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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Cipro / calcium channel blockers / amlodipine Attending: ___. Chief Complaint: Left mid-shaft femur fracture Major Surgical or Invasive Procedure: ___ Left femur open reduction and internal fixation with trochanteric fixation nail system History of Present Illness: ___ with hx of bilateral TKR pw left femur fracture s/p fall. Patient was ambulating with walker and fell. Seen at OSH and noted to have midshaft left femur fracture. Denies recent fevers or chills. Denies numbness, tingling. Only endorsing pain at her left femur. Past Medical History: Breast Cancer s/p surgery and radiation, currently on letrozole HTN CHF with EF of 49% per family GERD CAD no hx of MI or stenting HL Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Examination T99.7 HR58 BP116/59 RR16 O2 97% 2L A&O x 3 Calm and comfortable BLE skin clean and intact Deformity of left thigh. ttp at left midthigh No edema, induration or ecchymosis Thighs and leg compartments soft Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ ___ ___ TA Peroneals Fire 2+ ___ and DP pulses Discharge Physical Examination General: Awake, alert, no acute distress Vitals: T = 98.3, HR = 78, BP = 112/60, RR = 18, O2Sat = 93% RA Left lower extremity: incisions clean/dry/intact without erythema or drainage, wwp, 2+ DP pulse, SILT s/s/sp/dp/tib, (+) motor ___ Pertinent Results: LABORATORY On admisison ___ 11:37AM GLUCOSE-143* UREA N-24* CREAT-1.0 SODIUM-142 POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14 ___ 11:37AM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-1.4* ___ 01:15AM WBC-14.1* RBC-3.54* HGB-11.1* HCT-32.4* MCV-91 MCH-31.3 MCHC-34.3 RDW-14.6 ___ 01:15AM PLT COUNT-235 ___ 01:15AM ___ PTT-24.2* ___ On discharge ___ 06:12AM BLOOD WBC-11.1* RBC-3.17*# Hgb-9.9*# Hct-29.0* MCV-91 MCH-31.1 MCHC-34.0 RDW-15.6* Plt ___ ___ 06:12AM BLOOD Plt ___ ___ 06:12AM BLOOD Glucose-107* UreaN-19 Creat-1.0 Na-139 K-3.6 Cl-107 HCO3-28 AnGap-8 ___ 06:12AM BLOOD Calcium-8.2* Phos-1.7* Mg-2.0 IMAGING ___ Plain Films Pelvis, Left femur: No fracture or dislocation. No pubic symphysis or sacroiliac joint diastasis. Degenerative changes are present of the sacroiliac joint and the pubic symphysis. The alignment of a left femur midshaft fracture has improved with an external fixation device. The distal fragment remains displaced approximately 2 cm superiorly and 1.3 cm laterally. Left knee replacement is incompletely evaluated PATHOLOGY ___ Left femur tissue reamings: pending at time of discharge Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Omeprazole 20 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. HydrALAzine 30 mg PO TID 4. Atacand HCT *NF* (candesartan-hydrochlorothiazid) 32-25 mg Oral qday 5. Aspirin 81 mg PO DAILY 6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral qday 7. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg calcium- 250 unit Oral bid 8. Meclizine 25 mg PO Q8H:PRN vetigo 9. selenium *NF* 200 mcg Oral qday 10. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral qday 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Simvastatin 20 mg PO DAILY 13. letrozole *NF* 2.5 mg Oral qday Discharge Medications: 1. Fish Oil (Omega 3) 1000 mg PO DAILY 2. letrozole *NF* 2.5 mg Oral qday 3. Lisinopril 40 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Acetaminophen 650 mg PO Q6H 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 40 mg SC Q 24H Duration: 14 Days 9. Multivitamins 1 TAB PO DAILY 10. OxycoDONE (Immediate Release) 2.5-5.0 mg PO Q4H:PRN Pain 11. Senna 1 TAB PO DAILY 12. Aspirin 81 mg PO DAILY 13. Atacand HCT *NF* (candesartan-hydrochlorothiazid) 32-25 mg Oral qday 14. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral qday 15. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg calcium- 250 unit Oral bid 16. HydrALAzine 30 mg PO TID 17. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral qday 18. Meclizine 25 mg PO Q8H:PRN vetigo 19. Metoprolol Succinate XL 200 mg PO DAILY 20. selenium *NF* 200 mcg Oral qday Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left femoral midshaft femur 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 HISTORY: ___ female with left femur fracture status post external fixation. COMPARISON: Reference radiographs of ___ at 17:24. FINDINGS: PELVIS, 1 VIEW: No fracture or dislocation. No pubic symphysis or sacroiliac joint diastasis. Degenerative changes are present of the sacroiliac joint and the pubic symphysis. LEFT FEMUR, FRONTAL VIEWS: The alignment of a left femur midshaft fracture has improved with an external fixation device. The distal fragment remains displaced approximately 2 cm superiorly and 1.3 cm laterally. Left knee replacement is incompletely evaluated. IMPRESSION: Improved alignment of left femur midshaft fracture, with residual superior and lateral displacement of the distal fragment. Radiology Report HISTORY: ORIF left femur. Fluoroscopic assistance provided to surgeon in the OR without the radiologist present. Six spot views obtained. Fluoro time recorded as 219.2 seconds on the electronic requisition. Correlation with real-time findings and when appropriate conventional radiographs is recommended for full assessment. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: LOWER EXTREMITY INJURY Diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL temperature: 99.7 heartrate: 58.0 resprate: 16.0 o2sat: 97.0 sbp: 116.0 dbp: 59.0 level of pain: 2 level of acuity: 3.0

******SIGNS OF INFECTION******** - Please return to the emergency department or notify MD if you should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers > 101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. ********Wound Care******** - You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continues to be non-draining. ******WEIGHT-BEARING******* - You may weight bear as tolerated on your left leg ******MEDICATIONS*********** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink ___ glasses of water daily and take a stool softener (colace) to prevent this side effect. - Medication refills cannot be written after 12 noon on ___. *****ANTICOAGULATION****** - Take Lovenox for DVT prophylaxis for 2 weeks post-operatively. Physical Therapy: Activity: Out of bed w/ assist Pneumatic boots Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: Physical Therapy: Evaluate and Treat Occuapational Therapy: Evaluate and Treat Dressing changes qod

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: none History of Present Illness: Ms. ___ is an ___ ___ woman with PMH of CAD (NSTEMI s/p stent left circumflex & RCA in ___, HTN, HLD, PVD and asthma who presents with dyspnea. Pt reports that the shortness of breath began during adult day-care today, around 12PM. It began suddenly, which she states is usually the case for her asthma attacks. She was given O2 in the center and her SOB improved. The SOB worsened when she was off the O2 on her way home. Upon her arrival home, she appeared in distress to her daughter, tachypneic, and she had a supported fall. Her SOB did not improve with albuterol and so her daughter called an ambulance. She reports very mild CP associated with this attack today. She denies fevers, chills, palpitations, syncope, leg swelling, orthopnea, or PND. She began having episodic SOB and was diagnosed with asthma about ___ years ago. She has been having daily SOB asthma attacks which usually improve with albuterol. However, possibly due to incorrect use of her inhaler, she is usually out of her albuterol before she can get another one. On a few occasions, she had to use her daughter's inhaler to control her attacks. She is not recieving any other treatment for her asthma at the moment. Today's attack seemed the most severe in these ___ years. In the ED, initial vital signs were 98.4 67 147/67 24 100% 10L Non-Rebreather. She initially required a non-rebreather. Chem-7 and CBC with eosinophilia. Trop-T: <0.01, BNP EKG showed NSR @ 54, LVH, lateral st depressions (old) no STE or new ischemic changes. CXR was negative for pulmonary edema or infiltrate. Patient was given duonebs x4, magnesium 2g, and methylprednisolone 125mg. Pt improved with treatment but still very tight on exam. On transfer Vitals were BP 109/55 HR 58, RR 14, 99% O2 on 6L Neb. She feels much better, and reports no SOB or CP. Review of Systems: (+) per HPI+ dysuria, burning on urination, frequent urination. (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria. Past Medical History: - Asthma (diagnosed ___ years ago at age ___ - CAD, status post inferior NSTEMI with stent placement in L circumflex and RCA in ___ myocardial perfusion scan(___) - Medium size infarct involving the inferolateral wall w/ minimal ___ ischemia.Severe inferolateral hypokinesis. (EF: 64%. Cath ___: Patent PRCA stent, 40% mid vessel stenosis. Echo ___: Mild regional LV dysfunction with inferior lateral hypokinesis, EF 50%, ___ AR, ___ - Hypertension - Peripheral vascular disease - Adjustment with depressed mood - s/p right eye cataract surgery (R eye ___ at ___) - s/p L eye cataract surgery ___ Social History: ___ Family History: Asthma in brother, daughter and grandaughter. Mother died in childbirth. No other known. Physical Exam: ADMISSION: VS: T 98.5, BP 140/68, HR 67, RR 20, ___, GENERAL: thin woman uncomfortable, somewhat tearful HEENT: NC/AT PERRL EOMI, sclera anicteric, MMM OP clear NECK: supple, no LAD, no JVD, no thyromegaly CARDIAC: distant sounds. RRR, S1, S2, no m/r/g CHEST: somewhat scoliotic LUNG: some wheezing bilaterally. distant lung sounds ABDOMEN: soft NT ND +BS no organomegally GU: no foley EXT: Severe arthritic changes in hands, ulnar deviation. WWP no c/c/e 2+ radial DP, ___, strength ___ BUE and BLE. Neuro: aaox3 Skin: no rashes, excoriations Discharge: Vitals: 98 (111-162/51-68) 67 20 98%/3L General: thin frail elderly female, lying in bed in NAD HEENT: NCAT, PERRL, EOMI, MMM, OP clear Neck: no LAD, no JVD CV: distant heart sounds S1,S2 no murmurs Lungs: increased respiratory effort, poor air movement b/l, no whezzing Abdomen: firm, NT ND, +BS no hepatomegaly GU: no foley Ext: cool, 1+DP, moving all 4 extremities Neuro: AAOx3, CN grossly intact no focal neurologic deficits Skin: no rashes Pertinent Results: ___ 04:19PM BLOOD WBC-6.5 RBC-4.24 Hgb-13.2 Hct-38.0 MCV-90 MCH-31.1 MCHC-34.7 RDW-12.7 Plt ___ ___ 04:19PM BLOOD Neuts-73.5* Lymphs-14.9* Monos-5.1 Eos-5.8* Baso-0.7 ___ 04:19PM BLOOD ___ PTT-34.5 ___ ___ 04:19PM BLOOD Plt ___ ___ 04:19PM BLOOD Glucose-134* UreaN-18 Creat-1.0 Na-133 K-4.4 Cl-99 HCO3-24 AnGap-14 ___ 04:19PM BLOOD cTropnT-<0.01 ___ 04:19PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0 ___ 04:31PM BLOOD Type-ART Temp-36.9 pO2-126* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 Intubat-NOT INTUBA Comment-O2 DELIVER ___ 04:31PM BLOOD Lactate-1.1 ___ 04:31PM BLOOD O2 Sat-98 URINE: ___ 06:41PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:41PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 06:41PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 06:41PM URINE CastHy-1* ___ 06:41PM URINE Mucous-RARE MICRO: ___ URINE URINE CULTURE-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING Imaging: CXR (___): Possible bilateral pleural effusions with small retrocardiac opacity consistent with atelectasis or consolidation. Discharge: None Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 600 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. Albuterol-Ipratropium 2 PUFF IH Q6H 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY hold for sbp<100 6. Atorvastatin 80 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL PRN chest pain 8. Clopidogrel 75 mg PO DAILY 9. Acetaminophen 1000 mg PO Q8H:PRN pain 10. Aspirin 81 mg PO DAILY 11. Atenolol 50 mg PO DAILY 12. Losartan Potassium 100 mg PO DAILY hold for SBP<100 13. Mirtazapine 15 mg PO HS 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 1 TAB PO DAILY 16. Vitamin D 400 UNIT PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Calcium Carbonate 600 mg PO BID 5. Clopidogrel 75 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. Mirtazapine 15 mg PO HS 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 1 TAB PO DAILY 12. Vitamin D 400 UNIT PO BID 13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing SOB RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg NEB Q4H:PRN Disp #*60 Vial Refills:*0 14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1 IH INH twice a day Disp #*1 Inhaler Refills:*0 15. Metoprolol Succinate XL 50 mg PO DAILY hold for HR<60 or BP<100 RX *metoprolol succinate 50 mg 1 tablet extended release 24 hr(s) by mouth Daily Disp #*30 Tablet Refills:*0 16. PredniSONE 40 mg PO DAILY Duration: 9 Days RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*18 Tablet Refills:*0 17. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP IH Daily Disp #*30 Capsule Refills:*0 18. Nitroglycerin SL 0.3 mg SL PRN chest pain 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma Please use either the albuterol inhaler or nebulizer and not together at the same time. RX *albuterol sulfate 90 mcg 2 PUFF IH every four (4) hours Disp #*1 Inhaler Refills:*0 20. Nebulizer machine Diagnosis: Reactive Airway Disease Needed for albuterol treatments 21. Inhaler spacer Please provide an inhaler spacer for albuterol inhaler. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Hypoxia secondary to reactive airway disease Secondary: CAD HTN HLD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ female with shortness of breath. COMPARISON: Multiple prior exams, most recently of ___. FINDINGS: Single frontal view of the chest. The heart size is mildly enlarged and cardiomediastinal contours are stable. The bilateral costophrenic angles are indistinct, potentially due to effusions or potentially in part due to overlying soft tissues and technique. Retrocardiac opacity could represent atelectasis or consolidation. No pneumothorax. IMPRESSION: Possible bilateral pleural effusions with small retrocardiac opacity consistent with atelectasis or consolidation. Gender: F Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: DYSPNEA Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION temperature: 98.4 heartrate: 67.0 resprate: 24.0 o2sat: 100.0 sbp: 147.0 dbp: 67.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___. You came to the hospital because you were short of breath. We found that you have reactive airway disease. You were treated with steroids and nebulizers which improved your symptoms. We have made adjustments to your medications as outlined below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Opioids - Morphine Analogues / propoxyphene Attending: ___. Chief Complaint: falls and ___ weakness Major Surgical or Invasive Procedure: CERVICAL DECOMPRESSION AND FUSION C4-C7 History of Present Illness: ___ hx of MR presents from ___ s/p fall. She lives alone and had a mechanical fall hitting her right orbit and right knee. She was transferred here for neurology evaluation for multiple falls over the last month for which she has been doing ___. She states that for about 1 month she has had problems with balance and multiple falls. She denies any new neck pain, back pain, weakness, numbness, urinary or bowel incontinence, saddle anesthesia or fever. Her friends have ___ been concerned about left sided weakness and intermittent dysarthria. The spine service was consulted for a c5-c6 osteophyte seen on CT c-spine reportedly causing spinal stenosis. IMAGING:CT c-spine c5-6 osteophyte with central canal stenosis Past Medical History: Developmental delay Osteoporosis HLD GERD PPM remote hx of seizures but off meds Social History: no smoking or IVDU, lives in assisted living Physical Exam: Orthopaedic Spine Consult Physical Exam ___- In general, the patient is in no acute distress. Vitals: 97.8 86 150/74 16 98% RA a&ox3 abrasion right orbit RRR no increased WOB soft, NT/ND bilateral upper extremity tremor Spine exam: no C, T, L or S tenderness Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 No muscle wasting. -Sensory: Sensory UE C5 (Ax) R nl, L nl C6 (MC) R nl, L nl C7 (Mid finger) R nl, L nl C8 (MACN) R nl, L nl T1 (MBCN) R nl, L nl T2-L2 Trunk R nl, L nl Sensory ___ L2 (Groin): R nl, L nl L3 (Leg) R nl, L nl L4 (Knee) R nl, L nl L5 (Grt Toe): R nl, L nl S1 (Sm toe): R nl, L nl S2 (Post Thigh): R nl, L nl -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 ___: neg Babinski: upgoing bilaterally Clonus: none Perianal sensation: intact Rectal tone: intact BUE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearm compartments soft No pain with passive motion Axillary, Radial, Median, Ulnar SILT EPL FPL EIP EDC FDP FDS fire Pelvis stable to AP and lateral compression. BLE skin clean, R knee abrasion No tenderness, deformity, erythema, edema, induration or ecchymosis Thighs and leg compartments soft No pain with passive motion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ ___ TA Peroneals Fire Pertinent Results: ___ 12:50PM BLOOD WBC-8.6 RBC-3.96* Hgb-10.9* Hct-34.3* MCV-87 MCH-27.6 MCHC-31.8 RDW-14.9 Plt ___ ___ 08:48AM BLOOD Neuts-73.1* ___ Monos-4.8 Eos-1.4 Baso-0.3 ___ 12:50PM BLOOD Plt ___ ___ 12:50PM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-27 AnGap-13 ___ 01:50AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8 ___ EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with developmental delay status post C3-7 decompression fusion now altered mental status and possibly aphasia and decreased right-sided movement. Please evaluate for bleed or intracranial process. 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: 1212 mGy-cm CTDI: 54 mGy COMPARISON: CT from ___. FINDINGS: Evaluation is limited secondary to patient motion. There is no evidence of acute hemorrhage, mass effect, edema or infarctions. The ventricles and sulci are stable in size and configuration. Cavum septum pellucidum et vergae is incidentally noted. No osseous abnormalities seen. There is left maxillary and bilateral ethmoid air cell mucosal thickening. The other paranasal sinuses, mastoid air cells and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Evaluation is limited secondary to patient motion. No definite evidence of acute intracranial process. ___ EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ year old woman with developmental delay status post C3-7 decompression and fusion now with altered mental status and aphasia and decreased right sided movement. Please evaluate for cervical spine hematoma post-operatively. TECHNIQUE: Contiguous axial images were obtained of the cervical spine. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 669 mGy DLP: 32 mGy-cm COMPARISON: CT from ___. FINDINGS: Evaluation is limited secondary to patient motion. The patient is status post laminectomy and posterior fusion spanning from C3-C7. The surgical drain is seen along posterior aspect of the spinal canal, entering at C6, with the tip terminating at the level of C4 on the right. There are multilevel degenerative changes as noted before with endplate irregularity, disc height loss and posterior osteophytosis most notable at C5-C6. Evaluation of the central canal is limited due to technique and patient motion, though no definitive hematoma is seen. IMPRESSION: 1. Evaluation is limited secondary to motion. Status post laminectomy and posterior fusion spanning from C3-C7, with a surgical drain at the level of C6, with the tip terminating at the level of C4 and right. 2. The central canal is not well evaluated on CT and motion artifact limits evaluation, though no large hematoma is seen. Medications on Admission: Citalopram Fludrocortisone Pantoprazole Simvastatin Tramadol Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Citalopram 10 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Senna 17.2 mg PO HS 7. Simvastatin 40 mg PO QPM 8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 9. TraZODone 25 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: C5-6 osteophyte central stenosis 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: CTA HEAD AND CTA NECK INDICATION: ___ year old woman s/p C4-6Decompression/C3-7 Fusion on ___ here with imaging concerning for stroke. R/o vascular stenosis. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, rapid axial imaging was performed from the aortic arch through the brain during infusion of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated. This report is based on interpretation of all of these images. DOSE: DLP: 2628.43 mGy-cm; CTDI: 55.75 mGy COMPARISON: CT head from ___. FINDINGS: Streak artifact from the recent C3-7 spinal fusion hardware degrades image quality and limits evaluation. Head CT: There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The ventricles and sulci are normal in caliber with anatomical variation consistent with septum cavum pellucidum et vergae. No fractures are identified. There is a grossly unchanged air-fluid level in the left maxillary sinus, suggesting a chronic inflammatory process. Incidental note of right lung apical scarring is made (3:68), warranting clinical correlation with dedicated chest imaging if necessary. Patient is status post C3-C7 posterior spinal fusion, with no perihardware lucency to suggest loosening. Degenerative changes of the cervical spine are again noted. Periodontal disease/ periapical lucency of the left incisor is noted. Head CTA: There are no intracranial vascular abnormalities. There is no evidence of aneurysm, stenosis or occlusion. Atherosclerotic calcifications of the cavernous portions of the bilateral internal carotid arteries are identified. Neck CTA: The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. The right carotid artery measures 5.9 mm proximally and 4.0 mm distally. The left carotid artery measures 7.5 mm proximally and 4.4 mm distally. There is no evidence of internal carotid stenosis by NASCET criteria. IMPRESSION: 1. No evidence of vascular stenosis. 2. Status post C3-C7 posterior spinal fusion. Streak artifact from the hardware degrades image quality and limits evaluation. 3. Incidental note of right lung apical scarring is made, warranting clinical correlation and dedicated chest imaging, if clinically indicated. Radiology Report EXAMINATION: CERVICAL SINGLE VIEW IN OR INDICATION: C4-C7 fusion. TECHNIQUE: Screening provided operating room without a radiologist present. FINDINGS: Images demonstrate instrumentation of the cervical spine and posterior fusion. Fused levels appear to be C3 through C7. For details of the procedure, please consult the procedure report. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with developmental delay status post C3-7 decompression fusion now altered mental status and possibly aphasia and decreased right-sided movement. Please evaluate for bleed or intracranial process. 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: 1212 mGy-cm CTDI: 54 mGy COMPARISON: CT from ___. FINDINGS: Evaluation is limited secondary to patient motion. There is no evidence of acute hemorrhage, mass effect, edema or infarctions. The ventricles and sulci are stable in size and configuration. Cavum septum pellucidum et vergae is incidentally noted. No osseous abnormalities seen. There is left maxillary and bilateral ethmoid air cell mucosal thickening. The other paranasal sinuses, mastoid air cells and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Evaluation is limited secondary to patient motion. No definite evidence of acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ year old woman with developmental delay status post C3-7 decompression and fusion now with altered mental status and aphasia and decreased right sided movement. Please evaluate for cervical spine hematoma post-operatively. TECHNIQUE: Contiguous axial images were obtained of the cervical spine. Sagittal and coronal reformatted images were generated. No contrast was administered. CTDIvol: 669 mGy DLP: 32 mGy-cm COMPARISON: CT from ___. FINDINGS: Evaluation is limited secondary to patient motion. The patient is status post laminectomy and posterior fusion spanning from C3-C7. The surgical drain is seen along posterior aspect of the spinal canal, entering at C6, with the tip terminating at the level of C4 on the right. There are multilevel degenerative changes as noted before with endplate irregularity, disc height loss and posterior osteophytosis most notable at C5-C6. Evaluation of the central canal is limited due to technique and patient motion, though no definitive hematoma is seen. IMPRESSION: 1. Evaluation is limited secondary to motion. Status post laminectomy and posterior fusion spanning from C3-C7, with a surgical drain at the level of C6, with the tip terminating at the level of C4 and right. 2. The central canal is not well evaluated on CT and motion artifact limits evaluation, though no large hematoma is seen. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Transfer Diagnosed with ABNORMALITY OF GAIT, UNSPECIFIED FALL temperature: 97.8 heartrate: 86.0 resprate: 16.0 o2sat: 98.0 sbp: 150.0 dbp: 74.0 level of pain: 4 level of acuity: 3.0

Posterior cervical fusion You have undergone the following operation: Posterior Cervical Decompression and Fusion Immediately after the operation: • Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. • Rehabilitation/ Physical Therapy: ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. • Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. • Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain. . Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline x rays and answer any questions. We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: -Weight bearing as tolerated -Gait, balance training -No lifting >10 lbs -No significant bending/twisting Treatments Frequency: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Codeine / Darvocet-N 100 / Demerol / Maxalt / Vimpat / acetaminophen Attending: ___. Chief Complaint: Left thigh pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with history of anxiety, heroin abuse on methadone, reported seizure disorder, fibromyalgia and other comorbidities who presents with one month of posterior left thigh pain and swelling. It appears she initially presented to the ED, left AMA with Rx for oral antibiotics and then represented. Upon the second presentation, she agreed to bedside I&D, which was uncomplicated. She reported to the ED that she has had increasing pain, swelling of the posterior left thigh over the past month after she sustained a cut driving her boyfriend's car. At this point it had progressed to the point she had difficulty walking. She had similar abscesses on the right leg in the past that required incision and drainage under anesthesia. She reported relapsing on heroin 3 times in past two days to self-medicate her leg pain. Last use day prior to ED evaluation. Both times she overdosed and her boyfriend gave her narcan. Reports SI in the ED, but no plan. She reported she had a suicide attempt one month ago but did not elaborate. She was evaluated by psychiatry during one of her ED presentations, and was deemed to have capacity and able to leave AMA. Please see psychiatry note from ___. I n the ED, initial vitals were: ___ pain, temp 97 (remained afebrile), BP 131/65, RR 14, 100% on RA. Labs notable for: Imaging notable for: WBC 11.3 with normal differential. CRP 38.7. Normal BMP. Serum tox screen negative. Urine tox screen positive for benzos, opriates, cocaine, methadone. Patient was given: clonazepam 1mg, morphine 4mg IV, lorazepam 2mg, clonidine 0.1mg, morphine sulfate 2mg IV, and amp-sulbactam 3mg IV and underwent bedside I&D of the left lateral thigh. Vitals prior to transfer: 98.2, 91, 93/49, 16, 97% on RA On the floor, she was sleeping, oversedated and arouse to light physical contact and loud voice. She endorsed feeling "like crap" but could not be more specific. She denied headache, chest pain, abdominal pain, diarrhea. Was unable to give a reliable complete ROS. ROS: (+) Per HPI Limited by oversedation, see above. Past Medical History: - IVDU on methadone with recent relapse - seizure condition (since childhood) - history of abdominal pain, unclear etiology, resolved - choledocholithiasis - fibromyalgia - restless leg syndrome Social History: ___ Family History: Unable to obtain Physical Exam: ADMISSION PHYSICAL EXAM Vital Signs: 97.9, 107/68, 80, 18, 97% on RA General: Sleeping, snoring, no acute distress. Difficult to arouse. awakens to touch and voice. 3 word answers. Falls asleep after each sentence. No apneic events. HEENT: Sclera anicteric, pupils 4-5mm and reactive. MMM 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. Left lateral thigh with dressing from I&D C/D/I. Neuro: face symemetric. Moves all extremities. DISCHARGE PHYSICAL EXAM Vital Signs: Tm 98 Tc 98 BP 102-137/55-79 HR ___ RR 18 O2Sat 96RA General: Easily arousable, NAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi BACK: Tenderness to palpation of spinous processes and paraspinal muscles of lower back Abdomen: Soft, non-tender, non-distended, NABS, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. L lateral thigh w/gauze (not blood stained) Pertinent Results: ADMISSION LABS ------------------ ___ 02:20PM BLOOD WBC-11.3* RBC-4.30 Hgb-12.7 Hct-39.7 MCV-92 MCH-29.5 MCHC-32.0 RDW-13.4 RDWSD-45.1 Plt ___ ___ 02:20PM BLOOD Neuts-55.8 ___ Monos-5.3 Eos-2.4 Baso-0.3 Im ___ AbsNeut-6.32* AbsLymp-4.05* AbsMono-0.60 AbsEos-0.27 AbsBaso-0.03 ___ 02:20PM BLOOD Glucose-89 UreaN-7 Creat-0.9 Na-137 K-5.1 Cl-101 HCO3-25 AnGap-16 ___ 11:16AM BLOOD Calcium-9.1 Phos-2.4* Mg-2.0 ___ 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING --------- CT LEFT LOWER EXTREMITY (___): 0.7 x 2.4 by 1.9 cm subcutaneous collection in the left upper lateral thigh with internal hyperdense material and gas locules. Evaluation for abscess is limited given the lack of intravenous contrast. No evidence of extension into the fascia or muscles of the thigh. DISCHARGE/INTERVAL LABS ___ 10:40AM BLOOD WBC-10.4* RBC-3.88* Hgb-11.5 Hct-36.0 MCV-93 MCH-29.6 MCHC-31.9* RDW-13.9 RDWSD-46.7* Plt ___ ___ 10:40AM BLOOD Glucose-85 UreaN-4* Creat-0.8 Na-141 K-4.0 Cl-103 HCO3-29 AnGap-13 ___ 10:40AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. ClonazePAM 1 mg PO TID 3. CloNIDine 0.3 mg PO QID 4. Gabapentin 400 mg PO QID 5. Ibuprofen 800 mg PO Q8H 6. LamoTRIgine 100 mg PO DAILY 7. Pregabalin 450 mg PO QAM 8. Pregabalin 300 mg PO QPM 9. Prazosin 2 mg PO QHS 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY 11. Promethazine 50 mg PO QAM 12. Promethazine 50 mg PO QPM 13. Pramipexole 0.5 mg PO QHS Discharge Medications: 1. CloNIDine 0.3 mg PO TID 2. ClonazePAM 1 mg PO TID 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Gabapentin 400 mg PO QID 5. Ibuprofen 800 mg PO Q8H 6. LamoTRIgine 100 mg PO DAILY 7. Pramipexole 0.5 mg PO QHS 8. Prazosin 2 mg PO QHS 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY 10. Promethazine 50 mg PO QAM 11. Promethazine 50 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: Left lateral thigh abscess Secondary: IVDU on methadone, seizure condition (since childhood), abdominal pain of unclear etiology, choledocholithiasis, fibromyalgia, restless leg syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with L lateral and posterior thigh abscess s/p incision and drainage on ___ // infection? TECHNIQUE: Axial images of the left lower extremity from the pelvis through the distal femur were obtained without intravenous contrast. Sagittal and coronal reformats were obtained and reviewed. DOSE: Total exam DLP T: 1056.82 CTDIvol: 19.71 COMPARISON: None available FINDINGS: There is a 2.7 x 2.4 x 1.9 cm subcutaneous collection demonstrating internal gas locules and hyperdense material and communicates with the skin (series 3, image 27). There is associated skin thickening and subcutaneous fat stranding. Evaluation for an abscess is limited in the lack of intravenous contrast. The subcutaneous inflammatory changes do not extend to the muscular fascia. No abnormal muscle enhancement or muscular edema. IMPRESSION: 0.7 x 2.4 by 1.9 cm subcutaneous collection in the left upper lateral thigh with internal hyperdense material and gas locules. Evaluation for abscess is limited given the lack of intravenous contrast. No evidence of extension into the fascia or muscles of the thigh. Gender: F Race: WHITE Arrive by WALK IN WALK IN Chief complaint: L Leg swelling, L Leg pain Wound eval Diagnosed with Cellulitis of left lower limb Cellulitis of left lower limb, Suicidal ideations temperature: 97.0 98.5 heartrate: 76.0 63.0 resprate: 14.0 18.0 o2sat: 100.0 100.0 sbp: 131.0 120.0 dbp: 65.0 78.0 level of pain: 9 9 level of acuity: 3.0 3.0

Dear Ms. ___, You were admitted to ___ after an infected pocket of fluid found in your left thigh was drained. You were treated with some antibiotics and you were monitored to make sure that you did not develop any additional symptoms or new infections. It is important that you make every effort to schedule a follow-up appointment with your PCP (Dr. ___, ___ within ___ days. Please follow-up with your ___ clinic (Habit OPCO) after discharge to continue your Methadone taper. It was a pleasure taking care of you! We wish you the best! Your ___ team

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, "fluid in lungs" Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old homeless man currently residing in a shelter with PMH of schizophrenia, heart failure with reduced ejection fraction (EF 30%), CAD s/p CABG ___ with post-op course complicated by persistent inotrope dependence and new onset atrial fibrillation treated with amiodarone not on anticoagulation. The history is difficult to obtain as he refused to answer some questions, however he reports several months of ongoing dyspnea on exertion and "fluid in my lungs." He also reports palpitations during this time that make it unable for him to sleep. He denies frank chest discomfort. He has never lost consciousness. He sometimes has fluid in his legs, but he feels this is less prominent now. He reports catching a "bug" in his shelter that everyone had. He endorsed coughing up discolored sputum. In the ED initial vitals were: 98.7 81 117/83 36 92% Nasal Cannula EKG showed NSR with TWI in V1 and no ST changes. Troponins were <0.01 x2. BNP was 13304. WBC count was 12.9. CXR showed cardiomegaly, moderate pulmonary edema, moderate right and small left pleural effusions, and dense right basilar opacity may represent atelectasis or pneumonia. He was given Lasix 80mg IV. On the floor the patient continues to feel SOB and is worried about his palpitations. REVIEW OF SYSTEMS: Positive per HPI. Otherwise ROS negative. Past Medical History: Past Psychiatric History: Per Dr. ___ note ___ (per chart review): -Diagnoses: schizophrenia vs schizoaffective -Hospitalizations: At least 5 prior psychiatric hospitalizations, and a hospitalization "at ___ from ___ until ___ -Current treaters and treatment: No current treaters, last treater Dr. ___ known to ___ Healthcare for the homeless street team - ___ ___ -Medication and ECT trials: previously did well on Depakote 500mg BID and Abilify 15mg; also took zyprexa in the past -Self-injury: "previous SI with plan to jump off bridge in ___ -Harm to others: History of assault -Access to weapons: Unknown -Arrests: ___ seen at ___, pt in police custody, thought to be at potential harm towards others. Per ___ records h/o A&B charges -Convictions and jail terms: Unknown -Guardian: ___: ___ PMH: - ?PVD - ___ Bilateral IPH, Bilateral ___ S/P AUTO-PED - CAD - STEMI ___ - CHF (30%) Social History: Substance use history: -Alcohol: Extensive history with tendency toward violence when intoxicated (quantities unknown) -Tobacco: Unknown, but patient has in the hospital required nicotine patches -Illicits: Unknown . Personal and Social History: Collateral from ___ ___ for the Homeless, street outreach team (___) (Per Dr. ___ note ___: ___ knows Mr. ___ well and was actually looking for him today. Patient was supposed to be evicted today due to hoarding behaviors and ___ was able to obtain a shelter bed for him at ___. He had JRI support in his unit but it was not sufficient. He has a history of schizophrenia vs schizoaffective but she definitely thinks there's a mood component to his mental illness. He is often grandiose and delusional. He has been off meds for years and currently does not have a psychiatric provider. His last psychiatrist was Dr. ___ at ___ ___. Of note, Mr. ___ has been complaining of abdominal pain for some months but has not follow-up due to delusional thinking. ___ anticipates that Mr. ___ will be agitated upon extubation given his level of paranoia. She says she is available to come see him (on weekdays) if that would be helpful. Family History: Unknown; Patient does not recall family history. Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.5 95 / 62 87 22 94 3L Weight: refused General: disheveled, malodorous, shouting CV: refused JVP examination, tachycardic, regular rhythm, no murmurs PULM: crackles to mid lung fields, increased work of breathing, no wheezes ABD: soft, NT, ND EXT: trace ___ edema R>L, wwp, chronic venous stasis changes PSYCH: pressured speech, repeats phrases often, does not make eye contact DISCHARGE PHYSICAL EXAM Vitals: Refusing vitals ___. No requirement for O2 >95% RA. Weight: ___ kg I/Os: patient not saving General: disheveled, malodorous, shouting CV: refused JVP examination, rrr, no murmurs, rubs, or gallops PULM: Decreased breath sounds in lung bases bilaterally, crackles RLL base ABD: soft, NT, ND EXT: trace ___ edema R>L, wwp, chronic venous stasis changes PSYCH: pressured speech, repeats phrases often, does not make eye contact Pertinent Results: ADMISSION LABS ___ 07:25AM BLOOD WBC-12.9* RBC-4.51* Hgb-14.2 Hct-41.8 MCV-93 MCH-31.5 MCHC-34.0 RDW-17.6* RDWSD-58.8* Plt ___ ___ 07:25AM BLOOD Neuts-88.0* Lymphs-4.9* Monos-6.4 Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.38* AbsLymp-0.63* AbsMono-0.82* AbsEos-0.00* AbsBaso-0.02 ___ 07:25AM BLOOD Glucose-121* UreaN-15 Creat-0.8 Na-129* K-4.3 Cl-90* HCO3-22 AnGap-17 ___ 07:25AM BLOOD ___ ___ 07:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7 ___ 07:25AM BLOOD cTropnT-<0.01 ___ 02:25PM BLOOD cTropnT-<0.01 INTERVAL LABS ___ 03:15PM BLOOD ALT-12 AST-17 LD(LDH)-308* AlkPhos-109 TotBili-0.6 DISCHARGE LABS ___ 08:15AM BLOOD WBC-8.1 RBC-4.49* Hgb-13.7 Hct-41.5 MCV-92 MCH-30.5 MCHC-33.0 RDW-16.0* RDWSD-54.5* Plt ___ ___ 08:15AM BLOOD Glucose-94 UreaN-22* Creat-0.9 Na-137 K-4.5 Cl-97 HCO3-30 AnGap-10 ___ 08:15AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0 MICROBIOLOGY Blood culture (___): Negative Sputum Culture (___): contamination with upper respiratory secretions IMAGING: CT Chest WO Contrast (___): 1. Large, non hemorrhagic right and small left pleural effusions; no pleural mass or evidence of appreciable loculation. Mild pulmonary edema. 2. Right upper and middle lobe relaxation atelectasis. No bronchial obstruction. 3. Nonhemorrhagic fluid collection adjacent to the right heart could represent loculated paramediastinal pleural effusion or postoperative mediastinal seroma. Small anterior mediastinal postoperative seroma. 4. Reactive mediastinal lymph nodes. CXR (___): 1. Perihilar opacities and cardiomegaly suggest moderate pulmonary edema. 2. Moderate right and small left pleural effusions. 3. Dense right basilar opacity may represent atelectasis or pneumonia. 4. Cardiomegaly, with sternotomy wires. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 2. Amiodarone 200 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. ClonazePAM 0.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Furosemide 60 mg PO QAM 7. Furosemide 40 mg PO QPM 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea 9. PALIperidone Palmitate 234 mg IM Q1MO (MO) 10. Lisinopril 2.5 mg PO DAILY 11. Metoprolol Succinate XL 12.5 mg PO DAILY 12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 13. Aspirin 81 mg PO DAILY 14. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral DAILY 15. Magnesium Oxide 800 mg PO BID 16. Multivitamins 1 TAB PO DAILY 17. Polyethylene Glycol 17 g PO DAILY:PRN no BMs >24 hours Discharge Medications: 1. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. ClonazePAM 0.5 mg PO BID 8. FoLIC Acid 1 mg PO DAILY 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea 10. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral DAILY 11. Lisinopril 2.5 mg PO DAILY 12. Magnesium Oxide 800 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. PALIperidone Palmitate 234 mg IM Q1MO (MO) 15. Polyethylene Glycol 17 g PO DAILY:PRN no BMs >24 hours 16. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until seeing your cardiologist Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Acute on chronic heart failure with reduced ejection fraction Community Acquired Pneumonia Secondary diagnosis =================== Schizoaffective disorder, bipolar type Atrial fibrillation Coronary artery disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History: ___ with dyspnea, reports h/o heart failure// plz evaluate for evidence of fluid overload, infectious process TECHNIQUE: Chest AP COMPARISON: None FINDINGS: Right mid and lower lung opacity obscures the right heart border and hemidiaphragm. Granular left and right perihilar opacities may suggest pulmonary edema. Postoperative mediastinum with sternotomy wires numerous surgical clips demonstrates substantial cardiomegaly. Moderate right and small left pleural effusions. No pneumothorax. IMPRESSION: 1. Perihilar opacities and cardiomegaly suggest moderate pulmonary edema. 2. Moderate right and small left pleural effusions. 3. Dense right basilar opacity may represent atelectasis or pneumonia. 4. Cardiomegaly, with sternotomy wires. Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with history of HFrEF (EF30%), CAD s/p CABG, p/w subacute cough discolored sputum and SOB, admitted for acute on chronic CHF exacerbation also with CAP still with O2 requirement.// ?Evaluate RLL consolidation ?loculation ?fluid status TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent and reconstructed as contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 40.7 cm; CTDIvol = 10.6 mGy (Body) DLP = 429.1 mGy-cm. Total DLP (Body) = 429 mGy-cm. COMPARISON: None available. FINDINGS: NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal. Supraclavicular and axillary lymph nodes are not enlarged. MEDIASTINUM: Multiple mediastinal lymph nodes are measurable but not enlarged: For example, a subaortic measures 0.9 cm (series 2, image 20) and a pretracheal lymph node measures 0.8 cm (series 2, image 23). Nonhemorrhagic fluid collection alonside the right lower heart (series 302, image 195) is a loculated paramediastinal pleural effusion or postoperative mediastinal seroma. Another small postoperative seroma is also seen in the anterior mediastinum (series 302, image 109). HILA: Hilar lymph nodes are not enlarged. HEART: The heart is moderately enlarged. The patient is status post CABG with extensive coronary artery calcification. There is no pericardial effusion. VESSELS: Vascular configuration is conventional. Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. Atherosclerotic calcifications of thoracic aorta is moderate. PULMONARY PARENCHYMA: Consolidation in the anterior segment of the right upper lobe and medial segment of the right middle lobe is consistent with atelectasis. There is no bronchial obstruction. Bilateral septal thickening and ground-glass opacities are are due to mild pulmonary edema. No suspicious pulmonary nodules or mass. There is no emphysema. AIRWAYS: The airways are patent to the subsegmental level bilaterally. PLEURA: Bilateral non-hemorrhagic pleural effusions are large on the right and small on the left. CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion. Multilevel degenerative changes are mild. No acute fractures. Midline sternotomy wires are intact. UPPER ABDOMEN: Limited evaluation of the upper abdomen demonstrate vascular calcification, but otherwise unremarkable. IMPRESSION: 1. Large, non hemorrhagic right and small left pleural effusions; no pleural mass or evidence of appreciable loculation. Mild pulmonary edema. 2. Right upper and middle lobe relaxation atelectasis. No bronchial obstruction. 3. Nonhemorrhagic fluid collection adjacent to the right heart could represent loculated paramediastinal pleural effusion or postoperative mediastinal seroma. Small anterior mediastinal postoperative seroma. 4. Reactive mediastinal lymph nodes. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Heart failure, unspecified temperature: 98.7 heartrate: 81.0 resprate: 36.0 o2sat: 92.0 sbp: 117.0 dbp: 83.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, It was a pleasure taking care of you at ___. You came to the hospital because you had worsening cough and shortness of breath, admitted for a heart failure exacerbation and for treatment of pneumonia. What was done while I was in the hospital? - You were given antibiotics ceftriaxone and azithromycin to treat a pneumonia - You were given IV medications furosemide in order to remove extra fluid from your body because of your heart failure exacerbation What should I do when I go home? - Continue to take all of your medications as prescribed including torsemide 60mg PO QDaily - If your weight increases by more than 3 pounds, call your primary care doctor - Follow-up with your heart failure NP within 1 week - Follow-up with your primary care doctor within 1 week - Follow-up with all of your other scheduled appointments below It was a pleasure taking care of you. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: adhesive tape Attending: ___. Chief Complaint: Disc Herniation Major Surgical or Invasive Procedure: L5-S1 TILF History of Present Illness: Recent revision microdiscectomy with Dr. ___ on ___ 4 days of worsening pain, MRI with recurrent hernitation now s/p L5-S1 TLIF Past Medical History: disc herniation Social History: ___ Family History: ___ Physical Exam: 98.7 PO 103 / 65 L Lying 87 20 96 Ra NAD, A&Ox4 nl resp effort RRR Sensory: ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: ___ 05:20PM GLUCOSE-100 UREA N-18 CREAT-1.1 SODIUM-137 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-11 ___ 05:20PM estGFR-Using this ___ 05:20PM WBC-9.7 RBC-4.89 HGB-14.5 HCT-41.9 MCV-86 MCH-29.7 MCHC-34.6 RDW-12.1 RDWSD-37.8 ___ 05:20PM NEUTS-66.2 ___ MONOS-5.1 EOS-4.7 BASOS-0.5 IM ___ AbsNeut-6.42* AbsLymp-2.24 AbsMono-0.50 AbsEos-0.46 AbsBaso-0.05 ___ 05:20PM PLT COUNT-177 Medications on Admission: see omr Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 capsule(s) by mouth q___ prn Disp #*90 Capsule Refills:*0 2. Bisacodyl 10 mg PO/PR DAILY RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Diazepam 5 mg PO BID:PRN pain RX *diazepam 5 mg 1 tab by mouth BID PRN Disp #*60 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth q4-6h prn Disp #*60 Tablet Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Recurrent disc herniation Discharge Condition: stable Followup Instructions: ___ Radiology Report EXAMINATION: LUMBAR SINGLE VIEW IN OR INDICATION: POST. L5-S1 FUSION TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine. COMPARISON: X-rays ___ FINDINGS: 2 intraoperative images of the lumbar spine were obtained during L5-S1 fusion. On the first image markers are seen at the L5-S1 level. Instruments and orthopedic hardware is evident. Please refer to the operative report. IMPRESSION: Intraoperative images lumbar spine. Radiology Report EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT) INDICATION: ___ year old man with L5-S1 fusion// post op post op TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine. COMPARISON: Intraoperative images dated ___ FINDINGS: 5 non-rib-bearing lumbar vertebral bodies are present. The patient is status post posterior fusion of L5 and S1 as well as placement of an interbody spacer. A skin staples project over the subcutaneous tissues at midline. A drain is present. The alignment is maintained as are the vertebral body heights. There is no evidence of acute hardware related complications. A substantial amount of stool and gas project throughout the colon. IMPRESSION: Postoperative changes as described above. No acute hardware related complication is identified. Substantial stool burden. Radiology Report EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT) INDICATION: ___ year old man s/p L5/S1 TLIF, drain pulled out inadvertently// evaluation for retained drain evaluation for retained drain TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine. COMPARISON: ___ FINDINGS: The drain has been removed. There is no evidence of a retained drain within the subcutaneous tissues of the back. Skin staples are still present. The alignment of the lumbar spine is unchanged. There is no evidence of acute hardware related complications. Interval decrease in the amount of stool seen throughout the colon. IMPRESSION: No radiographic evidence of a retained portion of the drain. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Back pain, Wound eval Diagnosed with Low back pain temperature: 98.8 heartrate: 87.0 resprate: 18.0 o2sat: 98.0 sbp: 115.0 dbp: 94.0 level of pain: 5 level of acuity: 3.0

Lumbar decompression with fusion: You have undergone the following operation: Lumbar Decompression With Fusion Immediately after the operation: • Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. • Rehabilitation/ Physical Therapy: ___ ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. ___ Limit any kind of lifting. • Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. • Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. • Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: ___ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ___ At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. ___ We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: EMERGENCY Allergies: nafcillin / piperacillin Attending: ___. Chief Complaint: Dyspnea & Hypoxemia Major Surgical or Invasive Procedure: MULTIPLE BRONCHOSCOPY/BAL ___: PERCUTANEOUS PLACEMENT OF J TUBE: History of Present Illness: Mr. ___ is a ___ with PMHx of C4 quadriplegia secondary to a football accident ___ years ago, Hx of hyponatremia (Na 125-130 ___ ___, ?CAD per chart, multiple UTIs, and other issues who was transferred from an OSH after presenting with dypsnea. He describes URI sypmtoms starting 4 days ago which progressed to cough with dyspnea. He went to an urgent care center, where pt reports a CXR was negative for pneumonia. Nevertheless, he was started on azithromycin, possibly for bronchitis vs. URI (___). Despite this he required increasing frequency of albuterol nebulizers at home, and his father reports increasing cough with mucous production, requiring quad cough assistance. Last night, he developed respiratory distress and was brought by ambulance to an OSH. There, he was tachypneic and hypoxemic on NC but reportedly satting well on ventimask. He was found to have Na 101, K 2.8, Mg 1.0 and unilateral L whiteout noted on CXR. Other labs include TropI <0.015, lactate 1.4, WBC 5.9, Plt 170, Na+ 102 @ 05:10am, Ddimer 2.02 (elevated, RR 0.19-0.5 mg/L), Alb 2.6, AST 140, ALT 91, ALP 181, and CPK 643. He was given Zosyn and Azithromycin for pneumonia ___ a total volume of 350 cc's D5W), Duonebs, 3g Mg, and 40mEq K. He received a total of 450 cc's of normal saline at the OSH. UOP there was 4.1 L. Mental status was reportedly completely normal with no report of seizure, but he was started on 500 cc's of 3% saline at 20 cc's/hr through a PIV prior to transfer. On arrival to the ___ ED, he reported feeling fatigued and dyspneic without much change ___ his sypmtoms since his initial presentation. ___ the ED, intial VS were 97.5 71 118/86 22 96% 6L. Exam notable for mental status alert and oriented but sleepy, speaking ___ full sentences. He appeared euvolemic. He was tachypneic with ronchi throughout and some wheezing. His abdomen was quite distended; bedside US revealed a large bladder, so a foley catheter was placed. Labs were notable for Na 102, K 2.8, Cl 66, BUN/Cr ___, serum osms 207, urine Na 30, urine osms 208. CBC w/ normal WBCs but 21% bands. CXR showed a large L opacity with evidence of volume loss and no clear air bronchograms, suggestive of collapsed lung, with patchy alveolar infiltrates at the R base. EKG showed NSR @ 70 bpm, normal axis, no T wave changes, no ST segment changes. His hypertonic saline was stopped (unclear how much he received; reportedly bag was still mostly full). He received NS w/ 40 mEq K @ 150 cc's/hr and 40 mEq PO K, and was admitted to the ICU for hypoxemia and hyponatremia. VS prior to transfer were 96.8 65 156/99 26 89-91% NC. On arrival to the ICU, patient was sleepy but AOx3 and reported feeling anxious but with stable breathing. UOP was 400 cc's ___ the first hour, with an addittional 1.5L emptied ___ our ED. His parents report that his mental status has been slightly altered since ___. He has had minimal PO intake of food since then but has been drinking water, estimating his intake at ~20 oz per day. Past Medical History: -C4 quadriplegia ___ football accident ___ ___ (had a tracheostomy during that hospitalization, and reportedly also had DVT/PE requiring IVC filter placement, still be ___ place. Also had PNA during that hospitalizaiton; no pneumonias since. Does CIC BID for neurogenic bladder and digital stimulation for bowel movements). -Hx of multiple UTIs (does not have indwelling foley; uses clean intermittent catheter BID at home, usually emptying 1200-1500 cc's BID, and a condom cath at night) -Orthostatic hypotension (BP usually ___ -Hyponatremia (Na 125 ___ ___, per pt has been 120s-130s; PCP with no labs on record) -Hx of Dysphagia at the time of spinal cord injury -?CAD -Pernicious anemia Social History: ___ Family History: deferred Physical Exam: Admission Physical Exam: GENERAL: Alert but sleepy and with slowed speech. AOx3, ___ mild respiratory distress; belly breathing and speaking ___ short phrases. HEENT: Sclera anicteric, oropharynx clear, mucous membranes moistr NECK: Old tracheostomy scar present. No appreciable JVD. LUNGS: Absent breath sounds at L base, good air movement on the R. No wheezes anteriorly. Diffuse ronchi posteriorly. CV: Regular rate and rhythm, no murmurs/rubs/gallops ABDOMEN: soft, non-tender, non-distended, bowel sounds quiet, no rebound tenderness or guarding, no organomegaly GU: + Foley ___ place EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Paraparesis ___ bilat LEs and RUE, LUE with flexion contracture and some residual movement SKIN: warm, dry, no rashes or lesions DISCHARGE PHYSICAL: GENERAL: Alert and oriented x3. NAD HEENT:Sclera anicteric, oropharynx clear, mucous membranes moistr NECK: Trach site looks clean and ___ place LUNGS: Coarse breath sounds bilaterally CV: Regular rate and rhythm, no murmurs/rubs/gallops ABDOMEN: soft, non-tender, non-distended, bowel sounds quiet, no rebound tenderness or guarding, no organomegaly GU: + Foley ___ place EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Paraparesis ___ bilat LEs and RUE, LUE with flexion contracture and some residual movement SKIN: warm, dry, no rashes or lesions Pertinent Results: Admission Labs: ================================================ ___ 09:01PM GLUCOSE-104* UREA N-7 CREAT-0.4* SODIUM-107* POTASSIUM-4.2 CHLORIDE-75* TOTAL CO2-26 ANION GAP-10 ___ 09:01PM CALCIUM-7.4* PHOSPHATE-1.1* MAGNESIUM-1.9 ___ 09:01PM OSMOLAL-223* ___ 04:42PM GLUCOSE-83 UREA N-7 CREAT-0.3* SODIUM-103* POTASSIUM-3.6 CHLORIDE-72* TOTAL CO2-24 ANION GAP-11 ___ 04:42PM CALCIUM-7.3* PHOSPHATE-1.3* MAGNESIUM-2.0 ___ 04:42PM OSMOLAL-215* ___ 11:42AM GLUCOSE-101* UREA N-6 CREAT-0.3* SODIUM-102* POTASSIUM-3.6 CHLORIDE-67* TOTAL CO2-27 ANION GAP-12 ___ 11:42AM CALCIUM-7.5* PHOSPHATE-1.6* MAGNESIUM-1.6 ___ 11:42AM OSMOLAL-205* ___ 08:57AM ___ COMMENTS-GREEN TOP ___ 08:57AM GLUCOSE-127* LACTATE-2.2* NA+-102* K+-2.8* CL--66* TCO2-27 ___ 08:57AM HGB-11.3* calcHCT-34 ___ 08:55AM URINE HOURS-RANDOM CREAT-16 SODIUM-30 POTASSIUM-26 CHLORIDE-34 CALCIUM-4.3 URIC ACID-18.6 ___ 08:55AM URINE OSMOLAL-208 ___ 08:55AM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 08:55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR ___ 08:55AM URINE RBC-1 WBC-4 BACTERIA-MANY YEAST-NONE EPI-<1 ___ 08:55AM URINE AMORPH-FEW ___ 08:55AM URINE MUCOUS-OCC ___ 08:50AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 08:30AM GLUCOSE-130* UREA N-5* CREAT-0.4* SODIUM-101* POTASSIUM-3.2* CHLORIDE-64* TOTAL CO2-23 ANION GAP-17 ___ 08:30AM estGFR-Using this ___ 08:30AM ALT(SGPT)-105* AST(SGOT)-161* ALK PHOS-168* TOT BILI-0.7 ___ 08:30AM proBNP-1026* ___ 08:30AM ALBUMIN-3.4* CALCIUM-8.0* PHOSPHATE-1.7* MAGNESIUM-1.8 URIC ACID-1.9* ___ 08:30AM WBC-6.3 RBC-3.78* HGB-11.2* HCT-29.8* MCV-79* MCH-29.6 MCHC-37.4* RDW-15.0 ___ 08:30AM NEUTS-72* BANDS-21* LYMPHS-2* MONOS-3 EOS-0 BASOS-0 ATYPS-2* ___ MYELOS-0 ___ 08:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-1+ ___ 08:30AM PLT SMR-NORMAL PLT COUNT-152 ___ 08:30AM ___ PTT-30.2 ___ MICROBIOLOGY: ================================================ SPUTUM ___ 6:00 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. RESPIRATORY CULTURE (Final ___: RARE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 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. SENSITIVIES CONFIRMED BY REPEAT ___. CEFOXITIN sensitivity testing confirmed by ___. YEAST.SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S RESPIRATORY CULTURE (Final ___: ~5000/ML Commensal Respiratory Flora. STAPH AUREUS COAG +. ~8OOO/ML. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S ___ 9:11 pm SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ON ___. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S 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 ___ 11:58 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final ___: Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. Commensal Respiratory Flora Absent. ___. ___ (___) REQUESTED FOR THE GRAM NEGATIVE RODS WORK UP ON ___. YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. RARE GROWTH ___ MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S 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 PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ___ 1:45 pm SPUTUM Source: Expectorated. **FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S 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 ___ 10:06 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. ___ MORPHOLOGY. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 4 S <=2 S CEFAZOLIN------------- <=4 S <=4 S 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 PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S BRONCHOALVEOLAR LAVAGE BAL ___ 3:13 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: OSITIVE FOR RESPIRATORY VIRUSES. Reported to and read back by ___. ___ ___ 10:30AM ___. ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. Sputum ___ 9:11 pm SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___ PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ON ___. SENSITIVITIES: MIC expressed ___ MCG/MG ______________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S 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 ___ 5:08 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. ___ 5:53 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. **FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. ___. ___ 5:00 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. RESPIRATORY CULTURE (Final ___: >100,000 ORGANISMS/ML. Commensal Respiratory Flora. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM NEGATIVE ROD #2. ~1000/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens ___ amounts >=10,000 cfu/ml. YEAST. ~3000/ML. Isolates are considered potential pathogens ___ amounts >=10,000 cfu/ml. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S 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 ___ 2:46 pm BRONCHOALVEOLAR LAVAGE LINGULA BAL. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): ___ Commensal Respiratory Flora. Further workup requested by ___ ___ (___) ___. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. GRAM NEGATIVE ROD #2. ~3000/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens ___ amounts >=10,000 cfu/ml. YEAST. ___. Isolates are considered potential pathogens ___ amounts >=10,000 cfu/ml. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): MICROBIOLOGY SEROLOGIES ___ CMV BLOOD IgG/IgM Ab negative ___ EBV BLOOD IgG Ab positive, IgM Ab negative ___ 12:21 pm CATHETER TIP-IV Source: ___. **FINAL REPORT ___ WOUND CULTURE (Final ___: No significant growth. BLOOD CX NEGATIVE (DATED ___ X 2, ___ 2, ___, ___ X 2, ___ X 2, ___ X2) ___ BLOOD CX PENDING URINE CX NEGATIVE/CONTAMINATED (DATED ___, ___ 2:41 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. ___ LEGIONALLA URINARY ANTIGEN NEGATIVE ___ C DIFF STOOL ANTIGEN NEGATIVE ___ C DIFF STOOL ANTIGEN NEGATIVE RAPID RESPIRATORY VIRAL SCREEN & CULTURE ___ 3:13 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: POSITIVE FOR RESPIRATORY VIRUSES. Reported to and read back by ___. ___ 10:30AM ___. ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. Reported to and read back by ___ ___ 2:26PM. Respiratory Viral Antigen Screen (Final ___: Less than 60 columnar epithelial cells;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Negative results should not be used to discontinue precautions.. Recommend new sample be submitted for confirmation.. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Reported to and read back by ___ (4I) ___ ___ 5:08 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. Respiratory Viral Antigen Screen (Final ___: Greater than 400 polymorphonuclear leukocytes;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Negative results should not be used to discontinue precautions.. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. ___ 2:43 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. IMAGING ================================================ CXR (___): Extensive left lung opacification concerning for pneumonia. Right lower lung reticular opacities may reflect aspiration or pneumonia. Probable moderate left pleural effusion. Recommend followup to resolution. CXR (___): Generalized improvement ___ background lung density concurrent with mild decrease ___ heart size suggests improvement ___ the component of pulmonary edema, but considerable abnormality remains, particular bibasilar consolidation due to infection or hemorrhage. Left pleural effusion is probably moderate ___ size, unchanged. There is no pneumothorax. ET tube is ___ standard placement, transesophageal drainage tube passes into the stomach and out of view. Left PIC line ends ___ the mid SVC. CXR (___): ___ comparison with the study of ___, there is little overall change. Monitoring and support devices remain ___ place. Bibasilar at areas of opacification are again seen. On the left, poor definition of the hemidiaphragms suggests substantial volume loss ___ the left lower lobe. Again, however, ___ the appropriate clinical setting it would be difficult to definitely exclude superimposed pneumonia. The contrast material ___ the the esophagus is not definitely appreciated on this study. CT ABD/PELVIS (___): IMPRESSION: 1. Normal appearing liver. 2. Small, focal dissection ___ the abdominal aorta, extending from below the right renal artery to the right common iliac artery. No evidence of end organ ischemia. 3. Thickened bladder. While this may represent a neurogenic bladder, correlation with urinalysis is recommended to exclude acute on chronic cystitis. 4. Trace amount of ascites, non drainable. 5. Findings ___ the chest reported separately. CT CHEST W/CONTRAST (___): IMPRESSION: 1. Bilateral pulmonary opacities, some of which are consolidative, some of which are ground-glass, and some of which are ___, are ___ keeping with the history of a Staph pneumonia. The different opacities likely represent the infectious process at different levels of maturity. Of note, one opacity at the right apex has a small central cavitation. 2. Mediastinal and left hilar lymphadenopathy. This is likely reactive, though a repeat chest CT is recommended after treatment to ensure resolution of both the opacities and this lymphadenopathy. CTA TORSO (___): -Unchanged appearance of focal dissection extending from below the right renal artery to the right common iliac arterial ostium. -More confluent solid/ground-glass opacification of the right middle and lower lobes compared to prior study. Numerous solid/ground-glass pulmonary nodules are again demonstrated within the visualized lungs, consistent with history of pneumonia. New moderate left subpulmonic effusion. -Mediastinal adenopathy, likely reactive. -Marked bladder wall thickening, possibly representing cystitis. Mild prominence of retroperitoneal nodes, possibly reactive. - Other findings as detailed above. CTA CHEST (___): 1. No evidence of pulmonary embolism to the segmental level. Evaluation of the subsegmental pulmonary arteries is limited by respiratory motion. 2. Interval improvement ___ multifocal pneumonia with persistent left lower lobe consolidation. 3. Unchanged cavitary nodule ___ the right lung apex. 4. Stable mediastinal lymphadenopathy, likely reactive. 5. ET tube with secretions above the cuff. ECHO ___: The left atrium is normal ___ size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. ___: RUE U/S No evidence of deep vein thrombosis ___ the right upper extremity. ___: VIDEO OROPHARYNGEAL SWALLOW: Aspiration of thin, nectar, and honey thick liquids. ___: PERCUTANEOUS PLACEMENT OF J TUBE: Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip ___ the proximal jejunum. The gastric port should not be used for 24 hours. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Midodrine 10 mg PO TID 2. Azithromycin 250 mg PO Q24H 3. methenamine hippurate 1 gram oral BID bladder spasm 4. Pseudoephedrine 30 mg PO Q6H:PRN hypotension Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days Stop date ___ 2. Senna 8.6 mg PO BID:PRN Constipation 3. Sarna Lotion 1 Appl TP QID:PRN rash/itching 4. Polyethylene Glycol 17 g PO DAILY 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 6. Midodrine 10 mg PO TID 7. Midodrine 12.5 mg PO QHS 8. Acetylcysteine 20% ___ mL NEB Q6H:PRN To be used with albuterol or to help with secretions 9. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB to be given for break through shortness of breath if needed 10. Albuterol Inhaler ___ PUFF IH Q4H 11. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 12. Atropine Sulfate 0.5-1 mg IV ONCE:PRN bradycardia 13. Bisacodyl 10 mg PO/PR DAILY Constipation 14. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN discomfort from ET tube 15. ClonazePAM 1 mg PO TID:PRN anxiety, insomnia 16. Dextromethorphan-Guaifenesin (Sugar Free) 10 mL PO Q6H:PRN cough 17. Docusate Sodium (Liquid) 100 mg PO BID 18. Famotidine 20 mg PO Q12H 19. Glycopyrrolate 1 mg PO BID 20. Miconazole Powder 2% 1 Appl TP QID:PRN rash on buttocks 21. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 22. OLANZapine 5 mg PO QHS:PRN insomnia 23. Methenamine Hippurate 1 gram ORAL BID bladder spasm 24. Pseudoephedrine 30 mg PO Q6H:PRN hypotension Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Trach/Peg placement Respiratory distress Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report EXAMINATION: AP chest x-ray. INDICATION: A ___ man with a cough, hypoxic, outside hospital transfer with report of white out, evaluate for pneumonia or pleural effusion. TECHNIQUE: AP chest radiographs. COMPARISON: Outside hospital chest radiograph ___ at 04:20. FINDINGS: There is significant leftward rotation of the patient on current radiograph. Allowing for changes due to this, the cardiomediastinal silhouette is unchanged from same-day outside hospital chest radiograph. Extensive left lung opacification limits full evaluation of the cardiac silhouette, which appears normal. There is no evidence of pulmonary vascular congestion or pulmonary edema. Extensive consolidation with air bronchograms involving the majority of the left lung is concerning for pneumonia. More ill-defined reticular opacities within the right lower lung may reflect sequela of aspiration or pneumonia. Underlying emphysema is suspected. There is no right pleural effusion. There is likely at least a moderate left pleural effusion. There is no pneumothorax. IMPRESSION: Extensive left lung opacification concerning for pneumonia. Right lower lung reticular opacities may reflect aspiration or pneumonia. Probable moderate left pleural effusion. Recommend followup to resolution. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with L new PICC // Evaluate L new PICC 46cm ___ ___ Contact name: ___: ___ Evaluate L new PICC 46cm ___ ___ IMPRESSION: In comparison with the earlier study of this date, there has been placement of a left subclavian PICC line that extends to the mid to lower portion of the SVC. Little change in the appearance of the heart and lungs. NOTIFICATION: ___, a venous access nurse. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with LLL PNA - intubated // eval for ETT placement eval for ETT placement IMPRESSION: In comparison with the earlier study of this day, there has been placement of an endotracheal tube with its tip approximately 5 cm above the carina. Nasogastric tube is in the stomach, though the side hole is probably just proximal to the esophagogastric junction. Otherwise little change. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: interval changes TECHNIQUE: Semi upright portable AP radiograph of the chest was obtained. COMPARISON: Frontal chest radiograph ___. FINDINGS: There is an endotracheal tube with tip terminating approximately 5.7 cm cephalad to the carinal. There is nasogastric tube with tip terminating below the diaphragm. There is a left PICC with tip terminating in the lower superior vena cava. There is improved aeration of the left hemi thorax with decrease in size of left layering pleural effusion. There is marked increase aeration of the left upper lung. There is irregularity and enlargement of the left hilum the right hilum and right lung are unremarkable. There is no evidence of pneumothorax. Cardiomediastinal silhouette and pulmonary vasculature are within normal limits. IMPRESSION: 1. Improved aeration of the left lung with decrease in size of the layering left pleural effusion. 2. Enlargement and irregularity of the left hilum. CT scan is recommended for further evaluation. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ in person on ___ at 9:00 AM, at the time of discovery. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with hypoxemia s/p bronch broad antibiotics persistent fevers. // fevers? fevers? TECHNIQUE: Portable AP frontal chest radiograph was obtained. COMPARISON: Frontal chest radiograph ___. FINDINGS: Endotracheal tube tip projects 6.9 cm cephalad to the carina. Left PICC tip projects over the low superior vena cava. Nasogastric tip projects below the diaphragm, however the side hole projects at the level of the gastroesophageal junction. Layering left pleural effusion is unchanged. Left mid and upper lung opacities have increased. Diffuse interstitial markings throughout the remaining lungs are unchanged. Heart size is not enlarged. Mediastinal silhouette is not widened. IMPRESSION: Increased opacification of the left upper and left mid lung may be secondary to pulmonary edema or developing pneumonia. Radiology Report INDICATION: Quadriplegia, Staph pneumonia and new transaminitis. Evaluate left-sided pleural effusion as well as liver given transaminitis. TECHNIQUE: MDCT axial images were acquired through the torso after the uneventful administration of 130 ml of Omnipaque. Coronal and sagittal reformations were provided and reviewed. Oral contrast was administered. Findings in the chest are reported separately. DOSE: DLP: 1304.50 mGy-cm COMPARISON: None. FINDINGS: Findings in the chest, including the left lower lobe consolidation and pleural effusion, are reported separately. Abdomen: Study is limited by bowel motion artifact in the anterior abdomen. The liver enhances homogeneously without focal lesions. There is a small amount of fluid within the gallbladder fossa in the setting of trace abdominal ascites, otherwise, the gallbladder is normal. There is no intra or extrahepatic biliary ductal dilation. The spleen, pancreas and adrenal glands are unremarkable. The kidneys enhance symmetrically and excrete contrast without hydronephrosis. Bilateral renal hypodensities are too small to characterize but are presumably simple cysts. An enteric tube courses into the fundus of the stomach. Evaluation of the bowel is again limited by motion artifact. There is no bowel wall thickening or obstruction. There is no free air. There is no retroperitoneal or mesenteric lymphadenopathy. The portal vein, splenic vein and superior mesenteric vein are patent. An infrarenal IVC filter is noted. The aorta is normal caliber. There is a small focal dissection of the aorta, extending from the level of the right renal artery to the right iliac vein. There are no findings to suggest end organ ischemia and all major arterial branches are patent. Pelvis: The bladder is thickened and a Foley catheter is in place. The rectum is unremarkable. There is a small amount of free pelvic fluid. There is no inguinal or pelvic sidewall lymphadenopathy. Bones and soft tissues: The bones are diffusely demineralized, consistent with disuse. There is an 8 mm sclerotic lesion in the left iliac wing, which is likely a bone island in the absence of an oncologic history. Severe degenerative changes of both hips are noted with near bone-on-bone articulation. IMPRESSION: 1. Normal appearing liver. 2. Small, focal dissection in the abdominal aorta, extending from below the right renal artery to the right common iliac artery. No evidence of end organ ischemia. 3. Thickened bladder. While this may represent a neurogenic bladder, correlation with urinalysis is recommended to exclude acute on chronic cystitis. 4. Trace amount of ascites, non drainable. 5. Findings in the chest reported separately. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ telephone on ___ at 5:25 ___, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: Quadriplegic, known Staph pneumonia, and new transaminitis. Evaluate pneumonia and pleural effusions. TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent and reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: Please see the abdominal CT report for the total DLP value. COMPARISON: Multiple chest radiographs, dating to ___. FINDINGS: The thyroid gland is enlarged. No discrete nodules identified. An irregularity in the skin along the anterior neck may be from a prior tracheostomy. There is no discrete fluid collection or stranding in the subcutaneous tissues. There is no axillary lymphadenopathy. There are numerous enlarged mediastinal lymph nodes measuring up to 15 mm. Additionally, there is one enlarged left hilar lymph node measuring 13 mm (2, 28). There is no right hilar lymphadenopathy. The heart is normal in size. There is no pericardial effusion. The thoracic aorta is normal in caliber without significant atherosclerotic calcifications. The main pulmonary arteries are enlarged for patient of this age, suggesting pulmonary hypertension. An endotracheal tube is in satisfactory position within the mid trachea. The mainstem bronchi are patent. Mucus plugging and bronchial wall thickening is noted throughout the segmental and subsegmental bronchi, likely related to the underlying infection. Motion significantly limits evaluation of the bases. Within the limitations, there is a dense low attenuation consolidation filling the majority of the left lower lobe with some associated volume loss. There are air bronchograms. This is most consistent with a pneumonia. Additionally, there are other opacities throughout all lobes of the long. For example, in the right upper lobe there is a rounded opacity with a small central cavitation (4, 43). Additionally there are ___ and ground-glass opacities with associated significant bronchial wall thickening. In the right middle and lower lobes, there are similar ___ opacities and macronodular opacities. In the left upper lobe there are innumerable nodular opacities which are coalescing into a larger opacity. All these opacities are in keeping with a history of staph pneumonia, and likely represent the infection at different stages of maturity. There is a small left pleural effusion. No right pleural effusion is identified. There is no pneumothorax. There are no concerning lytic or sclerotic osseous lesions. A few mild compression deformities and moderate degenerative changes in the upper thoracic spine are likely chronic. Incidentally noted is osseous bridging between a few anterior left ribs (8, 69 and 67) which may be posttraumatic Please see the abdominal CT report for complete subdiaphragmatic details. IMPRESSION: 1. Bilateral pulmonary opacities, some of which are consolidative, some of which are ground-glass, and some of which are ___, are in keeping with the history of a Staph pneumonia. The different opacities likely represent the infectious process at different levels of maturity. Of note, one opacity at the right apex has a small central cavitation. 2. Mediastinal and left hilar lymphadenopathy. This is likely reactive, though a repeat chest CT is recommended after treatment to ensure resolution of both the opacities and this lymphadenopathy. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man intubated with pneumonia // Interval change? IMPRESSION: As compared to ___ radiograph, diffuse am, heterogeneous bilateral pulmonary opacities are mostly similar except for worsening in the right lower lung. Poorly defined nodular opacities are present with apparent cavitation. Findings are consistent with multifocal infection. In the setting of cavitation, septic emboli and granulomatous infection should be considered. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with mrsa pneumonia, recently extubaed, now with increased work of breathing, tachypnea, concern for pulmonary edeama // pulm edema, other cause for tachypnea pulm edema, other cause for tachypnea IMPRESSION: In comparison with the and nasogastric tubes have study of ___, the endotracheal been removed. Diffuse bilateral pulmonary opacifications are essentially unchanged. The poorly defined nodular opacities with apparent cavitation suggests the possibility of septic emboli or a granulomatous infection. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with quadrapelegia, now s/p cardiac arrest with brief cpr, and reintubated // og tube position, ETT position, any trauma from cpr Contact name: ___: ___ og tube position, ETT position, any trauma from cpr IMPRESSION: In comparison with the earlier study of this date, there is an placement of an endotracheal tube with its tip approximately 4.5 cm above the carina. Nasogastric tube extends at least to the upper stomach, though the side port appears to be above the esophagogastric junction. Diffuse bilateral pulmonary opacifications persist. Radiology Report EXAMINATION: CR -ABDOMEN (SUPINE ONLY) INDICATION: ___ year old man with quadriplegia, on fentanyl for sedation, without bowel movements for days. Please assess for stool burden. TECHNIQUE: Single supine radiograph of the abdomen. COMPARISON: CT abdomen pelvis from ___. FINDINGS: Air is present in nondilated loops of small and large bowel. No evidence of obstruction. Moderate fecal loading is present in the left colon. An NG tube and its side-hole pass just below the diaphragm. IVC filter is present just to the right of the L3-L4 interspace. IMPRESSION: Moderate fecal loading without evidence of obstruction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man without appropriate increase in hemoglobin after transfusion, concern for TRALI // Please evaluate for change since this morning's xray Please evaluate for change since this morning's xray COMPARISON: Chest radiographs ___ through ___ at 11:57 a.m. IMPRESSION: Generalized improvement in background lung density concurrent with mild decrease in heart size suggests improvement in the component of pulmonary edema, but considerable abnormality remains, particular bibasilar consolidation due to infection or hemorrhage. Left pleural effusion is probably moderate in size, unchanged. There is no pneumothorax. ET tube is in standard placement, transesophageal drainage tube passes into the stomach and out of view. Left PIC line ends in the mid SVC. Radiology Report EXAMINATION: CTA TORSO INDICATION: ___ year old man with continued fevers, anemia, and recent cardiac arrest. CT scan on ___ with focal dissection in the abdominal aorta, extending from below the right renal artery to the right common iliac artery. // Evaluate prior dissection, assess for extension or worsening TECHNIQUE: Spiral aquisition was performed during single phase after administration of IV contrast. Multiplanar reformats were created. DOSE: 562 mGy*cm COMPARISON: CT ___ FINDINGS: Study is limited by patient motion artifact. No significant atherosclerosis of normal caliber thoracic aorta. Widely patent great vessel ostia. No thoracic aortic dissection. Again demonstrated is a focal right lateral dissection of normal caliber abdominal aorta extending from just caudal to the right renal artery to the right common iliac artery ostium, unchanged from prior. No pseudoaneurysm formation. Aortic branches are widely patent. Normal appearance of the iliac arteries. Enteric tube likely terminates within the gastric body allowing for motion artifact. A moderate left subpulmonic effusion is demonstrated, new since prior. Atelectasis of the left more than right lung bases. Images of the included chest demonstrate scattered nodular of the solid and ground-glass opacities, many centrilobular in distribution. Multiple more confluent opacities now involve the right middle and lower lobes compared to prior study. No pneumothorax. Small amount of secretions within the esophagus. Left PICC terminates in the cephalad SVC. No pericardial effusion. Mediastinal adenopathy is again noted, largest 1.1 cm right peritracheal. Motion compromised images of the liver, gallbladder, spleen and adrenals are unremarkable. Pancreas is grossly unremarkable. No biliary dilatation. Malrotated right kidney. No hydronephrosis. Subcentimeter hypodensities are noted, similar to prior, too small to characterize, likely cysts. Decompressed stomach. Contrast within the rectum and distal colon. No small bowel dilatation. Infrarenal IVC filter. Mild generalized stranding of the abdominal mesenteries noted, possibly artifactual, nonspecific finding. Mild prominence of retroperitoneal nodes, largest 1.2 cm. Foley catheter within markedly thick-walled bladder. Trace free pelvic fluid. Marked bony demineralization with degenerative changes of bilateral hip joints. Degenerative changes of the posterior elements of the spine. Re- demonstrated sclerotic focus within the left iliac bone, probable bone island. IMPRESSION: -Unchanged appearance of focal dissection extending from below the right renal artery to the right common iliac arterial ostium. -More confluent solid/ground-glass opacification of the right middle and lower lobes compared to prior study. Numerous solid/ground-glass pulmonary nodules are again demonstrated within the visualized lungs, consistent with history of pneumonia. New moderate left subpulmonic effusion. -Mediastinal adenopathy, likely reactive. -Marked bladder wall thickening, possibly representing cystitis. Mild prominence of retroperitoneal nodes, possibly reactive. - Other findings as detailed above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ETT, Staph PNA // ETT positioning, interval change consolidations ETT positioning, interval change consolidations COMPARISON: Chest radiographs ___ through ___. IMPRESSION: Severe multi focal pneumonia has not improved. Small to moderate left pleural effusion is stable. Heart size is normal. ET tube and left PIC line are in standard placements. Nasogastric tube ends in the upper stomach the would need to be advanced 8 cm to move all the side ports beyond the GE junction. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with pneumonia, intubated // Any interval change in pna? TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Bilateral diffuse consolidations / multifocal pneumonia, larger in the left lower hemi thorax have worsened. ET tube is in standard position. Right PICC tip is in the mid to lower SVC. NG tube tip is in the stomach but the side port is probably at the EG junction and could be advanced for more standard position. There is no evident pneumothorax. Small left effusion is unchanged. Patient has known mediastinal lymphadenopathy. Cardiac size is normal Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new picc // 41cm right picc. ___ iv ___ Contact name: ___: ___ right picc. ___ iv ___ IMPRESSION: IN COMPARISON WITH THE STUDY OF ___, THE LEFT PICC LINE HAS BEEN REMOVED AND REPLACED WITH A A RIGHT PICC LINE THAT EXTENDS TO THE MID PORTION OF THE SVC. THE OPACIFICATION AT THE BASES HAS DECREASED ESPECIALLY ON THE RIGHT. . Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ETT, PNA // ETT position, interval change in consolidations ETT position, interval change in consolidations IMPRESSION: In comparison with the study of ___, there has been some decrease in the diffuse bilateral opacification is, clinically consistent with pneumonia. Some degree of .vascular congestion could well be present. Little change in the monitoring and support devices Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ETT increased O2 requirement // interval change in consolidations TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: ET tube tip is 5.4 cm above the carinal. NG tube tip is in the stomach. Cardiomediastinal silhouette is stable. Widespread parenchymal opacities are demonstrated. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ETT new fever // PNA progression PNA progression TECHNIQUE: Portable semi erect frontal chest radiograph. COMPARISON: Frontal chest radiograph ___. Chest CT ___. FINDINGS: Endotracheal tube tip terminates 4.6 cm cephalad to the carinal. Nasogastric tube extends below the diaphragm, however the side port projects at the level of the gastroesophageal junction. Right PICC tip terminates in the low superior vena cava. Medial left lower lobe consolidation with air bronchograms is unchanged likely representing atelectasis. Patchy right basilar airspace opacities are unchanged. Mild pulmonary vasculature encroachment is unchanged. IMPRESSION: 1. Persistent left lower lobe atelectasis. 2. Orogastric tube with side hole projecting at the gastroesophageal junction. Recommend advancement 5 cm. 3. Unchanged mild pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ETT, PNA // tube position COMPARISON: ___. IMPRESSION: As compared to the previous radiograph, no relevant change is seen. Signs of overinflation an additional multifocal parenchymal opacities, likely reflecting a combination of scarring and active infection. Predominant foci of these changes are seen at the right lung bases, the right mid lung and the left lung bases. Normal size of the cardiac silhouette. No pulmonary edema. The position of the endotracheal tube and the nasogastric tube are unchanged. The nasogastric tube could be advanced by approximately 5 cm. Radiology Report EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY INDICATION: ___ year old man with tachycardia, fever, hypotension, known pneumonia // PE, abscess formation from MRSA/Klebsiella PNA TECHNIQUE: MDCT axial images were acquired through the chest following intravenous administration of 100cc of Omnipaque scanning in the early arterial phase. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 255 mGy-cm. COMPARISON: CTA torso dated ___ and CT chest from ___ FINDINGS: Although this study is not designed for assessment of intra-abdominal structures, the visualized upper abdomen is unremarkable. CHEST: The thyroid is unremarkable and there is no supraclavicular lymph node enlargement. An ET tube is in appropriate position. Secretions are noted in the trachea above the ET tube cuff. There is stable mediastinal and hilar lymphadenopathy. The heart, pericardium and great vessels are within normal limits. No hiatal hernia is present. An enteric tube is seen with the tip in the stomach Evaluation of the pulmonary parenchyma is limited by respiratory motion. Diffuse bilateral ___ and ground-glass nodules have somewhat improved compared to the prior study. A cavitated 13 x 21 mm nodule in the right lung apex is unchanged. Consolidation of the right lower lobe are also unchanged. The previous seen left pleural effusion has decreased in size, now small. CTA CHEST: The aorta and main thoracic vessels are well opacified. The aorta demonstrates normal caliber throughout thorax without intramural hematoma or dissection. The pulmonary arteries are opacified to the segmental level. Evaluation of the subsegmental pulmonary arteries is limited by respiratory motion. There is no filling defect in the main, right, left, or lobar pulmonary arteries. OSSEOUS STRUCTURES: No lytic or sclerotic lesion concerning for malignancy is present. Increased sclerosis of the right fourth and eighth ribs posteriorly may be related to prior trauma. IMPRESSION: 1. No evidence of pulmonary embolism to the segmental level. Evaluation of the subsegmental pulmonary arteries is limited by respiratory motion. 2. Interval improvement in multifocal pneumonia with persistent left lower lobe consolidation. 3. Unchanged cavitary nodule in the right lung apex. 4. Stable mediastinal lymphadenopathy, likely reactive. 5. ET tube with secretions above the cuff. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3:22 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ year old man with new RUE swelling new, PICC right side // DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. The right internal jugular and axillary veins are patent and compressible with transducer pressure. The right brachial, basilic, and cephalic veins are patent, compressible with transducer pressure and show normal color flow and augmentation. The patient's basilic PICC is visualized. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with quadriplegia chronic respiratory failure now intubated // interval change interval change IMPRESSION: In comparison with the study of ___, the monitoring and support devices are unchanged. Again there is hyperinflation with multifocal areas of opacification, especially at the bases, consistent with some combination of scarring and active infection. There may be some decrease in the basilar opacifications. Cardiac silhouette remains within normal limits and there is no evidence of vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new trach and OG tube // placement of OG tube and new trach TECHNIQUE: Portable AP radiograph of the chest. COMPARISON: ___. FINDINGS: The patient has been extubated, but a tracheostomy tube has been placed. A nasogastric tube terminates in the stomach, however the side port sits at the level of the GE junction. A right-sided PICC line terminates in the upper SVC. A left basilar airspace opacity containing air bronchograms is not appreciably changed. Scattered reticular nodular opacities, including a rounded opacity at the right base, are in keeping with the known diagnosis of multifocal pneumonia. IMPRESSION: Persistent multifocal pneumonia with large left lower lobe consolidation and atelectasis. Newly placed NG tube terminates in stomach, but its side-port sits at the GE junction. Advancement by at least 3-4 cm is advised. Radiology Report INDICATION: ___ year old man with sudden SOB // ? mucous plug/flash edema EXAMINATION: CHEST (PORTABLE AP) TECHNIQUE: Portable Chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Right PICC terminates at and mid SVC. Tracheostomy tube is in appropriate position. Transesophageal tube courses below the diaphragm and out of view. There are wires and screws projecting over the cervical spine. Reticulonodular interstitial pattern and left lower lobe consolidation is consistent with multifocal pneumonia. There is no increased pulmonary edema. IMPRESSION: No significant interval change. Persistent reticulonodular interstitial pattern and left lower lobe consolidation consistent with multifocal pneumonia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with trach // change in opacity? TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: NG tube tip is in the stomach. Progression of left lower lobe. Atelectasis is demonstrated. A endotracheal tube tip is approximately 7.7 cm above the carinal. The apices are unremarkable. Right central venous line tip is at the level of mid SVC. Right basal opacity most likely represents atelectasis but attention to this area is recommended. Left basal consolidation is unchanged Radiology Report EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW INDICATION: ___ year old male with past medical history of C4 quadriplegia with hypoxemic respiratory failure now status post trach, evaluate swallowing. TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 02:53 min. COMPARISON: None. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is aspiration of thin, nectar, and honey thick liquids. IMPRESSION: Aspiration of thin, nectar, and honey thick liquids. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ year old man with new trach and sputum // ?pna ?pna IMPRESSION: In comparison with the study of ___, the monitoring and support devices are essentially unchanged. Tracheostomy tube is in place. Bibasilar areas of opacification are again seen. On the left, there is poor definition of the hemidiaphragm, suggesting substantial volume loss in the left lower lobe. In the appropriate clinical setting, superimposed pneumonia would have to be considered. Of incidental note is contrast material within the esophagus related to the very recent oropharyngeal swallow examination. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new secretions and FiO2 // ?pneumonia ?pneumonia IMPRESSION: In comparison with the study of ___, there is little overall change. Monitoring and support devices remain in place. Bibasilar at areas of opacification are again seen. On the left, poor definition of the hemidiaphragms suggests substantial volume loss in the left lower lobe. Again, however, in the appropriate clinical setting it would be difficult to definitely exclude superimposed pneumonia. The contrast material in the the esophagus is not definitely appreciated on this study. Radiology Report INDICATION: ___ year old man with C4 quadriplegia and aspiration with trach placement. Now needs GJ tube placement // GJ tube placement please COMPARISON: CT torso ___. TECHNIQUE: OPERATORS: Dr. ___ resident) and Dr. ___ ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___, ___ radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75mcg of fentanyl and 1 mg of midazolam throughout the total intra-service time of 40 min 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: 1 mg glucagon IV. CONTRAST: 30 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 12 min, 40 mGy PROCEDURE: 1. Placement of a MIC gastrojejunostomy tube. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the health care proxy. 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. The stomach was insufflated through the indwelling nasogastric tube. Using a marker, the skin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilute contrast. The needle trajectory was directed towards the pylorus. A ___ wire was introduced and coiled within the stomach. A small skin incision was made along the needle and the needle was removed. Kumpe catheter was then introduced over the wire and the ___ was exchanged for a Glidewire. The Glidewire and a Kumpe cathter was used to advance the wire into the ___ part of the duodenum. The Glidewire was then exchanged for an Amplatz wire. The sheath was then removed and, after sequential dilation, a peel-away sheath was placed over the wire. A 16 ___ MIC gastrojejunostomy catheter was advanced over the wire into position. The sheath was then peeled away. The wire and sheath were removed. The catheter was locked by instilling 7 ml of dilute contrast into the balloon in the stomach after confirming the position 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 noimmediate complications. FINDINGS: 1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. IMPRESSION: Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. The gastric port should not be used for 24 hours. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with respiratory failure // change in left lower lobe volume change in left lower lobe volume IMPRESSION: In comparison with the study of ___, the nasogastric tube is been removed. Tracheostomy tube and right PICC line remain in good position. The little change in the appearance of the heart and lungs. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal sodium level, Dyspnea, Transfer Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 97.5 heartrate: 71.0 resprate: 22.0 o2sat: 96.0 sbp: 118.0 dbp: 86.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the ___ after you experienced respiratory distress symptoms. This was thought initially to be triggered by a viral illness initially. During your hospital stay, you required the ventilator to help you breathe given your significant distress. You were eventually weaned off the ventilator and had a trach/PEG tube placed. Throughout the hospitalization, you were treated for a number of pneumonias and treated with various course of antibiotics which will be listed your discharge summary. You will require follow up with Dr. ___ and Dr. ___. Please see below for further details. We wish you the very best, ___ ICU team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old woman awakening at 0800 with left sided weakness. She has a history of a prior stroke (likely an intraparenchymal hemorrhage from a cavernous malformation in ___ with left sided weakness), CAD, HTN (on three antihypertensives), HL, and DM2. She was last seen well at 2200 (her bedtime) on ___. She awoke and could not move her left side well. She did not think her face was asymmetric and did not have any dysarthria. She did not have any headache. She felt tired and lethargic but has been able to stay awake. She had a recent cold with rhinorrhea which she had just recovered from yesterday. She was brought to ___ where a ___ revealed a right thalamic IPH, and she was subsequently transferred here. A Nicardipine infusion was started in the ED for a BP 210/106 at triage which has since kept her SBP in the 120-140 range. She feels that her symptoms have remained overall unchanged since this morning. On review of systems, the patient endorses: left sided weakness. On review of systems, the patient denies the following: - Neurologic: headache, confusion, difficulty producing speech, difficulty understanding speech, vision loss, diplopia, vertigo, dysarthria, dysphagia, sensory loss, gait imbalance. - Constitutional: fever, rigors, night sweats, unintentional weight loss. - Cardiovascular: chest pain, palpitations, lightheadedness. - Gastrointestinal: nausea, emesis, diarrhea, constipation. - Genitourinary: dysuria, urinary urgency, urinary incontinence. - Ear, Nose, Throat: tinnitus, hearing loss, rhinorrhea, odynophagia. - Hematologic: bleeding, easy bruising. - Musculoskeletal: arthralgia, myalgia. - Psychiatric: anxiety, depression. - Respiratory: dyspnea, cough, hematemesis. - Skin: rash, new skin lesions. Past Medical History: [] Neurologic - Stroke (uncertain type, but reported history of intracranial cavernous angioma; ___, episode with ) [] Cardiovascular - CAD, HTN, HL [] Endocrine - DM2 [] Gastrointestinal - GERD [] Psychiatric - Depression, Anxiety Social History: ___ Family History: Family History: Stroke (mother, unknown type). ___ (mother). Physical Exam: Physical Examination: VS T: 97.6 HR: 80 BP: 210/106 -> ___ RR: 20 SaO2: 98% 2LNC -> RA - General/Constitutional: Lying in bed comfortably, tired appearing elderly woman. - Eyes: Round, regular pupils. No conjunctival icterus, no injection. - Ear, Nose, Throat: No oropharyngeal lesions. No external auditory canal lesions. - Neck: No meningismus. No carotid, vertebral, or subclavian bruits appreciated. No lymphadenopathy. - Musculoskeletal: Range of motion with neck rotation minimally limited bilaterally. No focal spinal tenderness. - Skin: No rashes. No concerning lesions appreciated. - Cardiovascular: Regular rate. Regular rhythm. No murmurs, rubs, or gallops appreciated. Normal distal pulses. - Respiratory: Lungs clear to auscultation bilaterally. No crackles. No wheezes. - Gastrointestinal: Soft. Nontender. Nondistended. Obese. - Psychiatric: Mood congruent with affect, occasionally smiles appropriately. Intact insight. Neurologic Examination: - Mental Status - Awake, drowsy. Oriented to name, ___, current location; not oriented to day of week or date. Attention to examiner easily attained and maintained. Abulic and bradyphrenic. Recalls a coherent history, but with little detail volunteered initially. Speech is fluent with short sentences. Follows midline and appendicular commands. Intact repetition. Intact high frequency and low frequency naming. No paraphasias. Normal prosody. No dysarthria. No ideomotor apraxia. No hemineglect. - Cranial Nerves - [II] PERRL 3->1 brisk. VF full to number counting. Unable to perform fundoscopy due to small pupils. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally. [VII] No facial movement asymmetry. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally to confrontation, but incomplete elevation of the left shoulder. [XII] Tongue midline. - Motor - Normal bulk and tone. Left arm pronation and drift, but not to the bed. No tremor, asterixis, or myoclonus. [ Direct Confrontational Strength Testing ] Arm Deltoids [C5] [R 4 pain limited] [L 3] Biceps [C5] [R 50] [L 4+] Triceps [C6/7] [R 5-] [L 4-] Extensor Carpi Radialis [C6] [R 5] [L 4] Extensor Digitorum [C7] [R 5] [L 5-] Flexor Digitorum [C8] [R 5] [L 5] Leg Iliopsoas [L1/2] [R 5] [L 4-] Quadriceps [L3/4] [R 5] [L 5] Hamstrings [L5/S1] [R 5] [L 4] Tibialis Anterior [L4] [R 5-] [L 4] Gastrocnemius [S1] [R 5] [L 5] - Sensory - No deficits to cold temperature or proprioception bilaterally. No extinction to DSS. - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L 3 3 3 2 1 R 3 3 3 0 1 Plantar response flexor on the right, extensor on the left. ___ signs present bilaterally. Pectoralis reflexes present bilaterally. Grip and grasp reflexes present bilaterally. - Coordination - No dysmetria with finger to nose testing on the right. Intact cadence and accuracy with rapid alternating movements (finger tap) on the right. Too weak to elevate left arm. - Gait - Unable to assess at the time of examination. Discharge: Physical Examination: NAD RRR NTND Normal WOB Ext WWP Neurologic Examination: - Mental Status - Awake, Oriented to name, hospital, ___. Attention to examiner easily attained and maintained. Follows midline and appendicular commands. Intact repetition. - Cranial Nerves - [II] PERRL 3->1 brisk. VF full to number counting. Unable to perform fundoscopy due to small pupils. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally. [VII] No facial movement asymmetry. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally to confrontation, but incomplete elevation of the left shoulder. [XII] Tongue midline. - Motor - Normal bulk and tone. Left arm pronation and drift, but not to the bed. No tremor, asterixis, or myoclonus. Limited due to patient cooperation Arm Deltoids [C5] [R 5] [L 3] Biceps [C5] [R 5] [L 4+] Triceps [C6/7] [R 5-] [L 4-] Extensor Carpi Radialis [C6] [R 5] [L 4] Extensor Digitorum [C7] [R 5] [L 5-] Flexor Digitorum [C8] [R 5] [L 5] Leg Iliopsoas [L1/2] [R 5] [L 4-] Quadriceps [L3/4] [R 5] [L 5] Hamstrings [L5/S1] [R 5] [L 4] Tibialis Anterior [L4] [R 5-] [L 4] Gastrocnemius [S1] [R 5] [L 5] - Sensory - No deficits to cold temperature or proprioception bilaterally. No extinction to DSS. - Coordination - No dysmetria with finger to nose testing on the right. Intact cadence and accuracy with rapid alternating movements (finger tap) on the right. Too weak to elevate left arm. Pertinent Results: ___ 01:15PM LIPASE-24 ___ 01:15PM cTropnT-<0.01 ___ 01:15PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.9 ___ 01:15PM WBC-9.2 RBC-4.89 HGB-13.5 HCT-43.4 MCV-89 MCH-27.5 MCHC-31.0 RDW-14.7 ___ 01:15PM NEUTS-79.3* LYMPHS-14.7* MONOS-4.7 EOS-0.8 BASOS-0.6 ___ 01:15PM PLT COUNT-313 ___ 01:15PM ___ PTT-31.8 ___ ___ 05:45AM BLOOD WBC-8.7 RBC-3.98* Hgb-11.0* Hct-35.1* MCV-88 MCH-27.7 MCHC-31.4 RDW-15.0 Plt ___ ___ 06:00AM BLOOD WBC-10.2 RBC-4.44 Hgb-12.1 Hct-39.0 MCV-88 MCH-27.2 MCHC-30.9* RDW-15.1 Plt ___ ___ 05:45AM BLOOD ___ ___ 01:50AM BLOOD ___ PTT-29.0 ___ ___ 01:15PM BLOOD ___ PTT-31.8 ___ ___ 05:45AM BLOOD Glucose-127* UreaN-26* Creat-0.8 Na-137 K-3.8 Cl-108 HCO3-23 AnGap-10 ___ 06:00AM BLOOD Glucose-135* UreaN-20 Creat-0.8 Na-139 K-4.1 Cl-109* HCO3-22 AnGap-12 ___ 02:49AM BLOOD Glucose-142* UreaN-17 Creat-0.9 Na-139 K-4.3 Cl-106 HCO3-18* AnGap-19 ___ 05:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 ___ 06:00AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1 MRI brain with and without contrast: IMPRESSION: 1. Organizing hematoma with vasogenic edema centered in the right thalamus, likely hypertensive in origin. Given the presence of blood products at the site, evaluation for another underlying substrate, such as cavernous angioma, is quite limited. 2. Patchy marginal enhancement at this site, above, likely reflecting an organizing hematoma. 3. Numerous microbleeds in the usual target sites for hypertension; however, there are also atypical superficial foci, as well as evidence of superficial siderosis involving the posterior aspect of the right temporal lobe, raising the possibility of leptomeningeal involvement from underlying cerebral amyloid angiopathy. 4. No space-occupying lesion or pathologic enhancement elsewhere in the brain. 5. Relatively mild global atrophy, with no finding to suggest hydrocephalus. CT brain without contrast on ___: The intraparenchymal hemorrhage centered in the right basal ganglia is stable in size, measuring 2.1 x 1.3 cm (3:18). There is no new hemorrhage. There is no shift of normally midline structures. The ventricles and sulci are normal in size configuration. The basal cisterns are patent and the gray-white matter differentiation is preserved. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Stable right basal ganglia intraparenchymal hemorrhage. Medications on Admission: Glipizide ER 2.5 mg daily, Metoprolol tartrate 100 mg BID, Fluoxetine 40 mg daily, Lisinopril 40 mg daily, Clonidine 0.3 mg HS, Simvastatin 20 mg daily, Aspirin 81 mg daily, Trazodone 25 mg HS, Ibuprofen 800 mg prn Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Calcium Carbonate 500 mg PO QID:PRN heart burn 4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT 5. Fluoxetine 40 mg PO DAILY 6. Glucose Gel 15 g PO PRN hypoglycemia protocol 7. Heparin 5000 UNIT SC TID 8. HydrALAzine 10 mg IV Q6H:PRN SBP > 140 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. Lisinopril 40 mg PO DAILY 11. Metoprolol Tartrate 100 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Thalamic stroke 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: History of intraparenchymal hemorrhage, weakness, evaluate for intraparenchymal bleed. COMPARISON: Reference CT from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the use of intravenous contrast material. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were obtained. Due to motion, multiple scans were attempted. FINDINGS: There continues to be a right thalamic hemorrhage with associated edema, relatively similar in size compared to the CT from ___ at 10:43 a.m. No new acute hemorrhage, mass effect or vascular territorial infarction is noted. There is preservation of normal gray-white matter differentiation. Periventricular and subcortical white matter hyperdensities are likely sequela of chronic small vessel ischemic disease. The ventricles and sulci are appropriate in size and configuration for age. vExtensive vascular calcifications are seen with ectatic arteries. No fractures are identified. The visualized paranasal sinuses and mastoid air cells are clear. The globes are intact. IMPRESSION: Stable right thalamic hemorrhage with associated edema, similar in size compared to CT from ___ at 10:43 a.m. Radiology Report MR EXAMINATION OF THE BRAIN WITHOUT AND WITH CONTRAST, ___ HISTORY: ___ female with right intraparenchymal hemorrhage, history of cavernous hemangioma; evaluate extent of IPH, hydrocephalus and compression of the third ventricle. TECHNIQUE: Routine ___ enhanced MR examination, comprising T1-weighted axial SE and sagittal MP-RAGE sequences, the latter with axial and coronal reformations. FINDINGS: The study is compared with the NECT dated ___. Again demonstrated is the parenchymal hemorrhage centered in the right thalamus, demonstrating predominant T1-iso and T2-hyperintensity with "substantial blooming" susceptibility artifact on the GRE sequence, representing deoxyhemoglobin related to acute hemorrhage. There is a zone of vasogenic edema with some mass effect on adjacent structures, but no subfalcine or more central herniation. While there is no other acute hemorrhage, there is a superficial "blooming" artifact involving the posterior right temporal cortex, superficially (___), which may represent superficial siderosis. There are also numerous smaller foci of susceptibility artifact scattered through both cerebral hemispheres, including three such foci in the contralateral thalamus, as well as in the brainstem and both cerebellar hemispheres, without associated vasogenic edema. These deeper microbleeds are strongly suggestive of a hypertensive etiology, particularly given the current thalamic hemorrhage, as well as the moderate sequela of chronic small vessel ischemic disease. However, the more superficial foci of susceptibility artifact, not explained by calcification on the CT, as well as the apparent focal superficial siderosis, are more strongly suggestive of underlying cerebral amyloid angiopathy. The remainder of the examination demonstrates relatively mild global atrophy, with no finding to suggest hydrocephalus. Allowing for the extensive susceptibility artifact, above, there is no focus of slow diffusion to suggest acute ischemia, and the principal intracranial vascular flow voids, including those of the dural venous sinuses, are preserved and these structures enhance normally. There is wispy marginal enhancement about the hematoma, particularly its right posterolateral aspect (14:14, 101:78). Otherwise, there is no pathologic parenchymal, leptomeningeal or dural focus of enhancement. IMPRESSION: 1. Organizing hematoma with vasogenic edema centered in the right thalamus, likely hypertensive in origin. Given the presence of blood products at the site, evaluation for another underlying substrate, such as cavernous angioma, is quite limited. 2. Patchy marginal enhancement at this site, above, likely reflecting an organizing hematoma. 3. Numerous microbleeds in the usual target sites for hypertension; however, there are also atypical superficial foci, as well as evidence of superficial siderosis involving the posterior aspect of the right temporal lobe, raising the possibility of leptomeningeal involvement from underlying cerebral amyloid angiopathy. 4. No space-occupying lesion or pathologic enhancement elsewhere in the brain. 5. Relatively mild global atrophy, with no finding to suggest hydrocephalus. 6. Likely dolichoectasia of the intracranial vessels. Radiology Report STUDY: Pre-MRI orbits ___. CLINICAL HISTORY: ___ woman with right thalamic ICH and ocular implant. FINDINGS: Two views of the patient looking up and down demonstrate no radiopaque densities projecting over the orbits. The paranasal sinuses are within normal limits. Based on these images, there are no contraindications to MRI imaging. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with IPH // hemorrhage size. Evaluation for interval change. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 829 mGy-cm CTDI: 52.66 mGy COMPARISON: ___ at 15:55. FINDINGS: The intraparenchymal hemorrhage centered in the right basal ganglia is stable in size, measuring 2.1 x 1.3 cm (3:18). There is no new hemorrhage. There is no shift of normally midline structures. The ventricles and sulci are normal in size configuration. The basal cisterns are patent and the gray-white matter differentiation is preserved. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Stable right basal ganglia intraparenchymal hemorrhage. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: HEAD BLEED Diagnosed with INTRACEREBRAL HEMORRHAGE temperature: 97.6 heartrate: 80.0 resprate: 20.0 o2sat: 98.0 sbp: 210.0 dbp: 106.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were hospitalized due to symptoms of left sided weakness ultimatley found to be a bleed in your brain. We believe that this is due to your high blood pressure and abnormal vessels in your brain called a cavernous malformation. You were initially in the ICU but after several brain images, the bleed was stable. We restarted your home medicaitons for blood pressure control. Physical therapy recommended you go to ___ rehab.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cough/Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with history of CKD, HTN and CHF on 60 mg Torsemide daily presenting with cough, SOB, and orthopnea over the last month worsening over the last few days. Notes he has been sleeping up in a chair over the last 2 days due to orthopnea. Also noted pink streaked sputum with cough though no fever or chills. He denies any chest pain. Lower extremity edema improved from his baseline per his report. The patient notes he weighs himself almost daily and that his weight has gone up a few pounds over the last week. He believes his dry weight is about 205 lbs. He notes he misses his torsemide dose regularly about 3 times per week. He Does not know the names of all of his medications notes that are taken from a pill box set up for him and takes a total of 7 pills per day. He denies any fever, chills, abdominal pain, nausea, vomiting, chest pain, palpitations, or dysuria. In the ED initial vitals were: Temp 98.3 HR 95 BP 164/109 RR 18 SpO2 98% RA EKG: Sinus rhythm. Biatrial enlargement. Right bundle-branch block unchanged from prior. Labs/studies notable for: WBC 9.2, Hg 10.6, Hct 33.0, platelets 206. Na 138, K 3.1, Cl 98, bicarb 26, BUN 40, Cr 5.3, glucose 173. BNP 4912 (baseline 6721-17, 108), trop 0.10 (baseline 0.10). INR 1.0 CXR showed: FINDINGS: Compared to the previous examination of ___. The heart appears smaller enlarged and there is increased generalized haziness of the lung fields indicating interstitial edema. No focal pneumonia. No pleural effusions. Conclusion: Enlarged heart with CHF. Patient was given: 20 mg PO Torsemide Vitals on transfer: Temp 98.2, HR 88, BP 174/110, RR 17, 97% RA On the floor, the patient notes he feels well. He continues to have intermittent cough and orthopnea but is resting comfortably currently. ROS: 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, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: Systolic Heart failure: EF 35%, NYHA class 2 3. OTHER PAST MEDICAL HISTORY: Stage IV CKD, HTN, Prior h/o DM. Social History: ___ Family History: HTN DMII CAD Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T= 98.2 BP= 115/105 HR= 88 RR= 18 O2 sat= 8=98% RA weight 98.2 kg GENERAL: 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 xanthelasma. NECK: Supple with JVP of 5 cm above sternal angle HOB at 45 degrees. CARDIAC: Normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bilateral crackles ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ edema to mid-shins bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ======================== VS: T=97.7 Tm = 98.4 BP 140/95 (130-155/79-105) HR85 (78-88) R18 94% RA Weight 97.9 GENERAL: NAD. Mood, affect appropriate HEENT: PERRL. Sclera anicteric. MMM. NECK: JVP of 5cm above sternal angle HOB at 45 degrees. CARDIAC: RRR. No murmurs rubs or gallops. S4. LUNGS: Mild bibasilar crackles. ABDOMEN: +BS, nontender to palpation. EXTREMITIES: No pedal edema. Warm. DP pulses palpable and symmetric. No stasis changes. Pertinent Results: ADMISSION LABS: =============== ___ 03:52PM BLOOD WBC-9.2# RBC-3.40* Hgb-10.6*# Hct-33.0* MCV-97 MCH-31.2 MCHC-32.1 RDW-14.5 RDWSD-51.2* Plt ___ ___ 03:52PM BLOOD Neuts-78.7* Lymphs-11.0* Monos-6.2 Eos-2.9 Baso-0.4 Im ___ AbsNeut-7.25* AbsLymp-1.01* AbsMono-0.57 AbsEos-0.27 AbsBaso-0.04 ___ 03:52PM BLOOD ___ PTT-29.5 ___ ___ 03:52PM BLOOD Plt ___ ___ 03:52PM BLOOD Glucose-173* UreaN-40* Creat-5.3* Na-138 K-3.1* Cl-98 HCO3-26 AnGap-17 ___ 03:52PM BLOOD CK(CPK)-546* ___ 03:52PM BLOOD CK-MB-5 proBNP-4912* ___ 03:52PM BLOOD cTropnT-0.10* DISCHARGE LABS: =============== ___ 07:49AM BLOOD WBC-7.2 RBC-3.27* Hgb-9.9* Hct-31.6* MCV-97 MCH-30.3 MCHC-31.3* RDW-14.8 RDWSD-51.9* Plt ___ ___ 07:49AM BLOOD Plt ___ ___ 02:12PM BLOOD Glucose-186* UreaN-47* Creat-5.2* Na-141 K-3.8 Cl-103 HCO3-23 AnGap-19 ___ 02:12PM BLOOD Calcium-7.4* Phos-4.0 Mg-2.2 ___ 03:59AM BLOOD calTIBC-252* Ferritn-195 TRF-194* IMAGING: ======== ___ TTE: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%) secondary to mild global hypokinesis. Right ventricular chamber size is normal with mild global free wall hypokinesis. 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 mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild-moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, mild global right ventricular systolic dysfunction is now appreciated. Other findings are similar. ___ CXR: Compared to the previous examination of ___. The heart appears smaller enlarged and there is increased generalized haziness of the lung fields indicating interstitial edema. No focal pneumonia. No pleural effusions. Conclusion: Enlarged heart with CHF. MICROBIOLOGY: ___ Sputum Culture: GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Tamsulosin 0.8 mg PO QHS 3. Amlodipine 10 mg PO DAILY 4. Carvedilol 25 mg PO BID 5. HydrALAzine 50 mg PO Q8H 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. Torsemide 60 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. HydrALAzine 50 mg PO Q8H RX *hydralazine 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Tamsulosin 0.8 mg PO QHS RX *tamsulosin 0.4 mg 2 capsule(s) by mouth at bedtime Disp #*60 Capsule Refills:*0 7. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Congestive heart failure exacerbation Hypertension Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with COUGH // PNA FINDINGS: Compared to the previous examination of ___. The heart appears smaller enlarged and there is increased generalized haziness of the lung fields indicating interstitial edema. No focal pneumonia. No pleural effusions. Conclusion: Enlarged heart with CHF. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea, Cough Diagnosed with Heart failure, unspecified temperature: 98.3 heartrate: 95.0 resprate: 18.0 o2sat: 98.0 sbp: 164.0 dbp: 109.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was our pleasure caring for you during your hospital stay at ___. You were admitted due to cough and shortness of breath. We think that this was due to worsening of your heart failure, likely due to missed doses of your water pill (torsemide). We gave you an intravenous version of the water pill and your breathing improved. We also performed an ultrasound of your heart that showed slight worsening of its filling ability. Your discharge weight is 97.9kg. You should weigh yourself at the same time every morning. If your weight goes up by more than 3lbs in one day, please call your doctor. You should also take all of your pills as prescribed. Please follow up with your cardiologist, nephrologist, and primary care physician. We wish you the best. -Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base / Lactose / vancomycin Attending: ___ Chief Complaint: Weakness/Fatigue Major Surgical or Invasive Procedure: Endotracheal intubation ___ Central Venous Catheter insertion ___ Peripherally Inserted Central Catheter placement ___ History of Present Illness: Ms. ___ is a ___ yo F w/ PMH significant for primary biliary cirrhosis s/p OLT in ___ (on chronic immunosuppresion), afib s/p PPM (on coumadin) and recurrent skin infections who presented to OSH with weakness. Per family, the patient was complaining of back pain and presented to the OSH. There she was found to be hypotensive. She was bolused IVFs, started on dopamine and transferred to ___ for further management. In the ED, initial vitals 0 70 85/40 20 100% RA (on dopamine) and patient subsequently spiked a fever to 103.9. She was given levofloxacin/cefepime and dexamethasone and started on levophed as well as 4L of NS. Labs were notable for WBC 10.8 (8% bands), Hct 49.3 (bl 38), plt 170 (bl 250), INR 2.6 (on coumadin), creatinine 1.5 (bl 1.1), Na 132 (bl 130), K 6.2 (hemolyzed), bicarb 18 (non-gap), lactate 3.4, ALT/AST ___ (hemolyzed), Tbili 1.7, UA with trace blood, prot, 3 WBC, no bacteria. On arrival to the MICU, the patient is intubated and sedated. Review of systems: unable to obtain secondary to sedation. Past Medical History: -primary biliary cirrhosis s/p OLT in ___ (on chronic immunosuppresion) -tachyarrhythmias (AFib and AFlutter) s/p multiple ablations, s/p pacemaker -mild hypertrophic cardiomyopathy, EF >55% -ascending aortic aneurysm, 4.2 x 4.3 cm in ___ -primary biliary cirrhosis s/p OLT ___ on chronic immunosuppression -thyroid colloid cyst -stable lung nodules -rosacea -retroperitoneal adenopathy -skin cancer -Raynaud's syndrome -h/o cellulitis of thumb and left lower extremity -keratosis on Left ___ which has tract -s/p hernia repair -s/p TIPS prior to transplant -s/p C-section Social History: ___ Family History: Mom had ovarian cancer. Dad had hypertension, hyperlipidemia, dementia, and ___ disease. Physical Exam: ADMISSION EXAM: Vitals- 99.8, 94/56, 70, 100% on 50%FI02, CMV 500/18 PEEP 8 General- chronically ill appearing, sedated and intubated HEENT- pupils constricted and sluggish CV- RRR, no appreciable MRG, displaced PMI with enlarged cardiac heave Lungs- clear to auscultation bialterally when ausculated anteriorly Abdomen- soft, previous scar well healed with thickness felt in epigastrium and RUQ just inferior to visible scar. No ascites. GU- foley in place draining clear urine Ext- RLE with 3cm cut on anterior shin with surrounding erythema a warmth, with some inudration no flucutance Neuro- sedated DISCHARGE EXAM: Vitals: T 98.4 BP 122/84 HR 85 RR 20 SaO2 94% on RA GEN: NAD HEENT: Several vesicular lesions on superior OP/hard palate with surrounding erythema. Neck: Bilateral cervical LAD present Lungs: CTAB, breathing comfortably CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, nontender,nondistended Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Diffusely distributed telangiectasia, palmar erythema. Neuro: Alert and oriented X3, No flapping. No focal neurological signs. Pertinent Results: ADMISSION LABS: ___ 08:30PM BLOOD WBC-10.8 RBC-5.23# Hgb-17.0*# Hct-49.3*# MCV-94 MCH-32.4* MCHC-34.4 RDW-14.8 Plt ___ ___ 08:30PM BLOOD Neuts-86* Bands-8* Lymphs-2* Monos-4 Eos-0 Baso-0 ___ Myelos-0 ___ 08:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 08:30PM BLOOD ___ PTT-44.4* ___ ___ 08:30PM BLOOD Glucose-83 UreaN-28* Creat-1.5* Na-132* K-6.2* Cl-104 HCO3-18* AnGap-16 ___ 08:30PM BLOOD ALT-53* AST-96* AlkPhos-104 TotBili-1.7* ___ 08:30PM BLOOD Albumin-3.6 Calcium-8.9 Phos-2.4* Mg-1.3* ___ 04:46AM BLOOD tacroFK-5.9 ___ 11:02PM BLOOD Type-ART pO2-276* pCO2-38 pH-7.26* calTCO2-18* Base XS--9 ___ 08:34PM BLOOD Lactate-3.4* K-5.9* ___ 11:02PM BLOOD O2 Sat-98 DISCHARGE LABS: ___ 07:00AM BLOOD WBC-7.3 RBC-4.24 Hgb-13.6 Hct-38.5 MCV-91 MCH-32.1* MCHC-35.3* RDW-14.7 Plt ___ ___ 07:00AM BLOOD ___ ___ 07:00AM BLOOD Glucose-71 UreaN-16 Creat-0.8 Na-139 K-3.0* Cl-99 HCO3-36* AnGap-7* ___ 07:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.7 IMAGING: TTE ___ The left atrium is mildly elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild to moderate (___) aortic regurgitation is seen directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate (___) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild-moderate aortic regurgitation. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Pulmonary artery hypertension. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Dilated ascending aorta. No discrete vegetation identified. TEE ___ No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate (___) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations. Mild to moderate mitral, aortic, and tricuspid regurgitation. Normal global biventricular systolic function. CT SPINE ___ FINDINGS: There is no lumbar spine fracture or malalignment. There is no evidence of discitis, osteomyelitis, or paraspinal soft tissue abnormality. There are no abnormal areas of enhancement. CT is limited for the evaluation of epidural abscess. Incidentally noted, is a sclerotic lesion within the left iliac wing likely representing bone island or prior bony infarct. In addition, small subcentimeter well-circumscribed renal hypodensities, likely represent cysts. There is bilateral symmetric retroperitoneal stranding which is slightly increased when compared to reference CT from ___, and likely represents third-spacing of ascites. IMPRESSION: 1. No osseous signs of infection within the lumbar spine. No paraspinal soft tissue abnormality or abnormal enhancement. CT lacks sensitivity for evaluating epidural abscess. 2. Incidental note is made of a sclerotic lesion in the left iliac wing, likely a bone island or prior bony infarct. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Azathioprine 50 mg PO BID 3. Calcium Carbonate 500 mg PO BID 4. Digoxin 0.125 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. PredniSONE 5 mg PO DAILY 8. Tacrolimus 1 mg PO Q12H 9. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 10. Furosemide 40 mg PO DAILY 11. Levofloxacin 500 mg PO DAILY 12. Magnesium Oxide 800 mg PO DAILY 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Warfarin 0.5 mg PO DAILY Discharge Medications: 1. Azathioprine 50 mg PO DAILY 2. PredniSONE 5 mg PO DAILY 3. Tacrolimus 0.5 mg PO Q12H 4. Warfarin 0.5 mg PO DAILY16 5. CefazoLIN 2 g IV Q8H MSSA Sepsis Needs 4 weeks of antibiotics. Start: ___. End: ___. 6. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID Mouth pain 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Heparin Flush (10 units/ml) 2 mL IV PRN and PRN, line flush 9. Amiodarone 200 mg PO DAILY 10. Calcium Carbonate 500 mg PO BID 11. Furosemide 40 mg PO DAILY 12. Lisinopril 2.5 mg PO DAILY 13. Magnesium Oxide 800 mg PO DAILY 14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 15. Vitamin D 1000 UNIT PO DAILY 16. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 17. ValACYclovir 1000 mg PO Q12H HSV Stomatitis Duration: 10 Days Continue until ___. 18. Outpatient Lab Work Weekly CBC/diff, Chem-7, creatinine, BUN, AST, ALT, albumin, alkaline phosphatase, INR and fax results to ___ OPAT ___ to monitor antibiotic therapy. ICD-9 995.1 (Sepsis) 19. Outpatient Lab Work Q3 day tacrolimus trough levels, goal ___. Fax results to Q3 Dr. ___ at ___. ICD-9 V42.7 (Liver transplant) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY # Septic Shock due to Methicillin Sensitive Staphylococcus aureus bacteremia, secondary to RLE wound # Stomatitis # Atrial fibrilation / Sick sinus with implanted Biventricular Pacemaker SECONDARY: # Status-post Orthotopic Liver Transplantation for Primary Biliary Cirrhosis 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: ___ female with line placement. COMPARISON: ___ at 16:17. FINDINGS: Single portable view of the chest. New right IJ central venous line is seen with catheter tip in the mid SVC. There is no pneumothorax. Indistinct pulmonary vascular markings are suggestive of interstitial edema. Linear right basilar opacity may be due to atelectasis. Cardiac silhouette is slightly enlarged. Left chest wall dual lead pacing device is again noted. No acute osseous abnormalities detected. IMPRESSION: Interstitial pulmonary edema. New right IJ line with tip in the mid SVC. No pneumothorax. Radiology Report REASON FOR EXAMINATION: Evaluation of the patient with ETT placement. Portable AP chest radiograph was compared to ___. The ET tube tip is 3.5 cm above the carina. The NG tube passes below the diaphragm terminating in the stomach. The pacemaker leads terminate in right atrium and right ventricle. Cardiomediastinal silhouette is unchanged including cardiomegaly. Interstitial pulmonary edema has progressed in the interim, currently severe. Radiology Report HISTORY: ___ woman with MSSA bacteremia and back pain, evaluate for abscess. COMPARISON: Reference Abdominal CT ___ TECHNIQUE: Helical axial MDCT sections were obtained through the lumbar spine. Reformatted images in sagittal and coronal axes were obtained. Total Exam DLP: 934mGy-cm CTDIvol 32mGy FINDINGS: There is no lumbar spine fracture or malalignment. There is no evidence of discitis, osteomyelitis, or paraspinal soft tissue abnormality. There are no abnormal areas of enhancement. CT is limited for the evaluation of epidural abscess. Incidentally noted, is a sclerotic lesion within the left iliac wing likely representing bone island or prior bony infarct. In addition, small subcentimeter well-circumscribed renal hypodensities, likely represent cysts. There is bilateral symmetric retroperitoneal stranding which is slightly increased when compared to reference CT from ___, and likely represents third-spacing of ascites. IMPRESSION: 1. No osseous signs of infection within the lumbar spine. No paraspinal soft tissue abnormality or abnormal enhancement. CT lacks sensitivity for evaluating epidural abscess. 2. Incidental note is made of a sclerotic lesion in the left iliac wing, likely a bone island or prior bony infarct. Radiology Report HISTORY: ___ woman with MSSA bacteremia and back pain. COMPARISON: None available. TECHNIQUE: Helical axial MDCT sections were obtained through the thoracic spine. Reformatted images in sagittal and coronal axes were obtained. Total Exam DLP: 1115mGy-cm CTDIvol 32mGy FINDINGS: There is no thoracic spine fractures or malalignment. CT is low sensitivity for an epidural abscess, however there are no osseous signs of infection. In addition, there are no abnormal areas of enhancement. There are bilateral pleural effusions and atelectasis. The soft tissues are unremarkable. There is no lymphadenopathy noted by CT size criteria. IMPRESSION: 1. CT is limited in the assessment for epidural abscess, however there are no signs of osseous infection of the thoracic spine. 2. Bilateral pleural effusions. Radiology Report HISTORY: ___ woman with MSSA bacteremia and altered mental status, assess for intracranial abnormality. COMPARISON: NCHCT ___. 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. Total Exam DLP: 1026mGy-cm CTDIvol: 63mGy FINDINGS: There is no evidence of intracranial hemorrhage, edema, mass effect, large vascular territory infarction. Ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. The visualized intracranial vasculature appears patent. No fracture is identified. The included paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Gender: F Race: WHITE Arrive by UNKNOWN Chief complaint: WEAKNESS Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear ___, ___ was a pleasure taking care of you at ___. You were admitted for sepsis (infection in your blood) for which we treated you with antibiotics, and you improved dramatically. It is not clear where the source of this bacteria was, presumably from your dental procedure or from the cut on your leg. There was no evidence that your pacemaker was infected, but we considered this. You will need to continue on antibiotics for 4 weeks. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

