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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: History of Present Illness: ___ male with history of metastatic pancreatic cancer to the lungs and liver presenting with right side pain. The pain began abruptly the morning of presentation, was present in the axilla and chest, not associated with palpitations, chest pressure. It is associated with dyspnea on exertion and pleuritic chest pain. No fevers, chills, or cough. Patient had C2D8 Gemzar/Abraxane on ___. Has been using his oral analgesics at home without significant relief. Has had multiple episodes of non-bloody vomiting, unchanged from the week in clinic, and a 3 lb weight loss in 3 days. Vitals in the ER: 99.1 57 ___ 100% RA Pt received Zofran 4mg IV x2, Dilaudid 1mg IV, and IV heparin ggt with a bolus (ER did not have a reason for choosing Heparin over Lovenox) . REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, chest pain, chest pressure, palpitations, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. All other ROS negative . Past Medical History: ONCOLOGIC HISTORY: He presented to his primary care physician on ___, with epigastric pain that was unrelieved with antacids Prilosec or Protonix. Abdominal ultrasound at ___ on ___, showed multiple circumscribed lesions in both liver lobes that were suspicious for neoplasm. The largest was 3.4 x 2.2 x 3.4 cm in the right lobe. He met with Dr. ___ on ___, and started hydrochlorothiazide for hypertension and a Prevpac for positive H. pylori as was detected on routine screening labs that were drawn on ___. A CT of the abdomen and pelvis was performed and showed numerous hypoenhancing liver lesions without biliary dilatation. There is an ill-defined soft tissue abutting the pancreatic head and neck, measuring 3 x 2.8 x 4 cm with a similar focus of tissue along the periphery of the distal pancreatic body without pancreatic ductal dilatation. He had extensive peripancreatic aortocaval and left paraaortic lymphadenopathy that appeared to be causing at least a partial gastric outlet obstruction. His labs were remarkable for an ALT of 391 and AST of 151 and alkaline phosphatase of 392 and a total bilirubin of 2.88, CEA was 37.2 and his CA ___ was approximately 45,000. On ___, an ERCP showed a 2 cm stricture in the common bile duct consistent with a prestenotic biliary dilatation, a biliary stent was placed, and common bile duct brushings were performed. These were negative for malignant cells. On ___, he underwent an endoscopic ultrasound with Dr. ___ demonstrated a mass measuring 3.2 x 2.4 cm in the pancreatic neck, which was hypoechoic and heterogeneous in echotexture with irregular and poorly defined borders. There was suspicion for invasion into the splenic vein and SMV as well. Multiple liver lesions were seen in the left lobe. FNA of the pancreatic head mass as well as the celiac lymph node demonstrated positive cytology for adenocarcinoma, poorly differentiated and cell block was consistent with a signet ring morphology. We initially saw him on ___, he had significant abdominal pain despite frequent p.r.n. oxycodone, and he was jaundiced with a bilirubin of 7.1 and unable to tolerate any oral liquids. In addition, he had had no bowel movement for three weeks. He was admitted to the hospital and eventually discharged on ___. ERCP was performed with removal of his common bile duct stent and replacement of the right and left hepatic ducts stents with improvement in his total bilirubin to 3. He had a bowel movement after enemas and was able to tolerate p.o.s without nausea and vomiting. An attempted celiac plexus neurolysis was made, but not performed due to inability to identify the plexus due to surrounding adenopathy. He was initiated on long-term oxycodone and p.r.n. Dilaudid. He began cycle 1, day 1 of gemcitabine and Abraxane chemotherapy, which were both dose reduced by 20% because of his total bilirubin of 2.5. Chemo was held on cycle 1, day 8 because his platelet count was 68,000. His serum sodium was also 126. He received two liters of IV fluid and stopped hydrochlorothiazide. He returned for second dose of gentamicin and Abraxane on ___, and had significant pruritus and evidence for cellulitis on his nose, pain control was better. He was admitted to ___ on ___, through ___, with nausea, vomiting, and diarrhea that resolved with supportive care. C. difficile and norovirus testing was negative. This was felt to be most likely a viral gastroenteritis. He was seen again on ___, for the institution of cycle 2, day 1 of gemcitabine and Abraxane therapy Past Medical Hx: Hypertension . Social History: ___ Family History: Patient denies family h/o GB, pancreatic CA. Father died of MI at ___. Brother and mother are healthy. Physical Exam: Admission: Vitals: T 97.9 bp 96/70 HR 84 RR 18 SaO2 98 RA Wt 181.8 lbs, 70.5" GEN: ill-appearing, uncomfortable, awake HEENT: supple neck, dry mucous membranes, no oropharyngeal lesions; right cheek has redness with pustule PULM: normal effort, CTAB CV: RRR, no r/m/g/heaves ABD: soft, diffusely tender and distended without rebound or guarding. bowel sounds present EXT: normal perfusion SKIN: warm, dry, jaundiced NEURO: no focal sensory or motor deficits PSYCH: cooperative Discharge: VITALS: 98.1, 109/76. 83. 17 93% RA GEN: ill-appearing, comfortable, awake HEENT: alopecia, supple neck, moist mucous membranes, no oropharyngeal lesions; right cheek has redness with pustule PULM: normal effort, CTAB, no rales, wheezes or rhonchi CV: RRR II/VI systolic murmur throughout precordium, no gallops or rubs ABD: soft, no tenderness to palpation, no rebound or guarding, no HSM EXT: normal perfusion, no C/C/E, 2+ DP, no cords along lower legs, negative ___ signs bilaterally SKIN: warm, dry NEURO: no focal sensory or motor deficits PSYCH: cooperative Pertinent Results: Admission: ___ 03:01AM ___ PTT-29.2 ___ ___ 11:43PM LACTATE-1.8 ___ 11:35PM GLUCOSE-102* UREA N-6 CREAT-0.6 SODIUM-130* POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-22 ANION GAP-19 ___ 11:35PM cTropnT-<0.01 proBNP-89 ___ 11:35PM WBC-8.7 RBC-3.77* HGB-11.7* HCT-34.5* MCV-92 MCH-31.1 MCHC-33.9 RDW-15.9* ___ 11:35PM NEUTS-80.3* LYMPHS-15.9* MONOS-0.8* EOS-2.7 BASOS-0.2 ___ 11:35PM PLT COUNT-226 Discharge: ___ 08:00AM BLOOD WBC-2.1* RBC-2.91* Hgb-8.9* Hct-26.7* MCV-92 MCH-30.8 MCHC-33.5 RDW-15.6* Plt ___ ___ 08:00AM BLOOD Glucose-98 UreaN-4* Creat-0.6 Na-139 K-3.6 Cl-103 HCO3-29 AnGap-11 ___ 08:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6 Imaging: Radiology Report CHEST (PA & LAT) Study Date of ___ 11:41 ___ FINDINGS: There is minimal bilateral lower lobe atelectasis. The lungs are otherwise 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 findings Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___ 12:25 AM CHEST CT: There are widespread bilateral pulmonary emboli, with thrombus seen along the distal aspects of both the right and left main pulmonary arteries, extending into multiple bilateral segmental and subsegmental branches of all pulmonary lobes. There is no leftward bowing of the intraventricular septum to suggest right heart strain. The right ventricular outflow tract is normal in caliber. The thoracic aorta is normal in caliber. Scattered aortic calcifications are seen. There are also scattered coronary artery calcifications. The heart is normal in size. There is no pericardial effusion. Small mediastinal lymph nodes do not meet CT size criteria. Prominent bilateral hilar lymph nodes measure up to 8 mm on the right and 7 mm on the left, increased in size compared to the prior CT from ___, likely reactive. There are no pathologically enlarged axillary lymph nodes. Lymph nodes within the epipericardial space measure up to 13 x 6 mm (2:81), not significantly changed. There is biapical pleuroparenchymal thickening/scarring, right greater than left, not significantly changed. Scattered bilateral pulmonary nodules measuring up to 5 mm in the right upper lobe (3:69, 74, 94, 132) are not significantly changed compared to the prior CT from ___. There is subsegmental bilateral upper and lower lobe dependent atelectasis. There is also paraseptal emphysema as well as mild centrilobular emphysema, similar in appearance to the prior study. The tracheobronchial tree is patent to the segmental level bilaterally. There are no pleural effusions. This study was not optimized for evaluation of the subdiaphragmatic contents. Limited assessment of the upper abdomen demonstrates innumerable hepatic metastases, increased in size and number compared to prior CT from ___. A biliary stent is partially imaged, new compared to the prior study. A 14-mm lymph node is seen along the celiac axis. BONE WINDOW: No suspicious lytic or blastic lesions are identified. Degenerative changes of the thoracic spine are noted. IMPRESSION: 1. Widespread pulmonary emboli within the distal aspects of the right and left pulmonary arteries as well as segmental and subsegmental arteries throughout all lobes of the lungs. No evidence of right heart strain. 2. Scattered pulmonary nodules, measuring up to 5 mm in the right upper lobe, not significantly changed compared to the recent CT from ___. Attention on followup studies is warranted. 3. Innumerable hepatic metastases, increased in size and number. Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 2:25 AM FINDINGS: There is no evidence of hemorrhage, edema, shift of normally midline structures, hydrocephalus, or infarction. Calcifications are seen of the bilateral cavernous carotid arteries. The visualized portions of the orbits are unremarkable. Minimal mucosal thickening is seen within bilateral ethmoidal air cells. The remainder of the visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Normal study. ___ Radiology BILAT LOWER EXT VEINS : Preliminary L common femoral into great saphenous clot ** Final Read Pending ** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain 2. Morphine SR (MS ___ 90 mg PO Q8H 3. Lorazepam 0.5 mg PO Q6H:PRN Nausea 4. Ondansetron 8 mg PO Q8H:PRN Nausea 5. Prochlorperazine 10 mg PO Q6H:PRN Nausea 6. Senna 1 TAB PO BID:PRN constipation 7. PredniSONE 5 mg PO DAILY 8. traZODONE 100 mg PO HS:PRN insomnia 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Omeprazole 40 mg PO DAILY 11. Cephalexin 250 mg PO Q12H started ___ for 10 days for facial abscess Discharge Medications: 1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain 2. Lorazepam 0.5 mg PO Q6H:PRN Nausea 3. Morphine SR (MS ___ 90 mg PO Q8H 4. Omeprazole 40 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. PredniSONE 5 mg PO DAILY 7. Prochlorperazine 10 mg PO Q6H:PRN Nausea 8. Senna 1 TAB PO BID:PRN constipation 9. traZODONE 100 mg PO HS:PRN insomnia 10. Ondansetron 8 mg PO Q8H:PRN Nausea 11. Mirtazapine 7.5 mg PO HS RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 12. Enoxaparin Sodium 80 mg SC Q12H RX *enoxaparin 80 mg/0.8 mL ___very twelve (12) hours Disp #*60 Syringe Refills:*0 13. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 2 capsule(s) by mouth every six (6) hours Disp #*20 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: pancreatic cancer, pulmonary emboli (blood clot in lungs) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: History of metastatic pancreatic cancer, now with right chest and axillary pain as well as shortness of breath. Evaluate for pulmonary embolism. COMPARISON: CT chest from ___. CT abdomen and pelvis from ___. TECHNIQUE: MDCT axial images were acquired through the chest during the administration of 100 cc of intravenous Omnipaque contrast material. Multiplanar reformats were performed, including maximum intensity projection oblique images. TOTAL DLP: 494 mGy-cm. CHEST CT: There are widespread bilateral pulmonary emboli, with thrombus seen along the distal aspects of both the right and left main pulmonary arteries, extending into multiple bilateral segmental and subsegmental branches of all pulmonary lobes. There is no leftward bowing of the intraventricular septum to suggest right heart strain. The right ventricular outflow tract is normal in caliber. The thoracic aorta is normal in caliber. Scattered aortic calcifications are seen. There are also scattered coronary artery calcifications. The heart is normal in size. There is no pericardial effusion. Small mediastinal lymph nodes do not meet CT size criteria. Prominent bilateral hilar lymph nodes measure up to 8 mm on the right and 7 mm on the left, increased in size compared to the prior CT from ___, likely reactive. There are no pathologically enlarged axillary lymph nodes. Lymph nodes within the epipericardial space measure up to 13 x 6 mm (2:81), not significantly changed. There is biapical pleuroparenchymal thickening/scarring, right greater than left, not significantly changed. Scattered bilateral pulmonary nodules measuring up to 5 mm in the right upper lobe (3:69, 74, 94, 132) are not significantly changed compared to the prior CT from ___. There is subsegmental bilateral upper and lower lobe dependent atelectasis. There is also paraseptal emphysema as well as mild centrilobular emphysema, similar in appearance to the prior study. The tracheobronchial tree is patent to the segmental level bilaterally. There are no pleural effusions. This study was not optimized for evaluation of the subdiaphragmatic contents. Limited assessment of the upper abdomen demonstrates innumerable hepatic metastases, increased in size and number compared to prior CT from ___. A biliary stent is partially imaged, new compared to the prior study. A 14-mm lymph node is seen along the celiac axis. BONE WINDOW: No suspicious lytic or blastic lesions are identified. Degenerative changes of the thoracic spine are noted. IMPRESSION: 1. Widespread pulmonary emboli within the distal aspects of the right and left pulmonary arteries as well as segmental and subsegmental arteries throughout all lobes of the lungs. No evidence of right heart strain. 2. Scattered pulmonary nodules, measuring up to 5 mm in the right upper lobe, not significantly changed compared to the recent CT from ___. Attention on followup studies is warranted. 3. Innumerable hepatic metastases, increased in size and number. Radiology Report INDICATION: History of metastatic pancreatic cancer, evaluate for brain metastases prior to administration of heparin for pulmonary embolism. COMPARISON: None. TECHNIQUE: Sequential axial images were acquired through the head without the administration of intravenous contrast material. Multiplanar reformats were performed. CTDIvol 63, DLP 1026 FINDINGS: There is no evidence of hemorrhage, edema, shift of normally midline structures, hydrocephalus, or infarction. Calcifications are seen of the bilateral cavernous carotid arteries. The visualized portions of the orbits are unremarkable. Minimal mucosal thickening is seen within bilateral ethmoidal air cells. The remainder of the visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Normal study. Radiology Report INDICATION: ___ male with bilateral pulmonary embolism. Question DVT. COMPARISON: CTA dated ___. FINDINGS: Grayscale and color Doppler sonograms were performed of bilateral lower extremities. There is normal compressibility and color flow in the right common femoral, superficial femoral, and popliteal veins, as well as posterior tibial and peroneal veins. On the left, there is expansion and near occlusive thrombosis of the common femoral vein extending into greater saphenous vein. However, more distally, there is normal color flow in the common femoral, superficial femoral, and popliteal veins, as well as in the posterior tibial and peroneal veins. IMPRESSION: 1. Left common femoral vein thrombosis extending into greater saphenous vein. Distal extremity veins are patent. 2. Patent right lower extremity veins. Findings reported to Dr. ___ at 10:05 a.m. via phone on ___ by Dr. ___. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: RIGHT SIDE PAIN Diagnosed with PULM EMBOLISM/INFARCT, MALIG NEO PANCREAS NOS, SECOND MALIG NEO LIVER temperature: 99.1 heartrate: 57.0 resprate: 18.0 o2sat: 100.0 sbp: 108.0 dbp: 76.0 level of pain: 10 level of acuity: 2.0

Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with chest discomfort and shortness of breath. A CAT scan showed clots in your lungs. You were started on a blood thinning medication called Lovenox, which you will need to continue. Medication changes: START Lovenox 80 mg every twelve hours START Clindamycin 600 mg every 6 hours for 5 days (last day ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / heparin Attending: ___. Chief Complaint: tachypnea and respiratory distress Major Surgical or Invasive Procedure: ___: Intubation and ventilation ___: ___ placement History of Present Illness: ___ year old ___ lady with history of CAD (s/p NSTEMI and new diagnosis of systolic CHF vs Takotsubo cardimyopathy in ___, recent history of cold symptoms 4 days ago, who was brought in by ambulance to the ___ ED with subjective fevers and chills, cough productive of sputum x3-4 days, and dyspnea. She is on intermittent oxygen at home but has required constant oxygen ___ over last several days. She denies chest pain and leg swelling. Comfortable on nasal cannula until ___, became more tachycardic, hypoxic, and tachypneic after a coughing fit. Her respiratory rate increased to 32. She was placed on bipap and did not tolerate this, as such she was intubated in the ED. Afterwards she was hypotensive ___, which was prolonged given that sedation was a difficult (agitated, attempting to pull out ET tube). By the time of transfer her BP was in mid ___, though was 130s/60s before intubation. She was given 3.5 L NS, vanc/cefepime/azithro for HCAP, and started on versed and fent drips. In the ED, initial vitals: 08:32 0 98.7 103 125/52 18 99% 15L Non-Rebreather. On arrival to the MICU, she was intubated and sedated. Further history was obtained from her two daughters (there is no HCP, so they share joint decision making responsibility). She had cold symptoms 4 days ago and seemed feverish. Cough was bothersome and she couldn't lie down without coughing. No weight gain and went to see Dr. ___ weeks ago and daughters note her health has been stable. Review of systems: (+) Per HPI - recent subj fever, chills. No headache, diarrhea, nausea, or vomiting. No NEW rash. No chest pain or palpitations. Past Medical History: Fall with head trauma ___, discharged AMA Diabetes mellitus type II, A1c 6 in ___ Hypertension Prior NSTEMI in ___ and ___, medically managed w/o catheterization. NSTEMI ___ at ___, cardiac cath showed moderate CAD: 50% ___ LAD lesion, 40% mid RCA lesion. Systolic CHF with EF of 25% in ___ - concern for Takotsubo Cardiomyopathy ___ fall (previously diagnosed with dCHF, EF 55% in ___ HIT in ___ though has been on heparin products without incident since that time legally blind Hard of hearing (L ear is good ear) Past Surgical History: -Open cholecystectomy, ___ -Appendectomy -Total abdominal hysterectomy -Incisional hernia repair x3 (___). Procedure in ___ performed at ___ (___): exlap w/ primary repair of incarcerated incisional hernia -SBO with LOA, complex abdominal closure ___ c/b surgical site infection -MVA (pedestrian vs. car, ___, small SAH) Social History: ___ Family History: Per OMR, father with CAD. Physical Exam: ADMISSION PHYSICAL EXAM 98.0 - 70/50 (-->93/52) - 90 - 22 - 100% on AC w/ RR 22, Vt 400, PEEP 12, FiO2 75. I/o urine output 175 GENERAL: obese lady, intubated, sedated HEENT: Sclera anicteric, PERRL, MM dry NECK: supple, JVP not elevated, no cervical LAD LUNGS: mechanical breath sounds bilaterally, no crackles or wheeze CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly EXT: extremities are warm, well perfused, no clubbing, cyanosis or edema SKIN: large flesh-colored discrete non-confluent plaques w/o scale or crust on abdomen and under breasts. 1x2 cm erosion on L anterior abdomen w/o surrounding erythema. NEURO: unable to follow commands, EOM appear to be intact. face symmetric at rest. 2+ patellar reflexes. DISCHARGE PHYSICAL EXAM Vitals: 97.5 | 138/55 | 71 | 20 | 95%/1L Is: 470 Os: 1000 Balance: -530 General: Heavy set elderly lady, sleeping comfortably in bed with nasal cannula. HEENT: Sclera anicteric, pale conjunctiva, dry MM, oropharynx clear Neck: supple, no LAD Lungs: Limited due to adiposity. Improved breath sounds w/less ronchi and crackles. CV: Limited due to adiposity. Regular rate and rhythm, normal S1 + S2. Abdomen: Non-distended, 8x10 RLQ eventration covered by dry dressings, BS+, soft,mildly tender on LLQ, limited deep palpation. Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis. Ne edema. Skin: Dry, distally cold, non-elastic Neuro: AOx3, diffuse muscular atrophy and weakness. Normal sensation to light touch. Pertinent Results: ADMISSION LABS ___ 09:50AM GLUCOSE-159* UREA N-19 CREAT-1.0 SODIUM-137 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-19* ANION GAP-20 ___ 09:50AM WBC-12.1*# RBC-4.68 HGB-10.9* HCT-35.2* MCV-75* MCH-23.4* MCHC-31.1 RDW-17.1* ___ 09:50AM proBNP-464 ___ 09:50AM cTropnT-<0.01 ___ 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG DISCHARGE LABS ___ 05:24AM BLOOD WBC-6.7 RBC-4.30 Hgb-10.0* Hct-33.5* MCV-78* MCH-23.2* MCHC-29.8* RDW-17.5* Plt ___ ___ 05:24AM BLOOD Glucose-124* UreaN-35* Creat-1.1 Na-141 K-3.9 Cl-98 HCO3-35* AnGap-12 ___ 05:24AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.4 Cr TRENDS ___ 05:24 1.1 ___ 06:34 1.3* ___ 12:45 1.3* ___ 06:24 1.4* ___ 05:52 1.2* ___ 02:31 0.8 ___ 16:24 0.8 ___ 06:00 0.8 ___ 21:00 0.8 ___ 03:38 0.8 ___ 19:31 0.7 ___ 04:02 0.9 ___ 02:44 0.9 ___ 09:50 1.0 Studies ___ Bilateral scattered opacities in the lungs, most notable in the left lung base and right upper lobe concerning for pneumonia. ___ The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal ___ of the left ventricle, most consistent with Takotsubo cardiomyopathy, although LAD-territory infarction cannot be excluded. The remaining segments contract normally (LVEF delineated to be 40%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild regional left ventricular systolic dysfunction, most c/w Takotsubo cardiomyopathy. Mild mitral regurgitation. Compared with the prior study (images reviewed) of ___, LV function has substantially improved. CHEST (PORTABLE AP) Study Date of ___ 3:47 AM There is a right-sided PICC line with distal lead tip in the distal SVC. There is a left retrocardiac opacity and bilateral pleural effusions which are moderate in size. There is mild pulmonary edema. There are no pneumothoraces. Overall, these findings are stable. ___ 9:54 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. x2 ___ 11:50 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 6:10 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH. ___ 1:40 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. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. GlyBURIDE 2.5 mg PO BID 4. Lisinopril 10 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL EVERY ___. Torsemide 40 mg PO DAILY 8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 9. Warfarin 2 mg PO DAILY16 10. Isosorbide Mononitrate 30 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Acetaminophen 1000 mg PO Q8H 5. Artificial Tears ___ DROP BOTH EYES TID 6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 7. Guaifenesin ___ mL PO Q6H 8. GlyBURIDE 2.5 mg PO BID 9. Nitroglycerin SL 0.3 mg SL EVERY ___. Ipratropium Bromide Neb 1 NEB IH Q6H 11. Miconazole Powder 2% 1 Appl TP BID:PRN yeast 12. Polyethylene Glycol 17 g PO DAILY 13. Milk of Magnesia 30 mL PO DAILY 14. Torsemide 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY #Hypoxic respiratory failure #Healthcate Associated Pnemonia #Decompensated Systolic Heart Failure #Acute Kidney Failure SECONDARY: #Type 2 Diabetes Mellitus #Severe constipation ___ Skin Infection #Large Abdominal Incisional Hernia #Deconditioning 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 HISTORY: ___ female with shortness of breath and hypoxia. COMPARISON: Chest radiograph dated ___. FINDINGS: AP upright frontal and lateral chest radiograph demonstrates opacification of the left lung base concerning for atelectasis or aspiration. Within the right upper lobe, there is a subtle opacity which is concerning for pneumonia. There are mildly increased bronchovascular markings within the upper lobes bilaterally. The cardiomediastinal and hilar contours are unchanged since ___ examination with a heart size which is top normal. There is no pleural effusion or pneumothorax. IMPRESSION: Bilateral scattered opacities in the lungs, most notable in the left lung base and right upper lobe concerning for pneumonia. Radiology Report HISTORY: Post-intubation. TECHNIQUE: Portable frontal chest radiograph was obtained. COMPARISON: Chest radiographs from ___ and ___. FINDINGS: There has been interval placement of an endotracheal tube and nasogastric tube. The endotracheal tube appears to be in appropriate position terminating 4.5 cm above the carina. The nasogastric tube is seen passing below the diaphragm. There continues to be a right upper and lower lobe opacification and a possible retrocardiac opacity. IMPRESSION: Appropriate position of ET tube and nasogastric tube. No significant change in pulmonary opacities. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with pneumonia and respiratory failure, now intubated // interval change in RUL opacity IMPRESSION: In comparison with the study ___, the area of increased opacification in the right upper zone has substantially cleared. Bibasilar opacifications persist. Monitoring and support devices are unchanged. Radiology Report INDICATION: ___ year old woman with new R PICC // 41cm R brachial DL PICC - ___ ___ Contact name: ___: ___ TECHNIQUE: Portable chest x-ray. COMPARISON: Multiple prior radiographs of the chest dated ___ through ___. FINDINGS: Portable semi upright radiograph of the chest demonstrates low lung volumes which results in bronchovascular crowding. Bibasilar opacifications are unchanged as compared to the prior study. The cardiomediastinal and hilar contours are unchanged. The endotracheal tube ends 2.8 cm from the carinal. A nasogastric tube courses into the stomach and out of field of view. A right-sided PICC line ends at the cavoatrial junction. IMPRESSION: Right-sided PICC line ends at the cava atrial junction. Radiology Report INDICATION: ___ year old woman with acute respiratory distress // Assess for interval change TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ and ___. FINDINGS: The patient is now extubated. Enteric tube has been removed. Allowing for differences in projection small bilateral pleural effusions are likely slightly larger. Streaky opacity in the right upper lobe is resolved. There may be increased pulmonary vascular congestion and mild interstitial pulmonary edema. The heart is slightly larger. The mediastinal contours are normal. IMPRESSION: 1. Increased heart size, now with moderate cardiomegaly and worsening mild to moderate pulmonary edema. 2. Small bilateral pleural effusions are also likely larger. Radiology Report INDICATION: ___ year old woman with hypoxemic respiratory failure from pneumonia and chf // assess for interval change TECHNIQUE: Portable chest x-ray. COMPARISON: Multiple prior radiographs of the chest dated ___ through ___. FINDINGS: Portable semi-upright radiograph of the chest demonstrates low lung volumes results in bronchovascular crowding. There are moderate size bilateral pleural effusions with adjacent atelectasis. Soft tissues of the head and neck overly the lung apices. The cardiomediastinal and hilar contours are unchanged. There is no pneumothorax. A right-sided PICC line is in unchanged position. There has been interval removal of the endotracheal tube. IMPRESSION: Moderate bilateral pleural effusions with adjacent atelectasis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ y/o F with pneumonia and CHF // Assess for interval change Assess for interval change IMPRESSION: In comparison with the study ___, there is again enlargement of the cardiac silhouette with evidence of pulmonary vascular congestion and bilateral pleural effusions with compressive atelectasis at the bases. The basilar opacification is less prominent than on the previous study, which could either reflect decreasing pleural effusions or a more upright position of the patient. Radiology Report STUDY: AP chest performed on ___. CLINICAL HISTORY: ___ woman with shortness of breath. Evaluate for pleural effusion versus pneumonia. FINDINGS: Comparison is made to prior study from ___. There is a right-sided PICC line with distal lead tip in the distal SVC. There is a left retrocardiac opacity and bilateral pleural effusions which are moderate in size. There is mild pulmonary edema. There are no pneumothoraces. Overall, these findings are stable. Radiology Report STUDY: Portable abdomen, ___. CLINICAL HISTORY: ___ woman with no stool for eight days. Evaluate for ileus or small bowel obstruction. FINDINGS: Comparison is made to radiographs of the pelvis from ___. Images are somewhat limited as the patient could not lie supine and thus decubitus radiographs were performed. These demonstrate air within the stomach. There is also air within loops of colon, which are nondilated. Stool is seen throughout the sigmoid colon. There are few air-filled loops of small bowel within the left abdomen, which are mildly prominent. There is no definite free intra-abdominal gas. Degenerative changes of the lower lumbar spine and bilateral hip joint spaces are seen. IMPRESSION: Nonspecific bowel gas pattern with air and stool seen throughout the colon extending into the rectum and sigmoid colon. There also appears to be air-filled loops of mildly dilated loops of small bowel within the left abdomen. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with CHF, pleural effusions // assess for changes in effusions assess for changes in effusions IMPRESSION: In comparison with the study ___, there is again enlargement of the cardiac silhouette with bilateral pleural effusions and compressive atelectasis and mild to moderate pulmonary edema. Gender: F Race: WHITE - RUSSIAN Arrive by AMBULANCE Chief complaint: Dyspnea Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA temperature: 98.7 heartrate: 103.0 resprate: 18.0 o2sat: 99.0 sbp: 125.0 dbp: 52.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ was a pleasure to take care of you during your recent stay at ___. You were admitted with a serious pneumonia that required you to have a breathing tube and treatment in the intensive care unit. Your heart and kidneys were also affected and you improved little by little. You are now ready to go to rehab to get your strength back before going home. Please make sure to follow-up with your primary care physician and your new outpatient cardiologist. We wish you a quick recovery! Your ___ 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, ab pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female with a history of pancreatic cancer s/p gemcitabine . On further interview w/ daughter who lives w/ pt, she was taken into BIN clinic for IVF hydration as she was persistently nauseous and not eating for several days after receiving chemo. She had also had fevers >100 on two occasions earlier in the week but none since ___. Prev treated for UTIs over past months but denied any dysuria recently. Did have some ab pain but was not primary cause for bringing her in. On arrival she was transferred to ED, had hypoxia to mid ___, developed restlessness thought to have wheezing and respiratory distress and was placed on bipap briefly but then weaned to NC. She had CT ab that showed extensive disease involving primary panc mass as well as celiac axis, peritoneal nodules and umbilicus, new liver met, new possible mets to endometrium and L ovary and unchanged abdominal LAD. She received IVF and IV antibiotics and was transferred to ___ for further eval. On arrival she was afebrile w/o any ab pain or SOB, NC weaned to RA. she is eating, denies any nausea although does not have much appetite, per daughter she has been forcing herself to eat for several weeks. overall doing well since yest. remains on RA. denies SOB but does have cough, w/ white phlegm, afebrile since admission. cr up today and UOP decreased. REVIEW OF SYSTEMS: No fever/chills, chest pain, lightheadedness, melena, hematochezia, sore throat, rhinorrhea, sinus pain/pressure. no dysuria remainder of 10 pt ROS negative other than HPI above. REVIEW OF SYSTEMS: - All reviewed and negative except as noted in the HPI. Past Medical History: Pancreatic Cancer - Ms. ___ sustained a mechanical fall while walking her dog on ___. She landed on her buttocks and then developed pain in the left low back/left flank, which prompted her to present to the ___ Emergency Department. CT abdomen/pelvis incidentally identified a 2.9 cm mass in the pancreatic head/body, multiple bilateral lung lesions concerning for metastases as well as peripancreatic and retroperitoneal lymphadenopathy. Also notable was a thickened endometrium. She was discharged and met with her PCP who obtained ___ CA ___ on ___ which was elevated at 682. CT chest on ___ showed widespread pulmonary nodules consistent with pulmonary metastases. She underwent ___ biopsy of a right lower lobe lung nodule on ___. Pathology showed adenocarcinoma with immunostains positive for CK7, CEA, CDX2, focally positive for CK20 and negative for TTF-1, and Napsin. The phenotype was consistent with a pancreatico-biliary origin. - Gemcitabine C1 ___. PAST MEDICAL HISTORY: -Hypertension. -GERD. -Depression. -Status post cholecystectomy. Social History: ___ Family History: The patient's mother died at ___ years and her father ___ years. She has five siblings. One brother died in a war at ___ years. Another brother died at ___ years of old age. A brother died of pancreatic cancer at ___ years. A sister died of ___ disease at ___ years and another died at ___ years. She has a daughter who has asthma and a son without health concerns. Physical Exam: General: NAD VITAL SIGNS: 98.1 110/70 78 18 98%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: decreased at bases o/w CTAB, nonlabored ABD: mod distended but soft and tympanitis, BS active, firm 2cm nodule palpable at umbilicus LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficitis. Pertinent Results: ADMISSION LABS: ___ 09:30AM BLOOD ___-15.5*# RBC-3.70* Hgb-10.5* Hct-32.0* MCV-87 MCH-28.4 MCHC-32.8 RDW-14.5 RDWSD-45.5 Plt ___ ___ 09:30PM BLOOD Neuts-93* Bands-5 Lymphs-1* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-10.58* AbsLymp-0.11* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00* ___ 09:30AM BLOOD UreaN-35* Creat-1.4* Na-128* K-4.5 Cl-94* HCO3-20* AnGap-19 ___ 09:30AM BLOOD ALT-21 AST-29 AlkPhos-90 TotBili-1.1 ___ 09:30AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.7 DISCHARGE LABS: ___ 05:13AM BLOOD Glucose-100 UreaN-49* Creat-1.3* Na-131* K-4.4 Cl-101 HCO3-20* AnGap-14 ___ 05:13AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 IMAGING: CT abdomen; CT Abdomen: 1. There is again seen a large hypo enhancing pancreatic mass causing upstream pancreatic dilatation. There is increased abnormal soft tissue now tracking up to encased the trifurcation of the celiac artery and abutting the superior mesenteric artery. The splenic vein is occluded. Appearances are consistent with local progression of disease. 2. No significant interval change in the numerous bibasal pulmonary metastases. 3. Moderate right, small left pleural effusions increased when compared the prior study. 4. Small volume ascites. Multiple peritoneal soft tissue deposits have increased in size consistent with progressive peritoneal metastatic disease. A soft tissue nodule is seen within the umbilicus also. 5. New segment 5 liver lesion consistent with a metastasis. A linear hypo enhancing structure also in segment 5 has increased compared to the prior study but is of unclear etiology. 6. No significant interval change in the retrocrural, retroperitoneal and mesenteric lymphadenopathy. 7. Fluid in the endometrial cavity with an apparent soft tissue mass, this could reflect either a primary endometrial mass such as a polyp or carcinoma versus metastatic disease. New enlargement of the left ovary also concerning for metastatic disease. 8. Enlarged gonadal vessels, particularly on the left, likely related to occlusion of the splenic vein. 9. New hypo enhancing lesion within the spleen may reflect an infarct versus an additional area of metastatic disease. CT chest IMPRESSION: 1. Numerous pulmonary nodules consistent with metastasis are larger compared to ___. 2. Small to moderate right and small left pleural effusions are new. 3. Prominent pericardial lymph nodes are larger. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 12.5 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY 3. Meclizine 25 mg PO DAILY:PRN Dizziness 4. Omeprazole 20 mg PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN Nausea 6. Prochlorperazine 10 mg PO Q6H:PRN Nausea 7. Aspirin 81 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. Albuterol Inhaler 1 PUFF IH DAILY 11. Mirtazapine 7.5 mg PO QHS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Mirtazapine 7.5 mg PO QHS 3. Multivitamins 1 TAB PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN Nausea 5. Vitamin D ___ UNIT PO DAILY 6. Benzonatate 200 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth TID prn Disp #*90 Capsule Refills:*0 7. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 10 mL by mouth every 6 hours as needed Refills:*0 8. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing, SOB RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL inhaled every 4 hours as needed Disp #*30 Ampule Refills:*1 9. Meclizine 25 mg PO DAILY:PRN Dizziness 10. Omeprazole 20 mg PO DAILY 11. Prochlorperazine 10 mg PO Q6H:PRN Nausea 12. Ensure Clear (nut.tx.impaired digest fxn) 0.035-1 gram-kcal/mL oral TID W/MEALS RX *nut.tx.impaired digest fxn [Ensure Clear] 0.035 gram-1 kcal/mL 200 mL by mouth TID w/ meals Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Severe nausea and vomiting Dehydration Acute kidney injury Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old woman with metastatic pancreatic cancer and new hypoxia. // Evaluate for cause of hypoxia. TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent 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: Acquisition sequence: 1) Spiral Acquisition 5.1 s, 33.4 cm; CTDIvol = 5.4 mGy (Body) DLP = 177.5 mGy-cm. Total DLP (Body) = 178 mGy-cm. COMPARISON: Chest CT without contrast ___ FINDINGS: The thyroid is normal. Supraclavicular, axillary, and mediastinal lymph nodes are not enlarged. Prominent pericardial lymph nodes are larger than before. A 0.7 cm pericardial node (5:217) was 0.2 cm before. A Right jugular venous line terminates in low SVC. Aorta and pulmonary arteries are normal size. Heavy coronary artery calcification is noted. Trace pericardial effusion is physiologic. Evaluation of lung parenchyma is limited due to motion artifact. Numerous pulmonary metastasis appear overall larger than before. For example, a 1.1 cm lesion in the left upper lobe (5:120) was 0.9 cm before. A 1.6 cm lesion in the lingula (5:152) was 1.0 cm before. Small to moderate right and small left pleural effusions are new. Limited evaluation of upper abdomen is notable for small ascites. Hypodensity lesions in the liver were better evaluated on CT abdomen and pelvis with contrast from 1 day ago. Sclerotic lesions in T7 and 8 vertebral bodies are unchanged. IMPRESSION: 1. Numerous pulmonary nodules consistent with metastasis are larger compared to ___. 2. Small to moderate right and small left pleural effusions are new. 3. Prominent pericardial lymph nodes are larger. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Dyspnea Diagnosed with Unspecified abdominal pain, Dyspnea, unspecified temperature: 99.4 heartrate: 94.0 resprate: 24.0 o2sat: 100.0 sbp: 110.0 dbp: 78.0 level of pain: 0 level of acuity: 2.0

Dear Ms ___, it was a pleasure caring for you during your stay at ___. You were admitted with abdominal pain, nausea and vomiting and also had an episode of respiratory distress while at ___. The vomiting was likely a side effect of chemotherapy and led to dehydration. The respiratory distress improved quickly and you did not need any further oxygen on arrival here. There was no pneumonia and only a small fluid collection on CT chest. Continue using nebulizer treatments at least ___ or more frequently if needed. Lastly you had a kidney injury from a combination of dehydration, medications and CT dye however this is improving.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pravachol / Lipitor Attending: ___. Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is an ___ with h/o Alzeihmer's dementia who p/w SOB and new onset productive cough that started as a dry cough 3 days prior. She has had this since awakening this AM, worsening throughout the day. EMS called for rr30's, SaO2 80's, but afebrile by report. No O2 sat recorded there but 86% on RA per EMS. Pt denies CP. States never been SOB previously. Per family, no hx of CHF. Denies increased ___ edema. States she felt well when she went to bed yesterday evening. Never had these symptoms before. . In the ED, initial VS were: 96.4 104 168/84 36 95% 10L Non-Rebreather. CXR showed lower lobe, ___ opacities c/w PNA, aspiration, or atelectasis. Some vascular prominence concerning for mild edema. BNP 4300. WBC 13 with neutrophil predominence. Initial cardiac enzymes show CK-MB 11, MBI 5.4, troponin 0.11. Discussed with cardiology who thought that MICU would be appropirate given absence of cardiac history and no evidence of ischemic changse on EKG. Given ASA, nitro SL, lasix 40mg IV x1, vanc/ceftriaxone for HCAP. . On arrival to the MICU, the patient has advanced dementia and can not participate in the interview. Talking to her son and HCP, he says that she has been in her USOH until this AM. She lives in an Alzheimers community. Her PMH is only significant for hyperlipidemia and ? silent MI in the past. Her vitals on admission are 99.9 ax, 94, 95% on CPAP ___. . Review of systems: (+) Per HPI The rest is unable to be elicited by the patient Past Medical History: Advanced Alzheimers Dementia Hyperlipidemia Silent MI in the past (inferior Q-waves) Critical Aortic Stenosis - valve area 0.6 cm Social History: ___ Family History: NC Physical Exam: ADMISSION EXAM 98.2 ___ 143/82 rr24 on cpap CPAP 5cmH2O General: Agitated, trying to get out of bed, AOx1 HEENT: Sclera anicteric, on BIPAP mask Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, loud ejection murmur of AS, possible MR, no rubs, gallops Lungs: Scattered rhonchi at bases, bibasilar crackles, no wheezes, no increased work of breathing Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: nonfocal . On discharge: Alert, pleasantly demented. Oriented only to self. Lungs with diffuse rales but mostly clear, unlabored/no wheezing. On room air. Soft, nontender abdomen. Harsh systolic murmur. Pertinent Results: ADMISSION LABS: ___ 05:35PM BLOOD WBC-13.2* RBC-4.43 Hgb-12.8 Hct-38.3 MCV-87 MCH-29.0 MCHC-33.5 RDW-13.7 Plt ___ ___ 05:35PM BLOOD Neuts-89.1* Lymphs-7.6* Monos-2.5 Eos-0.5 Baso-0.3 ___ 05:35PM BLOOD Glucose-200* UreaN-22* Creat-0.7 Na-134 K-4.2 Cl-99 HCO3-23 AnGap-16 ___ 05:35PM BLOOD CK(CPK)-202* ___ 05:35PM BLOOD CK-MB-11* MB Indx-5.4 proBNP-4350* ___ 01:40AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0 ___ 10:22PM BLOOD Type-ART Temp-37.2 Rates-/27 Tidal V-400 PEEP-5 FiO2-100 pO2-85 pCO2-42 pH-7.44 calTCO2-29 Base XS-3 AADO2-603 REQ O2-96 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NIV ___ 05:42PM BLOOD Lactate-2.2* K-4.0 . MICRO DATA: ___ URINE Legionella Urinary Antigen: negative ___ BLOOD CULTURE x 2 (pending) . CXR ___: IMPRESSION: Basilar opacities worrisome for pneumonia in the appropriate clinical setting although lower airway inflammation, atelectasis or even aspiration are other etiologies that could be considered in the appropriate clinical setting. Although there is perhaps minimal vascular prominence, since opacities are focal in the lower lungs, pulmonary edema is doubted as the primary etiology but could be seen with an atypical pattern. . TTE ___: IMPRESSION: Critical aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Pulmonary artery hypertension. Mild aortic regurgitation. Increased PCWP. . CTA ___: IMPRESSION: 1. No evidence for PE. 2. Multifocal pneumonia involving the right upper, middle and both lower lobes with bilateral hilar lymphadenopathy. 3. No evidence for a mass. . Bladder ultrasound: IMPRESSION: Foley catheter present within a collapsed bladder. Superior to the bladder there is a large cystic structure with no internal nodules identified. This may represent a paraovarian or ovarian cyst or peritoneal inclusion cyst. MRI pelvis is suggested for further characterization . On discharge: ___ 06:50AM BLOOD WBC-10.8 RBC-3.51* Hgb-10.1* Hct-30.7* MCV-88 MCH-28.7 MCHC-32.9 RDW-13.4 Plt ___ ___ 05:40AM BLOOD ___ PTT-31.9 ___ ___ 05:50AM BLOOD Glucose-92 UreaN-22* Creat-0.7 Na-138 K-4.2 Cl-102 HCO3-26 AnGap-14 Medications on Admission: MED LIST FROM ___ Seroquel 25mg BID Seroquel 12.5mg daily PRN Namenda 10mg BID Donepezil 10mg daily Citalopram 15mg daily vitamin D 800IU daily Nystatin cream Discharge Medications: 1. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for agitation. 3. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. citalopram 10 mg Tablet Sig: 1.5 Tablets PO once a day. 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain/fever. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Pneumonia Critical aortic stenosis Rectal bleeding NSTEMI Peritoneal cyst . Secondary: Advanced Alzheimers Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Has been getting 1-person assitance here. Followup Instructions: ___ Radiology Report CT OF THE CHEST WITH AND WITHOUT IV CONTRAST INDICATION: ___ woman with hypoxic respiratory distress, also with smoking history and tracheal deviation. Evaluate for mass, pulmonary embolus. CT OF THE CHEST WITH AND WITHOUT IV CONTRAST, TECHNIQUE: Multidetector scanning is performed from the thoracic inlet through the diaphragm prior to and during dynamic injection of 100 cc of Omnipaque. No prior studies are available for comparison. There are small peritracheal lymph nodes, the largest node measures 0.9 x 0.8 cm. These do not meet CT criteria for pathologic enlargement. There is no axillary lymphadenopathy. There is prominent soft tissue in the hilum bilaterally. In the left hilum, this measures 1.1 x 1.1 cm. Right hilar lymphadenopathy measures 1.5 x 1.4 cm. There are no pleural effusions. On lung windows, there are focal opacities in the upper lobes, right more than left, in the right middle lobe and both lower lobes. While some of these areas enhance normally with IV contrast and thus represent atelectasis, other foci are less enhancing (series 3, image 59 in the left lower lobe and series 3, image 55 in the right lower lobe). The trachea is somewhat deviated to the right; however, this is due to the aortic arch. There is no mass causing tracheal deviation. The depicted portions of the liver and spleen are unremarkable. On bone windows, there are no concerning osteolytic or osteosclerotic lesions. CT ANGIOGRAPHY: The ascending aorta is normal in caliber measuring 2.7 cm. There is no filling defect in the pulmonary arteries or its branches. IMPRESSION: 1. No evidence for PE. 2. Multifocal pneumonia involving the right upper, middle and both lower lobes with bilateral hilar lymphadenopathy. 3. No evidence for a mass. Radiology Report CHEST RADIOGRAPH INDICATION: Pneumonia, oxygen requirement, evaluation for progression. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the pre-existing volume loss in the middle lobe has improved. However, the pre-existing right basal opacity, predominantly in peribronchial location and displaying multiple air bronchograms, unchanged. Minimal improvement of a pre-existing retrocardiac atelectasis, a pre-existing plate-like atelectasis at the left lung base has resolved. Unchanged moderate cardiomegaly, no indication for pleural effusions. Signs of mild fluid overload might be present. Radiology Report INDICATION: Advanced Alzheimer's and pneumonia. Please evaluate for urinary retention as nursing continues to show greater than 700 cc on the bladder scanner despite placement of a Foley catheter. COMPARISON: None. FINDINGS: The bladder is distended, with a calculated volume of 713 mL. There is no Foley catheter identified within the bladder. IMPRESSION: Distended bladder to 713 mL. No Foley catheter is seen within the bladder. Radiology Report ULTRASOUND: INDICATION: ___ woman with pneumonia and bladder over 70 mL. Please evaluate disease. Foley balloon is visualized and bladder are not seen on exam yesterday ? concern for cyst. COMPARISON: Comparison is made to previous ultrasound dated ___. FINDINGS: A Foley catheter is identified within a collapsed bladder. Superior to the bladder, there is a 10.6 x 8.8 x 11.9 cm cystic structure with no internal nodules or suspicious features, which is deviating the uterus anteriorly. There are multiple calcified fibroids within the uterus, the largest measuring 1.9 x 1.7 x 1.8 cm within the lower uterine segment. The uterus measures 4.5 x 2.7 cm in transverse dimension. Normal endometrial thickness of 4 mm. The ovaries were not visualized bilaterally. IMPRESSION: Foley catheter present within a collapsed bladder. Superior to the bladder there is a large cystic structure with no internal nodules identified. This may represent a paraovarian or ovarian cyst or peritoneal inclusion cyst. MRI pelvis is suggested for further characterization. Findings were discussed with Dr. ___ by phone with Dr. ___ ___ at 1:46pm on ___. Radiology Report CHEST RADIOGRAPH HISTORY: Shortness of breath. COMPARISONS: None. TECHNIQUE: Chest, portable semi-upright AP portable. FINDINGS: The heart is mild to moderately enlarged. Mild unfolding of the thoracic aorta is noted. The pulmonary vascularity is minimally prominent. Streaky left mid and lower lung opacities are probably compatible with minor atelectasis, but there is also a vague retrocardiac opacity. There is more widespread but patchy opacification involving the right lower lung, probably in the right middle lobe, raising concern for pneumonia. IMPRESSION: Basilar opacities worrisome for pneumonia in the appropriate clinical setting although lower airway inflammation, atelectasis or even aspiration are other etiologies that could be considered in the appropriate clinical setting. Although there is perhaps minimal vascular prominence, since opacities are focal in the lower lungs, pulmonary edema is doubted as the primary etiology but could be seen with an atypical pattern. Radiology Report AP CHEST, 3:36 A.M., ___ HISTORY: ___ woman with cough, fever and hypoxia. IMPRESSION: AP chest compared to ___, 5:24 p.m.: Volume loss has developed in a region of prior consolidation in the right lower lobe, probably in the course of developing pneumonia with retained secretions. Atelectasis in the left mid lung is more linear. Moderate cardiomegaly and mediastinal vascular engorgement have increased suggesting a component of mild cardiac decompensation. Pleural effusions are small, if any. No pneumothorax. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: DYSPNEA Diagnosed with RESPIRATORY ABNORM NEC, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE temperature: 96.4 heartrate: 104.0 resprate: 36.0 o2sat: 95.0 sbp: 168.0 dbp: 84.0 level of pain: 0 level of acuity: 1.0

It was a pleasure caring for you at the ___ ___. You were admitted to the hospital for a severe pneumonia. We treated you with antibiotics and you improved. We also discovered that you have a very narrow heart valve - known as aortic stenosis. You will follow-up with a cardiologist for this problem. Finally, you developed rectal bleeding later on in your admission - we think this is from either hemorrhoids or diverticuli and we will manage this conservatively for now. . We made the following changes to your medications: We STARTED aspirin 81 mg per day We STARTED Toprol 25 mg per day . Your follow-up information is listed below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Allopurinol And Derivatives Attending: ___. Chief Complaint: AMS, fever Major Surgical or Invasive Procedure: ___ Central venous line History of Present Illness: History of Present Illness: ___ year old male with history of mild cognitive impairment, hyperlipidemia, BPH, and gout presents with altered mental status, vomiting, and shaking chills. He was watching ___ speak at the ___ and he began to feel very cold and started vomiting. As the night went on, he became more tired and less responsive and the wife called EMS. She reported to them that he was not acting like himself and was talking nonsense. On transfer, he became more lethargic and even less responsive. Patient triggered on arrival for altered mental status. ___ sugar was normal. He took his first dose of donepezil tonight, but did not make any other medication changes. No other localizing symptoms to speak of. Per urgent care note from Dr. ___ experienced malaise with numbness in his fingers and chills while in ___, ___ ___ about 4 weeks ago. He was taken to the local emergency room in that area (___) and his symptoms of fever and malaise resolved since then. No definite cause of this acute illness was found. There was a concern about possible Lyme disease because of exposure to deer near his home. The patient denies any tick bite and claims that he rarely goes out in his yard, where they do have deer. He was started on doxycycline for concern of potential Lyme exposure given that they live in a wooded area. Lyme serology eventually returned negative. The wife reports that his current symptoms are very similar to this presentation, but he appeared more confused this time. In the ED, initial vitals were: 122 102/55 28 91% 2L NC. He was following basic commands on arrival. Rectal temp of 103. Labs were notable for low WBC at 3.5 and otherwise normal CBC. Creatinine on 1.3 close to baseline and LFTs within normal limits. Lactate originally at 4.3, then repeated at 5.7 after 2L NS. Urinalysis unremarkable and CXR clear. Head CT without acute intracranial process and moderate paranasal sinus disease, similar to prior. CT abd/pelv showed a hiatal hernia, cholelithiasis w/o cholecystitis, nonspecific perinephric stranding, enlarged prostate, small left fat-containing inguinal hernia (similar to prior CT in ___. Without obvious infectious cause, he was covered empirically with vanc/zosyn + ceftriaxone. LP refused by wife. ___ pressures have trended down to the SBPs ___ but wife also refused ___ placement so patient was started on peripheral norepinephrine. 4th liter hanging prior to transfer and SBPs in ___ with normal oxygenation. On arrival to the MICU, he continued to be hypotensive despite uptitration of levophed and another 1L NS bolus. The wife is amenable to a central line placement here in the unit and willing to discuss further procedures needed for his care. The patient is having word-finding difficulties per his baseline and has trouble completing sentences. Orientation is therefore difficult to assess. Past Medical History: PMH: Uric acid nephrolithiasis s/p GU interventions in the past Hypercholesterolemia Gout (last attack ___ years ago) PSH: L URS with laser and cystolithalopaxy with ___ in ___ Cystolithalopaxy in ___ Social History: ___ Family History: - Diabetes in uncles - ___ Cancer in father Physical ___: T: 98.2, BP:85/60, P: 101 R: 9, O2: 93% on 3L General: eyes closed, responds to command intermittently but is responsive to question, has difficulty forming his answers, no acute respiratory 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 GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Fasciculations evident in calves bilaterally (patient unaware) Neuro: CNII-XII intact, difficult to assess strength/sensation given inability to follow commands reliably. Pertinent Results: ___ 08:13PM LACTATE-5.4* ___ 07:24PM GLUCOSE-206* UREA N-19 CREAT-1.4* SODIUM-138 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-18* ANION GAP-21* ___ 07:24PM ALT(SGPT)-20 AST(SGOT)-27 ALK PHOS-29* TOT BILI-0.3 ___ 07:24PM CALCIUM-7.0* PHOSPHATE-3.8# MAGNESIUM-1.6 ___ 07:24PM WBC-38.7* RBC-4.29* HGB-12.8* HCT-38.3* MCV-89 MCH-29.8 MCHC-33.3 RDW-13.7 ___ 02:52PM URINE ___ NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM ___ 02:52PM URINE RBC-137* WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 ___ 02:21PM LACTATE-6.8* ___ ___ Culture: GNR SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) | CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S TOBRAMYCIN------------ S Imaging: Echo ___ IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen. Normal global and regional biventricular systolic function. ___: NO GROWTH. KUB ___: IMPRESSION: No signs of obstruction or intraperitoneal free air. Prostate US ___ IMPRESSION: 1. No evidence of an abscess within the prostate. 2. Substantial BPH with a prostatic volume of 72 mL, correlating with a predicted PSA of 8.6. ___ CT abdomen, pelvis IMPRESSION: 1. No acute intra-abdominal process; moderate colonic fecal burden. 2. Hiatal hernia. 3. Enlarged prostate and left fat- and bladder-containing inguinal hernia. 4. Mildly thickened left renal pelvis urothelium of unclear significance; no evidence of hydronephrosis or pyelonephritis. ___ CT head w/o contrast IMPRESSION: Minimal paranasal sinus mucosal thickening. Otherwise normal study. CXR ___ IMPRESSION: Low lung volumes but no evidence of pneumonia. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Meclizine 50 mg PO X1 PRN vertigo 2. Clotrimazole Cream 1 Appl TP QHS to feet 3. Ibuprofen 200 mg PO DAILY pain 4. Donepezil 10 mg PO AT NOON WITH LUNCH 5. tadalafil *NF* 20 mg Oral q72h PRN erectile dysfunction 6. Probenecid ___ mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: E. Coli septic shock. Secondary: Acute confusion on chronic mild cognitive impairment. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: ___ male with fever and altered mental status. STUDY: Portable AP upright chest radiograph. COMPARISON: ___ chest radiograph. FINDINGS: The heart size is within normal limits. Mediastinal contours demonstrate calcified atherosclerotic disease of the aortic knob. The lung volumes are low but clear of consolidation. There is no large pleural effusion or pneumothorax. IMPRESSION: Low lung volumes but no evidence of pneumonia. Radiology Report HISTORY: ___ male with increased lethargy, confusion, and vomiting. STUDY: CT of the head without contrast; images were acquired in the soft tissue and bone algorithms. Coronal and sagittal reformatted images were also generated. COMPARISON: ___. FINDINGS: There is no evidence of hemorrhage, edema, or mass effect. The gray-white matter differentiation is intact. The ventricles and sulci are normal for age. Moderate mucosal thickening is present in the lower frontal and ethmoid sinuses. The mastoid air cells are clear. Mucosal thickening is also present in the base of the maxillary sinuses bilaterally. IMPRESSION: Minimal paranasal sinus mucosal thickening. Otherwise normal study. Radiology Report HISTORY: ___ male with vomiting, fever, and lethargy. STUDY: CT OF THE ABDOMEN AND PELVIS WITH CONTRAST; 130 cc of Omnipaque intravenous contrast was administered without adverse reaction or complication. Coronal and sagittal reformatted images were also generated. COMPARISON: Abdomen CT from ___, and abdomen and pelvis CT from ___. FINDINGS: ABDOMEN: Bibasilar atelectasis is present as well as a small hiatal hernia. Calcified atherosclerotic disease is present in the coronary arteries, and mitral valve calcifications are also present. The liver shows no focal lesion or intrahepatic biliary dilatation. The gallbladder shows a single calcified layering stone, but no wall edema or pericholecystic fluid. Spleen is normal in size. The pancreas is markedly atrophic with a punctate calcification, possibly representing a degree of chronic pancreatitis. The adrenal glands are normal appearing bilaterally. The kidneys enhance with and excrete contrast symmetrically. Small subcentimeter hypodensities in each kidney are too small to characterize, but likely represents cysts. Mild urothelial thickening is present in the left renal pelvis. Non-specific perinephric stranding is present bilaterally. The small and large bowel show no evidence of wall edema or obstruction. The colon demonstrates a moderate fecal burden. The aorta is of a normal caliber along its course with areas of calcified and non-calcified atherosclerotic disease present. Scattered subcentimeter retroperitoneal lymph nodes are seen in the periaortic stations, but none meet pathologic size criteria. There is no free air or free fluid. PELVIS: The bladder is decompressed around a Foley balloon with herniation of the left aspect of the bladder into the primarily fat-containing left inguinal hernia. The prostate continues to be enlarged. There is no pelvic lymphadenopathy or free fluid, and the rectum appears unremarkable. BONES: There are no aggressive-appearing lytic or sclerotic lesions. Mild-to-moderate degenerative changes are seen throughout the thoracolumbar spine. IMPRESSION: 1. No acute intra-abdominal process; moderate colonic fecal burden. 2. Hiatal hernia. 3. Enlarged prostate and left fat- and bladder-containing inguinal hernia. 4. Mildly thickened left renal pelvis urothelium of unclear significance; no evidence of hydronephrosis or pyelonephritis. Radiology Report CHEST RADIOGRAPH INDICATION: Altered mental status, hypotension, new PICC line placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient shows increased vascular diameters and markings, likely reflecting mild pulmonary edema. The patient has received a right internal jugular vein catheter. The tip projects over the low SVC. There is no evidence of complication, notably no pneumothorax. Normal size of the cardiac silhouette. No pleural effusions. Radiology Report INDICATION: Sepsis with increasing lactate and no localizing source. Concern for occult prostatitis. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: The seminal vesicles are full and symmetric. The central portion of the prostate is expanded, consistent with benign prostatic hypertrophy. Within the right lateral aspect of the prostate, there are two small cysts, each measuring approximately 5 mm. There is no fluid collection within either the prostate or seminal vesicles to suggest an abscess. The prostate measures 5.6 x 4.2 x 5.9 cm, yielding a volume of 72 mL. A Foley catheter is in place. IMPRESSION: 1. No evidence of an abscess within the prostate. 2. Substantial BPH with a prostatic volume of 72 mL, correlating with a predicted PSA of 8.6. Radiology Report INDICATION: ___ man with rapidly rising lactate and WBC count to 34, evaluate for acute abdominal pathology. COMPARISON: CT abdomen and pelvis from earlier today. FINDINGS: AP supine and left lateral decubitus views of the abdomen and pelvis show gas-filled non-distended loops of bowel with no signs of obstruction. No definitive free air is seen on the lateral decubitus position. Degenerative changes are seen in the lumbar spine and the hips. No significant soft tissue calcifications. IMPRESSION: No signs of obstruction or intraperitoneal free air. Radiology Report INDICATION: ___ male with Gram-negative bacteremia and right upper quadrant pain. COMPARISON: CT abdomen and pelvis ___. FINDINGS: The liver demonstrates normal echotexture. A 1.2-cm echogenic left hepatic lobe lesion, likely represents a hemangioma. There is no intra- or extra-hepatic biliary dilatation. CBD is normal measuring 4 mm. The gallbladder is mildly distended, and contains two mobile gallstones. There is no gallbladder wall thickening or pericholecystic fluid to suggest acute cholecystitis. The main portal vein has normal hepatopetal flow. IMPRESSION: 1. Cholelithiasis in a distended gallbladder. No signs of acute cholecystitis. 2. Left hepatic lobe hemangioma. Radiology Report HISTORY: Sepsis. FINDINGS: In comparison with the study of ___, there is increasing pulmonary vascular congestion. The right hemidiaphragm is not well seen, suggestive of a developing pleural effusion with atelectasis at the right base. In the appropriate clinical setting, supervening pneumonia would have to be considered. Radiology Report ABDOMEN AND PELVIC CT INDICATION: ___ man with gram-negative rod sepsis, now improving, looking for etiology. COMPARISON: Comparison was performed with prior CT study from ___. TECHNIQUE: Multidetector axial CT images were acquired through abdomen and pelvis and reconstructed into coronal and sagittal planes. Study was performed after intravenous contrast was administered with 130 cc and scanning was performed in the portal venous phase. DLP: 885 mGy-cm. FINDINGS: ABDOMEN: Moderate right pleural effusion and small left pleural effusions are noted, accompanied by secondary atelectasis. Aortic valve calcifications. A small hiatal hernia is seen. The liver demonstrates no focal lesions throughout. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains a dependent stone. There is no evidence of gallbladder wall thickening. The spleen is of normal size and attenuation throughout. The pancreas is mildly atrophic, but without evidence of focal lesions throughout. The adrenals are unremarkable bilaterally. The right kidney is unremarkable. The left kidney shows a focal 1-cm lesion in the anterior mid pole (2:38), which is too small to characterize on the current study. Small retroperitoneal lymph nodes are noted. Diffuse atherosclerosis of the abdominal aorta is seen. The visualized small and large bowel loops are within normal limits. PELVIS: The urinary bladder is catheterized. The bladder is extending into the left inguinal hernia (2:96). The inguinal hernia also contains fat. The rectum is unremarkable. There is no evidence of pelvic lymphadenopathy. Small amount of fluid is seen along the bilateral flanks. Degenerative changes in the lumbar spine are noted. IMPRESSION: 1. Left inguinal hernia containing urinary bladder and fat. 2. Small hiatal hernia. 3. Bilateral pleural effusions, moderate on the right and small on the left, accompanied with secondary atelectasis. 4. No abscess or source of occult infection identified. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LETHARGIC Diagnosed with SEPTICEMIA NOS, FEVER, UNSPECIFIED, SEPSIS , ACCIDENT NOS temperature: nan heartrate: 122.0 resprate: nan o2sat: 91.0 sbp: 102.0 dbp: 55.0 level of pain: nan level of acuity: 1.0

Mr. ___, It was a pleasure taking care of you at the ___. You were admitted for altered mental status and fever. We found a serious bacterial infection in your ___. You were admitted to the intensive care unit where you received lots of fluids, intravenous antibiotics, and ___ pressure support. After a few days you were transfered to the general medicine floor where you finished your 7 day course of intravenous antibiotics. You will go home and take antibiotic pills by mouth for another 7 days to complete the course of the antibiotics. You had a rash on your legs, abdomen and arms the last day and half of your stay. The rash is likely due to a reaction to the antibiotic Ceftriaxone. This will likely start to spread over the next few days, and may itch. You can use the sarna lotion for itch, or over-the-counter hydrocortisone. Call Dr. ___ the rash spreads over the entire body, if you have severe itching, or if you develop ANY BLISTERING AT ALL. Please call your primary physician ___ at ___ if you have any signs of infection again. These include fevers, chills, cough, pain on urination, increased frequency of urination among other symptoms. Please finish all the antibiotic we have given you. An appointment has been made for you with Dr. ___ on ___. However, he will likely see you sooner than that. He will call you in the next few days to schedule an appointment with him as early as tomorrow or ___. MEDICATIONS STARTED: Ciprofloxacin 500mg twice a day for 7 days starting ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Right hip pain. Major Surgical or Invasive Procedure: ___ - Operative treatment right intertrochanteric hip fracture with sliding hip screw. History of Present Illness: Patient is a ___ y.o. female who had a fall from standing while walking to the bathroom earlier this evening. Denies prodromal sx, denies syncopal type episode. Was taken to the ED and complained about hip pain. Denies pain to other anatomic areas. Denies LOC. Past Medical History: CARCINOMA, SKIN, SQUAMOUS CELL DIFFUSE LARGE B CELL LYMPHOMA ___ RCHOP x 6 GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA HYPOTHYROIDISM LYMPHOMA NEC, MLIG INTRATHORACIC MONOCLONAL GAMMOPATHY URINARY TRACT INFECTION PRIMARY MEDIASTINAL B CELL LYMPHOMA HIP FRACTURE H/O TRANSIENT ISCHEMIC ATTACK Social History: ___ Family History: Non-contributory (M died at ___, F died at ___, both of CAD; does not know cause of death of her siblings). Physical Exam: EXAM ON ADMISSION: VS: AVSS Gen: NAD, AAO x 3 CV: Non-labored breathing. RRR MSK: RLE: Leg externall rotated and slightly shortened. Skin intact. Compartments soft. ___ pulse. ___. Foot warm, well perfused. EXAM ON DISCHARGE: VS: AVSS Gen: NAD, AAO x 3 CV: Non-labored breathing. RRR ABD: Soft, non-tender, non-distended, BS+ RLE: Incisions clean/dry/intact. DP pulse 1+. ___. Foot warm, well perfused. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 06:22 7.0 3.10* 9.8* 29.7* 96 31.5 33.0 13.6 161 Medications on Admission: Levothyroxine Lansoprazole Aspirin Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 112 mcg PO DAILY 4. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY 5. Enoxaparin Sodium 30 mg SC Q12H 6. Calcium Carbonate 500 mg PO TID 7. Multivitamins 1 CAP PO DAILY 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain 9. Senna 1 TAB PO BID:PRN Constipation 10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 11. Vitamin D 400 UNIT PO DAILY 12. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right intertrochanteric hip 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 INDICATION: Right hip pain after fall. Evaluation for fracture. TECHNIQUE: Single AP view of the pelvis. Additional two views of the right hip and distal femur. COMPARISON: ___. FINDINGS: There is an intertrochanteric fracture to the right proximal femur with mild displacement. No fracture is seen in the distal femur. Intramedullary rod and fixing screw in the left proximal femur is again noted along with remote avulsion fracture of the left lesser trochanter. Non-obstructive bowel gas pattern obscures the sacrum. The SI joints and pubic symphysis are unremarkable. IMPRESSION: Mildly displaced intertrochanteric fracture of the right proximal femur. Radiology Report INDICATION: Right hip pain after fall. History of lymphoma on prior radiation. COMPARISON: CTA chest, ___. Multiple prior chest radiographs most recently on ___. FINDINGS: Frontal chest radiograph again demonstrates scarring and opacification in the right apex from prior radiation along with the deviation of the trachea to the right. The left apex is more opacified than on prior imaging. The lungs are hyperexpanded. Hiatal hernia is again noted. There is no pleural effusion or pneumothorax. IMPRESSION: 1. Chronic changes from prior radiation along the right lung apex. 2. Left apical opacity raises question of infection. Recommend obtaining PA and lateral radiographs for better charachterization of this finding. Radiology Report HISTORY: ORIF. FINDINGS: Images from the operating suite show placement of a fixation device about previous fracture. Further information can be gathered from the operative report. Radiology Report RIGHT HIP FILMS ON ___ HISTORY: Status post dynamic hip screw. FINDINGS: There is interval placement of a right-sided dynamic hip screw spanning the right-sided intertrochanteric fracture. The alignment is much improved. The intramedullary rod and fixation screw in the left proximal femur again noticed with old avulsion fracture in this region. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: MECHANICAL FALL Diagnosed with INTERTROCHANTERIC FX-CL, ACC POISONING-DRUG NEC, HYPOTHYROIDISM NOS temperature: 97.6 heartrate: 124.0 resprate: 18.0 o2sat: 98.0 sbp: 160.0 dbp: 100.0 level of pain: 9 level of acuity: 2.0

********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******* - Weight bearing as tolerated right lower extremity. ******MEDICATIONS*********** - Resume your pre-hospital medications unless otherwise instructed by your surgeon. - 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: WBAT RLE. Treatments Frequency: Monitor wound site. Physical therapy WBAT RLE.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chills, malaise Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo M w/ h/o afib (on warfarin), syncopal events s/p PPM, DM (not on insulin), COPD, HTN, and newly diagnosed unresectable cholangiocarcinoma s/p p/w chills and feeling unwell. He underwent exploratory laparotomy ___ and biopsy of a portal mass, that showed gallbladder hard w/ adherent omentum, large portal mass extended the length of porta hepatis, tumor of the right side of the port as well as tumor involving the left side of the porta and a shelf of tumor along the surface of the caudate lobe. Biopsy showed adenocarcinoma c/w pancreaticobiliary origin. He was referred to ERCP, done ___. Previously placed plastic stent placed in the biliary duct was found in the major papilla, and was removed. He was also found to have single irregular stricture of malignant appearance that was 2 cm long was seen at the common hepatic duct, w/ post-obstructive dilation. A biliary stent was placed in the common hepatic duct and main duct. He was given cipro. The next day he felt chillish/hot on and off and generally unwell. He has mild discomfort around incision site. He denies n/v, d/c, melena, hematochezia. He has on/off back discomfort for years, denies weakness, urine/bowel inc. In the ED: VS T99.1, HR95, BP134/67, RR16, O2 98% RA. Labs: ALT: 120 AP: 500 Tbili: 2.5 Alb: 3.8 AST: 78 Lactate: 2.4 WBC: 9.7. Lines & Drains: 20g R AC Fluids: 500ml NS Drips: Vanc/Unasyn Surgery was consulted. . Currently, he has back discomfort ___ in the lumbar area, non-radiating and w/o parasthesias. . ROS: 12 point ROS is otherwise negative. Past Medical History: -Atrial fibrillation, on warfarin -s/p PPM for episodes of "passing out" -Hypertension -Diabetes mellitus type 2 -COPD -HLD, previously on a statin but d/c due to jaundice -Newly diagnosed unresectable cholangiocarcinoma: ___ Exploratory laparotomy and biopsy of a portal mass. ERCP w/ biliary stent placed ___. Is to start chemo tx at the ___. Social History: ___ Family History: One brother had melanoma, another brother had lung cancer. No family history of pancreatic or hepatobiliary cancer. Physical Exam: Vitals: T 98, BP 138/96, HR 96, RR 18 100% RA GEN: well appearing NAD HEENT: NC/AT, PERRLA, EOMI, MMM, OP clear NECK: supple, no thyromegaly HEART: RR, nl S1-S2, no MRG LUNGS: CTAB, no r/rh/wh ABDOMEN: +BS, well healed incision c/d/i, NT/ND, no guarding/rebound tenderness EXTREMITIES: wwp, no edema NEURO: awake, oriented x3, CN2-12 intact, ___ strength at ___ bl, sensation to light touch intact throughout, tenderness in the paraspinal area of the lumbosacral spine Discharge exam: VSS, afebrile during hospital course GEN: well appearing NAD HEENT: NC/AT, PERRLA, EOMI, MMM, OP clear NECK: supple, no thyromegaly HEART: RR, nl S1-S2, no MRG LUNGS: CTAB, no r/rh/wh ABDOMEN: +BS, well healed incision c/d/i, NT/ND, no guarding/rebound tenderness EXTREMITIES: wwp, no edema NEURO: awake, oriented x3, CN2-12 intact, ___ strength at ___ bl, sensation to light touch intact throughout Pertinent Results: ___ 01:15PM WBC-9.7 RBC-3.79* HGB-12.1* HCT-36.1* MCV-95 MCH-32.1* MCHC-33.7 RDW-14.5 ___ 01:15PM NEUTS-87.4* LYMPHS-6.1* MONOS-5.5 EOS-0.5 BASOS-0.4 ___ 01:15PM PLT COUNT-186 ___ 01:15PM ALBUMIN-3.8 ___ 01:15PM LIPASE-18 ___ 01:15PM estGFR-Using this ___ 01:15PM GLUCOSE-196* UREA N-13 CREAT-0.9 SODIUM-135 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15 ___ 01:23PM LACTATE-2.4* ___ 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-NEG ___ 04:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:20PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 Discharge labs: WBCRBC Hgb Hct MCVMCH MCHCRDW Plt Ct 6.63.61*11.3*34.7*9631.2 32.514.7 171 GlucoseUreaNCreatNaKClHCO3AnGap 100 13 1.0 1403.7102 27 15 ALTASTAlkPhos TotBili 9053 440* 2.5* ___ blood cultures pending CXR: There is an unchanged left-sided pacemaker with leads ending in the right atrium and right ventricle. The lungs are clear, the cardiomediastinal shilouette and hila are normal. There is no pleural effusion and no pneumothorax Medications on Admission: propanolol 10mg bid coumadin 5mg daily metformin 500mg bid spiriva advair albuterol omeprazole 40mg bid cipro 500mg bid x5 days *nolonger taking triamteren/hctz Discharge Medications: 1. Propranolol 10 mg PO BID hold for sbp<100, hr<60 2. Warfarin 2 mg PO DAILY16 RX *Jantoven 2 mg 1 tablet(s) by mouth daily Disp #*30 Unit Refills:*3 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Tiotropium Bromide 1 CAP IH DAILY 6. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea 7. Omeprazole 40 mg PO BID 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*28 Unit Refills:*0 9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*42 Unit Refills:*0 10. Outpatient Lab Work Please check INR and AST, ALT, Total bilirubin, and alk phos on ___. Fax results to Dr. ___ at ___ and Dr. ___ at ___. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: cholangitis cholangiocarcinoma Secondary Diagnosis: atrial fibrillation on warfarin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with rigors, sweats. Please assess for pneumonia. TECHNIQUE: Frontal and lateral radiographs of the chest were obtained. COMPARISON: Chest radiograph from ___. FINDINGS: There is an unchanged left-sided pacemaker with leads ending in the right atrium and right ventricle. The lungs are clear, the cardiomediastinal shilouette and hila are normal. There is no pleural effusion and no pneumothorax. IMPRESSION: No acute cardiothoracic process. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: FEVER S/P CATH Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, ATRIAL FIBRILLATION, DIABETES UNCOMPL ADULT temperature: 99.1 heartrate: 95.0 resprate: 16.0 o2sat: 98.0 sbp: 134.0 dbp: 67.0 level of pain: 0 level of acuity: 3.0

You were admitted to the hospital with chills after ERCP. There was concern for infection, and you were monitored for 24 hours. There was no fever, elevated white blood cell count, or evidence of infection while you were in the hospital. You tolerated a full diet, and were discharged on ___. The following changes were made to your medications START ciprofloxacin 500 mg twice a day for 14 days START metronidazole 500 mg three times a day for 14 days no other medication changes were made. It is very important that your INR (Coumadin level) be monitored closely on antibiotics.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ultram / Seroquel / ketorolac Attending: ___. Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ y/o female with history of HCV and EtOH cirrhosis (reportedly c/b varices and ascites) who presents with report of BRBPR in setting of month-long alcohol binge. Pt states she had bloating of her abdomen on ___ associated with numerous episodes of vomiting but no hematemesis or coffee ground emesis. She was able to sleep ___ night but awoke ___ morning with multiple epsiodes of BRBPR which brought her to the ED. In the ED, initial vitals: T 98.6, 87, 113/59, 16, 96% RA - Exam: FAST exam negative, no ascites on ultrasound, rectal exam with external hemorrhoids but no melena or BRBPR - Labs: Hgb 7.8 (slightly down from 8's), WBC 3.6, Plts 39, INR 1.4, K 3.0, Cr 0.5. - Medications given: --- Lorazepam 0.5mg PO --- Folic acid and thiamine --- Potassium chloride 40meq PO --- Protonix 40mg IV --- Ceftriaxone 1g IV Patient was admitted to ___ service for further management of her BRBPR and for determination of whether there was an underlying infectious process. On arrival to floor, patient reports that her last drink was ___ at about 10AM. Was drinking about 0.5-1.0 pint of vodka each day. Has been drinking that much daily for almost 1 month. Has barely been eating due to her drinking habits. Has had EtOH withdrawal in the past: endorses seizures from EtOH withdrawal ___ years ago at ___; denies hallucinations. Had nausea and vomiting the day prior to presentation but none the day of admission. Denies any hematemesis. She's unsure what medications she takes regularly -- the ones she can name are ___, trazodone, Zoloft, folic acid. She denies fevers, chills, dysuria, chest pain, shortness of breath. Past Medical History: - EtOH use/abuse - hx of IV opiate abuse in past - chronic hepatitis C - "metal" in her right forearm and L knee - hx of appendectomy - cervical surgery Social History: ___ Family History: mom - esophageal cancer Physical Exam: ADMISSION EXAM: ============================= Vitals: 98.3, 130 / 81, 87, 18, 96% RA Weight: 59.2kg standing on admission (up 8 lbs from admission) GEN: Chronically ill appearing woman, uncomfortable/restless in appearance but in NAD. HEENT: Anicteric sclera, MMM COR: RRR w/o m/r/g LUNGS: CTAB ABD: Soft, non-distended. Mildly tender mostly in RUQ. No suprapubic tenderness. Rectal: external hemmorhoids, no melena or BRBPR DISCHARGE EXAM: ============================= VS: 99.5 138 / 90 83 16 94 RA GENERAL: Chronically ill appearing woman, uncomfortable/restless in appearance but in NAD. HEENT: Anicteric sclera, MMM NECK: Supple HEART: RRR, S1+S2, no m/r/g LUNGS: CTAB, no wheezing or rales ABDOMEN: Soft, non-distended, non-tender in all regions. NEURO: AOx3, CN2-12 intact PSYCH: Pleasant, relaxed Pertinent Results: ADMISSION LABS: =============================== CBC: ___ 09:45PM BLOOD WBC-3.6* RBC-3.05* Hgb-7.8* Hct-25.7* MCV-84 MCH-25.6* MCHC-30.4* RDW-27.5* RDWSD-82.4* Plt Ct-39* ___ 09:45PM BLOOD Neuts-41.3 ___ Monos-6.1 Eos-1.4 Baso-0.3 NRBC-0.6* Im ___ AbsNeut-1.50* AbsLymp-1.82 AbsMono-0.22 AbsEos-0.05 AbsBaso-0.01 COAGS: ___ 09:45PM BLOOD ___ PTT-32.9 ___ CHEM: ___ 09:45PM BLOOD Glucose-90 UreaN-9 Creat-0.5 Na-142 K-3.0* Cl-106 HCO3-23 AnGap-16 ___ 07:15AM BLOOD Albumin-2.9* Calcium-7.5* Phos-2.3* Mg-2.3 LIVER: ___ 07:15AM BLOOD ALT-24 AST-103* AlkPhos-161* TotBili-1.1 TOX: ___ 07:15AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICRO: =============================== ___ 4:55 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 7:15 am IMMUNOLOGY **FINAL REPORT ___ HCV VIRAL LOAD (Final ___: 1,340,000 IU/mL. Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0 Test. Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08 IU/mL. Limit of detection: 1.50E+01 IU/mL. IMAGING: =============================== ___ ABDOMINAL ULTRASOUND: 1. Cirrhotic liver, without evidence of focal lesion. 2. Patent portal veins. 3. Trace perihepatic ascites which is not amenable to aspiration. 4. Mild splenomegaly. 5. 1.7 cm exophytic cyst arising from the left kidney is difficult to visualize but shows some complex features that are concerning for wall thickening or nodularity. MRI is recommended for further evaluation. DISCHARGE LABS: =============================== CBC: ___ 09:15AM BLOOD WBC-3.4* RBC-3.22* Hgb-8.0* Hct-28.1* MCV-87 MCH-24.8* MCHC-28.5* RDW-27.4* RDWSD-85.1* Plt Ct-UNABLE TO COAGS: ___ 09:15AM BLOOD ___ PTT-33.3 ___ CHEM: ___ 05:40AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-134 K-4.9 Cl-101 HCO3-22 AnGap-16 ___ 05:40AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.7 LIVER: ___ 04:24AM BLOOD ALT-23 AST-95* LD(LDH)-274* AlkPhos-176* TotBili-1.6* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO QHS 2. Gabapentin 300 mg PO TID 3. Sertraline 25 mg PO DAILY 4. TraZODone 150 mg PO QHS:PRN sleep Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Gabapentin 300 mg PO TID 5. Gabapentin 300 mg PO QHS 6. Sertraline 25 mg PO DAILY RX *sertraline 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. TraZODone 150 mg PO QHS:PRN sleep RX *trazodone 150 mg 1 tablet(s) by mouth before bed Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: - Alcohol abuse - Hemorrhoidal bleed SECONDARY DIAGNOSIS: - Alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old woman with cirrhosis p/w BRBPR // ? portal vein thrombosis, ? presence of ascites pocket amenable to diagnostic paracentesis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: The report from the CT abdomen ___ FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with known cirrhosis. There is no focal liver mass. The main, right and left portal vein is patent with hepatopetal flow. There is trace perihepatic ascites that is not amenable to aspiration. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 0.3 mm. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 12.3 cm. KIDNEYS: The right kidney measures 11.5 cm. The left kidney measures 12.0 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. A simple renal cyst is seen in the interpolar region of the right kidney measuring 1.3 x 0.9 x 1.1 cm. An exophytic cyst is seen arising from the interpolar region of the left kidney measuring 1.7 x 1.1 x 1.3 cm which is difficult to visualize but shows features are concerning for wall thickening or nodularity. MRI is recommended for further evaluation. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhotic liver, without evidence of focal lesion. 2. Patent portal veins. 3. Trace perihepatic ascites which is not amenable to aspiration. 4. Mild splenomegaly. 5. 1.7 cm exophytic cyst arising from the left kidney is difficult to visualize but shows some complex features that are concerning for wall thickening or nodularity. MRI is recommended for further evaluation. RECOMMENDATION(S): MRI for further evaluation of the left renal cyst. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: BRBPR Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 98.6 heartrate: 87.0 resprate: 16.0 o2sat: 96.0 sbp: 113.0 dbp: 59.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted to the hospital because of a lower GI bleed that was most likely due to your hemorrhoids. You were observed in the hospital and did not have further episodes of bleeding. You were also counseled on alcohol detoxification, which we recommend. Please continue to abstain from alcohol and present for urgent medical attention if you feel like you are having symptoms of withdrawal or seizures. We will send physical therapy to see you at home to make sure that you are steady on your feet. It was a pleasure taking care of you and we wish you the best! - 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: fall Major Surgical or Invasive Procedure: ___ Left hemicraniectomy History of Present Illness: ___ transferred from ___ with ___. Was drinking and smoking marijuana last evening when he fell backward while running. His girlfriend was present and noted he did have LOC for a brief period of time, awoke and was confused. He was taken to ___ where he was reportedly awake and alert but intermittently confused / somnolent. A CT scan demonstrated L-sided SDH with 3mm of midline shift. He was transferred to ___ for further evaluation. On arrival to ___, per ED staff he was initially somnolent / lethargic and then agitated / purposeful when foley catheter was placed. On my exam, he was lethargic, minimally responsive to vocal or painful stimuli; however, he purposefully moves all extremities in order to avoid being examined. He is uncooperative with the exam. A repeat CT head demonstrates interval increase in the SDH and midline shift. Past Medical History: None Social History: ___ Family History: noncontributory Physical Exam: On Admission: AVSS Gen somnolent, minimally arousable RRR CTAB And S/NT/ND Ext WWP Neuro - PERRLA, does not open eyes to voice - responds intermittently to vocal stimulation with ___ words - spontaneously moves all extremities, no commands On Discharge: the patient was alert and oriented to person/place/time strength is full sensation intact pupils are equal and reactive no pronator drift incision is well approximated - staples are removed Pertinent Results: CT HEAD W/O CONTRAST ___ 1. Previously visualized left fronto-parieto-temporal subdural hematoma has enlarged, particularly overlying the temporal lobe where it measures up to 21-mm from the inner table of the skull compared to 6-mm previously. There is increased mass effect with 11-mm rightward shift of midline structures compared to 6-mm previously. Additionally, there is increased mass effect on the left lateral ventricle with relative dilatation of the right lateral ventricle raising suspicion for obstruction at the level of the third ventricle. Continued followup is recommended. 2. Again noted is a nondisplaced fracture of the right portion of the occipital bone is again noted with extension to the right occipital condyle. 3. Stable left parafalcine subdural hematoma. Blood is again noted layering along the left leaflet of the tentorium. CT HEAD W/O CONTRAST ___ 1. Expected postsurgical changes status post left hemicraniectomy, with interval improvement of midline shift and effacement of left lateral ventricle. 2. Nondisplaced fracture of the right occipital bone, unchanged from prior ___ ___ ___ Cardiovascular Report ECG Study Date of ___ 2:47:08 ___ Sinus rhythm with sinus arrhythmia. Normal ECG. No previous tracing available for comparison. Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 164 96 372/396 37 -18 10 ___ CXR Two serial chest radiographs were performed. The initial one demonstrates an orogastric tube with side port above the GE junction. The second image demonstrates advancement into the stomach, which is moderately distended. Endotracheal tube is in standard position on both radiographs. Cardiomediastinal contours are within normal limits. Lungs are clear except improving atelectasis in the left lower lobe. ___ CT Head: 1. Increased extra-axial hyperdensity in the left hemicraniectomy defect, suggesting increased blood products. 2. Mild herniation of the brain parenchyma through the left hemicraniectomy defect appears new compared to ___, but comparison is limited by differences in patient positioning. 3. Stable mild rightward shift of midline structures and partial effacement of the left lateral ventricle. 4. Stable large left and small right inferior frontal hemorrhagic contusions. 5. Right occipital bone fracture extending to the right occipital condyle is again seen. ___ CT Head: 1. Minimal increase in extra-axial hyperdensity in the left hemi craniectomy defect suggesting minimal increased blood products. Stable mild rightward shift of midline structures and partial effacement of the left lateral ventricle. 2. Stable appearance of herniation of brain parenchyma through the left he hemi craniectomy defect. 3. Stable left temporal, left inferior frontal, and right inferior frontal hemorrhagic contusions with minimal increase in left inferior frontal lobe edema. 4. Right occipital bone fracture extending to the right occipital condyle again noted. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications. Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache contains tylenol- do not exceed 4 grams in 24 hours RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 2. LeVETiracetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 3. OLANZapine 5 mg PO HS RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Capsule Refills:*1 5. TraMADOL (Ultram) 50 mg PO Q12H:PRN headache, pain RX *tramadol 50 mg 1 tablet(s) by mouth q12 Disp #*60 Tablet Refills:*0 6. Outpatient Physical Therapy 7. Outpatient Speech/Swallowing Therapy 8. Outpatient Occupational Therapy Discharge Disposition: Home Discharge Diagnosis: Left Subdural hematoma with midline shift Traumatic brain injury Cerebral edema Suicidal ideation Discharge Condition: Mental Status: alert and oriented to person/place/time- needs reminders and can be impulsive Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires helmet at all times. strength is full staples removed incision well approximated Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with s/p L hemicraniectomy for left subdural hematoma and left temporal hemorrhagic contusion. Evaluate for interval change s/p drain pull. TECHNIQUE: Noncontrast head CT with sagittal and coronal reformatted images. DL P ___ mGy-cm. COMPARISON: ___ FINDINGS: Left hemicraniectomy is again seen. Previously noted left subdural drain has been removed. There is decreased air and increased hyperdensity in the hemicraniectomy defect, suggesting increased blood products. There is mild herniation of the brain parenchyma through the hemicraniectomy defect, which was not clearly seen on ___, but comparison is limited by the tilt of the patient's head on the present exam. Allowing for differences in patient positioning, mild rightward shift of midline structures and partial effacement of the left lateral ventricle are unchanged. There is persistent edema and trace blood at the site of the left temporal hemorrhagic contusion, where blood products have been resected. Large left and small right inferior frontal hemorrhagic contusions are stable allowing for differences in patient position. No new parenchymal edema is seen. Basal cisterns are stable in size. Right occipital bone fracture extending to the right occipital condyle is again seen. A mucous retention cyst is again seen in the left sphenoid sinus. Fluid in the right sphenoid sinus and left ethmoid air cells is new, likely related to prolonged supine positioning. IMPRESSION: 1. Increased extra-axial hyperdensity in the left hemicraniectomy defect, suggesting increased blood products. 2. Mild herniation of the brain parenchyma through the left hemicraniectomy defect appears new compared to ___, but comparison is limited by differences in patient positioning. 3. Stable mild rightward shift of midline structures and partial effacement of the left lateral ventricle. 4. Stable large left and small right inferior frontal hemorrhagic contusions. 5. Right occipital bone fracture extending to the right occipital condyle is again seen. Radiology Report HISTORY: Status post left hemicraniectomy for left subdural hematoma and left temporal hemorrhagic contusion with worsening exam. TECHNIQUE: Contiguous axial images were obtained through the brain without intravenous contrast. Multiplanar reformatted images were prepared and reviewed. DLP: 891.93 mGy-cm. CTDIvol: 53.59 mGy. COMPARISON: Multiple prior studies with the most recent CT Head from ___. FINDINGS: Post left hip hemi craniectomy changes are again noted. There is minimal increase in width of blood products in the hemi craniectomy defect with minimal increased hyperdensity suggesting minimal increased hemorrhage in this region. Minimal herniation of the brain through the craniectomy defect is again noted as seen previously. Again noted is 3 mm rightward shift of midline structures with partial effacement of the left lateral ventricle as seen previously. Persistent edema with minimal blood is again noted and left temporal hemorrhagic contusion. Large left and small right inferior frontal hemorrhagic contusions are stable with perhaps minimal increase in edema in the left inferior frontal lobe. No new parenchymal hemorrhage is identified. The basal cisterns are patent. Again noted is a right occipital bone fracture extending from the to the right occipital condyle. Mixed retention cyst is again noted in the left sphenoid sinus. Fluid in the right sphenoid sinus and the ethmoid air cells is again noted. IMPRESSION: 1. Minimal increase in extra-axial hyperdensity in the left hemi craniectomy defect suggesting minimal increased blood products. Stable mild rightward shift of midline structures and partial effacement of the left lateral ventricle. 2. Stable appearance of herniation of brain parenchyma through the left he hemi craniectomy defect. 3. Stable left temporal, left inferior frontal, and right inferior frontal hemorrhagic contusions with minimal increase in left inferior frontal lobe edema. 4. Right occipital bone fracture extending to the right occipital condyle again noted. Radiology Report HISTORY: Evaluation of patient with subdural hematoma TECHNIQUE: Contigous axial images were obtained through the brain without intravenous contrast. Multiplanar reformatted images were prepared and reviewed. DLP: 1003.42 mGy-cm. CTDIvol: 55.75 mGy. COMPARISON: Outside hospital head CT from ___ at 1:51 AM. FINDINGS: Previously visualized left fronto-parieto-temporal subdural hematoma has enlarged, particularly overlying the temporal lobe where it measures up to 21-mm from the inner table of the skull compared to 6-mm previously. Left parafalcine subdural hematoma and blood layering along the tentorium appear stable. There is increased mass effect with 11-mm rightward shift of midline structures compared to 6-mm previously. Additionally, there is increased mass effect on the left lateral ventricle with relative dilatation of the right lateral ventricle raising suspicion for obstruction at the level of third ventricle. There is no evidence of an infarction at this point. A nondisplaced fracture of the right portion of the occipital bone is again noted (3:35) with extension to the right occipital condyle. There is mild opacification of the left sphenoid sinus with hyperdense fluid, suggesting possible hemorrhage versus high-density mucous retention cyst. The visualized mastoid air cells and paranasal sinuses are clear. IMPRESSION: 1. Previously visualized left fronto-parieto-temporal subdural hematoma has enlarged, particularly overlying the temporal lobe where it measures up to 21-mm from the inner table of the skull compared to 6-mm previously. There is increased mass effect with 11-mm rightward shift of midline structures compared to 6-mm previously. Additionally, there is increased mass effect on the left lateral ventricle with relative dilatation of the right lateral ventricle raising suspicion for obstruction at the level of the third ventricle. Continued followup is recommended. 2. Again noted is a nondisplaced fracture of the right portion of the occipital bone is again noted with extension to the right occipital condyle. 3. Stable left parafalcine subdural hematoma. Blood is again noted layering along the left leaflet of the tentorium. Findings were discussed by Dr. ___ with Dr. ___ telephone at the time of discovery at 6:02 am on ___ 12, ___. ATTENDING NOTE: Now apparent are bilateral temporal and sinferior frontal hemorrhagic contusions. There is subfalcine herniation. Radiology Report HISTORY: Dural hematoma, for evaluation of endotracheal tube placement. COMPARISON: Chest radiograph from the same day from outside hospital. FINDINGS: An endotracheal tube is noted in the upper trachea at 6.5 cm from the carina. Enteric tube traverses to the stomach. The lungs are clear. There is no pleural effusion or pneumothorax. No acute fractures are identified. IMPRESSION: The endotracheal tube is in the upper trachea at 6.5 cm from the carina. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man with L SDH s/p L hemicraniectomy, please evaluate for post op changes // ___ year old man with L SDH s/p L hemicraniectomy, please evaluate for post op changes TECHNIQUE: Signed report DOSE: DLP: 891.93 mGy-cm CTDI: 53.31 mGy COMPARISON: Comparison is made with CT head from earlier the same day, ___. FINDINGS: The patient is status post left hemicraniectomy and evacuation of blood products, with the expected postsurgical changes and pneumocephalus seen. Hypodensity is noted at the site of the prior bleed. Frontal contusions are seen, similar prior exam. There has been interval decrease in midline shift, which now measures 5 mm rightward (previously 11 mm). Effacement of the left lateral ventricle has improved from prior exam. There is no evidence of new acute hemorrhage, edema, mass effect, or infarction. A nondisplaced fracture of the right occipital bone including the right occipital condyle is again seen. A mucous retention cyst is seen in the left sphenoid sinus. Otherwise, the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are unremarkable. IMPRESSION: 1. Expected postsurgical changes status post left hemicraniectomy, with interval improvement of midline shift and effacement of left lateral ventricle. 2. Nondisplaced fracture of the right occipital bone, unchanged from prior exam. Radiology Report PORTABLE CHEST, ___ COMPARISON: Study of earlier the same date. FINDINGS: Two serial chest radiographs were performed. The initial one demonstrates an orogastric tube with side port above the GE junction. The second image demonstrates advancement into the stomach, which is moderately distended. Endotracheal tube is in standard position on both radiographs. Cardiomediastinal contours are within normal limits. Lungs are clear except for improving atelectasis in the left lower lobe. Gender: M Race: WHITE Arrive by HELICOPTER Chief complaint: SDH Diagnosed with CL SKL BASE FX/MENIN HEM, UNSPECIFIED FALL temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: nan level of acuity: nan

Have a friend/family member check your incision daily for signs of infection. You are being discharged to ___ with 24 hour supervision in the care of your mother as was discussed in the family meeting today. ¨ Take your pain medicine as prescribed. ¨ Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨ You may wash your hair in 72 hours now that your staples have been removed. ¨ You may shower before this time using a shower cap to cover your head. ¨ 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, and Ibuprofen etc. ¨ You have been prescribed Keppra for anti-seizure medicine. ¨ Clearance to drive and return to work will be addressed at your post-operative office visit. ¨ Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨ New onset of tremors or seizures. ¨ Any confusion or change in mental status. ¨ Any numbness, tingling, weakness in your extremities. ¨ Pain or headache that is continually increasing, or not relieved by pain medication. ¨ Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ¨ Fever greater than or equal to 101.5° F.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chief Complaint: Shortness of Breath Reason for MICU transfer: Hypoxemia Major Surgical or Invasive Procedure: ___ Intubation ___ bronchoscopy ___ Extubation History of Present Illness: Ms. ___ is a ___ y/o G2P1 who is 6 days post-partum (40w5d - cesarian section) presented with shortness of breath. SOB started the evening prior to admission. She stated that she used her albuterol inhalers without relief, which prompted her to call EMS. Per report, she was tachypnic to the ___, satting in the ___, which only improved on NRB. She reported a history of 1 asthma exacerbation in her lifetime, had never required intubation. Last asthma exacerbation was as a child. Only used albuterol at home. She endorsed myalgias and cough in the days preceeding admission. In the ED, initial VS were: T 98 HR 90 BP 159/109 RR 38 O2 Sat 91% RA Labs were notable for ABG 7.5/___, lactate 1.0 and HCT 30 (baseline 37). She was cultured and given Vanc/Ceftraixone/Azithro/Tamiflu and nebulizers. CTA was performed and showed no e/o PE, but was notable for multifocal PNA. She was admitted to the MICU for tachypnea. VS at the time of transfer were: T 98 HR 90 122/69 RR ___ O2 Sat99% on NRB On arrival to the MICU, initial VS were: T 98 BP 120/80 HR 90 RR 60 O2 Sat 98% NRB She was able to speak in short sentences and stated she was not having significant pain with respirations. Review of systems: (+) Per HPI (-) Denied fever, chills, night sweats, recent weight loss or gain. Denied headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denied nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denied dysuria, frequency, or urgency. Denied arthralgias or myalgias. Denied rashes or skin changes. Past Medical History: POB: G2P1 - LTCS ___ for NRFHT after IOL for ?SROM, macrosomia, and non-reassuring NST - TAB x 1. PGYN: Denies hx of STI/abnl Pap PMH: Asthma, depression, obesity PSH: D&C TAB Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM General- Obese Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Diminished air entry throughout, no wheezes, rales, ronchi CV- Tachycardic , normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Abd wound stable GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Discharge: Gen: NAD Lungs: CTAB CV: RRR, nomral S1 S2 Abd: soft, NT, ND, normoactive BS, no r/g, inc c/d/i GU: voiding spontaneously Ext: WWP, no edema Pertinent Results: ADMISSION LABS ___ 06:17AM BLOOD WBC-9.9 RBC-4.11* Hgb-9.1* Hct-29.4* MCV-72* MCH-22.0* MCHC-30.8* RDW-17.5* Plt ___ ___ 06:17AM BLOOD Neuts-68.3 ___ Monos-5.3 Eos-2.3 Baso-0.4 ___ 06:17AM BLOOD Plt ___ ___ 06:44AM BLOOD ___ PTT-30.2 ___ ___ 06:17AM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-141 K-3.8 Cl-106 HCO3-23 AnGap-16 ___ 06:17AM BLOOD LD(LDH)-240 ___ 03:03AM BLOOD GGT-43* ___ 06:17AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8 ___ 04:16AM BLOOD Triglyc-182* ___ 07:30PM BLOOD Vanco-8.5* ___ 06:41AM BLOOD ___ pO2-85 pCO2-28* pH-7.50* calTCO2-23 Base XS-0 Comment-GREEN TOP ___ 10:44AM BLOOD Type-ART pO2-66* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 ___ 06:41AM BLOOD Lactate-1.0 ___ 06:44AM BLOOD B-GLUCAN-Test negative URINE ___ 03:05AM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:05AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG ___ 03:05AM URINE RBC-0 WBC-0 Bacteri-MOD Yeast-NONE ___ MICROBIOLOGY ___ Blood culture X 2 PENDING ___ Urine NEGATIVE ___ BAL GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. ~1000/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | TRIMETHOPRIM/SULFA---- <=1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. ___ Rapid respiratory viral screen (BAL): no respiratory viruses isolated (no Adenovirus, influenza A&B, parainfluenza 1,2,3 or respiratory synctial virus) ___ Sputum ___ with no microrganisms, commensal respiratory flora, no legionella ___ Blood culture X 2 PENDING ___ Urine cx NEG ___ Urine cx NEG ___ Blood culture PENDING PERTINENT IMAGING ECHO ___: Normal size and function of the left ventricle. The right ventricle is mildly dilated with hypokinesis of the right ventricular free wall with relative preservation of the RV apex ___ sign - due to RV overload of any cause such as pulmonary embolism, pneumonia etc.). Unable to estimated pulmonary artery systolic pressure. No significant valvular abnormality. CTA (___): No evidence of pulmonary embolism. Findings most consistent with multifocal pneumonia. CXR ___ The patient has an endotracheal tube with the tip projecting approximately 6 cm above the carina. The tip of the tube is difficult to visualize as it overlays with the nasogastric tube. The nasogastric tube shows a normal course and the tip is located in the stomach. The lung volumes are low. Extensive bilateral mid and lower lobe parenchymal opacities and consolidation, likely associated to small pleural effusions. Moderate cardiomegaly, no overt pulmonary edema. Medications on Admission: Albuterol prn, percocet, ibuprofen Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Ibuprofen 600 mg PO Q6H:PRN pain 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain 4. cefPODOXime 200 mg oral BID RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0 5. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Six days postpartum with tachypnea and shortness of breath and decreased O2 saturation. Evaluate for pulmonary embolism. COMPARISON: None available. TECHNIQUE: MDCT images were obtained through the chest with IV contrast. Coronal and sagittal reformations were performed. Right and left MIP reconstructions were performed. FINDINGS: The thyroid is unremarkable. The pericardium is unremarkable. There is no significant pericardial effusion. The aorta is normal in caliber and there is no evidence of aortic dissection. There is no filling defect in the pulmonary arteries to the segmental level. The airways are patent to the subsegmental level. The esophagus is normal. There are diffuse patchy ground-glass and more confluent consolidations, worse in the lower lobes, which is most consistent with multifocal pneumonia. No pleural effusion or pneumothorax. OSSEOUS STRUCTURES: No suspicious osseous lesions are identified. IMPRESSION: No evidence of pulmonary embolism. Diffuse bilateral parenchymal opacities most consistent with multifocal pneumonia. Radiology Report CHEST RADIOGRAPH. INDICATION: Respiratory failure, multifocal pneumonia, assessment for endotracheal tube. COMPARISON: No comparison available at the time of dictation. FINDINGS: The patient has an endotracheal tube with the tip projecting approximately 6 cm above the carina. The tip of the tube is difficult to visualize as it overlays with the nasogastric tube. The nasogastric tube shows a normal course and the tip is located in the stomach. The lung volumes are low. Extensive bilateral mid and lower lobe parenchymal opacities and consolidation, likely associated to small pleural effusions. Moderate cardiomegaly, no overt pulmonary edema. Radiology Report CHEST RADIOGRAPH INDICATION: Multifocal pneumonia, new line placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient continues to be intubated. The course of the nasogastric tube is unchanged. Patient received a new right internal jugular vein catheter. The course of the catheter is unremarkable, the tip of the catheter projects over the inflow tract of the right atrium. The preexisting parenchymal opacities, both on the left and on the right, have minimally decreased in overall extent and severity. No evidence of larger pleural effusions. No new opacities in the lung parenchyma. Radiology Report INDICATION: Respiratory failure and multifocal pneumonia. ___, CT ___. FRONTAL PORTABLE CHEST: Endotracheal tube ends 3.4 cm above the carina. Nasogastric tube extends to the stomach with the tip out of view. Right internal jugular catheter projects over the right atrium, unchanged in position. Lung volumes are lower than on the prior study. Allowing for this, bibasilar opacities are unchanged. Re-examining the series of images, including the CT, the patient may have concurrent pulmonary edema and pneumonia. Small pleural effusions are probably present. Cardiac and mediastinal silhouettes are stable. There is no pneumothorax. IMPRESSION: No change from ___ at 6:34 p.m., allowing for differences in inspiration. Dr. ___ the findings with ___ by phone at 9:15 a.m. on ___. Radiology Report CHEST RADIOGRAPH: INDICATION: Pneumonia, respiratory failure, fever. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is improved ventilation at the left and right lung bases, as reflected by increase radiolucency at both lung bases. However, the pre-existing parenchymal opacities on both the left and the right remain clearly visible. Moderate cardiomegaly. Unchanged position and course of the right internal jugular vein catheter. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: DYSPNEA Diagnosed with OTH CURR COND-POSTPARTUM, PNEUMONIA,ORGANISM UNSPECIFIED temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: 136.0 dbp: 90.0 level of pain: nan level of acuity: 1.0

You were admitted with pneumonia and improved with antibiotics. Please keep your follow up appointments recommended below to ensure full resolution of your illness. Please call your doctor if you experience any of the concerning symptoms listed below. Please take your medications as prescribed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall at home Major Surgical or Invasive Procedure: None History of Present Illness: ___ who sustained a fall at home from the toilet. Found to have 4 rib fractures. Otherwise well. Past Medical History: Hypothyroid SVT with pacer Anxiety GERD HTN (mild LVH on echo, cardiomegaly on CXR) Psoriasis Urinary incontinence Mild CRI, baseline Cr ___ S/p cataract surgery S/p chole S/p right ___ toe distal amputation ___ infection Osteoarthritis with DJD Glaucoma Social History: ___ Family History: DM Asthma Physical Exam: on day of discharge: Gen: Appears consistent with stated age, AOx3, NAD Cor: RRR without MRG Res: Normal WOB, CTAB Abd: Soft nt/nd Ext: WWP without edema Neuro: Without focal deficit Pertinent Results: ___ 09:55AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 09:55AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 09:02AM GLUCOSE-126* UREA N-37* CREAT-1.3* SODIUM-139 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 ___ 09:02AM estGFR-Using this ___ 09:02AM estGFR-Using this ___ 09:02AM NEUTS-77.3* LYMPHS-15.1* MONOS-6.7 EOS-0.8 BASOS-0.2 ___ 09:02AM PLT COUNT-190 ___ 09:02AM ___ PTT-31.6 ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Isosorbide Mononitrate 15 mg PO DAILY:PRN angina 2. Omeprazole 20 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Verapamil SR 240 mg PO Q24H 6. Sertraline 50 mg PO DAILY 7. Acetaminophen 650 mg PO TID:PRN pain 8. Pilocarpine 1% 1 DROP BOTH EYES Q6H 9. latanoprost *NF* 0.005 % ___ HS 10. Citracal Plus Magnesium *NF* (cal cit-mag-D3-Zn-cop-man-bor) 250-40-125 mg-mg-unit Oral daily Discharge Medications: 1. Acetaminophen 650 mg PO TID:PRN pain 2. Aspirin 81 mg PO DAILY 3. Citracal Plus Magnesium *NF* (cal cit-mag-D3-Zn-cop-man-bor) 250-40-125 mg-mg-unit Oral daily 4. Isosorbide Mononitrate 15 mg PO DAILY:PRN angina 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Sertraline 50 mg PO DAILY 8. Verapamil SR 240 mg PO Q24H 9. Pilocarpine 1% 1 DROP BOTH EYES Q6H 10. latanoprost *NF* 0.005 % ___ HS 11. Senna 1 TAB PO BID 12. Docusate Sodium 100 mg PO BID 13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right ___ rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory with walker and personal assistance. Medically stable. Followup Instructions: ___ Radiology Report PELVIS AND RIGHT HIP FILMS: ___ HISTORY: ___ female with fall and right-sided posterior right rib pain. FINDINGS: PELVIS: AP view of the pelvis. No prior. The bones are diffusely demineralized. There is no evidence of displaced fracture. Pubic symphysis and SI joints are unremarkable. Degenerative changes are seen at the femoroacetabular joints with joint space loss and osteophyte formation. Phleboliths are seen in the pelvis and scattered atherosclerotic calcifications also noted. Degenerative changes are seen in the lower lumbar spine. RIGHT HIP: AP and frog-leg views of the right hip. No prior. There is no fracture or acute osseous abnormality. Femoroacetabular joint is anatomically aligned. Soft tissue calcifications seen adjacent to the greater trochanter are likely dystrophic. Soft tissues are otherwise unremarkable. IMPRESSION: No visualized fracture. Radiology Report PORTABLE CHEST, ___. HISTORY: ___ female with fall and right-sided posterior rib pain. FINDINGS: Single portable view of the chest is compared to previous exams from ___. The lungs are clear of focal consolidation. There is no pneumothorax. Cardiac silhouette is enlarged but stable in configuration. Dual-lead pacing device is seen with lead tips over the right ventricle and left atrium. Known right posterolateral rib fractures are better seen on dedicated rib series. Otherwise, the included osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Known right posterior rib fractures, better seen on dedicated rib series. No visualized pneumothorax. Radiology Report RIGHT RIBS, MULTIPLE VIEWS. HISTORY: ___ female with fall and right-sided posterior rib pain. FINDINGS: Multiple oblique views of the right ribs were obtained. There are acute minimally-angulated, but not significantly displaced fractures identified through the posterolateral aspects of the right seventh through tenth ribs. No other rib fractures identified. Hypertrophic changes are seen in the spine. Dual-lead pacing device leads are partially visualized. IMPRESSION: Acute, slightly-angulated posterior fractures to the right seventh through tenth ribs. Radiology Report INDICATION: Fall, question bleed. COMPARISON: Nonenhanced head CT from ___ and ___. TECHNIQUE: Continuous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted images in coronal, sagittal, and thin section bone algorithm reconstructed images were acquired. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large vascular territory infarction. Prominent ventricles and sulci suggest age-related atrophy. There is a small right periventricular white dystrophic calcification, which is unchanged dating back to ___. The basal cisterns appear patent and there is preservation of gray-white differentiation. There is suggestion of a subcentimeter cystic structure in the posterior aspect of the sella, unchanged. No fracture is identified. There is mucosal thickening of the left maxillary sinus. The remaining visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The lenses have been replaced bilaterally. The globes are otherwise unremarkable. CONCLUSION: 1. No evidence of acute intracranial process. 2. Mild mucosal thickening of the left maxillary sinus. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: S/P FALL Diagnosed with SYNCOPE AND COLLAPSE, FRACTURE ONE RIB-CLOSED, UNSPECIFIED FALL temperature: 97.7 heartrate: 78.0 resprate: 12.0 o2sat: 100.0 sbp: 229.0 dbp: 74.0 level of pain: 4 level of acuity: 3.0

You were admitted to the acute care surgery service for pain control following your right ___ rib fractures. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, coughing up blood, shortness of breath, or wheeze. *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 an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day with assistance and a walker, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfatrim / Sulfa (Sulfonamide Antibiotics) / Tape ___ Attending: ___. Chief Complaint: Altered mental status, alcohol intoxication, back pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ woman with a pmhx. of HCV cirrhosis and ETOH abuse with recent diagnosis of metastatic adenocarcinoma (pancreaticobilliary source) who is admitted from the ED with altered mental status. Apparently patient was found slumped over on a bus and an ambulance was called. In the ED, initial vitals were: 97.8 92 108/51 14 96%RA. Labs were notable for WBC 5, Platelets 96, Cr 0.8, ALT 49, AST 96, AP 135, EtOH 237, lactate of 3.6. UA unremarkable. Remainder of tox screens negative. CXR with an enlarged heart and atelectasis ?CHF. Patient received 3L of fluid and was given lorazepam and haldol for agitation. Vitals prior to transfer were 97.6-103-16 127/92 98 RA. Past Medical History: Hep C EtOH abuse Depression Cirrhosis L humerus fracture s/p ORIF ___ s/p removal of hardware and repair of left humerus nonunion w/ bone graft and locking plate ___ s/p washout and debridement on ___ and ___. Social History: ___ Family History: No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: 98.2, 121/59, 80, 20, 97% on RA GENERAL: Slightly uncomfortable appearing, non-toxic HEENT: Mucous membranes dry CHEST: CTA bilaterally, no wheezes, rales, or rhonchi CARDIAC: RRR, ___ systolic murmur best heard at left lower sternal boarder ABDOMEN: +BS, non-tender, no fluid wave appreciated SKIN: Spider angiomas BACK: Paraspinal tenderness, no muscle spasms appreciated, no vertebral tenderness EXTREMITIES: No edema bilaterally DISCHARGE PHYSICAL EXAM VS: T 98.4 BP 122/70 P 91 RR 20 96%RA General : appearing comfortable, sitting up in bed HEENT: EOMI, anicteric sclera, Mucous membranes moist CHEST: Clear to auscultation bilaterally no wheezes/rhales/rhonci HEART: nl S1 ___ holosystolic murmmur ABDOMEN: soft , non-tender, non-distened, normoactive bowel sounds SKIN: multiple spider angiomas on face, chest and back EXTREMITES: no lower extremity edema, 2+ BP and radial pulses bilaterally Pertinent Results: ADMISSION LABS: Utox: negative ___ 03:00PM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03:00PM WBC-5.0 RBC-3.99* HGB-12.1 HCT-38.6 MCV-97 MCH-30.3 MCHC-31.3 RDW-15.2 ___ 03:00PM GLUCOSE-103* UREA N-13 CREAT-0.8 SODIUM-137 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-20* ANION GAP-15 ___ 03:30PM LACTATE-3.6* ___ 03:00PM ALT(SGPT)-49* AST(SGOT)-96* ALK PHOS-135* TOT BILI-1.3 ___ 03:00PM ALBUMIN-3.5 ___ 03:00PM LIPASE-29 ___ 08:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG PERTINENT LABS: ___ 11:00PM BLOOD Lactate-3.4* ___ 07:59AM BLOOD CEA-72* IMAGING: CT SPINE- WET READ : C-SPINE- NO NEW FRACTURE. NO ENHANCING SOFT TISSUE. SEVERAL BILATERAL NODES NO OVERLY ENGLARGENED T-SPINE/L-SPINE- NO OBVIOUS LYTIC METS. OLD POSTERIOR RIB FRACTURE DISCHARGE LABS: ___ 07:59AM BLOOD WBC-4.8 RBC-3.65* Hgb-11.5* Hct-35.6* MCV-97 MCH-31.5 MCHC-32.3 RDW-15.0 Plt Ct-85* ___ 07:59AM BLOOD ALT-50* AST-98* AlkPhos-153* TotBili-1.9* Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Lactulose Dose is Unknown mL PO Frequency is Unknown 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. Fluoxetine 20 mg PO DAILY 4. Gabapentin 600 mg PO TID 5. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain hold for sedation 6. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Fluoxetine 20 mg PO DAILY 3. Gabapentin 600 mg PO TID 4. Lactulose 30 mL PO TID Titrate to ___ BMs daily. ___ MD if change in mental status. 5. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain hold for sedation RX *oxycodone 10 mg 1 tablet(s) by mouth every eight (8) hours Disp #*6 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis- Alcohol intoxication Secondary Diagnosis- Back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report INDICATION: ___ female with history of alcoholic cirrhosis and new diagnosis of liver adenocarcinoma, presenting with back pain. Evaluate for metastases. COMPARISONS: CT abdomen and pelvis of ___. TECHNIQUE: 2.5 helical axial MDCT sections were obtained through thoracic and lumbar spine. Axial images were interpreted in conjunction with coronal and sagittal reformats. Images were obtained before and after administration of 70 cc of IV Omnipaque contrast. FINDINGS: Numbering used is shown on se 108b, im 44. There is no evidence of fracture. Vertebral body heights are maintained. Multilevel degenerative changes are present with anterior osteophytosis, endplate degenerative changes in the lower thoracic spine, and vacuum disc phenomenon at L4-5 and L5-S1. There is mild smooth anterior wedging of L4, which is similar to ___ however, new since ___. There is also mild wedging of L5 body with superior end-plate depression and vacuum henomenon in adjacent discs, stable since ___ but new since ___. Posterior disc bulges at L3-4, L4-5, and L5-S1 are similar to prior and cause mild-moderate spinal canal narrowing. There is mild depression of the superior end-plate of T3 with a thin linear lucency underneath. It is unclear if this is degenerative or related to recent trauma if any. T11 and T12 chronic-appearing right posterior rib fractures are present. No focal lytic or sclerotic osseous lesion concerning for malignancy. Following injection of IV contrast, no enhancing soft tissue mass is seen along the thoracic or lumbar spine to suggest metastatic disease in this region. Subcutaneous soft tissue stranding posterior to L4 is nonspecific (304:124), but similar to ___. There is incomplete visualization of the intra-abdominal organs. The visualized portion of the liver appears cirrhotic and nodular. There is a small-to-moderate amount of ascites, which may be slightly increased since ___. A 1.8-cm calcified gallstone is seen at the neck of the gallbladder, which is distended, although no overt wall thickening is present seen. Numerous retroperitoneal and mesenteric nodes are present. Splenomegaly is incompletely imaged. IMPRESSION: 1. T3 body- Mild depression of superior end-plate with thin lucency underneath- ? degenerative/ recent trauma. No soft tissue swelling. No fracture or acute alignment abnormality in the lumbar spine. Lower lumbar posterior disc bulges cause mild-moderate spinal canal narrowing, similar torecent study of ___. 2. No evidence of lytic or sclerotic osseous metastasis. No enhancing soft tissue lesion seen along the thoracic or lumbar spine to suggest metastasis to this region. Correlate with other more sensitive modalities if needed. 3. Intra-abdominal organs are incompletely imaged but abdominal ascites appears slightly increased since prior. Retroperitoneal and mesenteric lymphadenopathy is present. 4. 1.8-cm calcified gallstone at the neck of gallbladder, which is incompletely imaged. Please correlate with clinical symptoms for cholecystitis. 4. Evaluation of lungs is limited due to artifacts. Cirrhosis. NOTE ON ATTENDING REVIEW: The present study was performed as the pt. did not want to have MRI as cannot lie down longer. Details of the risks and limitations of CT study were discussed with ___ by ___ in detail on the day of the study- ___. Radiology Report HISTORY: Elevated lactate. Rule out infiltrate. CHEST, SINGLE AP PORTABLE VIEW: There are low inspiratory volumes, though the possibility of background hyperinflation/COPD cannot be excluded. Suspect cardiomegaly, though this may be accentuated by low lung volumes. There is upper zone redistribution and mild diffuse vascular blurring, suggesting mild CHF. There is patchy opacity at the left lung base consistent with atelectasis, though an early pneumonic infiltrate would be difficult to exclude. No effusion is identified. At the edge of these films, hardware related to the left shoulder is noted. Radiology Report INDICATION: ___ female with history of alcoholic cirrhosis and new diagnosis of liver adenocarcinoma presenting with back pain. Evaluate for metastases. TECHNIQUE: 2.5 helical axial MDCT sections were obtained through the cervical spine from the skull base through the superior aspect of T2 vertebral body. Axial images were interpreted in conjunction with coronal and sagittal reformats. Images were obtained before and after administration of 70 cc of Omnipaque IV contrast. FINDINGS: Vertebral body heights are maintained. There is minimal leftward rotation of C1 on C2, which is similar to ___. This is likely positional. Multilevel degenerative changes are again seen, all of which are grossly similar to ___. Posterior disc-osteophyte complexes, most prominent at C6-7, indent the thecal sac with mild canal stenosis at C3/4 to C6/7 levels. Multilevel left neural foraminal narrowing is present with uncovertebral and facet hypertrophy, most pronounced at C3-4. Multilevel intervertebral disc space loss, most severe at C5-6 and C6-7 , are similar to prior. Posterior arch of atlas is not fused. No focal lytic or sclerotic osseous lesion is present to suggest osseous metastatic disease. After administration of IV contrast, no enhancing soft tissue lesion is seen in the cervical spine. There is no evidence of fracture. The prevertebral soft tissues are unremarkable. No cervical lymphadenopathy is present. Several supraclavicular lymph nodes are present bilaterally, some of which are borderline. The thyroid is prominent and the left lobe is heterogeneous with a hypodense area posteriorly. There is mild fullness in the left pirirform sinus. Bilateral patchy ground-glass opacities are seen in the lung apices, right greater than left, compatible with airtrapping. Aortic arch and ascending aorta are ectatic. IMPRESSION: 1. No evidence of fracture, acute alignment abnormality, or prevertebral soft tissue abnormality. 2. No evidence of osseous metastatic lesion or enhancing soft tissue lesion in the cervical spine. Correlate with other 1modalities if needed. 3. Several bilateral supraclavicular lymph nodes, some of which are borderline. 4. Enlarged left lobe of thyroid with possible hypodense nodule-correlate with ultrasound. 5. Prominent/ectatic aortic arch and ascending aorta- correlate with dedicated imaging. NOTE ON ATTENDING REVIEW: The present study was performed as the pt. did not want to have MRI as cannot lie down longer. Details of the risks and limitations of CT study were discussed with ___ by ___ in detail on the day of the study- ___. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ETOH/UNABLE TO AMBULATE Diagnosed with ALCOHOL ABUSE-UNSPEC temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted for alcohol intoxication and the inability to walk. After your stay in the hospital, you alcohol level has gone down, and you did not experience any withdrawl symptoms. During your hospital stay you were also found to have new back pain for the last week. You had a CT scan of the spine to evaluate your back pain. The preliminary results from the CT scan showed no new fracture and no obvious sperading of your cancer to your back. Your pain was most likley musculoskeletal and has improved on day of discharge. You have an appointment with Dr. ___ ___ , your liver doctor. It is very important to keep this appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Aspirin / Penicillins / Iodine / Motrin Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of an incarcerated ventral hernia s/p repair with complex component separation in ___ who presents with acute abdominal pain. The patient developed abdominal pain at approximately 5AM this morning with associated nausea and non-bloody emesis (he describes as greenish-yellow). He reports recent constipation and has not had a bowel movement in ___ days, but continues to pass gas. He denies fevers/chills, chest pain, shortness of breath. He reports symptoms of heartburn, worse at night and lying down, but denies regurgitation or dysphagia. He presented to ___ for evaluation, where CT A/P was concerning for high-grade SBO and he was transferred to ___ for further evaluation. At time of surgical evaluation, he is non-toxic in appearance and reports significant improvement in abdominal pain and nausea. He continues to pass gas. The patient has a complicated past surgical history. His first exploratory laparotomy in ___ for a bowel obstruction, at the ___ per the patient he had an obstructive picture and there was concern he had a parasite in the setting of recent travel. He had a subsequent bowel obstruction in ___ that also required an exploratory laparotomy. In ___, he presented to ___ with an incarcerated ventral hernia and underwent extensive lysis of adhesions and component separation with placement of both underlay and overlay mesh. He also had an hiatal hernia repair at an unclear time. He has never had an EGD. He reports routine surveillance colonoscopies without intervention. Past Medical History: Past Medical History: -GERD -iron Deficiency Anemia - b12 deficiency - nephrolithiasis - h/o frequent UTIs - h/o renal AVM s/p embolization - h/o prostatitis - gout Past Surgical History: for narrative see above Exploratory laparotomy, lysis of adhesions ___, ___ Exploratory laparotomy, lysis of adhesions ___, ___ Exploratory laparotomy with extensive lysis of adhesion, ventral hernia repair with component separation and with underlay (Ventralight) and overlay (Prolene) of mesh. complex component Social History: ___ Family History: Mother has a history of AV malformation. - h/o uric acidemia/gout Physical Exam: Admission Physical Exam: Vitals: T97.8, HR84 , BP126/83, RR16 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes dry CV: regular rate and rhythm PULM: non-labored breathing, no respiratory distress ABD: scaphoid appearance of abdomen, soft, mildly distended, tender to palpation in LUQ without rebound or guarding, midline surgical incision well-healed with palpable Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 98.0, 130/82 56 18 100 Ra Gen: Ambulating in room, NAD CV: HRR Pulm: LS ctab Abd: healing midline scar. palpable mesh in left side of abdomen. Abd soft, reportedly mildly TTP over LLQ. No guarding or rebound tenderness. Ext: No edema Pertinent Results: ___ 12:40PM BLOOD WBC-5.8 RBC-4.45* Hgb-13.0* Hct-38.7* MCV-87 MCH-29.2 MCHC-33.6 RDW-12.2 RDWSD-38.9 Plt ___ ___ 06:45AM BLOOD WBC-5.8 RBC-4.59* Hgb-13.5* Hct-41.3 MCV-90 MCH-29.4 MCHC-32.7 RDW-12.6 RDWSD-41.4 Plt ___ ___ 11:17AM BLOOD WBC-7.4 RBC-4.96 Hgb-14.4 Hct-44.3 MCV-89 MCH-29.0 MCHC-32.5 RDW-12.9 RDWSD-42.1 Plt ___ ___ 08:55PM BLOOD WBC-12.4*# RBC-5.23 Hgb-15.3 Hct-45.5 MCV-87 MCH-29.3# MCHC-33.6 RDW-12.6 RDWSD-39.8 Plt ___ ___ 12:40PM BLOOD Glucose-82 UreaN-11 Creat-0.9 Na-141 K-3.9 Cl-101 HCO3-27 AnGap-13 ___ 06:45AM BLOOD Glucose-86 UreaN-17 Creat-0.9 Na-147 K-4.7 Cl-107 HCO3-28 AnGap-12 ___ 11:17AM BLOOD Glucose-76 UreaN-20 Creat-1.0 Na-141 K-4.3 Cl-102 HCO3-26 AnGap-13 ___ 08:55PM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-141 K-4.6 Cl-105 HCO3-22 AnGap-14 ___ 12:40PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.5* ___ 06:45AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7 ___ 11:17AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.8 Imaging: CT A/P (OSH, 1PM): dilated jejunum in LUQ, decompressed ileum, fecalization of large and small bowel (OSH interpretation concerning for closed loop obstruction given "multiple loops of dilated mid-small bowel) CT A/P ___, 1AM): 1. No evidence of small-bowel obstruction with contrast noted in the cecum and ascending colon. The there is small bowel wall thickening and adjacent fat stranding of a loop of small bowel in the mid abdomen, which may be inflammatory or infectious in etiology. Of note, this loop of bowel is deep to the area of prior ventral hernia repair. 2. Large hiatal hernia. 3. Diverticulosis without evidence of diverticulitis. 4. Bilateral punctate nonobstructing nephrolithiasis. ___ Abdomina1 XRay: 1. Residual contrast is again demonstrated throughout the colon and rectum, which may show mild interval clearance, though no significant change from prior radiograph. 2. Enteric tube remains in similar position with tip terminating within the stomach. 3. No dilated loops of small or large bowel. Medications on Admission: Ranitidine 150 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID 4. Ranitidine 150 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT abdomen pelvis INDICATION: +PO contrast; History: ___ with abd pain+PO contrast// eval for SBO 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 administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.1 s, 48.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 476.6 mGy-cm. Total DLP (Body) = 477 mGy-cm. COMPARISON: Outside CT abdomen pelvis ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial 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 within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: 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 focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. Bilateral punctate calcifications in bilateral kidneys are consistent with nonobstructing renal stones the largest measuring up to 2 mm (2; 25). There is no perinephric abnormality. GASTROINTESTINAL: Moderate hiatal hernia. NG tube is partially visualized with tip in the stomach. Small bowel loops demonstrate normal caliber without evidence of small-bowel obstruction and oral contrast has been visualized in the cecum and ascending colon. Of note, there is significant fat stranding surrounding a loop of small bowel in the mid abdomen (2; 31) with small bowel wall thickening. Diverticulosis of the 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 prostate and seminal vesicles are normal. 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. 0.6 cm sclerotic focus within the right sacral ala is unchanged since ___ (2; 55), likely a bone island. Additional sclerotic foci within the left iliac bone measuring up to 2 mm are also unchanged since ___ (2; 58). SOFT TISSUES: A left inguinal hernia containing fat is noted. Patient status post prior ventral hernia repair. Soft tissue stranding in the anterior abdominal wall near the mid abdomen may be secondary to prior ventral hernia repair. IMPRESSION: 1. No evidence of small-bowel obstruction with contrast noted in the cecum and ascending colon. The there is small bowel wall thickening and adjacent fat stranding of a loop of small bowel in the mid abdomen, which may be inflammatory or infectious in etiology and can be compatible with focal enteritis. 2. Moderate hiatal hernia. 3. Diverticulosis without evidence of diverticulitis. 4. Bilateral punctate nonobstructing nephrolithiasis. Radiology Report INDICATION: ___ with bowel obstruction// Confirm NGT TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Enteric tube is seen with tip in the stomach, side-port however is likely above the hiatus. Hiatal hernia seen on prior is not clearly delineated on this portable view. The lungs are clear. Cardiomediastinal silhouette is within normal limits. Enteric contrast noted in the colon. No acute osseous abnormalities. IMPRESSION: Enteric tube tip below the diaphragm, side-port however likely above the hiatus. Radiology Report INDICATION: ___ y/o M w/ SBO, received PO gastroview to evaluate for passage of contrast through bowel. First abdominal x-ray was ordered to be performed at 4 hours after gastrograph.// interval change from the first abdominal (supine and erect) x-ray. Please obtain this x-ray 8 hours after the first abdominal x-ray was performed to eval for the passage of contrast through the bowel TECHNIQUE: Supine and upright views of the abdomen COMPARISON: CT scan of the abdomen and pelvis ___ FINDINGS: There is a hiatal hernia with the enteric tube seen with the tip in the stomach, this is better appreciated on the recent CT scan. Contrast is seen throughout the colon. The colon is not dilated. A copious amount of stool is noted in the rectum. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications in the region that is not obscured by contrast. IMPRESSION: Hiatal hernia with the enteric tube within the stomach, seen to better advantage on the recent CT scan. Contrast is seen throughout the colon. Radiology Report INDICATION: ___ y/o M w/ SBO. Evaluation for passage of gastroview, 8hrs after contrast injection. TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Abdominal radiographs from ___. CT abdomen/pelvis from ___. FINDINGS: Enteric tube is again seen, with tip terminating within the stomach. Residual contrast is again demonstrated throughout the colon and rectum. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: 1. Residual contrast is again demonstrated throughout the colon and rectum, which may show mild interval clearance, though no significant change from prior radiograph. 2. Enteric tube remains in similar position with tip terminating within the stomach. 3. No dilated loops of small or large bowel. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: SBO, Transfer Diagnosed with Other intestnl obst unsp as to partial versus complete obst temperature: 97.8 heartrate: 84.0 resprate: 16.0 o2sat: 98.0 sbp: 126.0 dbp: 83.0 level of pain: 6 level of acuity: 3.0

