterior circulation is otherwise unremarkable. There is a normal 3 vessel left-sided aortic arch. The common carotid, internal carotid and external carotid arteries are patent without evidence of significant stenosis based on NASCET criteria. There is minimal calcified atherosclerotic disease of the carotid bifurcations bilaterally. There is moderate stenosis at the origin of of the left vertebral artery. The right vertebral artery is unremarkable. There is minimal bilateral dependent atelectasis. IMPRESSION: Noncontrast head CT demonstrates subtle hyperdensity in the left parietal region suggestive of an acute infarct. No intracranial hemorrhage. CT perfusion demonstrates increase in mean transit time and decrease in cerebral blood flow in the left parietal region without decrease in cerebral blood volume. Findings are indicative of ischemia in this region, but ambiguous in regards to completed infarction. However, given the hypodensity on the noncontrast head CT favor infarction. There is moderate stenosis at the origin of the left vertebral artery. The head and neck CTA is otherwise unremarkable without evidence of significant stenosis, aneurysm or dissection. Case discussed with Dr. ___ by Dr. ___ telephone at 14:19h, on ___, immediately after the findings were made. Radiology Report INDICATION: CHF, AFib, ICD, new stroke, increased white blood cell count, evaluate for pneumonia. COMPARISON: ___. FINDINGS: AP and portable view of the chest. There is new diffuse hazy opacities in lungs bilaterally and also increase in fullness of the hila bilaterally, which may represent new pulmonary vascular congestion. No pleural effusions. No pneumothorax. A small retrocardiac opacity appears to be slightly increased in size, may represent atelectasis or pneumonia. A left-sided ICD is in appropriate position. IMPRESSION: Slight increase in mild pulmonary vascular congestion. Retrocardiac opacity is slightly increased in size and may represent atelectasis or possibly early pneumonia. Radiology Report CHEST RADIOGRAPH INDICATION: Status post right internal jugular vein placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, no relevant change is seen. The patient has received a right internal jugular vein catheter. The course of the catheter is unremarkable, the tip of the catheter projects over the lower SVC. No evidence of complications, notably no pneumothorax. The parenchymal changes and the borderline size of the cardiac silhouette are constant in appearance. Radiology Report AP CHEST, 7:23 P.M., ___ HISTORY: A ___ man after lead extraction. Evaluate possible pneumo- or hemothorax. IMPRESSION: AP chest compared to ___: No pneumothorax, hemothorax, mediastinal widening. Right jugular line ends in the upper-to-mid SVC. Transvenous right atrial and right ventricular pacer defibrillator lead are in standard placements. Mild-to-moderate cardiomegaly stable. Pulmonary vasculature mildly engorged, no edema or appreciable pleural effusion. Radiology Report HISTORY: Lead position. FINDINGS: In comparison with study of ___, the pacer leads extend to the region of the right atrium and apex of the right ventricle. Continued enlargement of the cardiac silhouette without definite vascular congestion. Atelectatic changes are seen at the left base. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Cardiac arrest Diagnosed with SYNCOPE AND COLLAPSE temperature: 97.8 heartrate: 68.0 resprate: 18.0 o2sat: 98.0 sbp: 106.0 dbp: 57.0 level of pain: 0 level of acuity: 1.0

Mr. ___ is a ___ with PMHx of CAD (s/p PCI), sCHF (EF ___, inducible sustained VT s/p ICD ___, PAF on coumadin, presents after VT arrest due to ICD lead impedance complication. ACUTE ISSUES: ============= # Ventricular Tachycardia: Patient with lead malfunction which incorrectly sensed VT, delivered inappropriate shocks which put him into VT. There was not a lead fracture on CXR. The malfunction was thought due to an issue with lead impedance. He was temporarily on an amiodarone drip s/p VT, but was discontinued. On ___, the patient underwent sucsessful lead revision. Had small hematoma around ICD post-procedure; stable on discharge. To have follow up with EP next week. # Stroke: Found to have acute non-fluent aphasia and right facial droop with mild right sided weakness around 12:30 on routine nursing check. He could follow commands but speech was dysarthric and nonsensical. He was last seen well by the same nurse at 12:06. A CODE STROKE was called; Neurology evaluated the patient, and he underwent NCHCT and CTA Head & Neck that showed left MCA ischemia. Etiology of stroke thought most likely embolic from left atrial appendage clot later identified on ECHO in setting of paroxysmal atrial fibrillation. At time of CVA, INR was still 2.0, so patient was transitioned from coumadin to rivaroxaban. Had initial improvement in symptoms with supine positioning and with-holding blood pressure medications. However, later that evening the patient required dopamine to elevate his blood pressures in setting of recrudescence of symptoms with SBPs 90-100s. He was transfered to the CCU for further pressor administration. A central line was placed and he was transitioned from dopamine to norepinephrine, then to phenylephrine due to ectopy. He was kept on pressors for 48 hours and then weaned off, without recurrence of symptoms. Further blood pressure medications, other than metoprolol, were held on discharge to allow for continued permissive hypertension. CHRONIC ISSUES: =============== # Chronic systolic heart failure: Patient with ischemic cardiomyopathy with EF 25% on ECHO this admission, showing regional left ventricular systolic dysfunction with akinesis of the distal segments and an aneurysmal apex with mild dyskinesis. Continued home metoprolol, but held ___ in setting of permissive hypertension. Sent home on furosemide 20mg every other day. # Paroxysmal Atrial Fibrillation: Currently in sinus rhythm, but atrial fibrillation recurred later in his hospital stay. Admitted on warfarin, placed on heparin IV ___, and transitioned to rivaroxaban post-lead revision in setting of stroke and sub-therapeutic INR. # CAD: History of anteroseptal MI s/p LAD ___, s/p stent left posterior descending and OM in ___. Continued ASA and metoprolol, but held other BP lowering meds (losartan, imdur) in setting of recent stroke. # H/o LV aneurysm: ECHO this admission showed aneurysmal apex with mild dyskinesis. No thrombi in LV, but thrombus in RV and left atrial apendage. Discharged on rivaroxaban. # HLD: Continued home pravastatin. # HTN: Held home amlodipine and losartan in setting of permissive hypertension for recent stroke. # Cough: Being treated for pneumonia as outpatient with amoxicillin (started ___, finished seven days on ___. # Rheumatoid Arthritis: Patient restarted on prednisone 10mg as outpatient one month ago, tapered to 5mg one week ago. Continued home hydroxychloroquine and home prednisone.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Claritin / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Cardiac catheterization History of Present Illness: ___ yo M with CAD with NSTEMI in ___ s/p DES to LAD who presents with chest pain. Patient reports that he developed right-sided chest pain while shopping for groceries at 13:00. He denies radiation to jaw, shoulder, or back and associated shortness of breath, nausea, vomiting, diaphoresis, and pre-syncope. He describes the pain as a "gripping" sensation that was ___ in severity. Chest pain subsided without intervention after about 30 minutes. At 15:00, patient reports that pain occured again. This episode was entirely similar to initial chest pain. The patient called EMS. Per EMS, patient seemed to be hiding in his apartment, which was filthy. Patient was transported to ___. En route to ___, patient was given aspirin 324 mg and NTG which resulted in complete resolution of his chest pain. In the ED, initial vital signs were 98, 64, 163/85, 18, and 97% RA. Labs were remarkable for WBC 12.2, Cr 1.3, and troponin 0.05. Immediately after having labs drawn and prior to their return, patient left AMA. Patient was called back on discovery of the elevated troponin. He returned to the ED, where CXR showed no acute cardiopulmonary process. Patient was admitted to ___, with plan to hold on heparin gtt pending next set of cardiac biomarkers. On transfer, vital signs were 97.9, 66, 149/78, 16, 99% RA. On the floor, patient reports that he remains free of chest pain and that he feels completely well at this time. He denies fever, chills, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, and urinary symptoms. He is not sure why he has to be in the hospital. Review of Systems: As per HPI Past Medical History: - Hypertension - CAD with NSTEMI in ___ s/p DES to LAD - COPD not on oxygen - Chronic lymphocytic leukemia - Prostate cancer - DVT and PE in ___ - GERD - Raynaud's syndrome - Osteoarthritis of left knee - Osteoporosis - Spinal stenosis - Attention deficit disorder - Anxiety and depression Social History: ___ Family History: - Sister has a brain tumor. - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; father had colon cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7, 60, 146/78, 18, 94% RA GENERAL: Well appearing male in no distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated CARDIAC: RRR, nl S1/S2, no MRG LUNG: CTAB, no wheezes/rales/rhonchi ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: Warm, well-perfused, no cyanosis/clubbing/edema NEURO: AAOx3, CN II-XII grossly intact SKIN: No concerning lesions DISCHARGE PHYSICAL EXAM: Vitals: Tm 98.7, 133/67, 61, 20, 96%RA GENERAL: Well appearing male in no distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, No JVD CARDIAC: RRR, nl S1/S2, no MRG LUNG: CTAB, no wheezes/rales/rhonchi ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: Right femoral cath site intact, no edema NEURO: AAOx3, CN II-XII grossly intact Pertinent Results: === ADMISSION LABS ==== ___ 07:00PM BLOOD WBC-12.2* RBC-4.86 Hgb-14.4 Hct-43.8 MCV-90 MCH-29.7 MCHC-32.9 RDW-15.1 Plt ___ ___:00PM BLOOD Neuts-50.5 Lymphs-42.5* Monos-5.6 Eos-1.1 Baso-0.4 ___ 07:33PM BLOOD ___ PTT-29.5 ___ ___ 07:00PM BLOOD Glucose-98 UreaN-39* Creat-1.3* Na-141 K-4.8 Cl-103 HCO3-28 AnGap-15 ___ 11:00AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.6 === PERTINENT LABS === ___ 07:00PM BLOOD cTropnT-0.05* ___ 06:10AM BLOOD CK-MB-4 cTropnT-0.08* ___ 11:00AM BLOOD CK-MB-4 cTropnT-0.08* ___ 06:02AM BLOOD cTropnT-0.10* === DISCHARGE LABS === ___ 06:02AM BLOOD WBC-12.9* RBC-4.65 Hgb-14.1 Hct-41.2 MCV-88 MCH-30.4 MCHC-34.4 RDW-14.8 Plt ___ ___ 06:02AM BLOOD Glucose-88 UreaN-29* Creat-1.1 Na-138 K-4.6 Cl-100 HCO3-28 AnGap-15 === STUDIES === CARDIAC CATH (___): - LMCA: normal - LAD: proximal 30% smooth disease. The prior stents are widely patent. - Circumflex: 80% eccentric hazy mid lesion - RCA: normal - Outcome: Successful placement of DES in left circumflex Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Lorazepam 1.5 mg PO QHS insomnia 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN 7. DiphenhydrAMINE 25 mg PO QHS insomnia 8. Multivitamins 1 TAB PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. modafinil 200 mg oral BID 13. lisinopril-hydrochlorothiazide ___ mg oral As directed 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 15. AndroGel (testosterone) 1.25 gram/ actuation (1 %) transdermal 5 pumps daily Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Clopidogrel 75 mg PO DAILY 5. DiphenhydrAMINE 25 mg PO QHS insomnia 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN 7. Lorazepam 1.5 mg PO QHS insomnia 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. AndroGel (testosterone) 1.25 gram/ actuation (1 %) transdermal 5 pumps daily 12. lisinopril-hydrochlorothiazide ___ mg ORAL AS DIRECTED 13. modafinil 200 mg ORAL BID 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually Q5MIN Disp #*30 Tablet Refills:*0 15. Atorvastatin 80 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: NSTEMI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with chest pain. TECHNIQUE: Frontal and lateral chest radiographs were obtained with the patient in the upright position. COMPARISON: CT from ___ and radiograph from ___. FINDINGS: The lungs are hyperinflated and clear of focal consolidation, pleural effusion or pulmonary edema. There is atelectasis in the right lung base. The heart is normal in size, and mediastinal contours are stable. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by AMBULANCE AMBULANCE Chief complaint: Chest pain Elevated troponin Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS, HX VENOUS THROMBOSIS/EMBOLISM ABN CARDIOVASC STUDY NEC, HYPERTENSION NOS temperature: 97.9 98.0 heartrate: 64.0 64.0 resprate: 16.0 18.0 o2sat: 98.0 97.0 sbp: 158.0 163.0 dbp: 80.0 85.0 level of pain: 4 0 level of acuity: 2.0 2.0

___ year old male with hx of CAD with NSTEMI in ___ (s/p 2x DES to LAD) and ___ (s/p PTCA and balloon dilatation of 50% in-stent restenosis) who presented with chest pain on exertion and was found to have an NSTEMI. # NSTEMI: Patient with two episodes of chest pain the day of admission associated with exertion. Found to have elevated troponin of 0.05 in the ED without ischemic changes on EKG. He was subsequently diagnosed with an NSTEMI, started on a heparin gtt and admitted to ___ for further management. His troponin continued to trend upwards to 0.08. He underwent cardiac catheterization on ___ which revealed 80% eccentric hazy mid-lesion, LAD with proximal 30% smooth disease and widely patent prior stents, normal LMCA and RCA. A DES was placed in the left circumflex artery. Recommended continuation of aspirin indefinately and Plavix for a minimum of ___ year. He was continued on his home ASA 81mg and Plavix 75mg qday during his hospital stay. He declined to stay for inpatient ECHO to assess EF. ==== TRANSITIONAL ISSUES ==== # NSTEMI: - Patient has cardiology followup with ___. ___ on ___. - Will need outpatient ECHO (declined to remain in-house for this) # CODE STATUS: DNI/DNR (confirmed with patient on ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cozaar / Ace Inhibitors / Morphine / IV Dye, Iodine Containing Contrast Media Attending: ___ ___ Complaint: no urine output Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ PMHx DM, CAD s/p CABG, CHF (EF ___, CKD (Cr 2.0, recently in the 3s), recent admission for CHF exacerbation (___) requiring milrinone + lasix drips (discharge wt 81.6kg) presenting with decreased UOP. After recent hospitalization was discharged to ___, and then discharged home this past ___ no medication changes since discharge (remains on diuretic regimen of torsemide daily), but reports that on morning of presentation noticed decreased UOP. He took his usual 80mg PO torsemide this morning. He felt the need to urinate, but was unable to as he usually does. He was concerned that is kidneys were worsening in function and so he called the ED and was instructed to come into the ED. Denies dysuria/hematuria, decreased PO intake, dietary indiscretion (follows his fluid restriction diet, <1.5L/day); no CP, SOB/DOE, PND. At baseline, patient can walk from one telegraph pole to the next, but not further without feeling SOB. . In the ED, initial vitals were 98.2 67 149/57 16 100%. Exam notable for trace edema to mid-shin, 8cm JVD, lungs CTA, no abdominal/scrotal edema. Labs and imaging significant for Cr 2.4 (baseline reportedly ___, but has been low 3's most recently), Hct 28 (at baseline), K of 3.4. UA with WBCs, large leuks, and bacteria. CXR showed evidence of vascular engorgement. Patient took his home torsemide 80mg and after foley placement, put out 300cc to that. ECG showed AV pacing without ST elevations or depressions. ED discussed this pt with Dr. ___ recommended admission to ___. Vitals on transfer were T 97.1 °F (Oral), Pulse: 70, RR: 16, BP: 127/77, O2Sat: 98RA. . On arrival to the floor, patient states he feels well and is without any complaints. Past Medical History: CARDIAC HISTORY: Hyperlipidemia, Hypertension, Diabetes mellitus CABG: ___ (SVG-distal LAD, distal LCx, distal RCA), re-do in ___ PERCUTANEOUS CORONARY INTERVENTIONS: None PACING/ICD: ___ biventricular ICD (placed in ___ PAST MEDICAL & SURGICAL HISTORY 1. Paroxysmal atrial fibrillation 2. Infarct-related cardiomyopathy with significant coronary disease, (EF ___, left ventricular systolic dysfunction with akinesis of the inferior septum, inferior wall, and inferolateral wall) 3. Coronary artery disease 4. Ventricular tachycardia storm status-post biventricular ICD placement in ___ ___ ___ generator replacement in ___ VT ablation ___. Atrial tachycardia status-post ablation (___), atrial flutter status-post ablation, and AVNRT status-post slow pathway modification 6. Prior history of stroke post-CABG in ___ another stroke (___) - mild residual visual disturbance and unsteady gait 7. Prostate cancer s/p TURP 8. Insulin dependent diabetes mellitus 9. Chronic renal insufficiency (baseline 2.0-2.3, more recently 3s) 10. h/o nephrolithiasis 11. Intermittent vertigo history 12. Mild insomnia (sleeps ___ hours nightly) 13. s/p Tonsillectomy (at age ___ 14. s/p Mastoidectomy Social History: ___ Family History: Patient is adopted. Unaware of biological family history. Physical Exam: Admission Exam: VS: 97.5, 122/57, 73, 20, 96%RA Wt 82.3kg (last discharge wt: 81.6kg) GENERAL: ___ elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Very poor dentition. NECK: Supple with JVP not elevated. CARDIAC: PMI not felt. RRR, normal S1, S2. ___ systolic murmur over the ___ and ___. No r/g. No thrills, lifts. No S3 or S4. Left sided ICD. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, mild rales R>L base, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. 3x4inch bruise over abdomen lateral to umbilicus. GU: foley inplace with dark yellow urine EXTREMITIES: No c/c. Trace edema of feet to shins. SKIN: No ulcers, scars, or xanthomas. Chronic ___ skin changes. Old sternotomy scar healed. PULSES: 1+ DP and ___ b/l Discharge Exam: VS: 97.7, 132/98, 71, 18, 96%RA Wt 82.0kg GENERAL: ___ elderly man with central obesity in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, Very poor dentition. NECK: Supple with JVP 6-7cm at 90 degrees. CARDIAC: PMI not felt. RRR, normal S1, S2. ___ systolic murmur over the ___ and ___. No r/g. No thrills, lifts. No S3 or S4. Left sided ICD. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, with only mild velcro rales at the right base, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. GU: no foley in place EXTREMITIES: No c/c. Trace edema of feet and shins. SKIN: Chronic ___ skin changes. Old sternotomy scar healed. 3x4inch bruise over abdomen lateral to umbilicus. PULSES: 1+ DP and ___ b/l Pertinent Results: Admission Labs: ___ 01:20PM BLOOD WBC-8.6 RBC-3.34* Hgb-9.2* Hct-28.9* MCV-87 MCH-27.6 MCHC-31.9 RDW-18.2* Plt ___ ___ 01:20PM BLOOD Neuts-76.3* Lymphs-17.5* Monos-4.4 Eos-1.3 Baso-0.4 ___ 01:20PM BLOOD Glucose-190* UreaN-53* Creat-2.4* Na-134 K-3.4 Cl-95* HCO3-27 AnGap-15 ___ 01:20PM BLOOD Mg-2.2 ___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___ ___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 02:00PM URINE RBC-1 WBC-44* Bacteri-MANY Yeast-NONE Epi-0 ___ 02:00PM URINE CastHy-47* Discharge Labs: ___ 07:45AM BLOOD WBC-8.4 RBC-3.55* Hgb-9.7* Hct-31.3* MCV-88 MCH-27.4 MCHC-31.1 RDW-18.3* Plt ___ ___ 07:45AM BLOOD ___ PTT-35.5 ___ ___ 07:45AM BLOOD Glucose-132* UreaN-50* Creat-2.2* Na-138 K-4.0 Cl-98 HCO3-32 AnGap-12 ___ 07:45AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.3 Imaging: ___ CXR: Frontal and lateral views of the chest were compared to previous exam from ___. When compared to prior, there is more prominent central pulmonary vascular engorgement and indistinct pulmonary vasculature suggestive of pulmonary edema. There is no large effusion. Cardiac silhouette is enlarged but stable in configuration. Triple-lead pacing device is seen in stable position. Median sternotomy wires and mediastinal clips again noted. Osseous and soft tissue structures are unremarkable. IMPRESSION: Findings suggestive of mild failure, similar to previous exam. Medications on Admission: ATORVASTATIN [LIPITOR] - 20 mg Tablet - one tablet by mouth once a day Quinidine ER 324mg TID ISOSORBIDE DINITRATE - 20 mg Tablet - 1 Tablet(s) by mouth three times a day METOLAZONE - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth Once a week, as directed METOPROLOL ?SUCCINATE - 200 daily Mexilitine 150mg Q8h NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually every ___ minutes x 3 as needed for chest pain call doctor if the chest pain does not go away after second pill TORSEMIDE [DEMADEX] - 20 mg Tablet - 4 tablets daily ASCORBIC ACID - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet, Chewable CHOLECALCIFEROL (VITAMIN D3) 1,000 unit Capsule - 2 Capsule(s) Qday COD LIVER OIL - (OTC) - Oil - 1 TBS Oil(s) by mouth Daily FOLIC ACID - (OTC) - 0.4 mg Tablet - Tablet(s) by mouth MINERAL OIL - (OTC) - Emulsion - 2 tablespoons by mouth daily MULTIVITAMIN - (OTC) - Tablet - Tablet(s) by mouth VITAMIN E - (OTC) - 400 unit Capsule once a day B complex daily Lantus 20units Qhs Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. quinidine gluconate 324 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). 3. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day: every ___ minutes x 3 as needed for chest pain call doctor if the chest pain does not go away after second pill. 5. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. cod liver oil Oil Sig: One (1) TBS PO once a day. 9. folic acid ___ mcg Tablet Sig: One (1) Tablet PO once a day. 10. mineral oil Oil Sig: Two (2) tablespoons PO once a day. 11. multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a day. 13. B Complex Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 14. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 15. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* 16. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 17. Outpatient Lab Work ___ Draw Basic Metabolic Panel and fax results to Dr. ___: ___, Fax: ___. 18. Lantus 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime: Please check your finger sticks at night and in the morning and record them for Dr. ___. Discharge Disposition: Home With Service Facility: ___ ___: Primary Diagnosis: Urinary Retention Secondary Diagnosis: Chronic Kidney Disease Congestive Heart Failure CAD s/p CABG 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 CHEST, TWO VIEWS: ___. HISTORY: ___ male with CHF, presents with decreased urine output. FINDINGS: Frontal and lateral views of the chest were compared to previous exam from ___. When compared to prior, there is more prominent central pulmonary vascular engorgement and indistinct pulmonary vasculature suggestive of pulmonary edema. There is no large effusion. Cardiac silhouette is enlarged but stable in configuration. Triple-lead pacing device is seen in stable position. Median sternotomy wires and mediastinal clips again noted. Osseous and soft tissue structures are unremarkable. IMPRESSION: Findings suggestive of mild failure, similar to previous exam. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: NO URINE OUTPUT Diagnosed with URIN TRACT INFECTION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, AORTOCORONARY BYPASS, DIABETES UNCOMPL ADULT, CONGESTIVE HEART FAILURE, UNSPEC temperature: 98.2 heartrate: 67.0 resprate: 16.0 o2sat: 100.0 sbp: 149.0 dbp: 57.0 level of pain: 0 level of acuity: 3.0

___ yo M with h/o DM, CAD (s/p CABG in ___, infarct related cardiomyopathy (EF ___, s/p BiV ICD, prostate cancer s/p b/l orchiectomy and TURP, ___ of bladder stones and radiotherapy ___, who p/w decreased UOP consistent with urinary retention. # Urinary retention: Patient is s/p TURP. Had urinary retention last admission in the context of having a foley placed. He presented to the ED with a complaint of anuria with a sensation to urinate but inability to do so. Foley was placed and 300cc urine evacuated, indicating that patient's anuria was likely due to urinary retention. Patient made adequate urine during his time in the hospital. Foley was removed the morning after discharge and the patient voided twice without difficulty prior to discharge. He has follow up with Dr. ___ 2 days after discharge. BPH medications can be considered if voiding issues persist. . # CHF: EF 25% on ___ echo. Patient appears close to euvolemic (100% sat RA, clear lungs, no signs of right sided heart failure, but mild pulm edema on CXR). Weight is close to discharge weight on last admission. Torsemide was decreased to 60mg PO daily. Metolazone was discontinued. Patient has follow up with Dr. ___ on ___ for further management. . # RHYTHM/ h/o afib: Pt is A/V paced, has BiV pacemaker for chronic dCHF, not on coumadin at home. Aspirin 325mg, mexilitine, quinidine, and metoprolol was continued. . # CAD s/p CABG: EKG showed no new ischemic changes. Denies any symptoms of ACS. Continued home aspirin 325 mg, isordil, metoprolol and atorvastatin. . # Chronic kidney failure: He presented with decreased UOP, however once foley was placed in the ED, he put out 300cc and continues to put out clear yellow urine. Cr improved from last admission, 2.2 on discharge. . # Positive UA: Patient is asymptomatic with a positive UA. No antibiotics were given. . # DM: A1C 7.7% on ___. Continued on home Lantus and sliding scale. Patient was discharged from rehab on lantus 20units Qhs. Patient was unclear what dose he was taking at home. This admission, lantus was decreased to 16 units Qhs and patient was requested to monitor finger sticks ___ daily and to record them for his upcoming appointment with Dr. ___. . # HLD: Good lipid profile last admission ___ Tchol 109, HDL 40, LDL 54, ___ 69). Continued home atorvastatin. . # Anemia: Hct 28.9 on admission. Baseline appears to be in the low ___, with occasional values in the high ___. Labs on previous admission last month was suggestive anemia of chronic disease with likely contribution from CKD. Hct on discharge 31.3.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: itching Major Surgical or Invasive Procedure: -___ Ophtho laser procedure for proliferative diabetic retinopathy -___ Colposcopy w/ biopsies -___ Cervical suture, cautery and packing in OR for persistent bleeding from cervical biopsy History of Present Illness: The patient is a ___ hx IDDM, idiopathic cirrhosis (thought to be ___ NASH during previous admission), IDDM and asthma now presenting with itching and jaundice. She was recently admitted to ___ for decompensated cirrhosis, with worsening bilirubin as well as headaches and cough. Infectious workup was negative. Abdominal ultrasound demonstrated no ascites or portal vein thrombosis. MRCP did not demonstrate any hepatobiliary obstruction. The patient's TBili peaked at 13.4 and stabilized to 12.2. She had a liver biopsy during this admission, which showed stage IV cirrhosis and hepatocellular cholestasis. The etiology of the patient's hyperbilirubinemia was unclear, but may be in the setting of worsening liver disease. The patient has consistently denied alcohol abuse (she says she does not drink any alcohol). At time of discharge on ___, the patient was asymptomatic and had no complaints. On ___, the patient again presented to the ED with worsening itching and jaundice. Per her sister (HCP), she has also seemed somewhat confused. The patient states that since her discharge, she adhered to her medication regimen (with no added supplements) and abstained from alcohol as she always does. The patient's sister confirmed that the patient does not drink alcohol. The patient reports that she has been feeling well overall, with no symptoms of infection--she denies fever, chills, nausea, vomiting, SOB, CP, dysuria, abdominal pain. She has a persistent headache similar to the one she had on her last admission. She has been having approximately 5 BMs a day on lactulose, and she has noticed that her stool has been lighter in color. Her urine has also been darker but non-bloody. Of note, the patient reports that she had an EGD done about one year ago, which was negative. Admitted before could go to outpt apt with Dr. ___ after last admission. ED course: T 96.8 HR 59 BP 127/58 RR 18 O2sat 100% RA Labs showed hyperbilirubinemia (Tbili 21.2, Dbili 16.2) and mildly elevated LFTs, with normal PTT (32.7) and mildly elevated ___ (15.5). No leukocytosis and normal electrolytes. RUQUS showed cholelithiasis with no e/o cholecystitis or obstructive process, cirrhotic appearing liver, splenomegaly, and no e/o portal vein thrombosis or ascites. Patient received IV Diphenhydramine 25 mg once. Transfer VS were T 97.8 HR 58 BP 137/66 RR 19 O2sat 99%RA GI/Hepatology were consulted. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports that she is feeling well except for her itchiness. She continues to deny fever, chills, nausea, vomiting, SOB, CP, abdominal pain. Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: - Cirrhosis - Hypertension - Diabetes - Elevated cholesterol - Asthma Social History: ___ ___ History: HTN - mother and father CAD - father No significant family history of stomach, breast or colon cancer. Physical Exam: Admission Physical Exam: VS: T 97.8 HR 57 BP 151/73 RR 20 O2sat 98%RA GENERAL: NAD, jaundiced HEENT: AT/NC, EOMI, PERRL, scleral icterus, MMM NECK: JVP ~9cm HEART: RRR, S1/S2, soft systolic murmur loudest at USB LUNGS: CTAB, breathing comfortably ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, + caput medusa, scattered bruises at insulin injection sites EXTREMITIES: 1+ pitting edema in ___ b/l, no cyanosis or clubbing, no palmar erythema, moving all 4 extremities with purpose, 2+ DP pulses bilaterally NEURO: AOx3, CN II-XII intact, ___ strength throughout b/l SKIN: jaundiced, warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== 134 | 100 | 16 ---------------< 254 4.7 | 24 | 0.8 Ca: 8.2 Mg: 1.6 P: 2.2 12.1 3.7 >------< 44 12.1 44 37.5 MCV 97 ___: 15.5 PTT: 32.7 INR: 1.4 ALT: 36 AP: 176 Tbili: 21.2 Alb: 2.6 AST: 91 LDH: Dbili: 16.2 TProt: ___: Lip: 47 U/A SpecGr 1.015 pH 6.5 Urobil 0.2 Bili Lg Leuk Tr Bld Neg Nitr Neg Prot Neg Glu 100 Ket Neg RBC 1 WBC 2 Bact Few Yeast None Epi 2 IMAGING: ======== ___ Liver Or Gallbladder Us (Single Organ) 1. No evidence of portal vein thrombosis. 2. Cirrhotic appearing liver with splenomegaly and recannulized umbilical vein. 3. Cholelithiasis. 4. Mild gallbladder wall edema is unchanged from abdominal ultrasound ___ and is likely secondary to third spacing from cirrhosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 5 mg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH QDAILY 3. Furosemide 40 mg PO DAILY 4. Lactulose ___ mL PO TID 5. Meclizine 25 mg PO TID 6. Nadolol 20 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Rifaximin 550 mg PO BID 9. Spironolactone 100 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Vitamin E 400 UNIT PO DAILY 12. Ursodiol 300 mg PO BID 13. albuterol sulfate 90 mcg/actuation inhalation Q24H Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Artificial Tear Ointment 1 Appl BOTH EYES PRN open eyes 3. Aspirin 81 mg PO DAILY for aortic conduit-for life 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. Fluconazole 400 mg PO Q24H 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Glucose Gel 15 g PO PRN hypoglycemia protocol 8. Glargine 16 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner NPH 38 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 10. Lidocaine 5% Patch 1 PTCH TD QPM 11. LOPERamide 2 mg PO BID 12. Metoprolol Tartrate 12.5 mg PO BID Hold for sbp <110 or HR <60 13. Mycophenolate Mofetil 500 mg PO QID 14. PredniSONE 12.5 mg PO DAILY follow printed taper 15. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN lowers potassium RX *sodium polystyrene sulfonate 15 grams by mouth once a day Refills:*2 16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 17. Tacrolimus 5 mg PO Q12H continue for 2 doses on ___ then decrease to 3mg twice daily starting ___. Tacrolimus 3 mg PO Q12H start ___ dose decrease due to Fluconazole increase on ___ 19. ValGANCIclovir 450 mg PO Q24H 20. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 21. Escitalopram Oxalate 5 mg PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: ===================== - Acute on chronic liver failure SECONDARY: ===================== Non-alcoholic Fatty Liver disease Malnutrition DM Pleural effusion hypothyroid (sick thyroid) 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: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with RUQ abdominal pain // ?portal vein thrombosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. Th a large recannulized umbilical vein is again noted unchanged from abdominal ultrasound ___. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: There is a conglomerate of gallbladder stones. There is mild gallbladder wall edema, nonspecific and unchanged from ___. The gallbladder is nondistended. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity and enlarged measuring 14.3 cm, previously measuring 14.2 cm on ___. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No evidence of portal vein thrombosis. 2. Cirrhotic appearing liver with splenomegaly and recannulized umbilical vein. 3. Cholelithiasis. 4. Mild gallbladder wall edema is unchanged from abdominal ultrasound ___ and is likely secondary to third spacing from cirrhosis. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with decompensated cirrhosis. // ? evidence of infection TECHNIQUE: Chest two views COMPARISON: ___ FINDINGS: Shallow inspiration. Normal heart size, pulmonary vascularity. No edema. Lungs are clear. No pneumothorax. No effusion. IMPRESSION: Normal chest Radiology Report EXAMINATION: MRCP INDICATION: Ms. ___ is a ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis unknown etiology who is again presenting with jaundice and worsening direct hyperbilirubinemia. Evaluate for hepatobiliary obstruction. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: MRCP from ___. FINDINGS: Lower Thorax: Within the limitations of MRI the lung bases are grossly clear. The visualized heart and pericardium are unremarkable. Liver: The liver is diffusely nodular in contour compatible with known cirrhosis. No suspicious focal liver lesion is identified. There is a very large recanalized paraumbilical vein with extensive varices within the midline subcutaneous soft tissues shunting blood flow away from the main portal vein. There are also esophageal varices. Biliary: The gallbladder is very collapsed and not well evaluated on today's exam. Punctate foci of low signal intensity in the gallbladder fossa could represent known gallstones. There is no definite gallbladder wall thickening or pericholecystic fluid. There is mild intrahepatic biliary ductal dilatation in the left lobe of the liver, minimally changed since the prior study from ___. No obstructing mass or stricture is identified, although the central aspect of the left biliary ducts is obscured by a very large recanalized paraumbilical vein. Pancreas: The pancreas demonstrates normal signal intensity and enhancement. Scattered cystic lesions are again seen in the pancreas measuring up to 9 mm in the body, likely side branch IPMNs. There is no pancreatic ductal dilatation. Spleen: The spleen is markedly enlarged measuring 14.5 cm. It demonstrates homogeneous enhancement. A splenule is incidentally noted. Adrenal Glands: Bilateral adrenal glands are normal. Kidneys: The kidneys demonstrate normal enhancement without hydronephrosis or suspicious solid renal lesion. Punctate 3 mm cyst is present in the interpolar region of the right kidney. Gastrointestinal Tract: The stomach, included small and large bowel are grossly unremarkable. Lymph Nodes: There is no mesenteric or retroperitoneal lymphadenopathy. Vasculature: The abdominal aorta is normal in caliber. Major branching vessels are patent. Hepatic arterial anatomy is conventional. There is persistent unchanged filling defect in the posterior aspect of the upper SMV which is compatible with a chronic appearing thrombus (series 19, image 68). Osseous and Soft Tissue Structures: Marrow signal is within normal limits. Extensive varices in the anterior abdominal wall are noted. IMPRESSION: 1. Mild left lobe intrahepatic biliary ductal dilatation is minimally changed since the ___ study, with the central portions obscured by a large recanalized paraumbilical vein. No obstructing mass or stone. 2. Cirrhosis with sequelae of portal hypertension including splenomegaly, large recanalized paraumbilical vein, and extensive abdominal wall and esophageal varices. 3. Unchanged chronic-appearing non-occlusive thrombus along the posterior aspect of the upper SMV. 4. Collapsed gallbladder. Known gallstones are not clearly visualized on today's exam. 5. Scattered pancreatic cystic lesions measuring up to 9 mm, likely side branch IPMNs. ___ year follow-up MRCP is recommended as previously suggested. RECOMMENDATION(S): Followup MRCP in ___ year. Radiology Report EXAMINATION: TEETH (PANOREX FOR DENTAL) INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis unknown etiology who is again presenting with jaundice and worsening direct hyperbilirubinemia. Performing expedited transplant workup. // Dental eval for liver transplant eval Dental eval for liver transplant eval IMPRESSION: No comparison. Multiple missing teeth. No evidence of chronic infectious changes. Radiology Report EXAMINATION: BILATERAL DIGITAL DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD INDICATION: Patient on transplant list. Decompensated cirrhosis and worsening for expedited transplant workup. COMPARISON: None. Baseline. TECHNIQUE: Digital CC and MLO views were obtained. Computer aided detection was utilized and assisted with interpretation. FINDINGS: Tissue density: B - There are scattered areas of fibroglandular density. Benign calcifications noted in the right inferior medial breast.There is no dominant mass, unexplained architectural distortion or suspicious grouped microcalcifications in either breast. IMPRESSION: No specific evidence of malignancy. RECOMMENDATION: Age and risk appropriate screening is recommended. NOTIFICATION: A lay report will be sent to the patient with this result. BI-RADS: 2 Benign. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis unknown etiology who is again presenting with jaundice and worsening direct hyperbilirubinemia of unclear etiology. W/ Fall this AM// r/o hemorrhage/trauma TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 47.4 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 843 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute infarction,hemorrhage,edema, or mass. There is probable chronic lacunar infarct in the upper left thalamus. There is probable chronic lacunar infarct versus prominent prevascular space in the right centrum semiovale. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. 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: There are no acute findings. There is no hemorrhage. Radiology Report EXAMINATION: Carotid Doppler Ultrasound INDICATION: ___ year old woman with history of possible stroke, undergoing liver transplant// stenosis TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound imaging of the carotid arteries was obtained. COMPARISON: None FINDINGS: RIGHT: The right carotid vasculature has no atherosclerotic plaque. The peak systolic velocity in the right common carotid artery is 83 cm/sec. The peak systolic velocities in the proximal, mid, and distal right internal carotid artery are 41, 65, and 48 cm/sec, respectively. The peak end diastolic velocity in the right internal carotid artery is 16 cm/sec. The ICA/CCA ratio is 0.78. The external carotid artery has peak systolic velocity of 79 cm/sec. The vertebral artery is patent with antegrade flow. LEFT: The left carotid vasculature has no atherosclerotic plaque. The peak systolic velocity in the left common carotid artery is 75 cm/sec. The peak systolic velocities in the proximal, mid, and distal left internal carotid artery are 29, 60, and 37 cm/sec, respectively. The peak end diastolic velocity in the left internal carotid artery is 12 cm/sec. The ICA/CCA ratio is 0.8. The external carotid artery has peak systolic velocity of 76 cm/sec. The vertebral artery is patent with antegrade flow. IMPRESSION: No sonographic evidence of hemodynamically significant stenosis or plaques in the carotid arteries. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with worsening encephalopathy// PNA PNA IMPRESSION: Comparison to ___. Low lung volumes. Borderline size of the cardiac silhouette. Mild elongation of the descending aorta. Mild fluid overload but no overt pulmonary edema. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: Ms. ___ is a ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis (Childs B-C, MELD 26 on ___ unknown etiology who is again presenting with jaundice and worsening direct hyperbilirubinemia, transplant pending. Now w/ ___. Eval for ascites// eval for ascites TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: Targeted ultrasound images were obtained of the abdominal cavity. No ascites could be identified. IMPRESSION: No ascites was identified. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM, and asthma who was admitted less than 2 weeks ago for decompensated cirrhosis (Childs B-C, MELD 26 on ___, worked up for liver transplant. Now w/ pleuritic chest pain and crackles.// r/o pulm edema, PNA TECHNIQUE: Portable AP chest COMPARISON: Chest radiographs from ___ and ___. FINDINGS: Compared to ___, lung volumes are improved. The heart is mildly enlarged. The mediastinal contours are within normal limits. There is increased pulmonary edema, right greater than left, with small bilateral effusions. A possible superimposed pneumonia cannot be excluded in the appropriate clinical setting. There is no pneumothorax. IMPRESSION: 1. Compared to ___, mild cardiomegaly with increased asymmetric pulmonary edema, right greater than left, and small bilateral effusions. 2. A possible superimposed pneumonia cannot be excluded in the proper clinical setting. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p liver transplant// assess for interval change assess for interval change IMPRESSION: The patient is of the liver transplantation, the examination is compared to ___. All monitoring and support devices, including the Swan-Ganz catheter and the endotracheal tube are in correct expected position. Lung volumes are low but there is no evidence of pulmonary edema or larger pleural effusions. Mild retrocardiac atelectasis. No pneumothorax. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman POD0 liver transplant// assess vasculature, ductal dilation, perihepatic collection TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: Note is made that the ultrasound is severely technically limited due to overlying bandages limiting the sonographic windows and inaccessible approach to the midline and subcostal region. Within that limitation the liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. The common hepatic duct could not be visualized. There is trace perihepatic ascites. There is a moderate right pleural effusion. A ___ fluid collection/hematomas is identified measuring 5 cm at the dome of the right lobe. The spleen measures 13.1 cm and has normal echotexture. DOPPLER: Doppler evaluation of the hepatic vessels is technically limited due to overlying bandages, as described above. The main hepatic cannot be visualized. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.72. The main portal vein could not be visualized. The right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Severely technically limited ultrasound due to overlying bandages and limited sonographic windows. 2. Patent intrahepatic vasculature with appropriate waveforms. Note is made that the main hepatic artery and main portal vein cannot be evaluated on today's exam. 3. No evidence of intrahepatic ductal dilatation. 4. Trace perihepatic ascites with a fluid collection/hematoma measuring approximately 5 cm at the posterior dome of the right lobe. 5. Moderate right pleural effusion. 6. Mild splenomegaly. NOTIFICATION: The findings were discussed with ___, M.D. by ___, on the telephone on ___ at 1:55pm, 30 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman POD0 liver transplant with increasing O2 requirement// interval change TECHNIQUE: Portable AP chest COMPARISON: Chest radiographs from ___ through ___. FINDINGS: Compared to ___ at 04:28, lung volumes remain low. The right Swan-Ganz catheter is now positioned in the descending portion of the right pulmonary artery. Other tubes and lines are unchanged in position. There is diffusely increased opacification over the right lung, which may be due to a layering effusion or breast shadowing. There is mild vascular congestion. No pneumothorax is seen. Retrocardiac atelectasis persists. IMPRESSION: 1. Compared to ___ at 04:28, lung volumes remain low with diffusely increased opacification over the right lung, which may be due to a layering effusion breast shadowing. 2. Persistent retrocardiac atelectasis. 3. Right Swan-Ganz catheter position in the descending portion of the right pulmonary artery. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p liver transplant with open abdomen// please evaluate endotracheal tube position please evaluate endotracheal tube position TECHNIQUE: Since ___, most recently ___. IMPRESSION: Compared to chest radiograph since ___, most recently ___. Relatively uniform opacification of the right lower hemithorax persists. The explanation is uncertain, either posteriorly layering pleural effusion or severe consolidation or collapse of the lower lobe. Chest CT would be definitive in distinguishing among these possibilities. Left lower lobe consolidation and previous mild pulmonary edema have improved. Heart size is normal. Cardiopulmonary support devices are in standard placements unchanged. RECOMMENDATION(S): Consider chest CT for explanation pleural pulmonary findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with s/p liver transplant// evaluate volume status pt on CVVH Surg: ___ (abdominal closure) COMPARISON: Chest x-ray from ___ at 13:21 FINDINGS: The ET tube lies approximately 5.1 cm above the carina, at the upper edge of the clavicular heads. NG tube extends beneath diaphragm, off film. Right IJ sheath overlies the mid/distal SVC. Right IJ Swan-Ganz catheter probably lies in the proximal right pulmonary artery--full characterization is somewhat limited due to patient rotation. Allowing for differences in position and technique, cardiomediastinal silhouette is probably unchanged. It appears slightly prominent, but this is likely accentuated by low lung volumes and lordotic positioning. There is mild vascular plethora, also likely accentuated by low lung volumes. Increased retrocardiac density is again seen, compatible left lower lobe collapse and/or consolidation. No gross left effusion. Hazy opacity at the right base likely reflects a layering small right pleural effusion. IMPRESSION: Lines and tubes as described. The ET tube lies approximately 5.1 cm above the carina. Clinical correlation regarding advancement is requested. Allowing for low lung volumes, no definite change in cardiac silhouette. Layering right pleural effusion. Increased retrocardiac density consistent with left lower lobe collapse and/or consolidation. These findings are similar to the prior study. Apparent vascular plethora is likely accentuated by low lung volumes. Radiology Report EXAMINATION: ABD (SINGLE VIEW ONLY) IN O.R. INDICATION: Rule out retained lap pad prior to closing during abdominal surgery. Performed per protocol, though no clinical concern for retained material. TECHNIQUE: Intraoperative AP view of the chest and abdomen. COMPARISON: None. FINDINGS: The patient is on a temperature control pad or other device that introduces artifact throughout the images. No separate image of the item of interest (lap pad) is available for review at this time. The extreme right and left abdominal soft tissues are excluded from the film. There is tubing overlying the lower abdomen and pelvis.. Apparent dual lumen right femoral line versus 2 adjoining right femoral lines. ET tube with tip approximately 4.4 cm above the carina. NG tube, with tip below diaphragm. Right Swan-Ganz catheter tip proximal right pulmonary artery. Metallic surgical instrument overlies the chest. There are scattered linear densities that are thought to represent surgical clips and, also, skin staples which may be either on or adjacent to the patient. Inspiratory lung volumes are low with some increased retrocardiac density consistent with left lower lobe collapse and/or consolidation. Allowing for this, no focal radiopacity suggestive of a lap pad is identified. IMPRESSION: Limited exam due to considerable overlying artifact. However, no radiodensity suggestive of a lap pad is detected. If clinical concern were high, then a dedicated radiograph of the item of interest could be obtained to help for further assessment. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p liver transplant// interval change interval change IMPRESSION: In comparison with the study ___, the endotracheal tube appears to have been removed. Other monitoring and support devices are stable. Continued low lung volumes with enlargement of the cardiac silhouette and some elevation of pulmonary venous pressure. No acute focal consolidation is appreciated. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new central line.// appropriate line placement? Central and NG tube Contact name: ___: ___ TECHNIQUE: Portable AP chest COMPARISON: Chest radiographs from ___, ___. FINDINGS: Compared to ___, there is a new right IJ central venous catheter with its distal tip in the lower right atrium. Endotracheal and enteric tubes are in appropriate and unchanged position. Lung volumes remain low. The cardiomediastinal silhouette is unchanged. Vascular congestion is unchanged. A right layering pleural effusions again noted. A left pleural effusion is also seen, with volume loss in the left base. IMPRESSION: 1. Compared to ___, new right IJ central venous catheter with distal tip in the low right atrium. Recommend withdrawing approximately 7 cm for positioning at the cavoatrial junction, if desired. 2. The heart lungs are not significantly changed in appearance with persistent vascular congestion, layering right pleural effusion, a left pleural effusion and volume loss at the left base. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:15 pm, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new line placement// line positioning Contact name: ___: ___ line positioning IMPRESSION: In Comparison with the earlier study of this date, the right IJ catheter has been pulled back. The tip is still approximately 2 cm below the cavoatrial junction. Little overall change in the appearance of the heart and lungs. Radiology Report EXAMINATION: ___ intestinal tube advancement. INDICATION: ___ w/ hx IDDM, idiopathic cirrhosis (likely NASH), and asthma here for decompensated cirrhosis unknown etiology s/p deceased donor liver transplant. ___ intestinal tube advancement. DOSE: Acc air kerma: 4.6 mGy; Accum DAP: 123.28 uGym2; Fluoro time: 0.3 COMPARISON: ___ chest radiograph. ___ MRCP. FINDINGS: The left nare was anesthetized with lidocaine jelly. Under intermittent fluoroscopic guidance, the existing Dobhoff feeding tube was advanced post-pylorically using a guidewire. 12 cc of Optiray contrast were used to confirm post pyloric placement. Final fluoroscopic spot images demonstrated the tip of the feeding tube in at the duodenojejunal junction. The feeding tube was affixed to the patient's nose using tape. IMPRESSION: Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is ready to use. Radiology Report INDICATION: ___ year old woman s/p liver transplant// interval change TECHNIQUE: Chest PA and lateral COMPARISON: ___ at 17:10 FINDINGS: Right-sided IJV CVP in situ with the tip in the proximal right atrium. Two nasogastric feeding tubes in situ. Elevation of the left hemidiaphragm. Platelike atelectasis in the left lower lung zone. Moderate right-sided pleural effusion appears slightly increased compared to prior. Increased airspace density in the right mid and lower lung zones is most likely secondary to the pleural effusion. Mild pulmonary vascular congestion. Perihepatic abdominal drain in situ. IMPRESSION: Suspected mild increase in size of the right-sided pleural effusion. Mild increase in pulmonary vascular congestion, but no overt pulmonary edema. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman s/p liver transplant with new dobhoff// evaluate dobhoff position TECHNIQUE: Portable AP chest COMPARISON: Chest radiographs from ___. FINDINGS: Compared to ___ at 04:19, there is a new Dobhoff tube with its tip in the proximal stomach, near the gastroesophageal junction. Other lines and tubes are unchanged in position. There is little change to the appearance of the heart and lungs. IMPRESSION: 1. Compared to ___ at 04:19, there is a new Dobhoff tube with tip in the proximal stomach, near the gastroesophageal junction. Recommend advancing 8-10 cm for more optimal positioning. 2. There is little change in the appearance of heart lungs. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new trialysis line// line position Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___ 13:52 FINDINGS: Right IJ central line tip near cavoatrial junction. Very shallow inspiration. 2 enteric tubes tips well below diaphragm. More prominent left basilar opacity, likely atelectasis. Right pleural effusion is more apparent, adjacent mild atelectasis. Normal heart size, mildly prominent pulmonary vascularity. No pneumothorax. Catheter projected over right upper quadrant, upper abdomen. Surgical staples upper abdomen. IMPRESSION: New right IJ central line, no pneumothorax. More prominent right pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p liver transplant and known pleural effusion// interval change interval change IMPRESSION: Compared to chest radiographs since ___, most recently ___. Lung volumes remain very low. Moderate right pleural effusion has not improved. Left lower lobe atelectasis is mild to moderate, but improved over the past several days. Pulmonary vasculature is engorged but there is no edema. Heart size is normal. No pneumothorax. Esophageal drainage tube ends in the upper stomach. Feeding tube passes out of the field of view. Right jugular dual channel catheter ends in the right atrium as before. Radiology Report INDICATION: ___ year old woman s/p liver transplant// interval change TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Serial interval increase in size of the right-sided pleural effusion with associated atelectasis. The left lung is clear. Mild left basal atelectasis with elevation of the left hemidiaphragm. Tube positions unchanged. IMPRESSION: Serial interval progression of the right-sided pleural effusion with associated atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p liver transplant, now with increased work of breathing// Interval change TECHNIQUE: Single AP radiograph of the chest. COMPARISON: Chest radiograph with the same date. FINDINGS: Right jugular catheter terminates in the right atrium. Post pyloric Dobhoff tube is appropriate. NGT with tip and side hole below the diaphragm. Layering right pleural effusion is unchanged, moderate in size. No new focal consolidations. No pulmonary edema. Stable appearance of the cardiomediastinal silhouette. No pneumothorax. IMPRESSION: Unchanged examination with a moderate right pleural effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman s/p DDLT 1 week ago, now with acute blown left pupil. Otherwise following commands. Please assess for hemorrhagic stroke. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: CTDIvol: 46.71 mGY DLP: ___ Mgy-cm COMPARISON: Head CT ___ FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are stable in size and configuration. There are periventricular and subcortical lucencies, which may represent small vessel ischemic changes. Chronic left basal ganglia, left thalamic and right corona radiata probable lacunar infarcts are again noted. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. Endotracheal tube and nasogastric tube are partially visualized. IMPRESSION: 1. No evidence of acute intracranial hemorrhage or large territorial infarction. 2. Please note that MRI is more sensitive for the detection of infarction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with ? pulm edema// ? pulmonary edema COMPARISON: None. FINDINGS: Low inspiratory volumes. 2 enteric type tubes both of which extend beneath the diaphragm off the film. Additional tubing overlies the right upper quadrant, source uncertain. Dual lumen right IJ catheter with both tips over the right atrium. Inspiratory volumes are quite low. No pneumothorax detected. Arts heart size is borderline, probably not enlarged. No CHF, focal infiltrate or effusion is identified. Minimal subsegmental atelectasis present. While tiny bilateral effusions cannot be excluded, no gross effusion identified. IMPRESSION: Low inspiratory volumes. Doubt overt CHF. No pulmonary edema. Radiology Report INDICATION: ___ year old woman with right pleural eff, s/p ___// r/o ptx TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: Low bilateral lung volumes. The right pleural effusion has decreased in size, now likely trace in extent. No pneumothorax. Minimal bibasilar atelectasis. Unchanged 2 positions. IMPRESSION: Interval decrease in size of the right pleural effusion, now likely trace in extent. No pneumothorax. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: r/o hepatic artery stenosis, rejection TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Ultrasound from ___. FINDINGS: Liver: The hepatic parenchyma is within normal limits. No focal liver lesions are identified. A perihepatic crescentic fluid collection/hematoma is noted, decreased in size from prior exam. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct was not visualized. Pancreas: Pancreas is not well seen to overlying bowel gas. Spleen: The spleen demonstrates normal echotexture, measuring up to 13.5 cm Kidneys: Limited views of the right kidney are unremarkable. No stones, masses, or hydronephrosis are identified in either kidney. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 81.6 cm/sec. Right and left portal veins are patent, with antegrade flow. Main hepatic artery is patent with brisk systolic upstroke in contiguous antegrade flow. Peak systolic velocity is 62 cm/s. Right hepatic artery is patent with the resistive index of 0.73. Left hepatic artery is also patent with a resistive index of 0.83. IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. Resistive the indices in the right and left hepatic arteries of 0.73 and 0.83. 2. No intrahepatic biliary ductal dilatation. The common hepatic duct was not visualized. 3. Interval decrease in size of perihepatic fluid collection/hematoma. 4. Stable mild splenomegaly. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with liver transplant, now s/p drainage of pleural effusion// interval change COMPARISON: Chest x-ray from ___ at 04:54 FINDINGS: Again seen are 2 enteric tubes, which both extend beneath diaphragm, off this film. Also again seen is a dual lumen catheter from a right IJ approach, unchanged. No pneumothorax detected. As before, inspiratory volumes are low. Prominence of the cardiomediastinal silhouette is likely accentuated by low inspiratory volumes and technical factors. No gross effusion is identified, though minimal blunting of the costophrenic angles is likely present. There is bibasilar atelectasis, but no frank consolidation. Allowing for low lung volumes, no definite CHF. Previously seen drain in the right upper quadrant is no longer visualized. IMPRESSION: Apparent interval removal of right upper quadrant abdominal drain. No gross change compared 1 day earlier. Inspiratory volumes are lower. Small tiny bilateral effusions are likely present. Radiology Report INDICATION: ___ year old woman with liver transplant, now with increased shortness of breath// Interval change TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of a right internal jugular catheter projects over the right atrium. Enteric tubes course below the level of the diaphragms but beyond the field of view of this radiograph. Low bilateral lung volumes with probable layering bilateral pleural effusions. No large focal consolidation or pneumothorax. The appearance of the cardiac silhouette is unchanged. IMPRESSION: No significant interval change since the prior chest radiograph. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p liver transplant// Interval change Interval change IMPRESSION: Compared to chest radiographs ___ through ___. Mild edema is exaggerated by low lung volumes. Mild right basal atelectasis has worsened. Small right pleural effusion is likely. No appreciable left pleural effusion or pneumothorax. Heart size top-normal exaggerated by low lung volumes. Transesophageal feeding tube passes alongside a drainage tube ending in the mid stomach, passing into the duodenum and out of view. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) Abdominal ultrasound with Doppler INDICATION: Please assess by Doppler the hepatic vasculature. Also assess for fluid collections TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: Abdominal doppler ultrasound ___ FINDINGS: Liver: The hepatic parenchyma is within normal limits. There is a subcapsular hematoma which is grossly unchanged as compared to abdominal ultrasound ___. There is no evidence of focal liver lesions or biliary dilatation. There is a small right pleural effusion which is unchanged. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. The common hepatic duct measures 2 mm. Pancreas: The imaged portion of the pancreas appears within normal limit, with portions of the pancreatic tail obscured by overlying bowel gas. Spleen: The spleen demonstrates normal architecture but is enlarged measuring 13.9 cm across maximal diameter. Kidneys: Survey images of the right kidney demonstrate no gross abnormality. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 84.6 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: 1. Patent hepatic vasculature. 2. Subcapsular hematoma is grossly unchanged as compared to abdominal ultrasound with Doppler ___. 3. Stable small right pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ idiopathic vs. NASH cirrhosis s/p DDLT w/ aortic conduit c/b coagulopathy requiring intra-abdominal packing with open abdomen s/p washout, CBD reconstruction, closure with feeding tube. Now with nausea/vomiting// assess location of feeding tube tip TECHNIQUE: Chest single COMPARISON: ___ FINDINGS: Feeding tube is not identified, it may be coiled in the oral cavity or pharynx. Right central line tip in the right atrium. Mild right, small left pleural effusions. Shallow inspiration accentuates heart size, pulmonary vascularity which are prominent, similar to mildly worsened since prior. Surgical staples in the abdomen wall. Right basilar opacity, likely atelectasis. IMPRESSION: Feeding tube is not identified. Radiology Report INDICATION: ___ year old woman with DHT placed// Assess for placement of DHT TECHNIQUE: Portable upright chest radiographs COMPARISON: ___ at 16:43 IMPRESSION: A right IJ approach dialysis catheter terminates in the right atrium. The enteric tube terminates in the gastric antrum. Lung volumes are low with mild interstitial edema and a moderate right pleural effusion. No significant left pleural effusion. No pneumothorax. Heart size is stably enlarged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p dobhoff insertion// for placement of tubethank you TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Dobhoff tube tip isin the stomach. No other interval change from prior study. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with liver txp, now w/ subjective dyspnea// Assess for thoracic pathology or gastric dilatation Assess for thoracic pathology or gastric dilatation IMPRESSION: Comparison to ___. Minimal decrease in extent of the pre-existing right pleural effusion. Mild cardiomegaly persists. No pulmonary edema, no pneumonia. Stable monitoring and support devices. The radiograph provides no evidence for gastric dilatation. Radiology Report EXAMINATION: Chest AP and lateral INDICATION: ___ year old woman with SOb susp pleural eff on the Rt// status of pleural eff on the Rt, other consolidation? TECHNIQUE: Chest AP and lateral COMPARISON: Chest x-ray dated ___. FINDINGS: Since most recent prior dated ___, there has been no change in loculated right-sided pleural effusion. No left-sided pleural effusion is seen. Low lung volumes. No evidence of pneumonia. Mild cardiomegaly. Mediastinal and hilar contours are unchanged. No pneumothorax. Monitoring and support devices are stable. IMPRESSION: Unchanged right-sided pleural effusion. No evidence of pneumonia. Radiology Report EXAMINATION: Portable AP chest INDICATION: ___ year old woman with dyspnea// assess for interval change TECHNIQUE: Portable AP chest COMPARISON: Chest x-ray dated ___. FINDINGS: Low lung volumes. There has been an increase in right-sided pleural effusion. Cardiomediastinal and hilar silhouettes are unchanged. No pneumothorax. There is been interval removal of the right-sided hemodialysis catheter. IMPRESSION: Increase in right-sided pleural effusion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with recurrent pleural effusion s/p chest tube// pneumothorax? tube placement? TECHNIQUE: Chest single view COMPARISON: ___ 06:14 FINDINGS: Enteric tube tip is well below diaphragm, out of view. Very shallow inspiration accentuates heart size, pulmonary vascularity. Right pleural effusion has nearly resolved, there is new right pleural catheter. No pneumothorax. Minimal right basilar atelectasis. Surgical staples abdomen. IMPRESSION: Improvement since prior. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with R pleural effusion s/p pigtail placement.// Assess for interval change. TECHNIQUE: Single frontal view of the chest COMPARISON: Study performed 7 hours earlier IMPRESSION: Right lower lobe atelectasis has worsened. Right basal pigtail catheter remains in place. There are low lung volumes. No other interval change from prior study. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with R pigtail chest tube// assess for interval change. Please perform at 0500 ___ TECHNIQUE: Single frontal view of the chest COMPARISON: Study performed 3 hours earlier IMPRESSION: Is aeration of the right lower lobe has minimally improved. No other interval change from prior study. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman post procedure day 1 from thoracentesis with drain placement, continued O2 requirement// Please assess chest without contrast s/p thoracentesis ___ with drain in placew still having O2 requirement. ? reaccumulation of fluid TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material, multiplanar reconstructions. DOSE: DLP: 407 mGy-cm COMPARISON: No previous CT examination available for comparison. FINDINGS: No incidental thyroid findings. No supraclavicular, infraclavicular or axillary lymphadenopathy. Patient carries a feeding tube. No enlarged lymph nodes in the mediastinum. Severe coronary calcifications, no pericardial effusion. Punctate splenic calcification. No abnormalities are noted at the level of the large mediastinal vessels. No osteolytic lesions at the level of the ribs, the sternum, or the vertebral bodies. Mild degenerative vertebral disease. No vertebral compression fractures. Mild right-sided pneumothorax. A right pleural drain is in situ. The tip of the drain is located in the posterior aspect of the right lung. The right lower lobe shows signs of volume loss and a rather large masslike parenchymal consolidation (302, 91). No larger fluid collections on either the left or the right side are noted. Minimal atelectasis at the left lung basis. Non characteristic small left-sided subpleural ground-glass nodule (302, 69). IMPRESSION: Right pleural chest drain in situ. Right pneumothorax of mild extent. Masslike right lower lobe consolidation, likely of infectious origin. Non characteristic nodule on the left. Otherwise unremarkable left hemithorax. Radiology Report INDICATION: ___ year old woman with pleural effusion, mild pneumothorax on CT chest this morning. S/P chest tube removal this afternoon.// ?pneumothorax TECHNIQUE: AP portable chest radiograph COMPARISON: CT chest from earlier today FINDINGS: Low bilateral lung volumes. Opacities at both lung bases may reflect atelectasis and/or consolidation. No discrete pneumothorax is identified. The size of the cardiac silhouette is within normal limits. An enteric tube extends into the stomach. IMPRESSION: Low bilateral lung volumes. No discrete pneumothorax identified. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with R pigtail chest removed// Assess for interval change. Please perform at 0500 ___ Assess for interval change. Please perform at 0500 ___ IMPRESSION: Type of tube tip is in the stomach. Heart size and mediastinum are stable. Bibasal consolidations and bilateral pleural effusions are unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with recurrent simple exudate after liver transplant// ?recurrent exudate ?recurrent exudate IMPRESSION: Type of tube passes below the diaphragm. Heart size and mediastinum are stable. Lung volumes are low. Bibasal areas of consolidations are unchanged. There is no pneumothorax. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS INDICATION: 61 ___ w/ idiopathic vs. NASH cirrhosis s/p DDLT w/ aortic conduit c/b coagulopathy requiring intra-abdominal packing with open abdomen s/p washout, CBD reconstruction, closure// assistance w/ dobhoff tube placement assistance w/ dobhoff tube placement IMPRESSION: In comparison with study of ___, the new Dobhoff tube extends to the mid body of the stomach. Continued low lung volumes without acute pneumonia or vascular congestion, blunting of both costophrenic angles is again seen. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Jaundice Diagnosed with Unspecified jaundice, Right upper quadrant pain temperature: 96.8 heartrate: 59.0 resprate: 18.0 o2sat: 100.0 sbp: 127.0 dbp: 58.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ w/ hx IDDM, idiopathic cirrhosis (thought to be NASH), IDDM, and asthma who was admitted for decompensated cirrhosis. Given worsening liver function, encephalopathy, and rising bilirubin with no clear source, expedited transplant workup was performed and patient was offered a liver on ___ at which point she was transferred to the transplant surgery service. Patient noted to have nonocclusive thrombus on MRCP. Coumadin held prior to surgery. Of note, on ___ she underwent Colposcopy w/ biopsies: LGSIL and on ___ required cervical suture, cautery and packing in OR for persistent bleeding from cervical biopsy. Bleeding resolved. On ___, she underwent deceased donor liver transplant, temporary portacaval shunt, arterial conduit (will need to be on ASA for life), portal vein thrombectomy and staged transplant with temporary abdominal closure and packing. Surgeons were Drs. ___ and ___. She had massive hemorrhage (10 L) and received the following:PRBC 23, FFP 20, Plt 7, Cryo 2, Factor VII x1, Cell saver 370, Crys 7L Postop, she went to the SICU intubated where the a liver u/s appeared wnl, but the main portal or main hepatic artery could not be seen given Abthera dressing. She was given broad spectrum antibiotics were given (Vanco, Aztreonam and Flagyl). A right femoral dialysis catheter was placed and CRRT started. On ___, Dr. ___ took her back to the OR for removal of the abdominal packing and wash out of hematoma, choledochocholedochostomy and temporary abdominal closure. Pressor support was weaned off and sedation lightened. LFTs decreased after an initial expected increase. Mental status improved and CRRT was stopped on ___. Medial JP output was high. She required intermittent blood products, but was stable. On ___, she went back to the OR for re-exploration of liver transplant with abdominal washout and removal of retained packs and abdominal closure. Surgeon was Dr. ___. Please refer to operative notes for further intraop details. Broad antibiotic coverage was given (Vanco, Postop, CRRT was resumed via the femoral line that was later removed and a R IJ trialysis line was placed. CVVHD continued until urine output improved and overall volume status improved. NG was removed and a post pyloric feeding tube placed. Tube feeds were started using glucerna. Insulin drip was used for hyperglycemia then this was switched to Lantus and sliding scale. NPH was later added to cover steroid. She had bouts of diarrhea with several stools sent and negative for c.diff. Imodium was started on ___ with decreased stools the next day on ___ ( 7 daily down to 2 daily). LFTs continued to improve. Repeat liver duplex (___) demonstrated patent vasculature and no biliary ductal dilatation. LFTs decreased, but alk phos 300-240 range and alt ranged in 60-70s. On ___ while still in SICU, there was concern for pupillary asymmetry in setting of slow mentation. A non-con head CT was done that was negative for intracranial process. She continued to be intermittently delirious. Seroquel was given. CRRT was held on ___, but HD was resumed on ___ for rising BUN and sedation. Urine culture was positive for yeast on ___ while on Fluc. The foley was removed. On ___, she was also dyspneic with decreased breath sounds on right. CXR demonstrated pleural effusion. Intermittent doses of Lasix were given. Thoracentesis was performed by IP for 650ml of fluid on ___. Cell count showed PMNs and no organisms. Fluid was exudative per Light's criteria. Blood cultures were negative. Dyspnea resolved. On ___, CT chest revealed a small pneumothorax, and RLL local post expansion pneumonia or local consolidation. The pigtail drain was removed by IP. She continued to improve. Mental status improved. Speech and swallow continued to eval and gradually diet was progressed to solid food and thin liquids. The lateral JP was removed on ___ and the medial on ___. Output was non-bilious. Incision staples were removed on ___. Incision was intact without redness or drainage. Weight was down to 77.6 kg on ___. LFTs were stable normal. Immunosuppression consisted of cellcept 1 gram bid that was changed to 500mg 4 times daily for frequent stools/gi complaints. Steroids were weaned to prednisone taper which decreased to 12.5mg on ___. Tacrolimus was started and adjusted per daily trough levels (trough goal 10). Dose was increased to 5mg twice daily for trough of 6.0 on ___. Trough increased to 8.3 on ___. Given that Fluconazole dose was increased on ___, Tacrolimus dose will need to decrease to 3mg twice daily starting ___. Fluconazole inhibits Tacrolimus. She should have labs done on ___ with Tacrolimus lab couriered to ___ lab control for stat processing. ___ Tacro 5mg/5mg ___ Tacro 5mg/5mg (6.0) ___ Tacro 4mg/4mg (5.7) ___ Tacro 3mg/3mg (6.6) ___ Tacro 2.5mg/2.5mg(6.2) ___ Tacro 2mg/2mg (-) ___ Tacro 2mg/2mg (10.9) ___ assessed and determined rehab needs. A bed was available at ___ and she was discharged in stable condition. CHRONIC ISSUES: # Diabetes Mellitus Type 2: Most recent HbA1c 7.6. - continue Glargine 58 Units Bedtime - Insulin SC Sliding Scale using Humalog Insulin - recheck HbA1c # Depression: - continue home Escitalopram Oxalate 5 mg PO DAILY # Asthma - continue Fluticasone Propionate 110mcg 2 PUFF IH QDAILY - Albuterol Sulfate (Extended Release) 1 INH PO Q6H:PRN wheezing TRANSITIONAL ISSUES =================== #CODE STATUS: full (confirmed) #CONTACT: ___ (___) Daughter: ___ (in ___: ___ (home-preferred#) ___ (cell)

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / Losartan Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: none History of Present Illness: CC: ___, Failure To Thrive HISTORY OF PRESENT ILLNESS: Ms ___ is a ___ with PMHx CKD, afib, DM, no known psych hx who presents on ___ from her PCPs office for AMS and agitation. Pt saw her PCP today and PCP ___ pt due to paranoid delusions and AMS. History is obtained from notes as pt is unable to recount history and son was not answering the phone when I called. Per ED notes, pt was living with her son but there was some concern about her safety there - apparently the house was very cluttered and she was noted being adequately cared for. She therefore moved in w/ family friend 1 week ago and family friend noted change in her mental status ever since, with decreased PO, wt loss, paranoid delusions, pressured speech, agitation, and behavioral disturbance. Pt was sent to ER by PCP due to concerns for her safety at home and altered mental status. Pt denies any recent falls. In the ED, initial vitals were: 98.0 50 131/53 20 98% RA. Labs were notable for trop 0.02, neg tox screen, creatinine 1.7. CT showed no acute process. CXR showed congestion with mild interstitial edema. Pt was given 5 mg olanzapine. On the floor, pt is unable to recount her history and ___ is difficult to understand. Attempted interview with interpreter however patient remained difficult to understand and was switching back and forth between speaking in creole and ___. She is able to tell me that she is in the hospital but is unable to tell me why she came into the hospital. She states that she doesn't feel great, but also doesn't feel bad but is unable to elaborate. She is cooperative and generally following commands. Review of systems: unable to obtain due to altered mental status Past Medical History: PAST MEDICAL HISTORY (per chart, unable to confirm with pt): CHRONIC KIDNEY DISEASE ? SLEEP APNEA PULMONARY HYPERTENSION ? CORONARY ARTERY DISEASE - Referenced in renal note, ___ SICKLE CELL TRAIT OSTEOPOROSIS HYPERLIPIDEMIA HYPERTENSION GASTROESOPHAGEAL REFLUX OSTEOARTHRITIS HxBRADYCARDIA,ICD H/O BREAST CANCER - S/P lumpectomy, XRT - Patient has deferred mammographic follow-up H/O CONGESTIVE HEART FAILURE - Per renal note, ___ H/O DIABETES MELLITUS LUMPECTOMY ___ Social History: ___ Family History: FAMILY HISTORY(per chart, unable to confirm with pt):Mother with sickle cell Physical Exam: Admission Physical Exam: ======================== Constitutional: Thin, Alert, oriented to hospital not to date, no acute distress EYES: Sclera anicteric, EOMI, PERRL ENMT: MMM, oropharynx clear, normal hearing, normal nares CV: Irregular, normal S1 + S2, ___ SEM, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, 1+ bilat pitting edema to mid shin NEURO: aaox1, CNII-XII and strength grossly intact SKIN: no rashes or lesions Discharge Physical Exam: ======================== Gen: Lying in bed in no apparent distress Vitals: Eflowsheets HEENT: Anicteric, eyes conjugate, MMM, no JVD Cardiovascular: RRR no MRG, nl. S1 and S2 Pulmonary: Lung fields clear to auscultation throughout Gastroinestinal: Soft, non-tender, non-distended, bowel sounds present, no HSM MSK: No edema Skin: No rashes or ulcerations evident Neurological: Alert, interactive, speech fluent, face symmetric, moving all extremities Psychiatric: pleasant, appropriate affect Pertinent Results: Admission Labs ============== ___ 01:05PM BLOOD WBC-6.4 RBC-3.83* Hgb-11.8 Hct-36.3 MCV-95 MCH-30.8 MCHC-32.5 RDW-13.1 RDWSD-45.1 Plt ___ ___ 01:05PM BLOOD Glucose-70 UreaN-23* Creat-1.7* Na-142 K-4.9 Cl-103 HCO3-24 AnGap-15 ___ 01:05PM BLOOD ALT-10 AST-26 CK(CPK)-132 AlkPhos-90 TotBili-1.3 ___ 01:05PM BLOOD CK-MB-6 cTropnT-0.02* ___ 07:50PM BLOOD cTropnT-0.02* ___ 01:05PM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.1 Mg-2.0 ___ 06:45AM BLOOD VitB12-371 ___ 06:45AM BLOOD TSH-1.1 ___ 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 01:21PM BLOOD Lactate-2.0 Imaging: ======== CT Head: 1. No acute intracranial hemorrhage or evidence of infarction. 2. Chronic involutional changes consistent with age as well as evidence of chronic microangiopathy Discharge Labs: =============== ___ 06:55AM BLOOD WBC-5.3 RBC-3.70* Hgb-11.5 Hct-34.8 MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 RDWSD-47.0* Plt ___ ___ 06:35AM BLOOD Glucose-86 UreaN-52* Creat-1.7* Na-144 K-4.8 Cl-105 HCO3-29 AnGap-10 ___ 06:35AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.7* Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Apixaban 2.5 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. Furosemide 20 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Ranitidine 150 mg PO BID 6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 7. Calcium Carbonate 1500 mg PO DAILY 8. Vitamin D 200 UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. OLANZapine 5 mg PO QHS RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #*30 Packet Refills:*0 3. Ramelteon 8 mg PO QHS RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. TraZODone 25 mg PO QHS RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*15 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 7. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 9. Calcium Carbonate 1500 mg PO DAILY RX *calcium carbonate 600 mg calcium (1,500 mg) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 11. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Vitamin D 200 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 14.Ensure Ensure TID ICD 10 E44 Dispense: 90 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Dementia Fever Secondary: CKD DM HTN Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with AMS// eval for pna COMPARISON: ___ FINDINGS: AP upright and lateral views of the chest provided. Right chest wall pacer device is again seen with leads extending to the region the right atrium and right ventricle. Pulmonary vascular congestion is noted with possible mild interstitial pulmonary edema. No large effusion, pneumothorax or signs of pneumonia. Cardiomediastinal silhouette appears unchanged. Imaged bony structures are intact. High riding right humeral head suggests chronic rotator cuff disease. Bilateral AC joint arthropathy is partially visualized. Degenerative changes in the spine appear grossly unchanged with partially visualized lumbar levoscoliosis. IMPRESSION: Congestion with mild interstitial edema. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with AMS// eval for acute head bleed 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: Total DLP (Head) = 1,605 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute major infarction,hemorrhage,edema,or discrete mass. There is prominence of the ventricles and sulci suggestive of involutional changes, consistent with age. Multiple subcortical and periventricular white matter hypodensities are likely sequela of chronic microangiopathy. There is no acute fracture. 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. No acute intracranial hemorrhage or evidence of infarction. 2. Chronic involutional changes consistent with age as well as evidence of chronic microangiopathy. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with dementia, afib, now with fever// please eval for evidence of aspiration or consolidation IMPRESSION: In comparison with the study of ___, there are lower lung volumes. Cardiac silhouette is at the upper limits of normal in size without appreciable vascular congestion, pleural effusion, or acute focal pneumonia. Dual channel pacer leads again extend to the right atrium and right ventricle. Otherwise, little change. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Agitation, Failure to thrive Diagnosed with Restlessness and agitation temperature: 98.0 heartrate: 50.0 resprate: 20.0 o2sat: 98.0 sbp: 131.0 dbp: 53.0 level of pain: 0 level of acuity: 2.0

___ with PMHx CKD, afib, DM, dementia who presented from her PCP with acute encephalopathy. # Acute encephalopathy # FTT # Moderate protein-calorie malnutrition # Paranoid delusions Presenting with agitation and aggression at home, and was referred to the ED by her PCP on ___ due to paranoid and agitated behavior. Head CT was negative for acute process. Infectious workup including CXR, urinalysis, and blood cultures were negative. Toxicology screen was negative. In terms of reversible causes of dementia, TSH and RPR were normal and B12 was low normal (would consider methylmalonic acid testing as an outpatient). She remained pleasant and interactive in the morning and with sundowning starting around 5 ___ with severe aggression and paranoid delusions. She was seen by psychiatry who recommended titration of antipsychotic medications. She was discharged on 5mg olanzapine at night and should follow up with her primary care medication to discuss possibly downtitrating this medication as an outpatient. Overall her agitated and paranoid behavior was thought to be secondary to progressive dementia. She was not deemed to be safe to be alone and 24 hour care was recommended. After several family meetings decision was made that patient will go to stay with her niece ___ at her home where 24 hour care can be provided. Her family will apply in the meantime for expanded care coverage through ___. If this is eventually arranged to cover 12 hour daytime care then she may eventually be able to return home (son stays in apartment overnight). # Fever: had single isolated fever to 100.6 during 11 day hospital stay. She was asymptomatic without localizing symptoms. Repeat CXR and urinalysis were negative for infection. Blood cultures were sent and were pending at time of discharge. # CKD: creatinine mostly at baseline. Did increase on several days when PO intake was poor and home Lasix was held on those days. Creatinine at discharge was 1.7 which was within range of baseline # DM: per chart however does not appear to be on meds. Monitored on insulin sliding scale but did not require supplemental insulin # Afib: rate controlled, hx of bradycardia with pm in place. Continued home apixaban and metoprolol # HLD: continued home atorvastatin # ___, chronic dCHF: seen by cardiology recently, thought to be due to pulmonary hypertension/elevated filling pressures as well as decreased physical activity/venous stasis. She was continued on home Lasix at 20mg daily dose (had recently been increased to BID) given at times poor PO intake secondary to agitation or lethargy. > 30 minutes spent on discharge coordination and planning

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Transient word-finding difficulties Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ M w/ multiple vascular risk factors including AFib/AFlutter on Coumadin s/p DC version ___, CAD s/p LAD PCI ___ and CABG ___, CHF, CKD w/ b/l Cr 1.3-1.5, renal artery stenosis s/p stents, bilateral carotid artery stenosis s/p L ICA stent ?___, who presents with transient word-finding difficulties resolved after 15mins. History is obtained by patient and his daughter who witnessed the event. He was in his usual state of health until dinner today around 5:45pm when he suddenly had difficulty speaking the word "zinfadel". He states that he was able to think of the word but he had trouble producing the word and it came out "scrambled". He denies slurred speech. He was able to speak other words and understand his daughter, but he found trouble saying certain other words as well such as "alphabet". Daughter called ambulance who brought him to ___ ED. At time of evaluation, patient reports his symptoms are completely resolved and he is able to say both "zinfadel" and "alphabet easily. He denies weakness, sensory changes, visual changes, headache, dysarthria, difficulty comprehending speech, bowel or bladder incontinence. ED course: In ED, initial VS sig for BP 179/76, HR 76, 100% RA. Neurologic examination was essentially wnl with normal language/speech and memory, mild chronic sensory loss on LLE. EKG showed sinus rhythm. He underwent CT noncontrast at 1840 which was negative for acute bleed. Labs revealed INR 2.8, CBC wnl, BMP w/ Cr 1.3 (chronic). Later at ___, patient had worsening of his symptoms with inability to remember his daughter's and his roommates' names. On evaluation he was inattentive and had some difficulty naming objects, mistaking watch for "telephone" and poor memory. CTA head/neck around ___ reveal new left temporal hyperdensity c/w hemorrhage; also revealed right-sided complete ICA occlusion as well as mod stenosis of left ICA but patent stent. No large MCA cutoff. Noncontrast head CT was performed and showed increased size of hemorrhage with extension into the occipital horn of left lateral ventricle. Neurosurgery was consulted who initially recommended continued monitoring and no indication for surgery currently. He was subsequently given IV vitamin K and prothrombin complex to reverse his INR, and given 1u platelets given he was on dual antiplatelet therapy. Admitted to Neuro ICU. Past Medical History: Coronary artery disease (s/p LAD stent in ___, ___, s/p 3-vessel CABG ___ Meningioma s/p resection Adjustment disorder Left posterior meningioma s/p resection Sleep apnea Obesity Carotid stenosis s/p left ICA stent (___) CHF (congestive heart failure), ___ class III Chronic renal insufficiency Bilateral renal artery stenosis s/p stents (___) Hyperlipidemia Hypertension Left lumbar radiculopathy Atrial flutter Atrial fibrillation Social History: ___ Family History: Mother with TIAs in her ___, breast cancer, skin cancers Father with MI at age ___ Physical Exam: ========================= ADMISSION PHYSICAL EXAM ========================= Vitals: BP 179/76, HR 76, RR 13, spO2 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, R>L 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 x3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register ___ objects and recall ___ at 10 minutes, remembered ___ with category cue. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. 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: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 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 2+ 2+ 2+ 3 2+ R 2+ 2+ 2+ 3 2+ Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred. On repeat exam at ___: -MS: Patient was oriented to ___ and hospital, but could not name which hospital he was at, and perseverated on the date. Able to name ___ but not backwards. Able to repeat simple phrases, speech fluent but with paraphasic errors. Named thumb and nail, but could not name cuticle, and stated "telephone" for watch. Able to follow commands. -CN, Motor, Sensory exams unchanged ========================= DISCHARGE PHYSICAL EXAM ========================= Tmax: 36.8°C (98.3°F) T current: 36.6°C (97.9°F) HR: 82 (80 - 120) bpm BP: 117/87(91) {94/50(58) - 166/120(129)} mmHg RR: 18 (16 - 31) insp/min SPO2: 99% Total In:1,865 mL PO:1,865 mL Total out:1,525 mL Urine:1,525 mL Balance:340 mL General: Awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, R>L carotid bruits appreciated Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: Soft, NT/ND Extremities: No C/C/E bilaterally Skin: No rashes or lesions noted Neurologic: -Mental Status: Alert, oriented to person and time only. States in ___ but unable to state the name of the hospital. Able to name high frequency objects but not low frequency objects. Semantic paraphasic errors (e.g. thermostat for stethoscope). Repetition intact to simple phrases but impaired for complex phrases. Able to follow 3-step commands. Perseverative. Decreased short term memory. Pt was able to register ___ words and recall ___ at 1 minute. Able to read a sonnet but skips words and phrases. Names only 1 animal in 1 minute. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to finger wiggling. Facial sensation intact to light touch. Face symmetric. ___ strength in trapezii bilaterally. Tongue midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L ___ 3 2 R ___ 3 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred. Pertinent Results: ========== LABS ========== ___ 06:30PM BLOOD ___ PTT-43.5* ___ ___ 03:42AM BLOOD ___ PTT-34.3 ___ ___ 06:30PM BLOOD ALT-42* AST-49* AlkPhos-82 TotBili-0.5 ___ 06:30PM BLOOD Lipase-142* ___ 06:30PM BLOOD cTropnT-<0.01 ___ 03:42AM BLOOD %HbA1c-5.9 eAG-123 ___ 03:42AM BLOOD Triglyc-70 HDL-56 CHOL/HD-3.0 LDLcalc-99 ___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 02:40AM BLOOD Glucose-100 UreaN-19 Creat-1.2 Na-139 K-4.3 Cl-101 HCO3-25 AnGap-17 ========== IMAGING ========== CTA HEAD AND NECK (___): 1. In the interval between the initial head CT without contrast and CTA examination, development of a 4.6 left temporal lobe parenchymal hemorrhage. No definite spot sign or aneurysm. 2. Multi segment high-grade stenosis of the left intracranial ICA, complete occlusion of the right ICA from the carotid bifurcation to the right carotid terminus. The remainder of the intracranial circulation is patent, allowing for anatomic variation. No aneurysm. 3. Metallic stent covers the proximal cervical left internal carotid artery where there is multifocal luminal narrowing resulting in approximately 75% stenosis by NASCET criteria. Complete occlusion of the cervical right internal carotid artery. Multifocal high-grade stenosis of the left V1 segment. The right vertebral artery is grossly unremarkable. 4. Multiple left pulmonary nodules, unchanged in appearance from CTA chest of ___. NCHCT (___): 1. Left temporal intraparenchymal hemorrhage appears grossly similar to prior CTA performed 4 hours prior. 2. Extension of hemorrhage into the left lateral ventricle and third ventricle. 3. Small amount of left parietal subarachnoid hemorrhage. ECHO (___): The left atrium is mildly dilated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, no clear change. NCHCT (___): 1. Slight interval increase the left temporal intraparenchymal hemorrhage with mass effect and minimal uncal herniation. 2. Intraventricular extension of hemorrhage and less conspicuous left parietal subarachnoid hemorrhage. NCHCT (___): 1. Unchanged appearance of left temporal lobe parenchymal hemorrhage with minimal left uncal herniation. 2. No interval change in appearance of hemorrhage extension into left occipital horn of the lateral ventricle and third ventricle. 3. No hydrocephalus. No new hemorrhage or acute territorial infarct. MRI HEAD WITH AND WITHOUT CONTRAST (___): 1. Left temporal lobe hemorrhage with intraventricular extension is not significantly changed compared to prior CTs, allowing for inter-modality differences. 2. No evidence of acute infarction, underlying mass lesion or new intracranial hemorrhage elsewhere in the brain. 3. Left occipital craniotomy changes and associated focal encephalomalacia, unchanged. 4. Dural thickening versus a small sliver residual subdural collection is noted along the left frontotemporal convexity. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Warfarin 7.5 mg PO DAILY16 4. Nasacort (triamcinolone acetonide) 55 mcg nasal Other 5. Atorvastatin 80 mg PO QPM 6. Sildenafil Dose is Unknown PO Frequency is Unknown 7. BuPROPion (Sustained Release) 150 mg PO QAM 8. Furosemide 20 mg PO BID 9. Lisinopril 5 mg PO DAILY 10. Sotalol 80 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Furosemide 20 mg PO BID 4. Acetaminophen ___ mg PO Q6H:PRN PAIN 5. Atorvastatin 80 mg PO QPM 6. Nasacort (triamcinolone acetonide) 55 mcg nasal Other 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 9. Outpatient Speech/Swallowing Therapy Speech evaluation and treatment Diagnosis: Left temporal lobe ischemic stroke with hemorrhagic conversion Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Left temporal lobe ischemic stroke with hemorrhagic conversion Secondary diagnosis: AFib/AFlutter status post cardioversion ___ CAD status post LAD PCI ___ and CABG ___ CHF CKD (baseline Cr 1.3-1.5) Renal artery stenosis status post stents (___) Bilateral carotid artery stenosis status post L ICA stent (___) 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 difficulty speaking // Eval for ICH 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 70 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. Please note, noncontrast head CT was performed at 7 ___. The CTA portion of the examination was performed at ___. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP = 35.4 mGy-cm. 4) Spiral Acquisition 5.2 s, 40.9 cm; CTDIvol = 32.1 mGy (Head) DLP = 1,313.8 mGy-cm. Total DLP (Head) = 1,349 mGy-cm. COMPARISON: CTA chest with without contrast of ___. FINDINGS: CT HEAD WITHOUT CONTRAST: PERFORMED AT 7pm on ___ The patient is status post left occipital craniotomy with left occipital lobe encephalomalacia. There is no intra or extra-axial mass effect, acute hemorrhage or territorial infarct. Sulci, ventricles and cisterns are within expected limits for the patient's age related global cerebral volume loss, allowing for encephalomalacia. The paranasal sinuses are essentially clear. The orbits are unremarkable. The mastoid air cells are clear. ble. CTA HEAD: PERFORMED at ___ on ___ Interval development of a 4.5 x 2.3 cm (AP, TRV) left temporal lobe parenchymal hemorrhage with mild surrounding edema pattern, resulting in mild left uncal herniation. Although there appears to be traversing vessels through the hemorrhage, no clear spot sign is identified. There is complete occlusion of the right internal carotid artery starting at the carotid bifurcation extending into the cavernous portion with reconstitution of the M1 segment, from collateral flow. The left internal carotid artery contains a proximal cervical segment metallic stent, and is patent but with multifocal narrowing throughout the stent. There is severe narrowing of the proximal petrous portion of the left ICA as well as the cavernous portion. Atherosclerotic calcification of the bilateral cavernous segments are also noted. The bilateral M1 and M2 segments appear patent without stenosis or occlusion. Bilateral ACAs are patent. There is fetal type origin of the right PCA. The left posterior communicating artery is not visualized. The posterior circulation is also patent. The left vertebral artery ends in ___. CTA NECK: In addition to the above, There is a 3 vessel arch. As noted above, there is complete occlusion of the right cervical internal carotid artery at the level of the bifurcation. A metallic stent covers the proximal cervical internal carotid artery with multifocal narrowing with approximately 75% stenosis by NASCET criteria. Atherosclerotic calcification at the origin of the left vertebral artery results in high-grade stenosis of the left V1 segment is also identified with reconstitution at the V2 level at C6. The right vertebral artery is grossly unremarkable from its origin to the skullbase. The bilateral common carotid arteries are patent. There is narrowing at the origin and proximal left vertebral artery which reconstitutes at the level of C6. OTHER: There is a 4 mm ground-glass nodule in the left upper lobe (series 28, image 9), an additional scattered less than 2 mm nodules near the lung apices are similar appearance to prior CTA chest of ___. No new pulmonary nodules. There is no lymphadenopathy by size criteria. The thyroid gland is unremarkable. The visualized aerodigestive tract is also unremarkable. Median sternotomy wires are noted. IMPRESSION: 1. In the interval between the initial head CT without contrast and CTA examination, development of a 4.6 left temporal lobe parenchymal hemorrhage. No definite spot sign or aneurysm. 2. Multi segment high-grade stenosis of the left intracranial ICA, complete occlusion of the right ICA from the carotid bifurcation to the right carotid terminus. The remainder of the intracranial circulation is patent, allowing for anatomic variation. No aneurysm. 3. Metallic stent covers the proximal cervical left internal carotid artery where there is multifocal luminal narrowing resulting in approximately 75% stenosis by NASCET criteria. Complete occlusion of the cervical right internal carotid artery. Multifocal high-grade stenosis of the left V1 segment. The right vertebral artery is grossly unremarkable. 4. Multiple left pulmonary nodules, unchanged in appearance from CTA chest of ___. RECOMMENDATION(S): Follow-up of multiple left pulmonary nodules as suggested on CTA chest of ___. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ male with new bleed on cta (since prior noncontrast head CT). Evaluate for a bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 903 mGy-cm. COMPARISON: CTA head neck from 21 Nvember ___ at 18:40. FINDINGS: There is a 3.8 x 2.5 cm left temporal lobe intraparenchymal hemorrhage, grossly similar in size to the prior CTA from 4 hours prior. A small amount of subarachnoid hemorrhage is noted along the right parietal lobe (series 2a:image 19). Extension of the hemorrhage into the left lateral ventricle and third ventricle is noted. No hydrocephalus is seen. No shift of midline structures is noted. Prior left occipital craniotomy is noted pulse well as underlying encephalomalacia in the left occipital lobe. 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. Left temporal intraparenchymal hemorrhage appears grossly similar to prior CTA performed 4 hours prior. 2. Extension of hemorrhage into the left lateral ventricle and third ventricle. 3. Small amount of left parietal subarachnoid hemorrhage. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with left temporal intraparenchymal hemorrhage. Assess for interval change in bleed. 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: Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head from ___ 22:10. FINDINGS: A left temporal intraparenchymal hemorrhage appears slightly increased in size, currently measuring 4.5 x 2.8 cm compared to 3.6 x 2.3 cm (series 2: Image 12). Associated mass-effect is seen causing minimal uncal herniation. Extension of the hemorrhage into the left lateral ventricle and third ventricle is seen. Ventricular configuration in size is unchanged from prior exam. A small amount of right parietal subarachnoid hemorrhage is less conspicuous on this exam. No new infarct, hemorrhage, edema or mass is seen. Prior left suboccipital craniotomy is noted. There is no evidence of fracture. 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. Slight interval increase the left temporal intraparenchymal hemorrhage with mass effect and minimal uncal herniation. 2. Intraventricular extension of hemorrhage and less conspicuous left parietal subarachnoid hemorrhage. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with L ischemic temporal stroke with hemorrhagic conversion // ? interval change TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 844 mGy-cm. COMPARISON: CT head without contrast of ___ at 04:26 and ___. FINDINGS: Left 4.2 x 2.6 cm (AP, TRV) the temporal lobe parenchymal hemorrhage with surrounding vasogenic edema pattern is essentially unchanged in size when compared to the prior examination of ___ at 04:26. Associated mass effect with minimal uncal herniation is unchanged. Ventricular extension the hemorrhage into the occipital horn of the left lateral ventricle and superior third ventricle is also stable. The configuration and size of the ventricles are unchanged without evidence of developing ventriculomegaly. No new hemorrhages. No acute territorial infarct. Suggestion of right parietal subarachnoid hemorrhage is noted. There is essentially no midline shift. Remote left occipital craniotomy and left occipital encephalomalacia are stable. The visualized paranasal sinuses are essentially clear. The orbits are unremarkable. The mastoid air cells and middle ear cavities are well pneumatized and clear. IMPRESSION: 1. Unchanged appearance of left temporal lobe parenchymal hemorrhage with minimal left uncal herniation. 2. No interval change in appearance of hemorrhage extension into left occipital horn of the lateral ventricle and third ventricle. 3. No hydrocephalus. No new hemorrhage or acute territorial infarct. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with L temporal bleed // ?ischemia, ?characterization 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: ___. CT head: ___ and ___. FINDINGS: A large left temporal lobe hematoma appears unchanged in size compared to prior CTs, allowing for inter modality differences. There is a central T1 hyperintense component (2:6), representing acute/subacute blood products, with large blooming artifact on gradient recalled echo images. There is surrounding vasogenic edema, causing local mass effect with no significant shift of the normally midline structures. Dural thickening versus a small sliver residual subdural collection is noted along the left frontotemporal convexity (11:16). Extension of hemorrhagic products into the occipital horn of the left lateral ventricle is noted on axial FLAIR sequence images (11:12). Prior left occipital craniotomy changes are again noted, with associated encephalomalacia in the left occipital lobe (12:9). Postcontrast images reveal no evidence of underlying enhancing mass in the region of the left temporal hemorrhage or elsewhere within the brain. There is no acute infarction. Ventricles and sulci are stable in size and configuration. Intracranial vascular flow voids are preserved and dural venous sinuses are patent. IMPRESSION: 1. Left temporal lobe hemorrhage with intraventricular extension is not significantly changed compared to prior CTs, allowing for inter-modality differences. 2. No evidence of acute infarction, underlying mass lesion or new intracranial hemorrhage elsewhere in the brain. 3. Left occipital craniotomy changes and associated focal encephalomalacia, unchanged. 4. Dural thickening versus a small sliver residual subdural collection is noted along the left frontotemporal convexity. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Slurred speech Diagnosed with Nontraumatic intcrbl hemorrhage in hemisphere, cortical, Aphasia temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Mr. ___ is a ___ yo man with a past medical history notable for atrial fibrillation and atrial flutter on coumadin status post cardioversion (___), CAD s/p LAD PCI ___ and CABG ___, CHF, CKD (baseline Cr 1.3-1.5), renal artery stenosis s/p stents (___), and bilateral carotid artery stenosis s/p L ICA stent ___ posterior meningioma s/p resection, who presented ___ with transient word-finding difficulties. During his ED course, neurologic deficits recurred with NCHCT revealing a left temporal intraparenchymal hemorrhage. CTA showed a likely chronically occluded R ICA and high grade stenosis (~75%) of the L ICA stent. Pt was admitted to the neurologic ICU for further management. Pt's bleed was presumed to be due to a hemorrhagic conversion of an ischemic infarct. MRI did not reveal an underlying lesion or microhemorrhages. The hemorrhagic conversion was likely related to pt's use of ASA, Plavix and warfarin. These medications were all held at admission. Pt's infarct was felt to be an embolic infarct either due to a cardiac source (given his history of atrial fibrillation and recent cardioversion) or atherosclerotic source (given his severe atherosclerosis). TTE did not show an intracardiac thrombus. For management, systolic blood pressure goals were between 120 and 160 to maintain adequate cerebral perfusion given pt's severe atherosclerotic disease while also preventing expansion of the bleed. INR was reversed to a goal of <1.5. Neurosurgery was consulted who deferred surgical management. Pt's statin was initially held as there was concern this would worsen the hemorrhage. On hospital day #4, aspirin 81 mg daily was restarted. This was started to prevent stent thrombosis and also for secondary stroke prevention. Warfarin will be restarted on ___. Pt's cardiologist was contacted who was in agreement that the risk associated with starting dual anti-platelet in conjunction with warfarin outweighed the benefits. Once INR is therapeutic on warfarin, plans are to discontinue aspirin 81mg daily. Pt's PCP and cardiologist have been contacted regarding this plan. Otherwise, pt's renal function remained stable during hospitalization. ======================================================= AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (X) Yes - () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (X) Yes - () No