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: Mr. ___ is a ___ with PMHx of CAD (s/p 5v CABG, AVR, aortic arch graft), HTN, HLD, DM, CHF (EF 45-50%, multiple myeloma, recently started on pomalidomide on ___, who presents with dyspnea. Pt reports wt of 174 on ___ but was ___ yesterday. He denies salt/medication noncompliance. No localizing infectious symptoms. Reports worsening dyspnea that awoke him from sleep the night of ___ requiring him to sit in a chair. He was having some mild left sided axillary chest pain which is chronic in nature. EMS was called. He was started on BiPAP in the field and given sl ntg for SPBs in the 180s. In the ED, initial VS were 93 149/71 20 100% cpap. Labs were notable for BNP of 14000 and Na 129. Cre was 2.0 (baseline). CXR was c/w pulmonary edema. EKG showed LBBB. VS prior to transfer were 98.1 91 118/65 19 100% cpap. In the ED, he was given lasix 80 IV, to which he did not respond. He was continued on BiPAP and transferred to the CCU. Past Medical History: 1. CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, SVG-OM-D1, SVG-RDPA) 2. CHF (EF 45-50%) 3. Ascending aortic aneurysm s/p bioprosthetic AVR/ascending aortic graft ___ 4. Cardiac arrest ___ (? vagal episode) 5. CVA 6. DM 7. Dyslipidemia 8. HTN 9. CKD 10. LBBB 11. MM 12. R-sided vocal cord paralysis 13. GERD 14. Anemia Social History: ___ Family History: His father had diabetes. His mother had asthma. He has two brothers, one is well and one died from unclear causes. Physical Exam: Admission Physical Exam: 98.2 92 136/84 20 100% on BIPAP ___ 40% FIO2 General: NAD HEENT: EOMI, PERRL, BIPAP mask in place Neck: supple CV: RRR, ___ systolic murmur at RUSB Lungs: crackles ___ way up bilateral posterior lung fields Abdomen: obese, nt, nd, abdominal rounding with breathing GU: no foley Ext: 1+ edema bilaterally, distal pulses in tact Neuro: moving all 4 extremities, A&Ox3 Skin: no rash Discharge Physical Exam: Tmax/Tcurrent:98.0 HR: ___ RR:21 ___ O2 sat:92-95% RA I/O:-1.5 litres 24hr: 1320/___ 8hr ___ Weight:80.4k (79.3k) ___: 250-314 Tele: Sinus rhythm with LBBB 80-90's, prolonged PRI no VEA General:No acute distress HEENT: PERRLA CV: RRR S1S2 III/VI systolic ejection murmur Resp: Faint crackles in bases bilaterally L>R ABD: soft, non-distended, normal bowel sounds Extr: 1+ BLE edema to chins, feet warm. 1+DP bilaterally JVD: None appreciated while sitting upright Neuro: A+Ox3, denies pain. Pertinent Results: Admission labs: ___ 04:30AM ___ PTT-29.7 ___ ___ 04:30AM WBC-10.1 RBC-2.83* HGB-7.3* HCT-25.5* MCV-90 MCH-26.0* MCHC-28.8* RDW-16.6* ___ 04:30AM NEUTS-77.7* LYMPHS-13.5* MONOS-4.1 EOS-4.1* BASOS-0.5 ___ 04:30AM PLT COUNT-341 ___ 04:30AM CALCIUM-8.5 PHOSPHATE-5.8*# MAGNESIUM-3.3* ___ 04:30AM CK-MB-2 proBNP-1445* ___ 04:30AM cTropnT-<0.01 ___ 04:30AM CK(CPK)-120 ___ 04:30AM GLUCOSE-532* UREA N-36* CREAT-2.0* SODIUM-129* POTASSIUM-4.5 CHLORIDE-88* TOTAL CO2-30 ANION GAP-16 Interim Labs: ___ 09:55AM CK-MB-2 cTropnT-<0.01 ___ 09:55AM CK(CPK)-113 ___ 09:55AM SODIUM-133 POTASSIUM-4.7 CHLORIDE-91* ___ 04:00PM CALCIUM-9.0 PHOSPHATE-4.2# MAGNESIUM-2.9* ___ 04:00PM GLUCOSE-293* UREA N-38* CREAT-2.0* SODIUM-131* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-34* ANION GAP-13 Discharge Labs: ___ 03:12AM BLOOD WBC-6.3 RBC-2.69* Hgb-6.8* Hct-23.7* MCV-88 MCH-25.4* MCHC-28.9* RDW-16.5* Plt ___ ___ 03:12AM BLOOD Glucose-196* UreaN-44* Creat-2.0* Na-136 K-4.1 Cl-93* HCO3-35* AnGap-12 ___ 03:12AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.6 Micro: MRSA Screen Negative ___ 8:09 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ <=1 S Reports: ___ EKG Sinus rhythm. Left atrial abnormality. Compared to the previous tracing of ___, the rate has slowed. The ST-T wave changes are less prominent and left bundle-branch block persists. Otherwise, no diagnostic interimi change. ___ CXR A prosthetic valve and median sternotomy wires are again noted. The aortic knob is calcified. Motion limits evaluation of the film. Left lower lobe linear opacities are unchanged and likely represent atelectasis. There are patchy new alveolar infiltrates bilaterally. There is prominent pulmonary vasculature.small left pleural effusion. IMPRESSION: Fluid overlad. New opacities in the correct clinical setting could represent pneumonia or could be due to CHF . Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acyclovir 400 mg PO Q12H 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Carvedilol 12.5 mg PO BID 6. sevelamer CARBONATE 800 mg PO TID W/MEALS 7. Docusate Sodium 100 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Senna 8.6 mg PO BID:PRN constipation 10. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headaches 11. NexIUM (esomeprazole magnesium) 40 mg Oral daily 12. Prochlorperazine ___ mg PO Q6H:PRN n/v 13. Glargine 15 Units Breakfast Glargine 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Gabapentin 300 mg PO TID 15. Torsemide 100 mg PO DAILY Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headaches 2. Acyclovir 400 mg PO Q12H 3. Allopurinol ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO DAILY 6. Carvedilol 12.5 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Prochlorperazine ___ mg PO Q6H:PRN n/v 10. Senna 8.6 mg PO BID:PRN constipation 11. sevelamer CARBONATE 800 mg PO TID W/MEALS 12. Gabapentin 300 mg PO TID 13. NexIUM (esomeprazole magnesium) 40 mg Oral daily 14. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 15. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Q 12H Disp #*14 Tablet Refills:*0 17. Outpatient Lab Work Chem 7 ___ Please fax results to: ___. ___ Fax: ___ ___. MD, ___ ___ ICD-9 428.32 18. Glargine 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: Primary: Heart failure exacerbation Secondary: Diabetes Multiple Myeloma Chronic renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL INDICATION: Shortness of breath. Evaluation for congestive heart failure. COMPARISON: Multiple prior chest radiographs, the most recent of ___. PORTABLE UPRIGHT FRONTAL VIEW OF THE CHEST: A prosthetic valve and median sternotomy wires are again noted. The aortic knob is calcified. Motion limits evaluation of the film. Left lower lobe linear opacities are unchanged and likely represent atelectasis. There are patchy new alveolar infiltrates bilaterally. There is prominent pulmonary vasculature.small left pleural effusion. IMPRESSION: Fluid overlad. New opacities in the correct clinical setting could represent pneumonia or could be due to CHF . Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: DYSPNEA Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Mr ___ was a pleasure taking care of you at ___ ___. You were admitted for shortness of breath due to an exacerbation of your heart failure. This may have been caused by extra salt in your diet. You were given IV diuretics to rid of fluid, and did very well with this. Please continue to take your medications as prescribed. Your Multiple Myeloma medication Pomalidomide should not be contributing to your heart failure. Please continue to take this medication and follow up with Dr ___ this issue. You were also diagnosed with a urinary tract infection which we are treating with an antibiotic called Ciprofloxacin. Please finish the entire course of this medication. WE have also started you on a medication Lisinopril to decrease the resistance the heart has to pump against. You will need labs in one week to evaluate the kidneys response to this medication. For your heart failure please continue to weigh yourself every morning, call Dr. ___ if weight goes up more than 3 lbs in two days. Please also try to avoid sodium in your diet which can cause an exacerbation of your heart failure symptoms.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, constipation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ old man with locally advanced pancreatic adenocarcinoma with liver metastases C6D28 of gemcitabine/nab-paclitaxil and cyberknife SBRT (completed on ___ who presents with generalized weakness. The patient reports one week of generalized weakness limiting his ability to ambulate. He also reports 5 days of constipation. He denies abdominal pain, nausea, vomiting, fever, chills, chest pain, shortness of breath, cough. In the ED, initial VS were: T 98.2 HR 111 BP 118/74 RR 18 SpO2 99% RA. Exam was notable for external hemorrhoids, bright red blood on rectal exam, patient was guaiac positive. Initial labs were notable for H/H of 8.7/27.8 (near baseline), lactate 2.1, elevated LFTs (ALT ___ AST 47, AP 504, TBili 0.4), albumin 2.5. GI was consulted for hematochezia and recommended serial Hcts. Patient received 1 L NS. CXR was unremarkable. The patient was admitted to OMED for further management. On arrival to the floor, patient reports ___ weakness and unsteady gait. He reports he sustained a abdominal muscle strain about one week ago in the setting of lifting. He saw his PCP and was prescribed muscle relaxants. Since his injury, he reports he has not been ambulating well. He denies any falls or headstrike. He also experiences some difficulty standing up but denies any lightheadedness, chest pain, dyspnea, falls, dysuria, abdominal pain, fevers, chills, nausea, or vomiting. He reports ongoing constipation with his last bowel movement about 4 days ago. He denies any numbness around his buttock region and denies any urinary incontinence. Past Medical History: - appendectomy - tonsillectomy - HTN - hyperlipidemia Social History: ___ Family History: Father with MI Physical Exam: ON ADMISSION: VS: T 97.5 HR 92 BP 114/76 RR 20 SpO2 not available Wt 161.5 lbs GENERAL: Elderly man in NAD HEENT: Sclera icteric. MMM, no OP lesions. CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: CN II-XII intact. Full strength and sensation in UE and ___ bilaterally. Unstable gait with walking a few steps. No saddle anesthesia SKIN: Sacral pressure ulcer with granulation tissue otherwise without obvious erythema or discharge. ON DISCHARGE: VS: T 98.7 Tc 97.9 HR ___ BP 108-140/58-70 RR ___ SpO2 97-98% RA Wt 160.2 lbs, I/O 24h 640/850, 8h 100/500 GENERAL: Elderly man in NAD HEENT: Sclera icteric. MMM, no OP lesions. CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: clear to auscultation, no wheezes or rhonchi ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema PULSES: 2+DP pulses bilaterally NEURO: CN II-XII intact. Full strength and sensation in UE and ___ bilaterally. Unstable gait with walking a few steps. No saddle anesthesia SKIN: Sacral pressure ulcer with granulation tissue otherwise without obvious erythema or discharge. Pertinent Results: ADMISSION LABS: ___ 02:00PM BLOOD WBC-8.5 RBC-2.98* Hgb-8.7* Hct-27.8* MCV-93 MCH-29.1 MCHC-31.2 RDW-19.8* Plt ___ ___ 02:00PM BLOOD Neuts-73.5* Lymphs-17.4* Monos-8.5 Eos-0.4 Baso-0.2 ___ 02:00PM BLOOD Plt ___ ___ 02:00PM BLOOD Glucose-112* UreaN-9 Creat-0.4* Na-135 K-3.9 Cl-103 HCO3-21* AnGap-15 ___ 02:00PM BLOOD ALT-61* AST-47* AlkPhos-504* TotBili-0.4 ___ 02:00PM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.7 Mg-1.8 ___ 02:23PM BLOOD Lactate-2.1* ___ 06:09AM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:09AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 06:09AM URINE ___ Bacteri-OCC Yeast-NONE Epi-0 IMAGING: CHEST (PA & LAT) ___: IMPRESSION: No acute cardiopulmonary process. ABDOMEN (SUPINE & ERECT) ___: IMPRESSION: No evidence of obstruction or ileus. There is a large amount of stool within the colon. MICROBIOLOGY: ___ 2:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): DISCHARGE LABS: ___ 04:35AM BLOOD WBC-10.1 RBC-2.90* Hgb-8.7* Hct-26.9* MCV-93 MCH-30.1 MCHC-32.5 RDW-19.4* Plt ___ ___ 04:35AM BLOOD Plt ___ ___ 04:35AM BLOOD Glucose-113* UreaN-9 Creat-0.4* Na-135 K-3.6 Cl-101 HCO3-22 AnGap-16 ___ 04:35AM BLOOD ALT-40 AST-31 LD(LDH)-183 AlkPhos-518* TotBili-0.4 ___ 04:35AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.7 ___ 04:35AM BLOOD CA ___ -PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 6. Omeprazole 40 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN Nausea 8. Prochlorperazine 10 mg PO Q6H:PRN Nausea 9. Docusate Sodium 100 mg PO BID 10. Senna 8.6 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Docusate Sodium 100 mg PO BID 4. Lisinopril 20 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN Nausea 8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 9. Senna 8.6 mg PO BID 10. Prochlorperazine 10 mg PO Q6H:PRN Nausea 11. Bisacodyl 10 mg PO DAILY RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. Prescription for ___ Prescription. ICD-9 code Pancreatic Cancer 157. Patient deconditioned and needs walker for ambulation. 13. Polyethylene Glycol 17 g PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Constipation Weakness Pancreatic adenocarcinoma 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 pancreatic CA on chemo p/w generalized weakness // r/o PNA TECHNIQUE: PA and lateral views of the chest. COMPARISON: CT chest from ___. FINDINGS: Right chest wall port is seen with catheter tip in the right atrium. The lungs are clear without focal consolidation or effusion. The cardiomediastinal silhouette is within normal limits. Atherosclerotic calcifications are noted at the aortic arch. No acute osseous abnormalities identified. No free air seen below the diaphragm. Stent is partially visualized in the upper abdomen. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: ABDOMEN (SUPINE AND ERECT) INDICATION: ___ year old man with ___ old man with locally advanced pancreatic adenocarcinoma with liver metastases C6D28 of gemcitabine/nab-paclitaxil and cyberknife SBRT (completed on ___ with abdominal pain, constipation // evaluate for obstruction, ileus, stool TECHNIQUE: Two views of the abdomen COMPARISON: CT abdomen and pelvis ___. FINDINGS: There is a CBD stent noted in the right upper quadrant. The bowel gas pattern is nonspecific and nonobstructive. There are no abnormally dilated loops of small or large bowel. There is no evidence of pneumatosis or pneumoperitoneum. There is a large amount of stool within the colon. IMPRESSION: No evidence of obstruction or ileus. There is a large amount of stool within the colon. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Weakness, Pain Diagnosed with OTHER MALAISE AND FATIGUE, RECTAL & ANAL HEMORRHAGE temperature: 98.2 heartrate: 111.0 resprate: 18.0 o2sat: 99.0 sbp: 118.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure caring for you at the ___ ___. As you know, you were admitted for weakness and constipation. You were treated with bowel medications and an enema which relieved your constipation. You were also given your chemotherapy on ___ during your admission. You worked with physical therapy for your weakness and improved. Please continue your bowel medications at home as follows: -Colace, senna, miralax daily -Add bisacodyl if no BM greater than 1 day Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Double Vision Major Surgical or Invasive Procedure: ___ - Lumbar Puncture ___ - Lumbar Puncture History of Present Illness: Mrs. ___ is ___ year-old lady with a history of high grade DLBCL (diagnosed ___, currently on C3D16 R-CHOP s/p C1 of prophylactic HD-MTX and ulcerative colitis who is presenting with visual changes and headache. She was in a parking lot on her car on the day prior to admission, at which point she noted that the road signs looked "double" for her. Had her daughter take over and drive home where it resolved. Otherwise, she was in her usual state of health when she went to bed last night. On the morning of admission, she awoke reporting double vision (around 0830). Also reporting a mild headache, centered behind her right eye. She denies any fevers or chills, neck stiffness, difficulty walking, weakness or paresthesias. She was recently hospitalized at ___ for fever (negative infectious work-up, treated for 2 days with antibiotics and ultimately afebrile and discharged off antibiotics). Seen in the office on ___ by Dr ___ for ___ from previous hospitalization, where pt was reporting ongoing shin pain, which had been present during hospitalization. Per note, Dr ___ reaction to Neulasta in the setting of tapering steroids. Had been taking ibuprofen and naproxen for the past few days with little improvement. ED initial vitals: T 96.3, HR 96, BP 128/79, RR 18,SpO2 100% RA. ED labs were significant for: - CBC: WBC: 10.2*. HGB: 6.9*. Plt Count: 428*. Neuts%: 82*. - Chemistry: Na: 138. K: 3.9. Cl: 100. CO2: 25. BUN: 11. Creat: 0.4. Ca: 8.6. Mg: 2.2. PO4: 4.2. - Lactate: 1.4 - Imaging: CT head w/o contrast -- no acute intracranial abnormality. - Patient was given: nothing - Consults: neurology, recommended MRI w/ and w/o contrast and LP afterwards - Decision was made to admit to ___ for ongoing work-up of diplopia On arrival to the floor, patient reports ongoing diplopia without blurry vision. Headache has resolved. She continue to have mild pain in her right shin as well as pins/needles sensation in bilateral toes. Patient denies fevers/chills, night sweats, dizziness/lightheadedness, weakness/numbnesss, 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: -___: Referred to Dr ___ in our dept for probable malignancy. 30 pound wt loss over the past year and 8 pound drop over the fall. Developed worsening confusion and unsteadiness in early ___ and found to be hypercalcemic (Ca ___. Admitted to ___ where she was given iv fluids, Calcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC showed early myeloid forms and some nuc rbc and her LDH was elevated at 656. CT scans of chest, abd, pelvis did not show any adenopathy or splenomegaly. There was a 5mm low attenuation lesion in the panc head and a 1.3 cm lesion in the right adrenal gland. There was a large 8.7x7.7x6.5 mass inseparable from the uterus where a fibroid had been noted previously. Subsequent MRI showed diffused dilatation of the panc duct raising concern for IPM of the main panc duct and endoscopic ultrasound was suggested as well as a dedicated adrenal washout CT for the small adrenal lesion. -Dr. ___ a BM asp and Bx that day which did not show any abnormal lymphocytes in the aspirate and the cytogenetics and FISH were normal. However, the biopsy showed a multifocal infiltrate of malignant lymphocytes with Ki67 of 50-60%, felt to be an aggressive B cell lymphoma of germinal center origin. -___: Upper endoscopy showed mult gastric ulcers - bx showed lymphoma, cytogenetics showed BCL6, no myc or BCL2 translocations. -___: First cycle Rit/CHOP with split dose Rituxan. -___ for febrile neutropenia despite neulasta then ulc colitis flare. Restarted Pred. -___: Fever, diarrhea due to C.dif. Rx'd po vanco and pneumonia, rx'd Levoflox. -___: cycle 2 Rit/CHOP. PAST MEDICAL HISTORY: - Ulcerative Colitis - Rhinitis, allergic - Eczema - Headache, common migraine. *MRI performed ___ due to complaints of headache, and was unremarkable. - Hyperlipidemia - Fatty Liver - Fibroids - Osteoarthritis - Adrenal Nodule - Pancreatic Cyst Social History: ___ Family History: Paternal aunt with breast CA. Sister with breast CA in her ___. Physical Exam: ======================== Admission Physical Exam: ======================== VS: 98.1 PO 110 / 70 94 18 99 RA GENERAL: Well-appearing lady, in no distress lying, in bed comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear. CARDIAC: Regular rate and rhythm, normal heart sounds, 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. No lower extremity edema. No erythema or tenderness. NEURO: A&Ox3, good attention and linear thought. No apparent palsy of the III, IV, VI oculomotors, diplopia at baseline, convergence, horizontal and vertical gaze. Absent nystagmus. Otherwise CN V,VII-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. ======================== Admission Physical Exam: ======================== VS: Temp 98.0, BP 100/60, HR 89, RR 16, O2 sat 100% RA. GENERAL: Pleasant lady, in no distress lying, in bed comfortably. HEENT: Anicteric, PERLL, OP clear. Right ptosis. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought. Right eye ptosis stable, improved from several days ago. RLE weakness 4+/5. LLE ___ strength. Both upper extremities ___ strength. No other deficits noted. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. Pertinent Results: =============== Admission Labs: =============== ___ 12:00PM BLOOD WBC-10.2* RBC-2.07* Hgb-6.9* Hct-22.7* MCV-110* MCH-33.3* MCHC-30.4* RDW-19.7* RDWSD-78.7* Plt ___ ___ 12:00PM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-8 Eos-0 Baso-1 ___ Myelos-1* NRBC-1* AbsNeut-8.36* AbsLymp-0.82* AbsMono-0.82* AbsEos-0.00* AbsBaso-0.10* ___ 05:46AM BLOOD ___ PTT-31.4 ___ ___ 12:00PM BLOOD Glucose-257* UreaN-11 Creat-0.4 Na-138 K-3.9 Cl-100 HCO3-25 AnGap-17 ___ 12:00PM BLOOD Calcium-8.6 Phos-4.2 Mg-2.2 ___ 12:17PM BLOOD Lactate-1.4 ============== Interval Labs: ============== ___ 05:27AM BLOOD %HbA1c-6.9* eAG-151* ___ 06:27AM BLOOD RheuFac-<10 ___ ==================== Methotrexate Levels: ==================== ___ 12:29PM BLOOD mthotrx-0.53 ___ 12:07PM BLOOD mthotrx-0.07 ___ 05:37AM BLOOD mthotrx-0.02 =============== Discharge Labs: =============== ___ 05:41AM BLOOD WBC-3.8* RBC-2.74* Hgb-9.0* Hct-29.3* MCV-107* MCH-32.8* MCHC-30.7* RDW-15.9* RDWSD-63.3* Plt ___ ___ 05:41AM BLOOD Glucose-124* UreaN-9 Creat-0.5 Na-142 K-4.1 Cl-103 HCO3-27 AnGap-16 ___ 05:41AM BLOOD ALT-66* AST-42* AlkPhos-90 TotBili-0.2 ___ 05:41AM BLOOD Calcium-9.1 Phos-5.2* Mg-2.2 ============ ___ Studies: ============ ___ 01:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* Polys-0 ___ ___ 01:50PM CEREBROSPINAL FLUID (CSF) TotProt-79* Glucose-94 ___ 01:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-104* Polys-2 ___ Monos-25 Basos-2 ___ Macroph-2 Other-5 ___ 01:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-23* Polys-1 ___ Monos-17 Eos-1 Basos-1 ___ Macroph-1 Other-7 ___ 01:25PM CEREBROSPINAL FLUID (CSF) TotProt-61* Glucose-66 LD(LDH)-21 ___ 01:50PM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT ___ EBV PCR- Negative ___ Borrelia Burg___ Antibody - Pending ___ Angiotensin 1 Converting Enzyme - 11 (Negative) ___ CMV PCR- Negative ___ HSV PCR - Negative ___ Paraneoplastic Autoantibody Evaluation - Negative ___ VZV PCR - Negative ___ Toxoplasma Gondii PCR - Negative ___ VDRL - Non-Reactive ============= Microbiology: ============= ___ Blood Culture - No Growth ___ Urine Culture - Coag Negative Staph ___ CSF Culture - No Growth ___ Quantiferon-TB Gold - Negative ======== Imaging: ======== Head CT w/o Contrast ___ Impression: No acute intracranial abnormality on noncontrast head CT. MRI Head w/o Contrast ___ Impression: No evidence for intracranial metastatic disease. 5 mm right parietal dural calcification versus completely calcified meningioma is stable. MRI Orbit w/ and w/o Contrast ___ 1. Thickening and enhancement of the left oculomotor nerve from the interpeduncular cistern to the cavernous sinus. Mild enhancement of the right oculomotor nerve near the cavernous sinus. Given the patient's clinical history, this may represent lipomatous involvement. 2. No cavernous sinus lesion identified. CT Head/Neck ___ 1. Dental amalgam streak artifact limits study. 2. No evidence of acute intracranial hemorrhage. 3. No evidence ofaneurysm greater than 3 mm, dissection or significant luminal narrowing. 4. Left parotid gland oval soft tissue nodule may reflect a lymph node but remains incompletely characterized. Ultrasound or MRI can be obtained on a nonemergent basis for further evaluation. =================== Cytology/Pathology: =================== ___ CSF Cytology - Negative for malignant cells. Lymphocytes and monocytes. ___ CSF Flow Cytometry - Immunophenotypic findings are of involvement by a small population of kappa light chain restricted B cells. Review of corresponding cytospin preparation reveals medium to large atypical lymphoid cells with one to several prominent nucleoli and dark blue cytoplasm with vacuolations. Correlation with clinical, cytogenetic, and other ancillary findings is recommended. ___ CSF Cytogenetics - Negative for BCL6 rearragnement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Headache 2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Simvastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache 2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Lymphomatous Meningitis: - Diploplia: - CN III Palsy - High Grade B-Cell Lymphoma 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 right headache, diplopia. // CVA? TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: MRI head ___ FINDINGS: 5 mm calcified focus arising from the right parasagittal parietal inner table (series 3, image 47) corresponds to a focus gradient echo susceptibility artifact seen on prior MRI, likely representing a calcified meningioma. There is no intra or extra-axial mass effect, acute hemorrhage or large territory infarct. Ventricles and sulci are within expected limits for the patient's age. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial abnormality on noncontrast head CT. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: History of high-grade diffuse large B-cell lymphoma post chemotherapy presenting with new onset diplopia. Evaluate for infarct or leptomeningeal spread of disease, in particular the cavernous sinus. 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: MR head ___. Noncontrast head CT ___. FINDINGS: Previously noted focus of susceptibility artifact along the right parietal dura corresponds to a 5 mm dural calcification on recent CT examination (6:16), without evidence of contrast enhancement on MP RAGE images (10:139). There is no evidence for an enhancing mass or abnormal meningeal contrast enhancement. There is no evidence for edema, acute infarction, or new blood products. Ventricles and sulci are normal in size. A single punctate focus of left frontal subcortical white matter FLAIR hyperintensity is unchanged, nonspecific, though may reflect changes from chronic small vessel ischemic disease (7:20). The principal intracranial vascular flow voids are preserved. Dural venous sinuses appear patent on postcontrast MP RAGE images. This routine brain MRI is not optimized for detailed evaluation of the cavernous sinuses. The cavernous sinuses appear normal in size without evidence for a large mass. IMPRESSION: No evidence for intracranial metastatic disease. 5 mm right parietal dural calcification versus completely calcified meningioma is stable. RECOMMENDATION(S): If clinically warranted, a dedicated cavernous sinus protocol MRI with fat-suppressed postcontrast images could better assess the cavernous sinuses. Radiology Report EXAMINATION: MR ORBIT ___ ANDW/O CONTRAST T9123 MR ___ INDICATION: History of diffuse large B-cell lymphoma presenting with new diplopia and right eyelid ptosis. TECHNIQUE: Multiplanar, multi-sequence MRI of the orbits was performed before and after the uneventful administration of 5 mL Gadavist intravenous contrast agent. Images acquired at 3 mm slice thickness. Precontrast sequences included axial and coronal T1, coronal STIR. Postcontrast sequences included axial and coronal T1 with fat saturation. COMPARISON: MR head ___ and ___. FINDINGS: ORBITS: There is asymmetric thickening and enhancement of the left oculomotor nerve (series 7, image 9 and 10; cyst series 8, image 23), from the interpeduncular cistern to the cavernous sinus which may represent lymphomatous involvement. In addition, there is less prominent enhancement along the right oculomotor nerve as it enters the cavernous sinus (series 7, image 9). The remainder of the visualized cranial nerves are grossly unremarkable. The bony orbits and preseptal soft tissues are normal. The globes are intact and normal in appearance. The optic nerves and complex are normal, without edema or abnormal enhancement. The extraocular muscles are uniform in size and normal in signal. The lacrimal apparatus is normal. Retrobulbar soft tissues are normal. OTHER FINDINGS: The imaged portion of the brain is normal, without masses, abnormal enhancement, or edema, better assessed on the recent dedicated head MR. ___ cavernous sinuses are unremarkable. There is trace mucosal wall thickening in the floors of the bilateral maxillary sinuses. The remainder of the imaged paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Thickening and enhancement of the left oculomotor nerve from the interpeduncular cistern to the cavernous sinus. Mild enhancement of the right oculomotor nerve near the cavernous sinus. Given the patient's clinical history, this may represent lipomatous involvement. 2. No cavernous sinus lesion identified. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:51 ___, 20 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old woman with diffuse large B cell lymphoma with new R eye ptosis // to rule out aneurysm. 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) Spiral Acquisition 9.8 s, 20.1 cm; CTDIvol = 51.9 mGy (Head) DLP = 1,047.7 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 8.2 mGy (Head) DLP = 3.3 mGy-cm. 3) Stationary Acquisition 0.9 s, 0.2 cm; CTDIvol = 19.6 mGy (Head) DLP = 3.9 mGy-cm. 4) Spiral Acquisition 7.0 s, 37.0 cm; CTDIvol = 33.4 mGy (Head) DLP = 1,246.0 mGy-cm. Total DLP (Head) = 2,301 mGy-cm. COMPARISON: MR head with contrast performed ___. FINDINGS: Dental amalgam streak artifact limits study. CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. 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: 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: Mild paraseptal emphysema involves the lung apices bilaterally and symmetrically. A right chest port traverses the right chest wall and into the right internal jugular vein, its tip incompletely imaged. A 1.1 x 0.9 cm soft tissue oval density within the left parotid gland (5:151) may reflect a lymph node although remains incompletely characterized. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Dental amalgam streak artifact limits study. 2. No evidence of acute intracranial hemorrhage. 3. No evidence ofaneurysm greater than 3 mm, dissection or significant luminal narrowing. 4. Left parotid gland oval soft tissue nodule may reflect a lymph node but remains incompletely characterized. Ultrasound or MRI can be obtained on a nonemergent basis for further evaluation. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: Visual changes Diagnosed with Diplopia temperature: 96.3 heartrate: 96.0 resprate: 18.0 o2sat: 100.0 sbp: 128.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of at the ___ ___. You were admitted for evaluation of your double vision. While in the hospital you also developed drooping of your right eyelid and right leg weakness. You had lumbar punctures and an MRI of your brain/orbits which were concerning for central nervous system involvement by lymphoma (also called lymphomatous meningitis). You were evaluated by Dr. ___ in ___ Oncology who recommended started chemotherapy with methotrexate and rituximab for treatment of your neurological symptoms. You tolerated the chemotherapy without any issues. You will be admitted to the hospital every two weeks to receive your methotrexate. Please plan on returning to ___ on ___ in the morning. We hope that with treatment your symptoms continue to improve. You will also have weekly Rituximab infusions for the next 3 weeks. The next infusion is due on ___. This is currently being scheduled for you at ___. You will be called at home in a day or two to confirm the timing of your appointment. The following week (week of ___, you will need to go to ___ on either ___ or ___ (___) for your Rituximab. You will then come to ___ on ___ as above for your methotrexate. You were also been by Ophthalmology and found no evidence of ocular lymphoma. They were also able to provide some advice for helping with the double vision. If your double vision does not improve you can see them in clinic as well for further evaluation. You will ___ with the ___ Oncology team. You will also ___ with Dr. ___ who is one of the Oncologists at ___ for discussion on future chemotherapy plan. All the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: bacitracin Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: laparoscopic appendectomy History of Present Illness: Mr. ___ is a ___ year old male with no significant medical history who presents with generalized abdominal pain. He reports that the pain started yesterday and has been near the lower midline portion of the abdomen. It is associated with anorexia, bloating and subjective fevers, diaphoresis but no n/v or changes in BMs. He has never had similar pain. He reported eating seafood a couple of days ago but his wife did not develop similar symptoms. ROS is positive for headaches, URI symptoms, and fatigue starting late last week, for which he has been taking ibuprofen. He has no personal or family history of IBD and has never had a colonoscopy. His grandfather had colon cancer in his ___. He last ate at breakfast time ___ a bagel). Past Medical History: none Social History: ___ Family History: Colon cancer in grandfather in ___. Otherwise noncontributory Physical Exam: Vitals: T 97.8, HR 80, BP 117/64, RR 18, SpO2 98% RA GEN: A&Ox3, lying comfortably in bed HEENT: No scleral icterus CV: RRR PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, non-distended, appropriately mildly tender to palpation. Surgical incisions clean, dry, well approximated EXT: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 11:00AM BLOOD WBC-7.5 RBC-5.20 Hgb-15.3 Hct-45.6 MCV-88 MCH-29.4 MCHC-33.6 RDW-12.6 RDWSD-40.3 Plt ___ ___ 11:00AM BLOOD Neuts-62.2 ___ Monos-9.3 Eos-1.6 Baso-0.4 Im ___ AbsNeut-4.68 AbsLymp-1.97 AbsMono-0.70 AbsEos-0.12 AbsBaso-0.03 ___ 11:00AM BLOOD Plt ___ ___ 11:00AM BLOOD ___ PTT-34.7 ___ ___ 11:00AM BLOOD Glucose-109* UreaN-13 Creat-1.0 Na-139 K-4.4 Cl-99 HCO3-28 AnGap-12 ___ 11:00AM BLOOD ALT-24 AST-18 AlkPhos-52 TotBili-0.5 ___ 11:00AM BLOOD Lipase-33 ___ 11:00AM BLOOD Albumin-4.7 Medications on Admission: Ibuprofen PRN Headaches Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever Do not exceed more than 4000mg/day. Careful when taking other meds that contain Tylenol. 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe Please only take the minimum amount necessary to treat your pain. RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*10 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: acute appendicitis s/p appendectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with abd pain, frequent NSAID use// please perform upright CXR to eval for free air under the diaphragm TECHNIQUE: PA and lateral views the chest. COMPARISON: None FINDINGS: Lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. No free intraperitoneal air. IMPRESSION: No acute cardiopulmonary process. No free intraperitoneal air. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with abdominal pain TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the 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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 22.0 mGy (Body) DLP = 1,165.2 mGy-cm. 3) Spiral Acquisition 0.9 s, 7.1 cm; CTDIvol = 15.3 mGy (Body) DLP = 109.0 mGy-cm. Total DLP (Body) = 1,283 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 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. Fluid-filled appendix, measuring up to 8 mm, with increased mucosal enhancement and surrounding fat stranding (03:51). No evidence of perforation, abscess. Overall, this is consistent with uncomplicated appendicitis. 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. 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: Uncomplicated acute appendicitis. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Unspecified acute appendicitis temperature: 97.3 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 137.0 dbp: 88.0 level of pain: 4 level of acuity: 3.0

Dear Mr. ___, You were admitted to ___ ___ and underwent a laparoscopic appendectomy. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: ACTIVITY: -Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. -You may climb stairs. -You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. -Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. -You may start some light exercise when you feel comfortable. -You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: -You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. -You may have a sore throat because of a tube that was in your throat during surgery. -You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. -You could have a poor appetite for a while. Food may seem unappealing. -All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: -Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you may have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). If your incisions are closed with dermabond (surgical glue), this will fall off on it's own in ___ days. -Your incisions may be slightly red. This is normal. -You may gently wash away dried material around your incision. -Avoid direct sun exposure to the incision area. -Do not use any ointments on the incision unless you were told otherwise. -You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. -You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: -Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. -If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: -It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". -Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. -You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. -Your pain medicine will work better if you take it before your pain gets too severe. -Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. -If you are experiencing no pain, it is okay to skip a dose of pain medicine. -Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Warm regards, Your ___ Surgery Team

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 Major Surgical or Invasive Procedure: Hepatic bile lake drain placement ___ Subsequent ERCP with CBD stent placement History of Present Illness: ___ w/ fibrolamellar HCC s/p TACE on ___, dc-ed on ___ who presented to ___ ED with fever, nasuea, headache. The patient called the hem onc fellow, stated she had a fever last evening to ___ for which she took advil. This morning, she reported another fever to 101.5F. Also felt nauseated. She reported no jaundice, rashes, ___ stools. The fellow advised her to come to the ED for lab check (LFTs, CBC, CHem) and to r/o infection with blood cultures. - In the ED, initial VS were 6 101.7 104 132/73 18 100%. - Labs were notable for na 131, uptrending LFTs but otherwise normal chem panel, cbc, lactate, UA and -ve hcg. Blood cultures sent. - Patient given tylenol, zofran, oxycodone, ibuprofen and 1L NS. - Patient was admitted to OMED for further management. - VS prior to ED 8 100.6 105 124/66 16 97% RA. The patient was VSS on arrival although was febrile. She complained of a headache, nausea, says she hasnt had much to drink other than gingerale, has also had ice cream. Abdominal pain reported epigastric and in RUQ. REVIEW OF SYSTEMS: +ve per HPI. Past Medical History: PAST ONCOLOGIC HISTORY (updated from last dc summary): -___: Began experiencing intermittent episodes of non- radiating, localized mid-epigastric pain associated with nausea and occasionally emesis when the pain was more severe. She states the episodes of pain would occur initially on the order of once every few weeks. However, over the course of the past year, the intense episodes occur almost daily in the form of severe pain with n/v; aside from the severe pain, she now also experiences a constant dull mid-epigastric pain. In addition to the pain, she has also noted an unintentional forty pound weight loss since ___ with decreased appetite and early satiety. She had been experiencing almost nightly drenching night sweats soaking through her clothes and wetting mher hair for the past six months in addition to generalized mfatigue and an infrequent subjective fever (once every month). -___ medical attention a few times for these symptoms. In ___, she went into walk-in clinics on a few occasions and was given antiacids or told she had anxiety. -___: ___ ED because she noted 2 tablespoons of blood with a bout of emesis. She was discharged from the ED and placed on pepcid for a month. -___: Due to a severe bout of abdominal pain and emesis, she presented to ___. Doppler Ultrasound of the abdomen showed a large mass of the left lobe of liver extending to the caudate lobe measuring 8.8 x 5.5 x 7.6 cm, a well-defined hypoechoic mass posterior to the pancreas measuring 4.0 x 2.5 x 3.6 cm concerning for an enlarged lymph node, and fatty infiltration of the liver with appropriate Doppler blood flow in the portal veins with no evidence of splenic enlargement. A CT Abdomen and Pelvis revealed a large heterogenous left liver lobe mass measuring 0.5 x 8.1 x 9.4 cm, a heterogeneously enhancing mass adjacent the head of the pancreas measuring 3.4 x 3.0 x 4.3 cm, and multiple periportal lymph nodes measuring up to 2.0 x 1.6 cm. Her labs were reflective of a WBC of 13.9 with 77.8% PMNs and 10.8% lymphocytes, a negative urine pregnancy test, an AST/ALT of 670/188, an alkaline phosphatase of 112, and a normal bilirubin. -Transferred to the ___. CT Chest no evidence of masses or lymphadenopathy. -___: ___ liver biopsy which consistent with fibrolamellar hepatocellular carcinoma. Her AFP was notably not elevated. She was discharged on ___ with prn dilaudid for her associated abdominal pain. -___, her case was presented at liver tumor conference. After discussion with the multidisciplinary team (surgery, radiation oncology, and oncology), it was recommended for her to proceed with surgical excision -___: Exploratory laparotomy, intraoperative ultrasound, left hepatic lobectomy, portal lymph node dissection, and placement of fiducial markers. Course complicated by biloma s/p ___ drainage **PATH: -Pancreatic head and portal lymph node #1, resection (2A-2B): Metastatic hepatocellular carcinoma, fibrolamellar variant in one lymph node. Residual lymphoid tissue is seen (___). -Lymph node, right portal vein (3A-3B): One lymph node, no carcinoma seen (___). -Lymph node, hepatic artery (4A-4E): Metastatic HCC, fibrolamellar variant in one lymph node (___). Residual lymphoid tissue is seen. -Greatest dimension: 8.6 cm. Additional ___: 5.5 cm. x 3.2 cm. G2: Moderately differentiate. Negative for invasive carcinoma. Macroscopic Venous (Large Vessel) Invasion: Present Microscopic (Small Vessel) Invasion: Present Perineural Invasion: Present -___: Percutaneous transhepatic cholangiography with biliary drain placement -___: CT A/P *Large fluid collection along the left hepatic lobectomy site, compatible with biloma. *New moderate intrahepatic biliary ductal dilatation with the etiology unclear. There are sutures and clips near the site of caliber change as well as the JP drainage catheter passing this region, however the etiology is not definitely identified and could be due to extrinsic compression by the biloma. -___: cholangiogram and exchange of percutaneous transhepatic biliary drain placement (now internal-external drain) -___: D/Ced from hospital -___: D/ced after admission for fever; Interventional Radiology performed a cholangiogram noting a small fluid collection along the anterior aspect of the hepatectomy site with the pigtail catheter terminating more posteriorly, where there was no longer residual fluid; dced on IV abx -___: Admitted to ___ for Adbl pain with fluid collection; biliary withdrawn to terminate in the fluid. -___: Surgery clinic drain removed; placed on Augmentin. -___: Cholangiogram w/persistent area of stenosis at main RHD and CBD; balloon dilatation performed with some improvement; PTBD upsized to ___. Fever s/p procedure and admitted to ___. -___: Cultures grew E. Coli; txed with Unasyn and switched to PO Bactrim on discharge. -___: CT A/P: *Interval decrease in fluid collection adjacent to the medial portion of the remnant liver. A percutaneous transhepatic biliary drain is identified in appropriate position. *Status post left hepatectomy. No evidence of disease recurrence within the remaining liver. No evidence of metastatic disease within the abdomen and pelvis. *Thrombosed portal vein branch supplying segment IVb, unchanged since prior examination. -___: Cholangiogram *Pre-existing 10 ___ internal-external biliary drain in appropriate position. *Cholangiogram showing brisk flow of contrast into the duodenum. There was moderate improvement in the degree of stenosis at the junction of the main right hepatic duct and common bile duct, although some mild residual narrowing remains. There was satisfactory forward flow. No dilatation was performed. *Successful exchange of 10 ___ percutaneous transhepatic biliary drainage catheter for a 10 ___ Amplatz anchor drain. -___: CT Chest-negative; MRI Abdomen-multiple hyperenhancing lesions maximal 10mm -___: CT Pelvis and bone scan-no lesions - ___ underwent subselective Seg VII, VIII lobe TACE - ___ readmitted with pain, nausea and fevers PAST MEDICAL HISTORY: - Stage ___ fibrolamellar hepatocellular carcinoma (T2N1M0) - L leg fracture - Nephrolithiasis - Depression w/ h/o suicide attempt w/ OD x1 Past Surgical History: - L hepatic lobectomy - LLE plates/screws for fx and 1 revision procedure Social History: ___ Family History: No liver disease or cancer Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD VITAL SIGNS: 102.2 125/67 108 16 97 ra HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, soft, mild tenderness in RUQ, 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 excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities DISCHARGE EXAM: VS 98.1 106/68 71 18 98 RA HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, R jp drain in place draining green/clear bile, nontender abdomen other than at drain insertion site in RUQ, no distention, no masses. LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: ___, EOMI, face symmetric, moves all ext against resistance, sensation intact to light touch Pertinent Results: ADMISSION LABS: ___ 05:20PM BLOOD ___ PTT-31.5 ___ ___ 07:36AM BLOOD Glucose-91 UreaN-4* Creat-0.7 Na-137 K-4.2 Cl-102 HCO3-28 AnGap-11 ___ 05:20PM BLOOD ALT-121* AST-122* AlkPhos-210* TotBili-0.3 ___ 07:36AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9 CT abdomen/pelvis ___: IMPRESSION: 1. Findings concerning for biliary ischemia including new bile lakes about the portal vein branches. Superinfection cannot be excluded by CT. 2. Hypoattenuation of multiple hepatic metastases seen on prior MRI consistent with post TACE state. 3. Patent portal and hepatic veins. The extrahepatic hepatic artery is patent. MRCP ___ IMPRESSION: 1. Ischemic cholangitis with bile lakes in segments VII and VIII status post TACE. No MRI findings to suggest superinfection. 2. Peripheral enhancement surrounding a 1.3 cm treated lesion in segment VIII may reflect post treatment change, although a small developing abscess is not excluded. 3. Overall improvement in diffuse hepatic metastases particularly in the treated segments, however multiple persistent enhancing lesions in segments V and VI remain consistent with viable HCC metastases. MRCP ___: IMPRESSION: Progression of sequela of ischemic cholangiopathy with increasing size of previously seen the bile lakes. Despite presence of gas within the lakes, and heterogeneous parenchymal enhancement, there is no one particular collection which demonstrates definitive features of infection or different features from the collections elsewhere. Gas and enhancement can be accounted for by recent interventions, sphincterotomy, and vascular insults. Numerous treated and several viable foci of metastatic disease. Bilateral renal parenchymal edema and heterogeneous enhancement suggestive of pyelonephritis. Echo ___ The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: No evidence of valvular vegetations. Preserved biventricular regional/global systolic function. No significant valvular disease. Percutaneous Drain ___: FINDINGS: 1. Limited grayscale ultrasound imaging of the liver re- demonstrates multiple heterogeneous and hypoechoic areas within the right lobe of the liver, consistent with areas identified on the prior MRI. 2. Sinogram of the accessed collection demonstrates filling of the cavity. No obvious connection to the biliary tree is identified, however aggressive distension of the cavity was not performed given known infected nature of the fluid. 3. 8 ___ APDL drainage catheter placed. 4. 12 cc brownish fluid removed and sent for microbiology evaluation. IMPRESSION: Successful placement of 8 ___ drainage catheter into hepatic collection/cavity. ERCP ___ The scout film revealed previous surgical clips and biliary drain in place. The bile duct was deeply cannulated with the sphincterotome and then with the balloon over the guidewire. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. The CBD was 8mm in diameter. There were no filling defects. The right hepatic ducts and all intrahepatic branches were normal. There was no evidence of bile leak. Given clinical presentation with biloma with ongoing output from biliary drain, decision was made to place a CBD stent. A 10cm by ___ plastic stent was placed successfully in the CBD. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum DISCHARGE LABS: ___ 05:30AM BLOOD WBC-8.5 RBC-3.24* Hgb-8.7* Hct-26.3* MCV-81* MCH-26.9* MCHC-33.1 RDW-14.5 Plt ___ ___ 05:30AM BLOOD Glucose-94 UreaN-4* Creat-0.7 Na-139 K-4.1 Cl-103 HCO3-26 AnGap-14 ___ 05:30AM BLOOD ALT-29 AST-43* AlkPhos-751* TotBili-0.6 ___ 05:30AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.4* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Lorazepam 0.5 mg PO Q6H:PRN anxiety 3. Ondansetron 8 mg PO Q8H:PRN nausea 4. MetRONIDAZOLE (FLagyl) 500 mg PO TID 5. Ranitidine 150 mg PO BID 6. Sulfameth/Trimethoprim DS 1 TAB PO BID 7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 8. Morphine SR (MS ___ 15 mg PO Q8H 9. Docusate Sodium 100 mg PO DAILY 10. Senna 8.6 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cholangitis Bacteremia 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 with intravenous contrast. INDICATION: ___ year old woman with fibrolamellar liver CA s/p TACE h/o abscess now with high fevers and GPC bacteremia pls r/o liver abscess thank you! // r/o liver abscess/other intra-abd infection, any CBD dilation, thank you! 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 reviewed on PACS. Oral contrast was administered. DOSE: DLP: 1042.80 mGy-cm (abdomen and pelvis. IV Contrast: 130 mL Omnipaque COMPARISON: MRI abdomen ___. CT abdomen ___. FINDINGS: LOWER CHEST: There is bibasilar atelectasis. There is no pleural or pericardial effusion. Heart size is not enlarged. Abdomen/pelvis: Surrounding the portal tracts are irregular branching and lobulated hypodensities consistent with bile lakes that are new in the interval since prior MR of ___. At least one air containing structure is seen consistent with small quantity of pneumobilia within a bile duct in the center of one such lake (4:20). There are numerous round hypoenhancing foci throughout the liver consistent with lesions treated with trans arterial chemo embolization. Some segmental biliary ductal dilation is redemonstrated along the anterior aspect of the hepatic remnant (4:30), unchanged. There has been prior left hepatectomy. Portal and hepatic vein branches remain patent. The extrahepatic portion of the hepatic artery opacifies (4:28). The spleen measures 13.4 cm in length. There is no evidence of pancreatic mass or pancreatic ductal dilatation. There is symmetric renal enhancement and excretion of intravenous contrast. Urinary bladder is mildly distended without gross abnormality. There are no dilated loops of bowel. There is no evidence of bowel wall thickening. There is no intraperitoneal free air or free fluid. The abdominal aorta has a normal course and caliber. There are no enlarged inguinal or iliac chain lymph nodes. There is no suspicious osseous lesion. IMPRESSION: 1. Findings concerning for biliary ischemia including new bile lakes about the portal vein branches. Superinfection cannot be excluded by CT. 2. Hypoattenuation of multiple hepatic metastases seen on prior MRI consistent with post TACE state. 3. Patent portal and hepatic veins. The extrahepatic hepatic artery is patent. NOTIFICATION: Results were discussed with the clinical team caring for the patient 15 minutes following discovery on ___ via telephone. Radiology Report INDICATION: ___ year old woman with RA biliary dilation post TACE // R PTBD COMPARISON: CT from ___. TECHNIQUE: OPERATORS: Dr. ___ resident) and Dr. ___ ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___ radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: General anesthesia was administered by the anesthesiology department. Please refer to anesthesiology notes for details. MEDICATIONS: 1 g ceftriaxone CONTRAST: 65 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 16.4 min, 3000 cGy-cm2 PROCEDURE: 1. Transabdominal ultrasound. 2. Ultrasound guided right percutaneous transhepatic bile duct access. 3. Right cholangiogram 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 right abdomen was prepped and draped in the usual sterile fashion. Multiple passes were made through the liver utilizing a 21 gauge cook needle under ultrasound and fluoroscopic guidance. Initial images demonstrate a irregular collection of contrast near segments 7 and 8 of the liver corresponding to the CT images. Ultrasound was utilized extensively which did not demonstrate any dilated bile ducts, only normal caliber ducts adjacent to portal vessels. Eventually, under fluoroscopic guidance, a Cook needle was advanced into the right posterior biliary system and a right-sided cholangiogram was performed which demonstrated normal caliber bile ducts and prompt flow to the CBD and into the small bowel. The right anterior bile duct was also opacified and was noted to be of normal caliber and coursing through the area of earlier identified collection. There was no clear communication with this collection and the traversing bile duct. Given that there was no dilation or obstruction of the biliary system and prompt flow of contrast through the common bile duct, as well is no communication with the collections surrounding the right anterior ducts, the decision was made not to place a percutaneous drain. The needles were removed. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Normal caliber intra and extrahepatic bile ducts with prompt drainage through to the duodenum and no evidence of obstruction. 2. Opacified collection of likely necrotic tissue surrounding the right anterior ducts, but with no clear communication with the transversing ducts. IMPRESSION: Transhepatic cholangiogram performed with results as above. RECOMMENDATION: MRCP could be performed to evaluate the relation between the collections demonstrated on the previous CT and the biliary system. Radiology Report EXAMINATION: MRI abdomen with and without contrast. INDICATION: ___ year old woman with liver cancer s/p TACE now with cholangitis and CT with ?biliary abscesses but attempted drainage unsuccessful, need to characterize these further. PLEASE ALSO DO WITH CONTRAST TO CHARACTERIZE LIVER TUMOR // ?biliary abscesses but attempted drainage unsuccessful, need to characterize these further. PLEASE ALSO DO WITH CONTRAST TO CHARACTERIZE LIVER TUMOR TECHNIQUE: Multiplanar T1 and T2 weighted sequences were obtained in a 1.5 Tesla magnet including dynamic 3D imaging performed prior to, during, and after the uneventful administration 8cc of ___. COMPARISON: MRI abdomen of ___ FINDINGS: Minimal atelectasis is present at the lung bases. There are no pleural effusions. The liver demonstrates changes of prior left hepatectomy. Multiple serpiginous areas of fluid signal intensity are present throughout segments VII and VIII following the course of the intrahepatic bile ducts. This appearance is characteristic for ischemic cholangitis and corresponds to the segments treated by recent TACE. There is no peripheral enhancement or loculated gas to suggest superinfection. A 1.3 cm lesion at the periphery of segment VIII now demonstrates progressive peripheral enhancement (1602:49), possibly due to treatment change. Other previously arterial enhancing lesions in segments VIII and VII are no longer seen. Numerous lesions persist in segments V and VI ; essentially all of these display arterial phase hyperenhancement with subsequent washout consistent with HCC metastases. One lesion at the periphery of segment V is slightly enlarged, 1.3 cm currently from prior 0.9 cm (1601:84). Other lesions are smaller or less conspicuous: For example, a prior 0.9 cm lesion at the inferior margin of segment VI is not measurable on the current study. Two hyperenhancing foci in segment V, new from the prior exam, are most consistent with perfusion difference (1601:70). The spleen, pancreas, adrenal glands, and kidneys have a normal appearance. Visualized bowel and mesentery are unremarkable. There is no retroperitoneal or mesenteric lymphadenopathy. A small volume of free fluid is present in the pelvis. No concerning osseous lesion is identified. IMPRESSION: 1. Ischemic cholangitis with bile lakes in segments VII and VIII status post TACE. No MRI findings to suggest superinfection. 2. Peripheral enhancement surrounding a 1.3 cm treated lesion in segment VIII may reflect post treatment change, although a small developing abscess is not excluded. 3. Overall improvement in diffuse hepatic metastases particularly in the treated segments, however multiple persistent enhancing lesions in segments V and VI remain consistent with viable HCC metastases. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with just got PICC. Evaluate line placement. TECHNIQUE: Single portable AP view of the chest. COMPARISON: Chest PA and lateral from ___. FINDINGS: The left PICC line tip terminates in the right atrium and should be withdrawn at least 6.5 cm to be positioned in the lower SVC, if desired. No pneumothorax. There is minimal right basilar atelectasis. The lungs are otherwise clear without focal consolidation or large effusions. Heart size, mediastinal, and hilar contours are normal. IMPRESSION: The left PICC line tip terminates in the right atrium and should be withdrawn at least 6.5 cm to be positioned in the lower SVC, if desired. NOTIFICATION: The above findings were communicated on the telephone by Dr. ___ to ___ (IV RN) at 16:36 on ___, 2 min after discovery. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with picc adjustment // pls eval picc placement Contact name: white, ___: ___ TECHNIQUE: Single frontal view of the chest COMPARISON: Study performed 2 hours earlier IMPRESSION: Right PICC tip is in thecavoatrial junction. No other interval change Radiology Report EXAMINATION: MRI of the abdomen with and without contrast INDICATION: ___ year old woman with Fibrolamellar HCC post TACE, persistent fevers worsening LFTs // eval for coalescing bile lakes from worsening ischemic cholangitis vs abscess formation TECHNIQUE: Multiplanar MRI of the abdomen is obtained at 1.5 Tesla per the liver mass protocol. T1 and T2 weighted sequences are acquired both pre and post administration of 8 mL of gadavist. COMPARISON: Multiple prior abdominal CTs and MRIs most recently dating ___ FINDINGS: Hepatic morphology is consistent with provided history of a prior left hepatectomy. There has been a significant interval change since the most recent examination 3 days previously. The previously-seen bile lakes, denoted by serpiginous areas of fluid intensity along the course of the intrahepatic bile ducts are re-demonstrated. There appear to be at least three discretely separate fluid collections seen centrally originating adjacent to the resection margin. As these extend superiorly into segments VII and VIII, the middle fluid collection expands and bifurcates (5:14). This component has significantly increased in size from a 1.5 x 2.4 cm nonenhancing component to a 7.7 x 3.9 cm region of nonenhancement (903:30). The new areas of fluid signal correlate with the previously seen areas of parenchymal heterogeneity of signal and enhancement, presumably representing progressive liquefaction of ischemic parenchyma. While parts of this segment VIII abnormality demonstrate T2 hyperintensity of fluid (4:11), more peripheral areas are edematous and nonenhancing, but less T2 hyperintense (4:13). Each of these fluid pockets is variably T2 hyperintense and T1 hypointense and nonenhancing. There are punctate foci of susceptibility artifact within the bile lakes, consistent with gas. Despite this finding, there is no identified region of restricted diffusion and most have no surrounding rim of hyperenhancement to suggest suprainfection. This gas is likely on the basis of prior sphincterotomy given gas within the central bile duct, as well as prior attempted drainage. Bile lakes adjacent to the resection margin which were previously present and are unchanged in size do demonstrate a thin rim of hyperenhancement (904:54), particularly on delayed sequences. This likely represents maturation and organization rather than evidence of suprainfection. The extrahepatic bile duct appears in tact. The central intrahepatic biliary tree adjacent to the resection margin are notable for thickened, hyperenhancing walls (901:64). This is slightly more apparent on the prior examination. This may simply represent ischemic but intact bile duct walls. Cholangitis is not excluded. The portal venous system remains patent. However, the posterior branches are somewhat attenuated, likely due to mass effect from the enlarging bile lakes. This results in heterogeneous parenchymal enhancement, seen particularly on the arterial phase. The hepatic arteries are variable in their degree of enhancement as they course through the bile lakes. There are numerous foci of subtle T2 hypointensity, central nonenhancement and a rim of hyperenhancement throughout the liver. These appear to represent treated, nonviable metastases, correlating with previously artery hyperenhancing lesions. Several persistently arterially hyperenhancing and nodules are noted within segments V and VI. Some of these appear to have slightly increased in size by 1-2 mm (901:110). The spleen is relatively normal in size with maximum diameter of 13 cm. There is no evidence of chronic portal hypertension. Pancreas and adrenal glands are unremarkable. There is bilateral diffuse renal abnormality. The parenchyma is edematous on T2 weighted sequences, heterogeneous on DWI and enhances in a striated pattern (903:114). The appearance is highly suggestive of pyelonephritis, likely hematologically distributed. No ascites is currently appreciated. There is some subcutaneous edema noted, as well as a trace right pleural effusion. IMPRESSION: Progression of sequela of ischemic cholangiopathy with increasing size of previously seen the bile lakes. Despite presence of gas within the lakes, and heterogeneous parenchymal enhancement, there is no one particular collection which demonstrates definitive features of infection or different features from the collections elsewhere. Gas and enhancement can be accounted for by recent interventions, sphincterotomy, and vascular insults. Numerous treated and several viable foci of metastatic disease. Bilateral renal parenchymal edema and heterogeneous enhancement suggestive of pyelonephritis. NOTIFICATION: Findings were communicated via phone by Dr ___ to Dr ___ at approximately 9:30 am on ___. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with fevers post TACE // please eval size/echogenicity of bile lakes/hepatic collections, in preparation for possible aspiration or drain placement by ___ TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MRI ___. FINDINGS: LIVER: The patient is status post left hepatectomy. A complex heterogeneous area with air is seen in the right hepatic lobe as noted on the prior MRI. On today's ultrasound, it is not clear that all portions of the collection communicate with each other although they are communicating on the prior MRI. ___ components of the collection has minimal through transmission, but no distinct fluid component is identified. Main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. Pneumobilia is present. The CBD measures 8 mm. GALLBLADDER: The gallbladder is absent. PANCREAS: The head of the pancreas is within normal limits. The body and tail of the pancreas are not visualized due to the presence of gas. SPLEEN: Normal echogenicity, measuring 12.7 cm. KIDNEYS: Limited views of the right kidney showed no hydronephrosis. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: Heterogenous complex intrahepatic collection, better evaluated on the prior MRI. No distinct fluid component is seen within it and areas still appears solid on ultrasound. Drainability is uncertain at this time. Short-term followup is suggested. RECOMMENDATION(S): The findings were discussed by Dr. ___ with Dr. ___ (surgery) in person on ___ at 11:00 a.m., 5 minutes after discovery of the findings. Aditionally, Dr. ___ the findings with Dr. ___ ___ Fellow) by phone at 1pm on ___. Radiology Report INDICATION: ___ year old woman with fibrolamellar ___ s/p TACE with presence of multiple enlarging bile lakes continuing to spike fevers. // Aspiration of bile lake/collection COMPARISON: MRI ___, ultrasound ___ TECHNIQUE: OPERATORS: Dr. ___ radiology attending) performed the procedure assisted by Dr. ___ radiology fellow) and, Dr. ___ resident) . The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___ radiologist, personally performed all the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 20 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: Fentanyl, midazolam CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: None PROCEDURE: 1. Ultrasound-guided needle aspiration from hepatic collection. 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. A preliminary right upper quadrant ultrasound again demonstrated multiple complex hypoechoic collections in the right lobe with internal septations and tiny echogenic foci. A superficial collection in the right lobe with posterior acoustic shadowing was targeted or aspiration. Under direct ultrasound guidance, a 21 gauge needle was advanced into the collection. 8 cc of turbid brown fluid were aspirated. The specimen was sent to the lab for Gram stain and culture. FINDINGS: 1. Multiple complex collections in the right lobe of the liver with internal septations and tiny echogenic foci compatible with air. The targeted collection had increased posterior acoustic through transmission suggestive of liquification. 2. 8 cc of turbid brown fluid aspirated from one of these collections. IMPRESSION: Successful fine needle aspiration from one of several right hepatic lobe complex collections. Radiology Report INDICATION: ___ female with fibrolamellar hepatocellular carcinoma status post TACE complicated by development of biliary lakes. Request aspiration of biliary leak collections. COMPARISON: Abscess aspiration from ___, liver ultrasound from ___, and MRI of the abdomen from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___ radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 250mcg of fentanyl and 5 mg of midazolam throughout the total intra-service time of 53 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: Fentanyl, midazolam. CONTRAST: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 8.5 minutes, 513 cGy-cm2 PROCEDURE: 1. Transabdominal ultrasound. 2. Ultrasound-guided access into the mive echogenicity hepatic collection. 3. Placement of 8 ___ drainage catheter into the hepatic collection. 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. Limited transabdominal ultrasound of the right upper quadrant was performed, Re demonstrating multiple heterogeneous and hyperechoic areas in the right lobe of the liver, towards the liver dome. Under ultrasound guidance, an entrance site was selected from a right intercostal approach. 1% lidocaine was instilled for local anesthesia. Under direct ultrasound guidance, a 21 gauge Cook needle was advanced into the dominant appearing hepatic collection. Upon return of small amount of brownish fluid, a Nitinol wire was advanced into the collection. A small skin incision was made. The needle was exchanged for an Accustick sheath, which was advanced over the wire and into the collection. The inner stiffener and dilator were removed. A ___ wire was advanced through the Accustick sheath and passed several times back and forth through the collection in attempts to disrupt any loculations or septations. A small injection with dilute contrast was then performed to opacify the hepatic collection. ___ wire was advanced through the Accustick sheath and coiled within the collection. The Accustick sheath was then removed and an 8 ___ APDL drainage catheter was advanced over the wire and into appropriate position. Positioning was confirmed with injection of dilute contrast. Approximately 12 cc of brownish opaque fluid was obtained and sent to microbiology. The pigtail was formed and locked with securing suture and the catheter was attached to a JP bulb for drainage. The catheter was secured to the skin with 0-silk suture and a Stat Lock device. Sterile dressings were applied. The patient tolerated the procedure well without any immediate post-procedure complications. FINDINGS: 1. Limited grayscale ultrasound imaging of the liver re- demonstrates multiple heterogeneous and hypoechoic areas within the right lobe of the liver, consistent with areas identified on the prior MRI. 2. Sinogram of the accessed collection demonstrates filling of the cavity. No obvious connection to the biliary tree is identified, however aggressive distension of the cavity was not performed given known infected nature of the fluid. 3. 8 ___ APDL drainage catheter placed. 4. 12 cc brownish fluid removed and sent for microbiology evaluation. IMPRESSION: Successful placement of 8 ___ drainage catheter into hepatic collection/cavity. RECOMMENDATION: Monitor output. When the patient is more clinically stable a contrast study through the catheter may be performed to assess for a communication with the biliary tree. Radiology Report EXAMINATION: Fistulagram INDICATION: History of fibrolamellar HCC status post TACE complicated by fluid collection status post percutaneous drain placement. Question of possible communication with the biliary tree. TECHNIQUE: Existing right abdominal percutaneous drainage catheter was gently injected with 50 cc Optiray contrast under continuous fluoroscopy DOSE: Fluoroscopy time: 60 seconds COMPARISON: Abscess drainage procedure ___. Abdominal ultrasound ___. Abdominal MR ___. FINDINGS: After gentle injection of Optiray contrast, opacification of the collection cavity is noted which appears to communicate with the common bile duct with prompt flow of the contrast material through the existing CBD stent into the duodenum. No opacification of the intrahepatic biliary tree. IMPRESSION: Fistulization of the known fluid collection with the common bile duct. CBD stent appears patent with prompt outflow of injected contrast into the duodenum. No back filling of the intrahepatic biliary tree. Radiology Report EXAMINATION: CT ABD WANDW/O C INDICATION: ___ year old woman with s/p tace, liver CA, here with infected bile lakes/liver abscess now with diaphoresis, leukocytosis, elevated alk phos // please do MULTIPHASIC CT OF THE LIVER (per ___ request) eval for abscess/collections/bile lakes. TECHNIQUE: Helical CT acquisition was performed during multiple phases after the administration of nonionic IV contrast. Oral contrast was also administered. Multiplanar reformats were obtained. DOSE: 705 mGy*cm. COMPARISON: Multiple priors including fistulogram ___, MRI ___ FINDINGS: Small right pleural effusion with passive atelectasis. Air bronchograms are present within the atelectatic right lower lobe, pneumonia is difficult to exclude. Post insertion of percutaneous pigtail catheter into the largest heterogenous hepatic dome biliary collection. Injected contrast, likely remaining from the prior fistulogram, is present within the collections and communicating bile lakes. Plastic biliary stent is present within the CBD. Multiple other hypodense collections are present, not containing injected contrast, largest 5 x 1.8 cm, prior 5.1 x 2.5 cm. Moderate intrahepatic ductal dilatation is otherwise present. Postoperative changes reflect fibrolamellar HCC resection. There is suspected thrombosis of the peripheral anterior portal venous branches, without well-defined portal veins supplying the superior liver and associated transient perfusion difference. This is slightly more pronounced than prior study, possibly due to technique. Previously demonstrated foci of metastatic disease are less well appreciated, the largest measuring 1.5 x 1 cm (4, 50) within the subcapsular aspect of segment VI. Unremarkable pancreas without main ductal dilatation. Splenomegaly. Normal adrenals. No nephrolithiasis or hydronephrosis. No concerning renal mass. Slightly mottled postcontrast appearance of the renal cortex is noted bilaterally. Ingested material within stomach. Stool and contrast within colon. No small bowel dilation. Normal caliber abdominal aorta. Patent celiac trunk and SMA. Single bilateral renal arteries. 1.2 cm left periaortic lymph node is noted, in addition to 1.2 cm right pericardial lymph node, slightly larger than prior. Probable partially visualized anterior subcutaneous fat injection granuloma. No suspicious osseous lesions. IMPRESSION: 1. The largest bile lake at the hepatic dome contains indwelling pigtail catheter and contrast from recent percutaneous contrast injection. Other smaller bile lakes are present, largest 5 x 1.8 cm within segment VII, slightly decreased in size from prior MRI, possibly due to drainage and or communication with biliary system. Otherwise moderate intrahepatic ductal dilatation appears grossly simple. 2. Previously demonstrated foci of metastatic disease are less conspicuous, likely due to different imaging modality, as the prior examination was performed with MRI. The largest measures 1.5 x 1 cm (4, 50) within the subcapsular aspect of segment VI. 3. Plastic CBD stent appropriately positioned. 4. Heterogenous renal cortical enhancement is again noted, possibly secondary to renal edema or pyelonephritis. 5. Increased conspicuity of enlarged retroperitoneal and pericardial lymph nodes as noted above. Radiology Report INDICATION: ___ year old woman with fibrolamellar Ca s/p TACE. S/p abscess drain placement with communication to biliary tree. // Sinogram/cholangiogram +/- tube upsize/exchange. COMPARISON: Sinogram from ___ and CT of the abdomen and pelvis from ___. TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___ radiology attending) performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___ radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 200mcg of fentanyl and 3 mg of midazolam throughout the total intra-service time of 25 min 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: Fentanyl, midazolam, ceftriaxone. CONTRAST: 15 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 11.5 min, 694 cGy-cm2 PROCEDURE: 1. Sinogram through existing biliary drainage catheter. 2. Upsize of 8 ___ drain to 10 ___ modified APDL catheter. 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 right abdomen was prepped and draped in the usual sterile fashion. Initial scout images showed biliary drain in the appropriate position. The right tube was injected with dilute contrast. The images were stored on PACS. Following the subcutaneous injection of 1% lidocaine and instillation of lidocaine jelly into the skin site, the right catheter was cut and ___ wire was advanced through the catheter into the hepatic cavity. Following dilatation with a 10 ___ dilator, a new ___ modified (additional side hole cut) APDL catheter was advanced over the wire and into the hepatic collection/cavity. Positioning was confirmed with dilute contrast injection. The wire and inner stiffener were then removed, the catheter was flushed, the loop was formed, the catheter was attached to a bag and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Sinogram demonstrates complex cavity, not significantly changed in size compared to the prior exam. No biliary communication was identified, as seen on the prior sinogram from ___. 2. Upsize with placement of a 10 ___ modified APDL catheter into the hepatic cavity. IMPRESSION: Successful exchange/upsize of existing ___ drainage catheter with new ___ modified APDL catheter. RECOMMENDATION: Continued monitoring of output from the drainage catheter . Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: FEVER POST PROCEDURE Diagnosed with FEVER, UNSPECIFIED temperature: 101.7 heartrate: 104.0 resprate: 18.0 o2sat: 100.0 sbp: 132.0 dbp: 73.0 level of pain: 6 level of acuity: 3.0

You were admitted with an infection in the liver and the bloodstream. We treated you with IV antibiotics. You will go home with a picc line to continue those antibiotics. You will need to follow up with the infectious disease clinic to determine the final duration of antibiotic therapy but it will likely be for a total of ___ weeks (including the time you were in the hospital). Start date was ___ (the date of the drain placement) and plan to at least go until ___. While you are on this antibiotic you will need weekly bloodwork (WEEKLY: CBC with differential, BUN, Cr, CPK, LFTs) your doctors ___ help ___ with that. IT IS VERY VERY IMPORTANT YOU KEEP A LOG OF THE DRAIN OUTPUT EVERY DAY. The interventional radiologists will NEED this information to decide when to re-image the area and/or pull the drain out. It is very important you take the senna/colase/dulcolax every day because otherwise the pain meds will cause you to develop severe constipation which will cause abdominal pain and all kinds of other problems that you don't need!! Make sure you call Dr. ___ have an appointment to see her within a week of your discharge. I am sending you home with a prescription for ritalin which you can use for fatigue if you need to. We are also sending you with MS contin which you are currently taking 45mg TID (three times a day) but you can probably go back down to 30mg TID so do this as soon as you feel you are ready. If you find you are very sleepy from pain meds or you are not needing to use the dilaudid that is the time to go down on the MS contin to 30mg three times a day (TID) We are starting a new medicine called ursodiol. THis medication thins the bile and it will hopefully help things drain better. RECORD THE DRAIN OUTPUT EVERY DAY!!! Can't say this enough!! =) Your daptomycin antibiotic should be daily. We have services being set up at home for this for you. You also must take the fluconazole pill in the morning every day to treat the fungal infection. The daptomycin and the fluconazole are treatments for the infection and you will probably need to do them for another 2 weeks though infectious disease will help you decide about this.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Lipitor Attending: ___ Chief Complaint: L sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ PMHx HTN, HLD, pre-DM, OSA/COPD, prior tobacco use and obesity who presents with left hand and face weakness. For the past month, pt has had URI symptoms. He has had intermittent productive cough with green and yellow sputum, nasal congestion, and rhinorrhea. He was hospitalized at ___ for these symptoms in early ___ and he was diagnosed with acute bronchitis and given nebulizers and azithromycin. Since discharge, he continued to have these symptoms which waxed and waned. He saw his PCP ___ and, at that time, also describes intermittent room spinning sensation and left eyelid drooping (lasting ___ in the AM, subtle L ptosis observed on PCP ___ so an MRI brain +/- and MRA ordered. He did not have any weakness, diplopia, dysarthria, or swallowing difficulties. His MRI showed small vessel ischemic changes and L ICA stenosis. Carotid ultrasound then revealed severe (70-79%) stenosis of the left internal carotid artery. He was then referred to vascular surgery. On the day of presentation, the vascular surgery office called to schedule an appt. During their conversation, pt stated that he felt weak in his left hand and had been dropping things and therefore pt was referred to the ED. At the time of my assessment, pt reports that he has been weak in his left hand for several days, starting after his MRI. He first noticed this when he had difficulty holding onto his fork and dropped his fork while eating. He also had difficulty squeezing his denture cream. He feels these symptoms were sudden in onset and have remained stable since onset. He also has noticed on the day of presentation that his left lower face was drooping but he does not know exactly when this started. Of note, before his MRI, he reports noticing intermittent paresthesias in his left hand which continue. He walks with a cane (over last ___ years) and does not report a change in his gait or recent falls. He also continues to have an intermittent room spinning sensation accompanied by nausea. He denies any diplopia. Past Medical History: Mixed sensorimotor polyneuropathy and polyradiculopathy due to lumbar spondylosis DEPRESSION PRE-DM GOUT HYPERLIPIDEMIA HYPERTENSION LOW BACK PAIN OBESITY OSTEOPOROSIS SLEEP APNEA ASCENDING THORACIC AORTIC ANEURYSM Social History: Marital status: Married Tobacco use: Former smoker Tobacco Use 1ppd x ___ , quit ___ years ago Occasional alcohol. No illicit substances. Retired ___/multiple jobs. - Modified Rankin Scale: [X] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: Brother ___ CIRRHOSIS BREAST CANCER Sister DIABETES MELLITUS Physical Exam: ADMISSION: General: NAD, resting in bed HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes, sclerae anicteric Neck: Supple ___: RRR Pulmonary: CTAB Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented to person, place and time. Attention to examiner easily maintained. Recalls a coherent history. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling. EOMI, no nystagmus. ?subtle L eyelid ptosis. On upgaze x30s, no worsening ptosis or diplopia. V1-V3 without deficits to light touch bilaterally. L NLFF, forehead raise intact bilaterally. Eyelid closure intact B/L. Hearing intact to finger rub bilaterally. No dysarthria. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk and tone. +downward drift on L. No tremor or asterixis. Neck flexion/extension ___. No fatiguable weakness in strong muscles on R. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4+ ___ ___ 4+ 5 4+ 5 5 4+ R 5 ___ ___ 5 5 5 5 5 5 - Sensory - No deficits to light touch bilaterally, although pt has difficultly with this aspect of the exam. Proprioception intact at the fingers and great toe bilaterally. Cortical sensory testing intact in left hand. -DTRs: Bi Tri ___ Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response flexor bilaterally. - Coordination - No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait - Deferred. DISCHARGE PHYSICAL EXAM: Unchanged from admission although motor exam of LUE/LLE shows more giveway than true weakness Pertinent Results: ___ 07:50AM BLOOD WBC-7.6 RBC-4.98 Hgb-15.1 Hct-47.2 MCV-95 MCH-30.3 MCHC-32.0 RDW-12.4 RDWSD-42.5 Plt ___ ___ 11:30AM BLOOD WBC-7.8 RBC-4.74 Hgb-14.5 Hct-44.1 MCV-93 MCH-30.6 MCHC-32.9 RDW-12.5 RDWSD-43.4 Plt ___ ___ 07:50AM BLOOD Glucose-110* UreaN-18 Creat-1.0 Na-142 K-4.4 Cl-104 HCO3-23 AnGap-19 ___ 11:30AM BLOOD Glucose-192* UreaN-19 Creat-1.0 Na-135 K-6.8* Cl-101 HCO3-21* AnGap-20 ___ 11:30AM BLOOD ALT-20 AST-45* AlkPhos-47 TotBili-0.5 ___ 11:30AM BLOOD cTropnT-0.01 ___ 07:50AM BLOOD Calcium-9.9 Phos-3.3 Mg-2.3 Cholest-172 ___ 11:30AM BLOOD Albumin-4.0 Calcium-9.3 Phos-2.7 Mg-2.2 ___ 07:50AM BLOOD %HbA1c-6.7* eAG-146* ___ 07:50AM BLOOD Triglyc-133 HDL-55 CHOL/HD-3.1 LDLcalc-90 ___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS* Barbitr-NEG Tricycl-NEG ___ H&N 1. Periapical lucency surrounding what appears to be a residual fragment of the left maxillary lateral incisor, compatible with periodontal disease. Formal dental evaluation is advised. 2. Thyroid nodule. No follow up recommended. ___ Head w/o 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality including hemorrhage or infarct. 3. Extensive paranasal sinus disease concerning for acute sinusitis, as described. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Gabapentin 300 mg PO QHS 3. Oxybutynin 5 mg PO QHS 4. Benzonatate 100 mg PO TID:PRN Cough 5. Diazepam 5 mg PO QHS 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Ipratropium Bromide Neb 2 NEB IH Q8H 8. Pravastatin 40 mg PO QPM 9. Ascorbic Acid ___ mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Vitamin B Complex 1 CAP PO DAILY 12. Vitamin E 400 UNIT PO DAILY 13. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Moderate 14. Fluticasone Propionate 110mcg 2 PUFF IH BID 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation DAILY:PRN Discharge Medications: 1. Rosuvastatin Calcium 40 mg PO QPM RX *rosuvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*3 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation DAILY:PRN 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Benzonatate 100 mg PO TID:PRN Cough 6. Diazepam 5 mg PO QHS 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Gabapentin 300 mg PO QHS 9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Moderate 10. Ipratropium Bromide Neb 2 NEB IH Q8H 11. Lisinopril 10 mg PO DAILY 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Oxybutynin 5 mg PO QHS 14. Vitamin B Complex 1 CAP PO DAILY 15. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left sided weakness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with left sided weakness, cough // Pneumonia or other mass TECHNIQUE: AP view of the chest. COMPARISON: ___. FINDINGS: There is streaky left basilar opacity. Elsewhere, lungs are clear. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: Streaky left basilar opacity which is most likely atelectasis. Possibility of infection is difficult to exclude. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ man with left-sided weakness with known carotid stenosis. Evaluate for infarct, hemorrhage or vascular 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 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 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 130.7 mGy (Head) DLP = 65.3 mGy-cm. 3) Spiral Acquisition 5.2 s, 41.2 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,314.6 mGy-cm. Total DLP (Head) = 2,277 mGy-cm. COMPARISON: ___, outside hospital noncontrast head CT. ___, contrast head MRI and MRA. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. Subtle areas of periventricular and subcortical white matter hypodensity are in a configuration most suggestive of chronic small vessel ischemic disease. There is mild to moderate bilateral frontal sinus mucosal thickening, near complete opacification of the bilateral ethmoid air cells and right sphenoid sinus, mild background polypoid mucosal wall thickening of the bilateral maxillary sinuses and left sphenoid sinus, as well as aerosolized fluid in the right maxillary sinus. Periapical lucency is seen surrounding what appears to be a remnant fragment of the left maxillary lateral incisor with erosion of the anterior cortex (___). The mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is variant partial fetal type origin of the left posterior cerebral artery. The left A1 segment of the ACA is hypoplastic with apparent common origin of the bilateral A2 segments are from the right A1, a normal variant. There is trace atherosclerotic calcification at the right ICA terminus without significant narrowing. The vessels of the circle of ___ and their principal intracranial branches otherwise appear patent without significant stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is moderate calcified and noncalcified atherosclerotic plaque of the visualized aortic arch. Minimal left vertebral artery origin nonocclusive narrowing is noted (see 650:16). There is mild atherosclerotic calcification at the origin of the left subclavian artery without significant narrowing. There is a 3 vessel aortic arch. There is severe left and mild-to-moderate right calcified and noncalcified atherosclerotic plaque at the carotid bifurcations. This produces 75% stenosis of the left internal carotid artery and 10% stenosis the right internal carotid artery by NASCET criteria. The carotid and vertebral arteries and their major branches are otherwise patent with no evidence of additional stenosis, occlusion, or dissection. OTHER: The visualized portion of the lungs are clear. There is an 8 mm hypodense left lobe thyroid nodule. There is no lymphadenopathy by CT size criteria. There is mild multilevel cervical spondylosis. IMPRESSION: 1. No acute intracranial abnormality. 2. Patent intracranial arterial vasculature without significant stenosis, occlusion, or aneurysm. 3. 75% left and 10% right internal carotid artery stenosis by NASCET criteria. 4. Minimal nonocclusive narrowing of left vertebral artery origin. Otherwise patent cervical arterial vasculature without additional areas of significant stenosis, occlusion, or evidence of dissection. 5. Severe paranasal sinus disease, as described, with areas of aerosolized fluid suggestive of active inflammation. 6. Periapical lucency surrounding what appears to be a residual fragment of the left maxillary lateral incisor, compatible with periodontal disease. Formal dental evaluation is advised. 7. 8 mm hypodense 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. RECOMMENDATION(S): 1. Periapical lucency surrounding what appears to be a residual fragment of the left maxillary lateral incisor, compatible with periodontal disease. Formal dental evaluation is advised. 2. Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ male with left-sided weakness. Evaluate for infarct. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON ___, outside hospital noncontrast head CT. ___, contrast head MRI and MRA. ___, contrast head and neck CTA. FINDINGS: Study is mildly degraded by motion. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration for age. Areas of scattered periventricular, subcortical and deep white matter T2/FLAIR hyperintensities are in a configuration most suggestive of chronic small vessel ischemic disease. There is no abnormal focus of slowed diffusion. The principal intracranial vascular flow voids are preserved. There is mild polypoid mucosal wall thickening in the bilateral maxillary and left sphenoid sinuses. There is aerosolized fluid in the right maxillary sinus. There is near complete opacification of the right sphenoid sinus and near complete opacification of the bilateral ethmoid air cells. There is mild moderate mucosal wall thickening of the bilateral frontal sinuses. There are changes from bilateral lens replacement surgery. The orbits otherwise grossly unremarkable. There is no abnormal fluid signal in the mastoid air cells. IMPRESSION: 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality including hemorrhage or infarct. 3. Extensive paranasal sinus disease concerning for acute sinusitis, as described. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: Dizziness, Headache, L Weakness Diagnosed with Cerebral infarction, unspecified temperature: 96.9 heartrate: 64.0 resprate: 16.0 o2sat: 98.0 sbp: 143.0 dbp: 74.0 level of pain: 4 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of L sided weakness. We were initially worried that you may have had a stroke, but we did an MRI which showed that you DID NOT have a stroke. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: High blood pressure High cholesterol Sleep apnea Prediabetes History of smoking Obesity We are changing your medications as follows: Please start taking Rosuvastatin 40mg daily instead of pravastatin. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Zantac / Amoxicillin / Lamisil / Penicillins / Levaquin Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___ s/p Sapian ___ilateral femoral groin access History of Present Illness: ___ with a history of cad s/p RCA stent (98/99) and LAD (___), PAF on coumadin, diabetes, s/p AVJ ablation and ___ PPM (gen changed ___, chronic systolic heart failure (25%) and severe aortic stenosis who initially presented with SOB. Patient was transferred from ___ for work-up of aortic valve replacement. He was recently admitted here from ___ - ___ for a very similar presentation. He was diuresed in the hospital and felt to not require diuretics upon discharge. Since then, he has had gradually progressive SOB that became significantly worse in the past 3 days. The SOB is worse with exertion, and not pleuritic in nature. He has also noted a weight gain of ___ over the past 4 days. He feels like it has been harder to button his pants. The patient underwent TAVR on ___ with successful implantation of ___ 3 with no complications. On arrival to the CCU, patient is alert and oriented and has no complaints. Vitals are: T 96.2, HR 65 in AF V-Paced, BP 156/50, RR 15, 100% RA. Past Medical History: -Coronary artery disease : s/p RCA stents 98, 99. s/p PCI to LAD in ___ -Paroxysmal atrial fibrillation s/p AV ablation and pacemaker -Hypertension -Hyperlipidemia -Diabetes type II -Melanoma -Meningitis (residual numbness tingling is baseline) -s/p tracheostomy -Hearing loss -Esophageal stricture with dilatation -GERD Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM ============================= VS: GENERAL: Well developed, well nourished in NAD. Oriented x3. Nasal cannula in place. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. LVEDP 35 in cath lab. CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ON Discharge ___: VS: T 98.9 HR 67 RR 18 BP 153/54 98% RA tele ___ vpaced General: A&O x 3 NAD HEENT: supple, non-distended JVP CV: RRR normal S1, S2 II/VI murmur best heart RUSB LUNGS: CTAB, decreased air exchange bases ABDOMEN: soft, NT, +BS Extremities: warm and dry, B groin sites d/I (left with staining), mild ecchymosis noted R>L, resolving hematoma on the right, without bleed or bruit bilaterally, +1DP no edema Skin:warm and dry The patient was seen by Dr. ___ and was deemed appropriate for discharge at 14:29 ___ ___. Pertinent Results: ADMISSION LABS: ___ 08:15AM BLOOD WBC-8.8 RBC-3.28* Hgb-10.9* Hct-32.2* MCV-98 MCH-33.2* MCHC-33.9 RDW-13.8 RDWSD-49.6* Plt ___ ___ 08:15AM BLOOD ___ PTT-47.6* ___ ___ 08:15AM BLOOD Glucose-118* UreaN-40* Creat-1.5* Na-141 K-4.3 Cl-107 HCO3-21* AnGap-17 ___ 08:06PM BLOOD ALT-31 AST-27 CK(CPK)-51 AlkPhos-63 TotBili-0.9 ___ 08:15AM BLOOD proBNP-8597* ___ 08:15AM BLOOD cTropnT-0.03* ___ 08:06PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.1 Mg-1.9 ___ 08:06PM BLOOD TSH-0.25* ___ 06:57AM BLOOD WBC-8.7 RBC-3.54* Hgb-11.4* Hct-34.3* MCV-97 MCH-32.2* MCHC-33.2 RDW-14.0 RDWSD-48.9* Plt ___ ___ 06:28AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.6* Hct-32.3* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.9 RDWSD-48.0* Plt ___ ___ 06:25AM BLOOD WBC-7.4 RBC-3.19* Hgb-10.2* Hct-31.2* MCV-98 MCH-32.0 MCHC-32.7 RDW-13.7 RDWSD-48.8* Plt ___ ___ 04:36AM BLOOD WBC-6.8 RBC-3.18* Hgb-10.3* Hct-30.4* MCV-96 MCH-32.4* MCHC-33.9 RDW-13.8 RDWSD-48.7* Plt ___ ___ 06:10AM BLOOD WBC-7.6 RBC-3.02* Hgb-9.7* Hct-29.6* MCV-98 MCH-32.1* MCHC-32.8 RDW-13.8 RDWSD-48.9* Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD ___ ___ 04:36AM BLOOD ___ ___ 03:45PM BLOOD ___ PTT-32.0 ___ ___ 06:25AM BLOOD ___ PTT-33.9 ___ ___ 06:28AM BLOOD ___ PTT-39.2* ___ ___ 06:10AM BLOOD Glucose-162* UreaN-32* Creat-1.4* Na-141 K-4.2 Cl-105 HCO3-22 AnGap-18 ___ 04:36AM BLOOD Glucose-148* UreaN-28* Creat-1.4* Na-142 K-3.3 Cl-104 HCO3-26 AnGap-15 ___ 03:45PM BLOOD Glucose-179* UreaN-32* Creat-1.3* Na-140 K-4.0 Cl-106 HCO3-24 AnGap-14 ___ 06:25AM BLOOD Glucose-157* UreaN-38* Creat-1.5* Na-143 K-4.4 Cl-106 HCO3-28 AnGap-13 ___ 06:28AM BLOOD Glucose-168* UreaN-36* Creat-1.4* Na-142 K-4.3 Cl-106 HCO3-24 AnGap-16 ___ 03:05PM BLOOD Glucose-193* UreaN-41* Creat-1.6* Na-142 K-4.3 Cl-106 HCO3-24 AnGap-16 ___ 06:57AM BLOOD Glucose-156* UreaN-34* Creat-1.5* Na-142 K-4.4 Cl-104 HCO3-24 AnGap-18 ___ 12:04AM BLOOD Glucose-157* UreaN-38* Creat-1.6* Na-142 K-3.5 Cl-106 HCO3-22 AnGap-18 ___ 06:28AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:57AM BLOOD CK-MB-3 cTropnT-0.02* ___ 04:36AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.6 ___ 03:45PM BLOOD Calcium-8.7 Phos-3.9 Mg-1.7 ___ 06:25AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8 ___ 03:05PM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1 URINE: ___ 09:31PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 9:31 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 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 STUDIES: ___ Successful implantation of TAVR. Final report not available at time of discharge summary. ___ ULTRASOUND RIGHT FEMORAL ARTERY No evidence of pseudoaneurysm or hematoma. PORTABLE TTE ECHO ___: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Global hypokinesis is seen with relative sparing of the basal segments. Right ventricular chamber size is normal with borderline normal free wall function. A ___ 3 aortic valve bioprosthesis is present. The transaortic gradient is normal for this prosthesis. A paravalvular jet of trace aortic regurgitation is seen. The aortic valve VTI = 31.9 cm. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. IMPRESSION: Normally functioning ___ 3 aortic valve with a trace paravalvular leak. Moderately depressed left ventricular systolic function. Mild mitral regurgitation. Moderate to severe tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, there has been interval placement of ___ 3 aortic valve. Severe aortic stenosis is no longer appreciated. The global left ventricular systolic function appears slightly more vigorous. The severity of tricuspid regurgitation may have increased (was not well assessed in the apical view on the prior study). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin EC 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Lisinopril 2.5 mg PO QHS 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Pantoprazole 40 mg PO Q24H 6. Warfarin 6 mg PO 2X/WEEK (___) 7. Warfarin 5 mg PO 5X/WEEK (___) 8. Januvia (sitaGLIPtin) 100 mg oral DAILY 9. GuaiFENesin ___ mL PO Q6H:PRN cough 10. GuaiFENesin ER 1200 mg PO Q12H 11. Amiodarone 400 mg PO DAILY 12. Atorvastatin 40 mg PO QPM 13. Carvedilol 6.25 mg PO BID Discharge Medications: 1. Amiodarone 400 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Carvedilol 6.25 mg PO BID 5. Lisinopril 2.5 mg PO QHS 6. Pantoprazole 40 mg PO Q24H 7. Warfarin 6 mg PO 2X/WEEK (___) 8. Warfarin 5 mg PO 5X/WEEK (___) 9. GuaiFENesin ___ mL PO Q6H:PRN cough 10. GuaiFENesin ER 1200 mg PO Q12H 11. Januvia (sitaGLIPtin) 100 mg oral DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Sulfameth/Trimethoprim DS 1 TAB PO BID x 5 days; check your BUN/Creatinine in 3 days Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: acute on chronic systolic heart failure s/p TAVR for aortic stenosis Discharge Condition: ___ year old male transferred from ___ with history of CAD s/p stent ___, PAF on Coumadin, diabetes, s/p AVJ ablation and pacemaker, and chronic systolic heart failure with worsening aortic stenosis for TAVR evaluation; underwent ___ 3 TAVR procedure ___ found to have urinary tract infection so started on Bactrim DS; echo ___ showed no significant AI; Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Plan: # Severe aortic stenosis: s/p successful implantation ___ 3 valve. - activity and groin care reviewed - f/u with Dr. ___ with outpatient echo # Acute on chronic systolic heart failure with reduced EF: LVEF of 25% as of ___, post TAVR echo EF 35% - daily weights - Continue home Aspirin EC 81 mg PO DAILY, Lisinopril 2.5 mg PO QHS, Carvedilol 6.25 mg PO BID # NSTEMI, Type II: Demand ischemia in the setting of acute on chronic heart failure. Trops peaked at 0.03 on ___. # CAD s/p DES to LAD ___: - continue Aspirin EC 81 mg PO DAILY, Atorvastatin 40 mg PO QPM, Carvedilol 6.25 mg PO BID. - Will D/C Plavix now that therapeutic on coumadin (pt already had >6 months of DAPT) per Dr. ___ # Paroxysmal afib s/p ablation: - Coumadin at usual dosing for goal INR 2.0- 3.0 - continue Carvedilol 6.25 mg PO BID, Amiodarone 400 mg PO DAILY - recheck INR in ___ days as outpatient -- Management per ___ ___ clinic #Hypertension: - Continuing home Lisinopril 2.5 mg PO QHS, Carvedilol 6.25 mg PO #Hyperlipidemia: - continue home atorvastatin 40mg daily #Diabetes type II: on Januvia and metformin at home. - HISS - resume Januvia and metformin ___ #GERD: on pantoprazole 40mg daily - continue home pantoprazole 40mg daily #UTI -- asymptomatic - Keflex x 7 days Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with severe AS s/p TAVR // post-op CXR s/p TAVR TECHNIQUE: Single frontal view of the chest COMPARISON: ___. IMPRESSION: Moderate to severe cardiomegaly is stable. Aortic stent is in place. Pacer leads are in standard position. There is mild vascular congestion. Bibasilar atelectasis larger on the left side have improved. There is no pneumothorax or pleural effusion Radiology Report EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY INDICATION: ___ year old man AFib on Coumadin, s/p TAVR, evaluate for pseudoaneurysm R groin TECHNIQUE: Grayscale, color Doppler, and spectral Doppler images of the right lower extremity were performed. COMPARISON: None. FINDINGS: Targeted imaging in the area of clinical concern reveals normal arterial and venous waveforms within the common femoral artery and common femoral vein, respectively. There is no evidence of pseudoaneurysm or hematoma. IMPRESSION: No evidence of pseudoaneurysm or hematoma. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Transfer Diagnosed with Nonrheumatic aortic (valve) stenosis temperature: 98.2 heartrate: 89.0 resprate: 20.0 o2sat: 98.0 sbp: 152.0 dbp: 55.0 level of pain: 0 level of acuity: 2.0

You were admitted because of worsening shortness of breath and worsening aortic stenosis; You underwent a TAVR procedure to improve your aortic stenosis. Your Plavix has been stopped due to being on Coumadin and aspirin. Coumadin and aspirin will be continued. You need to have an INR checked... You were found to have a urinary tract infection so will need to take an antibiotic, Bactrim for 5 days. Your BUN/Creatinine should be checked in three days given the use of this drug. We also recommend repeating a UA at the completion of treatment when you follow up with your PCP. All of your other medications should be continued. Activity and care of the groin sites per written discharge guidelines Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lantus / Prochlorperazine Attending: ___ Chief Complaint: Acute Renal Failure Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with history of HCV cirrhosis s/p liver transplant c/b by graft cirrhosis due to HCV recrudescence presented to the ED from his PCP's office due to elevated creatinine to 3.4 (baseline creatinine is 1.9) noted on scheduled labs on ___. Mr. ___ was recently hospitalized ___ with acute renal failure in the setting of NSAID (Ibuprofen) overuse to treat pain from Herpes Zoster s/p valcyclovir. Patient was discharged home on ___ with a serum creatinine of 2.8. He was scheduled for a post-discharge follow-up appointment and lab check with his PCP ___ ___, at which time his creatinine was noted to be elevated to 3.4. At this point he was sent to the ___ ED. Patient states that since his discharge he has been increasingly bothered by back pain from his zoster infection. This pain is right-sided, lower back and dull. It is worse with movement and does not radiate. He has taken no medication for it since his last admission--namely, he has avoided ibuprofen and Tylenol. In the time since discharge, he endorses urinary frequency. He denies fevers, chills, abdominal pain, dysuria, urinary hesitancy, and lower extremity edema worse than baseline. Incidentally, Mr. ___ notes that he vomited once on ___ ___, just after eating breakfast. The vomitus was nonbloody, nonbilious, no coffee ground emesis. He felt back to his baseline immediately afterward and has had no nausea or vomiting since. In addition, Mr. ___ describes a syncopal episode during which he lost consciousness for a few seconds while driving on ___. He states that he felt flushed and faint and then his vision went black. He was able to move his foot to the break and stop. He quickly regained full consciousness and felt back at his baseline. Had full memory of the event, denied loss of bowel or bladder function. He reports that he has had a few near-syncopal episodes recently when going from sitting to standing; he attributes this to his blood pressure. Past Medical History: - HCV cirrhosis (genotype 1a) s/p OLT ___ years prior complicated by graft cirrhosis, now cured s/p Harvoni -> EGD ___ w/o varices -> no hx of Hepatic encephalopathy -> no ascites -> RUQ US ___: no masses -> Immunosuppression: On tacrolimus monotherapy - DLBCL s/p 6 cycles of CHOP, most recent PET without disease - Chronic Kidney Disease: Seen by Dr. ___. Baseline Cr=1.5-1.8 before recent admission, last discharge Cr=2.8 - Hypertension - DM2: A1c 10.6% ___ Admission ___ for hyperglycemia - Peripheral neuropathy on gabapentin - Chronic headaches thought ___ immunosuppression medications - Anemia: normal colonoscopy ___. EGD ___ without varices, gastric/duodenal ulcers. - Thrombocytopenia Social History: ___ Family History: Mother - died ___ heart failure. Father - died ___ prostate cancer. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: T 97.9 HR 71 BP 182/94 RR 24 O2 100% RA General: Alert, oriented, 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, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM ======================= Vital Signs: 97.9 PO 146 / 81 76 18 97 RA General: Alert, oriented, 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. Port in place on right side of chest with no erythema. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding. Surgical scars--midline and transverse. Mesh in right side of abdomen. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace edema. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, normal gait Pertinent Results: ADMISSION LABS ============== ___ 10:00PM BLOOD WBC-4.0 RBC-3.18* Hgb-9.9* Hct-29.5* MCV-93 MCH-31.1 MCHC-33.6 RDW-15.9* RDWSD-52.7* Plt Ct-83* ___ 10:00PM BLOOD Neuts-47.7 ___ Monos-10.6 Eos-4.8 Baso-0.8 Im ___ AbsNeut-1.90 AbsLymp-1.42 AbsMono-0.42 AbsEos-0.19 AbsBaso-0.03 ___ 10:00PM BLOOD Plt Ct-83* ___ 10:00PM BLOOD Glucose-138* UreaN-44* Creat-2.9* Na-139 K-3.9 Cl-109* HCO3-20* AnGap-14 ___ 10:00PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.4* IMAGING ======= Renal Ultrasound ___ IMPRESSION: Bilateral increased renal cortical echogenicity suggestive of medical renal disease. No hydronephrosis or obstructive cause ___ identified. DISCHARGE LABS ============== ___ 05:08AM BLOOD WBC-3.5* RBC-3.23* Hgb-10.1* Hct-29.7* MCV-92 MCH-31.3 MCHC-34.0 RDW-15.6* RDWSD-50.9* Plt Ct-97* ___ 05:08AM BLOOD Plt Ct-97* ___ 05:08AM BLOOD Glucose-90 UreaN-40* Creat-2.4* Na-140 K-3.8 Cl-108 HCO3-22 AnGap-14 ___ 05:08AM BLOOD ALT-25 AST-20 LD(LDH)-181 AlkPhos-82 TotBili-0.3 ___ 05:08AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0 ___ 05:03AM BLOOD calTIBC-181* ___ Ferritn-129 TRF-139* ___ 09:00AM BLOOD tacroFK-3.1* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 240 mg PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Gabapentin 200 mg PO BID 4. OLANZapine 5 mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. PARoxetine 40 mg PO DAILY 7. Tacrolimus 1 mg PO Q12H 8. Thiamine 100 mg PO DAILY 9. HydrALAZINE 50 mg PO TID 10. Levemir (insulin detemir) 80 units subcutaneous BREAKFAST 11. Levemir (insulin detemir) 80 units subcutaneous QHS Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % Please place 1 patch in the affected area once a day Disp #*30 Patch Refills:*0 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Gabapentin 200 mg PO BID 5. HydrALAZINE 50 mg PO TID 6. Levemir (insulin detemir) 80 units SUBCUTANEOUS QHS 7. Levemir (insulin detemir) 80 units SUBCUTANEOUS BREAKFAST 8. OLANZapine 5 mg PO QHS 9. Omeprazole 20 mg PO DAILY 10. PARoxetine 40 mg PO DAILY 11. Tacrolimus 1 mg PO Q12H 12. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Acute Kidney Injury 2. HCV Cirrhosis s/p transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old man with ___ on CKD, cirrhosis s/p liver transplant // Please eval for hydronephrosis, obstructive causes ___ TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Abdominal ultrasound ___ abdominal ultrasound ___ FINDINGS: The right kidney is poorly visualized and measures 11.4 cm. The left kidney measures 12.2 cm. There is no hydronephrosis, stones, or masses bilaterally. Re-identification of a right interpolar cyst measuring 1.24 x 0.96 x 0.98 cm. Increased cortical echogenicity seen bilaterally suggestive of medical renal disease. The bladder is moderately well distended and normal in appearance. IMPRESSION: Bilateral increased renal cortical echogenicity suggestive of medical renal disease. No hydronephrosis or obstructive cause ___ identified. Gender: M Race: BLACK/CAPE VERDEAN Arrive by WALK IN Chief complaint: Abnormal labs, Back pain Diagnosed with Acute kidney failure, unspecified temperature: 97.6 heartrate: 76.0 resprate: 18.0 o2sat: 98.0 sbp: 126.0 dbp: 71.0 level of pain: 6 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted here for further evaluation of your kidney function, and we have been monitoring your lab tests closely and they have been steadily improving. We also have been changing your medications to help alleviate pain that do not necessarily interfere with your kidney function. Please continue to follow up with your primary care physician and your hepatologist upon leaving the hospital. Take Care, Your ___ Team.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ultram / Methadone / Avelox / Cymbalta Attending: ___. Chief Complaint: Fever, Cough x 3d Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMH myasthenia ___, afib w ICD, CAD s/p MI, CHF, ITP s/p splenectomy p/w fever recorded at rehab. Patient was admitted s/p fall from ___. For the past 3 days has experienced fever up to ___, as well as chills and night sweats. The patient has noticed increasing urinary retention sx of dribbling and hesitancy for the past few days. He denies current dysuria, hematuria, or suprapubic pressure. He says his urine intermittently is dark or foul smelling. Continues to have persistent left sided chest wall and flank pain that is unchanged since his fall. He has had cough productive of brown sputum for ___ weeks. He has had throat pain related to his sputum. He has been experiencing R sided chest pressure associated with eating, non-exertional. He has been having SOB intermittently for ___ weeks. No headache, dyspnea, nausea, vomiting, dysuria, diarrhea. In the ED, initial vitals 97.9 63 100/55 19 99%. He was given Dilaudid, CTX, and azithromycin. ROS: positive per HPI (see above). denies constipation, diarrhea, vomiting, blood per rectum. Past Medical History: 1. Myasthenia ___ - last admission ___ 2. Atrial Fibrillation s/p AICD, PPM 3. Coronary Artery Disease s/p MI ___, CABG x4 in ___, CHF 4. Obstructive Sleep Apnea 5. ITP s/p splenectomy 6. CHF with EF 40% by TTE ___ 7. Hypertension 8. Hypercholesterolemia 9. Depression 10. Lupus anticoagulant c/b PE and DVT on AC 11. 5 back surgeries per patient 12. hernia repair ___. left THR ___. multiple level degenerative changes Lumbar and cervical spine 15. complete heart block s/p pacemaker insertion 16. reports crush injury to the right leg about ___ years ago, with subsequent right foot drop. uses a cane ever since then. 17. Uvulopalatopharyngoplasty in the 1980s for OSA. 18. Pulmonary nodules ___hest) Social History: ___ Family History: father - ___ in his ___, leukemia brother - ___ in his ___ Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.2 99/62 66 16 98% 2L GENERAL - Obese, in pain but improved HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no carotid bruits, no LAD 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, distant heart sounds ABDOMEN - NABS, soft/ND, mildly tender to palpation on RUQ and LUQ, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (DPs) SKIN - no rashes or lesions DISCHARGE PHYSICAL EXAM: VS- 98.7 110-114/57-65 59-69 16 97%RA HEENT- MMM, no oral erythema, unable to assess JVD, no LAD Pulm- Crackles at bases b/l improve with subsequent breaths, no wheezes CV- Distant, S1S2 RRR no m/g/c/r Abd- Soft, nt/nd, no organomegaly, BS+ Ext- No c/c/e Pertinent Results: ADMISSION LABS: ___ 01:20PM BLOOD WBC-13.2* RBC-4.27* Hgb-12.9* Hct-40.3 MCV-95 MCH-30.3 MCHC-32.1 RDW-15.7* Plt ___ ___ 01:20PM BLOOD Neuts-88.3* Lymphs-5.0* Monos-5.7 Eos-0.9 Baso-0.2 ___ 01:20PM BLOOD ___ PTT-39.5* ___ ___ 01:20PM BLOOD Glucose-101* UreaN-14 Creat-0.8 Na-139 K-4.4 Cl-102 HCO3-30 AnGap-11 ___ 01:20PM BLOOD CK(CPK)-33* ___ 01:20PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:04PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:04PM BLOOD CK(CPK)-31* ___ 05:50AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.7 ___ 01:40PM BLOOD Lactate-1.3 ___ 11:46PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG ___ 11:46PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-0 DISCHARGE LABS: ___ 01:54PM BLOOD WBC-6.0 RBC-4.15* Hgb-12.2* Hct-38.7* MCV-93 MCH-29.5 MCHC-31.6 RDW-15.5 Plt ___ ___ 01:54PM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-134 K-4.0 Cl-99 HCO3-31 AnGap-8 ___ 01:54PM BLOOD Calcium-9.1 Phos-1.8* Mg-1.8 IMAGING: CXR 1. Blunting of posterior costophrenic angle on the lateral view may be technical, although trace pleural effusions may be present. 2. Persistent cardiomegaly. Possible minimal pulmonary vascular congestion. Barium Swallow Normal esophagram with no evidence of stricture or narrowing. EKG x3: No ST/T Changes, stable MICROBIOLOGY: Blood Cx x2 Negative Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Aspirin EC 325 mg ___ DAILY 2. Dabigatran Etexilate 150 mg ___ BID 3. Diazepam 10 mg ___ Q8H:PRN insomnia 4. Lisinopril 10 mg ___ DAILY 5. Docusate Sodium 100 mg ___ BID:PRN constipation 6. Metoprolol Succinate XL 100 mg ___ DAILY 7. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY:PRN rash 8. Mycophenolate Mofetil 1500 mg ___ BID 9. Pantoprazole 40 mg ___ Q24H 10. PredniSONE 15 mg ___ DAILY 11. Rosuvastatin Calcium 20 mg ___ DAILY 12. Sertraline 200 mg ___ DAILY 13. HYDROmorphone (Dilaudid) ___ mg ___ Q3H:PRN pain please give 2 mg first, reassess 1 hr later, can give second dose if alert and still in pain. hold for sedation 14. azelastine *NF* 137 mcg NU BID prn post nasal drip 15. Diphenoxylate-Atropine 1 TAB ___ Q6H:PRN diarrhea 16. Ferrous Sulfate 325 mg ___ BID 17. Furosemide 40 mg ___ DAILY 18. modafinil *NF* 200 mg Oral daily 19. Polyethylene Glycol 17 g ___ DAILY:PRN constipation Discharge Medications: 1. Aspirin EC 325 mg ___ DAILY 2. Dabigatran Etexilate 150 mg ___ BID 3. Diazepam 10 mg ___ Q8H:PRN insomnia 4. Docusate Sodium 100 mg ___ BID:PRN constipation 5. Ferrous Sulfate 325 mg ___ BID 6. Furosemide 40 mg ___ DAILY 7. Lisinopril 10 mg ___ DAILY 8. Metoprolol Succinate XL 100 mg ___ DAILY 9. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY:PRN rash 10. Mycophenolate Mofetil 1500 mg ___ BID 11. Pantoprazole 40 mg ___ Q24H 12. Polyethylene Glycol 17 g ___ DAILY:PRN constipation 13. PredniSONE 15 mg ___ DAILY 14. Rosuvastatin Calcium 20 mg ___ DAILY 15. Sertraline 200 mg ___ DAILY 16. azelastine *NF* 137 mcg NU BID prn post nasal drip 17. Diphenoxylate-Atropine 1 TAB ___ Q6H:PRN diarrhea 18. modafinil *NF* 200 mg Oral daily 19. HYDROmorphone (Dilaudid) ___ mg ___ Q6H:PRN pain take 2mg first, if alert after 30min, take 2mg again RX *hydromorphone 2 mg ___ tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary: Bronchitis, Dysphagia Secondary: Myasthenia ___, CAD, CHF, HTN, Atrial Fibrillation, OSA, Spinal Stenosis 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 EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: ___ male with history of status post chest trauma, fever. ___. FINDINGS: Frontal and lateral views of the chest were obtained. The patient is status post median sternotomy. A dual-lead left-sided pacemaker is seen with leads in the expected positions of the right atrium and right ventricle. The posterior costophrenic angles are not well seen on the lateral view which may be technical, although trace pleural effusions may be present. No focal consolidation or pneumothorax is seen. The cardiomediastinal silhouette is stable, with persistent cardiomegaly. There is possible minimal pulmonary vascular congestion. IMPRESSION: 1. Blunting of posterior costophrenic angle on the lateral view may be technical, although trace pleural effusions may be present. 2. Persistent cardiomegaly. Possible minimal pulmonary vascular congestion. Radiology Report HISTORY: ___ man with worsening dysphagia over the past few weeks, evaluate for obstruction/dysmotility. COMPARISON: None available. ESOPHAGRAM: Barium passes freely through the esophagus to the stomach with normal primary peristaltic contractions. The caliber and contour of the esophagus is normal with no evidence of focal narrowing or stricture. No hiatal hernia. A 13-mm barium tablet was given which was momentarily held up at the level of the GE junction. IMPRESSION: Normal esophagram with no evidence of stricture or narrowing. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SOB Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 98.8 heartrate: 64.0 resprate: 22.0 o2sat: 98.0 sbp: 103.0 dbp: 56.0 level of pain: 7 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. You were admitted from the ED after having fevers/cough while at rehab. CXR did not show pneumonia. The urine did not show an infection. You did have a high white blood cell count which quickly resolved the next day. Since we did not see any obvious source of infection and you came in with fevers and a cough, we treated you for bronchitis with antibiotics. In addition, you voiced complaints of worsening trouble swallowing and pain with eating. We ordered a barium swallow study that did not show narrowing or stricture. We apoke with your Neurologist who suggested we try a 3day course of IVIG with the hope that it would help treat your symptoms. After receiving IVG x3days, you felt somewhat better. At this time, we found you safe to be discharged home with home ___. Please follow-up with the appointments made for you. You need to see your PCP in order to manage your pain medications. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Keflex / Catapres / Trazodone / Levaquin in D5W / Colchicine / Fluoxetine / Lexapro / Lisinopril / metformin / gabapentin Attending: ___ ___ Complaint: chest pain and dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman, MI c/p PCI (___), CHF (EF 34%), VT s/p ICD, COPD, two prior early-stage lung adenocarcinomas s/p resection now with metastatic poorly-differentiated NSCLC with recent progression through first-line on palliative carboplatin/pemetrexed p/w chest pain and dyspnea. Ms. ___ describes her pain as dull, constant pressure on her right chest without radiation that started yesterday afternoon. The pain worsened over the night and through this morning. She endorses a slight increase in SOB which has made her sleeping more uncomfortable. Her symptoms are quite severe, and she could not get out of bed. She also notes that her appetite has decreased in the past few weeks and she has had decreased PO. Her recent restaging scans on ___ showed enlarging right hilar mass causing severe narrowing of the RUL anterior segmental pulmonary artery and superior right pulmonary vein with moderate compression of the right superior and right middle lobe bronchi. Patient also endorses some nausea after she eats, but this has been chronic for years. Patient also endorses a recent upper respiratory illness x 4 days with some rhinorrhea, mild headache. In the ED, initial vitals: 98.6 120 90/43 22 96% on RA. Labs notable for: chem7 with K 3.2 and BUN/Cr ___ (baseline 1.2-1.3), CBC H&H 10.9/33.8 (at baseline). She was given full dose ASA 325mg, heparin bolus and gtt for presumed PE, 2L NS, digoxin 0.125mg, metoprolol 2.5mg IV x1, morphine 5mg IV x1, albuterol neb x1, lorazepam 1mg x1. Imaging: CXR with left midlung and retrocardiac opacity that could be layering effusion or atelectasis/consolidation. CTA with no e/o PE and mass stable for prior CT on ___. On transfer, vitals were: 98 86 100/67 46 on NC. Patient is complaining chest pain ___, and mild dyspnea, nausea. Denies fevers, chills, abdominal pain, pedal edema, calf pain, diarrhea. Review of systems: (+) Per HPI Past Medical History: Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension 1. Coronary ___ disease, status post inferoposterior lateral MI in ___, status post stent in the left circumflex and two stents in the right coronary artery with a known chronically occluded right coronary artery. 2. Carotid stenosis status post left carotid stent placement by Dr. ___. 3. Hypertension. 4. Hyperlipidemia. 5. Type 2 diabetes. 6. Ischemic cardiomyopathy with EF of 30%. 7. History of ischemic mitral regurgitation. 8. History of ventricular tachycardia, status post ICD placement in ___, generator change in ___. 9. An 80-pack-year history of tobacco, quit ___ years ago. 10. COPD. 11. Lung cancer status post left lobectomy with a new lung nodule on the right. Per patient, she had recently seen her oncologist, Dr. ___ confirmed the stability of the lung nodule and feels that she is okay to follow up within one year. Social History: ___ Family History: Father died of MI at ___ yo. Mother had CVA at ___ yo. 2 sister, both healthy. Physical Exam: ADMISSION Vitals: T: 98 BP: 101/56 P: 82 R: 12 O2: 92% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Decreased air movement bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, III/VI systolic murmur, 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 Pertinent Results: ADMISSION ___ 10:20AM BLOOD WBC-8.6 RBC-3.75* Hgb-10.9* Hct-33.8* MCV-90 MCH-29.1 MCHC-32.2 RDW-18.5* RDWSD-60.7* Plt ___ ___ 10:20AM BLOOD Glucose-175* UreaN-28* Creat-1.2* Na-139 K-3.2* Cl-98 HCO3-24 AnGap-20 ___ 10:20AM BLOOD ALT-24 AST-17 AlkPhos-101 TotBili-0.5 ___ 10:20AM BLOOD proBNP-3697* ___ 10:20AM BLOOD cTropnT-0.02* ___ 10:20AM BLOOD Digoxin-0.5* ___ 10:20AM BLOOD Albumin-3.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Bisacodyl 20 mg PO QOD:PRN constipation 4. Clopidogrel 75 mg PO DAILY 5. Colchicine 0.6 mg PO QOD 6. Digoxin 0.125 mg PO EVERY OTHER DAY 7. Febuxostat 80 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Furosemide 60 mg PO DAILY 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Lorazepam 0.5 mg PO BID:PRN anxiety, insomnia 12. Losartan Potassium 75 mg PO DAILY 13. Metoprolol Tartrate 100 mg PO BID 14. Pantoprazole 40 mg PO Q12H 15. Sertraline 125 mg PO QAM 16. Spironolactone 12.5 mg PO DAILY 17. Tiotropium Bromide 1 CAP IH DAILY 18. Acetaminophen 650 mg PO Q6H 19. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 20. bifidobacterium infantis 4 mg oral daily 21. GlyBURIDE 5 mg PO BID 22. melatonin 3 mg oral qhs 23. Nitroglycerin SL 0.3 mg SL PRN chest pain 24. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 3. Aspirin 325 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY 5. Bisacodyl 20 mg PO QOD:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Colchicine 0.6 mg PO QOD 8. Digoxin 0.125 mg PO EVERY OTHER DAY 9. Febuxostat 80 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. Levothyroxine Sodium 150 mcg PO DAILY 12. Metoprolol Tartrate 100 mg PO BID 13. Nitroglycerin SL 0.3 mg SL PRN chest pain 14. Pantoprazole 40 mg PO Q12H 15. Senna 8.6 mg PO BID:PRN constipation 16. Sertraline 150 mg PO DAILY 17. Tiotropium Bromide 1 CAP IH DAILY 18. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 19. bifidobacterium infantis 4 mg oral daily 20. GlyBURIDE 5 mg PO BID 21. melatonin 3 mg oral qhs 22. Ondansetron 8 mg PO Q8H:PRN nasea RX *ondansetron 8 mg 1 tablet(s) by mouth q8h prn Disp #*30 Tablet Refills:*0 23. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*50 Tablet Refills:*0 24. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Refills:*0 25. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 26. ClonazePAM 0.5 mg PO TID RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day Disp #*50 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: Hypotension Atrial fibrillation Secondary diagnosis: Metastatic non small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with chest pain, shortness of breath // eval for pneumothorax, pneumonia, PE TECHNIQUE: Single portable view of the chest. COMPARISON: ___. FINDINGS: There is a large right paramediastinal mass abutting the hilum as seen on prior. There is also a pleural-based mass projecting over the right mid to lower lung also seen on prior. New from prior is hazy left mid lung and retrocardiac opacity. Left chest wall pacing device is again noted. IMPRESSION: Known right hilar and right pleural based mass as on prior. Hazy left mid lung and retrocardiac opacity could represent a layering effusion or potentially atelectasis/ consolidation. Consider PA and lateral to further assess. Radiology Report EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY INDICATION: ___ with chest pain, shortness of breath // eval for pneumothorax, pneumonia, PE, increasing lung mass TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 397 mGy-cm. COMPARISON: Chest CT from ___. FINDINGS: Aorta and great vessels are unremarkable without dissection or aneurysm. The pulmonary arteries are well opacified to the subsegmental level without filling defect to suggest pulmonary embolism. There is however is significant attenuation of the right-sided pulmonary arterial tree particularly to the right upper lobe. Right middle lobe pulmonary arterial segmental branch is also significantly attenuated by the mass with decreased opacification distally (3:90, 91). Heart size is normal. Coronary artery and aortic root calcifications are noted. Atherosclerotic calcifications are also noted throughout the aorta and great vessels. There is a small pericardial effusion. Large mass centered at the right hilum and paramediastinal region is again noted. It measures approximately 7.5 cm AP x 5.7 cm TRV, previously 7.0 x 4.7 cm when measured in similar ___. Narrowing of the pulmonary arterial branches is as detailed above. There is also narrowing of the right superior pulmonary vein. Peribronchial wall thickening distal to the mass particularly involving the right upper lobe is unchanged. Pleural based/chest wall mass between the anterior right fourth and fifth ribs is again seen measuring 4.4 x 3.5 cm, not significantly changed. The left lung is clear without consolidation, effusion or pneumothorax. Small pulmonary nodule (03:44) in the superior segment of the left lower lobe is unchanged. Patient is status post left upper lobectomy. Finding of increased opacity in the left hemi thorax on same-day chest x-ray was likely technical. Right upper lobe wedge resection changes are also noted. Limited images of the upper abdomen are notable for a partially visualized right adrenal nodule which is unchanged from prior. No suspicious osseous lesions identified. There is no acute fracture. Chronic left lateral rib fractures are noted. IMPRESSION: 1. No pulmonary embolism or acute aortic abnormality. 2. Large right paramediastinal/hilar mass minimally enlarged since exam from ___ with mass effect on adjacent structures as detailed above. Right pleural based/chest wall mass grossly unchanged. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with Chest pain, unspecified temperature: 98.6 heartrate: 120.0 resprate: 22.0 o2sat: 96.0 sbp: 90.0 dbp: 43.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, You were admitted to the ___ Intensive ___ Unit (ICU) because you were having chest pain and shortness of breath with low blood pressure. Your heart seemed to be in an irregular rhythm called atrial fibrillation. You had a CT scan which showed that you did not have a blood clot in your lung, which is reassuring. Your chest pain is likely caused by your cancer. You were given fluid through an IV and your blood pressure improved. Your heart rate was controlled through medications. Your pain and anxiety were controlled with new medications (clonazepam, oxycodone), which you will be discharged home with. We have set up a visiting nurse to help you at home. The visiting nurse and your physicians ___ help you continue to address your goals of ___. Thank you for allowing us to participate in your ___. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: esophageal impaction Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: This is a ___ year-old Male with a PMH significant for esophageal achalasia (diagnosed in the ___, trialed CCBs and nitrates; s/p three prior Botox injections following food impaction, s/p esophageal myotomy at ___ in ___ who now presents with 7-days of acute onset crampy abdominal pain, nausea with emesis and loose, non-bloody stools associated with odynophagia to solids and liquids. . The patient initially awoke 7-days prior with acute onset ___ crampy abdominal pain in a band-like distribution, without radiation that has been intermittent; associated with nausea and food particulate and bilious emesis episodes. He also had a few episodes of loose, watery and non-bloody stools. He denies fevers or chills. Over the course of several days he started to note odynophagia to solids and liquids, without inciting factor. He notes no identifiable foods that precipitate his achalasia flares. He notes some decreased PO intake over the last several days, without weight loss (stable at 163-lbs). He was seen at ___ and Dr. ___ recommended against endoscopy. He was transferred to ___ for further management. He is passing flatus and his last BM was formed yesterday. His nausea, emesis and diarrhea has resolved, only his abdominal discomfort remains. He denies sick contacts, recent travel or recent antibiotic use. No globus sensation, no regurgitation or hiccups. . In the ___ ED, initial VS 98.7 80 ___ 97% RA. A chest radiograph showed large particulate filled structure adjacent to the right heart border consistent with a markedly distended esophagus filled with residual ingested material. He received 1L NS x 1. His laboratory studies were only remarkable for a normocytic anemia to 27.3% on admission. He was reportedly guaiac positive at ___. Past Medical History: 1. Esophageal achalasia (diagnosed in the 1990s, initially medically managed with CCBs and nitrates; three prior Botox injections - two performed in ___ and ___ following endoscopy at ___ and one at ___ s/p surgical myotomy in ___ at ___ 2. Grade III esophagitis (treated with Omeprazole in ___ Social History: ___ Family History: Niece with ulcerative colitis. No other family history of GI malignancy (colon, stomach cancer). Physical Exam: Vitals: 97.2 100/60 66 18 96/RA GENERAL - well-appearing male lying in bed in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Right sided vesicular breath sounds posteriorly over middle of right lung, otherwise CTA w/ good air mvmt. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Admission labs: ___ 09:00PM GLUCOSE-89 UREA N-10 CREAT-0.7 SODIUM-140 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 ___ 09:00PM WBC-6.4 RBC-2.95* HGB-8.9* HCT-26.0* MCV-88 MCH-30.3 MCHC-34.4 RDW-13.6 ___ 09:00PM NEUTS-63.6 ___ MONOS-4.3 EOS-1.6 BASOS-0.3 ___ 09:00PM PLT COUNT-469* ___ 09:00PM ___ PTT-27.1 ___ ___ 08:26PM GLUCOSE-93 UREA N-10 CREAT-0.8 SODIUM-139 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 ___ 08:26PM estGFR-Using this ___ 08:26PM WBC-6.7 RBC-3.10* HGB-9.5* HCT-27.3* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.5 ___ 08:26PM NEUTS-65.0 ___ MONOS-4.6 EOS-1.5 BASOS-0.3 ___ 08:26PM PLT COUNT-457* ___ 08:26PM ___ PTT-27.1 ___ Discharge Labs: ___ 06:50AM BLOOD WBC-6.4 RBC-2.95* Hgb-9.0* Hct-25.8* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.5 Plt ___ ___ 06:50AM BLOOD Ret Aut-6.0* ___ 06:50AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-137 K-3.4 Cl-103 HCO3-27 AnGap-10 ___ 06:50AM BLOOD LD(LDH)-116 TotBili-0.2 DirBili-0.0 IndBili-0.2 ___ 06:50AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.3 Iron-43* ___ 06:50AM BLOOD calTIBC-278 Ferritn-23* TRF-214 CXRay: FINDINGS: PA and lateral views of the chest were obtained. There is marked mediastinal widening which extends into significant portion of the right hemithorax. In this patient with provided history of achalasia, findings are concerning for esophageal impaction. There is no evidence of aspiration. No large pleural effusion is seen. No pneumothorax. Heart size is difficult to assess. Bony structures appear intact. IMPRESSION: Findings concerning for esophageal impaction within a markedly dilated esophagus. . EGD: Impression: Large quantities of solid and liquid food in massively dilated esophagus. Cobblestoning of the whole esophagus Normal mucosa in the stomach Normal mucosa in the duodenum The GE junction was able to be traversed easily with colonoscope. Otherwise normal EGD to third part of the duodenum Recommendations: Follow-up biopsy results Recommend Surgery consult to evaluate for repeat Myotomy vs. esophagectomy. Manometry can be considered and if the resting pressures are high at the LES, repeat Myotomy can be considered. Recommend full liquid diet until the Achalasia is treated. Medications on Admission: MVI Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Achalasia, massive esophageal dilatation 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: None. CLINICAL HISTORY: ___ man with achalasia, presents with chest pain, assess for esophageal impaction. FINDINGS: PA and lateral views of the chest were obtained. There is marked mediastinal widening which extends into significant portion of the right hemithorax. In this patient with provided history of achalasia, findings are concerning for esophageal impaction. There is no evidence of aspiration. No large pleural effusion is seen. No pneumothorax. Heart size is difficult to assess. Bony structures appear intact. IMPRESSION: Findings concerning for esophageal impaction within a markedly dilated esophagus. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: FOOD IMPACTION Diagnosed with ABDOMINAL PAIN EPIGASTRIC, ACHALASIA & CARDIOSPASM temperature: 98.7 heartrate: 80.0 resprate: 16.0 o2sat: 97.0 sbp: 112.0 dbp: 72.0 level of pain: 7 level of acuity: 3.0

It was a pleasure caring for you at the ___. You were admitted with abdominal pain and were found to have severe dilatation of your esophagus because of worsening of your chronic achalasia. You had a upper endoscopy with suctioning of food products. The gastroenterologists here recommended that you remain on a liquid diet and consider repeat surgery, or even removal of your esophagus. You wanted a second opinion from your gastroenterologist so we are discharging you home. It is very important that you follow up as soon as possible with your gastroenterologist, Dr. ___. In the meantime, please remain on a liquid diet. We would recommend Ensure, Boost shakes or something similar to augment your nutrition. You were not started on any medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ativan / Compazine Attending: ___. Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD x3 with clipping History of Present Illness: ___ yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial gastrectomy ___, sarcoidosis, afib not on coumadin, hematemesis with anastamotic ulcer on EGD in ___ p/w nausea and vomiting last night. She was in her usual state of health during the day, went out for ___ food for dinner around 5 pm. Initially felt well afterwards, around 10 pm felt nauseated and started vomiting. Was up all night with abdominal pain and nausea, vomited about five times last night. This morning around 6 am vomited bright red blood. Not sure how much it was, no coffee grounds. Also may have had a dark stool this AM but she is not sure. Denies any diarrhea currently, but had diarrhea last week. She does get nauseated about once a week, used to be followed in GI clinic for this and was thought to be related to GERD and possible ulcer disease, has been on a BID PPI and PRN promethazine at home, takes promethazine about weekly. Unable to take last night due to nausea. No h/o liver disease. No h/o liver disease. Denies chest pain, shortness of breath, lightheadedness, joint pain, rashes, sick contacts. . In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L NC. EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs and new lateral ST depressions. Pt given IV NS, protonix 80 mg bolus and started on drip, zofran 4 mg, and morphine. Pt appeared dry on exam, rectal exam with no stool in the vault. NG lavage not done given presence of bright red blood in vomit. Hct 36 so no blood products were given, coags wnl. Access with PIV x 2. Received 2.5 L of IV NS. GI called from ___, recommended EGD. Admitted to ICU for active vomiting of blood noted in ED. VS on transfer temperature 97.8. HR 86 RR 20 BP 152/81, afib, sat 100% 2L. . On arrival to ICU, pt feels nauseated and abdominal pain in lower part of abdomen which started last night as well, nonradiating, feels like cramping. No fever since episodes started but did have a fever to 101 about 2 weeks ago for which she was treated with amoxicillin. Has had 4 episodes total of blood in vomit, although unable to quantify amount of blood. . Review of systems: (+) Per HPI, also + for cough for the last few weeks, recently treated for presumed PNA with 10 day course of amoxicillin, suspected that cough may be related to pulmonary sarcoidosis per daughter (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. HTN 2. Hypercholesterolemia 3. systolic CHF, etiology unclear 4. Bleeding gastric ulcer s/p partial gastrectomy in ___. 5. Hematemesis ___ years ago. No source was found on EGD. 6. Lap cholecystetomy in ___ complicated by liver laceration and PE 7. Post-op PE requiring brief intubation and s/p IVC filter and anticoagulation in ___ 8. S/p appendectomy 9. Iron deficiency anemia 10. OA of left knee requiring knee replacement 11. S/p fall complicated by displacement of anterior arch of C1 one year ago; wore hard collar for one year and is now s/p surgical fixation in ___ at ___ 12. L TKR due to non ___ of femur fx ___ at OSH 13. h/o depression 14. atrial fibrillation 15. hematemesis bleeding ulcer noted at ___ II anasthamosis in ___ (gastrin level wnl and H. pylori negative) 16. sarcoidosis dx ___ with pulmonary symptoms and lymph node bx Social History: ___ Family History: Her father died of renal cancer; brother with lung cancer; no hx of CAD; no hx of colon cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.7 HR 86 BP 143/74 sat 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, tacky mucous membranes, no oropharyngeal lesions Neck: supple, JVP not elevated, no LAD Lungs: crackles at bases bilaterally, no wheezes, rhonchi CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur best heard at apex Abdomen: soft, mild ttp throughout, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ___ 07:05AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.7* Hct-36.9 MCV-92 MCH-29.1 MCHC-31.6 RDW-14.9 Plt ___ ___ 12:55PM BLOOD WBC-10.6 RBC-2.90*# Hgb-8.7*# Hct-26.4*# MCV-91 MCH-29.9 MCHC-32.9 RDW-15.0 Plt ___ ___ 07:25PM BLOOD Hct-24.0* ___ 02:53AM BLOOD WBC-14.9* RBC-3.22* Hgb-9.6* Hct-28.8* MCV-89 MCH-29.9 MCHC-33.5 RDW-14.8 Plt ___ ___ 09:22AM BLOOD Hct-26.0* ___ 03:30PM BLOOD Hct-28.9* ___ 04:24AM BLOOD WBC-8.6 RBC-2.66*# Hgb-8.1*# Hct-23.6*# MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-84* ___ 07:05AM BLOOD ___ PTT-29.9 ___ ___ 04:59AM BLOOD ___ PTT-29.2 ___ ___ 07:05AM BLOOD ___ 07:05AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140 K-4.3 Cl-102 HCO3-25 AnGap-17 ___ 02:53AM BLOOD Glucose-124* UreaN-25* Creat-0.6 Na-141 K-3.8 Cl-110* HCO3-22 AnGap-13 ___ 04:24AM BLOOD Glucose-67* UreaN-21* Creat-0.5 Na-141 K-3.6 Cl-112* HCO3-21* AnGap-12 ___ 07:05AM BLOOD ALT-20 AST-43* LD(LDH)-432* AlkPhos-120* TotBili-0.3 ___ 02:53AM BLOOD ALT-14 AST-24 AlkPhos-77 ___ 07:05AM BLOOD Lipase-19 ___ 07:05AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.8 ___ 02:53AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.9 ___ 04:24AM BLOOD Calcium-6.5* Phos-2.6* Mg-1.7 ___ 03:10AM BLOOD Digoxin-0.5* ___ 04:34AM BLOOD freeCa-1.00* ___ 08:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR ___ 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 MICRO: Urine (___): no growth EKG (___): Rate 82. Sinus rhythm. First degree A-V block. Leftward axis. Poor R wave progression. Lateral ST-T wave abnormalities. Compared to the previous tracing of ___ first degree A-V block is now present. CXR (___): IMPRESSION: 1. No evidence of intra-abdominal free air. 2. Stable cardiomegaly. 3. No evidence of decompensated congestive heart failure or pneumonia. Hand (___) Xray: PND EGD ___: Impression: Normal mucosa in the esophagus Blood in the stomach body Dieulafoy lesion in the Anastomotic site (endoclip) Both the limbs were identified and no source of bleeding was noticed in those. Otherwise normal EGD to third part of the duodenum Medications on Admission: alendronate 70 qweek atenolol 25mg qam 50 qpm dig 0.125 qd lidoderm patch for back or knee lisionpril 30mg qday omeprazole 20mg bid pravastatin 40mg qd ropinirole 1mg qhs effexor 150 mg qd vit d -allergies: ativan, compazine and advair Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed due to gastric ulcer Acute blood loss anemia Atrial fibrillation Hypertension 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: Hematemesis, evaluate for intra-abdominal free air. COMPARISONS: Chest radiograph from ___. PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The underinflated lungs are clear. There is stable moderate cardiomegaly. There is no pneumothorax or pleural effusion. There is bibasilar atelectasis. The pulmonary vascularity is normal. There is no evidence of intra-abdominal free air. Surgical clips are noted in the right upper quadrant, consistent with probable prior cholecystectomy. There is S-shaped scoliosis of the thoracic spine. IMPRESSION: 1. No evidence of intra-abdominal free air. 2. Stable cardiomegaly. 3. No evidence of decompensated congestive heart failure or pneumonia. Radiology Report STUDY: Three views of the bilateral hands ___. COMPARISON: Bilateral radiographs ___. INDICATION: Question rheumatoid arthritis. Hand swelling. FINDINGS: RIGHT HAND: Mild dorsal soft tissue swelling. Unchanged subluxation and degenerative changes of the index and long finger and MCP joint and thumb CMC joint. No definite fracture. No dislocation. IV tubing is noted across the distal forearm. LEFT HAND: IV tubing overlies the hand. Mild dorsal soft tissue swelling. Unchanged degenerative changes of the ring finger PIP joint and index and long finger MCP joints and thumb CMC joint. No fracture or dislocation. IMPRESSION: No significant interval change. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: GI BLEED Diagnosed with GASTROINTEST HEMORR NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

You were admitted after vomiting blood. You were found to have a GI bleed with anemia. In the ICU, you underwent EGD showing bleeding ulcers. These were successfully clipped. After 6 blood transfusions your bleeding stopped. It is very important that you take the twice daily Protonix to prevent bleeding. You were also found to have mild arthritis in your hand, most likely felt to be "Pseudogout." You completed a short course of Prednisone. Please see the medication sheet on discharge. Please note that your Lisinopril dose was decreased to 10mg daily. Please minimize the use of any opiate medications you receive from your physicians as this can cause an increased risk of falls. Oxycodone will only be prescribed by your PCP.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: alendronate sodium Attending: ___. Chief Complaint: N/V, mechanical fall Major Surgical or Invasive Procedure: Therapeutic paracentesis on ___ Nasogastric tube placement on ___ History of Present Illness: Ms. ___ is a ___ woman with metastatic serous carcinoma of likely GYN origin presenting with abdominal pain, nausea/vomiting, and a mechanical fall. She reports that for ___ days prior to admission, she was having abdominal pain and constipation (no bowel movement x4 days). She was taking limited p.o. over that time. She describes a band of pain like "twisting intestines" that is pulsatile/intermittent. There are no obvious aggravating or alleviating factors. The night prior to admission (___) she developed nausea and had a small bout of emesis; the morning of admission she had emesis again of the food she had eaten. No blood noticed. She subsequently slipped in her own emesis with a head strike (no loss of consciousness). She did not have any new neurologic symptoms. She has had no fevers or chills. In the ED, initial vitals were: 98.4 | 87 | 108/60 | 18 | 100% RA Labs were notable for: 9.2 > 11.1/36.1 < 205 (MCV 105) 142 | 100 | 28 Ca 9.1 --------------< 144 Mg 1.8 3.4 | 29 | 1.2 P 3.7 AST/ALT ___, AP 55, Tbili 0.5, Alb 3.8 ___ 11.2, ___ 24.7, INR 1.0 Lactate 1.3 UA bland but for protein and 10 ketones Imaging performed included: # CT A/P with contrast: 1. Short segment of small bowel wall thickening and wall edema in the mid abdomen with few fluid filled loops of small bowel, most compatible with enteritis. 2. Redemonstration of large volume ascites. 3. New ground-glass opacities in the right lower lobe. Correlate clinically for aspiration or pneumonia. 4. Stable dilation of the main pancreatic duct and CBD without obstructing lesion. # CT C-spine without contrast: 1. No malalignment or fractures a sequela of trauma. 2. Stable multilevel degenerative changes worse at C5-C6 and C6-C7 levels. # CT Head without contrast: 1. No acute intracranial findings. 2. Paranasal sinus disease. The patient was given: 500mg LR IV 40 mEq potassium 4 mg morphine IV 4 mg Zofran IV 1 g ceftriaxone IV 500 mg metronidazole IV Vitals prior to transfer: 98.0 | 71 | 129/47 | 17 | 96% RA Upon arrival to the floor, Ms. ___ confirmed the above story with her son ___ (son ___ also at bedside). REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative except for as noted in the HPI. She does also describe chronic increased urinary frequency and intermittent incontinence that are long-standing. Past Medical History: PAST ONCOLOGIC HISTORY, per primary oncologist note: Pt reported increasing bloating and abdominal pain beginning in early ___ that worsened for a month. She was seen at her PCP's office on ___ at which point TSH, albumin, LFTs were drawn and were all within normal limits. She underwent an abdominal ultrasound on ___ which showed large volume ascites with peritoneal nodularity visualized within the pelvis with concern for ovarian malignancy or other primary. She had a follow up CT abdomen/pelvis on ___ which showed massive ascites. Neither ovary were clearly visualized nor was the appendix. Peritoneal nodularity seen on US was not clearly identified though there was some mild hyperenhancement of the inferior peritoneal surface just superior to the bladder. She subsequently had a therapeutic paracentesis on ___ with evacuation of 3L of fluid. Cytology report showed high grade serous carcinoma with p53 showing mutant pattern staining. She was seen by OB/GYN on at which point she noted the fluid appeared to be recurring. ___ weight gain in the last 6mo. She has a history of leg swelling for which she takes lasix 30mg QD. She was recommended tumor markers including CA125, CEA, and ___ CT-Chest; diagnostic laparoscopy to assess disease extent which will likely be followed by chemotherapy with a possible interval cytoreductive surgery including a total hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy, omentectomy, and removal of residual disease. Hearing this plan, pt expressed interest in forgoing surgery. At first oncology visit on ___, she explained her greatest source of discomfort was abdominal pain/bloating. We recommended CT chest to complete staging and a visit with OB/GYN to discuss the role for surgical management of her disease. ___ C1D1 ___ AUC 2 (day 1, 15) ___ C2D1 ___ AUC 2 (day 1, 8) ___ C3D1 ___ AUC 2 (d1,8) ___ C4D1 ___ AUC 2 (d1, 15) ___ C5D1 ___ AUC 2 (d1, 15) ___ C6d1 ___ AUC 2 (d1, 15) ___ Break from chemotherapy; CA125 had plateaued and is slightly increased today, indicating carboplatin resistance. Scans overeall had improvd PAST MEDICAL HISTORY: - HTN - HLD - IgA/IgG pemphigus foliaceous (on cellcept and low dose prednisone) - Positive PPD, neg CXR - refused INH - Chronic ___ edema - Postherpetic neuralgia - Low back pain - DJD on LS-spine XR ___ - Osteoporosis - Plantar Fasciitis - Cataracts Social History: ___ Family History: - no known history of breast, cervical, endometrial, uterine, or colon CA - no known history of bleeding or clotting disorder Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 97.9 | 120/80 | 87 | 18 | 96%RA GENERAL: Cachectic and chronically ill-appearing woman, nontoxic, no acute distress HEENT: Normocephalic, atraumatic, approximately 3 x 3 cm area of tenderness to palpation over posterior/temporal left region (area of headstrike). No scleral icterus, no conjunctival pallor. Dry mucous membranes. Poor dentition. NECK: No concerning lymphadenopathy CV: Regular rate and rhythm, systolic murmur best over left sternal border PULM: Breathing comfortably on room air, no accessory muscle use, lateral fields clear ABD: Distended, normoactive bowel sounds, tender to palpation worse in the right upper quadrant; palpable ?Intestines vs. Mass vs hepatomegaly to 4 fingerbreadths below costal margin. No rebound or guarding. EXT: Warm, well-perfused, no edema. SKIN: No rashes/lesions. Umbilicus somewhat dry/crusted. NEURO: Oriented to "hospital," city, ___ Attentive to DOWB. ACCESS: Right chest port, dressing c/d/i DICHARGE PHYSICAL EXAM ====================== VS: T: 97.7 PO BP: 154 / 77 HR: 86 RR: 16 SaO2: 95 RA GENERAL: Cachectic and chronically ill-appearing woman, sitting upright in bed HEENT: Dry mucous membranes. NGT in place draining bilious fluid, less than days prior. This was removed just prior to discharge CV: Regular rate and rhythm, systolic murmur best over left sternal border PULM: Breathing comfortably on room air, no accessory muscle use, clear to auscultation bilaterally ABD: Soft, non distended, nontender throughout without rebound or guarding EXT: Warm, trace edema SKIN: Has several bruise-appearing lesions over abdomen related to pemphigus, stable per patient NEURO: ___ grossly in tact, able to move all 4 extremities spontaneously ACCESS: Right chest port, dressing c/d/i Pertinent Results: CYTOLOGY FROM PARACENTESIS ___: Peritoneal fluid: POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma of gynecologic origin. A serous ovarian carcinoma is favored. Note: Immunohistochemistry performed shows the following profile in the tumor cells: Positive: ___, B72.3, PAX8, CK7, WT1 Negative: CK20, TTF-1, CDX-2, calretinin ADMISSION LABS ============== ___ 11:30AM BLOOD WBC-9.2 RBC-3.44* Hgb-11.1* Hct-36.1 MCV-105* MCH-32.3* MCHC-30.7* RDW-12.5 RDWSD-47.8* Plt ___ ___ 11:30AM BLOOD Neuts-87.7* Lymphs-5.0* Monos-6.5 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.06* AbsLymp-0.46* AbsMono-0.60 AbsEos-0.02* AbsBaso-0.02 ___ 11:30AM BLOOD Glucose-144* UreaN-28* Creat-1.2* Na-142 K-3.4* Cl-100 HCO3-29 AnGap-13 ___ 11:30AM BLOOD ALT-10 AST-21 AlkPhos-55 TotBili-0.5 ___ 11:30AM BLOOD Lipase-28 ___ 11:30AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.7 Mg-1.8 ___ 11:45AM BLOOD Lactate-1.3 MICROBIOLOGY ============ ___ 11:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 4:20 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:25 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 12:25PM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:25PM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:25PM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-1 TransE-<1 ___ 12:25PM URINE CastHy-10* ___ 12:25PM URINE Mucous-MANY* IMAGING ======= CT ABDOMEN AND PELVIS W CONTRAST, ___: 1. Short segment of small bowel wall thickening and wall edema in the mid abdomen with few fluid filled loops of small bowel, most compatible with enteritis. 2. Redemonstration of large volume ascites. 3. New ground-glass opacities in the right lower lobe. Correlate clinically for aspiration or pneumonia. 4. Stable dilation of the main pancreatic duct and CBD without obstructing lesion. KUB, ___: 1. Mildly dilated loops of small bowel with air-fluid levels in the absence of colonic dilatation suggest partial small bowel obstruction. CT may be performed if further characterization is needed. 2. Ascites as well as small bilateral pleural effusions. ___ GUIDED PARACENTESIS, ___: 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 1.75 L of fluid were removed. KUB, ___: Unchanged appearance of dilated loops of fossa bowel with air-fluid levels remain concerning for small bowel obstruction. KUB, ___: Unchanged appearance of dilated loops of small bowel with air-fluid levels consistent with a partial small-bowel obstruction when compared to prior radiograph dated ___. OTHER PERTINENT STUDIES ======================= ___ 12:50PM BLOOD CA125-74* ___ 05:24AM BLOOD TSH-0.89 ___ 05:24AM BLOOD Ret Aut-2.6* Abs Ret-0.08 ___ 05:24AM BLOOD VitB12-1656* Ferritn-286* ___ 05:03AM BLOOD freeCa-1.09* ___ 03:49AM BLOOD Triglyc-203* DISCHARGE LABS ============== ___ 05:25AM BLOOD WBC-6.7 RBC-3.22* Hgb-10.3* Hct-33.4* MCV-104* MCH-32.0 MCHC-30.8* RDW-12.2 RDWSD-46.4* Plt ___ ___ 05:25AM BLOOD Glucose-143* UreaN-8 Creat-0.8 Na-137 K-3.9 Cl-99 HCO3-27 AnGap-11 ___ 05:25AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.3 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 2. PredniSONE 5 mg PO DAILY 3. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second Line 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Polyethylene Glycol 17 g PO DAILY 7. betamethasone, augmented 0.05 % topical BID 8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 9. Simvastatin 20 mg PO QPM 10. Mycophenolate Mofetil 1000 mg PO QAM 11. Mycophenolate Mofetil 500 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 14. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Bisacodyl ___ID:PRN Constipation - Second Line 2. Dexamethasone 4 mg PO DAILY 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity 4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 5. LORazepam 0.25 mg PO Q4H:PRN nausea 6. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H 7. Mycophenolate Mofetil 1000 mg PO QAM 8. Mycophenolate Mofetil 500 mg PO QHS 9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second Line 11. HELD- betamethasone, augmented 0.05 % topical BID Duration: 2 Weeks This medication was held. Do not restart betamethasone, augmented until your doctor tells you to do so 12. HELD- Polyethylene Glycol 17 g PO DAILY This medication was held. Do not restart Polyethylene Glycol until your doctor tells you it is safe to do so 13. HELD- Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID This medication was held. Do not restart Triamcinolone Acetonide 0.1% Ointment until your doctor tells you to do so Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Malignant bowel obstruction Metastatic high grade serous adenocarcinoma, likely ovarian Malnutrition SECONDARY: IgA/IgG pemphigus foliaceus Macrocytic anemia Hypertension Hyperglycemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with fall, +headstrike// fracture, dislocation, 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: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Atherosclerosis seen in intracranial ICAs and bilateral distal vertebral arteries. There is no evidence of fracture. There is partial opacification of the anterior right ethmoidal air cells, mucosal thickening in posterior mucosal ethmoidal air cells. The remainder 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 evidence fracture, mass, hemorrhage or infarction. 2. Paranasal sinus disease. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: History: ___ with fall, +headstrike// fracture, dislocation, bleed fracture, dislocation, bleed 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 5.6 s, 22.0 cm; CTDIvol = 23.0 mGy (Body) DLP = 505.6 mGy-cm. Total DLP (Body) = 506 mGy-cm. COMPARISON: CT cervical spine ___ FINDINGS: Alignment is normal. No fractures are identified. Unchanged mild-to-moderate multilevel degenerative changes with osteophyte formation, most prominent at C5-C6 and C6-C7 and T1-T2 levels. Mild-to-moderate neural foraminal stenosis remains worse at C5-C6 and C6-C7 due to uncovertebral spurring. There is no evidence of spinal canal stenosis.There is no prevertebral soft tissue swelling. IMPRESSION: 1. No evidence of fracture or subluxation. 2. Stable multilevel degenerative changes worse at C5-C6 and C6-C7 levels. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with abdominal pain, vomitingNO_PO contrast// mass, infection TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the 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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP = 8.4 mGy-cm. 2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 8.0 mGy (Body) DLP = 413.3 mGy-cm. Total DLP (Body) = 422 mGy-cm. COMPARISON: CT abdomen pelvis and chest ___. FINDINGS: LOWER CHEST: New ground-glass opacities in the right lower quadrant are incompletely evaluated. Incompletely seen also is a atelectasis in the right middle lobe. Coronary calcifications. No pleural effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout with few hypodensities again seen, too small to characterize, but likely hepatic cysts. There is no evidence of focal lesions. There is no evidence of intrahepatic biliary dilatation. The CBD continues to be prominent to the level of the ampulla. The gallbladder contains gallstones without wall thickening or surrounding inflammation. Fundal adenomyomatosis. PANCREAS: The pancreas has normal attenuation throughout. Dilation of the main pancreatic duct is unchanged from prior, without evidence of obstructing lesion. 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. Tiny hypodensities bilaterally are too small to characterize. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Short-segment of small bowel in the mid abdomen shows edematous and thickened wall. Multiple loops of small bowel seen the right and mid abdomen are fluid-filled, with air-fluid levels small bowel in the right and lower abdomen, present air-fluid levels, edematous and thickened wall. The with target sign seen in the mid abdomen (2:63). There is normal enhancement throughout. The colon and rectum are within normal limits. Redemonstrated large amount of ascites. PELVIS: The urinary bladder and distal ureters are unremarkable. 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: Generalized bone demineralization without acute fractures or suspicious bone lesions. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Short segment of small bowel wall thickening and wall edema in the mid abdomen with few fluid filled loops of small bowel, most compatible with enteritis. 2. Redemonstration of large volume ascites. 3. New ground-glass opacities in the right lower lobe. Correlate clinically for aspiration or pneumonia. 4. Stable dilation of the main pancreatic duct and CBD without obstructing lesion. Radiology Report INDICATION: ___ year old woman with gyn malignancy, difficulty tolerating PO// eval for SBO TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT scan dated ___. FINDINGS: Multiple mildly dilated loops of small bowel with air-fluid levels seen in the right upper quadrant. The colon is not abnormally dilated. Air seen in the rectum. There is no free intraperitoneal air. Osseous structures are unremarkable. Central displacement of the bowel loops in keeping with ascites. Small bilateral pleural effusions There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: 1. Mildly dilated loops of small bowel with air-fluid levels in the absence of colonic dilatation suggest partial small bowel obstruction. CT may be performed if further characterization is needed. 2. Ascites as well as small bilateral pleural effusions. Radiology Report EXAMINATION: ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS INDICATION: ___ year old woman with metastatic GYN cancer and large volume ascites on CT abdomen. Request for ultrasound-guided therapeutic paracentesis. TECHNIQUE: Limited grayscale ultrasound imaging of the abdomen demonstrated moderate ascites. A suitable target in the deepest pocket in the left lower quadrant was selected for paracentesis. COMPARISON: Comparison to prior therapeutic paracentesis from ___. Comparison to prior CT abdomen/pelvis from ___. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated moderate ascites. A suitable target in the deepest pocket in the left lower quadrant was selected for paracentesis. PROCEDURE: Ultrasound guided therapeutic paracentesis Location: left lower quadrant Fluid: 1.75 L of serosanguinous fluid Samples: None 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. Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest fluid pocket. 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: 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 1.75 L of fluid were removed. Radiology Report INDICATION: ___ year old woman with metastatic serous carcinoma of GYN origin with likely pSBO// SBO? TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Prior radiograph dated ___. FINDINGS: Small bilateral pleural effusions. Multiple dilated loops of small bowel with air-fluid levels in the central abdomen similar in size and appearance to prior radiograph dated ___. Air is again seen in the descending colon and rectum which are not dilated. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: 1. Dilated loops of small bowel with air-fluid levels re-demonstrated from prior radiograph, similar in size and appearance. Consistent with persistent partial small bowel obstruction. CT may be performed if further characterization is needed. 2. There is again seen ascites and small bilateral pleural effusions. Radiology Report INDICATION: ___ year old woman with metastatic serous carcinoma with pSBO// ?SBO TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Prior abdominal radiographs, most recently ___. FINDINGS: Again seen are multiple dilated loops of small bowel showing air-fluid levels similar in dimension as compared to prior radiograph from ___. Air is no longer seen in colon loops. Unchanged appearance of intra-abdominal ascites and small bilateral pleural effusions. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Unchanged appearance of dilated loops of fossa bowel with air-fluid levels remain concerning for small bowel obstruction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman s/p NGT placement// NGT placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The enteric tube projects over the stomach. A right chest wall Port-A-Cath tip extends to the cavoatrial junction. There is blunting of the costophrenic angles bilaterally possibly reflective of small pleural effusions. There is no pneumothorax identified. The size of the cardiac silhouette is within normal limits. IMPRESSION: The enteric tube projects over the stomach. Small bilateral pleural effusions. Radiology Report INDICATION: ___ year old woman with Metastatic serous carcinoma with pSBO// Still obstructed? TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Prior abdominal radiographs, most recently ___ and ___. FINDINGS: Multiple dilated loops of small bowel are again demonstrated showing air-fluid levels similar in dimension when compared to prior. There is no air visualized within the large bowel. There is no free intraperitoneal air. Osseous structures are notable for calcific changes in the costochondral cartilage. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. There has been interval placement of a gastric tube with the side port and tip within the gastric body. There are small bilateral pleural effusions. A prepectoral port is seen overlying the right anterior chest wall. IMPRESSION: Unchanged appearance of dilated loops of small bowel with air-fluid levels consistent with a partial small-bowel obstruction when compared to prior radiograph dated ___. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: Constipation, s/p Fall Diagnosed with Unspecified abdominal pain temperature: 98.4 heartrate: 87.0 resprate: 18.0 o2sat: 100.0 sbp: 108.0 dbp: 60.0 level of pain: 7 level of acuity: 3.0