You were admitted to ___ with abdominal pain and findings of a small bowel obstruction seen on Ct scan. You were managed non-operatively with bowel rest, IV fluids, and nasogastric tube for stomach decompression. Your obstruction has resolved and you are now having bowel function and tolerating a regular diet. You are medically clear for discharge home. 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

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine Attending: ___. Chief Complaint: R hand clumsiness, dysarthria, and lower extremity weakness Major Surgical or Invasive Procedure: Carotid Endarterectomy (___) History of Present Illness: ___ is a ___ old man with a history of MGUS, hypertension and hyperlipidemia who presents with one week of stuttering symptoms in right hand and right leg. He was last in his normal state of health ten days ago. That morning he had the abrupt onset of numbness in his right hand extending up to his mid forearm. His hand was clumsy and would not obey him correctly. This lasted for ten minutes and then resolved. The next morning, he had an identical episode, again lasting ten minutes and then resolving. These symptoms next occurred last night, at which point they did not resolve, and his right hand has been clumsy since that time. Over the past week he has also had intermittent symptoms of left leg numbness. He first noticed this at work; he works as a ___ and walks for hours a day. He had the abrupt onset of numbness in his left foot and ankle, extending partway up the calf. This lasted for about 10 minutes and resolved. The leg felt "weak" but there were no specific functional deficits. He had multiple episodes of left leg numbness over the course of the next several days. Over the course of the day today, which has largely been in the hospital, he has had several episodes of lightheadedness on standing, possibly with a vertiginous character. His wife has also noted several episodes of slurred speech today but his speech is currently back at baseline. These symptoms brought him in to see his PCP, who sent him in to the emergency department at ___. There, he underwent CTA head and neck which showed an 80% stenosis of the R ICA. He was transferred to ___ for further evaluation and possible treatment. Past Medical History: Hypertension Hyperlipidemia MGUS Social History: ___ Family History: - Mother with valve replacement. Grandparent with colon cancer. Brother with blood clots in the legs. Physical Exam: ADMISSION EXAM: General: Overweight man sitting up in no apparent distress. HEENT: NC/AT Neck: No carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Vesicular breath sounds bilaterally, no wheezes or crackles appreciated. Cardiac: S1/S2 appreciated, RRR, no M/R/G. Abdomen: Obese, soft, nontender, nondistended. Bowel sounds present. Extremities: No lower extremity edema Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Mildly inattentive, recites ___ backwards slowly to ___ and gives up. Language is fluent and intact to reading, writing, repetition, naming of high and low frequency objects, and comprehension of cross-body, grammatically complex and multi-step commands. Able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 3mm with no RAPD. VFF to confrontation with finger counting. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch, temperature in all distributions. VII: Right nasolabial fold flattening but activation is full, and ___ strength in upper and lower distributions, bilaterally VIII: Hearing intact to finger-rub bilaterally, slightly harder to hear on left. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline, and is ___ bilaterally to confrontation with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. R-sided pronation and severe drift. No tremor or asterixis. RUE is weakest proximally and in the hand. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ 4+ ___ 5 5 5 5 R 4 4+ 4+ 4- 4+ ___ ___ 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 - Plantar response was flexor bilaterally. -Sensory: No deficits to light touch, pinprick, cold sensation throughout. Proprioception intact in the toes. Graphesthesia intact in the hands bilaterally, can detect direction of touch in lower extremity. No extinction to DSS. -Coordination: No intention tremor or dysmetria noted on FNF on the left; on R, dysmetria appeared consistent with No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Medium to narrow-based, normal stride and arm swing. Able to walk in tandem after some practice. Romberg absent. DISCHARGE EXAM: T 98.8, HR 78, BP 135/65, RR 18, O2 sat 97 RA General: NAD, A&Ox3 HEENT: NC/AT Neck: No carotid bruits Pulmonary: Normal work of breathing. CTA ___, no w/r/r Cardiac: normal S1/S2, RRR, no M/R/G. Abdomen: Obese, soft, nontender, nondistended. Pertinent Results: ___ 05:45AM WBC-12.2* RBC-4.48* HGB-14.5 HCT-42.2 MCV-94 MCH-32.4* MCHC-34.4 RDW-11.9 RDWSD-41.0 ___ 05:45AM PLT COUNT-260 ___ 05:45AM GLUCOSE-98 UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 ___ 05:45AM CALCIUM-9.7 PHOSPHATE-3.1 MAGNESIUM-2.1 CHOLEST-149 ___ 10:39PM ALT(SGPT)-35 AST(SGOT)-37 ALK PHOS-59 TOT BILI-0.8 ___ 10:39PM cTropnT-<0.01 ___ 10:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG CTA Head/Neck-OSH (___): 1. Study is moderately degraded by motion and dental streak artifact. 2. Severe left internal carotid artery stenosis immediately distal to origin, with greater than 80% narrowing. 3. 50% left external carotid artery narrowing. 4. 30% distal left common carotid artery narrowing. 5. 50% right internal carotid artery narrowing. 6. Additional cervical and intracranial atherosclerotic disease as described. 7. No evidence of acute intracranial hemorrhage. 8. No evidence ofaneurysm greater than 3 mm, dissection or vascular malformation. 9. Please note MRI of the brain is more sensitive for the detection of acute infarct. 10. Periodontal disease as described, recommend correlation with dental exam. Doppler US Carotids (___): Bilateral less than 40% carotid stenosis MRI/MRA Head/Neck (___): 1. Study is mildly degraded by motion. 2. Right parasaggital parietal and left frontal, parietal, and centrum semiovale acute to subacute infarcts. Distribution suggestive of bilateral watershed territory infarcts, with differential considerations of embolic infarcts. No definite evidence of hemorrhagic conversion. Recommend correlation neurologic exam and attention on followup imaging. 3. Patent circle of ___ as described. 4. Paranasal sinus disease as described. CTA Head/Neck (___): 1. Evolving left anterior cerebral artery distribution infarct, better characterized on prior head MRI, without evidence of hemorrhage. No evidence of new infarction. 2. Ulcerated, predominantly hypodense plaque at the left carotid bulb with intraluminal thrombus causing high-grade luminal stenosis measuring 73% by NASCET criteria. 3. Patent intracranial vasculature. 4. Right maxillary molar periapical lucency. Echocardiogram (___): Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. DISCHARGE LABS: ___ 05:45AM %HbA1c-5.3 eAG-105 ___ 05:45AM TSH-2.3 ___ 05:45AM TRIGLYCER-121 HDL CHOL-44 CHOL/HDL-3.4 LDL(CALC)-81 ___ 07:00PM INH SCR-POS ___ 07:00PM THROMBN-11.9 ___ 09:00PM SERUM VIS-1.6 ___ 07:00PM PEP-ABNORMAL B IgG-1757* IgA-88 IgM-101 IFE-MONOCLONAL Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 10 mg PO QPM 2. Atenolol 25 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet by mouth daily Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet by mouth QPM Disp #*30 Tablet Refills:*2 3. Enoxaparin Sodium 115 mg SC BID anticoagulation / lupus-anticoagulant Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 120 mg/0.8 mL 1 syringe SC every twelve (12) hours Disp #*20 Syringe Refills:*0 4. Acetaminophen 650 mg PO Q6H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet by mouth every 6 hours Disp #*40 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet by mouth two times per day Disp #*30 Tablet Refills:*0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth two times per day Disp #*30 Tablet Refills:*0 8. Atenolol 25 mg PO DAILY 9. Warfarin 5 mg PO ONCE Duration: 1 Dose RX *warfarin 5 mg 1 tablet by mouth daily Disp #*2 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Bilateral Acute Ischemic Strokes Carotid Artery Stenosis Hypertension High Cholesterol Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CAROTID SERIES COMPLETE CLINICAL HISTORY ___ year old man with carotid artery disease, CVA // eval carotid disease eval carotid disease FINDINGS: Duplex was performed of bilateral carotid arteries. There is bilateral homogeneous plaque in proximal ICA. Right: Peak velocities are 79, 109, and 228 cm/sec in the ICA, CCA, and ECA respectively. This is consistent with less than 40% stenosis Left: Peak velocities are 113, 84, and 221 cm/sec in the ICA, CCA, and ECA respectively. This is consistent with less than 40% stenosis. Vertebral flow is antegrade bilaterally. IMPRESSION: Bilateral less than 40% carotid stenosis Radiology Report EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD INDICATION: ___ year old man with stroke symptoms. Evaluate for acute infarct or circle of ___ steno-occlusive disease. TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain. Sagittal and axial T1 weighted imaging were performed along with diffusion imaging. Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. Three dimensional maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. COMPARISON: ___ outside head and neck CTA. FINDINGS: Study is mildly degraded by motion. MR BRAIN: Several foci of restricted diffusion within the left frontal lobe, centrum semiovale, and left parietal lobe involving the cortex as well as gray-white matter junction are associated with increased T2 and FLAIR signal. Additional foci of restricted diffusion is identified at the vertex to the right of the midline (4:29) as well as right frontal lobe (4:22), both within the right anterior cerebral artery territory. Numerous of these foci associated with T2 and FLAIR hyperintensity. None of these lesions demonstrate associated increase susceptibility. There is no evidence of acute hemorrhage. Minimally prominent ventricles and sulci likely reflect age related volume loss. There is no shift of normally midline structures. The orbits are unremarkable bilaterally. Minimally mucosal thickening involves the left maxillary sinus. Remaining imaged paranasal sinuses and mastoid air cells are clear. MRA BRAIN: The right A1 is hypoplastic. The right vertebral artery terminates in a AICA / ___ complex and the left vertebral artery is dominant. Otherwise, the intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: 1. Study is mildly degraded by motion. 2. Right parasaggital parietal and left frontal, parietal, and centrum semiovale acute to subacute infarcts. Distribution suggestive of bilateral watershed territory infarcts, with differential considerations of embolic infarcts. No definite evidence of hemorrhagic conversion. Recommend correlation neurologic exam and attention on followup imaging. 3. Patent circle of ___ as described. 4. Paranasal sinus disease as described. RECOMMENDATION(S): Recommend correlation neurologic exam and attention on followup imaging. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 4:04 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: SECOND OPINION CT NEURO PSO1 CT INDICATION: ___ male with carotid artery disease and episode of numbness with word retrieval issues. Second read request for CTA head and neck. TECHNIQUE: Head and neck CTA was performed on ___ 14:29 at ___ ___, and was submitted for second opinion review on ___.. DOSE: DLP: 4593.14 mGy-cm CTDI: 76.77 mGy COMPARISON: None. FINDINGS: Study is moderately degraded by motion and dental streak artifact. Within these confines: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. 0.7 x 0.5 cm hypodensity within the right putamina is most consistent with a chronic infarct or prominent Virchow ___ space. The ventricles and sulci are normal in size and configuration. No fracture identified. Mild mucosal thickening of the left maxillary sinus is noted. The additional visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Calcification of the cavernous portions of internal carotid arteries are noted. CTA HEAD: The right V4 segment is hypoplastic and ends in a AICA / ___ complex. The left vertebral artery is dominant. Atherosclerotic calcifications are noted of bilateral carotid bifurcations. The right A1 segment is hypoplastic. The vessels of the circle of ___ and their principal intracranial branches are otherwise grossly patent without evidence of stenosis, occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Concentric noncalcified plaque just distal to the origin of the left internal carotid artery demonstrates greater than 80% diameter reduction (5:141). Similar noncalcified plaque is seen at the origin of the left external carotid artery with approximately 50% narrowing. Noncalcified atheroma is seen within the distal left common carotid artery causing mild narrowing of 30%. Calcified and noncalcified plaque at the origin of the right internal carotid artery is seen causing 50% narrowing. There is mild narrowing of the right external carotid arteries. Minimal noncalcified atheroma along the right common carotid artery without significant narrowing. Minimal nonocclusive narrowing of the right vertebral artery origin is noted (see 701 8:92). The internal carotid arteries, vertebral arteries and their major branches are otherwise patent. No aneurysm greater than 3 mm or dissection. Calcified and noncalcified atherosclerotic plaque within the aortic arch. OTHER: The visualized portion of the lungs demonstrate emphysematous changes. . The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. A punctate radiopacity within the right parotid gland is consistent with a small sialolith. Periapical lucency adjacent to right mandibular molar are noted (see ___. IMPRESSION: 1. Study is moderately degraded by motion and dental streak artifact. 2. Severe left internal carotid artery stenosis immediately distal to origin, with greater than 80% narrowing. 3. 50% left external carotid artery narrowing. 4. 30% distal left common carotid artery narrowing. 5. 50% right internal carotid artery narrowing. 6. Additional cervical and intracranial atherosclerotic disease as described. 7. No evidence of acute intracranial hemorrhage. 8. No evidence ofaneurysm greater than 3 mm, dissection or vascular malformation. 9. Please note MRI of the brain is more sensitive for the detection of acute infarct. 10. Periodontal disease as described, recommend correlation with dental exam. RECOMMENDATION(S): Periodontal disease as described, recommend correlation with dental exam. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: ___ male with multiple infarcts concerning for left internal carotid artery stenosis. Evaluate for carotid artery disease. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP = 30.0 mGy-cm. 3) Spiral Acquisition 5.4 s, 42.4 cm; CTDIvol = 31.1 mGy (Head) DLP = 1,315.2 mGy-cm. Total DLP (Head) = 2,248 mGy-cm. COMPARISON: ___ head and neck MRI and MRA. ___ carotid ultrasound. ___ outside head and neck CTA. FINDINGS: CT head: There is hypodensity at the left centrum semiovale, mid frontal parietal and temporal occipital cortex corresponding to infarct better characterized on prior MRI. There is no evidence of new infarction, hemorrhage, or mass effect. The ventricles and cortical sulci are normal in caliber configuration. The extra-axial spaces are unremarkable. The orbits, calvarium, and soft tissues are unremarkable. The mastoid air cells and middle ears are clear. There is mild mucosal thickening within the bilateral maxillary sinuses with a small amount of aerosolized secretions at the posterior aspect of the left maxillary sinus. CTA head: There is calcification of the bilateral intracranial internal carotid arteries, without significant stenosis. The anterior communicating artery is visualized. The bilateral posterior communicating arteries are not definitively seen. There is hypoplastic right A1 segment. There is a left dominant vertebral artery with the right vertebral artery predominantly ending in the posterior inferior cerebellar artery. The anterior and posterior circulations are patent without occlusion, dissection, significant stenosis, or aneurysm. The dural venous sinuses are patent. CTA neck: There is a 3 vessel aortic arch. There is atherosclerosis of the aortic arch and great vessel origins without significant stenosis. There is calcific atherosclerosis at the right carotid bifurcation and bulb without significant stenosis by NASCET criteria. There is predominantly hypodense atherosclerosis involving the left distal common, bifurcation, bulb, and proximal external carotid arteries. There is a hypodense atheroma at the left carotid bulb with an irregular luminal surface and intraluminal filling defect consistent with an ulcerated plaque with intraluminal thrombus (3:184). This is causing 73% stenosis by NASCET criteria. The vertebral arteries are patent, with left dominance. The pharynx, larynx, nasal cavity, and oral cavities are unremarkable. The masticator and parapharyngeal spaces are unremarkable. New the thyroid and salivary glands are unremarkable. There is no lymphadenopathy by CT criteria. There is a right mandibular molar periapical lucency (03:20 9). There are multilevel degenerative changes of the cervical spine without fracture or osseous lesion. The lung apices are clear. IMPRESSION: 1. Evolving left anterior cerebral artery distribution infarct, better characterized on prior head MRI, without evidence of hemorrhage. No evidence of new infarction. 2. Ulcerated, predominantly hypodense plaque at the left carotid bulb with intraluminal thrombus causing high-grade luminal stenosis measuring 73% by NASCET criteria. 3. Patent intracranial vasculature. 4. Right maxillary molar periapical lucency. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: R Hand numbness, L Leg numbness Diagnosed with Cerebral infarction, unspecified, Essential (primary) hypertension temperature: 98.6 heartrate: 69.0 resprate: 16.0 o2sat: 98.0 sbp: 169.0 dbp: 85.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of R handed weakness, difficulty speaking, and lower extremity weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where 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: Carotid Artery Stenosis High Cholesterol High Blood Pressure Carotid Endarterectomy Patient Discharge Instructions: WHAT TO EXPECT: Bruising, tenderness, mild swelling, numbness and/or a firm ridge at the incision site is normal. This will improve gradually in the next 2 weeks. You may have a sore throat and or mild hoarseness. Warm tea, throat lozenges, or cool drinks usually help. It is normal to feel tired for ___ weeks after your surgery. MEDICATION INSTRUCTIONS: Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! It is very important that you take Aspirin every day! You should never stop this medication before checking with your surgeon. You should take Tylenol ___ every 6 hours, as needed for neck pain. If this is not enough, take your prescription pain medication. You should require less pain medication each day. Do not take more than a daily total of 3000mg of Tylenol. Tylenol is used as an ingredient in some other over-the-counter and prescription medications. Be aware of how much Tylenol you are taking in a day. Narcotic pain medication can be very constipating. If you take narcotics, please also take a stool softener such as Colace. If constipation becomes a problem, your pharmacist can suggest an additional over the counter laxative. CARE OF YOUR NECK INCISION: You may shower 48 hours after your procedure. Avoid direct shower spray to the incision. Let soapy water run over the incision, then rinse and gently pat the area dry. Do not scrub the incision. Your neck incision may be left open to air and uncovered unless you have a small amount of drainage at the site. If drainage is present, place a small sterile gauze over the incision and change the gauze daily. Do not take a bath or go swimming for 2 weeks. ACTIVITY: Do not drive for one week after your procedure. Do not ever drive after taking narcotic pain medication. You should not push, pull, lift or carry anything heavier than 5 pounds for the next 2 weeks. After 2 weeks, you may return to your regular activities including exercise, sexual activitiy and work. DIET: It is normal to have a decreased appetite. Your appetite will return over time. Follow a well-balanced, heart healthy diet, with moderate restriction of salt and fat. SMOKING: If you smoke, it is very important for you to stop. Research has shown that smoking makes vascular disease worse. Talk to your primary care physician about ways to quit smoking. If you use tobacco, the ___ Smokers' Helpline is a FREE and confidential way to get support and information to help you quit smoking. Call ___ CALLING FOR HELP If you need help, please call us at ___. Remember your doctor, or someone covering for your doctor is available 24 hours a day, 7 days a week. If you call during non-business hours, you will reach someone who can help you reach the vascular surgeon on call. To get help right away, call ___. Call the surgeon right away for: •headache that is not controlled with pain medication or headache that is getting worse •fever of 101 degrees or more •bleeding from the incision, or drainage the is new or increased, or drainage that is white yellow or green •pain that is not relieved with medication, or pain that is getting worse instead of better If you notice any of the following signs of stroke, call ___ to get help right away. •sudden numbness or weakness of the face, arm or leg (especially on one side of the body) •sudden confusion, trouble speaking or trouble understanding speech •trouble seeing in one or both eyes •sudden trouble walking, dizziness, loss of balance or coordination •sudden severe headache with no known cause You underwent removal of a section of artery in your neck (called a carotid endartarectomy). You are doing quite well and are now ready to be discharged home to continue the remainder of your recovery. Please follow-up with Neurology and Vascular Surgery at the appointments listed below. You will also need to follow-up in ___ weeks in the ___ (___). Additionally, you will need to follow-up with your PCP, ___. ___, for monitoring of your INR and dosing your Coumadin accordingly. Thank you for allowing us to partake in your care. We look forward to seeing you at your follow-up visit in clinic! Sincerely, Your ___ Vascular Surgery Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim Attending: ___. Chief Complaint: Odynophagia, rash Major Surgical or Invasive Procedure: 1. EGD with esophageal biopsy 2. Liver biopsy 3. Bone marrow biopsy History of Present Illness: Ms. ___ is a ___ with hx of AIDS (CD4 count 22, ___ not on HAART, VL 208,000), HepC, asthma, female presenting from ___ w/ severe dyspnea, severe chest and abdominal pain. Of note, she was recently discharged from ___ on after admission for PCP PNA on ___. She had been feeling well until this past ___ when she began gradually developing pain with swallowing foods and eventually liquids. She woke up on the morning of ___ with severe epigastric and substernal chest pain which was not relieved with tums or omeprazole. Over last 2 says she has severe odynophagia when swallowing pills and liquids. She has also had several episodes of non-bloody emesis. She was found to have thrush during last admission and had been rx nystatin mouth wash. She had been using it but doesnt think it was helping. Prior to transfer, she received IV morphine with improvement in pain. Additionally, she was also found to have a fever to 102 and new rash. She was recently started on Bactrim for PCP ___. Rash is pruitic and non-painful. She denies any chills/sweats, diarrhea, headache, or SOB. In the ED, vitals were. She was orthostatic per note. Labs notable for AST/ALT 323/563, AP 387, tbili 2.6 (2.2 direct), Na 132. CBC and UA normal. A CTA torso demonstrated improving lung infiltrates from prior study, mild to moderate inflammation of the esophagus, and gonadal varices. ID was consulted and was concerned for Bactrim allergy and recommended switching to clina and primaquin. They also recommended empiric micafungin for ___ esophagitis. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HIV, recent CD4 of 22, complicated by PCP pneumonia ___ HepC Asthma Anxiety Depression PSH- cholecystectomy many years ago Social History: ___ Family History: Noncontributory Physical Exam: Admission Physical: =============== Vitals - T:98.3 BP:106/54 HR:91 RR:18 02 sat: 99% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, extensive thrush in mouth with no ulcerations appreciated 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, no hepatosplenomegaly EXTREMITIES: eccymosis (almost purpura appearings on b/l popliteal regions, non painful, moving all extremities well, no cyanosis, clubbing or edema. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, no focal deficits SKIN: Morbilliform rash over upper chest and b/l arms, blanching.warm and well perfused. Discharge Physical: ================ Afebrile, BP 100s/50s HR ___ RR 18 100%RA General: Well appearing, comfortable, awake and alert HEENT: MMM, Oropharynx clear without lesions Cardiac: RRR, no m/r/g Lungs: clear to auscultation bilaterally without wheezes or crackles Abd: Soft, nontender, nondistended Extremities: WWP, no bruising or erythema Neuro: Grossly intact, walking well Skin: No rash Pertinent Results: Admission Labs: =========== ___ 02:20PM BLOOD WBC-5.8# RBC-3.78* Hgb-12.1 Hct-36.8 MCV-97 MCH-32.1* MCHC-33.0 RDW-15.0 Plt ___ ___ 02:20PM BLOOD Neuts-67.8 ___ Monos-2.8 Eos-4.6* Baso-0.3 ___ 08:05AM BLOOD ___ ___ 02:20PM BLOOD Glucose-101* UreaN-15 Creat-0.6 Na-132* K-4.7 Cl-102 HCO3-21* AnGap-14 ___ 02:20PM BLOOD ALT-325* AST-563* LD(LDH)-342* AlkPhos-387* TotBili-2.6* DirBili-2.2* IndBili-0.4 ___ 02:20PM BLOOD Lipase-51 ___ 02:20PM BLOOD Albumin-2.4* ___ 02:45PM BLOOD Calcium-6.9* Phos-2.0* Mg-1.7 ___ 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG LFT Trends: ========= ___ 08:05AM BLOOD ALT-325* AST-508* AlkPhos-370* TotBili-4.5* ___ 06:30AM BLOOD ALT-151* AST-219* LD(___)-227 AlkPhos-278* TotBili-5.8* DirBili-4.9* IndBili-0.9 ___ 06:50AM BLOOD ALT-103* AST-206* AlkPhos-402* TotBili-4.5* ___ 06:10AM BLOOD ALT-59* AST-124* LD(LDH)-272* AlkPhos-464* TotBili-2.7* ___ 06:30AM BLOOD ALT-50* AST-138* AlkPhos-420* TotBili-2.1* ___ 06:40AM BLOOD ALT-53* AST-179* AlkPhos-447* TotBili-1.6* ___ 07:05AM BLOOD ALT-71* AST-225* AlkPhos-473* TotBili-1.4 WBC Trend: ========== ___ 06:30AM BLOOD WBC-3.2* RBC-3.04* Hgb-10.0* Hct-29.9*# MCV-98 MCH-33.0* MCHC-33.6 RDW-15.2 Plt ___ ___ 06:30AM BLOOD WBC-2.4* RBC-3.06* Hgb-9.6* Hct-30.4* MCV-99* MCH-31.4 MCHC-31.6 RDW-15.7* Plt ___ ___ 06:50AM BLOOD WBC-1.9* RBC-3.18* Hgb-10.3* Hct-31.9* MCV-100* MCH-32.3* MCHC-32.2 RDW-15.9* Plt ___ ___ 05:55AM BLOOD WBC-1.3* RBC-2.68* Hgb-8.8* Hct-27.0* MCV-101* MCH-33.0* MCHC-32.7 RDW-16.7* Plt ___ ___ 06:30AM BLOOD WBC-2.2* RBC-2.71* Hgb-9.0* Hct-27.7* MCV-102* MCH-33.3* MCHC-32.5 RDW-17.9* Plt ___ ___ 06:55AM BLOOD WBC-1.6* RBC-2.64* Hgb-8.4* Hct-27.7* MCV-105* MCH-31.9 MCHC-30.3* RDW-18.8* Plt ___ ___ 06:10AM BLOOD WBC-2.5*# RBC-2.84* Hgb-9.8* Hct-30.1* MCV-106* MCH-34.5* MCHC-32.6 RDW-18.1* Plt ___ ___ 07:05AM BLOOD WBC-2.4* RBC-3.00* Hgb-10.1* Hct-31.9* MCV-106* MCH-33.6* MCHC-31.6 RDW-18.8* Plt ___ ___ 06:50AM BLOOD Neuts-29* Bands-3 Lymphs-48* Monos-8 Eos-6* Baso-0 Atyps-6* ___ Myelos-0 NRBC-1* ___ 06:30AM BLOOD Neuts-29.2* Lymphs-58.1* Monos-7.7 Eos-4.3* Baso-0.7 ___ 06:55AM BLOOD Neuts-28.4* Lymphs-52.5* Monos-8.1 Eos-10.1* Baso-0.9 ___ 06:10AM BLOOD Neuts-40.6* Lymphs-47.4* Monos-6.7 Eos-3.5 Baso-1.7 ___ 06:10AM BLOOD Neuts-40.6* Lymphs-47.4* Monos-6.7 Eos-3.5 Baso-1.7 ___ 07:05AM BLOOD Neuts-41.6* Lymphs-42.6* Monos-9.8 Eos-4.6* Baso-1.4 Sodium Trend: ============ ___ 08:05AM Glucose-85 UreaN-11 Creat-0.6 Na-130* K-4.8 Cl-101 HCO3-19* ___ 02:45PM Glucose-107* UreaN-9 Creat-0.6 Na-125* K-4.5 Cl-100 HCO3-21* ___ 06:30AM Glucose-91 UreaN-9 Creat-0.4 Na-128* K-3.8 Cl-101 HCO3-24 AnGap-7* ___ 06:30AM Glucose-84 UreaN-8 Creat-0.4 Na-133 K-4.2 Cl-101 HCO3-26 AnGap-10 ___ 07:00AM Glucose-112* UreaN-7 Creat-0.5 Na-130* K-4.2 Cl-100 HCO3-24 ___ 06:10AM Glucose-90 UreaN-8 Creat-0.4 Na-135 K-4.3 Cl-104 HCO3-23 AnGap-12 ___ 06:45AM Glucose-94 UreaN-9 Creat-0.4 Na-137 K-4.3 Cl-107 HCO3-24 AnGap-10 INR Trend: ======== ___ 06:30AM BLOOD ___ PTT-55.5* ___ ___ 06:30AM BLOOD ___ ___ 06:50AM BLOOD ___ PTT-39.2* ___ ___ 05:55AM BLOOD ___ ___ 06:30AM BLOOD ___ Miscellaneous: ============ ___ 06:00PM BLOOD IgG-1153 IgA-1204* IgM-176 ___ 06:00PM BLOOD ___ * Titer-1:40 ___ 06:00PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 03:45PM BLOOD IgM HAV-NEGATIVE ___ 10:30AM BLOOD Triglyc-264* ___ 10:30AM BLOOD ___ Ferritn-1033* ___ 10:30AM BLOOD D-Dimer-968* ___ 06:10AM BLOOD GGT-592* ___ 10:30AM BLOOD Ret Aut-4.2* Discharge Labs: =========== ___ 11:00AM BLOOD WBC-3.6* RBC-3.56* Hgb-11.9* Hct-37.9 MCV-106* MCH-33.4* MCHC-31.4 RDW-18.5* Plt ___ ___ 11:00AM BLOOD ___ ___ 07:05AM BLOOD Glucose-90 UreaN-13 Creat-0.4 Na-138 K-4.2 Cl-108 HCO3-25 AnGap-9 ___ 11:00AM BLOOD ALT-100* AST-308* AlkPhos-553* TotBili-1.6* Microbiology: =========== Blood Cultures ___: Negative Urine Culture ___ coag negative staph CMV ___: CMV DNA detected, less than 137 IU/mL Mycolytic cultures ___: pending CMV IgG antibody ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 100 AU/ML. Liver Biopsy ___: Gram stain w/o PMNs, no organisms, tissue: NGTD, Anaerobic culture no growth, PCP: negative, fungal culture: negative, viral culture: negative, CMV early antigen test: negative RPR: negative Urine culture ___: mixed bacterial flora Bone marrow biopsy ___: Fluid culture: No growth, AFB culture, fungal culture: pending Anti Actin IgG: Positive EBV PCR blood: positive - ___ H Hep E IgM: Negative HSV 1 IGG TYPE SPECIFIC AB 2.59 H HSV 2 IGG TYPE SPECIFIC AB <0.90 HSV ___ IgM: negative ___: CT Chest/Abd/Pelvis 1. Persistent but improving multifocal pulmonary opacities, mostly characterized by vague ground glass areas, more extensive in the upper than lower lungs. In the setting of HIV infection, differential considerations include improving pneumocystis pneumonia or other atypical forms of infection; correlation with recent clinical circumstances is recommended. Several coinciding small nodules are likely incidental although potentially inflammatory or infectious. 2. Similar mild lymphadenopathy in the chest. 3. No evidence of pulmonary embolism. 4. Prior cholecystectomy without biliary dilatation or definite hepatic parenchymal abnormality. 5. Mild distal esophageal thickening, equivocal, but potentially due to an inflammatory process. 6. Mild splenomegaly and retroperitoneal lymphadenopathy, notably periportal lymph nodes, which can be an indication of underlying liver disease or hepatic inflammation. 7. Large left gonadal varices. Liver/Gallbladder US ___: Normal abdominal sonogram. Patent portal veins. MRI Head with and without contrast ___: Slightly prominent sulci for the patient's age, likely related with the immunological status, no focal lesions are identified, there is no evidence of abnormal enhancement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO BID:PRN anxiety 2. Nystatin Oral Suspension 5 mL PO QID 3. Sulfameth/Trimethoprim DS 2.5 TAB PO TID 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or chest tightness 5. PredniSONE 20 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or chest tightness 2. ALPRAZolam 0.5 mg PO BID:PRN anxiety 3. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone 750 mg/5 mL 10 mL by mouth Daily Refills:*0 4. Dolutegravir 50 mg PO DAILY RX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY RX *emtricitabine-tenofovir [___] 200 mg-300 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 6. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 7. QUEtiapine Fumarate 100 mg PO QHS RX *quetiapine 100 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 8. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 9. ValACYclovir 1000 mg PO Q8H Duration: 3 Days RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every eight (8) hours Disp #*8 Tablet Refills:*0 Discharge Disposition: Home with Service Facility: ___ ___ Diagnosis: Primary Diagnoses: 1. ___ esophagitis 2. Bactrim Toxicity 3. Febrile neutropenia with HCAP 4. Elevated LFTs 5. Depression 6. Hyponatremia Secondary Diagnoses: 1. HIV 2. Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: AIDS, hepatitis-C, transaminitis. COMPARISON: None. FINDINGS: Grayscale and Doppler ultrasound images of the abdomen were obtained. The liver is normal without focal or echotextural abnormality. Status post cholecystectomy. The common duct measures 3 mm and there is no intra- or extra-hepatic bile duct dilatation. The pancreas is unremarkable. The aorta is of normal caliber throughout. The visualized portions of the IVC appear normal. Color flow and spectral Doppler waveform analysis were obtained. The main, left, right anterior, and right posterior portal veins are patent with hepatopetal flow. IMPRESSION: Normal abdominal sonogram. Patent portal veins. Radiology Report INDICATION: ___ year old woman with HIV/AIDS (CD4 22), HCV untreated here with severe esophagitis, rising LFTs, fevers, concern for disseminated HSV or CMV, bactrim reaction. Please do RUSH LIVER BIOPSY, prior to 10am for RUSH pathology. Please send CMV, viral studies, PCP, ___, fungal cultures and Pathology // ? HSV or CMV, ? bactrim reaction, ? cirrhosis COMPARISON: Ultrasound dated ___. PROCEDURE: Ultrasound-guided non-targeted core biopsy of the liver. OPERATORS: Dr. ___, abdominal radiology fellow, and Dr. ___, attending radiologist, who was present and supervising throughout the total procedure time. FINDINGS: Limited pre-procedure grayscale and Doppler ultrasound imaging of the right hepatic lobe was performed and a suitable approach for non-targeted liver biopsy was determined. No other abnormalities were identified on the limited imaging. 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. Based on the pre-procedure imaging, an appropriate skin entry site for the biopsy was chosen in the right upper quadrant. The site was marked. The skin was then prepped and draped in the usual sterile fashion. The superficial soft tissues to the liver capsule were anesthetized with 10 mL 1% lidocaine. Under real-time ultrasound guidance, a 16 gauge core biopsy needle was then advanced into the liver with two separate passes and two core biopsy samples were obtained - one was placed in formalin while the other was placed in sterile saline for cultures. The samples were brought to the lab for rush analysis as per the team's orders. The skin was then cleaned and a dry sterile dressing was applied. There were no immediate complications. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 50 mcg fentanyl by an indepent-trained radiology nurse throughout the total ___ time of 12 minutes during which patient's hemodynamic parameters were continuously monitored by an independent-trained radiology nurse. IMPRESSION: Uncomplicated non-targeted core biopsy of the liver with two separate samples sent for rush analysis as per the team's orders. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old woman with HIV/AIDs, Hep C, PCP pneumonia and HSV esophagitis with ongoing fevers and new SIADH // evaluate for opportunist infection, cause of SIADH TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair, axial diffusion weighted and axial gradient echo images. The T1 weighted images were repeated after the administration of intravenous gadolinium contrast. COMPARISON: No prior examinations of the head are available here FINDINGS: There is no evidence of intracranial hemorrhage or mass effect, the ventricles and sulci are slightly prominent for the patient's age, probably related with the immunological status of this patient there is no evidence of abnormal enhancement, no diffusion abnormalities are detected. The major vascular arterial flow voids are present and demonstrate normal distribution. The orbits are normal, the paranasal sinuses are notable for mucosal thickening in the sphenoid sinus, ethmoidal air cells and right maxillary sinus, suggesting an inflammatory process. IMPRESSION: Slightly prominent sulci for the patient's age, likely related with the immunological status, no focal lesions are identified, there is no evidence of abnormal enhancement. NOTIFICATION: These findings were communicated via phone call to Dr. ___ by Dr. ___ on ___ at 15:10 hr. Radiology Report EXAMINATION: Abdominal MRI. MRCP. INDICATION: ___ year old woman with HIV/AIDS, Hep C here with acute on chronic hepatitis with elevated bili and alk phos. // ? AIDS cholangiopathy, ? biliary obstruction, vanishing bile ducts TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired within a 1.5 Tesla magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 8 cc of Gadavist intravenous contrast. COMPARISON: Ultrasound from ___. FINDINGS: MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Included views of the lung bases demonstrates a trace right pleural effusion and moderate bibasilar atelectasis (series 5, image 6). The heart size is normal. There is no pericardial effusion. The hepatic parenchyma demonstrates mild signal drop-off on T1 weighted out of phase images in comparison to in phase sequences, denoting steatosis. The liver contour appears smooth, however, there is widening of the hilar periportal space (series 13, image 16), measuring at least 11 mm, suggestive of early cirrhosis. Moderate periportal edema is present. Peripheral arterial hyper enhancement throughout the right hepatic lobe is superimposed over areas of peripheral vascular crowding (series 13, image 13), suggestive of acute hepatitis over mild background fibrosis. No concerning hepatic mass is detected. There is no intra or extrahepatic bile duct dilation. A prominent accessory right intrahepatic duct is present (series 9, image 4), further assessment limited due to extensive motion artifact. The spleen is mildly enlarged. The adrenal glands, kidneys, pancreas, stomach, and intra-abdominal loops of small and large bowel are normal. There is no mesenteric or retroperitoneal lymphadenopathy, and no ascites. The abdominal aorta, celiac trunk, SMA, and renal arteries appear patent and normal in caliber. There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. Mild hepatitis superimposed on mild cirrhosis and peripheral fibrosis. No concerning hepatic mass. 2. Mild hepatic steatosis. 3. Examination limited by motion, however, no bile duct stricture or mass. No intra or extrahepatic bile duct dilation. 4. Mild splenomegaly, mayy reflect chronic portal hypertension. 5. Trace right pleural effusion and moderate bibasilar atelectasis. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old woman with AIDS recent PCP, ___, also with hepatitis s/p liver biopsy now with severe abdominal pain. // ?hematoma and evaluate hepatic flow TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: US guided liver biopsy dated ___ and CT of the abdomen and pelvis dated ___. FINDINGS: LIVER: The echogenicity of the liver is homogeneous. The contour of the liver is smooth. There is no focal liver mass. Main portal vein is patent with hepatopetal flow. There is no ascites. There is no perihepatic hematoma. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm. GALLBLADDER: Status post cholecystectomy. PANCREAS: The head and body of the pancreas are within normal limits. The tail of the pancreas is not visualized due to the presence of gas. SPLEEN: Mild splenomegaly, measuring 13.3 cm. KIDNEYS: The right kidney measures 12.8 cm. The left kidney measures 11.6 cm. Limited views of the kidneys are unremarkable. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. DOPPLER EXAMINATION: The main, right and left portal veins are patent with normal flow. The main, right, and left hepatic arteries are patent with appropriate waveforms. The hepatic veins are also patent. IMPRESSION: 1. No evidence of perihepatic hematoma or other cause for right upper quadrant pain. 2. Patent hepatic vasculature. 3. Mild splenomegaly. Radiology Report STUDY: AP CHEST, ___. CLINICAL HISTORY: ___ with AIDS and new fever. Evaluate for pneumonia. FINDINGS: Comparison is made to previous study from ___. Since the previous study, there has been improvement in the diffuse airspace opacities throughout both lung fields. There remain residual areas of consolidation within the bases. Heart size is prominent. There are no pneumothoraces. There are no pleural effusions. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman with HIV/AIDs, Hep C, and HSV esophagitis. Now with worsening abdominal pain and peritoneal symptoms. ? abdominal abscess, ? free air, abdominal perforation. TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast . Sagittal and coronal reformats were prepared. DLP: 768 mGy-cm COMPARISON: Prior CT chest, abdomen and pelvis from ___, ultrasound abdomen from ___ and MRCP from ___. FINDINGS: ABDOMEN: New small right pleural effusion is identified. There is evidence bibasal consolidation/ atelectasis. Mild persistent thickening of the distal esophagus is noted. Small perihepatic ascites is now identified. The liver demonstrates homogeneous enhancement. No intrahepatic or extrahepatic biliary ductal dilatation. Portal veins and hepatic veins are patent. The no suspicious focal hepatic lesions are identified. Cholecystectomy clips are identified. The pancreas and adrenal glands are unremarkable. There is persistent mild splenomegaly, with the spleen measuring up to 14.9 cm. The kidneys demonstrate symmetric enhancement and excretion of contrast. No hydronephrosis. No focal renal lesions are identified. Caliber of small and large bowel is within normal limits. Nonspecific mild fold thickening of distal small bowel loops is noted (5:72). Colonic fecal loading is identified. Stomach is unremarkable. Caliber of abdominal aorta is within normal limits, with no evidence of abdominal aortic aneurysm. Few persistent nonspecific mildly enlarged retroperitoneal lymph nodes are again identified (05:42). Few lymph nodes are identified in the porta hepatis (05:31). Small of fluid tracts into the region of the porta hepatis. No intraperitoneal free air. PELVIS: Urinary bladder is within normal limits. The uterus and rectum are unremarkable. Persistent prominent bilateral gonadal vessels are identified. No inguinal or pelvic lymphadenopathy. A few prominent pelvic lymph nodes are identified, not meeting size criteria for pathologic enlargement (5:97). No pelvic free fluid. Mild bilateral flank body wall stranding/ edema is noted. Slightly ill-defined hypodensity is identified in the left hemipelvis medial to the left external iliac vessels (5:69), likely in keeping with small amount of fluid. Underlying lymph node is not excluded. OSSEOUS STRUCTURES: No suspicious osteolytic or osteoblastic lesions are identified. Small focus of periarticular sclerosis at the left iliac bone (6b:37), likely relates to a small bone island. IMPRESSION: 1. No evidence of intra-abdominal fluid collections to suggest abscess. No intraperitoneal free air. 2. Small right pleural effusion. Bibasal consolidation/atelectasis. 3. Mild persistent thickening of distal esophagus. 4. Small amount of perihepatic, abdominal and pelvic ascites. Slightly ill-defined hypodensity in the left hemipelvis medial to the left external iliac vessels likely in keeping with small amount of fluid. Underlying lymph node is not excluded. 5. Persistent mild splenomegaly and mildly enlarged retroperitoneal lymph nodes. Slightly prominent lymph nodes in the porta hepatis. 6. Persistent prominent bilateral gonadal vessels. 7. Colonic fecal loading. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ woman with HIV AIDS, hepatitis-C and persistent right upper quadrant pain. Decreased breath sounds on the right. Suspect pleural effusion. COMPARISON: Chest radiographs ___ IMPRESSION: Moderate right pleural effusion is responsible for elevation of the apparent right hemidiaphragm. In addition there is a large to region of consolidation in the right lower lung, localized to the middle lobe on the lateral view. Small left pleural effusion is unchanged. A large region of atelectasis at the left lung base, is unchanged since ___. The widespread pneumonia present in ___ which it cleared by ___ has not returned. Heart size is normal. Mediastinal contours reflect substantial central adenopathy. Radiology Report CT TORSO HISTORY: Shortness of breath, epigastric pain, elevated bilirubin after cholecystectomy with fever. COMPARISONS: Chest radiographs are available from ___. TECHNIQUE: Multidetector CT images of the chest were obtained with intravenous contrast in the pulmonary arterial phase. Sagittal and coronal reformations were also performed. This was followed by CT imaging of the abdomen and pelvis with intravenous contrast. Sagittal and coronal reformations of the abdomen and pelvis were also performed. FINDINGS: CT CHEST: There is mild bilateral hilar and mediastinal lymphadenopathy. A cluster of right hilar nodes measures up to 19 x 14 mm in axial ___. A left hilar lymph node measures up to 9 mm in shortest dimension. A right subcarinal node is borderline measuring up to 12 x 22 mm in axial ___. A prevascular lymph node measures 16 x 9 mm. There are no enlarged supraclavicular or axillary nodes. No filling defects are visualized among the pulmonary arteries. There are no pleural or pericardial effusions. The heart is normal in size. Central airways suggest mild wall thickening which is likely inflammatory. The upper lungs show heterogeneous opacification with predominantly ground-glass opacities, which affect the lower lobes to a lesser degree. Opacities, however, have markedly improved since the prior although probably unchanged since the more recent radiographs. Streaky dependent opacities suggest some degree of minor coinciding atelectasis. In the right upper lobe, there is a very small solid nodule measuring 4 mm (3:83). There is also a 2 mm solid nodule (3:86). An additional nodule in the right middle lobe measures 4 mm (602B:17), while in the right upper lobe, a further 4 mm nodule (3:97). CT ABDOMEN: The patient is status post cholecystectomy. There is no biliary dilatation. The liver appears within normal limits. The spleen is mildly enlarged, measuring up to 13.8 cm in length. The pancreas and adrenal glands appear within normal limits. The kidneys are unremarkable. The stomach, small and large bowel appear within normal limits. The wall of the distal esophagus appears borderline thickened along the lower third. There are several mildly prominent periportal nodes with vague attenuation increase in the surrounding fat. Representative is a portacaval node measuring up to 21 x 12 mm in axial ___ (2B:109), which is borderline. There are also scattered small, probably reactive periaortic lymph nodes. CT PELVIS: The left gonadal vein is enlarged with striking left gonadal varices. The major mesenteric arteries and veins appear patent. The uterus and adnexal regions are otherwise unremarkable. The bladder appears within normal limits. There is no ascites. BONE WINDOWS: There are no suspicious lytic or blastic bone lesions. A sclerotic focus in the left ilium is consistent with a benign bone island. The appendix appears normal. IMPRESSION: 1. Persistent but improving multifocal pulmonary opacities, mostly characterized by vague ground glass areas, more extensive in the upper than lower lungs. In the setting of HIV infection, differential considerations include improving pneumocystis pneumonia or other atypical forms of infection; correlation with recent clinical circumstances is recommended. Several coinciding small nodules are likely incidental although potentially inflammatory or infectious. 2. Similar mild lymphadenopathy in the chest. 3. No evidence of pulmonary embolism. 4. Prior cholecystectomy without biliary dilatation or definite hepatic parenchymal abnormality. 5. Mild distal esophageal thickening, equivocal, but potentially due to an inflammatory process. 6. Mild splenomegaly and retroperitoneal lymphadenopathy, notably periportal lymph nodes, which can be an indication of underlying liver disease or hepatic inflammation. 7. Large left gonadal varices. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with ESOPHAGITIS UNSPECIFIED, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ASYMPTOMATIC HIV INFECTION temperature: 98.8 heartrate: 94.0 resprate: nan o2sat: 97.0 sbp: 99.0 dbp: 55.0 level of pain: 8 level of acuity: 3.0

Dear Ms. ___, You were admitted to the hospital with severe chest pain, rash and fevers. You were thought to be having a reaction to bactrim and this medication was stopped. You were found to have esophagitis (inflammation in your food pipe aka esophagus) which was treated with fluconazole and acyclovir. It is important that you take valcyclovir as prescribed until ___. You were also found to have very abnormal liver function tests and pain around your liver. A liver biopsy was done and showed chronic changes from hepatitis C as well as acute inflammation. Your acute inflammation improved. It is important that you follow-up with the liver doctors to continue to discuss treatment of your liver and your hepatitis C. While you were here, your white blood cell counts dropped and you were treated with antibiotics for your fevers and low blood counts. These have started to resolve after stopping primaquine (for PCP) and with starting antiretroviral medications. In order to prevent this infection from re-occurring it is very important to take your atovaquone everyday. It is VERY important that you continue to take all of your medications exactly as prescribed to prevent recurrence of infections related to your disease. After discharge, you will follow-up at ___ program for partial psychiatric hospitalization, a day program to work on depression and anxiety related to your illness. Please call ___ at ___ to set up an intake appointment for ___ or ___ of this week. It was a pleasure taking care of you! 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: Leg and elbow pain after a fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with a history of progressive dementia, atrial fibrillation, and congestive heart failure, presenting after a fall at home. The night prior to admission, the patient fell after getting out of bed. His wife heard a thud and found the patient lying ___ feet away from the bed, next to a wall. The family thought the patient may have hit the wall while falling. At that time the patient denied any pain and appeared in his usual state of health. The next morning, the patient's wife and son noticed that he was having difficulty walking and was complaining of pain in his left leg and arm. He also had a left elbow abrasion. He was brought to the ___ ED. In the ED, initial vitals were: T 98.0, HR 88, BP 119/61, RR 16, O2S 99% RA Blood cultures x2 sent. He was given 1g tylenol and 1 L NS. Labs were significant for: 10:50 AM: INR 3.6, WBC 12.6, Cr 2.3, BUN 112, glucose 214, lactate 3.5 U/a: neg leuk, neg nitrite Thorough trauma evaluation revealed a fracture of the greater trochanter of the left proximal femur. He was evaluated by orthopedics, who recommended conservative management. He was admitted to medicine for pain control and ___ evaluation. In speaking with the patient's son, the patient has fallen several times in the past month. The falls occur at night as he gets out of bed to urinate. He has a commode at his bedside but prefers to use the bathroom. His wife finds him down and calls their son to help move him. The patient and his wife have some help at home during the day, but not at night. Past Medical History: Basal ganglion stroke ___: during 2 week period off warfarin) h/o ALCOHOL USE. No current EtOH use AORTIC INSUFFICIENCY AFib BPH NHL - FOLLICULAR LYMPHOMA GOUT MENTAL STATUS CHANGES - likely vascular dementia Hx OBESITY OSTEOARTHRITIS SENSORINEURAL HEARING LOSS - has hearing aid SLEEP APNEA Distant L elbow contusion with permanent decrease in ROM Social History: ___ Family History: Father had strokes and became forgetful in his ___. Both parents died at ___ Physical Exam: EXAM ON ADMISSION: VS: 97.8 160/83 86 16 97%RA GEN: Alert, lying in bed, no acute distress. AAOx1, stuttering speech, aphasic, sometimes nonsensical speech HEENT: Tacky MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema. L hip tender to palpation. R shoulder without tenderness. Intact radial and pedal pulses NEURO: CN II-XII grossly intact, aphasic, interactive, nonsensical speech. ___ R grip strength, ___ L grip strength. Able pronate and supinate L arm. EXAM AT DISCHARGE: VS: T 97.1, Tm 98.4, HR 65 (65-90), BP 146/41 (115-146/39-64), RR 20, O2S 96+ RA GEN: Alert, lying in bed, no acute distress. oriented to self only, stuttering speech, answers some questions appropriately, alternating with nonsensical speech. HEENT: Dry MMs, dark red oropharynx, anicteric sclerae, no conjunctival pallor NECK: Supple, JVP not elevated PULM: CTA b/l without wheeze or rhonchi COR: irregularly irregular, (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema. L lateral thigh w/ mild tenderness to palpation. ___ strength in left hip flexor, appears limited by pain. Winces on external rotation of L arm. Limited ROM on straightening of L elbow. SKIN: Multiple small ecchymoses on arms, excoriations on L elbow NEURO: CN II-XII grossly intact, aphasic, interactive, stuttering speech not comprehensible after ___ words Pertinent Results: ADMISSION LABS ___ 12:40PM URINE HOURS-RANDOM ___ 12:40PM URINE HOURS-RANDOM ___ 12:40PM URINE UHOLD-HOLD ___ 12:40PM URINE GR HOLD-HOLD ___ 12:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 10:52AM ___ COMMENTS-GREEN TOP ___ 10:52AM LACTATE-3.5* ___ 10:49AM GLUCOSE-214* UREA N-112* CREAT-2.3* SODIUM-136 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18 ___ 10:49AM estGFR-Using this ___ 10:49AM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-1.8 ___ 10:49AM WBC-12.6* RBC-6.02 HGB-14.2 HCT-43.7 MCV-73* MCH-23.6* MCHC-32.5 RDW-20.2* RDWSD-48.4* ___ 10:49AM NEUTS-92.2* LYMPHS-2.9* MONOS-4.2* EOS-0.0* BASOS-0.3 IM ___ AbsNeut-11.63* AbsLymp-0.36* AbsMono-0.53 AbsEos-0.00* AbsBaso-0.04 ___ 10:49AM PLT COUNT-394 ___ 10:49AM ___ PTT-49.6* ___ DISCHARGE LABS ___ 07:25AM BLOOD WBC-10.9* RBC-5.30 Hgb-12.3* Hct-39.7* MCV-75* MCH-23.2* MCHC-31.0* RDW-20.0* RDWSD-51.9* Plt ___ ___ 07:25AM BLOOD ___ PTT-46.9* ___ ___ 07:25AM BLOOD Glucose-97 UreaN-105* Creat-2.6* Na-141 K-4.8 Cl-108 HCO3-18* AnGap-20 CT PELVIS Acute fracture of the greater trochanter of the left proximal femur. Associated left hip and gluteal intramuscular hematoma. Small amount of left intrapelvic hematoma. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Warfarin 5 mg PO DAILY16 3. Allopurinol ___ mg PO DAILY 4. Terazosin 5 mg PO QHS 5. Calcitriol 0.25 mcg PO 3X/WEEK (___) 6. Finasteride 5 mg PO DAILY 7. Torsemide 20 mg PO 5X/WEEK (___) 8. Torsemide 10 mg PO 2X/WEEK (MO,TH) 9. FoLIC Acid 1 mg PO DAILY 10. Pyridoxine 50 mg PO DAILY 11. Thiamine 100 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Calcitriol 0.25 mcg PO 3X/WEEK (___) 4. Finasteride 5 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Pyridoxine 50 mg PO DAILY 7. Terazosin 5 mg PO QHS 8. Thiamine 100 mg PO DAILY 9. Torsemide 20 mg PO 5X/WEEK (___) 10. Torsemide 10 mg PO 2X/WEEK (MO,TH) 11. Acetaminophen 650 mg PO TID 12. Docusate Sodium 100 mg PO BID 13. Senna 17.2 mg PO HS 14. TraMADOL (Ultram) 25 mg PO Q12H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q12h PRN Disp #*30 Tablet Refills:*0 15. Warfarin 2.5 mg PO DAILY16 16. Caphosol 30 mL ORAL QID 17. Nystatin Oral Suspension 5 mL PO QID:PRN thrush Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left femur fracture, greater trochanter Elbow contusion Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable at times (especially mornings), then alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT PELVIS ORTHO INDICATION: ___ year old man with history of AFib on Coumadin s/p fall, negative vs equivocal L hip film TECHNIQUE: MDCT axial images were acquired through the pelvis following without intravenous contrast. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 725 mGy-cm. COMPARISON: Hip radiograph ___ FINDINGS: There is an acute fracture of the greater trochanter (2:72, 300b:71) of the left proximal femur. The left femoral neck is intact. No additional fractures seen. Left hip and gluteal intramuscular hematoma noted, measures at least 4.3 x 4.7 cm (2:84). Severe multilevel degenerative changes are noted throughout the lumbar spine. Also noted is a small amount of RP and left pelvic hematoma is seen tracking along the lower aorta and the left iliac vessels (series 2, images 14- 45). The partially visualized small and bowel loops demonstrate no gross abnormalities. Appendix is normal. Left kidney is markedly atrophic, but only partially imaged. Bladder is unremarkable. Prostate gland is enlarged. IMPRESSION: Acute fracture of the greater trochanter of the left proximal femur. Associated left hip and gluteal intramuscular hematoma. Small amount of left intrapelvic hematoma. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with dementia s/p fall, no neck ttp, L sided head ttp // eval ? ICH, neck injury TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformats were also performed. DOSE: Total DLP (Head) = 1,003 mGy-cm. COMPARISON: ___ noncontrast head CT. FINDINGS: There is no evidence of acute territorial infarction, hemorrhage, edema, or large mass. Prominence of the ventricles and sulci is suggestive of global volume loss. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are essentially clear besides partially opacified left ethmoids. The visualized portion of the orbits are unremarkable. Cavernous carotid calcifications are severe. IMPRESSION: Global volume loss without acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with dementia s/p fall, no neck ttp, L sided head ttp // eval ? ICH, neck injury TECHNIQUE: Non-contrast helical multidetector CT was performed. Axial image data was collimated to display separate 2.5 mm soft tissue and bone algorithm axial images. Coronal and sagittal reformations were then constructed. DOSE: Total DLP (Body) = 1,777 mGy-cm. COMPARISON: CT C-spine ___ FINDINGS: Alignment is normal. No fractures are identified. There is no prevertebral soft tissue swelling. Atherosclerotic calcification of the carotid arteries bilaterally is seen. Irregular dependent opacity in the trachea (03:59) is likely debris. Multilevel degenerative changes are again seen. IMPRESSION: No acute fracture or traumatic malalignment. Radiology Report INDICATION: ___ with s/p fall and L sided injuries // eval ? shoulder / elbow fx TECHNIQUE: Three views of the left shoulder. COMPARISON: Correlation made to CT torso from ___ and chest CT from ___. FINDINGS: There is no acute fracture. Moderate degenerative changes noted at the acromioclavicular joint. Glenohumeral joint is anatomically aligned. There is lucent lesion within the left scapular body better seen on prior exams. Included portion of the left ribs are unremarkable. Interstitial opacities in the lungs are better seen on concurrent chest CT. IMPRESSION: No fracture or dislocation. Radiology Report INDICATION: ___ with s/p fall and L sided injuries // eval ? shoulder / elbow fx TECHNIQUE: Three views of the left elbow. COMPARISON: ___. FINDINGS: Extensive heterotopic bone formation seen at the medial condyle and coronoid process as on prior. This limits evaluation for subtle osseous abnormality. No displaced fractures are identified. There is a linear lucency through the region of the radial head on the oblique view (image 1) but given significant overlap of adjacent osseous structures, is not definitive for fracture. Cannot assess for elbow joint effusion given low positioning on the lateral view. IMPRESSION: Heterotopic ossification which significantly limits evaluation. Linear lucency through the radial head on one view could be due to overlapping shadows although fracture would be difficult to exclude. Radiology Report INDICATION: ___ with s/p fall L sided hip and femur pain // eval ? L hip / femur fx TECHNIQUE: AP view of the pelvis. AP and lateral views of the proximal and distal left femur. COMPARISON: Scout view of prior PET-CT from ___. FINDINGS: There is slight cortical irregularityinvolving the lateral and medial aspect of the left greater trochanter raising the possibility of fracture. The left femur is otherwise unremarkable. Femoroacetabular joint is anatomically aligned. Extensive degenerative changes partially visualized at the left knee with joint space loss, osteophyte formation and subchondral sclerosis. The pubic symphysis and SI joints are preserved. Mild degenerative changes noted at the hips bilaterally. Degenerative changes are noted in the lower lumbar spine. IMPRESSION: Cortical irregularity raising possibility of fracture involving the left greater trochanter. If desired, CT scan could help further characterize. Radiology Report INDICATION: ___ s/p fall L sided injuries, T-spine ttp // eval ? rib fractures, intrathoracic injury. Please obtain T-spine recons TECHNIQUE: Axial multidetector CT images were obtained through the thorax without intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and thoracic spine images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 726 mGy-cm. COMPARISON: FDG PET-CT ___ and CT torso ___ FINDINGS: The ascending aorta measures 4.5 cm at the level of the main pulmonary artery, similar to prior PET-CT. Great vessels are unremarkable. The main pulmonary artery measures up to 4.4 cm. Opacity in the trachea is partially aerated and likely represents debris. There is mild dependent atelectasis and paraseptal emphysema bilaterally. Increased interstitial markings in a subpleural and basilar distribution raises the possibility of underlying interstitial process such as fibrosis. There is no pleural effusion or pneumothorax. The airways are patent to the subsegmental level. Coronary artery calcifications are significant. Cardiomegaly is moderate. Small pericardial effusion is similar to prior. There is no supraclavicular, axillary, or mediastinal lymphadenopathy. The thyroid is unremarkable. The spleen is enlarged measures 17 cm. Ovoid hypodensities in the spleen, the largest measuring up to 1.8 cm, are incompletely characterized. The left kidney is atrophic. No lytic or blastic osseous lesion suspicious for malignancy is identified. Focal lucencies involving the C6 vertebral body and the left C6 pedicle appear similar to CT torso ___. Lucent lesion in the left scapula is unchanged from ___. IMPRESSION: 1. No fracture or evidence of acute injury. 2. Changes in the lungs raise the possibility of underlying interstitial process such as fibrosis. 3. Persistent small pericardial effusion. 4. Splenomegaly. 5. Enlarged main pulmonary artery suggests pulmonary hypertension. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, L Hip pain Diagnosed with TROCHANTERIC FX NOS-CLOS, UNSPECIFIED FALL, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT temperature: 98.0 heartrate: 88.0 resprate: 16.0 o2sat: 99.0 sbp: 119.0 dbp: 61.0 level of pain: 13 level of acuity: 3.0

Dear Mr. ___ and family, You were admitted to ___ on ___ with pain in your left hip and arm after falling at home. You had a scan of your brain and spine to make sure you didn't have a life-threatening injury. You also had X-rays of your hip, arm, and shoulder, as well as a scan of your hip; these showed that you had fractured a small part of your thigh bone. You were evaluated by the orthopedic surgery team. They determined that you did not require surgery and that your bone would recover on its own. You worked with physical therapists who determined that you would need strengthening to avoid falls in the future. You will go to rehab where physical therapists will work with you to strengthen your muscles as you recover. Please use a walker when you walk, since your risk of another fall is extremely high. At night, please use a commode or urinal by your bed, rather than getting up to go to the bathroom. You may want to have a fall alarm at home so that someone can help you if you get out of bed. If you have increasing pain, another fall, or any new symptoms, please call a doctor. It has been a pleasure taking part in your care, Best wishes, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ ___ female with no cardiac history, but does have a history of hypertension and blood pressures not uncommonly are elevated in the office setting. In any event, she presents with chest discomfort that started in the left scapular region last evening around 11 o'clock and she fell asleep with it, awakened with it, and had developed discomfort around the left side of her chest and into the left anterior chest and in the inframammary region and just medial to it. This has been pleuritic in the back and in the inframammary region anyway. It hurts more when she is supine versus sitting up. It hurts more when she coughs or sneezes. She denies chest wall trauma. She has had no blatant dyspnea, but because it hurts to breathe in, the pattern of her breathing may have been upset, but she is not huffing and puffing. It hurts more when she leans forward too sometimes. She denies nausea, vomiting, diaphoresis, or further radiation of the symptoms. She had symptoms on the right side of her chest years ago that was thought to be muscular. She denies exertional symptoms and exercises regularly. She does the treadmill, does ___, all of which are without symptoms. Last time she exercised was 2 weeks ago. She has history of hypertension, has been maintained on labetalol 300 mg twice daily and nifedipine extended release that was recently increased from 30 to 60 mg daily. She denies fevers, chills, coughing, exertional dyspnea, TIA symptoms, claudication, palpitations, presyncope, or syncope. Past Medical History: hypertension h/o uterine fibroids Social History: ___ Family History: Father had CHF in his ___. Otherwise negative. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.6 136/84 77 18 99% RA General: well appearing woman in NAD, comfortable Neck: unable to assess for JVD due to body habitus CV: distant heart sounds, normal rate, regular rhythm, no m/r/g, unable to appreciate friction rub Lungs: CTAB Abdomen: soft, NTND, NABS GU: no Foley Ext: wwp, no c/c/e Pulses: 2+ DP and radial pulses b/l DISCHARGE PHYSICAL EXAM: VS: 98.6 154/88 87 18 97% RA, 131.2 kg General: comfortable in NAD Neck: unable to assess for JVD due to body habitus CV: RRR, no murmurs or gallops, no rub appreciated, unable to reproduce pain with palpation of inferior chest wall, axillary region or scapular region Lungs: CTAB, no adventitious sounds Abdomen: soft, +BS, NT/ND Ext: no cyanosis or edema Pulses: 2+ radial, DP pulses bilaterally Neuro: nonfocal Pertinent Results: PERTINENT LABS: ___ 08:00AM BLOOD WBC-6.1 RBC-4.62 Hgb-11.3* Hct-35.3* MCV-76* MCH-24.5* MCHC-32.0 RDW-13.4 Plt ___ ___ 10:30AM BLOOD Neuts-63.8 ___ Monos-4.2 Eos-5.3* Baso-0.7 ___ 10:30AM BLOOD ___ PTT-29.7 ___ ___ 08:00AM BLOOD ESR-19 ___ 08:00AM BLOOD Glucose-117* UreaN-11 Creat-0.9 Na-138 K-4.1 Cl-101 HCO3-24 AnGap-17 ___ 10:50PM BLOOD cTropnT-<0.01 ___ 04:32PM BLOOD cTropnT-<0.01 ___ 10:30AM BLOOD cTropnT-<0.01 ___ 08:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 ___ 11:55AM BLOOD D-Dimer-573* ___ 08:00AM BLOOD TSH-1.5 ___ 10:30AM BLOOD HCG-<5 ___ 08:00AM BLOOD CRP-13.8* ___ 08:00AM BLOOD ___ ECG: nonspecific abnormalities with T-wave abnormalities in aVL, V5, and V6, and slightest PR depression in V1, II IMAGING: ___ CXR FINDINGS: Frontal and lateral radiographs were reviewed. Heart size is top normal. Mediastinal and hilar contours are stable. There is no pleural effusion or pneumothorax. Lungs are clear. Pulmonary vasculature is within normal limits. IMPRESSION: No acute cardiopulmonary process. ___ CT-A TECHNIQUE: MDCT images were taken through the chest in the arterial phase after the administration of 100 cc of Omnipaque intravenous contrast material. Coronal and sagittal reformats as well as oblique maximum intensity projection images were also examined. FINDINGS: CTA: The aorta and pulmonary arteries are well opacified. The aorta maintains a normal contour without evidence of acute aortic syndrome. There is no pulmonary embolism in the main, right, left, lobar, or subsegmental pulmonary arteries. The heart is normal size without pericardial effusion. The thyroid is normal. The airways are patent to the subsegmental level. There is no mediastinal, hilar, axillary, or supraclavicular lymphadenopathy. There is no concerning pulmonary nodule, mass, or confluent consolidation. Bibasilar atelectasis is present. There is no pleural effusion or pneumothorax. Soft tissue density in the anterior mediastinum is compatible with residual thymus. A 1.8 x 1.6 fluid density lesion in the right medial breast is noted (2:24). The imaged portion of the upper abdomen is unremarkable. No suspicious lesion is seen in the visualized osseous structures. IMPRESSION: 1. No pulmonary embolism or evidence of acute aortic syndrome. 2. Hypodense lesion in the right medial breast likely reflects a cyst, but correlation with breast ultrasound and possibly mammography is suggested. ___ TTE The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality.Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. NIFEdipine CR 60 mg PO DAILY 2. Labetalol 300 mg PO BID 3. Prenatal Vitamins 1 TAB PO DAILY Discharge Medications: 1. Labetalol 300 mg PO BID 2. NIFEdipine CR 60 mg PO DAILY 3. Ibuprofen 200 mg PO 3 TABLETS, THREE TIMES A DAY FOR 7 DAYS; 1 TABLET THREE TIMES A DAY FOR THE NEXT THREE DAYS; 1 TABLET TWICE A DAY FOR THE NEXT THREE DAYS, THEN STOP pericarditis Duration: 13 Days RX *ibuprofen 200 mg 3 capsule(s) by mouth three times a day Disp #*63 Tablet Refills:*0 RX *ibuprofen 200 mg 1 capsule(s) by mouth three times a day Disp #*9 Tablet Refills:*0 RX *ibuprofen 200 mg 1 capsule(s) by mouth twice a day Disp #*6 Tablet Refills:*0 4. Prenatal Vitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule,delayed ___ by mouth daily Disp #*13 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: pericarditis, idiopathic vs viral Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Left-sided chest pain. COMPARISON: None. FINDINGS: Frontal and lateral radiographs were reviewed. Heart size is top normal. Mediastinal and hilar contours are stable. There is no pleural effusion or pneumothorax. Lungs are clear. Pulmonary vasculature is within normal limits. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: Chest pain. COMPARISON: None. TECHNIQUE: MDCT images were taken through the chest in the arterial phase after the administration of 100 cc of Omnipaque intravenous contrast material. Coronal and sagittal reformats as well as oblique maximum intensity projection images were also examined. FINDINGS: CTA: The aorta and pulmonary arteries are well opacified. The aorta maintains a normal contour without evidence of acute aortic syndrome. There is no pulmonary embolism in the main, right, left, lobar, or subsegmental pulmonary arteries. The heart is normal size without pericardial effusion. The thyroid is normal. The airways are patent to the subsegmental level. There is no mediastinal, hilar, axillary, or supraclavicular lymphadenopathy. There is no concerning pulmonary nodule, mass, or confluent consolidation. Bibasilar atelectasis is present. There is no pleural effusion or pneumothorax. Soft tissue density in the anterior mediastinum is compatible with residual thymus. A 1.8 x 1.6 fluid density lesion in the right medial breast is noted (2:24). The imaged portion of the upper abdomen is unremarkable. No suspicious lesion is seen in the visualized osseous structures. IMPRESSION: 1. No pulmonary embolism or evidence of acute aortic syndrome. 2. Hypodense lesion in the right medial breast likely reflects a cyst, but correlation with breast ultrasound and possibly mammography is suggested. Dr. ___ Dr. ___ item 2 in the Impression via telephone at 7:15 ___ on ___. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Chest pain, Back pain Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS temperature: 99.0 heartrate: 80.0 resprate: 16.0 o2sat: 97.0 sbp: 146.0 dbp: 86.0 level of pain: 6 level of acuity: 2.0

Dear ___, ___ was a pleasure participating in your care while you were inpatient here at ___. You came in with chest pain that we think was from inflammation around the lining of your heart, called pericarditis. You improved quickly after starting to take ibuprofen. Please continue ibuprofen as follows: 600 mg ibuprofen three times a day for seven days 200 mg ibuprofen three times a day for the next three days 200 mg ibuprofen twice a day for the next three days stop ibuprofen after thirteen days We hope that you continue to feel better. Take care!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Toe Pain Major Surgical or Invasive Procedure: ___ RLE toe debridement (Podiatric Surgery) ___ FOCUSED EXAM: ___ pulses dopplerable. cap refill less than 3 sec to the digits. Normal proximal to distal cooling. Erythema of the right ___ from ankle to proximal calf as well as localized to the right hallux. There is a blood filled blister to the right hallux which after debridement revealed an underlying ulceration (2x2cm) which extended to the subcutaneous tissue. There was a small amount of pus noted during debridement. There is no probe to bone, tracking, nor fluctuance to the ulcerative area. Light touch sensation diminished to the b/l ___. no pain to the right hallux or RLE. History of Present Illness: ___ year old ___ speaking woman with a history of HTN, NIDDM2, and hypothyroidism presenting with right lower extremity swelling and R first metatarsal pain and swelling. History is limited by confusion and difficulty using the interpreter phone. Pt reports that she first noticed redness and pain ___ the right great toe at least 1 month ago. She denies trauma to the foot. She is still able to ambulate, although is limited by pain. She denies fevers/chills/nausea/vomiting Collateral history was obtained form patient's HCP ___ ___), who reports that the pt's legs have chronically appeared "red" and "swollen". During ___ most recent visit last week, the pt appeared to be doing well. She uses a walker to ambulate short distances, but usually needs a wheelchair for longer distances (i.e. down the corridor). Reviewing documentation from ___, she received Keflex for 5 days at end of ___ for unclear indication. ___ the ED, initial vitals: 97.6 63 149/49 18 99%RA Exam notable for erythema, warmth and induration of both the anterior and posterior RLE below the knee extending to the ankle. The erythema stops there and then begins again at the mid foot where it extends to the R ___ metatarsal where there is a 3cm blood blister (wet gangrene). Pulses present with Doppler. Labs were significant for: 18.0 > 10.9/35.3 < 582 135|99|30 ---------<254 4.7|22|1.0 Imaging showed R Toes(s) radiograph ___ (PRELIMINARY REPORT): IMPRESSION: Soft tissue swelling about the right great toe without discrete underlying bony erosion or fracture. Vascular calcifications and osteopenia are also present. Please note that plain film is not sensitive for detection of osteomyelitis. If further imaging workup is required, MRI is recommended. Chest Radiograph (PA and Lateral) ___: IMPRESSION: Low lung volumes, with interval resolution of moderate interstitial pulmonary edema. No new focal consolidation concerning for pneumonia. Podiatric Surgery was consulted. They performed the following ___ exam: ___ FOCUSED EXAM: ___ pulses dopplerable. cap refill less than 3 sec to the digits. Normal proximal to distal cooling. Erythema of the right ___ from ankle to proximal calf as well as localized to the right hallux. There is a blood filled blister to the right hallux which after debridement revealed an underlying ulceration (2x2cm) which extended to the subcutaneous tissue. There was a small amount of pus noted during debridement. There is no probe to bone, tracking, nor fluctuance to the ulcerative area. Light touch sensation diminished to the b/l ___. no pain to the right hallux or RLE. ___ the ED, she received Cefepime 2gm IV, Vancomycin 1500mg IV Vitals prior to transfer: 97.3 63 135/48 18 98% RA Currently, the patient is unable to confirm the above history due to confusion with the interpreter phone. She reports that she is "tired" and would prefer to rest. She denies pain currently ___ RLE. ROS: (+) as per HPI (-) otherwise Past Medical History: Arthitis, NIDDM, HTN, Hypothyroidism Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98 BP 143/55 P 77 RR 20 O2 98% RA GEN: Alert, lying ___ bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA bilaterally without wheezes or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: LLE: 2+ DP, biphasic ___ RLE: biphasic ___. There is erythema, warmth and induration of both the anterior and posterior RLE below the knee extending to the ankle. The erythema stops there and then begins again at the mid foot where it extends to the R ___ metatarsal where there is a 2x1cm ulcer extending to subcutaneous tissue without drainage or purulence. NEURO: Pt oriented to name and date ___ but not location ("hotel"). CN II-XII grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM: ======================= VS: Tm 98.3 BP 148/65 P 64 (50-64) RR 18 O2 95% RA GEN: Alert, lying ___ bed, no acute distress NEURO: A&Ox3. CN II-XII grossly intact, motor function grossly normal HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA bilaterally without wheezes or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: LLE: 2+ DP, biphasic ___ RLE: biphasic ___. Erythema and warmth of RLE and R foot is improved. 2x1cm ulcer extending to subcutaneous tissue is clean, with healthy granulation tissue and minimal ss drainage without e/o purulent drainage or surrounding erythema. Pertinent Results: ADMISSION LABS: --------------- ___ 10:30AM BLOOD WBC-18.0* RBC-3.67* Hgb-10.9* Hct-35.3 MCV-96 MCH-29.7 MCHC-30.9* RDW-12.8 RDWSD-44.7 Plt ___ ___ 10:30AM BLOOD Neuts-82* Bands-0 Lymphs-16* Monos-1* Eos-1 Baso-0 ___ Myelos-0 AbsNeut-14.76* AbsLymp-2.88 AbsMono-0.18* AbsEos-0.18 AbsBaso-0.00* ___ 10:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL ___ 10:30AM BLOOD Glucose-254* UreaN-30* Creat-1.0 Na-135 K-4.7 Cl-99 HCO3-22 AnGap-19 ___ 06:28AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.5* ___ 06:28AM BLOOD VitB12-719 ___ 06:28AM BLOOD TSH-3.7 DISCHARGE LABS: ------------ ___ 06:04AM BLOOD WBC-11.6* RBC-3.62* Hgb-10.8* Hct-34.8 MCV-96 MCH-29.8 MCHC-31.0* RDW-12.7 RDWSD-44.6 Plt ___ ___ 06:04AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-138 K-4.4 Cl-102 HCO3-25 AnGap-15 ___ 06:04AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.0 MICROBIOLOGY ------------ ___ 12:01 pm SWAB Source: R Foot . GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. WOUND CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ___ 12:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING TOE(S), 2+ VIEW RIGHT Study Date of ___ 12:06 ___ IMPRESSION: Soft tissue swelling about the right great toe without discrete underlying bony erosion or fracture. Vascular calcifications and osteopenia are also present. Please note that plain film is not sensitive for detection of osteomyelitis. If further imaging workup is required, MRI is recommended. CHEST (PA & LAT) Study Date of ___ 12:07 ___ IMPRESSION: Low lung volumes, with interval resolution of moderate interstitial pulmonary edema. No new focal consolidation concerning for pneumonia. UNILAT LOWER EXT VEINS RIGHT Study Date of ___ 7:27 ___ IMPRESSION: No evidence of deep venous thrombosis ___ the right lower extremity veins. The peroneal veins were not identified by ultrasound. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lidocaine 5% Patch 1 PTCH TD QAM 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO QHS 4. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY 5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate 6. Acetaminophen 650 mg PO TID 7. Atorvastatin 10 mg PO QPM 8. ciclopirox 0.77 % topical PRN 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Januvia (SITagliptin) 100 mg oral DAILY 12. MetFORMIN (Glucophage) 500 mg PO TID 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Sertraline 25 mg PO DAILY 15. Bisacodyl 5 mg PO DAILY 16. Levothyroxine Sodium 125 mcg PO DAILY 17. polyvinyl alcohol 1.4 % ophthalmic BID:PRN dry eyes 18. TraZODone 25 mg PO QHS insomnia 19. Meclizine 12.5 mg PO TID:PRN nausea 20. Omeprazole 20 mg PO BID 21. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 22. meloxicam 15 mg oral DAILY:PRN Discharge Medications: 1. Cephalexin 500 mg PO Q6H 2. Clotrimazole Cream 1 Appl TP BID 3. Sulfameth/Trimethoprim DS 2 TAB PO BID 4. Acetaminophen 650 mg PO TID 5. Atorvastatin 10 mg PO QPM 6. Bisacodyl 5 mg PO DAILY 7. ciclopirox 0.77 % topical PRN 8. Docusate Sodium 100 mg PO BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Januvia (SITagliptin) 100 mg oral DAILY 12. Levothyroxine Sodium 125 mcg PO DAILY 13. Lidocaine 5% Patch 1 PTCH TD QAM 14. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY 15. Meclizine 12.5 mg PO TID:PRN nausea 16. meloxicam 15 mg oral DAILY:PRN pain 17. MetFORMIN (Glucophage) 500 mg PO TID 18. Omeprazole 20 mg PO BID 19. polyvinyl alcohol 1.4 % ophthalmic BID:PRN dry eyes 20. Senna 17.2 mg PO QHS 21. Sertraline 25 mg PO DAILY 22. Silver Sulfadiazine 1% Cream 1 Appl TP DAILY 23. TraMADol 25 mg PO Q6H:PRN Pain - Moderate 24. TraZODone 25 mg PO QHS insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ----------------- Right lower extremity cellulitis Superficial diabetic toe ulcer (R ___ hallux) SECONDARY DIAGNOSIS: ------------------- Altered mental status Diabetes mellitus type 2 Hypertension Onychomycosis 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: TOE(S), 2+ VIEW RIGHT INDICATION: ___ with right great toe pain and discoloration. Evaluate for osteomyelitis. TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs of the right great toe. COMPARISON: None available. FINDINGS: Hallux valgus deformity of the right great toe is present with moderate degenerative changes of the first MTP, indicated by joint space narrowing and osteophytes. There is diffuse osteopenia. No discrete fracture or bony erosion is detected in the right great toe. No radiopaque foreign body. Small vascular calcifications are present. There is likely a small amount of soft tissue swelling about the right great toe. IMPRESSION: Soft tissue swelling about the right great toe without discrete underlying bony erosion or fracture. Vascular calcifications and osteopenia are also present. Please note that plain film is not sensitive for detection of osteomyelitis. If further imaging workup is required, MRI is recommended. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with rt big toe pain and discoloration. Evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph of ___ and ___. FINDINGS: Mild cardiomegaly persists. Compared with the prior radiograph, mild to moderate interstitial pulmonary edema has essentially resolved. No new focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: Low lung volumes, with interval resolution of moderate interstitial pulmonary edema. No new focal consolidation concerning for pneumonia. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old woman with erythematous, warm, and swollen RLE concerning for cellulitis vs DVT. Evaluate for 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 is identified in 1 of the posterior tibial veins. The peroneal veins were not identified by ultrasound. 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. The peroneal veins were not identified by ultrasound. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Toe pain Diagnosed with Cellulitis of right lower limb, Type 2 diabetes mellitus with foot ulcer, Non-prs chronic ulcer oth prt right foot w unsp severity temperature: 97.6 heartrate: 63.0 resprate: 18.0 o2sat: 99.0 sbp: 145.0 dbp: 49.0 level of pain: unable level of acuity: 3.0

Dear Ms. ___, You were hospitalized because of pain, redness, and swelling ___ your right lower leg and right big toe. We believe these symptoms were due to an infection ___ the skin of your leg and toe. You were seen by podiatry (foot) doctors who ___ the blister on your toe and took cultures of the wound. You received antibiotics to treat the infection, and the redness, pain, and swelling of your leg significantly improved. You should continue taking antibiotics until ___. Finally, you were evaluated by physical therapists who recommend you go to rehab to continue to build strength. Please take all medications as prescribed and attend all follow up appointments. We are glad that you are feeling better. All the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Ciprofloxacin / aspirin Attending: ___ Chief Complaint: dizziness, headache Major Surgical or Invasive Procedure: None History of Present Illness: NEUROLOGY STROKE ADMISSION/CONSULT NOTE No code stroke was called The NIHSS was performed: Date: ___ Time: 1600 ___ Stroke Scale score was : 0 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: Dizziness, unbalanced HPI: Mr. ___ is a ___ year old right handed-man with PMH of right proximal stenosis of M1 with two previous stroke, including right frontal infarct (___) and right basal ganglia stroke (unknown when occurred), DMII complicated by nephropathy and neuropathy, CKD (baseline creatinine of 2.5-3.0) hypertension, and hyperlipidemia who neurology has been consulted for headache and dizziness with concern for TIA/stroke. Mr. ___ reports that he was doing well until yesterday evening when he acutely developed dizziness which he defined as feeling unbalanced. Mr. ___ was watching television in a chair and did not feel that he could sit further without falling over. He does not feel like he was being pushed in one direction or another. He got up and walked from his living room to his bedroom. He normally walks with a cane, but had to depend on it more so than normal and reports that he also had to use furniture and walls for support. He felt he was moving from side to side, but did not feel he was veering preferentially in one direction versus another. He was able to make it to his bed and felt that after about five minutes he was much better, but continued to feel as if something was wrong with him. He denied that his dizziness was lightheadedness or vertigo. Mr. ___ reports that he woke up this morning and felt normal. He was having a bowel movement and in the context of such he started to feel dizzy again. He also felt unbalanced. He denied lightheadedness and vertigo. He also developed a headache in the right frontoparietal region. The headache feels like pressure, like someone is pushing on the area. He crawled back to his bed from the restroom and laid down. He felt better in bed. Mr. ___ nurse came to visit him. His blood pressure and blood sugar was normal. She left. Mr. ___ decided to call EMS because he was concerned that he might have had a stroke. Mr. ___ in the ___ denies that he has dizziness, but continues to endorse mild headache in the right frontoparietal area. He has no other complaints. Pertinently, Mr. ___ was admitted to our stroke service from ___ after presenting with dizziness and generalized weakness. He was found to have a new right frontal stroke. He was also found to have right proximal M1 stenosis. He before this admission was taking clopidogrel and the plan was to start him on aspirin. He never started taking the aspirin because he reports that it causes GI upset. In his discharge summary, it is documented that he should take aspirin with ranitidine, but he reports that he was never given this message. ROS: On neuro ROS, the patient denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the 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: Right proximal stenosis of M1 with two previous stroke including right frontal infarct (___) and right basal ganglia stroke (unknown when occurred) DMII complicated by nephropathy and neuropathy CKD (baseline creatinine of 2.5-3.0) Hypertension Hyperlipidemia Obesity Sleep apnea Social History: ___ Family History: maternal grandmother, maternal uncle, maternal aunt had DM. Physical Exam: EXAM ON ADMISSION: ================= Presentation vitals: Temperature: 96.6 Pulse: 76 Blood pressure: 155/78 Respiratory rate: 16 Oxygen saturation: 98% RA General examination: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic examination: Mental status: Flat affect. He lacks intonation to his voice. He is awake, alert, and cooperative with the exam. He says that he cannot do months of the year backwards and makes no attempt to do so, but can do days of the week backwards correctly. Fund of knowledge is intact. He is oriented to place and date. Language is fluent. Memory for recent and remote history is intact. Cranial nerves: Pupils are equal and reactive. Extraocular movements are full. No nystagmus on fixation or with end gaze. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full. Sensation: He reports reduced appreciation of pinprick from about the ankle downward. He can appreciate large upward and downward excursions of his giant toe, but not smaller ones. Coordination: No ocular dysmetria. He can suppress the vestibulocular reflex with visual fixation. No rebound. No overshoot with mirroring. Finger-nose-finger and finger-to-nose are intact without dysmetria bilaterally. He has smooth and fast alternating movements of both hands. He is accurate with finger tapping of the index finger to crease of thumb He can hold a rhythm. HTS without dysmetria. No truncal ataxia. Reflexes: Bi Tri ___ Pat Ach L 2 2 1 1 1 R 2 2 1 1 1 Plantar response was flexor bilaterally. Gait: He can walk in a straight line with his walker, he does not appear to be veering or staggering. Exam on discharge: ================== VS: 24 HR Data (last updated ___ @ 400) Temp: 98.0 (Tm 98.3), BP: 167/87 (152-171/87-98), HR: 72 (72-88), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: Ra General examination: General: Comfortable and in no distress, lying in bed Head: MMM CV: RRR, no m/g/r Lungs: Unlabored breathing Ext: Warm, no peripheral edema Skin: No rashes or lesions Neurologic examination: Mental status: Awake, alert, cooperative with exam. Cranial nerves: Pupils 3->2 bilaterally, right eye exotropia, EOMI with difficulty burying on right, some saccadic breakdown on eye movements, face symmetric, palate elevates symmetrically, visual fields full. Motor: Tone is normal. Diminished bulk in bilateral hands and thighs. Slight pronation on left side. IP ___ bilaterally, hamstrings ___ bilaterally. Sensation: Sensation intact to light touch throughout. Coordination: Both postural and intention tremor bilaterally, no dysmetria on FNF R, slight dysmetria on L associated with known weakness. Reflexes: deferred Gait: deferred Pertinent Results: ADMISSION LABS: =============== ___ 09:45PM BLOOD WBC-4.4 RBC-3.28* Hgb-9.9* Hct-31.2* MCV-95 MCH-30.2 MCHC-31.7* RDW-13.5 RDWSD-47.3* Plt ___ ___ 09:45PM BLOOD ___ PTT-33.0 ___ ___ 10:40AM BLOOD Glucose-140* UreaN-37* Creat-4.0* Na-145 K-4.7 Cl-111* HCO3-23 AnGap-11 ___ 09:45PM BLOOD ALT-17 AST-16 LD(LDH)-179 CK(CPK)-225 AlkPhos-74 TotBili-0.2 ___ 09:45PM BLOOD CK-MB-5 cTropnT-0.03* ___ 09:45PM BLOOD TotProt-5.7* Albumin-2.7* Globuln-3.0 Cholest-218* ___ 09:45PM BLOOD Triglyc-225* HDL-36* CHOL/HD-6.1 LDLcalc-137* ___ 09:45PM BLOOD TSH-1.8 ___ 01:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ NCHCT - no large territory infarct ___ MRI brain, MRA head and neck 1. Small acute/early subacute right MCA infarct. 2. Large area of chronic right MCA infarct. 3. Occluded right M1 MCA, and nearly absent right MCA arborization. 4. Normal neck MRA. ___ TTE IMPRESSION: Normal left ventricular cavity size with low normal systolic function. Normal right ventricular cavity size/systolic function. No definite structural cardiac source of embolism identified. DISCHARGE LABS: ___ 04:55AM BLOOD WBC-4.7 RBC-3.27* Hgb-9.7* Hct-30.9* MCV-95 MCH-29.7 MCHC-31.4* RDW-13.3 RDWSD-46.0 Plt ___ ___ 04:55AM BLOOD Plt ___ ___ 04:55AM BLOOD Glucose-91 UreaN-39* Creat-3.6* Na-144 K-4.8 Cl-113* HCO3-22 AnGap-9* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Finasteride 5 mg PO DAILY 5. Ranitidine 150 mg PO BID 6. Tamsulosin 0.4 mg PO QHS 7. Ketoconazole 2% 1 Appl TP BID:PRN itching, fungal infection 8. Clopidogrel 75 mg PO DAILY 9. GlipiZIDE XL 5 mg PO DAILY 10. Propranolol 10 mg PO BID 11. B Complex 1 (vitamin B complex) 1 tablet oral DAILY 12. Ascorbic Acid ___ mg PO DAILY 13. Simethicone 80 mg PO QID:PRN gas Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Ascorbic Acid ___ mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. B Complex 1 (vitamin B complex) 1 tablet oral DAILY 5. Clopidogrel 75 mg PO DAILY 6. Finasteride 5 mg PO DAILY 7. GlipiZIDE XL 5 mg PO DAILY 8. Ketoconazole 2% 1 Appl TP BID:PRN itching, fungal infection 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Lisinopril 5 mg PO DAILY 11. Propranolol 10 mg PO BID 12. Ranitidine 150 mg PO BID 13. Simethicone 80 mg PO QID:PRN gas 14. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute ischemic stroke 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 dizziness// eval PNA; eval ischemia, bleed TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiograph from ___. FINDINGS: The cardiomediastinal and hilar contours are normal. No focal consolidations are seen. There is no pulmonary edema or pleural abnormality. IMPRESSION: No evidence of acute intrathoracic process. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 INDICATION: History: ___ with lightheadedness// eval ischemia TECHNIQUE: Multidetector CT images of the head were obtained without intravenous contrast. Sagittal and coronal reformations were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 19.9 cm; CTDIvol = 45.5 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: Prior study from ___. FINDINGS: Ventricles, cisterns and sulci appear stable. Areas of right cortical and parietal encephalomalacia indicating prior infarcts appear stable. Volume loss of the right caudate head is also unchanged. There is no evidence of acute ongoing territorial infarction. No evidence of acute intracranial hemorrhage. Surrounding soft tissue structures are unremarkable visualized paranasal sinuses and mastoid air cells appear clear aside from minimal opacification of a few cells on the left. No evidence of fracture or bone destruction. IMPRESSION: No evidence of acute intracranial abnormality. Prior right frontal and parietal infarcts, unchanged. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ INDICATION: ___ year old man with episodes of unbalance// Stroke? TECHNIQUE: Three dimensional time of flight MR arteriography was performed through the brain with maximum intensity projection reconstructions. Brain imaging was performed with diffusion, T1, FLAIR, T2, and gradient echo technique. Noncontrast 3D MRA of the neck was performed. T1 and MPRAGE post contrast imaging was then performed. Multiplanar reformats of the MPRAGE images were created. 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: None. FINDINGS: MRI BRAIN: Large chronic right MCA distribution infarct, involving middle, inferior frontal gyrus, insula, operculum, right basal ganglia, lateral right temporal lobe, right parietal lobe. Areas of punctate mineralization. Small focus of restricted diffusion within chronic infarct, consistent with more recent subacute infarct. Right hemispheric brain parenchymal atrophy. Moderate chronic small vessel ischemic changes. No mass, no acute hemorrhage. The paranasal sinuses are essentially clear with the exception of mild anterior ethmoid air cell mucosal thickening. The orbits are unremarkable. MRA BRAIN: The right M1 MCA is occluded, with trickle flow the proximal M2 and absent M2, M3, M4 arborization on the right. Mild-to-moderate narrowing bilateral paraclinoid ICA. Mild narrowing left paraclinoid ICA. Remainder of the intracranial vessels are patent. No aneurysm. MRA NECK: Origin of great vessels are not adequately covered. The common, internal and external carotid arteries appear normal. No ICA stenosis by NASCET criteria. Patent visualized vertebral arteries. IMPRESSION: 1. Small acute/early subacute right MCA infarct. 2. Large area of chronic right MCA infarct. 3. Occluded right M1 MCA, and nearly absent right MCA arborization. 4. Normal neck MRA. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Headache Diagnosed with Acute kidney failure, unspecified temperature: nan heartrate: nan resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: uta level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of headache and dizziness that were concerning for stroke. As you know, you have had strokes in the past. Because of your stroke history, we admitted you to the hospital to manage your symptoms and determine if you had a new stroke. The type of stroke you have had in the past occurs from lack of blood flow to an area 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. We did an MRI of your brain to look for a new stroke. We found a small new stroke in the area of your old 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: - Diabetes - High Cholesterol - High Blood Pressure We added a baby aspirin to your list of medications to protect you from stroke. Please continue to take your medicines 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: F Service: SURGERY Allergies: adhesive tape / Cat/Feline Product Derivatives / Dust & Pollen Filter Mask / latex Attending: ___. Chief Complaint: Small bowel obstruction Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of multiple sclerosis and neurogenic bladder s/p appendicovesicostomy (___), then exploratory laparotomy, excision of Mitrofanoff, subtotal colectomy, creation of colovesicostomy (___) due to progression of her MS, colonic inertia, and progressive inability to manage her bowel movements. She was discharged to rehab and eventually returned to home. The patient had been well until approximately one week ago when she developed sudden onset of acute epigastric and periumbilical abdominal pain associated with nausea and projectile bilious vomiting. She presented to ___, where CT showed SBO. She was also found to have an E-coli UTI (treated with ceftriaxone, then nitrofurantoin). For her SBO, she was treated conservatively (no NGT was placed) and she was discharged just yesterday. However, this morning, she again experienced severe abdominal pain, nausea, and dry heaves. She therefore went to ___ again where an NGT was placed, KUB taken (again showed SBO) and she was transferred to ___ for further management. Past Medical History: Past Surgical History: Tonsillectomy, hysterectomy, placement and removal of sacral nerve stimulator and the Botox injection. C-section. Appendicovesicostomy (___) Past Medical History: Multiple sclerosis and related symptoms. carcinoma in situ of the cervix. Hypertension, depression. Social History: ___ Family History: non-contributory Physical Exam: On admission: VS - 98.8 104 147/94 20 97% GEN - appears somewhat disheveled but NAD ___ - tachy, regular PULM - no resp distress, CTAB ABD - R ileostomy with scant bilious liquid and no gas, L urostomy with fibrinous exudate in appliance and clear yellow urine in bag; well-healed midline scar; abdomen is moderately distended and tympanitic on exam; she has mild epigastric tenderness to palpation, no rebound/guarding EXTREM - contractures of the hands and feet On discharge: VS: 97.9 74 155/71 18 99%RA Gen: NAD, A&Ox3 CV: RRR Pulm: breathing comfortably on room air Abd: soft, +BS, mildly distended, nontender. R ileostomy with stool and air. L urostomy bac with urine. ext: wwp, contractures of the hands and feet. Pertinent Results: KUB ___: FINDINGS: Small bowel is similarly dilated the previous examination with scattered air-fluid levels, possibly less prominent than on the previous examination which may relate to nasogastric tube decompression. No free intraperitoneal air is identified. Nasogastric tube is curled in the stomach. Imaged lung bases are unremarkable with note made of elevated left hemidiaphragm. IMPRESSION: Unchanged bowel dilatation related to known obstruction. No free intraperitoneal air. Satisfactory position of nasogastric tube. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Baclofen 10 mg PO TID 2. Gabapentin 600 mg PO QID 3. Oxcarbazepine 450 mg PO TID Discharge Medications: 1. Baclofen 10 mg PO TID 2. Gabapentin 600 mg PO QID 3. Oxcarbazepine 450 mg PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report INDICATION: ___ year old woman with SBO. Air fluid levels? distention? free air? TECHNIQUE: Supine and left lateral decubitus abdominal radiographs. COMPARISON: ___ from ___ hospital. FINDINGS: Small bowel is similarly dilated the previous examination with scattered air-fluid levels, possibly less prominent than on the previous examination which may relate to nasogastric tube decompression. No free intraperitoneal air is identified. Nasogastric tube is curled in the stomach. Imaged lung bases are unremarkable with note made of elevated left hemidiaphragm. IMPRESSION: Unchanged bowel dilatation related to known obstruction. No free intraperitoneal air. Satisfactory position of nasogastric tube. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: SBO Diagnosed with INTESTINAL OBSTRUCT NOS temperature: 98.8 heartrate: 104.0 resprate: 20.0 o2sat: 97.0 sbp: 147.0 dbp: 94.0 level of pain: 3 level of acuity: 3.0

You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but you should not have prolonged constipation. 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 are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. 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. 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: M Service: MEDICINE Allergies: adhesive / sutures Attending: ___. Chief Complaint: Vomiting x 8 day; constipation; rash of left leg and left back Major Surgical or Invasive Procedure: ___ ___ of J-tube History of Present Illness: HMED ATTENDING ADMISSION NOTE DATE/TIME: ___ PCP: Dr. ___: Dr. ___ / ___: Dr. ___: Dr. ___ CC: rash HPI: ___ yo M with stage IIB esophageal adenoCA, s/p neoadjuvant chemo/XRT (___), s/p esophagectomy (___), s/p j-tube (___), tube-feed dependent, has been having 8 days of vomiting at home with decreased stool output. Was recently seen at ___ for GI symptoms and CT imaging c/w constipation, now presents with dislodged J-tube (since yesterday) and new rash on left leg, L buttock, L groin x 48 hours, concerning for shingles/Zoster in the L1-L3 dermatomes. . Recently seen in ED at ___ on ___ for abd pain, N/V. There received IV Compazine, IV Zofran, CT chest - unremarkable, CT A/P - moderate to large fecal load in right and transverse colon, Mild leukocytosis WBC 12, otherwise routine labs unremarkable, Discharged home same day with bowel regimen with subsequent passage of bowel movements. . In ED here: Triage VS: 98.8, 85, 132/82, 22, 95% on RA, pain ___. ED labs notable for Na 130, Cl 92, lactate 2.9, WBC 10.1. KUB and CXR unremarkable. Foley placed in J-tube tract, ___ consulted for J-tube replacement and this was done prior to arrival to 12 ___. IV Acyclovir was started in ER. Also received IVF 1L NS, 1L LR. Additonal ED meds: IV Zofran, IV morphine, IV Reglan, IV Ativan. ROS: 10-point ROS negative except as noted above. Specifically, no fever, chills, no abdominal pain or diarrhea. (+) intermittent nausea, vomiting. (+) daily migraine headaches unchanged from baseline. no pain/neuralgia, no CP, SOB. (+) chronic cough unchanged (+) 4 lb wt loss last 8 days. Past Medical History: PMH: Ulcerative colitis, in remission Migraine Asthma Hypercholesterolemia Esophageal CA stage IIB esophageal adenocarcinoma (T3N0M0) - s/p neoadjuvant chemo, carboplatin/Taxol, (completed ___ - s/p XRT, 23 sessions (completed ___ - s/p esophgectomy Gastric dysmotility - s/p Botox injection - currently on Reglan Right inguinal hernia PSH: Minimally invasive ___ esophagectomy and pericardial fat pad buttress (___) s/p laprascopic J-Tube Placement (___) s/p appendectomy ___ Social History: ___ Family History: Father - died due to a blood clot Siblings - brother with lung cancer, brother with CAD Physical Exam: ADMISSION EXAM: 98.1, 150/92, 96, 18, 97%RA Anicteric, OP clear, neck supple no ___ CTA bilat COR RRR ?___ mid LSB ABD soft, NT/ND no R/G (+) J tube in place EXT no edema SKIN discrete vesicular rash in left L1-L3 (L upper & mid anterior thigh, L high posterior buttock, L2 anterior groin area) does NOT cross the midline, NEURO fluent speech, nl cogntion, no hypesthesia DISCHARGE EXAM: VS: AF, 98.2, 126/85, 90, 16, 96% on RA Pain: zero/10 Gen: NAD, comfortable Resp: comfortable Abd: soft, NT, + J-tube with dressing C/D/I Skin: many vesicular lesions, in various stages of crusting, distributed in left L1 - L3 dermatomal distribution, does not cross mid-line. Neuro: AAOx3, fluent speech Pertinent Results: ADMISSION LABS: ___ 06:40PM BLOOD WBC-10.1* Hgb-16.6 Hct-47.7 MCV-86 RDW-13.2 RDWSD-41.0 Plt Ct-UNABLE TO Neuts-76.1* Lymphs-11.7* Monos-10.8 Eos-0.5* Baso-0.3 Im ___ AbsNeut-7.66* AbsLymp-1.18* AbsMono-1.09* AbsEos-0.05 AbsBaso-0.03 Glucose-107* UreaN-17 Creat-0.7 Na-130* K-4.2 Cl-92* HCO3-24 AnGap-18 Albumin-3.9 Calcium-9.5 Phos-2.6* Mg-2.5 ALT-32 AST-33 AlkPhos-85 TotBili-0.5 Lipase-17 cTropnT-<0.01 . . DISCHARGE LABS: ___ 10:30AM BLOOD WBC-10.3* Hgb-14.9 Hct-43.6 MCV-88 RDW-13.7 Plt ___ ___ 06:45AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-134 K-3.9 Cl-99 HCO3-29 AnGap-10 Calcium-8.7 Phos-3.4 Mg-2.2 . . MICROBIOLOGY: ___ Blood Culture x 2 sets: NGTD, final PENDING ___ Skin VZV and HSV culture: NGTD, final PENDING . . IMAGING: ___ PA/LAT CXR IMPRESSION: No acute cardiopulmonary process. . ___ Abdominal X-ray IMPRESSION: Nonobstructive bowel gas pattern. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation DAILY 2. Lactulose 15 mL PO TID 3. Metoclopramide 10 mg PO TID 4. Omeprazole 20 mg PO DAILY 5. Ondansetron 4 mg PO BID:PRN nausea 6. Acetaminophen 1000 mg PO Q6H:PRN headache 7. caffeine 200 mg oral DAILY:PRN headache 8. Polyethylene Glycol 17 g PO BID:PRN constipation Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN headache 2. Lactulose 15 mL PO TID 3. Metoclopramide 10 mg PO TID 4. Omeprazole 20 mg PO DAILY 5. Polyethylene Glycol 17 g PO BID:PRN constipation 6. Ondansetron 4 mg PO BID:PRN nausea 7. caffeine 200 mg oral DAILY:PRN headache 8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION DAILY 9. ValACYclovir 1000 mg PO Q8H Duration: 5 Days RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 8 hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dislodged J-tube Constipation Local zoster (shingles) 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 pulled out J tube // Please replace. COMPARISON: ___ AND ___ 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: 50 mg of fentanyl were administered. MEDICATIONS: Lidocaine jelly CONTRAST: 15 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 2 mins, 5 mGy PROCEDURE: PROCEDURE: 1. Replacement of a MIC jejuostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The tube site was prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. Contrast was injected through the existing Foley demonstrating appropriate position. The Foley catheter was removed after a glidewire was advanced through the tube into the jejunum. This was exchanged for the same type of tube as the patient previously had ___ MIC jejunostomy tube, modified to a shorter length). The balloon was inflated with 4 cc of contrast and contrast injection confirmed position. The catheter was then flushed, capped and the retention disk was cinched down and secured with 0-silk sutures. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful replacement of a MIC jejunostomy tube. Balloon inflated to 4 cc of contrast. FINDINGS: 1. Successful placement of a MIC jejunostomy tube. IMPRESSION: Successful placement of a MIC gastrostomy tube. The catheter is ready to use Gender: M Race: ASIAN - ASIAN INDIAN Arrive by WALK IN Chief complaint: Abd pain, Dyspnea, Vomiting Diagnosed with NONSPECIF SKIN ERUPT NEC, VOMITING, OTHER COLOSTOMY COMP, ABN REACT-EXTERNAL STOMA temperature: 98.8 heartrate: 85.0 resprate: 22.0 o2sat: 95.0 sbp: 132.0 dbp: 82.0 level of pain: 5 level of acuity: 2.0

You presented to the hospital with multiple issues: dislodgement of your J-tube, constipation and a new body and leg rash. Your J-tube was replaced by Interventional Radiology and functioning well. Your constipation improved with an increased bowel regimen and an enema. Your rash is consistent with a clinical diagnosis of zoster (shingles) and you are being treated with a course of anti-viral medication. . Please see your physicians as instructed. . Please take your medications as listed. .