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine / Latex Attending: ___. Chief Complaint: weakness, epigastric/left-sided chest pain, globus sensation Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. ___ is a ___ year old lady with history of HTN, HLD, chronic HA, OA, aortic stenosis, frequent falls, questionable ___ disease vs. multiple system atrophy who presented to our emergency department with reported R sided weakness and epigastric pain since this morning. Pt reports right sided and epigastric abdominal pain. She has felt something "growing inside" of her for the last 1 month and the pain worsened this morning. Lower back pain X 1 week. Pt reports recent fall 2 weeks ago where she hit the left side of her face with no LOC. Per grandson, he has noticed worsened stability with leaning to the right side over the last week and "not making sense" intermittently but denies confusion. She has had increased difficulty picking up both feet. Patient reports pleuritic right sided chest pain and tightness in chest with associated shortness of breath. Tenderness to palpation ~R 5th rib. She also reports she has felt some discomfort/something stuck in throat since this morning after eating banana. Denies dysphagia. PE in the ___, significant for PERRL, nonfocal neurological exam, CNII-XII grossly intact, sensation grossly intact b/l ___ no epigastric mass palpated, +Rovsings sign The ___ felt that she may have appendicitis vs AAA, ?TIA, so she had a CT head non-contrast which showed no acute ICP. Abd ultrasound ruled out AAA. CT a/p with PO contrast initially normal, but per further review by radiology, ascending ___ may have some thickening vs artifact from mixing with PO contrast and stool. No concern for inflammation or colitis. They recommended follow up with colonoscopy to make sure there is no underlying mass. No CXR done. LFTs and lipase were normal. EKG was NSR. ___ MD attempted to walk her, gait test patient unable to support herself even with assistance. Noted leaning towards one side or the other. Given that patient has little assistance at home, patient lives with ___ young nephews, ___ to walk without stance. Daughter is working on placement to nursing home but worries she may be denied because of income level. In the ___, initial vs were: ___ 73 124/71 18 97%. Patient was given morphine, carbidopa-levidopa, and 1 liter of NS. Past Medical History: Obesity Osteopenia Osteoarthritis Diverticulosis Degenerative disk disease Hypercholesterolemia Hypertensive retinopathy Benign Hypertension Borderline diabetes s/p cholecystectomy ___ s/p hysterectomy ___ s/p shoulder surgeries, most recently ___ s/p left total knee arthroplasty, ___ persistent epigastric pain, felt to be possible costochondritis by GI ___ disease vs. multiple system atrophy Hemorrhagic calluses and hyperkeratosis of bilateral feet Chronic daily headache Aortic stenosis Social History: ___ Family History: Positive for breast cancer in sisters. Her mother died of congestive heart failure. Physical Exam: ADMISSION PHYSICAL EXAM: . Vitals: 97.5 - 152/68 - 57 - 18 - 100ra General: pleasant obese interactive elderly lady HEENT: nc/at sclera anicteric mucosa moist Neck: supple Lungs: clear to auscultation CV: ___ systolic murmur reg rate and rhythm Abdomen: soft, non tender Ext: no edema. R hand chronically flexed, difficult to open Skin: no rashes Neuro: alert, oriented x3, moves all 4 extremities; no cogwheel rigidity bilaterally, no ratchet like movements of arms, gait not tested, speech fluent linear and appropriate. tongue seems to deviate slightly ot the right. face asymmetric: keeps R eye closed on purpose as has R eye lateral deviation chronically w/ double vision, but eyebrow lift symmetric . DISCHARGE PHYSICAL EXAM: . Vitals: T 98.2 BP 145/86 HR 62 RR 18 100% on RA General: pleasant obese interactive elderly lady HEENT: non-reactive dialated pupils, sclera anicteric, mucosa moist, R eye exotropia Neck: supple, no palpable thyroid masses/nodules Lungs: clear to auscultation CV: ___ systolic murmur reg rate and rhythm, chest pain reproducable on palpation Abdomen: soft, tenderness over epigastrum and ___ ribs, soft, maleable masses palpated in epigastrum as well as in left quadrant Ext: no edema. R hand chronically flexed Skin: no rashes Neuro: alert, oriented x3, moves all 4 extremities; no cogwheel rigidity bilaterally, no ratchet like movements of arms, speech fluent w/hypophonia. tongue seems to deviate slightly ot the right. face asymmetric: keeps R eye closed on purpose as has R eye exotropia, but eyebrow lift symmetric. Pertinent Results: ADMISSION LABS: ___ 05:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR ___ 05:15PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-2 ___ 01:33PM LACTATE-2.3* K+-4.3 ___ 01:00PM GLUCOSE-147* UREA N-16 CREAT-1.0 SODIUM-138 POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-20* ANION GAP-20 ___ 01:00PM ALT(SGPT)-21 AST(SGOT)-57* ALK PHOS-96 TOT BILI-0.3 ___ 01:00PM LIPASE-46 ___ 01:00PM CK-MB-6 cTropnT-<0.01 ___ 01:00PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.1 ___ 01:00PM TSH-2.4 ___ 01:00PM WBC-6.5 RBC-4.58 HGB-13.2 HCT-39.4 MCV-86 MCH-28.7 MCHC-33.5 RDW-14.2 ___ 01:00PM NEUTS-59.1 ___ MONOS-5.4 EOS-1.4 BASOS-0.4 ___ 01:00PM PLT COUNT-214 ___ 01:00PM ___ PTT-23.9* ___ ___ 01:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR ___ 01:00PM URINE RBC-0 WBC-5 BACTERIA-FEW YEAST-NONE EPI-12 TRANS EPI-<1 . ADMISSION IMAGING: . ___ CHEST XRAY: As compared to the previous radiograph, the lung volumes are unchanged. Status post left shoulder surgery. No evidence of pleural effusions or pneumothorax. The size of the cardiac silhouette continues to be borderline, without evidence of pulmonary edema. In the interval, the tortuosity of the thoracic aorta has increased and the diameter of the aortic arch and aortic knob also appears increased. This effect could in large parts be due to patient rotation. However, there also is the possibility of an aortic disease at the level of the arch and proximal part of the descending aorta. Therefore, if clinically possible, a CTA of the aorta should be performed to rule out acute aortic disease. ___ CT ABD & PELVIS W/O CON:IMPRESSION: Normal appendix. No evidence of nephrolithiasis or hydronephrosis. Diverticulosis without evidence of diverticulitis. Equivocal mild wall of the ascending ___ vs artifact from oral contrast mixing with stool. This may be artifactual. Findings could be confirmed with outpatient colonoscopy. ___ CT HEAD W/O CONTRAST: No acute intracranial process. ___ ABD U/S: No evidence of abdominal aortic aneurysm. . INTERIM IMAGING: . ___ CTA CHEST W/&W/O Contrast: No evidence of acute aortic pathology or pulmonary embolus. Widened mediastinum on radiograph is likely due to a combination of mild thoracic aortic tortuosity as well as patient rotation. Dilated main PA suggestive of chronic pulmonary hypertension. Thoracic aortic atheromatous subtle ulcerative plaques at the level of the arch, no thoracic aneurysm. Hiatal hernia. . DISCHARGE LABS: . ___ 01:20PM BLOOD WBC-12.4* RBC-4.19* Hgb-12.0 Hct-35.5* MCV-85 MCH-28.6 MCHC-33.7 RDW-14.2 Plt ___ ___ 01:20PM BLOOD Plt ___ ___ 06:50AM BLOOD Glucose-94 UreaN-22* Creat-1.1 Na-141 K-5.0 Cl-103 HCO3-30 AnGap-13 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcium Carbonate 500 mg PO TID W/MEALS 3. Carbidopa-Levodopa (___) 1.5 TAB PO TID W/MEALS 4. Omeprazole 20 mg PO DAILY 5. traZODONE 50 mg PO HS:PRN insomnia 6. Vitamin D 800 UNIT PO DAILY 7. Acetaminophen 1000 mg PO Q8H:PRN pain, fever 8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 9. Docusate Sodium 100 mg PO BID 10. Senna 2 TAB PO BID:PRN constipation Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Vitamin D 800 UNIT PO DAILY 3. traZODONE 50 mg PO HS:PRN insomnia 4. Senna 2 TAB PO BID:PRN constipation 5. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule,delayed ___ by mouth twice a day Disp #*30 Capsule Refills:*1 6. Docusate Sodium 100 mg PO BID 7. Carbidopa-Levodopa (___) 1.5 TAB PO TID W/MEALS 8. Calcium Carbonate 500 mg PO TID W/MEALS 9. Aspirin 81 mg PO DAILY 10. Acetaminophen 650 mg PO Q6H pain, fever for at least 2 weeks; if no improvement in pain may discontinue after this time RX *acetaminophen 325 mg 2 tablet(s) by mouth four times a day Disp #*84 Tablet Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: #Primary: - musculoskeletal chest pain and possible GERD/gastritis #Secondary: - Parkinsons vs. multisystem atrophy - Aortic Stenosis - Osteopenia - Osteoarthritis - Insomnia - Depression 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 INDICATION: Epigastric pain. Evaluate for abdominal aortic aneurysm. COMPARISON: CT Torso from ___. FINDINGS: The proximal aorta measures 2.4 cm in maximal diameter. The mid aorta measures 2.3 cm in diameter. The distal aorta measures 1.9 cm in diameter. The common iliac arteries measure 1.4 cm in diameter bilaterally. There is normal color flow throughout the aorta. No significant atherosclerotic disease is seen. The bilateral kidneys are without stones or hydronephrosis. The right kidney measures 11.2 cm and the left kidney 10.6 cm in length. IMPRESSION: No evidence of abdominal aortic aneurysm. Radiology Report HISTORY: Right-sided weakness with nonfocal neurologic exam. Evaluate for TIA or stroke. TECHNIQUE: MDCT acquired contiguous axial images were obtained through the head. No contrast was administered. Coronal and sagittal reformats reviewed. COMPARISON: CT of the head from ___. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or vascular territorial infarction. The ventricles and sulci are proportionally prominent, consistent with age related involutional changes. Periventricular and subcortical white matter hypodensities are suggestive of chronic small vessel ischemic disease. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. Radiology Report HISTORY: Right-sided abdominal pain. Evaluate for appendicitis. TECHNIQUE: MDCT acquired axial images were obtained from the lung bases to the pubic symphysis after enteric contrast only. Coronal and sagittal reformats reviewed. COMPARISON: CT from ___. FINDINGS: The lower chest is unremarkable. ABDOMEN: Limited, noncontrast views of the liver, intrahepatic biliary tree, the spleen, adrenal glands, and pancreas are unremarkable. Minimal dilation of the CBD is stable and likely secondary to cholecystectomy. An extra renal pelvis is noted on the right side, stable. The kidneys are symmetric in size, without hydronephrosis, stone, or mass. There is no perinephric fluid collection or stranding. The stomach is collapsed. The small bowel, and large bowel are normal in caliber. There is equivocal mild wall thickening at ascending, most likely due to mixing of contrast and fecal material. There is colonic diverticulosis without evidence of diverticulitis. The appendix is normal. There is no ascites, fluid collection, pneumoperitoneum, or focal mesenteric fat stranding. There is no lymphadenopathy. The abdominal aorta is normal in caliber. PELVIS: The urinary bladder and rectum are unremarkable. There are no stones within either ureter or within the bladder. The there is no pelvic free fluid, lymphadenopathy, or mass. The uterus and ovaries are not well-seen. MUSCULOSKELETAL: There are no destructive osseous lesions concerning for malignancy or infection. Stable compression fracture of L1. IMPRESSION: 1. Normal appendix. 2. No evidence of nephrolithiasis or hydronephrosis. 3. Diverticulosis without evidence of diverticulitis. 4. Equivocal mild wall of the ascending colon vs artifact from oral contrast mixing with stool. This may be artifactual. Findings could be confirmed with outpatient colonoscopy. NOTIFICATION: Impression #4 was communicated to Dr. ___ by Dr. ___ on ___ at 9:05 pm via telephone. Radiology Report CHEST RADIOGRAPH INDICATION: Epigastric pain, right-sided abdominal pain, evaluation. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the lung volumes are unchanged. Status post left shoulder surgery. No evidence of pleural effusions or pneumothorax. The size of the cardiac silhouette continues to be borderline, without evidence of pulmonary edema. In the interval, the tortuosity of the thoracic aorta has increased and the diameter of the aortic arch and aortic knob also appears increased. This effect could in large parts be due to patient rotation. However, there also is the possibility of an aortic disease at the level of the arch and proximal part of the descending aorta. Therefore, if clinically possible, a CTA of the aorta should be performed to rule out acute aortic disease. At the time of dictation and observation, 8:52 a.m., the referring physician, ___, was paged for notification. At 9:40 a.m. on the same day, findings were discussed over the telephone with Dr. ___ the recommendation for a CTA. Radiology Report HISTORY: Aortic stenosis and parkinsonism who presents with left-sided chest pain and dysphagia. On chest radiograph found to have widened mediastinum. Concern for enlarged thyroid. COMPARISON: Chest radiograph ___, CT torso ___. TECHNIQUE: Axial helical MDCT images were obtained of the chest after the administration of IV contrast in the arterial phase. Multiplanar reformatted images were generated in the coronal and sagittal planes as well as bilateral oblique maximum intensity projection images. DLP: 478.30 mGy-cm. FINDINGS: The thyroid is not imaged. The trachea is midline and the airways are patent to the subsegmental level. Minimal atelectasis is noted in bilateral lung bases. The lung parenchyma is otherwise clear without nodule or focal consolidation. The pleural surfaces are clear without focal thickening, effusion, or pneumothorax. Heart size is normal with minimal characterization of aortic valve and coronary artery calcifications due to contrast administration. A mildly tortuous thoracic aortic arch is normal in caliber, with note made of lumenal ulcerative atheromatous plaques. There is no evidence of aneurysm or dissection. The main pulmonary artery is dilated to a maximum diameter of 3.4 cm suggestive of chronic pulmonary hypertension. There is no pulmonary embolus to the subsegmental level. There is no supraclavicular, axillary, hilar or mediastinal lymphadenopathy by CT size criteria. This study is not tailored for the evaluation of subdiaphragmatic structures; however, within those limitations, the visualized portions of the upper abdominal organs are grossly unremarkable. There is a small hiatal hernia. OSSEOUS STRUCTURES: There are no focal blastic or lytic lesions in the visualized osseous structures concerning for malignancy. IMPRESSION: 1. No evidence of acute aortic pathology or pulmonary embolus. Widened mediastinum on radiograph is likely due to a combination of mild thoracic aortic tortuosity as well as patient rotation. 2. Dilated main PA suggestive of chronic pulmonary hypertension. 3. Thoracic aortic atheromatous subtle ulcerative plaques at the level of the arch, no thoracic aneurysm. 4. Hiatal hernia. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: RIGHT SIDED WEAKNESS/ABD PAIN Diagnosed with OTHER MALAISE AND FATIGUE, ABDOMINAL PAIN OTHER SPECIED temperature: 98.8 heartrate: 73.0 resprate: 18.0 o2sat: 97.0 sbp: 124.0 dbp: 71.0 level of pain: 8 level of acuity: 2.0

Ms ___ was admitted for chest pain and fatigue. She also complained of a sensation of globus. She has is also very weak and deconditioned and has had multiple falls recently. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: CC: ___ days of L sided upper abdominal pain Major Surgical or Invasive Procedure: Left percutaneous nephrostomy tube History of Present Illness: ___ year old M with PMH CAD (s/p 3 stents, last in ___, atrial fibrillation on Coumadin, bladder CA x ___ years (s/p tumor resection) who presents with ___ days of constant, new upper L abdominal pain. Patient was diagnosed with bladder cancer ___ years ago and has had intermittent local recurrences requiring tumor resections. On ___, patient underwent an uneventful tumor resection at ___. He had 2 episodes of passing which resolved after irrigation with urology. Last ___, patient also started passing clots and bleeding "profusely" in his urine associated with penile pain and went to the hospital early ___ morning. These symptoms resolved again with irrigation. On ___ afternoon, he developed L upper abdominal pain he associated with constipation. He was unable to eat secondary to nausea and retching. No vomiting. His urologist recommended he come into the hospital. Patient denies having fevers/chills. Patient stopped taking his Coumadin last ___ (last dose on ___. Last BM 3 days ago. No headaches, dizziness, lightheadedness. No chest pain or shortness of breath. Feels fatigued but no weakness, numbness or tingling. At ___, patient was HD stable. A foley was inserted and showed maroon, red urine. His creatinine was 1.75 (b/l 1.13) and HB 10.8. CT showed a periureteral/RP fluid collection and left sided hydronephrosis. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: CAD/MI s/p 3 stents (___) and angioplasty ___ DMII (FSBG 135-145) Bladder cancer s/p TURBT (multiple) R ear ___ surgery Social History: ___ Family History: FAMILY HISTORY: Brother - CA *unknown origin Sister - alive - breast cancer, in remission Brothers - 1 w/DMII, kidney stone Physical Exam: VITALS: T 99.3 BP 120/65 RR 59 RR 18 O2: 95% on RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils constricted some reactivity with light, symmetric ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: RRR, no mrg RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, ttp of left upper abdomen. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation. Foley draining yellow urine MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge Physical Exam: T: 98.5, BP: 135 / 78, HR: 83 RR: 18, O2: 99% RA GENERAL: Alert and in no apparent distress EYES: Anicteric, PERRL, symmetric ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: NS1/S2, RRR, ___ systolic murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, TTP LLQ otherwise NT Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation. Foley draining yellow urine, left nephrostomy tube draining yellow urine MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ___ 06:30AM BLOOD WBC-6.0 RBC-3.08* Hgb-10.4* Hct-31.0* MCV-101* MCH-33.8* MCHC-33.5 RDW-14.0 RDWSD-51.8* Plt ___ ___ 06:30AM BLOOD WBC-5.2 RBC-2.91* Hgb-9.9* Hct-29.3* MCV-101* MCH-34.0* MCHC-33.8 RDW-13.9 RDWSD-52.2* Plt ___ ___ 06:40AM BLOOD WBC-6.2 RBC-2.83* Hgb-9.6* Hct-28.7* MCV-101* MCH-33.9* MCHC-33.4 RDW-14.2 RDWSD-52.8* Plt ___ ___ 07:14AM BLOOD WBC-8.2 RBC-3.25* Hgb-11.0* Hct-33.5* MCV-103* MCH-33.8* MCHC-32.8 RDW-14.6 RDWSD-55.5* Plt ___ ___ 06:40AM BLOOD Neuts-64.5 ___ Monos-10.6 Eos-2.3 Baso-0.5 Im ___ AbsNeut-3.97 AbsLymp-1.34 AbsMono-0.65 AbsEos-0.14 AbsBaso-0.03 ___ 07:14AM BLOOD Neuts-69.6 ___ Monos-9.0 Eos-0.2* Baso-0.2 Im ___ AbsNeut-5.73 AbsLymp-1.67 AbsMono-0.74 AbsEos-0.02* AbsBaso-0.02 ___ 06:30AM BLOOD Plt ___ ___ 06:30AM BLOOD ___ ___ 06:30AM BLOOD Plt ___ ___ 06:30AM BLOOD ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD ___ ___ 07:14AM BLOOD Plt ___ ___ 07:14AM BLOOD ___ PTT-24.1* ___ ___ 06:30AM BLOOD Glucose-149* UreaN-16 Creat-1.0 Na-143 K-4.9 Cl-105 HCO3-28 AnGap-10 ___ 06:40AM BLOOD Glucose-139* UreaN-23* Creat-1.2 Na-142 K-4.7 Cl-104 HCO3-27 AnGap-11 ___ 07:14AM BLOOD Glucose-164* UreaN-32* Creat-1.7* Na-138 K-4.4 Cl-100 HCO3-25 AnGap-13 ___ 06:30AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8 ___ 06:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 ___ 06:40AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1 ___ 06:40AM BLOOD VitB12-403 Folate-13 ___ 06:30AM BLOOD TSH-0.65 ___ 07:28AM BLOOD Lactate-1.5 ___ 07:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 07:00AM URINE Blood-MOD* Nitrite-NEG Protein-30* Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD* ___ 07:00AM URINE RBC-114* WBC-26* Bacteri-NONE Yeast-NONE Epi-0 **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Abd XR: no e/o intestinal obstruction or free intraperitoneal air. ___ 7:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. UA: neg for infection CT a/p with contrast: increased hydronephorosis on L side and there is now retroperitoneal fluid extending from level of L renal pelvis to just above the uretrerovesicular junction. High grade obstruction or possibly ureteral leak. Undergone resection of L sided bladder neoplasm. Final Report ___ INDICATION: ___ year old man with left RP fluid, abdominal pain// please perform nephrostogram and PCN placement TECHNIQUE: OPERATORS: Dr. ___, interventional Radiology Fellow and ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 0 mg of midazolam throughout the total intra-service time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1g of Cephazolin CONTRAST: 15 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 4.6 min, 40 mGy PROCEDURE: 1. Left ultrasound guided renal collecting system access. 2. Left nephrostogram. 3. Left ___ nephrostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left flank was prepped and draped in the usual sterile fashion. After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues, the left renal collecting system was accessed through a posterior lower pole calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound images of the access were stored on PACS. Prompt return of urine confirmed appropriate positioning. Injection of a small amount of contrast outlined a dilated renal collecting system. Under fluoroscopic guidance, a Headliner wire was advanced into the renal collecting system. After a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of the sheath was in the collecting system; the sheath was advanced over the wire, inner dilator and metallic stiffener. The wire and inner dilator were then removed and diluted contrast was injected into the collecting system to confirm position. A ___ wire was advanced through the sheath and coiled in the collecting system. The sheath was then removed and a 8 ___ nephrostomy tube was advanced into the renal collecting system. The wire was then removed and the pigtail was formed in the collecting system. Contrast injection confirmed appropriate positioning. The catheter was then flushed, 0 silk stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag. FINDINGS: Ureteral extravasation of contrast into retroperitoneum. No passage of contrast into the bladder. IMPRESSION: Successful placement of 8 ___ nephrostomy on the left. RECOMMENDATION(S): 1. Follow up antegrade nephrostogram in 1 month. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Amiodarone 200 mg PO DAILY 3. Warfarin 4 mg PO DAILY16 4. Atorvastatin 20 mg PO QPM 5. Metoprolol Succinate XL 50 mg PO DAILY 6. GlipiZIDE 2.5 mg PO BID 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Fenofibrate 54 mg PO DAILY 9. Tolterodine 4 mg PO DAILY 10. Maginex (magnesium aspartate HCl) 61 mg (615 mg) oral BID 11. Aspirin 81 mg PO Q48H 12. Nitroglycerin SL 0.3 mg SL PRN chest pain Discharge Medications: 1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp #*8 Tablet Refills:*0 2. Polyethylene Glycol 17 g PO DAILY Constipation - Third Line RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth daily as needed for constipation Disp #*30 Packet Refills:*0 3. TraMADol 25 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Take ___ tablet (25 mg) every 6 hours as needed for pain Disp #*20 Tablet Refills:*0 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO Q48H 6. Atorvastatin 20 mg PO QPM 7. Fenofibrate 54 mg PO DAILY 8. GlipiZIDE 2.5 mg PO BID 9. Maginex (magnesium aspartate HCl) 61 mg (615 mg) oral BID 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Nitroglycerin SL 0.3 mg SL PRN chest pain 13. Warfarin 4 mg PO DAILY16 14. HELD- Tolterodine 4 mg PO DAILY This medication was held. Do not restart Tolterodine until seen by urology or PCP ___: Home With Service Facility: ___ Discharge Diagnosis: Left sided hydronephrosis Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with left RP fluid, abdominal pain// please perform nephrostogram and PCN placement TECHNIQUE: OPERATORS: Dr. ___, interventional Radiology Fellow and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 50 mcg of fentanyl and 0 mg of midazolam throughout the total intra-service time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1g of Cephazolin CONTRAST: 15 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 4.6 min, 40 mGy PROCEDURE: 1. Left ultrasound guided renal collecting system access. 2. Left nephrostogram. 3. Left ___ nephrostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left flank was prepped and draped in the usual sterile fashion. After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues, the left renal collecting system was accessed through a posterior lower pole calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound images of the access were stored on PACS. Prompt return of urine confirmed appropriate positioning. Injection of a small amount of contrast outlined a dilated renal collecting system. Under fluoroscopic guidance, a Headliner wire was advanced into the renal collecting system. After a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of the sheath was in the collecting system; the sheath was advanced over the wire, inner dilator and metallic stiffener. The wire and inner dilator were then removed and diluted contrast was injected into the collecting system to confirm position. A ___ wire was advanced through the sheath and coiled in the collecting system. The sheath was then removed and a 8 ___ nephrostomy tube was advanced into the renal collecting system. The wire was then removed and the pigtail was formed in the collecting system. Contrast injection confirmed appropriate positioning. The catheter was then flushed, 0 silk stay sutures applied and the catheter was secured with a Stat Lock device and sterile dressings. The catheter was attached to a bag. FINDINGS: Ureteral extravasation of contrast into retroperitoneum. No passage of contrast into the bladder. IMPRESSION: Successful placement of 8 ___ nephrostomy on the left. RECOMMENDATION(S): 1. Follow up antegrade nephrostogram in 1 month. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with Unspecified abdominal pain temperature: 97.4 heartrate: 66.0 resprate: 14.0 o2sat: 97.0 sbp: 114.0 dbp: 68.0 level of pain: 6 level of acuity: 2.0

___ year old male with PMH CAD (s/p 3 stents, last in ___, atrial fibrillation on Coumadin, bladder CA x ___ years (s/p tumor resection) who presents with ___ days of constant, new upper L abdominal pain. Concern for tumor progression causing obstruction versus obstruction from clots causing hydronephrosis. Also possible there was some ureter injury causing leakage and an RP fluid collection now s/p left perc nephrostomy tube on ___ by interventional radiology. Urology also consulted while hospitalized. He was continued on pain medications (Morphine IV and Morphine PO) while hospitalized and transitioned to Tramadol PO on discharge for LLQ pain at site of tube placement. ___ improved on discharge with creatinine 1.1 on discharge. He will need to follow-up with interventional radiology as an outpatient. He will need follow-up antegrade nephrostogram in 1 month. Discussed with his urology team at ___, has scheduled cystoscopy/TURBT on ___ with Dr. ___ at ___. He will need preop appointment prior to this and they requested he stop taking Coumadin on ___ and follow-up for pre-op appointment in addition to obtaining stress ECHO as outpatient. Told patient to discuss these directions with his cardiologist and to follow-up with urology at ___ to discuss directly. He will follow-up with his PCP ___ ___ to have repeat INR drawn. Continue current dose of Coumadin on discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol / ribavirin / Tylenol / Epclusa Attending: ___. Chief Complaint: Acute on Chronic Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old man with history of CAD s/p DES (___), HCV, CKD, charcot foot on chronic opioids who was referred from ___ clinic for altered mental status, n/v, and abdominal pain. He ran out of his pain meds early (took 7 days worth in 5 days). History limited by altered mental status and fixation on his pain medications. He reports abdominal pain which he initially says is chronic ___ years but then says is worse than usual and diffuse. He is not sure when he took his last dose of opiates (told his NP it was the night before admission). Denies taking any other meds, etoh, non rx drug use. The ED resident spoke with the outpatient provider who knows him well. Of note: - He is on a narcotics contract, now back to receiving prescriptions for one week because he was not following contract. - He had a recent increase in pain meds ___ weeks ago, then misused. - Previously had someone else managing his meds, now he's doing it himself and misuses them. Getting ___ day prescriptions at a time. - At his baseline, he is a/o x3 - Abdominal symptoms are atypical for him - He has had diverticulitis a few times In the ED, initial vital signs were: 98.0 84 130/70 16 97% RA - Exam notable for: disheveled appearance, oriented to place, person, does not know date/year, harsh breath sounds, abdomen soft, diffusely reports tenderness, guards intermittently in LLQ, no ___ edema - Labs were notable for: Lactate 1.6 CBC hemoconcentrated, leukocyotosis to 11.9 (baseline 4k, 80% PMNs) INR 1.2 Cr at baseline (1.2), BUN elevated to 40 LFTS to 49/59 (similar to prior values--though normalized in ___ Lipase 23 Phos 1.9 UA w/ SG 1.039, TR protein & ketones, Urine culture pending. UTox with amphetamines and opiates - Studies performed include ___ CT HEAD (prelim read): IMPRESSION: No acute intracranial abnormality. ___ CT A/P (prelim read): 1. Bibasilar bronchogenic ground glass opacities, left worse than right, nonspecific, in the appropriate clinical setting would reflect pneumonia. 2. Diverticular disease without evidence of diverticulitis. 3. Moderate fecal loading. ___ CXR (AP/Lateral): IMPRESSION: Lower lung opacities, left greater than right, worrisome for pneumonia. - Patient was given: ___ 17:35 IVF NS ( 1000 mL ordered) ___ 17:57 PO OxyCODONE (Immediate Release) 10 mg ___ 17:57 PO Azithromycin 500 mg ___ 17:57 IV CeftriaXONE (1 g ordered) ___ 19:01 PO Morphine SR (MS ___ 30 mg ___ 19:01 PO Metoprolol Succinate XL 50 mg ___ 19:01 PO/NG Gabapentin 800 mg - Vitals on transfer: T 98 HR 81 BP 144/91 RR16 SaO2 97% RA Upon arrival to the floor, the patient states that he came in because he has been in severe pain since last weekend and did not want to be stuck at home during the snow storm. He states that he has "pain everywhere". He also notes some loose stools without vomiting. He endorses fevers and chills but did not take his temperature. He endorses shortness of breath without cough or wheeze. He endorses palpitations and dizziness. He endorses pain of his head, chest/back, abdomen, both arms, both legs. He endorses some hesitancy while urinating and burning. He endorses weakness in both legs. Review of Systems: (+) per HPI Past Medical History: Per records: -peripheral neuropathy (currently on gabapentin) -Hepatitis C --genotype 2b infection; intolerant of interferon/ribavirin in 1990s --Fibroscan ___ consistent with Metavir stage ___ liver scarring --stage I fibrosis per last liver biopsy in ___ -Depression with prior suicide attempts -Diverticulosis -CAD; s/p 2 DES to RCA ___ -Hypertension -Hyperlipidemia; total cholesterol 156, HDL 60 in ___. -Polysubstance abuse: heroin, alcohol (last drink 1980s), benzodiazepines -Chronic foot pain due to Charcot deformity, s/p multiple surgeries -GERD -BPH -Erectile dysfunction -Reiter's syndrome -Bell's palsy -history of mitral valve prolapse -history of osteomyelitis -history of chronic constipation. Social History: ___ Family History: Per records: His mother is alive, she has dementia and history of alcoholism. Mother had colon cancer in her ___. His father is deceased (age ___, had history of CAD and CHF. Physical Exam: Admission Physical Exam: Vitals: 98.1PO 175 / 92 69 18 96 RA GENERAL: Lying in bed. NAD HEENT: EOMI. 4mm pupils b/l. OP clear NECK: Supple, no LAD CARDIAC: Distant heart sounds LUNGS: CTAB CHEST: Severe pain to sternal palpation radiating to L ribs ABDOMEN: Diffusely tender, no rebound/guarding EXTREMITIES: No edema SKIN: Scratches on hand ("cat") NEUROLOGIC: A&O x 2.5 (name, situation, month but not day or year). DISCHARGE PHYSICAL EXAM: VS: T 98.2 BP 126/76 HR 53 RR 18 O2 ___ Ra GENERAL: Lying in bed. NAD HEENT: EOMI. Has lower dentures. MMM. PERRL CARDIAC: Distant heart sounds LUNGS: CTAB CHEST: Severe pain to sternal palpation radiating to L ribs ABDOMEN: Soft, non-distended, very mild TTP. EXTREMITIES: No edema SKIN: Scratches on hand ("cat") NEUROLOGIC: A&Ox3 Pertinent Results: ADMISSION LABS: ___ 03:15PM BLOOD WBC-11.9*# RBC-4.16* Hgb-12.4* Hct-36.2* MCV-87 MCH-29.8 MCHC-34.3 RDW-15.7* RDWSD-49.6* Plt ___ ___ 03:15PM BLOOD Neuts-80.9* Lymphs-10.9* Monos-7.3 Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.60*# AbsLymp-1.29 AbsMono-0.86* AbsEos-0.01* AbsBaso-0.03 ___ 03:15PM BLOOD ___ PTT-26.8 ___ ___ 03:15PM BLOOD Glucose-128* UreaN-39* Creat-1.2 Na-135 K-4.3 Cl-98 HCO3-22 AnGap-19 ___ 03:15PM BLOOD ALT-49* AST-59* CK(CPK)-137 AlkPhos-70 TotBili-0.7 ___ 03:15PM BLOOD Albumin-4.0 Calcium-9.5 Phos-1.9* Mg-1.8 ___ 03:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:45PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04:45PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 ___ 04:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG ________________________ MICRO: ___ 4:45 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ________________________ IMAGING: ___ CHEST (PA & LAT): Lower lung opacities, left greater than right, worrisome for pneumonia. ___ CT ABD & PELVIS WITH CO: 1. Bibasilar bronchogenic ground glass opacities, left worse than right, nonspecific, in the appropriate clinical setting would reflect pneumonia. 2. Nodular contour of the liver with splenomegaly is consistent with history of cirrhosis and suggestive of portal hypertension. No ascites. 3. Moderate fecal loading throughout, worst in the rectum and left hemicolon. No bowel obstruction. ___ CT HEAD W/O CONTRAST: No acute intracranial abnormality. ________________________ DISCHARGE LABS: ___ 07:40AM BLOOD WBC-6.7 RBC-4.11* Hgb-12.4* Hct-35.7* MCV-87 MCH-30.2 MCHC-34.7 RDW-15.7* RDWSD-49.7* Plt ___ ___ 07:40AM BLOOD Glucose-104* UreaN-25* Creat-1.0 Na-138 K-3.5 Cl-101 HCO3-24 AnGap-17 ___ 07:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. BuPROPion 75 mg PO BID 4. Gabapentin 1200 mg PO TID 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Morphine SR (MS ___ 30 mg PO Q12H 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain - Moderate 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID:PRN constipation 12. TraZODone 300 mg PO QHS insomnia 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Lisinopril 40 mg PO DAILY 15. DULoxetine 30 mg PO DAILY 16. Chlorthalidone 25 mg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 4 Days RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 2. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 3. Narcan (naloxone) 4 mg/actuation nasal ONCE RX *naloxone [Narcan] 4 mg/actuation 1 spray nasally once Disp #*1 Spray Refills:*0 4. Morphine SR (MS ___ 15 mg PO Q8H RX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. BuPROPion 75 mg PO BID 9. Chlorthalidone 25 mg PO DAILY 10. DULoxetine 30 mg PO DAILY 11. Gabapentin 1200 mg PO TID RX *gabapentin 600 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*0 12. Lisinopril 40 mg PO DAILY 13. Metoprolol Succinate XL 50 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 40 mg PO BID 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation 18. Senna 8.6 mg PO BID:PRN constipation 19. TraZODone 300 mg PO QHS insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Chronic pain (dorsalgia, peripheral neuropathy), opiate withdrawal hyperesthesia, pneumonia Secondary Diagnoses: Anxiety/depression, Charcot foot Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest x-ray INDICATION: ___ with AMS, ?infection// any e/o pneumonia or aspiration? TECHNIQUE: AP and lateral chest radiograph COMPARISON: Chest radiograph dated ___ FINDINGS: AP and lateral chest radiograph. There are ill-defined opacities in the lower lungs, more prominent on the left, concerning for pneumonia. Cardiomediastinal and hilar contours are stable relative to prior examination. There is no evidence of pleural effusion, pneumothorax or pulmonary edema. There is no air under the right hemidiaphragm. IMPRESSION: Bilateral lower lobe pneumonia. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with multiple falls, AMS// any e/o subdural? 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: Total DLP (Head) = 903 mGy-cm. COMPARISON: Unenhanced head CT dated ___ FINDINGS: There is no hemorrhage, edema, or mass effect. Ventricles and sulci are age appropriate in size and configuration. Very mild periventricular white matter hypodensities are nonspecific, likely sequela of chronic small vessel ischemia. There is no shift of normally midline structures. Basal cisterns are patent. Gray-white matter differentiation is preserved. The orbits are unremarkable. Imaged paranasal sinuses, bilateral mastoid air cells, and middle ear cavities are clear. The bony calvarium is intact. IMPRESSION: No acute intracranial abnormality. Radiology Report INDICATION: NO_PO contrast; History: ___ with abdominal painNO_PO contrast// any e/o diverticulitis 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 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 5.2 s, 56.5 cm; CTDIvol = 16.2 mGy (Body) DLP = 916.8 mGy-cm. Total DLP (Body) = 929 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: LOWER CHEST: Bronchocentric ground-glass opacities within the lower lungs, left worse than right, are new relative to prior examinations dated ___. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout, slightly nodular in contour. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas appears atrophic without pancreatic duct dilation or a focal lesion. There is no peripancreatic stranding. SPLEEN: The spleen shows normal attenuation throughout, without evidence of focal lesions. The spleen is mildly enlarged. 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. Moderate fecal loading is noted throughout the colon. There is mild diverticular disease without inflammatory changes to suggest acute diverticulitis. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized 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. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Mild degenerative changes are present, worst at the L4-L5 level with intervertebral disc space narrowing. Probable hemangioma involves the T11 vertebral body (02:17), stable. SOFT TISSUES: A small umbilical fat containing hernia is noted. IMPRESSION: 1. Bibasilar bronchogenic ground glass opacities, left worse than right, nonspecific, in the appropriate clinical setting would reflect pneumonia. 2. Nodular contour of the liver with splenomegaly is consistent with history of cirrhosis and suggestive of portal hypertension. No ascites. 3. Moderate fecal loading throughout, worst in the rectum and left hemicolon. No bowel obstruction. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: Altered mental status Diagnosed with Pneumonia, unspecified organism temperature: 98.0 heartrate: 84.0 resprate: 16.0 o2sat: 97.0 sbp: 130.0 dbp: 70.0 level of pain: 7 level of acuity: 2.0

___ is a ___ year old man with history of CAD s/p DES (___), HCV, CKD, charcot foot on chronic opioids who was referred from ___ clinic for altered mental status and abdominal pain found to have pneumonia and concern for constipation on imaging with diverticulosis without evidence of active diverticulitis. The patient's primary concern was pain control. He had taken all 7 days of his pain medications in 5 days and ran out. Once we re-started his home pain medication, his pain was under much better control, indicating that the issue was withdrawal hyperesthesia. His abdominal pain resolved and he was back to his baseline of leg pain and low back pain. He was also AOx3 by discharge. He was discharged for close outpatient follow up and with a course of antibiotics to finish treating his pneumonia. TRANSITIONAL ISSUES: ==================================== CODE STATUS: Full Code CONTACT: Proxy name: ___ Relationship: friend Phone: ___ _________________________ FYI: - The patient's pain resolved once he was back on his home pain regimen. There were no studies, labs, or clinical signs that were concerning for significant abdominal pathology. _________________________ TO DO: [ ] F/U pain regimen and tolerance: decreased MS contin back to his prior outpatient dose [ ] Patient may require a podiatry follow up for dry gangrene on his foot [ ] ___ consider a TCA for pain control. Patient had multiple points of tenderness on exam here concerning for fibromyalgia. _________________________ MEDICATIONS: - Discharged with Narcan spray and ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Concern for EtOH Withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with past medical history significant for alcohol abuse, alcohol withdrawal seizures, subdural hematoma status post craniotomy presents with alcohol intoxication, acute on chronic ___ transferred from ___ for further evaluation by ___, management of altered mental status. The patient reports that he fell 2 days ago, and has been having headaches since that time as well as lower abdominal pain. He reports abdominal pain today, which is what brought him to the outside hospital. He has been intermittently taking insulin but ran out supplies earlier this week. He last ___ at the start of ___. He denies IV drug use, cocaine. Began drinking 1L whiskey on ___, At the outside hospital, work-up did not demonstrate a clear etiology for his abdominal pain, however work-up redemonstrated a subdural hematoma. He was however noted to have a bicarb level of 17, anion gap of 28, glucose 385, concerning for DKA. The patient was transferred for further evaluation and treatment. In ED initial VS: T: 98.2 HR: 103 BP: 118/73 RR: 18 SO2: 95% RA Labs significant for: WBC: 5.0 Hgb: 12.7 (MCV 77) Plt: 226 Na: 137 Cl: 92 BUN: 8 K: 4.4 HCO3: 19 Crt: 0.7 Glu: 337 pH 7.41 pCO2 24 pO2 85 HCO3 16 BaseXS -6 Lactate:4.6 Serum EtOH 350 UA notable for Glu 1000 Ket 150 ___: 11.5 PTT: 29.8 INR: 1.1 Serum ASA, Acetmnphn, ___, Tricyc Negative Patient was given: ___ 23:41 IVF NS ___ 01:31 PO/NG Diazepam 10 mg ___ 01:32 IVF NS 1000 mL ___ 01:32 IV Thiamine 500 mg Imaging notable for: CT HEAD (OSH): Status post interval redo left-sided craniotomy and frontoparietal region with decrease in size of left sided subdural hematoma/collection with reduced mass-effect. There is persistent subdural collection of different densities with hyperdense component is particularly along the left frontal region suggesting an acute on chronic component. Persistent mass-effect with effacement of the sulci on the left and mid bowing of the midline falx Consults: Neurosurgery assessed patient as severely intoxicated, PERRL, confused, following simple commands, antigravity all 4 extremities. High lactate and BG, possible DKA per ED. Interval improvement in previous L acute on chronic SDH compared to last discharge scan. "Ok with Medicine admission if needed for metabolic abnormalities, we will follow." VS prior to transfer: T: 98.2 HR:99 BP: 112/64 RR: 22 SO2: 94% RA On arrival to the MICU, patient is drowsy but confirms history as above. Past Medical History: 1. History of alcoholic pancreatitis. 2. Hypertension. 3. Hyperlipidemia. 4. Asthma. 5. Diabetes. 6. Assault ___ with facial and nasal fractures 7. Subdural hematoma s/p craniotomy for evacuation ___ Social History: ___ Family History: Non contributory Physical Exam: ADMISSION EXAM =============== VITALS: Reviewed in metavision GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rhythm tacycardic, 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: bruising left ___ nail no obvious splinter hemorrhages, no obvious needle track marks NEURO: follows commands crossing midline, repetition intact, language fluent, mild dysarthria, UE ___ ___ ___ DISCHARGE EXAM ================ VITALS: T 98.3 BP 108 / 68 HR 86 RR 18 SpO2 98 Ra GENERAL: AAOx3, no apparent distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, 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: bruising left ___ nail no obvious splinter hemorrhages, no obvious needle track marks NEURO: CN intact. Strength UE ___, ___ ___. Pertinent Results: ADMISSION LABS ================ ___ 11:50PM WBC-5.0 RBC-5.00# HGB-12.7* HCT-38.7* MCV-77*# MCH-25.4* MCHC-32.8 RDW-15.4 RDWSD-42.0 ___ 11:50PM NEUTS-50.8 ___ MONOS-8.0 EOS-0.2* BASOS-1.0 IM ___ AbsNeut-2.56# AbsLymp-2.00 AbsMono-0.40 AbsEos-0.01* AbsBaso-0.05 ___ 11:50PM PLT COUNT-226 ___ 11:50PM ___ PTT-29.8 ___ ___ 11:50PM ALBUMIN-4.8 CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-2.4 ___ 11:50PM LIPASE-9 ___ 11:50PM ALT(SGPT)-25 AST(SGOT)-29 ALK PHOS-197* TOT BILI-0.9 ___ 11:50PM GLUCOSE-337* UREA N-8 CREAT-0.7 SODIUM-137 POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-19* ANION GAP-26* ___ 11:53PM LACTATE-4.6* ___ 12:34AM ___ PO2-85 PCO2-24* PH-7.41 TOTAL CO2-16* BASE XS--6 STUDIES/IMAGING ================ ___ CXR No acute intrathoracic abnormality. ___ CT Head (OSH) Status post interval redo left-sided craniotomy and frontoparietal region with decrease in size of left sided subdural hematoma/collection with reduced mass-effect. There is persistent subdural collection of different densities with hyperdense component is particularly along the left frontal region suggesting an acute on chronic component. Persistent mass-effect with effacement of the sulci on the left and mid bowing of the midline falx. MICROBIOLOGY ============ Blood and urine cultures pending. Discharge labs =============== ___ 07:20AM BLOOD WBC-3.2* RBC-4.05* Hgb-10.5* Hct-32.8* MCV-81* MCH-25.9* MCHC-32.0 RDW-15.6* RDWSD-44.3 Plt ___ ___ 06:22AM BLOOD Glucose-169* UreaN-17 Creat-0.7 Na-139 K-4.0 Cl-101 HCO3-24 AnGap-14 ___ 06:22AM BLOOD Calcium-8.4 Phos-5.4* Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Headache 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 300 mg PO TID 5. LevETIRAcetam ___ mg PO Q12H 6. Multivitamins 1 TAB PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: decreased dose 9. Thiamine 100 mg PO DAILY 10. Glargine 35 Units Bedtime Novolog 13 Units Breakfast Novolog 13 Units Lunch Novolog 16 Units Dinner Insulin SC Sliding Scale using Novolog Insulin Discharge Medications: 1. alcohol swabs 1 swab topical PRN RX *alcohol swabs [BD Alcohol Swabs] 1 swab prn Disp #*100 Pad Refills:*0 2. BD Ultra-Fine Nano Pen Needles (pen needle, diabetic) 32 gauge x ___ miscellaneous qACHS RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needles] 32 gauge X ___ as directed qACHS Disp #*200 Box Refills:*0 3. Docusate Sodium 100 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. FreeStyle Lancets (lancets) 28 gauge miscellaneous PRN RX *lancets [FreeStyle Lancets] 28 gauge one lancet fours times daily Disp #*100 Each Refills:*0 6. FreeStyle Lite Strips (blood sugar diagnostic) 1 strip miscellaneous PRN RX *blood sugar diagnostic [FreeStyle Lite Strips] 1 strip four times daily Disp #*100 Strip Refills:*0 7. Gabapentin 300 mg PO TID 8. HydrOXYzine 25 mg PO Q6H:PRN anixety RX *hydroxyzine HCl 25 mg 1 by mouth every six (6) hours Disp #*20 Tablet Refills:*0 9. insulin syringe-needle U-100 0.3 mL 29 gauge x ___ miscellaneous PRN RX *insulin syringe-needle U-100 [Lite Touch Insulin Syringe] 29 gauge x ___ 1 syringe PRN Disp #*100 Syringe Refills:*0 RX *insulin syringe-needle U-100 [FreeStyle Precision] 30 gauge x ___ 1 syringe prn Disp #*100 Syringe Refills:*0 10. Multivitamins 1 TAB PO DAILY 11. Thiamine 100 mg PO DAILY 12. TraZODone 25 mg PO QHS:PRN anxiety, sleep RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 13. Glargine 30 Units Breakfast Novolog 15 Units Breakfast Novolog 15 Units Lunch Novolog 15 Units Dinner Insulin SC Sliding Scale using novolog Insulin RX *insulin glargine [Lantus] 100 unit/mL AS DIR 30 Units before BKFT; Disp #*5 Vial Refills:*3 RX *insulin aspart [Novolog] 100 unit/mL AS DIR 15 Units before BKFT; 15 Units before LNCH; 15 Units before DINR; Disp #*5 Vial Refills:*3 14. LevETIRAcetam ___ mg PO BID 15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: decreased dose 16. Acetaminophen 650 mg PO Q8H:PRN Headache 17. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Alcohol intoxication Diabetic Ketoacidosis Secondary Diagnosis: Acute on Chronic Subdural Hematoma 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 LATERAL) INDICATION: History: ___ with DKA, weakness// eval for pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unremarkable. There is no focal consolidation, pleural effusion, or pneumothorax. Streaky bibasilar opacities are most consistent with atelectasis. No definite focal consolidation is identified. Left hilar lymph node calcifications are probably due to previous granulomatous infection. There is no evidence of recurrent infection. IMPRESSION: No acute intrathoracic abnormality. Gender: M Race: HISPANIC/LATINO - GUATEMALAN Arrive by AMBULANCE Chief complaint: ETOH, Transfer Diagnosed with Headache, Alcohol abuse with intoxication, unspecified temperature: 98.2 heartrate: 103.0 resprate: 18.0 o2sat: 95.0 sbp: 118.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

This is a ___ old male with past medical history significant for alcohol abuse, alcohol withdrawal seizures, insulin dependent diabetes, subdural hematoma status post craniotomy ___, admitted to the ICU for DKA and ETOH withdrawal on phenobarbital taper, now called out to the floor for further DM management and monitoring during alcohol detoxification. =============

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / lisinopril Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with history of diastolic CHF, prostate cancer s/p radiation and cyberknife, HCV cirrhosis c/b HCC s/p OLT ___ (mild cellular rejection in ___, recent R brachiocephalic AVF ___ for CKD. He presents for worsening shortness of breath and dyspnea on exertion. The patient's symptoms began 1 week prior to arrival when he realized that he became short of breath while walking around the block. He was still able to walk his normal distance, but felt that he had to breath harder than usual. This progressed throughout the week to the point that he became significantly short of breath while walking his normal distances. Last night, the patient awoke in bed at 1:30 AM with palpitations, which subsequently resolved. The patient also notices that his legs have been swelling equally for the past week. His appetite has also been down. He reports gaining 10 lbs over the past week and his dry weight is reportedly 164lbs. He was sent in by his PCP this morning. He denies fever, chills, cough, sputum production, rhinorrhea, abdominal pain (besides incisional pain), diarrhea, constipation, chest pain, or dysuria. No blood in stools. Of note, the patient had a peritoneal dialysis catheter removed ___ and also had a right-sided AV fistula created for his CKD. He has not yet had dialysis, but decided with his family that HD would be better for him. Also of note, the patient was recently seen in the clinic on ___ with Dr. ___ with plan to transition to Prograf plus everolimus for renal protective effect. Per office note: - Starting prograf 2 mg BID with a goal of ___ and will discontinue cyclosporine. - He'll come back in 4 days to check prograf level and at that point will start Everolimus at 1.5 mg BID with a goal of ___. -Will also reduce MMF to 500 mg BID on ___. Our plan is to eventually take him off cellecpt." In the ED, initial VS were: 98.5 73 162/79 18 95% RA Exam notable for crackles at the bases of his lungs. Has a clean, dry, and intact surgical site on the abdomen to the left of the umbilicus. He has tenderness over this area, with no rebound or guarding. 2+ bilateral pitting edema in both legs. Labs showed: tacroFK: 2.7, K:5.3, Lactate:0.9, Bicarb 15, Cr 3.1, Trop-T: 0.04, AST: 50, ___: ___, Hb 7.6 UA not suggestive of infection, but Protein 100 Imaging showed CXR: Small right and trace left pleural effusions. Enlarged cardiac silhouette. Mild to moderate interstitial edema. Right base opacity may relate to fluid overload, however, consolidation due to pneumonia may be present in the appropriate clinical setting. Liver US: Patent hepatic vasculature with appropriate waveforms. Received 80mg IV Lasix per renal Transfer VS were 98.5, 183/88, 82, 18, 99 RA Hepatology, transplant surgery and renal services were consulted. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports he is feeling baseline at rest, no SOB, CP, lightheadedness or dizziness. Reports some pain from foley insertion. Past Medical History: EtOH/HCV cirrhosis c/b portal hypertension, ascites, grade 3 esophageal varices ___, s/p 4 bands), encephalopathy, and asymptomatic hepatopulmonary syndrome, HCC s/p OLT ___ Hypothyroidism Surgery for exophthalmos ___ peripheral vascular disease in bilateral lower extremities chronic venous stasis Benign Hypertension incision hernia repair ___ Social History: ___ Family History: Mother with DM, HTN. Brother with DM. 2 uncles with prostate CA as well as his brother with prostate cancer. Physical Exam: ADMISSION EXAM: VS - 98.5, 183/88, 82, 18, 99%RA GENERAL: Pt uncomfortable with foley, standing and pacing in room HEENT: AT/NC, EOMI, PERRL, sclera slightly pigmented, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, JVP within normal limits CARDIAC: RRR, S1/S2, ___ systolic murmur heard throughout the precordium LUNG: Crackles bilaterally in the lower lung fields, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild ___ tenderness, no rebound/guarding, liver percussed just below the costal margin EXTREMITIES: no cyanosis/clubbing, moving all 4 extremities with purpose, 2+ pitting edema from the feet bilaterally to the knees, no asterixis, no palmar erythema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength ___ in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes. AV fistula site on right arm, non-erythematous and clean. DISCHARGE EXAM: VS - 98.0 134/65 62 16 100 RA GENERAL: NAD, resting comfortably HEENT: Much improved bilateral mild R>L swelling of the lips, cheeks, sublingual and submandibular areas without airway compromise. No pain on palpation. No stridor. Able to visualize malampati III view, No LAD, PERRL, sclera slightly pigmented, MMM NECK: nontender supple neck, no LAD, JVP wnl CARDIAC: RRR, S1/S2, ___ systolic murmur heard throughout the precordium LUNG: Crackles bilaterally in the lower lung fields, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild ___ tenderness, no rebound/guarding, liver percussed just below the costal margin EXTREMITIES: no cyanosis/clubbing, moving all 4 extremities with purpose, no ___ edema, no asterixis, no palmar erythema PULSES: 2+ DP pulses bilaterally NEURO: Grossly intact, alert and oriented SKIN: warm and well perfused, no excoriations or lesions, no rashes. AV fistula site on right arm, non-erythematous and clean, bruit present. Pertinent Results: ADMISSION LABS: ___ 11:53AM BLOOD WBC-5.5 RBC-2.80* Hgb-7.6* Hct-25.9* MCV-93 MCH-27.1 MCHC-29.3* RDW-15.7* RDWSD-53.1* Plt ___ ___ 11:53AM BLOOD Neuts-67.6 Lymphs-16.1* Monos-11.8 Eos-2.2 Baso-0.5 Im ___ AbsNeut-3.73 AbsLymp-0.89* AbsMono-0.65 AbsEos-0.12 AbsBaso-0.03 ___ 06:45AM BLOOD ___ PTT-29.8 ___ ___ 11:53AM BLOOD Glucose-107* UreaN-58* Creat-3.1* Na-140 K-6.6* Cl-114* HCO3-15* AnGap-18 ___ 11:53AM BLOOD ALT-11 AST-50* AlkPhos-107 TotBili-0.3 ___ 11:53AM BLOOD cTropnT-0.04* ___ ___ 11:53AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.5 Mg-2.6 ___ 06:45AM BLOOD VitB12-1520* Folate-16.9 ___ 11:53AM BLOOD tacroFK-2.7* IMAGING: ___ CXR: Small right and trace left pleural effusions. Enlarged cardiac silhouette. Mild to moderate interstitial edema. Right base opacity may relate to fluid overload, however, consolidation due to pneumonia may be present in the appropriate clinical setting. ___ Liver US: Patent hepatic vasculature with appropriate waveforms. ___ TTE: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF = 45 %) secondary to hypokinesis of the inferior and posterior walls. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of ___ the left ventricular ejection fraction is somewhat reduced. MICRO: ___ Blood cx NO GROWTH Discharge Labs: ___ 06:25AM BLOOD WBC-2.8* RBC-2.82* Hgb-7.4* Hct-25.5* MCV-90 MCH-26.2 MCHC-29.0* RDW-14.6 RDWSD-47.5* Plt ___ ___ 06:25AM BLOOD Plt ___ ___ 06:25AM BLOOD Glucose-93 UreaN-43* Creat-2.6* Na-141 K-4.2 Cl-110* HCO3-20* AnGap-15 ___ 06:25AM BLOOD ALT-7 AST-17 AlkPhos-87 TotBili-0.2 ___ 06:25AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.3 Mg-2.0 Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with SOB on exertion, lower extremity edema // Eval fluid overload TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: There is a small right pleural effusion and trace left pleural effusion. Mild to moderate interstitial edema. Right lower lobe opacity is seen, which may relate to fluid overload, however, pneumonia may be present in the appropriate clinical setting. Peribronchial thickening is also seen. The mediastinal contours unremarkable. The cardiac silhouette is mild to moderately enlarged. IMPRESSION: Small right and trace left pleural effusions. Enlarged cardiac silhouette. Mild to moderate interstitial edema. Right base opacity may relate to fluid overload, however, consolidation due to pneumonia may be present in the appropriate clinical setting. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with fluid overload, dyspnea on exertion s/p liver transplant ___ years ago // Eval with Doppler for patency of vessels for liver transplant TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound dated ___. MR liver dated ___. FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. The common hepatic duct measures 0.7 cm, unchanged compared to prior. There is a small amount of perihepatic ascites, which is unchanged compared to ultrasound dated ___. The spleen measures 10.9 cm and has normal echotexture. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 47. Appropriate arterial waveforms are seen in the right and left hepatic arteries. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: Patent hepatic vasculature with appropriate direction of flow. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with CHF and now angioedema in the setting of starting lisinopril // ?interval changed of pulmonary edema ?interval changed of pulmonary edema IMPRESSION: In comparison with the study ___, there again is substantial enlargement of the cardiac silhouette. However, the degree of pulmonary vascular congestion has substantially decreased. No evidence of acute focal pneumonia or definite effusion. Probable atelectatic changes at the left base. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea on exertion Diagnosed with Heart failure, unspecified temperature: 98.5 heartrate: 73.0 resprate: 18.0 o2sat: 95.0 sbp: 162.0 dbp: 79.0 level of pain: 6 level of acuity: 2.0

The patient is a ___ year-old male with a history of diastolic congestive heart failure, prostate cancer status-post radiation and cyberknife, hepatitis C virus cirrhosis complicated by hepatocellular carcinoma status-post liver transplant ___ (mild cellular rejection in ___, recent right brachiocephalic AV fistula ___ for chronic kidney disease. He presented for worsening shortness of breath and dyspnea on exertion, found to have decreased systolic function on echocardiogram, and improved with diuresis. On the morning of ___, patient developed acute facial swelling concerning for angioedema in the setting of recent lisinopril. He was given methylprednisone, Benadryl and transferred to the ICU for airway monitoring. In the ICU, he was monitored for airway compromise and was transferred back to the floor following improvement in his symptoms. He was discharged at ___ without any diuretic. His immune suppression was titrated and should be closely monitored outpatient. #Angioedema, likely ACEi-associated: On the morning of ___, patient developed acute facial swelling concerning for angioedema in the setting of recent lisinopril. He was given methylprednisone, Benadryl and transferred to the ICU for airway monitoring. In the ICU, he was monitored for airway compromise and was transferred back to the floor following improvement in his symptoms. Allergy was consulted and described a possibility of starting ___ at some point in the future, although this does carry some risk for repeated angioedema. He should not be started on ACE inhibitors in the future, and this was added as an allergy to his list. #Acute on chronic systolic congestive heart failure: The patient was admitted with signs of volume overload on exam, with elevated BNP and CXR with interstitial edema. He had a transthoracic echocardiogram which showed mildly depressed ayatolic dysfunction (EF = 45 %) secondary to hypokinesis of the inferior and posterior walls. EKG was unchanged from prior and his troponins remained flat at approximately 0.5. He had no symptoms of acute coronary syndrome. He was given IV and subsequently oral Lasix diuresis until he reached euvolemia. He should follow up with his cardiologist as an outpatient for his systolic congestive heart failure. His home pravastatin was switched to atorvastatin 40mg daily and this was continued upon discharge. #Chronic Kidney Disease, stage V: The patient has chronic kidney disease with unclear and fluctuating baseline creatinine. He recently had placement of an AV fistula. He presented with high creatinine that did not appear to be acutely elevated over at least the last few weeks. Nephrology was consulted and recommended diuresis as above and oral bicarbonate for non-anion-gap acidosis. There was no indication for urgent dialysis during this hospitalization. The patient should follow up in the outpatient setting for his chronic kidney disease. He should continue taking 650mg bicarb twice daily. #Non anion-gap metabolic acidosis: The patient was found to have a non-anion-gap acidosis that was attributed to his chronic kidney disease and decreased acid clearance. This improved with diuresis and oral bicarbonate as above. #Hyperkalemia: The patient presented with borderline hyperkalemia that was attributed to his chronic kidney disease and decreased clearance of potassium. This improved with diuresis and oral bicarbonate as above. #Normocytic Anemia (baseline Hb ___: The patient presented with a normocytic anemia below baseline. He has been worked up in the past and iron and ferritin were normal in ___. EGD in ___ showed varices at the lower third of the esophagus (ligation) and erosions and superficial ulcers in the antrum. B12 was 1520 and folate was normal. There were no signs of active bleeding. The patient should follow up in the clinic with a repeat CBC and discussion of possible epogen therapy as appropriate with his chronic kidney disease. #Troponinemia: The patient was found to have elevated but stable troponin of approximately 0.5 in the absence of acute coronary symptoms. This is likely in the setting of possible mild demand ischemia and stage V chronic kidney disease. EKG was stable from prior. He was continued on his home aspirin, statin, and carvedilol. #Hepatitis C Virus status-post liver transplant: The patient had a right upper quadrant ultrasound that was normal without evidence of ascites. He had no signs of liver failure on exam. Although his AST was very mildly elevated on admission, his transaminases otherwise remained in normal range. His home immunosuppression regimen was adjusted for discharge: Everolimus 2mg BID and Tacrolimus 1mg BID, home Mycophenolate Mofetil unchanged. He should follow up in the clinic with his transplant hepatologist. #Hypertension: The patient remained hypertensive but stable. He was continued on his home carvedilol, hydralazine, imdur, and Norvasc.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: =============== Admission labs =============== ___ 05:05PM BLOOD WBC-4.5 RBC-3.72* Hgb-11.3 Hct-37.2 MCV-100* MCH-30.4 MCHC-30.4* RDW-15.0 RDWSD-54.0* Plt Ct-45* ___ 05:05PM BLOOD Neuts-91.5* Lymphs-4.7* Monos-3.4* Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.08 AbsLymp-0.21* AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00* ___ 05:05PM BLOOD ___ PTT-36.7* ___ ___ 05:05PM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-144 K-4.0 Cl-100 HCO3-32 AnGap-12 ___ 05:05PM BLOOD ALT-9 AST-20 AlkPhos-51 TotBili-1.4 ___ 05:55AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 ___ 05:05PM BLOOD Albumin-4.2 =============== Pertinent labs =============== ___ 06:12AM BLOOD METHYLMALONIC ACID-################### ___ 03:20AM BLOOD HIV Ab-##################### ___ 06:12AM BLOOD HCV Ab-NEG ___ 06:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 05:55AM BLOOD VitB12-252 Hapto-109 ___ 11:00AM BLOOD Ret Aut-1.9 Abs Ret-0.06 ___ 11:00AM BLOOD Poiklo-1+* Macrocy-1+* Ovalocy-1+* Tear Dr-1+* =============== Discharge labs =============== ___ 04:08AM BLOOD WBC-4.3 RBC-3.25* Hgb-10.1* Hct-32.8* MCV-101* MCH-31.1 MCHC-30.8* RDW-15.3 RDWSD-55.8* Plt Ct-51* ___ 04:08AM BLOOD Glucose-94 UreaN-20 Creat-0.9 Na-144 K-3.8 Cl-98 HCO3-34* AnGap-12 ___ 04:08AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9 =============== Studies =============== ECG ___: Sinus tachycardia Cannot rule out Inferior MI - indeterminate age Otherwise normal ECG When compared with ECG of ___ 16:26, No significant change was found UGI study ___: IMPRESSION: 1. No gross evidence of esophageal stricture, web, or ring. 2. Diffuse tertiary contractions through the mid through lower esophagus. 3. Small hiatal hernia. CXR ___: No acute cardiopulmonary abnormality. Emphysema and bibasilar atelectasis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 2. Azithromycin 250 mg PO ___ 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation DAILY 4. Famotidine 20 mg PO BID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. LevoFLOXacin 500 mg PO Q24H 7. LORazepam 0.5 mg PO BID:PRN anxiety 8. Levothyroxine Sodium 100 mcg PO DAILY 9. PredniSONE 10 mg PO DAILY 10. roflumilast 500 mcg oral DAILY 11. sodium chloride 0.9 % inhalation Q8H:PRN 12. umeclidinium 62.5 mcg/actuation inhalation DAILY 13. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 14. Senna 17.2 mg PO QHS:PRN Constipation - First Line Discharge Medications: 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 2. Azithromycin 250 mg PO ___ 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 4. Famotidine 20 mg PO BID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Levothyroxine Sodium 100 mcg PO DAILY 7. LORazepam 0.5 mg PO BID:PRN anxiety 8. PredniSONE 10 mg PO DAILY 9. roflumilast 500 mcg oral DAILY 10. Senna 17.2 mg PO QHS:PRN Constipation - First Line 11. sodium chloride 0.9 % inhalation Q8H:PRN 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation DAILY 13. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # GERD # Possible peptic ulcer # Severe COPD # Otitis media # Pancytopenia 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: CT chest, abdomen and pelvis with contrast INDICATION: History: ___ with hx small cell cancer s/p of chemo; gnawing abd pain, productive cough for 1 week. // ?pna, ?metastasis TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 8.1 s, 64.1 cm; CTDIvol = 15.8 mGy (Body) DLP = 1,011.1 mGy-cm. Total DLP (Body) = 1,023 mGy-cm. COMPARISON: CT chest, abdomen, and pelvis ___ FINDINGS: CHEST: HEART AND VASCULATURE: Mild calcified atherosclerosis about the aortic arch is again seen. The thoracic aorta is normal in caliber without evidence of acute injury. Although not tailored for the evaluation of pulmonary emboli, no central pulmonary emboli are seen. Stable mild cardiomegaly with mild aortic valvular and mitral annular calcifications. Moderate coronary artery calcifications. No pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Left upper lobe subpleural lesion measuring 1.2 x 0.4 cm is unchanged (2:25), previously 0.5 x 1.1 cm. Multiple previously described pulmonary nodules measuring up to 5 mm are unchanged. No new or growing pulmonary nodules. Lungs are clear without masses or areas of parenchymal opacification. Moderate narrowing of right bronchus intermedius with secretions. Otherwise, the airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: The thyroid is heterogeneous with multiple subcentimeter hypoattenuating thyroid nodules. ABDOMEN: HEPATOBILIARY: The liver contour is nodular. Few subcentimeter hypoattenuating lesions throughout are unchanged. No new focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen is mildly enlarged measuring 13.2 cm. There is normal attenuation throughout, without evidence of focal lesion or laceration. 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. Few subcentimeter hypodensities throughout the bilateral kidneys are too small to characterize, statistically likely cysts. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. The small bowel is generally decompressed throughout. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Apparent mild mural thickening and mucosal hyperenhancement throughout the colon is likely due to underdistention, although subtle pericolonic fat stranding about the cecum may suggest this finding is real. Mild pancolonic diverticulosis. The appendix is not visualized. There is no free fluid or free air in the abdomen. PELVIS: The urinary bladder is underdistended, limiting its evaluation. The distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: A 1.2 cm retrocrural lymph node (2:46) is stable. Elsewhere, there is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Moderate atherosclerotic disease is noted. BONES: There is no acute fracture. No focal suspicious osseous abnormality. Unchanged mild anterolisthesis of L2 on L3. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No new findings to suggest metastatic disease within the abdomen or pelvis. 2. Suggestion of mural thickening and mucosal hyperenhancement throughout the colon could suggest mild pancolitis, which if real, is likely infectious or inflammatory. 3. Mildly enlarged retrocrural lymph node and indeterminate subcentimeter hepatic lesions are stable. 4. Cholelithiasis without acute cholecystitis. Radiology Report EXAMINATION: Esophagram INDICATION: ___ year old woman with severe COPD on 3LNC and a history of lung cancer presenting with severe epigastric pain // evaluate for esophageal strictures TECHNIQUE: Barium esophagram. DOSE: Acc air kerma: 12 mGy; Accum DAP: 167.4 uGym2; Fluoro time: 1 minute 46 seconds COMPARISON: CT chest abdomen pelvis ___ FINDINGS: The esophagus was not dilated. There was no stricture within the esophagus. There was no esophageal mass. There are diffuse tertiary contractions were seen throughout the mid and lower esophagus. The lower esophageal sphincter opened and closed normally. There was no gastroesophageal reflux. There was a small hiatal hernia. No overt abnormality in the stomach or duodenum on limited evaluation. IMPRESSION: 1. No gross evidence of esophageal stricture, web, or ring. 2. Diffuse tertiary contractions through the mid through lower esophagus. 3. Small hiatal hernia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Cough, Ear pain Diagnosed with Unspecified abdominal pain temperature: 97.3 heartrate: 112.0 resprate: 20.0 o2sat: 95.0 sbp: 142.0 dbp: 74.0 level of pain: 0 level of acuity: 3.0

SUMMARY: ======== Ms. ___ is an ___ year old woman with a history of COPD (GOLD D on 3L home O2), stage IIIb small cell lung cancer s/p chemo XRT (completed ___, hx of perforated diverticuli s/p ___ procedure/colostomy now reversed, and multiple hospital admissions for PNA and COPD who presents abdominal pain concerning for PUD.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cold right foot Major Surgical or Invasive Procedure: Lysis catheter to R below-knee popliteal artery and ___ R Popliteal Artery Aneurysm resection History of Present Illness: ___ PMH HTN, HLD, right popliteal artery aneurysm (since at least ___ presents from OSH with cool right foot since earlier today (10 am) and intramural thrombus of the right popliteal artery aneurysm seen on US. Patient reports he noticed bruising on his right leg on ___ upon awakening which turned to a scab and became slightly erythematous around it. He can recall no injury to the area. On ___, he experienced foot pain/numbness and presented to ___ for evaluation. There he says he had an ultrasound, but is unsure what it showed. He was given a single dose of Lovenox, an antibiotic shot, and a prescription for Keflex and Bactrim. The symptoms subsided and he was discharged home. On ___, he had recurrent pain, numbness and tingling and presented to ___ for evaluation. There he was noted to have intramural thrombus within the popliteal artery aneurysm. Symptoms again subsided within several hours and he was discharged home with a prescription for Xarelto and a follow-up appointment with Dr. ___. He tried to fill the Xarelto, but could not afford the more than $400 co-pay. His symptoms resumed this morning at 10am and have continued to worsen. He again presented to ___ who started him on a heparin drip and transferred him to ___ for further management. Past Medical History: -HTN -HLD -right popliteal artery aneurysm Social History: ___ Family History: -no family history of vascular disease, aneurysms, connective tissue disorder, or sudden death Physical Exam: ADMISSION PHYSICAL EXAM Physical Exam: Afebrile, vitals WNL GEN: NAD HEENT: EOMI, MMM CV: RRR PULM: non-labored breathing ABD: soft, NT/ND EXT: RLE with sharply demarcated area of pallor along base of all 5 toes, cool to touch compared to right foot. Decreased sensation to light palpation over dorsal aspect of RLE and unable to appreciate light palpation over distal most aspect of all 5 right toes. Able to plantarflex/dorsiflex foot and move all toes of RLE with preservation of strength compared to LLE. Right anterior midshin with area of ecchymosis and skin necrosis with some draininage of serosanguinous fluid with palpation. No evidence of infection. PULSES: LLE-palp femoral, palp popliteal, palp DP, dop ___ RLE-palp femoral, large pulsatile mass in right popliteal fossa, monophasic ___, no signal DP NEURO: A&Ox3 PSYCH: appropriate mood, appropriate affect DISCHARGE PHYSICAL EXAM VS: 98.6 PO 122 / 67 94 18 98 Ra General: oriented x 3, in nad CV: regular rate and rhythm Pulm: no respiratory distress or work of breathing, comfortable on RA Abdomen: soft, nontender, resolving maculopapular rash on back, R groin with resolving hematoma, erythema without tenderness or discharge Extremities: RLE with superficial bullae at distal aspect that have popped, diffuse petechiae, mild pitting edema, staples on medial aspect of RLE, foot warm to touch Pulses: Doppler signals at R ___ Pertinent Results: ADMISSION LABS ___ 02:00PM GLUCOSE-97 UREA N-17 CREAT-1.3* SODIUM-143 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17* ___ 02:00PM estGFR-Using this ___ 02:00PM ALT(SGPT)-41* AST(SGOT)-61* ALK PHOS-90 TOT BILI-0.3 ___ 02:00PM LIPASE-27 ___ 02:00PM cTropnT-<0.01 ___ 02:00PM ALBUMIN-3.8 ___ 02:00PM WBC-14.1* RBC-4.55* HGB-14.1 HCT-42.1 MCV-93 MCH-31.0 MCHC-33.5 RDW-13.0 RDWSD-43.8 ___ 02:00PM NEUTS-64.7 ___ MONOS-7.5 EOS-2.6 BASOS-0.9 IM ___ AbsNeut-9.12* AbsLymp-3.33 AbsMono-1.06* AbsEos-0.36 AbsBaso-0.12* ___ 02:00PM PLT COUNT-226 ___ 02:00PM ___ PTT-150* ___ DISCHARGE LABS ___ 06:08AM BLOOD WBC-14.2* RBC-2.51* Hgb-7.8* Hct-23.4* MCV-93 MCH-31.1 MCHC-33.3 RDW-12.7 RDWSD-43.8 Plt ___ ___ 06:08AM BLOOD Plt ___ ___ 06:08AM BLOOD Glucose-101* UreaN-20 Creat-0.9 Na-137 K-4.8 Cl-101 HCO3-24 AnGap-12 ___ 06:08AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0 PERTINENT LABS ___ 05:42AM BLOOD CK(CPK)-1782* ___ 11:47PM BLOOD CK(CPK)-921* ___ 06:28AM BLOOD CK(CPK)-777* Medications on Admission: 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Pravastatin 40 mg PO QPM Discharge Medications: 1. Apixaban 10 mg PO BID Duration: 7 Days RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 2. Apixaban 5 mg PO BID Duration: 3 Months RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*168 Tablet Refills:*0 3. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours as needed for pain Disp #*15 Capsule Refills:*0 5. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate [Toprol XL] 100 mg 1.5 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Allopurinol ___ mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Lisinopril 40 mg PO DAILY 9. Pravastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Popliteal Aneurysm s/p ___ ___ Acquired Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: VEIN MAPPING-Lower extremities INDICATION: ___ year old man with R popliteal aneurysm scheduled for resection today// vein mapping TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral lower extremity veins. COMPARISON: None. FINDINGS: RIGHT: The great saphenous vein is patent with diameters ranging from 0.39 to 0.5 cm. The right small saphenous vein is patent with diameters ranging from 0.22 to 0.33 cm. LEFT: The great saphenous vein is patent with diameters ranging from 0.35 to 0.63 cm AK. BTK diameters are smaller 0.14-0.21cm The left small saphenous vein is patent with diameters ranging from 0.26 to 0.6 cm. IMPRESSION: The great and small saphenous veins are patent bilaterally. Please see digitized image on PACS for formal sequential measurements. The left GSV is small below the level of the knee. Radiology Report INDICATION: ___ PMH HTN, HLD, and R popliteal artery aneurysm w/ acute onset pain, pallor, and pulselessness to RLE now s/p RLE lysis catheter (removed) and R SFA-BKpop bypass with pop aneurysm resection// ?pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: None available FINDINGS: There is a retrocardiac infiltrate which given the lack of prior imaging may reflect a focus of consolidation/pneumonia. No focal consolidation is seen within the right lung. There is no pleural effusion or pneumothorax. IMPRESSION: Possible left lower lobe pneumonia. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R Leg pain, R POPLITEAL ANEURYSM Diagnosed with Pain in left leg temperature: 98.8 heartrate: 86.0 resprate: 20.0 o2sat: 96.0 sbp: nan dbp: nan level of pain: 9 level of acuity: 2.0

___ y/o M with a PMH of HTN, HLD admitted as a transfer from an outside hospital with acute limb ischemia of the right lower limb found to have a right popliteal artery aneurysm with intramural thrombus now s/p TPA lysis catheters and popliteal aneurysm resection with return of signals. #R Popliteal artery aneurysm s/p resection: Admitted with cool right foot and US report from OSH ___ ___ noting 4.34 cm popliteal aneurysm with intramural thrombus. He was transferred to ___ on heparin drip. Admission evaluation noted bounding R popliteal artery aneurysm and monophasic ___, but no signal at DP. He was taken to the OR ___ for RLE angio which demonstrated patent tibial trifurcation with slow fill, but not visualization of tibial vessels in distal extent or at level of the foot. Thrombolysis catheter was placed in the right below-knee popliteal artery. On ___ he was taken back for lysis check with repeat angio that revealed sluggish filling of the distal right anterior tibial and posterior tibial arteries without patent anterior tibial or posterior tibial across the right ankle. Subsequently had angiojet of ___ and AT with placement of infusion catheters in ___ and AT and improvement in signals. On ___ catheters were removed and patient underwent Right SFA to below-knee popliteal bypass using non- reversed greater saphenous vein and ligation and resection of the popliteal artery aneurysm. Post-operatively patient was briefly continued on heparin drip and then transitioned to xarelto. Due to insurance issues patient was discharged on therapeutic apixiban dose. Pulse exam on discharge with strong Doppler signals in R DP and ___ #Pneumonia: Patient febrile on with leukocytosis and tachycardia, found to have left lower lobe pneumonia on ___. Started on levofloxacin x 7 days with improvement in symptoms and downtrending leukocytosis. TRANSITIONAL ISSUES =================== []Tachycardia: Home metoprolol xl uptitrated from 100 to 150mg with appropriate HR control <110 []s/p popliteal aneurysm resection and lysis catheters: Patient to continue apixiban 10mg bid x 7 days, followed by 5mg BID for a total of 3 months []Pneumonia: continue levofloxacin 750mg daily x 5 days (total 7 day course) []Follow-up with Dr. ___ ___ @ 10:00am in ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cortisone / Poison ___ / Aleve Attending: ___. Chief Complaint: Weight gain, abdominal distention, hallucinations Major Surgical or Invasive Procedure: Diagnostic paracentesis ___ Therapeutic paracentesis ___ (5L removed) History of Present Illness: Mr. ___ is a ___ yo male with a PMHx significant for HCV/EtOH cirrhosis, HCC s/p TACE x3, hepatic vein thrombus, radiotherapy with CyberKnife, sorafenib ___, recently discharged on ___ after hospitalized for nausea/vomiting thought to be secondary to sorafenib now transitioned to capecitabine, presenting to the ED with abdominal distention, weight gain and SOB for about 2 weeks. States that over the last 2 wks weight has gone from 175lb to 198lb with increasing abdominal girth and decreased UOP, progressive SOB with exertion. He also reports swelling of his lower extremities L>R. He minimizes his report of hallucinations, stating about once a month "when his blood gets all messed up with medications" he will see something out of the corner of his eye or see words or writing that isn't really there. In the ED, initial vitals were 98.4 61 114/67 20 99%. In triage, he was noted to be a+ox2-3, but having hallucinations. On exam: no asterixis, significant abdominal distension, guiaiac negative. Labs significant for WBC 2.4 with 76.6% PMN, 4.4% eos, 12% lymphs, Hct 36.9 (at ___, Plats 62 (at ___ INR 1.7 (up from 1.4 as far back as ___, AST/ALT 51/21, AP 72, T bili 1.9, alb 2.9, lipase 22. U/A pos for bili but no e/o infection. CHEM-7 WNL with cr 0.8 (at ___. A paracentesis was performed and did not show evidence of SBP. On arrival to the floor, ___ is irritated with repetative questioning and frustrated by his right knee pain which he has not had pain meds for yet today and reports that he "shouldn't have come to the hospital, should have put a bullet in my head instead". Upon further questioning he states he was not serious, has not thought seriously about hurting himself, does not have and never has had a plan to hurt himself or anyone else, does not own or have access to firearms. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - HCV diagnosed in ___. - History of alcohol abuse/cirrhosis - Hypercholesterolemia. - Upper GI bleed in ___ due to a gastric ulcer. - History of grade 1 to 2 varices. - Status post bilateral knee surgery. - Status post left inguinal and umbilical hernia repair ___. - CAD: inferolateral wall MI ___. CK 844, MB 135, EF 40%-47%. - h/o pAfib - Multiple HCC s/p TACE ___ to segment VII/VIII, RFA ___, TACE ___, and TACE ___ to right hepatic lobe and right hepatic vein segment thrombus. s/p CyberKnife right liver and hepatic vein tumor thrombus ___. Started sorafenib ___ but self-discontinued ___ due to poor tolerance (N/V). Started capecitabine ___ at a dose of 1000 mg/m2 b.i.d. days 1 through 14 of a 21-day cycle. Social History: ___ Family History: The ___ father died of an MI at ___ years. He has two brothers and three sisters. One brother had a stroke at ___ years. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9F, BP 113/71, HR 66, RR 17, 100%RA 87.6Kg GENERAL: Ill appearing M in mild distress ___ knee pain HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple no ___ or JVD CARDIAC: irregularly irregular, S1 S2 clear and of good quality without murmurs, rubs or gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but soft, non-tender to palpation. Dullness to percussion over dependent areas. Paracentesis site clean no leakage. Blanchable erythema 10in dia paraumbilical EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ left leg edema, 1+ right leg edema; L SKIN: dry flaking erythema over shoulders, chest, forearms, peeling on feet. DISCHARGE PHYSICAL EXAM: VS: 98.1, BP 98/68, HR 91, RR 20, 100%RA GENERAL: Ill appearing M in NAD HEENT: Sclera anicteric. PERRL, EOMI. CARDIAC: irregularly irregular, S1 S2 clear and of good quality without murmurs, rubs or gallops. LUNGS: CTAB ABDOMEN: Distended but soft, non-tender to palpation. Dullness to percussion over dependent areas. Paracentesis site clean no leakage. Blanchable erythema 10in dia paraumbilical improving EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ left leg edema, 1+ right leg edema; L SKIN: dry flaking erythema over shoulders, chest, forearms, peeling on feet. scattered spider hemangiomas on back Pertinent Results: ADMISSION LABS: ___ 11:40AM BLOOD WBC-2.4* RBC-3.71* Hgb-12.4* Hct-36.9* MCV-99* MCH-33.5* MCHC-33.7 RDW-24.3* Plt Ct-62* ___ 11:40AM BLOOD Neuts-76.6* Lymphs-12.1* Monos-6.3 Eos-4.4* Baso-0.6 ___ 11:40AM BLOOD ___ PTT-36.8* ___ ___ 11:40AM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-135 K-4.2 Cl-101 HCO3-28 AnGap-10 ___ 11:40AM BLOOD ALT-21 AST-51* AlkPhos-72 TotBili-1.9* ___ 11:40AM BLOOD Lipase-22 ___ 11:40AM BLOOD Albumin-2.9* ___ 12:15PM ASCITES WBC-250* RBC-420* Polys-19* Lymphs-14* Monos-37* Mesothe-11* Macroph-19* ___ 12:15PM ASCITES TotPro-0.8 Glucose-113 Albumin-PND DISCHARGE LABS: ___ 06:00AM BLOOD WBC-1.5* RBC-3.20* Hgb-10.6* Hct-31.9* MCV-100* MCH-33.1* MCHC-33.1 RDW-24.2* Plt Ct-63* ___ 06:00AM BLOOD Neuts-71.3* Lymphs-16.1* Monos-8.3 Eos-4.1* Baso-0.4 ___ 06:00AM BLOOD ___ ___ 06:00AM BLOOD Glucose-137* UreaN-13 Creat-0.8 Na-139 K-3.8 Cl-104 HCO3-31 AnGap-8 ___ 06:00AM BLOOD ALT-21 AST-36 AlkPhos-61 TotBili-1.7* ___ 06:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0 PERTINENT MICRO: ___ URINE CULTURE- NEG FINAL ___ Blood Culture, Routine-PENDING ___ Blood Culture, Routine-PENDING ___ PERITONEAL FLUID GRAM STAIN- NEG FINAL; FLUID CULTURE-NEG FINAL; ANAEROBIC CULTURE-PRELIMINARY PATH: cytology peritoneal fluid ___ Peritoneal fluid: NEGATIVE FOR MALIGNANT CELLS. PERTINENT IMAGING ___ Liver US with doppler IMPRESSION: 1. Persistent thrombosis of the anterior right portal vein. There is no there is no extension of thrombus into the other central portal branches 2. Increasing ascites since ___. Splenomegaly. 4. Gallbladder wall thickening secondary to ascites. ___ 2-view CXR FINDINGS: As compared to the previous radiograph, the lung volumes have decreased. No pleural effusions are seen on the frontal and the lateral radiographs. Plate-like areas of atelectasis at the left lung base, better appreciated on the frontal than on the lateral image. No evidence of pneumonia. Borderline size of the cardiac silhouette. Normal hilar and mediastinal structures. ___ non-con head CT IMPRESSION: No acute intracranial process. Please note that MRI is more sensitive for the detection of subtle masses and early infarct and may be considered in the correct clinical setting if there are no contraindications to the use of MRI. ___ ___ left leg IMPRESSION: No evidence of deep vein thrombosis in the left leg. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Capecitabine 500 mg PO Q12H 2. Citalopram 20 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 5. Lisinopril 2.5 mg PO DAILY ___ unsure if still taking 6. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea/vomiting 7. Nadolol 20 mg PO DAILY 8. OLANZapine 2.5 mg PO DAILY nausea 9. Omeprazole 40 mg PO DAILY 10. Simvastatin 10 mg PO DAILY 11. Aspirin 325 mg PO DAILY 12. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Outpatient Lab Work CBC on ___. Diagnosis: pancytopenia, cirrhosis, HCC on chemo Please fax results to Dr. ___ (___) 2. Citalopram 20 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 5. Nadolol 20 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Simvastatin 10 mg PO DAILY 8. Aspirin 325 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. OLANZapine 2.5 mg PO DAILY nausea 11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea/vomiting 12. Amiloride HCl 10 mg PO DAILY RX *amiloride 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 13. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Lactulose 30 mL PO TID titrate to 3 BM daily RX *lactulose 10 gram/15 mL 30 mL by mouth three times a day Disp #*3000 Milliliter Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: hallucinations, possibly hepatic encephalopathy. ascites Secondary: hepatocellular carcinoma cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ man with advanced hepatocellular carcinoma and known right anterior portal vein from thrombus presenting with worsening ascites. COMPARISON: Multiphasic abdominal CT ___, duplex ultrasound ___ , abdominal MRI ___. FINDINGS: The liver has a nodular contour. The extent of the known infiltrative hepatocellular carcinoma is incompletely assessed on this limited ultrasound which was tailored specifically towards patency of the hepatic vasculature. The gallbladder wall is thickened up to 5 mm. There is no intra or extrahepatic biliary dilatation. Common bile duct measures 5 mm. The spleen is enlarged up to 20 cm. The left kidney measures 10.6 cm. The right kidney measures 12.2 cm. There is no hydronephrosis in either kidney. Large volume ascites has increased since ___. Hepatic Doppler: The main portal vein is patent with hepatopetal flow. The posterior right portal vein is patent on real-time visualization. The anterior right portal vein branch is not well seen, compatible with previously seen thrombosis. The left portal vein is patent with hepatopetal flow. The hepatic veins are patent with patent appropriate hepatopetal flow. The IVC is normal in caliber and appearance. The main hepatic artery is patent with normal arterial waveforms. IMPRESSION: 1. Persistent thrombosis of the anterior right portal vein. There is no there is no extension of thrombus into the other central portal branches. 2. Increasing ascites since ___. Splenomegaly. 4. Gallbladder wall thickening secondary to ascites. Radiology Report CHEST RADIOGRAPH INDICATION: Hepatic encephalopathy, questionable infection. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the lung volumes have decreased. No pleural effusions are seen on the frontal and the lateral radiographs. Plate-like areas of atelectasis at the left lung base, better appreciated on the frontal than on the lateral image. No evidence of pneumonia. Borderline size of the cardiac silhouette. Normal hilar and mediastinal structures. Radiology Report INDICATION: ___ man with hepatitis C and alcoholic cirrhosis, now with visual hallucinations. COMPARISON: CT head with and without contrast ___. TECHNIQUE: Contiguous axial images were obtained through the brain without the administration of IV contrast. Multiplanar reformats were generated and reviewed. FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. Gray-white matter differentiation is preserved with no evidence of acute major vascular territory infarction. Bilateral mastoid air cells and visualized paranasal sinuses are clear. Orbits and conus are symmetric. IMPRESSION: No acute intracranial process. Please note that MRI is more sensitive for the detection of subtle masses and early infarct and may be considered in the correct clinical setting if there are no contraindications to the use of MRI. Radiology Report HISTORY: ___ man with left greater than right lower extremity edema, evaluate for DVT. COMPARISON: No previous exam for comparison. FINDINGS: Grayscale, color, and Doppler images were obtained of the left common femoral, femoral, popliteal and tibial veins. Normal flow, compression and augmentation is seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left leg. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ACITIES,SOB,PAIN Diagnosed with CHEST PAIN NEC, MAL NEO LIVER, PRIMARY temperature: 98.4 heartrate: 61.0 resprate: 20.0 o2sat: 99.0 sbp: 114.0 dbp: 67.0 level of pain: 7 level of acuity: 2.0

Mr. ___ is a ___ yo male with a history of HCV/EtOH cirrhosis, MELD 15 but 22 for ___, presenting with increasing abdominal girth and visual hallucinations concerning for hepatic encephalopathy. # Encephalopathy: ___ presented with visual hallucinations, reported seeing things out of the corner of his eyes and seeing words that we not there. He was reportedly experiencing further visual hallucinations in the ED though no further details of this were documented and ___ denied that these visual disturbances were significant or persistent. He was alert and oriented x3, without asterixis. Work up for hepatic encephalopathy was unrevealing, showed patent liver vessels, diagnositic paracentesis negative for infection. Infectious work up was negative though several cultures were pending at discharge. Non-contrast head CT was negative for acute bleed. He was started on rifaximin and lactulose was titrated to ___ bowel movements per day and sedating medications were held. His chemotherapy agent, capecitabine was also held per discussion with Dr. ___. - Discharged on lactulose, consider adding rifaximin if concern for HE persists - Blood and peritoneal fluid cultures pending at discharge # Cirrhosis: HCV/EtOH related cirrhosis, complicated by ascites, encephalopathy, HCC. MELD on admission was 15 (22 for HCC), ___ not on transplant list. - SBP: total ascites protein 0.8, no known h/o SBP, Cipro ppx started for low ascites protein - Hepatic Encephalopathy: as above - Varices: Continued nadolol - Ascites: Continue lasix, 2g Na diet, SAAG consistent with cirrhosis over malignant effusion, cytology negative for malignant cells. Started on amiloride while admitted. # HCC: On capecitabine C3D6 (___), followed by Dr. ___ ___. ___ is s/p TACE x3, radiotherapy with CyberKnife, sorafenib ___. Dr. ___ was notified of the admission and capecitabine was held, to be restarted as directed by Dr. ___ - ___ follow up with Dr. ___ in clinic #Asymmetric lower extremity edema: concerning for DVT in chronically ill man with malignancy, but LENIs of the left leg were negative for DVT. #Atrial fibrillation: ___ reports known history of paroxysmal AFib, not on anticoagulation. He was noted to be in Afib with normal rate during this admission and hemodynamically stable. ___ declined telemetry, was made aware of risks of not using continuous monitoring. -Continued nadolol for history of varices #Pancytopenia: likely from cirrhosis and recent chemotherapy. ANC was just above 1000 at time of discharge, ___ was instructed to present to the emergency room immediately if he developed fever. - Continued iron supplementation - Should have repeat labs ___ #GERD: continued omeprazole #Chronic knee pain: continued dilaudid, lidocaine patch #Anxiety/depression: continued citalopram, held ativan for AMS - ___ may take ativan as needed, if AMS recurs, consider holding again #CAD: inferolateral wall MI ___. CK 844, MB 135, EF 40%-47%. - Did #Hyperlipidemia: continued simvastatin

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Agitation Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with CAD, HTN, CKD, and DLBCL to CNS admitted from clinic for relapsed CNS lymphoma and cycle #4 high-dose methotrexate. Previous MTX was complicated by ___. He was then changed to temazolamide and then to pemetrexed, but now he has relapsed presenting to clinic with mild confusion and failure to thrive. He was given high-dose MTX, dose reduced to 3.0g/m2 to avoid worsening renal failure. Dexamethasone was increased from 4mg daily to 4mg BID. Pt cleared MTX and was discharged to a rehab facility yesterday. Upon arrival at rehab pt was agitated and wanted to leave, so was sent back. Pt had been confused during admission, but never agitated prior. Wife thinks the thought of rehab made him think he would not return home. Currently, pt denies any complains, has been explained and understands the purpose of going to rehab and is willing to return. Full ten point ROS is negative except for fatigue. Past Medical History: PAST ONCOLOGIC HISTORY (per Dr/ ___ note ___ Developed renal failure ___ Abdominal LAD found, had biopsy Pathology: B-cell lymphoma ___ BMBx negative ___ Left calf DVT ___ - ___ CHOP-R and CVP ___ Developed dizziness and falls ___ Brain MRI showed left temporal lesion ___ CT-guided biopsy of left temporal lesion by Dr. ___: Lymphoma ___ C1D1 HD-MTX 3.5 g/m2 ___ C1D15 HD-MTX 3.5 g/m2 ___ C2D1 HD-MTX 3.5 g/m2 ___ C2D15 HD-MTX 3.5 g/m2 ___ C1D1 Pemetrexed 600 mg/m2 ___ C1D15 Pemetrexed 600 mg/m2 ___ Developed rash ___ C1 Temodar ___ - ___ Admitted for fatigue ___ C2D1 Temozolomide ___ MRI brain shows new lesion ___ C2D1 Pemetrexed ___ C3D1 Pemetrexed ___ HD MTX . PAST MEDICAL HISTORY: 1. NHL, brain involvement as above 2. Hypertension 3. Peptic ulcer disease 4. Left lower extremity DVT ___ 5. Abdominal aortic aneurysm repair ___ 6. Renal failure when presented with NHL 7. Pulmonary interstitial fibrosis (does not require O2 at baseline) 8. Cardiomegaly 9. Gout Social History: ___ Family History: Eldest child with ALS. Son had ___, now resected. Physical Exam: Physical Examination: VS: Tcurr 96.4, BP 132/78, HR 69, RR 18, O2 Sat 95% RA, GEN: A,Ox2 (not year) NAD HEENT: Sclerae non-icteric, EOM intact, CNs intact, no thrush, MMM. Neck: Supple, no LAD. CV: S1S2, reg rate and rhythm, no MRG. RESP: Good air movement bilaterally, no rhonchi or wheezing. BACK: No spine, rib, or iliac tenderness. ABD: Soft, non-tender, non-distended, no HSM, + bowel sounds. EXTR: No edema or calf tenderness. No finger clubbing. NEURO: Strength ___, non-focal. SKIN: No rash. PSYCH: Occionally confused, but calm, appropriate. Pertinent Results: ___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 01:30AM GLUCOSE-113* UREA N-28* CREAT-1.4* SODIUM-138 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-32 ANION GAP-11 ___ 01:30AM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-2.0 ___ 01:30AM CARBAMZPN-LESS THAN ___ 01:30AM WBC-6.9 RBC-3.02* HGB-10.3* HCT-31.7* MCV-105* MCH-34.0* MCHC-32.5 RDW-16.7* ___ 01:30AM NEUTS-85.4* LYMPHS-11.6* MONOS-1.6* EOS-1.1 BASOS-0.4 ___ 01:30AM PLT COUNT-___: IMPRESSION: 1. No change from recent studies of ___ and ___, with left temporal and frontoparietal vasogenic edema related to the known left temporal lobar intra-axial mass. 2. Impending left uncal herniation, unchanged in degree, with no subfalcine herniation. . CXR ___: FINDINGS: No change from ___. No acute process. Medications on Admission: 1. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): to start one day prior to next Methotrexate admission. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: ___ Drops Ophthalmic PRN (as needed) as needed for dry eyes. 12. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. multivitamin Tablet Sig: One (1) Tablet PO once a day. 15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 4 days. Discharge Medications: 1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. 2. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 3 days. 3. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four times a day. 13. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: One (1) Ophthalmic four times a day as needed for dry eyes. 14. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 15. Zyprexa 2.5 mg Tablet Sig: ___ Tablets PO once a day as needed for agitation. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: DLBCL with CNS involvement Pneumonia Confusion Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with mental status change. TECHNIQUE: Frontal and lateral radiographs of the chest were obtained. COMPARISON: Chest radiograph from ___. FINDINGS: There is mild cardiomegaly. The cardiomediastinal shilouette and hila are normal. No effusion. The lungs are clear. A left Port-A-Cath ends at the cavoatrial junction. No change from ___. FINDINGS: No change from ___. No acute process. Radiology Report INDICATION: ___ with mental status change. TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal reformats were acquired. COMPARISON: NECT of the head from ___, and enhanced MRI of the head from ___. FINDINGS: CT OF THE HEAD: There is no hemorrhage. There is extensive vasogenic edema spreading throughout the left temporal and frontoparietal lobe associated with underlying left temporal lobe mass, better demonstrated on the recent MRI. The degree of impending left uncal herniation is similar compared to that on the MR study, with stable mild effacement of the left lateral ventricle, and no significant shift of midline structures. There is moderate confluent hypodensity in the centra semiovale and periventricular, as well as central pontine, white matter, as before, consistent with sequelae of chronic small vessel ischemic disease. Allowing for these abnormalities, there is no large acute vascular territorial infarction. A burr hole is seen in the left paramedian frontal bone. There is no suspicious lytic or sclerotic bony lesion or fracture. The included paranasal sinuses, middle ear cavities and mastoid air cells are clear. IMPRESSION: 1. No change from recent studies of ___ and ___, with left temporal and frontoparietal vasogenic edema related to the known left temporal lobar intra-axial mass. 2. Impending left uncal herniation, unchanged in degree, with no subfalcine herniation. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: AGITATED Diagnosed with ALTERED MENTAL STATUS , SPECIAL SYMPTOM NEC/NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, RENAL FAILURE, UNSPECIFIED temperature: 96.8 heartrate: 67.0 resprate: 16.0 o2sat: 96.0 sbp: 157.0 dbp: 75.0 level of pain: 0 level of acuity: 3.0