Dear ___, You were admitted to ___ because you were having abdominal pain, nausea and vomiting. What happened in the hospital? - You were found to have a bowel obstruction. This is due to the cancer in your belly - You were given several medications to help improve the obstruction, but unfortunately it did not help. - A tube was inserted into your nose to relieve some of the pressure in your abdomen. This helped your symptoms but was removed prior to discharge. - You underwent a procedure to remove over a liter of fluid in your belly. This fluid is called ascites and is due to your cancer. What should I do when I go home? - We have made changes to your medication list, so please take your medications as prescribed. - We also recommend that you use the bisacodyl suppositories two time a day to help with your constipation and relieve pressure from below - Please go to your follow up appointments listed below - We recommend that you call your oncologist, Dr. ___ at ___ to schedule a sooner appointment in the next ___ weeks - If you develop symptoms of nausea, vomiting or severe abdominal pain, please call your doctor or return to the emergency room. It was a pleasure taking part in your care. We wish you all the best. Sincerely, The team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypoxic respiratory failure Major Surgical or Invasive Procedure: Cardiac catheterization, stent placement Intubation w/ mechanical ventilation History of Present Illness: Patient is a ___ year old smoker with a past medical history CAD (h/o multiple stents > ___ yrs ago in ___ and ___ years ago in ___, DM and HTN who present with an acute episode of hypoxic respiratory failure yesterday in the setting of hypertension and tachycardia. Patient had at least two ER visits in the past few days for epigastric pain thought to be due to constipation on the first visit and to a hiatal hernia on the second visit. Per daughter, epigastric pain is similar to prior presentations of ACS requiring PCI and stenting; patient felt strongly that source of pain was cardiac. His OSH CXR from his ___ ER visit was unremarkable. After his second discharge home he continued to have severe epigastric pain and developed new and rapidly worsening shortness of breath. EMS was called, and on arrival to the OSH ER (___) he was hypertensive to 215/113, tachypneic to 27, tachycardic with a heart rate of 117. Rhythmm unclear sinus vs. SVT, given adenosine, did not convert. Labs at OSH were significant for wbc 19, creat 1.4, lactate 4, trop 0.27; kub showed no air fluid levels. Pt saturating 79% on RA and in the 90's on bag mask ventilation w/ crackles throughout. His respiratory status quickly decompensated, and he was intubated. Repeat CXR showed a new RLL infiltrate in a background of mild pulmonary edema. (clear OSH CXR from two days prior). He was given rocephin, levofloxacin and lasix 80mg (Uop s/p lasix administration unknown) and he was transferred to ___. In the ED, initial vitals were HR 92 BP 120/59 RR 21 satting 99% (intubated on CMV assist control, FiO2% 70; PEEP:5). Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+), Hypertension (+) 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: At ___ ___ years ago, at ___, multiple stents placed, unknown anatomy -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: GERD Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: HR 62, BP 97/56, RR 20, satting 100% (intubated) GENERAL: WDWN male in NAD, intubated, sedated. HEENT: NCAT. NECK: Supple with JVP of 14 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. Poor exam ___ sedation, intubation. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ DISCHARGE PHYSICAL EXAMINATION Pertinent Results: ADMISSION LABS ___ 02:36AM BLOOD WBC-11.8* RBC-4.88 Hgb-14.5 Hct-45.1 MCV-93 MCH-29.8 MCHC-32.2 RDW-12.7 Plt ___ ___ 04:00AM BLOOD ___ PTT-36.1 ___ ___ 02:36AM BLOOD Glucose-252* UreaN-29* Creat-1.5* Na-143 K-5.5* Cl-106 HCO3-22 AnGap-21* ___ 02:36AM BLOOD ALT-30 AST-43* CK(CPK)-286 AlkPhos-73 TotBili-0.8 ___ 02:36AM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.2 Mg-1.9 ___ 03:55AM BLOOD Type-ART Temp-37.1 PEEP-5 FiO2-70 pO2-125* pCO2-46* pH-7.38 calTCO2-28 Base XS-1 -ASSIST/CON Intubat-INTUBATED OTHER PERTINENT LABS ___ 02:36AM BLOOD CK-MB-34* MB Indx-11.9* proBNP-1196* ___ 02:36AM BLOOD cTropnT-0.30* ___ 08:57AM BLOOD CK-MB-79* MB Indx-14.9* cTropnT-1.19* ___ 08:04PM BLOOD CK-MB-62* cTropnT-2.78* ___ 06:31AM BLOOD CK-MB-65* MB Indx-4.9 cTropnT-2.05* ___ 02:49AM BLOOD Lactate-2.9* ___ 03:49PM BLOOD Lactate-1.1 ___ 08:39PM BLOOD Lactate-1.0 ECHO ___ The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is an apical left ventricular aneurysm. There is also a posterobasal left ventricular aneurysm. Overall left ventricular systolic function is severely depressed (LVEF = 15 %) secondary to extensive anterior, septal, apical, and posterobasal akinesis with focal apical dyskinesis. The rest of the left ventricle is hypokinetic. No masses or thrombi are seen in the left ventricle. The remaining left ventricular segments are hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: profound left ventricular systolic dysfunction, most likely of coronary etiology, with preserved right ventricular contractile function CXR ___ FINDINGS: In comparison with study of ___, there has been some decrease in the consolidation at the right base. Continued mild enlargement of the cardiac silhouette with evidence of pulmonary edema. The tip of the endotracheal tube measures approximately 4.5 cm above the carina. ___-Ganz catheter from the femoral region extends to the right pulmonary artery. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Donnatol 0.4 mg PO DAILY 2. Ramipril 20 mg PO DAILY Hold for SBP<100 3. Clopidogrel 75 mg PO DAILY 4. Metoprolol Tartrate 50 mg PO BID 5. glimepiride *NF* 2 mg Oral qd 6. Furosemide 40 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. lansoprazole *NF* 15 mg Oral daily 10. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Medications: 1. Outpatient Lab Work check chem-7 and INR on ___ with results to Dr. ___ at Phone: ___ Fax: ___ ICD 9 428 2. Nitroglycerin SL 0.4 mg SL PRN chest pain RX *nitroglycerin 0.4 mg one tab sublingually every 5 minutes for a total of 3 doses Disp #*25 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 7. Benzonatate 100 mg PO TID RX *benzonatate 100 mg one capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 8. Eplerenone 12.5 mg PO DAILY RX *eplerenone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*2 9. glimepiride *NF* 2 mg ORAL QD 10. Lansoprazole *NF* 15 mg ORAL DAILY 11. Donnatol 0.4 mg PO DAILY 12. Levofloxacin 500 mg PO DAILY Duration: 3 Days RX *levofloxacin 500 mg one tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 13. Lisinopril 10 mg PO DAILY RX *lisinopril 20 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 14. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 15. TiCAGRELOR 90 mg PO BID do not stop taking this medicine or skip any doses unless Dr. ___ that it is OK to do so. RX *ticagrelor [Brilinta] 90 mg one tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 16. Warfarin 5 mg PO DAILY16 check your warfarin level on ___. RX *warfarin 5 mg one tablet(s) by mouth dailiy Disp #*30 Tablet Refills:*2 17. Levofloxacin 500 mg PO DAILY Duration: 3 Days Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Non ST elevation Myocardial Infarction Acute systolic heart failure Acute on chronic kidney injury atrial tachycardia Diabetes mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Intubated for dyspnea at outside ___, here to evaluate for pulmonary edema and ETT position. COMPARISON: Outside chest radiographs performed at ___ dated ___ and ___. TECHNIQUE: Portable supine frontal radiograph of the chest. FINDINGS: An endotracheal tube is in place with the tip terminating just at the level of the thoracic inlet 9 cm above the carina. An orogastric tube is seen coursing below the diaphragm and out of view on this image. There is a focal airspace consolidation in the right lung base on this single frontal view, which is unchanged from ___ at which time the patient was also intubated but new from the pre intubation study of ___. Mild pulmonary vascular congestion and edema is improved from ___. No significant pleural effusion or pneumothorax is detected. The cardiac silhouette is enlarged but stable. The mediastinal contours are within normal limits. The trachea is midline. IMPRESSION: 1. Right basilar consolidation new from pre intubation chest radiograph of ___ raises the possibility of aspiration. Less likely, this may represent asymmetric flash pulmonary edema. 2. Mild pulmonary vascular congestion and edema improved from ___. 2. ET tube at thoracic inlet. NG tube below the diaphragm. Radiology Report HISTORY: Pulmonary edema. FINDINGS: In comparison with study of ___, there has been some decrease in the consolidation at the right base. Continued mild enlargement of the cardiac silhouette with evidence of pulmonary edema. The tip of the endotracheal tube measures approximately 4.5 cm above the carina. Swan-Ganz catheter from the femoral region extends to the right pulmonary artery. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: INTUBATED Diagnosed with ACUTE LUNG EDEMA NOS temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

It was a pleasure taking care of you at ___. You had a heart attack and needed 3 drug eluting stents to be placed in your heart arteries. It is extremely important that you take ticagrelor and aspirin every day for at least one year and possibly longer to prevent the stents from clotting off and causing another heart attack. Do not stop taking aspirin and ticagrilor or miss any doses unless Dr. ___ that it is OK. Your heart is very weak after the heart attack, please check your weight every day in the morning before breakfast. Call Dr. ___ weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. You have been started on warfarin, a blood thinner to prevent blood clots from your weak heart. Dr. ___ will tell you how much warfarin to take every day. Please have your warfarin level and other labs on ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Aztreonam Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ year old woman with diabetes mellitus type 2 (last A1C 5.3%) complicated by gastroparesis/neuropathy/foot ulcer in RLE/nephropathy, CKD stage V not on HD, HTN, HLD, PVD, asthma, obesity who presents with altered mental status in the setting of hypoglycemia. Per chart review, patient has a complicated history of type 2 DM diagnosed at an early age. She was previously on insulin therapy however given frequent admissions for hypoglycemia in the setting of progressive kidney dysfunction, her ___ provider has stopped ___ and currently she is on glipizide 2.5mg BID which patient reports she has been adherent with. She recently underwent endometrial ablation and cervical lac repair under anesthesia (800cc EBL ___ with improvement in control of menstrual cycles. Yesterday, she reports feeling well and went to bed last night after taking her ___ meds. She reports she does not remember what happened today. Per report from family, pt was found to be altered in the monrning and hypoglycemic with a BG of 28. EMS called, she was given glucagon. On arrival pt disoriented to self, but knows she is at the hospital, unable to provide much history due to altered mental status. In the ED, initial VS were: 96.9 100 171/95 14 100% RA . On arrival ___ 100 ED physical exam was recorded as: oriented x 0 --> repeat exam- oriented x3- still very poor historian. unable to perform ED pelvic exam due to pain. ROS + non specific abdominal pain ED labs were notable for: WBC 12 H/H 9.5/27.4 plt 405 BUN/Cr ___ gap 24 HCO 14 K 8.6 --> 4.6 Ca 8, Phos 6.5 alk phos 128 lactate 1.1 serum tox negative Imaging showed: CXR with no intrathroacic process Patient refused other imaging studies Ob gyn was consulted due to initial concern for endometritis given mild leukocytosis and recent procedure. Given that pt reports baseline pain with pelvic exam to the point of requiring sedation for the exams, bimanual exam may not aid in diagnosis therefore not attempted. Recommended continued monitoring for signs/symptoms of infection and consideration of presumptive treatment for endometritis if clinical concern increases. Being admitted for management of blood sugars and for dialysis consult. Patient was given: ___ 08:00 IVF 1000 mL NS 1000 mL ___ 08:00 PO Acetaminophen 650 mg ___ 09:04 IH Albuterol 0.083% Neb Soln 1 NEB ___ 11:20 IVF 1000 mL D10W ___ 12:29 IVF 1000 mL NS 1000 mL ___ 15:40 IVF 1000 mL D10W ___ 15:40 PO Acetaminophen 650 mg Transfer VS were: 97.8 101 167/82 18 100% RA When seen on the floor, she is oriented times 3. She reports her sugars have been low recently prompting stopping her insulin. She thinks her kidney function is worse due to medications that were prescribed to her in the past. She is convinced that her diabetes is contributing to her CKD. She is refusing dialysis. She denies headache, cough, chest pain, shortness of breath, abdominal or pelvic pain. REVIEW OF SYSTEMS: A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: DM c/b gastroparesis/neuropathy/foot ulcer in RLE/nephropathy HTN hypercholesterolemia PVD asthma CKD stage V obesity chronic cognitive deficits Social History: ___ Family History: Diabetes in her mother, and 5 of her 6 siblings. Per patient report, mother died while on hemodialysis. Physical Exam: Gen: NAD, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Right BKA. RUE AVF with bruit and thrill Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect aox3, awake and apppropiate clear breath sounds regular pulse soft abdomen Pertinent Results: ___ 11:30AM GLUCOSE-53* UREA N-41* CREAT-5.8* SODIUM-137 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-14* ANION GAP-24* ___ 08:24AM GLUCOSE-56* UREA N-41* CREAT-5.4* SODIUM-136 POTASSIUM-7.3* CHLORIDE-103 TOTAL CO2-16* ANION GAP-24* ___ 11:40AM K+-4.6 ___ 08:24AM ALT(SGPT)-18 AST(SGOT)-40 ALK PHOS-133* TOT BILI-0.3 ___ 08:24AM LIPASE-26 ___ 08:24AM ALBUMIN-4.3 CALCIUM-8.3* PHOSPHATE-6.8* MAGNESIUM-2.1 ___ 08:24AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:24AM WBC-12.0* RBC-3.38* HGB-9.5* HCT-27.4* MCV-81* MCH-28.1 MCHC-34.7 RDW-14.5 RDWSD-41.8 ___ 08:24AM PLT COUNT-405* ___ 08:24AM ___ PTT-28.8 ___ ___ 07:35AM GLUCOSE-73 UREA N-43* CREAT-5.4* SODIUM-136 POTASSIUM-7.1* CHLORIDE-106 TOTAL CO2-12* ANION GAP-24* ___ 07:35AM ALT(SGPT)-17 AST(SGOT)-34 ALK PHOS-128* TOT BILI-0.3 ___ 07:35AM LIPASE-24 ___ 07:35AM ALBUMIN-4.1 CALCIUM-8.0* PHOSPHATE-6.5* MAGNESIUM-2.0 ___ 07:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:27AM LACTATE-1.1 K+-8.6* ___ 04:50PM BLOOD WBC-10.2* RBC-3.04* Hgb-8.5* Hct-24.0* MCV-79* MCH-28.0 MCHC-35.4 RDW-14.7 RDWSD-41.9 Plt ___ ___ 06:45AM BLOOD Glucose-110* UreaN-38* Creat-5.2* Na-138 K-4.7 Cl-107 HCO3-18* AnGap-18 ___ 06:25AM BLOOD ALT-13 AST-14 LD(LDH)-240 AlkPhos-118* ___ 08:24AM BLOOD Albumin-4.3 Calcium-8.3* Phos-6.8* Mg-2.1 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED 3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing 4. Gabapentin 300 mg PO TID 5. Fluticasone Propionate 110mcg 1 PUFF IH BID 6. Calcitriol 1 mcg PO 2X/WEEK (___) 7. Calcitriol 0.25 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: hypoglycemia encephalopathy diabetes typ2 complicated by esrd Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with AMS // ?cpd TECHNIQUE: PA and lateral views of the chest provided. COMPARISON: Chest radiograph dated ___. FINDINGS: Lung volumes are normal. There is no focal consolidation, effusion or pneumothorax. There is no central vascular congestion or overt pulmonary edema. Mediastinal and hilar contours are normal. Heart size is normal. IMPRESSION: No acute intrathoracic process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Hypoglycemia Diagnosed with Type 2 diabetes mellitus with hypoglycemia without coma temperature: 96.9 heartrate: 88.0 resprate: 12.0 o2sat: 98.0 sbp: 120.0 dbp: 80.0 level of pain: 0 level of acuity: 2.0

you were hospitalized because of low blood sugar it is very important that you only take glipizide (your diabetes medication) when you are eating. if you are fasting or not eating for some reason, do not take glipizide. measure your finger stick glucose twice a day please continue to discuss when you should consider dialysis with your usual doctors ___ were ___ after your gynecological surgery and received a blood transfusion

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Codeine Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ year old fa male who had a fall ___ days ago, at that time the images of the head and spine were negative for hemorrhage or fractures. Since her fall ___ days ago she fell again on three different occasions, and was referred to the ED by her PCP for evaluation. She denies headaches, dizziness, nausea, or vomiting. Past Medical History: PMHx: 1. Dementia 2. Hypercholesterolemia 3. Osteoporosis 4. Depression 5. Urinary incontinence Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: O: T: 98.3 BP: 118/48 HR: 68 R: 16 O2Sats: 98% Gen: WD/WN elderly lady , comfortable, NAD. Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, and hospital (baseline) 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, 2 to 1 mm bilaterally. 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 t/o. Toes downgoing bilaterally Coordination: normal on finger-nose-finger. PHYSICAL EXAMINATION ON DISCHARGE: A&O to self PERRL EOMs intact MAE with good strength No pronator drift Pertinent Results: CT Cervical Spine: ___ 1. No evidence of acute traumatic injury. 2. No significant change from the study 10 days prior with degenerative changes as above. 2. Increased sclerosis at the inferior endplate of T1 is stable since ___ but new since ___ and may represent compression deformity. CT Head: ___ 1. Acute left subdural hematoma as detailed above. No signs of herniation. 2. Large left supraorbital hematoma. Chest X-Ray AP & Lateral: ___ No acute intrathoracic process. CT Sinus/Mandible/Maxillofacial: ___ 1. Mild mucosal thickening of the anterior ethmoidal air cells and maxillary sinuses bilaterally. Small amount of fluid is seen layering in the left sphenoid sinus. 2. Stable left supraorbital hematoma, globes are unremarkable. CT Head: ___ 1. Interval increase of a left subdural hematoma with new extension along the left parietal lobe. Small infratentorial component is stable. No herniation. 2. Stable left supraorbital hematoma. Medications on Admission: Aricept 10 mg daily, Calcium Citrate + 315 mg-200 unit, Namenda 5mg BID, Risperdal 0.5mg BID, Vitamin D3 1,000 unit daily, Myrbetriq 25 mg daily. Discharge Medications: 1. Donepezil 10 mg PO HS 2. Heparin 5000 UNIT SC TID 3. RISperidone 0.5 mg PO BID 4. Vitamin D 1000 UNIT PO DAILY 5. Memantine 5 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Calcium Carbonate 500 mg PO DAILY 8. Bisacodyl 10 mg PO DAILY 9. Acetaminophen 650 mg PO Q4H:PRN pain/fever Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left Subdural Hematoma 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 CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: Prior exam from ___. CLINICAL HISTORY: Worsening falls, question pneumonia. FINDINGS: AP upright and lateral views of the chest were provided. The lungs appear clear without focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is stable and normal. Atherosclerotic calcifications are seen along the thoracic aorta. Chronic deformity at the left humeral head is not significantly changed. An old injury of the left distal clavicle is also stable. No acute bony injuries are seen. IMPRESSION: No acute intrathoracic process. Radiology Report INDICATION: Three falls with head strike within the last week. Evaluate for bleed. COMPARISON: CT head, ___. TECHNIQUE: Axial MDCT images were obtained through the brain without IV contrast. Multiplanar coronal, sagittal, and thin section bone algorithm reconstructed images were generated. FINDINGS: There is an acute left cerebral subdural hemorrhage, layering along the left tentorium and to a lesser extent extending along the superior falx (2:11, 10, 17) with a small infratentorial component maximally measuring 8mm (2:9). No other focus of hemorrhage is detected. There is no evidence of herniation, edema, mass effect or large territorial infarction. The ventricles and sulci are prominent, compatible with age-related atrophy. Periventricular and subcortical white matter hypodensities are nonspecific, but can be seen in the setting of chronic microvascular ischemic disease. The basal cisterns are patent and there is preservation of gray-white differentiation. No fracture is detected. There is a left supraorbital hematoma (3:6). The partially visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are grossly intact. IMPRESSION: 1. Acute left subdural hematoma as detailed above. No signs of herniation. 2. Large left supraorbital hematoma. Radiology Report INDICATION: Three falls with head strike within the last week. Evaluate for bleed. COMPARISON: Recent CT C-spine ___ and ___ TECHNIQUE: Contiguous helical MDCT images were obtained from the skull base through the T2 level without IV contrast. Multiplanar axial, coronal, sagittal and thin section bone algorithm reconstructed images were generated. TOTAL BODY DLP: 680.05 mGy-cm. FINDINGS: There is no evidence of acute traumatic fracture or dislocation. Overall, there is no appreciable change from the study 10 days prior. The atlantodental interval is preserved. The dens are normally positioned between the lateral masses of C1. Increased sclerosis at the inferior enplate of T1 (602b:24) is unchanged since ___ but new since ___ and may represent compression. Overall alignment is preserved. There are moderate degenerative changes with anterior and posterior osteophytes. Disc osteophyte complexes cause mild central canal narrowing at C4-C5 and C5-C6. Uncovertebral and facet joint arthropathy cause mild neural foraminal narrowing at several vertebral levels. There is no prevertebral or paravertebral soft tissue abnormality. The thyroid shows an 8 mm hypodense nodule. The included lung apices are clear. IMPRESSION: 1. No evidence of acute traumatic injury. 2. No significant change from the study 10 days prior with degenerative changes as above. 2. Increased sclerosis at the inferior endplate of T1 is stable since ___ but new since ___ and may represent compression deformity. Updated results called to Dr. ___ by ___ at 5:20 pm, ___. Radiology Report HISTORY: Left tentorium hemorrhage. Evaluate for evolution of hemorrhage. COMPARISON: Prior head CT from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without IV contrast. Sagittal, coronal and bone thin algorithm reconstructions were generated. Total exam DLP: 1036 mGy-cm. CTDI: 63 mGy. FINDINGS: There is redemonstration of a in left subdural hemorrhage, layering along the left tentorium, extending along the superior falx which appears enlarged when compared to prior examination. There is now also extension along the left parietal lobe (02:20). Small infratentorial component measures a maximum of 8 mm, not significantly changed since prior examination. No new focus of hemorrhage is identified. There is no herniation, edema, mass effect or large territorial infarction. Prominence of cortical sulci, fissures, ventricles and extra-axial CSF spaces representing atrophy are likely age-related. Periventricular white matter hypodensities are likely the sequelae of chronic small vessel ischemic disease. Basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is detected. Again seen is a left supraorbital hematoma (03:17). There is mild mucosal thickening of the anterior ethmoidal air cells. Otherwise, remaining visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: 1. Interval increase of a left subdural hematoma with new extension along the left parietal lobe. Small infratentorial component is stable. No herniation. 2. Stable left supraorbital hematoma. Radiology Report HISTORY: Status post fall with left tentorium hemorrhage. Evaluate for evolution of hemorrhage. COMPARISON: Prior head CTs from ___ and ___. TECHNIQUE: Helical axial images were acquired through the paranasal sinuses. Coronal and sagittal reformatted images were prepared. Total exam DLP: 813 mGy-cm. CTDI: 36 mGy. FINDINGS: The frontal sinuses are clear. There is mild mucosal thickening of the anterior ethmoid air cells. Small amount of fluid is seen layering in the left sphenoid sinus. Middle ear cavities are clear. There is mild mucosal thickening of the maxillary sinuses bilaterally. The ostiomeatal units are patent. The cribriform plates are intact. There is no nasal septal defect. The lamina papyracea is intact. There is redemonstration of a left supraorbital hematoma, not significantly changed since prior examination. The globes are unremarkable. There is no proptosis. Note is made of calcification of the carotid siphons bilaterally. IMPRESSION: 1. Mild mucosal thickening of the anterior ethmoidal air cells and maxillary sinuses bilaterally. Small amount of fluid is seen layering in the left sphenoid sinus. 2. Stable left supraorbital hematoma, globes are unremarkable. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: S/P FALL Diagnosed with TRAUMATIC BRAIN HEM NEC, UNSPECIFIED FALL temperature: 98.3 heartrate: 68.0 resprate: 16.0 o2sat: 98.0 sbp: 118.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0

Non-surgical Hemorrhage Discharge Instructions: •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. •If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may safely resume taking this when cleared by you Neurosurgeon.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / aspirin Attending: ___. Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: ___ Critical is a ___ year old female nursing home resident on Coumadin for pe who was last seen normal the night prior to admission. She reportedly woke up with right facial asymmetry and incomprehensible speech; she is verbal at baseline. Nursing home staff was unclear if she had a fall. She was taken to ___ where a ___ was performed and significant for bilateral subdural hematomas. Her INR at the outside hospital was 2.5. She was given KCentra and Vitamin K. She was also hypertensiveat the OSH requiring nicardipine gtt. She was intubated and transferred to ___ for neurosurgery evaluation. Past Medical History: recurrent DVTs on coumadin type 2 diabetes mellitus asthma/COPD coronary artery disease rheumatoid arthritis anxiety disorder muscle wasting and atrophy major depressive disorder thoracolumbar disc degeneration Social History: ___ Family History: ___ Physical Exam: ON ADMISSION ============ t103 140/99 97 19 94% intubated Intubated Neuro: EO to voice, PERRL ___. No commands. Overbreathing vent. +cough, no gag. Localizing uppers, RUE tremor/asterixis. Mild contractures bilateral uppers with increased tone. LLE triple flex to noxious, RLE weak withdrawal. ON DISCHARGE ============ VITALS: T 98 BP 185/71(syst BP over last 24 h 117-150) HR 80 RR 18 SO2 95 on 1 liters via nasal cannula; weight 118.5 (119.4), 4 soft/loose bowel movements yesterday ___: Appears comfortably lying in her bed. EYES:PERRLA. EOM intact. No scleral icterus. No conjunctival redness. HEENT: Head atraumatic. Poor dentition. Pink and moist mucous membranes. CV: Regular rate and rhythm. Normal S1 and S2. Systolic heart murmur with radiation to both carotid and L axilla. Strong peripheral pulses. RESP: Vesicular lung sound bilaterally. No adventitious lungs sounds on auscultation from anterior. GI: Bowel sounds present. Abdomen soft, no tenderness, no rebound, no guarding. Extremities: No peripheral edema. SKIN: No rash. NEURO: A/o x3. Cranial nerve, motor and sensory exam grossly intact. Pertinent Results: Admission Labs: =============== ___ 02:52PM BLOOD WBC-12.9* RBC-4.13 Hgb-11.4 Hct-36.4 MCV-88 MCH-27.6 MCHC-31.3* RDW-13.7 RDWSD-43.8 Plt ___ ___ 02:52PM BLOOD Neuts-80.2* Lymphs-14.4* Monos-4.2* Eos-0.1* Baso-0.4 Im ___ AbsNeut-10.32* AbsLymp-1.85 AbsMono-0.54 AbsEos-0.01* AbsBaso-0.05 ___ 02:52PM BLOOD ___ PTT-29.0 ___ ___ 02:52PM BLOOD Glucose-333* UreaN-23* Creat-1.2* Na-131* K-5.0 Cl-92* HCO3-20* AnGap-19* ___ 02:52PM BLOOD ALT-7 AST-18 AlkPhos-109* TotBili-1.4 ___ 02:52PM BLOOD Albumin-3.1* Calcium-9.1 Phos-2.9 Mg-1.5* ___ 02:55PM BLOOD Lactate-2.1* Discharge Labs: =============== ___ 06:30AM BLOOD WBC-7.0 RBC-2.84* Hgb-8.0* Hct-26.5* MCV-93 MCH-28.2 MCHC-30.2* RDW-15.2 RDWSD-49.8* Plt ___ ___ 06:30AM BLOOD Plt ___ ___ 06:30AM BLOOD Glucose-225* UreaN-41* Creat-1.3* Na-143 K-4.8 Cl-103 HCO3-27 AnGap-13 ___ 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.7 Microbiology: ============= ___ Urine Culture: ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ Urine Culture: ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ C. difficile DNA amplification assay: Positive for toxigenic C difficile by the Cepheid nucleic amplification assay. Imaging ======= ___ CT head w/o contrast: Overall stable, from 9 hours prior, bilateral subdural hematomas without midline shift. ___ CT head w/o contrast: 1. Allowing for differences in scanning technique, there is no significant interval change from CT head performed ___ at 22:14. 2. Re-demonstration of bilateral convexity, parafalcine, and tentorial subdural hematomas, that are essentially unchanged in size. There is no significant shift of midline structures. 3. No new evidence of intracranial hemorrhage, or infarct. ___ CT head w/o contrast: 1. Decreased bilateral mixed density subdural hematomas compared to ___ with near complete resolution of sulcal effacement, re-expansion of the lateral and third ventricles, and substantially improved mass effect on the midbrain. 2. No evidence for new intracranial abnormalities. ___ BILAT LOWER EXT VEINS: No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ ABDOMEN ULTRASOUND: 1. Cholelithiasis without signs of obstruction. 2. Echogenic foci in right renal pelvis possibly resulting from nephrocalcinosis. 3. Right renal cyst. ___ HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT: No obvious fracture detected involving the right hip. However, given the degree of osteoporosis, if there is high clinical suspicion for nondisplaced fracture, then MRI or CT could help for further assessment Mild right and left hip degenerative changes and degenerative changes of both SI joints. Dense vascular calcification. EEG === ___ EEG: This is an abnormal continuous ICU EEG monitoring study because of (1) Amplitude asymmetry with decreased voltages and a relative attenuation of faster frequencies on the right, consistent with the known subdural hematoma on that side. (2) Generalized background slowing consistent with a mild-moderate encephalopathy, nonspecific with regards to etiology. There are no electrographic seizures. Compared to the day priors study, the previously noted left frontotemporal sharp waves are no longer present, and the background is improved. Medications on Admission: aspirin 325mg daily atorvastatin 20mg daily Benadryl 25mg bid pRN budesonide suspension 0.5mg/2ml 1 unit inhale daily for corticosteroids cetirizine 10mg daily Coumadin 6mg/6.5mg QOD Cymbalta 30mg bid Colace 100mg bid florastor 250mg bid furosemide 20mg 0.5tab qod isosorbide mononitrate 30mg daily lactobacillus cap bid lantus 20units daily at b edtime metoprolol tartrate 25mg bid miralax 17g daily nitrofurantoin macrocrystal 100mg bid for uti x 10 days (started ___ novbolog sliding scale omeprazole 20mg bid risperidone 1mg qhs saline nasal spray senna 1 tab qhs vicodin ___ arthritis vitamin b12 1000mcg daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 3. amLODIPine 10 mg PO DAILY 4. CefTAZidime 1 g IV Q12H UTI Duration: 3 Days last dose on ___. Heparin 5000 UNIT SC BID 6. Glargine 20 Units Bedtime Regular 6 Units Breakfast Regular 6 Units Lunch Regular 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Labetalol 300 mg PO TID 8. Vancomycin Oral Liquid ___ mg PO Q6H to complete on ___. Aspirin 81 mg PO DAILY 10. DULoxetine 50 mg PO DAILY 11. Atorvastatin 20 mg PO QPM 12. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral DAILY 13. Budesonide Nasal Inhaler 0.5mg/2ml 1 unit nasal DAILY 14. Cetirizine 10 mg PO DAILY 15. ClonazePAM 1 mg PO BID anticonvusant RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 16. DiphenhydrAMINE 25 mg PO Q12H:PRN allergies 17. Florastor (Saccharomyces boulardii) 250 mg oral BID 18. Isosorbide Mononitrate 30 mg PO DAILY 19. RisperiDONE 1 mg PO QHS 20. Sodium Chloride Nasal 1 SPRY NU Q2 H nasal congestion 21. HELD- Furosemide 10 mg PO EVERY OTHER DAY This medication was held. Do not restart Furosemide until ___ talk to your doctor 22. HELD- Furosemide 20 mg PO EVERY OTHER DAY This medication was held. Do not restart Furosemide until ___ talk to your doctor 23. HELD- Furosemide 20 mg PO EVERY OTHER DAY This medication was held. Do not restart Furosemide until ___ talk to your doctor 24. HELD- Warfarin 6 mg PO EVERY OTHER DAY This medication was held. Do not restart Warfarin until reassessment by neurosurgery. 25. HELD- Warfarin 6.5 mg PO EVERY OTHER DAY This medication was held. Do not restart Warfarin until ___ talk to neurosurgery Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: bilateral subdural hematomas E. coli UTI ___ C. diff colitis Secondary Diagnosis: Diabetes mellitus Hyperglycemia 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 INDICATION: ___ intubated s/p SDH// ETT placement TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray from earlier the same day at 13:33. FINDINGS: Endotracheal tube tip is 1.8 cm from the carina, slightly retracted since prior. Enteric tube passes below the field of view. Lung volumes are slightly low. There is retrocardiac opacity progressed since prior which could represent worsening atelectasis. Underlying effusion or infection/aspiration are possible. Streaky right basilar opacity is likely atelectasis. Cardiac silhouette is difficult to assess given opacity at the left lung base. No acute osseous abnormalities. IMPRESSION: ET tube tip 1.8 cm from the carina. Dense left basilar opacity, potentially combination of effusion with atelectasis though infection or aspiration would be possible. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with bilat SDH, intubated// eval ETT, OGT. r/o pna eval ETT, OGT. r/o pna IMPRESSION: Compared to chest radiographs ___. Tip of the endotracheal tube is no less than 12 mm from the carina, but it is probably to close and should be withdrawn 2 cm for better function. Esophageal drainage tube passes into the mid stomach. Stomach is probably distended with fluid. Small left pleural effusion and moderate left basal atelectasis have improved. Right lung is grossly clear. Moderate enlargement of cardiac silhouette is stable. No pneumothorax. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with history of PE on coumadin bilat SDH from OSH p/w intubation and sedated// eval for interval change in bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.2 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: CT head without contrast from 9 hours prior FINDINGS: Re-demonstrated are bilateral convexity mixed density subdural hematomas, unchanged since the prior examination, measuring up to 12 mm along the right frontal convexity. Bilateral parafalcine subdural hematomas are also stable in size, measuring up to 5 mm in the left priors falcine region. There is no midline shift. No focal mass or infarct is identified. Bilateral mucous retention cysts are seen in the maxillary sinuses. The ethmoid air cells are clear. The mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Overall stable, from 9 hours prior, bilateral subdural hematomas without midline shift. Radiology Report EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD INDICATION: ___ year old woman with ___ f hx PE on Coumadin INR 2.5 at OSH given Kcentra/vit K. INR 1 NCHCT consistent with bilateral subdural hematomas, intubated// assess size of bleed, please perform now thank you TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: ___ MGy-cm . COMPARISON: Noncontrast CT head ___. FINDINGS: Allowing for differences in scanning technique and patient position, there is re-demonstration of bilateral convexity mixed density subdural hematomas, that are essentially unchanged from prior exam performed ___. Bilateral parafalcine subdural hematomas are also stable in size. Small subdural hematomas along the tentorium are also appreciated, and unchanged from prior head CT performed ___. There is no significant shift of midline structures. There is no new evidence of intracranial hemorrhage, or infarct. There are no fractures identified. Bilateral maxillary mucous retention cysts are once again identified. The remaining visualized paranasal sinuses are clear. The mastoid air cells are clear. There is a soft tissue density in the right external auditory canal, which likely represents cerumen. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Allowing for differences in scanning technique, there is no significant interval change from CT head performed ___ at 22:14. 2. Re-demonstration of bilateral convexity, parafalcine, and tentorial subdural hematomas, that are essentially unchanged in size. There is no significant shift of midline structures. 3. No new evidence of intracranial hemorrhage, or infarct. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with picc// r dl picc 53cm iv ___ ___ Contact name: ___: ___ r dl picc 53cm iv ___ ___ IMPRESSION: ET tube tip is at the level of the carina less than 1.5 cm from the carina and should be pulled back at least 2 cm. Right PICC line tip crosses the midline in continues toward the left brachycephalic vein and and left subclavian vein and should be repositioned. Bibasal areas of atelectasis and left pleural effusion are unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with R PICC malpositioned// R PICC repo attempted, retracted 6cm ___ ___ COMPARISON: Chest radiographs from ___ through earlier on ___ FINDINGS: Semi supine AP portable view of the chest provided. The right PICC tip ends in the right atrium. The endotracheal tube tip extends less than 1 cm past the carina into the proximal right mainstem bronchus. The nasogastric feeding tube tip ends in the stomach. The cardiomediastinal silhouette is mildly enlarged, but stable. Bilateral lower lobe atelectasis is again present, unchanged. There is no pleural effusion, pulmonary edema or pneumothorax. IMPRESSION: 1. Right PICC tip ends in the right atrium. 2. Endotracheal tube tip extends less than 1 cm past the carina into the proximal right mainstem bronchus. Recommend withdrawing the tube by at least 3 cm. 3. Bilateral lower lobe atelectasis, unchanged. 4. Mild cardiomegaly, unchanged. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:06 pm, 10 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with ___ f hx PE on Coumadin INR 2.5 at OSH given Kcentra/vit K. INR 1 NCHCT consistent with bilateral subdural hematomas, intubated// assess placement of ETT TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the endotracheal tube projects over the mid thoracic trachea. A nasogastric tube projects over the stomach. The tip of a right PICC projects over the cavoatrial junction. Atelectasis is noted in the left midlung zone unchanged. No large pneumothorax. IMPRESSION: The tip of the endotracheal tube projects over the mid thoracic trachea. Otherwise no significant interval change since prior. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: ___ year old woman with SDH// New NGT please assess placement TECHNIQUE: Portable chest x-ray COMPARISON: Portable chest x-ray from ___ FINDINGS: The tip of the nasogastric tube is within the stomach. The tip of the right PICC projects over the cavoatrial junction. Subsegmental atelectasis is again noted in the left midlung. The heart and mediastinal structures cannot adequately be assessed secondary to patient obliquity. The aorta is atherosclerotic. IMPRESSION: The tip of the endotracheal tube is within the stomach. Lungs appear unchanged. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: ___ year old woman with NG tube, got pulled out slightly and replaced// evaluate NG tube placement TECHNIQUE: Portable supine chest x-ray COMPARISON: Previous portable chest x-ray from ___. FINDINGS: The NG tube descends below the left hemidiaphragm, the tip is not seen. The tip of the right PICC projects over the cavoatrial junction. The heart and medius structures cannot be adequately assessed secondary to patient obliquity. The aorta is atherosclerotic. Subsegmental atelectasis is again noted in the left midlung. IMPRESSION: The NG tube descends below the left hemidiaphragm, the tip is not imaged. Cardiomegaly. Subsegmental atelectasis left midlung. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: ___ year old woman with NG tube, need to confirm placement. Tip not see in CXR just done// evaluate NG tube placement TECHNIQUE: Semi-erect portable chest x-ray COMPARISON: Previous supine chest x-ray from earlier in the same day, less than 1 hour previous FINDINGS: The NG tube tip is seen within the stomach. The uppermost aspect of the chest is not visualized. Within that limitation, there is no significant change when compared to the prior study. IMPRESSION: NG tube tip is seen in the stomach. Radiology Report INDICATION: ___ year old woman with subduiral hematoma// dobhoff TECHNIQUE: Portable chest x-ray semi erect COMPARISON: None FINDINGS: The chest and upper abdomen are imaged. The tip of the top of tube is coiled within the stomach. The right PICC tip overlies the cavoatrial junction. Patient obliquity precludes adequate evaluation of the heart and mediastinal structures. Subsegmental atelectasis is noted in the mid-lungs. IMPRESSION: The Dobhoff tube is coiled within the stomach. Subsegmental atelectasis midlung spared Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: NGT in good position?// s/p NGT placement TECHNIQUE: Single frontal view of the chest COMPARISON: Multiple prior radiographs, most recently on ___ at 15:46 FINDINGS: A enteric tube passes below the diaphragm and into the stomach, the very distal tip of which is not visualized, however the side port is in the left upper quadrant, likely in the stomach. A central venous catheter terminates at the cavoatrial junction. There is mild atelectasis at the lung bases and in the left midlung. No new focal consolidation. No pleural effusion or pneumothorax. IMPRESSION: The very distal tip of an enteric tube is not visualized, however the side port terminates within the stomach. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with h/o DVT/PE, now with TBI and holding anticoagulation// 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. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old woman with RUQ discomfort// evaluate for biliary obstruction 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. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm. GALLBLADDER: Cholelithiasis without gallbladder wall thickening. 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, measuring 12.7 cm. KIDNEYS: The right kidney measures 10 cm. The left kidney measures 10.2 cm. Echogenic foci in right renal pelvis but more than typically seen with stones. There is a cystic lesion in the upper pole of the right kidney. There is no evidence of masses or hydronephrosis in the kidneys. IMPRESSION: 1. Cholelithiasis without signs of obstruction. 2. Echogenic foci in right renal pelvis possibly resulting from nephrocalcinosis. 3. Right renal cyst. Radiology Report INDICATION: Status post NGT-placement. Tube in good position? TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Portable chest from ___ through ___ FINDINGS: An NG tube projects over the left upper quadrant with its tip and side-port within the stomach. PICC line is seen with its tip projecting over the cavoatrial junction. There are no abnormally dilated loops of large or small bowel. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: NG tube is seen with its tip and side-port within the stomach. Radiology Report Portable chest x-ray Indication: PICC line placement TECHNIQUE: Portable chest x-ray COMPARISON: Previous portable chest x-ray from ___ FINDINGS: The study is compromised secondary to patient obliquity. The PICC line tip overlies the right atrium. The enteric tube has been removed. Heart size is difficult to assess given patient positioning. Subsegmental atelectasis is seen in the left midlung. There are no large pleural effusions. IMPRESSION: PICC tip overlies the right atrium. If the desired location is the SVC repositioning by 2 cm is advised. Subsegmental atelectasis left midlung. Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ year old woman s/p dobhoff placement. Assess position. TECHNIQUE: Single portable semi upright frontal chest radiograph. COMPARISON: Chest radiograph ___. FINDINGS: Slightly limited evaluation due to patient rotation. The lungs are moderately well inflated with persistent bibasilar opacities. Mild cephalization of vasculature noted. Heart is top-normal in size and partially obscured due to patient positioning and overlying parenchymal abnormality. Persistent small left pleural effusion. No large right pleural effusion. No pneumothorax. An enteric feeding tube courses below the left hemidiaphragm with tip out of field of view. A right PICC tip is within the right atrium. IMPRESSION: 1. Right PICC tip in right atrium. 2. Vascular congestion with persistent small left pleural effusion. RECOMMENDATION(S): Consider withdrawing right PICC 2 cm for better positioning in the SVC. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 7:24 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: s/p NGT placement// NGT in good position? TECHNIQUE: Portable chest x-ray COMPARISON: Previous portable chest x-ray from ___ approximately 2 hours prior FINDINGS: The upper third of the chest is not included on the radiograph. The NG tube tip is within the stomach. The side-port is also evident within the stomach. Bibasilar opacities are grossly unchanged. Heart size cannot be adequately assessed given patient positioning. IMPRESSION: NG tube tip is within the stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: s/p NGT placement// NGT in good position? IMPRESSION: In comparison with the study of ___, the nasogastric tube has been advanced so that the tip extends at least to the midportion of the stomach. Streaks of atelectasis are seen in the mid and lower zones, but no evidence of acute pneumonia or vascular congestion. Radiology Report INDICATION: ___ year old woman with displaced NGT// Evaluate for proper dobhoff placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: The enteric tube has been removed. The tip of the right PICC line projects over the cavoatrial junction. Atelectasis noted in the left midlung and left lung base. No pneumothorax or large pleural effusion. The size of the cardiac silhouette is enlarged but unchanged. IMPRESSION: Interval removal of the enteric tube. Otherwise no significant interval change. Radiology Report INDICATION: ___ year old woman with dobhoff displaced// Please evaluate for dobhoff placement TECHNIQUE: AP portable chest radiographs COMPARISON: ___ from earlier in the day FINDINGS: Sequential images demonstrate advancement of a Dobhoff into the stomach. The tip of the right PICC line projects over the cavoatrial junction. Atelectasis is noted within the left midlung zone and left lung base. There is no pleural effusion or pneumothorax identified. The size of the cardiac silhouette is unchanged. IMPRESSION: Sequential images demonstrate advancement of a Dobhoff into the stomach. Radiology Report INDICATION: ___ year old woman with c difficile now with abdominal pain. Evaluate for obstruction, perforation. TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Abdominal ultrasound ___. FINDINGS: Limited abdominal radiograph due to portable technique and body habitus. Nonspecific bowel gas pattern. Arteriovascular calcifications. No acute osseus abnormality. Osteopenia. IMPRESSION: Limited study. Nonspecific bowel gas pattern. Radiology Report EXAMINATION: DX PELVIS AND HIP UNILATERAL INDICATION: ___ year old woman with R hip pain.// Fracture? COMPARISON: None. FINDINGS: Assessment of fine bony detail is limited by background osteopenia and overlying soft tissues, with underpenetration. Allowing for this, no lucent or sclerotic fracture line or displaced fracture fragment is detected in the right proximal femur or about the right hip. There is intracortical tunneling in the proximal femur consistent with osteoporosis. There is mild degenerative change of the right hip joint, with mild joint space narrowing and marginal spurring. Assessment of the left hip is quite limited on this single AP view,, but shows similar mild degenerative change. The pelvic girdle remains grossly congruent, with degenerative changes of both SI joints. Extensive vascular calcifications noted. IMPRESSION: No obvious fracture detected involving the right hip. However, given the degree of osteoporosis, if there is high clinical suspicion for nondisplaced fracture, then MRI or CT could help for further assessment Mild right and left hip degenerative changes and degenerative changes of both SI joints. Dense vascular calcification. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman s/p bilateral subdural hematomas now change in level of consciousness. Evaluate for acute hemorrhage. 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: Noncontrast CT head performed ___. FINDINGS: Right mixed-density subdural hematoma and smaller left mixed-density, predominantly hypodense subdural hematoma have both decreased in size since ___. Small residual parafalcine subdural hematoma is are slightly smaller. Previously seen paratentorial subdural blood is no longer visualized on axial images. There is no new hemorrhage. Sulcal effacement has essentially resolved. Lateral and third ventricles have re-expanded. Mass effect on the midbrain has substantially improved. There is no CT evidence for an acute major vascular territorial infarction. No suspicious bone lesion is seen. Again demonstrated are bilateral mucous retention cysts in the maxillary sinuses. Nasogastric tube is again seen in the left naris. Mastoid air cells are grossly clear allowing for absence of dedicated bone algorithm images. IMPRESSION: 1. Decreased bilateral mixed density subdural hematomas compared to ___ with near complete resolution of sulcal effacement, re-expansion of the lateral and third ventricles, and substantially improved mass effect on the midbrain. 2. No evidence for new intracranial abnormalities. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: SDH, Transfer Diagnosed with Nontraumatic subdural hemorrhage, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: intubated level of acuity: 1.0

Dear ___, ___ were admitted to the hospital with brain hemorrhage. ___ had given medications at an outside hospital to reverse the effect of your blood thinner. At the time of your admission ___ had a breathing tube in your windpipe and were on a ventilator. ___ were admitted to an intensive care unit. ___ were closely monitored in the ICU and CT scans of your head showed that the bleed was not getting bigger and the breathing tube was taken out and ___ were transferred out of the ICU to a regular medical ward. ___ were treated with anti seizure medications for a week. Please follow the neurosurgical discharge instructions as outlined below. ___ had two episodes of worsening of your kidney function while ___ were treated in the hospital. The first episode occurred while ___ were treated in the ICU, the second while ___ were treated on the regular ward. Your kidney function subsequently returned to normal. The cause of the first episode is not entirely but the second episodes was related to fluid losses due to your diarrhea. We treated ___ with fluids and your kidney function improved. When ___ were admitted to the hospital ___ were on an antibiotic called nitrofurantion for a urinary tract infection and ___ were found to grow a bacterium called E. coli in your urine. We completed the course with nitrofurantoin. Later during your hospital course ___ again developed symptoms of a urinary tract infection and were found to have cell that fight infections in your urine. ___ were again found to grow E. coli in your urine and we started ___ on an antibiotic called ceftazidime for a 7 day course. While ___ were in the hospital and after ___ had completed your first course of antibiotics for your urinary tract infection ___ developed diarrhea. Your diarrhea was caused by a bacterium called Clostridium difficile which sometimes causes and infections of the large bowels after treatment with antibiotics. We started on antibiotic treatment with an antibiotic called Vancomycin. ___ blood work showed at times mildly elevated calcium levels. As reduced mobilization can sometimes be the cause for this ___ were treated with physical therapy. Discharge Instructions - Neurosurgery Brain Hemorrhage without Surgery Activity · We recommend that ___ avoid heavy lifting or other strenuous exercise until your follow-up appointment. · ___ make take leisurely walks and slowly increase your activity at your own pace once ___ are symptom free at rest. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If ___ experienced a seizure while admitted, ___ are NOT allowed to drive by law. Medications · ***Please do NOT take any blood thinning medication (Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · ___ may use Acetaminophen (Tylenol) for minor discomfort if ___ are not otherwise restricted from taking this medication. What ___ ___ Experience: · ___ may have difficulty paying attention, concentrating, and remembering new information. · Emotional and/or behavioral difficulties are common. · Feeling more tired, restlessness, irritability, and mood swings are also common. · Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If ___ are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: · Headache is one of the most common symptom after a brain bleed. · Most headaches are not dangerous but ___ should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. · Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. · There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if ___ experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / CellCept Attending: ___. Chief Complaint: weakness, fatigue, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ year old female with PMH of ESRD on dialysis ___, HTN, h/o seizure in setting of missing dialysis, chronic pleural effusion, referred by PCP ___ 3 weeks of weakness, fatigue and altered mental status. At the office visit, the patient's husband described the patient has become increasingly lethargic and forgetful over the last three weeks. She has had distinct episodes lasting about one hour during which she is confused and "not herself." He describe The episodes lasted approximately one hour at a time, but since ___ she has consistently unable to express herself. She has also become weak, becoming more dependent on her rollator for walking. In the office, she had no focal neurologic deficits on exam, was hypertensive to 190/80. The patient and husband deny fevers, chills, chest pain, shortness of breath. They do report that she has had more intermittent loose stool. No blood in the stool. Her blood pressure had been uncontrolled; she was hypertensive at dialysis ___ with systolic blood pressures over 200. The patient was unsure whether she took her medications that morning, so her husband brought in her medications, and she took them at dialysis. Her blood pressure went down appropriately. In the emergency room she coughed and spit up po hydralazine. In the ED, initial VS were: 98.5 69 193/63 18 98% RA Exam notable for: Cranial nerves II -XII intact, 5 out of 5 strength bilaterally upper and lower extremities, full sensation bilaterally ECG: sinus, nl intervls, no st-twave changes, LVH by criteria, Labs showed: PLT 78, no leukocytosis, H/H baseline, Ca ___, BUN 22, Cr 4.7 Imaging showed: CT head with no acute intracranial process, CXR Blunting of the right posterior costophrenic angle is compatible with right lung base rounded atelectasis seen on prior CT. Consults: none Patient received: IV hydralazine Transfer VS were: 98.1 68 183/68 18 100% RA On arrival to the floor, patient with difficulty piecing together sentences. Per husband, this has been constant since ___. She does not find this frustrating. She complains of hand soreness. Husband states she has not been able to take her atorvastatin, aspirin, lisinopril for the past three weeks. She usually is unsupervised taking her medications. He believes she has missed doses at least twice this week of her carvedilol. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: - ESRD on HD ___ s/p failed living related-donor kidney transplant due to inability to tolerate cellcept; listed for repeat transplant at ___ - Chronic right pleural effusion (lymphocyte-predominant) and mediastinal/hilar lymphadenopathy s/p EBUS biopsy ___ - HFpEF - HTN c/b hypertensive emergency ___ - Seizure in setting of missed dialysis ___ - Anemia of chronic disease - Lactose intolerance - Shingles - Ovarian cyst - Previous falls c/b rib fractures -- posterior left ___ and 6th ribs fractured; lateral left ___ rib fractures ___. - Low transverse cesarean section ___ - LUE AV fistula (___) ___ - CCY - Living Related-Donor Kidney Transplant Social History: ___ Family History: Significant for Mother: HTN, stroke in ___. Physical Exam: ADMISSION PHYSICAL EXAM ========================= VS: 196 / 69 68 18 98 RA GENERAL: NAD, laying comfortably in bed, very pleasant HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no edema NEURO: Alert, cannot say where she is, does say yes when hospital is named, oriented to person, date. CN II-XII intact. ___ strength in ___ bilaterally. Sensation grossly intact. Rigidity in B/L UE. Reflexes deferred. Gait not observed. does not follow commands to completion. FTN extremely slow movement, will approach but not make contact with finger. DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ========================== ___ Temp: 98.6 PO BP: 171/54 HR: 67 RR: 18 O2 sat: 99% O2 delivery: RA weight 57.6kg GENERAL: Sitting in bed, pleasant, NAD HEENT: AT/NC, anicteric sclera, MMM CV: RRR, S1/S2, III/VI systolic ejection murmur heard best at the USB PULM: CTAB EXTREMITIES: No extremity edema. NEURO: AOx3. Fluent speech. MoCA ___ ___ strength on delt, 4+/5 on quads, ___ on TA bilaterally. Rigidity improved in the UE, barely there. Sensation grossly intact. 2+ reflex throughout. No clonus. Gait not observed. DERM: warm and well perfused. Pertinent Results: ADMISSION LABS =============== ___ 11:23PM ___ PTT-30.1 ___ ___ 06:30PM GLUCOSE-83 UREA N-22* CREAT-4.7* SODIUM-140 POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-31 ANION GAP-13 ___ 06:30PM estGFR-Using this ___ 06:30PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-91 TOT BILI-0.7 ___ 06:30PM ALBUMIN-3.9 CALCIUM-10.7* PHOSPHATE-4.3 MAGNESIUM-2.4 ___ 06:30PM VIT B12-247 ___ 06:30PM TSH-3.1 ___ 06:30PM WBC-5.4 RBC-2.87* HGB-9.6* HCT-29.2* MCV-102* MCH-33.4* MCHC-32.9 RDW-15.9* RDWSD-59.4* ___ 06:30PM NEUTS-51.3 ___ MONOS-15.0* EOS-8.7* BASOS-0.7 IM ___ AbsNeut-2.77 AbsLymp-1.30 AbsMono-0.81* AbsEos-0.47 AbsBaso-0.04 ___ 06:30PM PLT COUNT-78* ADMISSION IMAGING ================== CT HEAD WITHOUT CONTRAST ___ IMPRESSION: 1. No acute intracranial process. 2. Interval improvement in opacification of the left mastoid air cells and left middle ear cavity. MRI HEAD WITHOUT CONTRAST ___ IMPRESSION: 1. Interval progression since ___ of bilateral, confluent periventricular and subcortical white matter T2/FLAIR hyperintensities with involvement of the splenium of the corpus callosum. Given appearance, this patient's age, and prior presentations of hypertension, findings are favored to represent subcortical leukoencephalopathy/small vessel dementia/Binswanger disease. 2. No acute intracranial infarction or hemorrhage. 3. Global involutional changes EEG ___ IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of moderate diffuse background slowing, slow posterior dominant rhythm and frequent runs of frontal intermittent rhythmic delta activity (FIRDA). These findings are indicative of moderate diffuse cerebral dysfunction, which is nonspecific as to etiology. Common causes include infection, medication effects, and toxic-metabolic encephalopathies. FIRDA can also be seen with deep midline structural lesions, hydrocephalus, increased intracranial pressure, and brain stem lesions. There are no focal abnormalities, epileptiform discharges, or electrographic seizures. DISCHARGE LABS =============== ___ 06:15AM BLOOD Glucose-86 UreaN-41* Creat-5.0*# Na-137 K-4.8 Cl-99 HCO3-23 AnGap-15 INTERVAL LABS ================== ___ MMA 740 ___ B1 pending ___ intrinsic factor pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Calcitriol 1 mcg IV Frequency is Unknown with dialysis 4. Carvedilol 25 mg PO BID 5. Epoetin Alfa 5000 UNIT IV Frequency is Unknown with dialysis 6. HydrALAZINE 25 mg PO TID:PRN BP >180 7. Lisinopril 40 mg PO DAILY 8. sevelamer CARBONATE 800 mg PO TID W/MEALS 9. Aspirin 81 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. diclofenac sodium 1 % topical 3X/WEEK wrist after dialysis Discharge Medications: 1. HydrALAZINE 100 mg PO Q8H 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Calcitriol 1 mcg IV WITH HD with dialysis 6. Carvedilol 25 mg PO BID 7. diclofenac sodium 1 % topical 3X/WEEK (___) wrist after dialysis 8. Epoetin Alfa 5000 UNIT IV ONCE with dialysis Duration: 1 Dose 9. Lisinopril 40 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. sevelamer CARBONATE 800 mg PO TID W/MEALS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #Small vessel ischemic disease #MAHA #B12 deficiency #Thrombocytopenia #Uncontrolled hypertension Discharge Condition: Patient is stable. She is alert and oriented x3. She is able to ambulate with a walker. Followup Instructions: ___ Radiology Report INDICATION: ___ with ams, weakness// ?pneumonia TECHNIQUE: AP and lateral views the chest. COMPARISON: X-ray from ___. Chest CT from ___. FINDINGS: Patient is rotated to the right. Blunting of the right posterior costophrenic angle is compatible with right lung base rounded atelectasis seen on prior CT. The lungs are otherwise grossly clear. Cardiomediastinal silhouette is stable. No acute osseous abnormalities, chronic deformities of posterior left ribs are noted. IMPRESSION: No definite acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with hypertension and encephalopathy// ?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: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: MR head ___, CT head ___ FINDINGS: There is no evidence of acute infarction,hemorrhage,edema, or mass. Again seen is confluent bilateral periventricular and subcortical white matter hypodensities which are nonspecific, likely the sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. A left parietal osteoma is seen. There is decreased opacification of the left mastoid air cells. The visualized portion of the paranasal sinuses, right mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Interval improvement in opacification of the left mastoid air cells and left middle ear cavity. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD. INDICATION: ___ year old woman with expressive aphasia, word finding difficulties, subacute presentation// eval for CVA, PRES, amyloid angiopathy. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON 1. MR head ___. 2. MR head ___. FINDINGS: Limited exam due to patient motion on multiple sequences. Within limitation: again seen are bilateral white matter T2/FLAIR hyperintense signal abnormalities. Although the majority of these are periventricular in distribution and confluent, there are additional areas of focal and confluent subcortical white matter involvement worst in the left frontal lobe but also involving the left parietal lobe and right frontal and parietal lobes (for example see series 9 images 16, 15, and 14). Additionally, there is T2/FLAIR signal abnormality involving much of the splenium of the corpus callosum (09:12). These findings are progressed from prior studies of ___. There is no evidence of acute intracranial infarction, hemorrhage, mass, or mass effect, although note the GRE images are degraded by motion. Prominence of the ventricles and sulci is stable and consistent with global involutional changes. The major intracranial vascular flow voids are grossly preserved. There is a cavum septum pellucidum, a normal anatomic variant. The globes are unremarkable. IMPRESSION: 1. Interval progression since ___ of bilateral, confluent periventricular and subcortical white matter T2/FLAIR hyperintensities with involvement of the splenium of the corpus callosum. Given appearance, this patient's age, and prior presentations of hypertension, findings are favored to represent subcortical leukoencephalopathy/small vessel dementia/Binswanger disease. 2. No acute intracranial infarction or hemorrhage. 3. Global involutional changes. Gender: F Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by WALK IN Chief complaint: Altered mental status, Weakness Diagnosed with Altered mental status, unspecified temperature: 98.5 heartrate: 69.0 resprate: 18.0 o2sat: 98.0 sbp: 193.0 dbp: 63.0 level of pain: 0 level of acuity: 2.0

Dear Ms ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted because you were confused, feeling fatigued and you also had difficulties remembering words. Your blood pressures were also very high. WHAT HAPPENED TO ME IN THE HOSPITAL? - We took some imaging of your head which did not show any active bleeding or acute stroke. However, there were some changes in your brain's small blood vessels which we suspect are due to your high blood pressure. This could explain why you have been confused lately. - We also did some lab tests to check for infection but we did not find any infection. - One of your vitamins called B12 was low so we gave you 2 injections to help bring your levels up. Sometimes when B12 is low, it can make people feel confused. - We also did another test to check your brain activity. This test showed that you were not having a seizure. - Your blood pressure was also very high so we increased your medications. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments as scheduled below. - Follow-up with your primary care doctor after discharge from acute rehab. - Follow-up with the cognitive neurology team as scheduled below. We wish you the best! Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness, abdominal distention Major Surgical or Invasive Procedure: ___: Exploratory laparotomy, excision of subcutaneous metastases and ileocolic bypass History of Present Illness: ___ year old woman with uterine leiomyosarcoma metastatic to lung s/p surgery and adjuvant XRT who has very aggressive disease that was noted to progress even while receiving XRT, s/p 8 cycles of Gemcitabine/Docetaxol, recent progression noted ___, currently on AIM C2D14. Patient was discharged one week ago after being admitted from ___ to ___ with a SBO secondary to a large pelvic mass which is inoperable, s/p PEG placement for decompression. Patient reports that she was feeling fairly well on discharge one week ago but a couple of days later slowly started feeling weak and this progressed to the point where she had difficulty walking. No focal weakness rather weakness in her muscles and fatigue. No DOE, no SOB. No cough. No CP. No palpitations. No headache. Had dizziness when rising from a seated position. Reports that she has not been taking any PO other than liquids and no medications other than sucralfate. She feels that she can not swallow pills because despite drinking lots of fluids her throat is dry. She notes that she has had increase in pelvic/abdominal pain that is of the same quality as prior. No new sites of pain. She was not taking pain medication at home; at the present she has no pain after receiving Dilaudid in the ED. No stool from rectum. No N/V. No problems with PEG. Has been getting TPN at night. Normal UOP. No dysuria. No URI sx. Reports feeling improved since treatment in the ED. REVIEW OF SYSTEMS is negative in detail other than as noted above and frequent heartburn. Past Medical History: OBGYNHx: Gravida 0. Menopausal symptoms of hot flashes for ___ year. Has a history of fibroids. No hx of ovarian cysts, STD's or abnormal pap smears. Last pap was in ___ and was normal. Mammogram in ___ was nml. PMH: Denies history of asthma, heart disease, diabetes, HTN, thromboembolic disease and breast cancer. PSH: Open cholecystectomy in ___ Past Oncological History: ___: Initiated a 9 month period of amenorrhea -___: Menstrual cycle recommenced with flow similar to her previous menstrual cycles. However, as the days went by, she began experiencing menorrhagia with large blood clots the size of a tennis ball. -___: ___ Emergency department. She underwent a transvaginal ultrasound that showed an 8 x 11 x 9.2 cm uterus with a complex cystic mass in the central uterus measuring 7.5 x 4.5 cm with multiple septations. She also underwent a biopsy of the cervix in the emergency department with pathology revealing poorly differentiated pleomorphic malignant neoplasm likely pleomorphic leiomyosarcoma, positive focally for caldesmon, P16, KI67 increased and negative for melcam, AE1/3, EMA, P53, P63, inhibin, GATA-3, MelanA, HMB-45, ERG, CD34. -___: Evaluated by her gynecologist in the office, Dr. ___. MRI showed a complex 8.2 x 8.8 cm mass. -___: Established care with Dr. ___. Pelvic exam revealed the cervix with foul-smelling necrotic tissue, and a biopsy was performed in clinic. -___: CT chest, abdomen and pelvis that showed suspicious left external iliac lymph nodes, two 7 mm periaortic lymph nodes, a 3-mm left lower lobe nodular atelectasis and a 15.5 x 10.9 x 9.9 cm mass around the lower uterus. -___: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral lymph node sampling, cystoscopy and omental biopsy. Intraoperatively, the mass extended to the bilateral pelvic sidewalls with large external bilateral iliac lymph nodes and a normal omentum. **PATH: 9.5 cm mass consistent with leiomyosarcoma with lymphovascular invasion, positive for desmin and ER/PR negative. The vagina also had fragments of leiomyosarcoma, zero out of three lymph nodes were positive, but there was involvement of perinodal fat with leiomyosarcoma. The peritoneal washings were negative. -___: Adjuvant radiation therapy started with ___ in ___ -___: CT imaging at ___'s office showed nodules in lung -___: CT Torso: *Interval development of multifocal, multilobuated,heterogeneously -enhancing mass in the pelvis containing cystic and soft tissue components with pelvic wall lymphadenopathy, concerning for disease recurrence. *Moderate hydroureteronephrosis on the left kidney secondary to mass effect from above lesion. *Multiple new pulmonary nodules, predominantly in the lower lobes consistent with metastatic disease. -___: C1D1 Gemcitabine/docetaxel started -___: C1D8 Docetaxel allergic reaction manifested as cp, flushing, and dyspnea which resolved with steroids and benadryl. -___ to ___ with slow infusion of docetaxel, well-tolerated Social History: ___ Family History: Denies family hx of cancer, heart disease, DM Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITAL SIGNS: T 98 BP 126/84 HR 118 RR 20 SpO2 96% 3L General: Fairly well-appearing woman in NAD. HEENT: NC/AT, constricted pupils, alopecia, MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, tachycardic, NL S1S2 no MRG PULM: decreased breath sounds bilaterally at the bases, no rales or wheezing ABD: markedly hypoactive bowel sounds, hard mass appreciated in the pelvis particularly around area of previous surgical incision, no fluid wave appreciated, no tenderness to palpation LIMBS: warm, well-perfused, no calf ttp, no edema SKIN: No rashes or skin breakdown NEURO: A&OX3, CN II-XII intact (visual acuity not tested), proximal/distal strength ___ X 4 extremities, sensation grossly intact DISCHARGE PHYSICAL EXAM: ======================== General: doing well, tolerating a regular diet, pain controlled by pain medications by mouth. VSS Neuro: A&OX3 Cardio/pulm: no chest pain, no resp distress Abd: soft, nontender, surgical site intact. Pertinent Results: ADMISSION LABS: =============== ___ 04:30PM BLOOD WBC-4.8 RBC-3.62*# Hgb-8.7*# Hct-27.4* MCV-76* MCH-23.9* MCHC-31.7 RDW-16.2* Plt Ct-60*# ___ 04:30PM BLOOD Glucose-142* UreaN-51* Creat-1.2* Na-140 K-2.4* Cl-76* HCO3-GREATER TH ___ 10:05PM BLOOD ALT-123* AST-95* AlkPhos-192* TotBili-0.3 ___ 04:30PM BLOOD Calcium-9.0 Phos-4.4# Mg-2.7* ___ 06:34PM BLOOD Lactate-2.7* DISCHARGE LABS: =============== MICRO: ====== - PRELIM BLOOD CX FROM ___: GNRs in ___ bottles, pending. - Blood Cultures: No growth, pending. - Urine Cultures: No growth, pending. - C. diff PCR: NEGATIVE RELEVANT STUDIES: ================= - CT CHEST W/ CONTRAST (___): 1. Numerous pre-existing pulmonary metastases demonstrate a mixed response to treatment, with some lesions demonstrating complete resolution, many lesions showing a decrease in size, and a small minority of lesions demonstrating interval growth. 2. Partially imaged upper abdomen shows new dilatation of multiple proximal small bowel loops unclear etiology. For a more detailed discussion of the upper abdomen, please refer to the separate report from the CT abdomen/pelvis performed concurrently. 3. Healing left tenth rib fracture - CT ABDOMEN W/ CONTRAST (___): 1. Worsening dilatation of the small bowel loops with numerous air-fluid levels and collapsed colon consistent with small bowel obstruction. The transition point is not included on this study but was seen to be at the level of the pelvic mass on the pelvic MRI. 2. Unchanged size of a ___ nodule in the anterior abdominal wall measuring 3.6 x 5.4 cm the last exam, but increased since ___ exam. 3. Hypo attenuating liver consistent with hepatic steatosis. 4. No new metastatic lesions are seen in the abdomen. For details regarding the pelvis please see pelvic MRI dated ___ and for details regarding the chest see dedicated chest CT report. - MRI PELVIS (___): 1. Progressive increase in size of the dominant cystic pelvic tumor, as well as the ___ nodule. No new metastatic disease identified within the pelvis. 2. Progressive dilatation of chronically obstructed small bowel loops. - EKG (___): Sinus tachycardia. Non-specific ST segment changes diffusely. No previous tracing available for comparison. - CXR (___): Heart size and mediastinum are stable. Multiple pulmonary nodules a present but overall appear to be decrease in the extent and number as compared to prior examination, may be potentially reactive to chemotherapy. No large pleural effusion demonstrated. No definitive focal consolidations seen. Right Port-A-Cath catheter tip terminates at the lower SVC. ___ 06:46AM BLOOD WBC-10.0 RBC-2.74* Hgb-7.7* Hct-24.1* MCV-88 MCH-28.0 MCHC-31.8 RDW-20.2* Plt ___ ___ 11:00AM BLOOD WBC-12.5* RBC-2.93* Hgb-8.3* Hct-25.9* MCV-88 MCH-28.5 MCHC-32.2 RDW-20.0* Plt ___ ___ 05:45AM BLOOD WBC-12.4* RBC-3.09* Hgb-8.7* Hct-26.4* MCV-86 MCH-28.1 MCHC-32.8 RDW-19.0* Plt ___ ___ 06:19AM BLOOD WBC-18.7* RBC-3.13* Hgb-8.8* Hct-27.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-19.4* Plt ___ ___ 08:48AM BLOOD Hgb-9.0* Hct-26.6* ___ 02:57AM BLOOD WBC-20.8* RBC-3.12* Hgb-9.0* Hct-26.8* MCV-86 MCH-28.8 MCHC-33.5 RDW-19.2* Plt ___ ___ 02:09PM BLOOD Hct-31.8* ___ 07:36AM BLOOD Hct-32.3* ___ 03:53AM BLOOD WBC-26.7* RBC-3.81* Hgb-11.0* Hct-32.6*# MCV-85 MCH-28.8 MCHC-33.7 RDW-19.3* Plt ___ ___ 06:46AM BLOOD Glucose-97 UreaN-5* Creat-0.4 Na-140 K-3.9 Cl-106 HCO3-27 AnGap-11 ___ 08:10AM BLOOD Glucose-116* UreaN-12 Creat-0.4 Na-140 K-4.4 Cl-105 HCO3-28 AnGap-11 ___ 05:24AM BLOOD Glucose-133* UreaN-11 Creat-0.3* Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 ___ 03:46PM BLOOD Glucose-96 UreaN-8 Creat-0.3* Na-140 K-3.7 Cl-107 HCO3-27 AnGap-10 ___ 07:15AM BLOOD Glucose-119* UreaN-11 Creat-0.3* Na-140 K-3.8 Cl-106 HCO3-31 AnGap-7* ___ 05:45AM BLOOD Glucose-171* UreaN-11 Creat-0.4 Na-141 K-3.2* Cl-105 HCO3-29 AnGap-10 ___ 06:19AM BLOOD Glucose-128* UreaN-13 Creat-0.5 Na-139 K-4.1 Cl-104 HCO3-28 AnGap-11 ___ 06:46AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.9 ___ 08:10AM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.7 Mg-1.9 ___ 05:24AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.9 ___ 07:15AM BLOOD Calcium-7.5* Phos-3.0 Mg-2.0 ___ 05:45AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.8 ___ 06:19AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0 ___ 02:57AM BLOOD Albumin-2.0* Calcium-7.1* Phos-2.4*# Mg-2.0 ___ 10:33PM BLOOD Lactate-1.4 ___ 09:56PM BLOOD Lactate-1.6 ___ 11:18AM BLOOD Lactate-2.0 ___ 06:34PM BLOOD Lactate-2.7* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sucralfate 1 gm PO QID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain do not give more than 3000mg of tylenol in 24 hours RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*45 Tablet Refills:*0 2. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush 3. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain hold for increased sedation or rr<12 RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 5. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Leiomyosarcoma causing 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: CHEST (PORTABLE AP) INDICATION: ___ year old woman with uterine sarcoma admitted with weakness and recent history of low grade temperatures. Now with oxygen requirement. // Please evaluate for effusions or evidence of infections, metastasis. TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: Heart size and mediastinum are stable. Multiple pulmonary nodules a present but overall appear to be decrease in the extent and number as compared to prior examination, may be potentially reactive to chemotherapy. No large pleural effusion demonstrated. No definitive focal consolidations seen. Right Port-A-Cath catheter tip terminates at the lower SVC. Radiology Report EXAMINATION: MRI of the pelvis with and without contrast INDICATION: ___ year old woman with serous ovarian cancer s/p 2 cycles chemotherapy, C2D15 of AIM // please evaluate for interval change of cancer burden ___ medical record reports radical hysterectomy and bilateral salpingo-oophorectomy for high-grade leiomyosarcoma involving the lower uterine segment and cervix, with extensive lymphatic and vascular invasion. There has been progressive small-bowel obstruction secondary to the enlarging pelvic mass. TECHNIQUE: Multiplanar MRI of the pelvis is obtained at 1.5 Tesla per the female pelvis protocol. T1 and T2 weighted sequences are acquired both pre and post administration 7 mL of Gadavist COMPARISON: Multiple prior pelvic and abdominal CTs dating ___ 3 most recently ___. There is a single MRI of the pelvis dating ___. FINDINGS: There continues to be progressive increase in size of the dominant anterior midline cystic pelvic mass. This has current ___ of 14 x 11.6 x 12.3 cm (increased from 11.7 x 8.7 x 10.1cm on ___. The mass is cystic with innumerable irregular septations and enhancing nodules. It is predominately in capsulated with several foci of extension beyond the capsule. These excrescences are both cystic (08:13) and solid enhancing (1501:79). The mass abuts the roof of the bladder, without macroscopic invasion. There is been minimal interval growth of the Sister ___ nodule at the umbilicus, now 5.5cm in transverse dimension. No additional metastatic disease is noted within the included field of view. There is no free pelvic fluid or lymphadenopathy. Visualized small bowel loops are progressively dilated with multiple air-fluid levels. A transition to completely decompressed distal ileum is again noted at the posterior right lateral aspect of the pelvic mass. Note is made of a new 9mm pocket of nonenhancing T1 hyperintense material along the posterior aspect of the lower vagina just left of midline, with surrounding ___ (___). The location is most consistent with a Bartholin gland cyst, with potential superinfection given the surrounding enhancement. There is diffuse pelvic amount muscular edema as well as well as subcutaneous edema suggestive of generalized anasarca. IMPRESSION: Progressive increase in size of the dominant cystic pelvic tumor, as well as the Sister ___ nodule. No new metastatic disease identified within the pelvis. Progressive dilatation of chronically obstructed small bowel loops. New, potentially infected, 9mm Bartholin gland cyst. Radiology Report EXAMINATION: ABD SUPINE AND LAT DECUB INDICATION: ___ year old woman with uterine sarcoma, hx of sbo ___ mass // signs of obstruction TECHNIQUE: Portable radiographs of the abdomen. COMPARISON: Correlation with CT abdomen pelvis performed ___ performed. FINDINGS: There are air-filled, dilated loops of small bowel seen in the abdomen. Multiple decubitus views demonstrate air-fluid levels. These findings are concerning for small bowel obstruction. There are cholecystectomy clips in the right upper quadrant. IMPRESSION: Multiple air-filled dilated loops of small bowel with air-fluid levels, concerning for small bowel obstruction. NOTIFICATION: Above findings were discussed over the phone with ___ ___ by Dr. ___ on ___ at 17:38 Radiology Report INDICATION: ___ year old woman with h/o leiomyosarcoma metastatic to lung s/p ___ cycle of AIM chemotherapy // please evaluate tumor response to chemotherapy TECHNIQUE: CT of the abdomen DOSE: DLP: 973 mGy-cm (abdomen. COMPARISON: MR from ___ and CT the abdomen pelvis from ___ FINDINGS: LOWER CHEST: Please refer to the CT chest from the same day for full description of thorax including multiple lung base nodules. ABDOMEN: The liver is diffusely hypodense compatible with hepatic steatosis. No focal liver lesions are identified. Both kidneys are within normal limits. The adrenal glands are normal. The pancreas is normal. No focal splenic lesions are identified. There is no abdominal free fluid. There is no retroperitoneal lymphadenopathy by CT criteria. Extensive dilated loops of small bowel are found throughout the imaged portion the abdomen measuring up to 6 cm. The colon is collapsed. The transition point is not imaged on this CT however was imaged on the MR from ___. A PEG tube is in place. A 3.5 x 5.4 Sister ___ node is imaged, new since ___. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Worsening dilatation of the small bowel loops with numerous air-fluid levels and collapsed colon consistent with small bowel obstruction. The transition point is not included on this study but was seen to be at the level of the pelvic mass on the pelvic MRI. 2. Unchanged size of a Sister ___ nodule in the anterior abdominal wall measuring 3.6 x 5.4 cm the last exam, but increased since ___ exam. 3. Hypo attenuating liver consistent with hepatic steatosis. 4. No new metastatic lesions are seen in the abdomen. For details regarding the pelvis please see pelvic MRI dated ___ and for details regarding the chest see dedicated chest CT report. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ female with history of leiomyosarcoma metastatic to the lung s/p second cycle of chemotherapy. Evaluate for response to treatment. TECHNIQUE: Contrast-enhanced 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. 100 cc of Omnipaque 350 were administered intravenously without reported complication. DOSE: As per CT abdomen/pelvis. COMPARISON: ___. FINDINGS: A hypodense left thyroid lobe nodule appears slightly smaller on today's exam measuring 5 mm, previously 8 mm (5, 4). There is no supraclavicular, mediastinal, hilar or axillary lymphadenopathy. Heart size is normal with no pericardial effusion. The main pulmonary artery and thoracic aorta are normal caliber. The tip of a right pectoral MediPort extends into the right atrium. There is no pericardial effusion. The main pulmonary artery and thoracic aorta are normal caliber. No incidental central pulmonary embolus is identified. Numerous pre-existing pulmonary metastases demonstrate a mixed response to treatment. For reference, the largest left lower lobe juxtapleural metastasis has decreased in size measuring 2.1 x 2.5 cm, previously 2.7 x 3.4 cm (6, 152). A previously referenced lingular metastasis has also decreased in size measuring 1.0 x 1.5 cm, previously 1.5 x 1.8 cm (6, 110). However, a right apical subpleural metastasis is stable measuring 7 x 7 mm (6, 41). A right apical metastasis has grown slightly larger and demonstrates increased calcification measuring 0.8 x 1.0 cm, previously 0.6 x 0.7 cm (6, 53). A right lower lobe metastasis has also increased in size measuring 1.2 x 1.1 cm, previously 0.8 x 0.9 cm (6, 160). A handful of previously seen metastases have completely resolved. Bilateral linear and subsegmental atelectasis is new since the prior exam. There is no endobronchial lesion. A trace left pleural effusion is new. There are no bone lesions in the thorax worrisome for infection or malignancy. A healing left posterolateral tenth rib fracture is again identified. Images of the upper abdomen show new marked dilatation of multiple proximal small bowel loops. A gastrostomy tube has been placed. For a more detailed discussion of the upper abdomen, please refer to the separate report from the CT abdomen/pelvis performed concurrently. IMPRESSION: Numerous pre-existing pulmonary metastases demonstrate a mixed response to treatment, with some lesions demonstrating complete resolution, many lesions showing a decrease in size, and a small minority of lesions demonstrating interval growth. Partially imaged upper abdomen shows new dilatation of multiple proximal small bowel loops unclear etiology. For a more detailed discussion of the upper abdomen, please refer to the separate report from the CT abdomen/pelvis performed concurrently. Healing left tenth rib fracture. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with metastatic uterine sarcoma // preop eval preop eval IMPRESSION: IN COMPARISON WITH THE STUDY OF ___, THERE ARE LOWER LUNG VOLUMES BUT OTHERWISE LITTLE CHANGE IN THE APPEARANCE OF HEART AND LUNGS. PORT-A-CATH REMAINS IN POSITION. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with tachycardia, s/p small ___ bypass ileocolic ___ to uterine leiomyosarcoma, got 4 liters of fluids // pulmonary edema? pulmonary edema? IMPRESSION: In comparison with the study of ___, there continued low lung volumes. There is increasing opacification at both bases, most likely reflecting atelectatic change. In the appropriate clinical setting, superimposed pneumonia would have to be considered. The Port-A-Cath extends to the level of the cavoatrial junction. There is prominent dilatation of gas-filled loops of bowel within the visualized portion of the abdomen. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with met cancer tachycardic, // dvt? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. FINDINGS: Left: There is normal compressibility, flow and augmentation of the left common femoral, and popliteal veins. Compression of the superficial femoral vein was difficult to achieve due to surrounding soft tissue edema, however walls wall flow was demonstrated in the superficial femoral vein. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. Right: There is normal flow, compressibility and augmentation of the right common femoral, superficial femoral popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial veins. The peroneal veins are not well visualized. 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 bilateral lower extremity veins. The right peroneal veins were not visualized. Radiology Report EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY INDICATION: Metastatic leiomyosarcoma with tachycardia. Rule out pulmonary embolus. TECHNIQUE: Multidetector CT through the chest performed with 100 ml of IV contrast. Coronal and sagittal reformations were provided and reviewed. Oblique maximum intensity projection images were created and reviewed as well. DOSE: 254.80 mGy-cm COMPARISON: Chest CT ___. FINDINGS: Contrast opacifies the segmental and subsegmental vessels of the pulmonary arterial tree, without filling defects to indicate a pulmonary embolus. The aorta and main pulmonary artery are normal caliber. The heart is normal size and there is no pericardial effusion. A right-sided MediPort courses into the right atrium. The trachea is normal caliber. The airways are patent through the subsegmental level. There is a new small left pleural effusion from ___. Bibasilar atelectasis is worse from that time as well. Atelectasis in the superior segment of the right lower lobe is unchanged. There are multiple metastases seen throughout both lungs which are unchanged from ___. Hypoenhancement of these masses is likely related to the timing of contrast. There is no evidence for active infection. A 6 mm hypodensity in the left thyroid lobe is unchanged. There is no supraclavicular, axillary or central lymphadenopathy. The esophagus is unremarkable. Limited views of the spleen are unremarkable. Hypoattenuation of the liver is compatible with fatty infiltration. Again, a dilated loop of small bowel is seen in the left upper quadrant. The gastrostomy tube appears to be well-positioned. There are no lytic or blastic osseous lesions. A healing left tenth rib fractures again noted (5:121). IMPRESSION: 1. No pulmonary embolus. 2. New, small left pleural effusion with an increase in bibasilar atelectasis from 8 days prior. 3. Partially image dilated loops of small bowel, similar to prior. 4. Unchanged, intrathoracic metastatic disease. Radiology Report EXAMINATION: Supine and upright abdominal plain film INDICATION: ___ with malignant SBO is setting of uterine leiomyosarcoma s/p open small bowel bypass w/ ileocolic anastomosis // Eval SBO COMPARISON: Comparison to prior study dated ___ FINDINGS: Air is seen in mildly dilated loops of small bowel with multiple air fluid levels on the upright study and a relative paucity of gas within the colon. These findings could represent postoperative ileus although partial small bowel obstruction should be considered. Clips in the right upper quadrant are consistent with prior cholecystectomy. No free air is seen. Lung bases are incompletely visualized. A gastrostomy tube projects over the expected location of the stomach. IMPRESSION: Multiple loops of dilated bowel with air-fluid levels. Findings favor partial small bowel obstruction rather than postoperative ileus given the paucity of gas within the colon. Clinical correlation is advised and followup imaging should be based on the clinical assessment. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Dizziness, Hypokalemia Diagnosed with HYPOKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 97.5 heartrate: 124.0 resprate: 18.0 o2sat: 95.0 sbp: 103.0 dbp: 81.0 level of pain: 4 level of acuity: 2.0

You were admitted to the hospital with a bowel obstruction related to your cancer. You were tansferred to the Colorectal Surgery Service after a ileocolonic bipass of Leiomyosarcoma mass causing obstruction. Your symptoms are much improved after your surgery and you are now eating a regular diet. You have recovered from this procedure well and you are now ready to return home. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. We will ocntinue your TPN overnight to supplement your nutrition and the oncology team and Dr. ___ will discontinue the TPN when your are tolerating a bit more regular food. You should continue to eat small frequent meals with foods that contain protein for healing: fish, chicken, yogurt, cheese, nuts and contiue to take ensure supplements 3 times daily. If you cannot tolerate ensure, a nutritional shake that you enjoy would be fine as well. You will come back to the hospital after the weekend for your oncology appointment and to recieve chemotherapy. ___ has cleared you for chemotherapy. Please continue to care for the right sided chest port has you have been. The visiting nurses ___ assist you. Please monitor your bowel function closely. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. You have a small area that is redened on your pubis area below the incision, this does not seem to be related to the surgical incision, however, please monitor for increasing redness or pain and call the office with issues. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. ___. You may gradually increase your activity as tolerated but clear heavy exercise with Dr. ___. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: prednisone Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ woman with hx of CF (was just officially diagnosed in ___, has a rare gene mutation) presents with epigastric pain, nausea, vomiting (up to 10x), diarrhea since last night, similar to previous admissions for pancreatitis. She called her gastroenterologist, Dr. ___ instructed her to go to the ED. She describes her epigastric pain as nonstop and sharp. She was last admitted here in ___ for pancreatitis. Reports decreased appetite; has not eaten since ___ dinner (fajitas). She reports she has had three episodes of bronchitis recently ___, ___. For these episodes she went to see Dr. ___ at ___ who is her CF doctor. In the ED, initial VS were 97.3 66 14 146/91 100 RA Exam was notable for severe epigastric and LUQ tenderness, abdominal distension. Labs showed WBC 5.4, Hb 10.2, Hct 30.9, Plt 406, Na 141, K 5.9(hemolyzed), Cl 102, HCO3 25, BUN 6, Cr 0.5, Gl 91, Lactate 1.6, AST 65, Lip 35 Imaging: ___: CXR showed no evidence of pneumonia. No intraperitoneal free air. Received in ED: 2L NS, morphine 4mg x4, and Zofran 4mg x1 Transfer VS were: ___ 100/66 15 98% RA On arrival to the floor, patient reports she has a headache and thinks it was from the morphine. She reports that her pain is currently a 7 and was at worst an 8. REVIEW OF SYSTEMS: (+)PER HPI: Positive for nausea, vomiting, diarrhea also positive for headache since ED Denies chest pain or SOB. Past Medical History: Chronic pancreatitis relating to CF gene mutation arthritis s/p L and R TKR Cervical CA s/p TAHBSO Depression GERD L shoulder arthroplasty (___) L shoulder surgery (___) Nephrolithiasis Social History: ___ Family History: maternal grandmother: diabetes, "heart problems" 2 brothers - have not been tested yet 1 daughter - has not been tested Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 2219 97.5 PO 126 / 58 L Lying 60 18 97 Ra GENERAL: In obvious distress and pain, lying supine in bed. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Tattoo on abdomen. Extremely tender to palpation in the epigastric area, non tender elsewhere. Diminished bowel sounds. EXTREMITIES: no cyanosis, clubbing. 1+ pretibial pitting edema. DISCHARGE PHYSICAL EXAM ======================= VS: 98.2 148/73 58 18 96 Ra GENERAL: Comfortable lying supine in bed. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Tattoo on abdomen. Mildly TTP in epigastric area, non tender elsewhere. Diminished bowel sounds. EXTREMITIES: no cyanosis, clubbing. 1+ pretibial pitting 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 Pertinent Results: ADMISSION LABS ============== ___ 12:36PM BLOOD WBC-5.4 RBC-3.44* Hgb-10.2* Hct-30.9* MCV-90 MCH-29.7 MCHC-33.0 RDW-13.7 RDWSD-44.9 Plt ___ ___ 12:36PM BLOOD Neuts-50.5 ___ Monos-8.7 Eos-3.5 Baso-0.6 Im ___ AbsNeut-2.75 AbsLymp-1.98 AbsMono-0.47 AbsEos-0.19 AbsBaso-0.03 ___ 12:36PM BLOOD ___ PTT-29.1 ___ ___ 12:36PM BLOOD Glucose-91 UreaN-6 Creat-0.5 Na-141 K-5.9* Cl-102 HCO3-25 AnGap-14 ___ 12:36PM BLOOD ALT-30 AST-65* AlkPhos-68 TotBili-<0.2 ___ 12:36PM BLOOD Albumin-3.6 Calcium-9.2 Phos-4.5 Mg-1.7 DISCHARGE LABS ============== ___ 06:45AM BLOOD WBC-5.1 RBC-3.60* Hgb-11.0* Hct-32.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-13.3 RDWSD-44.4 Plt ___ ___ 06:45AM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-142 K-4.2 Cl-103 HCO3-23 AnGap-16 ___ 06:45AM BLOOD Calcium-9.7 Phos-5.2* Mg-1.6 MICRO ===== ___ 4:25 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= ___ Chest Xray IMPRESSION: No evidence of pneumonia. No evidence of free air. ___ KUB IMPRESSION: No radiographic evidence of obstruction. Moderate fecal retention. ___ Lower Extremity Ultrasound IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea 2. Escitalopram Oxalate 20 mg PO DAILY 3. Gabapentin 600 mg PO TID 4. Omeprazole 20 mg PO DAILY 5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 6. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit oral TID W/MEALS 7. Atorvastatin 10 mg PO QPM 8. Amitriptyline 25 mg PO QHS:PRN insomnia Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth daily Refills:*0 3. Senna 8.6 mg PO BID RX *sennosides [senna] 8.8 mg/5 mL 1 by mouth twice a day Refills:*0 4. Amitriptyline 25 mg PO QHS:PRN insomnia 5. Atorvastatin 10 mg PO QPM 6. Escitalopram Oxalate 20 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. Omeprazole 20 mg PO DAILY 9. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 10. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit oral TID W/MEALS 11. HELD- Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea This medication was held. Do not restart Diphenoxylate-Atropine until you see your PCP. this can cause constipation Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= Abdominal Pain Constipation Secondary Diagnosis =================== GERD Hyperlipidemia Depression Chronic Abdominal Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with upper abd pain// concern for GI perf vs PNA TECHNIQUE: Chest: Upright AP frontal and Lateral COMPARISON: Chest radiograph ___. FINDINGS: Patient is status post left shoulder hemiarthroplasty.The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. There is no intraperitoneal free air. IMPRESSION: No evidence of pneumonia. No evidence of free air. Radiology Report INDICATION: ___ year old woman with acute on chronic pancreatitis and abdominal distention. Look for obstruction TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: CT abdomen pelvis from ___ FINDINGS: Lung bases are clear. Mediastinal silhouette is within normal limits. There are no abnormally dilated loops of large or small bowel. Moderate amount of stool seen throughout the colon. There is no free intraperitoneal air. Osseous structures are notable for mild scoliosis at L2-L3. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No radiographic evidence of obstruction. Moderate fecal retention. Radiology Report EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) INDICATION: ___ year old woman with pancreatitis in for management of possible acute pancreatitis.// 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 and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Other chronic pancreatitis temperature: 97.3 heartrate: 66.0 resprate: 14.0 o2sat: 100.0 sbp: 146.0 dbp: 91.0 level of pain: 8 level of acuity: 3.0

Dear Ms ___, You came to ___ because you had severe abdominal pain. You were found to have severe constipation. Your liver and pancreas functions were normal during this admission. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: - We made you NPO (we restricted your oral intake) in order to give your bowels a rest, as this is a typical approach for people who present with a flare of pancreatitis. Your pancreas functions however were normal during this admission. - You had an image of your abdomen taken which showed that you were very constipated - We controlled your pain with Oxycodone and IV Dilaudid for breakthrough pain - We gave you a bowel regimen with Senna, Colace and Miralax which helped you have bowel movements. Your abdominal pain greatly improved after you had several bowel movements. - Your blood sugar was low at 67 and you received orange juice when this happened with appropriate response of your blood sugar WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please follow up with your primary care doctor ___ ___ ___ days after discharge - Please follow-up with your GI doctor (___) and your CF doctor ___ further discuss management of your blood sugars - Please take all of your medications as prescribed (see below). - We discontinued Diphenoxylate-Atropine as this can worsen your constipation - We wrote prescriptions for a bowel regimen (Senna, Miralax and Colace) which we recommend you to take to prevent getting constipated, since one of the side effects of the pain medication you are taking (Oxycodone) can be severe constipation - Seek medical attention if you have Abdominal pain, Abdominal swelling Nausea and vomiting, Vomiting blood, Difficulty swallowing, Diarrhea Constipation, Blood in stool, Black stool or other symptoms of concern.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin / ciprofloxacin / gabapentin Attending: ___ Chief Complaint: Urinary tract infection Major Surgical or Invasive Procedure: NONE History of Present Illness: Ms. ___ is a ___ w/ h/o DM1 c/b retinopathy, nephropathy, neuropathy, gastroparesis, CAD s/p CABG with bioprosthetic MVR, HFpEF, recurrent diabetic foot ulcers with recent below the knee amputation of left leg presenting for incontinence and suprapubic fullness. Patient had UTI 2 weeks ago that was treated by her outpatient nephrologist. She completed treatment with gentamycin last week. She reports having suprapubic fullness and incontinence today while trying to get to a commode. She denies any dysuria or hematuria. The suprapubic pressure has been occuring since her last UTI and has persisted even after treatment. She denies any assocaited fevers, chill, nausea, vomiting, diarrhea, chest pain, abdominal pain or shortness of breath. In the ED, initial vitals: 8 98.5 73 141/74 18 98% RA Labs notable for: WBC 13.0, Hgb/Hct 12.3/36.7, BUN/Cr 45/3.9, U/A with large leuks, negative nitrites, many bacteria. Patient was given her home medications and 500mg of IV meropenum Vitals prior to transfer: 98.4 65 ___ 18 97% Nasal Cannula REVIEW OF SYSTEMS(+) As 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: - ___ ___ TTE: Well seated bioprosthetic mitral prosthesis high normal gradient. Mild symmetric LVH. LVEF >55% - Mild PAH - ESRD: tunneled HD line ___ - CAD s/p CABG/bio MVR ___ - Afib (following CABG) on coumadin - DM1 (complicated by retinopathy, nephropathy, neuropathy, gastroparesis) - Diabetic foot ulcers, PVD: non-healing L heel ulcer s/p angio ___ followed by ___ - CAD s/p CABG and MVR ___ - Charcot foot - HLD - HTN - Mitral regurgitation s/p bioprosthetic MVR ___ - Endometriosis - Blind in R eye - Orthostatic hypotension secondary to autonomic neuropathy Recent admissions: ___ (C diff, ___ ___ (___) ___ (foot ulcer, UTI, dCHF) ___ (___ - CMED) ___ (foot ulcer - VSurg) ___ (___) ___ (CHF) ___ (___) ___ (___) ___ (pyelonephritis) ___ (Hyperglycemia) ___ (Left below the knee amputation) PAST SURGICAL HISTORY - CABG w/MVR (___) - Laproscopic procedures for endometriosis - Tonsillectomy - Multiple eye surgeries - Multiple B/L foot debridements (with podiatry) - Amputation of Left leg below the knee Social History: ___ Family History: Mother: HTN, ___ Father: ___, CVA, CAD, MI No history of malignancy Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 69 104/43 18 100%RA General: AAOx3, NAD HEENT: enuculeated R eye, conjunctiva pink, sclera anicteric, MMM CV: RRR, ___ SEM heard best at ___ Pulm: CTAB, no wheezes, rhonchi or rales Abd:soft, +BS, non-distended, suprapubic tenderness to palpation Thorax: R HD line, erythema present around site, non tender to palpation RLE: trace edema, mild ttp LLE: tender to palpation around right knee (patient states its been tender since amputation) no erythema, amputation below the knee DISCHARGE PHYSICAL EXAM: Vitals: 98.1 68 154/52 18 98 % RA General: AAOx3, NAD HEENT: enuculeated R eye, conjunctiva pink, sclera anicteric, MMM CV: RRR, ___ SEM heard best at LUSB Pulm: CTAB, no wheezes, rhonchi or rales Abd:soft, +BS, non-distended, suprapubic tenderness to palpation Thorax: R HD line, erythema present around site, non tender to palpation RLE: trace edema, mild ttp LLE: Amputation below the knee Pertinent Results: Admission Labs ___ 04:50AM BLOOD WBC-13.0*# RBC-3.96*# Hgb-12.3# Hct-36.7# MCV-93 MCH-31.0 MCHC-33.4 RDW-15.6* Plt ___ ___ 04:50AM BLOOD Neuts-86.8* Lymphs-6.2* Monos-4.6 Eos-2.1 Baso-0.2 ___ 04:50AM BLOOD Glucose-336* UreaN-45* Creat-3.9*# Na-130* K-5.2* Cl-92* HCO3-25 AnGap-18 ___ 04:50AM BLOOD Calcium-9.2 Phos-5.2*# Mg-2.4 ___ 07:22AM BLOOD K-4.8 ___ 04:30AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 04:30AM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ 04:30AM URINE RBC-30* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 ___ 04:30AM URINE WBC Clm-MOD Discharge Labs ___ 10:17AM BLOOD WBC-9.6 RBC-3.89* Hgb-11.6* Hct-35.1* MCV-90 MCH-29.8 MCHC-33.0 RDW-15.4 Plt ___ ___ 10:17AM BLOOD Glucose-308* UreaN-39* Creat-2.5* Na-133 K-4.5 Cl-94* HCO3-28 AnGap-16 ___ 10:17AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.3 MICRO Date/Time: ___ 6:53 am URINE ADDED TO GRAY HOLD ___. URINE CULTURE (Preliminary): Fosfomycin REQUESTED BY ___. ___ (___) ___.. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 32 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 4 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S IMAGING ___ 9:15 AM# ___ RENAL U.S. 1. Multiple small, bilateral, nonobstructive renal calculi. No hydronephrosis. 2. Distended urinary bladder with layering sediment and mild smooth wall thickening. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO DAILY 2. Acetaminophen 1000 mg PO Q8H 3. Lisinopril 10 mg PO DAILY 4. Gabapentin 100 mg PO TID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Docusate Sodium 100 mg PO BID Constipation 8. Senna 8.6 mg PO BID:PRN constipation 9. Apixaban 5 mg PO BID 10. Epoetin Alfa 4000 units SC 3 TIMES A WEEK 11. Atorvastatin 80 mg PO QPM 12. Ferrous Sulfate 100 mg PO 1X/WEEK (___) 13. Fentanyl Patch 50 mcg/h TD Q72H 14. HYDROmorphone (Dilaudid) ___ mg PO BID:PRN pain 15. TraMADOL (Ultram) 50 mg PO BID 16. sevelamer CARBONATE 800 mg PO TID W/MEALS 17. Omeprazole 40 mg PO DAILY 18. Aspirin 81 mg PO DAILY 19. Cetirizine 10 mg PO DAILY 20. Levothyroxine Sodium 25 mcg PO DAILY 21. Cyanocobalamin 500 mcg PO DAILY 22. Nephrocaps 1 CAP PO DAILY 23. NPH 32 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Cetirizine 10 mg PO DAILY 6. Cyanocobalamin 500 mcg PO DAILY 7. Docusate Sodium 100 mg PO BID Constipation 8. Fentanyl Patch 50 mcg/h TD Q72H 9. Gabapentin 100 mg PO DAILY 10. HYDROmorphone (Dilaudid) ___ mg PO BID:PRN pain 11. NPH 32 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 12. Lactulose 30 mL PO DAILY 13. Levothyroxine Sodium 25 mcg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Lisinopril 10 mg PO DAILY 16. Nephrocaps 1 CAP PO DAILY 17. Omeprazole 40 mg PO DAILY 18. Senna 8.6 mg PO BID:PRN constipation 19. sevelamer CARBONATE 800 mg PO TID W/MEALS 20. TraMADOL (Ultram) 50 mg PO BID 21. Epoetin Alfa 4000 units SC 3 TIMES A WEEK 22. Ferrous Sulfate 100 mg PO 1X/WEEK (___) 23. Metoprolol Succinate XL 50 mg PO DAILY 24. Meropenem 1000 mg IV POST HD (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS URINARY TRACT INFECTION END STAGE RENAL DISEASE SECONDARY DIAGNOSIS TYPE 1 DIABETES MELLITUS 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: RENAL U.S. INDICATION: ___ w/ h/o DM1 c/b retinopathy, nephropathy, neuropathy, gastroparesis, CAD s/p CABG with bioprosthetic MVR, HFpEF, recurrent diabetic foot ulcers with recent below the knee amputation of left leg presenting for incontinence, suprapubic fullness, leukocytosis and UA concerning for UTI. // rule out perinephric abscess TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal ultrasound dated ___. FINDINGS: The right kidney measures 9.5 cm. The left kidney measures 9.6 cm. Multiple small, nonobstructive calculi are noted within the upper and lower poles of the bilateral kidneys. There is no hydronephrosis or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is well distended, measuring approximately 350-400 cc in pre-void volume. There is a small amount of layering debris, and mild smooth urinary bladder wall thickening which is similar to the prior examination. IMPRESSION: 1. Multiple small, bilateral, nonobstructive renal calculi. No hydronephrosis. 2. Distended urinary bladder with layering sediment and mild smooth wall thickening. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dysuria Diagnosed with URIN TRACT INFECTION NOS, PRESSURE ULCER, LOWER BACK, PRESSURE ULCER, UPPER BACK, PRESSURE ULCER, UNSPECIFIED STAGE temperature: 98.5 heartrate: 73.0 resprate: 18.0 o2sat: 98.0 sbp: 141.0 dbp: 74.0 level of pain: 8 level of acuity: 3.0

You came to the hospital due to a bladder infection with urine culture showing Klebsiella that was multidrug resistant. You are being treated with meropenem which will be given with dialysis. It is possible that you may be able to get an oral medication called fosfomycin but the results of the sensitivities in the microbiology lab are pending at this time. You wanted to leave before this result was available. Unfortunately, it is not known if your dialysis center will have meropenem available on ___ as they were in the process of looking into this when you requested to be discharged. You have an appointment with your primary care doctor on ___. If your urine infection is sensitive to fosfomycin, you will request for Dr. ___ to prescribe you this medication on ___. Otherwise, it is possible that the pheresis unit on ___ may administer this medication to you on ___ (they were closed when we tried to reach them), or you stated you will present to the ED for a one time dose. You were found to retain urine and it is important that you have straight catheterizations daily by ___ to avoid continued risk of having bladder infections.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / latex Attending: ___. Chief Complaint: abdominal pain and fever Major Surgical or Invasive Procedure: Left percutaneous nephrostomy tube ___ History of Present Illness: ___ female with history of HTN, DM, biopolar disease, nephrolithiasis with prior placement of ureteral stents and lithotripsy, anatomic urologic anomalies, who presented to the ED w/ abd pain, hypotension, and fever. Per report, patient presented from assisted living facility with fever/chills, abdominal pain, and hypotension (SBPs in ___. Her symptoms reportedly started on ___. She also had accompanying decreased UOP, N/V, and CP/SOB. Per group home director, patient takes daily macrobid for UTI prophylaxis. On arrival per EMS, patient lethargic but SBPs ___. Of note, patient has history of MDR UTI. She has a duplicated bilateral renal collecting system with joining of the systems at the left UPJ and mild chronic left sided hydronephrosis. She takes daily Macrobid as suppressive therapy. Her last UTI in ___ and ___ was E. Coli, resistant to ceftaz, ceftriaxone and cipro but sensitive to Zosyn. In ___ she had a MRSA UTI. In ___ she had a pan-sensitive pseudomonas UTI. ED Course notable for: Initial vitals: 102.1 91 96/47 18 97% RA Receieved IV fluids as well as Zosyn/Vanc. She was found to have a significant leukocytosis and rising Cr, with a UA significant for large Leuk, >182 WBCs, and moderate bacteria. CXR concerning for LLL pneumonia and pleural effusion, renal U/S w/ left hydronephrosis secondary to an obstructing 6 mm left proximal ureteral stone. CT abd showed moderate hydroureteronephrosis of both the superior and inferior moiety secondary to an obstructing punctate calculus at the left ureterovesicular junction. Urology was consulted in the ED, recommended emergent ___ Left PCN for decompression. Patient initially refused procedure, but after discussion with HCP. she was intubated and taken down for the procedure. Per ___ sign out the procedure was successful and L PCN was placed. Patient required levophed given peripherally during procedure. A-line was placed for blood pressure monitoring. Patient was extubated in the PACU and is maintaining O2 sats on nasal cannula. Prior to transfer SBP 160s On arrival to the MICU, patient reports she would like to go back to her room. She wants spaghetti for dinner. She is not having any abdominal pain or flank pain. She has pain in her L leg, which she reports is chronic in nature. She denies fevers, chills, shortness of breath. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: Fetal alcohol syndrome Schizophrenia Diabetes mellitus type 2, non-insulin dependent Asthma Hypertension Hypothyroidism Hyperparathyroidism with hx nephrolithiasis s/p b/l stent placement, s/p Parathyroidectomy with Re-implantation & Partial thyroidectomy Fecal Incontinence Urinary Incontinence Past Surgical Hx: Mastoidectomy/tympanoplasty, left percutaneous nephrolithotomy, left laser lithotripsy, bilateral ureteral stents Social History: ___ Family History: No significant family history of UTI / sepsis. Physical Exam: Admission physical exam ====================== VITALS: Reviewed in metavision GENERAL: Alert, oriented to person, tremulous HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Crackles in L lung base 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, L PCN in place over L flank. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No swelling of LLE, L knee without notable effusion Discharge physical exam =========================== VITALS: ___ 1144 Temp: 98.7 BP: 161/102 L Lying HR: 79 RR: 18 O2 sat: 94% O2 delivery: RA FSBG: 257 GENERAL: NAD, sitting up in bed, bright, alert and awake EYES: Anicteric, PERRL ENT: MMM. poor dentition CV: Heart regular, no m/g. JVP 6cm RESP: Lungs CTAB no w/r/r. Breathing comfortably GI: Abdomen soft, NTND. Bowel sounds present. GU: No suprapubic ttp or fullness; L nephrostomy site clean w/ red (fruit punch) colored urine without clots MSK: Extremities warm without edema. Moves all extremities SKIN: No rashes or ulcerations noted on examined skin NEURO: follows simple commands, moves all extremities, unable to assess orientation as she does not answer questions PSYCH: calm Pertinent Results: Admission labs ================= ___ 12:30AM BLOOD WBC-24.9* RBC-3.60* Hgb-11.2 Hct-34.9 MCV-97 MCH-31.1 MCHC-32.1 RDW-15.8* RDWSD-56.2* Plt ___ ___ 12:30AM BLOOD Neuts-77.9* Lymphs-7.1* Monos-12.1 Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.42* AbsLymp-1.76 AbsMono-3.01* AbsEos-0.00* AbsBaso-0.02 ___ 12:30AM BLOOD ___ PTT-26.1 ___ ___ 12:30AM BLOOD Glucose-144* UreaN-51* Creat-2.7*# Na-139 K-5.3 Cl-101 HCO3-22 AnGap-16 ___ 12:30AM BLOOD ALT-17 AST-16 AlkPhos-91 TotBili-0.3 ___ 08:45AM BLOOD Calcium-8.2* Phos-5.0* Mg-1.8 ___ 01:18PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-135* pCO2-27* pH-7.45 calTCO2-19* Base XS--2 Intubat-INTUBATED Vent-CONTROLLED Discharge labs =============== ___ 06:20AM BLOOD WBC-11.6* RBC-3.05* Hgb-9.2* Hct-29.3* MCV-96 MCH-30.2 MCHC-31.4* RDW-16.5* RDWSD-57.5* Plt ___ ___ 06:20AM BLOOD Glucose-121* UreaN-35* Creat-1.5* Na-147 K-4.8 Cl-110* HCO3-24 AnGap-13 ___ 06:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.7 Microbiology ============= Blood Culture, Routine (Pending): No growth to date. ___ 5:58 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. ___ 8:07 pm URINE Source: Catheter. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. ___ 2:10 pm URINE,KIDNEY Source: Kidney. FLUID CULTURE (Preliminary): ESCHERICHIA COLI. > 10,000 CFU/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- =>512 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ___ 12:15 am BLOOD CULTURE Site: ARM Blood Culture, Routine (Pending): No growth to date. ___ 12:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ X ___ ___ 23:20. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ___ ___ 23:20. ___ 12:30 am URINE Site: CATHETER **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- =>512 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING ============ CTU (Abd/Pel) without contrast (___) IMPRESSION: 1. Duplex left renal collecting system with moderate hydronephrosis of both the superior and inferior pole moieties. Both moieties have a common ureter which is obstructed by a punctate calculus lodged at the left ureterovesical junction. The entire left kidney is enlarged with extensive stranding of perinephric fat and locules of air within the left renal lower pole collecting systems concerning for underlying infection. There are multiple non-obstructing left renal moiety lower pole calculi. 2. Imaging findings of chronic pancreatitis remain unchanged dating back to ___. 3. Stable 1.8 cm incompletely characterized right adrenal nodule is unchanged dating back ___. Chest CT W/O contrast (___) IMPRESSION: 1. Mild narrowing of the mid trachea. 2. Substantial left lower lobe atelectasis with mucus plugging. Lesser right lower lobe atelectasis. 3. Very small pleural effusions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO QHS 2. Nitrofurantoin (Macrodantin) 100 mg PO QHS 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. GuaiFENesin 5 mL PO Q6H:PRN cough 5. Carvedilol 12.5 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Levothyroxine Sodium 137 mcg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. ClonazePAM 0.5 mg PO DAILY 11. Levemir 8 Units Breakfast 12. Spironolactone 25 mg PO DAILY 13. SITagliptin 50 mg oral DAILY 14. BuPROPion (Sustained Release) 100 mg PO QAM 15. Divalproex (DELayed Release) 500 mg PO BID 16. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY 17. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % ophthalmic (eye) QID 18. GlipiZIDE XL 5 mg PO DAILY 19. QUEtiapine Fumarate 300 mg PO BID Discharge Medications: 1. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 2. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 3. Piperacillin-Tazobactam 2.25 g IV Q6H Last dose ___. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 5. Glargine 6 Units Breakfast Insulin SC Sliding Scale using Novalog Insulin 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. BuPROPion (Sustained Release) 100 mg PO QAM 10. Carvedilol 12.5 mg PO BID 11. ClonazePAM 0.5 mg PO DAILY 12. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY 13. Divalproex (DELayed Release) 500 mg PO BID 14. Docusate Sodium 100 mg PO QHS 15. GlipiZIDE XL 5 mg PO DAILY 16. GuaiFENesin 5 mL PO Q6H:PRN cough 17. Levothyroxine Sodium 137 mcg PO DAILY 18. QUEtiapine Fumarate 300 mg PO BID 19. SITagliptin 50 mg oral DAILY 20. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % ophthalmic (eye) QID 21. Vitamin D 1000 UNIT PO DAILY 22. HELD- Nitrofurantoin (Macrodantin) 100 mg PO QHS This medication was held. Do not restart Nitrofurantoin (Macrodantin) until finish course of Zosyn on ___, then may be resumed 23. HELD- Spironolactone 25 mg PO DAILY This medication was held. Do not restart Spironolactone until sees PCP ___: Extended Care Facility: ___ Discharge Diagnosis: Sepsis from 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 INDICATION: History: ___ with CP SOB fevers// ?PNA TECHNIQUE: Portable frontal chest radiograph. COMPARISON: ___ chest radiograph. FINDINGS: Lung volumes are low. In the left lower lobe is an opacity obscuring the heart apex and left hemidiaphragm with air bronchograms, likely reflecting left lower lobe pneumonia. Prominence of the bilateral central pulmonary vasculature suggest mild interstitial pulmonary edema. There is likely also a small left pleural effusion. No evidence of pneumothorax. IMPRESSION: 1. Dense opacity in the left lower lung field suggests left lower lobe pneumonia/atelectasis. 2. Mild bilateral pulmonary vascular congestion. 3. Left pleural effusion. Radiology Report EXAMINATION: RENAL U.S. INDICATION: History: ___ with history of HTN, bipolar disorder, here with abdominal pain and likely UTI septic from this on this presentation// please evaluate for hydro ___ nephric stranding TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: Right kidney: 9.6 cm. Re-demonstrated in the mid to lower pole of the right kidney is an anechoic 2.7 x 2.5 x 2.9 cm simple cyst. Left kidney: 15.4 cm. Multiple stones are re-demonstrated within the left kidney, measuring up to 1.3 cm in the left lower pole. There is moderate left-sided hydronephrosis and proximal hydroureter. A 6 mm nonobstructing calculus is noted within the dilated left renal pelvis. There are additional shadowing echogenic foci in the dilated left renal mid and lower pole calices that are nonobstructing. The urinary bladder is distended with urine however neither ureteral jets are identified. IMPRESSION: 1. Moderate left hydronephrosis and proximal hydroureter. A 6 mm nonobstructing calculus is seen within the dilated left renal pelvis. Additional nonobstructing left renal lower pole calculi also noted. Exact etiology for obstruction not seen on the scan and it is likely that there is a distal ureteric obstructing calculus which could be further evaluated by a noncontrast CT of the abdomen. 2. 2.8 cm simple cyst within the lower pole of the right kidney. No right-sided hydronephrosis or calculi noted. Radiology Report INDICATION: NO_PO contrast; History: ___ with DMII, HTN, and new pyelonephritis with obstructing stones NO_PO contrast// please evaluate for other obstructing stones 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 3.9 s, 51.7 cm; CTDIvol = 14.7 mGy (Body) DLP = 757.3 mGy-cm. Total DLP (Body) = 757 mGy-cm. COMPARISON: Same day ___ renal ultrasound, ___ CTU. FINDINGS: Optimal evaluation of organ pathology and vasculature is limited without the benefit of intravenous contrast. LOWER CHEST: Atelectasis of the dependent left lung base. Small left pleural effusion. 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 distended with no radiopaque calculi within it. PANCREAS: Extensive pancreatic calcifications and stably dilated main pancreatic duct measuring 13 mm are consistent with chronic pancreatitis. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: 1.8 x 1.1 cm right adrenal nodule (02:29) is unchanged dating back to ___. URINARY: Right kidney: There is a simple 0.3 cm right renal cyst. No hydronephrosis seen on the right side. Faint cortical calcification within the right kidney associated with a scar (601:24) is as before. No renal calculi seen on the right side. Left kidney: There is a duplicated collecting system on the left side. The superior pole moiety demonstrates mild hydronephrosis with no obstructing calculi within it. The lower pole moiety demonstrates presence of multiple nonobstructing calculi and foci of air within it. There is a single left ureter formed by ___ of with 2 renal pelves, the left ureter is dilated in its entire extent secondary to obstruction by a punctate calculus lodged at the left ureterovesical junction (2:77). Significant stranding of left perinephric fat associated with urothelial thickening of the dilated ureter in presence of air locules in the left renal collecting system are concerning for underlying infection. GASTROINTESTINAL: There is a small hiatal hernia. The remainder of the stomach is unremarkable. No bowel obstruction. Large stool burden seen throughout the colon. PELVIS: There is a Foley catheter in place with air within the urinary bladder. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus contains calcified fibroids. There are no adnexal masses. LYMPH NODES: There are numerous enlarged left renal hilar and left para-aortic lymph nodes measuring up to 1.0 cm in short axis (02:34), likely reactive. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Moderate to severe bilateral hip osteoarthritis and mild multilevel degenerative disease of the lumbar spine. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Duplex left renal collecting system with moderate hydronephrosis of both the superior and inferior pole moieties. Both moieties have a common ureter which is obstructed by a punctate calculus lodged at the left ureterovesical junction. The entire left kidney is enlarged with extensive stranding of perinephric fat and locules of air within the left renal lower pole collecting systems concerning for underlying infection. There are multiple nonobstructing left renal moiety lower pole calculi. 2. Imaging findings of chronic pancreatitis remain unchanged dating back to ___. 3. Stable 1.8 cm incompletely characterized right adrenal nodule is unchanged dating back ___. Radiology Report INDICATION: ___ female with history of HTN, DM, bipolar disease, nephrolithiasis with prior placement of ureteral stents and lithotripsy, duplicated bilateral renal collecting system and mild chronic left sided hydronephrosis. Presents to the ED with abdominal pain, hypotension and fever. UA positive and US demonstrates moderate left hydronephrosis with a proximal 6mm obstructing stone. We were consulted for placement of a left PCN for decompression and source control. Left PCN for pyelo COMPARISON: CT ___ TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ Interventional ___ and Dr. ___, Interventional Radiology fellow performed the procedure. Dr. ___ personally supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Anesthesia was provided by the general anesthesia team. MEDICATIONS: CONTRAST: 3 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 6.3 minutes, 42 mGy PROCEDURE: 1. Left ultrasound guided renal collecting system access. 2. Left nephrostogram. 3. 8 ___ nephrostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the health care proxy. The patient was then brought to the angiography suite and placed prone 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 Nitinol wire was advanced into the renal collecting system. After a skin ___, the needle was exchanged for an Accustick sheath. One 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: Initial contrast injection demonstrated moderate hydronephrosis of the inferior moiety collecting system. Contrast injection demonstrated appropriate final position of a new 8 ___ percutaneous nephrostomy catheter in the renal pelvis of the lower moiety of the duplicated collecting system. IMPRESSION: Successful placement of 8 ___ nephrostomy on the left. Radiology Report EXAMINATION: Chest CT. INDICATION: ___ year old woman with hydronephrosis s/p PCN placement with difficult intubation and concern for narrowing inferior to vocal cords.// evaluate for tracheal stenosis TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Chest CT ___. FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart is mildly enlarged. The pericardium and great vessels are within normal limits based on an unenhanced scan. No pericardial effusion is seen. Moderate coronary artery calcifications. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is present. No mediastinal mass or hematoma. The esophagus is patulous. PLEURAL SPACES: Very small bilateral pleural effusions with associated atelectasis. No pneumothorax. LUNGS/AIRWAYS: Evaluation of the lung parenchyma is limited by respiratory motion. Within this limitation, there is a calcified granuloma of the right middle lobe (4:158). There is mild but increased atelectasis in the posterior basilar right lower lobe. The left lower lobe is largely collapsed with segmental areas of mucus plugging. The trachea is perhaps mildly narrowed particularly along the mid portion but unchanged. A small dependent secretion is visible in the mid trachea. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Mild narrowing of the mid trachea. 2. Substantial left lower lobe atelectasis with mucus plugging. Lesser right lower lobe atelectasis. 3. Very small pleural effusions. Radiology Report INDICATION: ___ year old woman s/p ___ guided PCN.// assess proper placement of PCN. TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Prior abdominal radiograph dated ___. FINDINGS: There are no abnormally dilated loops of large or small bowel. No evidence of free air on this portable supine radiograph. Osseous structures are remarkable for degenerative changes in the hips. Percutaneous nephrostomy tube is seen coiled in overlying the left mid abdomen. Positioning is similar to that seen on the intraoperative images (dated ___. Multiple phleboliths in pelvis. IMPRESSION: Unchanged positioning of the left-sided percutaneous nephrostomy tube, which is seen projecting over the left mid abdomen. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, Lethargy Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic temperature: 102.1 heartrate: 91.0 resprate: 18.0 o2sat: 97.0 sbp: 96.0 dbp: 47.0 level of pain: 10 level of acuity: 2.0

Dear Ms. ___, You were admitted to the hospital for low blood pressure and urine infection, which caused you to be very sick with sepsis. You were initially treated in the ICU and when you were doing better you were transferred to the medical floor. You will now be transitioned to rehab where you will finish the course of antibiotics for your infection. It was a pleasure taking care of you! Sincerely, your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: distal fibula fracture Major Surgical or Invasive Procedure: None. History of Present Illness: Patient seen and examined and agree with house officer admit note by Dr. ___ ___ with additions below. ___ year old Female with mild mental retardation, who presents after falling down 3 steps and fracturing her fibula. The patient states she was walking down the stairs, and normally holds the railing very closely, but missed a step and was not holding on as tightly, so fell down 3 steps. Due to the pain in her leg, she eventually came to orthopedics clinic who diagnosed her with a non-displaced fibular fracture. She was sent to the ED as given her weight bearing status and living on the ___ floor ___, she would need ___ evaluation and likely acute rehab. She was seen and evaluated in the ED by ___ who felt she was a risk to fall and would need more extensive stair-training along with some pain control at acute rehab. She feels somewhat better today, and is willing for ___ days of acute rehab. Past Medical History: Mental retardation, tubal ligation, knee surgery, depression, dysmenorrhea, headaches, low back pain, asthma Social History: ___ Family History: Cousin: Cancer of unknown type Physical Exam: Admission: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, + Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 99.1, 132/81, 94, 24, 94% GEN: NAD, Obese Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: Massive ventral hernia, NT, +BS, - CVAT EXT: - CCE, Left leg in cast to knee with boot NEURO: CAOx3 Discharge: Vitals: 99 138/77 70 20 95%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple Abdomen: Bowel signs positive, midline abdominal surgical scar noted, distended due to ventral hernia, soft, non-tender, no rebound or guarding GU: no foley Ext: Warm, well perfused, no clubbing, cyanosis or edema. L leg in cast to knee with boot, good cap refill Neuro: CNII-XII intact, able to move toes in left leg cast Pertinent Results: ANKLE (AP, LAT & OBLIQUE) LEFT Study Date of ___ 3:54 ___ IMPRESSION: Nondisplaced intra-articular distal fibula fracture, consistent with Weber B fracture. Medications on Admission: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Alendronate Sodium 35 mg PO QFRI 3. Omeprazole 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Albuterol Inhaler 2 PUFF IH PRN DYSPNEA shortness of breath (per pharmacy she has not filled this in months) Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. Alendronate Sodium 35 mg PO QFRI 3. Omeprazole 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Albuterol Inhaler 2 PUFF IH PRN DYSPNEA shortness of breath (per pharmacy she has not filled this in months) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Fall Distal fibular fracture Secondary diagnoses: Developmental delay ventral hernia eczema asthma depression 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 HISTORY: Fall and ankle swelling. COMPARISON: None available. FINDINGS: 3 views of left ankle. There is a nondisplaced transverse fracture through the distal fibula which extends into the ankle joint. The ankle mortise is intact. There is soft tissue swelling about the lateral malleolus. There are superior and inferior calcaneal enthesophytes. There is mild spurring at the tarsometatarsal joints. IMPRESSION: Nondisplaced intra-articular distal fibula fracture, consistent with Weber B fracture. These findings were discussed with Dr. ___ by Dr. ___ for 4:20pm on ___ via telephone at time of discovery. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with FX ANKLE NOS-CLOSED, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING temperature: 97.4 heartrate: 60.0 resprate: 16.0 o2sat: 98.0 sbp: 156.0 dbp: 83.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted with a fractured left fibula (smaller bone in your lower leg) after falling at home. Your leg has been casted and right now you are not able to bear weight on that leg. Because your home has stairs we have recommended that you briefly go to rehab to recuperate and learn stair climbing technique. You should follow up with orthopedics as below. In the future, when your leg has healed and you are climbing stairs, always remember to take your time and hold onto the handrail. We have spoken to ___, your case manager at ___, who mentioned that you might benefit from moving to a home without stairs. We agree that this would be the safest option for you, to help prevent more falls in the future. Please take your medication as prescribed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Pancytopenia Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo M with recent diagnoses of high-grade large cell neuroendocrine lung carcinoma complicated by malignant pleural effusion on C1D14 of carboplatin/etoposide who presents with pancytopenia. Patient was recently admitted at ___ from ___ to ___. During that admission, diagnosis of lung cancer was made by thoracentesis with pleural fluid cytology. Patient was started on carboplatin/etoposide in house, first day ___. Hospital course was complicated by acute hypoxic respiratory failure, thought to be due to a combination of malignant pleural effusion and HCAP, s/p thoracentesis, multiple chest tubes, and 8 day course of levofloxacin. Other chronic issues were stable during hospitalization. Patient received Neupogen day 4 and onward with appropriate response in counts. Today, patient presented for labs and was found to be markedly pancytopenic for which he was referred to the ED. In the ED, initial vital signs were 98.4, 60, 106/48, 16, 99% NC. Initial labs were remarkable for WBC 17.8 -> 2.0, Hgb 8.8 -> 6.1, and Plt 110 -> 23, prior CBC on ___. ___ Oncology was consulted, and patient was admitted to OMED for further management. Past Medical History: CAD, s/p CABG (cardiologist Dr ___ ? CHF Lung mass Osteoarthritis Long-term anticoagulation use Depression Schatzki's ring s/p dilation, last endoscopy ___ Pancytopenia Peripheral vascular disease Diverticulitis Esophageal motility disorder Atrial fibrillation Thrombocytopenia Hypertension Hypercholesterolemia Gout Macrocytosis BPH Glaucoma Central retinal vein occlusion Social History: ___ Family History: No family history of blood diseases. Mother died of pancreatic cancer Physical Exam: ON ADMISSION: ================ vital signs were 73, 114/48, ___, 100% NC. GENERAL: Pleasant, lying in bed comfortably HEENT: 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: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes ON DISCHARGE: ================= vs: 97.7 117-99/43-59 ___ 95% ON 1.5l nc GENERAL: Pleasant, lying in bed comfortably HEENT: 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: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes Pertinent Results: LABS ___ 09:02PM WBC-1.8* RBC-2.20* HGB-6.9* HCT-21.4* MCV-97 MCH-31.4 MCHC-32.2 RDW-19.7* RDWSD-65.1* ___ 01:45PM GLUCOSE-96 UREA N-13 CREAT-0.7 SODIUM-138 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14 ___ 01:45PM estGFR-Using this ___ 01:45PM CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-1.9 ___ 01:45PM WBC-2.0*# RBC-1.97*# HGB-6.1*# HCT-19.8*# MCV-101* MCH-31.0 MCHC-30.8* RDW-19.5* RDWSD-66.2* ___ 01:45PM NEUTS-30* BANDS-1 ___ MONOS-24* EOS-1 BASOS-1 ATYPS-1* ___ MYELOS-3* AbsNeut-0.62* AbsLymp-0.80* AbsMono-0.48 AbsEos-0.02* AbsBaso-0.02 ___ 01:45PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ ___ 01:45PM PLT SMR-VERY LOW PLT COUNT-23*# ___ 01:45PM ___ PTT-36.4 ___ ___ 10:45AM BLOOD WBC-2.2* RBC-2.36* Hgb-7.4* Hct-23.3* MCV-99* MCH-31.4 MCHC-31.8* RDW-20.7* RDWSD-64.4* Plt Ct-24* ___ 02:57PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-135 K-3.2* Cl-96 HCO3-29 AnGap-13 ___ 02:57PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 IMAGING 1. Small left pleural effusion likely slightly improved from ___. 2. Mild pulmonary edema improved from ___. 3. Vague bilateral opacities could represent developing pneumonia or combination of atelectasis and pulmonary edema. CULTURES: NONE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Furosemide 40 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO BID 9. Sertraline 200 mg PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 12. Vitamin D ___ UNIT PO DAILY 13. Acetaminophen 650 mg PO Q8H:PRN pain 14. Docusate Sodium 100 mg PO BID 15. Heparin 5000 UNIT SC BID 16. LOPERamide 2 mg PO TID:PRN diarrhea 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation 18. Senna 17.2 mg PO BID:PRN constipation 19. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. LOPERamide 2 mg PO TID:PRN diarrhea 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO BID 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 17.2 mg PO BID:PRN constipation 12. Sertraline 200 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS 14. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 15. TraZODone 50 mg PO QHS:PRN Insomnia 16. Vitamin D ___ UNIT PO DAILY 17. Furosemide 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pancytopenia secondary to chemotherapy acute on chronic systolic diastolic heart failure. Large cell neuroendocrine lung carcinoma coronary artery disease Glaucoma Depression 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 neutropenia and shortness of breath // does this patient have pneumonia or worsening of his effusion? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___. CT of the chest from ___. FINDINGS: Lung volumes are slightly increased with residual bibasilar atelectasis. Mild pulmonary edema is improved from ___. The left apical mass-like opacity is unchanged. Multiple vague opacities may represent combination of atelectasis and edema or evolving pneumonia. A small left pleural effusion is likely improved from ___ but difficult to assess given differences in technique. No substantial right pleural effusion. Postoperative mediastinal contours and cardiac borders are stable. IMPRESSION: 1. Small left pleural effusion likely slightly improved from ___. 2. Mild pulmonary edema improved from ___. 3. Vague bilateral opacities could represent developing pneumonia or combination of atelectasis and pulmonary edema. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal labs, Transfer Diagnosed with Malignant neoplasm of unsp part of unsp bronchus or lung temperature: 98.4 heartrate: 60.0 resprate: 16.0 o2sat: 99.0 sbp: 106.0 dbp: 48.0 level of pain: 0 level of acuity: 2.0