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: naproxen / ___ pig Attending: ___. Chief Complaint: short of breath Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ year old female with asthma (multiple episodes requiring intubation), bronchiectasis, and tobacco use who presents with 3 days of rapidly progressive wheezing and SOB not responsive to her home nebs (recently filled prescription). She says that things started getting worse about 2 weeks ago when her eldest brother passed away. It seems at that time she stopped closely adhering to her asthma regimen, but she did apparently start a prednisone taper at 60 mg which she stopped earlier this week at 20 mg. Since then her symptoms have gotten worse. She has bad night-time coughing unresponsive to her nebs. The day of presentation she was watching her ___ month old granddaughter and felt that she couldn't keep up with her. Later that day at work she continued to struggle with her breathing. After coming home she decided to come to the ED here. She reports that she hasn't been hospitalized since ___ when she was seen here. She denies fevers, chills, nausea, vomiting, diarrhea and dysuria. She denies sick contacts. She has seasonal allergies. In the ED, initial VS 97.8, ___, 30, 97% on RA. By report she was unable to speak in full sentences, tripoding, and had diffuse wheezing. Labs were notable for WBC 12.3 with 9.2% eosinophils (previously known to be elevated), normal chem 10 and lactate. CXR showed no acute process. She received 125mg IV solumedrol x 1, Mag sulfate 2gm IV x 1, 1L NS, acetaminophen 1g PO and albuterol/ipratropium nebs and was transferred to the ___ for further management. On arrival to the ___, her vital signs were: 98.4, 111, 144/98, 15, 95% on face mask O2. Past Medical History: - Asthma (diagnosed in ___ - Brochiectasis - Pulmonary nodules (detected in ___, follow-up CT in ___ showed no progression) - positive PPD Social History: ___ Family History: Cancer (stomach and uterine per OMR) and T2DM Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 98.4, 111, 144/98, 15, 95% on face mask O2 General: Alert, oriented, mild respiratory distress, able to speak comfortably HEENT: Sclera anicteric Lungs: Bilateral wheezing throughout with moderate-poor air movement. No use of accessory muscles. Prolonged dry coughing with inspiration CV: Regular rhythm, tachycardic normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98.1 135/90 76 18 96%RA ___: FSBS 128 (180-190) General: no apparent distress, seated in bed reading on her computer, appears well and eager for discharge. Appears well ENT: MMM Cardiovasc: rr, nl rate, no murmur Resp: Breathing comfortably without accessory muscles or retractions, no distress, no coughing, auscultration with prolonged expiration and reduced air movement throughout with mild wheezes at bases, no rales or rhonchi Skin: No visible rash. No jaundice. Neuro: AAOx3. GU: No foley. Pertinent Results: Labs: ___ 08:05PM BLOOD WBC-12.3* RBC-4.77 Hgb-12.9 Hct-39.6 MCV-83 MCH-27.0 MCHC-32.5 RDW-15.2 Plt ___ ___ 08:05PM BLOOD Neuts-59.5 ___ Monos-4.9 Eos-9.2* Baso-0.4 ___ 08:05PM BLOOD Glucose-120* UreaN-7 Creat-0.8 Na-137 K-3.7 Cl-100 HCO3-25 AnGap-16 ___ 08:05PM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1 Most recent labs prior to discharge: ___ 07:05AM BLOOD WBC-13.8* RBC-4.42 Hgb-12.0 Hct-36.6 MCV-83 MCH-27.0 MCHC-32.7 RDW-15.7* Plt ___ ___ 07:05AM BLOOD Neuts-86.4* Lymphs-10.4* Monos-2.7 Eos-0.2 Baso-0.2 ___ 07:20AM BLOOD Glucose-284* UreaN-21* Creat-0.9 Na-136 K-3.9 Cl-96 HCO3-26 AnGap-18 ___ 07:20AM BLOOD Mg-2.0 ___ 07:05AM BLOOD ALT-21 AST-14 AlkPhos-114* TotBili-0.4 Images: CXR: No acute cardiopulmonary process Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 3. Montelukast 10 mg PO DAILY 4. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation Daily 5. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Montelukast 10 mg PO DAILY 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing 4. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation Daily 5. Tiotropium Bromide 1 CAP IH DAILY 6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing, sob RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb IH Q2hours Disp #*100 Vial Refills:*0 7. Azathioprine 100 mg PO QAM RX *azathioprine 50 mg 2 tablet(s) by mouth QAM Disp #*60 Tablet Refills:*0 8. Azathioprine 50 mg PO HS RX *azathioprine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 9. Hydrochlorothiazide 25 mg PO DAILY RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 10. PredniSONE 60 mg PO DAILY Taper Prednisone by 10mg every 3 days starting ___ RX *prednisone 10 mg 6 tablet(s) by mouth Daily Disp #*65 Tablet Refills:*0 11. MetFORMIN (Glucophage) 500 mg PO BID RX *metformin [Glucophage] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation Hyperglycemia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with shortness of breath // ?pneumonia TECHNIQUE: Single portable view of the chest. COMPARISON: ___. FINDINGS: The lungs are clear. The cardiomediastinal silhouette is within normal limits for technique. No acute osseous abnormality is identified. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Asthma exacerbation Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION temperature: 97.8 heartrate: 121.0 resprate: 30.0 o2sat: 97.0 sbp: nan dbp: nan level of pain: 0 level of acuity: 1.0

Ms. ___, It was a pleasuret treating you during this hospitalization. You were admitted for a severe asthma exacerbation. You were seen by the pulmonary doctors and treated with steroids, azathioprine, nebs, and other agents. You eventually started feeling better and you were able to return home. You are being discharged on a prednisone taper and also with a few new medications including a blood pressure medication and a diabetes medication. It is possible these may be able to be stopped once the steroids are reduced but for now you should continue taking them. You are also being restarted on Azathioprine.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: shortness of breath, leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ yo female with history of recurrent DVT and PE on intermittent coumadin who presents with leg pain and shortness of breath. Pt reports she had an upper respiratory illness 2 weeks ago with associated shortness of breath. Her symptoms improved with antibiotics but shortness of breath restarted on ___, followed by leg pain on ___. She states that she is supposed to be on life long coumadin, though she doesn't have her INR checked reliably, last was several months ago. She has never been evaluated for a clotting disorder, though states her PCP did refer her to hematology for further evaluation. She essentially titrates her coumadin dose to her vaginal bleeding and will self- decrease her dose of coumadin when her bleeding increases. She reports daily vaginal bleeding, which she attributes to fibroids. She has followed with a gynecologist as an outpatient, though states that she hasn't been offered any definitive therapy for her fibroids and has been managing with her bleeding for years. In the ED, initial vitals: 97.9 98 178/86 20 90%. Pt had a CXR without any acute processes. She had bilateral LENIs which showed left sided DVT. Labs were notable for anemia with hct 31.6 (baseline), INR 1.4, otherwise unremarkable. She was noted to be guaiac negative in the ED. She was started on a heparin drip and admitted to the floor. Vitals prior to transfer: 98.1 97 176/83 20 99% RA Currently, pt reports increasing in her vaginal bleeding, soaking through 3 pads in 1.5 hours. She is a ___ witness and will not accept blood products. She will take iron supplements. She is unsure about other products such as albumin. Past Medical History: Obesity DM type 2 Hyperlipidemia Recurrent DVT/PE Fibroid Uterus Anemia Social History: ___ Family History: Family history of hypertension. Denies any significant family history of blood clots, states father had DVT in his ___. Physical Exam: ADMISSION EXAM: =============== Vitals- 99.1 137/63 103 20 89%RA, 95% 2L General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding GU- no foley, blood noted on underwear soaking through pad Ext- warm, well perfused, 2+ pulses, 2+ pitting edema bilateral to knees, R> L, tender to palpation left calf, healed wound on right shin with chronic venous stasis changes Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE EXAM: ============== VS 98.9 146/53 90 18 96%RA General- Alert, oriented, no acute distress, morbidly obese and pleasant HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, mild ttp over RUQ and mid-epigastrium, normal bowel sounds, no rebound or guarding GU- no foley Ext- warm, well perfused, 2+ pulses, ___ pitting edema bilateral to knees, L>R, tender to palpation left calf, healed wound on right shin with chronic venous stasis changes Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ================ ___ 09:54AM BLOOD WBC-9.6 RBC-4.32 Hgb-8.8* Hct-31.6* MCV-73* MCH-20.4* MCHC-27.8* RDW-18.1* Plt ___ ___ 09:54AM BLOOD ___ PTT-31.4 ___ ___ 09:54AM BLOOD Glucose-211* UreaN-9 Creat-0.7 Na-142 K-4.0 Cl-103 HCO3-27 AnGap-16 DISCHARGE LABS: ================= ___ 06:00AM BLOOD WBC-7.7 RBC-3.73* Hgb-8.4* Hct-27.1* MCV-73* MCH-22.6* MCHC-31.2 RDW-19.0* Plt ___ ___ 06:00AM BLOOD ___ PTT-50.6* ___ ___ 06:00AM BLOOD Glucose-133* UreaN-8 Creat-0.7 Na-138 K-4.2 Cl-105 HCO3-27 AnGap-10 MISC LABS: =========== ___ 07:20AM BLOOD ALT-16 AST-26 LD(LDH)-308* AlkPhos-50 TotBili-0.2 ___ 09:54AM BLOOD cTropnT-<0.01 ___ 09:54AM BLOOD proBNP-663* MICROBIOLOGY: =============== ___ 1:38 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ========== # BILAT LOWER EXT VEINS Study Date of ___ IMPRESSION: The distal left superficial femoral vein is distended with echogenic contents, not compressible with transducer pressure and has minimal flow on power Doppler. Findings represent acute DVT of the left distal superficial femoral vein. There is no DVT found in the right leg. # CHEST (PA & LAT) Study Date of ___ IMPRESSION: Non-specific left upper and right lower lung consolidation. Consider repeat with improved inspiratory effort. # PELVIS U.S., TRANSVAGINAL Study Date of ___ FINDINGS: The uterus is anteverted and measures 10.8 x 8.9 x 14.6 cm. Multiple intramural fibroids are again identified, including 2 prominent 4.6 x 3.2 x 5.4 cm and 5.9 x 6.2 x 5.2 cm cm fundal fibroid, enlarged since prior study. The ovaries were not visualized on transabdominal or endovaginal imaging. The endometrium measures 0.7 cm visualized at the lower uterine segment. There isnofree fluid. IMPRESSION: Multiple fibroids, enlarged since prior study. Ovaries not identified. No adnexal masses. # MRI ABDOMEN W/O CONTRAST Study Date of ___ Early termination of the examination due to claustrophobia. Multiple fibroids which are primarily intramural largest measuring up to 6.2 cm. Severe degenerative disc disease at L5-S1 with disc protrusion. # ABDOMEN US (COMPLETE STUDY) Study Date of ___ IMPRESSION: 1. Hepatic steatosis. 2. Normal gallbladder without stones. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 6 mg PO DAILY16 Discharge Medications: 1. Warfarin 3 mg PO DAILY16 RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN abd pain RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ tablespoons by mouth four times a day Refills:*0 3. Provera (medroxyPROGESTERone) 10 mg oral BID Please start taking this medication once daily next ___ ___ RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth twice daily Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: DVT, likely PE vaginal bleeding ___ fibroids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Left leg pain. TECHNIQUE: Grey scale, color and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Left lower extremity vein doppler on ___. FINDINGS: Left: The distal left superficial femoral vein is distended with echogenic contents, and not compressible with transducer pressure. There is very minimal flow detected the using power Doppler. Otherwise, there is normal compressibility, flow and augmentation of the left common femoral, proximal and mid femoral veins. Of note, these images of the left leg were initially mislabeled as the 'right' leg. Clot is only found in the left leg. Right: There is normal compressibility, flow and augmentation of the right common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. The peroneal and posterior tibial veins are not visualized. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: The distal left superficial femoral vein is distended with echogenic contents, not compressible with transducer pressure and has minimal flow on power Doppler. Findings represent acute DVT of the left distal superficial femoral vein. There is no DVT found in the right leg. Radiology Report HISTORY: Shortness of breath. TECHNIQUE: PA and lateral views of the chest. COMPARISON: Multiple chest radiographs the most recent on ___. FINDINGS: The lung volumes are low. There is a subtle opacity in the left upper lung and right lung base. The cardiomediastinal silhouette and hilar contours are normal. The pleural surfaces are normal without effusion or pneumothorax. The pulmonary vasculature is normal. IMPRESSION: Non-specific left upper and right lower lung consolidation. Consider repeat with improved inspiratory effort. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with heavy vaginal bleeding on heparin drip. Evaluate for fibroids. 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: Prior CT abdomen and pelvis from ___ and pelvis ultrasound from ___. FINDINGS: The uterus is anteverted and measures 10.8 x 8.9 x 14.6 cm. Multiple intramural fibroids are again identified, including 2 prominent 4.6 x 3.2 x 5.4 cm and 5.9 x 6.2 x 5.2 cm cm fundal fibroid, enlarged since prior study. The ovaries were not visualized on transabdominal or endovaginal imaging. The endometrium measures 0.7 cm visualized at the lower uterine segment. There isnofree fluid. IMPRESSION: Multiple fibroids, enlarged since prior study. Ovaries not identified. No adnexal masses. Radiology Report EXAMINATION: MR pelvis INDICATION: Multiple enlarged fibroids on pelvic ultrasound with vaginal bleeding. Please evaluate fibroids in preparation for upcoming uterine artery embolization. TECHNIQUE: Localizer and sagittal T2 images of the pelvis were obtained without contrast. The examination was terminated early due to patient claustrophobia. COMPARISON: Compared with prior CT abdomen pelvis from ___ and prior pelvic ultrasound from ___. FINDINGS: There are multiple fibroids which are primarily intramural, the largest measuring 6.2 x 6.2 cm. The uterus is anteverted. The ovaries appear grossly unremarkable. The bladder appears unremarkable. There is no free fluid in the pelvis. There is severe degenerative disc disease at L5-S1 with disc protrusion. IMPRESSION: 1. Early termination of the examination due to claustrophobia. Multiple fibroids which are primarily intramural largest measuring up to 6.2 cm. 2. Severe degenerative disc disease at L5-S1 with disc protrusion. Radiology Report HISTORY: Right upper quadrant abdominal pain. COMPARISON: CT abdomen and pelvis, ___. TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the abdomen. FINDINGS: The liver is diffusely echogenic compatible with steatosis. There are no focal hepatic lesions. There is no intrahepatic biliary ductal dilatation. The CBD was not definitively visualized given limited visualization of the hepatic hilum. The portal vein is shown to be patent with hepatopetal flow, however. The gallbladder is thin-walled and unremarkable without stones. The pancreatic head and proximal body is unremarkable. The distal pancreas is not seen due to overlying bowel gas. The abdominal aorta is normal in caliber, though the distal most abdominal aorta was not visualized. The visualized portions of the IVC are unremarkable. The spleen is homogeneous in echotexture, measuring 12.7 cm in length, at the upper limits of normal size. The right kidney measures 12.8 cm and the left kidney measures 11.7 cm. There are numerous non-obstructing calculi in bilateral lower pole kidneys, measuring up to 8 mm on each side. There is no ascites. IMPRESSION: 1. Hepatic steatosis. 2. Normal gallbladder without stones. 3. Several non-obstructing renal stones bilaterally, measuring up to 8 mm. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dyspnea Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, HYPOXEMIA, PULM EMBOLISM/INFARCT temperature: 97.9 heartrate: 98.0 resprate: 20.0 o2sat: 90.0 sbp: 178.0 dbp: 86.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted with shortness of breath and leg pain. You were found to have a DVT in your left leg, and likely pulmonary embolism. You were started on a heparin drip, which caused worsening of your vaginal bleeding. You were evaluated by the gynecologist, who recommended starting provera in the short term. Long term, you should follow up with the gynecologist for endometrial biopsy and with interventional radioloty for uterine artery embolization. You were started on lovenox and coumadin. You will need to have your coumadin levels monitored closely.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Methotrexate / ciprofloxacin / chlorhexadine Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with a history of rheumatoid arthritis on prednisone and hydroxychloroquine, multiple prior abdominal surgeries (hemicolectomy for diverticulosis in ___, SBO's requiring lysis of adhesions), chronic right foot ulcer status post debridements, chronic venous insufficiency, prior lower extremity osteo-myelitis, prior C. difficile, restrictive ventilatory defect due to right hemidiaphragmatic paralysis, hypertension, hyperlipidemia who presents with abdominal pain and fevers. Of note, she has had multiple recent hospitalizations. ___ for Strep group C bacteremia thought to be from chronic ___ skin wounds in setting of chronic immunosuppression. She then was admitted ___ for ___ complicated cellulitis. During both hospitalizations she endorsed abdominal pain though possibly d/t mesenteric ischemia iso hypotension for sepsis. Both hospital stays were also c/b atrial tachycardia possibly triggered by hypovolemia iso sepsis. Since that discharge she was followed up by PCP where she reported feeling well. She also followed up with cariology outpatient for holter monitoring, which upon review showed some episodes of atach. Plan was for further monitoring with Ziopatch to determine burden with consideration for CCB as she was previous intolerant of beta-blocker. She also followed up with podiatry on ___ who completed in-clinic debridement. On day of presentation to the ED, she reported having a HA and 104 fever for which prompted her to call EMS. She also reports left sided abd pain. She denied any other symptoms during this time. - In the ED, initial vitals were: 100.4 | 74 | 20 | 95% RA She later developed 104.4 with tachycardia to 110s. She then developed a 4L O2 requirement but this was weaned to 2L. - Exam was notable for: Abdomen is tender in the left upper and lower quadrants without rebound or guarding. The right lower extremity is mildly swollen and erythematous with a foul odor relatively to the left. Pulses are intact in both lower extremities. - Labs were notable for: \ 9.6 / 138 | 102 | 30 20.8 ----- 192 ----------------<102 / 32.7 \ 4.8 | 24 | 0.9 Lactate 2.5 -> 1.7 Trop 0.06 -> 0.08 -> 0.08 EKG: Sinus tachycardia 109, though is in atrial fibrillation in the room. Normal axis and intervals. T wave inversions and ST depressions in inferior and lateral precordial leads. ST segment changes are similar to those seen on ___, but the ST depressions are more pronounced. No STEMI. - Studies were notable for: CXR: Low lung volumes with lower lung atelectasis, no definite signs of pneumonia. FOOT AP,LAT & OBL RIGHT XRAY: No signs of osteomyelitis. Soft tissue swelling along the dorsum of the midfoot may reflect cellulitis CT ABD & PELVIS WITH CO: 1. No evidence of acute abdominal abnormality to explain symptoms. 2. Pancolonic diverticulosis without evidence of diverticulitis. 3. 2 nonobstructive renal calculi in the right inter pole measuring up to 3 mm. 4. Ectatic distal aorta measuring up 2.3 cm. - The patient was given: IVF X2L Cefepime 2g Vanc 1000mg Metronidazole 500mg IV Hydrocortisone 100mg IV - No consults placed On arrival to the floor, she was very somnolent and not responding to questions. However she was able to follow simple commands and state where she was and her name. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: Rheumatoid arthritis on prednisone and hydroxychloroquine Restrictive ventilatory defect ___ right diaphragmatic paralysis (supplemental O2 at night) Supraventricular tachycardia - Diagnosed ___ Hypertension Hyperlipidemia Diverticulosis s/p hemicolectomy, lysis of adhesions History of left foot osteomyelitis OSA on CPAP PSH: Left ___ toe amputation (___) Excisional biopsy of left elbow mass (___) Split-thickness skin graft from right thigh to right foot (___) Incision and drainage of abscess of right foot (___) Incision and drainage of abscess, right foot (___) hemicolectomy (___) cholecystectomy Social History: ___ Family History: - Mother, MI, died ___ - Father, AAA, kidney cancer, died ___ - Brother, AF, living ___, Rheumatoid - Sister, AF, living ___, Rheumatoid Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 0313 Temp: 97.4 PO BP: 111/61 L Lying HR: 75 RR: 20 O2 sat: 98% O2 delivery: 2 L GENERAL: Ill appearance. Somnolent but arousable though. HEENT: PERRL, EOMI. Dry mucous membrane. CARDIAC: RRR. Soft S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB. No wheezes, rhonchi or rales. BACK: Mild tenderness to palpation along entire spine. ABDOMEN: Non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Hands with lateral displacement at the wrist. Left ___ toe distal joint amputation. SKIN: Chronic venous stasis changes bilaterally. Erythema of RLE with area of petechia-like pattern on medial and posterior calf, no purulence. No difference in warmth between each ___. Stage 1 decubitus ulcer over coccyx NEUROLOGIC: AOx2. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 742) Temp: 97.9 (Tm 98.1), BP: 124/78 (110-142/78-88), HR: 77 (68-88), RR: 20 (___), O2 sat: 93% (93-95), O2 delivery: ra HEENT: PERRL, EOMI. Dry mucous membranes. CARDIAC: RRR. Soft S1 and S2. No murmurs/rubs/gallops. LUNGS: CTAB. Mild crackles at the bases bilaterally. BACK: Mild tenderness to palpation along entire spine. ABDOMEN: Non distended, tender to palpation along the left abdomen, no masses or hepatosplenomegaly, no rebound or guarding EXTREMITIES: Hands with lateral displacement at the wrist. Left ___ toe distal joint amputation. SKIN: Chronic venous stasis changes bilaterally. RLE with area of petechia-like pattern on medial and posterior calf, no purulence or erythema (improved). No difference in warmth between each ___. Stage 1 decubitus ulcer over coccyx NEUROLOGIC: AOx2. Moving all 4 limbs spontaneously. Pertinent Results: ADMISSION LABS: ============== ___ 04:40PM BLOOD WBC-20.8* RBC-3.73* Hgb-9.6* Hct-32.7* MCV-88 MCH-25.7* MCHC-29.4* RDW-18.2* RDWSD-58.1* Plt ___ ___ 04:40PM BLOOD Neuts-94.5* Lymphs-1.7* Monos-2.9* Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.59* AbsLymp-0.36* AbsMono-0.61 AbsEos-0.01* AbsBaso-0.02 ___ 05:36PM BLOOD ___ PTT-23.6* ___ ___ 04:40PM BLOOD Glucose-102* UreaN-30* Creat-0.9 Na-138 K-4.8 Cl-102 HCO3-24 AnGap-12 ___ 04:40PM BLOOD ALT-19 AST-61* AlkPhos-66 TotBili-0.3 ___ 04:40PM BLOOD Albumin-3.8 Calcium-8.9 Phos-2.4* Mg-1.7 ___ 04:40PM BLOOD Lipase-36 ___ 04:40PM BLOOD cTropnT-0.06* ___ 08:30PM BLOOD cTropnT-0.08* ___ 12:57AM BLOOD cTropnT-0.08* ___ 05:06PM BLOOD ___ pO2-35* pCO2-46* pH-7.42 calTCO2-31* Base XS-4 PERTINENT LABS: ============= ___ 05:10AM BLOOD Glucose-59* UreaN-32* Creat-1.3* Na-139 K-5.4 Cl-107 HCO3-13* AnGap-19* ___ 11:04AM BLOOD Type-ART Temp-36.7 pO2-81* pCO2-37 pH-7.43 calTCO2-25 Base XS-0 Intubat-NOT INTUBA Comment-NASAL ___ ___ 04:46PM BLOOD Lactate-2.5* ___ 08:46PM BLOOD Lactate-1.7 ___ 11:04AM BLOOD Lactate-1.0 ___ 03:30PM BLOOD calTIBC-228* Ferritn-126 TRF-175* ___ 04:46PM BLOOD Hgb-9.9* calcHCT-30 ___:30AM BLOOD ANCA-NEGATIVE B ___ 03:30PM BLOOD CRP->300* ___ 04:40PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04:40PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 04:40PM URINE Mucous-RARE* ___ 10:10PM STOOL CDIFPCR-NEG DISCHARGE LABS: ============= ___ 05:15AM BLOOD WBC-15.0* RBC-3.35* Hgb-8.5* Hct-29.6* MCV-88 MCH-25.4* MCHC-28.7* RDW-18.4* RDWSD-58.6* Plt ___ ___ 05:15AM BLOOD Glucose-102* UreaN-34* Creat-0.9 Na-142 K-4.4 Cl-108 HCO3-25 AnGap-9* MICROBIOLOGY: ============= ___ 4:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 5:36 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 5:10 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 3:30 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 10:10 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. IMAGING: =============== FOOT AP,LAT & OBL RIGHTStudy Date of ___ 5:54 ___ IMPRESSION: No signs of osteomyelitis. Soft tissue swelling along the dorsum of the midfoot may reflect cellulitis. CHEST (PA & LAT)Study Date of ___ 5:54 ___ IMPRESSION: Low lung volumes with lower lung atelectasis, no definite signs of pneumonia. CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 7:02 ___ IMPRESSION: 1. No evidence of acute abdominal abnormality to explain symptoms. 2. Pancolonic diverticulosis without evidence of diverticulitis. 3. 2 nonobstructive renal calculi in the right inter pole measuring up to 3 mm. 4. Ectatic distal aorta measuring up 2.3 cm. EKG ___ Sinus rhythm Nonspecific intraventricular conduction delay Abnrm T, consider ischemia, anterior precordial leads. compared to previous ECG , ST/T wave changes are less pronounced. CT LOW EXT W/O C RIGHTStudy Date of ___ 12:02 ___ IMPRESSION: 1. No CT evidence for acute osteomyelitis. 2. Postoperative changes throughout the foot. HIP UNILAT MIN 2 VIEWS LEFTStudy Date of ___ 6:07 ___ IMPRESSION: No acute osseous injury of the left hip or significant degenerative change. EKG ___ Sinus tachycardia ST & T wave abnormality, consider inferior ischemia ST & T wave abnormality, consider anterolateral ischemia When compared with ECG of ___ 10:26, (Unconfirmed) premature atrial depolarizations are no longer present the rate has increased and ST/T wave changes persist. TTE ___ IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Mild aortic regurgitation with mildly thickened leaflets but no discrete vegetation. Compared with the prior TTE ___, the findings are ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Carbidopa-Levodopa (___) 1 TAB PO QPM 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate NASAL 2 SPRY NU QHS 6. Hydroxychloroquine Sulfate 200 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. PredniSONE 5 mg PO DAILY 9. PredniSONE 4 mg PO QPM 10. Psyllium Wafer 1 WAF PO DAILY 11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 12. Ursodiol 300 mg PO TID 13. Vitamin D ___ UNIT PO EVERY OTHER DAY 14. Calcium Carbonate 1500 mg PO DAILY 15. Diclofenac Sodium ___ 75 mg PO DAILY 16. GuaiFENesin ___ mL PO QHS:PRN cough 17. Indapamide 1.25 mg PO DAILY 18. Loratadine 10 mg PO QHS:PRN allergies 19. Vitamin B Complex 1 CAP PO BID Discharge Medications: 1. Betamethasone Valerate 0.1% Ointment 1 Appl TP DAILY 2. Cephalexin 500 mg PO TID 3. Hydrocerin 1 Appl TP TID:PRN rash 4. Sulfameth/Trimethoprim DS 1 TAB PO BID 5. Omeprazole 40 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Calcium Carbonate 1500 mg PO DAILY 9. Carbidopa-Levodopa (___) 1 TAB PO QPM 10. Docusate Sodium 100 mg PO BID 11. Fluticasone Propionate NASAL 2 SPRY NU QHS 12. GuaiFENesin ___ mL PO QHS:PRN cough 13. Hydroxychloroquine Sulfate 200 mg PO DAILY 14. Indapamide 1.25 mg PO DAILY 15. Loratadine 10 mg PO QHS:PRN allergies 16. PredniSONE 5 mg PO DAILY 17. PredniSONE 4 mg PO QPM 18. Psyllium Wafer 1 WAF PO DAILY 19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 20. Ursodiol 300 mg PO TID 21. Vitamin B Complex 1 CAP PO BID 22. Vitamin D ___ UNIT PO EVERY OTHER DAY 23. HELD- Diclofenac Sodium ___ 75 mg PO DAILY This medication was held. Do not restart Diclofenac Sodium ___ ___ physician tells you that this is ok Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis Sepsis Right lower extremity cellulitis Secondary Diagnosis Hypokalemia Anion gap metabolic acidosis Abdominal pain NSTEMI II Chronic hypoxemic respiratory distress Chronic anemia Chronic foot ulcers Coronary artery disease Rheumatoid arthritis Hypertension History of atrial tachycardia Gastroesophageal reflux ___ Chronic venous stasis 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 LOW EXT W/O C RIGHT Q61R INDICATION: ___ year old woman with hx RA on immunosuppressants, p/w sepsis unknown source, has chronic ulcers on RLE// osteomyelitis DOSE: Acquisition sequence: 1) Spiral Acquisition 4.4 s, 69.7 cm; CTDIvol = 10.2 mGy (Body) DLP = 710.5 mGy-cm. Total DLP (Body) = 711 mGy-cm. COMPARISON: Foot radiographs from ___ FINDINGS: There is no bony destruction to indicate CT evidence of acute osteomyelitis. No acute fractures or dislocations are seen. There is a physiologic amount of knee joint fluid. There is demineralization. There are mild degenerative changes of the knee joint. The patella is slightly subluxed laterally from the trochlea. There are degenerative changes and clawtoe deformities of the toes. Postoperative changes are seen at the MTP joints. There has been resection of portion of the first metatarsal shaft. There is muscle atrophy. IMPRESSION: 1. No CT evidence for acute osteomyelitis. 2. Postoperative changes throughout the foot. Radiology Report EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT INDICATION: ___ year old woman with sepsis of unknown source// septic joint? TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of the left hip. COMPARISON: ___, CT scan of the abdomen and pelvis dated ___ FINDINGS: There is no fracture or dislocation. There are mild degenerative changes about the hips bilaterally. Extensive degenerative changes in the lumbar spine are incompletely evaluated. There is no suspicious lytic or sclerotic lesion. No erosions. Soft tissue granulomas overlying the left buttocks are unchanged. Excreting contrast material opacifies the bladder and enteric contrast material is seen within the sigmoid colon and rectum. IMPRESSION: No acute osseous injury of the left hip or significant degenerative change. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain Diagnosed with Sepsis, unspecified organism, Cellulitis of right lower limb, Unspecified abdominal pain temperature: 100.4 heartrate: 74.0 resprate: 20.0 o2sat: 95.0 sbp: nan dbp: nan level of pain: 3 level of acuity: 3.0

Dear Ms. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were were having high fevers and pain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were treated for a skin and soft tissue infection of your right leg with antibiotics and fluids - You were seen by podiatry for your chronic foot ulcers - You were found to have low potassium, an electrolyte, for which you were also treated and monitored for - We found you to have iron deficiency anemia for which you were monitored for and we recommend having continued workup as an outpatient WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take your antibiotics, Bactrim 1 DS tab BID and Keflex ___ TID, through ___, or until instructed to a physician to discontinue these medications - Please avoid taking NSAIDs including diclofenac, as these can cause ulcers and bleeding from the stomach. - Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for new/or worsening symptoms (worsening abdominal pain, vomiting blood, bloody stools, fevers/chills). If you do not feel like you are getting better or have any other concerns,please call your doctor to discuss or return to the emergency room. We wish you all the best! Sincerely, Your ___ Care 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: fall Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ year old male patient who presented after a fall, patient stated that he was drinking tonight, when he tried to pick up a mail package, he tripped and fell forward, ? LOC, c/o headaches, no vomiting or weakness Social History: +ETOH Physical Exam: PHYSICAL EXAM: AVSS Gen: WD/WN, comfortable, NAD. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. AxOx3 follows commadns throughout PERRL, EOMI, FSTM no drift MAE x ___ sensation intact to light touch EXAM ON DISCHARGE: NEuro intact + abrasion to back of his head. Pertinent Results: HEAD CT: ___ IMPRESSION: 1. Interim enlargement of the right frontal hemorrhagic contusion. 2. Small right superior frontal extra-axial hematoma adjacent to the nondisplaced frontal bone fracture is stable. This may represent an epidural hematoma. 3. Bilateral frontal and left temporal subdural hematomas are stable. Medications on Admission: Not put in the system. List reviewed with pt prior to discharge and advised pt to hold aspirin for 7 days. Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Please do not drive mechanical machinery or have any alcohol itake while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth Q 4hrs Disp #*20 Tablet Refills:*0 3. LeVETiracetam 500 mg PO BID Only take for 7 days twice a day. RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Right frontal lobe contusion and bilateral SDH. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ male status post fall. TECHNIQUE: Multi detector CT images through the brain were obtained in soft tissue and bone algorithm windows. Coronal and sagittal reformations were generated and reviewed. DOSE: 892 mGy-cm. COMPARISON: None available. FINDINGS: There is an nondisplaced fracture of the frontal bone, located in the midline at the vertex and taking a right parasagittal course inferiorly. No extension into the frontal sinus orbit is seen. There is a small right frontal subgaleal hematoma. Best seen on sequence 2, images 26 and 25, as well as coronal sequence 601 b, image 44, there is a 1.0 x 0.9 cm right superior frontal hemorrhagic contusion with minimal edema. There is a small adjacent extracted hematoma without mass effect, which may be epidural given the adjacent fracture. There are bilateral anterior/inferior frontal subdural hematomas, larger on the right, extending along the right anterior falx. On the left, the subdural hematoma also extends into the middle cranial fossa along the lateral, medial, anterior, and inferior temporal lobe. There is no sulcal effacement or shift of midline structures. Ventricles and sulci are prominent due to underlying age-related cerebral atrophy. Fluid density space in the anterior aspect of the right middle cranial fossa is suggestive of an arachnoid cyst. Basal cisterns are not compressed. There is minimal mucosal thickening in anterior ethmoidal air cells bilaterally. Other visualized paranasal sinuses are well aerated. Right mastoid air cells are partially opacified. Left mastoid air cells are clear. IMPRESSION: 1. Nondisplaced fracture involving the midline and right aspects of the frontal bone. 2. Small right superior frontal hemorrhagic contusion. Adjacent small extra-axial hematoma, without mass effect, may be were, given the proximity to the frontal bone fracture. 3. Small bilateral subdural hematomas, along the frontal lobe on the right, and along the frontal and temporal lobes on the left. No significant mass effect due to underlying age-related cerebral atrophy. 4. Probable arachnoid cyst in the right middle cranial fossa. NOTIFICATION: These findings communicated to the ED physician via telephone at 6:05 am on ___ at the time findings were discovered. Radiology Report EXAMINATION: NON CONTRAST HEAD CT INDICATION: Right frontal subdural hematoma. TECHNIQUE: Contiguous axial MDCT images were obtained through the head without IV contrast. Sagittal, coronal and bone thin algorithm reconstructions were generated. Total exam DLP: 892 mGy-cm. CTDI: 53 mGy. COMPARISON: Head CT from ___ at 05:31. FINDINGS: Nondisplaced fracture involving the midline and right aspect of the right frontal bone is again seen. Right superior frontal hemorrhagic contusion has increased in size, now measuring 14 x 10 mm (series 2, image 23). There is surrounding mild vasogenic edema. Small adjacent extra-axial hematoma, which may be epidural given the proximity to the fracture, is stable in size. Bilateral inferior frontal subdural hematomas, slightly larger on the right, which extend along the anterior inferior falx, are stable. Small subdural hematoma surrounding the left temporal lobe is stable. There is no associated sulcal effacement, given the underlying age-related cerebral atrophy. There is no shift of normally midline structures. The basal cisterns are not compressed. A probable arachnoid cyst is again seen in the right middle cranial fossa. A small focus of hypodensity in the left caudate head likely reflects a prior lacunar infarction (series 2, image 14). Areas of low density in the periventricular and deep white matter of the cerebral hemispheres are likely sequela of chronic small vessel ischemic disease in a patient of this age. Partial right mastoid air cell opacification and mild mucosal thickening in bilateral ethmoid air cells are again seen. IMPRESSION: 1. Interim enlargement of the right frontal hemorrhagic contusion. 2. Small right superior frontal extra-axial hematoma adjacent to the nondisplaced frontal bone fracture is stable. This may represent an epidural hematoma. 3. Bilateral frontal and left temporal subdural hematomas are stable. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, Transfer, ICH Diagnosed with SEMICOMA/STUPOR temperature: 98.6 heartrate: 101.0 resprate: 18.0 o2sat: 97.0 sbp: 163.0 dbp: 98.0 level of pain: 2 level of acuity: 3.0

Nonsurgical Brain Hemorrhage •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. ****Please HOLD aspirin for 7 days. •**You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion, lethargy or change in mental status. •Any numbness, tingling, weakness in your extremities. •Pain or headache that is continually increasing, or not relieved by pain medication. •New onset of the loss of function, or decrease of function on one whole side of your body. *******Please continue to take all your other medications as prescribed, except your Aspirin.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Remicade / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Compazine / lithium Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Sigmoidoscopy: Impression: Evidence of previous colectomy with ileo-rectal anastomosis. Mild erythema and staple noted, but no marginal ulcers or bleeding. Ulcers in the neo-TI Ulcers in the rectum Otherwise normal sigmoidoscopy to ileum Recommendations: - continue steroids - will need to discuss starting biologic, likely as outpatient. - while he has active disease, it does not appear to be severe enough to explain abdominal pain. History of Present Illness: ___ h/o Crohn's Disease ___ years with recent hemicolectomy at OSH 10 months PTA, presents with abdominal pain x5 days. Patient states he has been having a "Crohn's Flair" x5 days PTA described as abdominal pain, nausea and diarrhea c/w previous flairs. He was seen by his outpatient gastroenterologist who started him on Prednisone 40mg PO. Patient had a flex sig 4 days PTA which confirmed a Crohn's flair. The patient continued his prednisone, however, the next day due to his nausea and abdominal pain the patient was unable to take PO. This persisted over the next few days with worsening abdominal pain and nausea. After discussing with his outpatient gastroenterologist, it was decided that he should come to ___ for further evaluation given that his disease has been difficult to manage, failing "multiple biologic therapies", including anaphylaxis to remicaide. Regarding his Crohn's disease, he does not take any daily medications. Per GI pt was diagnosed at age ___ and was treated with 5ASA and prednisone. He had a PEG placed a few years later. In his teens he was on IFX and either ___ or MTX (not clear, probably the latter). He had issues with possible anaphylaxis with IFX but was subsequently able to tolerate. At age ___ he was flaring and switched to Cimzia and then Humira, but without response. At some point he was on Imuran. At age ___, he underwent what seems to be total colectomy with ileo-rectal anastomosis for stricturing complications.He has tried multiple biologic therapies (unable to name specifics). No fevers/chills, no chest pain or shortness of breath. +decreased PO. No mouth ulcers. Vomiting x1, non-bloody. No melena or hematochezia. +blood on toilet paper after wiping In the ED, initial vitals were: 97.8 103 140/84 16 100% RA Patient was given: IV Morphine Sulfate 4 mg IV Ondansetron 4 mg IVF 1000 mL NS 1000 mL IV Morphine Sulfate 4 mg IVF 1000 mL NS 1000 mL IV MethylPREDNISolone Sodium Succ 32 mg On the floor, patient was hemodynamically stable complaining of abdominal pain and nausea Past Medical History: - Crohn's disease: diagnosed at age ___ - s/p partial colectomy in ___ in setting of bowel obstruction - s/p G-tube at age ___ (later removed) Social History: ___ Family History: no family history of IBD Physical Exam: ADMISSION PHYSICAL Vital Signs: 117/72 83 18 98ra GEN: NAD HEENT: sclerae anicteric. No oral ulcers. Poor dentition. No precervical LAD. No tonsilar exudates. No PND or nasal discharge ___: RRR no MRG LUNGS: CTAB, no increased WOB, no rhonchi or crackles ABD: well healed central incision with some granulation tissue. Generalized tenderness to palpation. No rebound or guarding. EXT: Warm, no edema NEURO: CN II-XII grossly intact. Strength ___ UE and ___ b/l PSYC: Normal affect DISCHARGE PHYSICAL 98.1 126/67 88 18 98ra GEN: NAD HEENT: sclerae anicteric. ___: RRR no MRG LUNGS: CTAB, no increased WOB, no rhonchi or crackles ABD: well healed central incision with some granulation tissue. Generalized tenderness to palpation (unchanged from ___ per pt). No rebound or guarding. EXT: Warm, no edema PSYC: Normal affect Pertinent Results: ___ LABS ___ 05:11AM BLOOD WBC-7.0 RBC-4.24* Hgb-11.1* Hct-35.4* MCV-84 MCH-26.2 MCHC-31.4* RDW-14.1 RDWSD-42.2 Plt ___ ___ 05:11AM BLOOD Neuts-75.6* Lymphs-14.6* Monos-7.4 Eos-1.0 Baso-1.1* Im ___ AbsNeut-5.29 AbsLymp-1.02* AbsMono-0.52 AbsEos-0.07 AbsBaso-0.08 ___ 05:11AM BLOOD Glucose-87 UreaN-8 Creat-0.8 Na-138 K-3.5 Cl-103 HCO3-25 AnGap-14 ___ 05:11AM BLOOD ALT-14 AST-17 LD(LDH)-165 AlkPhos-113 TotBili-0.9 ___ 05:11AM BLOOD CRP-8.7* PERTINENT LABS ___ 05:17AM BLOOD Lactate-1.4 ___ 05:17AM BLOOD Lactate-1.4 ___ 05:11AM BLOOD CRP-8.7* DISCHARGE LABS ___ 04:30AM BLOOD WBC-7.9 RBC-3.88* Hgb-9.9* Hct-32.2* MCV-83 MCH-25.5* MCHC-30.7* RDW-13.8 RDWSD-41.3 Plt ___ ___ 04:30AM BLOOD Glucose-135* UreaN-14 Creat-0.8 Na-142 K-3.3 Cl-105 HCO3-27 AnGap-13 MICROBIOLOGY __________________________________________________________ ___ 1:43 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. __________________________________________________________ ___ 1:46 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. __________________________________________________________ ___ 12:23 pm URINE Source: ___. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PANTHER System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ ___ Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. __________________________________________________________ ___ 1:00 pm SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. __________________________________________________________ ___ 10:00 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:40 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:46 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. IMAGING ___ MRE IMPRESSION: 1. Unchanged mild pouchitis. 2. No evidence of active Crohn's disease in the small bowel. 3. No fistula or abscess. 4. Stable longstanding probable sequelae of fat necrosis in left upper quadrant. ___ SIGMOIDOSCOPY Impression: Evidence of previous colectomy with ileo-rectal anastomosis. Mild erythema and staple noted, but no marginal ulcers or bleeding. Ulcers in the neo-TI Ulcers in the rectum Otherwise normal sigmoidoscopy to ileum Recommendations: - continue steroids - will need to discuss starting biologic, likely as outpatient. - while he has active disease, it does not appear to be severe enough to explain abdominal pain. ___ need to consider evaluation for other causes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. PredniSONE 40 mg PO DAILY 3. Ondansetron 4 mg PO Q6H:PRN nausea Discharge Medications: 1. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Ondansetron 4 mg PO Q6H:PRN nausea 3. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Take while you are on prednisone. RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every six (6) hours Disp #*16 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Crohn's Disease SECONDARY DIAGNOSIS Anxiety/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 Crohn's disease with a rising lactate. // evaluate for perforation TECHNIQUE: Supine upright views of the abdomen. COMPARISON: CT abdomen pelvis on ___. FINDINGS: No evidence of free air. Surgical clips project of the left upper quadrant. Patient is status post total colectomy. A gas-filled loop of small bowel in the right mid abdomen measures up to 4.5 cm in diameter, without air-fluid levels. IMPRESSION: No evidence of free air. Focally dilated loop of small bowel in the right mid abdomen. CT can be performed for further evaluation. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 5:41 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: MR ___ INDICATION: History of Crohn's disease with worsening abdominal pain. Evaluate for cause of pain. TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis were acquired within a 1.5 T magnet, including 3D dynamic sequences performed prior to, during, and following the administration of 0.1 mmol/kg of Gadavist intravenous contrast (8 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0 mg of Glucagon was administered IM to reduce bowel peristalsis. COMPARISON: CT of the abdomen and pelvis from ___. MR enterography from ___. FINDINGS: MR ENTEROGRAPHY: The patient is status post colectomy. The distal aspect of the ileal pouch has mild wall hyperenhancement and surrounding fat stranding, compatible with mild pouchitis. It is unchanged from the prior exam. The superior pouch wall is normally enhancing without significant thickening or evidence of edema. The anastomosis appears patent. There is no significant upstream dilation to suggest obstruction, though the upstream ileum is mildly patulous, similar to the prior exams, and likely due to chronic changes. The remainder of the small bowel appears to be within normal limits. There is no edema, mucosal hyperenhancement, or abnormal wall thickening. No fistula or abscess is identified. Adjacent to the stomach, there is nonenhancing soft tissue which is slightly hypointense on the T2 weighted images (6, 1). This was better characterized on the prior CT. There is no fluid within this region to suggest an abscess. This likely represents post surgical changes, possibly chronic fat necrosis. There are no abnormal mesenteric lymph nodes or mesenteritis. Trace free fluid is identified in the perihepatic space, which is nonspecific (4, 18). MRI OF THE ABDOMEN AND PELVIS: The imaged portions of the liver are normal without a focal lesion. The portal veins are patent. There is no intra or extrahepatic biliary duct dilation. Note, the entire liver is not included in the field of view. The gallbladder is underdistended, which limits its evaluation. Within the limitations, it is normal. No stones are identified. The spleen is normal in size, measuring 12.4 cm. There are no focal lesions. A 21 mm accessory spleen is noted in the left upper quadrant. The pancreas is normal without duct dilation or a mass. The bilateral adrenal glands and kidneys are normal. There are no worrisome renal lesions, hydronephrosis, or perinephric abnormalities. The abdominal aorta is normal in caliber without evidence of an aneurysm or significant atherosclerotic plaque. Incidentally noted is an accessory right renal artery. There is no retroperitoneal or periportal lymphadenopathy. The bladder is unremarkable without wall thickening or a mass. The imaged portions of the seminal vesicles and prostate gland are within normal limits. There is no pelvic or inguinal lymphadenopathy. No free fluid is identified in the pelvis. There are no concerning osseous lesions. Postsurgical changes are noted in the anterior abdominal wall, with foci of susceptibility artifact and scarring. No hernia or fluid collection is identified. The soft tissues are otherwise unremarkable. IMPRESSION: 1. Unchanged mild pouchitis. 2. No evidence of active Crohn's disease in the small bowel. 3. No fistula or abscess. 4. Stable longstanding probable sequelae of fat necrosis in left upper quadrant. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new line // new right PICC 44 cm ___ ___ Contact name: ___: ___ TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Right PICC tip is in thecavoatrial junction. Cardiac size is normal. The lungs are clear. There is no pneumothorax or pleural effusion. Radiology Report INDICATION: ___ year old male with Crohn's disease status post flexible sigmoidoscopy on ___ with worsening abdominal abdominal pain. Evaluate for acute intra-abdominal process or bowel perforation. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP = 7.2 mGy-cm. 2) Spiral Acquisition 4.4 s, 47.5 cm; CTDIvol = 11.3 mGy (Body) DLP = 537.8 mGy-cm. Total DLP (Body) = 545 mGy-cm. COMPARISON: MRE from ___ and abdominal radiograph from ___. 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. There is a trace amount of hematoma, similar to prior exam and likely post-surgical in nature. 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 patient is status post colectomy and ileal pouch anastomosis. Surgical clips are noted along the splenic flexure and anterior abdomen. There is mucosal hyperemia of the reservoir pouch and just proximal to the anastomosis concerning for Crohn's flare. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No significant atherosclerotic disease is noted. The abdominal aorta and its major branches are patent. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Anterior midline postsurgical changes are noted. IMPRESSION: Mucosal hyperemia of the reservoir pouch and proximal to the anastomosis concerning for Crohn's flare. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, n/v/d Diagnosed with Unspecified abdominal pain temperature: 97.8 heartrate: 103.0 resprate: 16.0 o2sat: 100.0 sbp: 140.0 dbp: 84.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, You came to the hospital for abdominal pain from your Crohn's Flair. You were seen by our gastroenterologists who did a scope that showed active, but not severe, disease. You were started on steroids for the flare. Your symptoms improved and you requested an expedited discharge. You will be discharged on oral prednisone 40 mg daily and a low-dose antibiotic (called Bactrim) to prevent infections while you are on prednisone. You should follow up with your outpatient GI doctor to determine the length of your prednisone course and for planning further treatment. Your discharge medications are detailed in the discharge medication list. We wish you the best. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Chantix Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of COPD, polysubstance abuse, IBS and gastritis who presents with worsening epigastric pain associated with nausea/vomiting and general malaise. She notes chronic history of abdominal pain especially in epigastrium in addition to nausea and vomiting and generally just feeling unwell for a while but more recently has had worsening epigastric pain, has been feeling sleepy all the time, unsteady on her feet and just overall doesn't feel well. She has h/o IBS and states she's always had issues with her bowel movements either not going or having loose stool. She was previously on linzess but more recently she underwent ___ in late ___ and since then has only been on BID PPI for gastritis noted on EGD. The colonoscopy was normal and the EGD was otherwise reassuring as well. She reports a history of alcohol abuse but denies alcohol dependence or prior history of alcohol withdrawal. She denies any other ingestions or illicit drug use. She denies a history of pancreatitis, abdominal surgeries or pancreatic insufficiency. She has noted darker urine recently but otherwise denies dysuria, hematuria or blood in stool or vomitus. She denies recent changes in her medications and currently just takes PPI bid and inhalers. In the ED: Vitals: Tmax 99.1, P ___ -->116-120, BP 120-150/70's, RR ___, 98-100% on RA Exam: Uncomfortable, Abdomen Soft, minimally tender to palpation diffusely, nondistended, no masses, fecal occult negative brown stool. otherwise benign neuro and cardiopulm exam Labs: CBC 18.6>15.9<336; vbg:7.24/___, lactate 2.5, serum bicarb 7, AG 38, Sosm 308 --> repeat vbg 7.38/19, lactate 1.9. BUN/Cr 33/1.4, mild transaminitis 41/48, normal Tbili, lipase 257, Utox positive for benzo's and cocaine, serum tox negative Imaging: 2vCXR without acute changes, RUQUS with stable PD dilation, unable to exlude pancreatitis but visualized portion appears normal Impression: pt w/ ___ and pancreatitis and persistent tachycardia and odd acidosis Interventions: GI cocktail and 3L of LR Plan: Renal consult, treat for pancreatitis, admit ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Lyme disease, HTN, tobacco use, lung nodule, thyroid nodule, spontaneous pneumothorax, GERD, abdominal pain Social History: ___ Family History: no history of MS, strokes, seizures Physical Exam: Admission Exam: GENERAL: tired appearing but in no acute distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen somewhat firm but not tense and non-distended, tender to palpation in mid-epigastrium, a-peritoneal, no guarding or rebound GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly symmetric SKIN: No obvious rashes or ulcerations noted on cursory skin exam NEURO: Sleepy, oriented but somewhat of a poor historian, falling asleep during conversation at times but somewhat volitional, face symmetric, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Discharge Exam: VITALS: ___ 0721 Temp: 97.6 PO BP: 130/70 Sitting HR: 77 RR: 16 O2 sat: 100% O2 delivery: RA GENERAL: improved overall appearance, smiling, NAD EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: SNTND BS+ NEURO / PSYCH: Alert, oriented, pleasant appropriate affect Medications on Admission: The Preadmission Medication list is accurate and complete. 1. linaCLOtide 145 mcg oral DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Pantoprazole 20 mg PO Q12H 5. Metoclopramide 5 mg PO DAILY AT LUNCH 6. Align (Bifidobacterium infantis) 4 mg oral DAILY 7. amLODIPine 10 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Align (Bifidobacterium infantis) 4 mg oral DAILY 3. amLODIPine 10 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. linaCLOtide 145 mcg oral DAILY 6. Metoclopramide 5 mg PO DAILY AT LUNCH 7. Pantoprazole 20 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Pancreatitis 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 abd pain// ?pneumonia TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Chest CT from ___ and chest radiograph from ___ FINDINGS: Change sutures in emphysematous changes overlying the right upper lung are re-demonstrated. No focal consolidation is seen. There is no pleural effusion or pneumothorax. No pulmonary edema is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with pancreatitis// ?gallstone/cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver, gallbladder ultrasound dated ___, and ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 7 mm and unchanged from prior GALLBLADDER: There is no evidence of stones or 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. Could not exclude the presence of acute pancreatitis. SPLEEN: Normal echogenicity Spleen length: 6.4 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 10.4 cm Left kidney: 11.0 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No evidence of cholelithiasis or acute cholecystitis. 2. The common hepatic duct appears borderline to mildly dilated, but this is similar compared to prior studies from ___ and ___. Please correlate with liver function tests. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Tachycardia Diagnosed with Bradycardia, unspecified temperature: nan heartrate: 145.0 resprate: nan o2sat: nan sbp: nan dbp: nan level of pain: Critical level of acuity: 1.0

Dear Ms. ___, You were admitted for pancreatitis. Now you are doing better and can go home to follow-up with your outpatient doctors. Please work on minimizing the amount of alcohol you drink. We wish you the ___ with your health. ___ Medicine

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Demerol / Latex / Medazepam Attending: ___ ___ Complaint: Left total knee replacement pain & infection Major Surgical or Invasive Procedure: Left total knee irrigation & debridement, liner exchange History of Present Illness: ___ year old female with history of left knee replacement s/p MVC ___, Dr. ___ p/w atraumatic L knee pain and swelling x 4 days a/w subjective fevers. While pt is afebrile, no leukocytosis, lactate 1.6, given her limited ROm as well as effusion and elevated CRP concern for septic arthritis. Past Medical History: *S/P TOTAL KNEE REPLACEMENT ___ ESOPHAGUS CHRONIC PAIN DEPRESSION HEPATITIS C HEROIN ABUSE HERPES SIMPLEX MRSA CULTURE POSITIVE S/P BREAST AUGMENTATION S/P MVA MYOCLONIC JERKS GASTROESOPHAGEAL REFLUX TENSION HEADACHES H/O COMMUNITY ACQUIRED PNEUMONIA H/O FOLLICULITIS H/O URINARY RETENTION RHEUMATOID ARTHRITIS Social History: ___ Family History: Mother: HTN. MGM: Thyroid disease. PGM: Lung CA. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 07:05AM BLOOD WBC-6.2 RBC-3.17* Hgb-8.6* Hct-27.8* MCV-88 MCH-27.1 MCHC-30.9* RDW-16.3* RDWSD-52.9* Plt ___ ___ 07:11AM BLOOD WBC-6.6 RBC-3.02* Hgb-8.3* Hct-26.2* MCV-87 MCH-27.5 MCHC-31.7* RDW-16.8* RDWSD-53.1* Plt ___ ___ 06:08AM BLOOD WBC-6.4 RBC-3.22* Hgb-8.9* Hct-28.6* MCV-89 MCH-27.6 MCHC-31.1* RDW-16.9* RDWSD-55.2* Plt ___ ___ 04:15AM BLOOD WBC-7.7 RBC-3.69* Hgb-10.0* Hct-31.0* MCV-84 MCH-27.2 MCHC-32.3 RDW-16.8* Plt ___ ___ 04:40PM BLOOD WBC-9.8 RBC-3.90* Hgb-10.7* Hct-32.3* MCV-83 MCH-27.3 MCHC-33.0 RDW-16.8* Plt ___ ___ 04:40PM BLOOD Neuts-61.0 ___ Monos-5.3 Eos-3.7 Baso-0.3 ___ 07:05AM BLOOD Plt ___ ___ 07:11AM BLOOD Plt ___ ___ 06:08AM BLOOD Plt ___ ___ 04:15AM BLOOD Plt ___ ___ 04:40PM BLOOD Plt ___ ___ 07:05AM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-137 K-4.2 Cl-102 HCO3-29 AnGap-10 ___ 07:11AM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-136 K-4.1 Cl-104 HCO3-24 AnGap-12 ___ 06:08AM BLOOD Glucose-127* UreaN-6 Creat-0.7 Na-143 K-4.6 Cl-107 HCO3-28 AnGap-13 ___ 04:40PM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-138 K-5.3* Cl-105 HCO3-26 AnGap-12 ___ 07:11AM BLOOD ALT-14 AST-17 AlkPhos-57 ___ 06:50PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 07:05AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9 ___ 07:11AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1 ___ 06:08AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.0 ___ 04:40PM BLOOD CRP-159.5* ___ 07:11AM BLOOD HIV Ab-NEGATIVE ___ 07:10AM BLOOD Vanco-14.4 ___ 07:05AM BLOOD Vanco-14.2 ___ 07:00PM BLOOD Vanco-9.4* ___ 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:51PM BLOOD Lactate-1.6 Medications on Admission: 1. ClonazePAM 1 mg PO BID 2. CloniDINE 0.2 mg PO QHS 3. Cyclobenzaprine 10 mg PO TID:PRN spasm 4. Nicotine Patch 21 mg TD DAILY 5. QUEtiapine Fumarate 50 mg PO QHS 6. Ranitidine 150 mg PO DAILY 7. Sertraline 100 mg PO DAILY Discharge Medications: 1. ClonazePAM 1 mg PO BID 2. CloniDINE 0.2 mg PO QHS 3. Cyclobenzaprine 10 mg PO TID:PRN spasm 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QD Duration: 28 Days 6. Gabapentin 600 mg PO TID 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain 8. Morphine SR (MS ___ 15 mg PO Q12H 9. Nicotine Patch 21 mg TD DAILY 10. QUEtiapine Fumarate 50 mg PO QHS 11. Ranitidine 150 mg PO DAILY 12. Rifampin 300 mg PO Q12H 13. Sertraline 100 mg PO DAILY 14. Levofloxacin 750 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Left total knee infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT INDICATION: ___ with pain in L knee s/p replacement TECHNIQUE: Three views of the left knee. COMPARISON: Tib-fib radiographs ___. FINDINGS: Again seen is evidence of prior left total knee arthroplasty. The prosthetic components appear well seated, without evidence of hardware related complication or periprosthetic fracture. A superior patellar enthesophyte is noted, which appears slightly more conspicuous than on prior. There is a small suprapatellar joint effusion. IMPRESSION: 1. Status post left knee arthroplasty with small joint effusion. 2. Small suprapatellar enthesophyte. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with new R PICC // Evaluate new R single-lumen Power PICC 45cm ___ ___ Contact name: ___: ___ COMPARISON: ___ IMPRESSION: The patient has received the new right-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the cavoatrial junction. No complications, notably no pneumothorax. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Knee pain Diagnosed with PYOGEN ARTHRITIS-LOWER LEG temperature: 99.0 heartrate: 81.0 resprate: 15.0 o2sat: 100.0 sbp: 94.0 dbp: 56.0 level of pain: 10 level of acuity: 4.0

1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. ___ STOCKINGS x 6 WEEKS. 9. WOUND CARE: Please keep your Silverlon dressing clean and dry. REMOVE one week after surgery. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. You may place a dry sterile dressing on the wound after the Silverlon dressing is removed, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by at your follow-up visit in 3 weeks. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. 12. WEEKLY LABS: draw on ___ and send result to ID RNs at: ___ R.N.s at ___. - CBC/DIFF - BUN - LFTS - ESR/CRP Physical Therapy: WBAT LLE Mobilize frequently No range of motion restrictions Treatments Frequency: DSD daily prn drainage upon removal of Silverlon Ice and elevate TEDs *Staples will be removed at your first post-operative visit in three(3)weeks

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine / Heparin Agents / Levaquin / Bactrim / Lisinopril / Valsartan / Intelence / Benadryl Attending: ___ Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ history of HCV cirrhosis (treated), HIV, presenting with cough. Patient states that she is "feeling sick" overall that brought her into the ED. Patient reports that she originally thought she had a bacterial infection because she had been frequently re-using a water bottle without cleaning it. She reports that she stopped doing this but her symptoms (cough and headache) continued to worsen. She reports after this she tried Theraflu and acetaminophen which only temporarily broke her fever but it always came back. Patient reports her cough has been ongoing for a week associated with shortnesss of breath. Also has had some intermittent nausea, did have 1 episode of non-bloody emesis several days prior with interval resolution. Also having soft stools did have several episodes of diarrhea the other day however recently has been soft. Also complaining of some burning on urination. In the ED: Initial vital signs were notable for: T99.1 HR 98 BP 127/78 RR 19 O2Sat 92% RA. Tmax while in ED 101.5F Exam notable for: - Gen: Coughing with productive sputum - Lungs: Clear, no wheezes, rales, or rhonchi - Abd: Mildly distended, otherwise soft, no m/r/g - Ext: 2+ peripheral pulses, no c/c/e Labs were notable for: normal CBC, negative Flu panel, lactate 2.3 Studies performed include: CXR: Findings worrisome for multifocal pneumonia; large area of left lung opacity and streaky opacity in the inferior aspect of the right upper lobe. Patient was given: Levofloxacin 750 mg, 1 L NS, APAP 650 mg Vitals on transfer: 24 HR Data (last updated ___ @ 1809) Temp: 97.7 (Tm 97.7), BP: 120/78, HR: 100, RR: 19, O2 sat: 93%, O2 delivery: Ra, Wt: 154.0 lb/69.85 kg Upon arrival to the floor, patient reports that she is feeling better. Denies any acute complaints. Past Medical History: - HIV diagnosed in ___ - HCV genotype I - HSV I - Ppd pos, quant gold neg ___ - EGD ___ with salmon esophagus suggestive of barretts: bx neg - Colonoscopy ___ with rectal carcinoid and adenoma; 5hiaa 24 hour urine and octreotide scan neg - Papillary thyroid cancer T1bN1b s/p total thyroidecomy, left modified radical neck dissection, and thyrogen stimulated I 131 treatment with 150 mCi - Kidney disease proteinuria: segmental global glomerulosclerosis, ___ sclerotic/remainder mod mesangeal proliferation with patchy intersititial fibrosis (not cryoglobulinemia) - Prior polysubstance abuse (cocaine, etoh) - Depression - Tobacco - HTN - Fibroids - Fsh high at 47/ postmenopausal - Decreased hearing left ear, hearing aid - Hoarse voice with large laryngoceles and vocal cord deviated left: ___ right saccular cyst left after left removal - Pancreatitis in ___ Social History: ___ Family History: Both mother and father passed away from lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 1809) Temp: 97.7 (Tm 97.7), BP: 120/78, HR: 100, RR: 19, O2 sat: 93%, O2 delivery: Ra, Wt: 154.0 lb/69.85 kg GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. Right eye with cataract and vision loss. CARDIAC: RRR no m/r/g LUNGS: Cough productive of brownish colored sputum. Decreased breath sounds bilaterally. ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout. AOx3. DISCHARGE PHYSICAL EXAM GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. Right eye with cataract CARDIAC: RRR no m/r/g LUNGS: CTAB, resolution of cough ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: clubbing on bilateral upper extremities SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout. AOx3. Pertinent Results: ADMISSION LAB RESULTS ===================== ___ 02:45PM BLOOD WBC-9.4 RBC-5.03 Hgb-14.7 Hct-41.4 MCV-82 MCH-29.2 MCHC-35.5 RDW-18.4* RDWSD-53.4* Plt ___ ___ 07:15AM BLOOD WBC-8.2 Lymph-16* Abs ___ CD3%-82 Abs CD3-1078 CD4%-17 Abs CD4-227* CD8%-63 Abs CD8-828* CD4/CD8-0.27* ___ 04:43PM BLOOD Glucose-131* UreaN-22* Creat-1.7* Na-132* K-4.2 Cl-101 HCO3-18* AnGap-13 ___ 04:43PM BLOOD ALT-38 AST-121* CK(CPK)-219* AlkPhos-80 TotBili-2.2* ___ 04:43PM BLOOD Albumin-2.6* Calcium-8.6 Phos-2.2* Mg-2.1 DISCHARGE LAB RESULTS ===================== ___ 07:09AM BLOOD ___-6.7 RBC-4.25 Hgb-12.3 Hct-34.5 MCV-81* MCH-28.9 MCHC-35.7 RDW-17.0* RDWSD-50.1* Plt ___ ___ 07:15AM BLOOD WBC-8.2 Lymph-16* Abs ___ CD3%-82 Abs CD3-1078 CD4%-17 Abs CD4-227* CD8%-63 Abs CD8-828* CD4/CD8-0.27* ___ 07:09AM BLOOD Glucose-96 UreaN-17 Creat-1.5* Na-137 K-4.2 Cl-104 HCO3-18* AnGap-15 ___ 07:09AM BLOOD ALT-29 AST-81* LD(LDH)-281* AlkPhos-88 TotBili-0.9 ___ 07:09AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2 IMAGING ======= ___ CXR Findings worrisome for multifocal pneumonia; large area of left lung opacity and streaky opacity in the inferior aspect of the right upper lobe. ___ Renal Ultrasound Mild cortical hyperechogenicity is unchanged, suggestive of medical renal disease. No etiology for hematuria identified. ___ Abdominal Ultrasound Nodular cirrhotic liver with borderline splenomegaly. No concerning liver masses identified. No evidence of portal vein thrombosis. MICROBIOLOGY ============ ___ Urinary study Legionella Urinary Antigen (Final ___: positive Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dolutegravir 50 mg PO DAILY 2. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY 3. Gabapentin 600 mg PO QHS 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___) 6. Spironolactone 25 mg PO DAILY 7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB Discharge Medications: 1. Azithromycin 500 mg PO/NG Q24H RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*11 Tablet Refills:*0 2. Levothyroxine Sodium 75 mcg PO DAILY RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 4. Dolutegravir 50 mg PO DAILY 5. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY 6. Gabapentin 600 mg PO QHS 7. Spironolactone 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Legionella pneumonia Secondary diagnoses HIV CKD Cirrhosis Hypothyroidism 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 history of HCV cirrhosis, HIV, presenting with fevers, worsening shortness of breath and cough// Eval for PNA TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Large area of left mid to lower lung opacity is seen. There is also streaky opacity in the inferior aspect of the right upper lobe. No large pleural effusion or pneumothorax is seen. Cardiac silhouette size is mildly enlarged. Mediastinal contours are unremarkable. IMPRESSION: Findings worrisome for multifocal pneumonia; large area of left lung opacity and streaky opacity in the inferior aspect of the right upper lobe. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ history of HCV cirrhosis previously on treatment however did not complete, HIV (last CD4 ___ VL 1.4 ___, presenting with productive cough, subjective fevers and chills, concerning for CAP with unexplained hematuria.// ?etiology of hematuria, evidence of CKD TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: There is no hydronephrosis, stones, or masses bilaterally. Mild cortical hyperechogenicity is unchanged. Right kidney: 11.1 cm Left kidney: 10.8 cm The bladder is moderately well distended and normal in appearance. IMPRESSION: Mild cortical hyperechogenicity is unchanged, suggestive of medical renal disease. No etiology for hematuria identified. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ year old woman with history of incompletely treated ___. Now here with abdominal pain, diarrhea, nausea, elevated LFTs, elevated T bili, and elevated lipase.// Please evaluate liver, gallbladder and pancreas given lab abnormalities. Please perform WITH Doppler to evaluate for portal vein thrombosis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with cirrhosis. There is no focal liver mass. A small 4 mm cyst is seen in the left lobe. There is no ascites. Color flow on pulse Doppler assessment of the liver vasculature shows full patency of the left right and main portal veins with normal Doppler waveforms. Hepatic veins and arteries are also normal. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: There is no evidence of stones or 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. Spleen length: 11.6 cm. 1.3 cm splenic hemangioma unchanged from the prior scan. KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Right kidney: 9.3 cm Left kidney: 10.2 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Nodular cirrhotic liver with borderline splenomegaly. No concerning liver masses identified. No evidence of portal vein thrombosis. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: ILI Diagnosed with Pneumonia, unspecified organism temperature: 99.1 heartrate: 98.0 resprate: 19.0 o2sat: 92.0 sbp: 127.0 dbp: 78.0 level of pain: 5 level of acuity: 3.0

Dear Ms. ___, You were hospitalized at ___. Why did you come to the hospital? ================================== You came to the hospital because you were not feeling well, and had a fever. What did we do for you? ======================= We diagnosed you with a very severe pneumonia, called Legionella pneumonia. We gave you an antibiotic called azithromycin to help. We also talked to your endocrinologist and changed the dose of your levothyroxine medication. What do you need to do? ======================= It is very important that you continue taking your antibiotics as prescribed. You should take this for a total of 14 days. Day 1 = ___, Day 14 = ___. It is also very important follow-up with your primary care doctor ___ information below). It was a pleasure taking care of you. We wish you the best! Sincerely, Your ___ medical team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Infected right proximal humeral pathologic fracture Major Surgical or Invasive Procedure: Irrigation & Debridement ___ History of Present Illness: ___ is a ___ female undergoing a work up for right humeral pathologic fracture of unclear etiology. Had ___ biopsy done ___ which by report was purulent, but on microscopy was without bacteria, although rich in WBC. Overnight ___ had fever to 100.2 (skin probe), called Dr. ___ was advised to come here for eval. Past Medical History: Depression No history of CA Social History: ___ Family History: non-contributory Physical Exam: NAD, AOx3 LUE skin clean and intact No LUE tenderness, deformity, erythema, edema, induration or ecchymosis. RUE in splint, notable for warmth and tenderness to RUE about deltoid, pain in anterior flexion, internal/external rotation, and abduction. incision closed w/ silk sutures; intact. Mild drainage at previous drain site. Arms and forearms are soft No pain with passive motion R M U SITLT b/l but slightly decreased to dorsum right thumb. EPL FPL EIP EDC FDP FDI fire 2+ radial pulses Pertinent Results: ___ 10:50AM GLUCOSE-115* UREA N-13 CREAT-0.6 SODIUM-132* POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-28 ANION GAP-16 ___ 10:50AM CRP-GREATER TH ___ 10:50AM WBC-17.5* RBC-3.53* HGB-7.9* HCT-25.6* MCV-73* MCH-22.4* MCHC-30.9* RDW-17.5* ___ 10:50AM NEUTS-84.9* LYMPHS-9.5* MONOS-5.1 EOS-0.2 BASOS-0.3 ___ 10:50AM SED RATE-UNABLE TO Medications on Admission: Sertraline 25 mg PO DAILY BuPROPion 150 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever 2. Bisacodyl 10 mg PR HS:PRN if no BM 1300 on ___ pt may refuse 3. BuPROPion 150 mg PO DAILY 4. CefePIME 2 g IV Q12H Duration: 6 Weeks RX *cefepime 2 gram infuse 2 g q12hr Disp #*60 Gram Refills:*0 5. Docusate Sodium 100 mg PO BID hold for loose stool 6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. RX *Heparin Lock 10 unit/mL infuse into picc every four (4) hours Disp ___ Milliliter Refills:*0 7. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 6 Weeks RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain Hold for sedation, RR<12 or altered mental status. Ok to start while on PCA RX *oxycodone 5 mg ___ tablet(s) by mouth q3hr Disp #*90 Tablet Refills:*0 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation daily until BM 10. Senna 2 TAB PO BID hold for loose stool 11. Sertraline 25 mg PO DAILY 12. Outpatient Lab Work Weekly CBC w/ differetial weekly Chem 7 Weekly ESR/CRP ___ laboratory results should be faxed to the ___ R.N.s at ___. ___ questions regarding outpatient parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when the clinic is closed. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R arm fracture / infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female status post ORIF for pathological fracture. COMPARISONS: None. FINDINGS: Frontal and lateral views of the chest were obtained. The heart is of normal size with normal cardiomediastinal contours. The lungs are clear without focal or diffuse abnormality. No pleural effusion or pneumothorax is identified. The known right humeral fracture is not visualized on this exam. The osseous structures are otherwise unremarkable. No radiopaque foreign body. IMPRESSION: No acute cardiopulmonary process. Radiology Report REASON FOR EXAMINATION: PICC line placement. Portable AP radiograph of the chest was compared to ___. Left PICC line is malpositioned, continuing towards the left internal jugular line with its tip above the superior margin of the radiograph, reposition is required. Heart size and mediastinum are stable. Lungs are essentially clear with no pleural effusion or pneumothorax. Radiology Report INDICATION: ___ female with osteomyelitis, failed bedside PICC placement. A midline was left in place. OPERATORS: ___, M.D., supervised by ___, M.D, the attending radiologist who was present and supervising. PROCEDURE: Exchange of left-sided midline with left-sided PICC. PROCEDURE DETAILS: Appropriate time-out was performed. Patient was positioned supine, and the left upper arm was prepped and draped in sterile fashion. A 0.018'' guide wire was placed through the indwelling midline, and over this, the midline was removed, and a breakaway sheath was placed. The distance to the SVC was then measured with the wire tip positioned in the SVC and the PICC was cut to size. The PICC was then placed over the wire, and the breakaway sheath was removed. The PICC was affixed to the skin with adhesive device and covered with the appropriate dressing. The PICC is a double lumen PICC, cut to 45 cm, and is ready to use. Fluoroscopy was used intermittently during the examination. FLUORO TIME: 2.1 minutes, 3 mGy total dose. IMPRESSION: Uncomplicated exchange of indwelling left-sided midline for a PICC, 45 cm long, two lumens, tip in SVC, ready for use. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: FEVER S/P BX ___ NOW FEVER Diagnosed with POSTPROCEDURAL FEVER temperature: 98.3 heartrate: 104.0 resprate: 16.0 o2sat: 98.0 sbp: 95.0 dbp: 52.0 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 continued to be non-draining. ******WEIGHT-BEARING******* non weight bearing R arm ******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 ___. Physical Therapy: NWB RUE; in posterior splint Treatments Frequency: No need to change dressing if dry. If wet, use xeroform or equivalent to incision, gauze pads and protective adhesive dressing

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: L toe pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o IDDM, HTN, CKD stage III and peripheral neuropathy who presents with worsening left foot pain and difficulty walking. Pt diagnosed with frostbite in ___ after remaining out in the cold for several hours and was evaluated by Podiatry. During his follow up appt with Podiatry on ___ he was given a 10 day course of amox/clavulanate, which he states he has been taking. He reports persistent pain in his left foot in the area of the frostbite without erythema or swelling. Denies any new exposures or trauma to the foot. Denies fevers, chills, SOB, chest pain, abdominal pain, N/V or diarrhea. He has not been taking his insulin for the last several days because he "is neglecting" himself. He gives himself short-acting insulin sometimes, but not according to the sliding scale. Medication adherence, especially insulin adherence has been a long-standing issue. Endorsed polyuria in ED but denies on the floor, denies increased thirst. Follows with ___ and ___ saw them ___. In the ED, initial VS were: 97.4 64 172/95 18 94% RA. Exam significant for well-defined area of eschar with purpuric discoloration on left toes ___, mild erythema and linear area on lateral left foot where blister previously removed by podiatry. Initial labs were significant for Na of 129, BUN/Cr of ___, Hct of 36.8, lactate of 1.7, and VBG of ___. Blood cultures obtained. Left foot XR was negative for fracture or dislocation, or obvious osteomyelitis. He received 1L of IV normal saline, 1g of acetaminophen, and 20 units of insulin lispro. He was evaluated by podiatry, with admission to medicine advised for expedited vascular work-up, including ABIs/PVRs and antibiotics. Upon transfer vital signs were: 97.9 84 151/83 16 100% RA. On arrival to the floor, patient reports intermittent shooting pain, electric-like, as well as increased tenderness when he stands on the foot. He reports falling this morning after losing his balance and scraped his shin. Denies LOC, head strike, lightheadedness or dizziness prior to the event. Past Medical History: H/o LBBB Prostate ca Salivary gland Hypertrophy Sleep apnea HTN HLD Heart murmur Hearing loss Thyroid nodules Urinary incontinence Lacunar stroke x2 R DMII CKD Stage III Cardiomyopathy Anemia Constipation Social History: ___ Family History: No known heart disease, DM, cancer in family Physical Exam: Admission PE: VITALS: 97.6 157/71 HR 91 18 100% RA ___ pain GENERAL: thin elderly male in NAD, very mobile in the bed HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, patent nares, MMM, moderate dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, soft systolic murmur, no 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, no hepatosplenomegaly, no suprapubic tenderness EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally, dry eschar on R foot medial aspect great toe, dry eschar on distal ___ toes on the L foot with mild surrounding erythema, TTP, ulceration at sole with increased warmth. L toes skin is thickened and hyperpigmented. No fluctuance. NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes . Discharge PE: VS: 97.7 ___ 100/ra ___ 196 GENERAL: thin elderly male in NAD, very mobile in the bed HEENT: AT/NC, EOMI, PERRL, nontender supple neck, no LAD CARDIAC: RRR, S1/S2, soft systolic murmur, no gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi ABDOMEN: nondistended, nontender, +BS, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no edema PULSES: 1+ DP and ___ pulses bilaterally. Dry eschar on the medial aspect of the great toe of his R foot. Dry eschars on the plantar aspect of toes ___ on his L foot without significant erythema, fluctuance, or drainage. NEURO: CN II-XII intact SKIN: warm and well perfused, no rashes Pertinent Results: Admission Labs: ___ 03:00PM BLOOD WBC-7.0 RBC-4.50* Hgb-12.7* Hct-36.8* MCV-82 MCH-28.2 MCHC-34.5 RDW-13.1 Plt ___ ___ 03:00PM BLOOD Glucose-512* UreaN-27* Creat-2.0* Na-129* K-4.3 Cl-94* HCO3-26 AnGap-13 ___ 04:31PM BLOOD ___ pO2-21* pCO2-51* pH-7.41 calTCO2-33* Base XS-4 . Discharge Labs: ___ 06:30AM BLOOD WBC-5.6 RBC-4.12* Hgb-11.2* Hct-33.2* MCV-81* MCH-27.3 MCHC-33.9 RDW-13.1 Plt ___ ___ 06:30AM BLOOD ___ PTT-30.0 ___ ___ 06:30AM BLOOD Glucose-150* UreaN-26* Creat-1.6* Na-135 K-4.3 Cl-101 HCO3-26 AnGap-12 ___ 06:30AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0 . >> IMAGING: - ABIs, prelim: Right greater than left tibial disease. Exercise test was not performed due to pain from foot ulcers. . - L foot x-ray: No acute fracture or dislocation. . >> MICRO: - bl cx pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 55 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Aspirin 325 mg PO DAILY 5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 7. Vesicare (solifenacin) 10 mg oral DAILY 8. Furosemide 20 mg PO DAILY 9. Metoprolol Succinate XL 200 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY Hold for SBP < 100 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Glargine 55 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin 5. Metoprolol Succinate XL 200 mg PO DAILY 6. Acetaminophen 325-650 mg PO Q6H:PRN pain 7. Furosemide 20 mg PO DAILY Hold for SBP < 95. 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Vesicare (solifenacin) 10 mg oral DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis: Frostbite, poorly controlled IDDM Secondary Diagnoses - CKD Stage III - HTN - HLD 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 IDDM, HTN who presents with worsening foot pain in area of previous ___, no trauma. // Assess for bony involvement, fracture TECHNIQUE: Left foot, three views COMPARISON: ___ FINDINGS: There has been no interval change from the prior exam. No acute fracture or dislocation is present. Joint spaces are preserved. No concerning lytic or sclerotic osseous abnormality is visualized. There are no radiopaque foreign bodies or soft tissue calcifications. Tiny posterior calcaneal spur is present. IMPRESSION: No acute fracture or dislocation. Radiology Report EXAMINATION: Noninvasive arterial evaluation. INDICATION: ___ year old man with persistent foot ulceration and pain // ABI/PVR/toe pressures 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: None. FINDINGS: On the right side, triphasic Doppler waveforms are seen in the right femoral, superficial femoral and popliteal arteries. Biphasic posterior tibial artery waveform and monophasic dorsalis pedis. The right ABI was 0.79. On the left side, triphasic Doppler waveforms are seen at the left femoral, superficial femoral, popliteal arteries. Biphasic posterior tibial artery waveform and monophasic dorsalis pedis. The left ABI was 0.91. Pulse volume recordings showed abnormal amplitude at the level of the right ankle and metatarsal consistent with the right tibial disease. Normal amplitude on the left. IMPRESSION: Right greater than left tibial disease. Exercise test was not performed due to pain from foot ulcers. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: L Foot pain Diagnosed with PAIN IN LIMB, DIABETES UNCOMPL JUVEN, HYPERTENSION NOS temperature: 97.4 heartrate: 64.0 resprate: 18.0 o2sat: 94.0 sbp: 172.0 dbp: 95.0 level of pain: 6 level of acuity: 3.0

Mr. ___, You were admitted to the hospital due to pain in your foot. This was concerning because of your recent diagnosis of frotsbite in that foot that is following its natural progression. There were no clear signs of infection related to your toes. Podiatry saw you as well. It will be important for you to follow up with your primary care doctor, the doctor that follows your diabetes management, and your podiatrist as noted below. It was a pleasure caring for you during this hospitalization. We wish you the very best in health. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / sulfadiazine Attending: ___. Chief Complaint: Fever and fatigue Major Surgical or Invasive Procedure: PTC w ___ History of Present Illness: ___ h/o Metastatic Pancreatic Adenocarcinoma (progressed on FOLFOX, awaiting discussion of next regimen), Recent EColi Bacteremia (presumably ___ cholangitis, s/p ___ipro), and Recurrent C diff who presents from home with fevers and fatigue. Patient noted that since his last hospitalization he has felt well and discontinued his vancomycin/ciprofloxacin dosing without any missed doses. He noted that yesterday he went to play in a concert as he is a member of a band, but felt extremely fatigued after the first saw and was very lightheaded so went home to rest. He then took a single dose of medical marijuana which was his first-ever and went to bed. This morning patient noted that he continued to be fatigued and checked his temperature found to be 102° so presented to the emergency department. Denied any sore throat, cough, nausea, vomiting, abdominal pain, dysuria, rash. He noted that he intermittently has loose stools which is baseline for patient and feels that his current stooling (varies between soft formed and loose) is not consistent with similar C. difficile infections in quantity or odor. Of note, patient noted he had several pills left in vanco course as scheduled. In the ED, initial vitals: 100.1 97 140/64 15 98% RA. Temperature then increased to 102.9. -Labs revealed WBC 11.5, Hgb 8.5 (baseline 10), INR 1.2, BUN/Cr of ___ (baseline ___ -Patient was given 1 L NS, Vancomycin, Cefepime, Flagyl, Tylenol. -ERCP team consulted who record considering MRCP tomorrow if further workup for infection is negative, but are not planning on ERCP currently. REVIEW OF SYSTEMS: as above otherwise 10point ROS negative Past Medical History: PAST ONCOLOGIC HISTORY: -___: neoadjuvant FOLFIRINOX -___: CyberKnife x 3 treatments -___: pylorus preserving pancreaticoduodenectomy (Whipple). -___: adjuvant Gemcitabine/capecitabine initially, then d/c capecitabine and continue with gemcitabine alone starting ___ d/t cytopenias. -___: FOLFOX (first line tx of metastatic disease) -___: patient was briefly treated with investigational isoquercetin to prevent venous thromboembolic events, came off trial d/t patient preference. -___: Disease progression. Stopped FOLFOX PAST MEDICAL HISTORY: -Back pain since ___ -? colitis in the past (dx not confirmed), not autoimmune, currently controlled since childhood 1960s -Elevated PSA ___ -HTN, HLD -R inguinal hernia repair in ___ -Basal Cell s/p removal from nose in ___ -Vasectomy ___ -Tonsillectomy ___ c/b hemorrhage -Ocular migraines ___ years -Arthroscopic knee surgery at age ___ -Chronic nasal congestion x ___ years -Recurrent CDiff colitis (last ___ Social History: ___ Family History: Father with squamous cell s/p removal, died ___ from Alzheimers (alcoholic). Mother with lung CA, smoker, died age ___. Younger sister with BCC and older sister (half-sister)s/p lumpectomy ("benign growths"). Physical Exam: DISCHARGE EXAM 98.6 167/82 81 aox3 not jaundiced ctab rrr soft abd no guarding or rebound, no focal tenderness or organomegaly no peripheral edema Pertinent Results: ADMISSION LABS ___ 05:55PM BLOOD WBC-11.5*# RBC-2.61* Hgb-8.5* Hct-26.4* MCV-101* MCH-32.6* MCHC-32.2 RDW-14.2 RDWSD-51.3* Plt ___ ___ 05:55PM BLOOD Neuts-77.7* Lymphs-10.0* Monos-11.1 Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.91*# AbsLymp-1.15* AbsMono-1.28* AbsEos-0.06 AbsBaso-0.04 ___ 06:21PM BLOOD ___ PTT-25.6 ___ ___ 05:55PM BLOOD Glucose-106* UreaN-26* Creat-1.5* Na-141 K-4.4 Cl-98 HCO3-22 AnGap-21* ___ 05:55PM BLOOD ALT-47* AST-93* CK(CPK)-57 AlkPhos-665* TotBili-0.6 ___ 06:17AM BLOOD calTIBC-217* ___ Ferritn-789* TRF-167* ___ 06:09PM BLOOD Lactate-2.4* DISCHARGE LABS*** IMAGING/STUDIES: -MRCP ___: 1. Increased size and number of extensive hepatic metastases. Notably, all hepatic lesions demonstrate similar appearance although in the setting of diffuse metastatic disease the ability to completely exclude a small liver abscess is difficult. 2. Mild segmental areas of biliary duct dilation in the left hepatic lobe without MR evidence of cholangitis. The dilation is likely from obstruction by metastases. 3. No interval change to recurrent pancreatic mass, necrotic retroperitoneal and mesenteric lymphadenopathy, and mesenteric soft tissue mass adjacent to the SMV/SMA. -RUQ US ___: Mild intrahepatic biliary dilatation, primarily in the left lobe of the liver which may be secondary to malignant obstruction. Common bile duct measures 6 mm. Innumerable hypoechoic masses in the liver consistent with known metastatic disease. Pancreatic head mass, better seen on prior CT. Patient status post cholecystectomy. - RUQUS (___): No significant change in mild intrahepatic biliary duct dilatation in the left hepatic lobe. No extrahepatic biliary duct dilatation. Grossly unchanged innumerable hepatic metastases. - Left UENIS (___): 1. Occlusive thrombus throughout the left basilic vein. 2. No evidence of deep vein thrombosis in the left upper extremity. - US NECK (___): Occlusive thrombus within the noncompressible right internal jugular vein, at the site of right neck pain and swelling, as indicated by the patient. - INCOMPLETE MRCP (___): 1. Despite incomplete examination, there is no significant interval change compared to the recent MRCP from ___ including to the extensive hepatic metastases, recurrent pancreatic mass, lymphadenopathy, and soft tissue mass adjacent to the SMV. 2. Unchanged severity of mild segmental areas of intrahepatic biliary duct dilation, most pronounced in the left lobe, likely a result of obstruction from hepatic metastases. - CT NECK (___): 1. Right-sided internal jugular clot with extensive surrounding fluid which extends as far anterior as the thyroid gland and posteriorly into the retropharyngeal space, crossing the midline. The fluid extends in the prevertebral space from C2 to C5. - CTA CHEST (___): 1. New filling defects in bilateral lobar pulmonary arteries, compatible with acute pulmonary emboli. No evidence of right heart strain. 2. Numerous hepatic metastases are better characterized on the MRCP from the same day. Known right IJ thrombus reflected by expansion of the vein. - NCHCT (___): There is no evidence of infarction, hemorrhage, edema,or mass. Incidental note is made of cavum velum interpositum. There is prominence of the ventricles and sulci suggestive of involutional 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: 1. No evidence of hydrocephalus or intracranial hemorrhage. - TTE (___): The left atrium is normal in size. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >60%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echo evidence of endocarditis. Color doppler suggestive of small ASD/stretched PFO of no hemodynamic significance given normal right ventricular size at age ___. Mildly dilated thoracic aorta. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Creon 12 4 CAP PO TID W/MEALS 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Lisinopril 40 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. NIFEdipine CR 60 mg PO DAILY 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 8. Pantoprazole 40 mg PO Q12H 9. Pravastatin 20 mg PO DAILY 10. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 11. Ciprofloxacin HCl 500 mg PO Q12H 12. Vancomycin Oral Liquid ___ mg PO BID 13. Ascorbic Acid ___ mg PO DAILY 14. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm 15. Ferrous Sulfate 325 mg PO DAILY 16. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg oral BID:PRN heartburn 17. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN indigestion 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 3. Enoxaparin Sodium 80 mg SC Q12H RX *enoxaparin 80 mg/0.8 mL 80 MG SC every twelve (12) hours Disp #*30 Syringe Refills:*0 4. Gabapentin 300 mg PO QHS take 100mg qAM and 100mg in afternoon and 300mg qHS RX *gabapentin 100 mg 3 capsule(s) by mouth at bedtime Disp #*90 Capsule Refills:*0 5. LOPERamide 2 mg PO QID:PRN diarrhea 6. LORazepam 0.5 mg PO Q8H:PRN anxiety RX *lorazepam 0.5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 7. OxyCODONE SR (OxyconTIN) 40 mg PO QAM RX *oxycodone [OxyContin] 20 mg 2 tablet(s) by mouth qAM Disp #*90 Tablet Refills:*0 8. OxyCODONE SR (OxyconTIN) 60 mg PO QPM 9. Simethicone 40-80 mg PO QID:PRN gas 10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*90 Tablet Refills:*0 12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 13. Ascorbic Acid ___ mg PO DAILY 14. Creon 12 4 CAP PO TID W/MEALS 15. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm 16. Ferrous Sulfate 325 mg PO DAILY 17. Fluticasone Propionate NASAL 1 SPRY NU DAILY 18. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg oral BID:PRN heartburn 19. Lisinopril 40 mg PO QHS 20. Multivitamins 1 TAB PO DAILY 21. NIFEdipine CR 60 mg PO DAILY 22. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 23. Pantoprazole 40 mg PO Q12H 24. Pravastatin 20 mg PO DAILY 25. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting RX *prochlorperazine maleate 10 mg 10 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 26. Vancomycin Oral Liquid ___ mg PO BID Discharge Disposition: Home Discharge Diagnosis: Sepsis/infection due to hepatobiliary source Acute on chronic anemia Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with fever and RUQ abdominal pain// ?cholecystitis ?stone ?cholangitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma nodular with innumerable hypoechoic masses consistent with known metastatic disease. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is mild intrahepatic biliary dilation primarily in the left lobe of the liver which may be secondary to malignant obstruction. The CHD measures 6 mm. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: There is a hypoechoic pancreatic head mass measuring 3.0 x 2.8 cm, better seen on prior CT. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Mild intrahepatic biliary dilatation, primarily in the left lobe of the liver which may be secondary to malignant obstruction. Common bile duct measures 6 mm. Innumerable hypoechoic masses in the liver consistent with known metastatic disease. Pancreatic head mass, better seen on prior CT. Patient status post cholecystectomy. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: ___ year old man with metastatic pancreatic cancer with recent cholangitis + ecoli bacteremia now presents with fever, please r/o biliary stricture or liver abscess// please r/o biliary stricture or liver abscess TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 7 mL Gadavist. COMPARISON: CT abdomen and pelvis ___, CTA abdomen and pelvis ___ FINDINGS: Lower Thorax: The lung bases are clear. There is no pleural effusion. Liver: Numerous T2 hyperintense hypoenhancing masses replacing much of the liver parenchyma have progressed in number and size compared to prior. For example, a hepatic segment VIII lesion measures 3.8 x 2.8 cm, previously 3.5 x 1.6 cm (series 5, image 13). All of these lesions demonstrate a similar morphology. There is associated peripheral hyperenhancement with these lesions, likely transient hepatic intensity differences. There is periportal edema, as well as edema within the porta hepatis, similar to prior CT, likely reflective of post treatment change. Biliary: Gallbladder is surgically absent. There are multifocal segmental areas of mild intrahepatic biliary duct dilation in the left lobe of the liver, most pronounced in hepatic segment ___ (series 5, image 15). Areas of intrahepatic biliary duct dilation are present in segment III and II (series 5, image 20, 18, 17). There is also thickening of the extrahepatic biliary duct wall. There is no biliary duct hyperenhancement or restricted diffusion to suggest cholangitis. Pancreas: Patient is status post Whipple. There is dilation of the pancreatic duct in the body and tail with an abrupt transition adjacent to a 4.0 x 3.3 cm hypoenhancing partially necrotic T2 intermediate intensity mass in the pancreatic body, unchanged from prior. Spleen: The spleen is normal in size and signal intensity. Adrenal Glands: The right and left adrenal gland are unremarkable. Kidneys: The kidneys enhance symmetrically. There are bilateral renal cysts measuring up to 3.5 x 3.4 cm in the left upper pole. There is a minimally complex cyst in the right lower pole measuring 1.0 x 1.3 cm. There is no hydronephrosis. Gastrointestinal Tract: There is no hiatal hernia. Views of the small and large bowel are unremarkable. Lymph Nodes: There are enlarged and necrotic mesenteric and retroperitoneal lymph nodes. Examples of enlarged necrotic retroperitoneal/mesenteric lymph nodes include unchanged 1.1 cm aortocaval and 1.2 cm mesenteric node (series 5, image 34, 37). Bilobed necrotic soft tissue nodule adjacent to the SMV/SMA causing narrowing but no occlusion of the the SMV measuring 3.2 x 2.2 cm is essentially unchanged compared to prior. Vasculature: The portal vein and hepatic veins are patent. Note is made of a somewhat small left portal vein, which remains patent. There is no abdominal aortic aneurysm. There is narrowing of the common hepatic artery secondary to the large pancreatic mass. The SMA is patent. As described above, the distal aspect of the SMA abuts the necrotic soft tissue mesenteric mass. Osseous and Soft Tissue Structures: There is no superficial soft tissue abnormality. There is no suspicious bony lesion. IMPRESSION: 1. Increased size and number of extensive hepatic metastases. Notably, all hepatic lesions demonstrate similar appearance although in the setting of diffuse metastatic disease the ability to completely exclude a small liver abscess is difficult. 2. Mild segmental areas of biliary duct dilation in the left hepatic lobe without MR evidence of cholangitis. The dilation is likely from obstruction by metastases. 3. No interval change to recurrent pancreatic mass, necrotic retroperitoneal and mesenteric lymphadenopathy, and mesenteric soft tissue mass adjacent to the SMV/SMA. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with pancreatic cancer, previous biliary infection treated with abx, now worsening// please eval for progressive ductal dilation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal ultrasound on ___, MRCP on ___ FINDINGS: LIVER: The hepatic parenchyma is again nodular with innumerable hypoechoic masses consistent with known metastatic disease. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: Mild intrahepatic biliary duct dilatation in the left hepatic lobe is not significantly changed. The CHD measures 5 mm. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 11.6 cm. KIDNEYS: Limited views of the bilateral kidneys show no hydronephrosis. Bilateral renal cysts, the largest measuring 4.2 cm in the right lower pole, are not significantly changed. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: No significant change in mild intrahepatic biliary duct dilatation in the left hepatic lobe. No extrahepatic biliary duct dilatation. Grossly unchanged innumerable hepatic metastases. Radiology Report EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL INDICATION: ___ year old man with new superficial thrombosis on left forearm.// Please eval for deeper clot, DVT in LUE TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial and cephalic veins are patent, compressible and show normal color flow and augmentation. There is occlusive thrombus throughout the left basilic vein. IMPRESSION: 1. Occlusive thrombus throughout the left basilic vein. 2. No evidence of deep vein thrombosis in the left upper extremity. Radiology Report EXAMINATION: MRCP INDICATION: ___ year old man with metastatic pancreatic cancer with recent cholangitis now with worsening fever, RUQ pain, cholangitis by exam, eval for biliary pathology, choledocholithiasis, need for stent or drainage TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. No intravenous contrast. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: MRCP ___ FINDINGS: Incomplete examination. LIVER: Again seen, are numerous metastatic lesions replacing the liver parenchyma, overall unchanged in size and number compared to recent prior MRI. No new lesions are identified. There is small volume ascites. BILIARY: Gallbladder is surgically absent. There is unchanged thickening of the extrahepatic common bile duct, as seen previously. Again seen is segmental biliary duct dilation that is mild in severity, most pronounced in the left lobe of the liver. There is also focal biliary duct dilation at the hepatic dome. Overall, intrahepatic biliary duct dilation is unchanged in severity and extent compared to the recent prior examination. PANCREAS: Patient is status post Whipple. Again seen is in ill-defined partially necrotic mass in the pancreatic body resulting in pancreatic upstream severe pancreatic duct dilation. There is atrophy of the pancreatic body and tail, as seen previously. Soft tissue mass mass adjacent to the SMV and enlarged retroperitoneal/mesenteric lymph nodes that are also stable. SPLEEN: The spleen is normal in size and signal intensity. ADRENALS: The right and left adrenal glands are unremarkable. KIDNEYS: There are bilateral simple renal cysts with the largest exophytic cyst on the right measuring 4.6 cm. There is no hydronephrosis. VASCULATURE: Flow voids are preserved. Unable to evaluate vessels adequately secondary to no intravenous contrast. OSSEOUS STRUCTURES: There is no superficial soft tissue abnormality. There is no suspicious bony lesion. IMPRESSION: 1. Despite incomplete examination, there is no significant interval change compared to the recent MRCP from ___ including to the extensive hepatic metastases, recurrent pancreatic mass, lymphadenopathy, and soft tissue mass adjacent to the SMV. 2. Unchanged severity of mild segmental areas of intrahepatic biliary duct dilation, most pronounced in the left lobe, likely a result of obstruction from hepatic metastases. Radiology Report EXAMINATION: US NECK, SOFT TISSUE INDICATION: ___ year old man with right neck pain. Please eval IJ/EJ for clot, and for soft tissue masses, lymphadenitis, or fluid collection. TECHNIQUE: Grey scale and Doppler evaluation was performed on the soft tissues of the right neck in the region of swelling and pain, as indicated by the patient. COMPARISON: Left upper extremity ultrasound from the prior day. FINDINGS: There is normal flow with respiratory variation in the bilateral subclavian veins. At the site of right neck swelling and pain as indicated by the patient, there is occlusive thrombus within the right internal jugular vein, which is noncompressible and expanded. The imaged right subclavian vein is patent. IMPRESSION: Occlusive thrombus within the noncompressible right internal jugular vein, at the site of right neck pain and swelling, as indicated by the patient. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 09:59 on ___, 2 minutes after discovery. Radiology Report EXAMINATION: CTA CHEST INDICATION: ___ year old man with known new IJ clot- c/o sudden onset sensation of being unable to breathe. Evaluate for pulmonary embolism. 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.6 mGy (Body) DLP = 2.7 mGy-cm. 3) Spiral Acquisition 5.5 s, 35.5 cm; CTDIvol = 6.0 mGy (Body) DLP = 208.2 mGy-cm. Total DLP (Body) = 213 mGy-cm. COMPARISON: Chest CT of ___. MRCP from the same day FINDINGS: The aorta and its major branch vessels are patent. The known right internal jugular venous clot is not well assessed on current exam, however the vein appears expanded reflecting the known thrombosis. Compared with the prior study, there are new filling defects in bilateral lobar pulmonary arteries, compatible with acute pulmonary emboli (5: 51, 79, 81, 88). There is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. There unchanged subcentimeter right thyroid nodules. There is no evidence of pericardial effusion. There is no pleural effusion. There is mild bibasilar atelectasis. Subpleural less than 4 mm nodules along the right major fissure are stable. The airways are patent to the subsegmental level. Limited images of the upper abdomen are notable for numerous hepatic metastases, better characterized on the MRCP from the current day. No aggressive osseous lesions demonstrated. Calcified loose bodies in the glenohumeral joints are partially seen. IMPRESSION: 1. New filling defects in bilateral lobar pulmonary arteries, compatible with acute pulmonary emboli. No evidence of right heart strain. 2. Numerous hepatic metastases are better characterized on the MRCP from the same day.Known right IJ thrombus reflected by expansion of the vein. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 16:52 on ___, 2 minutes after discovery. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old man with known new IJ clot- c/o sudden onset sensation of something being stuck around throat and being unable to breathe.// ? mass/ obstruction TECHNIQUE: Imaging was performed without contrast administration. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.7 s, 30.2 cm; CTDIvol = 7.1 mGy (Body) DLP = 208.5 mGy-cm. Total DLP (Body) = 209 mGy-cm. COMPARISON: None. FINDINGS: Evaluation of the aerodigestive tract demonstrates no mass and no areas of focal mass effect. Dental amalgam limits evaluation in the surrounding area. Within this limitation: The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears normal. There is no lymphadenopathy by CT criteria. There is no flow in the right internal jugular vein, with hypodense clot seen surrounded by enhanced wall. There is extensive surrounding fluid which extends anteriorly to the thyroid gland and posteriorly into the retropharyngeal space and crosses the midline. The fluid is also seen extending in the prevertebral space from C2 to the lower margin of C4 and upper margin of C5. The remaining vessels of the neck appear patent. A central venous catheter is partially visualized. The imaged portion of the lung apices are clear. There are no osseous lesions. IMPRESSION: 1. Right-sided internal jugular clot with extensive surrounding fluid which extends as far anterior as the thyroid gland and posteriorly into the retropharyngeal space, crossing the midline. The fluid extends in the prevertebral space from C2 to C5. RECOMMENDATION(S): The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:14 pm, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with IJ vclot, pancreatic cancer// brain met eval pre-AC TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP = 752.0 mGy-cm. Total DLP (Head) = 752 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema,or mass. Incidental note is made of cavum velum interpositum. There is prominence of the ventricles and sulci suggestive of involutional 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: 1. No evidence of hydrocephalus or intracranial hemorrhage. Radiology Report INDICATION: ___ year old man with biliary obstruction and persistent fevers// PTBD COMPARISON: ___ MRCP. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: General anesthesia was administered by the anesthesiology department. MEDICATIONS: Please refer to anesthesia record. Ceftriaxone was given pre-procedure as antibiotic prophylaxis. CONTRAST: 25 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 6.7 min, 41 mGy PROCEDURE: 1. Transabdominal ultrasound. 2. Ultrasound and Fluoroscopic guided right percutaneous transhepatic bile duct access. 3. Right cholangiogram 4. Ultrasound fluoroscopic guided attempts to obtain left percutaneous transhepatic bile duct access. 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 and mid abdomen was prepped and draped in the usual sterile fashion. Under Ultrasound and Fluoroscopic guidance, a 21G Cook needle was advanced into the rightbiliary system. Images of the access were stored on PACS. Gentle injection of dilute contrast opacified the biliary system, with rapid transit through the central biliary ducts into the duodenum. No central biliary obstruction was identified. Subsequently, using ultrasound and fluoroscopic guidance, multiple attempts were made to access the left biliary system using a 21 gauge Cook needle. Given the nondilated biliary system, successful access was unable to be obtained. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: Normal percutaneous cholangiogram of right and central bile ducts with brisk drainage into bowel. No dilated bile ducts identified on ultrasound. Extensive intrahepatic metastases. IMPRESSION: Successful percutaneous transhepatic cholangiogram via a right-sided approach. No central biliary obstruction was identified. No biliary drain placed. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with Fever, unspecified temperature: 100.1 heartrate: 97.0 resprate: 15.0 o2sat: 98.0 sbp: 140.0 dbp: 64.0 level of pain: 1 level of acuity: 3.0

Mr. ___, You were admitted with fever likely due to hepatobiliary source in setting of your cancer, which is now the second similar recent infection in the past month. You were treated with antibiotics with good control of the infection. The interventional radiology team took pictures that did not show evidence of bile duct blockage. You also developed anemia requiring blood transfusions. Although you may have some anemia in the setting of your cancer this acute drop is likely the setting of infection, which should improve over the next couple weeks. Dr. ___ will continue to follow your numbers. You will follow up with Dr. ___ to determine when to resume chemotherapy. Please take all medications as prescribed and keep all scheduled doctor's appointments. Seek medical attention if you develop a worsening or recurrence of the same symptoms that originally brought you to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern you. We discussed risks of combining opiates with benzo diazepines and described not driving for the time being. We discussed taking the lowest effective dose and not combining with alcohol. We started a blood thinner, lovenox injections to treat blood clots. It was a pleasure taking care of you! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: paper tape / Tegaderm / Triple Antibiotic Ointment Attending: ___. Chief Complaint: Tunneled HD line accidental removal Major Surgical or Invasive Procedure: ___ tunneled hemodialysis line placement History of Present Illness: Ms. ___ is a ___ with ESRD (MWF sessions) secondary to HTN versus hepatitis C, and previous CVA who presents because she accidentally removed her tunneled HD line in her sleep last night and she has no current suitable HD access. She was recently admitted to ___ ___ with a staph epidermidis HD catheter related blood stream infection that was treated with line removal, holiday, and replacement, followed by 4 weeks of vancomycin with HD ending on ___ (she sadly missed many of her OPAT appointments). Prior to that she was hospitalized from ___ with a Pantoea species catheter-related BSI that required several weeks of ceftazidime QHD. She has a poor followup compliance record- for this reason it was felt that she needed inpatient admission for line replacement and HD. She has a complicated HD access history- She had a left upper arm AV fistula that required multiple interventions and ultimately thrombosed and was non-salvageable. A right brachiobasilic fistula was created in ___ by Dr. ___, ___ the procedure to superficialize it was delayed due to frequent hospitalizations for blood stream infections. It was finally accomplished on ___. In the ED, initial vitals were 97.8 78 137/79 17 98% ra. There was no bleeding or erythema of the previous catheter site. Transplant surgery evaluated the fistula site because it was erythematous but concluded it was a local reaction possibly from tape. She was admitted for ___ placement of the HD tunneled line. ROS: per HPI, denies 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: HCV ESRD on HD since ___ Asthma HTN - resolved after weight loss (not on meds now) gout - on allupurinol, no attacks in ___ years. CVA at age ___. Residual visual def. AV-fistula ___. Was going to be superficialized in ___ (delayed because of line infection) Social History: ___ Family History: Mom - stroke @ ___ Dad - dies of "old age" No DM, early MI Physical Exam: PHYSICAL EXAMINATION: VS: 98.1 152/89 77 18 100% RA GENERAL: Well appearing F NAD. Comfortable, HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender to palpation. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ ___ bilaterally to knees. Pertinent Results: ___ 11:00AM BLOOD WBC-7.1 RBC-3.70* Hgb-10.8* Hct-32.9* MCV-89 MCH-29.2 MCHC-32.9 RDW-15.7* Plt ___ ___ 05:15AM BLOOD ___ PTT-28.5 ___ ___ 11:00AM BLOOD Glucose-95 UreaN-77* Creat-5.4* Na-139 K-4.3 Cl-107 HCO3-17* AnGap-19 ___ 11:00AM BLOOD Calcium-8.2* Phos-5.7* Mg-2.1 ___ 06:00AM BLOOD Vanco-13.1 ___ 03:35PM BLOOD Vanco-19.1 ___ 05:55AM BLOOD Vanco-15.6 ___ 05:15AM BLOOD Vanco-15.1 . ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTURE NOT PROCESSED INPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGINPATIENT ___ VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL {ENTEROCOCCUS SP.}-carrier Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Cinacalcet 30 mg PO QHS 5. Mirtazapine 15 mg PO HS 6. Bactroban *NF* (mupirocin;<br>mupirocin calcium) 2 % Topical QHD Apply to the exit site of dialysis catheter after each dialysis. 7. Vancomycin 1500 mg IV HD PROTOCOL Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath RX *albuterol 2 puffs Q6H:PRN Disp #*1 Inhaler Refills:*2 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. Mirtazapine 15 mg PO HS RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 4. CefTAZidime 1 g IV QHD LAST DOSE ___ RX *ceftazidime-dextrose (iso-osm) [Fortaz in D5W] 1 gram/50 mL following HD on MWF Disp #*3 Bag Refills:*0 5. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*2 6. Bactroban *NF* (mupirocin;<br>mupirocin calcium) 2 % Topical QHD Apply to the exit site of dialysis catheter after each dialysis. RX *mupirocin [Bactroban] 2 % Apply to the exit site of dialysis catheter after each dialysis QHD Disp #*1 Tube Refills:*2 7. Cinacalcet 30 mg PO QHS RX *cinacalcet [Sensipar] 30 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: -Accidental removal of HD line -HCV -ESRD on HD since ___ -Asthma -HTN - resolved after weight loss (not on meds now) -gout - on allupurinol, no attacks in ___ years. -CVA at age ___. Residual visual def. -AV-fistula ___. superficialized ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ female with end-stage renal disease and complicated access history, now status post accidental removal of the hemodialysis line from the left side, please replace. PHYSICIAN: ___, M.D., fellow, performed the procedure. ___, M.D., attending, was present and supervising the procedure. MEDICATIONS: Moderate sedation was provided by administering divided doses of fentanyl totalling 175 mcg and Versed totaling 3.5 mg throughout the total intraservice time of 25 minutes, during which the patient's hemodynamic parameters were continuously monitored. PROCEDURE: Replacement of left IJ tunneled hemodialysis line through existing tract. PROCEDURE DETAILS: Informed consent was obtained from the patient. She was positioned supine. The area was prepped and draped in sterile fashion. A timeout was performed. Fluoroscopy was used intermittently. Local anesthesia was applied. A micropuncture sheath was gently inserted into the tunnel exit site, and local anesthesia was injected through this as well. We then gently probed with a 0.018 wire through the micropuncture sheath to enter into the venous structures. Over this wire, we then used the AccuStick sheath, and with this sheath tip in the venous structures, we removed the inner stiffener and the 0.018 wire and then placed a 0.035 wire all the way into the inferior vena cava to confirm venous placement. We then performed serial dilation over this wire and placed the peel-away sheath for the new catheter over this wire through the tunnel, the tip of which was in the superior vena cava. The new 27-cm tip-to-cuff length hemodialysis catheter had been soaked in antibiotic solution. This was also flushed. This was then pushed through the peel-away sheath to have its tip in the right atrium. It was secured to the skin with suture and covered with an appropriate dressing. Both lumens aspirated and flushed very easily. Heparin was left dwelling in the line. The position was documented on the fluoroscopic scout image. There were no complications. CONCLUSION: Uncomplicated replacement of tunneled hemodialysis line through the existing tract into the left internal jugular vein, tip in the right atrium, 27-cm tip-to-cuff length. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: CHEST CATHETER PULLED OUT Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS temperature: 97.8 heartrate: 78.0 resprate: 17.0 o2sat: 98.0 sbp: 137.0 dbp: 79.0 level of pain: 0 level of acuity: 3.0

Ms. ___: Please bring this documentation with you to dialysis, so that they may also review your recent medical history. It was a pleasure to take care of you here at ___. You were admitted to the hospital because of an accidental removal of your tunneled hemodialysis line, which is necessary for dialysis. While here, we continued you on antibiotics including an additional dose of vancomycin (to complete treatment for your previous blood stream infection) as well as cefepime and ceftazidime because of erythema (redness) around your fistula site on your right arm. This erythema may have been a simple tape reaction, but given the importance of the fistula, antibiotics were applied. Once you received antibiotics and blood cultures remained negative, you received another hemodialysis line placement via interventional radiology with plan to resume normal dialysis. We are discharging you with a plan to resume normal hemodialysis treatment. We would also like you to receive ceftazidime for a week to continue treatment for potential infection around the fistula site. You no longer need to be treated with IV vancomycin or vancomycin dwells in the catheter, as you have completed this treatment regimen. Changes to your medication regimen include: -discontinue vancomycin -start ceftazidime with HD as prescribed

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Haldol Attending: ___. Chief Complaint: L2 compression fracture after fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ year-old woman who was transferred from ___ after a CT torso showed evidence of an L2 vertebral fracture following a fall. According to Ms. ___, she was having a "heated" conversation on the train platform in ___ when she fell backwards and landed on her back. She stood up after the fall and was able to walk some distance, before police picked her up and took her to ___. She reports no weakness, no sensory loss and no radiating pain. She has had no incontinence since the fall, and has noticed only the pain which is just in her lower back at this time. She states that she had a small amount of alcohol that evening, and that she had recently started using IV heroin in the past few days. EtOH level at OSH was 48. Past Medical History: hx of IV drug abuse Social History: ___ Family History: Mother - she reports she died from a heroin overdose Father - unknown Physical ___: ___ at the time of admission Exam: 99 86 124/77 18 97% ra General: drowsy but easily aroused by voice, cooperative, complianing of lower back pain. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes Rectal: normal sphincter tone Neurologic: Mental Status: alert and oriented to place date and name. Language fluent with some mild dysarthria with no paraphasias, normal repetition and able to follow complex commands. Memory of recent events inact. Cranial Nerves: pupils small at 1mm b/l and minimally reactive to light. EOMI w/out nystagmus. Fields full to confrontation. Sensation intact to pinprick b/l, face symmetric, hearing intact to fingerrub b/l, tongue movements rapid and normal. Motor: no pronator drift, full strength in upper and lower extremities Sensory: intact to pinprick throughout with intact proprioception at toes b/l Reflexes: symmetric and normal throughout with flexion toes b/l Coordination: intact FNF and HTS b/l Gait: unable to ambulate due to back pain and level of sedation On the day of discharge: neurologically intact Pertinent Results: Radiology Report MR ___ SPINE W/O CONTRAST Study Date of ___ 2:02 AM IMPRESSION: 1. Transitional anatomy at the lumbosacral junction with partial lumbarization of the first sacral segment and numbering schema, as above. 2. Acute compression fracture of the superior endplate of L2 with roughly 50% loss of height, anteriorly, and 5 mm retropulsion of its dorsal cortex; while this narrows the ventral canal, effacing the thecal sac, there is no definite impingement upon the conus medullaris or the proximal cauda equina nerve roots. 3. L5-S1: Disc degeneration with bulging and L5 inferior endplate spondylosis, eccentric to the left with neural foraminal narrowing, but no definite exiting L5 neural impingement. COMMENT: Preliminary interpretation of "L2 compression fracture. Minimal retropulsion, indents thecal sac, but no spinal cord compression or neural foraminal narrowing." was posted to PACS by Dr. ___ at the time of the study. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: L2 compression fracture Discharge Condition: neurologically intact Followup Instructions: ___ Radiology Report EXAMINATION: Lumbar spine without contrast, ___. HISTORY: ___ female status post fall with L2 compression fracture with mild retropulsion (seen on CT torso). TECHNIQUE: Routine ___ non-enhanced study with sagittal STIR FSE sequence. FINDINGS: The study is compared with the prompting CECT of the torso (___) obtained some six hours earlier. There is transitional anatomy at the lumbosacral junction with partial lumbarization of the first sacral segment. Based on numbering from the most caudal rib-bearing thoracic vertebral body, the vertebra, bearing the iliolumbar ligaments is numbered "L5." Using this schema, the thecal sac terminates at the S2-3 level. As on the prompting study, there is a markedly abnormal appearance to the L2 vertebral body which demonstrates relatively uniform STIR-hyperintensity representing marrow edema centered about a low-signal fracture line involving the superior endplate. There is anterior wedge deformity with approximately 50% loss of height, compared to its neighbors. There is 5 mm retropulsion of the superior aspect of the dorsal cortex which slightly narrows the ventral canal, effacing that aspect of the thecal sac, with no definite impingement upon the proximal nerve roots of the cauda equina. There is only mild kyphosis centered at this level. The conus medullaris is normal in morphology and terminates immediately rostral to this site, at the L1-L2 level. The remaining lumbar vertebrae demonstrate relatively uniform slight T1-hypointensity, which may represent red marrow reconversion in response to anemia (in a patient of this age and gender). Otherwise, there is only relatively mild focal STIR-hyperintensity involving the right and left lateral aspects of the L5 inferior and S1 superior endplates, representing ___ I discogenic change related to degeneration of that intervening disc. There is mild bulging, eccentric to the left which, with inferior endplate spondylosis, narrows the caudal aspect of both neural foramina, without definite exiting L5 neural impingement. The lumbar intervertebral discs are otherwise preserved in height and in signal intensity. The paraspinal and limited included retroperitoneal soft tissues are unremarkable. IMPRESSION: 1. Transitional anatomy at the lumbosacral junction with partial lumbarization of the first sacral segment and numbering schema, as above. 2. Acute compression fracture of the superior endplate of L2 with roughly 50% loss of height, anteriorly, and 5 mm retropulsion of its dorsal cortex; while this narrows the ventral canal, effacing the thecal sac, there is no definite impingement upon the conus medullaris or the proximal cauda equina nerve roots. 3. L5-S1: Disc degeneration with bulging and L5 inferior endplate spondylosis, eccentric to the left with neural foraminal narrowing, but no definite exiting L5 neural impingement. COMMENT: Preliminary interpretation of "L2 compression fracture. Minimal retropulsion, indents thecal sac, but no spinal cord compression or neural foraminal narrowing." was posted to PACS by Dr. ___ at the time of the study. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall, ETOH, Lower back pain Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL temperature: 99.0 heartrate: 86.0 resprate: 18.0 o2sat: 97.0 sbp: 124.0 dbp: 77.0 level of pain: 13 level of acuity: 3.0

L2 compression fracture •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. •Have a friend or family member check your incision daily for signs of infection. •You are required to wear TLSO back brace whenever you are sitting up or out of bed. •You may shower briefly without the back brace; unless you have been instructed otherwise. •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. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. •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. •Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. •Fever greater than or equal to 10.5° F. •Any change in your bowel or bladder habits (such as loss of bowl or urine control).