___ man with CAD, HTN, CKD, and DLBCL to CNS admitted from clinic for relapsed CNS lymphoma and cycle #4 high-dose methotrexate. Previous MTX was complicated by ___. He was then changed to temazolamide and then to pemetrexed, but now he has relapsed presenting to clinic with mild confusion and failure to thrive. He was given high-dose MTX, dose reduced to 3.0g/m2 to avoid worsening renal failure. Dexamethasone was increased from 4mg daily to 4mg BID. Pt received MTX ___, was discharged last night to rehab and was sent back due to agitation. . # Agitation: Likely delirium, with baseline confusion and sundowning due to underlying CNS lymphoma. -full infectious w/u done and negative so far, repeat HCT negative -pt will need re-direction and encouragement while he djusts to rehab facility, wife will accompany him there (or meet him there) -will add prn Zyprexa for agitation if needed . # CNS lymphoma: s/p Cycle #4 high-dose MTX 3.0g/m2 given worsening renal function with previous 3.5g/m2 dose ___. - Continue levetiracetam. - Increased dexamethasone from 4mg daily to 4mg BID. - Plan for Rituxan next ___ in clinic followed by admission for HD MTX . # Pneumonia: To complete treatment with Ceftriaxone/azithromycin . # CKD: MTX dose adjusted for creat clearance. However, poor prognosis for malignancy now supersedes risk to kidneys. cont to renally dose meds . # CAD/CHF: - Cont ASA (Hold aspirin during MTX and restart after MTX clears). - Continue carvedilol and lisinopril. - Follow Ins/Outs and daily weights. . # Thrush: on nystatin until clearance . # Hypertension: Continued carvedilol and lisinopril. . # Hyperlipidemia: Hold atorvastatin due to transaminitis and MTX. . # FEN: Regular diet, Replete lytes PRN. . # DVT prophylaxis: Ambulation, pneumoboots. . # GI prophylaxis: H2 blocker (hold PPI until while getting intermittent MTX). Bowel regimen. . # Lines: Port and peripheral IV. . # Precautions: None. . # CODE: FULL. . # Contact: Wife. . # Discussed with: Patient Nursing Houses___ PCP ___ ___ Oncologist . # Dispo: Rehab [x ] Discharge documentation reviewed, stable for discharge. [x ] Time spent on discharge activity was greater than 30min. [ ] Time spent on discharge activity was less than 30min. . Active meds: See below. . . . _________________________________ ___, MD, pager ___ .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ male patient with a history of COPD, CHF, Afib on warfarin who presented with SOB. He states that he has SOB at baseline over many months, but that it acutely worsened this week. For the last 5 days or so, he felt as though he wasn't able to walk the same distances or do the same activities without becoming increasingly SOB. During this time he also noticed that he was having rhinorrhea, a worsening cough, and a sore throat. He also noticed increased ___ swelling. Was here in the ED yesterday ___ ___ut appears to have been seen for hypoglycemia and UTI. Was sent home on cefpodoxime for 10 days for UTI and no intervention was needed for hypoglycemia. Denied fever, chills, chest pain, but does endorse multiple hospitalizations this year for COPD and HF. In the ED: ================================= - Initial vital signs were notable for: Temp not taken, HR 88, BP 132/84, RR 30, SpO2 92% - Exam notable for: General: Accessory muscles to breath, uncomfortable appearing CV: RRR w/o MRG Pulm: Bilateral wheezes - Labs were notable for: BUN 72, Cr 2.9 (baseline difficult to assess ___, Glu 60 BNP 726 WBC 10.4 (80% Neut), Hgb 8.9, Hct 31.0, Plt 246 All others WNL - Studies performed include: Chest Xray ___: 1. Redemonstration of a right pleural effusion. A superimposed pneumonia would be difficult to exclude. 2. Mild pulmonary vascular congestion edema, similar to slightly improved compared to the most recent prior examination of ___. EKG: Sinus rhythm Nonspecific intraventricular conduction delay Probable anterior infarct, age indeterminate QTc 550 - Patient was given: Albuterol, Atrovent IH x2 Azithromycin 500mg PO at 10AM Prednisone 40mg PO at 10AM Furosemide 80mg IV at 10AM Albuterol Neb at 2:30PM - Consults: None currently Vitals on transfer: HR 79, BP 129/69, RR 22, 96% on 3L NC Upon arrival to the floor: ================================= Confirms the above history and states that he does have SOB at baseline, but the last couple days have been really bad for him. He denies any increased sputum or change in sputum color (has intermittent white colored sputum). Feels a little bit better after getting the nebulizer treatments, but still not feeling like he is at baseline. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD - Pump: LVEF 67% ___ - SR, hx of paroxysmal AF 3. OTHER PAST MEDICAL HISTORY HFpEF GERD Gout GCA (___) GI bleed CAD COPD EOTH abuse CVA PVD CKD Stage 3 Afib on warfarin Social History: ___ Family History: Uncles with alcoholism. Mother with a heart attack after ___ y/o. Daughter passed away of complications due to diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= Vitals: 24 HR Data (last updated ___ @ ___) Temp: 97.7 (Tm 97.7), BP: 135/78, HR: 78, RR: 18, O2 sat: 93%, O2 delivery: 2L GENERAL: Alert and interactive. Laying at 30 degree angle. Does require some pauses between sentences to catch breath. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Decreased breath sounds bilaterally, most difficult to appreciate over the right lower lung fields. Mild expiratory wheezes bilaterally, basilar crackles appreciated over left lower lung fields, no rhonchi. Some increased work of breathing. ABDOMEN: Normal bowels sounds, distended but not tense abdomen, non-tender to deep palpation in all four quadrants. No organomegaly. Umbilical hernia that is reducible and non-tender is present. EXTREMITIES: Amputation of the right leg at the level of the thigh. Left leg has non-tense pitting edema to the thigh. Radial pulses 2+, ___ and DP not appreciated in LLE. Decreased sensation in foot/ankle. No tenderness to palpation, erythema, or warmth in the LLE. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. CN2-12 intact. PSYCH: appropriate mood and affect Discharge physical exam ======================= 24 HR Data (last updated ___ @ 1710) Temp: 97.5 (Tm 98.6), BP: 134/73 (122-148/63-80), HR: 75 (65-75), RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: RA, Wt: 214.51 lb/97.3 kg EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Fine wheezes that clear with cough. No crackles. No increased work of breathing. ABDOMEN: Normal bowels sounds, distended but not tense abdomen, non-tender to deep palpation in all four quadrants. No organomegaly. Umbilical hernia that is reducible and non-tender is present. EXTREMITIES: Amputation of the right leg at the level of the thigh. Left leg has tray edema to ankle. Radial pulses 2+, ___ and DP not appreciated in LLE. Decreased sensation in foot/ankle. No tenderness to palpation, erythema, or warmth in the LLE. Pertinent Results: Admisison labs =============== ___ 08:39AM PLT COUNT-246 ___ 08:39AM BLOOD WBC-10.4* RBC-3.95* Hgb-8.9* Hct-31.0* MCV-79* MCH-22.5* MCHC-28.7* RDW-18.1* RDWSD-51.8* Plt ___ ___ 08:39AM BLOOD ___ ___ 06:02AM BLOOD ___ PTT-46.4* ___ ___ 08:39AM BLOOD Glucose-60* UreaN-72* Creat-2.9* Na-144 K-4.4 Cl-108 HCO3-24 AnGap-12 ___ 08:39AM BLOOD proBNP-726 ___ 08:39AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0 Discharge labs =============== ___ 06:21AM BLOOD WBC-10.9* RBC-4.29* Hgb-9.7* Hct-32.7* MCV-76* MCH-22.6* MCHC-29.7* RDW-17.6* RDWSD-48.2* Plt ___ ___ 06:21AM BLOOD ___ PTT-37.1* ___ ___ 06:21AM BLOOD Glucose-207* UreaN-85* Creat-2.1* Na-139 K-5.1 Cl-94* HCO3-30 AnGap-15 ___ 06:21AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0 ___ 06:04AM BLOOD calTI___ Ferritn-22* TRF-244 TTE ___ CONCLUSION: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 55 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Mildly dilated right ventricular cavity with normal free wall motion. The aortic sinus diameter is normal for gender. There is a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. 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 pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is systolic notching of the right ventricular outflow tract/pulmonary artery Doppler spectrum (Flying W sign) is present, suggesting a significant precapillary component of right ventricular outflow impedance.There is a trivial pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function. Mild right ventricular cavity dilation with normal systolic function. Mild tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. CXR ___ FINDINGS: Lung volumes remain low. Cardiac, mediastinal and hilar contours appear stable. Very small pleural effusions are probably unchanged. No visible pneumothorax. Left perihilar opacity is mostly resolved. There is still slight asymmetry probably corresponding resolving infection, but similar bilateral opacities suggest mild pulmonary edema. Mild atelectasis is similar to somewhat increased in the lung bases. IMPRESSION: Findings suggest mild pulmonary edema. Mostly resolved suspected left perihilar pneumonia from the previous month. Findings CS mild atelectasis CXR ___ EXAMINATION: CHEST (PA AND LAT) IMPRESSION: Comparison to ___. Persistent small right pleural effusion and minimal left pleural effusion. Stable low lung volumes. On today's radiograph the patient shows signs of mild to moderate pulmonary edema. Mild cardiomegaly is present. Mild elongation of the descending aorta. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Allopurinol ___ mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 6. CARVedilol 25 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 9. Gabapentin 400 mg PO BID 10. Isosorbide Dinitrate 10 mg PO TID 11. Pantoprazole 40 mg PO Q24H 12. Tamsulosin 0.4 mg PO QHS 13. FoLIC Acid 1 mg PO DAILY 14. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line 15. umeclidinium 62.5 mcg/actuation inhalation DAILY 16. Clopidogrel 75 mg PO DAILY 17. Senna 17.2 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 18. Warfarin 7.5 mg PO DAILY16 19. HydrALAZINE 100 mg PO TID 20. Torsemide 60 mg PO DAILY 21. linaGLIPtin 5 mg oral DAILY 22. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 23. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 24. Warfarin 10 mg PO 2X/WEEK ___ fib 25. Warfarin 7.5 mg PO 5X/WEEK ___ fib 26. Glargine 15 Units Dinner Humalog 7 Units Dinner Discharge Medications: 1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*0 2. HydrALAZINE 25 mg PO Q8H RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 3. Glargine 18 Units Bedtime Humalog 6 Units Dinner 4. Torsemide 100 mg PO DAILY RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 7. Allopurinol ___ mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 11. CARVedilol 25 mg PO BID 12. Clopidogrel 75 mg PO DAILY 13. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 14. Fluticasone Propionate NASAL 2 SPRY NU DAILY 15. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 16. FoLIC Acid 1 mg PO DAILY 17. Gabapentin 400 mg PO BID 18. Isosorbide Dinitrate 10 mg PO TID 19. linaGLIPtin 5 mg oral DAILY 20. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line 21. Pantoprazole 40 mg PO Q24H 22. Senna 17.2 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 23. Tamsulosin 0.4 mg PO QHS 24. umeclidinium 62.5 mcg/actuation inhalation DAILY 25. Warfarin 7.5 mg PO DAILY16 26. Warfarin 10 mg PO 2X/WEEK ___ fib 27. Warfarin 7.5 mg PO 5X/WEEK ___ fib Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Acute on Chronic HFpEF excerterbation Chronic Obstructive Pulmonary Disease Dysphagia Chronic microcytic anemia Asymptomatic bacteruria Chronic Kidney Disease Stage IV Paroxysmal Atrial fibrillation Secondary diagnosis =================== Diabetes Mellitus Type II Peripheral Vascular Disease Hyperlipidemia Gastrointestinal Reflux Disease Gout Benign Prostatic Hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with SOB, tachypnea, hx CHF // ?acute process,volume overload, consolidation TECHNIQUE: Portable AP chest COMPARISON: Multiple prior chest radiographs, most recently ___. FINDINGS: Lung volumes are low. Small right pleural effusion remains. A superimposed pneumonia would be difficult to exclude in the correct clinical context. Bilateral interstitial opacities suggest mild pulmonary vascular congestion and edema, similar to slightly improved compared to the prior examination. The cardiomediastinal contours are unchanged. IMPRESSION: 1. Redemonstration of a right pleural effusion. A superimposed pneumonia would be difficult to exclude. 2. Mild pulmonary vascular congestion edema, similar to slightly improved compared to the most recent prior examination of ___. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ male patient with a history of CHF, COPD, Afib onwarfarin, CKD, and uncontrolled DM who presented with 1 weekhistory of acute on chronic dyspnea that significantly worsened the last 2 days with concurrent URI symptoms concerning for CHF exacerbation // rule out pneumonia rule out pneumonia IMPRESSION: Comparison to ___. Persistent small right pleural effusion and minimal left pleural effusion. Stable low lung volumes. On today's radiograph the patient shows signs of mild to moderate pulmonary edema. Mild cardiomegaly is present. Mild elongation of the descending aorta. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Dyspnea, Wheezing Diagnosed with Shortness of breath, Chronic obstructive pulmonary disease w (acute) exacerbation, Dyspnea, unspecified temperature: nan heartrate: 67.0 resprate: 26.0 o2sat: 100.0 sbp: 132.0 dbp: 77.0 level of pain: 0 level of acuity: 2.0

This is a ___ male patient with a history of CHF, COPD, Afib on warfarin, CKD, and uncontrolled DM who presented with 1 week history of acute on chronic dyspnea that significantly worsened 2 days prior to presentation with concurrent URI symptoms, increased ___ edema and chest Xray notable for pulmonary edema and pleural effusion concerning for Acute on chronic HFpEF exacerbation. =================== TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 97.3 kg (214.51 lb) DISCHARGE Cr: 2.1 DISCHARGE DIURETIC: Torsemide 100mg daily [] Patient's hydralazine was decreased from 100mg TID to 25mg TID, please follow of blood pressure control in the outpatient adjust dosage as needed. [] Patient presented with elevated INR peaked to 4.3. His warfarin was slowly restarted. Recommend close monitoring of his INR and possible education on diet while on warfarin. [] Due to elevated blood glucose levels, increased his glargine to 18 units and added Humalog 6 units at lunch and dinner. However discharged on only Humalog 6 units at dinner and glargine 18 units due to concern for insulin administration. Please follow-up outpatient and adjust insulin regiment as needed. [] Torsemide dose was changed to 100MG Daily. Of note patient gets most of his home medications in blister packs from pharmacy, but torsemide is not included in this. Please make sure that he takes his torsemide daily and continue to monitor volume status and adjust dose as needed. ACUTE ISSUES ============ #Dyspnea on exertion #Acute on chronic HFpEF exacerbation ( EF 55% ___ Patient presented with increasing dyspnea on exertion, exam notable for lower extremity edema. Chest x-ray notable for vascular congestion, history of HFpEF (last echo 63% in ___ managed primarily on carvedilol 25mg BID and torsemide 40mg daily increased from 20mg daily. Repeat echo ___, noted EF 55%, Unclear trigger, likely due to medication changes versus dietary indiscretions . Unclear baseline weight as patient does not measure weight daily. His volume overload was managed with IV Lasix 100mg BID and he was transitioned to torsemide 100mg daily. After loaded reduction with reduced hydralazine at 25MG TID and Isosorbide Dinitrate 10 mg PO/NG TID and Neurohormonal blockage with carvedilol 25MG BID. #Possible COPD Exacerbation Noted to have URI symptoms of rhinorrhea, cough w/o change in sputum, and sore throat prior. He had had some improvement with nebulizer therapy since here, initially requiring 2L NC to maintain saturation 88-92%. Chest X-ray without pulmonary process; however, there is a right sided pleural effusion. He was initially started on prednisone 40mg and azithromycin.Given low suspicion of COPD excertabtion azithromycin and prednisone were stopped. He was quickly weaned to RA on the flow. He was managed with DuoNebs Q6H PRN and Albuterol Neb Q4H:PRN. Continued home fluticasone-salmeterol inhaler BID and fluticasone propionate nasal spray daily. His Umeclidinium inhaler held due to non-formulary and restarted on discharge. #Dysphagia States that he has a history of dysphagia and has been seen by speech and swallow as an outpatient. Has an episode of choking about once every three months, usually manages by chopping up food small and eating slowly. Felt SOB with the event but quickly back to baseline. No episodes of dysphasia today. Consulted speak and swallow, recommended diet: Soft/thin Medications: Whole as tolerated and Aspiration Precautions:1:1 supervision with all PO. #Chronic microcytic anemia. Patient could potentially have underlying iron deficiency. Unclear if patient has received iron supplementation in the past. Likely component of CKD also contributing. Repeat iron studies notable for iron of 29, TIBC 217, Ferritin of 22 and Transeferrin 244. He received IV Iron X1 prior to discharge and discharged on oral iron supplements. # DM II Most recent documented prescription is 15U insulin glargine at dinner or bedtime and 7U of Humalog at dinner, but the patient is unsure if this is what he has been taking. It appears this regimen was adjusted by ___ during his previous hospital stay in ___. He also on linagliptin 5mg daily. Had elevated blood sugars at lunch and dinner. Increased to 18U insulin glargine at bedtime, Started 6 units Humalog at lunch and dinner, however we stopped the lunch time insulin, we became aware that son, who ___ his insulin would be unable to give lunch dose. His linagliptin was continued on discharge. Continue home gabapentin 400mg PO BID for peripheral neuropathy and phantom leg pain. #Hypertension: Home meds include: hydralazine 100 mg TID, Isosorbide dinitrate 10 mg TID, Carvedilol 25 BID, and amlodipine 10mg QD. His hydralazine 100mg TID,was decreased to 25 mg TID, which was sufficient to manage his blood pressures. #Asymptomatic bacteruria. Presented to ED 2 days prior to admission, UA notable for WBC 14, few bacteria, 30 protein, positive leukocyte Estrase but negative nitrates. He was started on Cefpodoxime 200 ___ mg for 10-day course. However patient denied any urinary symptoms, except for polyuria which could be explained by his diuretics, denies dysuria discharge or CVA tenderness. Antibiotics were stopped and no new symptoms during the hospitalization. #CKD stage IV (baseline Cr ___ Noted to gave elevated Cr of 2.9 on ___ felt likelya component of cardio renal syndrome based his presenting volume overloaded state. His creatine improved to baseline with diuretics. His discharge creatine was 2.1 CHRONIC ISSUES ============== #pAFib:(CHADS2VASc:5) Previously on apixaban but switched to warfarin given renal function. Sinus rhythm on admission. Presented with INR of 3.9, which peaked to 4.3. His warfarin was initially held and slowly restarted. Discharge INR at 3.3. He was given 4 mg of warfarin prior to discharge. # PVD: S/P R right AKA (___) and left fem to ATA bypass with reversed greater saphenous ___. -Continued home clopidogrel 75 mg QDay #Hyperlipidemia Continued home atorvastatin 80mg PO QPM #GERD: Continued home pantoprazole 40 mg daily #Gout: Continued home allopurinol ___ mg daily #BPH: Continue home Tamsulosin 0.4 mg QD Agree with hospital course as documented. 35 minutes spent on discharge preparation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine Attending: ___. Chief Complaint: "hopelessness and feeling sick" Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with depression and polysubstance use (IV meth) who presented to the ED with 1 day of fevers as well as increasing thoughts of suicidality. History from patient is limited as he just got Benadryl in the ED for redman syndrome from vancomycin and is very drowsy. He says he came to the ED because, "I was feeling hopeless and feeling sick," he says. He was feeling hopeless and wanted to kill himself. His plan was to take a large amount of heroin. He has been feeling this way for months. He has had 3 suicide attempts in the past, all by overdose. He also complained of generalized malaise and vomiting for about a week. The emesis has been orange colored. The last episode was about 24 hours ago. He says he is nauseated but is also asking for food. He had subjective fevers for the past 1 day. He denies diarrhea - he has not had a bowel movement for 1 week, which is common for him because of the heroin and Suboxone he uses. No dysuria. No unintentional weight loss. He denies headache, visual changes. No chest pain, palpitations, or shortness of breath. He denies back pain or joint pain/swelling. His skin is "a mess," mostly from picking. He has a lesion on his penis from "picking and having a lot of sex." He only has female partners. He has had 2 partners in the last month. He does not use protection. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. ED COURSE: VS: Tmax 100, HR ___, BP 120s-150s/70s-80s, RR ___, SpO2 94-97% on RA Exam: excoriations across bilateral lower extremities and penis, lungs CTAB, no cardiac murmur, no stigmata of endocarditis, no back tenderness Labs: Normocyctic anemia, WBC wnl, plt wnl, CRP 77.1, Lactate 1.6, Utox positive for amphetamines, flu negative Imaging: CXR clear Interventions: acetaminophen 1000 mg PO, vancomycin 1500 mg IV He developed Red Man syndrome to vanco and was given Benadryl Past Medical History: Major depressive disorder with prior suicide attempts Polysubstance abuse Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION VITALS: T 98.1, HR 73, BP 124/82, RR 14, SpO2 95% on RA GENERAL: Drowsy but able to rouse, breathing room air comfortably EYES: Anicteric, PERRL ENT: OP clear, mucous membranes slightly tacky CV: NR/RR, no m/r/g. JVP not elevated. RESP: CTAB, no wheezes or crackles. GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: ~0.5 cm penile ulceration MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Scabs and excoriations over all limbs, no ___ lesions ___ nodes, no splinter hemorrhages NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: withdrawn DISCHARGE VS: 98.4 PO 118 / 71 52 18 95 RA Gen - asleep, awakening to voice, then sitting up; comfortable appearing Eyes - EOMI, PERRL ENT - OP clear, MMM Ext - no edema Skin - erythematous lesion on shaft of penis with clean borders; now with overlying scab, improved in appearance; no exudate; no other skin lesions Vasc - 2+ DP/radial pulses Neuro - AOx3, moving all extremities Psych - appropriate affect Pertinent Results: ADMISSION ___ 09:50AM BLOOD WBC-7.7 RBC-4.42* Hgb-12.9* Hct-38.3* MCV-87 MCH-29.2 MCHC-33.7 RDW-13.2 RDWSD-41.0 Plt ___ ___ 09:50AM BLOOD Glucose-102* UreaN-11 Creat-0.9 Na-135 K-3.7 Cl-95* HCO3-22 AnGap-18 ___ 12:40PM BLOOD ALT-21 AST-32 AlkPhos-70 TotBili-0.4 CXR - ___ No evidence of acute cardiopulmonary process. ___ - BCx - WITHOUT GROWTH AT DISCHARGE ___ - Bcx - WITHOUT GROWTH AT DISCHARGE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO BID Discharge Medications: 1. DULoxetine 60 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: # Nausea and vomiting secondary to viral enteritis # Polysubstance abuse # Major depressive disorder with suicidal ideation # Penis rash Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with fever, evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: There is no focal consolidation, pleural effusion, pulmonary edema, or pneumothorax. The cardiomediastinal silhouette is within normal limits. Platelike atelectasis is noted on the lateral viewed due to low lung volumes. IMPRESSION: No evidence of acute cardiopulmonary process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SI, Substance use Diagnosed with Fever, unspecified temperature: 100.0 heartrate: 103.0 resprate: 20.0 o2sat: 194.0 sbp: 153.0 dbp: 87.0 level of pain: 4 level of acuity: 2.0

Mr. ___ is a ___ male past medical history of majkor depressive disorder and polysubstance abuse admitted ___ with viral enteritis and suicidal ideation, recommended for voluntary inpatient psychiatric admission, course notable for patient expressing interest in suboxone re-initiation, discharged to ___. # Nausea and vomiting secondary to viral enteritis Patient presented with several days of nausea and vomiting in setting of malaise. Patient had a nonfocal abdominal exam and labs were reassuring. He was felt to have viral enteritis and was treated supportively with improvement in his symptoms over ___ days following admission. Blood cultures remained without growth during his hospital course. # Penis rash Admitted with erythematous patch over shaft of penis. Patient reported he thought it was related to friction from "too much sex". He declined HIV testing. GC/chlamydia testing negative. RPR negative. No vesicular component to suggest HSV. Patch resolved without intervention--may have actually related to friction. Counseled re: important of safe sex. # Major depressive disorder with suicidal ideation Patient reported worsening depression and suicidal ideation at time of admission. He was seen by psychiatry service who recommended voluntary inpatient psychiatric admission. Patient was screened by BEST team and was subsequently discharged to HRI. Continued home duloxetine. # Polysubstance abuse On admission patient reported recent use of multiple drugs, including suboxone he had purchased illicitly. He had mild opiate withdrawal symptoms including diaphoresis and anxiety, treated symptomatically with clonidine. He reported previously being prescribed suboxone, but not in recent years. He expressed an interest in being initiated on this--before this could be done, a psychiatric bed was identified. Would consider suboxone initiation while at facility. # Drug reaction Developed "red man syndrome" in the ED while receiving IV vancomycin. No respiratory issues. Resolved by the time patient arrived on the floor. Antibiotics were not continued given no indication. Transitional issues - Patient discharged to ___ for psychiatric treatment for depression - Patient previously on suboxone in the remote past; more recently reported abusing opiates and buying suboxone illicitly; this admission he expressed an interest in starting suboxone treatment; please consider starting on suboxone with coordination with his PCP's office - Would consider HIV testing if patient will consent > 30 minutes spent on this discharge

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right foot and ankle infection Major Surgical or Invasive Procedure: ___: Right Foot debridement with ___ metatarsal base resection History of Present Illness: This is a ___ male who presents to the ED on ___ for a worsening infection of right foot. Patient is followed closely by Dr. ___ for chronic ulcerations right foot. Patient was last seen in clinic on ___ where it was noted he has a right foot infection and was placed on PO Ciprofloxacin and Bactrim. A culture was taken with preliminary cultures growing GNR and GPC. Today, patient states there is an increased redness to his wounds with overall malaise. Denies fever, chills, nausea, vomiting, shortness of breath, chest pain. Past Medical History: - DM last HbA1c 6.7% ___ - HTN - Basal Cell Skin CA Social History: ___ Family History: -Mother: DM, HTN -Father: ___ CA -___: MI -MGF: Alzheimers Physical Exam: PHYSICAL EXAMINATION on admission: VITAL SIGNS: T 98.5 HR 80 BP 148/77 RR 18 O2 100%RA GENERAL: Well appearing, in no acute distress. CARDIOVASCULAR: Well perfused lower extremities. RESPIRATORY: No respiratory distress. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Right lower extremity exam: DP and ___ pulses are palpable. Capillary refill time is less than 3 seconds to all digits. Erythema and edema noted to the right foot with minor increased warmth. Protective sensation grossly diminished to right foot, ulceration on the lateral aspect of the right fifth metatarsal base with a deep central area probing. No fluctuance, no purulence. Wound to lateral aspect right ankle with no underlying fluctuance. Surrounding erythema and edema surrounding both wounds. PHYSICAL EXAMINATION on discharge: VITAL SIGNS: AVSS GENERAL: Well appearing, in no acute distress. CARDIOVASCULAR: Well perfused lower extremities. RESPIRATORY: No respiratory distress. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Right lower extremity exam: DP and ___ pulses are palpable. Capillary refill time is less than 3 seconds to all digits. Surgical dressing in place. prior to surgical dressing placement the incision to the lateral right foot was noted to have intact sutures with no drainage or signs of infection. Granular wound noted to the lateral aspect of the ankle with no deep probing or signs of infection. Pertinent Results: ___ 02:50PM GLUCOSE-153* UREA N-20 CREAT-1.3* SODIUM-130* POTASSIUM-6.2* CHLORIDE-93* TOTAL CO2-19* ANION GAP-24* ___ 02:50PM estGFR-Using this ___ 02:50PM ALT(SGPT)-25 AST(SGOT)-47* ALK PHOS-115 TOT BILI-0.2 ___ 02:50PM ALBUMIN-4.7 ___ 02:50PM CRP-9.9* ___ 02:50PM WBC-7.8 RBC-4.13* HGB-12.6* HCT-37.3* MCV-90 MCH-30.5 MCHC-33.8 RDW-12.2 RDWSD-40.4 ___ 02:50PM NEUTS-78.0* LYMPHS-15.1* MONOS-5.9 EOS-0.3* BASOS-0.3 IM ___ AbsNeut-6.05 AbsLymp-1.17* AbsMono-0.46 AbsEos-0.02* AbsBaso-0.02 ___ 02:50PM PLT COUNT-283 Pertinent Imaging: Right foot and ankle images: Ulcers along the lateral mid and hindfoot are noted. There is bony destruction at the base of the fifth metatarsal concerning for osteomyelitis. Also noted is a fracture at the base of fifth metatarsal which appears subacute. The lateral hindfoot is poorly visualized though no definite signs of osteomyelitis seen. Right ankle: Lateral soft tissue swelling with small ulceration noted at the right ankle. No fracture, dislocation. Mortise is symmetric. No convincing signs of osteomyelitis. IMPRESSION: Osseous destruction at the base of fifth metatarsal is concerning for osteomyelitis. No additional areas of osteomyelitis definitively identified. Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Lisinopril 20 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Sulfameth/Trimethoprim DS 1 TAB PO BID 6. Aspirin 81 mg PO DAILY 7. Cal-Citrate (calcium citrate-vitamin D2) uncertain oral DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Cal-Citrate (calcium citrate-vitamin D2) 1 tablet oral DAILY 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right foot infection 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 INDICATION: ___ with charcot of bilateral feet, now with R ankle and foot ulcerations COMPARISON: Prior right foot radiograph dated ___ FINDINGS: Right foot: Ulcers along the lateral mid and hindfoot are noted. There is bony destruction at the base of the fifth metatarsal concerning for osteomyelitis. Also noted is a fracture at the base of fifth metatarsal which appears subacute. The lateral hindfoot is poorly visualized though no definite signs of osteomyelitis seen. Right ankle: Lateral soft tissue swelling with small ulceration noted at the right ankle. No fracture, dislocation. Mortise is symmetric. No convincing signs of osteomyelitis. IMPRESSION: Osseous destruction at the base of fifth metatarsal is concerning for osteomyelitis. No additional areas of osteomyelitis definitively identified. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL RIGHT INDICATION: ___ year old man s/p ___ met base resection // postop COMPARISON: Right foot radiographs from ___. FINDINGS: Compared with ___ , the ossific fragment at the base of fifth metatarsal as well as the proximal segment of the remaining portion of the fifth metatarsal bone have been removed. Otherwise, doubt significant interval change. Again seen is diffuse osteopenia and varus angulation centered in the hindfoot, with deformity of a distal talus and navicular bones, compatible or Charcot osteoarthropathy. Scattered lucent foci are again noted in the second and third metatarsal bones, possibly areas of more pronounced osteopenia. No cortical transgression is identified in these areas. Soft tissue swelling and subcutaneous emphysema is consistent with recent surgery. A bandage is in place. IMPRESSION: Interval resection of the proximal portions of the fifth metatarsal bone. No new fracture or dislocation detected. Radiology Report INDICATION: ___ year old man with known Charcot // surgical planning for Charcot TECHNIQUE: Contiguous helical MDCT images were obtained through the head right foot and ankle without IV contrast. Multiplanar axial, coronal, sagittal and thin section bone algorithm reconstructed images were generated. Deformity of the midfoot limits optimal reconstruction in the coronal and sagittal planes. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.8 s, 20.8 cm; CTDIvol = 14.1 mGy (Body) DLP = 293.3 mGy-cm. Total DLP (Body) = 293 mGy-cm. COMPARISON: Radiographs of the right foot ___. FINDINGS: The tibiotalar and subtalar joints are congruent with mild degenerative change. There is severe degenerative change at the talonavicular joint with bony fragmentation and flattening of the anterior talus (403b:64). Nonweightbearing views are limited for assessment of the arch, however there is apparent collapse of the transverse arch of the midfoot. There is mild inferior subluxation of the cuboid in relation to the calcaneus but no dislocation (403b:56). The fourth and fifth rays are inferiorly subluxed relative to the first through third metatarsals but in line with the cuboid. There is fragmentation of the anterior process of the calcaneus (403 b:63) but no evidence of acute fracture. The navicular-cuneiform articulations are preserved, however the lateral cuneiform is inferiorly subluxed relative to the navicular bone (401b:153). There are postoperative changes surrounding the base of the fifth metatarsal from previous resection. The margins of amputation are unremarkable. There is expected postoperative edema and scattered locules of gas (403b:81). There is mild degenerative change at the first metatarsophalangeal joint and an incidentally noted bipartite tibial hallux sesamoid. There is moderate subcutaneous edema about the ankle and foot. Vascular calcifications are extensive. The distal Achilles tendon is intact with a dorsal calcaneal enthesophyte. This study is limited for evaluation of the tendons and ligaments about the ankle, however there is no tenosynovitis and the imaged portions of the flexor, extensor and peroneal tendons are grossly intact. IMPRESSION: 1. Charcot foot with collapse of the transverse arch as detailed above. 2. Postoperative changes following resection of the base of the fifth metatarsal. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Wound eval, R Foot pain Diagnosed with Type 2 diabetes mellitus with foot ulcer, Cellulitis of right lower limb temperature: 98.5 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 148.0 dbp: 77.0 level of pain: 0 level of acuity: 3.0

The patient was admitted to the podiatric surgery service after presenting to the ED for a Right foot and ankle infection, failing a course of PO antibiotics. On admission, he was started on broad spectrum IV antibiotics. Upon admission, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient was taken to the operating room on ___ for right foot ___ met resection, 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 remained stable from both a cardiovascular and pulmonary standpoint. He was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with oral antibiotics. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. the patient was seen by a member of the physical therapy team who cleared the patient to return home non-weight bearing to the right foot. The patient was subsequently discharged to home on POD 1 with oral antibiotics. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Prior to discharge the patient had a CT of the Right foot and ankle for preoperative planning for reconstruction of the right foot.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever, malaise Major Surgical or Invasive Procedure: None History of Present Illness: Patient with a h/o HLD presents with fevers and malaise after recently returning from ___. She saw her PCP ___ ___ with cough and fever to 102.6 x 1d. CXR at that time showed no acute abnormality and rapid influenza was negative. At that time, denied N/V or diarrhea. She returned to ___ ___ ___ for high fevers (102.6 in PCP ___ and malaise. Of note, she went to ___ mid ___ returned to ___ ___. She started feeling sick after one week in ___ with complaints of high fevers, abdominal pain and diarrhea. Notes no sick contacts in ___. Diarrhea is improving, though patient attributed this to decreased PO intake. She had a watery stool yesterday after drinking apple juice. She has a productive cough. She also endorses feeling dizzy when she stands up and intermittent headache when she coughs. She has no neck pain or stiffness and myalgias but no arthritis. No sob, chest pain or wheezing. No nausea or vomiting. She was referred to ___ ED by her PCP. In the ED, initial vitals were: 101.9 80 124/80 28 98% RA. Her labs were significant for a white count of 2.4 (5.7 on ___, H/H 13.2/40 (13.3/40.1) and a platelet count of 64 (268 on ___. She also had elevated ALT to 51 (15 in ___, AST to 125, and lipase to 95. Her PTT was 43.3, INR 1.1. On the floor, she is resting comfortably and states that she is feeling better now that her fever has come down. She states that her abdominal pain is intermittent and is improved by ___. Diarrhea is improving. No joint pain. +headache. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. 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. Past Medical History: Obesity Hyperlipidemia ___ Adenoma Social History: ___ Family History: Maternal Aunt - ___ Mother - ___ CVA Sister - ___ Cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:99.6 BP:104/59 P:71 R:18 O2:98/RA General: Alert, oriented, mild distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, +submandibular lymphadenopathy Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rash Neuro: PEERL. AOx3 DISCHARGE PHYSICAL EXAM: VS: 98.6 ___ 70 100% RA GENERAL: NAD, alert, interactive HEENT: NC/AT, sclerae anicteric, MMM LUNGS: Clear to auscultation, no w/r/r HEART: RRR, no m/r/g ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox3 Pertinent Results: ------------------- ADMISSION LABS ___: ------------------- WBC-2.5* RBC-4.65 Hgb-12.1 Hct-36.9 MCV-79* MCH-26.1* MCHC-33.0 RDW-13.2 Plt Ct-64* Neuts-26* Bands-9 Lymphs-50* Monos-7 Eos-1 Baso-0 Atyps-7* ___ Myelos-0 Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL ___ PTT-43.3* ___ Glucose-124* UreaN-7 Creat-0.7 Na-134 K-3.4 Cl-99 HCO3-24 AnGap-14 Albumin-3.0* Calcium-7.7* Phos-2.3* Mg-1.8 Lactate-1.1 ------------------- URINE ___: ------------------- Color-Yellow Appear-Clear Sp ___ Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG RBC-<1 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 CastHy-4*Mucous-RARE ------------------- OTHER HEME LABS: ------------------- ___ ___ ------------------- HEPATITIS SEROLOGIES: ------------------- ___ IgM HAV-NEGATIVE ___ HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE ___ HCV Ab-NEGATIVE ------------------- CV LABS: ------------------- ___ 07:40AM BLOOD Triglyc-203* LFT trend: ___ ALT-51* AST-125* ___ ALT-43* AST-81* ___ ALT-44* AST-83* ___ ALT-128* AST-277* ___ ALT-139* AST-178* ------------------- MICRO: ------------------- - Parasite smear negative x2 - Malaria Ag negative - Hep A IgM-/IgG+ - HBsAg-/HBsAb+/HBcAb- - HCV Ab negative - HIV negative, VL undetectable - EBV VCA-IgG Ab+ / EBNA IgG Ab + / VCA IgM negative / EBV PCR ___ - Monospot negative - CMV IgM-/IgG+, VL undetectable - Dengue Fever IgG 10.11 (positive) / Dengue Fever IgM 0.86 (negative) - Chikungunya Ab IgM negative, IgG negative - Blood Culture (___): negative - Urine Culture (___): negative - Stool Culture (___): negative ------------------- Imaging: ------------------- # US Liver & Gallbladder: Normal examination of the liver. The liver does not appear enlarged on ultrasound. ------------------- DISCHARGE LABS: ------------------- ___ WBC-5.5 RBC-4.48 Hgb-11.9* Hct-35.5* MCV-79* MCH-26.5* MCHC-33.4 RDW-15.1 Plt ___ ___ Glucose-97 UreaN-6 Creat-0.7 Na-139 K-4.8 Cl-102 HCO3-26 AnGap-16 ___ ALT-139* AST-178* LD(LDH)-484* AlkPhos-56 TotBili-0.8 ___ Calcium-9.1 Phos-4.0 Mg-2.4 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO DAILY 2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral daily Discharge Medications: 1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral daily 2. Ciprofloxacin HCl 500 mg PO/NG Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: viral infection, neutropenia, thrombocytopenia 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: ___ year old woman with fevers, thrombocytopenia, leukopenia, and worsening transaminitis // ?hepatomegaly, infiltrate TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. Main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. GALLBLADDER: The gallbladder is contracted without evidence of stones. PANCREAS: Imaged portion of the pancreas appears heterogenous, but is within normal limits, without masses or pancreatic ductal dilation, with portions of the inferior head and distal pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 10.1 cm. KIDNEYS: The right kidney measures 12.1 cm. The left kidney measures 10.4 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones or hydronephrosis in the kidneys. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: Normal examination of the liver. The liver does not appear enlarged on ultrasound. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by AMBULANCE Chief complaint: Fever, Cough Diagnosed with FEVER, UNSPECIFIED, LEUKOCYTOPENIA, UNSPECIFIED temperature: 101.9 heartrate: 80.0 resprate: 28.0 o2sat: 98.0 sbp: 124.0 dbp: 80.0 level of pain: 8 level of acuity: 2.0

Ms. ___ is a ___ female with recent travel to ___ who presented with high fevers and diarrhea and was found to have neutropenia and thrombocytopenia. Her fevers and diarrhea resolved over the course of her hospitalization as did her neutropenia and thrombocytopenia. Workup consistent with viral syndrome.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / Demerol / morphine / hydrocodone / erythromycin base / Penicillins / nadolol / Iodinated Contrast Media - IV Dye / Furadantin / radiopaque dye / Artificial Tears / latex / sodium chloride / mependine / Macrobid Attending: ___ Chief Complaint: low back pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ with h/o CAD, HTN, A. fib on Coumadin, chronic back pain who presented to OSH for lower back pain and was transferred for further evaluation of T12 compression fracture. Pt is currently delirious and tells me that she came into the hospital because "a horse knocked her down," therefore history is obtained primarily from ___ and ___ records and from speaking with her daughter who is a ___ and also her HCP. The pts sxs started about 10 days ago when she was seen at ___ for LBP. She was admitted there and ultimately discharged on tramadol for pain. A few days later she went for a steroid injection as an outpatient. Just prior to this admission she stood up and had twisted her body and developed severe ___ acute lower back pain, prompting her to call an ambulance for evaluation at the ___. She denied stool incontinence, numbness/weakness in lower extremities, fever. Her daughter does not think that she fell prior to this admission however she has had falls in the past. Her daughter tells me that the patient attributed the pain to "downsizing". She has no history of dementia/delerium/confusion. Of note, records indicate that the pt has a chronic indwelling foley however on talking with the pts daughter, she states that this is not true. Pt did endorse 2 episodes of urinary incontinence on arrival to the ED. While at ___ a CT L-spine showed acute compression fracture of T12 and L1 compression fracture deformity without significant change. Severe spinal stenosis at L3-L4. She was transferred to ___ for neurosurgical eval. In the ___ ED, initial vitals were: 98.4 90 156/74 16 96% RA. Labs were notable for creatinine of 1.5, lactate of 1.8, INR 1.9. Head CT showed no acute process. Pt was seen by psychiatry for delirium and ultimately required multiple doses of Seroquel, haldol and Lorazepam for agitation. She was also seen by spine and ___ who recommended against surgery, TLSO brace for comfort, rehab placement. She was given lidocaine patch, cyclobenzaprine, Tylenol, ketorolac, home medications of acyclovir, amlodipine, amiodarone, losartan, pravastatin, gabapentin, furosemide. On the floor, she states back pain is about ___. She has no new complaints. She is able to recount some of her medications however is hypervigilant and tangential, unable to recount details of why she came to the hospital. Past Medical History: CAD, s/p CABG of LAD in ___ ___ afib on Coumadin HTN Glaucoma s/p cataract surgery trigeminal neuralgia HLD myelodysplaia essential thrombocytosis schatzki ring hysterectomy GERD ocular herpes c/b corneal abrasion cataracts Social History: ___ Family History: HTN Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 98.4 ___ Constitutional: Agitated, hypervigilant, confused EYES: Sclera anicteric, EOMI, PERRL ENMT: MMM, oropharynx clear, normal hearing, normal nares CV: Regular rate and rhythm, normal S1 + S2, ___ SEM, no rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: Foley in place draining clear urine EXT: Warm, well perfused, no CCE NEURO: aao to person only. Unable to do full neuro exam due to agitation although CNII-XII and strength grossly intact SKIN: large bruise on R back, cluster of 4 crusted lesion on R upper back, several crusted lesions on face MSK: no pain on palpation of lumbar spine DISCHARGE PHYSICAL EXAM: ======================== afebrile, 162/69 60 sat well on RA, BED WEIGHT (not standing) is 127.4 lbs pleasant, NAD MMM JVP flat RRR, II/VI SEM best at RUSB with radiation to R carotid, preserved S2 CTAB sntnd wwp, neg edema A&Ox3, DOWB intact, EOMI, slight R>L anisocoria, R pupil reactive but sluggish (h/o B cataracts), L pupil normally reactive, B consensual response, ___ BUE, 4+/5 R hip flexion (pt reports ___ pain) otherwise ___ BLE, SILT BUE/BLE except chronic R plantar numbness, downgoing toes bilaterally, 2+ patellar DTRs ___ Results: ADMISSION LABS: =============== ___ 11:38AM BLOOD WBC-4.9 RBC-3.31* Hgb-12.2 Hct-34.9 MCV-105* MCH-36.9* MCHC-35.0 RDW-13.8 RDWSD-52.8* Plt ___ ___ 11:38AM BLOOD ___ PTT-28.2 ___ ___ 11:38AM BLOOD Glucose-111* UreaN-47* Creat-1.5* Na-142 K-4.9 Cl-99 HCO3-25 AnGap-18 ___ 11:38AM BLOOD ALT-20 AST-39 AlkPhos-39 TotBili-0.5 ___ 11:38AM BLOOD Albumin-4.2 Calcium-9.4 Phos-4.0 Mg-2.3 ___ BLOOD CULTURE PENDING ___ URINE cx neg final IMAGING: ======== ___ CXR No focal consolidation. CT non con head FINDINGS: Some of the images were repeated due to motion artifact on the initial scan. There is no evidence of acute hemorrhage, edema, mass effect, or acute major vascular territorial infarction. Periventricular, deep, and subcortical white matter hypodensities are nonspecific, however likely due to chronic small vessel ischemic disease in this age group. There is moderate global parenchymal volume loss with prominent ventricles and sulci, likely age-related. No concerning bone lesion is seen. Aerosolized secretions are seen in a right middle ethmoid air cell. There is trace opacification of left mastoid tip air cells. There is evidence of bilateral cataract surgery. IMPRESSION: No evidence acute intracranial abnormalities. MRI would be more sensitive for an acute infarction, if clinically warranted. DISCHARGE LABS: =============== ___ 09:40AM BLOOD WBC-4.7 RBC-3.13* Hgb-11.6 Hct-32.5* MCV-104* MCH-37.1* MCHC-35.7 RDW-14.3 RDWSD-54.0* Plt ___ ___ 06:34AM BLOOD ___ PTT-25.6 ___ ___ 09:40AM BLOOD Glucose-183* UreaN-23* Creat-0.9 Na-144 K-4.6 Cl-109* HCO3-22 AnGap-13 ___ 09:40AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Amiodarone 200 mg PO DAILY 3. Fenofibrate 54 mg mg PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU BID 5. Furosemide 20 mg PO DAILY 6. Gabapentin 100 mg PO TID 7. Hydroxyurea 500 mg PO DAILY 8. Losartan Potassium 50 mg PO BID 9. Nitroglycerin Patch 0.1 mg/hr TD Q24H 10. Pravastatin 20 mg PO QPM 11. timolol 0.5 % ophthalmic (eye) BID 12. Warfarin 1.25 mg PO 3X/WEEK (___) 13. Warfarin 2.5 mg PO 4X/WEEK (___) 14. Acyclovir 400 mg PO Q12H 15. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 16. Vitamin D 1000 UNIT PO DAILY 17. Metoprolol Succinate XL 25 mg PO DAILY 18. TraMADol 50 mg PO TID:PRN Pain - Moderate 19. Calcium Carbonate 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Lidocaine 5% Patch 1 PTCH TD QAM lbp RX *lidocaine 5 % Apply 1 patch to painful area of back once daily Disp #*30 Patch Refills:*0 4. Senna 8.6 mg PO BID 5. Losartan Potassium 25 mg PO BID 6. Acyclovir 400 mg PO Q12H 7. Amiodarone 200 mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 10. Calcium Carbonate 500 mg PO BID 11. Fenofibrate 54 mg mg PO DAILY 12. Fluticasone Propionate NASAL 2 SPRY NU BID 13. Gabapentin 300 mg PO QHS 14. Hydroxyurea 500 mg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Nitroglycerin Patch 0.1 mg/hr TD Q24H 17. Pravastatin 20 mg PO QPM 18. timolol 0.5 % ophthalmic (eye) BID 19. TraMADol 50 mg PO TID:PRN Pain - Moderate 20. Vitamin D 1000 UNIT PO DAILY 21. Warfarin 1.25 mg PO 3X/WEEK (___) 22. Warfarin 2.5 mg PO 4X/WEEK (___) 23. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until instructed by your doctors ___: Extended Care Facility: ___ Discharge Diagnosis: # T12 compression fracture # Acute renal failure # Urinary retention # Agitated delirium # Atrial fibrillation 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: Frontal and lateral views INDICATION: History: ___ with new confusion// pna?cva? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: None. FINDINGS: Left chest wall dual-chamber cardiac pacer, multiple mediastinal cerclage wires and mediastinal surgical clips are noted.The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. Sclerotic focus in the left humeral head, partially imaged in obscured by the overlying marker likely represents an enchondroma. IMPRESSION: No focal consolidation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with new confusion. Cerebrovascular accident? TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Some of the images were repeated due to motion artifact on the initial scan. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 100.3 mGy-cm. 2) Sequenced Acquisition 7.0 s, 14.3 cm; CTDIvol = 49.3 mGy (Head) DLP = 702.4 mGy-cm. 3) Sequenced Acquisition 1.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 100.3 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: None. FINDINGS: Some of the images were repeated due to motion artifact on the initial scan. There is no evidence of acute hemorrhage, edema, mass effect, or acute major vascular territorial infarction. Periventricular, deep, and subcortical white matter hypodensities are nonspecific, however likely due to chronic small vessel ischemic disease in this age group. There is moderate global parenchymal volume loss with prominent ventricles and sulci, likely age-related. No concerning bone lesion is seen. Aerosolized secretions are seen in a right middle ethmoid air cell. There is trace opacification of left mastoid tip air cells. There is evidence of bilateral cataract surgery. IMPRESSION: No evidence acute intracranial abnormalities. MRI would be more sensitive for an acute infarction, if clinically warranted. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Lower back pain, Transfer Diagnosed with Low back pain, Abnormal coagulation profile, Fall on same level, unspecified, initial encounter, Chest pain, unspecified temperature: 98.4 heartrate: 90.0 resprate: 16.0 o2sat: 96.0 sbp: 156.0 dbp: 74.0 level of pain: 2 level of acuity: 3.0

___ is an ___ year old woman with no prior neuropsychiatric history, with CAD, AF (on warfarin), AS and hypertension, who presented with back pain secondary to a T12 compression fracture, found to have urinary retention, ___ as well as agitated delirium. ACTIVE ISSUES # low back pain: due to compression fractures. Pt was evaluated by neurosurgery in the ED who advised no acute surgical intervention. Given the lack of any other spinal signs or symptoms (despite urinary retention), as well as CT findings, they recommended no indication for MRI (pt also has pacemaker). She has minimal chronic R foot numbness which is unchanged and minimal R hip weakness ___ pain otherwise no deficits. A TLSO brace was offered for comfort. She will follow up with spine as outpatient. Pain was reasonably controlled with home gabapentin and standing acetaminophen and lidocaine patch. Tramadol was held as below given delirium and because it could have caused urinary retention as below. ___ saw and recommended rehab. # ___: Last creatinine on record was 1.2 ___. Likely combination of pre-renal and ___ urinary retention. Cr downtrended with holding ___, gentle IVF, resolved to 0.9 on discharge and downtrending. Resumed lower dose losartan as below. PVR not pathologically elevated thereafter. # toxic metabolic encephalopathy # delirium: Multiple potential causes of delirium include pain, pain medications, urinary retention, ___, medications (e.g. tramadol), hyperNa. No s/s of infection currently. Pt received several doses of Haldol and olanzapine in ED, as well as Ativan. Per ED, Ativan worked well. LFTs/TSH/Ca/Mg/phos/UCx wnl. Resolved with above mgmt. # urinary retention: pt retaining >1 L on arrival to the floor, ___ placed as pt unlikely to tolerate straight cath in setting of delirium. While this could be a sign of cord compression, her exam is otherwise reassuring and it seems more likely that this is related to medications (? tramadol given that she had a single dose prior to admission). UA negative for infection. Foley removed promptly and urinated well, PVR was minimal. # AS: unclear severity per family, chronic. BP control as below, held furosemide as above. Euvolemic on discharge. # Afib: currently rate controlled, continued home amiodarone, metoprolol. Continued home warfarin but gave a single extra dose of 1mg warfarin on ___. # ocular herpes: cont acyclovir # mild hypernatremia: resolved with IVF # CAD s/p CABG remotely: continued nitro patch, metop, BP mgmt. # HTN: continued home amlodipine, initially held losartan in setting ___ but now resolved and resumed and uptitrating. Changed to 25mg po BID on ___ from QD with BP in low 160s systolic, anticipate will require uptitration in coming days. # HLD: cont statin, fenofibrate # essential thrombocytosis: cont home hydroxyurea # glaucoma: cont brimodine and timolol eye drops > 30 minutes spent on patient care and coordination on day of discharge Anticipate <30 day stay at rehab.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lipitor Attending: ___. Chief Complaint: malaise Major Surgical or Invasive Procedure: none History of Present Illness: ___ p/w ILI (fever, myalgia, cough, dyspnea, diarrhea) for the past 5 days. She has had associated decreased PO. Multiple family memebers living with her have had similar symptoms. On arrival to the ED, T 100.2, HR 144 (afib), BP 103/70, 18, 97% on RA. Influenza A positive. Labs notable for normal WBC, H/H 11.7/33.4. INR 2.9. Chem panel notable for K 3.1, BUN 9, Cr 0.5. Trop <0.01, lactate 1.6. CXR without evidence of consolidation or pulmonary edema. UA benign. While in the ED, BP dropped transiently to 80/42, though repeat BP with cuff on the leg was 107/56. She received 2.5L NS, oseltamivir, metoprolol 5mg IV x1, and potassium chloride. Her vital signs did not change significantly, but she had improvement in her symptoms. She then received home metoprolo tartrate 50mg daily and was admitted to the ICU for further manegemen given transient hypotension and continued tachycardia On arrival to the MICU, pt. reports feeling significantly better. HR 80 (sinus), BP 101/63, RR 18, SpO2 98% on RA. Past Medical History: 1. Sick sinus syndrome, status post DDD pacemaker. 2. Paroxysmal atrial fibrillation. 3. Diabetes. 4. Hypertension. 5. Osteoporosis 6. Hypothyroidism 7. Diastolic heart failure 8. Aortic aneurysm Social History: ___ Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Admission Exam: Vitals- HR 80, BP 101/63, RR 18, SpO2 98% on RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated LUNGS: Occasional expiratory wheeze throughout; no crackles CV: Regular rate and rhythm,distant heart sounds ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ DP, no edema Discharge Exam: Vitals- 98.6 133/80(110-140/60-70) 69(60-70s) 18 97% on RA Tele: HR ___ GENERAL: pleasant, ___ speaking elderly woman, obese, comfortable, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated LUNGS: lungs now ctab, no wheezing, no crackles CV: Regular rate and rhythm, distant heart sounds ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ DP, no edema NEURO: AOx3. CN II-XII intact. Moving all extremities. Pertinent Results: LABS: ___ 04:30AM BLOOD WBC-8.8 RBC-4.19* Hgb-11.7* Hct-33.4* MCV-80*# MCH-27.8 MCHC-34.9 RDW-14.5 Plt ___ ___ 06:30AM BLOOD WBC-6.2 RBC-3.48* Hgb-9.4* Hct-28.8* MCV-83 MCH-26.9* MCHC-32.6 RDW-14.8 Plt ___ ___ 03:45PM BLOOD WBC-9.9# RBC-3.59* Hgb-10.0* Hct-29.6* MCV-83 MCH-28.0 MCHC-33.9 RDW-14.5 Plt ___ ___ 04:30AM BLOOD Neuts-65.0 ___ Monos-6.4 Eos-0.3 Baso-0.3 ___ 04:30AM BLOOD ___ PTT-43.0* ___ ___ 06:30AM BLOOD ___ PTT-43.0* ___ ___ 04:30AM BLOOD Glucose-111* UreaN-9 Creat-0.5 Na-138 K-3.1* Cl-101 HCO3-23 AnGap-17 ___ 11:25AM BLOOD Glucose-98 UreaN-6 Creat-0.4 Na-142 K-3.9 Cl-113* HCO3-20* AnGap-13 ___ 06:30AM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-139 K-3.4 Cl-106 HCO3-23 AnGap-13 ___ 04:30AM BLOOD ALT-13 AST-23 AlkPhos-52 TotBili-0.3 ___ 04:30AM BLOOD cTropnT-<0.01 ___ 04:30AM BLOOD proBNP-1323* ___ 06:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7 ___ 04:30AM BLOOD Albumin-3.5 ___ 04:34AM BLOOD Lactate-1.6 ___ 06:19AM URINE Color-Straw Appear-Hazy Sp ___ ___ 06:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04:40AM OTHER BODY FLUID FluAPCR-POSITIVE FluBPCR-NEGATIVE IMAGING: CXR ___: Low lung volumes without pulmonary edema or focal consolidation EKG: In ED: afib with RVR On arrival to MICU: sinus rhythm, HR 70, left axis, AV conduction delay Discharge labs: ___ 04:56PM BLOOD WBC-8.8 RBC-3.67* Hgb-9.7* Hct-30.2* MCV-82 MCH-26.4* MCHC-32.0 RDW-14.4 Plt ___ ___ 06:00AM BLOOD Glucose-108* UreaN-12 Creat-0.5 Na-138 K-3.9 Cl-105 HCO3-26 AnGap-11 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dofetilide 250 mcg PO Q12H 2. Furosemide 40 mg PO QAM 3. Furosemide 20 mg PO QPM 4. Gabapentin 300 mg PO QPM 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 500 mg PO BID 8. Metoprolol Tartrate 50 mg PO BID 9. Oxybutynin 5 mg PO HS 10. Pravastatin 20 mg PO DAILY 11. Warfarin 5 mg PO 2X/WEEK (MO,FR) 12. Enablex (darifenacin) 15 mg Oral qPM 13. Warfarin 7.5 mg PO 5X/WEEK (___) Discharge Medications: 1. Dofetilide 250 mcg PO Q12H 2. Furosemide 40 mg PO QAM 3. Gabapentin 300 mg PO QPM 4. Levothyroxine Sodium 88 mcg PO DAILY 5. Oxybutynin 5 mg PO HS 6. Pravastatin 20 mg PO DAILY 7. Warfarin 5 mg PO 2X/WEEK (MO,FR) 8. Warfarin 7.5 mg PO 5X/WEEK (___) 9. Enablex (darifenacin) 15 mg Oral qPM 10. MetFORMIN XR (Glucophage XR) 500 mg PO BID 11. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 12. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral BID 13. Docusate Sodium 100 mg PO BID 14. Ferrous Sulfate 325 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Acetaminophen 1000 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: primary diagnosis: influenza atrial fibrillation secondary diagnosis: Sick Sinus Syndrome s/p permanent pacemaker diastolic CHF diabetes mellitus, type 2 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 INDICATION: ___ female with shortness of breath, evidence of pneumonia. TECHNIQUE: Frontal chest radiographs were obtained with the patient in the upright position. COMPARISON: Radiograph from ___. FINDINGS: There is bibasilar atelectasis with low lung volumes crowding the bronchovascular markings. There is no focal consolidation or pulmonary edema. The heart is enlarged, and a left cardiac device is in stable position with its leads projecting over the right atrium and ventricle. IMPRESSION: Low lung volumes without pulmonary edema or focal consolidation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with influenza, dCHF, no consolidation on CXR. now with afib w/ rvr to 120-130s. // eval for interval change, pulmonary edema, new consolidation. TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: Pacemaker leads terminate in the expected location of right atrium and right ventricle. Cardiomegaly is substantial, unchanged. Interstitial opacities in the perihilar and lower lobes are concerning for mild interstitial pulmonary edema. Two-view right basal consolidation has slightly increased in the interim most likely due to progression of the edema but underlying infection is a possibility and assessment after diuresis is recommended Gender: F Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: ILI Diagnosed with FLU W RESP MANIFEST NEC, ATRIAL FIBRILLATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HYPOTHYROIDISM NOS, LONG TERM USE ANTIGOAGULANT temperature: 100.2 heartrate: 144.0 resprate: 18.0 o2sat: 97.0 sbp: 103.0 dbp: 70.0 level of pain: 13 level of acuity: 1.0

Ms. ___ is an ___ w/ history notable for SSS s/p PPM, afib on coumadin, dCHF, and DM2 who presents with malaise and fever found to be flu positive with ED course c/b afib with RVR and intermittent hypotension. Continued to have several episodes of afib with RVR which resolved prior to discharge. She converted back to NSR and was on room air, and normotensive. Treating with oseltamivir for a five day course. # Afib with RVR: Noted in the ED but resolved on arrival to the ICU. RVR likely in setting of flu and hypovolemia. On arriving from the MICU to ___ 2, she was in afib with RVR, HR to 160s. Chest pain free, no palpitations (had not received 8pm meds prior to callout from MICU). Asymptomatic, not short of breath. O2 sat stable. Continued to go in and out of afib with RVR and HR ___. Repeat CXR showed mild increase in pulmonary edema. Metoprolol increased to 37.5mg q6h. RVR resolved, HR ___ for >24hours prior to discharge. Discharged on metoprolol succinate 150mg daily. CHADS2 of 4 so continued on anticoagulation. Held warfarin for INR 4.1, restarted ___. # Hypotension: Resolved. Baseline SBPs 120s-130s. In MICU and on floor SBP 88-100s, likely secondary to infection as well as increase in metoprol dose. Asymptomatic. Pt appeared hydrated on exam and began taking PO. Held lisinopril 10mg daily for hypotension, did not restart on discharge. Restarted morning dose of home lasix 40mg PO prior to discharge. Was initially held for hypotension. Did not restart 20mg lasix PO evening dose. Should follow up outpatient for further heart rate and blood pressure monitoring. # Influenza A: Symptoms started 5 days ago, but given ICU admission treated with oseltamivir nonetheless. No e/o bacterial superinfection, no focal consolidation on CXR. Sputum culture was contaminated. Oseltamivir was initiated on ___ with intent to treat for 5 days. Although the patient has no documented history of asthma/COPD, she was wheezy on exam and was given nebulizers periodically. Improved respiratory status, afebrile. Oseltamivir x5days (Day 1 = ___, Day 5 = ___. # Hypothyroidism: Levothyroxine was continued. # DM2: Metformin was held while inpatient and pt was placed on an insulin sliding scale. Metformin restarted on discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Trauma: assault to face nasal bridge laceration - repaired nasal septum fracture Left superior orbit hematoma Major Surgical or Invasive Procedure: suturing of laceration left side of nose History of Present Illness: This patient is a ___ year old male who complains of ASSAULT. Patient was brought in by EMS from scene after he was assaulted in his driveway, reportedly was punched kicked and struck with a bottle in the head. There was a reported 2 minutes loss of consciousness. He was then alert for her EMS although somewhat combative, no concern for language barrier. He denies any abdominal or chest pain. Past Medical History: none Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 99.8 HR: 107 BP: 114/67 Resp: 20 O(2)Sat: 97 Normal Constitutional: Constitutional: Comfortable, No acute distress, A+O x 3 Head/Eyes: Significant left-sided facial swelling, periorbital ecchymosis, 2 cm laceration over her medial aspect of left thigh, actively bleeding, no loose teeth, midface stable, no obvious ptosis, pupils reactive bilaterally. ENT/Neck: No midline tenderness Chest/Resp: NO chest wall tenderness or crepitus, bilateral breath sounds Cardiovascular: Regular rate and rhythm GI/Abdominal: Soft, nontender, nondistended GU/Flank: No Costovertebral angle tenderness Musculoskeletal: No deformity Skin: No abrasions, lacerations, ecchymosis Neuro: GCS 15, spontaneously moves all extremities to command Psych: Normal mood Pertinent Results: ___ 12:43AM BLOOD WBC-6.3 RBC-5.07 Hgb-14.1 Hct-40.2 MCV-79* MCH-27.8 MCHC-35.1* RDW-14.1 Plt ___ ___ 12:43AM BLOOD Plt ___ ___ 12:43AM BLOOD ___ PTT-28.6 ___ ___ 12:43AM BLOOD ___ 04:39AM BLOOD Glucose-88 UreaN-11 Creat-1.0 Na-138 K-3.8 Cl-101 HCO3-29 AnGap-12 ___ 12:43AM BLOOD UreaN-17 Creat-1.0 ___ 04:39AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0 ___ 12:43AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:49AM BLOOD freeCa-1.14 ___: chest x-ray: IMPRESSION: Low lung volumes. Otherwise, unremarkable chest radiographic examination. Of note, this study is suboptimal for the assessment of rib fractures and if there is clinical concern, dedicated rib views should be performed. ___: cat scan of the head: 1. No evidence of acute intracranial injury. 2. Partially visualized facial fractures and soft tissue injuries. Please refer to the concurrent facial bone CT report for further detail. ___: cat scan of the c-spine: No cervical spine fracture or malalignment. ___: cat scan of sinus and mandible: 1. Comminuted bilateral nasal bones and nasal septum fractures, as well as nondisplaced fracture of the anterior nasal spine of the maxilla. 2. Large left preseptal periorbital hematoma and a small postseptal, extraconal hematoma in the superomedial left orbit, with involvement of the superior rectus and superior oblique muscles, and inferolateral displacement of the left globe. No orbital fracture. Ophtalmology consultation is recommended. 3. Comminuted fracture of the posterolateral left maxillary sinus wall. This finding was not included in the preliminary report; it was communicated by Dr. ___ to Dr. ___ from surgery on ___ at 10:04 am over the telephone. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 7 day course, last dose ___ RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*13 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain avoid driving while on this medication, may cause drowsiness RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Trauma: hit in face nasal bridge laceration - repaired nasal septum fracture Left superior orbit hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male status post assault with loss of consciousness. Evaluate for pneumothorax or any other evidence of trauma in the chest. COMPARISON: None available. TECHNIQUE: Frontal supine chest radiograph. FINDINGS: Assessment is limited due to artifact from trauma board. Allowing for these limitations, the lung volumes are low, without focal opacities. Cardiomediastinal and hilar contours are unremarkable. There is no pleural effusion or pneumothorax. No rib fractures are identified. A normal bowel gas pattern is seen. IMPRESSION: Low lung volumes. Otherwise, unremarkable chest radiographic examination. Of note, this study is suboptimal for the assessment of rib fractures and if there is clinical concern, dedicated rib views should be performed. Radiology Report HISTORY: Status post trauma after assault with loss of consciousness COMPARISON: None available. TECHNIQUE: Axial contiguous MDCT images were obtained through the head without administration of IV contrast. Coronal, sagittal, and thin slice bone reformations were generated. DLP: 1282.15 mGy-cm FINDINGS: Some of the images were repeated due to motion on the initial scan. There is no acute intracranial hemorrhage, edema, mass effect, or loss of gray-white matter differentiation. The sulci, ventricles and basal cisterns are normal in size and configuration. There is no calvarial fracture. Left periorbital hematoma, bilateral nasal bone fractures, nasal septum fracture, left maxillary sinus posterior wall fracture, and fluid in the left maxillary sinus are partially visualized, better seen on the concurrent facial bone CT. There is blood in the left frontal sinus. There is mucosal thickening, and fluid or blood, in bilateral ethmoidal air cells. There is a focus of secretions or globular mucosal thickening in the anterior left sphenoid sinus. Mastoid air cells are clear. IMPRESSION: 1. No evidence of acute intracranial injury. 2. Partially visualized facial fractures and soft tissue injuries. Please refer to the concurrent facial bone CT report for further detail. Radiology Report HISTORY: ___ male with trauma after assault and loss of consciousness. TECHNIQUE: Axial helical MDCT images were obtained from the skull base to the level of T1 without administration of IV or oral contrast. Coronal, sagittal and thin slice bone reformations are generated. DLP: 693.23 mGy-cm COMPARISON: None. FINDINGS: There is no acute fracture, malalignment or prevertebral soft tissue swelling. Minimal depression of the superior anterior corner of the vertebral body of C5 has associated sclerosis and appears chronic. There are chronic non-united fractures of the spinous processes of T1 and T2 with sclerotic margins. Disc space heights are preserved, and the outline of the thecal sac is grossly unremarkable, within the limitations of CT. The imaged lung apices are clear. Left maxillary sinus posterolateral wall fracture is partially visualized; concurrent head and facial bone CTs are reported separately. IMPRESSION: No cervical spine fracture or malalignment. Radiology Report HISTORY: ___ male status post facial trauma with loss of consciousness COMPARISON: None available TECHNIQUE: Axial helical MDCT images were obtained through the paranasal sinuses and mandible and without administration of IV contrast. Coronal and sagittal reformations were generated. DLP: 779 mGy-cm. FINDINGS: There are bilateral, extensively comminuted nasal bone fractures with rightward deviation of main distal fragments. There is a minimally displaced fracture through the anterior nasal spine of the maxilla. There is a comminuted nasal septum fracture. The nasal septum is deviated to the right anteriorly and to the left posteriorly. There is a communited fracture of the posterolateral wall of the left maxillary sinus, with a free fragment displaced into the sinus. There is a small amount of fluid in the left maxillary sinus, presumably blood, though insufficient in amount for density measurements. There is a large hematoma overlying the left orbit, maxilla and mandible. With the regard to the orbit, there is a large preseptal hematoma and a small postseptal, extraconal hematoma in the superomedial aspect of the orbit, displacing the left globe inferolaterally. The globe is intact. The left superior rectus and superior oblique muscles are thickened, suggesting edema and/or hematoma. There is no orbital fracture or zygomatic arch fracture. The mandible and the maxillary alveolar ridge appear intact. There is blood in the left frontal sinus. There is mucosal thickening, and fluid or blood, in bilateral ethmoidal air cells. There is a focus of secretions or globular mucosal thickening in the anterior left sphenoid sinus. Ostiomeatal units are narrowed by mucosal thickening but not occluded. There are secretions in the nasopharynx. The imaged mastoid air cells are clear. Concurrent head and cervical spine CTs are reported separately. IMPRESSION: 1. Comminuted bilateral nasal bones and nasal septum fractures, as well as nondisplaced fracture of the anterior nasal spine of the maxilla. 2. Large left preseptal periorbital hematoma and a small postseptal, extraconal hematoma in the superomedial left orbit, with involvement of the superior rectus and superior oblique muscles, and inferolateral displacement of the left globe. No orbital fracture. Ophtalmology consultation is recommended. 3. Comminuted fracture of the posterolateral left maxillary sinus wall. This finding was not included in the preliminary report; it was communicated by Dr. ___ to Dr. ___ from surgery on ___ at 10:04 am over the telephone. Radiology Report FACIAL BONE CT WITHOUT CONTRAST, ___ INDICATION: Status post assault with left orbital septal injury. Please perform thin cuts to assess for an orbital fracture. COMPARISON: Facial bone CT performed earlier today on ___. TECHNIQUE: Axial non-contrast multidetector CT images of the facial bones were obtained and displayed with 1.25-mm slice thickness. Sagittal and coronal reformatted images were generated with 1-mm slice thickness. FINDINGS: Extensive left periorbital preseptal soft tissue swelling is again noted. The previously noted small post-septal, extraconal hematoma in the superomedial aspect of the left orbit has decreased in extent and conspicuity. The superior rectus and superior oblique muscles no longer appear overtly thickened. Previously noted inferolateral displacement of the left globe has decreased in conspicuity. The left globe is intact. No orbital fracture is seen. There is no zygomatic arch fracture. A comminuted fracture of the posterolateral wall of the left maxillary sinus, with a free fracture fragment mildly depressed into the sinus, is again seen. Small amount of blood in the left maxillary sinus has decreased. Mild mucosal thickening now remains present in the left maxillary sinus. Bilateral comminuted nasal bone fractures are again seen, with rightward angulation of distal fracture fragments. A comminuted fracture of the nasal septum is also again seen. The nasal septum is deviated to the right anteriorly and to the left posteriorly, as before. A non-displaced fracture through the anterior nasal spine of the maxilla is also again seen. Again seen is a large hematoma overlying the left maxilla and mandible. There is no mandibular fracture and no fracture of the maxillary alveolar ridge. Fluid and blood is again seen in the left frontal sinus. Mucosal thickening is again seen in bilateral ethmoidal air cells. There is persistent mild mucosal thickening in the left sphenoid sinus, but the previously noted focus of secretions in its anterior aspect, has resolved. The imaged mastoid air cells and middle ear cavities are well aerated. IMPRESSION: 1. Large left preseptal periorbital hematoma is unchanged. Small post-septal, extraconal hematoma in the superomedial left orbit has decreased, and the superior rectus and superior oblique muscles no longer appear overtly edematous/thickened. No orbital fracture is seen. 2. Unchanged appearance of comminuted bilateral nasal bone fractures, comminuted nasal septum fracture, and nondisplaced fracture of the anterior nasal spine of the maxilla. 3. Unchanged appearance of the comminuted fracture of the left posterolateral maxillary sinus wall. Gender: M Race: OTHER Arrive by UNKNOWN Chief complaint: ASSAULT Diagnosed with NASAL BONE FX-CLOSED, ASSAULT NEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

The patient was admitted to the hospital after he was assaulted. The patient reportedly was punched, kicked and struck with a bottle in the head. There was a reported 2 minutes loss of consciousness. Upon admission to the hospital, the patient was made NPO, given intravenous fluids, and underwent imaging. Cat scan images of the head and neck were normal. The patient was reported to have a bilateral nasal bone and nasal septum fracture, as well as nondisplaced fracture of the anterior nasal spine of the maxilla. He was also reported to have a left preseptal periorbital hematoma and a postseptal, extraconal hematoma in the superomedial left orbit, with involvement of the superior rectus and superior oblique muscles, and inferolateral displacement of the left globe. No orbital fracture was identified. Because of his injuries, the ophthalmology was consulted and after ocular examination of the patient recommended orbital cat scan to assess the extension of the postseptal hematoma. The postseptal hematoma remained unchanged and there was no orbital fracture. The patient was placed on sinus precautions because of his injuries and had ice pack applied to the swellling on the left side of his face. He was started on a 1 week course of augmentin per recommendations of the Plastic surgery service. Since there was no indication for surgery, the patient was started on clears and advanced to a regular diet. His vital signs remained stable and he was afebrile. He received oral analgesia for management of his pain. He was placed on sinus precautions. He was seen by the Social worker who provided support to both him and his family. Because of his loss of consciousness, he was evaluated by the occupational therapist who made recommendations for outpatient cognitive evaulation. Patient was kept in the hospital for ophthalmology re-evaluation, but left AMA, before being re-evalated and before receiving discharge instructions.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: BRBPR and abdominal pain for 1 day Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo F with no significant PMH who presents with BRBPR and abdominal pain for 1 day. The only change in her health that she noticed in the last few days was that she was passing more gas than usual. Otherwise, she was in her usual state of health until midnight when she woke up with cramping hypogastric abdominal pain, nausea, cold sweats and had a normal bowel movement. She then proceeded to have up to 10 bowel movements throughout the night, and the stool transitioned from solid to soft and then watery, and then around 3:30 AM she began to have blood and pass blood clots. She had substantial blood in the toilet (she had photo documentation). She had ___ total bloody bowel movements, her last bloody bowel movement was at 9:30 AM, and she has not had any passing of gas or blood or bowel movement since that time. She saw her PCP this morning, who did a rectal exam which was positive for blood and then sent her to the ED. She has had no fevers, recent antibiotic use, sick contacts, new food exposures, or recent travel. She has never had abnormal bowel movements (consistently 1 BM every other day, normal size and consistency), pain with defecation, or prior GI bleeding. She has never had visual changes, joint pains or effusions, or rashes. In the ED, her vitals were T 97.2, HR 68, BP 135/72, RR 16 and O2 sat 100% RA. Patient was given 1 L NS and IV morphine and Zofran. Her labs were notable for WBC of 12.7 with 85% PMN predominance, Hg 12.6, Hct 39.7, Plt 259, normal ___ PTT and INR 1.0, lactate of 1.0, and Chem 7 within normal limits. Pregnancy test was negative. UA with + ketones, RBC 6, WBC 3. Urine and blood culture sent and pending. Her CT abd and pelvis with contrast showed significant wall thickening and pericolonic stranding involving the left colon, suggesting infectious or inflammatory colitis, and less likely ischemic colitis given sparing of sigmoid and rectum. Past Medical History: -Hemorrhoids after pregnancies, protrudes when she strains. Social History: ___ Family History: Father has an ulcer, HTN and cholesterol in the family. No bleeding disorders, UC/Crohn history, or autoimmune disorders that she is aware of. Physical Exam: ADMISSION EXAM Vitals: T 98.4 BP 146/74 HR 70 RR 18 O2 sat 100% RA Pain ___ General: Appears uncomfortable and dry heaving in bed HEENT: Extraocular movements intact, pupils equal and reactive to light, moist mucous membranes, throat without erythema or lesions Lymph: Shotty lymph nodes in anterior cervical chain and supraclavicular chain CV: Normal S1 and S2, RRR, no murmurs/rubs/gallops Lungs: Equal chest rise bilaterally, CTAB, no wheezing/rhonchi Abdomen: Bowel sounds present but diminished, abdomen nondistended, tender to light palpation in the hypogastric region, but nontender to light or deep palpation in other regions. No rebound tenderness/guarding. Ext: No edema or swelling, normal tone and range of movement of lower extremity joints Neuro: Alert and oriented x3 Skin: No rashes, bruises, or lesions DISCHARGE EXAM Vitals: T 98.8 BP 118/47 (SBP 95-120, DBP 35-60) HR 71 RR 16 O2 sat 100% RA General: Appears comfortable, lying in bed HEENT: Extraocular movements intact, moist mucous membranes CV: Normal S1 and S2, RRR, no murmurs/rubs/gallops Lungs: Equal chest rise bilaterally, CTAB, no wheezing/rhonchi/crackles Abdomen: Bowel sounds diminished, abdomen nondistended, no tenderness to light palpation, tender to deep palpation in the hypogastric region. No rebound tenderness/guarding. Ext: No edema or swelling, normal tone and range of movement of lower extremity joints Neuro: Alert and oriented x3 Skin: No rashes, bruises, or lesions Pertinent Results: ADMISSION LABS ___ WBC 12.7 Hgb 12.6 Hct 39.7 Plt 259 MCV 90 Neutrophils 85.4% lymphs 10.0% monos 4.0% eosinophils 0.2% Na 137 Cl 104 BUN 5 Glucose 95 AGap=17 K 4.6 HCO3- 21 Cr 0.7 ___ 11.4 PTT 34.7 INR 1.0 Glucose 95 Urea 5 Cr 0.7 HCO3 21 Anion gap 17 Beta-hcg <5 Lactate 1.0 UA color yellow, clear, ___ >1.050, Ketone 10, pH 6.5 Leuks neg Nitrite neg RBC 6 WBC 3 Bacteria none yeast none DISCHARGE LABS ___ WBC-7.6 RBC-3.75* Hgb-10.9* Hct-35.3 MCV-94 MCH-29.1 MCHC-30.9* RDW-12.8 RDWSD-44.2 Plt ___ ___ PTT-33.8 ___ Glucose-79 UreaN-5* Creat-0.6 Na-139 K-3.5 Cl-105 HCO3-25 AnGap-13 ALT-8 AST-13 LD(LDH)-126 AlkPhos-43 TotBili-1.4 Albumin-4.0 Calcium-8.8 Phos-2.8 Mg-2.1 OTHER LABS ___ 07:05AM BLOOD CRP-13.9* ___ 07:05AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0 MICROBIOLOGY C dif DNA amplification assay negative EHEC O157:H7 Vibrio Yersenia and Stool culture (Campylobacter, Salmonella, shigella) pending Urine culture: Mixed bacterial flora consistent with skin and/or genital contamination Blood culture pending IMAGING CT ABD & PELVIS WITH CONTRAST ___ impression (per radiology):Acute colitis involving the descending colon. Differential considerations include infectious or inflammatory colitis. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: primary: colitis; likely infectious. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Followup Instructions: ___ Radiology Report INDICATION: ___ with diffuse abd pain and BRBPR // eval ? colitis, enteritis TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 100 mL Omnipaque. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was not administered. DOSE: Total DLP (Body) = 550 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver enhances homogeneously. Punctate hypodensity in segment 6 is too small to characterize (02:24). There is no intra or extrahepatic biliary duct dilation. The gallbladder is normal. PANCREAS: The pancreas has normal attenuation throughout, 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. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is circumferential wall thickening, hyperemia and pericolonic stranding involving the left colon. No evidence of perforation or pneumatosis. The sigmoid and rectum appear to be spared. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. There is a 1.9 cm right corpus luteal cyst (2:63). The left ovary appears normal. There is small amount of free fluid in the pelvis. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: Acute colitis involving the descending colon. Differential considerations include infectious or inflammatory colitis. Gender: F Race: ASIAN Arrive by WALK IN Chief complaint: BRBPR, Abd pain Diagnosed with Noninfective gastroenteritis and colitis, unspecified temperature: 97.2 heartrate: 68.0 resprate: 16.0 o2sat: 100.0 sbp: 135.0 dbp: 72.0 level of pain: 5 level of acuity: 2.0

___ year old lady with ?hx of hemorrhoids presents on ___ after one day of ___ episodes of BRBPR and abdominal pain in the past day. #COLITIS: Her clinical presentation, physical exam, labs, and imaging were consistent with both infectious and inflammatory colitis. Once she arrived on the floor, she remained afebrile with normal and stable vitals. She had 3 more episodes of diarrhea, and each episode was less bloody, and stool was sent for cultures for detection of possible C. Dif, Campylobacter, Salmonella, Shigella, Vibrio, Yersenia, or E. Coli O157:H7. Stool cultures were negative for C. dif, and other stool cultures are still pending. Gastroenterology was consulted in order to help differentiate between infectious vs inflammatory colitis, and to determine whether any further work-up or procedures like a colonoscopy was needed. Gastroenterology felt that her presentation was most consistent with an infectious process, and recommended following up her H&H, which trended from 12.6 to 10.1 to 10.9 during her course, following up on stool cultures, and scheduling an outpatient appointment with them in ___ weeks to see if symptoms have resolved. Ms. ___ was hemodynamically stable and clinically improved by the time of discharge. She was tolerating a normal diet, having less bowel movements, exhibiting less tenderness to palpation, and had a stabilized H&H and downtrending WBC by discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Seizures, coffee ground emesis Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ with PMHx of ICH c/b seizures, depression/anxiety, early onset dementia and ETOH abuse who lives ___ long term care facility (___) transferred given seizure. Per report patient had several seizures within a short period of time at his ___ facility not responsive to IM benzos. EMS was called. Upon arrival patient was still actively seizing (normal FSBS) and had episode of vomiting coffee ground emesis. There were no reports of medication non-adherence. He was taken to ___. Upon arrival to ___ patient was non-verbal. Examination was notable for tonic R eye deviation with blinking initially. Labs were notable for Hgb 10.9, WBC 6.7, ABG 7.30/55/135, Cr 0.8, Negative UA, VPA level 39.8 uG/mL. Patient was intubated for airway protection. Intubation was not reported to be traumatic. While at ___, Hgb decreased to 9.1. OG tube returned about 200cc of coffee grounds so he was transfused 1 unit pRBC and given IV PPI.Stool was guiac negative. CT Head was negative for acute bleed or shift of midline. For ongoing seizures, he was treated with propofol, phenobarbital load, and AEDs. He was given an additional Keppra load (60/kg). ___ total he received 4mg LZP, 1000mg Keppra, 500mg Fosphenytoin, 500mg of Valproate, and1819.5mg of phenobarbital. He was started on At this time he was transferred to ___. ___ ED initial VS: 33, 100/59, 13, 100% Intubation Labs significant for: Cr 0.7, Hgb 10.6, Plt 253, INR 0.9, UTox positive for benzos, barbs, and opiates and serum tox positive for barbs, Lipase 22, VBG 7.41/36, Lactate 1.8 Patient was given: CTX, Propofol and Levophed Imaging notable for: CXR showing ETT, NGT, Left subclavian and mild bibasilar opacities most likely due to atelectasis, small component of aspiration is not excluded. Consults: Neurology and GI - Neurology: Recommended cEEG, infectious work up, antibiotics, continuation of AEDs and reloading with VPA. VS prior to transfer: 97.8, 62, 144/79, 20, 100% intubated On arrival to the MICU, patient is intubated and sedated. Withdrawing lower extremities to painful stimuli. Of note patient had a similar presentation ___ and ___ when he presented from ___ facility with multiple seizures refractory to Ativan management, requiring re-loading of AEDs. Trigger for each seizure event thought either due to medication non-compliance, medication underdosing or reduced seizure threshold ___ the setting of infection (PNAs). REVIEW OF SYSTEMS: Per HPI Past Medical History: - Hypertension - Asthma - Epilepsy - History of ICH, with residual left parietal infarct - History of alcohol abuse - Generalized anxiety disorder - Dementia, early onset - Thrombocytopenia Social History: ___ Family History: Not obtained. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== GENERAL: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, ETT ___ place NECK: left subclavian central line ___ place LUNGS: Mechanical breath sounds CV: Bradycardic, regular 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 NEURO: Intubated, sedated, withdrawing lower extremities to pain DISCHARGE PHYSICAL EXAM: ======================== General: alert, A+Ox2 Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: Somewhat limited as patient not consistently following commands. Face symmetric, EOMI. Moving all 4 extremities. Gait not assessed. Pertinent Results: ADMISSION LABS: =============== ___ 10:00PM BLOOD WBC-9.1 RBC-4.24* Hgb-10.6* Hct-32.8* MCV-77* MCH-25.0* MCHC-32.3 RDW-17.4* RDWSD-48.4* Plt ___ ___ 10:00PM BLOOD ___ PTT-26.4 ___ ___ 04:02AM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-139 K-4.0 Cl-103 HCO3-24 AnGap-12 ___ 04:02AM BLOOD ALT-14 AST-16 LD(LDH)-131 AlkPhos-54 TotBili-0.3 ___ 02:54AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7 ___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Carbamz-<2* Acetmnp-NEG Bnzodzp-NEG Barbitr-POS* Tricycl-NEG ___ 10:32PM BLOOD pO2-85 pCO2-36 pH-7.41 calTCO2-24 Base XS-0 ___ 10:32PM BLOOD Glucose-133* Lactate-1.8 Na-136 K-4.3 Cl-104 ___ 10:32PM BLOOD Hgb-11.4* calcHCT-34 O2 Sat-95 COHgb-2 MetHgb-0 PERTINENT INTERVAL LABS: ======================== ___ 04:02AM BLOOD Phenyto-8.1* Valproa-47* ___ 02:54AM BLOOD Phenyto-8.4* Valproa-46* ___ 04:07AM BLOOD Phenyto-8.9* Valproa-40* IMAGING/STUDIES: ================ ## CXR ___ Endotracheal tube terminates 5.7 cm above the carina. Enteric tube courses below the diaphragm, out of the field of view. Left PICC terminates ___ the proximal SVC. Mild bibasilar opacities most likely due to atelectasis, small component of aspiration is not excluded. ## ___ EGD: - Normal duodenum - Grade C esophagitis ___ the distal esophagus - Erosions ___ the stomach body MICROBIOLOGY: ============= ___ 3:03 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: THIS IS A CORRECTED REPORT (___). ___ PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. PREVIOUSLY REPORTED AS (___). ___ PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. Reported to and read back by ___ 10:34 ON ___. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. ACINETOBACTER BAUMANNII. MODERATE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". STAPH AUREUS COAG +. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. ASPERGILLUS FUMIGATUS COMPLEX. RARE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII | AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S LEVOFLOXACIN---------- 0.25 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GuaiFENesin ER 600 mg PO BID:PRN cough 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 3. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line 4. Lactulose 30 mL PO DAILY:PRN constipation 5. LORazepam 1 mg IM Q2HRS seizures 6. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First Line 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 8. Ipratropium-Albuterol Neb 1 NEB NEB Q8H 9. LevETIRAcetam 1250 mg PO BID 10. Phenytoin Infatab 200 mg PO BID 11. amLODIPine 5 mg PO DAILY 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Divalproex (DELayed Release) 1000 mg PO BID 14. Fluticasone Propionate 110mcg 2 PUFF IH BID Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days Through ___ 2. Pantoprazole 40 mg PO BID 3. Valproic Acid ___ mg PO Q6H 4. GuaiFENesin ___ mL PO Q6H:PRN cough 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. amLODIPine 5 mg PO DAILY 8. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line 9. Fluticasone Propionate 110mcg 2 PUFF IH BID 10. Lactulose 30 mL PO DAILY:PRN constipation 11. LevETIRAcetam 1250 mg PO BID 12. LORazepam 1 mg IM Q2HRS seizures 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Phenytoin Infatab 200 mg PO BID 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis - Seizure Secondary Diagnosis - Epilespy - Aspiration pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with intubated*** WARNING *** Multiple patients with same last name!// eval tube TECHNIQUE: Single frontal view of the chest COMPARISON: Earlier today, ___ at 20:46 FINDINGS: Endotracheal tube terminates 5.7 cm above the carina. Enteric tube courses below the diaphragm, out of the field of view. Left-sided PICC terminates in the proximal SVC. Mild bibasilar opacities are most likely due to atelectasis, small component of aspiration is not excluded. No focal consolidation seen elsewhere. There is no pleural effusion or pneumothorax. The cardiac mediastinal silhouettes are unremarkable. IMPRESSION: Endotracheal tube terminates 5.7 cm above the carina. Enteric tube courses below the diaphragm, out of the field of view. Left PICC terminates in the proximal SVC. Mild bibasilar opacities most likely due to atelectasis, small component of aspiration is not excluded. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with seizures, intaubted for airway protection// ETT placement ETT placement IMPRESSION: Compared to chest radiographs ___. ET tube in standard placement. Esophageal drainage tube passes into the stomach and out of view. Left central venous catheter ends at the origin of the SVC. Previous pulmonary vascular congestion has improved. There is no pulmonary edema. Moderate bibasilar peribronchial opacification has improved on the right, stable on the left. This could be due to recent aspiration. No pneumonia in the upper lungs. No appreciable pleural effusion or evidence of pneumothorax. Radiology Report EXAMINATION: AP portable chest radiograph. INDICATION: ___ year old man with ICH and seizures s/p intubation// r/o PNA, lines/tubes TECHNIQUE: AP portable chest radiograph COMPARISON: Reference made to the prior portable chest radiograph dated ___ at 13:50 as well as multiple priors dating back to ___. FINDINGS: In comparison to the prior radiograph dated ___ at 13:50, the lungs remain clear without focal consolidation. Trace right basilar opacities likely represent atelectasis. The pulmonary vasculature is within normal limits. There is no large pleural effusion. There is no pneumothorax. Endotracheal tube terminates 4.1 cm above the carina. A left central venous catheter ends in the proximal SVC. An enteric tube courses below the level of the diaphragm before disappearing from view. IMPRESSION: 1. In comparison to the prior radiograph dated ___, the lungs remain clear without focal consolidation or large pleural effusion. 2. Monitoring and support devices are in unchanged in appropriate position. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old man with ICH and seizures admitted with coffee ground emesis and seizure; now with new OGT placement// please eval placement of OGT IMPRESSION: In comparison with the earlier study of this date, the there has been placement of a new orogastric tube with the tip extending to the antrum. Otherwise, little overall change. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old man with encephalopathy, seizures. Concern for structural lesion.// Structural lesions to explain encephalopathy TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 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: None. FINDINGS: There is no evidence of acute hemorrhage, edema, masses, mass effect, midline shift or acute infarction. Encephalomalacia and chronic blood products in the left posterior parietal lobe is compatible with chronic infarct or prior parenchymal hemorrhage. There is no abnormal enhancement after contrast administration. The ventricles, cerebral sulci, and basal cisterns are normal in size for age. There are small foci of high T2 signal in the subcortical, deep, and periventricular white matter of the cerebral hemispheres, which are nonspecific but may be related to sequela of chronic small vessel ischemic disease in a patient of this age. Major arterial flow voids are grossly preserved. Mucosal thickening and near complete opacification of the bilateral maxillary sinuses is visualized as well as mild mucosal thickening of the left ethmoidal air cells. Otherwise the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormalities or acute infarcts. 2. Changes of encephalomalacia and chronic blood products in the left parietal lobe could be related to prior infarcts or previa parenchymal hemorrhage. 3. No abnormal enhancement is seen. 4. Sequelae of probable chronic small vessel ischemic disease. Radiology Report EXAMINATION: SKULL APANDLAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING INDICATION: ___ year old man with MR SCREENING// MR SCREENING MR SCREENING TECHNIQUE: Lateral view of the skull, frontal view of the neck, frontal view of the chest, abdomen and pelvis were obtained COMPARISON: None FINDINGS: No radio-opaque foreign body is detected over the orbits. The skull and paranasal sinuses are unremarkable. The upper cervical spine is well aligned. There are no radiodense foreign bodies projecting over the soft tissues of the neck. The lungs are clear with no focal consolidation, pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits. There are no abnormally dilated loops of bowel within the abdomen or pelvis. IMPRESSION: No radio-opaque foreign body is detected over the skull, neck, chest, abdomen or pelvis. Radiology Report EXAMINATION: Video oropharyngeal swallow INDICATION: ___ year old man with swallowing difficulty// swallow TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the Speech-Language Pathologist from the Voice, Speech & Swallowing Service. Multiple consistencies of barium were administered. DOSE: Fluoro time: Less than 5 minutes. COMPARISON: None FINDINGS: There was no gross aspiration or penetration. IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Seizure, Transfer Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus, Urinary tract infection, site not specified, Gastrointestinal hemorrhage, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

___ with PMHx of ICH c/b seizures, depression/anxiety, early onset dementia and ETOH abuse who lives ___ long term care facility (___) transferred intubated given breakthrough seizures. # ICH C/B RECURRENT SEIZURES # BREAKTHROUGH SEIZURE Reported breakthrough seizures again at ___, not responsive to IV Ativan, eventually responsive after phenobarb load, intubation/sedation with propofol and re-loading of AEDs. Etiology of breakthrough seizures suspected to be lowering of threshold due to infection (PNA) vs. GI bleed. No acute process on ___. Pt was loaded with VPA x2. Levels of VPA noted to be slightly low - per neurology, this is expected as phenytoin inhibits VPA. Also loaded with phenytoin x2 with improvement of levels. Discharged on valproic acid ___ q6H as well as home Keppra and Phenytoin. MRI head showed old blood and chronic small vessel changes, no acute infarcts. Recommend follow-up with outpatient neurology to discuss regimen further. # COFFEE GROUND EMESIS # UGIB Coffee grounds noted on OGT at ___. Hgb 10 stable from past admission value from ___ without further evidence of active GIB. Evaluated with EGD which showed gastritis, esophagitis for which he was treated with PPI. Will need repeat EGD ___ 8 weeks. # HYPOTENSION Admitted requiring low dose levophed, likely sedation related given no need prior to intubation. Unlikely hemorrhagic given stable Hgb. Unlikely distributive/septic given afebrile, normal WBC and no reported infectious symptoms. Lactate normal. Pressor requirement resolved after extubation/stopping sedation. # ACUTE HYPOXIC RESPIRATORY FAILURE # VAP/ASPIRATION PNA Intubated ___ the setting of breakthrough seizures, inability to protect airway, with CXR unable to r/o aspiration. High risk for aspiration based on past admissions. Noted to have acinetobacter ___ sputum. Hypoxia resolved with treatment. Continue Augmentin 875mg q12H for 7 days for PNA (through ___. TRANSITIONAL ISSUES: ====================== - Discharged on valproic acid ___ q6H as well as home Keppra and Phenytoin. - Recommend follow-up with outpatient neurology to discuss regimen further. - MRI final read was pending on discharge and should be followed-up as outpatient. - Discharged on PPI. Should have repeat EGD ___ 8 weeks (GI will schedule) - Continue Augmentin 875mg q12H for 7 days for PNA (through ___. - Should f/u with outpatient epileptologist as phenytoin and VPA inhibit each other so difficult to get levels therapeutic. - Recommend chest XR 4 weeks after antibiotic course to assure resolution given acinetobacter # Communication: HCP is his brother, ___, ___. # Code: Full, presumed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Acetaminophen / aspirin Attending: ___. Chief Complaint: Diarrhea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ with a history of celiac sprue, and T1DM c/b retinopathy and R eye blindness, neuropathy, and ESRD s/p LRRT from her brother (___) on MMF and tacro who presents with 2 days of diarrhea and vomiting. She had acute onset of vomiting and diarrhea waking her from sleep early in the morning the day prior to admission. She has also had watery diarrhea which has been decreasing in frequency. No blood that she has noticed although she has poor color vision. No fevers, chills, or rigors. No sick contacts. She has not eaten anything unusual or eaten out recently. She did have a cup of coffee the day prior to onset of her symptoms that tasted strange and later learned that the milk was expired so is not sure if that is the cause of her symptoms. She also has dyspnea which she has had since starting immunosuppression. No cough or chest pain. Past Medical History: - CKD stage IV, possibly ___ DM1, s/p living donor related transplant in ___ - recurrent UTIs - DM1 (dg ___ with nephropathy, neuropathy, retinopathy - Legally blind ___ diabetic retinopathy and lost right eye ___ - glaucoma - DLD - HTN - Depression - Bulimia - celiac - genital herpes Social History: ___ FAMILY HISTORY: - Both parents with type 1 diabetes mellitus Family History: Her mother has anxiety. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.1PO 121/73L Lying 79 18 99 RA GENERAL: NAD HEENT: MMM, sclerae anicteric, conjunctivae noninjected HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: warm, no edema NEURO: Alert and interactive, moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM 24 HR Data (last updated ___ @ 1203) Temp: 98.1 (Tm 98.4), BP: 112/68 (111-132/66-77), HR: 71 (70-77), RR: 18 (___), O2 sat: 100% (96-100), O2 delivery: RA, Wt: 135.7 lb/61.55 kg PHYSICAL EXAMINATION: GENERAL: NAD HEENT: MMM, sclerae anicteric, conjunctivae noninjected HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no tenderness over renal allograft EXTREMITIES: warm, no edema NEURO: AAOx3, moving all 4 extremities with purpose SKIN: no rashes Pertinent Results: ADMISSION LABS ============= ___ 04:35PM BLOOD WBC-7.6 RBC-4.08 Hgb-12.5 Hct-37.4 MCV-92 MCH-30.6 MCHC-33.4 RDW-12.2 RDWSD-40.7 Plt ___ ___ 04:35PM BLOOD Neuts-74.7* Lymphs-15.7* Monos-6.9 Eos-1.6 Baso-0.7 Im ___ AbsNeut-5.66 AbsLymp-1.19* AbsMono-0.52 AbsEos-0.12 AbsBaso-0.05 ___ 04:35PM BLOOD Glucose-243* UreaN-27* Creat-1.4* Na-136 K-6.0* Cl-98 HCO3-22 AnGap-16 ___ 04:35PM BLOOD ALT-26 AST-30 AlkPhos-109* TotBili-1.1 ___ 04:35PM BLOOD Lipase-14 ___ 04:35PM BLOOD cTropnT-<0.01 ___ 04:35PM BLOOD Albumin-4.3 ___ 04:43PM BLOOD tacroFK-18.7 ___ 04:43PM BLOOD ___ pO2-86 pCO2-35 pH-7.41 calTCO2-23 Base XS--1 Intubat-NOT INTUBA Comment-GREEN TOP ___ 04:43PM BLOOD K-4.4 INTERVAL LABS: =============== ___ 05:40AM BLOOD tacroFK-20.5* MICRO ======== URINE CULTURE: PENDING BLOOD CULTURES: PENDING IMAGING ========= ___ CXR (READ PENDING) ___ RENAL US FINDINGS: The left iliac fossa transplant renal morphology is normal. The transplant kidney measures 12.8 cm, previously 12.5 cm. The cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.72 to 0.76, borderline elevated, previously 0.61-0.71. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 76.8 cm/sec near the hilum and increasing to 160 cm/sec closer to the anastomosis, increased from previous value of 84.3 cm/sec. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. The urinary bladder is underdistended, limiting evaluation. DISCHARGE LABS: =============== ___ 06:00AM BLOOD WBC-3.8* RBC-3.59* Hgb-11.3 Hct-32.5* MCV-91 MCH-31.5 MCHC-34.8 RDW-12.1 RDWSD-39.4 Plt ___ ___ 06:00AM BLOOD Glucose-238* UreaN-14 Creat-1.2* Na-143 K-4.1 Cl-105 HCO3-27 AnGap-11 ___ 05:40AM BLOOD ALT-20 AST-14 AlkPhos-102 TotBili-0.9 ___ 06:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8 ___ 06:00AM BLOOD tacroFK-8.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mycophenolate Mofetil 500 mg PO BID 2. Tacrolimus 2.5 mg PO Q12H 3. Vitamin D ___ UNIT PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. BuPROPion XL (Once Daily) 150 mg PO BID 7. Citalopram 20 mg PO DAILY 8. Ferrous Sulfate 325 mg PO BID 9. Glargine 15 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia Discharge Medications: 1. Glargine 15 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 2. Tacrolimus 2 mg PO Q12H RX *tacrolimus 1 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. BuPROPion XL (Once Daily) 150 mg PO BID 6. Citalopram 20 mg PO DAILY 7. Ferrous Sulfate 325 mg PO BID 8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia 9. Mycophenolate Mofetil 500 mg PO BID 10. Vitamin D ___ UNIT PO DAILY 11.Outpatient Lab Work Renal transplant T86.1 Please check Chem10 and tacrolimus level on ___ and fax results to ___ in attn. of Dr ___ ___ Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Viral gastroenteritis SECONDARY DIAGNOSES =================== Supratherapeutic Tacrolimus Acute Kidney Injury Type I DM s/p Liver Donor Renal Transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ woman with shortness of breath, cough, vomiting and diarrhea. Evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: Lungs are well expanded and clear. No focal consolidation, edema, effusion, or pneumothorax. The heart is normal in size. The mediastinum is not widened. Vertebral body heights are preserved. IMPRESSION: No focal pneumonia. Radiology Report EXAMINATION: RENAL TRANSPLANT U.S. INDICATION: ___ woman with kidney transplant, vomiting and diarrhea; evaluate patency of transplant. Transplant ___ TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images of the renal transplant were obtained. COMPARISON: The renal transplant ultrasound dated ___. FINDINGS: The left iliac fossa transplant renal morphology is normal. The transplant kidney measures 12.8 cm, previously 12.5 cm. The cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.72 to 0.76, borderline elevated, previously 0.61-0.71. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 76.8 cm/sec near the hilum and increasing to 160 cm/sec closer to the anastomosis, increased from previous value of 84.3 cm/sec. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. The urinary bladder is underdistended, limiting evaluation. IMPRESSION: Patent renal vasculature and similar waveforms to prior, but now borderline elevated intrarenal artery resistive index, now 0.72 to 0.76, previously 0.61 to 0.71, and MRA peak systolic velocity now up to 160 cm/sec, previously 84.3 cm/sec. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Diarrhea, Vomiting Diagnosed with Shortness of breath temperature: 97.7 heartrate: 86.0 resprate: 18.0 o2sat: 100.0 sbp: 105.0 dbp: 75.0 level of pain: 0 level of acuity: 2.0