Dear ___ ___ was a pleasure taking care of you at the ___ You were admitted because of low blood counts which is likely secondary to your chemotherapy. This is an expected response to your chemotherapy and you were admitted to receive blood and for close monitoring. You receive 2 units of blood which improved your counts. You also developed some shortness of breath which is likely from fluid overload from receiving the 2 blood unit. this was treated with IV Lasix. In addition we stopped your aspirin because your platelets counts were low. consult your doctor on when to restart your aspirin. Please take you medication as prescribed and convey to your doctor an concerning symptoms. It was a pleasure taking care of you at the ___. We wish you all the best. You ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bacitracin / Ciprofloxacin Attending: ___ Chief Complaint: Palpitations Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of hypertension, dyslipidemia, CAD, atrial fibrillation (on warfarin), bilateral breast cancers s/p mastectomies (___), LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p CyperKnife therapy, left atrial clot, who presents with atrial fibrillation with rapid ventricular rate (RVR). She awoke the morning of admission with increased fatigue. She had difficulty going about her daily routine at home. She noted a pounding and fast heartbeat. This was associated with dizziness and lightheadedness. She felt increasingly weak and felt that her BP must be low. She denied chest pain, shortness of breath, nausea. She called EMS who noted HR in the 170s and SBP 90. On arrival to the ED, she reported feeling terrible, like she is "going to die". She has a recent diagnosis of atrial fibrillation. Of note, earlier this month, her metoprolol (75 mg daily) was stopped in the setting of orthostatic hypotension noted at an oncology office visit. Further review of one of the EKGs at that visit noted atrial fibrillation with RVR, so metoprolol was restarted, though at a lower dose (12.5 mg BID). In the ED, initial vitals were SBP 80-90s, VR 170s, SpO2 98% on RA. Her EKG showed atrial fibrillation with RVR. CXR did not show any acute changes from baseline. Labs were notable for WBC 11.9, INR 2.4. Cardiology was consulted. Patient was given 2 L NS, metoprolol 5 mg IV x 2, metoprolol 50 mg PO. VR came down to low 100s and BP was 103/71. She was admitted to cardiology for further management of atrial fibrillation and uptitration of beta blockade. Past Medical History: 1. CAD RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -atrial fibrillation on warfarin -positive ETT in ___ but subsequent ETTs negative 3. OTHER PAST MEDICAL HISTORY: - ___ x2 (___), on home O2 (2 Lpm NC continuously) - ___ s/p LUL lobectomy (stage IA NSCLC), no post XRT/chemo - ___ recurrence on RUL (CT/PET), mucinous adenocarcinoma s/p CyberKnife radiation, s/p recurrence and initiation of pemetrexed ___ - Bilateral breast CA (___) s/p R mastectomy (___) and L mastectomy (___). No XRT. - Depression - Memory impairment - Osteoporosis - Seizure disorder - Seborrheic dermatitis - Enchondroma - h/o ankle fracture Social History: ___ Family History: Her father died at age ___ of "old age." He had a stroke earlier in life. Her mother died at age ___ of "old age." She suffered from hyperlipidemia and diabetes later in life. She has one brother and two sons. One of her sons died of presumed sudden cardiac death at the age of ___, but she does not know the details. There is no family history notable for hypertension. Physical Exam: On admission General: Elderly Caucasian woman in NAD, pleasant, sitting comfortably in bed VS: T 97.5 BP 98/63 HR 96 RR 12 SaO2 99% on 2 Lpm via NC HEENT: NC/AT, PERRL, sclera anicteric, no conjunctival injection, oropharynx clear Neck: supple, no LAD, no JVP elevation, no carotid bruits CV: Tachycardic, irregularly irregular rhythm, normal s1 and s2; no murmurs, rubs or gallops Lungs: good effort, clear bilaterally Abdomen: soft, nontender, nondistended, normoactive bowel sounds GU: no Foley Ext: warm, well perfused, no edema Neuro: oriented x 3, alert and appropriate affect, moves all 4 extremities symmetrically Skin: warm, no lesions or rash At discharge General: pleasant elderly woman sitting comfortably in bed in NAD VS: T 97.3 BP 135/64 (130s-150s/60s) HR 78 (60s-70s) RR 20 SaO2 96% on 3 Lpm NC Tele: NSR in ___ Unchanged from admission, except as noted below CV: RRR, normal s1 and s2; no murmurs, rubs or gallops Lungs: good effort, scattered rhonchi, no crackles or wheezes Pertinent Results: ___ 08:40AM BLOOD WBC-11.9*# RBC-4.36 Hgb-11.3* Hct-36.2 MCV-83 MCH-26.0* MCHC-31.2 RDW-15.8* Plt ___ ___ 08:40AM BLOOD Neuts-77.6* Lymphs-15.6* Monos-5.4 Eos-0.8 Baso-0.6 ___ 09:00AM BLOOD ___ PTT-37.7* ___ ___ 08:40AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-95* HCO3-25 AnGap-21* ___ 08:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9 ___ 08:40AM BLOOD Phenyto-1.1* ___ 8:41:04 AM ECG Atrial fibrillation with a rapid ventricular response. Right bundle-branch block. Left anterior hemiblock. Non-specific ST-T wave changes. Compared to the previous tracing of ___ the heart rate is faster. ___ PORTABLE CXR Single AP upright portable view of the chest was obtained. Fiducial marker is again seen overlying the right upper chest with underlying large opacity in this patient with known malignancy, grossly similar to prior. Increased interstitial markings in a background of pulmonary emphysema are again seen. The lungs remain hyperinflated. Patient's known left-sided chain sutures are obscured by overlying external artifact. No definite new focal consolidation is seen. There is no large pleural effusion or evidence of pneumothorax. The cardiac and mediastinal silhouettes are stable. There is diffuse osteopenia. Sclerotic foci projecting over the left glenoid and partially imaged proximal left humerus are stable. IMPRESSION: No significant interval change. ___ Echocardiogram 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. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >60%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic arch 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 mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mildly dilated aortic arch DISCHARGE LABS ___ 09:00AM BLOOD WBC-6.3 RBC-4.20 Hgb-10.6* Hct-34.5* MCV-82 MCH-25.2* MCHC-30.7* RDW-15.8* Plt ___ ___ 09:00AM BLOOD ___ ___ 09:00AM BLOOD Glucose-125* UreaN-9 Creat-0.6 Na-138 K-3.9 Cl-99 HCO3-25 AnGap-18 ___ 09:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Acetaminophen 325 mg PO Q6H:PRN pain 3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath / wheezing 4. Benzonatate 100 mg PO TID:PRN cough 5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 6. QUEtiapine Fumarate 25 mg PO QHS 7. Metoprolol Tartrate 12.5 mg PO BID 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Warfarin 2.5 mg PO DAILY16 10. Phenytoin Sodium Extended 100 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO BID 13. Aspirin 81 mg PO DAILY 14. Venlafaxine XR 225 mg PO DAILY 15. FoLIC Acid 1 mg PO DAILY 16. Simvastatin 40 mg PO DAILY 17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 18. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal symptoms 19. Lorazepam 0.5 mg PO ONCE:PRN prior to imaging studies for anxiety 20. Milk of Magnesia 5 mL PO DAILY:PRN constipation Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Benzonatate 100 mg PO TID:PRN cough 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath / wheezing 7. Metoprolol Tartrate 12.5 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO BID 10. Phenytoin Sodium Extended 100 mg PO BID 11. QUEtiapine Fumarate 25 mg PO QHS 12. Venlafaxine XR 225 mg PO DAILY 13. Amiodarone 200 mg PO BID RX *amiodarone 200 mg 1 tablet(s) by mouth two times a day for 5 days and 1 time a day thereafter Disp #*40 Tablet Refills:*0 14. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 17. Lorazepam 0.5 mg PO ONCE:PRN prior to imaging studies for anxiety 18. Milk of Magnesia 5 mL PO DAILY:PRN constipation 19. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal symptoms 20. Warfarin 1 mg PO 4X/WEEK (___) First dose on ___. Atorvastatin 20 mg PO DAILY 22. Warfarin 2 mg PO 3X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Atrial fibrillation with rapid ventricular rate Sinus bradycardia with pauses Hypertension Dsylpidemia Non-small cell lung cancer Depression Seizure disorder 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 EXAM: Chest, single AP upright portable view. CLINICAL INFORMATION: Dyspnea. ___. FINDINGS: Single AP upright portable view of the chest was obtained. Fiducial marker is again seen overlying the right upper chest with underlying large opacity in this patient with known malignancy, grossly similar to prior. Increased interstitial markings in a background of pulmonary emphysema are again seen. The lungs remain hyperinflated. Patient's known left-sided chain sutures are obscured by overlying external artifact. No definite new focal consolidation is seen. There is no large pleural effusion or evidence of pneumothorax. The cardiac and mediastinal silhouettes are stable. There is diffuse osteopenia. Sclerotic foci projecting over the left glenoid and partially imaged proximal left humerus are stable. IMPRESSION: No significant interval change. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: DIZZINESS Diagnosed with ATRIAL FIBRILLATION temperature: nan heartrate: 175.0 resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

You were admitted to ___ with an irregular heart rhythm called atrial fibrillation. Your heart was going very fast and we had to give you medications to slow it down. Your heart broke out of this rhythm by itself, but it began to beat too slowly and you became very symptomatic. This resolved. You were started on a new medication called amiodarone to keep your heart in a regular rhythm. This interacts with warfarin so you will have to take a lower dose of warfarin while you are on this medication. You will continue on a very low dose of metoprolol to prevent your heart from going too fast if you go into atrial fibillation. You will go home on a monitor for your heart rhythm. You will follow up with Dr. ___ in 1 month to see how your heart rhythm is doing. Please take your medicaitons as listed below. Please follow up with your doctors as listed below. It was a pleasure taking care of you and we wish you a speedy recovery!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: This is an ___ gentleman with a pmhx. significant for stage IV rectal CA (s/p LAR in ___, now with liver mets and receiving FOLFOX) and recent port-a-cath placement on ___ who is admitted from the ED for general malaise and fatigue and a fever to 101.3 at home. Mr. ___ had recent left subclavian indwelling port placement port placement on ___ and received FOLFOX on ___. He was seen by a ___ on day of admission whereupon his port was accessed and chemo infusion was stopped; he was told that he had a low grade fever and that he should continue checking it throughout the day. Patient subsequently had a temperature of 101.3 and was told by his oncologist to present to the emergency department. Mr. ___ states that since his port placement he has felt tired; however, he thinks this might be related to the chemotherapy as well. He did not notice overt fevers at home (until the day of admission) but did notice chills on the night of ___. He denies any chest pain, shortness of breath, nausea, vomiting, diarrhea, blood in his stools, or other concerning signs or symptoms. In the ED, initial vitals were: 98.7 82 93/67 16 97% RA. The ED was unable to access patient's port and 2 blood cultures were drawn peripherally. Recieved NS (though unclear how much). Patient was given 1 dose of vancomycin over concern for port infection. Past Medical History: ONCOLOGIC HISTORY: Diagnosed with rectal cancer in ___ after being found to have heme positive stools and colonoscopy showed mass at 22cm. Biopsy revealed adenocarcinoma and he underwent LAR on ___. Staged as a Dukes C and would be a stage III cancer by current staging. This was a T2, N1lesion and he was placed on a research protocol. He received concurrent ___ and radiation. He underwent multiple repeat colonoscopies following this and had no evidence of disease. He was followed from ___, at the time of diagnosis, until ___, at which time he was ___ years out and it was determined that he needed no further followup. Recently underwent cardiac MRI for bradycardia and PVCs to evaluate LV function on ___, it was incidentally noted that he had a concerning area within the liver concerning for liver tumor. This lesion measured 8.9 x 7.1 cm and there is a second small lesion in the dome of the liver measuring 1.3 x 1.0 cm. He was set up for an ultrasound-guided biopsy of this, which was performed on ___ and the pathology of this was noted to be metastatic adenocarcinoma, morphologically consistent with his primary previous tumor; however, also could be a new tumor. Currently undergoing treatment with FOLFOX. Last cycle on ___. PAST MEDICAL HISTORY: --Hypertension --Vitamin D deficiency --GERD --Obesity --Hypothyroidism --Rectal cancer s/p colon resection surgery, radiation, now receiving FOLFOX --Bradycardia --Depression --Glucose intolerance --Neck and lower back pain --Prostatic hypertrophy s/p TURP and prostatectomy --CPPD / pseudogout --Anemia / chronic --Erectile dysfunction --s/p hernia repair. Social History: ___ Family History: Father died of leukemia. Mother died at ___ of natural causes. One sister died with pancreatic cancer. Three children, one daughter died from cancer related to a drug prescribed to the mother during the pregnancy. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.6, 118/66, 76, 16, 94% on RA GENERAL: Well appearing man, looks younger than stated age, no acute distress HEENT: Mucous membranes moist, no lesions CHEST: CTA bilaterally, no wheezes, rales, or rhonchi, seborrheic keratosis on back CARDIAC: RRR, normal S1 and S2, II/IV systolic murmur ABDOMEN: +BS, obese, non-tender, non-distended EXTREMITIES: No edema bilaterally PORT SITE: Port in place in left upper subclavian region, no erythema, no fluctuance NEURO: Alert and oriented x3 DISCHARGE PHYSICAL EXAM: Vitals - 98.1-99.8, 130/60, 64, 18, 97/RA GENERAL: Well appearing man HEENT: Mucous membranes moist, no lesions CHEST: CTA bilaterally CARDIAC: RRR, normal S1 and S2, II/IV systolic murmur ABDOMEN: +BS, obese, non-tender, non-distended EXTREMITIES: No edema bilaterally PORT SITE: Port in place in left upper subclavian region, no erythema, no fluctuance. Some areas of hematoma in vicinity of port. Pertinent Results: ___ 08:33PM BLOOD WBC-13.2*# RBC-4.41* Hgb-14.1 Hct-42.1 MCV-95 MCH-31.9 MCHC-33.4 RDW-14.9 Plt ___ ___ 03:23AM BLOOD WBC-10.3 RBC-4.00* Hgb-12.5* Hct-37.2* MCV-93 MCH-31.4 MCHC-33.8 RDW-14.6 Plt ___ ___ 03:23AM BLOOD ALT-29 AST-56* LD(___)-650* AlkPhos-151* TotBili-3.1* DirBili-0.7* IndBili-2.4 ___ 07:46AM BLOOD ALT-25 AST-46* LD(LDH)-568* AlkPhos-155* TotBili-3.6* ___ 06:00AM BLOOD ALT-23 AST-32 LD(___)-435* AlkPhos-176* TotBili-3.6* ___ 07:50AM BLOOD ALT-27 AST-32 LD(LDH)-349* AlkPhos-310* TotBili-4.1* ___ 06:00AM BLOOD ALT-31 AST-35 LD(LDH)-292* AlkPhos-385* TotBili-2.8* IMAGING: CXR ___: no evidence of acute disease RUQ U/S ___: IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. No bile duct dilation. 2. Hypoechoic area in the medial right hepatic lobe likely corresponds to known metastasis, incompletely evaluated. This study does not evaluate for new liver metastases and if further evaluation is desired, CT or MRI should be performed. MRCP ___: FINDINGS: Again visualized is a large heterogeneous T2 bright mass in the central right hepatic lobe at the hilum, with peripheral rim hyperenhancement and central T1 and T2 dark signal, measuring approximately 9.2 x 9.7 x 9.5 cm, demonstrating interval growth since prior CT torso of ___. Multiple small satellite nodules are seen adjacent and just superior and lateral to the dominant mass which appear unchanged. Mild intrahepatic biliary ductal dilatation which is likely secondary to obstruction from the dominant tumor mass. The visualized branches of the portal venous system appear patent. There is compression of the middle hepatic vein by the large mass, displacing the vein anteriorly. The right hepatic vein appears to traverse through the mass and is completely encompassed by it. Patent splenic vein and superior mesenteric veins. Normal-appearing spleen, pancreas, bilateral adrenal glands. Bilateral simple-appearing renal cortical cysts as well as large left renal parapelvic cyst, unchanged. Small subcentimeter periportal lymph nodes. Cholelithiasis again noted. No evidence of choledocholithiasis. Visualized small and large bowel unremarkable. No evidence of ascites. IMPRESSION: 1. Interval growth of large rim-enhancing mass in the liver hilum, with multiple small satellite nodules, consistent with patient's history of metastatic colon cancer. 2. Cholelithiasis without evidence of choledocholithiasis. 3. Bilateral simple renal cysts, unchanged. Medications on Admission: . Information was obtained from . 1. Ondansetron 8 mg PO Q8H:PRN Nausea 2. Lorazepam 0.5 mg PO Q8H:PRN Nausea Please hold for oversedation. 3. Prochlorperazine 10 mg PO Q6H:PRN Nausea 4. Allopurinol ___ mg PO DAILY 5. BuPROPion (Sustained Release) 300 mg PO QAM 6. Carvedilol 3.125 mg PO BID Please hold for SBP <100 or HR <55. 7. Colchicine 0.6 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Levothyroxine Sodium 75 mcg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Trandolapril 4 mg PO DAILY Please hold for SBP <100. 12. Vitamin D ___ UNIT PO DAILY 13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain Please hold for oversedation 14. Aspirin 325 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. BuPROPion (Sustained Release) 300 mg PO QAM 3. Carvedilol 3.125 mg PO BID Please hold for SBP <100 or HR <55. 4. Colchicine 0.6 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Lorazepam 0.5 mg PO Q8H:PRN Nausea Please hold for oversedation. 8. Omeprazole 20 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN Nausea 10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain Please hold for oversedation 11. Prochlorperazine 10 mg PO Q6H:PRN Nausea 12. Trandolapril 4 mg PO DAILY Please hold for SBP <100. 13. Vitamin D ___ UNIT PO DAILY 14. Aspirin 325 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fever Colon cancer Hyperbilirubinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPHS HISTORY: Fever. COMPARISONS: ___. TECHNIQUE: Chest, PA and lateral. FINDINGS: A left-sided Port-A-Cath terminates in the superior vena cava, as before. The cardiac, mediastinal and hilar contours appear unchanged. There is no pleural effusion or pneumothorax. The lungs appear clear. Mild hyperinflation is present. The lungs appear clear. Mild degenerative changes are similar along the mid-to-lower thoracic spine. IMPRESSION: No evidence of acute disease. Radiology Report INDICATION: ___ man with metastatic colon cancer to liver with mildly elevated LFTs and recent abdominal pain and fevers. COMPARISON: CT ___. FINDINGS: Targeted right upper quadrant ultrasound was performed. Note, the liver was not fully evaluated, specifically to assess for metastatic disease. A hypoechoic area in the medial right hepatic lobe likely corresponds to the known large liver metastasis, incompletely evaluated on this study. There is no intra- or extra-hepatic bile duct dilation. Shadowing, mobile gallstones are seen within the gallbladder without wall edema or pericholecystic fluid. The common duct is not dilated measuring 3 mm. Doppler assessment of the main portal vein shows patency and normal hepatopetal flow. IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. No bile duct dilation. 2. Hypoechoic area in the medial right hepatic lobe likely corresponds to known metastasis, incompletely evaluated. This study does not evaluate for new liver metastases and if further evaluation is desired, CT or MRI should be performed. Radiology Report MRCP. HISTORY: ___ man with metastatic colon cancer on chemotherapy, here with fevers, elevated T bili and alk phos, evaluate for choledocholithiasis. COMPARISON: Liver ultrasound ___, CT torso ___. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet, including dynamic 3D imaging, obtained prior to, during, and after the uneventful intravenous administration of 9 cc of gadolinium-DTPA. In addition, 2.5 cc of Gadovist with 75 cc of water were given as oral contrast. FINDINGS: Again visualized is a large heterogeneous T2 bright mass in the central right hepatic lobe at the hilum, with peripheral rim hyperenhancement and central T1 and T2 dark signal, measuring approximately 9.2 x 9.7 x 9.5 cm, demonstrating interval growth since prior CT torso of ___. Multiple small satellite nodules are seen adjacent and just superior and lateral to the dominant mass which appear unchanged. Mild intrahepatic biliary ductal dilatation which is likely secondary to obstruction from the dominant tumor mass. The visualized branches of the portal venous system appear patent. There is compression of the middle hepatic vein by the large mass, displacing the vein anteriorly. The right hepatic vein appears to traverse through the mass and is completely encompassed by it. Patent splenic vein and superior mesenteric veins. Normal-appearing spleen, pancreas, bilateral adrenal glands. Bilateral simple-appearing renal cortical cysts as well as large left renal parapelvic cyst, unchanged. Small subcentimeter periportal lymph nodes. Cholelithiasis again noted. No evidence of choledocholithiasis. Visualized small and large bowel unremarkable. No evidence of ascites. IMPRESSION: 1. Interval growth of large rim-enhancing mass in the liver hilum, with multiple small satellite nodules, consistent with patient's history of metastatic colon cancer. 2. Cholelithiasis without evidence of choledocholithiasis. 3. Bilateral simple renal cysts, unchanged. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: FEVER Diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ABN REACT-PROCEDURE NEC, MALIGNANT NEOPL RECTUM, HYPERTENSION NOS temperature: 98.7 heartrate: 82.0 resprate: 16.0 o2sat: 97.0 sbp: 93.0 dbp: 67.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital for fever. You were treated with antibiotics, and your fevers resolved. While the cultures are still pending, there currently is no evidence of infection in your blood, your urine, or your lungs. Some of your liver enzymes (bilirubin and alkaline phosphatase) were elevated, so we did an ultrasound which showed gallstones, but no infection. We also did an MRCP to see whether there was a blockage in your liver causing the elevated enzymes, which showed no signs of intervenable bile duct obstruction. We consulted our liver specialists, who thought that the increased enzymes were likely due to your cancer and invasive procedures would be unlikely to solve the problem. No changes to your home medications were made. It was a pleasure taking care of you during your hospitalization. We wish you all the best going forward.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: pentosan polysulfate sodium / Bactrim / Penicillins / Ativan / minocycline Attending: ___. Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD ___ TIPS ___ History of Present Illness: Ms. ___ is a ___ yo woman with a PMH of alcoholic cirrhosis c/b esophageal varices (s/p banding x 7, done at ___, HTN, migraines, arthralgias, asthma/COPD, and folliculitis who presents to ___ with a massive GI bleed/vomiting blood. Per husband, she was in her usual state of health and had been sober for 3 weeks, started drinking yesterday (husband estimates ___ pint vodka). He noticed she was behaving somewhat confused yesterday, forgetting where she was and/or what she was doing. Today she complained of feeling cold and had several episodes of coffee ground and frank hematemesis. ROS was negative for recent fever, illness, difficulty breathing, chest pain, abdominal pain, diarrhea, hematochezia or melena. She had decreased PO over the past 2 days. ***Unclear where she gets her GI care or how she presented***. Of note, she was evaluated in the ___ clinic in ___ for self-reported cases of ___ syndrome in the past. She felt that she was still experiencing lesions from this syndrome but only had evidence of folliculitis on exam. She left abruptly before the exam could be finished. -In the ED, initial vitals: 97.7 140 148/92 16 98% RA -Labs significant for: H/B ___ (previously 15.7/45.4 in ___, Plt 103, normal electrolytes (K slightly low at 3.5), ALT/AST 40/150, Tbili 5.2, lipase 80, ethanol level 184, lactate 3.4. UA was bland and blood cx pending. -On history, she had reportedly been drinking alcohol today and was confused. She was vomiting blood in the ED. An NG tube was placed and 1L of blood was suctioned from her stomach. She was intubated for airway protection. Access was obtained with two 18 and one 20-guage IV. She was not given any antibiotics due to her reported history of ___ syndrome. -Hepatology was consulted and planned to perform an EGD. -She received 1L NS, 2U PRBC's, and IV PPI. She was ordered for octreotide. -On transfer, vitals were: 97.7 ___ 22 100% Intubation On arrival to the MICU, she remained afebrile, was tachycardic and normotensive, sedated and intubated. GI performed bedside EGD and identified a small esophageal varix with evidence of prior bleeding. Variceal banding was attempted but unsuccessful, and provoked frank bleeding from the varix. The varix was irrigated and bleeding self-resolved after approximately 15 minutes. Interventional radiology was consulted for TIPS and diagnostic paracentesis. Patient was brought to ___ suite approx. 2:00 AM. Post-EGD she was started on IV ciprofloxacin for SBP concern, protonix gtt and octreotide gtt. She was sedated on fentanyl and versed drip upon arrival to the floor; her versed was discontinued and she was started on propofol. Given her history of alcohol abuse she was started on phenobarbital protocol. sign-out with ___: TIPS and paracentesis performed successfully without complication. Portosystemic pressure 21 --> 11 pre/post TIPS respectively. normal hepatopedal flow visualized through the TIPS. No significant varices visualized during procedure. Performed successful paracentesis and drained approx. 3.5L ascetic fluid which was sent for labs and cultures. Review of systems: + per HPI, all other ROS negative Past Medical History: ALCOHOLIC CIRRHOSIS C/B ESOPHAGEAL VARICES HYPERTENSION ASTHMA/COPD GERD MIGRAINE HEADACHES ___ SYNDROME (to penicillins) ARTHRALGIAS FOLLICULITIS HIDRADENTIS SUPPURATIVA ESOPHAGEAL VARICES ___: Banding procedure x 7 OVARIAN CYSTS ___ Social History: ___ Family History: Mother Living ___ DIABETES MELLITUS Father Living UNKNOWN Comments: 2 brothers good health Physical Exam: ADMISSION PHYSICAL EXAM ========================= Vitals: T: 97.7 P: 125 BP: 148/92 R: 22 O2: 100% GENERAL: sedated, intubated HEENT: scleral icterus, perrl NECK: supple, distended EJ LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: no murmurs, rubs, gallops ABD: Distended, firm. 3cm abrasion to RUQ. EXT: no pitting edema. Warm, well perfused, 2+ pulses bilaterally SKIN: no jaundice NEURO: sedated DISCHARGE PHYSICAL EXAM ======================== Vitals: Tm99.3 HR110s BP90s-120s/50s-70s O2 98 RA GENERAL: lying in bed, NAD. HEENT: mildly icteric sclerae; dobhoff in place LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic; regular rhythm; no appreciable murmurs ABD: mildly distended, nontender, not tense. EXT: no edema, warm and well perfused. SKIN: jaundiced NEURO: alert, oriented to place, month but does not know year, no asterixis Pertinent Results: ADMISSION LABS ================= ___ 08:15PM BLOOD WBC-8.4 RBC-3.21*# Hgb-11.0*# Hct-33.0*# MCV-103* MCH-34.3* MCHC-33.3 RDW-18.1* RDWSD-68.9* Plt ___ ___ 08:15PM BLOOD ___ PTT-36.0 ___ ___ 08:15PM BLOOD Plt ___ ___ 08:15PM BLOOD Glucose-116* UreaN-9 Creat-0.5 Na-142 K-3.5 Cl-104 HCO3-24 AnGap-18 ___ 08:15PM BLOOD ALT-40 AST-150* AlkPhos-166* TotBili-5.2* ___ 08:15PM BLOOD Albumin-3.0* ___ 06:52AM BLOOD Albumin-2.6* Calcium-7.8* Phos-4.0 Mg-1.3* ___ 08:15PM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:55AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-120* pCO2-31* pH-7.49* calTCO2-24 Base XS-2 Intubat-INTUBATED ___ 08:33PM BLOOD Lactate-3.4* MICROBIOLOGY: Peritoneal fluid and blood cultures negative IMAGING AND DIAGNOSTICS: ___ EKG Sinus tachycardia. No previous tracing available for comparison. ___ CXR IMPRESSION: Endotracheal tube in satisfactory position. ___ KUB IMPRESSION: No definite signs of obstruction. ___ CXR IMPRESSION: Compared to prior chest radiographs, ___ and ___. Substantial increase in opacification in the left lower hemi thorax is probably a combination of worsening atelectasis and increasing moderate left pleural effusion. Heart is top-normal size. Pulmonary vasculature is mildly engorged but there is no pulmonary edema or right pleural effusion. No pneumothorax. Tip of the endotracheal tube at the thoracic inlet is in standard position, 5.5 cm above the carina. Esophageal drainage tube passes to the mid portion of a nondistended stomach. TIPS US ___: IMPRESSION: 1. Patent TIPS with wall to wall flow and top normal velocities. 2. Very nodular cirrhotic appearing liver. No gross liver lesion identified. 3. Minimal ascites. 4. Splenomegaly. 5. Cholelithiasis. DISCHARGE LABS: ============================= ___ 05:40AM BLOOD WBC-4.4 RBC-2.82* Hgb-9.3* Hct-28.7* MCV-102* MCH-33.0* MCHC-32.4 RDW-18.5* RDWSD-69.2* Plt Ct-59* ___ 03:44AM BLOOD Neuts-59.9 ___ Monos-8.6 Eos-2.8 Baso-0.3 Im ___ AbsNeut-1.96 AbsLymp-0.92* AbsMono-0.28 AbsEos-0.09 AbsBaso-0.01 ___ 05:40AM BLOOD ___ PTT-35.4 ___ ___ 05:40AM BLOOD Glucose-110* UreaN-7 Creat-0.4 Na-131* K-3.9 Cl-100 HCO3-22 AnGap-13 ___ 05:40AM BLOOD ALT-25 AST-75* AlkPhos-111* TotBili-3.3* ___ 05:40AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.6 Mg-1.7 ___ 05:40AM BLOOD TSH-5.0* ___ 05:45AM BLOOD HAV Ab-POSITIVE ___ 07:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE ___ 06:13PM ASCITES WBC-283* RBC-4350* Polys-13* Lymphs-17* ___ Mesothe-4* Macroph-66* ___ 05:08AM ASCITES WBC-87* RBC-2925* Polys-20* Lymphs-18* ___ Mesothe-21* Macroph-41* ___ 05:08AM ASCITES TotPro-0.8 Glucose-123 Creat-0.2 LD(LDH)-49 Amylase-14 TotBili-0.6 Albumin-<1.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 2. Cyclobenzaprine 20 mg PO HS 3. Gabapentin 800 mg PO QHS 4. Omeprazole 40 mg PO DAILY 5. Propranolol 80 mg PO DAILY 6. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain Discharge Medications: 1. TraMADOL (Ultram) 50 mg PO BID PRN pain 2. Azithromycin 500 mg PO Q24H Duration: 5 Days RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 3. Ciprofloxacin 0.3% Ophth Soln 2 DROP RIGHT EAR BID RX *ciprofloxacin HCl 0.2 % 2 drop otic twice a day Disp #*1 Tube Refills:*0 4. Dexamethasone Ophthalmic Susp 0.1% 4 DROP RIGHT EAR BID RX *dexamethasone [Maxidex] 0.1 % 1 drop otic twice a day Refills:*0 5. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Lactulose 30 mL PO Q6H RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours Refills:*0 7. Magnesium Oxide 400 mg PO BID RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 8. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Spironolactone 50 mg PO DAILY RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Thiamine 500 mg PO DAILY RX *thiamine HCl (vitamin B1) 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob 13. Omeprazole 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Variceal bleed Alcohol hepatitis Decompensated EtOH cirrhosis External otitis media SECONDARY DIAGNOSES Alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Sometimes confused. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with intubation // assess et tube TECHNIQUE: Portable chest x-ray. COMPARISON: None. FINDINGS: Lung volumes are somewhat low. The cardiomediastinal silhouette and pulmonary vasculature are unremarkable. An endotracheal tube terminates approximately 4 cm above the carina. A transesophageal tube is seen coursing out of the field of view, but the side port overlying the region of the stomach. No definite focal consolidation is identified. There is mild left basilar atelectasis. There is no pleural effusion or pneumothorax. IMPRESSION: Endotracheal tube in satisfactory position. Radiology Report INDICATION: ___ year old woman with massive variceal bleed, hematemesis // TIPS to be placed COMPARISON: None available TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: General anesthesia was administered by the anesthesia department. MEDICATIONS: Please see anesthesia notes. Clindamycin 600 mg CONTRAST: 85 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 28.5 min, 904 mGy PROCEDURE: 1. Paracentesis in the right upper quadrant with placement of a 5 ___ flush catheter. 2. Right internal jugular venous access using ultrasound. 3. Pre-procedure right atrial, right hepatic balloon-occluded and portal vein pressure measurements. 4. CO2 portal venogram in AP and lateral projections. 5. Contrast enhanced portal venogram. 6. Placement of a 10 mm x 8 cm x 2 cm Viatorr covered stent. 7. Post-stenting balloon angioplasty of the TIPS shunt with a 10 mm balloon. 8. Post-stenting portal venogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the healthcare proxy. 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 neck and abdomen was prepped and draped in the usual sterile fashion. Under ultrasound guidance a 19 gauge needle was inserted into the right upper quadrant peritoneum until there was flow of ascites fluid through the needle. A ___ wire was advanced through the needle and coiled in the right upper quadrant. Under fluoroscopic guidance, a 5 ___ straight flush catheter was advanced over the ___ wire and left in the perihepatic space. The catheter was then attached to tubing and 3.5 L of straw-colored ascites was drained. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Images of ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. A small incision was made at the needle entry site. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a ___ wire was advanced distally into the IVC. The micropuncture sheath was then removed and a 9 ___ sheath was advanced over the wire into the inferior vena cava. Using a MPA and a angled glide, access was obtained in the right hepatic vein. Appropriate position was confirmed with contrast injection and fluoroscopy in AP and lateral views. Then a occlusion balloon was advanced over the wire into the distal right hepatic vein. The wire was then removed and portal pressure measurements were obtained after balloon occlusion. The pressure measurements were obtained through the sheath to obtain free hepatic vein pressures. A CO2 portal venogram was performed in the AP and lateral projections. Following procedural planning, the Amplatz wire and occlusion balloon were removed and the TIPS metal cannula was advanced through the sheath. Once the sheath was placed in an appropriate position, the cannula device was inserted over the Amplatz wire and the wire was exchanged for ___ needle. The angled sheath was turned anteriorly. The needle was then advanced through liver parenchyma and the needle was withdrawn over its sheath. The TIPS sheath was withdrawn while gentle suction was applied. Upon blood return, a Glidewire was introduced into the catheter to attempt to pass into the portal vein. The angled Glidewire was unable to be passed into the main portal vein and therefore was exchanged for a headliner micro wire. The headliner microwire was passed into the main portal vein. A micro catheter (renegade ___) was advanced over the headliner into the main portal vein. The headliner wire was exchanged for V18 micro wire. The micro catheter was then removed and a 4 ___ C2 glide catheter was advanced over the V18 into the splenic vein. The micro wire was exchanged for an Amplatz wire and extended into the splenic vein. Attempts to pass a straight flush catheter was unsuccessful through the liver parenchymal tract. Therefore a 6 mm mustang balloon was advanced over the Amplatz wire and pre dilation of the liver tract was performed. Subsequently the straight flush catheter was advanced over the wire and a contrast enhanced portal venogram was performed. Next direct portal pressure measurements and right atrial pressure measurements were obtained. An Amplatz wire was advanced through the straight flush catheter into the splenic vein. The catheter was removed and a 10 mm x 8 cm x 2 cm Viatorr covered stent was advanced into appropriate position and deployed. Following stent deployment, the stent was dilated using a 10 mm balloon. The straight flush catheter was advanced over the wire and the wire was removed. Repeat portal and right atrial pressure measurements were performed. The sheath was then removed from the right internal jugular vein site and pressure held for 10 minutes to achieve hemostasis. Steri-strips and sterile dressings were applied. The patient tolerated the procedure well. There were no immediate post-procedure complications. The patient was transferred to the PACU in stable condition. FINDINGS: 1. Pre-TIPS right atrial pressure of 40 and balloon-occluded portal pressure measurement of 19 resulting in portosystemic gradient of 21 mmHg. 2. CO2 portal venogram showing normal portal venous anatomy with a favorable trajectory from the right hepatic vein to the right portal vein. 3. Contrast enhanced portal venogram showing hepatofugal flow towards the splenic vein. Enlarged coronary vein with retrograde flow into the gastroesophageal varices. 4. Post-TIPS portal venogram showing restoration of hepatopetal flow with brisk flow through the TIPS shunt into the right atrium. No filling of the esophageal varices is identified. 5. Post-TIPS right atrial pressure of 30 and portal pressure of 19 resulting in portosystemic gradient of 11 mmHg. 6. 3.5 L of straw-colored ascites removed through a peritoneal drain. Sample sent for culture. IMPRESSION: 1. Successful right internal jugular access with transjugular intrahepatic portosystemic shunt placement with decrease in porto-systemic pressure gradient from 21 to 11 mm Hg. 2. 3.5 liters of ascites drained. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with ett // ett ett IMPRESSION: Compared to prior chest radiographs, ___ and ___ one. Substantial increase in opacification in the left lower hemi thorax is probably a combination of worsening atelectasis and increasing moderate left pleural effusion. Heart is top-normal size. Pulmonary vasculature is mildly engorged but there is no pulmonary edema or right pleural effusion. No pneumothorax. Tip of the endotracheal tube at the thoracic inlet is in standard position, 5.5 cm above the carina. Esophageal drainage tube passes to the mid portion of a nondistended stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with recent NG tube placement // Please check tube position Please check tube position IMPRESSION: Compared to prior chest radiographs ___. 2 successive frontal chest radiographs show advancement of the esophageal drainage tube, initially looped in the mid esophagus and terminating in the hypopharynx, to standard position in the mid stomach. Moderate left pleural effusion has increased substantially since ___. There is no right pleural effusion and no pneumothorax. Some left lower lobe atelectasis is presumed. Radiology Report INDICATION: ___ year old woman with UGIB, bilious emesis // please evaluate for obstruction TECHNIQUE: Single supine view of the abdomen was obtained. COMPARISON: None available FINDINGS: There are no abnormally dilated loops of large or small bowel. A transesophageal tube is noted, terminating in the stomach. Free air is difficult to assess on this single supine film. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No definite signs of obstruction. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old woman with etoh cirrhosis, s/p TIPS ,evaluating tips // post TIPS ultrasound TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: TIPS procedure ___ FINDINGS: LIVER: The hepatic parenchyma is coarse and echogenic The contour of the liver is very nodular. There is no focal liver mass identified. There is mild ascites predominantly in the perihepatic space. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm. GALLBLADDER: Several small gravel like stones are seen in the neck of the gallbladder. PANCREAS: The pancreas is unremarkable but is only minimally visualized due to overlying bowel gas. SPLEEN: Normal echogenicity, measuring 16.3 cm. KIDNEYS: No hydronephrosis on limited views of the kidneys. DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow at a velocity of 32 cm/sec. The TIPS shunt is patent with wall wall flow and velocities of 170, 148 and 146 cm/sec in the proximal, mid and distal portions respectively. Flow within the right and left portal veins is toward the TIPS. IMPRESSION: 1. Patent TIPS with wall to wall flow and top normal velocities. 2. Very nodular cirrhotic appearing liver. No gross liver lesion identified. 3. Minimal ascites. 4. Splenomegaly. 5. Cholelithiasis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Hematemesis, Altered mental status Diagnosed with Hematemesis temperature: 97.7 heartrate: 140.0 resprate: 16.0 o2sat: 98.0 sbp: 148.0 dbp: 92.0 level of pain: unable level of acuity: 1.0

Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at the ___. You were admitted with a bleed from your esophagus. This bleed was caused by something called varices, which are caused by the high blood vessel pressures that develop when you have liver cirrhosis. You underwent a procedure called transjugular intrahepatic portosystemic shunt, called a TIPS, and this helps lower the pressure within those blood vessels. We cannot stress to you how important it is that you never consume alcohol again. This will lead to worsening of liver disease, increase in the pressures discussed above, and inevitably, death. It is also important that you consume a low sodium diet. Please do not add salt to your food and read the labels of the foods you buy. You should be wary of eating out in restaurants, and always inform them you require low sodium. Please continue to have high protein shakes at least 3 times a day, this includes ensure or carnation breakfast shakes. You also had ear pain while you were hospitalized, likely caused by an ear infection. If this pain does not improve in 2 days, or gets worse, please contact your PCP ___. Your nutritional status is extremely important. Please drink AT LEAST 3 Ensures or 3 carnation instant breakfast supplements daily, with a goal of 6. These should be taken in addition to your regular meals. You should re-evaluate your need for a feeding tube to help with your nutrition at your next liver appointment. If you develop confusion, fevers, chills, worsening fluid in your abdomen or legs, vomiting of blood or black stools, please seek medical attention. We wish you the ___ of luck in your health. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Fatigue, Weakness Major Surgical or Invasive Procedure: Right heart catheterization ___ Coronary angiography ___ History of Present Illness: ___ year old man with history of coronary artery disease s/p PTCA LAD in ___, IMI in ___, LAD PCI at the time, BMS (minivision) in LPDA in ___, ischemic cardiomyopathy (EF 32% in ___ s/p ICD, and paroxysmal atrial fibrillation on amiodarone, who presents for fatigue. Patient was in his USOH and was planned for a R hip replacement due to femoral loosening of prior THR. He was in fact seen at ___ cardiology pre-operatively and had exercise MIBI that was notable for partially reversible, small, moderate severity perfusion defect involving the RCA territory (as well as fixed large severe perfusion defect involving the LAD territory consistent with prior MIs). The plan was to follow up in 3 months rather than planned 6 month follow up given this new finding but there was no plan for cath prior to that. He then underwent unremarkable R THR (___, ___ and was discharged to rehab after 4 day admission. He completed 2 weeks of rehab and then was at home. He noted at home that he was able to go up and down stairs of his townhouse normally; however, sometimes he was SOB with exertion at the top of the stairs. Occasionally he had "very mild chest pressure, not pain" in the ___ his chest with this SOB. He states this is different from prior MIs in that that was a/w more pain. He reported this to his PCP (BWH) and to cards (BI). Given that he was initially having cough worse while lying flat (+/- ?orthopnea, not clear from the story), PCP initiated on ___ 10, then increased to 20 when he did not derive any significant benefit. PCP also initiated imdur 30 daily given concern that there may be anginal component to this. Since patient did not have any relief, he stopped imdur about 3 days ago. BI cards was amenable to this plan with the intention of seeing patient in ___ clinic on ___. However, patient reported too significant fatigue and so presented to ED. He specifically denies recent fevers, chills, cough, sore throat, palpitations, lightheadedness, orthopnea, ___ edema (has some improving RLE edema after his procedure), chest pain, cold/heat intolerance. In the ED initial vitals were: 98.0, 69, 109/55, 16, 98% RA Exam notable for: AAOX3, NAD, RRR, Very faint bibasilar cackles, JVP not elevated, no TTP, no peripheral edema. surgical site R, c/d/i well healing EKG: per ED, sub mm ST depressions v5, v6 otherwise unchanged from prior Labs/studies notable for: - CXR negative - trop neg x1 - proBNP: 1454 - WBC 7.1, HGB 9.1, PLT 274 - BMP WNL, Cr 0.7 ___ labs: ___ BNP 2332, Hgb 10.3 Patient was given: ___ 14:58 PO Acetaminophen 1000 mg Past Medical History: 1. CARDIAC RISK FACTORS: (+)Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: PTCA to LAD in ___ and TPA and directional atherectomy to LAD in ___ -PACING/ICD: ___ ___ ___ ___ dual-chamber ICD placed ___. . 3. OTHER PAST MEDICAL HISTORY: - CAD s/p anterior wall MI - Atrial fibrillation - Ischemic cardiomyopathy, EF 35% - CVA ___ with very minor residual short term memory deficit - TIA ___ during hip surgery - Prostate CA- radiation tx ___. Social History: ___ Family History: Father - MI, CVA. Two sisters - MI s/p CABG. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM ========================== VS: 98.3 110/65 71 18 97 RA GENERAL: Well developed, well nourished adult man in NAD; appears younger than stated age. Oriented x3. Mood, affect appropriate. HEENT: PERRL, Conjunctiva were pink NECK: Supple. JVP not seen at 45 degrees CARDIAC: III/VI systolic murmur heard best at ___, no rubs or gallops LUNGS: Faint rales in L base, no rhonchi or wheeze ABDOMEN: Soft, non-tender, non-distended EXTREMITIES: 1+ R > L ___ edema SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE EXAM ========================== VS: 24 HR Data (last updated ___ @ 328) Temp: 98.1 (Tm 98.6), BP: 106/52 (106-148/51-71), HR: 62 (60-66), RR: 18 (___), O2 sat: 93% (93-97), O2 delivery: RA GENERAL: alert and interactive, NAD HEENT: EOMI, MMM, OP clear NECK: Supple. JVP not seen at 45 degrees CARDIAC: III/VI systolic murmur heard best at ___, no rubs or gallops LUNGS: CTAB, unlabored respirations ABDOMEN: Soft, non-tender, non-distended EXTREMITIES: 1+ R > L ___ edema SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS =========================== ___ 12:29PM BLOOD WBC-7.1 RBC-3.27* Hgb-9.1* Hct-30.2* MCV-92 MCH-27.8 MCHC-30.1* RDW-16.4* RDWSD-54.1* Plt ___ ___ 12:29PM BLOOD Neuts-74.5* Lymphs-11.1* Monos-10.5 Eos-3.1 Baso-0.1 Im ___ AbsNeut-5.31 AbsLymp-0.79* AbsMono-0.75 AbsEos-0.22 AbsBaso-0.01 ___ 12:29PM BLOOD Glucose-114* UreaN-16 Creat-0.7 Na-140 K-4.3 Cl-100 HCO3-25 AnGap-15 ___ 12:29PM BLOOD proBNP-1454* ___ 12:29PM BLOOD cTropnT-<0.01 ___ 04:02PM BLOOD cTropnT-<0.01 ___ 12:29PM BLOOD TSH-1.9 MICROBIOLOGY =========================== ___ 3:16 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. RELEVANT STUDIES =========================== ___ CXR PA/LATERAL: Comparison to ___. No relevant change is noted. The lung volumes are normal. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. No evidence of pneumonia, pulmonary edema or pleural effusions. Mild elongation of the descending aorta. Left pectoral pacemaker in situ. ___ RLE U/S: No evidence of deep venous thrombosis in the right lower extremity veins. DISCHARGE LABS =========================== ___ 07:40AM BLOOD WBC-6.5 RBC-3.37* Hgb-9.2* Hct-30.8* MCV-91 MCH-27.3 MCHC-29.9* RDW-16.2* RDWSD-54.2* Plt ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Enalapril Maleate 5 mg PO BID 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Amiodarone 200 mg PO DAILY 4. Warfarin 2.5 mg PO DAILY16 5. Atorvastatin 40 mg PO QPM 6. sildenafil 50 mg oral 1X:ASDIR 7. Aspirin 81 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. potassium chloride 20 mEq oral DAILY 11. TraMADol 50 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Warfarin 3 mg PO DAILY16 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Enalapril Maleate 5 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. sildenafil 50 mg oral 1X:ASDIR 8. TraMADol 50 mg PO Q8H:PRN Pain - Moderate Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Fatigue Systolic heart failure Secondary diagnosis: Atrial fibrillation Coronary artery disease Normocytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with CAD, ischemic cardiomyopathy, prostate cancer and CVA presents with fatigue, weakness and cough.// Please assess of pneumonia vs. pulmonary edema Please assess of pneumonia vs. pulmonary edema IMPRESSION: Comparison to ___. No relevant change is noted. The lung volumes are normal. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. No evidence of pneumonia, pulmonary edema or pleural effusions. Mild elongation of the descending aorta. Left pectoral pacemaker in situ. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old man with recent R hip replacement and residual RLE edema; now presenting with increased fatigue and persistent RLE edema; r/o DVT// R/O DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fatigue, Weakness Diagnosed with Dyspnea, unspecified, Chest pain, unspecified, Weakness temperature: 98.0 heartrate: 69.0 resprate: 16.0 o2sat: 98.0 sbp: 109.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___. Why was I here? - You had been more fatigued at home and you were admitted for further work-up of your fatigue. What was done for me while I was here? - Your ICD was checked by the Cardiologists. There were no abnormal arrhythmias to explain your fatigue. - You had a cardiac catheterization which showed mild-moderate coronary artery disease but no blockages that needed stenting. - You had an ultrasound of your heart. The ultrasound showed your heart was not pumping as strongly as it did in ___. What should I do when I go home? - You should take all of your medications as prescribed. - You should attend all of your follow-up appointments. - You should weigh yourself every day. If your weight increases more than 3 pounds in one week, please contact your PCP about restarting ___. We wish you the best in the future. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Tetracycline Analogues / Sulfa (Sulfonamide Antibiotics) / Ampicillin / Clindamycin / surgical glue Attending: ___. Chief Complaint: Left ankle fracture Major Surgical or Invasive Procedure: Left ankle ORIF ___, ___ History of Present Illness: ___ female status post trip and fall with a left bimalleolar ankle fracture Past Medical History: IBS, depression, SI, endometriosis, fibroids Social History: ___ Family History: non-contributory Physical Exam: LLE: In short leg splint Sensation intact over exposed toes Fires ___ and FHL Toes warm and well perfused Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 450 mg PO QAM 2. DULoxetine 60 mg PO DAILY 3. ARIPiprazole 7.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. ARIPiprazole 7.5 mg PO DAILY 7. BuPROPion (Sustained Release) 450 mg PO QAM 8. DULoxetine 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left bimalleolar ankle fracture, right ankle sprain with avulsion 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: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: History: ___ with mechanical fall and pain in the left lower extremity// Rule out fracture TECHNIQUE: Frontal, lateral, and sunrise view radiographs of COMPARISON: ___ knee radiographs. FINDINGS: Left total knee arthroplasty hardware is noted. There is a curvilinear lucency along the medial femoral condyle separating a curvilinear avulsed bone flake from femur which is new from ___ radiograph. This corresponds to the proximal insertion site of the medial collateral ligament. Findings suggest an avulsion fracture of the medial upper condyle secondary to major collateral ligament injury. There is no dislocation. There is a small knee joint effusion. No suspicious lytic or sclerotic lesions are identified. IMPRESSION: New curvilinear lucency along the medial femoral condyle is concerning for an avulsion fracture of the medial femoral condyle with associated medial collateral ligament injury. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: History: ___ with mechanical fall and pain in the left lower extremity// Rule out fracture TECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula. COMPARISON: Same day foot ankle radiograph. FINDINGS: There is an oblique anterolaterally displaced fracture of the left distal fibula diaphysis and an ___ displaced fracture of left medial malleolus. The tibiotalar joint is laterally subluxed and 1 cm widening of the medial tibiotalar joint space is consistent with ligamentous injury. Swelling of the surrounding soft tissues. Ankle joint effusion also noted. No suspicious lytic lesion, sclerotic lesion, or periosteal new bone formation is detected. No soft tissue calcification or radio-opaque foreign bodies are detected. Limited views of the left knee joint is notable for total knee arthroplasty. IMPRESSION: 1. Oblique anterolaterally displaced fracture of the distal fibula diaphysis. 2. ___ displaced fracture of left medial malleolus with lateral tibiotalar joint subluxation and suspected deltoid ligamentous injury. Radiology Report EXAMINATION: FOOT AP,LAT AND OBL LEFT INDICATION: History: ___ with fall and pain in the left lower extremity// Rule out fracture TECHNIQUE: Three views of the left foot COMPARISON: ___ left foot radiograph. FINDINGS: There is a comminuted inferior medially displaced fracture of the medial malleolus with widening of the medial joint space consistent with deltoid ligamentous injury. Tibiofibular and talofibular the ligamentous injury are also suspected. There is marked swelling of the surrounding ankle soft tissues. Mineralization is normal. There are no erosions. IMPRESSION: Acute displaced fracture of the medial malleolus with tibiotalar joint subluxation and evidence of ligamentous injury. Marked surrounding soft tissue swelling. Radiology Report EXAMINATION: CHEST (PRE-OP AP ONLY) INDICATION: History: ___ with left lower extremity fracture, preop chest x-ray// Rule out intrathoracic process TECHNIQUE: Portable frontal upright chest radiograph COMPARISON: ___ chest CT FINDINGS: The lungs are well aerated. There is no focal consolidation. There is no pleural effusion or pneumothorax. Cardiac silhouette size is mildly enlarged. Mediastinal contours are unremarkable. No evidence of pulmonary edema. Lower cervical fusion hardware is partially visualized. IMPRESSION: No evidence of pneumonia. Radiology Report EXAMINATION: DX ANKLE AND FOOT; DX KNEE AND TIB/FIB INDICATION: History: ___ with fracture status post reduction// Postreduction film Postreduction film Postreduction film TECHNIQUE: Four views of the left ankle and foot as well as 6 views of the left tibia fibula and knee were obtained COMPARISON: Radiographs performed earlier today IMPRESSION: The patient is status post reduction of a displaced medial malleolar fracture with tibiotalar subluxation and an obliquely oriented fracture of the left fibular diaphysis. Splint material is present obscuring fine osseous detail. Re-demonstrated is a displaced fracture of the medial malleolus. There appears to be continued widening of the medial gutter. A mildly displaced oblique fracture of the left fibular diaphysis is also noted. The talar dome appears preserved on these views. A left knee prosthesis is present without evidence of hardware related complications. There is a fairly linear but obliquely oriented lucency involving the proximal fibular diaphysis which could reflect a nondisplaced fracture or nutrient foramen. Radiology Report EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT INDICATION: LEFT ANKLE FX.ORIF COMPARISON: Plain radiograph of the Left foot ___. FINDINGS: 3 intraoperative fluoroscopic images, demonstrate placement of syndesmotic screws, tension band wire and percutaneous pins, for fixation of the distal tibial fractures. There remains a high fibular fracture. Improved alignment. Total fluoroscopic time 18.1 seconds. IMPRESSION: Please refer to operative report. Radiology Report INDICATION: ___ year old woman with R ankle pain// ?fx COMPARISON: Prior from ___ FINDINGS: AP, lateral, oblique views of the right ankle were provided. There is no acute fracture or dislocation. A tiny well corticated ossific density inferior to the lateral malleolus is unchanged from prior and may reflect an old injury. There is also a tiny ossific density inferior to the medial malleolus which was not clearly seen on the prior exam and may represent a tiny avulsion, please correlate clinically. There is a small plantar calcaneal spur which appears unchanged. IMPRESSION: Tiny bony fragment inferior to the medial malleolus, not clearly seen on prior may represent an acute avulsion. Please correlate for focal pain. Otherwise no acute findings. Radiology Report EXAMINATION: TIB/FIB (AP AND LAT) RIGHT INDICATION: ___ year old woman with ankle and proximal fibula pain// ?___ TECHNIQUE: Two views right tibia and fibula COMPARISON: Right ankle radiographs ___ FINDINGS: No fracture or dislocation seen. No destructive lytic or sclerotic bone lesions. Small rounded calcification anterior to the mid tibia likely within the soft tissues may reflect a small phleboliths. Mild degenerative changes in the right knee. IMPRESSION: No acute bony injury seen. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Ankle pain Diagnosed with Displaced bimalleolar fracture of left lower leg, init, Fall (on) (from) other stairs and steps, initial encounter temperature: 98.3 heartrate: 81.0 resprate: 18.0 o2sat: 98.0 sbp: 137.0 dbp: 72.0 level of pain: 8 level of acuity: 3.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing left lower extremity in splint, weightbearing as tolerated right lower extremity in ankle stirrup MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take aspirin 325 mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. Physical Therapy: Nonweightbearing left lower extremity in splint, weightbearing as tolerated right lower extremity in ankle stirrup when ambulating, may remove when in bed, range of motion as tolerated right lower extremity Treatments Frequency: LLE in splint, no wound care, leave splint until f/u

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left Monteggia fracture Major Surgical or Invasive Procedure: Left elbow open reduction and internal fixation History of Present Illness: ___ who was walking her dog today and had dog get tied up around her causing her to fall to ground and strike left forearm. Immediate onset of pain and swelling at the elbow. No head strike or LOC. No pain elsewhere. Evaluated at OSH, where she was found to have elbow fracture. Also noted to have some numbness and tingling in left ___ and ___ digit. The tingling and numb sensation has completely resolved. Past Medical History: HTN Hep C Social History: ___ Family History: NC Physical Exam: Exam on admission: AVSS Gen: A+Ox3, NAD LUE: Significant swelling at the left elbow No evidence of open fracture Pain with palpation of the left elbow +EPL, DIO, FPL SILT in r/u/m distribution Radial pulse 2+ No TTP over the left shoulder Exam on discharge: AFVSS NAD, A+Ox3 LUE: Dressings c/d/i Orthoplast splint for comfort Compartments soft and compressible No pain with passive finger motion Motor intact EPL, FPL, intrinsics SILT over M/R/U distributions WWP fingers, 2+ rad pulse Pertinent Results: ___ 12:07PM BLOOD WBC-5.6 RBC-3.23* Hgb-10.3* Hct-30.7* MCV-95 MCH-31.9 MCHC-33.6 RDW-13.2 Plt ___ ___ 06:31PM BLOOD Neuts-66.3 ___ Monos-4.6 Eos-1.9 Baso-0.8 ___ 12:07PM BLOOD Plt ___ ___ 07:01PM BLOOD ___ PTT-29.4 ___ ___ 12:07PM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-141 K-4.7 Cl-106 HCO3-30 AnGap-10 ___ 12:07PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.7 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 100 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Outpatient Occupational Therapy Left upper extremity: Non weight bearing Full active and passive ROM in LUE, including flexion, extension, pronation, supination. Resting orthoplast splint for sleeping and ambulation 2. Acetaminophen 1000 mg PO Q6H:PRN pain 3. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*50 Tablet Refills:*0 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left Monteggia fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PRE-OP AP ONLY) INDICATION: History: ___ with arm fracture, likely to OR // eval for pre op TECHNIQUE: Semi-upright AP view of the chest COMPARISON: ___ FINDINGS: Heart size is normal. The aorta is unfolded. Mediastinal and hilar contours are unremarkable. Pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is present. No acute osseous abnormalities identified. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: ELBOW, AP AND LAT VIEWS LEFT IN O.R. INDICATION: Intraoperative fluoroscopy TECHNIQUE: ELBOW, AP AND LAT VIEWS LEFT IN O.R. COMPARISON: ___ IMPRESSION: 3 spot fluoroscopy images obtained during open reduction and internal fixation of the left elbow will bronchial review. Total fluoroscopy time 4.6 seconds was recorded. For pre size details please review procedure report Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, LEFT ARM FX Diagnosed with FX UP RADIUS W ULNA-CLOS, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, ACTIVITIES INVOLVING WALKING AN ANIMAL, HYPERTENSION NOS temperature: 98.0 heartrate: 64.0 resprate: 18.0 o2sat: 99.0 sbp: 167.0 dbp: 87.0 level of pain: 9 level of acuity: 3.0

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - No weight bearing in left arm - Full active and passive range of motion in left arm, including flexion, extension, pronation, supination. - Resting orthoplast splint for sleeping and ambulation Physical Therapy: LUE NWB, full active and passive ROMAT including pronation/supination Orthoplast resting splint during sleeping and ambulation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right Distal Femur Fx, Right Tib Plateau Fx, L Cuboid Fx Major Surgical or Invasive Procedure: ___ - R knee I&D History of Present Illness: ___ s/p helmeted motorcycle collision. No LOC. On presentation GCS 15, HD stable, FAST neg. Found to have left foot cuboid fracture and right knee wound. Patient also reports mild to moderate pain in left shoulder. Patient denies numbness, paresthesias and pain in other extremities. Past Medical History: Denies Social History: ___ Family History: NC Physical Exam: Gen: NAD MSK: RLE: Incisions c/d/i, drain in place w/ SS output. SILT s/s/sp/dp/t Fires ___, FHL, G/S, TA, 1+ DP LLE: splint in place c/d/i, SILT over distal toes, wiggles toes, toes wwp Medications on Admission: Denies Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Senna 17.2 mg PO BID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*60 Tablet Refills:*0 6. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right Distal Femur Fracture, Right Tibial Plateau Fracture, L Cuboid Fracture Discharge Condition: Stable Followup Instructions: ___ Radiology Report INDICATION: ___ year old man with right knee laceration. Found small piece of bone upon exploration. ? from patella or from other source. // Eval for open joint fracture TECHNIQUE: Axial CT images of the right knee were obtained without intravenous contrast. Coronal and sagittal reformats were generated. DOSE: Acquisition sequence: 1) Spiral Acquisition 11.5 s, 24.5 cm; CTDIvol = 20.2 mGy (Body) DLP = 494.4 mGy-cm. Total DLP (Body) = 494 mGy-cm. COMPARISON: None available FINDINGS: There is a comminuted nondisplaced impaction fracture of the lateral femoral condyle anterolaterally. Intra-articular extension is appreciated. There is a comminuted minimally displaced intra-articular fracture of the lateral tibial plateau posteriorly without significant depression. The fracture line extends into the lateral tibial spine. No patellar fracture is identified. There is a small lipohemarthrosis with locules of air within the joint. Laceration is seen just superior to the patella within the subcutaneous tissues. Soft tissue swelling is noted anteriorly. IMPRESSION: 1. Comminuted nondisplaced impaction fracture of the lateral femoral condyle. 2. Comminuted intra-articular nondepressed fracture of the lateral tibial plateau posteriorly. Should there be concern for ligamentous injury, MRI can be performed. Radiology Report EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE INDICATION: ___ year old man with neck pain s/p MCC w/ numbness // eval for vert fracture eval for vert fracture 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 12.3 s, 48.1 cm; CTDIvol = 32.7 mGy (Body) DLP = 1,572.6 mGy-cm. Total DLP (Body) = 1,573 mGy-cm. COMPARISON: CT abdomen and pelvis: ___. FINDINGS: Alignment is normal. No fractures are identified. There is no evidence of critical spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. Mild, multilevel degenerative changes are noted throughout the thoracic spine, including anterior posterior osteophytosis. The imaged portion of the lungs and retroperitoneum is unremarkable. IMPRESSION: No evidence of thoracic spine fracture or traumatic malalignment. Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR INDICATION: ___ year old man with numbness in ___ like distribution of upper chest and shoulders status post motorcycle accident// eval for spinal cord injury, hematoma, central cord syndrome TECHNIQUE: Sagittal T2, sagittal STIR, and sagittal T1 weighted sequences of the cervical, thoracic, and lumbar spine were obtained. The examination was prematurely terminated at the patient's request due to claustrophobia. COMPARISON: CT thoracic spine ___ CT abdomen and pelvis ___ CT cervical spine ___ FINDINGS: CERVICAL: The alignment of the cervical spine is normal. The bone marrow is normal without evidence of edema or fractures. The height of the vertebral bodies are maintained. The spinal cord is normal in signal and caliber. No fluid collections or masses are identified. There is minimal edema anterior to the C3, C4, and C5 vertebral bodies. There is no spinal canal stenosis. THORACIC: The alignment of the thoracic spine is normal. There is linear T1 hypointense and T2/STIR hyperintense signal along the superior endplate of the T6 vertebral body. There is no marrow edema in the posterior elements. A T1/T2 hyperintense and heterogeneously STIR hyperintense lesion in the T11 vertebral body, measuring 1.4 cm, likely represents an intraosseous hemangioma. The vertebral bodies are maintained in height. Schmorl's nodes are scattered throughout the thoracic spine. The spinal cord is normal in signal and caliber. No fluid collections or masses are identified. LUMBAR: The alignment of the lumbar spine is normal. There is T1 hypointense and T2/STIR hyperintense signal along the right posterior and superior endplate of the L5 vertebral body and minimal T1 hypointense and T2/STIR hyperintense signal along the right inferior endplate of the L4 vertebral body. The height of the vertebral bodies are maintained. The conus medullaris terminates at T12-L1. The spinal cord is normal in signal. No fluid collections or masses are identified. At T12-L1 through L3-L4, there is no spinal canal or neural foraminal stenosis. At L4-L5, disc bulge and facet joint hypertrophy cause mild-to-moderate left neural foraminal stenosis. At L5-S1, bulge causes mild bilateral neural foraminal stenosis, right greater than left. IMPRESSION: 1. Incomplete examination due to lack patient cooperation. 2. Acute, nondisplaced fracture through the superior endplate of the T6 vertebral body. 3. Minimal prevertebral edema anterior to the C3, C4, and C5 vertebral bodies, suggestive of anterior longitudinal ligamentous sprain. 4. Edema of the L4-L5 endplates likely represent degenerative changes rather than traumatic injury. 5. No epidural fluid collections. 6. Normal signal and caliber of the spinal cord. 7. Mild degenerative changes of the cervical, thoracic, and lumbar spine without evidence of spinal canal or neural foraminal stenosis. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 9:25 AM, 10 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Motorcycle accident Diagnosed with Nondisp unsp condyle fx low end r femr, 7thB, Displaced bicondylar fracture of right tibia, init, Disp fx of cuboid bone of left foot, init for clos fx, Mtrcy driver injured pick-up truck, pk-up/van in traf, init temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated R lower extremity, NWB L lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Aspirin 325mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. Physical Therapy: NWB LLE WBAT RLE Treatments Frequency: Wound Monitoring ___ Drain Care: Monitor output and can d/c drain when <30cc/24h for at least 48h

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: ___ with recent traumatic SDH, had been admitted to neurosurg here. He was discharged from here to ___, and then after completing rehab there, transferred today to ___ ___. There he was physically aggressive and agitated. The ___ called EMS to request xfer back to rehab, but EMS took him to ___ instead. He had labs drawn there (in Careweb and on chart) and a head CT and the case was d/w Dr. ___ did not think his agitation related to his head bleed or hydrocephalus and was concerned about a medical cause of his delirium. the pt was given Zyprexa 5 and Ativan 2 and then transferred here. Apparently patient was combative and tried to punch a nurse at ___ but is calm and cooperative at this time and has showed no signs of agitation in the ___. In the ___, initial VS were: 97.6 72 160/81 16 96%. UA consistent with UTI and he was started on CTX. On arrival to the floor, he is somnolent but arousable. He does not follow commands. He withdraws to pain and arouses to noxious stimuli. Past Medical History: TBI from a motrocycle accident many years ago ___ HTN Social History: ___ Family History: NA Physical Exam: ADMISSION EXAM: 97.9 146/86 80 99%RA FSBG 108 GENERAL - Somnolent man awakes to noxious stimuli HEENT - NC/AT, dry MM. PEERL pupils 4mm and reactive NECK - supple LUNGS - CTA bilat HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS NT ND EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) Neuro: AAOX0. Withdraws to pain and awakens to noxious stimuli DISCHARGE EXAM: VS: Tc 97.6 137/77 68 18 100% RA GENERAL - awake, alert, oriented to person and date, not oriented to place HEENT - NC/AT, MMM. PEERL, EOMI, oral mucosa moist, without lesions NECK - Supple LUNGS - CTA bilat, no wheezing/rales/rhonchi HEART - RRR, no MRG, nl S1-S2 ABDOMEN - +BS/Soft/NT/ND, no r/g EXTREMITIES - WWP, no c/c/e NEURO: Left mouth droop with slurred speech (unchanged). He had ___ strength in upper and lower exermities. dysarthric with left facial droop (unchanged) Pertinent Results: ADMISSION LABS ___ 08:10AM BLOOD WBC-6.9 RBC-4.30* Hgb-11.8* Hct-37.4* MCV-87 MCH-27.5 MCHC-31.6 RDW-14.3 Plt ___ ___ 07:30PM BLOOD WBC-7.6 RBC-4.48* Hgb-12.2* Hct-38.6* MCV-86 MCH-27.4 MCHC-31.7 RDW-14.5 Plt ___ ___ 07:20AM BLOOD Glucose-86 UreaN-15 Creat-0.6 Na-140 K-4.0 Cl-102 HCO3-28 AnGap-14 ___ 07:30PM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-143 K-4.3 Cl-101 HCO3-31 AnGap-15 ___ 01:03AM BLOOD TSH-1.1 ___ 01:07AM BLOOD Type-ART pO2-94 pCO2-45 pH-7.44 calTCO2-32* Base XS-5 ___ 10:30PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG ___ 03:16PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 10:30PM URINE RBC-14* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 ___ 03:16PM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-0 ___ 10:30 pm URINE TAKEN FROM 1902S. MOST RECENT LABS AT DISCHARGE ___ 09:15AM BLOOD WBC-6.5 RBC-4.65 Hgb-12.8* Hct-40.4 MCV-87 MCH-27.5 MCHC-31.7 RDW-14.0 Plt ___ ___ 09:15AM BLOOD Plt ___ ___ 09:15AM BLOOD Glucose-91 UreaN-16 Creat-0.6 Na-142 K-4.0 Cl-102 HCO3-28 AnGap-16 ___ 09:15AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1 MICRO **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 8 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ___ 3:16 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 11:54 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___: CT Head: 1 resolution of subdural hematoma and evolution in the right parietal epidural hematoma which has decreased in size and is now hypotense and 12 mm thickness. 2 interval development of ventriculomegaly indicating communicating hydrocephalus. Number 3 resolution of prior hemorrhagic contusions with hypodensities indicative of encephalomalacia in both frontal regions. ___ 9:05 ___ CT HEAD W/O CONTRAST IMPRESSION: 1. Little overall change in comparison to prior study from ___ right parietal epidural hematoma which is minimally decreased in size andnow measures 9 mm from the inner table of the skull. 2. Again noted is ventriculomegaly indicating communicating hydrocephalus. 3. Again noted is a right parietal comminuted fracture extending into bilateral occipital and right temporal bones. ___: CT head: IMPRESSION: 1. Decreased size of right parietal epidural hematoma. 2. Minimal interval worsening of hydrocephalus. 3. Evolving contusion in the right inferior frontal lobe Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. LeVETiracetam 1000 mg PO BID 4. traZODONE 25 mg PO HS 5. Aripiprazole 10 mg PO DAILY Please give at 2pm 6. Quetiapine Fumarate 50 mg PO QHS 7. BusPIRone 20 mg PO TID 8. Ranitidine 150 mg PO BID 9. Phenazopyridine 200 mg PO TID Duration: 3 Days 10. Multivitamins 1 TAB PO DAILY 11. Quetiapine Fumarate 25 mg PO DAILY At 4PM 12. Acetaminophen 325-650 mg PO Q6H:PRN pain Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. BusPIRone 20 mg PO TID 3. LeVETiracetam 1000 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Ranitidine 150 mg PO BID 6. traZODONE 25 mg PO HS 7. OLANZapine 5 mg PO BID 8. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN aggitation 9. Acetaminophen 325-650 mg PO Q6H:PRN pain 10. Enalapril Maleate 20 mg PO DAILY 11. OLANZapine 2.5 mg PO QPM Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Urinary Tract Infection Altered Mental Status Delirium Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Followup Instructions: ___ Radiology Report INDICATION: New altered mental status and agitation. COMPARISONS: Chest radiograph ___. CT chest ___. FINDINGS: The lung volumes are low, which somewhat limits the evaluation. Within the limitations, there is no consolidation or edema. There is no pleural effusion or pneumothorax. The mediastinal contours are normal. The heart size is at the upper limits of normal, and stable from the prior exam. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: History of subdural hemorrhage and hydrocephalus status post fall today with new altered mental status. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Multiplanar reformatted images were prepared and reviewed. COMPARISON: Multiple prior CT head scans from ___ to ___. PROCEDURE: FINDINGS: Overall, there is little interval change in comparison to the prior study from ___. Again visualized is a right parietal epidural hematoma measuring 9 mm from the inner table of the skull, slightly decreased in comparison to prior study when it measured 11 mm. There is no evidence of new hemorrhage, edema, large vessel territorial infarction or shift of midline structures. Areas of encephalomalacia are again noted in bilateral frontal lobes. The ventricles are large including temporal horns and ___ and ___ ventricles again suggestive of communicating hydrocephalus. Again noted is a comminuted right parietal bone fracture extending into bilateral occipital bones and into the right temporal bone; better delineated on dedicated CT facial from ___. Mucosal thickening is again noted throughout the ethmoid air cells and the left maxillary sinus with a mucous retention cyst. The remainder of the visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Little overall change in comparison to prior study from ___ with right parietal epidural hematoma which is minimally decreased in size and now measures 9 mm from the inner table of the skull. 2. Again noted is ventriculomegaly indicating communicating hydrocephalus. 3. Again noted is a right parietal comminuted fracture extending into bilateral occipital and right temporal bones. Radiology Report HISTORY: Recent traumatic epidural hematoma and hydrocephalus. Evaluate for change in hydrocephalus and hematoma. TECHNIQUE: MDCT acquired contiguous axial images were obtained through the head without contrast. Coronal and sagittal reformats reviewed. COMPARISON: CT from ___. FINDINGS: There is minimally edema in the right inferior frontal lobe, likely representing an evolving contusion (2:14). The right parieto-occipital epidural hematoma has significantly decreased in size, with a maximal width of 4 mm, compared to 9 mm on the last study. The ventricular size has slightly increased from the prior study, particularly noticeable in the occipital horn of the right lateral ventricle. There is no new hemorrhage. There is no significant shift in midline structures. The comminuted fracture of the right parietal, occipital and temporal bones is unchanged. The mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Decreased size of right parietal epidural hematoma. 2. Minimal interval worsening of hydrocephalus. 3. Evolving contusion in the right inferior frontal lobe. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: NEURO EVAL Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS temperature: 97.6 heartrate: 72.0 resprate: 16.0 o2sat: 96.0 sbp: 160.0 dbp: 81.0 level of pain: 0 level of acuity: 2.0

Mr ___, It was a pleasure taking care of you. You were admitted with altered mental status (not acting like yourself) with a urinary tract infection. You were treated for a urinary tract infection for 7 days with IV antibiotics and your urine cleared. You were seen by neurosurgery who felt that there no additional intervention is needed at this time. You were also seen by psychiatry and your medications were changed- see below. You should follow up with your appointments listed below. Medication Changes: Please START OLANZapine Please STOP Aripiprazole Please STOP Phenazopyridine Please STOP Quetiapine Please INCREASE enalapril from 10mg to 20mg daily

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / aspirin / shrimp Attending: ___. Chief Complaint: Difficulty Urinating Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o HTN, HLD, T2DM, EtOH cirrhosis, CAD, HFrEF (LVEF 20%), prior PE no longer on anticoagulation presented to the ED ___ for difficulty urinating. Per history obtained in ED, She was seen by her PCP ___ for decreased urination over the past ___ days so her daughter reportedly "doubled up her diuretics." The daughter at bedside notes that she took double only her torsemide for two days, and denies taking any additional other medication. During that appointment she had HR 84. Today she was complaining of fullness in her lower abdomen, so her daughter brought her to the ED. She denies any associated chest pain, shortness of breath, abdominal pain but does note palpitations that "just started." She was triggered in the ED on ___ for bradycardia (HR ___ that spontaneously resolved with no further episodes on telemetry. No episodes of brady in ED since triage. - In the ED, initial vitals were: 99.3 | 38 | 135/80 | 16, 98% RA - Exam was notable for: General- NAD HEENT- PERRL, EOMI, normal oropharynx Lungs- Non-labored breathing, CTAB CV- RRR, no murmurs, normal S1, S2, no S3/S4 Abd- Soft, nontender, nondistended, no guarding, rebound or masses Msk- No spine tenderness, moving all 4 extremities Neuro-A&O x3, CN ___ intact, normal strength and sensation in all extremities, normal speech and gait. Ext- No edema, cyanosis, or clubbing - Labs were notable for: proBNP: ___, trop negative x 2. Lactate: 3.2 -> ___ s/p 1L IVF SCr: 2.2 -> 1.9 (Baseline 1.5 ___. Hgb: 10.8 Plt: 56 Mg2+: 1.3 -> 2.4 Phos: 2.5 -> 3.5 - Studies were notable for: CXR: No acute cardiopulmonary process. No pulmonary edema. - The patient was given: ___ 03:24 SC Insulin 10 UNIT ___ 04:00 IVF LR 500 mL ___ 06:58 IV Magnesium Sulfate 4 gm ___ 09:31 SC Insulin 4 Units ___ 09:31 PO/NG PARoxetine 40 mg ___ 09:31 PO/NG FoLIC Acid 1 mg ___ 09:31 PO Pantoprazole 40 mg ___ 10:23 PO/NG Cyanocobalamin 500 mcg ___ 14:26 SC Insulin 6 Units ___ 19:04 SC Insulin 6 UNIT ___ 19:04 SC Insulin 6 Units ___ 19:05 IVF NS 500 mL On arrival to the floor, patient endorses HPI as above. Says she has not been having anymore difficulty urinating. Denies any dysuria, suprapubic pain, flank pain. Says she will intermittently feel palpitations, denies any associated dizziness/lightheadedness, cp, SOB. Denies any orthopnea or increased ___ edema. Past Medical History: - Alcoholic cirrhosis c/b medium esophageal varices - Alcohol use disorder in remission - last drink was around ___ - Non-ischemic cardiomyopathy - likely related to alcohol - LVEF 17% in ___ (OSH; nuclear stress negative), 40-45% in ___, 20% in ___. - Diabetes II - Hypertension - Dyslipidemia - Anemia of Chronic Disease + Iron Deficiency - Prior history of GI bleeds - Asthma - no h/o hospitalizations, steroids, intubation - Depression - GERD - Macular degeneration - Osteoarthritis - s/p TAH Social History: ___ Family History: Father died of CHF exacerbation in mid-___. Mother alive and no cardiac history. 2 kids alive and well. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 97.7 | 145/78 | 87 | 21, 99% Ra GENERAL: WDWN elderly woman, NAD. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: JVP 10cm. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: S, ND, NT, BS+ EXTREMITIES: WWP. No clubbing, cyanosis. Trace ___ edema b/l. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: AOx3. CN2-12 grossly intact. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: ======================== ___ 0654 Temp: 98.7 PO BP: 123/73 R Lying HR: 75 RR: 18 O2 sat: 97% O2 delivery: Ra O2 sat: 96% O2 delivery: Ra General- NAD HEENT- EOMI, normal oropharynx Lungs- Non-labored breathing, CTAB CV- RRR, no murmurs, normal S1, S2, no S3/S4 Abd- Soft, nontender, nondistended, no guarding, rebound or masses Msk- No spine tenderness, moving all 4 extremities with purpose Neuro-A&O x3, normal strength and sensation in all extremities, normal speech and gait. Ext- trace pitting edema of the BLE; distal pulses intact Pertinent Results: ADMISSION LABS: =============== ___ 11:54PM BLOOD WBC-4.7 RBC-3.94 Hgb-10.8* Hct-34.9 MCV-89 MCH-27.4 MCHC-30.9* RDW-17.1* RDWSD-53.8* Plt Ct-56* ___ 11:54PM BLOOD ___ PTT-26.4 ___ ___ 11:54PM BLOOD Glucose-229* UreaN-53* Creat-2.2* Na-142 K-4.0 Cl-104 HCO3-23 AnGap-15 ___ 11:54PM BLOOD ___ 11:54PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.3* ___ 12:02AM BLOOD Lactate-3.2* K-3.8 MICRO: ====== ___ Urine Culture: No growth ___ Blood Culture x2: No growth IMAGING: ======== ___ CXR FINDINGS: No acute cardiopulmonary process. DISCHARGE LABS: ============== ___ 05:44AM BLOOD WBC-4.5 RBC-3.61* Hgb-9.9* Hct-32.4* MCV-90 MCH-27.4 MCHC-30.6* RDW-17.2* RDWSD-57.0* Plt Ct-41* ___ 05:44AM BLOOD Glucose-167* UreaN-31* Creat-1.2* Na-143 K-3.7 Cl-105 HCO3-25 AnGap-13 ___ 05:44AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7 Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: Scratch ___ with palpitations// Palpitations TECHNIQUE: Chest AP COMPARISON: Chest radiograph dated ___ FINDINGS: Lung volumes are low. There is mild cardiomegaly, unchanged. There is no definite focal consolidation to suggest pneumonia. No pneumothorax or large pleural effusion. No pulmonary edema. There are chronic posterior rib fractures bilaterally. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Bradycardia, Dysuria Diagnosed with Acute kidney failure, unspecified temperature: 99.3 heartrate: 38.0 resprate: 16.0 o2sat: 98.0 sbp: 135.0 dbp: 80.0 level of pain: 0 level of acuity: 1.0

Dear Ms. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You came to the hospital because you were having abdominal pain, and not urinating as much as usual. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were dehydrated likely due to getting extra doses of your home water pill, and your kidneys had some mild damage. - You were given fluids through an IV, which helped rehydrate you and improved your kidneys. - You were started back on your normal medications, were feeling better, and were ready to leave the hospital. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ Please continue to: [ ] Take all your medications [ ] Follow up with your doctors at your ___ appointments. [ ] Weigh yourself each morning, before you eat and before you take your medications. If your weight changes by more than 3 pounds from your original weight, please call your doctor. We wish you all the best! Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Toradol / Tequin / Rocephin / vancomycin / amoxicillin / Penicillins / Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old Female presents with chest pain and dyspnea after taking a ___ train trip the week prior to admission. She was coming to ___ for the funeral of her daughter who committed suicide 1 week prior. She states that 4 days prior to presentation she had exertional left chest pain radiating to her scapula, and notes that the pain is ___ and sharp in nature. She does have a history of DVT and PE, although was not on anticoagulation. She states her Left leg was swollen since the trip. She has had a cough, but no hemoptysis. The patient is apparently allergic to iodine. In addition to the chest pain, she also notes 5 episodes of melena on the day of presentation and multiple episodes of bilious vomiting. In the ED her initial vitals were 96.2, ___, 16, 100%RA. She was given 2L of IV fluids, Morphine, diphenhydramine, dilaudid and metoclopramide. Past Medical History: DVT/PE Ovarian Cancer s/p TAHBSO Right Heart Failure Supraventricular Tachycardia (has loop recorder in) s/p Ablation ECT PTSD Social History: ___ Family History: Mother: CAD Father: HTN Daughter: Died of ___ Brother: COPD Uncle: SVT Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: + Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia, + Melena PULM: + Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 97.9, 90, 156/93, 16, 100%RA GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, ___ DISCHARGE EXAM Vital Signs: 98.3 109/66 80 18 98%RA Pain ___ GEN: Alert, NAD, AxOx3, speaking full sentences, no accessory muscle use HEENT: NC/AT, OP clear, MMM CV:regular, S1, S2, no m/r/g PULM: CTA B, no w/r/r GI: obese, S/ND, BS present, no r/g PSYCH: talkative, brighter affect than prior days Pertinent Results: ___ 08:00PM BLOOD ___ ___ Plt ___ ___ 08:00PM BLOOD ___ ___ Im ___ ___ ___ 08:00PM BLOOD ___ ___ ___ 08:00PM BLOOD ___ ___ ___ 08:00PM BLOOD cTropnT-<0.01 ___ ___ 08:00PM BLOOD ___ ___ 08:29PM BLOOD ___ ___ 08:29PM BLOOD ___ Base XS--4 ___ 08:29PM BLOOD ___ ___ 8:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): CHEST (PA & LAT) Study Date of ___ 7:34 ___ IMPRESSION: No acute cardiopulmonary process. UNILAT LOWER EXT VEINS LEFT Study Date of ___ 9:04 ___ IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. ___ ___: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. ___ CTA Chest: The aorta is unremarkable without dissection or aneurysm. Great vessels are unremarkable. The pulmonary arteries are well opacified to the subsegmental level without filling defect to suggest pulmonary embolism. Pulmonary arteries are normal in caliber. Left sided central line noted. There is no evidence of pulmonary parenchymal abnormality. There is no pleural effusion or pneumothorax. The airways are patent to the subsegmental level. Heart is unremarkable. There is no pericardial effusion. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. Included portion of the thyroid is unremarkable. Included portion of the upper abdomen is unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. There is no fracture. Spondylosis of the thoracic spine. Metallic device located in the subcutaneous tissues of the left breast is visualized. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. ___ TTE: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No definite structural cardiac source of embolism identified. Normal PCWP. ___ EGD: Irregular ___ (biopsy, biopsy) Erythema and a single erosion in the antrum compatible with erosive gastritis Otherwise normal EGD to third part of the duodenum ___ sig: Mild decrease in vascularity in the sigmoid. Normal vascularity in the rectum. (biopsy, biopsy) Otherwise normal sigmoidoscopy to sigmoid colon Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Metoprolol Tartrate 50 mg PO BID 3. Zolpidem Tartrate 10 mg PO QHS Discharge Medications: 1. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #*180 Tablet Refills:*0 3. Albuterol ___ PUFF IH Q6H:PRN Bronchospasm RX *albuterol sulfate [ProAir HFA] 90 mcg ___ PUFF INH every 6 hours Disp #*1 Inhaler Refills:*0 4. ARIPiprazole 5 mg PO DAILY RX *aripiprazole 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. ARIPiprazole 10 mg PO QHS RX *aripiprazole 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 6. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN pain RX *hydromorphone 2 mg 1 tablet(s) by mouth twice a day Disp #*3 Tablet Refills:*0 7. Sucralfate 1 gm PO QID RX *sucralfate 1 gram 1 tablet(s) by mouth 4 times a day Disp #*28 Tablet Refills:*0 8. Pantoprazole 40 mg PO Q12H 9. Prazosin 5 mg PO QHS RX *prazosin 5 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 10. Lorazepam 0.5 mg PO QHS:PRN insomnia / anxiety RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth at bedtime Disp #*5 Tablet Refills:*0 11. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 12. HydrOXYzine ___ mg PO Q6H:PRN itching RX *hydroxyzine HCl 25 mg ___ tabs by mouth every 6 hours Disp #*60 Tablet Refills:*0 13. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 14. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Chest pain, NOS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old woman with concern for PE. Needs premedication for dye allergy // rule out PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.9 mGy (Body) DLP = 3.0 mGy-cm. 4) Stationary Acquisition 2.3 s, 0.2 cm; CTDIvol = 62.9 mGy (Body) DLP = 12.6 mGy-cm. 5) Spiral Acquisition 4.1 s, 30.5 cm; CTDIvol = 17.1 mGy (Body) DLP = 442.7 mGy-cm. Total DLP (Body) = 458 mGy-cm. COMPARISON: Chest x-ray ___ FINDINGS: The aorta is unremarkable without dissection or aneurysm. Great vessels are unremarkable. The pulmonary arteries are well opacified to the subsegmental level without filling defect to suggest pulmonary embolism. Pulmonary arteries are normal in caliber. Left sided central line noted. There is no evidence of pulmonary parenchymal abnormality. There is no pleural effusion or pneumothorax. The airways are patent to the subsegmental level. Heart is unremarkable. There is no pericardial effusion. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. Included portion of the thyroid is unremarkable. Included portion of the upper abdomen is unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. There is no fracture. Spondylosis of the thoracic spine. Metallic device located in the subcutaneous tissues of the left breast is visualized. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Chest pain, Dyspnea Diagnosed with Other chest pain, Gastrointestinal hemorrhage, unspecified temperature: 96.2 heartrate: 112.0 resprate: 16.0 o2sat: 100.0 sbp: 146.0 dbp: 107.0 level of pain: 9 level of acuity: 2.0

Dear Ms. ___, You came to the emergency room with chest pain and shortness of breath with exertion. You had a CT scan, which did not show any blood clot in your lungs. You also had an ultrasound of your heart that showed normal cardiac function. You were kept on the heart monitor, which did not show any strange heart rhythms. You had an episode of fast heart rate with exertion, your EKG was normal and your heart rate improved within minutes. You also reported significant symptoms of PTSD. You were seen by psychiatry as well as social work. You were started on Abilify and Prazosin. Your lisinopril was decreased, and your metoprolol was changed to once a day (long acting). It is very important that you follow up with your new primary care doctor and at the ___ violence prevention. We wish you all the best, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: codeine Attending: ___. Chief Complaint: Right parietal mass Major Surgical or Invasive Procedure: ___ Right stereotactic brain biopsy History of Present Illness: This is a ___ with newly diagnosed right parietal mass. Pt reports having intermittent headaches for a few months. Over the last 2 weeks she developed worsening left hand numbness and a right sided headache. She denies any F/C/CP/SOB/N/V/dizziness/light headedness/unsteady gait/LOC. She was seen by her PCP and ___ mass was found on imaging. She was sent here for further evaluation Past Medical History: hypothyroid, tachycardia, recent right oophrectomy and resection of benign uterine mass Social History: ___ Family History: Non-contributory Physical Exam: Exam on Admit ___: O: T: 99.3 BP: 114/62 HR: 76 R 14 98 O2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4 to 2 bilat EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech intact Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: face symmetric, 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, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On discharge: alert and oriented x 3 PERRL EOMI face symmetric MAE ___ strength Slight L drift Incision c/d/i Pertinent Results: ___ 08:25PM BLOOD WBC-8.7 RBC-5.09 Hgb-15.6 Hct-43.9 MCV-86 MCH-30.7 MCHC-35.6* RDW-12.8 Plt ___ ___ 08:25PM BLOOD Neuts-85.4* Lymphs-12.3* Monos-1.5* Eos-0.6 Baso-0.2 ___ 08:25PM BLOOD ___ PTT-30.1 ___ ___ 08:25PM BLOOD Glucose-141* UreaN-9 Creat-0.7 Na-141 K-3.6 Cl-103 HCO3-21* AnGap-21* ___ 07:00AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.___cm right parietal lobe mass with associated vasogenic edema. CHEST CT W/ CONTRAST (___) 1. A right upper paratracheal lymph node is mildly enlarged, 11 mm in diameter. 2. No evidence of intrathoracic metastatic disease. ___ CT Abdomen and pelvis: 4.8 cm complex right adnexal mass. Per history, the patient has had a recent right oophorectomy but this appearance is not consistent with a postoperative collection. Further evaluation with MRI is recommended. Radiology Report MR HEAD W & W/O CONTRAST Study Date of ___ 4:04 ___ IMPRESSION: 1. Two adjacent 2.9 and 1.8 cm enhancing masses in the right frontoparietal lobe with necrosis, blood products, areas of slowed diffusion consistent with dense cellularity, and marked surrounding vasogenic edema most consistent with a high-grade glioma. The 2.9 cm mass is predominantly within the right parietal lobe with some extension into the frontal lobe and the 1.8 cm mass also appears to bridge the frontal and parietal lobes. 2. Ill-defined foci of enhancement measure up to 7 mm within the deep white matter and cortex of the high right parasagittal parietal lobe. This appears to be parenchymal enhancement associated with the two dominant enhancing masses. Cardiovascular Report ECG Study Date of ___ 11:12:42 AM Sinus rhythm. Left axis deviation. Compared to the previous tracing of ___ no diagnostic change. Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 182 92 386/415 56 -32 61 Radiology Report MR HEAD W/ CONTRAST Study Date of ___ 7:30 AM IMPRESSION: Sterotactic frame in place. Two right frontoparietal heterogeneous enhancing masses with surrounding vasogenic edema, representing metastatic disease or primary tumor, are overall unchanged from the prior exam. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 11:38 AM IMPRESSION: Expected post-surgical changes following biopsy of right parietal lobe mass. Radiology Report MR PELVIS W&W/O CONTRAST Study Date of ___ 1:15 AM IMPRESSION: 1. Rounded mass arising from the right cervix, most likely an exophytic fibroid with degeneration. Please correlate with prior imaging to determine the stability of this lesion and if none are available, followup with pelvic ultrasound is recommended in 6 months. 2. Diverticulosis of the sigmoid. RECOMMENDATIONS: Correlation with prior imaging is recommended to determine the stability of this lesion appearing to arise from the right cervix and if none are available, followup with pelvic ultrasound is recommended in 6 months. Medications on Admission: amitripytline, levothyroxine, nadolol, sertraline, simvastatin Discharge Medications: 1. Amitriptyline 10 mg PO QHS 2. Famotidine 20 mg PO BID RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 3. LeVETiracetam 500 mg PO BID RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Nadolol 40 mg PO DAILY 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth Q4-6 H PRN pain Disp #*60 Tablet Refills:*0 8. Sertraline 50 mg PO DAILY 9. Simvastatin 20 mg PO QPM 10. Dexamethasone 3 mg PO Q6H Duration: 48 Hours 3mgQ6x 2 days, 3mg Q8 x 2 days, 3mg Q12 x 2 days, 2mg Q12 ongoing RX *dexamethasone 1 mg 1 tablet(s) by mouth taper per instructions Disp #*90 Tablet Refills:*3 11. Lorazepam 0.5 mg PO Q12H:PRN anxiety RX *lorazepam 0.5 mg 1 tab by mouth Q12H PRN anxiety Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right parietal mass Right adnexal mass 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: ___ F new rt brain mass on CT // Pls eval for primary lesion. The patient reportedly had a recent right oophorectomy and resection of a benign uterine mass. 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: 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 surgically absent. 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. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding.. Appendix contains air, has normal caliber without evidence of fat stranding. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is minimal 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: 4.8 x 3.7 cm mass in the right adnexa has solid and cystic components (2:98). A normal uterus is not visualized. The left adnexa is unremarkable. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: 4.8 cm complex right adnexal mass. Per history, the patient has had a recent right oophorectomy but this appearance is not consistent with a postoperative collection. Further evaluation with MRI is recommended. 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 reviewed on PACS. Oral contrast was administered. MDCT images were obtained from the lung bases to the lesser trochanters after the administration of intravenous contrast. Coronal and sagittal reformations were prepared. DOSE: DLP: ___ MGy-cm (chest abdomen and pelvis. IV Contrast: 130 mL Omnipaque Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ F newly diagnosed parietal brain mass // eval mass TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 7cc 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: Noncontrast CT head ___ FINDINGS: There is a 2.6 x 2.9 x 2.6 cm (AP x TV x SI) enhancing intra-axial mass in the right frontoparietal lobe (series 13, image 14). Just laterally within the right frontoparietal lobe, there is a 1.1 x 1.7 x 1.8 cm enhancing intra-axial mass (series 13, image 14). Within the posterior parietal lobe, there are a few foci of ill-defined enhancement that appear to be within the deep white matter and cortex and measure up to 7 mm (series 14, image 92). Enhancing parts of the two largest masses demonstrate slowed diffusion consistent with dense cellularity. T1 hypointense, T2 hyperintense portions of the two largest masses demonstrate CSF signal on diffusion weighted images, consistent with necrosis or cystic change. There are blood products in the largest mass. There is extensive surrounding vasogenic edema throughout the right parietal, frontal, and temporal lobes. There is mass effect on the occipital horn of the right lateral ventricle but no midline shift or effacement of the cisterns. Major intravascular flow voids are preserved. There is normal patency of the major intracranial arteries and dural venous sinuses following contrast administration. Marrow signal is within normal limits. There is mild mucosal thickening of the ethmoid and left maxillary sinuses. There is a mucous retention cyst in the left posterior nasal cavity or sphenoid sinus. The mastoid air cells appear clear. There has been bilateral lens surgery. IMPRESSION: 1. Two adjacent 2.9 and 1.8 cm enhancing masses in the right frontoparietal lobe with necrosis, blood products, areas of slowed diffusion consistent with dense cellularity, and marked surrounding vasogenic edema most consistent with a high-grade glioma. The 2.9 cm mass is predominantly within the right parietal lobe with some extension into the frontal lobe and the 1.8 cm mass also appears to bridge the frontal and parietal lobes. 2. Ill-defined foci of enhancement measure up to 7 mm within the deep white matter and cortex of the high right parasagittal parietal lobe. This appears to be parenchymal enhancement associated with the two dominant enhancing masses. Radiology Report EXAMINATION: Chest CT INDICATION: Ambulation of the patient with brain lesion 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: None. FINDINGS: Aorta and pulmonary arteries. Assessment demonstrate normal pattern of enhancement and atherosclerotic disease of the aorta, mild. A right upper paratracheal lymph node is mildly enlarged, 11 mm in diameter. No hilar or sub- carinal or axillary lymphadenopathy is present. Heart size is normal. There is no pericardial pleural effusion. Image portion of the upper abdomen reveals no appreciable abnormality Airways are patent to the subsegmental level bilaterally. Bilateral apical opacities most likely represent areas of scarring. Centrilobular nodules are noted bilaterally, diffuse and might represent respiratory bronchiolitis or airway infection/ inflammation unrelated to smoking. No discrete masses noted. Interstitial fibrosis, focal a adjacent to the right spinal osteophyte is present, chronic. No interstitial lung disease is demonstrated. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. IMPRESSION: No evidence of intrathoracic metastatic disease. For assessment of the upper abdomen please review CT abdomen and the corresponding report. The only abnormality detected is mildly enlarged right paratracheal lymph node that should be reassessed in 3 months for documentation of stability. Radiology Report EXAMINATION: MR HEAD W/ CONTRAST INDICATION: ___ year old woman with right parietal brain mass. TECHNIQUE: After administration of 70-cc of Gadavist intravenous contrast, axial imaging was performed with MPRAGE and T1 technique. MPRAGE images were re-formatted in sagittal and coronal orientations. COMPARISON: MR head dated ___. FINDINGS: The sterotactic frame is in place. Two right frontoparietal intra-axial enhancing heterogeneous masses are again demonstrated and overall unchanged in appearance, the more medial, larger mass measures 2.6 x 2.8 cm and the smaller adjacent one measures 1.9 x 1.7 cm. The larger mass has some blood products as demonstrated before. Surrounding vasogenic edema is also grossly unchanged involving the right parietal, frontal, and temporal lobes. Mass effect on the occipital horn of the right lateral ventricle persists and is grossly unchanged. There is no midline shift. The cisterns are patent. Small vessel ischemic diseases are seen in the white matter. IMPRESSION: Sterotactic frame in place. Two right frontoparietal heterogeneous enhancing masses with surrounding vasogenic edema, representing metastatic disease or primary tumor, are overall unchanged from the prior exam. Radiology Report EXAMINATION: MR PELVIS WANDW/O CONTRAST INDICATION: ___ year old woman with history of uterine mass resection now with right-sided adnexal mass. // Further assessment of adnexal mass. TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the pelvis were obtained on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during, and after the administration of 7 mL Gadavist gadolinium based contrast. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: The patient appears to be status post supracervical hysterectomy. Neither ovary is clearly identified. Nabothian cysts are seen in the cervix. 4.8 x 3.5 x 3.3 cm well-defined rounded mass arising from the right aspect of cervix is seen (04:23). The rim of the mass is isointense to hypointense on T2WI and is enhancing. There are internal T2 hyperintense nonenhancing components, consistent with cystic spaces (5:5, 101:40) as well as enhancing internal septations. There are no blood products. There is no nodular enhancement. There is tiny amount of free fluid in the pelvis. The partially distended bladder is grossly unremarkable. There is diverticulosis in the sigmoid colon, without signs of diverticulitis. There is no significant pelvic or inguinal lymphadenopathy. The osseous structures are unremarkable. IMPRESSION: 1. Rounded mass arising from the right cervix, most likely an exophytic fibroid with degeneration. Please correlate with prior imaging to determine the stability of this lesion and if none are available, followup with pelvic ultrasound is recommended in 6 months. 2. Diverticulosis of the sigmoid. RECOMMENDATIONS: Correlation with prior imaging is recommended to determine the stability of this lesion appearing to arise from the right cervix and if none are available, followup with pelvic ultrasound is recommended in 6 months. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old female status-post brain biopsy of a right parietal lobe mass. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: DLP: 922 mGy-cm CTDI: 53 mGy COMPARISON: MR head from ___. FINDINGS: Study is limited by motion artifact. Expected post-biopsy changes with pneumocephalus and subcutaneous emphysema. Two right parietal masses are again demonstrated, better characterized on MR. ___ extensive vasogenic edema is unchanged. Mass effect from the largest right parietal mass is unchanged. The overall configuration and size of the ventricles is unchanged from the prior MR. ___ cisterns are patent. The partially visualized paranasal sinuses, mastoid air cells, and middle ear cavities are grossly clear. The orbits are unremarkable. IMPRESSION: Expected post-surgical changes following biopsy of right parietal lobe mass. NOTIFICATION: The findings were conveyed by Dr. ___ with Dr. ___ ___ from the referring neurosurgery team via text page on ___ at 12:04 ___, 1 minutes after discovery of the findings. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Headache Diagnosed with BRAIN CONDITION NOS, SKIN SENSATION DISTURB temperature: 98.1 heartrate: 62.0 resprate: 18.0 o2sat: 99.0 sbp: 146.0 dbp: 67.0 level of pain: 4 level of acuity: 2.0

Surgery •You underwent surgery to remove a brain lesion from your brain. ••Please keep your incision dry for 10 days after surgery. You have dissolvable suture in place and will not need suture removal •You may shower at this time but keep your incision dry. •It is best to keep your incision open to air but it is ok to cover it when outside. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •***You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. ••You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may experience headaches and incisional pain. •You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. •You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. •Feeling more tired or restlessness is also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine / Penicillins Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ Laparoscopic Cholecystectomy History of Present Illness: ___ F w/ 18 hrs of abdominal pain prior to presentation. The patient states that she had abrupt onset abdominal pain starting the evening prior to presentation. She has not had any nausea/vomiting. She has a history of GERD, but states that this feels significantly different than her previous GERD symptoms. She had one episode of vomiting, no fevers/chills. She has never had any previous biliary disease. Past Medical History: HL, Hepatitis (unknown type), Narrow angle glaucoma Social History: ___ Family History: Noncontributory. No malignancy Physical Exam: Vitals: 99.7 80 124/74 16 100RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, Tender RUQ/Midepigastric, no guarding or rebound Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 09:06AM LACTATE-2.5* ___ 08:56AM GLUCOSE-123* UREA N-16 CREAT-0.8 SODIUM-140 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17 ___ 08:56AM estGFR-Using this ___ 08:56AM ALT(SGPT)-138* AST(SGOT)-175* ALK PHOS-97 TOT BILI-0.9 ___ 08:56AM LIPASE-2965* ___ 08:56AM ALBUMIN-4.1 ___ 08:56AM ALBUMIN-4.1 ___ 08:56AM WBC-18.5*# RBC-4.76 HGB-14.8 HCT-44.3 MCV-93 MCH-31.0 MCHC-33.3 RDW-13.6 ___ 08:56AM NEUTS-91.1* LYMPHS-4.3* MONOS-4.2 EOS-0.4 BASOS-0.1 ___ 08:56AM PLT COUNT-257 ___ 08:56AM ___ PTT-26.2 ___ ___ 08:30AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 08:30AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-1 ___ 08:30AM URINE MUCOUS-RARE Medications on Admission: PPI, Halcion 0.25 mg qd, HCTZ 25 mg qd Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 650 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills:*0 2. Famotidine 20 mg PO DAILY RX *famotidine [Heartburn Relief] 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills:*0 4. Hydrochlorothiazide 25 mg PO DAILY PRN edema RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 5. TRIAzolam 0.25 mg PO HS PRN insomnia 6. Multivitamins 1 TAB PO DAILY 7. Calcium Carbonate 500 mg PO DAILY RX *calcium carbonate [Antacid] 200 mg calcium (500 mg) 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Gallstone pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Chest pain and epigastric pain. TECHNIQUE: Frontal lateral views of the chest. COMPARISON: None. FINDINGS: There is mild left base atelectasis. No focal consolidation is seen. There is no large pleural effusion. No pneumothorax is seen. Minimal biapical pleural parenchymal thickening is seen. The aorta is somewhat tortuous. The cardiac silhouette is not enlarged. No evidence of free air is seen beneath the diaphragms. IMPRESSION: Minimal left base atelectasis. No focal consolidation. No evidence of free air beneath the diaphragms. Radiology Report HISTORY: Right upper quadrant epigastric pain. Tender to palpation and epigastric region and vomiting. Question cholecystitis. TECHNIQUE: Grayscale and Doppler ultrasound images of the abdomen were obtained. COMPARISON: None available. FINDINGS: The liver shows no evidence of focal lesions or textural abnormality. There is no evidence of intra or extrahepatic biliary dilatation and the common bile duct measures 4 mm. The gallbladder demonstrates sludge and small stones measuring up to 3 mm. There is no gallbladder wall thickening or pericholecystic fluid. The pancreas is unremarkable without evidence of focal lesions or pancreatic duct dilatation. The spleen measures 7.8 cm and has a homogeneous echotexture. The right and left kidneys are normal without masses, hydronephrosis or stones. The right kidney measures 10.4 cm and the left kidney measures 8.9 cm. The aorta is of normal caliber throughout. The visualized portion of the inferior vena cava appears normal. IMPRESSION: Cholelithiasis and gallbladder sludge with no evidence of acute cholecystitis. Radiology Report HISTORY: Gallstone pancreatitis. Evaluate for CBD stone. TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5T magnet including dynamic 3D imaging obtained prior to, during and after the uneventful intravenous administration of 5 mL of Gadavist. The patient also received 2.5 mL of Gadavist diluted with water p.o. FINDINGS: Pericholecystic fluid is noted surrounding the gallbladder and there are multiple gallstones within the gallbladder. The gallbladder wall is not thickened and enhances normally post-contrast. There is cystic change and thickening of the fundus of the gallbladder consistent with adenomyomatosis (sequence 9 image 28). No intra or extrahepatic duct dilatation. No filling defects within the biliary tree. The pancreas is normal in signal intensity and enhances normally post-contrast. No peripancreatic fat stranding. Within segment VII of the liver, there is a peripheral area of wedge-shaped enhancement on the arterial phase which appears to be surrounding a small cyst (sequence 16 image 6). The enhancement does not persist on the portal venous or delayed phase. No diffusion abnormality is demonstrated within the liver. There are mutliple subcentimeter T2 hyperintense lesions in the liver which likely represent small cysts. The liver is otherwise unremarkable. The portal and hepatic veins are patent. The hepatic artery is patent with conventional hepatic arterial anatomy. There are multiple peripelvic and simple cysts within both kidneys, more marked on the left than the right. The kidneys are otherwise unremarkable. There are single renal arteries bilaterally. The adrenals and spleen are within normal limits. There is a 3.9 cm diverticulum arising from the third part of the duodenum and contains oral contrast within it (seq 16 im 60). The visualized small and large bowel is otherwise unremarkable. A 0.6 cm lymph node is noted at the porta hepatis (sequence 6 image 64). There is also a 0.5 cm lymph node adjacent to the falciform ligament (sequence 6 image 57). Bibasal atelectasis is noticed within the lung bases. There is scoliosis of the upper lumbar spine convex to the right. Bone marrow signal is normal. No destructive osseous lesions. IMPRESSION: 1. No evidence of CBD calculi or biliary obstruction. 2. Cholelithiasis. Pericholecystic fluid surrounding the gallbladder. No features suggestive of cholecystitis. 3. Adenomyomatosis at the gallbladder fundus. 4. Normal pancreas. No features suggestive of pancreatitis. 5. Peripheral enhancement within segment VII of the liver which likely represents a perfusion anomaly, although hepatitis is not outruled. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: EPIGASTRIC PAIN Diagnosed with ACUTE PANCREATITIS, CHOLELITHIASIS NOS temperature: 98.6 heartrate: 85.0 resprate: 16.0 o2sat: 98.0 sbp: 120.0 dbp: 66.0 level of pain: 5 level of acuity: 2.0

You have undergone surgery to have your gallbladder removed. Stones from your gallbladder were blocking the main duct from your pancreas and causing pancreatitis, a potentially dangerous condition. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. Don't lift more than ___ lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap.) You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Your incision may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next ___ months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of narcotic pain medication. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left-sided facial rash and altered mental status Major Surgical or Invasive Procedure: Lumbar puncture ___ Nasogastric tube placement History of Present Illness: CC: L eye discharge, rash HPI: ___ with hx of Graves' disease, htn, mild cognitive impairment, recent evaluation in ___ ED on ___ for headache and concern for zoster presenting with increased L eye discharge. History is obtained from review of OMR, discussion with pt's son ___ overnight and - to a limited extent - from pt, who is somewhat confused on arrival to the floor at 1 am. Son, ___, describes onset of significant headache ___, which initially responded to ibuprofen and Tylenol. Headache then became more pronounced on ___. Pt reported to ___ that he had developed terrible pain over the L sided of his face on ___ pm. Pt was initially seen in ___ for headache x6 days on ___. At that time, he apparently described ___ headache, sharp, without significant relief from Tylenol or advil. He denied F/C, N/V, visual changes, rash at that time. He was noted to have area of redness over L forehead, conjunctivitis of L eye, pain with L EOMI, and photophobia, without ear imvolvement. Fluoroscein exam at that time "no dendritic lesion." He was prescribed valacyclovir 1 gm PO q8h x7 days, and gabapentin 100 mg PO TID x3 days, and discharged back to ___. On ___, brother ___ noted increased eye involvement with thick yellow discharge from L eye, and bilateral eyelid edema; after discussion with RN at ___ by phone, decision was made to go to the ED for further care. Prior to presentation, pt was not reporting painful eye at rest. According to son ___, at no point did he describe visual changes, F/C. Rash was first noticed on arrival to the ED on ___. According to ___, pt has had progressive cognitive decline over the past 5 months. Increasingly, he has difficulty with time, calling sons in the middle of the night not realizing what time it is. He has always recognized all members of the family; on the day of presentation, son ___ noted markedly increased confusion, pt trying to eat a towel, said that someone was downstairs trying to buy crackers and cheese. ___ reports that he has never seen pt quite like that, although has noted significantly increased confusion over the past 5 months. In the ___ ED: VS 98.6, 78, 170/82, 96% RA Exam notable for copious purulent discharge from L eye, severe conjunctivitis, minimal discharge in R, early vesicular rash on V1/V2, concern for dendritic lesion on L eye, difficult to obtain exam Labs notable for - CBC: 7.7/14.0/42.6/235 - Lytes: ___ - UA: negative for UTI Consults: Ophthalmology - "Possible Herpes Zoster anterior uveitis and epithelial keratitis left eye. Slit lamp exam was deferred due to patient comfort/infirmity. On bedside exam, his injection and elevated IOP OS are consistent with HSV iritis. He had SPK that was dendritiform in the left eye, though without classic dendrite. However, he does have crusting of his RIGHT lower lid as well. This could be reactive discharge from both eyes, but primary team may consider other etiologies for his rash such as impetigo. From an ophthalmic perspective, we will treat him for HSV iritis and keratitis OS." Received: IVF Labetalol 5 mg IV Acyclovir 600 mg IV Tylenol ___ mg PO Metoprolol tartrate 25 mg Brimonidine tartrate 0.15% ophth 1 drop Cyclopentolate 1% 1 drop Erythromycin 0.5% ophth ointment 0.5 in On arrival to the floor, pt endorses pain over L eye. History obtained as above. ROS: Limited by AMS Past Medical History: Sciatica BPH s/p shaving and laser light therapy Memory loss Constipation EtOH use disorder Tinnitus - L ear, since age ___ Bilateral hearing loss Graves' disease - labs from ___ with hyperthyroidism, scan ___ with uniform uptake of 62%, consistent with Graves' disease, started on methimazole C. diff infection Social History: ___ Family History: Mother died in her ___ of a stroke. Father died in his ___ of a myocardial infarction. A brother died from a motor vehicle accident midlife. Physical Exam: ADMISSION: =========== VS: 97.4 AdultAxillary 203/105->170/80Manual 60 20 96 Ra GEN: elderly male lying in bed with facial rash, alert and interactive, comfortable, no acute distress HEENT: Pupils are dilated, symmetric, not responsive to light and accommodation after dilation in ED. Copious yellow discharge from L eye, scant yellow crusting over R eye. + L>R conjunctival injection. Erythema and edema with crusted, scaling rash surrounding L eye, with occasional crusted vesicle, in V1/V2 distribution. Oropharynx without lesion or exudate, moist mucus membranes, ears without lesions or apparent trauma LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops LUNGS: coarse breath sounds with occasional crackles at R base, otherwise clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, nontender, without rebounding or guarding, nondistended with normal active bowel sounds, no hepatomegaly appreciated EXTREMITIES: 1+ bilateral pitting edema, with R>L ___ erythema, warmth, scaling, WWP GU: no foley SKIN: Facial rash and scaling over RLE as above NEURO: Alert and interactive to person, "emergency room...." unable to name type or name of building, year is ___ Hard of hearing, able to state that he lives at ___, then perseverates on the specific address ___. Bilateral extraocular muscles intact with pain with L eye movement. Strength is ___ in UE and ___ bilaterally. PSYCH: normal mood and affect DISCHARGE: ========== 24 HR Data (last updated ___ @ 827) Temp: 97.9 (Tm 97.9), BP: 139/83, HR: 114 (88-114), RR: 18 (___), O2 sat: 94%, O2 delivery: RA GEN: Elderly male sleeping/lying almost flat in bed. Mild agitated distress. HEENT: No discharge from left eye. Left conjunctival injection decreased. Crusted rash surrounding left eye and face and scalp; underlying erythema is unchanged, but edema is decreasing. No vesicles noted. Scattered excoriations likely from sloughed skin/crust are scabbing. Oropharynx without lesion; but with unchanged significant thick mucous; moist mucus membranes. Left eye ~6 mm and minimally reactive, right eye not dilated and more reactive to light (ophthalmology states left eye changes are related to eye drops). Slight perioral blunting on left that improves with smile. CARDIOVASCULAR: Heart regular rate and rhythm. No murmur. Radial and DP pulses 2+. LUNGS: Bibasilar crackles, unchanged. GI: Abdomen is soft, nontender, nondistended, normal active bowel sounds EXTREMITIES: Trace bilateral pitting edema, unchanged. SKIN: Facial rash and scaling as above NEURO: Sleepy, but arousable for brief conversation. Oriented to person (doctor) and place (hospital). Strength not assessed due to increased agitation today. Patient raises both arms equally against gravity and moving both legs spontaneously. PSYCH: Pleasant. Pertinent Results: ADMISSION: ========== ___ 02:50PM BLOOD WBC-7.7 RBC-4.43* Hgb-14.0 Hct-42.6 MCV-96 MCH-31.6 MCHC-32.9 RDW-14.5 RDWSD-50.6* Plt ___ ___ 02:50PM BLOOD Neuts-69.9 Lymphs-12.6* Monos-15.2* Eos-1.3 Baso-0.6 Im ___ AbsNeut-5.38 AbsLymp-0.97* AbsMono-1.17* AbsEos-0.10 AbsBaso-0.05 ___ 02:50PM BLOOD Glucose-103* UreaN-23* Creat-1.0 Na-132* K-4.6 Cl-95* HCO3-24 AnGap-13 ___ 09:50PM BLOOD CK-MB-7 cTropnT-<0.01 ___ 06:50AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7 ___ 06:50AM BLOOD TSH-6.8* ___ 06:50AM BLOOD Free T4-0.9* DISCHARGE: ========== XXXXX UA (straight cath): tr blood, neg nit, 100 prot, neg ___, 3 RBCs, < 1 WBC UNa 154, Uosm 767 (before IVFs, it appears) CSF (___): TNC 4, 3 RBCs, 4% PMNs, 3% other, Tprot 152, Glu 57 HSV PCR CSF (___): pending Enterovirus CSF (___): pending CSF (___): 1+ PMNs, no organisms; Cx pending UCx (___): negative BCx (___): pending IMAGING: ======== LP (___): Report pending NCHCT (___): 1. No acute intracranial findings. No mass or mass effect. 2. Sequela from chronic small vessel disease bilaterally. TTE: Normal left ventricular wall thickness and biventricular cavity sizes and regional/ global systolic function. Mild pulmonary artery systolic hypertension. No prior TTE available for comparison. MRI Head: 1. No evidence of acute infarction, hemorrhage or intracranial mass. There is mild enhancement of the left trigeminal nerve within Meckel's cave, potentially reflective of herpes zoster. There is also suggestion of mild nonspecific dural thickening along the internal auditory canals, potentially representative of lumbar puncture sequela, although infectious process not entirely excluded. No other abnormal intracranial enhancement. 2. Extensive white matter changes in the cerebral hemispheres bilaterally and in the pons, likely sequela of chronic small vessel ischemic changes. Small punctate infarct in the left anterior corona radiata. 3. Additional findings described above. EEG: IMPRESSION: This is an abnormal continuous video-EEG monitoring study due to: 1. Intermittent runs of semi-rhythmic delta activity over the right central- temporal region, indicative of focal cerebral dysfunction, non-specific as to etiology. 2. Generalized slowing with rare broad based right>left triphasic waves, indicative of a moderate encephalopathy, which is nonspecific with regard to etiology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sertraline 100 mg PO DAILY 2. ValACYclovir 1000 mg PO Q8H 3. Gabapentin 100 mg PO TID 4. Metoprolol Tartrate 50 mg PO DAILY 5. MethIMAzole 7.5 mg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Align (Bifidobacterium infantis) 4 mg oral DAILY 8. Vitamin D ___ UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. niacinamide 500 mg oral BID 11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8H PRN Disp #*10 Tablet Refills:*0 2. Artificial Tears ___ DROP BOTH EYES Q4H RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1 %-0.3 % 1 application ophth twice a day Disp #*1 Tube Refills:*0 3. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID RX *erythromycin 5 mg/gram (0.5 %) 1 application left eye twice a day Refills:*0 4. LevETIRAcetam 500 mg PO Q12H RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 5. LORazepam 1 mg PO Q8H:PRN anxiety or agitation RX *lorazepam 1 mg 1 tablet(s) by mouth Q8H PRN Disp #*10 Tablet Refills:*0 6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q2H:PRN Moderate to severe pain RX *morphine concentrate 20 mg/mL ___ ml by mouth Q3H PRN Disp #*3 Syringe Refills:*0 7. Senna 8.6 mg PO BID:PRN Constipation RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth BID PRN Disp #*10 Tablet Refills:*0 8. Timolol Maleate 0.5% 1 DROP LEFT EYE BID RX *timolol maleate 0.5 % 1 drop ophth twice a day Refills:*0 9. ValACYclovir 1000 mg PO Q12H 10. MethIMAzole 7.5 mg PO DAILY 11. Metoprolol Tartrate 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Dysphagia Malnutrition Varicella zoster ophthalmicus and encephalitis Possible Seizure activity: trigger of CNS infection versus PRES. Acute metabolic encephalopathy: Multifactorial from VZV encephalitis, PRES, hospital/illness-related delirium, infection associated metabolic encephalopathy, hyponatremia, progressive or decompensated cognitive decline with probable dementia, malnutrition and deconditioning, delirium Ecoli urinary tract infection Hypertensive urgency SVT Acute renal failure: pre-renal azotemia Possible diastolic congestive heart failure Headache Hyponatremia, likely SIADH Hypovolemic hypernatremia Graves disease Depression Benign prostatic hyperplasia Discharge Condition: Mental Status: Confused - always. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old man with likely localized Zoster and AMS. Plan for LP.// Please eval for mass effect. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 11.2 s, 23.0 cm; CTDIvol = 51.9 mGy (Head) DLP = 1,198.3 mGy-cm. Total DLP (Head) = 1,198 mGy-cm. COMPARISON: CT ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Diffuse periventricular and subcortical white matter hypodensities are demonstrated bilaterally, consistent with sequela from chronic small vessel disease. Dense vascular atherosclerotic calcifications are seen in the carotid siphons and distal vertebral arteries. There is no evidence of fracture. There is fluid within the bilateral ethmoid air cells, 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: 1. No acute intracranial findings. No mass or mass effect. 2. Sequela from chronic small vessel disease bilaterally. Radiology Report EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE INDICATION: ___ year old man with Graves, HTN, mild cognitive impairment p/w c/f HSV encephalitis. Family requesting single attempt and bedside would be very difficult.// Would very much appreciate LP TECHNIQUE: After informed consent was obtained from the patient explaining the risks, benefits, and alternatives to the procedure, the patient was laid in prone position on the fluoroscopic table. A pre-procedure time-out was performed confirming the patient's identity, relevant history, procedure to be performed and labs. Puncture was performed at L4-5. Approximately 5 cc of 1% lidocaine was administered for local anesthesia. Under fluoroscopic guidance, a 20 gauge, 3.5 inch spinal needle was inserted into the thecal sac. There was good return of clear CSF. 14 mls of CSF were collected in 4 tubes and sent for requested analysis. COMPARISON: None. FINDINGS: 14 mls of CSF were collected in 4 tubes. The patient tolerated the procedure well. Upon completion of the procedure a small 2 x 3 cm hematoma at the site of the puncture was identified. Appropriate hemostasis was achieved with manual compression for 5 minutes. The site of the hematoma was supple and without evidence of hematoma reaccumulation. The extent of the hematoma was marked and a compression dressing was applied. IMPRESSION: 1. Successful lumbar puncture at L4-5 without complication. 2. Small hematoma at the site of the puncture with appropriate hemostasis achieved after manual compression for 5 minutes. The hematoma site was marked. Findings were discussed with Dr. ___ via telephone on ___ at 17:00 pm and instructions for postprocedure puncture site check within the next hour was requested. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man p/w facial rash and AMS.// Please eval for PNA COMPARISON: None FINDINGS: AP portable semi upright view of the chest. Patient's chin obscures the superior mediastinum and portions of the lung apices. Lung volumes are low. Allowing for limitations, the lungs appear clear. The heart appears mildly enlarged. No large effusion or definite pneumothorax. No signs of congestion or edema. Bony structures are intact IMPRESSION: No signs of pneumonia on this limited exam. Cardiomegaly. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with Graves, HTN, mild cog impairment p/w facial rash (? VZV), headaches, and encephalopathy.// Please evaluate for evidence of encephalitis. 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 head from ___ and ___. CTA of the head and neck from ___. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There is a tiny punctate focus of susceptibility artifact in the left inferior cerebellar hemisphere (series 6, image 2) which may be artifactual or represent a tiny microhemorrhage. There are extensive confluent periventricular T2/FLAIR hyperintensities in the cerebral hemispheres bilaterally and in the pons, nonspecific but suggestive of extensive chronic small vessel ischemic changes. There is a tiny old lacunar infarct in the left anterior corona radiata. There is abnormal enhancement of the left trigeminal nerve within Meckel's cave (series 1001, image 74), which may be reflective of clinical history herpes zoster. Correlation with affected side is recommended. There is also minimal dural thickening enhancement within the internal auditory canals, nonspecific, and could be reflective of recent lumbar puncture and intracranial hypotension. There is no other abnormal enhancement after contrast administration. There is diffuse generalized parenchymal volume loss, most likely age related. Prominence of the ventricular system and extra-axial CSF spaces is unchanged and consistent with the previously mentioned parenchymal volume loss. Major vascular flow voids appear preserved. Major dural venous sinuses are patent. There is mild mucosal thickening in the left frontal sinus and along the ethmoid air cells with a small mucosal retention cyst in the left maxillary sinus. The mastoid air cells appear clear. Note is made of bilateral lens replacement surgery. The orbits appear otherwise unremarkable. IMPRESSION: 1. No evidence of acute infarction, hemorrhage or intracranial mass. There is mild enhancement of the left trigeminal nerve within Meckel's cave, potentially reflective of herpes zoster. There is also suggestion of mild nonspecific dural thickening along the internal auditory canals, potentially representative of lumbar puncture sequela, although infectious process not entirely excluded. No other abnormal intracranial enhancement. 2. Extensive white matter changes in the cerebral hemispheres bilaterally and in the pons, likely sequela of chronic small vessel ischemic changes. Small punctate infarct in the left anterior corona radiata. 3. Additional findings described above. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old man with likely herpes encephalitis, new seizure activity// pls eval for new intracranial pathology, 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 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) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP = 940.0 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9 mGy-cm. 3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9 mGy-cm. 4) Stationary Acquisition 14.6 s, 0.2 cm; CTDIvol = 233.0 mGy (Head) DLP = 46.6 mGy-cm. 5) Spiral Acquisition 6.5 s, 42.4 cm; CTDIvol = 32.7 mGy (Head) DLP = 1,364.4 mGy-cm. 6) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. Total DLP (Head) = 3,212 mGy-cm. COMPARISON: CT head from ___ FINDINGS: CT HEAD WITHOUT CONTRAST: Initial noncontrast CT Head was limited by motion, and additional repeat CT was obtained after the CTA portion of the exam, which is slightly limited by presence of residual IV contrast in the vasculature. Allowing for these limitations, there is no evidence of obvious infarction,hemorrhage,edema,ormass. There are atherosclerotic changes along both carotid siphons and the bilateral intradural vertebral arteries. There are confluent periventricular hypodensities, nonspecific but unchanged and suggestive of chronic small vessel ischemic changes. There is generalized parenchymal volume loss. Prominence of the ventricular system and extra-axial CSF spaces is consistent with the previously mentioned parenchymal volume loss. There is mild mucosal thickening along the ethmoid air cells with a mucous retention cyst in the left maxillary sinus. The remainder of the paranasal sinuses is clear. The visualized portion of the mastoid air cells,and middle ear cavities are clear. Note is made of bilateral lens replacement surgery. The visualized portion of the orbits are unremarkable. CTA HEAD: There are severe atherosclerotic changes along both carotid siphons partly resulting in focal moderate stenosis especially along the paraclinoid right ICA. There are vessel wall irregularities along the anterior circulation vasculature, consistent with atherosclerotic disease. There appears to be severe vessel stenosis at the origin of the left anterior temporal artery (series 8, image 279). Short-segment atherosclerotic changes along both intradural vertebral arteries result in mild left and moderate right luminal narrowing. The vertebrobasilar junction is unremarkable. Mild vessel irregularities along the basilar artery most likely reflect atherosclerotic change but there is no high-grade stenosis. There are additional mild vessel wall irregularities along both PCAs but no high-grade stenosis or vessel occlusion. There is otherwise no evidence of vessel occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is a 3 vessel aortic arch with moderate atherosclerotic changes extending in to the origin of the great vessels and resulting in mild narrowing of the right subclavian, left common carotid and left subclavian arteries. There are atherosclerotic plaques at the origin of both vertebral arteries resulting in at least mild stenosis. There is some remodeling of the cervical portion of both vertebral arteries due to hypertrophic degenerative changes of the cervical spine. There are mixed atheromatous and atherosclerotic changes at the left carotid bifurcation resulting in less than 20% luminal narrowing by NASCET criteria and mild stenosis at the origin of the left external carotid artery. There are severe atherosclerotic changes at the right carotid bifurcation resulting in short segment 60-70% stenosis of the proximal right ICA and mild stenosis at the origin of the right external carotid artery. OTHER: There is gravity dependent atelectasis. No suspicious pulmonary nodules. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. Thin note is made of scalp edema. There is diffuse cutaneous thickening overlying the left face, potentially representing clinical suspicion herpes zoster. IMPRESSION: 1. The initial CT head is limited by motion and a repeat CT head is limited by the presence of IV contrast. Allowing for this limitation, there is no obvious acute infarction, hemorrhage or intracranial mass. 2. Diffuse periventricular hypodensities are nonspecific but unchanged and suggestive of chronic small vessel ischemic changes. 3. Focal 60-70% stenosis of the proximal right ICA and less than 20% focal stenosis at the origin of the left ICA. Mild stenosis at the origin of both external carotid arteries. 4. Severe stenosis at the origin of the left anterior temporal artery. Otherwise diffuse mild vessel irregularities throughout the intracranial vasculature without high-grade stenosis, occlusion or aneurysm formation. 5. Diffuse atherosclerotic changes of the cervical vasculature resulting in mild stenosis at the origin of the great vessels and bilateral vertebral arteries. No evidence of dissection. 6. Additional findings as described above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with encephalopathy with worsening mental status and increasing WBC. Please eval for infiltrate// Please evaluate for infiltrate. Please evaluate for infiltrate. IMPRESSION: Heart size is top-normal. Mediastinum is stable. There are parenchymal opacities, new in right middle lower lung concerning for pneumonia. Unchanged. No appreciable pleural effusion. No pneumothorax. RECOMMENDATION(S): Followup of the patient 4 weeks after completion of antibiotic therapy for documentation of resolution of right lung opacities. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with dysphagia s/p NG tube placement// Assess NG tube placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the nasogastric tube projects over the stomach. The lung bases demonstrate mild atelectasis. Air-filled loops of colon are seen over the upper abdomen. IMPRESSION: The tip of the nasogastric tube projects over the stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with dobhoff NG tube placement// Assess for appropriate placement. TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the Dobhoff projects over the stomach. There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. The thoracic aorta is noted to be tortuous. IMPRESSION: The tip of the Dobhoff projects over the stomach. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with dobhoff NG tube placement// Assess appropriate location/placement. Assess appropriate location/placement. IMPRESSION: Compared to chest radiographs ___ through ___. Feeding tube ends in the upper stomach, partially withdrawn from its location in the mid stomach yesterday. Lungs grossly clear. Heart size normal. No definite pleural abnormality. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Eye discharge, Herpes zoster Diagnosed with Zoster ocular disease, unspecified temperature: 98.6 heartrate: 78.0 resprate: 20.0 o2sat: 96.0 sbp: 170.0 dbp: 82.0 level of pain: 5 level of acuity: 3.0