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Shellfish / Norvasc / Univasc / lisinopril Attending: ___ Chief Complaint: ICD shock, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with infarct-related cardiomyopathy and subsequent history of monomorphic VT s/p substrate ablation in ___ (with appropriate ICD shock in ___ who presents following 2 ICD shocks earlier this morning. He was on his way to a clinic appointment when he was climbing up stairs and felt a shock. A few minutes later he sat down and felt additional shock. He was experiencing dyspnea on exertion at the time but denies any cp, lh, dizziness, or sensation of palpations. He dyspnea on exertion has been progressive over the last ___ months and is thought to be secondary to amio toxicity vs. COPD. He recently had f/up PFTs demonstrating mild COPD. He was started on tiotropium earlier this week. A CTA chest did not show any abnormalities. He has had a chronic cough over this time thought to be ___ post nasal drip which has somewhat improved with flonase. He has had intermittent sputum production but denies any recent sf, chills, or sweats. In the ED intial vitals were: 97.5 74 121/82 16 96% 2L Nasal Cannula. Labs were all at baseline aside from slight pump in trop to .03. He was seen by EP who recommended stopping amio and admitting him to possibly start new antiarrythmic. He was found to have VT on interrogation and have an appropriate shock. He as also one sequence of AVT. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS:coronary artery disease s/p inferolateral MI in ___, s/p LCx PCI with no progressive coronary disease on angiography ___ - PACING/ICD: -s/p primary prevention ___ ICD placed in ___ after EP study positive for inducible VT; Fidelis lead working well -monomorphic VT, s/p VT substrate ablation in inferoapical scar region in ___, on amiodarone for ___ years 3. OTHER PAST MEDICAL HISTORY: infarct-related cardiomyopathy with LVEF 30% (inferior and lateral hypokinesis) OSA AAA s/p repair Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: 97.5 74 121/82 16 96% 2L HEENT: no conjunctival pallor. No icterus. Dry mucous membranes NECK: Supple, JVD not noted CV: regular rhythm with normal S1/S2, I/VI holosystolic murmur at apex LUNGS: clear to ascultation bialterally ABD: soft, nontender, AAA scar on abdomen, no hepatomegaly EXT: no edema, warm, DP 2+ bilaterally DISCHARGE EXAM: VS:98.1 99-110/58-64 ___ 18 93/2L HEENT: no conjunctival pallor. No icterus. Dry mucous membranes NECK: Supple, JVD not noted CV: regular rhythm with normal S1/S2, I/VI holosystolic murmur at apex LUNGS: clear to ascultation bialterally ABD: soft, nontender, AAA scar on abdomen, no hepatomegaly EXT: no edema, warm, DP 2+ bilaterally Pertinent Results: ADMISSION LABS: ___ 05:40PM BLOOD WBC-4.3 RBC-4.26* Hgb-14.2 Hct-43.0 MCV-101* MCH-33.3* MCHC-33.0 RDW-14.0 Plt ___ ___ 05:40PM BLOOD Neuts-55.4 ___ Monos-11.1* Eos-10.4* Baso-1.7 ___ 05:40PM BLOOD Glucose-103* UreaN-24* Creat-1.1 Na-141 K-4.0 Cl-109* HCO3-24 AnGap-12 ___ 05:55PM BLOOD cTropnT-0.03* ___ 05:40PM BLOOD Calcium-9.4 Phos-3.5 Mg-2.0 DISCHARGE LABS: ___ 05:45AM BLOOD WBC-4.8 RBC-4.15* Hgb-14.2 Hct-41.4 MCV-100* MCH-34.2* MCHC-34.3 RDW-13.3 Plt ___ ___ 05:45AM BLOOD Glucose-87 UreaN-22* Creat-1.2 Na-140 K-3.9 Cl-107 HCO3-26 AnGap-11 CXR ___ IMPRESSION: Similar to findings as compared to prior chest radiograph, perhaps increased opacity along the left lateral mid to lower lung. Central opacities may be in part due to underlying pulmonary edema; however, there may also be a component of amiodarone toxicity or cryptogenic organizing pneumonia as described on the recent prior chest CT. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. QUEtiapine Fumarate 25 mg PO QHS 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Amiodarone 200 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Atorvastatin 40 mg PO HS 8. Nitroglycerin SL 0.4 mg SL PRN chest pain 9. Ibuprofen 800 mg PO QAM 10. Ibuprofen 600 mg PO QHS 11. Aspirin 81 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. omega 3-dha-epa-fish oil unknown dosage oral daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO HS 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Losartan Potassium 25 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN chest pain 6. QUEtiapine Fumarate 25 mg PO QHS 7. Tiotropium Bromide 1 CAP IH DAILY 8. Ibuprofen 800 mg PO QAM 9. Ibuprofen 600 mg PO QHS 10. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet by mouth daily Disp #*30 Tablet Refills:*0 11. Vitamin D 1000 UNIT PO DAILY 12. Home oxygen Please provide 2Liter via NC home oxygen, continuous, pulsed dose for poratbility, RA sat 87% Dx COPD 13. omega 3-dha-epa-fish oil 0 dosage ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - recurrent ventricular tachycardia, ICD Secondary diagnoses: - COPD - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest, frontal and lateral views. CLINICAL INFORMATION: Dyspnea. ___. FINDINGS: Frontal and lateral views of the chest were obtained. Dual-lead left-sided AICD is again seen, unchanged in position. Cardiac and mediastinal silhouettes are stable. Haziness of the hila with perihilar opacities are again seen, somewhat similar to prior, which may be due to pulmonary edema; however, as also noted on the prior, amiodarone toxicity is also in the differential. Bibasilar and peripheral right mid lung and left mid to lower lung opacities are again seen, as was also the case on the prior study. Mediastinal and hilar lymph nodes seen on chest CT from ___ are better assessed on that study. There is no large pleural effusion or evidence of pneumothorax, but there may be trace fluid tracking along a fissure. IMPRESSION: Similar to findings as compared to prior chest radiograph, perhaps increased opacity along the left lateral mid to lower lung. Central opacities may be in part due to underlying pulmonary edema; however, there may also be a component of amiodarone toxicity or cryptogenic organizing pneumonia as described on the recent prior chest CT. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Dyspnea, DEFIB FIRE X 2 Diagnosed with PAROX VENTRIC TACHYCARD, DUE TO OTHER CARDIAC DEVICE,IMPLANT,GRAFT, ABN REACT-ARTIF IMPLANT, HYPERTENSION NOS temperature: 97.5 heartrate: 74.0 resprate: 16.0 o2sat: 96.0 sbp: 121.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was our pleasure participating in your care here at ___. You were admitted after having an irregular heart rhythm causing your ICD to fire. Your ICD was reprogrammed while you were here. Please do not drive a vehicle for the next week. You should call your cardiologist to discuss when you can restart driving. Please make sure to see your new medication list. You will need to stop taking the amiodarone and take a higher dose of your metoprolol. Again, it was our pleasure participating in your care. We wish you the very best, -- Your ___ Medicine 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: Abnormal Labs, Presyncope Major Surgical or Invasive Procedure: EGD/Colonoscopy ___ History of Present Illness: ___ man with a past medical history significant for NSTEMI (2 LAD DES on ___ and recent diagnosis of beta thalassemia trait, transferred from ___ for evaluation of presyncope, anemia and leukocytosis. The patient has been in his usual state of health up until the day prior to admission. He was on the bus commute home from work, and felt cold and clammy. He initially attributed this to the air conditioning on the bus. Then, he was walking home from the bus stop, a 0.5 mile walk that usually takes him 15 minutes, and he felt lightheaded. The walk took him 45 minutes as he felt weak and lightheaded. No other associated symptoms. No palpitations, chest pain, nausea, shortness of breath, or incontinence. No falls. When he arrived home, he went straight to bed. Woke up 3 hours later and his wife was concerned for tactile fever. Gave him 2 Tylenol and he went back to sleep. He awoke at 3 am and called out to her as he felt lightheaded again. He then went back to sleep. On the morning of the day of admission, he reports that he felt lightheaded again, this time with clammy extremities. ___ daughter, ___ ___ from the ___, came over to take his BP. He was mildly hypotensive with HR ___, SBP ___. He had very little to eat or drink in the last 24 hours. He then went to the ___ to be evaluated. When he presented to Urgent Care, there was concern for cardiac etiology given his previous history of NSTEMI and anginal equivalent of diaphoresis. EKG without overwhelming concerning signs of ischemia, troponin negative. However, he was found to have a hgb of 7.6 and to have a leukocytosis up to 17. He was therefore transferred to the ___ ED for further evaluation and management. - In the ED, initial vitals were: 98.0 86 122/84 18 98% RA - Exam was notable for: Gen: Middle-aged man, seen sitting comfortably Pulm: CTAB no WRR, unlabored breathing CV: RRR no MRG HEENT: Dry mucous membranes, PERRLA, EOMI, no scleral icterus Abdomen: Soft NTND, no rebound tenderness Extremities: FROM in all 4 extremities, 2+ pulses peripherally, no significant edema Skin: Warm, dry and intact Neuro: No gross neurologic deficits, alert and oriented, moves all extremities no obvious facial abnormalities Rectal exam: Normal rectal tone. Black stool, no gross blood, guaiac positive - Labs were notable for: 7.6 17.1 > ------- < 197 24.4 137 | 109 | 48 --------------- < 108 4.3 | 19 | 1.1 Ca: 8.9 Mg: 2.1 P: 3.0 Lactate:1.4 Trop-T: <0.01 blood cx, urine cx pending - Studies were notable for: EKG new ectopic atrial rhythm, QTC ~400, T wave inversion in anterolateral leads CXR ___ IMPRESSION: No acute intrathoracic process. - The patient was given: IV Pantoprazole 40 mg 2 L IVF On arrival to the floor, the patient endorses the above history. Additionally, he reports that he has been in very good health. He does report use of antibiotics at the beginning of ___ for 5 days, after his wife was diagnosed with PNA and he did have some cough as well. He did not have fever. He has been taking all of his medications as directed. He hasn't missed a dose. He has continued his daily excessive and smoking cessation from ___. Other than that, he has been feeling very well. He denies PND, orthopnea, palpitations, and leg edema. He has had no other episodes of lightheadedness. He has no muscle aches. He denies cough, dysuria, melena, BRBPR, GERD-symptoms, headaches, visual changes. Bowel movements have been regular. He endorses a decreased appetite over the last few 24 hours. Past Medical History: + NSTEMI (2 LAD DES on ___ + beta thalassemia trait + s/p cholecystectomy. + colonoscopy at ___ : (___) reportedly normal, was told to return in ___ years Social History: ___ Family History: Father in ___, recently diagnosed with Type A aortic dissection. No family history of early MI No family history of sudden cardiac death. Daughters and wife have beta thalassemia trait Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 1842 Temp: 98.0 PO BP: 120/77 HR: 90 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVD not elevated. No carotid bruit appreciated CARDIAC: rrr no m/r/g. LUNGS: cta bilaterally BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Warm. SKIN: No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM =========================== VITALS:24 HR Data (last updated ___ @ 2309) Temp: 98.1 (Tm 98.2), BP: 150/92 (117-150/75-92), HR: 75 (62-75), RR: 19 (___), O2 sat: 97% (96-98), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: rrr no m/r/g. LUNGS: cta bilaterally ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Warm. SKIN: grossly normal NEUROLOGIC: grossly normal Pertinent Results: ADMISSION LABS =================== ___ 03:15PM BLOOD WBC-17.1* RBC-3.53* Hgb-7.6* Hct-24.4* MCV-69* MCH-21.5* MCHC-31.1* RDW-16.1* RDWSD-39.1 Plt ___ ___ 03:15PM BLOOD Glucose-108* UreaN-48* Creat-1.1 Na-137 K-4.3 Cl-109* HCO3-19* AnGap-9* ___ 05:29PM BLOOD Lipase-31 ___ 05:29PM BLOOD cTropnT-<0.01 ___ 03:15PM BLOOD cTropnT-<0.01 ___ 03:15PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 Iron-236* ___ 03:15PM BLOOD calTIBC-257* Ferritn-692* TRF-198* ___ 05:44PM BLOOD Lactate-1.4 DISCHARGE LABS =================== ___ 01:11PM BLOOD WBC-11.1* RBC-3.59* Hgb-8.5* Hct-26.8* MCV-75* MCH-23.7* MCHC-31.7* RDW-19.9* RDWSD-51.8* Plt ___ ___ 05:03AM BLOOD Glucose-99 UreaN-15 Creat-1.1 Na-144 K-4.2 Cl-116* HCO3-19* AnGap-9* IMAGING ============ COLONOSCOPY ___ - Normal mucosa was noted in the whole colon and 2cm into the terminal ileum - Medium non-bleeding internal hemorrhoids were noted EGD ___ ESOPHAGUS A small hiatal hernia was seen Normal mucosa was noted in the whole esophagus STOMACH Normal mucosa was noted in the whole stomach. Multiple cold forceps biopsies were performed for histology in the stomach. DUODENUM Normal mucosa was noted in the whole examined duodenum. Multiple cold forceps biopsies were performed for histology. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with cough fever leukocytosis// PNA COMPARISON: Prior CT of the chest from ___ and chest radiograph from ___ FINDINGS: PA and lateral views of the chest provided. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Gender: M Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: Abnormal labs, Dizziness, Presyncope Diagnosed with Anemia, unspecified temperature: 98.0 heartrate: 86.0 resprate: 18.0 o2sat: 98.0 sbp: 122.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, WHY WAS I ADMITTED TO THE HOSPITAL? ====================================== - You were having chills, and low blood pressure and we were worried you were having a GI bleed. WHAT HAPPENDED WHILE I WAS IN THE HOSPITAL? ============================================== - You had a colonoscopy and EGD that did not show any signs of bleeding in your GI tract so the GI doctors recommend that ___ have a capsule study. - We noticed that your iron levels were high. We recommend that you follow up with your hematologist to see if this is related to your beta thalassemia. We are scheduling this appointment for you. - We spoke with your cardiologist, Dr. ___ recommended that you do not take your ticagelor until you follow up with him. WHAT SHOULD I DO WHEN I GO HOME? =================================== - Please take your medications as directed. - Please go to all of your appointments listed below. Take care, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Somatostatin / Compazine / Meperidine / Percocet / Bactrim / Fentanyl / OxyContin / Paxil / Demerol / Droperidol / Lactose / Barium Sulfate / Iodine-Iodine Containing / Pantoprazole / Omeprazole / Codeine / Sulfa (Sulfonamide Antibiotics) / tramadol / Lovenox / Ambien / ondansetron / Dilaudid / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin Attending: ___. Chief Complaint: Partial small bowel obstruction Major Surgical or Invasive Procedure: PICC line insertion Rt arm ___ (for difficult access) History of Present Illness: ___ with PMHx of chronic abdominal pain, hepatitis C Ab positivity (without detected viral load), sclerosing mesenteritis (s/p multiple abdominal surgeries), multiple small bowel obstruction, chronic anemia, and line-associated DVT (on rivaroxaban), with recent admission to ___ ICU for sepsis, altered mental status, and liver failure who presents to the ___ ED this evening with symptoms of obstruction. The patient reports that she began to experience severe sharp epigastric/left-sided periumbilical pain last night. She reports that the pain would worsen after PO intake and was felt to be progressing. She reports that her pain is very similar to her previous bowel obstructions. She reports that her last bowel movement was ___ morning, which is unusual for her as she normally has multiple loose stools every day. She has also not passed any flatus today. She denies any associated fevers, chills, chest pain, shortness of breath, or changes in her sensorium. Past Medical History: - sclerosing mesenteritis (dx'd in ___, s/p multiple abdominal surgeries, including placement of decompressive G-tube) - chronic SBO - chronic GI dysmotility - IBS - NSAID-related gastritis and UGI bleed - Hepatitis C (transmitted via transfusion in ___ - GERD - Esophagitis - multiple LOAs - colonic decompressions - small bowel resections - parts of duodenum, entire ileum - repair of incisional hernias - appendectomy - open CCY - G-tube placement ___ - report of recent removal - extraction of duodenal bezoar - multiple port-a-cath placements and removals - recurrent DVTs, line associated - anemia of chronic disease - mitral valve prolapse - asthma - chronic tachycardia (HR in the 120s) - nocturnal benign myoclonus - migraine HAs w/ visual aura - "seizures" - whole body twitching previously characterized as pseudoseizures - depression - osteopenia - sjogren's syndrome - history of stroke - hypothyroidism - hypercalcemia - recurrent UTIs - sebaceous cysts - L hemi-thyroidectomy - breast reduction and multiple breast lumpectomies - tooth extractions - b/l knee arthroscopies - b/l ankle reconstructions - c-section - tonsillectomy with adenoidecomty - ganglion cyst removal Social History: ___ Family History: Mother deceased at ___ with premenopause, myelofibrosis, breast cancer, DM2. Father deceased at ___ with coronary artery disease, abdominal aortic aneurysm, myocardial infarction, triple bypass, DM2, HTN. Sister living with breast cancer, lupus. Sister living with breast cancer. Brother deceased at ___ with glioblastoma. Two sons with celiac and one with JRA. Physical Exam: Discharge physical exam Vitals: Temp: 97.9 HR: 94 BP: 111/76 Resp: 18 O(2)Sat: 97% Gen: NAD, resting comfortably in bed CV: RRR, palpable peripheral pulses P: nonlabored breathing GI: nondistended, soft, nontender; no rebound or guarding. Multiple prior surgical scars are well healed. Ext: WWP, no CCE Pertinent Results: ___ 07:32AM BLOOD WBC-3.8* RBC-3.40* Hgb-9.3* Hct-31.4* MCV-92 MCH-27.4 MCHC-29.6* RDW-14.8 RDWSD-50.0* Plt ___ ___ 04:42AM BLOOD WBC-4.2 RBC-2.88* Hgb-8.0* Hct-26.7* MCV-93 MCH-27.8 MCHC-30.0* RDW-14.8 RDWSD-50.2* Plt ___ ___ 08:20PM BLOOD WBC-5.2 RBC-3.25*# Hgb-9.0* Hct-29.8* MCV-92 MCH-27.7 MCHC-30.2* RDW-14.7 RDWSD-49.5* Plt ___ ___ 08:20PM BLOOD Neuts-60.4 ___ Monos-10.0 Eos-2.5 Baso-1.0 Im ___ AbsNeut-3.13 AbsLymp-1.33 AbsMono-0.52 AbsEos-0.13 AbsBaso-0.05 ___ 07:32AM BLOOD Plt ___ ___ 04:42AM BLOOD Plt ___ ___ 04:42AM BLOOD ___ PTT-33.6 ___ ___ 08:20PM BLOOD Plt ___ ___ 08:20PM BLOOD ___ PTT-37.9* ___ ___ 07:32AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-135 K-4.5 Cl-98 HCO3-24 AnGap-18 ___ 05:05AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-138 K-4.8 Cl-103 HCO3-23 AnGap-17 ___ 04:42AM BLOOD Glucose-75 UreaN-12 Creat-0.6 Na-135 K-3.5 Cl-99 HCO3-23 AnGap-17 ___ 08:20PM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-134 K-4.5 Cl-96 HCO3-23 AnGap-20 ___ 04:42AM BLOOD ALT-36 AST-42* AlkPhos-171* TotBili-0.4 ___ 08:20PM BLOOD ALT-42* AST-50* AlkPhos-195* TotBili-0.5 ___ 07:32AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.9 ___ 05:05AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.4 ___ 04:42AM BLOOD Calcium-7.7* Phos-4.9* Mg-1.5* ___ 08:20PM BLOOD Albumin-3.4* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO BID 2. Rivaroxaban 10 mg PO BID 3. LamoTRIgine 200 mg PO DAILY 4. Abilify (ARIPiprazole) 20 mg oral DAILY 5. Furosemide 5 mg PO EVERY OTHER DAY 6. Potassium Chloride 20 mEq PO BID 7. Pantoprazole 20 mg PO Q12H 8. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB 9. Calcitriol 0.25 mcg PO DAILY 10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, if albuterol inhaler does not relieve symptoms 11. LOPERamide 8 mg PO QAM 12. TraZODone 25 mg PO QHS:PRN insomnia 13. Simethicone 80 mg PO DAILY 14. Cyanocobalamin 1000 mcg PO DAILY 15. Promethazine 25 mg PO Q6H:PRN nausea/vomiting 16. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN pain ___. onabotulinumtoxinA unknown strength injection Q3MONTHS for migraine headaches; next injection due on ___ 18. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 19. diphenhydrAMINE HCl 12.5 mg/5 mL oral Q6H:PRN itching 20. Vitamin D ___ UNIT PO 1X/WEEK (MO) 21. Calcium with Vitamin D (calcium carbonate-vitamin D3) 2 tabs oral BID Discharge Medications: 1. Famotidine 20 mg PO Q12H 2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN R arm pain RX *lidocaine 5 % Apply to right arm for pain daily Disp #*7 Patch Refills:*0 3. Gabapentin 1200 mg PO BID RX *gabapentin [Neurontin] 600 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 6. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB 7. ARIPiprazole 20 mg oral DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium with Vitamin D (calcium carbonate-vitamin D3) 2 tabs oral BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. diphenhydrAMINE HCl 12.5 mg/5 mL oral Q6H:PRN itching 12. Furosemide 5 mg PO EVERY OTHER DAY 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing, if albuterol inhaler does not relieve symptoms 14. LamoTRIgine 200 mg PO DAILY 15. LOPERamide 8 mg PO QAM 16. onabotulinumtoxinA unknown injection Q3MONTHS FOR MIGRAINE HEADACHES; NEXT INJECTION DUE ON ___ 17. Pantoprazole 20 mg PO Q12H 18. Potassium Chloride 20 mEq PO BID 19. Promethazine 25 mg PO Q6H:PRN nausea/vomiting 20. Rivaroxaban 10 mg PO BID 21. Simethicone 80 mg PO DAILY 22. TraZODone 25 mg PO QHS:PRN insomnia 23. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with h/o SBO, multiple surgeries and sclerosing mesenteritis p/w abdominal pain and vomiting // evaluate for obstruction TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. There is mild elevation of the right hemidiaphragm. Spine catheter re- demonstrated, similar in appearance. No evidence of free air is seen beneath the diaphragms. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: History: ___ with h/o SBO, multiple surgeries and sclerosing mesenteritis p/w abdominal pain and vomiting. Evaluate for obstruction. TECHNIQUE: Supine and upright radiographic views of the abdomen. COMPARISON: L wall radiographs of ___, and CT abdomen and pelvis of ___. FINDINGS: Multiple air-fluid levels are identified on the upright view. There is no free intraperitoneal air. Air and stool are identified in the distal large bowel/rectum. Patient has known chronic dilatation of the jejunum. Osseous structures are notable for mild degenerative changes of the bilateral hips. Several surgical clips are scattered throughout the abdomen. IMPRESSION: 1. Multiple air-fluid levels on the upright view. However, air and stool are identified in the distal large bowel/rectum, and patient has known chronic dilatation of the jejunum. Findings could indicate ileus. No high grade obstruction or transition point detected. 2. No free intraperitoneal air. Radiology Report INDICATION: ___ year old woman with recurrent SBO, no IV access // please place PICC, has required fluoro in past for placement TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: none CONTRAST: 0 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 0.3 min, 4 mGy PROCEDURE: 1. Single lumen midline placement through the right brachial vein. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava using fluoroscopic guidance. A single lumen midline measuring 14 cm in length was then placed through the peel-away sheath with its tip positioned in the right axillary under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. The accessed vein was patent and compressible. 2. Brachialvein approach single lumen right midline with tip in the axillary vein. IMPRESSION: Successful placement of a right 14 cm brachial approach single lumen midline with tip in the axillary vein. The line is ready to use. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, Nausea Diagnosed with Vomiting without nausea, Unspecified intestinal obstruction temperature: 98.6 heartrate: 100.0 resprate: 16.0 o2sat: 98.0 sbp: 116.0 dbp: 76.0 level of pain: 9 level of acuity: 3.0

Ms. ___, it has been a pleasure to have taken care of you at the ___. Please read below for your discharge instructions: You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and vowel movments and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. 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. 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: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation ___ Lumbar puncture ___ History of Present Illness: ___ with end stage multiple sclerosis c/b torticollis who presents to ED from long-term care facility with AMS. Patient with chronic indwelling foley, and she finished a course of cipro on ___ for a UTI. She became increasing altered in the days prior to admission and became unresponsive in the ED. She was admitted to the ICU with BP of 86/40 and was intubated for airway protection. She was fluid responsive, and never on pressors. Initially she put on Vanc/Cefepime/Cipro for sepsis of unknown source. Urine cx grew Vanc-sensitive enterococcus, and abx were narrowed to Vanc alone. Due to persistent altered state, EEG was ordered which showed concern for non-convulsive status epilepticus. She was by neuro and started on Keppra with resolution of seizure activity. LP, although difficult, was negative for high OP, meningitis, and HSV. She remained intubated until ___. Prior to extubation, tan secretions were noted and she was placed on VAP protocol with Vanco, Tobra (given no cipro for seizures), Zosyn. MiniBAL and sputum cx are pending. . Currently, patient denies difficulty breathing or cough. She is hungry, asking for doritos, and denies abdominal pain or nausea. She has no headache. Past Medical History: - Multiple sclerosis diagnosed at age ___, wheel chair bound since ___ - Torticollis - Scoliosis s/p ___ rod placement - Constipation - Chronic pain - Allergic rhinitis - Depression - Peripheral vascular disease - Urinary incontinence - Neurogenic bladder with chronic Foley catheter - HTN - Osteoporosis - Obstructive hydrocephalus - Insomnia Social History: ___ Family History: Parents lived till mid ___ w/o major medical ailments. Father died of heart attack. Grandmother developed dementia at last year of her life. Physical Exam: FEX ON MICU ADMISSION Vitals: T: 101, BP: 130s-170s/40s-90s, P: 120s-130s, R: 15 O2: 100% on AC with TV=400, PEEP=5, FiOs=50% General: Intubated/sedated, responds to painful stimuli HEENT: Sclera anicteric, dry MM, ET tube in place, PERRL Neck: muscle contractures with rightward head deviation from torticollis CV: Tachcardic, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: Bilateral upper extremities appear mottled and cool to the touch with good pulses. Lower extremities are warm, well perfused, 2+ pulses, no clubbing or edema Neuro: intubated/sedated, responds to painful stimuli, opens eyes spontaneously, marked muscular contractures, rightward head deviation from torticollis FEX ON DISCHARGE VS - 98.8 98.3 159/77 96 20 97%RA General: Awake, alert, oriented and appropriate HEENT: Sclera anicteric, MMM Neck: Muscle contractures with rightward head deviation from torticollis CV: RRR, no murmurs, rubs, gallops Lungs: Appears comfortable on RA. Limited posterior ausculatation clear. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: No CCE, no joint swelling or pain, RLE with anterior bruising, no increased swelling or pain. Neuro: awake, alert, and oriented. Good attention and follows commands. Marked muscular contractures, rightward head deviation from torticollis. Strength unchanged Pertinent Results: PERTINENT MICROBIOLOGY: ___ 12:04 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. Time Taken Not Noted Log-In Date/Time: ___ 11:54 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. ENTEROCOCCUS FAECALIS. 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 = 2.0 MCG/ML SENSITIVE Sensitivity testing performed by Etest. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ ___ ON ___ - ___. GRAM POSITIVE COCCI. PAIRS AND SHORT CHAIN. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by ___. ___ ___ 12:18PM. Time Taken Not Noted Log-In Date/Time: ___ 11:11 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S . . PERTINENT STUDIES: ___ Radiology CHEST PORT. LINE PLACEM Rotated positioning. Previously seen left IJ catheter has been removed. Left subclavian PICC line is present. The tip may be partially obscured by the spinal hardware. However, I suspect it is unchanged in position and likely lies at the SVC/RA junction. No pneumothorax is detected. Again seen is obscuration of the left diaphragm and increased retrocardiac density. There is more pronounced patchy opacity at the right base. Suspect mild pulmonary vascular plethora. ___ Radiology CHEST (PORTABLE AP) Interval extubation. Stable bilateral pleural effusions, large on the left and small on the right. Possible minimal pulmonary edema. ___ Neurophysiology EEG This is an abnormal continuous ICU monitoring study because of frequent bifrontal and parasagittal generalized periodic epileptiform discharges. Although some of the bifrontal discharges have triphasic features but, given their evolution, these are most likely related to earlier epileptiform activity. These findings are indicative of focal cortical irritability and potential epileptogenicity predominantly in the bifrontal regions. In addition, the background is diffusely slow and disorganized indicative of moderate to severe encephalopathy. Compared to the prior day's recording, there is improvement with fewer blunted discharges and longer periods of disorganized theta activity without bifrontal discharges. ___ Radiology MR HEAD W & W/O CONTRAS 1. Unchanged ventriculomegaly with associated cerebellar atrophic changes, with no evidence of transependymal migration of CSF. Scattered foci of high signal intensity are identified in the subcortical and periventricular white matter, likely consistent with chronic microvascular ischemic changes. 2. Chronic hydrocephalus, possibly communicating, is a consideration, there is no evidence of leptomeningeal enhancement to suggest arachnoiditis, the possibility of a Dandy-Walker variant is also a consideration. 3. Unchanged opacity of the ethmoidal air cells and sphenoid sinus suggesting an ongoing inflammatory process. ___ Cardiovascular ECHO Poor image quality. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The RV is not well seen but overall normal free wall contractility is probably normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) 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. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. ___ Neurophysiology EEG This is an abnormal continuous ICU monitoring study because of frequent generalized periodic epileptiform discharges (GPEDs) at times as frequent as one to two per second. These do not evolvefurther into non-convulsive status epilepticus. However, these findings are indicative of severe cortical irritability and potential epileptogenicity in a generalized distribution. The backgroundtowards the later portion of the recording is diffusely slow and disorganized indicative of moderate to severe encephalopathy. ___ Radiology BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in either lower extremity. The study and the report were reviewed by the staff radiologist . ___ Radiology CT HEAD W/O CONTRAST 1. No evidence for intracranial hemorrhage or other definite acute process. 2. Moderate enlargement of all ventricles, more striking than background cerebral atrophic changes, although cerebellar atrophy is substantial. There is no hypodensity about the ventricles to suggest transependymal edema. Correlation with clinical history is recommended and comparison to prior head CT, if available, may be helpful to assess for chronicity. Major differential considerations include chronic hydrocephalus, probably communicating, associated with a prior inflammatory process such as arachnoiditis or perhaps in association with a congenital lesion such as Dandy-Walker variant. 3. Opacification of the left sphenoid sinus with bony thickening suggesting longer chronicity and hyperdense material suggestive of fungal colonization. Blood: ___ 12:54PM BLOOD WBC-20.3* RBC-4.26 Hgb-13.0 Hct-38.2 MCV-90 MCH-30.4 MCHC-33.9 RDW-12.6 Plt ___ ___ 01:15PM BLOOD WBC-15.5* RBC-3.44* Hgb-10.1* Hct-29.0* MCV-84 MCH-29.5 MCHC-35.0 RDW-13.1 Plt ___ ___ 03:09AM BLOOD WBC-15.3* RBC-3.38* Hgb-9.8* Hct-28.3* MCV-84 MCH-29.0 MCHC-34.6 RDW-13.1 Plt ___ ___ 02:15AM BLOOD WBC-17.6* RBC-3.55* Hgb-10.3* Hct-30.6* MCV-86 MCH-29.0 MCHC-33.7 RDW-13.1 Plt ___ ___ 05:20AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.4* Hct-26.5* MCV-82 MCH-29.1 MCHC-35.5* RDW-13.5 Plt ___ ___ 05:16AM BLOOD WBC-13.9* RBC-3.29* Hgb-9.9* Hct-27.5* MCV-84 MCH-30.1 MCHC-36.1* RDW-14.0 Plt ___ ___ 01:15PM BLOOD ___ PTT-31.9 ___ ___ 04:31AM BLOOD ___ PTT-37.4* ___ ___ 12:54PM BLOOD Glucose-149* UreaN-30* Creat-0.8 Na-145 K-3.7 Cl-112* HCO3-18* AnGap-19 ___ 03:41AM BLOOD Glucose-125* UreaN-10 Creat-0.2* Na-142 K-3.2* Cl-106 HCO3-29 AnGap-10 ___ 03:09AM BLOOD Glucose-131* UreaN-9 Creat-0.3* Na-144 K-3.7 Cl-101 HCO3-35* AnGap-12 ___ 03:40AM BLOOD Glucose-135* UreaN-15 Creat-0.4 Na-137 K-4.2 Cl-100 HCO3-24 AnGap-17 ___ 05:20AM BLOOD Glucose-112* UreaN-6 Creat-0.4 Na-141 K-2.9* Cl-104 HCO3-27 AnGap-13 ___ 05:16AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-141 K-3.8 Cl-105 HCO3-29 AnGap-11 ___ 12:54PM BLOOD ALT-18 AST-30 LD(LDH)-367* CK(CPK)-171 AlkPhos-92 Amylase-111* TotBili-0.4 ___ 01:15PM BLOOD ALT-18 AST-29 LD(LDH)-360* AlkPhos-94 Amylase-57 TotBili-0.5 ___ 12:54PM BLOOD Lipase-26 ___ 12:54PM BLOOD CK-MB-10 MB Indx-5.8 cTropnT-0.06* ___ 03:57PM BLOOD Calcium-9.1 Phos-1.2* Mg-1.8 ___ 03:09AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 ___ 05:39AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7 ___ 05:16AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9 ___ 03:41AM BLOOD Cortsol-8.3 ___ 03:57PM BLOOD TSH-0.84 ___ 09:09PM BLOOD Vanco-8.0* ___ 03:40AM BLOOD Vanco-32.0* ___ 02:15AM BLOOD Tobra-1.8* ___ 08:53PM BLOOD Vanco-14.5 ___ 10:49AM BLOOD Type-ART pO2-160* pCO2-53* pH-7.31* calTCO2-28 Base XS-0 ___ 09:06AM BLOOD Type-ART pO2-67* pCO2-41 pH-7.34* calTCO2-23 Base XS--3 ___ 02:25PM BLOOD Type-ART PEEP-5 pO2-141* pCO2-40 pH-7.48* calTCO2-31* Base XS-6 Intubat-INTUBATED ___ 11:08AM BLOOD Lactate-4.4* ___ 12:51PM BLOOD Lactate-1.8 ___ 09:06AM BLOOD Glucose-148* Lactate-2.5* Na-143 K-4.4 Cl-115* ___ 01:24PM BLOOD Lactate-0.7 ___ 02:25PM BLOOD Lactate-1.8 URINE: ___ 04:14PM URINE Color-AMBER Appear-Cloudy Sp ___ ___ 04:14PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD ___ 04:14PM URINE RBC-121* WBC-62* Bacteri-MANY Yeast-NONE Epi-1 ___ 04:14PM URINE CastHy-8* ___ 10:07AM URINE Color-Straw Appear-Clear Sp ___ ___ 10:07AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CSF: ___ 03:46PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-1 ___ ___ 03:46PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-85 ___ 03:46PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-NEGATIVE ___ 2:09 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. Medications on Admission: - Alendronate 70mg weekly on ___ - ASA 81mg daily - Baclofen 10mg TID - Bethanechol 50mg QID - Calcium carbonate 500mg TID - Cranberry 475mg daily - Docusate 200mg BID - Fish Oil daily - Fleet enema rectally every day PRN constipation - Loratadine 10mg daily - Fiber daily - Metoprolol succinate 150mg daily - Multivitamin daily - Miralax 17 grams twice daily - Selenium 200mcg - Senna 4 tabs twice daily every other day - Vitamin B complex daily - Vitamin C 500mg daily - Vitamin D 1000 units daily - Ibuprofen 600mg TID - Lidoderm 5% patch topically to sternum (12 hrs on/12 hrs off) - Tylenol ___ three times daily - Morphine ER 30mg BID - Tramadol 75mg every 6 hours prn pain - Abilify 2.5mg at bedtime - Citalopram 40mg daily - Gabapentin 100mg every morning - Gabapentin 300mg at 2PM and 8PM - Risperdal 0.5mg BID prn agitation - Trazodone 100mg at bedtime - Voltaren 1% gel to chest every 4 hours PRN pain - Lisinopril 10mg daily - Flaxseed oil 1000mg daily Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: on ___. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 5. cranberry 475 mg Capsule Sig: One (1) Capsule PO once a day. 6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Fish Oil Oral 8. Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 10. Fiber Supplement Powder Oral 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 12. multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Miralax 17 gram/dose Powder Sig: One (1) pack PO twice a day as needed for constipation. 14. selenium 200 mcg Capsule Sig: One (1) Capsule PO once a day. 15. senna 8.6 mg Capsule Sig: Four (4) Capsule PO every other day. 16. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 17. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 21. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three times a day. 22. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 23. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day. 25. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln Intravenous every four (4) hours for 3 days: Last dose ___ ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Sepsis from a urinary source Status epilepticus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Followup Instructions: ___ Radiology Report INDICATION: New oxygen requirement. Tachycardia. Poor mobility at baseline. TECHNIQUE: Bilateral lower extremity Doppler ultrasound. COMPARISON: None available. FINDINGS: Grayscale and Doppler sonograms of the bilateral common femoral, superficial femoral and popliteal veins were performed. Evaluation of the calf veins is limited due to body habitus. There is normal compressibility, flow and augmentation. IMPRESSION: No evidence of deep venous thrombosis in either lower extremity. Radiology Report HISTORY: Septic shock, recently intubated, question interval change. CHEST, SINGLE AP PORTABLE VIEW: Rotated positioning, low lung volumes. An ET tube is present, tip approximately 4.8 cm above the carina. An NG tube is present, tip beneath diaphragm, overlying stomach. Extensive spinal hardware noted. The heart borders are obscured, but the heart is probably not enlarged. There are diffuse opacities throughout both lungs, with denser left retrocardiac opacity and obscuration of left-greater-than-right hemidiaphragms. Possibility of small effusions cannot be excluded. Compared with ___ at 20:18 p.m.and allowing for technical differences, there has been possible increase in the degree of hazy opacity in the right and left mid zones, reflecting worsening CHF. Otherwise, findings are overall similar. IMPRESSION: 1. ET tube as described. 2. Left lower lobe collapse and/or consolidation, unchanged. 3. Hazy opacity in both lungs, slightly worse in the midzones, most suggestive of worsening CHF. Possibility of underlying infectious infiltrate is difficult to exclude. 4. Possible small bilateral effusions. Radiology Report Indication: evaluate for meningitis. Comparison: none Technique: The ICU patient is intubated and sedated. Risk, benefits and alternative managment were explained to the ___, the patient's proxy, who gave us the consent over the phone.The patient was brought to the fluroscopy room and was placed on the table in prone position. A pre-procedure timeout and huddle per ___ standard was performed prior to the initiation of the procedure. The lower back was prepped and drapped in the usual sterile fashion. After subcutaneos administration of 1% lidocaine, a spinal needle was placed at the level of L4 under fluoroscopic guidance, and 18 cc of CSF were extracted and sent to the lab. No complications. Dr. ___ was ___ during the entire procedure. Radiology Report HISTORY: Chest, single AP portable view. Rotated positioning. Note is made of a wet reading provided by radiology resident, Dr. ___. An ET tube is present, tip approximately 6 cm above the carina. Left IJ central line is present, tip difficult to assess, but likely overlying right atrium. An NG tube is present, tip extending beneath diaphragm, off film. Bilateral spinal hardware noted. There are very low inspiratory volumes, with hazy opacity throughout both lungs. The appearance is grossly unchanged compared with ___ at 3:55 a.m., but, in this setting, it is difficult to distinguish pulmonary edema, pleural fluid, infectious infiltrates, and even ARDS. Because findings have progressed relatively rapidly compared with at ___ at 11:12 a.m., a component of CHF should be considered. Radiology Report STUDY: MRI of the head with and without contrast. CLINICAL INDICATION: ___ woman with non-conclusive status. Assess for meningeal enhancement. COMPARISON: Prior head CT dated ___. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained, axial FLAIR, axial T2, axial magnetic susceptibility, and axial diffusion-weighted sequences, the T1-weighted sequences were repeated after the administration of gadolinium contrast in axial T1, sagittal MP-RAGE, axial and coronal reformations were provided. FINDINGS: Again in comparison with the prior examination, significant enlargement of the infra- and supratentorial ventricular system is identified with no evidence of transependymal migration of CSF. Scattered foci of high signal intensity are noted in T2 and FLAIR, distributed in the subcortical and periventricular white matter, which are nonspecific and may reflect chronic microvascular ischemic disease. The sulci are slightly prominent, possibly indicating mild cortical volume loss. No diffusion abnormalities are detected to suggest acute or subacute ischemic changes. There is no evidence of abnormal enhancement to suggest leptomeningeal disease or arachnoiditis. In the posterior fossa, the inferior aspect of the cerebellum is small, possibly atrophic and also there is loss of the cortical volume in both cerebellar hemispheres. The superior aspect of the vermis appears complete and the fourth ventricle is prominent, normal flow void signal is noted at the major vascular structures. The orbits are grossly unremarkable. The paranasal sinuses demonstrate bilateral mucosal thickening at the frontoethmoidal recesses, ethmoidal air cells, and sphenoid sinus, possibly indicating an ongoing inflammatory process, there is also patchy mucosal thickening at the mastoid air cells, more significant on the right. The visualized aspect of the cervical spine demonstrates mild degenerative changes at C3/C4 and C4/C5 levels, partially evaluated in this examination. IMPRESSION: 1. Unchanged ventriculomegaly with associated cerebellar atrophic changes, with no evidence of transependymal migration of CSF. Scattered foci of high signal intensity are identified in the subcortical and periventricular white matter, likely consistent with chronic microvascular ischemic changes. 2. Chronic hydrocephalus, possibly communicating, is a consideration, there is no evidence of leptomeningeal enhancement to suggest arachnoiditis, the possibility of a Dandy-Walker variant is also a consideration. 3. Unchanged opacity of the ethmoidal air cells and sphenoid sinus suggesting an ongoing inflammatory process. Radiology Report HISTORY: Intubated. CHEST, SINGLE AP VIEW: Markedly rotated positioning. Allowing for this, pulmonary findings are likely similar to the film obtained on ___ at 20:43 p.m. with low inspiratory volumes, cardiomegaly, extensive pulmonary edema, and layering right-greater-than-left effusions. The CHF findings appear asymmetric, more pronounced in the right lung likely due to patient position. The carina is not well delineated, but the ET tube position is probably unchanged. The NG tube extends beneath the diaphragm off the film. The left IJ central line is unchanged and lies in the region of the cavoatrial junction. No pneumothorax is detected. Spinal hardware again noted. Radiology Report AP CHEST, 3:32 A.M., ___ HISTORY: Intubated ___ woman. IMPRESSION: AP chest compared to ___: Tracheostomy tube is consistently positioned higher than desirable, which puts the cuff in the larynx. The tip is no less than 9 cm above the carina with the chin down. Standard positioning would require advancing the tube no less than 7.5 cm. Left lower lobe remains collapsed. Moderate right and small left pleural effusion, unchanged. Moderate cardiomegaly, stable. Enteric drainage tube passes to the distal stomach and out of view. Findings were discussed by telephone with Dr. ___ at the time of dictation. Radiology Report AP CHEST, 11:15 ___ ON ___ HISTORY: Central line pulled back. IMPRESSION: AP chest compared to 10:36 a.m.: Left internal jugular line projects over the upper SVC. ET tube, now less than 5 cm above the upper margin of the clavicles and 8 cm from the carina has been repositioned due to findings on subsequent chest radiographs and conversations with the clinician following this study. Left lower lobe collapse and moderate left pleural effusion have increased. Small right pleural effusion is suspected as well. The heart is enlarged but margins are obscured and comparison is not possible. No pneumothorax. Radiology Report INDICATION: Advancement of ET tube. COMPARISON: Radiograph available from ___. FRONTAL CHEST RADIOGRAPH: The patient is severely rotated and kyphotic. Lower thoracic fusion hardware is unchanged in orientation. A left-sided IJ catheter terminates at the mid SVC. The endotracheal tube has been advanced, now terminating 3.3 cm above the carina. An orogastric tube terminates within the stomach. Severe left lower lobe atelectasis is unchanged in appearance. Superimposed mild-to-moderate pulmonary edema is stable. The heart is enlarged. There is no pneumothorax. IMPRESSION: 1. ET tube advanced, now terminating 3.3 cm above the carina 2. Severe left lower lobe atelectasis and moderate edema, both stable. Radiology Report AP CHEST, 2:42 A.M., ___ HISTORY: ___ woman intubated. Assess interval change. IMPRESSION: AP chest compared to ___: With the chin down, the tip of the endotracheal tube is just above the upper margin of the clavicles no less than 4 cm from the carina. Left internal jugular line ends in the upper-to-mid SVC. Lung volumes are still quite low though minimally improved since ___. Mild pulmonary edema has also improved. Moderate right pleural effusion and moderate-to-severe left basal atelectasis are also decreased. Heart size is indeterminate. No pneumothorax. Radiology Report HISTORY: MS with urosepsis. FINDINGS: In comparison with the study of ___, the patient has taken a somewhat better inspiration. Monitoring and support devices remain in place. There is continued enlargement of the cardiac silhouette. Right pleural effusion is again seen. Opacification at the left base is consistent with volume loss in the lower lobe and associated effusion. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Urosepsis, intubated. Comparison is made to prior study ___. Bilateral pleural effusions larger on the left are stable. They are associated with left greater than right large atelectasis. Cardiomediastinal contours are unchanged. Lines and tubes remain in stable standard position. There are no new lung opacities. There is severe scoliosis. A spinal hardware is noted. Radiology Report INDICATION: Recent extubation. Please assess for interval change. COMPARISON: Comparison is made to multiple chest radiographs, most recently dated ___. FINDINGS: Portable chest radiograph demonstrates interval removal of endotracheal tube and nasogastric tube. Stable bilateral pleural effusions, left greater than right with unchanged associated atelectasis, left greater than right. Possible minimal pulmonary edema is unchanged. Left heart border is somewhat obscured by overlying colon; otherwise cardiomediastinal borders are normal. No pneumothorax evident. Stable severe scoliosis and thoracolumbar fusion hardware. IMPRESSION: Interval extubation. Stable bilateral pleural effusions, large on the left and small on the right. Possible minimal pulmonary edema. Radiology Report HISTORY: New left PICC line. CHEST, SINGLE AP PORTABLE VIEW. Rotated positioning. A left subclavian PICC line is present -- the tip is not optimally visualized but appears to lie in the region of the cavoatrial junction. A left subclavian central line present, tip over proximal SVC. No pneumothorax detected. As before, the left hemidiaphragm is elevated, obscuring the cardiac silhouette. There is hazy opacity at the right lung base, with improved atelectasis at the right base. Opacity at the right base may relate to a layering effusion. The left hemidiaphragm is elevated with patchy opacity at the left base, also slightly improved. Small left effusion. Spinal rods noted. Radiology Report HISTORY: PICC line status post IJ removal, assess PICC. chest, 1 vw Rotated positioning. Previously seen left IJ catheter has been removed. Left subclavian PICC line is present. The tip may be partially obscured by the spinal hardware. However, I suspect it is unchanged in position and likely lies at the SVC/RA junction. No pneumothorax is detected. Again seen is obscuration of the left diaphragm and increased retrocardiac density. There is more pronounced patchy opacity at the right base. Suspect mild pulmonary vascular plethora. Radiology Report CHEST RADIOGRAPH HISTORY: Intubation. COMPARISONS: None. TECHNIQUE: Chest, supine AP portable. FINDINGS: An endotracheal tube terminates approximately 1.5 cm above the carina. The lung volumes are low, obscuring cardiac borders, although the heart is probably normal in size. There is moderate-to-severe elevation of the diaphragm with coinciding dilatation of the viscus in the left upper quadrant, probably the splenic flexure of the colon. A splenic shadow is not clearly visualized. Patchy left basilar opacity may be associated with atelectasis, but is not entirely specific or characterized here. In addition, there is mild diffuse interstitial abnormalities suggesting pulmonary edema. The patient has a leftward convex spinal curvature with fixation devices to the partly imaged and characterized along the lower thoracic and upper lumbar spines. IMPRESSION: 1. Endotracheal tube terminating approximately 1.5 cm above the carina. If clinically indicated, the tube could be retracted somewhat for more optimal positioning. 2. Left basilar opacity with elevation of the left hemidiaphragm, suggestive of volume loss. 3. Findings suggesting moderate pulmonary edema. 4. Prominent air-filled viscus in the left upper quadrant, suggesting moderate distal colonic distension. Clinical correlation suggested. Radiology Report HEAD CT HISTORY: Altered mental status. COMPARISONS: None. TECHNIQUE: Non-contrast head CT. FINDINGS: There is no mass effect or shift of the normally midline structures. The cisterns and sulci are moderately prominent, suggesting mild atrophic changes. Cerebellar hemispheres are more strikingly atrophic. All of the ventricles are moderately dilated out of proportion to other findings associated cerebral atrophy, but there sulci are not effaced and there is no evidence for transependymal edema. The cisterna magna is enlarged with a small vermis. There is no evidence for intra- or extra-axial hemorrhage. The vertebrobasilar system is tortuous. Patchy vascular calcifications are present. The sphenoid is bipartite with a dominant left-sided air cell, which is almost completely opacified, including linear hyperdense striations suggesting inspissated material and raising suspicion for fungal colonization. The walls of the left side of the sphenoid sinus are also mildly thickened and sclerotic suggesting longer chronicity to the process. Moderate patchy ethmoid air cell opacification is also noted bilaterally, while the maxillary and frontal sinuses appear clear aside from patchy right posterior mastoid opacification. Aerosolized secretions are present within the nasopharynx, which coincide with endotracheal intubation. IMPRESSION: 1. No evidence for intracranial hemorrhage or other definite acute process. 2. Moderate enlargement of all ventricles, more striking than background cerebral atrophic changes, although cerebellar atrophy is substantial. There is no hypodensity about the ventricles to suggest transependymal edema. Correlation with clinical history is recommended and comparison to prior head CT, if available, may be helpful to assess for chronicity. Major differential considerations include chronic hydrocephalus, probably communicating, associated with a prior inflammatory process such as arachnoiditis or perhaps in association with a congenital lesion such as Dandy-Walker variant. 3. Opacification of the left sphenoid sinus with bony thickening suggesting longer chronicity and hyperdense material suggestive of fungal colonization. Radiology Report INDICATION: Patient with urosepsis. COMPARISONS: Chest radiograph of ___. FINDINGS: Portable AP view of the chest demonstrates ET tube terminating 3.9 cm above the carina. Nasogastric tube is positioned in the stomach. Low lung volumes. Costophrenic angles is obscured, suggestive of small pleural effusions. No pneumothorax is present. Hilar and mediastinal silhouettes are unremarkable. Moderate pulmonary edema appears minimally progressed since prior, expecially in the upper lobes. Left lung base consolidation likely represents atelectasis. Spinal fixation hardware is noted. IMPRESSION: In comparison to ___ pleural exam, there is minimal interval progression of moderate pulmonary edema. Stable small bilateral pleural effusions and left lung base atelectasis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: LETHARGY Diagnosed with ALTERED MENTAL STATUS , MULTIPLE SCLEROSIS, HYPERTENSION NOS temperature: 98.5 heartrate: 110.0 resprate: 14.0 o2sat: nan sbp: 115.0 dbp: 72.0 level of pain: nan level of acuity: 1.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted because you had a severe urinary tract infection which led to persistent seizures. You were treated in the intensive care unit, and you were intubated for several days. You were started on IV antibiotics to treat your infection and started on levetiracetam (Keppra) to control the seizures. Once these were controlled, you were transferred to the floor, and we watched you for a few days while we adjusted your medications. At this time, it is safe for you to return home. You should follow up with your neurologist as scheduled below. Please note the following changes to your medications: Start Keppra 750mg po bid Start ampicillin 2 IV q4 to complete 2 weeks Decrease baclofen to 5mg tid Stop bethanechol Stop morphine Stop Tramadol Stop gabapentin Stop Risperdal Stop trazodone Stop voltaren

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Motrin Attending: ___. Chief Complaint: Fever/Chills Major Surgical or Invasive Procedure: Placement of PICC History of Present Illness: ___ with h/o chronic ___ edema, AFib on coumadin, diastolic CHF, s/p R-TKR in ___, CLL, and presumed right ankle osteomyelitis in ___ and group B strep bacteremia in ___ with presumed source right ankle, though imaging negative for osteomyelitis, presenting with left ankle pain and swelling and fevers. He reports that he developed left ankle pain and swelling last night. He was shaking but was unable to take his temperature, however note from rheum says his temp was up to 103. He "shook all night" and lost control of his bowels. In the morning, his daughters saw him and brought him to the ER for further evaluation. He denies trauma to the left ankle. He believes that the left ankle is always more swollen than the right, but the infections have been localized to the right ankle. Denies SOB, chest pain, chest pressure. Past Medical History: # Lung adenocarcinoma -- s/p resection of right upper lobe on ___ by Dr ___ -- ___ negative # Atrial fibrillation # Hypertension # Hypercholesterolemia # Chronic lymphocytic leukemia -- diagnosed ___ # Cervical radiculopathy # Diverticulosis # History of upper GI bleed, NSAID related, in ___ # Possible history of TIA # Spinal stenosis # Status post right total knee replacement, ___ # Status post appendectomy # Status post pilonidal cyst removal Social History: ___ Family History: Father died of an MI at ___ yo. Mother was healthy, lived to ___ yo. Brother and sister had lung cancers as well. Physical Exam: ADMISSION: 98.1 60 96/47 16 98% Chronically ill appearing elderly male HEENT: PERRL, EOMI NECK: no carotid bruits, JVD LUNGS: CTAB HEART: Irregularly, irregular rhythm, holosystolic murmur ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: Left leg with chronic venous stasis changes with overlying erythema and warmth. Tenderness to palpation of calf. 2+ swelling starting at ankle extending up to knee, with prominent swelling and warmth. No pain with passive ROM DISCHARGE: VS: Afebrile 98.6 136/71 58 18 98% RA GEN Chronically ill appearing obese man. In good spirits this morning. CHEST/LUNGS: Clear to auscultation bilaterally HEART: Irregularly irregular rhythm with ___ holosystolic murmur ABDOMEN: Soft, obese, nontender, bowel sounds positive. EXTREMITIES: b/l chronic venous stasis changes of ___. LLE w/ overlying erythema, warmer than RLE. Significant swelling from foot to knee w/ 1+ pitting edema to knee on L. Ankle architecture unable to be seen due to swelling. Mildly TTP over R shoulder, R clavicle. Good ROM of R arm with minimal pain. NEUROLOGIC: A+Ox3, sensation of lower extremities intact except at plantar, distal toes. SKIN: papular/vesicular erythematous rash over L clavicle and neck; well-circumscribed, approx 5cm diameter. Non-tender. Lesion overlying L wrist appears to be basal cell carcinoma. Will encourage f/u with PCP. Pertinent Results: ___ 06:45PM BLOOD WBC-17.6*# RBC-3.39* Hgb-10.0* Hct-32.5* MCV-96 MCH-29.4 MCHC-30.7* RDW-17.5* Plt ___ ___ 06:00AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.2* Hct-27.0* MCV-96 MCH-29.2 MCHC-30.5* RDW-17.5* Plt ___ ___ 06:00AM BLOOD Neuts-91.6* Lymphs-4.1* Monos-3.9 Eos-0.2 Baso-0.2 ___ 06:45PM BLOOD ___ PTT-45.5* ___ ___ 06:00AM BLOOD ___ PTT-57.6* ___ ___ 05:50AM BLOOD ___ ___ 06:45PM BLOOD ESR-54* ___ 06:45PM BLOOD Glucose-76 UreaN-46* Creat-1.9* Na-135 K-4.3 Cl-98 HCO3-24 AnGap-17 ___ 06:00AM BLOOD Glucose-97 UreaN-19 Creat-0.7 Na-140 K-3.6 Cl-108 HCO3-23 AnGap-13 ___ 06:00AM BLOOD ___ 05:50AM BLOOD Calcium-8.2* Phos-2.1*# Mg-2.1 ___ 06:45PM BLOOD CRP-143.8* ___ 06:00AM BLOOD %HbA1c-5.8 eAG-120 ___ 06:00AM BLOOD PEP-NO SPECIFI ___ 06:45AM BLOOD Lactate-1.4 ___ 06:51PM BLOOD Lactate-2.9* Microbiology: ___ 8:00 pm BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): BETA STREPTOCOCCUS GROUP G. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 7:02 pm JOINT FLUID Source: R SC joint. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final): NO GROWTH. Imagining: MRI LLE ___: IMPRESSION: 1. Limited examination due to limited sequences and patient motion during the examination. 2. Trace edema within the medial aspect of the talus. Mild cortical irregulariy subjacent to the edema. The findings likely reflect tractional changes or prior injury injury. No evidence of acute osteomyelitis. 3. Mild bone marrow edema surrounding the calcaneocuboid joint, likely degenerative. 4. Moderate-to-severe circumferential soft tissue edema consistent with cellulitis in the appropriate clinical circumstance, correlate clinically. 5. Mild tendinopathy and tenosynovitis of the posterior tibialis tendon. 6. Mild tenosynovitis of the flexor hallucis longus and flexor digitorum longus tendons. 7. Mild tenosynovitis of the peroneal tendons. MRI R clavicle ___: IMPRESSION: 1. Osteomyelitis of the right proximal clavicle with extensive periosteal and soft tissue edema as well as joint fluid, consistent with septic arthritis. 2. Small amount of fluid in the left sternoclavicular joint. 3. Left thyroid nodule can be evaluated on ultrasound. TTE ___: IMPRESSION: No vegetations seen. Normal global and regional left ventricular systolic function. Dilated right ventricle with borderline systolic function and evidence of pressure/volume overload. Mild calcific aortic stenosis. Moderate to severe tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior study (images reviewed) of ___, estimated aortic stenosis severity is less (measured LVOT velocity was lower on the prior study). Pulmonary pressures are significantly higher on the current study. Discharge Labs: ___ 06:19AM BLOOD WBC-6.2 RBC-2.70* Hgb-7.9* Hct-25.6* MCV-95 MCH-29.3 MCHC-30.9* RDW-18.4* Plt ___ ___ 06:19AM BLOOD Plt ___ ___ 06:19AM BLOOD ___ PTT-35.4 ___ ___ 06:19AM BLOOD Glucose-87 UreaN-12 Creat-0.6 Na-137 K-3.5 Cl-101 HCO3-30 AnGap-10 ___ 06:19AM BLOOD estGFR-Using this ___ 06:19AM BLOOD ALT-30 AST-27 LD(LDH)-234 AlkPhos-260* TotBili-1.0 ___ 06:19AM BLOOD Albumin-3.1* Chest Xray ___: IMPRESSION: 1. Left subclavian PICC line tip over proximal SVC. 2. Cardiomegaly and prominent hila. 3. Probable mild-to-moderate CHF with vascular plethora and mild interstitial edema. 4. Bibasilar atelectasis and increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. 5. Known sternoclavicular joint and clavicle abnormality is not well depicted. ___. ___ ___: MON ___ 7:36 AM Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Furosemide 60 mg PO DAILY 2. Colchicine 0.6 mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Klor-Con *NF* (potassium chloride) 20 mg Oral TID 5. Gabapentin 100 mg PO TID 6. Allopurinol ___ mg PO DAILY 7. Warfarin 5 mg PO Q TUES WED THURS SAT SUN 5mg po daily on all days except ___ and ___ 8. Warfarin 7.5 mg PO Q MON FRI 7.5 mg on ___ and ___ (5mg all other days) 9. Simvastatin 20 mg PO QHS 10. AcetaZOLamide 250 mg PO QHS Discharge Medications: 1. Simvastatin 20 mg PO QHS 2. CeftriaXONE 1 gm IV Q24H 3. Allopurinol ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Furosemide 60 mg PO DAILY 6. Enoxaparin Sodium 100 mg SC Q 12H Continue until INR theraputic then for 5 more days 7. Nystatin Cream 1 Appl TP BID Apply to groin b/l. 8. Sarna Lotion 1 Appl TP DAILY:PRN itching Apply to right side of back as needed. 9. AcetaZOLamide 250 mg PO QHS 10. Gabapentin 100 mg PO TID 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain hold for sedation and rr<12 12. Outpatient Lab Work Please draw CBC, BNP, LFTs, ESR, and CRP every ___ and fax results to Infectious Disease at ___. 13. Outpatient Lab Work Please draw ___ every ___ and use to titrate Coumadin dosing. 14. Warfarin 5 mg PO Q TUES WED THURS SAT SUN 5mg po daily on all days except ___ and ___ 15. Warfarin 7.5 mg PO Q MON FRI 7.5 mg on ___ and ___ (5mg all other days) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bacteremia Cellulitis Osteomyelitis 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 LEFT ANKLE AND LEFT FOOT RADIOGRAPHS: ___. HISTORY: ___ male with history of osteomyelitis, gout, presents with acute onset of pain. Question fracture or osteomyelitis. FINDINGS: LEFT ANKLE: AP, lateral and oblique views of the left ankle. No prior. There is diffuse osteopenia of the bones about the ankle. Degenerative changes are noted at the talonavicular joint; however, no definite acute fractures identified. There is no definite area of focal osteolysis. Diffuse atherosclerotic calcifications are noted. There is no subcutaneous gas. LEFT FOOT: AP, lateral, and oblique views of the left foot are compared to previous exam from ___. Diffuse osteopenia is seen. Degenerative changes are noted at the talonavicular joint as well as the first metatarsophalangeal joint, similar to prior. There is no evidence of more focal osteolysis. There is no subcutaneous gas. Small vessel atherosclerotic calcifications are noted. Small inferior calcaneal spur is noted. IMPRESSION: Diffuse osteopenia and degenerative changes without evidence of acute fracture or focal osteolysis. Radiology Report INDICATION: Acute pain, worsening swelling, erythema in left lower extremity. Please assess for deep vein thrombosis. COMPARISON: Comparison is made to right lower extremity ultrasound performed ___. FINDINGS: Exam limited by body habitus. Within this limitation, gray-scale and Doppler sonogram was performed of the left common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins. Normal compressibility, flow and augmentation noted throughout. IMPRESSION: No left lower extremity deep vein thrombosis. Radiology Report HISTORY: ___ male with history of chronic venous stasis, now presenting with increasing left lower extremity edema. Patient with tiny focal superficial ulcer at the tip of the left great toe. Assess for evidence of osteomyelitis surrounding the left ankle. COMPARISON: Left foot and ankle radiographs from ___ TECHNIQUE: Multiplanar MR images of the left ankle were acquired on a 1.5 Tesla magnet. Sequences include: axial T1, T2 and STIR images; coronal T1 and STIR images. Axial T1-weighted images were repeated after the intravenous administration of gadolinium contrast. Coronal sequences were also repeated after contrast administration. No sagittal sequences were obtained as the patient could no longer tolerate the exam. MRI OF THE LEFT ANKLE WITH AND WITHOUT GADOLINIUM CONTRAST: The examination is extremely limited due to patient motion. Sagittal sequences could not be completed due to patient's inability to complete the examination. There is circumferential soft tissue edema and skin thickening surrounding the left ankle joint. There is irregularity of the skin surface at the level of the medial malleolus, though no definite superficial ulcer or sinus tract is evident. The musculature surrounding the left ankle appears diffusely atrophic. There is mild bone marrow edema at the calcaneocuboid joint (8:29) which is likely degenerative. Additionally, there is minimal edema within the anteromedial aspect of the talus adjacent to the subtalar joint (8:22). Mild irregularity of the cortex of the medial talus is also noted but no edema at this location to suggest acute osteomyelitis. The tendons within the extensor compartment anteriorly appear normal in signal intensity without signs of tendinopathy or tenosynovitis. Within the medial compartment, there is mild thickening of the posterior tibialis tendon distally and a small amount of fluid surrounding the tendon proximally, findings consistent with distal tendinosis and mild proximal tenosynovitis. Fluid is also seen surrounding the tendons present in the master knot of ___, findings consistent with mild tenosynovitis of the the flexor hallucis longus and flexor digitorum longus tendons. The tendons of the lateral compartment including the peroneus longus and brevis appear normal surrounded by a small amount of fluid. Evaluation of the syndesmotic ligaments is limited due to patient motion and limited views, however, they are likely intact. Anterior talofibular, posterior talofibular and calcaneofibular ligaments are not well seen on the views provided. There are small focal ossific densities within the anterolateral gutter. IMPRESSION: 1. Limited examination due to limited sequences and patient motion during the examination. 2. Trace edema within the medial aspect of the talus. Mild cortical irregulariy subjacent to the edema. The findings likely reflect tractional changes or prior injury injury. No evidence of acute osteomyelitis. 3. Mild bone marrow edema surrounding the calcaneocuboid joint, likely degenerative. 4. Moderate-to-severe circumferential soft tissue edema consistent with cellulitis in the appropriate clinical circumstance, correlate clinically. 5. Mild tendinopathy and tenosynovitis of the posterior tibialis tendon. 6. Mild tenosynovitis of the flexor hallucis longus and flexor digitorum longus tendons. 6. Mild tenosynovitis of the peroneal tendons. Dr. ___ communicated the above preliminary results to Dr. ___ at approximately 11:10 a.m. on ___ by telephone. Radiology Report INDICATION: ___ male with group G strep bacteremia and right shoulder pain. Question osteomyelitis. COMPARISON: CTA chest dated ___. TECHNIQUE: MRI of the mediastinum was performed prior to and following the administration of intravenous contrast with images acquired on a 1.5 Tesla. Multiplanar T1- and T2-weighted images were acquired. FINDINGS: Current exam is highly limited due to motion degradation of multiple sequences. Allowing for such, there is abnormal T2 hyperintense and T1 hypointense signal in the proximal right clavicle subjacent to the sternoclavicular articulation, involving approximately 3.8 cm of the proximal clavicle, with post-gadolinium enhancement, compatible with osteomyelitis. No definite rim enhancement about interosseous increased T2 signal to suggest interosseous abscess. There is extensive associated periosteal and soft tissue edema. The sternum is difficult to assess due to motion degradation, but there is likely reactive edema. There is fluid within the sternoclavicular joint. Small amount of fluid is also present in the left sternoclavicular joint. A 1.7-cm left thyroid nodule was noted on ___ CTA. Allowing for significantly limited assessment due to motion, the lung apices and mediastinal structures appear grossly intact. Assessment for mediastinitis is limited. IMPRESSION: 1. Osteomyelitis of the right proximal clavicle with extensive periosteal and soft tissue edema as well as joint fluid, consistent with septic arthritis. 2. Small amount of fluid in the left sternoclavicular joint. 3. Left thyroid nodule can be evaluated on ultrasound. Findings reported to Dr. ___ phone at 3 p.m. on ___. Radiology Report HISTORY: Check PICC line. CHEST, SINGLE AP PORTABLE VIEW. A left subclavian PICC line is present -- the tip overlies the distal SVC. No pneumothorax is detected. There are low inspiratory volumes. The right hemidiaphragm is elevated. The cardiac contour is prominent and irregular, with prominent hila bilaterally, similar to prior. Probable mild vascular plethora. Bibasilar atelectasis and increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. Minimal blunting of the right greater than left costophrenic angle which is probably not new. The patient has known abnormality of the right sternoclavicular joint and right proximal clavicle, not well depicted on this film. IMPRESSION: 1. Left subclavian PICC line tip over proximal SVC. 2. Cardiomegaly and prominent hila. 3. Probable mild-to-moderate CHF with vascular plethora and mild interstitial edema. 4. Bibasilar atelectasis and increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. 5. Known sternoclavicular joint and clavicle abnormality is not well depicted. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: LE ___ Diagnosed with CELLULITIS OF LEG, LEUKOCYTOSIS, UNSPECIFIED , HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.1 heartrate: 60.0 resprate: 16.0 o2sat: 98.0 sbp: 96.0 dbp: 47.0 level of pain: 6 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital for fevers and chills. We found that you had a serious infection of your left leg that did not involve the bone. We tested your blood for infection and found that you had bacteria in your blood. We also found that you had an infection of your collar bone of the right side. To treat all of these infections, we gave you an antibiotic called ceftriaxone through your IV. You will need to continue taking this antibiotic for a total of six weeks. You were seen by specialists in infectious disease, orthopedic surgery, and thoracic surgery. They all agreed that this antibiotic was the right treatment for your infections. In order to give you this medication after you left the hospital, we had to insert a PICC (peripherally inserted central catheter). This is like a very long IV that extends into the larger veins in your chest. You will receive antibiotics through your PICC daily. We have made the following changes to your medications: 1. Ceftriaxone: we have added this medication 2. colchicine: we have stopped this medication 3. acetazolamid: we had stopped this medication Please make an appointment to see your primary care physician within one week of leaving the hospital.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year-old man with h/o dementia, DM, prior CVA and HTN who presents with progressive confusion over 2 weeks. Patient was seen by his neurologist this afternoon and referred to the emergency department. He is accompanied by his daughter. I interviewed them with the use of a translator. Denies any fevers or chills. Denies any urinary incontinence. Denies any falls. He has not complained of any headache, chest pain, pain in extremities, cough, shortness of breath, swelling. Per daughter, patient has not had bowel movement for one week though he has not reported any abd pain. Patient does report that he has not passed any gas though unclear if he completely understands questions. Of note, per neurology note, patient was hospitalized at ___ for 7 days for unclear reasons though daughter believes it may have been secondary to ?stroke. He has not had any fevers or chills. She thought he may have had some mild shortness of breath. He had not complained of any chest pain, abdominal pain, diarrhea or constipation. She says that prior to the ___, admission to ___, he had been having increased weakness of both legs and was "not able to move them." He was also unable to talk for a period of two hours and subsequently he was able to speak again and pronounce words. In the ED, initial vitals were: 97.5 72 145/85 16 98% RA - Labs were significant for anemia (H/H 10.7/33.9 - below baseline), normal chem 7. Lactate initially 2.2, improved to 1.3 after fluid. UA with 11 WBCs, few bacteria, moderat leukocytes, negative nitrates, trace ketones, 41 RBCs. - CXR showed atelecatasis, no PNA. CT A/P showed no acute process, small umbilical hernia and small bowel mal-rotation. CT head unremarkable, CT C-spine without acute process. R shoulder plain film negative for fracture, showed degenerative changes. - The patient was given 500cc NS, 1g CTX and 50mg metoprolol. Vitals prior to transfer were: 98.1 77 193/129 16 97% RA Upon arrival to the floor, Patient coughed up dime sized amount of blood. Caretaker at bedside and states that he has been confused for one day. Seeing things. Uses wheelchair/walker but hasnt' gotten up for few days. Per caretaker at the bedside, patient is demented at baseline but appears more confused than usual over the last 24 hours. REVIEW OF SYSTEMS: (+) Per HPI Past Medical History: Type 2 Diabetes Hyperlipidemia Diabetic Retinopathy Glaucoma Benign Hypertension Prior Stroke Peripheral Neuropathy Social History: ___ Family History: No family history of stroke Physical Exam: ================= ADMISSION EXAM: ================= Vitals: T98.1 ___ Hr71 RR18 98%RA General: Alert, oriented to self, at "her house", "date unknown", no acute distress HEENT: Sclera anicteric, dry MM, 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 Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, moving all extremities without difficulty, gait deferred. ================== DISCHARGE EXAM: ================== VITALS: T 97.5 BP 150/83 HR 71 RR 20 98% RA General: Somnnolent but arousable, in NAD HEENT: Sclera anicteric, MMM, oropharynx clear CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally Abdomen: BS+, soft, non-tender, non-distended, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no edema, b/l shins wrapped in gauze Neuro: Moving all extremities without difficulty, gait deferred. Pertinent Results: ================= ADMISSION LABS: ================= ___ 06:15PM BLOOD WBC-8.6 RBC-3.47* Hgb-10.7* Hct-33.9* MCV-98 MCH-30.8 MCHC-31.6* RDW-12.6 RDWSD-44.5 Plt ___ ___ 06:15PM BLOOD Glucose-203* UreaN-20 Creat-1.1 Na-141 K-4.3 Cl-103 HCO3-28 AnGap-14 ___ 06:28PM BLOOD Lactate-2.2* ======================== PERTINENT RESULTS: ======================== LABS: ======================== ___ 08:17AM BLOOD calTIBC-239* Ferritn-57 TRF-184* ___ 04:20AM BLOOD calTIBC-252* Ferritn-58 TRF-194* ___ 10:31PM BLOOD Lactate-1.3 ======================== MICROBIOLOGY: ======================== ___ 6:15 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date === ___ 8:43 pm URINE URINE CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. === ___ 10:27 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date ========================= IMAGING/STUDIES: ========================= ECG Study Date of ___ 4:48:00 AM Sinus rhythm. A-V conduction delay. Possible inferior wall myocardial infarction of indeterminate age. Possible anteroseptal myocardial infarction of indeterminate age. Non-specific T wave changes. Compared to the previous tracing of ___ the heart rate is faster but other findings are similar. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 74 258 90 402 426 ___ === ECG Study Date of ___ 4:58:23 ___ Sinus rhythm. A-V conduction delay. Inferior wall myocardial infarction of indeterminate age. Anterior wall myocardial infarction of indeterminate age. Compared to the previous tracing of ___ the heart rate is slower. Other findings are similar. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 71 338 90 ___ ___ === R GLENO-HUMORAL XRAY (___): Degenerative changes without definite evidence for fracture or dislocation. === CT C-SPINE W/O CONTRAST (___): No acute fracture, malalignment, or prevertebral soft tissue abnormality of the cervical spine. === CT HEAD W/O CONTRAST (___): No acute intracranial abnormality. Motion limited exam. === CT ABD/PELVIS W/ CONTRAST (___): 1. No acute intra-abdominal abnormality to explain the patient's presentation. 2. Small fat containing umbilical hernia. === CXR (___): AP portable supine view of the chest. Low lung volumes limits assessment. There is atelectasis in the right lung base. No convincing evidence for pneumonia or edema. No large effusion for supine evidence for pneumothorax. Cardiomediastinal silhouette appears normal. Bony structures are intact. IMPRESSION: No convincing evidence for pneumonia. === PORTABLE ABDOMINAL XRAY (___): 1. Nonobstructive nonspecific bowel gas pattern. 2. Large amount of stool throughout the colon. === CT ABD/PELVIS W/ CONTRAST (___): No evidence of bowel obstruction with a large stool burden noted in the colon. =================== DISCHARGE LABS: =================== ___ 07:10AM BLOOD WBC-6.0 RBC-3.52* Hgb-10.9* Hct-33.9* MCV-96 MCH-31.0 MCHC-32.2 RDW-12.7 RDWSD-44.6 Plt ___ ___ 06:50AM BLOOD Glucose-166* UreaN-24* Creat-1.1 Na-141 K-4.3 Cl-104 HCO3-30 AnGap-11 ___ 06:50AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 Radiology Report INDICATION: ___ with increasing confusion and right shoulder TTP / COMPARISON: None FINDINGS: Three views of the right shoulder were provided. There is no definite fracture or dislocation. Degenerative changes at the right AC joint evident with bony hypertrophy. Spurring at the inferior glenohumeral joint noted. No soft tissue calcifications. IMPRESSION: Degenerative changes without definite evidence for fracture or dislocation. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: Evaluate for intracranial hemorrhage in a patient with increasing confusion and right shoulder tenderness palpation concerning for trauma. 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: Total DLP (Head) = 1,405 mGy-cm. COMPARISON: Noncontrast CT head from ___. FINDINGS: The exam is limited by motion artifact. There is no evidence of acute large territorial infarction, hemorrhage, edema, or mass effect. Prominent ventricles and sulci are suggestive of age-related involutional change. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. Motion limited exam. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with increasing confusion and right shoulder TTP 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) = 743 mGy-cm. COMPARISON: Noncontrast CT cervical spine from ___. FINDINGS: No acute fracture is identified.Mild retrolisthesis of the C3 on C4 vertebral bodies is unchanged compared to ___ is no significant spinal canal stenosis. Moderate neural foraminal narrowing, left greater than right, at the C3-4 and C4-5 levels. Mild bilateral neural foraminal narrowing is seen at the C5-6 level. There is no prevertebral soft tissue swelling. Thyroid gland appears normal. The imaged lung apices are clear. IMPRESSION: No acute fracture, malalignment, or prevertebral soft tissue abnormality of the cervical spine. Radiology Report EXAMINATION: CT ABDOMEN PELVIS INDICATION: Diffuse abdominal tenderness to palpation and confusion. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 130 mL Omnipaque. Oral contrast was not administered.Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 919 mGy-cm. COMPARISON: None. FINDINGS: LOWER CHEST: The visualized lung bases are clear, without pleural or pericardial effusion. Coronary artery calcifications are noted. The heart is top normal in size. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no focal lesion or intrahepatic biliary duct dilation. The main portal vein is patent. The gallbladder is within normal limits. PANCREAS: The pancreas is diffusely atrophic. No focal lesion or ductal dilation is identified. 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 symmetric and normal in size, demonstrating normal nephrograms and excreting contrast promptly. There is a large exophytic simple renal cyst arising from the interpolar region of the right kidney. Smaller hypodensities in the left kidney are too small to characterize, but also likely represent simple renal cysts. There is no concerning focal lesion or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is decompressed, but there is no obvious wall thickening or focal mass. Small bowel loops are normal in caliber, without wall thickening or evidence of obstruction. The colon and rectum are within normal limits. The appendix is not definitely visualized, but there are no secondary signs of acute appendicitis. PELVIS: Urinary bladder wall thickening may be related in part to chronic obstruction as well as underdistention. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is markedly 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. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is a small fat containing umbilical hernia. IMPRESSION: 1. No acute intra-abdominal abnormality to explain the patient's presentation. 2. Small fat containing umbilical hernia. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ with confusion // eval for pneumonia COMPARISON: ___ FINDINGS: AP portable supine view of the chest. Low lung volumes limits assessment. There is atelectasis in the right lung base. No convincing evidence for pneumonia or edema. No large effusion for supine evidence for pneumothorax. Cardiomediastinal silhouette appears normal. Bony structures are intact. IMPRESSION: No convincing evidence for pneumonia. Radiology Report INDICATION: ___ year old man with no bowel movement for one week, reports not passing flatus evaluate for stool burden or small bowel obstruction. TECHNIQUE: Supine abdominal radiograph was obtained. COMPARISON: ___ CT of the abdomen and pelvis with contrast. FINDINGS: There are no abnormally dilated loops of large or small bowel. There is a large amount of stool seen in colon. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are notable for degenerative changes of the lumbar spine. IMPRESSION: 1. Nonobstructive nonspecific bowel gas pattern. 2. Large amount of stool throughout the colon. Radiology Report INDICATION: ___ year old man with no stool x 17 days despite aggressive bowel regimen. Evaluate for obstruction. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis without intravenous contrast administration. IV Contrast: None Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: DLP: 903 mGy-cm. COMPARISON: Abdominal radiograph from ___ and CT abdomen pelvis from ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. Coronary artery calcifications are noted. 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: Fatty replacement of the pancreas is noted, and there is no 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. A right lower pole simple cyst is noted. There is no perinephric abnormality, and there is no hydronephrosis bilaterally. GASTROINTESTINAL: The stomach is minimally distended and unremarkable. Small bowel loops opacified with oral contrast and demonstrate normal caliber and wall thickness throughout without signs of obstruction. The colon and rectum are within normal limits, and there is a large stool burden throughout the colon. The appendix is not visualized. PELVIS: The urinary bladder is collapsed due to a Foley catheter, and the distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. 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: Degenerative changes are seen in the lumbar spine, most pronounced at L5-S1 with a disc bulge. SOFT TISSUES: A small fat containing umbilical hernia is noted. IMPRESSION: No evidence of bowel obstruction with a large stool burden noted in the colon. Gender: M Race: HISPANIC/LATINO - DOMINICAN Arrive by AMBULANCE Chief complaint: Confusion Diagnosed with Urinary tract infection, site not specified temperature: 97.5 heartrate: 72.0 resprate: 16.0 o2sat: 98.0 sbp: 145.0 dbp: 85.0 level of pain: ua level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of ___ during your recent admission to ___ came to us because your Neurologist was concerned that ___ were confused at your appointment. Images of your head did not show any new changes. Your family thought that ___ were no more confused than usual. We also found that ___ were constipated, and gave ___ medications to help with this. We wish ___ the best of health. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: CHIEF COMPLAINT: Shortness of Breath REASON FOR TRANSFER: Respiratory Distress Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ y/o gentleman with a PMHX of non schemic sCHF EF 15% s/p ICD, OSA on bipap, recent admission from ___ for CHF exacerbation, now with chest pain and shortness of breath c/w prior admission. With regards to his recent admission, he was discharged at dry weight of 378 pounds and an NT BNP of around 5500 which is near his baseline. He was seen at cardiology clinic on ___ and was noted to be continued acute on chronic systolic CHF. His weight was 383 at that admission and it was noted that his first dose of Bumex post-discharge was that day as he had not filled the prescription. Labs were checked on ___ and showed hypokalemia to 2.9. He was advised to hold his bumex and prn metolazone due to hypokalemia. Labs were rechecked on ___ and K was < 2.0 for which he was given 60 mEq K. Around noon today Mr. ___ developed ___ cp radiaiting to r and left sides. About one hr prior to admission, he developed siginificant sob and so called ___. EMS found the pt diaphoretic in respiratory distress. He was given 2 nitro sprays and placed on nrb and brought to ___ ED. He denies recent/current f/c, abd pain, n/v/d, dysuria In the ED, initial vitals were: 99.0 123 94/58 28 100% 15L NRB -initial labs: Na/K 132/2.7; BUN/Cr ___ (baseline cr 1.0 in ___ CK 102, MB 3, Trop 0.08, proBNP 5815, WBC 11.5, Hgb/Hct 12.5/36.6, Plt 345, INR 1.4, Lactate 4.4 - CXR: Cardiomegaly with mild pulmonary edema. - ___ was negative for DVT - Patient was given 80mEq potassium, Ativan 1 mg, 2g magnesium, 25 mg spirinolactone On arrival to ICU, VS were: T 98.3, BP 108/71, HR 114, RR 20, 95% on 3L NC. Patient reported ongoing cp, abd discomfort, and sob. REVIEW OF SYSTEMS: + as per HPI. ALso reported orthopnea, ___ swelling (chronic per patient) and palpitations. Denied f/c/ns, n/v, light-headedness/dizziness, diarrhea, melena, BRBPR, or dysuria. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: CHF with nonischemic cardiomyopathy s/p ICD placement, EF 15% Hyperlipidemia Hypertension Hypokalemia Morbid Obesity OSA on BiPAP Social History: ___ Family History: Mother died from an MI at age ___ Never knew his father No family history of cancer. Physical Exam: Admission physical exam: ============================= VS: T 98.3, BP 108/71, HR 114, RR 20, 95% on 3L NC. Gen: Obese male, sitting up in bed, in NAD HEENT: NC/AT, poor dentition, EOMI, sclera anicteric NECK: JVP at angle of jaw CV: Tachycardic, no r/m/g LUNGS: CTAB, no wheezes or rhonchi ABD: Protuberant abdomen, soft, NTTP, normal active bowel sounds EXT: 2+ radial and DP pulses, ___ with 2+ pitting edema to knee SKIN: No rashes or excoriations NEURO: Moving all extremities, speech fluent, gait assessment deferred DISCHARGE PHYSICAL EXAMINATION: =============================== VS: 97.9 ___ 18 99RA IO: ___ Wt: 171.7(d/c 6 / 3)->177.5kg(admission)->175.6->176.6->175.7->172.6->168.3->167.9 Gen: Obese male, sitting up in bed, in NAD HEENT: NC/AT, EOMI, sclera anicteric NECK: JVP not elevated CV: Regular, normal S1, S2. No r/m/g LUNGS: CTAB, no wheezes or rhonchi ABD: Obese abdomen with large pannus, soft, NTTP, normal active bowel sounds EXT: 2+ radial and DP pulses, ___ with trace pitting edema to knee, L>R. warm SKIN: No rashes or excoriations Pertinent Results: Admission labs: =============================== ___ 08:45PM BLOOD WBC-11.5* RBC-4.67 Hgb-12.5* Hct-36.6* MCV-79* MCH-26.7* MCHC-34.0 RDW-17.7* Plt ___ ___ 08:45PM BLOOD Neuts-74.1* Lymphs-17.1* Monos-5.7 Eos-2.6 Baso-0.4 ___ 08:45PM BLOOD ___ PTT-27.5 ___ ___ 08:45PM BLOOD Glucose-165* UreaN-26* Creat-1.4* Na-132* K-2.7* Cl-87* HCO3-29 AnGap-19 ___ 08:45PM BLOOD CK(CPK)-102 ___ 08:45PM BLOOD CK-MB-3 proBNP-5815* ___ 08:45PM BLOOD Mg-1.3* ___ 01:28AM BLOOD ___ pO2-72* pCO2-34* pH-7.52* calTCO2-29 Base XS-4 ___ 09:06PM BLOOD Lactate-4.4* ___ 03:19AM BLOOD Lactate-4.8* ___ 08:12AM BLOOD Lactate-3.1* ___ 08:12AM BLOOD freeCa-1.05* ___ 01:28AM BLOOD O2 Sat-93 STUDIES: ======================= + CXR (___): Left chest wall single lead pacing device is again seen. Moderate cardiomegaly is stable in configuration. There is mild pulmonary edema. No focal consolidation identified. IMPRESSION: Cardiomegaly with mild pulmonary edema. + EKG (___): sinus tachycardia, delayed r-wave progression, c/w prior, no ischemic changes + TTE (___): The left atrial volume index is normal. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. 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 leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Profound biventricular contractile dysfunction. + ___ (___): No evidence of deep venous thrombosis in the left lower extremity veins. Nonvisualization of the calf veins. DISCHARGE LABS: ======================== ___ 04:30AM BLOOD WBC-10.0 RBC-5.05 Hgb-13.1* Hct-42.7 MCV-85 MCH-25.9* MCHC-30.7* RDW-19.9* RDWSD-58.2* Plt ___ ___ 04:30AM BLOOD Glucose-79 UreaN-29* Creat-1.4* Na-136 K-3.4 Cl-86* HCO3-35* AnGap-18 ___ 04:30AM BLOOD ALT-35 AST-35 AlkPhos-66 TotBili-1.6* ___ 04:30AM BLOOD Calcium-10.3 Phos-4.7* Mg-2.8* Iron-47 ___ 04:30AM BLOOD calTIBC-564* Ferritn-160 TRF-434* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Amiodarone 200 mg PO DAILY 3. Bumetanide 5 mg PO BID 4. Clotrimazole Cream 1 Appl TP DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH BID 6. Lisinopril 40 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Spironolactone 25 mg PO BID 10. Magnesium Oxide 800 mg PO BID 11. Pravastatin 20 mg PO QPM 12. Pulmicort (budesonide) 0.25 mg/2 mL inhalation 1 puff daily 13. Sertraline 50 mg PO DAILY 14. Potassium Chloride (Powder) 30 mEq PO DAILY 15. Metolazone 5 mg PO PRN weight gain greater than 1kg in 24H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Amiodarone 200 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Clotrimazole Cream 1 Appl TP DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH BID 6. Lisinopril 40 mg PO DAILY 7. Magnesium Oxide 800 mg PO BID 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Potassium Chloride (Powder) 90 mEq PO DAILY Hold for K > RX *potassium chloride 40 mEq/15 mL 35 ml by mouth daily Refills:*0 10. Pravastatin 20 mg PO QPM 11. Sertraline 50 mg PO DAILY 12. Spironolactone 50 mg PO BID RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Bumetanide 5 mg PO BID Hold this medication on ___, and restart on ___. Pulmicort (budesonide) 0.25 mg/2 mL inhalation 1 puff daily 15. Outpatient Lab Work Please recheck electrolytes on ___. Please draw at ___ lab. Send results to Dr. ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Acute on Chronic Systolic Heart Failure Exacerbation Secondary Diagnosis: Hypokalemia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with hx sob. sudden onset cp, ___ swelling // eval for fluid overload TECHNIQUE: Single portable view of the chest. COMPARISON: ___. FINDINGS: Left chest wall single lead pacing device is again seen. Moderate cardiomegaly is stable in configuration. There is mild pulmonary edema. No focal consolidation identified. IMPRESSION: Cardiomegaly with mild pulmonary edema. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ with unilateral left leg swelling, evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the left common femoral, superficial femoral, and popliteal veins. The calf veins were not 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 left lower extremity veins. Nonvisualization of the calf veins. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with HYPOKALEMIA, RESPIRATORY ABNORM NEC, CHEST PAIN NOS temperature: 99.0 heartrate: 123.0 resprate: 28.0 o2sat: 100.0 sbp: 94.0 dbp: 58.0 level of pain: 6 level of acuity: 1.0

Dear Mr. ___, It was a pleasure meeting you and taking care of you. You were admitted with weight gain and shortness of breath. You were found to have gained five kilograms since your recent admission. You were given IV forms of your home bumex regimen and then switched to an oral regimen you can take at home. You will be taking 5 milligrams of a medication called bumex (also called bumetanide) twice a day to make sure you do not gain weight. Unfortunately, the medication only comes in 1mg pills so you'll have to take 5 of them twice a day. Your discharge weight is 168 kg or 371 lbs. If your weight goes up by more than 1 kilogram or 3 pounds in 24 hours call your Heart Failure team. It is important to have your electrolytes regularly monitored during this time. You should take 90 mEq of potassium chloride every day to ensure that your potassium does not go too low. Your should have your blood drawn on ___ at ___ to monitor your kidney function and electrolytes You will be following up with several doctors ___. Your first appointment is tomorrow. Your appointments are all written below. It was a pleasure taking care of you and we wish you all the best. Sincerely, Your ___ team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / codeine Attending: ___. Chief Complaint: Left Intertrochanteric Fracture Major Surgical or Invasive Procedure: Long Trochanteric Fixation Nail History of Present Illness: ___ year old male with past medical history per family notable for opioid abuse presents as a transfer from OSH status post unwitnessed fall, possibly trip over cord onto cement patio, with laceration over left eye, left volar digit laceration, and left intertrochanteric fracture. Per report, essentially unresponsive in the field. Given Narcan x2, and subsequently arousable by sternal rub. In the ED, GCS 14. Patient was somnolent and unable to fully cooperate with interview or exam. Past Medical History: Opioid Abuse Chronic Back Pain Social History: ___ Family History: Non-contributory Physical Exam: AVSS NAD, A&Ox3 Left Lower Extremity: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP pulse, wwp distally. Discharge Physical exam: VS: 97.4 PO 123 / 74 R Lying 74 18 97 Ra Gen: NAD, AxOx3 HEENT: left eye ecchymosis Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, non-tender, non-distended Ext: L knee wrapped Pertinent Results: Radiology: ___ Ct head: 1. Left middle cranial fossa aneurysm clip streak artifact limits examination. 2. Left temporal and left periorbital soft tissue swelling. 3. Probable chronic left orbital floor fracture versus suture, and with age-indeterminate induration of left orbit fat inferior to left inferior rectus muscle, which is noted to not be directly above area of orbital floor fracture. 4. Age indeterminate left posterior maxillary sinus wall fracture. 5. Left temporal craniotomy and adjacent left temporal encephalomalacia. 6. Left frontal craniotomy postsurgical changes. 7. Left middle cranial fossa aneurysm clip. 8. Within limits of study, no definite evidence of acute intracranial hemorrhage. Please note MRI of the brain is more sensitive for the detection of acute infarct. 9. Findings suggestive of left maxillary chronic sinus disease, with differential considerations of hemosinus not excluded on the basis of this examination. 10. Additional paranasal sinus disease, as described. 11. Probable right frontal ventriculostomy catheter postoperative changes as described. ___ Pelvis: 1. Immediate postsurgical changes of cephalomedullary fixation of left femoral intertrochanteric fracture. ___ Hip: Intraoperative images were obtained during femoral intertrochanteric fracture fixation. Please refer to the operative note for details of the procedure. ___ Hand: 1. No evidence of fracture or dislocation. ___ knee: Corticated ossicle adjacent to the medial femoral metaphysis, favored related to remote trauma. Recommend clinical correlation. No definite acute fracture seen. ___ CXR: Lungs are now clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. LABORATORY: ___ 06:36AM BLOOD WBC-12.4* RBC-3.46* Hgb-10.4* Hct-31.1* MCV-90 MCH-30.1 MCHC-33.4 RDW-14.2 RDWSD-44.7 Plt ___ ___ 08:26AM BLOOD WBC-15.9* RBC-3.53* Hgb-10.6* Hct-31.9* MCV-90 MCH-30.0 MCHC-33.2 RDW-14.0 RDWSD-44.2 Plt ___ ___ 07:55AM BLOOD WBC-13.1* RBC-3.15* Hgb-9.4* Hct-28.3* MCV-90 MCH-29.8 MCHC-33.2 RDW-13.6 RDWSD-42.7 Plt ___ ___ 09:19AM BLOOD WBC-10.3* RBC-2.97* Hgb-8.8* Hct-26.6* MCV-90 MCH-29.6 MCHC-33.1 RDW-13.1 RDWSD-41.8 Plt ___ ___ 06:37AM BLOOD WBC-9.4 RBC-2.94* Hgb-8.9* Hct-26.5* MCV-90 MCH-30.3 MCHC-33.6 RDW-12.8 RDWSD-41.6 Plt ___ ___ 07:50AM BLOOD WBC-10.4* RBC-2.90* Hgb-8.8* Hct-26.1* MCV-90 MCH-30.3 MCHC-33.7 RDW-12.8 RDWSD-41.9 Plt ___ ___ 10:04AM BLOOD WBC-14.5* RBC-3.22* Hgb-9.7* Hct-29.4* MCV-91 MCH-30.1 MCHC-33.0 RDW-12.9 RDWSD-42.6 Plt ___ ___ 08:00AM BLOOD WBC-18.6* RBC-4.01* Hgb-11.9* Hct-36.2* MCV-90 MCH-29.7 MCHC-32.9 RDW-12.9 RDWSD-42.5 Plt ___ ___ 08:00AM BLOOD ___ PTT-27.1 ___ ___ 01:09AM BLOOD ___ PTT-27.1 ___ ___ 07:55AM BLOOD Glucose-87 UreaN-17 Creat-0.6 Na-142 K-4.7 Cl-102 HCO3-25 AnGap-15 ___ 09:19AM BLOOD Glucose-102* UreaN-11 Creat-0.6 Na-141 K-4.1 Cl-102 HCO3-27 AnGap-12 ___ 06:37AM BLOOD Glucose-150* UreaN-10 Creat-0.5 Na-144 K-3.7 Cl-106 HCO3-22 AnGap-16 ___ 07:50AM BLOOD Glucose-113* UreaN-11 Creat-0.5 Na-141 K-3.8 Cl-103 HCO3-27 AnGap-11 ___ 10:04AM BLOOD Glucose-105* UreaN-12 Creat-0.6 Na-140 K-4.1 Cl-101 HCO3-28 AnGap-11 ___ 08:00AM BLOOD Glucose-139* UreaN-13 Creat-0.7 Na-139 K-4.1 Cl-101 HCO3-24 AnGap-14 ___ 09:19AM BLOOD ALT-22 AST-23 AlkPhos-58 TotBili-0.7 ___ 01:09AM BLOOD Lipase-7 ___ 07:55AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0 ___ 09:19AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.7 ___ 06:37AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8 ___ 07:50AM BLOOD Calcium-9.1 Phos-2.4* Mg-1.8 ___ 10:04AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.8 ___ 08:00AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.7 ___ 01:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 01:21AM BLOOD Glucose-135* Lactate-1.0 Creat-0.6 Na-140 K-3.9 Cl-100 calHCO3-25 ___ 1:05 am URINE STROKE. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY 2. Sertraline 150 mg PO DAILY 3. Atorvastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 30 mg SC Q12H 4. Haloperidol 2.5 mg PO QHS 5. Haloperidol 2.5 mg PO TID:PRN agitation or insomnia 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Wean as tolerated. Patient may request partial fill. 7. Polyethylene Glycol 17 g PO DAILY 8. Senna 8.6 mg PO BID 9. Tamsulosin 0.4 mg PO QHS 10. Atorvastatin 20 mg PO QPM 11. Sertraline 150 mg PO DAILY 12. HELD- Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY This medication was held. Do not restart Buprenorphine-Naloxone Film (8mg-2mg) until weaned off oxycodone. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Left ___ finger laceration -Left ___ finger PIP dorsal dislocation with overlying wound -Left hip fracture -Traumatic Brain Injury with concussion Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO LEFT INDICATION: Left hip fracture ORIF COMPARISON: CT pelvis ___ FINDINGS: 10 intraoperative images were acquired without a radiologist present. Images show intertrochanteric fracture fixation with a intramedullary gamma nail. IMPRESSION: Intraoperative images were obtained during femoral intertrochanteric fracture fixation. Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: PELVIS AP ___ VIEWS INDICATION: ___ year old man s/p L TFN.// s/p L TFN, eval hardware/alignment TECHNIQUE: 2 AP views of the pelvis. COMPARISON: ___. FINDINGS: Interval postsurgical changes of cephalomedullary fixation of comminuted left intertrochanteric femoral fracture.The alignment is near anatomic. Continued moderate superior medial displacement of the lesser trochanteric fragment.There are severe degenerative changes at L5-S1.Hip joints are congruent. IMPRESSION: 1. Immediate postsurgical changes of cephalomedullary fixation of left femoral intertrochanteric fracture. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ male with past medical history per family notable for opioid abuse presents as a transfer from OSH status post unwitnessed fall, with left intertrochanteric fracture s/p long TFN. Now with decreased interaction. C/f SDH or other IC bleed.// Interval change 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 10.0 s, 17.5 cm; CTDIvol = 47.1 mGy (Head) DLP = 824.4 mGy-cm. Total DLP (Head) = 838 mGy-cm. COMPARISON: None. FINDINGS: Left middle cranial fossa aneurysm clipping postoperative changes noted with surgical hardware streak artifact limiting examination. Induration of the left temporal and left periorbital soft tissues is noted. Within limits of study there is no definite evidence of acute intracranial hemorrhage. Left temporal craniectomy and adjacent encephalomalacia is seen. Otherwise, the ventricles and sulci are grossly preserved in size and configuration. Additional left frontal craniotomy postoperative changes are seen. Postsurgical changes suggestive of prior right frontal burr hole and ventriculostomy catheter placement are seen. There is no evidence of acute large territorial infarction,acute intracranial hemorrhage,edema,or mass. There is no evidence of acute fracture. Within the left orbital floor a well corticated defect is seen (see 602: ___. Question minimal nonspecific induration of the left orbit medial intraorbital fat inferior to the inferior rectus muscle (602:24). An age indeterminate left maxillary sinus posterior wall defect is seen (see 3:6). The left maxillary sinus is completely opacified and is asymmetrically smaller than the right maxillary sinus. Question minimal bony sclerosis surrounding the right maxillary sinus. Question areas of high density within the right maxillary sinus opacification. Left frontal sinus mucosal thickening is present. Minimal bilateral ethmoid air cell mucosal thickening is present. The visualized portion of the middle ear cavities and mastoid air cells are clear. The visualized portion of the right orbit is preserved. IMPRESSION: 1. Left middle cranial fossa aneurysm clip streak artifact limits examination. 2. Left temporal and left periorbital soft tissue swelling. 3. Probable chronic left orbital floor fracture versus suture, and with age-indeterminate induration of left orbit fat inferior to left inferior rectus muscle, which is noted to not be directly above area of orbital floor fracture. 4. Age indeterminate left posterior maxillary sinus wall fracture. 5. Left temporal craniotomy and adjacent left temporal encephalomalacia. 6. Left frontal craniotomy postsurgical changes. 7. Left middle cranial fossa aneurysm clip. 8. Within limits of study, no definite evidence of acute intracranial hemorrhage. Please note MRI of the brain is more sensitive for the detection of acute infarct. 9. Findings suggestive of left maxillary chronic sinus disease, with differential considerations of hemosinus not excluded on the basis of this examination. 10. Additional paranasal sinus disease, as described. 11. Probable right frontal ventriculostomy catheter postoperative changes as described. Radiology Report EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ found unresponsive with lac left eye, L hip fracture// Interval change? Interval change? IMPRESSION: Compared to chest radiograph ___. Lungs are now clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with trauma// eval trauma TECHNIQUE: Frontal view COMPARISON: None FINDINGS: The lungs are well expanded and clear. No pleural effusion or pneumothorax. Heart size is top-normal. The mediastinal silhouette is otherwise unremarkable. IMPRESSION: No evidence of an acute cardiopulmonary abnormality. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT INDICATION: History: ___ with trauma// ?fx TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the right knee. COMPARISON: None. FINDINGS: No acute fracture or dislocation is seen. There is a corticated ossicle adjacent to the medial femoral metaphysis, favored related to remote trauma. No significant soft tissue swelling seen. There are no significant degenerative changes. There is no knee joint effusion. There is normal osseous mineralization. No suspicious lytic or sclerotic lesions are identified. IMPRESSION: Corticated ossicle adjacent to the medial femoral metaphysis, favored related to remote trauma. Recommend clinical correlation. No definite acute fracture seen. Radiology Report EXAMINATION: Noncontrast pelvis CT INDICATION: ___ year old man with left hip fx// eval left hip fracture, operative planning TECHNIQUE: Multidetector CT images of the pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.3 s, 35.9 cm; CTDIvol = 25.0 mGy (Body) DLP = 897.4 mGy-cm. Total DLP (Body) = 897 mGy-cm. COMPARISON: None. FINDINGS: PELVIS: The partially visualized small and large bowel are unremarkable. Normal appendix. There is a Foley catheter in the urinary bladder with a few locules of intravesicular gas. Hyperdense material within the bladder is seen. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no pelvic or inguinal lymphadenopathy. VASCULAR: Mild atherosclerotic disease is noted. BONES: There is a moderately comminuted left intertrochanteric fracture with superolateral apex angulation and mild impaction and lesser trochanter displacement. An obliquely oriented fracture line extends to the posterior cortex just inferior to the level of the lesser trochanter. No left hip dislocation. No other fractures identified. There is grade 1 anterolisthesis of L5 on S1 with bilateral L5 spondylolysis. SOFT TISSUES: There is indistinct intramuscular hematoma and edema adjacent to intertrochanteric fracture as evidenced by asymmetric expansion of the adjacent musculature. There is a small, fat containing left inguinal hernia. There is a small, fat containing umbilical hernia. IMPRESSION: 1. Comminuted and mildly varus angulated, impacted and displaced left intertrochanteric femoral fracture with superior medial displacement of the lesser trochanter. No hip dislocation. No other fractures identified. 2. Hyperdense material within the bladder suggestive of possible blood products. Recommend clinical correlation. 3. L5 spondylolysis with grade 1 spondylolisthesis. Radiology Report EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT INDICATION: History: ___ with dislocated finger// eval for post reduction TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist and hand. COMPARISON: None. FINDINGS: A splint obscures assessment of fine osseous detail. No fracture or dislocation is seen. Scattered degenerative changes most pronounced and mild at the basal joints of the thumb and distal interphalangeal joints. No bone erosion or periostitis is identified. No suspicious lytic or sclerotic lesion is identified. No soft tissue calcification or radio-opaque foreign bodies are detected. IMPRESSION: 1. No evidence of fracture or dislocation. Gender: M Race: UNKNOWN Arrive by AMBULANCE Chief complaint: L Hip fracture, Transfer Diagnosed with Altered mental status, unspecified temperature: 100.2 heartrate: 68.0 resprate: 18.0 o2sat: 98.0 sbp: 124.0 dbp: 76.0 level of pain: 0 level of acuity: 1.0

Dear Mr. ___, You were admitted to the hospital after a fall and you were found to have a left finger laceration, a left finger dislocation, a laceration near your eye, a bad concussion and a right hip fracture. The Plastic Surgery service reduced the finger dislocation and cleaned and repaired your finger laceration. The Orthopedic Surgery service took you to the operating room and you underwent surgical repair of the right hip. This procedure went well. You sustained a traumatic brain injury from the fall and will continue to benefit from Occupational Therapy for post-concussion management. You are now ready to be discharged to rehab to continue your recovery. Please follow the discharge instructions below: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You may bear weight as tolerated on the right leg. *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. Return to the Emergency Department or see your own doctor right away if any problems develop, including the following: • Persistent nausea or vomiting. • Increasing confusion, drowsiness or any change in alertness. • Loss of memory. • Dizziness or fainting. • Trouble walking or staggering. • Worsening of headache or headache feels different. • Trouble speaking or slurred speech. • Convulsions or seizures. These are twitching or jerking movements of the eyes, arms, legs or body. • A change in the size of one pupil (black part of your eye) as compared to the other eye. • Weakness or numbness of an arm or leg. • Stiff neck or fever. • Blurry vision, double vision or other problems with your eyesight. • Bleeding or clear liquid drainage from your ears or nose. • Very sleepy (more than expected) or hard to wake up. • Unusual sounds in the ear. • Any new or increased symptoms

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / metformin Attending: ___. Chief Complaint: Multiple falls, right ___ Major Surgical or Invasive Procedure: ___ Right burr hole evacuation of ___ History of Present Illness: ___ yo M hx A-Fib on Coumadin who presents with multiple falls in the last few months, 2 falls in the last 24 hours with headtrikes. Pt feels that he fell due to weakness and imbalance. No LOC. Pt transferred from ___ where head CT showed enlarging right SDH and stable left hygroma compared to prior films. At OSH he was reversed with Vit K and KCentra for an INR 1.8. Troponin at OSH was 0.11. Pt denies HA, numbness, weakness, vision changes, chest pain, shortness of breath. He has baseline right arm weakness from right humerus fx ___ months ago. Past Medical History: Essential tremor atrial fibrillation, on coumadin Pace maker (placed ___ yrs ago) HTN BPH GERD NIDDM Social History: ___ Family History: NC Physical Exam: On Admission: O: T:97.5 HR:92 BP:137/92 RR: 16 SAt:98% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: decreased bulk and normal tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout except right upper weakness in Bi/tri/Delt 4+/5. Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger On Discharge: ___ Alert and oriented x3. PERRL. EOMs intact. Face symmetrical. Mild left tongue deviation. Pain limited strength on RUE due to humerus fracture. Improved ROM on Left shoulder, able to lift arm over head. Full strength ___ on bilateral bi/tri/grip. Deltoid ___ bilaterally. No pronator drift. LEs full strength ___. Staples post burr hole and post drain intact, well approximated. No redness, no drainage. Pertinent Results: ___ CT head : Right subacute on chronic SDH max thickness 3cm with 6mm MLS. Left hygroma. Labs ___: 138/ 103/ 30 ----------------<118 4.___/ 1.7 11.3 7.6>-----<218 34.4 N:73.1 L:15.1 M:10.2 E:0.8 Bas:0.4 ___: 0.4 Absneut: 5.57 Abslymp: 1.15 Absmono: 0.78 Abseos: 0.06 Absbaso: 0.03 ___: 13.4 PTT: 28.3 INR: 1.2 Trop: 0.11 CXR ___: A left chest cardiac conduction device generator is contiguous with cardiac leads. Aortic arch calcifications are dense. Biapical pleural calcifications are noted. There is no focal consolidation. No pleural effusion or pneumothorax. ___ CT head 13:00: 1. The patient is status post right trans parietal subdural catheter placement via a burr hole with pneumocephalus now replacing the majority of a large right hemispheric acute on chronic subdural hematoma. Trace amount of dependent hemorrhage is noted along the right parietal lobe. 2. There remains prominent mass effect on the right hemisphere resulting in approximately 10 mm leftward midline shift, similar in appearance to prior examination. 3. Left subdural collection measuring approximately 10 mm in greatest thickness is unchanged. 4. No acute large territory infarct or new hemorrhage is identified. ___ CT head 21:00: 1. Interval decrease in right pneumocephalus with resultant decreased midline shift and mass effect. Otherwise no significant interval change. 2. Mild nonspecific hypodensity of the right frontal lobe which is felt likely to be secondary to sulcal effacement, postoperative edema in changes. This does not appear to affect the precentral gyrus and is improved in appearance from immediate postoperative examination. ___ Shoulder Xrays: FINDINGS: THIS EXAM WAS READ IN CONJUNCTION WITH A SINGLE AXILLARY VIEW OF THE LEFT SHOULDER FROM ___ AT 12:50. ALTHOUGH THAT IMAGE IS SUBOPTIMAL DUE TO POSITIONING, THE GLENOHUMERAL JOINT APPEARS CONGRUENT. THE AC JOINT IS CONGRUENT. NO FRACTURE IS DETECTED ABOUT THE LEFT SHOULDER. THERE IS PROBABLE DIFFUSE OSTEOPENIA. CURVILINEAR DENSITY EXTENDING ALONG THE LATERAL EDGE OF THE SCAPULA INFERIOR GLENOID LIKELY REPRESENTS VASCULAR CALCIFICATION. THE ACROMIOHUMERAL DISTANCE IS PRESERVED. MILD DEGENERATIVE CHANGES OF THE AC JOINT ARE NOTED. THE LEFT-SIDED RIBS ARE PARTIALLY OBSCURED BY A PACEMAKER BATTERY PACK, BUT, WHERE VISIBLE, APPEAR INTACT. NO SIGNIFICANT PLEURAL FLUID OR THICKENING IS SEEN ALONG THE UPPER LEFT CHEST WALL ADJACENT TO THE LEFT SHOULDER. ___ Echo TTE: The left atrium is elongated. The right atrium is moderately 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). Diastolic function could not be assessed. Right ventricular chamber size is normal with normal free wall contractility. The aortic root is mildly dilated at the sinus level. 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mildly dilated aortic root. Mild pulmonary hypertension. ___ CT head: 1. Significant interval decrease in the right pneumocephalus with resolution of the midline shift. 2. Persistent bifrontal and left posterior fossa subdural fluid collections. 3. Slight hypodensity in the right frontal lobe is is essentially resolved. ___ CT Head: 1. Subdural fluid collections along the bilateral frontal convexity ribs with mild sulcal effacement are grossly unchanged as compared to noncontrast head CT ___. 2. Left posterior fossa fluid collection with mild compression upon the left cerebellum is grossly unchanged. 3. No intracranial hemorrhage. 4. No midline shift. ___ Non-contrast head CT: IMPRESSION: Interval removal of a right convexity subdural drain with mildly increased small amount of pneumocephalus along the convexity. Unchanged size of hypodense subdural fluid collections at the bilateral cerebral convexities and the left cerebellopontine angle, as described. Medications on Admission: omeprazole 20 mg daily cholecalciferol daily Coumadin 2 mg daily amlodipine 5 mg Daily pravastatin 20 mg Daily Flomax 0.4 mg daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain Do not exceed 4gm acetaminophen in 24 hours 2. amLODIPine 5 mg PO DAILY 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Heparin 5000 UNIT SC BID 6. LevETIRAcetam 500 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Pravastatin 20 mg PO QPM 9. Senna 17.2 mg PO HS 10. Sodium Chloride 2 gm PO BID 11. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right Subdural Hematoma Left Hygroma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph. INDICATION: History: ___ with sdh // ? infectious process TECHNIQUE: Single AP view COMPARISON: None. FINDINGS: A left chest cardiac conduction device generator is contiguous with cardiac leads. Aortic arch calcifications are dense. Biapical pleural calcifications are noted. There is no focal consolidation. No pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with R SDH s/p burr hole evacuation. Please perform at 1300. // evaluate interval difference TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 20.0 s, 20.9 cm; CTDIvol = 48.0 mGy (Head) DLP = 1,003.4 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: Outside hospital CT head of ___. FINDINGS: The patient is status post right trans parietal subdural catheter placement via a burr hole with drain overlying the right frontal parietal convexity. There is now pneumocephalus replacing the previously described acute on chronic right hemispheric subdural hematoma with amount of dependent residual hematoma adjacent to the right parietal lobe (series 2, image 26). Essentially unchanged leftward midline shift now measuring approximately 10 mm compared to previously described 9mm unchanged appearance of chronic left hemispheric subdural collection measuring approximately 10 mm in greatest thickness. Unchanged 5.7 x 2.5 cm (AP, TRV) CSF density focus in the left posterior fossa resulting in mass effect on the left cerebellar hemisphere and the brainstem. Prominent atherosclerotic calcification of the bilateral internal carotid arteries and vertebral arteries are unchanged. The ventricles are unchanged from prior exam. The basilar cisterns are patent. There is no evidence of acute large territorial infarct. No new hemorrhage. The orbits are unremarkable. Mild mucosal thickening along the inferior aspects of the maxillary sinuses is noted. The remainder the paranasal sinuses are essentially clear. The mastoid air cells middle ears are clear. IMPRESSION: 1. The patient is status post right trans parietal subdural catheter placement via a burr hole with pneumocephalus now replacing the majority of a large right hemispheric acute on chronic subdural hematoma. Trace amount of dependent hemorrhage is noted along the right parietal lobe. 2. There remains prominent mass effect on the right hemisphere resulting in approximately 10 mm leftward midline shift, similar in appearance to prior examination. 3. Left subdural collection measuring approximately 10 mm in greatest thickness is unchanged. 4. No acute large territory infarct or new hemorrhage is identified. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with new LUE weakness/pain s/p burr hole evac for ___ // evaluate for new changes since post-op head CT 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, 17.3 cm; CTDIvol = 46.5 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Nonenhanced head CT dated ___ at 13:06 FINDINGS: Interval decreased right pneumocephalus measuring approximately 2.7 cm from the inner table, previously 3.6 cm. The drainage catheter is seen overlying the right cerebral convexity. There is decreased shift of midline structures now all 5 mm, previously 10 mm. There is otherwise unchanged appearance including the left subdural chronic collection and the CSF density collection in the left posterior fossa a resulting in mass effect on the left cerebellar hemispheres brainstem. There is decreased mass effect on the lateral ventricles. The basal cisterns remain patent. There is mild hypodensity of the right frontal lobe, which is felt to be likely secondary to sulcal effacement, edema and postoperative changes, improved in appearance from prior exam which does not involve the right precentral gyrus. IMPRESSION: 1. Interval decrease in right pneumocephalus with resultant decreased midline shift and mass effect. Otherwise no significant interval change. 2. Mild nonspecific hypodensity of the right frontal lobe which is felt likely to be secondary to sulcal effacement, postoperative edema in changes. This does not appear to affect the precentral gyrus and is improved in appearance from immediate postoperative examination. However given the clinical symptoms, if there is high clinical concern for infarct, MRI would be more sensitive. NOTIFICATION: The finding of impression #2 were discussed with NP ___ by ___, M.D. on the telephone on ___ at 8:00 AM, 1 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old man with new L shoulder pain and Left upper extremity weakness. // evaluate for fracture FINDINGS: THIS EXAM WAS READ IN CONJUNCTION WITH A SINGLE AXILLARY VIEW OF THE LEFT SHOULDER FROM ___ AT 12:50. ALTHOUGH THAT IMAGE IS SUBOPTIMAL DUE TO POSITIONING, THE GLENOHUMERAL JOINT APPEARS CONGRUENT. THE AC JOINT IS CONGRUENT. NO FRACTURE IS DETECTED ABOUT THE LEFT SHOULDER. THERE IS PROBABLE DIFFUSE OSTEOPENIA. CURVILINEAR DENSITY EXTENDING ALONG THE LATERAL EDGE OF THE SCAPULA INFERIOR GLENOID LIKELY REPRESENTS VASCULAR CALCIFICATION. THE ACROMIOHUMERAL DISTANCE IS PRESERVED. MILD DEGENERATIVE CHANGES OF THE AC JOINT ARE NOTED. THE LEFT-SIDED RIBS ARE PARTIALLY OBSCURED BY A PACEMAKER BATTERY PACK, BUT, WHERE VISIBLE, APPEAR INTACT. NO SIGNIFICANT PLEURAL FLUID OR THICKENING IS SEEN ALONG THE UPPER LEFT CHEST WALL ADJACENT TO THE LEFT SHOULDER. IMPRESSION: NO FRACTURE OR DISLOCATION DETECTED ABOUT THE LEFT SHOULDER. FINDINGS ARE CONCORDANT WITH THE WET READING DOCUMENTED BELOW. Radiology Report INDICATION: ___ year old man with multiple recent falls, shoulder pain and limited ROM // Axillary view please FINDINGS: ALTHOUGH THIS IMAGE IS SOMEWHAT SUBOPTIMAL DUE TO POSITIONING , THE LEFT GLENOHUMERAL JOINT APPEARS CONGRUENT. NO FRACTURE IS DETECTED. VASCULAR CALCIFICATIONS ARE NOTED. PLEASE SEE SEPARATE REPORT ON THE AP VIEWS OF THE LEFT SHOULDER UNDER CLIP ___. IMPRESSION: AS ABOVE. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with ___ s/p right crani for evacuation // eval for interval change TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: CT head without contrast ___ FINDINGS: Patient is status post right craniotomy and drain placement. The drain is in unchanged position in the right cerebral convexity. There has been significant interval decrease in the right frontal pneumocephalus and associated mass effect. Previously seen mild left shift of midline structures has resolved. There is persistent right subdural fluid collection as well as left posterior fossae subdural fluid collection causing mass-effect on the left cerebellar hemisphere and the brainstem. Replacing the postoperative pneumocephalus is a right frontal subdural fluid collection measuring approximately 1.5 cm in greatest thickness. Previously described right frontal hypodensity has now resolved. IMPRESSION: 1. Significant interval decrease in the right pneumocephalus with resolution of the midline shift. 2. Persistent bifrontal and left posterior fossa subdural fluid collections. 3. Slight hypodensity in the right frontal lobe is is essentially resolved. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ y/o man w/ Right subacute on chronic SDH s/p Right burr hole evacuation of ___. Head CT without contrast to evaluate amount of residual fluid. // CT Head without contrast to evaluate for amount of residual fluid given increase in drain output. TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 954 mGy-cm CTDI: ___ MGy COMPARISON: Noncontrast head CT ___ Noncontrast head CT ___ 21:13 Noncontrast head CT outside hospital study ___ FINDINGS: Patient is status post right sided craniotomy and drain placement. The drain terminating along the right cerebral convexity is unchanged in position since comparison study. The subdural fluid collections along the bilateral frontal convexities with mild local sulcal effacement are grossly unchanged in size since ___. The left posterior fossa collection (3:9) mildly compressing the left cerebellum is grossly unchanged since comparison study. Previously seen pneumocephalus along the right frontal convexity has resolved in the interval. There is no new or worsening intracranial hemorrhage. There is no shift of midline structures. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: 1. Subdural fluid collections along the bilateral frontal convexity ribs with mild sulcal effacement are grossly unchanged as compared to noncontrast head CT ___. 2. Left posterior fossa fluid collection with mild compression upon the left cerebellum is grossly unchanged. 3. No intracranial hemorrhage. 4. No midline shift. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ male status post right burr hole evacuation for subdural hemorrhage. Evaluate for changes post drain discontinuation. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.8 cm; CTDIvol = 50.6 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: ___ and ___ head CTs. FINDINGS: There is a right frontal burr hole with overlying scalp emphysema and skin staples. There is a right parietal burr hole with overlying scalp emphysema and skin staples. There has been interval removal of previously seen right cerebral convexity drain. There is a small amount of pneumocephalus within the right cerebral convexity. There are bilateral hypodense subdural fluid collections measuring up to 1.2 cm in depth on the right and 1.6 cm in depth on the left. There is asymmetric prominence of the left cerebellopontine angle extra-axial fluid which measures up to 2.7 cm in depth and causes mild mass effect on the left cerebellar hemisphere (3:8). The size of these extra-axial fluid collections are relatively unchanged comparison to prior study. The gray-white matter differentiation is intact without CT evidence of acute territorial infarct, hemorrhage, or mass. The ventricles and cortical sulci are unchanged in size, caliber, and configuration. There is calcification of the intracranial vasculature. The bilateral native lenses are absent, otherwise the orbits are unremarkable. The visualized paranasal sinuses, mastoid air cells, and middle ears are clear. IMPRESSION: Interval removal of a right convexity subdural drain with mildly increased small amount of pneumocephalus along the convexity. Unchanged size of hypodense subdural fluid collections at the bilateral cerebral convexities and the left cerebellopontine angle, as described. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, SDH Diagnosed with Syncope and collapse temperature: 97.5 heartrate: 92.0 resprate: 16.0 o2sat: 98.0 sbp: 137.0 dbp: 92.0 level of pain: 0 level of acuity: 2.0