___ is a ___ with a history of celiac sprue, HTN, and T1DM c/b retinopathy and R eye blindness, neuropathy, and ESRD s/p LRRT from her brother (___) on MMF and tacro who presents with 2 days of diarrhea and vomiting found to have ___ in the setting of elevated tacrolimus level. Patient was given fluid resuscitation, supportive care with improvement on Tacrolimus level and Cr. Tacrolimus was held temporarily, and it was restarted at a lower dose of 2mg BID at discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tequin / Hydrocodone Attending: ___ Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with a history of metastatic breast cancer to liver, ?left adrenal, L4 presents with fever, nausea, vomiting, diarrhea, and weakness. Patient reports that over the last month she has felt progressively more weak. The night prior to presentation she was reportedly found slumped in a chair. Reports feeling so weak that she could not walk to the bathroom. Denied fall. Also reports intermittent nausea but worse in the last few weeks with vomiting. Has had some diarrhea over the last few weeks but no BMs today after taking Imodium yesterday. Reports chills x 1 day. Denies headaches, chest pain, shortness of breath, cough, abdominal pain, urinary symptoms. Of note, blood pressure has been low recently and pcp has discontinued some meds. In the ED, initial vitals were 97.8 111 105/63 16 94% RA. Labs significant for mild hyponatremia. CXR showed effusion, atelectasis and could not exclude underlying infiltrate. She was given cefepime, vanco, and zofran and admitted to OMED. Vitals on transfer 97.8 100 112/53 21 96% RA. REVIEW OF SYSTEMS: A 10 point review of systems was performed in detail and is negative except as noted in the HPI. PAST ONCOLOGIC HISTORY (per OMR): - In ___, Mrs. ___ underwent regular mammography and was found to have a left breast nodule. Same day core needle biopsy showed infiltrating ductal carcinoma that was hormonal receptor positive. She was found to have positive FNA on the left axilla. She opted for a left mastectomy, which revealed two foci of cancer 1.8 and 1.2 cm each, accompanied by extensive intermediate grade DCIS and focal lymphatic invasion. Her margins were clear, ___ lymph nodes were positive, the largest being 1.2 cm. Following mastectomy, she received radiation therapy. She underwent adjuvant chemotherapy with cyclophosphamide, doxorubicin and a taxane. - She received endocrine therapy from ___ to ___ with anastrozole daily. Her HER2 status was unclear for initial tumor. There is some description of it being 0, likely reflecting immunohistochemistry to be negative. - She did not experience any side effects from chemotherapy or hormonal therapy. She subsequently received active surveillance of right breast. - In ___, her mammogram showed an inferior lateral mass on the right breast. She received a same-day ultrasound, which detected a 1.8-cm hypoechoic mass. A biopsy was performed. There are no detectable lymph nodes in the right axillary area. Pathology revealed grade 3 infiltrating ductal carcinoma, ER/PR positive, HER-2/neu is 3+ by immunohistochemistry. - On ___, she received lumpectomy with sentinel lymph node evaluation. The final pathology showed pT1c, pN0, pMX (stage I) - ___ paclitaxel with trastuzumab weekly (total of 8 doses received) - ___ starting trastuzumab Q3wk - ___ radiation - ___ starting anastrozole - ___ completed one year of trastuzumab She had a colonoscopy in ___ which showed an ulcerated lesion in her cecum. Dr. ___ at ___ then scheduled her for a CT scan of the abdomen and pelvis with contrast. scan showed in the lower chest a right pleural effusion which was partially loculated. In the liver, low-attenuation lesions were noted throughout the liver compatible with metastases. In addition to the liver finding with multiple lesions, there was a 1.2 x 1.3 cm mass in the medial limb of the left adrenal gland. Her kidneys showed very small lesions which were likely cysts. There was nodularity of the greater omentum and transverse mesocolon in keeping with a diagnosis of peritoneal carcinomatosis. There was a 2.2 cm lesion seen in the left ovary. She also has calcified fibroids. Paraesophageal, porta hepatis and portacaval lymph nodes were noted. On bone windows, there was a 1.7 cm blastic focus in the L4 vertebral body. There are multilevel degenerative changes in the spine as well as an old left ninth rib fracture. The impression from the scan primarily was that of metastases in the liver, left adrenal gland and peritoneal cavity as well as probably in the body of L4 and possibly in her ovary. She had a liver biopsy in ___ which showed this tumor is estrogen and progesterone receptor positive and non-amplified for HER-2. This is therefore more compatible with her ___ left breast malignancy than it is with the more recent right breast cancer which was amplified for HER-2. ___ was initiated on Xeloda on ___. Past Medical History: 1. Diabetes. 2. Hypertension. 3. Hypothyroidism. 4. Obesity. 5. Metastatic breast CA see above 1. Mastectomy ___ years ago. 2. C-section above ___ years ago. Social History: ___ Family History: maternal cousin with breast cancer and there is one additional relative with a cancer of unspecified primary site Physical Exam: VS: T T 97.5, HR 79, BP 124/52, RR 18, O2 sat 99% RA Gen: NAD, resting Eyes: EOMI, no scleral icterus HENT: NCAT, trachea midline CV: RRR, S1-S2, ___ holosystolic murmur, no edema, 2+ ___ BLE Lungs: CTA B, decreased lung sounds in RLL and RML are improved today and still did not appreciate crackles or wheezes GI: +BS, soft, NTTP, NDGU: No foley MSK: ___ strength bilaterally,now able to transfer on own Neuro: Moving all extremities, no focal deficits, A+Ox3 Skin: No rash or ecchymosis Psych: Congruent affect, good judgment Pertinent Results: ___ CT head 1. No acute intracranial abnormality. ___ CXR Large right pleural effusion with overlying atelectasis, underlying consolidation not excluded. ___ CT chest No obvious explanation for the persistent moderate to large nonhemorrhagic right pleural effusion or large areas of atelectasis in the right lung, all stable since ___. Previously questioned right adenopathy has either resolved or was miss identified. There is no supraclavicular or axillary adenopathy today. Moderate emphysema. Moderately severe coronary atherosclerotic calcification. . Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Capecitabine 1500 mg PO BID 2. Gabapentin 800 mg PO BID 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. LOPERamide 2 mg PO Frequency is Unknown 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Janumet (SITagliptin-metformin) 50-1,000 mg oral daily 8. Ascorbic Acid Dose is Unknown PO DAILY 9. Aspirin 81 mg PO DAILY 10. Vitamin D Dose is Unknown PO DAILY 11. Cyanocobalamin Dose is Unknown PO Frequency is Unknown 12. ginkgo biloba unknown oral Other 13. Glucosamine (glucosamine sulfate) unknown oral unknown 14. Ibuprofen Dose is Unknown PO Frequency is Unknown 15. Fish Oil (Omega 3) 1000 mg PO Frequency is Unknown 16. Vitamin B Complex 1 CAP PO DAILY Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Cyanocobalamin 100 mcg PO DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. ginkgo biloba unk tab ORAL DAILY 5. Glucosamine (glucosamine sulfate) 1 tab ORAL DAILY 6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 7. LOPERamide 2 mg PO TID:PRN diarrhea 8. Vitamin D 1000 UNIT PO DAILY 9. Aspirin 81 mg PO DAILY 10. Capecitabine 1500 mg PO BID 11. Gabapentin 800 mg PO BID 12. Janumet (SITagliptin-metformin) 50-1,000 mg oral daily 13. Levothyroxine Sodium 75 mcg PO DAILY 14. Lisinopril 40 mg PO DAILY 15. Prochlorperazine 10 mg PO Q6H:PRN nausea 16. Vitamin B Complex 1 CAP PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. R Pleural Effusion 2. Deconditioning/General Malaise 3. Metastatic Breast CA 4. Protein Calorie Malnutrition Discharge Condition: Stable Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with fever, weakness, cough // infiltrate TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Moderate to large right pleural effusion with overlying atelectasis is seen, underlying consolidation not excluded. The left lung is grossly clear. No left pleural effusion is seen. There is no pneumothorax. Cardiac mediastinal silhouettes are grossly stable given partially obscured by the right sided opacity. IMPRESSION: Large right pleural effusion with overlying atelectasis, underlying consolidation not excluded. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with fall yesterday // eval acute intracranial injury 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: Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or large mass. Deep white matter periventricular hypodensities are nonspecific but likely represent sequela of chronic small vessel ischemic disease. The ventricles and sulci are normal in size and configuration. There is no acute fracture. Air-fluid levels are noted in the sphenoid sinuses. The paranasal sinuses are otherwise clear. IMPRESSION: No acute intracranial abnormality. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with metastatic breast cancer with pleural effusion and fevers with concern for pneumonia. TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Contrast agent was not administered. All images were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.3 s, 33.4 cm; CTDIvol = 13.5 mGy (Body) DLP = 455.4 mGy-cm. Total DLP (Body) = 455 mGy-cm. COMPARISON: CHEST CT SCAN ___. FINDINGS: 11 mm right supraclavicular lymph node, poorly defined in the absence of intravenous contrast agent, is stable or slightly smaller compared ___. There is no left supraclavicular or left axillary lymph node enlargement. Previously questioned right axillary lymph node is either a miss identified muscle, or it has resolved. Patient has had left mastectomy. Evaluation of the breasts would require mammography, for example, a spiculated 16 x 18 mm nodular collection of tissue in the right breast, 5:172. Marked enlargement of the right thyroid lobe is homogeneous, unlikely to represent a mass, and unchanged since ___. Atherosclerotic calcification is not apparent in head neck vessels, but is substantial in the coronary arteries. Had aorta is normal size. Main pulmonary arteries are mildly enlarged. Pericardial effusion is small, unchanged, with no calcification or evidence of cardiac tamponade. There is no left pleural effusion. Moderate, nonhemorrhagic right pleural effusion is nearly all dependent, in the right posterior chest, but there is small volume that is probably loculated anterior to the middle lobe, 5:131. Pleural surfaces are not distinguishable from the effusion in the absence of intravenous contrast agent. Lungs: Emphysema is widespread, moderately severe. A large region of peripheral consolidation in the right middle lobe is probably atelectasis, unchanged since ___. Smaller amount of atelectasis is also present at the base of the right lung. There is no bronchial obstruction to explain either. Subpleural scarring in the left lung anteriorly reflects previous radiation. New atelectasis at the left base is mild. Bronchi are patent to subsegmental levels and there is no bronchiectasis. A sharply defined round sclerotic lesion in the midportion of a mid thoracic vertebral body has any central dense calcification. This could be an osteoma. There are no bone lesions in the chest cage suspicious for malignancy and no compression or pathologic fractures. IMPRESSION: No obvious explanation for the persistent moderate to large nonhemorrhagic right pleural effusion or large areas of atelectasis in the right lung, all stable since ___. Previously questioned right adenopathy has either resolved or was miss identified. There is no supraclavicular or axillary adenopathy today. Moderate emphysema. Moderately severe coronary atherosclerotic calcification. . Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, s/p Fall, Fever Diagnosed with Pneumonia, unspecified organism temperature: 97.8 heartrate: 111.0 resprate: 16.0 o2sat: 94.0 sbp: 105.0 dbp: 63.0 level of pain: 8 level of acuity: 2.0

Ms. ___ is a ___ yo CF with PMH recurrent metastatic breast CA ER/PR+/HER2+ and h/o ER/PR+/HER2Neg, hypothyroidism, htn, T2DM presented on ___ with cough and subjective fever. # Cough/ R pleural effusion - likely malignant but cannot rule out underlying infection. However afebrile, no WBC, and cough can be attributed to effusion. --D/C abx and no fever, cough improved. Likely all due to pleural effusion. CT showed similar size of pleural effusion. No O2 requirements and no dyspnea # Deconditioning - s/p chemotherapy with severe decline in functional status --___ eval today with daily work, pt has stairs at home --Nutrition for help with po intake # Diarrhea - resolved by time of admission, soft abd/+BS. Patient had improvement with food as well. # Dehydration/Malnutrition - dry mucous membranes. Improved with fluids and able to tolerate a full diet and finish 100% meal at time of discharge # T2DM - held janumet on admission for contrasted CT, restarted when goes home. SSI in hospital controlled. # Functional status: Evaluated by ___, independent but set up ___ for next week # Consults: Nutrition, ___ # Diet: Regular # GI Prophy: None Indicated # Precautions: None # Code status: DNR per patient request. Updated primary oncologist as well. # Contact: ___ son ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex / Crestor Attending: ___. Chief Complaint: Tumor lysis syndrome Major Surgical or Invasive Procedure: ___: bone marrow biopsy History of Present Illness: ___ yo female with PMHx JAK2+ myeloproliferative disorder previously on hydroxyurea stopped ___ pancytopenia, COPD, aortic stenosis, HTN, HLD, DM who presented to ___ with several days of confusion and lethargy. On arrival to the OSH ED, the patient was noted to be confused and unable to give the ED team information on her care. She explained that she had recently stopped hydroxyurea ___ pancytopenia. She notes recent history of lethargy and difficulty walking over the past several days. Also complains of abdominal pain, back pain and lightheadedness. Denies CP, SOB. She follows with oncologist ___. Per his colleague, the patient had been on hydroxyurea for myeloproliferative disorder since ___, but it was stopped around ___ due to pancytopenia. At ___, labs were notable for: WBC: 26.8 Hb: 4.4 Na: 134 K: 6.5 Cr: 2.35 BUN: 56 Calcium: 7.1 Alk phos: 198 AST: 98 ALT: 46 CT the abdomen pelvis was notable for: Mild mural prominence of the splenic flexure with mild pericolic fat stranding, likely accentuated by underdistention. Findings suggest mild infectious or inflamed or colitis. She received IVF, allopurinol, morphine, Zofran, calcium gluconate, insulin, D50. Due to finding of 11% blasts and labs consistent with TLS, she was transferred to ___ for further management. On arrival to ___, physical exam was notable for: patient confused and unable to explain presentation, cardiac murmur, LUQ and RLQ tenderness to palpation. Labs were notable for: WBC 90, 15% "other", uric acid 17.2, K 6.0, Cr 2.7, lactate 3.7, Ca 8.1, Phos 6.8. EKG was within normal limits. BMT and Renal were consulted. She receive IVF, allopurinol, rasburicase. Hyperkalemia was managed with insulin/dextrose, calcium gluconate. She was admitted to ___ for TLS management and concern for acute transformation of AML. On arrival to the FICU, patient complains of confusion, weakness, dizziness of several weeks duration. She says she has felt generally unwell, very fatigued and not like herself. She complains of ongoing diarrhea that is unchanged from chronic. Also complains of worsening shortness of breath of several weeks duration. Past Medical History: COPD aortic stenosis (mild to moderate) HTN HLD DM s/p partial ___ mastectomy ?CML Hx of myeloproliferative disorder (Jak 2 +) on hydroxyurea since ___. Social History: ___ Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: temp 97.8, HR 98, BP 98/67, RR 18, O2 sat 97% on 2L GEN: AAOx2, confused, tearful EYES: PERRLA HENNT: MMM, anicteric sclera, no mucosal lesions, dentures in place CV: RRR, ___ systolic murmur RESP: bibasilar crackles, normal inspiratory effort GI: soft, nondistended. + mild tenderness to palpation in LUQ, RLQ MSK: moving all extremities SKIN: no skin lesions NEURO: CNs intact, sensation intact in upper and lower extremities, strength intact in ___ upper and lower extremities PSYCH: normal affect, depressed mood DISCHARGE PHYSICAL EXAM ======================= ___.___ Gen: no acute distress, lying on bed HEENT: dentures in, clear OP, MMM. PERRLA CARDIAC: RRR, III/VI systolic murmur best heard at ___ LUNGS: CTAB, no R/R/W, breathing comfortably on RA ABD: S/NT/ND DERM: purpura in RLQ abd c/w SQH EXT: WWP, 1+ BLE pitting edema NEURO: alert, oriented. PERRLA LINES: R chest port without access; RIJ C/D/I Pertinent Results: ADMISSION LABS: ======================== ___ 12:15AM BLOOD WBC-89.8* RBC-3.50* Hgb-11.3 Hct-38.5 MCV-110* MCH-32.3* MCHC-29.4* RDW-23.2* RDWSD-90.0* Plt ___ ___ 12:15AM BLOOD Neuts-50 Bands-7* Lymphs-6* Monos-17* Eos-1 Baso-1 Atyps-2* Metas-1* Myelos-0 Blasts-15* NRBC-11* Other-0 AbsNeut-51.19* AbsLymp-7.18* AbsMono-15.27* AbsEos-0.90* AbsBaso-0.90* ___ 12:15AM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-2+* Macrocy-2+* Microcy-OCCASIONAL Polychr-1+* Ovalocy-1+* Burr-2+* Tear Dr-OCCASIONAL ___ 12:15AM BLOOD ___ PTT-36.8* ___ ___ 04:58AM BLOOD ___ ___ 12:15AM BLOOD Ret Man-12.5* Abs Ret-0.44* ___ 12:15AM BLOOD Glucose-147* UreaN-57* Creat-2.7* Na-135 K-6.0* Cl-98 HCO3-15* AnGap-22* ___ 04:58AM BLOOD ALT-44* AST-94* LD(___)-2500* AlkPhos-191* TotBili-1.7* DirBili-1.1* IndBili-0.6 ___ 12:15AM BLOOD Albumin-2.6* Calcium-8.1* Phos-6.8* Mg-2.9* UricAcd-17.2* ___ 04:58AM BLOOD Hapto-<10* ___ 12:49AM BLOOD ___ pO2-60* pCO2-40 pH-7.25* calTCO2-18* Base XS--9 Comment-GREEN TOP ___ 12:49AM BLOOD Lactate-3.7* Creat-2.7* K-5.7* ___ 04:19PM BLOOD freeCa-2.87* ___ 06:29PM BLOOD freeCa-1.14 RELEVANT LABS: ======================== ___ 04:58AM BLOOD WBC-96.3* RBC-3.26* Hgb-10.5* Hct-35.4 MCV-109* MCH-32.2* MCHC-29.7* RDW-23.0* RDWSD-87.4* Plt ___ ___ 03:50AM BLOOD WBC-68.4* RBC-3.02* Hgb-9.7* Hct-32.9* MCV-109* MCH-32.1* MCHC-29.5* RDW-23.5* RDWSD-88.8* Plt ___ ___ 03:50AM BLOOD WBC-45.0* RBC-2.98* Hgb-9.7* Hct-31.8* MCV-107* MCH-32.6* MCHC-30.5* RDW-22.5* RDWSD-86.2* Plt ___ ___ 04:00AM BLOOD WBC-28.9* RBC-3.00* Hgb-9.6* Hct-32.2* MCV-107* MCH-32.0 MCHC-29.8* RDW-21.8* RDWSD-84.9* Plt ___ ___ 03:33AM BLOOD WBC-16.4* RBC-2.59* Hgb-8.3* Hct-27.7* MCV-107* MCH-32.0 MCHC-30.0* RDW-21.7* RDWSD-83.0* Plt Ct-90* ___ 03:14AM BLOOD WBC-11.9* RBC-2.67* Hgb-8.8* Hct-28.5* MCV-107* MCH-33.0* MCHC-30.9* RDW-21.7* RDWSD-83.2* Plt Ct-72* ___ 03:19AM BLOOD WBC-6.0 RBC-2.65* Hgb-8.6* Hct-28.0* MCV-106* MCH-32.5* MCHC-30.7* RDW-22.0* RDWSD-81.5* Plt Ct-59* ___ 02:27AM BLOOD WBC-4.1 RBC-2.50* Hgb-7.9* Hct-25.9* MCV-104* MCH-31.6 MCHC-30.5* RDW-21.9* RDWSD-80.4* Plt Ct-50* ___ 04:18AM BLOOD WBC-2.3* RBC-2.07* Hgb-6.7* Hct-21.7* MCV-105* MCH-32.4* MCHC-30.9* RDW-21.8* RDWSD-80.3* Plt Ct-31* ___ 01:39AM BLOOD WBC-2.4* RBC-2.39* Hgb-7.6* Hct-24.3* MCV-102* MCH-31.8 MCHC-31.3* RDW-21.4* RDWSD-75.0* Plt Ct-22* ___ 05:04AM BLOOD WBC-2.3* RBC-2.20* Hgb-7.1* Hct-22.6* MCV-103* MCH-32.3* MCHC-31.4* RDW-20.7* RDWSD-73.3* Plt Ct-13* ___ 12:00AM BLOOD WBC-2.0* RBC-2.19* Hgb-6.9* Hct-22.6* MCV-103* MCH-31.5 MCHC-30.5* RDW-20.4* RDWSD-73.0* Plt Ct-14* ___ 12:00AM BLOOD WBC-1.0* RBC-2.46* Hgb-7.7* Hct-24.3* MCV-99* MCH-31.3 MCHC-31.7* RDW-20.5* RDWSD-70.3* Plt Ct-26* ___ 12:00AM BLOOD WBC-0.7* RBC-2.30* Hgb-7.3* Hct-22.7* MCV-99* MCH-31.7 MCHC-32.2 RDW-19.9* RDWSD-68.3* Plt Ct-20* ___ 12:00AM BLOOD WBC-0.5* RBC-2.19* Hgb-6.7* Hct-21.3* MCV-97 MCH-30.6 MCHC-31.5* RDW-19.3* RDWSD-64.3* Plt Ct-18* ___ 12:00AM BLOOD WBC-0.6* RBC-2.39* Hgb-7.3* Hct-23.1* MCV-97 MCH-30.5 MCHC-31.6* RDW-18.7* RDWSD-62.5* Plt Ct-19* ___ 12:00AM BLOOD WBC-0.7* RBC-2.25* Hgb-6.8* Hct-21.6* MCV-96 MCH-30.2 MCHC-31.5* RDW-18.6* RDWSD-61.8* Plt Ct-13* ___ 12:00AM BLOOD WBC-0.8* RBC-2.63* Hgb-8.1* Hct-24.4* MCV-93 MCH-30.8 MCHC-33.2 RDW-19.6* RDWSD-61.4* Plt Ct-11* ___ 12:00AM BLOOD WBC-0.6* RBC-2.48* Hgb-7.4* Hct-23.4* MCV-94 MCH-29.8 MCHC-31.6* RDW-19.1* RDWSD-61.8* Plt Ct-7* ___ 12:00AM BLOOD WBC-0.8* RBC-2.57* Hgb-7.9* Hct-24.4* MCV-95 MCH-30.7 MCHC-32.4 RDW-19.1* RDWSD-61.3* Plt Ct-13* ___ 12:00AM BLOOD WBC-0.9* RBC-2.44* Hgb-7.5* Hct-23.3* MCV-96 MCH-30.7 MCHC-32.2 RDW-19.9* RDWSD-61.0* Plt Ct-15* RELEVANT MICRO ======================== ___ BLOOD CULTURE: NO GROWTH ___ URINANALYSIS: Negative leuks, negative nitrites, 10 WBCs ___ URINE CULTURE: STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL. RELEVANT IMAGING ======================== ___ CXR AP No prior chest radiographs available. Heart size top-normal. Lungs grossly clear. No pleural abnormality. Right jugular central venous infusion catheter ends at the origin of the SVC. ___ TTE Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mild aortic stenosis. Moderate tricuspid regurgitation. ___ RIGHT UPPER QUADRANT ULTRASOUND 1. Splenomegaly, measuring up to 18.0 cm. The previously seen peripheral mass was not demonstrated on the current study. 2. Trace perihepatic ascites. 3. Post cholecystectomy without intrahepatic or extrahepatic biliary ductal dilation. ___. No acute intracranial process. 2. Suggestion of mild acute sphenoid sinusitis. ___ CT ABDOMEN WITHOUT CONTRAST (___) 1. Moderate hepatosplenomegaly consistent with myeloproliferative neoplasm. 2. Small amount of ascites. 3. Small bilateral pleural effusions with adjacent compressive atelectasis. 4. Minimal colonic thickening at the splenic flexure with mild fat stranding may be related to hypoalbuminemia. A delayed follow-up CT abdominopelvic scan with oral contrast demonstrated in the sigmoid colon may help to further characterize the colonic wall. 5. A 32 x 32 mm soft tissue density is demonstrated in the lateral left breast. 6. Diffusely heterogenous osseous structures is consistent with known myelodysplastic neoplasia. ___ CT ABDOMEN WITHOUT CONTRAST (___) 1. Moderate hepatosplenomegaly consistent with the myeloproliferative neoplasm. 2. Unfortunately, the contrast in the small bowel did not reach the sigmoid. 3. Small amount of ascites. 4. Left lateral breast mass partially covered. ___ VENTILATION/PERFUSION SCAN Low likelihood ratio for recent pulmonary embolism. ___ CT CHEST WITHOUT CONTRAST 1. Partially visualized left lateral breast mass for which dedicated mammogram is recommended for further evaluation. 2. Aortic valve calcifications for which referral to the Aortic Center is recommended. ___ CXR AP Mild interstitial pulmonary edema with small bilateral pleural effusions. RELEVANT PATHOLOGY ======================== ___ BONE MARROW BIOPSY FLOW CYTOMETRY Immunophenotypic findings consistent with involvement by an abnormal CD34 positive myeloid blasts comprising 8% of the total analyzed events. Correlation with clinical, morphologic (see separate pathology/cytogenetics report ___ and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. PATHOLOGY INVOLVEMENT BY PATIENT'S KNOWN MYELOPROLIFERATIVE NEOPLASM WITH SIGNIFICANT MYELOFIBROSIS AND INCREASED BLASTS, SEE NOTE. Note: The marrow biopsy is hypercellular with myeloid dominant Hematopoieis, dysplastic megakrayocytes, and increased blasts (___) which together with an absolute monocytosis, raise the possibility of involvement by chronic myelomonocytic leukemia further subclassified as CMML-2. However, myeloproliferative neoplasm (MPN) can also be associated with monocytosis or can develop it during the course of the disease; these cases may mimic CMML. The patient's previously reported JAK2 mutation along with the significant marrow fibrosis (MF-3) and the lack of significant dysgranulopoiesis in the peripheral blood tend to support the diagnosis of a myeloproliferative neoplasm (MPN) with monocytosis rather than CMML. Nevertheless, both increased fibrosis and increasing blasts are signs of disease progression. Correlation with clinical, cytogenetic studies and laboratory findings is recommended. MYELOID NGS JAK2 V617F mutation was detected by targeted next generation sequencing. FLT3-ITD by PCR was NOT DETECTED FLT3-TKD by PCR was NOT DETECTED CALR insertion/deletion by PCR was NOT DETECTED DISCHARGE LABS ======================== WBC 1.4, Hgb 7.9, Hct 25.4, Platelets 27 Diff: Neutrophils 47%, ANC 660 Glucose 113, BUN 18, Cr 1.2, Na 140, K 3.3, Cl 99, Bicarb 27 proBNP 3695 Calcium 8.2, Phos 2.8, Mg 1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 80 mg PO DAILY 2. Metoprolol Succinate XL 12.5 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. Lisinopril 40 mg PO DAILY 5. ALPRAZolam 0.5 mg PO BID:PRN anxiety 6. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First Line 7. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea 8. Aspirin 81 mg PO DAILY 9. hyoscyamine sulfate 0.125 mg oral Q6H:PRN 10. Nystatin Cream 1 Appl TP BID under breasts 11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 12. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 13. Glargine 30 Units Bedtime Insulin SC Sliding Scale using Aspart Insulin Discharge Medications: 1. Acyclovir 400 mg PO Q12H RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX *chlorhexidine gluconate 0.12 % 15 mL oral rinse twice a day Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*0 4. FoLIC Acid 1 mg PO DAILY 5. Furosemide 100 mg PO DAILY RX *furosemide 20 mg 5 tablet(s) by mouth Daily Disp #*150 Tablet Refills:*0 6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH PAIN Reason for PRN duplicate override: Alternating agents for similar severity 7. Posaconazole Delayed Release Tablet 300 mg PO DAILY RX *posaconazole [Noxafil] 100 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 8. Potassium Chloride 40 mEq PO DAILY RX *potassium chloride 10 mEq 4 capsule(s) by mouth Daily Disp #*120 Capsule Refills:*0 9. Glargine 20 Units Bedtime Insulin SC Sliding Scale using Aspart Insulin 10. Lisinopril 20 mg PO DAILY 11. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 12. ALPRAZolam 0.5 mg PO BID:PRN anxiety 13. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea 14. FLUoxetine 80 mg PO DAILY 15. hyoscyamine sulfate 0.125 mg oral Q6H:PRN 16. Metoprolol Succinate XL 12.5 mg PO DAILY 17. Omeprazole 20 mg PO BID 18. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First Line 19.commode commode for home use Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES #Myeloproliferative neoplasm with monocytosis #Tumor lysis syndrome #Disseminated intravascuar coagulation #Depression #Goals of care #Left breast mass #Vision changes SECONDARY DIAGNOSES #T2DM #COPD #HTN #Mild aortic stenosis #Chronic back pain 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: CT CHEST W/O CONTRAST INDICATION: ___ w/o h/o JAK2+ MPN with monocytosis who initially p/w TLS c/b ___ s/p CRRT. Recent V/Q scan shows underlying pulmonary abnormalities. Patient notes intermittent dyspnea.// please characterize lungs and examine for etiology of dyspnea TECHNIQUE: Axial images of the chest were obtained without IV contrast. Coronal and sagittal reformats were obtained. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.2 s, 33.9 cm; CTDIvol = 11.4 mGy (Body) DLP = 377.7 mGy-cm. Total DLP (Body) = 378 mGy-cm. COMPARISON: No prior chest CT for comparison FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The distal tip of right chest wall port terminates within the cavoatrial junction. The visualized thyroid gland is unremarkable. No axillary adenopathy. UPPER ABDOMEN: Except for small hiatal hernia and splenomegaly, the visualized upper abdominal structures are unremarkable. MEDIASTINUM: Few scattered prominent but non pathologically enlarged mediastinal lymph nodes. No abnormal mediastinal masses. HILA: No abnormal hilar masses or hilar adenopathy. HEART and PERICARDIUM: The heart is enlarged. Coronary atherosclerotic vascular calcifications and aortic valve calcifications are noted. There is no pericardial effusion. PLEURA: No fusion LUNG: 1. PARENCHYMA: Rounded atelectasis is noted in the right middle lobe and right lower lobe. There are diffuse ground-glass opacities in the left upper lobe which are nonspecific and may represent infection or drug toxicity. 2. AIRWAYS: Diffuse bilateral minimal bronchial wall thickening of the small airways suggests infectious or inflammatory/drug reactive process. 3. VESSELS: Mild aortic atherosclerotic the calcified and noncalcified plaque. CHEST CAGE: There is a partially visualized left lateral breast mass for which dedicated mammogram is recommended for further evaluation. Bones have a diffusely sclerotic appearance which can be seen in matter dysplastic syndrome. There is no aggressive osseous lesion within the imaged chest. IMPRESSION: 1. Diffuse nonspecific ground-glass opacities in the left upper lobe, in the setting of minimal bronchial wall thickening of the small airways, suggests an infectious or inflammatory process versus changes related to drug toxicity. 2. Partially visualized left lateral breast mass for which dedicated mammogram is recommended for further evaluation. 3. Aortic valve calcifications for which referral to the Aortic Center is recommended. RECOMMENDATION(S): 1. Partially visualized left lateral breast mass for which dedicated mammogram is recommended for further evaluation. 2. Aortic valve calcifications for which referral to the Aortic Center is recommended. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 15:31 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with wheezing and volume overload// evaluate for pulmonary edema, effusion TECHNIQUE: Portable chest x-ray COMPARISON: Chest x-ray ___ FINDINGS: Distal tip of the right chest wall port overlies the mid SVC. Cardiomediastinal silhouette is unchanged. There are small bilateral pleural effusions with mild interstitial pulmonary edema. IMPRESSION: Mild interstitial pulmonary edema with small bilateral pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ yo female with PMHx CML previously on hydroxyurea stopped ___ pancytopenia presented to St. ___ hospital w/confusion, diarrhea, found to have 11% blasts and labs c/w TLS.// infiltrate infiltrate IMPRESSION: No prior chest radiographs available. Heart size top-normal. Lungs grossly clear. No pleural abnormality. Right jugular central venous infusion catheter ends at the origin of the SVC. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with CML// Placement of new RIJ dialysis catheter Contact name: ___: ___ TECHNIQUE: Chest AP view COMPARISON: ___ IMPRESSION: Right-sided central line is unchanged. A right IJ line has been placed with its tip in the SVC. The right hilar looks more prominent than on the prior study, could be related to vascular structures. Cardiomediastinal silhouette is stable. Lungs are low volume with bibasilar atelectasis. No pneumothorax is seen. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with transformation of CML to AML with bilirubinemia// ?cholethiasis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen dated ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace perihepatic ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 18.0 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Splenomegaly, measuring up to 18.0 cm. The previously seen peripheral mass was not demonstrated on the current study. 2. Trace perihepatic ascites. 3. Post cholecystectomy without intrahepatic or extrahepatic biliary ductal dilation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ w/ CMML-2 and thrombocytopenia (most recently 14) ___ chemo now c/o light sensitivity.// ?ICH TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 45.3 mGy (Head) DLP = 684.4 mGy-cm. Total DLP (Head) = 684 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical white matter hypodensities are nonspecific but suggest chronic small vessel ischemic changes. There is no evidence of fracture. Trace fluid in the sphenoid sinus. Paranasal sinuses, mastoids otherwise clear. IMPRESSION: 1. No acute intracranial process. 2. Suggestion of mild acute sphenoid sinusitis. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 11:25 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with CMML-2 on chemotherapy w/ new dyspnea.// ?hypervolemia vs. consolidation TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tips of a right chest wall Port-A-Cath in right internal jugular central line project over the upper SVC and right atrium respectively. There is no focal consolidation or pneumothorax. Small bilateral pleural effusions are suspected. IMPRESSION: Suspected small bilateral and subjacent atelectasis.. Radiology Report EXAMINATION: CT abdomen and pelvis without intravenous contrast INDICATION: ___ w/ myeloproliferative neoplasm who p/w TLS, s/p CRRT and back to the floor, now on chemo and neutropenic. Now w/ abdominal pain. CT A/P 2 weeks ago at OSH noted ?mild mural prominence ofthe splenic flexure with mild pericolic fat stranding.// please e/o evidence of inflammation and/or infection TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.4 s, 47.9 cm; CTDIvol = 25.4 mGy (Body) DLP = 1,199.8 mGy-cm. Total DLP (Body) = 1,200 mGy-cm. COMPARISON: CT abdomen pelvis from outside hospital dated ___. FINDINGS: LOWER CHEST: Small bilateral pleural effusions, right greater than left with adjacent atelectasis. There is diffuse interlobular septal thickening likely secondary to fluid overload. Cardiac size is within normal limits. No evidence of pericardial effusion. Moderate calcified atherosclerosis is demonstrated in the coronary arteries and aortic valve. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: Moderately, atrophic pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: A well-circumscribed hypodensity within the spleen measures 36 x 33 mm demonstrate attenuation of 13 Hounsfield units consistent with a splenic cyst. Splenomegaly up to 15.2 cm. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. In the interpolar region of the left kidney is a 23 mm well-circumscribed pedunculated lesion with the tenuous shin of 11.8 ___ units consistent with a simple renal cyst a there is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. Unchanged colonic wall thickening at the splenic flexure with mild fat stranding may be related to hypoalbuminemia. The appendix is not visualized. A small amount ascitic fluid is demonstrated. PELVIS: The urinary bladder and distal ureters are unremarkable. There is a trace amount of simple free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. 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. BONES: Visualized bones are diffusely heterogenous which is suggestive of an infiltrative osseous process. A small hyperdense lesion is demonstrated in the vertebral body at L2 likely a bone island. SOFT TISSUES: Diffuse soft tissue stranding is consistent with anasarca. A 32 x 32 mm soft tissue density is demonstrated in the lateral left breast, (series 3, image 8). IMPRESSION: 1. Moderate hepatosplenomegaly consistent with myeloproliferative neoplasm. 2. Small amount of ascites. 3. Small bilateral pleural effusions with adjacent compressive atelectasis. 4. Minimal colonic thickening at the splenic flexure with mild fat stranding may be related to hypoalbuminemia. A delayed follow-up CT abdominopelvic scan with oral contrast demonstrated in the sigmoid colon may help to further characterize the colonic wall. 5. A 32 x 32 mm soft tissue density is demonstrated in the lateral left breast. 6. Diffusely heterogenous osseous structures is consistent with known myelodysplastic neoplasia. RECOMMENDATION(S): 1. A delayed follow-up CT abdominopelvic scan with oral contrast demonstrated in the sigmoid colon may help to further characterize the colonic wall. 2. Mammography is recommended to further characterize the soft tissue mass in the left breast. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:05 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ CMML-2 who p/w TLS s/p CRRT, now off it. Again w/ recurrent dyspnea and O2 in mid ___ on RA.// please e/o consolidation, fluid overload please e/o consolidation, fluid overload IMPRESSION: Compared to chest radiographs ___ and ___ one. Small left pleural effusion is new. Lungs grossly clear. Heart size normal. Dual channel right supraclavicular central venous line ends in the right atrium. Jugular line ends in the upper SVC. Radiology Report EXAMINATION: Abdominal pelvis CT INDICATION: ___ h/o MPN w/ p/w TLS. Now w/ abdominal pain, prior OSH CT ___ w/ ?splenic flexure bowel inflammation. Follow up CT.// please examine for e/o bowel inflammation TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.2 s, 46.9 cm; CTDIvol = 24.7 mGy (Body) DLP = 1,140.8 mGy-cm. Total DLP (Body) = 1,141 mGy-cm. COMPARISON: Abdominal pelvis CT from ___ at 15:44 FINDINGS: LOWER CHEST: Small bilateral pleural effusion with the right greater than left adjacent atelectasis is again seen. Partially seen is a left breast Mass measuring 2.6 cm. There is a right posterior chest wall lipoma measuring 2.3 x 3.1 cm. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of focal lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: Moderate atrophy of the pancreatitis again seen. No main duct dilatation. SPLEEN: Splenomegaly measuring 15.8 cm. Again seen is a 3.8 x 3.3 hypodense lesion consistent with a splenic cyst. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. Again seen is a 2.3 cm pedunculated cyst in the interpolar of the left kidney. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Uncomplicated colonic diverticulosis. Unfortunately, the contrast in the small bowel did not reach the sigmoid. PELVIS: The urinary bladder and distal ureters are unremarkable. Small amount of ascites in the abdomen and pelvis. REPRODUCTIVE ORGANS: The visualized 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. Mild atherosclerotic disease is noted. BONES: Diffuse patchy sclerotic appearance of the bones in keeping with the myelodysplastic syndrome. SOFT TISSUES: Diffuse soft tissue stranding suggestive of anasarca. IMPRESSION: 1. Moderate hepatosplenomegaly consistent with the myeloproliferative neoplasm. 2. Unfortunately, the contrast in the small bowel did not reach the sigmoid. 3. Small amount of ascites. 4. Left lateral breast mass partially covered. RECOMMENDATION(S): Mammography is recommended to further characterize the left breast Mass. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Diarrhea, Weakness Diagnosed with Tumor lysis syndrome temperature: 97.8 heartrate: 98.0 resprate: 18.0 o2sat: 96.0 sbp: 98.0 dbp: 67.0 level of pain: 0 level of acuity: 2.0

====================== SUMMARY ====================== ___ with PMHx MPN previously on hydroxyurea stopped ___ pancytopenia presented to ___ w/confusion, diarrhea, found to have 11% blasts and labs c/w TLS, with BMB showing high risk CMML. She was initially restarted on hydroxyurea and then started on 20mg/m2 IV decitabine (___) for 5 days. She was temporarily on CRRT for urate nephropathy causing renal failure. She was pancytopenic initially due to restarting hydroxyurea and later due to the effects of decitabine. She was followed by psychiatry and palliative care and remained full code with the goal to treat her malignancy. ====================== ACUTE ISSUES ====================== #MPN with monocytosis #TLS #DIC Patient follows with oncologist ___. She had recently been taken off of hydroxyurea ___ pancytopenia. On arrival, labs were consistent with TLS and DIC. Patient had not received any recent treatment so this was felt to be due to likely transformation of CML to AML. ___ was consulted. They recommended acutely treating TLS with allopurinol and the patient ended up requiring two doses of rasburicase. She was placed back on hydroxyurea. Once she was stabilized, bone marrow biopsy was performed which showed hypercellular marrow c/w MDS/MPN disorder w/ ___ blasts so did not quite meet threshold for acute leukemia diagnosis though was felt to be progressing towards AML. Due to worsening pancytopenia, hydroxyurea was discontinued. Following ___ conversations, she was started on chemotherapy with decitabine at 20mg/m2 for 5 days. She tolerated the chemotherapy without significant issue. Labs are notable for persistent pancytopenia requiring transfusion support about every other day. For prophylaxis, she is on acyclovir, and posaconazole. Levofloxacin was discontinued as ANC >500 upon d/c. She was also recommended to start ruxolitinib given her JAK2+ status under her outpatient oncologist's guidance. ___ #Hypervolemia Patient was noted to have ___ on admission felt to be secondary to uric acid nephropathy. She was rapidly placed on CRRT due to electrolyte abnormalities and rapidly changing renal function. This was continued until ___ when TLS had resolved and she was taken off. Following this, her creatinine remained stable and she did not have any further need for dialysis. She initially received aggressive fluid resuscitation for her ___ causing her to be volume overloaded. She then received Lasix with/without diuril as needed for diuresis. #HFpEF #Moderate tricuspid regurgitation #Mild aortic stenosis: After receiving aggressive fluid resuscitation for TLS and ___, clinically appeared volume overloaded with edematous legs B/L and elevated JVP. TTE with HF with preserved EF, mild AS, and moderate TR. Initially cardiac meds (lisinopril/metoprolol) were held, but metoprolol succinate was re-started at home dose of 12.5mg daily and lisinopril was halved to 20mg daily given softer BPs and recovering ___. Likely can go back on full dose lisinopril as outpatient if BPs and kidneys tolerate. For diuresis she was given IV Lasix +/- diuril and transitioned to Lasix 100mg PO daily. #___ #Depression Patient initially have very depressed mood and was confused regarding ongoing treatment. As she improved clinically, she became much more aware of her medical status and the interventions that were being done. Following ___ conversations, she decided she wanted to move forward with treatment. Psychiatry and Palliative care both were consulted. She was continued on fluoxetine, alprazolam. Also received QHS ramelteon. #Left breast mass Incidentally noted on imaging. Patient has a history of right-sided breast cancer s/p lumpectomy without radiation and 2 months of aromatase inhibitor. Has h/o known left-sided atypical ductal hyperplasia s/p incisional biopsy ___ years prior. Outpatient oncology Dr. ___ was made aware of this incidental finding. #Vision changes, light sensitivity Patient intermittently c/o blurry vision and light sensitivity. Notes it as a chronic issue since having a fall and injuring her neck ___ years prior. CT head without issue. ====================== CHRONIC/RESOLVED ISSUES ====================== #T2DM Patient was on insulin at home, which was changed while inpatient. She was discharged on home regimen. #COPD Patient initially required oxygen supplementation but was weaned off. She received albuterol PRN. #HTN Patient was not on any anti-hypertensive medications while in the hospital. Lisinopril and metoprolol were held. BP was well-controlled off antihypertensives. #Chronic back pain Was on tramadol at home. Given small doses of oxycodone here and sent home with 30 5mg tablets. #Urinary frequency/dysuria: Resolved without treatment. UCx with coag negative staph. Did not treat as symptoms resolved. # Code Status: Full Code # Emergency Contact: Husband ___ ======================

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / lisinopril / bee stings / shellfish derived Attending: ___ Chief Complaint: Vertigo Major Surgical or Invasive Procedure: None History of Present Illness: Time (and date) the patient was last known well: ___ unknown time (24h clock) ___ Stroke Scale Score: 2 The NIHSS was performed: Date: ___ Time: 1215 (within 6 hours of patient presentation or neurology consult) 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 1 (chronic) 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 1 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 t-PA given: -No Reason t-PA was not given or considered: outside of time window Thrombectomy performed: [] Yes [x] No -If no, reason thrombectomy was not performed or considered: outside of time window I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. Pre-mRs:3 REASON FOR CONSULTATION: Code stroke/or stroke HPI: Ms. ___ is a ___ female with medical history notable for asthma complicated by recurrent exacerbations, obesity, chronic pain/fibromyalgia syndrome, history of CVA, hypertension, hypothyroidism who presents with dizziness. Briefly, patient reports that 3 days ago she suddenly developed sudden onset vertigo, room spinning to the right while walking to her kitchen. This is been persistent. Is worse with certain movements, and is resolves when laying still. Patient has fallen multiple times over the last 2 days, soft falls with abrasions to her left elbow, no head strike. Denies associated neurological symptoms such as new focal weakness (has chronic left weakness from previous stroke), no numbness or difficulty with language, no dysarthria. Denied any diplopia, however on formal testing found to have diplopia when looking to the right. headaches. No headache, but does report nausea. Patient also reports mild leg swelling over the past 1 week, no chest pain or shortness of breath. Regarding her past stroke: ___, CVA, it was apparently an atypical presentation secondary to a right leg DVT and pulmonary embolus in the setting of right foot surgery. This is the same foot that in ___ had to be reconstructed and revascularized from a traumatic motorcycle accident. The CVA apparently occurred through a small patent foramen ovale that was not suspected. She was worked up at ___. Again, it did not present as an acute stroke, it was more of a slow developing weakness of the upper and lower extremities, which persists and diminished left-sided hearing. The patent foramen ovale was, therefore, determined relatively late and they did not recommend closure at that time. She remains aware of upper and lower extremity weakness on the left and reduced hearing." Of note patient has been seen in the ED two times last week for back and neck pain. This has much improved and does not currently bother her. Also upon chart review it appears that she is coming to the ED at least ___ times per months for years for various problems. Also per chart review was seen for vertigo once in ___ ROS: 10 point ROS reviewed as in HPI Past Medical History: ___: ___, CVA (residual L side weakness) ___ RLE DVT/PE, PFO, OSA, hx PNA, Lumbar DJD w/spinal stenosis, HTN, asthma, hypothyroid, neuropathy, obesity (BMI 38.8), fibromyalgia, migraines, GERD, Raynaud syndrome, OSA(on 2 liters O2 qhs) L knee OA, and diverticulosis, herniated cervical discs, fatty liver. Social History: ___ Family History: Pancreatic cancer, GERD, stomach ulcers, COPD and asthma. Physical Exam: ADMISSION PHYSICAL EXAM ========================= - General: Awake, cooperative, NAD. - HEENT: NC/AT - Neck: Supple - Pulmonary: no increased WOB - Cardiac: well perfused - Abdomen: soft, nontender, nondistended - Extremities: trace edema in BLE, pulses palpated - Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Diplopia on right lateral gaze resolved when covering right eye. However not resolved when covering left eye. She was unable to tell me which image disappeared. III, IV, VI: EOMI with nystagmus on lateral gaze V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. 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: Normal bulk, tone throughout. LUE drift (chronic) No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 4 5- ___ 5 5 5 5 5 5 R 5 ___ 5 5 5 5 5 5 5 -DTRs: [Bic] [Tri] [___] [Quad] L 2+ 2+ 2+ 2+ R 2+ 2+ 2+ 2+ Plantar response flexor bilaterally. -Sensory: No deficits to light touch, pinprick throughout. No extinction to DSS. -Coordination: No intention tremor. Dysmetria on FNF bilaterally. -Gait: Able to get of bed by herself and walk a few steps, appears unsteady and somewhat broad based. *HIT w/o correction *Subtle skew deviation noted *No nystagmus with ___ hall pike DISCHARGE PHYSICAL EXAM ======================== - General: Awake, cooperative, NAD. - HEENT: NC/AT - Neck: Supple - Pulmonary: no increased WOB - Cardiac: well perfused - Abdomen: obese, soft, nontender, nondistended - Extremities: trace edema in BLE, no cyanosis or clubbing - Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. 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: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. No diplopia. III, IV, VI: EOMI with bilateral nystagmus without fatigue. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger snapping bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. LUE drift (chronic) No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 5 R 5 ___ 5 5 5 5 5 5 5 -DTRs: [Bic] [Tri] [___] [Quad] L 2+ 2+ 2+ 2+ R 2+ 2+ 2+ 2+ Plantar response flexor bilaterally. -Sensory: No deficits to light touch, pinprick throughout. No extinction to DSS. -Coordination: No intention tremor. Dysmetria on FNF bilaterally (L>R) -Gait: Able to get of bed by herself and walk a few steps, unsteady, veered to left side when standing with eyes closed. Broad based. Pertinent Results: ADMISSION LABS ================ ___ 11:55AM BLOOD WBC-10.2* RBC-4.11 Hgb-12.6 Hct-36.4 MCV-89 MCH-30.7 MCHC-34.6 RDW-14.2 RDWSD-45.5 Plt ___ ___ 11:55AM BLOOD Neuts-72.4* Lymphs-16.9* Monos-7.4 Eos-2.3 Baso-0.6 Im ___ AbsNeut-7.36* AbsLymp-1.72 AbsMono-0.75 AbsEos-0.23 AbsBaso-0.06 ___ 11:55AM BLOOD Plt ___ ___ 11:05AM BLOOD Glucose-153* UreaN-13 Creat-0.9 Na-146 K-2.9* Cl-101 HCO3-29 AnGap-16 ___ 11:05AM BLOOD ALT-37 AST-39 AlkPhos-100 TotBili-0.3 ___ 11:05AM BLOOD Lipase-24 ___ 11:05AM BLOOD cTropnT-<0.01 ___ 11:05AM BLOOD proBNP-41 ___ 11:05AM BLOOD Albumin-3.8 Calcium-9.6 Phos-2.7 Mg-1.8 ___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS ================ ___ 08:13AM BLOOD WBC-6.7 RBC-3.98 Hgb-12.1 Hct-35.6 MCV-89 MCH-30.4 MCHC-34.0 RDW-14.1 RDWSD-45.7 Plt ___ ___ 08:13AM BLOOD Plt ___ ___ 08:13AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-146 K-3.5 Cl-103 HCO3-32 AnGap-11 ___ 08:13AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 IMAGING ======== FINDINGS: CTA HEAD W&W/O C & RECONS Study Date of ___ CT HEAD WITHOUT CONTRAST: There is no evidence of acute large territorial infarction, hemorrhage, edema, or mass effect. The ventricles and sulci are within expected limits in size and configuration. There is trace mucosal thickening of the right sphenoid sinus and left maxillary sinus. The remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Mild motion artifact, photon starvation and timing of bolus results in slightly suboptimal evaluation of the carotid and vertebral vessels within the neck. Within this confines, the carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. 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. Unremarkable CTA head and neck. No evidence of high-grade stenosis, occlusion or aneurysm. No stenosis of the cervical internal carotid arteries by NASCET criteria. 2. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. 3. Additional findings as described above. MR HEAD W/O CONTRAST Study Date of ___ FINDINGS: Evaluation is suboptimal due to motion artifact. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are prominent, consistent with global cerebral volume loss. Minimal patchy periventricular T2 hyperintensities are most consistent with chronic small vessel ischemic disease. The visualized paranasal sinuses are clear. The mastoid air cells are clear. The intraorbital contents are normal. IMPRESSION: 1. No acute intracranial abnormalities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO BID 2. Chlorthalidone 25 mg PO DAILY 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Aspirin 162 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN SOB 8. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN 9. Esomeprazole 20 mg Other BID 10. Ranitidine 300 mg PO QHS 11. Baclofen 10 mg PO TID 12. BuPROPion 100 mg PO BID 13. Citalopram 40 mg PO QHS 14. Gabapentin 600 mg PO TID 15. Promethazine 25 mg PO Q6H:PRN allergies 16. lutein 20 mg oral unknown Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth DAILY Disp #*90 Tablet Refills:*3 2. LORazepam 0.5 mg PO DAILY:PRN anxiety RX *lorazepam 0.5 mg 1 tablet(s) by mouth DAILY Disp #*6 Tablet Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 4. amLODIPine 5 mg PO BID 5. Aspirin 162 mg PO DAILY 6. Baclofen 10 mg PO TID 7. BuPROPion 100 mg PO BID 8. Chlorthalidone 25 mg PO DAILY 9. Citalopram 40 mg PO QHS 10. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN 11. Esomeprazole 20 mg Other BID 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. Gabapentin 600 mg PO TID 14. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN SOB 15. Levothyroxine Sodium 125 mcg PO DAILY 16. lutein 20 mg oral unknown 17. Promethazine 25 mg PO Q6H:PRN allergies 18. Ranitidine 300 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: #Vertigo #HLD #HTN #Asthma #Hypothyroid #Chronic pain #Fibromyalgia #Depression 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 INDICATION: ___ with leg swelling, abrasions on elbow; +vertigo, +HINTS, concern for vertebral infarct// eval PNA, pulm edema; eval fracture; eval stenosis TECHNIQUE: Frontal lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ with leg swelling, abrasions on elbow; +vertigo, +HINTS, concern for vertebral infarct// eval PNA, pulm edema; eval fracture; eval stenosis TECHNIQUE: Three views of the left elbow. COMPARISON: None. FINDINGS: There is no acute fracture. Well corticated ossific density adjacent to the trochlea appears chronic, potentially degenerative. There is no elbow joint effusion. Soft tissues are unremarkable. IMPRESSION: No fracture. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: History: ___ with leg swelling, abrasions on elbow; +vertigo, +HINTS, concern for vertebral infarct// eval PNA, pulm edema; eval fracture; eval stenosis 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 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 3.0 s, 0.5 cm; CTDIvol = 15.0 mGy (Body) DLP = 7.5 mGy-cm. 3) Spiral Acquisition 4.7 s, 36.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 560.3 mGy-cm. Total DLP (Body) = 568 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: No relevant priors on PACS. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of acute large territorial infarction, hemorrhage, edema, or mass effect. The ventricles and sulci are within expected limits in size and configuration. There is trace mucosal thickening of the right sphenoid sinus and left maxillary sinus. The remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Mild motion artifact, photon starvation and timing of bolus results in slightly suboptimal evaluation of the carotid and vertebral vessels within the neck. Within this confines, the carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. 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. Unremarkable CTA head and neck. No evidence of high-grade stenosis, occlusion or aneurysm. No stenosis of the cervical internal carotid arteries by NASCET criteria. 2. No acute intracranial abnormality on noncontrast head CT. Specifically no large territory infarct or intracranial hemorrhage. 3. Additional findings as described above. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: ___ year old woman with vertigo// eval stroke TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CT of head and neck dated ___ FINDINGS: Evaluation is suboptimal due to motion artifact. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are prominent, consistent with global cerebral volume loss. Minimal patchy periventricular T2 hyperintensities are most consistent with chronic small vessel ischemic disease. The visualized paranasal sinuses are clear. The mastoid air cells are clear. The intraorbital contents are normal. IMPRESSION: 1. No acute intracranial abnormalities. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, s/p Fall Diagnosed with Dizziness and giddiness temperature: 97.8 heartrate: 95.0 resprate: 16.0 o2sat: 100.0 sbp: 145.0 dbp: 82.0 level of pain: 0 level of acuity: 3.0

Ms. ___ is a ___ year old woman with medical history notable for asthma complicated by recurrent exacerbations, obesity, chronic pain/fibromyalgia syndrome, history of CVA with residual left sided weakness, hypertension and hypothyroidism who presented with 3 days of vertigo. She had an MRI of her brain which was negative for any acute stroke. #Vertigo ___ to peripheral vestibulopathy Presented with several days of vertigo and sensation of room spinning, associated with headache. Her dizziness resulted in a fall in which she hit her left elbow and knee. Initial exam notable or bilateral nystagmus on lateral gaze, monocular diplopia, and bilateral dysmetria. ___ hall pike negative. CT head with no acute process. CTA head and neck with patent vessels. She had a prior CVA in ___, presented as slow left-sided weakness of upper and lower extremities, may have been in setting of R leg DVT and PE following foot surgery, found to have PFO which was not closed. She was admitted to the stroke service for MRI. Throughout her admission, her repeat neurologic exams were notable for persistent gait unsteadiness (swayed to left with eyes closed) and bilateral nystagmus. She continued to have positional vertigo and intermittent headaches. Her MRI demonstrated NO STROKE. Her symptoms drastically improved and she was able to ambulate independently at the time of discharge. Her stroke risk factors were assessed and notable for LDL: 139, A1C 4.8. She was initiated on atorvastatin 40 mg daily, she was continued on her home aspirin 162 mg daily. #Asthma: Chronic, complicated by multiple exacerbations. On 3L oxygen in evening. No evidence of exacerbation on admission. Continued home duonebs, Fluticasone-Salmeterol in-house. Other home medications non formulary. #HTN: Continued home amlodipine, chlorthalidone. #Hypothyroidism: TSH 0.93. Continued home levothyroxine. #Chronic pain #Fibromyalgia: Peripheral inflammatory markers elevated. No evidence of acute flare. Continued home gabapentin. #Depression: Continued home citalopram, wellbutrin. She expressed significant anxiety, she was given 3 days of Ativan until she sees her PCP.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___. Chief Complaint: L ankle pain Major Surgical or Invasive Procedure: Ex-fix left tibia History of Present Illness: ___ with left pilon fracture. Patient fell off a ladder. Originally presented to ___. X-rays showed a distal communinuted fracture of the left distal tibia and fibula. At the time he was noted to have a cold foot and pulses were unable to be found by doppler. He was then transferred. Past Medical History: HTN, HLD Social History: ___ Family History: nc Physical Exam: Admission PE: In general, the patient is a well-appearing man Vitals: 98.7 96 154/88 14 98% RA Left lower extremity: Skin intact Soft, non-tender thigh Patient with mild deformity of left ankel with intact skin Non-palpable DP or ___ pulses but strong signal found by doppler Full, painless AROM/PROM of hip, knee, Difficulty with ROM of left ankle due to pain ___ fire +SILT SPN/DPN/TN/saphenous/sural distributions Discharge PE: AVSS NAD LLE: Dressing c/d/i. nvid. Pertinent Results: ___ 04:25AM BLOOD WBC-15.9* (improving) RBC-4.82 Hgb-15.0 Hct-42.6 MCV-89 MCH-31.1 MCHC-35.2* RDW-13.6 Plt ___ Medications on Admission: Lisinopril 20 mg qdaily Simvastatin 40 mg qdaily ASA 81 mg Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc qpm Disp #*14 Syringe Refills:*0 5. Lisinopril 20 mg PO DAILY 6. Ondansetron ___ mg PO Q8H:PRN nausea RX *ondansetron 4 mg ___ tablet(s) by mouth q8h prn Disp #*30 Tablet Refills:*0 7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain hold for sedation. decrease dosage as soon as possible. RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*50 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. Simvastatin 40 mg PO QPM Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: L tibia/fibula fracture Discharge Condition: Improved. AO3. NWB LLE in ex-fix. Followup Instructions: ___ Radiology Report INDICATION: ___ with tib fib fracture s/p reduction // eval for post reduction TECHNIQUE: AP and lateral views of the proximal and distal left tibia and fibula. COMPARISON: None. FINDINGS: Overlying cast obscures fine bony detail. There is a comminuted intra-articular distal left tibia fracture. There is approximately 7 mm of medial displacement of the largest medial fracture fragment. Similar degree of posterior displacement seen of the posterior malleolus. Distal left fibular fracture at the level of the syndesmosis is noted. There is medial angulation of the distal fracture fragment. Proximally, there is no tibia or fibular fracture. Radiology Report INDICATION: ___ with 8 foot fall // eval for rib fracture, ptx TECHNIQUE: Single supine view of the chest. COMPARISON: None. FINDINGS: The lungs are clear of focal consolidation, effusion, or evidence of pneumothorax on this supine film. The cardiomediastinal silhouette is within normal limits. No displaced rib fracture identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: A ___ man with a fall and headache, concern for intracranial hemorrhage or fracture. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: ___ MGy-cm. CTDI: ___ MGy. COMPARISON: None. FINDINGS: There is no hemorrhage, acute large vascular territorial infarct, or brain edema. The basal cisterns are patent. There is no shift of normally midline structures. There is no ventriculomegaly. There is preservation of gray-white matter differentiation. The visualized paranasal sinuses and mastoid air cells are clear. The globes and bony orbits are unremarkable. There is no fracture. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: A ___ man with a fall and headache, evaluate for C-spine injury. TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal reformatted images were generated. No contrast was administered. DLP: 975.27 mGy-cm. COMPARISON: None. FINDINGS: There is no fracture or traumatic subluxation. There is no prevertebral soft tissue swelling or hematoma. There are mild degenerative joint changes of the cervical spine. Uncovertebral osteophytes result in mild neural foraminal narrowing, worst at C5-6. There is no critical central spinal canal narrowing. IMPRESSION: No fracture or traumatic subluxation. NOTIFICATION: The above findings were communicated over telephone to Dr. ___ by Dr. ___ on ___ at 15:15. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT IN O.R. INDICATION: Left ankle external fixator placement. TECHNIQUE: 17 spot fluoroscopic images obtained in the OR without radiologist present. Fluoroscopy time: 23.2 seconds COMPARISON: Left tibia and fibula radiographs ___ FINDINGS: The available images show placement of external fixator device with proximal transfixing through screws through the tibia and a distal screw than appears to pass through the calcaneus. There is again visualized a comminuted fracture of the distal tibia and fibula with talar tilt and intra-articular extension. The subsequent images show distraction of the tibiotalar joint with improved alignment. There is diffuse soft tissue swelling. Please see the operative report for further details. IMPRESSION: Intraoperative images from external fixation of a distal tibia and fibula fracture. Radiology Report INDICATION: ___ year old man s/p fall now s/p L tib ex-fix application. Eval in traction for ORIF planning. // post op eval; ex-fix L tibia COMPARISON: Left ankle radiographs dated ___. Intraoperative spot fluoroscopic views from ___ FINDINGS: External fixation devices are present, secured in the posterior calcaneus and tibial midshaft. There are markedly comminuted fractures of the distal tibia and fibula. The tibial fracture extends to the articular surface of the tibial plafond. There are components of the fracture which exit at the distal tibial metadiaphysis and an additional vertical fracture line subtending the medial malleolus. There is marked comminution and morselization of bone in the region of the tibial metaphysis. Along the tibial plafond, there is a punch-die type defect that measures approximately 12.3 mm (anteroposterior), with depression of approximally 13.1 mm(400 b: 38 -40). In addition, there is a large posterior tibial fragment, which is depressed relative to its usual position, resulting in marked widening of the tibiotalar joint posteriorly. This involves approximately 10.1 mm of the posterior tibial articular surface (anteroposterior), with depression of approximately 23.8 mm. More anteriorly, the tibial articular surface is located in its usual position (400 b: 46). Multiple punctate ossific fragments lie within the mortise joint itself (400 b: 43-44). The distal fibular diaphyseal fracture is in overall anatomic alignment, with very slight (cortical width) anterior displacement of the distal fragment and very slight anterior and lateral apex angulation. No other fractures are identified. The subtalar, talonavicular, calcaneocuboid, and remaining tibiotalar joints remain congruent on this nonstress exam. The talar dome is intact, without evidence of talar dome OCD. Incidental note is made of an os trigonum ossicle. Tiny ossific densities adjacent to the medial talus (2:121), likely represent a small bipartite accessory navicular ossicle. Rounded lucency with surrounding sclerosis in the distal medial navicular abutting the navicular cuneiform joint space is not fully characterized, but likely represents a degenerative cyst with reactive sclerosis. Scattered foci of subcutaneous emphysema are present. Assessment of the surrounding soft tissues is limited, but there is prominent soft tissue swelling. As noted on the wet reading, the tibialis posterior and flexor digitorum longus tendons lie in close proximity to a posteromedial fracture line, with the PTT interposed within both fracture fragments, concerning for possible entrapment (3:99). Vascular calcification noted. IMPRESSION: 1. Comminuted fracture of the distal tibia with components involving the distal meta diaphysis, medial malleolus, and tibial plafond. 2. The tibial plafond component is compatible with a severely comminuted pilon type fracture. There is considerable distraction and depression of the fracture fragments, with respect to the usual tibial plafond articular surface, detailed above. Punctate fracture fragments noted within the mortise joint. 3. Comminuted fracture of the distal fibular diaphysis, in overall anatomic alignment, with only minimal offset and angulation. 4. No other fractures detected about the ankle/hindfoot. 5. Tibialis posterior tendon interposed between 2 tibial fracture fragments along the posterior tibia, with the FDL tendon immediately adjacent to it (3:99). This finding raises concern for tendon entrapment. 6. External fixation device in place. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: TRAUMA TRANSFER Diagnosed with FX ANKLE NOS-CLOSED, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, HYPERTENSION NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have L ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ex-fix L ankle, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after 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 perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home w/services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB in the LLE, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cyclobenzaprine / Humira Attending: ___. Chief Complaint: Left hip pain and erythema Major Surgical or Invasive Procedure: Left hip washout ___ PICC line insertion ___ TEE cardioversion ___ History of Present Illness: ___ with multiple medical problems, including atrial fibrillation on warfarin, presenting from ___ ___ ___ with left hip erythema and pain. The patient recently completed a course of vancomycin on ___ for left hip osteomyelitis vs. septic hip. Since discontinuation of antibiotic therapy the patient has experienced increased left hip symptoms. ___ the ED initial vitals signs were: 98.9 80 105/62 97% 3L NC. He spiked a fever to 100.3 while ___ the emergency deparmtne. A CT scan of the left hip showed extensive fragmentation and osteolysis of the left femoral head likely osteomyelitis with concern for phlegmon/abscess. The CT scan also noted bibasilar lung consolidations potentially representing aspiration/PNA. Orthopedics was consulted ___ the ED and recommended IV antibiotics, ___ aspiration, and consideration of washout after ___ drainage. The patient was given vancomycin and Zosyn ___ the ED. While ___ the ED, the patient was transiently hypotensive to systolic blood pressures of 60-80. His blood pressure was responsive to two 500cc boluses. His EKG was significant for STE ___ AVR and ST depressions ___ v3-v6. Troponin was elevated at 0.14 -> 0.14 with normal CK MB. His BNP was noted to be 7700. His INR was theraputic at 2.4. His white blood cell count was 10 at rehab, increasing to 16.9 on admission. On arrival to the MICU, the patient is complaining of right wrist pain, chronic low back pain and left hip pain. He is vague with regards to the onset and timing of his symptoms. He denies fevers, chills, dysuria, N/V/D, CP, SOB, HA, and abd pain. Review of systems: Per HPI Past Medical History: MRSA bacteremia Left hip septic arthritis treated with vancomycin for 6 weeks Hypercholesterolemia Chronic venous insufficency Rheumatoid arthritis, Coronary artery disease s/p CABG Osteoarthritis OS blindness Adrenal insufficiency Hiatal hernia Chronic tinnitus Fatty liver Substernal thyroid OSA Restless legs syndrome Pulmonary hypertension Gout Neuropathy peripheral Vitamin D deficiency Osteopenia Iron deficiency anemia Monoclonal gammopathy Keratosis Diabetes mellitus with neurological manifestation Systolic HF AL amyloidosis Diverticulitis of large intestine with perforation s/p colostomy Asbetosis on home oxygen (3L) Atrial fibrillation/atrial flutter Social History: ___ Family History: Father: renal failure, heart failure Mother: myocardial infarction Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 99.8 BP: 108/55 P: 113 R: 24 O2: 95% on 4 L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx with copius discharge, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, right sided colostomy bag, mid abdominal wound healing by secondary intention. BACK: Stage 3 sacral decub per nursing. GU: no foley Ext: Left hip is erythematous, warm, tender, decreased ROM ___ pain. warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Moving all extremities. Sensation intact. Pt awake, alert. DISCHARGE PHYSICAL EXAM: Vitals: 98.4 125/88 64 16 100% on 3L General: Alert, orientedx3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx w/o mucosal lesions, EOMI, right pupil RRL, left pupil s/p cataract surgery Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, soft systolic murmur, no rubs or gallops Lungs: Fine crackles at bases bilaterally Abdomen: soft, non-tender, non-distended, right sided colostomy bag, mid abdominal wound healing by secondary intention. BACK: Stage 3 sacral decub per nursing. GU: no foley Ext: Upper extremity rheumatoid deformities. Left hip dressing C/D/I with surrounding edema w/o erythema. Extremities warm, well perfused, 2+ pulses, no clubbing/cyanosis. Neuro: Moving all extremities. Sensation intact. Pertinent Results: ADMISSION LABS: ___ 09:30PM BLOOD WBC-16.9* RBC-3.69* Hgb-11.9* Hct-36.6* MCV-99* MCH-32.2* MCHC-32.5 RDW-16.6* Plt ___ ___ 09:30PM BLOOD Neuts-89.2* Lymphs-4.4* Monos-3.1 Eos-3.0 Baso-0.2 ___ 03:45AM BLOOD ___ ___ 06:23AM BLOOD ESR-120* ___ 09:30PM BLOOD Glucose-83 UreaN-34* Creat-1.0 Na-139 K-4.8 Cl-96 HCO3-29 AnGap-19 ___ 09:30PM BLOOD CK(CPK)-35* ___ 06:23AM BLOOD Albumin-2.7* Calcium-8.7 Phos-4.2 Mg-1.6 ___ 04:15AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04:15AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 04:15AM URINE RBC-6* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 DISCHARGE LABS: ___ 05:58AM BLOOD WBC-13.0* RBC-2.81* Hgb-8.8* Hct-27.8* MCV-99* MCH-31.5 MCHC-31.8 RDW-16.8* Plt ___ ___ 05:58AM BLOOD Neuts-81.6* Lymphs-9.4* Monos-7.7 Eos-0.9 Baso-0.4 ___ 05:58AM BLOOD ___ PTT-38.1* ___ ___ 05:58AM BLOOD Glucose-79 UreaN-26* Creat-0.7 Na-139 K-5.5* Cl-100 HCO3-28 AnGap-17 ___ 01:05PM BLOOD Na-140 K-5.2* Cl-100 ___ 05:58AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8 PERTINENT LABS: ___ 06:23AM BLOOD ESR-120* ___ 02:41AM BLOOD Hapto-410* ___ 06:23AM BLOOD CRP->300 ___ 09:30PM BLOOD CK-MB-3 cTropnT-0.14* proBNP-7705* ___ 05:10AM BLOOD CK-MB-4 cTropnT-0.14* ___ 09:40AM BLOOD CK-MB-5 cTropnT-0.14* ___ 11:07PM BLOOD CK-MB-4 cTropnT-0.09* ___ 04:05AM BLOOD CK-MB-4 cTropnT-0.07* ___ 02:41AM BLOOD CK-MB-3 cTropnT-0.05* ___ 06:40AM BLOOD Vanco-16.2 ___ 06:20AM BLOOD Vanco-18.6 ___ 06:54AM BLOOD Vanco-17.5 ___ 05:58AM BLOOD Vanco-18.3 CT Abdomen/Pelvis ___ IMPRESSION: 1. Extensive fragmentation and osteolysis involving the left femoral head, which may represent osteomyelitis ___ the appropriate clinical settings. There is extensive mildly enhancing soft tissue surrounding the left hip joint. Anterior to the left hip joint, there is a 2.6 x 3.6cm hypodense collection with hyper-enhancing rim, which likely represents an abscess. 2. Small bibasilar consolidations, right greater than left, concerning for infection or aspiration ___ the appropriate clinical setting. 3. Extensive calcified atherosclerotic disease without associated aneurysmal changes. 4. Bilateral renal cysts. 5. Colonic diverticula without evidence of acute diverticulitis. 6. Small hiatal hernia. 7. Small ventral hernias, containing decompressed small bowel loops. No evidence of bowel obstruction. Joint Aspiration ___ IMPRESSION: 1. Uneventful left hip joint aspiration of approximately 3 mL of sanguinous nonpurulent left hip joint fluid. Specimens were obtained and carried directly to the pathology laboratory for microbiologic and fluid analysis. 2. Imaging demonstrates advanced joint space loss ___ the left hip joint, with destruction of the femoral head and remodeling of the left acetabulum. L Leg ___ Doppler IMPRESSION: No evidence of DVT ___ the left lower extremity. CT Abdomen/Pelvis ___ IMPRESSION: 1. Interval development of a large right rectus abdominis hematoma measuring approximately 9.7 x 7.3 x 13.3 cm with intrapelvic extension. Tiny hyperdense focus within hematoma may represent punctate pseudoaneurysm. Close monitoring of hematocrit advised. 2. Interval improvement of bibasilar clung onsolidations. 3. Interval increased fragmentation and osteolysis of the left femoral head consistent and placement of drain consistent with interval debridement of known septic hip. Interval resolution of rim-enhancing adjacent collection evident on prior study. 4. Additional stable (nonemergent) findings as ___ the body of this report. TTE ___ The left atrium is elongated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. LV systolic function appears depressed probably moderately to severely but views are technically suboptimal. Estimated left ventricular ejection fraction is uncertain, possibly 25%. The right ventricular cavity is mildly dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. TEE ___ No spontaneous echo contrast or thrombus is seen ___ the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. There are simple atheroma ___ the descending thoracic aorta. The aortic valve leaflets are mildly thickened (?3). The left and noncoronary cusp appear partially fused as a result of degenerative change. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. Moderate [2+] tricuspid regurgitation is seen. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. IMPRESSION: No intra-atrial SEC or clot. At least moderate mitral regurgitation and moderate tricuspid regurgitation with no vegetations or abcesses seen. CT ABD/PELVIS FINDINGS: Note is again made of calcified pleural plaques bilaterally. Again also seen is a chronic appearing small subdiaphragmatic fluid collection. Extensive coronary calcifications are present within a mildly enlarged heart. Within the limits of this unenhanced study, the liver, spleen, and pancreas appear unremarkable. The adrenal glands are unremarkable. Multiple kidney cysts bilaterally are again noted. There is no pelvicaliceal dilatation or perinephric abnormality present. Again seen is a mixed type hiatal hernia. The stomach and small bowel are unremarkable. The patient is status post partial colectomy with colostomy seen ___ the right lower quadrant, unremarkable. Again seen is a anterior midline small bowel hernia. Again also seen is a rectus sheath hematoma appearing largely stable compared to the prior study. It currently measures 8.7 x 7.7 cm. The mild surrounding inflammatory change is less prominent on the current study. There is no new area of fluid collection concerning for hematoma. Again seen is stable appearance of the left femoral head with removal of the catheter which resided ___ the joint space. There is no focal fluid collection ___ this area. Again noted is a right total hip replacement. Stable degenerative changes of the spine are again seen. Asymmetrical muscle bulk ___ the left hip is again noted. IMPRESSION: 1. No new source of bleeding identified. 2. Stable appearance of rectus sheath hematoma. CULTURE DATA ___ 9:30 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES PERFORMED ON CULTURE # ___ FROM ___. STAPH AUREUS COAG +. ___ MORPHOLOGY. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 615PM ___. GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS. Aerobic Bottle Gram Stain (Final ___: Time Taken Not Noted ___ Date/Time: ___ 6:51 am URINE Site: NOT SPECIFIED **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA OXYTOCA | | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S 8 R CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 ___ /___ 11:00 am TISSUE FEMORAL HEAD + NECK BONE. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. Reported to and read back by NURSE ___ (___) ON ___ AT 3:00PM. TISSUE (Final ___: ___. ___ ___ REQUESTED SENSITIVITIES TO BE PERFORMED SEPARATELY ___. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPH AUREUS COAG +. SPARSE GROWTH. SECOND MORPHOLOGY. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S 0.25 S OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S VANCOMYCIN------------ 1 S 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ 11:00 am SWAB SUPERFICIAL LEFT HIP. SWAB FROM AN ABSCESS. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___, ___. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Medications on Admission: 1. Morphine SR (MS ___ 90 mg PO Q8H 2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze 4. Furosemide 20 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN pain 6. Metoprolol Tartrate 50 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Warfarin 8 mg PO DAILY16 9. traZODONE 50 mg PO HS:PRN insomnia 10. Senna 2 TAB PO HS 11. Bisacodyl 10 mg PO DAILY:PRN constipation 12. Ondansetron 4 mg PO Q6H:PRN nausea 13. Sorbitol 30 mL PO QPM:PRN constipation 14. Colchicine 0.6 mg PO BID 15. Milk of Magnesia 30 mL PO QHS:PRN constipation *AST Approval Required* 16. Fleet Enema ___AILY:PRN constipation 17. Magnesium Citrate 10 ounces PO DAILY:PRN constipation 18. PredniSONE 30 mg PO DAILY 19. Ascorbic Acid ___ mg PO DAILY 20. Allopurinol ___ mg PO DAILY 21. Glargine 20 Units Breakfast 22. Simvastatin 40 mg PO QHS 23. Gabapentin 300 mg PO BID patient states still taking this Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze 2. Allopurinol ___ mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID 6. Furosemide 20 mg PO DAILY 7. Gabapentin 300 mg PO Q8H 8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 10. Metoprolol Tartrate 50 mg PO QID 11. Morphine SR (MS ___ 60 mg PO Q8H 12. PredniSONE 20 mg PO DAILY 13. Warfarin 7.5 mg PO DAILY16 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 80 mg PO DAILY 16. Digoxin 0.125 mg PO DAILY 17. Famotidine 20 mg PO Q12H 18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 19. Lisinopril 10 mg PO DAILY 20. Miconazole Powder 2% 1 Appl TP QID:PRN rash 21. Miconazole Powder 2% 1 Appl TP BID:PRN rash 22. Sarna Lotion 1 Appl TP QID:PRN itch 23. Sulfameth/Trimethoprim DS 1 TAB PO MWF 24. Thiamine 100 mg PO DAILY 25. Vancomycin 1500 mg IV Q 24H continue until ___ 26. Acetaminophen 650 mg PO Q6H:PRN pain 27. Lidocaine 5% Patch 1 PTCH TD DAILY 28. Magnesium Citrate 10 ounces PO DAILY:PRN constipation 29. Milk of Magnesia 30 mL PO QHS:PRN constipation 30. Senna 2 TAB PO HS 31. Ondansetron 4 mg PO Q6H:PRN nausea Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: MRSA bacteremia Left septic hip Atrial flutter 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: Residual bone cleanup. FINDINGS: Images from the operating suite are presented. Further information can be gathered from the operative report. Radiology Report PORTABLE AP SEMI-ERECT CHEST FILM, ___ AT 22:03 CLINICAL INDICATION: ___ with septic hip. Evaluate for pulmonary edema. ___ at 6:44. A portable semi-erect chest film, ___ at 22:03 is submitted. IMPRESSION: 1. Overall stable cardiac and mediastinal contours in this patient status post median sternotomy for CABG. Interval improvement in pulmonary edema since the previous study, although there is still residual mild edema on the current examination. There is a large hiatal hernia. Calcified diaphragmatic pleural plaques are again seen consistent with prior asbestos exposure. Interval removal of the right PICC line. Probable small left effusion. No evidence of pneumothorax. Radiology Report INDICATION: History of diverticulitis and perforation, status post ostomy with abdominal hernia with increasing right lower quadrant abdominal pain, area feels firm on examination. Please evaluate for incarcerated hernia or abdominal wall hematoma. COMPARISON: Comparison is made to CT abdomen and pelvis performed ___. TECHNIQUE: Contrast-enhanced axial images obtained from the lung bases to the pelvic outlet. Coronal and sagittal reformations were provided. FINDINGS: There is redemonstration of an incompletely visualized mixed-type hiatal hernia. The stomach is otherwise unremarkable. The patient is status post a partial colectomy with colostomy evident in the right lower quadrant. There is diastasis of the rectus abdominis muscles progressing to an anterior midline small bowel containing hernia more inferiorly. There has been interval development of a large 9.7 x 7.3 x 13.3 cm (TRV x AP x CC) right rectus sheath hematoma with break through into the intraperitoneal space. A tiny hyperdense focus is identified in the inferomedial aspect of the hematoma (2:68) which may represent a punctate pseudoaneurysm. Attention on follow-up. The right inferior epigastric artery is remote from hyperdense focus. The new right rectus sheath hematoma is causing some narrowing of neck of lower midline hernia though there is no evidence of associated small bowel obsruction or strangulation. There is a mild amount of surrounding inflammatory change in both overlying superficial soft tissues and adjacent intrabdominal fat. Majority of visualized muscle bulk is severly atrophic likely related to longterm immobility associated with known left septic hip. Asymmetric muscle bulk in the right piriformis and proximal aspect of the right gluteus maximus (2:70, 2:75)is unchanged compared to prior study and likely due to assymetric atrophy than another area of intramuscular hematoma. There is increased fragmentation and osteolysis of the left femoral head consistent with continued debridement of known septic joint. A catheter now terminates in the joint space and the previously noted adjacent rim enhancing collection has resolved. There are significant surrounding inflammatory changes and soft tissue edema without focal fluid collection. Specifically, a fluid collection noted on the ___ study is no longer evident. Right total hip hardware appears intact. Stable degenerative changes noted in the lumbar spine including bialteral L5 pars defects and associated grade 1 anterolisthesis of L5 on S1 . Calcified pleural plaques are identified bilaterally. There is chronic-appearing small subdiaphragmatic fluid collection on the left measuring 1.3 cm, unchanged from prior. In addition, there are multiple areas of partially calcified complex fluid density collections the abdomen (2:66, 2:55) which may relate to resolving collections from prior operative intervention. The liver is homogeneous in attenuation without discrete masses or lesions. There is no intra- or extra-hepatic biliary ductal dilatation. The gallbladder is unremarkable. The pancreas is atrophic. The spleen is normal. The bilateral adrenal glands are unremarkable. Multiple cysts are identified in the bilateral kidneys, unchanged compared to prior study. There is no hydronephrosis or hydroureter evident. Coronary artery calcifications are identified. Heart size is mildly enlarged. Extensive atherosclerotic changes are noted throughout the abdominal aorta without aneurysm or dissection. Calcified plaques were noted at the ostia of the celiac and superior mesenteric artery. Within the proximal superior mesenteric artery, there is a large noncalcified plaque causing significant narrowing of the vessel and post-stenotic dilatation (2:26, 603B:44). The distal superior mesenteric artery is well perfused. IMPRESSION: 1. Interval development of a large right rectus abdominis hematoma measuring approximately 9.7 x 7.3 x 13.3 cm with intrapelvic extension. Tiny hyperdense focus within hematoma may represent punctate pseudoaneurysm. Close monitoring of hematocrit advised. 2. Interval improvement of bibasilar clung onsolidations. 3. Interval increased fragmentation and osteolysis of the left femoral head consistent and placement of drain consistent with interval debridement of known septic hip. Interval resolution of rim-enhancing adjacent collection evident on prior study. 4. Additional stable (nonemergent) findings as in the body of this report.. Radiology Report HISTORY: ___ male patient with left PICC line placement. COMPARISON: Prior chest radiograph from ___. TECHNIQUE: Portable AP chest radiograph. FINDINGS: The left PICC line tip is seen at the level of the mid to lower SVC. There are stable mediastinal and cardiac contours. There is residual pulmonary edema. Again seen are calcified diaphragmatic pleural plaques consistent with prior asbestos exposure. There is no pneumothorax. Sternotomy wires are intact. IMPRESSION: Left PICC line tip at level of mid to lower SVC. These findings were discussed with ___, venous access nurse, by Dr. ___ telephone on ___ at 11:00 AM, time of discovery. Radiology Report HISTORY: Rectus sheath hematoma with dropping hematocrit. TECHNIQUE: Contiguous axial CT images were obtained through the abdomen and pelvis without the administration of contrast. Coronal sagittal reformats were also examined. DLP: 846.65 mGy-cm. COMPARISON: CT abdomen pelvis ___. FINDINGS: Note is again made of calcified pleural plaques bilaterally. Again also seen is a chronic appearing small subdiaphragmatic fluid collection. Extensive coronary calcifications are present within a mildly enlarged heart. Within the limits of this unenhanced study, the liver, spleen, and pancreas appear unremarkable. The adrenal glands are unremarkable. Multiple kidney cysts bilaterally are again noted. There is no pelvicaliceal dilatation or perinephric abnormality present. Again seen is a mixed type hiatal hernia. The stomach and small bowel are unremarkable. The patient is status post partial colectomy with colostomy seen in the right lower quadrant, unremarkable. Again seen is a anterior midline small bowel hernia. Again also seen is a rectus sheath hematoma appearing largely stable compared to the prior study. It currently measures 8.7 x 7.7 cm. The mild surrounding inflammatory change is less prominent on the current study. There is no new area of fluid collection concerning for hematoma. Again seen is stable appearance of the left femoral head with removal of the catheter which resided in the joint space. There is no focal fluid collection in this area. Again noted is a right total hip replacement. Stable degenerative changes of the spine are again seen. Asymmetrical muscle bulk in the left hip is again noted. IMPRESSION: 1. No new source of bleeding identified. 2. Stable appearance of rectus sheath hematoma. Radiology Report AP CHEST, 9:07 A.M., ___ HISTORY: ___ man with episode of hypoxia and rising white count. Suspect pneumonia. IMPRESSION: AP chest compared to ___: I would be tempted to call the increased peribronchovascular opacification in the right mid lung recent aspiration, however on ___, when the patient was resolving pulmonary edema, the right lung had the same appearance. Therefore, I prefer vascular dilatation and early edema. Nevertheless, I would continue close radiographic surveillance if pneumonia is suspected. Linear calcifications in the right lung and nodular opacities in the left lung could all be due to prior asbestos exposure. Moderate cardiomegaly is stable, less pronounced today than it was on ___. There is probably a good-sized hiatus hernia. Because of the complexity of multiple intrathoracic findings, if the clinical situation is equally unclear, I would strongly recommend CT scanning for assessment. Left PIC line ends in the upper SVC. Pleural effusion is small if any. No pneumothorax. Radiology Report REASON FOR EXAMINATION: Picc line placement. Portable AP radiograph of the chest was reviewed in comparison to ___. The right PICC line tip is at the level of cavoatrial junction. Heart size and mediastinum are unchanged including cardiomegaly. There is slight interval improvement of pulmonary edema, but still present substantial vascular engorgement and nodular opacities in the lower lungs, partially assessed on the current study as well as right lower lobe consolidation worrisome for infectious process. Radiology Report FLUOROSCOPIC-GUIDED LEFT HIP ASPIRATION DATED ___. CLINICAL INDICATION: Left hip erythema and extreme pain. ?septic arthritis. COMPARISON: CT dated ___. PROCEDURE: Written informed consent was obtained after explaining the procedure to be performed, risks, and alternatives. A preprocedure timeout confirmed the procedure to be performed and the identity of the patient using three patient identifiers. The skin entry site at the left anterolateral hip was chosen and the skin was prepped in standard sterile fashion. Approximately 2 mL of 1% lidocaine was infiltrated into the subcutaneous soft tissues overlying region of interest. Under intermittent fluoroscopic guidance, an 18 gauge spinal needle was advanced into the left hip joint space. Approximately 3 mL of red nonpurulent left hip joint space fluid was aspirated. The needle was removed, pressure applied to needle entry site, and hemostasis achieved. Patient tolerated the procedure well. There were no immediate complications. FINDINGS: There is advanced joint space loss in the left hip joint with destruction of the left femoral head, which is displaced superiorly. There is remodeling of the left acetabulum. IMPRESSION: 1. Uneventful left hip joint aspiration of approximately 3 mL of sanguinous nonpurulent left hip joint fluid. Specimens were obtained and carried directly to the pathology laboratory for microbiologic and fluid analysis. 2. Imaging demonstrates advanced joint space loss in the left hip joint, with destruction of the femoral head and remodeling of the left acetabulum. Dr. ___, the attending radiologist, was present and supervising throughout the procedure. Radiology Report HISTORY: Persistent cellulitis in the left leg. Evaluate for DVT. TECHNIQUE: Grayscale, color and spectral Doppler ultrasound images of the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal color flow and compressibility is demonstrated in the right posterior tibial and peroneal veins. There is normal respiratory variation of the common femoral veins bilaterally. IMPRESSION: No evidence of DVT in the left lower extremity. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: HIP PAIN Diagnosed with CELLULITIS OF LEG, SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: 98.96 heartrate: 80.0 resprate: nan o2sat: 97.0 sbp: 105.0 dbp: 62.0 level of pain: 8 level of acuity: 3.0