Mr ___, It was a pleasure taking care of you while you were in the hospital. You were admitted with a rash and confusion and were found to have zoster ophthalmicus and encephalitis. You were treated with standard of care, but unfortunately have become weakened from the illness. We have maintained your comfort and will discharge you to a facility that can continue a comfort focused care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: ERCP ___ History of Present Illness: In brief, this patient is a ___ year old s/p DDLT ___ on cellcept and ___ with multiple recent hospitalization for fevers presenting with after a fever to 101.3. Pt reports developing fevers and fatigue at home ___, and subsequently presented to ___ ED. Pt was discharged from the ED after labs were found to be normal. Pt continued to have fevers at home, and ___ had a measured temp to 101.3. Pt denies URI sx, cough, SOB, abdominal pain, nausea, vomiting, diarrhea, skin lesions. In the ___ ED, pt was afebrile but slightly tachycardic at 103. Labs were notable for WBC 7, H/H 10.8/___.7, Tbili 0.4, AP 118, AST 45 (hemolyzed), Cr 1.8. CXR did not show evidence of PNA, and RUQ U/S showed no biliary dilatation or fluid collections, normal vasculature, and normal liver appearance. Pt was seen by hepatology in the ED, and per recommendations, pt was started on broad spectrum abc with Vanc and ___. This AM, pt's VS were 97.8 106/56 75 20 98%RA. Pt denies abdominal pain and fevers/chills. He reports only being tired, and would like to eat. Past Medical History: - Cholangitis c/b citrobacter bacteremia in ___ - Cryptogenic cirrhosis s/p transplant ___ - Hiatal hernia - GERD - Esophageal dismotility - Prostate cancer s/p prostatectomy and penile prosthesis - Depression - Chronic kidney disease with baseline creatinine 1.3-3.0 - History of pancreatic cyst (monitored with MRCP) - Hypertension - Hypertriglyceridemia Social History: ___ Family History: No family history of liver disease, diabetes, or premature CAD. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.8 106/56 75 20 98%RA General: elderly gentleman lying comfortably in bed in NAD HEENT: NC/AT. anicteric sclerae. conjunctiva pink. MMM, no erythema or exudates. No LAD CV: normal rate, regular rhythm. III/VI SEM at apex Lungs: CTAB Abdomen: soft, non-distended. surgical scars present. some tenderness to palpation in LLQ. no rebound/guarding. NABS Ext: wwp. trace edema in ___ b/l Neuro: CN II-XII intact, strength full throughout Skin: no rashes or other lesions noted DISCHARGE PHYSICAL EXAM: ======================== VS: 98 123/56 (106-134/60s-70s) 70s-90s 18 100% RA General: comfortable in NAD HEENT: anicteric sclerae. MMM CV: normal rate, regular rhythm. III/VI SEM at apex Lungs: CTAB Abdomen: soft, non-distended. surgical scars present. non-tender. no rebound/guarding. NABS Ext: wwp. no edema Neuro: A&Ox3. moving all extremities. Skin: no rashes Pertinent Results: ADMISSION LABS: =============== ___ 09:00PM BLOOD WBC-7.0 RBC-3.60* Hgb-10.8* Hct-31.7* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.2 Plt ___ ___ 09:00PM BLOOD Neuts-66.2 ___ Monos-6.3 Eos-4.2* Baso-0.3 ___ 09:00PM BLOOD ___ PTT-32.9 ___ ___ 09:00PM BLOOD Plt ___ ___ 09:00PM BLOOD Glucose-104* UreaN-31* Creat-1.8* Na-137 K-5.6* Cl-100 HCO3-24 AnGap-19 ___ 09:00PM BLOOD ALT-26 AST-45* AlkPhos-118 TotBili-0.3 ___ 09:00PM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.2 ___ 09:23PM BLOOD Lactate-1.2 DISCHARGE LABS: =============== ___ 06:26AM BLOOD WBC-4.5 RBC-3.59* Hgb-10.7* Hct-31.7* MCV-88 MCH-29.7 MCHC-33.6 RDW-14.0 Plt ___ ___ 06:26AM BLOOD Plt ___ ___ 06:26AM BLOOD ___ PTT-31.8 ___ ___ 06:26AM BLOOD Glucose-190* UreaN-25* Creat-1.6* Na-145 K-3.9 Cl-108 HCO3-25 AnGap-16 ___ 06:26AM BLOOD ALT-17 AST-19 AlkPhos-123 TotBili-0.2 ___ 06:26AM BLOOD Calcium-9.6 Phos-2.7 Mg-2.1 ___ 06:26AM BLOOD rapmycn-4.0* MICRO: ====== BLOOD CULTURE ___ - Pending URINE CULTURE ___ - Pending STUDIES: ======== Chest X-Ray PA and Lateral ___ FINDINGS: PA and lateral views of the chest provided demonstrate no focal consolidation, effusion or pneumothorax. The cardiomediastinal silhouette appears normal. Bony structures are intact. No free air below the right hemidiaphragm. A catheter is seen projecting over the mid abdomen in the lateral projection. IMPRESSION: No signs of pneumonia. RUQ Ultrasound ___ IMPRESSION: Normal appearance of the transplanted liver with normal hepatic vasculature. 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: The 3 previously placed plastic biliary stents (2 straight, 1 double pigtail) were found in good position at the major papilla. The plastic stents were removed using a snare. Evidence of a previous sphincterotomy was noted at the major papilla. Cannulation: Cannulation of the biliary duct was successful and deep with a balloon using a free-hand technique. Contrast medium was injected resulting in complete opacification. Fluoroscopic Interpretation of the Biliary Tree: Scout film revealed ___ previous biliary stents in place. The bile duct was deeply cannulated with the balloon. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. The previous seen smooth stricture of benign appearance at the biliary anastamosis was significantly improved. A very slight narrowing remained but there was excellent flow of contrast and minimal resistance to passage of the 12mm balloon. No filling defects were identified. The left and right hepatic ducts and IHD were normal. The biliary tree was swept with a 9-12mm balloon starting at the bifurcation. Two stones and a small amount of sludge was removed. Based on the drastic improvement in the anastamotic narrowing, no stent was replaced. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. Radiologic interpretation: I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. The total fluoroscopy time was 3.2mins. Impression: Scout film revealed ___ previous biliary stents in place. The 3 previously placed plastic biliary stents (2 straight, 1 double pigtail) were found in good position at the major papilla. The plastic stents were removed using a snare. Evidence of a previous sphincterotomy was noted at the major papilla. The bile duct was deeply cannulated with the balloon. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. The previous seen smooth stricture of benign appearance at the biliary anastamosis was significantly improved. A very slight narrowing remained but there was excellent flow of contrast and minimal resistance to passage of the 12mm balloon. No filling defects were identified. The left and right hepatic ducts and IHD were normal. The biliary tree was swept with a 9-12mm balloon starting at the bifurcation. Two stones and a small amount of sludge was removed. Based on the drastic improvement in the anastamotic narrowing, no stent was replaced. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fish Oil (Omega 3) 1000 mg PO BID 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. mycophenolate sodium 360 mg Oral BID 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Sirolimus 1.5 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 9. Ursodiol 300 mg PO BID 10. Mirtazapine 15 mg PO HS Discharge Medications: 1. Mirtazapine 15 mg PO HS 2. mycophenolate sodium 360 mg Oral BID 3. Sirolimus 1.5 mg PO DAILY 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 6. Ursodiol 300 mg PO BID 7. Fish Oil (Omega 3) 1000 mg PO BID 8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days take for 10 days. last day ___ RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*19 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES # cholangitis SECONDARY DIAGNOSIS: # status post liver transplant 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: Chest CT from ___ and a chest radiograph from ___. CLINICAL HISTORY: Fever, on immunosuppression after liver transplant, question pneumonia. FINDINGS: PA and lateral views of the chest provided demonstrate no focal consolidation, effusion or pneumothorax. The cardiomediastinal silhouette appears normal. Bony structures are intact. No free air below the right hemidiaphragm. A catheter is seen projecting over the mid abdomen in the lateral projection. IMPRESSION: No signs of pneumonia. Radiology Report HISTORY: Fever in a liver transplant patient. COMPARISON: Ultrasound from ___. FINDINGS: The liver is normal in size and echotexture. There is no focal liver lesion. The gallbladder is unremarkable and the biliary tree is normal. There is no ascites. The spleen has normal echotexture and measures 9.3 cm. The imaged portion of the abdominal aorta is normal. DOPPLER: Color Doppler and spectral waveform examination of the hepatic vasculature was performed. The main, right, and left portal veins are patent with hepatopetal flow and normal waveforms. Appropriate arterial waveforms are seen in the main hepatic artery, the right hepatic artery, and the left hepatic artery, with resistive indices of 0.50, 0.58, and 0.63, respectively. Appropriate flow is seen in the hepatic veins and inferior vena cava. The splenic vein and the visualized portion of the superior mesenteric vein are patent. IMPRESSION: Normal appearance of the transplanted liver with normal hepatic vasculature. Gender: M Race: PORTUGUESE Arrive by WALK IN Chief complaint: Fever Diagnosed with FEVER, UNSPECIFIED temperature: 99.6 heartrate: 103.0 resprate: 18.0 o2sat: 97.0 sbp: 125.0 dbp: 84.0 level of pain: 7 level of acuity: 3.0

Mr. ___, It was a pleasure taking care of you during your stay at ___. You presented after having fevers at home. There was concern for recurrent cholangitis, and you underwent ERCP to evaluate your biliary tract. In ERCP, your previous stents were noted to be blocked and were removed. You were initially treated with intravenous antibiotics which were switched to oral ciprofloxacin prior to discharge. Please take your medications as prescribed and follow up with your doctors as ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Lyrica Attending: ___. Chief Complaint: malaise, subjective fevers, abdominal pain Major Surgical or Invasive Procedure: Dilation and curettage History of Present Illness: ___ yo ___ s/p uncomplicated D&E at 16weeks on ___ for trisomy ___. She did well post-operatively with WNL pain and bleeding which quickly resolved. Yesterday she began to have malaise, body aches, subjective fevers and lower abdominal cramping pain. This pain has increased in severity overnight. Her discomfort began aftrer sexual intercourse yesterday. ROS: Denies dysuria, vaginal bleeding, vomiting, diarrhea, sick contacts, abdominal trauma Past Medical History: OBHx: ___, C/S 1005, cerclage ___, D&E x2 for TAB. -___: TAB x 2 D&E -___: "miscarriage" - pt states at "6 months", c/b GDMA -___: SVD, full term, ___, 6lbs 9 oz, no complications -___: classical C/S, delivered at 25 weeks, PPROM, Tyji, 1 lbs 8 oz -___: classical C/S, delivered at 25 weeks, cervical insufficiency, cerclage, states she had infection and emergency c/s, Cibreena, 1 lbs 5.8 oz. -___: TAB GynHx:hx of Chlamydia, HPV, trich; hx of abnl Paps. PMH: migraines, depression, anxiety, seasonal allergies. PSH: classical CSx2, cerclage x1, D&Ex2, thumb surgery, Family History: noncontributory Physical Exam: On initial evaluation: General: Appears uncomfortable Cardiac: RRR Pulm: CTA Back: No CVAT Abdomen: soft, TTP R and LLQ. +voluntary guarding SSE: normal external anatomy, pink vaginal mucosa, closed cervix with copious clear yellow discharge. BME: markedly tender uterus and adenexa. On day of discharge General: comfortable CV: RRR PULM: CTABL ABD: soft, NT, ND, fundus is firm No VB Pertinent Results: ___ 07:20PM BLOOD WBC-21.8*# RBC-4.02* Hgb-13.4 Hct-39.6 MCV-99* MCH-33.4* MCHC-33.8 RDW-13.1 Plt ___ ___ 08:40AM BLOOD WBC-5.1# RBC-3.68* Hgb-12.2 Hct-36.5 MCV-99* MCH-33.1* MCHC-33.5 RDW-12.6 Plt ___ ___ 03:00PM BLOOD WBC-6.5 RBC-3.81* Hgb-12.8 Hct-38.0 MCV-100* MCH-33.6* MCHC-33.7 RDW-12.7 Plt ___ ___ 06:15AM BLOOD WBC-7.9 RBC-3.21* Hgb-10.7* Hct-31.5* MCV-98 MCH-33.4* MCHC-34.1 RDW-12.5 Plt ___ ___ 07:20PM BLOOD Neuts-91.0* Lymphs-6.0* Monos-2.4 Eos-0.3 Baso-0.3 ___ 06:40AM BLOOD Neuts-85.1* Lymphs-10.6* Monos-3.5 Eos-0.6 Baso-0.2 ___ 08:40AM BLOOD Neuts-70.1* ___ Monos-5.8 Eos-0.6 Baso-0.9 ___ 07:20PM BLOOD ___ PTT-29.8 ___ ___ 08:40AM BLOOD Glucose-88 UreaN-8 Creat-0.7 Na-138 K-3.8 Cl-105 HCO3-24 AnGap-13 Radiology Report HISTORY: Lower abdominal pain status post abortion. COMPARISON: ___ intraoperative ultrasound FINDINGS: Transabdominal and transvaginal ultrasound exam were performed, the latter for better visualization of the endometrium and ovaries. The uterus measures 12.8 x 6.6 x 7.8 cm. A heterogeneous iso- to hypoechoic lesion measuring approximately 2.5 x 4.0 cm is seen within the endometrial canal with multiple anechoic spaces towards the fundus which demonstrate vascular flow in a somewhat serpiginous configuration. Doppler sonography of the area demonstrated elevated arterial systolic velocities up to 69 centimeters/second. Both ovaries are normal. There is no free fluid. IMPRESSION: Findings are concerning for vascularized retained products of conception versus an arterial venous malformation. If an intraoperative procedure is planned, recommend interventional radiology involvement for evaluation for possible embolization. Radiology Report INDICATION: ___ woman status post D&E on ___, now presents with acute onset lower abdominal cramping pain. The patient has diffuse tenderness over the fundus and adnexa on exam. The patient is afebrile, with an elevated white count of 22. COMPARISON: Pelvic ultrasound ___. TECHNIQUE: Multiplanar T1- and T2-weighted MR images of the pelvis were performed prior to and after uneventful intravenous administration of 8 mL of Gadovist. FINDINGS: The uterus is anteverted and mildly enlarged, measuring 14.0 x 7.0 x 8.8 cm. The endometrial cavity is distended by small amount of blood products, as well as enhancing soft tissue along the right lateral uterine body and fundus (2602:35), measuring approximately 3.5 x 1.9 cm, consistent with vascularized retained products of conception. No enlarged flow voids are seen within the myometrium to suggest an arteriovenous malformation. The adnexa are unremarkable, except for a 3-cm left ovarian follicular cyst. No pelvic lymphadenopathy or free fluid is seen. No pelvic abscess is seen. The imaged portion of liver, spleen, adrenal glands, kidneys and pancreas are unremarkable, except to note mild periportal edema as well as trace perihepatic/retroperitoneal edema, likely related to third spacing from fluid overload. No pathologic retroperitoneal or mesenteric lymphadenopathy is seen. The abdominal aorta is normal in caliber. The stomach, small and large bowel loops, including the appendix are normal. No marrow signal abnormality is evident. IMPRESSION: 1. Enhancing soft tissue along the right lateral uterine body and fundus, associatd with some blood products, consistent with retained products of conception. Lack of flow voids, makes AVM unlikely. 2. 3-cm left ovarian follicular cyst. 3. No evidence for acute appendicitis. 4. Periportal/retroperioneal edema likely relate to third spacing. Radiology Report HISTORY: ___ woman with likely retained products of conception status post D & E on ___. COMPARISON: ___ TECHNIQUE: Grayscale and color Doppler ultrasound images were performed. FINDINGS: Ultrasound guidance for D&C was performed. Blood and other debris is seen within the cavity at the end of the procedure. IMPRESSION: Ultrasound guidance for D&C. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ABDOMINAL PAIN OTHER SPECIED, FEVER, UNSPECIFIED temperature: 96.6 heartrate: 76.0 resprate: 18.0 o2sat: 100.0 sbp: 123.0 dbp: 59.0 level of pain: 10 level of acuity: 3.0

General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 weeks * No heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower. No bath tubs for 2 weeks. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide / Lipitor / Ultram Attending: ___. Chief Complaint: dizziness and fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of AAA, HTN, asymptomatic bradycardia, who presents s/p presyncope and fall. The pt states she was out shopping and got groceries. She brought them home and when she bent over to pick them up, she became dizzy and fell, striking of left face and L side. She denies LOC. She states she sat on the floor for 2minutes until her husband helped her get up. She denies HA, blurry vision, CP, SOB, weakness. She denies subsequent dizziness, but did develop a mild HA with facial pain. The pt has not suffered a fall in the past but has had occasional dizziness. Of note, she has chronically elevated BP and was started on Hydralazine 10mg TID in ___. This was increased to 20mg TID in ___ however she experienced increased dizziness and so was titrated back down to 10mg TID with improved symptoms. Per cards note she was supposed to stop atenolol however per pcp note she was told to continue. The pt states she thinks she's still taking this at present. Of note, the pt was also started on Pravastatin in ___, with a hx of myalgias in the past with simvastatin. The pt also endorses hx of bradycardia but states that it has always been asymptomatic. . In the ED, initial VS: 96.8 65 ___ FSG 108. The pt had ekg and labs without acute changes. u/a clean, CXR nl, pelvis XR nl, head CT nl, spine CT - degenerative changes, left knee XR - nl. tetanus updated. She was given acetaminophen 650mg and oxycodone 5mg x1. . Currently, the pt is 96 168/69 67 18 100%RA. She endorses some L facial pain, L sided breast and bony tenderness, but denies dizziness, HA, sob, blurry vision, weakness. . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, 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: - Hypertension - Hyperchloseterolemia - AAA - infra-renal 3.3cm - GERD - Left Renal Mass -> nodular enhancing solid/cystic left renal mass 16x13mm - Spinal stenosis -> with symptoms and signs of radicular compression with an MRI from ___ disclosing severe spinal stenosis at the L4-L5 level, grade 1 spondylolisthesis of L4 over L5, severe foraminal stenosis at L4-L5 and mild-to-moderate stenosis at L3-L4 - degenerative joint disease of ankles and knees secondary to severe mechanical alterations w/ Tricompartmental OA of left knee thyroid nodules . Cardiac Risk Factors: (-)Diabetes, (+) Dyslipidemia and Hypertension Social History: ___ Family History: mother died from childbirth father diabetes Physical ___: ON ADMISSION: VS - 96 168/69 67 18 100%RA. Orthostatic on standing with HR from 55 --> 90 GENERAL - L facial abrasion, periorbital swelling, but NAD, pleasant, A&Ox3 HEENT - left facial abrasion, periorbital swelling and tenderness, L forehead hematoma, PERRLA NECK - supple, no thyromegaly, no JVD, loud carotid bruits particularly on the right side LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - ___ systolic murmur ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 1+ ___ edema, L knee abrasionSKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout . AT DISCHARGE: VS - AF 96.6 BP 140-168/60-69 ___ 100% RA exam otherwise unchanged Pertinent Results: . CT HEAD ___: IMPRESSION: No evidence of injury. . CT C-spine:1. Moderate degenerative changes including spondylolisthesis at two sites which is mild and can very likely be attributed to background degenerative changes, although ligamentous injuries are difficult to entirely exclude by imaging. Clinical correlation is advised. 2. Heterogeneous thyroid including a dominant right lobe nodule. When clinically appropriate, evaluation with ultrasound is suggested. 3. Vascular calcifications. . L KNEE XRAY ___: IMPRESSION: No acute process. . Pelvic XR ___ There are mild degenerative changes at the femoroacetabular joints. Moderate degenerative changes are seen in the lower lumbar spine with a possible transitional vertebral body. Calcified uterine fibroids are seen . CXR ___ no cardiopulmonary abnormalities . - prior cath: normal epicardial coronary arteries; - ECHO ___: (LVEF 70%) There are focal calcifications in the aortic arch. minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen. mild pulmonary artery systolic hypertension. - Asymptomaptic, slowly growing infra-renal AAA measuring 48.1 mm (was 43 mm in ___ and ___ --> 45 mm in ___ --> 48 mm now). . UA ___ negative. . ADMISSION LABS: ___ 05:36PM BLOOD WBC-6.0 RBC-4.16* Hgb-11.4* Hct-35.6* MCV-86 MCH-27.4 MCHC-32.0 RDW-13.8 Plt ___ ___ 05:36PM BLOOD ___ PTT-32.4 ___ ___ 05:36PM BLOOD Glucose-88 UreaN-19 Creat-1.0 Na-141 K-3.6 Cl-105 HCO3-23 AnGap-17 ___ 06:57AM BLOOD Calcium-8.9 Phos-4.4# Mg-1.6 . DISCHARGE LABS: virtually unchanged Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily HYDRALAZINE - 10 mg Tablet - 1 Tablet(s) by mouth three times a day LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth daily OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 po Capsule(s) by mouth once a day PRAVASTATIN 20mg daily unclear if pt still taking amlodipine. pt believes she is, but in last PCP note indicates they are holding atenolol. . Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily Discharge Medications: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 10 days. Disp:*35 Tablet(s)* Refills:*0* 2. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO every six (6) hours as needed for pain for 10 days: Please use the tylenol first and then if you continue to have pain take oxycodone. Oxycodone can make you sleepy. Disp:*15 Capsule(s)* Refills:*0* 3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 4. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pre-syncope due to dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Can walk independently, but uses walker. Followup Instructions: ___ Radiology Report INDICATION: The patient with left knee pain. TECHNIQUE: Single frontal radiograph of the chest was obtained. COMPARISON: Chest CT from ___, frontal and lateral radiographs from ___. FINDINGS: The lungs are clear, the cardiomediastinal silhouette and hila are normal. There is atherosclerotic calcification of the aorta. No pneumonia, no pleural effusion and no pneumothorax. IMPRESSION: No acute cardiothoracic process. Radiology Report INDICATION: Patient after trip and fall, left knee pain. TECHNIQUE: Single frontal view of the pelvis was obtained. COMPARISON: There are no comparison studies available. FINDINGS: There are mild degenerative changes at the femoroacetabular joints. Moderate degenerative changes are seen in the lower lumbar spine with a possible transitional vertebral body. Calcified uterine fibroids are seen. IMPRESSION: No fracture. Radiology Report INDICATION: Patient after trip and fall, left knee pain. TECHNIQUE: Three views of the left knee joint were obtained. COMPARISON: Left knee joint from ___. FINDINGS: The patient is status post total left knee arthroplasty. There is no evidence of hardware loosening, bony or hardware fracture. No knee joint effusion. IMPRESSION: No acute process. Radiology Report HEAD CT HISTORY: Status post fall. Question head injury. COMPARISONS: None. TECHNIQUE: Non-contrast head CT. FINDINGS: There is no mass effect, hydrocephalus or shift of the normally midline structures. The ventricles, cisterns and sulci are unremarkable without effacement. Patchy calcifications are noted in each basal ganglia. A small focus of hypodensity in the anterior limb of the left internal capsule as well as more vague hypodensity along the more anterior part of the internal capsule suggests chronic small vessel ischemic disease, which is also apparent in periventricular regions of white matter posterior to the lateral ventricles in the parietal regions. Surrounding soft tissue structures are unremarkable. There is no evidence for fracture. Minimal polypoid thickening is noted along the floor of the left maxillary sinus. IMPRESSION: No evidence of injury. Radiology Report CT OF THE CERVICAL SPINE HISTORY: Status post fall with head and neck pain. COMPARISONS: None. TECHNIQUE: Multidetector CT images of the cervical spine were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. FINDNIGS: The entire thyroid appears heterogeneous including a dominant 18 mm diameter nodule in the right lobe which is hypodense. Calcifications are prominent along each carotid bulb. There are moderate degenerative changes throughout the cervical spine which can probably explain slight spondylolisthesis of C3 on C4 and C4 on C5. Specifically facet joint degenerative changes are prominent bilaterally from C2-C3 through C7-T1. At C7-T1 there is again mild spondylolisthesis. Particularly from C4-C5 through T1-T2 there are small marginal osteophytes and mild to moderately narrowed interspaces. Also from C3-C4, throughout the remaining part of the cervical spine and associated with facet and uncovertebral joint spurring, there is mild to moderate neural foraminal narrowing that appears most prominent at C4-C5. There is no evidence for fracture, dislocation or bone destruction. IMPRESSION: 1. Moderate degenerative changes including spondylolisthesis at two sites which is mild and can very likely be attributed to background degenerative changes, although ligamentous injuries are difficult to entirely exclude by imaging. Clinical correlation is advised. 2. Heterogeneous thyroid including a dominant right lobe nodule. When clinically appropriate, evaluation with ultrasound is suggested. 3. Vascular calcifications. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: S/P FALL Diagnosed with JOINT PAIN-SHLDER, HYPERTENSION NOS temperature: 96.8 heartrate: 65.0 resprate: 24.0 o2sat: 100.0 sbp: 203.0 dbp: 59.0 level of pain: 13 level of acuity: 2.0

It was a pleasure taking care of you during your recent hospitalization. You were admitted because you had dizziness and a fall. We found no evidence of broken bones on imaging. We evaluated your heart with an EKG and overnight monitoring and there was no evidence of abnormal rhythms. There was no evidence indicating you had a heart attack or stroke (CT also showed no bleeding in your head). We felt that the dizziness was because you had not been eating or drinking much that day in the setting of recent changes to your blood pressure medications. You had some changes in your heart rate and blood pressure that indicated you were dehydrated as well. You will follow up with your PCP to discuss this further. . We made the following CHANGES to your medications during this hospitalization: - STARTED tylenol. please take this for pain from fall injuries. - STARTED oxycodone. please take this if the tylenol is not enough to control pain, but it can make you sleepy so do not drive while taking this medication.

Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PODIATRY Allergies: Cipro / pain medication Attending: ___. Chief Complaint: L foot pain, N/V Major Surgical or Invasive Procedure: ___: Amputation left ___ digit, left foot debridement ___: Left foot debridement ___: Left foot debridement History of Present Illness: This is a ___ y/o woman with PMHx IDDM, PVD s/p multiple digital amputations, HTN, HLD presents with polyuria, polydypsia, nausea, and vomiting ___ weeks and left foot infection. She reports she stopped taking her insulin approximately 1 week ago. Complaining of CP, ___ SOB. Reports worsening foot discharge and pain starting about ___ weeks ago. Also has significant white thick vaginal discharge. Left foot with foul smell, draining purulent discharge from ___ toe. Clear wet gangrene. AAOx3 although seems somewhat altered/confused. Crying easily and anxious. In the ED, the patient's VS were 98 104 119/80 20 98% RA. Labs were notable for VBG: 7.32/___, INR 1.2, WBC 26.7 (84% PMNs), glucose 660, Lactate 2.7, alk phos 187, K 5.1, HCO3 13, Na 125, AG 29. Repeat labs pending. Insulin gtt was started at 8U/hr. She was given Vanc/Zosyn for wet gangrene of the lower extremities, and ondansetron for nausea. She got 2 L NS. Blood and urine cultures were drawn EKG with nsr. Foot films w/ read pending but w/ gas visible and foreign object on prelim read, CXR negative for acute cardiopulmonary process, LENIs negative for DVT. Vascular surgery was consulted, and recommended continuing abx, defer to podiatry since she has followed with them previously for toe amps of R foot. She was admitted to the MICU for HHS, wet gangrene, vaginal yeast infection. Past Medical History: --IDDM (does not have regular podiatry or ophtho follow-up) --HTN --HL --Right ___ toe amputation ___ ___ --Right ___ toe amputation ___ ___ --C-sections x2 (___) Social History: ___ Family History: Mother and father with DM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: BP 124/80, HR 100, RR 16, O2 99% on RA General- ill appearing but not in overt distress HEENT- ncat, extremely dry mucous membranes, ___ oral thrush, due to nausea did not examine throat/oropharynx Neck- hyperdynamic carotid pulsation. ___ JVD. CV- Tachycardic without murmurs rubs or gallops Lungs- CTAB. ___ wheezing or ronchi. ___ crackles. Abdomen- Soft, nontender, nondistended, NABS, ___ organomegaly GU- not examined—reportedly had thick white vaginal discharge Ext- ___ peripheral edema. The pedal (pt and dp) pulses are palpable b/l. Right foot s/p amputation of digits ___. Left foot with fifth metatarsal lesion on dorsal surface with exposed subcutaneous ___ visible bone. ___ frank discharge. Malodorous. Positive crepitus. Neuro- Alert and oriented times three. Moves all of her extremities with purpose. Follows commands appropriately. Strength is ___ in her upper and lower extremities bilaterally. ___ asterixis. DISCHARGE PHYSICAL EXAM: VSS, Afebrile Gen - AAOx3, NAD Cardio: RRR Pulm: CTA, ___ respiratory distress Abdomen: soft, NT, ND Ext: L foot TMA site skin edges are well opposed with minimal serosanguinous draiange. Sutures are intact. Plantar incision shows healthy granular tissue with minimal drainage. The flap appears well vascularized . The patient is in a bi-valve dorsiflexory cast. Pertinent Results: ADMISSION LABS ___ 03:50PM BLOOD WBC-26.7*# RBC-4.32 Hgb-12.2 Hct-40.0 MCV-93# MCH-28.2 MCHC-30.5* RDW-14.4 Plt ___ ___ 03:50PM BLOOD Neuts-84.9* Lymphs-11.7* Monos-2.9 Eos-0 Baso-0.5 ___ 03:50PM BLOOD ___ PTT-33.1 ___ ___ 03:50PM BLOOD Glucose-660* UreaN-33* Creat-1.9* Na-125* K-5.0 Cl-83* HCO3-13* AnGap-34* ___ 03:50PM BLOOD ALT-5 AST-9 AlkPhos-187* TotBili-0.5 ___ 03:50PM BLOOD Lipase-57 ___ 03:50PM BLOOD cTropnT-<0.01 ___ 09:40PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03:14AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03:50PM BLOOD Albumin-3.3* ___ 09:40PM BLOOD Calcium-8.0* Phos-1.4*# Mg-2.0 ___ 03:50PM BLOOD Osmolal-332* ___ 03:41PM BLOOD ___ Temp-36.6 pO2-34* pCO2-29* pH-7.32* calTCO2-16* Base XS--9 ___ 04:00PM BLOOD Glucose->500 Lactate-2.7* Na-131* K-5.1 Cl-93* calHCO3-14* ___ 09:54PM BLOOD freeCa-1.14 PERTINENT RESULTS: Final Report HISTORY: Bilateral gangrene. Evaluate for deep vein thrombosis. TECHNIQUE: Duplex Doppler examination was performed on both lower extremities. COMPARISON: None. FINDINGS: There is normal compression and augmentation of the common femoral, superficial femoral and popliteal veins bilaterally. There is normal flow and compression seen within the calf veins. Normal respiratory phasicity seen within the common femoral veins bilaterally. IMPRESSION: ___ deep vein thrombosis in the right or left lower extremity. The study and the report were reviewed by the staff radiologist. BILATERAL FOOT FILMS: ___. HISTORY: ___ female with bilateral gangrene. Question osteomyelitis. FINDINGS: RIGHT FOOT: AP, lateral and oblique views of the right footare compared to right foot films from ___. There is evidence of prior resections involving the second through fifth digits, similar compared to prior. There is ___ new focal area of osteolysis or periosteal reaction. There is mild soft tissue swelling without subcutaneous gas or radiopaque foreign body. Degenerative changes again seen at the hindfoot including unchanged configuration of the talus and calcaneus which are severely flattened and dysmorphic. LEFT FOOT: AP, lateral and oblique views of the left foot. ___ prior. There is a radiopaque foreign body measuring approximately 4 mm at the lateral plantar soft tissues overlying the proximal phalanx of the small toe on the left. There is subcutaneous gas locally and extending to the forefoot dorsally and on the plantar surface. There is ___ evidence of focal osteolysis. Joint spaces of the foot are unremarkable. Degenerative changes are seen in the hindfoot. Plantar and posterior calcaneal spurs are identified. IMPRESSION: 1. ___ change in the appearance of the right foot, with multiple amputations. 2. Radiopaque metallic foreign body in the left foot with subcutaneous gas as described above. ___ osseous changes, ___ radiographic evidence of osteomyelitis. BILATERAL LOWER EXTREMITY DOPPLERS ___ FINDINGS: There is normal compression and augmentation of the common femoral, superficial femoral and popliteal veins bilaterally. There is normal flow and compression seen within the calf veins. Normal respiratory phasicity seen within the common femoral veins bilaterally. IMPRESSION: ___ deep vein thrombosis in the right or left lower extremity. CXR ___ IMPRESSION: ___ acute cardiopulmonary process. ___ focal consolidation. Findings This study was compared to the prior study of ___. LEFT ATRIUM: Mild ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). Apically displaced papillary muscle (normal variant). ___ resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. ___ 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. ___ PS. Physiologic PR. PERICARDIUM: ___ pericardial effusion. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and ___ aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is ___ mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is ___ pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. ___ valvular pathology or pathologic flow identified. ___ 6:01 am STOOL CONSISTENCY: WATERY **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Final Report HISTORY: Left foot infection, status post amputation of digits two through five, now spiking fevers and elevated white count, ? abscess. TECHNIQUE: Imaging performed at 3 Tesla using an extremity coil. Routine protocol. Multiplanar images with and without contrast. LEFT ANKLE MRI WITHOUT CONTRAST: There is marrow edema and enhancement in the shaft of the fifth metatarsal, extending beyond the distal edge of these films. Small cysts and edema at the base of the first metatarsal medially is thought to reflect degenerative change. Otherwise, ___ significant marrow edema is identified. There is prominent diffuse edema and enhancement in the dorsal and flexor musculature extending into the mid foot, beyond the edge of these images. In addition, there is a large surgical defect along the plantar aspect of the foot. There is scattered subcutaneous edema. The tendons about the ankle are intact, allowing for mild tendinosis in the distal posterior tibial tendon and a small accessory navicular ossicle. There is trace tenosynovitis about the PTT, flexor digitorum, flexor hallucis, and peroneal tendons. There is mild degenerative signal in the distal Achilles tendon (7:13, 5:11), without discrete tear. There is trace fluid in the tibiotalar, subtalar, and talonavicular joints, without gross effusion. There is expansion and degenerative signal in the proximal plantar fascia, with a small inferior calcaneal spur. Following contrast enhancement, ___ evidence of osteomyelitis or abscess about the ankle is identified. ___ obvious abscess in the visualized portion of the mid foot. IMPRESSION: 1. ___ abscess or osteomyelitis is detected about the ankle. 2. Edema in the fifth metatarsal is nonspecific. While this could represent postoperative changes, the differential diagnosis does include osteomyelitis. This abnormality extends beyond the distal edge of these images. DISCHARGE LABS: Medications on Admission: ___: lantus 30 units HS, humalog ___ 81mg qd, lisinopril 5mg', pravastatin 40mg HS Discharge Medications: 1. Piperacillin-Tazobactam 4.5 g IV Q8H 2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush 3. Glargine 42 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Lisinopril 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Pravastatin 40 mg PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Wet gangrene, diabetic foot infection, left foot Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report HISTORY: Bilateral gangrene. Evaluate for deep vein thrombosis. TECHNIQUE: Duplex Doppler examination was performed on both lower extremities. COMPARISON: None. FINDINGS: There is normal compression and augmentation of the common femoral, superficial femoral and popliteal veins bilaterally. There is normal flow and compression seen within the calf veins. Normal respiratory phasicity seen within the common femoral veins bilaterally. IMPRESSION: No deep vein thrombosis in the right or left lower extremity. Radiology Report HISTORY: ___ female with diabetic ketoacidosis. COMPARISON: ___. FINDINGS: Single portable view of the chest. Relatively low lung volumes are seen. The lungs however are clear. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormality is detected. IMPRESSION: No acute cardiopulmonary process. No focal consolidation. Radiology Report BILATERAL FOOT FILMS: ___. HISTORY: ___ female with bilateral gangrene. Question osteomyelitis. FINDINGS: RIGHT FOOT: AP, lateral and oblique views of the right footare compared to right foot films from ___. There is evidence of prior resections involving the second through fifth digits, similar compared to prior. There is no new focal area of osteolysis or periosteal reaction. There is mild soft tissue swelling without subcutaneous gas or radiopaque foreign body. Degenerative changes again seen at the hindfoot including unchanged configuration of the talus and calcaneus which are severely flattened and dysmorphic. LEFT FOOT: AP, lateral and oblique views of the left foot. No prior. There is a radiopaque foreign body measuring approximately 4 mm at the lateral plantar soft tissues overlying the proximal phalanx of the small toe on the left. There is subcutaneous gas locally and extending to the forefoot dorsally and on the plantar surface. There is no evidence of focal osteolysis. Joint spaces of the foot are unremarkable. Degenerative changes are seen in the hindfoot. Plantar and posterior calcaneal spurs are identified. IMPRESSION: 1. No change in the appearance of the right foot, with multiple amputations. 2. Radiopaque metallic foreign body in the left foot with subcutaneous gas as described above. No osseous changes, no radiographic evidence of osteomyelitis. Findings were discussed with Dr. ___ the phone at 8:50 p.m. at the time of interpretation. Radiology Report HISTORY: Abscess and cellulitis left forefoot, status post amputation. TECHNIQUE: Left forefoot three views obtained portably. COMPARISON: Left foot radiographs from ___. Compared with that time, the patient has undergone amputation of the second through fifth rays, with successive resection of distal portions of the metatarsals, most extensive at the fifth metatarsal. Subcutaneous emphysema and skin defect are consistent with recent surgery. Some residual subcutaneous emphysema along the plantar aspect of the mid foot is also seen. Severe background osteopenia is noted. Allowing for the recent surgery, no area of focal osteolysis is detected. Degenerative changes of the mid foot and calcaneal enthesophytes again noted. Radiology Report HISTORY: Debridement. FINDINGS: In comparison with the study of ___, there has been apparent further debridement about the remaining portions of the second through fifth metatarsals. Further information can be gathered from the operative report. Radiology Report HISTORY: Foot debridement with fever. FINDINGS: Low lung volumes accentuate the transverse diameter of the heart. No radiographic evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Radiology Report MR EXAMINATION OF THE LEFT FOREFOOT WITH AND WITHOUT INTRAVENOUS CONTRAST HISTORY: Left foot infection. Status post amputation of the second through fifth toes. Multiple debridements. Rising white count. Evaluation for abscess. TECHNIQUE: Multisequence, multiplanar MR examination of the left foot was performed both pre- and post-intravenous administration of gadolinium. Sagittal post-contrast fat sat sequence was performed. COMPARISON: Radiographs of the left foot performed, ___. FINDINGS: There is a large open surgical defect within the lateral aspect of the left forefoot which contains packing material. There has been amputation of the second through fifth toes. There has also been partial resection of the distal third through fifth metatarsals. There is heterogeneous enhancing marrow edema within the distal aspect of the partially resected fifth metatarsal (8:4, 12:23, 100:24). There is trace edema within the distal aspect of the partially resected fourth metatarsal. There is subchondral cystic change within the base of the first metatarsal at the first tarsometatarsal joint (8:21), degenerative in etiology. There is minimal subchondral edema at the calcaneocuboid joint, also likely degenerative in etiology. There is prominent enhancing subcutaneous and muscular edema within the dorsal and plantar aspects of the foot without evidence of a fluid collection and / or abscess. There has been resection of a large amount of soft tissue from the lateral aspect of the left mid foot as well as the distal fourth and fifth metatarsals. IMPRESSION: 1. No MR evidence of an abscess within the left forefoot. 2. Findings suggestive of osteomyelitis superimposed upon post-surgical changes within the distal aspect of the partially resected fifth metatarsal. Trace edema is also present within the partially resected fourth metatarsal. 3. Prominent enhancing subcutaneous and muscular edema throughout the left forefoot, likely neuropathic in etiology, however an infectious etiology can not be excluded. 4. Large open surgical defect within the lateral aspect of the forefoot. 5. Degenerative joint disease of the calcaneocuboid and first tarsometatarsal joints. Findings discussed with ___ of the surgical team at 8:30 am on ___. Radiology Report HISTORY: Left foot infection, status post amputation of digits two through five, now spiking fevers and elevated white count, ? abscess. TECHNIQUE: Imaging performed at 3 Tesla using an extremity coil. Routine protocol. Multiplanar images with and without contrast. LEFT ANKLE MRI WITHOUT CONTRAST: There is marrow edema and enhancement in the shaft of the fifth metatarsal, extending beyond the distal edge of these films. Small cysts and edema at the base of the first metatarsal medially is thought to reflect degenerative change. Otherwise, no significant marrow edema is identified. There is prominent diffuse edema and enhancement in the dorsal and flexor musculature extending into the mid foot, beyond the edge of these images. In addition, there is a large surgical defect along the plantar aspect of the foot. There is scattered subcutaneous edema. The tendons about the ankle are intact, allowing for mild tendinosis in the distal posterior tibial tendon and a small accessory navicular ossicle. There is trace tenosynovitis about the PTT, flexor digitorum, flexor hallucis, and peroneal tendons. There is mild degenerative signal in the distal Achilles tendon (7:13, 5:11), without discrete tear. There is trace fluid in the tibiotalar, subtalar, and talonavicular joints, without gross effusion. There is expansion and degenerative signal in the proximal plantar fascia, with a small inferior calcaneal spur. Following contrast enhancement, no evidence of osteomyelitis or abscess about the ankle is identified. No obvious abscess in the visualized portion of the mid foot. IMPRESSION: 1. No abscess or osteomyelitis is detected about the ankle. 2. Edema in the fifth metatarsal is nonspecific. While this could represent postoperative changes, the differential diagnosis does include osteomyelitis. This abnormality extends beyond the distal edge of these images. Radiology Report PORTABLE AP CHEST X-RAY INDICATION: New PICC line. COMPARISON: ___ through ___. FINDINGS: New right-sided PICC line crosses the midline and goes into the mid left subclavian vein. Mild cardiac enlargement is unchanged. The lungs are otherwise clear. There is no pleural effusion or pneumothorax. CONCLUSION: Right-sided PICC line crosses the midline and ends in the left subclavian vein. This was discussed with ___, IV nurse, at the time of the finding at 9:30 a.m. Radiology Report PICC LINE EXCHANGE INDICATION: Malposition of indwelling PICC line. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Dr. ___ performed the procedure. TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling right arm PICC line which was in the left brachiocephalic vein, and subsequently into the SVC under fluoroscopic guidance. The old PICC line was then removed and a peel-away sheath was then placed over the guidewire. A new 4 ___ single-lumen PICC line measuring 43 cm in length was then placed through the peel-away sheath with its tip positioned in the 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. IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 4 ___ single-lumen PICC line. Final internal length is 43 cm, with the tip positioned in the SVC. The line is ready to use. Radiology Report AP CHEST, 8:36 A.M. ON ___ HISTORY: ___ woman with a new PICC line. IMPRESSION: AP chest compared to ___: Right PICC line has been withdrawn and repositioned now in the upper SVC. Moderate cardiomegaly stable. Lungs clear. No pleural abnormality. Radiology Report HISTORY: Resection. FINDINGS: In comparison with study of ___, there has been extensive resections with only portions of the metatarsals remaining. No acute abnormality is appreciated. Overlying cast somewhat obscures detail. Gender: F Race: OTHER Arrive by WALK IN Chief complaint: N/V Diagnosed with NAUSEA WITH VOMITING, DIABETES UNCOMPL ADULT temperature: 98.0 heartrate: 104.0 resprate: 20.0 o2sat: 98.0 sbp: 119.0 dbp: 80.0 level of pain: 8 level of acuity: 1.0

You were admitted to ___ on ___ with a significant left foot diabetic infection. You were initially admitted to the ICU for dangerously high blood sugar levels and sepsis. The ___ diabetes team helped to control your blood sugars while in the hospital. You were started on broad spectrum IV antibiotics. You were taken to the operating room several times to debride and remove the affected part of your foot. Once your blood sugars and labs normalized, you were transferred to the regular floor. Infectious disease helped to guide your antibiotics. You will be on an IV antibiotics for at least 3 more weeks. This medication will be given through your PICC line. Please keep your dressing clean, dry and intact. The dressing should be changed daily, and you should remain in the bivalve cast at all times remaining completly non-wieghtbearing to your left foot. Please keep all follow up appointments. Please resume all of your regular at-home medications and normal frequency and dosage except with the changes to your diabetic medication as thjis has been adjusted by the ___ Diabetes team. Again, you will be receiving IV antibiotics through your PICC line. If you notice any of the following, please call the office or return to the ER: Increased redness/swelling/drainage from foot/nausea/vomiting/fever >101/chills or any other concerning symptoms.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Gold Salts / Penicillins / Remicade / Erythromycin Base / myochristine / trazodone / naproxen Attending: ___. Chief Complaint: L elbow pain Major Surgical or Invasive Procedure: ___ ORIF left olecranon fx History of Present Illness: Ms. ___ is a ___ RHD-F w/ PMHx of RA s/p multiple joint replacements who was transferred from ___ after sustaining a left olecranon fracture after a mechanical fall yesterday. No HS or LOC. Isolated injury. No numbness or paresthesias. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: Community Acquired Pneumonia in ___ (RUL, sp cefpodoxime and azithro) Rheumatoid arthritis (dx'd ___ prior) Osteoarthritis Depression Cataracts Cerebral aneurysm, s/p removal ___ yrs ago Surg Hx: Cerebral aneurism removal ___ yrs ago s/p R THR s/p L shoulder arthroplasty s/p cerical facet injection Social History: ___ Family History: Father died of pneumonia in ___ Mother died of Lung Cancer at age ___. Physical Exam: PHYSICAL EXAMINATION in ADM: Vitals: 98 75 ___ 100%RA General: Well-appearing female in no acute distress. Left upper extremity: - Skin intact - Scattered ecchymosis and edema, palpable defect at the olecranon - Soft, non-tender arm and forearm - Full, painless ROM at wrist and digits. Unable to extend the elbow. - Fires EPL/FPL/DIO - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, WWP Bilateral lower extremity: - Skin intact - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM at hip, knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP PE in DC: AVSS NAD, A&Ox3 foley in place LUE:Incision well approximated. Fires EPL/FPL/FDP/FDS/EDC/DIO. SITLT radial/median/ulnar. 1+ radial pulse, wwp distally. Pertinent Results: n/p Medications on Admission: ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - Tylenol-Codeine #3 300 mg-30 mg tablet. ___ tablet(s) by mouth q4hr prn - (Prescribed by Other Provider) ACYCLOVIR - acyclovir 400 mg tablet. 1 tablet(s) by mouth bid for chronic suppression - (Prescribed by Other Provider) BUSPIRONE - buspirone 15 mg tablet. 3 tablet(s) by mouth qam, 1 q1pm, q6pm - (Prescribed by Other Provider) ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Vitamin D2 50,000 unit capsule. 1 capsule(s) by mouth q2 wks - (Prescribed by Other Provider) ESTROGEN - estrogen . 0.25mg patch - (Prescribed by Other Provider) GABAPENTIN - gabapentin 300 mg capsule. 3 capsule(s) by mouth three times a day - (Prescribed by Other Provider) HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 300 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) LEUCOVORIN CALCIUM - leucovorin calcium 5 mg tablet. 2 tablet(s) by mouth once a week - (Prescribed by Other Provider) LISINOPRIL - lisinopril 5 mg tablet. 1 tablet(s) by mouth - (Prescribed by Other Provider) METHOCARBAMOL - methocarbamol 750 mg tablet. 1 tablet(s) by mouth 2 tab qam, 2 tab at 1pm, 1 tab at 6pm - (Prescribed by Other Provider) METHOTREXATE SODIUM - methotrexate sodium 25 mg/mL injection solution. 25 mg sq once a week - (Prescribed by Other Provider) METHYLPHENIDATE - methylphenidate ER 10 mg tablet,extended release. 3 tablet(s) by mouth qam po - (Prescribed by Other Provider) METHYLPHENIDATE - methylphenidate 10 mg tablet. 1 tablet(s) by mouth 1pm daily po for add - (Prescribed by Other Provider) METHYLPREDNISOLONE - methylprednisolone 4 mg tablet. 1.5 tablet(s) by mouth once a day - (Prescribed by Other Provider) NABUMETONE - nabumetone 750 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) NORTRIPTYLINE - nortriptyline 10 mg capsule. 1 capsule(s) by mouth at bedtime - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet(s) by mouth tid prn - (Prescribed by Other Provider) OXYBUTYNIN CHLORIDE - oxybutynin chloride 5 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) POTASSIUM CHLORIDE [KLOR-CON M20] - Klor-Con M20 mEq tablet,extended release. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) SIMVASTATIN - simvastatin 5 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) TOCILIZUMAB [ACTEMRA] - Actemra 400 mg/20 mL (20 mg/mL) intravenous solution. 13 ml iv as needed for as directed - (Prescribed by Other Provider) TRETINOIN [RETIN-A] - Retin-A 0.025 % topical cream. Apply to affected areas qpm prn - (Prescribed by Other Provider) VENLAFAXINE - venlafaxine ER 150 mg capsule,extended release 24 hr. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth daily po as a preventative - (Prescribed by Other Provider) CALCIUM CARBONATE-VITAMIN D3 [CALTRATE 600 + D] - Caltrate 600 + D 600 mg (1,500 mg)-800 unit chewable tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) MULTIVITAMIN - multivitamin capsule. 1 capsule(s) by mouth once a day - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 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 0.4 ml QPM Disp #*30 Syringe Refills:*0 5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. Tamsulosin 0.4 mg PO QHS 8. Acyclovir 400 mg PO Q12H 9. Aspirin 81 mg PO DAILY 10. BusPIRone 15 mg PO QPM 11. BusPIRone 45 mg PO QAM 12. Gabapentin 900 mg PO TID 13. Hydrochlorothiazide 25 mg PO DAILY 14. Leucovorin Calcium 10 mg PO 1X/WEEK (WE) 15. Lisinopril 5 mg PO DAILY 16. Methylprednisolone 6 mg PO DAILY 17. Nabumetone 750 mg PO BID 18. Omeprazole 40 mg PO DAILY 19. Oxybutynin 5 mg PO BID 20. Simvastatin 5 mg PO QPM 21. Tretinoin 0.025% Cream 1 Appl TP QHS:PRN itching 22. Venlafaxine XR 150 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L olecranon fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT IN O.R. INDICATION: Left elbow fracture, ORIF TECHNIQUE: 5 spot fluoroscopic images obtained in the OR without radiologist present Fluoroscopy time: 7.4 seconds. COMPARISON: Left elbow radiographs ___. FINDINGS: The available images show steps related to open reduction internal fixation of an olecranon fracture. Alignment is improved when compared to the preoperative study. 2 percutaneous pins and cerclage wires transfix the fracture site. Please see the operative report for further details. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Arm fracture Diagnosed with Disp fx of olecran pro w/o intartic extn left ulna, init, Unspecified fall, initial encounter temperature: 98.0 heartrate: 75.0 resprate: 16.0 o2sat: 100.0 sbp: 110.0 dbp: 95.0 level of pain: 6 level of acuity: 3.0

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Non Weight Bearing & passive range of motion in all modes MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower with covering the area. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - please only wear your splint in sleeping or ambulation DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: LUE:: NWB, PROMAT in all modes sling only during sleeping or ambulation Treatments Frequency: OT, ___ & Rehab Foley care

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / amlodipine Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of HCV cirrhosis complicated by ___, s/p liver txp ___ on tacrolimus, chronic pancreatitis s/p Puestow procedure in ___, presents with epigastric abdominal pain radiating to the back as well as right upper quadrant abdominal pain for the past 2 days. Per ED record, "She has associated nausea without vomiting. Some loose stools but no diarrhea. No blood in the stool. No fevers. Mild headache. No chest pain or shortness of breath. She states this feels similar to her previous episodes of pancreatitis." In the ED, initial VS were: 99.7 60 107/83 16 100% RA Exam notable for: not documented Labs showed: 12.5 5.0 >-----< 142 37.4 ALT: 26 AP: 116 Tbili: 0.6 Alb: 4.7 AST: 24 Lip: 13 144 ___ -----------------< AGap=14 4.0 27 1.3 U/A: unremarkable Imaging showed: Abdominal U/S 1. Patent hepatic vasculature. 2. Common bile duct measures 7 mm, previously 9 mm. Patient received: ___ 23:06 IV Morphine Sulfate 4 mg ___ 23:06 IVF NS 1000 mL ___ 00:32 IV Morphine Sulfate 4 mg Hepatology was consulted in the ED. Recommendations: "Unclear of trigger for pancreatitis. lipase is not elevated but this may be because of chronic pancreatitis. -infectious work up -pain management -IV fluids -abdominal ultrasound -NPO for now" Transfer VS were: 00:57 5 98 75 144/78 16 96% RA On arrival to the floor, patient reports that on ___ night she started having a small amount of abdominal [pain. She reports she did not have a lot ot eat this AM, just had some tea and weight watchers meal (rice and oriental chicken.) She reports She had a throbbing pain in the middle of the abdomen associated with back pain and nausea. She denies vomiting. She reports some constipation feeling; she reports her last BM was this AM; denies blood in stool or dark black color though reports it looked like a light color. Denies sick contact, cough, dysuria. She reports the pain currently is ___. Reports some occasional pain under the L side of the chest/L breast which she reports she has not had previously; she reports that sometime this pain "comes and goes" and has been happening on and off for the last "few months". She reports it can come at rest but also occurs with activity. she reports she has not had this pain since the day prior to admission. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: - HCV cirrhosis - HCC - Chronic pancreatitis - GERD - Anxiety - Depression - Superficial thrombophlebitis - UE DVT - Lyme disease PSH: - OLT ___ - CCY - Appendectomy - Tonsillectomy - Breast reduction - Puestow procedure in ___, numerous ERCP in past, transduodenal minor papilla sphincteroplasty ___ Social History: ___ Family History: Father died of an MI at ___; alcoholic. Two brothers have coronary artery disease. Other brother died at age ___ of an arrhythmia. Mother with diabetes, asthma and COPD. Physical Exam: ADMISSION PHYSICAL EXAM: VS: ___ 98.5 PO 156 / 89 73 20 91 Ra General: Alert, pleaseant and in NAD. appears comfortable, talkative and able to provide full history HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. chest pain non reproducible on palpation of L chest wall Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, with midline and RUQ surgical scars, appears well healed. non-distended, bowel sounds hypoactive. no organomegaly, no rebound or guarding but tender to palpation most notably in RUQ and epigastrium. GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities DISCHARGE PHYSICAL EXAM Vitals: 98.6 PO 143 / 79 66 16 96 RA General: more alert and comfortable this morning, sitting upright in bed. nad. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: good effort. Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to light palpation in the epigastric and LUQ, non-distended, normoactive bowel sounds, no rebound tenderness or guarding, no HSM Ext: 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: =============== ___ 09:11PM BLOOD WBC-5.0 RBC-4.21 Hgb-12.5 Hct-37.4 MCV-89 MCH-29.7 MCHC-33.4 RDW-12.6 RDWSD-40.3 Plt ___ ___ 05:35AM BLOOD ___ PTT-32.1 ___ ___ 09:11PM BLOOD Glucose-86 UreaN-20 Creat-1.3* Na-144 K-4.0 Cl-103 HCO3-27 AnGap-14 ___ 09:11PM BLOOD ALT-26 AST-24 AlkPhos-116* TotBili-0.6 ___ 05:35AM BLOOD Albumin-4.5 Calcium-9.0 Phos-4.5 Mg-1.6 ___ 05:35AM BLOOD tacroFK-5.5 IMAGING: ======== MRCP ___ IMPRESSION: 1. No evidence of acute pancreatitis. 2. Unchanged mild central intrahepatic biliary ductal dilatation and common bile duct prominence which is likely related to post cholecystectomy state. 3. Additional findings as above. CXR ___ IMPRESSION: Lungs are low volume otherwise clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen KUB ___ IMPRESSION: Nonspecific gas pattern with an air-fluid level in the left mid abdomen, probably representing early ileus. No clear evidence of free intraperitoneal air noted. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Calcium Carbonate 500 mg PO TID 3. Citalopram 10 mg PO DAILY 4. Hyoscyamine 0.125 mg PO TID 5. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN throat burning 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Tacrolimus 1 mg PO Q12H 9. Vitamin D 800 UNIT PO DAILY 10. Carvedilol 25 mg PO BID 11. Esomeprazole 40 mg Other DAILY 12. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit oral TID Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe RX *oxycodone [Oxaydo] 5 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*14 Tablet Refills:*0 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 500 mg PO TID 5. Carvedilol 25 mg PO BID 6. Citalopram 10 mg PO DAILY 7. Esomeprazole 40 mg Other DAILY 8. Hyoscyamine 0.125 mg PO TID 9. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN throat burning 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID:PRN constipation 12. Tacrolimus 1 mg PO Q12H 13. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit oral TID 14. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ================== 1. Chronic Pancreatitis Secondary Diagnosis: =================== 1. s/p Liver Transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with abdominal pain ___ chronic pancreatitis, also back pain and chest pain// please evaluate for evidence of PNA, pulmonary edema, atelectasis TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Lungs are low volume otherwise clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen Radiology Report INDICATION: ___ year old woman with abdominal pain due to chronic pancreatitis, also back pain and chest pain. Please evaluate for evidence of ileus, free air. TECHNIQUE: Upright and supine abdominal radiograph. COMPARISON: CT from ___. Radiograph from ___. FINDINGS: There are scattered air-filled small and large bowel loops. Gas is noted in the rectosigmoid. There is an air-fluid level in the left mid abdomen projecting over the anastomosis. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. Surgical clips and suture material overlie the low abdomen and pelvis. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Nonspecific gas pattern with an air-fluid level in the left mid abdomen, probably representing early ileus. No clear evidence of free intraperitoneal air noted. Radiology Report EXAMINATION: MRI ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST. INDICATION: ___ year old woman with ___ s/p liver transplant on tacro and chronic pancreatitis s/p Puestow procedure. p/w severe n/v// evaluate for pancreatitis TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis were acquired in a 1.5 T magnet. Intravenous contrast: 6 mL Gadavist. COMPARISON: MRCP ___. CT torso ___. FINDINGS: Lower thorax: Mild right greater than left basilar atelectasis. No pleural effusions. Liver: Status post liver transplant. There is no focal hepatic lesion. No evidence of hepatic steatosis. Biliary: The gallbladder is surgically removed. Common bile duct measures 1 cm which is in keeping with post cholecystectomy state. Mild central intrahepatic biliary prominent is again likely related to post cholecystectomy state, unchanged. Pancreas: There is atrophy of the pancreas. This is unchanged from prior. The pancreatic duct is not dilated. No focal pancreatic lesion. There is no peripancreatic edema to suggest pancreatitis. Spleen: Spleen is intact measuring 12.1 cm. Tiny splenule. Adrenal Glands: Again demonstrated is nodule scarring adjacent to the lateral limb of the right adrenal gland. The left adrenal gland is normal Kidneys: No hydronephrosis or focal renal lesion. Gastrointestinal Tract: The bowel is normal caliber. Lymph Nodes: No adenopathy Vasculature: Aorta and IVC are normal caliber. Portal vein and hepatic veins are patent. Osseous and Soft Tissue Structures: No suspicious osseous lesion. IMPRESSION: 1. No evidence of acute pancreatitis. 2. Unchanged mild central intrahepatic biliary ductal dilatation and common bile duct prominence which is likely related to post cholecystectomy state. 3. Additional findings as above. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with Epigastric pain temperature: 99.7 heartrate: 60.0 resprate: 16.0 o2sat: 100.0 sbp: 107.0 dbp: 83.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, You came to ___ because you were having severe abdominal pain . Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team =================================== WHAT HAPPENED AT THE HOSPITAL? =================================== - You were found to have worsening pancreatitis, as your pain was consistent with your previous flares. - In addition, you had imaging of your abdomen called an MRCP, which did not show any evidence of acute pancreatitis. - You were given IV fluids, pain medications, and anti-nausea medications, and over a few days you started to improve symptomatically. - You were discharged back home and will follow up with your PCP. ================================================== WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL? ================================================== - Please continue to take all of your medications as prescribed - Please follow up with your PCP and GI doctor - Please contact us if you have any further abdominal pain, nausea, or vomiting, or any other symptom that concerns you

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: fall, question of syncope Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F h/o DM2, HTN, dementia, who presented with an unwitnessed fall under unclear circumstances at her assisted living facility. Patient reportedly fell at her facility on ___. Per her son she was not herself on ___ and needed help with dressing. Last night she was noted to be hyperglycemic to the 400s. This morning she was found after she fell on the floor with blood from her hand laceration. She was then taken to the ED for evaluation. . The patient reports feeling herself prior to admission. She does not remember falling. Denies pain and does not believe that she struck her head. Fall was unwitnessed. She denies chest pain, palpitations, urinary incontinence, tongue biting. No prior seizure history. Of note, patient had a recent admission in ___ for increasing confusion and difficult to control blood sugars (~ 500s). During that admission it was felt that her hyperglycemia was likely related to a dose decrease of her insulin regimen in setting of poor po intake, however prior to that admission, was having hyperglycemia. She was not found to have any infections; nl TSH, and AM cortisol wnl. She was evaluated by ___ who increased her lantus and her blood sugars improved. In the ED, initial VS 97.2 92 148/86 16 97% RA. CT of head/spine negative. CXR normal. EKG noted to have ST changes in inferior/lateral leads. Finger stick in the 400s and recevied 8 units of regular insulin. Labs notable for a gap of 18, ketones in urine. pH: 7.48. Noted to have a laceration on right ___ digit and evaluated by plastic surgery. Her neurovascular and range of motion were noted to be intact. Area was sutured and advised xeroform to distal aspect if some gapping observed. Recommended antibiotics for seven days. She was given 1 gram of cefazolin. Vs prior to transfer: 98.2 103 130/68 18 100% RA. Noted to be a heavy drinker. Currently, blood sugar is in 200s and patient would like to eat dinneer. She has no recollection of her events, however is requesting to drink vodka. Past Medical History: 1. Type 2 diabetes mellitus - The patient is followed by Dr. ___ at the ___. 2. Status post syncopal episodes/falls 3. Dementia (probable Alzheimer's type) 4. Osteoarthritis 5. Hypertension 6. Depression 7. Anorexia 8. Osteopenia PAST SURGICAL HISTORY: 1. Status post microdiscectomy - ___ 2. Status post left total knee replacement - ___ Social History: ___ Family History: Non-contributory Physical Exam: VS - Temp 98.6F, BP 144/60, HR 94, R 18, O2-sat 97% RA GENERAL - elderly female, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) RUE with laceration over R. ___ finger with dressing c/d/i. SKIN - no rashes or lesions NEURO - awake, A&Ox person, hospital, year but slow to respond. CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: admission labs ___ 09:50AM BLOOD WBC-11.8*# RBC-3.24* Hgb-10.4* Hct-32.1* MCV-99* MCH-32.0 MCHC-32.4 RDW-13.6 Plt ___ ___ 09:50AM BLOOD Neuts-92.6* Lymphs-4.7* Monos-2.5 Eos-0 Baso-0.1 ___ 05:45AM BLOOD ___ PTT-24.6* ___ ___ 09:50AM BLOOD Glucose-457* UreaN-33* Creat-0.9 Na-135 K-4.7 Cl-95* HCO3-22 AnGap-23* ___ 09:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:22PM BLOOD Type-ART pO2-77* pCO2-35 pH-7.48* calTCO2-27 Base XS-2 . other pertinent labs: ___ 09:50AM BLOOD cTropnT-<0.01 ___ 05:45AM BLOOD CK-MB-4 cTropnT-0.02* ___ 07:00AM BLOOD cTropnT-<0.01 ___ 12:36AM BLOOD CK(CPK)-104 ___ 05:45AM BLOOD LD(LDH)-153 CK(CPK)-95 TotBili-0.7 ___ 07:00AM BLOOD ALT-12 AST-18 AlkPhos-63 TotBili-0.5 ___ 05:45AM BLOOD Hapto-185 . discharge labs ___ 06:40AM BLOOD WBC-5.1 RBC-2.62* Hgb-8.1* Hct-25.6* MCV-98 MCH-30.8 MCHC-31.5 RDW-13.7 Plt ___ ___ 06:30AM BLOOD Glucose-133* UreaN-17 Creat-0.8 Na-141 K-4.1 Cl-103 HCO3-31 AnGap-11 ___ 06:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9 . urine ___ 10:46AM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:46AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . micro Blood Culture, Routine (Final ___: NO GROWTH. . studies ECG: ___: Sinus rhythm. Modest inferolateral ST-T wave changes that are non-specific. Compared to the previous tracing of ___, there is no significant diagnostic change. . CT head: IMPRESSION: No evidence of acute intracranial process. . CT Cspine without contrast: No evidence for acute fracture in the setting of unchanged severe degenerative changes of the cervical spine. . L. Knee - 3 views IMPRESSION: No evidence of acute process. Status post left total knee replacement. . R. hand xray: Degenerative changes and findings which may reflect prior inflammation or trauma involving the second and third metacarpophalangeal joints. Correlation with localizing findings is recommended, but there is no definite evidence for fracture. . CXR: IMPRESSION: No evidence of acute disease. New mild elevation of the left hemidiaphragm. Medications on Admission: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day. 8. insulin glargine 100 unit/mL Solution Sig: 7 units Subcutaneous at bedtime. 9. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 10 units Subcutaneous QAM. Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO twice a day. 6. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*7 Tablet(s)* Refills:*0* 10. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 11. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Fifteen (15) units Subcutaneous qAM. Discharge Disposition: Home With Service Facility: ___. Discharge Diagnosis: primary diagnosis: mechanical fall, hyperglycemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH HISTORY: Status post fall. Question fracture. COMPARISONS: Scout view from chest CT performed on ___. TECHNIQUE: Chest, AP supine. FINDINGS: The heart is normal in size. The aortic arch is calcified. The mediastinal and hilar contours appear unchanged. The lungs appear clear. There is no pleural effusion or pneumothorax. Mild relative elevation of the left hemidiaphragm compared to the right appears new. Prior fractures involve the posterior seventh and eighth ribs with callus appear incompletely united. IMPRESSION: No evidence of acute disease. New mild elevation of the left hemidiaphragm. Radiology Report RIGHT HAND RADIOGRAPHS HISTORY: Status post fall. Question fracture. COMPARISONS: None. TECHNIQUE: Left hand, three views. FINDINGS: Mild degenerative changes are noted at the first carpometacarpal joint. There are mild-to-moderate degenerative changes involving the first metacarpophalangeal and interphalangeal joints. The second through fifth proximal interphalangeal joints show mild degenerative changes and moderate degenerative change including prominent osteophytes are noted at the second through fifth distal interphalangeal joints. Degenerative changes are most prominent at the fifth. The second, fourth and fifth metacarpophalangeal joints are mildly narrowed. The third appears more severely narrowed with subluxation and subchondral sclerosis, both likely chronic. There are chronic-appearing erosive changes along the second and third metatarsal heads with corticated margins, with suggestion of remodeling of each head; this appearance may be consistent with remote prior trauma or possibly inflammation. The possibility of prior inflammatory arthropathy could be considered in the appropriate clinical setting, however. Vascular calcifications and demineralization are noted. IMPRESSION: Degenerative changes and findings which may reflect prior inflammation or trauma involving the second and third metacarpophalangeal joints. Correlation with localizing findings is recommended, but there is no definite evidence for fracture. Radiology Report RADIOGRAPHS OF THE LEFT KNEE HISTORY: Status post fall. Question fracture. COMPARISONS: ___. TECHNIQUE: Left knee, three views. FINDINGS: The patient is status post left total knee replacement. The femoral and tibial prostheses appear well-seated without evidence for hardware loosening. There is again a small osteophyte along the superior margin of the patella. There is no evidence for fracture, dislocation or bone destruction. Vascular calcifications are present. There has been no significant change. IMPRESSION: No evidence of acute process. Status post left total knee replacement. Radiology Report INDICATION: Fall, evaluate for fracture or intracranial injury. COMPARISONS: CT of the head ___. TECHNIQUE: Continuous axial images were obtained through the brain without the administration of IV contrast. Coronal, sagittal, and thin slice bone reconstructed images were provided and reviewed. FINDINGS: There is no acute hemorrhage, edema, or shift of the normally midline structures. No large territorial vascular infarction is seen. Prominence of the ventricles and sulci likely relates to age-related volume loss. White matter hypodensities, though nonspecific, are compatible with sequela of chronic small vessel disease. Gray-white matter differentiation is preserved. The basal cisterns remain patent. The visualized paranasal sinuses and mastoid air cells are well aerated. As previously mentioned, a bony projection seen in the left sphenoid sinus may represent an osteoma. There is no fracture. The lenses and globes are normal. IMPRESSION: No evidence of acute intracranial process. Radiology Report INDICATION: Fall, evaluate for fracture. COMPARISONS: CT of the cervical spine ___. TECHNIQUE: MDCT axial images were obtained through the cervical spine without the administration of IV contrast. Coronal, sagittal and thin section bone reformations were provided and reviewed. FINDINGS: There is no fracture. No prevertebral soft tissue swelling or malalignment is noted. Again seen are severe degenerative changes of the cervical spine marked by anterior osteophytosis and loss of disc height. This appears most severe at C4-5 through C6-7. At this level, there is mild canal stenosis, otherwise, the spinal canal is grossly patent. The visualized lung apices are unremarkable. The thyroid is normal. Vascular calcifications are seen at the carotid bifurcations. IMPRESSION: No evidence for acute fracture in the setting of unchanged severe degenerative changes of the cervical spine. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with SYNCOPE AND COLLAPSE, OPEN WOUND OF FINGER, ACC-CUTTING INSTRUM NEC, SENILE DEMENTIA UNCOMP temperature: 97.2 heartrate: 92.0 resprate: 16.0 o2sat: 97.0 sbp: 148.0 dbp: 86.0 level of pain: 13 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you while you were admitted to ___. You were admitted because you feel at home and were found to have a laceration on your right hand. Your hand was evaluated in the emergency department and stitches were placed. Your fall may have been mechanical in nature or due to dehydration and dizziness upon standing. Your heart was monitored overnight and you were given intravenous fluids for dehydration. Your blood sugars were also very high during admission and your insulin regimen was adjusted. The following changes have been made to your medication regimne. Please START taking - augmentin 875 mg twice daily for 6 more days - thiamine - folic acid . Please CHANGE your insulin regimen to lantus 15 units every evening novolog mix 70-30 15 units every morning . Please STOP taking lisinopril . Please take the rest of your medications as prescribed and follow up with your doctors as ___. You will need to have the stitches removed from your hand in 1 week.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cipro / lidocaine / morphine / Sulfa (Sulfonamide Antibiotics) / lisinopril Attending: ___. Major Surgical or Invasive Procedure: ___: Coronary angiography attach Pertinent Results: ADMISSION LABS =============== ___ 04:09PM NEUTS-65.6 LYMPHS-16.8* MONOS-12.0 EOS-4.7 BASOS-0.4 IM ___ AbsNeut-6.58* AbsLymp-1.69 AbsMono-1.20* AbsEos-0.47 AbsBaso-0.04 ___ 04:09PM WBC-10.0 RBC-3.85* HGB-11.9 HCT-37.4 MCV-97 MCH-30.9 MCHC-31.8* RDW-13.7 RDWSD-48.6* ___ 04:09PM ALBUMIN-4.1 ___ 04:09PM cTropnT-<0.01 ___ 04:09PM LIPASE-63* ___ 04:09PM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-94 TOT BILI-0.3 ___ 04:09PM GLUCOSE-95 UREA N-35* CREAT-1.6* SODIUM-139 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13 ___ 04:36PM ___ PTT-38.4* ___ ___ 04:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0 LEUK-MOD* ___ 04:46PM URINE RBC-3* WBC-7* BACTERIA-FEW* YEAST-NONE EPI-3 TRANS EPI-<1 ___ 08:05PM cTropnT-<0.01 DISCHARGE LABS =============== ___ 07:00AM BLOOD WBC-8.3 RBC-3.39* Hgb-10.5* Hct-33.0* MCV-97 MCH-31.0 MCHC-31.8* RDW-13.7 RDWSD-48.8* Plt ___ ___ 07:00AM BLOOD Glucose-101* UreaN-39* Creat-1.7* Na-139 K-5.2 Cl-96 HCO3-28 AnGap-15 ___ 07:00AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.5 OTHER PERTINENT LABS ===================== ___ 08:45AM BLOOD Triglyc-161* HDL-54 CHOL/HD-2.6 LDLcalc-52 PERTINENT IMAGING/REPORTS ========================== CHEST CT ___: 1. No evidence of pulmonary embolism or acute thoracic aortic abnormality. 2. Ill-defined, ground-glass opacity within the right upper lobe, measuring 1.3 cm, is nonspecific and could be infectious or inflammatory in etiology. 3. Multifocal areas of mucous plugging within the bilateral lower lobe airways. CORONARY ANGIOGRAPHY ___: • No angiographically apparent coronary artery disease. • Widely patent LAD stent. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 100 mg PO DAILY 2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Atorvastatin 40 mg PO QPM 6. Escitalopram Oxalate 10 mg PO DAILY 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Furosemide 80 mg PO DAILY 12. Pantoprazole 40 mg PO Q12H 13. Cyanocobalamin 500 mcg PO DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN belching, GI upset RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ ml by mouth four times a day Disp #*1 Bottle Refills:*0 2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 puff inh three times a day Disp #*3 Ampule Refills:*0 3. Amiodarone 100 mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Cyanocobalamin 500 mcg PO DAILY 8. Escitalopram Oxalate 10 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. Furosemide 80 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Levothyroxine Sodium 88 mcg PO DAILY 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Pantoprazole 40 mg PO Q12H 15. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES =================== # Chest pain # Chronic heart failure with preserved ejection fraction SECONDARY DIAGNOSES ==================== # Atrial fibrillation # Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with chest pressure // eval for acute pathology TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: None. FINDINGS: Heart size is mildly enlarged. The mediastinal and hilar contours are unremarkable apart from atherosclerotic calcifications at the aortic knob. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. Eventration of the right hemidiaphragm is incidentally noted. There are no acute osseous abnormalities. Mild degenerative changes are noted in the thoracic spine. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: History: ___ with chest pain and back pain // eval for aortic pathology 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 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP = 9.1 mGy-cm. 2) Spiral Acquisition 3.4 s, 27.1 cm; CTDIvol = 13.5 mGy (Body) DLP = 366.3 mGy-cm. Total DLP (Body) = 375 mGy-cm. COMPARISON: Chest x-ray ___. FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. Moderate coronary artery calcifications. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy. Right hilar lymph node is prominent, measuring up to 11 mm, and may be reactive. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: An ill-defined, ground-glass opacity within the right upper lobe measures 1.3 cm (3:36), nonspecific. Mild dependent atelectasis in both lower lobes. Multifocal areas of mucous plugging within the bilateral lower lobes and mild airway wall thickening. Otherwise, the central airways are patent to the level of the proximal bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: The study is not tailored for evaluation of the subdiaphragmatic structures. Within this limitation, a subcentimeter hypodensity within the spleen is too small to characterize. The remaining imaged upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or acute thoracic aortic abnormality. 2. Ill-defined, ground-glass opacity within the right upper lobe, measuring 1.3 cm, is nonspecific and could be infectious or inflammatory in etiology. 3. Multifocal areas of mucous plugging within the bilateral lower lobe airways. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with history of heart failure s/p cath for which she received pre hydration. Now worsening dyspnea and crackles on exam. // Pulmonary edema TECHNIQUE: Portable chest AP COMPARISON: Chest radiograph dated ___ chest CT dated ___ FINDINGS: Low lung volumes. Mild cardiomegaly, unchanged from prior. Minimal evidence of microvascular engorgement. No pleural effusion or pneumothorax. Redemonstration of eventration of the right hemidiaphragm. IMPRESSION: Minimal microvascular engorgement. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified temperature: 98.6 heartrate: 73.0 resprate: 18.0 o2sat: 96.0 sbp: 114.0 dbp: 67.0 level of pain: 10 level of acuity: 2.0

Dear ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You came to the hospital because you had worsening chest pain. - You had a catheterization planned as an outpatient because you had a posititve stress test that ended up being done while inpatient WHAT HAPPENED IN THE HOSPITAL? ============================== - You received treatment for your chest pain with blood thinners and nitroglycering while you waited for your procedure. - In order to protect your kidneys from the contrast used in the procedure we gave you IV fluids. - You had your catheterization which did not show any blockages in your coronary arteries. - After the procedure your shortness of breath was worse when walking to the bathroom. We thought that this was due to the extra fluid your received for the procedure and accumulated in your lungs. - We gave you extra doses of Lasix through the IV to help get rid of the extra fluid and your shortness of breath improved. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor ___ you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Mercaptopurine Analogues (Thiopurines) / Remicade / Humira / Cymarin / Dilaudid / Morphine / Erythromycin Base / Halothane / Mercaptopurine / ciprofloxacin / Zofran (as hydrochloride) Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ w/ PMH history of ulcerative colitis status post colectomy with ileal pouch anal anastomosis complicated by recurrent pouchitis (now on vedolizumab and budesonide), primary sclerosing cholangitis, recurrent peritoneal inclusion cysts (s/p ___ drainage ___, who presents with diffuse abdominal pain, constipation and decreased urinary output. Patient has a complicated history of chronic pelvic pain, with recurrent peritoneal inclusion cysts, s/p drainage by ___ several times in ___ and most recently in ___. Her sxs have only partially responded to these procedures and she usually has recurrence of these cysts. She also has a history of voiding dysfunction (seen by urology in ___, has had urodynamic studies) and the leading diagnosis is incomplete bladder emptying due to incomplete pelvic relaxation that improved with intermittent self catheterization and pelvic ___ in ___. Finally, regarding her UC, she is s/p colectomy with ileal-anal anastomosis and has had pouchitis episodes in the past. SHe sees Dr. ___, Dr. ___, Drs. ___ (GI), Dr. ___, and Dr. ___ at ___ (Liver). She reports right lower abdomen cramping and pressure that has essentially been present since the end of ___ but has acutely worsened over the past week. She was seen in clinic on ___ for this and on US found to have a left sided peritoneal inclusion cyst that was drained by ___ on ___. At that time a right sided ovarian cyst was also noted, for which she was referred to ___ clinic (Dr ___ and recommended for observation. Following seen she was again seen in the ED on ___ for abdominal pain and distenstion and was found to have a right adnexal cyst (possibly peritoneal inclusion cyst), small pelvic free fluid and fibroid uterus on CT. This was also confirmed on ultrasound. ED diagnosis was constipation although no significant burden was seen on imaging. She did not respond to disimpaction and enemas and was discharged on bowel regimen. She has been using oxycodone, ibuprofen for pain. Her LMP was ___. Since discharge from ED on ___, she has had only one small liquid BM over past 48 hours despite the bowel regimen, (normally has 5 BMs daily) and also has very poor urine output with frequent small voids and urinary urgency sxs. She denies any dysuria, fever, nausea, vomiting, headache. She denies chest pain, shortness of breath. Endorses non propductive cough and chills. She initially presented to ___ UC and was referred here. In the ED, initial VS were: 98.1 74 ___ 99% RA ED physical exam was recorded as: In no acute distress Abd with mild diffuse discomfort to palpation, voluntary guarding, no rebound. Mild distension POCUS with distended bladder, apparent pelvic adnexal cyst with ? loculations ED labs were notable for: lipase 73, otherwise all normal TVUS showed no significant change compared to 3 days prior. An anechoic right adnexal cyst measures up to 6.1 cm, possibly a peritoneal inclusion cyst. There is persistent free fluid the pelvis, portions with homogeneous internal echoes suggestive of proteinaceous content. The uterus is fibroid. She was given several doses of IV reglan, Ativan and NS. She declined a NGT. 400+ straw colored urine drained from straight cath of bladder. Surgery was consulted, did not feel there was a role for surgical intervention. Admitted to medicine given ongoing abd pain, nausea. Past Medical History: PAST MEDICAL HISTORY: - UC s/p total colectomy and ileal pouch-anal anastomosis (___) c/b recurrent pouchitis and intraabdmoinal abscess - PSC - SBO - Vit D deficiency - GERD - Hx of hip bursitis - Depression - Anxiety - Bipolar disorder (per patient) - PTSD - Eating disorder PSH: - ___ Total colectomy with ileoanal pouch and diverting ileostomy (c/b sepsis and abscess) - ___ Ileostomy takedown and reversal - Broken ankle surgery - Sinus surgery - Wisdom teeth extraction Social History: ___ Family History: - Father: Living ___. ___ disease, depression, IBS - Mother: ___, arthritis - MGF: HTN - Uncle: ___ Cancer Physical Exam: Admission Exam: Gen: appears uncomfortable, sleepy but arousable, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, diffusely tender to palpation with no rebound or guarding, worst in RLQ, ND, bowel sounds present. Multiple well healed scars seen MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: tearful, anxious Discharge Exam: Afebrile, aVSS Odd affect Appears overall well, encountered eating, ate entire ___ of breakfast Abdomen is soft, NT, ND, prior well healed surgical scars, ecchymoses from heparin injections ___ exam notable for bilateral ___ strength at major joints, full sensation bilaterally, normal reflexes. However, she at several times appeared to be volitionally avoiding lifting her leg as evidence by lack of contralateral downward force indicating lack of effort. When distracted she is able to lift leg off bed without difficulty. Gait is normal when she is not being observed though with observation she drags her left foot though has clear normal dorsiflexion Pertinent Results: Admission Labs: ___ 07:55PM GLUCOSE-82 UREA N-8 CREAT-0.6 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-21* ANION GAP-20 ___ 07:15PM URINE UCG-NEGATIVE ___ 07:15PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE EPI-8 ___ 08:06PM COMMENTS-GREEN TOP ___ 07:55PM LIPASE-73* ___ 07:15PM URINE MUCOUS-RARE Discharge Labs: None on day of discharge Reports: Pelvic US : No significant change compared to 3 days prior. 1. An anechoic right adnexal cyst measures up to 6.1 cm and may representa peritoneal inclusion cyst. 2. There is persistent free fluid the pelvis, portions with homogeneous internal echoes suggestive of proteinaceous content. Stable compared to prior examination 3. The uterus is fibroid. 4. Tubular structure in the left adnexa may represent a hydrosalpinx versus a small bowel loop although peristalsis was not observed during the examination MRI L-Spine: 1. Essentially unremarkable MR of the lumbar spine without evidence of spinal canal or neural foraminal narrowing. 2. A large right adnexal cyst is better described on prior CT abdomen and pelvis of ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Budesonide 9 mg PO DAILY 2. Cholestyramine 4 gm PO DAILY 3. Escitalopram Oxalate 5 mg PO DAILY 4. Famotidine 20 mg PO BID 5. Fludrocortisone Acetate 0.1 mg PO DAILY 6. HydrOXYzine 100 mg PO QHS 7. Multivitamins 1 TAB PO DAILY 8. Ursodiol 600 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Vancomycin Oral Liquid ___ mg PO/NG Q6H 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 12. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN headache 13. Diazepam 10 mg PO QHS 14. Fluticasone Propionate 110mcg 2 PUFF IH BID 15. olopatadine 0.1 % ophthalmic BID 16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY 17. Metadate CD (methylphenidate) 20 mg oral QAM 18. Methylphenidate SR 72 mg PO QAM 19. LORazepam 0.5 mg PO Q6H:PRN nausea 20. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild 21. Metoclopramide 5 mg PO Q8H nausea Discharge Medications: 1. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth Q6Hr Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 3. Budesonide 9 mg PO DAILY 4. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN headache 5. Cholestyramine 4 gm PO DAILY 6. Diazepam 10 mg PO QHS 7. Escitalopram Oxalate 5 mg PO DAILY 8. Famotidine 20 mg PO BID 9. Fludrocortisone Acetate 0.1 mg PO DAILY 10. Fluticasone Propionate 110mcg 2 PUFF IH BID 11. HydrOXYzine 100 mg PO QHS 12. LORazepam 0.5 mg PO Q6H:PRN nausea 13. Metadate CD (methylphenidate) 20 mg oral QAM 14. Methylphenidate SR 72 mg PO QAM 15. Metoclopramide 5 mg PO Q8H nausea 16. Multivitamins 1 TAB PO DAILY 17. olopatadine 0.1 % ophthalmic BID 18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild RX *oxycodone 5 mg ___ tablet(s) by mouth Q4HR Disp #*40 Tablet Refills:*0 19. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY 20. Ursodiol 600 mg PO BID 21. Vancomycin Oral Liquid ___ mg PO Q6H 22. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Flu-like upper respiratory infection Abdominal pain secondary to right-sided ovarian cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: PELVIS U.S., TRANSVAGINAL INDICATION: History: ___ with new urinary retention, know 5.6cm R adnexal mass // eval adnexal mass 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: ___ pelvic ultrasound FINDINGS: The uterus is anteverted and measures 8.4 x 4.2 x 4.5 cm. The endometrium is homogenous and measures 1 mm. Multiple fibroids are again seen. A fibroid arising from the right aspect of the uterine body measures 1.9 x 1.7 cm. A fibroid arising from the posterior aspect of the left uterine body measures 2.3 x 1.1 cm. An anechoic cyst in the right adnexa measuring 6.1 x 4.0 x 4.7 cm is unchanged. The adjacent ovarian tissue demonstrates normal vascularity. The left ovary is normal. A 5.4 x 1.4 cm fluid containing structure in the region of the left adnexa may represent a hydrosalpinx. A moderate amount of free fluid in the pelvis is overall similar in quantity to the prior examination. However, portions of the free fluid demonstrate homogeneous internal echoes related to proteinaceous content. IMPRESSION: No significant change compared to 3 days prior. 1. An anechoic right adnexal cyst measures up to 6.1 cm and may represent a peritoneal inclusion cyst. 2. There is persistent free fluid the pelvis, portions with homogeneous internal echoes suggestive of proteinaceous content. Stable compared to prior examination 3. The uterus is fibroid. 4. Tubular structure in the left adnexa may represent a hydrosalpinx versus a small bowel loop although peristalsis was not observed during the examination Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with cough, pleuritic chest pain // r/o pna r/o pna IMPRESSION: In comparison with the study of ___, there is no interval change or evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. Radiology Report EXAMINATION: SPLEEN ULTRASOUND INDICATION: ___ year old woman with pharyngitis, flu-like symptoms, possible mono // assess for splenomegaly TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: SPLEEN: Normal echogenicity, measuring 9.5 cm. No focal lesions. IMPRESSION: No splenomegaly. Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE INDICATION: ___ year old woman with multiple medical issues, now with urinary retention, left leg/ankle weakness, back pain, ankle clonus (bilateral) // eval for cauda equina syndrome eval for cauda equina syndrome TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. COMPARISON: CT abdomen and pelvis performed ___. FINDINGS: Alignment of the lumbar spine is anatomic. Bone marrow signal intensity is within normal limits. Disc signal intensity and heights are preserved. There is no acute fracture. The conus terminates at the L1 level. Spinal canal is normal in caliber. There is no abnormal prevertebral soft tissue edema. No epidural abnormality is identified. There are no significant degenerative changes. There is no appreciable neural foraminal narrowing. Right adnexal cyst is partially imaged (07:23), previously described on CT abdomen and pelvis dated ___. No appreciable retroperitoneal abnormality is identified. IMPRESSION: 1. Essentially unremarkable MR of the lumbar spine without evidence of spinal canal or neural foraminal narrowing. 2. A large right adnexal cyst is better described on prior CT abdomen and pelvis of ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with Unspecified abdominal pain temperature: 98.1 heartrate: 74.0 resprate: 16.0 o2sat: 99.0 sbp: 104.0 dbp: 80.0 level of pain: 9 level of acuity: 3.0

Ms. ___, It was a pleasure caring for you during this hospitalization. You were admitted to the hospital with multiple symptoms including abdominal pain and symptoms of an upper respiratory illness. CT scans of your abdomen were negative for any acute process and you underwent flexible sigmoidoscopy which showed minimal inflammation only, which is felt not to be the cause of your symptoms. You were evaluated by OBGYN, who felt your symptoms were related to your right ovarian cyst. They have recommended that you have a repeat ultrasound of this in six months. Your upper respiratory symptoms were felt to be related to viral infection. Testing for flu was negative, Unfortunately testing for other viruses that could cause your symptoms had to be canceled because not enough specimen was collected. However, you improved with supportive care alone, without antibiotics, again confirming that this was likely due to a viral process. Later in your hospital stay you developed abrupt left leg weakness and as a result were sent for an MRI of your lumbar spine, which was largely normal. Your exam, labs and imaging were reassuring. Please follow up with your primary care provider regarding these symptoms.

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: none History of Present Illness: ___ with a PMH significant for ___ and pAFib who had transverse colectomy in ___ for colon cancer who has had approximately ___ SBOs over the past 3 decades, none of which have required operative management. He was feeling well in his usual state of health until around 6pm last night when he experienced band like epigastric pain. The pain is intermittent and woke him up several times throughout the night always in the same location. He reports some nausea with no emesis. He did have a small bowel movement and passed flatus this morning. He is currently experiencing epigastric pain. Past Medical History: pAFib (on Coumadin), HTN, Cancer s/p transverse colectomy and chemotherapy (___), Hyperplastic colonic polyps, and adenomatous polyps (Last c-scope ___, melanoma, bilateral lung cancer (RLL SCC, LLL Adenoca), Cardiac stress and perfusion normal ___, h/o diastolic CHF, Ocular myasthenia ___, Hypertension, Hyperlipidemia, Peripheral neuropathy, Lumbar radiculopathy, Gout Social History: ___ Family History: Dad with CHF, mom with DM and celiac sprue (only autoimmune dz in the family). Physical Exam: Upon admission: Pain ___ 122/45 17 92% RA Gen: Uncomfortable but NAD, A&O, Pleasant and conversive, cooperative with exam CV: RRR, No R/G/M RESP: CTAB ABD: Soft, moderately distended with epigastric tenderness, no guarding, no rebound. NGT placed in ED with 2000cc of brown/tan drainage EXT: WWP BLE, no appreciable edema Upon discharge: VITALS: 98.8 90 109/53 18 97RA GEN: AAOx3, NAD HEART: RRR S1S2 LUNGS: CTAB no respiratory distress AB: soft, NT, mild distention EXT: warm well perfused Pertinent Results: ___ 06:20AM BLOOD WBC-7.1 RBC-3.81* Hgb-11.6* Hct-36.0* MCV-94 MCH-30.4 MCHC-32.2 RDW-15.2 Plt ___ ___ 07:15AM BLOOD ___ ___ 06:20AM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-147* K-4.3 Cl-109* HCO3-31 AnGap-11 CT abdomen/pelvis ___ Complete small bowel obstruction with a transition in the right lower quadrant most consistent with adhesion. No pneumatosis, free air or free fluid. Medications on Admission: Torsemide 20 mg Doxazosin 2 mg daily Pravastatin 40 mg daily Amlodipine 10 mg daily Lisinopril 20 mg daily Coumadin 5 mg Allopurinol ___ mg Metoprolol Succinate 50mg daily Discharge Medications: 1. Torsemide 20 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Amlodipine 10 mg PO DAILY 4. Doxazosin 1 mg PO BID 5. Lisinopril 20 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Pravastatin 40 mg PO DAILY 8. Warfarin 5 mg PO DAILY 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 HISTORY: Colectomy for colon cancer with prior small bowel obstruction now with lower abdominal pain. Evaluate for a small bowel obstruction. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis without the administration of IV contrast. Oral contrast was administered. Coronal and sagittal reformations were provided and reviewed. DLP: 1000.93 mGy/cm. COMPARISON: CT abdomen pelvis ___. FINDINGS: The included lung bases show no pleural effusion or pneumothorax. The imaged heart is normal in size. There is a trace, physiologic pericardial effusion. The oral contrast bolus remains within the stomach. Contrast is also seen in the esophagus, consistent with reflux. Loops of small bowel are dilated and range up to 4.2 cm. There is a transition of bowel caliber seen within the right lower quadrant, after which the distal loops of small and large bowel are collapsed. Fecalization of small bowel contents is noted at this level as well. There is no bowel wall thickening. There is no free air or free fluid. There is no pneumatosis. The right and transverse colon is surgically absent. Evaluation of the intra-abdominal organs is limited by lack of intravenous contrast. Within this limitation, the liver, gallbladder, spleen, pancreas and adrenal glands are unremarkable. The kidneys show no nephrolithiasis or hydronephrosis. A simple 2.3 mm cyst in the upper pole of the right kidney is noted. There is a moderate amount of atherosclerosis within a non aneurysmal aorta. Dense calcifications are noted at the origin of the celiac and superior mesenteric arteries. Evaluation for vessel patency is limited by lack of IV contrast. Pelvis: The right lateral wall of the bladder is seen within a right inguinal hernia. The prostate and seminal vesicles are unremarkable. There is mild sigmoid diverticulosis without diverticulitis. Bones: Spinal hardware is seen within the spinous process of L3. There are mild degenerative changes of the lumbar spine with loss of disc space, worse at L3-4. There are no concerning lytic or blastic lesions. A sclerotic focus within the right iliac wing is unchanged from ___ (2:53). IMPRESSION: Complete small bowel obstruction with a transition in the right lower quadrant most consistent with adhesion. No pneumatosis, free air or free fluid. Radiology Report PORTABLE CHEST ___ COMPARISON: ___ and ___ radiographs. FINDINGS: Interval placement of nasogastric tube, with tip terminating in the stomach. Stable cardiomegaly and persistent right pleural effusion opacity, which appears to predominantly be due to pleural thickening on recent abdominal CT of ___ with only a trace amount of pleural fluid. There is also either pleural thickening or fluid within the adjacent fissure. Mild volume loss is present in the right hemithorax and note is made of volume loss and scarring in the right lower lobe and right middle lobe. The left lung demonstrates surgical chain sutures in the mid lung region and is otherwise clear. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain Diagnosed with INTESTINAL OBSTRUCT NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, LONG TERM USE ANTIGOAGULANT temperature: 97.8 heartrate: 93.0 resprate: 16.0 o2sat: 100.0 sbp: 147.0 dbp: 55.0 level of pain: 13 level of acuity: 3.0

You were admitted to the Acute Care Surgery service with a small bowel obstruction. You were treated with bowel rest and NG tube placement, and you are now ready to complete your recovery at home. Please follow the instructions below: -You may resume a normal diet as tolerated. -You may resume normal activity as tolerated. -Your coumadin was held while you had the NG tube in place and was restarted when you resumed a normal diet. Please follow up with your PCP ___ 1 week and obtain regular INR checks. -You are also advised to follow up with your cardiologist and your gastroenterologist within ___ weeks. -You may reach the Acute Care Surgery office at ___ if you have any questions or concerns. -If you experience severe abdominal pain, fever>101, or anything else that concerns you, please call your doctor or go the closest emergency room.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Dysuria Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ DM, HTN, h/o SBO, h/o ovarian cancer, p/w dysuria and ___. Pt reports dysuria x 2 weeks. She was treated with Bactrim x 3 days. However, she cont. to have dysuria and increased urgency. Wears diapers at baseline. also endorses decreased appetite over the last few days. Denies fever, chills, back pain, n/v. She reports chronic intermittent diarrhea - at baseline. This am, pt also feel to the floor from bed while trying to walk to dresser. Pt reports hitting her R arm. Denies LOC. The fall was unwitnessed. Daughter found pt on the ground about 45 minutes later. PCP ___ ___ showed K 5.5, BUN 44, Cr 1.6 increase from ___, and referred pt to the ED. Family denies recent new meds other than Bactrim. no OTC NSAIDS use. denies sig. dizziness/lightheadedness while at all. Pt does report that it has been hard to urinate. In the ED, initial vitals were: 98.3 82 160/80 20 95% RA - Labs were significant for K 6.0, Cr 1.3, no leukocytosis, UA w/ pos nitrite and large leuks; CK 43 - The patient was given ___ 15:44 IVF 1000 mL NS 1000 mL ___ 16:50 IV CeftriaXONE 1 gm ___ 19:36 PO Acetaminophen 1000 mg ___ 19:36 PO Phenazopyridine 100 mg Repeat K was 5.2. Past Medical History: History of Ovarian Cancer - s/p TAH/BSO ___ years ago Hypertension Depression recent SBO in ___ DM occasional pipe smoker Social History: ___ Family History: Diabetes and HTN run in the family. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7 105/68 75 18 97RA General: Alert, oriented to person and hospital HEENT: Sclera anicteric, dry MM 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 BACK: no CVA tenderness GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities DISCHARGE PHYSICAL EXAM: VS - 98.5 110/68 65 16 95% on RA General: NAD, comfortable HEENT: Sclera anicteric, EOMI, swelling of left>right lower eyelid mildly improved, MMM, patent oropharynx, no teeth Neck: Supple, no LAD CV: RRR, normal S1/S2, no murmurs/rubs/gallops Lungs: CTAB, no increased work of breathing, no wheezes/rales/rhonchi Abdomen: Non-tender. LLQ hernia is firm and distended. Otherwise soft and non-distended. +BS. No HSM. No rebound or guarding. GU: Wearing a diaper. Ext: Warm and well perfused. No clubbing, cyanosis, or edema. Neuro: Moving all extremities equally. Skin: No rashes or bruises. Pertinent Results: ADMISSION LABS =============== ___ 12:02PM BLOOD WBC-8.3 RBC-4.39 Hgb-11.2 Hct-38.2 MCV-87 MCH-25.5* MCHC-29.3* RDW-15.6* RDWSD-49.1* Plt ___ ___ 12:02PM BLOOD Neuts-57.3 ___ Monos-7.2 Eos-3.1 Baso-1.0 Im ___ AbsNeut-4.78 AbsLymp-2.57 AbsMono-0.60 AbsEos-0.26 AbsBaso-0.08 ___ 12:02PM BLOOD UreaN-44* Creat-1.6* Na-138 K-5.5* Cl-105 HCO3-24 AnGap-15 ___ 12:02PM BLOOD TSH-0.53 ___ 12:02PM BLOOD CRP-39.8* ___ 09:00PM BLOOD K-5.2* PERTINENT FINDINGS =================== Renal Ultrasound ___: 1. Normal renal ultrasound. 2. Splenic cyst with layering debris. Head CT ___: No acute intracranial process. DISCHARGE LABS: ================ ___ 07:15AM BLOOD WBC-6.6 RBC-3.84* Hgb-9.9* Hct-32.5* MCV-85 MCH-25.8* MCHC-30.5* RDW-15.1 RDWSD-45.3 Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-147* UreaN-31* Creat-1.0 Na-139 K-4.8 Cl-108 HCO3-24 AnGap-12 ___ 07:15AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Atenolol 25 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Losartan Potassium 100 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Mirtazapine 15 mg PO QHS 8. MetFORMIN (Glucophage) 850 mg PO BID 9. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Mirtazapine 15 mg PO QHS 4. Atenolol 25 mg PO DAILY 5. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral BID 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. Losartan Potassium 100 mg PO DAILY 9. MetFORMIN (Glucophage) 850 mg PO BID 10. Cefpodoxime Proxetil 100 mg PO Q12H RX *cefpodoxime 100 mg 1 tablet(s) by mouth Every 12 hours Disp #*8 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - UTI - ___ Secondary: - Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with diabetes and unwitnessed fall and possible head strike. Evaluate for acute intracranial abnormality such as 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 ___ and MR head from ___. FINDINGS: There is no evidence of acute infarction, hemorrhage, or edema.. A calcified lesion in the left cerebellar peduncle is stable and likely reflects a cavernoma, as previously noted on prior MRI. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and deep white matter hypodensities likely reflect chronic microangiopathic changes. 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: No acute intracranial process. Radiology Report EXAMINATION: RENAL U.S. INDICATION: Evaluate for hydronephrosis or other evidence of renal obstruction, in a patient with ___ and difficulty urinating. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT abdomen/pelvis from ___. FINDINGS: The right kidney measures 11.4 cm. The left kidney measures 10.7 cm. There is no hydronephrosis, stone, or solid mass bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. As on prior CT, there are bilateral simple renal cysts, measuring 8 x 9 x 10 mm in the upper pole of the left kidney, 15 x 14 mm in the upper pole of the right kidney, and 12 x 15 mm in the lower pole of the right kidney. A complex cyst in the lower pole of the spleen measuring 4.8 x 4.8 x 5.3 cm is similar in size compared to ___, and demonstrates some layering debris. The bladder is completely decompressed and cannot be fully assessed on the current study. IMPRESSION: 1. Normal renal ultrasound. 2. Splenic cyst with layering debris. Gender: F Race: BLACK/CAPE VERDEAN Arrive by AMBULANCE Chief complaint: Dysuria Diagnosed with Urinary tract infection, site not specified, Acute kidney failure, unspecified temperature: 98.3 heartrate: 82.0 resprate: 20.0 o2sat: 95.0 sbp: 160.0 dbp: 80.0 level of pain: UTA level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ for a urinary tract infection. You were started on antibiotics and given a medication to help reduce the pain/discomfort with urination. Once the cultures from your urine returned, you were started on an oral antibiotic, Cefpodoxime, which should be taken for a total of 7 days (last day ___. You should plan to follow up with your PCP once the antibiotic regimen is completed. It was a pleasure taking care of you during your stay at ___. We wish you the best in your recovery. If you have any questions about the care you received, please do not hesitate to ask. Sincerely, Your Inpatient ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Estrogens / Ancef / Tegretol / Keflex / Allegra / Tequin / Minocin / Forteo / carbamazepine / Cephalosporins Attending: ___. Chief Complaint: Confusion/dysarthria Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: ___ year old woman with history of SLE, c/b Devic's neuromyelitis optica and transverse myelitis on chronic prednisone presenting with episode of altered mental status. Staff at her facility reported that she became confused around 10 AM with speech change, facial clonus, auditory hallucinations and SpO2 82%. She was recently admitted with hallucinations s/p left hip repair, thought to be due to post-op delirium and steroid psychosis which resolved. During that admission she developed episodes of acute slurred speech and feeling unwell. Symptoms would often start with a feeling of chest heaviness and dyspnea. She had a head CT which did not show any acute intracranial process. She also had an EEG which captured these episodes and showed non specific slowing but no epileptiform activity. Neurology did not recommend any anti-epileptic medication at that time. On arrival to ER, vitals 101.6 121 ___ 94% RA. Patient feeling generally unwell but no focal symptoms. Chest x-ray without infiltrate. Her tachycardia improved with IV fluid and antipyretics. While in the ED patient had an 'episode' similar to previous admission during which she has a staring spell with tachypnea. This resolved sponataneously. She was given vancomycin due to concern for health care associated infection. She was also given baclofen, due to report that baclofen pump was due to be refilled. Of note, it was interogated on previous admission and was functioning properly and not due for refill until ___. Vitals prior to transfer 98.2 102 141/71 25 97% RA. On the floor, VS are 98.1, 130/74, 82, 118, 98%RA. She feels well and reports that she has no recollection of any events since leaving the hospital last night. Currently she is without hallucinations, feels like she is coming out of a fog but is not confused about the current situation. She denies any new weakness, chest pain, SOB, nausea, abdominal pain, hip pain. Past Medical History: 1) SLE. Complicated by neuromyelitis optica (right eye blindness) and pericarditis. Followed by Dr. ___. Had been treated with cytoxan. On Pred. 2) Transverse Myelitis diagnosed in ___ after patient presented with fall. Complicated by neurogenic bladder requiring ileal loop diversion ___. On steroids. Had baclofen pump placed in ___. 3) h/o urosepsis complicated by acral necrosis while on pressors 4) h/o frequent nephrolithiasis with staghorn calculi s/p lithotripsy, urostomy tube placement 5) Right lower extremity DVT ___, treated with coumadin 6) Steroid-induced hyperglycemia 7) Bilateral knee arthritis 8) Left eye capsular ossification or a secondary cataract, corrected w/ laser surgery ___ 9) Hypothyroidism 10) Osteoporosis secondary to chronic steroids 11) Liver hemangioma 12) HTN Social History: ___ Family History: as per prior OMR notes Mother died at ___ metastatic BCA Father died at ___ aplastic anemia only child Physical Exam: ADMISSION PHYSICAL EXAM: Vitals-98.1, 130/74, 82, 118, 98%RA General: Sitting up in bed comfortably. Alert, interactive, oriented x3. Smiling and pleasant, NAD. Not attending to external stimuli. HEENT: sclera anicteric, conjunctiva clear. L exotropia. Dry mucous membranes, tongue tremor. Neck: Supple, no LAD CV- regular rhythm, no murmurs Pulm- CTAB, no wheezes or rales Abd- soft, NT, urostomy conduit draining dark urine with sediment Ext- left lateral leg with 3 surgical incisions, staples in place, C/D/I and non-tender. No edema. WWP pulses symmetric Neuro- R eye blindness (chronic), otherwise CN2-12 intact. ___ ___ plegia, able to wiggle toes L>R. ___ strength ___ UE DISCHARGE PHYSICAL EXAM: VS 98.6, 124/62, 87, 100, 98% on RA General: Sitting up in bed comfortably. Alert, interactive, oriented x3. Smiling and pleasant, NAD. Not attending to external stimuli. HEENT: sclera anicteric, conjunctiva clear. L exotropia. Dry mucous membranes, tongue tremor. Neck: Supple, no LAD CV- regular rhythm, no murmurs Pulm- CTAB, no wheezes or rales Abd- soft, NT, urostomy conduit draining clear fluid with some whitish sediment Ext- left lateral leg with 3 surgical incisions, staples removed, C/D/I and non-tender. No edema. WWP pulses symmetric Neuro- R eye blindness (chronic), otherwise CN2-12 intact. ___ ___ plegia, able to wiggle toes L>R. ___ strength ___ UE Pertinent Results: Admission Labs: ___ 10:00AM SODIUM-135 POTASSIUM-4.4 CHLORIDE-105 ___ 06:00AM UREA N-20 CREAT-0.5 SODIUM-136 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-18* ANION GAP-16 ___ 06:00AM CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-2.2 ___ 06:00AM WBC-13.2* RBC-3.40* HGB-10.8* HCT-33.8* MCV-99* MCH-31.7 MCHC-31.9 RDW-13.9 ___ 06:00AM PLT SMR-NORMAL PLT COUNT-421 ___ 06:00AM LD(LDH)-418* ALK PHOS-159* ___ 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG ___ 03:00PM URINE RBC-25* WBC-158* BACTERIA-FEW YEAST-NONE EPI-0 Discharge Labs: ___ 07:36AM BLOOD WBC-9.5 RBC-3.45* Hgb-10.9* Hct-34.2* MCV-99* MCH-31.7 MCHC-32.1 RDW-13.5 Plt ___ ___ 07:36AM BLOOD Glucose-101* UreaN-28* Creat-0.6 Na-141 K-4.5 Cl-108 HCO3-25 AnGap-13 ___ 07:36AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.3 Imaging/Reports: #CXR ___ IMPRESSION: No acute cardiopulmonary process. No significant interval change. #Renal U/S ___ IMPRESSION: 1. Distended calices in the upper pole of the left kidney with multiple shadowing stones throughout the left kidney, similar to prior CT. No evidence of left hydronephrosis. 2. Right kidney not well visualized, but no evidence of right hydronephrosis. # KUB ___ FINDINGS: A nonspecific bowel gas pattern is seen without evidence of obstruction. Marked levoscoliosis is again noted, relatively similar to ___. Radiopaque densities overlying the left renal pelvis likely corresponds to previously noted calculi. A baclofen pump is seen overlying the left lower quadrant with intact wires running posteriorly into the midline spine. Exact location of the wires cannot be identified on these single projection images but appear similar to CT from ___. Left femoral surgical hardware is partially visualized. IMPRESSION: Baclofen pump with intact wires running posteriorly appear in similar position to CT from ___. #EEG ___ IMPRESSION: This was a normal continuous video EEG. There were no epileptiform discharges or electrographic seizures. HEAD MRI ___ IMPRESSION: 1. No acute infarct, intracranial hemorrhage or space-occupying lesion. 2. Diffuse white matter signal abnormalities most likely represent the sequela of small vessel ischemic disease. Microbiology: ___ Urine culture URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. ___ Blood culture Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:38 am CSF;SPINAL FLUID TUBE 3. LP. 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.. FLUID CULTURE (Final ___: NO GROWTH. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. ___ 8:34 am URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. ___ 11:03 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ 3:17PM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Baclofen 10 mg PO TID 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID 6. Enoxaparin Sodium 40 mg SC QPM 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. PredniSONE 10 mg PO EVERY OTHER DAY 10. PredniSONE 30 mg PO EVERY OTHER DAY 11. Ranitidine 150 mg PO DAILY 12. Senna 8.6 mg PO BID 13. Valsartan 40 mg PO DAILY 14. Ibuprofen 400 mg PO Q8H:PRN pain 15. ertapenem 1 gram injection daily 16. Sodium Bicarbonate 650 mg PO TID 17. Vitamin D 1000 UNIT PO DAILY 18. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 19. QUEtiapine Fumarate 12.5 mg PO QHS Discharge Medications: 1. Baclofen 10 mg PO TID 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID 5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 6. Ibuprofen 400 mg PO Q8H:PRN pain 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. PredniSONE 30 mg PO EVERY OTHER DAY 10. QUEtiapine Fumarate 12.5 mg PO QHS 11. Senna 8.6 mg PO BID 12. Sodium Bicarbonate 650 mg PO TID 13. Valsartan 40 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. PredniSONE 10 mg PO EVERY OTHER DAY 16. Fluconazole 200 mg PO Q24H 17. Acetaminophen 650 mg PO Q8H 18. Ranitidine 150 mg PO DAILY 19. MetRONIDAZOLE (FLagyl) 500 mg PO TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Altered mental status Secondary: Devic's neuromyelitis optica and transverse myelitis Steroid induced hyperglycemia hypothyroidism 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 HISTORY: Fever, altered mental status. TECHNIQUE: AP upright and lateral views of the chest. COMPARISON: ___. FINDINGS: The patient is somewhat rotated and thoracolumbar scoliosis is again seen. Left-sided PICC / midline is again seen, terminating in the region of the proximal left axillary vein. There is persistent elevation the right hemidiaphragm with overlying right basilar atelectasis. No focal consolidation is seen. There is no pleural effusion pneumothorax. Cardiac mediastinal silhouettes are stable. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. No significant interval change. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old woman with Devic's NMO/transverse myelitis, SLE, here with confusion/dysarthria/hallucinations. TECHNIQUE: Multiplanar, multi sequence MR images of the head were obtained before and after the administration of intravenous contrast. COMPARISON: CT head dated ___ and ___. FINDINGS: There is no acute infarct or acute intracranial hemorrhage. No mass, mass effect or midline shift is present. There is no abnormal enhancement. Patchy and confluent areas of T2 and FLAIR hyperintensity are present within the periventricular, deep and subcortical white matter, and there are a couple of foci of hyperintensity within the pons is well. Mild cerebral atrophy is present with dilatation of the ventricles and widening of the cortical sulci. Fluid signal is seen within the right mastoid. IMPRESSION: 1. No acute infarct, intracranial hemorrhage or space-occupying lesion. 2. Diffuse white matter signal abnormalities most likely represent the sequela of small vessel ischemic disease. Radiology Report HISTORY: Ileal diversion, history of staghorn calculus status post lithotripsy, UTI. COMPARISON: Comparison made with CT abdomen and pelvis from ___ and renal ultrasound from ___. TECHNIQUE: Grayscale and color Doppler ultrasound images of the kidneys were obtained. FINDINGS: The right kidney is not well visualized, but measures approximately 10.4 cm and does not demonstrate evidence of hydronephrosis. The left kidney measures 12.2 cm. There are distended calices in its upper pole of the left kidney, similar to prior CT. Multiple shadowing stones are seen throughout the left kidney. There is no evidence of hydronephrosis. The bladder is not well visualized on this exam. IMPRESSION: 1. Distended calices in the upper pole of the left kidney with multiple shadowing stones throughout the left kidney, similar to prior CT. No evidence of left hydronephrosis. 2. Right kidney not well visualized, but no evidence of right hydronephrosis. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: ___ year old woman with SLE complicated by Devic's disease, on baclofen pump for transverse myelitis, needs pump position assessed prior to brain MRI. // assess position of baclofen pump TECHNIQUE: Supine frontal abdominal radiographs were obtained. COMPARISON: Ultrasound from ___, radiograph from ___ and CT from ___. FINDINGS: A nonspecific bowel gas pattern is seen without evidence of obstruction. Marked levoscoliosis is again noted, relatively similar to ___. Radiopaque densities overlying the left renal pelvis likely corresponds to previously noted calculi. A baclofen pump is seen overlying the left lower quadrant with intact wires running posteriorly into the midline spine. Exact location of the wires cannot be identified on these single projection images but appear similar to CT from ___. Left femoral surgical hardware is partially visualized. IMPRESSION: Baclofen pump with intact wires running posteriorly appear in similar position to CT from ___. Radiology Report EXAMINATION: Lumbar puncture under fluoroscopic guidance. INDICATION: ___ year old woman with SLE complicated by Devic's disease and transverse myelitis for which she has a baclofen pump, admitted for hallucinations/confusion concerning possible lupus cerebritis. // LP for cytology, oligoclonal bands, hSV, VZV PCR (will order) TECHNIQUE: Fluoroscopic guided lumbar puncture. COMPARISON: None. FINDINGS: The benefits, risks and alternatives of the procedure were explained to the patient. All questions were answered. Informed consent was obtained and placed in the chart. The patient was transported to the special procedure fluoroscopy room and placed in prone position. A preprocedural time out was performed. The lower back was prepped and draped in the standard sterile fashion. Lidocaine was administered at the L4-L5 level for local anesthesia. Under fluoroscopic guidance, a 22-gauge spinal needle was inserted at the L4-L5 level. A fluoroscopic image of the lumbar spine was obtained (and retained in the PACS system), confirming the needle position at L4-L5. A total of 16.5 cc of clear cerebrospinal fluid was obtained and placed in 4 separate tubes. The needle was subsequently removed. Patient tolerated the procedure well without immediate complication. The fluid was brought to the laboratory. IMPRESSION: Successful fluoroscopic guided lumbar puncture. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Altered mental status Diagnosed with FEVER, UNSPECIFIED, SEMICOMA/STUPOR temperature: nan heartrate: 131.0 resprate: 30.0 o2sat: 98.0 sbp: 154.0 dbp: 116.0 level of pain: 13 level of acuity: 1.0

Ms ___, It was a pleasure taking care of you at ___ ___. You were admitted for confusion and difficulty speaking. You were evaluated by neurology, who recommended an extended EEG which showed no seizure activity. You had an MRI which showed no sign of active inflammation. You also underwent a lumbar puncture and your CSF studies were all normal. We restarted your home Seroquel. It is unclear why you experience hallucinations, but we believe that it may be related to infection. We began treating you for a yeast infection as your urine cultures were positive for yeast. You will need to continue a 2 week course of fluconazole when you return to your facility. You also developed C. diff diarrhea for which you will also take antibiotics as well. We also continued your treatment for a bacterial urinary tract infection from your prior hospitalization. You had an ultrasound to rule out infection in your kidneys. Please follow-up with your outpatient providers as instructed below. Thank you for allowing us to participate in your care. All best wishes for your recovery. Best, Your ___ medical team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yof with poorly controlled DM, HTN, depression and history of alcoholism who presents with nausea, vomiting, and abdominal pain after recent flu-like illness. EMS found patient to have blood glucose of 525 with temperature of 100.1. Patient has history of multiple admissions for poor glucose control including DKA in ___. Patient reports intermittent compliance with her NPH and checks blood glucose only in mornings. She initially had several days of myalgias, rhinorrhea, and general malaise that preceded her nausea, vomiting, and abdominal pain. Sick contacts of mother and sister w/ "flu". She denied diarrhea or dysuria. Patient was noted to have cough in ED. In the ED: She was found to have K 7.6, bicarb of 8, blood glucose of 587 and anion gap of 30. She received 3 L of NS, then switched to MIVF of D5 with K. She was started on on insulin drip: bolus of 10, then 8 u/hr since 0100. At time of transfer to the ICU, her blood glucose was 300. On arrival to CCU: Patient reports abdominal pain is much improved. REVIEW OF SYSTEMS: No diarrhea, dysuria Past Medical History: DM2 w/moderately severe B nonproliferative diabetic retinopathy HTN Depression- one psych hospitalization in ___ for SI h/o EtOH abuse- never experienced withdrawal sx, in early remission Social History: ___ Family History: Mother with DM2, HTN. No known family history of cancer. Physical Exam: ADMISSION Vitals: T 101 HR 115 BP 121/58 RR 16 O2 100% Gen: NAD HEENT: poor dentition Neck: no JVD CV: NR, RR, no murmurs Pulm: CTAB Abd: NT, ND, soft Ext: no peripheral edema Neuro: A&O, no gross deficits Psych: appropriate Skin: no lesions noted DISCHARGE Vitals: T: 98.1, BP: 120/82, P: 108, R: 18, O2: 100% RA General: Alert, oriented, no acute distress, obese HEENT: Sclera anicteric, MMM, oropharynx clear but poor dentition 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: CN ___ intact, ___ strength in b/l upper and lower extremities Pertinent Results: ADMISSION ___ 01:00AM GLUCOSE-587* UREA N-30* CREAT-1.4* SODIUM-136 POTASSIUM-7.6* CHLORIDE-99 TOTAL CO2-8* ANION GAP-37* ___ 01:00AM ALT(SGPT)-17 AST(SGOT)-43* ALK PHOS-100 TOT BILI-0.4 ___ 01:00AM LIPASE-22 ___ 01:00AM ALBUMIN-4.7 ___ 01:00AM K+-6.9* ___ 01:00AM WBC-7.2# RBC-3.66* HGB-10.1* HCT-35.3* MCV-96 MCH-27.5 MCHC-30.6* RDW-16.1* ___ 01:00AM NEUTS-76* BANDS-1 LYMPHS-17* MONOS-6 EOS-0 BASOS-0 ___ MYELOS-0 ___ 01:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-OCCASIONAL TEARDROP-OCCASIONAL BITE-OCCASIONAL ___ 01:00AM PLT COUNT-306 ___ 01:00AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 01:00AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:00AM URINE HYALINE-2* ___ 05:30AM BLOOD WBC-3.5* RBC-3.57* Hgb-10.2* Hct-31.7* MCV-89 MCH-28.7 MCHC-32.3 RDW-15.8* Plt ___ ___ 05:30AM BLOOD Glucose-110* UreaN-11 Creat-0.5 Na-138 K-3.5 Cl-109* HCO3-21* AnGap-12 CXR ___: Portable chest radiograph demonstrates no focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is normal. IMPRESSION: No acute cardiopulmonary process. UCG: Neg MICRO: Flu swab negative Medications on Admission: The Preadmission Medication list is accurate and complete. 1. 70/30 26 Units Breakfast 70/30 24 Units Bedtime 2. Lisinopril 2.5 mg PO DAILY hold for BP less than 100 3. Venlafaxine 225 mg PO DAILY 4. Mirtazapine 30 mg PO HS Discharge Medications: 1. 70/30 26 Units Breakfast 70/30 24 Units Bedtime 2. Lisinopril 2.5 mg PO DAILY hold for BP less than 100 3. Mirtazapine 30 mg PO HS 4. Venlafaxine 225 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis Diabetes Mellitus Type 2 Secondary: Hypertension Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Diabetic ketoacidosis and fever. Evaluate for pneumonia. COMPARISON: None. FINDINGS: Portable chest radiograph demonstrates no focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is normal. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: ABD PAIN Diagnosed with IDDM UNCONTROLLED W/KETOACID, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS temperature: 101.0 heartrate: 115.0 resprate: 16.0 o2sat: 100.0 sbp: 121.0 dbp: 58.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ for nausea and vomiting. You were found to be in diabetic ketoacidosis (DKA). You have been admitted for this multiple times in the past. You were treated with IV fluids and insulin and you improved. This episode of DKA may have been caused by a combination of a viral illness and missing some doses of insulin. You will be discharged on your previous dose of insulin 70/30. It is extremely important that you take your insulin as prescribed every day. You should also check your blood sugars in the morning and before meals and keep a record of these so your doctors ___ adjust your insulin dose. It is very important that you followup with the ___ diabetes doctors within ___ days to come up with a strategy to prevent you from being admitted for DKA in the future. It was a pleasure taking part in your care, and we wish you a speedy recovery!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea, Fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with primary mediastinal B-cell lymphoma who presents with 1 day of profuse watery diarrhea and fever of 102.5. Per patient, he started having diarrhea on ___ AM, up to every hour. States he lost count of how many times he had to go but it was definitely more than 10. Describes stool as very watery, foul smelling. Reported associated abdominal cramping but no pain. States his partner at home had an episode of self limited diarrhea approximately 8 days ago and had attributed it to something he ate. Denies any other sick contacts. Later yesterday afternoon, patient stated he had some chills and later developed a fever up to 102.5 taken orally. He decided to present to the ED at that time. Of note, patient recently completed C5 of da-EPOCH-R which started and was discharged on ___. He has not started taking his filgastrim-sndz yet and had planned to start taking it ___ AM. Endorsed slightly nausea improved with Zofran at home. Denies any abdominal pain, constipation, CP, SOB, vomiting, BRBPR, melena, headaches, ___ edema, night sweats, dysuria. In the ED, initial vitals: 100.7 | 102 | 117/73 | 18 | 97% RA. Labs with WBC 7.6, ANC 7.52, Hgb 10.3, Plts 139, AST/ALT 103/60, AP 36, T bili 1.0, Na 134, CO2 21, AG 13, LA 1.2, INR 1.8, ___ 19.9. C diff PCR sent and is pending. Flu swab negative for Flu A/B. UA with rare mucous, trace protein. Blood cx x2, and UCx sent. EKG with NSR, HR 79, no acute ischemic changes.CXR with no acute intrathoracic process. Patient given 2L LR, Tylenol 1gm. Patient admitted to ___ for additional evaluation and management. Past Medical History: PAST ONCOLOGIC HISTORY: ~ ___: Develops new back pain, initially thought to be musculoskeletal in etiology. - ___: Develops new left lower quadrant abdominal pain. - ___: Abdominal pain becomes excruciating, prompting a visit to his PCP, who recommends a CT abdomen. - ___: CT abdomen reveals a 3.2 cm mass in the tail of the pancreas with fat stranding surrounding the splenic vessels and extending towards the splenic hilum and infiltration of the left adrenal gland causing splenic vein thrombosis, concerning for pancreatic adenocarcinoma, as well as lytic lesions in the iliac wing bilaterally right more than left concerning for metastatic disease, and a small amount of ascites. - ___: CT chest shows a soft tissue mass in the anterosuperior mediastinum abutting the ascending aorta and superior vena cava. The mass has imaging characteristics of lymphoma, though metastatic lesions may have a similar appearance. - ___: Initial evaluation by Drs. ___ in Pancreatic ___ clinic. Bone biopsy and mediastinal biopsy are arranged. - ___: Bone biopsy reveals involvement by Diffuse Large B Cell Lymphoma favor non-germinal center type by ___. A history of concurrent mediastinal mass is noted; this finding along with the fibrotic background seen in this biopsy and the CD23 expression raise the possibility of a metastatic primary mediastinal (thymic) large B-cell lymphoma. FISH positive for gain of JAK2 (suggestive of PMBCL) and gain of MYC. There is no evidence of the IGH/BCL2 gene rearrangement or rearrangements of the BCL6 and MYC genes. - ___: Mediastinal mass biopsy reveals a limited core needle biopsy with extensive crush artifact and atypical large B-cell infiltrate. - ___: PET demonstrtes FDG-avid mediastinal mass, pancreatic mass, mediastinal and pelvic lymphadenopathy, multiple bone lesions, and small volume ascites. - ___: Admitted to ___ for expedited treatment initiation. Port-a-Cath placed. C1D1 da-EPOCH, dose level 1, uncapped vincristine. - ___: Discharged to home. Admission further complicated by isolated INR elevation of uncertain etiology, thought to be most likely Vitamin K deficiency, given Vitamin K 5 mg PO x 3 days. - ___: Dose 1 Rituximab. - ___: Admitted with febrile neutropenia, treated with intravenous antibiotics and quickly resolved. MRI of the spine on ___ shows that the T3 spinous process tumor extended into the epidural space, with no encroachment on the spinal cord, extensive neoplastic involvement of the sacrum and iliac bones without spinal canal compromise, and degenerative disease at L4-5 with compression of the L5 nerve roots, as well as large right anterior mediastinal mass. - ___: Dose 2 Rituximab. Planned for C2 da-EPOCH on ___ delayed because of persistent thrombocytopenia. - ___: C2D1 da-EPOCH, dose level 1, uncapped vincristine. Bactrim stopped because of possible contribution to thrombocytopenia, Atovaquone initiated for pneumocystis prophylaxis. - ___: Lumbar puncture attempted for diagnosis and prophylactic intrathecal chemotherapy, but unsuccessful. - ___: Dose 3 Rituximab. - ___: Planned for C3 da-EPOCH but delayed because of persistent thrombocytopenia. - ___: Admitted for C3D1 da-EPOCH, dose level 2, vincristine reduced by 25% because of peripheral neuropathy on ___. CT abdomen to evaluate left upper abdominal pain shows no evidence of splenic abnormality, with patent splenic vein without evidence of thrombosis. It also demonstrates interval improvement in lytic lesion through the bilateral iliac wings. - ___: Undergoes Lumbar Puncture with prophylactic intrathecal methotrexate x 1. This reveals 2 WBC (69% lymphs), 7 RBCs, TProt 29, and Gluc 70, with normal FISH and flow cytometry. - ___: Discharged to home. - ___: ED visit for post-LP headache, improved with IV fluids and Fioricet. - ___: Dose 4 Rituximab. - ___: Bone Marrow Biopsy performed for persistent moderate thrombocytopenia. This reveals a mildly hypercellular myeloid-dominant bone marrow with maturing trilineage hematopoiesis. The karyotype is 46,XY[20], and FISH is negative for the MDS panel. Myeloid sequencing reveals no mutations. - ___: C4D1 da-EPOCH, dose level 1, vincristine dose-reduced by 50% (for peripheral neuropathy). - ___: Dose 5 Rituximab. - ___: da-EPOCH, dose level 2 PAST MEDICAL HISTORY: Primary Mediastinal B Cell Lymphoma, as above Social History: ___ Family History: Extensive family history of rheumatological disease. Mother with RA. Uncle with SLE. Aunt with history of "multiple benign tumors" who eventually developed cancer. No other family history of cancer, lymphoma, or leukemia. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 24 HR Data (last updated ___ @ 337) Temp: 98.5 (Tm 98.5), BP: 103/57, HR: 74, RR: 16, O2 sat: 100%, O2 delivery: RA, Wt: 197.2 lb/89.45 kg GENERAL: Lying comfortably in bed, NAD HEENT: Clear OP without lesions or thrush EYES: PERRL, anicteric NECK: supple, no JVD RESP: No increased WOB, no wheezing, rhonchi or crackles ___: RRR, no murmurs GI: soft, non-tender, no rebound or guarding, slightly hyperactive BS EXT: no edema, warm SKIN: dry, no obvious rashes NEURO: alert, fluent speech. PERRL, EOMI. ACCESS: POC, dressing C/D/I DISCHARGE PHYSICAL EXAM VSS GENERAL: Lying comfortably in bed, NAD, alopecia HEENT: NC/AT, sclera anicteric, PERRL, EOMI. OP clear. MMM. Sore right lateral surface of tongue. RESP: CTAB, no adventitious LS, non-labored. ___: RRR, normal S1/S2. No M/R/G GI: soft, NT, somewhat distended. No rebound or guarding, hyperactive BS, no HSM EXT: WWP. No ___ SKIN: Dry, no rashes or lesions NEURO: A+Ox3, non-focal ACCESS: L CW POC without erythema, drainage or tenderness. Pertinent Results: ADMISSION LABS ___ 03:52AM BLOOD WBC-2.3* RBC-3.27* Hgb-9.3* Hct-28.4* MCV-87 MCH-28.4 MCHC-32.7 RDW-18.8* RDWSD-60.6* Plt Ct-42* ___ 03:52AM BLOOD Neuts-94* Lymphs-6* Monos-0* Eos-0* Baso-0 AbsNeut-2.16 AbsLymp-0.14* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 03:52AM BLOOD Glucose-85 UreaN-17 Creat-0.7 Na-139 K-3.5 Cl-104 HCO3-23 AnGap-12 ___ 03:52AM BLOOD ALT-50* AST-22 LD(LDH)-159 AlkPhos-47 TotBili-1.1 ___ 03:52AM BLOOD Albumin-3.5 Calcium-8.4 Phos-4.1 Mg-2.0 DISCHARGE LABS ___ 11:10PM BLOOD WBC-10.0 RBC-3.21* Hgb-9.2* Hct-29.3* MCV-91 MCH-28.7 MCHC-31.4* RDW-19.1* RDWSD-61.6* Plt Ct-62* ___ 11:10PM BLOOD Neuts-81* Bands-8* Lymphs-5* Monos-5 Eos-0* ___ Myelos-1* NRBC-1.7* AbsNeut-8.90* AbsLymp-0.50* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.00* ___ 11:10PM BLOOD Glucose-109* UreaN-5* Creat-0.7 Na-144 K-3.9 Cl-105 HCO3-28 AnGap-11 ___ 11:10PM BLOOD ALT-46* AST-22 LD(LDH)-230 AlkPhos-82 TotBili-0.3 ___ 11:10PM BLOOD Albumin-3.8 Calcium-8.8 Phos-4.4 Mg-2.0 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Atovaquone Suspension 1500 mg PO DAILY 3. Cetirizine 10 mg PO DAILY:PRN seasonal allergies/bony pain 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia 6. Senna 8.6 mg PO BID:PRN constipation 7. Vitamin B Complex 1 CAP PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Allopurinol ___ mg PO DAILY 10. Filgrastim-sndz 300 mcg SC ASDIR 11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 12. Omeprazole 40 mg PO DAILY 13. OLANZapine 2.5 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Allopurinol ___ mg PO DAILY 3. Atovaquone Suspension 1500 mg PO DAILY 4. Cetirizine 10 mg PO DAILY:PRN seasonal allergies/bony pain 5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia 6. OLANZapine 2.5 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Vitamin B Complex 1 CAP PO DAILY 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================== primary mediastinal B cell lymphoma diarrhea fever splenic infarct nausea 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 DLBCL admitted w/ fever and GI sxs // ongoing profuse diarrhea w/ intermittent abdominal discomfort, evaluate for colitis or other intra-abdominal infection TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained with oral and intravenous contrast. Sagittal and coronal reformations were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 14.2 s, 0.2 cm; CTDIvol = 242.8 mGy (Body) DLP = 48.6 mGy-cm. 3) Spiral Acquisition 8.3 s, 53.9 cm; CTDIvol = 18.0 mGy (Body) DLP = 959.2 mGy-cm. Total DLP (Body) = 1,010 mGy-cm. COMPARISON: Prior studies available from ___. FINDINGS: Central venous catheter terminates at the cavoatrial junction. Visualized lung bases appear clear. No pleural effusions. No focal liver lesions are identified. There is no biliary dilatation. Phrygian cap along the gallbladder.Pancreas is unremarkable. Adrenals appear normal. The spleen is again enlarged. It measures up to 18.5 cm in length, essentially unchanged. Spleen shows a new area of infarction (7:15) which is partly liquified. No evidence for stones, solid masses, or hydronephrosis involving either kidney. The stomach is nondistended. Small bowel is unremarkable. Mildly prominent fluid content along the colon but without dilatation, wall thickening or pericolonic inflammatory changes. Appendix appears normal. Small focus of air in right anterior subcutaneous fat suggests injects near site. Prostate is mildly enlarged with central hypertrophy. Seminal vesicles appear normal. Bladder is unremarkable. Right mid ureter is again slightly prominent in caliber. There is no lymph adenopathy or free fluid. There is a large gastro omental collateral that is unchanged and probably due to a collateral pathway associated with marked narrowing of the splenic vein although it remains patent. There are no suspicious bone lesions. Bones appear demineralized. Sclerotic areas in the pelvis demonstrate no short-term change. There is a slight new compression fracture of the superior endplate of T12 without healing, new since ___. Late ___. IMPRESSION: 1. Nonspecific mildly prominent fluid content along the colon without specific evidence for colitis. 2. Moderately enlarged spleen, unchanged in size, but with new splenic infarct. 3. New mild superior endplate compression fracture of T12 since late ___. Radiology Report EXAMINATION: CT angiography of the abdomen and pelvis. INDICATION: Primary mediastinal B-cell lymphoma with splenic infarct. TECHNIQUE: Following acquisition of a noncontrast scan of the abdomen, multidetector CT images of the abdomen were obtained in arterial and portal venous phases following intravenous contrast administration. The portal venous phase images include the pelvis. In addition, delayed phase images of the abdomen are included at 16.3 minutes. Sagittal and coronal reformations of the arterial and portal venous phase images are included as well as a coronal MIP image. This study also includes multiplanar MIP and volume high for an rendered reformations of the arterial and venous vasculature of the abdomen. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.1 s, 33.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 185.5 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 3) Stationary Acquisition 21.3 s, 0.2 cm; CTDIvol = 362.4 mGy (Body) DLP = 72.5 mGy-cm. 4) Spiral Acquisition 4.4 s, 28.3 cm; CTDIvol = 18.6 mGy (Body) DLP = 515.1 mGy-cm. 5) Spiral Acquisition 8.6 s, 55.6 cm; CTDIvol = 17.6 mGy (Body) DLP = 969.7 mGy-cm. 6) Spiral Acquisition 4.4 s, 28.3 cm; CTDIvol = 18.6 mGy (Body) DLP = 515.1 mGy-cm. Total DLP (Body) = 2,260 mGy-cm. COMPARISON: CT performed on the prior day and ___. FINDINGS: Venous catheter terminates at the cavoatrial junction. Visualized lung bases appear clear. No focal liver lesions are identified. There is no biliary dilatation. Phrygian cap along the gallbladder, consistent with a normal variant. Pancreas appears normal. Spleen is again enlarged, measuring up to 17.9 cm in length without short-term change. An infarct in the spleen is also unchanged. Adrenals appear normal. Stomach is nondistended. Small bowel shows mildly prominent fluid content distally, and similar to the recent prior study, there is mildly prominent fluid content along the whole colon, but without wall thickening or associated inflammatory changes. Prostate is again enlarged with central hypertrophy. Distal ureters, seminal vesicles and bladder appear normal. There is no ascites. There is no discrete lymphadenopathy, only stable soft tissue thickening in the splenic hilum which is unchanged since at least ___. There is similar narrowing of the mid splenic vein and probably multifocal narrowings among splenic venous branches at the hilum that are sequela of prior lymphoma at the site and thrombosis that has resolved. Owing to this circumstance, there are numerous collateral vessels draining the spleen including extensive gastric fundal varices, without short-term change. There also small paraesophageal varices and a large gastro omental collateral from the splenic hilar venous branches in the hilum to the superior mesenteric vein. Bony structures are unchanged, including bilateral iliac lesions. Slight superior compression deformity of T12 is unchanged. IMPRESSION: 1. No evidence of splenic venous thrombosis. Unchanged sequela of prior splenic venous thrombosis and lymphoma in the splenic hilum, however, with narrowed venous structures and associated collateral flow including gastric varices. 2. Unchanged splenic infarct. Stable moderate splenomegaly. 3. Mildly prominent fluid content along the distal small bowel and colon, similar to recent prior findings, nonspecific. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Diarrhea, Fever Diagnosed with Fever, unspecified temperature: 100.7 heartrate: 102.0 resprate: 18.0 o2sat: 97.0 sbp: 117.0 dbp: 73.0 level of pain: 0 level of acuity: 3.0