Surgery •You underwent a surgery called a burr hole evacuation to have blood removed from your brain. •Please keep your staples along your incision dry until they are removed. •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) until cleared by the neurosurgeon. •You were on an anticoagulation medication called Coumadin (Warfarin) for your atrial fibrillation prior to your injury. Do not resume this medication until cleared by your neurosurgeon. •You have been discharged on Keppra (Levetiracetam), please continue to take this medication as prescribed. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •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. What You ___ Experience: •You 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. •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. •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. Headaches: •Headache is one of the most common symptoms after a brain bleed. •Most headaches are not dangerous but you 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 you 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: Lexapro / Aciphex Attending: ___. Chief Complaint: Fatigue Major Surgical or Invasive Procedure: Paracentesis ___ PleurX abdominal catheter placed ___ History of Present Illness: Ms ___ is a ___ year old female with metastatic squamous cell carcinoma of the cervix who presents with weakness after a recent hospitalization at ___. The patient was discharged yesterday from ___ after she was admitted for progressive back pain. Imaging demonstrated bilateral hydronephrosis in addition to metastatic spine disease. She was given radiation and her pain medications were titrated. She was then discharged home. Since discharge, the patient has noted increased lethargy and poor PO intake. She was seen by her ___ who noted orthostasis with tachycardia to 155 (from 100) upon standing. The patient has noted stable, neck pain for the last month without radiation. In addition, she notes progressive pain in her lower spine and ribs. She has no perineal paresthesia or bowel/bladder incontinence. No chest pain or dyspnea. Noted nausea and vomiting x2 days. Last BM 2 days ago. No melena, hemathochezia or dysuria. Initial vitals in the ED were notable for: T 97.9 HR 121 -> 98 BP 197/97 R 12 SpO2 100% RA Labs were notable for: Ca ___ Cr 0.5 Hgb 9.4 INR 1.3 Flu PCR negative Patient received: ___ 20:01 IV Ondansetron 4 mg ___ 20:02 IV HYDROmorphone (Dilaudid) 1 mg ___ 21:24 IVF NS ( 1000 mL ordered) ___ 21:24 IV HYDROmorphone (Dilaudid) 1 mg Imaging demonstrated: ___ 20:58 Chest (Pa & Lat) IMPRESSION: No pneumonia or acute cardiopulmonary process. ECG: NSR. Normal intervals. QTc 419. TWI V1-V3 No J waves. Increased QRS voltages comparted to prior ECG. ROS: 10 point review of systems discussed with patient and negative unless noted above Past Medical History: PAST ONCOLOGIC HISTORY: - ___: Began having heavy, persistent vaginal bleeding along with severe pelvic pain radiating to her legs -___ Exam under anesthesia: Pap smear and cervical biopsies. Intraoperative findings were notable for "eroded massive tissue that was the cervix with sloughing of tissue. The cervix was noted to be completely eroded and friable and bleeding. There is no distinctive anterior lip of the cervix or posterior cul-de-sac. It appeared that the anterior vaginal wall was adhered to the cervical tissue. Cervical tissue was noted to be very nodular and friable. The anterior vaginal wall was also very nodular. A Pap smear was completed of the cervix. In doing so, 1 cm pieces of cervical tissue sloughed. This was sent for frozen section. The frozen section came back as invasive carcinoma without being able to identify the primary source though it does appear to be cervical. Hysteroscopy was deferred given the persistent cervical bleeding and tissue sloughing. -___ CT A/P shows multiple liver lesions, retroperitoneal and pelvic LAD, focal lytic lesion in L5 vertebra. -___: CT chest shows multiple asymmetric PE's -___: liver biopsy confirms metastatic cervical CA -___: C1D1 ___ -___: Noted to have extensive LLE DVT. Lovenox dosing increased to 60 BID. -___: C2D1 ___ -___: C3D1 ___ -___: CT Torso shows mixed response to treatment; improvement in liver lesions, but multiple new bony mets and worsening inguinopelvic LAD. -___: C1 Pembrolizumab -___: admitted for worsening pain; s/p pelvic XRT PAST MEDICAL HISTORY: Squamous Cell Cervical Cancer Anxiety Asthma Depression Hypothyroidism ___ pembro Social History: ___ Family History: -Breast cancer in maternal aunt -___ cancer in maternal uncle -stroke: father, maternal grandfather, maternal grandmother -___: Father, maternal grandfather, mother -Cardiac arrest: maternal grandfather Physical ___: ADMISSION PHYSICAL EXAM: VITALS: T 98.6 BP 115/76 HR 98 R 18 SpO2 97 RA GENERAL: Thin, chronically ill appearing, NAD HEENT: dry membranes, no lesions. No thrush EYES: PERRL, anicteric NECK: supple RESP: CTAB, no increased WOB, no wheezing, rhonchi or crackles ___: RRR no MRG GI: soft, diffuse TTP on palpation no rebound or guarding SKIN: dry NEURO: CN II-XII intact, strength ___ ___ b/l ACCESS: PIV DISCHARGE PHYSICAL EXAM: T 99.5 PO, BP 114 / 73, HR 120, RR 20, O2 98 ra General: Pleasant but ill and cachectic young woman. HEENT: MMM, no thrush, no OP lesions. Tongue deviates to the left. Symmetric palate. CV: RRR PULM: Respirations unlabored. Decreased BS at the bases bilaterally with soft crackles. Speaks in full sentences ABD: Soft, mild distension, mild tenderness in lower quadrants with small amount of rebound tenderness. LIMBS: 1+ LLE edema. Decreased bulk SKIN: No rashes on extremities. NEURO: Fatigued but oriented x3. Some psychomotor slowing, but strength grossly intact. PSYCH: Mood remains appropriately apprehensive and affect is appropriate, congruent and full. Continues to have some difficulty processing her advanced illness but her thought process is linear and goal directed. Pertinent Results: ADMISSION LABS: =============== ___ 07:55PM BLOOD WBC-8.9 RBC-3.33* Hgb-9.4* Hct-30.2* MCV-91 MCH-28.2 MCHC-31.1* RDW-17.4* RDWSD-55.5* Plt ___ ___ 09:00PM BLOOD ___ PTT-27.9 ___ ___ 07:55PM BLOOD Glucose-98 UreaN-7 Creat-0.5 Na-136 K-4.2 Cl-94* HCO3-28 AnGap-14 ___ 07:55PM BLOOD ALT-11 AST-23 AlkPhos-171* TotBili-0.3 ___ 07:55PM BLOOD Albumin-3.2* Calcium-12.5* Phos-3.3 Mg-1.6 ___ 07:55PM BLOOD TSH-83* ___ 07:30AM BLOOD T4-4.1* calcTBG-1.22 TUptake-0.82 T4Index-3.4* Free T4-0.5* ___ 07:55PM BLOOD Cortsol-20.3* 25VitD-18* DISCHARGE LABS: =============== ___ 06:50AM BLOOD WBC-11.8* RBC-2.92* Hgb-8.4* Hct-27.3* MCV-94 MCH-28.8 MCHC-30.8* RDW-18.6* RDWSD-61.4* Plt Ct-91* ___ 06:50AM BLOOD Glucose-68* UreaN-18 Creat-0.9 Na-132* K-4.7 Cl-93* HCO3-27 AnGap-12 ___ 06:50AM BLOOD ALT-25 AST-57* TotBili-0.2 ___ 06:50AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1 IMAGING: ___ Imaging PERITONEAL DRAINAGE CAT Technically successful peritoneal PleurX catheter placement ___ Imaging PARACENTESIS DIAG/THERA 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 2.5 L of fluid were removed and sent for requested analysis. ___HEST W/CONTRAST 1. Small to moderate bilateral pleural effusions with compressive atelectasis, new from prior. 2. Progression of diffuse osseous metastases, including a pathologic compression fracture of T2, as seen on same day MR. 3. Please refer to separate report of CT abdomen and pelvis performed same day for description of subdiaphragmatic findings. ___ Imaging CT NECK W/CONTRAST (EG: 1. Osseous metastases involving the cervical spine, with severe pathologic compression fracture of C6. Mild retropulsion results in mild spinal canal narrowing. 2. Osseous metastases replacing much of the left mastoid, right occipital condyle and left styloid process. 3. Asymmetric enlargement of the right tongue base, as seen on prior MR, suggestive of denervation of the hypo glossal nerve due to aforementioned metastatic disease in the right occipital condyle. 4. Please refer to separate report of CT chest performed same day for description of thoracic findings. ___BD & PELVIS WITH CO 1. Progression of disease, with numerous hepatic lesions and scattered splenic lesions concerning for metastases, as well as ascites and peritoneal thickening and enhancement suggestive of peritoneal carcinomatosis. 2. Diffuse anasarca. 3. Diffuse osseous metastases, similar to prior, including lytic lesions involving the right acetabulum and right iliac bone which predispose to pathologic fracture. 4. Moderate right hydronephrosis, similar to prior. Mild-to moderate left hydronephrosis is new from prior. 5. Stable borderline enlarged left external iliac chain lymph node. 6. Redemonstration of left external iliac and proximal left femoral vein thrombus. 7. Please refer to separate report of CT chest performed same day for description of thoracic findings. ___ Imaging MR HEAD W & W/O CONTRAS 1. 2.2 cm likely mildly enhancing lesion in the left mastoid with apparent erosion of the left lateral mastoid wall, with overlying soft tissue enhancement, left mastoid effusion. Finding is nonspecific however highly suspicious for metastasis from known primary neoplasm. Differential consideration include infection such as confluent otomastoiditis although there is no evidence of surrounding soft tissue enhancement or edema. 2. Expansile lesion of the right occipital condyle and osseous lesion of the left occipital condyle. There appears to be obliteration of the right hypoglossal canal. 3. Intrinsically T1 isointense small foci of the calvarium are associated with diffusion-weighted hyperintensity, concerning for metastatic disease and/or hemangiomas. 4. No evidence of intracranial metastatic disease at this time. No acute infarct. ___ Imaging MR ___ W/O CONTR 1. Diffuse cervical bony metastatic disease. Difficult to exclude early epidural extension into the anterior epidural space at C6. 2. Moderate to severe compression deformity of C6 is likely subacute, mild marrow edema, presumably pathologic in nature. 3. Mild central spinal canal narrowing at the level of the C6 fracture due to retropulsion of the buckled posterior cortex into the spinal canal by approximately 3 mm. No spinal cord contact or cord signal abnormality. 4. Incidentally noted soft tissue fullness, right base of tongue, felt to be likely secondary to denervation secondary to skullbase lesion. There is also asymmetric fullness of the right lateral oro- pharyngeal wall, incompletely characterized, and may be artifactual. Recommend further evaluation with CT soft tissue neck for further evaluation. 5. Layering biapical pleural effusions are partially visualized. 6. Mild cervical spondylosis. 7. Please see separate report for intracranial findings from same-day MR ___. ___ Imaging UNILAT LOWER EXT VEINS 1. Interval improvement in clot burden from ___, with resolution of previously seen nonocclusive thrombus in the left mid to lower femoral, popliteal and calf veins. 2. Residual clot burden in the left common femoral vein is mildly improved and is now nonocclusive. 3. Non-occlusive thrombus in the left upper femoral vein appears similar. ___ Imaging MR PITUITARY ___ CONT 1. The exam is limited secondary to patient motion. 2. Within the limitation of the exam, the pituitary gland is within normal limits. 3. If there is concern for metastatic lesions within the brain parenchyma, cervical spine or skull base, further evaluation with dedicated brain MRI with and without contrast and skullbase protocol as well as dedicated MRI evaluation of the cervical spine could be performed as clinically indicated. ___ Imaging CHEST (PA & LAT) No pneumonia or acute cardiopulmonary process. MICROBIOLOGY: ___ Influenza A/B PCR - Negative ___ Urine Culture - < 10,000 CFU/mL ___ Blood Culture - Negative ___: Blood Cx x2 - Negative ___: Urine Cx - <10K CFU ___ Peritoneal fluid - Gram Stain Negative; Culture - No growth ___ Peritoneal fluid cytology - PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 2. Gabapentin 100 mg PO BID 3. Gabapentin 300 mg PO QHS 4. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 17.2 mg PO BID 7. Bisacodyl 10 mg PO DAILY 8. ClonazePAM 1 mg PO QHS 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 12. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 13. Levothyroxine Sodium 50 mcg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Severe Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain or bloating RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth q8 hours Disp #*180 Tablet Refills:*0 2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Duration: 10 Days RX *amoxicillin-pot clavulanate 200 mg-28.5 mg/5 mL 10 mL by mouth q8 hours Disp #*300 Milliliter Refills:*0 3. Dexamethasone 4 mg PO DAILY RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Lidocaine 5% Patch 1 PTCH TD QPM cervical leison, pain RX *lidocaine 5 % 1 patch q 24 hours Disp #*30 Patch Refills:*0 5. Methadone 15 mg PO QAM 8am RX *methadone 5 mg 3 tabs by mouth qam Disp #*90 Tablet Refills:*0 6. Methadone 10 mg PO BID 2pm and 8pm RX *methadone 10 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 7. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 8am and 2pm RX *methylphenidate HCl 5 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Simethicone 40-80 mg PO QID:PRN bloating RX *simethicone [Gas Relief] 80 mg 1 tab by mouth four times a day Disp #*120 Tablet Refills:*0 9. Levothyroxine Sodium 100 mcg PO DAILY RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth twice a day Disp #*48 Packet Refills:*0 11. Bisacodyl 10 mg PO DAILY RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 12. ClonazePAM 1 mg PO QHS RX *clonazepam 1 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 13. Gabapentin 100 mg PO BID RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 14. Gabapentin 300 mg PO QHS RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 15. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Severe RX *hydromorphone 4 mg 1 - 2 tablet(s) by mouth q4 hours Disp #*240 Tablet Refills:*0 16. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 8 mg 1 tablet(s) by mouth q8 hours Disp #*90 Tablet Refills:*0 17. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6 hours Disp #*120 Tablet Refills:*0 18. Senna 17.2 mg PO BID RX *sennosides [senna] 8.6 mg 2 bid po constipation Disp #*120 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Metastatic squamous cancer of the cervix # Cancer associated cachexia # Peritoneal carcinomatosis # Secondary malignancy of bone # Secondary malignancy of liver # Hypercalcemia # Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with tachycardia, weakness// Please evaluate for pneumonia or effusion TECHNIQUE: Chest PA and lateral views. COMPARISON: Chest radiograph ___. FINDINGS: Lungs are clear without focal consolidation, pleural effusion, or pneumothorax. Mediastinal and hilar contours are within normal limits. Heart size is normal. No acute osseous abnormality. IMPRESSION: No pneumonia or acute cardiopulmonary process. Radiology Report EXAMINATION: MR PITUITARY ___ CONTRAST T___ MR HEAD SUB. INDICATION: ___ with metastatic cervical cancer with bone mets s/p XRT and on pembo who presents with fatigue, weakness, and orthostatis found to have hypercalcemia, dehydration, and hypothyroidism. Labs were elevated prolactin, low FSH/LH.// Evaluate for pituitary mass/met. TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with coronal T2 imaging. Sagittal and coronal T1 weighted imaging were repeated after the uneventful intravenous administration of 4 mL of ___ contrast agent. Exam is limited secondary to patient motion. Best possible images were obtained. COMPARISON MR thoracic spine ___. MR ___ ___. FINDINGS: Images of the pituitary gland are within normal limits. Pituitary signal intensity is normal both before and after contrast administration. The pituitary stock is normal in caliber and configuration. No masses are identified within the pituitary gland. The parasellar, suprasellar cisterns, and cavernous sinuses are within normal limits. Limited evaluation of the brain parenchyma appears unremarkable. No gross abnormalities are noted in the partially visualized tongue base, incompletely evaluated. Note is made of heterogeneous marrow signal in the partially visualized cervical spine. IMPRESSION: 1. The exam is limited secondary to patient motion. 2. Within the limitation of the exam, the pituitary gland is within normal limits. 3. If there is concern for metastatic lesions within the brain parenchyma, cervical spine or skull base, further evaluation with dedicated brain MRI with and without contrast and skullbase protocol as well as dedicated MRI evaluation of the cervical spine could be performed as clinically indicated. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ year old woman with h/o DVT now with increased swelling of LLE// eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: Bilateral lower extremity ultrasound from ___. FINDINGS: There is nonocclusive thrombus in the left common femoral vein, which is improved from ___, where occlusive thrombus was noted. Nonocclusive thrombus is again noted in the upper left femoral vein. There is now normal compressibility and color flow of the left mid to lower 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: 1. Interval improvement in clot burden from ___, with resolution of previously seen nonocclusive thrombus in the left mid to lower femoral, popliteal and calf veins. 2. Residual clot burden in the left common femoral vein is mildly improved and is now nonocclusive. 3. Non-occlusive thrombus in the left upper femoral vein appears similar. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with metastatic cervical cancer with worsening malaise and new fevers, undetermined source// evaluate for source of fever TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 2) Stationary Acquisition 9.3 s, 0.2 cm; CTDIvol = 157.8 mGy (Body) DLP = 31.6 mGy-cm. 3) Spiral Acquisition 11.4 s, 73.9 cm; CTDIvol = 9.7 mGy (Body) DLP = 708.9 mGy-cm. Total DLP (Body) = 742 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed same day. ABDOMEN: HEPATOBILIARY: There are numerous ill-defined hypodensities throughout the liver, measuring up to 2.4 cm, new from prior. 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. There are scattered subtle hypoattenuating lesions measuring up to 1 cm (04:47, 53), new from prior. 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 are no focal lesions. Moderate right hydronephrosis is similar to prior. Mild-to-moderate left hydronephrosis is new from prior. 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. There is large volume ascites, and peritoneal enhancement and thickening. PELVIS: The urinary bladder and distal ureters are unremarkable. REPRODUCTIVE ORGANS: Known cervical malignancy is not well evaluated on CT. No adnexal abnormalities are demonstrated. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. A left external iliac chain lymph node is unchanged, measuring 1.0 cm (4:109) there is no inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. An IVC filter is in place. The left external iliac vein and proximal femoral vein is not opacified, consistent with known thrombus. BONES: Extensive osseous metastases are again seen, including a 2.3 cm lytic lesion in the left iliac bone (4:103), and a 2.5 cm lytic lesion in the vertebral body of L1. A 1.1 cm lytic lesion in the right iliac bone demonstrates apparent cortical break at the posterior aspect and cortical thinning at the anterior aspect, and a 1.6 cm right acetabular lytic lesion demonstrates at least near complete cortical breakthrough, both of which can predispose to pathologic fracture. A chronic healed fracture of the right lateral seventh rib is unchanged. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. There is diffuse anasarca. IMPRESSION: 1. Progression of disease, with numerous hepatic lesions and scattered splenic lesions concerning for metastases, as well as ascites and peritoneal thickening and enhancement suggestive of peritoneal carcinomatosis. 2. Diffuse anasarca. 3. Diffuse osseous metastases, similar to prior, including lytic lesions involving the right acetabulum and right iliac bone which predispose to pathologic fracture. 4. Moderate right hydronephrosis, similar to prior. Mild-to-moderate left hydronephrosis is new from prior. 5. Stable borderline enlarged left external iliac chain lymph node. 6. Redemonstration of left external iliac and proximal left femoral vein thrombus. 7. Please refer to separate report of CT chest performed same day for description of thoracic findings. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD INDICATION: ___ year old woman with metastatic cervical cancer w/ failure to thrive, now w/ inability to move her tongue in all directions// rule out brain mets esp involving the hypoglossyl nerve TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: None available. FINDINGS: There is a 2.2 x 1.6 x 2.0 cm likely mildly enhancing lesion within the left mastoid (16:50 and 52). There is apparent erosion through/dehiscence of the lateral mastoid wall, with overlying soft tissue enhancement. There is a partial left mastoid effusion. There is diffusion-weighted hyperintense signal of the bilateral occipital condyles more prominent on the right. There is associated enhancing soft tissue expansion and apparent remodeling of the right occipital condyle measuring approximately 1.4 x 1.3 cm (series 16, image 34; series 10, image 9), and abnormal signal of the right occipital condyle (series 10, image 13), concerning for metastatic disease. There is presumed obliteration of the right hypoglossal canal. A few foci of intrinsically T1 isointense foci in the left and right frontal calvarium (see series 11, image 23 and 22) demonstrate faint high signal on diffusion-weighted images, raising concern for possible metastatic disease and/or hemangiomas. There is no evidence of hemorrhage, edema, brain parenchymal mass, mass effect, midline shift or infarction. The ventricles and sulci are within expected limits in caliber and configuration. There is no abnormal brain parenchymal enhancement after contrast administration. Right frontal developmental venous anomaly is noted. Aside from dysconjugate gaze, the globes and orbits are unremarkable. Major intracranial vascular flow voids are preserved. Major dural venous sinuses are patent. The visualized paranasal sinuses and right mastoid appears clear. IMPRESSION: 1. 2.2 cm likely mildly enhancing lesion in the left mastoid with apparent erosion of the left lateral mastoid wall, with overlying soft tissue enhancement, left mastoid effusion. Finding is nonspecific however highly suspicious for metastasis from known primary neoplasm. Differential consideration include infection such as confluent otomastoiditis although there is no evidence of surrounding soft tissue enhancement or edema. 2. Expansile lesion of the right occipital condyle and osseous lesion of the left occipital condyle. There appears to be obliteration of the right hypoglossal canal. 3. Intrinsically T1 isointense small foci of the calvarium are associated with diffusion-weighted hyperintensity, concerning for metastatic disease and/or hemangiomas. 4. No evidence of intracranial metastatic disease at this time. No acute infarct. RECOMMENDATION(S): 1. CT neck with contrast for impression 1 and 2. 2. Bone scan for further assessment of additional calvarial lesions, indeterminate. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 2:49 pm, 10 minutes after discovery of the findings. Radiology Report EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE INDICATION: ___ year old woman with metastatic cervical cancer w/ failure to thrive, now w/ inability to move her tongue in all directions// rule out progressive cervical spine mets TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 and gradient echo imaging were next performed. After administration of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was performed. COMPARISON: MR ___ ___. FINDINGS: Images are moderately motion degraded, limiting assessment. Within these confines: There is multifocal T1 hypointense, faintly enhancing, STIR hyperintense signal throughout the cervical spine involving multiple vertebral bodies including C2, C3, C5, C6, as well as T1 and T2, compatible with cervical and upper thoracic metastases, involving both the vertebral bodies and posterior elements (For example see series 300, image 7). There is faint enhancement posterior to the C6 vertebral body as well as C7, which may be normal enhancing venous plexus, however slight epidural extension is difficult to exclude given the degree of motion degradation (19:8). Osseous metastatic disease of the right greater than left occipital condyles is also identified. There is moderate to severe compression deformity of C6, with mild marrow edema, possibly a subacute fracture, presumably pathologic in nature. There is 3 mm bony retropulsion of the buckled posterior cortex into the spinal canal without spinal cord contact, causing mild spinal canal narrowing (05:29). There is 2 mm of C4-5 anterolisthesis, likely degenerative. Alignment elsewhere is normal. Aside from C6, vertebral body heights are preserved. The cervical spinal cord is normal in caliber and signal intensity. There are mild cervical spine degenerative changes. Aside from mild narrowing at C6 (as above), no additional cervical central canal narrowing. There is mild uncovertebral osteophytosis causing mild multilevel neural foraminal narrowing, worst (mild) on the right at C4-5 (06:21). Layering biapical pleural effusions are noted. There is asymmetric enlargement of the right tongue base, felt likely sequela of denervation secondary to skullbase lesion described in the MRI head. However, the right lateral oropharyngeal wall also appears possibly asymmetrically thickened, incompletely characterized (05:12 and 06:13). Please see separate report for intracranial findings from same-day MRI head. IMPRESSION: 1. Diffuse cervical bony metastatic disease. Difficult to exclude early epidural extension into the anterior epidural space at C6. 2. Moderate to severe compression deformity of C6 is likely subacute, mild marrow edema, presumably pathologic in nature. 3. Mild central spinal canal narrowing at the level of the C6 fracture due to retropulsion of the buckled posterior cortex into the spinal canal by approximately 3 mm. No spinal cord contact or cord signal abnormality. 4. Incidentally noted soft tissue fullness, right base of tongue, felt to be likely secondary to denervation secondary to skullbase lesion. There is also asymmetric fullness of the right lateral oro- pharyngeal wall, incompletely characterized, and may be artifactual. Recommend further evaluation with CT soft tissue neck for further evaluation. 5. Layering biapical pleural effusions are partially visualized. 6. Mild cervical spondylosis. 7. Please see separate report for intracranial findings from same-day MR head. RECOMMENDATION(S): Recommend CT tissue neck for further evaluation of the base of tongue/right lateral oropharyngeal wall. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ with metastatic cervical cancer with worsening malaise and new fevers, undetermined source// evaluate for source of fever TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 2) Stationary Acquisition 9.3 s, 0.2 cm; CTDIvol = 157.8 mGy (Body) DLP = 31.6 mGy-cm. 3) Spiral Acquisition 11.4 s, 73.9 cm; CTDIvol = 9.7 mGy (Body) DLP = 708.9 mGy-cm. Total DLP (Body) = 742 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Prior Chest CTs ___ FINDINGS: NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal. Supraclavicular and axillary lymph nodes are not enlarged. MEDIASTINUM: Mediastinal lymph nodes are not enlarged. HILA: Hilar lymph nodes are not enlarged. HEART: The heart is not enlarged and there is no coronary arterial calcification. There is a small pericardial effusion. VESSELS: Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. PULMONARY PARENCHYMA: There is no evidence of infection or malignancy. There is bilateral lower lobe atelectasis. There is no emphysema. AIRWAYS: The airways are patent to the subsegmental level bilaterally. PLEURA: There are small to moderate bilateral pleural effusions. CHEST WALL AND BONES: There is a pathologic compression fracture of C6, as seen on same day MR. ___ lytic osseous metastases are increased in size from prior. For example, a lesion in the T2 vertebral body measures 1.3 cm, previously 0.7 cm (05:58) and a lytic lesion in the sternum measures 2.5 cm in transverse dimension (5:98), previously 2.0 cm. There is suggestion of the lesion in the right inferior scapula (5:176) and in numeral rim lesions are present.. UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report for subdiaphragmatic findings. IMPRESSION: 1. Small to moderate bilateral pleural effusions with compressive atelectasis, new from prior. 2. Progression of diffuse osseous metastases, including a pathologic compression fracture of T2, as seen on same day MR. 3. Please refer to separate report of CT abdomen and pelvis performed same day for description of subdiaphragmatic findings. Radiology Report EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old woman with metastatic cervical SCC. Hypoglossal paralysis, MRI with extesnsive osseous lesions, particularly ? erosive mastoid lesion. Also with recurrent fever// Better eval lesions noted on CT. Particularly erosoive mastoid lesion. Eval recurrent fever. TECHNIQUE: Imaging was performed after administration of Omnipaque intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 185.2 mGy-cm. Total DLP (Body) = 185 mGy-cm. COMPARISON: MR ___ dated earlier same day. FINDINGS: As seen on prior MR, there is asymmetric enlargement of the right tongue base (03:26). The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears enlarged but homogeneous.There is no lymphadenopathy by CT criteria. The neck vessels are patent. There is a severe compression deformity of C6, which is extensively replaced by lytic osseous metastasis, consistent with pathologic fracture. There is mild retropulsion into the spinal canal, with mild spinal canal narrowing. Additional lytic lesions are noted diffusely throughout the spine. Lytic metastasis replaces much of the left mastoid (04:36), with cortical destruction involving the medial and lateral aspects. The right occipital condyle is partially replaced by soft tissue (06:34). The left styloid process is discontinuous, suggestive of metastatic involvement. Please refer to separate report for description of thoracic findings. IMPRESSION: 1. Osseous metastases involving the cervical spine, with severe pathologic compression fracture of C6. Mild retropulsion results in mild spinal canal narrowing. 2. Osseous metastases replacing much of the left mastoid, right occipital condyle and left styloid process. 3. Asymmetric enlargement of the right tongue base, as seen on prior MR, suggestive of denervation of the hypo glossal nerve due to aforementioned metastatic disease in the right occipital condyle. 4. Please refer to separate report of CT chest performed same day for description of thoracic findings. Radiology Report EXAMINATION: Ultrasound guided paracentesis INDICATION: ___ year old woman with metastatic cervical cancer and new peritoneal carcinomatosis// eval for diagnostic/therapeutic paracentesis FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated a large amount of ascites. A suitable target in the deepest pocket in the left lower quadrant was selected for paracentesis. PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis Location: left lower quadrant Fluid: 2.5 L of clear, straw-colored fluid Samples: Fluid samples were submitted to the laboratory the requested analysis (cytology, chemistry, hematology, microbiology). 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 diagnostic and therapeutic paracentesis. 2. 2.5 L of fluid were removed and sent for requested analysis. Radiology Report INDICATION: ___ year old woman with metastatic cervical cancer and peritoneal carcinomatosis; recurrent malignant ascites// eval for pleurX placement COMPARISON: Paracentesis ___ TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___, Interventional Radiology fellow performed the procedure. Dr. ___ supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 1mcg of fentanyl and 50 mg of midazolam throughout the total intra-service time of 30 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1 g of Ancef CONTRAST: None FLUOROSCOPY TIME AND DOSE: 1.2 minutes, 4 mGy PROCEDURE: 1. Limited abdominal ultrasound 2. Peritoneal PleurX catheter placement The procedure, risks, benefits and alternatives were discussed with the patient and written informed consent was obtained. The abdomen was cleaned and draped in standard sterile fashion. A pre-procedure time-out was performed as per ___ protocol. Under ultrasound guidance, an entrance site was selected in the right lower quadrant. 1% lidocaine was instilled for local anesthesia. Under direct ultrasound guidance, a 5 ___ catheter was advanced into the ascitic fluid. A ___ wire was passed through the catheter and crossed to the left side of the abdominal cavity. A location for the subcutaneous tunnel was chosen and 1% lidocaine was administered at the skin entry site and along the tunnel tract. A skin incision was made and the catheter was tunneled to the peritonotomy site. The 5 ___ catheter site was dilated and a peel-away sheath was inserted. The wire and inner cannula were removed and the PleurX catheter was passed through the peel-away sheath. Final position of the catheter was confirmed with fluoroscopy. The ___ catheter site was closed with ___ Vicryl subcuticular suture and Steri-Strips. 1100 cc of clear yellow fluid was aspirated. The tube was then capped and the site was dressed. The patient tolerated the procedure well without any immediate postprocedure complications. FINDINGS: Limited grayscale ultrasound imaging of the abdomen demonstrated small volumeascites. A suitable target in the deepest pocket in the right lower quad quadrant was selected for PleurX catheter placement. IMPRESSION: Technically successful peritoneal PleurX catheter placement Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Lethargy, N/V Diagnosed with Weakness temperature: 97.9 heartrate: 121.0 resprate: 12.0 o2sat: 100.0 sbp: 137.0 dbp: 97.0 level of pain: 6 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You were admitted with increasing fatigue, weakness, and pain. We found you had high calcium levels and low thyroid levels, and we increased your thyroid medication and also gave you medicine to lower your calcium. Unfortunately, further imaging showed significant progression of your cancer despite treatment with pembrolizumab. This was causing you to develop a large amount of fluid in your abdomen, which we drained off, and ultimately put in a long-term drain you can use at home. We also adjusted your pain medicines to better treat your pain. After discussion with radiation oncology we decided against further radiation treatments. You also had intermittent fevers, which we think are due to the cancer. However, we went ahead and started you on a course of antibiotics to treat an underlying infection, if present. We also met extensively with your medical oncology team, and unfortunately no viable chemotherapy options are possible. In order to allow you to enjoy time with your family, we have arranged for you to be discharged with hospice care. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Vancomycin / Iodine-Iodine Containing / Meropenem / Ceftriaxone / Ciprofloxacin / Flagyl / Levaquin / Aztreonam / moxifloxacin / Bactrim Attending: ___ ___ Complaint: diarrhea/nausea/vomiting/palpitations Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ yo female w/ a hx of AML s/p alloSCT in ___, in remission since, course c/b GVHD of skin, lung, and gut; CAD s/p 1v-CABG in ___, asthma (FEV1 40-45%), with recent exacerbation of lung GVHD, currently on Prednisone 20 mg PO QD with improvement in Sx, Afib on rivaroxiban and other issues presents to the ED with palpitations. Last night she noted acute onset palpitations (HR in the 120s) around 1 am that woke her from sleep. She did not have chest pain or shortness of breath. She has since vomited 2x, once at home and once in the ED. Her palpitations intermittently resolved but then worsened again. She denies recent fever/chills, cough/SOB, dysuria/hematuria, or preceding diarrhea. She does note having mutliple episodes of diarrhea. She reports adequate PO intake (eating more lately ___ steroids). In the ED, initial vital signs were: 96.3 85 124/56 18 96% RA she received Zofran with good relief for he nausea. Initially her HR was in the ___ and appeared to be sinus w/ frequent PACs; however, around 10:30a she was noted to be in Afib with RVR with rates in the 120s-130s, occasionally up to the 150s. SBP in the 100s (pt reports 110s normal for her), no chest pain or SOB. ECG 8:38a: Sinus arrhythmia, old Q waves inferolaterally, no new ST segment or T wave changes (TWIs in V1-V3 are old). ECG 10:28a: Afib w/ HR 150s, with ST depressions in V2-V4. CXR with no acute process. Cardiology was consulted and recommended rate control, increased metoprolol succinate from 25 mg PO QD to 50 mg PO QD, troponin was negative x2. While in the ED HR shot up to the 150s while having a bowel movement, then subsequently became bradycardic down to the ___ in sinus and became hypotensive to the ___ systolic. While patient was being assessed, her HR improved to the ___ and her BP recovered to the 120s. It was suspected this was a vasovagal episode (given bradycardia and hypotension) in the setting of a bowel movement. Non-con CT abd/pelvis was performed to rule out colitis given chronic steroid use and new diarrhea. Exam was notable for NAD, irreg irreg, no abd tenderness, euvolemic. Labs were notable for WBC 13, Cr of 1.4, TSH 4.9 troponins negative x2, UA - small bacteria and positivenitrites but no pyuria, given no Sx decision was made not to treat will not treat. Patient was given ___ 10:37 IV Metoprolol Tartrate 5 mg ___ 10:37 IVF 1000 mL NS 1000 mL ___ 11:20 PO Metoprolol Succinate XL 50 mg ___ 12:07 IV Magnesium Sulfate 2 gm ___ 18:24 IV Ondansetron 4 mg On Transfer Vitals were: 72 117/57 18 100% RA Since coming to the floor patient reports feeling fatigued, nauseous and having loose stools. Denies SOB, chest pain, palpitations and abdominal pain Review of Systems: As per HPI Past Medical History: . PAST ONCOLOGIC HISTORY: - AML diagnosed ___ on routine bloodwork showing pancytopenia; bone marrow biopsy showed myelodysplasia without cytogenetic abnormalities - repeat bone marrow biopsy showed acute erythroleukemia - admitted ___ for induction 7+3 with cytarabine and idarubicin, day 14 marrow showed no blasts - ___ allogeneic transplantation from an HLA matched sibling donor with pentostatin/TBI in ___ c/b mild GVHD - post-transplant course complicated by STEMI ___ with DES to RCA ___ and CABG (LIMA-LAD) ___ - complicated by GVHD of the skin and lungs, on Prednisone 7.5mg currently . OTHER MEDICAL HISTORY: - CAD s/p STEMI ___ with DES to RCA ___ and CABG (LIMA-LAD) ___ - Afib - Diverticulitis, hx of perforated diverticulum ___ ___ complicated by multiple abdominal abscesses; sigmoidostomy with ___ pouch and colostomy; reversed ___ - CHF with EF 40-45% Hypertension - Hypercholesterolemia - GERD - Type two diabetes mellitus - Diverticulosis - Occasional bronchospasm - History of SVC clot ___ PORT (s/p course of lovenox) - History of C.Diff ___ & ___ - History of VRE - History of Shingles - History of Asthma - basal cell carcinoma-s/p electrodessication and curettage on ___ - tonsillectomy at the age of ___; - D&C for question of some polyps back in ___ - Hospitalization for pneumonia ___ - ___ - ADRENAL INSUFFICIENCY . Social History: ___ Family History: The patient's mother with a history of stroke. Both of her maternal and paternal grandmothers also had a history of CVA. Father with history of colon ___. No other known history of cancer in the family. No known blood disorders. Has a sister with ___. She has 2 sisters, the other sister with hypertension. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.1 118/52 76 18 98%RA Wt 73.8 height 5'6 General: ill appearing, NAD HEENT: dry mucus membranes, EOMI CV: RRR no m/r/g Lungs: CTA bilaterally no wheezes, rhonchi or rales Abdomen: +BS, soft, NTTP, ND Ext: WWP, no edema Neuro: AOX3, strength and sensation grossly intact Skin: warm no visible rashes DISCHARGE PHYSICAL EXAM: Vitals: 97.8 80 108/64 20 96%RA I/O ___ Tele: Sinus rhythm, no alarms General: patient appears more comfortable lying in bed, NAD HEENT: MMM, EOMI CV: RRR no m/r/g Lungs: CTA bilaterally no wheezes Abdomen: +BS, soft, no TTP, ND Ext: WWP, no edema Neuro: AOX3, strength and sensation grossly intact Skin: warm, no visible rashes, erythema over chest, decresed skin turgor Pertinent Results: ADMISSION LABS: ___ 09:25AM BLOOD WBC-13.8* RBC-4.95 Hgb-15.0 Hct-44.4 MCV-90 MCH-30.3 MCHC-33.8 RDW-17.3* Plt ___ ___ 09:25AM BLOOD Neuts-66.3 ___ Monos-8.5 Eos-2.3 Baso-0.4 ___ 09:25AM BLOOD Glucose-151* UreaN-25* Creat-1.4* Na-140 K-4.3 Cl-102 HCO3-25 AnGap-17 ___ 09:25AM BLOOD ALT-22 AST-16 AlkPhos-52 TotBili-0.5 ___ 09:25AM BLOOD Albumin-4.2 Calcium-9.9 Phos-2.9 Mg-1.8 ___ 09:25AM BLOOD TSH-4.9* ___ 10:22PM BLOOD ___ pO2-220* pCO2-32* pH-7.37 calTCO2-19* Base XS--5 Comment-GREEN TOP ___ 10:22PM BLOOD Lactate-1.6 ___ 01:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:00PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:00PM URINE RBC-0 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 ___ 01:00PM URINE Mucous-RARE DISCHARGE LABS: ___ 05:49AM BLOOD WBC-4.8 RBC-3.68* Hgb-11.1* Hct-32.2* MCV-87 MCH-30.1 MCHC-34.4 RDW-17.3* Plt ___ ___ 05:49AM BLOOD Neuts-71* Bands-0 ___ Monos-7 Eos-1 Baso-0 ___ Myelos-0 ___ 05:49AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear ___ ___ 05:49AM BLOOD Plt Smr-NORMAL Plt ___ ___ 05:49AM BLOOD ___ PTT-31.8 ___ ___ 05:49AM BLOOD Glucose-148* UreaN-12 Creat-1.0 Na-139 K-4.3 Cl-106 HCO3-25 AnGap-12 ___ 05:49AM BLOOD ALT-35 AST-33 LD(LDH)-252* AlkPhos-36 TotBili-0.4 ___ 05:49AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.7 Mg-1.9 ___ 06:02AM BLOOD IgG-320* IMAGING CHEST (PA & LAT)Study Date of ___ No pneumonia or CHF. Known aortic pseudoaneurysm. CT ABD & PELVIS W/O CONTRASTStudy Date of ___ 1. No evidence of acute pathology within the abdomen or pelvis. 2. Extensive colonic diverticulosis without evidence of acute diverticulitis. 3. 3.3 cm infrarenal abdominal aortic aneurysm, increased in size since ___. 4. Cholelithiasis without evidence of acute cholecystitis. MICRO ___ 1:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ 5:36 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 20 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Atovaquone Suspension 750 mg PO DAILY 5. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea, insomina 6. Metoprolol Succinate XL 25 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Docusate Sodium 100 mg PO DAILY 9. Rivaroxaban 20 mg PO DAILY 10. Famotidine 20 mg PO BID 11. Atorvastatin 80 mg PO QPM 12. Acyclovir 400 mg PO Q12H 13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 14. Azithromycin 250 mg PO Q24H 15. Omeprazole 20 mg PO DAILY 16. Aspirin 81 mg PO DAILY 17. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheezing 18. GlipiZIDE 5 mg PO DAILY 19. Levothyroxine Sodium 25 mcg PO DAILY 20. Cyanocobalamin 500 mcg PO DAILY 21. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Atovaquone Suspension 750 mg PO DAILY 5. Azithromycin 250 mg PO 3X/WEEK (___) 6. Cyanocobalamin 500 mcg PO DAILY 7. Docusate Sodium 100 mg PO DAILY 8. Famotidine 20 mg PO BID 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. Levothyroxine Sodium 25 mcg PO DAILY 11. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea, insomina 12. Montelukast 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. PredniSONE 20 mg PO DAILY 15. Rivaroxaban 20 mg PO DAILY 16. Tiotropium Bromide 1 CAP IH DAILY 17. Vitamin D ___ UNIT PO DAILY 18. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheezing 19. GlipiZIDE 5 mg PO DAILY 20. Lisinopril 2.5 mg PO DAILY 21. MetFORMIN (Glucophage) 500 mg PO BID 22. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Rotovirus UTI; Afib w/RVR; AML s/p allo BMT in ___ with skin and lung GVHD SECONDARY: T2DM, CAD 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: Weakness, nausea, vomiting, palpitations. Assess for acute process. COMPARISON: Chest radiograph ___. FINDINGS: Frontal and lateral chest radiograph demonstrates well-expanded and clear lungs, unchanged in appearance ___. Stable bulge at aortic arch corresponds to patient's known pseudoaneurysm as seen on CT chest dated ___. No pleural effusion or pneumothorax. Heart size, mediastinal contour and hila are unremarkable. IMPRESSION: No pneumonia or CHF. Known aortic pseudoaneurysm. Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: ___ with paroxysmal Afib and new nausea/vomiting and diarrhea, rule out colitis. TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis without the administration of IV contrast . Coronal and sagittal reformatted images were also generated for review. DOSE: 598 mGy-cm COMPARISON: CT torso from ___ FINDINGS: Evaluation of intra-abdominal soft tissues in organs is somewhat limited without the administration of IV contrast. LOWER CHEST: There is mild atelectasis at the lung bases bilaterally which are otherwise clear. LIVER: The liver demonstrates homogeneous attenuation. No focal liver lesion is seen given the limitations of this noncontrast enhanced study. The gallbladder contains small gallstones without pericholecystic fluid or wall edema. There is no intra or extrahepatic biliary ductal dilatation. PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic stranding or fluid collection. SPLEEN The spleen is homogeneous and normal in size. ADRENALS: The adrenal glands are unremarkable. KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation or perinephric abnormalities are present. GI TRACT: The stomach, duodenum, and small bowel are within normal limits, without evidence of wall thickening or obstruction. The colon is non-dilated without obstructive lesions. There is extensive colonic diverticulosis without evidence of acute diverticulitis. Anastomotic site suggesting prior partial colectomy seen in the sigmoid. The appendix is not visualized but there are no secondary signs of appendicitis. VASCULAR: There is an infrarenal abdominal aortic aneurysm measuring 3.3 x 2.8 cm, increased in size since ___, when it measured 2.8 x 2.4 cm. Atherosclerotic calcifications are seen at the origins of the celiac axis, SMA, and bilateral renal arteries extending into the major branches of the abdominal aorta. RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph node enlargement. No ascites, free air, or abdominal wall hernias are noted. PELVIC CT: The urinary bladder and distal ureters are unremarkable. No pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic free fluid. Uterus and adnexae are unremarkable. OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy present. IMPRESSION: 1. No evidence of acute pathology within the abdomen or pelvis. 2. Extensive colonic diverticulosis without evidence of acute diverticulitis. 3. 3.3 cm infrarenal abdominal aortic aneurysm, increased in size since ___. 4. Cholelithiasis without evidence of acute cholecystitis. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Palpitations Diagnosed with ATRIAL FIBRILLATION, NAUSEA WITH VOMITING temperature: 96.3 heartrate: 85.0 resprate: 18.0 o2sat: 96.0 sbp: 124.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

Dear ___, ___ was a pleasure to take part in your care during you stay here at ___. You came into the hospital after experiencing multiple day of nausea/vomitting/diarrhea and mild fever. You were admitted to the hospital on the medicine service. You were started on antibiotics for a urinary tract infection and to treat a possible bacterial infection in your gut. ON the day of your discharge you were found to have Rotavirus. You were transferred to the Oncology service for continuing care in the hospital. You were found to have low IgG (infection fighting proteins) in your blood. You were given a dose of IgG. You should have your blood levels of this protein checked at your first clinic visit. Your diarrhea, nausea and fatigue resolved prior to you leaving the hospital. You likely had a virus that caused your symptoms. You will follow up with Dr. ___ within one week of leaving the hospital. Thank you for allowing us to participate in your care during your stay. Sincerely, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ACE Inhibitors Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a history of metastatic myxofibrosarcoma (to the lung) with a recent admission from ___ for a second cycle of inpatient chemotherapy (AIM) who presents with febrile neutropenia. To summarize his recent history, in ___, he completed pre-operative chemoradiation with six cycles of doxorubicin weekly (cumulative dose 95mg/m2; 211mg), and total radiation dose of 50 Gy. In ___, he went resection. Due to positive margins, he required further reoperation and reconstruction, which was complicated by poor wound healing (from radiation) in ___. Further irradiation was held. In ___, imaging showed lung lesions, which were consistent with high-grade malignancy, most consistent with metastatic sarcoma. He started AIM chemotherapy and tolerated his second cycle well. He was discharged home on ___. On the day prior to presentation, he began to develop fevers, mild headache, and fatigue. He presented to a outside hospital, where CXR was concerning for a R middle lobe consolidation. ANC was 500. He was given vanc/cefepime/levo and was transferred to ___ for further management. In the ED, initial vitals: 98.3 110 112/70 20 98% RA. Labs significant for: WBC 0.2 with 3% neutrophils (ANC 6), plt 47, H/H 7.6/23.6, ALT 48, other electrolytes and LFT's WNL. He was given vanc/cefepime and admitted to OMED. Vitals upon transfer: 97.9 93 123/72 18 100% RA. Past Medical History: =============================== PAST ONCOLOGIC HISTORY: =============================== - ___: Noted mild increase in the size and discomfort in his right thigh. He noticed while sitting that there was an apparent mass, which impeded his ability to move the leg and caused pain while he was sitting. He eventually sought care with his primary care physician who ordered imaging studies. These demonstrated a large heterogeneous enhancing mass in the right thigh. - ___, MRI right lower extremity showed a 32 cm mass involving the medial aspect of the right upper thigh. The mass enhances on contrast administration and is heterogeneous in nature. - ___, biopsy under image guidance. Pathology from this procedure showed myxofibrosarcoma, intermediate grade; cytokeratin, MNF116, S100, desmin and SMA were all negative. - ___: Completed pre-operative chemoradiation with doxorubicin weekly continuous infusion (cumulative dose 95mg/m2; 211mg), and total radiation dose of 50 Gy. -___. Resection by Dr. ___, one area of medial margin was focally positive. - ___. Reoperation with reconstruction of right thigh vascularized tissue, nerve coaptation, free muscle left thigh to the right thigh extensor reconstruction. Fiducials also placed at the site of positive margin at the time of surgery. - ___: Post-operative planning for stereotactic radiation to resection site was planned, however due to ongoing poor wound healing in the previously irradiated flaps and prior negative margins, decision made to hold off on further radiation therapy - ___: CT Chest reveals multiple pulmonary nodules up to 1.5cm mostly in the right lung, highly suspicious for metastatic disease - ___ Lung wedge pathology: metastatic high-grade malignancy most consistent with metastatic sarcoma . =============================== PAST MEDICAL/SURGICAL HISTORY: =============================== Intermediate grade myxofibrosarcoma of the right thigh s/p excision ___ HTN DM2 hyperlipidemia arthritis gout s/p tonsillectomy (___) Social History: ___ Family History: Father: colon cancer Other cancers in the family: Sister with breast cancer, brother with skin cancer Physical Exam: ========================================= PHYSICAL EXAM ON ADMISSION ========================================= VS: T 99.5, BP 122/74, HR 100, R 20, SpO2 99%/RA, weight 214.9 lbs, height 69" GENERAL: NAD, comfortable in bed HEENT: NC/AT, EOMI, PERRL, MMM CARDIAC: borderline tachycardic, regular, normal S1 & S2, without murmurs, S3 or S4 LUNG: remarkable only for faint R lung base crackles ABD: +BS, soft, NT/ND, no rebound or guarding; inguinal incision site mostly healed, without granulation tissue/open wound, but honey-golden crusting easily removed EXT: No lower extremity pitting edema; RLE in immobilizer with large, well-healed scar over anterior R thigh, 2+ DP pulses bilaterally NEURO: face symmetric, palate elevates evenly, tongue protrudes midline, gait not assessed SKIN: Warm and dry, honey-crusting in R inguinal fold incision (as described above); Port-A-Cath accessed over R chest - appears uninfected ========================================= PHYSICAL EXAM ON DISCHARGE ========================================= VS: 97.8 (98.5) 102/52 88 18 97RA GENERAL: NAD, comfortable in bed HEENT: EOMI, PERRL, neck supple, no cervical LAD CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 LUNG: CTAB ABD: +BS, soft, NT/ND, no rebound or guarding EXT: No lower extremity pitting edema; RLE in immobilizer with large, well-healed scar over anterior R thigh, 2+ DP pulses bilaterally NEURO: CN ___ intact, strength ___ and sensation intact bilaterally upper and lower. SKIN: Warm and dry, Port-A-Cath accessed over R chest - appears uninfected Pertinent Results: ADMISSION LABS ============== ___ 03:45AM BLOOD WBC-0.2*# RBC-2.86* Hgb-7.6* Hct-23.6* MCV-83 MCH-26.6 MCHC-32.2 RDW-13.5 RDWSD-40.7 Plt Ct-47*# ___ 03:45AM BLOOD Neuts-3* Bands-0 Lymphs-91* Monos-3* Eos-3 Baso-0 ___ Myelos-0 AbsNeut-0.01* AbsLymp-0.18* AbsMono-0.01* AbsEos-0.01* AbsBaso-0.00* ___ 03:45AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 03:45AM BLOOD ___ PTT-29.3 ___ ___ 03:45AM BLOOD Glucose-153* UreaN-24* Creat-1.2 Na-134 K-3.6 Cl-101 HCO3-21* AnGap-16 ___ 03:45AM BLOOD ALT-48* AST-26 LD(LDH)-112 AlkPhos-73 TotBili-0.6 ___ 03:45AM BLOOD Albumin-3.9 ___ 06:06AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0 ___ 07:45AM URINE Color-Straw Appear-Clear Sp ___ ___ 07:45AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 07:45AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 PERTINENT LABS ============== ___ 06:06AM BLOOD WBC-0.2* RBC-2.82* Hgb-7.6* Hct-23.2* MCV-82 MCH-27.0 MCHC-32.8 RDW-13.3 RDWSD-40.2 Plt Ct-27* ___ 06:06AM BLOOD Neuts-7* Bands-0 Lymphs-74* Monos-15* Eos-4 Baso-0 ___ Myelos-0 AbsNeut-0.01* AbsLymp-0.15* AbsMono-0.03* AbsEos-0.01* AbsBaso-0.00* ___ 05:25AM BLOOD ALT-91* AST-40 LD(LDH)-104 AlkPhos-144* TotBili-0.4 DISCHARGE LABS ============== ___ 05:08AM BLOOD WBC-3.1*# RBC-2.96* Hgb-8.1* Hct-24.5* MCV-83 MCH-27.4 MCHC-33.1 RDW-13.2 RDWSD-40.0 Plt Ct-93*# ___ 05:08AM BLOOD Neuts-78* Bands-4 Lymphs-13* Monos-2* Eos-0 Baso-0 ___ Metas-1* Myelos-1* Promyel-1* AbsNeut-2.54 AbsLymp-0.40* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00* ___ 05:08AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr-OCCASIONAL ___ 05:08AM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-140 K-3.4 Cl-102 HCO3-26 AnGap-15 ___ 06:15AM BLOOD ALT-99* AST-39 AlkPhos-202* TotBili-0.5 ___ 05:08AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8 MICROBIOLOGY ============ ___ 7:45 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 3:45 am BLOOD CULTURE (x2) Blood Culture, Routine (Pending): IMAGING ======= ___ CXR IMPRESSION: Moderate right pleural effusion and probable right middle lobe collapse unchanged since ___. Left lung is clear. Heart size normal. Mediastinum midline. Right supraclavicular dual channel central venous infusion port catheter ends close to the superior cavoatrial junction. No pneumothorax. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 600 mg PO QHS 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 10. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 11. Senna 8.6 mg PO BID:PRN constipation 12. Simvastatin 40 mg PO QPM 13. Loratadine 10 mg PO DAILY 14. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting 15. irbesartan 300 mg oral DAILY 16. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN HEADACHE, PAIN, FEVER 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 600 mg PO QHS 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. irbesartan 300 mg oral DAILY 8. Loratadine 10 mg PO DAILY 9. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 13. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 14. Prochlorperazine 10 mg PO Q6H:PRN nausea 15. Senna 8.6 mg PO BID:PRN constipation 16. Simvastatin 40 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: metastatic myxofibrosarcoma, neutropenic fever Secondary diagnoses: diabetes mellitus, hypertension, hyperlipidemia 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 man with meta. mixofibrosarcoma, C1D11 of AIM chemo regimen, p/w febrile neutropenia to OSH, with OSH CXR report of RML consolidation? Pt. has h/o RLL wedge resection of met // eval for PNA? eval for PNA? COMPARISON: Prior chest radiographs ___. IMPRESSION: Moderate right pleural effusion and probable right middle lobe collapse unchanged since ___. Left lung is clear. Heart size normal. Mediastinum midline. Right supraclavicular dual channel central venous infusion port catheter ends close to the superior cavoatrial junction. No pneumothorax. Gender: M Race: WHITE - OTHER EUROPEAN Arrive by AMBULANCE Chief complaint: Fever, Neutropenia Diagnosed with Pneumonia, unspecified organism temperature: 98.3 heartrate: 110.0 resprate: 20.0 o2sat: 98.0 sbp: 112.0 dbp: 70.0 level of pain: 4 level of acuity: 2.0

Dear ___, You were admitted to ___ with fever, in the setting of low white blood cell counts ("neutropenic fever"). We tested you for infections, but found no obvious source. During this time, we empirically treated you with antibiotics (vancomycin & cefepime) and monitored you for fever. You had no further fever. Your Neulasta injection began to work and your bone marrow began to recover from the chemotherapy - your white blood cells and platelets began to normalize. It was a pleasure caring for you. We wish you the very best. -- Your team at ___

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: acute onset word finding difficulty, garbled speech and right hand parasthesiaes lasting ___ minutes. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ old right-handed man with history of hypertension who presented with acute onset word finding difficulty, garbled speech and right hand parasthesiaes lasting ___ minutes. Mr. ___ was in his usual state of health today until approximately 2:45pm when he developed difficulty speaking to his wife while lying in bed watching TV. His wife notes that he tried to ask her about dinner, saying "are you making sauce?" but he meant to say, "are you making rice." He also meant to ask about dinner and said, "are you making the bed?" He had long pauses in his speech when he would try to get words out, and say, "umm and uhhh" when looking for the words he wanted to say. His wife said that some of the words were made up and unintelligible so she had trouble figuring out what he was trying to say. He also called one of his daughters by the wrong name. During this time, he also noticed right hand numbness and pins and needles, like a sensation of his hand falling asleep. This did not extend past his hand. He grabbed a stress ball and squeezed it with both hands to compare the sensation in both hands and he was able to squeeze it with the right hand. He was able to lift his right arm antigravity and bring the ball over his head. His wife did not notice any facial droop. The right side of his body did not feel weak. There were no other parasthesiaes. The whole episode lasted approximately 10 - 15 minutes, though they are not sure about the exact timeline. His wife was concerned about a stroke and told him they were going to the ED. The patient walked down the stairs and took a shower before coming. He also shaved with his right hand. By the time he was out of the shower, he was back to normal. He was able to recall the whole episode, though when asked about feeling confused and realizing that he was saying the wrong thing, he said he didn't notice the words were coming out different. He never had a headache, and nothing like this has happened to him before. He does not take aspirin or any other anti-platelet. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties comprehending speech. Denies focal weakness. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: HTN Social History: ___ Family History: - Mother: HTN, patient states she "probably" had MI at ___ - Father: HTN, stroke at ___, patient states he "maybe" had stroke at ___ Physical Exam: Admission Exam: Vitals: T= 99.1 F, BP= 172/91, HR= 89, RR= 18, SaO2= 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Pulmonary: nonlabored breathing Cardiac: RRR Abdomen: soft, nondistended Extremities: no edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Fund of knowledge intact. Able to relate history 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 per stroke card. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Able to follow multi-step commands. Attentive to exam. Pt. was able to register 3 objects and recall ___ at 5 minutes ___ with cues). There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch in all distributions. No extinction to double simultaneous light touch. VII: No facial droop, no facial asymmetry, facial musculature symmetric, eye closure not overcome bilaterally 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. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R ___ ___ ___ 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 - Plantar response was withdrawal bilaterally. - Crossed Adductors are absent. -Coordination: No intention tremor noted. No dysmetria on FNF or HKS bilaterally. No dysdiadochokinesia. No clumsiness on right finger tap. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Able to walk to toes and heels. Discharge Exam: Neurologic: -Mental Status: Alert, oriented x 3. Fund of knowledge intact. Able to relate history 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 per stroke card. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Able to follow multi-step commands. Attentive to exam. Pt. was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch in all distributions. No extinction to double simultaneous light touch. VII: No facial droop, no facial asymmetry, facial musculature symmetric, eye closure not overcome bilaterally 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. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R ___ ___ ___ 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 - Plantar response was withdrawal bilaterally. - Crossed Adductors are absent. -Coordination: No intention tremor noted. No dysmetria on FNF or HKS bilaterally. No dysdiadochokinesia. No clumsiness on right finger tap. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Able to walk to toes and heels. Pertinent Results: ___ 05:20PM WBC-7.3 RBC-4.87 HGB-14.9 HCT-45.0 MCV-92 MCH-30.6 MCHC-33.1 RDW-12.2 RDWSD-42.0 ___ 05:20PM NEUTS-50.0 ___ MONOS-8.9 EOS-7.8* BASOS-0.7 IM ___ AbsNeut-3.65 AbsLymp-2.35 AbsMono-0.65 AbsEos-0.57* AbsBaso-0.05 ___ 05:20PM GLUCOSE-94 UREA N-13 CREAT-0.9 SODIUM-138 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-11 Imaging: CTA head ___ IMPRESSION: 1. No acute intracranial abnormality. 2. Patent intracranial vasculature without significant stenosis, occlusion, oraneurysm. 3. Patent cervical vasculature without significant stenosis, occlusion, ordissection. 4. Periapical lucency around 2 left maxillary molars, suggestive of periodontal disease. 5. Multinodular enlargement of the right thyroid lobe with nodules measuringup to 21 x 14 mm in the right lobe. The ___ College of Radiology guidelines suggest thyroid ultrasound for further evaluation. TTE ___ The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. [A single microbubble is seen in the left atrium 6 beats after RA opacification and most c/w transpulmonic flow.] The estimated right atrial pressure is ___ mmHg. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 69 %). There is no ventricular septal defect. 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: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. No definite structural cardiac source of embolism identified. MRI Head non con ___ IMPRESSION: 1. No acute intracranial abnormality including hemorrhage, infarct, or suggestion of mass. 2. Paranasal sinus disease, as described. TEE ___ No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. IMPRESSION: No intracardiac source of embolism identified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Naproxen 500 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Naproxen 500 mg PO Q8H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: TIA or Stroke (Ischemic or Hemorrhagic) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with TIA symptoms lasting 10 min, dysarthria and aphasia, evaluate for acute cardiopulmonary disease. TECHNIQUE: Chest PA and lateral COMPARISON: None available. FINDINGS: The cardiomediastinal contours are within normal limits. The bilateral hila are unremarkable. The lungs are clear without focal consolidation. There is no evidence of pulmonary vascular congestion. There is no pneumothorax or pleural effusion. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CTA HEAD AND CTA NECK Q16 CT INDICATION: 10 minutes of dysarthria and aphasia. Evaluate for bleed 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 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP = 21.8 mGy-cm. 3) Spiral Acquisition 5.2 s, 40.8 cm; CTDIvol = 31.9 mGy (Head) DLP = 1,304.3 mGy-cm. Total DLP (Head) = 2,223 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is moderate polypoid mucosal wall thickening and/or mucous retention cysts in the left maxillary sinus. There is mild mucosal thickening in the inferior aspect of the right maxillary sinus as well as in the bilateral ethmoid air cells. There is punctate mucous retention cyst in the left sphenoid air cell. The v remainder of the isualized 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 patent without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is common origin of the brachiocephalic and left common carotid artery. The carotid and vertebral arteries and their major branches appear patent with no evidence of stenosis or occlusion or dissection. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: The visualized portion of the lungs are clear. There is heterogeneous enlargement of the right thyroid lobe with multiple hypodense nodules measuring up 21 x 14 mm on the right (5:72). There is no lymphadenopathy by CT size criteria. There are periapical lucencies around 2 left maxillary molars, suggestive of periodontal disease. IMPRESSION: 1. No acute intracranial abnormality. 2. Patent intracranial vasculature without significant stenosis, occlusion, or aneurysm. 3. Patent cervical vasculature without significant stenosis, occlusion, or dissection. 4. Periapical lucency around 2 left maxillary molars, suggestive of periodontal disease. 5. Multinodular enlargement of the right thyroid lobe with nodules measuring up to 21 x 14 mm in the right lobe. The ___ College of Radiology guidelines suggest thyroid ultrasound for further evaluation. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: Word-finding difficulty and right hand numbness for 10 min. 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 CTA head and neck ___. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Minimal periventricular and deep white matter T2/FLAIR hyperintensity, mainly around the occipital horns of the lateral ventricles is 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 moderate mucosal wall thickening the left maxillary sinus, minimal mucosal wall thickening the right maxillary sinus as well as minimal mucosal wall thickening the left frontal sinus and bilateral ethmoid air cells. IMPRESSION: 1. No acute intracranial abnormality including hemorrhage, infarct, or suggestion of mass. 2. Paranasal sinus disease, as described. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Altered mental status Diagnosed with Transient cerebral ischemic attack, unspecified temperature: 99.1 heartrate: 89.0 resprate: 18.0 o2sat: 100.0 sbp: 172.0 dbp: 91.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were hospitalized due to symptoms of word finding difficulty, garbled speech and right hand numbness lasting ___ minutes resulting from a transient ischemic attack, a condition where a blood vessel providing oxygen and nutrients to the brain is temporarily not receiving enough oxygen. 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 and transient ischemic attacks can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. Your risk factor such as hemoglobin A1C which measures your blood sugar as well as your lipids are normal. We are changing your medications as follows: Aspirin 81 mg daily Please take your other medications as prescribed. We also will send you home with a event monitor which you will wear for 30 days to evaluate for abnormal heart rhythm that might have been the cause of your symptoms. Please call ___ ___ for event monitor at ___. Please follow up 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 Of note, your work up also showed an enlarged thyroid gland which is containing multiple nodules measuring up to 14 mm on the right. We recommend f/u as outpatient and a thyroid scan.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Bactrim DS Attending: ___. Chief Complaint: headache, nausea, vomiting, neck stiffness Major Surgical or Invasive Procedure: ___ - Left craniectomy and wound washout History of Present Illness: ___ yo female 10 days post-op from left craniotomy and temporal meningioma resection. She was last seen in the office ___ for suture removal and was doing well at that time and only c/o of some mild HAs since stopping decadron on ___. She presents to the ED today with 2 days of worsening HA, N/V, photophobia, neck stiffness and diarrhea x 3 today. She denies fevers, but does c/o chills. She denies any weakness or visual changes. Past Medical History: IDDM Temporal meningioma s/p resection ___ Social History: ___ Family History: Non-contributory Physical Exam: On admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ EOMs: intact Neck: Neck stiffness and pain with chin to chest. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric, with the exception of mild left nasolabial fold flattening.. 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 =================== ON DISCHARAGE: =================== Patient is alert and oriented to person, place and time. Face symmetrical with mild left nasolabial flattening. Tongue midline, EOMI, PERRL No pronator drift and moves all extremities ___. Incision is clean, dry and intact. Closed with sutures. Pertinent Results: Please refer to reports in OMR for pertinent lab and imaging results. Medications on Admission: Humulin N 35units Q AM Keppra 500mg BID Regular insulin SS >200 Multivitamin Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild Do not exceed 4G of Acetaminophen is any form in a 24 hour period. 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. NPH 30 Units Breakfast Insulin SC Sliding Scale using REG Insulin 5. LevETIRAcetam 1000 mg PO BID RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN constipation 7. Vancomycin 1250 mg IV Q 8H RX *vancomycin 500 mg 1250 mg IV every eight hours Disp #*313 Vial Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Wound infection Hyperglycemia skull defect 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/ AND W/O CONTRAST Q1212 CT HEAD INDICATION: ___ T2DM, HTN, hx recent elective resection of meningioma who presents with chills, nausea, vomiting, diarrhea.// please evaluate for acute intracranial process TECHNIQUE: Contiguous axial images of the brain were obtained before and after the intravenous administration of 70 mL of Omnipaque contrast agent. Thin bone-algorithm reconstructed images and coronal and sagittal reformatted images were then produced. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 3) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 50.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 2,408 mGy-cm. COMPARISON: MRI ___ FINDINGS: There is a hypoattenuated extra-axial fluid collection along the left cerebral convexity which measures 1.2 cm from the inner table (series 4:20) with associated effacement of the left lateral ventricle an 8 mm rightward midline shift is new as compared to MRI head ___. This could represent a subdural hygroma or chronic subdural hematoma. In the surgical resection bed of the previously characterized left temporal meningioma, there is no abnormal enhancement or hemorrhage. There is also a presumed left epidural mixed density collection measuring 5 mm from the inner table (series 2:15). There is mild interval increased prominence of the bilateral temporal horns and right lateral ventricle. Left frontal craniotomy changes are noted. There is now a prominent extracranial fluid collection overlying the craniotomy measuring approximately 6 mm in greatest thickness, not seen on prior examination. Correlation for postoperative pseudomeningocele is recommended. There is no acute fracture. Mucosal thickening bilateral ethmoid air cells are noted. Remaining paranasal sinuses are clear. Middle ear cavities are patent. IMPRESSION: 1. Hypoattenuated extra-axial fluid collection along the left cerebral convexity measuring 1.2 cm from the inner table with associated effacement of the leftlateral ventricle and 8 mm of rightward midline shift is new as compared to MRI ___. This could represent a subdural hygroma versus less likely a chronic subdural hematoma given that the surgical resection was on ___. There is suggestion of mild increased prominence of the right lateral ventricle and bilateral temporal horns, raising the possibility of developing hydrocephalus. Continued close attention is recommended. 2. Left epidural mixed density collection along the left frontal convexity measuring 5 mm from the inner table (series 2:15) compatible with a mixed age epidural hematoma. 3. Extracranial CSF density collection measuring approximately 6 mm in greatest thickness overlying the craniotomy site. Clinical correlation for postoperative pseudomeningocele is recommended. 4. No definite abnormality in the left temporal resection bed. 5. No definite abnormal enhancement to suggest infectious process at this time. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with meningitis// preop TECHNIQUE: Semi-upright AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes are slightly lower compared to the previous exams. Cardiac silhouette size remains mildly enlarged. The mediastinal and hilar contours are unremarkable. Pulmonary vasculature is not engorged. Lungs are clear. No pleural effusion or pneumothorax is seen. No acute osseous abnormalities present. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman s/p repeat craniotomy, wound washout// 10 days s/p craniotomy and L frontal meningioma resection, repeat craniotomy and wound washout today 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 14.0 s, 15.6 cm; CTDIvol = 45.1 mGy (Head) DLP = 702.4 mGy-cm. Total DLP (Head) = 702 mGy-cm. COMPARISON: CT head without contrast ___ 03:22 FINDINGS: New hemorrhage is identified at bilateral cerebellum, presumed to be subarachnoid in nature. There is also trace sulcal hyperintensity involving the right temporal parietal lobe (series 2, image ___ also likely representing subarachnoid hemorrhage. There does appear to be mild edema predominantly involving the left cerebellar folia. Minimal apparent increased hypodensity of the left anterior temporal lobe when compared to preoperative examination, likely artifactual in nature. However clinical correlation is recommended. Patient is post left frontal craniectomy and washout. Small amount fluid is noted between the skin flap and left frontal lobe. A drain is left in place. There is small amount of pneumocephalus. Left frontal subdural hematoma is small. Leftward midline shift by 3 mm is improved from 5 mm 7 hours ago. Previously described subgaleal fluid collection is no longer noted. Small amount of fluid is noted in right sphenoid sinus. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. New hemorrhage is identified at bilateral cerebellum, compatible with subarachnoid hemorrhage. There is edema of the cerebellar folia, most prominent on the left. 2. Patient is post left frontal craniectomy and washout with expected postoperative changes and improved mild leftward midline shift. 3. Previously described subgaleal fluid collection is no longer seen. 4. Apparent increased hypodensity of the left anterior temporal lobe when compared to preoperative examination. This is likely artifactual in nature, however clinical correlation is recommended. 5. Additional findings described above. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 11:57 pm, 15 minutes after discovery of the findings. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman Wound washout and L hemicraniectomy, epidural hemovac drain with high output, increased HA, nausea// interval change TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 746.8 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CT head dated ___ FINDINGS: There is a left frontal temporal craniectomy defect status post removal of an infected craniotomy flap. There is unchanged dural thickening at the surgical site. The distal end of the left frontal approach epidural drainage catheter is located near the posterior margin of the craniectomy defect. The volume of fluid within the left supra zygomatic masticator space external to the craniectomy appear similar to the prior study. Low attenuation within the left anterior temporal lobe appear similar to the prior head CT and most likely reflects retraction injury, however cerebritis is an alternative consideration given the known craniotomy flap related infection. The ventricular configuration appears similar to the prior study, without hydrocephalus. There is 2 mm of midline shift, similar to the prior study. The basilar cisterns are patent, without evidence of downward herniation. The degree of blood products within the cerebellar fissures appear similar to the prior study. No new intracranial hemorrhage is identified. IMPRESSION: 1. Left frontal temporal craniectomy for resection of an infected craniotomy flap. Low attenuation within the anterior left temporal lobe may reflect retraction related injury, however superimposed cerebritis is difficult to exclude. 2. The ventricular configuration and 2 mm rightward midline shift appear similar to the prior study. 3. Acute blood products within the posterior fossa likely reflects subarachnoid hemorrhage and appear similar to the prior study. No new hemorrhage is identified. 4. Thickening adjacent to the left lateral dural surface of the cavernous sinus, left petrous apex, and left dorsal surface of the clivus likely reflects postoperative change. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with craniectomy and washout// interval change TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CT from ___. FINDINGS: Patient is status post removal of infected craniotomy flap with a left frontotemporal craniectomy defect. There is been interval replacement of the previously seen left frontal approach epidural drainage catheter now with a small simple fluid collection between the skin flap and the dura at the surgical site. Dural thickening persists however has decreased from prior study. In comparison with prior study area of hypoattenuation of the left anterior temporal lobe is unchanged. There is re-demonstration of subarachnoid hemorrhage within the cerebellum not signet changed from ___ study. No new intracranial bleed is identified. The ventricles and sulci are stable in size and configuration with a small rightward midline shift unchanged from prior. The basal cisterns are patent. 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. Patient is status post removal of infected craniotomy flap with left frontotemporal craniotomy defect and interval removal of left frontal approach epidural drainage catheter. Small simple fluid collection between skin flap and dura at the surgical site likely sequela of catheter removal. Small amount of blood products at the craniectomy site is unchanged. Small left-sided subdural collection is more prominent since study and likely due to the recent procedure. 2. Hypoattenuation of the left anterior temporal lobe is unchanged in appearance from prior study. 3. Small stable rightward midline shift and stable ventricular configuration. 4. Stable cerebellar subarachnoid hemorrhage with no new intracranial bleed identified. 5. Stable dural thickening adjacent to the surgical site likely postoperative. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with low grade temps, low fluid output, sleepy// Eval for signs of PNA Eval for signs of PNA IMPRESSION: Compared to chest radiographs ___ status ___. Top-normal heart size unchanged. Lungs grossly clear. No pleural effusion. Slight leftward deviation of the trachea could be due to an enlarged right lobe of the thyroid. Clinical correlation advised. Radiology Report EXAMINATION: Portable chest x-ray INDICATION: ___ year old woman with PICC// Pt had a R PICC,42cm, ___ ___ Contact name: ___: ___ TECHNIQUE: Single frontal view of the chest was obtained. COMPARISON: ___ FINDINGS: Since the prior examination, there is a new right-sided pleural effusion. The cardiomediastinal silhouette and pulmonary vasculature are unchanged. A new right-sided PICC terminates in the mid SVC. No pneumothorax. IMPRESSION: Right-sided PICC terminates in the mid SVC. New right-sided pleural effusion. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Headache, N/V Diagnosed with Headache temperature: 97.7 heartrate: 78.0 resprate: 18.0 o2sat: 100.0 sbp: 157.0 dbp: 75.0 level of pain: 10 level of acuity: 2.0

Surgery •You underwent surgery to have your craniotomy incision washed out and reclosed. You also had your skull bone removed. Please wear your helmet when out of bed to protect your brain. •Please keep your sutures along your incision dry until they are removed. •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: •Headache or pain along your incision. •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. •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 Call ___ and go to the nearest Emergency Room if you 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 You have been sent home on NPH and Regular Insulin. When taking you NPH, please start at 20 units, and take no more than 35 units per the recommendation of the ___ Diabetes doctors.

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 ___ year-old woman with PMH significant for ___ (most recent ___ EF 30%), poorly-controlled IDDM2, hx E. coli urosepsis requiring nephrostomy placement ___ who presents with nausea/vomiting. Of note, the patient with several recent ___ system hospitalizations. Of note patient recently admitted in ___ of this year at ___ with nausea, vomtiting, diarrhea and hyperglycemia. CT abdomen/pelvis showed ampullary fullness, which was followed up with an MRCP that showed normal ampulla and no biliary tract dilatation. Gastric emptying study showed no gastroparesis. Stool guaiac was negative. She was started on metoclopramide and Zofran for symptomatic relief, and pain improved. She was also admitted at ___ from ___, through ___. Per an OMR note by Dr. ___, the patient presented with a syncopal episode and hyperglycemia. Per the report, the patient's fall was thought to be due to orthostatic hypotension. EKG wasnoted to be unremarkable. Head CT showed chronic CVA and microvascular change. It was thought that her chronic hyperglycemia and her anorexia may have led to volume depletion coupling with being on torsemide. She was asked to stop Norvasc and torsemide. Her carvedilol dose was changed from 25 mg b.i.d. to 12.5 mg b.i.d. Her lisinopril dose was changed from 40 mg to 20 mg. Patient states she has had a change in smell of her urine for the past week but no associated dysuria or increased urinary frequency. She developed nausea and vomiting since ___. She denies diarrhea and state she had a normal BM this am. She denies cp or sob. Patient denies travel or sick contacts. In the ___ ED: - Initial VS 97.2 ___ 16 100% RA - Labs notable for Chem-7 with Glu 385 otherwise wnl (Cr 1.0 at baseline), CBC with WBC 6.1 and H/H 9.2/27.7 (baseline Hct 28), LFTS wnl, VBG with 7.36/58, lactate 1.6. UA with large leukocytes, moderate blood, 1000 glc, 10 ketones, RBC 31, >182 WBC - CXR with no acute intrathoracic abnormality. Abdominal KUB with nonobstructive bowel gas pattern. Stool filled loops of colon. Posttraumatic changes involve the right inferior pubic ramus. - The patient was administered ___ 16:35 IV Ondansetron 4 mg ___ 16:35 IVF 1000 mL NS 1000 mL ___ 18:11 PO/NG Carvedilol 6.25 mg ___ 18:11 PO/NG Lisinopril 40 mg ___ 18:31 IV CeftriaXONE 1 gm ___ 18:34 IVF 1000 mL NS 1000 mL ___ 19:41 SC Insulin 12 Units - VS prior to transfer 98.5 95 184/89 18 100% RA Upon arrival to the floor, VS 97.9 162/81 91 16 100%RA FSBG 290. The patient reports that he nausea/vomiting resolved after administration of IV Zofran in ED and has been able to eat a sandwich without subsequent symptoms. Past Medical History: - Hx H. Pylori - T2DM: dx ___, c/b retinopathy, nephropathy, and cataracts - sCHF (EF 50%) - Hypertension - Osteoporosis - HLD - s/p fibroid removal in ___ - Hx N/V with work-up notable for normal gastric emptying study ___, CT showing prominent ampulla, MRCP ___ with atrophic panc, +H. pylori ___ rx'd but not compliant with treatment - Anemia ___ iron and B12 deficiency - Hx +PPD, s/p 6 months INH in 89 - Hx pyelonephritis ___ s/p ARDS/prolonged intubation/critical illness Social History: ___ Family History: Mother and father with HTN Aunt with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.9 162/81 91 16 100%RA FSBG 290 GENERAL: Cachectic woman, lying in bed, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, soft II/VI holosystolic murmur, no rubs/gallops LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Prior R urostomy scar well-healed C/D/I. No CVA tenderness. Abdomen nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS - 98.5 145/82 85 16 100RA GENERAL: Cachectic woman, lying in bed, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, soft II/VI holosystolic murmur, no rubs/gallops LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Prior R urostomy scar well-healed C/D/I. No CVA tenderness. Abdomen nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 04:05PM BLOOD WBC-6.1 RBC-3.16* Hgb-9.2* Hct-27.7* MCV-88 MCH-29.1 MCHC-33.2 RDW-13.1 RDWSD-41.5 Plt ___ ___ 04:05PM BLOOD Neuts-69.0 ___ Monos-6.8 Eos-0.7* Baso-0.3 Im ___ AbsNeut-4.18 AbsLymp-1.39 AbsMono-0.41 AbsEos-0.04 AbsBaso-0.02 ___ 04:05PM BLOOD Glucose-385* UreaN-25* Creat-1.0 Na-138 K-4.3 Cl-98 HCO3-31 AnGap-13 ___ 04:05PM BLOOD ALT-11 AST-30 AlkPhos-61 TotBili-1.1 ___ 04:05PM BLOOD Lipase-15 ___ 04:05PM BLOOD cTropnT-<0.01 ___ 04:05PM BLOOD Albumin-3.5 ___ 04:22PM BLOOD ___ pO2-29* pCO2-58* pH-7.36 calTCO2-34* Base XS-3 Intubat-NOT INTUBA ___ 04:22PM BLOOD Lactate-1.6 DISCHARGE LABS ___ 07:40AM BLOOD WBC-5.2 RBC-2.69* Hgb-7.8* Hct-24.0* MCV-89 MCH-29.0 MCHC-32.5 RDW-13.3 RDWSD-43.0 Plt ___ ___ 07:40AM BLOOD Glucose-74 UreaN-27* Creat-1.1 Na-143 K-3.7 Cl-104 HCO3-29 AnGap-14 ___ 07:40AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8 URINE ___ 04:40PM URINE Color-Straw Appear-Hazy Sp ___ ___ 04:40PM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ 04:40PM URINE RBC-31* WBC->182* Bacteri-FEW Yeast-NONE Epi-2 **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >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-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING - ___ KUB: Nonobstructive bowel gas pattern. Stool filled loops of colon. Posttraumatic changes involve the right inferior pubic ramus. - ___ CXR: No acute intrathoracic abnormality. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Carvedilol 12.5 mg PO BID 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. Lisinopril 40 mg PO DAILY 7. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral TID W/MEALS 8. Glargine 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Pantoprazole 40 mg PO Q24H 10. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) 600 mg(1,500mg) -500 unit oral BID W/ FOOD 11. Vitamin D ___ UNIT PO DAILY 12. Docusate Sodium 100 mg PO BID:PRN constipation 13. Senna 8.6 mg PO DAILY:PRN constipation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Carvedilol 12.5 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Glargine 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Lisinopril 40 mg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 9. Pantoprazole 40 mg PO Q24H 10. Senna 8.6 mg PO DAILY:PRN constipation 11. Vitamin D ___ UNIT PO DAILY 12. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) 600 mg(1,500mg) -500 unit oral BID W/ FOOD 13. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral TID W/MEALS 14. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Nausea Urinary Tract Infection Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with vomiting, h/o chf // r/o chf, obstruction TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___ FINDINGS: PA and lateral chest radiograph demonstrate clear lungs bilaterally. Cardiomediastinal and hilar contours are within normal limits. There is no evidence of pulmonary edema, pleural effusion, or pneumothorax. Imaged upper abdomen is unremarkable. No air is seen under the right hemidiaphragm. IMPRESSION: No acute intrathoracic abnormality. Radiology Report INDICATION: ___ with vomiting, h/o chf // r/o chf, obstruction TECHNIQUE: AP supine and upright radiographs COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: AP supine and upright radiographs through the abdomen demonstrates a nonspecific bowel gas pattern. Stool fills the colon which is otherwise unremarkable. Posttraumatic changes involve the right inferior pubic ramus and better depicted on CT dated ___ and MR performed ___. There is no evidence of pneumobilia. Lung bases are clear. IMPRESSION: Nonobstructive bowel gas pattern. Stool filled loops of colon. Posttraumatic changes involve the right inferior pubic ramus. Gender: F Race: BLACK/CARIBBEAN ISLAND Arrive by WALK IN Chief complaint: N/V, Hyperglycemia Diagnosed with Urinary tract infection, site not specified temperature: 97.2 heartrate: 104.0 resprate: 16.0 o2sat: 100.0 sbp: 208.0 dbp: 108.0 level of pain: 0 level of acuity: 2.0

Dear. Ms. ___, You were admitted with nausea and vomiting. We did tests which demonstrated you had a urinary tract infection and we treated you with antibiotics. Your blood sugars and blood pressures were also very high which improved with your home insulin and blood pressure medications. You were also treated with nausea medications (called Zofran) which improved your symptoms. You were feeling better and able tolerate food with these interventions. You had our nurse educate your about taking your insulin correctly. It is very important to take your medications regularly to avoid these problems in the future. Please followup with your health care providers. Sincerely, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Darvocet-N 100 / levofloxacin Attending: ___. Chief Complaint: N/V/D Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ aplastic anemia/hypoplastic MDS now day ___ ___ allogeneic BMT complicated by disseminated nocardiosis and recently hospitalized ___ to ___ with abdominal pain, PO intolerance and found have colitis noted on OSH imaging with non-neutropenic culture negative fever, presents with ___ in setting of ongoing diarrhea/vomiting. Past Medical History: PAST ONCOLOGIC HISTORY: per ___ is a ___ female with a history of hypoplastic MDS/aplastic anemia, status post one cycle of ATG cyclosporine in ___, followed by a second cycle in ___. Course complicated by AVN of left hip. Patient also with hx of hemolytic anemic. Recent DAT neg. Patient required frequent HLA-matched platelets approximately twice a week. There was a question of an immune component and had been on and off Prednisone in this setting. Also has had periodic course of Rituxan in this setting. Just prior to transplant we had trial of Promacta but did not have any significant improvement in platelet count. Due to refractory disease proceed with bone marrow transplant. She is current day + ___ ___ reduced intensity Bone "marrow" transplant from unrelated donor with Fludarabine/Cytoxan/Campath for conditioning regimen. Her transplant course was complicated by ICU admission with dyspnea, hypoxia, elevated troponin and acute heart failure with acute global cardiac dysfunction in setting of bone marrow infusion. Etiology of Ms. ___ decompensation not completely clear though ? of some capillary leak process. She got pure marrow--not peripheral stem cells--and it's likely that the product contained hemolyzed cells, fat, cellular debris, etc. that caused her to react. Although her post-infusion labs looked like she was hemolyzing, the DAT was negative and her hemoglobin did not drop. Most likely she had been transfused lysed cells (?likely happened during harvesting procedure) that gave her a transaminitis, elevated bili, blood inurine, etc. Unfortunately however, even after washing the bonemarrow, Ms. ___ continued to have this reaction and the reaction was to the same bag. DAT was negative. It was felt that she had some sort of endothelial, microvascular damage from the bone marrow transplant. Was supported through this episode. EF improved on repeat ECHO to 43% (from 20%). Also, of note, two cultures that were done from stem cells came back + for Propionibacterium species. Unclear if contaminant but covered with antibiotics for this. Patient otherwise after this acute event did well in the transplant setting and was discharged from hospital on ___ and has been followed closely in outpatient clinic. No other past medical history Social History: ___ Family History: Mother died of lung cancer in her ___ after heavy tobacco use. Father died of CAD in his ___. 2 healthy brothers and 1 sister. Healthy son. Physical Exam: ADMISSION PHYSICAL EXAM: PHYSICAL EXAM: General: NAD, thin, resting in bed VITAL SIGNS: 98.3 100/60 66 18 98% RA Wt 111 (down from 116 on ___ HEENT: MMM, no OP lesions, Neck: supple, no JVD 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: ___ strength throughout, alert and oriented x 4, ___, EOMI, no nystagmus, face symmetric, no tongue deviation, full hand grip, shoulder shrug and bicep flexion, full toe dorsiflexion and hip flexion against resistance bilateral, sensation intact to light touch, no clonus DISCHAGE PHYSICAL EXAM: General: NAD, thin, resting in bed VITAL SIGNS: 98.5 100/62 64 16 98% RA Wt on admit 111.6 (down from 116 on ___: 107.9 HEENT: MMM, no OP lesions Neck: supple, no JVD 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, face symmetric Pertinent Results: ___ 06:25AM BLOOD WBC-3.9* RBC-2.54* Hgb-8.0* Hct-24.6* MCV-97 MCH-31.4 MCHC-32.4 RDW-15.9* Plt ___ ___ 10:15PM BLOOD Neuts-58.4 ___ Monos-7.3 Eos-5.7* Baso-0.3 ___ 06:25AM BLOOD Glucose-76 UreaN-19 Creat-1.2* Na-136 K-5.5* Cl-105 HCO3-24 AnGap-13 ___ 10:15PM BLOOD Glucose-81 UreaN-26* Creat-1.5* Na-135 K-5.8* Cl-102 HCO3-21* AnGap-18 ___ 06:25AM BLOOD ALT-21 AST-23 LD(LDH)-140 AlkPhos-65 TotBili-0.2 ___ 10:15PM BLOOD ALT-32 AST-38 AlkPhos-80 TotBili-0.2 ___ 06:25AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.3 Mg-1.8 ___ 10:15PM BLOOD Albumin-3.2* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. CycloSPORINE (Neoral) MODIFIED 125 mg PO Q12H 3. FoLIC Acid 5 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Sulfameth/Trimethoprim DS 2 TAB PO BID Nocardiosis 6. Ondansetron 4 mg PO TID 30 mins pre meals 7. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, headache Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. FoLIC Acid 5 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Ondansetron 4 mg PO TID 30 mins pre meals 5. Sulfameth/Trimethoprim DS 2 TAB PO BID Nocardiosis 6. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 7. Acetaminophen 325-650 mg PO Q6H:PRN mild pain, headache 8. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: hx MDS ___ MUD allo ___ diarrhea +AFB stool culture ___ 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: Weakness. Assess for infiltrate. COMPARISON: Chest radiograph ___ FINDINGS: Frontal and lateral chest radiograph demonstrates hyperinflated lungs with persistent bilateral scattered areas of parenchymal opacities many of which have nodular components, similar to ___. Chronic bronchiectasis is stable. Heart size, mediastinal contour, and hila are otherwise unremarkable. No pleural effusion or pneumothorax. Limited assessment of the upper abdomen is unremarkable. IMPRESSION: Persistent multifocal parenchymal with nodular components are similar dating back to ___. No definite new focal opacity but subtle abnormalities would be difficult to detect within the setting of complex baseline abnormality. CT would be more sensitive and may be considered if warranted clinically. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 10:41 AM. Radiology Report EXAMINATION: US RENAL ARTERY DOPPLER INDICATION: ___ year old woman with ___ not responding to IVF completely // r/o obstruction, please do with dopplers to r/o renal vein thrombus. please do BOTH KIDNEYS TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: The right kidney measures 10 cm. The left kidney measures 10 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Renal Doppler: Within the right kidney the main renal artery and renal vein are patent with normal waveforms. Intraparenchymal renal arteries demonstrate normal waveforms with resistive indices ranging from 0.55-0.67. Within the left kidney the main renal artery and renal vein are patent with normal waveforms. Intraparenchymal renal arteries demonstrate normal waveforms with resistive indices ranging from 0.64-0.65. The bladder is moderately well distended and normal in appearance. IMPRESSION: Normal renal doppler ultrasound. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Weakness, Transfer Diagnosed with OTHER MALAISE AND FATIGUE, ACUTE KIDNEY FAILURE, UNSPECIFIED temperature: 98.6 heartrate: 58.0 resprate: 16.0 o2sat: 96.0 sbp: 93.0 dbp: 61.0 level of pain: 0 level of acuity: 2.0

Ms. ___, You were admitted with diarrhea/nausea/vomiting which continued since your last admission and because of this you had dehydration of your kidneys. Your kidney function improved with IV fluids and your nausea/diarrhea subsided. However, your kidney function still remains slightly elevated with a high potassium level. This may be associated with your cyclosporine and/or bactrim. We started tapering your cyclosporine to see if this helps. We also found an infection in your stool but since you are feeling better we think it might not need to be treated. You need to follow up with Dr. ___ this as stated below. You will also f/u in clinic on ___ to recheck your kidney function and potassium level. Please call in the meantime if you have any questions or concerns.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: vancomycin Attending: ___. Chief Complaint: Fevers Hypotension Major Surgical or Invasive Procedure: central venous line placement History of Present Illness: Patient is ___ year old woman with PMH significant for CAD (recent DES ___, afib on coumadin, ___, and DM presenting with high fever and somnolence for 1 day. At ___ rehab she was noted to be febrile to 103 and more somnolent over last 24 hrs. Labs there showed elevated LFTs with AST 434, ALT 159, alk phos 250, tbili 2.1 with Trop I <0.06. WBC 6.3 HCT 40 plt 228, INR 3 Cr 2.3 (baseline 1.6). She received 3g IV unasyn and trasnfered to this instituation. In the ED, initial VS were T 99.1, HR 90, BP 158/138, RR 18, SaO2 98% 2L. She was complaining of abdominal and back pain. No chest pain or shortness of breath. No cough. A bedside US showed a negative FAST with RUQ US positive for gallbladder wall thickening and IVC with >50% variation with inspiration. The aorta was not visualized due to body habitus. ABX were broadened with levaquin and ceftriaxone in addition to the unasyn before presentation (pt is allergic to vanco). ERCP was consulted and they recommended vitamin K and FFP to reverse INR of 4.9. She was given the vitamin K but as procedure will be delayed until at least the next morning FFP was held. Surgery was also consulted. Pt received a non-con CT abdomen/pelvis and was admitted to MICU for urosepsis vs cholangitis. On arrival to the MICU, vital signs were T 98, HR 84, BP 135/73, RR 10, satting 98% on 2L NC. Pt tired-appearing but comfortable, no acute distress. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: 1. Cardiac catheterization, ___: 30% ___ LAD, 30% mid LAD, 90% D1 (status post BMS), increased LV filling pressure (LVEDP 18). 2. Echocardiogram, ___: ___, mild LVH, LVEF 60%, cannot assess regional wall motion, mildly dilated ascending aorta, minimal AS, borderline pulmonary artery systolic hypertension. 3. Nuclear Persantine stress test, ___: No symptoms, no ECG changes, normal wall motion, normal perfusion, LVEF 59%, no change versus ___. 4. Holter monitor, ___: Normal sinus rhythm, normal intervals, no significant pauses, rare isolated APBs, three atrial couplets, one atrial triplet, trivial isolated ventricular ectopy, three or four symptomatic episodes showed normal sinus rhythm without ectopy or ST-T wave changes. -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: BMS to D1 in ___ as above -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: ASTHMA COLON POLYP, ___ polypectomy CORONARY ARTERY DISEASE, s/p stent ___ DEPRESSION DYSPEPSIA HYPERCHOLESTEROLEMIA HYPERTENSION INSULIN DEPENDENT DIABETES MELLITUS IRRITABLE BOWEL SYNDROME OBESITY OSTEOARTHRITIS SLEEP STUDY-DIAGNOSTIC CELLULITIS PERIPHERAL NEUROPATHY Social History: ___ Family History: Her father died at age ___ of unknown causes. He suffered from several strokes. He sustained his first MI in his ___ and also had diabetes. Her mother died at age ___ of a stroke. She has two brothers, two sisters, and no children. All of her siblings suffer from hypertension. She has one sister who died of a myocardial infarction at age ___, she suffered from diabetes. One brother has diabetes. There is no family history notable for hyperlipidemia or sudden cardiac death. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PE: Vitals: T: 98 BP: 135/73 P: 84 R: 10 O2: 98% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, obese, JVP difficult to assess, RIJ in place CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: distant breath sounds posteriorally, no wheezes, rales, ronchi Abdomen: soft, obese, mildly tender in LUQ, non-distended, bowel sounds present, no organomegaly GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact DISCHARGE EXAM 98.9 ___ 82-120 (mostly in ___ 18 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, obese, JVP difficult to assess CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: distant breath sounds posteriorally, no wheezes, rales, ronchi Abdomen: soft, obese, nontender, non-distended, bowel sounds present, no organomegaly GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing; 2+ pitting edema to thighs; chronic venous stasis changes Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS: ___ 07:26PM BLOOD WBC-16.3*# RBC-4.20 Hgb-12.0 Hct-35.6* MCV-85 MCH-28.5 MCHC-33.6 RDW-15.3 Plt ___ ___ 07:26PM BLOOD Neuts-81* Bands-4 Lymphs-8* Monos-6 Eos-0 Baso-1 ___ Myelos-0 ___ 07:26PM BLOOD ___ PTT-45.3* ___ ___ 07:26PM BLOOD Glucose-185* UreaN-87* Creat-2.7*# Na-134 K-3.0* Cl-91* HCO3-24 AnGap-22* ___ 07:26PM BLOOD ALT-432* AST-933* LD(LDH)-912* CK(CPK)-208* AlkPhos-239* TotBili-1.7* ___ 07:27PM BLOOD Lactate-5.5* ___ 10:58PM BLOOD Lactate-2.5* K-3.5 ___ CXR Limited study due to patient rotation and low lung volumes. Mild pulmonary edema and bibasilar atelectasis. Infection in the lung bases however cannot be completely excluded. ___ RUQ US Cholelithiasis. Gallbladder wall thickening within a non-distended gallbladder is nonspecific and may be due liver disease, volume overload, or hypoproteinemia. Acute cholecystitis is considered unlikely given the absence of gallbladder distention. ___ CT ABD AND PELVIS W/O CONTRAST 1. Cholelithiasis. Gallbladder wall thickening is better appreciated on the ultrasound exam of the same date and is likely from underdistension an dchronic changes. No pericholecystic fluid collection. No evidece of acute cholecystitis 2. A 4.8 x 3.5 intermediate density left renal lesion, which may represent an underlying neoplasm, though hemorrhagic or proteinaceous cysts are possible. Further assessment with MRI is recommended on non-emergent basis. 3. Small hiatal hernia. 4. Non-obstructive left renal stone. MICRO __________________________________________________________ ___ 2:05 pm BLOOD CULTURE Source: Line-L-IJ. Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:35 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 4:53 am BLOOD CULTURE Source: Line-RT IJ central line. Blood Culture, Routine (Pending): __________________________________________________________ ___ 4:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. KLEBSIELLA PNEUMONIAE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in 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 Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). __________________________________________________________ ___ 7:20 pm URINE URINE CULTURE (Preliminary): CITROBACTER KOSERI. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER ___ | 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 __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 7:26 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. GRAM NEGATIVE ROD #2. SECOND MORPHOLOGY. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ AT 8:21AM ON ___. Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). DISCHARGE LABS ___ 07:12AM BLOOD WBC-9.8 RBC-4.05* Hgb-11.6* Hct-34.8* MCV-86 MCH-28.6 MCHC-33.3 RDW-15.3 Plt ___ ___ 07:12AM BLOOD ___ PTT-58.3* ___ ___ 07:12AM BLOOD Glucose-215* UreaN-58* Creat-1.6* Na-133 K-3.5 Cl-92* HCO3-25 AnGap-20 ___ 06:03AM BLOOD ALT-177* AST-84* LD(LDH)-313* AlkPhos-185* TotBili-0.7 ___ 07:12AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.8 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Gabapentin 700 mg PO TID 3. Lovastatin *NF* 20 mg Oral daily 4. Ranitidine 150 mg PO BID 5. Digoxin 0.125 mg PO DAILY 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob 7. Align *NF* (bifidobacterium infantis) 4 mg Oral daily 8. Beano *NF* (alpha-d-galactosidase) 300 unit Oral daily gas 9. ___ Oil (Omega 3) 1000 mg PO DAILY 10. Lactaid *NF* (lactase) 3,000 unit Oral TID:prn with dairy 11. Multivitamins 1 TAB PO DAILY 12. Niacin SR 500 mg PO QHS 13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 14. Aspirin 81 mg PO DAILY 15. Clopidogrel 75 mg PO DAILY 16. Losartan Potassium 50 mg PO DAILY 17. Metolazone 2.5 mg PO 3X/WK 18. Metoprolol Succinate XL 200 mg PO DAILY 19. Polyethylene Glycol 17 g PO DAILY 20. Senna 2 TAB PO BID:PRN constipation 21. Torsemide 100 mg PO DAILY 22. Warfarin 7.5 mg PO DAILY16 23. Furosemide 100 mg IV QD:PRN weight gain >3lbs in day 24. Acetaminophen 650 mg PO Q8H:PRN pain 25. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 26. Docusate Sodium 100 mg PO BID 27. Miconazole Powder 2% 1 Appl TP TID:PRN rash 28. Potassium Chloride (Powder) 10 mEq PO DAILY Hold for K >5.0 Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob 4. Aspirin 81 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Digoxin 0.125 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 9. Lovastatin *NF* 20 mg ORAL DAILY 10. Miconazole Powder 2% 1 Appl TP TID:PRN rash 11. Multivitamins 1 TAB PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Ranitidine 150 mg PO BID 14. Senna 2 TAB PO BID:PRN constipation 15. Torsemide 100 mg PO DAILY 16. Warfarin 7.5 mg PO DAILY16 17. Lactaid *NF* (lactase) 3,000 unit Oral TID:prn with dairy 18. Losartan Potassium 50 mg PO DAILY 19. Metoprolol Succinate XL 200 mg PO DAILY 20. Align *NF* (bifidobacterium infantis) 4 mg Oral daily 21. Beano *NF* (alpha-d-galactosidase) 300 unit Oral daily gas 22. Potassium Chloride (Powder) 10 mEq PO DAILY Hold for K >5.0 23. Lidocaine 5% Patch 1 PTCH TD DAILY back 24. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 25. Metolazone 2.5 mg PO 3X/WK diuresis The patient may need this medication to diurese until she has no ___ edema - we held this medication in house as she was diuresing well with torsemide 100 mg qday alone. Goal diuresis is ~ 1L per day. 26. Furosemide 100 mg IV QD:PRN weight gain >3lbs in day 27. Heparin IV Sliding Scale 28. Ciprofloxacin HCl 500 mg PO Q12H Complete ___ay ___, so until ___ 29. Gabapentin 400 mg PO Q12H 30. 70/30 65 Units Breakfast 70/30 70 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - Gram negative sepsis secondary to citrobacter UTI - Acute on chronic systolic heart failure - Shock liver - Acute renal failure - Atrial fibrillation with RVR - 4.8 x 3.5 left renal lesion NOS - Perivaginal and gluteal excoriations - Right paraspinal pain (over ___ rib) NOS Secondary: - Ischemic cardiomyopathy EF 35% - Coronary artery disease, BMS D1 ___ ___ - Insulin dependent diabetes mellitus - Acute renal failure secondary to vancomycin - Asthma - Peripheral neuropathy - Hypertension - Hyperlipidemia - Depression - Arthritis 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: Abdominal pain and altered mental status. COMPARISONS: Abdominal ultrasound exam with the same date, ___. CT pelvis of ___. TECHNIQUE: MDCT-acquired contiguous images through the abdomen were obtained without intravenous contrast at 5-mm slice thickness. Coronally and sagittally reformatted images were provided. FINDINGS: CT ABDOMEN: Bibasilar areas of dependent atelectasis are noted. There is no pleural effusion. Heart is mildly enlarged without pericardial effusion. Aortic valve calcifications are noted. Evaluation of visceral organs is limited due to lack of intravenous contrast. Within this limitation, the liver demonstrates homogeneous attenuation. There is no intrahepatic biliary ductal dilatation. The gallbladder is mildly distended. Gallbladder wall edema is better appreciated on the ultrasound exam of the same date. Large gallstone is seen within its lumen, with peripheral rim calcification. The spleen appears normal. Pancreas demonstrates homogeneous attenuation without ductal dilatation or peripancreatic fluid collection. The adrenal glands are normal. The non-contrast appearance of the kidneys is unremarkable. A nonobstructive renal stone is seen within the left interpolar region of the left kidney. There is no hydronephrosis. There is a 4.8 x 3.5 cm isodense lesion arising from the interpolar region of the left kidney measuring 33 Hounsfield units in attenuation. This lesion was characterized as simple cysts on ___ ultrasound exam. Increased density may be attributed to internal hemorrhage or protein content. Imaged small and large bowel loops are normal in caliber without evidence of bowel wall thickening or obstruction. There is no free air or free fluid within the abdomen. There are scattered mesenteric and retroperitoneal lymph nodes, which do not meet CT criteria for pathologic enlargement. Intra-abdominal aorta is normal in caliber. CT PELVIS: The bladder is collapsed around a Foley catheter. The rectum and sigmoid colon are unremarkable. There is no pelvic lymphadenopathy. There is no free air or free fluid within the pelvis. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. IMPRESSION: 1. Cholelithiasis. Gallbladder wall thickening is better appreciated on the ultrasound exam of the same date and is likely from underdistension an dchronic changes. No pericholecystic fluid collection. No evidece of acute cholecystitis 2. A 4.8 x 3.5 intermediate density left renal lesion, which may represent an underlying neoplasm, though hemorrhagic or proteinaceous cysts are possible. Further assessment with MRI is recommended on non-emergent basis. 3. Small hiatal hernia. 4. Non-obstructive left renal stone. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: FEVERS Diagnosed with URIN TRACT INFECTION NOS temperature: 99.1 heartrate: 90.0 resprate: 18.0 o2sat: 98.0 sbp: 158.0 dbp: 138.0 level of pain: unable level of acuity: 1.0