___ with a past medical history of CAD s/p CABG, atrial fibrillation/flutter on warfarin, diverticulitis s/p colostomy, and recurrent left hip osteomyelitis/septic arthritis who presented with weakness and hypotension, found to have septic arthritis and MRSA bacteremia. #Septic arthritis The patient presented with weakness and pain ___ his left hip. He had a history of recurrent septic arthritis ___ his left hip and was s/p multiple courses of IV vancomycin and aspiration procedures ___ the previous ___ months at ___. The last course of antibiotics was completed 2 weeks before admission. Interestingly, the patient has a history of R hip replacement ___ years prior, but this joint has never been involved. CT abdomen/pelvis on arrival demonstrated signs of osteomyelitis of the L hip. The patient was started on IV vancomycin ___ house. Initially, interventional radiology performed aspiration of the joint that was not convincing for septic arthritis. Infectious Disease was consulted who encouraged the Orthopedics service to perform a washout of the joint. The patient underwent two separate washout procedures ___ and ___, during which large abscesses were found, and necrotic bone, including the entire femoral head, was removed. Cultures from the washouts grew MRSA. The patient was afebrile with sterile cultures after these washouts. The incisions and covering dressings remained C/D/I. He continues to have mild left hip edema w/o erythema or warmth. He will complete a six week course vancomycin, last dose ___. He will be followed at ___ for this and lab work should be faxed to them on a weekly basis to ___. He will also follow up ___ ___ clinic. #MRSA bacteremia The patient was treated with IV vancomycin as above. The patient had a PICC on arrival to ___ which was removed. One blood culture grew out VRE, but the ID service felt this to be a contaminant, especially since the patient was improving clinically while on vancomycin only. The patient had a TEE performed that ruled out endocarditis as a source of his bacteremia. No vegetations were seen on the TEE. #Atrial flutter/fibrillation with RVR After his second washout procedure, the patient developed atrial flutter/fibrillation with RVR. While at home, he takes metoprolol for rate control and warfarin for anticoagulation. Warfarin was held on admission due to the impending surgical procedures. The patient's rates were inadequately controlled on nodal agents. He underwent a TEE that showed no ___. He was then given heparin and a successful cardioversion was performed. He was discharged to the medical floor ___ normal sinus rhythm on digoxin and metoprolol with plan to consider outpt coumadin. INRs should be monitored on a daily basis to start given need for close titration. He will follow up with Atrius cardiology. #NSTEMI The patient presented with a troponin of .17, which eventually down-trended. At___ Cardiology was consulted who uptitrated his beta blocker therapy and recommended atorvastatin 80mg. The patient again had a troponin bump during his initial run of atrial flutter with RVR after the second washout procedure. This episode was also associated with ST depressions on ECG. The patient never complained of any chest discomfort or shortness of breath during these episodes. ST depressions resolved with rate control. Subsequent ECHO did show significant decrease ___ EF from prior study. The patient should have a repeat echo should he develop signs/symptoms of heart failure. #RLQ Hematoma/Blood loss anemia The patient complained of RLQ pain also after his second washout procedure. General Surgery was consulted who recommended a CT Abdomen which showed a rectus sheath hematoma. This was likely from a poorly positioned heparin SQ injection. After consultation with surgery and cardiology, the decision was made to move forward with IV heparin and the TEE/cardioversion. The patient was discharged to the medical floor hemodynamically stable with a stable hct while on a heparin gtt. His hematocrit was trended and he received 2 units of pRBCs on the general medicine floor. #Delirium The patient developed marked delirium while ___ the ICU. He often imagined his son ___ the room while he was not there. On the general medicine floor the patient continued to be delirius. ___ talking with the family it appeared the patient has been delirous before while on cholchine. Cholchine was discontinued. The patient's delirium was also significantly improved with blood transfusions. #Pain Control The patient's pain was difficult to control. He would often refuse PO pain medication. A dilaudid PCA was tried, but the patient reported he would forget to use the button. The patient was transferred to the medical floor on an aggressive PO regimen. He was continued on chronic prednisone along with ranitidine and TMP-SMX prophylaxis. # Systolic heart failure: LVEF uncertain, potentially 25% on ECHO ___ setting of NSTEMI and SVT. BNP of 7700 this admission. Breathing comfortable. He was treated with and discharged on BB, ACEi, digoxin, and furosemide 20mg PO daily # Rheumatoid Arthritis: On daily prednisone 30mg daily as outpt, decreased to 20mg daily ___ house with GI and bactrim ppx. ___ consider further outpt taper after discussion with his rheumatologist given his wound healing difficulties. # Wound dehiscence – Inspection of prior abdominal surgical incision was suspicious for possible dehiscence. The patient was seen by the general surgery service for this issue who recommended close monitoring. Wound care followed ___ and he should have continued wound care to the area.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old gentleman, with recent admission for relapsed hairy cell leukemia, now D24 of cladribine (___), who was transferred from ___ with fevers and abdominal pain. . In brief, hairy cell leukemia was diagnosed in ___, initially treated with cladribine (___). Disease relapsed in ___. Patient began treatment with second course of cladribine on ___, with course complicated by neuotropenic fevers that were attributed to chemotherapy (infectious work-up was unrevealing), as well as left basilic non-occlusive thrombus (previous ___ site) demonstrated on U/S ___, profound hypophosphatemia, and bilateral lower extremity discomfort. He was discharged on ___. . Since then, patient began experiencing low grade fevers on ___. He was evaluated by Dr. ___ in clinic that day, found to have temp of 100.3, with complaint of a cough. Chest x-ray at that time was unremarkable. Labs were notable for Hct 22.8, from 26.6 at the time of discharge on ___ he received one unit PRBCs, with resultant Hct ___ of 23.2. He continued to experience low-grade fevers. At 5 am on ___, he awoke with sharp, epigrastric pain and presented to ___, where he was found to have Hct 19, ANC 900, lipase 900, and CT torso with very mild jejunal fluid vs. inflammation, no evidence of pancreatic or biliary abnormalities. He receieved cefepime and vancomycin, as well as 1 unit PRBCs. He was given food there as well. En route to ___, the ride was "bumpy," and patient vomited pink-tinged vomit (from Gatorade at ___. On arrival to ___ ED, he finished vancomycin and PRBCs. GI cocktail (Maalox/lidocaine) helped abdominal pain, but morphine/Dilaudid did not. No vomiting. No rectal exam was done, given neutropenia. Labs notable for WBC 1.8 with 67.5%N, Hct 20.8. He had no vomiting in the ED. . On arrival to the floor, the patient was comfortable, but complaining of continued abdominal discomforts. Notes that he ate lettuce, potato salad in oil dressing, chicken salad, and lactaid chocolate milk the night before presentation. No know sick contacts, no melena or hematochezia, no vomiting at home. States that his diffuse abdominal pain has been unchanged for the past three weeks. Wonders whether he has chest wall tenderness from coughing. . Review of symptoms: Positive as noted in the HPI. +cough recently, with frequent colds over the past year. Frequent headaches (chronic), +continued calf discomfort relieved by stretching Negative: chills or night sweats. He denies any , lightheadedness, shortness of breath, or chest pain. He has no further pain on his right side. No melena or hematochezia. No dysuria or hematuria. No diarrhea or constipation. No GERD. All other ROS negative. Past Medical History: Oncologic history: First presented with hairy cell leukemia when he was admitted to ___ on ___ after noting shortness of breath particularly on exertion as well as increased fatigue. He was found to be anemic with a hematocrit of 13% and thrombocytopenic with a platelet count of 37,000, his white count was 11.9 with decreased neutrophils. Bone marrow aspirate and biopsy was concerning for hairy cell leukemia, and he was transferred to ___ on ___ for further treatment and evaluation. He received treatment with 2-CdA therapy for seven days with day one on ___. During his admission, he was noted for neutropenic fevers, although no infection source was found. He also developed a PICC-associated cephalic vein thrombosis. He was treated prophylactically for a period of time with acyclovir and Bactrim. Following this, ___ had done very well with recovery of his counts. He was noted for mild elevation of his liver function tests, but these eventually normalized. Because of proximity to his home, he transferred his care to Dr. ___ at ___ in ___ and is now being followed by Dr. ___. In ___, ___ was noted for dropping counts, particularly in his platelets and also noted increasing fatigue. He had previously noted a viral illness, and it was felt that possibly his counts were low because of this, but he recovered from this illness, and his counts remained low; he subsequently underwent bone marrow aspirate and biopsy on ___, which showed evidence for recurrent hairy cell leukemia. Given that it has been over ___ years since his last treatment, the plan is to move forward with a second cycle of 2-CdA. ___ was seen on ___ for this admission but was noted for an upper respiratory infection. He underwent a chest xray which did not show any evidence for pneumonia and was treated with a Z-pak. ___ presents today for admission for this treatment. . OTHER PAST MEDICAL HISTORY: 1. Status post hernia operation as a child. 2. History of a broken wrist. 3. Hypothyroidism. 4. Hypercholesterolemia; no treatment at this time. 5. Hairy cell leukemia as noted above. 6. Chronic headaches. Social History: ___ Family History: Grandmother died from possible cancer. His mother is alive with skin cancers. Father is alive in his ___. ___ has a twin brother and another brother. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.5 125/63 20 85 99%RA Gen: Well-appearing, overweight, NAD HEENT: NCAT, PERRL, EOMI, anicteric sclerae, clear oropharynx Neck: Supple, no cervical supraclavicular LAD. Lungs: CTAB, good air movement, no wheezes/crackles Heart: RRR, Nl S1/S2, No MRG Chest: No costochondral tenderness Abd: Normoactive bowel sounds, soft, nondistended, slight non-localized tenderness Extr: WWP, no edema, 2+ distal pulses Skin: Without rashes. Access: 2 PIVs . DISCHARGE PHYSICAL EXAM: VS: 98.0 (98.2) 138/58 (102-138/58-70) 76 (75-82) 20 96%RA (96-100%RA) I/O 8h ___ | 2742/3650 + 2 large formed G-neg stool Gen: Well-appearing, overweight, NAD HEENT: NCAT, PERRL, EOMI, anicteric sclerae, clear oropharynx Neck: Supple, no cervical supraclavicular LAD. Lungs: CTAB, good air movement, no wheezes/crackles Heart: RRR, Nl S1/S2, No MRG Chest: No costochondral tenderness Abd: Normoactive bowel sounds, soft, nondistended, slight non-localized tenderness Extr: WWP, no edema, 2+ distal pulses Skin: Without rashes. Access: 2 PIVs Pertinent Results: ADMISSION LABS: ___ 10:50AM BLOOD WBC-1.8* RBC-2.35* Hgb-7.3* Hct-20.8* MCV-89 MCH-31.1 MCHC-35.0 RDW-15.5 Plt ___ ___ 10:50AM BLOOD Neuts-67.5 ___ Monos-2.7 Eos-5.8* Baso-0.4 ___ 10:50AM BLOOD ___ PTT-18.4* ___ ___ 10:50AM BLOOD Glucose-141* UreaN-9 Creat-0.6 Na-136 K-4.2 Cl-103 HCO3-26 AnGap-11 ___ 10:50AM BLOOD ALT-61* AST-72* AlkPhos-117 TotBili-0.8 ___ 10:50AM BLOOD Lipase-66* ___ 10:50AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1 ___ 09:31PM BLOOD Triglyc-102 ___ 09:31PM BLOOD TSH-6.8* ___ 09:31PM BLOOD Free T4-1.1 ___ 11:01AM BLOOD Glucose-138* Lactate-1.7 Na-136 K-4.2 Cl-102 calHCO3-25 ___ 11:01AM BLOOD freeCa-1.03* ___ 11:01AM BLOOD ___ pH-7.41 ___ 01:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG . RELEVANT LABS: ___ 06:00AM BLOOD Lipase-26 . DISCHARGE LABS: ___ 06:05AM BLOOD WBC-2.9* RBC-2.70* Hgb-8.6* Hct-24.1* MCV-89 MCH-31.7 MCHC-35.5* RDW-16.3* Plt ___ ___ 06:05AM BLOOD Neuts-46* Bands-4 ___ Monos-2 Eos-14* Baso-0 ___ Myelos-0 ___ 06:05AM BLOOD ___ PTT-27.5 ___ ___ 06:05AM BLOOD Glucose-120* UreaN-9 Creat-0.8 Na-139 K-4.0 Cl-104 HCO3-25 AnGap-14 ___ 06:05AM BLOOD ALT-43* AST-21 LD(LDH)-190 AlkPhos-84 Amylase-59 TotBili-0.6 ___ 06:05AM BLOOD Lipase-43 ___ 06:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2 . MICROBIOLOGY: ___ BLOOD CULTURES X2: no growth to date ___ BLOOD CULTURE: no growth to date ___ URINE CULTURE: no growth . IMAGING: ___ CHEST X-RAY (PA/LAT): The lungs are clear with no evidence of consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette remains top normal but stable. Visualized osseous structures are normal. IMPRESSION: No acute cardiopulmonary process. . ___ NON-CONTRAST CT CHEST: The lungs are clear bilaterally. No pulmonary nodules or areas concerning for infection are noted. The airways are clear. There is no mediastinal, hilar, or axillary lymphadenopathy. The heart size is normal without pericardial effusion. The myocardium is slightly denser than the intraventricular blood, suggesting anemia. There is minimal coronary calcification of the left coronary artery. There is no pleural effusion. This examination is not tailored for subdiaphragmatic evaluation. However, the non-contrast appearance of the visualized upper abdomen is within normal limits. BONE WINDOWS: No concerning osseous lesions are identified. IMPRESSION: No findings to explain patient's continued cough. No evidence of infection. . ___ EKG: NSR @ 80 bpm, NA/NI, no change from prior. . ___ RUQ U/S: The liver appears diffusely echogenic. The gallbladder demonstrates sludge. The wall is within normal limits in thickness at 3 mm and is not striated in echogenicity; that it appears hypoechoic is because of the hyperechogenicity of the adjacent liver. No sonographic ___ sign was elicited. The common bile duct measures 0.5 cm. The spleen measures 13.6 cm, mildly enlarged. There is no free fluid. The main portal vein is patent. The pancreatic neck and body and superior portions of the head and medial portions of the tailwere visualized and without abnormality; however, the remainder of the pancreas was not clearly visualized on this study. IMPRESSION: 1. Gallbladder with sludge. Gallbladder wall is not thickened and there are no secondary signs of acute cholecystitis. 2. Highly echogenic liver consistent with fatty deposition. However, as the density of the liver on ___ Chest CT was only suggestive of slight fatty Medications on Admission: 1. levothyroxine 25 mcg Tablet PO daily 2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H 3. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain: Do not take more than 4g per day. 4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA). 5. potassium & sodium phosphates ___ mg Powder in Packet Sig: Two (2) Powder in Packet PO BID (2 times a day). Disp:*60 Powder in Packet(s)* Refills:*0* 6. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. acetaminophen 500 mg Tablet Sig: ___ Tablets PO q6h prn as needed for fever or pain: Do not exceed 4g per day. 4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week: on ___. 5. potassium & sodium phosphates ___ mg Powder in Packet Sig: Two (2) packet PO twice a day. 6. pentamidine 300 mg Recon Soln Sig: Three Hundred (300) mg Inhalation once a month: first dose ___. 7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: ___ MLs PO QID (4 times a day) as needed for heartburn. ML(s) 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Gastroesophageal reflux disease . Secondary diagnoses: Hypothyroidism Hairy cell leukemia Eosiniophilia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ gentleman with recent admission for relapsed hairy cell leukemia with fevers and abdominal pain. Lipase at ___ was 939, however in-house is presently 66. COMPARISON: Abdominal ultrasound from ___, CT of the chest ___, CT of the abdomen and pelvis ___ at 6:28 at ___ ___. LIVER AND GALLBLADDER ULTRASOUND: The liver appears diffusely echogenic. The gallbladder demonstrates sludge. The wall is within normal limits in thickness at 3 mm and is not striated in echogenicity; that it appears hypoechoic is because of the hyperechogenicity of the adjacent liver. No sonographic ___ sign was elicited. The common bile duct measures 0.5 cm. The spleen measures 13.6 cm, mildly enlarged. There is no free fluid. The main portal vein is patent. The pancreatic neck and body and superior portions of the head and medial portions of the tailwere visualized and without abnormality; however, the remainder of the pancreas was not clearly visualized on this study. IMPRESSION: 1. Gallbladder with sludge. Gallbladder wall is not thickened and there are no secondary signs of acute cholecystitis. 2. Highly echogenic liver consistent with fatty deposition. However, as the density of the liver on ___ Chest CT was only suggestive of slight fatty deposition, other forms of diffuse liver disease should be considered. 3. Pancreas incompletely visualized on today's study but without duct dilation or abnormality seen. 4. Mild splenomegaly. Initial interpretation was discussed with Dr. ___ at 7:40 p.m. on ___ via telephone by Dr. ___. The final interpretation was discussed by ___ by Telephone with Dr. ___ at 935 am on ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: CP/ HEMATEMESIS Diagnosed with ACUTE PANCREATITIS, NEUTROPENIA, UNSPECIFIED , ANEMIA NOS temperature: 97.6 heartrate: 78.0 resprate: 20.0 o2sat: 98.0 sbp: 140.0 dbp: 79.0 level of pain: 2 level of acuity: 2.0

Mr. ___ is a ___ year old gentleman, with recent admission for relapsed hairy cell leukemia, now s/p 7-day course of cladribine (___), who was transferred from ___ with fever at OSH and abdominal pain, initially concerning for pancreatitis; labs prior to admission were also concerning for acute bleed. Admission was complicated by development of eosinophilia. . .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: gastric outlet obstruction Major Surgical or Invasive Procedure: ___ 1. Laparoscopic reduction of hiatal hernia. 2. Closure of diaphragmatic hiatus. 3. ___ fundoplication. History of Present Illness: ___ M h/o chronic thromboembolic pulmonary HTN on ___, ___ esophagus presents as transfer from OSH with paraesophageal hernia resulting in gastric outlet obstruction. Patient reports being in his usual state of health until 3 days ago when he had epigastric pain and intolerance to PO. He had several episodes of NB/NB emesis (whatever he ate). He has never had these symptoms before. Per patient and wife, he was admitted to ___ on ___ where CT scan demonstrated an paraesophageal hernia resulting in GOO. He had immediate relief of symptoms with NGT decompression. Patient reports that during his hospital course he had an EGD with "attempted decompression of his hernia". It was thought to be successful initially and his NGT was removed yesterday. After attempted PO, he had recurrent symptoms. The NGT was replaced and the patient was transferred to ___ for further management. Patient denies fevers, chills, diarrhea, palpitations, dysphagia, dyspnea. Past Medical History: PMH: HLD, diverticulosis, asthma, ___ esophagus (followed at ___ (last EGD ~ ___ yr ago), colonic adenoma, chronic thromboembolic pulm HTN on ___ (unclear etiology) PSH: b/l inguinal hernia repair at age ___, R shoulder surgery, R wrist surgery Social History: ___ Family History: NC; Denies family history of GI cancer, IBD Physical Exam: VS: 99.1 75 157/96 16 96% Gen: NAD, AOx3 Neck: Trachea midline, supple, no cervical, no supraclavicular lymphadenopathy ___: reg Pulm: CTA-B Abd: Soft, min distended, NT ___: No LLE Pertinent Results: ___ 03:26PM WBC-10.2 RBC-5.11 HGB-14.9 HCT-44.7 MCV-87 MCH-29.2 MCHC-33.5 RDW-14.6 ___ 03:26PM ___ PTT-27.1 ___ ___ 03:26PM GLUCOSE-104* UREA N-21* CREAT-0.9 SODIUM-142 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14 ___ Ba swallow : No evidence of obstruction or leakage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ___ 20 mg PO DAILY 2. Sucralfate 1 gm PO QHS 3. Omeprazole 20 mg PO DAILY 4. Sildenafil 20 mg PO ASDIR Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. Sildenafil 20 mg PO ASDIR 3. Sucralfate 1 gm PO QHS 4. ___ 20 mg PO DAILY 5. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 7. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 8. Milk of Magnesia 30 mL PO Q12H:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Incarcerated diaphragmatic hernia with obstruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with OSH CT with no report // please eval for obstruction hernia TECHNIQUE: MDCT axial images of abdomen and pelvis with intravenous and oral contrast as well as coronal and sagittal reformations were available for review. were . DOSE: DLP: 603 mGy-cm . COMPARISON: None. FINDINGS: LOWER CHEST: Mild bibasilar atelectasis is noted. There is no evidence of pleural or pericardial effusion. ABDOMEN: GENERAL: There is no intra-abdominal free air or free fluid. HEPATOBILIARY: 1 cm hypodensity in the liver segment 4B is likely a simple cyst or biliary hamartoma. The gallbladder is unremarkable. PANCREAS: Unremarkable. SPLEEN: Unremarkable. ADRENALS: Unremarkable. URINARY: There are multiple simple renal cysts bilaterally. Other several hypodensities in bilateral kidneys are too small to be characterized. GASTROINTESTINAL: There is gastric antrum herniating paraesophageally above the diaphragm. The antral wall appears mildly thickened. Only trace amount of oral contrast passes from fundus to antrum at the site of hernia. There is narrowing as the distal part of the stomach passes superiorly into the mediastinum, which may be due to crural mass effect, not necessarily twisted; however, the possibility of obstruction and/or incomplete organoaxial volvulus is not excluded. Colon and small bowel loops demonstrate normal caliber.Appendix is unremarkable. LYMPH NODES: Prominent mesenteric lymph nodes are likely lymph nodes. VASCULAR: Abdominal aorta is normal in caliber. PELVIS: The bladder and prostate are unremarkable. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. IMPRESSION: There is gastric antrum, which appears mildly thickened, herniating paraesophageally above the diaphragm. Enteric contrast in the gastric fundus without significant progression into the antrum. Possibility of obstruction and/or incomplete organoaxial volvulus is not excluded. Radiology Report INDICATION: ___ M h/o chronic thromboembolic pulmonary HTN on ___, ___ OSH txfr w/ paraesophageal hernia w/GOO // pre-op cxr Surg: ___ TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Enteric tube terminates in the stomach. The lungs are well inflated. Linear left lower zone opacity likely linear atelectasis. No lobar consolidation present. No pleural effusion or pneumothorax. Bony thorax is unremarkable. IMPRESSION: No lobar consolidation. Likely left lower lobe linear atelectasis. Radiology Report INDICATION: ___ M s/p paraesophageal hernia repair // please r/o PTX COMPARISON: Radiographs from ___ IMPRESSION: There is subcutaneous emphysema at the base of neck and along the right lateral chest wall. Rounded air-filled structure projects over the left retrocardiac area possibly within a hiatal hernia. Lungs are grossly clear. There is a small left-sided pleural effusion. No pneumothoraces are pneumomediastinum is seen. Radiology Report INDICATION: ___ year old man s/p lap esophageal hernia // interval assesment of PTX COMPARISON: Radiographs from ___ IMPRESSION: There is mild improvement of the subcutaneous emphysema. Heart size is upper limits of normal but stable. There is a left retrocardiac opacity, consistent with prior surgery. Small bilateral effusions are seen. There is no overt pulmonary edema or pneumothoraces. Small amount of free air underneath the right hemidiaphragm is seen. Radiology Report INDICATION: ___ M s/p paraesophageal hernia repair // Interval assesment COMPARISON: Radiographs from ___ IMPRESSION: There is again seen subcutaneous emphysema at the base of the neck. The subcutaneous emphysema along the right lateral chest wall has improved. There is unchanged cardiomegaly. There is a left retrocardiac opacity which likely represents fluid filling the hiatal hernia. Small left-sided pleural effusion is stable. There is no overt pulmonary edema or pneumothoraces. Radiology Report EXAMINATION: Esophagram INDICATION: ___ year old man s/p paraesophageal hernia repair, in need of barium swallow study // barium swallow study please TECHNIQUE: Multiple images of the esophagus and stomach were obtained after the administration of water soluble iodinated contrast, followed by thin barium. COMPARISON: None FINDINGS: Barium flows through the esophagus and into the stomach without evidence of obstruction or leakage. Mild slow transit time through the gastroesophageal junction is likely due to postop inflammation. Contrast is seen passing from the stomach into the proximal small bowel. IMPRESSION: No evidence of obstruction or leakage. Radiology Report INDICATION: Evaluate for interval change in a patient with oxygen desaturation after hernia repair. COMPARISON: Chest radiographs from ___. FINDINGS: Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal silhouette and well-aerated lungs. Retrocardiac opacity is unchanged. There is no new focal consolidation, pleural effusion, or pneumothorax. The visualized upper abdomen demonstrates air distended bowel loops with layering radiodense contrast. Free air under the right hemidiaphragm is decreased. Subcutaneous emphysema is increased. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 99.1 heartrate: 75.0 resprate: 16.0 o2sat: 96.0 sbp: 157.0 dbp: 96.0 level of pain: 0 level of acuity: 3.0

Mr. ___ presented to the ___ on ___ with paraesophageal hernia resulting in gastric outlet obstruction. He was admitted to the thoracic surgery service. A nasogastric tube was placed for decompression initially. Heparin gtt was started for history of chronic thromboembolic pulmonary HTN. He was taken to the Operating Room on ___ and underwent a laparoscopic reduction of hiatal hernia, closure of diaphragmatic hiatus and a Nissen fundoplication. He tolerated the procedure well and returned to the PACU in stable condition. He maintained stable hemodynamics and his pain was controlled with IV Dilaudid. Following transfer to the Surgical floor he continued to progress well. A barium swallow was done on ___ which showed no leak and he was placed on a liquid diet which he tolerated well. He was up and walking independently and his port sites were dry. His oxygen saturations were only 94% on 4L on post day #1, possibly due to pain inhibiting his deep breathing. He was switched to oral Dilaudid and was better. He was able to be weaned off of oxygen and his ambulatory room air saturations were 95%. His pre op ___ was resumed on post op day #1. After an uncomplicated recovery he was discharged to home on ___ and will follow up in the Thoracic Clinic in 2 weeks.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ceclor / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: nausea, vomiting/malaise Major Surgical or Invasive Procedure: ___: ___ ___ drain to bulb drainage for collection left thorocentesis History of Present Illness: ___ y/o F with a h/o hypothyroidism presents to the ED as a transfer from ___ with L pleural effusion. Patient was a pedestrian struck by a car in ___ with a splenic embolization, L rib fracture, and L femur fracture. She was discharged from rehab 1 week ago and was seen at her PCP on ___. At her PCP's, she was found to have Afib (previously had in the past but was corrected) and new diabetes so she was started on Coumadin and Metformin. She was also placed on antibiotics for a UTI and possible sinus infection. She presented today to ___ with palpitations, nausea, vomiting and diarrhea. Per EMS, patient was found to have left pleural effusion with a large splenic air and fluid collection. She was brought here for further evaluation and treatment. She is followed by Dr. ___. She currently denies any pain or discomfort. Past Medical History: HTN, Afib not on anticoagulation, Burn to torso as child, Nonegastric bypass, B/L knee replacement surgery, cholecystectomy, hand surgery Social History: ___ Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION upon admission: ___ Temp: 99.4 HR: 107 BP: 123/79 Resp: 18 O(2)Sat: 98 Normal Constitutional: Constitutional: comfortable Head / Eyes: NC/AT ENT: OP WNL Resp: CTAB Cards: RRR. s1,s2. no MRG. chest wall tendenress Abd: S/NT/ND Flank: no CVAT Skin: no rash Ext: No c/c/e; L leg in CAM device Neuro: speech fluent Psych: normal mood Physical examination: upon discharge: vital signs: 99.7, hr=69, 148/77, rr=18, 96% room air GENERAL: NAD CV: Ns1, s2, no murmurs LUNGS: clear left side, diminished right lateral ABDOMEN: soft, non-tender, DSD left abdominal drain site EXT: Bledoe brace left leg, no pedal edema bil, no calf tenderness NERURO: alert and oriented x 3, speech clear, no tremors Pertinent Results: ___ 05:00AM BLOOD WBC-6.4 RBC-3.64* Hgb-9.1* Hct-30.6* MCV-84 MCH-25.0* MCHC-29.7* RDW-18.3* RDWSD-56.2* Plt ___ ___ 09:53AM BLOOD WBC-7.0 RBC-3.87* Hgb-9.6* Hct-32.4* MCV-84 MCH-24.8* MCHC-29.6* RDW-18.3* RDWSD-53.9* Plt ___ ___ 01:06PM BLOOD WBC-10.0 RBC-4.04 Hgb-10.0* Hct-33.3* MCV-82 MCH-24.8* MCHC-30.0* RDW-17.9* RDWSD-52.9* Plt ___ ___ 10:43PM BLOOD WBC-7.9 RBC-4.02# Hgb-10.0* Hct-33.1*# MCV-82 MCH-24.9* MCHC-30.2* RDW-17.7* RDWSD-50.1* Plt ___ ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD ___ ___ 05:00AM BLOOD Glucose-196* UreaN-12 Creat-0.3* Na-137 K-4.2 Cl-99 HCO3-25 AnGap-17 ___ 09:53AM BLOOD Glucose-312* ___-9 Creat-0.4 Na-137 K-3.8 Cl-98 HCO3-22 AnGap-20 ___ 06:28AM BLOOD Glucose-133* UreaN-8 Creat-0.2* Na-137 K-3.8 Cl-100 HCO3-24 AnGap-17 ___ 05:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2 ___ 09:53AM BLOOD Free T4-1.4 ___: ___ drain: FINDINGS: 1. Limited grayscale ultrasound imaging of the left upper abdomen demonstrated a mildly complex ___ collection. 2. Successful placement of ___ all-purpose drain within the collection. A very small volume was able to be aspirated with appearance of hematoma. 3. A small volume of aspirate was sent to the laboratory for analysis. IMPRESSION: Successful placement of ___ F all-purpose drain with in the ___ collection. ___: pleural aspirant: IMPRESSION: Successful ultrasound-guided thoracentesis on the left. ___: ct abd. /pelvis: 1. Patent portal veins. 2. Moderate ___ collection measures 9.3 x 8.4 x 7.6 cm. 3. Known hepatic segment VIII/VII infarction. 4. Heterogeneous area of enhancement at the junction of the right and left hepatic lobes likely represent vascular shunting but correlate with LFTs. 5. Persistent large pleural effusion at the left lung base. ___ 6:43 pm ABSCESS Source: Splenic Abscess. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Calcium Carbonate 500 mg PO BID:PRN Heartburn 4. Docusate Sodium 100 mg PO BID 5. Coumadin 6. Lidocaine 5% Patch 1 PTCH TD QAM pain 7. Omeprazole 20 mg PO DAILY 8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN 9. Senna 8.6 mg PO BID:PRN constipation 10. Amphetamine-Dextroamphetamine 30 mg PO BID 11. Citalopram 20 mg PO DAILY 12. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY 13. Metoprolol Succinate XL 100 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H last dose ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*15 Tablet Refills:*0 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. ___ MD to order daily dose PO DAILY16 daily ___ dosing as per PCP 9. Citalopram 20 mg PO DAILY 10. Metoprolol Succinate XL 100 mg PO QHS 11. Omeprazole 20 mg PO DAILY 12. Zolpidem Tartrate 2.5 mg PO QHS Discharge Disposition: Home With Service Facility: ___ ___: left pleural effusion ___ collection 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: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ h/o Afib newly on Coumadin ped vs veh s/p ___ embo splenic aa. L ___ rib, humerus, femur fx managed nonop p/w dyspnea/malaise, N/V CT w/ L pleural effusion splenic abscess // evaluate extent of splenic collection, evaluate portal vein latency 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 not 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 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy (Body) DLP = 17.4 mGy-cm. 3) Spiral Acquisition 13.9 s, 47.8 cm; CTDIvol = 11.1 mGy (Body) DLP = 513.5 mGy-cm. Total DLP (Body) = 545 mGy-cm. COMPARISON: Outside facility chest CT ___ FINDINGS: LOWER CHEST: There is a large non-hemorrhagic pleural effusion on the left, partially imaged. No pleural effusion on the right. ABDOMEN: HEPATOBILIARY: There is a wedge shaped hypodensity involving hepatic segment VIII/VII, which appears similar to ___, and consistent with a hepatic infarction. Heterogeneous enhancement is noted at the junction of the right and left hepatic lobes, with suggestion of tiny nodular foci; this is a non-specific finding, and may be perfusional. Minimal intrahepatic and extrahepatic biliary dilation are likely within normal limits post-cholecystectomy. The gallbladder is surgically absent. Portal vein is patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: There is a perisplenic collection containing air that measures 9.3 x 8.4 x 7.6 cm AP x TV x CC (5:23). Interval placement of a pigtail catheter within this collection. 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 hydronephrosis. Subcentimeter hypodensities in the right kidney are too small to characterize, but statistically likely represent cysts. There is no perinephric abnormality. GASTROINTESTINAL: Patient is status post prior gastric bypass surgery. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. Normal appendix. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is lobular in appearance with hypodense lesions, likely representing necrotic fibroids. 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. Patient is status post distal splenic artery coil embolization. BONES: There are chronic left-sided rib fractures. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Patent portal veins. 2. Moderate perisplenic collection measures 9.3 x 8.4 x 7.6 cm. 3. Known hepatic segment VIII/VII infarction. 4. Heterogeneous area of enhancement at the junction of the right and left hepatic lobes likely represent vascular shunting but correlate with LFTs. 5. Persistent large pleural effusion at the left lung base. Radiology Report EXAMINATION: Ultrasound-guided thoracentesis INDICATION: ___ year old woman with left pleural effusion. TECHNIQUE: Ultrasound guided therapeutic thoracentesis on the left. COMPARISON: Outside hospital CT chest dated ___ FINDINGS: Limited grayscale ultrasound imaging of the left hemithorax demonstrated a moderate volume of simple appearing pleural fluid. A suitable target in the deepest pocket in the left mid axillary line was selected for thoracentesis. PROCEDURE: The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. A preprocedure time-out was performed discussing the planned procedure, confirming the patient's identity with 3 identifiers, and reviewing a checklist per ___ protocol. Under ultrasound guidance, an entrance site was selected and the skin was prepped and draped in the usual sterile fashion. 1% lidocaine was instilled for local anesthesia. A ___ catheter was advanced into the largest fluid pocket in the left mid-axillary line and 500 mL of clear straw-colored fluid was removed. The patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. IMPRESSION: Successful ultrasound-guided thoracentesis on the left. Radiology Report INDICATION: ___ year old woman with splenic abscess. COMPARISON: Outside hospital CT chest dated ___ TECHNIQUE: OPERATORS: Dr. ___ fellow and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 200 mcg of fentanyl and 4 mg of midazolam throughout the total intra-service time of 50 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected subcutaneously at the access site. MEDICATIONS: As above. CONTRAST: 5 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.5 min, 6.4 mGy PROCEDURE: 1. Limited left upper quadrant abdominal ultrasound 2. Placement of perisplenic ___ all-purpose drain The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. The abdomen was cleaned and draped in standard sterile fashion. A pre-procedure time-out was performed as per ___ protocol. Under ultrasound guidance, an entrance site was selected in the left intercostal mid axillary line. 1% lidocaine was instilled for local anesthesia. Under direct ultrasound guidance, an 18 gauge needle was advanced into the perisplenic collection. Aspiration was unsuccessful. A small volume of contrast was injected to confirm location. A ___ wire was advanced through the needle. After a skin ___ was made over the needle, the needle was removed. An ___ dilator was advanced over the wire to dilate the entrance site. The dilator was removed and a ___ all-purpose drain was advanced over the wire into the perisplenic collection. The drain was advanced over its metal stiffener. The metal stiffener was removed and the pigtail was formed. A small hand contrast injection confirmed placement. A small volume of perisplenic hematoma was aspirated and sent to the laboratory. The catheter was secured with 0 silk suture and attached to a JP bulb. Sterile dressings were applied. The patient tolerated the procedure well and there no immediate postprocedure complications. FINDINGS: 1. Limited grayscale ultrasound imaging of the left upper abdomen demonstrated a mildly complex perisplenic collection. 2. Successful placement of ___ all-purpose drain within the collection. A very small volume was able to be aspirated with appearance of hematoma. 3. A small volume of aspirate was sent to the laboratory for analysis. IMPRESSION: Successful placement of ___ F all-purpose drain with in the perisplenic collection. RECOMMENDATION: Please keep the drain to JP bulb drainage. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, Palpitations Diagnosed with Pleural effusion, not elsewhere classified temperature: 99.4 heartrate: 107.0 resprate: 18.0 o2sat: 98.0 sbp: 123.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

___ year old female who was admitted to the hospital on ___ after being a struck by a car. As a result of the accident, she sustained a splenic laceration, left sided ___ rib fractures, and a left humerus and femur fracture. Her fractures were managed non-operatively by the Orthopedic surgery service. She underwent a splenic arteriogram and was reported to have active extravasation from a splenic arterial branch and underwent ___ embolization. She was discharged to a rehabilitation facility of ___ and discharged home 1 week ago. Since that time she noted malaise, dyspnea, nausea, vomiting and diarrhea. She also reported a decreased appetite. During a ___ visit, she was found to be in atrial fibrillation with a heart rate of 130. She was started on anti-coagulation. She presented to the emergency room on ___ for further evaluation. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. Imaging studies showed a left pleural effusion and ___ collection. The patient was taken to ___ where a drain was placed into the ___ collection. Fluid was aspirated and a culture was sent. The patient was started on a course of Zosyn. Results of the culture showed no micro-organisms. During the patient's hospitalization, she had bouts of rapid atrial fibrillation which was controlled with intravenous metoprolol along with her home dose. Electrolytes were monitored and repleted. She was noted to have a decreased TSH and instructed to follow-up with her Endocrinologist. The patient continued on Coumadin with daily dosing and monitoring of ___. The ___ drain was removed by radiology on ___ after it was reported to have minimal output despite normal saline flushes and instillation of TPA. The patient prepared for discharge home on ___. Her vital signs were stable and she was afebrile. Her white blood cell count normalized. She was tolerating a regular diet and voiding without difficulty. Her heart rate normalized and intravenous metoprolol was discontinued. An appointment for follow-up was made with the Acute care service with a scheduled abdominal cat scan prior to the visit. The patient was instructed to follow-up with her primary care provider, ___, and Endocrinologist. ___ services were arranged to monitor the patient's cardiovascular status and ___ for Coumadin dosing. The patient was instructed to complete a week course of amoxicillin. Her daughter was present when the discharge instructions were reviewed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: vancomycin Attending: ___. Chief Complaint: Coughing up blood and right leg pain Major Surgical or Invasive Procedure: ___ -- Bronchoscopy History of Present Illness: Mr. ___ is a ___ man with no past medical history and low utilization of medical care who presented to ___ with one week of hemoptysis, chest pain, and right leg pain and weakness, found to have a new lung mass consistent with malignancy, and transferred to ___ out of concern for metastasis to the spine. ___ was in his normal state of health until five days ago, when he developing a deep pain on the right side of his back that radiated down to his knee. Prior to this, he was able to walk easily, including climbing stairs, but now he noted that walking was much more difficult, and he walked with a limp. He stated this was due to both pain and weakness. He also complained of a deep chest pain "like my chest was caved in" that was associated with coughing up a mixture of bright red blood, clots, and sputum. This happened several times a day, and was never of large volume. He denied fevers, but has had chills over the past several weeks, and night sweats several times a week, requiring him to change clothes. He also has had new onset of migraines in the last two months -- severe bilateral headaches. No stool incontinence, no saddle anesthesia. No weakness in his upper extremities. No changes in vision or hearing. Numbness in his RLE, but nowhere else. No mouth abscesses. No swollen lymph nodes. No abdominal pain. At ___, vitals notable for temp 98.3, BP 179/85. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. He had an initial chest x-ray which showed: Left lower lobe pneumonia. Focal hemorrhage is in the differential. Follow-up chest x-rays in 6 weeks is recommended to ensure resolution. Because of his leg weakness, a head CT was obtained, which showed: No acute intracranial process by CT. Mild age-related atrophy with chronic small vessel ischemic change of the periventricular white matter. Finally, a CTA abd/pelvis was obtained which showed: No CT evidence for thoracoabdominal aortic dissection. Large medial left lower lobe lung mass measuring up to 8.9 cm in sagittal dimension of concern for carcinoma abuts the medial pleura. Small subcarinal lymph node. Because of his leg weakness/pain, and new diagnosis of presumed metastatic lung cancer, he was transferred to ___. In the ___ ED, a code cord was called and an MRI of his spine was obtained, which showed: Cord or cauda equina compression: yes, posterior disc bulge and ligamentum flavum hypertrophy at C3-4 causes cord compression with abnormal cord signal at this level (7; 18). Posterior disc bulge, facet arthropathy, ligamentum flavum hypertrophy cause cauda equina compression at L5-S1. There is severe spinal canal stenosis at C5-6, C6-7, T2-3, and L4-5 with cord/cauda equina deformation, however a posterior rim of CSF remains visible. Neurosurgery evaluated, and their preliminary recommendations are that this is degenerative changes, not requiring an acute intervention. With this, he was admitted to the medicine service for expedited work up of his presumed lung malignancy. Past Medical History: 1. HTN 2. HLD 3. Chronic back pain Social History: ___ Family History: No family history of malignancy. Physical Exam: ADMISSION EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Poor dentition, no dental abscesses note. CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: No wheezes, normal I:E ratio. Normal breath sounds, in left midlung, dullness to percussion. No dullness at the bases. GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: CN II-XII tested, and are intact. UE ___, RLE hip flexion, fleg flexion, extension, plantar/dorsiflexion of foot all ___. Patellar reflexes are brisk bilaterally. Decreased sensation to light touch over the left shin and foot. PSYCH: pleasant, appropriate affect DISCHARGE EXAM: VITALS: ___ 0752 Temp: 98.1 PO BP: 148/62 HR: 60 RR: 18 O2 sat: 93% O2 delivery: RA ___ ___ Dyspnea: 9 RASS: 0 Pain Score: ___ ___ 0920 Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. HEENT: NCAT, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. No pain to palpation of chest. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: No lower leg edema DERM: No active rash. Neuro: moves all four extremities, non-focal. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS -------------- ___ 07:26AM BLOOD WBC-7.1 RBC-4.91 Hgb-14.3 Hct-43.9 MCV-89 MCH-29.1 MCHC-32.6 RDW-13.1 RDWSD-42.5 Plt ___ ___ 11:30PM BLOOD Neuts-71.8* Lymphs-18.0* Monos-6.8 Eos-2.5 Baso-0.7 Im ___ AbsNeut-7.07* AbsLymp-1.77 AbsMono-0.67 AbsEos-0.25 AbsBaso-0.07 ___ 07:26AM BLOOD Glucose-85 UreaN-16 Creat-1.0 Na-144 K-4.4 Cl-105 HCO3-26 AnGap-13 ___ 11:30PM BLOOD ALT-17 AST-16 AlkPhos-82 TotBili-0.4 ___ 11:30PM BLOOD Lipase-14 ___ 11:30PM BLOOD cTropnT-<0.01 ___ 11:30PM BLOOD Albumin-4.1 ___ 11:42PM BLOOD Lactate-1.2 IMAGING ------- CXR ___: 1. No pneumothorax. 2. Redemonstration of the left lower lobe lobulated mass. Bronchoscopy cytology brushing ___: Positive for squamous cell carcinoma MICROBIOLOGY ------------ Urine culture ___: negative DISCHARGE LABS -------------- ___ 07:10AM BLOOD WBC-9.5 RBC-4.73 Hgb-13.7 Hct-42.1 MCV-89 MCH-29.0 MCHC-32.5 RDW-12.9 RDWSD-42.3 Plt ___ ___ 07:10AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-141 K-4.4 Cl-104 HCO3-26 AnGap-11 Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 3. Gabapentin 200 mg PO BID RX *gabapentin 100 mg 2 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 4. Lidocaine 5% Patch 2 PTCH TD QAM RX *lidocaine 5 % 1 patch daily Disp #*10 Patch Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN moderate to severe RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Lung cancer Cervical stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: History: ___ with new cancer diagnosis, leg weaknessIV contrast to be given at radiologist discretion as clinically needed// eval compression; new diagnosis likely lung cancer with new leg numbness. Please prioritize lumbar, then thoracic, then cervical. eval compression; new diagnosis likely lung cancer with new leg numbness. Please prioritize lumbar, then thoracic, then cervical., eval compression; new diagnosis likely lung cancer with new leg numbness. Please prioritize lumbar, then thoracic, then cervical., eval compression; new diagnosis likely TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. COMPARISON: CT of the chest, abdomen and pelvis dated ___. FINDINGS: Large 5.6 cm mass left lower lobe, better seen on CT chest ___. Exam is moderately motion degraded. CERVICAL: There is straightening of the normal cervical lordosis.There is mild multilevel loss of vertebral body height. Disc osteophyte complexes with hypertrophy of the ligamentum flavum are seen at C2-3, C3-4, C4-5, C5-6 and C6-7. Posterior element hypertrophic changes. Congenital narrowing spinal canal. C2-C3: Moderate central canal narrowing, mild cord flattening, preserved CSF, moderate to severe bilateral foraminal narrowing. At C3-C4 level there is severe central canal narrowing, central bright T2 signal within both hemi cords, most consistent with spondylotic myelomalacia. Cord flattening. Moderate severe bilateral foraminal narrowing. At C4-C5 level there is moderate central canal narrowing, mild cord flattening. Moderate to severe bilateral foraminal narrowing. At C5-6 level there is severe central canal narrowing, cord flattening, equivocal cord edema. Moderate to severe bilateral foraminal narrowing. At C6-C7 level there is moderate to severe central canal narrowing, no definite cord edema. Moderate bilateral foraminal narrowing. At C7-T1 level, mild central canal narrowing. Mild-to-moderate bilateral foraminal narrowing. THORACIC: Alignment is normal.Mild multilevel loss of vertebral body height and intervertebral disc signal intensity is seen.No cord T2 signal abnormality. Disc bulges with hypertrophy ligamentum flavum are seen at T2-3, T3-4, T4-5, T10-11 and T11-12. T1-T2 level: Mild central canal narrowing, severe bilateral foraminal narrowing. T2-T3: Moderate central canal narrowing. Severe bilateral foraminal narrowing.. T3-T4: Mild-to-moderate central canal narrowing. Moderate left, mild right foraminal narrowing.. T4-T5: Mild central canal narrowing. Moderate bilateral foraminal narrowing.. Mild central canal narrowing T10-T11, T11-T12, mild-to-moderate central canal narrowing T12-L1 level LUMBAR: Transitional anatomy is seen with partial lumbarization of L5. There is mild levoconvex curvature of the lumbar spine with the apex at L3. There is mild multilevel loss of vertebral height. Mild endplate edema L 2, L3, L4, L5 levels, likely reactive. No worrisome osseous lesions. The spinal cord appears normal in caliber and configuration and terminates at L1.Disc bulges with hypertrophy of the ligamentum flavum and facets are seen at T12-L1, L1-L 2, L2-L3, L3-L4 and L4-L5. Postoperative changes lower lumbar spine. Advanced facet arthritis. T12-L1: Mild central canal narrowing. Mild bilateral foraminal narrowing. L1-L2: Small right paramedian, inferior disc protrusion, measures 5 mm in AP diameter, narrowed lateral recess, mild mass effect on traversing right L2 nerve, mild-to-moderate central canal narrowing. Mild-to-moderate bilateral foraminal narrowing. L2-L3: Moderate spinal canal. Mild left, moderate right foraminal narrowing. L3-L4: Severe spinal canal narrowing with clumping of the nerve roots. Moderate to severe bilateral foraminal narrowing. L4-L5: Mild facet arthropathy. Severe spinal canal narrowing with clumping of the nerve roots. Severe right, moderate to severe left foraminal narrowing. L5-S1: No spinal canal or foraminal narrowing. OTHER: Subcentimeter benign simple cyst left kidney. Prominent extrarenal pelvis bilaterally. Mild thickening left adrenal gland. IMPRESSION: 1. Large mass left lower lobe, consistent with malignancy. 2. Advanced degenerative changes cervical spine, with areas of moderate, and severe central canal narrowing, cord flattening, worse at C3-C4 level. Findings most consistent with spondylotic myelomalacia at C3-C4 level. Multilevel significant foraminal narrowing cervical spine. 3. Partial lumbarization L5 level, for counting purposes. 4. Severe central canal narrowing L3-L4, L4-5 level. 5. Multilevel significant foraminal narrowing lumbar spine, as above. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:08 am, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: MRI of the brain with and without contrast. INDICATION: ___ year old man with new diagnosis of metastatic lung cancer, with left lower leg weakness. Spine with chronic changes. MRI for staging and diagnostic purposes.// Please evaluate for brain metastasis. TECHNIQUE: Planned protocol was for multisequence, multiplanar MR images of the head both prior to and following the weight based intravenous administration of gadolinium-based contrast, per departmental protocol. Following acquisition of 3-plane localizer images and sagittal T1 weighted images, the patient endorsed significant claustrophobia and declined further imaging. The following report is based on the provided images. COMPARISON: Unenhanced head CT ___. FINDINGS: 3-plane localizer images and sagittal T1 weighted images were obtained. Available images are markedly motion-degraded. Grossly, sagittal T1 images demonstrate normal midline structures including a fully formed corpus callosum and normal appearance of the sella turcica. No definite evidence of intracranial mass-effect. Further assessment is precluded. IMPRESSION: Nondiagnostic study, with only limited MR scout and sagittal T1-weighted images obtained, as the patient endorsed claustrophobia, and declined further imaging. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: Post bronchoscopy. Rule out pneumothorax. TECHNIQUE: AP radiograph of the chest. COMPARISON: Outside reference chest radiograph ___. Outside reference CT torso ___. FINDINGS: There is redemonstration of the lobulated mass in the left lower lobe. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. There are no acute osseous abnormalities. IMPRESSION: 1. No pneumothorax. 2. Redemonstration of the left lower lobe lobulated mass. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: ___ year old man with hemoptysis s/p bronchoscopy// Hemorrhage? Pneumothorax? TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___ at 15:55 FINDINGS: There is redemonstration of the lobular mass in the left lower lobe. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. IMPRESSION: Redemonstration of the lobular mass in the left lower lobe. No pneumothorax. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with new diagnosis of metastatic lung cancer, with left lower leg weakness. Spine with chronic changes. MRI for staging and diagnostic purposes. Eval for brain metastases. 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: CT head without contrast dated ___ from outside facility. FINDINGS: Examination is mildly degraded by motion. There is no evidence of acute intracranial hemorrhage, edema, masses, or acute infarction. Tiny focus of susceptibility artifact in the left cerebellum on gradient recalled echo images likely represents microhemorrhage. The ventricles and sulci are age-appropriate in size and configuration with no mass effect or midline shift. Patchy to confluent areas of T2 and FLAIR hyperintense signal abnormalities in the periventricular and subcortical white matter are nonspecific, but likely reflect chronic small vessel ischemic changes. No abnormally enhancing lesions or masses are seen. No leptomeningeal enhancement is definitively visualized. The major intracranial arterial flow voids are preserved. The dural venous sinuses are patent. There is mild mucosal thickening of the ethmoid sinuses. The mastoid air cells are clear. Unremarkable intraorbital contents. IMPRESSION: 1. No convincing evidence of metastatic disease. No evidence of abnormal enhancing lesions are left meningeal enhancement normal exam is limited due to artifact. 2. No evidence of acute infarction or intracranial hemorrhage. 3. Moderate chronic small vessel ischemic disease. Radiology Report EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE INDICATION: ___ year old man with worsening of long standing cervical and back pain. Stenosis of cervical spine seen on earlier MRI a few day ago but Ortho spine is recommending dedicated cervical MRI for better evaluation. Cervical pain. TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique. Axial T2 and gradient echo imaging were next performed. COMPARISON: MRI cervical spine dated ___. FINDINGS: Examination is mildly degraded by motion. There is unchanged straightening of the normal cervical lordosis which may relate to patient positioning or muscle spasm. There is mild multilevel loss of vertebral body height. There is a 6 mm cystic lesion in the tip of the dens. There is multilevel disc desiccation. There is multilevel ligamentum flavum thickening, uncovertebral joint hypertrophy, and facet joint hypertrophy. The spinal cord appears normal in caliber and configuration without evidence of edema. C2-C3: Disc bulge with effacement of the ventral and dorsal CSF spaces and flattening along the ventral aspect of the cord. Mild to moderate spinal canal and moderate to severe bilateral neural foraminal narrowing. C3-C4: Disc bulge with effacement of the ventral and dorsal CSF spaces and flattening along the ventral aspect of the cord. Signal abnormalities within the spinal cord are consistent with spondylotic myelomalacia (image 16 of series 14). Severe spinal canal and moderate to severe bilateral neural foraminal narrowing. C4-C5: Disc bulge with superimposed disc protrusion and mild flattening of the ventral aspect of the cord. Moderate spinal canal narrowing and moderate to severe bilateral neural foraminal narrowing. C5-C6: Disc bulge with effacement of the ventral and dorsal CSF spaces and deformation of the spinal cord. Mild-to-moderate spinal canal narrowing and moderate to severe bilateral neural foraminal narrowing. C6-C7: Disc bulge with effacement of the ventral and dorsal CSF spaces and flattening along the ventral aspect of the cord. Moderate spinal canal narrowing and moderate to severe bilateral neural foraminal narrowing. C7-T1: Mild spinal canal narrowing and moderate bilateral neural foraminal narrowing. The paraspinal muscles are unremarkable. IMPRESSION: 1. Severe multilevel multifactorial degenerative disc disease of the cervical spine as described above. 2. Spondylotic myelomalacia of the spinal cord seen at C3-C4. 3. Severe spinal canal stenosis at C3-4 level and moderate spinal canal narrowing at C4-5 and C6-7 levels. 4. Multilevel moderate-to-severe foraminal changes as described above. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hemoptysis, L Leg weakness Diagnosed with Hemoptysis temperature: 97.9 heartrate: 58.0 resprate: 18.0 o2sat: 93.0 sbp: 179.0 dbp: 76.0 level of pain: 4 level of acuity: 2.0

Mr. ___ is a ___ year-old man who presented with acute onset of chest pain and hemoptysis and was found to have newly diagnosed likely metastatic lung cancer. He receieved a bronchoscopy and biopsy on ___, which showed squamous cell carcinoma. MRI of his head was obtained for staging, which showed no malignancy. He will receive a PET scan as an outpatient. He will follow up with Oncology soon after discharge. # New presumed metastatic lung CA: Bronchoscopy done by IP, biopsy back with moderately differentiated squamous cell carcinoma. MRI brain did not show any evidence of metastases. He will follow up with Oncology soon after discharge, and PET scan will be performed as an outpatient. He had chest and back pain treated with oxycodone and acetaminophen. # Concer for cauda equina compression and left lower leg weakness. A code cord was obtained in the emergency room, but the MRI of his spine showed only degenerative changes. He will need to follow up with Dr. ___ in the ___. A cervical MRI is being repeated for better images as per Dr. ___ and was negative for compression. # Hypertension: continued amlodipine 10 mg. # Social: patient is not happy with the place where he currently lives. Social Work saw the patient and was given information about Rest Homes, a possible supportive housing option available through ___. An advocacy letter can also be provided by Oncology team once he has a clear diagnosis to give him extra help for housing and transportation. TRANSITIONS OF CARE ------------------- # Follow-up: patient will follow up with Oncology following discharge, and will need to get a PET scan. He should also follow up with the Spine team within one week, as well as his PCP. # Code Status/ACP: full code (please also see current POE order)

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: nausea/vomiting/epigastric pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of HLD and anxiety who presents for nausea, vomiting, and bradycardia. She says that a few days ago she was removing a tightly-fitted bra and immediately felt nauseated afterwards. Her nausea has continued since. This has caused her to vomit ___ times the past few days. Nausea is constant and she has been unable to tolerate much oral intake. She denies abdominal pain, constipation, diarrhea, or dysuria. She was evaluated by her PCP who obtained an EKG and noted that her heart rate was sinus in the ___ (she has no history of bradycardia). CXR obtained showed increased interstitial markings from prior study in ___ concerning for CHF. She was referred to ED for possible CHF exacerbation and further investigation into possible pacemaker for new bradycardia. In the ED, initial vitals were: T 98.4, P 40, BP 134/56, RR 16, O2sat 98% Nasal Cannula Labs notable for: UA with few bacteria and small leukocytes Normal CBC and chem-7 Negative trop Imaging notable for: RUQ US @ ___ ___. Unremarkable appearance of the gallbladder and biliary tree. 2. Unchanged heterogenous appearance of the liver parenchyma. CXR @ ___ ___. Increased interstitial markings compared to ___ suggest pulmonary edema. 2. New, somewhat linear small opacity at the left base could represent atelectasis, aspiration, pneumonia, or projectional artifact. Patient was given IV Lorazepam .25 mg Cardiology was consulted and recommended admission for possible pacemaker placement. Vitals prior to transfer were T 98.1, P 40, BP 129/78, RR 18, O2sat 95% on RA On the floor, patient endorsed some continued nausea but denied abdominal pain. She denied chest pain, orthopnea, and lower extremity swelling. She endorsed exertional dyspnea but stated that this has been stable for the past ___ years. Past Medical History: Anxiety controlled on medication History of painful neuropathy of her feet History of hypercholesterolemia Urinary frequency Social History: ___ Family History: No family history of heart disease. Physical Exam: ADMISSION PHYSICAL EXAM: ==================== Vital Signs: T 97.7, BP 156/57, P 38, RR 18, O2sat 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: bradycardic, normal rhythm, no murmurs Lungs: slight crackles on LLL Abdomen: slightly TTP in epigastric region, otherwise benign abdomen GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength in upper and lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM: ==================== VS - T 98.2-98.5, BP 102-134/59-60, P ___ , RR ___, O2sat 96-97% on RA General: no acute distress, appears comfortable HEENT: Sclera anicteric, JVP not elevated CV: RRR, no murmurs, rubs, or gallops Lungs: CTA anteriorly Abdomen: nontender, nondistended, normoactive bowel sounds GU: No foley Ext: Warm, well perfused, +reticulated and varicose veins, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact Pertinent Results: ADMISSION LABS: =============== ___ 06:15PM BLOOD WBC-9.2 RBC-4.43# Hgb-13.3# Hct-40.7# MCV-92# MCH-30.0 MCHC-32.7 RDW-13.3 RDWSD-45.0 Plt ___ ___ 06:15PM BLOOD Neuts-78.7* Lymphs-13.8* Monos-7.0 Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.24* AbsLymp-1.27 AbsMono-0.64 AbsEos-0.00* AbsBaso-0.01 ___ 06:15PM BLOOD ___ PTT-26.8 ___ ___ 06:15PM BLOOD Glucose-106* UreaN-21* Creat-0.7 Na-139 K-4.1 Cl-107 HCO3-22 AnGap-14 ___ 06:15PM BLOOD CK(CPK)-194 ___ 06:15PM BLOOD Lipase-20 ___ 06:15PM BLOOD CK-MB-6 cTropnT-<0.01 ___ 06:54PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM ___ 06:54PM URINE RBC-0 WBC-6* Bacteri-FEW Yeast-NONE Epi-0 OTHER RELEVANT LABS: ================== ___ 06:15AM BLOOD ALT-16 AST-25 LD(LDH)-208 AlkPhos-57 TotBili-0.4 ___ 06:15AM BLOOD TSH-5.7* ___ 06:15AM BLOOD Free T4-1.5 DISCHARGE LABS: ================= ___ 07:00AM BLOOD WBC-7.6 RBC-5.10 Hgb-15.1 Hct-46.6* MCV-91 MCH-29.6 MCHC-32.4 RDW-13.4 RDWSD-44.6 Plt ___ ___ 07:00AM BLOOD Glucose-92 UreaN-23* Creat-1.0 Na-139 K-4.5 Cl-101 HCO3-27 AnGap-16 ___ 07:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2 IMAGING: ================= CT Abdomen and Pelvis with Contrast (___) IMPRESSION: 1. No small bowel obstruction 2. Extensive colonic diverticulosis without evidence of diverticulitis 3. 2.5 cm aneurysm of the left internal iliac artery with mural thrombus. Ectasia of the infrarenal abdominal aorta. ECHO (___): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic regurgitation. Medications on Admission: 1. Simvastatin 20 mg PO QPM 2. Multivitamins 1 TAB PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Citalopram 20 mg PO DAILY 5. TraZODone 100 mg PO QHS 6. Oxybutynin 5 mg PO DAILY 7. LORazepam 0.5 mg PO DAILY:PRN anxiety 8. Gabapentin 300 mg PO QAM 9. Gabapentin 600 mg PO QPM Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Ranitidine 300 mg PO QHS 4. Senna 8.6 mg PO BID 5. Citalopram 20 mg PO DAILY 6. Gabapentin 300 mg PO QAM 7. Gabapentin 600 mg PO QPM 8. LORazepam 0.5 mg PO DAILY:PRN anxiety 9. Multivitamins 1 TAB PO DAILY 10. Simvastatin 20 mg PO QPM 11. TraZODone 100 mg PO QHS 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Nausea Sinus bradycardia 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: CT the abdomen and pelvis INDICATION: NO_PO contrast; History: ___ with vomiting, nauseaNO_PO contrast // evaluate for small bowel obstruction 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: Total DLP (Body) = 886 mGy-cm. COMPARISON: CT abdomen pelvis from ___ and ultrasound of the abdomen from ___ FINDINGS: LOWER CHEST: Visualized lung fields show bibasilar atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, 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 hydronephrosis. There is no perinephric abnormality. Bilateral kidney interpolar region and left upper pole subcentimeter hypodensities which are too small to characterize but may be cysts. Ultrasound could be considered for further evaluation GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon shows extensive diverticulosis without diverticulitis. The appendix is not seen. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is ectasia of the infrarenal aorta, measuring up to 2.5 cm. Mild aortic atherosclerotic disease is noted. Aneurysm of the left internal iliac artery with mural thrombus, measuring up to 2.5 cm. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Evidence of prior right-sided healed rib fractures. Degenerative changes. Left screw fixation across the femoral neck with surrounding heterotopic ossification. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No small bowel obstruction 2. Extensive colonic diverticulosis without evidence diverticulitis 3. 2.5 cm aneurysm of the left internal iliac artery with mural thrombus. Ectasia of the infrarenal abdominal aorta. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Bradycardia Diagnosed with Bradycardia, unspecified temperature: 98.4 heartrate: 40.0 resprate: 16.0 o2sat: 98.0 sbp: 134.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a ___ female with a history of HLD and anxiety who presents with nausea, vomiting, and bradycardia. #Sinus bradycardia: Patient presented with sinus bradycardia, intermittently with HRs in the ___. This was thought to be secondary to increased vagal tone from her nausea/vomiting. She experienced no syncope or lightheadedness. This improved with management of her GI symptoms (see below). At time of discharge, her heart rate was in the ___ in normal sinus rhythm. Of note, citalopram has occasionally been associated with sinus bradycardia so patient was discontinued from this medication. However, after the development of her GI symptoms concerning for citalopram withdrawal and due to the fact that the patient but has been on this medication for years, she was restarted on citalopram. Her heart rate improved again while on citalopram. She has no history concerning for CHF or MI and no current symptoms/EKG findings for current MI. She was evaluated by electrophysiology who recommended no pacemaker placement emergently at this time. ECHO was notable for normal global and regional biventricular systolic function and mild aortic regurgitation. TSH was mildly elevated at 5.7, but free T4 was wnl at 1.5. She was monitored on telemetry without incident. #Nausea, dyspepsia: These symptoms were thought to be secondary to GERD. She received symptomatic management for nausea with Compazine and Zofran, and her symptoms then improved greatly on ranitidine. #Anxiety: Ativan was continued. Citalopram was initially held and then restarted during this hospitalization. #Neuropathy: Gabapentin was continued during this hospitalization. #HLD: Simvastatin was continued during this admission.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Wasp Venom Attending: ___. Chief Complaint: Epigastric Pain Major Surgical or Invasive Procedure: ERCP with sphincteroplasty History of Present Illness: ___ with h/o appy, chole, p/w epigastric pain, started last night 30 mins after dinner, achy, ___, no radiation, no f/c, n/v/d. Passing flatus, last BM in AM. Pt notes a similar pain started ___ years ago, recently much worse, more frequent, several times a week and usually postprandial. On ___ was seen in clinic and LFTs were 90/235 with alk phos 78 TB 0.1. Very functional at baseline, no CAD, PVD, HLD, HTN, DM. . In the ED, initial vitals: 97.6 88 158/72 16 99% RA. Labs notable for WBC 8.9, AST 1300, AST ___, Alk Phos, 156 TB 1.7. RUQ with dilated CBD. She received a dose of Unasyn. ERCP team was consulted. . Currently, patient feeling well on the floor and on ROS she denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. A complete 10 point ROS otherwise stable. Past Medical History: # Depressive disorder # Diverticulosis # Pulmonary nodule/lesion, solitary # Macular drusen # Ocular hypertension # Vitamin D deficiency # Mild stage glaucoma # Primary open angle glaucoma Social History: ___ Family History: Extensive family history of gallstones. No autoimmune diseases Physical Exam: VS: 99.8 150/71 84 18 95RA GENERAL: NAD, comfortable, appropriate HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK: supple, no thyromegaly, no JVD HEART: PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN: no rashes or lesions NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait . Discharge Exam: AVSS No icterus Abdomen benign Pertinent Results: Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 07:15 4.31 3.97* 12.5 38.5 97 31.4 32.4 14.5 138* ___ 05:04 8.9 4.71 15.2 45.2 96 32.3* 33.6 12.8 215 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 07:15 ___ 3.6 ___ ___ 05:04 ___ 143 3.7 ___ ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 07:15 1267* 691* 152* 2.5* ___ 05:04 1387* 2154* 156* 1.7* INR 1.2 MRCP IMPRESSION: 1. Choledocholithiasis and stones within the remnant cystic duct; ductal wall hyperenhancement indicates cholangitis. Largest stone within the common bile duct measures up to 6 mm. Mild intrahepatic biliary ductal dilation. 2. Mild periportal edema, hepatic enlargement and heterogeneous arterial enhancement suggest hepatitis; a chronic hepatic abnormality is possible. 2. Normal homogeneous-appearing pancreas without evidence of gallstone pancreatitis. . U/S: IMPRESSION: Common bile duct dilation up to 16 mm with associated mild intrahepatic biliary duct dilation. No stone is identified within the ducts, although it is not traced completely to the pancreatic head. There is no evidence of pancreatic duct dilation. Given these findings, further evaluation with an MRCP is recommended to exclude a distal stone or obstructing mass. . ERCP: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree Fluoroscopic Interpretation: The common bile duct was found to be dilated to 13mm. Given the clinical presentation, elevated liver enzymes and dilated common bile duct, a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Procedures: A balloon sweep was performed with extraction of sludge. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. Total fluoro time: 3.1min. Impression: Normal major papilla Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. The common bile duct was found to be dilated to 13mm. Given the clinical presentation, elevated liver enzymes and dilated common bile duct, a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A balloon sweep was performed with extraction of sludge. Otherwise normal ercp to third part of the duodenum Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Psyllium Wafer 1 WAF PO DAILY Discharge Medications: 1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Psyllium Wafer 1 WAF PO DAILY 4. Outpatient Lab Work Please have CBC, Chem 7, AST, ALT, Alk Phos, T. Bili, D. Bili and Lipase checked on ___. Please call Dr. ___ with the results at ___ Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Choledocolithiasis with obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Presenting with right upper quadrant pain. Has a history of a prior cholecystectomy. Evaluate for retained stone. COMPARISONS: None. TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the right upper quadrant. FINDINGS: The liver is normal in shape and contour. There is normal echogenicity. No focal hepatic lesions are identified. The main portal vein is patent with normal hepatopetal flow. The patient is status post cholecystectomy. There appears to be mild intrahepatic biliary duct dilation. The common bile duct is very dilated measuring up to 16 mm. No stone is visualized within the ducts. The duct cannot be completely followed to the pancreatic head, although the majority of its course is visualized. The pancreas appears normal. The pancreatic duct is within normal limits measuring 2 mm. The pancreatic tail is somewhat obscured by overlying bowel gas. There is no evidence of ascites in this limited right upper quadrant ultrasound. Limited views of the right kidney demonstrate an extrarenal pelvis. IMPRESSION: Common bile duct dilation up to 16 mm with associated mild intrahepatic biliary duct dilation. No stone is identified within the ducts, although it is not traced completely to the pancreatic head. There is no evidence of pancreatic duct dilation. Given these findings, further evaluation with an MRCP is recommended to exclude a distal stone or obstructing mass. Radiology Report MRCP INDICATION: ___ woman status post cholecystectomy with abdominal pain, LFTs in the ___ and ___, evaluate for CBD stone. TECHNIQUE: Multiplanar and multisequence MR imaging was obtained before and after the administration of IV contrast. 7 cc of Gadavist IV contrast was administered. 2.5 cc of Gadavist mixed with 75 cc of water was administered orally. FINDINGS: Lung bases demonstrate minimal bibasilar subsegmental atelectasis. The visualized heart is prominent without pericardial effusion. The liver appears enlarged with very heterogeneous arterial phase enhancement which normalizes on subsequent post-contrast images. There is a mild amount of intrahepatic biliary ductal dilatation and mild periportal edema noted. Remnant cystic duct is dilated with a few large filling defects noted measuring up to 6 mm. These demonstrate mild susceptibility artifact on the corresponding in-phase images. Significant dilation of the common hepatic/common bile duct is again seen measuring up to 13 mm at the level of the extrapancreatic common bile duct. Distally, the common bile duct measures up to 8 mm, with intraluminal stones measuring up to 6 mm. No definitive cholecystectomy clips are appreciated. Additionally, the common hepatic, common bile and cystic duct walls have slight hyperenhancement consistent with cholangitis. The pancreas, however, is homogeneous with top normal pancreatic ductal caliber. No evidence of gallstone pancreatitis is seen. No significant peripancreatic fluid collection or significant lymphadenopathy is appreciated. Incidental note of bilateral extrarenal pelves, without evidence of hydronephrosis. Renal cyst is noted within the right upper kidney. The visualized skeletal structures demonstrate no significant abnormality. IMPRESSION: 1. Choledocholithiasis and stones within the remnant cystic duct; ductal wall hyperenhancement indicates cholangitis. Largest stone within the common bile duct measures up to 6 mm. Mild intrahepatic biliary ductal dilation. 2. Mild periportal edema, hepatic enlargement and heterogeneous arterial enhancement suggest hepatitis; a chronic hepatic abnormality is possible. 2. Normal homogeneous-appearing pancreas without evidence of gallstone pancreatitis. CRITICAL FINDINGS COMMUNICATION: PRELIMINARY FINDINGS SIMILAR TO ABOVE FINAL FINDINGS WERE VERBALLY COMMUNICATED BY PHONE TO ___. ___ FELLOW) IN THE AFTERNOON ON ___. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 97.6 heartrate: 88.0 resprate: 16.0 o2sat: 99.0 sbp: 158.0 dbp: 72.0 level of pain: 8 level of acuity: 3.0

___ with hx of CCY, presenting with acute on chronic sharp, crampy epigastric pain post-prandially found to have a dilated CBD and transaminases >1000. . # Choledocolithiasis: Pt presented with transaminases >1000. DDx includesd choledocolithiasis with obstruction, acute cholangitis, acute viral hepatitis, shock liver, autoimmune hepatitis. MRCP and subsequent ERCP confirmed dx of biliary sludge and the patient AST/ALT downtrended the following day (see above). The pt was without fever or leukocytosis, thus abx were discontinued. The pt was instructed to have her labs checked on ___ and have the results called to the ERCP fellow, Dr. ___ at ___. . # Glaucoma: Continued Home timolol dosing

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: aspirin / Penicillins / bee sting / epinephrine Attending: ___. Chief Complaint: Seizures Major Surgical or Invasive Procedure: Intubation, mechanical ventilation History of Present Illness: EU Critical ___ ___ is a ___ M with h/o primary generalized epilepsy (GTCs and myoclonic seizures, h/o AED noncompliance, on VPA) and EtOH abuse (h/o multiple admissions for withdrawal seizures) who is transferred to ___ from ___ for status epilepticus, which has resolved s/p PHT 1.5g load, intubation and sedation with fent/midaz. IN ___: p/w status. Loaded with fosphenytoin about 1500 PE equivalents. BP at time of intubation in the 110's systolic increasing to 230/100 following intubation. Propofol drip started with stable BP x 20 minutes then decreasing to 80's. Propofol discontinued and patient switched to Versed gtt with bolused Fentanyl with improved stability and sedation however low MAP's so on small dose neo gtt to maintain MAP's > 90. Given persistent hypotension despite 3L of NS and no propofol, central access obtained in right groin. Labs in ___ only remarkable for ETOH level of 160. Transferring given no EEG available at ___ overnight. In our ___, vitals 97 57 148/107 22 100% intubated. Patient sedated with midazolam and fentanyl, but responsive to questions, follows commands. NCHCT remarkable only for sinus disease, no intercranial process. Neurology consulted. Per their exam in ___, sensorimotor exam and reflexes are intact, tone is normal, and toes are downgoing. There is no meningismus. Patient no longer in status. Past Medical History: -Epilepsy: Diagnosed at the age of ___, described above. States that his baseline for seizures is approximately 1-2/year. -___ Disease: Diagnosed in ___ with tremor, problems writing (Dr. ___ - CAD s/p ___ MIs: ___ and 8 stents -Hypercholesterolemia-familial -Restless leg syndrome -GERD -Sciatica -Anxiety -Depression Social History: ___ Family History: Family history of DM, HTN, MI, strokes and EtOH abuse on both maternal and paternal sides. Sister with epilepsy. Physical Exam: Vitals: see metavision General- intubated, minimally responsive HEENT- Sclera anicteric, MMM Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- foley in place Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ___ 05:53PM VALPROATE-65 ___ 03:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 03:00PM URINE RBC-24* WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 ___ 08:18AM TYPE-CENTRAL VE TEMP-37.2 PO2-61* PCO2-47* PH-7.30* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED ___ 08:18AM LACTATE-1.5 ___ 07:29AM ALT(SGPT)-47* AST(SGOT)-33 ALK PHOS-38* TOT BILI-0.2 ___ 07:29AM PHENYTOIN-2.5* ___ 04:35AM ASA-NEG ETHANOL-57* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___ 04:35AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 03:12AM TYPE-ART RATES-15/ TIDAL VOL-500 PEEP-5 O2-100 PO2-490* PCO2-56* PH-7.19* TOTAL CO2-22 BASE XS--7 AADO2-170 REQ O2-38 -ASSIST/CON INTUBATED-INTUBATED ___ 04:35AM WBC-10.3 RBC-4.89 HGB-15.3 HCT-44.8 MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 IMAGING: head CT ___: 1. No acute intracranial abnormality. 2. Paranasal sinus disease, including aerosolized secretions in the sphenoid sinus. Recommend clinical correlation for acute sinusitis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO DAILY:PRN constipation 2. Diltiazem Extended-Release 120 mg PO DAILY 3. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily 4. Diazepam 10 mg PO TID 5. Divalproex (DELayed Release) 500 mg PO BID 6. Ezetimibe 10 mg PO DAILY 7. Rosuvastatin Calcium 40 mg PO DAILY 8. Ropinirole 1 mg PO BID Discharge Medications: 1. Diazepam 10 mg PO TID 2. Ropinirole 1 mg PO BID 3. Rosuvastatin Calcium 40 mg PO DAILY 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Divalproex (DELayed Release) 500 mg PO TID 6. Docusate Sodium 100 mg PO DAILY:PRN constipation 7. Ezetimibe 10 mg PO DAILY 8. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily Discharge Disposition: Home Discharge Diagnosis: Seizure Discharge Condition: Discharge condition: fair Mental status: awake, alert and oriented Ambulatory status: ambulates independently Followup Instructions: ___ Radiology Report INDICATION: Found down with status epilepticus. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Sagittal, coronal, and thin section bone reformatted images were obtained and reviewed. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or large vascular territory infarction. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. No fracture is identified. There is a mucus retention cyst in the right maxillary sinus, mucosal thickening throughout the paranasal sinuses, and aerosolized secretions in the sphenoid sinus. Mastoid air cells and middle ear cavities are clear. Soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Paranasal sinus disease, including aerosolized secretions in the sphenoid sinus. Recommend clinical correlation for acute sinusitis. Radiology Report CHEST RADIOGRAPH INDICATION: Seizure, intubation. Evaluation. COMPARISON: No comparison available at the time of dictation. FINDINGS: The patient is intubated. The tip of the endotracheal tube projects 6 cm above the carina. The tube should be advanced by 1-2 cm. The technical quality of the image is limited. A part of the left costophrenic sinus is missing. Lung volumes are low. There is a calcified granuloma in the right upper lobe. Borderline size of the cardiac silhouette without pulmonary edema. Minimal atelectasis in the retrocardiac lung areas. No pneumothorax. A minimal right pleural effusion might be present. Radiology Report HISTORY: Fever and seizures COMPARISON: Same day earlier in the morning. FINDINGS: There is mild cardiomegaly. Widened upper mediastinum is new. Bilateral basal atelectasis greater in the left have minimally increased. There is mild vascular congestion. There is a small left effusion. ET tube is in standard position. NG tube tip is below the diaphragm, out of view. IMPRESSION: New mild vascular congestion. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: ETOH;SZ Diagnosed with GRAND MAL STATUS, ALCOH DEP NEC/NOS-CONTIN temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

___ with h/o seizure d/o and EtOH abuse transferred from OSH with status epileptic in the form of multiple GTCs. Was intubated and sedated prior to admission to MICU. Extubated on ___. # Status Epilepticus (RESOLVED): Etiology was thought to be ___ AED noncompliance vs EtOH withdrawal. Given concern over EtOH withdrawal he was admitted to the MICU. Prior to transfer to the MICU he was loaded with fosphenytoin at OSH, but this was subseqently discontinued. In the ___ at ___, valproate level was checked, which was subtherapeutic. Per admission records, pt was on valproate 500mg BID recently but was noncompliant with meds. Of note he was previously on up to 4g of valproate daily in the past. In the MICU he was restarted on his valproate at 500mg TID. He was also started on midazolam drip for first day in ICU. In the ICU he had two episodes of GTC seizures both of which were aborted with midazolam boluses. Seizures occured before EEG monitoring was set up. On HD1 he was extubated and did not have any more seizure activity in the ICU. His midazolam was stopped prior to extubation and his home diazepam was restarted. Patient was on EEG monitoring but that was discontinued on ___ given that there is no EEG findings suggestive of seizures. Patient has no clinical seizures after the discontinuation of his EEG. ___ seizures are thought to be a combination or medication non-compliance and withdrawal from ETOH and intermittent use of valium. Patient is counseled on limiting ETOH use and the importance of taking medications as directed. Patient will be followed up at Dr. ___ after discharge with the plan to transition his care to a provider that is closer to his home. # Alcohol Abuse/Withdrawal: Pt presented with etoh level in ___, so less likely that he was actually withdrawing, although he does have a reported hx of DTs, so could potentially be withdrawing from etoh even with an serum etoh level. After extubation pt was asked about his etoh use and he reports that he only drinks once a week. Regardless, he was started on CIWA scale after extubation. He was given 3 doses of PO valium for a total of 30mg. On HD2 pt was not scoring on CIWA scale, so it was discontinued. His home diazepam dose was restarted. Pt was also given IV thiamine, MVI and folate while in the MICU. Inactive issues: # CAD s/p ___ MIs: ___ and 8 stents. Pt was continued on home dose of plavix. He is not on ASA because of reported allergy. He was also continued on home dose rosuvastatin and zetia. # Parkinsonism: continued on home ropinerole dose. # GERD: continued on home dose of nexium.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Invega / Klonopin / Detrol / Compazine Attending: ___ Chief Complaint: Confusion, Worsening ___ Symptoms Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F with PMHx of early-onset ___ disease as well as ? sleep disorder, who was sent in from clinic yesterday when she was noted to be altered. Pt reports that she initially felt off from baseline earlier this week, with increased rigidity. She also noted worsening of her tremors as well as myocolonic movements of the LEs. She notes dysuria, abnormal smell to her urine, as well as dark matter (?clots) in her urine. She denies any fevers or chills, but does endorse hot flashes. Symptoms are consistent with recent UTI's per patient. Of note, she also have a fall earlier this week, which she attributes to increased rigidity and gait instability. No LOC / head strike. No prodromal s/s prior to fall. ED Course: Initial VS: 98.8 115 131/81 20 99% RA Pain ___ Labs significant for + UA. Imaging: CXR without acute process. Hand films with nondisplaced fracture through the shaft of the fifth metacarpal. Meds given: ___ 20:43 IVF 1000 mL NS 1000 mL ___ 21:51 PO Acetaminophen 650 mg ___ 00:01 IVF 1000 mL NS 1000 mL ___ 00:33 PO/NG Carbidopa-Levodopa (___) 1 TAB ___ 00:33 IV Meropenem 500 mg VS prior to transfer: 98.2 96 108/60 18 100% RA Pain ___ On arrival to the floor, the patient reports that she feels better after getting abx in the ED. She does endorse being tired after being awake all night. She reports that her right hand ___ been "stiff" but is starting to feel better. she reports some lightheadedness earlier, now resolve. ROS: As above. Denies headache, lightheadedness, dizziness, sore throat, sinus congestion, chest pain, heart palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, focal numbness or tingling, skin rash. The remainder of the ROS was negative. Past Medical History: GAIT DISTURBANCE BACK PAIN LUMBAR RADICULOPATHY ___ DISEASE DEPRESSION DELIRIUM NEUROGENIC BLADDER C.DIFF Social History: ___ Family History: 2 maternal aunts with MS and grandfather with dementia. Also history of hypertension, diabetes mellitus, and CAD. No FH of PD. Physical Exam: ADMISSION EXAM: VS - 97.9 118/61 95 18 100 RA GEN - Alert, NAD HEENT - Atraumatic, masked facies, symmetric, tongue midline, MMM NECK - Supple CV - RRR, no m/r/g appreciated RESP - CTA B BACK - no CVAT ABD - S/NT, BS present GU - Foley catheter in place EXT - splint in place on right hand SKIN - No apparent rashes NEURO - Alert, able to recount history easily, face symmetric, ___ strength in all 4 extremities, significant rigidity noted in the LEs, + cogwheeling in the LUE, ___ patellar DTRs bilaterally PSYCH - ___, appropriate DISCHARGE EXAM: VSS, AF GEN: Alert, NAD HEENT: NC/AT, masked facies CV: RRR, no m/r/g PULM: CTA B GI: S/NT/ND, BS present NEURO: Alert, Still with rigidity noted in the LUE with some cogwheeling EXT: right hand splinted Pertinent Results: ___ 08:45PM BLOOD WBC-8.5 RBC-4.13 Hgb-12.1 Hct-34.5 MCV-84 MCH-29.3 MCHC-35.1 RDW-12.9 RDWSD-38.7 Plt ___ ___ 08:45PM BLOOD Neuts-60.5 ___ Monos-5.7 Eos-0.4* Baso-0.2 Im ___ AbsNeut-5.12 AbsLymp-2.79 AbsMono-0.48 AbsEos-0.03* AbsBaso-0.02 ___ 08:45PM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-137 K-4.1 Cl-103 HCO3-21* AnGap-17 ___ 08:56PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:56PM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG ___ 08:56PM URINE RBC-2 WBC-32* Bacteri-FEW Yeast-NONE Epi-2 ___ 07:20AM BLOOD WBC-7.6 RBC-4.33 Hgb-12.3 Hct-36.5 MCV-84 MCH-28.4 MCHC-33.7 RDW-12.9 RDWSD-39.5 Plt ___ ___ 07:20AM BLOOD Glucose-83 UreaN-9 Creat-0.6 Na-139 K-4.2 Cl-106 HCO3-25 AnGap-12 ___ 07:20AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 Hand Films - IMPRESSION: Oblique nondisplaced fracture through the shaft of the fifth metacarpal, without intra-articular extension. CXR - IMPRESSION: No acute cardiopulmonary process. Renal U/S - IMPRESSION: Normal renal ultrasound. No sonographic evidence of perinephric fluid collection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. carbidopa-levodopa-entacapone ___ mg oral QID 2. Amantadine 100 mg PO TID 3. Carbidopa-Levodopa (___) 2 TAB PO QHS 4. Pramipexole 1 mg PO TID 5. Sertraline 200 mg PO QHS 6. Nitrofurantoin (Macrodantin) 100 mg PO DAILY 7. Ascorbic Acid ___ mg PO BID 8. Myrbetriq (___) 50 mg oral QHS 9. LORazepam 0.75 mg PO QHS 10. Necon 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35 mg-mcg oral DAILY Discharge Medications: 1. amantadine HCl 100 mg oral TID 2. ascorbic acid (vitamin C) 500 mg oral BID 3. ascorbic acid (vitamin C) 500 mg oral BID 4. Ascorbic Acid ___ mg PO BID 5. Carbidopa-Levodopa (___) 2 TAB PO QHS 6. carbidopa-levodopa-entacapone ___ mg oral QID 7. LORazepam 0.75 mg PO QHS 8. Myrbetriq (mirabegron) 50 mg oral QHS 9. Necon 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35 mg-mcg oral DAILY 10. pramipexole 1 mg oral TID 11. Sertraline 200 mg PO QHS 12. sennosides-docusate sodium 8.6-50 mg oral DAILY:PRN constipation 13. melatonin 12 mg oral QHS 14. Sulfameth/Trimethoprim DS 1 TAB PO BID Last dose of this medication is the evening of ___ Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Urinary Tract Infection Early-onset ___ Right ___ metacarpal shaft fracture 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: RENAL U.S. INDICATION: ___ woman with UTI, back pain; assess for evidence of perinephric abscess. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal ultrasound dated ___. FINDINGS: The exam is slightly limited secondary to overlying bowel gas. The right kidney measures 9.8 cm. The left kidney measures 9.6 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. No evidence of perinephric fluid collections. The bladder is partially distended and normal in appearance. IMPRESSION: Normal renal ultrasound. No sonographic evidence of perinephric fluid collection. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Confusion, Dysuria Diagnosed with Dysuria temperature: 98.8 heartrate: 115.0 resprate: 20.0 o2sat: 99.0 sbp: 131.0 dbp: 81.0 level of pain: 5 level of acuity: 2.0

___ y/o F with PMHx of early-onset ___ disease as well as ? sleep disorder, here with confusion and worsening ___ s/s, found to have UTI. # Urinary Tract Infection: Pt presented with dysuria, worsening ___ symptoms, as well as confusion. She reported that presentation was consistent with prior episodes of UTI's. She was treated with meropenem, given h/o ESBL E.coli. ID was consulted. Ultimately, she grew proteus that was pan-sensitive to antibiotics, so was switched to Bactrim DS on ___ to complete a total of 10 days of antibiotics (end date = ___. She should be RESTARTED on Nitrofurantoin for suppressive therapy after she completes the course of Bactrim as per outpatient ID. # ___ Metacarpal Fracture: In splint and is non-weight bearing for now. She needs a repeat xray by ___ or ___ to assess healing and will need follow-up with Plastic Surgery at ___ (number on discharge worksheet). # ___ Disease: Recent worsening symptoms likely related to acute infection. Maintained on home regimen of carbidopa-levodopa-entacapone ___ mg oral QID, Amantadine 100 mg PO TID, Carbidopa-Levodopa (___) 2 TAB PO QHS, Pramipexole 1 mg PO TID, and Myrbetriq (mirabegron) 50 mg oral QHS. Neurology was involved during admission and recommended continuation of home regimen. Her outpatient sleep medications were also continued.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: adhesive tape Attending: ___. Chief Complaint: Weakness, Lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with a history of metastatic prostate cancer on cabazitaxel, afib (not on anticoagulation), HFpEF, orthostatic hypotension (on midodrine), CKD, and hydroureteronephrosis s/p percutaneous nephrostomy tube placement who presents with disorientation. The patient was admitted to ___ two weeks ago with a dislodged percutaneous nephrostomy tube. This was replaced, but his urine grew E. coli resistant to most agents but susceptible to pip/tazo and meropenem. He completed meropenem through his midline on ___. For the past few days, however, the patient has been acting confused. At baseline he has some forgetfulness, but recently he has been saying strange things, has been disoriented, and at times has been slightly agitated. His wife is unaware of any fevers, reports of pain, difficulty breathing, or diarrhea. His percutaneous nephrostomy has been functioning as expected, and there were no problems with the midline. His wife gave him oxycodone a couple nights ago. Besides this and the meropenem he has not had any new medications. Regarding his prostate cancer, his last cabazitaxel was on ___. His PSA has been rising lately. In the ED he was tachycardic and had a leukocytosis to 12.3. Lactate was 1.2. Urine obtained from the percutaneous nephrostomy tube showed WBCs and bacteria. He otherwise does not usually pass urine on his own. Pip/tazo was started. ROS: Unable to obtain secondary to encephalopathy. Past Medical History: 1. Metastatic prostate cancer 2. Atrial fibrillation on Coumadin 3. Orthostatic hypotension 4. CKD III 5. HFpEF 6. Anemia 7. Malnutrition 8. Hydronephrosis 9. Perc neph placement Social History: ___ Family History: No family history of prostate cancer Physical Exam: ADMISSION EXAM GENERAL: Elderly thin gentleman, hard of hearing, lying in bed, awake NECK: Normal ROM, JVD not elevated HEART: Regular at time of exam, no murmurs LUNGS: CTAB, good air movement ABDOMEN: Soft, non tender, non distended, +BS BACK: L nephrostomy tube insertion site, dressed and clean, no surrounding erythema or induration, yellow urine in bag EXTREMITIES: Left midline with dried blood under bandage but no purulent drainage NEURO: Oriented to person only. Conversant but talking about unrelated topics SKIN: Sacral erythema but no ulcer, present prior to admission 98.1 PO 143 / 77 67 18 99 RA tired and lying down in AM but asking for food, then more alert and interactive sitting up L nephrostomy draining yellow urine, site not painful no peripheral edema or labored breathing Pertinent Results: ADMISSION LABS: ___ 11:24AM BLOOD WBC-12.3*# RBC-3.11* Hgb-9.5* Hct-30.5* MCV-98 MCH-30.5 MCHC-31.1* RDW-16.9* RDWSD-60.3* Plt ___ ___ 11:24AM BLOOD Neuts-75.4* Lymphs-13.0* Monos-9.8 Eos-0.5* Baso-0.4 Im ___ AbsNeut-9.28*# AbsLymp-1.60 AbsMono-1.20* AbsEos-0.06 AbsBaso-0.05 ___ 11:24AM BLOOD Glucose-90 UreaN-23* Creat-1.2 Na-139 K-4.0 Cl-99 HCO3-26 AnGap-14 ___ 11:24AM BLOOD ALT-23 AST-31 AlkPhos-75 TotBili-1.1 ___ 11:24AM BLOOD Lipase-12 ___ 11:24AM BLOOD Albumin-3.5 Calcium-9.4 Phos-3.9 Mg-2.2 ___ 05:47AM BLOOD PSA-42.6* ___ 11:31AM BLOOD Lactate-1.2 ___ 01:40PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE URINE STUDIES ___ 01:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:00PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* ___ 01:00PM URINE RBC-4* WBC-61* Bacteri-FEW* Yeast-NONE Epi-0 URINE CULTURE (Final ___: NO GROWTH. CT HEAD - IMPRESSION: Within limitations caused by severe motion artifact, no acute intracranial process. No evidence of intracranial hemorrhage. CXR - IMPRESSION: Comparison to ___. Stable normal lung volumes. Borderline size of the cardiac silhouette. No pulmonary edema. No pneumonia, no pleural effusion. Stable rounded radiodensity in the left lung apex, very likely caused by a calcified costosternal junction, and not visualized on the lateral image. RENAL U/S - IMPRESSION: Limited examination demonstrating moderate right renal atrophy and mild fullness of the bilateral renal collecting systems without frank hydronephrosis. Left percutaneous nephrostomy tube is partially visualized, though the distal pigtail location is not well seen. ___ 06:24AM BLOOD WBC-8.5 RBC-3.10* Hgb-9.4* Hct-30.5* MCV-98 MCH-30.3 MCHC-30.8* RDW-17.0* RDWSD-60.0* Plt ___ ___ 06:24AM BLOOD Glucose-134* UreaN-26* Creat-1.2 Na-141 K-4.7 Cl-104 HCO3-24 AnGap-13 ___ 05:47AM BLOOD PSA-42.6* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Midodrine 5 mg PO TID 3. Mirtazapine 15 mg PO QHS 4. Multivitamins W/minerals Liquid 15 mL PO DAILY 5. Vitamin D 400 UNIT PO DAILY 6. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 7. zoledronic acid 4 mg injection Q3MONTHS 8. PredniSONE 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Toxic Metabolic Encephalopathy Prostate Cancer 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: History: ___ with altered mental status// Eval for pneumoniaEval for subdural Eval for pneumoniaEval for subdural IMPRESSION: Comparison to ___. Stable normal lung volumes. Borderline size of the cardiac silhouette. No pulmonary edema. No pneumonia, no pleural effusion. Stable rounded radiodensity in the left lung apex, very likely caused by a calcified costosternal junction, and not visualized on the lateral image. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with altered mental status// Eval for pneumoniaEval for subdural TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 1,003.4 mGy-cm. 2) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 1,003.4 mGy-cm. Total DLP (Head) = 2,007 mGy-cm. COMPARISON: None. FINDINGS: The study is severely limited due to motion artifact, despite repeat scan. Within these limitations: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of age-related cerebral volume loss. Periventricular and subcortical white matter hypodensities are nonspecific, though likely sequelae of chronic small vessel ischemic disease. Atherosclerotic vascular calcifications are noted of bilateral vertebral and cavernous portions of internal carotid arteries. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Within limitations caused by severe motion artifact, no acute intracranial process. No evidence of intracranial hemorrhage. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with met prost cancer, perc neph// Assess for fat stranding suggestive of pyelo, dislodgement of perc neph, hydronephrosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Abdominal ultrasound ___. FINDINGS: Examination is limited due to available acoustic window and inability of patient to fully cooperate with the examination. The right kidney measures 7.6 cm. The left kidney measures 10.6 cm. There is mild fullness of the bilateral renal collecting systems without frank hydronephrosis. There is no obvious stone or focal renal mass. A left percutaneous nephrostomy tube is partially visualized, though the distal position is not visualized. The bladder is nearly completely collapsed and not fully evaluated. IMPRESSION: Limited examination demonstrating moderate right renal atrophy and mild fullness of the bilateral renal collecting systems without frank hydronephrosis. Left percutaneous nephrostomy tube is partially visualized, though the distal pigtail location is not well seen.. Gender: M Race: ASIAN Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with Altered mental status, unspecified temperature: 97.9 heartrate: 115.0 resprate: 18.0 o2sat: 97.0 sbp: 133.0 dbp: 61.0 level of pain: Unable level of acuity: 2.0

___ male w/ hx of metastatic prostate cancer on cabazitaxel, afib (not on anticoagulation), HFpEF, orthostatic hypotension (on midodrine), CKD, and hydroureteronephrosis s/p percutaneous nephrostomy tube placement who presents with encephalopathy / weakness / FTT. # Toxic Metabolic Encephalopathy / Weakness / Failure to Thrive: Head CT unremarkable. CXR without clear evidence of PNA. Given WBC's and few bacteria on UA, there was concern for UTI, for which patient was started on zosyn. However, urine culture returned negative, making UTI unlikely. Given reports of sleep disruption at home, the patient's initial altered mental status could be explained by delirium superimposed on a background of failure to thrive in the setting of progression of his prostate CA. Furthermore, his initial somnolence could have been medication effect from the olanzapine and haloperidol he received on the evening of admission. ___ consulted. # Orthostatic Hypotension: The patient has known orthostatic hypotension and chronically low BPs. During a previous admission, he was noted to have orthostatic hypotension that persisted despite IV fluids, blood transfusion, and discontinuing beta blocker. He is on midodrine at home. He is also on steroids for suspected adrenal insufficiency. Steroid dose was briefly increased in the setting of concern for acute infection. # Metastatic Prostate Cancer: Patient with known metastatic prostate cancer since ___. Is currently on cabazitaxel. Follows with Dr. ___. Missed his most recent administration due to this presentation. PSA noted to be higher than recent values. Oncology was consulted and recommended follow up next week on ___ to discuss declining performance status and progressive cancer and discussion of goals of care. # CKD: Review of ___ records shows recent baseline Cr 1.1-1.3. More recent values in OMR closer to 1.4. Cr improved . # Anemia: H/H largely consistent with recent baseline. No evidence of bleeding on exam. H/H stable today. - continue iron supplementation # Paroxysmal Afib: Rates well controlled. Not currently on anticoagulation ___ fall risk. Will need to continue discussions re: a/c with PCP. # HFpEF: Appears euvolemic-to-hypovolemic on exam. Not on home diuretics. Continue to monitor volume status closely. >30min on discharge activities medically stable for discharge

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Shellfish Derived Attending: ___ Chief Complaint: Pelvic pain Major Surgical or Invasive Procedure: Abscess drainage under imaging guidance Depo Provera injection ___ Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, minimally TTP in midline pelvis, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: LABS =================== ___ 06:00AM BLOOD WBC-11.3* RBC-4.04 Hgb-10.5* Hct-32.9* MCV-81* MCH-26.0 MCHC-31.9* RDW-13.4 RDWSD-40.0 Plt ___ ___ 12:50PM BLOOD WBC-13.4* RBC-4.27 Hgb-11.1* Hct-34.8 MCV-82 MCH-26.0 MCHC-31.9* RDW-13.4 RDWSD-39.6 Plt ___ ___ 06:15AM BLOOD WBC-11.9* RBC-3.94 Hgb-10.3* Hct-32.4* MCV-82 MCH-26.1 MCHC-31.8* RDW-13.5 RDWSD-40.2 Plt ___ ___ 06:51AM BLOOD WBC-10.1* RBC-3.73* Hgb-9.8* Hct-30.5* MCV-82 MCH-26.3 MCHC-32.1 RDW-13.5 RDWSD-40.3 Plt ___ ___ 06:06AM BLOOD WBC-11.4* RBC-3.41* Hgb-8.9* Hct-27.5* MCV-81* MCH-26.1 MCHC-32.4 RDW-13.6 RDWSD-39.6 Plt ___ ___ 07:05AM BLOOD WBC-12.6* RBC-3.30* Hgb-8.7* Hct-26.3* MCV-80* MCH-26.4 MCHC-33.1 RDW-13.4 RDWSD-39.5 Plt ___ ___ 06:45AM BLOOD WBC-13.4* RBC-3.18* Hgb-8.4* Hct-25.4* MCV-80* MCH-26.4 MCHC-33.1 RDW-13.4 RDWSD-38.8 Plt ___ ___ 06:40AM BLOOD WBC-14.3* RBC-3.24* Hgb-8.5* Hct-26.2* MCV-81* MCH-26.2 MCHC-32.4 RDW-13.4 RDWSD-39.7 Plt ___ ___ 02:20PM BLOOD WBC-14.5* RBC-3.44* Hgb-9.0* Hct-28.3* MCV-82 MCH-26.2 MCHC-31.8* RDW-13.5 RDWSD-40.1 Plt ___ ___ 06:30PM BLOOD WBC-14.2* RBC-3.64* Hgb-9.6* Hct-29.7* MCV-82 MCH-26.4 MCHC-32.3 RDW-13.3 RDWSD-39.8 Plt ___ ___ 06:00AM BLOOD Neuts-67.1 ___ Monos-6.3 Eos-1.8 Baso-0.4 Im ___ AbsNeut-7.57* AbsLymp-2.56 AbsMono-0.71 AbsEos-0.20 AbsBaso-0.04 ___ 12:50PM BLOOD Neuts-75.0* Lymphs-18.5* Monos-4.1* Eos-0.6* Baso-0.4 Im ___ AbsNeut-10.01* AbsLymp-2.47 AbsMono-0.55 AbsEos-0.08 AbsBaso-0.05 ___ 06:15AM BLOOD Neuts-67.1 ___ Monos-5.1 Eos-1.9 Baso-0.4 Im ___ AbsNeut-7.98* AbsLymp-2.84 AbsMono-0.61 AbsEos-0.23 AbsBaso-0.05 ___ 06:51AM BLOOD Neuts-70.2 ___ Monos-4.8* Eos-2.5 Baso-0.4 Im ___ AbsNeut-7.09* AbsLymp-2.05 AbsMono-0.48 AbsEos-0.25 AbsBaso-0.04 ___ 06:06AM BLOOD Neuts-73.9* Lymphs-17.4* Monos-5.9 Eos-1.0 Baso-0.3 Im ___ AbsNeut-8.44* AbsLymp-1.99 AbsMono-0.67 AbsEos-0.11 AbsBaso-0.03 ___ 07:05AM BLOOD Neuts-78.6* Lymphs-12.7* Monos-6.1 Eos-0.9* Baso-0.4 Im ___ AbsNeut-9.95* AbsLymp-1.60 AbsMono-0.77 AbsEos-0.11 AbsBaso-0.05 ___ 06:45AM BLOOD Neuts-79.6* Lymphs-12.5* Monos-5.7 Eos-1.0 Baso-0.2 Im ___ AbsNeut-10.70* AbsLymp-1.68 AbsMono-0.76 AbsEos-0.13 AbsBaso-0.03 ___ 06:40AM BLOOD Neuts-79.6* Lymphs-12.7* Monos-6.0 Eos-0.7* Baso-0.2 Im ___ AbsNeut-11.33* AbsLymp-1.81 AbsMono-0.86* AbsEos-0.10 AbsBaso-0.03 ___ 02:20PM BLOOD Neuts-77.8* Lymphs-13.6* Monos-7.3 Eos-0.3* Baso-0.3 Im ___ AbsNeut-11.29* AbsLymp-1.97 AbsMono-1.06* AbsEos-0.04 AbsBaso-0.04 ___ 06:30PM BLOOD Neuts-79.8* Lymphs-12.4* Monos-6.7 Eos-0.3* Baso-0.2 Im ___ AbsNeut-11.35* AbsLymp-1.76 AbsMono-0.96* AbsEos-0.04 AbsBaso-0.03 ___ 06:00AM BLOOD Plt ___ ___ 12:50PM BLOOD Plt ___ ___ 06:15AM BLOOD Plt ___ ___ 06:51AM BLOOD Plt ___ ___ 10:40AM BLOOD ___ PTT-31.7 ___ ___ 06:06AM BLOOD Plt ___ ___ 07:05AM BLOOD Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 02:20PM BLOOD Plt ___ ___ 02:20PM BLOOD ___ PTT-27.3 ___ ___ 06:30PM BLOOD Plt ___ ___ 06:06AM BLOOD Creat-0.7 ___ 02:20PM BLOOD Glucose-72 UreaN-8 Creat-0.7 Na-137 K-4.1 Cl-100 HCO3-22 AnGap-19 ___ 06:30PM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-135 K-3.8 Cl-96 HCO3-23 AnGap-20 ___ 08:50AM BLOOD HIV Ab-Negative ___ 03:40PM BLOOD HIV Ab-Negative ___ 06:35PM BLOOD Lactate-0.8 ___ 02:10PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:59PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 07:59PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 07:59PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 07:59PM URINE UCG-NEGATIVE MICROBIOLOGY =================== **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: Reported to and read back by ___ ___ ___ AT 11:04A. FUSOBACTERIUM NUCLEATUM. SPARSE GROWTH. BETA LACTAMASE NEGATIVE. ___ 3:40 pm SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. ___ 2:54 pm SWAB Source: Vaginal. **FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. ___ 2:30 pm URINE **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. ___ 2:10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 7:59 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGING =================== ___ CT Final Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: NO_PO contrast; History: ___ with LLQ, L flank pain, partially treated UTI. NO_PO contrast// eval for intraabdominal infection 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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 4.5 s, 49.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 491.3 mGy-cm. Total DLP (Body) = 500 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is a subcentimeter hypodensity seen in the right hepatic lobe, too small to fully characterize but likely representing hepatic cyst or biliary hamartoma. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, 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. 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: There is a fibroid uterus with an IUD appearing appropriately placed. There is a 3.9 x 3.8 cm left adnexal cystic structure with demonstrates rim enhancement, concerning for tubo-ovarian abscess (series 2: Image 58). Smaller rim enhancing fluid collections seen lateral to the dominant collection likely represents additional abscesses. There is associated peritoneal thickening (series 601b: Image 19) with reactive wall thickening of the adjacent sigmoid colon. There is associated stranding and inflammatory changes seen along the gonadal vein. A hypodense focus seen within the gonadal vein (series 2: Image 43), is concerning for a tiny clot. The right adnexa appears unremarkable. LYMPH NODES: There is no retroperitoneal lymphadenopathy. Multiple small mesenteric lymph nodes appear prominent, particularly in the left lower quadrant, without meeting CT size criteria for lymphadenopathy.. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. 3.9 cm dominant left adnexal rim enhancing cystic collection concerning for tubo-ovarian abscess with smaller adjacent collections likely also representing abscesses. There is associated inflammatory changes seen along the gonadal vein with a hypodense focus seen within the vein concerning for tiny clot. Additionally, there is peritoneal thickening and reactive sigmoid colonic wall thickening. 2. Fibroid uterus with an IUD seen appropriately placed. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 8:52 am, 5 minutes after discussion of findings with attending radiologist. Patient had been discharged home with Ob-gyn follow up visit scheduled, and upon discussion with ED following the updated read, the decision was made to contact the patient for return to the hospital for further treatment. ___ PELVIC US Final Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman admitted with ___ and gonadal vein thrombosis// Please evaluate for interval changes in ___ TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: CT ___ ultrasound ___ FINDINGS: The uterus is anteverted. The uterus is enlarged and measures 11.5 x 5.0 x 6.1 cm. Uterine fibroids are present. The largest fibroid is exophytic located on the right measuring 5.3 x 4.1 x 4.3 cm. The endometrium is distorted due to fibroids however, where seen appears homogenous and measures 4 mm. There is a complex left adnexal lesion/collection with central complex cystic component and thick-walled rim measuring overall 7.7 x 4.8 x 6.6 cm, previously 5.8 cm by ultrasound. The largest cystic component measures 5.2 cm, previously 3.2 cm by ultrasound. There is no vascularity demonstrated with color flow Doppler. The right ovary is not visualized. There is a trace amount of free fluid. IMPRESSION: 1. Complex left adnexal lesion/collection which was characterized as a left tubo-ovarian abscess on most recent CT. When compared to the most recent CT, there has been no significant change in the overall size of this structure however, with slightly larger cystic component. Overall no significant change when compared to most recent CT. When compared to most recent ultrasound, this has increased in size overall. 2. Stable fibroid uterus. 3. Nonvisualization of the right ovary. ___ CT-GUIDED DRAINAGE EXAMINATION: CT-GUIDED DRAINAGE INDICATION: ___ year old woman with left ___, on IV abx x 72h, with enlarging ___// please drain as much as ___ as possible, and send for microbiology. COMPARISON: CT abdomen and pelvis dated ___ PROCEDURE: CT-guided drainage of a left pelvic collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___ ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan was performed with a grid to localize the collection. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed, and the tract was progressively dilated using 6 ___ and 8 ___ dilators. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 42 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 168.8 mGy-cm. 2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 13) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 168.8 mGy-cm. Total DLP (Body) = 394 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 17 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited preprocedural planning CT of the pelvis demonstrates a heterogeneous left adnexal collection, in keeping with the previously characterized tubo- ovarian abscess. Intra procedural fluoroscopic CT demonstrates appropriate positioning of the ___ needle within this collection. A limited postprocedural CT demonstrates the pigtail catheter in appropriate position within this collection, which has decreased in size after drainage. IMPRESSION: 1. Successful CT-guided placement of an ___ pigtail catheter into the left hemi- pelvic collection, presumed to be a tubo-ovarian abscess. Samples were sent for microbiology evaluation. 2. 40 mL of pus was aspirated and a sample was sent for microbiology and cultures. RECOMMENDATION(S): 1. Monitor output. 2. Flush catheter with 10 mL of normal saline Q 8 hours. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman admitted with ___ and gonadal vein thrombosis// Please evaluate for interval changes in ___ TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: CT ___ ultrasound ___ FINDINGS: The uterus is anteverted. The uterus is enlarged and measures 11.5 x 5.0 x 6.1 cm. Uterine fibroids are present. The largest fibroid is exophytic located on the right measuring 5.3 x 4.1 x 4.3 cm. The endometrium is distorted due to fibroids however, where seen appears homogenous and measures 4 mm. There is a complex left adnexal lesion/collection with central complex cystic component and thick-walled rim measuring overall 7.7 x 4.8 x 6.6 cm, previously 5.8 cm by ultrasound. The largest cystic component measures 5.2 cm, previously 3.2 cm by ultrasound. There is no vascularity demonstrated with color flow Doppler. The right ovary is not visualized. There is a trace amount of free fluid. IMPRESSION: 1. Complex left adnexal lesion/collection which was characterized as a left tubo-ovarian abscess on most recent CT. When compared to the most recent CT, there has been no significant change in the overall size of this structure however, with slightly larger cystic component. Overall no significant change when compared to most recent CT. When compared to most recent ultrasound, this has increased in size overall. 2. Stable fibroid uterus. 3. Nonvisualization of the right ovary. Radiology Report EXAMINATION: CT-GUIDED DRAINAGE INDICATION: ___ year old woman with left ___, on IV abx x 72h, with enlarging ___// please drain as much as ___ as possible, and send for microbiology. COMPARISON: CT abdomen and pelvis dated ___ PROCEDURE: CT-guided drainage of a left pelvic collection. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the CT scan table. Limited preprocedure CT scan was performed with a grid to localize the collection. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed, and the tract was progressively dilated using 6 ___ and 8 ___ dilators. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 42 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to suction bulb. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 168.8 mGy-cm. 2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 4.2 mGy (Body) DLP = 5.1 mGy-cm. 13) Spiral Acquisition 4.5 s, 23.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 168.8 mGy-cm. Total DLP (Body) = 394 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 17 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited preprocedural planning CT of the pelvis demonstrates a heterogeneous left adnexal collection, in keeping with the previously characterized tubo- ovarian abscess. Intra procedural fluoroscopic CT demonstrates appropriate positioning of the ___ needle within this collection. A limited postprocedural CT demonstrates the pigtail catheter in appropriate position within this collection, which has decreased in size after drainage. IMPRESSION: 1. Successful CT-guided placement of an ___ pigtail catheter into the left hemi- pelvic collection, presumed to be a tubo-ovarian abscess. Samples were sent for microbiology evaluation. 2. 40 mL of pus was aspirated and a sample was sent for microbiology and cultures. RECOMMENDATION(S): 1. Monitor output. 2. Flush catheter with 10 mL of normal saline Q 8 hours. Gender: F Race: WHITE Arrive by WALK IN WALK IN Chief complaint: Pelvic pain Abd pain Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic Salpingitis and oophoritis, unspecified temperature: 99.2 97.4 heartrate: 96.0 79.0 resprate: 18.0 16.0 o2sat: 99.0 96.0 sbp: 129.0 110.0 dbp: 78.0 67.0 level of pain: 9 3 level of acuity: 3.0 3.0