Mr. ___, You were admitted for diarrhea. Your diarrhea was treated with IV antibiotics. You completed your antibiotic course and are now medically ready for discharge. Sincerely, your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iron / adhesive tape Attending: ___. Chief Complaint: Chest tightness Atrial fibrillation with RVR Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ hx of CAD (s/p ___ DES to RCAx3, distal RCAx1, marginal branchx1), atrial fibrillation s/p cardioversion (___) on warfarin, HTN, DM, ESRD s/p renal transplant, and presenting with RVR, chest pressure without hemodynamic instability. Patient has been experiencing three days of chest pain beginning ___. Pain ranges from a ___, with radiation to the back, worsened by exertion. Initially relieved by nitro x1 on Wednseday but pain returned on ___. Associated with SOB and lightheadedness but no diaphoresis. He additionally denies any fevers/chills, nausea/vomiting, abd pain, diarrhea/constipation, or dysuria. He presented to ___ for outpatient follow-up and was found to be atrial fibrillation with HR in 110s. Patient was recently admitted to ___, 2 weeks ago for a-fib with RVR that was managed with sedated cardioversion and diltiazem. Stay was complicated by NSTEMI with DES placed on ___ RCAx3 and again on ___ RCAx1 marginal arteryx1. Patient was discharged on ___ in sinus rhythm with no chest pain on coumadin, spirin 81mg and plavix. -In the ED initial vitals were: T: 98.1 HR: 116 BP: 109/80 RR: 16 SO2: 99% RA. -EKG showed atrial fibrillation with ventricular rate of 133 -Labs/studies notable for subtherapetuic INR 1.8, Cr 1.6 (from 1.3 on discharge), trop 0.19 (0.50 ___. CXR shows no acute cardiopulmonary process. -Patient was given: Diltiazem 15 mg IV (h/o of depressed EF last admission), started on IV heparin gtt, 25 mg metop tartrate x 1, SL nitro 0.4 mg. -Cardiology was consulted and recommended continuing antiplatelet, heparinizing given INR subtherapeutic, giving metop 25 mg q6h, cycling trops, and admission to cardiology. On the floor, he appears comfortable, with no acute comlaints of chest pain, chest tightness. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies fevers or chills. 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 exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: HYPERCHOLESTEROLEMIA HYPERTENSION DIABETES TYPE II 2. CARDIAC HISTORY: - PUMP FUNCTION: >55% - PACING/ICD: None. - CHRONIC ANGINA 3. OTHER PAST MEDICAL HISTORY: CHRONIC OBSTRUCTIVE PULMONARY DISEASE h/o ERSD on hemodialysis since ___ bilateral AV fistulae s/p cadaveric renal transplant (R) anastomosed to right iliac artery/vein on ___ IMPOTENCE LUNG NODULE OSTEOPENIA TOE FRACTURE BILATERAL KNEE PAIN (RIGHT >LEFT) ENLARGED LYMPH NODES DEPRESSION ALLERGIC RHINITIS H/O GI ULCER H/O TOE FRACTURE H/O GASTROINTESTINAL BLEEDING Social History: ___ Family History: Significant for hypertension in his mother. A granddaughter had an unspecified cardiomyopathy at age ___ that required heart transplant. Father with diabetes and prostate Ca. Mother with DM. Brother with 3x CVAs. Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VS: Afebrile, Tachycardic to 110s, BPs 100s-110s/50s-60s, RR: 18, >95RA General: NAD HEENT: NCAT, PERRL, EOMI, Neck: no e/o of JVP distension. CV: irregular rhythm, not tachycardic +II/VI systolic murmur greatest at ___ Lungs: CTABL no w/c/r Abdomen: soft, NDNT, no ttp on right lower abdomen. Ext: non edemaatous, Neuro: CNII-XII intact, grossly non-focal, full strength Upper extremities and lower extremities (___), sensation normal. Skin: +palpable former fistula, no bruit PHYSICAL EXAM ON DISCHARGE: =========================== Vitals: T Afebrile, HR: 80-90s BP: 100s-120s/60s-70s RR: ___ >95RA. General: AOx3, NAD. HEENT: NCAT, PERRL, EOMI, mucous membranes moist. NECK: Supple, no appreciable JVD. CV: sinus, +II/VI systolic murmur greatest at ___ LUNGS: Clear to auscultation bilaterally with no crackles, wheezes, or rhonchi. Abdomen: soft, NDNT, nontender to palpation at prior kidney transplant on Rt side. Ext: no ___ edema, wwp, +DPP Neuro: CNII-XII intact, grossly non-focal, UEs + LEs ___ strength b/l. Skin: +palpable former fistula, no bruit Pertinent Results: Labs on Admission ================= ___ 03:26PM BLOOD WBC-5.8 RBC-4.07* Hgb-11.7* Hct-37.3* MCV-92 MCH-28.7 MCHC-31.4* RDW-12.9 RDWSD-43.2 Plt ___ ___ 03:26PM BLOOD Plt ___ ___ 04:55PM BLOOD ___ PTT-34.0 ___ ___ 03:26PM BLOOD Glucose-218* UreaN-29* Creat-1.6* Na-135 K-5.0 Cl-102 HCO3-21* AnGap-17 ___ 03:26PM BLOOD cTropnT-0.19* ___ 01:13AM BLOOD CK-MB-4 cTropnT-0.18* ___ 10:35AM BLOOD CK-MB-3 cTropnT-0.18* ___ 03:57AM BLOOD CK-MB-2 cTropnT-0.13* ___ 09:20AM BLOOD CK-MB-2 cTropnT-0.12* ___ 09:42AM BLOOD Calcium-9.8 Phos-3.1 Mg-1.5* ___ 09:42AM BLOOD tacroFK-4.7* Labs at Discharge ================= ___ 09:05AM BLOOD WBC-4.9 RBC-4.23* Hgb-12.1* Hct-38.4* MCV-91 MCH-28.6 MCHC-31.5* RDW-13.1 RDWSD-43.6 Plt ___ ___ 09:05AM BLOOD Plt ___ ___ 09:05AM BLOOD ___ PTT-64.0* ___ ___ 09:05AM BLOOD Glucose-154* UreaN-28* Creat-1.7* Na-134 K-4.0 Cl-99 HCO3-23 AnGap-16 ___ 09:05AM BLOOD Calcium-10.0 Phos-3.2 Mg-1.8 ___ 09:05AM BLOOD tacroFK-5.9 ___ 09:20AM BLOOD tacroFK-5.5 rapmycn-6.0 Pertinent studies: ================== CXR ___: 1. No acute cardiopulmonary process. 2. Stable prominence of right pulmonary artery is suggestive of pulmonary artery hypertension. 3. Stable mild cardiomegaly. No pulmonary edema. 4. Stable left lung 10 mm pulmonary nodule, unchanged from ___ and better assessed on CT chest from ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Enalapril Maleate 2.5 mg PO DAILY 5. Sirolimus 1 mg PO DAILY 6. Tacrolimus 0.5 mg PO QAM 7. Tacrolimus 1 mg PO QHS 8. Doxazosin 4 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. amLODIPine 5 mg PO DAILY 11. Warfarin 3 mg PO DAILY16 12. PredniSONE 2.5 mg PO DAILY 13. Tiotropium Bromide 1 CAP IH DAILY 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY 15. Furosemide 20 mg PO DAILY 16. ZEMplar (paricalcitol) 1 mcg oral DAILY 17. Clopidogrel 75 mg PO DAILY 18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 20. Pantoprazole 40 mg PO Q24H 21. Metoprolol Succinate XL 12.5 mg PO DAILY 22. Humalog 3 Units Breakfast Levemir 6 Units Bedtime 23. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 24. Psyllium Powder 1 PKT PO DAILY:PRN constipation Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Metoprolol Succinate XL 150 mg PO QHS 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. Warfarin 2 mg PO DAILY 6. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 10. Clopidogrel 75 mg PO DAILY 11. Doxazosin 4 mg PO DAILY 12. Fluticasone Propionate NASAL 1 SPRY NU DAILY 13. Furosemide 20 mg PO DAILY 14. Humalog 3 Units Breakfast Levemir 6 Units Bedtime 15. Multivitamins 1 TAB PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 17. PredniSONE 2.5 mg PO DAILY 18. Psyllium Powder 1 PKT PO DAILY:PRN constipation 19. Sirolimus 1 mg PO DAILY 20. Tacrolimus 0.5 mg PO QAM 21. Tacrolimus 1 mg PO QHS 22. Tiotropium Bromide 1 CAP IH DAILY 23. ZEMplar (paricalcitol) 1 mcg oral DAILY 24. HELD- Enalapril Maleate 2.5 mg PO DAILY This medication was held. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Atrial Fibrillation w/ RVR Chest pressure 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 chest pain. Assess for pneumothorax. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: The lungs are hyperinflated and clear. No pleural effusion or pneumothorax. Prominence of the right pulmonary artery is stable. Again seen is a 10 mm nodular opacity projecting over the anterior left sixth rib which is unchanged dating back to ___. Stable mild cardiomegaly. Aortic arch, mitral annular disease and coronary artery calcifications are present. Mediastinal contour and hila are unremarkable. IMPRESSION: 1. No acute cardiopulmonary process. 2. Stable prominence of right pulmonary artery is suggestive of pulmonary artery hypertension. 3. Stable mild cardiomegaly. No pulmonary edema. 4. Stable left lung 10 mm pulmonary nodule, unchanged from ___ and better assessed on CT chest from ___. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Chest pain Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction temperature: 98.1 heartrate: 116.0 resprate: 16.0 o2sat: 99.0 sbp: 109.0 dbp: 80.0 level of pain: 2 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ because you had an irregular heart rhythm with a fast rate. You were started on Amiodarone to help control the heart rhythm. You will be taking 400 mg twice a day (2 tablets twice a day, with last dose on ___. You will then take Amiodarone 400 mg once a day (2 tablets daily for seven days starting on ___ last dose on ___. You will then be on Amiodarone 200 mg daily there after to help control your irregular rhythm. You will need to follow up with your heart doctor to decide whether to continue this medication. You were also given ___ of Hearts monitor (to monitor your heart rhythm). Please follow the instructions provided and follow up the results with your heart doctor. Your metoprolol XL at discharge was 150mg daily. We also made several changes to your medications. We discharged you with Imdur 60mg. We stopped your amlodipine (for blood pressure) because your blood pressures were better controlled. We also stopped your enalapril (heart medication) because your blood pressure was maintained while you were in the hospital. We also decreased your warfarin dose (blood thinner) because your blood number were in good control. Please discuss these medication changes with your heart doctor at your next appointment on ___. You will need to continue your other heart medications, which have not changed. In particular, you should continue to take aspirin and clopidogrel (also known as Plavix). These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents, and you may die from a heart attack. Please do not stop taking either medication without taking to your heart doctor, even if another doctor tells you to stop the medications. It was a pleasure to take care of you. We wish you the best with your health! Your ___ Cardiac Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: adhesive tape / Bactrim / Monurol Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: ================ ___ 08:35PM OTHER BODY FLUID ___ ___ 05:23PM ___ ___ 05:08PM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 05:08PM ___ this ___ 05:08PM ALT(SGPT)-65* AST(SGOT)-79* ALK ___ TOT ___ ___ 05:08PM ___ ___ 05:08PM ___ ___ 05:08PM ___ ___ ___ 05:08PM ___ ___ ___ ___ 05:08PM ___ ___ ___ REVI ___ 05:08PM PLT ___ PLT ___ ___ 05:08PM ___ ___ ___ 12:30PM UREA ___ ___ TOTAL ___ ANION ___ ___ 12:30PM ALT(SGPT)-69* AST(SGOT)-81* LD(LDH)-513* ALK ___ TOT ___ ___ 12:30PM ___ ___ ___ 12:30PM ___ ___ 12:30PM ___ ___ ___ 12:30PM ___ ___ IM ___ ___ ___ 12:30PM PLT ___ PERTINENT INTERVAL LABS: ======================== ___ 12:46AM BLOOD ___ ___ Plt ___ ___ 12:38AM BLOOD ___ ___ Plt ___ ___ 02:09AM BLOOD ___ ___ Plt ___ ___ 12:46AM BLOOD ___ ___ ___ ___ 12:38AM BLOOD ___ ___ ___ ___ 05:08PM BLOOD ___ ___ ___ ___ 12:46AM BLOOD ___ ___ ___ 12:38AM BLOOD ___ ___ ___ 06:01AM BLOOD ___ ___ ___ 02:09AM BLOOD ___ ___ ___ 05:08PM BLOOD ___ ___ ___ 12:46AM BLOOD ___ LD(LDH)-467* ___ ___ ___ 12:38AM BLOOD ___ LD(LDH)-439* ___ ___ ___ 02:09AM BLOOD ___ ___ 12:46AM BLOOD ___ ___ 12:38AM BLOOD ___ ___ 02:09AM BLOOD ___ ___ 12:30PM BLOOD ___ DISCHARGE LABS: ================ ___ 09:28PM BLOOD ___ ___ Plt ___ ___ 09:28PM BLOOD ___ ___ ___ ___ 09:28PM BLOOD ___ ___ ___ RBC ___ REVI ___ 09:28PM BLOOD ___ ___ ___ 09:28PM BLOOD ___ LD(LDH)-431* ___ ___ ___ 09:28PM BLOOD ___ MICRO: ====== ___ 4:25 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only beperformed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. BCX ___ x2 NGTD MRSA SCREEN (Final ___: No MRSA isolated. Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. IMAGING: ========= CT A/P ___ IMPRESSION: 1. Finding suggest right middle lobe pneumonia. 2. Mildly distended gallbladder with stones but without specific evidence for acute cholecystitis. 3. Findings concerning for chronic liver disease. 4. Moderate bladder distension, which might explain mild new right hydroureter. CXR ___ IMPRESSION: Opacities at the right lung base which may be due to aspiration, pneumonia, possibly asymmetric edema; less typical for atelectasis. Suspected mild coinciding vascular congestion. RUQUS ___ IMPRESSION: No features of cholecystitis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Atovaquone Suspension 750 mg PO DAILY 3. Escitalopram Oxalate 20 mg PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 400 mg PO BID 7. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate 8. Isavuconazonium Sulfate 372 mg PO DAILY 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. LORazepam ___ mg PO QHS:PRN inaomnia 12. Mycophenolate Mofetil 500 mg PO BID 13. Nitrofurantoin (Macrodantin) 100 mg PO DAILY 14. Omeprazole 20 mg PO DAILY 15. PredniSONE 7.5 mg PO DAILY 16. Promethazine 12.5 mg PO Q6H:PRN nausea 17. Jakafi (ruxolitinib) 5 mg oral BID 18. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 19. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 20. calcium citrate 250 mg calcium oral BID 21. Vitamin D 1000 UNIT PO DAILY 22. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 23. Loratadine 10 mg PO DAILY 24. Magnesium Oxide 140 mg PO DAILY 25. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third Line 26. Artificial Tears ___ DROP BOTH EYES Q4H:PRN itching 27. Senna 8.6 mg PO DAILY:PRN Constipation - First Line Discharge Medications: 1. LevoFLOXacin 750 mg PO DAILY Duration: 3 Doses One pill daily from ___ RX *levofloxacin 750 mg 1 tablet(s) by mouth once daily Disp #*3 Tablet Refills:*0 2. Vancomycin Oral Liquid ___ mg PO/NG BID RX *vancomycin 50 mg/mL 125 mg by mouth twice a day Refills:*0 RX *vancomycin 50 mg/mL 125 mg by mouth twice a day Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. Acyclovir 400 mg PO Q12H 5. Artificial Tears ___ DROP BOTH EYES Q4H:PRN itching 6. Atovaquone Suspension 750 mg PO DAILY 7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 8. calcium citrate 250 mg calcium oral BID 9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 10. Escitalopram Oxalate 20 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. FoLIC Acid 1 mg PO DAILY 13. Gabapentin 400 mg PO BID 14. Isavuconazonium Sulfate 372 mg PO DAILY 15. Jakafi (ruxolitinib) 5 mg oral BID 16. Levothyroxine Sodium 112 mcg PO DAILY 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. Loratadine 10 mg PO DAILY 19. LORazepam ___ mg PO QHS:PRN inaomnia 20. Magnesium Oxide 140 mg PO DAILY 21. Mycophenolate Mofetil 500 mg PO BID 22. Omeprazole 20 mg PO DAILY 23. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third Line 24. PredniSONE 7.5 mg PO DAILY 25. Promethazine 12.5 mg PO Q6H:PRN nausea 26. Senna 8.6 mg PO DAILY:PRN Constipation - First Line 27. Vitamin D 1000 UNIT PO DAILY 28. HELD- HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate This medication was held. Do not restart HYDROmorphone (Dilaudid) until you talk to your oncologist. This was weaned during hospitalization. 29. HELD- Nitrofurantoin (Macrodantin) 100 mg PO DAILY This medication was held. Do not restart Nitrofurantoin (Macrodantin) until you finish your levofloxacin. Pls restart when you are finished with your course of levofloxacin. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: =================== Pneumonia Hypoxic respiratory failure Sepsis Secondary diagnosis: ==================== Diarrhea Active GVHD of liver CVID History of recurrent diffuse large ___ lymphoma History of CMV VL detection History of recurrent C. diff T12 compression fracture hypothyroidism Depression GERD Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph, portable AP semi-upright. INDICATION: Shortness of breath. COMPARISON: CT is available from ___. FINDINGS: Central venous catheter terminates in the right atrium. Patient is status post mitral valve replacement. Lung volumes are very low. Cardiac, mediastinal and hilar contours appear stable. There is no definite pleural effusion. No visible pneumothorax. Patchy nonspecific left basilar opacity, although most frequently this would be due to atelectasis as there is some chronic scarring at the site. Right basilar opacity is patchy and may be due to newly developed pneumonia or aspiration since the recent prior CT of the abdomen, which depicted the lung bases. Mild vascular congestion. IMPRESSION: Opacities at the right lung base which may be due to aspiration, pneumonia, possibly asymmetric edema; less typical for atelectasis. Suspected mild coinciding vascular congestion. RECOMMENDATION(S): Short-term follow-up repeat radiographs may be helpful. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST ___ INDICATION: NO_PO contrast; History: ___ with abdominal pain. NO_PO contrast // cholecystitis? cholangitis? TECHNIQUE: Abdominal pain. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 2) Spiral Acquisition 5.9 s, 46.6 cm; CTDIvol = 13.2 mGy (Body) DLP = 613.4 mGy-cm. Total DLP (Body) = 623 mGy-cm. COMPARISON: ___. FINDINGS: Patient is status post mitral valve replacement. Heart is mildly enlarged. Opacities at each lung base suggest atelectasis, but right middle lobe opacity with air bronchograms raises suspicion for pneumonia. Morphological changes of the liver suggest fibrosis/cirrhosis including enlargement of the left lateral segments and caudate with respect to the right lobe which is moderately striking. No focal liver lesions are identified on this monophasic portal venous examination. There is no biliary dilatation. Gallbladder shows small layering stones, but is otherwise unremarkable. The pancreas appears normal. Patient is status post splenectomy. Adrenals are unremarkable. Very small simple appearing cyst along the upper pole of the right kidney. Mild scarring along the left upper pole. These findings are unchanged. In each case there is again prominent extrarenal pelvis, which is usually a normal variant. However, in this case the right ureter is also mildly dilated. This may be secondary to bladder distension. The stomach and small bowel appear normal. The extent of stool along the whole colon is moderately prominent. Hyperdense pill fragments are found within the colon. Appendix is identified and appears normal. Bladder is moderately distended. Again observed are moderate-sized left gonadal varices. Uterus and adnexa are otherwise unremarkable. Vascular calcification is mild. Major vascular structures appear widely patent. There is no lymphadenopathy, free air, or free fluid. Diastasis rectus. Bones appear demineralized. There are no suspicious bone lesions. Sclerotic focus in the left acetabulum is again consistent with a bone island. Moderate degenerative changes affect lower lumbar facets. Compression deformities of the T12 and L1 vertebral bodies are stable including kyphoplasty/vertebroplasty changes in T12. IMPRESSION: 1. Finding suggest right middle lobe pneumonia. 2. Mildly distended gallbladder with stones but without specific evidence for acute cholecystitis. Ultrasound may be helpful to evaluate further, however, if that remains a potential concern based on clinical grounds. Owing to its deep location, however, it would be difficult to assess for ___ sign regardless, however. 3. Findings concerning for chronic liver disease. 4. Moderate bladder distension, which might explain mild new right hydroureter. Radiology Report EXAMINATION: US ABD LIMIT, SINGLE ORGAN INDICATION: ___ year old woman with gallbladder distension, cholelithiasis, abd pain // CBD dilation, wall edema, e/o cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the right upper quadrant were obtained. COMPARISON: Prior CT abdomen pelvis done ___ FINDINGS: LIVER: No suspicious focal lesions on limited liver ultrasound. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 2 mm GALLBLADDER: Is partially collapsed. Multiple sub 5 mm cholesterol polyps are noted. Dependent small hyperdense calculi/gravel are noted in the gallbladder. No wall thickening. No sonographic ___. IMPRESSION: No features of cholecystitis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Weakness Diagnosed with Pneumonia, unspecified organism temperature: 101.6 heartrate: 80.0 resprate: 26.0 o2sat: 95.0 sbp: 103.0 dbp: 59.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___! WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you needed treatment for pneumonia. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You started on broad spectrum antibiotics and transitioned to oral antibiotics by the time of your discharge. - You were also given antibiotics to prevent C. diff infection. - You were given fluids. - You were weaned off of your dilaudid. - You were given oxygen to support your breathing. WHAT SHOULD I DO WHEN I GO HOME? - Please take all your medications as prescribed. - Please ___ with your doctor as noted in your discharge paperwork. We wish you the best, Your ___ care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Language difficulties and headache, found to have left parietal intraparenchymal hemorrhage Major Surgical or Invasive Procedure: ___ Three-vessel cerebral angiogram History of Present Illness: ___ is a ___ right handed woman with a history of breast cancer (s/p mastectomy in ___, undergoing XRT), Afib on Coumadin, CAD on ASA/plavix, and HTN who presented to the ED with language difficulties and headache, found to have left parietal intraparenchymal hemorrhage (IPH) on head CT. She has had "memory problems" since her surgery in ___, described as word finding difficulty and not answering questions appropriately. She had a non-contrast head CT in ___ for workup of this at ___, which showed small vessel disease but was otherwise unremarkable. She began having headaches began 6 weeks ago. She does not get headaches at baseline. These stopped for a couple weeks but then returned last week. The HA has been severe and is described as pounding all over. She has taken Tylenol which helps a ___. She has decreased appetite with the HA. She has difficulty describing details but does say sometimes the HA wakes her up from sleep. She had an MRI with and without contrast ___ at ___ to work up the headache which revealed leptomeningeal/sulcal FLAIR hyperintensity in the posterior left parietal lobe and anterolateral left occipital lobe. This was felt more likely to be collaterals related to left MCA or PCA stenosis as opposed to leptomeningeal metastatic disease given lack of significant enhancement. There were no masses seen. Of note, she called her doctor ___ endorsing waking from sleep at 6am with a ___ headache. This morning, she continued to have a headache and had worsening of her speech. She wasn't speaking well and couldn't hold a conversation. A friend came to visit and was having trouble understanding her. Her speech was "jumbled" - she rambled nonsensically on different subjects but was able to say the most important words. The words were understandable but the conversation didn't make much sense. Currently per the family, her speech is back at her baseline. Of note, her INR was elevated to 3.4 on ___ and has been running high recently. In the ED, head CT revealed a 1.9 cm left parietal IPH with surrounding edema concerning for hemorrhagic mass. Neurosurgery was consulted to recommended no urgent neurosurgical intervention. Her INR was elevated to 2.8 and she received Kcentra and 10mg IV vitamin K. Blood pressure was elevated to 214/102 and she was started on a nicardipine drip for goal SBP<160 per neurosurgery recommendations. She was given one dose of Keppra for sz prophylaxis. Neurology was consulted for further management. Review of Systems: Difficult to obtain ___ speech problems. Endorses some problems seeing intermittently. Endorses dizziness, weakness in legs while walking. Denies dysphagia, Endorses numbness in feet. Endorses difficulty with gait. No bowel or bladder problems. Denies recent fever or chills. Endorses recent weight loss. Denies cough, shortness of breath. Endorses hoarse voice. Past Medical History: Past Medical and Surgical History: - CKD stage 3 - CAD,Hx of MI - HTN - Hypercholesterolemia - gout - colonic adenoma - breast cancer, s/p partial mastectomy. Undergoing XRT - afib, on Coumadin - glucose intolerance - chronic sCHF, EF 45% Social History: ___ Family History: - sister died recently of ICH - HTN in the family Physical Exam: Admission Exam ___ EXAMINATION Vitals: 96.7 74 186/136 18 98% General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple. Pulmonary: clear to auscultation bilaterally Cardiac: RRR, no murmurs Abdomen: soft, nondistended Extremities: no edema, warm Skin: no rashes or lesions noted. NEUROLOGIC EXAMINATION -Mental Status: Awake and alert. Has difficulty relating history. Language is fluent but with semantic and phonemic paraphasic errors. She is perseverative and does not answer most questions appropriately. She cannot name hammock, cactus, nor feather on the stroke cards. She has difficulty describing the cookie jar picture but does describe things on both the left and right. Reading is intact to phrases on stroke card. She makes mistakes with repeating of phrases. She has difficult following the commands of the examination but can follow simple midline and appendicular commands. Speech was not dysarthric. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm bilaterally. Cannot comply with confrontation testing of visual fields, but appears to blink to threat less on the right. Unable to cooperate with funduscopic exam. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch in all distributions VII: No facial droop with symmetric upper and lower facial musculature bilaterally VIII: Hearing intact to voice. X: Voice is mildly hoarse. XI: cannot comply with strength testing of trapezii and SCM XII: Tongue protrudes in midline -Motor: She is full strength in deltoids and triceps bilaterally but is otherwise unable to cooperate with formal testing. She has pronation of the right hand. No tremor noted. Legs are antigravity and she moves them symmetrically. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 - Toes were equivocal bilaterally. -Sensory: Endorses no deficits to light touch or pinprick throughout. -Coordination: patient unable to cooperate with this exam -Gait: deferred given mental status and HTN Discharge Exam ___ Pertinent Results: ------- ------- Imaging ------- ------- ___ CT Head w/o contrast 1. 1.9 cm intraparenchymal hemorrhage with surrounding edema within the left parietal lobe with associated effacement of adjacent sulci is worrisome for a hemorrhagic metastatic lesion. No evidence of herniation. 2. Chronic changes including age-related cortical volume loss and sequelae of chronic small vessel ischemic disease. 3. 0.3 cm hypodensity within left putamen may represent chronic lacune or prominent Virchow ___ space. 4. Empty sella. ___ CTA HEAD W&W/O C & RECO 1. Stable 1.8 cm intraparenchymal left parietal hemorrhage with surrounding edema and mass effect causing effacement of the sulci. Underlying intracranial metastasis or mass lesion is not excluded. Recommend clinical correlation and attention on followup imaging to resolution. 2. Unremarkable CTA and CTV of the brain with no evidence of vascular malformation. ___ MR HEAD W & W/O CONTRAS 1. Study is markedly motion degraded limiting the evaluation. 2. Redemonstration of approximately 1.7 x 1.5 cm left temporal area of acute hemorrhage. Within limits of examination, lesions is not clearly demonstrate enhancement. Recommend followup imaging to resolution to exclude underlying mass obscured by hemorrhage. 3. Additional punctate areas of hemorrhage in right temporal lobe, raising concern for possible amyloid angiopathy. Recommend clinical correlation. ___ CAROTID/CEREBRAL BILAT BILAT Right PCOMM infundibulum/small aneurysm M3/M4 branch irregularities and beading of the vessels possibly consistent with local reversible cerebral vascular constriction syndrome Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 6. Oxybutynin 15 mg PO DAILY 7. Vitamin D ___ UNIT PO DAILY 8. Warfarin 1 mg PO DAILY16 9. Hydrochlorothiazide 25 mg PO DAILY 10. Anastrozole 1 mg PO DAILY 11. Torsemide 10 mg PO DAILY 12. Gabapentin 100 mg PO BID 13. Sertraline 50 mg PO DAILY 14. meTOPROLOL succinate 25 mg oral DAILY Discharge Medications: 1. Atorvastatin 20 mg PO QPM 2. Torsemide 5 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Amlodipine 10 mg PO DAILY 5. Verapamil SR 240 mg PO Q24H 6. Anastrozole 1 mg PO DAILY 7. Gabapentin 100 mg PO BID 8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 9. Oxybutynin 15 mg PO DAILY 10. Sertraline 50 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. Aspirin 81 mg PO DAILY 13. Clopidogrel 75 mg PO DAILY 14. Carvedilol 3.125 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L parietal IPH with SAH secondary to ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with question of delirium TECHNIQUE: Upright AP view of the chest COMPARISON: None. FINDINGS: Severe enlargement of the cardiac silhouette is demonstrated. The aorta is tortuous and potentially dilated. Mediastinal and hilar contours are otherwise unremarkable. Pulmonary vasculature is not engorged. Minimal streaky opacities in the lung bases likely reflect areas of atelectasis. No focal consolidation, pleural effusion or pneumothorax is visualized. Multiple clips are seen projecting over the right axillary region. There are no acute osseous abnormalities. IMPRESSION: Severe cardiomegaly. Bibasilar streaky atelectasis without focal consolidation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with breast cancer with severe headache. TECHNIQUE: Contiguous multidetector CT scan through the head was performed without intravenous contrast. Axial images displayed as separate 5 mm soft tissue and 2.5 mm bone algorithm image series DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 8.0 s, 16.1 cm; CTDIvol = 55.5 mGy (Head) DLP = 891.9 mGy-cm. Total DLP (Head) = 892 mGy-cm. COMPARISON: None. FINDINGS: A 1.9 x 1.9 cm (02:14) area of intraparenchymal hemorrhage with surrounding edema is seen within the left parietal lobe with associated effacement of adjacent sulci. No significant mass effect on the left lateral ventricle. There is no evidence of large territorial infarction. Mild prominence of ventricles and sulci is consistent age-related cortical volume loss. Periventricular, subcortical, and deep white matter hypodensities are likely sequelae of chronic small vessel ischemic disease. 0.3 cm hypodensity within the left putamen may represent a chronic lacune or prominent Virchow ___ space. There is an empty sella incidentally noted. No fracture identified. Bilateral mastoid air cells are partially opacified. The visualized portion of the paranasal sinuses and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Atherosclerotic calcifications of bilateral cavernous portions of internal carotid arteries are noted. IMPRESSION: 1. 1.9 cm intraparenchymal hemorrhage with surrounding edema within the left parietal lobe with associated effacement of adjacent sulci is worrisome for a hemorrhagic metastatic lesion. No evidence of herniation. 2. Chronic changes including age-related cortical volume loss and sequelae of chronic small vessel ischemic disease. 3. 0.3 cm hypodensity within left putamen may represent chronic lacune or prominent Virchow ___ space. 4. Empty sella. RECOMMENDATION(S): Recommend dedicated MR with contrast for further evaluation. Radiology Report EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD INDICATION: ___ year old female with intraparenchymal hemorrhage. Evaluate for vascular malformation. 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. 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: This study involved 7 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 55.8 mGy (Head) DLP = 891.9 mGy-cm. 4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7 mGy-cm. 5) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5 mGy-cm. 6) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 34.7 mGy (Head) DLP = 777.5 mGy-cm. 7) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 34.6 mGy (Head) DLP = 777.0 mGy-cm. Total DLP (Head) = 2,474 mGy-cm. COMPARISON: ___ noncontrast head CT. ___ contrast brain MRI. FINDINGS: CT HEAD WITHOUT CONTRAST: Again seen is a 1.8 x 1.8 cm intraparenchymal hemorrhage in the left parietal lobe (see 2:16) with surrounding edema and minimal surrounding mass effect causing effacement of the overlying sulci. Underlying intracranial metastasis of massive not completely excluded. No intraventricular or extra-axial hemorrhage is seen. No midline shift is seen. There is prominence of the ventricles and sulci suggestive involutional changes. No new intracranial hemorrhage is seen. There are scattered foci of periventricular, subcortical and deep white matter hypodensities ; nonspecific, likely secondary to small vessel ischemic changes. There is intracranial atherosclerotic calcification. Partially empty sella is incidentally seen. There is a small mucous retention cyst in the right maxillary sinus. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are otherwise clear. The orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches are patent, without high grade stenosis, occlusion, malformation,aneurysm greater than 3 mm in sizeor other vascular abnormality. The dural venous sinuses are patent. CTV head: Patent cerebrovascular venous circulation. IMPRESSION: 1. Stable 1.8 cm intraparenchymal left parietal hemorrhage with surrounding edema and mass effect causing effacement of the sulci. Underlying intracranial metastasis or mass lesion is not excluded. Recommend clinical correlation and attention on followup imaging to resolution. 2. Unremarkable CTA and CTV of the brain with no evidence of vascular malformation. RECOMMENDATION(S): Stable 1.8 cm intraparenchymal left parietal hemorrhage with surrounding edema and mass effect causing effacement of the sulci. Underlying intracranial metastasis or mass lesion is not excluded. Recommend clinical correlation and attention on followup imaging to resolution. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old female with intraparenchymal hemorrhage . Evaluate for intracranial mass or amyloid angiopathy. 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. The examination was performed using a 1.5T MRI. COMPARISON: ___ contrast head CTA. ___ noncontrast head CT. FINDINGS: The study is moderately degraded by motion limiting the evaluation. There is a 1.7 x 1.5 cm left temporal lobe non enhancing T1 hypointense, T2 hyperintense, nonenhancing lesion with fast diffusion and associated susceptibility artifact in keeping with a focus of intracranial hemorrhage as seen on recent prior CT of the head. There is surrounding FLAIR signal abnormality in keeping with vasogenic edema. There is no associated underlying enhancement to suggest an intracranial metastasis though evaluation for the postcontrast images is markedly limited given the motion artifact. There is suggestion of punctate right temporal areas of susceptibility that do not clearly correspond to areas of calcification on ___ noncontrast head CT, raising concern for punctate areas of hemorrhage (see 11:10). No acute intracranial infarct is seen. No midline shift is seen. The ventricles and sulci are normal in caliber and configuration. No osseous abnormalities are seen. There is mild mucosal thickening in bilateral maxillary sinuses with partial fluid opacification of bilateral mastoid air cells. The remaining paranasal sinuses and middle ear cavities are clear. The orbits are unremarkable. The visualized portion of the principle vascular flow voids are preserved. IMPRESSION: 1. Study is markedly motion degraded limiting the evaluation. 2. Redemonstration of approximately 1.7 x 1.5 cm left temporal area of acute hemorrhage. Within limits of examination, lesions is not clearly demonstrate enhancement. Recommend followup imaging to resolution to exclude underlying mass obscured by hemorrhage. 3. Additional punctate areas of hemorrhage in right temporal lobe, raising concern for possible amyloid angiopathy. Recommend clinical correlation. RECOMMENDATION(S): 1. Redemonstration of approximately 1.7 x 1.5 cm left temporal area of acute hemorrhage. Within limits of examination, lesions is not clearly demonstrate enhancement. Recommend followup imaging to resolution to exclude underlying mass obscured by hemorrhage. 2. Additional punctate areas of hemorrhage in right temporal lobe, raising concern for possible amyloid angiopathy. Recommend clinical correlation. Radiology Report INDICATION: ___ year old woman with concern for reversible cerebrovascular constriction syndrome. COMPARISON: None TECHNIQUE: The patient was transferred from the intensive care unit to the angio suite and positioned on the angio table. The patient was prepped and draped in usual fashion and a time-out was performed. Next, the right femoral artery was localized using anatomic landmarks and the skin superficial was infiltrated with local anesthetic. A 5 ___ sheath was placed into the femoral artery an ___ 2 diagnostic catheter was used to select the right common carotid artery, left common carotid artery, left vertebral artery. AP, lateral and oblique views of the intracranial circulation were obtained. The patient tolerated the procedure well the groin was sealed with Angio-Seal and the patient was transferred back to the intensive care unit. DEVICES: ___ 2 0.038 hydrophilic wire PROCEDURE: 1. Three-vessel cerebral angiogram FINDINGS: Right common carotid artery: There is significant tortuosity in the common carotid artery proximally without carotid bifurcation arteriosclerotic disease or stenosis. The intracranial vasculature is unremarkable with exception of a slight dilatation in the area of the PCOMM origin which may represent an infundibulum or small aneurysm. Left common carotid artery: The distal internal external carotid artery, anterior cerebral artery and middle cerebral artery of well visualized. Distally in the middle cerebral artery in the M3/M4 branch territory there is some caliber irregularities and some beading of the artery. Left vertebral artery: AP and lateral views of the posterior circulation are somewhat limited due to motion artifact. There is, however, no gross abnormality noted. IMPRESSION: Right PCOMM infundibulum/small aneurysm Left M3/M4 branch irregularities and beading of the vessels possibly consistent with local reversible cerebral vascular constriction syndrome I, ___, participated in this procedure. I, ___ ___, was present for the entirety of this procedure and supervised all critical steps. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with prior L parietal IPH and SAH and RCVS. Need to know whether or not to restart home coumadin. // Evaluate interval changes. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. No reformatted images were produced. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 6.4 s, 16.7 cm; CTDIvol = 53.8 mGy (Head) DLP = 897.1 mGy-cm. Total DLP (Head) = 897 mGy-cm. COMPARISON: ___ contrast-enhanced head MRI. ___ noncontrast head CT. FINDINGS: Again seen is a 1.9 x 1.7 cm focus of intraparenchymal hemorrhage and adjacent cytotoxic edema noted within the left temporal lobe (03:15), largely unchanged from the prior examination due to ___. No additional areas of intracranial hemorrhage are identified. There is no significant mass effect or evidence of midline shift. A hypodensity within the left putamen is unchanged and likely represents a chronic infarct. No large vascular territorial infarction. The ventricles and sulci are moderately enlarged, compatible with age related atrophic changes. Periventricular and subcortical white matter hypodensities are noted, likely the sequelae of chronic small vessel ischemic disease. There is preservation of gray-white matter differentiation. The basal cisterns are patent. 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. Stable appearance of a left temporal intraparenchymal hemorrhage with mild surrounding vasogenic edema. No evidence for new intracranial hemorrhage or appreciable local mass effect. 2. Evidence of moderate global cerebral atrophy and sequelae of chronic small vessel ischemic disease. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with sCHF EF45% // ? pulmonary edema ? pulmonary edema IMPRESSION: In comparison with the study of ___, there is again substantial enlargement of the cardiac silhouette without vascular congestion or pleural effusion. This combination raises the possibility of cardiomyopathy, or even possibly pericardial effusion. No evidence of acute focal pneumonia. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Headache, Lethargy Diagnosed with INTRACEREBRAL HEMORRHAGE, HYPERTENSION NOS, HX OF BREAST MALIGNANCY, LONG TERM USE ANTIGOAGULANT temperature: 96.7 heartrate: 74.0 resprate: 18.0 o2sat: 98.0 sbp: 186.0 dbp: 136.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, You were hospitalized due to symptoms of language difficulty and headache resulting from an ACUTE HEMORRHAGIC STROKE (ACUTE CEREBRAL HEMORRHAGE), a condition in which a blood vessel providing oxygen and nutrients to the brain ruptures preventing adequate blood flow to portions of the brain. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. The hemorrhage may have been caused by REVERSIBLE CEREBRAL VASOCONSTRICTION SYNDROME, which is a result of constriction of the blood vessels supplying your brain. To determine if this is the cause, you were started on a new medication (verapamil). You should continue verapamil for 3 months and we will complete a new scan in 3 months. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - High blood pressure - Heart disease with cardiac stents that require blood thinners. You should continue your aspirin and plavix. We discussed your warfarin medication with your cardiologist and we decided you should stop this medication and undergo telemetry monitoring to determine if you have an irregular heart rhythym at rehab. If you do, then you and your cardiologist can discuss re-starting the medication, but we do not recommend that you use aspirin, plavix and warfarin together. You will need strict management of your blood pressure. Please purchase a blood pressure cuff at your nearest pharmacy and start measuring your blood pressure daily. Your systolic blood pressure (the top number) goal is <140. Keep a log of your blood pressures and bring them to every appointment. We also recommend a heart healthy diet (low fat, low salt), daily exercise, and stress reduction techniques. Please follow up with your primary care physician in the next ___ weeks. We would also like you to follow up in our clinic in ___ months. We are changing your medications as follows: START Amlodipine 10 mg daily START Verapamil 240 mg daily. Continue for 3 months. START Carvedilol 3.125 CHANGE to Atorvastatin 20 mg daily CHANGE to Torsemide 5 mg from 10 mg STOP Hydrochlorothiazide 25 STOP Metoprolol Succinate 25 STOP Warfarin 1 mg Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o HLD presenting with 2 weeks of fevers, night sweats, dry cough and new onset of crampy, right-sided non-radiating abdominal pain. He reports on ___, two weeks ago. While sitting on the couch watching TV a "wave of coldness" hit him with chills and sweats that lasted for about half an hour. Since then he's had intermittent, sudden-onset bouts of sweats/chills with fever to 102.6 F. He also reports fatigue, aching muscles and joints diffusely. He has had no weight loss, but endorses loss of appetite. He has had some nausea but no vomiting. He has had intermittent loose, nonbloody stools and less urination than normal. No chest pain or shortness of breath. Does have cough that has worsened over past month. He has had off and on headaches that worsen when he coughs or sneezes, improve with Tylenol/ibuprofen. Feels a "clicking" in his neck but no specific stiffness. No visual or hearing changes, no photophobia. No rashes or known tick bites although patient is a ___ and reports many insect bites. No sick contacts or family members. No recent travel. His initial vitals in the ED were 99.0 F, HR 91, BP 120/80, RR 18, O2 sat 99%RA. Tmax was 100.6. Labs were notable for ALT 378, AST 252, AP 370, CRP 76.1, WBC 5.4, H/H 14.7/43.0, PLT 84, normal chemistry, normal lactate, unremarkable UA, and negative parasite smear. Lyme serologies were sent. Blood and urine cultures were drawn. Chest x-ray showed "No acute cardiopulmonary process." He received acetaminophen 650mg PO, ketorolac 30mg IV, 1L NS IVF, and doxycycline 100mg PO. Past Medical History: HLD Social History: ___ Family History: Father: HLD Mother: h/o knee replacements x2 Physical Exam: On admission: Vital Signs: 98.4 F, BP 120/63, HR 72. RR 18, O2 sat 98% RA General: Alert, oriented, conversant, lying in bed looking up at the ceiling HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated, no LAD CV: RRR, no murmurs appreciated Lungs: CTAB Abdomen: Diffusely TTP, bloated-appearing and tympanitic to percussion, no HSM appreciated Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: EOMI, PERRL, symmetric face, facial muscles intact, strength ___ MSK: no muscle tenderness or joint pain to palpation. Joints appear non-erythematous, non-swollen On discharge: Vitals: T: 99.2 F (max overnight) BP: 102/59 P: 66 R: 18 O2: 100% RA General: Alert, oriented, fatigued, lying in bed HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, no murmurs appreciated Abdomen: soft, NTND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes appreciated Neuro: EOMI, PERRL, moving all four limbs equally Pertinent Results: ___ 06:50AM BLOOD WBC-5.3 RBC-3.54* Hgb-13.1* Hct-37.1* MCV-105* MCH-37.0* MCHC-35.3 RDW-15.2 RDWSD-59.3* Plt Ct-84* ___ 01:10PM BLOOD WBC-5.4 RBC-4.06* Hgb-14.7 Hct-43.0 MCV-106* MCH-36.2* MCHC-34.2 RDW-15.2 RDWSD-59.7* Plt Ct-84* ___ 01:10PM BLOOD Neuts-70.1 ___ Monos-8.4 Eos-0.2* Baso-0.4 Im ___ AbsNeut-3.74 AbsLymp-1.08* AbsMono-0.45 AbsEos-0.01* AbsBaso-0.02 ___ 06:50AM BLOOD Plt Ct-84* ___ 06:50AM BLOOD ___ PTT-28.4 ___ ___ 01:10PM BLOOD Plt Ct-84* ___ 06:50AM BLOOD ___ ___ 06:50AM BLOOD ___ ___ 01:10PM BLOOD Parst S-NEGATIVE ___ 01:10PM BLOOD Ret Aut-2.7* Abs Ret-0.11* ___ 06:50AM BLOOD Glucose-102* UreaN-11 Creat-1.0 Na-139 K-3.9 Cl-102 HCO3-25 AnGap-16 ___ 01:10PM BLOOD Glucose-96 UreaN-9 Creat-1.2 Na-136 K-3.9 Cl-99 HCO3-25 AnGap-16 ___ 01:10PM BLOOD estGFR-Using this ___ 06:50AM BLOOD ALT-254* AST-130* LD(LDH)-266* AlkPhos-298* TotBili-0.7 ___ 01:10PM BLOOD ALT-378* AST-252* LD(LDH)-360* CK(CPK)-60 AlkPhos-370* TotBili-1.0 ___ 06:50AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0 ___ 01:10PM BLOOD Albumin-4.0 ___ 06:50AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND ___ 06:50AM BLOOD CRP-56.6* ___ 01:10PM BLOOD CRP-76.1* ___ 06:50AM BLOOD HCV Ab-PND ___ 02:07PM BLOOD Lactate-1.1 ___ 06:00PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Cialis (tadalafil) 10 mg oral Other Discharge Disposition: Home Discharge Diagnosis: Final diagnosis: Fever Secondary diagnosis: HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male with fever and cough. Evaluate for acute infectious process TECHNIQUE: Frontal and lateral chest radiographs were obtained with the patient in the upright position. COMPARISON: None. FINDINGS: The lungs are clear of focal consolidation, pleural effusion or pneumothorax. The heart size is normal. The mediastinal contours are normal. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with new transaminitis, thrombocytopenia and fevers. Evaluate for etiology of transaminitis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic compatible with fatty infiltration. 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. The CBD measures 5 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas was not well seen secondary to overlying bowel gas. KIDNEYS: Survey views of the right kidney does not demonstrate any masses, hydronephrosis, or stones. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease including hepatic fibrosis or cirrhosis or steatohepatitis cannot be excluded on the basis of this examination. Gender: M Race: OTHER Arrive by WALK IN Chief complaint: Fever, Cough Diagnosed with FEVER, UNSPECIFIED temperature: 99.0 heartrate: 91.0 resprate: 18.0 o2sat: 99.0 sbp: 120.0 dbp: 80.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, You were admitted to ___ for evaluation of your episodic fevers. We treated you empirically with an antibiotic called doxycycline against tick-borne illnesses. While taking this medication, you should avoid direct sunlight, as you are at risk for developing a rash while on this medication. We also did diagnostic tests that were pending at the time of discharge. You should follow up these results with your primary care doctor to discuss with you when they become available. It was a pleasure caring for you, and we wish you all the best. Sincerely, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / ibuprofen Attending: ___. Chief Complaint: Found down Major Surgical or Invasive Procedure: arterial line x 2 PICC ___ History of Present Illness: Ms. ___ is ___ year old female with PMH HTN, HLD, stroke, and OSA who was found down by her family at 10:45am this morning of unclear etiology s/p intubation for airway protection now transferred to MICU for further management. Per the patient's family, the patient was ___ her normal state of health until a couple of days ago when she was a little more somnolent and "out of it" with intermittent episodes of "incoherent speech." No focal deficits noted and the patient was not complaining of any fevers, chills, n/v, CP, SOB, diarrhea or urinary symptoms. This morning, her friend was visiting her and per the family, stated that the patient looked overall unwell/sickly. The friend called EMS given that the patient looked ill and following the phone call, the patient reportedly fell to the ground and began "convulsing." By the time EMS arrived, the convulsions had stopped and the patient was unresponsive. Per EMS evaluation, the patient was unresponsive with pinpoint pupils and SpO2 50%. She was bagged without difficulty and her O2 sats improved. She was given narcan without improvement and brought into ___ ED. Once ___ the ED, the patient was again bag ventilated without difficulty but was intubated for airway protection. Upon arrival to the ED, initial vitals: 100.2 83 ___ Intubation Labs notable for: WBC 14.5 HgB 12.6 Plt 391 Na:142 K:4.6 Cl:109 TCO2:15 BUN 14 Cr 0.7 Glu:244 ___: 11.4 PTT: 28.7 INR: 1.1 Lactate:11.4, Fibrinogen 422 Utox: Negative Stox: Negative UA: Neg for leuks, neg for nitrites, >600 protein, 1000 glucose, trace ketones, no bacteria Imaging notable for: CXR showed appropriate ET tube placement. Low lung volumes with basilar atelectasis as well as streaky opacity ___ left lung base c/f aspiration Non-con head CT: no evidence of acute bleed or infarction. Has hypodensity ___ the right centrum semiovale extending into basal ganglia compatible with chronic infarct CTA Head and Neck: Read pending Neurology was consulted given concern for stroke and recommended MRI head, empiric treatment for HSV and bacterial meningitis as well as LP. An LP was performed and the patient was given: -Acyclovir 550 mg IV ONCE -CefePIME 2 g IV ONCE -Vancomycin 1000 mg IV ONCE -NiCARdipine 0.5-3 mcg/kg/min IV DRIP TITRATE TO Goal BP<180 Upon arrival to the MICU, the patient had an episode of full body convulsions. She was given Ativan 2mg IV x1 with improvement of symptoms. Past Medical History: HLD HTN Stroke ___ with left sided facial droop and left arm weakness with imaging at that time showing infarct ___ the right corona radiata extending to the superior portion of the right basal ganglia region NIDDM OSA Known thyroid nodule Primary hyperparathyroidism Social History: ___ Family History: -Mother: DM, HTN, stroke at age ___ no seizures or migraines -Father: ___ Physical ___: ADMISSION PHYSICAL EXAM: ========================= VITALS: 99.4 144/72 80 30 100% on 350/26 PEEP 5 FiO2 50% GENERAL: Intubated, sedated, not following commands HEENT: ET tube ___ place, dry MM, pinpoint pupils that are minimally reactive to light LUNGS: Clear to auscultation bilaterally on anterior lung exam CV: Regular rate and rhythm, no murmurs ABD: soft, non-tender, +BS EXT: Warm, well perfused, no edema NEURO: Sedated, not withdrawing to pain or following commands DISCHARGE EXAM: ========================= VS - 98.7PO 155/56 hr51 18 96 RA General: well appearing, NAD ___ bed, CPAP on HEENT: sclera anicteric, MMM, Neck: No JVD, visible carotid upstroke CV: RRR, III/VI systolic murmur Lungs: CTAB, no r/m/g Abdomen: BS present, soft NTND GU: deferred Ext: WWP, no calf tenderness, DP 2+ Neuro: CNII-XII intact, ___ throughout, sensation intact throughout Skin: no rash Pertinent Results: ADMISSION LABS: ============== ___ 11:20AM BLOOD ___ PTT-28.7 ___ ___ 07:16PM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-142 K-3.0* Cl-107 HCO3-24 AnGap-14 ___ 07:16PM BLOOD ALT-21 AST-81* LD(LDH)-292* AlkPhos-79 TotBili-0.3 ___ 03:39AM BLOOD proBNP-360* ___ 07:16PM BLOOD Calcium-10.9* Phos-2.3* Mg-1.3* ___ 04:06AM BLOOD %HbA1c-6.5* eAG-140* ___ 11:20AM BLOOD Lipase-39 ___ 11:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: ======== ___ EEG: This is an abnormal continuous ICU monitoring study because of 1) occasional runs of bifrontal blunted sharp waves with a triphasic morphology, consistent with bifrontal cortical irritability that may be toxic-metabolic ___ etiology. (2) Discontinuous and diffusely slow background, indicative of a moderate to severe etiologically-nonspecific encephalopathy or due to medication effects. The excessive beta activity can be due to medication effects. There is one pushbutton activation for tremulous body movement, without EEG correlate. There are no electrographic seizures. ___ CTA HEAD/NECK 1. No evidence of acute intracranial abnormality. 2. The vessels of the circle of ___ and their major intracranial branches are patent without stenosis, occlusion, or aneurysm formation. 3. The carotid and vertebral arteries and their major branches are patent without evidence of significant stenosis or occlusion. 4. 1.4 x 1.9 cm heterogeneous left thyroid lobe lesion is incompletely evaluated on this exam. Recommend dedicated thyroid ultrasound for further evaluation. 5. Paranasal sinus disease, as described above. ___ MRI HEAD W/O CONTRAST 1. Right parietal lobe subacute infarction. 2. No evidence of acute infarction, hemorrhage or mass. 3. Right basal ganglia chronic lacunar infarction. 4. Enlargement of bilateral pterygoid muscles with corresponding enhancement, which is new from ___ and increased from ___. Given the absence of fatty infiltration on CT, finding is felt most likely to be related to myositis, perhaps related to a seizure. ___ TTE The left atrium is elongated. No atrial septal defect is seen on color flow Doppler, but there is early appearance of agitated saline/microbubbles ___ the left atrium/ventricle at rest most consistent with an atrial septal defect or stretched patent foramen ovale (though a very proximal intrapulmonary shunt cannot be fully excluded). There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: ASD/PFO detected on resting bubble study ___ RENAL ARTERY ULTRASOUND 1. Suboptimal right renal arterial waveforms, although without overt tardus parvus morphology. Overall diastolic flow on the right appears decreased, although unclear whether this is technical ___ nature. If clinically needed, consider either CTA or MRA for better assessment of renal arterial supply. 2. Left renal arterial waveforms are within normal limits. 3. Unremarkable morphologic appearance of the bilateral kidneys. Left renal cyst. ___ CXR NG tube tip is ___ the stomach. ET tube is ___ standard position. The cuff appears mildly hyperinflated. Cardiac size cannot be evaluated. There are low lung volumes. Pulmonary arteries are enlarged consistent with pulmonary hypertension. There is mild interstitial edema. Bibasilar opacities are consistent with atelectasis increased from prior. ___ CT ABD/PEL C+ 1. Mild fat stranding about the duodenum, may reflect duodenitis. 2. Homogeneously enhancing 1.6 x 1.5 cm left adrenal nodule is indeterminate, but statistically likely an adenoma. If further characterization is desired, a dedicated adrenal protocol CT or MRI could be obtained. 3. Diverticulosis. 4. CT chest dictated separately. ___ CT CHEST C+ 1. Predominantly right upper lobe alveolar abnormality is unlikely to be asymmetric pulmonary edema, more likely infection and/or hemorrhage. 2. Bibasilar consolidation, left greater than right, likely atelectasis. 3. Small, bilateral layering, nonhemorrhagic pleural effusions. 4. Moderately severe, compression fracture of the T10 vertebral body is age indeterminate. 5. Pulmonary artery enlargement is suggestive of although not diagnostic for pulmonary hypertension. ___ MRI/MRA RENAL, ABDOMEN/PELVIS 1. 1.8 cm left adrenal nodule is consistent with an adrenal adenoma. 2. No evidence of renal artery stenosis. 3. Hepatic steatosis. 4. Thickening and edema of the duodenum is consistent with duodenitis. MICROBIOLOGY: ============= ___ BLOOD CX: negative ___ URINE CX: negative ___ CSF CX: negative. Gram stain: negative. HSV PCR: negative. ___ SPUTUM CX: GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. CHRYSEOBACTERIUM INDOLOGENES. SPARSE GROWTH. STENOTROPHOMONAS MALTOPHILIA. SPARSE GROWTH. 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. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S DISCHARGE LABS ___ 02:00PM BLOOD WBC-9.1 RBC-2.62* Hgb-7.9* Hct-24.3* MCV-93 MCH-30.2 MCHC-32.5 RDW-15.0 RDWSD-50.0* Plt ___ ___ 02:00PM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-140 K-3.7 Cl-100 HCO3-23 AnGap-21* ___ 08:10AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 12:00PM BLOOD ALT-7 AST-15 LD(LDH)-280* AlkPhos-55 TotBili-0.2 ___ 07:00AM BLOOD Albumin-3.4* Calcium-11.3* Mg-1.7 ___ 05:39AM BLOOD calTIBC-252* VitB12-623 Folate-11 Ferritn-100 TRF-194* ___ 04:06AM BLOOD %HbA1c-6.5* eAG-140* ___ 05:39AM BLOOD TSH-3.0 ___ 08:52AM BLOOD PTH-117* ___ 03:19AM BLOOD 25VitD-31 ___ 12:00PM BLOOD PEP-NO SPECIFI IgG-947 IgA-201 IgM-23* IFE-NO MONOCLO Medications on Admission: The Preadmission Medication list is accurate and complete. 1. mometasone furoate (bulk) 100 % INH DAILY 2. Loratadine 10 mg PO DAILY 3. Jardiance (empagliflozin) 10 mg oral DAILY 4. Lisinopril 80 mg PO DAILY 5. Venlafaxine 37.5 mg PO BID 6. Labetalol 200 mg PO BID 7. Alendronate Sodium 70 mg PO QMON 8. Gabapentin 300 mg PO QHS 9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON 10. Omeprazole 40 mg PO BID 11. glimepiride 0.5 mg oral DAILY:PRN bs > 150 12. amLODIPine 10 mg PO HS 13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 14. Atorvastatin 20 mg PO QPM 15. Gemfibrozil 600 mg PO BID 16. Vitamin D 6000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cinacalcet 30 mg PO BID 3. HydrALAZINE 100 mg PO Q8H 4. Isosorbide Dinitrate ER 40 mg PO BID 5. Rivaroxaban 15 mg PO BID Duration: 21 Days 6. Spironolactone 200 mg PO DAILY 7. Labetalol 200 mg PO TID 8. Lisinopril 40 mg PO QHS 9. Alendronate Sodium 70 mg PO QMON 10. amLODIPine 10 mg PO HS 11. amLODIPine 10 mg PO HS 12. Atorvastatin 20 mg PO QPM 13. Gabapentin 300 mg PO QHS 14. Gemfibrozil 600 mg PO BID 15. glimepiride 0.5 mg oral DAILY:PRN bs > 150 16. Jardiance (empagliflozin) 10 mg oral DAILY 17. Loratadine 10 mg PO DAILY 18. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 19. mometasone furoate (bulk) 100 % INH DAILY 20. Omeprazole 40 mg PO BID 21. Venlafaxine 37.5 mg PO BID 22. Vitamin D 6000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Primary hyperparathyroidism Seizure Hypertensive emergency ___ Pneumonia DVT Secondary diagnoses: Anemia GERD Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: History: ___ with s/p intubation // Confirm ETT TECHNIQUE: Portable upright chest radiograph COMPARISON: None FINDINGS: The endotracheal tube terminates approximately 3.7 cm above the carina. The enteric tube courses beyond the diaphragm, terminating in the left upper quadrant. Lung volumes are low with bibasilar atelectasis. More confluent streaky opacity at the left lung base may represent sequelae of aspiration. Heart size is likely accentuated by the portable technique. No pneumothorax or large pleural effusion. IMPRESSION: 1. Appropriate positioning of endotracheal and enteric tubes. 2. Low lung volumes with bibasilar atelectasis. More confluent streaky opacity at the left lung base could be due to aspiration. Radiology Report EXAMINATION: 5 Q16 CT NECK INDICATION: History: ___ with sudden unreresponsiveness // ?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 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 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 897.1 mGy-cm. 2) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 81.7 mGy (Head) DLP = 40.8 mGy-cm. 3) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 31.8 mGy (Head) DLP = 1,207.9 mGy-cm. Total DLP (Head) = 2,146 mGy-cm. COMPARISON: CT head without contrast from ___ FINDINGS: CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage or evidence of acute infarction on this noncontrast CT. There is a hypodensity in the right centrum semiovale extending into the basal ganglia, compatible with a chronic infarct. Ventricles and sulci are normal in size and configuration. Mild mucosal thickening is seen in the bilateral ethmoid air cells. Aerosolized secretions, mild-to-moderate mucosal thickening, and a mucous retention cyst right noted in the left maxillary sinus. Otherwise, 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: There is a dominant right 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. An enteric tube is partially visualized in the esophagus. An ETT terminates in the distal trachea. A 1.4 x 1.9 cm heterogeneous lesion is noted in the left thyroid lobe (series 5: Image 75). Atelectasis is noted in the bilateral dependent lung apices. Atherosclerotic calcifications are seen in the aortic arch, right vertebral artery origin, and bilateral carotid bifurcations. IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. The vessels of the circle of ___ and their major intracranial branches are patent without stenosis, occlusion, or aneurysm formation. 3. The carotid and vertebral arteries and their major branches are patent without evidence of significant stenosis or occlusion. 4. 1.4 x 1.9 cm heterogeneous left thyroid lobe lesion is incompletely evaluated on this exam. Recommend dedicated thyroid ultrasound for further evaluation . 5. Paranasal sinus disease, as described above. RECOMMENDATION(S): Recommend dedicated thyroid ultrasound for further evaluation. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ patient with hypertension, prior stroke, found down at home. Concern for stroke versus encephalitis. 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: MRI and MRA brain ___, CTA head and neck ___, CT head ___ FINDINGS: There is no evidence of acute infarction or hemorrhage. There is right lentiform nucleus and caudate chronic lacunar infarction with mild ex vacuo dilatation of the right lateral ventricle. There is hyperintense T2/FLAIR signal changes within the medial right parietal lobe (11:15), which is new from the prior study dated ___, with associated small focus of enhancement (13:15), adjacent to cortical and subcortical FLAIR hyperintensity. This likely reflects a subacute infarction There is no mass effect or midline shift. There is no other abnormal enhancement. The dural venous sinuses appear patent on post-contrast MPRAGE images. The intracranial vascular flow voids are patent. There is enlargement of bilateral pterygoid muscles, right greater than left, with corresponding enhancement (100a: 28), which is new from the remote brain MRI from ___. The edematous appearance of the pterygoid muscles is increased when compared with the prior CT head from ___, without evidence of fatty infiltration. Although the etiology of this is uncertain, the symmetry suggests this may be inflammatory. Perhaps myositis after a seizure. There is mucosal opacification of the left maxillary sinus with a mucosal retention cyst, and mild opacification of bilateral ethmoid sinuses. The remaining paranasal sinuses appear clear. There is mild opacification of bilateral mastoid air cells with fluid. The orbits and soft tissues appear unremarkable. IMPRESSION: 1. Right parietal lobe subacute infarction. 2. No evidence of acute infarction, hemorrhage or mass. 3. Right basal ganglia chronic lacunar infarction. 4. Enlargement of bilateral pterygoid muscles with corresponding enhancement, which is new from ___ and increased from ___. Given the absence of fatty infiltration on CT, finding is felt most likely to be related to myositis, perhaps related to a seizure. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:54 ___, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with AMS found down s/p intubation with concern for aspiration PNA // Please assess for interval change Please assess for interval change IMPRESSION: ET tube tip is very low, and the level of the carina approximately 1 cm above the carina and should be pulled back at least 4 cm. NG tube tip is in the stomach. Heart size and mediastinum are stable but there is interval development of left basal atelectasis most as well as right basal atelectasis most likely due to abnormal position of the ETT. No vascular congestion. No pulmonary edema. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:23 AM, 3 minutes after discovery of the findings. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with AMS, hypertensive emergency, decrease urine output. // please do with Doppler, etiology of decreased urine output, please assess for renal artery stenosis TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 11.1 cm. The left kidney measures 11.7 cm. There is no hydronephrosis, stones, or solid masses bilaterally. There is a dominant central renal cyst within the left pelvis measuring 2.9 x 3.3 x 2.8 cm. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Renal Doppler: Right-sided intrarenal arteries demonstrate for visualization of flow, although unclear whether this is of technical cause. Where visualized, arterial upstrokes appear fairly brisk, although for assessment of diastolic flow. Intrarenal arteries on the left show normal waveforms with sharp systolic peaks and continuous antegrade diastolic flow. The resistive indices of the left intra renal arteries range from 0.7-0.8. The resistive indices on the right are not well assessed. Bilaterally, the main renal arteries are patent with normal waveforms. . Main renal veins are patent bilaterally with normal waveforms. The bladder is moderately well distended and normal in appearance. IMPRESSION: 1. Suboptimal right renal arterial waveforms, although without overt tardus parvus morphology. Overall diastolic flow on the right appears decreased, although unclear whether this is technical in nature. If clinically needed, consider either CTA or MRA for better assessment of renal arterial supply. 2. Left renal arterial waveforms are within normal limits. 3. Unremarkable morphologic appearance of the bilateral kidneys. Left renal cyst. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with hypoxia // Evaluate for pulmonary edema TECHNIQUE: Single frontal view of the chest COMPARISON: ___. IMPRESSION: NG tube tip isin the stomach. ET tube is in standard position. The cuff appears mildly hyperinflated. Cardiac size cannot be evaluated. There are low lung volumes. Pulmonary arteries are enlarged consistent with pulmonary hypertension. There is mild interstitial edema. Bibasilar opacities are consistent with atelectasis increased from prior. . Radiology Report INDICATION: ___ year old woman with NGT // Eval for NGT placement COMPARISON: Radiographs from ___ IMPRESSION: Endotracheal tube has been removed. There is a nasogastric tube whose tip and side port are below the GE junction appropriately sited. There is unchanged cardiomegaly. There are low lung volumes. Pulmonary arteries are again prominent. There is persistent pulmonary edema and bibasilar opacities which may represent atelectasis or early infiltrate. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT INDICATION: ___ year old woman with unilateral LUE edema, evaluate for 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 bilateral subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial and basilic veins are patent, compressible, and show normal color flow and augmentation. There is occlusive thrombus of the distal left cephalic vein near the antecubital fossa. IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Superficial thrombophlebitis of the left cephalic vein at the level of the antecubital fossa. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:10 ___, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) INDICATION: ___ year old woman with persistent altered mental status with PFO with concern for possible DVT, 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. Within the left deep femoral vein there is echogenic intraluminal material without documented color flow, which extends slightly into the left common femoral vein. Normal color flow and compressibility are demonstrated in the right posterior tibial and peroneal veins. There is normal compressibility of the left posterior tibial veins. The left peroneal veins could not be identified. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: Acute occlusive DVT in the left deep femoral vein, extending slightly into the left common femoral vein, where it is nonocclusive. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:10 ___, 1 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with fever and recent extubation. // progression of infiltrate COMPARISON: Radiographs from ___. IMPRESSION: Feeding tube is again seen. There is unchanged cardiomegaly. There is a right perihilar opacity and left basilar opacity which have worsened. There is mild pulmonary edema and likely small bilateral effusions. There are no pneumothoraces. Radiology Report INDICATION: ___ year old woman with PNA in ICU no BMs in several days. // ? obstruction TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: None available. FINDINGS: There are no abnormally dilated loops of large or small bowel. The stomach is distended. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are notable for degenerative disease of the lumbar spine. The enteric tube terminates in the stomach. IMPRESSION: No radiographic evidence of obstruction. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old woman with known DVT now with right arm welling // clot (right) TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: Left arm ultrasound ___ FINDINGS: There is normal flow with respiratory variation in the subclavians veins bilaterally. The right internal jugular, axillary and brachial veins are patent, show normal color flow and compressibility. The right basilic, and cephalic veins are patent. Superficial edema is incidentally noted. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Superficial edema incidentally noted. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new R PICC // R DL Power PICC 45cm ___ ___ Contact name: ___: ___ TECHNIQUE: Chest single view COMPARISON: ___ 10:04 FINDINGS: Right PICC line tip at cavoatrial junction. Enteric tube tip well below diaphragm, not included on the radiograph. Increased heart size, pulmonary vascularity, stable since prior. Probable small bilateral pleural effusions, similar. Bibasilar opacities, left lower lobe consolidation are stable. Right perihilar opacity may represent asymmetric edema, similar. No pneumothorax. IMPRESSION: New right PICC line. Otherwise stable. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman admitted to ___ for pneumonia, found to have bilateral lower extremity DVTs and upper extremity DVT. // Malignancy workup for hypercoagulability TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy (Body) DLP = 17.4 mGy-cm. 3) Spiral Acquisition 16.3 s, 62.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 789.8 mGy-cm. Total DLP (Body) = 826 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: 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 surgically absent. 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: Right adrenal gland is normal in size and shape. There is a homogeneously enhancing left adrenal nodule measuring 1.6 x 1.5 cm, 62 ___, indeterminate. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no hydronephrosis. No focal lesions in the right kidney. There is a 4.8 cm simple cyst in the left kidney. There is no perinephric abnormality. GASTROINTESTINAL: Enteric tube terminates in the body of the stomach. There is mild stranding about the duodenum (5:62), which may represent duodenitis. Small bowel loops otherwise demonstrate normal caliber, wall thickness, and enhancement throughout. Colonic diverticulosis. The rectum is fluid-filled. Normal appendix. No ascites. PELVIS: There is post instrumentation air within the bladder. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus is unremarkable in appearance. 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. Minimal anterolisthesis of L5 on S1 is noted. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Mild fat stranding about the duodenum, may reflect duodenitis. 2. Homogeneously enhancing 1.6 x 1.5 cm left adrenal nodule is indeterminate, but statistically likely an adenoma. If further characterization is desired, a dedicated adrenal protocol CT or MRI could be obtained. 3. Diverticulosis. 4. CT chest dictated separately. RECOMMENDATION(S): Consider adrenal protocol CT or MRI for further evaluation of the left adrenal nodule. NOTIFICATION: The findings and recommendation were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 5:48 ___, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ female admitted for pneumonia with bilateral lower extremity and upper extremity deep venous thromboses. Malignancy workup for hypercoagulability. TECHNIQUE: Multi detector CT images through the chest were performed after the administration of intravenous contrast. Coronal and sagittal reformations as well as axial maximum intensity projection reformations were generated 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 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy (Body) DLP = 17.4 mGy-cm. 3) Spiral Acquisition 16.3 s, 62.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 789.8 mGy-cm. Total DLP (Body) = 826 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: None. FINDINGS: The imaged thyroid gland is homogeneous in attenuation without focal nodularity. Scattered axillary nodes are not pathologically enlarged and normal in morphology. A right PICC terminates within the right atrium. Several mediastinal nodes are present. A right upper paratracheal node measures 8 mm the level of the thoracic inlet (05:16). A right lower paratracheal station node measures 7 mm (05:22). An aortopulmonary window node measures 8 mm in diameter (05:22). The ascending aorta is non aneurysmal. The main pulmonary artery is dilated measuring up to 44 mm (05:25) suggestive of although not diagnostic for pulmonary hypertension. Study is not designed for detection of pulmonary emboli beyond the lobar level. Heterogeneity within a right lower lobe pulmonary artery branch could very well reflect mixing artifact. There is no pericardial effusion. Multi-chamber heart enlargement is moderate. Diffuse coronary artery calcifications are moderately severe. Moderate calcifications involve the aortic arch, origins of head and neck vessels, and descending thoracic aorta. An enteric tube descends the thorax within the esophagus, its tip incompletely imaged. Small pleural effusions are nonhemorrhagic and layering, left greater than right. Secretions are present within the trachea. Consolidation within the left lower lobe and to a smaller degree the right lower lobe medially are associated with air bronchograms, may be atelectatic in etiology. A heavy volume of bronchocentric, ground-glass opacities is confined to the right upper lobe, confluent above fissural thickening of the minor fissure, as best appreciated on the sagittal reformations image 61. There are no worrisome osseous lesions in the chest cage. Moderately severe, compression fracture of the T10 vertebral body with depression of the anterior and superior endplate is age indeterminate. For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis performed concurrently, clip number ___. IMPRESSION: 1. Predominantly right upper lobe alveolar abnormality is unlikely to be asymmetric pulmonary edema, more likely infection and/or hemorrhage. 2. Bibasilar consolidation, left greater than right, likely atelectasis. 3. Small, bilateral layering, nonhemorrhagic pleural effusions.. 4. Moderately severe, compression fracture of the T10 vertebral body is age indeterminate. 5. Pulmonary artery enlargement is suggestive of although not diagnostic for pulmonary hypertension. 6. For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis performed concurrently, clip number ___. Radiology Report EXAMINATION: MRI of the abdomen INDICATION: ___ year old woman with resistant hypertension and adrenal mass on CT scan. // protocol for adrenal TECHNIQUE: T1 and T2 weighted images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 40 mL MultiHance. COMPARISON: CT performed ___. FINDINGS: The exam is limited due to motion artifact. Lower Thorax: The visualized lung bases demonstrate trace left pleural effusion. Liver: Visualized portions of the liver demonstrate normal contour. Hepatic steatosis. No focal liver lesion is seen. Biliary: Gallbladder is absent. No intrahepatic or extrahepatic biliary duct dilatation. Pancreas: Pancreas is unremarkable. Spleen: Spleen is normal size. No focal splenic lesion. Adrenal Glands: In the apex of the left adrenal gland, there is an 1.8 x 1.7 cm adrenal nodule. This demonstrates signal dropout on out of phase imaging and is consistent with an adrenal adenoma. Right adrenal gland is normal. Kidneys: The kidneys are normal size and symmetric. In the interpolar region of the left kidney, there is a 5.1 cm cyst. No evidence of renal artery stenosis. No accessory renal arteries. Gastrointestinal Tract: Hiatal hernia. Thickening and edema of the second portion of the duodenum, consistent with findings of duodenitis on prior CT. Lymph Nodes: No enlarged lymph nodes. Vasculature: Abdominal aorta is normal caliber. Mild atherosclerotic disease is noted of the abdominal aorta. Mild narrowing of the origin of the celiac axis. Osseous and Soft Tissue Structures: Bone marrow signal intensity is normal. IMPRESSION: 1. 1.8 cm left adrenal nodule is consistent with an adrenal adenoma. 2. No evidence of renal artery stenosis. 3. Hepatic steatosis. 4. Thickening and edema of the duodenum is consistent with duodenitis. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by UNKNOWN Chief complaint: Unresponsive Diagnosed with Altered mental status, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: 1.0

Dear Ms. ___, It was a pleasure to take care of you during your stay at ___ ___. Why did I have to stay ___ the hospital? You had to stay ___ the hospital because of confusion, high blood pressure, and high calcium. What was done for me? You had to stay ___ the ICU for two weeks because of your illness. You were seen by the endocrinologists (aka hormone doctors) and the nephrologists (aka kidney doctors) for your high blood pressures and high calcium. Your blood pressures and calcium were controlled with medications. What should I do after I leave the hospital? You should continue to take your medications as prescribed. You should follow up with your regular doctor. You should follow up with your endocrinologist. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Falls, left leg weakness and numbness. Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ y.o. right handed, ___ only speaking woman, with no past medical history except for calcifications seen on mammogram which have been followed, who is presenting with a 1 week history of left lower extremity weakness, numbness, and 3 falls in the context of dizziness. Mrs. ___ has been in her usual state of health, until the last 2 weeks. She has been reporting some headaches and lightheadedness, which is however not new or unusual for her. She also noticed some weakness in her left leg. One week ago (last ___, she was going upstairs at work when she suddenly felt that she got dizzy, her vision got blurry, her left leg felt numb and gave away. She fell towards the left, and landed on her lower back. She reports that it took her about 10 minutes for the lightheadedness (which did not have a vertigo component), to go away. She has not had a loss of consciousness. No SOB associated with this. Since then, she has been reporting on and off paresthesias in her left leg, sparing the foot, with cold sensation in her knee and shin. She has also been reporting weakness in her "knee", and this has been the same. The onset is however unclear. She has had difficulty with gait and has noticed that she is dragging her left leg. She has been reporting lower back pain, mostly on the left side, since her first fall. On ___, she was walking up the stairs when she also had a sensation of lightheadedness and fell. This sensation only occurs with position change and never when she is sitting or lying in bed. On neuro ROS, she reports intermittent right ear tinnitus for the last ___enies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, vertigo,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: Abnormal mammogram in ___ with calcifications, no biopsy, followed up and believed to be stable. Social History: ___ Family History: Negative for strokes. Physical Exam: Physical Exam on Admission: Vitals: T: 99.2 P: 63 R: 18 BP:114/51 SaO2: 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. She has a positive leg raising test on the left. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. Speech was not dysarthric (per ___ interpreter understanding). 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: 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, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Motor: Normal bulk and tone, no rigidity or bradykinesia. Left: Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad ___, Ham ___, TA 4+/5, ___ 4+/5, Gastroc 4+/5 Right: Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad ___, Ham ___, TA ___, ___ ___, Gastroc ___ -Sensory: Loss of sensation to light touch and pinprick in a patchy L3 and L4 distribution in the left leg, in addition to paraspinal areas on the right and left corresponding to L3. There was an area of sensory loss on the left flank, encompassing L1, T12, T10, T9, without involving the whole dermatomes but only the left side of her torso. I was unable to perform vibration and proprioception due to lack of time with the ___ interpreter. -Rectal tone normal, with normal anal wink, and no saddle anesthesia. Reflexes: DTRs Right: ___ 2 Tri 2 Brach2 Patellar 2 Achilles 1 Left: ___ 2 Tri 2 ___ 2 Patellar 2 Achilles 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. does drag her left foot. Rhomberg with mild sway to the left. Physical Exam on Discharge: Neuro exam with ___ strength in L IP, hamstring, TA; ___ in all other muscle groups in LEs and UEs. Sensation is intact to light touch throughout, improved since admission. Pertinent Results: Labs on Admission: ___ 06:20PM WBC-7.1 RBC-3.82* HGB-11.8* HCT-36.3 MCV-95 MCH-30.9 MCHC-32.5 RDW-12.6 ___ 06:20PM NEUTS-59.5 ___ MONOS-4.2 EOS-1.0 BASOS-0.5 ___ 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM ___ 06:20PM GLUCOSE-86 UREA N-11 CREAT-0.6 SODIUM-139 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12 ___ 07:30AM WBC-6.0 RBC-3.87* HGB-12.2 HCT-36.7 MCV-95 MCH-31.7 MCHC-33.3 RDW-12.5 ___ 07:30AM TRIGLYCER-134 HDL CHOL-47 CHOL/HDL-3.5 LDL(CALC)-89 ___ 07:30AM %HbA1c-5.6 eAG-114 ___ 07:30AM CHOLEST-163 ___ 07:30AM GLUCOSE-96 UREA N-11 CREAT-0.6 SODIUM-138 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 Imaging: Non Con Head CT FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. The ventricles and sulci are normal in size and configuration. There is no shift of normally midline structures. No acute fracture is detected. The middle ear cavities, mastoid air cells, and included views of the paranasal sinuses are clear. The right mastoid air cells are incidentally noted to be underdeveloped (2:7). IMPRESSION: No acute intracranial process. MRI C/L/T spine w/ and w/o contrast 1. No evidence of cord signal abnormality. 2. Multiple levels of cord impingement in the cervical spine caused by disc-osteophyte complexes, worst at c5/c6 and c6/7 where there is also left neural forminal narrowing. 3. Large annular tear with broadbase protrusion which significantly indents the ventral theca at the L4/5 level and the traversing the left L5 nerve root. It may also be contacting the right L5 nerve root, but not impinging this. 4. In the lower T and L spine, no paraspinal or epidural enhancing soft tissue mass. No pathologic or leptomengingeal cord focus of enhancement. Patient could not complete post contrast C-spine imaging. 5. No evidence of marrow replacement by cancer or epidural sot tissue mass however diffusely abnormal bone marrow signal, likely red marrow reconversion or osteopenia. Medications on Admission: none Discharge Medications: 1. ___ stockings 2. Outpatient Physical Therapy Evaluate and treat for left lower extremity weakness for cervical and lumbar spondylosis with radiculopathy Discharge Disposition: Home Discharge Diagnosis: cervical spondylosis with neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Level of Consciousness: Lethargic but arousable. Neuro exam with ___ strength in L IP, hamstring, TA; ___ in all other muscle groups in LEs and UEs. Sensation is intact to light touch throughout, improved since admission. Followup Instructions: ___ Radiology Report HISTORY: ___ woman with history of abnormal mammogram (but no history of malignancy, per OMR), left lower extremity weakness and sensory, and back pain. Query disc herniation versus malignant infiltration. COMPARISONS: None. TECHNIQUE: MRI of the entire spine, with and without contrast. N.B. The patient could not tolerate the entire exam and only post-gadolinium imaging of the lower thoracic and lumbar spine could be obtained. FINDINGS: There is diffuse heterogeneous T1- and T2-hypointensity of the all the veterbral bodies; while there is no evidence of marrow replacement by malignancy, the diffuse bone marrow signal abnormality could be related to red marrow reconversion (in response to anemia or systemic treatment) or osteopenia. There is no spinal cord signal abnormality through the conus medullaris, which is normal in morphology and terminates at the L2 level. The imaged retroperitoneal and paraspinal soft tissues are unremarkable in overall appearance. In the lower T and L-spine, where post-gadolinium images were obtained, there is no enhancing paraspinal or epidural soft tissue mass. There is no pathologic leptomeningeal or intramedullary focus of enhancement. CERVICAL SPINE: There are multiple levels of degenerative changes noted in the cervical spine. At C3/C4, there is central disc protrusion causing minimal compression of the thecal sac but no foraminal narrowing. At C4/C5, there is flattening of the thecal sac caused by broad-based disc-osteophyte complex. There is also bilateral mild to moderate neural foraminal narrowing at this level. At C5/C6, there is disc protrusion which extends into the the proximal left neural foramen and indents the spinal cord as well as narrows the left neural foramen, impinging upon the exiting C6 nerve root (5:18). At C6/C7, there is similar narrowing of the left intraforaminal zone and again narrowing of the neural foramina, impinging upon the exiting C7 nerve root. THORACIC SPINE: No significant degenerative changes are noted in the thoracic spine. LUMBAR SPINE: Again, there are multilevel, multifactoral degenerative changes in the lumbar spine, worst at L4/L5. In the L3 vertebral body, a somewhat rounded, well defined 1.4 x 1.1 cm T1- and T2-hyperintense lesion does not parallel the endplate and its signal is suppressed on "water" IDEAL images indicating a likely hemangioma. A similar, although slightly larger 1.5 x 1.4 cm lesion in the L4 vertebra also likely represents a hemangioma. Subtle ___ I and ___ changes are seen at the anterior aspect of the L4 vertebral endplate. At L4/L5, there is disc desiccation with a large transverse annular tear with broad-based protrusion which significantly indents the ventral theca and impinges upon the traversing left L5 nerve root (11:19). This also contacts the traversing right L4 nerve root; however, the degree of impingement is not nearly as severe on this side. At this level, there is also ligamentum flavum thickening, facet arthrosis and a significant narrowed subarticular recess At L5/S,1 there is again disc desiccation and a a small transversely-oriented annular tear with an accompanying protrusion which barely abuts the traversing S1 nerve roots. IMPRESSION: 1. No evidence of spinal cord signal abnormality. 2. Multilevel cord deformity in the cervical spine caused by disc-osteophyte complexes, most severe at C5/C6 and C6/C7, where there is also significant left neural foraminal narrowing with impingement upon the exiting left C6 and C7 nerve roots. 3. Multilevel degenerative disease in the lumbar spine, most marked at the L4/L5 level where a large annular tear with accompanying broad-based protrusion indents the ventral thecal sac and significantly impinges upon the traversing left L5 nerve root. 4. In the lower T- and the L-spine, no enhancing paraspinal or epidural soft tissue mass. No pathological or leptomeningeal, intramedullary or radicular focus of enhancement. (The patient could not tolerate post-contrast C-spine imaging.) 5. No evidence of marrow replacement by malignancy. However, the diffusely abnormal bone marrow signal may be due to red marrow reconversion, myeloproliferative disorders or osteopenia, and should be correlated clinically. COMMENT: These findings were discussed with the requesting provider, Dr. ___ (Neurology service), by Dr. ___ via telephone, at 5:25 p.m. on the day of the study. Gender: F Race: ASIAN - CHINESE Arrive by WALK IN Chief complaint: HYPOTENSION/FALLING Diagnosed with OTHER MALAISE AND FATIGUE, HEADACHE temperature: 99.2 heartrate: 63.0 resprate: 18.0 o2sat: 98.0 sbp: 114.0 dbp: 51.0 level of pain: 13 level of acuity: 3.0

Dear Ms. ___, You were admitted to the hospital with left leg weakness and numbness, back pain, and lightheadedness. You had an MRI of your spine which showed spine disease with the bones pressing on your spinal cord which explains your symptoms of weakness and numbness. On discharge, you should wear a cervical collar and work with physical therapy for your leg as an outpatient. However, DO NOT do any physical therapy involving your neck. Also, you should avoid lifting anything heavier than 10 pounds. You MUST wear your cervical at ALL times, 24 hours per day. Please do not return to work on discharge as we do not want you to exacerbate your injuries. When you follow up in neurology clinic as scheduled below, we will re-assess whether or not it is safe for you to return to work. The lightheadedness you have experienced is likely due to low blood pressure. We recommend that you stay hydrated and make sure you have some salt in your diet. For example, try to eat a bowl of soup daily. Also, you should wear ___ stockings to prevent your blood from pooling in your legs (prescription for these stockings is included). We have not made any changes to your medications. On discharge, please follow up with Drs. ___ in neurology clinic as scheduled below. It was a pleasure taking care of you, we wish you all the best!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending: ___. Chief Complaint: cough, fever Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ year old man w ___ CAD s/p MI w PCI, ischemic cardiomyopathy with EF ___, h/o VT with ICD in place, h/o L ventricular apical thrombus on A/C, CKD, suspicion for prostate ca, p/w fever and worsening cough. The patient noted fever to 102.4 the night prior to presentation. He has had a cough over the past ___ weeks, which worsened acutely over the past week/few days. For the past couple of nights the cough has been so bad that it kept him up at night. The cough is productive of white/yellow sputum with streaks of blood. He has also felt increasingly SOB for the past few weeks which he mostly notices when going up stairs. Denies chills, sweats, chest pain, recent ICD firinng. he had some nausea associated with coughing but no vomiting. No diarrhea. No URI sx, no sick contacts. Of note he was supossed to follow up with outpatient pulmonology for evaluation of his ongoing cough. His PCP had recommended he get PFTs. There was some concern for possible amiodarone toxicity leading to chronic cough. In the ED VS were 97.6 100.9 107/71 18 98% ra. CXR showed R middle lobe pneumonia. EKG unchanged from prior. He recieved Furosemide 20 mg PO, fluticasone, Azithro 500, CTX 1 gram, Tylenol 1 gram. Labs showed INR 1.8 Cr 1.4, K 3.1. He was admitted to medicine with pneumonia. Past Medical History: - ischemic cardiomyopathy, CHF- EF ___ - ICD in place (St. ___ V193). history ofnmultiple shocks in ___, was quiet after that on amiodarone therapy - s/p MI with 3VD. PCI x2 ___, s/p PTCA/stenting of the LAD and s/p PCI in ___ to LCX - Hypertension. - Hyperlipidemia. - History of left ventricular apical thrombus, status post Coumadin therapy. This was noted on his echo note dated ___. It is postulated that this has endotheliazed and not at major risk for embolic phenomenon. - ___ mitral regurgitation. - History of heavy alcohol use. - Chronic kidney disease with a baseline creatinine around 1.7. An SPEP and a UPEP were negative. This was attributed to vascular disease. - History of supraventricular tachycardia. - Status post excision of facial basal cell carcinoma. - Osteoarthritis. - GERD. - Questionable history of gout. Had rheumatology evaluation in ___ with no evidence of gout. - Iron deficiency anemia. - Elevated PSA and patient, thought to be ___ prostate ca, patient deferred further work up. - History of vasectomy. - History of ? left eye embolic phenomenon - Basal cell ca of the skin, s/p excision - chronic back pain Social History: ___ Family History: Three maternal uncles died suddenly before being ___ old. Father died at ___ of CHF. Otherwise ___. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.9 117/74 85 22 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no JVP at clavicle at 45 degrees Lungs: Rhoncherous transmitted upper respiratory sounds. No weezes or crackles, good air movement throughout. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ edema R>L. Per patient this is not far off from his baseline. ADMISSION PHYSICAL EXAM: Vitals: Tm ___ yest evening 98.5 117/86 % RA Weight 108-->107.6-->106.3--> 107.1 today General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to 1 cm above the clavicle at 90 degrees Lungs: Rhoncherous transmitted upper respiratory sounds, increaed at the R lung base. No weezes or crackles, good air movement throughout. CV: Regular rhythm at about 100 Bpm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ ___ edema R>L. Pertinent Results: ADMISSION LABS ___ 10:06PM URINE ___ ___ 10:06PM URINE GR ___ ___ 10:06PM URINE ___ SP ___ ___ 10:06PM URINE ___ ___ ___ 10:06PM URINE ___ WBC-<1 ___ ___ ___ 10:06PM URINE ___ ___ 11:20AM ___ UREA ___ ___ TOTAL ___ ANION ___ 11:20AM ___ this ___ 11:20AM cTropnT-<0.01 ___ 11:20AM ___ ___ 11:20AM VIT ___ ___ 11:20AM ___ ___ ___ 11:20AM ___ ___ ___ 11:20AM ___ ___ ___ 11:20AM PLT ___ Bcx ___ - pending, no growth to date ___ 10:06 pm URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference ___. 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. ___ 12:05 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Sputum Cx x 2 -- non diagnostic specemin CXR ___ Findings consistent with pneumonia. ___ radiographs are recommended to show resolution within eight weeks. CXR ___ 1. Worsening pneumonia, mostly in the right middle and lower lobes with a new focal right perihilar consolidation. 2. Separate from these findings is an apparently slowly growing nodule in the right upper lobe. Radiographic follow up within 8 weeks is recommended for evaluation of interval resolution of the ___ right middle/lower lobe pneumonia. If increase in right upper lobe nodule size persists at that time, further followup is recommended with CT. DISCHARGE LABS ___ 07:20AM BLOOD ___ ___ Plt ___ ___ 07:20AM BLOOD Plt ___ ___ 07:20AM BLOOD ___ ___ ___ 07:20AM BLOOD ___ ___ ___ 01:15PM BLOOD ___ ___ 01:15PM BLOOD ___ ___ 07:20AM BLOOD ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY hold for SBP < 100 2. Clopidogrel 75 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. Furosemide 40 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY hold for SBP < 100, HR < 60 6. Rosuvastatin Calcium 10 mg PO DAILY 7. Spironolactone 25 mg PO DAILY hold for SBP < 100 8. Valsartan 40 mg PO DAILY hold for SBP < 100 9. Warfarin 5 mg PO 4X/WEEK (___) 10. Warfarin 2.5 mg PO 3X/WEEK (___) 11. Aspirin 81 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Cyanocobalamin ___ mcg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Cyanocobalamin ___ mcg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Rosuvastatin Calcium 10 mg PO DAILY 10. Spironolactone 25 mg PO DAILY 11. Valsartan 40 mg PO DAILY 12. Benzonatate 100 mg PO TID RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 13. ___ Phosphate 10 mL PO Q6H cough Do not drive or operate heavy machinery while taking this medication RX ___ 100 ___ mg/5 mL 10 mL by mouth every 6 hours as needed Disp #*1 Bottle Refills:*0 14. Acetaminophen 500 mg PO Q6H:PRN pain, fever do not exceed 2 grams daily 15. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 16. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 17. Outpatient Lab Work ___: Please draw INR and fax results to ___ ___ clinic at ___. If drawn at a ___ facility, please be sure to draw and fax labs before noon. 18. Levofloxacin 750 mg PO DAILY Duration: 2 Doses ___ and ___ are the last 2 doses RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 19. Warfarin 2.5 mg PO ONCE Duration: 1 Doses take on ___, have labs drawn on ___ and follow up with ___ clinic for dosing 20. Outpatient Lab Work ___: please draw serum ___ and fax results to fax # ___ (phone # ___ Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis 1. community acquired pneumonia 2. chronic systolic congestive heart failure Secondary diagnosis 1. history of left ventricular apical thrombus on anticoagulation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Patient with shortness of breath, cough, and fever. Evaluate for acute cardiopulmonary process. COMPARISONS: Multiple prior chest radiographs, most recent ___. TECHNIQUE: PA and lateral chest radiographs. FINDINGS: The lungs are well expanded. An opacity in the right lower lung field obscuring the right heart border is new compared with prior exam. Opacities are mostly in the right middle lobe although there is also coinciding right lower lobe subpleural opacity. The remaining lung parenchyma is unremarkable. There is no pleural effusion or pneumothorax. Mild cardiomegaly stable. A single-lead pacemaker in the left hemithorax is unchanged. IMPRESSION: Findings consistent with pneumonia. Follow-up radiographs are recommended to show resolution within eight weeks. Radiology Report INDICATION: ___ male patient with pneumonia and continued high fevers. Study requested to rule out worsening pneumonia, abscess and/or pleural effusion. COMPARISON: Prior chest radiograph from ___ through ___. TECHNIQUE: PA and lateral chest radiographs. FINDINGS: As compared to prior radiograph from ___, there has been interval worsening. There is increased opacification of the right heart border and right hemidiaphragm, concerning for worsening pneumonia, mostly at the right middle and lower lobes. There is a new right perihilar consolidation. There is no pleural effusion or pneumothorax. Cardiomegaly is unchanged. A single-channel pacemaker lead terminates in the right ventricle. At the intersection of the right second anterior rib and the right fifth posterior rib there is a linear and nodular opacity which has apparently increased compared to prior examination from ___ and appears separate from the above findings. IMPRESSION: 1. Worsening pneumonia, mostly in the right middle and lower lobes with a new focal right perihilar consolidation. 2. Separate from these findings is an apparently slowly growing nodule in the right upper lobe. Radiographic follow up within 8 weeks is recommended for evaluation of interval resolution of the above-described right middle/lower lobe pneumonia. If increase in right upper lobe nodule size persists at that time, further followup is recommended with CT. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: FEVERS/COUGH Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED temperature: 97.6 heartrate: 100.0 resprate: 18.0 o2sat: 98.0 sbp: 107.0 dbp: 71.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted for pneumonia, and improved with antibiotics. It is important that you take all medications as prescribed, and keep all follow up appointments. You should get your labs drawn on ___ and have results faxed to your ___ clinic and PCP. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ y/o female with a history of HTN, HLD, and pre-diabetes who presents with one day of cough. The patient notes that she started having a dry cough yesterday. She then has coughing spells which then result in her developing substernal burning pain and trouble catching her breath. The chest discomfort and SOB will last for about ___ minutes after her coughing spell and then gradually resolve. She dose not have any chest pain outside of these episodes and is not associated with exertion. She denies a history of asthma or GERD. No fever or chills. No orthopnea, PND, DOE, ___ edema. She also notes 2 episodes of post-tussive emesis (NBNB). In the ED initial vitals were: 98.7 ___ 16 100% - Labs were significant for WBC 13.2 with 73% polys, normal chem-7, normal LFTs, troponin negative, d-dimmer negative. - EKG showed SR at 105 with ~1mm STE in V1-V2, TVI in III with no prior. CXR showed a mild retrocardiac opacification which could represent pneumonia - Patient was given 1L IVFs and levofloxacin. On the floor, the patient reports that she is feeling well. She has no specific complaints at this time. She is no longer experiencing the chest discomfort or SOB. Not currently coughing. She has had mild congestion, but no other URI symptoms. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -HTN -HLD -pre-diabetes -colon adenoma -obesity -lichen planus -vitamin d deficency Social History: ___ Family History: Mother - DM Father - unknown Sister - DM Brother - DM Physical Exam: EXAM ON ADMISSION: =============== Vitals - T: 97.9 BP: 168/87 HR: 102 RR: 16 02 sat: 100% RA GENERAL: well appearing pleasant ___ y/o female in NAD HEENT: NCAT, 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: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: no edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength ___ throughout, sensation intact to light touch SKIN: warm and well perfused, no excoriations or lesions, no rashes EXAM ON DISCHARGE: =============== Vitals - T: 97.8-97.9 BP: 152-168/87 HR: 102-113 RR: ___ 02 sat: 100% RA GENERAL: well appearing pleasant ___ y/o female who appears younger than stated age, in NAD HEENT: NCAT, 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: CTAB with the exception of bibasilar crackles, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: no edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength ___ throughout, sensation intact to light touch SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: LABS ON ADMISSION: =============== ___ 09:10PM BLOOD WBC-13.2* RBC-4.48 Hgb-13.7 Hct-40.7 MCV-91 MCH-30.7 MCHC-33.7 RDW-14.5 Plt ___ ___ 09:10PM BLOOD Neuts-72.6* ___ Monos-6.0 Eos-2.0 Baso-0.8 ___ 09:10PM BLOOD ___ PTT-34.5 ___ ___ 09:10PM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-142 K-3.8 Cl-104 HCO3-23 AnGap-19 ___ 09:10PM BLOOD ALT-26 AST-31 AlkPhos-88 TotBili-0.6 ___ 09:10PM BLOOD cTropnT-<0.01 ___ 09:10PM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.3 Mg-2.2 LABS ON DISCHARGE: =============== ___ 07:00AM BLOOD WBC-11.3* RBC-4.50 Hgb-13.4 Hct-40.6 MCV-90 MCH-29.8 MCHC-33.1 RDW-14.5 Plt ___ ___ 07:00AM BLOOD Glucose-103* UreaN-13 Creat-1.0 Na-144 K-4.2 Cl-105 HCO3-28 AnGap-15 ___ 07:00AM BLOOD CK(CPK)-701* ___ 07:00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 07:00AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.0 STUDIES: ======= CXR ___: FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. The lung volumes are low with mild elevation of the right hemidiaphragm. Patchy opacities at the lung bases are probably compatible with atelectasis, and not out of proportion to reduced lung volumes, but potential are infectious. IMPRESSION: Mild retrocardiac opacification, atelectasis versus pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral daily 2. estradiol 0.01 % (0.1 mg/gram) vaginal daily 3. Atorvastatin 80 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Vitamin D ___ UNIT PO DAILY 2. estradiol 0.01 % (0.1 mg/gram) vaginal daily 3. irbesartan 150 mg oral daily 4. Azithromycin 250 mg PO Q24H RX *azithromycin [Zithromax Z-Pak] 250 mg 1 tablet(s) by mouth daily Disp #*6 Tablet Refills:*0 5. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath Please take this for shortness of breath of cough as needed RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs every 6 hours PRN shortness of breath Disp #*1 Inhaler Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Asthma/Reactive Airway Disease Elevated CK Secondary Hyperlipidemia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST RADIOGRAPHS INDICATION: Cough and chest pain. COMPARISON: None. TECHNIQUE: Chest, PA and lateral. FINDINGS: The heart is normal in size. The mediastinal and hilar contours appear within normal limits. The lung volumes are low with mild elevation of the right hemidiaphragm. Patchy opacities at the lung bases are probably compatible with atelectasis, and not out of proportion to reduced lung volumes, but potential are infectious. IMPRESSION: Mild retrocardiac opacification, atelectasis versus pneumonia. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with history of cough and previous opacification on CXR. // compare to prior COMPARISON: ___. IMPRESSION: Cardiomediastinal contours are normal. The lungs are currently clear, with no evidence of pneumonia. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, Vomiting Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS temperature: 98.7 heartrate: 111.0 resprate: 16.0 o2sat: 100.0 sbp: 163.0 dbp: 110.0 level of pain: 4 level of acuity: 3.0

Dear ___, It was a pleasure taking care of you at ___. You came in with coughing fits that improved with an inhaler. We think this is most likely do to some asthma or irritation of the airway, possibly from dust exposure at your job. For this we will send you with a medication called an albuterol inhaler that it is important to take whenever you feel short of breath or feel like you are coughing. The possibility that these symptoms are from pneumonia or lung infection are unlikely, however we will give you a medication called azithromycin for you take for a total 5 day course. While taking this medication it is important to stop taking atorvostatin because of a possible interaction between these medications. Sincerely, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Pedestrian struck Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old male who presents to the emergency department after being struck by a motor vehicle reported to be moving at ___ MPH. There was positive loss of consciousness at the scene. The patient was taken to the ___ emergency department and intubated. There is no family available at the time of this consultation for further history of the events. Prior to the intubation the patient was given etomidate and succinylcholine. The patient was also administered fentayl and bolus' of versed due to agitation Past Medical History: laprascopic hernia repair Social History: ___ Family History: NC Physical Exam: O: T:99 BP: 122/76 HR:60 R:20 O2Sats99% ventilated Gen: intubated and recently medicated with etomidate, succinylcholine, fentanyl,versed HEENT:No Battle sign, No ottohea, No rhinorrhea. left forehead laceration, ecchymotic left eye Pupils: 2.5-2mm EOMs not able to test due to sedation/mental status Neck: hard cervical collar in place Extrem: Warm and well-perfused .localizing equally with upper extremities and moving all four extremities antigravity to noxious stimulus. no commands Neuro: Mental status: no commands, no eye opening, intubated GCS 7 T following multiple versed boluses. Orientation/Recall/Language: intubated with recent trauma patient unable to perform at this time Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,2.5 to 2mm mm bilaterally. Visual fields - unable to assess III, IV, VI: Extraocular movements- unable to assess V, VII: Facial strength- grossly intact VIII, IX, X, XI, XII: unable to test due to sedation and current mental status Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. localizing equally with upper extremities and moving all four extremities antigravity to noxious stimulus. no commands Toes mute PHYSICAL EXAM ON DISCHARGE: AVSS Gen: WD/WN, comfortable, NAD. HEENT: Atraumatic, normocephalic. PERRLA. EOMs intacat Neck:immobilized by cervical collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Cranial Nerves: II-XII intact Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ to left upper and lower extremities. Full stregnth to RLE extremity. RUE deltoid ___, bicep 4+/5, tricep ___, grip ___. No pronator drift Sensation: Intact to light touch Babinki's negative. No clonus Pertinent Results: CT C-spine ___: 1. Left hard palate lucency concerning for a fracture. A dedicated facial series would be helpful to further assess extent of injury. 2. Right occipital condyle fracture. 3. Prevertebral soft tissue thickening raises concern for an underlying ligamentous injury. MR is recommended to further assess. CT head ___: 1. No intracerebral hemorrhage. 2. Left frontal bone fracture with extra conal air, irregularity of the medial wall of the orbit and probable extension of the fracture to the sinuses posteriorly. 3. Left frontal subgaleal hematoma CT Chest/abdomen/pelvis ___: 1. Subtle fragmentation of the right transverse processes at L1 is likely chronic. Clinical correlation for focal pain is recommended. 2. Bibasilar atelectasis. 3. No acute intra-abdominal or pelvic injury. CT Max/Face ___: 1. Frontal bone fracture extending through the left frontal sinus, left maxillary sinus and contiguous with a left hard palate fracture line. No pneumocephalus. 2. Left superior orbital extraconal hematoma and left-sided proptosis. 3. Right occipital condyle fracture. MRI C-Spine ___: 1. Prevertebral edema in the upper cervical spine with edema of the anterior longitudinal ligament from C2-3 through C5-6, and edema of the posterior longitudinal ligament from C1-2 through C3-4. Interspinous ligament edema from the craniocervical junction through C6-7, with adjacent posterior paravertebral and suboccipital muscle edema. 2. Acute spinal cord edema versus chronic myelomalacia at C3-4, where the spinal cord is deformed by a disc osteophyte complex which results in moderate spinal canal stenosis. 3. 12 mm oval fluid-intensity structure in the distal left T1-2 neural foramen and extraforaminal space, which may represent a nerve root sleeve diverticulum, but traumatic avulsion of the T1 nerve root cannot be excluded. please correlate clinically. 4. Bone marrow edema along the superior endplate of the T4 vertebral body without loss of height, which may indicate a bone contusion or a non-displaced fracture. Bone marrow edema along the known right occipital condyle fracture. Right shoulder x-ray ___: Two projections performed as a portable radiograph are provided. The assessment is limited. The right humeral head is in correct position. On the current images, there is no convincing evidence of a fracture at the level of the right shoulder. Again documented are known rib fractures, as seen on a CT torso examination from ___ with multiple rib fractures and pleural calcifications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Docusate Sodium 100 mg PO BID 3. Senna 1 TAB PO BID 4. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Anterior longitudinal ligmanet and posterior longitudinal ligmament injury -Cervical cord contusion at C3-4 -R occipital condyle fx -L1 transverse process fx -L Frontal bone fracture extending through the left frontal sinus, left maxillary sinus and contiguous with a left hard palate fracture line Left superior orbital extraconal hematoma and left-sided proptosis 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: Pedestrian struck. Rule out injury. COMPARISON: None. FINDINGS: The overlying trauma board limits evaluation. An endotracheal tube is in satisfactory position, 3.5 cm above the carina. A density projecting over the right clavicle could reflect a foreign object. No pleural effusion, pneumothorax or focal airspace consolidation. The cardiac size and mediastinum are unremarkable on this study. A large pleural calcification is seen along the lateral right hemithorax. Radiology Report HISTORY: Pedestrian struck, unknown history, noncommunicative. Rule out injury. COMPARISON: None available. TECHNIQUE: Axial CT images were obtained through the brain without IV contrast. Coronal, sagittal and thin bone algorithm reconstruction were generated. FINDINGS: There is no hemorrhage, major vascular territory infarction, edema, mass or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. There is a fracture at the left frontal bone probably extending to the sinuses, given the presence of air within the ethmoid sinuses. There pockets of air within the extra Conal region and anterior to the globe on the left. There is irregularity of the medial wall of the orbit and opacification of the left frontal sinus, ethmoid air cells and right sphenoid sinus. The mastoid air cells are clear. There is a small left frontal subgaleal hematoma. There is a small left superior orbital extraconal hematoma. IMPRESSION: 1. No intracerebral hemorrhage. 2. Left frontal bone fracture with extra conal air, irregularity of the medial wall of the orbit and probable extension of the fracture to the sinuses posteriorly. 3. Left frontal subgaleal hematoma. Findings discussed with Dr. ___ (neurosurgery), by ___ ___ in person at 9:01 AM, time of discovery. Radiology Report HISTORY: Pedestrian struck, unknown history, noncommunicative. Rule out injury. COMPARISON: None available. TECHNIQUE: Axial helical MDCT images were obtained through the cervical spine without IV contrast. Coronal and sagittal reformats were generated. FINDINGS: There is a linear lucency extending throught the left hard palate which is concerning for an acute fracture. There is a fracture at the right occpitial condyle without significant displacement. Prevertebral thickening is concerning for a ligamenotus injury. Multilevel degenerative changes are noted with subchondral cysts, endplate sclerosis and anterior osteophytosis. There is mucosal thickening of the left maxillary sinus. IMPRESSION: 1. Left hard palate lucency concerning for a fracture. A dedicated facial series would be helpful to further assess extent of injury. 2. Right occipital condyle fracture. 2. Prevertebral soft tissue thickening raises concern for an underlying ligamentous injury. MR is recommended to further assess. Initial findings discussed with Dr. ___ (neurosurgery), by ___ in person on ___ at 9:01 AM, time of discovery. Additional findings regarding fractures discussed via telephone with ___ ___ by ___ at 9:30 AM. Prevertebral thickening finding discussed with Dr. ___ by ___ via telephone on ___ at 10:05 AM. Radiology Report HISTORY: Pedestrian struck, unknown history, noncommunicative. Rule out injury. COMPARISON: None available. TECHNIQUE: Axial helical MDCT images were obtained through the chest, abdomen and pelvis after the uneventful administration of 130 cc of Omnipaque IV contrast. Coronal and sagittal reformats were generated. FINDINGS: CT CHEST: There is no evidence of aortic traumatic injury. There is no mediastinal hematoma. The great vessels are within normal limits. The heart is normal in size. There is no pericardial effusion. Endotracheal tube is in adequate position. There is atelectasis at the lung bases bilaterally. No pneumothorax or pleural effusion. Calcified pleural plaque noted at the lateral and medial aspect of the right lung as well as the left lung base. There is a small hiatal hernia. CT OF THE ABDOMEN: The liver, gallbladder, pancreas and adrenal glands are normal. The portal vein is patent. The spleen is within normal limits. The kidneys enhance symmetrically and excrete contrast with no evidence of hydronephrosis or masses. Stomach is within normal limits. There is no bowel obstruction or bowel wall abnormality. There is no mesenteric contusion. The aorta is of normal caliber. The celiac axis, SMA, bilateral renal arteries and ___ are patent. There is no free air or free fluid. CT OF THE PELVIS: The urinary bladder and terminal ureters are within normal limits. The prostate is normal. There is no pelvic free fluid. There is no pelvic or inguinal lymphadenopathy. OSSESOUS STRUCTURES: Subtle fragmentation of the right transverse processes at L1 is likely chronic. Clinical correlation is recommended. Otherwise, no lytic or blastic lesions concerning for malignancy. IMPRESSION: 1. Subtle fragmentation of the right transverse processes at L1 is likely chronic. Clinical correlation for focal pain is recommended. 2. Bibasilar atelectasis. 3. No acute intra-abdominal or pelvic injury. Findings discussed with Dr. ___ by ___ in person on ___ at 9:01 AM, time of discovery and subsequently with Dr. ___ telephone at 10:00 AM. Radiology Report HISTORY: ___ male with facial trauma, frontal bone fracture. COMPARISON: Prior head CT and cervical spine CT from ___. TECHNIQUE: Axial helical MDCT images were obtained through the facial bones and sinuses without IV contrast. Coronal and sagittal reformats were generated. FINDINGS: A frontal bone fracture line extends through the left frontal sinus, the posterior table of the skull and through the left maxillary sinus (2:3, 18, 21, 44), contiguous with a fracture identified in the left hard palate. There is no evidence of pneumocephalus. There is near complete opacification of the left frontal sinus. There is mucosal thickening of the right frontal sinus, ethmoidal air cells and right sphenoid sinus. The mandible and pterygoids are intact. There is a small left superior orbital extraconal hematoma. There is left sided propotosis. Deformities of the nasal bones could represent an acute fracture. There is a right occipital condyle fracture. Periapical lucencies may be related to an infectious process. IMPRESSION: 1. Frontal bone fracture extending through the left frontal sinus, left maxillary sinus and contiguous with a left hard palate fracture line. No pneumocephalus. 2. Left superior orbital extraconal hematoma and left-sided proptosis. 3. Right occipital condyle fracture. Radiology Report CERVICAL SPINE MRI WITHOUT CONTRAST, ___ INDICATION: ___ man struck by a motor vehicle with a prevertebral cervical edema on cervical spine CT. Assess for ligamentous injury. COMPARISON: Cervical spine CT performed earlier on the same day. TECHNIQUE: Sagittal T1-weighted, T2-weighted, and fat-suppressed T2-weighted images of the cervical spine, with axial gradient echo images. FINDINGS: There is bone marrow edema in the right occipital condyle related to the fracture demonstrated on the preceding CT scan (3:12). There is bone marrow edema along the superior endplate of the T4 vertebral body, without associated deformity or loss of height, which may indicate a bone contusion or a non-displaced fracture (3:8). Questionable linear lucencies parallel to the superior endplates of T4 and T5 vertebral bodies, without loss of height, as seen on the torso CT performed earlier on the same day. No bone marrow edema is seen in the cervical vertebrae. There is prevertebral edema from the craniocervical junction through C5-6. There is edema in the anterior longitudinal ligament from C2-3 through C5-6, and edema in the posterior longitudinal ligament from C1-2 through C2-3 levels. There is no evidence for ligamentous disruption, or intervertebral disc disruption. There is edema in the interspinous ligaments from the craniocervical junction through C6-7, as well as edema in the paravertebral muscles of the cervical spine and suboccipital muscles. There is no evidence for an epidural collection. At C2-3, there is mild right neural foraminal narrowing by facet osteophytes. At C3-4, there is a central disc osteophyte complex which indents the ventral spinal cord and flattens its ventral surface, with moderate spinal canal narrowing. There is high T2 signal within the cord at this level spanning 13 mm craniocaudad, compatible with edema or myelomalacia. Gradient echo images demonstrate no evidence of blood products within the spinal cord at this level. There is also mild bilateral neural foraminal narrowing by uncovertebral osteophytes. At C4-5, there is a left paracentral disc osteophyte complex which abuts the ventral surface of the spinal cord on the left, with mild flattening but no edema. There is mild to moderate associated spinal canal narrowing. There is mild bilateral neural foraminal narrowing by uncovertebral osteophytes. At C5-6, there is a small central disc osteophyte complex which mildly narrows the spinal canal but does not deform the spinal cord. There is mild right and moderate left neural foraminal narrowing by uncovertebral osteophytes. At C6-7, no significant spinal canal or neural foraminal narrowing is seen. At C7-T1, no significant spinal canal narrowing is seen. At T1-2, there is an oval 12 x 9 x 6 mm fluid-intensity structure extending from the distal left neural foramen into the extraforaminal soft tissues. This could represent a nerve root sleeve diverticulum, but traumatic avulsion of the root cannot be excluded. Cerebellar tonsils are normally positioned. Imaged portion of the posterior fossa is grossly unremarkable; this study is not technically optimized for its evaluation. Mucosal thickening is noted in the imaged portions of the maxillary sinuses. Known fractures through the left maxillary sinus and left hard palate are not well demonstrated on this exam. IMPRESSION: 1. Prevertebral edema in the upper cervical spine with edema of the anterior longitudinal ligament from C2-3 through C5-6, and edema of the posterior longitudinal ligament from C1-2 through C3-4. Interspinous ligament edema from the craniocervical junction through C6-7, with adjacent posterior paravertebral and suboccipital muscle edema. 2. Acute spinal cord edema versus chronic myelomalacia at C3-4, where the spinal cord is deformed by a disc osteophyte complex which results in moderate spinal canal stenosis. 3. 12 mm oval fluid-intensity structure in the distal left T1-2 neural foramen and extraforaminal space, which may represent a nerve root sleeve diverticulum, but traumatic avulsion of the T1 nerve root cannot be excluded. Please correlate clinically. 4. Bone marrow edema along the superior endplate of the T4 vertebral body without loss of height, which may indicate a bone contusion or a non-displaced fracture. Bone marrow edema along the known right occipital condyle fracture. Radiology Report HISTORY: ___ male status post trauma, intubation, and orogastric tube placement. TECHNIQUE: Single frontal chest radiograph was obtained portably with the patient in a semi upright position. COMPARISON: ___ at approximately 7:30 a.m. FINDINGS: Endotracheal tube tip terminates approximately 6 cm above the carina. There has been interval placement of an orogastric tube, which courses into the left upper quadrant with tip out of view. No focal consolidation, pleural effusion, pneumothorax, or pulmonary edema is detected. Heart and mediastinal contours are within normal limits. Large pleural calcification along the right lateral hemithorax is again noted. IMPRESSION: Satisfactory orogastric tube placement. Interval retraction of the endotracheal tube from 3 to 6 cm above the carina. This change was reported to ___ by ___ by phone at 4:02 p.m. on ___. Radiology Report RIGHT SHOULDER INDICATION: Status post motor vehicle accident. FINDINGS: Two projections performed as a portable radiograph are provided. The assessment is limited. The right humeral head is in correct position. On the current images, there is no convincing evidence of a fracture at the level of the right shoulder. Again documented are known rib fractures, as seen on a CT torso examination from ___ with multiple rib fractures and pleural calcifications. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: PED STRUCK Diagnosed with CLOSED SKULL VAULT FX, CLOS SKULL BASE FRACTURE, FX FACIAL BONE NEC-CLOSE, MV COLL W PEDEST-PEDEST, OPEN WOUND OF FOREHEAD temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

•Do not smoke. •No pulling up, lifting more than 10 lbs., or excessive bending or twisting. •Limit your use of stairs to ___ times per day. •Wear your cervical collar at all times except when bathing for 1 month. •You may shower briefly without the collar if you are sitting in a tub or shower and not at risk for falling and you wound is covered. •Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. You pain medication should be used as needed. You do not need to take them if you do not have pain. •Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: •Pain that is continually increasing or not relieved by pain medicine. •Any weakness, numbness, tingling in your extremities. •Fever greater than or equal to 101.5 ° F. •Loss of control of bowel or bladder.