Dear Ms ___, it was a pleasure taking care of you. You were admitted due to fever and confusion at your rehab, While hospitalized it was determined this was caused by a urinary tract infection, You symptoms improved with antibiotics. You will need to continue antibiotic treatment for a total of two weeks. Please see an attached list of your medications; non-essential medications (niacin, ___ oil were discontinued) Again be sure weigh yourself every morning, call MD if weight goes up more than 3 lbs (at rehab they will administer IV Lasix and/or metolazone). Please call Dr. ___ office at ___ to see if your appointment for heart failure can be moved sooner (you may be able to see one of her nurse practitioners at an earlier date). You should be monitored very closely given your heart failure.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / Ceclor Attending: ___. Chief Complaint: Altered mental status, acute kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old woman transferred from outside hospital with UTI, altered mental status. The patient had undergone dental work more than one week ago, receiving incisor implants. She also went to a hospital in the middle of the last week for new-onset back pain. X-ray showed degenerative joint disease and facet disease. She was prescribed Vicodin. The patient noticed that she became "loopy" on the Vicodin on ___, with worsening mental status. She was taken today to ___, who reported: ___ female who presents with altered mental status and back pain. Upon evaluation today the patient is confused with a nonfocal neuro exam, nl rectal tone and sensation. Laboratory analysis is notable for acute renal failure with a creatinine in the fives. Patient has a white count of 11 with 10 bands; however, reassuringly her lactate is 1.4. After 1 L of IV fluid, the patient's blood pressure normalized to 120/70. Urinalysis is notable for infection. The patient is also noted to have hyperbilirubinemia, with a predominance of direct bilirubin. CT imaging of the head notes a small hyperdensity concerning for, but not diagnostic of, hemorrhage. The patient has a normal INR at this time and platelets of 74. In the past the patient has had altered mental status in the setting of urinary tract infection. Concerned for possible underlying malignancy. Patient was treated with broad-spectrum IV antibiotics and fluid resuscitation. She'll be transferred to the ___ in ___ for further intensive medical evaluation and care. Of note, CT imaging of the abdomen without contrast did not reveal any gross pathology including ureteral obstruction, liver or abdominal mass." In our ED, the patient was stable. She received a head CT, which showed tiny hypodensity in right frontal lobe (different location from ___. RUQ ultrasound also completed, with no evidence of dilation. On transfer her vitals were T 97.9 HR 94 BP 127/76 96% RA RR 22. Past Medical History: Hypertension, degenerative disk disease with facet disease Social History: ___ Family History: Patient's son has diabetes. Patient's sister had ___ cancer. Multiple family members have hypertension. Physical Exam: Admission physical exam: Vitals: T: 97.9, BP: 124/75, P: 90, R: 25, O2: 95% RA General: Oriented X 1, paranoid, will not answer many questions HEENT: Sclera icteric as is frenulum of tongue, mucous membranes dry, oropharynx clear, EOMI, PERRL, dried blood on roof of mouth and near incisor on right maxilla Neck: supple, no LAD CV: S1 + S2, systolic murmur heard best at mitral listening position Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present GU: Foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, patient has non-blanching petechial rash on her arms Neuro: CN III-XII intact, ___ strength upper/lower extremities, 2+ patellar reflexes Discharge exam: Vitals: Tc99.0 (Tm99.0), BP124/56, HR84, 95% on RA General: Lying in bed comfortable appearing HEENT: MMM, PEERLA, no oropharyngeal lesions Neck: Supple, no LAD CV: normal S1 and S2, no audible MRG apprecitaed Lungs: CTAB Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: Foley removed, with prolapse organ protruding from vagina. Ext: Right shoulder with decreased ROM, and weakness associated. Petichaiel rash on her right forearm area. No visible stigmata of endocarditis. Neuro: AAOx3 Pertinent Results: ___ LABS: WBC 11.3 Hgb 10.7 Hct 31.1 Plt 74, Bands 10%, PMNs 84%, 2% Lymphs, Lactate 1.4 Na 129, K 3.1, Cl 88 Hco3 22, BUN 96, Cr 5.8, Glc 104; UA Nitrite positive, leuk estarase 500, WBCs ___ Albumin 2.8 Total protein 6.4 Total bili 6.9, Alk Phos 159, ALT 23, AST 23, lipase 41, troponin 0.012 ___ IMAGING: ___ CT abdomen and pelvis: IMPRESSION: 1. SPLENOMEGALY. 2. MILD BLUNTING OF THE RENAL CALYCES BILATERALLY. 3. HYPODENSE RENAL AND LIVER LESIONS MAY REPRESENT CYSTS BUT ARE NOT FULLY CHARACTERIZED. CONSIDER AN ULTRASOUND FOR FURTHER CHARACTERIZATION. 4. SIGMOID DIVERTICULOSIS WITHOUT DIVERTICULITIS. 5. HEAVY ATHEROSCLEROTIC CALCIFICATION OF THE ABDOMINAL AORTA. 6. TRACE BILATERAL PLEURAL EFFUSIONS. ___ CT head: IMPRESSION: 1. FOCAL AREA OF HIGH ATTENUATION WITHIN THE CENTRUM SEMIOVALE ON THE RIGHT CONCERNING FOR A SMALL HEMORRHAGE. IMAGING FOLLOW UP IS RECOMMENDED WITHIN THE NEXT EIGHT HOURS. IF NO CLINICAL CONTRAINDICATION, MRI IS ADVISED. 2. BILATERAL CALCIFICATIONS OF BASAL GANGLIA, PLEASE CORRELATE CLINICALLY. ___ CXR: IMPRESSION: NO EVIDENCE OF ACUTE CARDIOPULMONARY ABNORMALITIES. ================== Admission labs: ___ 11:24PM GLUCOSE-104* UREA N-95* CREAT-5.1* SODIUM-136 POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-22* ___ 11:24PM CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-2.3 URIC ACID-10.8* ___ 09:00PM ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-140* TOT BILI-7.1* ___ 09:00PM ALBUMIN-3.1* ___ 11:24PM ___ PTT-25.6 ___ ___ 09:00PM AMMONIA-22 ___ 11:24PM SED RATE-66* ___ 11:24PM CRP-278.5* ___ 11:24PM HAPTOGLOB-218* ___ 11:24PM CK-MB-8 cTropnT-<0.01 ___ 11:24PM LD(___)-281* CK(CPK)-202* Discharge labs: ___ 06:12AM BLOOD WBC-10.6 RBC-3.04* Hgb-9.0* Hct-27.5* MCV-91 MCH-29.6 MCHC-32.7 RDW-15.4 Plt ___ ___ 06:12AM BLOOD Glucose-84 UreaN-18 Creat-1.0 Na-136 K-3.7 Cl-100 HCO3-26 AnGap-14 ___ 06:12AM BLOOD ALT-20 AST-28 LD(___)-213 AlkPhos-115* TotBili-3.1* ___ 06:12AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.9 IMAGING: ___ ABDOMINAL U/S: IMPRESSION: 1. Segment VI liver cyst. 2. No biliary dilation. ___ NON-CONTRAST HEAD CT: IMPRESSION: Stable tiny focus of hyperdensity in the right frontal centrum semiovale white matter; no new hemorrhage. ___ TEE: The left atrium is elongated. 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 aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Mild pulmonary artery systolic hypertension. ___ RENAL U/S: IMPRESSION: Unremarkable appearance of the kidneys with only a tiny left renal simple cyst noted. ___ CXR: FINDINGS: In comparison with study of ___, there has been placement of an endotracheal tube with its tip approximately 3 cm above the carina. Nasogastric tube extends to the mid body of the stomach, then coils back on itself so that the tip lies in the fundus just beneath the left hemidiaphragm. There has been the development of increased opacification at the left base with silhouetting of the hemidiaphragm and obliteration of the costophrenic angle. This is consistent with substantial volume loss in the left lower lobe and pleural effusion. ___ EEG: IMPRESSION: Abnormal EEG due to the slow, disorganized, and usually low voltage background and due to the bursts of generalized slowing. These findings indicate widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disorders, and infection are among the most common causes. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features. ___ MR SPINE: IMPRESSION: 1. Endplate irregularity at L1/L2, with hyperintense disc signal. Given the provided history, these findings raise the possibility of discitis and osteomyelitis. Note that sclerotic endplate changes are present at the corresponding level on CT, suggesting that this is likely related to degenerative findings. Nevertheless, if clinical concern persists for infection, would recommend repeat imaging with contrast if the patient's renal function will tolerate, and/or with sagittal STIR/IDEAL sequences. 2. No other evidence of spinal infection. 3. Lower lumbar spinal degenerative findings, including severe narrowing on the left appearing to impinge upon the traversing left L5 nerve root, posterior to the L4/5 intervertebral disc. Note is also made of a left lateral disc protrusion at L5/S1, with disc material appearing to contact the exiting left L5 nerve root. ___ MR BRAIN: Note is made of a 7 x 5 mm focus of abnormally slow diffusion in the right frontal lobe (series 4 and 5, image 17). There is no other abnormally slow focus of diffusion to suggest infarction. Ventricles and sulci are normal in size and configuration. The focus of abnormally slow diffusion is bright on FLAIR and T2-weighted images. Scattered smaller FLAIR hyperintense white matter foci are also visualized, possibly reflecting prior vascular insult. Primary intracranial flow voids are normal. Incidental note is made of mineralization at the globus pallidus bilaterally. A small amount of fluid is seen within the mastoid air cells on the left, and minimally on the right. Note is made of mild mucosal thickening of the ethmoid air cells bilaterally. There is no intracranial hemorrhage, or mass effect. ___ MR ANGIOGRAPHY OF THE BRAIN: Primary intracranial arterial structures show appropriate flow related signal hyperintensity. There is no luminal caliber regularity to suggest thromboembolic filling defect, dissection or aneurysm. Note is made of a large fenestration at the base of the basilar artery. Anatomy is otherwise conventional in orientation. IMPRESSION: 1. Small right frontal infarct as described above, with no intracranial hemorrhage. 2. Fenestration at the base of the basilar artery and otherwise normal MR angiography of the brain. ___ TEE: Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is a focal thickening on the right coronary cusp of the aortic valve which may be a vegetation (images #37, #41, #89 and #102 amont others). No annular abscess seen. Mild (1+) centrally directed aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: Possible vegetation on the aortic valve with mild aortic regurgitation. No other echo evidence of endocarditis/abscess seen. In comparison to the TTE of ___, on image #2 of the prior study a similar thickening is seen on the aortic cusp. ___ SHOULDER PLAIN FILMS: FINDINGS: No acute fracture or dislocation. Normal bone mineralization, joint spaces, and alignment. Prominence of the soft tissues in the region of the right shoulder. Imaged portion of the right lung are clear. Imaged portions of the right ribs are intact. Endotracheal tube terminates approximately 3.4 cm proximal to the carina. Nasogastric tube extends below the left hemidiaphragm. IMPRESSION: 1. No acute fracture or dislocation. 2. No radiographic evidence for osteomyelitis. 3. Support lines and tubes, unchanged position. Radiology Report INDICATION: Right upper quadrant pain, fever, elevated bilirubin. Evaluate for biliary dilation. Correlation to CT from ___ Hospital dated ___ at 12:00. RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echogenicity, with a 1.4 x 1.2 x 1.2 cm cyst in segment VI. Normal hepatopetal flow in the portal vein. There is no intra- or extra-hepatic biliary ductal dilation. The common duct measures 4 mm. Gallbladder is normal without distention, stones, sludge, wall edema, or pericholecystic fluid. Ultrasonographic ___ sign is negative. Pancreatic head and body are normal, and the tail is not well visualized due to shadowing bowel gas. Pancreatic duct measures 2 mm. IMPRESSION: 1. Segment VI liver cyst. 2. No biliary dilation. Radiology Report INDICATION: ___ female with intracranial hemorrhage and altered mental status. COMPARISON: ___ at approximately 3 p.m. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. Images through the top half of the head were repeated due to motion artifact, with improvement. Coronal and sagittal reformatted images were reviewed. FINDINGS: Tiny focus of hyperdensity in the right frontal deep white matter appears similar compared to recent prior exam. No focus of new intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus is detected. There is preservation of gray-white matter differentiation. The basal cisterns appear patent. Mild white matter hypodensity is likely secondary to sequela of chronic small vessel ischemic disease. Dense bilateral basal ganglia mineralization is seen. The visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. No acute bony abnormality is detected. IMPRESSION: Stable tiny focus of hyperdensity in the right frontal centrum semiovale white matter; no new hemorrhage. Radiology Report HISTORY: ___ female with AMS, ARF, evaluate for etiology renal failure. COMPARISON: Liver ultrasound ___. FINDINGS: The right kidney measures 13.0 cm and the left kidney measures 10.4 cm. There is no hydronephrosis. A tiny simple exophytic cyst is noted at the lower pole of the left kidney measuring 1.2 x 1.3 x 1.0 cm. No stone or concerning solid renal mass is visualized. No perinephric fluid collection is identified. IMPRESSION: Unremarkable appearance of the kidneys with only a tiny left renal simple cyst noted. Radiology Report HISTORY: Tube placement. FINDINGS: In comparison with study of ___, there has been placement of an endotracheal tube with its tip approximately 3 cm above the carina. Nasogastric tube extends to the mid body of the stomach, then coils back on itself so that the tip lies in the fundus just beneath the left hemidiaphragm. There has been the development of increased opacification at the left base with silhouetting of the hemidiaphragm and obliteration of the costophrenic angle. This is consistent with substantial volume loss in the left lower lobe and pleural effusion. Radiology Report INDICATION: Altered mental status. COMPARISON: Head CT from ___. TECHNIQUE: Multiplanar MR images are acquired through the brain without intravenous contrast. Three-dimensional time-of-flight MR angiography is also performed, from which dedicated 3D vascular reconstructions are created. FINDINGS: MR BRAIN: Note is made of a 7 x 5 mm focus of abnormally slow diffusion in the right frontal lobe (series 4 and 5, image 17). There is no other abnormally slow focus of diffusion to suggest infarction. Ventricles and sulci are normal in size and configuration. The focus of abnormally slow diffusion is bright on FLAIR and T2-weighted images. Scattered smaller FLAIR hyperintense white matter foci are also visualized, possibly reflecting prior vascular insult. Primary intracranial flow voids are normal. Incidental note is made of mineralization at the globus pallidus bilaterally. A small amount of fluid is seen within the mastoid air cells on the left, and minimally on the right. Note is made of mild mucosal thickening of the ethmoid air cells bilaterally. There is no intracranial hemorrhage, or mass effect. MR ANGIOGRAPHY OF THE BRAIN: Primary intracranial arterial structures show appropriate flow related signal hyperintensity. There is no luminal caliber regularity to suggest thromboembolic filling defect, dissection or aneurysm. Note is made of a large fenestration at the base of the basilar artery. Anatomy is otherwise conventional in orientation. IMPRESSION: 1. Small right frontal infarct as described above, with no intracranial hemorrhage. 2. Fenestration at the base of the basilar artery and otherwise normal MR angiography of the brain. These results were discussed via telephone by Dr. ___ with Dr. ___ ___ at 14:25 on ___. Radiology Report INDICATION: Altered mental status, concern for endocarditis and question of septic emboli and/or epidural abscess. COMPARISON: Comparison is made to an MR of the brain from the same date dictated separately. TECHNIQUE: Multiplanar MR images were acquired through the cervical, thoracic, and lumbar spine without intravenous contrast. Note, the contrast was withheld secondary to patient's decreased estimated glomerular filtration rate. FINDINGS: MR CERVICAL SPINE: Vertebral body heights are normal. Alignment reveals a mild scoliotic curvature which may be positional. Marrow signal reveals no concerning focal abnormalities. Signal within the spinal cord is also normal. Note is made of small posterior disc bulges at C3/C4 and C5/C6. The latter results in minimal narrowing of the spinal canal, without evidence of deformation of the spinal cord. Soft tissue structures of the neck reveal fluid dependently in the oro- and nasopharynx, likely related to the known endotracheal intubation. MR THORACIC SPINE: Vertebral body heights are normal. Alignment is notable for scoliotic curvature. Marrow signal reveals focal T1-weighted and T2-weighted hyperintensities in T7 and T8 vertebral bodies, consistent with hemangiomata. Signal within the spinal cord is normal. There is no spinal canal stenosis or significant neural foraminal stenosis. MR LUMBAR SPINE: Vertebral body heights are normal. Alignment is also normal. Marrow signal reveals meningiomata at L1, 3 and 5. Note is made, however, of mild endplate irregularity at L1/L2, as well as abnormally T2-weighted hyperintense signal in the expected location of the L1/L2 intervertebral disc. The conus medullaris terminates posterior to the L1 vertebral body. At L1/L2, there are abnormal disc endplate changes as described above. Note is also made of bulging of the disc, as well as a right paracentral annular fissure. These findings result in mild narrowing of the spinal canal. Note is also made of moderate right neural foraminal narrowing and minimal left neural foraminal narrowing. At L2/L3, there is a circumferential disc bulge which does not narrow the spinal canal. Both neural foramina are also patent. There is mild bilateral facet arthropathy. At L3/L4, there is moderate spinal canal narrowing (series 24, image 11) related primarily to moderately severe bilateral facet arthropathy, as well as a circumferential disc bulge. The left neural foramen is patent and the right neural foramen is moderately narrowed. At L4/L5, there is a circumferential disc bulge which is eccentric to the left, as well as moderate bilateral facet arthropathy. Findings result in mild spinal canal narrowing, as well as impingement of the traversing left L5 nerve root between the disc and the superior articular facet. There is no neural foraminal stenosis. At L5/S1, there is a circumferential disc bulge, with focal left lateral protrusion. The spinal canal is appropriately patent. The right neural foramen is normal and the left neural foramen is mildly narrowed, with lateral disc protrusion material appearing to contact the exiting left L5 nerve root. Incidental note is made of moderate bilateral hydronephrosis. IMPRESSION: 1. Endplate irregularity at L1/L2, with hyperintense disc signal. Given the provided history, these findings raise the possibility of discitis and osteomyelitis. Note that sclerotic endplate changes are present at the corresponding level on CT, suggesting that this is likely related to degenerative findings. Nevertheless, if clinical concern persists for infection, would recommend repeat imaging with contrast if the patient's renal function will tolerate, and/or with sagittal STIR/IDEAL sequences. 2. No other evidence of spinal infection. 3. Lower lumbar spinal degenerative findings, including severe narrowing on the left appearing to impinge upon the traversing left L5 nerve root, posterior to the L4/5 intervertebral disc. Note is also made of a left lateral disc protrusion at L5/S1, with disc material appearing to contact the exiting left L5 nerve root. These results were discussed via telephone by Dr. ___ with Dr. ___ ___ at 2:25 p.m. on ___. Radiology Report HISTORY: ___ woman with shoulder pain. Evaluation for possible septic arthritis. TECHNIQUE: Four views of the right shoulder. COMPARISON: Portable chest radiograph performed one day prior. FINDINGS: No acute fracture or dislocation. Normal bone mineralization, joint spaces, and alignment. Prominence of the soft tissues in the region of the right shoulder. Imaged portion of the right lung are clear. Imaged portions of the right ribs are intact. Endotracheal tube terminates approximately 3.4 cm proximal to the carina. Nasogastric tube extends below the left hemidiaphragm. IMPRESSION: 1. No acute fracture or dislocation. 2. No radiographic evidence for osteomyelitis. 3. Support lines and tubes, unchanged position. Radiology Report INDICATION: Left PICC. COMPARISON: Chest radiograph from ___. ONE VIEW OF THE CHEST: The lungs are low in volume and show mild bibasilar atelectasis. The cardiomediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. A left PICC terminates in the brachiocephalic vein. IMPRESSION: Left PICC in the brachiocephalic vein. Advancement by 4 cm will place it in in the lower SVC. Bibasilar atelectasis. These findings were communicated to ___, RN via telephone at 9:29 a.m. on ___ after discovery at 9:28 p.m. Radiology Report INDICATION: New left PICC line exchanged over guidewire. Evaluate for PICC position. COMPARISON: Radiograph of the chest ___ and ___. TECHNIQUE: Portable AP radiograph of the chest. FINDINGS: A left PICC line terminates in the low SVC. Compared to chest radiograph ___, there is improvement in vascular congestion and volume loss and with relief of left lower lobe atelectasis. The endotracheal tube and nasogastric tube have been removed. There is no vascular congestion or pneumonia. The cardiomediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. IMPRESSION: 1. Left PICC in the low SVC. 2. Improvement in left lower lobe atelectasis and resolution of vascular congestion compared to radiograph 5 days prior. Additionally, the ET tube and gastric tube have been removed. Gender: F Race: AMERICAN INDIAN/ALASKA NATIVE Arrive by AMBULANCE Chief complaint: ICH/RENAL FAILURE Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, FEVER, UNSPECIFIED, INTRACRANIAL HEMORR NOS, HYPERTENSION NOS temperature: 97.2 heartrate: 90.0 resprate: 20.0 o2sat: 96.0 sbp: 118.0 dbp: 65.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you while you were here at ___. You were admitted to the hospital because you were very confused. You were found to have had an infection in your blood that created an infection on your heart valve called endocarditis. This lead to infection in one of your back bones. You were initially in the intensive care unit as you were very confused and your kidneys were not working very well. However with treatment with antibiotics you have improved and are now ready to leave the hospital. You continue to have shoulder pain, which does not seem related to your infection. You are taking pain medication for this. You will continue to need physical and occupational therapy at home until you regain your strength. You will also need several more days of antibiotic therapy for which you have had a PICC line placed. We have stopped your blood pressure medications while you recover from your infection. Your blood pressures in the hospital were normal at the time of discharge. Please discuss resuming these with your primary care doctor on follow up. Please take your medications as prescribed and follow up with your doctors as ___ below.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left sided weakness and numbness Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old man with a history of HTN who presented to an OSH with left sided weakness and numbness, found to have a right basal ganglia bleed. His symptoms began at 11pm last night (___) with a headache after getting home from a dinner party. He took advil. At 1:30 am this morning he began to notice left hand numbness and weakness. The symptoms then progressed to involve his entire arm and leg as well as some facial numbness which is now improving. He woke up his wife who thought he was having a stroke and brought him to the ED. CT head at the OSH showed IPH. SBP was noted to be 200. He was given keppra and vitamin K and transferred to ___. At ___, BP was in the ___ systolic and he was started on a nicardipine gtt. He endorsed ongoing left sided weakness and sensation changes. He has difficulty using his left hand and has not tried to walk with his left leg weakness. He feels the sensation in his face has improved. He also endorses some mild SOB. Past Medical History: HTN HLD Social History: ___ Family History: - HTN in father. no strokes in the family Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vitals: 98.3 114 163/79 18 96% RA ___: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple Pulmonary: CTABL Cardiac: tachycardic, intermittently to 120s and 130s with activity. RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented. Able to relate history without difficulty. Language is fluent with ___ accent. Intact repitition, comprehension and naming to high and low frequency items. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, able to name ___ backward without difficulty. Had finger substitution with coming hair but not with teeth brushing or unlocking a door. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. pinprick is 50% on L compared to R. VII: No facial droop, facial musculature symmetric VIII: Hearing intact to ___ bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in SCM bilaterally. Shoulder shrug is weak on the left (4+/5) XII: Tongue protrudes in midline -Motor: Normal bulk throughout. Decreased tone on left. Marked pronator drift on left. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5- ___- ___- ___ 4 5- 4+ R ___ ___ ___ 5 5 5 5 -DTRs: noted to be 1 at patella bilaterally, 0 at achilles - Plantar response was flexor on right, extensor on left. -Sensory: Compared to the right, light touch is full on the face, 80% in arm/leg; pinprick is 50% on face and 0% on arm/leg; cold sensation is "mild" on left arm/leg. vibration and proprioception are intact. -Coordination: No intention tremor, no dysmetria on FNF noted on right; exam on left limited by weakness. -Gait: deferred for fall risk DISCHARGE PHYSICAL EXAM: ================================= Vitals: Tc: 97.7 Tm:98.3 BP: SBP ___ ___ RR:18 99% RA ___: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple Pulmonary: CTABL Cardiac: RRR, no M/R/G Abdomen: soft, nontender, nondistended, +BS Extremities: no edema Neurologic: -Mental Status: Alert, oriented. Language is fluent with ___ accent. Able to follow commands. Attentive. No paraphasic errors. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: No facial droop, slight NLFF on Right. VIII: Hearing intact to ___ bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in SCM bilaterally. XII: Tongue protrudes in midline -Motor: Normal bulk throughout. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl IP Quad Ham L ___ 5 5 ___ R ___ 5 5 ___ -Sensory: Light touch intact bilateral. -Coordination: No intention tremor, no dysmetria on FNF noted on right -Gait: deferred Pertinent Results: ADMISSION LABS: ====================== ___ 04:25PM BLOOD ___ ___ Plt ___ ___ 04:25PM BLOOD ___ ___ Im ___ ___ ___ 04:25PM BLOOD ___ ___ ___:25PM BLOOD ___ ___ ___ 04:25PM BLOOD ___ ___ ___ 04:30PM URINE ___ ___ ___ 04:30PM URINE ___ Sp ___ DISCHARGE LABS: ====================== ___ 07:20AM BLOOD ___ ___ Plt ___ ___ 07:20AM BLOOD ___ ___ Im ___ ___ ___ 07:20AM BLOOD ___ ___ ___ 07:20AM BLOOD Plt ___ ___ 07:20AM BLOOD ___ ___ ___ 07:20AM BLOOD ___ ___ 07:20AM BLOOD ___ IMAGING: ===================== CT HEAD W/O CONTRAST ___ IMPRESSION: 1. Slight enlargement of the 2.7 x 1.2 cm left putaminal hematoma. Mild surrounding edema. 2. No new areas of hemorrhage. 3. Minimal local ___. MRI & MRA BRAIN AND MRA ___ IMPRESSION: 1. Left putaminal hematoma in a location most typical of a hypertensive hemorrhage. 2. Unremarkable MRA of the head and neck. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Sertraline 50 mg PO DAILY 3. Losartan Potassium 50 mg PO BID 4. Pravastatin 40 mg PO QPM Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Losartan Potassium 50 mg PO BID 3. Pravastatin 40 mg PO QPM 4. Sertraline 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left Basal Ganglia Bleed 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 Q111 CT HEAD INDICATION: ___ year old man with intracranial hemorrhage // please perform repeat CT to eval for change in intracranial hemorrhage at 130 AM ___ year old man with intracranial hemorrhage, please repeat to evaluate for change. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. Unenhanced head CT ___ at 13:37. FINDINGS: Again seen is a left putaminal hematoma measuring 2.7 x 1.2 cm in axial ___ (series 2, image 16), that appears slightly larger than on the prior head CT from ___ at 13:37. There is mild surrounding edema. There is no evidence of new or additional focus of hemorrhage elsewhere. There is no evidence of infarction. There is minimal local mass effect. The ventricles and sulci are stable and normal in caliber and configuration. The visualized paranasal sinuses and mastoid air cells are clear. The globes and bony orbits are intact and unremarkable. IMPRESSION: 1. Slight enlargement of the 2.7 x 1.2 cm left putaminal hematoma. Mild surrounding edema. 2. No new areas of hemorrhage. 3. Minimal local mass-effect. Radiology Report EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ INDICATION: ___ year old man with L basal ganglia bleed // assess etiology 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 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: Head CT from ___ FINDINGS: MRI Brain: Again seen is left putamen hematoma with associated surrounding FLAIR signal abnormality and minimal mass effect causing effacement of the frontal horn of left lateral ventricle. There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are patent and symmetric noting the mild effacement of the frontal horn of left lateral ventricle. Scattered foci of T2/FLAIR hyperintensity in the subcortical and periventricular white matter and pons, nonspecific, likely secondary to small vessel ischemic changes. The orbits are unremarkable. Visualized paranasal sinuses and mastoid air cells are clear. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. Incidentally seen is fetal origin of bilateral posterior cerebral arteries. MRA neck: The common, internal and external carotid arteries appear normal. There is no evidence of internal carotid artery stenosis by NASCET criteria. The origins of the great vessels, subclavian and vertebral arteries appear normal bilaterally. IMPRESSION: 1. Left putaminal hematoma in a location most typical of a hypertensive hemorrhage. 2. Unremarkable MRA of the head and neck. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: ICH, Transfer Diagnosed with Nontraumatic intracranial hemorrhage, unspecified, Essential (primary) hypertension temperature: 98.2 heartrate: 110.0 resprate: 18.0 o2sat: 98.0 sbp: 148.0 dbp: 64.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted for difficultly speaking and found to have a bleed in your brain. This is likely due to high blood pressure, with a goal blood pressure less than 140. We recommend you follow up with your PCP and ___. Please take your medications as prescribed. 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: GTC seizure, respiratory/cardiac arrest Major Surgical or Invasive Procedure: Intubation ___ Left PICC Placement ___ ___ Guided LP ___ ___ guided ___ tube placement ___ History of Present Illness: ___ w/PMHx HTN and history of seizure who was transferred from ___ for seizure and is being admitted to the MICU post-cardiac arrest. History is largely derived from notes, as patient is intubated on arrival. Per report, patient was watching TV during which time he had a witnessed GTC seizure lasting approximately 1 minute. He bit his tongue and lost bladder continence. Patient was smoking marijuana and drinking alcohol at the time. He denied any trauma or headache. He denied any significant alcohol history. When EMS arrived, pt was noted to be post ictal and combative, requiring restraints and Haldol. He was initially brought to ___. At ___ 98.6; 90; 122/70; 18; 96% (unknown supplemental oxygen). He was reportedly pleasant and cooperative on arrival. Labs were notable for Na 119, K 2.8, Mg 1.3, H/H 11.5/31.9 (MCV 90.6), Prolactin 117.5 STox with positive marijuana, UTox with EtOH level of 20. Patient was given 1L NS and brought to ___ for further evaluation. ___ the ED, initial vitals: 97.2; 88; 144/84; 18; 96% RA On exam pt was noted to have an enlarged liver and swollen tongue. Labs were significant for: Na 119 K 3.7 Bicarb 27 Mg 1.2 Phos 1.9 Imaging was significant for: NCHCT IMPRESSION: 1. No acute intracranial abnormality. 2. There is a 0.3 cm extra-axial calcified lesion adjacent to the falx, which may represent a tiny meningioma. 3. There is a large polyp that extends from the right frontal sinus into the anterior ethmoidal air cells and multiple mucous retention cysts or polyps ___ the bilateral maxillary sinuses and sphenoid sinuses. After returning from his ___, pt called the emergency call bell ___ the bathroom and was found slumped over on toilet and cyanotic. It is no clear if there was a pulse. Chest compressions started immediately and code called. Moved back to stretcher, and was noted to have pulse and compressions stopped. Per report, he underwent ___ rounds of compressions. Patient was subsequently intubated. Post arrest VBG was ___ with lactate 16.3. Repeat ABG was 7.40/34/295/22 and lactate 6.6. On exam: There was no reported spontaneous movement afterward. Patient was given IV Calcium Gluconate (2 g ordered) IV DRIP Fentanyl Citrate ___ mcg/hr ordered) Started 50 mcg/hr IV DRIP Midazolam (0.5-2 mg/hr ordered) Started 2 mg/hr IVF NS ( 1000 mL ordered) IVF Sodium Chloride 3% (Hypertonic) - 500 mL IV Magnesium Sulfate (4 gm) Patient was also started on bicarb gtt at 150cc/hr. Consults: Post-arrest Team recommended consideration of cooling. On transfer, vitals were: 98.3; 82; 121/75; 100% (vent settings not recorded) On arrival to the MICU, patient was breathing against the ventilator and appeared to be pulling at lines and his clothing. However, he did not follow commands, though he was notably on fentanyl/midazolam gtt. Past Medical History: HTN Seizure ___ setting of alcohol withdrawal Evidence of seizure activity, even when not withdrawing History of trauma to LLE as a teenager EtOH abuse Social History: ___ Family History: Unable to obtain. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: 137; 168/73; 39; 97% PSV FiO2 50% ___ GENERAL: Intubated, sedated. ETT ___ place. Withdraws to noxious stimuli. Does not open eyes to command. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-distended, bowel sounds present, firm liver with edge approximately 5cm below costophrenic angle. No ascites appreciated. GU: Foley ___ place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Deformity of LLE, with well-healed scars. SKIN: No lesions. NEURO: Upgoing Babinski bilaterally. Sluggish pupils bilaterally, equal. Withdraws to noxious stimuli. During exam, patient began biting ETT and posturing, appearing to be having a GTC. After this, patient appeared to be having jerking movements of his lower jaw, consistent with myoclonus. ACCESS: PIVs DISCHARGE EXAM: ===================== Vitals: 98.1 PO 142 / 95 98 20 96 Ra GENERAL: Alert and interactive, oriented x 3, NAD CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops LUNGS: Clear to auscultation anteriorly without wheezes, rales, rhonchi ABDOMEN: Soft, non-tender, mildly-distended, bowel sounds present, +firm hepatomegaly, no rebound or guarding EXTREMITIES: Warm, well perfused, 2+ pulses NEURO: Alert and oriented x 3. Mildly dysarthric. Finger to nose intact. Heel to shin mildly impaired. Pertinent Results: ADMISSION LABS ============== ___ 05:19AM BLOOD WBC-8.3 RBC-3.08* Hgb-10.5* Hct-29.0* MCV-94 MCH-34.1* MCHC-36.2 RDW-14.6 RDWSD-50.4* Plt ___ ___ 05:19AM BLOOD Neuts-83.5* Lymphs-5.8* Monos-9.9 Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.91* AbsLymp-0.48* AbsMono-0.82* AbsEos-0.01* AbsBaso-0.02 ___ 08:31AM BLOOD ___ PTT-30.5 ___ ___ 08:31AM BLOOD ___ 04:00AM BLOOD Glucose-122* UreaN-4* Creat-0.5 Na-119* K-3.7 Cl-81* HCO3-27 AnGap-15 ___ 05:30AM BLOOD ALT-88* AST-286* AlkPhos-197* TotBili-3.8* DirBili-1.8* IndBili-2.0 ___ 05:30AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 04:00AM BLOOD Calcium-8.6 Phos-1.9* Mg-1.2* ___ 05:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:37AM BLOOD ___ pO2-37* pCO2-93* pH-6.95* calTCO2-22 Base XS--16 ___ 05:37AM BLOOD Lactate-16.3* ___ 08:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:00AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG ___ 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 PERTINENT LABS ============== ___ 08:00AM BLOOD calTIBC-335 Ferritn-201 TRF-258 ___ 08:00AM BLOOD Osmolal-253* ___ 08:00AM BLOOD TSH-4.1 ___ 08:00AM BLOOD Free T4-1.7 ___ 02:41AM BLOOD Cortsol-12.9 ___ 07:00PM BLOOD Cortsol-12.8 ___ 10:09PM BLOOD Cortsol-22.4* ___ 02:53PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-122* Polys-65 ___ Macroph-20 ___ 02:53PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-78 LD(LDH)-27 DISCHARGE LABS AND OTHER RELEVANT LABS ======================================= ___ 06:50AM BLOOD WBC-6.3 RBC-3.28* Hgb-11.1* Hct-33.9* MCV-103* MCH-33.8* MCHC-32.7 RDW-15.9* RDWSD-60.7* Plt ___ ___ 06:50AM BLOOD ___ PTT-35.1 ___ ___ 06:50AM BLOOD Glucose-112* UreaN-3* Creat-0.4* Na-135 K-4.7 Cl-100 HCO3-22 AnGap-18 ___ 06:50AM BLOOD ALT-33 AST-85* AlkPhos-274* TotBili-1.2 ___ 06:50AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.5 Mg-1.7 ___ 03:31AM BLOOD Vit___-___* ___ 08:00AM BLOOD calTIBC-335 Ferritn-201 TRF-258 ___ 03:30AM BLOOD Triglyc-121 ___ 08:00AM BLOOD TSH-4.1 ___ 08:00AM BLOOD Free T4-1.7 ___ 10:09PM BLOOD Cortsol-22.4* ___ 08:50AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative IMAGING ======= CT HEAD ___: 1. Normal CT of the brain.. 2. Extensive opacification of the left ethmoid and frontal sinuses with erosion of the ethmoid septae deep. This may represent a mucocele, a polyp or a neoplasm. Further evaluation with direct visualization and perhaps MR imaging may be helpful. RIGHT UPPER QUADRANT U/S ___: 1. Nodular echogenic liver concerning for cirrhosis. 2. Splenomegaly and small volume ascites suggests portal hypertension. 3. Main portal vein and central branches are patent with hepatopetal flow. CTA CHEST ___: No evidence of pulmonary embolism or aortic abnormality. Enteric tube is ___ place and terminates within the distal esophagus, recommend advancement. Long segment distal esophageal wall thickening, consider esophagitis. Bibasilar moderate left lower lobe, mild right lower lobe atelectasis, with areas of bilateral lower lobe mucous plugging. Lung nodules, largest measures 0.4 cm, benign and no further follow-up needed ___ the absence of history of smoking or malignancy. If there is history of smoking, follow-up CT chest without contrast ___ 12 months recommended. Inhomogeneous attenuation of the liver, may be due to fatty infiltration or underlying liver disease. ___ Guided LP ___ 1. Lumbar puncture at L4-5 without complication. 2. Elevated opening pressure of 32 cm CSF. Ankle XR ___ No radiopaque foreign bodies. Chronic fracture deformity of the left tibia, fibula. Foot XR b/l one view ___ Pin fixation third toe. Bunion deformities first MTP joints bilaterally Knee Single View b/l ___ No radiopaque foreign bodies. Subtle lucency right tibial metaphysis, subacute fracture cannot be excluded, clinically correlate. Fracture deformity of the left fibula. Degenerative changes bilateral knees. CXR ___ 1. Interval removal of an enteric tube. 2. Low lung volumes with bronchovascular crowding and bibasilar opacities, probably atelectasis. Concurrent pneumonia cannot be excluded ___ the appropriate clinical setting, particularly ___ the right lung. CT HEAD ___ No interval change from head CT ___. No evidence of anoxic brain injury. MICROBIOLOGY ============ ___ Culture, Routine-PENDING ___ 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 ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ___ CULTURE-FINAL no growth ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). RARE GROWTH. ___ FLUIDGRAM STAIN-FINAL; FLUID CULTURE-FINAL no growth ___ CSF; SPINAL FLUID HSV1/HSV2 NEGATIVE ___ SCREEN-FINAL negative ___ Culture, Routine-FINAL no growth ___ Culture, Routine-FINAL no growth ___ CULTURE-FINAL no growth NEUROPHYSIOLOGY =============== EEG ___ This is an abnormal continuous ICU EEG monitoring study because of a severely suppressed background. No epileptiform activity was identified with the one pushbutton activation noted. The presence of extended periods with muscle artifact could have masked subtle findings. Interim results were provided to the treatment team intermittently during this recording period. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. lisinopril-hydrochlorothiazide ___ mg oral DAILY 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. CefTAZidime 2 g IV Q12H Duration: 8 Days 2. FoLIC Acid 1 mg PO DAILY 3. Keppra XR (levETIRAcetam) ___ mg oral DAILY 4. Lactulose 30 mL PO Q6H 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Rifaximin 550 mg PO BID 7. Thiamine 100 mg PO DAILY 8. Diltiazem Extended-Release 240 mg PO DAILY 9. HELD- Levothyroxine Sodium 50 mcg PO DAILY This medication was held. Do not restart Levothyroxine Sodium until your doctor says it is okay Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ====================== -Seizure (multifactorial, not only from EtOH withdrawal) -Alcohol Abuse -Hyponatremia -New cirrhosis diagnosis SECONDARY DIAGNOSES ======================= -HTN -Seizure ___ setting of alcohol withdrawal Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with respiratory arrest s/p ETT placement // Is the ETT in the correct Is the ETT in the correct IMPRESSION: In comparison with the study of earlier in this date, the endotracheal tube has been pushed forward so that the tip lies approximately 6 cm above the carina. The tip of the nasogastric tube can only be followed definitely to the lower esophagus. If this clinically a has been advanced beyond this point, a repeat study could be obtained with the upper margin at the hilum pain using abdominal technique. Little change in the appearance the heart and lungs. Radiology Report EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ year old man with firm hepatomegaly // Is there normal flow through the liver? Is there evidence of mass in the liver? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma is diffusely heterogeneous and echogenic. The degree of echogenicity makes it difficult to fully assess the hepatic architecture. No gross liver lesion is identified. The contour of the liver is nodular. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not visualized due to overlying bowel gas. SPLEEN: Normal echogenicity, measuring 12.7 cm. KIDNEYS: The right kidney measures 12.2 cm. The left kidney measures 13.4 cm. Visualization of the kidneys is limited. No hydronephrosis is seen bilaterally. DOPPLER EXAMINATION: The main and left portal veins are patent with hepatopetal flow. The intrahepatic right portal vein is not well visualized due to limited visualization of the liver. The hepatic veins are patent. Appropriate arterial waveforms are seen in the main, right and left hepatic arteries. IMPRESSION: 1. Patent hepatic vasculature. Note is made of limited visualization of the portal veins. 2. No gross liver lesion identified. The hepatic parenchyma is heterogeneous, echogenic and nodular. No biliary dilatation. 3. The spleen is at the upper limits of normal. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ man with seizure, now post arrest. Starting cooling protocol, evaluate for evidence of anoxic brain injury. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 926 mGy-cm. COMPARISON: Head CT ___ 04:30. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. The patient is intubated. Again seen, are numerous bilateral maxillary sinus mucous retention cysts versus polyps. There is a rim calcified polypoid lesion in the anterior right ethmoid air cells resulting in erosion of the ethmoid septa. This lesion extends into the right frontal sinus superiorly and superior nasal passage inferiorly. There is mucosal thickening in the sphenoid sinus and ethmoid air cells. The mastoid air cells are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Polypoid opacification of the right anterior ethmoid air cells causing ethmoid septa erosion and extending into the frontal sinus and nasal passage, as recommended previously, if clinically indicated and further characterization is needed consider MR imaging or direct visualization. RECOMMENDATION(S): If clinically indicated, direct visualization or MR imaging to further characterize ethmoid sinus findings. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with picc // l dl picc 48cm iv ping ___ Contact name: ping, ___: ___ l dl picc 48cm iv ping ___ IMPRESSION: Compared to chest radiographs earlier on ___. New left PIC line ends in the low SVC close to the superior cavoatrial junction. Tip of nasogastric tube just above the upper margin of the clavicles, no less than 6 cm from the carina should not be withdrawn any further. Nasogastric drainage tube ends in the low esophagus and is probably looped in the hypopharynx. It would need to be advanced at least 15 cm to move all the side ports into the stomach. Borderline cardiomegaly is stable. Aside from mild right basal atelectasis, lungs are clear. No pleural abnormality. NOTIFICATION: PIC line placement was reported to the IV nurse by telephone at 13:00. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with hyponatremia with large variations in Na level. // eval for cerebral edema TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP = 911.9 mGy-cm. Total DLP (Head) = 925 mGy-cm. COMPARISON: Head CT ___ 09:55 FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is no CT evidence of osmotic demyelination syndrome. There is no evidence of fracture. There multiple submucosal retention cysts in bilateral maxillary, right frontal sinuses. There is ovoid fullness in the right ethmoid sinus, stable since prior, causing expansion of the septa, extending into the right nasal cavity. There is new fluid in the right maxillary sinus, likely from tube use. Bilateral mastoid air cells, middle ear cavities are patent. The The visualized portion of the orbits are unremarkable. IMPRESSION: 1. There are no new intracranial abnormalities. 2. Polypoid mass in the right ethmoid sinus, nasal cavity stable. Radiology Report EXAMINATION: CTA of the chest INDICATION: ___ year old man with hypoxic event found in PEA. // Eval for 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) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 1.5 s, 1.0 cm; CTDIvol = 3.5 mGy (Body) DLP = 3.5 mGy-cm. 3) Spiral Acquisition 8.3 s, 31.8 cm; CTDIvol = 12.1 mGy (Body) DLP = 366.3 mGy-cm. Total DLP (Body) = 379 mGy-cm. COMPARISON: Chest x-ray ___ FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. Heart is mildly enlarged. Coronary artery calcifications. There is no pleural effusion. There is moderate right, mild left lower lobe mucous plugging. There is moderate volume loss and consolidation the left lower lobe from atelectasis, and mild atelectasis in the right lower lobe. There is 0.4 cm nodule in the right lower lobe series 6, image 171. 0.3 cm nodule right middle lobe series 6, image 131. 0.2 cm nodule right upper lobe image 87. Endotracheal tube is in place, the tip terminates 5 cm above the carina. Enteric tube is in place. The tip is within the distal esophagus, as seen on ___ 11:57 radiograph, recommend advancement. Long segment distal esophageal wall thickening, consider esophagitis. Visualized liver shows a heterogeneous enhancement pattern, this may be due to fatty infiltration or underlying liver disease. There is a small amount of perihepatic ascites. Left PICC is in place, the tip terminates in the upper most SVC. There are multiple nondisplaced subtle fractures of the anterior bilateral ribs, of indeterminate age. Benign mid vertebral body hemangioma. There is mild T11 compression fracture, age indeterminate, possibly chronic there is no adjacent edema. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Enteric tube is in place and terminates within the distal esophagus, recommend advancement. Long segment distal esophageal wall thickening, consider esophagitis. Bibasilar moderate left lower lobe, mild right lower lobe atelectasis, with areas of bilateral lower lobe mucous plugging. Lung nodules, largest measures 0.4 cm, benign and no further follow-up needed in the absence of history of smoking or malignancy. If there is history of smoking, follow-up CT chest without contrast in 12 months recommended. Inhomogeneous attenuation of the liver, may be due to fatty infiltration or underlying liver disease. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 5 EXAMS INDICATION: ___ year old man with hypernatremia, post- ?seizure // NG tube placement NG tube placement IMPRESSION: Compared to 3 chest radiographs on ___. 5 successive chest radiographs performed over 15 min show failure to advance the esophageal drainage tube in beyond the level of the gastroesophageal junction. Several of the images, including the final one in the series, performed at 00:35 shows a proximal loop of the drainage tube in the hypopharynx. Final radiograph in the series also shows top-normal heart size, low lung volumes, no focal consolidation, mild pulmonary vascular engorgement, but no edema or pleural effusion. Tip of the ET tube above the upper margin of the clavicles is no less than 6 cm from the carina and could be advanced 2 cm for more secure positioning. Radiology Report EXAMINATION: PELVIS PORTABLE INDICATION: ___ year old man found down, hx of trauma to bilateral legs // any e/o residual surgical hardware? TECHNIQUE: Pelvis single view COMPARISON: None FINDINGS: Foley catheter in place. Mild degenerative changes lower lumbar spine, bilateral hips. Pelvic phleboliths. No fractures. IMPRESSION: No fractures. Radiology Report EXAMINATION: KNEE( (SINGLE VIEW) BILATERAL INDICATION: ___ year old man found down, hx of trauma to bilateral legs // any e/o residual surgical hardware? TECHNIQUE: Single AP view bilateral knees, one view each side. COMPARISON: None FINDINGS: Right knee: Subtle mid diaphyseal lucency of the proximal tibia, subacute fracture cannot be excluded. Degenerative arthritis of the right knee, with hypertrophic changes. Arterial calcifications. Left knee: Degenerative arthritis of the left knee, medial compartment narrowing. Chronic fracture deformity of the fibular diaphysis, with posttraumatic heterotopic calcification. Arterial calcifications. IMPRESSION: No radiopaque foreign bodies. Subtle lucency right tibial metaphysis, subacute fracture cannot be excluded, clinically correlate. Fracture deformity of the left fibula. Degenerative changes bilateral knees. Radiology Report EXAMINATION: ANKLE 1 VIEW BILATERAL INDICATION: ___ year old man found down, hx of trauma to bilateral legs // any e/o residual surgical hardware? TECHNIQUE: Single AP view bilateral ankles COMPARISON: None FINDINGS: Right ankle: Soft tissue calcification inferior to medial malleolus, well ___ be related to prior trauma, no adjacent soft tissue swelling. There are benign soft tissue calcifications in the distal leg. There are no fractures. Right ankle otherwise normal. Left ankle: There is chronic, displaced healed fracture of the distal tibial diaphysis,, with significant callus formation. Significant ossification projects over distal tibia at the fracture site and distal to it, likely posttraumatic. Chronic posttraumatic deformity of the mid fibular diaphysis. The degenerative changes ankle. No soft tissue swelling. No radiopaque foreign bodies. IMPRESSION: No radiopaque foreign bodies. Chronic fracture deformity of the left tibia, fibula. Radiology Report EXAMINATION: FOOT 1 VIEW BILATERAL INDICATION: ___ year old man found down, hx of trauma to bilateral legs // any e/o residual surgical hardware? TECHNIQUE: Single AP view of each foot, one view each side COMPARISON: None FINDINGS: Right foot: Bunion deformity, degenerative changes first MTP joint. Mild degenerative changes midfoot. No fractures. Left foot: Pin fixation across PIP, DIP joint third toe. Bunion deformity, degenerative changes first MTP joint. Scattered degenerative changes midfoot. Posttraumatic or postsurgical change PIP joint fifth toe. No fractures. IMPRESSION: Pin fixation third toe. Bunion deformities first MTP joints bilaterally Radiology Report EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE. INDICATION: ___ year old man found down cyanotic with concern for central infection // Please obtain CSF. TECHNIQUE: After informed consent was obtained from the patient's healthcare proxy over the phone 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 22 gauge, 13 cm spinal needle was inserted into the thecal sac. There was good return of clear CSF. 16 mls of CSF were collected in 4 tubes and sent for requested analysis. Fluoroscopy time: 0.2 min Air kerma: 8.1 mGy Dose area product: 52.69 uGy cm 2 COMPARISON: None. FINDINGS: 16 mls of clear CSF were collected in 4 tubes. Opening pressure was measured at 32 cm CSF. IMPRESSION: 1. Lumbar puncture at L4-5 without complication. 2. Elevated opening pressure of 32 cm CSF. 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 radiograph INDICATION: ___ year old man with likely respiratory arrest, now positive sputum gram stain, c/f PNA // interval change TECHNIQUE: Portable semi upright view of the chest COMPARISON: Chest radiograph from ___ FINDINGS: The tip of an ETT is seen approximately 6.3 cm above the carina. Lung volumes are low with bronchovascular crowding and bibasilar opacities, likely representing atelectasis. Concurrent pneumonia cannot be excluded in the appropriate clinical setting, particularly in the right lung. The enteric tube has been removed. The cardiomediastinal silhouette and hilar contours are likely unchanged. No pneumothorax or pulmonary edema. The left PICC has been pulled back and is seen in the low SVC. IMPRESSION: 1. Interval removal of an enteric tube. 2. Low lung volumes with bronchovascular crowding and bibasilar opacities, probably atelectasis. Concurrent pneumonia cannot be excluded in the appropriate clinical setting, particularly in the right lung. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with likely respiratory arrest, now positive sputum gram stain, c/f PNA // interval change interval change IMPRESSION: Comparison to ___, 11:05. No relevant change is noted. Moderate cardiomegaly. Mild retrocardiac atelectasis. No evidence of pneumonia. No larger pleural effusions. No pulmonary edema. The monitoring and support devices, including the endotracheal tube, are stable. Radiology Report EXAMINATION: Chest radiograph. INDICATION: ___ year old man with AMS, intubated // interval change TECHNIQUE: Single AP COMPARISON: Chest radiograph ___. FINDINGS: Heart size within normal limits. A left PICC line terminates in the mid SVC. An endotracheal tube ends in the mid thoracic trachea. Persistent ill-defined opacities at the left lung base are unchanged. No significant pleural effusion. IMPRESSION: Persistent ill-defined opacities at the left lung base are unchanged, but improved from ___. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old man s/p cardiac arrest, continued AMS, previous CT with no e/o intracranial abnormalities however concerned for evolving process. // interval change, e/o anoxic brain injury? TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP = 911.9 mGy-cm. Total DLP (Head) = 927 mGy-cm. COMPARISON: CT head ___ FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. There are multiple mucous retention cysts in both maxillary sinuses and right frontal sinus. There is ovoid fullness of the right ethmoid sinus with rightward deviation of the nasal septum, unchanged. There is mild mucosal thickening the sphenoid sinuses and left ethmoid air cells Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION: No interval change from head CT ___. No evidence of anoxic brain injury. Radiology Report EXAMINATION: NASOINTESTINAL TUBE PLACEMENT WITH FLUOROSCOPY INDICATION: ___ year old man with need for PO access and unable to place with glidescope.// Please place NG or OG tube DOSE: Acc air kerma: 42.1 mGy; Accum DAP: 1233.5 uGym2; Fluoro time: 4.1 minutes COMPARISON: None. FINDINGS: The left nare was anesthetized with lidocaine jelly. Under intermittent fluoroscopic guidance, ___ feeding tube was placed into the stomach and then advanced post-pylorically using a guidewire. 10 cc of Optiray contrast were used to confirm post pyloric placement. Final fluoroscopic spot images demonstrated the tip of the feeding tube in the second portion of the duodenum. The feeding tube was affixed to the patient's nose and cheek using tape. IMPRESSION: Successful post-pyloric placement of ___ feeding tube. The tube is ready to use. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with alcohol abuse and increased secretions. // interval changes interval changes IMPRESSION: Comparison to ___. The patient remains intubated and has received a feeding tube. The course of this tube is unremarkable, the tip is not displayed on the image. The left PICC line is unchanged. Minimally increased fluid overload but no overt pulmonary edema. Atelectatic retrocardiac lung zone. No larger pleural effusions. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new retrocardiac opacities, originally read as atelectasis, continues to be febrile, c/f PNA // interval change interval change IMPRESSION: Comparison to ___. No relevant change is noted. The monitoring and support devices are stable. There is a stable retrocardiac opacity more likely to reflect atelectasis but the presence of additional pneumonia cannot be excluded on the basis of the radiographs alone. No larger pleural effusions. Mild fluid overload but no overt pulmonary edema. Mild cardiomegaly persists. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with pseudomonal pneumonia// Eval for interval change in consolidation Eval for interval change in consolidation IMPRESSION: In comparison with the study of ___, the Dobhoff tube has been removed and the patient has taken a better inspiration. Cardiac silhouette remains at the upper limits of normal in size and there is mild elevation of pulmonary venous pressure. Minimal bibasilar atelectatic changes without evidence of acute focal pneumonia. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with EtOH history, and uptrending alk phos// hepatic congestion? TECHNIQUE: Abdominal ultrasound COMPARISON: Abdominal ultrasound from ___ and CT C-spine from ___ FINDINGS: The liver appears enlarged, echogenic with nodular contour concerning for cirrhosis. No discrete lesion is seen within the liver. Trace right pleural effusion is suspected. Common bile duct is nondilated. Pancreas not well visualized. No intrahepatic biliary ductal dilation. Gallbladder is collapsed. No gallstones are seen. Spleen is mildly enlarged at 14.2 cm in length. Limited views of both kidneys demonstrate no hydronephrosis. A small cyst arising from the left renal midpole is noted measuring up to 2.3 cm. Small volume ascites tracks into the lower quadrant. Doppler: Main portal vein is patent with hepatopetal flow. The right and left branches of the portal vein are patent with hepatopetal flow. The hepatic arterial system appears patent with normal waveforms. Color flow is noted within the hepatic veins. IMPRESSION: 1. Nodular echogenic liver concerning for cirrhosis. 2. Splenomegaly and small volume ascites suggests portal hypertension. 3. Main portal vein and central branches are patent with hepatopetal flow. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with seizure // eval for intracranial mass/bleed 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, 16.6 cm; CTDIvol = 48.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. No fractures. There are multiple (greater than 15) mucous retention cysts or polyps in the bilateral maxillary sinuses. There is erosion of the ethmoid septae eye in the right ethmoid sinus and extending into the right frontal sinus. This may represent an ethmoid sinus mucocele, one or several polyps, a neoplasm or a combination of these factors. If the distinction between polyp versus neoplasm and mucocele is clinically significant, magnetic resonance imaging may be helpful. There are few small mucous retention cysts/ polyps in the bilateral sphenoid sinuses. The mastoid air cells and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Normal CT of the brain.. 2. Extensive opacification of the left ethmoid and frontal sinuses with erosion of the ethmoid septae deep. This may represent a mucocele, a polyp or a neoplasm. Further evaluation with direct visualization and perhaps MR imaging may be helpful. RECOMMENDATION(S): Centered or visualization and MR imaging for further evaluation of the ethmoid sinus findings NOTIFICATION: The recommendation of direct visualization and perhaps MR imaging for further evaluation of the ethmoid sinus findings was emailed to the Emergency Department QA nurses 10:12 ___ by Dr. ___ ___ upon reviewing the study. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with seizure // confirm endotracheal tube placement TECHNIQUE: Single portable supine AP chest radiograph COMPARISON: None. FINDINGS: The endotracheal tube terminates approximately 9.2 cm above the carina. Heart and mediastinum are normal. Lungs are clear. No pleural effusion. No pneumothorax. IMPRESSION: 1. The endotracheal tube terminates 9.2 cm above the carina. 2. No acute cardiopulmonary abnormality. Gender: M Race: UNKNOWN Arrive by UNKNOWN Chief complaint: Seizure, Transfer Diagnosed with Abn lev hormones in specimens from female genital organs, Epilepsy, unsp, not intractable, without status epilepticus, Cardiac arrest, cause unspecified temperature: 97.2 heartrate: 88.0 resprate: 18.0 o2sat: 96.0 sbp: 144.0 dbp: 84.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. Why you were here: - You had seizures from alcohol withdrawal and from having low sodium. The low sodium was probably from not getting proper nutrition. - You became very confused and not yourself from seizures, alcohol withdrawal and poor nutrition. You also got a pneumonia. What we did while you were here: - We treated you for seizures, alcohol withdrawal, and pneumonia and confusion. - We gave you medication to prevent alcohol withdrawal and improved your nutrition with vitamins. - We treated you with antibiotics for pneumonia. - We helped you to name ___ healthcare proxy. What to do when you go home: - Please take your antibiotics as prescribed, last day is ___. Then they can remove your PICC line. - Please take your medications as prescribed below. - We saw that you may have liver damage from alcohol. You will need to see a liver specialist. - We very strongly suggest that you not drink more alcohol. Please ask your rehab facility and your primary care doctor to connect you with Alcoholics Anonymous or inpatient or outpatient alcohol rehab programs. - Please follow up with a neurologist (brain doctor) for seizures. you need to stay on antiseizure medicines. - Please ask your primary care doctor to make referrals to a NEUROLOGIST and a HEPATOLOGIST (LIVER DOCTOR). Unfortuantely we were unable to make these appointments for you. It is very important that you make these appointments. We wish you the best. Sincerely, Your care team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Effexor / codeine / amoxicillin / omeprazole / arthrexa / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: New R facial droop Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with PMHx of ETOH abuse, IDDM, epilepsy, Schizophrenia, and Hepatitis C, recent GIB (___) presenting to the ED with weakness, right facial droop, and fever. As patient unable to give details prior to EMS arrival and husband not at bedside, pre-admission details per Neurology evaluation note. Pt seen at baseline health this afternon following a trip from beauty shop. Husband ___ became concerned when he noted non-rhythmic upper body shaking and the pt felt warm to touch. Pt able to respond appropriately to him, but called EMS given recent admission. EMS called by patient's husband due to shaking and altered mental status. Per EMS, initial VS on assessmeent T: 103 BP: 170/80 with slow affect, abnormal R sided facial droop, tremulous, weakness b/l grip strength, without slurred speech GCS 15. Fingerstick WNL. Pt transferred to ___ ED for concern for stroke. Past Medical History: Schizophrenia with auditory hallucinations Type II DM (insulin dependent) Hypertension Hepatitis C (untreated), genotype 1b - Fibroscan score Metavir Stage ___, per last GI note ___ anticipate initiation of lediposuvir-sofosbuvir when approved by insurance Seizure disorder, complex partial, on depakote (last seizure ___ years ago) Collagenous enteritis and microscopic colitis Chronic low back pain EtOH abuse with hx of withdrawal hallucinations Social History: ___ Family History: Mother with colon cancer, father with leukemia, brother with sickle cell and sister with lupus and lung cancer. No family history of renal disease. Physical Exam: VS 97.6 155/68 78 20 96% RA General: Alert, oriented x 3, slow affect but appropriate HEENT: Sclera anicteric, MMM, EOMI, PERRL CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, no tenderness of lower abdomen with palpation. No rebouund, guarding or rigidity. No suprapubic tenderness. Non-distended, bowel sounds present GU: No flank pain Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAO x3, moving all extremities Pertinent Results: ___ 07:10AM BLOOD WBC-16.3* RBC-2.92* Hgb-8.5* Hct-24.7* MCV-85 MCH-29.1 MCHC-34.4 RDW-15.6* RDWSD-46.0 Plt ___ ___ 07:30PM BLOOD WBC-22.8*# RBC-3.16* Hgb-9.6* Hct-27.9* MCV-88 MCH-30.4 MCHC-34.4 RDW-15.7* RDWSD-48.6* Plt ___ ___ 07:10AM BLOOD Glucose-124* UreaN-12 Creat-0.7 Na-133 K-3.5 Cl-100 HCO3-21* AnGap-16 ___ 07:30PM BLOOD ALT-20 AST-55* AlkPhos-177* TotBili-0.6 ___ 07:25AM BLOOD Valproa-33* ___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q8H 2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat discomfort 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 100 mg PO TID 5. HumaLOG (insulin lispro) 8 Units subcutaneous TID 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. LOPERamide 2 mg PO QID:PRN loose stools 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Nicotine Patch 21 mg TD DAILY 11. OLANZapine 10 mg PO QHS 12. Thiamine 100 mg PO DAILY 13. Tizanidine 2 mg PO QHS 14. Vitamin D 1000 UNIT PO DAILY 15. Amlodipine 5 mg PO DAILY 16. insulin glargine 30 units subcutaneous QPM 17. Lisinopril 40 mg PO DAILY 18. Magnesium Oxide 400 mg PO DAILY 19. Pantoprazole 40 mg PO Q12H 20. Phosphorus 500 mg PO BID 21. Divalproex (DELayed Release) 250 mg PO BID 22. LaMOTrigine 25 mg PO EVERY OTHER DAY 23. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat discomfort 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 100 mg PO TID 5. HumaLOG (insulin lispro) 8 Units subcutaneous TID 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Lisinopril 40 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. LOPERamide 2 mg PO QID:PRN loose stools 10. Magnesium Oxide 400 mg PO DAILY 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Thiamine 100 mg PO DAILY 13. Phosphorus 500 mg PO BID 14. Pantoprazole 40 mg PO Q12H 15. Nicotine Patch 21 mg TD DAILY 16. Multivitamins 1 TAB PO DAILY 17. Amlodipine 5 mg PO DAILY 18. Divalproex (DELayed Release) 250 mg PO BID 19. insulin glargine 30 units subcutaneous QPM 20. OLANZapine 10 mg PO QHS 21. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain 22. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 23. LACOSamide 100 mg PO BID RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary tract infection E. coli bacteremia 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 new right sided weakness after possible seizure. Evaluate for mass/stroke/intracranial lesion. TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. 3D time-of-flight MRA of the brain was obtained with multiplanar maximum intensity projection angiographic reformatted images. 2D time-of-flight MRA of the neck was obtained with multiplanar maximal intensity projection angiographic reformatted images. 3D coronal T1 weighted gradient echo imaging of the neck was obtained before, during, and after intravenous gadolinium administration with multiplanar maximum intensity projection angiographic reformatted images. COMPARISON: Brain MRI with intravenous contrast ___. Noncontrast head CT ___. CTA head and neck ___. FINDINGS: BRAIN MRI: There is no acute infarction. Punctate focus of high signal in the right anterior frontal cortex on the diffusion tracer sequence (image 17:16), without a correlate on the ADC map or FLAIR images, is consistent with artifact. There is no evidence for an intracranial mass, parenchymal edema, or blood products. Few small foci of high T2 signal in the left frontal deep white matter appear slightly progressed since ___, nonspecific but compatible with sequela of mild chronic small vessel ischemic disease in a patient of this age. A punctate focus of high T2 signal at the anterior margin of the right internal capsule is unchanged. Ventricles and sulci are prominent due to parenchymal volume loss, unchanged since ___ but unexpected for age. Major dural venous sinuses are patent on postcontrast MP RAGE images. There is mild mucosal thickening in the maxillary sinuses. NECK MRA: There is a 3 vessel aortic arch. Common carotid and bilateral cervical carotid arteries are patent without stenosis by NASCET criteria. Mild irregularity of the proximal right internal carotid artery, corresponding to mild atherosclerotic plaque on the ___ CTA, is unchanged. Evaluation of the right vertebral artery origin is limited by artifact. The remainder of the right vertebral artery, as well as left vertebral artery, are widely patent without stenosis. BRAIN MRA: Images are moderately limited by motion artifact. Irregular appearance of bilateral carotid siphons is likely exaggerated by artifacts, as the demonstrate only minimal plaque on the ___ CTA. The major anterior circulation branches, as well as the intracranial vertebral arteries and their major branches, appear patent without evidence for flow-limiting stenosis. Posterior circulation MIP images suggest a small right lateral outpouching of the proximal basilar artery, but this is explained by tortuosity of the distal right vertebral artery as well as artifact on the source data. No evidence for an aneurysm greater than 3 mm is seen. IMPRESSION: 1. No acute infarction and no evidence for other acute intracranial abnormalities. No evidence for an intracranial mass. 2. Few small foci of high T2 signal in the left frontal deep white matter appear slightly progressed since ___, nonspecific but compatible with sequela of mild chronic small vessel ischemic disease in a patient of this age. 3. Global parenchymal volume loss is unexpected for age but unchanged compared to ___. 4. Limited evaluation of the right vertebral artery origin. Otherwise, no evidence for flow-limiting arterial stenosis in the neck. 5. Moderately motion limited brain MRA demonstrates no evidence for flow-limiting intracranial arterial stenosis. Irregularity of bilateral carotid siphons is likely exaggerated by artifacts, as the demonstrated only minimal plaque on the ___ CTA. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with GNR bacteremia from presumed urinary source // assess for pyelonephritis TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Abdomen ultrasound ___ FINDINGS: The right kidney measures 10.8 cm. The left kidney measures 12.4 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is normal in appearance, with postvoid ___ of 6.1 x 3.2 x 4.2 cm. IMPRESSION: No renal stones, hydronephrosis or abscesses. Complete assessment for pyelonephritis requires a contrast enhanced study such as CT or MRI. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Facial droop, Weakness Diagnosed with SEPTICEMIA NOS, URIN TRACT INFECTION NOS, SEPSIS , ACCIDENT NOS, SEMICOMA/STUPOR temperature: 101.0 heartrate: 123.0 resprate: nan o2sat: nan sbp: 126.0 dbp: 69.0 level of pain: nan level of acuity: 1.0

Dear Ms. ___, You were admitted to the hospital here at ___ because you were found to have urinary tract infection (UTI) and an infection of your blood (bacteremia) from your UTI. This was likely the cause of your shaking rather than a seizure. You were treated with IV antibiotics and improved. You should continue to take the antibiotic pills until you finish a 2 week course. Please follow-up with your PCP regarding your UTI and ongoing health maintenance. If you continue to have diarrhea, please see your primary care doctor. It was a pleasure taking care of you, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim DS / Gantrisin Pediatric / Keflex / Latex / Erythromycin Base / Codeine / Percocet / Nitroglycerin / Darvocet-N 100 / Epinephrine / Cortisone / Skelaxin / Ultram / Ciprofloxacin / Meloxicam Attending: ___. Chief Complaint: Severe epigastric pain radiating to back Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with asthma, IDDM, GERD, fibromyalgia, HLD, HTN, PUD, and anxiety presents with acute onset of epigastric pain radiating around both flanks and to her right shoulder blade. She reports having daily epigastric pain ___ GERD, but two days ago she began having abdominal pain that was slightly worse. She also reports increased flatulence, and mildly foul taste in her mouth. Yesterday she had a small supper of an omelette, and soon after began having severe epigastric pain that came on quickly. It was ___ and worse than any pain she had experienced before. Nothing made the pain better, and she tried moving in all positions. It radiated around both sides to her back and up under her right shoulder blade. She denies CP or positional changes. She felt it was slightly worse with breathing. She denies fever, shortness of breath. She had no nausea, or vomitting, but her stomach did not feel well and she had a bad taste in her mouth persistently. She feels it was slightly relieved with prilosec. She had a bowel movement last night that she described as "yellow" and has been passing gas regularly. She had no melena, or blood in her stool. The pain persisted overnight and was relieved slightly after hours of not eating. She came to the ED this morning still in severe pain. She denies any history of gall stones, and does not drink alcohol. She denies any history of hypercalcemia but does have hyperlipidemia. She reports that last week she had elevated BP related to stress and was taking hydrochlorothiazide more often than regularly. She usually only takes ___ a tablet when she has edema, but last week she took a full tab every day, which is "more than I ever take." In the ED, initial vs were T 97.6, HR 70, BP 203/84, RR 18, O2 99% on RA. She received atenolol for her elevated BP. Given chest pain, had cardiac work up: EKG showed no change from previous and initial troponins were negative. Found to have elevated lipase and started on IVF, patient refused pain meds. RUQ ultrasound was limited by body habitus but showed a normal gall bladder with no distention or stones. Transfer VS T 97.9, HR 60, BP 185/70, RR 14, O2 100% on RA On arrival to the floor, patient reports that her pain is much improved with oxycodone. She denies any headache or vision changes, and reports her elevated BP is about where it has been at home. 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: - GERD - DM type 2 - HLD - HTN - Peptic ulcer disease - Diverticulosis - Diverticulitis treated medically - Anxiety - Asthma - DJD - Osteoarthritis - Chronic hives - LBP - Obesity - Fibromyalgia - Irritable bowel syndrome - Herpes simplex Social History: ___ Family History: Mother - ___ cancer, GERD Father - ___ died of a blood clot. Intractable HTN since he was ___. CAD Physical Exam: ADMISSION EXAM: VS: 98.8, 201/88, 88, 98%RA GEN: comfortable, NAD, laying in bed, Alert, oriented, recoutns above story and very good historian HEENT: Dry mucosa with poor dentition, sclera anicteric, NECK: Pickwickian and large, supple PULM: Good aeration, CTAB no wheezes, rales, ronchi, auscultated posteriorly and anteriorly CV: RRR normal S1/S2, no mrg ABD: Obese, soft, mild tenderness on very deep epigastric palpation,normoactive bowel sounds, no r/g EXT: No ___ edema, 2+ pulses palpable bilaterally NEURO: CNs2-12 intact, motor function grossly normal, sat up on her own, no focal deficits DISCHARGE EXAM: VS T 97.9, BP 158/82, HR 56, 18 RR, O2 96%RA, FSBG 119-247 Is and Os: I PO not recorded but had liquids, IV 3.4Ls, O BRP GEN Alert, oriented, no acute distress HEENT EOMI, moist mucus membranes, sclera anicteric, OP clear with no erythema, exudates or lesions NECK supple, obese, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi. No dullness to percussion. No sign of pleural effusion CV RRR normal S1/S2, no mrg ABD soft, obese, normoactive bowel sounds, non-distended. Mildly tender to deep palpation in the epigastric region; worse in LUQ than RUQ. Says pain is ___ when press. No rebound or guarding. EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers, leisions, rashes, or hives Pertinent Results: ADMISSION LABS: ___ 11:10AM BLOOD WBC-10.7 RBC-4.85 Hgb-14.1 Hct-43.0 MCV-89 MCH-29.0 MCHC-32.8 RDW-12.5 Plt ___ ___ 11:10AM BLOOD Neuts-76.9* Lymphs-16.7* Monos-4.7 Eos-1.3 Baso-0.4 ___ 11:10AM BLOOD Plt ___ ___ 11:10AM BLOOD Glucose-267* UreaN-15 Creat-0.7 Na-137 K-4.1 Cl-101 HCO3-26 AnGap-14 ___ 11:10AM BLOOD ALT-9 AST-18 AlkPhos-76 TotBili-0.4 ___ 09:10PM BLOOD cTropnT-<0.01 ___ 11:10AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.8 Mg-1.9 ___ 11:10AM BLOOD Triglyc-160* PERTINENT LABS: ___ 11:10AM BLOOD Lipase-129* ___ 09:10PM BLOOD cTropnT-<0.01 IMAGING: ___ CXR: No acute cardiopulmonary process. Specifically, no evidence of pleural effusion. ___ LIVER AND GB US: IMPRESSION: Limited study due to patient body habitus demonstrates no acute findings. The gallbladder is normal with no evidence of stones or distention. ___: MRI ABDOMEN W/O CONTRAST IMPRESSION: 1. Mild acute pancreatitis with edema in the pancreatic head and surrounding fat stranding. Compression of the pancreatic duct within the head of the pancreas secondary to the pancreatic edema. No evidence of pancreatic necrosis. 2. No evidence of biliary obstruction. No biliary calculi. 3. 1.8 x 1.2 cm right adrenal adenoma. 4. Multiple subcentimeter cystic lesions within the pancreatic body which likely represent side-branch IPMNs. Follow-up MRI in ___ year is recommended. . DISCHARGE LABS: ___ 06:00AM BLOOD WBC-8.7 RBC-4.54 Hgb-13.3 Hct-40.4 MCV-89 MCH-29.2 MCHC-32.8 RDW-12.6 Plt ___ ___ 06:00AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-141 K-3.9 Cl-101 HCO3-27 AnGap-17 ___ 06:00AM BLOOD ALT-8 AST-17 LD(LDH)-198 AlkPhos-66 TotBili-0.6 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO BID hold for sbp < 100, hr < 55 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 3. budesonide *NF* 0.25 mg/2 mL Inhalation Daily:PRN wheezing 4. Clotrimazole Cream 1 Appl TP BID:PRN rash 5. Hydrochlorothiazide 12.5 mg PO DAILY hold for sbp < 100, hr < 55 6. NPH 30 Units Breakfast NPH 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Lorazepam ___ mg PO Q8H:PRN anxiety hold for sedation 8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 10. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Atenolol 50 mg PO QID 2. Clotrimazole Cream 1 Appl TP BID:PRN rash 3. NPH 32 Units Breakfast NPH 22 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 5. Lorazepam ___ mg PO Q8H:PRN anxiety hold for sedation 6. Omeprazole 20 mg PO BID 7. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. ZYRtec *NF* 10 mg Oral qd prn itchiness 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 10. Budesonide *NF* 0.25 mg/2 mL INHALATION DAILY:PRN wheezing Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - Pancreatitis SECONDARY: - Hypertension - Type 2 Insulin Dependent DM - GERD - Non insulin dependent Type 2 DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Acute onset epigastric pain and tenderness, question pleural effusion. ___. FINDINGS: Frontal and lateral views of the chest were obtained. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The aorta is somewhat tortuous. The cardiac silhouette is top normal. No overt pulmonary edema is seen. Some degenerative changes are seen along the spine, stable. IMPRESSION: No acute cardiopulmonary process. Specifically, no evidence of pleural effusion. Radiology Report HISTORY: Elevated lipases with abdominal pain. COMPARISON: CT abdomen and pelvis from ___. FINDINGS: The study is limited due to patient body habitus. Again noted is a 1.6 x 1.0 x 1.2 cm hypoechoic structure in segment 4B of the liver without flow, consistent with a simple cyst. Otherwise, the remainder of the liver is within normal limits. There is no intra or extrahepatic ductal dilatation with the common bile duct measuring 4 mm. The main portal vein is patent with hepatopetal flow. The gallbladder is normal with no evidence of stones or distention. The spleen is limited in evaluation but appears normal where seen. IMPRESSION: Limited study due to patient body habitus demonstrates no acute findings. The gallbladder is normal with no evidence of stones or distention. Radiology Report HISTORY: Elevated lipase and signs and symptoms consistent with pancreatitis. Right upper quadrant ultrasound benign. CBD obstruction/stone? Not looking for abscess or fluid collection. TECHNIQUE: Multiplanar T2 and axial T1 weighted sequences were acquired on a 1.5 Tesla magnet without intravenous contrast. The patient states a history of previous contrast allergy to gadolinium. FINDINGS: There is T2 hyperintensity surrounding the head of the pancreas on the T2 weighted fat saturated sequence (sequence 6 image 15), consistent with edema. There is also surrounding fat stranding. The pancreatic duct within the head of the pancreas appears compressed (sequence 8 image 2) -which is likely secondary to the edema in the pancreatic head. The remainder of the pancreatic duct is within normal limits. Multiple subcentimeter pancreatic cystic lesions are noted within the body of the pancreas (sequence 8 image 2) with the largest measuring 6 mm in diameter (sequence 3 image 16). No focal fluid collections. The pancreas is otherwise unremarkable. There is a mildly enlarged lymph node superior to the pancreatic neck measuring 0.7 cm in short axis diameter (sequence 6 image 11). Multiple T2 hyperintense cystic lesions are noted within the liver, the largest of which measures 1.3 cm in diameter in segment IVb (sequence 4 image 14) - these likely represent biliary hamartomas. The liver is otherwise unremarkable. No intra or extrahepatic duct dilatation. The gallbladder is normal. There is a 1.8 x 1.2 cm lesion within the lateral limb of the right adrenal gland which demonstrates signal loss on the out of phase sequences (sequence 5 image 13) consistent with a right adrenal adenoma. It is unchanged since the previous CT dated ___. The left adrenal gland is within normal limits. There is a subcentimeter simple cyst within the upper pole of the right kidney. The kidneys are otherwise unremarkable. The spleen is within normal limits. The visualized small and large bowel is unremarkable. No retroperitoneal adenopathy. Bone marrow signal is normal. No destructive osseous lesions. IMPRESSION: 1. Mild acute pancreatitis with edema in the pancreatic head and surrounding fat stranding. Compression of the pancreatic duct within the head of the pancreas secondary to the pancreatic edema. No evidence of pancreatic necrosis. 2. No evidence of biliary obstruction. No biliary calculi. 3. 1.8 x 1.2 cm right adrenal adenoma. 4. Multiple subcentimeter cystic lesions within the pancreatic body which likely represent side-branch IPMNs. Follow-up MRI in ___ year is recommended. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: CHEST PAIN (CARDIAC FEATURES) Diagnosed with ACUTE PANCREATITIS temperature: 97.6 heartrate: 70.0 resprate: 18.0 o2sat: 99.0 sbp: 203.0 dbp: 84.0 level of pain: 13 level of acuity: 2.0

Ms. ___, It was a pleasure taking care of you at ___. You were admitted for severe abdominal pain due to Pancreatitis. Ultrasound and MRI did not find gallstones or other potential cause of your pancreatitis. It is possible this was caused by Hydrochlorthiazide, which we stopped. Your pain resolved with stopping all food and fluid by mouth. You received fluids through the vein for 24 hours, we then restarted your diet slowly. Your pain did not return after you started to eat. Please make sure to talk to your ___ doctor in regards to managing your NPH insulin. In the hospital you recieved 50% of your home dose. STOP MEDICATIONS: - Hydrochlorothiazide START MEDICATIONS: - Chlorthalidone 25 mg by mouth daily ADJUST MEDICATIONS: - NPH Insulin - your home dose is 32U in AM and 22U in ___, you received 16U in AM and 11U in ___ due to the low food intake, please continue at the lower dose and adjust as needed per your ___ doctor Please follow up with Dr. ___ ___ (see details below)

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Gluten / Percocet / sugar / adhesive tape / mosquito / Lactose / onions / clindamycin Attending: ___. Chief Complaint: urinary frequency/leg sweliing Major Surgical or Invasive Procedure: n/a History of Present Illness: Ms. ___ is a very pleasant ___ with PMHx breast cancer, single kidney ___ prior TB infx, chronic dCHF not on diuretics, hx SBO, hx Pott's disease, and recently diagnosed C. diff (discharged ___ after admission for worsening cdiff while on flagyl, was switched to PO vanc) presenting with urinary frequency without dysuria, back pain and bilateral ___ edema. Back pain is atraumatic, located in thoracic spine at site of deformity, non-radiating and worse with position changes. No perineal anesthesia, numbness/tingling/weakness or urinary/fecal retention/incontinence. Pts urinary frequency occurred in setting of increase in BMs, as pt states that she has urination with every BM and this has increased in setting of cdiff. Leg swelling is bilateral and pitting, accompanied by mild pain and itching. She has had mild ankle swelling in the past which she thinks improved with new diet started last ___, however has never had ___. No recent increase in salt intake, no dietary changes other than decrease in fruits/vegetables since diarrhea began. No SOB, mild cough x1 month. No chest pain. Finally pt endorses red spots on legs and hands, first noticed yesterday. She states overall she is feeling better from the standpoint of her c diff infection. In the ED, initial vitals were: 99.1 64 130/80 14 94% RA. Exam was notable for bilateral pitting edema to the knees, pulm exam with RLL crackles. CXR showed possible small right pleural effusion. Otherwise, no acute cardiopulmonary process. Initially read was concerning for PNA, therefore patient was given a dose of ceftriaxone and admitted to the medicine for further management. On the floor, pt states that her diarrhea has improved significantly since switching to vanc, less explosive and more formed, however still frequent and having 5, however at ___ has 4. Endorses constant nausea in last year-year and a half. Abd pain persists since c. diff dx, however is stable. Endorses HA, which is unusual for her, band like from forehead rading to back of head, no photophobia, vision changes, now resolved. Pt also states that she has recently been less active than prior due to c. diff infx. Denies respiratory sxs. 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 vomiting, constipation. No dysuria. Denies arthralgias or myalgias. 10 pt ros otherwise negative. Past Medical History: migraines H/o breast cancer ___ yrs s/p lumpectomy, refused chemo Spondylosis Celiac disease Carpal tunnel syndrome GERD Pott's disease Raynaud's H/o TB, dx'd at age ___, pt states she never received treatment Kyphosis HFpEF H/o SBO H/o L hip replacement s/p L nephrectomy heart murmur HLD Hemorrhoids s/p hip replacement x2 Social History: ___ Family History: (per chart, confirmed with pt): Sister with jaw cancer. Mother and father with heart problems, arthritis Physical Exam: ADMISSION EXAM: Vitals: 97.9 PO107 / 71 63 18 93 RA Constitutional: Alert, oriented, no acute distress EYES: Sclera anicteric, EOMI, PERRL ENT: MMM, oropharynx clear Neck: Supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, has faint L-sided crackles which clear with inspiration GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, 2+ bilat pitting edema to knees NEURO: aaox3 CNII-XII and strength grossly intact SKIN: several small, faint red papules on dorsum of hands bilat and bilat ___: severe kyphosis, thoracic spine abnormality with no TTP, mild overlying erythema with no skin breakdown. DISCHARGE EXAM: Vitals: 98.1 PO 122 / 77 56 18 94 RA Constitutional: Alert, oriented, no acute distress EYES: Sclera anicteric, EOMI, PERRL ENT: MMM, oropharynx clear Neck: Supple, JVP not elevated CV: RRR, no m/r/g Respiratory: clear bilaterally GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding EXT: Warm, well perfused, trace bilat pitting edema to knees (after pulling down her compression stockings which she was wearing) NEURO: aaox3 CNII-XII and strength grossly intact SKIN: several small, faint red papules on dorsum of hands bilat and bilat ___: severe kyphosis, thoracic spine abnormality with no TTP, mild overlying erythema with no skin breakdown. Mepilex overlying the area of erythema Pertinent Results: Labs on admission: ___ 05:29PM URINE HOURS-RANDOM ___ 05:29PM URINE UHOLD-HOLD ___ 05:29PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 05:10PM GLUCOSE-106* UREA N-10 CREAT-0.9 SODIUM-140 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-31 ANION GAP-15 ___ 05:10PM ALT(SGPT)-20 AST(SGOT)-35 CK(CPK)-79 ALK PHOS-57 TOT BILI-0.4 ___ 05:10PM cTropnT-<0.01 ___ 05:10PM CK-MB-2 proBNP-231 ___ 05:10PM ALBUMIN-4.2 ___ 05:10PM WBC-4.8 RBC-4.36 HGB-13.0 HCT-41.7 MCV-96 MCH-29.8 MCHC-31.2* RDW-14.0 RDWSD-48.6* ___ 05:10PM NEUTS-70.1 ___ MONOS-6.9 EOS-2.9 BASOS-0.6 IM ___ AbsNeut-3.34 AbsLymp-0.91* AbsMono-0.33 AbsEos-0.14 AbsBaso-0.03 ___ 05:10PM PLT COUNT-239 STUDIES: CXR Possible small right pleural effusion. Otherwise, no acute cardiopulmonary process given limitation detailed above. EKG: TWI in inferlatoral leads, unchanged from prior. Bilateral ___ Doppler ultrasounds ___: INDINGS: 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. 0.9 x 1.0 x 0.4 cm ___ cyst is identified in left medial popliteal fossa. IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Small left ___ cyst. Discharge Labs: ___ 06:25AM BLOOD WBC-6.3 RBC-3.70* Hgb-11.2 Hct-35.1 MCV-95 MCH-30.3 MCHC-31.9* RDW-13.9 RDWSD-48.2* Plt ___ ___ 06:25AM BLOOD Glucose-79 UreaN-11 Creat-0.8 Na-138 K-4.8 Cl-101 HCO3-29 AnGap-13 ___ 06:25AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vancomycin Oral Liquid ___ mg PO Q6H 2. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Lower Extremity Swelling ___ Cyst C diff infection Immobility 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 bilateral lower extremity swelling // Please assess for pulmonary congestion, pneumonia TECHNIQUE: Chest radiograph dated ___. COMPARISON: None. FINDINGS: Thoracic cavity is distorted due to patient's severe kyphosis noted at the lower thoracic spine as on prior. Low lung volumes. There is obscuration of the right lateral costophrenic angle suggesting underlying effusion. Patchy opacities at the bases bilaterally likely reflect atelectasis. No additional focal consolidations to suggest pneumonia. No pulmonary edema. Stable appearance of the cardiomediastinal silhouette. No pneumothorax. Severe kyphotic deformity of the thoracolumbar spine is re- demonstrated, unchanged. IMPRESSION: Possible small right pleural effusion. Otherwise, no acute cardiopulmonary process given limitation detailed above. Radiology Report EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT) INDICATION: ___ year old woman with bilateral ___ swelling and pain. also history of breast CA. // rule out 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. 0.9 x 1.0 x 0.4 cm ___ cyst is identified in left medial popliteal fossa. IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Small left ___ cyst. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Urinary frequency, Diarrhea Diagnosed with Diarrhea, unspecified temperature: 99.1 heartrate: 64.0 resprate: 14.0 o2sat: 94.0 sbp: 130.0 dbp: 80.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were admitted for lower extremity swelling and pain following your recent hospitalization for c diff infection. You were continued on your oral vancomycin therapy and your infection appears to be improving well. We gave you a small dose of diuretic to help with the leg swelling and you were given leg compression stockings, which you can continue to wear to help with the leg swelling. Lower extremity ultrasounds were done to rule out a blood clot which was negative on both legs however it did show a ___ Cyst on your left leg, which may explain your occasional discomfort. pain from a ___ cyst typically improves over time. You may take over the counter Tylenol as directed as needed for pain. Since you are having trouble with your legs, we recommend that your son drive you home today and you avoid driving until you are no longer having trouble with your legs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R Leg Pain Major Surgical or Invasive Procedure: ___ - R Tibial Intramedullary Nailing History of Present Illness: ___ female, otherwise healthy, presenting with the above-mentioned fractures following a mechanical fall. Patient states stepped off a curb, and slipped on acorn suture in the street, falling and catching her right ankle so that it twisted as she fell. She felt a pop and had immediate onset pain preventing her from bearing weight. She had no head strike, no loss of consciousness, no nausea or vomiting, no headache, no confusion. Patient continues to have severe right lower leg pain but otherwise has no complaints. Past Medical History: Gastritis Social History: ___ Family History: Non-contributory Physical Exam: On Admission: Vitals: AVSS General: Well-appearing female in no acute distress. Right lower extremity: - Skin intact -Diffuse edema of the right lower leg with proximal lateral point tenderness in the anterior distal point tenderness - No deformity, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM at hip, knee - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP ================================================================ On Discharge: Vital Signs: stable O2 delivery: RA General: Well-appearing, breathing comfortably MSK: Dressing with small SS staining anteriorly on shin ACB in place Wiggles exposed toes SiLT exposed toes Well perfused Pertinent Results: ___ 08:05AM BLOOD WBC-9.5 RBC-3.69* Hgb-10.4* Hct-32.3* MCV-88 MCH-28.2 MCHC-32.2 RDW-15.3 RDWSD-49.0* Plt ___ Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever Do not take more than 4000mg acetaminophen (Tylenol) total, daily. 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Do not drink or drive on this medication. Hold for sedation. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R Tibial Shaft Fracture 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: DX ___ AND ANKLE INDICATION: ___ with R ankle and ___ pain after a fall// eval for fx TECHNIQUE: Three views of the right tibia fibula and three views of the right ankle joint. COMPARISON: None FINDINGS: There is an oblique fracture of the proximal fibula involving the proximal shaft with slight anterior and lateral displacement of the distal fragment. The proximal tibia is intact. Degenerative changes at the right knee include mild marginal spurring. No joint effusion is seen at the right knee. The level of the distal shaft of the right tibia, there is an oblique fracture with approximately 10 mm lateral displacement of the distal fracture fragment. Linear fracture lucencies extend along the distal fragment into the tibial plafond without significant displacement. There is also a fracture line involving the posterior malleolus of the distal tibia best seen on the lateral radiograph of the right ankle, nondisplaced. Ankle mortise is symmetric. Talar dome is smooth. Distal fibula is intact. No heel spurs. No gross soft tissue abnormalities detected. IMPRESSION: 1. Oblique fracture involving the proximal shaft of the right fibula with mild anterolateral displacement of the distal fragment. 2. Oblique fracture through the distal shaft of the right tibia with lateral displacement of the distal fragment. Nondisplaced fracture lines extend along the distal tibial fracture fragment to the tibial plafond and posterior malleolus. 3. Ankle mortise remains symmetric. Radiology Report INDICATION: History: ___ with ANKLE FX// PREOP TECHNIQUE: Chest PA and lateral COMPARISON: None FINDINGS: The lungs are well expanded and clear. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. Radiology Report INDICATION: ___ year old woman with distal tibial and proximal fibular fractures// eval tib/fib fractures TECHNIQUE: Multiple views 2.5 mm axial images were obtained through the lower leg without the administration of intravenous contrast. Coronal and sagittal reformatted images were obtained. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.1 s, 64.9 cm; CTDIvol = 10.2 mGy (Body) DLP = 662.0 mGy-cm. Total DLP (Body) = 662 mGy-cm. COMPARISON: Radiographs from ___ FINDINGS: There is a comminuted predominantly spirally oriented fracture through the distal tibia with extension to the ankle joint. Fracture lines extends to involve the posterior malleolus. There is mild displacement of the distal tibial shaft measuring 7 mm. In addition, there is also a fracture of the proximal fibular shaft which is obliquely oriented. There is a prominent exostosis along the posterolateral aspect of the tibia. This may represent an osteochondroma or large osteophyte. There are moderate to severe degenerative changes of the patellofemoral and medial compartments of the knee. Ankle mortise is grossly preserved. There is mild prepatellar tibial soft tissue edema. IMPRESSION: 1. Small spirally oriented fracture of the distal tibia with extension into the ankle joint and also involving the posterior malleolus 2. Oblique fracture of the proximal fibular shaft. Radiology Report EXAMINATION: Right tibia/fibula INDICATION: ORIF. COMPARISON: CT of the tibia/fibula ___. FINDINGS: 22 intraoperative images were acquired without a radiologist present. Images show intramedullary rod and screw placement for distal tibial shaft fracture. Total fluoroscopic time 207.5 seconds. IMPRESSION: Please refer to the operative note for details of the procedure. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: R Leg pain, s/p Fall Diagnosed with Pain in right lower leg temperature: 96.5 heartrate: 73.0 resprate: 16.0 o2sat: 100.0 sbp: 179.0 dbp: 92.0 level of pain: 9 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: - Touchdown weight bearing in the right lower extremity. Please wear your Aircast walking boot when walking. It is ok to remove the boot when in bed/resting. MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add dilaudid 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 enoxaparin 40mg qHS for 4 weeks from your operation. End date ___. 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. 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: Touch down weight bearing in an AirCast walking boot in the RLE. ROMAT Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Percocet / Lisinopril / Azithromycin / morphine / codeine / latex Attending: ___ ___ Complaint: Nausea, dehydration Major Surgical or Invasive Procedure: Laparoscopic sigmoid colectomy with takedown of splenic flexure and temporary diverting loop ileostomy (___) History of Present Illness: Ms. ___ is a ___ lady who is status post laparoscopic sigmoid colectomy with diverting loop ileostomy on ___ for diverticulitis with abscess. She presents to the ED with persistent malaise, nausea, and poor PO intake. Her creatinine has also been rising per her PCP. She was discharged home with ___ on ___ after an ___ hospital stay. Since discharge, she has had increasing fatigue. Additionally, for about 1 week, she has had nausea and bloating which prevents her from drinking more than a few sips at a time. She reports anorexia and dizziness. She reports ileostomy output of 500-650 cc/day that is liquid (typically greenish). She denies vomiting, fevers, chills, abdominal pain aside from occasional cramping, change in urine output, and any output from her rectum (no stool, blood, mucous, air). She was called by Dr. ___ office on ___ at which time she reported liquid stool and was advised to take Imodium. She has taken 8 pills per day since with no real change in output, possibly slight thickening in output though. She saw her PCP ___ ___. At that time her creatinine was 1.6 (was 0.9 on the day of discharge ___ so she was told to hold her anti-hypertensives and was given PO zofran. She saw her PCP again on the day of admission. Her creatinine was found to be 2.1 and her temperature was 100.8. Her PCP called Dr. ___ ___ for Dr. ___, who told the patient to come in for evaluation. Past Medical History: 1) Diverticulitis/Diverticulosis 2) IBS 3) Osteoarthritis 4) Hyperlipidemia 5) Pulmonary nodules 6) Benign positional vertigo 7) Osteopenia at hip 8) Hypertension 9) GERD 10) Breast cancer - left atypical hyperplasia diagnosed in ___ right LCIS and DCIS diagnosed in ___ status post lumpectomy, XRT, Tamoxifen therapy (for ___ years) 11) Carpal tunnel (right wrist) 12) Trigger finger (left hand) 13) Frozen shoulder 14) Game keeper's thumb/disease 15) Hiatal hernia (___) 16) Esophagitis treated with PPI 17) Scoliosis since age ___ 18) Toxic multinodular goiter, followed by Dr. ___, has had suppressed TSH recently ============================= Past Surgical History: 1) Right thigh lipoma removal 2) Bilateral bunion removal with joint replacement 3) Right breast lumpectomy for DCIS/LCIS Social History: ___ Family History: Her father died of gastric cancer at age ___ (received radiation to his tonsils twice as a child). No family history of autoimmune diseases. Her first and second cousins have breast cancer. Physical Exam: Vitals: Temp 98.7, HR 74, BP 108/50, RR 16, SpO2 100% on room air Gen: Pleasant lady in no acute distress, alert and oriented CV: Regular rate and rhythm Lungs: Clear to auscultation bilaterally, non-labored breathing, no respiratory distress Abd: Soft, non-distended, non-tender to palpation. Well-healed laparoscopic incisions. Stoma beefy red. Ostomy bag in place with gas and stool present. Ext: Warm and well-perfused without edema Pertinent Results: CT ABDOMEN/PELVIS (___): Focus of air and contrast adjacent to the anastomosis, given the lack of surrounding fat stranding, this is more likely an contrast within an outpouching of the surgical anastomosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO QAM 2. Lorazepam 1 mg PO QHS sleeping 3. Omeprazole 20 mg PO QAM 4. Paroxetine 15 mg PO LUNCH 5. Valsartan 80 mg PO QAM 6. Acetaminophen 1000 mg PO TID 7. Diclofenac Sodium ___ 50 mg PO BID 8. Hyoscyamine 0.375 mg PO BID 9. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain 10. Docusate Sodium 100 mg PO BID:PRN constipation. Discharge Medications: 1. Hydrochlorothiazide 25 mg PO QAM 2. Omeprazole 20 mg PO QAM 3. Acetaminophen 1000 mg PO TID 4. Diclofenac Sodium ___ 50 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation. 6. Hyoscyamine 0.375 mg PO BID 7. Lorazepam 1 mg PO QHS sleeping 8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain 9. Paroxetine 15 mg PO LUNCH 10. Valsartan 80 mg PO QAM 11. LOPERamide 2 mg PO QID RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by mouth four times a day Disp #*56 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: 1 week of nausea, chills, fatigue, and low-grade temperatures in a patient status post sigmoid colectomy with diverting ileostomy on ___, secondary to diverticulitis complicated by abscess. TECHNIQUE: Non-contrast scan: 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. 120 cc of water-soluble contrast with was administered per rectum. Coronal and sagittal reformations were performed and reviewed on PACS. No oral contrast was administered. DOSE: DLP: 523.5 mGy-cm (abdomen and pelvis. IV Contrast: None COMPARISON: CT abdomen/pelvis from ___. FINDINGS: LOWER CHEST: The visualized lung bases are clear. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The nonenhanced appearance of the liver is normal. There is no obvious mass.. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: No peripancreatic stranding or fluid collection is identified. SPLEEN: The spleen is normal in size. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are symmetric and normal in size, without hydronephrosis or stone.. GASTROINTESTINAL: Small bowel loops are normal in caliber, without obvious wall thickening or evidence of obstruction. There is a diverting loop ileostomy. Contrast administered per rectum extends to the level of the cecum. The patient is status post sigmoid colectomy, with an anastomosis in the pelvis. A focus of air and contrast adjacent to the anastomosis (2:60, 61b:38) . However, given the lack of surrounding fat stranding, this is more likely air and contrast within an outpouching of the surgical anastomosis. No fluid collection to suggest an abscess is identified at this location. A normal appendix is visualized. 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: Calcified uterine fibroids are noted. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Other than at the diverting ileostomy in the right lower quadrant, as noted above, the abdominal and pelvic wall is unremarkable. IMPRESSION: Focus of air and contrast adjacent to the anastomosis, given the lack of surrounding fat stranding, this is more likely an contrast within an outpouching of the surgical anastomosis. NOTIFICATION: Updated findings were discussed via telephone by Dr. ___ ___ with Dr. ___ at 10:00 on ___. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Fever Diagnosed with POSTPROCEDURAL FEVER, ABDOMINAL PAIN GENERALIZED, ABN REACT-SURG PROC NEC temperature: 97.8 heartrate: 96.0 resprate: 18.0 o2sat: 95.0 sbp: 163.0 dbp: 73.0 level of pain: 3 level of acuity: 3.0

Dear Ms. ___, ___ were ___ to ___ with malaise, nausea and poor PO intake. ___ were found to be dehydrated. While ___ were here we gave ___ hydration with resolution of your symptoms. ___ had a new ileostomy placed on ___. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However, it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. ___ monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. Thank ___ for allowing us to participate in your care!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percodan Attending: ___. Chief Complaint: right sided rib pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with history of dementia, multiple falls, CAD s/p multiple stents on aspirin, Afib & recent thromboembolic left PCA stroke (___) s/p tPA & discharged to a rehabilitation center on ___ who was found down at her bathroom yesterday night by the staff. She does not know if she lost consciousness or hit her head and has no knowledge of circumstances surrounding the fall. She was brought to ___ ED and was complaining of right side pain so she underwent panscan which showed right ___ rib fractures and evolution of her known left PCA territorial stroke with no evidence of hemorrhagic conversion or acute hemorrhage Past Medical History: Dementia NIDDM HTN CAD s/p multiple PCI, followed by Dr. ___ not previously on anticoagulation given multiple falls, started ___ ___ L PCA stroke HLD collagenous colitis with chronic mild anemia on mesalamine lumbar spinal stenosis gait instability and frequent falls L eye blind after cataract surgery Shoulder impingement/rotator cuff tendinopathy urinary incontinence multinodular thyroid Social History: ___ Family History: Two children with epilepsy. Physical Exam: Physical Exam: upon admission: ___: Vitals: 97.8 60 163/43 16 97% Nasal Cannula GEN: Mildly confused but alert. HEENT: No scleral icterus, mucus membranes dry. In c-collar CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Tender to palpation over right side ribs. No obvious hematoma or swelling. Abdomen soft, nondistended, nontender, no rebound or guarding, DRE: Deferred Ext: No ___ edema, ___ warm and well perfused DISCHARGE PHYSICAL EXAM: VITALS: 97.7 PO 173/63 L Lying 54 18 97 RA GENERAL: Alert, oriented x2 (knows self, hospital, not which one), no acute distress HEENT: NC/AT, Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD, wearing a wig CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops CHEST: Lungs clear to auscultation bilaterally without wheezes, rales, rhonchi, right sided rib pain directly above RUQ, lidocaine patch in placeABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding SKIN: No bruising, hematoma, evidence of head trauma EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Face grossly symmetric. Moving all limbs with purpose against gravity. Strength 4+/5 left sided, ___ right sided upper and lower extremitis. No dysarthria. Pertinent Results: ADMISSION LABS: --------------- ___ 03:20AM BLOOD WBC-13.5* RBC-3.54* Hgb-10.6* Hct-33.4* MCV-94 MCH-29.9 MCHC-31.7* RDW-13.0 RDWSD-44.6 Plt ___ ___ 03:20AM BLOOD Neuts-41.6 ___ Monos-4.4* Eos-1.6 Baso-0.3 NRBC-0.1* Im ___ AbsNeut-5.62 AbsLymp-6.97* AbsMono-0.60 AbsEos-0.21 AbsBaso-0.04 ___ 03:20AM BLOOD ___ PTT-27.3 ___ ___ 03:20AM BLOOD Plt Smr-NORMAL Plt ___ ___ 03:20AM BLOOD Glucose-131* UreaN-27* Creat-1.1 Na-138 K-4.6 Cl-102 HCO3-21* AnGap-20 INTERIM LABS: ------------- ___ 05:22AM BLOOD WBC-10.1* RBC-3.39* Hgb-10.2* Hct-32.5* MCV-96 MCH-30.1 MCHC-31.4* RDW-13.1 RDWSD-45.7 Plt ___ ___ 05:22AM BLOOD ___ PTT-29.0 ___ ___ 05:55AM BLOOD Glucose-132* UreaN-21* Creat-0.9 Na-139 K-4.7 Cl-102 HCO3-25 AnGap-17 ___ 05:22AM BLOOD Glucose-112* UreaN-23* Creat-0.9 Na-141 K-5.2* Cl-103 HCO3-24 AnGap-19 ___ 05:22AM BLOOD ALT-14 AST-20 LD(LDH)-224 AlkPhos-83 TotBili-0.2 ___ 10:17PM BLOOD K-4.3 DISCHARGE LABS: ---------------- ___ 05:55AM BLOOD WBC-10.4* RBC-3.45* Hgb-10.2* Hct-32.7* MCV-95 MCH-29.6 MCHC-31.2* RDW-12.8 RDWSD-44.0 Plt ___ ___ 05:55AM BLOOD Plt ___ ___ 05:55AM BLOOD Glucose-132* UreaN-21* Creat-0.9 Na-139 K-4.7 Cl-102 HCO3-25 AnGap-17 ___ 05:55AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0 MICROBIOLOGY: ------------- **FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S IMAGING: ---------- ___: CT c-spine: 1. No acute fracture or traumatic mal-alignment. 2. Extensive degenerative changes as described above most pronounced at C3-C4 through C5-C6 with moderate spinal canal stenosis at these levels. 3. Markedly enlarged nodular thyroid gland. ___: CT HEAD NON-CONTRAST 1. No acute intracranial hemorrhage. 2. Evolving infarcts involving the left temporal occipital lobe and the left thalamus. No evidence of hemorrhagic conversion. 3. 2.3 x 1.3 cm left planum sphenoidale meningioma. 4. Left sphenoid mucocele ___: CT TORSO 1. Acute non-displaced fractures involving the right sixth through eighth ribs laterally as well as the eighth and ninth ribs posteriorly. 2. No intra-thoracic or intra-peritoneal hematoma. No evidence of visceral organ injury. 3. Cholelithiasis with gallbladder wall edema in a mildly distended gallbladder. This is nonspecific. However, if there is concern for acute cholecystitis, a HIDA scan may be obtained. 4. Significant but diffuse enlargement and thickening of the right adrenal gland, new since ___. This is unlikely to represent adrenal hemorrhage. Consultation with Endocrinology can be done on a non-emergent basis. 5. Markedly enlarged multi-nodular thyroid. RECOMMENDATION(S): Endocrine evaluation for diffusely thickened and enlarged right adrenal gland. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Digoxin 0.125 mg PO DAILY 4. Diltiazem Extended-Release 240 mg PO DAILY 5. FLUoxetine 20 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Apixaban 2.5 mg PO BID 9. Cholestyramine 4 gm PO BID 10. Fish Oil (Omega 3) 1000 mg PO BID 11. melatonin 5 mg oral QHS 12. Mesalamine 1.2 g oral DAILY 13. MetFORMIN (Glucophage) 1000 mg PO DAILY 14. Tolterodine 4 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Calcium Carbonate 1000 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days Day one ___, Day five ___. Lidocaine 5% Patch 1 PTCH TD QAM 5. TraMADol 25 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 4 hours as needed Disp #*4 Tablet Refills:*0 6. Vitamin D 1000 UNIT PO DAILY 7. Diltiazem Extended-Release 120 mg PO DAILY 8. Apixaban 2.5 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Cholestyramine 4 gm PO BID 12. Digoxin 0.125 mg PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO BID 14. FLUoxetine 20 mg PO DAILY 15. Lisinopril 10 mg PO DAILY 16. melatonin 5 mg oral QHS 17. Mesalamine 1.2 g oral DAILY 18. MetFORMIN (Glucophage) 1000 mg PO DAILY 19. Multivitamins W/minerals 1 TAB PO DAILY 20. Tolterodine 4 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Multiple right sided rib fractures, ___ bacteriuria, likely catheter-associated UTI Gait instability, frequent falls Diffuse enlargement and thickening of the right adrenal gland Markedly enlarged multinodular thyroid homogeneous intensely enhancing brain mass, likely meningioma Cholelithiasis with gallbladder wall edema Atrial fibrillation Recent L PCA stroke CAD, HTN, HLD, Depression, collagenous colitis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ woman with fall and neck pain. Evaluate for cervical spine 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 5.4 s, 21.1 cm; CTDIvol = 36.9 mGy (Body) DLP = 779.4 mGy-cm. Total DLP (Body) = 779 mGy-cm. COMPARISON: Cervical spine CT from ___ FINDINGS: There is no acute fracture or traumatic malalignment. There is no prevertebral soft tissue swelling. There is mild anterolisthesis of C3 on C4 with retrolisthesis of C4 on C5, unchanged since the prior exam. There are significant degenerative changes with disc space narrowing, endplate sclerosis as well as osteophyte formation most pronounced at C3-C4 through C6-C7 levels. At these levels there is extensive uncovertebral and facet hypertrophy causing severe right neural foraminal narrowing at C4-C5, bilateral moderate neural foraminal narrowing at C5-C6, and mild neural foraminal narrowing at C6-C7. There are also posterior disc osteophyte complexes at C3-C4 through C5-C6 causing causing moderate spinal canal stenosis at these levels. The lung apices are clear. Markedly enlarged and nodular thyroid gland is again identified. There is no cervical lymphadenopathy. IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Extensive degenerative changes as described above most pronounced at C3-C4 through C5-C6 with moderate spinal canal stenosis at these levels. 3. Markedly enlarged nodular thyroid gland. Radiology Report INDICATION: ___ found down, right chest and upper abdominal pain, on anticoagulation. Evaluate for bleed. TECHNIQUE: MDCT axial images were acquired through the chest, 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) Spiral Acquisition 9.1 s, 71.6 cm; CTDIvol = 9.4 mGy (Body) DLP = 673.2 mGy-cm. Total DLP (Body) = 673 mGy-cm. COMPARISON: CTA chest from ___ FINDINGS: A markedly enlarged thyroid gland is again identified. There are prominent axillary and mediastinal lymph nodes, slightly increased in size compared to the prior study. There is no supraclavicular lymphadenopathy. Hilar lymph nodes are also not enlarged. The heart is normal in size. There are heavy atherosclerotic calcifications involving all coronary arteries. Calcifications are also seen at the aortic arch. Valvular calcifications are heavy involving the aortic as well as the mitral valves. There is a small, likely physiologic pericardial effusion. The main pulmonary artery is not enlarged. The central airways are patent. There are multifocal areas of atelectasis. A 5 mm ground-glass nodule in the right apex is unchanged. There is no consolidation, pleural effusion, or pneumothorax. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesion or laceration. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains multiple large gallstones with gallbladder-wall edema, which is nonspecific. The gallbladder itself is mildly distended. There is no pericholecystic 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 lesion or laceration. ADRENALS: The left adrenal gland is thickened with an indeterminate 1.2 cm nodule, slightly increased since the prior study. There is diffuse enlargement and thickening of the right adrenal gland, new since the prior study. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Scattered cortically based hypodensities are identified, too small to fully characterize but likely represent cysts. No hydronephrosis or perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. The stomach is otherwise unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The sigmoid is redundant. There is diffuse moderate fecal loading. The appendix is visualized and normal. There is no evidence of mesenteric injury. There is no free fluid or free air in the abdomen. PELVIS: The urinary bladder is distended and contains some air, possibly related to prior instrumentation. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexal regions 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 or retroperitoneal hematoma. Severe atherosclerotic disease is noted. BONES: Hardware is noted at the L3-L4 spinous process. There are acute nondisplaced fractures involving the right sixth through eighth ribs laterally as well as the eighth and ninth ribs posteriorly. No other acute fracture is identified. Degenerative changes are seen throughout the thoracic and lumbar spine. No focal suspicious osseous abnormality. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Acute nondisplaced fractures involving the right sixth through eighth ribs laterally as well as the eighth and ninth ribs posteriorly. 2. No intrathoracic or intraperitoneal hematoma. No evidence of visceral organ injury. 3. Cholelithiasis with gallbladder wall edema in a mildly distended gallbladder. This is nonspecific. However, if there is concern for acute cholecystitis, a HIDA scan may be obtained. 4. Significant but diffuse enlargement and thickening of the right adrenal gland, new since ___. This is unlikely to represent adrenal hemorrhage. Consultation with Endocrinology can be done on a non-emergent basis. 5. Markedly enlarged multinodular thyroid. RECOMMENDATION(S): Endocrine evaluation for diffusely thickened and enlarged right adrenal gland. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ woman status post fall. Evaluate for intracranial 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, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: CT head from ___ and MRI brain from ___ FINDINGS: There is no acute intracranial hemorrhage. There are evolving infarcts involving the left temporal occipital lobes as well as the thalamus. There is no evidence of hemorrhagic conversion. There is prominence of the ventricles and sulci compatible with age related parenchymal atrophy. Periventricular and subcortical white matter hypodensities are nonspecific but likely reflect sequelae of chronic small vessel ischemic disease. A 2.3 x 1.3 cm planum sphenoidale meningioma is again identified. There is no evidence of fracture. A left sphenoid sinus mucocele is again identified. There is also mucosal thickening involving the bilateral maxillary sinuses and the ethmoid air cells. The remaining visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Bilateral lens replacements are identified. Dense atherosclerotic calcifications of the carotid siphons and vertebral arteries are identified. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Evolving infarcts involving the left temporal occipital lobe and the left thalamus. No evidence of hemorrhagic conversion. 3. 2.3 x 1.3 cm left planum sphenoidale meningioma. 4. Left sphenoid mucocele. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: s/p Fall Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Other fall on same level, initial encounter temperature: 98.0 heartrate: 67.0 resprate: 16.0 o2sat: 100.0 sbp: 139.0 dbp: 49.0 level of pain: 3 level of acuity: 3.0

Dear ___, ___ came to the hospital after a fall at rehab. ___ fractured some ribs, for which ___ received pain medication. ___ had bacteria in your urine and started treatment for a urinary tract infection. ___ also had imaging done that showed an abnormal looking adrenal gland, a small organized area in your brain that may be a meningioma, a large thyroid gland, and a gallbladder with gallstones and some swelling. These are all things ___ should discuss with your primary care doctor. ___ have an endocrinology appointment as an outpatient as well. When ___ leave the hospital: Take your medications as prescribed: - Ciprofloxacin 500 mg two times a day for urinary tract infection, last day is ___ - Calcium and Vitamin D supplements were started for bone health. - Social Work will contact ___ to come to your home and see if ___ could benefit from more assistance. - Attend your appointments as below. It was a pleasure caring for ___ and we wish ___ the best, Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Erythromycin Base Attending: ___. Chief Complaint: lower back pain and fever Major Surgical or Invasive Procedure: ___ Interventional radiology drainage of paraspinal soft tissue abscess History of Present Illness: ___ with history of DM, afib with RVR, diastolic heart failure, PVD, COPD presents with severe low back pain (sacrum/buttocks) and rectal temp of 103. He presented initially to ___ and is now being transferred to ___ for MRI to rule out epidural abscess. Per patient history, he started having severe bilateral lower back pain on ___ while golfing. Does not remember any trauma or physical action that may have triggered his back pain. The pain felt deep, throbbing, aching, and radiated across his buttocks. It does not feel like any back pain that he has had before. He had no chest pain, abdominal pain, dyspnea. He also felt weak and "had a terrible game", then came home and went straight to bed. At that point, his pain was ___. He has also not had a BM x 1 week and recently has been having very weak urinary stream. No knowledge of prostate issues. He denies nausea/vomiting, fevers/chills/sweats. Yesterday, ___, he presented to ___ for pain. At ___, he was noted to have temp 103 and also noted to have urinary retention: urinated 100cc and put out 600cc more when catheterized. No stool incontinence. No weakness. Has baseline lower extremity numbness bilaterally. He had afib with RVR to 146 (he has not been taking home meds, including home digoxin and metoprolol due to back pain). This was treated with tylenol and Dilaudid and IVF 500cc bolus (CHF on CXR) with resolution of HR to 110s. Troponin was found to be 0.05, thought to be demand ischemia from rate; patient had no chest pain. Workup for fever included UA (negative), CT abdomen/pelvis which showed acute cholecystitis but the patient has no RUQ TTP or thoracic back pain and question of L1 endplate erosion, infection vs degenerative changes). No blood cultures were sent. At this point, differential for back pain was atypical presentation of cholecystitis versus epidural abscess or osteomyelitis. The patient was treated with IV Vancomycin and ceftriaxone. Since MRI cannot be done at ___, he was transferred to ___. At ___ ED, initial vitals were: 98.4 82 116/64 16 98% - Labs were significant for negative troponin, dig 0.5, lipase 61 otherwise normal LFT, Hct 37.7, INR 1.3. No leukocytosis but left-shifted with 83% PMNs. - Patient was given morphine 5mg - Liver ultrasound: per attending radiologist, concerning for acute cholecystitis. -MRI spine: per neuroradiology, shows 2 fluid collections, L4-L5 posterior spinal canal fluid collection and paraspinal soft tissue abscess -He dropped his pressure at one point due to morphine, that resloved with the gentle IV fluids. He then developed some rapid afib and received metoprolol and Digoxin Po with good effect and no BP issues. Vitals prior to transfer were: HR 102 110/66 22 97% RA On the floor, initial VS: 99, HR 100 afib, BP 124/82, 18 99% RA. Over 8 hrs, made 600cc urine. The patient continues to have ___ back pain radiating across his buttocks. Does not change with position or exertion. Feels very "deep". Past Medical History: 1. New onset atrial fibrillation with RVR (___) 2. Acute respiratory failure on chronic respiratory failure. 3. Pneumonia. 4. Noncompliance. 5. Diabetes mellitus. 6. Acute diastolic heart failure. 7. Pulmonary hypertension. 8. Hyperlipidemia. 9. Carpal tunnel release. 10. Chronic constipation. 11. Rectal abscess. 12. History of hemorrhoids. 13. Gastroesophageal reflux disease. 14. History of peripheral vascular disease, status post bypass ___ ___. 15. History of mild CKD secondary to diabetic nephropathy/hypertensive nephrosclerosis, baseline creatinine is around 1.2-1.3. 16. Status post appendectomy. 17. COPD. 18. Status post left arm fracture. 19. History of right knee surgery. 20. Degenerative joint disease. 21. Status post hemorrhoid resection. 22. History of GI bleeding before. Social History: ___ Family History: Not contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 99, HR 100 afib, BP 124/82, 18 99% RA GENERAL: No acute distress but uncomfortable. Sitting still ___ bed. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: Irregular rate, S1 S2, no MRG LUNG: Bibasilar crackles, otherwise CTAB ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally SPINE: No tenderness to palpation of midline or of flanks. Pain does not change with position or palpation. NEURO: CN II-XII intact. ___ plantarflexion and dorsiflexion, 4+/5 hip flexion. Has decreased sensation to light touch ___ bilateral feet to ankles (baseline). SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals: 98.5/98.5, 148/86, 96, 18, 96% RA GENERAL: Sitting ___ bed, eating breakfast, no acute distress HEENT: AT/NC, EOMI, anicteric sclera, Mucous membranes moist, nontender supple neck, no JVD CARDIAC: Irregular rate, S1 S2, no MRG LUNG: faint crackles @ bases, otherwise CTAB, no wheezes ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing, b/l 1+ pitting edema around ankles PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 12:56AM BLOOD WBC-9.1 RBC-3.89* Hgb-12.2* Hct-37.7* MCV-97 MCH-31.4 MCHC-32.5 RDW-14.5 Plt ___ ___ 12:56AM BLOOD Neuts-83.4* Lymphs-10.5* Monos-5.6 Eos-0.2 Baso-0.3 ___ 12:56AM BLOOD ___ PTT-27.2 ___ ___ 11:10AM BLOOD ESR-75* ___ 12:56AM BLOOD Glucose-327* UreaN-18 Creat-0.9 Na-133 K-4.1 Cl-96 HCO3-27 AnGap-14 ___ 12:56AM BLOOD ALT-14 AST-11 AlkPhos-60 TotBili-0.6 ___ 12:56AM BLOOD Lipase-61* ___ 12:56AM BLOOD cTropnT-<0.01 ___ 11:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7 ___ 12:56AM BLOOD Albumin-3.6 ___ 11:10AM BLOOD CRP-186.2* ___ 12:56AM BLOOD Digoxin-0.5* DISCHARGE LABS: ___ 05:17AM BLOOD WBC-5.4 RBC-3.51* Hgb-10.5* Hct-33.8* MCV-96 MCH-29.8 MCHC-31.0 RDW-14.2 Plt ___ ___ 05:17AM BLOOD ___ PTT-32.3 ___ ___ 05:17AM BLOOD Glucose-216* UreaN-20 Creat-1.0 Na-137 K-4.4 Cl-102 HCO3-30 AnGap-9 ___ 05:17AM BLOOD Phos-3.7 Mg-1.9 MICROBIOLOGY: ___ Blood culture negative ___ Blood cultures x 2 negative ___ Paraspinal abscess drainage: GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. Reported to and read back by ___ ___ ___ ___. FLUID CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): IMAGING/STUDIES: ******* ___ MRI CSPINE, TSPINE, LSPINE ******* EXAMINATION: MR cervical, thoracic and lumbar spine. INDICATION: ___ with fever, back pain, urinary retention. Rule out epidural abscess. TECHNIQUE: Multiplanar, multi sequence MR images of the cervical, thoracic and lumbar spines were obtained before and after the administration of intravenous contrast. COMPARISON: CT abdomen and pelvis ___. FINDINGS: Cervical spine: Cervical spine alignment is maintained. Vertebral body heights are preserved. There is loss of disc space height most notable at C5-C6. Bone marrow signal is mildly heterogeneous without focal suspicious abnormality. No abnormal enhancement or epidural fluid collection is identified. The cervical cord is normal ___ signal intensity. C2-C3: A small central disc protrusion is present without significant spinal canal narrowing. There is mild to moderate left neural foraminal narrowing secondary to uncovertebral and facet osteophytes. The right neural foramen is patent. C3-C4: A small central disk protrusion mildly effaces the ventral subarachnoid space. The right neural foramen is patent. There is moderate to severe left neural foraminal narrowing secondary to uncovertebral and facet osteophytes. C4-C5: A broad-based disc osteophyte complex is present, and there is thickening of the ligamentum flavum contributing to moderate spinal canal narrowing. There is we moderate to severe left neural foraminal narrowing and mild to moderate right neural foraminal narrowing secondary to uncovertebral and facet osteophytes. The degree of neural foraminal narrowing is difficult to precisely determine secondary to patient motion artifact at this level. C5-C6: A broad-based disc osteophyte complex completely effaces the ventral subarachnoid space causing moderate spinal canal narrowing. There is moderate to severe bilateral neural foraminal narrowing secondary to uncovertebral and facet osteophytes. C6-C7: A broad-based disc protrusion is present which effaces the ventral subarachnoid space and causes mild spinal canal narrowing. There is mild right and moderate left neural foraminal narrowing secondary to uncovertebral and facet osteophytes. C7-T1: No significant spinal canal or neural foraminal narrowing is present. Thoracic spine: Thoracic spine alignment is preserved. There is chronic loss of anterior height of multiple vertebral bodies. Bone marrow signal is heterogeneous without focal suspicious abnormality. Chronic degenerative endplate changes are most pronounced at T8-T9 and T9-T10. There is diffuse loss of disc space height. The thoracic cord is small ___ caliber. There is no abnormal cord signal. No abnormal enhancement or epidural fluid collection is identified. Scattered small disc protrusions are present without significant spinal canal or neural foraminal narrowing. Lumbar spine: There is grade 1, 4 mm anterolisthesis of L5 with respect S1 with associated bilateral chronic pars defects. Lumbar spine alignment is otherwise preserved. Vertebral body heights are maintained. There is diffuse loss of disc space height and signal most notable at L1-L2, L4-L5 and L5-S1. Chronic degenerative endplate changes are noted at these levels as well. The conus medullaris is normal ___ morphology and signal intensity and terminates at the level of T12-L1. ___ the left paraspinal soft tissues at the level of L4 and L5, there is a rim enhancing loculated collection measuring 2.9 cm AP x 1.0 cm TR by 3.3 cm SI. An additional rim enhancing collection is present ___ the posterior spinal canal at the levels of L4 and L5 which measures 1.4 cm AP x 1.4 cm TR x 3.4 cm SI. Enhancing phlegmon extends into the sacral spinal canal. The epidural collection exerts mass effect on the posterior aspect of the thecal sac. Edema and enhancement is seen within the adjacent L4 and L5 spinous processes and left pedicles. T12-L1 and L1-L2: There are mild diffuse disc bulges and facet degenerative changes without significant spinal canal or neural foraminal narrowing. L2-L3: There is a diffuse disc bulge which is slightly e centric to the left and narrows the left subarticular recess. Mild degenerative facet changes are present without significant spinal canal or neural foraminal narrowing. L3-L4: A small left foraminal disc protrusion is present which mildly narrows the left neural foramen. The spinal canal and right neural foramen are patent. Mild facet degenerative changes are present. L4-L5: There is a mild diffuse disc bulge, facet degenerative changes and thickening of the ligamentum flavum. The disc bulge is slightly centric to the right and causes mild right neural foraminal narrowing. The left neural foramen is patent. L4-L5: ___ addition to the anterolisthesis at this level there is a disc bulge and facet degenerative changes. The epidural collection at this level causes mild narrowing of the thecal sac. Mild bilateral neural foraminal narrowing is present. Multiple T2 hyperintense lesions are present within both kidneys, compatible with renal cysts. IMPRESSION: 1. Rim enhancing collection within the posterior spinal canal at the levels of L4 and L5 compatible with epidural abscess. Additional abscess is seen within the left paraspinal musculature at these levels. There is edema and enhancement within the adjacent left L4 and L5 pedicles and spinous processes which may indicate osteomyelitis. There is no evidence for compression of the cauda equina or cord compression. 2. Multilevel cervical, thoracic and lumbar spine degenerative changes as described. ******* ___ RUQ US ******* CLINICAL INDICATION: Cholecystitis per CAT scan. Evaluate for cholecystitis. TECHNIQUE: Gray-scale, spectral and color Doppler ultrasound evaluation of the abdomen. COMPARISON: CT abdomen and pelvis ___. FINDINGS: The liver is normal ___ echotexture and contour. No focal liver lesions are identified. The portal vein is patent and demonstrates normal hepatopetal flow. There is no intrahepatic biliary duct dilation. The common bile duct measures 5 mm ___ diameter. The gallbladder is distended and the gallbladder wall is edematous. There is minimal pericholecystic fluid. No gallstones are identified. There are simple cysts ___ the right kidney, the largest measuring 1.9 cm. There is no hydronephrosis or stones. The visualized portions of the aorta and IVC appear normal. IMPRESSION: Distended gallbladder with an edematous gallbladder wall and adjacent pericholecystic fluid. No gallstones. Considering that the patient is a diabetic these findings are concerning for acalculous cholecystitis. COMMENT: Changes to preliminary read communicated to ___ by ___ and ___ at 8:30 ___. The study and the report were reviewed by the staff radiologist. ******* ___ CT ___ PARASPINAL ABSCESS DRAINAGE ******* INDICATION: ___ year old man with paraspinal and epidural abscesses. Aspirate paraspinal abscess and send material for culture COMPARISON: CT abdomen and pelvis ___. PROCEDURE: CT-guided aspiration of left posterior paraspinal abscess. OPERATORS: Dr. ___ fellow and Dr. ___, ___ radiologist, who was present and supervising throughout the total procedure time. 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 ___ a prone position on the CT scan table. Limited preprocedure CTscan of the intended site of aspiration was performed. Based on the CT findings an appropriate position for the aspiration was chosen. The site was marked. The site was prepped and draped ___ the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 18 gauge ___ needle was introduced into the left paraspinal abscess at L4-L5 level. Multiple attempts at aspiration yielded 4 cc of thick purulent material. Samples were sent to microbiology as requested. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: DLP: 338 mGy-cm SEDATION: Divided doses of 50 mcg fentanyl throughout the total intra-service time of 30 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited non-contrast pre-procedure imaging demonstrates an abscess ___ the left paraspinal musculature (03:19). Extensive degenerative changes of the imaged lumbosacral spine is noted. Known epidural abscess is extremely difficult to visualized on this study. Limited views of the pelvis demonstrate extensive aortoiliac atherosclerosis. IMPRESSION: Technically successful CT-guided aspiration of a left paraspinal abscess at L4-L5 level. Samples sent for microbiology as requested. The study and the report were reviewed by the staff radiologist. ******* ___ HIDA SCAN ******* RADIOPHARMACEUTICAL DATA: 4.4 mCi Tc-99m DISIDA ___ HISTORY: Back pain and fever. TECHNIQUE: Following the intravenous injection of tracer, serial one-minute images of tracer uptake into the hepatobiliary system were obtained for 60 minutes. INTERPRETATION: Serial images over the abdomen show homogeneous uptake of tracer into the hepatic parenchyma. At 7 minutes, the gallbladder is visualized with tracer activity noted ___ the small bowel at 13 minutes. IMPRESSION: Normal hepatobiliary scan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation Daily 3. Aspirin 81 mg PO DAILY 4. Metoprolol Tartrate 50 mg PO BID 5. Digoxin 0.125 mg PO DAILY 6. PredniSONE 5 mg PO DAILY 7. Tamsulosin 0.4 mg PO HS 8. TraZODone 50 mg PO HS:PRN insomnia 9. Gabapentin 300 mg PO TID 10. Ezetimibe 10 mg PO DAILY 11. fenofibrate 150 mg oral daily 12. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous TID 13. Levemir (insulin detemir) 100 unit/mL subcutaneous QHS Discharge Medications: 1. Nafcillin 2 g IV Q4H RX *nafcillin ___ dextrose iso-osm 2 gram/100 mL 2 g intravenous Every 4 hours Disp #*252 Intravenous Bag Refills:*0 2. Rivaroxaban 15 mg PO BID Duration: 3 Weeks After 3 weeks, this should be switched to 20mg daily for ___ months. RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth Twice per day Disp #*42 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Digoxin 0.25 mg PO DAILY RX *digoxin 250 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Ezetimibe 10 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. PredniSONE 5 mg PO DAILY 8. Tamsulosin 0.4 mg PO HS 9. TraZODone 50 mg PO HS:PRN insomnia 10. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day Disp #*60 Capsule Refills:*0 11. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth Once per day Disp #*30 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 13. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 capsule by mouth Twice per day Disp #*60 Capsule Refills:*0 14. fenofibrate 150 mg oral daily 15. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous TID 16. Levemir (insulin detemir) 100 unit/mL subcutaneous QHS 17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION DAILY 18. Tiotropium Bromide 1 CAP IH DAILY 19. Outpatient Lab Work Please check Chem7, CBC, and LFTs weekly starting ___. Please Fax results to: OPAT (Outpatient antibiotic therapy) phone: ___, fax: ___ 20. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate [Toprol XL] 200 mg 1 tablet(s) by mouth once per day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ------------------- PRIMARY DIAGNOSES ------------------- - Paraspinal and epidural abscess L4-L5 - Sepsis - Pulmonary embolism - Right leg deep vein thrombosis - Atrial fibrillation with RVR - Acute on chronic diastolic congestive heart failure exacerbation ------------------- SECONDARY DIAGNOSES ------------------- - COPD - diastolic and systolic chronic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: BILATERAL LOWER EXTREMITY ULTRASOUND INDICATION: Lower extremity swelling. Dyspnea. TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both common femoral veins, superficial femoral, popliteal and proximal calf veins were obtained. COMPARISON: None available. FINDINGS: There is normal respiratory variation in both common femoral veins. Echogenic noncompressible clot is seen within the right posterior tibial vein (image 13), demonstrating minimal adjacent flow. The right common femoral, superficial femoral, and popliteal veins demonstrate normal compressibility. Normal flow is demonstrated within the right peroneal vein. Arising from the right popliteal fossa is a 4.5 x 2.2 x 1.2 cm collection. There is normal flow, compressibility, and augmentation of the left common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins. IMPRESSION: 1. Nonocclusive thrombus within the right posterior tibial vein (DVT). 2. 4.5 cm right popliteal fossa fluid collection. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ telephone at the time of interpretation, 11:57 AM, ___. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with dyspnea // Eval for edema, pneumonia IMPRESSION: In comparison with the earlier study of this date, there is little overall change. Again there are low lung volumes which accentuate the transverse diameter of the heart. No definite vascular congestion or pleural effusion. Mild bibasilar atelectatic changes persist. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi INDICATION: ___ year old man with 48cm right PICC. ___ ___ // 48cm right PICC. ___ ___ Contact name: ___: ___ COMPARISON: Chest radiographs ___ through ___. IMPRESSION: New right PIC line ends low in the SVC. Borderline cardiomegaly unchanged. Lungs clear. No pleural abnormality. Radiology Report EXAMINATION: MR cervical, thoracic and lumbar spine. INDICATION: ___ with fever, back pain, urinary retention. Rule out epidural abscess. TECHNIQUE: Multiplanar, multi sequence MR images of the cervical, thoracic and lumbar spines were obtained before and after the administration of intravenous contrast. COMPARISON: CT abdomen and pelvis ___. FINDINGS: Cervical spine: Cervical spine alignment is maintained. Vertebral body heights are preserved. There is loss of disc space height most notable at C5-C6. Bone marrow signal is mildly heterogeneous without focal suspicious abnormality. No abnormal enhancement or epidural fluid collection is identified. The cervical cord is normal in signal intensity. C2-C3: A small central disc protrusion is present without significant spinal canal narrowing. There is mild to moderate left neural foraminal narrowing secondary to uncovertebral and facet osteophytes. The right neural foramen is patent. C3-C4: A small central disk protrusion mildly effaces the ventral subarachnoid space. The right neural foramen is patent. There is moderate to severe left neural foraminal narrowing secondary to uncovertebral and facet osteophytes. C4-C5: A broad-based disc osteophyte complex is present, and there is thickening of the ligamentum flavum contributing to moderate spinal canal narrowing. There is we moderate to severe left neural foraminal narrowing and mild to moderate right neural foraminal narrowing secondary to uncovertebral and facet osteophytes. The degree of neural foraminal narrowing is difficult to precisely determine secondary to patient motion artifact at this level. C5-C6: A broad-based disc osteophyte complex completely effaces the ventral subarachnoid space causing moderate spinal canal narrowing. There is moderate to severe bilateral neural foraminal narrowing secondary to uncovertebral and facet osteophytes. C6-C7: A broad-based disc protrusion is present which effaces the ventral subarachnoid space and causes mild spinal canal narrowing. There is mild right and moderate left neural foraminal narrowing secondary to uncovertebral and facet osteophytes. C7-T1: No significant spinal canal or neural foraminal narrowing is present. Thoracic spine: Thoracic spine alignment is preserved. There is chronic loss of anterior height of multiple vertebral bodies. Bone marrow signal is heterogeneous without focal suspicious abnormality. Chronic degenerative endplate changes are most pronounced at T8-T9 and T9-T10. There is diffuse loss of disc space height. The thoracic cord is small in caliber. There is no abnormal cord signal. No abnormal enhancement or epidural fluid collection is identified. Scattered small disc protrusions are present without significant spinal canal or neural foraminal narrowing. Lumbar spine: There is grade 1, 4 mm anterolisthesis of L5 with respect S1 with associated bilateral chronic pars defects. Lumbar spine alignment is otherwise preserved. Vertebral body heights are maintained. There is diffuse loss of disc space height and signal most notable at L1-L2, L4-L5 and L5-S1. Chronic degenerative endplate changes are noted at these levels as well. The conus medullaris is normal In morphology and signal intensity and terminates at the level of T12-L1. In the left paraspinal soft tissues at the level of L4 and L5, there is a rim enhancing loculated collection measuring 2.9 cm AP x 1.0 cm TR by 3.3 cm SI. An additional rim enhancing collection is present in the posterior spinal canal at the levels of L4 and L5 which measures 1.4 cm AP x 1.4 cm TR x 3.4 cm SI. Enhancing phlegmon extends into the sacral spinal canal. The epidural collection exerts mass effect on the posterior aspect of the thecal sac. Edema and enhancement is seen within the adjacent L4 and L5 spinous processes and left pedicles. T12-L1 and L1-L2: There are mild diffuse disc bulges and facet degenerative changes without significant spinal canal or neural foraminal narrowing. L2-L3: There is a diffuse disc bulge which is slightly e centric to the left and narrows the left subarticular recess. Mild degenerative facet changes are present without significant spinal canal or neural foraminal narrowing. L3-L4: A small left foraminal disc protrusion is present which mildly narrows the left neural foramen. The spinal canal and right neural foramen are patent. Mild facet degenerative changes are present. L4-L5: There is a mild diffuse disc bulge, facet degenerative changes and thickening of the ligamentum flavum. The disc bulge is slightly centric to the right and causes mild right neural foraminal narrowing. The left neural foramen is patent. L4-L5: In addition to the anterolisthesis at this level there is a disc bulge and facet degenerative changes. The epidural collection at this level causes mild narrowing of the thecal sac. Mild bilateral neural foraminal narrowing is present. Multiple T2 hyperintense lesions are present within both kidneys, compatible with renal cysts. IMPRESSION: 1. Rim enhancing collection within the posterior spinal canal at the levels of L4 and L5 compatible with epidural abscess. Additional abscess is seen within the left paraspinal musculature at these levels. There is edema and enhancement within the adjacent left L4 and L5 pedicles and spinous processes which may indicate osteomyelitis. There is no evidence for compression of the cauda equina or cord compression. 2. Multilevel cervical, thoracic and lumbar spine degenerative changes as described. NOTIFICATION: The results were discussed with Dr. ___ via telephone at 10:0 0 hr on ___ ___. Radiology Report CLINICAL INDICATION: Cholecystitis per CAT scan. Evaluate for cholecystitis. TECHNIQUE: Gray-scale, spectral and color Doppler ultrasound evaluation of the abdomen. COMPARISON: CT abdomen and pelvis ___. FINDINGS: The liver is normal in echotexture and contour. No focal liver lesions are identified. The portal vein is patent and demonstrates normal hepatopetal flow. There is no intrahepatic biliary duct dilation. The common bile duct measures 5 mm in diameter. The gallbladder is distended and the gallbladder wall is edematous. There is minimal pericholecystic fluid. No gallstones are identified. There are simple cysts in the right kidney, the largest measuring 1.9 cm. There is no hydronephrosis or stones. The visualized portions of the aorta and IVC appear normal. IMPRESSION: Distended gallbladder with an edematous gallbladder wall and adjacent pericholecystic fluid. No gallstones. Considering that the patient is a diabetic these findings are concerning for acalculous cholecystitis. COMMENT: Changes to preliminary read communicated to ___ by ___ and ___ at 8:30 ___. Radiology Report INDICATION: ___ year old man with paraspinal and epidural abscesses. Aspirate paraspinal abscess and send material for culture COMPARISON: CT abdomen and pelvis ___. PROCEDURE: CT-guided aspiration of left posterior paraspinal abscess. OPERATORS: Dr. ___ fellow and Dr. ___ radiologist, who was present and supervising throughout the total procedure time. 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 prone position on the CT scan table. Limited preprocedure CTscan of the intended site of aspiration was performed. Based on the CT findings an appropriate position for the aspiration was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 18 gauge ___ needle was introduced into the left paraspinal abscess at L4-L5 level. Multiple attempts at aspiration yielded 4 cc of thick purulent material. Samples were sent to microbiology as requested. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: DLP: 338 mGy-cm SEDATION: Divided doses of 50 mcg fentanyl throughout the total intra-service time of 30 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Limited non-contrast pre-procedure imaging demonstrates an abscess in the left paraspinal musculature (03:19). Extensive degenerative changes of the imaged lumbosacral spine is noted. Known epidural abscess is extremely difficult to visualized on this study. Limited views of the pelvis demonstrate extensive aortoiliac atherosclerosis. IMPRESSION: Technically successful CT-guided aspiration of a left paraspinal abscess at L4-L5 level. Samples sent for microbiology as requested. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with history diastolic heart failure now with acute SOB. // acute sob TECHNIQUE: CHEST (PORTABLE AP) COMPARISON: ___ IMPRESSION: HEART SIZE IS ENLARGED, UNCHANGED. MEDIASTINUM IS OVERALL STABLE. BIBASAL ATELECTASIS IS UNCHANGED. NO OVERT PULMONARY EDEMA OR VASCULAR ENLARGEMENT IS PRESENT. NO INTERVAL INCREASE IN PLEURAL EFFUSION OR DEVELOPMENT OF PNEUMOTHORAX IS PRESENT. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Back pain, NEEDS MRI Diagnosed with FEVER, UNSPECIFIED, LUMBAGO, RETENTION URINE UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 98.4 heartrate: 82.0 resprate: 16.0 o2sat: 98.0 sbp: 116.0 dbp: 64.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, You were admitted to the hospital because you had high fevers and back pain. We found that your fever and back pain were due to an infection ___ your back. This pocket of infection was drained by Interventional Radiology, which improved your back pain. We also treated you with antibiotics. You will need to continue the antibiotic nafcillin for the next 6 weeks. You received a PICC line, which is a special IV, that will allow you to continue IV nafcillin at home. You will follow up with the Infectious Disease doctor ___ appointment time below) and they may decide to do more imaging of your back. They will tell when it is appropriate to stop your antibiotic. After you stop, the visiting nurse ___ remove the PICC line from your arm. While you were ___ the hospital, you also felt very short of breath. We think this was caused by multiple reasons. We found a blood clot ___ your leg and did an ultrasound that showed some right heart strain, suggesting that you have a blood clot ___ your lungs, which may be causing shortness of breath. We treated this initially with IV heparin. Then you were switched to Xarelto (rivaroxaban), which is a pill you must take twice per day. We recommend 15 mg twice per day for 3 weeks then switching to 20 mg once per day for ___ months. Your PCP ___ help you decide when to stop this medication. We also think your shortness of breath may be due to some fluid ___ your lungs because you received IV fluids ___ the hospital, so we treated this with Lasix, a medication that helps your body get rid of extra fluid. We continued to treat your COPD with nebulizers and inhalers. We also think that you will benefit from a sleep study once you leave the hospital. This may be very important to help you breath at night and help you sleep through the night. Your atrial fibrillation medications were also increased while you were ___ the hospital, because your heart rate was very rapid and difficult to control. A rapid heart rate can be triggered by infection and a blood clot ___ your lungs. So it is possible that ___ several weeks, your PCP may decide to decrease your metoprolol and digoxin again. Please continue to follow up with your doctors. It was a pleasure to take care of you ___ the hospital. We wish you the best! Your ___ 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: Weakness and Nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female with a history of endometrial cancer who is admitted with weakness and nausea. The patient states she has been feeling fatigued, weak, and nauseated since her chemotherapy and neulasta last week. She states after she went home from her neulasta she had a "deep sleep" all evening and night until the next morning. She denies any vomiting. She denies any fever, shortness of breath, congestion, or dysuria. She does have a yeast infection under her breasts which she gets intermittently. She does have an intermittent non productive cough which she states she has had for years. She states she had similar weakness of nausea with his prior doses of chemotherapy. Of not she admits to having some diarrhea recently but it was after she took a large amount of miralax after she had been taking Imodium and it has since resolved. Of note she was last admitted from ___ - ___ with weakness that was thought to be from her chemotherapy and she was treated supportively with improvement. In the ED her vital signs were unremarkable. Labwork was notable for leukocytosis. A UA and flu swab were negative. A chest X-ray was unremarkable. She was given Zofran and IV fluids. Past Medical History: - T2DM on insulin - Neuropathy of hands and feet b/l ___ diabetes - Anxiety, depression, past history of suicide attempt and hospitalizations - Asthma, prior hospitalization, never intubated - Osteoarthritis - Hyperlipidemia - Left adrenal mass - s/p left breast lumpectomy, benign Social History: ___ Family History: Sister died breast cancer in ___. Brother died throat cancer. Mother died lung cancer. Daughter died of asthma/respiratory failure. Denies a known family history of ovarian, uterine, cervical, or colon malignancy. Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD VITAL SIGNS: T 97.8 BP 156/70 HR 91 RR 20 O2 96%RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: CTAB ABD: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixi SKIN: Erythema under breasts. NEURO: Alert and oriented, no focal deficits. DISCHARGE PHYSICAL EXAM: 98.2 150/72 88 20 General: NAD, sitting up in bed finished breakfast HEENT: AT/NC, no OP lesions, MMM, EOMI, no JVD CV: RRR, s1+s2 normal, no m/g/r appreciated PULM: CTAB ABD: +BS, soft, non-tender, non-distended, no organomegaly appreciated LIMBS: No edema, clubbing, tremors, or asterixis SKIN: Erythema under breasts. NEURO: No motor/sensory deficits elicited Pertinent Results: ADMISSION LABS: ___ 05:35PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 04:00PM URINE HOURS-RANDOM ___ 04:00PM URINE UHOLD-HOLD ___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:17PM LACTATE-1.2 ___ 03:00PM GLUCOSE-102* UREA N-17 CREAT-0.9 SODIUM-142 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 ___ 03:00PM estGFR-Using this ___ 03:00PM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-129* TOT BILI-0.2 ___ 03:00PM LIPASE-16 ___ 03:00PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-1.7 ___ 03:00PM WBC-17.2* RBC-3.35* HGB-10.6* HCT-32.7* MCV-98 MCH-31.6 MCHC-32.4 RDW-15.9* RDWSD-56.4* ___ 03:00PM NEUTS-74* BANDS-7* LYMPHS-11* MONOS-8 EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-13.93* AbsLymp-1.89 AbsMono-1.38* AbsEos-0.00* AbsBaso-0.00* ___ 03:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-1+* MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+* ___ 03:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-1+* MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+* DISCHARGE LABS: ___ 05:30AM BLOOD WBC-10.6* RBC-3.03* Hgb-9.6* Hct-29.4* MCV-97 MCH-31.7 MCHC-32.7 RDW-15.4 RDWSD-53.9* Plt ___ ___ 05:30AM BLOOD Plt ___ ___ 05:30AM BLOOD Glucose-221* UreaN-14 Creat-0.8 Na-144 K-4.5 Cl-107 HCO3-25 AnGap-12 ___ 05:30AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.6 IMAGING: ___ CXR: No signs of pneumonia. MICRO: ___ 4:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___: Blood Cx x2: PND Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. BusPIRone 30 mg PO BID 4. FLUoxetine 40 mg PO DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH BID 6. Gabapentin 1200 mg PO QHS 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath/wheezing 8. LamoTRIgine 25 mg PO QAM 9. LamoTRIgine 50 mg PO QPM 10. Lisinopril 5 mg PO DAILY 11. Montelukast 10 mg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. Oxybutynin 15 mg PO DAILY 14. Topiramate (Topamax) 75 mg PO QHS 15. TraZODone 200 mg PO QHS:PRN insomnia 16. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing 17. Hydrocortisone Cream 2.5% 1 Appl TP BID 18. Ketoconazole 2% 1 Appl TP BID 19. Lactaid (lactase) 3,000 unit oral TID W/MEALS 20. LOPERamide 2 mg PO QID:PRN diarrhea 21. melatonin 3 mg oral QHS 22. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 23. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 24. Novolog 20 Units Breakfast Novolog 20 Units Lunch Novolog 20 Units Dinner Tresiba 76 Units Bedtime Discharge Medications: 1. Novolog 20 Units Breakfast Novolog 20 Units Lunch Novolog 20 Units Dinner Tresiba 76 Units Bedtime 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. BusPIRone 30 mg PO BID 6. FLUoxetine 40 mg PO DAILY 7. Fluticasone Propionate 110mcg 1 PUFF IH BID 8. Gabapentin 1200 mg PO QHS 9. Hydrocortisone Cream 2.5% 1 Appl TP BID 10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath/wheezing 11. Ketoconazole 2% 1 Appl TP BID 12. Lactaid (lactase) 3,000 unit oral TID W/MEALS 13. LamoTRIgine 50 mg PO QPM 14. LamoTRIgine 25 mg PO QAM 15. Lisinopril 5 mg PO DAILY 16. LOPERamide 2 mg PO QID:PRN diarrhea 17. melatonin 3 mg oral QHS 18. Montelukast 10 mg PO DAILY 19. Omeprazole 40 mg PO DAILY 20. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 21. Oxybutynin 15 mg PO DAILY 22. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 23. Topiramate (Topamax) 75 mg PO QHS 24. TraZODone 200 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis Endometrial Cancer Secondary Diagnosis Weakness Nausea Diabetes Mellitus Anxiety Depression Asthma 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 productive cough, on chemo for uterine ca// pna? TECHNIQUE: Chest AP and lateral COMPARISON: Chest radiograph dated ___. Dated ___. FINDINGS: Right chest wall Port-A-Cath terminates in the region of the cavoatrial junction. The lungs are clear, though volumes are somewhat low. The pulmonary vasculature is unremarkable. No pleural abnormalities. The cardiomediastinal silhouette stable with dense mitral annular calcification again seen. No acute osseous abnormalities. IMPRESSION: No signs of pneumonia. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: N/V, Weakness Diagnosed with Nausea with vomiting, unspecified temperature: 96.9 heartrate: 80.0 resprate: 20.0 o2sat: 95.0 sbp: 143.0 dbp: 94.0 level of pain: 0 level of acuity: 2.0