On ___ Ms. ___ was admitted to the Gynecology service for management of a left tubo-ovarian abscess and gonadal vein thrombosis. *) Tubo-ovarian abscess: CT scan on the day of admission demonstrated a 3.9 cm left tubo-ovarian abscess with smaller adjacent cysts. Pt had a Tmax of 101.2 on ___. She remained afebrile from ___ @ 20:15 throughout the remainder of her hospital stay. She also had a downtrending leukocytosis: 14.5 (___) -> 11.4 ___ 10.1 (___) -> 11.9 (___) -> 13.4 (___) -> 11.3 (___). She was started on IV Ampicillin/Gentamicin/Clindamycin (___). On ___ she continued to have pelvic pain, thus repeat imaging was performed. Pelvic ultrasound on ___ revealed a complex left adnexal lesion measuring 7.7 x 4.8 x 6.6 cm (When compared to the most recent CT, there has been no significant change in the overall size of this structure however, with slightly larger cystic component. Overall no significant change when compared to most recent CT.). On ___ she underwent CT-guided drainage of 42cc of purulent fluid. The drain culture grew prelim 2+ OMNs and anaerobic GNR. She was transitioned to PO Doxycline/Flagyl (___). On ___ her regimen was changed to Levofloxacin/Flagyl. She was discharged on this regimen. *) Left gonadal vein thrombosis: Pt received lovenox 70mg BID throughout this admission. *) Contraception: Pt underwent bedside removal of her Mirena IUD. Pt elected for Depo Provera, and she received an IM dose on ___. By ___, pt's abdomianl pain was minimal, she was afebrile, and her leukocytosis had improved. She was tolerating a regular diet and ambulating without issues. She was then discharged to home in good condition with outpatient follow-up scheduled.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Actos / omeprazole / Fosamax Attending: ___. Chief Complaint: left hip pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ woman with diabetes, hypertension, alcoholism (alcoholic cerebellar degeneration--ataxia), osteoporosis presenting with gradual onset of hip pain, beginning 10 hours prior to presentation to ED. It is a sharp pain that became progressively worse with ambulation. She usually ambulates with a walker and was stil able to bear weight on the left hip, but with increasing pain. This is the second admission to the ED in 2 days, she was discharged yesterday for back pain, now presenting with L-hip pain, tender to touch on presentation to ED, but on the floor patient reports now non-tender to palpation after tylenol. It does not hurt when she tries to move it now. Denies recent illness, fevers/chills, N/V. She had one episode of non-bloody diarrhea on ___, which resolved. This was the last BM. She does not feel constipated now. She notes decreased appetite for ___ weeks, but no weight loss. In the ED, initial VS were T99, HR 107, BP 153/82, RR 16, 100%RA. Labs showed WBC 11.3 (81%pmn), normal lytes and INR. Received 1000mg PO acetaminophen. Transfer VS were HR101, BP 148/62, RR 16, 98% RA. Past Medical History: *Alcohol abuse, c/b ataxia ___ alcoholic cerebellar degeneration and peripheral neuropathy *T2DM, insulin-dependent *Osteoporosis *Osteoarthritis, needs bilateral TKR ___ esophagus *Chronic abdominal pain s/p H. pylori treatment *Obesity *Hypercholesterolemia *Hypertension *Depression *Chronic anemia *PVD, chronic peripheral edema *recurrent cellulitis *ovarian cyst *total abdominal hysterectomy *c sections X 4 *cholecystectomy *appendectomy *ventral hernia Social History: ___ Family History: The patient reports a mother with reported history of breast cancer in the ___, now deceased. She denies a family history of ovarian, uterine, cervical, vaginal, colon, or any other cancers. She reports a family history significant for diabetes, hypertension, hypercholesterolemia, and heart disease. Physical Exam: Admission exam: VS - HR101, BP 148/62, RR 16, 98% RA. General: obese woman, in no distress lying comfortably in bed HEENT: normocephalic Neck: CV: regular rate, rhythm. normal S2, S2. Lungs: clear bilaterally, breath sounds distant. Abdomen: soft, nontender. +BS x4 quadrants Ext: pedal pulses 2+, pitting edema 2+ to knees. Neuro: moving all extremities freely, no gross neuro abnormalities, sensation intact Skin: erythematous patches on bilateral lower extremities to mid-shin with overlying white-yellow hypertrophic scale. pt reports this is chronic. not warm to touch or tender to palpation. Discharge exam: VS - Tc 99.2 HR 79 BP 138-185/74-80, RR 18, 97% RA. General: obese woman, in no distress lying comfortably in bed HEENT: normocephalic CV: regular rate, rhythm. normal S2, S2. Lungs: clear bilaterally, breath sounds distant. Abdomen: soft, nontender. +BS x4 quadrants Ext: pedal pulses 2+, pitting edema 2+ to knees. left hip not tender to palpation, not warm to touch. no pain with active or passive ROM. Neuro: moving all extremities freely, no gross neuro abnormalities, sensation intact Skin: erythematous patches on bilateral lower extremities to mid-shin with overlying white-yellow hypertrophic scale. pt reports this is chronic. not warm to touch or tender to palpation. Pertinent Results: IMAGING: ==================== CT ABD/PEL ___ IMPRESSION: 1. New compression deformity of L3. 2. Multiple chronic findings including small hiatal hernia, complex cystic lesion in the upper pole of the right kidney, ventral abdominal wall hernia, left adrenal adenoma, and right adnexal cyst are unchanged. ==================== MRI HIP ___ READ PENDING as of ___ ====================== PLAIN FILMS OF HIPS ___ FINDINGS: Apparent shortening of the right femoral neck is likely positional. No fracture of the right hip on CT performed two days prior. There is joint space loss of the right hip. There is more severe joint space loss in the left hip. However, there is no fracture or dislocation. The remainder of the left femur is also intact. The partially visualized left knee shows severe degenerative changes with near complete tricompartmental joint space loss, subchondral sclerosis and spurring. IMPRESSION: Degenerative changes in both hips and partially visualized left knee as detailed above but no evidence of fracture or dislocation. Admission labs: ___ 04:56AM BLOOD WBC-11.3* RBC-4.88 Hgb-13.1 Hct-42.1 MCV-86 MCH-26.9* MCHC-31.2 RDW-13.8 Plt ___ ___ 04:56AM BLOOD Neuts-81.5* Lymphs-12.5* Monos-5.2 Eos-0.5 Baso-0.2 ___ 04:56AM BLOOD ___ PTT-30.0 ___ ___ 04:56AM BLOOD Plt ___ ___ 04:56AM BLOOD ESR-37* ___ 04:56AM BLOOD Glucose-176* UreaN-20 Creat-0.8 Na-142 K-4.4 Cl-102 HCO3-23 AnGap-21* ___:56AM BLOOD CRP-69.8* Discharge labs: ___ 06:10AM BLOOD WBC-7.6 RBC-4.39 Hgb-11.8* Hct-37.0 MCV-84 MCH-26.8* MCHC-31.8 RDW-13.6 Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-127* UreaN-17 Creat-0.8 Na-143 K-3.9 Cl-105 HCO3-28 AnGap-14 ___ 06:10AM BLOOD Calcium-9.6 Phos-2.3* Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Levemir 16 Units Lunch 3. Lisinopril 40 mg PO DAILY 4. Metoprolol Tartrate 100 mg PO BID 5. Ranitidine 150 mg PO BID 6. Simvastatin 40 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral BID 9. Docusate Sodium 100 mg PO BID 10. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Levemir 16 Units Lunch 5. Lisinopril 40 mg PO DAILY 6. Metoprolol Tartrate 100 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Ranitidine 150 mg PO BID 9. Simvastatin 40 mg PO DAILY 10. Acetaminophen 1000 mg PO Q6H pain RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*80 Tablet Refills:*0 11. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral BID 12. Miconazole Powder 2% 1 Appl TP TID:PRN fold mycosis 13. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain Duration: 3 Doses RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth q4 Disp #*15 Capsule Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: primary diagnosis: hip pain, osteoarthritis secondary diagnoses: diabetes, hypertension, alcoholism, osteoporosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: Left hip pain. Evaluate for fracture. COMPARISON: CTA of the abdomen and pelvis ___. TECHNIQUE: AP view of the pelvis with additional AP and lateral views of the left femur. FINDINGS: Apparent shortening of the right femoral neck is likely positional. No fracture of the right hip on CT performed two days prior. There is joint space loss of the right hip. There is more severe joint space loss in the left hip. However, there is no fracture or dislocation. The remainder of the left femur is also intact. The partially visualized left knee shows severe degenerative changes with near complete tricompartmental joint space loss, subchondral sclerosis and spurring. IMPRESSION: Degenerative changes in both hips and partially visualized left knee as detailed above but no evidence of fracture or dislocation. Radiology Report EXAMINATION: MR HIP ___ CONRAST LEFT INDICATION: ___ year old woman with left hip pain // fx? TECHNIQUE: Imaging performed at 1.5 TESLA, sequences acquired include coronal T1 and STIR, axial T1, axial T2 fat sat, sagittal oblique axial coronal proton density fat sat weighted sequences. COMPARISON: CT abdomen and pelvis ___, left hip radiographs ___. FINDINGS: Imaging is directed towards evaluation of the left hip joint. Mild degenerative changes seen in the left hip joint (10:11). No marrow edema identified about the hip. There is minimal fluid in both hips, within physiologic limits and without frank joint effusion. There is moderate fatty atrophy of the pelvic girdle muscles. There is mild edema as the origin of the left hamstrings (07:34) which may reflect tendinosis. No edema is identified about the greater trochanter to suggest trochanteric bursitis. The piriformis muscles are symmetric. Degenerative disk disease noted at L5-S1 (04:14). Assessment of the pelvic parenchymal structures is limited, nonetheless a large right anterior abdominal wall hernia is seen (06:18) containing loops of small bowel. There is a 5.6 x 5.2 x 4 cm cystic structure in the right adnexal region (4:8), unchanged compared to multiple prior studies dating back to ___. IMPRESSION: 1. No evidence of a left hip fracture. 2. Possible tendinosis of the left hamstring origin. 3. 5.6 cm cystic structure in the right adnexa region, stable to mildly decreased when compared to prior studies. 4. Mild degenerative change at L5-S1 Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: L Hip pain Diagnosed with JOINT PAIN-PELVIS temperature: 99.0 heartrate: 107.0 resprate: 16.0 o2sat: 100.0 sbp: 153.0 dbp: 82.0 level of pain: 10 level of acuity: 3.0

HOSPITAL COURSE: ___ woman with diabetes, hypertension, alcoholism (alcoholic cerebellar degeneration--ataxia), PVD, osteoporosis, presenting with 1 day of gradual onset of hip pain. Had MRI which showed only osteoarthritis and possible trochanteric bursitis. Stable on oral pain regimen. ___ saw her and recommended rehab. ACUTE ISSUES =============== #Left hip pain No evidence of fracture on plain films. Low suspicion for septic joint (no fever, normal WBC count, able to bear weight, move joint) though ESR, CRP elevated. She was evaluated by orthopedics who recommended ___ aspiration if high suspicion for infection. Ortho considered likely progression of severe osteoarthritis and low back pain. Also thought she may have trochanteric bursitis. Pain is actually more localized to lower back, not localized to left hip joint. Pain well controlled with acetaminophen 1000mg q6h standing dose. Physical therapy evaluation recommended ___ rehab with ___ to improve strength, weight-bearing status, and mobility. #Medicaion list Medications reconciled from OMR. Family/patient do not know most recent meds/doses. Because admitted over the weekend, unable to contact adult daily center who adminsters medication (center is closed ___. CHRONIC ISSUES =============== #Diabetes mellitus, type 2 -Sliding scale insulin, fingerstick qid. #Hypertension -monitor BP -continued home meds, BP stable in systolic 120s-140s TRANSITIONAL ISSUES ===================== ___ benefit from steroid injections given severity of osteoarthritis and chronic pain. Low suspicion for septic hip--"hip" pain described actually localizing to left lower back. ANTICIPATED LENGTH OF STAY AT REHAB IS LESS THAN 30 DAYS

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, positive stress test Major Surgical or Invasive Procedure: None History of Present Illness: ============================================ ___ CARDIOLOGY ADMISSION NOTE ============================================ OUTPATIENT CARDIOLOGIST: Dr. ___: ___. CHIEF COMPLAINT: Chest pain, ? Syncope HISTORY OF PRESENTING ILLNESS: ___ w/___ CAD, CKD and hx of MI ___ years ago treated with Coumadin who is presenting with chest tightness, lightheadedness and syncope after walking up the stairs to her apartment today. Patient has recurrent epistaxis and was seen in the ED this morning for epistaxis and was discharged after her right nares were packed and she had stable labs. She did not had any p.o. intake today. On arrival to her home with her daughter, patient began to have chest tightness and increased lightheadedness while walking up the stairs. At the top of the stairs she slipped down to the floor with her daughter assisting to lower her with questionable loss of consciousness for less than one minute. No head strike. She reports this feels similar to her previous heart attack where she was catheterized but did not receive any stenting or bypass procedures due to "too many blockages." 911 was called and she was brought to the ED by ambulance. On arrival, she was no longer having chest tightness or pain, but endorsed persistent lightheadedness that improved with lying on the stretcher. She denied shortness of breath, nausea, vomiting, diarrhea, persistent bleeding from the nares or elsewhere, vision changes, numbness or blood in the urine or stool. In the ED initial vitals were: 98.6 87 106/70 19 97% RA EKG: NSR, no STE, QTc 516 Labs/studies notable for: Neg troponin, Cr 1.9, positive nuclear stress test Vitals on transfer: Afebrile 74 112/48 18 98% RA On the floor patient reports feeling better. She denies losing consciousness at home. She states she had just felt very weak. She did not notice chest pain or shortness of breath at that time. Currently denies fever, chills, dysuria. Past Medical History: PAST MEDICAL HISTORY: Cataract, nuclear sclerotic senile Positive ___ (antinuclear antibody) Chronic kidney disease, stage IV (severe) Atrial fibrillation CAD (coronary artery disease) s/p MI Hypertension, essential Hypercholesterolemia Macular degeneration Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Physical Exam: PHYSICAL EXAMINATION: VS: Afebrile 137/92 66 20 100% on RA ___: Elderly female in NAD HEENT: NCAT. MMM CARDIAC: RRR without MRG, normal S1 and S2 LUNGS: CTAB without increased WOB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: WWP without edema Neuro: AAOx3, moving all ext, CN II-XII intact Discharge Physical Exam: VS: orthostatics: Lying down 109/65 pulse 60 sitting 114/64, pulse 64 Standing up 97/62 63 bpm ___: Elderly female in NAD HEENT: NCAT. MMM Nasal packing in place CARDIAC: RRR without MRG, normal S1 and S2 LUNGS: CTAB without increased WOB ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: WWP without edema Neuro: AAOx3, moving all ext, CN II-XII intact Pertinent Results: Admission Labs: ___ 07:15AM BLOOD WBC-11.2* RBC-3.50* Hgb-10.2* Hct-34.2 MCV-98 MCH-29.1 MCHC-29.8* RDW-15.9* RDWSD-55.8* Plt ___ ___ 06:49PM BLOOD Neuts-70.4 ___ Monos-6.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.18* AbsLymp-2.57 AbsMono-0.76 AbsEos-0.02* AbsBaso-0.02 ___ 07:15AM BLOOD ___ PTT-37.0* ___ ___ 07:15AM BLOOD Glucose-134* UreaN-25* Creat-1.8* Na-145 K-4.6 Cl-110* HCO3-25 AnGap-15 ___ 06:49PM BLOOD cTropnT-<0.01 ___ 06:49PM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0 Discharge Labs: ___ 07:15AM BLOOD WBC-9.1 RBC-2.71* Hgb-7.9* Hct-26.4* MCV-97 MCH-29.2 MCHC-29.9* RDW-16.1* RDWSD-57.6* Plt ___ ___ 06:49PM BLOOD Neuts-70.4 ___ Monos-6.6 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.18* AbsLymp-2.57 AbsMono-0.76 AbsEos-0.02* AbsBaso-0.02 ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-95 UreaN-21* Creat-1.5* Na-143 K-4.5 Cl-108 HCO3-23 AnGap-17 ___ 07:15AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 ___ 07:45AM BLOOD VitB12-273 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Amiodarone 100 mg PO DAILY 3. Cyanocobalamin 1000 mcg IM/SC MONTHLY 4. Aspirin 81 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Warfarin 1 mg PO 3X/WEEK (___) 9. Warfarin 1.5 mg PO 4X/WEEK (___) 10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 11. Torsemide 5 mg PO 5X/WEEK (___) Discharge Medications: 1. Isosorbide Dinitrate 10 mg PO BID 2. Oxymetazoline 1 SPRY NU BID Duration: 3 Days 3. Amiodarone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 7. Cyanocobalamin 1000 mcg IM/SC MONTHLY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 1 mg PO 3X/WEEK (___) 12. Warfarin 1.5 mg PO 4X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Orthostasis, coronary artery disease Secondary: Anemia, CKD, epistaxis, Afib Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with syncope and chest tightness// ? pneumonia TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ FINDINGS: Moderate to severe cardiac enlargement is unchanged. Mediastinal and hilar contours are similar. Mild atherosclerotic calcifications are seen at the aortic knob. Pulmonary vasculature is normal. Linear opacities in the lung bases likely reflect areas of atelectasis, without focal consolidation. No pleural effusion or pneumothorax is seen. Mild multilevel degenerative changes are noted in the thoracic spine with mild anterior compression deformity of a mid thoracic vertebral body, unchanged. IMPRESSION: Mild bibasilar atelectasis without focal consolidation to suggest pneumonia. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE AMBULANCE Chief complaint: Epistaxis Dizziness, Presyncope Diagnosed with Epistaxis, Unspecified atrial fibrillation Dizziness and giddiness, Essential (primary) hypertension temperature: 98.4 98.6 heartrate: 72.0 87.0 resprate: 18.0 19.0 o2sat: 100.0 97.0 sbp: 184.0 106.0 dbp: 89.0 70.0 level of pain: 4 0 level of acuity: 3.0 2.0

Summary ___ w/pmh CAD, CKD and hx of MI ___ years ago treated with Coumadin who is presenting with chest tightness, lightheadedness and weakness after walking up the stairs to her apartment. She was found to have positive stress test in the ED. On floor she was found to be orthostatic and she improved with IVF. She was also treated for possible UTI. She was discharged home in good condition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: fish products Attending: ___ Chief Complaint: ___ Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with s past medical history of HTN, MR, and ciguatera poisoning who presented with melena. He reports that one week ago he felt the need to have a bowel movement and proceeded to have a large amount of bright red blood per rectum. He is a naturopathic doctor and took something called Soldier Pills to help stop the bleeding. For the following two days he did not have any further bleeding. Then on the third day he had a large amount of black stools along with bright red liquid. He also felt that his stomach was very bloated. He had an additional episode of bleeding after that, he is unsure of when, but decided to go to ___ to seek further medical care. He has not been taking his aspirin and blood pressure medications since he began having bleeding. He reports prior colonoscopy in ___ with adenomas, negative for malignancy. He has a history of mitral regurgitation and is scheduled for upcoming surgery at ___. He has never had symptomatic heart failure and denies shortness of breath. In the ED, he was found to have copious melanotic stool in the rectal vault. Hg remained stable at 12.2. CTA did not reveal source of bleed. He was seen by GI who recommended IV PPI BID, NPO, and possible EGD/colonoscopy in the AM. In the ED he received esomeprazole and IV fluids. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: -s/p cervical and lumbar spinal fusions in last ___ years -s/p ciquatera ingestion ___ -HTN -depression -HFrEF with LVEF 40-45% Social History: ___ ___: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION EXAM ============== GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, systolic murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM ============== GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, systolic murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: =============== ___ 01:50PM BLOOD WBC-5.3 RBC-3.88* Hgb-12.2* Hct-37.0* MCV-95 MCH-31.4 MCHC-33.0 RDW-13.1 RDWSD-45.3 Plt ___ ___ 02:19PM BLOOD ___ PTT-24.9* ___ ___ 01:50PM BLOOD Glucose-113* UreaN-10 Creat-0.8 Na-143 K-4.1 Cl-105 HCO3-26 AnGap-12 ___ 01:50PM BLOOD ALT-20 AST-28 AlkPhos-84 TotBili-0.6 ___ 05:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1 ___ 04:56PM BLOOD Lactate-1.0 DISCHARGE LABS: =============== ___ 05:21AM BLOOD WBC-6.3 RBC-3.73* Hgb-11.8* Hct-36.0* MCV-97 MCH-31.6 MCHC-32.8 RDW-13.2 RDWSD-46.6* Plt ___ ___ 06:05AM BLOOD ___ ___ 06:05AM BLOOD Glucose-102* UreaN-6 Creat-0.9 Na-147 K-4.0 Cl-109* HCO3-27 AnGap-11 ___ 06:05AM BLOOD Calcium-8.4 Mg-2.0 IMAGING: ======== ___ CTA Abd/Pelvis: 1. No active extravasation to localize bleeding in the bowel. 2. No retroperitoneal hematoma or evidence abdominopelvic hemorrhage. 3. Colonic diverticulosis without diverticulitis. 4. Severe stenosis of the celiac origin. 5. Severe hepatic steatosis. 6. Prostatomegaly. PROCEDURES: ========== EGD ___: Impression: Esophagitis in the lower third of the esophagus Scattered erosions in the antrum (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: GI consult service to discuss with inpatient primary team. Follow-up biopsy results Proceed to colonoscopy COLONOSCOPY ___: Impression: Diverticulosis of the primarily in sigmoid colon but also scattered throughout whole colon Grade 1 internal hemorrhoids Two tattoos seen in the sigmoid colon. The area was carefully examined and no residual polypoid tissue was found. No fresh blood, old blood or potential bleeding sources were seen. Most likely source of bleeding is diverticular. Otherwise normal colonoscopy to cecum Recommendations: Repeat colonoscopy in ___ years. GI consult service to discuss with primary team Follow-up CBC with PCP within one week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 3. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: GI bleed Diverticulosis Esophagitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA ABD AND PELVIS INDICATION: History: ___ with bright red blood per rectum and melena for 1 week with Hgb drop of 1 point.//eval for intraluminal extravasation TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 14.0 s, 48.2 cm; CTDIvol = 6.4 mGy (Body) DLP = 297.6 mGy-cm. 2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 3) Stationary Acquisition 5.0 s, 1.0 cm; CTDIvol = 11.6 mGy (Body) DLP = 11.6 mGy-cm. 4) Spiral Acquisition 12.6 s, 48.5 cm; CTDIvol = 15.1 mGy (Body) DLP = 707.4 mGy-cm. 5) Spiral Acquisition 12.6 s, 48.5 cm; CTDIvol = 15.0 mGy (Body) DLP = 703.9 mGy-cm. Total DLP (Body) = 1,735 mGy-cm. COMPARISON: None. FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. There is a replaced right hepatic artery off SMA. Severe narrowing of the celiac origin with post stenotic dilatation is noted (06:37, 12:79). LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout compatible with steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, 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 stones or hydronephrosis. Bilateral hypodensities measure up to 2.8 cm in the lower pole of the left kidney and 2.4 cm in the interpolar region of the right kidney measuring 7 and 2 Hounsfield units, compatible with simple cysts. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Enteric tube terminates in the stomach. Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. There is prominent diverticulosis of the sigmoid colon without wall thickening or surrounding fat stranding to suggest diverticulitis. The rectum is unremarkable. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. No contrast extravasation intraluminally to suggest active site of bleeding. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. No retroperitoneal hematoma. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged measuring up to 6.7 cm in transverse dimension. The seminal vesicles are unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Bilateral small to moderate size inguinal hernias containing fat are noted. IMPRESSION: 1. No active extravasation to localize bleeding in the bowel. 2. No retroperitoneal hematoma or evidence abdominopelvic hemorrhage. 3. Colonic diverticulosis without diverticulitis. 4. Severe stenosis of the celiac origin. 5. Severe hepatic steatosis. 6. Prostatomegaly. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: BRBPR Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 98.0 heartrate: 90.0 resprate: 18.0 o2sat: 97.0 sbp: 163.0 dbp: 80.0 level of pain: 0 level of acuity: 3.0

# GI bleed: # Divertciulosis # Esophagitis/antral erosions Pt presented with alternating melena and BRBPR. Hg was found to be relatively stable, in the ___ range and pt was otherwise hemodynamically stable. He underwent EGD/colonoscopy which showed some esophagitis and antral erosions and severe diverticulosis that were felt to be the most likely source of bleeding (though no active bleeding seen on scopes). Pt was started on a PPI for esophagitis/antral erosions (biopsy pending), counseled on lifestyle modifications for diverticulosis and started on docusate/senna for constipation. He had no further reported melena post-procedure. # Hypertension: Held home lisinopril and metoprolol in the setting of bleed, restarted on discharge Billing: greater than 30 minutes spent on discharge counseling and coordination of care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ breast cancer admitted from clinic after had chest pain and diuresis after getting unit of pRBC in clinic. On arrival to ED, patient's VS were stable, CXR -ve, trops normal, and no further symptoms. However was admitted due to some questionable t wave changes on EKG. Past Medical History: - Coronary artery disease: s/p BMS to proximal ramus (___) - Mitral regurgitation: moderate-severe with MVP/partial flail (___) - Aortic regurgitation: Moderate (TTE ___ - Heart failure: Diastolic. (EF 55% ___ - Hypertension - Dyslipidemia - Permanent atrial fibrillation - CHADS2=3 (age, CHF, HTN). - Pulmonary artery HTN - (PASP of ___+ RA, TTE ___. - Invasive breast cancer T2N3 ER+, HER-2/neu -, s/p left mastectomy on tamoxifen (___) - Chronic kidney disease, stage III: Baseline cr 1.6 - Obstructive sleep apnea, on CPAP Social History: ___ Family History: - Father: Died at age ___ from MI, stroke - Mother: Died at age ___ from bowel cancer - Siblings: Brother with bowel cancer, sister died at ___ - Children: Son, daughter, 5 grandchildren are healthy - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS: 98.8 140/66 94 18 100 RA HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: IRREGULARLY IRREGULAR, LOUD ___ SYSTOLIC MURMUR LOUDEST IN APEX PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits, neuro exam grossly normal, mentating fine, gait normal Pertinent Results: ADMISSION: ___ 10:35AM BLOOD WBC-1.9* RBC-2.79* Hgb-8.0* Hct-25.1* MCV-90 MCH-28.5 MCHC-31.6 RDW-23.1* Plt ___ ___ 10:35AM BLOOD Neuts-64.5 ___ Monos-5.1 Eos-3.3 Baso-1.2 ___ 10:35AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-3+ Macrocy-1+ Microcy-2+ Polychr-NORMAL Ovalocy-2+ Schisto-OCCASIONAL Burr-1+ Pencil-1+ Tear Dr-2+ Bite-OCCASIONAL Fragmen-OCCASIONAL ___ 02:45PM BLOOD Glucose-120* UreaN-29* Creat-1.3* Na-134 K-3.5 Cl-101 HCO3-25 AnGap-12 ___ 02:45PM BLOOD ALT-28 AST-41* AlkPhos-131* TotBili-1.4 ___ 02:45PM BLOOD Lipase-76* ___ 09:33AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 02:45PM BLOOD cTropnT-<0.01 proBNP-1428* ___ 02:45PM BLOOD Albumin-3.4* Calcium-9.5 Phos-2.5* Mg-2.0 ___ 05:30PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE DISCHARGE: ___ 01:05PM BLOOD WBC-2.0* RBC-2.96* Hgb-8.7* Hct-26.4* MCV-89 MCH-29.3 MCHC-32.8 RDW-22.0* Plt ___ CXR ___: Cardiomegaly and interstitial prominence, right greater than left concerning for asymmetric edema versus lymphangitic tumor spread. Diffuse bony metastatic disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Potassium Chloride 10 mEq PO BID 4. Tamoxifen Citrate 20 mg PO DAILY 5. Vitamin D ___ UNIT PO DAILY 6. Apixaban 2.5 mg PO BID 7. Sodium Chloride Nasal ___ SPRY NU QID 8. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride) 1 rinse nasal DAILY:PRN nasal congestion 9. Torsemide 20 mg PO DAILY 10. Metoprolol Succinate XL 12.5 mg PO DAILY 11. Aspirin 81 mg PO DAILY Discharge Medications: 1. Apixaban 2.5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Potassium Chloride 10 mEq PO BID 7. Sodium Chloride Nasal ___ SPRY NU QID 8. Tamoxifen Citrate 20 mg PO DAILY 9. Torsemide 20 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Neilmed Sinus Rinse Complete (sodium bicarb-sodium chloride) 1 rinse nasal DAILY:PRN nasal congestion Discharge Disposition: Home Discharge Diagnosis: Tranfusion Reaction Breast Cancer 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: ___ with CP s/p blood transfusion, history of breast cancer. COMPARISON: Chest x-ray dated ___. FINDINGS: AP upright and lateral chest radiograph. Cardiomegaly is again noted with asymmetric prominence of the interstitial pulmonary markings which raises concern for edema though lymphangitic tumor spread is difficult to exclude. No large effusion is seen. No pneumothorax. Diffuse osseous metastatic disease is re- demonstrated. IMPRESSION: Cardiomegaly and interstitial prominence, right greater than left concerning for asymmetric edema versus lymphangitic tumor spread. Diffuse bony metastatic disease. Gender: M Race: WHITE - RUSSIAN Arrive by WALK IN Chief complaint: Chest pain Diagnosed with CHEST PAIN NOS, ANEMIA NOS, NEUTROPENIA, UNSPECIFIED , MAL NEO MALE BREAST NEC temperature: 98.3 heartrate: 89.0 resprate: 18.0 o2sat: 100.0 sbp: 137.0 dbp: 65.0 level of pain: nan level of acuity: 2.0

HOSPITAL COURSE: Admitted after transfusion reaction to getting one unit of blood in clinic. Hct stable however, outpatient oncologist wanted additional unit of blood given which was then given as inpatient. Given concurrent lasix. # AFIB; continued apixaban, aspirin, metop # CHF; assymetric edma from MR. ___ torsemide and gave additinoal lasix with pRBC # HTN: continued lisinopril # Breast Cancer; continue tamoxifen, will get Bm biospy on next clinic visit # HLD: continued atorva

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Confusion and agitation Major Surgical or Invasive Procedure: ___ Placement History of Present Illness: ___ year old female with ___, CAD s/p CABG, ischemic sCHF (EF 40%), atrial fibrillation on warfarin, T2DM (on insulin), and recent admission for decompression and laminectomy for T9 fracture with cord compression presents with several days of increased confusion and agitation. Her son ___ raised concerns yesterday with PCP that ___ has been ___, calling out names of deceased family members in the middle of the night since she was discharged home from ___. He also reports she had been calling out at night while in rehab during the preceding three weeks. A ___ obtained a UA last week that cultured positive today for two bacteria, per son's report. PCP subsequently sent ___ to ED for further evaluation. She was unable to give a full history in the ED, with significant confusion. Her son endorses that she was taking 1 mg lorazepam at night to help with sleep and has had significant pain around her lower flanks/abdomen requiring up to 200 mg tramadol at night. He denies she had taken any trazodone or oxycodone, or other sleep aids/neuroleptics since coming home. An infectious workup including a head CT, given that she is on Coumadin, was pursued. EKG was notable for afib with no changes from prior result (___.) She is admitted to SIRS with Dr. ___, ___, for ___, UTI, and PNA on CXR. In the ED, initial vitals: - Exam notable for: AOx2, normocephalic/atraumatic head, normal mentation, fluent speech, no CVA tenderness, healed spinal scar with no tenderness/erythema - Labs notable for: UA with 47 WBCs, 5 RBC, 1 epi and 13 hyaline casts, BUN 86, cr up to 1.6 (from 1.1 on ___, eGFR 31, WBC 8.4, Hbg 11/Hct 33.3 (baseline ___, ___ 20.3, INR 1.8. Blood culture x 2 and urine culture pending - Imaging: CT head negative, AP/lat CXR with mild congestion and mild edema with left basal opacity concerning for atelectasis versus pneumonia and possible effusion. - Consultants: Dr. ___ (endocrine)- *be sure* to involve him in any endocrinology-related issues. - Patient was given: 1 L NS, cefepime 2 g IV, vanc 1 g IV, carbidopa-levodopa ___ x 2, Tramadol 50 mg, acetaminophen 1 g - Vitals prior to transfer: ___, 97.4, 56, 130/56, 21, 97% on RA On arrival to the floor, pt is conversant with logical thought process and reports her side pain (along upper pelvic rim) is well controlled. She endorses she has been confused, calling out at night for just the last 2 days, which she attributes to sleep medications (per son, only sleep aid is lorazepam, taking 0.5 mg x2 at night.) She also endorses mild cough, denies SOB, fever, chest pain. Denies dysuria, hematuria, flank pain. Her son reports she had been fecally continent. However, patient was incontinent of urine and feces during interview. Past Medical History: PMH -sCHF with EF 40% -CAD s/p 2 stents, CABG -DIABETES MELLITUS on 10 units lantus QAM and sliding scale 3 units for FSG >150 before meals -HYPERCALCEMIA -HYPERCHOLESTEROLEMIA -HYPERTENSION -HYPOTHYROIDISM -OBESITY -___ DISEASE -MACULAR DEGENERATION -RETINOPATHY -EPIDURAL HEMATOMA PSH -CABG as above -Laminectomy with T6-T11 Instrumentation Social History: ___ Family History: Several family members with MI at early age - mother in ___, brother in ___, and sister in ___. Physical Exam: PHYSICAL EXAM on admission: Vitals: 97.5 58 132/44 20 measured by ___, Sub-I, 93% on RA General: AOx2 (person, place), comfortable appearing HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink. tachy mucus membranes. OP clear. Neck: supple, no LAD, no JVP elevation Lungs: diffuse bilateral crackles lower ___, more dense R>L, no w/r/r CV: irregular, normal S1 and S2, no m/g/r Abdomen: NABS, soft, nondistended, nontender. No HSM. Skin: 1x.05 cm stage 2 ulcer on upper sacrum GU: foley to gravity, urine clear yellow Ext: WWP. 2+ peripheral pulses. No edema. No nail on L ___ toe (secondary to fungus per pt) Neuro: CNs II-XII intact. Grossly normal sensation bilagteral UE and ___. Rest tremor RUE. Grossly normal strength bilateral UE, ___ quads, ___ plantarflexion, ___ dorsiflexion bilaterally PHYSICAL EXAM on discharge: VS: 98.1; ___ 60-70; 20; 97RA Wt: Innacurate Bed Weights, 91kg on transfer to cardiology service but 100kg on day of discharge desite significant diuresis on heart failure service, I/Os: 570/___ 24H GENERAL: obese female, fatigued, opens eyes to voice, answering questions appropriately HEENT: NCAT, MMM, no LAD NECK: JVP 8-10cm Lungs: Upper airway transmitted sounds throughout, no crackles/wheezes CV: irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: non-tender, non-distended, bowel sounds present GU: foley Ext: warm, pulses not palpable, 1+ pitting edema to knees Pertinent Results: ADMISSION LABS: ___ 12:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 12:00PM URINE HYALINE-13* ___ 10:18AM GLUCOSE-122* UREA N-86* CREAT-1.6* SODIUM-136 POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 ___ 10:18AM ALT(SGPT)-10 AST(SGOT)-45* LD(LDH)-460* ALK PHOS-99 TOT BILI-0.7 ___ 10:18AM ALBUMIN-3.0* CALCIUM-9.1 PHOSPHATE-4.2# MAGNESIUM-2.0 ___ 10:18AM WBC-8.4 RBC-3.78*# HGB-11.0*# HCT-33.3*# MCV-88 MCH-29.2 MCHC-33.2 RDW-18.3* ___ 10:18AM ___ PTT-34.7 ___ DISCHARGE LABS: ___ 05:12AM BLOOD WBC-4.4 RBC-3.13* Hgb-9.3* Hct-28.2* MCV-90 MCH-29.7 MCHC-33.1 RDW-18.1* Plt ___ ___ 05:12AM BLOOD ___ PTT-39.8* ___ ___ 05:12AM BLOOD Glucose-148* UreaN-64* Creat-1.6* Na-136 K-3.8 Cl-106 HCO3-22 AnGap-12 ___ 05:12AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9 MICRO: C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ 9AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). Blood Cx: No growth Urine Cx: No growth STUDIES/IMAGING: CT Chest: Increased left lower lobe opacity may be due to atelectasis or pneumonia. Increased small bilateral pleural effusions. Stable mild pulmonary edema. TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild-moderate global left ventricular hypokinesis (LVEF = 40 %). The right ventricular cavity is dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with mild global biventricular systolic dysfunction. Moderate pulmonary artery hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of ___, the findings are similar. The higher PA systolic pressure on current study was found post-Optison, while the non-Optison estimated PA systolic pressure was similar to the prior study. CXR ___: In comparison with the study of ___, the right subclavian catheter has been replaced with one that extends to the mid to lower portion of the SVC. There are extremely low lung volumes with opacification at the left base consistent with volume loss in the lower lobe and pleural effusion. Posterior fusion device in the thoracic spine is again seen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Carbidopa-Levodopa (___) 1 TAB PO TID 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lorazepam 0.5 mg PO ___ TABS QPM PRN insomnia 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Omeprazole 20 mg PO BID 9. Senna 8.6 mg PO BID:PRN constipation 10. Torsemide 20 mg PO BID 11. TraMADOL (Ultram) 50 mg PO ___ TABS BID 12. Glargine 10 Units Breakfast 13. Warfarin 2 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Carbidopa-Levodopa (___) 1 TAB PO TID 5. Insulin SC Sliding Scale Fingerstick TID with meals Insulin SC Sliding Scale using HUM Insulin 6. Lidocaine 5% Patch 1 PTCH TD QPM 7. Ranitidine 150 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Senna 8.6 mg PO BID:PRN constipation 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Torsemide 40 mg PO DAILY 12. Warfarin 0.5 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: - Acute on chronic systolic heart failure with reduced ejection fraction - C. Difficile Infection SECONDARY DIAGNOSIS: - Acute Kidney Injury - IDDM - ___ disease - Atrial Fibrillation - Hypothyroidism - Gastroesophageal Reflux Disease - Anemia 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 EXAMINATION: CHEST (AP AND LAT) INDICATION: ___ with AMS delirum COMPARISON: ___. FINDINGS: AP upright and lateral views of the chest provided. Midline sternotomy wires again noted. Spinal hardware again noted. Previously seen right adjacent venous catheter, skin staples, endotracheal tube and orogastric tubes have been removed. Lung volumes are markedly low. There is consolidation in the left lower lung which was seen on prior exam in may represent effusion, atelectasis versus pneumonia. There is right basal atelectasis also noted. Mild edema and congestion is likely present. No large pneumothorax. Heart size grossly stable. IMPRESSION: Mild congestion and mild edema with left basal opacity concerning for atelectasis versus pneumonia and possible effusion. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ woman with altered mental status and delirium; evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: DLP: 1226 mGy-cm CTDI: 112 mGy COMPARISON: Head CT dated ___. FINDINGS: There is no evidence of acute infarction, hemorrhage, edema, or mass effect. Periventricular and subcortical white matter hypodensities are nonspecific but may represent sequelae of chronic small vessel ischemic disease and are minimally progressed to unchanged compared to the prior exam. Bilateral, symmetric prominence of the ventricles and sulci is also nonspecific, but likely age-related, and is overall stable. No shift of normally midline structures. The perimesencephalic cisterns are patent. Intracranial vascular calcifications are again seen. Bilateral basal ganglia calcifications are unchanged. No fracture. The soft tissues of the calvarium are unremarkable. There is partial opacification of the left ethmoidal air cells. There is mild mucosal thickening of the left maxillary and sphenoid sinuses. The remaining incompletely visualized paranasal sinuses as well as mastoid air cells are clear. Debris in the right external ear canal is probably cerumen. The lens have been replaced; otherwise, the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality, including no intracranial hemorrhage. 2. Overall no change from the prior head CT in ___. Radiology Report EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL) INDICATION: ___ year old woman with hematuria, left flank pain, and elevated creatinine. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Abdominal ultrasound from ___. FINDINGS: The right kidney measures 10.0 cm. The left kidney measures 12.1 cm. There is no hydronephrosis, stones, or suspicious masses bilaterally. A 6 x 8 x 7 mm simple exophytic cyst is seen in the midpole of the left kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is decompressed with a Foley catheter. Limited views of the spleen demonstrate a 1.4 x 1.4 x 1.3 cm simple cyst. IMPRESSION: Essentially normal renal ultrasound with a 8 mm simple cysts in left kidney. No evidence of hydronephrosis or stones bilaterally. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with ?PNA // f/u CXR for pneumonia vs atelectasis. Please evaluate for edema TECHNIQUE: Portable AP radiograph of the chest. COMPARISON: Plain chest radiograph dated ___. Correlation made to thoracic spine CT dated ___. FINDINGS: Lung volumes are low. Chronic small bilateral pleural effusions have increased. Despite vascular crowding, mild pulmonary edema likely persists. The left lower lobe airspace opacity has increased, and is worrisome for pneumonia or atelectasis. The heart and mediastinum are magnified by the projection. Sternotomy wires and spinal fixation hardware are again noted. IMPRESSION: Increased left lower lobe opacity may be due to atelectasis or pneumonia. Increased small bilateral pleural effusions. Stable mild pulmonary edema. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with AMS and questionable PNA seen on CXR // Please evaluate for pneumonia vs pulmonary edema TECHNIQUE: Non-contrast chest CT was performed acquiring sequential axial images from the thoracic inlet through the adrenal glands. Thin section axial, coronal, sagittal and axial MIP's were also obtained. DOSE: Total DLP = 823.23mGy-cm COMPARISON: ___. FINDINGS: The thyroid gland is unremarkable. Several small mediastinal lymph nodes measuring up to 8 mm in short axis in the right lower paratracheal location are stable (2, 17). There are no pathologically enlarged supraclavicular, axillary, or mediastinal lymph nodes. Hilar lymphadenopathy is difficult to exclude in the absence of intravenous contrast. The patient has had prior CABG. Moderate cardiomegaly with multichamber enlargement is unchanged. Moderate aortic annular calcifications are unchanged. Extensive coronary artery calcifications and mitral annular/valvular are also all unchanged. Mild dilatation of the main pulmonary artery to 3.4 cm is also unchanged. Multiple images of the lungs are substantially degraded by respiratory motion artifact, which may limit detection of small nodules and subtle parenchymal lesions. Images were also inadvertently acquired in expiration. Geographic areas of heterogeneous attenuation in the right lung are due to air trapping or mild pulmonary edema. Bilateral bandlike areas of linear and subsegmental atelectasis are present. New moderate right and small left nonhemorrhagic pleural effusions contribute to bilateral subpleural atelectasis. The left pleural effusion is associated with visceral and parietal pleural thickening suggesting chronicity. The large area of dependent left lower lobe consolidation containing aspirated barium is progressive and associated with swirling of the bronchovascular structures, a feature of rounded atelectasis (4, 126). A similar opacity in the lingula is also larger (602, 104). A 2 mm left apical nodule is stable (4, 32). A calcified left upper lobe granuloma is incidentally noted. There is no endobronchial lesion. The patient has had prior cholecystectomy. Extensive vascular calcifications diffusely involve the descending aorta and its tributaries, particularly the splenic artery. There is mild anasarca at both partially imaged flanks. Generalized osteopenia and extensive multilevel spinal degenerative changes are present. The patient has had prior spinal fusion. There are old compression fractures at T8, T9 and L1, as well as old healed bilateral rib and sternal fractures. IMPRESSION: Motion limited exam. No evidence of pneumonia. The increasing opacity left lower lobe opacity seen on recent chest radiograph likely corresponds to progressive left lower lobe rounded atelectasis in the setting of chronic pleural thickening and chronic effusion. T here is also progressive rounded atelectasis in the lingula, and atelectasis in the right lower lobe. These opacities may be followed by chest radiography. Mild pulmonary edema and/or airtrapping. Chronic left pleural thickening. New moderate right and stable small left nonhemorrhagic pleural effusions. Extensive coronary artery calcifications. Stable mild dilatation of the main pulmonary artery suggests pulmonary arterial hypertension. Mild anasarca and small ascites. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with CHF, now hypoxia and crackles // Please eval for edema COMPARISON: ___. IMPRESSION: Low lung volumes persist. Unchanged sternal wires and vertebral fixation devices. Moderate cardiomegaly. Small bilateral pleural effusions and mild pulmonary edema are unchanged. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with picc // r dl picc 42cm iv ping ___ Contact name: ping, ___: ___ COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, the patient has received the new right PICC line. The line is coiled in the subclavian vein and needs to be repositioned. No pneumothorax or other complication. Otherwise unchanged radiograph. Radiology Report INDICATION: ___ year old woman with CHF, ___, and C diff. Bedside PICC malpositioned // Please place PICC COMPARISON: Same day chest radiograph. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings ANESTHESIA: None. MEDICATIONS: None. CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 1.1 min, 3 mGy PROCEDURE: 1. Repositioning of right PICC. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing PICC line was aspirated and flushed and a Nitinol guidewire was introduced into the superior vena cava (SVC). A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava. A double lumen PIC line measuring 43 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Existing right arm approach PICC coiled in the right axillary vein, replaced with a new double lumen PIC line with tip in the distal SVC. IMPRESSION: Successful placement of a 43 cm right arm approach double lumen PowerPICC with tip in the distal SVC. The line is ready to use. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: Evaluate for hemorrhage in a ___ woman status post fall and head strike, with an elevated INR. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 897.1 mGy-cm CTDI: 55.5 mGy COMPARISON: Noncontrast CT head from ___. FINDINGS: There is no evidence of acute large territory infarction, hemorrhage, edema, or mass effect. Prominent ventricles and sulci are suggestive of age-related involutional changes. Periventricular, subcortical, and deep white matter hypodensities are consistent with chronic small vessel ischemic disease. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. Specifically, no evidence of acute hemorrhage. 2. Age-related involutional changes and likely sequela of chronic small vessel ischemic disease. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new o2 requirement // eval for infiltrate, pulmonary edema eval for infiltrate, pulmonary edema IMPRESSION: In comparison with the study of ___, the right subclavian catheter has been replaced with one that extends to the mid to lower portion of the SVC. There are extremely low lung volumes with opacification at the left base consistent with volume loss in the lower lobe and pleural effusion. Posterior fusion device in the thoracic spine is again seen. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.0 heartrate: 60.0 resprate: 18.0 o2sat: 97.0 sbp: 121.0 dbp: 63.0 level of pain: 0 level of acuity: 3.0

___ year old female with ___, CAD s/p CABG, ischemic sCHF (EF 40%), atrial fibrillation on warfarin, T2DM (on insulin), and recent admission for spinal surgery c/b delirium presents with increased confusion and agitation found to have prerenal ___ and pulmonary edema/effusion c/w CHF exacerbation as well as a C. Diff infection. ACTIVE PROBLEMS: #Acute decompensated sCHF (EF 40%): The patient has been followed in ___ clinic by Dr. ___ visit ___, with an EF of 40% per last echo in ___. On admission, the patient had 2+ pitting edema to her calves and diffuse bibasilar crackles, indicating volume overload. Patient with ___ initially on admission so home diuretic held, however volume status worsened. Therefore, patient was transferred to the CHF service for aggressive IV diuresis with lasix gtt with intermittined large dose IV lasix boluses. The patient diuresed well on lasix gtt, however when transitioned to lasix IV boluses alone, had minimal output, though volume status felt to remain stable with only mild pitting edema of lower extremities. At discharge, plan for diuretic regimen of 40mg torsemide daily. #Altered mental status: The patient was oriented to name and place on admission, inattentive, intermittently somnolent and hallucinating conversations with deceased relatives, consist with delirium. Her delirium was initially thought to be a new onset due to pneumonia based on initial CXR with LLL opacity, which was treated with 5 days of antibiotics, but was ultimately determined be an ongoing delirium that had begun in ___ when the patient suffered a T9 compression injury and spinal hematoma requiring complex spinal surgery. Also felt that delerium was acutely worsened ___ CHF exacerbation and C. Diff infection and improved with treatment of each respectively. Pain was controlled with standing tylenol and lidocaine patch to her lower spine. Lantus was discontinued and sliding scale with insulin was administered only for FSG>200. Her Parkinsonism and hallucinations were also concerning for ___ Body dementia, so Haldol was listed as an allergy. Non-pharmacologic measures included having the patient out of bed for meals, avoidance of constraints, bed by window, discouragement of naps, avoidance of overnight vitals/labs/medications, and frequent reorientation. Also discontinued patient's home benadryl and Lorazepam as concern that these medications may be contributing to her delirium/AMS. # C Diff: The patient had ___ large BM on ___, prompting stool culture that was positive for C diff. Given her AMS, she was treated with flagyl 500mg TID. Plan for ___ompleted ___. # ___: The patient had a creatinine of 1.1 in ___ and 1.6 on admission. Given exam consistent with volume overload, low effective circulating volume was likely due to CHF exacerbation. She was initially given IVF, however with worsening volume overload, started on diuresis. Renal function remained stable at 1.3-1.6 which likely represents new patient baseline. ___: The patient was continued carbidopa/levodopa ___ TID during her admission. #Insomnia: The patient has had difficulty sleeping for years, which has acutely worsened since her spine surgery. Trazodone has caused substantial paranoia per her family and seroquel caused profound somnolence during the day, so all sleep aids were stopped. #Atrial fibrillation: The patient was taking 2 mg warfarin at home and has a CHADS2 risk score of 3 for age, DM, and CHF, indicating anticoagulation should be continued. Warfarin given this admission to maintain INR goal of ___. Was discharged on 0.5mg daily due to INR of 3.2 though levels and warfarin requirement fluctated this admission. During week prior to discharge required 8mg total warfarin. #IDDM, type 2: The patient was taking 10 units glargine in the morning with sliding scale of 3 units humalog for glucose levels >150 before meals. However, the majority of her FSGs were in the ___ during her admission with ___ daily measurements <70 that prompted discontinuation of glargine. To avoid hypoglycemia, humalog sliding scale was adjusted to 2 units if glucose >200 before meals. #Instability: the patient has been unable to move her legs against resistance since her spinal compression injury. ___ and OT consults were conducted, which recommended keeping the patient in a rehab facility after discharge. #Anemia: The patient has chronic anemia wit hemoglobin ___. Hbg remained stable this admission. #Hypothyroidism: The patient was continued home levothyroxine 50mcg daily.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: AMS, abd pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ invasive bladder carcinoma s/p b/l PCN, AF on Coumadin, dementia, CHF, HTN, HLD who presents with 1 day of worsening abd pain and fatigue. Patient has dementia and most history gathered from son who was at the bedside. She has bilateral PCNs placed in ___ and changed q3 months, last change one week PTA. Her left PCN was capped one week ago with plans for internalization, per the son. Minimal Foley output for the past few days. This morning he uncapped the L neph tube and noted drainage of 400cc (over the next few hours). No fever, although patient feels more weak and lethargic and complains of lower abdominal pain that improved with uncapping of left nephrostomy tube. No cough, headache, LOC, recent trauma, chest pain, shortness of breath, diarrhea. In the ED, initial vitals were: 99.1 51 142/68 18 99% RA Exam notable for: nephrostomy tubes in place, Foley in place lower abdominal tenderness lungs clear Labs notable for: Chem panel with Cr at 1.8 (less than recent baseline of 2), bicarb 21. CBC with WBC to 11.1, h.h stable with prior. thrombocytosis to 523, above baseline. Lactate 1.4. Grossly positive US from bilateral nephrostomy tubes with pyuria. Imaging notable for: CT abd pelvis w/ contrast: 1. No acute intra-abdominal process. 2. Well-positioned bilateral PCNU stents. No evidence of hydronephrosis. CXR: No report on transfer Patient was given: ___ 14:51 IV CefePIME 2 g ___ ___ 15:30 PO Acetaminophen 1000 mg ___ ___ 15:30 IVF 1000 mL NS 1000 mL ___ ___ consulted and recommended: Patient with bilateral PCNUs, concern for changing status / ?infection. CT obtained and reviewed: both PCNUs in good position, no perinephric, periureteral or intra-abdominal fluid collections, no evidence of hydro (both tubes functioning). No manipulation or intervention for PCNUs required at this time. Vitals prior to transfer: 97.9 50 153/43 16 97% RA On the floor, son reports that patient looks improved but not at her baseline. She seems more tired and weak than she is usually. Patient reports no complaints. Denies any current pain, n/v, SOB, chills, sweats or fever. Past Medical History: high grade sarcomatoid carcinoma of the bladder c/b ureteral obstruction requiring bl PCN s/p TURBT and radiation dementia afib gait instability hypothyroidism hx CVA CHF HLD HTN Family History: Mother had breast cancer Physical Exam: ADMISSION PHYSICAL EXAM Vital Signs: 97.6 PO 137 / 39 50 18 98 RA General: Alert, oriented to self, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE PHYSICAL EXAM VS - 98.6, 150/58, 48, 16, 99% r.a. General: AAO x 1 (self) HEENT: EOMI, no JVD, no LAD Neck: supple CV: irregularly irregular, normal S1/S2, no m/r/g Lungs: CTA b/l= Abdomen: sntnd, + bs GU: nephrostomy tubes in place, no foley Ext: wwp, 2+ Neuro: grossly in tact Pertinent Results: PERTINENT LABS =============== ___ 01:10PM WBC-11.1* RBC-3.07* HGB-8.5* HCT-27.9* MCV-91 MCH-27.7 MCHC-30.5* RDW-17.0* RDWSD-55.9* ___ 01:10PM NEUTS-72.7* LYMPHS-12.9* MONOS-9.5 EOS-3.6 BASOS-0.6 IM ___ AbsNeut-8.09*# AbsLymp-1.44 AbsMono-1.06* AbsEos-0.40 AbsBaso-0.07 ___ 01:10PM proBNP-___* ___ 01:10PM ALBUMIN-3.2* ___ 01:10PM ALT(SGPT)-9 AST(SGOT)-17 ALK PHOS-104 TOT BILI-0.2 ___ 01:10PM LIPASE-41 ___ 01:10PM GLUCOSE-73 UREA N-28* CREAT-1.8* SODIUM-137 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17 ___ 01:25PM URINE RBC-95* WBC->182* BACTERIA-MOD YEAST-NONE EPI-<1 ___ 01:25PM URINE RBC-125* WBC-127* BACTERIA-FEW YEAST-NONE EPI-0 ___ 1:25 pm URINE LEFT NEPHRO. URINE CULTURE (Preliminary): CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | CEFTAZIDIME----------- =>___ R CEFTRIAXONE----------- =>___ R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. melatonin 1 mg oral QHS:PRN insomnia 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Amiodarone 100 mg PO DAILY 4. Levothyroxine Sodium 88 mcg PO DAILY 5. Metoprolol Tartrate 25 mg PO BID 6. Nystatin Cream 1 Appl TP BID 7. Vitamin D 1000 UNIT PO DAILY 8. Sarna Lotion 1 Appl TP QID:PRN itching 9. Lidocaine 5% Patch 1 PTCH TD QAM left shoulder pain 10. TraZODone 25 mg PO QHS:PRN insomnia 11. FLUoxetine 10 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Senna 8.6 mg PO BID:PRN constipation 14. Warfarin 2 mg PO DAILY16 15. amLODIPine 2.5 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 2. Senna 8.6 mg PO BID:PRN constipation 3. Acetaminophen 650 mg PO Q6H:PRN pain 4. Amiodarone 100 mg PO DAILY 5. amLODIPine 2.5 mg PO DAILY 6. FLUoxetine 10 mg PO DAILY 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM left shoulder pain 9. melatonin 1 mg oral QHS:PRN insomnia 10. Metoprolol Tartrate 25 mg PO BID 11. Nystatin Cream 1 Appl TP BID 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Sarna Lotion 1 Appl TP QID:PRN itching 14. TraZODone 25 mg PO QHS:PRN insomnia 15. Vitamin D 1000 UNIT PO DAILY 16. Warfarin 2 mg PO DAILY16 17.hospital bed 18.Outpatient Lab Work On ___ ___ clinic ICD-9: 427.31 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: urinary tract infection 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: Chest: Frontal and lateral views INDICATION: ___ with increasing weakness. // ___ with increasing weakness. TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: This study was made available for my interpretation, today, ___. There may be trace pleural fluid. No definite focal consolidation is seen. Slight increase in interstitial markings bilaterally may be due to mild interstitial edema. No pneumothorax is seen. The cardiac silhouette remains enlarged. The aorta is calcified and tortuous. Old left-sided posterior sixth rib fracture/ deformity is noted. The bones are diffusely osteopenic. IMPRESSION: Possible trace pleural fluid. Cardiomegaly. Interstitial edema. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST. INDICATION: ___ woman with lower abdominal pain and tenderness as well as increased lethargy, history of invasive bladder carcinoma with bilateral PCNU/ TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: DLP: 611 mGy-cm. COMPARISON: Abdominal and pelvic CT ___ FINDINGS: LOWER CHEST: There is bibasilar atelectasis. There are severe coronary artery and aortic valvular calcifications. There is no pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A segment ___ liver hypodensity measuring 9 mm is unchanged and most consistent with a simple cyst. There is mild intrahepatic biliary duct dilation, unchanged. The gallbladder mildly distended without surrounding stranding. PANCREAS: The pancreas has normal attenuation throughout, 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: There are bilateral PCNU stents which appear well-positioned. There is no hydronephrosis. Atrophic right kidney unchanged in appearance. There is a 1.8 x 1.3 cm simple cyst in the left lower pole. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Stomach is decompressed. Small and large bowel are normal in caliber without focal wall thickening. Not visualized but no secondary signs of appendicitis in the right lower quadrant. There is diverticulosis of the sigmoid colon. PELVIS: Streak artifact from right total hip arthroplasty limits evaluation of deep pelvic structures. Within these limitations, a Foley catheter is seen within a decompressed bladder. No large pelvic mass or free fluid is seen. REPRODUCTIVE ORGANS: The reproductive organs are not well seen. 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. There are multilevel degenerative changes of the lumbar spine including mild anterolisthesis of L4-5, also seen previously. In addition there is disc space narrowing at L4-5 and L5-S1. SOFT TISSUES: There is a small umbilical hernia. IMPRESSION: 1. No acute intra-abdominal process. 2. Well-positioned bilateral PCNU stents. No evidence of current hydronephrosis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Lethargy Diagnosed with Urinary tract infection, site not specified temperature: 99.1 heartrate: 51.0 resprate: 18.0 o2sat: 99.0 sbp: 142.0 dbp: 68.0 level of pain: 0 level of acuity: 2.0

___ yo female with w/ invasive bladder carcinoma s/p b/l PCN, AF on Coumadin, dementia presents with 2 days of worsening abd pain and fatigue with pyuria from bilateral nephrostomy tubes. # UTI: Likely explains suprapubic pain and UA notable for significant pyuria. Patient placed on amp/sulbactam (covers both recent e.coli and enterococcus species and she tolerated it during her last admission). Patient transitioned to oral augmentin and stable/improving. Citrobacter sensitive to augmentin came back day of discharge. Pt is to continue augmentin bid x 12 more days (end ___. Pt to continue followup with interventional radiology on ___ regarding her nephrostomy tube care. # AMS: Patient initially more fatigued than baseline likely in the setting of UTI. Suspicion that her left nephrostomy tube which was capped was not draining leading to retained urine and nidus of infection. Patient is HD stable. Now that tube is draining she has source control. Patient placed on amp/sulbactam (covers both recent e.coli and enterococcus species and she tolerated it during her last admission) but transitioned to augmentin as above. Citrobacter sensitive to Bactrim came back day of discharge. Pt is to continue Bactrim DS bid x 12 more days (end ___. Pt at baseline per son at time of discharge. # afib: Pt continued on home Coumadin, metoprolol, amiodarone # HTN: Pt continued on home amlodipine # hypothyroidism: Pt continued on home levothyroxine # Depression: Pt continued on fluoxetine TRANSITIONAL ============= - Pending blood culture x 2 and urine culture x 1 from ___. - Pt to follow-up with radiology on ___ regarding her nephrostomy tube care

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Bactrim Attending: ___ Chief Complaint: cord compression Major Surgical or Invasive Procedure: none History of Present Illness: Mr ___ is a ___ man with hx of bladder CA being treated w radiation who presented to ___ today with quadriplegia. Per patient, he walked towards his front door this morning to open the door for the visiting nurse. Unfortunately, he did not make it to the door. Next thing he remember is that he woke up from the floor. Before he regained conciousness, the visiting nurse had already got a spare key from his neighbor, opened the door, found him down on the floor and called ___. At OSH, He was AAOx3. He was unable to move any limbs and had sensory level at T5 at OSH. MD at ___ pt regained sensation and was able to moves LEs, but Mr ___ says he cannot move legs on command. CT head, neck, T, L, S spine was negative for acute injury. He was transferred to ___ for further evaluation. Of note, he was discharged from ___ yesterday after admission for UTI. At ___, his UA was dirty and he was treated with Vanc and ceftriaxone. Also at ___, he was hypotensive even after IVF bolus and he was started on levophed before he was transferred to ___. ROS is positive for severe neck pain and inability to move all four of his limbs. Pt A&Ox3 and complained of neck pain. MD at ___ pt regained sensation and was able to moves LEs, but stated that he was not in control of them. Cannot move legs on command. 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. No bowel or bladder incontinence or retention that he knows of. (He is quite distracted at this point so ROS is not entirely reliable.) On general review of systems, the pt denies recent fever or chills. Denies cough. Denies chest pain. Past Medical History: Glaucoma Gastritis Vertigo Cholecystectomy GERD Bladder cancer, status post TURBT in ___ followed Dr. ___ ___ History: ___ Family History: No family history of bladder, prostate, testicle, kidney cancer. Physical Exam: ADMISSION PHYSICAL EXAM Physical Exam: Vitals: T:96.7 P:72 R: 16 BP:97/42--->138/75 (s/p IVF bolus and placed on levophed at OSH) SaO2: 97%RA General: Awake, alert, easily distractable. Very hard of hearing In moderate distress. HEENT: NC/AT Neck: in C-collar Pulmonary: Lungs CTA anteriorly Cardiac: RRR Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Neurologic: -Mental Status: Alert, oriented to self, ___, month and year. Date was off by one day. Able to relate history but quite distractable. Language is fluent grossly with normal prosody. 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: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: ?Skew deviation. (left eye slightly elevated compared to right eye.) Otherwise, EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. 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: Normal bulk, decreased tone throughout. He has spontaneous movements in the legs (sliding on the bed) but he is not aware of the movements and insists that he cannot move the legs. No spontaneous movement in the arms. There is no withdrawal in all four extremities to noxious stimuli. -Sensory: (Patient was very inattentive and hard of hearing so exam was difficult) Decreased light touch throughout UE and ___ bilaterally. PP decreased throughout UE and ___ bilaterally as well as chest wall except for L shoulder (~C4) and L chest wall ~T3-5 area. Vibration decreased throughout UE and ___ bilaterally except on L shoulder Loss of proprioception in biilateral fingers, wrists, toes and ankles. -DTRs: ___ diminished ___ bilateral UE and ___. Unable to do augmentation. Plantar response was flexor on the right and mute on the left. -Coordination: Unable to perform -Gait: Unable to perform DISCHARGE PHYSICAL EXAM deceased Pertinent Results: ADMISSION LABS ___ 04:52AM GLUCOSE-139* UREA N-31* CREAT-1.7* SODIUM-140 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16 ___ 04:52AM estGFR-Using this ___ 04:52AM ALT(SGPT)-17 AST(SGOT)-23 ___ 04:52AM CALCIUM-8.2* PHOSPHATE-3.2 MAGNESIUM-2.2 ___ 04:52AM TSH-1.2 ___ 04:52AM WBC-10.9 RBC-3.46* HGB-9.8* HCT-30.6* MCV-88 MCH-28.3 MCHC-32.0 RDW-14.5 ___ 04:52AM PLT COUNT-254 ___ 06:13PM GLUCOSE-209* UREA N-31* CREAT-1.9* SODIUM-135 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15 ___ 06:13PM ALT(SGPT)-20 AST(SGOT)-27 ALK PHOS-82 TOT BILI-0.3 ___ 06:13PM LIPASE-17 ___ 06:13PM cTropnT-<0.01 ___ 06:13PM ALBUMIN-3.3* ___ 06:13PM WBC-12.2* RBC-3.51* HGB-10.0* HCT-30.7* MCV-87 MCH-28.6 MCHC-32.7 RDW-14.5 ___ 06:13PM NEUTS-92.4* LYMPHS-3.8* MONOS-3.3 EOS-0.2 BASOS-0.3 ___ 06:13PM PLT COUNT-318 ___ 06:13PM ___ PTT-27.7 ___ ___ 06:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 06:13PM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 06:13PM URINE RBC->182* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 ___ 06:13PM URINE WBCCLUMP-FEW MUCOUS-RARE MRI + MRA ___ No evidence for acute ischemia. No vascular cutoff in the neck or intracranially. MRI C spine Findings concerning for ALL injury at C6-C7 as well as posterior interspinous ligament injury at the same level. Severe cord compression at C2-C3 and C3-C4 relating to underlying degenerative disc and spondylotic changes. Cord signal increased at C4 likely represents myelomalacia, acute on chronic. No acute post-traumatic changes in the thoracic or lumbar spine. KUB ___ Massively dilated loops of small and large bowel, findings favor ileus over obstruction. Renal US ___ Stable mild right-sided hydronephrosis. Poorly visualized 2.5 cm complex cystic lesion in the left renal upper pole. Recent CT demonstarted a calcified cyst. Urinary bladder could not be assessed. DISCHARGE LABS ___ 03:44AM BLOOD WBC-8.3 RBC-3.31* Hgb-9.4* Hct-30.3* MCV-92 MCH-28.4 MCHC-31.0 RDW-16.3* Plt ___ ___ 03:44AM BLOOD Glucose-146* UreaN-28* Creat-1.9* Na-142 K-3.5 Cl-114* HCO3-20* AnGap-12 ___ 03:44AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.0 ___ 04:52AM BLOOD TSH-1.2 ___ 06:13PM BLOOD Albumin-3.3* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY Discharge Medications: N/a DECEASED Discharge Disposition: Expired Facility: ___ ___ Diagnosis: Primary diagnosis 1. acute cord compression 2. spinal shock 3. ileus 4. hypotension 5. klebsiella urinary tract infection, Discharge Condition: N/a DECEASED Followup Instructions: ___ Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: New-onset paraplegia. Assess line. Comparison is made with prior study ___. Left subclavian catheter tip is in the mid SVC. There is no pneumothorax. Cardiac size is normal. The aorta is tortuous. Minimal increased opacities in the left lower lobe are worrisome for aspiration. There is no pleural effusion. Radiology Report HISTORY: ___ male with quadraparesis and a distended abdomen, assess for obstruction or ileus. COMPARISON: CT abdomen and pelvis ___. FINDINGS: One frontal view of the abdomen shows multiple air-filled dilated loops of small and large bowel. The cecum measures up to 1.2 cm. There is a paucity of gas in the rectum. There is no pneumatosis or secondary evidence of free air. There are surgical clips noted in the right upper abdomen. In addition, there are degenerative changes of the visualized osseous structures. IMPRESSION: Massively dilated loops of small and large bowel, findings favor ileus over obstruction. Critical findings were communicated to Dr. ___ by Dr. ___ the telephone on ___ at 10:15, 15 min after findings were made. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with SPINAL CORD INJURY NOS, UNSPECIFIED FALL temperature: 96.7 heartrate: 72.0 resprate: 18.0 o2sat: 97.0 sbp: 138.0 dbp: 75.0 level of pain: 0 level of acuity: 1.0

Mr ___ is a ___ man with hx of bladder CA being treated w radiation who was found down in the setting of sudden onset inability to move all four extremities. Neuro exam is remarkable for quadraparesis, decreased PP in all fours. MR of the whole spine was remarkable for cord compression at C2-C3 and C3-C4 spinal stenosis with cord flattening and acute on chronic myelomalacia. Mr ___ presentation is likely ___ to compression of the cervical cord s/p fall. Spine surgery was consulted. There is no need for steroid at this time. Surgical decompression was considered but was not thought to be appropriate given his age and likely a small chance of benefit for recovery of his function. Also, patient himself is not sure about whether he wanted to undergo the surgery. He was kept in the ICU on pressors due to hypotension from spinal shock. He also developed an ileus requiring flexiseal placement. He also developed a UTI which was treated with CTX. With continued hypotension requiring pressors, a meeting was held with the patient (who remained lucid with capacity per psych eval) and family, in which the patient clearly stated he wished to be made DNR/DNI as well as CMO and Do Not Hospitalize. He felt he would have poor quality of life as a quadraparetic. Per the patient's wishes he was taken off pressors and transfered to the floor. He remained hypotensive but was intermittently awake. He required pain control for severe neck pain, and sometimes got delerious or sleepy with the pain medication. On the afternoon of ___, he expired. The family was notified and autopsy was declined.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / narcotics Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of lung cancer and a LLL lobectomy presents with 1day cough, shortness of breath. Ms. ___ states that on ___ she felt completely well with no symptoms. Waking up on ___ she felt that her asthma symptoms were worsening due to ragweed, but albuterol provided no relief. She had persistent cough productive of non-bloody phlegm that is mostly clear. She also felt short of breath and was experiencing wheezing. Fever of 104 at ___. CTA negative for PE but showed parenchymal necrosis of RLL. Given Vanc/CTX, Zosyn, levaquin as well as 125mg solumedrol. Transferred to ___. Rec'd ceftriaxone 1g at 1525. Rec'd levaquin 750mg at 1624. Rec'd Venco 1750mg at 1723. Also rec'd solumedrol 125mg at 1456 and IV Tylenol and 2L NS at OSH. Received 2L NS at outside hospital. In our ED initial vitals T97.5, HR 81, BP 124/59, RR20, 93% on nasal cannula. Labs notable for WBC 19.5 (90% PMN), Blood Glucose 225, Lactate 3.4, 7.47/32. On arrival to the MICU, she was saturating >95% on 2L n/c. ROS as above, but somewhat limited on admission given acute respiratory illness. Past Medical History: - Congestive heart failure - Not on Lasix due to hx hypotension/hypokalemia - R eye shingles - on daily prednisone drops - Mechanical fall and found to have sustained a T8 compression fracture Underwent kyphoplasty by neurosurgery ___ - Asthma - Hypothyoridism - Anxiety - Transient ischemic attacks - Degenerative joint disease - Lung cancer, status post left lower lobe lobectomy in ___, no chemo or radiation - COPD - Glaucoma - Peripheral neuropathy - osteoporosis - Asthma - Bone scan on ___ which showed an abnormal intake in the region of medial left clavicle the chest CT a on admission showed old healing fracture of the left clavicular head Surgical History Appendectomy, hysterectomy, sinus surgery and tonsillectomy. Social History: ___ Family History: Mother: ___ ___ from MI Father: ___ ___ from emphysema Sister: ___ ___ from heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: T98.4, HR 76, BP104/84, RR19, SaO2 97%2LN/c GENERAL: Tired, well appearing woman sitting in bed speaking to me comfortably HEENT: Pupils equal and reactive, no scleral icterus, moist mucous membranes NECK: No JVD LUNGS: Loud wheezes in R lung base, otherwise no wheezing or rhonchi, intermittently coughing during exam but no respiratory distress CV: S1/S2 regular with no murmurs, rubs or S3/S4 ABD: Soft, non-tender, nondistended EXT: No lower extremity edema, warm extremities NEURO: A+Ox3, no gross abnormalities DISCHARGE PHYSICAL EXAM ======================== VS: 97.6 112/59 hr92 rr18 93%2l GENERAL: Elderly woman in NAD HEENT: Moist mucus membranes. Conjunctival erythema on right eye HEART: Regular rhythm this morning, no murmur rubs or gallops LUNGS: Crackles at right mid to lower lung field, a few crackles at left lower base. Otherwise clear to auscultation without wheeze. No use of accessory muscles. ABDOMEN: Soft, nondistended, nontender EXTREMITIES: warm, no edema NEURO: Face grossly symmetric, alert, oriented to date, location, medical situation SKIN: Erythematous macular rash present on right buttocks. Pertinent Results: ADMISSION LABS: ============== ___ 09:10PM WBC-19.5* RBC-3.93 HGB-13.1 HCT-37.8 MCV-96 MCH-33.3* MCHC-34.7 RDW-12.0 RDWSD-42.0 ___ 09:10PM NEUTS-90.0* LYMPHS-3.0* MONOS-5.5 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-17.56* AbsLymp-0.58* AbsMono-1.08* AbsEos-0.00* AbsBaso-0.03 ___ 09:16PM LACTATE-3.4* ___ 09:16PM O2 SAT-89 ___ 09:16PM ___ PO2-56* PCO2-32* PH-7.47* TOTAL CO2-24 BASE XS-0 ___ 03:45AM GLUCOSE-211* UREA N-15 CREAT-0.8 SODIUM-139 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15 INTERVAL LABS/MICROBIOLOGY =========================== Sputum, induced: NEGATIVE FOR MALIGNANT CELLS. 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. MRSA SCREEN (Final ___: No MRSA isolated. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Blood cultures: NGTD ___ 04:55AM BLOOD %HbA1c-6.1* eAG-128* ___ 06:24AM BLOOD TSH-3.3 ___ 06:45PM BLOOD Vanco-20.5* ___ 07:55PM BLOOD Vanco-13.5 ___ 06:15AM BLOOD Vanco-11.9 IMAGING =================== ___ CXR A roughly 4 cm wide thick walled ring shadow projects lateral to the right descending pulmonary artery. Perhaps this is the referenced necrotizing pneumonia. It looks more like a mass or abscess, but should be reviewed on the chest CT scan when that becomes available. A d 3 cm wide oval radiopacity also projecting over the right hilus is presumably cement in the mid thoracic vertebral body but that 2 would need to be confirmed. Lungs are otherwise clear. Heart size is normal and pleural effusions small if any. No pneumothorax. DISCHARGE LABS =================== ___ 05:55AM BLOOD WBC-6.1 RBC-3.03* Hgb-10.3* Hct-30.0* MCV-99* MCH-34.0* MCHC-34.3 RDW-12.2 RDWSD-42.9 Plt ___ ___ 05:55AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-138 K-4.2 Cl-100 HCO3-27 AnGap-11 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Gabapentin 200 mg PO TID 3. ALPRAZolam 0.5 mg PO QHS 4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 5. Tiotropium Bromide 1 CAP IH DAILY 6. Montelukast 10 mg PO QHS 7. Calcitonin Salmon 200 UNIT NAS DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY 10. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze 11. azelastine 2 spray nasal BID 12. Atorvastatin 20 mg PO QPM 13. Senna 17.2 mg PO QHS 14. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Benzonatate 100 mg PO TID:PRN cough 3. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough 4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H wheezing 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Rivaroxaban 15 mg PO BID RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by mouth twice a day Disp #*1 Dose Pack Refills:*0 7. Vancomycin 1250 mg IV Q 12H 8. ALPRAZolam 0.5 mg PO QHS RX *alprazolam 0.5 mg 1 tablet(s) by mouth at night Disp #*2 Tablet Refills:*0 9. Atorvastatin 20 mg PO QPM 10. azelastine 2 spray nasal BID 11. Calcitonin Salmon 200 UNIT NAS DAILY 12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 13. Gabapentin 200 mg PO TID 14. Levothyroxine Sodium 88 mcg PO DAILY 15. Montelukast 10 mg PO QHS 16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY 17. Senna 17.2 mg PO QHS 18. Tiotropium Bromide 1 CAP IH DAILY 19. Vitamin D ___ UNIT PO DAILY 20. HELD- Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze This medication was held. Do not restart Albuterol Inhaler until you are off the nebulizer version Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis ================ MRSA necrotizing pneumonia Atrial fibrillation Secondary diagnosis ================ Osteoporosis Hypothyroidism COPD 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: ___ year old woman with CT findings consistent with necrotizing PNA// Eval for PNA Eval for PNA IMPRESSION: No prior chest images available for review. A roughly 4 cm wide thick walled ring shadow projects lateral to the right descending pulmonary artery. Perhaps this is the referenced necrotizing pneumonia. It looks more like a mass or abscess, but should be reviewed on the chest CT scan when that becomes available. A d 3 cm wide oval radiopacity also projecting over the right hilus is presumably cement in the mid thoracic vertebral body but that 2 would need to be confirmed. Lungs are otherwise clear. Heart size is normal and pleural effusions small if any. No pneumothorax. Radiology Report EXAMINATION: Chest radiograph PA and lateral INDICATION: ___ year old woman with necrotizing MRSA pneumonia not improving, with ongoing new AF and wheezing// evaluate for evidence of heart failure, interval changes in pna TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Lung volumes are low. There is a perihilar right lower lobe opacification concerning for pneumonia. There are bilateral pleural effusions. Heart size is top-normal. Evidence of thoracic vertebral kyphoplasty. IMPRESSION: Right lower lobe pneumonia. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with picc// s/p r 47cm picc ___ ___ Contact name: ___: ___ TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___ 15:36 IMPRESSION: Compared to the earlier same day examination, there has been placement of a right-sided PICC which is malpositioned coursing in the right internal jugular vein with the tip outside of field-of-view. There is no other interval change with persistent low lung volumes and right perihilar and lower lobar consolidation unchanged. There may be tiny bilateral pleural effusions. There is no new consolidation. There is no pneumothorax. Mid thoracic vertebroplasty changes are seen. NOTIFICATION: The findings were discussed with ___ of the venous access team by ___, M.D. on the telephone on ___ at 5:48 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with malplaced picc, repositioned// confirm positioning TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___ 17:30 IMPRESSION: Compared to the examination from roughly 1 hour prior, the right PICC remains malpositioned coursing through the right internal jugular vein and requires repositioning. No interval changes seen. Radiology Report INDICATION: ___ year old woman with malpositioned picc// reposition picc. thank you! COMPARISON: Chest x-ray from ___ TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure. Dr. ___ supervised during the key components of the procedure and has reviewed and agrees with the findings. ANESTHESIA: None. MEDICATIONS: None CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 0.9 min, 6 mGy PROCEDURE: 1. Repositioning of right PICC. PROCEDURE DETAILS: Under real-time fluoroscopic guidance, the existing PICC line was flushed multiple times and successfully repositioned from the right internal jugular vein into the right atrium. Due to distal positioning within the lower right atrium, the existing PICC line was retracted with tip at the cavoatrial junction. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Existing right arm approach PICC with tip in the right internal jugular vein repositioned with tip in the cavoatrial junction. IMPRESSION: Successful repositioning right arm approach single lumen PowerPICC with tip in the cavoatrial junction. The line is ready to use. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Fever, Transfer Diagnosed with Pneumonia, unspecified organism temperature: 97.5 heartrate: 81.0 resprate: 20.0 o2sat: 93.0 sbp: 124.0 dbp: 59.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is a ___ year old woman with a history of LLL lung cancer s/p resection in ___ (no chemo/radiation) who presents with hypoxia and a necrotizing MRSA pneumonia of the RLL.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: back pain Major Surgical or Invasive Procedure: right L4-5 microdiscectomy History of Present Illness: ___ yo M s/p L4-5 right microdiscectomy on ___ with Dr. ___ presents with progression of radicular symptoms. Pt was seen and evaluated in the ED on ___. In brief the patient developed worsening low back pain ___ weeks ago. He saw his chiropractor for manipulation, underwent massage therapy and cupping therapy but the pain worsened and he developed right leg radicular pain approximately 1 week ago, similar to his preoperative pain. Subsequently he started ___ on ___. On the morning of ___ he had significant pain and presented to the ED. An MRI was recommended at that time however pt elected not to wait for the MRI and wanted to follow up outpatient. Today he developed worsening back pain and new left leg radicular pain into buttock and posterior thigh. He feels the right leg is "going dead" with tingling and pins and needles in the thigh. Denies Saddle anesthesia, denies numbness in his groin or perianal region, denies bowel or bladder incontinence, denies new weakness but has increasing difficulty walking due to pain. Past Medical History: depression, hyperlipidemia Right hand and knee surgery and lithotripsy. Social History: ___ Family History: Cancer, diabetes. Physical Exam: Physical exam on admission: O: T:97.3 HR 88 BP 112/80 RR 16 98% RA Gen: WD/WN, significanat discomfort Extrem: Warm and well-perfused. Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: IP Q H AT ___ G R 5 5 5 5 5 5 L 5 5 5 5 5 5 Sensation: Intact to light touch bilaterally. Reflexes: Pa Ac Right 1+ 1+ Left 1+ 1+ Toes downgoing bilaterally Physical exam on discharge: Gen: WD/WN, significanat discomfort Extrem: Warm and well-perfused. Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: IP Q H AT ___ G R 5 5 5 5 5 5 L 5 5 5 5 5 5 Sensation: Intact to light touch bilaterally. Reflexes: Pa Ac Right 1+ 1+ Left 1+ 1+ Toes downgoing bilaterally Dressing over his midline back is clean, dry and intact without surrounding erythema, induration, or palpable fluctuance. Pertinent Results: unremarkable. Medications on Admission: Klonopin 0.5 mg tablet 1 tablet(s) by mouth twice daily as needed ___ Multivitamin For Men 200 mcg-175 mcg-250 mcg 1 tablet daily Vicodin 5 mg-300 mg tablet 2 tablet(s) by mouth every 6 hours PRN atorvastatin 20 mg tablet 1 tablet(s) by mouth once a day ibuprofen 100 mg tablet (dose uncertain) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 20 mg PO QPM 3. Methylprednisolone 8 mg PO DAILY Duration: 24 Hours This is dose # 5 of 7 tapered doses RX *methylprednisolone [Medrol] 2 mg 1 tablet(s) by mouth four times a day Disp #*4 Tablet Refills:*0 4. Methylprednisolone 4 mg PO DAILY Duration: 24 Hours This is dose # 6 of 7 tapered doses RX *methylprednisolone [Medrol] 2 mg 1 tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0 5. Methylprednisolone 2 mg PO DAILY Duration: 24 Hours This is dose # 7 of 7 tapered doses 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 6 hours Disp #*12 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: L4-L5 radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE INDICATION: ___ year old man with recurrent radiculopathic pain.// ? etiology of radiculopathy ? etiology of radiculopathy TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 33.6 cm; CTDIvol = 27.2 mGy (Body) DLP = 913.9 mGy-cm. Total DLP (Body) = 914 mGy-cm. COMPARISON: Lumbar spine MRI from an outside facility of ___ MRI total spine of ___ FINDINGS: There is no evidence of fracture or subluxation. The patient is status post right L4 hemilaminectomy with a small amount of postoperative fluid at the surgical site. Multilevel degenerative changes are better assessed on lumbar spine MRI of ___. These changes are most severe at L4-5 where a central disc protrusion causes severe canal narrowing and moderate to severe bilateral neural foraminal narrowing. A disc bulge at L3-4 in combination with ligamentum flavum hypertrophy causes moderate canal narrowing. Neural foraminal narrowing is also mild bilaterally at L3-4 and moderate on the left and mild on the right at L5-S1. Bilateral nonobstructing calculi are demonstrated in the kidneys, measuring up to 5 mm in the right upper pole collecting system. Moderate atherosclerotic calcifications of the abdominal aorta and iliac vessels are present. IMPRESSION: 1. No evidence of fracture or malalignment. 2. Central disc protrusion at L4-5 causes severe canal narrowing and moderate to severe bilateral neural foraminal narrowing, better assessed on MRI of the lumbar spine from the day prior. 3. Additional mild-to-moderate degenerative changes as described above. 4. Status post right L4 hemilaminectomy with a small amount of postoperative fluid at the surgical site. Radiology Report EXAMINATION: L-SPINE FLEX AND EXT (2 VIEWS) INDICATION: ___ year old man with radicular pain// stability? TECHNIQUE: 2 lateral views of the lumbar spine, 1 labeled flexion the other labeled flexion. COMPARISON: L targeted review of L-spine CT from ___. L-spine radiographs from ___ at FINDINGS: There is limited range of motion on the flexion view, where there are 5 non-rib-bearing vertebral bodies. No vertebral body compression. Mild degenerative spurring at multiple levels, with slight disc space narrowing at L4/5 and L5/S1 and trace retrolisthesis at L5/S1. Moderate to moderately severe facet arthrosis, worst from L3 through S1. Scattered aortic calcification. On the extension view, no gross change in alignment. IMPRESSION: Mild multilevel discogenic degenerative changes, most pronounced at L4-S1 and moderate to moderately severe facet degenerative changes worst from L3-L1. Trace retrolisthesis at L4/5. No gross change in alignment detected on flexion/extension views. Limited range of motion in flexion. Radiology Report EXAMINATION: LUMBAR SINGLE VIEW IN OR INDICATION: Posterior L4-L5 microdiskectomy TECHNIQUE: Single lateral view of the lumbar spine obtained in the OR without radiologist present COMPARISON: Lumbar spine radiographs ___ and CT lumbar spine ___ FINDINGS: The single available image shows surgical equipment positioned at the posterior elements of L4. Please see the operative report for further details. Radiology Report EXAMINATION: MRI OF THE THORACIC SPINE WITHOUT CONTRAST INDICATION: *** CODE CORD *** History: ___ with microdiscectomy L5 5w/a. Saw ___, unilat R radiculopathy and benign exam. Now bilateral pain and BLE weakness on examIV contrast to be given at radiologist discretion as clinically needed// eval for central cord compression, post op complication, infection TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the thoracic and the lumbar spine were acquired. T1 sagittal and axial images obtained following the administration gadolinium. COMPARISON: ___. FINDINGS: Thoracic spine: Mild multilevel degenerative changes seen. There is no spinal stenosis or cord compression. No abnormal signal seen within the spinal cord. Incidental hemangiomas are seen in the thoracic vertebral bodies. Lumbar spine: Since the previous study, the patient has undergone right-sided hemilaminectomy. There is a central disc herniation seen which compresses the thecal sac and demonstrates marginal enhancement indicative of epidural scarring. Findings are consistent with a recurrent disc herniation with a moderate-to-severe spinal stenosis. Small amount of fluid the laminectomy sites at appear postoperative in nature. There is no evidence of enhancement of the vertebral margins or indistinct vertebral margins or enhancement within the disc to indicate discitis or osteomyelitis. Mild degenerative changes in the lumbar region again seen. IMPRESSION: 1. Recurrent disc herniation at L4-5 level with compression of the thecal sac and resulting in moderate-to-severe spinal stenosis at this level. 2. Mild degenerative changes at other levels in the lumbar region unchanged from the previous MRI. 3. No evidence of cord compression in the thoracic region. No abnormal signal within the thoracic spinal cord up to conus level. 4. Small amount of fluid the laminectomy site appears postoperative in nature. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Back pain, Weakness, Transfer Diagnosed with Other dorsalgia temperature: 97.3 heartrate: 88.0 resprate: 16.0 o2sat: 98.0 sbp: 112.0 dbp: 80.0 level of pain: 3 level of acuity: 2.0

___ with a history of anxiety presents with radiculopathy and is now status post right L4-L5 microdisectomy. #radiculopathy: Patient presented with back pain 6 weeks L5-S1 microdisectomy for radiculopathy. His neurological exam was intact. He was admitted for pain control and right L4-L5 microdisectomy. His procedure was complicated by CSF leak and he was kept flat on bedrest for 48 hours post-operatively. After 48 hours the head of his bed was advanced and he ambulated easily around the unit without difficulty. He was tolerating a diet and voiding appropriately. He was discharged home in stable condition. #Anxiety: His Klonipin for anxiety was continued while he was inpatient. #hyperlipidemia: his atorvastatin for hyperlipidemia was continued while he was inpatient.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: shellfish derived / peanut Attending: ___. Chief Complaint: Right lower quadrant abdominal pain Major Surgical or Invasive Procedure: ___: Open appendectomy, small bowel resection History of Present Illness: Mr ___ is a ___ yo M s/p laparascopic drainage for an appendiceal abscess on ___ now presenting with recurrent right lower quadrant pain. He states the pain began last evening. It began with a crampy quality. It has become progressively more severe. It is worst in the right lower quadrant though does extend across his lower abdomen. He has relief when he lies still with his back slightly elevated. He tried some tylenol for pain relief without effect. He did note that on the ride to the hospital he had sharp abdominal pain with bumps in the road. He denies fevers, chills, or night sweats. Denies nausea or vomiting. Denies anorexia though the last time he had anything to eat was 3PM yesterday. He has had two episodes of diarrhea over the past 24 hours. Review of systems: negative for chest pain, shortness of breath, new bleeding or bruising problems, dysuria, frequency, urgency, lower extremity swelling, blood per rectum, vision changes or hearing changes. Past Medical History: Asthma Hypercholesterolemia Social History: ___ Family History: Father deceased age ___ from complications of "lung and prostate cancer" Mother deceased age ___ from lung CA 7 brothers, 2 sisters in reported ___ Physical Exam: VS: Temp 98.7, HR 81, BP 153/82, RR 18, SpO2 98%RA GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: Soft, mildly tender to palpation incisionally, non-distended. Incisions: clean, dry and intact, with staples on top half of wound. Wound vac in place on lower half of wound. No erythema or fluctuance noted. EXTREMITIES: Warm, well perfused, pulses palpable, (+/-) edema. Pertinent Results: CT Abdomen/Pelvis (___): Findings suggest recurrent acute appendicitis with severe inflammatory changes in the right lower quadrant with tethering of adjacent small bowel. No macro perforation or discrete abscess though small phlegmon difficult to exclude. Medications on Admission: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Recurrent appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with lower abd pain. Pt had appendiceal abscess in ___. Now with one day of lower abd pain, max tender RLQ. TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and submitted to PACS for review. No oral contrast was administered. DOSE: DLP: 883 mGy-cm (abdomen and pelvis. COMPARISON: CT abdomen pelvis on ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: A subcentimeter hypodensity in the right lobe is too small to characterize but unchanged, otherwise the liver demonstrates homogenous attenuation throughout with no evidence of other focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, 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 stones, focal renal lesions or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: The appendix is hyperemic and dilated up to 13 mm in diameter. There is small bowel tethered to the inflamed appendix with adjacent fat stranding and small amount of free fluid. No discrete abscess is seen though early phlegmonous changes difficult to exclude. No free air is present. Sigmoid colon is partially tethered as well with minimal reactive thickening is noted. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits BONES AND SOFT TISSUES: Unremarkable. IMPRESSION: Findings suggest recurrent acute appendicitis with severe inflammatory changes in the right lower quadrant with tethering of adjacent small bowel. No macro perforation or discrete abscess though small phlegmon difficult to exclude. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ at 14:15 on ___ in person at time of discovery. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ACUTE APPENDICITIS NOS temperature: 98.0 heartrate: 102.0 resprate: 16.0 o2sat: 98.0 sbp: 129.0 dbp: 84.0 level of pain: 5 level of acuity: 3.0