Name: ___ ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx HTN and recent admission for pyogenic liver abscess on IV CTX/flagyl who presents with RUQ pain and pleuritic chest pain. Pt endorses worsening RUQ abdominal/flank/back pain since last admission. Endorses subjective fevers, malaise. Also notes pain in proximal thigh bilaterally and pleuritic chest pain with deep inspiration. States that since discharge from previous hospitalization, pt has been laying in bed most of the day. Of note, had recent hospitalization at ___ ___, found to have a pyogenic liver abscess. The abscess was unable to be drained by ___, several biopsies were taken, gram stain showed ___ polys or microorganisms, tissue culture without growth. Pt was treated with empiric flagyl and vanc/zosyn --> cefepime, and discharged on IV CTX/flagyl for planned course of ___ weeks pending surveillance imaging. Also had productive cough and CXR with consolidation c/f possible HAP, and was treated with above abx. Additionally, had type II NSTEMI and likely stress cardiomyopathy at OSH with repeat TTE showing recovered LVEF 65% from 35%. In the ED: - Initial vital signs: T 98, HR 107, BP 98/75, RR 16, O2 95% RA Had desaturation to 88% on RA, placed on 2L NC and stable O2 - Exam notable for: well-appearing, TTP in RUQ, CTAB, RRR, ___ murmur, non-tender chest wall, ___ JVD - Labs were notable for: WBC 9.1, Hgb 10, Plt 234, Na 139, K 3.9, BUN/Cr ___, LFTs wnl, Lactate 1.4 - Studies performed include: -- UA: few bacteria, trace leuk, neg nitrite, 3 WBC, 30 protein -- CXR: left PICC terminating in left axillary vein, low lung volumes with persistent right hemidiaphragmatic elevation, presumed bibasilar patchy atelectasis -- CT A/P w con: PE in RLL posterior and lateral basal segments, patchy peripheral consolidation in posterior/lateral/anterior basal RLL could represent infarction v pna v aspiration. Occlusive thrombus from left common iliac vein to at least the left femoral vein. Occlusive thrombus extending from right femoral vein and distally. Interval decrease in size of known right hepatic lobe abscess currently measuring 4.5 x 3.5 x 3.6 cm. -- Bl ___ Dopplers (prelim): extensive bilateral deep vein thrombosis - Patient was given: Heparin gtt, CTX/flagyl, 2L IVF, Morphine, Zofran ___ 20:11 IV Morphine Sulfate 4 mg ___ 20:11 IV Ceftriaxone 2 gm ___ 20:11 IV Ondansetron 4 mg ___ 20:11 IVF NS at 150 mL/hr ___ 22:13 IV MetroNIDAZOLE 500 mg ___ 22:13 IV Morphine Sulfate 4 mg ___ 02:18 IVF LR at 125 mL/hr ___ 02:43 IV Heparin 6100 UNIT ___ 02:43 IV Heparin at 1350 units/hr ___ 05:05 IV Alteplase 1mg/2mL (Clearance ie. PICC) ___ 07:42 IV Morphine Sulfate 2 mg ___ 09:46 IV Morphine Sulfate 2 mg ___ 10:30 IV MetroNIDAZOLE 500 mg ___ 13:12 IV Morphine Sulfate 4 mg - Consults: Vascular Medicine Vitals on transfer: T 99.2, HR 97, BP 131/87, RR 18, O2 98% RA Upon arrival to the floor, pt endorses above history however is sleepy and slow to answer questions. Endorses right sided abdominal/flank/back pain with deep breaths, states pain is severe, may have been relieved by morphine in ED. Endorses mild dizziness, bl hip pain as well as mild dysuria and urinary urgency. Otherwise denies ha, lh, LOC, cp, palp, sob or doe, abd pain in other locations, diarrhea/constipation, n/v, BRBPR/melena, hematuria. Past Medical History: Hypertension BPH Hiatal hernia, Gastric ulcerations ___ NSTEMI, type II ___ Stress Cardiomyopathy, resolved Anemia Thyroid nodule s/p b/l knee replacement Social History: ___ Family History: Son - deceased, car accident Son - deceased, poisoned 2 Daughters healthy ___ family history of VTE, early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 98.6, BP 112/75, HR 93, RR 18, O2 94% 2L NC GENERAL: In ___ acute distress. Sleepy, intermittently falling asleep during conversation, slow to answer questions. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. ___ wheezes, rhonchi or rales. ___ increased work of breathing. ABDOMEN: Normal bowels sounds, soft, mildly distended, TTP RUQ and right flank. Otherwise non-tender to deep palpation. MSK: ___ spinous process tenderness. ___ CVA tenderness. EXT: Trace pitting edema of LLE, ___ edema RLE. ___ clubbing or cyanosis. ___ calf/popliteal tenderness, ___ tenderness of bl thighs. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. ___ rash. NEUROLOGIC: CN2-12 intact. ___ strength in bl UE and bl hip flexors. Unable to participate in remainder of neuro exam d/t sleepiness. AOx3. PSYCH: appropriate mood and affect, occasional inappropriate response to questions, however able to redirect with repeat questioning DISCHARGE PHYSICAL EXAM: GENERAL: In ___ acute distress, sitting in bed HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ murmurs/rubs/gallops, JVP~7cm RESP: Clear to auscultation bilaterally. ___ wheezes, rhonchi or rales. ___ increased work of breathing. ABDOMEN: Normal bowels sounds, soft, mildly distended, mild TTP RUQ and right flank. Otherwise non-tender to deep palpation MSK: ___ spinous process tenderness. ___ CVA tenderness EXT: Trace pitting edema of LLE, ___ edema RLE. ___ clubbing or cyanosis. ___ calf/popliteal tenderness, ___ tenderness of bl thighs. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. ___ rash. ___ evident skin findings, swelling, or deformity at liver biopsy site NEUROLOGIC: CN2-12 intact. ___ strength in bl UE and bl hip flexors. AOx3. Pertinent Results: ADMISSION LABS ================= ___ 11:25PM BLOOD WBC-9.1 RBC-3.10* Hgb-10.0* Hct-31.1* MCV-100* MCH-32.3* MCHC-32.2 RDW-14.1 RDWSD-51.5* Plt ___ ___ 11:25PM BLOOD Neuts-75.1* Lymphs-9.3* Monos-14.0* Eos-0.7* Baso-0.3 Im ___ AbsNeut-6.82* AbsLymp-0.84* AbsMono-1.27* AbsEos-0.06 AbsBaso-0.03 ___ 10:20AM BLOOD ___ PTT-96.3* ___ ___ 11:25PM BLOOD Glucose-108* UreaN-28* Creat-0.8 Na-139 K-3.9 Cl-98 HCO3-24 AnGap-17 ___ 11:25PM BLOOD ALT-6 AST-17 AlkPhos-70 TotBili-0.4 ___ 11:25PM BLOOD cTropnT-<0.01 proBNP-375* ___ 11:25PM BLOOD Albumin-3.0* ___ 08:57PM BLOOD Lactate-1.4 ___ 08:52PM URINE Color-Red* Appear-Clear Sp ___ ___ 08:52PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR* ___ 08:52PM URINE RBC-1 WBC-3 Bacteri-FEW* Yeast-NONE Epi-<1 TransE-<1 ___ 08:52PM URINE CastHy-5* DISCHARGE LABS ========================== ___ 05:04AM BLOOD WBC-5.8 RBC-3.44* Hgb-11.0* Hct-34.9* MCV-102* MCH-32.0 MCHC-31.5* RDW-14.1 RDWSD-52.9* Plt ___ ___ 05:04AM BLOOD ___ PTT-35.3 ___ ___ 05:04AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-139 K-4.0 Cl-100 HCO3-25 AnGap-14 ___ 05:04AM BLOOD ALT-6 AST-14 AlkPhos-70 TotBili-0.4 ___ 05:04AM BLOOD Albumin-2.8* Calcium-7.5* Phos-2.5* Mg-1.8 MICROBIOLOGY ================== NGTD on discharge on ___ blood cultures IMAGING ============ CT ABDOMEN/PELVIS WITH CONTRAST ___ 1. Pulmonary embolism in the right lower lobe posterior and lateral basal segments. Patchy peripheral consolidation in the posterior and lateral basal, as well as anterior basal right lower lobe, new compared to ___, could represent infarction, versus pneumonia or aspiration. Also new small right pleural effusion. 2. Occlusive thrombus extending from the left common iliac vein to at least left femoral vein and out of view. Occlusive thrombus extending from the right femoral vein and distally out of view. 3. Interval decrease in size of the known right hepatic lobe abscess currently measuring 4.5 x 3.5 x 3.6 cm. LOWER EXTREMITY DOPPLER ___ FINDINGS: On the right side, there is extensive noncompressible occlusive thrombus in the common femoral, femoral, popliteal veins, posterior tibial and peroneal veins. Venous Doppler waveforms are seen in the proximal right common femoral vein proximal to the thrombus. Possible slow flow versus artifact is seen in the right popliteal, however this may represent collateralization. On the left side, there is extensive noncompressible occlusive thrombus in the common femoral, femoral, popliteal veins, and posterior tibial veins. The peroneal veins not well visualized but likely thrombosed as well. Some flow is seen within the left popliteal vein, without respiratory variability. ___ evidence of medial popliteal fossa (___) cyst. IMPRESSION: Extensive bilateral lower extremity deep vein thrombosis. CT ANGIOGRAM CHEST ___ 1. Bilateral pulmonary emboli as detailed above. ___ CT findings of right heart strain. 2. Consolidation in the right lower lobe, which is in part compatible with mild atelectasis. Heterogeneous enhancement suggests superimposed infarction in the setting of pulmonary emboli and/or infection. 3. Small right pleural effusion. TRANSTHORACIC ECHOCARDIOGRAM ___ CONCLUSION: There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 60-65%. Dilated right ventricular cavity with depressed and possible dyskinetic free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is depressed. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. IMPRESSION: Follow-up study to assess ventricular function. Suboptimal image quality. Base of the right ventricle not well visualized but the mid-wall appears dyskinetic and the wall of the right ventricular outflow tract is dilated to 4.7cm (normal 3.5cm). Mild pulmonary artery systolic hypertension. Compared with the prior TTE (images reviewed) of ___, the findings are similar. LIVER/GALLBLADDER ULTRASOUND ___ Limited examination due to patient positioning. Previously seen heterogeneous lesion within liver segment V/VIII on CT abdomen pelvis performed ___, compatible with biopsy-proven abscess, is not well visualized sonographically. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CefTRIAXone 2 gm IV Q24H 2. Docusate Sodium 100 mg PO BID 3. MetroNIDAZOLE 750 mg PO TID 4. Polyethylene Glycol 17 g PO BID 5. Senna 8.6 mg PO BID 6. Gabapentin 300 mg PO TID 7. Hydrochlorothiazide 25 mg PO DAILY 8. Omeprazole 20 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. ___ 10 mg PO BID Duration: 4 Days 3. ___ 5 mg PO BID First dose ___ after completing ___ loading doses on ___ 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. OxyCODONE (Immediate Release) 10 mg PO BID:PRN BREAKTHROUGH PAIN Duration: 3 Days RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 6. CefTRIAXone 2 gm IV Q24H 7. Docusate Sodium 100 mg PO BID 8. Gabapentin 300 mg PO TID 9. Hydrochlorothiazide 25 mg PO DAILY 10. MetroNIDAZOLE 750 mg PO TID 11. Omeprazole 20 mg PO BID 12. Polyethylene Glycol 17 g PO BID 13. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS bilateral deep vein thrombosis submassive pulmonary embolism 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: Evaluate for change, known liver abscess, worsening pain and fevers. TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the 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 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP = 15.6 mGy-cm. 2) Spiral Acquisition 6.3 s, 49.6 cm; CTDIvol = 14.0 mGy (Body) DLP = 694.1 mGy-cm. Total DLP (Body) = 710 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: There is right lower lobe posterior and lateral basal segmental and subsegmental pulmonary embolism. In the setting, patchy peripheral consolidation in the posterior, lateral, and anterior basal right lower lobe, new compared to ___, is concerning for pulmonary infarct, versus pneumonia or aspiration. There is a small right pleural effusion, new compared to ___. the heart is enlarged. No clear CT evidence for right heart strain. Coronary artery calcifications are noted. ABDOMEN: HEPATOBILIARY: Again seen is a 4.5 x 3.5 x 3.6 cm right hepatic lobe hepatic abscess, previously measuring up to 7.0 x 5.5 x 0.1 cm. 2 unchanged punctate left hepatic lobe hypodensities near the hepatic dome are too small to characterize. The liver is otherwise normal in attenuation and morphology throughout. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder appears unremarkable. PANCREAS: The pancreas demonstrates age-appropriate bulk. Distal pancreatic duct in the head is top-normal in caliber at 3 mm. There is no peripancreatic stranding. SPLEEN: The spleen is normal in size and unremarkable in appearance. 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 solid renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is within normal limits. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is mildly enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. There is occlusive thrombus in the proximal right femoral vein extending distally out of view with surrounding stranding (series 601, image 23). There is also occlusive thrombus extending from the left common iliac vein to proximal femoral vein and out of view with surrounding stranding (series 601, image 39 and 27). BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There are left inguinal and left femoral hernias. IMPRESSION: 1. Pulmonary embolism in the right lower lobe posterior and lateral basal segments. Patchy peripheral consolidation in the posterior and lateral basal, as well as anterior basal right lower lobe, new compared to ___, could represent infarction, versus pneumonia or aspiration. Also new small right pleural effusion. 2. Occlusive thrombus extending from the left common iliac vein to at least left femoral vein and out of view. Occlusive thrombus extending from the right femoral vein and distally out of view. 3. Interval decrease in size of the known right hepatic lobe abscess currently measuring 4.5 x 3.5 x 3.6 cm. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:52 am, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with DVTs found on the abdomen pelvis. // Please eval extent of DVTs TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Same-day CT abdomen and pelvis FINDINGS: On the right side, there is extensive noncompressible occlusive thrombus in the common femoral, femoral, popliteal veins, posterior tibial and peroneal veins.. Venous Doppler waveforms are seen in the proximal right common femoral vein proximal to the thrombus. Possible slow flow versus artifact is seen in the right popliteal, however this may represent collateralization. On the left side, there is extensive noncompressible occlusive thrombus in the common femoral, femoral, popliteal veins, and posterior tibial veins. The peroneal veins not well visualized but likely thrombosed as well. Some flow is seen within the left popliteal vein, without respiratory variability. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: Extensive bilateral lower extremity deep vein thrombosis. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old man with extensive bl DVT, PE on CT A/P in RLL // 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: Acquisition sequence: 1) Spiral Acquisition 2.1 s, 27.6 cm; CTDIvol = 11.1 mGy (Body) DLP = 305.7 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP = 11.6 mGy-cm. Total DLP (Body) = 319 mGy-cm. COMPARISON: There are no comparison studies listed FINDINGS: HEART AND VASCULATURE: There are bilateral pulmonary emboli, including an embolus which completely occludes the right middle lobe artery, an embolus within the distal right interlobar artery extending to right lower lobe segmental branches, and an embolus at the branch point of the left anterior segmental artery. There is no right heart strain. There is mild dilatation of the main pulmonary artery, measuring up to 3.2 cm, nonspecific but can be seen in setting of underlying pulmonary hypertension. There is mild atherosclerotic disease of the thoracic aorta with focal outpouching of the aortic arch immediately distal to the left subclavian artery which could represent a ductus diverticulum. There is no dissection or intramural hematoma. Heart size is mildly enlarged. There is no flattening of the interventricular septum to suggest right heart strain. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: Small right pleural effusion. No left pleural effusion. No pneumothorax. LUNGS/AIRWAYS: There is consolidation in the right lower lobe, which is in part compatible with mild atelectasis. Heterogeneous enhancement suggests superimposed infarction in the setting of pulmonary emboli and/or infection. There is mild subsegmental atelectasis in the left lower lobe. There is no evidence of mass or suspicious nodules in the aerated lungs. Central airways are patent. There is collapse of subsegmental airways in the right lower lobe.. BASE OF NECK: Visualized portions of the base of the neck are unremarkable. ABDOMEN: Included portion of the upper abdomen is unremarkable. There is a small hiatal hernia. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. Bilateral pulmonary emboli as detailed above. No CT findings of right heart strain. 2. Consolidation in the right lower lobe, which is in part compatible with mild atelectasis. Heterogeneous enhancement suggests superimposed infarction in the setting of pulmonary emboli and/or infection. 3. Small right pleural effusion. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: ___ with PMHx HTN and recent admission for pyogenic liver abscess on IV CTX/flagyl who presents with worsening RUQ pain and pleuritic chest pain, found to have extensive bl proximal DVTs and submassive subsegmental PE on CTA. Continuing to have severe RUQ pain and focal tenderness // Evaluate for evidence of hematoma, abscess, TECHNIQUE: Targeted gray scale and color Doppler ultrasound images of the liver was obtained. COMPARISON: CT abdomen pelvis performed ___. Abdominal ultrasound performed ___. FINDINGS: Examination is limited due to patient positioning. Within these confines: Hepatic parenchyma appears within normal limits. The contour of the liver is smooth. The previously seen heterogeneous lesion within liver segment V/VIII on CT abdomen pelvis performed ___, compatible with biopsy-proven abscess, is not well visualized sonographically. There is no intrahepatic biliary ductal dilatation. There is no perihepatic ascites. Limited views of the gallbladder are unremarkable. IMPRESSION: Limited examination due to patient positioning. Previously seen heterogeneous lesion within liver segment V/VIII on CT abdomen pelvis performed ___, compatible with biopsy-proven abscess, is not well visualized sonographically. Gender: M Race: BLACK/AFRICAN Arrive by AMBULANCE Chief complaint: RUQ abdominal pain Diagnosed with Right upper quadrant pain temperature: 98.0 heartrate: 107.0 resprate: 16.0 o2sat: 95.0 sbp: 98.0 dbp: 75.0 level of pain: 10 level of acuity: 3.0

Dear Dr. ___, ___ was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for chest pain and found to have blood clots in the lungs and legs. What was done for me while I was in the hospital? - You were started on a blood thinner to prevent extension of the blood clots or formation of additional clots. - You had severe abdominal pain at the site of your recent liver biopsy. Repeat imaging showed ___ evidence of bleeding, infection, or other complications, and your pain gradually improved. - You were continued on antibiotics that were started prior to this hospitalization. What should I do when I leave the hospital? - Continue to take all of your medications as prescribed - Attend all of your follow-up appointments Sincerely, Your ___ Care Team

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 Major Surgical or Invasive Procedure: Transesophageal echocardiography ___ Peripherally inserted central catheter (PICC) placement ___ History of Present Illness: HISTORY OF PRESENT ILLNESS: Mr. ___ is a ___ year old M with a history of DM, ESRD on HD, afib on coumadin, AVR, ___, CAD s/p CABG, ICD implanted for Vtach presenting from dialysis with fever. Patient reports feeling generally unwell for the past ___ days with fatigue, malaise. He had one episode of loose stools, not black or bloody, yesterday, but otherwise has no focal symptoms. Denies headache, sore throat, chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting. He sometimes makes a very small amount of urine, however denies dysuria. Denies rash. He was admitted in ___ for an infection of his ICD pocket which was treated and ICD was resited. Pt denies pain or discomfort related to new ICD site. He presented to dialysis this morning and was noted to be febrile. CBC and blood cultures were drawn and he was given 1 g of Tylenol and sent to the ED. He did not receive any dialysis. In the ED, initial VS were 99.6 78 113/68 16 96% RA. Initial labs were notable for K 7.4, BUN/Cr of 92/11.9, Na 131, Phos 6.8, CK 508, HCO3 17. EKG demonstrated NSR at 74, PR prolonged at 274, QS wide at 140, QTc 456, TWI I/L with ___epression laterally. Pt received calcium gluconate and insulin with D50. Pt was emergently dialyzed in the ED. Pt also received Vancomycin 1.5g and Gentamicin 200mg for possible Transfer VS were 99.0 109 139/70 16 100% Nasal Cannula. On arrival to the floor, pt's VS ___ 105/60 18 95% on 2L. Pt reports he feels febrile, but reports his nausea and diarrhea are improved. Past Medical History: 1. CARDIAC RISK FACTORS - HTN - HLD - T2DM 2. CARDIAC HISTORY - CAD/MI: ___ s/p CABG and PCI OM c/b VT and IABP for hemodynamic instability - Chronic dCHF (LVEF=40%) - Thromboembolic CVA ___ d/t ASD (lost left eye sight) - Atrial fibrillation - Aortic Stenosis s/p AVR ___ - CAD s/p CABG on ___ - Vtach - episode ___ periMI, also ___ postop s/p partial penectomy - Atrial fibrillation - Aortic Stenosis s/p mechnical AVR - Chronic dCHF 3. OTHER PAST MEDICAL HISTORY - ESRD ___ diabetic nephropathy) on HD ___ - Gangrenous penile ulcer s/p penectomy (___) - Obesity - Obstructive sleep apnea on CPAP - Right pleural effusion s/p thoracotomy/pleurectomy in ___ - Pancreatitis ischemic infarct - GERD - Carpal tunnel syndrome - Thromboembolic CVA ___ d/t ASD (lost left eye sight) - Bilateral Cataracts Social History: ___ Family History: Father - DM, Mother - heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS - ___ 105/60 18 95% on 2L General: Diaphoretic appearing, lying in bed, no apparent distress HEENT: NCAT, PERRL, EOMI, OP clear Neck: No thyromegaly CV: S1 S2, mechanical, no murmurs Lungs: crackles at bases bilaterally Abdomen: Obese, non-tender, non-distended, hyperactive BS GU: Deferred Ext: Trace edema, no cyanosis or clubbing Neuro: Moving all 4 extremities Skin: AVF fistula on RUE bandaged c/d/i DISCHARGE PHYSICAL EXAM: ======================== VS: Temp 97.1-98.1, HR 52-60, BP 90-102/50-73, RR 18, O2sat 97-100% (RA), FSG 84-139, Wt on ___ 110.3 kg (was 105.7 on ___ I/O: 210 IV/BRP General: Well appearing, NAD HEENT: EOMI, MMM. CV: RRR, normal S1 and loud mechanical-sounding S2. No murmurs, rubs, or gallops. Lungs: No increased respiratory effort. Sparse crackles at the bases bilaterally. No wheezes or rhonchi. Abdomen: Obese, soft, non-tender, non-distended with normal bowel sounds. Ext: WWP. 2+ pitting edema to the mid-shin bilaterally. Neuro: Awake and alert. Oriented to situation. Pertinent Results: ADMISSION LABS ============== ___ 09:52AM BLOOD WBC-10.6 RBC-3.56* Hgb-11.8* Hct-35.0* MCV-98 MCH-33.0* MCHC-33.6 RDW-14.8 Plt ___ ___ 09:52AM BLOOD Neuts-87.0* Lymphs-6.2* Monos-5.9 Eos-0.9 Baso-0.1 ___ 09:52AM BLOOD ___ PTT-44.7* ___ ___ 09:52AM BLOOD Glucose-78 UreaN-92* Creat-11.9*# Na-130* K-8.4* Cl-93* HCO3-15* AnGap-30* ___ 12:00PM BLOOD CK(CPK)-508* ___ 12:00PM BLOOD CK-MB-6 ___ 12:00PM BLOOD Calcium-8.6 Phos-6.8*# Mg-1.9 ___ 10:04AM BLOOD Lactate-3.2* K-7.4* PERTINENT INPATIENT LABS ======================== ___ 07:05AM BLOOD WBC-11.5* RBC-3.43* Hgb-11.0* Hct-33.8* MCV-99* MCH-32.2* MCHC-32.7 RDW-14.9 Plt ___ ___ 04:16PM BLOOD ___ PTT-46.9* ___ ___ 07:05AM BLOOD Glucose-91 UreaN-47* Creat-7.8*# Na-138 K-5.3* Cl-97 HCO3-27 AnGap-19 ___ 07:05AM BLOOD Calcium-8.4 Phos-5.7* Mg-1.9 ___ 07:23AM BLOOD WBC-8.0 RBC-3.24* Hgb-10.6* Hct-31.7* MCV-98 MCH-32.8* MCHC-33.5 RDW-15.0 Plt ___ ___ 07:23AM BLOOD ___ ___ 07:23AM BLOOD Glucose-142* UreaN-66* Creat-9.4*# Na-131* K-5.6* Cl-91* HCO3-24 AnGap-22 ___ 07:23AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.0 ___ 08:10AM BLOOD WBC-8.2 RBC-3.48* Hgb-11.2* Hct-34.6* MCV-99* MCH-32.2* MCHC-32.4 RDW-14.9 Plt ___ ___ 08:10AM BLOOD ___ PTT-43.5* ___ ___ 08:10AM BLOOD ESR-76* ___ 08:10AM BLOOD CRP-255.1* ___ 08:10AM BLOOD Glucose-101* UreaN-38* Creat-6.7*# Na-131* K-4.7 Cl-89* HCO3-28 AnGap-19 ___ 08:10AM BLOOD ALT-34 AST-53* LD(LDH)-281* AlkPhos-75 TotBili-0.7 ___ 08:10AM BLOOD Albumin-3.6 Calcium-8.2* Phos-4.3# Mg-1.9 ___ 06:50AM BLOOD ___ PTT-36.9* ___ ___ 06:10AM BLOOD Glucose-122* UreaN-53* Creat-8.5*# Na-129* K-4.5 Cl-88* HCO3-25 AnGap-21* ___ 06:10AM BLOOD Calcium-7.5* Phos-5.0* Mg-2.2 ___ 06:10AM BLOOD Vanco-22.0* ___ 03:30PM BLOOD Genta-1.5* ___ 07:55AM BLOOD ___ PTT-35.5 ___ ___ 11:52PM BLOOD ___ PTT->150* ___ ___ 07:55AM BLOOD Glucose-103* UreaN-34* Creat-6.0*# Na-136 K-4.1 Cl-97 HCO3-31 AnGap-12 ___ 07:55AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.0 ___ 07:55AM BLOOD Genta-1.5* ___ 06:00AM BLOOD ___ PTT-94.8* ___ ___ 01:15PM BLOOD PTT-150* ___ 09:00PM BLOOD PTT-85.4* ___ 06:00AM BLOOD Glucose-99 UreaN-42* Creat-7.6*# Na-137 K-4.4 Cl-95* HCO3-24 AnGap-22* ___ 06:00AM BLOOD ALT-27 AST-33 LD(LDH)-264* AlkPhos-72 TotBili-0.3 ___ 06:00AM BLOOD Albumin-3.5 Calcium-7.9* Phos-4.0 Mg-2.4 ___ 07:15AM BLOOD WBC-6.2 RBC-3.27* Hgb-10.6* Hct-32.7* MCV-100* MCH-32.4* MCHC-32.3 RDW-15.7* Plt ___ ___ 02:52AM BLOOD ___ PTT-89.3* ___ ___ 07:15AM BLOOD Glucose-108* UreaN-57* Creat-9.1*# Na-136 K-4.8 Cl-96 HCO3-24 AnGap-21* ___ 07:15AM BLOOD Calcium-8.0* Phos-5.7*# Mg-2.1 DISCHARGE LABS ============== ___ 07:20AM BLOOD WBC-4.6 RBC-3.21* Hgb-10.4* Hct-32.2* MCV-100* MCH-32.3* MCHC-32.2 RDW-15.6* Plt ___ ___ 07:20AM BLOOD ___ PTT-36.4 ___ ___ 07:20AM BLOOD Glucose-107* UreaN-31* Creat-6.4*# Na-141 K-4.4 Cl-96 HCO3-29 AnGap-20 ___ 07:20AM BLOOD Calcium-8.0* Phos-4.6* Mg-2.2 PERTINENT MICROBIOLOGY RESULTS ============================== ___ 6:00 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin 2 MCG/ML Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ 2 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ ___ ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Blood cultures positive for Enterococcus faecalis on ___, ___ STUDIES: ======== TRANSESOPHAGEAL ECHOCARDIOGRAM (___) The left atrium is dilated. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed (LVEF= ___ %). with moderate global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. The prosthetic aortic valve leaflets appear normal A mild paravalvular aortic valve leak is present (best seen in the short axis view at 5 o'clock, clips 48-50). No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. The mitral valve leaflets are mildly thickened with mild mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no abscess of the tricuspid valve. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations or abscesses. Left ventricular hypertrophy with normal cavity size and moderate global systolic dysfunction. Moderate right ventricular systolic dysfunction. Well seated mechanical aortic valve with mild paravalvular leak. Simple atheroma in the thoracic aorta. EKG ___: Sinus rhythm. P-R interval prolongation. Left axis deviation. Intraventricular conduction delay. Since the previous tracing of ___ the axis is now more leftward and limb lead voltage is less prominent. Precordial ST-T wave abnormalities are more prominent. EKG ___: Normal sinus rhythm. One ventricular premature complex. Diffuse non-specific ST-T wave abnormalities. Non-specific intraventricular conduction delay. The P-R interval is slightly prolonged at 220 milliseconds. Delayed R wave progression in the precordial leads. Compared to the previous tracing of ___ the P-R interval is shorter. The premature ventricular complexes are new and the ST-T wave abnormalities are slightly less marked but the Q-T interval is longer. PERTINENT INPATIENT IMAGING =========================== Chest Radiograph, PA and Lateral (___): FINDINGS: AP and lateral views of the chest. There is chronic blunting of the right lateral costophrenic angle as on prior. Lungs are clear of focal consolidation or effusion. Cardiomediastinal silhouette is stable given differences in positioning. Cutaneous ICD lead seen with lead in unchanged position. Chronic deformities of the right posterior lateral ribs again seen. No definite acute osseous abnormalities. IMPRESSION: No definite acute cardiopulmonary process. UNILAT UP EXT VEINS US RIGHT (___): FINDINGS: At the proximal fistula, there is possible thickening along the posterior wall, possibly indicating a very small amount of chronic mural thrombus. There is no intraluminal thrombus. The fistula demonstrates good flow along the proximal, mid and distal segments. There is no adjacent fluid collection. IMPRESSION: Mildly thickened proximal portion of the fistula, likely secondary to more chronic mural thrombus; however, with good flow seen throughout its proximal, mid and distal course. No fluid collection identified. CT ABD & PELVIS WITH CONTRAST (___): IMPRESSION: 1. No evidence of acute intra-abdominal process. No discrete fluid collection or abscess formation. 2. Atrophic kidneys compatible with history of end-stage renal disease. 3. Extensive calcified atherosclerotic disease of the aorta and its major branches without aneurysmal changes. 4. Slight thickening of the bladder wall, which may relate to its underdistention. Clinical correlation is recommended. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lidocaine-Prilocaine 1 Appl TP PRN apply over fistula 30 minutes prior to dialysis three times per week prior to dialysis 3. Omeprazole 40 mg PO BID 4. Pravastatin 80 mg PO HS 5. ammonium lactate 12 % topical daily 6. folic acid-B complex & C ___ mg oral DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain 9. Cinacalcet 30 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Warfarin 7 mg PO DAILY 12. sevelamer CARBONATE 800 mg PO TID W/MEALS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cinacalcet 30 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lidocaine-Prilocaine 1 Appl TP PRN apply over fistula 30 minutes prior to dialysis three times per week prior to dialysis 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Omeprazole 40 mg PO BID 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain 8. Pravastatin 80 mg PO HS 9. Ampicillin 2 g IV Q24H RX *ampicillin sodium 2 gram 2 g IV once a day Disp #*37 Vial Refills:*0 10. Gentamicin 80 mg IV ONCE Duration: 1 Dose RX *gentamicin 20 mg/2 mL 8 mL IV after HD Disp #*64 Vial Refills:*0 11. Warfarin 7 mg PO DAILY16 12. sevelamer CARBONATE 800 mg PO TID W/MEALS 13. ammonium lactate 12 % topical daily 14. folic acid-B complex & C ___ mg oral DAILY 15. Outpatient Lab Work Please draw CBC with differential, BUN, Cr, ALT, AST, Alk phos, Total bilirubin, ESR, CRP ___ while receiving IV antibiotics All laboratory results should be faxed to the ___ R.N.s at ___. 16. Outpatient Lab Work Please draw Gentamicin level 2 hours post hemodialysis every other ___ All laboratory results should be faxed to the ___ R.N.s at ___. 17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush RX *sodium chloride 0.9 % [BD PosiFlush Normal Saline] 0.9 % ___ mL IV once a day Disp #*50 Syringe Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: # Enterococcal sepsis # Hyperkalemia # Polymorphic ventricular tachycardia SECONDARY DIAGNOSES: # End stage renal disease on hemodialysis # Coronary artery disease # Diabetes mellitus # Obstructive sleep apnea # Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST, TWO VIEWS: ___ HISTORY: ___ male with fever and shortness of breath. COMPARISON: ___. FINDINGS: AP and lateral views of the chest. There is chronic blunting of the right lateral costophrenic angle as on prior. Lungs are clear of focal consolidation or effusion. Cardiomediastinal silhouette is stable given differences in positioning. Cutaneous ICD lead seen with lead in unchanged position. Chronic deformities of the right posterior lateral ribs again seen. No definite acute osseous abnormalities. IMPRESSION: No definite acute cardiopulmonary process. Radiology Report INDICATION: Patient with end-stage renal disease on hemodialysis, now with bacteremia. Assess for intra-abdominal abscess formation or source of infection. COMPARISONS: CT pelvis of ___ and CT abdomen and pelvis of ___. FINDINGS: CT OF THE ABDOMEN: The liver demonstrates homogeneous enhancement without suspicious focal lesions. There is no evidence of intrahepatic or extrahepatic biliary ductal dilatation. The portal vein is patent. The gallbladder is surgically absent. CBD is of normal caliber measuring 6 mm. The spleen is normal in size. The pancreas enhances homogeneously without ductal dilatation or peripancreatic fluid collection. The adrenal glands are thickened without discrete nodularity, unchanged. The kidneys appear atrophic, consistent with known history of end-stage renal disease. There is lack of renal parenchymal enhancement without hydronephrosis. Perirenal fat stranding is noted, which is nonspecific in nature. Small and large bowel loops are normal in caliber without evidence of bowel wall thickening or obstruction. The appendix is visualized and is normal. No discrete fluid collection is seen. No abscess formation. Diastasis of the rectus abdominal muscles is noted. Mild periumbilical stranding is present. Scattered mesenteric and retroperitoneal lymph nodes, which are not pathologically enlarged. Intra-abdominal aorta and its major branches demonstrate calcified atherosclerotic disease without aneurysmal changes. The bladder is non-distended. There is mild bladder wall thickening, which most likely relates to underdistension. The rectum and sigmoid colon are unremarkable. There is no evidence of diverticulitis. Heavily calcified vas deferens are noted bilaterally, which is often seen in the setting of diabetes. Bilateral fat-containing inguinal hernia is present. There is no inguinal or pelvic wall lymphadenopathy. Extensive iliac vessel calcifications are noted. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion is seen. Right anterior rib deformity is stable, likely relates to prior trauma. IMPRESSION: 1. No evidence of acute intra-abdominal process. No discrete fluid collection or abscess formation. 2. Atrophic kidneys compatible with history of end-stage renal disease. 3. Extensive calcified atherosclerotic disease of the aorta and its major branches without aneurysmal changes. 4. Slight thickening of the bladder wall, which may relate to its underdistention. Clinical correlation is recommended. Radiology Report INDICATION: History of end-stage renal disease on hemodialysis, presenting with enterococcus bacteremia. Please assess fistula for infected clot. COMPARISONS: Fistulagram from ___. TECHNIQUE: Focused ultrasound of the right fistula. FINDINGS: At the proximal fistula, there is possible thickening along the posterior wall, possibly indicating a very small amount of chronic mural thrombus. There is no intraluminal thrombus. The fistula demonstrates good flow along the proximal, mid and distal segments. There is no adjacent fluid collection. IMPRESSION: Mildly thickened proximal portion of the fistula, likely secondary to more chronic mural thrombus; however, with good flow seen throughout its proximal, mid and distal course. No fluid collection identified. Radiology Report INDICATION: ___ year old man with new left PICC. TECHNIQUE: Portable chest radiograph. COMPARISON: Chest radiographs ___ through ___. FINDINGS: Interval placement of a left PICC which ends in the right atrium and can be pulled back approximately 3-4 cm. There is no pneumothorax. The cardiomediastinal and hilar contours are unchanged. The lungs are grossly clear. There is no pleural effusion. IMPRESSION: New left PICC ends in the right atrium and can be pulled back approximately 3-4 cm. NOTIFICATION: Findings were paged to ___ the IV nurse by Dr. ___ on ___ at 11:45, 40 minutes after they were made. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new PICC // assess PICC placement Contact name: ___: ___ TECHNIQUE: Portable chest radiograph COMPARISON: ___. FINDINGS: The left PICC line is now at the junction of the superior vena cava and the atrium. No other change. IMPRESSION: PICC line in correct position. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Fever, Diarrhea Diagnosed with FEVER, UNSPECIFIED, HYPERKALEMIA, ABNORM ELECTROCARDIOGRAM, END STAGE RENAL DISEASE temperature: 99.6 heartrate: 78.0 resprate: 16.0 o2sat: 96.0 sbp: 113.0 dbp: 68.0 level of pain: 3 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were hospitalized because he had high fevers and were found to have bacteria in your blood. You were treated with antibiotics, and your condition improved. You had a peripherally inserted central catheter (PICC) placed so you can continue to receive antibiotics at home. You had a high level of potassium in your blood when you came to the hospital and were treated to return the potassium levels to normal. You had a serious abnormal heart rhythm twice during hemodialysis on ___. The implanted defibrillator applied shocks to your heart, and your heart returned to a normal rhythm. You will receive daily Ampicillin infusions at home for a total 6 week course (ending ___. You should continue hemodialysis on your regular ___ schedule. You will also receive Gentamicin when at hemodialysis for a total of 6 weeks. You will have a Gentamicin level drawn every other week 2 hours after dialysis and receive Gentamicin based on that level. Please follow up with your scheduled audiology, primary care, and infectious disease appointments as scheduled. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you a speedy recovery. Best regards, Your ___ TEAM

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / Bactrim / Compazine / tramadol Attending: ___. Chief Complaint: abdominal pain, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with the past medical history noted below who presented to the ED w/ abdominal pain; diarrhea and fever. History has been obtained by discussing w/ patient and her daughter at the bedside and reviewing records. Approximately ___ days back she started experiencing primarily upper abdominal discomfort that was intermittent in nature w/out any specific exacerbating or relieving factors. Progressively worsened to involve right side of abdomen too and at times was radiating to the back. At it worst, she rates it as ___ in intensity. Over the same period, she reports fever as high as ___ at home. Shortly after the aforementioned symptoms started -- she dev. profuse watery diarrhea - upto 12 times/day. Initially non-bloody and then turned out to be admixed w/ bright red blood and "dark blood". No vomiting but endorses dry heaves. Her daughter finally convinced her to come to the hospital and following arrival in the ED, after basic work-up, she was referred for admission to Hospitalist service. Patient has had 3 prior C. difficile infections -- most recent ___ for which she completed prolonged Vancomycin taper. At some point, fecal microbiota transplant was considered but was eventually deferred as she had no recurrence for several months. In ___ this year she was treated again for presumptive C. difficile infection (PCR+; tox neg). Denies recent Abx use with the last month. Uses BID PPI for GERD. Apart from this, she reports compliance w/ home meds -- except that she ran out of Advair inhaler (asthma). Has chronic heartburn. Intermittent ___ swelling. No chest pain. Feels weak and reports shortness of breath at times. Non-compliant w/ CPAP. Of note -- patient's daughter states that some family members w/ sick w/ nausea/diarrhea around the same time but they have since recovered. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: HTN HLD OSA - CPAP NON-COMPLIANT DM GERD POSSIBLE CELIAC DZ ASTHMA SEASONAL ALLERGIES DIASTOLIC CHF DEPRESSION Nephrolithiasis w/ mult. ESWL; stenting + stone extraction Recurr. C.difficile infection Hepatic steatosis Social History: ___ Family History: Mother: deceased - ___ Mellitus, Myocardial infarction Father: deceased- ___ Cancer (dx at ___), Deep venous thrombophlebitis Sister: deceased ___ ___ Cancer (dx at ___) Sister: ?IBD Daughter: IBS Physical Exam: ADMISSION: ========= VITALS: Afebrile and vital signs stable (see eFlowsheet) 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 - dry 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, primarily epigastric ttp but no guarding or rigidity. 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 . Old tattoos -- RLE 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 The patient was examined on the day of discharge. Pertinent Results: ADMISSION/SIGNIFICANT LABS: ======================== ___ 08:53PM BLOOD WBC-8.5 RBC-4.66 Hgb-13.3 Hct-41.5 MCV-89 MCH-28.5 MCHC-32.0 RDW-14.5 RDWSD-46.6* Plt ___ ___ 08:53PM BLOOD Neuts-50 ___ Monos-10 Eos-1 Baso-0 Atyps-3* Plasma-1* AbsNeut-4.25 AbsLymp-3.23 AbsMono-0.85* AbsEos-0.09 AbsBaso-0.00* ___ 08:53PM BLOOD Glucose-112* UreaN-13 Creat-0.7 Na-141 K-4.6 Cl-98 HCO3-29 AnGap-14 ___ 12:37AM BLOOD ALT-26 AST-23 AlkPhos-91 TotBili-0.2 ___ 12:41AM BLOOD Lactate-1.7 MICRO: ===== Cdiff PCR and toxin assay positive IMAGING/OTHER STUDIES: ==================== CT a/p ___ IMPRESSION: -Nonobstructing 8 mm stone in the right kidney. -No acute findings in the abdomen and pelvis. LABS ON DISCHARGE: ================ ___ 07:20AM BLOOD WBC-7.7 RBC-4.15 Hgb-11.7 Hct-36.8 MCV-89 MCH-28.2 MCHC-31.8* RDW-14.2 RDWSD-46.3 Plt ___ ___ 07:20AM BLOOD Glucose-116* UreaN-6 Creat-0.5 Na-144 K-4.1 Cl-103 HCO3-29 AnGap-12 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DICYCLOMine 20 mg PO BID 2. Lisinopril 40 mg PO DAILY 3. Loratadine 10 mg PO DAILY 4. Metoprolol Succinate XL 150 mg PO DAILY 5. Pantoprazole 40 mg PO Q12H 6. Ondansetron 8 mg PO BID:PRN nausea 7. Pravastatin 80 mg PO QPM 8. Ranitidine 300 mg PO QHS 9. Sucralfate 1 gm PO TID:PRN EPIGASTRIC DISCOMFORT 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4-6H:PRN 11. MetFORMIN (Glucophage) 500 mg PO BID 12. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Moderate 13. Furosemide 60 mg PO DAILY 14. AirDuo RespiClick (fluticasone propion-salmeterol) 232-14 mcg/actuation inhalation BID 15. LOPERamide 2 mg PO TID:PRN diarrhea 16. Montelukast 10 mg PO DAILY Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO QID RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth asdirected in taper Disp #*68 Capsule Refills:*0 2. AirDuo RespiClick (fluticasone propion-salmeterol) 232-14 mcg/actuation inhalation BID 3. DICYCLOMine 20 mg PO BID 4. Lisinopril 40 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Metoprolol Succinate XL 150 mg PO DAILY 8. Montelukast 10 mg PO DAILY 9. Ondansetron 8 mg PO BID:PRN nausea 10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Moderate 11. Pantoprazole 40 mg PO Q12H 12. Pravastatin 80 mg PO QPM 13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4-6H:PRN 14. Ranitidine 300 mg PO QHS 15. Sucralfate 1 gm PO TID:PRN EPIGASTRIC DISCOMFORT 16. HELD- Furosemide 60 mg PO DAILY This medication was held. Do not restart Furosemide until instructed by PCP or as per detailed in discharge instructions. 17. HELD- LOPERamide 2 mg PO TID:PRN diarrhea This medication was held. Do not restart LOPERamide until you complete treatment for Cdiff colitis. Discharge Disposition: Home Discharge Diagnosis: # Recurrent CDI: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with heart failure, hypoxemia// pna? chf? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___. FINDINGS: Low lung volumes with bibasilar atelectasis. There is no focal consolidation, pleural effusion, or pneumothorax. Cardiomediastinal silhouette is within normal limits. IMPRESSION: No focal consolidation or pulmonary edema. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with fever, abdominal pain, bloody stools. Evaluate for colitis. TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the 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 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP = 14.4 mGy-cm. 2) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 27.5 mGy (Body) DLP = 1,484.9 mGy-cm. Total DLP (Body) = 1,499 mGy-cm. COMPARISON: CT of the abdomen from ___. FINDINGS: LOWER CHEST: Mild bibasilar atelectasis without consolidation or pleural effusion. Moderate calcifications of the coronary arteries. No pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous no attenuation throughout, which may be associated steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal is mildly enlarged. No focal lesions are identified. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Several small hypodensities in the left kidney are too small to characterize, may reflect cysts. Otherwise, the kidneys are of normal and symmetric size with normal nephrogram. 8 mm stone is noted in the lower pole of the right kidney (series 2, image 51). There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: A small hiatal hernia is noted. The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not visualized. 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. 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: -Nonobstructing 8 mm stone in the right kidney. -No acute findings in the abdomen and pelvis. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Fever, RUQ abdominal pain, Weakness Diagnosed with Diarrhea, unspecified temperature: 98.6 heartrate: 80.0 resprate: 18.0 o2sat: 94.0 sbp: 111.0 dbp: 71.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___, It was a privilege to care for you at the ___ ___. You were admitted with abdominal pain and diarrhea due to recurrent C.diff colitis. You were started on another course of PO vancomycin, which you will need to take for several weeks. You will be seen by your PCP and GI doctor after discharge. It is very important that you keep these appointments to ensure that you continue to recover and stay healthy. Please note that we are holding your diuretic or "water pill" called furosemide for now as your diarrhea subsides. It is very important that you weigh your self as soon as you get home and continue to weigh yourself daily. You should resume your Lasix if you gain more than two pounds or if you notice any swelling in your legs or feet. You can call your PCP for additional guidance if you have any questions. We wish you the best. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / Pyridium / amoxicillin / Penicillins / Neosporin (neo-bac-polym) / Carbapenems Attending: ___. Chief Complaint: blurry vision, feeling "off" Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o female with a past medical history of multiple myeloma currently C1D23 velcade/dexamethasone, history of HTN, CAD, allergies who presented to the ED with fatigue, blurry vision and low grade temp elevation. Patient was recently started on V/D and had a reaction to zometa with severe eye inflammation for which she was seen by optho and started on eye drops. Her cycle 2 was delayed because of this. She also has had worsening seasonal allergies and was instructed to restart a prednisone taper, which she has done in the past, is taking 10mg daily. Regarding her vision blurriness was very sever over the past week, she could see almost nothing from L eye, says that eye doctor told her she was legally blind in that eye. was red but not painful, no discharge or swelling. since starting drops she has noticed ongoing improvement, still blurry but getting better. no double vision Today she reports "feeling off" but has difficult time describing further. says she felt foggy and just felt that something was wrong. she took temp and was 99 which she reports is high for her. when asked if she was confused says "yes maybe". no HA, no numbness or focal weakness. no nausea, ab pain or diarrhea. she has been constipated since starting chemo, not having adequate BM w/ senna/Colace just started miralax. she denies any dysuria but has been urinating frequently. no flank pain. does have some back pain in lower back that started yesterday after episode of sneezing, not radiating, has improved since yesterday but w/ certain movements she still has sharp pains. In the ED, T 98.4, BP 143/64, HR 85, 100% RA, RR 18. Labs were notable for WBC 5.4, PMN 75%, Hb 9.6, PLT 377, Na 131, Ca 8.3, lactate 1.2, UA negative however had few bacteria. Patient received 1L NS and cipro 250 mg PO for presumed UTI. Vitals prior to transfer were T 98.2, HR 86, BP 140/76, RR 18, 100% RA. Past Medical History: PAST ONCOLOGIC HISTORY: -Multiple myeloma, cycle 1 velcade/dex (day 1: ___ bony lesions (right hip), monoclonal protein, new anemia and gross proteinuria and BMBx that shows 80% plasma cell involvement (IgG Lambda). -nephrotic range proteinuria s/p renal biopsy ___ with evidence of light chain proximal tubulopathy -Corneal abrasion -Coronary artery disease (40% mid LAD, 20% ostial OM1, ___. -OA -HTN -Zoster -Asthma -Environmental allergies -HLD -s/p CCY Social History: ___ Family History: Her father died at age ___ of an MI. Her mother died at age ___ of colon cancer. She has one brother, one sister and no children. Her brother has diabetes, hypertension, and hyperlipidemia. Her sister has hypertension and hyperlipidemia. There is no family history notable for stroke, early coronary artery disease or sudden cardiac death. Physical Exam: Vitals: afeb, OVSS Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: supple, no JVD, no LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: WWP. No ___ edema. mild ttp in L lower paraspinal region SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. L pupil dilated 4mm min reactive (pt was told by opthal that eye will remain dilated into next week) EOMI, face symmetric, no tongue deviation, no nystagmus. moves all ext against resistance although R hip flexion difficult to sustain due to arthritis in R hip. sensation intact to light touch. visual fields full to confrontation bilat although unable to read clock or bulletin board across the room when closing R eye. Pertinent Results: ___ 05:25AM BLOOD WBC-3.9* RBC-2.67* Hgb-8.8* Hct-27.8* MCV-104* MCH-33.0* MCHC-31.7* RDW-13.7 RDWSD-52.5* Plt ___ ___ 05:25AM BLOOD Glucose-106* UreaN-6 Creat-0.5 Na-137 K-4.1 Cl-105 HCO3-26 AnGap-10 ___ 05:25AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 CXR: No evidence of pneumonia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. Montelukast 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Acyclovir 400 mg PO Q8H 6. Lisinopril 20 mg PO DAILY 7. OxyCODONE (Immediate Release) ___ mg PO TID:PRN pain 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Docusate Sodium 100-200 mg PO BID:PRN constipation 10. Senna 8.6-17.2 mg PO BID:PRN constipation 11. triamcinolone acetonide 55 mcg nasal daily prn congestion 12. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 13. DiphenhydrAMINE ___ mg PO QHS:PRN sleep 14. Fexofenadine 60 mg PO DAILY 15. PredniSONE 10 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Acetaminophen ___ mg PO Q8H:PRN headache, mild pain Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN headache, mild pain 2. Acyclovir 400 mg PO Q8H 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. DiphenhydrAMINE ___ mg PO QHS:PRN sleep 6. Docusate Sodium 100-200 mg PO BID:PRN constipation 7. Fexofenadine 60 mg PO DAILY 8. Fluticasone Propionate 110mcg 2 PUFF IH DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. Lisinopril 20 mg PO DAILY 11. Montelukast 10 mg PO DAILY 12. OxyCODONE (Immediate Release) ___ mg PO TID:PRN pain 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. PredniSONE 10 mg PO DAILY 15. Senna 8.6-17.2 mg PO BID:PRN constipation 16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 17. triamcinolone acetonide 55 mcg nasal daily prn congestion 18. Tobramycin-Dexamethasone Ophth Oint 1 Appl LEFT EYE QHS 19. Cyclopentolate 1% 1 DROP LEFT EYE TID 20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2 HR Discharge Disposition: Home Discharge Diagnosis: Multiple Myeloma 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 multiple myeloma and fever, evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___. FINDINGS: Cardiomediastinal silhouette is stable. There is no pleural effusion or pneumothorax. There is no focal lung consolidation. Biapical scarring is stable. IMPRESSION: No evidence of pneumonia. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with Urinary tract infection, site not specified temperature: 98.4 heartrate: 85.0 resprate: 18.0 o2sat: 100.0 sbp: 143.0 dbp: 64.0 level of pain: 0 level of acuity: 3.0

You were admitted with concern for a fever but you did not have a fever while you were here.

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: lisinopril Attending: ___ Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: tPA at 1710 on ___ History of Present Illness: Reason for Consult: Code Stroke Neurology at bedside for evaluation after code stroke activation within: 1 minute Time (and date) the patient was last known well: 16:00 ___ Stroke Scale Score: 1 t-PA given: Already given ___ Total Score: 2 1a. Level of Consciousness: 0 1b. Month/Age: 0 1c. Follow Two Commands: 0 2. Best Gaze: 0 3. Visual Fields: 0 4. Facial Weakness: 1 5a. Left Arm Motor: 1 5b. Right Arm Motor: 0 6a. Left Leg Motor: 0 6b. Right Leg Motor: 0 7. Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction: 0 HISTORY OF PRESENT ILLNESS: Mr. ___ is a ___ year old ___ man with a past medical history of afib s/p cardioversion, CAD, HTN, HLD, and DM who presents today with sudden onset of left arm and face weakness. He states that he was in his usual state of health, doing work on his patio. While doing this, all of a sudden he wasn't able to move his left arm. He went to get his wife, had no leg weakness or trouble walking. His wife noted that his arm was "dead" and limp by his side, and that his face was also drooping on the left. The patient is not sure if the arm was numb. She called 911 and he was brought to ___. In the ___, ___ 5 for mild dysarthria, moderate facial paresis, LUE drift and "borderline" LLE drift. ___ unremarkable and he was given tPA at 17:10, and transferred to ___ ___. En route, the patient stated that his symptoms improved. On arrival he is able to move his left arm without issue, and his wife says that his face looks much better. He notes that his only current problem is that his left hand is still very weak. He has had a recent URI. Otherwise ROS negative. He states that he was on pradaxa ___ years ago for one month after cardioversion. He is no longer on it. There is some note of hematuria in the chart however patient denies this. On neurologic review of systems, the patient 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. Denies difficulty with gait. On general review of systems, the patient 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: - Afib. s/p cardioversion ___, then on xarelto, stopped ___ for hematuria. Unclear if continued afib - CAD (prior RCA stent, LAD stent ___ - HTN - Ventricular bigeminy - CKD stage III - Type II DM Social History: ___ Family History: Unable to obtain - code stroke Physical Exam: Admission Exam: Vitals: 76 144/87 14 97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA bilaterally Cardiac: irregular 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. 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. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Left lower facial droop, mild. 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 pronation on the left due to hand weakness but no drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 0 0 0 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: ___ Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. FNF on left limited by plegia of left hand, however no clear dysmetria on top of this. -Gait: Deferred. Discharge Exam: beginning to regain small amount of motion in paretic hand. Pertinent Results: EKG ___: " Heart Rate: 71 RR Interval: 845 QRSD Interval: 110 QT Interval: 390 QTC Interval: 424 QRS Axis: -8 T Wave Axis: 29 EKG Severity - ABNORMAL ECG - EKG Impression: Atrial fibrillation EKG Impression: Multiple ventricular premature complexes EKG Impression: Abnormal R-wave progression, early transition" OSH NCHCT: FINDINGS: There is no evidence of infarction, hemorrhage, edema, ormass. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. There is mild mucosal thickeningof the bilateral ethmoid air cells. The visualized portion of the remain paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No intracranial hemorrhage or major territory acute infarction. ___ TTE 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. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior wall. There is very mild hypokinesis of the remaining segments (LVEF = 50 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with normal free wall contractility. 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 mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___ the right ventricle is now mildly dilated. Focal hypokinesis of the basal inferior wall is seen but was likley present before (has old RCA stent). Other findings are similar. ___ MRI Brain, MRA head/neck 1. Acute infarction in the right precentral gyrus without evidence of hemorrhagic conversion. 2. Patent circle of ___. 3. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. ___ CT Head 1. No evidence of infarction. No evidence of hemorrhage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 4. Aspirin 325 mg PO DAILY 5. Doxycycline Hyclate 50 mg PO EVERY OTHER DAY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth before bed Disp #*30 Tablet Refills:*3 2. Doxycycline Hyclate 50 mg PO EVERY OTHER DAY 3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 4. Atenolol 25 mg PO DAILY RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 5. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 6. Outpatient Physical Therapy ICD10 I63.4 Cerebral infarction due to embolism Left hand weakness Assess and treat 7. Outpatient Occupational Therapy ICD10 I63.4 Cerebral infarction due to embolism Left hand weakness Assess and treat Discharge Disposition: Home Discharge Diagnosis: Embolic stroke Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ INDICATION: ___ year old man with left face/hand weakness // eval for stroke TECHNIQUE: Three dimensional time of flight MR arteriography was performed through the brain with maximum intensity projection reconstructions. Dynamic MRA of the neck was performed during administration of 20 mL of Multihance intravenous contrast. Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient echo and diffusion technique. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. The examination was performed using a 1.5T MRI. COMPARISON: CT head ___ FINDINGS: MRI Brain: Restricted diffusion in the right precentral gyrus is associated with T2/FLAIR hyperintense signal. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Scattered foci of T2/FLAIR hyperintensities in the periventricular and subcortical white matter are nonspecific, but may represent the sequela of chronic small vessel ischemic disease. There is mild mucosal thickening in the right maxillary sinus. The mastoid air cells are clear. The orbits are unremarkable. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches are patent without evidence of stenosis, occlusion, or aneurysm formation. MRA neck: There is a normal 3 vessel branching pattern of the aortic arch. The common, internal and external carotid arteries are patent. There is no evidence of internal carotid artery stenosis by NASCET criteria. The origins of the great vessels, subclavian and vertebral arteries are patent bilaterally. IMPRESSION: 1. Acute infarction in the right precentral gyrus without evidence of hemorrhagic conversion. 2. Patent circle of ___. 3. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 04:14 AM. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ male with stroke. Evaluate for pulmonary infiltrate. TECHNIQUE: Portable chest radiograph COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes are normal. Streaky left lung base opacity likely represents atelectasis. There is no other focal consolidation, pleural effusion or pneumothorax. No pulmonary edema. Mild cardiomegaly. No subdiaphragmatic free air. No acute osseous abnormalities identified. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD. INDICATION: ___ year old man with l. stroke 24hr s/p TPA // ? CVA / bleeding. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP = 746.1 mGy-cm. Total DLP (Head) = 761 mGy-cm. COMPARISON: CT head ___. FINDINGS: There is no evidence of hemorrhage, edema, or mass. 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: 1. No evidence of infarction. No evidence of hemorrhage. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: CVA, Transfer Diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac, Unspecified atrial fibrillation temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Mr ___, You were admitted to the ___ for weakness in the left hand which was due to a stroke affecting the frontal lobe on the right side of your brain. This is likely attributable to your atrial fibrillation and you would benefit from an anticoagulant such as apixaban. Taking your age, weight, and kidney function into account, the recommended dose is 5mg two times per day. It is important that you do not miss any doses, as there may be a clotting "rebound" effect where you are more likely to have a clot if you do miss ___ dose. You should not take this together with aspirin or other NSAIDs (such as ibuprofen, naproxen, etc). The main side effect of this medication is bleeding so please come to the emergency room if you have any major injuries (especially if you injure your head). Some of your other medications have changed. We increased your Lipitor from 40mg to 80mg in an effort to better reduce your risk of stroke. We decreased your atenolol from 50 to 25mg daily because your blood pressure was well controlled and your pulse was already quite low on half your prior dose. I agree with your endocrinologist that we do need to better control your blood sugars though we will defer to her expertise as to which drug to use to do so. Please do not hesitate to call us with any problems. Please see the "warning signs" below. It is very important to follow up with your PCP, ___, endocrinologist, and neurologist.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: fevers Major Surgical or Invasive Procedure: none. History of Present Illness: Mr. ___ is a ___ with cryptogenic cirrhosis 8 months s/p liver transplant ___, 1 month s/p R indirect hernia repair, also recently admitted ___ for fevers, thought to be viral in origin, GERD, esophageal dysmotility, DM on insulin presenting from home with fevers/chills that started the night prior to presentation. Pt reports having Tmax 101.3 at home; reports having the chills and shaking, says that he couldn't stop shivering. Also reports some associated fatigue and malaise. No joint paint or muscle pain. He denies any recent runny nose, sore throat, no recent sick contacts. No changes in his bowel movements, no diarrhea, no n/v. He also denies any chest pain, palpitations, no shortness of breath, no trouble breathing. Denies any abdominal pain, no urinary symptoms. . Of note, the patient is immunosuppression for liver transplant, including Rapamune 3.5 ___, Tacro 3 mg BID, and Myfortic 360 mg BID. . In the ED, initial vitals were 100.0 ___ 18 100% RA. Noted to be febrile. Blood and urine cultures sent. UA without evidence of infection. CXR. Patient diarrhea concerning for C. Diff so sent for toxin. Blood counts near baseline. Creatinine elevated at 3.0 with recent baseline 2.3. Potassium elevated to 6.2. EKG unchanged. Patient was given kayexalate 30mg and regular insulin 10U IV. Vitals prior to transfer 98.1, Pulse: 89, RR: 18, BP: 120/64, O2Sat: 100%. . On arrival to the floor, the patient appeared comfortably, just tired and wanting to sleep. He was complaining of some pain at his IV site; was otherwise feeling well. Past Medical History: Hiatal hernia GERD esophageal dysmotility prostate cancer s/p prostatectomy and penile prosthesis depression end-stage liver disease (liver cirrhosis) s/p transplant diabetes on insulin . Past Surgical History: ___ Deceased donor liver transplant. ___ Exploratory laparotomy with removal of packs liver biopsy and abdominal closure prostatectomy Social History: ___ Family History: No family history of liver disease, diabetes, or premature CAD. Physical Exam: Admission PE: Vitals: T 100.0 93/33 93 20 97 on RA General: well appearing, pleasant elderly gentleman, NAD, laying comfortably in bed HEENT: sclera anicteric, mmm Neck: supple, no LAD Heart: RRR, S1, S2, no murmurs/rubs/gallops appreciated Lungs: good air movement, clear to auscultation b/l, no wheezes/rhonchi/crackles Abdomen: soft, nontender, nondistended, well healed surgical scar, + suprapubic mass (5cm), no tenderness to palpations (pt says c/w penile implant) Extremities: 2+ DP pules b/l, warm, well perfused extremities, no ___ edema appreciated Neurological: alert and oriented . Discharge PE: Vitals: Tc 99.6 Tm 100 96/50 (93-125/33-64) 91 (85-105) 12 98 RA 850+ out/~2.3L in General: well appearing, NAD, sitting up comfortably in chair watching television HEENT: sclera anicteric, mmm Neck: supple, no LAD Heart: RRR, S1, S2, no murmurs/rubs/gallops appreciated Lungs: good air movement, clear to auscultation b/l, no wheezes/rhonchi/crackles Abdomen: soft, nontender, nondistended, well healed surgical scar, + suprapubic mass (5cm), no tenderness to palpations (pt says c/w penile implant) Extremities: 2+ DP pules b/l, warm, well perfused extremities, no ___ edema appreciated Pertinent Results: ___ 10:10AM BLOOD WBC-5.2 RBC-3.04* Hgb-8.9* Hct-27.1* MCV-89 MCH-29.1 MCHC-32.7 RDW-16.9* Plt ___ ___ 06:30AM BLOOD WBC-5.5 RBC-2.90* Hgb-8.5* Hct-26.2* MCV-91 MCH-29.3 MCHC-32.4 RDW-16.9* Plt ___ ___ 06:30AM BLOOD ___ ___ 10:10AM BLOOD Glucose-200* UreaN-55* Creat-3.0* Na-138 K-6.2* Cl-105 HCO3-24 AnGap-15 ___ 05:10PM BLOOD Glucose-121* UreaN-45* Creat-2.5* Na-141 K-5.3* Cl-106 HCO3-26 AnGap-14 ___ 06:30AM BLOOD Glucose-114* UreaN-39* Creat-2.4* Na-140 K-4.2 Cl-105 HCO3-24 AnGap-15 ___ 10:10AM BLOOD ALT-47* AST-38 AlkPhos-189* TotBili-0.2 ___ 06:30AM BLOOD ALT-47* AST-37 AlkPhos-177* TotBili-0.2 ___ 05:10PM BLOOD Calcium-9.7 Phos-3.3 Mg-2.1 ___ 06:30AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.1 Mg-1.9 Medications on Admission: Lasix 40 mg ___ metoprolol tartrate 12.5 mg ___ BID lansoprazole 30 mg ___ fenofibrate 54 mg ___ insulin lispro ISS mirtazapine 30 mg ___ HS Myfortic 360 mg ___ BID sulfamethoxazole-trimethoprim 400-80 mg ___ tacrolimus 3 mg BID Sirolimus 3.5 mg qday tramadol 50 mg ___ Q6H PRN pain ursodiol 300 mg BID ferrous sulfate 300 mg (60 mg iron) TID MVI acetaminophen 650 q6H pain Colace 100 mg BID Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet ___ BID (2 times a day). 2. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1) Tablet,Rapid Dissolve, ___ ___. 3. mirtazapine 30 mg Tablet Sig: One (1) Tablet ___ HS (at bedtime). 4. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) ___ BID (2 times a day). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet ___. 6. ursodiol 300 mg Capsule Sig: One (1) Capsule ___ BID (2 times a day). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet ___ TID (3 times a day). 8. multivitamin Tablet Sig: One (1) Tablet ___. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule ___ BID (2 times a day). 10. acetaminophen 325 mg Tablet Sig: One (1) Tablet ___ Q6H (every 6 hours) as needed for pain/fever. 11. tramadol 50 mg Tablet Sig: One (1) Tablet ___ Q6H (every 6 hours) as needed for pain. 12. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous as directed: please take insulin according to your sliding scale. 13. sirolimus 1 mg Tablet Sig: Four (4) Tablet ___ once a day. Discharge Disposition: Home Discharge Diagnosis: fever secondary to viral infection 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 liver transplant, now with fevers and chills. COMPARISON: Multiple chest radiographs, the latest from ___. TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. No pleural effusion or pneumothorax is present. IMPRESSION: No acute intrathoracic process. Gender: M Race: PORTUGUESE Arrive by WALK IN Chief complaint: FEVER/CHILLS Diagnosed with FEVER, UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED, LIVER TRANSPLANT STATUS temperature: 100.0 heartrate: 109.0 resprate: 18.0 o2sat: 100.0 sbp: 99.0 dbp: 51.0 level of pain: 9 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you while you were hospitalized at ___. You were admitted to the hospital because you were having a fever at home. We sent blood and urine tests, and so far we have not found a reason for your fever. We think that you likely got this fever from a viral infection. By the time of discharge, you were no longer having fevers and were feeling better. . We made the following changes to your medications: STOP Tacrolimus 3 mg by mouth twice ___ INCREASE Sirolimus to 4 mg by mouth once ___ STOP Lasix 40 mg ___ (please follow up in liver clinic about when to restart this) . You will need to have your Sirolimus level checked next week, and you will have to follow up in the liver clinic on ___, ___. Please call ___ to confirm this appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F 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: ___ experiencing ~24 hrs of abdominal pain that began as a band across the upper abdomen and a band across the lower abdomen that now focusing in the RLQ. The pain felt dizzy in the morning and the pain began yesterday afternoon and worsened in intensity through the night ___ by 3am). The pain was alleviated somewhat by a bowel movement at 3am. The patient also reports feeling the same dizziness she experiences episodes of fibrillation, as well as nausea without vomiting and cold sweats. Patient denies chest pain but endorses shortness of breath. Pain is currently ___. Past Medical History: PMH: - CAD w/ stends - Hyperlipidemia - Afib on Xarelto - CAD: LAD with 60% and 80% serial lesions s/p DES ___ Social History: ___ Family History: Father: Died at ___, myocarditis. Mother: Died at ___, liver cancer (did not drink alcohol). Paternal grandfather: Died of MI in ___. No siblings. Three children all healthy. Physical Exam: GEN: NAD HEENT: NCAT, EOMI, no scleral icterus CV: RRR RESP: no respiratory distress, breathing comfortably on room air GI: soft, appropriately TTP, no R/G/D, laparoscopic port incisions C/D/I and covered with Dermabond EXT: WWP, no peripheral edema Pertinent Results: ___ 08:50AM BLOOD WBC-13.9*# RBC-4.19 Hgb-13.0 Hct-37.9 MCV-91 MCH-31.0 MCHC-34.3 RDW-13.6 RDWSD-45.1 Plt ___ ___ 06:55AM BLOOD ___ PTT-31.9 ___ ___ 06:55AM BLOOD Glucose-81 UreaN-6 Creat-0.7 Na-140 K-4.0 Cl-105 HCO3-22 AnGap-17 ___ 08:50AM BLOOD ALT-35 AST-29 AlkPhos-73 TotBili-1.2 ___ 08:50AM BLOOD Lipase-26 ___ 03:30PM BLOOD cTropnT-<0.01 ___ 06:55AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9 ___ 09:02AM BLOOD Lactate-1.3 CT A/P ___: 1. Acute appendicitis. No abscess demonstrated. 2. Diminutive enhancing focus within the uterus/endometrium, likely an endometrial polyp. 3. 1 cm pancreatic cystic lesion in the uncinate process may represent a side branch IPMN. Medications on Admission: - Xarelto 20' - metoprolol 50' - atorvastatin 80' - Aspirin 81' - Nitroglycerin 0.4 as needed for angina - Estradiol cream Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe 4. Atorvastatin 80 mg PO QPM 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN prn chest pain 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: ___ with cough and fever// pna? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ FINDINGS: Lungs are well expanded and clear. The cardiomediastinal silhouette and hila are within normal limits with redemonstrated tortuous aorta. There is no pleural effusion or pneumothorax. Exaggerated thoracic kyphosis is unchanged. IMPRESSION: No focal consolidation to suggest pneumonia. Radiology Report INDICATION: ___ with lower abdominal pain // eval for acute process 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 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 2) Spiral Acquisition 4.6 s, 50.4 cm; CTDIvol = 9.3 mGy (Body) DLP = 470.9 mGy-cm. Total DLP (Body) = 481 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: Lung bases are clear. ABDOMEN: HEPATOBILIARY: The liver and gallbladder are unremarkable. PANCREAS: There is a 1 cm cystic lesion in the uncinate process. This may represent an intraductal papillary mucinous neoplasm. No main ductal dilatation seen. SPLEEN: Unremarkable. ADRENALS: Unremarkable. URINARY: Unremarkable. GASTROINTESTINAL: There is no bowel obstruction. The appendix is fluid-filled, enlarged measuring maximally 13 mm with hyperemic mucosa and wall edema (2:61, 602b:28, 601b:24). There is no free fluid or pneumoperitoneum. No abscess is seen. PELVIS: An enhancing 6 mm focus at the uterine fundus, likely an endometrial polyp. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: A few left periuterine varices are noted. Mild atherosclerotic calcifications. BONES: No aggressive osseous lesion. Small fat containing umbilical hernia. IMPRESSION: 1. Acute appendicitis. No abscess demonstrated. 2. Diminutive enhancing focus within the uterus/endometrium, likely an endometrial polyp. 3. 1 cm pancreatic cystic lesion in the uncinate process may represent a side branch IPMN. *** ED URGENT ATTENTION *** RECOMMENDATION(S): MRI follow-up for the pancreatic cystic lesion in ___ year. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:35 pm, 2 minutes after discovery of the findings. The impression and recommendation above was entered by Dr. ___ on ___ at 18:03 into the Department of Radiology critical communications system for direct communication to the referring provider. Gender: F Race: WHITE - OTHER EUROPEAN Arrive by WALK IN Chief complaint: Abd pain, Palpitations Diagnosed with Unspecified abdominal pain temperature: 100.7 heartrate: 80.0 resprate: 18.0 o2sat: 100.0 sbp: 116.0 dbp: 56.0 level of pain: 5 level of acuity: 3.0

Ms. ___, It was a pleasure taking care of you here at the ___ ___. You were admitted to our hospital for acute inflammation of your appendix. You had a laparoscopic appendectomy during this admission without complications. You tolerated the procedure well and are ambulating, stooling, tolerating a regular diet, and your pain is controlled by medications by mouth. You are now ready to be discharged home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. You should continue to walk several times a day. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may start some light exercise when you feel comfortable. Slowly increase your activity back to your baseline as tolerated. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - No heavy lifting (10 pounds or more) until cleared by your surgeon, usually about 6 weeks. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during the surgery. YOUR BOWELS: - Constipation is a common side effect of narcotic pain medicine such as oxycodone. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - You are being discharged with a prescription for oxycodone for pain control. You may take Tylenol as directed, not to exceed 3500mg in 24 hours. Take regularly for a few days after surgery but you may skip a dose or increase time between doses if you are not having pain until you no longer need it. You may take the oxycodone for moderate and severe pain not controlled by the Tylenol. You may take a stool softener while on narcotics to help prevent the constipation that they may cause. Slowly wean off these medications as tolerated. - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - chest pain, pressure, squeezing, or tightness - cough, shortness of breath, wheezing - pain that is getting worse over time or pain with fever - shaking chills, fever of more than 101 - a drastic change in nature or quality of your pain - nausea and vomiting, inability to tolerate fluids, food, or your medications - if you are getting dehydrated (dry mouth, rapid heart beat, feeling dizzy or faint especially while standing) -any change in your symptoms or any symptoms that concern you MEDICATIONS: - Please restart your home doses of Xarelto and Aspirin on ___ - Continue all of your other medications as you were taking them prior to this hospitalization - If you have any questions about what medicine to take or not to take, please call your surgeon. WOUND CARE: -You may shower with any bandage strips or Dermabond that may be covering your wound. Do not scrub and do not soak or swim, and pat the incision dry. -Do not take baths, soak, or swim for 6 weeks after surgery unless told otherwise by your surgical team. -Notify your surgeon if you notice abnormal (foul smelling, bloody, pus, etc) or increased drainage from your incision site, opening of your incision, or increased pain or bruising. Watch for signs of infection such as redness, streaking of your skin, swelling, increased pain, or increased drainage. ***You were noted to have an incidentally found cyst in the head of your pancreas. This kind of finding can be monitored over time; you should have an MRI of this area called an MRCP in ___ year and should discuss this finding with your PCP. Please call with any questions or concerns. Thank you for allowing us to participate in your care. We hope you have a quick return to your usual life and activities. Good Luck

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vicodin / Erythromycin Base / Lipitor / Penicillins Attending: ___. Chief Complaint: Fatigue, lethargy, pain Major Surgical or Invasive Procedure: ___ Superior hypogastric block with neurolysis ___ Ganglion impar block with neurolysis History of Present Illness: Mr ___ is a ___ yr old male with hx DM II, of neuroendocrineCa of rectum metastatic to liver currently treated w/ topotecan after progression on ___, C1D1 ___ who is admitted w/ severe hyperglycemia and pseudohypoNa.At his last onc visit ___ he was noted to have some decline. was having increased rectal pain requiring increased pain regimen tofent patch 75mcg + oxycodone 20mg q3. pain attributed to recent rectal XRT. Also more fatigued which was felt to be due to under lying disease, XRT and recent chemo and narcotic use, Ritalin use considered in future. He did not Glc level that visit, but prior levels ranging high 100s to 300, appear to have been elevated over the past ___ months. He has not been treated w/ insulin or oral anti hypoglycemic agents thus far. He was seen for C1D5 topotecan today, reported ongoing fatigue and lethargy for 3 days and lightheadedness and urinary frequency. Noted to have SBP 96, received 1L NS. He received his treatment but found to have Glc 700+. He was also reporting increased rectal pain w/ defecation. Pt was referred to ED for treatment of hyperglycemia w/ plan for endocrine consult as well as pain control and palliative consult. Pt reports that at home he was never on meds including insulin or metformin for previous diagnosis of diabetes, he lost weight and was told didn't need treatment. Yesterday checked FSG because he was urinating a lot(no dysuria) and machine read >500. Initial VS in ED 98.3 90 120/70 18 100%RA Glc 730, AG 28, VBG w/ nl pH, bicarb 20 In ED pt was started on DKA protocol, received 1L NS, NS +40K @ 250/hr. glucose improved to 610 and at 9:40 pm was down to 313. On arrival to the floor he reports rectal pain and requesting medication, denies hematochezia, diarrhea, constipation, abd pain or nausea/vomiting. This is the same pain he has had since diagnosis but seems to flare every now and then. Otherwise 10 point ROS neg. Past Medical History: PAST ONCOLOGIC HISTORY: per ___ initially presented in ___ with hematochezia and rectal pain, and physical exam finding of a rectal mass. On ___, he underwent pelvic MRI which identified a tumor at the anorectal junction involving much of the anus and left lower rectum invading along the left anorectal wall. Multiple mesorectal lymph nodes were enlarged. On ___ he underwent colonoscopy under anesthesia. Biopsy of the mass revealed poorly-differentiated carcinoma consistent with large cell neuroendocrine carcinoma, staining positive for cytokeratin, synaptophysin and chromogranin and weakly positive for CDX2. Findings were consistent with poorly-differentiated large cell neuroendocrine carcinoma. CT torso ___ identified multiple liver lesions consistent with metastases. On ___, Mr. ___ initiated palliative chemotherapy with carboplatin/etoposide. -___ C1D1 ___ -___ C2D1 ___ -___: CT Torso: good PR -___ C3D1 ___ -___ C4D1 ___ -___ C5D1 ___ -___: CT Torso with continued good PR -___: C6D1 ___ -___: C7D1 ___ -___: CT Torso increased size of multiple liver mets -___: C8D1 ___ -___: MRI pelvis showing increased primary tumor, stable pelvic LN -___: Palliative radiation to the rectum -___: CTAP showing PD of liver mets -___: Consented to topotecan PAST MEDICAL HISTORY: 1. Basilar artery syndrome, status post TIA ___. 2. Type 2 diabetes mellitus, diet controlled. 3. Hypercholesterolemia. 4. Hypertension. 5. Obstructive sleep apnea. 6. Chronic low back pain. Social History: ___ Family History: Family History: The patient's mother died at ___ years with ulcerative colitis. His father died at ___ years with Alzheimer's disease. His maternal grandfather was treated for head and neck cancer at ___ years and died at ___ years. A paternal grandfather died of cardiovascular disease. He has one brother who has hypertension and a history of alcohol excess. He has two daughters, one of whom is adopted, without health concerns. Physical Exam: ADMISSION PHYSICAL EXAM: =============================== General: NAD VITAL SIGNS: 104/56 98.4 79 16 97%RA HEENT: MMM, no OP lesions, Neck: supple, no JVD Lymph: no cervical, supraclavicular, axillary or inguinal adenopathy CV: RR, NL S1S2 no S3S4 or MRG PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly EXT: warm well perfused, no edema SKIN: No rashes or skin breakdown NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, ___ strength trhoughout without tremor/asterixis DISCHARGE PHYSICAL EXAM: ================================ Vitals: T 98.4 BP 94 / 56 HR 66 RR 18 98 RA General: NAD HEENT: MMM; OP clear Neck: supple, no JVD CV: RRR, normal S1/S2; no MRGs. PULM: CTA b/l; no wheezes, rhonchi, or rales. ABD: BS+, soft, NTND, no masses or hepatosplenomegaly EXT: warm well perfused, no ___ edema SKIN: No rashes or skin breakdown NEURO: A&Ox3; CNs II-XII grossly intact. Pertinent Results: ADMISSION LABS: ============================== ___ 04:10PM BLOOD WBC-1.9*# RBC-2.74* Hgb-9.0* Hct-26.6* MCV-97 MCH-32.8* MCHC-33.8 RDW-16.8* RDWSD-60.2* Plt Ct-74*# ___ 04:10PM BLOOD Plt Smr-VERY LOW Plt Ct-74*# ___ 04:10PM BLOOD UreaN-16 Creat-0.9 Na-125* K-4.4 Cl-81* HCO3-20* AnGap-28* ___ 04:10PM BLOOD ALT-21 AST-17 LD(LDH)-171 AlkPhos-119 TotBili-0.7 ___ 04:10PM BLOOD Albumin-4.0 Calcium-9.1 Phos-5.1* Mg-1.6 ___ 07:17PM BLOOD %HbA1c-11.4* eAG-280* ___ 07:04PM BLOOD ___ pO2-45* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 ___ 07:04PM BLOOD Lactate-1.3 ___ 06:50PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG MICRO: ================================= ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD DISCHARGE LABS: =============== ___ 05:47AM BLOOD WBC-4.7 RBC-2.31* Hgb-7.5* Hct-23.8* MCV-103* MCH-32.5* MCHC-31.5* RDW-18.3* RDWSD-69.3* Plt ___ ___ 05:47AM BLOOD Glucose-119* UreaN-10 Creat-0.7 Na-131* K-4.3 Cl-97 HCO3-28 AnGap-10 ___ 05:47AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.9 ___ 05:50AM BLOOD calTIBC-196* Ferritn-1552* TRF-151* ___ 07:17PM BLOOD %HbA1c-11.4* eAG-280* ___ 04:07 C-PEPTIDE Test Result Reference Range/Units C-PEPTIDE 0.49 L 0.80-3.85 ng/mL THIS TEST WAS PERFORMED AT: ___ ___ ___ Comment: C-PEPTIDE ADDED TO ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS 2. FoLIC Acid 1 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Fentanyl Patch 75 mcg/h TD Q72H 5. Aspirin 325 mg PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth Three times a day Disp #*180 Tablet Refills:*0 2. Bisacodyl 10 mg PO DAILY:PRN constipation/hard stool RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth Once a day Disp #*14 Tablet Refills:*0 3. Docusate Sodium 200 mg PO BID RX *docusate sodium 100 mg 2 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 4. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth Three times a day Disp #*90 Tablet Refills:*0 5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Mild RX *hydromorphone 4 mg ___ tablet(s) by mouth Every 3 hours Disp #*60 Tablet Refills:*0 6. Glargine 5 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 5 Units before BED; Disp #*1 Syringe Refills:*0 RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 4 units before breakfast, lunch and dinner Disp #*1 Syringe Refills:*0 7. Methadone 7.5 mg PO Q8H RX *methadone 5 mg ASDIR tabs by mouth Three times a day Disp #*60 Tablet Refills:*0 8. Methadone 2.5 mg PO QHS 9. needle (disp) 31 gauge 31 gauge x ___ miscellaneous QID BD Insulin pen needles ___ 31 gauge needle Dispense 100 RX *needle (disp) 31 gauge [Easy Touch Hypodermic Needle] 31 gauge x ___ BD Insulin pen needles ___ 31 gauge needle QID (at night and 3x with meals) Disp #*100 Box Refills:*3 10. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Once a day Disp #*30 Packet Refills:*0 11. Senna 17.2 mg PO BID RX *sennosides 8.6 mg 2 tabs by mouth Twice a day Disp #*120 Tablet Refills:*0 12. Simethicone 120 mg PO QID:PRN gas pain RX *simethicone 125 mg 1 tab by mouth Four times a day Disp #*60 Tablet Refills:*0 13. Aspirin 325 mg PO DAILY 14. Atorvastatin 40 mg PO QPM 15. FoLIC Acid 1 mg PO DAILY 16. Ondansetron 8 mg PO Q8H:PRN nausea 17. Tamsulosin 0.4 mg PO QHS 18.Glucometer Please provide glucometer, lancets and test strips. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Type 2 diabetes complicated by diabetic ketoacidosis Metastatic neuroendocrine carcinoma of the rectum SECONDARY: Pain secondary to metastatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with neutropenia and elevated glucose COMPARISON: Prior CT of the chest dated ___ FINDINGS: AP portable upright view of the chest. Overlying EKG leads are present. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No acute intrathoracic process Radiology Report FINDINGS: Chest fluoroscopy was performed in the OR without a Radiologist present. Eight seconds of fluoro time was used. A single image was submitted to PACS. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Hyperglycemia, Rectal pain Diagnosed with Hyperglycemia, unspecified, Other specified diseases of anus and rectum temperature: 98.3 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 127.0 dbp: 70.0 level of pain: 5 level of acuity: 2.0

Dear Mr. ___, It was a pleasure meeting you and taking care of you during your stay at ___. You were admitted to ___ for fatigue, lethargy, increased thirst, increased urination and progressively worsening rectal pain. On admission, you were found to have elevated blood sugars. You were treated with insulin, and you were seen by the ___ endocrinology service for better management of your blood sugar levels. You were started on both nighttime and mealtime insulin, and a stable regimen was achieved. You tolerated this regimen well with marked improvement in your blood glucose levels at the time of discharge. Furthermore, on this admission, you were noted to be having significant rectal pain. You were treated with oral pain meds with initial improvement in your pain. You were taken for a couple of nerve blocks with our Anesthesia Pain service. Fortunately, these interventions helped your pain. You were discharged on a stable dose of Methadone 7.5MG AM, 7.5MG noon time and 10mg ___ dosing. In addition, you were given oral medications for pain as needed. On this regimen, you had significant improvement in your pain relief, and at the time of discharge you were able to tolerate activity that you could not tolerate at the time of admission. During this admission, you also received chemotherapy. Please followup in the ___ clinic per the followup appointments listed below. Please also continue to monitor your blood sugars and pain level at home, and reach out to the following phone numbers below if you experience very high or very low blood sugar levels, or if you have unremitting pain. Please also followup at the appointments listed below which have been made on your behalf. Once again it was a pleasure taking care of you during your stay at ___, and we wish you the best of luck! Your ___ care team

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: ___: US-guided percutaneous cholecystectomy drain placement History of Present Illness: This is a ___ year-old gentleman with history of rectal cancer s/p low anterior resection and diverting ileostomy with subsequent takedown (___), who was recently admitted to the hospital given a 5-day history of abdominal pain, found on workup to have acute cholecystitis. Given duration of symptoms, decision was made to treat non-operatively and administer antibiotics (percutaneous cholecystostomy tube placement was not pursued given minimal gallbladder distention). He responded well to initial therapy and was discharged home after a 24-hour stay, having tolerated clear liquids diet and being free of pain. He now presents less than 12 hours after discharge with recurrent abdominal pain, which appeared shortly after dinner consisting of spinach omelette and rice. Similar to his previous pain, he describes it as sharp and severe, located over his epigastrium and radiating towards the right upper quadrant and back. Pain worsens with deep inspiration. Concomitantly, he endorses nausea but no emesis, chills but no fever, as well as bloating sensation, mostly after meals. Past Medical History: PMH: none PSH: none Social History: ___ Family History: Noncontributory Physical Exam: On admission: Vital signs - 98.3 74 117/67 18 99% RA Constitutional - Well appearing, in no acute distress Cardiopulmonary - RRR, normal S1 and S2. No murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally Abdominal - Well healed incisional scars from prior operations. Soft, mildly distended, tender over epigastrium and right upper quadrant with voluntary guarding. No rebound tenderness Extremities - Atraumatic. Warm and well-perfused Neurologic - Grossly intact. Alert and oriented x 3 On discharge: VSS Gen: NAD Chest: RRR, CTAB Abd: soft, nondistended. no tenderness. No rebound or rigidity. Drain in place extr: no edema Pertinent Results: ___ 04:10AM PLT COUNT-177 ___ 04:10AM WBC-6.8 RBC-5.02 HGB-15.0 HCT-42.7 MCV-85 MCH-29.9 MCHC-35.2* RDW-14.1 ___ 04:10AM CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-2.1 ___ 04:10AM GLUCOSE-80 UREA N-15 CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14 ___ 12:14AM ___ PTT-29.7 ___ ___ 12:14AM PLT COUNT-212 ___ 12:14AM NEUTS-57.8 ___ MONOS-6.2 EOS-6.1* BASOS-0.5 ___ 12:14AM WBC-8.0 RBC-5.21 HGB-15.6 HCT-42.5 MCV-82 MCH-30.0 MCHC-36.7* RDW-13.6 ___ 12:14AM ALBUMIN-4.2 ___ 12:14AM LIPASE-55 ___ 12:14AM ALT(SGPT)-34 AST(SGOT)-21 ALK PHOS-62 TOT BILI-0.6 ___ 12:14AM GLUCOSE-140* UREA N-23* CREAT-0.9 SODIUM-138 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13 Medications on Admission: none Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice daily Disp #*20 Tablet Refills:*0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN moderate pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Ultrasound guided percutaneous cholecystostomy. INDICATION: ___ year old man with chronic cholecystitis // please evaluate for percutaneous cholecystostomy tube placement COMPARISON: Abdominal ultrasound ___. PROCEDURE: Ultrasound-guided percutaneous cholecystostomy. OPERATORS: Dr. ___ trainee and Dr. ___ 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 with use of interpreter service. 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 slight left posterior oblique position on the ultrasound table. Limited preprocedure imaging was performed to localize the gallbladder. An appropriate skin entry site was chosen and the site marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, an ___ Exodus drainage catheter was advanced via trocar technique. The wall of the gallbladder was difficult to traverse, likely due to chronic inflammation. Gentle aspiration was attempted times which failed to yield bilious fluid. Patient began to experience significant pain at which time procedure was aborted. Given sudden increase in patient pain, a noncontrast CT abdomen was obtained to evaluate for acute abdominal process and is dictated under separate accession number. SEDATION: Moderate sedation was provided by administering divided doses of 4.5 mg Versed and 250 mcg fentanyl throughout the total intra-service time of 110 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Gallbladder wall is dilated measuring up to 8 mm in thickness. There are echogenic structures with posterior acoustic shadowing consistent with gallstones. IMPRESSION: Attempted ultrasound guided percutaneous cholecystostomy was aborted due to difficulty traversing the thickened, likely chronically inflamed gallbladder wall and due to patient pain. Radiology Report EXAMINATION: CT abdomen without contrast. INDICATION: Followup ultrasound. TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without the intravenous contrast administration. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was not administered. DOSE: DLP: 365 mGy-cm (abdomen and pelvis. COMPARISON: Same date ultrasound. CT abdomen ___. FINDINGS: LOWER CHEST: Bibasilar atelectasis is mild. The the there is no 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. Gallbladder wall thickening is re- demonstrated. Dense material within dependent aspect of the gallbladder likely represents vicarious excretion of intravenous contrast from prior CT ___. There are small foci of free air at the level of the falciform ligament. Small amount of free air is also visualized anterior to the right renal vein with suggestion of tracking towards the gallbladder fossa. There is no intra-abdominal free fluid. 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 There is no evidence of stones or hydronephrosis. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Visualized colon is within normal limits. 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. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Small amount of free air posterior to the pancreas with questionable extension to the gallbladder fossa. This air may have been introduced at time of procedure during aspiration or when the stylet was placed back in the catheter. There is no abdominal fluid collection. Additional small foci of air anterior to the falciform ligament and along the right anterior hepatic margin (03:23) 2. Gallbladder wall thickening consistent with chronic cholecystitis. Dependent hyperintense material within the gallbladder lumen likely represent vicarious contrast excretion from prior CT. This would indicate patent cystic duct. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:37 ___. Radiology Report EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement INDICATION: ___ year old man with acute cholecystitis COMPARISON: Ultrasound from ___ PROCEDURE: Ultrasound-guided percutaneous cholecystostomy. OPERATORS: Dr. ___ fellow and Dr. ___ 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 ultrasound table. Limited preprocedure imaging was performed to localize the gallbladder. An appropriate skin entry site was chosen and the site marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, an ___ drainage catheter was advanced via trocar technique into the gallbladder. A sample of fluid was aspirated, confirming catheter position within the collection. The plastic stiffener was removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Ultrasound images were stored on PACS. Approximately 15 cc of black, bilious fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. 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 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 15 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited preprocedure ultrasound of the right upper quadrant demonstrates a gallbladder with wall thickening that is not significantly distended and is similar to the prior ultrasound -for further details please see recent ultrasound and CT from ___. IMPRESSION: Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. Gender: M Race: WHITE - BRAZILIAN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ACUTE CHOLECYSTITIS, ABDOMINAL PAIN RUQ, ABDOMINAL PAIN EPIGASTRIC temperature: 98.3 heartrate: 74.0 resprate: 18.0 o2sat: 99.0 sbp: 117.0 dbp: 67.0 level of pain: 10 level of acuity: 3.0

You were admitted to ___ with abdominal pain and were found to have cholecystitis. You were made nothing by mouth and given IV fluids and IV antibiotics. You underwent a CT-guided percutaneous placement of a gallbladder drain, which will stay in place to decompress the gallbladder for the next few weeks. You should follow-up in clinic at the appointment listed below to discuss having your gallbladder removed at a future date, once the inflammation settles down. Please complete the course of antibiotics as prescribed and note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o HTN, HLD, prostate CA s/p resection ___, PMR on prednisone, recently admitted to ___ ___ for inferior STEMI, now presenting with 3 days of tachycardia, chills, malaise, and foul smelling urine at home. Pt reports that on ___ he began feeling unwell. He had been monitoring his HR and BP since discharge, and he noticed that his heart was "fast" and he could feel it pounding in his chest. His body felt "sloshy" and very weak. This got worse on ___. On ___ he presented to the ED. He denies ever having chest pain. He did feel some occasional need to catch his breath randomly when lying in bed. But it resolved by taking a few deep breaths. He denies DOE or PND. No weight gain ___ edema. No cough. He never checked a temperature at home or felt febrile, but he did have chills/sweats. He had foul smelling urine and increased urinary frequency but no dysuria. He never had nausea, vomiting, abdominal pain, diarrhea, constipation, HA, myalgias or arthralgias. His malaise improved significantly in the ED with treatment, as did his "palpitations." In the ED he started getting RLQ pain similar to urologic pain he has had in the past. He denies flank pain. In the ED, initial vitals: 101.3 105 ___ 97% RA. Pt HR improved to ___. Pt fever came down to 99.6, but he re-spiked to 102.9. Labs/Studies notable for: trop 0.02 x3, Cr 1.5 (baseline 1.7), WBC 11.8, and positive UA. Blood and urine cultures were not drawn. EKG showed NA/NI, TWI in II, III, and aVF stable from EKG post cath on ___. CXR showed no acute CP process. He developed LUQ pain while being obs'd in the ED, so CT A/P was performed to r/o nephrolithiasis. It showed chronic left UPJ obstruction with severe hydronephrosis of the left kidney, no ureteral stone visualized, + tranding about the left kidney. Urology was consulted, who felt that the findings were chronic and pt should be treated for pyelonephritis. Patient was given: 1L NS and cipro 750mg. Vitals prior to transfer: 98.6 85 107/55 20 97% RA. Of note, pt was recently admitted for inferior stemi. At___ cardiology was consulted in the ED who recommended trending troponin x3 to r/o instent restenosis. Troponins were flat at 0.02. Atrius cardiology had no further recommendations. Currently, he feels well and all of the above symptoms have resolved. Past Medical History: HTN HLD Polymyalgia Rheumatica - Temporal artery bx negative, C-Spine imaging negative CKD stage 3, GFR ___ ml/min - ___ left UPJ obstruction w/ out improvement s/p stenting ___ so stent removed ___ Prostate cancer (s/p prostatectomy) ___ TREMOR BASAL CELL CARCINOMA Colonic adenoma KERATOSIS - ACTINIC THYROID NODULE GLAUCOMA SUSPECT HEADACHE LOW BACK PAIN DISC DISORDER OF LUMBAR REGION CAD - Inferior STEMI ___ s/p DES to RCA Social History: ___ Family History: Glaucoma: mother, ___, and sister Brother - ___ retina, retinal Hole no hx of ESRD or CKD. Mother died of CHF, brother has unknown arrhythmia Physical Exam: Admission exam: Vitals: 98.4, 117/76, 99, 16, 100% on RA General: AAOx3, pleasant, comfortable appearing, NAD HEENT: EOMI, PERRL, MMM. OP clear. sclera anicteric. Neck: no JVP, supple, no LAD Lungs: CTAB, no w/r/r CV: RRR, no m/g/r Abdomen: nabs, s, nd, mildly ttp in LLQ without rebound or guarding GU: no foley Ext: wwp, no edema Neuro: CNs II-XII intact, ___ strength, normal gait. Discharge exam: VS- 102.5 @ ___ yesterday, ___ 88-121 18 97%RA Gen: Ambulating through hall, AAOx3 HEENT: MMM, anicteric CV: S1S2 RRR no m/g/c/r PULM: CTAB Abd: Mild TTP in LLQ, no r/g Ext: No c/c/e Back: L CVA tenderness Pertinent Results: Admission labs: ___ 02:00PM BLOOD WBC-11.8*# RBC-3.85* Hgb-12.5* Hct-35.9* MCV-93 MCH-32.4* MCHC-34.8 RDW-14.0 Plt ___ ___ 02:00PM BLOOD Neuts-89.8* Lymphs-4.8* Monos-5.1 Eos-0.2 Baso-0.1 ___ 02:00PM BLOOD Glucose-132* UreaN-22* Creat-1.5* Na-134 K-4.2 Cl-98 HCO3-24 AnGap-16 ___ 02:00PM BLOOD cTropnT-0.02* ___ 08:30PM BLOOD cTropnT-0.02* ___ 01:55AM BLOOD cTropnT-0.02* Discharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 08:30 9.9 3.97* 12.5* 37.0* 93 31.6 34.0 13.8 272 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 08:30 ___ 130* 3.7 91* 25 18 Micro: ___ 5:33 pm URINE Site: NOT SPECIFIED CHEM# ___ ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. 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 NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Imaging: ___ EKG: NA/NI, TWI in II, III, and aVF stable from EKG post cath on ___ ___ EKG: NA/NI, TWI in II, III, and aVF stable from EKG post cath on ___ ___ CT Abdomen/pelvis 1. Chronic left UPJ obstruction with severe hydronephrosis of the left kidney. Thickening of left perinephric septae may be chronic or due to recent forniceal rupture. Evaluation for pyelonephritis cannot be performed in the absence of IV contrast. 2. Status post prostatectomy without sign of metastatic disease. ___ CXR: No acute cardiopulmonary process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 12.5 mg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. PredniSONE 8 mg PO DAILY Tapered dose - DOWN 4. Vitamin D ___ UNIT PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. TiCAGRELOR 90 mg PO BID 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Losartan Potassium 12.5 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 7. PredniSONE 8 mg PO DAILY Tapered dose - DOWN 8. TiCAGRELOR 90 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Cefpodoxime Proxetil 200 mg PO Q12H 12 days of treatment RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp #*24 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pyelonephritis 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 fatigue +fever // pneumonia? TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Heart size is normal. Cardiomediastinal silhouette and hilar contours are unremarkable. Lungs are clear. There is trace bibasilar atelectasis. There is no edema. Pleural surfaces are clear without effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report INDICATION: ___ with ckd with LLQ pain and UTI. TECHNIQUE: Non-contrast scan: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast with the patient in the prone position. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Coronal and sagittal reformations were performed and submitted to PACS for review. No oral contrast was administered. DOSE: DLP: 524.45 mGy-cm (abdomen and pelvis. COMPARISON: None. FINDINGS: LOWER CHEST: Bibasilar scarring is present. The heart is normal in size. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. 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 pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The noncontrast appearance of the right kidney is unremarkable. Chronic UVJ obstruction is seen in the left kidney with severe hydronephrosis. There is no left hydroureter. Perinephric stranding without fluid collection is noted about septal thickening the left kidney, which is nonspecific. Ureteral stone is visualized. 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. RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder and distal ureters are unremarkable. Surgical clips along the external and common iliac lymph node chains bilaterally is consistent with prior lymph node dissection. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The patient is status post prostatectomy. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. L5-S1 degenerative changes are noted. Abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Chronic left UPJ obstruction with severe hydronephrosis of the left kidney. Thickening of left perinephric septae may be chronic or due to recent forniceal rupture. Evaluation for pyelonephritis cannot be performed in the absence of IV contrast. 2. Status post prostatectomy without sign of metastatic disease. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 9:09 AM. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with CHEST PAIN NOS, URIN TRACT INFECTION NOS, RESPIRATORY ABNORM NEC temperature: 101.3 heartrate: 105.0 resprate: 16.0 o2sat: 97.0 sbp: 107.0 dbp: 74.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to ___ for fevers and a suspected urinary tract infection. You were started on IV antibiotics and improved with treatment, we transitioned you to the same antibiotic in the pill format. You will take this medication for another 12 days (total 14 days with the IV antibiotics). We scheduled you a follow up visit with your PCP. At this time, there is no urgent need for you see your Urologist. Please discuss the need to see your Urologist with your PCP. ___ MDs

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins Attending: ___ Chief Complaint: fever, LLQ pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo with hx of fallopian cancer and known left lymphocele presents with fever and LLQ pain PPD ___ s/p ___ drainge. She has been on oral levo and flagyl but depite this had a temp of 100.9 today. She was directed to the ED where she had a CT abd/pelvis for evaluate for collection. On ROS she notes right sided flank pain consistent with her prior infected lymphoceles. Otherwise eating well without difficulty. No CP, SOB. No other complaints. Past Medical History: Gyn-onc hx: -stage IA, grade 3 papillary serous right fallopian tube cancer and underwent a staging surgery ___ (Laparoscopy, total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, laparoscopic total pelvic lymphadenectomy, laparoscopic para-aortic lymph node resection, infracolic omentectomy, peritoneal biopsy, cystoscopy). -s/p chemotherapy (six cycles of adjuvant chemotherapy with carboplatin and paclitaxel), completed on ___ -lymphoceles bilaterally, with infection on the right side, s/p drainage on ___, recurrence on the left side by ___. -most recent CA 125 ___ = 10 (at 10 since ___ -BRCA testing negative OB/GYN History: -G2P0, 2 TABs in the early ___ -cervical dysplasia that was treated with cryosurgery -history of PID, warts, and gonorrhea -history of infertility. -history of Dalkon Shied use, which was taken care of with removal of the IUD secondary to pain. Current Medications: Past Medical History: -reflux: for which she uses Nexium. Past Surgical History: -cryosurgery of the cervix in ___ for cervical dysplasia -Laparoscopy, total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, laparoscopic total pelvic lymphadenectomy, laparoscopic para-aortic lymph node resection, infracolic omentectomy, peritoneal biopsy, cystoscopy ___ Social History: ___ Family History: She denies any family history of breast cancer, ovarian cancer, or uterine cancer. She denies family history of other gynecologic malignancies. She reports her mother had polyps of the colon and a paternal uncle had colon cancer. Physical Exam: On admission: VS: 100.2 89 159/71 16 99% RA Gen: NAD Card: Regular rate, +SEM (___) Resp: Clear bilaterally Flank: No CVAT, right sided soreness Abd: Soft, no rebound or guarding, +TTP in LLQ -> healing <1cm incision from ___ without signs of superficial infection. +BS Pelvic: Deferred Ext: NT, NE On discharge: VS: afebrile, AVSS Gen: NAD Card: RRR Resp: Clear bilaterally Flank: No CVAT Abd: Soft, no rebound or guarding, Pelvic: Deferred Ext: NT, NE Pertinent Results: ___ 09:50PM BLOOD WBC-5.7 RBC-3.24* Hgb-10.6* Hct-32.0* MCV-99* MCH-32.7* MCHC-33.1 RDW-12.1 Plt ___ ___ 06:30AM BLOOD WBC-5.8 RBC-3.15* Hgb-10.2* Hct-31.3* MCV-99* MCH-32.2* MCHC-32.5 RDW-13.2 Plt ___ ___ 09:50PM BLOOD ___ PTT-30.3 ___ ___ 06:45AM BLOOD ___ PTT-32.3 ___ ___ 09:50PM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-104 HCO3-28 AnGap-12 ___ 06:30AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-142 K-4.4 Cl-104 HCO3-30 AnGap-12 ___ 06:45AM BLOOD Calcium-8.5 Phos-3.5# Mg-2.0 ___ 06:30AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 CT of abd/pelvis ___: Interval partial re-accumulation of left-sided pelvic wall fluid collection with rim enhancement, with surrounding fat stranding and adjacent enlarged inguinal lymph node similar to the prior imaging appearance. Though CT cannot exclude the presence of infection, the imaging features are noted to be similar to the previous, pre-drainage examination. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. MetRONIDAZOLE (FLagyl) 500 mg PO TID 2. Levofloxacin 500 mg PO Q24H 3. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily Discharge Medications: 1. Levofloxacin 750 mg PO Q24H Duration: 10 Days RX *Levaquin 750 mg 1 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 10 Days RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 3. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: fever likely due to infected lymphocysts. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Recent ___ drainage of lymphocele, now with fever. Patient has history of fallopian tube cancer and known prior lymphocele. TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was obtained after the administration of 130 cc IV Omnipaque contrast. Coronal and sagittal reformations were prepared. COMPARISON: Multiple prior examinations, most recent dedicated CT dated ___ and review of CT images from drainage procedure dated ___. FINDINGS: As compared to the post-procedure images from the prior drainage, there has been partial re-accumulation of a left pelvic fluid collection now measuring 3.3 x 2.7 cm (2:62) in the same location, though smaller than the previously drained collection. There is again surrounding rim enhancement. A 2.2 x 1.4 cm left inguinal lymph node (2:68) is unchanged. Mild fat stranding surrounding the fluid collection is similar to the prior examination. The included portions of the lung bases demonstrate a stable right subpleural nodule (2:10). The liver, spleen, pancreas, adrenal glands, and kidneys appear grossly unremarkable. The gallbladder is minimally distended, however, otherwise normal. Visualized loops of small and large bowel are normal in size and caliber. Multiple surgical clips from prior lymph node dissection are noted. No abdominal free air, free fluid collection or lymphadenopathy is seen. Within the pelvis, the bladder and distal ureters appear unremarkable. The patient is status post hysterectomy. Distal loops of large bowel and rectum are normal in size and caliber. There are scattered diverticula; however, no evidence of diverticulitis is seen. Again surgical clips from lymph node dissection are noted. No concerning osseous lesion is seen. IMPRESSION: Interval partial re-accumulation of left-sided pelvic wall fluid collection with rim enhancement, with surrounding fat stranding and adjacent enlarged inguinal lymph node similar to the prior imaging appearance. Though CT cannot exclude the presence of infection, the imaging features are noted to be similar to the previous, pre-drainage examination. Gender: F Race: WHITE Arrive by OTHER Chief complaint: R/O INFECTION Diagnosed with FEVER, UNSPECIFIED temperature: 100.2 heartrate: 89.0 resprate: 16.0 o2sat: 99.0 sbp: 159.0 dbp: 71.0 level of pain: 2 level of acuity: 3.0

Dear ___, You were admitted to the gynecologic oncology service for fever likely due to infected lymphocysts. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * You may eat a regular diet * Finish the Levofloxacin and Flagyl and take it as prescribed To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfamethizole Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___: Coronary angiogram Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. Interventional Details Complications: There were no clinically significant complications. Findings • No angiographically apparent coronary artery disease. History of Present Illness: ___ y F with history of Raynauds, depression, anxiety, who presented with chest pain, found to have ST elevations in anterolateral leads s/p cardiac catheterization without coronary artery disease, now admitted to cardiology NP service. She reports waking up from sleep with chest pain. Feels like she can't take a deep breath. Feels like a pressure, radiating into the jaw. Her chest pain is worse when lying flat. She has no family history of cardiac disease. No HTN, HLD, diabetes, or smoking. - In the ED, initial vitals were:70 ___ 100% RA - Labs were notable for: trop 1.12, BNP 451 wbc 10.2, hgb 12.5, plt 219, Na 135, K 4.2, Cl 95, bicarb 24, BUN 22, Cr 0.8, - Studies were notable for: EKG NSR HR 75 ST elevations in I, V3-V6, no reciprocal changes, normal intervals CXR: No acute cardiopulmonary abnormality. - The patient was given: ASA 325, nitro SL, heparin gtt Code STEMI was called and she was taken to cath lab, underwent angiogram with right radial access, found to have no angiographically apparent coronary artery disease. On arrival to the floor, VSS: T:98.3 BP: 99/62 HR:69 RR:18 SpO2: 99% RA. She reports ongoing chest "tightness" that has improved from the chest pressure she felt overnight. She denies shortness of breath, lightheadedness/ dizziness. Past Medical History: anxiety depression osteoporosis Raynauds Social History: ___ Family History: paternal aunt breast cancer, no ovarian or colon cancers, no diabetics, no premature cad, no clotting disorders, melanoma, no d/s/etoh. Physical Exam: Physical Exam on Admission: General: Awake, pleasant female lying in bed appears to be in no acute distress Neuro: Alert and oriented x4. Pleasant and cooperative. Speech clear, appropriate and comprehensible. Tongue midline, smile symmetric. Equal and strong hand grasps and foot pushes. HEENT: Neck supple, No JVD noted CV: RRR, Normal S1/S2, no murmur Lungs: Clear ___, posteriorly, respirations are non-labored. No use of accessory muscles noted. Abdomen: soft, non-tender PV: WWP, No edema Access sites: Right radial soft without bleeding or hematoma. +2 radial pulse. CSM WNL. Physical Exam on Discharge: ___ 0734 Temp: 99.8 PO BP: 103/62 R Lying HR: 85 RR: 18 O2 sat: 93% O2 delivery: Ra ___ 0803 BP: 113/56 R Sitting HR: 83 ___ 1312 BP: 89/53 R Sitting HR: ___ FSBG: ___ mild ___, ___ PO Amt: 420ml ___ Urine Amt: 1575ml Today's Weight: 62.5 kg Tele: SR 60-80s, no arrhythmia alarms per telemetry review Pertinent Cardiovascular Imaging: TTE ___ revealed distal anterior and apical akinesis; left ventricular ejection fraction is 40-45%. Physical Examination: General: Awake, pleasant lying in bed, NAD Neuro: Alert and oriented x4. Pleasant and cooperative. PERRLA @3mm. Speech clear, appropriate and comprehensible. Tongue midline, smile symmetric. Equal and strong hand grasps and foot pushes. HEENT: Neck supple, No JVD noted CV: RRR, Normal S1 S2, or systolic/diastolic murmur Lungs: Clear ___, posterior and anteriorly, non-labored. No use of accessory muscles noted. Abdomen: soft, non-tender, + BS x4 PV: WWP, + pedal pulses, No edema, Palpable Pedal pulses ___. Access sites: Right radial soft without bleeding or hematoma. +2 radial pulse. CSM WNL. Soft ecchymosis noted. Pertinent Results: Labs on Admission: ___ 02:50AM WBC-10.2* Hgb-12.5 Hct-38.1 Plt ___ PTT-25.1 ___ Glucose-123* UreaN-22* Creat-0.8 Na-135 K-4.2 Cl-95* HCO3-24 AnGap-16 cTropnT-1.12* proBNP-451* CRP-0.5 Coronary angiogram (___): Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. Interventional Details Complications: There were no clinically significant complications. Findings • No angiographically apparent coronary artery disease. TTE (___): CONCLUSION: The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is moderate regional left ventricular systolic dysfunction with apical LV akinesis (see schematic). Overall left ventricular systolic function is mildly depressed. The visually estimated left ventricular ejection fraction is 40-45%. There is no resting left ventricular outflow tract gradient. There is Grade I diastolic dysfunction. 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. 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 pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is no pericardial effusion. IMPRESSION: 1) Moderate focal in setting of mild global LV systolic dysfunction suggestive of ___'s cardiomyopathy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lubricating Drops (carboxymethylcellulose-glycern) 0.5-0.9 % ophthalmic (eye) BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever, pain 2. Metoprolol Succinate XL 12.5 mg PO DAILY 3. Warfarin 5 mg PO DAILY16 Target INR ___. Lubricating Drops (carboxymethylcellulose-glycern) 0.5-0.9 % ophthalmic (eye) BID Discharge Disposition: Home Discharge Diagnosis: ___'s cardiomyopathy Discharge Condition: 24-hour events: Chest pain improved today. Low grades temps yesterday. Improved with incentive spirometer use hourly. She was dizzy and hypotensive yesterday requiring IV bolus of 250 cc and was not able to get metoprolol or lisinopril as limited by blood pressure. Her blood pressure was better this morning with SBP greater than 100 and got 12.5 of metoprolol tartrate and 2.5 of lisinopril. A few hours later she was slightly dizzy with blood pressure 89/53. She was encouraged to increase p.o. fluids and her dizziness resolved. She is now ambulating without any symptoms. Post-Procedure Day ___ s/p Cardiac Catheterization for ST elevations; no obstructive CAD, no intervention Subjective: "I am nervous to go home as I feel I am being watched closely here." ROS: negative unless noted below [X] CP [] SOB [] Pain [X] Dizziness [] Headache [] Nausea/Vomiting [] Decreased appetite 24-hour data: ___ 0734 Temp: 99.8 PO BP: 103/62 R Lying HR: 85 RR: 18 O2 sat: 93% O2 delivery: Ra ___ 0803 BP: 113/56 R Sitting HR: 83 ___ 1312 BP: 89/53 R Sitting HR: ___ FSBG: ___ mild ___, NP notified ___ PO Amt: 420ml ___ Urine Amt: 1575ml Admit Weight: 61.4kg Today's Weight: 62.5 kg Tele: SR 60-80s, no arrhythmia alarms per telemetry review LABS: ___ 06:11AM BLOOD WBC: 4.2 RBC: 3.41* Hgb: 10.4* Hct: 31.3* MCV: 92 MCH: 30.5 MCHC: 33.2 RDW: 13.4 RDWSD: 45.___* ___ 06:11AM BLOOD ___: 16.4* PTT: 32.9 ___: 1.5* ___ 06:11AM BLOOD Glucose: 90 UreaN: 12 Creat: 0.7 Na: 135 K: 4.6 Cl: 100 HCO3: 25 AnGap: 10 ___ 06:11AM BLOOD Calcium: 8.1* Phos: 2.7 Mg: 2.1 Pertinent Cardiovascular Imaging: TTE ___ revealed distal anterior and apical akinesis; left ventricular ejection fraction is 40-45%. Physical Examination: General: Awake, pleasant lying in bed, NAD Neuro: Alert and oriented x4. Pleasant and cooperative. PERRLA @3mm. Speech clear, appropriate and comprehensible. Tongue midline, smile symmetric. Equal and strong hand grasps and foot pushes. HEENT: Neck supple, No JVD noted CV: RRR, Normal S1 S2, or systolic/diastolic murmur Lungs: Clear ___, posterior and anteriorly, non-labored. No use of accessory muscles noted. Abdomen: soft, non-tender, + BS x4 PV: WWP, + pedal pulses, No edema, Palpable Pedal pulses ___. Access sites: Right radial soft without bleeding or hematoma. +2 radial pulse. CSM WNL. Soft ecchymosis noted. Current medications reviewed [x] --------------- --------------- --------------- --------------- --------------- --------------- --------------- --------------- Active Inpatient Medication list as of ___ at 1424: Medications - Standing Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush Lubricating Drops 0.5-0.9 % ophthalmic (eye) BID Warfarin 5 mg PO/NG DAILY16 Metoprolol Succinate XL 12.5 mg PO DAILY Medications - PRN Acetaminophen 650 mg PO/NG Q6H:PRN fever, pain Ramelteon 8 mg PO/NG QHS:PRN Insomnia Senna 8.6 mg PO/NG BID:PRN Constipation - First Line Polyethylene Glycol 17 g PO/NG DAILY:PRN Constipation - First Line --------------- --------------- --------------- --------------- --------------- --------------- --------------- --------------- Assessment: ___ with history osteoporosis, depression, anxiety, who presented with chest pain, found to have ST elevations in anterolateral leads s/p cath with no evidence of coronary artery disease; TTE revealed Takotsubo cardiomyopathy. Her blood pressures have been soft with mild dizziness requiring small IV bolus yesterday of 250cc. This morning her SBP was greater than 100 and she was able to get 2.5 mg of lisinopril and 12.5 mg of metoprolol tartrate. Within a few hours her blood pressure was 89/53 and she had mild dizziness. She increased her p.o. fluid intake and her symptoms resolved. She is now ambulating without any symptoms. As per Dr. ___ will send her home with metoprolol only and stop the lisinopril. Also to note her hemoglobin is 10.4 today with hematocrit 31.3 and platelets 133. These have been down trending since starting on Lovenox, and Coumadin. She has no evidence of bleeding. Plan: # Takotsubo Cardiomyopathy - Medically manage - Coumadin 5mg daily for apical akinesis (Goal INR ___ INR 1.5 today - Stop lisinopril - Metoprolol succinate 12.5 mg daily - Encourage stress management upon discharge; defer to PCP for resources and options; appointment requested - CARDIOLOGY ___: Care to be established with Dr. ___ as scheduled # Anemia: Hemoglobin 10.4, hematocrit 31.3, platelets 133; no evidence of bleeding. This has been down trending since admission in the setting of Lovenox and Coumadin. -Continue Coumadin without bridge -Stop Lovenox -Repeat CBC on ___ at ___ when she is they are having INR checked; results requested to go to cardiologist and PCP -___ was educated on signs and symptoms of bleeding and was instructed to seek urgent medical evaluation for any bleeding # Chest Pain: Much improved today - Tylenol PRN # Family/HCP updated? Yes Nutrition: Regular; ___ gm sodium /Heart healthy Transitional: -CBC to be checked on ___ -Follow up with Dr. ___ at ___ -Anticoagulation to be managed at ___ with Dr. ___ INR scheduled for ___. Dispo: Discharge home without services Anticipate: [X] d/c home without services [] d/c home with services [] d/c to rehab/LTC ** Above plan reviewed and discussed with Dr. ___ ** Above plan discussed with Ms. ___ who agrees. All questions answered to patients satisfaction. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Import Discharge Condition Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with CP// eval for intra-thoracic process TECHNIQUE: Portable AP chest radiograph COMPARISON: Chest radiographs ___ FINDINGS: The lungs are well inflated and clear. No pleural effusion or pneumothorax. Heart size is normal. The mediastinal contours are unremarkable. Surgical clips again project over the mid to lower left lung. The inferolateral left ribs are excluded from view. IMPRESSION: No acute cardiopulmonary abnormality. Gender: F Race: WHITE - EASTERN EUROPEAN Arrive by UNKNOWN Chief complaint: Chest pain, Lightheaded Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site temperature: 97.0 heartrate: 70.0 resprate: 16.0 o2sat: 100.0 sbp: 105.0 dbp: 90.0 level of pain: 6 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You came to the emergency room for evaluation of chest pain. WHAT HAPPENED IN THE HOSPITAL? ============================== - EKGs and lab tests indicated stress on your heart. - You had a cardiac catheterization that showed no blockages in your coronary arteries. - An echocardiogram showed "___'s cardiomyopathy." WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take all of your medications as prescribed (listed below). - ___: INR check for coumadin dosing as scheduled below - ___: Get blood counts checked; labs slip provided (results to got o PCP and cardiologist) - Seek urgent medical evaluation for any bleeding such as in stool, urine or vomit. - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs. - Your weight at discharge is 137.5 lbs or 62.5 kg - Please weigh yourself today at home and use this as your new baseline - You should call an ambulance for any chest pain experienced after discharge - PCP ___: Please discuss stress relief measures and options It was a pleasure participating in your care. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner. The ___ Cardiac access phone number for all non-urgent concerns is ___. -Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with COPD, DM, sarcoid, and HLD presents with chest pain for the past three to five days. The pain is central/left sided in distribution, and hurts with inhaling. The patient reports no dyspnea. She reports feeling better when sitting up. The patient was resting when the pain started most recently a few days ago. There is no fevers/chills, no N/V, no abd pain, no D/C. There have been no sick contacts. About 3 weeks ago the patient had similar chest pain. She also had runny nose, cough, headache, and sore throat. The upper respiratory symptoms resolved except for ongoing mild cough. The chest pain also resolved after ~2 days until ~5 days ago when it recurred and worsened. In the ED, initial vitals were 99 128/58 32 78%RA. Patient was placed on a non-rebreather and improved with this and nebulizers. ECG showed ST changes in the inferior leads. Patient received aspirin 325 mg x 1. Troponin was negative x 2. Bedside ultrasound showed no perdicardial effusion or notable wall motion abnormality. Chem7 was unremarkable. CBC showed elevated WBC count to 12.2K, no left shift. proBNP was 625. Lactate was 1.8. D-dimer was elevated, and CTA chest showed no pulmonary embolism on preliminary read. Flu swab was obtained given tachypnea and hypoxia. Cardiology was consulted and thought the ECG and TTE did not represent ischemia, more likely pericarditis. They recommended 500 mg additional aspirin and colchicine. She triggered for heart rate while awaiting placement with atrial fibrillation with RVR in the 140s-150s, and systolic blood pressure in the ___. Diltiazem 10 mg x 1 was given. Patient was given 60 mg prednisone, concurrent with her home dose. On review of systems, she 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. She denies recent fevers or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. + recent chills + loose stool x 3 three days ago Cardiac review of systems is notable for absence of current chest pain (much better now than in the ED), dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (-) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: COPD Asthma Gastric ulcer Sarcoidosis Tobacco abuse, quit smoking 2 weeks ago Social History: ___ Family History: sister has "enlarged heart" Physical Exam: ADMISSION: VS: 97.9, 106/57, 68, 20, 96% 2L Gen: pleasant, NAD HEENT: no conjunctival pallor, mmm, OP clear Neck: supple, ormal carotid upstroke without bruits. Chest: lungs with crackles present at the bases bilaterally. CV: RRR, nl S1,S2, No murmurs, rubs, or gallops Abdomen: soft, NT, ND, BS+ Extremities: wwp, 2+ pulses bilaterally. Trace ___ edema. Skin: no rashes, ecchymoses. Neuro: A&Ox3. CN II-XII grossly intact. Strength ___ bilaterally . DISCHARGE: VS: 98.0/98.0, 98/59 (93/54-106/57), 63-68, 20, 98% 2L => 95% on RA Wt: 77.3kg Gen: pleasant, NAD HEENT: no conjunctival pallor, mmm, OP clear Neck: supple, normal carotid upstroke without bruits. Chest: lungs with crackles present at the bases bilaterally. CV: RRR, nl S1,S2, No murmurs, rubs, or gallops Abdomen: soft, NT, ND, BS+ Extremities: wwp, 2+ pulses bilaterally. Trace ___ edema. Skin: no rashes, ecchymoses. Neuro: A&Ox3. CN II-XII grossly intact. Pertinent Results: ___ 08:30AM BLOOD WBC-12.2* RBC-4.88 Hgb-14.5 Hct-45.0 MCV-92 MCH-29.8 MCHC-32.2 RDW-14.1 Plt ___ ___ 08:30AM BLOOD Neuts-62.8 ___ Monos-4.3 Eos-2.9 Baso-0.9 ___ 08:30AM BLOOD WBC-13.3* RBC-4.32 Hgb-12.7 Hct-39.9 MCV-92 MCH-29.4 MCHC-31.8 RDW-13.7 Plt ___ ___ 08:30AM BLOOD ___ PTT-150* ___ ___ 10:20AM BLOOD Glucose-79 UreaN-11 Creat-1.0 Na-142 K-4.0 Cl-105 HCO3-26 AnGap-15 ___ 08:30AM BLOOD CK(CPK)-73 ___ 08:30AM BLOOD proBNP-625* ___ 08:30AM BLOOD cTropnT-0.01 ___ 02:45PM BLOOD cTropnT-<0.01 ___ 08:30AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 08:30AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1 ___ 08:30AM BLOOD D-Dimer-1438* ___ 02:45PM BLOOD TSH-3.0 ___ 09:08AM BLOOD Lactate-1.8 ___ 03:00PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG ___ 03:00PM URINE RBC-1 WBC-10* Bacteri-FEW Yeast-NONE Epi-37 . MICRO: ___ -- blood culture x 2 pending ___ -- Influenza A/B by ___ Source: Nasopharyngeal aspirate. DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by ___ testing. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by ___ testing. . EKGs ___ (as per cardiology consult in ED): Initially SR with STE in the inferior leads with PR depression, additional non-specific ST and T changes. Then AF with RVR and non-specific ST and T changes. Then SR with atrial and ventricular ectopy and non-specific ST and T changes. . 2D-ECHOCARDIOGRAM ___: Conclusions The left atrium is normal in size. The interatrial septum is aneurysmal. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] 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 tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved regional and global systolic function. Right ventricular cavity dilation with preserved free wall motion. Moderate to severe pulmonary artery hypertension. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, the right ventricular cavity is now slightly larger and the severity of tricuspid regurgitation has slightly increased. The other findings are similar. . CTA CHEST ___: 1. There is no evidence of PE or aortic dissection. 2. Bibasilar atelectasis and emphysematous changes bilaterally, worse since the comparison study. 3. Prominent main pulmonary artery may be due to a component of pulmonary hypertension. 4. Enlarged hilar and mediastinal lymph nodes are more prominent and may relate to patient's history of sarcoidosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Furosemide 60 mg PO DAILY 3. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours Hold for K > 5 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheezing 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Ipratropium Bromide MDI 2 PUFF IH QID 7. Ipratropium Bromide Neb 1 NEB IH Q6H dyspnea, wheezing 8. PredniSONE 2.5 mg PO DAILY 9. Vitamin B Complex 1 CAP PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Vitamin E 200 UNIT PO DAILY 12. Desonide 0.05% Cream 1 Appl TP DAILY 13. Fluocinonide 0.05% Ointment 1 Appl TP BID 14. Sulfacetamide 10% Ophth Soln. ___ DROP BOTH EYES Frequency is Unknown 15. Tobramycin 0.3% Ophth Ointment 1 Appl BOTH EYES BID 16. MetRONIDAZOLE (FLagyl) 500 mg PO BID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheezing 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Furosemide 60 mg PO DAILY 5. Ipratropium Bromide MDI 2 PUFF IH QID 6. Ipratropium Bromide Neb 1 NEB IH Q6H dyspnea, wheezing 7. MetRONIDAZOLE (FLagyl) 500 mg PO BID 8. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*7 Capsule Refills:*0 9. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours Hold for K > 5 10. PredniSONE 2.5 mg PO DAILY 11. Sulfacetamide 10% Ophth Soln. ___ DROP BOTH EYES Frequency is Unknown 12. Tobramycin 0.3% Ophth Ointment 1 Appl BOTH EYES BID 13. Vitamin B Complex 1 CAP PO DAILY 14. Ibuprofen 800 mg PO Q8H Duration: 7 Days RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 15. Desonide 0.05% Cream 1 Appl TP DAILY 16. Fluocinonide 0.05% Ointment 1 Appl TP BID 17. Vitamin E 200 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: chest pain possible pericarditis hypoxia chronic obstructive pulmonary disease (COPD) sarcoidosis 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 and hypoxia. Evaluate for infectious process versus fluid. TECHNIQUE: Semi-upright AP frontal radiographs of the chest. COMPARISON: Multiple prior radiographs of the chest, most recent ___. FINDINGS: The patient is rotated to the right significantly limiting evaluation of the mediastinal structures. Allowing for these limitations a faint small focal opacity in the left upper lobe is not appreciably changed since ___ and may correspond to scarring. Bibasilar hazy opacities are likely due to atelectasis, however small pleural effusions cannot be excluded on this limited frontal radiograph, and there is mild blunting of the lateral costophrenic sulci. The mediastinal structures are not well evaluated, however, the heart appears mildly enlarged. There is no evidence of pulmonary edema or pneumothorax. IMPRESSION: 1. Bibasilar opacities likely a combination of atelectasis and possibly trace pleural effusions. 2. If clinically indicated a repeat frontal and lateral radiograph with normal positioning would provide a more complete evaluation. Radiology Report HISTORY: Chest pain, new atrial fibrillation. Evaluate for PE or aortic dissection. TECHNIQUE: Helical MDCT images were obtained through the chest after administration of 100 cc of Omnipaque IV contrast. Multiplanar axial, coronal, and sagittal images were generated and reviewed. COMPARISON: CT chest ___. FINDINGS: CT thorax: Although this study is not designed to evaluate the intra-abdominal structures, the visualized solid organs are grossly unremarkable. The thyroid is unremarkable and there is no supraclavicular or axillary lymph node enlargement. The airways are patent at the subsegmental level. Hilar and mediastinal lymphadenopathy is more prominent: 1.4 cm right lower paratracheal lymph node (3: 83), 3 x 2.7 cm subcarinal lymph node (3:96). The pericardium, and great vessels are within normal limits. Lung windows demonstrate bilateral emphysematous changes worse since the prior study. There is bibasilar atelectasis. There is no pleural effusion or pneumothorax. CTA thorax: The aorta and major vessels are well opacified. The aorta is of normal caliber throughout the thorax without intramural hematoma, aneurysm, or dissection. The main pulmonary artery is somewhat prominent suggesting a component of pulmonary hypertension. The pulmonary arteries are opacified to the subsegmental level. There is no filling defect in the main, right, left, lobar or subsegmental pulmonary arteries. Osseous structures: There is no focal osseous lesion concerning for malignancy. IMPRESSION: 1. There is no evidence of PE or aortic dissection. 2. Bibasilar atelectasis and emphysematous changes bilaterally, worse since the comparison study. 3. Prominent main pulmonary artery may be due to a component of pulmonary hypertension. 4. Enlarged hilar and mediastinal lymph nodes are more prominent and may relate to patient's history of sarcoidosis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: CP Diagnosed with PERICARDIAL DISEASE NOS, HYPERTENSION NOS, SARCOIDOSIS temperature: nan heartrate: 99.0 resprate: 32.0 o2sat: 78.0 sbp: 128.0 dbp: 58.0 level of pain: 8 level of acuity: 1.0

Dear Ms. ___, You were admitted to the hospital with chest pain. Your lab tests were NOT suggestive of a heart attack. However, you may have a condition called pericarditis, which is inflammation of the sack that sits around the heart. For this condition, you should take ibuprofen 800mg three times a day for 7 days. Please take this for the full 7 days even if you no longer feel the pain. While taking this, you should take 40mg daily of omeprazole instead of your usual 20mg daily. You were also found to have an abnormal heart rhythm called atrial fibrillation. It's possible that your heart goes in and out of this rhythm. Please discuss with your primary care physician whether or not you should begin taking a medication to slow your heart rate, as well as whether or not you should begin taking a blood thinner to prevent stroke (your risk of stroke is increased with atrial fibrillation). You should take a full dose aspirin instead of the baby aspirin for now. It is extremely important for you to stop smoking. Smoking can lead to cancer, heart disease, and death, and will worsen your COPD. Please follow up as instructed below and please take all medications as prescribed. It was a pleasure participating in your care.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Novocain / lidocaine Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: ___ M to F transgender, borderline personality d/o, bipolar d/o, hx of multiple foreign body ingestions currently on treatment for pneumonia with levofloxacin presents with persistent headache. She was recently admitted ___ with complaints of headache, neck pain and fevers. She was diagnosed with HCAP, started on vancomycin/cefepime and transitioned to levofloxacin. Because of neck stiffness, she underwent an LP which revealed a WBC 1, normal protein, and normal glucose levels. Her neck stiffness was attributed to MSK etiology and her pain managed with oxycodone and morphine as needed. She returned to the ED ___ with complaints of dizziness and headache. She was diagnosed with post-LP HA after it was noted to be positional and better when laying flat. She was discharged from the ED after symptomatic control. She went to her PCPs office ___ with persistent severe HA. Because of the positional nature of the HA and that it had not improved, she was referred to the ED for further management. In the ED, initial vitals were: 98.9 67 126/90 18 98% ra Patient was given 1 L NS, fiorcet, zofran, and oxycodone with no relief. Pain service was consulted for epidural blood patch and will see patient in the morning. On the floor, she reports that the headache is better in the dark with sunglasses. She is still having a lot of nausea, occasional emesis. She is wondering if this is related to any ingestions. She reports her last ingestion was in ___ because she got in a fight with her roommate. The HA is also better when she is flat in bed. She has also noted dizziness, mild gait instability, and poor PO appetite. She also has neck pain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies 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: PAST MEDICAL & SURGICAL HISTORY: - Osteomyelitis of right ankle - Right ankle fracture s/p ORIF in ___ - Alcohol abuse - Bipolar disorder - Depression - Multiple suicide attempts and foreign body ingestions - Borderline personality disorder - Post-operative trans-gender (Male to Female) Social History: ___ Family History: FAMILY HISTORY: Esophageal cancer in father Physical Exam: ADMISSION PHYSICAL EXAM: vitals: 98.5 97/42 61 18 95%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: +brudzinskis, 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, diffusely TTP, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: TTP along cervical spine and lumbar spine, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: intact no rash Neuro: CN II-XII intact, ___ strength in UE and ___ DISCHARGE PHYSICAL EXAM: Vital Signs: 98 108/64 101 18 96 RA General: Alert, oriented, comfortable appearing. HEENT: Sclera anicteric, MMM, oropharynx clear. No photophobia today. NECK: Range of motion significantly limited by pain. Overall fullness to neck but no discrete LAD. Tender to palpation of the supraclavicular areas bilaterally, over SCMs, and over posterior neck. Tender of cervical spinous processes. Back: Tender at site of LP. No surorunding erythema fluctuance or warmth. Lungs: CTAB CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Tender diffusely, soft, nondistended, bowel sounds present. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Without rashes or lesions Neuro: A/Ox3. PERRL. +photophobia. Pertinent Results: ADMISSION LABS ___ 10:30PM PLT COUNT-342 ___ 10:30PM NEUTS-68.0 ___ MONOS-8.6 EOS-2.1 BASOS-0.7 IM ___ AbsNeut-7.28* AbsLymp-2.13 AbsMono-0.92* AbsEos-0.22 AbsBaso-0.08 ___ 10:30PM WBC-10.7* RBC-3.92 HGB-11.3 HCT-34.8 MCV-89 MCH-28.8 MCHC-32.5 RDW-13.4 RDWSD-43.5 ___ 10:30PM GLUCOSE-92 UREA N-14 CREAT-1.0 SODIUM-135 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16 DISCHARGE LABS ___ 03:48PM PLT COUNT-332 ___ 03:48PM NEUTS-74.8* LYMPHS-15.2* MONOS-6.7 EOS-2.0 BASOS-0.6 IM ___ AbsNeut-8.16* AbsLymp-1.66 AbsMono-0.73 AbsEos-0.22 AbsBaso-0.07 ___ 03:48PM WBC-10.9* RBC-3.95 HGB-11.4 HCT-35.1 MCV-89 MCH-28.9 MCHC-32.5 RDW-13.3 RDWSD-43.3 ___ 03:48PM GLUCOSE-88 UREA N-10 CREAT-0.9 SODIUM-134 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-18 IMAGING: KUB ___ Metallic foreign objects visualized within the cecum. Non-obstructive bowel gas pattern. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levofloxacin 750 mg PO Q24H 2. Estrogens Conjugated 5 mg PO DAILY 3. Spironolactone 200 mg PO DAILY 4. Senna 8.6 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Estrogens Conjugated 5 mg PO DAILY 2. Levofloxacin 750 mg PO Q24H 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Senna 8.6 mg PO BID 5. Spironolactone 200 mg PO DAILY 6. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN HEADACHE RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1 capsule(s) by mouth every 8 hours Disp #*15 Capsule Refills:*0 7. Cyclobenzaprine 10 mg PO BID:PRN neck pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice daily Disp #*10 Tablet Refills:*0 8. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN PAIN RX *hydromorphone 4 mg 1 tablet(s) by mouth every 6 hours Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: post-lumbar puncture headache Secondary diagnoses: pneumonia, bipolar disorder, depression, history of alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with hx of ingestion // more ingestions TECHNIQUE: Supine and upright frontal abdominal radiographs were obtained. COMPARISON: Abdominal radiographs dated ___. FINDINGS: The metallic foreign objects are visualized within the cecum. There are barium filled diverticula in the left lower quadrant. The bowel gas pattern is unremarkable with gas seen in nondistended loops of large and small bowel. There is no evidence of ileus or obstruction. There is no evidence of intraperitoneal free air. The bony structures are unremarkable. IMPRESSION: Metallic foreign objects visualized within the cecum. Non-obstructive bowel gas pattern. Gender: F Race: WHITE Arrive by WALK IN WALK IN Chief complaint: Headache Headache, Dizziness Diagnosed with HEADACHE LUMBAR PUNCTURE REACTION, ABN REACT-FLUID ASPIRAT temperature: 98.9 97.9 heartrate: 67.0 73.0 resprate: 18.0 18.0 o2sat: 98.0 98.0 sbp: 126.0 122.0 dbp: 90.0 75.0 level of pain: 9 9 level of acuity: 3.0 3.0

Dear ___, You were admitted to ___ after developing headache from your spinal tap (post-lumbar puncture headache). For your neck stiffness, we gave you a muscle relaxant, which helped. We connected you with the chronic pain management team (___) to consider a blood patch for therapy. Call them/your primary doctor if it persists. It was a pleasure caring for you, Your team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex Attending: ___. Chief Complaint: chest pain, abnormal stress Major Surgical or Invasive Procedure: Cardiac catheterization ___ History of Present Illness: ___ year old woman with IDDM and hypertension who presents with 2 weeks of exertional and rest chest pain. For the past 2 weeks she's had pain/pressure in her chest that radiates mostly to her left arm (sometimes to the right) with radiation to her left neck and jaw as well. She has had right-sided chest pain which is sharp, located at the mid right rib cage, has been going on for 1 month, and is worse with breathing or taking deep breaths. Her second chest pain is a tight to sharp mid chest pain under her sternum, which occurs when she walks around or tries to climb stairs, and is associated with shortness of breath. Given worsening nature and more frequent symptoms she presented to the ED. She denies any major bleeding issues. Sometimes notices blood tinged toilet paper after BM's with probable hemorrhoids. Patient underwent an exercise stress test in the ED which was stopped after 3 minutes (estimated peak MET capacity of 2.4) due to her feeling lightheaded/dizzy with her report of chest pain as well. Formal report notes she did not experience chest pain though mentions progressive dizziness during exercise which resolved during early recovery. Upon evaluation by the cardiology fellow in the ED, patient was chest pain free. In the ED initial vitals were: 96.5 76 148/87 18 97% RA Exam notable for: bibasilar crackles, no murmur, soft abdomen, no leg swelling, no CVA tenderness Labs notable for: 1. BMP: Na 136 K 4.6 Cl 97 Bicarb 28 BUN 14 Cr 0.8 Glu 255 2. CBC: wbc 6.3 hgb 11.5 plt 230 3. d dimer 271 4. trop <0.01 x 5. bnp 28 Images notable for: CXR No acute process EKG: (PER ED DASH) EKG is sinus at 84, normal axis, normal intervals, there is a 1 mm J-point elevation in V2, this is isolated, there are no other ST changes, there are no ischemic appearing T-wave inversions, there is no prior available for comparison. Patient was given: metop 12.5, aspirin 81 mg, atorva 10, 1L NS, insulin as per ___ recs, Levothyroxine 150mcg, fluoxetine 40mg, trazadone 25mg On the floor patient denies any chest pain or shortness of breath or dizziness. Notes that symptoms only occur with exertion and have been worsening over the past 2 weeks though present over the past 6 months. Exertional chest pain and dyspnea with pleuritic chest pain in the right lower chest. Chest pain/shortness of breath and dizziness have never occurred at rest. Denies fevers/chills, cough, periods of stasis, abdominal pain, hematuria, melena. Past Medical History: 1. CARDIAC RISK FACTORS - poorly controlled insulin-dependent diabetes with HbA1c of 18 c/b neuropathy - hypertension - hyperlipidemia 2. OTHER MEDICAL HISTORY hypothyroidism (s/p total thyroidectomy ___ thyroid CA, on replacement) HTN HLD Depression/anxiety Ovarian cysts Social History: ___ Family History: Father- diabetes, heart disease Mother- diabetes MGM, ___, borther- DM Sister- HTN Physical ___: ADDMISION PHYSICAL EXAMINATION: V: 98.3 PO BP 119 / 74R Sitting 77 20 Sat96%RA GENERAL: Well developed, well nourished in NAD. Oriented x3. HEENT: Sclera anicteric. PERRL. EOMI. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 8 cm at 45 degrees CARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. no peripheral edema. PULSES: Distal and radial palpable and symmetric. Psych: full affect, denies SI/HI DISCHARGE PHYSICAL EXAMINATION: VS: 24 HR Data (last updated ___ @ 653) Temp: 98.9 (Tm 98.9), BP: 96/56 (79-106/43-67), HR: 78 (78-95), RR: 16 (___), O2 sat: 94% (93-99), O2 delivery: Ra, Wt: 112.87 lb/51.2 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. HEENT: Sclera anicteric. PERRL. EOMI. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated CARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: CTAB, no m/r/g ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. no peripheral edema. PULSES: Distal and radial palpable and symmetric. Psych: full affect, denies SI/HI Pertinent Results: ADMISSION LABS =============== ___ 11:55AM BLOOD WBC-6.4 RBC-4.46 Hgb-11.0* Hct-32.4* MCV-73* MCH-24.7* MCHC-34.0 RDW-14.4 RDWSD-37.4 Plt ___ ___ 11:55AM BLOOD Neuts-61.2 ___ Monos-7.1 Eos-0.2* Baso-0.5 Im ___ AbsNeut-3.89 AbsLymp-1.95 AbsMono-0.45 AbsEos-0.01* AbsBaso-0.03 ___ 11:55AM BLOOD ___ PTT-27.0 ___ ___ 11:55AM BLOOD Glucose-417* UreaN-9 Creat-0.7 Na-131* K-4.4 Cl-92* HCO3-26 AnGap-13 ___ 11:55AM BLOOD ALT-22 AST-25 AlkPhos-94 TotBili-0.2 ___ 11:55AM BLOOD proBNP-28 ___ 11:55AM BLOOD cTropnT-<0.01 ___ 06:22PM BLOOD cTropnT-<0.01 ___ 12:00PM BLOOD ___ pO2-36* pCO2-47* pH-7.41 calTCO2-31* Base XS-3 INTERVAL LABS =============== ___ 04:45AM BLOOD calTIBC-241* Ferritn-61 TRF-185* ___ 04:45AM BLOOD Triglyc-147 HDL-94 CHOL/HD-2.3 LDLcalc-89 ___ 04:45AM BLOOD TSH-62* ___ 04:45AM BLOOD Free T4-0.4* DISCHARGE LABS ================ ___ 07:00AM BLOOD WBC-7.6 RBC-4.33 Hgb-10.6* Hct-31.8* MCV-73* MCH-24.5* MCHC-33.3 RDW-14.7 RDWSD-39.3 Plt ___ ___ 07:00AM BLOOD Glucose-171* UreaN-16 Creat-0.7 Na-134* K-4.0 Cl-100 HCO3-25 AnGap-9* STUDIES/IMAGING =============== ___ CXR No acute intrathoracic process. ___ Stress Test INTERPRETATION: This ___ yo woman with h/o HTN, HLD, and poorly controlled IDDM was referred to the lab from the ED following negative serial cardiac enzymes for evaluation of chest discomfort. The patient exercised for 2.9 minutes of a Modified ___ protocol and was stopped at the patient's request for fatigue and dizziness. The estimated peak MET capacity was 2.4, which represents a poor exercise tolerance for her age. There were no reports of chest, back, neck, or arm discomforts during the study. The patient noted progressive dizziness during exercise which resolved during early recovery. There were no significant ST changes noted during exercise or recovery. Rhythm was sinus with no ectopy. There was an appropriate heart rate and blood pressure response to the achieved workload. Normal blood sugar recorded post-exercise of 210 mg/dl. IMPRESSION: Poor functional capacity with dizziness as noted. No anginal type symptoms or ischemic EKG changes. Appropriate hemodynamic response to low workload. ___ TTE The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. The interatrial septum is bowed to the right suggesting high left atrial pressures. 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 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 aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal left ventricular wall thickness, cavity size, and regional/global systolic function. Mild tricuspid regurgitation. ___ Coronary Cath Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is without significant disease. * Left Anterior Descending The LAD is with mild diffuse disease. * Circumflex The Circumflex is with mild diffuse proximal disease. The ___ Marginal is without significant disease. * Right Coronary Artery The RCA is with 30% proximal. The Right PDA is without significant disease. MICROBIOLOGY ============= Urine cultures negative Blood cultures pending at time of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. Atorvastatin 10 mg PO QPM 4. Aspirin 81 mg PO DAILY 5. FLUoxetine 40 mg PO DAILY 6. Levothyroxine Sodium 150 mcg PO DAILY 7. TraZODone 25 mg PO QHS:PRN insomnia 8. Glargine 30 Units Breakfast Glargine 30 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Discharge Medications: 1. Glargine 25 Units Dinner Novolog 9 Units Breakfast Novolog 8 Units Lunch Novolog 8 Units Dinner Insulin SC Sliding Scale using Novolog Insulin 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. FLUoxetine 40 mg PO DAILY 5. Levothyroxine Sodium 150 mcg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. TraZODone 25 mg PO QHS:PRN insomnia 8. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until your PCP tells you to restart Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypothyroidism IDDM 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 retrosternal CP// Eval for PNA, acute process COMPARISON: ___ FINDINGS: PA and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, Hyperglycemia Diagnosed with Chest pain, unspecified, Type 1 diabetes mellitus with hyperglycemia, Long term (current) use of insulin temperature: 96.5 heartrate: 76.0 resprate: 18.0 o2sat: 97.0 sbp: 148.0 dbp: 87.0 level of pain: 8 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why were you admitted to the hospital? - You were came to the hospital because you were feeling fatigued and having shortness of breath with activity. - You went to the ED first and a stress test was done, but you could not walk on the treadmill very long because your symptoms got worse. What was done while you were in the hospital? - A procedure called a cardiac cath was done to look at the arteries that supply blood to your heart. This showed that you do not have any major blocks in these vessels. - You met with our diabetes doctors to help ___ your diabetes. - You met with our thyroid doctors to help ___ your thyroid disease. What should you do when you go home? - Please take all your medications as directed. It is very important that you take your thyroid medication 1 hour before breakfast every day. You should also take your insulin as instructed every day. - Please follow up with all your outpatient doctors as ___ below. We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pressure, orthopnea, dyspnea on exertion Major Surgical or Invasive Procedure: ___ AVR(21 StJ tissue)CABG x2(free LIMA-LAD,SVG-OM) History of Present Illness: ___ year old female with severe aortic stenosis, moderate to severe mitral regurgitation and moderate tricuspid regurgitation here with chest pressure and shortness of breath. Patient is normally quite active (water aerobics, etc) but since the ___ has noted worsening dyspnea on exertion. She was diagnosed with AS (valve area 0.5cm2), MR, and TR in ___ and was scheduled to undergo cardiac cath on ___ prior to AVR with possible MVR and CABG on ___. Over the past week, the patient has noted worse DOE - unable to attend water aerobics, short of breath walking from one end of the house to the other. This exacerbation seemed insidious. On ___, she felt acutely short of breath after walking from her car. This was accompanied by chest pressure. The pressure improved with rest but persisted. Lying flat seemed to make her symptoms worse so she slept sitting in a chair. At that time, she did not have any nausea, vomiting, dizziness, chest pain, jaw pain, arm pain, back pain, syncope, PND, peripheral edema, claudication. Of note, she has gained about 5lbs in the past week, and has had a decreased appetite along with some abdominal distention. She has a chronic non-productive cough for the past year that seems worse when lying flat. She has noted that she has had to use two pillows to sleep instead of one at night for the past month. Denies fevers or chills. In the ED, initial vitals were 98.4 133/82 86 18 100%RA. ECG showed sinus arrhythmia at 77 with LV strain pattern. Labs notable for trop 0.01, sodium of 128, bicarb 19 w/o gap, creat 0.4, BNP 6579, D-dimer 774. CXR showed moderate pulmonary edema, ?atypical infxn. CTA Chest shows diffuse opacifications c/w edema vs infection. Patient received ASA and 2.5mg morphine x 1 with resolution of her pain and great improvement to her SOB. Currently, patient has mild shortness of breath and her chest pressure is 0-1/10. She is very mildly nauseated. There is no light-headedness, dizziness, palpitation, lower extremity edema. She denies any hx of TIA/stroke, blood clots, myalgias, joint pains, hemoptysis, black stools, bloody stools (recent hemorrhoid that resolved w/suppositories), constipation, diarrhea, dysuria, hematuria, oliguria. Past Medical History: Aortic Stenosis Coronary Artery Disease acute systolic congestive heart failure PMH: Hyperlipidemia Hypothyroidism Hyponatremia GERD Depression Intersitial fibrosis (per patient this is also inaccurate, though fibrosis was noted on OSH CT scan in ___, followed by ___ of Pulmonology) Osteopenia Social History: ___ Family History: Mother with ___ Heart disease and mitral valve disease, died of CHF at ___. Father died at ___. No family hx of SCD or CAD. Physical Exam: Admission exam: 99.1 99/53 88 18 98 2L 73.3kg GENERAL: Pleasant WDWN woman in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. NECK: Supple with JVP of 10 cm. CARDIAC: RRR. Harsh ___ systolic murmur heard throughout precordium but best at R/LUSB w/radiation to carotids. The tricuspid and mitral positions show a more holosystolic murmur that does not appear to have respirophasic variation. No S3,4. LUNGS: Two distinct patterns of rales. Early inspiratory rales at both bases. Mid-late inspiratory rales heard across most of both lung fields. Speaking in full sentences without distress or accessory muscle use. No acral cyanosis. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. 1+ ___, 2+ radial Pertinent Results: ___ Intra-op TEE Conclusions Pre-CPB: The left atrium is mildly dilated. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. ___ was notified in person of the results at time of study. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO Frequency is Unknown 2. Lovastatin *NF* 10 mg Oral daily 3. Multivitamins 1 TAB PO DAILY 4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Fluoxetine 20 mg PO BID 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Calcium Carbonate 500 mg PO Frequency is Unknown Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 2. Levothyroxine Sodium 75 mcg PO DAILY RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 3. Multivitamins 1 TAB PO DAILY 4. Carvedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 6. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth q4h prn Disp #*45 Tablet Refills:*0 ___ MD to order daily dose PO DAILY RX *warfarin [Coumadin] 2.5 mg Daily per MD ___ by mouth daily Disp #*150 Tablet Refills:*1 9. Alendronate Sodium 70 mg PO RESUME PREOP DOSING 10. Calcium Carbonate 500 mg PO RESUME PREOP DOSING 11. Vitamin D 400 UNIT PO DAILY 12. Lovastatin *NF* 10 mg ORAL DAILY 13. Warfarin 5 mg PO ONCE Duration: 1 Doses RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once Disp #*1 Tablet Refills:*0 14. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY RX *isosorbide mononitrate [Imdur] 30 mg 0.5 (One half) tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Aortic Stenosis Coronary Artery Disease acute systolic congestive heart failure PMH: Hyperlipidemia Hypothyroidism Hyponatremia GERD Depression Intersitial fibrosis (per patient this is also inaccurate, though fibrosis was noted on OSH CT scan in ___, followed by ___ of Pulmonology) Osteopenia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema Followup Instructions: ___ Radiology Report HISTORY: ___ female with severe aortic stenosis and coronary artery disease, now with concern for pulmonary fibrosis versus volume overload; recent diuresis performed. STUDY: AP portable upright chest radiograph. COMPARISON: Chest radiograph and chest CTA from ___. FINDINGS: The heart size is within normal limits. The mediastinal and hilar contours are normal. Again are seen diffuse areas of ground-glass opacities are similar to slightly improved in extent from prior exam. There is no large pleural effusion or pneumothorax. No pulmonary consolidation is present. IMPRESSION: Diffuse ground-glass opacities with minimal improvement after diuresis most compatible with either an atypical infection or inflammatory process. Radiology Report AP CHEST, 5:39 P.M., ___ HISTORY: After CABG and AVR. Assess lines and tubes and complications. IMPRESSION: AP chest compared to ___: Mediastinum has a normal post-operative appearance, particularly given supine positioning. There is no evidence of mediastinal bleeding or other fluid accumulation. Swan-Ganz catheter probably ends in the left descending pulmonary artery. ET tube is in standard placement. An upper enteric tube would need to be advanced 6 cm to move all the side ports into the stomach. Midline drains in place. Pleural effusion minimal if any. No pneumothorax. Pre-operative edema has cleared from the lower lungs, but there is still extensive peripheral opacification in both upper lobes, raising possibility of findings not related to cardiac decompensation, such as chronic eosinophilic pneumonia, vasculitis, or even infection. Findings were discussed by telephone with Dr. ___ at 8:55 a.m. on ___. Radiology Report HISTORY: ___ female with removal of chest tube, evaluate for pneumothorax. COMPARISON: ___. FINDINGS: Portable upright frontal chest radiograph demonstrates interval removal of a left chest tube. Airspace opacity is similar in distribution bilaterally likely reflecting edema accentuated by low lung volumes. A right pleural effusion is increased. The postoperative cardiac silhouette and mediastinal contours are unchanged. Median sternotomy wires are unchanged. There has been interval removal of an endotracheal tube, NG tube, epicardial pacing wires, right IJ sheath, and Swan-Ganz catheter. There may be a trace left pneumothorax without evidence of tension. The stomach is distended with air. IMPRESSION: Increasing right pleural effusion and pulmonary edema, exaggerated by low lung volumes status post extubation. Radiology Report CLINICAL HISTORY: Pulmonary edema, on therapy, evaluate for improvement. CHEST: The current film is considerably better penetrated than the prior film of ___. The degree of failure is probably the same. Some areas show more opacification, others less. The right effusion, however, is probably less. IMPRESSION: Little change in the degree of failure. Radiology Report CLINICAL HISTORY: Central venous line placed, check position. The right subclavian line has gone into the internal jugular vein and its tip cannot be seen. Focal opacities are again noted within both the right and left lobes and a right effusion is likely present. These could represent a patchy bronchopneumonia rather than resolving failure. IMPRESSION: Central line in right neck. Radiology Report CLINICAL HISTORY: Central line repositioned. Check current status. The tip of the right central line now lies in the mid-to-lower SVC in a good position. The patchy focal opacities remain unchanged in both lungs. IMPRESSION: Tip of central line in SVC. Radiology Report HISTORY: Post-operative changes. FINDINGS: In comparison with the study of ___, the patient has taken a much better inspiration. Blunting of the costophrenic angles persists as well as an area of patchy opacification in the right mid zone laterally. There has been substantial improvement in the other areas of scattered pulmonary opacification. Radiology Report ___ Department of Radiology Standard Report Carotid US Study: Carotid Series Complete Reason: ___ year old woman with severe AS planned for surgical repair. Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is moderate calcified 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 135/38, 108/35, 116/53 cm/sec. CCA peak systolic velocity is 83/28 cm/sec. ECA peak systolic velocity is 78 cm/sec. The ICA/CCA ratio is 1.6. These findings are consistent with 40-59% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 113/42, 91/27, 106/25 cm/sec. CCA peak systolic velocity is 74/20 cm/sec. ECA peak systolic velocity is 176 cm/sec. The ICA/CCA ratio is 1.5 . These findings are consistent with 40-59% stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA 40-59% stenosis. Left ICA 40-59% stenosis. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: SOB/HEART RACING Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH temperature: 98.4 heartrate: 86.0 resprate: 18.0 o2sat: 100.0 sbp: 133.0 dbp: 82.0 level of pain: 7 level of acuity: 2.0

Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Chantix / Ambien Attending: ___. Chief Complaint: Wound vac failure Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old male well-known to the colorectal service who presents with a malfunctioning wound VAC. The patient has a complex surgical history and currently has a controlled colocutaneous fistula. The fistula emerges through and large abdominal wound that has been recently skin grafted. The patient was recently discharged with an ostomy appliance over the fistula and a wound VAC over the remaining wound. This patient has been in rehab and the VAC was changed last week in wound care clinic. He presents today with his VAC malfunctioning and leakage of stool from around the VAC. He otherwise has been doing well. Past Medical History: PMH: Complicated diverticulitis Depression Anxiety Alcoholism Hx of LUE DVT and PE HTN COPD CAD PAD/PVD - s/p arterial stenting in the left leg, indwelling Foley with leg bag, (placed by Dr. ___ for a hole in his bladder H/o MRSA H/o VRE UTI PSH: ___ Endoscopic clipping across fistula, replaced stent ___ STSG from R thigh ___ Metal stent placed ___ - Exploratory laparotomy, partial colectomy with hand-sewn colocolonic anastomosis. Ventral hernia repair with an inlay bridge of Phasix ST and skin flap advancement flaps ___ - Cystoscopy and bilateral stent placement by Dr. ___. Laparotomy, lysis of adhesions, takedown ileostomy with resection of ileostomy, takedown of enterocutaneous fistula with repair of colocolostomy, and flexible sigmoidoscopy. Ventral and parastomal hernia repair with Ventralight mesh and panniculectomy by Dr. ___. ___ - Gtube placement, diverting loop ileostomy, appendectomy ___ - Take-back exlap, partial colectomy and secondary colostomy, exlap/LOA, Takedown of colovesical fistula, Repair of bladder fistula, Sigmoid colon resection, End to end anastomosis of the descending colon to rectum, Take down of prolapsed end transverse colostomy with resection of end ostomy. Side to side antiperistaltic anastomosis between the transverse and descending colon. ___ - Reversal/takedown of ___ c/b septic shock and anastomotic leak ___ - ___ procedure for obstruction, complicated by cardiac arrest intraoperatively -> emergent colostomy ___ - CABG x3 Social History: ___ Family History: Father passed away from MI, at age ___. Mother passed away from unknown reasons, at a young age Physical Exam: Vitals:AVSS Gen: AAOx3 NAD CV: NRRR Chest: Clear without deformity Abd: Soft, at baseline level of distension. Notable for appx 10x8 cm abdominal wound with appropriately healing skin graft on left lateral portion of wound. CC fistula itself is located at right mid-lateral portion of wound, no active flow of stool. There is some mild to moderate tissue breakdown and friability immediately surrounding the fistula site with minor bleeding. There is no guarding. Extrem: Without deformity or edema Pertinent Results: ___ 06:25AM BLOOD WBC-6.2 RBC-3.14* Hgb-9.2* Hct-29.0* MCV-92 MCH-29.3 MCHC-31.7* RDW-16.4* RDWSD-55.8* Plt ___ ___ 11:15AM BLOOD WBC-7.7 RBC-3.20* Hgb-9.5* Hct-29.6* MCV-93 MCH-29.7 MCHC-32.1 RDW-16.8* RDWSD-56.8* Plt ___ ___ 11:15AM BLOOD Neuts-38.1 ___ Monos-12.3 Eos-10.4* Baso-0.9 Im ___ AbsNeut-2.94# AbsLymp-2.92 AbsMono-0.95* AbsEos-0.80* AbsBaso-0.07 ___ 06:25AM BLOOD Plt ___ ___ 11:15AM BLOOD Plt ___ ___ 11:15AM BLOOD ___ PTT-29.0 ___ ___ 07:53AM BLOOD Glucose-84 UreaN-10 Creat-0.9 Na-139 K-3.5 Cl-108 HCO3-19* AnGap-16 ___ 06:25AM BLOOD Glucose-95 UreaN-9 Creat-0.9 Na-138 K-3.6 Cl-102 HCO3-25 AnGap-15 ___ 11:15AM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-135 K-4.9 Cl-101 HCO3-24 AnGap-15 ___ 07:53AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.8 ___ 06:25AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.7 ___ 11:26AM BLOOD Lactate-1.4 Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Escitalopram Oxalate 20 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. LOPERamide 2 mg PO Q6H 6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain 7. LORazepam 0.5 mg PO Q4H:PRN anxiety/sleep 8. Octreotide Acetate 100 mcg SC Q8H 9. Pantoprazole 40 mg PO Q12H 10. Tiotropium Bromide 1 CAP IH DAILY 11. Levofloxacin 750 mg PO Q24H 12. Vancomycin Oral Liquid ___ mg PO/NG Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain do not drink alcohol while taking this medication, do not take more than 3000mg in 24 hours RX *acetaminophen 325 mg 1 tablet(s) by mouth every six (6) hours Disp #*55 Tablet Refills:*0 2. Cholestyramine 4 gm PO TID RX *cholestyramine (with sugar) 4 gram 1 powder(s) by mouth three times a day Disp #*90 Packet Refills:*0 3. Escitalopram Oxalate 20 mg PO DAILY RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain do not drink alcohol or drive a car while taking, please try to take less and less pain medication RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every six (6) hours Disp #*80 Tablet Refills:*0 5. LOPERamide 2 mg PO Q6H RX *loperamide 2 mg 1 tablet by mouth every six (6) hours Disp #*120 Tablet Refills:*0 6. LORazepam 1 mg PO Q8H:PRN anxiety/sleep RX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp #*28 Tablet Refills:*0 7. Psyllium Powder 1 PKT PO BID RX *psyllium husk (aspartame) [Metamucil Fiber Singles] 3.4 gram 1 powder(s) by mouth twice a day Disp #*60 Packet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Wound vac failure 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 multiple previous abdominal surgeries c/b ECF, admit for management of high ECF output, metal stent placement by GI across the fistula now with increasing output // assess stent position TECHNIQUE: Supine abdominal radiograph was obtained. FINDINGS: There are no abnormally dilated loops of large or small bowel. Colonic stent is no longer visualized. Moderate stool burden is mainly in the right colon. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are unremarkable. Median sternotomy wires are noted. Clips are noted in the inferior pelvis. IMPRESSION: Colonic stent is no longer visualized. No bowel dilation. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Wound eval Diagnosed with Unsp complication of internal prosth dev/grft, init, Exposure to other specified factors, initial encounter temperature: 98.0 heartrate: 79.0 resprate: 18.0 o2sat: 96.0 sbp: 118.0 dbp: 92.0 level of pain: 7 level of acuity: 2.0

Mr. ___: ___ were admitted to ___ on ___ for failure of your wound vac. At the time of admission the part of your wound immediately surrounding your colocutaneous fistula site was somewhat fragile and broken down, so neither a vac dressing or pouch could be placed over this. Instead a simple damp to dry dressing has been placed over the wound. During your hospitalization ___ have put minimal stool out from your fistula site. ___ were seen by the ostomy and wound care service who assisted and taught ___ to change your wound dressing. Wound care: ___ will be sent home with ___ to assist with your wound care daily. If your dressing becomes soiled, as is expected due to variation in your fistula output, ___ should change it in the same fashion as ___ have been taught by the wound/ostomy nurses. ___ should try to keep the dressing clean and in tact. Please adhere to the wound/ostomy nurse instructions regarding cleaning your wound site. Diet: Regular home diet Medications: ___ will be sent home on your usual medication regimen. ___ will no longer be taking octreotide or antibiotics. Activity: Engage in your normal home activity and exercise as tolerated Contact our clinic with any concerns or if new symptoms arise. ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / amoxicillin Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year old woman with history of COPD not on O2, HTN, HLD, who presents with cough, SOB, subjective fever, chills, body aches. Ms. ___ has a history of COPD without frequent exacerbations. She was admitted ___ with hemoptysis with evidence of bronchial artery bleeding that was not able to be embolized that self resolved. Since that time she has quit smoking cigarettes. Beginning ___ she has felt subjective fevers, diarrhea, myalgias, decreased appetite, and cough with increased green sputum production. She thought symptoms were improving throughout the week, however last night she was unable to lay flat and was up all night coughing. This morning she checked her ambulatory O2 sat which was 87%. This was very concerning to her which prompted evaluation at ___ urgent ___. There her O2 sat was 88%. CXR there normal other than likely atelectasis. Given hypoxemia patient was transferred to ___ for further evaluation. In the ED, initial vitals were: 97.9 85 129/79 14 96% Nasal Cannula Exam notable for scattered wheezing, no resp distress, no lower extremity edema. Peak flow 100, repeat 120 Labs notable for WBC 13.7 with 91.6% PMN, bicarb 16 Cr 0.9, baseline 0.5-0.6, lactate 1.1, UA with trace blood, bacteria, large leuks, neg nitrites Imaging notable for CXR Streaky opacities in the lung bases may reflect areas of atelectasis, though early infection cannot be completely excluded in the correct clinical setting. No focal consolidation. Patient was given Azithromycin 500 mg PO PredniSONE 60 mg IH Albuterol 0.083% Neb Soln 1 NEB IH Ipratropium Bromide Neb 1 NEB Decision was made to admit for COPD exacerbation Vitals on transfer 89 12 97% Nasal Cannula On the floor, patient reports feeling better after breathing treatment. Last loose stool on ___. No nausea or vomiting. She notes several weeks ago she had bilateral lower extremity swelling so she took her husband's HCTZ with subsequent 7lb weight loss and resolution of lower extremity swelling. She discussed with her PCP who thought this was related to her recent NSAID use but had planned for TTE which is ordered for ___. She has not had previous episodes of orthopnea, PND, lower extremity edema, dyspnea on exertion. She has also not had chest pain, palpitations. Past Medical History: COPD HTN hypercholesterolemia bladder CA s/p surgical removal ___ s/p breast lump/cyst removal rheumatic fever Social History: ___ FAMILY HISTORY: Breast cancer in sister, cousins. T2DM in brother, father. No FHx of bleeding. Family History: Breast cancer in sister, cousins. T2DM in brother, father. No FHx of bleeding. Physical Exam: Admission Physical Exam: ==================== VS: 98.6 PO 146 / 77 R Sitting 90 20 95 2L NC Gen: very pleasant well appearing older woman speaking in full sentences in NAD HEENT: PERRL, EOMI, +erythema in posterior pharynx, no exudate CV: RRR, S1, S2 with no m/r/g Pulm: decreased breath sounds, no crackles, wheezes, rhonchi Abd: soft, non distended, non tender to palpation, +BS GU: no CVA tenderness Ext: warm, well perfused, no edema Skin: no rashes Neuro: AxOx3, CNII-XII intact, moving all 4 extremities without deficit Discharge Physical Exam: ==================== VS: 97.9 132 / 73 84 20 92-95% RA; 85-93% ambulatory sat, on room air Gen: well appearing, A&Ox3, sitting up in chair in no acute distress; talking in full sentences; HEENT: MMM Neck: No JVP elevation sitting at 45 degree angle in bed Resp: Good air movement; lungs are clear without wheezes; diminished at base; talking in full sentences; able to carry on conversation while ambulating Cardiac: RRR, S1, S2, no murmurs Abd: soft, non-tender Ext: no peripheral edema Gait: steady without walker Pertinent Results: Admission Labs: =============== ___ 04:55PM BLOOD WBC-13.7* RBC-4.31 Hgb-11.8 Hct-36.3 MCV-84 MCH-27.4 MCHC-32.5 RDW-13.4 RDWSD-41.5 Plt ___ ___ 04:55PM BLOOD Neuts-91.6* Lymphs-4.7* Monos-2.9* Eos-0.2* Baso-0.2 Im ___ AbsNeut-12.53*# AbsLymp-0.65* AbsMono-0.40 AbsEos-0.03* AbsBaso-0.03 ___ 04:39PM BLOOD Glucose-122* UreaN-22* Creat-0.9 Na-134 K-4.7 Cl-94* HCO3-16* AnGap-29* ___ 07:32AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4 ___ 04:39PM BLOOD proBNP-215 ___ 04:48PM BLOOD Lactate-1.1 Discharge Labs: =============== ___ 07:32AM BLOOD WBC-10.6* RBC-4.04 Hgb-11.0* Hct-34.3 MCV-85 MCH-27.2 MCHC-32.1 RDW-13.4 RDWSD-42.0 Plt ___ ___ 07:32AM BLOOD Glucose-133* UreaN-22* Creat-0.7 Na-134 K-4.8 Cl-92* HCO3-23 AnGap-24* Imaging: =============== ___ CXR Streaky opacities in the lung bases may reflect areas of atelectasis, though early infection cannot be completely excluded in the correct clinical setting. No focal consolidation. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with shortness of breath, COPD, sputum production // pneumonia? TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: Mild enlargement of the cardiac silhouette is unchanged. The aorta remains mildly tortuous with dilatation of the ascending aorta better delineated on the recent CT. Hilar contours are within normal limits. The pulmonary vasculature is not engorged. Lungs are hyperinflated. Streaky opacities are noted in both lung bases, which may reflect atelectasis. No focal consolidation, pleural effusion or pneumothorax is present. There are no acute osseous abnormalities. IMPRESSION: Streaky opacities in the lung bases may reflect areas of atelectasis, though early infection cannot be completely excluded in the correct clinical setting. No focal consolidation. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, Fever, Productive cough Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation temperature: 97.9 heartrate: 85.0 resprate: 14.0 o2sat: 96.0 sbp: 129.0 dbp: 79.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure caring for you at ___. WHY YOU CAME TO THE HOSPITAL: You came because you felt short of breath and your oxygen level at home was 87%. WHAT WE DID FOR YOU: We diagnosed you with a flare-up of your COPD. We treated you with steroids to reduce inflammation, azithromycin antibiotic to reduce inflammation, and nebulizers to open up your airways. Your breathing improved. WHAT TO DO WHEN YOU GET HOME: - Continue taking azithromycin and prednisone for 3 more days (___) - We provided you with a prescription for albuterol nebulizer, and nebulizer equipment. You may use this if your shortness of breath is not relieved by inhaler. - Please follow-up with your PCP as soon as possible

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: ORIF left tib/fib fracture History of Present Illness: ___ year old woman with PMH of Left septic hip s/p resection arthroplasty in ___ complicated by DVT presents s/p mechanical fall at home with marked left ankle pain and deformity. The patient was cleaning her apartment this evening when she slipped and fell, twisting her left ankle underneath her. She felt immediate pain and deformity. She was transported to ___ in stable condition by EMS Past Medical History: -Hepatitis C -HTN -HLD -Frequent Falls -Past C-section Social History: ___ Family History: nc Physical Exam: T-96.6 HR-107 BP-112/63 RR-18 SaO2-100% RA A&O x 3 Calm and comfortable BUE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft No pain with passive motion R M U ___ EPL FPL EIP EDC FDP FDI fire 2+ radial pulses LLE skin clean and intact Marked tendernes and deformity about left ankle. No erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses IMAGING: Ankle 3 views: Fracture of the distal third of the tibia and fibula ~3 cm proximal to the ankle joint. Pertinent Results: ___ 02:06PM GLUCOSE-120* UREA N-12 CREAT-0.7 SODIUM-140 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13 ___:06PM MAGNESIUM-1.8 ___ 02:06PM WBC-8.8 RBC-3.42* HGB-11.3* HCT-36.3 MCV-106* MCH-33.1* MCHC-31.3 RDW-12.3 ___ 02:06PM PLT COUNT-308 ___ 01:00AM GLUCOSE-118* UREA N-13 CREAT-0.7 SODIUM-140 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-20 ___ 01:00AM estGFR-Using this ___ 01:00AM WBC-12.8* RBC-3.83*# HGB-13.1# HCT-40.4# MCV-105*# MCH-34.2* MCHC-32.4 RDW-12.4 ___ 01:00AM NEUTS-73.4* ___ MONOS-3.7 EOS-1.0 BASOS-0.7 ___ 01:00AM PLT COUNT-364 ___ 01:00AM ___ PTT-26.0 ___ Medications on Admission: Cyclobenzaprine 5mg q8 prn Zolpidem 5 mg qhs prn Discharge Medications: 1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain: Do not drink alcohol or drive while on this medication. Disp:*100 Tablet(s)* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. 5. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe Subcutaneous QHS (once a day (at bedtime)) for 4 weeks. Disp:*28 Syringe* Refills:*0* Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left distal tib/fib fracture s/p ORIF 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 fall and pain in the distal tibia/fibula. Evaluate for fracture. FINDINGS: A comminuted fracture of the left distal tibia and fibula are noted with posterior displacement of the distal fracture fragment with respect to the proximal fragment. No soft tissue calcifications or radiopaque foreign bodies are identified. Findings discussed with Dr. ___ at 2:00 a.m. on ___ via telephone. Radiology Report INDICATION: ___ female with fall and pain in the distal tibia/fibula. Evaluate for fracture. Single view of the chest obtained. Comparison made to images from ___. Bilateral low lung volumes are noted with crowding of bronchovascular markings. Cardiac silhouette is extenuated by low lung volumes. Radiology Report LEFT FIB AND TIB, TWO VIEWS REASON FOR EXAM: Reduction of fracture. Comparison is made with prior study performed two hours earlier. There is new cast in the right ankle. Comminuted fractures of the left distal tibia and fibula are less displaced than before. There is no evidence of dislocation. Radiology Report LEFT FIB AND TIB REASON FOR EXAM: ORIF. Seven fluoroscopic views of the left ankle were submitted show sequential steps of ORIF of the distal fibula and tibia for comminuted fractures of the distal fibula and tibia. For more detailed description, please refer to the OR note. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: LEFT TIB/FIB INJURY Diagnosed with FX SHAFT FIB W TIB-CLOS, UNSPECIFIED FALL, HYPERTENSION NOS, JOINT REPLACEMENT-HIP temperature: 96.6 heartrate: 107.0 resprate: 18.0 o2sat: 100.0 sbp: 112.0 dbp: 63.0 level of pain: 10 level of acuity: 2.0

******SIGNS OF INFECTION********** Please return to the emergency department or notify MD if you should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continued to be non-draining. ******WEIGHT-BEARING******* Touch down weight bearing left lower extremity ******MEDICATIONS*********** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink ___ glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on ___. *****ANTICOAGULATION****** - Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left foot drop Major Surgical or Invasive Procedure: None History of Present Illness: ___ year-old R handed who presents with worsening L buttock and L lower leg pain over several months and 2 days of left foot drop. Pt reports that has been dealing with left buttock pain and left left lower leg pain for years. She also has a history of b/l knee severe OA that is left worse than right that she has been dealing with. She notes that a left TKR has been delayed due to recent MI and requiring antiplatelets for stents. She reports that she has never gotten spine imaging and she has never brought up the following problems with her PCP. Over the last several months, she has gradual worsening of her left buttock pain, aching pain from her left knee down her anterior leg into her foot, as well as increased left knee pain when standing. She has tried several doses of ibuprofen and Tylenol without much relief. Instead, she has just become less active and has been sitting more due to the pain. She is able to walk but has increased pain in that left leg when doing so that makes her stop. No history of trauma or recent strenuous activity. Denies electric pain radiating from buttock down the back of her leg. 2 days ago, she was getting into her car and trying to use her left leg on the pedals when she felt that something was not right because she could not lift her foot well. This has become a noticeable problem with walking but she feels that the problem is stable. At ___, she had hypokalemia ordered for 20meq PO and 20meq in fluids. She takes 40meq PO daily at home. She was transferred to ___ for MRI as they did not have overnight MRI capabilities there. Past Medical History: - CAD s/p MI and 2 cardiac stents ___ - Kidney stones - OA in both knees Social History: ___ Family History: No family history of stroke or neurologic disease. Physical Exam: ============== ON ADMISSION ============== Vitals: 98.3F, HR 96, BP 169/89 RR 16, 100% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, ++ bowel sounds. No masses palpated. Extremities: very mild ___ edema 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 was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI several beats end gaze nystagmus bilaterally. VFF to confrontation. 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 1 5 4- 3 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: Decreased light touch and pinprick over superior and slightly mediated left ankle/foot. Does not include toes. R toe 14 seconds, L toe 10 seconds. Big toe joint proprioception intact, left toe is slightly decreased to smaller movements. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 1 R 2 2 2 2 1 Plantar response was mute on the left and up on the right vs withdrawal. NO ankle clonus. No pectoral jerks or crossed adductor. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF. No ataxia on toe to finger. -Gait: deferred. ============== ON DISCHARGE ============== General: Awake, cooperative, NAD. Neurologic: Alert, oriented x 3. Able to relate history without difficulty.Language is fluent with intact repetition and -Cranial Nerves: II, III, IV, VI: PERRL. EOMI V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to conversation. IX, X: Palate elevates symmetrically. XI: Full strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 1 5 3 3 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: Decreased pinprick over medial left foot through ankle. Intact to light touch throughout. Proprioception intact. Pertinent Results: ___ MRI L SPINE W/O CONTRAST IMPRESSION: 1. Multilevel degenerative changes of the lumbar spine, most advanced at L4-L5, where there is severe spinal canal and moderate left neural foraminal stenosis. 2. Partially visualized aneurysmal dilatation of the infrarenal abdominal aorta, better evaluated on the CTA performed ___. Medications on Admission: Plavix 75mg daily Atorvastatin 80mg daily ASA 81mg daily Atenolol 50mg daily Losartan 100mg daily Protonix 40mg daily CHlorthalidone 25mg daily KCl ER 40meq daily Vitamin D3 1000mg daily Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Chlorthalidone 25 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Acetaminophen 650 mg PO Q6H:PRN pain Do not take concurrently with Percocet, please take one or the other, or alternate every 6 hours 7. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain Do not take concurrently with Tylenol as it contains acetaminophen. Please take one or the other. RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 8. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 Discharge Disposition: Home with Service Discharge Diagnosis: L4-L5 spinal stenosis & left neural foraminal stenosis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR ___ SPINE W/O CONTRAST INDICATION: ___ with chronic left buttock pain with 2 days of L foot drop // eval for acute process TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, coronal T2, followed by axial T2 imaging. COMPARISON: CT urogram ___ CTA abdomen and pelvis ___ FINDINGS: The S-shaped scoliosis of the lower thoracic and lumbar spine with a moderate levoscoliosis of the lumbar spine, apex at L2-L3, is unchanged. The 4 mm left lateral listhesis of L3 on L4 and 8 mm anterolisthesis of L4 on L5 are also unchanged. The height of the vertebral bodies are maintained. Heterogeneous signal at the endplates of L2-L3 to L5-S1 represent mixed degenerative endplate changes. The intervertebral disc spaces of L2-L3 to L5-S1 are moderately to severely narrowed. The intervertebral discs are diffusely desiccated. The conus medullaris terminates at L1-L2. Small Tarlov cysts are visualized at the S2 level. The spinal cord is normal in signal. No fluid collections or masses are identified. The paraspinal soft tissues are normal. At T10-T11, T11-T12, and T12-L1, there is no spinal canal or neural foraminal stenosis. At L1-L2, there is no spinal canal or neural foraminal stenosis. At L2-L3, disc bulge with superimposed right neural foraminal disc protrusion and bilateral facet arthropathy narrows the right subarticular recess and cause mild-to-moderate right neural foraminal stenosis. There is no spinal canal stenosis. At L3-L4, disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy cause mild-to-moderate spinal canal and moderate bilateral neural foraminal stenosis. At L4-L5, uncovering of the disc secondary to anterolisthesis with a superior disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy cause severe spinal canal stenosis, and moderate left neural foraminal stenosis. At L5-S1, disc bulge and bilateral facet arthropathy cause mild bilateral neural foraminal stenosis. There is no spinal canal stenosis. The focal aneurysmal dilatation of the infrarenal abdominal aorta measures 3.5 cm in transverse dimension on 8:13 and is partially visualized, unchanged from ___. IMPRESSION: 1. Multilevel degenerative changes of the lumbar spine, most advanced at L4-L5, where there is severe spinal canal and moderate left neural foraminal stenosis. 2. Partially visualized aneurysmal dilatation of the infrarenal abdominal aorta, better evaluated on the CTA performed ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: L Leg pain, Transfer Diagnosed with Foot drop, left foot, Hypokalemia temperature: 98.3 heartrate: 96.0 resprate: 16.0 o2sat: 100.0 sbp: 169.0 dbp: 89.0 level of pain: 4 level of acuity: 3.0

Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • No contact sports until cleared by your neurosurgeon. Medications • Please stop taking your aspirin and Plavix 1 week prior to the date of your surgery (___). • Please do not take any other blood thinning medications including Ibuprofen/ Motrin. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. • It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers, headache, flank pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ year old lady with history of asthma, who presents from PCP's office with fevers, dysuria, and flank pain. Per patient, she started experiencing fevers since last ___ up to ___ F. This was associated with a headache, which she describes as R frontal, sharp, not associated with focal neurological changes (no visual changes, focal weakness, numbness, tingling, dizziness), or change in her chronic neck pain not worsening with Valsalva or cough, not waking her up from sleep. She looked this up from a virtual doctor, and was told that she could have meningitis. Alarmed, she presented to a physical doctor in ___ on ___. At that time she shares that blood and urine tests were sent, but she was told that everything was okay. She did also call the nurses afterwards and was told to "ride it out" and that perhaps she had fever of unknown origin. Her fever broke on ___ night, and she felt well enough to go to work. On ___, she had episode of severe chills, felt that her lips turned blue, and had recurrent fever at night to 101 degrees associated with night sweats. This was accompanied by new L flank pain as well as decreased appetite, although no nausea or vomiting. Today, she presented to her primary care doctor. Per PCP call in, there was a UCx reportedly with pansensitive E coli > 100K. She received 1 dose of ciprofloxacin at ___'s office, and was sent into the ED for further evaluation. In the ED, initial vitals: 97.8 96 103/65 99% RA Exam notable for: comfortable appearing, afebrile. She was complaining of headache and L flank discomfort but no nausea, vomiting, diarrhea, or SOB. She shared that she has not had much appetite since last ___ but was able to drink water. Labs: 1) WBC 10.2 Hgb 11.6 Plt 299 Neutrophils 78.1 2) Na 137 K 4.1 Cl 97 CO2 22 BUN 5 Cr 0.6 3) ALT 39 AST 19 AP 84 Tbili 0.7 4) TSH 1.5 5) U/A with negative nitrite and negative ___ ___ x 2 were drawn, lyme studies were sent, urine cultures sent as well Imaging: - CXR: No acute cardiopulmonary abnormality - CT A/P: Two thick walled lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2 cm, with small central fluid components, compatible with abscesses. Circumferential wall thickening of the bladder, greater than expected for the degree of distension, likely representing cystitis. She was seen by urology: "L sided flank pain is now mild but definitely tender to palpation. Abscesses too small for drainage at the time. Recommend IV antibiotics for now and monitoring: foley placement. Recommend medicine admission for pyelonephritis. GU will follow. She received: - Ceftriaxone 1 g x 1 - Acetaminophen 1000 mg Upon arrival to the floor, the patient confirms history as above. No acute concerns, is not interested in having Foley placed. Of note she has no known history of ___, urinary tract abnormalities, recent instrumentation. Past Medical History: Acne vulgaris Low back pain History of asthma Vitamin D deficiency Social History: ___ Family History: Father- MI, DM, Asthma MGM- Lung cancer MGF- Pancreatic cancer Uncle- Liver cancer Aunt- ___ cancer Uncle- Lung cancer Physical Exam: ADMISSION EXAM =============== VITALS: 98.9 99/64 77 18 98% RA GENERAL: Young female lying in bed in no acute distress EYES: EOMI ENT: MMM CV: Normal rate, regular rhythm, no m/r/g RESP: CTAB, no increased work of breathing GI: Soft, nontender, nondistended, + BS GU: Mild L CVA tenderness, mild TTP at flank MSK: Normal bulk and tone SKIN: No rashes appreciated NEURO: CN II-XII intact, strength ___ in bilateral upper and lower extremities, no dysmetria, no pronator drift DISCHARGE EXAM =============== VITALS: Tcur98.6 Tmax 100.0, 106/67, 60, 18, 98% Ra GENERAL: Well appearing woman, not ill appearing, laying in bed, in NAD ENT: EOMI, MMM CV: RRR, no m/r/g RESP: CTAB, no wheezes or crackles GI: Soft, non distended, mild left sided abdominal tenderness GU: No CVA tenderness on palpation SKIN: No rashes or lesions noted NEURO: AO x 3 Pertinent Results: ADMISSION LABS ================ ___ 09:05AM WBC-10.2* RBC-3.93 HGB-11.6 HCT-36.3 MCV-92 MCH-29.5 MCHC-32.0 RDW-12.7 RDWSD-43.4 ___ 09:05AM NEUTS-78.1* LYMPHS-10.1* MONOS-10.5 EOS-0.4* BASOS-0.5 IM ___ AbsNeut-8.00*# AbsLymp-1.03* AbsMono-1.07* AbsEos-0.04 AbsBaso-0.05 ___ 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 09:05AM UREA N-5* CREAT-0.6 SODIUM-137 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-22 ANION GAP-18* MICROBIOLOGY ============= Urine culture at OSH: Growing e. coli, pan sensitive UA at ___ negative Ucx at ___ ___ pending ___ at ___ ___ pending IMAGING ======== CT Abd and Pelv ___: 1. Two thick-walled lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2 cm with small central fluid components, which given the clinical history of pyelonephritis, are compatible with abscesses. 2. Circumferential wall thickening of the bladder, greater than expected for the degree of distension, likely representing cystitis. RENAL US ___: Echogenic area in the upper pole of the left kidney consistent with pyelonephritis, no evidence of fluid collection. Please note that CT is more sensitive for detection of abscess formation. DISCHARGE LABS =============== ___ 06:46AM BLOOD WBC-9.3 RBC-3.98 Hgb-11.5 Hct-36.1 MCV-91 MCH-28.9 MCHC-31.9* RDW-12.5 RDWSD-41.7 Plt ___ ___ 06:46AM BLOOD Plt ___ ___ 06:46AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-143 K-4.4 Cl-102 HCO3-25 AnGap-16 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D 400 UNIT PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*38 Tablet Refills:*0 2. Vitamin D 400 UNIT PO DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: E. coli pyelonephritis L renal abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen pelvis with IV contrast. INDICATION: ___ year old woman with fevers for a week, now with left flank pain r/o pyelonephritis// fevers for a week, now with left flank pain r/o pyelonephritis 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) = 352 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: Punctate hypodensity within the right lobe of the liver is too small to characterize, but likely represents a cyst or biliary hamartoma (series 5, image 18). The liver demonstrates homogenous attenuation throughout. There is no suspicious hepatic lesion. 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. An accessory spleen is seen at the hilum. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Within the upper pole of the left kidney, there are two thick-walled lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2 cm with central hypoattenuation (series 7, image 26, 28), which given the clinical history of pyelonephritis, are compatible with abscesses. A 9 mm hypodensity within the interpolar region of the left kidney is too small to characterize, but likely represents a simple cyst (series 7, image 30). Otherwise, the kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of 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: Circumferential wall thickening of the bladder, greater than expected for the degree of distension, likely representing cystitis. 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. 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. Two thick-walled lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2 cm with small central fluid components in the upper pole of the left kidney, which given the clinical history of pyelonephritis, are compatible with abscesses. 2. Mild circumferential wall thickening of the bladder, greater than expected for the degree of distension, likely representing cystitis. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:30 pm, 2 minutes after discovery of the findings. The impression above was also entered by Dr. ___ on ___ at 15:27 into the Department of Radiology critical communications system for direct communication to the referring provider. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with fevers, r/o infiltrate// fevers r/o infiltrate COMPARISON: Chest radiographs from ___, most recently ___ FINDINGS: PA and lateral views of the chest provided. The lungs are fully expanded and clear. The cardiomediastinal contours and pleural surfaces are normal. IMPRESSION: 1. No acute cardiopulmonary abnormality. NOTIFICATION: The findings were discussed with Ms. ___, RN by ___ ___, M.D. on the telephone on ___ at 11:30 am, 2 minutes after discovery of the findings. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman p/w fever found to have L renal abscesses on CT// eval renal abscess. Would like to know if can be seen via U/S for followup ultrasound as opposed to a f/u CT TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT ___ FINDINGS: The right kidney measures 10.0 cm. The left kidney measures 11.2 cm. There is no hydronephrosis or stones bilaterally. The right kidney has normal cortical echogenicity and corticomedullary differentiation. There is a circumferential echogenic irregularity or deformity in the upper pole of the left kidney which could correspond to the CT finding from ___. The bladder is moderately well distended and normal in appearance. IMPRESSION: 1. E chogenic area in the upper pole of the left kidney consistent with pyelonephritis, no evidence of fluid collection. Please note that CT is more sensitive for detection of abscess formation. Gender: F Race: ASIAN Arrive by WALK IN Chief complaint: Dysuria, L Flank pain Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic temperature: 97.8 heartrate: 98.0 resprate: 16.0 o2sat: 99.0 sbp: 103.0 dbp: 65.0 level of pain: 7 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why was I admitted to the hospital? - You were admitted because you had fevers, headache, and back pain. - Your PCP ordered some tests which showed that you had an infection of your kidneys. What was done while I was in the hospital? - You were started on antibiotics to help treat the infection. First you were given IV antibiotics and then you were transitioned to oral. - You were given Tylenol for your fever and headache. What should I do when I go home? - You should continue taking your antibiotic medication, ciprofloxacin, twice daily until ___ for a total of a 3 week course. - You should follow up with your new PCP on ___. You will also need repeat imaging of your kidneys to ensure that the abscesses are gone. Your PCP can help arrange that. Wishing you all the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lyrica Attending: ___. Chief Complaint: Foreign Body Ingestion Major Surgical or Invasive Procedure: Endoscopy with retrieval of foreign body History of Present Illness: ___ yo F with seizure disorder, mental retardation, depression, psychosis and multiple suicide attempts presents to ER from her group psychiatric facility after she reports swallowing a toothbrush cover ___ in size) in an attempt to kill herself. Patient was recently hospitalized at ___ for what were ultimately felt to be pseudo-seizures and was discharged to her current group psychiatric facility (___) on ___. She has a history per report of attention seeking behaviors but does have significant depression per report. At around 11 am on the day of admission, the patient reported swallowing a toothbrush cover (the kind used to cover bristles during travel). Some reports say this was followed by some emesis with small amount of blood, but she denies this upon interview on the floor. Since then she has not felt as though there is anything stuck in her throat, esophagus, or stomach and is able to manage her secretions without issue. She does complain of vague abdominal pain in her LLQ (though in the ED she complained of LUQ pain). No fevers or chills. No SOB or chest pain. Per her report she has not swallowed anything like this before. She has had 1 BM since swallowing the toothbrush cover and denies any blood in it. On arrival to the ED, VS were 97.9, 100, 138/86, 16, 99% RA. Exam was unremarkable, rectal exam guaiac negative. Plain films of abdomen and chest were obtained, but the foreign body was not seen. LLE US was also obtained because she complained of calf pain, which was negative for DVT. Labs unremarkable. GI consult obtained, recommended admission to medicine with plan for EGD under MAC anesthesia in the AM. On arrival to the floor, patient is sleeping comfortably. Upon awakening, she reports that she still has some pain in her LLQ. No other new symptoms. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: Depression Seizure disorder Mental retardation Obesity s/p CCY Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION: VS T 98.0, BP 138/80, HR 74, RR 18, O2 sat 96% RA GEN Obese young woman lying in bed, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft, obese, ND. Minimally tender to palpation along left abdomen/LLQ. normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions DISCHARGE: VS - 98.3 ___ 20 ___ ra GEN Obese young woman lying in bed, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft, obese, ND. no ttp. normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal, active SI, though no distress. Mood depressed SKIN no ulcers or lesions Pertinent Results: LABS: ___ 10:00PM BLOOD WBC-8.4 RBC-4.42 Hgb-12.5 Hct-38.1 MCV-86 MCH-28.4 MCHC-32.9 RDW-13.5 Plt ___ ___ 10:00PM BLOOD Neuts-58.8 ___ Monos-3.9 Eos-2.2 Baso-0.5 ___ 10:00PM BLOOD ___ PTT-29.8 ___ ___ 10:00PM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-141 K-4.2 Cl-107 HCO3-27 AnGap-11 ___ 10:00PM URINE UCG-NEGATIVE CXR: No radiopaque foreign body. Possible mild pulmonary edema with appearance likely accentuated due to low lung volumes and patient body habitus. AXR: No visualized radiopaque foreign body. RLE U/S: No evidence of deep venous thrombosis in the right lower extremity. EGD: - Normal mucosa in the esophagus - Plastic foreign body in the stomach status post successful foreign body removal. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Atorvastatin 40 mg PO DAILY 2. Benztropine Mesylate 1 mg PO Q12H:PRN extrapyramidal symptoms 3. Haloperidol 10 mg PO TID:PRN agitation 4. DiphenhydrAMINE 25 mg PO Q8H:PRN extrapyramidal sxs 5. Lorazepam 2 mg PO Q4H:PRN anxiety, agitation 6. LaMOTrigine 100 mg PO QAM Start: In am 7. LaMOTrigine 125 mg PO QPM 8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown 9. Vitamin D Dose is Unknown PO Frequency is Unknown 10. Risperidone 4 mg PO HS 11. traZODONE 100 mg PO HS 12. Zonisamide 200 mg PO HS 13. Ibuprofen 400 mg PO Q6H:PRN pain 14. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Benztropine Mesylate 1 mg PO Q12H:PRN extrapyramidal symptoms 3. DiphenhydrAMINE 25 mg PO Q8H:PRN extrapyramidal sxs 4. Haloperidol 10 mg PO TID:PRN agitation 5. LaMOTrigine 100 mg PO QAM 6. LaMOTrigine 125 mg PO QPM 7. Lorazepam 2 mg PO Q4H:PRN anxiety, agitation 8. Risperidone 4 mg PO HS 9. traZODONE 100 mg PO HS 10. Zonisamide 200 mg PO HS 11. Ibuprofen 400 mg PO Q6H:PRN pain 12. Multivitamins 1 TAB PO DAILY 13. Vitamin D 400 UNIT PO DAILY 14. Calcium Carbonate 500 mg PO TID:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Foreign Body Ingestion Mental Retardation 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 CHEST, TWO VIEWS: ___. HISTORY: ___ female with psychiatric history, potentially swallowed toothpaste cap. FINDINGS: Frontal and lateral views of the chest. No prior. Low lung volumes and large patient body habitus somewhat limited exam. There is no large confluent consolidation. There is crowding of the pulmonary vascular markings with indistinct vascular markings. No large confluent consolidation. No large effusion is identified. Cardiac silhouette is within normal limits. There is no radiopaque foreign body. IMPRESSION: No radiopaque foreign body. Possible mild pulmonary edema with appearance likely accentuated due to low lung volumes and patient body habitus. Radiology Report ABDOMEN, MULTIPLE VIEWS: ___. HISTORY: ___ female with psych history, may have swallowed toothpaste cap. Question foreign body. FINDINGS: Three views of the abdomen were evaluated. No prior. There is a nonobstructive bowel gas pattern identified with gas and stool throughout the colon. Surgical clips in the right upper quadrant suggest prior cholecystectomy. There is no other radiopaque foreign body identified. IMPRESSION: No visualized radiopaque foreign body. Radiology Report INDICATION: Patient initially presenting to the emergency department for swallowing a plastic toothpaste cap, now with right leg pain and swelling. TECHNIQUE: Right lower extremity Doppler ultrasound. COMPARISON: None available. FINDINGS: Grayscale and Doppler sonograms of the right common femoral, superficial femoral and popliteal veins were performed. There is normal compressibility, flow and augmentation. The calf veins were not visualized. Soft tissue swelling of the right calf is noted with no underlying fluid collection identified. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: SWALLOWED FB Diagnosed with FOREIGN BODY IN STOMACH, FB ENTERING OTH ORIFICE, SCHIZOAFFECTIVE-UNSPEC temperature: 97.9 heartrate: 100.0 resprate: 16.0 o2sat: 99.0 sbp: 138.0 dbp: 86.0 level of pain: 10 level of acuity: 3.0

Miss ___, It was a pleasure taking care of you at the ___. You were admitted from ___ after ingesting a toothbrush cover. You underwent an endoscopy procedure under anesthesia and the object was successfully retrieved. You were discharged back to Arbour in a stable condition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: abdominal pain x2 wks Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ lady with COPD, DM2/neuropathy, HTN, HL, h/o CVA and multiple admissions for abdominal pain who presented to the ED with abdominal pain. She describes 2 weeks of pain in LLQ that she describes as a "burning." She reports that it radiates towards her back and to her L shoulder. She denies vomiting, chest pain, diarrhea/constipation. No fevers. Of note, she was admitted 3 months ago for similar symptoms with vomiting and was treated for h.pylori infection. She reports that she went to her PCP who wanted her sent to the ED for a CT scan. . In the ED, initial VS were: 10 97.9 72 146/72 20 100%RA. Labs were unremarkable but abdominal pain persisted, with LLQ guarding but no rebound. There was concern for diverticulitis so she was given IV Cipro/Flagyl. CT abdomen revealed diverticulosis but no diverticulitis; no cause fo rthe abdominal pin was identified. She was given Morphine 2mg IV and was admitted to Medicine for pain control/observation. . On the floor, patient is comfortable. Her pain is down to a 2. She declines further interview and asks for a soda and some sleep. . REVIEW OF SYSTEMS: Denies fever, chills. No nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. No chest pain. Past Medical History: -Dyslipidemia -Hypertension -IDDM Type 2 (poorly controlled) -Old "right-sided stroke with residual left-sided weakness" as per OMR. -COPD -Peripheral neuropathy -lung nodule -gallbladder polyp -recently treated for H. pylori in ___ Social History: ___ Family History: Mother- died at age ___, had CAD, DM2, HTN Father- died at ___ of possible laryngeal cancer Notable for BPAD in a daughter. Physical Exam: Admission PEx: VS - Temp 97.1F, BP 131/60, HR 65, R 16, O2-sat 98% RA GENERAL: no a cute distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple. No JVD CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM.Very mild TTP of LLQ with no guarding and no rebound. EXTREMITIES: No c/c/e. SKIN: No rash . . . Discharge PEx: VITALS: ___ 115/71 69 16 99%RA BS 164 GENERAL: no acute distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple. No JVD CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM.Very mild TTP of LLQ with no guarding and no rebound. EXTREMITIES: No c/c/e. SKIN: No rash Guaiac: negative Pertinent Results: Labs on admission: ___ 03:00PM BLOOD WBC-6.9 RBC-4.32 Hgb-13.3 Hct-39.4 MCV-91 MCH-30.9 MCHC-33.8 RDW-12.6 Plt ___ ___ 03:00PM BLOOD Neuts-59.0 ___ Monos-2.9 Eos-1.7 Baso-0.3 ___ 03:00PM BLOOD Glucose-276* UreaN-9 Creat-1.0 Na-140 K-3.7 Cl-104 HCO3-25 AnGap-15 ___ 03:00PM BLOOD ALT-14 AST-19 CK(CPK)-73 AlkPhos-103 ___ 03:00PM BLOOD Lipase-15 ___ 03:00PM BLOOD Albumin-4.3 ___ 07:24PM BLOOD Lactate-1.4 ___ 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Micro: Blood cultures ___: negative x2 . . . Imaging: EKG: Sinus rhythm with atrial premature depolarizations. Left axis deviation. Left anterior fascicular block. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of ___ there is no significant change. . CT Abd/Pelvis: The included portions of the lung bases are unremarkable. The liver, gallbladder, pancreas, adrenal glands, and kidneys are grossly unremarkable. The spleen contains a hypodensity, too small to characterize (601B:35). Loops of small and large bowel are normal in size and caliber. There is extensive colonic diverticulosis without evidence of diverticulitis. The bladder, distal ureters and uterus appear normal. Distal loops of large bowel and rectum are normal in size and caliber with again note of diverticulosis. The appendix is normal. No free air, free fluid, or lymphadenopathy is seen. There is stable deformity of the superior endplate at L5. No concerning osseous lesion is seen. IMPRESSION: No acute findings to explain pain. Diverticulosis without evidence of diverticulitis. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1 puff inhaled as needed as needed for for shortness of breath, wheezing ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth daily FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff twice a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily HANDIHALER - - use with Spiriva daily For spiriva INSULIN DETEMIR [LEVEMIR FLEXPEN] - 100 unit/mL (3 mL) Insulin Pen - take 28 units QAM INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - bid as directed per sliding scale LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily METFORMIN - 1,000 mg Tablet - 1 and ___ Tablet(s) by mouth in Am, 1 tab in pm NORTRIPTYLINE - 10 mg Capsule - 1 Capsule(s) by mouth daily OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 cap inhale daily TRAZODONE - 50 mg Tablet - ___ Tablet(s) by mouth daily as needed for for sleep ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN [CHEWABLE-VITE] - Tablet, Chewable - 1 Tablet(s) by mouth daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___ Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. Disp:*100 Tablet(s)* Refills:*2* 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation BID (2 times a day). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. insulin detemir 100 unit/mL (3 mL) Insulin Pen Sig: Twenty Eight (28) units Subcutaneous QAM: As directed previously prior to your hospitalization. 8. insulin lispro 100 unit/mL Solution Sig: AS DIR Subcutaneous twice a day: AS DIRECTED by your sliding scale, prior to your hospitalization. 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metformin 1,000 mg Tablet Sig: AS DIRECTED Tablet PO once a day: 1.5 tablets in AM, 1 tablet in ___. 11. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO once a day. 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. trazodone 50 mg Tablet Sig: AS DIR Tablet PO QHS: PRN: 0.5-1 mg at night as needed for sleep. 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day: For constipation. Disp:*30 Tablet(s)* Refills:*1* 17. Colace 50 mg Capsule Sig: One (1) Capsule PO once a day: As needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Abdominal pain of unclear etiology Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Left upper quadrant pain. TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was obtained after the administration of 100 mL IV Optiray contrast. Coronal and sagittal reformations were prepared. COMPARISON: CT examination dated ___. FINDINGS: The included portions of the lung bases are unremarkable. The liver, gallbladder, pancreas, adrenal glands, and kidneys are grossly unremarkable. The spleen contains a hypodensity, too small to characterize (601B:35). Loops of small and large bowel are normal in size and caliber. There is extensive colonic diverticulosis without evidence of diverticulitis. The bladder, distal ureters and uterus appear normal. Distal loops of large bowel and rectum are normal in size and caliber with again note of diverticulosis. The appendix is normal. No free air, free fluid, or lymphadenopathy is seen. There is stable deformity of the superior endplate at L5. No concerning osseous lesion is seen. IMPRESSION: No acute findings to explain pain. Diverticulosis without evidence of diverticulitis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: LUQ PAIN Diagnosed with ABDOMINAL PAIN LLQ, DIABETES UNCOMPL ADULT temperature: 97.9 heartrate: 72.0 resprate: 20.0 o2sat: 100.0 sbp: 146.0 dbp: 72.0 level of pain: 10 level of acuity: 3.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted due to several weeks of abdominal pain. You underwent blood work and a CT scan of your stomach which did not demonstrate any clear cause of your discomfort. With supportive care and pain control, your symptoms improved. You will need follow up with your primary care physician and gastroenterologist as an outpatient as listed below. We have made the following changes to your medications: - DECREASE aspirin to 81mg by mouth daily (please discuss with your primary care physician) - START standing tylenol ___ by mouth every 6 hours for your pain - START senna and colace as necessary for constipation

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Shellfish / Nafcillin / Coumadin Attending: ___. Chief Complaint: fever and GPC bacteremia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ ___ gentleman with a PMH of ESRD on HD from FSGS, aortic valve MSSA endocarditis (___), s/p bioprosthetic AVR (___), s/p St. ___ mechanical AVR (___), on aspirin/Plavix (had significant bleeding complications on warfarin), now presenting with fever to 104.8 and blood culture positive for GPCs. Pt developed fever to 102, chills on ___. Blood cx was obtained, and pt was given vancomycin at ___ on the same day. Fever peaked to 104.8 subsequent day, with nausea, vomiting, diarrhea. Blood cutlure grew GPC today, and pt asked to come to the ED. Last home HD session ___. N/V/D only lasted a day and then resolved. Pt actually feels much better now. He is s/p two doses of vanco one and ___ and the second in the ED prior to admission. He underwent a TEE on ___ out of concern for repeat endocarditis when he initially developed fevers which was neg for vegetations. He is on home HD and administers HD to himself 5 times per wk on days of his choosing. In the ED, initial VS were: 97 93 131/69 18 100% RA. Physical exam was notable for a precordial lift and ___ systolic ejection murmur with mechanicla S2. Labs were remarkable for: WBC 4.7 with 22.7% eos, H/H 8.7/28.0; ALT 84, AST 56, Alb 3.4; BUN/Cr 81/12.2; Mg 2.2, P 6.9; lactate 0.6. Blood cultures x2 were sent. CXR PA/lat showed no acute cardiopulmonary process. Patient was given vancomycin 1g IV. VS on transfer: 98.5 79 117/68 16 100%. On arrival to the floor, pt was comfortably walking around room in NAD. He was able to answering all questions without difficulty and stated he was feeling back to his normal self. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: # ESRD on HD ___, ___ FSGS on renal bx in ___ # L AVF created ___ complicated by stenosis s/p percutaneous angioplasty ___ and ___ # Aortic valve endocarditis with MSSA s/p bioprosthetic AVR ___, presumed secondary to HD line infection - c/b ___ abscess that recurred after his initial # AVR requiring homograft valve and aortic root replacement with reimplantation of his coronary arteries (___) - Completed 6 week course of nafcillin on ___ - subsequently maintained on dicloxacillin through ___. - recurrent MSSA bacteremia with presumed recurrent endocarditis in ___ treated with 6 weeks of rifampin and cefazolin with 2 wks of gent - Porcine valve replaced with ___ valve on ___ c/b intrathoracic hematoma and hemothorax while on coumadin, now maintained on ASA and Plavix Social History: ___ Family History: mother - breast ca at ___, survivor, aunt - died of MI at ___, no other family hx of renal disease, no DM or other CA in the family Physical Exam: ADMISSSION PHYSICAL EXAM: VS: 98.7, 118/70, 88, 16, 98% RA GENERAL: well appearing, NAD HEENT: NC/AT, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD: flat LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, mechanical heart murmur, nl ___, well healed sternotomy scar ABDOMEN: normal bowel sounds, soft, ___, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp, fistula in LUE with palpable thrill NEURO: awake, A&Ox3, CNs ___ grossly intact, muscle strength ___ throughout, sensation grossly intact throughout . . DISCHARGE PHYSICAL EXAM: VS: 98.6, ___, 100% RA pain ___ GENERAL: well appearing, NAD, pleasant, thin HEENT: NC/AT, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, JVD: flat LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, loud mechanical heart sound heard without stethoscope, ___ SEM heard best at apex, nl ___, well healed sternotomy scar ABDOMEN: normal bowel sounds, soft, ___, no rebound or guarding, no masses, mutiple surgical scars EXTREMITIES: no edema, 2+ pulses radial and dp, fistula in LUE with palpable thrill NEURO: awake, A&Ox3, CNs ___ grossly intact, muscle strength ___ throughout, sensation grossly intact throughout SKIN: no rashes, no splinter hemorrhages, no ___ lesions or nodes, some new excoriations from itching on previous day Pertinent Results: Admission Labs: ___ 07:40PM BLOOD ___ ___ Plt ___ ___ 07:40PM BLOOD ___ ___ ___ 08:00AM BLOOD ___ ___ ___ ___ 12:23PM BLOOD Ret ___ ___ 06:20PM BLOOD ___ ___ 07:40PM BLOOD ___ ___ ___ 07:40PM BLOOD ___ ___ 08:10AM BLOOD ___ ___ 07:40PM BLOOD ___ ___ ___ 07:40PM BLOOD Hapto-<5* ___ 12:23PM BLOOD ___ ___ 08:10AM BLOOD ___ ___ 08:10AM BLOOD ___ ___ LDLmeas-<50 . . ___ 08:10AM BLOOD ___ ___ 08:00AM BLOOD HIV ___ ___ 08:10AM BLOOD ___ ___ 07:48PM BLOOD ___ ___ 08:10AM BLOOD STRONGYLOIDES ___ ___ 08:00AM BLOOD SCHISTOSOMA ___ Discharge Labs: ___ 08:00AM BLOOD ___ ___ Plt ___ ___ 08:00AM BLOOD ___ ___ ___ 08:00AM BLOOD ___ ___ ___ 08:10AM BLOOD ___ LD(LDH)-569* CK(CPK)-52 ___ 08:00AM BLOOD ___ Micro: ___ STOOL OVA + ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ INPATIENT ___ BLOOD CULTURE Blood Culture, ___ EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, ___ EMERGENCY WARD . . ___ CXR: IMPRESSION: No acute cardiopulmonary process. No significant interval change. . ___ ECG: Sinus rhythm. Left atrial abnormality. Right ___ block pattern Delayed R wave transition in the precordial leads. Cannot exclude a prior anteroseptal myocardial infarction. Compared to the previous tracing of ___ the rate is slightly faster. Otherwise, no diagnostic change. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Nephrocaps 1 CAP PO DAILY 3. Lanthanum 1000 mg PO TID W/MEALS 4. Fish Oil (Omega 3) 1000 mg PO BID 5. Clopidogrel 75 mg PO DAILY 6. Renagel *NF* 2400 mg Other TID with meals 7. Ascorbic Acid ___ mg PO DAILY 8. Vitamin E 1000 UNIT PO DAILY 9. Calcitriol 0.5 mcg PO EVERY OTHER DAY 10. Lisinopril 20 mg PO DAILY hold for sbp <100 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Calcitriol 0.5 mcg PO EVERY OTHER DAY 4. Clopidogrel 75 mg PO DAILY 5. Fish Oil (Omega 3) 1000 mg PO BID 6. Lanthanum 1000 mg PO TID W/MEALS 7. Lisinopril 20 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Nephrocaps 1 CAP PO DAILY 10. Renagel *NF* 2400 mg Other TID with meals 11. Vitamin D ___ UNIT PO DAILY 12. CefazoLIN 2 g IV POST HD ___ 13. CefazoLIN 2 g IV POST HD ___ 14. CefazoLIN 3 gm IV POST HD ___ 15. Vitamin E 1000 UNIT PO DAILY 16. Outpatient Lab Work ICD9 790.7 Bacteremia Please draw WEEKLY CBC, CHEM10, LFTS and fax to the Attn: Dr. ___. All laboratory results should be faxed to the ___ R.N.s at ___. All questions regarding outpatient parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the ___ ID fellow when the clinic is closed. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: MSSA bacteremia, eosinophilia, ESRD on HD Secondary diagnosis: CHF, CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Recent fever and Gram positive cocci in blood. TECHNIQUE: Frontal and lateral views of the chest. COMPARISON: ___. FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. The patient is status post median sternotomy. Vascular stenting appears stable in position. IMPRESSION: No acute cardiopulmonary process. No significant interval change. Gender: M Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: +VE BLC Diagnosed with BACTEREMIA NOS, FEVER, UNSPECIFIED, END STAGE RENAL DISEASE, HEART VALVE REPLAC NEC temperature: 97.0 heartrate: 93.0 resprate: 18.0 o2sat: 100.0 sbp: 131.0 dbp: 69.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you in the hospital. You were admitted for evaluation of bacteremia after having fevers at home. You were found to have MSSA bacteremia sensitive to cefazolin, which you will get for 6 weeks at outpatient hemodialysis 3 times per week until ___. You were also evaluated for significant eosinophilia for which the cause is thought to be related to your home hemodialysis equipment, but there are other tests pending for this as well. We have scheduled appointments for you with Hematology, ___ Disease and Primary Care, and you will see your nephrologist at hemodialysis. Please do not hesitate to reschedule them if you are unable to make it. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please see the attached sheet for your updated medication list. We wish you all the best.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: ? a cream Attending: ___. Chief Complaint: Stuttering speech Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old woman w PMH of plaquenoid maculopathy on prednisone (and recently on cellcept), breast cancer s/p resection, HTN, p/w acute onset stuttering x 1.5 weeks. The patient was at her sisters birthday party a week and a half prior top presentation, when suddenly the patient started stuttering at the dinner table. She says she had been a little anxious that day in terms of planning to get to the party on time, but if anything she was more relaxed during the dinner. She describes that she knows what she wants to say, but has difficulty physically forming the words when she is speaking. Her writing has similarly suffered, and her handwriting has gotten worse in the past 1.5 weeks as well. She has noted no improvement or worsening of her symptoms. She has gotten somewhat frustrated, and now tends to talk less since it is difficulty for her to speak. She is able to read ok, and understands what other people are stayin. She has also noted she seems to be holding her fork and her pen wrong for the last 1.5 weeks. On neurologic review of systems, the patient endorses mild headache since being in the ED, denies lightheadedness, or confusion. Denies difficulty with comprehending speech. Denies loss of vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies muscle weakness. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, rigors, or noticeable weight loss. She does have longstanding night sweats. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: - plaquenoid maculopathy - HTN - breast cancer s/p resection, radiation, and chemo - fatty liver/cirrhosis -uveitis,on prednisone (and recently on cellcept) Her ophthomologist is Dr. ___ ___ History: ___ Family History: Family History: no h/o stroke, seizure. no h/o rheumatologic disease. father had stents placed in his heart, and other family members had cancer Physical Exam: ADMISSION EXAM VS 97.5 9 164/100 16 96% RA General: NAD, lying in bed comfortably. + moon facies Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema, palpable pulses Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards. Recalls a coherent history. Speech is often stuttering, at other times it is haulting. Structure of speech demonstrates full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Abnormal prosody. No dysarthria. Verbal registration and recall ___. No apraxia. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - I. not tested II. Equal and reactive pupils (2mm to 1.5m). Visual fields were full to finger wiggling. III, IV, VI. smooth and full extraocular movements without diplopia or nystagmus. V. facial sensation was intact, muscles of mastication with full strength VII. face was symmetric with full strength of facial muscles VIII. hearing was intact to finger rub bilaterally. IX, X. symmetric palate elevation and symmetric tongue protrusion with full movement. XI. SCM and trapezius were of normal strength and volume. - Motor - Muscule bulk and tone were normal. No pronation, no drift. No tremor or asterixis. Delt Bic Tri ECR IO IP Quad Ham TA Gas ___ L 5 5 ___ 5 5 5 5 5 5 R 5 5 ___ 5 5 5 5 5 5 - Sensation - Intact to light touch, pinprick, and proprioception throughout. - DTRs - Bic Tri ___ Quad Gastroc L 2 2 2 0 0 R 2 2 2 0 0 Plantar response withdrawl bilaterally. - Cerebellar - No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait - Normal initiation. Narrow base. Normal stride length and arm swing. Stable without sway. No Romberg. DISCHARGE EXAM Unchanged with the exception of improved stuttering. Pertinent Results: ___ 07:35AM GLUCOSE-154* UREA N-10 CREAT-0.6 SODIUM-147* POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-30 ANION GAP-12 ___ 12:19PM %HbA1c-6.3* eAG-134* ___ 09:40PM WBC-5.7 RBC-3.72* HGB-13.0 HCT-37.3 MCV-100* MCH-35.1* MCHC-35.0 RDW-13.8 ___ 07:35AM TRIGLYCER-55 HDL CHOL-83 CHOL/HDL-2.0 LDL(CALC)-74 ___ 07:35AM TSH-0.35 MRI/A Brain and neck Subacute watershed distribution infarction in the left hemisphere. Severe left internal carotid artery stenosis in its supraclinoid segment extending to the bifurcation. No evidence of stenosis or occlusion in the neck. No evidence of internal carotid artery stenosis by NASCET criteria. NCHCT 1. No acute intracranial process. 2. Hypodense foci the left frontal lobe white matter, likely the sequelae of prior small vessel ischemia. TTE The left atrium is elongated. 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. Quantitative (3D) LVEF = 60%. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No PFO or ASD seen. Normal global and regional biventricular systolic function. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. anastrozole 1 mg oral DAILY 3. PredniSONE 30 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Mycophenolate Mofetil 1000 mg PO BID 2. Lisinopril 10 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. anastrozole 1 mg oral DAILY 6. PredniSONE 30 mg PO DAILY 7. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*0 8. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth at night Disp #*30 Tablet Refills:*0 9. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 11. Outpatient Speech/Swallowing Therapy Patient requires outtpatient speech therapy for her mild speech fluency issues Discharge Disposition: Home Discharge Diagnosis: Left MCA distribution ischemic infarct Left ICA stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neurological examination: Mental status reveals very slightly halting, hesitant speech. No anomia and repeats well. CN examination save existing visual issues is normal. Limb examination reveals full strength, normal saensation and no ataxia. Followup Instructions: ___ Radiology Report INDICATION: Aphasia for the past one and half weeks. Evaluate for stroke or intracranial hemorrhage. COMPARISON: None. TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast material. Multiplanar reformats were performed. TOTAL DLP: 780 mGy-cm. CTDIvol: 55.5 mGy. FINDINGS: There is no evidence of hemorrhage, edema, shift of normally midline structures, hydrocephalus, or infarction. Hypodense areas within the left frontal lobe are likely the sequelae of prior small vessel ischemia. Prominence of the ventricles and sulci are compatible with age-related involutional change. The visualized portions of the orbits are unremarkable. The imaged portions of the paranasal sinuses and the mastoid air cells are clear. IMPRESSION: 1. No acute intracranial process. 2. Hypodense foci the left frontal lobe white matter, likely the sequelae of prior small vessel ischemia. Radiology Report INDICATION: Aphasia for the past ___ weeks. Assess for infection. COMPARISON: None. FINDINGS: The lungs are clear. The heart size is normal. The mediastinal contours are normal. There are no pleural effusions. No pneumothorax is seen. IMPRESSION: No acute cardiac or pulmonary process. Radiology Report HISTORY: New onset stuttering. Left frontal hypodensity on CT. TECHNIQUE: Diffusion imaging and 3D time-of-flight MRA were performed through the brain. Sagittal T1 weighted imaging was performed. This was followed by axial T2, FLAIR, and gradient echo imaging. 2 dimensional time-of-flight MRA was performed through the neck. Subsequently, 3 dimensional time-of-flight MRA was performed during infusion of 17 cc of MultiHance intravenous contrast. COMPARISON: Head CT ___. FINDINGS: The brain MRA demonstrates apparent subacute infarction in a watershed distribution in the left deep white matter. A small focus of subacute infarction extends to the left frontal cortex. These areas demonstrate normal or fast diffusion and no evidence of hemorrhage. FLAIR images also demonstrate scattered deep periventricular and subcortical white matter hyperintensity suggesting chronic small vessel ischemia. The MRA demonstrates severe narrowing of the supraclinoid segment of the left internal carotid artery with poor filling of the carotid bifurcation and to the M1 segment of the left middle cerebral artery. The A-1 segment of the left anterior cerebral artery appears patent on the T2 weighted images, but poorly visualized on the MRA examinations, perhaps a consequence of slow flow. The vertebral arteries are patent bilaterally. The origins of the great vessels appear normal. IMPRESSION: Subacute watershed distribution infarction in the left hemisphere. Severe left internal carotid artery stenosis in its supraclinoid segment extending to the bifurcation. No evidence of stenosis or occlusion in the neck. No evidence of internal carotid artery stenosis by NASCET criteria. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: STUTTERING Diagnosed with CEREBRAL ART OCCLUS W/INFARCT temperature: 97.0 heartrate: 108.0 resprate: 18.0 o2sat: 97.0 sbp: 166.0 dbp: 109.0 level of pain: 0 level of acuity: 3.0

Dear ___, You were hospitalized due to symptoms of stuttering speech resulting from an ACUTE ISCHEMIC STROKE on the left side of your brain whcih accounts for your speech hesitancy. In a stroke, a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - Narrowing of your internal carotid artery on the left (an artery which supplies blood to your brain) whcih we saw on the vessel MRA imaging. We also requested an echocardiogram which was normal to look for any cardiac contribution for your stroke. Your goal blodo pressure should be a systolic 120-140 given the narrowing in your carotid artery. We have prescribed outpatient speech therapy for you. We are changing your medications as follows: - ADDED aspirin 81mg daily to reduce your stroke risk - ADDED clopidogrel 75mg daily to reduce your stroke risk - ADDED atorvastatin 40mg daily to lower your cholesterol - You may RESTART your cellcept, and continue on your prednisone Please take your other medications as prescribed. As your symptoms were determined to be secondary to your stroke and not to your cellcept, we have spoken to your ophthalmologist, Dr. ___ we have agreed that you should RESTART your cellcept at the same dose that you were on before. You should also continue on your prednisone. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / Celebrex / Motrin / entecavir Attending: ___. Chief Complaint: weakness, mumbled speech Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of left parietal glioblastoma s/p avastin last ___, CVA with baseline right-sided weakness presents with confusion, unintelligible mumbling, and worsening R weakness for the past 2 weeks. Per his son who is at the bedside (also HCP) He has not had diarrhea, constipation, dysuria, cough, fever, or any loss of consciousness however for the past two weeks he has been uttering confused mumbling which is much worse than his baseline though he does have confusion and word finding difficulty since his cancer diagnosis. The patient lives with his daughter, who manages his medications. His son here now does not know the home medications at this time. Regarding his GBM, he completed chemoradiation, and started cyclic temozolomide, but progressed clinically and radiologically and started bevacizumab as above. He has not complained of chest pain, dyspnea, or pain at all. ED COURSE: T 98.0 HR 74 BP 136/82 RR 16 97%RA. UA reassuring. Labs reassuring (bun/cr ___ of note) glucose 93. LFTs reassuring. WBC 14 with 56% pmns. Hct 44, plts 234. BNP 28. Pt was give n1L NS. CXR no pneumonia. CT head without acute process, known left temporal mass similar hypodensity in distribution compared to MRI from ___. Cspine CT showed no acute traumatic injury. At the time of my interview the patient appears calm and comfortable but mutters unintelligibly answers to questions. He does follow some commands however and is clearly alert and tracking with his eyes. Otherwise ROS unable to be obtained. Past Medical History: PAST ONCOLOGIC HISTORY: TREATMENT HISTORY: ___ N/V started ___ Brain MRI showed left temporal mass ___ Biopsy by Dr. ___: glioblastoma ___ Partial resection by Dr. ___: glioblastoma ___ - ___ IMRT/TMZ 30x2 Gy by Dr. ___ ___ Brain MRI shows progression ___ C1 TMZ ___ C2 TMZ ___ Admission with decline and failure to thrive ___ Brain MRI shows progression ___ C3 TMZ ___ C1 Bevacizumab ___ Brain MRI showed mixed response ___ C2 Bevacizumab ___ C4 TMZ ___ C3 Bevacizumab ___ Admission after a fall ___ Right zoster ophtalmicus ___ Brain MRI stable ___ C5 TMZ ___ C4 Bevacizumab ___ C6 TMZ ___ C5 Bevacizumab ___ C7 TMZ ___ Brain MRI showed progression ___ C6 Bevacizumab ___ C8 TMZ ___ C7 Bevacizumab ___ C9 TMZ ___ C8 Bevacizumab ___ C9 Bevacizumab ___ C10 TMZ ___ Brain MRI showed progression ___ C10 Bevacizumab ___ C11 Bevacizumab ___ C11 TMZ ___ C12 Bevacizumab PAST MEDICAL HISTORY: 1. Left temporal glioblastoma 2. Dural AV fistula, bifrontal craniotomy with microsurgical obliteration ___ 3. Chronic headaches 4. Hepatitis B 5. Arthritis, right knee 6. Hypertension 7. Herpes zoster ophthalmicus, right Social History: ___ Family History: He has four healthy children. He has six healthy siblings. His mother died at ___ in a car accident and his father died at ___ with a brain tumor. Physical Exam: Admission Physical ==================== VITAL SIGNS: 98.0 162/93 67 18 96%RA General: NAD, calm, appears comfortable, very alert and awake HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB but shallow inspirations not clearly following deep breathing commands GI: BS+, soft, largely NTND, no masses or hepatosplenomegaly. Mild tenderness to palpation in RLQ but no guarding/rebound LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Mutters unintelligibly (per son who speaks ___ when asked questions. DOes follow some commands and tracks spontaneously with eyes, lifts his arms in the air when asked to do so in ___ and motion is mimicked for him. Right side clearly weaker, per son this is chronic. RLE and RUE with ___ strength and left extremities with ___ strength. PERRLA. Discharge Physical =================== 98.3 PO124 / 77 L Lying 74 1897 RA General: Comfortable, following basic commands 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: Awake, unable to assess orientation, 2+/5 strength on right, 3+/5 distally, 2+/5 more proximally, 4+/5 strength on left Pertinent Results: Admission Labs: ================ ___ 07:00PM BLOOD WBC-14.1* RBC-6.34* Hgb-13.9 Hct-44.3 MCV-70* MCH-21.9* MCHC-31.4* RDW-18.2* RDWSD-40.5 Plt ___ ___ 07:00PM BLOOD Neuts-56.6 ___ Monos-10.3 Eos-7.0 Baso-0.9 Im ___ AbsNeut-7.96* AbsLymp-3.48 AbsMono-1.45* AbsEos-0.99* AbsBaso-0.12* ___ 07:00PM BLOOD ___ PTT-31.5 ___ ___ 07:00PM BLOOD Glucose-93 UreaN-23* Creat-1.2 Na-137 K-3.9 Cl-98 HCO3-26 AnGap-17 ___ 07:00PM BLOOD ALT-30 AST-25 AlkPhos-72 TotBili-0.4 ___ 07:00PM BLOOD Albumin-4.4 Calcium-9.0 Phos-3.9 Mg-2.7* Discharge Labs: ================ ___ 05:00PM BLOOD WBC-11.6* RBC-6.51* Hgb-14.3 Hct-44.9 MCV-69* MCH-22.0* MCHC-31.8* RDW-17.6* RDWSD-39.4 Plt ___ ___ 05:00PM BLOOD Glucose-111* UreaN-23* Creat-1.2 Na-140 K-3.7 Cl-104 HCO3-20* AnGap-20 ___ 05:00PM BLOOD ALT-31 AST-25 AlkPhos-77 TotBili-0.4 ___ 05:00PM BLOOD Calcium-9.4 Phos-4.8* Mg-2.2 Micro: ======== Urine culture ___: negative Blood cultures ___: NGTD Imaging: ========== MRI Head w/ and w/o contrast ___: 1. Study is mildly degraded by motion. 2. Findings concerning for interval progression of ___ known left temporal GBM, as described. 3. Interval progression of left parietal occipital lobe parenchymal signal intensity abnormalities, as described, concerning for tumor progression. 4. Left posterior limb of the internal capsule acute infarction versus tumor infiltration. 5. Interval progression of bilateral left greater than right white matter signal abnormality, concerning for tumor infiltration and/or post treatment changes. CT head w/o contrast ___: 1. No acute intracranial abnormality. 2. Known left temporal mass with white matter hypodensity similar in distribution compared FLAIR signal abnormalities on MR from ___. CT Cspine w/o contrast ___: 1. Mild anterolisthesis of the C2-C3 vertebral levels is possibly degenerative in etiology, although difficult to definitively conclude given the absence of prior studies. 2. Mild degenerative changes in the cervical spine with mild-to-moderate multilevel spinal canal and mild neural foraminal stenosis, as described in detail above. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H 2. Labetalol 400 mg PO TID 3. Pantoprazole 40 mg PO Q24H 4. Senna 17.2 mg PO DAILY 5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 7. Docusate Sodium 100 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY 9. Simethicone 40-80 mg PO QID:PRN abdominal bloating 10. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID 11. Entecavir 0.5 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN Pain - Moderate Discharge Medications: 1. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID 2. Ondansetron 8 mg PO DAILY Duration: 5 Days Take prior to chemotherapy 3. temozolomide 400 mg oral DAILY Duration: 5 Days 4. Topiramate (Topamax) 50 mg PO Q12H RX *topiramate 50 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 5. Labetalol 200 mg PO TID RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 6. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 8. Docusate Sodium 100 mg PO BID 9. Entecavir 0.5 mg PO DAILY 10. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN Pain - Moderate 11. Pantoprazole 40 mg PO Q24H 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 17.2 mg PO DAILY 14. Simethicone 40-80 mg PO QID:PRN abdominal bloating 15. Timolol Maleate 0.5% 1 DROP BOTH EYES BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Glioblastoma Multiforme with progress Right sided Weakness Dysarthria 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: CT HEAD W/O CONTRAST INDICATION: History: ___ with weakness, intracranial mass// eval for intracranial injury 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 16.0 s, 17.4 cm; CTDIvol = 46.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: MR brain from ___. FINDINGS: The patient is status post left temporal craniotomy and frontal craniotomy with expected postsurgical changes. Again seen is a partially resected Mass with calcification in the left temporal fossa. Extensive edema involving the right frontal lobe and left frontal and temporal lobes is similar in distribution compared 2 MR from ___. There is ex vacuo dilation of the left lateral ventricle. Bifrontal encephalomalacia is noted. No new hypodensity suggest acute infarct or evidence of hemorrhage is identified. Ventricles and sulci are enlarged, similar in caliber compared prior exam. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Known left temporal mass with white matter hypodensity similar in distribution compared FLAIR signal abnormalities on MR from ___. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with weakness// eval for pneumonia COMPARISON: Prior exam is dated ___. FINDINGS: AP upright and lateral views of the chest provided. Volumes are low limiting assessment. There is hilar congestion with mild interstitial pulmonary edema. No convincing evidence for pneumonia. No large effusion pneumothorax. Cardiomediastinal silhouette is stable. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Hilar congestion with mild interstitial pulmonary edema. No convincing evidence for pneumonia. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with fall, R-sided weakness// evall for c-spine fx TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 858 mGy-cm. COMPARISON: None. FINDINGS: There is mild anterolisthesis of the C2-C3, possibly degenerative in etiology, although difficult to definitively conclude given the absence of prior studies. No fractures are identified. There is mild-to-moderate multilevel spinal canal narrowing due to osteophyte formation and posterior disc bulge, notably at the C4-C5 and C5-C6 vertebral levels. Mild degenerative changes are seen in the cervical spine, particularly at the C5-C6 level. Mild neural foraminal stenosis noted at the C5-C6 level bilaterally. There is no prevertebral soft tissue swelling. The thyroid gland appears normal. The lung apices appear clear. IMPRESSION: 1. Mild anterolisthesis of the C2-C3 vertebral levels is possibly degenerative in etiology, although difficult to definitively conclude given the absence of prior studies. 2. Mild degenerative changes in the cervical spine with mild-to-moderate multilevel spinal canal and mild neural foraminal stenosis, as described in detail above. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with glioblastoma status post surgical resection in ___ and chemoradiation, now with worsening weakness and falls. Evaluate for disease progression, edema or ischemic 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: ___ contrast brain MRI. ___ noncontrast head CT. FINDINGS: Study is mildly degraded by motion. There are postsurgical changes from left temporal craniotomy. Again noted is a irregular, heterogeneously enhancing left temporal mass which, along its maximal ___, measures 8.0 x 4.7 cm (700:71), larger as compared to MRI head ___, previously measuring 7.4 x 5.0 cm. Furthermore, in the anterior aspect of this mass, there is a more homogeneously enhancing solid component measuring 2.3 x 2.2 cm (700:71), new since ___. There is also associated dural thickening and enhancement. There are associated diffusion abnormalities in the posterior aspect of this mass (402:11) Along the periventricular white matter in the left parietal and occipital lobes there is subtle ill-defined rim enhancement measuring approximately 1.9 x 1.6 cm (700:93) with associated restricted diffusion (402:17), significantly increased in size compared to ___. Centered in the left thalamus and likely involving the posterior limb of the internal capsule, there is a subtle irregular rim enhancing area measuring 1.7 x 1.4 cm (700:95) with associated restricted diffusion (402:18) and mild surrounding vasogenic edema, new since ___. These favors tumor spread versus less likely acute infarction. In the posterior limb of the left internal capsule, there is a focus of enhancement measuring approximately 4 x 3 mm (700:89) with associated restricted diffusion(402:16), new since ___, which could represent acute infarction versus tumor spread. There are small foci of susceptibility on gradient echo sequences in the area of the dominant left temporal mass (6:7), some of which are new as compared to ___ and likely represent small areas of hemorrhage. Diffuse vasogenic edema involving the left cerebral cortex and to a smaller extent the right cerebral cortex is mildly increased since ___. Ex vacuo change of left lateral ventricle is unchanged. The major intracranial vessels signal is normal. However the M1 and M2 portions of the left middle cerebral artery course through the dominant left temporal mass, minimally changed from ___. There is mild mucosal thickening of the bilateral ethmoid air cells. The remaining paranasal sinuses are patent. The orbit is normal. IMPRESSION: 1. Study is mildly degraded by motion. 2. Findings concerning for interval progression of patient's known left temporal GBM, as described. 3. Interval progression of left parietal occipital lobe parenchymal signal intensity abnormalities, as described, concerning for tumor progression. 4. Left posterior limb of the internal capsule acute infarction versus tumor infiltration. 5. Interval progression of bilateral left greater than right white matter signal abnormality, concerning for tumor infiltration and/or post treatment changes. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ on the telephone on ___ at 3:19 pm, 10 minutes after discovery of the findings. Gender: M Race: ASIAN - SOUTH EAST ASIAN Arrive by WALK IN Chief complaint: Abnormal CT, R Weakness Diagnosed with Weakness temperature: 98.0 heartrate: 74.0 resprate: 16.0 o2sat: 97.0 sbp: 136.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital with worsening weakness and impaired speech. You underwent an MRI which showed progression of your glioblastoma multiforme. This is the likely cause of your worsening weakness and difficulty speaking. You were seen by Dr. ___ neuro-oncologist, and the decision was made to trial an additional cycle of chemotherapy at a higher dose and rediscuss management if this is not successful at treating your symptoms and tumor. While you were here, you were restarted on your Topamax to prevent seizures. You should continue to take this twice per day as prescribed. Additionally, due to normal blood pressures while you were here, your labetalol was decreased. Please only take one tablet 3 times per day (instead of 2 tablets). In discussion with your family and yourself, you felt comfortable with discharge to home with home services as well as 24 hour care from your family. We have arranged to have a visiting nurse and physical therapy see you home to help manage your medications and rebuild your strength. Please continue to take all of your medications as prescribed. Dr. ___ has arranged for the Temozolomide and zofran to be sent to your house to be restarted at a higher dose per his instructions. It was a pleasure taking care of you, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Left ___ toe dry gangrene Major Surgical or Invasive Procedure: ___: LLE angiogram, Stenting L SFA, angioplasty of BK pop & AT origin History of Present Illness: ___ with history of IDDM s/p renal transplant PVD with tissue loss s/p R femoral-AT bypass graft ___ here with a non healing left foot ulcer. The patient is non ambulatory and her husband does most of her wound care as she is legally blind, additionally she has neuropathy so she is dependent on him for her wound care. She was recently admitted and treated with IV antibiotics for her left toe ulcer with improvement. Plan was for inpatient angiogram, but this was deferred due to patient preference and she was discharged home on oral antibiotics with plans for outpatient follow-up and scheduled angiogram. She presents today with worsening of her left toe ulcer in the setting of not taking her antibiotics as prescribed due to associated nausea. Her daughter reports that she noted some purulent discharge from the toe beginning yesterday so she decided to present to the ED for evaluation. She denies any fevers, chills, chest pain, or shortness of breath. Past Medical History: MHx: T2DM, neuropathy, PVD kidney transplant ___ ___ h/o PVD, ___ fem-AT right side c/b ?drop from OR table causing disruption of bypass graft SHx: ___ Family History: unremarkable family history Physical Exam: Vitals: AVSS, see flowsheets GEN: NAD, A&Ox3 CV: RRR PULM: no respiratory distress ABD: Obese, soft, non-tender, non-distended EXT: UE edematous b/l RLE: d/-/d/d, Right bypass scar well healed, LLE: p/-/d/d, incision is c/d/I with sutures and steri-strips in place Pertinent Results: =============== Pertinent labs =============== ___ 06:14AM BLOOD Glucose-89 UreaN-14 Creat-1.5* Na-138 K-4.8 Cl-101 HCO3-25 AnGap-12 ___ 06:54AM BLOOD Glucose-69* UreaN-17 Creat-1.9* Na-125* K-4.6 Cl-89* HCO3-23 AnGap-13 ___ 04:56AM BLOOD TSH-4.4* ___ 04:56AM BLOOD T4-7.4 T3-51* ___ 04:16PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 04:16PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM* ___ 04:16PM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-1 ___ 04:16PM URINE CastHy-28* ___ 04:16PM URINE Hours-RANDOM Na-20 Cl-28 ___ 04:16PM URINE Osmolal-289 ___ 06:56AM BLOOD WBC-9.1 RBC-3.12* Hgb-8.3* Hct-27.0* MCV-87 MCH-26.6 MCHC-30.7* RDW-18.6* RDWSD-57.9* Plt ___ ___ 05:48AM BLOOD WBC-10.1* RBC-3.08* Hgb-8.1* Hct-26.5* MCV-86 MCH-26.3 MCHC-30.6* RDW-18.4* RDWSD-57.2* Plt ___ ___ 12:56PM BLOOD WBC-8.0 RBC-3.14* Hgb-8.3* Hct-26.7* MCV-85 MCH-26.4 MCHC-31.1* RDW-18.4* RDWSD-56.5* Plt ___ ___ 05:19AM BLOOD WBC-8.2 RBC-3.12* Hgb-8.4* Hct-26.4* MCV-85 MCH-26.9 MCHC-31.8* RDW-18.2* RDWSD-55.7* Plt ___ ___ 06:14AM BLOOD WBC-7.9 RBC-3.08* Hgb-8.1* Hct-25.8* MCV-84 MCH-26.3 MCHC-31.4* RDW-17.9* RDWSD-54.4* Plt ___ ___ 04:56AM BLOOD WBC-8.1 RBC-3.25* Hgb-8.6* Hct-26.9* MCV-83 MCH-26.5 MCHC-32.0 RDW-17.5* RDWSD-52.4* Plt ___ ___ 12:15PM BLOOD Neuts-84.9* Lymphs-4.2* Monos-9.5 Eos-0.6* Baso-0.2 Im ___ AbsNeut-9.29* AbsLymp-0.46* AbsMono-1.04* AbsEos-0.07 AbsBaso-0.02 ___ 05:50PM BLOOD Neuts-79.0* Lymphs-7.6* Monos-10.5 Eos-1.7 Baso-0.4 Im ___ AbsNeut-7.91* AbsLymp-0.76* AbsMono-1.05* AbsEos-0.17 AbsBaso-0.04 ___ 06:56AM BLOOD ___ PTT-29.5 ___ ___ 05:48AM BLOOD ___ PTT-27.7 ___ ___ 12:56PM BLOOD ___ PTT-27.7 ___ ___ 06:56AM BLOOD Glucose-127* UreaN-15 Creat-1.6* Na-139 K-4.7 Cl-100 HCO3-29 AnGap-10 ___ 05:48AM BLOOD Glucose-41* UreaN-13 Creat-1.5* Na-141 K-4.7 Cl-101 HCO3-27 AnGap-13 ___ 12:56PM BLOOD Glucose-124* UreaN-13 Creat-1.6* Na-137 K-4.4 Cl-99 HCO3-28 AnGap-10 ___ 06:30AM BLOOD Glucose-118* UreaN-16 Creat-1.5* Na-134* K-5.0 Cl-96 HCO3-26 AnGap-12 ___ 03:25PM BLOOD Glucose-150* UreaN-17 Creat-1.6* Na-128* K-4.7 Cl-92* HCO3-25 AnGap-11 =============== Studies =============== Right upper extremity US (___): IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. No residual thrombus identified within the right internal jugular vein. CXR (___): IMPRESSION: In comparison with the study of ___, the cardiomediastinal silhouette is stable. There is increased indistinctness of engorged pulmonary markings, consistent with worsening pulmonary vascular congestion. Left pleural effusion is seen on the lateral view. =============== Microbiology =============== C. diff toxin PCR (___): NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Carvedilol 25 mg PO BID 5. CloNIDine 0.3 mg PO BID 6. Furosemide 40 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Mycophenolate Mofetil 500 mg PO BID 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Tacrolimus 1 mg PO Q12H 11. albuterol sulfate 90 mcg inhalation Q4H:PRN shortness of breath/wheezing 12. Clindamycin 600 mg PO ONCE:PRN prior to dental procedures 13. Ciprofloxacin HCl 500 mg PO Q12H 14. MetroNIDAZOLE 500 mg PO Q8H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN Constipation 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 6. MetroNIDAZOLE 500 mg PO Q8H 7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*5 Tablet Refills:*0 8. Pantoprazole 40 mg PO Q24H 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 10. Vitamin D 1000 UNIT PO DAILY 11. albuterol sulfate 90 mcg inhalation Q4H:PRN shortness of breath/wheezing 12. amLODIPine 5 mg PO DAILY 13. Aspirin 325 mg PO DAILY 14. Calcitriol 0.25 mcg PO DAILY 15. Carvedilol 25 mg PO BID 16. Clindamycin 600 mg PO ONCE:PRN prior to dental procedures 17. CloNIDine 0.3 mg PO BID 18. Furosemide 40 mg PO DAILY 19. Glargine 14 Units Breakfast Glargine 8 Units Bedtime Insulin SC Sliding Scale using REG Insulin 20. Levothyroxine Sodium 50 mcg PO DAILY 21. Mycophenolate Mofetil 500 mg PO BID 22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 23. Tacrolimus 1 mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Peripheral vascular disease, dry gangrene of left ___ toe 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 AP and lateral INDICATION: ___ with pitting edema// volume status TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: Lungs are well aerated. Streaky bibasilar opacities likely represent atelectasis. No focal consolidations are seen. Cardiomediastinal and hilar silhouettes are unchanged. No pulmonary edema. No pneumothorax. IMPRESSION: No acute intrathoracic process. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ with necrotic left great toe, swelling/edema of calf// dvt TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Ultrasound dated ___. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. The posterior tibial and peroneal veins are not well visualized. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. Subcutaneous soft tissue edema is noted over the left calf. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Subcutaneous soft tissue edema is noted over the left calf. Radiology Report INDICATION: ___ year old woman with pvd w/nausea// ileus? TECHNIQUE: PORTABLE SUPINE RADIOGRAPH OF THE ABDOMEN. COMPARISON: CT abdomen pelvis dated ___ and abdominal radiograph dated ___. FINDINGS: There is a nonspecific bowel gas pattern with air-filled loops of bowel in the left mid abdomen. Air is seen within the colon. Assessment for free intraperitoneal air is limited on supine radiographs. If there is clinical concern for pneumoperitoneum, advise upright or left lateral decubitus radiograph, or cross-sectional imaging. Degenerative changes are seen in the low lumbar spine and lumbosacral junction. Vascular calcifications are noted. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Nonspecific bowel gas pattern with air-filled loops of bowel in the left mid abdomen. If further evaluation is required, CT would have to be performed. Radiology Report INDICATION: ___ year old woman with ESRD s/p DDRT, PVD s/p R femoral-AT bypass graft w/ chronic ulcer L great toe with cellulitis and ischemic changes.// Please eval for effusion, PNA TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There is no evidence of focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiac silhouette is mildly enlarged but unchanged. Calcification of the aortic arch is again noted. IMPRESSION: No radiographic evidence of acute cardiopulmonary disease. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with new line // new right PICC 48 cm ___ ___ Contact name: ___: ___ new right PICC 48 cm ___ ___ IMPRESSION: Go there to chest radiographs since ___ most recently ___. Although mild to moderate cardiomegaly and pulmonary vascular congestion have not progressed, there is more mild pulmonary edema in the left lung today than there was on ___. Small left pleural effusion is also likely. No right pleural effusion. No pneumothorax. Right PIC line ends close to the superior cavoatrial junction. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with stroke stat// Stroke stat TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain window. DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 842 mGy-cm. COMPARISON: None available. FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Prominent ventricles and sulci compatible with age-related involutional changes. Periventricular white matter hypoattenuation is nonspecific but could represent chronic small vessel ischemic disease. A hypodensity is noted in the left basal ganglia likely reflecting a chronic lacunar infarct. There is mucosal thickening in the bilateral ethmoid air cells. Remaining paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. There are severe atherosclerotic calcifications of the bilateral carotid siphons. IMPRESSION: No acute intracranial abnormality. Please note that MRI is more sensitive for the detection of acute infarction. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old woman with c/f stroke// c/f stroke TECHNIQUE: Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion 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) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7 mGy-cm. 2) Stationary Acquisition 2.5 s, 1.0 cm; CTDIvol = 18.7 mGy (Head) DLP = 18.7 mGy-cm. 3) Spiral Acquisition 11.2 s, 43.2 cm; CTDIvol = 38.8 mGy (Head) DLP = 1,626.0 mGy-cm. Total DLP (Head) = 1,674 mGy-cm. COMPARISON: None. FINDINGS: The study is partially degraded due to motion artifact. CTA HEAD: There is significantly limited evaluation of the intracranial vessels due to motion artifact. The vessels of the circle of ___ and their principal intracranial branches appear grossly normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. A partially calcified right posterior parietal extra-axial lesion (series 6, image 419) is favored to represent a small calcified meningioma or a dural plaque. The CTA NECK: There are atherosclerotic calcifications at the origins of the great vessels. Calcified atheromatous plaque at the origin of the right ICA results in up to 60% stenosis. The carotid and vertebral arteries and their major branches appear otherwise normal with no evidence of stenosis or occlusion. There is no evidence of left internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs demonstrate interlobular septal thickening, small bilateral pleural effusions and passive atelectasis. The thyroid gland contains multiple subcentimeter hypoattenuating thyroid nodules and a relatively prominent left thyroid lobe. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Markedly limited study due to motion artifact. 2. Allowing for this, there is no gross vascular abnormality of the head and neck. 3. Calcified atheromatous plaque resulting in up to 60% stenosis of the right ICA. No evidence of left internal carotid stenosis by NASCET criteria. 4. Small partially calcified right posterior parietal extra-axial lesion is favored to represent a partially calcified meningioma or a dural plaque. 5. Evidence of mild pulmonary edema with associated small pleural effusions and passive atelectasis. 6. Multiple subcentimeter thyroid nodules. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or ___. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with ESRD s/p DDRT, PVD w/ gangrene, concern for pulmonary edema/effusion// Please eval for pulm edema/effusion, other interval change Please eval for pulm edema/effusion, other interval change IMPRESSION: Comparison to ___. Slightly increasing small left pleural effusion, with subsequent left basal parenchymal opacity with air bronchograms. Mild pulmonary edema persists. Moderate cardiomegaly. No pneumothorax. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ year old woman with worsening RUE swelling// Please eval for DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian vein. The right internal jugular vein is noncompressible and contains echogenic internal debris consistent with deep vein thrombosis. Venous flow is demonstrated on color and spectral Doppler imaging, this is consistent with nonocclusive DVT. The right axillary veins are patent, show normal color flow and compressibility. The right brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: Nonocclusive deep vein thrombosis of the right internal jugular vein. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, on the telephone on ___ at 3:24 pm, 60 minutes after discovery of the findings. Radiology Report INDICATION: ___ PMH ESRD s/p DDRT, PVD s/p R femoral-AT bypass graft w/ chronic ulcer L great toe with cellulitis and ischemic changes.// abi/pvr s/p intervention, interval change TECHNIQUE: Non-invasive evaluation of the arterial system in the lower extremities was performed with Doppler signal recording, pulse volume recordings and segmental limb pressure measurements. COMPARISON: ___ noninvasive arterial exam. FINDINGS: On the right side, monophasic doppler waveforms are seen in the right femoral, popliteal, and dorsalis pedis arteries. The right posterior tibial and dorsalis pedis arteries are noncompressible. A posterior tibial waveform was unable to be obtained. The right ABI was unable to be calculated. Right TBI of 0.27. On the left side, monophasic doppler waveforms are seen in the left femoral, popliteal, and dorsalis pedis arteries. A posterior tibial waveform was unable to be obtained. The left ABI was 0.73. Previously, the ABI was 0.15 on ___. IMPRESSION: 1. Improvement in left ABI, which is now 0.73 (previously 0.15 on ___. However, there are persistent monophasic waveforms seen within the left popliteal, and dorsalis pedis arteries, compatible with moderate arterial insufficiency. 2. Moderate to severe right lower extremity arterial insufficiency, with noncompressible posterior tibial and dorsalis pedis arteries. Right ABI unable to be calculated. Right TBI of 0.27. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ PMH ESRD s/p DDRT, PVD s/p R femoral-AT bypass graft w/ chronic ulcer L great toe with cellulitis and ischemic changes now endorsing SOB. Evaluate for interval change. TECHNIQUE: Frontal view of the chest. COMPARISON: Chest x-ray ___ through ___. FINDINGS: Stable, mild to moderate cardiac enlargement. Stable, small left pleural effusion. Stable, left lower lobe opacity, which could be atelectasis or pneumonia. Unchanged mild pulmonary edema. No pneumothorax. A right PICC terminates in the lower SVC. IMPRESSION: Unchanged mild pulmonary edema. Unchanged small left pleural effusion. Unchanged left lower lobe opacity, which could be atelectasis or pneumonia. Stable, mild to moderate cardiomegaly. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with asthma and PVD s/p renal transplant with wheezing and dry crackles on exam// evaluate for pulmonary edema IMPRESSION: In comparison with the study of ___, the cardiomediastinal silhouette is stable. There is increased indistinctness of engorged pulmonary markings, consistent with worsening pulmonary vascular congestion. Left pleural effusion is seen on the lateral view. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US INDICATION: ___ year old woman with nonocclusive deep vein thrombosis of the right internal jugular vein// please evaluate for progression of DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: Right arm ultrasound ___ FINDINGS: There is normal flow with respiratory variation in the subclavian veins bilaterally. The right internal jugular, axillary and brachial veins are patent, show normal color flow and compressibility. The right basilic and cephalic veins are patent. IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. No residual thrombus identified within the right internal jugular vein. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Wound eval Diagnosed with Cellulitis of left toe temperature: 97.5 heartrate: 62.0 resprate: 18.0 o2sat: 100.0 sbp: 183.0 dbp: 55.0 level of pain: 0 level of acuity: 3.0

Dear ___, You were admitted to ___ and underwent an angiogram and a left transmetatarsal amputation to remove an infected portion of your foot. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: MEDICATIONS: • Take your medications as prescribed in your medication list and continue to schedule close follow-up with your kidney transplant team as well as cardiologists. • Take pain medication (Tylenol and then oxycodone if needed) • Remember that narcotic pain medication can be constipating. Increase your fiber intake and take a stool softener if needed ACTIVITY: • You should be non weight bearing on the side of the transmetatarsal amputation for ___ weeks. • You should keep this amputation site elevated when ever possible. • You may use the heel of your effected foot for transfer and pivots, but it is best to try to avoid this • No driving until cleared by your Surgeon. • No heavy lifting greater than 20 pounds for the next ___ days. BATHING/SHOWERING: • You may shower when you get home • No tub baths or pools / do not soak your foot for 4 weeks from your date of surgery WOUND CARE: • Sutures / Staples may have been removed before discharge. If they are not, an appointment will be made for you to return for staple removal. • When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. CAUTIONS: • If you smoke, please make every attempt to quit. Your primary care physician can help with this. Smoking causes narrowing of your blood vessels which in turn decreases circulation. DIET: • Low fat, low cholesterol / if you are diabetic – follow your dietary restrictions as before CALL THE OFFICE FOR: ___ • Bleeding, redness of, or drainage from your foot wound • New pain, numbness or discoloration of the skin on the effected foot • Fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: morphine Attending: ___. Chief Complaint: left arm weakness s/p MVC History of Present Illness: This is a ___ year-old male presenting with left arm weakness and pain s/p MVC several hours ago. The patient reports that he was sideswiped by another car on the highway, then subsequently rear-ended another car at high speed. Pt reports that he was unrestrained. Per EMS, the patient was initially pulseless on scene with the police but had ROSC and was alert and oriented at the time of their arrival shortly afterward. The patient was subsequently seen at ___ ED where he had CT of the head (negative), torso (no acute finding), and c-spine, which demonstrated severe spinal stenosis in the upper cervical spine, relating to large posterior vertebral osteophyte and ligament ossification. On initial presentation to the OSH ED, the patient reported that he was unable to move his arms or legs directly after the accident, but reported full recovery of strength and sensation in his bilateral lower extremities prior to the time of transfer to ___. On presentation, the patient states that he now feels that he has full sensation in bilateral lower extremities, and the right upper extremity. He reports shooting pains from his left shoulder to his left hand, and reports weakness in the left hand and arm. He denies bowel or bladder incontinence. Past Medical History: HTN Social History: ___ Family History: NC Physical Exam: AFVSS General: resting comfortably in bed with C-collar Mental Status: Spine: (tenderness) No bruising or swelling appreciated. skin clean, dry and intact. mild ttp over c-spine @ C4-7, no step-off or deformity Vascular (R/L) Radial 2+/2+ DP 2+/2+ Sensory UE (R/L) C5 (Ax) nL/nL C6 (MC) nL/nL C7 (Mid finger) nL/nL C8 (MACN) nL/nL T1 (MBCN) nL/nL T2-L2 Trunk nL/nL Sensory ___ (R/L) L2(Groin) nL/nL L3(Leg) nL/nL L4(Knee) nL/nL L5(Grt Toe) nL/nL S1(Sm toe) nL/nL S2(Post Thigh) nL/nL Motor UE (R/L) Deltoid(C5)Ax nL/ ___ Biceps(C6)MC nL/ ___ WE(C6)R nL/ ___ Triceps(C7)R nL/nL WF(C7)M nL/ ___ FF(C8)AIN nL/ ___ Fing Abd(T1)U nL/ ___ Motor ___ (R/L) Add(L2) nL/nL Quad(L3) nL/nL Ant Tib(L4/DP) nL/nL ___ nL/nL Peroneal(S1/SP) nL/nL ___ nL/nL Reflexes (R/L) Biceps(C4-5) 1+/1+ BR(C5-6) 1+/1+ Triceps (C6-7) 1+/1+ Patellar (L3-4) 1+/1+ Achilles(L5-S1) 1+/1+ Straight Leg Raise Test: normal ___: normal Babinski: appropriate flexor plantar response Clonus: none Perianal sensation: intact, good rectal tone Estimated Level of Cooperation: Excellent Estimated Reliability of Exam: Excellent Pertinent Results: ___ 05:00PM GLUCOSE-134* UREA N-16 CREAT-0.9 SODIUM-141 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-18 ___ 05:00PM ETHANOL-75* ___ 04:20PM WBC-10.5 RBC-4.81 HGB-15.1 HCT-46.3 MCV-96 MCH-31.4 MCHC-32.6 RDW-13.7 Radiology Report HISTORY: Injury. TECHNIQUE: Single supine AP view of the chest. COMPARISON: None. FINDINGS: Underlying trauma board and other external artifact partially obscure the view. Given this, no focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No displaced fracture is seen. IMPRESSION: No acute intrathoracic process seen. Radiology Report HISTORY: Spinal pain after motor vehicle accident, left arm weakness, evaluate for cord contusion. TECHNIQUE: Multiplanar multisequence MRI of the cervical, thoracic, and lumbar spine was obtained without IV contrast as per department protocol. COMPARISON: No prior. FINDINGS: Cervical spine: There is mild increased STIR signal in the prevertebral soft tissues from C2-C4 level and to a lesser extent from C4-C7 levels suggesting ligamentous injury. There is high T2 signal within the C5-C6 disk suspicious for disc injury. There is high T2, high STIR, and isointense T1 signal in the anterior epidural space along the posterior margin of the C2 vertebral body extending inferiorly to C4 suspicious for epidural hematoma. There are superimposed broad-based disc bulges at C2-C3 and C3-C4 levels. There is abnormal signal within the cord from C2-C3 and C3-C4 suggesting compression/contusion due to a combination of diffuse disc bulges and epidural hematoma. At C5-C6, there is a left paracentral disc protrusion deforming the cord without abnormal signal within the cord. At C6-C7, there is a broad-based disc protrusion resulting in moderate bilateral neural foraminal narrowing. There is deformity of the anterior thecal sac without evidence of deformity of the cord. The paraspinal soft tissues are unremarkable. The vertebral body heights are within normal limits. Thoracic spine: There is no evidence of abnormal STIR signal. The vertebral body heights are unremarkable. The disc spaces are normal. The bone marrow signal is unremarkable. At T2-T3, there is an small disc bulge without evidence of spinal canal or neural foraminal narrowing. Otherwise, the spinal canal is preserved throughout the cervical spine. There is no evidence of abnormal cord signal. At T11-T12, there is diffuse ligamentum flavum thickening indenting the thecal sac posteriorly without deforming the cord. Lumbar spine: The alignment is normal. The bone marrow signal is unremarkable with the exception of a hemangioma within the L2 vertebral body. The vertebral body heights are normal. The conus medullaris terminates at L1 and has normal signal and configuration. At L4-L5 and L5-S1, diffuse disc bulges are noted indenting the thecal sac. There is a left far lateral disc protrusion disc protrusion at at L4-L5. The paraspinal soft tissues are unremarkable. IMPRESSION: 1. Cord contusion/compression at C2-C3 and C3-C4 due to a combination of diffuse disc bulges and epidural hematoma as described. 2. Abnormal STIR signal in the prevertebral soft tissues as described suggesting ligamentous injury. 3. Abnormal T2 hyperintensity in the C5-C6 disc in keeping with disc injury. 4. These findings were discussed with Dr. ___ 12:37 pm, on ___ via phone, and they were aware of all the findings. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: MVC Diagnosed with CENTRAL CORD SYND/C5-C7, MV COLLISION NOS-DRIVER temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

-Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. -Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. -Wound Care (if applicable): Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. -You should resume taking your normal home medications. -You have also been given Additional Medications to control your pain. . Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. -Follow up: oPlease Call the office and make an appointment for 2 weeks if this has not been done already. oAt the 2-week visit we will take baseline x rays and answer any questions. oWe will then see you at 6 weeks from the day of the operation. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine Attending: ___ Chief Complaint: Persistent fevers Major Surgical or Invasive Procedure: None History of Present Illness: PCP: Dr. ___ ___ female with hematomachrosis treated with regular phlebotomy based on blood leves who presents with fever of unknown origin. The patient was in her usual state of good health except for an episode hives the month prior to her sx starting and then she had 3 episodes of high fevers with a MAXIMUM TEMPERATURE of 105 over last 3 weeks. With regards to the episodes of hives, she developed pruritis on the back of her neck. She thought it was a mosquito bite. She then went out to see her neighbor who told her that she had a rash on her skin. She then took prednisone for 5 days after receiving a shot of steroids in urgent care. The next day it resolved. She was admitted to an outside hospital twice. Testing has been negative for infectious source both times. However, in between the 2 hospitalization she was found to have a pneumonia and completed course of antibiotics and 4 days of prednisone. Reviewing her d/c summary from her first admission in ___, she was found to have a small pleural effusion along with atelectasis and thus she was treated with levaquin. Imaging also revealed thickening of the gallbladder with possible fluid accumulation in the gallbladder. This raised the possibility of cholecysititis but the patient did not have sx clinically. A HIDA scan was negative. CT scan also demonstrated diverticulae without diverticulitis. During the admission her bilirubin did increase but then went back down to 1.2. Her LFTS remained elevated at AST/ALT: 93/208 at discharge decreasing from 482/316. Rheumatologic w/u included lupus panel in which a PTT was slightly elevated, and a cardiolipin IgG was slightly elevated at 19 which was indeterminate. She is up to date with mammograms having had one in the last year and she had a colonoscopy within the past ___ years that was WNL per patient. Of note she also received 6 days of prednisone for the pinched nerve in her neck to see if it could control the stinging/pruritis on her arms. The treatment that best helped that in the end was physicial therapy. She recently traveled here from ___ on ___ to attend a college ___ but denies any other travel. She reports that the fever started again today. She was seen at ___ ___ and found to be febrile to 101.4. A chest x-ray (negative)and blood tests were performed. Her lactate was elevated to 3.8. Potassium low at 3.4. LFTS WNL including direct bilirubin. WBC = 4.0 with 93% PMNS. UA negative. HCT = 38.7 with MCV = 106.9. The patient was then transferred to ___. Patient denies any symptoms currently. She denies any chest pain, shortness of breath, rhinorrhea, congestion cough. Denies any headache. She has chronic neck pain and developed back pain when making the bed this am which has occurred before. She denies any weakness, numbness, tingling. She denies any urinary incontinence or retention. She denies any bowel incontinence or retention. She has no history of IV drug use, malignancy, anticoagulation. She denies any sick contacts. She denies ever traveling to ___ or the ___. No sick contact She has had veneers put on two bottom teeth 3 months ago. No spinal injections. No recent surgeries. + 6 lb weight loss + nausea -> emesis today and it occurred before when her fever was elevated. No nausea prior to that. Mild hot flashes since menopause at night but no night sweats. When she has the fever she has flushing on her cheeks. + Rigors when her fevers occurs such that she cannot hold anything in her hands. She felt better after her first admission but after the second admission she never felt better because of fatigue, indigestion. Last endoscopy ___ years ago which demonstrated polyps in her stomach ___ LAB REVIEW LFTS: ALT 316/AST482 with a flat bilirubin Her K trnded down to 3.0 In the ED : triage VS: 3| 99.2| 99| 138/72| 13 |97% Nasal Cannula\ ___ 01:05POAcetaminophen 1000 ___ ___ 01:06POOxycoDONE (Immediate Release) 5 ___ ___ 02:22IVF1000 mL D5NS + 20 mEq Potassium ___ MStarted 150 mL/ No consults called and no imaging performed. ====================================== REVIEW OF SYSTEMS: CONSTITUTIONAL: As per HPI HEENT: [X] All normal RESPIRATORY: [X] All normal CARDIAC: [X] All normal GI: As per HPI- no diarrhea GU: [X] All normal- including no dysuria SKIN: [+] Per hPI MUSCULOSKELETAL: [+] Per HPI NEURO: [X] All normal ENDOCRINE: [X] All normal HEME/LYMPH: [+] chronic easy bruising without bleeding PSYCH: [X] All normal All other systems negative except as noted above Past Medical History: HTN H/o pinched nerve -> itch Hemachromatosis Diverticulsos Glaucoma Social History: ___ Family History: Her father died ___ Body Dementia at ___. He also had a h/o CAD s/p CABG. Her mother had a heart condition and died of old age at ___. Her sister is a breast cancer survivor s/p b/l masectomy Physical Exam: ADMISSION VS: T98.6 P 73 BP 133/78 RR18 SaO2 97% on RA CONS: NAD, comfortable appearing HEENT: ncat anicteric MMM CV: s1s2 rr, soft SEM at ___ BREAST EXAM: Very lumpy breast tissue, difficult to discern a focal mass RESP: b/l ae no w/c/r GI: +bs, soft, + RUQ tenderness without rebound or guarding back:+ tenderness at R parasinal space at L5 GU:no CVaT b/l MSK:no c/c/e 2+pulses SKIN: + ? b/l facial flushing NEURO: face symmetric speech fluent PSYCH: calm, cooperative LAD: no cervical, supraclavicular, axillary, or femoral lymphadenopathy. DISCHARGE VS: T98.6 118/60 ___ GEN: Well appearing female in no distress HEENT: No scleral icterus HEART: RRR, normal S1 S2, no murmurs LUNGS: Clear, no wheezes or rales ABD: Soft, NT ND, normal BS EXT: No edema NEURO: Alert, oriented Pertinent Results: ADMISSION LABS ___ 12:42AM ___ PTT-24.3* ___ ___ 12:14AM COMMENTS-GREEN ___ 12:14AM LACTATE-2.0 ___ 12:05AM GLUCOSE-112* UREA N-8 CREAT-0.7 SODIUM-143 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-22 ANION GAP-20 ___ 12:05AM estGFR-Using this ___ 12:05AM ALT(SGPT)-33 AST(SGOT)-78* ALK PHOS-44 TOT BILI-1.4 ___ 12:05AM LIPASE-21 ___ 12:05AM ALBUMIN-4.1 ___ 12:05AM WBC-8.7 RBC-3.53* HGB-12.8 HCT-37.0 MCV-105* MCH-36.3* MCHC-34.6 RDW-13.5 RDWSD-50.9* ___ 12:05AM NEUTS-95.0* LYMPHS-2.0* MONOS-1.2* EOS-1.2 BASOS-0.3 IM ___ AbsNeut-8.23* AbsLymp-0.17* AbsMono-0.10* AbsEos-0.10 AbsBaso-0.03 ___ 12:05AM PLT COUNT-180 ___ 12:05AM PARST SMR-NEGATIVE ========================================== CT CHEST: Supraclavicular and axillary lymph nodes are not enlarged. Excluding the breasts which require mammography for evaluation, elsewhere in the chest wall there are no soft tissue abnormalities concerning for malignancy or infection. There are no thyroid lesions warranting further imaging evaluation. Atherosclerotic calcification is not apparent head neck vessels or appreciable in the coronary arteries. Aorta and pulmonary arteries and cardiac chambers are normal size. There is no pleural or pericardial abnormality. Prevascular mediastinal lymph nodes are noteworthy for number, but not size. Largest mediastinal nodes are 9 mm, right lower paratracheal station, 12 mm, subcarinal. Hilar nodes are not enlarged. Esophagus is unremarkable. Aside from mild to moderate bibasilar atelectasis, right greater than left, lungs are clear. Tracheobronchial tree is normal to subsegmental levels. There are no bone lesions in the chest cage suspicious for malignancy. IMPRESSION: No evidence of intrathoracic infection. 2 top-normal mediastinal nodes in numerous smaller ones are not not necessarily pathologic. ___ imaging is not indicated. RECOMMENDATION(S): ___ imaging is not indicated. CT ABD/PELVIS: ABDOMEN: HEPATOBILIARY: The liver appears borderline hypodense compared to the spleen. However, the background 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 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. Diverticulosis of the descending and sigmoid colon is noted, without evidence of wall thickening and fat stranding. 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 in mid position, and is normal in size. There are no concerning adnexal masses. 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 of the lumbar spine is seen. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute abdominopelvic process relating to reported history of high-temperature fevers. 2. Borderline hepatic steatosis. 3. Extensive sigmoid and descending colonic diverticulosis without diverticulitis. 4. Please refer to the dedicated chest CT for intrathoracic findings. ___ LENIs No evidence of deep venous thrombosis in the right or left lower extremity veins. DISCHARGE LABS ___ 06:35AM BLOOD WBC-3.7* RBC-3.70* Hgb-13.3 Hct-38.8 MCV-105* MCH-35.9* MCHC-34.3 RDW-13.0 RDWSD-49.9* Plt ___ ___ 06:35AM BLOOD Neuts-43.5 ___ Monos-13.2* Eos-3.2 Baso-1.6* Im ___ AbsNeut-1.61# AbsLymp-1.41 AbsMono-0.49 AbsEos-0.12 AbsBaso-0.06 ___ 06:35AM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-138 K-3.7 Cl-102 HCO3-24 AnGap-16 ___ 06:35AM BLOOD ALT-43* AST-32 AlkPhos-45 TotBili-0.6 ___ 06:35AM BLOOD Lipase-20 ___ 06:35AM BLOOD Calcium-9.7 Phos-5.3* Mg-1.8 ___ 06:35AM BLOOD Folate-9.4 ___ 07:44AM BLOOD VitB12-738 Ferritn-294* ___ 12:05AM BLOOD TSH-2.5 ___ 07:30AM BLOOD HBsAg-Negative HBsAb-Negative IgM HBc-Negative IgM HAV-Negative ___ 07:44AM BLOOD ___ ___ 12:05AM BLOOD CRP-12.3* ___ 07:40PM BLOOD HIV Ab-Negative ___ 12:14AM BLOOD Lactate-2.0 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. LYME SEROLOGY (Final ___: NO ANTIBODY TO B. BURG___ DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in ___ weeks. Blood, urine cultures NGTD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 50 mg PO DAILY 2. Famotidine 20 mg PO BID 3. LamoTRIgine 50 mg PO DAILY 4. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 5. Tizanidine 4 mg PO QHS:PRN neck spasm 6. Lumigan (bimatoprost) 0.01 % ophthalmic QHS 7. Azopt (brinzolamide) 1 % ophthalmic BID Discharge Medications: 1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 2. Famotidine 20 mg PO BID 3. LamoTRIgine 50 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Tizanidine 4 mg PO QHS:PRN neck spasm 6. Azopt (brinzolamide) 1 % ophthalmic BID 7. Lumigan (bimatoprost) 0.01 % ophthalmic QHS Discharge Disposition: Home Discharge Diagnosis: Fever of unknown origin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT of abdomen pelvis with contrast. INDICATION: ___ year old woman with FUO to 105, hematomacrosis, who presents with fever and RUQ pain along with elevated LFTS. // Please evaluate for cause of fever. 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) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.3 mGy-cm. 2) Stationary Acquisition 26.9 s, 0.2 cm; CTDIvol = 449.9 mGy (Body) DLP = 90.0 mGy-cm. 3) Spiral Acquisition 7.1 s, 67.2 cm; CTDIvol = 6.4 mGy (Body) DLP = 433.3 mGy-cm. Total DLP (Body) = 526 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: The liver appears borderline hypodense compared to the spleen. However, the background 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 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. Diverticulosis of the descending and sigmoid colon is noted, without evidence of wall thickening and fat stranding. 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 in mid position, and is normal in size. There are no concerning adnexal masses. 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 of the lumbar spine is seen. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute abdominopelvic process relating to reported history of high-temperature fevers. 2. Borderline hepatic steatosis. 3. Extensive sigmoid and descending colonic diverticulosis without diverticulitis. 4. Please refer to the dedicated chest CT for intrathoracic findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: Fever right upper quadrant pain an hemochromatosis. Assess for possible pneumonia. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.3 mGy-cm. 2) Stationary Acquisition 26.9 s, 0.2 cm; CTDIvol = 449.9 mGy (Body) DLP = 90.0 mGy-cm. 3) Spiral Acquisition 7.1 s, 67.2 cm; CTDIvol = 6.4 mGy (Body) DLP = 433.3 mGy-cm. Total DLP (Body) = 526 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) FINDINGS: There are no prior chest CT scans for comparison. Supraclavicular and axillary lymph nodes are not enlarged. Excluding the breasts which require mammography for evaluation, elsewhere in the chest wall there are no soft tissue abnormalities concerning for malignancy or infection. Findings below the diaphragm will be reported separately. There are no thyroid lesions warranting further imaging evaluation. Atherosclerotic calcification is not apparent head neck vessels or appreciable in the coronary arteries. Aorta and pulmonary arteries and cardiac chambers are normal size. There is no pleural or pericardial abnormality. Prevascular mediastinal lymph nodes are noteworthy for number, but not size. Largest mediastinal nodes are 9 mm, right lower paratracheal station, 12 mm, subcarinal. Hilar nodes are not enlarged. Esophagus is unremarkable. Aside from mild to moderate bibasilar atelectasis, right greater than left, lungs are clear. Tracheobronchial tree is normal to subsegmental levels. There are no bone lesions in the chest cage suspicious for malignancy. IMPRESSION: No evidence of intrathoracic infection. 2 top-normal mediastinal nodes in numerous smaller ones are not not necessarily pathologic. Follow-up imaging is not indicated. RECOMMENDATION(S): Follow-up imaging is not indicated. Radiology Report EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ woman with fever of unknown origin visiting from ___ evaluate for deep venous thrombosis. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: No prior relevant imaging is available on PACS at the time of this dictation. FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Fever, Transfer Diagnosed with Fever, unspecified temperature: 99.2 heartrate: 99.0 resprate: 13.0 o2sat: 97.0 sbp: 138.0 dbp: 72.0 level of pain: 3 level of acuity: 3.0

Dear Ms. ___, You were admitted to ___ with fevers. You were evaluated for the cause and unfortunately none was found. You did not have any further fevers while you were in the hospital. You are stable for discharge. Please follow up with your PCP in the next several days, or as soon as you get back to ___, to continue the evaluation.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with multiple co-morbidities, including a history of back pain who presents with weakness, worsening back pain. Patient was recently admitted for hyperkalemia, UTI, CHF exacerbation, and LLE cellulitis. Diuresed while inpatient, and sent home on cefpodoxime for complicated UTI and cellulitis. Patient has been using a wheelchair for some time and is s/p amputation of R leg. Patient states that today, he was weaker than usual. He is usually able to stand with assistance but today was unable to do so. He states that he has had problems for some time with strength, but that today he feels weaker. He has also had cellulitis in the L foot. Denies cp/sob/ab pain. In the ED, initial vs were: 10 97.2 56 167/59 20 100% Exam notable for ttp over midline of the L spine, poor strength in the RLE; RLE amputation with prosthesis. Labs notable for creat 3.3 (recent baseline 2.7). CT pelvis and lumbar spine revealed 3mm non-obstructing R kidney stone, bladder wall thickening, multilevel degenerative joint disease without acute fracture or dislocation. Dr. ___ was called, and recommended holding off on antibiotics, reculturing in 24 hours and consider restarting antibiotics at this time. He was given IVF, home dose of clonidine for hypertension, and admitted to medicine. On the floor the patient was confortable and had the following complaints: -___ Lower back pain -___ Left hip pain -___ toe pain Past Medical History: PAST MEDICAL HISTORY: - CKD - CAD - Ischemic cardiomyopathy (EF 40-45%) - Cervical and Lumbar Spinal Stenosis - s/p surgery - CVA (silent, unknown chronology) - Hypertension. - Hypercholesterolemia. - Diabetes mellitus - Gout. - h/o atrial fibrillation - L2-S1 decompression c/b MRSA wound infection for which pt is on chronic prophylatic rifampin given all the hardware. - s/p RBKA for diabetic wound infection - Normocytic anemia (Hct ~30 since ___ since ___ - DVT dx ___ Past Surgical History: 1. C3-C4 cervical fusion, ___ 2. L3-L4 laminectomies in ___ 3. Right CEA 4. Right leg vein bypass in ___. 5. Left hip replacement in ___ 6. Right below-the-knee amputation, ___. 7. Posterior fusion L2-S1 Social History: ___ Family History: No known history of heart disease. Physical Exam: ON ADMISSION: ============== Vitals: 97.2 | 90/46 | 53 | 18 | 100%/RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moderate conjunctival pallor, dry oral mucosa, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Expansion is asymmetrical, diminished on the R. No breath sounds in R base, no egophony. Otherwise 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: RBKN. Warm, adequately perfused, 1+ pedial pulse, no clubbing, cyanosis. BLE 2+ pitting edema. Erythema and tenderness in ___ toe. Skin: eythema w/o induration or tenderness at lower ___ of L leg Neuro: AOx3. No gross sensory or motor deficits. MSK: TTP in lower back spinal processes as well as over L trochanter. Active and passive ROMs preserved ON DISCHARGE:: ============== Vitals 98, BP 124/40(124-147/36-51), HR 70, RR 18, O2 100%RA Gen: Pleasant, elderly main laying in bed s/p right leg amputation in NAD Extremities: s/p R foot and L great toe amputation. Tip of ___ toe with dried blood and erythema, no warmth or surrouding erythema, but R pretibial area is mildly erythematous. Heart: RRR, no m/r/g Lungs: CTAB Abd: Soft, NT/ND, +BS Neuro: AOx3, pleasant, conversing fluently about recent and remote events Pertinent Results: ADMISSION LABS: ================ ___ 12:40PM BLOOD WBC-4.6 RBC-2.87* Hgb-8.9* Hct-27.9* MCV-97 MCH-31.1 MCHC-32.0 RDW-14.3 Plt ___ ___ 12:40PM BLOOD ___ PTT-28.9 ___ ___ 12:40PM BLOOD Glucose-105* UreaN-90* Creat-3.3* Na-139 K-4.9 Cl-103 HCO3-24 AnGap-17 ___ 07:10AM BLOOD Calcium-8.2* Phos-5.6* Mg-2.4 PERTINENT LABS: ============== ___ 03:29AM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 ___ 03:29AM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-NEG Ketone-15 Bilirub-SM Urobiln-0.2 pH-6.0 Leuks-LG ___ 10:00PM URINE RBC-5* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 ___ 10:00PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 12:30PM URINE RBC-7* WBC->182* Bacteri-FEW Yeast-OCC Epi-0 ___ 12:30PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 11:13AM URINE Eos-POSITIVE ___ 02:49PM URINE Hours-RANDOM UreaN-554 Creat-92 Na-45 K-30 Cl-22 ___ 11:13AM URINE Hours-RANDOM UreaN-385 Creat-41 Na-81 K-32 Cl-73 DISCHARGE LABS: ================= ___ 08:20AM BLOOD WBC-5.1 RBC-2.50* Hgb-7.8* Hct-25.1* MCV-100* MCH-31.2 MCHC-31.1 RDW-15.0 Plt ___ ___ 08:20AM BLOOD Glucose-142* UreaN-70* Creat-3.4* Na-139 K-4.3 Cl-107 HCO3-22 AnGap-14 ___ 08:20AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.3 RELEVANT STUDIES: ================ CT L-SPINE W/C ___: 1. No evidence of acute fracture, though the exam is significantly limited by severe osteopenia, metallic artifact and degenerative changes. 2. Mild loss of height in T12 and L1, grossly unchanged from ___. 3. Status post L2 through S1 fusion with laminectomies of L3, L4, and L5, and no definite evidence of hardware complication. 4. Severe multilevel degenerative changes with posterior osteophytes and disc bulges extending posteriorly into the canal with at least moderate spinal canal narrowing at multiple levels. 5. 3-mm non-obstructing right renal stone. 6. Severe atherosclerotic disease. CT PELVIS/HIP W/C ___: 1. No evidence of fracture. 2. Status post left total hip arthroplasty without evidence of hardware complication. 3. Moderate degenerative changes in the right hip, bilateral sacroiliac joints, and pubic symphysis. 4. Mild bladder wall thickening maybe due to chronic obstruction from BPH, although correlation with UA is recommended to exclude cystitis. 5. Diverticulosis without evidence of diverticulitis. CXR ___: No acute cardiopulmonary process. Moderate cardiomegaly. ANIS ___: Findings as stated above which indicate significant left SFA and tibial disease, overall similar to the prior study of ___. Of note is a flat-line amplitude at the left metatarsal level. RENAL U/S ___: 1. No hydronephrosis, stones or solid renal mass. 2. Prostatic hypertrophy likely causes bladder outlet obstruction, accounting for difficulty voiding. MICROBIOLOGY: ============= URINE CX ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION URINE CX ___: <10,000 organisms/ml URINE CX ___: YEAST. >100,000 ORGANISMS/ML. BLOOD CX ___ X 2: NO GROWTH Radiology Report HISTORY: ___ female with acute on chronic injury. Evaluation for hydronephrosis. TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the bilateral kidneys and bladder. COMPARISON: Comparison is made to ultrasound of the kidneys from ___. FINDINGS: The right kidney measures 9.4 cm and the left kidney measures 9.7 cm. There is no evidence of hydronephrosis. No cyst, stone or solid mass is identified in either kidney. The bladder is trabeculated and median lobe prostate hyperplasia indents upon the bladder base. Layering debris is present in the bladder. IMPRESSION: 1. No hydronephrosis, stones or solid renal mass. 2. Prostatic hypertrophy likely causes bladder outlet obstruction, accounting for difficulty voiding. Radiology Report INDICATION: Weakness. Evaluate for pneumonia. COMPARISON: ___ chest radiograph. FINDINGS: PA and lateral views of the chest. There is no focal consolidation, pleural effusion, vascular congestion or pneumothorax. The aorta is tortuous. There is moderate cardiomegaly. Otherwise, the mediastinal and hilar contours are normal. There is mild elevation of the right hemidiaphragm, unchanged. IMPRESSION: No acute cardiopulmonary process. Moderate cardiomegaly. Radiology Report INDICATION: Back pain and weakness in the left leg. Evaluate for fracture. COMPARISONS: Lumbosacral spine radiographs from ___. CT abdomen and pelvis from ___. TECHNIQUE: Contiguous helical MDCT images were obtained through the lumbar spine without the administration of IV contrast. Sagittal, coronal, and bone reformatted images were obtained and reviewed. DLP TOTAL: 884.63 mGy-cm. CTDI VOLUME: 30.94 mGy. FINDINGS: The patient is status post L2 through S1 spinal posterior fusion with laminectomies of L4 through L5. The hardware appears intact without evidence of pedicle screw fracture. The rods are intact without evidence of a fracture or malalignment. The post-surgical changes with graft material from the posterior aspect of the pedicle screws are not significantly changed from the prior exam. There are severe multilevel degenerative changes with fusion of the left aspect of the L2 and L3 vertebral bodies and near-complete fusion of the right lateral aspect of the L4 and L5 vertebral bodies and the central aspect of the L5 and S1 vertebral bodies. This is similar to the prior exam. There is mild dextroscoliosis of the lumbar ___ at L2. There is straightening of the normal lumbar lordosis. Alignment is otherwise stable without significant anterolisthesis or retrolisthesis. The exam is limited by significant osteopenia, though no definite acute fracture is identified. There is mild loss of height in the anterior portion of the vertebral body of T12, unchanged from the prior exam. There is mild loss of height in L1, also unchanged. At T11-T12, there is loss of disc space height, small Schmorl's nodes, and vacuum phenomenon. There is likely a small disc bulge without significant central canal narrowing. At T12-L1, there is loss of disc height with small Schmorl's nodes. No significant disc bulge is identified. At L1-L2, there is severe loss of disc space height with significant vacuum phenomenon, endplate sclerosis, and osteophyte formation. A partially calcified osteophyte extends posteriorly into the central canal (400b, 30). This is likely causing moderate central canal narrowing. Evaluation is somewhat limited by surrounding metallic artifact. At L2-L3, there is severe loss of disc space height, endplate sclerosis. Evaluation at this level is significantly limited by surrounding metallic artifact, although there is an eccentric disc bulge on the right (2, 27), likely causing moderate central canal narrowing. At L3-L4, disc space height is preserved essentially on the right due to an interbody spacer. It is narrowed on the left. Interbody spacer has metallic artifact, posteriorly, and evaluation for significant disc disease is limited. At L4-L5, disc space height is also maintained due to interbody spacer. Again due to the metallic artifact, it is difficult to evaluate for disc disease. At L5-S1, there is severe disc space narrowing, endplate sclerosis, and osteophyte formation. There is a small posterior osteophyte (400b, 38), causing mild-to-moderate canal narrowing. Evaluation of the thecal sac throughout this exam was limited due to technique and artifact. No free fluid is identified in the pelvis. The psoas muscles are grossly symmetric without evidence of hematoma or fluid collection. No fluid collection is identified in the paraspinal muscles or post-surgical bed. There is a 3-mm non-obstructing right renal stone in the upper pole of the kidney (3, 3). Smaller calcifications around the renal hilum are likely atherosclerotic calcifications in the renal arteries. There are no left renal stones. No mass is identified in the imaged portions of the kidneys. There is no hydronephrosis. Imaged portions of the abdominal aorta are normal in caliber without evidence of an aneurysm. There is severe atherosclerotic disease, including at the takeoff of the celiac and SMA arteries. IMPRESSION: 1. No evidence of acute fracture, though the exam is significantly limited by severe osteopenia, metallic artifact and degenerative changes. 2. Mild loss of height in T12 and L1, grossly unchanged from ___. 3. Status post L2 through S1 fusion with laminectomies of L3, L4, and L5, and no definite evidence of hardware complication. 4. Severe multilevel degenerative changes with posterior osteophytes and disc bulges extending posteriorly into the canal with at least moderate spinal canal narrowing at multiple levels. 5. 3-mm non-obstructing right renal stone. 6. Severe atherosclerotic disease. Radiology Report INDICATION: Back pain and weakness in the left leg. Evaluate for fracture. COMPARISONS: CT of the lumbar spine obtained concurrently with this CT. CT of the abdomen and pelvis from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the pelvis without the administration of IV or oral contrast. Sagittal and coronal reformatted images were obtained and reviewed. TOTAL DLP: 1425.02 mGy-cm. FINDINGS: For details of the lumbar spine, please see the lumbar spine CT. Note, the patient is status post a L2 through S1 fusion with postoperative changes. Post-surgical changes are noted in the sacrum. There is no evidence of a sacral fracture. There are moderate degenerative changes of the bilateral sacroiliac joints with sclerosis and small subchondral cysts. The patient is status post a left bipolar total hip arthroplasty. The hardware appears intact without evidence of loosening or dislocation. Post-surgical changes are similar to the prior exam in ___. There is no evidence of fracture of the left femur around the prosthesis. There is no evidence of a pelvic fracture or right femur fracture. Moderate degenerative changes are noted in the right hip and at the pubic symphysis. Extensive atherosclerotic calcifications are noted in the bilateral common iliac arteries, and in internal and external iliac arteries. There is diverticulosis without evidence of diverticulitis. The imaged portions of the small bowel are normal. There is no pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. The prostate is mildly enlarged measuring 5.2 cm (2, 77). The bladder is moderately distended. Apparent wall thickening may be chronic, though recommend correlation with UA to exclude active cystitis. The pelvic musculature demonstrates fatty infiltration and some asymmetry, likely due to the left hip prosthesis. There is no evidence of intramuscular hematoma. Calcifications in the left buttocks are likely injection granulomas. There is moderate anasarca without a discrete fluid collection in the soft tissues. IMPRESSION: 1. No evidence of fracture. 2. Status post left total hip arthroplasty without evidence of hardware complication. 3. Moderate degenerative changes in the right hip, bilateral sacroiliac joints, and pubic symphysis. 4. Mild bladder wall thickening maybe due to chronic obstruction from BPH, although correlation with UA is recommended to exclude cystitis. 5. Diverticulosis without evidence of diverticulitis. Radiology Report ARTERIAL STUDY DATED THE ___ HISTORY: Peripheral vascular disease and right BKA. ABI on the left is 0.66 based on the DP artery. Doppler tracings demonstrate monophasic waveforms actually from the superficial femoral vein, distally. Volume recordings are in accord with the Doppler tracings. IMPRESSION: Findings as stated above which indicate significant left SFA and tibial disease, overall similar to the prior study of ___. Of note is a flat-line amplitude at the left metatarsal level. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Back pain Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS, LUMBAGO, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 97.2 heartrate: 56.0 resprate: 20.0 o2sat: 100.0 sbp: 167.0 dbp: 59.0 level of pain: 10 level of acuity: 2.0

Dear Mr. ___, It was a pleasure to take care of you during your recent admission at ___. You came after falling in the tub and fortunately did not break any bones. We found that your kidneys were a little worse and that your second left toe seems to be getting very little blood and may be infected. Unfortunately, the vessels that go to your to cannot be fixed but we're treating the infection with antibiotics to make sure it doesn't get worse. To help your kidneys, it is important that you drink water or other liquids when you feel thirsty to keep from getting dehydrated. To further investigate what is happening in your kidneys, you are scheduled for a kidney biopsy next week. Make sure to keep taking your medications and follow-up with Dr. ___. We wish you the best, Your ___ Medicine Team