Dear ___, It was a pleasure taking care of you during your hospitalization. Briefly, you were hospitalized with fatigue and weakness and nausea following chemotherapy and neulasta injection. You were given IV fluids and anti-nausea medications. You felt better. You will follow up with Dr. ___ to discuss further treatments. We wish you the best, Your ___ Treatment 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: numbness Major Surgical or Invasive Procedure: none History of Present Illness: ___ Stroke Scale Score: 0 NIHSS, GCS, and ICH score performed within 6 hours of presentation at: ___ 7:45 pm NIHSS Total: 0 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 GCS Score at the scene: 15 ICH Volume by ABC/2 method: 0.1 cc ICH Score: 0 Pre-ICH mRS: 1 REASON FOR CONSULTATION: basal ganglia bleed HPI: ___ yo female with recently diagnosed grade 3 invasive ductal carcinoma of the left breast, thrombocyosis of unclear etiology, chronic history of left foot drop s/p hip surgery, peripheral vascular disease, chronic smoker, transferred from OSH after presenting with headache and right-sided numbness, found to have a left basal ganglia bleed. Yesterday morning developed typical migraine with visual aura ("crimson halo"), which resolved after about 30 minutes (typically resolves after 10 minutes). Took Excedrin and then shortly after had recurrent migraine. Took second dose of Excedrin. Had on-going intermittent headache throughout the day. Then around 3:45 pm, when walking into a restaurant with her partner, developed acute onset full right arm numbness, with the sensation of a "pulse pounding" in her right hand. This slowly improved over time. She took some aspirin and went to bed and woke up again with worsening right arm numbness that seemed to improve with movement. This morning developed a recurrent headache and had two more episodes of right arm numbness, without returning completely to normal in between. Then at 1:30 pm, felt right facial numbness. Given these symptoms presented to OSH, where she had a CT scan notable for a small left basal ganglia hemorrhage. Here she reports that her symptoms have largely resolved, although she feels that the patch on her right arm near the PIV still feels "funny". Denies any weakness, but may have had more difficulty using the cane with her right arm. ROS: On neurological review of systems, the patient denies confusion, difficulties producing or comprehending speech, vision changes, or dizziness. Denies focal weakness. No bowel or bladder incontinence or retention. Walks with cane at baseline for left foot drop. On general review of systems, the patient denies recent fever. Denies cough, shortness Past Medical History: - Recently diagnosed grade 3 invasive ductal carcinoma of the left breast. Upcoming oncologist appointment; planning for chemo, radiation, and surgery. - Thrombocyosis of unclear etiology. Per hematology note, patient was taking aspirin, and patient initially reported being on a "blood thinner" - but patient indicated that the cilostazol was her blood thinner and did not list aspirin as a regular home medication. - Chronic history of left foot drop s/p hip surgery - Peripheral vascular disease Social History: Lives with her partner of many years. Adult son recently moved back in. Retired, reports that she functions independently at baseline. Quit smoking a few weeks ago. ___ year history of smoking, ___ ppd. Drinks ___ times per week. Denies any MJ, CBD, or other drug use. - Modified Rankin Scale: [] 0: No symptoms [x] 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 with intracranial bleed in the setting of trauma. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T: 97.3 BP: 115/51 HR: 68 RR: 16 SaO2: 98% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. 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. Able to name both high and low frequency objects. No dysarthria. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline. -Motor: Decreased bulk, normal tone. Very mild right pronator drift. Mild postural tremor. [___] L 5 5 5 5 5 5 5 5 5 3* 5 4* R 5 5 5 5 5 5 5 5 5 5 5 5 *Baseline left foot drop -Sensory: No deficits to light touch, pinprick. No extinction to DSS. Reports subjective numbness over dorsal aspect of distal right forearm. -Reflexes: [Bic] [___] [Pat] L 2 2 2 R 2 2 2 Plantar response was flexor bilaterally. -Coordination: Normal finger-tap bilaterally. No dysmetria on FNF bilaterally. -Gait: Deferred. Walks with cane at baseline. ================================================= DISCHARGE PHYSICAL EXAM: As above except no subjective numbness. Pertinent Results: ___ 07:13PM BLOOD WBC-11.0* RBC-3.95 Hgb-11.9 Hct-36.1 MCV-91 MCH-30.1 MCHC-33.0 RDW-14.6 RDWSD-48.8* Plt ___ ___ 07:55PM BLOOD Neuts-50.1 ___ Monos-12.7 Eos-2.7 Baso-0.9 Im ___ AbsNeut-5.32 AbsLymp-3.51 AbsMono-1.35* AbsEos-0.29 AbsBaso-0.10* ___ 07:13PM BLOOD ___ PTT-28.7 ___ ___ 07:55PM BLOOD WBC-10.6* RBC-4.14 Hgb-12.3 Hct-37.8 MCV-91 MCH-29.7 MCHC-32.5 RDW-14.3 RDWSD-47.8* Plt ___ ___ 07:55PM BLOOD ___ PTT-28.8 ___ ___ 07:55PM BLOOD Glucose-86 UreaN-10 Creat-0.5 Na-138 K-4.3 Cl-107 HCO3-19* AnGap-12 ___ 07:13PM BLOOD Glucose-102* UreaN-10 Creat-0.5 Na-136 K-4.4 Cl-104 HCO3-20* AnGap-12 ___ 07:55PM BLOOD ALT-20 AST-24 CK(CPK)-67 AlkPhos-89 TotBili-0.2 ___ 07:55PM BLOOD Lipase-52 ___ 07:55PM BLOOD cTropnT-<0.01 ___ 07:55PM BLOOD CK-MB-3 ___ 07:13PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.7 Cholest-159 ___ 07:55PM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.4 Mg-1.7 ___ 07:13PM BLOOD %HbA1c-5.0 eAG-97 ___ 07:13PM BLOOD Triglyc-160* HDL-50 CHOL/HD-3.2 LDLcalc-77 ___ 07:13PM BLOOD TSH-0.68 ___ 07:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 09:00PM URINE Blood-NEG Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 09:00PM URINE RBC-7* WBC-38* Bacteri-FEW* Yeast-NONE Epi-11 ___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Imaging: ___ CTA head/neck: 1. 1.4 cm and 0.6 cm hyperdense foci in the left postcentral gyrus and posterior internal capsule, respectively, likely representing metastatic lesions. 2. No acute large territorial infarct. 3. Bilateral mastoid effusions. 4. Severe right maxillary sinus disease. 5. Atherosclerotic changes of the bilateral cavernous and supraclinoid ICAs with mild bilateral narrowing with distal patency. 6. 50% right and 30% left narrowing of the ICAs, by NASCET criteria. 7. Multiple right pulmonary upper lobe and thoracic inlet masses, most likely representing metastatic disease, given the patient's history of breast cancer. These can be further evaluated with a CT of the chest with contrast. 8. Cervical spondylosis with moderate to severe bilateral foraminal narrowing at C4-5, C5-6 and C7 and mild-to-moderate spinal canal narrowing at C4-5. RECOMMENDATION(S): CT of the chest with contrast to further evaluate the masses seen in the thoracic cavity. ___ MRI brain w/wo contrast: 1. Study is mildly degraded by motion. 2. 1.5 cm and 0.7 cm enhancing lesions are seen in the left postcentral gyrus and left internal capsule, respectively, consistent with metastatic disease. The left basal ganglia lesion demonstrates internal hemorrhage, consistent with the hemorrhage seen on the prior CT of the head. 3. No acute infarct. 4. Severe right maxillary sinus disease and nonspecific bilateral mastoid fluid. ___ CT chest w/ contrast: 1. A 3.3 x 3.4 x 3.5 cm solid mass in the right upper lobe correlates with the finding seen on prior breast MR, concerning for second primary malignancy, less likely metastasis. Biopsy is recommended. 2. Mediastinal and bilateral hilar lymphadenopathy is concerning for disease involvement. 3. Known 2.7 cm left breast mass is better evaluated on prior breast MR and mammography. RECOMMENDATION(S): Biopsy is recommended for a 3.5 cm mass in the right upper lobe. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cilostazol 100 mg PO BID 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Alendronate Sodium 10 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Vitamin D ___ UNIT PO DAILY 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice daily Disp #*10 Capsule Refills:*0 2. Alendronate Sodium 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Cilostazol 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute intraparenchymal hemorrhage brain neoplasm hemorrhagic metastasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with newly diagnosed breast cancer, presents with left basal ganglia bleed.// Evaluate for source of bleed. With contrast, given diagnosis of CA. 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: CTA of the head and neck with and without contrast dated ___. FINDINGS: Study is mildly degraded by motion. A 1.5 cm x 1.4 cm enhancing lesion is seen in the left postcentral gyrus with minimal surrounding edema. A 7 mm heterogeneously enhancing lesion is seen in the left internal capsule demonstrating internal hemorrhage. There is no evidence of midline shift or infarction. There is mild prominence of the ventricles and sulci suggestive of involutional changes. Few periventricular and subcortical T2 and FLAIR hyperintensities are noted which may represent small vessel ischemic changes. There is complete opacification of the right maxillary sinus. Bilateral mastoid fluid is present. IMPRESSION: 1. Study is mildly degraded by motion. 2. 1.5 cm and 0.7 cm enhancing lesions are seen in the left postcentral gyrus and left internal capsule, respectively, consistent with metastatic disease. The left basal ganglia lesion demonstrates internal hemorrhage, consistent with the hemorrhage seen on the prior CT of the head. 3. No acute infarct. 4. Severe right maxillary sinus disease and nonspecific bilateral mastoid fluid. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old woman with breast cancer and concern for mets// lung mass TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated 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 2.0 s, 32.2 cm; CTDIvol = 5.7 mGy (Body) DLP = 184.7 mGy-cm. Total DLP (Body) = 185 mGy-cm. COMPARISON: Breast MR dated ___. FINDINGS: NECK, THORACIC INLET, AXILLAE: There is a coarse calcification in the left lobe of the thyroid. The visualized thyroid is otherwise unremarkable. Supraclavicular and axillary lymph nodes are not enlarged. MEDIASTINUM: There are multiple enlarged mediastinal lymph nodes, including a conglomerate at the thoracic inlet measuring 1.6 x 3.6 cm, and at the subcarinal station measuring 2.1 x 3.3 cm. HILA: There are multiple enlarged bilateral hilar lymph nodes, measuring up to 1.4 cm in short axis on the right and 1.0 cm in short axis on the left. HEART: The heart is not enlarged and there is moderate coronary arterial calcification. There is no pericardial effusion. VESSELS: Aortic caliber is normal. The main, right, and left pulmonary arteries are normal caliber. PULMONARY PARENCHYMA: There is a 3.3 x 3.4 x 3.5 cm round, slightly spiculated mass in the right upper lobe. There is bilateral lower lobe atelectasis. There is mild paraseptal and centrilobular emphysema. AIRWAYS: The airways are patent to the subsegmental level bilaterally. There is mild diffuse bronchial wall thickening in the lower lobes. PLEURA: There is no pleural effusion. CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion. Multilevel degenerative changes are moderate. Irregularity of the sternum likely represents healed fracture. A 2.7 x 1.9 cm soft tissue lesion in the left breast correlates with known invasive ductal carcinoma, better evaluated with dedicated mammography. UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen. Allowing for this, the partially visualized upper abdomen is unremarkable. IMPRESSION: 1. A 3.3 x 3.4 x 3.5 cm solid mass in the right upper lobe correlates with the finding seen on prior breast MR, concerning for second primary malignancy, less likely metastasis. Biopsy is recommended. 2. Mediastinal and bilateral hilar lymphadenopathy is concerning for disease involvement. 3. Known 2.7 cm left breast mass is better evaluated on prior breast MR and mammography. RECOMMENDATION(S): Biopsy is recommended for a 3.5 cm mass in the right upper lobe. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: ICH, Transfer Diagnosed with Nontraumatic intracranial hemorrhage, unspecified temperature: 97.2 heartrate: 74.0 resprate: 16.0 o2sat: 98.0 sbp: 117.0 dbp: 76.0 level of pain: 0 level of acuity: 2.0

Ms. ___, You were hospitalized due to symptoms of right arm and face numbness resulting from a brain hemorrhage, a condition where a blood vessel providing oxygen and nutrients to the brain breaks open and bleeds. 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: Cancer Peripheral arterial disease We are not changing your medications. Please take your medications as prescribed. Please follow up with Neurology, Oncology 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 Sincerely, Your ___ Neurology 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: Headache, L facial puffiness, increased salivation, L facial droop Major Surgical or Invasive Procedure: LP on ___, results pending for Cell Count and Differential; Glucose; Protein, Total; CSF culture & gram stain; Acid Fast (TB) Culture; Cytologic exam; Fungal culture; Angiotensin 1 Converting Enzyme; Immunophenotyping; Mycobacterium tuberculosis Complex, Non-respiratory History of Present Illness: ___ is a ___ F with h/o HTN, HLD, DM2 presenting with new intermittent headaches over the past 2 weeks. The patient states that the headaches are located on the left, start in the occipital region and radiate to the forehead and sometimes to the face. The quality is describes as constant and pressure like. The headaches have occurred daily over the past two weeks and tend to occur in the evenings around ___. They last for 30 minutes to 1 hour. The patient also states that over the past few days she has noticed that the left side of her face feels puffy and it is more difficult to chew on the left than the right. She also describes some difficulty pronouncing words intermittently, which she attributes to having more saliva in her mouth than usual. She has not had any issues finding the correct words and has not made any errors in language. Past Medical History: Breast cancer in ___ s/p chemo/radiation and lumpectomy HTN HLD DM2 glaucoma Social History: ___ Family History: Mother with breast cancer, headaches, HLD, HTN. No family history of stroke or other neurologic problems. Physical Exam: Admission Exam: Vitals: 98.6 59 185/76 15 100% GEN: Awake, cooperative, NAD. HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx NECK: Supple, no carotid bruits. RESP: CTAB no w/r/r CV: RRR, no m/r/g ABD: soft, NT/ND EXT: No edema, no cyanosis SKIN: no rashes or lesions noted. NEURO EXAM: MS: 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. Speech was not dysarthric. Pt was able to name both high and low frequency objects. Able to follow both midline and appendicular commands. Good knowledge of current events. No evidence of apraxia or neglect. CN: II: PERRLA 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: Patient states she is unable to follow the finger to either the left or right with her eyes, but frequently makes full lateral eye movements at other times throughout the exam. EOMI, no nystagmus. Normal saccades. There is ptosis on the left, which the patient states has been present since birth V: Sensation intact to LT. VII: Facial musculature activates symmetrically. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue protrudes midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ ___ 5 5 R ___ ___ ___ ___ 5 5 Sensory: No deficits to light touch, pinprick, vibratory sense, proprioception throughout. No extinction to DSS. Reflexes: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Toes downgoing bilaterally Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Discharge Exam: GEN: Awake, cooperative, NAD. HEENT: NC/AT, anicteric, MMM, L tongue swollen RESP: CTAB no w/r/r CV: RRR, no m/r/g ABD: soft, NT/ND EXT: No edema, no cyanosis NEURO EXAM: MS: Alert, oriented x 3. Attention, language intact. Speech was not dysarthric. Follows commands. No evidence of apraxia or neglect. CN: II: PERRLA 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI, no nystagmus. Normal saccades. There is stable ptosis on the left. V: Sensation intact to LT. VII: Facial musculature activates symmetrically. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate rise symmetric. XI: Trapezius and SCM ___ bilaterally. XII: Tongue with tip deviated to L. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements. No asterixis. Strength ___ bilaterally. Sensory: No deficits to light touch, pinprick, vibratory sense, proprioception throughout. Reflexes: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Toes downgoing bilaterally Coordination: No intention tremor. No dysmetria onFNF or HKS bilaterally. Gait: Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Pertinent Results: CTA ___ ___ IMPRESSION: 1. Unremarkable unenhanced CT examination of the brain. 2. There is asymmetric fullness of the left base of tongue, which effaces the vallecula, without evidence for a discrete enhancing mass. This may represent denervation effect although underlying mass lesion is not entirely excluded. Direct visualization is recommended. 3. Essentially unremarkable CTA of the ___ and neck. MR ___ ___ IMPRESSION: 1. No evidence of acute infarct. No acute intracranial process. 2. White matter changes, which are nonspecific, but commonly seen in setting of small vessel ischemic disease. MR ___ ___ IMPRESSION: 1. Finding consistent with the left hypoglossal nerve palsy with enlargement of the tongue and effacement of the left vallecula, a finding which may be seen on prior CTA of the ___ and neck performed on ___. No solid lesions are noted. 2. This exam is not optimized for evaluation of the intracranial facial nerve. If there remains clinical concern, a dedicated ___ MRI, if there no contraindications may yield additional information. 3. The parotid glands are unremarkable. 4. Visualized brain is unremarkable. CXR ___ IMPRESSION: No previous images. The cardiac silhouette is mildly enlarged and there is tortuosity of the descending aorta. No acute pneumonia, vascular congestion, or pleural effusions. Surgical clips are seen in the with right axillary region. No evidence of hilar or mediastinal adenopathy or prominence of interstitial markings to radiographically suggest sarcoidosis. ___ 08:25AM BLOOD ALT-198* AST-120* LD(LDH)-239 CK(CPK)-299* AlkPhos-119* TotBili-0.4 ___ 08:25AM BLOOD Triglyc-87 HDL-71 CHOL/HD-2.2 LDLcalc-71 ___ 04:00PM BLOOD ___ * Titer-PND ___ 04:00PM BLOOD CRP-2.3 ___ 04:00PM BLOOD ANCA-NEGATIVE B Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO DAILY 2. Enalapril Maleate 20 mg PO BID 3. MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 7. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 8. Aspirin EC 81 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Calcium Carbonate 500 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 4. Multivitamins 1 TAB PO DAILY 5. Calcium Carbonate 500 mg PO DAILY 6. Enalapril Maleate 20 mg PO BID 7. Hydrochlorothiazide 25 mg PO DAILY 8. MetFORMIN XR (Glucophage XR) 2250 mg PO DAILY 9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY Discharge Disposition: Home Discharge Diagnosis: Tongue hypertrophy of unclear etiology Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CTA HEAD AND CTA NECK INDICATION: History: ___ with headache, left facial droop hx of speech difficulty // ? stroke vs other intracranial process 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 70 cc of Omnipaque intravenous contrast material. Images were processed on a separate workstation with display of curved reformats, 3D volume redendered images, and maximum intensity projection images. DOSE: DLP: 2230.62mGy-cm COMPARISON: None on PACS. FINDINGS: Head CT: There is no intra or extra-axial mass effect, acute hemorrhage or infarct. The gray-white differentiation is preserved. Sulci, ventricles and cisterns are within expected limits. The paranasal sinuses are clear. The orbits are unremarkable. The mastoid air cells and middle ear cavities are well pneumatized and clear. CTA head: There are symmetric approximately 1 mm outpouchings arising from the lateral aspect of the cavernous segments of the internal carotid artery (series 3, image 212 and 210) likely representing infundibulum. Mild atherosclerotic calcifications of the carotid siphons are noted. Otherwise, the ACA, MCA and their major branches are unremarkable. The intracranial vertebral arteries are normal in course and caliber, noting a dominant left vertebral artery. The remainder of the posterior circulation is unremarkable. Small bilateral posterior communicating arteries are noted. There are no intracranial aneurysms larger than 3 mm. CTA neck: The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses, . The distal cervical internal carotid arteries measure 7.7 mm in diameter on the left and 8.1 mm in diameter on the right. There is no significant stenosis is based on NASCET criteria. There is no evidence of aneurysm formation or other vascular abnormality. The visualized lung apices are clear. The thyroid glands are unremarkable. No osseous abnormalities. There is no cervical lymphadenopathy by CT size criteria. Visualized parotid and submandibular glands are unremarkable. Although evaluation of the oral cavity is slightly limited by beam hardening artifact from dental hardware, there appears to be asymmetric fullness of the left base of tongue which effaces the vallecula, contacting in the epiglottis. There does not appear to be and discrete enhancing lesion. Direct visualization/correlation is recommended. IMPRESSION: 1. Unremarkable unenhanced CT examination of the brain. 2. There is asymmetric fullness of the left base of tongue, which effaces the vallecula, without evidence for a discrete enhancing mass. This may represent denervation effect although underlying mass lesion is not entirely excluded. Direct visualization is recommended. 3. Essentially unremarkable CTA of the head and neck. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 6:02 ___, 60 minutes after discovery of the findings. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old woman with transient facial droop // stroke? TECHNIQUE: MRI of the brain is performed and includes the following sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair, axial diffusion weighted and axial gradient echo images . COMPARISON: CTA head and CTA neck of ___. FINDINGS: There is no intra or extra-axial mass, acute hemorrhage or infarct. Sulci, ventricles and cisterns are within expected limits. There are diffuse punctate and areas of more patchy periventricular and subcortical white matter nonspecific T2/FLAIR hyperintensities, which may be seen in setting of small vessel ischemic disease. The major flow voids are preserved. The paranasal sinuses are clear. The orbits are unremarkable. The mastoid air cells are clear. IMPRESSION: 1. No evidence of acute infarct. No acute intracranial process. 2. White matter changes, which are nonspecific, but commonly seen in setting of small vessel ischemic disease. Radiology Report EXAMINATION: MRI SOFT TISSUE NECK, W/O AND W/CONTRAST INDICATION: ___ year old woman with L facial swelling, possible transient L facial droop, increased salivation // Please evaluate parotids and L facial nerve coursing through gland TECHNIQUE: Sagittal T1 precontrast, axial T1 precontrast, axial T1 IDEAL pre and postcontrast contrast water, fat, in phase sequences, T2 pre contrast IDEAL water, fat and inphase sequences and coronal T1 post water IDEAL of the neck following administration of 6 cc Gadavist. COMPARISON: MR head without contrast ___, CTA head and neck of ___. FINDINGS: There is asymmetric T2 hyperintense signal and trace increased enhancement of the left tongue with enlargement of the left aspect of the tongue, which effaces the left vallecula. No evidence of mass lesion. The findings are suggestive of paralysis. The parotid glands are unremarkable. Incidental note is made of a nonpathologic appearing subcentimeter lymph node within the left parotid gland. The submandibular glands are also unremarkable. The remainder of the visualized aerodigestive tract is unremarkable. No cervical lymphadenopathy by size criteria. Visualized lung apex is clear. The thyroid glands are unremarkable. No osseous abnormalities. The visualized paranasal sinuses are clear. The orbits are unremarkable. The mastoid air cells are clear. IMPRESSION: 1. Finding consistent with the left hypoglossal nerve palsy with enlargement of the tongue and effacement of the left vallecula, a finding which may be seen on prior CTA of the head and neck performed on ___. No solid lesions are noted. 2. This exam is not optimized for evaluation of the intracranial facial nerve. If there remains clinical concern, a dedicated ___ MRI, if there no contraindications may yield additional information. 3. The parotid glands are unremarkable. 4. Visualized brain is unremarkable. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with hypoglossal palsy // Query sarcoid, TB, ANCA vasculitis, other process Query sarcoid, TB, ANCA vasculitis, other process IMPRESSION: No previous images. The cardiac silhouette is mildly enlarged and there is tortuosity of the descending aorta. No acute pneumonia, vascular congestion, or pleural effusions. Surgical clips are seen in the with right axillary region. No evidence of hilar or mediastinal adenopathy or prominence of interstitial markings to radiographically suggest sarcoidosis. Gender: F Race: BLACK/AFRICAN Arrive by WALK IN Chief complaint: Weakness, Headache Diagnosed with TRANS CEREB ISCHEMIA NOS, HYPERTENSION NOS, DIABETES UNCOMPL JUVEN temperature: 98.6 heartrate: 59.0 resprate: 15.0 o2sat: 100.0 sbp: 185.0 dbp: 76.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, You were hospitalized due to symptoms of L facial droop, L face swelling, and increased salivation. Your symptoms are not due to 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 strokes, we plan to modify those risk factors. Your risk factors are: Hypertension, hyperlipidemia, diabetes mellitus type 2 We are changing your medications as follows: Stop taking your statin medication (for cholesterol). Your liver tests were slightly elevated. Your PCP ___ this. Please take your other medications as prescribed. 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: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: LUQ/Epigastric abdominal pain x4 days Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with history of pancreas divisum and recurrent pancreatitis at one point necrotizing with pseudocyst formation status post pseudocyst gastrostomy in ___ who presents with abdominal pain. He reports that he was in his usual state of health until 4 days prior to admission, when he developed gradual-onset intermittent "throbbing" left upper quadrant/midepigastric pain, up to ___ in intensity and radiating occasionally to the ipsilateral back. He is unable to identify a clear precipitant, but does note that pain is exacerbated by oral intake of any kind, with accompanying nausea, or activity. Pain is reminiscent of prior pancreatitis-associated pain in quality and intensity, but in past episodes, pain was not localized primarily to the left abdomen, wrapping instead across the epigastrum. While he does experience acid reflux symptoms at baseline following gastrostomy, for which he takes omeprazole, he denies chronic abdominal pain. He consumes a mainly low-fat diet and avoids NSAIDs, alcohol, and recreational substances. He denies recent fevers, chills, sweats, vomiting, diarrhea, constipation, melena, hematochezia, travel, or sick contacts. He recalls that he last developed abdominal pain in ___, at which time he presented to an outside hospital and underwent abdominal CT, demonstrating persistent pseudocyst, but was not admitted. In regards to his history of pancreatitis, the patient was in good healthy until ___ when he was first hospitalized with with acute pancreatitis with a lipase > 15,000 and CT showing involvement of the head, neck, and uncinate process of the pancreas. Ultrasound did not show choledocholithiasis at that time. Subsequently, he was hospitalized ___ more times for recurrent pain with elevation of his lipase into the 100s. Based on review of notes in our system, the etiology of his recurrent pancreatitis is still unclear- he was a social drinker prior to first episode of pancreatitis but no heavy EtOH, no stones observed, IgG4 negative. Because stones possible etiology, he underwent a laproscopic cholecystectomy ___. After the procedure, he was discharged home but returned with continued abdomin pain and CT showed 12.1cm pseudocyst. He was re-admitted and treated with bowel rest, IVF, and IV analgesics and received 6wk TPN. Subsequent CT showed a necrotizing component as well. Therefore, on ___ the patient underwent pancreatic pseudocyst gastrostomy for necrotizing pancreatitis with associated pseudocyst. The patient reports that after this procedure, he has not had any additional hospitalizations. The patient reports that he last developed abdominal pain in ___, at which time he presented to an outside hospital ___ ___ Outpatient ___ walk in clinic) and underwent abdominal CT. Per patient report, the CT demonstrated a persistent pseudocyst, but he was not admitted at that time. The patient also had an EGD performed in ___ (___ Digestive ___ Ct), and he was told that there were no concerning findings. In the ED initial vital signs were as follows: 97.5, 58, 150/90, 17, 99% RA. Admission labs were notable for unremarkable CBC, Chem7, and LFTs, and lipase of 108. CT abdomen/pelvis was deferred, given benign abdominal exam and desire to avoid further radiation. He received a total of 2mg IV hydromorphone prior to transfer to the floor. On the floor, he is comfortable with minimal abdominal pain following opioid administration in the ED. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Pancreatitis, recurrent s/p laparoscopic cholecystectomy ___ and pseudocyst gastrostomy in ___ Afib with autoconversion Acid reflux ADHD Social History: ___ Family History: Grandparents (both maternal and paternal) required cholecystectomy for gall stone disease at an older age, Prostate cancer in mother's side, father has infrequent ___ Physical Exam: Admission Physical Exam: ======================== VITALS: 97.8, 154/90, 53, 18, 98% RA GENERAL: NAD HEENT: EOMI, PERRL 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, left upper quadrant/midepigastric tenderness without guarding/rebound, no CVAT EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge Physical Exam: ========================= VITALS: Tm98.1F Tc97.5F ___ 52-68 ___ 98-100%RA GENERAL: Well-appearing gentleman lying in bed, no acute distress HEENT: NCAT, PERRL, moist mucous membranes CARDIAC: RRR, S1/S2 clear and of good quality, no murmurs, rubs, or gallops LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably on room air without use of accessory muscles ABDOMEN: Normoactive BS, soft, non-distended, mild tenderness with deep palpation to midepigastric region / LUQ without rebound or guarding, no hepatosplenomegaly. Midline and laparaoscopic port scars from prior surgeries well-healed. EXTREMITIES: Warm and well perfused, 2+ ___ pulses bilaterally, no cyanosis, clubbing or edema SKIN: No rashes, excoriations or lesions Pertinent Results: Admission Labs: =============== ___ 10:05PM BLOOD WBC-8.8# RBC-5.21# Hgb-15.1# Hct-45.3# MCV-87 MCH-29.0 MCHC-33.4 RDW-12.3 Plt ___ ___ 10:05PM BLOOD Neuts-72.5* ___ Monos-5.7 Eos-2.1 Baso-0.8 ___ 05:03AM BLOOD ___ PTT-30.9 ___ ___ 10:05PM BLOOD Glucose-114* UreaN-10 Creat-1.0 Na-141 K-4.1 Cl-101 HCO3-29 AnGap-15 ___ 10:05PM BLOOD ALT-22 AST-27 AlkPhos-63 TotBili-1.0 ___ 10:05PM BLOOD Lipase-102* ___ 10:05PM BLOOD Albumin-4.8 ___ 05:03AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0 Discharge Labs: =============== ___ 05:03AM BLOOD WBC-7.8 RBC-5.04 Hgb-14.8 Hct-43.9 MCV-87 MCH-29.3 MCHC-33.7 RDW-12.4 Plt ___ ___ 05:03AM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-139 K-4.2 Cl-100 HCO3-32 AnGap-11 ___ 07:20AM BLOOD ALT-27 AST-22 AlkPhos-70 TotBili-1.4 ___ 07:20AM BLOOD Lipase-41 ___ 05:03AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0 Studies: ======= MCRP ___: 1. Pancreatic duct stricture at the pancreatic neck, likely at the site of prior cystgastrostomy, with distal pancreatic duct dilatation. Recommend ERCP 2. Mild hepatic steatosis, predominantly surrounding the porta hepatis. 3. Portal venous confluence/ superior SMV appears slit-like and there is a large collateral vein seen adjacent to it. Radiology Report EXAMINATION: MRCP (MR ___ INDICATION: ___ year old man with pancreatic divism with history of necrotizing pancreatitis complicated by pseudocyst s/p cystogastrostomy now admitted with recurrent pancreatitis // Eval for biliary strictures and to eval the cystogastrostomy TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the abdomen 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. 1 mL Gadavist mixed with 50 mL water was also administered for oral contrast. COMPARISON: Reference abdominal CT on ___. FINDINGS: The lung bases are grossly clear. There is no ascites. Liver: There is heterogeneous fatty deposition seen in the liver, predominantly surrounding the porta hepatis. There are no suspicious hepatic lesions identified. There is no significant intra or extrahepatic biliary ductal dilatation. Gallbladder: The gallbladder is normal. There is no evidence of choledocholithiasis. Pancreas: The pancreatic neck body and tail are uniformly T1 hypointense, consistent with chronic pancreatitis due to duct obstruction. Additionally, there is mild peripancreatic edema consistent with acute pancreatitis. There is no peripancreatic fluid identified. Distal to the pancreatic neck there is pancreatic ductal dilatation throughout the body and tail including side branches as well as duct wall thickening. The duct is seen tapering and a point in the pancreatic neck likely at the site were the duct formerly emptied into the pseudocyst/ at the site of prior cystgastrostomy. Spleen: The spleen is normal in appearance. Kidneys and Adrenals: The adrenal glands are normal bilaterally. There is a subcentimeter cyst in the lower pole of the left kidney. No suspicious renal lesions are identified. Bowel: The visualized bowel loops and mesentery are within normal limits. Lymph Nodes: There is no significant mesenteric or retroperitoneal lymphadenopathy. Vessels: The aorta and its visualized branches are patent. The portal venous confluence/superior SMV appears slit-like and there is a large collateral vein seen adjacent to it. Bones: The osseous structures are unremarkable. IMPRESSION: 1. Pancreatic duct stricture at the pancreatic neck, likely at the site of prior cystgastrostomy or just upstream from it, with upstream pancreatic duct dilation. Recommend ERCP for further evaluation and possible stenting. 2. Mild hepatic steatosis, predominantly surrounding the porta hepatis. 3. Portal venous confluence, superior SMV, and medial splenic vein appear slit-like and there are large collateral veins in the porta hepatis. Gender: M Race: UNKNOWN Arrive by WALK IN Chief complaint: Abd pain Diagnosed with ACUTE PANCREATITIS temperature: 97.5 heartrate: 58.0 resprate: 17.0 o2sat: 99.0 sbp: 150.0 dbp: 90.0 level of pain: 10 level of acuity: 3.0

Dear Mr. ___, You were admitted for abdominal pain that is due to pancreatitis. During this admission, you were treated with bowel rest, IV fluids, and pain medications until the inflammation in your pancreas decreased and you were able to tolerate food intake. The MRI of your abdomen (MRCP) showed that you have a stricture near your pancreas, so you should follow-up with your outpatient gastroenterologist in the next few weeks for further work-up and evaluation. Thank you for letting us participate in your care! Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary angiogram s/p DES to LCx (___) History of Present Illness: ___ is an ___ year old women with ischemic cardiomyopathy, distant proximal LAD stenting, atrial fibrillation, CKD, diabetes, and hypertension who is presenting with a 1 day history of chest pain, now admitted with an NSTEMI. Patient was in her usual state of health until this morning when she suddenly developed left upper chest discomfort while reading the newspaper. This was an intense stabbing sensation, 10 out of 10, and there was associated dyspnea. There were two episodes of this severe pain, each lasting ___ minutes, she took a nitro x 2 with little to no relief and then called an ambulance. At some point in the ED the pain went away and the breathing improved. In the ED she presented with vitals signs of 97.5 80 136/84 20 100% RA. She appeared diaphoretic and uncomfortable. Serial EKGs did not show any ST elevations, just evidence of an old anterior infarct with a rhythm of sinus vs. junctional. Labs were notable for a rising troponin to 0.21, an elevated BNP to 4597, and a stably elevated BUN/SCr. Her UA had pyuria, CXR with moderate cardiomegaly, CTA showed no PE, no pericardial effusion, and no aortic abnormality. She was given an aspirin load in addition to doxycycline and ceftriaxone to treated both a cellulitis and a UTI. REVIEW OF SYSTEMS Notable for requiring 2L of home oxygen, chronic urinary incontinence, and chronic lower extremity wounds. Past Medical History: HTN Hypercholestrolemia Hypothyroidism MI ___ - acute anterior MI. At CATH, she has a right dominant system. The left main was free of any lesions. The LAD had discrete 99% lesion in the proximal segment that was stented to 0% residual. The left circumflex coronary artery had a discrete 80% lesion. The right coronary artery had a mid 35% lesion and a proximal 40% lesion. LVEF: 50% (___) Coronary angioplasty w/ ___ reflux CKD Stage III CHF w/ normal EF RLD ___ obesity Sleep apnea Asthma Arthritis Stress incontinence Social History: ___ Family History: Both parents passed away from ___. Family history of diabetes. Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vitals: 98.2 154/73 60 20 94 RA Last weight ___ 167 pounds (was 183 pounds ___ Gen: comfortable, laying flat speaking in full sentances Neck: JVP difficult to assess given obesity Chest: lungs clear bilaterally CV: RRR, S1S2, no MRG Abd: soft, NTND GU: wearing an adult diaper Ext: warm, mild pitting in legs, pink erythema to left shin with overlying scale, non tender to touch DISCHARGE PHYSICAL EXAM ======================== ___ 0535 Temp: 97.8 PO BP: 147/58 HR: 55 RR: 18 O2 sat: 96% O2 delivery: RA Fluid Balance (last updated ___ @ 528) Last 8 hours Total cumulative 0ml IN: Total 0ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative 599ml IN: Total 600ml, PO Amt 600ml OUT: Total 1ml, Urine Amt 1ml GEN: Sitting up in chair, NAD LUNGS: CTAB in bilateral posterior fields CV: RRR, normal S1/S2, no m/g/r EXT: trace edema b/l ___ to mid-calf. venous stasis changes bilaterally. Warm. Pertinent Results: ADMISSION LABS =============== ___ 10:40AM BLOOD WBC-8.5 RBC-3.47* Hgb-10.2* Hct-33.5* MCV-97 MCH-29.4 MCHC-30.4* RDW-16.5* RDWSD-58.7* Plt ___ ___ 10:40AM BLOOD Neuts-83.3* Lymphs-10.1* Monos-4.5* Eos-1.3 Baso-0.4 Im ___ AbsNeut-7.11* AbsLymp-0.86* AbsMono-0.38 AbsEos-0.11 AbsBaso-0.03 ___ 10:40AM BLOOD ___ PTT-37.4* ___ ___ 10:40AM BLOOD Glucose-315* UreaN-82* Creat-1.5* Na-141 K-4.4 Cl-99 HCO3-24 AnGap-18 ___ 10:40AM BLOOD CK-MB-3 proBNP-4597* ___ 10:40AM BLOOD cTropnT-0.04* ___ 03:46PM BLOOD cTropnT-0.13* ___ 08:00PM BLOOD cTropnT-0.21* ___ 06:19AM BLOOD CK-MB-6 cTropnT-0.25* ___ 03:40PM BLOOD CK-MB-4 cTropnT-0.19* ___ 06:19AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.8 ___ 04:03PM URINE Color-Straw Appear-Hazy* Sp ___ ___ 04:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 04:03PM URINE RBC-2 WBC-145* Bacteri-FEW* Yeast-NONE Epi-1 ___ 04:03PM URINE CastHy-2* ___ 04:03PM URINE Mucous-RARE* DISCHARGE LABS =============== IMAGING ======== CXR (___) -------------- IMPRESSION: Cardiomegaly without superimposed acute cardiopulmonary process. CTA CHEST (___) ------------------- IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. RIGHT KNEE X-RAYS (___) IMPRESSION: Tricompartmental osteoarthritis with a small right knee joint effusion. No fractures, lytic or blastic bone lesions identified. RIGHT KNEE ASPIRATION (___) GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. DISCHARGE LABS: ___ 06:54AM BLOOD WBC-8.3 RBC-3.07* Hgb-9.1* Hct-29.4* MCV-96 MCH-29.6 MCHC-31.0* RDW-16.0* RDWSD-56.0* Plt ___ ___ 06:54AM BLOOD Plt ___ ___ 06:54AM BLOOD ___ PTT-36.4 ___ ___ 06:54AM BLOOD Glucose-86 UreaN-116* Creat-1.6* Na-134* K-4.8 Cl-97 HCO3-23 AnGap-14 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Warfarin 2.5 mg PO DAILY16 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Losartan Potassium 25 mg PO BID 4. Torsemide 60 mg PO QAM 5. Gabapentin 100 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Omeprazole 40 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. Oxybutynin XL (*NF*) 10 mg Other DAILY 12. amLODIPine 2.5 mg PO DAILY 13. Torsemide 40 mg PO QPM 14. Calcium Carbonate 500 mg PO DAILY 15. Glargine 17 Units Dinner Insulin SC Sliding Scale using HUM Insulin 16. Acetaminophen w/Codeine 1 TAB PO QHS Discharge Medications: 1. Aspirin EC 81 mg PO DAILY Duration: 2 Days stop taking on ___ RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*2 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Colchicine 0.3 mg PO DAILY RX *colchicine 0.6 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*15 Tablet Refills:*0 4. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine [Lidoderm] 5 % 1 patch QAM Disp #*30 Patch Refills:*0 5. Glargine 26 Units Dinner Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR 4 units before breakfast, 4 units before lunch, 4 units before dinner Disp #*2 Syringe Refills:*0 6. Acetaminophen w/Codeine 1 TAB PO QHS 7. amLODIPine 2.5 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Calcium Carbonate 500 mg PO DAILY 10. Gabapentin 100 mg PO DAILY 11. Levothyroxine Sodium 150 mcg PO DAILY 12. Magnesium Oxide 400 mg PO DAILY 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Omeprazole 40 mg PO DAILY 16. Oxybutynin XL (*NF*) 10 mg Other DAILY 17. Torsemide 60 mg PO QAM 18. Torsemide 40 mg PO QPM 19. Warfarin 2.5 mg PO DAILY16 20. HELD- Losartan Potassium 25 mg PO BID This medication was held. Do not restart Losartan Potassium until you follow-up with your doctor in 1 week 21.Outpatient Lab Work N17: Acute kidney injury Please check chemistry-7, calcium, magnesium, and phosphorus on ___. Please fax results to Pt's cardiologist ___, ___ and PCP ___, ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Non ST segment elevation myocardial infarction SECONDARY DIGANOSES ==================== Heart failure with preserved ejection fraction Gout Atrial fibrillation Acute kidney injury 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: ___ year old woman with sudden onset chest pain// eval PTX TECHNIQUE: Single portable view of the chest. COMPARISON: Chest x-ray from ___. FINDINGS: Moderate cardiomegaly is unchanged. The lungs remain clear without consolidation. No obvious effusion noting that the right costophrenic angles excluded from the field of view. No pneumothorax. No acute osseous abnormalities. IMPRESSION: Cardiomegaly without superimposed acute cardiopulmonary process. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with sudden onset chest pain in left upper chest// eval dissection 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 5.0 s, 0.5 cm; CTDIvol = 30.4 mGy (Body) DLP = 15.2 mGy-cm. 2) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 16.3 mGy (Body) DLP = 485.1 mGy-cm. Total DLP (Body) = 500 mGy-cm. COMPARISON: None 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. Mild cardiomegaly. The pericardium, and great vessels are within normal limits. No pericardial effusion is seen. Coronary artery calcifications and probable stent are noted. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: There is trace left pleural effusion. No right pleural effusion or pneumothorax. LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. There is mild lower lobe bronchiolectasis. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Limited sections through the upper abdomen demonstrate a 2.3 x 1.4 cm, indeterminate nodule on the current exam but previously characterized as an adenoma. A punctate calcification is noted in the anterior aspect of the perihepatic space. BONES: No suspicious osseous abnormality is seen.? Multilevel degenerative changes noted. There is no acute fracture. CHEST WALL: Surgical clips noted in the right breast. IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Radiology Report EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT INDICATION: ___ year old woman with sudden onset severe knee pain// Cause of patient's severe knee pain? TECHNIQUE: Frontal, lateral, and sunrise view radiographs of right knee joint COMPARISON: None FINDINGS: There is mild diffuse demineralization. Decrease in tibiofemoral and patellofemoral joint compartment spaces with marginal osteophytosis noted. There is cortical thickening of the proximal shaft of the right fibula, possibly related to a chronic injury. Small right knee joint effusions seen. No fractures, lytic or blastic bone lesions identified. Extensive atherosclerotic calcification is seen projecting around the right knee joint. IMPRESSION: Tricompartmental osteoarthritis with a small right knee joint effusion. No fractures, lytic or blastic bone lesions identified. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Chest pain Diagnosed with Chest pain, unspecified temperature: 97.5 heartrate: 80.0 resprate: 20.0 o2sat: 100.0 sbp: 136.0 dbp: 84.0 level of pain: 5 level of acuity: 2.0

Dear Ms. ___, It was a pleasure taking care of you here at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted because you had chest pain, and you were found to be having a heart attack. WHAT WAS DONE WHILE I WAS HERE? - You underwent a procedure called a coronary angiogram. This looked at your heart vessels, and it found that you had a few blockages. The biggest blockage was opened up with a stent. - You were given antibiotics for a urinary tract infection. - You were given medications to protect your heart. - You were seen by our Rheumatology team for your right knee pain. They thought that your right knee pain was because of gout. You were treated with a medicine called colchicine for your gout. WHAT DO I NEED TO DO ONCE I LEAVE? - Please take all of your medications as prescribed. It is very important that you take your aspirin, Plavix, and warfarin every day. On ___, you will stop taking your aspirin. It is very important that you continue to take your Plavix and warfarin every day after that and do not stop either of them unless your cardiologist Dr. ___ you to. - Please keep all of your appointments. - If you have any questions or concerning symptoms arise such as chest pain or shortness of breath, please call the ___ Heartline at ___ to speak to a cardiologist. - Your weight was 175.5 pounds on the day you left the hospital. Reach out to your doctor if your weight goes up by 3 pounds. - DO NOT take your losartan (blood pressure medicine) until you follow up with your primary care doctor and have your kidney numbers re-checked. Be well, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Sigmoid colectomy, then sigmoid colostomy and closure distal stump. ___: Decompressive laparotomy, evacuation of intraperitoneal clot, abdominal washout, packing, VAC placement. ___: Reopening of recent laparotomy. Removal of packs, washout, and abdominal closure. History of Present Illness: This patient is a ___ year old male who complains of abdominal distention. this patient went to an outside hospital earlier today because of ___ days of gradually increasing abdominal distention without much pain. He has had a fair amount of constipation as well. No fevers or chills. He has a history of a ventral hernia repair. No cardiopulmonary symptoms. No urinary tract symptoms. At the outside hospital, he was found to have a large sigmoid volvulus, got 500 mg of Flagyl and 1 g of Rocephin and transferred here. He has severe rheumatoid arthritis. Past Medical History: PAST MEDICAL HISTORY: 1. Rheumatoid arthritis (he has not seen a rheumatologist in ___ years). 2. Chronic splenomegaly. 3. Osteopenia. 4. BPH. 5. Hiatus hernia. 6. Allergic rhinitis. 7. Overactive bladder. 8. Frozen shoulder status post fall. PAST SURGICAL HISTORY: 1. Status post appendectomy. 2. Status post cataract surgery. 3. Status post hernia repair. Social History: ___ Family History: FAMILY HISTORY: No polycythemia. Physical Exam: Admission Physical Exam: VS: 97.2 88 107/56 16 94% RA Gen: NAD CV: RRR Resp: comfortable on room air GI: marked abdominal distension, tympanitic, TTP diffusely, no guarding, no peritonitis Extrem: WWP Discharge Physical Exam: VS: T: 98.3, BP: 130/56, HR: 84, RR: 18, O2: 96% RA GEN: A+Ox3, NAD HEENT: atraumatic CV: RRR PULM: coarse rhonchi b/l, symmetric excursion, no acute respiratory distress GI: midline incision with steri-strips OTA, some erythema near inferior portion of wound, no drainage from midline, no induration. Reactive erythema from prior staples. Abd soft, non-distended, non-tender to palpation EXT: warm, well-perfused, no edema b/l Pertinent Results: IMAGING: ___: Portable Abdomen X-ray: Interval placement of rectal tube. Multiple dilated colonic loops, small bowel loops, mildly improved since prior. Previously seen dilated loop of sigmoid has resolved. Degenerative changes spine. Arterial calcifications. IMPRESSION: Mild improvement since prior. PATHOLOGY: ___: 1. Colon, sigmoid, resection: - Colon with transmural hemorrhagic infarction; ischemic changes extend to one specimen margin. 2. Hernia sac and contents: - Consistent with hernia sac. 3. Omentum, resection: - Fibroadipose tissue with congestion and acute serositis. ___: Chest Port Line Placement: In comparison with study of ___, this and placement of right IJ catheter that extends to the right atrium. No evidence of post procedure pneumothorax. Otherwise little change in the appearance of the heart and lungs and the significantly dilated loops of bowel in the abdomen. ___: Cest Port Line Placement: No definite change compared 1 day earlier. CHF findings may be slightly improved. Tip of the ET tube is unchanged, but difficult to confirm on the current film. Please see comments above. ___: EKG: Probable atrial tachycardia with 2:1 conduction. Non-specific inferolateral T wave flattening. Poor R wave progression. No previous tracing available for comparison. ___: Portable Abdomen x-ray: Multiple dilated loops of bowel measuring up to 7.7 cm, may represent ileus or bowel obstruction. ___: ECHO: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. ___: EKG: Probable sinus tachycardia with premature atrial beats in a trigeminal pattern. Poor R wave progression. Low QRS voltages in the limb leads. Compared to tracing #1 atrial trigeminy is present. The QRS changes in leads V3-V5 are probably due to lead placement. ___: KUB: No signs of retained surgical sponge. ___: Chest Port Line Tube: In comparison the earlier study of this date, the tip of the endotracheal tube now measures approximately 4.5 cm above the carina. Other monitoring support devices are unchanged. Continued opacification at the left base silhouetting the hemidiaphragm, consistent with substantial volume loss in left lower lobe and small layering pleural effusion. The right lung is essentially unchanged. ___: EKG: Atrial flutter, probably typical. Low limb lead voltage. Somewhat late R wave progression. Other ST-T wave abnormalities. No previous tracing available for comparison. ___: CXR: Comparison to ___. Stable appearance of the right hemithorax. Minimally improved ventilation of the left lung bases, with a decrease in extent and severity of the pre-existing left lower lobe atelectasis and a decrease in severity of the left pleural effusion. No new focal parenchymal changes. Stable correct position of the monitoring and support devices. ___: CXR: Compared to chest radiographs ___ through ___. Heterogeneous opacification has developed in the right lung, worsened on the left. Some of this is due to increasing pleural effusion, particularly in the left hemithorax, but the bilateral nature of the abnormality suggests pulmonary edema. Careful follow-up is recommended following attempts to improved hemodynamic status because of the possibility of on alternative explanation in bilateral pneumonia. No pneumothorax. Nasogastric drainage tube passes through nondistended stomach to the proximal duodenum. ___: Chest Port Line/Tube: Dobhoff tube tip isin the stomach. No other interval change from prior study. ___: CXR (PA&LAT): Pleural effusions. Basilar atelectasis. Pulmonary edema. ___: CT Abdomen/Pelvis: Areas of wall thickening involving large bowel, may be reactive, consider colitis. Major abdominal arteries, veins are patent. Few foci of air in the pelvis may be postsurgical, there is adjacent mild linear areas of enhancement, no organized fluid collection. Residual infection cannot be excluded, if patient does not improve clinically, follow-up exam recommended to exclude development of an abscess. Moderate ascites. Multiple dilated small bowel loops in the low abdomen, pelvis, with gradual transition point, more likely represent adynamic ileus than obstruction. 10 mm hypoattenuating nodule within the right adrenal gland is indeterminate. Further evaluation with CT adrenal protocol or MRI may be helpful. Bilateral pleural effusions, atelectasis. Indeterminate lesion lower pole left kidney, renal ultrasound recommended. Indeterminate retroperitoneal lymph nodes. RECOMMENDATION(S): If the patient is low risk by ___ ___ guidelines (minimal or absent history of smoking or other known risk factors for primary lung neoplasm), recommend follow-up dedicated chest CT at 12 months and if no change, no further imaging needed. If the patient is high risk by ___ ___ guidelines (history of smoking or other known risk factors for primary lung neoplasm), recommend initial follow-up chest CT at ___ months and then at ___ months if no change. ___: VIDEO OROPHARYNGEAL SWALLOW: Penetration without aspiration. Moderate-severe pharyngeal weakness. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. ___: CT Chest: Penetration without aspiration. Moderate-severe pharyngeal weakness. Please refer to the speech and swallow division note in ___ for full details, assessment, and recommendations. ___: CYTOLOGY: SPECIMEN(S) SUBMITTED: PLEURAL FLUID, right pleural effusion DIAGNOSIS: Pleural fluid, right: NEGATIVE FOR MALIGNANT CELLS. - Mesothelial cells, lymphocytes, and histiocytes. SPECIMEN DESCRIPTION: Received: 1000 ml, cloudy, yellow fluid.and 1 heme slide. The cytospin slide, prepared in Hematology, is labeled ___ Prepared: 1 cytospin, 1 monolayer, 1 cell block ___: CYTOLOGY: SPECIMEN(S) SUBMITTED: PLEURAL FLUID, left pleural effusion DIAGNOSIS: Pleural fluid, left: NEGATIVE FOR MALIGNANT CELLS. - Mesothelial cells, lymphocytes and histiocytes. SPECIMEN DESCRIPTION: Received: 800 ml, yellow, clear fluid.and 1 heme ___: CXR: In comparison with the study of ___, following thoracentesis there is no evidence pneumothorax. Otherwise, little overall change except for improved degree of inspiration. ___: CT Abdomen/Pelvis: 1. No organized fluid collection. Persistent but mild decrease in fluid in the left hemipelvis containing likely Surgicel (versus locules of air) with associated mild peritoneal thickening. 2. Persistent, but decreased small volume ascites. 3. Decrease bilateral pleural effusions. 4. Indeterminate left lower pole renal lesion, nonemergent renal ultrasound can be obtained for further characterization. 5. Splenomegaly and retroperitoneal lymphadenopathy, of uncertain significance. RECOMMENDATION(S): Nonemergent renal ultrasound LABS: ___ 06:50PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 06:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG ___ 06:50PM URINE RBC-41* WBC-5 BACTERIA-FEW YEAST-NONE EPI-0 ___ 06:50PM URINE HYALINE-42* ___ 06:50PM URINE MUCOUS-RARE ___ 05:09PM LACTATE-1.6 ___ 04:50PM GLUCOSE-134* UREA N-28* CREAT-1.1 SODIUM-134 POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-19* ANION GAP-19 ___ 04:50PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.9 ___ 04:50PM WBC-35.6* RBC-5.09 HGB-14.6 HCT-44.8 MCV-88 MCH-28.7 MCHC-32.6 RDW-16.4* RDWSD-52.4* ___ 04:50PM NEUTS-94.3* LYMPHS-0.8* MONOS-2.8* EOS-0.0* BASOS-0.2 IM ___ AbsNeut-33.58* AbsLymp-0.27* AbsMono-0.98* AbsEos-0.01* AbsBaso-0.08 ___ 04:50PM PLT COUNT-232 ___ 04:50PM ___ PTT-29.7 ___ MICRO: ___ 9:17 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:30 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:24 pm PLEURAL FLUID LEFT PLEURAL EFFUSION. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 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. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 2:22 pm PLEURAL FLUID RIGHT PLEURAL EFFUSION. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 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. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 5:00 pm STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). ___ 10:59 am URINE Source: Catheter. URINE CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S TOBRAMYCIN------------ <=1 S Medications on Admission: Omeprazole 20mg daily Doxazosin 8mg daily Finasteride 5mg daily Oxybutynin 5mg daily ASA 81 daily Iron 325 daily Flaxseed oil 1000mg daily Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days 3. Docusate Sodium 100 mg PO BID please hold for loose stool 4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 5. Glucose Gel 15 g PO PRN hypoglycemia protocol 6. Heparin 5000 UNIT SC TID 7. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using HUM Insulin 8. Metoprolol Tartrate 12.5 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Ramelteon 8 mg PO QHS:PRN Sleep (if pt having difficulty sleeping) 11. RisperiDONE (Disintegrating Tablet) 0.5 mg PO BID to Rehab: not a home medicine. Please consider weaning at discretion 12. Senna 8.6 mg PO BID:PRN constipation 13. Doxazosin 8 mg PO DAILY 14. Omeprazole 20 mg PO DAILY 15. Oxybutynin 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Sigmoid volvulus, necrotic sigmoid colon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid Followup Instructions: ___ Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with new CVL// CVL placement Surg: ___ (ex lap) Contact name: ___: ___ CVL placement IMPRESSION: In comparison with study of ___, this and placement of right IJ catheter that extends to the right atrium. No evidence of post procedure pneumothorax. Otherwise little change in the appearance of the heart and lungs and the significantly dilated loops of bowel in the abdomen. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p Hartmans// postop, evaluate ETT postop, evaluate ETT IMPRESSION: Compared to chest radiographs ___ and ___, most recently 09:59. New ET tube in standard placement. Nasogastric drainage tube ends in the intrathoracic stomach, partially decompressed and now containing more fluid. Severe colonic distention has worsened. Bibasilar pulmonary consolidation is more severe, could be atelectasis alone. Small left pleural effusion is larger. No pneumothorax. Heart size normal. Upper lungs show vascular engorgement and probable mild edema. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old man with line repositioning// line place Contact name: ___: ___ FINDINGS: ET tube tip lies approximately 5.6 cm above the carina. NG tube is similar configuration. However, the left hemidiaphragm gastric fundus are not well delineated making it difficult to confirm its position. Prior study suggested that it was in an elevated left hemidiaphragm. Right subclavian PICC right right IJ line tip overlies the SVC/RA junction. No pneumothorax is detected. There is dense retrocardiac density consistent with left lower lobe collapse and/or consolidation, but the possibility elevated left hemidiaphragm cannot be excluded. Platelike atelectasis at the right base. Mild vascular plethora, though this is likely accentuated by low lung volumes. Doubt overt CHF. No right-sided effusion. Small left effusion cannot be excluded. Distended loops of bowel seen in the upper abdomen are similar to the prior study. No free air is identified beneath the diaphragm. Old healed right-sided rib fracture noted. IMPRESSION: No definite change compared 1 day earlier. CHF findings may be slightly improved. Tip of the ET tube is unchanged, but difficult to confirm on the current film. Please see comments above. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ET tube TECHNIQUE: Chest x-ray from ___ at 23:52 FINDINGS: Inspiratory volumes are low. The ET tube tip lies approximately 3.3 cm above the carina. An NG tube is present, but loops, such that the tip overlies the cardiac silhouette--question reflecting the presence of a hiatal hernia. Right IJ central line tip overlies distal SVC/RA junction. No pneumothorax is detected. There is increased retrocardiac density consistent with left lower lobe collapse and/or consolidation and a probable small to moderate left effusion. There is subsegmental atelectasis at the right lung base. No gross right effusion. Prominent air-filled loops of small and large bowel are noted. Although very prominent, they not meet formal criteria for dilatation. IMPRESSION: Left lower lobe collapse and/or consolidation and small to moderate size left effusion., Without gross change compared with ___. Atypical configuration of the NG tube suggests presence of a hiatal hernia. Prominent air-filled loops of bowel in the abdomen again noted. Radiology Report INDICATION: ___ year old man with severe abdominal distension// ? ileus TECHNIQUE: Portable AP supine abdominal radiograph. COMPARISON: CT abdomen pelvis from outside hospital dated ___. FINDINGS: Right lateral hemiabdomen is excluded from the field of view limiting evaluation. Interval removal of previously seen rectal tube. Multiple metallic staples project over the midline of the lower abdomen. Multiple metallic coils projecting over the mid abdomen related to prior ventral hernia repair. There are multiple dilated loops of large and small bowel, the largest of which measures up to 7.7 cm in the left upper quadrant. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Multiple dilated loops of bowel measuring up to 7.7 cm, may represent ileus or bowel obstruction. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with sigmoid volvulus s/p ___, intubated// Interval change Interval change IMPRESSION: Compared to chest radiographs ___ through ___. Lung volumes have improved. Nevertheless left lower lobe is probably still collapsed. Moderate atelectasis has developed on the right as well. Small left pleural effusion is stable. Heart size normal. No pneumothorax. Indwelling cardiopulmonary support devices in standard placements. Radiology Report INDICATION: Question retained surgical instrument COMPARISON: Prior dated ___ FINDINGS: Two views of the abdomen/pelvis provided, patient positioned supine. A third image depicting surgical sponge also provided. A nasogastric tube is seen extending into the right upper abdomen. Mesh projects over the midabdomen. There is no evidence of retained surgical sponge. Gaseous distention of bowel noted. IMPRESSION: No signs of retained surgical sponge. Findings were discussed with Dr. ___ at the time of this dictation. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ with sigmoid volvulus, s/p GI decompression, plan for sigmoidectomy this admission// advanced ET tube advanced ET tube IMPRESSION: In comparison the earlier study of this date, the tip of the endotracheal tube now measures approximately 4.5 cm above the carina. Other monitoring support devices are unchanged. Continued opacification at the left base silhouetting the hemidiaphragm, consistent with substantial volume loss in left lower lobe and small layering pleural effusion. The right lung is essentially unchanged. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ p/w sigmoid volvulus s/p GI decompression followed by hartmanns and delayed abdominal closure left intubated// ?interval change, ?fluid overload ?interval change, ?fluid overload IMPRESSION: Comparison to ___. Stable appearance of the right hemithorax. Minimally improved ventilation of the left lung bases, with a decrease in extent and severity of the pre-existing left lower lobe atelectasis and a decrease in severity of the left pleural effusion. No new focal parenchymal changes. Stable correct position of the monitoring and support devices. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p open hartmanns with left lower atelectasis and effusion// interval change interval change IMPRESSION: Compared to chest radiographs ___ through ___. Heterogeneous opacification has developed in the right lung, worsened on the left. Some of this is due to increasing pleural effusion, particularly in the left hemithorax, but the bilateral nature of the abnormality suggests pulmonary edema. Careful follow-up is recommended following attempts to improved hemodynamic status because of the possibility of on alternative explanation in bilateral pneumonia. No pneumothorax. Nasogastric drainage tube passes through nondistended stomach to the proximal duodenum. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS INDICATION: ___ year old man with new dobhoff placement// assess dobhoff placement TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Dobhoff tube tip isin the stomach. No other interval change from prior study. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man ___ s/p ___ for sigmoid volvulus with persistent leukocytosis// please assess for atelectasis vs consolidation TECHNIQUE: Chest two views COMPARISON: ___ FINDINGS: Feeding tube tip is in the proximal stomach, similar to prior. Stable heart size. Mildly improved pulmonary vascularity. Stable pulmonary edema. Left lower lobe consolidation, likely atelectasis. Mild pleural effusions are stable. Few distended bowel loops in the upper abdomen, which are centralized in location, suggestive of ascites. No pneumothorax. IMPRESSION: Pleural effusions. Basilar atelectasis. Pulmonary edema. Radiology Report EXAMINATION: CT abdomen and pelvis with contrast. INDICATION: ___ with sigmoid volvulus, with necrotic sigmoid on ex-lap, now s/p ___ s/p decompressive laparotomy, clot evac, closed ___ now with rising WBC// ?infectious source (PO contrast through dobhoff) 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) Spiral Acquisition 3.4 s, 54.2 cm; CTDIvol = 15.6 mGy (Body) DLP = 843.2 mGy-cm. 2) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP = 18.2 mGy-cm. Total DLP (Body) = 861 mGy-cm. COMPARISON: CT abdomen pelvis from outside hospital dated ___. FINDINGS: LOWER CHEST: A 3 mm pulmonary nodule is present in the right middle lobe. Bilateral mild-to-moderate pleural effusions, right greater than left, with associated compressive atelectasis, with significant volume loss in the left lower lobe, and mild volume loss in the right lower lobe, lingula. ABDOMEN: Positioning of the arms across the upper abdomen causes significant streak artifact limiting evaluation of the upper abdomen. HEPATOBILIARY: Multiple hypoattenuating varying size lesions are scattered throughout the liver, some of which are too small to accurately characterize but likely represent cysts. Focal enhancement within hepatic segment 6 (02:35) is connects to a branch of portal ___ represent portal venous shunt., measuring 2.1 cm.. Otherwise, the liver demonstrates homogenous attenuation throughout. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is decompressed. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Moderate splenomegaly measuring up to 14 cm in the axial plane. No focal lesion is identified within the splenic parenchyma. ADRENALS: 10 mm hypoattenuating nodule within the right adrenal gland(02:30) is indeterminate. Left adrenal gland is normal. URINARY: Bilateral hypoattenuating structures are present in both kidneys, the largest of which measures up to 1.8 cm at the interpolar region of the right kidney. An exophytic structure at the lower pole of the left kidney measures 3.2 x 1.9 cm with an internal attenuation 35 ___ represent proteinaceous or hemorrhagic cyst. Renal ultrasound recommended. Otherwise, the kidneys are of normal and symmetric size with normal nephrogram. There is no perinephric abnormality. GASTROINTESTINAL: An enteric tube is present with the tip in the very proximal stomach, just past GE junction. There is large esophageal hiatal hernia, with nearly intrathoracic stomach as seen on prior. Patient is post sigmoid colectomy with sigmoid colostomy and creation of ___ pouch. Multiple prominent loops small bowel measuring up to 3.2 cm, without definite transition point identified. This finding likely reflects postoperative ileus or less likely a developing small bowel obstruction. There is mucosal enhancement and mild mural thickening of the ascending colon. The appendix is surgically absent. A rectal tube is present. There is moderate volume ascites. Free fluid in the pelvis is complex, there is mild enhancement about the surgical bed, few foci of air, findings may be postoperative, developing infection cannot be excluded. If patient does not improve clinically, follow-up scan could be obtained to exclude development of an abscess. There is presacral fluid edema, with some complex contents along the right margin series 2, image 77, which may represent prominent venous enhancement; there is no organized presacral fluid. PELVIS: Mild is circumferential thickening of the urinary bladder. Moderate volume intraperitoneal ascites. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: Few borderline retroperitoneal periaortic lymph nodes are stable since prior, largest measures 1.3 cm, indeterminate.. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Stable appearance of L2-L3 vertebral bodies. SOFT TISSUES: There is diffuse anasarca. Multiple surgical clips overlying the mid abdomen are related to recent surgery. Small fat only containing bilateral inguinal hernias. IMPRESSION: Areas of wall thickening involving large bowel, may be reactive, consider colitis. Major abdominal arteries, veins are patent. Few foci of air in the pelvis may be postsurgical, there is adjacent mild linear areas of enhancement, no organized fluid collection. Residual infection cannot be excluded, if patient does not improve clinically, follow-up exam recommended to exclude development of an abscess. Moderate ascites. Multiple dilated small bowel loops in the low abdomen, pelvis, with gradual transition point, more likely represent adynamic ileus than obstruction. 10 mm hypoattenuating nodule within the right adrenal gland is indeterminate. Further evaluation with CT adrenal protocol or MRI may be helpful. Bilateral pleural effusions, atelectasis. Indeterminate lesion lower pole left kidney, renal ultrasound recommended. Indeterminate retroperitoneal lymph nodes. RECOMMENDATION(S): If the patient is low risk by ___ society guidelines (minimal or absent history of smoking or other known risk factors for primary lung neoplasm), recommend follow-up dedicated chest CT at 12 months and if no change, no further imaging needed. If the patient is high risk by ___ society guidelines (history of smoking or other known risk factors for primary lung neoplasm), recommend initial follow-up chest CT at ___ months and then at ___ months if no change. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with rising WBC and e/o pleural effusions on CT A/P.// Pls eval chest for infectious etiology TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent 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: Acquisition sequence: 1) Spiral Acquisition 8.9 s, 34.0 cm; CTDIvol = 8.8 mGy (Body) DLP = 286.0 mGy-cm. 2) Spiral Acquisition 8.9 s, 34.0 cm; CTDIvol = 8.8 mGy (Body) DLP = 284.6 mGy-cm. Total DLP (Body) = 582 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: Thyroid gland appears heterogeneous and nodular. There is no supraclavicular adenopathy. There is no axillary adenopathy. There is diffuse subcutaneous edema over the chest wall. UPPER ABDOMEN: There is upper abdominal ascites. Hypoattenuating liver lesions likely represent hepatic cysts. These are better evaluated on the CT abdomen and pelvis. There is a large hiatal hernia. The patient's enteric tube terminates in the stomach. MEDIASTINUM: There is no mediastinal adenopathy. HILA: There is no gross hilar adenopathy. HEART and PERICARDIUM: There is no pericardial effusion. PLEURA: There are moderate to large bilateral pleural effusions. These appear simple without definite evidence of loculation or enhancing septations. LUNG: 1. PARENCHYMA: There is atelectasis/collapse of the entire left lower lobe and most of the right lower lobe. Evaluation for underlying lung nodules is limited due to patient respiratory motion. 2. AIRWAYS: The airways are patent to the segmental level. 3. VESSELS: Within normal limits. CHEST CAGE: No suspicious focal osseous lesion. IMPRESSION: 1. Moderate to large simple appearing bilateral pleural effusions with resulting atelectasis/collapse involving most of both lower lobes. 2. Findings in the abdomen were better evaluated on the dedicated CT abdomen and pelvis from ___. Radiology Report INDICATION: ___ y/o M ___ s/p Hartmans with dysphagia, aspiration// eval swallow functioning in order to advance diet TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 4 min. 31 seconds COMPARISON: None FINDINGS: There is moderate to severe pharyngeal weakness. There was deep penetration with thin and nectar liquids. Barium passes through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration. An NG tube is visualized within the esophagus. IMPRESSION: Penetration without aspiration. Moderate-severe pharyngeal weakness. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with heart failure, b/l thoracentesis// PTX? PTX? IMPRESSION: In comparison with the study of ___, following thoracentesis there is no evidence pneumothorax. Otherwise, little overall change except for improved degree of inspiration. Radiology Report EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST. INDICATION: ___ year old man POD18 xlap ___ procedure with persistent elevated WBC.// ?intraabdominal process? Fluid collections? Access? 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) Spiral Acquisition 3.5 s, 55.7 cm; CTDIvol = 14.7 mGy (Body) DLP = 815.7 mGy-cm. 2) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP = 18.2 mGy-cm. Total DLP (Body) = 834 mGy-cm. COMPARISON: CT abdomen pelvis ___ FINDINGS: LOWER CHEST: There are small to moderate bilateral pleural effusions, decreased from prior. There is associated bibasilar atelectasis. There is a 3 mm right middle lobe pulmonary nodule. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There are multiple simple hepatic cysts. Subcentimeter hypodensities at the hepatic dome are too small to characterize, but unchanged. There is a region of hyperenhancement in segment VI of the liver 12 x 16 mm, likely a venous varix (series 2, image 39). There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is decompressed. There is small to moderate volume ascites, decreased from prior. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen is enlarged measuring 16.7 cm. Subcentimeter splenic hypodensities are nonspecific, but unchanged. ADRENALS: The left adrenal gland is unremarkable. There is nodularity adrenal gland, as seen previously. URINARY: The kidneys enhance and excrete contrast symmetrically. There are bilateral simple renal and peripelvic cysts measuring up to 2.8 cm in the right upper pole. There is a multilobulated intermediate density 2.8 cm exophytic left lower pole renal cyst, likely a hemorrhagic cyst, but incompletely characterized. GASTROINTESTINAL: A nasoenteric tube is present in the stomach. There is a large hiatal hernia. There is no bowel obstruction. Postsurgical changes from ___ procedure are present. Left lower quadrant ileostomy appears intact. There is no bowel obstruction. There remains free fluid containing likely Surgicel in the left hemipelvis anterior to the pouch overall with associated peritoneal thickening, mildly decreased compared to ___. No organized collection is identified. There is extensive presacral edema and fluid, as seen previously. PELVIS: Air within the bladder is likely from instrumentation. Moderate pelvic free fluid, as described above. REPRODUCTIVE ORGANS: The prostate is mildly enlarged. LYMPH NODES: Again seen, are enlarged retroperitoneal lymph nodes measuring up to 11 mm (series 2, image 44). There is no pelvic sidewall or inguinal adenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There are scattered sclerotic lesions involving the pelvis, unchanged, likely bone islands. Is degenerative change of the lumbar spine with a mild leftward scoliosis. SOFT TISSUES: There is diffuse anasarca. IMPRESSION: 1. No organized fluid collection. Persistent but mild decrease in fluid in the left hemipelvis containing likely Surgicel (versus locules of air) with associated mild peritoneal thickening. 2. Persistent, but decreased small volume ascites. 3. Decrease bilateral pleural effusions. 4. Indeterminate left lower pole renal lesion, nonemergent renal ultrasound can be obtained for further characterization. 5. Splenomegaly and retroperitoneal lymphadenopathy, of uncertain significance. RECOMMENDATION(S): Nonemergent renal ultrasound NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:06 pm, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ with sigmoid volvulus// pre-op eval TECHNIQUE: Single portable view of the chest. COMPARISON: ___ at 14:42. FINDINGS: Enteric tube is seen with tip coursing through the chest with tip projecting over left upper quadrant. There is tortuosity in the lower chest likely due to hiatal hernia. Lung volumes are low with secondary bronchovascular crowding. Air-filled loops of colon noted throughout the abdomen. No definite free intraperitoneal air. Cardiomediastinal silhouette is within normal limits. Relatively high-riding humeral heads raises possibility of underlying rotator cuff abnormality. IMPRESSION: Enteric tube courses through the hiatal hernia with tip projecting over the left upper quadrant. Radiology Report EXAMINATION: PORTABLE ABDOMEN INDICATION: Sigmoid volvulus TECHNIQUE: Abdomen single view COMPARISON: CT ___ FINDINGS: Interval placement of rectal tube. Multiple dilated colonic loops, small bowel loops, mildly improved since prior. Previously seen dilated loop of sigmoid has resolved. Degenerative changes spine. Arterial calcifications. IMPRESSION: Mild improvement since prior. Gender: M Race: WHITE Arrive by UNKNOWN Chief complaint: SIGMOID VOLVULUS, Transfer Diagnosed with Volvulus temperature: 97.2 heartrate: 88.0 resprate: 16.0 o2sat: 94.0 sbp: 107.0 dbp: 56.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were admitted to the hospital with abdominal pain and were found to have a sigmoid volvulus (a bowel obstruction due to twisting of part of the colon). The Gastroenterology Service initially tried to decompress your bowels by endoscopically placing a rectal tube, but you did not improve and ultimately required surgical management. You were taken to the operating room and underwent surgical removal of your sigmoid colon as the bowel was diseased, and creation of a colostomy. After the procedure you had intra-abdominal bleeding and were urgently taken back to the operating room and underwent surgical repair and packing of the bleeding and had a wound vac sponge placed to help with temporary closure. You went back to the operating room later and underwent surgical closure of your abdominal wound. After surgery, you had difficulty swallowing and were seen by the Speech & Swallow team. You had a dobhoff tube placed in your nose and into your stomach so you could receive tube feedings for nutrition. You had a videoswallow study performed and were later cleared for food by mouth with tube feeds for nutritional supplementation. You had some difficulty breathing and were found to have pleural effusions (A buildup of fluid between the tissues that line the lungs and the chest) in both your left and right lungs. You underwent drainage of these fluid collections and tolerated this procedure well. Your white blood count, which is marker for inflammation and infection, was trended and noted to be elevated. You were worked up for an infection and the only positive finding was your urine culture which revealed a urinary tract infection. You were started on a course of an antibiotic, called Ciprofloxacin, and will be discharged on a course of this medication. Your ostomy is functioning well and you are tolerating tube feeds and food by mouth. Your pain is better controlled. You have worked with Physical Therapy and it is recommended that you be discharged to rehab to continue your recovery. You are now ready to be discharged from the hospital. Please 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. Monitoring Ostomy output/ Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hematuria Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of Prior Colon Cancer (s/p right colectomy w/ anastomosis ___, Diverticulosis, Metastatic pancreatic adenocarcinoma (liver mets s/p neoadjuvant FOLFIRINOX and CyberKnife), Recent cholecystitis (s/p percutaneous cholecystostomy tube s/p replacement ___, on augmentin), recent GI bleed (unknown source), who presented 1 day after discharge with hematuria Patient noted that since discharge yesterday he felt well but noticed that he had new hematuria. Denied seeing any clots, has difficulty describing how much blood was in his urine but he noted that it was "bright red". He denied any increase in urgency/frequency or dysuria. He noted that he has never had bleeding like this before. Denied any fever/chills, flank pain, nausea/vomiting. Of note patient said he has had intermittent bloody tinged fluid in cholecystostomy bag, unchanged from that which he had on past admission. Patient noted that fluid output is unchanged. He noted that his hematoma at right chest port site is unchanged, denied discomfort there. Noted that he continues to pass maroon colored stools but in much lesser amounts than prior hospitalization In the ED, initial VS were pain 8, T 98.1, HR 123, BP 110/65, RR 20, O2 100%RA. Initial labs notable for Na 140, K 5.0, HCO3 23, Cr 1.0, Ca 7.6, Mg 2.1, P 3.0, Ca 7.6, Mg 2.1, P 3.0, ALT 26, AST 85, ALP 519, TBili 1.7, DBili 0.6, Alb 2.2, INR 1.3. Lactate 3.8-->2.4. UA with >182 WBC and nitrate positive. RUQ US showed perc chole tube well positioned in collapses gall bladder and no evidence of intrahepatic dilation. CT a/p showed decompressed gallbladder with appropriately placed cholecystosomy tube, unchanged pneumobilia, and no intrahepatic dilation, and biliary stent inplace. Patient was given 2LNS along with IV zosyn and IV dilaudid x1. VS prior to transfer were T 99.3 HR 110 BP 154/91, RR 19, O2 100%RA. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: ___ was previously treated for a pT1N0 stage I right-sided colon cancer resected in ___. Mr. ___ was diagnosed with diabetes mellitus in ___. Despite initiation of metformin, when he represented in ___, his weight had decreased 20 pounds and hemoglobin A1c was elevated at 11.6. Given ongoing unintentional weight loss and associated hyperglycemia, he was referred for CT torso performed ___. This study revealed new pancreatic ductal dilatation and a hypodense mass in the pancreatic head. He then underwent MRCP ___ which showed a 1.2 cm pancreatic head mass. Endoscopic ultrasound was performed ___ which showed a 2 x 1.4 cm pancreatic head mass. Fine-needle aspirate showed adenocarcinoma. CT angiogram showed a 2 cm mass with contact of the portal vein and SMV greater than 180°. There was no arterial involvement and no evidence of distant metastases per torso CT. He was diagnosed with borderline resettable PDA and began neoadjuvant FOLFIRINOX ___. Mr. ___ completed three cycles of FOLFIFINOX as of ___ followed by CK SBRT 2400 cGy as of ___. On ___, CT scan showed liver metastasis and he was admitted to the hospital with acute cholecystitis and cholecystostomy tube was placed on ___. Discharged on ___ with plan to complete Zosyn through ___. Subsequently readmitted on ___ with GI bleed. Source ultimately localized to biliary tree, although no acute source localized - felt possibly due to oozing from tumor. Also had antibiotics switched to augmentin and PCT dislodged. After PCT dislodgement redeveloped hyperbilirubinemia and fever. PCT replaced on ___. PAST MEDICAL HISTORY: 1. pT1N0 right sided colon cancer resected ___ 2. Hypertension 3. Hyperlipidemia 4. Elevated PSA rising since ___ referred to urology for biopsy 5. Known complex right upper pole renal cyst 6. Obstructive sleep apnea status post uvulectomy 7. Status post hernia repair 8. type II diabetes mellitus 9. Pancreatic adenocarcinoma-as above 10. Cholecystitis s/p perc cholecystostomy (last replaced ___ 11. GI bleed (unknown etiology as ___ negative, capsule revealed possible bleeding around stent, possibly from his malignancy) Social History: ___ Family History: The patient's mother died of tobacco associated lung cancer at ___ years. His father had hepatitis C, hypertension, coronary artery disease, and diabetes mellitus. He has 2 brothers and 5 sisters and 4 children. Diabetes mellitus, hypertension and asthma affect family members. Physical Exam: ADMISSION PHYSICAL EXAM VS: 100.0 124/82 hr 113 20 99RA GENERAL: Pleasant man, in no distress, lying in bed comfortably. wife at bedside EYES: PERRLA HEENT: OP clear. MMM CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g. No peripheral edema LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-distended, no tenderness to palpation, no rebound, normal bowel sounds. Right-sided percutaneous cholecystostomy tube catheter with clotted blood on dressing and bag draining slightly blood tinged yellow fluid, though new drainage closest to abdomen is clear/yellow EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. Access: right chest port with palpable hematoma at site, no oozing into dressing, unchanged from last admission Pertinent Results: ADMISSION LABS: =============== ___ 04:30AM BLOOD WBC-16.5* RBC-2.66* Hgb-7.7* Hct-23.1* MCV-87 MCH-28.9 MCHC-33.3 RDW-16.0* RDWSD-50.4* Plt ___ ___ 04:30AM BLOOD ___ ___ 07:02PM BLOOD FDP-320-640* ___ 04:30AM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-138 K-4.2 Cl-100 HCO3-23 AnGap-15 ___ 04:30AM BLOOD ALT-24 AST-65* LD(LDH)-589* AlkPhos-512* TotBili-1.5 ___ 04:30AM BLOOD Albumin-2.3* Calcium-7.6* Phos-2.7 Mg-2.0 ___ 03:40PM BLOOD ___ ___ 07:25AM BLOOD CEA-721.9* ___ 01:37PM BLOOD Lactate-3.8* ___ 04:19PM BLOOD Lactate-2.4* ___ 03:40PM BLOOD Fibrino-57* IMAGING: ======== ___ CHEST W/CONTRAST - New right pleural effusion, small to moderate with adjacent atelectasis - Please review CT abdomen and pelvis in the corresponding report that will discuss intra-abdominal findings and involvement of the liver by metastatic disease. ___ ABD & PELVIS W & W/O 1. Metastatic and locally advanced pancreatic cancer, as described above, not significant changed from prior study of ___. 2. Please refer to same-day CT chest for characterization of thoracic findings. ___ ABD & PELVIS WITH CO 1. The gallbladder is decompressed with a percutaneous cholecystostomy tube present. 2. A common bile duct stent is present, with unchanged pneumobilia in the left hepatic lobe. No evidence of intrahepatic biliary duct dilatation. 3. Small perihepatic ascites is slightly increased from prior. ___ OR GALLBLADDER US 1. A percutaneous cholecystostomy tube appears well positioned in the collapsed gallbladder. 2. Pneumobilia slightly limits evaluation of the bile ducts, however there is no intrahepatic biliary duct dilatation. 3. Innumerable hepatic metastases are similar to prior. 4. Small ascites and small right pleural effusion. MICRO: ====== -___ VIRAL CULTURE-PRELIMINARY; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-FINALINPATIENT ___ -URINE CULTURE-FINAL {YEAST}INPATIENT ___ CULTURE Blood Culture, Routine-PENDINGINPATIENT -___ CULTURE Blood Culture, Routine-FINALEMERGENCY WARD -___ CULTURE Blood Culture, Routine-FINALEMERGENCY WARD -___ URINE CULTURE-FINALEMERGENCY WARD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Simvastatin 40 mg PO QPM 3. Calcium Carbonate 500 mg PO QID:PRN GERD 4. Omeprazole 20 mg PO DAILY 5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe 7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Senna 8.6 mg PO BID Discharge Medications: 1. Lactulose 30 mL PO TID Patient may refuse RX *lactulose 10 gram/15 mL 30 mL by mouth three times a day Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 325 mg 2 capsule(s) by mouth q6 hours Disp #*60 Capsule Refills:*0 3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Take through ___ RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 4. Calcium Carbonate 500 mg PO QID:PRN GERD RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth four times a day Disp #*60 Tablet Refills:*0 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*120 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 8. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Disseminated intravascular coagulapathy # Acute blood loss anemia # Hematuria # Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with metastatic pancreatic cancer worsening right upper quadrant pain in setting of recent cholecystitis with percutaneous tube placement and history of pancreatic cancer// Abscess? Tube in the correct position? Intrahepatic ductal dilation? biliary obstruction? TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CTA abdomen and pelvis on ___ FINDINGS: LIVER: Again seen are innumerable hypodense lesions throughout the liver compatible with metastases. The main portal vein is patent with hepatopetal flow. There is small ascites. There is a right pleural effusion. BILE DUCTS: There is air within the common bile ducts, similar to recent CT, and slightly limiting evaluation. No definite intrahepatic biliary duct dilatation. The CHD measures 4 mm. GALLBLADDER: A percutaneous cholecystostomy tube appears to terminate in the collapsed gallbladder. 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 8.6 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. There is a 5.8 cm right upper pole kidney cyst. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. A percutaneous cholecystostomy tube appears well positioned in the collapsed gallbladder. 2. Pneumobilia slightly limits evaluation of the bile ducts, however there is no intrahepatic biliary duct dilatation. 3. Innumerable hepatic metastases are similar to prior. 4. Small ascites and small right pleural effusion. Radiology Report EXAMINATION: CT abdomen and pelvis INDICATION: ___ with worsening right upper quadrant pain in setting of recent cholecystitis with percutaneous tube placement and history of pancreatic cancer// Abscess? Tube in the correct position? Intrahepatic ductal dilation? biliary obstruction? TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 920 mGy-cm. COMPARISON: CTA abdomen and pelvis on ___ FINDINGS: LOWER CHEST: There is a small right pleural effusion and adjacent atelectasis at the right lung base. Not significantly changed. No pericardial effusion. ABDOMEN: HEPATOBILIARY: Again seen are numerous hypodense lesions throughout the liver, not significantly changed in size and number compared with recent CT. A common bile duct stent is stable in position, with no significant change in pneumobilia in the left hepatic lobe. There is no evidence of intrahepatic biliary duct dilatation. A percutaneous gastrostomy tube terminates in the decompressed gallbladder. There is small perihepatic ascites, slightly increased from prior. Loculated fluid in the falciform ligament is similar to prior. PANCREAS: A known hypodense pancreatic mass surrounding fiducials, with upstream dilation of the pancreatic duct and associated vascular involvement, is not significantly changed, better characterized on recent multiphasic study. Narrowing at the portal splenic confluence by the pancreatic mass is similar to prior. SPLEEN: The spleen is normal in size. 2 splenic hypodensities measuring up to 1 cm are not significantly changed. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Bilateral cyst renal cyst measuring up to 4.9 cm in the left upper pole are not significantly changed. Multiple additional subcentimeter cortical hypodensities are too small to characterize, however likely represent cysts. No hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Patient is status post right hemicolectomy and ileocolonic anastomosis, not significantly changed in appearance. PELVIS: The urinary bladder and distal ureters are unremarkable. There is a small amount of free fluid in the pelvis, similar to prior. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. 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: Subcutaneous fluid tracking along the bilateral abdominal walls, right greater than left, is similar to prior. A left inguinal hernia containing fat is noted. IMPRESSION: 1. The gallbladder is decompressed with a percutaneous cholecystostomy tube present. 2. A common bile duct stent is present, with unchanged pneumobilia in the left hepatic lobe. No evidence of intrahepatic biliary duct dilatation. 3. Small perihepatic ascites is slightly increased from prior. Radiology Report EXAMINATION: CT abdomen pelvis with contrast INDICATION: ___ year old man with locally advanced pancreatic cancer// restaging study after chemotherapy and radiation- assess for progression vs response to therapy 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) Spiral Acquisition 3.2 s, 35.6 cm; CTDIvol = 12.8 mGy (Body) DLP = 445.9 mGy-cm. 2) Spiral Acquisition 3.3 s, 36.6 cm; CTDIvol = 14.1 mGy (Body) DLP = 504.6 mGy-cm. 3) Spiral Acquisition 10.2 s, 66.1 cm; CTDIvol = 16.7 mGy (Body) DLP = 1,093.0 mGy-cm. Total DLP (Body) = 2,044 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: LOWER CHEST: There is a moderate left pleural effusion not significant changed from prior. For further characterization of thoracic findings please refer to separate report of CT chest performed on the same day. ABDOMEN: HEPATOBILIARY: Innumerable hypodense lesions are visualized throughout the liver compatible with known metastatic disease burden. A CBD stent is visualized with pneumobilia. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder decompressed with a percutaneous cholecystostomy tube in place. Perihepatic ascites is visualized and not significant changed from prior with fluid tracking along the falciform ligament. PANCREAS: There is a heterogeneously hypodense pancreatic head mass with associated fiducial markers that measures approximately 4.6 x 4.6 cm with pancreatic ductal dilatation, narrowing of the portal vein, encasement of the hepatic artery, and abuts the SMA, not significant changed from prior study. SPLEEN: The spleen shows normal size and attenuation throughout. 2 hypodense cystic lesions are re-demonstrated not significantly changed from prior. 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 are multiple subcentimeter hypodense renal cysts bilaterally. Additionally there is a large renal cyst in the right kidney with a thin internal hyperdensity (4:98) that may represent an internal calcification, as well as a 2 cm simple renal cyst in the lower pole of the left kidney. There is no evidence of hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Patient is status post right hemicolectomy with the ileocolonic anastomotic site intact and free of complications otherwise the 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. The appendix is surgically absent. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Diffuse soft tissue edema and thickening, as well as subcutaneous fluid is visualized tracking along the flanks bilaterally. IMPRESSION: 1. Metastatic and locally advanced pancreatic cancer, as described above, not significant changed from prior study of ___. 2. Please refer to same-day CT chest for characterization of thoracic findings. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: Restaging study after chemotherapy and radiation for a locally advanced pancreatic cancer 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: ___ FINDINGS: Aorta and pulmonary arteries are unremarkable. Heart size is normal. There is no pericardial effusion. There is right pleural effusion, moderate, new. Image portion of the upper abdomen will be reviewed separately is part of the CT abdomen and pelvis in the corresponding report will be issued Airways are patent to the subsegmental level bilaterally. No new pulmonary nodules masses or consolidations demonstrated except for right basal minimal atelectasis secondary to right pleural effusion. No pathologically enlarged mediastinal hilar or axillary lymph nodes demonstrated. There are no lytic or sclerotic lesions worrisome for infection or neoplasm. IMPRESSION: New right pleural effusion, small to moderate with adjacent atelectasis Please review CT abdomen and pelvis in the corresponding report that will discuss intra-abdominal findings and involvement of the liver by metastatic disease. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Abd pain, Hematuria Diagnosed with Sepsis, unspecified organism, Urinary tract infection, site not specified, Right upper quadrant pain, Right lower quadrant pain temperature: 98.1 heartrate: 123.0 resprate: 20.0 o2sat: 100.0 sbp: 110.0 dbp: 65.0 level of pain: 8 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted due to increasing shortness of breath, high heart rate, and bleeding in your urine and around your liver drain. We found you had a condition called DIC that causes you to be very susceptible to severe bleeding. Although we transfused you blood and blood products to help treat the bleeding, the underlying cause of the DIC is your cancer. After discussion with you and your family, we elected against further cancer directed care with chemotherapy. Rather, we decided to focus on palliative care and allow you the chance to return home with your family under hospice care. We wish you all the best. 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: Poor pain control, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a ___ year-old gentleman with a history of ___ Disease, L THR (___) at OSH, who presents for pain control and change in mental status. Per pt's wife, after his THR he had to stay in the ICU for 24 hours ___ narcotic-sensitivity (to Dilaudid) and hypotension. Pt was discharged on celecoxib and tylenol for pain control. Pt continued to be in pain, so on ___ pt started tramadol. After two doses, pt had an episode of confusion in which he became enraged and started flailing and kicking. Pt discontinued tramadol at that time. On ___, pt took one dose of tylenol with codeine. This led to an episode of hallucination in which he told his wife that he was seeing people in the house. Hallucinations lasted into the next day. The patient has since been on celecoxib and extra strength tylenol, which resulted in unbearable ___ pain for the past two nights. Pt has also experienced persistent cough which started while he was at the OSH after his surgery. Cough is nonproductive. He was prescribed omeprazole, as it was thought to be secondary to GERD. In addition, since his surgery pt has noticed an increase in urination. Pt had to urinate every hour last night. Otherwise, pt denies fevers, CP, SOB, dysuria, ___ weakness, or ___ numbness. Initial VS in the ED were T 97.8, BP 148/80, HR 71, RR 16, O2 99%. Patient was noted to be alert, awake, and oriented x 3. Chemistry panel was witin normal limits. CBC was significant for elevated platelets to 442. UA was bland. CXR was without any intrathoracic process. Patient was given morphine 5 mg IV x 1. VS prior to transfer were T 98.5, BP 159/87, HR 89, RR 17, O2 100%. On arrival to the floor, the patient was comfortable and reported a ___ pain. He is accompanied by his wife. Past Medical History: ___ Disease Hyperlipidemia Esophageal dilation procedure (___ for ___ Disease L hip fracture ___ years ago, now s/p L THR Social History: ___ Family History: Mother had ___ Disease Physical Exam: Admission Physical Exam: Vitals: T 98.5, BP 156/81, P 85, R 16, O2 99% RA General: AOx3, NAD HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, oropharynx clear Neck: Supple, no carotid bruits, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present x 4, no rebound tenderness or guarding, no organomegaly Ext: WWP, 2+ UE and ___ pulses, no clubbing or cyanosis, dressing over L hip c/d/i, ___ nonpitting, nontender L pedal edema Neuro: CNs III-XII intact, muscle strength ___ RUE/LUE/RLE, ___ LLE, sensation intact throughout, rapid alternating movement intact, slow and shuffling gait Skin: Intact, no rashes, erythema, or lesions. Ecchymoses on lateral sides of left foot, non-TTP. Discharge Physical Exam: Vitals: T 99.4, BP 141/73, P 82, R 18, O2 100% RA General: AOx3, NAD HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, oropharynx clear Neck: Supple, no carotid bruits, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present x 4, no rebound tenderness or guarding, no organomegaly Ext: WWP, 2+ UE and ___ pulses, no clubbing, cyanosis, or edema, dressing over L hip c/d/i Neuro: CNs III-XII intact, muscle strength ___ RUE/LUE/RLE, ___ LLE, sensation intact throughout, rapid alternating movement intact, slow and shuffling gait Skin: Intact, ecchymoses on medial and lateral sides of left foot, non-TTP Pertinent Results: ADMISSION LABS: ___ 02:35PM BLOOD WBC-8.9 RBC-3.60* Hgb-11.3*# Hct-33.4* MCV-93 MCH-31.5 MCHC-34.0 RDW-13.3 Plt ___ ___ 02:35PM BLOOD Neuts-72.5* Lymphs-17.5* Monos-3.2 Eos-6.1* Baso-0.7 ___ 02:35PM BLOOD Plt ___ ___ 02:35PM BLOOD Glucose-92 UreaN-13 Creat-0.7 Na-135 K-4.2 Cl-99 HCO3-29 AnGap-11 ___ 02:35PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.3 ___ 02:35PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG DISCHARGE LABS: ___ 07:30AM BLOOD WBC-9.6 RBC-3.48* Hgb-10.8* Hct-33.1* MCV-95 MCH-31.0 MCHC-32.7 RDW-13.3 Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD ___ PTT-33.8 ___ ___ 07:30AM BLOOD Glucose-85 UreaN-16 Creat-0.8 Na-138 K-4.4 Cl-100 HCO3-30 AnGap-12 ___ 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2 IMAGING: ___ CXR PA/lat: Frontal and lateral views of the chest were obtained. The heart is of normal size with normal cardiomediastinal contours. Lungs are clear without focal or diffuse abnormality. No pleural effusion or pneumothorax. The pulmonary vasculature is unremarkable. No radiopaque foreign body. Deformity of the left clavicle is compatible with an old fracture. IMPRESSION: No acute cardiopulmonary process. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Omeprazole 20 mg PO BID 2. Aspirin EC 325 mg PO DAILY Start: In am 3. Multivitamins 1 TAB PO DAILY Start: In am 4. celecoxib *NF* 200 mg Oral BID w/food wtih breakfast and dinner 5. Azilect *NF* (rasagiline) 1 mg Oral daily in the morning 6. Carbidopa-Levodopa (___) 1 TAB PO TID 7. Trihexyphenidyl 2 mg PO TID 8. pramipexole *NF* 0.5 mg Oral TID 9. Warfarin 1 mg PO DAILY16 10. Docusate Sodium 200 mg PO HS 11. Simvastatin 10 mg PO HS 12. Senna 1 TAB PO HS 13. Acetaminophen 1000 mg PO Q8H:PRN pain 14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Aspirin EC 325 mg PO DAILY 4. Azilect *NF* (rasagiline) 1 mg Oral daily in the morning 5. Carbidopa-Levodopa (___) 1 TAB PO TID 6. celecoxib *NF* 200 mg Oral BID w/food wtih breakfast and dinner 7. Docusate Sodium 200 mg PO HS 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO BID 10. pramipexole *NF* 0.5 mg Oral TID 11. Senna 1 TAB PO HS 12. Simvastatin 10 mg PO HS 13. Trihexyphenidyl 2 mg PO TID 14. Warfarin 1 mg PO DAILY16 15. Morphine Sulfate ___ ___ mg PO Q4H:PRN breakthrough pain hold for AMS, sedation or RR < 12 RX *morphine 15 mg ___ tablet(s) by mouth every four hours Disp #*30 Tablet Refills:*0 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Bisacodyl 10 mg PR HS:PRN constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: remote L hip fracture s/p THR encephalopathy SECONDARY DIAGNOSES: ___ Disease GERD Hyperlipidemia 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: ___ male with mental status changes. Evaluate for pneumonia. COMPARISONS: None. FINDINGS: Frontal and lateral views of the chest were obtained. The heart is of normal size with normal cardiomediastinal contours. Lungs are clear without focal or diffuse abnormality. No pleural effusion or pneumothorax. The pulmonary vasculature is unremarkable. No radiopaque foreign body. Deformity of the left clavicle is compatible with an old fracture. IMPRESSION: No acute cardiopulmonary process. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: MENTAL STATUS CHANGES ? D/T PAIN MEDS Diagnosed with OTHER ACUTE POSTOPERATIVE PAIN , SEMICOMA/STUPOR, PARKINSON'S DISEASE, HYPERCHOLESTEROLEMIA temperature: 97.8 heartrate: 71.0 resprate: 16.0 o2sat: 99.0 sbp: 148.0 dbp: 80.0 level of pain: 1 level of acuity: 3.0

Dear Mr. ___, It was a pleasure to participate in your care here at ___ ___! You were admitted for better management of your pain medications, since some were causing agitation and confusion after your hip surgery. Please start the following medications: Morphine ___ Miralax Bisacodyl It is important that you continue all of your other medications, especially the ones to treat constipation. Please see below for your follow-up appointments. Wishing you all the best!

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Zithromax / Penicillins Attending: ___. Chief Complaint: Weakness/Hypotension Major Surgical or Invasive Procedure: R buttock decub debridement - ___ R buttock decub I&D, bone bx - ___ CTA with left colic artery embolization - ___ History of Present Illness: ___ with hx of alcohol abuse brought to the ED after found down and admitted to ICU for sepsis workup. Per report, daughter found her lying on the floor at home. EMS called. Pt was A&OX3, but hypotensive 70/40 and tachycardic to 130s. Pt noted to have large R decubitus ulcer. Brought to ___ ED. Per family, pt lives alone and has been reporting not feeling well over the last couple of weeks. Daughter reports that she last saw her about two weeks ago and pt appeared well. Has been in contact over the phone with pt. Daughter reports that the last person to see pt was the neighbor on ___ where she came and opened the door. Of note, has had new stool incontinence over the last month. In the ED, initial vitals: T 100 HR 136 BP 95/56 RR 20 96RA. Tmax at ED 100.5. Labs notable for leukocytosis, transaminitis, hypoNa, lactate 3.3. UA negative. CT head, abd/pelvis unremarkable for source of infection. Was given 3L NS and vanc, cefepime, flagyl. On transfer, vitals were: HR 102 112/71 22 98RA. On arrival to the MICU, pt A&OX3, but confused. Past Medical History: GERD HTN RA Fibromyalgia History of heart murmur Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PE: Vitals: T:98.4 BP:91/52 P:91 R: 18 O2: 98RA GENERAL: A&OX3 but confused, no acute distress HEENT: Sclera icteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: R buttock ulcer 5mm deep, 5X5cm with yellowish drainage around the edge, 1X1cm L buttock ulcer with no drainage, L middle upper back 2X4cm gash NEURO: CNII-XII intact, motor and sensory function grossly intact DISCHARGE PE: VS: 98.0 111/63 83-110 94%RA GENERAL: Alert, NAD HEENT: Sclera anicteric, no injection, MMM NECK: supple, no LAD LUNGS: CTAB CV: Tachycardic, regular rythm, normal S1 S2; ___ systolic ejection murmur loudest at L ___ ICS, no rubs or gallops ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; anasarca GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 2+ pitting edema up to ankles bilaterally, 2+ to knees (R>L), 1+ in thighs, dependent areas of edema along sacrum. SKIN: R buttock with stage 4 ulcer w/ wound vac in place NEURO: calm, non-focal, AOx3, cannot complete DOWB Pertinent Results: ADMISSION LABS: =============== ___ 12:30AM BLOOD WBC-17.2* RBC-3.64* Hgb-11.3 Hct-32.5* MCV-89 MCH-31.0 MCHC-34.8 RDW-14.9 RDWSD-47.6* Plt ___ ___ 12:30AM BLOOD Neuts-91.9* Lymphs-5.0* Monos-2.3* Eos-0.0* Baso-0.4 NRBC-0.1* Im ___ AbsNeut-15.82* AbsLymp-0.86* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.07 ___ 12:30AM BLOOD Plt ___ ___ 12:30AM BLOOD Glucose-143* UreaN-28* Creat-0.9 Na-129* K-4.2 Cl-86* HCO3-30 AnGap-17 ___ 12:30AM BLOOD ALT-106* AST-94* CK(CPK)-763* AlkPhos-210* TotBili-4.4* DirBili-2.7* IndBili-1.7 ___ 12:30AM BLOOD Albumin-3.0* Calcium-9.4 Phos-2.5* Mg-1.9 ___ 12:49AM BLOOD Lactate-3.3* K-4.0 DISCHARGE LABS: =============== ___ 04:46AM BLOOD WBC-6.2 RBC-2.54* Hgb-7.7* Hct-24.7* MCV-97 MCH-30.3 MCHC-31.2* RDW-18.6* RDWSD-65.7* Plt ___ ___ 04:46AM BLOOD Glucose-107* UreaN-8 Creat-0.4 Na-137 K-4.6 Cl-105 HCO3-26 AnGap-11 ___ 04:46AM BLOOD Albumin-1.7* Calcium-7.9* Phos-3.4 Mg-1.8 NUTRITIONAL LABS: =============== ___ 04:46AM BLOOD Albumin-1.7 ___ 04:00AM BLOOD Albumin-2.0* ___ 06:20AM BLOOD Albumin-1.7* ___ 05:25AM BLOOD Albumin-2.1* ___ 12:30AM BLOOD Albumin-3.0* IRON STUDIES: ============== ___ 04:51AM BLOOD calTIBC-101* VitB12-GREATER TH Hapto-223* Ferritn-2504* TRF-78* ___ 03:49AM BLOOD Hapto-160 INFLAMMATORY MARKERS: ===================== ___ 04:51AM BLOOD CRP-171.6*, ESR 63 ___ 04:46AM BLOOD CRP-19.0*, ESR pending OTHER PERTINENT LABS: ===================== ___ 06:23AM BLOOD GGT-796* ___ 12:30AM BLOOD Lipase-229* ___ 04:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ ___ 06:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 04:51AM BLOOD TSH-6.1* ___ 04:51AM BLOOD T3-65* Free T4-1.3 ___ 05:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. ========== MICRO: ========== Blood Cultures: ============== ___: No growth ___: No growth, with the exception of fungal/mycobacterial culture with NGTD, final report pending ___: NGTD, final report pending Urine Cultures: ================ ___: No growth Stool: ===== ___ C. Diff Positive Tissue: ======= ___ 1:54 pm TISSUE SACRAL BONE. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: ESCHERICHIA COLI. SPARSE GROWTH. Ertapenem Sensitivity testing per ___. ___ (___). Piperacillin/Tazobactam sensitivity testing performed by ___ ___. Ertapenem =INTERMEDIATE ( sensitivity testing performed by ___ ___ ). Cefepime Sensitivity testing performed by Etest. Interpretation of cefepime susceptibility is based on a dose of 1 gram every 12h. This isolate is intermediate (I) to cefepime, now referred to as susceptible-dose dependent (SDD). SDD isolates can be treated with cefepime, but an optimized dosing regimen should be prescribed. Please contact the AST (pager ___ or ID for assistance in determining the appropriate SDD cefepime dosing. CEFTAZIDIME/AVIBACTAM Sensitivity testing per ___. ___ ___ (___). CEFTAZIDIME/AVIBACTAM SENT TO LABORATORY SPECIALISTS,INC ___. CEFTAZIDIME/AVIBACTAM ___ MCG/ML = SUSCEPTIBLE (PERFORMED BY THE ALLERGAN REFERENCE LAB). ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE. LINEZOLID AND Daptomycin AND CEFTAROLINE PER ___. CEFTAROLINE ZONE SIZE IS 6MM Zone size determined using a method that has not been standardized for this drug- organism combination and for which no CLSI or FDA-approved interpretative standards exist. Interpret results with caution. CEFTAROLINE sensitivity testing performed by ___ ___. Daptomycin = 4 MCG/ML. Daptomycin Sensitivity testing performed by Etest. ENTEROCOCCUS SP.. SPARSE GROWTH. ___ MORPHOLOGY. ADD ON Daptomycin AND LINEZOLID AND CEFTAROLINE PER ___ ___. CEFTAROLINE ZONE SIZE 6MM Zone size determined using a method that has not been standardized for this drug- organism combination and for which no CLSI or FDA-approved interpretative standards exist. Interpret results with caution. CEFTAROLINE sensitivity testing performed by ___ ___. Daptomycin = 4MCG/ML. Daptomycin Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | ENTEROCOCCUS SP. | | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 8 I CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R DAPTOMYCIN------------ S S GENTAMICIN------------ =>16 R LINEZOLID------------- 2 S 2 S MEROPENEM-------------<=0.25 S PENICILLIN G---------- =>64 R =>64 R PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ =>32 R =>32 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Final ___: THIS IS A CORRECTED REPORT (___). ORIGINAL REPORT Reported to and read back by ___ ___ ___ @3:01 ___. CORRECTED REPORT Reported to and read back by ___. ___ ___ @3:35 ___. ___. Yeast Susceptibility:. Fluconazole RESISTANT. Voriconazole MIC 0.5 MCG/ML = SUSCEPTIBLE. Caspofungin MIC 0.5 MCG/ML = INTERMEDIATE. Antifungal agents reported without interpretation lack established CLSI guidelines. Results were read after 24 hours of incubation. Sensitivity testing performed by Sensititre. PREVIOUSLY REPORTED AS (___). Caspofungin SUSCEPTIBLE-DOSE-DEPENDENT INSTEAD OF INTERMEDIATE. POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. SWAB R GLUTEAL. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: CITROBACTER FREUNDII COMPLEX. RARE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. PROTEUS MIRABILIS. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | 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 ANAEROBIC CULTURE (Final ___: CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM. HEAVY GROWTH. TISSUE R GLUTEAL TISSUE. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). Reported to and read back by ___, ___ @ 01:00AM (___). SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final ___: PROTEUS MIRABILIS. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 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 ANAEROBIC CULTURE (Final ___: CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM. HEAVY GROWTH. ========== Pathology: ========== Sacrum ulcer base, debridement ___: Extensively necrotic tissue with bacterial overgrowth and foci of acute inflammation; necrotic bone. GI Mucosal biopsy, CSC ___: 1 A. Transverse polyp, polypectomy:Adenoma. 2 A. Sigmoid polyp, polypectomy:Hyperplastic polyp ================= STUDIES/EXAMS: ================= CARDIAC: ======== TTE ___: Left Ventricle - Ejection Fraction: 65% to 70% The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. 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. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMAGING: ======== Liver/gallbladder US ___: No biliary pathology identified. Mildly echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. Trace right pleural effusion CXR for PICC Placement ___: Right-sided PICC terminating in the mid to low SVC. No pneumothorax. Previously described abnormal contour of the left hilum, which may be due to pulmonary stenosis, can be further assessed with comparison with old radiographs or chest CT, if clinically indicated. CXR: ___ Prominence of the left pulmonary arterial window may reflect enlarged pulmonary artery or alternatively adenopathy. No focal opacity convincing for pneumonia. CT Head ___: No acute intracranial abnormality. Prominent ventricles and sulci suggest involutional changes. CT Abd/Pelvis ___: 1. Hepatic steatosis. 2. Prominent endometrium with possible trace fluid within the endometrial canal warrants non-emergent ultrasound evaluation. 3. Healed nondisplaced right ___, and ___ anterior right rib fractures. 4. Locules of air within the subcutaneous tissues overlying the right sacrum may reflect decubitus ulcer for which clinical correlation advised. Portable CXR ___: Right paramediastinal opacity, may indicate pneumonia in the right clinical setting. Portable CXR ___: In comparison with the study of ___, there again are low lung volumes. There is enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure. Retrocardiac opacification with obscuration of the hemidiaphragm is consistent with volume loss in the left lower lobe and small pleural he fusion. The opacification adjacent to the right aspect of the mediastinum appears to have decreased. Right PICC line again extends to the lower SVC and there is again an impression on the lower cervical trachea, suggestive of a right thyroid mass. KUB ___: 1. Nonspecific bowel-gas pattern. 2. Assessment for free intraperitoneal air is limited on supine radiographs. Recommend upright radiograph, left lateral decubitus radiograph, or cross-sectional imaging if there is clinical concern for pneumoperitoneum. Portable CXR ___: Moderate pulmonary edema has worsened since ___. Lung volumes are lower, with persistent relative elevation of the right hemidiaphragm. This may explain greater consolidation at the right lung base due to a combination of dependent edema and atelectasis, although pneumonia is not excluded. Moderate to severe cardiomegaly has worsened since ___, stable since ___. Pulmonary arteries are dilated probably due to pulmonary arterial hypertension. Pleural effusions are presumed, but not large. No pneumothorax. CT Chest ___: 1. Cardiomegaly, diffuse ground-glass opacities with interlobular septal thickening, small pericardial effusion and bilateral nonhemorrhagic pleural effusions most likely reflect sequela of pulmonary edema. Consolidative lung within the lower lobes bilaterally most consistent with atelectasis although infectious process cannot be entirely excluded. 2. Enlarged pulmonary artery is suggestive of though not diagnostic for pulmonary hypertension. 3. Extensive atherosclerotic calcifications involve the coronary arteries. Aortic valvular calcifications additionally noted. 4. For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis performed on the same date, ___, clip number ___. CT A/P ___: 1. Sacral decubitus ulcer with soft tissue defect exposing the osseous structures. There is no definite evidence for osteomyelitis. MRI would be more sensitive for evaluation of osteomyelitis. 2. No evidence of intra-abdominal infectious process. No abscess is identified. 3. Small volume nonhemorrhagic abdominal free fluid, mild periportal edema, and diffuse anasarca likely reflective of volume status. 4. For complete intrathoracic findings, please refer to CT chest dated ___, clip number ___. KUB ___: Embolization coils are projected over the left lower quadrant from recent left colonic artery branch embolization. Hemidiaphragms have not been included on this abdominal radiograph. Air is seen within the stomach and multiple loops of small bowel, none of which are overly dilated. Small amount of air seen within the colon projected over the left hemipelvis. No bowel wall thickening. On the second abdominal radiograph obtained, there are streaks of linearly oriented air is noted overlying the the left hemi abdomen, which may reflect material/sheets external to the patient. No acute or aggressive osseous lesions are demonstrated. IMPRESSION: No dilated loops of large or small bowel.. GI PROCEDURES: =============== SIGMOIDOSCOPY REPORT ___: Diverticulosis of the sigmoid colon Normal mucosa in the rectum No active bleeding. Evidence of recent bleeding seen up to the proximal descending colon with clean mucosa proximally. Polyp in the sigmoid colon Otherwise normal sigmoidoscopy to splenic flexure EGD ___: No blood or source of bleeding identified. Esophageal ring Otherwise normal EGD to third part of the duodenum Colonoscopy Findings ___: Diverticulosis of the left and right colon Abnormal vascularity and petechiae in the proximal sigmoid/descending colon compatible with ischemic changes likely due to recent embolization Polyps in the transverse colon (polypectomy) Polyp in the colon (polypectomy) Otherwise normal colonoscopy to cecum and terminal ileum INTERVENTIONAL RADIOLOGY REPORTS: ================================= MESENTERIC ARTERIOGRAM ___: FINDINGS: 1. Inferior mesenteric arteriogram demonstrates brisk bleeding from a branch of the left colic artery. 2. Left Colic arteriogram demonstrates brisk bleeding from a branch of the left colic artery, with delineation of the anatomy of the feeding arterial vessels. 3. Left Colic branch #1 arteriogram demonstrates brisk bleeding from this specific branch. 4. Left Colic branch #2 arteriogram demonstrates brisk bleeding from this specific branch. 5. Coil embolization of left colic artery branches 1 and 2 with post embolization left colic arteriogram demonstrating no further active extravasation. 6. Superior mesenteric arteriogram demonstrates no active extravasation. 7. Right common femoral vein access, ultrasound guided. Placement of a triple-lumen central line via the right common femoral vein. The line is ready for use. 8. Right common femoral artery arteriogram demonstrates appropriate puncture site for use of an Angio-Seal device. IMPRESSION: Brisk bleeding for multiple branches of the left colic artery treated with coil embolization with good angiographic result. No further bleeding angiographically upon completion of the embolization. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY 2. Ranitidine 150 mg PO DAILY 3. Loratadine 10 mg PO DAILY:PRN allergies 4. diclofenac epolamine 1.3 % transdermal BID:PRN pain 5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 6. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN dyspepsia 3. Ascorbic Acid ___ mg PO DAILY 4. Collagenase Ointment 1 Appl TP DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Meropenem 1000 mg IV Q8H 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Vancomycin Oral Liquid ___ mg PO Q6H 9. Zinc Sulfate 220 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Loratadine 10 mg PO DAILY:PRN allergies 12. Ranitidine 150 mg PO DAILY 13. Ondansetron 4 mg IV Q8H:PRN nausea 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 15. Phosphorus 500 mg PO TID 16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 18. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: -Severe sepsis secondary to osteomyelitis SECONDARY DIAGNOSIS: -Stage 4 decubitus ulcer of the right buttock -Cdiff colitis -anemia -SA nodal reentrant tachycardia -Diverticular bleed 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: History: ___ with weakness // eval for pna COMPARISON: None available FINDINGS: Single portable semi supine AP radiograph demonstrates abnormal contour involving the pulmonary arterial window either enlarged left pulmonary artery or adenopathy. Heart size is upper limits of normal. No evidence of pulmonary edema. No focal consolidation convincing for pneumonia is present. There is no pleural effusion or evidence of pneumothorax. Imaged osseous structures and upper abdomen are without an acute abnormality. IMPRESSION: Prominence of the left pulmonary arterial window may reflect enlarged pulmonary artery or alternatively adenopathy. No focal opacity convincing for pneumonia. Radiology Report INDICATION: History: ___ with sacral decubs, weakness // eval for fracture, bony erosion to spine COMPARISON: None available FINDINGS: AP supine and portable radiograph through the abdomen demonstrates a nonspecific bowel gas pattern. Multilevel degenerative changes are present and most pronounced within the lower lumbar spine. Bilateral femoral heads appears seated in the acetabulum. No evidence of dislocation or acute fracture. No osteolysis involves the bilateral ischial tuberosities or sacrum. Linear density projects over the pubic symphysis in the midline consistent with rectal thermometer. Allowing for suboptimal technique, no evidence of pneumoperitoneum. IMPRESSION: Nonspecific bowel-gas pattern. Degenerative changes within the lower lumbar spine. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with sepsis // eval for cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic. 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 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. No evidence of cholelithiasis or cholecystitis. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with ams, transaminitis // eval for pancreatic mass, obstructioneval for ich TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP = 802.7 mGy-cm. 4) Sequenced Acquisition 6.0 s, 6.1 cm; CTDIvol = 49.7 mGy (Head) DLP = 301.0 mGy-cm. Total DLP (Head) = 1,104 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and scattered white matter hypodensities are nonspecific though likely sequela of chronic small vessel ischemic disease. Basal cisterns are patent. There is no shift of normally midline structures. IMPRESSION: No acute intracranial abnormality. Prominent ventricles and sulci suggest involutional changes. Radiology Report INDICATION: NO_PO contrast; History: ___ with ams, transaminitisNO_PO contrast // eval for pancreatic mass, obstructioneval for ich TECHNIQUE: Multi detector CT images through the abdomen and pelvis were obtained after the administration of intravenous contrast. No oral contrast was administered. Coronal and sagittal reformations were generated and reviewed. DOSE: 356 mGy-cm. COMPARISON: None. FINDINGS: Chest: Bilateral atelectasis is mild and symmetric. Calcified nodule within the right lower lobe is most consistent with calcified granuloma.There is no pleural or pericardial effusion. Partially imaged mitral annular calcifications as well as aortic valve calcifications are noted. Abdomen: The liver is diffusely low in attenuation consistent with hepatic steatosis. There is no intrahepatic biliary duct dilation. The portal veins are patent. There is no radiopaque cholelithiasis. Pancreas is homogeneous in attenuation. There is no peripancreatic stranding. The spleen and bilateral adrenal glands are normal in appearance. The kidneys present symmetric nephrograms and excretion of contrast. There is no focal renal lesion, perinephric fluid collection or stranding. The stomach, duodenum, and loops of small bowel are grossly normal. The appendix is air-filled an normal. Scattered diverticular disease is present in the absence of findings to suggest diverticulitis. There is no abdominal free fluid or air. The aorta demonstrates moderate to severe atherosclerotic calcifications without aneurysmal dilatation. Bilateral common iliac arteries are dilated bilaterally measuring up to 1.4 cm. There is no retroperitoneal or mesenteric adenopathy. Pelvis: The bladder is decompressed with a Foley catheter present. There is no adnexal mass. The endometrium appears prominent with fluid present within the endometrial canal. There is no pelvic free fluid. There is no inguinal or pelvic sidewall adenopathy. No osseous lesion worrisome for malignancy or infection is identified. Healed nondisplaced anterior fifth, sixth and seventh right rib fracture (3:1) are noted. Multilevel degenerative changes are moderate. Anterolisthesis of L5 on S1 is mild, Grade I. Mild compression deformity at T12 vertebral body is additionally noted. Locules of air within the subcutaneous fat overlying the right sacrum extends into adjacent fascial planes may reflect decubitus ulcer. IMPRESSION: 1. Hepatic steatosis. 2. Prominent endometrium with possible trace fluid within the endometrial canal warrants non-emergent ultrasound evaluation. 3. Healed nondisplaced right ___, and ___ anterior right rib fractures. 4. Locules of air within the subcutaneous tissues overlying the right sacrum may reflect decubitus ulcer for which clinical correlation advised. RECOMMENDATION(S): Suggest non-urgent pelvic ultrasound for followup of endometrial thickening and possible fluid. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with sepsis // r/o edema r/o edema COMPARISON: Chest radiographs ___ through ___. IMPRESSION: There has been no interval change. Swan-Ganz catheter intra-aortic balloon pump are in standard placements respectively. Right PIC line ends at the origin of the SVC, as before. Moderate to severe cardiac enlargement is unchanged. The right pleural abnormality and unidentified spherical lesion in the right midlung laterally are unchanged. An the cardiac silhouette obscures the left lower lobe where there could be infrahilar atelectasis or consolidation. Pleural effusion is small if any. No pneumothorax. Radiology Report INDICATION: ___ year old woman with new line. New right PICC 40 cm, ___ ___ Contact name: ___: ___ TECHNIQUE: Upright portable AP chest radiograph COMPARISON: Chest radiographs from ___ and ___. FINDINGS: Right-sided PICC terminates in the mid to low SVC. The heart size is top-normal. Engorged vasculature is seen. Abnormal contour of the left hilum is not well seen on this exam. No pulmonary edema, effusion, consolidation or pneumothorax is seen. Mild increased an right lobe interstitial markings is likely due to atelectasis. IMPRESSION: Right-sided PICC terminating in the mid to low SVC. No pneumothorax. Previously described abnormal contour of the left hilum, which may be due to pulmonary stenosis, can be further assessed with comparison with old radiographs or chest CT, if clinically indicated. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with sepsis and mixed pattern of elevated LFTs // eval for hepatobiliary pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis ___, abdominal ultrasound ___ FINDINGS: LIVER: The liver is diffusely mildly echogenic. 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 3 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: 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 9.0 cm. KIDNEYS: The partially visualized kidneys are unremarkable. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. Trace right pleural effusion. IMPRESSION: No biliary pathology identified. Mildly echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. Trace right pleural effusion Radiology Report INDICATION: ___ year old woman with new fever. Please assess for new infectious process, edema, effusion, consolidation. TECHNIQUE: Semi upright portable AP chest radiograph. COMPARISON: Chest radiographs from ___. FINDINGS: Compared to ___, the lung volumes have decreased. Lordotic views accentuate the heart size and interstitial opacity. There is mild prominence of the pulmonary vessels and increased interstitial opacities, right worse than left, may suggest pulmonary edema. Right paramediastinal opacity may suggest consolidation. Moderate to severe cardiomegaly appear grossly unchanged. Right-sided PICC appear unchanged in position. There is a right-sided indentation of the lower cervical trachea, which may be due to enlarged thyroid. IMPRESSION: Right paramediastinal opacity, may indicate pneumonia in the right clinical setting. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with h/o RA with sepsis ___ infected stage 4 decubitus ulcer c/b osteo, +c diff colitis with tachycardia and new oxygen requirement. // eval for PNA, pulm edema eval for PNA, pulm edema IMPRESSION: In comparison with the study of ___, there again are low lung volumes. There is enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure. Retrocardiac opacification with obscuration of the hemidiaphragm is consistent with volume loss in the left lower lobe and small pleural he fusion. The opacification adjacent to the right aspect of the mediastinum appears to have decreased. Right PICC line again extends to the lower SVC and there is again an impression on the lower cervical trachea, suggestive of a right thyroid mass. Radiology Report INDICATION: ___ year old woman with h/o RA here w/ sepsis ___ stage 4 decub c/b osteo and cdiff colitis, with persistent fevers, chills and abd pain. // eval for colonic distenion, free air TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Abdominal radiograph ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. 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. Osseous structures are unremarkable. Degenerative changes are noted in the lumbosacral spine. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: 1. Nonspecific bowel-gas pattern. 2. Assessment for free intraperitoneal air is limited on supine radiographs. Recommend upright radiograph, left lateral decubitus radiograph, or cross-sectional imaging if there is clinical concern for pneumoperitoneum. RECOMMENDATION(S): Upright radiograph, left lateral decubitus radiograph, or cross-sectional imaging if there is clinical concern for pneumoperitoneum. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with sepsis // assess pulm edema assess pulm edema COMPARISON: Prior chest radiographs ___ through ___ at 15:12. IMPRESSION: Moderate pulmonary edema has worsened since ___. Lung volumes are lower, with persistent relative elevation of the right hemidiaphragm. This may explain greater consolidation at the right lung base due to a combination of dependent edema and atelectasis, although pneumonia is not excluded. Moderate to severe cardiomegaly has worsened since ___, stable since ___. Pulmonary arteries are dilated probably due to pulmonary arterial hypertension. Pleural effusions are presumed, but not large. No pneumothorax. Right PIC line ends in the region of the superior cavoatrial junction. Radiology Report INDICATION: ___ year old woman with known sacral decub, persistent fevers // r/o abscess 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) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 4) Spiral Acquisition 5.7 s, 62.9 cm; CTDIvol = 16.3 mGy (Body) DLP = 1,025.1 mGy-cm. 5) Spiral Acquisition 1.0 s, 11.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 144.5 mGy-cm. Total DLP (Body) = 1,179 mGy-cm. COMPARISON: None. FINDINGS: Chest: For complete intrathoracic findings, please refer to CT chest dated ___, clip number ___. Abdomen: The liver appears homogeneous in attenuation without a focal lesion identified. There is mild periportal edema. There is no intrahepatic biliary duct dilation. The gallbladder is without radiopaque cholelithiasis. The pancreas, spleen, and bilateral adrenal glands are normal in appearance. The kidneys present symmetric nephrograms and excretion of contrast. There is no hydronephrosis or focal renal lesion. The stomach, duodenum, and loops of small bowel are grossly normal in appearance without evidence of bowel wall thickening or obstruction. The appendix is visualized, air filled and normal. Mild diverticular disease involves the sigmoid colon without evidence of diverticulitis. Small volume abdominal fluid is nonhemorrhagic and layers within the pelvis. The abdominal aorta demonstrates moderate atherosclerotic calcifications without aneurysmal dilatation. There is no retroperitoneal or mesenteric adenopathy. A Foley catheter is present within a otherwise unremarkable bladder. Foci of air anteriorly is iatrogenic. The uterus is unremarkable. There is no adnexal mass. A rectal tube is present. There is no inguinal or pelvic sidewall adenopathy. A sacral decubitus ulcer is identified on series 2, ___ 91. With erosion of soft tissues down to the osseous structures. There is no cortical disruption to suggest osteomyelitis. Diffuse anasarca is moderate. No osseous lesion worrisome for malignancy or infection is identified. IMPRESSION: 1. Sacral decubitus ulcer with soft tissue defect exposing the osseous structures. There is no definite evidence for osteomyelitis. MRI would be more sensitive for evaluation of osteomyelitis. 2. No evidence of intra-abdominal infectious process. No abscess is identified. 3. Small volume nonhemorrhagic abdominal free fluid, mild periportal edema, and diffuse anasarca likely reflective of volume status. 4. For complete intrathoracic findings, please refer to CT chest dated ___, clip number ___. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ female with persistent fevers. TECHNIQUE: Multi detector CT images through the torso were obtained after the administration of intravenous contrast. Coronal and sagittal reformations were generated and reviewed. Axial maximum intensity projections sequences were additionally acquired. DOSE: DLP: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP = 9.6 mGy-cm. 4) Spiral Acquisition 5.7 s, 62.9 cm; CTDIvol = 16.3 mGy (Body) DLP = 1,025.1 mGy-cm. 5) Spiral Acquisition 1.0 s, 11.0 cm; CTDIvol = 13.2 mGy (Body) DLP = 144.5 mGy-cm. Total DLP (Body) = 1,179 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: None prior FINDINGS: The imaged thyroid gland is homogeneous in attenuation without a focal lesion identified. There is no axillary or supraclavicular adenopathy. Numerous central nodes are present, the largest located within the right lower paratracheal station which measures approximately 5 mm in short axis (02:16). A subcarinal node measures approximately 1.1 x 2.5 cm (02:23). Right hilar node measures 1.5 x 1.5 cm (02:20). Heart size is borderline enlarged. A central venous catheter terminates within the right atrium. The ascending aorta is non aneurysmal. The main pulmonary artery is enlarged, suggestive of though not diagnostic for pulmonary hypertension. Extensive atherosclerotic calcifications involve the coronary arteries, predominantly the left anterior descending coronary artery. Moderate aortic valvular calcifications are additionally noted. Trace pericardial fluid is present, nonhemorrhagic. There is no esophageal abnormality. Lung windows demonstrate patent airways. Bilateral nonhemorrhagic and layering pleural effusions, right greater than left, are small to moderate in size. Predominantly involving the right upper lobe, there are diffuse ground-glass opacities with interlobular septal thickening, findings most likely reflect pulmonary edema. Consolidated lung within the lower lobes bilaterally with air bronchograms is likely reflective of atelectasis though infectious process cannot be excluded. Anterior fifth, sixth, and seventh right rib fractures are nondisplaced and appear subacute. No suspicious lesion worrisome for malignancy or infection is identified. For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis performed on the same date, ___, clip number ___. IMPRESSION: 1. Cardiomegaly, diffuse ground-glass opacities with interlobular septal thickening, small pericardial effusion and bilateral nonhemorrhagic pleural effusions most likely reflect sequela of pulmonary edema. Consolidative lung within the lower lobes bilaterally most consistent with atelectasis although infectious process cannot be entirely excluded. 2. Enlarged pulmonary artery is suggestive of though not diagnostic for pulmonary hypertension. 3. Extensive atherosclerotic calcifications involve the coronary arteries. Aortic valvular calcifications additionally noted. 4. For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis performed on the same date, ___, clip number ___. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ RA, fibromyalgia and htn, p/w hypotension and tachycardia on ___, found to have a sig. R buttock DQ ulcer stage IV, s/p debridement, and + c. diff infection, in ICU for respiratory distress thought ___ pulm edema; now requiring more oxygen. // interval change IMPRESSION: As compared to ___ chest radiograph, cardiomegaly is stable, pulmonary vascular congestion has slightly improved, with associated decreasing asymmetrical pulmonary edema. Bibasilar areas of atelectasis and or consolidation have also slightly improved along with near resolution of a small left pleural effusion. No other relevant changes. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with stage IV decubitus ulcer complicated by osteomyelitis, clostridium difficile colitis with elevated alkaline phosphatase and positive GGT. Evaluate for biliary pathology. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT from ___. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is a small amount of ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm. GALLBLADDER: The gallbladder relatively contracted. Gallbladder wall edema and pericholecystic fluid is nonspecific and likely due to third spacing. No gallstones are seen. There is a possible gallbladder polyp. PANCREAS: 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 10.0 cm. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. A partially visualized right pleural effusion is noted. IMPRESSION: 1. Gallbladder wall edema and pericholecystic fluid is consistent with third spacing. 2. Small amount of ascites and partially visualized right pleural effusion. Radiology Report EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS INDICATION: ___ year old woman with BRBPR s/p 3 U pRBCs, evaluate location of bleed. TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) CT Localizer Radiograph 4) Spiral Acquisition 4.5 s, 49.5 cm; CTDIvol = 3.7 mGy (Body) DLP = 185.2 mGy-cm. 5) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8 mGy-cm. 6) Spiral Acquisition 6.1 s, 47.8 cm; CTDIvol = 15.8 mGy (Body) DLP = 755.1 mGy-cm. 7) Spiral Acquisition 6.1 s, 47.8 cm; CTDIvol = 15.8 mGy (Body) DLP = 756.8 mGy-cm. Total DLP (Body) = 1,702 mGy-cm. COMPARISON: CT abdomen pelvis from ___ FINDINGS: LOWER CHEST: There are bilateral moderate nonhemorrhagic pleural effusions with adjacent compressive atelectasis, unchanged since prior study atherosclerotic calcifications of the coronary arteries are noted. There is a trace pericardial effusion, similar to prior study. 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 nondistended. There is gallbladder wall edema, likely reflective of third spacing. The portal vein is patent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones, focal renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is grossly unremarkable. There is active extravasation of contrast into the sigmoid colon (3A: 110) which becomes more diffuse on the subsequent portal venous space compatible with active bleeding. Other areas of hyperdensity within areas of small bowel (3a: 112, 94, 115, and 121) are present on the noncontrast phase without significant change in the portal venous phase, and likely represent retained contrast from prior study or ingested material as opposed to true active bleeding. Small and large bowel are normal in caliber without dilatation or wall thickening. There is mild diverticulosis of the sigmoid colon. The appendix is visualized and normal. There is no mesenteric or retroperitoneal lymphadenopathy. There is moderate amount of ascites, increased since the prior study. VASCULAR: The abdominal aorta is normal in caliber without aneurysmal dilatation. There are moderate atherosclerotic calcifications. There are atherosclerotic calcifications of the origin of the bilateral renal arteries without significant distal flow limiting stenosis. PELVIS: A Foley catheter is seen within a nondistended bladder. Air within the bladder is likely related to Foley catheter manipulation. There is no evidence of pelvic or inguinal lymphadenopathy. There is moderate amount of free fluid within the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: A large sacral decubitus wound is again identified extending to the bony sacrum. A wound VAC is identified overlying this defect. There is diffuse anasarca within the subcutaneous soft tissues. IMPRESSION: 1. Active contrast extravasation within the sigmoid colon compatible with active bleeding. Mild sigmoid diverticulosis. Other areas of hyperdensity throughout segments of small bowel seen on all phases are likely related to prior retained contrast or ingested material as opposed to true active bleeding. 2. Bilateral moderate nonhemorrhagic pleural effusions with compressive atelectasis. 3. Moderate amount of intra-abdominal and intrapelvic ascites. Diffuse anasarca. 4. Gallbladder wall thickening, likely related to third spacing. 5. Large sacral decubitus wound extending to the bony sacrum covered by wound vac. NOTIFICATION: Findings were discussed with ___ by ___ phone at 12:15pm on ___, 5 minutes following discovery. Radiology Report INDICATION: ___ year old woman with GI bleed // GI bleed COMPARISON: CT abdomen pelvis dated ___. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. 37.5 mcg fentanyl was administered. MEDICATIONS: 1% lidocaine, 37.5 mcg fentanyl. CONTRAST: 106 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 23:30 min, 956 mGy PROCEDURE: 1. Right common femoral artery access. 2. Inferior mesenteric arteriogram. 3. Left Colic arteriogram. 4. Left Colic branch #1 arteriogram. 5. Left Colic branch #2 arteriogram. 6. Embolization of left colic artery branches 1 and 2 with figure of 8 coils and post embolization left colic arteriogram. 7. Superior mesenteric arteriogram. 8. Right common femoral vein access, ultrasound guided. 9. Placement of a triple-lumen central line via the right common femoral vein. 10. Right common femoral artery arteriogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient and her daughter. 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. Both groins were prepped and draped in the usual sterile fashion. Using palpatory and fluoroscopic guidance, the right common femoral artery was punctured using a micropuncture set at the level of the mid-femoral head. A 0.018 wire was passed easily into the vessel lumen. A small skin incision was made over the needle. Then the inner dilator and wire were removed and a ___ wire was advanced under fluoroscopy into the aorta. The micropuncture sheath was exchanged for a 5 ___ sheath which was attached to a continuous heparinized saline side arm flush. A RIM catheter was advanced over ___ wire into the aorta. The wire was removed and the inferior mesenteric artery was selectively cannulated and a small contrast injection was made to confirm position. A inferior mesenteric artery arteriogram was performed. An ___ micro catheter and Transcend micro wire were then carefully guided into the left colic artery. The wire was removed, and a contrast injection was performed to confirm positioning. A left colic arteriogram was performed. The STC micro catheter and Transcend micro wire were then carefully guided into the left colic artery branch 1. The wire was removed, and a contrast injection was performed to confirm positioning. A left colic branch 1 arteriogram was performed. Embolization of left colic artery branch 1 was then performed with 5 figure of 8 non detachable microcoils (2 mm x 5 mm). A post embolization angiogram was performed. The ___ micro catheter and Transcend micro wire were then carefully guided into the left colic artery branch 2. The wire was removed, and a contrast injection was performed to confirm positioning. A left colic branch 2 arteriogram was performed. Embolization of left colic artery branch 2 was then performed with 3 figure of 8, 0.018 microcoils (2 mm x 5 mm). A post embolization angiogram was performed. The micro catheter and micro wire were then removed. The RIM catheter was disengaged from the inferior mesenteric artery, and was exchanged for a C2 Cobra catheter over ___ wire. The C2 Cobra catheter was used to carefully cannulate the superior mesenteric artery. A contrast injection was performed to confirm positioning. A superior mesenteric arteriogram was performed. The right common femoral artery sheath was then injected with contrast, performing a right common femoral arteriogram. At the request of the medicine service, a central line was placed. US revealed patency of the right common femoral vein. Sonographic images were aquired. Using ultrasound and fluoroscopic guidance, the right common femoral vein was punctured using a micropuncture set at the level of the mid femoral head. A 0.018 inch wire was then passed easily into the vessel lumen. A small skin incision was made over the needle. Then the inner dilator and wire were removed and ___ wire was advanced under fluoroscopy into the IVC. The micropuncture sheath was exchanged for a triple lumen central catheter over wire. The wire was removed. All 3 lumens were aspirated and flushed. The catheter was secured to the skin with silk sutures. A sterile dressing was applied. All catheters and wires were removed. Right common femoral arterial access h emostasis was achieved with a ___ Angio-Seal device and manual pressure. Sterile dressings were applied. The patient tolerated the procedure well without any immediate complications. FINDINGS: 1. Inferior mesenteric arteriogram demonstrates brisk bleeding from a branch of the left colic artery. 2. Left Colic arteriogram demonstrates brisk bleeding from a branch of the left colic artery, with delineation of the anatomy of the feeding arterial vessels. 3. Left Colic branch #1 arteriogram demonstrates brisk bleeding from this specific branch. 4. Left Colic branch #2 arteriogram demonstrates brisk bleeding from this specific branch. 5. Coil embolization of left colic artery branches 1 and 2 with post embolization left colic arteriogram demonstrating no further active extravasation. 6. Superior mesenteric arteriogram demonstrates no active extravasation. 7. Right common femoral vein access, ultrasound guided. Placement of a triple-lumen central line via the right common femoral vein. The line is ready for use. 8. Right common femoral artery arteriogram demonstrates appropriate puncture site for use of an Angio-Seal device. IMPRESSION: Brisk bleeding for multiple branches of the left colic artery treated with coil embolization with good angiographic result. No further bleeding angiographically upon completion of the embolization. RECOMMENDATION(S): Continue to monitor hematocrit. Keep the rigth leg straight for 2 hr. Radiology Report INDICATION: ___ year old woman with ___ embolization of descending colon, with left sided abdominal pain // evidence of ileus, free air under diaphragm TECHNIQUE: Portable supine abdominal radiographs. COMPARISON: Portable abdominal radiograph ___. CT abdomen and pelvis ___. FINDINGS: Embolization coils are projected over the left lower quadrant from recent left colonic artery branch embolization. Hemidiaphragms have not been included on this abdominal radiograph. Air is seen within the stomach and multiple loops of small bowel, none of which are overly dilated. Small amount of air seen within the colon projected over the left hemipelvis. No bowel wall thickening. On the second abdominal radiograph obtained, there are streaks of linearly oriented air is noted overlying the the left hemi abdomen, which may reflect material/sheets external to the patient. No acute or aggressive osseous lesions are demonstrated. IMPRESSION: No dilated loops of large or small bowel.. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Weakness Diagnosed with Sepsis, unspecified organism, Other specified abnormal findings of blood chemistry, Essential (primary) hypertension temperature: 100.0 heartrate: 136.0 resprate: 20.0 o2sat: 96.0 sbp: 96.0 dbp: 56.0 level of pain: 4 level of acuity: 1.0