The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of right lower quadrant abdominal pain. Admission abdominal/pelvic CT revealed recurrent acute appendicitis with severe inflammatory changes in the right lower quadrant with tethering of adjacent small bowel. No macroperforation or discrete abscess though small phlegmon was difficult to exclude. WBC was elevated at 16.3. The patient underwent open appendectomy with small bowel resection on ___, which went well without complication (reader referred to the Operative Note for details). His PACU stay was uneventful and the patient was transferred to the floor. A wound vac was placed on the lower half of his midline abdominal incision on ___. This vac was changed on the day of discharge (___). When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient had slow return of bowel function, and did not pass flatus until hospital day 6. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Home ___ services were set up to assist the patient with wound care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right lower quadrant pain Major Surgical or Invasive Procedure: IV antibiotics History of Present Illness: ___ yo G0 transferred from ___ ED with RLQ and 17 cm right adnexal mass. RLQ pain suddenly developed ___ morning. Since then the pain has been constant. She was initially able to carry on with her usual activities, but it has become progressively worse since then. Yesterday she began to feel dizzy and lightheaded and by ___ afternoon she was no longer able to ambulate and carry on with daily activities and as a result presented to ___ ED. While there a transabdominal ultrasound (TAUS) revealed a "uterus measuring 6 x 3.4 x 4.2 cm. The endometrial echocomplex measured 6 mm. A distinct right ovary not delineated. Tubular cystic areas in the right adnexa noted, one measuring 10.9 x 11.4 x 12.9 cm and the other measuring 6.5 x 4.7 x 7.6 cm. There is some flow in the septation between these cysts. Left ovary measures 6 x 1.7 x 2.1 cm and demonstrates no definite abnormality. No free fluid." She subsequently had a pelvic/abdominal CT that showed "mild to moderate right-sided hydronephrosis with mild to moderate right hydroureter. A transition is in the pelvis at the site of a large pelvic mass. No stones are seen. Left kidney ureter demonstrates normal caliber. The appendix is visualized and is unremarkable. The visualized colon is unremarkable. No adenopathy is seen. No free fluid or free air. A large septated cystic structure is identified, extending from the right adnexa into the abdomen, measuring 16.9 x 10.0 x 13.0 cm. No uterine abnormality is seen. Left ovary is not well delineated. No free fluid is seen." At the OSH she was febrile to a tmax of 100.7 and tachycardic to 133. While at the OSH she received one dose of 2 g IV ceftriaxone given concern for pyelonephritis. She was then transferred to ___ ED for further management. Her pain was ___. She reported resolution of pain at the OSH after receiving 4 mg IV morphine. Denies n/v. Last ate ___ morning. Reported dysuria and hematuria since ___. Denied fevers. Reported palpitations. Last bowel movement was yesterday. She also developed light vaginal bleeding which is abnormal for her given she is in the middle of her cycle and her bleeding is usually very regular. Past Medical History: OB: G0, virginal GYN: - LMP: ___, menses once a month, last 7 days, denies dysmenorrhea, heavy menses - Sexually active: virginal, denies any form of sexual activity - STIs: denies - Contraception: denies - Pap: ? ___ years ago - h/o endometriosis, fibroids, cysts: denies PMH: denies PSH: denies Social History: ___ Family History: ___: - Paternal aunt cervical cancer - ___ great grandmother with cervical cancer - Denies breast, ovarian and colon cancer Physical Exam: TMax 100.2 TCurr 98.3PO BP 103 / 65 HR 100 RR 18 SpO2 99 ra General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: softly distended, +TTP and fullness RLQ without rebound or guarding, +CVAT slightly improved from yesterday Extremities: no edema, no TTP, pneumoboots in place bilaterally Pertinent Results: ___ 07:25AM BLOOD WBC-9.2# RBC-3.97 Hgb-9.8* Hct-32.1* MCV-81* MCH-24.7* MCHC-30.5* RDW-14.3 RDWSD-42.3 Plt ___ ___ 07:25AM BLOOD Neuts-70.8 Lymphs-16.0* Monos-11.0 Eos-1.7 Baso-0.1 Im ___ AbsNeut-6.47*# AbsLymp-1.46 AbsMono-1.01* AbsEos-0.16 AbsBaso-0.01 ___ 07:25AM BLOOD Plt ___ ___ 07:25AM BLOOD Glucose-87 UreaN-11 Creat-0.9 Na-140 K-3.9 Cl-106 HCO3-23 AnGap-11 ___ 07:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0 ___ 07:25AM BLOOD CEA-0.2 CA125-126* ___ 07:25AM BLOOD Estradl-56 ___ 05:34AM BLOOD Lactate-0.9 Pelvic US ___: IMPRESSION: 1. Large right adnexal cyst measuring at least 14.7 cm a sonographic appearance most consistent with endometrioma. However, in the setting of fever leukocytosis, tubo-ovarian abscess cannot be excluded possibility. 2. A heterogeneously echogenic 6.4 x 2.1 cm structure abutting the large right adnexal cyst may represent the right ovary. Given size and grayscale appearance, right ovarian torsion cannot be excluded. 3. Fibroid uterus with normal left ovary. Chest Xray ___: FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. MRI ___: IMPRESSION: 1. 21.2 cm right hematosalpinx. No enhancing components suspicious for malignancy. 2. Moderate right hydroureteronephrosis extending to the point where the right ureter crosses the iliac vessels, with delayed nephrogram likely related to mass effect from the right hematosalpinx. 3. Endometriosis and endometriomas, largest measuring 3.8 cm, adjacent to the right ovary. Findings equivocal for deep pelvic endometriosis. 4. Fibroid uterus. Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0 2. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice daily Disp #*24 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: pyelonephritis right hydronephrosis endometriosis with hydrosalpinx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: History: ___ with rt LQ pain// pelvic mass? TECHNIQUE: Grayscale and Doppler ultrasound images of the pelvis were obtained with transabdominal approach. Patient declined transvaginal evaluation. COMPARISON: Outside reference CT abdomen and pelvic ultrasound from ___. FINDINGS: The uterus is anteverted. The uterus is enlarged measuring 9.0 x 3.5 x 4.2 cm. Two uterine fibroids are seen in the anterior wall measuring 3.1 x 2.1 cm and 2.4 x 2.5 cm. The endometrium is homogenous and measures 7 mm. The left ovary is normal. A large, septated, predominantly homogeneously echogenic right adnexal cyst is seen and measures at least 14.7 cm. An adjacent tubular, fluid-filled structure may represent hydrosalpinx. Abutting this is a heterogeneously echogenic structure measuring approximately 6.4 x 2.1 cm, which demonstrates some internal vascularity, and may represent the right ovary. IMPRESSION: 1. Large right adnexal cyst measuring at least 14.7 cm a sonographic appearance most consistent with endometrioma. However, in the setting of fever leukocytosis, tubo-ovarian abscess cannot be excluded possibility. 2. A heterogeneously echogenic 6.4 x 2.1 cm structure abutting the large right adnexal cyst may represent the right ovary. Given size and grayscale appearance, right ovarian torsion cannot be excluded. 3. Fibroid uterus with normal left ovary. NOTIFICATION: The updated findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:35 am. Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with fever. infectious work up// PNA TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: None. FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: MR abdomen/pelvis. INDICATION: ___ year old woman with large adnexal mass extending into abdomen and ureteral obstruction causing pyelonephritis, concern for endometriosis. Assess for endometriosis burden, ?infiltrative endometriosis in area of ureteral obstructions TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis were acquired in a 1.5 T magnet. Intravenous contrast: 8 mL Gadavist. COMPARISON: Outside CT pelvis ___. FINDINGS: Lower thorax: Limited evaluation of the lung bases are clear. No pleural effusion. Liver: Liver is homogeneous in signal intensity without focal lesion. No ascites. Biliary: No intrahepatic or extrahepatic biliary duct dilatation. The gallbladder is unremarkable. Pancreas: Pancreas is homogeneous signal intensity without focal lesion. No pancreatic divisum. No peripancreatic fat stranding. Spleen: Normal in size without focal lesion. Adrenal Glands: Unremarkable. Kidneys: Again seen is moderate right hydronephrosis, unchanged since prior CT with mildly delayed nephrogram. Left kidney is unremarkable. No left hydronephrosis. No perinephric fat stranding. Gastrointestinal Tract: Distal esophagus, stomach, small and large bowel are unremarkable. Trace free fluid against the ascending colon noted. No obstruction. Pelvis: Small amount of pelvic free fluid noted. Fibroid uterus measures 6.8 x 3.9 x 6.5 cm with a dominant 3.2 x 2.5 cm left exophytic fibroid. (16:21). Endometrium and junctional zone are within normal limits. There is a large T1 hyperintense, mildly T2 hypointense, nonenhancing lesion within the pelvis adjacent to the right ovary which demonstrates few linear intraluminal incomplete septae, consistent with a hematosalpinx. Overall this area measures 8.0 cm AP x 13.4 cm TV x 21.2 cm SI. No enhancing nodular components. Adjacent to the right ovary is a 3.8 x 1.4 cm mildly T2 hyperintense, T1 hyperintense, nonenhancing cystic lesion consistent with an endometrioma which is in close approximation with the right-sided hematosalpinx. (16:27). Within the left ovary is a 1.4 cm T1 hyperintense lesion (17:89), consistent with an endometrioma. Left ovary is otherwise within normal limits. Few punctate T1 hyperintense foci as well as T2 hypointense foci along the posterior uterine wall are consistent with endometriomas with endometriosis. (3: 10; 17: 89). Uterosacral ligament is within normal limits. Lymph Nodes: Inguinal, pelvic sidewall, retroperitoneal, mesenteric lymph nodes nonenlarged. Vasculature: No abdominal aortic aneurysm; patent vasculature. Celiac axis, SMA, bilateral renal arteries, ___ are patent. Hepatic anatomy is conventional. Hepatic veins, main portal vein, SMV, and splenic vein are patent. Osseous and Soft Tissue Structures: Notable for a 0.6 cm bone island along the left femoral head. Otherwise osseous structures and soft tissues are unremarkable. IMPRESSION: 1. 21.2 cm right hematosalpinx. No enhancing components suspicious for malignancy. 2. Moderate right hydroureteronephrosis extending to the point where the right ureter crosses the iliac vessels, with delayed nephrogram likely related to mass effect from the right hematosalpinx. 3. Endometriosis and endometriomas, largest measuring 3.8 cm, adjacent to the right ovary. Findings equivocal for deep pelvic endometriosis. 4. Fibroid uterus. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 11:30 am, 5 minutes after discovery of the findings. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Fever, RLQ abdominal pain, Transfer Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic temperature: 100.9 heartrate: 113.0 resprate: 16.0 o2sat: 100.0 sbp: 115.0 dbp: 98.0 level of pain: 4 level of acuity: 3.0

On ___, Ms. ___ was admitted to the gynecology service for pain management and evaluation eight pyelonephritis and hydronephrosis concerning for obstruction likely from newly diagnosed 17 cm right adnexal mass consistent with large endometrioma. Regarding her pyelonephritis, she was febrile to 100.9 on arrival and was continued on IV ceftriaxone. Her pain was controlled with IV dilaudid and Tylenol. Urology was consulted, but percutaneous nephrostomy tube(s) were not indicated at that time. At time of admission, based on ultrasound findings, there was concern that the mass could represent a malignancy, and Gyn Oncology was consulted. However, final MRI was more consistent with a large hematosalpinx and endometriosis. Thus she was not seen by the Oncology team. By hospital day 1, she was afebrile, tolerating a regular diet, ambulating, voiding, and her pain was well controlled on oral medications. She was discharged home with follow up with the Minimally Invasive GTN team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Cephalexin / Lipitor Attending: ___. Chief Complaint: L ankle infection Major Surgical or Invasive Procedure: Ankle aspiration, superficial fluid collection growing coag+ staph aureus History of Present Illness: ___ year old female with PMH of psoriatic arthritis (not on immunosuppression), right ankle replacement at ___ in ___, presenting with concern for Right ankle infection. She has a history of a right ankle replacement as well as hammertoe correction on the right foot. She has been wearing an ___ brace to the area for the past 2 weeks, as Dr. ___ orthopedics felt that she would eventually need an amputation but that she could try bracing for the time being. She reports 2 weeks of progressively worsening Right ankle pain with weight bearing, and for the past 2 days she has noted a painful swelling to the lateral aspect of her Right ankle. She has no pain while at rest. Last night and today she noted serous drainage from the site. She denies fevers. Past Medical History: Psoriatic Arthritis HTN History of Breast Cancer s/p chemo, radiation, lumpectomy. In remission. HLD HYPOTHYROIDISM DEPRESSION ANXIETY OBESITY INACTIVE TUBERCULOSIS S/P GASTRECTOMY LAP SLEVE S/P BILATERAL OOPHORECTOMY S/P APPENDECTOMY Social History: ___ Family History: NC Physical Exam: AVSS NAD, A&Ox3 RLE mild erythema. Incision well approximated. Fires ___. SITLT s/s/dp/sp/tibial distributions. 1+ DP pulse, wwp distally. Pertinent Results: ___ 05:00PM JOINT FLUID WBC-156* HCT-3.0* POLYS-77* ___ MONOS-2 EOS-1* ___ 03:20PM WBC-9.6 RBC-4.19 HGB-12.6 HCT-38.8 MCV-93 MCH-30.1 MCHC-32.5 RDW-14.5 RDWSD-49.5* Medications on Admission: - aspirin (ASPIR-81) 81 mg tablet,delayed release (___) Take 81 mg by mouth daily - multivitamin capsule Take by mouth OTC - CALCIUM CARBONATE/VITAMIN D3 (CALCIUM 500 + D, D3, ORAL) Take by mouth OTC - Ferrous Sulfate 324 mg (65 mg iron) tablet,delayed release (___) Take by mouth OTC - lorazepam 1 mg tablet Take 1 mg by mouth at bedtime - omeprazole 20 mg capsule,delayed ___ TAKE ONE CAPSULE BY MOUTH EVERY DAY - pravastatin 40 mg tablet Take 40 mg by mouth daily - traMADol 50 mg tablet TAKE 2 TABLETS BY MOUTH EVERY EVENING - triamcinolone 0.1 % Cream Apply to the affected area twice daily - diclofenac potassium 50 mg tablet TAKE 2 TABLET(S) BY MOUTH ONCE A DAY as needed - Clobetasol 0.05 % Ointment USE TO RASH ON ARMS, BACK, CHEST, ABDOMEN TWICE A DAY AS NEEDED - sertraline 100 mg tablet Take 100 mg by mouth 2 tablets daily - levothyroxine 150 mcg tablet Take 1 tablet by mouth daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Nafcillin 2 g IV Q4H RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV every four hours Disp #*252 Intravenous Bag Refills:*0 4. Rifampin 300 mg PO Q12H RX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 5. Senna 17.2 mg PO HS 6. TraMADol 25 mg PO QHS:PRN pain 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate 500 mg PO QID 9. Ferrous Sulfate 325 mg PO DAILY 10. Levothyroxine Sodium 150 mcg PO DAILY 11. LORazepam 1 mg PO QHS:PRN insomnia/anxiety 12. Omeprazole 20 mg PO DAILY 13. Pravastatin 40 mg PO QPM 14. Sertraline 200 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R ankle hardware infection 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 INDICATION: ___ with hx of psoriatic arthritis and the right ankle replacement presenting with right lateral malleolus ulceration and cellulitis with swelling. // COMPARISON: Prior dated ___ FINDINGS: AP, lateral, oblique views of the right ankle provided. An ankle prosthesis is again noted. A long lag screw is again noted traversing the mid and hindfoot through the calcaneocuboid joint. Marked deformity of the midfoot and hindfoot is again noted similar in overall appearance with prior exam. No soft tissue gas or definite radiopaque foreign body. The talus is not visualized and may be surgically absent. In this patient with right lateral malleolar soft tissue ulceration, there is no definite underlying signs for osteomyelitis. Given extensive deformity, is difficult to exclude a subtle osteomyelitis. IMPRESSION: As above. Radiology Report INDICATION: ___ year old woman with 46cm left arm SL power PICC. ___ ___ // Left arm 46cm SL power PICC. ___ ___ Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the left PICC line projects over the mid SVC. There is no focal consolidation, pleural effusion or pneumothorax identified. Unchanged atelectasis/ scarring at the left lung base. The size of the cardiomediastinal silhouette is within normal limits. Bilateral shoulder arthroplasties. IMPRESSION: The tip of the left PICC line projects over the mid SVC. No pneumothorax is identified. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Wound eval Diagnosed with Cellulitis of right lower limb temperature: 97.9 heartrate: 95.0 resprate: 18.0 o2sat: 97.0 sbp: nan dbp: nan level of pain: 7 level of acuity: 3.0

Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have L ankle erythema and was admitted to the orthopedic surgery service. The patient had superficial fluid collection aspiration and was found to have coag+ staph, close to her L ankle arthroplasty site. Infectious disease was consulted and recommended long term IV abx. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services 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 extremity. The patient will 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: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall with difficulty walking, weakness and difficulty eating Major Surgical or Invasive Procedure: ___ Diagnostic Angiogram History of Present Illness: The patient recently came back from ___ (___) where he went for a week to visit his family. He was in his usual state of health until ___ when while laying at the edge of the bed he was turning and fell out of the bed. He said that was pretty high. When he fell he hit his head, there was no loss of consciousness. He said he had trouble getting up and his family had to help him. He has had this bilateral legs felt weak, but he denies any focal weakness. He said while in ___ his family had to help him get around. He also endorsed a mild headache since the fall. He denies any other focal neurological symptoms at this time. He flew back to ___ on ___. On arrival he had an episode of nausea and emesis and his wife noticed that he had difficulty with coordination while eating. He was brought to be ___ or CT head was obtained and showed left perimesencephalic hemorrhage. His INR was 2.56 and his platelets were 159. He was given 2 mg of IM vitamin K and transferred to ___ for further evaluation. He was seen by neurosurgery who recommended CTA head and neck which did not show any aneurysm or AVM. Patient denies any vertigo, visual deficits, trouble producing or comprehending speech, difficulty swallowing. He does endorse bilateral lower extremity numbness, and difficulty walking. Denies recent fevers, illness, weight loss or night sweats. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. 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: -Coronary artery disease status post coronary artery bypass grafting x3 -Atrial fibrillation status post pulmonary vein isolation with Maze procedure -Mitral regurgitation s/p mechanical mitral valve replacement -Chronic systolic heart failure, last dry weight 52.2kg -Rate controlled atrial flutter -Parkinsons disease -Hypertension -Hyperlipidemia -Hemorrhoidal lower gastrointestinal bleed -Erectile dysfunction -Hypoprolactinemia -Essential tremor -Subdural hematoma s/p fall ___, readmitted ___ for craniotomy and ___ evacuation -Permanent Pacemaker / ICD placement (___) Social History: ___ Family History: No family history of premature coronary artery disease or sudden death. Physical Exam: ON ADMISSION: VSS. Awake & alert. ___ -- intact. CN: II-XII intact, except for anisocria (R 3mm; L 2mm). +ve drift R UE; strength ___ proximally. Sensations intact. Toes down. + laceration over R vertex. + bruise over R knee. ON DISCHARGE: Vitals: 98.0 119/70 62 16 98% Ra General: chronically ill, no acute distress HEENT: Eyes open, neck is mobile Lungs: breathing comfortably on room air Abd: soft, nontender ___: No foley. No blood at meatus Ext: non-edematous Neuro: MS: Oriented to self, BI, city, month, date. Eyes open, fluent speech output. Hypophonic voice, moderate dysarthria, follows simple commands. CN: Eyes open, PERRL R 2>1; L 3>2; tracks, no facial asymmetry, tongue midline Motor: Increased tone right > left UE and ___, +spasticity, strength full in all muscles groups bilaterally. Reflexes: deferred Coord: deferred Pertinent Results: ___ 04:28AM BLOOD WBC-7.6# RBC-3.92* Hgb-12.1* Hct-37.8* MCV-96 MCH-30.9 MCHC-32.0 RDW-15.0 RDWSD-53.0* Plt ___ ___ 05:57AM BLOOD ALT-14 AST-21 ___ 04:28AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.8 ___ 02:36AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1 ___ 04:30AM BLOOD %HbA1c-5.8 eAG-120 ___ 04:30AM BLOOD Triglyc-61 HDL-50 CHOL/HD-2.4 LDLcalc-58 ___ 03:26AM BLOOD TSH-0.12* ___ 04:30AM BLOOD TSH-0.33 ___ 03:26AM BLOOD Free T4-1.7 ___ 08:06AM BLOOD Cortsol-13.8 ___ 12:50PM BLOOD ___ Titer-1:160* CRP-63.0* ___ 02:17PM BLOOD Lactate-0.9 ___ 12:50PM BLOOD NEURONAL NUCLEAR (___) ANTIBODIES-Negative ___ 12:50PM BLOOD ___ ANTIBODY-Negative ___ 12:50PM BLOOD QUANTIFERON-TB GOLD-Indeterminate ___ 12:50PM BLOOD DNA AUTOANTIBODIES, SS-Negative ___ 12:50PM BLOOD RO & LA-Negative ___ 12:50PM BLOOD GQ1B IGG ANTIBODIES-Negative ___ 12:50PM BLOOD GLUTAMIC ACID DECARBOXYLASE-Negative ___ 12:50PM BLOOD ANGIOTENSIN 1 - CONVERTING ___ Test Result Reference Range/Units LISTERIA AB, CF <1:8 IMAGING: CTA HEAD/NECK ___ IMPRESSION: 1. Hemorrhage centered within the left superior cerebellar peduncle with extension into the left ambient cistern and quadrigeminal plate cistern. No underlying PCA aneurysm identified. Narrowing of the basilar and proximal PCA vessels is likely secondary to atherosclerotic disease, or potentially vasospasm if the on set of hemorrhage was greater than 3 days prior. No ischemic infarct in the PCA distributions. 2. No obvious underlying mass. There is an increased number of enhancing veins in this area which may be reactive in nature or may represent an underlying vascular anomaly. Follow-up imaging after resolution of the hemorrhage advised to further evaluate this. 3. Generalized atherosclerotic changes of the neck and intracranial arteries, with less than 50% stenosis of the right cervical internal carotid artery by NASCET criteria and no stenosis on the left. 4. Chronic right temporal parietal infarct appear similar compared to prior. 5. Marked degenerative changes of the cervical spine. MR HEAD W AND W/O CONTRAST ___: 1. Acute to subacute punctate infarcts are present in the body of the right caudate nucleus and left occipital lobe. 2. Unchanged amount of subarachnoid hemorrhage is present within the left ambient and quadrigeminal plate cisterns with vasogenic edema in the adjacent parenchyma. There is also evidence of hemosiderin deposition in the same region. No discrete underlying lesion is demonstrated, however repeat imaging should be obtained upon resolution of the acute hemorrhage. 3. Postcontrast images are limited by patient motion, however no enhancing mass is identified. CT HEAD W/O CONTRAST ___: 1. Overall stable appearance of hemorrhage centered within the left superior cerebellar peduncle, extending into the left ambient cistern and quadrigeminal plate cistern. 2. No evidence of new or enlarging hemorrhage or large territory infarct. More conspicuous subarachnoid hemorrhage in the posterior fossa is likely due to interval redistribution of blood products rather than new hemorrhage. DIAGNOSTIC ANGIOGRAM ___: Right common carotid artery: Carotid bifurcations well-visualized. There is no significant atherosclerosis or carotid stenosis. Right internal carotid artery: The distal right ICA, proximal and distal MCA and ACA branches are well-visualized. Vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase . No vascular abnormalities identified. Left common carotid artery: Carotid bifurcations well-visualized. There is no significant atherosclerosis or carotid stenosis. Left internal carotid artery: Distal left ICA, proximal and distal MCA and ACA branches are well-visualized. Vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase . No vascular abnormalities identified. Left vertebral artery , left ___, basilar artery, bilateral AICA, bilateral SCA and bilateral PCAs are well-visualized. The right ___ is not well visualized as there was no cross-filling to the right vertebral artery. No vascular abnormalities identified, vessel caliber smooth and tapering. Arterial, capillary, venous phases were normal . Right common femoral artery: Well-visualized with a good caliber size for closure device. CTA HEAD W AND W/O C AND RECONS ___ 1. No evidence of aneurysm, or AVM. 2. Intracranial extracranial atherosclerotic disease 3. Stable parenchymal hematoma centered at left superior, middle cerebellar peduncles and posterior left brainstem. MR HEAD W/O CONTRAST ___: Confluent subarachnoid hemorrhage with involvement of the left dorsal mid brain, pons, superior and middle cerebellar peduncles, left dentate nucleus, and subarachnoid spaces appears unchanged from ___. Signal abnormality within the left dorsal midbrain on T2 weighted images may be slightly worse, however this is likely equivocal. No definite interval infarction or intracranial hemorrhage. Etiology of hemorrhage is indeterminate, consider cavernoma. This would be atypical location for sequela of amyloid angiopathy. Vasculopathy or vasculitis is very unlikely. Follow-up to resolution is recommended to exclude underlying neoplasm. The previously identified tiny infarct within the body of the right caudate nucleus is not seen on this exam, possibly secondary to slice selection. No findings to suggest interval infarction from ___. Old infarct within the left inferior parietal lobule and lateral occipital temporal gyrus with associated hemosiderin staining. Chronic lacunar infarcts. Parenchymal atrophy, right greater than left likely a sequela of prior infarct. EEGStudy Date ___ IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of frequent epileptiform discharges in the right frontocentral region, suggesting an area of increased epileptogenicity. Continuous slowing over the left hemisphere with background attenuation suggests a structural lesion and/or cortical dysfunction in this region. Overall background slowing suggests a nonspecific encephalopathy. No electrographic seizures are present. Compared to the day prior's recording, there is no significant change. CT HEAD W/O CONTRAST ___ IMPRESSION: Interval evolution of blood products centered at left brainstem, cerebellar peduncle. Follow-up MRI in 3 months suggested. Stable chronic infarcts. RECOMMENDATION(S): Follow-up MRI in 3 months. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 100 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Carbidopa-Levodopa ___ TAB PO TID 4. Losartan Potassium 12.5 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Pramipexole 1 mg PO TID 7. Ranitidine 150 mg PO BID 8. Torsemide 10 mg PO 5X/WEEK (___) 9. Warfarin 2 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Ferrous Sulfate 325 mg PO DAILY 12. Torsemide 20 mg PO 2X/WEEK (MO,FR) 13. Hyoscyamine 0.125 mg PO QID:PRN Cramping 14. Cyanocobalamin 500 mcg PO DAILY 15. Calcitriol 0.25 mcg PO EVERY OTHER DAY Discharge Medications: 1. Amantadine 100 MG PO DAILY 2. LevETIRAcetam 750 mg PO Q12H 3. ___ ___ UNIT PO Q8H 4. Ramelteon 8 mg PO QHS insomnia DISCONTINUE PRN RESOLUTION OF DELIRIUM OR AS OUTPATIENT 5. Tamsulosin 0.4 mg PO QHS 6. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY 7. Warfarin 2 mg PO DAILY16 8. Amiodarone 100 mg PO DAILY 9. Atorvastatin 80 mg PO DAILY 10. Calcitriol 0.25 mcg PO EVERY OTHER DAY 11. Cyanocobalamin 500 mcg PO DAILY 12. Ferrous Sulfate 325 mg PO DAILY 13. Hyoscyamine 0.125 mg PO QID:PRN Cramping 14. Losartan Potassium 12.5 mg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Pramipexole 1 mg PO TID 17. Ranitidine 150 mg PO BID 18. Torsemide 10 mg PO 5X/WEEK (___) 19. Torsemide 20 mg PO 2X/WEEK (MO,FR) 20. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Perimesencephalic hemorrhage ___ disease Atrial fibrillation 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: MR HEAD W AND W/O CONTRAST T9112 MR HEAD. INDICATION: ___ with head bleed; traumatic vs atraumatic. Evaluate for source of bleed. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 5 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 from ___. FINDINGS: The study is moderately limited by patient motion, particularly the MPRAGE acquisitions. Several foci of slow diffusion are demonstrated in the body of the right caudate nucleus (302:20) and left occipital lobe (320:13, 22). Subarachnoid hemorrhage within the left ambient and quadrigeminal plate cisterns causing mass effect upon the adjacent midbrain and aqueduct without occlusion is unchanged in comparison with the day prior. There is also susceptibility in this region suggestive of hemosiderin deposition. There is edema within the adjacent midbrain, left cerebellar hemisphere and left thalamus. There is no significant midline shift. An additional focus of susceptibility overlying the left parietal lobe probably reflects old blood products (12:17). The ventricles and sulci are prominent, compatible with involutional changes. T2 and FLAIR hyperintensity in the right parietal lobe is consistent with a chronic infarct. Additional periventricular and subcortical T2 and FLAIR hyperintensities most likely reflect chronic small vessel ischemic disease. Postoperative changes from a right frontotemporal craniotomy are noted. Postcontrast images are significantly limited due to patient motion, within this limitation no enhancing masses identified. The dural venous sinuses are grossly patent on MP-RAGE images. There is mild mucosal thickening in the bilateral maxillary sinuses and anterior ethmoid air cells. The orbits are unremarkable portion of bilateral lens replacements. IMPRESSION: 1. Acute to subacute punctate infarcts are present in the body of the right caudate nucleus and left occipital lobe. 2. Unchanged amount of subarachnoid hemorrhage is present within the left ambient and quadrigeminal plate cisterns with vasogenic edema in the adjacent parenchyma. There is also evidence of hemosiderin deposition in the same region. No discrete underlying lesion is demonstrated, however repeat imaging should be obtained upon resolution of the acute hemorrhage. 3. Postcontrast images are limited by patient motion, however no enhancing mass is identified. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with permesenphalic bleed.// worsening hemorrhage or infarct TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.4 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Head CTs from ___ and MRI from ___. FINDINGS: Again seen is hemorrhage centered within the left superior cerebellar peduncle, extending into the left ambient cistern and quadrigeminal plate cistern, not significantly changed in size and extent compared to ___. The fourth ventricle is stably narrowed due to vasogenic edema of the left cerebellum, pons and midbrain, though remains patent. More conspicuous is hyperdense thickening of the tentorium and the posterior falx as well as bilateral parieto-occipital gyri and the cerebellar folia, likely representing redistribution of prior hemorrhage. There is stable appearance of prior right frontoparietal craniotomy and right temporal parietal encephalomalacia from chronic infarct. There is no evidence of enlarging hemorrhage or large territory infarct. The ventricles and sulci are unchanged 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: 1. Overall stable appearance of hemorrhage centered within the left superior cerebellar peduncle, extending into the left ambient cistern and quadrigeminal plate cistern. 2. No evidence of new or enlarging hemorrhage or large territory infarct. More conspicuous subarachnoid hemorrhage in the posterior fossa is likely due to interval redistribution of blood products rather than new hemorrhage. Radiology Report INDICATION: ___ year old man with perimesencephalic hemorrhage, angiogram ___// cardiopulmonary process Surg: ___ (angiogram) TECHNIQUE: PA portable chest radiograph COMPARISON: ___ FINDINGS: A left chest wall dual lead AICD is present. There is no focal consolidation, pleural effusion or pneumothorax identified. Linear opacities in the left lower lung are unchanged likely reflective of atelectasis. There is mild pulmonary vascular congestion. The size the cardiac silhouette is unchanged. IMPRESSION: No radiographic evidence of acute cardiopulmonary disease. Radiology Report EXAMINATION: Right common carotid artery angiogram. Left common carotid artery angiogram. Left vertebral artery angiogram. Right common femoral artery angiogram. INDICATION: ___ year old man s/p fall ___ who presented with difficulty walking, generalized weakness, and uncoordinated eating since ___. CT with left perimesencephalic bleed.// Evaluate for vascular malformation ANESTHESIA: Moderate sedation was provided by administrating divided doses of Versed and fentanyl throughout the total intra service time of 56 minutes during which the patient's hemodynamic parameters were continuously monitored. TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via wrist band.The patient was placed supine on fluoroscopy table and bilateral groins were prepped and draped in the usual sterile manner. Time-out procedure was performed per institutional guidelines. The location of the right mid femoral head was located using anatomic and radiographic landmarks. 10 +10 cc of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was used to gain access to the right femoral artery, serial dilation was undertaken until a long 5 ___ groin sheath connected to a continuous heparinized saline flush could be inserted. ___ catheter was connected to the power injector and also to a continuous heparinized saline flush. This was advanced over the 0.038 glidewire brought up the aorta used to select the right common carotid artery. AP, oblique and lateral views of the anterior cerebral circulation were obtained . Catheter was then pulled back in the aorta and used to select the left common carotid artery. AP, oblique and lateral views of the anterior cerebral circulation were obtained. The catheter was then pulled back in the aorta and the left subclavian artery was selected. AP and lateral road map imaging was undertaken. Next, the left vertebral artery was selected. AP and lateral views were taken from this vessel for the posterior cerebral circulation. The catheter was then pulled back in the aorta fully removed from the body. A common femoral arteriogram was performed prior to use of a closure device, subsequently 6 ___ Angio-Seal was put in. At the conclusion of the procedure, there is no evidence of thromboembolic complication and the patient was at his neurologic baseline. COMPARISON: None. PROCEDURE: Diagnostic cerebral angiogram. FINDINGS: Right common carotid artery: Carotid bifurcations well-visualized. There is no significant atherosclerosis or carotid stenosis. Right internal carotid artery: The distal right ICA, proximal and distal MCA and ACA branches are well-visualized. Vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase . No vascular abnormalities identified . Left common carotid artery: Carotid bifurcations well-visualized. There is no significant atherosclerosis or carotid stenosis. Left internal carotid artery: Distal left ICA, proximal and distal MCA and ACA branches are well-visualized. Vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase . No vascular abnormalities identified . Left vertebral artery , left ___, basilar artery, bilateral AICA, bilateral SCA and bilateral PCAs are well-visualized. The right ___ is not well visualized as there was no cross-filling to the right vertebral artery. No vascular abnormalities identified, vessel caliber smooth and tapering. Arterial, capillary, venous phases were normal . Right common femoral artery: Well-visualized with a good caliber size for closure device. I, ___, participated in the procedure. I, ___, was present for the entirety of the procedure and supervised all critical steps. I, ___, have reviewed the report and agree with the fellow's findings. IMPRESSION: Diagnostic cerebral angiogram within normal limits. RECOMMENDATION(S): 1. Management of perimesencephalic none aneurysmal subarachnoid hemorrhage as per usual protocol. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with IPH started on hep for mechanical MVR as bridge to coumadin// eval IPH 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: Total exam DLP: 936.91 COMPARISON: Head CT of ___ FINDINGS: Again demonstrated is an evolving intraparenchymal hemorrhage centered in the left superior cerebellar peduncle extending into the left ambient and quadrigeminal plate cisterns, and interdigitating within the cerebellar sulci. There remains a similar degree of adjacent vasogenic edema and effacement of the fourth ventricle and aqueduct. The ventricles are unchanged in size. No new or increasing hemorrhage or large acute infarction is demonstrated. Right temporal parietal encephalomalacia is unchanged. Right fronto temporal craniotomy changes are stable. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable with the exception of bilateral lens replacements. IMPRESSION: Evolving intraparenchymal hemorrhage centered in the left superior cerebellar peduncle with extension into the subarachnoid space is essentially unchanged. There is a similar degree of effacement of the fourth ventricle without change in the size of the third or lateral ventricles. No evidence of new or increasing hemorrhage, or acute infarct. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with IPH, on heparin gtt. Delirium overnight, headache worse.// eval for change in IPH 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 18.0 s, 18.0 cm; CTDIvol = 23.4 mGy (Body) DLP = 421.9 mGy-cm. Total DLP (Body) = 422 mGy-cm. COMPARISON: Noncontrast head CT ___. FINDINGS: Again demonstrated, is a similar volume evolving intraparenchymal hemorrhage centered in the left superior cerebellar peduncle extending into the left ambient and quadrigeminal cisterns. There is similar extension into the subarachnoid space adjacently. There is similar degree of vasogenic edema and effacement of the fourth ventricle. No evidence of new areas of hemorrhage or acute territorial infarct. Right temporoparietal encephalomalacia is unchanged. The ventricles are unchanged in size. There is similar degree of mild rightward midline shift of approximately 4 mm. Right frontal temporal calvarial changes secondary to craniotomy are stable. Otherwise, there is no evidence of fracture. 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. Similar volume, evolving intraparenchymal hemorrhage centered in left superior cerebellar peduncle with extensions of subarachnoid space. 2. Similar mild rightward midline shift and fourth ventricle effacement. 3. No new areas of hemorrhage or acute territorial infarcts. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD INDICATION: ___ year old man with IPH s/p fall on heparin gtt for mechanical MV// evaluate evolution of IPH on heparin gtt TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Next, rapid axial imaging was performed through the brain during the uneventful infusion of mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered and segmented images were then generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.3 mGy-cm. 2) Spiral Acquisition 3.0 s, 23.2 cm; CTDIvol = 27.6 mGy (Head) DLP = 641.9 mGy-cm. 3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 73.8 mGy (Head) DLP = 36.9 mGy-cm. Total DLP (Head) = 1,613 mGy-cm. COMPARISON: CT head ___ 06:31 FINDINGS: CT HEAD WITHOUT CONTRAST: Intraparenchymal hemorrhage centered in the left superior cerebellar peduncle, posterior midbrain, pons, extending into the left middle cerebellar peduncle is stable. Interval evolution of blood products when compared to the ___ study. This hemorrhage is again seen extending into the left ambient and quadrigeminal cisterns. Stable adjacent subarachnoid hemorrhage. Unchanged in appearance mild mass effect on the fourth ventricle. No hydrocephalus. There is no evidence of new hemorrhage or acute large territorial infarction. There is a similar degree of rightward midline shift. The ventricles are unchanged in size. Right temporoparietal encephalomalacia from chronic infarct is unchanged. Moderate chronic small vessel ischemic changes. Postsurgical changes are again identified at the right frontotemporal calvarial region. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is no evidence of arterial venous malformation, aneurysm, or feeding vessels in region of the intraparenchymal hemorrhage. Mild narrowing right M1 segment. Moderate narrowing left M 2 segment. There is mild narrowing of the basilar artery which may represent atherosclerotic disease. Again seen is atherosclerotic disease within the V3 and V4 segments of the bilateral vertebral arteries. There is moderate to severe narrowing of the right vertebral artery V4 segment. Mild-to-moderate narrowing of the left V4 segment. There is moderate atherosclerotic disease of the bilateral cavernous segments internal carotid arteries, with mild-to-moderate narrowing bilaterally. Significant atherosclerotic calcifications are seen at the bilateral proximal ICA near origin, partially imaged on this scan. No evidence of aneurysm. Irregularity of bilateral PCAs is partially from motion, there may be mild atherosclerotic disease. Other vessels are patent. No early shunting vein. IMPRESSION: 1. No evidence of aneurysm, or AVM. 2. Intracranial extracranial atherosclerotic disease 3. Stable parenchymal hematoma centered at left superior, middle cerebellar peduncles and posterior left brainstem. RECOMMENDATION(S): Follow-up MRI brain without and with contrast in 3 months. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with acute unresponsiveness// Rule out infarct, no contrast necessary TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON ___ CTA head ___ MR head with without contrast ___ CTA head neck ___ CT head without contrast ___ CT head without contrast FINDINGS: There is expected interval evolution of blood products within the left dorsal mid brain, left superior and middle cerebellar peduncle, left dorsal pons, left dentate nucleus, and within the subarachnoid space of the surrounding quadrigeminal plate and ambient cisterns. There the degree of signal abnormality within the left midbrain on T2 weighted images may be slightly worse (series 10, image 14), however this is uncertain. The cerebral aqueduct is narrowed, however appears similar in caliber. The ventricular configuration appears stable, with dilation of the lateral ventricles and third ventricle likely secondary to parenchymal volume loss. There are chronic lacunar infarcts to the level of the bilateral basal ganglia. There is moderate brain parenchymal atrophy, with atrophy in the right temporal and parietal lobes greater than on the left, likely sequela of chronic right-sided infarct. Significant atrophy of the right hippocampus. The previously identified tiny acute infarct within the body of the right caudate nucleus is not seen on this exam, possibly due to slice selection. No findings to suggest an interval infarction from the ___ MRI. The volume of subarachnoid blood products within the bilateral parietal and occipital sulci appears unchanged. The encephalomalacia within the right inferior parietal lobule and lateral occipital temporal gyrus likely reflects a sequela of an old infarct, with residual hemosiderin staining. Additionally, there is an old infarct within the right inferior cerebellar hemisphere. Areas of hyperintense signal within the subcortical and periventricular white matter the, but likely reflect the sequela of moderate chronic small vessel disease. The major vascular flow voids are preserved. Small foci of susceptibility artifact within the left superior parietal lobule and right superior cerebellar hemisphere likely reflect chronic microhemorrhage and appear unchanged. There are bilateral lens implants. The orbits are otherwise unremarkable. IMPRESSION: Confluent subarachnoid hemorrhage with involvement of the left dorsal mid brain, pons, superior and middle cerebellar peduncles, left dentate nucleus, and subarachnoid spaces appears unchanged from ___. Signal abnormality within the left dorsal midbrain on T2 weighted images may be slightly worse, however this is likely equivocal. No definite interval infarction or intracranial hemorrhage. Etiology of hemorrhage is indeterminate, consider cavernoma. This would be atypical location for sequela of amyloid angiopathy. Vasculopathy or vasculitis is very unlikely. Follow-up to resolution is recommended to exclude underlying neoplasm. The previously identified tiny infarct within the body of the right caudate nucleus is not seen on this exam, possibly secondary to slice selection. No findings to suggest interval infarction from ___. Old infarct within the left inferior parietal lobule and lateral occipital temporal gyrus with associated hemosiderin staining. Chronic lacunar infarcts. Parenchymal atrophy, right greater than left likely a sequela of prior infarct. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old man with NG tube// eval placement TECHNIQUE: Portable frontal view of the chest. COMPARISON: ___. IMPRESSION: Upper enteric tube tip terminates in the proximal stomach with the side port is in the distal esophagus and should be advanced by roughly 7 cm for ideal placement. Aeration of the left lower lung has improved. Otherwise no interval change is seen. Postsurgical changes from CABG and moderate cardiomegaly are unchanged. There remains minimal left base atelectasis. Lungs are otherwise clear. There is no large effusion or pneumothorax. Left anterior chest wall AICD is unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ng tube check placement s/p advancing// ng tube eval placement ng tube eval placement IMPRESSION: Compared to chest radiographs since ___, most recently ___. Nasogastric drainage tube passes below the diaphragm and out of view. Transvenous right atrial and right ventricular pacer defibrillator leads in standard placements continuous from the left pectoral generator. Moderate cardiomegaly is stable but pulmonary vascular congestion has increased. Pleural effusions are small if any. No pneumothorax. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with perimesencephalic lesion// Eval resorption of blood 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 = 934.3 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: MRI brain ___, head CT ___. FINDINGS: There has been interval evolution of blood products within parenchymal hematoma involving left superior and middle cerebellar peduncles and adjacent brainstem, and adjacent extra-axial blood products. 0.9 cm focus of parenchymal hemorrhage is seen today, compared with 1.5 cm on prior, with surrounding mild edema. Chronic basal ganglia and parenchymal infarcts are again seen, better seen on MRI ___. No new hemorrhage. Stable ventricular size. Punctate focus of hemorrhage versus calcification within posterior right temporal lobe chronic infarct, similar to prior. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. NG tube in place. Right parietal craniotomy. IMPRESSION: Interval evolution of blood products centered at left brainstem, cerebellar peduncle. Follow-up MRI in 3 months suggested. Stable chronic infarcts. RECOMMENDATION(S): Follow-up MRI in 3 months. Radiology Report INDICATION: ___ year old man with ng tube// ng tube TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of a nasogastric tube projects over the distal stomach. A left chest wall dual lead AICD is present. The patient is post median sternotomy and cardiac valve replacement. Patchy opacities in both lungs may reflect pulmonary edema with atelectasis. Superimposed pneumonia/aspiration cannot be excluded in the proper clinical context. There is no large pleural effusion or pneumothorax identified. The size of the cardiac silhouette is enlarged but unchanged. The thoracic aorta is again noted to be unfolded. IMPRESSION: The tip of the nasogastric tube projects over the distal stomach. Pulmonary edema and atelectasis. Superimposed infection/aspiration cannot be excluded in the proper clinical context PA Radiology Report INDICATION: ___ year old man with NG// confirm NG placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from 3 hours prior IMPRESSION: The tip of the nasogastric tube projects over the stomach, unchanged. Overall, there is no significant interval change since the prior chest radiograph Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with Right PICC // Right Power PICC DL 44cm ___ ___ Contact name: ___: ___ Right Power PICC DL 44cm ___ ___ IMPRESSION: Compared to chest radiographs since ___ most recently ___. Severe cardiomegaly worsened between ___ and ___, subsequently unchanged. Pulmonary vasculature and hilar pulmonary arteries are also enlarged. There is probably no pulmonary edema or focal pulmonary abnormality. Small left pleural effusion unchanged. Right PIC line ends close to the superior cavoatrial junction. Nasogastric drainage tube passes below the diaphragm and out of view. Transvenous right atrial and pacer and right ventricular pacer defibrillator leads are continuous from the left pectoral generator. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with NGT placement // NGT placement Contact name: ___: ___ NGT placement IMPRESSION: Pacemaker defibrillator leads terminate in the right ventricle. Heart size and mediastinum are unchanged including moderate cardiomegaly. Replaced most likely mitral valve is in expected location. Right PICC line tip is at the cavoatrial junction. There is mild vascular congestion but no overt pulmonary edema NG tube tip is in the distal stomach. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: ___ year old man with NGT placement TECHNIQUE: Chest PA and lateral COMPARISON: Chest x-ray ___ approximately 18 hours previous FINDINGS: The tip of the NG tube is in the distal stomach. The right PICC tip is in the region of the cavoatrial junction, similar to previous. There is a left pacemaker in situ. The patient is status post valve replacement. There are low lung volumes which compromises evaluation. There may be a small left effusion. The heart is enlarged. There is pulmonary venous congestion. IMPRESSION: Cardiomegaly with pulmonary venous congestion. Possible small left effusion. NG tube tip in the distal stomach. Gender: M Race: ASIAN - SOUTH EAST ASIAN Arrive by AMBULANCE Chief complaint: ICH, Transfer Diagnosed with Contus/lac/hem crblm w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter temperature: 98.3 heartrate: 57.0 resprate: 15.0 o2sat: 99.0 sbp: 131.0 dbp: 85.0 level of pain: uta level of acuity: 2.0

The patient is a ___ w mechanical MV and atrial fibrillation on Coumadin who p/w intraparenchymal and perimesencephalic hemorrhage after mechanical fall. Upon multiple discussions with Neuroradiology, the etiology of the hemorrhage remains ultimately unclear, but the leading diagnosis is underlying cavernous malformation. At the OSH, his INR was 2.56 and his platelets were 159. He was given 2 mg of IM vitamin K for reversal prior to transfer. Anti-coagulation was held for 5 days in the setting of his intraparenchymal and perimesencephalic hemorrhage. In discussions with cardiology, given his high risk for further embolization in the setting of a mechanical MV and atrial fibrillation, we resumed anti-coagulation with heparin on ___. He continued to complain of a severe headache, which was treated with a trial of acetazolamide. Clinically, the patient had initially been very alert and stable upon resumption of heparin. However, he experienced an acute change in mental status/neuro exam on morning of ___, becoming acutely somnolent, rigid, with right hemiplegia and right gaze deviation. The etiology is still unclear regarding acute change. His exam at the time included right-sided hemiplegia and right gaze-deviation, which could be from hemorrhagic or ischemic involvement in his already affected left dorsal mid brain, pons, superior and cerebellar peduncles, and left dentate nucleus. Repeat imaging with non-con head CT and MRI w and w/o contrast showed relative stability of the IPH and was not conclusive for additional hemorrhage or infarct, although the sensitivity of imaging was confounded by the pre-existing blood. Anti-coagulation with heparin was continued in the absence of hemorrhagic evolution. Acetazolamide was discontinued given his acute change in mental status. The simplest explanation may be that the blood from his perimesencephalic hemorrhage may have resulted in mechanical pressure leading to compression of his paramedian arteries resulting in a localized infarct, vs. re-bleeding from the same focus. The old blood surrounding this area may compound our ability to detect a new infarct on MRI. Alternatively, since he has been off anticoagulation for several days, he may have also had an ischemic infarct from a seeded embolus from his mechanical mitral valve. We evaluated his mechanical valve via ECHO and did not detect signs of thrombus formation. A similar lesion in the midbrain reticular formation may also explain his somnolence and acute change in consciousness. As there was no clear difference on imaging for his acute change in mental status, we pursued an empiric diagnostic approach, including a trial of 2mg IV ativan out of concern for seizure, which had no clinical effect. Although continuous video EEG was negative for seizures, he did have frequent sharp wave discharges in the right frontal central region across F4-C4. We continued him on keppra 750 mg BID out of concern for a lower seizure threshold and a prior CVA representing a possible seizure focus. Alternative explanations for his altered mental status were also discussed and included metabolic derangements vs infectious etiologies, although the sudden change would be atypical. We discussed the possibility that his hemorrhage may have resulted from a possible infectious etiology, such as listeria, which sometimes presents with rhomboencephalitis. Although he was not reported to be clinically sick prior to his fall, out of concern for a possible infectious etiology with an atypical clinical presentation, we also started him on empiric antibiotic treatment with vancomycin (which was discontinued within 4 days), ampicillin, and ceftriaxone (2g BID). Although unlikely to be infectious, his clinical exam began to improve, while he has been on antibiotic therapy, the possibility of rhomboencephalitis (such as caused by listeria or mycobacteria) cannot be ignored. He was treated empirically with Ampicillin for 3 weeks. This was subsequently discontinued and he remained stable without infectious sign/symptoms. He has also developed what appears to be dystonic posturing on the right hemibody as well as worsening dysarthria and rigidity that could be reflectively of worsening parkinsonism in the setting of an acute injury affecting extrapyramidal pathways in the brainstem. This resolved with a trial of amantadine. His mental status began to improve with return to baseline within 4 days of his acute change. He was initially NG-tube dependent in the setting of his acute change but has improved and began to tolerate adequate PO intake. Coumadin was initiated on ___ with continued heparin bridge until his INR reached 2.0 on ___. Heparin was discontinued and coumadin was continued for goal INR 2.5-3.5. His hospital course was further complicated by delirium resulting in ongoing attempts to pull out his NG tube as well as his foley. Urology was consulted out of concern for ongoing hematuria. They recommended to keep his foley in place for at least ___ days to tamponade a possible abrasion site. He also developed a transient pre-renal ___ secondary to contrast and decreased PO intake which resolved with gentle IV hydration. # Perimesencephalic and intraparenchymal hemorrhage, later complicated by acute change in mental status - continue warfarin for goal INR 2.5-3.5 - repeat MRI with and without gadolinium by ___ (he has a pacemaker that is MR-compatible but this may require cardiology's involvement during MR scan pending hospital/radiology protocol) - monitor for adequate PO intake - continue ___, OT, speech therapy # Concern for infectious/auto-immune etiology for perimesencaphilc/intraparenchymal hemorrhage - blood cultures, urine cultures negative - Serum Listeria antibodies negative - autoimmune workup negative # ___ disease - continue amantadine - titrate dose of carvidopa/levidopa as needed # ___ - resolved, likely pre-renal in setting of poor PO and IV contrast # Hematuria - secondary to self-removal of foley in setting of anti-coagulation. Improved # Delirium - resolving - maximize delirium precautions, day-night reaffirmation - continue remelteon/melatonin qhs # ? Seizures, low seizure threshold at baseline - continue empiric keppra 750 mg PO BID. Plan to treat for 3 months empirically - wean keppra in outpatient setting (likely in ___ # Dysphagia, improving - Should have ongoing evaluation with speech/language pathologist for assessment and management of dysphagia = = = = = = = = = = = = = = ================================================================ AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Trazodone / morphine / Codeine Attending: ___. Chief Complaint: Abd pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with HCV genotype 3 and alcohol-mediated liver cirrhosis with course complicated by variceal bleeds status post banding and TIPS ___ ___, multiple admissions for hepatic encephalopathy, DM2, history of polysubstance abuse, multiple psychiatric diagnoses who presents with worsening abdominal pain and hyperglycemia. . Of note, he was recently admitted from ___ for hematemesis and abdominal pain and he left AMA. He was also seen in the ED on ___ for non-bloody emesisx2. He is now complaining of upper abdominal pain has been going on for 2 weeks. He states he lives with ___ abdominal pain but that it has been increased to ___. Today patient developed lower abdominal pain and nonbloody diarrhea he believes is from a UC flare. He reports approx 10 episodes of diarrhea today and reports nausea and chills but no vomiting, fevers, ___ swelling, confusion. . In the ED, initial VS were 97.5 80 112/66 18 96%. Rectal exam was guaic negative. LFTs at baseline. CXR clear. CT abdomen showed no acute process. He was given dilaudid 1 mg iv x 2. Admission Vitals were 120/74, hr 81, sao2 99, temp 98.1, rr 17 . On the floor the patient has not had any bowel movements and is AVSS. He is walking around frequently but still reports ___ abd pain and asking for pain meds. Past Medical History: - cirrhosis due to hepatitis C (genotype 3) and prior alcohol abuse; course complicated by esophageal variceal bleeds treated with banding at ___ and TIPS in ___ recent EGD ___ with only one cord of grade 1 varices; multiple prior episodes of hepatic encephalopathy; denied liver transplant at ___ because of history of relapse, was also turned down by ___ for same reason - hepatitis B - prior polysubstance abuse including clonazepam, alcohol and daily IV heroin - diabete mellitus on insulin; diagnosed over ___ yrs ago following an episode of severe pancreatitis; complicated by diabetic neuropathy - ulcerative colitis - hypertension - cocaine-induced MI in ___ - prior hernia repair - prior unilateral orchiectomy - anxiety - post-traumatic stress disorder - benign prostatic hyperplasia - s/p cholecystectomy Social History: ___ Family History: Father: ___ disease. Brother: ___ MJ Abuse. Physical Exam: VS - wt 88.2 kg Temp 97.4 F, BP 115-138/67-73, HR 70-80, R ___, O2-sat 98-100% RA GENERAL - well-appearing male in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, sl dry MM, 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 - scar present over RUQ, BS+, soft, diffuse mild TTP greatest in RUQ, no rebound or guarding, no HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, steady gait. no asterixis Pertinent Results: ___ 06:50PM GLUCOSE-284* UREA N-13 CREAT-0.6 SODIUM-134 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-8 ___ 06:50PM estGFR-Using this ___ 06:50PM ALT(SGPT)-261* AST(SGOT)-239* ALK PHOS-203* TOT BILI-1.1 ___ 06:50PM CRP-11.0* ___ 06:50PM WBC-4.0 RBC-3.66* HGB-12.6* HCT-35.3* MCV-97 MCH-34.5* MCHC-35.8* RDW-13.7 ___ 06:50PM NEUTS-74.7* LYMPHS-15.2* MONOS-7.3 EOS-2.3 BASOS-0.4 ___ 06:50PM PLT COUNT-63* ___ 06:50PM SED RATE-35* . ABD CT ___ FINDINGS: The imaged lung bases are clear. No pulmonary nodules. No pleural effusions. The imaged portion of the heart and pericardium are normal. The liver is shrunken and nodular in contour, consistent with known history of cirrhosis. A TIPS shunt is patent and is in optimal position. A stable 14-mm hypodense lesion within the left lobe, likely represents a simple hepatic cyst. The main portal vein is patent. The patient is status post cholecystectomy. Prominent mesenteric adenopathy at the level of the celiac axis, porta-hepatis and gastrohepatic ligament are unchanged. The adrenal glands and pancreas are normal. The spleen is enlarged, measuring 17.1 cm. Both kidneys enhance and excrete contrast symmetrically, without evidence of hydroureteronephrosis or concerning renal masses. The stomach, small and large bowel loops are normal, without evidence of bowel wall thickening, obstruction or active inflammation. The appendix is normal. Apparent wall thickening of the terminal ileum is likely due to peristalsis. The abdominal aorta has minimal atherosclerotic calcification without aneurysmal dilation. Prominent retroperitoneal lymph nodes do not meet CT criteria for significant adenopathy. There is no intra-abdominal free fluid or air. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, prostate, rectum and sigmoid colon are normal. No pelvic free fluid or adenopathy is seen. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. Degenerative changes are seen in the lumbar spine. IMPRESSION: 1. No acute abdominal or pelvic pathology. 2. Cirrhotic liver, with a patent TIPS shunt. Splenomegaly. No ascites. Medications on Admission: 1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. lactulose 10 gram/15 mL Syrup Sig: ___ (45) ML PO TID 6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate Oral 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 11. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a day. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO once 14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: ___ (28) units Subcutaneous once a day: Please take 28 units at breakfast. 16. Humalog 100 unit/mL Solution Sig: qs units Subcutaneous four times a day: Breakfast Lunch Dinner At Bedtime ___ mg/dL Proceed with hypoglycemia Protocol 71-150 mg/dL Units 4 Units 4 Units 4 Units 0 151-200 mg/dL Units 10 Units 10 Units 10 Units 0 201-250 mg/dL Units 14 Units 14 Units 14 Units 2 251-300 mg/dL Units 18 Units 18 Units 18 Units 4 301-350 mg/dL Units 22 Units 22 Units 22 Units 6 351-400 mg/dL Units 24 Units 24 Units 24 Units 8 . PER ___ REPORT ONLY Dilaudid 2 mg po BID (pt reports script from Health & Wellness pain clinic in ___ Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. lactulose 10 gram/15 mL (15 mL) Solution Sig: ___ (45) mL PO three times a day. 6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 13. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain: As prescribed from pain clinic in ___ (not confirmed). 16. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: ___ (28) Units Subcutaneous once a day: At breakfast. 17. Humalog 100 unit/mL Cartridge Sig: Per sliding scale Subcutaneous four times a day. Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest, frontal and lateral views. CLINICAL INFORMATION: ___ male with history of shortness of breath, chills. COMPARISON: ___. FINDINGS: Frontal and lateral views of the chest are obtained. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are stable and unremarkable, as are the hilar contours. Minimal degenerative changes are seen along the spine. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ man with ulcerative colitis, abdominal pain and diarrhea, to evaluate for acute intra-abdominal pathology. COMPARISON: CT of the abdomen with contrast ___. TECHNIQUE: MDCT helical images were acquired through the abdomen and pelvis after administration of 130 cc of Omnipaque intravenous contrast. Sagittal and coronal reformats were generated and reviewed. FINDINGS: The imaged lung bases are clear. No pulmonary nodules. No pleural effusions. The imaged portion of the heart and pericardium are normal. The liver is shrunken and nodular in contour, consistent with known history of cirrhosis. A TIPS shunt is patent and is in optimal position. A stable 14-mm hypodense lesion within the left lobe, likely represents a simple hepatic cyst. The main portal vein is patent. The patient is status post cholecystectomy. Prominent mesenteric adenopathy at the level of the celiac axis, porta-hepatis and gastrohepatic ligament are unchanged. The adrenal glands and pancreas are normal. The spleen is enlarged, measuring 17.1 cm. Both kidneys enhance and excrete contrast symmetrically, without evidence of hydroureteronephrosis or concerning renal masses. The stomach, small and large bowel loops are normal, without evidence of bowel wall thickening, obstruction or active inflammation. The appendix is normal. Apparent wall thickening of the terminal ileum is likely due to peristalsis. The abdominal aorta has minimal atherosclerotic calcification without aneurysmal dilation. Prominent retroperitoneal lymph nodes do not meet CT criteria for significant adenopathy. There is no intra-abdominal free fluid or air. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, prostate, rectum and sigmoid colon are normal. No pelvic free fluid or adenopathy is seen. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. Degenerative changes are seen in the lumbar spine. IMPRESSION: 1. No acute abdominal or pelvic pathology. 2. Cirrhotic liver, with a patent TIPS shunt. Splenomegaly. No ascites. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN, HYPERGLYCEMIA Diagnosed with ABDOMINAL PAIN RLQ, CIRRHOSIS OF LIVER NOS, DIABETES UNCOMPL JUVEN temperature: 97.5 heartrate: 80.0 resprate: 18.0 o2sat: 96.0 sbp: 112.0 dbp: 66.0 level of pain: 10 level of acuity: 3.0

___ with HCV and alcohol-mediated liver cirrhosis with course complicated by variceal bleeds status post banding and TIPS ___ ___, multiple admissions for hepatic encephalopathy, not on transplant list at ___ because of history of relapse, DM2, history of polysubstance abuse, multiple psychiatric diagnoses who presents with abdominal pain and profuse diarrhea admitted for ? UC flare. . # Ulcerative colitis: Presented with report of profuse diarrhea but has not had any here. CT did not show any evidence of an ulcerative colitis flare. He toleratee PO diet well. we planned to discharge him without any changes to his medications. However, when he heard he would be discharged he took his own IV out and left prior to receiving discharge paperwork. . #Abdominal pain: CT did not show any acute cause of his abdominal pain. He did not appear in significant pain on exam but continued to report ___ pain. He reported having received dilaudid from a pain clinic but could not recall the name only that it was in ___. This was never confirmed and he was not given any dilaudid at discharge. When told he would be discharged he took his own IV out and left prior to receiving discharge paperwork. . # Cirrhosis: From hepatitis C and prior alcohol abuse complicated by esophageal varices s/p banding and TIPS. EGD performed ___ revealed no sign of active bleeding, showed 2 cords of grade I varices. There was no significant interval change since ___. . # Diabetes mellitus: Continued home insulin regimen.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: unknown antibiotic Attending: ___. Chief Complaint: episode of left lip numbness/swelling and difficulty walking Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ man with a PMHx signifcant only for osteoarthritis s/p left hip replacement who presents today with acute onset left lip numbness and difficulty ambulating. He had been in his USOH until approximately 90 - 120 minutes or so prior to presentation when he was sitting in ___ and noted that his left lip suddenly felt "numb". He describes the feeling as like a "swelling" of his lip. Denies any weakness of his face, any difficulty speaking or extremity weakness. He then tried to get up and go to the bathroom and noted that he had some significant difficulty ambulating, stating that his left side felt like it didn't want to "support itself". When he got up, he also experienced some dizziness, stating that he felt lightheaded, but denies a sensation that the room was spinning or that the floor was moving. He was assisted to the bathroom by one of the baristas. In the bathroom, he had to lean against the wall in order to support himself. He then returned to his seat and his dizziness gradually resolved. Denies HA, visual changes, difficulty speaking. He has had two similar events ___ years ago that involved him becoming standing with dizziness. One caused him to lose his "balance" and fall down the stairs and fracture his C2. He is s/p five months in a c-collar. He was able to order a coffee and shortbread, but became concerned as his symptoms in his face persisted. He then called his brother, who came to ___ to pick him up 45 minutes later. In the interim, his facial symptoms resolved (lasted approximately one hour in duration). His gait was improved and he was able to ambulate with his cane to his brother's car. However, given his symptoms, he opted to come to the ___ ED for urgent evaluation. Given his acute onset, a code stroke was called. Past Medical History: 1. Osteoarthritis s/p left hip replacement back in ___. 2. GERD 3. Retinal detachment s/p repair a few months ago 4. Hemorroids Social History: ___ Family History: Father-MI ~___. Mother passed away from an MI at the age of ___. GF had diabetes requiring amputation of distal leg. Brother had an aortic dissection. Physical Exam: Initial Physical Exam: VS: T: 99.8 HR: 67 BP: 139/76 RR: 16 O2: 100% Genl: Awake, alert, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Abd: soft, NTND, NABS Ext: No lower extremity edema bilaterally Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, able to follow simple and multi-step commands. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. Reading intact. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: +anisocoria: +surgical pupil on right side (3mm), reactive on left (2->1mm). Visual fields are full to confrontation. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. +mild L NL fold flattening, but facial movement symmetric with activation. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. **left ___ somewhat limited by pain Del Tri Bi WE FE FF IP H Q DF PF TE R ___ ___ ___ ___ L ___ ___ ___ ___ Sensation: Intact to light touch, pinprick, vibration, position sense, and cold sensation throughout. No extinction to DSS. Reflexes: 2+ and symmetric throughout. Toes downgoing bilaterally. Coordination: finger-nose-finger and RAM normal. Gait: Narrow based, but antalgic. Discharge Physical Exam: Essentially unchanged from admission. Alert, oriented, nl mental status. No motor, sensory, coordination changes. Gait is antalgic due to hip pain. Pertinent Results: Admission Labs: ___ 04:02PM GLUCOSE-118* NA+-138 K+-4.0 CL--101 TCO2-26 ___ 03:59PM WBC-12.6* RBC-3.26* HGB-10.4* HCT-31.2* MCV-96 MCH-32.0 MCHC-33.5 RDW-14.2 ___ 03:59PM PLT COUNT-316 ___ 03:59PM ___ PTT-24.6 ___ ___ 04:00PM CREAT-1.1 ___ 03:59PM UREA N-38* Other Pertinent Labs: ___ 04:25AM BLOOD Triglyc-92 HDL-56 CHOL/HD-2.7 LDLcalc-76 ___ 04:25AM BLOOD ESR-87* ___ 04:25AM BLOOD CRP-0.6 ___ 04:25AM BLOOD CK-MB-7 cTropnT-0 ___ 04:25AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 Cholest-150 Pertient Radiology Studies: ___ CT HEAD W/O CONTRAST There is no acute intracranial hemorrhage, edema, masses, mass effect, or acute territorial infarction. The ventricles and sulci are prominent, compatible with age-appropriate atrophy. A hypodensity in the left cerebellum is similar to the CT of the C-spine from ___, likely representing a chronic infarct. Stable subcortical chronic infarct in the left parietal lobe (series 2, image 23) is redemonstrated. BONES: There are no suspicious lytic or sclerotic bony lesions. There is minimal mucosal thickening of the maxillary sinuses. Remaining paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute process in the head. 2. Stable subcortical chronic infarct in the left parietal lobe and in the left cerebellum. ___ CHEST (PA & LAT) FINDINGS: In comparison with the study of ___, there is again biapical thickening and adjacent pulmonary parenchymal scarring with tortuosity of the aorta. Mild elevation of the right hemidiaphragm is again seen. No evidence of pulmonary vascular congestion or acute focal pneumonia. ___ ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The abdominal aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, findings are similar. Trace aortic regurgitation is now detected. ECG: Baseline artifact. Sinus bradycardia. Short P-R interval. Since the previous tracing of ___ there is possibly no significant change but there is considerable artifact on both tracings. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 59 ___ -31 38 50 Medications on Admission: Tylenol and Tums prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Dizziness Old cerebral infarcts Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neuro: Right pupil is surgical 3mm; left pupil is reactive, 2-->1 with light. Left facial droop; Left IP strength ___ (chronic, prior hip replacement). Gait has slightly wide stance, limping left leg but relatively steady with cane. Followup Instructions: ___ Radiology Report INDICATION: ___ yo with TIA symptoms. TECHNIQUE: Axial images of the head were obtained. Coronal and sagittal reformats were acquired. COMPARISON: CT of the head from ___. FINDINGS: CT OF THE HEAD: There is no acute intracranial hemorrhage, edema, masses, mass effect, or acute territorial infarction. The ventricles and sulci are prominent, compatible with age-appropriate atrophy. A hypodensity in the left cerebellum is similar to the CT of the C-spine from ___, likely representing a chronic infarct. Stable subcortical chronic infarct in the left parietal lobe (series 2, image 23) is redemonstrated. BONES: There are no suspicious lytic or sclerotic bony lesions. There is minimal mucosal thickening of the maxillary sinuses. Remaining paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No acute process in the head. 2. Stable subcortical chronic infarct in the left parietal lobe and in the left cerebellum. Radiology Report HISTORY: Leukocytosis and dizziness. FINDINGS: In comparison with the study of ___, there is again biapical thickening and adjacent pulmonary parenchymal scarring with tortuosity of the aorta. Mild elevation of the right hemidiaphragm is again seen. No evidence of pulmonary vascular congestion or acute focal pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: DIZZY Diagnosed with TRANS CEREB ISCHEMIA NOS, JOINT REPLACEMENT-HIP temperature: 99.8 heartrate: 67.0 resprate: 16.0 o2sat: 100.0 sbp: 139.0 dbp: 76.0 level of pain: 0 level of acuity: 1.0

The cause of Mr. ___ transient lip numbness and lightheadedness was unclear. We doubted a TIA or vascular event. His head CT in the ED showed old infarcts, and he was slightly dehydrated. Therefore, we admitted him for observation, hydration, and to investigate the cause(s) of his prior infarcts. He was started on 325 ASA and stroke risk factors were assessed: his lipids were total cholesterol 150, LDL 76, HDL 56, HbA1C 5.9%. Repeat exam the following morning was nonfocal and stable. He had a TTE, which was unrevealing. Telemetry showed no evidence of atrial fibrillation. We planned to obtain a MRI/MRA head without contrast and MRA neck with contrast during his admission. Mr. ___ initially refused to undergo the MRI, unless his brother was present. We attempted to obtain it the following day, but this could not be done due to scheduling conflicts. Therefore, we elected to obtain his MRI as an outpatient within 1 week of discharge. Mr. ___ was in good condition upon discharge, with clear understanding of the reasons and need for undergoing MRI. He will follow up in the stroke clinic with Dr. ___, his Neurologist.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Protonix / iv contrast / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Hallucinations Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ female with history of dCHF, T2DM, HTN, and Stage V CKD who presents with reports of visual hallucinations. Per patient's ___, he reports visual and auditory hallucinations for about 1 month. It is unclear how long this has been going on as ___ has only been here for a week. The patient has been seeing male images and children running around. Her ___ has been visiting from ___ for the last week, but his sister noticed this for the last two weeks. She other appears well per her family. Her ___ is concerned about her safety living alone. He is interested in long term care options at this time. The patient reports that she currently feels well. She reports that she does sometimes see children on the wall but this does not bother her. She does note a headache yesterday and the day before, but none today. She denies fever/chills, shortness of breath, chest pain, cough, abdominal pain, and dysuria. In the ED, initial vital signs were: 99.5 70 164/70 16 94% RA. Labs were notable for WBC 3.4, H/H 8.6/27.0, plt 189, Na 140, K 4.7, BUN/Cr 64/6.8, INR 1.0, ammonia 11, BNP 10212, and UA bland. Imaging with CXR with mild pulmonary vascular congestion with small bilateral pleural effusions and Head CT with no acute intracranial process. The patient was given nothing. Orthostatic vital signs positive for >20mmHg drop in blood pressure standing (177->153). Vitals prior to transfer were: 73 182/69 18 95% RA. Upon arrival to the floor, patient is feeling well and has no complaints. Past Medical History: - Stage V Chronic Kidney Disease - Diastolic Congestive Heart Failure - Type II Diabetes - Hypertension - Orthostasis - Ductal Carcinoma in Situ s/p incision in ___ - Anemia - Sickle Cell Trait - Gallstone Pancreatitis s/p cholecystectomy Social History: ___ Family History: Father had history of DM, HTN Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Temp 97.8, BP 144/65, HR 79, RR 18, O2 sat 92% RA GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT: Normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP less than 10. CARDIAC: RRR, systolic murmur at ___. PULMONARY: Coarse breath sounds bilaterally. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, bilateral pedal edema. Maturing fistula on left arm. NEUROLOGIC - A&Ox2 ___, ___, CN II-XII grossly normal, gross strength and sensation intact, knows president, can state days of week forward but not backwards, unable to do simple arithmetic. DISCHARGE PHYSICAL EXAM: VITALS: 98.6 71 ___ 18 95% RA GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT: Normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP less than 10. CARDIAC: RRR, systolic murmur at ___. PULMONARY: Coarse breath sounds bilaterally. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, bilateral pedal edema. Maturing fistula on left arm. NEUROLOGIC - A&Ox3, CN II-XII grossly normal, gross strength and sensation intact, knows president, can state days of week forward but not backwards, unable to do simple arithmetic. Pertinent Results: ADMISSION LABS: ================= ___ 11:18AM BLOOD WBC-3.4* RBC-2.96* Hgb-8.6* Hct-27.0* MCV-91 MCH-29.1 MCHC-31.9* RDW-14.8 RDWSD-48.9* Plt ___ ___ 11:18AM BLOOD Neuts-57.4 ___ Monos-11.3 Eos-3.6 Baso-0.9 Im ___ AbsNeut-1.93 AbsLymp-0.89* AbsMono-0.38 AbsEos-0.12 AbsBaso-0.03 ___ 11:18AM BLOOD Glucose-114* UreaN-64* Creat-6.8* Na-140 K-4.7 Cl-106 HCO3-21* AnGap-18 ___ 11:18AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1 ___ 11:18AM BLOOD TSH-1.7 ___ 11:18AM BLOOD Ammonia-11 ___ 07:45AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.1 DISCHARGE LABS: ================= ___ 07:45AM BLOOD Glucose-101* UreaN-60* Creat-6.7* Na-141 K-4.3 Cl-107 HCO3-23 AnGap-15 ___ 07:45AM BLOOD WBC-3.6* RBC-2.85* Hgb-8.4* Hct-25.9* MCV-91 MCH-29.5 MCHC-32.4 RDW-14.5 RDWSD-48.6* Plt ___ PERTINENT FINDINGS: ==================== MICRO: ------- Time Taken Not Noted Log-In Date/Time: ___ 6:42 am SEROLOGY/BLOOD ADDED TO SPEC ___ ___. **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. Imaging: -------- CT Head ___: FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Prominence of ventricles and sulci are compatible with age related global atrophy. Ill-defined periventricular and subcortical white matter hypodensities are nonspecific but likely due to a sequela of chronic small vessel ischemic changes. There is stable appearance of the known aneurysm clip in the right supraclinoid region. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. Prior right temporal craniotomy is re-demonstrated. IMPRESSION: No acute intracranial process. CXR ___: FINDINGS: The heart is severely enlarged. There is mild pulmonary vascular congestion and small bilateral pleural effusions. Mediastinal silhouette is unchanged. No focal consolidation is identified. No pneumothorax. IMPRESSION: Mild pulmonary vascular congestion with small bilateral pleural effusions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 5. Omeprazole 40 mg PO BID 6. sevelamer CARBONATE 1600 mg PO TID W/MEALS 7. Sodium Bicarbonate 1300 mg PO BID 8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 9. Vitamin D ___ UNIT PO 1X/WEEK (MO) 10. Labetalol 200 mg PO TID 11. Amlodipine 10 mg PO HS 12. Torsemide 20 mg PO EVERY OTHER DAY 13. Acetaminophen 1000 mg PO Q8H:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Amlodipine 10 mg PO HS 3. Aspirin 81 mg PO DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Labetalol 200 mg PO TID 7. Omeprazole 40 mg PO BID 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS 9. Sodium Bicarbonate 1300 mg PO BID 10. Torsemide 20 mg PO EVERY OTHER DAY RX *torsemide 20 mg 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*0 11. Vitamin D ___ UNIT PO 1X/WEEK (MO) 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Discharge Disposition: Home With Service Facility: ___ ___: Primary: - Hallucinations, likely ___ Dementia NOS Secondary: - Diastolic Congestive Heart Failure - Hypertension - CKD Stage V - Anemia - GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with hallucinations/delirium // acute process TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.7 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. mGy-cm COMPARISON: CTA Head from ___ FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Prominence of ventricles and sulci are compatible with age related global atrophy. Ill-defined periventricular and subcortical white matter hypodensities are nonspecific but likely due to a sequela of chronic small vessel ischemic changes. There is stable appearance of the known aneurysm clip in the right supraclinoid region. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. Prior right temporal craniotomy is re-demonstrated. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with cough // acute process TECHNIQUE: Chest PA and lateral COMPARISON: Prior chest radiographs from ___, ___ FINDINGS: The heart is severely enlarged. There is mild pulmonary vascular congestion and small bilateral pleural effusions. Mediastinal silhouette is unchanged. No focal consolidation is identified. No pneumothorax. IMPRESSION: Mild pulmonary vascular congestion with small bilateral pleural effusions. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Hallucinations Diagnosed with Altered mental status, unspecified temperature: 99.5 heartrate: 70.0 resprate: 16.0 o2sat: 94.0 sbp: 164.0 dbp: 70.0 level of pain: 0 level of acuity: 2.0

Ms. ___ is an ___ female with history of dCHF, T2DM, HTN, and Stage V CKD who presented with reports of visual hallucinations. # Hallucinations: The patient as brought in by family after admitting to seeing seeing small children "playing and dancing around on the wall and on my floor" The patient denied having hallucinations this admission and notes that they did not interfere with her daily activities. Per family, patient with visual and auditory hallucinations for at least the past month. During interview with psychology, the patient was found to have suggestive of major neurocognitve decline/dementia, however exact etiology unclear, exam suggestive perhaps of combination of AD and vascular pathology. No obvious infectious cause (CXR, cultures negative, no leukocytosis, fevers, or changes in vitals, RPR negative). Electrolytes and TSH normal, no physical exam signs were consistent with uremia, and Nephrology did not believe it was related to her renal failure. Toxicology screen was negative and there were no recent medication changes. While the etiology remains unclear, thought most likely secondary to dementia. The patient was evaluated by ___ and OT and cleared for return to home with ongoing services. The family indicated they would be able to provide 24 hour supervision and patient was discharged home with plans for close follow up with her PCP, ___. # Diastolic Congestive Heart Failure: Patient was noted to be euvolemic on exam and satting well on RA. However, CXR showed pulmonary vascular congestion, so she was given 80 IV lasix, with moderate urine output. She was then restarted on her home torsemide. # Hypertension: Patient was normotensive with mild hypertension on the floor, likely due to volume status during hospital stay. She was continued on home labetalol and amlodipine. # Stage V Chronic Kidney Disease: Cr 6.8 on admission with baseline Cr from 6.2-7. Her electrolytes were stable and no signs of severe volume overload. No indication for hemodialysis, though has L AVF fistula, apparently mature. She was continued on home sevalamer, sodium bicarbonate, and calcitriol. She is scheduled for follow up with her Nephrologist, Dr. ___. Cr. 60/6.7, K+ 4.3, Phos 4.8 # Anemia: At baseline. Likely secondary to renal insufficiency and sickle trait. Patient on aransep as an outpatient. # GERD: Stable, continued home omeprazole

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ___ Allergies: Penicillins Attending: ___. Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: -percutaneous jejunostomy tube placement by ___ on ___ History of Present Illness: Mr. ___ is a very pleasant ___ year old gentleman with a history of PE on Coumadin, dysphagia/dysphonia followed by ENT who presents with progressively worsening dysphagia and inability to take PO. He states that his symptoms have been progressively worsening over the past week. He has recently completed a course of doxycycline for pneumonia. For the past few days he has been unable to tolerate eating or drinking due to aspiration. Patient states that "after I eat or drink its hard to clear my throat and then I cough." Cough is productive, clear sputum. Of note, he has lost approximately 8 pounds over the past week due to inability to keep PO intake down. He denies odynophagia and has been able to tolerate pills without difficulty. In the ED, initial vitals were: 97.8 HR 92 122/85 16 97% RA Labs were notable for WBC 9.9, Hgb 11.7 Plt 305. Chemistry with Cr 1.3 (baseline 0.9-1.0). Imaging was notable for: CXR with retrocardiac opacity is potentially atelectasis though infection or aspiration would be possible. He received 500cc NS. On call physician for Dr. ___ was reached by ED who agreed with plan for admission. On the floor, he appears comfortable though coughs and clears his throat throughout the interview and exam. He states that his voice has been more hoarse in recent days. He denies headache, vision changes, chest pain, dyspnea, abdominal pain, nausea, vomiting, diarrhea, constipation, melena/hematochezia, myalgias, arthralgias. Past Medical History: - Esophageal adenocarcinoma s/p esophageal resection and chemoradiation - Supraglottic soft tissue mass (sp bx ___ and ___ and resection ___ - Paroxysmal atrial fibrillation on warfarin - Renal cell carinoma s/p right partial nephrectomy - PUD (sp UGIB at BIN) - GERD - Thrush - Anemia - Thyroid nodules - multinodular w sick euthyroid - Osteopenia - H/o pulmonary embolism - H/o babesiosis in ___ - sessile colonic polyp noted on CS in ___ - ___ esophagus vs. squamous papilloma - Remote suspected tick-borne illness without serology approved for possible Babesia at ___ complicated by atrial fibrillation which resolved with treatment in ___ - Duodenitis - AR/MR Social History: ___ Family History: Mother had pancreatic cancer Father had stomach cancer Physical Exam: ADMISSION EXAM: Vital Signs: 98.2 88 16 95 RA General: Alert, oriented, no acute distress, clears throat throughout interview and exam HEENT: Sclerae anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD, uvula deviates to left CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented x3, moving about the room without difficulty DISCHARGE EXAM: VS: 98.0 PO 104 / 56 R Lying 62 16 95 RA Gen: comfortably sitting in bed, no respiratory distress, clearing his throat frequently HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear OP, MMM, tongue & palate midline Neck: +Goiter, no bruit or stridor, no LAD Cardiac: Irregularly irregular, no r/g/m Chest: CTAB Abd: Soft NT ND +BS, newly placed J tube in L abdomen c/d/i Ext: WWP, no edema, L great toe is ever so slightly warmer than R (although had his sock partially off of the R so hard to tell. no redness or swelling seen. Neuro: AAOx3, moving all four extremities Psych: Normal affect Pertinent Results: ADMISSION LABS: ___ 06:00PM BLOOD WBC-9.9 RBC-3.88* Hgb-11.7* Hct-37.3* MCV-96 MCH-30.2 MCHC-31.4* RDW-13.2 RDWSD-46.8* Plt ___ ___ 06:00PM BLOOD Neuts-73* Bands-3 Lymphs-13* Monos-9 Eos-2 Baso-0 ___ Myelos-0 AbsNeut-7.52* AbsLymp-1.29 AbsMono-0.89* AbsEos-0.20 AbsBaso-0.00* ___ 06:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Acantho-OCCASIONAL ___ 06:00PM BLOOD Glucose-129* UreaN-36* Creat-1.3* Na-142 K-4.5 Cl-104 HCO3-20* AnGap-23* IMAGING & STUDIES: ___ CT Neck: IMPRESSION: No definite tracheoesophageal fistula identified, however cannot be excluded on the basis of this examination. Direct visualization is again recommended. Secretions are noted within the vallecula and hypopharynx. Correlation for aspiration is recommended. ___ Video S&S: SUMMARY: Today's assessment was most notable for leak at approximately the level of the PES which nectar thick liquid barium was noted to then spill into the trachea. This is likely cause of current pneumonia and patient report of notable coughing with liquids. ___ CXR Retrocardiac opacity is potentially atelectasis though infection or aspiration would be possible. ___ PROCEDURE: Flexible videostroboscopy. INDICATIONS: Dysphonia that would not clearly be evaluated by indirect laryngoscopy. PREOPERATIVE DIAGNOSIS: Dysphonia. POSTOPERATIVE DIAGNOSES: Bilateral vocal fold hypomobility, bilateral vocal fold scar, primary muscle tension dysphonia, dysphagia with cricopharyngeal dysfunction, Zenker's diverticulum. FINDINGS: 1. Supraglottic hyperfunction: Moderate false vocal fold compression. 2. Right vocal fold movement: Abduction, adduction, longitudinal tension decreased. 3. Left vocal fold movement: Abduction, adduction, longitudinal tension decreased. 4. Arytenoid joint movement: Could not assess. 5. True vocal fold characteristics: Bilateral scar. 6. Masses or vibratory margin irregularities: Absent. 7. Other structural lesions: Pooled secretions. 8. Glottic Closure: Complete. 9. Vocal process height: Uneven, high on the left. 10. Vibration: Phase: Asymmetric mild. 11. Periodicity: Irregular. 12. Amplitude: Decreased left and right. 13. Waveform: Right and left decreased moderate. ___ EGD Previous esophago-gastric anastomosis of the esophagus At 20 cm just below the upper esophageal sphincter there was a 1.5 cm nodule and below the nodule there was an area likely where biopsy was done with an adherent clot and no visible bleeding. Otherwise normal EGD to third part of the duodenum ========================================================= MRI SOFT TISSUE NECK, W/O AND W/CONTRAST T925 MR NECK ___ 1. Homogeneous enhancement of the posterior supraglottic laryngeal soft tissue which is favored to represent posttreatment changes given the homogeneous nature of enhancement, however recurrent disease cannot be excluded. Short-term follow-up MRI is recommended for further evaluation. Comparison with prior studies would also be helpful. 2. Thyroid nodule as seen on the prior CT. Flexible and rigid esophagoscopy and microlaryngoscopy ___ Findings: Macule type area just underneath the cricopharyngeus that was consistent with the previous location and morphology of the lesion. This did not appear suspicious, the previous white fleshy coloration had resolved. A small Zenker diverticulum was found posteriorly and there was a small outpouching anteriorly (biopsy) with food contents. a balloon was used to dilate from 10-15 mm without undue resistance. Pathology: 1. "Diverticulum, contents": Fragments of food matter and fibrinopurulent exudate. 2. Diverticulum mucosa, excision: Squamous mucosa with focal acute esophagitis, detached fragments of fibrinopurulent exudate and food matter. 3. Anterior esophageal mass, excision: Squamous mucosa with focal acute esophagitis. Unremarkable submucosa. 4. Crico-pharyngeus mass, excision: Squamous mucosa with hyperplasia and focal acute esophagitis. Fragments of fibrinopurulent exudate. Note: No malignancy identified. Multiple levels are examined. EGD ___ Impression: Previous esophago-gastric of the esophagus. At 20 cm just below the upper esophageal sphincter there was a 1.5 cm nodule and below the nodule there was an area likely where biopsy was done with an adherent clot and no visible bleeding. I decided not to remove the clot. Otherwise normal EGD to third part of the duodenum (No biopsy). No pathology report available. Oropharyngeal swallowing videofluoroscopy ___ Impression: Penetration aspiration of thin liquid and nectar thick liquid. CXR ___ Impression: Compared to chest radiographs since ___, most recently ___. Hyperinflation indicates emphysema. Patient has had esophagectomy and gastric pull-up. Moderate amount of retained barium indicates right lower lobe aspiration. There may be a small region of new consolidation but the lungs are clear elsewhere. Oropharyngeal swallowing videofluoroscopy ___ Impression: Tracheoesophageal fistula at the level of the cricopharyngeus muscle / cricoid cartilage. Given history of esophagectomy, this may represent anastomotic dehiscence. Direct visualization with endoscopy is recommended. CT neck ___ Impression: No definite tracheoesophageal fistula identified, however cannot be excluded on the basis of this examination. Direct visualization is again recommended. Secretions are noted within the vallecula and hypopharynx. Correlation for aspiration is recommended. Bronchoscopy ___ Tracheo esophageal fistula just below vocal cords on the posterior trachea (almost 1 cm from vocal cords) ======================================================== J Tube Placement by ___ ___: PROCEDURE: 1. Placement of a 12 ___ Wills ___ jejunostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. Utilizing real-time ultrasound guidance, a 21 gauge x 15 cm percutaneous needle was advanced into a fluid filled loop of bowel which had been tacked up at the previous access site. Intraluminal positioning was confirmed with aspiration of air and injection of contrast. Next, a Nitinol micro wire was advanced into the lumen of the small bowel loop. The percutaneous needle was then removed and exchanged for the inner portion of a Accustick set. Next, the Nitinol micro wire and inner dilator were removed and a 0.035 glidewire was introduced into the bowel. Subsequently the micro sheath was removed and exchanged for a 5 ___ MPA catheter. The Glidewire was then removed and exchanged for an Amplatz wire. Next, serial dilatations from 6 ___, 8 ___, 10 ___ and 12 ___ were then performed. Finally, under fluoroscopic guidance, a 12 ___ Wills ___ jejunostomy tube is was advanced into the jejunum loops over the wire. The Amplatz wire was removed and injection of contrast confirmed intraluminal positioning. The catheter was secured by forming the retaining loop in the small bowel loop after confirming the positioning of the catheter with a contrast injection. The catheter was then flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a ___ F Wils Ogelsby jejunostomy tube IMPRESSION: Successful placement of a ___ F Wils ___ jejunostomy tube. The catheter should not be used for 24 hours for enteral feeding. ============================================================ MRI Neck ___: IMPRESSION: 1. Subtle defect of the posterior left paramedian trachea, roughly 1 cm inferior to the glottis, corresponding to a defect to better seen on the prior CT examination, which corresponds to the tracheoesophageal fistula on barium swallow examination. 2. Partial visualization of changes from esophagectomy and gastric pull-up. 3. 11 mm left thyroid lobe nodule. The ___ College of Radiology guidelines suggest that in the absence of risk factors for thyroid cancer, no further evaluation is recommended. 4. No neck mass identified. = ================================================================ Discharge Labs: ___ 10:20PM BLOOD WBC-8.9 RBC-3.33* Hgb-10.1* Hct-31.5* MCV-95 MCH-30.3 MCHC-32.1 RDW-12.9 RDWSD-44.5 Plt ___ ___ 06:30AM BLOOD WBC-7.1 RBC-3.03* Hgb-9.2* Hct-28.6* MCV-94 MCH-30.4 MCHC-32.2 RDW-13.1 RDWSD-45.1 Plt ___ ___ 07:05AM BLOOD WBC-9.0 RBC-3.10* Hgb-9.3* Hct-29.2* MCV-94 MCH-30.0 MCHC-31.8* RDW-13.1 RDWSD-44.6 Plt ___ ___ 10:20PM BLOOD ___ ___ 07:10AM BLOOD Glucose-168* UreaN-20 Creat-0.9 Na-134 K-4.2 Cl-98 HCO3-27 AnGap-13 ___ 10:20PM BLOOD Glucose-156* UreaN-16 Creat-1.0 Na-136 K-4.5 Cl-99 HCO3-28 AnGap-14 ___ 06:30AM BLOOD Glucose-122* UreaN-15 Creat-0.9 Na-136 K-3.7 Cl-102 HCO3-27 AnGap-11 ___ 07:10AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.8* ___ 10:20PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7 ___ 06:30AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.7 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methimazole 2.5 mg PO EVERY OTHER DAY 2. Warfarin 5 mg PO 3X/WEEK (___) 3. Ferrous GLUCONATE 324 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. calcium citrate-vitamin D3 315-250 mg-unit oral daily 7. Vitamin D 1000 UNIT PO DAILY 8. Warfarin 2.5 mg PO 4X/WEEK (___) Discharge Medications: 1. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg one half tablet(s) by mouth two times a day Disp #*30 Tablet Refills:*0 2. Neutra-Phos 1 PKT PO DAILY RX *potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg 1 powder(s) per J tube daily Disp #*14 Packet Refills:*0 3. Warfarin 2 mg PO DAILY16 4. Ascorbic Acid ___ mg PO DAILY 5. calcium citrate-vitamin D3 315-250 mg-unit oral daily 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Methimazole 2.5 mg PO EVERY OTHER DAY 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11.suction machine One suction machine and supplies 12.Tube Feeding Order Tubefeeding: Jevity 1.5 Full strength (or equivalent); Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate: 55 ml/hr Flush w/ 150 ml water q4h (can space out to q8h) Other instructions: cycle goal 95mL/h over 14h Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Tracheoesophageal Fistula. Hx Cricopharyngeal Mass (Benign Biopsies in the Past) with Hx Cricopharyngeal Dysfunction/Zenker's Diverticulum. Hx Bilateral Vocal Fold Hypomobility and Scar. Hx Lower Esophageal Ca s/p chemoXRT. Hx Atrial Fibrillation. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with worsening dysphagia/dysphonia, history multiple chronic pharyngeal issues and Zenker's diverticulum. // pls eval swallow function TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 12 seconds COMPARISON: Oropharyngeal video swallow from ___ Esophogram from ___. CT Neck from ___. FINDINGS: On limited views, bolus initiation and epiglottic closure are normal without penetration or passage of barium into the trachea under the epiglottis. At the level of the cricopharyngeus muscle, a communication between the esophagus and trachea results and barium passing into the airway. Given history of esophagectomy with unclear level of anastomosis (at the level of the azygous vein per operative report, but suture material visualized to the level of the cricoid cartilage on CT neck from ___ this could be at the level of the anastomosis. IMPRESSION: Tracheoesophageal fistula at the level of the cricopharyngeus muscle / cricoid cartilage. Given history of esophagectomy, this may represent anastomotic dehiscence. Direct visualization with endoscopy is recommended. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. RECOMMENDATION(S): Direct visualization with endoscopy is recommended. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 15:48 ___, 5 minutes after discovery of the findings. The updated findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:57 ___, 5 minutes after discovery of the updated findings. Radiology Report EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) INDICATION: ___ year old man with concern for trachea-esophageal fistula on video swallow // rule out fistula TECHNIQUE: MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base without IV contrast. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Total DLP (Body) = 221 mGy-cm. COMPARISON: Barium swallow on ___, CT neck on ___, MR neck on ___, thyroid ultrasound on ___ FINDINGS: Patient is status post esophagectomy and gastric pull-through, with stable appearance of the partially visualized proximal neo esophagus. There is no definite tracheoesophageal fistula identified. A small amount of secretions/debris is present in the esophagus. Initially secretions are noted layering within the vallecular on and hypopharynx (series 7 images 39-44). Previously seen isodense area posterior to the supraglottic larynx is less prominent compared with CT neck ___, and likely represented postsurgical change. The salivary glands enhance normally and are without mass or adjacent fat stranding. A 1.4 cm hypodense thyroid nodule is stable, and was previously evaluated by ultrasound. There is no lymphadenopathy by CT criteria. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. A small amount of debris is noted in the proximal left mainstem bronchus (4:90). Multilevel degenerative changes are similar to prior. There are no osseous lesions. Chronic appearing rim displaced right posterior sixth rib fracture. IMPRESSION: No definite tracheoesophageal fistula identified, however cannot be excluded on the basis of this examination. Direct visualization is again recommended. Secretions are noted within the vallecula and hypopharynx. Correlation for aspiration is recommended. RECOMMENDATION(S): Recommend direct visualization. Radiology Report INDICATION: ___ year old man with hx of esophageal ca s/p ___ surgery (___) now presenting with TE fistula // need for percutaneous feeding tube access COMPARISON: CT abdomen and pelvis ___ TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 25 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 45 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 5 cc 1% buffered lidocaine subcutaneous injection at the access site CONTRAST: 25 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 5.5 min, 14 mGy PROCEDURE: 1. Placement of a 12 ___ Wills ___ jejunostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. Utilizing real-time ultrasound guidance, a 21 gauge x 15 cm percutaneous needle was advanced into a fluid filled loop of bowel which had been tacked up at the previous access site. Intraluminal positioning was confirmed with aspiration of air and injection of contrast. Next, a Nitinol micro wire was advanced into the lumen of the small bowel loop. The percutaneous needle was then removed and exchanged for the inner portion of a Accustick set. Next, the Nitinol micro wire and inner dilator were removed and a 0.035 glidewire was introduced into the bowel. Subsequently the micro sheath was removed and exchanged for a 5 ___ MPA catheter. The Glidewire was then removed and exchanged for an Amplatz wire. Next, serial dilatations with 6 ___, 8 ___, 10 ___ and 12 ___ were then performed. Finally, under fluoroscopic guidance, a 12 ___ Wills ___ jejunostomy tube is was advanced into the jejunum loops over the wire. The Amplatz wire was removed and injection of contrast confirmed intraluminal positioning. The catheter was secured by forming the retaining loop in the small bowel loop after confirming the positioning of the catheter with a contrast injection. The catheter was then flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a ___ F Wils Ogelsby jejunostomy tube IMPRESSION: Successful placement of a ___ F Wils Ogelsby jejunostomy tube. The catheter should not be used for 24 hours for enteral feeding. Radiology Report EXAMINATION: MRI SOFT TISSUE NECK, W/O AND W/CONTRAST T925 MR NECK INDICATION: History of esophageal adenocarcinoma post resection and radiation with gastric pull-up as well as RCC post partial nephrectomy in remission presenting with tracheoesophageal fistula described on prior barium swallow and direct visualization 1 cm below the glottis. TECHNIQUE: Sagittal and axial T1 weighted imaging was performed along with axial fat-suppressed T2 weighted imaging. After administration of 8 mL of Gadavist intravenous contrast, axial and coronal T1 weighted imaging were performed with fat suppression. COMPARISON: Video or pharyngeal swallow examination ___. CT neck examinations from ___ and ___. MR soft tissue neck ___. FINDINGS: On prior CT examination from ___, there is a subtle, rounded defect within the posterior airway, roughly 1 cm inferior to the glottis, slightly to the left of midline (5:562 on the ___ examination), corresponding to the level of tracheoesophageal communication seen on prior barium swallow examination. A similar subtle abnormality is seen within the subglottic airway on the axial T1 post sequences (08:19). There is no exophytic mucosal mass. There is no lymphadenopathy by imaging criteria. The principal cervical vascular flow voids are preserved. The salivary glands are unremarkable without focal lesion. There is an 11 mm, loculated cystic appearing left lobe thyroid nodule. There is partial visualization of postsurgical changes from esophagectomy with gastric pull-up. IMPRESSION: 1. Subtle defect of the posterior left paramedian trachea, roughly 1 cm inferior to the glottis, corresponding to a defect to better seen on the prior CT examination, which corresponds to the tracheoesophageal fistula on barium swallow examination. 2. Partial visualization of changes from esophagectomy and gastric pull-up. 3. 11 mm left thyroid lobe nodule. The ___ College of Radiology guidelines suggest that in the absence of risk factors for thyroid cancer, no further evaluation is recommended. 4. No neck mass identified. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Decreased PO intake Diagnosed with Acute kidney failure, unspecified temperature: 97.8 heartrate: 92.0 resprate: 16.0 o2sat: 97.0 sbp: 122.0 dbp: 85.0 level of pain: 0 level of acuity: 2.0

Summary: Mr. ___ is a ___ M with hx of pAF, PE on Coumadin, hx esophageal Ca s/p chemoXRT and esophageal cancer s/p esophagogastrectomy in ___ complicated by cricopharyngeal dysfunction/Zenker's diverticulum, hx vocal fold hypomobility, hx post-infectious muscle tension dysphonia, recent dx pneumonia, admitted for progressive dysphonia & dysphagia, found to have new trachea-esophageal fistula on video speech-and-swallow ___. Thoracics was consulted who rec IP c/s for direct visualization via bronch. Hospital course notable for development of hypoglycemia on ___ in the setting of poor PO intake for which he was started D5W w/hypoglycemia protocol. His hospital course was complicated by rapid afib while walking (for which he triggered rates 130s, asymptomatic) after his metop had been held for two days (to minimize pills) which resolved after resuming metoprolol. He underwent a bronch on ___ by IP which confirmed a TE fistula was present. S/p ___ J tube placement on ___. Tube feeding began 24h later on the evening of ___ but was to be held now in preparation for MRI requested by ENT for planning purposes. He tolerated the MRI well on ___ and tube feeds were resumed and cycled overnight into ___, which he tolerated well. On further discussions with ENT, it was decided that, given his nutritional status, he would certainly not be having his surgery done this hospitalization and thus will follow up with ENT surgery as outpatient for surgical planning. Interval Events/ROS: Feeling well this morning. No nausea or vomting or ab pain after cycling tube feeds last night. His MRI went well. He is excited to go home. He mentioned a "twinge" in his L toe but was able to move it well and stand on his foot this morning. I could find little e/o gout on my exam. He thought he might have stubbed his toe on his bed last night while he was sleeping. Rest of hospital course/plan are outlined below by issue: # Progressive Dysphagia/Dysphonia # Known Cricopharyngeal Dysfunction/Zenker's Diverticulum # New Dx Tracheo-esophageal Fistula Patient thought to have multifactorial dysphonia/dysphagia for the many chronic reasons listed above, but found to have new TEF on video S&S exam ___. Seen by Thoracics, CT non-con did not find definite TEF, so direct visualization recommended. s/p bronch by IP on ___ which did confirm the TEF. On further discussion with thoracics and based on the anatomical location of the fistula, thoracics recommended ENT was more appropriate for the surgery so thoracics has signed off. -script for suction machine was written for the patient to have at home # ? Aspiration Pneumonia: # Leukocytosis Completed 5d Levaquin for retrocardiac opacity/bandemia on admission, presumed PNA. # Severe Malnutrition: albumin 2.8. Prealbumin 9. Prolonged period inpatient without PO intake due to multiple procedures and issues obtaining enteric access. # H/O PE # Atrial fibrillation # Supratherapeutic INR: - INR peaked at 10, s/p PO Vit K 2.5mg x3 on ___ & ___ & ___ with improvement of INR to 2.2 on ___ in prep for bronch. INR was finally 1.4 on ___. Warfarin was resumed on ___ after no further procedures were planned. He was restarted on 2mg daily (previous outpatient dose had been 2.5mg alternating with 5mg but reduced due to supratherapeutic INR recently). No anticoagulant bridge was used due to recent ___ procedure. - was on metop 12.5 q6h but was briefly held to minimize pills however developed rapid afib to 130s on ___ while walking (asymptomatic) so metop 12.5 mg q6h was resumed. he was also mildly hypomagnesemic at the time which was repleted. # Grave's Disease: - Continue home methimazole # Osteopenia: - Hold calcium and Vitamin D # GERD: - Converted to IV PPI to PO PPI # Transitional Issues: -new meds: metop 12.5 BID, daily phos-NaK (to continue while starting tube feeding, can be d/c'd by PCP based on electrolytes) -IP bronch biopsies will need to be followed up as outpatient by his oncologist -outpatient onc follow up (___), thoracic surgery, ENT follow up -Will need BMP with magnesium and phosphorous levels daily for at least the first two days of tube feeding, then twice weekly thereafter, these labs are to be followed up by PCP ___. ___ at Phone: ___. -He will also need INR monitoring for his Coumadin therapy and Coumadin dose adjusted (he is currently subtherapeutic but not on a anticoagulant bridge due to his recent ___ procedure). INR monitoring to be followed by his PCP ___ as above. First INR to be checked ideally within ___ after discharge. # CONTACTS: health care proxy: ___ Relationship: Son Phone number: ___ Cell phone: ___ -updated son ___ in person or over the phone daily while I was taking care of the patient. -I Called the ___ office and I spoke with Dr. ___ relayed the plan going forward and we discussed his hospital course. I specifically informed him of the follow up electrolytes and INR monitoring. #Nutrition: tube feeds ___ tarted per nutrition recs: jevity goal 55mL/h, Patient will remain NPO (except for pills in jello) for tracheoesophageal fistula - will likely need tube feeds for 3 months, replete electrolytes including phos, ongoing aspiration precautions, Consults: Thoracics (signed off), General Surgery (Dr. ___, IP, Nutrition, ENT Dispo: dc home with services today. Pt has been ambulating well without assistance. Spent > 30 minutes seeing the patient and organizing discharge. _________________________________ ___, MD ___ Pager ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: pcn Attending: ___. Chief Complaint: Diarrhea, nausea, chest discomfort Major Surgical or Invasive Procedure: ___ Placement History of Present Illness: ___ female with stage IV endometrial cancer on anastrazole, DM2, CAD, CKD, chronic respiratory failure with hypoxemia on home oxygen, and morbid obesity presents from her PCP's office with gastrointestinal illness and chest discomfort. She was in her usual state of health until ___, when she experienced the onset of fever, headache, diarrhea, heaving (mostly dry), and malaise. She noted some chest discomfort accompanying the dry heaves that felt "like someone punching her" in the chest (not like the pressure she felt with her prior MI). Her PCP was concerned about EKG changes, and sent her to the hospital. She has a history of cardiac disease, including an MI in ___. At that time, she was cathed and found to have significant disease but due to intolerance of the procedure no intervention was carried out. She has been medically managed in the interim. In the ED, initial vitals were T 99.4 HR 72 BP 102/45 RR 18 SpO2 98%2L. CT head w/o contrast was unremarkable. CXR showed mild cardiomegaly with central vascular congestion. Labs were remarkable for K of 3.0 for which she was given 40meq potassium. Vitals prior to transfer were T 100.4 HR 66 BP 129/69 RR 18 SpO296%2L. On the floor, vitals are stable and she feels better. She denies heaves, chest pain, difficulty breathing, nausea, or abdominal pain. She does endorse ongoing diarrhea. Past Medical History: Endometrial cancer: Diagnosed ___, Stage IV, s/p hysterectomy and radiation, on anastrazole DM2: Latest HbA1C 4.5 (___) CAD: ___ ___, underwent cardiac catheterization without intervention Chronic respiratory failure: 2L home oxygen CKD stage 3 HTN hypothyroidism thrombocytopenia anemia depression Social History: ___ Family History: Father died at ___ after ___ MIs Mother died at ___, had CHF Sister died of breast cancer Physical Exam: Admission: VS: T 98.4 BP 105/52 HR 64 RR 20 SpO2 98%2L General: Obese woman sleeping in hospital bed, easily arousable. HEENT: NCAT, MMM, no teeth Neck: Supple, no LAD, no JVD CV: Distant heart sounds. Regular rate and rhythm, no M/R/G appreciated. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, soft, non-distended, non-tender. Bowel sounds present. GU: Deferred Ext: Warm, 2+ distal pulses bilaterally, darkened skin around ankles (?stasis dermatitis), no edema Neuro: Alert, oriented, moving all extremities Discharge: VS: T 97.8 BP 104/52 HR (not recorded) RR 18 SpO2 94%RA General: Obese woman in hospital bed, no distress. HEENT: NCAT, mucous membranes moist Neck: Supple, no LAD CV: Regular rate and rhythm, distant heart sounds, no appreciable murmurs/rubs/gallops Lungs: Poor aeration throughout, otherwise clear to auscultation Abdomen: Obese, soft, non-distended. Bowel sounds present. Ext: Warm, 2+ distal pulses bilaterally, darkened skin around ankles (?stasis dermatitis), 2+ pitting edema Neuro: Alert, oriented, moving all extremities Pertinent Results: ___ 01:50PM BLOOD WBC-6.8 RBC-3.51* Hgb-9.5* Hct-29.2* MCV-83 MCH-27.1 MCHC-32.5 RDW-15.7* Plt Ct-62* ___ 08:25AM BLOOD WBC-5.2 RBC-3.67* Hgb-10.0* Hct-30.8* MCV-84 MCH-27.2 MCHC-32.5 RDW-15.8* Plt Ct-59* ___ 07:15AM BLOOD WBC-3.7* RBC-3.13* Hgb-8.4* Hct-26.3* MCV-84 MCH-26.9* MCHC-32.1 RDW-15.2 Plt Ct-46* ___ 01:30PM BLOOD WBC-3.4* RBC-3.12* Hgb-8.4* Hct-26.4* MCV-85 MCH-27.0 MCHC-31.9 RDW-15.3 Plt Ct-51* ___ 05:40AM BLOOD WBC-3.0* RBC-3.23* Hgb-8.9* Hct-27.3* MCV-84 MCH-27.6 MCHC-32.7 RDW-15.4 Plt Ct-53* ___ 05:36AM BLOOD WBC-1.9* RBC-3.08* Hgb-8.2* Hct-25.6* MCV-83 MCH-26.6* MCHC-31.9 RDW-15.2 Plt Ct-54* ___ 07:15AM BLOOD WBC-1.5* RBC-2.89* Hgb-7.7* Hct-24.0* MCV-83 MCH-26.6* MCHC-32.0 RDW-15.2 Plt Ct-71* ___ 03:40PM BLOOD WBC-2.2* RBC-3.07* Hgb-8.2* Hct-26.0* MCV-85 MCH-26.8* MCHC-31.6 RDW-15.3 Plt Ct-88* ___ 07:00AM BLOOD WBC-1.5* RBC-2.79* Hgb-7.6* Hct-23.6* MCV-85 MCH-27.4 MCHC-32.4 RDW-15.2 Plt Ct-81* ___ 01:20PM BLOOD WBC-1.9* RBC-3.24* Hgb-8.6* Hct-27.4* MCV-85 MCH-26.6* MCHC-31.5 RDW-15.1 Plt Ct-93* ___ 06:35AM BLOOD WBC-1.9* RBC-2.88* Hgb-7.9* Hct-24.2* MCV-84 MCH-27.5 MCHC-32.6 RDW-15.2 Plt Ct-90* ___ 01:50PM BLOOD Neuts-87.6* Lymphs-6.4* Monos-5.7 Eos-0.1 Baso-0.1 ___ 05:36AM BLOOD Neuts-73.4* Lymphs-17.0* Monos-7.0 Eos-2.3 Baso-0.3 ___ 07:15AM BLOOD Neuts-65 Bands-0 ___ Monos-5 Eos-5* Baso-0 ___ Myelos-0 ___ 06:35AM BLOOD Neuts-61.4 ___ Monos-12.3* Eos-1.5 Baso-0.9 ___ 01:50PM BLOOD Glucose-165* UreaN-19 Creat-1.0 Na-140 K-3.0* Cl-98 HCO3-33* AnGap-12 ___ 05:40AM BLOOD Glucose-103* UreaN-23* Creat-1.1 Na-135 K-3.8 Cl-101 HCO3-30 AnGap-8 ___ 06:35AM BLOOD Glucose-101* UreaN-16 Creat-0.7 Na-139 K-4.1 Cl-103 HCO3-31 AnGap-9 ___ 01:50PM BLOOD CK(CPK)-26* ___ 08:35PM BLOOD ALT-23 AST-28 CK(CPK)-20* AlkPhos-158* TotBili-1.8* ___ 05:36AM BLOOD CK(CPK)-11* ___ 07:00AM BLOOD ALT-24 AST-35 LD(LDH)-165 AlkPhos-288* TotBili-0.3 ___ 06:35AM BLOOD ALT-31 AST-48* AlkPhos-297* TotBili-0.3 ___ 01:50PM BLOOD CK-MB-1 cTropnT-0.21* ___ 08:35PM BLOOD CK-MB-1 cTropnT-0.17* ___ 03:15AM BLOOD CK-MB-1 cTropnT-0.16* ___ 08:25AM BLOOD CK-MB-1 cTropnT-0.19* ___ 07:15AM BLOOD CK-MB-1 cTropnT-0.14* ___ 01:50PM BLOOD Calcium-8.0* Phos-1.2* Mg-1.3* ___ 05:40AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0 ___ 06:35AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.6 Imaging ___ CHEST (PA & LAT): IMPRESSION: Mild cardiomegaly with central vascular congestion, but without frank edema. ___ CT HEAD W/O CONTRAST: IMPRESSION: No acute intracranial process. Small hypodensity in the left centrum semiovale may relate to small vessel ischemic change, however, given assymetric with the right side, nonurgent brain MRI would further evaluate. ___ Cardiovascular ECHO: Poor echo windows. The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. ___ RENAL U.S.: IMPRESSION: 1. No definite ultrasound findings to suggest pyelonephritis, although this diagnosis cannot be excluded sonographically. 2.1 cm hypoechoic lesion in the right upper renal pole, poorly visualized and indeterminate; this could represent a cyst but in the current clinical setting, focal infection or abscess cannot be excluded. Per the patient's report, there has been a recent abdominal CT performed at ___ comparison to this study is recommended. Of note, if this study is uploaded into PACS, an addendum could be issued at that time. If this study cannot be obtained, further evaluation could be performed with CT. 3. Right lower pole 15 mm cyst or calyceal diverticulum. 4. Possible duplex right kidney. ___ CT ABD & PELVIS WITH CO: IMPRESSION: 1. Large rim-enhancing fluid collection along the lower abdominal incision site, likely a seroma, is stable to slightly smaller since ___. Recommended clinical correlation to assess for possible superinfection. 2. No intra-abdominal pathology identified to explain the patient's symptoms. 3. Unexplained massive splenomegaly. 4. Cholelithiasis. ___ CHEST PORT. LINE PLACEM: IMPRESSION: 1. Right PICC at the cavoatrial junction. 2. Stable cardiomegaly. MICROBIOLOGY ___ 3:15 am BLOOD CULTURE RIGHT ARM. **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. anastrozole *NF* 1 mg Oral daily 3. Omeprazole 40 mg PO DAILY 4. Fluoxetine 40 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO BID 9. Aspirin 81 mg PO DAILY 10. TraZODone 25 mg PO HS 11. Nitroglycerin SL 0.4 mg SL PRN chest pain 12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 13. Naproxen 220 mg PO Q8H:PRN pain 14. Humulin N 15 Units Breakfast Humulin N 15 Units Bedtime Discharge Medications: 1. anastrozole *NF* 1 mg Oral daily 2. Aspirin 81 mg PO DAILY 3. Fluoxetine 40 mg PO DAILY 4. Humulin N 15 Units Breakfast Humulin N 15 Units Bedtime 5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO BID 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Omeprazole 40 mg PO DAILY 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 12. Simvastatin 20 mg PO DAILY 13. TraZODone 25 mg PO HS 14. Naproxen 220 mg PO Q8H:PRN pain 15. CeftriaXONE 2 gm IV Q24H RX *ceftriaxone 2 gram 2 g IV once daily Disp #*7 Syringe Refills:*0 16. Outpatient Lab Work Please check CBC with differential on ___ and fax results to PCP ___ MD Phone: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Diarrhea 2. Urinary tract infection 3. GNR bacteremia 4. Pancytopenia 5. Demand ischemia 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: Headache and vomiting. COMPARISON: None available. TECHNIQUE: Contiguous axial MDCT images were obtained of the head without contrast. Multiplanar reformation images were generated in the coronal and sagittal planes as well as thin section bone algorithm images. DLP: 1025.72 mGy-cm. FINDINGS: There is no hemorrhage, edema, mass effect or acute vascular territorial infarct. There is a small hypodensity in the left centrum semiovale. Mild prominence of the ventricles and sulci suggestive of age-related involutional change. Minimal periventricular white matter hypodensity is compatible with chronic small vessel ischemic disease. The basal cisterns are patent and there is preservation of the gray-white matter differentiation. Dense atherosclerotic vascular calcifications are noted within the vertebral arteries and carotid siphons. The visualized paranasal sinuses and middle ear cavities are clear. Bilateral mastoids are under pneumatized. The globes are intact. IMPRESSION: No acute intracranial process. Small hypodensity in the left centrum semiovale may relate to small vessel ischemic change, however, given assymetric with the right side, nonurgent brain MRI would further evaluate. Findings discussed with Dr. ___ at 11:30AM on ___ via telephone. Radiology Report HISTORY: Gram negative bacteremia and positive urinalysis. Assess pyelonephritis. COMPARISON: None at this institution. FINDINGS: The study is slightly limited due to suboptimal acoustic penetration. The kidneys are normal in size, with the right kidney measuring 12.4 cm and the left kidney measuring 11.8 cm. A band of renal parenchyma is seen extending across the right interpolar region, suggestive of a duplicated collecting system. Within the right lower renal pole, there is a 10 x 15 x 8 mm cyst or calyceal diverticulum. Within the right upper pole, there is a 2.1 x 1.7 x 2.3 cm hypoechoic structure, incompletely evaluated on the present study. There is no hydronephrosis or evidence of nephrolithiasis. The bladder is unremarkable. IMPRESSION: 1. No definite ultrasound findings to suggest pyelonephritis, although this diagnosis cannot be excluded sonographically. 2.1 cm hypoechoic lesion in the right upper renal pole, poorly visualized and indeterminate; this could represent a cyst but in the current clinical setting, focal infection or abscess cannot be excluded. Per the patient's report, there has been a recent abdominal CT performed at ___ comparison to this study is recommended. Of note, if this study is uploaded into PACS, an addendum could be issued at that time. If this study cannot be obtained, further evaluation could be performed with CT. 3. Right lower pole 15 mm cyst or calyceal diverticulum. 4. Possible duplex right kidney. Radiology Report INDICATION: ___ woman with stage IV endometrial cancer, post TAH-BSO in ___, radiation treatment in ___ now presents with hypoxemia, E. coli bacteremia, nausea, vomiting and diarrhea. COMPARISON: None. TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained after the uneventful intravenous administration of 150 cc of Omnipaque intravenous contrast. Sagittal and coronal reformations were performed and reviewed. TOTAL DLP: 888.98 mGy-cm. FINDINGS: The imaged portion of the lung bases and heart are normal. A small hiatal hernia is present. The liver enhances homogeneously, without focal lesions or biliary dilation. Multiple gallstones are seen, without evidence of acute cholecystitis. The spleen is enlarged measuring 19.7 cm. There is nodular thickening of the left adrenal gland without a focal mass. The right adrenal gland and pancreas are normal. Multiple subcentimeter hypodense lesions seen in both kidneys are not characterized in this single-phase contrast-enhanced study. There is no hydronephrosis. The abdominal aorta is normal in course and caliber. No significant retroperitoneal or mesenteric lymphadenopathy is seen. The stomach, small bowel and large bowel loops are unremarkable, without evidence of obstruction or inflammation. There is no intra-abdominal free fluid or air. CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is partially filled and appears unremarkable. The patient is status post total abdominal hysterectomy and bilateral salpingo-oophorectomy with expected post-surgical changes. The rectum and sigmoid colon are normal. Small external iliac lymph nodes do not meet CT criteria for significant adenopathy. BONES AND SOFT TISSUES: Bilateral sacroiliac joint degenerative changes are seen. No lytic or sclerotic bone lesion is is seen. A 14 x 6.2 x 3.0 cm rim-enhancing fluid collection seen along the ventral abdominal incision site in the lower abdomen/pelvis (2:70) with extensive surrounding fat stranding, is stable to slightly smaller compared to the prior outside hospital study of ___. IMPRESSION: 1. Large rim-enhancing fluid collection along the lower abdominal incision site, likely a seroma, is stable to slightly smaller since ___. Recommended clinical correlation to assess for possible superinfection. 2. No intra-abdominal pathology identified to explain the patient's symptoms. 3. Unexplained massive splenomegaly. 4. Cholelithiasis. Radiology Report INDICATION: ___ woman with new line placement. COMPARISONS: Chest radiograph from ___. FINDINGS: Single portable supine chest radiograph was provided. A new right PICC terminates at the cavoatrial junction. Again seen is cardiomegaly. There is no focal consolidation, pleural effusion or pneumothorax. The bones are intact. IMPRESSION: 1. Right PICC at the cavoatrial junction. 2. Stable cardiomegaly. Radiology Report HISTORY: Chest pain. COMPARISON: None available. TECHNIQUE: PA and lateral chest radiograph, two views. FINDINGS: Cardiac silhouette is mildly enlarged. Mild tortuosity of the thoracic aorta. There is mild central vascular congestion with cephalization. Streaky bibasilar atelectasis is noted. There is no focal consolidation worrisome for pneumonia. There is no pleural effusion or pneumothorax. IMPRESSION: Mild cardiomegaly with central vascular congestion, but without frank edema. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: N/V/D Diagnosed with DEHYDRATION temperature: 99.4 heartrate: 72.0 resprate: 18.0 o2sat: 98.0 sbp: 102.0 dbp: 45.0 level of pain: 4 level of acuity: 2.0

___ female with stage IV endometrial cancer on anastrazole, DM2, CAD, CKD, chronic respiratory failure with hypoxemia on home oxygen, and morbid obesity presents from her PCP's office with chest discomfort and possible EKG changes in the context of a gastrointestinal illness. . # Nausea/vomiting/diarrhea Patient presented following three days of diarrhea, nausea, and dry heaving. This was more severe than her chronic diarrhea from radiation, and was likely the result of a viral or bacterial gastroenteritis. Stool studies and C. diff testing were negative, and according to the patient's oncologist, Arimidex was not likely causative. Ondansetron was originally given for nausea but this was changed to compazine given concern about QTc prolongation. The nausea and vomiting resolved over the course of the hospital stay, and the diarrhea improved significantly. . # Chest pain Patient presented with chest discomfort that occurred in the context of dry heaving. Her PCP was concerned about EKG changes (septal Q waves and T wave inversions), especially concerning given the patient's significant history of CAD, including an MI that led to a cardiac catheterization in ___ (occlusion of the cardiac vessels was found at that time but patient did not tolerate the procedure and no intervention was done). However, following admission the patient noted that the discomfort was different from the pressure she had felt during her prior MI, and repeat EKG was similar to prior baseline (___). Troponins were elevated to 0.21 but downtrended. The overall presentation was not considered highly concerning for acute coronary syndrome, so anticoagulation was avoided given baseline thrombocytopenia. Cardiology (Atrius) was consulted and agreed that this was likely demand ischemia in the context of hypovolemia rather than ACS. . # Fever/GNR bacteremia (E.Coli) Febrile to 100.4 at ED, and had several further low-grade fevers on the floor. UA was positive for nitrites, and given diarrhea, GI was considered another possible source of infection. She was started on Bactrim on ___, but this was changed to meropenem on ___ when blood cultures grew gram negative rods. This was continued despite final culture results showing pan-sensitive E. coli due to concern about cross-reactivity of cephalosporins with a penicillin allergy and fluoroquinolones in the context of prolonged QTc. ID consulted and determined that it was likely safe for her to try ceftriaxone, which she did on ___, and she was discharged on this after PICC placement. Surveillance blood cultures were negative. Renal U/S and CT scan of abd/pelvis were obtained, which did not show evidence of abscess. She did have a fluid collection in the abdomen, but this is known from prior imaging approximately 1 month ago, and has improved in size. The collection is most likely a seroma. . #Pancytopenia Downtrending WBCs (to 1.5), hematocrit, and platelets; she was placed on neutropenic precautions. Possibly secondary to infection, antibiotics (Bactrim or meropenem), or other medication effect. OSH records showed baseline WBCs over past few months in 3s following radiation treatment. Although the levels did not return to baseline, they stabilized prior to discharge, and she will follow up with her outpatient providers. . # Elevated bicarb Bicarb elevated to 33 on admission, likely representing a metabolic alkalosis due to GI losses from diarrhea. Metabolic compensation for a chronic respiratory acidosis may also have contributed. Trended down shortly after admission. . # Diabetes Patient's home NPH was continued, and she was placed on an insulin sliding scale. . # Endometrial cancer Completed radiation therapy; not a candidate for chemo. Arimidex was continued. . TRANSITIONAL ISSUES 1. complete course of IV antibiotics for E. coli bacteremia 2. repeat CBC in 2 days to monitor leukopenia, anemia, thrombocytopenia 3. repeat LFT's at PCP ___ 4. non-emergent MRI head to evaluate small hypodensity seen on CT head from ___ (see below for report) 5. consider serial imaging of abdomen to monitor lesions in right kidney and fluid collection in abdomen. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary angiography Percutaneous Coronary Intervention History of Present Illness: ___ M w/ family history heart disease (father w/ CABG x4 in ___ who presents with around 8 weeks of progressive chest tightness over left breast. Mostly would occur when cycling to work, and occasionally radiating to left arm. Pain does not occur at rest. Pain dissipates approximately ___ minutes after stopping exercising. The discomfort is associated with SOB and breathlessness. No syncope or associated diaphoresis. In the ED, initial vitals were: 97.8 76 161/104 20 98% RA - Labs notable for troponin 0.02. CBC and chem panel unremarkable. BNP 183 - Imaging notable for CXR with no lung volumes, no infection or pulmonary edema. EKG with new Q waves and biphasic T waves anteriorly - Atrius cardiology was consulted and recommended: heparin drip and admission to cardiology - Patient was started on a heparin drip with bolus, also given atorvastatin 80mg. Received ASA 325mg in the ambulance. Decision was made to admit for unstable angina/NSTEMI. Vitals prior to transfer: 98.1 76 127/76 16 94% RA On the floor, the patient tells me that he is chest pain free. He has no complaints. ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: - Stickler syndrome c/b torn retina in R eye (s/p surgery at age ___: no vision in R eye, relatively preserved vision in L eye. - Hyperlipidemia - Osteopenia - Sensorineural hearing loss Social History: ___ Family History: Father with CABG X 4 in his ___. No other family history of heart disease. Grandfather committed suicide. No history of sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vital Signs: T 98.2, 151/94, 74, 18, 94%RA General: Alert, oriented, no acute distress HEENT: R eye s/p surgical changes, L eye with reactive pupil and preserved EOM. Oropharynx wnl. NECK: No JVP elevation. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended. Ext: Warm, well perfused, no clubbing, cyanosis or edema Access: PIV ADMISSION PHYSICAL EXAM: ======================== Vital Signs: T 98.2, 151/94, 74, 18, 94%RA General: Alert, oriented, no acute distress HEENT: R eye s/p surgical changes, L eye with reactive pupil and preserved EOM. Oropharynx wnl. NECK: No JVP elevation. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended. Ext: Warm, well perfused, no clubbing, cyanosis or edema. Right radial ecchymosis w/ intact distal pulses and sensation. Pertinent Results: ___ 08:23PM ___ PTT-31.7 ___ ___ 08:23PM ___ PTT-31.7 ___ ___ 06:40PM GLUCOSE-80 UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19 ___ 06:40PM estGFR-Using this ___ 06:40PM cTropnT-0.02* ___ 06:40PM proBNP-183* ___ 06:40PM WBC-7.3 RBC-4.69 HGB-14.7 HCT-43.1 MCV-92 MCH-31.3 MCHC-34.1 RDW-11.6 RDWSD-38.7 ___ 06:40PM NEUTS-52.7 ___ MONOS-8.0 EOS-4.3 BASOS-1.0 IM ___ AbsNeut-3.85 AbsLymp-2.44 AbsMono-0.58 AbsEos-0.31 AbsBaso-0.07 ___ 06:40PM PLT COUNT-278 INTERVAL/DC LABS: ================= ___ 06:45AM BLOOD WBC-6.6 RBC-4.46* Hgb-13.8 Hct-41.5 MCV-93 MCH-30.9 MCHC-33.3 RDW-11.6 RDWSD-39.7 Plt ___ ___ 06:45AM BLOOD Glucose-83 UreaN-13 Creat-1.0 Na-140 K-4.1 Cl-105 HCO3-20* AnGap-19 ___ 09:43PM BLOOD cTropnT-0.01 ___ 06:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3 IMAGING: ======= # CXR ___ No cardiopulmonary process. # CATH ___ Dominance: Right * Left Main Coronary Artery The LMCA is normal. * Left Anterior Descending The LAD has a discrete 99% mid stenosis, with a separate 50% stenosis more distally in the mid segment. There is TIMI 2 distal flow. * Circumflex The Circumflex has minimal luminal irregularities. * Right Coronary Artery The RCA is a small, non-dominant vessel and is normal. Impressions: 1 vessel CAD. Successful PTCA/stent of mid LAD using drug-eluting stent. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 2. Simvastatin 10 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Alendronate Sodium 70 mg PO 1X/WEEK (MO) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Non ST elevation myocardial infarction Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with progressive chest pain with exertion. Please evaluate for cardiomegaly, congestive heart failure, pleural effusion or wedge defect. TECHNIQUE: PA and lateral chest radiographs were obtained. COMPARISON: None. FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The aorta is tortuous. The cardiac silhouette is top-normal. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea on exertion Diagnosed with Cardiomyopathy, unspecified temperature: 97.8 heartrate: 76.0 resprate: 20.0 o2sat: 98.0 sbp: 161.0 dbp: 104.0 level of pain: 0 level of acuity: 2.0

___ gentleman with a family history of coronary disease (father had CABG), who presented to ___ ___ with 8 weeks of progressive exertional chest tightness. # NSTEMI Patient pressented with subacute yypical anginal sx. EKG showed new Q waves and biphasic T waves anteriology. Initial trp .02. He was given ASA, atorva, metop, hep ggt. Patient underwent catheterization on ___, which showed the following: He had a right dominant system with a normal left main coronary, his LAD had a discrete 99% mid stenosis with a separate 50% stenosis more distally in the mid segment. The circumflex had minimal irregularities and the right coronary was a small vessel and there was an additional branch of the right coronary and all of that was patent. He underwent a successful stenting procedure to the 99% LAD lesion with a 3.0 mm x 12 mm Promus PREMIER drug-eluting stent. He was continued on medical management with Plavix 75 mg a day, atorvastatin 80 mg a day, metoprolol tartrate 12.5 mg twice a day, aspirin 81 mg a day. Of note, patient did have ecchymosis/hematoma at right radial access site. Distal sensation and pulse intact. # Hypertension He also had elevated blood pressure throughout his hospitalization (SBP 150-170) and was started on lisinopril 5 mg daily. TRANSITIONAL ISSUES: ==================== [] Patient will need echo as an outpatient [] Optimization of blood pressure medication [] Physical therapy recommends referral to cardiac rehab as an outpatient [] f/u with cardiology as outpatient

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Neck swelling, Deep Venous Thrombosis Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ year old Male who presents afer recent parathyroidectomy on ___ who presented 1 day prior to admission with neck swelling. He initially presented with neck swelling on ___ to the ED and was thought to simply have marked post-operative swelling. He subsequently returned on the day of admission with additional concerns about his swelling. He denies any difficulty breathing, stridor or change in his voice. An ultrasound of the swelling noted a large non-occlusive thrombus in the internal jugular on the ipsilateral side from the surgery. Dr. ___ contacted the vascular surgery team for consultation inthe ED, who felt that he should be managed with lovenox and coumadin, however with his ESRD, he is admitted to the medical service for unfractionated heparin bridging to coumadin. He did not undergo hemodialysis while in the ED, despite it being his scheduled day, as the vascular issue was being clarified. The renal-HD consult team is aware of the patient. In the ED, initial vitals 96.8 76 190/92 18 100% RA. ROS: per HPI (-) Denies pain, fevers, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, nausea, dysphagia, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency, tingling/weakness Past Medical History: -HIV on tenofovir, abacavir and lopinavir/ritonavir (CD4:385 and undetectable viral load on ___ -HIV associated nephropathy s/p cadaveric renal transplant (___) which has been complicated by chronic allograft nephropathy and BK nephropathy, currently on hemodialysis MWF through Right AVF -subtotal parathyroidectomy secondary to his renal disease -HTN -neuropathy from HIV PSH: -Subtotal parathyroidectomy with 0.5 glands remaining (___), -Modified uvulopalatopharyngoplasty (___) -Superficialization right upper arm AV fistula (___) -Right brachiocephalic atrioventricular fistula (___) -Anterior cervical corpectomy, C4 and C5, arthrodesis, C3 through C6, Structural allograft, and plating plating, C3 to C6 -Right radiocephalic arteriovenous fistula (___) -Ligation left upper arm AV fistula (___), -Deceased donor kidney transplant, right iliac fossa over a ___ double-J stent ___ ___ -Transanal microscopically-assisted biopsy and laser destruction of anal condylomata ___ ___ Social History: ___ Family History: Father: DM Mother: healthy No history of renal disorders or coagulopathy in the family. Physical Exam: ADMISSION PHYSICAL EXAM: VSS: 97.6, 145/90, 85, 20, 99% GEN: A&O, NAD HEENT: EOMI, PERRL, sclera anicteric, MMM, no oral lesions, negative stridor/hoarseness NECK: parathyroidectomy incision well healed, no erythema or tenderness along site. Soft tissue swelling along anterior neck, on superior aspect of incision without erythema, warmth, induration, or drainage. Soft and nontender. Enlarged posterior lymph nodes b/l, mobile LUNGS: ctab, no crackles, wheezes, rhonchi CV: RRR, no m/g/r ABDOMEN: +BS, no guarding/rebound, soft, NT, ND, no organomegaly, surgical incision site well-healed Ext: R AVF with palpable thrill, no c/e NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout DISCHARGE PHYSICAL EXAM Vitals: Temp 98.6, BP 140/71, HR 82, RR 20, O2 sat 96% RA GEN: A&O, NAD NECK: Soft tissue swelling along anterior neck much improved from prior, almost completely resolved, neck remains free of erythema, warmth, induration, or drainage. Soft and nontender. Enlarged posterior lymph nodes b/l, mobile LUNGS: ctab, no crackles, wheezes, rhonchi CV: RRR, no m/g/r ABDOMEN: +BS, no guarding/rebound, soft, NT, ND, no organomegaly, surgical incision site well-healed Ext: R AVF with palpable thrill, +bruit NEURO: awake, A&Ox3 Pertinent Results: ADMISSION LABS ___ 05:40AM BLOOD WBC-3.9* RBC-3.83* Hgb-12.1* Hct-38.7* MCV-101* MCH-31.6 MCHC-31.3 RDW-15.6* Plt ___ ___ 05:40AM BLOOD Neuts-53.6 ___ Monos-7.1 Eos-2.5 Baso-0.5 ___ 05:40AM BLOOD Glucose-107* UreaN-51* Creat-13.1* Na-140 K-4.4 Cl-98 HCO3-27 AnGap-19 DISCHARGE LABS ___ 06:12AM BLOOD WBC-3.5* RBC-3.87* Hgb-12.4* Hct-38.6* MCV-100* MCH-32.0 MCHC-32.1 RDW-16.3* Plt ___ ___ 07:25AM BLOOD ___ PTT-119.4* ___ ___ 06:12AM BLOOD Glucose-81 UreaN-46* Creat-13.8*# Na-135 K-4.4 Cl-95* HCO3-25 AnGap-19 ___ 06:12AM BLOOD Calcium-6.2* Phos-4.5 Mg-2.1 RELEVANT LABS ___ 05:45AM BLOOD PTH-23 ___ 05:45AM BLOOD 25VitD-16* ___ 07:35AM BLOOD tacroFK-6.6 US NECK, SOFT TISSUE Study Date of ___ 8:00 AM IMPRESSION: 1. Partially occlusive clot with some retraction in the right internal jugular vein. 2. Complex collection superficial to the isthmus. This is potentially postop changes, but should be followed with repeat ultrasound. 3. Multiple enlarged lymph nodes bilaterally. Again these are likely reactive nodes secondary to postop changes; however, these could also be followed on the repeat ultrasound. ARTERIAL DUPLEX EXT U/S ___ IMPRESSION: 1. Patent brachial to basilic AV fistula with no evidence of intraluminal thrombus. 2. Elevated peak systolic velocities at the level of the arterial anastomosis. 3. Elevated access volume flow (mean 1618 ml/min). Medications on Admission: -abacavir 300 mg tablet BID -tenofovir 300mg ___ -labetalol 600 mg tablet TID -lopinavir-ritonavir [Kaletra] 50 mg-200 mg tablet 2 Tablets BID -methocarbamol 750 mg tablet 1 Tablet TID prn muscle spasm -omeprazole 40 mg once a day -prednisone 5 mg tablet once a day -Bactrim SS 1 Tablet by mouth daily -tacrolimus 0.5 mg capsule q ___ -tenofovir disoproxil fumarate [Viread] 300 mg tablet once a week -furosemide 40mg po daily Discharge Medications: 1. Abacavir Sulfate 300 mg PO BID 2. Calcitriol 2 mcg PO BID 3. Calcium Carbonate 500 mg PO QID 4. Furosemide 40 mg PO DAILY 5. Labetalol 600 mg PO TID please hold for SBP <100, HR <60 6. Lopinavir-Ritonavir 2 TAB PO BID 7. Omeprazole 40 mg PO DAILY 8. PredniSONE 5 mg PO DAILY 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Tacrolimus 0.25 mg PO 1X/WEEK (MO) 11. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (MO) 12. Nephrocaps 1 CAP PO DAILY RX *Nephrocaps 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 13. Warfarin 7.5 mg PO DAILY please adjust dose as instructed by your doctor RX *Coumadin 2.5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 14. Methocarbamol 750 mg PO TID:PRN muscle spasm 15. Outpatient Lab Work Please check INR at hemodialysis on ___ and fax results to Dr. ___ at ___. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: right internal jugular vein thrombosis, post-parathyroidectomy neck edema Secondary diagnosis: HIV on HAART, end-stage renal disease on hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ man status post parathyroidectomy, now with swelling. COMPARISON: None. TECHNIQUE: Neck ultrasound. FINDINGS: The left internal jugular is patent and compressible; however, the right internal jugular shows non-compressibility with thrombus within it. This thrombus shows some retraction and is partially occlusive in several areas with peripheral flow, but in other areas it appears to fill the entire vessel. The clot extends from the superior aspect of the posterior triangle of the neck down to the confluence of the internal jugular and subclavian, however, does not appear to extend into the superior vena cava or the subclavian. There are several enlarged lymph nodes on the left (up to 1.5 cm in the long axis) labeled as levels 2, 3 and 4. On the right side, a node at labeled level 3 measures up to 2 cm. Images of the thyroid show normal echotexture with no evidence of masses or lesions. Right thyroid measures 2.6 x 2.5 x 4.2 cm and the left thyroid measures 1.9 x 1.9 x 4.1 cm. Superficial to the isthmus, there is a complex area of cystic-appearing structure with linear internal echoes measuring 2.0 x 4.4 x 0.9 cm. IMPRESSION: 1. Partially occlusive clot with some retraction in the right internal jugular vein. 2. Complex collection superficial to the isthmus. This is potentially postop changes, but should be followed with repeat ultrasound. 3. Multiple enlarged lymph nodes bilaterally. Again these are likely reactive nodes secondary to postop changes; however, these could also be followed on the repeat ultrasound. Radiology Report INDICATION: ___ male with right upper extremity AV fistula, presenting with clot in the right internal jugular vein. TECHNIQUE AND FINDINGS: Ultrasound evaluation of the right upper extremity AV fistula was performed with B mode, color and spectral Doppler ultrasound. The native brachial artery proximal to the AV fistula is patent with peak systolic velocities ranging between 249 cm/sec and 299 cm/sec. At the level of the brachial artery to basilic vein anastomosis, the peak systolic velocity is 675 cm/sec. Peak systolic velocities in the venous outflow of the fistula ranged between 66 cm/sec and 165 cm/sec. Access volume flow measurements were obtained, demonstrating 1422 ml/min, 1403 ml/min and 2030 ml/min, with a mean of 1618 ml/min. IMPRESSION: 1. Patent brachial to basilic AV fistula with no evidence of intraluminal thrombus. 2. Elevated peak systolic velocities at the level of the arterial anastomosis. 3. Elevated access volume flow (mean 1618 ml/min). Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN WALK IN Chief complaint: NECK SWELLING NECK SWELLING Diagnosed with OTHER SPEC COMPL S/P SURGERY, SWELLING OF LIMB, ABN REACT-PROCEDURE NOS SWELLING OF LIMB, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE temperature: 99.0 96.8 heartrate: 81.0 76.0 resprate: 16.0 18.0 o2sat: 100.0 100.0 sbp: 139.0 190.0 dbp: 87.0 92.0 level of pain: 0 0 level of acuity: 3.0 3.0

___ gentlemen with h/o HIV (CD4>300, VL: undetectable) on HAART, ESRD ___ HIVAN s/p kidney transplant c/b chronic allograft and BK nephropathy now on HD presents for neck swelling post elective parathyroidectomy and clot in RIJ on ultrasound. # Deep Venous Thrombosis of the Right Internal Jugular Vein - Given the centrality of the vessel this is obviously a concerning DVT - As he has ESRD, he underwent heparin to coumadin bridging, and cannot take low molecular weight heparin - Given all the interactions below, started at a lower dose of coumadin and INR was closely monitored. Started on 3mg and increased to 7.5mg. His INR at discharge is 2.3 - Vascular surgery and primary surgical team was consulted, and did not feel a surgical intervention is required. - No airway compromise was noted # Neck Swelling: had parathyroidectomy on ___ due to secondary hyperparathyroidism. No complications post surgery. On ___ began to notice the swelling. He denied any dysphagia, difficulty breathing, or change in voice. The swelling progressively improved each day of hospitalization. At time of discharge, it was almost completely resolved. TSH in ___ was normal. -likely a secondary to post-surgical edema. No sign of infection (no erythema, warmth, fevers). -calcium levels were monitored carefully given recent parathyroidectomy and risk for "hungry bone syndrome." Patient denied any oral paresthesias, numbness, tingling. Ca at 6.2-6.6 range. He was continued on calcitriol and calcium supplements # ESRD on HD, Renal Transplant - Renal Consulted - HD MWF (although missed ___, underwent HD during his hospitalization without any problems - U/s to evaluate the patency of the fistula was obtained and it was normal - Continued on tacrolimus, prednisone, omeprazole and Bactrim for chronic prophylaxis - tacrolimus level obtained and it was 6.6 (___). Interaction was discussed with pharmacy team --> no interaction with warfarin. There is interaction with bactrim (increases INR) and Kaletra (decreases INR). PCP aware and ___ monitor closely. # HIV Asymptomatic and responding well to HAART, CD4>300, VL: undetectable - Continued on HAART medications: abacavir, tenofovir, and kaletra # CHRONIC ISSUES -HTN: continue home labetalol and furosemide -Anemia: ___ renal disease: Hct remained stable, receives EPO q ___ -OSA: s/p soft palatoplasty with uvulectomy for redundant tissue and obstructive sleep apnea. Significant improvement in sleep pattern post surgery. # TRANSITIONAL ISSUES -Arranged to obtain INR on ___ after HD and fax results to PCP (Dr. ___. Dr. ___ will call patient and adjust coumadin dose as appropriate. Dr. ___ will also arrange for setting up follow up with ___ clinic at ___ -Neck ultrasound showed fluid collection near thyroid gland and enlarged lymph nodes secondary to post-op changes. Please follow up with these changes with a repeat ultrasound

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro / Sulfa(Sulfonamide Antibiotics) / codiene / tamazepam / Plavix Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: ___ with past medical history significant for Afib, TIAs and recent admission for fall with left hip fracture and right subdural hematoma with subsequent seizures who presents from ___ with acute onset of agitation and altered mental status. Per the patient's daughter she has been slightly more irritable for the past few days, but she became acutely agitated this morning and bit her caregiver at her ___ causing bleeding. Per the daughter, this is the first time that she has been acting "this crazy." In the ED, initial vitals were 99.8 80 134/70 18 96% ra. Initial CBC, chemistry, urinalysis unremarkable. CT head did not show extension right posterior subdural hematoma without evidence of new intracranial hemorrhage. She received Zyprexa 5mg and Ativan 1mg. On arrival to the floor, initial vitals were 98.4 80 168/80 18 98%RA. She is loud and perseverating on getting a commode and drinking water. She is also saying that her daughter is lying and she does not want to be left alone. On questioning however, she is oriented to person, place ___, ___ and minimally to time (___. She complains of dull headache on the left frontotemporal side for the past day. No change in vision or speech. No muscle weakness. No chest pain, SOB, n/v, or abdominal pain. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Right subdural hemorrhage (___) - left hip fracture s/p fixation (___) - Atrial fibrillation on coumadin - prior stroke 9 months ago with residual left hemianopsia - HLD - Depression - peripheral neuropathy - hypothyroidism - IBS - insomnia Social History: ___ Family History: Brother died due to cardiac disease. Mother with multiple strokes. Father died of bowel obstruction. Physical Exam: Admission Physical Exam: Vitals- 98.4 80 168/80 18 98%RA General- Alert, oriented to person, place ___, ___ and minimally to time (___. Shouting in the room HEENT- PERRL, EOMI MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- orientation described above. speech fluent. attention intact. Left field of vision compromised. CNs2-12 intact, motor function grossly normal, however she will not allow fully strength testing. Unable to test DTRs. ___ unsteady. Discharge Physical Exam: Vitals- 97.3 116/68 (100-149/50-70s) 91 20 98%RA General- Cachectic appearing, alert, calling for "help" upon entering the room, wants me to bring her a sweater, having trouble finding words HEENT- PERRL, EOMI MM dry, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi, cachectic with protruding spinous processes CV- regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, NT ND +BS, no rebound tenderness or guarding GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- orientation described above. speech fluent but not always coherent. Pertinent Results: ADMISSION LABS: ___ 11:54AM BLOOD WBC-6.6 RBC-3.87* Hgb-12.1 Hct-36.7 MCV-95 MCH-31.2 MCHC-32.9 RDW-15.0 Plt ___ ___ 11:54AM BLOOD Neuts-73.6* Lymphs-17.4* Monos-6.3 Eos-1.9 Baso-0.7 ___ 12:51PM BLOOD ___ PTT-25.8 ___ ___ 11:54AM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-140 K-3.9 Cl-103 HCO3-23 AnGap-18 ___ 11:54AM BLOOD TSH-2.7 ___ 06:30AM BLOOD Phenyto-22.3* DISCHARGE LABS: ___ 07:50AM BLOOD WBC-6.4 RBC-3.89* Hgb-11.8* Hct-36.7 MCV-95 MCH-30.5 MCHC-32.2 RDW-15.5 Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-141 K-4.2 Cl-102 HCO3-30 AnGap-13 ___ 07:50AM BLOOD Phos-3.9 Mg-2.2 URINE: ___ 12:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG MICROBIOLOGY: ___ 5:44 URINE CULTURE : negative IMAGING: CT HEAD NON-CONTRAST ___ Hypodense material layering along the posterior right cerebral convexity and posterior aspect of the falx is consistent with expected evolution of previous subdural hematoma without interval increase in quantity of fluid. There is no acute intracranial hemorrhage, edema, mass effect or major vascular territory infarction. There is no shift of normally midline structures. Left temporal encephalomalacia is unchanged. Periventricular and subcortical white matter hypodensities suggest chronic small vessel ischemic disease. There is no fracture. Imaged paranasal sinuses and mastoid air cells reveal mild left maxillary mucosal thickening. IMPRESSION: Expected evolution of the right posterior subdural hematoma without evidence of new intracranial hemorrhage. EEG ___: Showed no evidence of epileptiform activity, but dud show nonspecific left and right temporal slowing. Radiology Report HISTORY: Recent subdural hemorrhage and prior stroke with altered mental status. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Multiplanar reformations were prepared. COMPARISON: ___. FINDINGS: Hypodense material layering along the posterior right cerebral convexity and posterior aspect of the falx is consistent with expected evolution of previous subdural hematoma without interval increase in quantity of fluid. There is no acute intracranial hemorrhage, edema, mass effect or major vascular territory infarction. There is no shift of normally midline structures. Left temporal encephalomalacia is unchanged. Periventricular and subcortical white matter hypodensities suggest chronic small vessel ischemic disease. There is no fracture. Imaged paranasal sinuses and mastoid air cells reveal mild left maxillary mucosal thickening. IMPRESSION: Expected evolution of the right posterior subdural hematoma without evidence of new intracranial hemorrhage. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ___ /BIT STAFF Diagnosed with SEMICOMA/STUPOR temperature: 99.8 heartrate: 80.0 resprate: 18.0 o2sat: 96.0 sbp: 134.0 dbp: 70.0 level of pain: 13 level of acuity: 2.0

___ with PMH of Afib, and recent admission for fall with left hip fracture and right subdural hematoma with subsequent seizures who presents from ___ with acute onset of agitation and altered mental status.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Zithromax / levofloxacin / vancomycin / Bactrim Attending: ___. Chief Complaint: dyspnea, cough Major Surgical or Invasive Procedure: No procedures performed ___ the hospital History of Present Illness: Ms. ___ is a ___ year old female with a PMHx of ectodermal dysplasia, hypogammaglobulinemia on IVIG, asthma, s/p flex bronch ___ with balloon dilation for bronchiectasis, prior PNA presenting with dyspnea, productive cough. Pt reports symptoms started last ___ developed increasing dyspnea, wheezing, and productive cough w/yellow sputum. She had fever and chills which "broke" on ___ currently no subjective fevers. She denies sick contacts. She has required increased use of duonebs (normally does x1/day, now increased) and has been compliant w/ other inhalers and meds. She was last on abx (Bactrim) approx. x6 weeks ago - she received cyclical abx per her Pulmonologist. She has not been on steroids since her last admission. She denies lightheadedness/dizziness, CP/palp, abd pain/N/V, dysuria, ___ edema. She reports constipation. Of note, she is due for IVIG on ___. ___ the ED, initial VS were 98.2 119 ___ 97% RA. Exam notable for accessory muscle use and diffuse wheezing throughout. Labs showed: Normal Chem 7, WBC 9.9 with 75% PMNs, Hgb 10.6 (MCV 72) with baseline ___, Plt 426 (baseline 300s). Lactate:1.3 UCG: Negative Unremarkable UA CXR showed: Subtle bibasilar opacities worrisome for multifocal infection. Known bronchiectasis was better seen on prior CT scan. Patient received: ___ 17:19 IH Albuterol 0.083% Neb Soln 1 NEB ___ 17:19 IH Ipratropium Bromide Neb 1 NEB ___ 18:40 IH Albuterol 0.083% Neb Soln 1 NEB ___ 18:40 IH Ipratropium Bromide Neb 1 NEB ___ 18:51 IV CefePIME 2 g ___ 18:51 PO PredniSONE 60 mg Decision was made to admit to medicine for further management. On arrival to the floor, patient reports fatigue and productive cough that is blood tinged ___ AM. She has been self-medicating at home with Robitussin DM and ibuprofen PRN for lung pain. She states this feels like her prior episodes of pneumonia, which she states she had >30 ___ the past. She endorses worsened dyspnea on exertion and orthopnea. Past Medical History: -asthma -bronchiectasis -humoral immunity deficiency, NOS on IVIG trial -ectodermal dysplasia -GERD -airway stenosis, thought due to chronic GERD -obesity -insomnia Social History: ___ Family History: cardiac disease ___ mom's side, dads father with stroke, aunt with brain ___, T2DM moms side Physical ___: ON ADMISSION ============ GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: diffuse expiratory and inspiratory wheezing, no rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes ON DISCHARGE ============= Vitals: 98.6 | 127/61 | 86 | 18 | 98 RA General: Well-appearing, alert, oriented, breathing with mild discomfort HEENT: PERRL, sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Fair air movement bilaterally, expiratory wheezing. No rhonchi or crackles. CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, no cyanosis or edema Neuro: nonfocal Pertinent Results: ON ADMISSION ============= ___ 05:15PM BLOOD WBC-9.9 RBC-4.95 Hgb-10.6* Hct-35.7 MCV-72*# MCH-21.4*# MCHC-29.7* RDW-16.4* RDWSD-41.8 Plt ___ ___ 05:15PM BLOOD Neuts-75.1* Lymphs-13.8* Monos-8.0 Eos-2.3 Baso-0.3 Im ___ AbsNeut-7.40*# AbsLymp-1.36 AbsMono-0.79 AbsEos-0.23 AbsBaso-0.03 ___ 05:15PM BLOOD Glucose-101* UreaN-7 Creat-0.6 Na-141 K-4.0 Cl-103 HCO3-28 AnGap-14 ___ 01:28PM BLOOD ALT-36 AST-24 LD(LDH)-143 AlkPhos-110* TotBili-0.1 ___ 05:15PM BLOOD Iron-25* ___ 05:15PM BLOOD calTIBC-433 Hapto-326* Ferritn-22 TRF-333 ___ 07:53AM BLOOD ___ pO2-138* pCO2-48* pH-7.38 calTCO2-29 Base XS-2 Comment-GREEN TOP MICRO ====== __________________________________________________________ ___ 2:15 am SPUTUM Source: Induced. GRAM STAIN (Final ___: >25 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. ACID FAST SMEAR (Preliminary): ACID FAST CULTURE (Preliminary): __________________________________________________________ ___ 6:45 pm SPUTUM Site: INDUCED Source: Induced. GRAM STAIN (Final ___: ___ 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. ACID FAST SMEAR (Preliminary): ACID FAST CULTURE (Preliminary): __________________________________________________________ ___ 1:28 pm SEROLOGY/BLOOD CRY ADDED TO ___. **FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. A negative serum does not rule out localized or disseminated cryptococcal infection. Appropriate specimens should be sent for culture. __________________________________________________________ ___ 11:58 am SPUTUM Source: Induced. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Preliminary): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. This is only a PRELIMINARY result. If ruling out tuberculosis, you must wait for confirmation by concentrated smear. ACID FAST CULTURE (Preliminary): __________________________________________________________ ___ 7:45 pm SPUTUM Source: Expectorated. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S __________________________________________________________ ___ 6:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:15 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING ========= CHEST (PA & LAT)Study Date of ___ 4:53 ___ Linear opacity extending laterally from the left hilum is likely atelectasis versus scarring. New compared to most recent exam are subtle areas opacity at the lung bases, likely ___ part within the right middle lobe. Bibasilar regions of bronchiectasis were better seen on prior CT scan. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: Subtle bibasilar opacities worrisome for multifocal infection. Known bronchiectasis was better seen on prior CT scan. CT CHEST W/O CONTRASTStudy Date of ___ 2:47 ___ Interval substantial progression of infectious process seen as worsening bronchiectasis, endobronchial secretions, extensive ___ opacities, narrowing of the airway origin with subsequent atelectasis as well as substantial lymphadenopathy that has progressed since the prior study. Findings might represent progression of known CV ID with superimposed diffuse bronchogenic infection. Malignancy is less likely although cannot be entirely excluded and short-term followup ___ ___ weeks after aggressive antibiotic treatment is recommended. DISCHARGE LABS: ================= ___ 07:50AM BLOOD WBC-7.9 RBC-4.52 Hgb-9.6* Hct-32.6* MCV-72* MCH-21.2* MCHC-29.4* RDW-16.4* RDWSD-41.9 Plt ___ ___ 07:50AM BLOOD Neuts-57.9 ___ Monos-6.6 Eos-0.9* Baso-0.4 Im ___ AbsNeut-4.56 AbsLymp-2.65 AbsMono-0.52 AbsEos-0.07 AbsBaso-0.03 ___ 07:50AM BLOOD Glucose-86 UreaN-13 Creat-0.5 Na-141 K-3.5 Cl-102 HCO3-30 AnGap-13 ___ 07:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9 Radiology Report INDICATION: ___ with recurrent pneumonia, dyspnea // pneumonia? TECHNIQUE: PA and lateral views of the chest. COMPARISON: ___ chest x-ray and chest CT from ___. FINDINGS: Linear opacity extending laterally from the left hilum is likely atelectasis versus scarring. New compared to most recent exam are subtle areas opacity at the lung bases, likely in part within the right middle lobe. Bibasilar regions of bronchiectasis were better seen on prior CT scan. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: Subtle bibasilar opacities worrisome for multifocal infection. Known bronchiectasis was better seen on prior CT scan. Radiology Report EXAMINATION: Chest CT INDICATION: ___ year old woman with bronchiectasis, epidermal dysplasia and CVID presenting with fevers 4 days ago and acute on chronic respiratory distress // Evaluate to confirm pneumonia as CXR not fully conclusive in patient with chronic lung fidings. PLEASE DO LOW DOSE STUDY. TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen. Axial images were reviewed in conjunction with coronal and sagittal reformats COMPARISON: Several chest radiographs dating back to ___ and chest CT from ___ FINDINGS: Right thyroid calcified nodule is unchanged with overall diffuse thyroid enlargement ranging up to 12 mm, series 3, image 2. Several mediastinal lymph nodes are enlarged and appear to be substantially increased as compared to previous study for example in the right mid paratracheal area 15 x 12.5 mm as compared to 8.5 x 7 mm, in right lower paratracheal area, 11 mm as compared to 4 mm, in paraesophageal location, 17 mm as compared to 8 mm. Hilar lymphadenopathy is difficult to determine in the absence of IV contrast but at least 1 cm lymph nodes are present. Heart size is normal. There is no pericardial pleural effusion. Aorta and pulmonary arteries are normal in diameter. Anemia is demonstrated he as increased density of the left ventricle. Trachea and main bronchi are patent. Substantial interval progression in bronchiectasis, extensive endobronchial secretions, the cystic component of bronchiectasis in particular in the lower lobes as well as the extent of bronchial narrowing in particular at the level of the right middle lobe bronchus and origin and right lower lobe bronchus origin, series 5 images 144 and 133 is demonstrated. Extensive ___ opacity, ground-glass opacities a new nodular opacities are also old in favor of active infection currently. New atelectasis, substantial of the left upper lobe is present, series 5, image 106, most likely related to segmental obstruction, series 5, image 115. Image portion of the upper abdomen reveals no appreciable abnormality. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. IMPRESSION: Interval substantial progression of infectious process seen as worsening bronchiectasis, endobronchial secretions, extensive ___ opacities, narrowing of the airway origin with subsequent atelectasis as well as substantial lymphadenopathy that has progressed since the prior study. Findings might represent progression of known CV ID with superimposed diffuse bronchogenic infection. Malignancy is less likely although cannot be entirely excluded and short-term followup in ___ weeks after aggressive antibiotic treatment is recommended. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea, Cough Diagnosed with Pneumonia, unspecified organism temperature: 98.2 heartrate: 119.0 resprate: 24.0 o2sat: 97.0 sbp: 112.0 dbp: 97.0 level of pain: 7 level of acuity: 2.0

Ms. ___ is a ___ year old female with asthma, bronchiectasis, ectodermal dysplasia, humoral immunity deficiency NOS on IVIG trial presenting with worsening dyspnea and productive cough. # Bronchiectasis exacerbation: Her presentation was more consistent with subacute to worsening chronic infectious process ___ setting of bronchiestasis and humoral deficiency NOS. CT Chest significant for interval worsening of bronchiectatic process, sputum cultures growing MSSA. Initially started on empiric broad coverage with Vancomycin, Cefepime and Doxycycline then based on IDs recommendations narrowed to ceftriaxone and doxycycline. Of note had allergic reaction to vancomycin, see details below. Was continued on ceftriaxone and doxycycline until discharge with clinical improvement, she was discharged on cefpodoxime and doxycycline to complete a 10-day course of antibiotics. Negative broad work-up including PJP smear, Cryptococcal serum Ag, Histoplasma Urine Ag, Aspergillus GM and Ab. Beta-D-glucan was positive which was thought to be related to her receiving IVIG. Had 3x induced sputum for AFB smears which were negative and culture which were pending at the time of discharge. #Iron deficiency anemia: MCV 73, ferritin 22, TRF 333, serum iron 25, TIBC 433, %Sat 5.4%. Started Ferrous sulfate 325mg PO BID w/ondansetron 4mg PO q8hr:PRN for nausea with iron. Nutrition saw the patient as an inpatient as well. #Humoral immunodeficiency: previously followed as an outpatient by Dr. ___ at ___. Received IVIG on ___, will have outpatient f/u. # Asthma exacerbation: Given significant wheezing and dyspnea she received prednisone 50mg ___ the hospital with a taper (decrease by 10mg each week) as well as albuterol/ipratropium nebs q4-6h and prn. Tiotropium, montelukast and ceterizine were continued. As symbicort was NF, she was bridged with Advair while ___ house. She was discharged on albuterol nebulizers and with a new nebulizer machine. # GERD: Continued on home omeprazole TRANSITIONAL ISSUES ================== - patient has switched insurance and is no longer eligible for ___ outpatient primary care - Her new PCP is ___ at ___ -> she needs a referral to see a new pulmonologist within ___ weeks of discharge from ___ - she received her dose of IVIG ___ house on ___ - she received pneumococcal vaccine on ___ - she received home nebulizer machine and was discharged w/nebs - pending infectious studies should be followed up by PCP and pulmonologist FULL CODE Fiance, ___ ___ HCP is sister, ___ ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: vertigo, nausea, vomiting, right facial droop Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a h/o prior stroke, HTN and HLD, who presents with acute onset of vertigo, unsteadiness, and slurred speech today. Mr. ___ was in his USOH this morning and went out doing his normal errands until 330PM today when he had sudden onset of vertigo. He also felt like his right face was numb. He sat down since he felt unsteady. His wife found him sitting down, speaking with notably slurred speech, and unable to stand. She called ___ and he was taken to an OSH, where he was noted to have marked ataxia, a right facial droop, and nystagmus. Assessment for tPA was performed through telemedicine neurology consult, and although a cerebellar infarct was suspected, given location, it was recommended no tPA be given and he be transferred to ___ for further care. At the OSH, he had emesis intermittently for 3 hours. During my evaluation, he had another episode of emesis, although he continues to deny nausea. He does report feeling unsteady and clumsy. He feels there has been no improvement and his vertigo persists. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. 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 diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Stroke ___ years ago- ?R.MCA, pt reports left hemiparesis, wife and ___ feel that he had a right facial droop and weakness. T2DM HTN HLD s/p CABG ___ Social History: ___ Family History: noncontributory Physical Exam: ADMISSION EXAM Vitals: T: 98.8 HR 65 BP 145/54 RR 18 O2 98% 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 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech is mildly dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: Nystagmus at rest with rotatory component. With EOMI, horizontal and vertical nystagmus seen. Denies diplopia. Normal saccades. V: Facial sensation intact to light touch. VII: Right NLF flattening and decreased activation of right side 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: Normal bulk, tone throughout. No pronator drift bilaterally. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 5 5 - ___ 5 5 5 5 5 5 5 *unable to test R. WE as he has baseline pain from fusion in that wrist -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense throughout. No extinction to DSS. JPS ___ bilaterally. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: Notable ataxia and slowness on right FNF, slightly slower on right RAM. Left FNF is mildly unsteady, RAM fluent. HKS normal bilaterally. Notable truncal ataxia with consistent falling toward right. -Gait: deferred DISCHARGE EXAM Vitals: T: 98.8 HR 60-80s BP 130-150/60s RR 18 O2 98% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Speech fluent but slowed. No evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 1mm on Right and 2 on left but reactive; VFF to confrontation. Nystagmus at endgaze with rotatory component but improved. Full EOMI. Endorses occasional diplopia. Normal saccades. V: Facial sensation intact to light touch. VII: Right NLF flattening and decreased activation of right side 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: Normal bulk, tone throughout. Slight right pronator drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: Today no deficits to pinprick though during admission had decreased pinprick on left arm/leg and right face. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: Mild ataxia and slowness on right FNF and less coordinated in right RAM. Left FNF is also unsteady. Minimal right tilt when sitting. -Gait: Wide-based gait and leans to right; very unstable. Pertinent Results: ADMISSION DATA: CBC: 13.5/___/170 N90L6M3 Coags: ___ Chem: ___ Ca 9.7 Mg 2.1 P3.4 Lactate 1.9 Serum tox and Utox neg UA +prt, +glucose, +ketones. Radiologic Data: ___: Reported negative MRI/MRA Head/Neck (___): Focal area of slow diffusion identified on the right medulla oblongata as described in detail above, visible only on the DWI sequence, suggesting a hyperacute ischemic change, please correlate clinically. Scattered foci of high signal intensity are identified in the subcortical white matter on FLAIR and T2, which are nonspecific and may reflect areas of small vessel disease. Essentially normal MRA of the head, with no evidence of flow stenotic lesions. The right vertebral artery is dominant. Tortuosity of both internal carotid arteries, with no evidence of flow stenotic lesions. Dominance of the right vertebral artery is present as a vascular anatomical variation. ECHO (___): The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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 leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No ASD or PFO. Normal global and regional biventricular systolic function. Mild mitral regurgitation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Rosuvastatin Calcium 20 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Amlodipine 20 mg PO DAILY 5. GlipiZIDE Dose is Unknown PO BID 6. MetFORMIN (Glucophage) Dose is Unknown PO BID 7. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous daily Patient on sliding scale based on morning fasting BG. If <100, no Lantus; If BG 150-200 then 14u; if BG>200, give 18u. Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Amlodipine 20 mg PO DAILY 4. Rosuvastatin Calcium 20 mg PO DAILY 5. GlipiZIDE 10 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Lantus *NF* (insulin glargine) 100 unit/mL Subcutaneous daily Patient on sliding scale based on morning fasting BG. If <100, no Lantus; If BG 150-200 then 14u; if BG>200, give 18u. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1) Right medullary infarct 2) Hypertension 3) Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Can walk while monitored but has significant lean to right when upright. Followup Instructions: ___ Radiology Report STUDY: MRI and MRA of the brain and MRA of the neck. CLINICAL INDICATION: History of ataxia, dizziness, possible cerebellar stroke, clots, occlusion. COMPARISON: Prior head CT dated ___. TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility, and axial diffusion-weighted sequences were obtained through the brain. MRA OF THE HEAD: 3D time-of-flight arteriography of the head was obtained, axial source images and multiplanar reformations were reviewed. MRA OF THE NECK: After the administration of intravenous gadolinium contrast, bolus tracking technique sequences were obtained throughout the neck vessels, coronal source images and multiplanar reformations were reviewed. FINDINGS: On the diffusion-weighted sequence, there is a focus of wall diffusion on the right at the level of the medulla oblongata, visible on the image #4, series #6, which is not clearly evident in the corresponding ADC. No FLAIR or T2 abnormalities are seen in this area, the possibility of hyperacute ischemic event is a consideration. A perivascular space is identified on the right side of the pons, the cerebellopontine cisterns and fourth ventricle are unremarkable. Supratentorially, the ventricles and sulci are slightly prominent, likely indicating cortical volume loss, and possibly age related and involutional in nature. Few scattered foci of high signal intensity are identified in the subcortical white matter, which are nonspecific and may reflect areas of small vessel disease. The major vascular flow voids are present and demonstrate normal distribution. The orbits are unremarkable. The paranasal sinuses demonstrate mild mucosal thickening at the ethmoidal air cells bilaterally, the mastoid air cells are clear. IMPRESSION: Focal area of slow diffusion identified on the right medulla oblongata as described in detail above, visible only on the DWI sequence, suggesting a hyperacute ischemic change, please correlate clinically. Scattered foci of high signal intensity are identified in the subcortical white matter on FLAIR and T2, which are nonspecific and may reflect areas of small vessel disease. Mild mucosal thickening noted at the ethmoidal air cells. MRA OF THE HEAD: There is evidence of vascular flow in both internal carotid arteries as well as the vertebrobasilar system, the right vertebral artery is dominant. The anterior and middle cerebral arteries are patent as well as the posterior cerebral arteries, with no evidence of flow stenotic lesions or aneurysms larger than 2 mm in size. IMPRESSION: Essentially normal MRA of the head, with no evidence of flow stenotic lesions. The right vertebral artery is dominant. MRA OF THE NECK: The origin of the supra-aortic vessels appears normal, both common carotid arteries are patent with no evidence of flow stenotic lesions, there is significant tortuosity along the left internal carotid artery and also significant tortuosity on the right internal carotid artery below the P2 segment with no evidence of flow stenotic lesions. The right vertebral artery is dominant. IMPRESSION: Tortuosity of both internal carotid arteries, with no evidence of flow stenotic lesions. Dominance of the right vertebral artery is present as a vascular anatomical variation. These findings were communicated to Dr. ___ at 13:05 hours on ___, via phone call by Dr. ___. Gender: M Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by WALK IN Chief complaint: R SIDED WEAKNESS/DROOP Diagnosed with LACK OF COORDINATION, MUSCSKEL SYMPT LIMB NEC, FACIAL WEAKNESS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: nan heartrate: 65.0 resprate: 16.0 o2sat: 100.0 sbp: 126.0 dbp: 75.0 level of pain: 0 level of acuity: 1.0

NEURO: Mr. ___ was admitted for further imaging and ECHO. His exam on admission was notable for right sided dysmetria with significant ataxia (fell to right on standing), nystagmus that changed direction with gaze, blurry vision/ghosting but no frank diplopia, mild right facial droop, and decreased sensation on the right face and left arm and leg. This picture of right sided ataxia and facial sensation changes and left body sensation changes was concerning for a lateral medullary (___) syndrome though it was unusual that there was no Horner's Syndrome. MRI/MRA did show a small right medullary infarct but no problems with the vasculature. Stroke work-up included an ECHO that showed normal systolic function and no ASD/PFO and labs, which showed an adequately controlled cholesterol (LDL 54, HDL 38, ___ 129) but a slightly elevated HgbA1c of 6.9%. Telemetry revealed sinus arrhythmia but no atrial fibrillation. Mr. ___ was switched from Aspirin to Plavix in hopes of secondary stroke prevention but no other medication changes were made. Physical therapy felt that he would need ___ rehabilitation. Nutrition recommended a diet of moist ground solids and nectar thick liquids due to aspiration risk. ENDO: Mr. ___ metformin and glipizide were held due to contrast CT. We spoke to his outpatient endocrinologist who reported that normally Mr. ___ uses Lantus on a sliding scale basis based on fasting AM blood glucose (0 if BG<150; 14u if 150-200; 18u if >200). We gave him 20units QHS of Lantus and an insulin sliding scale because he had BG 200-300s frequently through admission. Before discharge, we restarted Glipizide and Metformin and we restarted his home Lantus plan; this may have to be adjusted at rehab, especially given he had HgbA1c of 6.9%.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ y/o F with PMH of COPD (FEV1 66%, GOLD II) on home O2 when SOB who presented to the ED overnight on ___ with dyspnea. The patient reports worsening of her chronic dyspnea at ~10pm on the night of admission. Came to the ED where her initial RA sat was 77%. CXR notable for hyperexapnded lungs but no consolidations. No other infectious symptoms. ECG without ischemic changes. Thought to be having a COPD exacerbation and given duonebs x2 and methylpred. Her respiratory status improved with sats rising to the ___, however the patient began to become tired. Decision made to place the patient on BiPAP. Patient did well on BiPAP and was admitted to the MICU for further management. Of note, the patient was recently admitted here ___ with similar symptoms. Treated for a COPD exacerbation and improved. Also admitted to ___ in ___ for COPD exacerbation. Followed with Dr. ___ in clinic. There is some suggestion of medication non-adherance due to cost issues. States that she has been taking all medications as prescribed. On arrival to the MICU the patient is on BiPAP and appears comfortable. Still with audible wheezing. Past Medical History: 1. MVP history 2. Crohn's/uveitis c.o Dr. ___ 3. Postmenopausal 4. Hiatal hernia/GERD 5. Dyslipidemia . Surg: 1. s/p rectal fistula repair 2. bladder sling procedure in recent months Social History: ___ Family History: Mother (___): CAD, DM & ?ovarian cancer Father (___): died of lung cancer (heavy smoker) Denies premature MI, stroke, aneurysm, cholesterol problems, HTN, asthma, thyroid problems, bleeding tendencies, anemia, skin/breast/colon cancer Physical Exam: ADMISSION EXAM: T 98.9 HR 94 BP 111/65 RR 20 94% 4L GENERAL: Seated in bed, no accessory muscle use, speaking full sentences, NAD HEENT: No LAD, JVD < 10cm CV: normal S1 S2, no M/R/G PULM: Scattered bilateral expiratory wheezes, moderate air movement ABD: Soft, NT/ND, + BS GU: no foley NEURO: AAOx3 EXT: no edema, WWP, +pneumoboots DISCHARGE EXAM: 97.9, 117/70 (100-110s/60-70s), 88 (80-90s), 18, >91% RA GENERAL: Seated in chair, no accessory muscle use, speaking full sentences, NAD HEENT: No LAD, JVD < 10cm CV: normal S1 S2, no M/R/G PULM: Scattered bilateral expiratory wheezes, good air movement ABD: Soft, NT/ND, + BS GU: deferred NEURO: AAOx3, CN II-XII intact EXT: no edema, WWP Pertinent Results: ADMISSION: ___ 02:41PM TYPE-ART PO2-199* PCO2-34* PH-7.47* TOTAL CO2-25 BASE XS-2 INTUBATED-NOT INTUBA ___ 01:55PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:55PM URINE RBC-4* WBC-5 BACTERIA-FEW YEAST-NONE EPI-1 ___ 01:55PM URINE HYALINE-1* ___ 01:55PM URINE MUCOUS-RARE ___ 08:44AM TYPE-ART RATES-/20 PO2-75* PCO2-53* PH-7.34* TOTAL CO2-30 BASE XS-0 INTUBATED-NOT INTUBA VENT-SPONTANEOU ___ 05:05AM ___ COMMENTS-GREEN TOP ___ 05:05AM LACTATE-1.4 ___ 04:30AM GLUCOSE-154* UREA N-10 CREAT-0.7 SODIUM-136 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-16 ___ 04:30AM estGFR-Using this ___ 04:30AM cTropnT-0.02* ___ 04:30AM WBC-9.0 RBC-5.20 HGB-16.3* HCT-47.3 MCV-91 MCH-31.4 MCHC-34.5 RDW-14.4 ___ 04:30AM NEUTS-67.4 ___ MONOS-5.5 EOS-4.0 BASOS-1.2 ___ 04:30AM PLT COUNT-306 DISCHARGE: ___ 07:00AM BLOOD WBC-9.8 RBC-4.61 Hgb-14.7 Hct-42.4 MCV-92 MCH-31.9 MCHC-34.7 RDW-14.8 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ 07:00AM BLOOD Glucose-77 UreaN-19 Creat-0.6 Na-139 K-3.9 Cl-96 HCO3-32 AnGap-15 ___ 07:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1 IMAGING: ___ CXR: mild hyperinflation, no acute process. Hiatal hernia. ___ CXR: No acute process. Stable hiatal hernia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. ClonazePAM 0.5 mg PO TID:PRN anxiety 3. Omeprazole 40 mg PO DAILY 4. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB 5. Simvastatin 80 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Azithromycin 250 mg PO Q24H 8. Pulmicort Flexhaler (budesonide) 180 mcg/actuation Inhalation BID Discharge Medications: 1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB 2. Azithromycin 250 mg PO Q24H Duration: 1 Dose RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 3. ClonazePAM 0.5 mg PO TID:PRN anxiety 4. Omeprazole 40 mg PO DAILY 5. Simvastatin 80 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Citalopram 20 mg PO DAILY 8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H RX *albuterol sulfate 0.63 mg/3 mL 1 nebulizer inhaled q4hr Disp #*60 Unit Refills:*0 9. PredniSONE 60 mg PO DAILY Tapered dose - DOWN RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Pulmicort Flexhaler (budesonide) 180 mcg/actuation Inhalation BID 11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, shortness of breath RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 nebulizer solution inhaled every 6 hours Disp #*30 Not Specified Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Chronic Obstructive Pulmonary Disease Exacerbation (COPD) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Shortness of breath in a patient with a history of COPD. COMPARISON: Chest radiograph from ___. FINDINGS: Chest, portable upright. The lungs are hyperinflated but clear. The hilar and cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. IMPRESSION: No acute cardiopulmonary process. Hyperinflated lungs, consistent with the stated history of COPD. Radiology Report AP CHEST, 5:39 A.M., ___ HISTORY: ___ woman with COPD. IMPRESSION: AP chest compared to ___: Lungs clear. Heart size normal. Hiatus hernia noted. No pleural abnormality. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SOB Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 0 level of acuity: 1.0

___ yo F w/ h/o COPD (FEV1) and Crohn's (on remicade) presenting for increasing shortness of breath. ACUTE # COPD exacerbation: Pt with hx of mild COPD. On arrival to the ED on ___, she had O2 sats of 77%, and continued to require O2 throughout the admission until the day of discharge. She was given IV methylpred, azithromycin, and nebs with initial improvement in her symptoms, but was transferred to the MICU for bipap given concerns of respiratory fatigue. She was transferred to the floor on ___ w/ 4L O2 requirement, and ambulatory sats of 77%. ABG showed hypoxemia at 7.46/42/56 (pH/pCO2/pO2). Her nebs were spaced to q6h, with good air movement on exam and O2 sats of >91% on RA by ___. She should f/u with her outpt pulmonologist with repeat PFTs at that time. She did very well at rest but may benefit from O2 with activity - she refused this. She was discharged with prolonged steroid taper and sufficient azithromycin to complete a ___HRONIC #. Crohn's: She receives remicade as an outpatient, and her disease was stable this admission. She is followed by GI outpatient. #. HLD: She was continued on simvastatin. #. Depression/anxiety: She was continued on citalopram/klonipin. TRANSITION # COPD: plan for outpatient f/u with pulmonologist with repeat PFTs at that time.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Tetracycline / Hibiclens / Dilaudid / tramadol / oxycodone / morphine Attending: ___ ___ Complaint: Abdominal pain and emesis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman ___ UC s/p lap proctocolectomy w/ end ileostomy ___ with revision later that month, s/p repair of parastomal hernia on ___, recently admitted with SBO ___. An ileostomy was performed during that admission, which identified no frank obstruction. Biopsies taken at 70cm were read as 'mild ileitis'. Since her discharge, she has continued to have intermittent abdominal pain. This became much worse yesterday night. The pain occurs across the middle of her abdomen, behind her ostomy. The pain comes in waves, in crampy in nature, and does not radiate. She and her husband report that she has had impressive borborigmi during this time. She had an episode of small volume emesis early this morning around 3am, which produced only a few table spoons. This prompted her to seek care at the ___ ED. Of note, she reports continued flatus during this time as well as production of liquid stool, albeit at lower volumes than usual. Past Medical History: 1. Hyperlipidemia 2. Ulcerative proctitis. 3. Hypothyroidism. 3. Migraines. 4. Recurrent nephrolithiasis. 5. History of multiple skin cancers including basal cell, squamous cell, and melanoma in situ (___). 6. Genital herpes, with recent flare while on steroids 7. Oral thrush ___ on steroids Past Surgical History: 1. ___ Ileostomy revision 2. ___ Lap TPC with end ileostomy 3. ___ Left ureteroureterostomy with stent 4. ___ breast excision Social History: ___ Family History: Her brother has ulcerative colitis, he has never had surgery. A first cousin also has ulcerative colitis. Her father had an MI at age ___. Her mother had breast cancer. Many family members have hypertension. Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: No respiratory distress ABD: Soft, mildly tender to palpation in the mid abdomen and in the ___ area, well healed surgical scars, ostomy in place with liquid stool and some gas in bag wih red rubber in place. Ileostomy appears pink. EXT: No ___ edema, warm and well perfused Pertinent Results: ___ 06:00AM BLOOD WBC-4.0 RBC-2.62* Hgb-7.2* Hct-22.6* MCV-86 MCH-27.5 MCHC-31.9* RDW-13.2 RDWSD-41.5 Plt ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Simvastatin 10 mg PO QPM 3. Phenazopyridine 200 mg PO TID 4. Acyclovir 400 mg PO DAILY 5. Fish Oil (Omega 3) 1000 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Simvastatin 10 mg PO QPM 3. Phenazopyridine 200 mg PO TID 4. Acyclovir 400 mg PO DAILY 5. Fish Oil (Omega 3) 1000 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. Vitamin D 800 UNIT PO DAILY 8. rifaximin 550 mg TID for 14 days Discharge Disposition: Home Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with PMH of ulcerative colitis s/p laparoscopic proctocolectomy with end ileostomy (___), c/b parastomal hernia now s/p hernia repair on ___, and recent admission for symptoms of obstruction, who presents now with abdominal discomfort and nausea.// Recurrent obstruction? Ileitis? TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP = 6.0 mGy-cm. 2) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol = 8.5 mGy (Body) DLP = 355.1 mGy-cm. Total DLP (Body) = 361 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: There is minimal bibasilar atelectasis. Visualized lung fields are otherwise within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. The previously seen 8 mm cyst in the body the pancreas is stable. 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. Bilateral subcentimeter hypodensities are unchanged, too small to characterize. A 1.0 cm calculus in the lower pole of the right kidney is unchanged. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia, with a small amount of oral contrast noted within the hernia. The patient is status post proctocolectomy with right lower quadrant ileostomy and mesh placement at the ostomy site. There is focal narrowing at the ostomy site, with multiple upstream loops of dilated, fluid-filled small bowel measuring up to 3.7 cm. Appearance of possibly diluted contrast material within the jejunum.. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are grossly within normal limits. 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. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Multilevel degenerative changes of the spine are re-demonstrated, most pronounced at L4-5. SOFT TISSUES: Aside from the right lower quadrant ileostomy, the abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Focal narrowing at the right lower quadrant ostomy site, with multiple upstream loops of dilated, fluid-filled small bowel, consistent with partial versus early complete obstruction. 2. The previously noted possible cystic lesion of the pancreas for which MRCP was recommended is likely stable. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, N/V Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Unspecified abdominal pain, Nausea with vomiting, unspecified temperature: 98.5 heartrate: 90.0 resprate: 16.0 o2sat: 100.0 sbp: 115.0 dbp: 70.0 level of pain: 10 level of acuity: 3.0

Following her admission, Mrs ___ underwent a CT scan that failed to show a transition point. Because of this fact and how her ostomy continued to produce liquid stool and flatus, it was determined that there was no surgical pathology causing her symptoms at this time. Her stoma was also intubated with a red rubber catheter, which facilitated the passage of stool. Her nausea and vomiting decreased and she continued to progress over the next two days to the point where she was tolerating a regular diet well. Her pain and other symptoms were well controlled and she was able to ambulate independently. The catheter fell out of the stoma numerous times. We then decided to place a nasal trumpet into the stoma and stitch it in place. Stomal output was good and the patient was discharged home with stomal care instructions. She will also receive a course of rifaximin 550 mg TID for 14 days, per GI recommendations.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fall with abdominal pain Major Surgical or Invasive Procedure: ___ embolization of splenic artery ___- ___ coil embolization of proximal splenic artery History of Present Illness: ___ s/p fall ___, now tx from OSH after syncopal event, found to have grade III splenic laceration, active extravasation; s/p proximal ___ embolization x2 Past Medical History: PMH: HTN, HLD, h/o colon ca s/p R colectomy, gout PSH: Extended right colectomy approx ___ years ago, incisional hernia repair with mesh approx ___ years ago (in ___ Social History: ___ Family History: non-contributory Physical Exam: Exam on discharge: T 99 HR 69 BP 136/53 RR 19 96RA NAD RRR CTAB abd protuberant but soft and near baseline per patient no edema Pertinent Results: ___ 03:15PM BLOOD WBC-8.1 RBC-3.87* Hgb-11.7* Hct-34.0* MCV-88 MCH-30.3 MCHC-34.4 RDW-13.2 Plt ___ ___ 01:52AM BLOOD WBC-7.9 RBC-2.83* Hgb-8.7* Hct-25.3* MCV-89 MCH-30.7 MCHC-34.4 RDW-13.2 Plt ___ ___ 02:54PM BLOOD Hct-25.8* ___ 10:00PM BLOOD Hct-22.6* ___ 02:12AM BLOOD WBC-5.5 RBC-2.41* Hgb-7.4* Hct-21.1* MCV-88 MCH-30.8 MCHC-35.2* RDW-13.9 Plt ___ ___ 07:33AM BLOOD Hct-24.6* ___ 01:43PM BLOOD Hct-25.0* ___ 07:30PM BLOOD Hct-24.7* ___ 12:20AM BLOOD Hct-24.4* ___ 04:00AM BLOOD WBC-5.4 RBC-2.74* Hgb-8.6* Hct-24.2* MCV-88 MCH-31.2 MCHC-35.4* RDW-13.9 Plt ___ ___ 12:37PM BLOOD Hct-25.2* ___ 08:44PM BLOOD Hct-26.2* ___ 04:35AM BLOOD WBC-5.5 RBC-2.87* Hgb-8.9* Hct-25.4* MCV-88 MCH-30.9 MCHC-35.0 RDW-14.3 Plt ___ ___ 03:15PM BLOOD ___ PTT-28.9 ___ ___ 04:35AM BLOOD ___ PTT-30.1 ___ ___ 08:30PM BLOOD Glucose-164* UreaN-21* Creat-1.0 Na-140 K-4.9 Cl-104 HCO3-25 AnGap-16 ___ 04:35AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-135 K-3.9 Cl-99 HCO3-30 AnGap-10 ___ 01:59AM BLOOD Lactate-1.5 ___ Angio: Multiple areas of active extravasation involving the lower pole of the spleen, all of which supplied by a single lower pole artery. Selective coil embolization of supplying low pole artery. Medications on Admission: Lipitor 20'; Aspirin 81'; Nadolol 20'; Hydrochlorothiazide 25'; Indomethacin 50' Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Nadolol 20 mg PO DAILY 6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth every ___ hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: splenic laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ man status post fall one day ago with weakness and dizziness today. CTA demonstrating splenic laceration with active extravasation. Angiographic assessment with potential splenic artery embolization is requested in the setting of hemodynamic stability. OPERATORS: Dr. ___ (fellow) and Dr. ___ (attending) performed the procedure. PROCEDURE PERFORMED: 1. Celiac axis and selective splenic artery arteriograms. 2. Selective lower pole branch arteriogram. 3. Embolization of lower pole splenic artery branch. ANALGESIA: Moderate sedation was achieved by providing divided doses of 300 mcg of fentanyl and 4 mg of midazolam during the total intraservice time of 1 hour and 25 minutes. PROCEDURE DETAILS: Written informed consent was obtained outlining the risks, benefits, and potential complications of the procedure. The patient was brought to the angiography suite and placed supine on the imaging table. A preprocedure timeout was performed as per ___ protocol. Using a combined palpatory and fluoroscopic guidance approach and following administration of local anesthetic, the right common femoral artery was accessed with a 19 gauge single wall puncture needle. A 0.035 ___ wire was easily advanced into the lower thoracic aorta. The needle was removed and following a 2-mm incision, a 5 ___ vascular sheath was advanced over the ___ wire and into the common femoral artery. The inner dilator was removed and a sheath was attached to a continuous heparinized saline sidearm flush. A 5 ___ C2 glide catheter was then used to selectively cannulate the celiac axis. Run performed from this position demonstrated a large celiac trunk towards the right with relatively elongated splenic artery. Three areas of active extravasation were identified involving the lower pole of the spleen. Subsequently, a Glidewire was used to gain further purchase of the C2 glide catheter into the splenic artery. DSA run was performed from that position. The latter redemonstrated multiple active bleeding sources involving the lower pole of the spleen, all of them supplied by a lower pole splenic artery branch. Accordingly, a decision was made against proximal splenic artery embolization and selective embolization of the supplying lower pole splenic branch. Hence the combination of Renegade ___ and a double-angled Glidewire was used to select the lower pole branch. Another DSA run performed with the microcatheter confirmed the previous findings and was used to fine tune the position of the microcatheter for subsequent coiling. Subsequently, 5 and 6-mm Hilal Cook embolization coils were deployed in the lower pole splenic artery branch. A control run performed over the 5 ___ C2 glide catheter demonstrated satisfactory result with cessation of previously identified active extravasation and markedly reduced parenchymal blush involving the lower pole of the spleen. The catheter and the sheath were removed and hemostasis achieved by holding pressure for about 20 minutes. IMPRESSION: 1. Multiple areas of active extravasation involving the lower pole of the spleen, all of which supplied by a single lower pole artery. 2. Selective coil embolization of supplying low pole artery. Radiology Report HISTORY: Recent splenic artery embolization, new abdominal distention and tympany. FINDINGS: Single portable supine view of the abdomen is submitted. The bowel gas pattern is unremarkable without evidence of ileus or obstruction. The left upper quadrant embolization coil is appreciated. Bony structures and remaining soft tissues are grossly unremarkable, some vascular calcification. IMPRESSION: No ileus or obstruction. Radiology Report INDICATION: ___ man with splenic laceration following selective splenic artery embolization with continuous oozing down-trend of hematocrit. OPERATORS: Dr. ___ (fellow), Dr. ___, Dr. ___ ___ and Dr. ___. PROCEDURES PERFORMED: 1. Selective splenic artery arteriogram. 2. Reinforcement of selective lower pole splenic artery embolization by use of additional coils, Gelfoam and glue. 3. Proximal splenic artery embolization between the dorsal pancreatic and pancreatic magna. MEDICATION: Moderate sedation was achieved by providing divided doses of 6 mg of midazolam and 275 mcg of fentanyl during the entire procedure time of 280 minutes. RADIATION DOSE: 4867 mGy. PROCEDURE DETAILS: Written informed consent was obtained from the patient. The patient was brought to the angio suite and placed supine on the imaging table. A preprocedure timeout was performed as per ___ protocol. Using a combined palpatory and fluoroscopic guidance and following administration of local anesthetic, the right common femoral artery was accessed with a 19-gauge single wall puncture needle. A 0.035 ___ wire was easily advanced into the lower aorta and the needle then exchanged for a 5 ___ vascular sheath. The latter was attached to a continuous heparinized saline sidearm flush. A combination of Glidewire and 5 ___ C2 Glide catheter was then used to access the celiac trunk and advance the Glide catheter into the splenic artery. A DSA run performed from that position demonstrated persistent flow through the recently coiled lower pole splenic artery with signs of partial recanalization and identification of one active bleeding source. Once again no active extravasation was seen involving the remainder of the spleen. In an attempt to reinforce the lower pole artery embolization, four additional 5 mm Cook Hilal embolization coils were placed in the existing coil pack. This was performed after introducing a Renegade ___ microcatheter and advancing it by help of a 0.018 double J glidewire. In addition, about 2 cc of Gelfoam was deployed in the coil pack. Subsequently, Dermabond glue was mixed with lipiodol (1:4), the microcatheter in the coil pack primed with D5 solution and a small amount of glue injected in the area of the coil pack. However, as visualistion of the glue was suboptimal, we refrained from a more aggressive approach or occlusion of the entire feeding vessel. The microcatheter was then removed and an additional run performed over the main 5 ___ catheter. The latter demonstrated significant reduction of flow in the lobe artery, however, with residual flow and mild active extravasation despite all previous treatment attempts. Accordingly, a decision was made to at add a proximal splenic artery embolization between the dorsal pancreatic and pancreatic magna arteries. To this end, Renegade ___ catheter was advanced with a Transcend wire and adequately positioned. As 10 mm Hilal embolization coils would not form in the splenic artery, four 22 mm GDC coils were eventually deployed proximal to the pancreatic magna, resulting in subtotal occlusion of the splenic artery with cessation of active extravasation and significant reduction of parenchymal blush involving the lower splenic pole. At this point, note was also made of a new perfusion deficit involving the upper pole of the spleen, likely related to some degree of non-targeted embolization by previous Gelfoam injection. Given the satisfactory result, all catheters and the sheath were withdrawn and manual pressure was applied for 20 minutes. The patient withstood the procedure well and there were no immediate complications. IMPRESSION: 1. Reinforcement of selective lower pole splenic artery embolization by means of additional coils, Gelfoam and glue. 2. Performance of proximal splenic artery embolization. Gender: M Race: OTHER Arrive by UNKNOWN Chief complaint: SPLENIC INJURY Diagnosed with SPLEEN PARENCHYMA LACER, UNSPECIFIED FALL temperature: 98.0 heartrate: 82.0 resprate: 18.0 o2sat: 97.0 sbp: 118.0 dbp: 72.0 level of pain: 10 level of acuity: 2.0

Patient was found to have a Grade III splenic laceration and was initially taken by ___ where he had embolization of the lower pole. He was brought to the ICU for close monitoring afterwards and on serial Hcts he was noted to be drifting. He was normotensive and his Urine output was adequate. His abdomen was large but patient stated that this was near his baseline. He was transfused 2u RBC on ___ and then again on ___. He was not bumping appropraitely with the transfusions and after considering taking him to the operating room for a splenectomy ___ believed they could stop the slow drift and on repeat angio he was found to have a low extravasation and had proximal embolization of the splenic artery. After that point all was stable including his urine output, abd girth, hematocrit, and symptoms. He was discharged to home tolerating a regular diet, voiding, and with good pain control.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Metoclopramide Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: intubation and mechanical ventilation ___ - ___ History of Present Illness: ___ with hx of dementia (non-verbal at baseline), HTN, DM2, schizophrenia who presents from her nursing facility with AMS. Per report, patient has possible unwitnessed seizure as drooling when found and reported bleeding from her tongue. Per report obtained from brother in ___ and nursing home sign out, patient is non-verbal at baseline. On initial presentation to the ___ patient was unresponsive, drooling at mouth. Withdrawing to pain. GCS 6. Pupils equal, reactive to light. Vitals 100, 67, 144/79, 16, 89% on 2L. Patient was rapidly intubated for airway protection. Initial labs notable for white count 7.4, Hgb 12.8, Chem 7 with Cr of 1.8 (appears to be close to prior baseline) with AG of 18. Lactate elevated at 6.4. UA frankly positive. Trop 0.02. UTox negative. Patient given ~2L NS and 1gm IV Ceftriaxone. CT head without evidence of acute intracranial pathology. Neurology consulted and after obtaining collateral from nursing home, did not feel that patient had true seizure and was only noted to have occasional myoclonic jerks in the ___ for with Ativan was administered without effect. In the setting of toxic-metabolic encephaolopathy "Myoclonic jerks ... are not unexpected. As there is no clear semiology concerning for seizure, no personal or family history of seizure, would not obtain EEG at this time. No AED needed." Patient was then admitted to MICU. Of note, patient developed sinus bradycardia just prior to transfer to the MICU. HR dropped to 38 but then quickly came up to high ___. BP stable. EKG notable only for sinus bradycardia. On arrival to the MICU, patient intubated, sedated and HD stable. ROS: unable to obtain due to intubation and baseline non-verbal status. Past Medical History: Past Medical History: Schizophrenia-like disorder HTN h/o PNA chronic pulmonary disease DM ___ edema Lichen Planus Past Surgical History: Hysterectomy BSO Ventral hernia repair (?mesh) "Cyst excision" (after her ovarian resection) Social History: ___ Family History: mother w/ DM. No h/o cancer or significant CAD Physical Exam: ADMISSION PE: Vitals: T: 98.2 BP: 159/60 P: 60 R: 18 O2: 100% on ___ GENERAL: Intubated and sedated HEENT: Sclera anicteric, MMM, pinpoint pupils NECK: supple, JVP not apprecated ___ body habitus LUNGS: Ventilated breathsounds apprecaited anteriorly without rales, ronchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: obese. soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly appreciated EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema SKIN: no rashes/lesions noted NEURO: Intubated, sedated, not following commands. DISCHARGE PE: Vitals: Temp 98.9 HR ___ BP 130s-160s/60s-70s RR ___ SpO2 96-100% on 2L NC GENERAL: Babbling. Laying comfortably in bed. HEENT: Sclera anicteric, MMM NECK: supple, JVP not appreciated ___ body habitus LUNGS: clear to auscultation in all fields, no wheezes, ronchi, or increased WOB CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: obese. soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly appreciated EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema SKIN: no rashes/lesions noted NEURO: not following commands. wiggles toes spontaneously bilaterally. strength and sensation unable to be tested Pertinent Results: ADMISSION LABS: ___ 04:10PM BLOOD WBC-7.4 RBC-4.61 Hgb-12.8 Hct-42.2 MCV-92 MCH-27.8 MCHC-30.3* RDW-13.1 RDWSD-43.1 Plt ___ ___ 04:10PM BLOOD Neuts-67.6 ___ Monos-6.3 Eos-0.9* Baso-0.4 Im ___ AbsNeut-5.00 AbsLymp-1.81 AbsMono-0.47 AbsEos-0.07 AbsBaso-0.03 ___ 04:10PM BLOOD Plt ___ ___ 04:10PM BLOOD Glucose-220* UreaN-34* Creat-1.8* Na-144 K-4.5 Cl-105 HCO3-21* AnGap-23* ___ 04:10PM BLOOD ALT-9 AST-13 AlkPhos-84 TotBili-0.3 ___ 04:10PM BLOOD Lipase-31 ___ 04:10PM BLOOD cTropnT-0.02* ___ 04:10PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.9 Mg-1.9 ___ 05:52PM BLOOD Type-ART pO2-348* pCO2-37 pH-7.42 calTCO2-25 Base XS-0 ___ 04:29PM BLOOD Lactate-6.4* DISCHARGE LABS: ___ 07:35AM BLOOD WBC-5.8 RBC-3.95 Hgb-11.0* Hct-36.7 MCV-93 MCH-27.8 MCHC-30.0* RDW-13.1 RDWSD-44.2 Plt ___ ___ 07:35AM BLOOD Glucose-169* UreaN-20 Creat-1.4* Na-147* K-3.5 Cl-111* HCO3-23 AnGap-17 ___ 07:35AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0 ___ 08:32AM BLOOD ___ pO2-138* pCO2-42 pH-7.40 calTCO2-27 Base XS-1 MICRO: Blood Cx: NGTD Urine Cx: contaminated STUDIES/IMAGING: CXR: Low lung volumes with bibasilar opacities, likely atelectasis. Infection cannot be excluded. CT Head: 1. No acute intracranial process. 2. Age advanced atrophy 3. Chronic small vessel disease. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Senna 17.2 mg PO BID 2. Simvastatin 20 mg PO QPM 3. Vitamin D 400 UNIT PO DAILY 4. Acetaminophen 650 mg PO Q4H:PRN fever 5. Bisacodyl 10 mg PR QHS:PRN constipation 6. Amlodipine 10 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. GlipiZIDE 5 mg PO BID 9. MetFORMIN (Glucophage) 750 mg PO QHS 10. Metoprolol Tartrate 75 mg PO BID 11. Mirtazapine 30 mg PO QHS Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Metoprolol Tartrate 75 mg PO BID 4. Senna 17.2 mg PO BID 5. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q4H:PRN fever 7. Bisacodyl 10 mg PR QHS:PRN constipation 8. GlipiZIDE 5 mg PO BID 9. Mirtazapine 30 mg PO QHS 10. Simvastatin 20 mg PO QPM 11. Vitamin D 400 UNIT PO DAILY 12. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: complicated urinary tract infection seizures Secondary diagnosis: schizophrenia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ with AMS, ?seizure. intubated // eval for tube placement, eval for bleed TECHNIQUE: Single portable view of the chest. COMPARISON: None. FINDINGS: Low lung volumes are noted. Endotracheal tube tip is approximately 5.5 cm from the carina. There are bibasilar opacities, likely atelectasis. Superiorly the lungs are clear. Cardiac silhouette is likely accentuated by AP technique with low lung volumes. No acute osseous abnormalities. IMPRESSION: Low lung volumes with bibasilar opacities, likely atelectasis. Infection cannot be excluded. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with AMS, ?seizure. intubated TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformats were obtained. DOSE: Total DLP (Head) = 892 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute major, hemorrhage, edema, or large mass. There are extensive bilateral periventricular and subcortical white matter hypodensities, which are nonspecific but may represent a sequela of chronic small vessel ischemic changes. There is prominence of the ventricles and sulci suggestive involutional changes, age advanced. Atherosclerotic calcifications are seen within the bilateral carotid siphons. There is no fracture. Mild mucosal thickening is noted within the bilateral ethmoid air cells. Remainder of 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. No acute intracranial process. 2. Age advanced atrophy 3. Chronic small vessel disease. Radiology Report EXAMINATION: Chest radiograph INDICATION: Tube placement COMPARISON: ___ IMPRESSION: Newly placed nasogastric tube. The tip projects over the gastroesophageal junction. No evidence of complications. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with question seizures intubated for airway protection // interval change TECHNIQUE: Portable semi-upright chest radiograph. COMPARISON: Chest radiograph dated ___. FINDINGS: The ETT terminates 5 cm above the carina. The NG tube curls in the stomach. Low lung volumes. There is bibasilar atelectasis, left worse than right. The lungs are otherwise clear. Heart size is stable. The mediastinal and hilar contours are stable. The pulmonary vasculature is normal. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: 1. Appropriate positioning of the ETT and NG tube. 2. Bibasilar atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with altered mental status // Evaluate for infiltrates IMPRESSION: As compared to ___ radiograph, bibasilar atelectasis has slightly worsened. No other relevant changes. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Altered mental status, Hypoxia Diagnosed with URIN TRACT INFECTION NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, SENILE DEMENTIA UNCOMP, DIABETES UNCOMPL ADULT, HYPERTENSION NOS temperature: nan heartrate: 80.0 resprate: 16.0 o2sat: 89.0 sbp: 132.0 dbp: 68.0 level of pain: 13 level of acuity: 1.0

___ with hx of demenatia (non-verbal at baseline), HTN, DM2, schizophrenia who presents from her nursing facility with AMS likely ___ to urosepsis with concern for seizure. # Encephalopathy # Seizure disorder Most likely due to complicated UTI and seizure activity. Unfortunately, unclear mental baseline on admission and patient reportedly unable to follow commands or speak clearly at baseline. Patient intubated in ___ for airway protection and admitted to MICU. Patient given course of IV Ceftriaxone for presumed Urosepsis. Patient also with question of myoclonic jerks initally. Neurology intitially felt that unlikely sizure, however performed EEG which was felt to be consistent with seizure activity. Patient loaded and started on daily Keppra. She will need 1 month of Keppra and follow-up in Neurology clinic. Blood cultures obtained and were negative. Patient gradually returned to her baseline mental status. # Complicated UTI: Patient treated with ceftriaxone initially and transitioned to cefpodoxime at discharge. She should complete a 7 day course (___). # Respiratory Failure - intubated for airway protection in ___ with only minimal vent settings. Patient easily extubated on HD 2. Continued on famotidine while intubated. # Lactic Acidosis - DDx included urosepsis vs seizure vs metformin induced lactic acidosis. Lactate improved with IVF and seizure treatment as above.