Dear Ms. ___, You came in the hospital because your daughter found you on the ground at home and you were very sick. You were found to have a severe wound on your right buttock that caused you to get an infection of your bone. You also were found to have an imbalance in the bacteria in your gut called "c diff." You were given antibiotics to treat these infections, and you improved, but since your infection was so severe you had to spend some time in the intensive care unit. You had several surgeries to clean out your wound and a biopsy of your bone to tell us which antibiotics to give you. You were given antibiotics through an IV and your infection improved. You also had a bleed from your colon and had to spend more time in the intensive care unit to keep you safe. You had several blood transfusions and had a procedure done to stop the bleeding. You improved and were transferred to another hospital to continue antibiotics and get you stronger. It is very important that you make it to all of your follow-up appointments and stop drinking alcohol. It was a pleasure being involved in your care! Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Right flank pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y.o. woman with HTN, HL, CAD, diabetes mellitus complicated by neuropathy who presents with R flank pain. The patient reports that for the past ___ months, the patient has been experiencing intermittent episodes of sharp pain on her lower back. She reports that the pain would occasionally radiate to her R flank and inner R thigh. She describes the pain as a sharp, shooting pain that is worsened by sitting down or lying flat. She is unable to identify any triggers for the pain. The patient denies any recent falls or injuries. The patient endorses decreased urinary output in the past two weeks that is associated with burning on urination. The patient denies any dyspepsia, diarrhea, or constipation. Yesterday, the patient reports that the pain increased in severity and became an ___ sharp constant pain that did not radiate. She reports that Tylenol does not provide any relief. She reports that she was febrile to 102.9 and this was associated with nausea and poor appetite. The patient subsequently presented to the ED where her VS were 98 HR: 111 BP: 153/73 Resp: 18 O(2)Sat: 99 % RA. Initial labs were notable for normal electrolytes, Lactate 3.4, Glucose 139, normal LFTs, and lipase. UA was notable for trace blood, 100 protein, but negative for bacteria, nitrites, or leukocyte esterase. An Abd/Pelvic CT was notable for layering sludge or small stones in the gall bladder, but unremarkable for cholecystitis, renal or ureteral stones, hydronephrosis, or perinephric abnormalities. The patient was given IV fluids, Morphine, and Toradol and transferred to the floor for further diagnostic workup and management. Past Medical History: 1. Diabetus mellitus 2. Hypertension 3. Hypercholesterolemia 4. Coronary Artery Disease 5. Asthma 6. S/p two C-sections 7. Abdominal cellulitis (over ___ years ago) s/p pannilectomy 8. Pulmonary infection (?PCP) at ___ ___ year ago) Social History: ___ Family History: Breast and ovarian cancer, mother had diabetes Physical Exam: Vitals: 98 98 ___ (119/50-143/65) ___ 93-99% RA General- Resting in bed in pain. Appears short of breath. HEENT- Sclera anicteric, MMM, oropharynx clear Neck- Supple, no JVD, no LAD. Acanthosis nigricans on neck. Lungs- CTAB CV- RRR, normal S1 + S2, no murmurs, rubs, gallops Back: No spinal tenderness. R>L CVA tenderness. No focal tenderness on palpation of posterior hips bilaterally. Abdomen- Obese, no umbilicus. Scars under folds of skin at pubis. No rashes. Soft, non-distended. +Normactive BS. No focal tenderness, rebound tenderness, or guarding. Unable to assess hepatomegaly or splenomegaly. No masses. No suprapubic tenderness. No tenderness over RUQ on palpation with deep inspiration GU- Exam deferred. Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Negative Psoas Sign. Negative Straight Leg Test. Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: Admission Labs: --------------- ___ 01:05PM BLOOD WBC-8.8 RBC-5.15 Hgb-14.6 Hct-43.8 MCV-85 MCH-28.4 MCHC-33.5 RDW-13.3 Plt ___ ___ 01:05PM BLOOD Neuts-61.2 ___ Monos-4.9 Eos-6.2* Baso-0.5 ___ 01:05PM BLOOD Plt ___ ___ 01:05PM BLOOD Glucose-139* UreaN-13 Creat-0.8 Na-142 K-4.4 Cl-105 HCO3-23 AnGap-18 ___ 01:05PM BLOOD ALT-23 AST-23 LD(LDH)-224 AlkPhos-60 TotBili-0.3 ___ 01:05PM BLOOD Lipase-34 ___ 01:05PM BLOOD Albumin-4.1 ___ 01:12PM BLOOD Lactate-3.4* Discharge Labs: --------------- ___ 06:55AM BLOOD WBC-8.4 RBC-4.61 Hgb-12.9 Hct-39.6 MCV-86 MCH-28.0 MCHC-32.7 RDW-13.3 Plt ___ ___ 06:55AM BLOOD Glucose-175* UreaN-13 Creat-0.7 Na-140 K-4.6 Cl-106 HCO3-26 AnGap-13 ___ 01:05PM BLOOD ALT-23 AST-23 LD(LDH)-224 AlkPhos-60 TotBili-0.3 ___ 06:55AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9 ___ 01:05PM BLOOD Albumin-4.1 ___ 01:38PM BLOOD Lactate-1.4 Imaging: --------------- CT Urogram (ABD/PEL) W/O CONTR ___ IMPRESSION: 1. No evidence of renal or ureteral stones, hydronephrosis or perinephric abnormalities. 2. Tiny layering stones within the gallbladder with no evidence of cholecystitis. Microbiology: --------------- ___ URINE URINE CULTURE-FINAL NEGATIVE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Lisinopril 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Amlodipine 10 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. Pravastatin 20 mg PO DAILY 8. Zolpidem Tartrate 10 mg PO HS 9. QUEtiapine Fumarate 25 mg PO QAM 10. Lantus *NF* (insulin glargine) 50 units Subcutaneous HS 11. Victoza 2-Pak *NF* (liraglutide) 18 units Subcutaneous QAM Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 600 mg PO TID 5. Lisinopril 40 mg PO DAILY 6. Pravastatin 20 mg PO DAILY 7. QUEtiapine Fumarate 25 mg PO QAM 8. Zolpidem Tartrate 10 mg PO HS 9. Tizanidine 2 mg PO BID RX *tizanidine 2 mg 1 tablet(s) by mouth twice daily as needed for back pain Disp #*6 Tablet Refills:*0 10. Lidocaine 5% Patch 1 PTCH TD DAILY RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to lower back once daily for 12 hours and then remove Disp #*4 Transdermal Patch Refills:*0 11. Lantus *NF* (insulin glargine) 50 units Subcutaneous HS 12. Victoza 2-Pak *NF* (liraglutide) 18 units Subcutaneous QAM 13. Walker V724.2 Lumbago Please obtain a walker. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Muscle strain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: 3 months of right flank pain and fever. Evaluation for renal stones. TECHNIQUE: MDCT images were obtained of the abdomen and pelvis without the administration of oral or intravenous contrast. The patient refused intravenous contrast. Reformatted coronal and sagittal images were also reviewed. COMPARISON: Renal ultrasound from ___. FINDINGS: CT ABDOMEN WITHOUT IV CONTRAST: The bases of the lungs are clear. The liver demonstrates no focal lesions. There is no intrahepatic biliary ductal dilatation. There is some dependent layering high density material in the gallbladder (2:35), likely small stones. There are no secondary signs of cholecystitis. The pancreas, spleen, bilateral adrenal glands have an unremarkable noncontrast appearance. Minimal atherosclerotic calcifications are present within the abdominal aorta and renal arteries. There is no evidence of renal or ureteral stones. There is no hydronephrosis. No perinephric abnormalities are identified. The stomach and duodenum are unremarkable and the intra-abdominal loops of large and small bowel are of normal caliber and contour with no evidence of obstruction. There is no intraperitoneal free air or free fluid. CT PELVIS: The bladder is unremarkable. There is no evidence of stones within the bladder or at the ureterovesicular junction. The rectum and sigmoid colon are normal in appearance. There is no pelvic free fluid. The uterus is unremarkable. No adnexal masses are identified. The appendix is well visualized in the right lower quadrant and is normal. OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of renal or ureteral stones, hydronephrosis or perinephric abnormalities. 2. Tiny layering stones within the gallbladder with no evidence of cholecystitis. Gender: F Race: HISPANIC/LATINO - DOMINICAN Arrive by WALK IN Chief complaint: R Flank pain Diagnosed with ABDOMINAL PAIN OTHER SPECIED temperature: 98.0 heartrate: 111.0 resprate: 18.0 o2sat: 99.0 sbp: 153.0 dbp: 73.0 level of pain: 9 level of acuity: 3.0

Dear Ms. ___, You were admitted with back pain. There was some concern that this may be related to your kidney, but imaging and lab studies confirmed that it is a muscle strain. You worked with physical therapy and were given a lidocaine patch and a medicine called tizanidine to control the pain. In addition, physical therapists will visit you at home to work through some exercises. Finally, ___ ointment can help with the pain, and you can find this over the counter at a pharmacy. It was noticed that your metformin is causing a bad reaction, and that you can no longer take it. You have been scheduled to see the diabetes specialists at the ___ in 3 days. The details are described below. It is very important that you go to that appointment.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Heparin Agents Attending: ___. Chief Complaint: unwitnessed fall Major Surgical or Invasive Procedure: orthopedic surgery: R patellar open reduction and internal fixation History of Present Illness: The patient is a ___ w/ PMH HTN, HLD, DM, CAD s/p multiple MIs on medical management, CHF with EF 30%, s/p CAV ___ w/ resultant aphasia and R sided weakness, PAD s/p toe amputation, presenting after an unwitnessed fall. The paitient has difficulty expressing himself, but says he was on his way to use the bathroom (for both urination and bowels) when he fell down. He denies tripping or mechanical fall, he denies any pre-syncopal feelings such as CP, SOB, lightheadedness, or palpitations. He is not sure whether or not he lost conciousness, but he says he does not remember falling, and does not remember why he fell. He patient injured his R knee during the fall. Per the patient's daughter, the patient's aide heard him fall and came to find him on the bathroom floor, it seemed like he had fallen when he was turning around to sit down on the toilet. He was awake at that time. In the ED, the patient's VS were T 99.6 HR 84 BP 143/74 RR 14 O2sat 97% ra. He got ondansetron and morphine 5 mg. R knee X-ray showed patellar fracture, and orthopedics saw that patient in the ED and placed an immobilizer. CT head and C spine were wnl. CXR showed no acute process. R arm X-ray showed no fracture. He had elevated troponins 0.73 and then 0.71 with negative MB. He was admitted to cardiology for further workup of this syncopal episode. ROS: patient denies fever, chills, diarrhea, constipation, dysuria, and blood in the stool. Denies CP or SOB. He says he had some vomiting a week ago but feels better now. The patient's daughter says he has been in his usual state of health recently. Past Medical History: -- CVA w/ expressive aphasia ___: Residual expressive aphasia and right sided weakness, mostly wheelchair bound but gets up for transfers, adamantly refused ___ in past. -- CAD: S/p multiple MIs, including NSTEMI in ___ (attributed to acute OM2 occlusion, medically managed for 3VD on cardiac cath as not CABG candidate; followed by Dr. ___ -- Chronic systolic and diastolic CHF: EF 20% on ___ TTE post-MI -> ___ on ___ echo. -- CRF, likely ___ diabetes -- Depression -- Diabetes -- Hypertension -- HLD -- PVD s/p toe amputation ___ -- retinopathy -- glaucoma ___ doctor, had been unwilling to work with any mental health professionals; not currently followed by psychiatrist - H/o violence: Fired from ___ practice due to violence toward staff Social History: ___ Family History: mother with diabetes and heart disease. Physical Exam: ADMISSION EXAM: VS- T 98.2 BP 133/70 HR 81 RR 20 O2sat 100% ra GENERAL- NAD, frustrated with inability to tell his story, crying at one point, otherwise appropriate affect HEENT- EOMI, PERRL NECK- Supple with JVP of 10 cm. CARDIAC- RRR S1S2 no murmurs LUNGS- difficult to assess lung exam per patient cooperation and pain with moving from knee fracture. No crackles aneriorly, good air movement. ABDOMEN- soft NTND, + BS EXTREMITIES- no edema, vascular changes ___ arterial insufficiency, with an ulcer on R great toe, R little toe amputation. unable to feel pulses but extremeties warm b/l. R leg is in a brace per ortho recs. Neuro: alert and oriented, aphasic able to answer with few word answers. can move all extremeties. can feel all extremeties. EOMI. DISCHARGE EXAM: unchanged, R knee s/p ortho repair in a new mobile brace Pertinent Results: ___ 09:45AM CK(CPK)-245 ___ 09:45AM CK-MB-3 cTropnT-0.71* ___ 04:30AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 03:43AM GLUCOSE-179* UREA N-15 CREAT-1.3* SODIUM-134 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13 ___ 03:43AM estGFR-Using this ___ 03:43AM CK(CPK)-226 ___ 03:43AM CK-MB-3 cTropnT-0.73* ___ 03:43AM WBC-9.8 RBC-4.39* HGB-13.5* HCT-38.8* MCV-88 MCH-30.8 MCHC-34.8 RDW-13.8 ___ 03:43AM NEUTS-81.3* LYMPHS-13.0* MONOS-3.9 EOS-1.5 BASOS-0.3 ___ 03:43AM PLT COUNT-331 IMAGING- ___ CT Head w and w/o contrast: No acute intracranial process. CT C-spine: No acute fracture or malalignment. R knee X-ray: Transverse fracture of the patella. CXR: No acute cardiothoracic process. R arm, forearm, wrist Xray: No acute fracture or dislocation. EKG: no significant change from prior. NSR. Left bundle branch block with repolarization abnormalities. ECHO ___: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate to severe regional left ventricular systolic dysfunction with inferior and apical akinesis with a dyskinetic apical aneurysm.. There is an apical left ventricular aneurysm. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle with inferior and apical akinesis. There is an apical aneurysm that is dyskinetic - no evidence of thrombus seen with myocardial contrast. Mild aortic regurgitation. X ray Knee ___ (after surgery) 1. Status post open reduction internal fixation of previously noted displaced, mildly comminuted transverse mid pole right patellar fracture. 2. Surgical hardware intact. 3. Fragments of the patella are in near anatomical alignment. Labs ___ Na 134-->130 (about at baseline, likely partially dilutional after surgery) Hb 13.5 --> 11.9 after surgery (likely ___ hemodilution and blood loss) patient refused all lab draws in between admission and discharge. Radiology Report INDICATION: ___ with fall. TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal reformats were acquired. COMPARISON: Head CT from ___. FINDINGS: CT OF THE HEAD: Again seen is extensive multifocal cystic encephalomalacia related to chronic infarcts in the left more than right frontal, parietal, and occipital lobes and right cerebrallar hemisphere with associated ex vacuo dilatation of the left lateral and fourth ventricles, respectively. Chronic microvascular changes are again seen involving the centrum semiovale and periventricular white matter and no change from ___. There is a small frontal lipoma, unchanged. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: No evidence of hemorrhage or fracture. Extensive chronic infarctions, unchanged since ___. Radiology Report INDICATION: ___ with fall. TECHNIQUE: Contiguous MDCT images through the C-spine were obtained. Axial, coronal, and sagittal reformats were acquired. COMPARISON: CT of the C-spine from ___. FINDINGS: CT OF THE C-SPINE: There is no evidence of fracture, malalignment or prevertebral soft tissue swelling. Posterior osteophytes at C3-C4 and C6-C7 cause mild spinal canal narrowing and left greater than right facet hypertrophy, unchanged from ___. Emphysematous changes are seen at the lung apices. IMPRESSION: No acute fracture or acute malalignment. NOTE ADDED AT ATTENDING REVIEW: The large posterior osteophytes at C3-4 cause severe narrowing of the right side of the spinal canal. Although poorly characterized on non contrast CT, this appears to compress or displace the spinal cord on the right. There is a small midline protrustion at C4-5, and osteophytes significantly narrowing the spinal canal at C6-7. Radiology Report INDICATION: ___ after fall. TECHNIQUE: Four views of the right elbow were obtained. COMPARISON: None. FINDINGS: Extremely limited study due to difficult positioning. Enthesophyte is seen at the olecranon process of the ulna. There is no elbow joint effusion, dislocation or acute fracture. IMPRESSION: No acute fracture or dislocation. Radiology Report INDICATION: ___ after fall. TECHNIQUE: Frontal and lateral radiographs of the chest were obtained. COMPARISON: Chest radiograph from ___. FINDINGS: Low lung volumes. The cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. No evidence of pneumonia. IMPRESSION: No acute cardiothoracic process. Radiology Report INDICATION: ___ after fall. TECHNIQUE: Three views of the right knee were obtained. COMPARISON: None. FINDINGS: There is a displaced transverse fracture through the patella with prepatellar soft tissue swelling and only a small knee joint effusion. No other fractures are seen. IMPRESSION: Transverse fracture of the patella. Radiology Report STUDY: Right wrist, ___. CLINICAL HISTORY: ___ man status post fall. FINDINGS: THREE VIEWS OF THE RIGHT WRIST: There are degenerative changes of the first CMC and triscaphe joints. There are no signs for acute fractures or dislocation. Mineralization is normal. RIGHT FOREARM: No acute fractures or dislocations are seen. There is normal osseous mineralization. There is a prominent spur at the distal attachment of triceps to the olecranon. Radiology Report HISTORY: ___ man who is status post right patellar fracture. Status post open reduction and internal fixation. TECHNIQUE: Four intraoperative fluoroscopic images of the right knee. COMPARISON: Radiographs of the right knee performed on ___ at 0612 hours. FINDINGS: Two K-wires extend in vertical axis through the patella. Surgical cerclage wire courses in a figure-of-eight pattern along the anterior aspect of the patella. Markedly improved alignment of the patient's previously noted mildly comminuted transverse, displaced fracture of the patella. Fragments of the patella are in near anatomical alignment at this time. Distal right femur as well as the proximal right tibia and fibula are intact and normal in appearance. Please refer to the operative not for further description. IMPRESSION: 1. Status post open reduction internal fixation of previously noted displaced, mildly comminuted transverse mid pole right patellar fracture. 2. Surgical hardware intact. 3. Fragments of the patella are in near anatomical alignment. Please refer to the operative not for further description. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: S/P SLIP AND FALL Diagnosed with ABN SERUM ENZY LEVEL NEC, FRACTURE PATELLA-CLOSED, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA temperature: 99.6 heartrate: 84.0 resprate: 14.0 o2sat: 97.0 sbp: 143.0 dbp: 74.0 level of pain: 9 level of acuity: 3.0

Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted after a fall at home. It does not seem like you had any heart problems that caused the fall. However, you did break your R kneecap in the fall, which was repaired by orthopedic surgery in house. You can put as much weight on the leg as is tolerable with the pain, and we encourage as much ambulation as possible to get you back on your feet. It is important that you follow with physical therapy at home. It is important that you take all medications as perscribed, and keep all follow up appointments. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. When you see your primary doctor, please have then check your sodium level, as it has been a little low in the past and has been low in the hospital as well.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: tremor; AMS. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ PMH ESRD on HD ___, ___, Type 2 DM, seizure disorder after intracranial right hemispheric bleed ___, CVA in ___, ICH in ___ and recurrent UTIs who presents to the ED with tremor. The patient went to dialysis today. Daughter called to check up on how dialysis went (received whole session). Dialysis center said his hand shook on the left per daughter--just his hand, for seconds-to-minutes. Looked a little tired per daughter. Reported dry cough for months, but otherwise daughter noted no other complaints. Patient confirmed story in the ED, saying he remembers the whole incident, had a few minutes of tremors, no post-ictal state. The patient was taken to ___ where he was given amp/gent/cefepime at 3pm for uti (UA showed 1 epi, 29 rbc, 23 wbc, large leuk, neg nitrite, few bact). The pto come to ___, was told no beds for transfer, left AMA and came to ___. Notably from ___ to ___ patient was admitted for complicated urinary tract infection. The patient was admitted due to a floridly positive UA concerning for a complicated UTI. The patient was treated empirically treated with IV zosyn and vancomycin. He was transitioned to Bactrim for total 14 day course to end on ___. The patient's urine culture showed 10,000 CFU of GNR's thought to most likely be klebsiellae. Given his past pan-sensitive klebsiellae infection he was discharged on PO Bactrim to take 3 DS tabs post-hemodialysis on ___, ___. No f/c/s. Noted mild diarrhea past few days. In the ED, initial vital signs were: 98.0 64 156/72 18 98% . - Exam notable for: - Fistula good thrill - LLL crackles - Neuro NF except unable to assess OS due to blind and irregular pupil, LUE weakness (recent neuro note documents LUE weakness) - Labs were notable for: - Creatinine 4.3 (on HD) - Lactate 1.0 - Studies performed include: ___ CXR- Predominantly linear opacities in the left lower lobe may represent atelectasis. However, superimposed pneumonia is difficult to exclude in the appropriate clinical setting. - Patient was given: ___ 05:10 IV CeftriaXONE ___ Started ___ 06:17 IV CeftriaXONE 1 g ___ Stopped (1h ___ ___ 09:26 SC Insulin 0 Units ___ ___ 11:20 PO LevETIRAcetam 500 mg ___ ___ 11:20 PO/NG Lisinopril 2.5 mg ___ ___ 11:20 PO Metoprolol Succinate XL 50 mg ___ ___ 11:26 PO/NG LACOSamide 150 mg ___ - Vitals on transfer: 98.3PO 179/68 83 18 97RA Upon arrival to the floor, the patient states story as above. Shaking in left hand during HD, otherwise felt fine, did not feel like prior seizures. Falsely states he's anuric. Pan-denies any symptoms such as chest pain, dyspnea, cough, abdominal pain, fever, chills. Review of Systems: A full 10-point ROS was performed and was negative except as stated in HPI. Past Medical History: -- Chronic kidney disease, now on HD - Recurrent UTIs, usually treated with nitrofurantoin. Has previously had VRE UTI, but most recently has had enterococcus and klebsiella sensitive to nitrofurantoin - Diabetes mellitus, type 2: Complicated by nephropathy, retinopathy, andneuropathy. He has left eye blindness as a result of hisretinopathy. He is currently insulin-dependent - Dyslipidemia - Hypertension - Possible coronary artery disease: ECG findings of anterior, septal, and inferior distribution - Peripheral vascular disease: S/p R tibialis stent ___ and transmetatarsal amputation. - Persistent opacification of left lung base, uncertain etiology. - Incidental right upper lobe 4mm nodule ___ - Seizure disorder: Followed by neurology. History of parietotemporal intracranial hemorrhage in ___ status post craniectomy secondary to alcohol and head trauma. Last seizure ___ in status epilepticus after levitiracetam was underdosed. - Cerebrovascular accident (___) with left sided paralysis - Spindle cell carcinoma in his inguinal region, biopsy ___ - Asthma - History of alcoholism, last drink ___ - Gangrenous cholecystitis, s/p cholecystectomy - Malnutrition Social History: ___ Family History: Mom - no reported history Dad - died from liver cirrhosis due to alcohol use ___ - died in a fire Sister died of "heart trouble." Physical Exam: ADMISSION: ========= Vitals- 98.3PO 179/68 83 18 97 RA GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. Left eye blind, non-reactive. CARDIAC: RRR, no m/r/g LUNGS: CTAB ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation, no supra-pubic tenderness EXTREMITIES: No clubbing, cyanosis, or edema; these is some brusing on shins NEUROLOGIC: CN2-12 grossly intact. 4+/5 strength througout. No tremor. DISCHARGE: ========== Vitals: Tmax 99 BP 150/50-70s HR ___ RR 18 ___ on RA GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. Left eye blind, non-reactive. CARDIAC: RRR, no m/r/g LUNGS: CTAB ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation, no supra-pubic tenderness EXTREMITIES: No clubbing, cyanosis, or edema; these is some bruising on shins NEUROLOGIC: CN2-12 grossly intact. 4+/5 strength throughout. No tremor. LUE fistula: bruit and thrill + Pertinent Results: ADMISSION: ========== ___ 12:40AM BLOOD WBC-6.3 RBC-3.76* Hgb-10.4* Hct-34.0* MCV-90 MCH-27.7 MCHC-30.6* RDW-14.0 RDWSD-46.4* Plt ___ ___ 12:40AM BLOOD Neuts-72.6* Lymphs-12.7* Monos-11.3 Eos-2.9 Baso-0.3 Im ___ AbsNeut-4.57 AbsLymp-0.80* AbsMono-0.71 AbsEos-0.18 AbsBaso-0.02 DISCHARGE: ========== ___ 08:15AM BLOOD Glucose-95 UreaN-26* Creat-5.6*# Na-142 K-4.4 Cl-100 HCO3-28 AnGap-18 ___ 08:15AM BLOOD WBC-7.1 RBC-3.59* Hgb-10.2* Hct-33.0* MCV-92 MCH-28.4 MCHC-30.9* RDW-14.6 RDWSD-48.5* Plt ___ MICRO: ===== URINE CULTURE (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ======= CXR ___ Heart size is more prominent since prior. Normal pulmonary vascularity. No edema. Left basilar consolidation is more prominent, may represent atelectasis or pneumonia. More prominent partially loculated small left pleural effusion. Right infrahilar opacity is more prominent, may represent developing pneumonia. No right pleural effusion. No pneumothorax. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ammonium lactate 12 % topical BID 2. Clopidogrel 75 mg PO DAILY 3. LACOSamide 150 mg PO BID 4. LACOSamide 75 mg PO 3X/WEEK (___) After HD, in addition to standing dose 5. LevETIRAcetam 500 mg PO BID 6. LevETIRAcetam 250 mg PO 3X/WEEK (___) After HD, in addition to standing dose 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Simvastatin 40 mg PO QPM 9. Lisinopril 2.5 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 4 Doses 2. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 3. ammonium lactate 12 % topical BID 4. Clopidogrel 75 mg PO DAILY 5. LACOSamide 75 mg PO 3X/WEEK (___) After HD, in addition to standing dose 6. LACOSamide 150 mg PO BID 7. LevETIRAcetam 500 mg PO BID 8. LevETIRAcetam 250 mg PO 3X/WEEK (___) After HD, in addition to standing dose 9. Lisinopril 2.5 mg PO DAILY 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Nephrocaps 1 CAP PO DAILY 12. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis - Community acquired pneumonia Secondary diagnoses - Seizure disorder - End stage renal disease on HD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: Chest radiograph INDICATION: History: ___ with llll crackles, dialysis// pna TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___, ___, ___ FINDINGS: Predominantly linear opacities are seen in the retrocardiac region, which may represent atelectasis. However, superimposed pneumonia cannot be excluded in the appropriate clinical setting. Blunting of the left costophrenic angle may be due to a small pleural effusion. There is no pulmonary edema or pneumothorax. The cardiomediastinal silhouette and hilar contours are unchanged. Calcification seen projecting over the left lower lung may be due to pleural calcifications. Vascular stent projects over the expected region of the left axillary vein or artery. IMPRESSION: Predominantly linear opacities in the retrocardiac region may represent atelectasis. However, superimposed pneumonia is difficult to exclude in the appropriate clinical setting. Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with ESRD on HD with recurrent fever and recent CXR with ?basal consolidations.// please evaluate for interval change ie progression of PNA? TECHNIQUE: Chest two views COMPARISON: ___ FINDINGS: Heart size is more prominent since prior. Normal pulmonary vascularity. No edema. Left basilar consolidation is more prominent, may represent atelectasis or pneumonia. More prominent partially loculated small left pleural effusion. Right infrahilar opacity is more prominent, may represent developing pneumonia. No right pleural effusion. No pneumothorax. IMPRESSION: Interval mild worsening. Gender: M Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Tremor Diagnosed with Urinary tract infection, site not specified, Pneumonia, unspecified organism temperature: 98.2 heartrate: 93.0 resprate: 18.0 o2sat: 100.0 sbp: 169.0 dbp: 66.0 level of pain: 0 level of acuity: 3.0

Dear Mr. ___, You came to the hospital because you had a hand tremor at dialysis. You had some white blood cells in your urine, so you were initially treated for a urinary tract infection (UTI). The urine culture we took did not grow any bacteria, so we do NOT think you have a UTI. However, you continued to have fevers. We found that you had a pneumonia, which we treated with antibiotics, and you improved so that you were stable for discharge. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your ___ Health Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Tetracyclines Attending: ___. Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: Right femur retrograde nail. History of Present Illness: The patient is an ___ yo female with history of osteoporosis, transfer from OSH with right midshaft femur fracture after fall from standing into picnic table with direct strike on right thigh. Over past two months patient had developed right hip and upper thigh pain, xrays x 2 were negative. Unclear during this episode whether trauma occurred as a result of hitting the bench or as stress/insufficiency fracture causing her to fall into the bench. She has history of Fosamax use but discontinued several months ago because she no longer needed it. No head strike, LOC. No pain elsewhere. Denies numbness/tingling distally. Past Medical History: HTN Macular Degeneration (legally blind) Osteoporosis PSH: Bilateral TKR in ___ by Dr. ___ at ___ ___ in ___ Social History: ___ Family History: NC Physical Exam: DISCHARGE PHYSICAL EXAM: Gen: alert and oriented, no acute distress Cardio: RRR Resp: breathing unlabored RLE: Incisions clean/dry/intact, no excessive erythema, swelling, or drainage, foot and toes WWP with good cap refill, SILT saph/sural/tibial/sp/dp, fires ___ Radiology Report INDICATION: Known right femur fracture. Evaluation of orthopedic hardware as well as joints above and below the fracture. TECHNIQUE: Right femur, two views. FINDINGS: There is an oblique fracture of the femoral distal shaft, with 6cm of fragment overrifing, and one shaft width medial displacement. The distal fragment is angulated varus and anteriorly. The patient has a total right knee arthroplasty. There is no evidence of hardware loosening. Prominent vascular calcifications are noted. IMPRESSION: Displaced angulated fracture of the distal femoral shaft. Radiology Report INDICATION: Femur fracture. ORIF. COMPARISON: Radiographs from ___. IMPRESSION: Several fluoroscopic images of the right femur from the operating room demonstrates placement of an intramedullary rod with proximal and distal interlocking screws fixating a fracture involving the midshaft of the right femur. There is improved anatomic alignment. There is also a right total knee arthroplasty which appears grossly intact. The total intra service fluoroscopic time was 105 seconds. Please refer the operative note for additional details. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: FX FEMUR, Transfer Diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL, HYPERTENSION NOS temperature: 98.6 heartrate: 84.0 resprate: 18.0 o2sat: 97.0 sbp: 101.0 dbp: 66.0 level of pain: 4 level of acuity: 2.0

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 lovenox 30mg daily for 2 weeks WOUND CARE: - 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: - Activity as tolerated - Right lower extremity: weight bearing as tolerated, no ROM restrictions Physical Therapy: - Activity as tolerated - Right lower extremity: weight bearing as tolerated, no ROM restrictions Treatments Frequency: Wound: Surgical Incisions Comment: Keep incision clean and dry. OK to leave open to air if non-draining. If draining, dress with dry gauze and change daily or as necessary to keep dressings clean and dry

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: right hemiparesis, aphasia Major Surgical or Invasive Procedure: -Mechanical thrombectomy ___ -Percutaneous endoscopic gastrostomy (PEG) ___ History of Present Illness: ___ with PMH of AFIB on Eliquis (but non-adherent) s/p cardioversion for AFIB with RVR on ___ presented with global aphasia and right hemiparesis. She was last seen well on ___ at 2030 when she and her husband went to bed. He awoke at 1245 am when he heard a "bang" and he found his wife on the floor. She was immediately brought to ___ where she was found to have a left MCA hyperdensity on CT and a left M1 cutoff on CTA. She was not a ___ candidate do to being on Eliquis and arriving outside of the window of tPA therapy. She was transferred to ___ for mechanical thrombectomy. ROS: Unable to obtain Past Medical History: AFIB Depression Social History: former smoker (quit ___ years ago) EtOH ___ glasses of wine per day 4 times a week No illicit drug use - 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 Physical Exam: ADMISSION PHYSICAL EXAM: ======================= Vitals: T: 97.1 BP: 109/71 HR: 62 RR: 16 SaO2: 99% RA General: Awake, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: in a hard collar Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, globally aphasic. Unable to say any words. Regards examiner. -Cranial Nerves: PERRL 3 to 2mm and brisk. Eyes cross midline. No blink to threat on right. No facial droop, facial musculature symmetric. -Motor/sensory: Normal bulk and tone throughout. Left hemibody full strength. Left leg triple flex to noxious. Left arm does not move to noxious stimuli. -Reflexes: deferred -Coordination: unable to test due to aphasia -Gait: deferred DISCHARGE PHSYICAL EXAM: ======================= General: awake, no distress HEENT: Atraumatic CV: well perfused Lungs: no increased wob Abdomen: non-distended. Ext: no rash, no edema Skin: no rash Neuro: MS- alerts to voice. awake. followed command to show teeth but not others. Has minimal speech output, then closed eyes and did not participate CN- spontaneously looks left and right, but doesn't fully ___ sclera on right gaze, right facial droop minimal activation Sensory/Motor- LUE and LLE spontaneously antigravity, RUE brief flexion to noxious stimuli, RLE -no significant movement to noxious appreciated. Grimaced to noxious stim in all 4 extremities but R significantly less than L Reflexes-deferred Coordination/Gait- could not assess Pertinent Results: ADMISSION LABS: =============== ___ 04:00PM URINE HOURS-RANDOM ___ 04:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 04:00PM URINE MUCOUS-RARE* ___ 06:08AM GLUCOSE-131* UREA N-17 CREAT-0.7 SODIUM-140 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-11 ___ 06:08AM ALT(SGPT)-84* AST(SGOT)-43* LD(LDH)-185 CK(CPK)-81 ALK PHOS-65 TOT BILI-0.5 ___ 06:08AM GGT-52* ___ 06:08AM CK-MB-2 cTropnT-<0.01 ___ 06:08AM TOT PROT-6.1* ALBUMIN-3.6 GLOBULIN-2.5 CHOLEST-185 ___ 06:08AM %HbA1c-5.2 eAG-103 ___ 06:08AM TRIGLYCER-63 HDL CHOL-66 CHOL/HDL-2.8 LDL(CALC)-106 ___ 06:08AM TSH-2.0 ___ 06:08AM CRP-0.9 ___ 06:08AM WBC-7.4 RBC-3.79* HGB-12.4 HCT-37.1 MCV-98 MCH-32.7* MCHC-33.4 RDW-12.5 RDWSD-44.8 ___ 06:08AM NEUTS-82.8* LYMPHS-7.9* MONOS-8.1 EOS-0.4* BASOS-0.4 IM ___ AbsNeut-6.10 AbsLymp-0.58* AbsMono-0.60 AbsEos-0.03* AbsBaso-0.03 ___ 06:08AM PLT COUNT-219 ___ 06:08AM ___ PTT-27.4 ___ ___ 04:07AM COMMENTS-GREEN TOP ___ 04:07AM GLUCOSE-103 NA+-138 K+-4.2 CL--105 TCO2-23 ___ 03:57AM CREAT-0.6 ___ 03:57AM UREA N-18 CREAT-0.6 ___ 03:57AM estGFR-Using this ___ 03:57AM estGFR-Using this ___ 03:57AM ALT(SGPT)-81* AST(SGOT)-45* ALK PHOS-62 TOT BILI-0.3 ___ 03:57AM cTropnT-<0.01 ___ 03:57AM ALBUMIN-3.3* ___ 03:57AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG ___ 03:57AM WBC-8.4 RBC-3.58* HGB-11.4 HCT-35.5 MCV-99* MCH-31.8 MCHC-32.1 RDW-12.4 RDWSD-45.1 ___ 03:57AM NEUTS-82.8* LYMPHS-8.5* MONOS-7.3 EOS-0.5* BASOS-0.4 IM ___ AbsNeut-6.92* AbsLymp-0.71* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03 ___ 03:57AM PLT COUNT-169 ___ 03:57AM ___ PTT-27.1 ___ DISCHARGE LABS: ========== ___ 06:10AM BLOOD WBC-8.9 RBC-3.73* Hgb-12.0 Hct-38.2 MCV-102* MCH-32.2* MCHC-31.4* RDW-12.6 RDWSD-47.2* Plt ___ ___ 06:10AM BLOOD ___ PTT-28.3 ___ ___ 06:10AM BLOOD Glucose-136* UreaN-25* Creat-0.5 Na-151* K-4.2 Cl-109* HCO3-28 AnGap-14 ___ 06:10AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.3 IMAGING: ========= + CTA head and neck pre-Thrombectomy Noncontrast CT head: Hyperdense appearance of the left proximal MCA is concerning for thrombus. Irregular focal hypodensity involving the inferior aspect of the left frontal lobe probably extending to the subcortical region of the left insula may be concerning for subacute area of infarction. CTA head: Partial filling defect involving the left clinoid ICA and proximal left MCA are consistent with thrombus. +___ ___ post thromebectomy 1. New large left intraparenchymal basal ganglia, temporal hematoma. 2. 4 mm midline shift. 3. Left uncal herniation. 4. Subarachnoid hemorrhage extension. +NCHCT ___ interval scan 1. Unchanged large left intraparenchymal basal ganglia and temporal lobe hemorrhage resulting in unchanged 4 mm of rightward midline shift and left uncal herniation. 2. Re-demonstrated left frontal, temporal, and parietal lobe subarachnoid hemorrhage unchanged in extent from prior. No new intracranial hemorrhage identified. +NCHCT ___ IMPRESSION: 1. Similar appearance of intraparenchymal hemorrhage in left frontal lobe with associated uncal herniation compared to ___. Some of the blood products are still quite dense but some there does not seem to be an increase in the total amount of hemorrhage, any new interval hemorrhage seems doubtful. 2. No new hemorrhage or acute large territory infarct. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 20 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Sotalol 40 mg PO BID 5. Atorvastatin 40 mg PO QPM 6. Pantoprazole 20 mg PO DAILY Discharge Medications: 1. Labetalol 200 mg PO Q8H 2. Lisinopril 20 mg PO DAILY 3. Rivaroxaban 20 mg PO DINNER 4. FLUoxetine 20 mg PO DAILY 5. HELD- Atorvastatin 40 mg PO QPM This medication was held. Do not restart Atorvastatin until you follow up with neurology Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute ischemic stroke with hemorrhagic conversion. Discharge Condition: Mental Status: Aphasic Level of Consciousness: Alert Activity Status: Out of Bed with assistance to chair or wheelchair. Followup Instructions: ___ Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 INDICATION: ___ year old woman with left mca syndrome s/p thrombectomy. new post op exam change with worsening right hemiparesis and aphasia// interval change, assess for hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 748 mGy-cm. COMPARISON: CT head from ___ FINDINGS: A large intraparenchymal hemorrhage in the left MCA distribution, involving left putamen, superior left temporal lobe. Basal ganglia component of hemorrhage measures 4.2 cm. Temporal lobe component of hemorrhage measures 4.3 cm. There is hemorrhage extension to the sylvian fissure and subarachnoid hemorrhage overlying left frontal, temporal, parietal lobes. Mild local mass effect, 4 mm midline shift to the right, partial effacement left lateral ventricle. Left uncal herniation, with obliteration of bilateral perimesencephalic cisterns, superior cerebellar cistern, new since prior. No evidence of left PCA distribution infarct. Patent prepontine cistern, no tonsillar herniation. 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. New large left intraparenchymal basal ganglia, temporal hematoma. 2. 4 mm midline shift. 3. Left uncal herniation. 4. Subarachnoid hemorrhage extension. NOTIFICATION: Updated findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 12:16 p.m. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with L MCA with hemorrhagic conversion// interval change**1700 NCHCT** TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Total DLP (Head) = 748 mGy-cm. COMPARISON: CT head from ___ at 10:30 FINDINGS: There is re-demonstration of large intraparenchymal hemorrhage in the left MCA distribution involving the left putamen, and superior left temporal lobe, grossly unchanged in size or extent compared to prior study. Subarachnoid hemorrhage along the left frontal, temporal, and parietal lobes and sylvian fissure is unchanged. Resultant rightward midline shift of 4 mm is unchanged. Left uncal herniation with effacement of the bilateral perimesencephalic cisterns and superior cerebellar cistern is unchanged. No new intracranial hemorrhage is identified.. There is unchanged effacement of the left lateral ventricle 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. Unchanged large left intraparenchymal basal ganglia and temporal lobe hemorrhage resulting in unchanged 4 mm of rightward midline shift and left uncal herniation. 2. Re-demonstrated left frontal, temporal, and parietal lobe subarachnoid hemorrhage unchanged in extent from prior. No new intracranial hemorrhage identified. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD INDICATION: ___ year old woman with left mca syndrome// eval for degree of infarct, interval change in hemorrhagic conversion. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CT of the head dated ___. FINDINGS: A large 7.2 x 5.7 cm left basal ganglia and temporal lobe hematoma is seen, effacing the body of the left lateral ventricle and causing a slightly worse rightward midline shift now measuring 7 mm. No hydrocephalus. Mild edema surrounding hematoma, extending into the internal capsule, left cerebral peduncle., Cortical spinal tract. Subarachnoid hemorrhage is again seen in the left frontal, parietal and temporal lobes. Additionally, a punctate focus of diffusion restriction is seen in the high right parietal lobe. Small punctate foci of acute infarcts surrounding hematoma. Preserved suprasellar cistern. Mass effect on the left cerebral peduncle, upper midbrain. Partial effacement of the perimesencephalic cisterns. Mild left uncal herniation, stable. The paranasal sinuses, mastoid air cells and middle ear cavities are clear. The intraorbital contents are normal. IMPRESSION: 1. Large similar left basal ganglia, temporal lobe acute parenchymal hematoma,. 2. Stable left uncal herniation. Minimally worsened midline shift, 7 mm. 3. Stable subarachnoid hemorrhage. 4. Small foci of acute infarct not associated with hemorrhage left hemisphere, and single focus right vertex. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: ___ year old woman with R IJ CVL// eval R IJ CVL Contact name: ___: ___ TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___ at 07:58. FINDINGS: There has been interval placement of a right internal jugular central venous catheter with the tip terminating in the lower superior vena cava. Otherwise, no significant interval change. IMPRESSION: The right internal jugular central venous catheter terminates in the lower superior vena cava. Otherwise, no significant interval change. Radiology Report INDICATION: ___ year old woman with L MCA c/b hemorrhage// NGT placement TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: The right IJ line is unchanged. The NG tube projects over the proximal stomach. There is stable postsurgical and post radiation changes to the left chest wall. Patchy parenchymal opacity in the left lower lobe is unchanged. Small left pleural effusion stable. No pneumothorax is seen. Both apices not included in the field of view. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with stroke// NGT replaced, please eval NGT replaced, please eval IMPRESSION: Comparison to ___. The tip of the current feeding tube projects over the gastroesophageal junction. The tube could be advanced by 5-10 cm. Stable correct position of the right internal jugular vein catheter. No pneumothorax or other complications. Stable appearance of the lung and of the heart. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: ___ year old woman with new NGT// NGT placement TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. FINDINGS: There has been interval replacement of the nasogastric tube which now terminates in the body of the stomach. The right internal jugular central venous catheter is in stable position. There are small bilateral layering pleural effusions (left greater than right) which have increased in size compared to most recent prior study. There are patchy opacities in the bilateral lower lobes, which have increased compared to prior study and may represent atelectasis or aspiration pneumonitis. The cardiomediastinal silhouette is unchanged. Surgical clips are seen in the left axilla and left breast. IMPRESSION: 1. The new nasogastric tube terminates in the body of the stomach. 2. Increasing small bilateral pleural effusions (left greater than right). 3. Increasing patchy opacities in the bilateral lower lobes, which may represent aspiration pneumonitis or atelectasis. Radiology Report EXAMINATION: Frontal chest radiograph. INDICATION: ___ year old woman with new dobhoff// Eval tube location TECHNIQUE: Portable frontal chest radiographs. COMPARISON: Chest radiograph dated ___. FINDINGS: Multiple exposures are seen demonstrating placement of an enteric tube. The final image demonstrates the tip projecting over the left upper hemiabdomen, likely within the stomach. A right central venous catheter is seen terminating in the mid SVC. Multiple surgical clips are seen within the left axilla and overlying the left breast. There are small layering pleural effusions bilaterally with associated atelectasis. Mild interstitial pulmonary edema, unchanged. No focal consolidations. Unchanged appearance of cardiomediastinal silhouette. No pneumothorax. Osseous structures are unremarkable. IMPRESSION: 1. Appropriate position of the enteric tube, terminating within the stomach. 2. Mild interstitial pulmonary edema. Small bilateral pleural effusions with associated atelectasis. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with L Mca ischemic stroke, hemorrhagic conversion 3 days ago, worsening exam// Worsening cerebral edema or hemorrhage TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CT head dated ___ from outside hospital, CT head without contrast dated ___. MR head dated ___ FINDINGS: Re-demonstrated, is the large intraparenchymal hemorrhage in the left MCA distribution involving the left putamen and superior left temporal lobe. There has been interval increase in surrounding vasogenic edema. The subarachnoid hemorrhage along the left frontal, temporal, parietal lobes and left sylvian fissure demonstrate appropriate evolution. No new hemorrhage identified. Minimal decrease in the 0.3 cm rightward midline shift which previously measured 0.4 cm on MR head dated ___. The degree of effacement of the left and third ventricles are unchanged. The left uncal herniation with effacement of the bilateral perimesencephalic and cephalic cisterns in superior cerebellar cistern is unchanged. Evaluation of the bones and sinuses is limited by motion artifact. Within the previously mentioned limitation, 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. Relatively unchanged, large intraparenchymal hemorrhage in the left MCA distribution. 2. Interval increase in surrounding vasogenic edema of the left intraparenchymal hemorrhage. 3. No new areas of hemorrhage are identified. 4. Minimal decrease in the rightward midline shift. 5. Unchanged left uncal herniation. 6. The subarachnoid hemorrhage along the left cerebral hemisphere demonstrates appropriate evolution. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with left MCA infarct and hemorrhagic conversion. Interval scan. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. Total DLP (Head) = 748 mGy-cm. COMPARISON: Head CT obtained 4 days prior, and from ___. Head MR from ___. FINDINGS: The intraparenchymal hemorrhage in the left MCA territory involving the left putamen and superior left temporal lobe now measures 6.8 x 5.8 cm, previously 6.6 x 5.8 cm. The associated vasogenic edema is similar in distribution and there is mass effect evidenced by diffuse left hemispheric sulci and left lateral ventricle effacement, with a 8 mm rightward shift of normally midline structures with uncal herniation, similar to prior. Effacement of the quadrigeminal cistern is similar to slightly increased compared to prior study. No evidence of new hemorrhage is demonstrated. There is no large territorial infarction. Limited evaluation of the bones at the base of the skull and paranasal sinuses is limited by motion. Within this limitation, no gross abnormalities are demonstrated. IMPRESSION: 1. Overall stable appearance of intraparenchymal hemorrhage in the left MCA distribution, associated with uncal herniation. 2. No evidence of new hemorrhage or large territorial infarction. Radiology Report EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with stroke s/p NGT// NGT placement Contact name: ___: ___ IMPRESSION: In comparison with the study of ___, the Dobhoff tube is been removed. A new nasogastric tube has its tip close to the esophagogastric junction, though the side port is within the lower esophagus. The tube should be pushed forward at least 5-8 cm for more optimal positioning. The cardiomediastinal silhouette is stable and there is no evidence of appreciable vascular congestion or acute focal pneumonia. NOTIFICATION: Attempts to page Dr. ___ unsuccessful. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old woman with acute stroke// NGT placement NGT placement IMPRESSION: Comparison to ___. The course of the current nasogastric tube is unremarkable. The tip projects over the central parts of the stomach. There is no evidence of complications, notably no pneumothorax. Stable mild cardiomegaly and moderate scoliosis. Although there is no pulmonary edema, the diameter and visibility of the pulmonary vessels has increased in the interval. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with stroke with hemorrhagic conversion.// stability scan TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: Head CT dated ___. FINDINGS: Left intraparenchymal hemorrhage centered in the temporal lobe and centrum semiovale is re-demonstrated, with continued evolution of blood products measuring 6.5 x 5.6 cm using a similar measurement technique, which is essentially unchanged from ___. Surrounding vasogenic edema is similar. Mass effect upon the right lateral ventricle and effacement of left cortical sulci is similar. 5 8 mm of rightward midline shift is similar, along with subfalcine and uncal herniation. There is similar effacement of the interpeduncular cistern and quadrigeminal plate cistern. No new hemorrhage or evidence of acute infarction. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. Similar appearance of intraparenchymal hemorrhage in left frontal lobe with associated uncal herniation compared to ___. Some of the blood products are still quite dense but some there does not seem to be an increase in the total amount of hemorrhage, any new interval hemorrhage seems doubtful. 2. No new hemorrhage or acute large territory infarct. Radiology Report EXAMINATION: Mechanical thrombectomy for left internal carotid artery stroke During the procedure the following vessels were selectively catheterized angiograms performed: Left common carotid artery Left internal carotid artery after thrombectomy Right common femoral artery INDICATION: This is a ___ old female who was found down besides her bed with right-sided weakness and aphasia. She is on Eliquis and aspirin for atrial fibrillation. She was not a candidate for tPA. She was transferred from ___. Perfusion imaging showed a small choroidal large benign bridge she was felt to be candidate for mechanical thrombectomy. CTA at the outside hospital head revealed an ICA terminus occlusion. ANESTHESIA: The patient was maintained under moderate sedation by the anesthesia team. Please see separately dictated anesthesia documentation. Patient's hemodynamic and respiratory parameters were monitored continuously throughout the entirety of the case by a trained and independent observer. TECHNIQUE: Mechanical thrombectomy COMPARISON: CTA outside hospital PROCEDURE: The patient was identified and brought to the neuro radiology suite. She was transferred to the fluoroscopic table supine. Moderate sedation was administered. Bilateral groins were prepped and draped in standard sterile fashion. An emergency time-out was performed. The right common femoral artery was identified using anatomic and radiographic landmarks. The right common femoral artery was accessed using standard micropuncture technique after infiltration of local anesthetic. A long 8 ___ sheath was introduced, connected to continuous heparinized saline flush, and secured. Next a ___ diagnostic catheter was introduced. It was advanced over 038 glidewire through the aorta into the aortic arch. The wire was used to select left common carotid artery. The catheter was positioned over the wire into the left common carotid artery. The wire was removed. Vessel patency was confirmed via hand injection. Standard AP and lateral hand injection was performed which revealed a left carotid terminus occlusion. The purpose of the angiogram prior to the procedure was to confirm the location of the thrombus. It was used to informed the interventional procedure the followed. Smart mask was performed. Exchange length Glidewire was advanced in the external carotid artery. The diagnostic catheter was removed and a neuron max catheter was advanced into the left common carotid artery. The internal dilator and exchange length wire were removed. The guide catheter was connected to continuous heparinized saline flush. Vessel patency was confirmed via hand injection. Next a ___ intermediate catheter was loaded over an XT 27 microcatheter loaded with a synchro 2 standard wire. Both catheters were placed on flush prior to being introduced. The microcatheter was navigated over the microwire into the superior division of the left MCA. The intermediate catheter was placed at the ICA terminus. The microwire was removed. A 6 mm TRevo device was selected. It was introduced into the rotating hemostatic valve and allowed to flush. It was loaded into the microcatheter. It was deployed by unsheathed in the microcatheter through the affected segment. The intermediate catheter was connected to continuous mechanical suction. The microcatheter was removed while the stentriever was in place. The stentriever remained deployed for approximately 2 minutes. The stentriever was removed along with the ___ catheter in a single maneuver while aspiration was applied to the guide catheter. There was significant clot burden identified within the stentriever. Follow-up AP and lateral angiogram revealed complete reperfusion of the affected territory. Standard AP and lateral final runs were obtained. Next the guide catheter was removed. Right common femoral angiogram was performed via hand injection through the sheath. The sheath was removed and the arteriotomy was closed using a 6 ___ Perclose. The patient was removed from the fluoroscopy table and remained at her neurologic baseline without any evidence of thromboembolic complications. OPERATORS: Dr. ___ Dr. ___ physician performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. FINDINGS: Right common carotid artery: There is opacification of the carotid bifurcation. There is sluggish flow to the carotid terminus. There is no opacification of the MCA or ACA. Right internal carotid artery after first pass: There is opacification of the internal carotid artery as well as the MCA that was previously occluded. There is complete reperfusion of the affected territory. There is flash filling of the ACA. There is evidence of competitive flow and filling of the ACA territory from the contralateral side. There is evidence of some vasospasm within the petrous portion of the ICA that is not flow limiting. Right common femoral artery: Arteriotomy is above the bifurcation. There is good distal runoff. There is no evidence of dissection. Vessel caliber appropriate for closure device. IMPRESSION: TICI 3 of left internal carotid artery terminus occlusion with a single pass of a stentriever RECOMMENDATION(S): 1. Care per neurology Radiology Report EXAMINATION: CT BRAIN PERFUSION Q936 CT HEAD INDICATION: Suspected stroke with acute neurological deficit. // Please exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other vascular abnormality. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 802.7 mGy-cm. 2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP = 2,513.8 mGy-cm. Total DLP (Head) = 3,317 mGy-cm. COMPARISON: CTA of the head neck dated ___ (3 hours prior). FINDINGS: A subtle left dense MCA sign is seen, much better seen on the prior CT of the head. Decreased perfusion of the posterior left putamen on source images consistent with acute infarct. There is matched decreased cerebral blood volume, cerebral blood flow, in this area. Cerebral perfusion analysis reveals increased mean transit time involving nearly entire MCA territory, much larger than area of infarct, consistent with large penumbra. Please note that there is large area of T-max greater than 10 seconds. Small area of decrease in cerebral blood flow and cerebral blood volume, consistent with an infarct. T-max greater than 10 seconds volume is 112 mm. T-max greater than 6 seconds volume is 211 mm. See BF less than 30% volume 11 mm. Mismatch volume T-max greater than 6 seconds, see BF, 200 mL. Hyperdensity seen in the left cavernous sinus (series 2 image 10) causes bulging of the lateral border. This is better seen on the most recent CTA of the head as a vascular abnormality involving the cavernous segment of the left ICA. 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. Acute small infarct left putamen. 2. Large penumbra. Please note large area of T-max greater than 10 seconds. 3. Left dense MCA sign consistent with thrombosis. 4. No hemorrhage. NOTIFICATION: The findings were wet read into the electronic dashboard on ___ at 11:01 am, 5 minutes after discovery of the findings. Radiology Report INDICATION: ___ year old woman with PMH AFIB with RVR and acute ischemic stroke s/p thrombectomy// screening cxr TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with bibasilar atelectasis. There is mild pulmonary vascular congestion. Surgical clips are seen in the left axilla. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: CVA, Transfer Diagnosed with Cerebral infarction, unspecified temperature: 97.1 heartrate: 62.0 resprate: 16.0 o2sat: 99.0 sbp: 109.0 dbp: 71.0 level of pain: u/a level of acuity: 1.0

Dear Ms. ___, You were hospitalized due to symptoms of speech difficulties and right-sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where 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: Atrial Fibrillation We are changing your medications as follows: -xarelto 20mg at dinner - labetalol 200mg every 8 hours + lisinopril 20mg daily for your blood pressures Please take your other medications as prescribed. Please follow up 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 Sincerely, Your ___ Neurology Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ambien / Bactrim / Lasix / Gemfibrozil Attending: ___ Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy (___) History of Present Illness: Mr. ___ is a ___ year old ___ speaking male with a PMH of SLE(serologies positive for ___, ds DNA, Ro/La, & Sm) with lupus nephritis, history of alveolar hemorrhage and myopericarditis, who presents with BRBPR. History obtained from patient with assistance of phone interpreter. Patient reports that for a little over a week he has had bloody bowel movements. He reports that the blood is bright red, is normally separate from the stool, though occasionally has been mixed. Also blood when he wipes. The past few days his bowel movements have also been painful in the rectal area, and he reports that his bottom is now so sore that he has to sleep on his side or with a pillow for a cushion. He states that last week he was constipated, but in the past few days they have been loose. He has not had nausea, fevers or chills. No dark, tarry stools. Notes that he has had hemorrhoids "a long time ago" and that this is similar. Of note, he states that he has not had any abdominal pain until today, when he developed a mild pain in the right lower quadrant. In regards to his appetite, he states that when he was on predisone 40-60mg he had a very good appetite, but as it has been tapered down his appetite has been worse. He reports no nausea, fevers, or chills. Per review of records, patient has been followed at ___ since ___ when he presented with weight loss and FUO, with workup ultimately showing SLE. Most recently, he was admitted from ___ with a lupus flare, including acute on chronic kidney injury and a pericardial effusion. Following discharge, he was again admitted from ___ with anasarca ___ renal protein loss. He was discharged on Mycophenolate Mofetil 1000 mg PO BID and prednisone 60mg. Since discharge, his MMF has been uptitrated to 1500mg BID and his prednisone has been tapered to 5mg daily per patient. His atovaquone was stopped. It was also noted that his creatinine has been worsening over the past several weeks - on ___, Cr was 1.4, which has been uptrending to 3.2 on ___. In the ED: Initial vital signs were notable for: Exam notable for: ABDOMINAL: Nontender, nondistended, no rebound/guarding, no peritonitic signs GU: no CVAT RECTAL: light brown guaiac +. no obvious mass Labs were notable for: - CBC: WBC 7.8, Hgb 9.6, Plt 274 - Lytes: ___ --------------- 81 4.9 \ 23 \ 3.6 - LFTS: AST: 22 ALT: 21 AP: 33 Tbili: 0.3 Alb: 3.7 - lipase 271 - Lactate:0.7 - Coags: ___: 10.5 PTT: 29.1 INR: 1.0 - negative u/a Studies performed include: CT a/p w/o contrast showing: Peripancreatic extending along the head and uncinate process compatible with pancreatitis. A focal hypodensity along the body/tail of the pancreas measuring approximately 1.3 cm is difficult to evaluate on a nonenhanced scan. No peripancreatic fluid collection Patient was given: 2L LR Vitals on transfer: T 98.4, HR 91, BP 119/65, RR 16, 98% RA Upon arrival to the floor, patient is hungry and would like to know if he can have something to drink. He recounts history as above. He reports some mild RLQ abdominal pain. Past Medical History: - SLE c/b stage IV/V glomerulonephritis - history of diffuse alveolar hemorrhage and myopericarditis - DMII - Hypertriglyceridemia - Lumbar radiculopathy - GERD - hypertension Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION EXAM: GENERAL: Alert and in no apparent distress. Prominent tremor EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Overall poor dentition 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, mildly tender to palpation in RLQ without rebound or guarding. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Overall poor dentition 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, mildly tender to palpation in RLQ without rebound or guarding. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation, ___ in place MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ___ 09:40PM BLOOD WBC-7.8 RBC-3.31* Hgb-9.6* Hct-30.8* MCV-93 MCH-29.0 MCHC-31.2* RDW-13.2 RDWSD-44.8 Plt ___ ___ 09:40PM BLOOD Neuts-74.8* Lymphs-15.7* Monos-7.8 Eos-0.1* Baso-0.1 Im ___ AbsNeut-5.86 AbsLymp-1.23 AbsMono-0.61 AbsEos-0.01* AbsBaso-0.01 ___ 10:02PM BLOOD ___ PTT-29.1 ___ ___ 09:40PM BLOOD Glucose-81 UreaN-115* Creat-3.6* Na-145 K-4.9 Cl-106 HCO3-23 AnGap-16 ___ 06:33AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0 ___ 09:40PM BLOOD Albumin-3.7 ___ 09:40PM BLOOD ALT-21 AST-22 AlkPhos-33* TotBili-0.3 ___ 09:40PM BLOOD Lipase-271* ___ 05:13PM BLOOD Iron-125 ___ 05:13PM BLOOD calTIBC-316 ___ Ferritn-920* TRF-243 ___ 05:13PM BLOOD Ret Aut-0.9 Abs Ret-0.03 ___ 09:40PM BLOOD CRP-1.7 dsDNA-NEGATIVE ___ 09:40PM BLOOD C3-130 C4-36 MICRO: UCx (___): NO GROWTH. C.diff negative (___) CMV PCR stool pending *** Stool cx (___): NO SALMONELLA OR SHIGELLA FOUND. NO CAMPYLOBACTER FOUND. NO OVA AND PARASITES SEEN. NO VIBRIO FOUND. NO YERSINIA FOUND. No E. coli O157:H7 found. IMAGING: ___ CT abd/pelvis with PO and IV contrast: IMPRESSION: 1. Interval decrease in inflammation surrounding the pancreatic head and uncinate process. A 1.2 x 0.9 cm hypoattenuating lesion in the pancreatic body/tail is unchanged and could represent a pancreatic pseudocyst versus IPMN. As before, MRI/MRCP is recommended for further evaluation. 2. Mild bilateral hydronephrosis is presumably secondary to a markedly distended urinary bladder. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Trace pelvic ascites. - ___ CT a/p w/o contrast: Peripancreatic extending along the head and uncinate process compatible with pancreatitis. A focal hypodensity along the body/tail of the pancreas measuring approximately 1.3 cm is difficult to evaluate on a nonenhanced scan. No peripancreatic fluid collection. DISCHARGE LABS: ___ 06:33AM BLOOD WBC-6.2 RBC-2.67* Hgb-7.8* Hct-24.0* MCV-90 MCH-29.2 MCHC-32.5 RDW-13.7 RDWSD-44.5 Plt ___ ___ 06:35AM BLOOD Glucose-101* UreaN-21* Creat-1.2 Na-146 K-3.8 Cl-113* HCO3-20* AnGap-13 ___ 06:35AM BLOOD ALT-12 AST-18 AlkPhos-25* TotBili-0.4 ___ 06:35AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.5* ___ 05:13PM BLOOD calTIBC-316 ___ Ferritn-920* TRF-243 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Mycophenolate Mofetil 1500 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 300 mg PO QHS 7. Vitamin B Complex 1 CAP PO DAILY 8. Ethacrynic Acid 75 mg PO QAM 9. HydrALAZINE 25 mg PO BID 10. Lisinopril 10 mg PO DAILY 11. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) QID:PRN 12. Fenofibrate 160 mg PO DAILY 13. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 14. Ethacrynic Acid 50 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hemorrhoidal bleeding Acute blood loss anemia Gallstone pancreatitis Gastroenteritis Acute urinary retention Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old man with SLE and lupus nephritis presenting with BRBPR, found to have new RLQ pain with guarding. concern for acute process as above.// PO and IV contrast to eval for acute process in RLQ; perf/appendicitis/diverticulitis TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 23.7 s, 0.2 cm; CTDIvol = 404.8 mGy (Body) DLP = 81.0 mGy-cm. 3) Spiral Acquisition 7.8 s, 50.9 cm; CTDIvol = 10.6 mGy (Body) DLP = 534.2 mGy-cm. Total DLP (Body) = 617 mGy-cm. COMPARISON: CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Aside from minimal bibasilar atelectasis, the 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 contains gallstones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of pancreatic ductal dilatation. There has been interval decrease in soft tissue stranding surrounding the pancreatic head and uncinate process. A 1.2 x 0.9 cm hypoattenuating lesion in the pancreatic body/tail is re-demonstrated, but incompletely characterized on this exam. A punctate calcification is again noted in the tail the pancreas, likely reflecting sequela of prior pancreatitis. 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. Mild bilateral hydronephrosis is noted, likely secondary to a full urinary bladder. There is no evidence of obstruction. There is no evidence of focal renal lesions. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There are few scattered colonic diverticula without evidence of wall thickening or adjacent fat stranding. The appendix is normal. PELVIS: The urinary bladder is markedly distended. There is trace, simple appearing fluid within the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. A 1.8 cm area of sclerosis in the left femoral head is again noted and unchanged. SOFT TISSUES: There is diffuse soft tissue edema, consistent with anasarca. IMPRESSION: 1. Interval decrease in inflammation surrounding the pancreatic head and uncinate process. A 1.2 x 0.9 cm hypoattenuating lesion in the pancreatic body/tail is unchanged and could represent a pancreatic pseudocyst versus IPMN. As before, MRI/MRCP is recommended for further evaluation. 2. Mild bilateral hydronephrosis is presumably secondary to a markedly distended urinary bladder. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Trace pelvic ascites. RECOMMENDATION(S): MRI/MRCP. Radiology Report INDICATION: NO_PO contrast; History: ___ with pancreatitis and BRBPRNO_PO contrast// eval divertic/panc complication 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 6.4 s, 50.6 cm; CTDIvol = 10.1 mGy (Body) DLP = 510.7 mGy-cm. Total DLP (Body) = 511 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: LOWER CHEST: Bibasilar atelectasis is noted. There is no evidence of pleural or pericardial 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. Re-demonstrated are multiple gallstones within the gallbladder including the neck of the gallbladder however, similar to the prior study from ___, however there is no significant gallbladder distention or wall thickening. PANCREAS: There is peripancreatic stranding along the head and uncinate process. There is a focal hypodensity along the body/tail of the pancreas measuring approximately 1.3 x 1.0 cm (02:21), difficult to evaluate on a nonenhanced scan. A punctate calcification is noted along the tail of the pancreas (02:21). There is no 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 focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder is distended without wall thickening. There is no free fluid in the pelvis. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Sclerosis along the left femoral head is unchanged. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Findings of mild acute interstitial pancreatitis. 2. Cystic lesion in the body of the pancreas may represent a pseudocyst or IPMN. Recommend MRI/MRCP for further definitive evaluation. 3. Redemonstration of cholelithiasis without cholecystitis. RECOMMENDATION(S): Recommend MRI/MRCP. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:00 am, 20 minutes after discovery of the findings. Gender: M Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: BRBPR Diagnosed with Gastrointestinal hemorrhage, unspecified temperature: 97.8 heartrate: 90.0 resprate: 18.0 o2sat: 100.0 sbp: 122.0 dbp: 70.0 level of pain: 0 level of acuity: 3.0

Dear Mr ___, You were admitted to the hospital because you were having bloody diarrhea. Your diarrhea improved with supportive care and was likely due to an infectious cause. You continued to pass red blood in your stool, so you had a colonoscopy on ___ that showed large hemorrhoids that had been bleeding. Colorectal surgery was consulted for consideration of banding of the hemorrhoids to prevent them from bleeding. They recommended conservative management. You also were found to have pancreatitis during this hospital stay, which was most likely due to gallstones. General surgery saw you to evaluate you for gallbladder removal surgery. They do not think you need surgery while you are in the hospital, but they would like to see you in their clinic. You were found to have a lesion in your pancreas that will require an MRI as an outpatient to better characterize. You were having difficulty emptying your bladder, so a ___ catheter was placed and you were started on a medicine to help you empty your bladder. You will need to have the ___ catheter removed for a voiding trial. You may need to follow up in ___ clinic. You should follow up with your primary care doctor, kidney doctor, and rheumatologist as already scheduled. Best wishes for your continued healing! Take care, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: magnesium Attending: ___. Chief Complaint: nausea/vomiting, concern for seizure Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male, with a reported past medical history of motorcycle accident accident in ___ causing a traumatic brain injury, and subsequent seizures. Patient reports his baseline seizure rate is ___ seizures a year which are tonic-clonic in etiology. He also reports his minor seizures are in the visual limb shaking happens sporadically. Patient reports that on ___ he took his Depakote. On ___ he reported that he had 9 seizures, all tonic-clonic in etiology. On that same day he reports falling off the top of a 9 letter. He reports that the time is in urgent care, where they diagnosed him with a clavicular fracture. He reports persistent nausea and vomiting since then, he initially reported changes in vision but on further questioning reports that his visual symptoms have resolved. He reports that he also has residual muscle sensation from time of the fracture in his thumb index finger middle finger, approximately with a C6 nerve roots, and demonstrated squeezing his finger with all his might to show that he had no sensation. The same time if patient requested to not have his left arm examined due to excruciating pain. He reports that he has headaches, but are chronic in etiology, and no changes in consistency or frequency. When asked about his negative levels, exceptionally reported that he is not able to take his Depakote, and that he is only able to get down some Pedialyte and Powerade since the tubes incident. He reports having 3 seizures 2 days ago, and one seizure today. He reports that he did take Zofran for his nausea Is not sure if it helped. He denies dizziness, lightheadedness, vertigo, speech disturbance, diplopia, hearing change, dysarthria, dysphagia, focal weakness, paresthesiae, bowel or bladder incontinence, gait disturbance, fevers, chills, unintended weight change, nausea, vomiting, cough, dyspnea, chest discomfort, abdominal pain, changes in bowel or bladder habits, myalgias, arthralgias, or rash. Patient reports having good night sleep, no infection, and no triggers. This recent increase in seizure frequency. Patient reports no new emotional or physiological stressors. Past Medical History: Asthma Vertigo Major crush injury resulting in thoracic C7/T1 spinous process (discharged ___ Urinary retention (discharged with foley ___ OSA on CPAP MDD with history of prior suicide attempts Cyclical vomiting syndrome (significant workup at ___, improvement with erythromycin) Social History: ___ Family History: No family history of cardiac issues (adopted, however). Physical Exam: PHYSICAL EXAMINATION: Vitals: ___ 1105 Temp: 98.5 PO BP: 122/79 R Sitting HR: 78 RR: 18 O2 sat: 97% O2 delivery: Ra General: Awake, cooperative, in NAD. HEENT: NC/AT, MMM Pulmonary: no increased WOB on RA Cardiac: warm and well perfused Abdomen: Soft, ND, mild periumbilical TTP ___ rebound or guarding Extremities: No ___ edema. Skin: Dirty, very thick calluses, rough. Neurologic: -Mental Status: Alert, oriented x 3. Attentive to examiner. Language is fluent, no dysarthria. Follows simple & complex commands. No evidence of apraxia or hemineglect. -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: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk. (Of note, left arm was not examined adequately, due to limitations from patient's reported injury and reported severe and agonizing pain.) No pronator drift on right. No adventitious movements, such as tremor, noted. Delt Bic Tri FFl FE IP Quad Ham TA Gastroc L NA NA NA ___ 5 4* 4+* 5 R 5 ___ ___ 5 5 5 *Limited by hip pain since fall. -Sensory: Mild decreased sensation on left thumb and first 2 fingers and up lateral aspect of left arm to elbow. -DTRs: Bi ___ Pat L NA NA 2 R 2 2 2 -Coordination: No intention tremor or dysmetria on R. Pertinent Results: ___ 03:29AM BLOOD WBC-5.4 RBC-4.41* Hgb-13.2* Hct-40.4 MCV-92 MCH-29.9 MCHC-32.7 RDW-13.3 RDWSD-44.3 Plt ___ ___ 03:29AM BLOOD Neuts-56.1 ___ Monos-9.7 Eos-3.0 Baso-0.9 Im ___ AbsNeut-3.00 AbsLymp-1.59 AbsMono-0.52 AbsEos-0.16 AbsBaso-0.05 ___ 03:29AM BLOOD ___ PTT-29.9 ___ ___ 02:19AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-139 K-5.1 Cl-105 HCO3-20* AnGap-14 ___ 02:19AM BLOOD ALT-15 AST-35 AlkPhos-57 TotBili-0.4 ___ 02:19AM BLOOD Albumin-4.3 Calcium-9.2 Phos-4.6* Mg-2.0 ___ 02:19AM BLOOD Valproa-<3* ___ 02:00PM BLOOD Valproa-42* ___ 08:10AM BLOOD WBC-5.2 RBC-4.39* Hgb-13.1* Hct-39.3* MCV-90 MCH-29.8 MCHC-33.3 RDW-13.0 RDWSD-42.6 Plt ___ ___ 08:10AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-142 K-4.1 Cl-106 HCO3-25 AnGap-11 ___ 03:40PM BLOOD CK(CPK)-78 ___ 08:10AM BLOOD ALT-12 AST-14 AlkPhos-57 ___ 03:40PM BLOOD CK-MB-1 ___ 02:56AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 08:10AM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.2 Mg-1.8 Imaging: ___ CT Cspine ___ contrast IMPRESSION: Normal study. ___ CT head ___ contrast IMPRESSION: Normal study. ___ CT chest ___ contrast IMPRESSION: 1. No acute findings in the chest. No evidence for traumatic injury 2. Unchanged mild splenomegaly. ___ Liver/gallbladder U/S IMPRESSION: Normal abdominal ultrasound. No evidence of cholelithiasis or acute cholecystitis. ___ Left clavicle Xray IMPRESSION: Unremarkable radiographs of the left clavicle. ___ Abd Xray IMPRESSION: Mildly dilated single loop of probable sigmoid colon and a large amount of stool is seen throughout the ascending and descending colon. No abnormally dilated loops of small bowel are seen. ___ MR shoulder ___ contrast IMPRESSION: 1. Left acromioclavicular ligament rupture and disruption of the acromioclavicular capsule compatible with a grade 2 AC joint separation. 2. Diminutive anteroinferior glenoid labrum and suggestion of prior labral surgery with cystic changes of the anterior glenoid 3. Strain at the myotendinous junction of the infraspinatus. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Divalproex (EXTended Release) 500 mg PO BID 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or wheezing Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine [Lidocaine Pain Relief] 4 % place one patch on left shoulder daily as needed Disp #*30 Patch Refills:*0 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath or wheezing 3. Divalproex (EXTended Release) 500 mg PO BID 4.Outpatient Physical Therapy Discharge Disposition: Home Discharge Diagnosis: dual diagnosis epileptic and nonepileptic seizure disorder gastritis with gastric and duodenal ulcer disease traumatic left shoulder injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: ___ Radiology Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: History: ___ with Fall from 9 feet 3 days ago. Persistent vomiting and seizures. Neck pain, T-spine and L-spine pain. Rib pain bilaterally.// Intracranial hemorrhage, C-spine fracture, T-spine fracture, rib fracture TECHNIQUE: Contiguous axial images were acquired through the chest without intravenous contrast. Multiplanar reformats were performed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.5 s, 43.1 cm; CTDIvol = 23.0 mGy (Body) DLP = 990.9 mGy-cm. Total DLP (Body) = 991 mGy-cm. COMPARISON: CT torso from ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: A 1.5 cm low density lesion superior to the left brachiocephalic vein at the thoracic inlet (06:40, 601:45) is unchanged and likely represents lipoma. UPPER ABDOMEN: Splenomegaly of 14.1 cm unchanged. The remainder of the imaged upper abdomen is grossly unremarkable. MEDIASTINUM: Unremarkable. HILA: Unremarkable. HEART and PERICARDIUM: Unremarkable. PLEURA: No pleural effusion or pneumothorax. LUNG: 1. PARENCHYMA: There is minimal dependent atelectasis. The lungs are otherwise clear. 2. AIRWAYS: Airways are patent to the segmental level bilaterally. 3. VESSELS: Thoracic aorta and main pulmonary artery normal in caliber. CHEST CAGE: No acute fracture or suspicious osseous lesions. Mild anterior wedging of several midthoracic vertebral bodies is unchanged. IMPRESSION: 1. No acute findings in the chest. No evidence for traumatic injury 2. Unchanged mild splenomegaly. Radiology Report EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with Fall from 9 feet 3 days ago. Persistent vomiting and seizures. Neck pain, T-spine and L-spine pain. Rib pain bilaterally.// Intracranial hemorrhage, C-spine fracture, T-spine fracture, rib fracture 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, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: Outside reference CT head from ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. 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: Normal study. Radiology Report EXAMINATION: CT ___ W/O CONTRAST INDICATION: History: ___ with Fall from 9 feet 3 days ago. Persistent vomiting and seizures. Neck pain, T-spine and L-spine pain. Rib pain bilaterally.// Intracranial hemorrhage, ___ fracture, T-spine fracture, rib fracture TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.7 s, 22.5 cm; CTDIvol = 23.0 mGy (Body) DLP = 517.7 mGy-cm. Total DLP (Body) = 518 mGy-cm. COMPARISON: MR ___ from ___. FINDINGS: Alignment is normal. No fractures are identified. There is no significant canal or foraminal narrowing. There is no prevertebral edema. The thyroid and included lung apices are unremarkable. IMPRESSION: Normal study. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with nausea, vomiting, RUQ pain// Eval for cholelithiasis, bile duct/hepatic abnormalities 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. CHD: 2 mm GALLBLADDER: There is no evidence of stones or 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. Spleen length: 12.9 cm KIDNEYS: Limited views of the right kidney shows no hydronephrosis. RETROPERITONEUM: The visualized portions of IVC are within normal limits. IMPRESSION: Normal abdominal ultrasound. No evidence of cholelithiasis or acute cholecystitis. Radiology Report EXAMINATION: CLAVICLE LEFT INDICATION: ___ year old man with PMH TBI, seizures reports fall off ladder and pain in L clavicle since a few days ago// ?fracture TECHNIQUE: Two views of the left clavicle were obtained COMPARISON: CT chest performed ___ FINDINGS: There is no acute fracture of the left clavicle. The acromioclavicular joint is not widened. No evidence of a left glenohumeral dislocation. The visualized left lung apex is clear. IMPRESSION: Unremarkable radiographs of the left clavicle. Radiology Report INDICATION: This is a ___ man, with a past medical history of motorcycle accident in ___ causing a traumatic brain injury, and subsequent seizures who presents after fall vs seizure while on ladder in setting of 5ds of persistent vomiting w/ inability to tolerate PO. Has significant L shoulder pain related to recent trauma, which was reportedly associated w/ L clavicular fracture per patient reports, which was not confirmed on shoulder/chest imaging obtained on admission. Remains in sling for comfort per patient request despite negative imaging. With unclear history, VPA undetectable, and no increased seizure TECHNIQUE: Upright and supine abdominal radiographs were performed COMPARISON: ___ FINDINGS: There are no abnormally dilated loops of small bowel. Stool and air is seen within the ascending and descending colon. In the midline abdomen is a redundant appearing and somewhat dilated air-filled loop of bowel possibly reflecting sigmoid colon. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Mildly dilated single loop of probable sigmoid colon and a large amount of stool is seen throughout the ascending and descending colon. No abnormally dilated loops of small bowel are seen. Radiology Report EXAMINATION: MR SHOULDER ___ CONTRAST LEFT INDICATION: This is a ___ man, with a past medical history of motorcycle accident accident in ___ causing a traumatic brain injury, and subsequent seizures who presents after fall vs seizure while on ladder in setting of 5ds of persistent vomiting w/ inability to tolerate PO. Has significant L shoulder pain related to recent trauma, which was reportedly associated w/ L clavicular fracture per patient reports, which was not confirmed on shoulder/chest imaging obtained on admission. Remains in sling for comfort per patient request despite negative imaging. With unclear history, VPA undetectable, and no increased seizure TECHNIQUE: Noncontrast MRI of the left shoulder. Sequences include axial proton density fat sat, sagittal T1, sagittal and coronal T2 fat sat. COMPARISON: Prior radiograph dated ___. FINDINGS: Rotator Cuff: There is edema seen at the myotendinous junction of the infraspinatus tendon, suggestive of muscle strain; however, no full-thickness tear is seen. The supraspinatus, subscapularis, and teres minor tendons appear intact. There is no rotator cuff muscle atrophy. Acromio-clavicular joint: There is increased T2 hyperintensity around the acromioclavicular joint with increased distance between the acromion and clavicle, measuring approximately 8 mm, suggestive of disruption of the acromioclavicular capsule and rupture of the acromioclavicular ligament (series 6, image 11). The coracoclavicular ligaments are intact and there is no widening of the CC interval. Subacromial-subdeltoid bursa: Intact. Joint effusion: No significant joint effusion. Hyaline cartilage: Intact. Glenoid labrum: The anterior-inferior glenoid labrum is diminutive; however, no full-thickness tear is identified. Biceps tendon: Small of edema seen around the biceps longus tendon, suggestive of mild tenosynovitis. Bone marrow: Cystic changes seen within the anterior glenoid suggestive of prior surgery. Otherwise, bone marrow signal appears normal. Axilla: No soft tissue abnormality in the visualized portion of the axilla. IMPRESSION: 1. Left acromioclavicular ligament rupture and disruption of the acromioclavicular capsule compatible with a grade 2 AC joint separation. 2. Diminutive anteroinferior glenoid labrum and suggestion of prior labral surgery with cystic changes of the anterior glenoid 3. Strain at the myotendinous junction of the infraspinatus. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:42 pm, 5 minutes after discovery of the findings. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Abd pain, N/V, Seizure Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus, Nausea with vomiting, unspecified, Right upper quadrant pain temperature: 99.5 heartrate: 62.0 resprate: 18.0 o2sat: 98.0 sbp: 134.0 dbp: 93.0 level of pain: 7 level of acuity: 2.0

Mr. ___, You were admitted after a fall with concern for a seizure in the setting of several days of inability to maintain oral intake secondary to nausea and vomiting. You were monitored on EEG and had an episode of generalized shaking that was not an epileptic seizure. Although this event was not a seizure, that does not mean you have not had seizures in the past, including leading to your most recent fall. You were restarted on your anti-seizure medications intravenously until you were able to tolerate oral medications. You did not have any seizures during admission, and you should continue your seizure medications as prescribed and seizure precautions as recommended by your neurologist after discharge. You were also noted to have significant left shoulder pain. Your Xray and CT did not show a fracture. Your pain significantly improved with a lidocaine pain patch, which will be provided for you at discharge. An MRI of shoulder was obtained to ensure there was no tendon injury as you have had prior injury to your rotator cuff. We have requested a follow-up appointment for you with an outpatient orthopedic surgeon for further management of your shoulder pain/injury. As you presented with significant nausea and vomiting with mid-abdominal pain, the gastroenterology team was consulted for further evaluation. Upper endoscopy demonstrated significant inflammation in your stomach with some non-bleeding small ulcers in your stomach and small intestine. Your nausea/vomiting improved during your hospitalization, which could have been related to your recent fall as well as the gastritis. You will need to continue omeprazole for 8 weeks and should avoid all NSAIDs (ibuprofen, naproxen, aspirin, Goody powder, BC powder, ___ seltzer, etc.). You should follow-up with your primary care provider for further management of you abdominal pain and nausea. You were discharged with a cane from physical/occupational therapy with recommendations for intermittent support as needed from family and outpatient physical therapy for shoulder range of motion and strengthening. Thank you for allowing us to participate in your care. Sincerely, Your ___ neurology team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ___ Allergies: carbamazepine / donepezil / Penicillins Attending: ___ Chief Complaint: jaundice Major Surgical or Invasive Procedure: ___ ERCP with sphincteroplasty, stent placement History of Present Illness: HPI: The patient is a ___ male w/PMHx including mild dementia, COPD, presenting with painless jaundice for weeks, associated with dark urine, pale stools and fatigue, as well as ___ of >100lb weight loss, mostly unintentional, but no significant pain. He was seen at ___, a CT A/P showed biliary dilation without pancreatic mass. Labs showed alk phos 700s, Tbili 7, mild transaminitis. There is concern for cholangiocarcinoma, and ERCP was consulted, recommending MRCP and NPO p MN for possible endoscopy on ___. In the ED: noted to be "a+ox3 with mild dementia", per RNs had mild R mid back pain, also endorsed night sweats. VS were: 98.6 70 143/86 18 98% RA Seen on the floor, he was feeling ok. He very readily describes how he has dementia and how he handles that -- "I just don't stress out about it." We review his medical history, and he directs me to his wife with any additional questions. I speak with his wife to verify medications and other medical history. She has not been told what we're planning to do, or what we're concerned about. I explain that we're worried that the bile ducts are blocked based on his clinical history, labs and imaging and that we're getting an MRI. I also explain that one of the things that can cause the blockage of the bile ducts is cancer, and that's on our list. She understands. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Primary Care Provider: ___, NP at ___ outpatient clinic on ___. Past Medical History: PMHx: COPD HTN Hyperlipidemia Dementia Recurrent UTIs Seizure disorder ___ head injury after falling off a truck in ___, last seizure ___ Gout Osteoarthritis Headaches Depression Insomnia Prior NIDDM -- now off meds given improved sugars PSHx: Removal of skin cancer from face Eye surgery NOS Social History: ___ Family History: FHx: Mother possibly had breast cancer Father had dementia Physical Exam: Admission Physical Exam: VS: T 97.5, HR 78, BP 128/64, RR 18, O2 sat 100% on RA Lines/tubes: PIV Gen: jaundiced, obese older man lying in bed, alert, cooperative, NAD HEENT: icteric, MMM, PERRL Neck: supple, no ___: equal chest rise, fair air movement, CTAB posteriorly, no WOB or cough Cardiovasc: distant sounds, regular Abd: obese, soft, NTND apart from mild tenderness to deep RUQ palpation Extr: WWP, no pitting edema Skin: jaundiced, otherwise no obvious lesions Neuro: oriented to self, date, hospital, but cannot remember details of his medical conditions, CN II-XII intact (IX and X not specifically tested), strength ___ throughout, sensation to light touch intact throughout, reflexes symmetric Psych: normal affect Discharge Exam: T 98.1, BP 150/73, HR 70, RR 18, sat 99% on RA Lines/tubes: PIV Gen: jaundiced, obese older man seated on the edge of the bed, alert, cooperative, NAD HEENT: icteric, MMM Chest: equal chest rise, fair air movement, CTAB posteriorly, no WOB or cough Abd: obese, soft, NTND Extr: WWP, no pitting edema Skin: jaundiced, otherwise no obvious lesions Psych: normal affect Pertinent Results: Labs and Micro: ___: WBC: 3.6* ___: HGB: 13.4* ___: HCT: 40.4 ___: Plt Count: 162 ___: ___: 10.7 ___: INR: 1.0 ___: PTT: 31.8 ___: Na: 136 ___: K: 3.6 ___: Cl: 99 ___: CO2: 24 ___: BUN: 35* ___: Creat: 1.2 ___: eGFR: 60 ___: Glucose: 106* ___: Ca: 9.2 ___: Mg: 2.1 ___: PO4: 2.7 ___: ALT: 128* ___: AST: 95* ___: Alk Phos: 787* ___: Total Bili: 7.7* ___: Alb: 3.8 ___ MRCP -- (Preliminary Report) "IMPRESSION: Choledocholithiasis resulting in common bile duct and intrahepatic duct dilatation. Gastroenterology consult for ERCP is recommended. Multiple 1-2 mm cystic lesions in the body and tail of the pancreas are most in keeping with side branch IPMN. Follow-up MRI in ___ year to ensure stability is recommended. RECOMMENDATION(S): Follow-up MRI in ___ year to ensure stability of pancreatic cystic lesions most in keeping with side-branch IPMN." ___ ERCP -- Impression: The scout film was normal. A choledocho-duodenal fistula was noted above the major papilla. The fistula was deeply cannulated with the sphincterotome. The CBD was 15 mm in diameter. Multiple filling defects consistent with stones were identified in the CBD. A fistuloplasty was made with a with a CRE balloon from 10 to 12mm. The biliary tree was swept with a 15 mm balloon starting at the bifurcation. Multiple stones and sludge were removed. A 5cm by ___ double pig-tail plastic biliary stent was placed successfully. Recommendations: Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days. Repeat ERCP in ___ weeks with ___ stent pull and re-evaluation. Follow-up with Dr. ___ as previously scheduled. If no abdominal pain in the morning, advance diet to clear liquids and then advance as tolerated Discharge Day Labs ___ 06:05AM BLOOD WBC-3.5* RBC-4.09* Hgb-12.4* Hct-37.1* MCV-91 MCH-30.3 MCHC-33.4 RDW-14.3 RDWSD-47.6* Plt ___ ___ 06:05AM BLOOD Glucose-98 UreaN-24* Creat-1.0 Na-138 K-4.0 Cl-105 HCO3-23 AnGap-14 ___ 06:05AM BLOOD ALT-81* AST-64* AlkPhos-562* TotBili-4.0* ___ 06:05AM BLOOD Lipase-34 ___ 06:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.5* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Celebrex ___ mg oral DAILY 4. Citalopram 20 mg PO DAILY 5. Excedrin Extra Strength (aspirin-acetaminophen-caffeine) 250-250-65 mg oral BID:PRN headache 6. Flovent HFA (fluticasone) 44 mcg/actuation inhalation DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID 9. Lisinopril 40 mg PO DAILY 10. Oxcarbazepine 600 mg PO BID 11. Potassium Chloride 10 mEq PO BID 12. TraZODone 50 mg PO QHS 13. Simvastatin 40 mg PO QPM Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID 4. Lisinopril 40 mg PO DAILY 5. Oxcarbazepine 600 mg PO BID 6. TraZODone 50 mg PO QHS 7. Aspirin 81 mg PO DAILY 8. Celecoxib 200 mg ORAL DAILY 9. Excedrin Extra Strength (aspirin-acetaminophen-caffeine) 250-250-65 mg oral BID:PRN headache 10. Flovent HFA (fluticasone) 44 mcg/actuation INHALATION DAILY 11. Hydrochlorothiazide 25 mg PO DAILY 12. Potassium Chloride 10 mEq PO BID Hold for K > 13. Simvastatin 40 mg PO QPM 14. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Choledocholithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: MRCP INDICATION: ___ year old man with weight loss, painless jaundice, CT at OSH with biliary dilation // assess for cholangiocarcioma TECHNIQUE: Following the administration of 10 mL of Gadavist, multiplanar multisequence T1 and T2 weighted sequences were obtained in a 1.5 tesla magnet as per the MRCP biliary protocol. COMPARISON: CT abdomen dated ___ FINDINGS: Lower thorax: The lung bases are clear. No pleural or pericardial effusion. Liver: The liver is homogeneous in signal characteristics. No solid or cystic lesions. No abnormal areas of restricted diffusion. The liver contours are smooth. Biliary: Surgical absence of the gallbladder is noted. There are multiple calculi in the common bile duct measuring up to 13 mm. The common bile duct is dilated measuring up to 15 mm. There is circumferential narrowing spanning the most distal 2.2 cm of the common bile duct. There is no obstructing extra-luminal mass. There is mild duct enhancement and high T2 signal in keeping with edema. The narrowing is likely secondary to a benign stricture from a recently passed stone. There is intra-hepatic duct dilatation. Spleen: The spleen is mildly enlarged measuring up to 15.1 cm. No focal lesions. Pancreas: The pancreatic parenchyma maintains normal bulk, intrinsic hyperintense T1 signal and enhancement pattern. No focal lesion or ductal abnormality is seen. Multiple 1-2 mm cystic lesions in the body and tail of the pancreas are most in keeping with side branch IPMN. Adrenal glands: Unremarkable. Kidneys: The kidneys are normal in signal characteristics. The corticomedullary differentiation is well-maintained. There are no solid lesions. Multiple bilateral cortical cysts are noted. The largest cyst is in a lower pole of the left kidney measuring 2.3 cm. No hydronephrosis or hydroureter. GI tract: The GI tract is of normal caliber throughout. Lymph nodes and mesenteric No significant mesenteric, retroperitoneal or porta hepatis lymphadenopathy by size criteria. Vasculature: The abdominal aorta is of normal caliber throughout without any significant areas of narrowing or dilatation. There is mild atherosclerosis noted in the distal abdominal aorta. Conventional hepatic arterial anatomy. The portal and hepatic veins appear patent. Bones: The bone marrow demonstrates normal signal characteristics. No concerning osseous lesions. IMPRESSION: Choledocholithiasis resulting in common bile duct and intrahepatic duct dilatation. Gastroenterology consult for ERCP is recommended. Multiple 1-2 mm cystic lesions in the body and tail of the pancreas are most in keeping with side branch IPMN. Follow-up MRI in ___ year to ensure stability is recommended. RECOMMENDATION(S): Follow-up MRI in ___ year to ensure stability of pancreatic cystic lesions most in keeping with side-branch IPMN. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Jaundice, Transfer Diagnosed with JAUNDICE NOS temperature: 98.6 heartrate: 70.0 resprate: 18.0 o2sat: 98.0 sbp: 143.0 dbp: 86.0 level of pain: 0 level of acuity: 3.0

You were admitted with jaundice (yellowing of the skin) and after an MRI we found you had choledocholithiasis (gallstones in the bile ducts). You underwent an ERCP (endoscopy to remove the gallstones) and a stent was placed. It's important that you finish the antibiotics we're prescribing, and avoid blood thinners of any kind (e.g. aspirin, ibuprofen, Motrin, warfarin/Coumadin, etc.) for at least 5 days after the procedure. The ERCP team will be in touch with you to schedule a follow-up time when the stent that was placed will be removed.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Augmentin / Biaxin / amitriptyline / electrode adhesive Attending: ___. Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: none History of Present Illness: n brief this is a ___ year old man with IBS, mitral valve repair ___, and VT arrest s/p ICD ___ who presents today with hematochezia and abdominal cramping. Patient states that he dropped off his son at the airport yesterday AM and stopped at his son's office on the way home where he had sudden urge to have a bowel movement. He had several, of which the first was diarrhea and then he noted blood/mucus on subsequent voids (had to make two stops on the way home from the airport and also reports severe abdominal pain during the car ride, particularly when going over bumps, reaching ___ in severity). The stools have become progressively more "liquid" in nature with less stool. He went home and had many more BMs (he estimates >25). He has had significant urgency and also endorsed sweats and chills during some of the bowel movements. Patient also reports feeling increased fatigue and decreased appetite in the two days prior to onset of his symptoms as well as subjective fever and chills. He denies any abdominal pain or abdominal pain after eating. THe patient does endorse taking ibuprofen every ___ days though denies any dark stools. He endorses a history of IBS with hemorrhoids and a little bit of blood, on occassion. He denies history of CDiff, PUD, or Hpylori. Also denies recent travel or new diet. Prior to the onset of his symptoms, he had eaten a pasta dinner the night before and a blueberry muffin from the freezer for breakfast that morning. He had a colonoscopy (___) ___ years ago that showed a polyp, but otherwise was normal. Also of note, he recently finished 10 days of amoxicillin for sinusitis (last dose ___. He went to ___ in ___ where he had labs and a CT scan showing diverticulosis without stranding, phlegmon, free air. He was sent to ___ ED. In the ED initial vitals were: Time Pain Temp HR BP RR Pox Glucose Yest 17:32 97.6 66 142/81 18 100% RA Yest 20:05 98.3 65 153/76 16 97% RA Yest 20:05 98.3 65 153/76 16 97% RA Labs were significant for Hgb was stable x2. Cr was 1.4 from baseline of 1.0. WBC 12.5. Patient received fluids in the ED and was started on cipro/flagyl for uncomplicated diverticulitis despite normal CT findings (non-contrast). GI recs: Large bore IV access, T+S, xmatch for 4 u, NPO for now CTA if active bleeding Review of Systems: (+) per HPI (-) night sweats, headache, vision changes, rhinorrhea, sore throat, cough, shortness of breath, chest pain, constipation, hematochezia, dysuria, hematuria. Today, patient reports that he no longer has abdominal pain, though his belly is a bit "sore." He continues to have watery bloody bowel movements though much less frequent. Past Medical History: #V. tach arrest in the field with ROSC, s/p ICD placement with EP study - ___ ___ ICD, Energen ICD D E140) [The ICD is currently programmed with two tach zones. The VT detection is between 170 and 210 while the VF detection is greater than 210 beats per minute. The VT therapy equals anti-tachy pacing followed by six shocks at 41 joules, whereas the VF therapy equals anti-tachy pacing followed by 8 shocks at 41 joules. The bradycardic function of device is programmed VVI mode with a lower rate of 40 beats per minute] #Mitral valve repair (#32mm Physio ring) for severe MR/MVP on ___ (___) #Asthma #Chronic Constipation #Frontal Lobe Cyst complicated by infected shunt #Gastroesophageal Reflux Disease #Hiatal Hernia #Inguinal Hernia #Irritable Bowel Syndrome #Mitral Regurgitation #Mitral Valve Prolapse #Prostate Cancer SURGICAL HISTORY: #Frontal lobe cyst removal complicated by infected shunt, ___ #Hiatal Hernia Repair ___ #Fundoplication ___ #Hand Surgery #Prostatectomy ___ Social History: ___ Family History: Father - history of heart murmur, died of esophageal cancer Mother - history of mental illness Uncle - history of heart murmur, died of congestive heart failure Physical Exam: Physical Exam on Admission: ==================== Vitals - T: 97.8 BP:123/87 HR: 67 RR:18 02 sat:98% RA GENERAL: well appearing middle aged man in NAD HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: regular rate with ectopy, no murmurs/rubs/gallops LUNG: CTAB, breathing without use of accessory muscles ABDOMEN: Soft, nondistended, mildly tender in suprapubic area without rebound or guarding EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: Alert, oriented, good historian, CN II-XII intact, normal gate, no pronator drift SKIN: warm and well perfused, no excoriations or lesions, no rashes RECTAL: notable for hemorrhoids, guaiac negative Physical Exam on Discharge: ==================== VS: T 97.4-97.7, BP 119-122/72-93, HR 57-63, RR 16, O2 96RA GENERAL: well appearing middle aged man in NAD HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: regular rate with ectopy, no murmurs/rubs/gallops LUNG: CTAB, breathing without use of accessory muscles ABDOMEN: Soft, nondistended, mildly diffuse tenderness to palpation, no rebound or guarding EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: Alert, oriented, good historian, CN II-XII intact, normal gate, no pronator drift SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Labs on Admission: ================ ___ 04:30PM BLOOD WBC-12.5*# RBC-5.10 Hgb-15.7 Hct-47.2 MCV-93 MCH-30.8 MCHC-33.3 RDW-13.7 Plt ___ ___ 04:30PM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-142 K-4.3 Cl-104 HCO3-28 AnGap-14 ___ 04:30PM BLOOD ALT-19 AST-28 AlkPhos-66 TotBili-0.6 Labs on Discharge: ============== ___ 05:30AM BLOOD WBC-5.2 RBC-4.26* Hgb-13.3* Hct-39.2* MCV-92 MCH-31.3 MCHC-33.9 RDW-13.3 Plt ___ ___ 05:30AM BLOOD Plt ___ ___ 05:30AM BLOOD Glucose-82 UreaN-18 Creat-1.2 Na-140 K-3.9 Cl-105 HCO3-27 AnGap-12 ___ 05:30AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1 ___ 10:58 pm STOOL CONSISTENCY: NOT APPLICABLE C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. FECAL CULTURE - R/O VIBRIO (Pending): FECAL CULTURE - R/O YERSINIA (Pending): Studies: ========= CT abdomen Pelvis: IMPRESSION: Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin EC 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. NexIUM (esomeprazole magnesium) 40 mg oral daily 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Dofetilide 250 mcg PO Q12H 6. Metoprolol Tartrate 12.5 mg PO BID 7. Temazepam 30 mg PO HS:PRN insomnia Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Dofetilide 250 mcg PO Q12H 3. Metoprolol Tartrate 12.5 mg PO BID 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Temazepam 30 mg PO HS:PRN insomnia 6. Docusate Sodium 100 mg PO BID 7. NexIUM (esomeprazole magnesium) 40 mg oral daily Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: infectious colitis Secondary diagnoses: CAD s/p VT arrest, ICD implantation on dofetilide IBS 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 1 day of left sided abdominal pain and bloody stool with CT abd/pelvis from ___ Urgent Care ___ // eval for evidence of bowel ischemia vs diverticulitis TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis .Coronal and sagittal reformations were performed and submitted to PACS for review. This is an outside hospital study for second read. DOSE: This is an outside hospital study per second read. COMPARISON: None. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: Lack of IV contrast limits evaluation. HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no evidence of stones, focal suspicious renal lesions or hydronephrosis. Several renal cysts are seen bilaterally. 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 no calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. The 1.2 x 0.5 cm hypodense cystic lesion in the left pelvic sidewall is of doubtful clinical significance. The prostate is absent with clips in place. BONES AND SOFT TISSUES: There is no evidence of worrisome lesions. Abdominal and pelvic wall is within normal limits. IMPRESSION: Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. Bilateral renal cysts. Gender: M Race: WHITE Arrive by AMBULANCE Chief complaint: LLQ abdominal pain Diagnosed with GASTROINTEST HEMORR NOS, HYPERTENSION NOS temperature: 98.5 heartrate: 66.0 resprate: 16.0 o2sat: 98.0 sbp: 138.0 dbp: 90.0 level of pain: 3 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted with diarrhea that was likely caused by an infection. You were initially given antibiotics (Ciprofloxacin and flagyl) but your c.difficile test came back negative. In addition, the dofetilide you take for your heart can make you more likely to have abnormal heart rhythms. Ciprofloxacin makes this more likely and so this medication was discontinued. Most infectious diarrhea gets better on its own so you don't need any additional medications. If you develop further diarrhea, please don't take Immodium as this will prevent the infection from being cleared. You may resume taking your stool softeners after a few days to let your bowel rest. 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: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with HIV (CD4 225, CD4/CD8 0.4, VL 78,000 ___, Refsum's disease, reactive airway disease, restrictive lung disease who presents with dyspnea. He complains of increasing dyspnea x 2 weeks with increased albuteral inhaler usage, mostly because of the recent weather change and worsening allergy symptoms. It was really bad on ___ that he was using his albuterol inhaler ever couple of feet that he walks. He felt better on ___. However, today, the dypsnea came back, especially with exertion, and he was feeling a little lightheaded. These happened after he took his morning pills including the new Atripla. He also feels very dry. He reports minimal cough, non-productive, similar to post-nasal drip cough. He reports no chest pain, palpitation, N/V, sick contact, recent travel, recent TB exposure, abdominal pain, fever or chill. He has never had asthma exacerbation requiring intubation in the past. Of note, patient just started his Atripla today. Initial ___ VS were 99.4 113 178/86 20 93% RA. Labs were notable for normal WBC, Hgb 12.3/Hcg 36.7, Plt 173, no left shift, normal chemistry, Phos .3, Crt 0.9, UA negative, lactate 1.3, AST 45, but LFT otherwise normal. CXR showed ? small LLL consolidation. EKG showed sinus tachycardia, left axis deviation and right atrial enlargement. He received albuterol nebs x 2 and ipratropium neb, prednisone 20 mg, and ceftriaxone 1 g IV and most of the 500 mg IV azithromycin. ID fellow was apparently paged from the ___. Peak expiratory flow was 220 after albuterol neb. Past Medical History: - Refsum's disease (hereditary motor and sensory neuropathy type IV) - HIV infection - Knee replacements, bilateral - Reactive airway disease - Allergic rhinitis (recurrent) - Otitis media (recurrent) Social History: ___ Family History: - Sister: ___ disease - Mother: deceased, had metastatic breast cancer and Alzheimer's disease - Father: deceased, had throat cancer and had EtOH/smoking history Physical Exam: Physical exam at admission: VS - 99.1, 159/107, HR 114, 95-97% RA, RR 18 GENERAL - well appearing Caucasian male, NAD HEENT - PERRLA, OP clear, MMM NECK - supple, no LAD, no JVD LUNGS - CTAB, no w/c/r, no accessory muscle use HEART - regular tachycardic, normal S1 and S2, no m/r/g ABDOMEN - soft, NT, ND, BS+, no HSM EXTREMITIES - warm, dry, 2+ ___ pulses bilaterally, trace edema to the ankles NEURO - A&Ox3, + neuropathy, mostly peripheral, gait is normal, CN III-XII intact, no motor deficit noted. Physical exam at discharge: Vitals: 98.4 150/91 112 20 95%RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, OP clear HEART - RRR, nl S1-S2, no MRG LUNGS - no use of accessory muscles while breathing, able to speak in full sentences without gasping for air; + prominent end expiratory wheezing in bilateral lungs, worse in middle lobes; no egophony or dullness to percussion noted ABDOMEN - NABS, soft/NT/ND, no masses or HSM NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Labs at admission: ___ 04:55PM BLOOD WBC-5.1 RBC-4.38* Hgb-12.3* Hct-36.7* MCV-84 MCH-28.1 MCHC-33.5 RDW-15.4 Plt ___ ___ 04:55PM BLOOD Neuts-62.3 ___ Monos-5.0 Eos-9.8* Baso-0.6 ___ 04:55PM BLOOD Glucose-105* UreaN-14 Creat-0.9 Na-136 K-4.2 Cl-101 HCO3-26 AnGap-13 ___ 04:55PM BLOOD ALT-20 AST-45* AlkPhos-94 TotBili-0.6 Labs at discharge: ___ 08:10AM BLOOD WBC-4.7 RBC-4.45* Hgb-12.4* Hct-36.9* MCV-83 MCH-28.0 MCHC-33.7 RDW-15.8* Plt ___ ___ 08:10AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-138 K-3.7 Cl-100 HCO3-29 AnGap-13 ___ 08:10AM BLOOD Calcium-10.0 Phos-2.8 Mg-2.3 IMAGING: CXR ___: Possible focal opacity at the inferior lingula, could represent pneumonia in the correct clinical setting. Clinical correlation is advised. EKG ___: Sinus tachycardia with sinus arrhythmia. Otherwise, within normal limits. No major diagnostic interim change from the previous tracing. Medications on Admission: The Preadmissions Medication list may be inaccurate and require further investigation. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea/wheezing 2. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg Oral Once a day HIV 3. Hydrochlorothiazide 12.5 mg PO DAILY Hypertension 4. Lorazepam 0.5 mg PO HS:PRN Insomnia 5. Asmanex Twisthaler *NF* (mometasone) 220 mcg (120 doses) Inhalation Twice a day 6. Nasonex *NF* (mometasone) 50 mcg/actuation NU Once a day 7. traZODONE 50 mg PO HS:PRN Insomnia 8. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia 9. clemastine *NF* 1.34 mg Oral Daily:PRN Post-nasal drip 10. Fexofenadine 60 mg PO BID 11. Ibuprofen 400 mg PO Q8H:PRN arthritis 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Fexofenadine 60 mg PO BID 2. Hydrochlorothiazide 12.5 mg PO DAILY Hypertension 3. Lorazepam 0.5 mg PO HS:PRN Insomnia 4. Multivitamins 1 TAB PO DAILY 5. Azithromycin 250 mg PO Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 6. PredniSONE 20 mg PO DAILY RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 7. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea/wheezing 8. Asmanex Twisthaler *NF* (mometasone) 220 mcg (120 doses) Inhalation Twice a day 9. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg Oral Once a day HIV 10. clemastine *NF* 1.34 mg Oral Daily:PRN Post-nasal drip 11. Ibuprofen 400 mg PO Q8H:PRN arthritis 12. Nasonex *NF* (mometasone) 50 mcg/actuation NU Once a day 13. traZODONE 50 mg PO HS:PRN Insomnia 14. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia Discharge Disposition: Home Discharge Diagnosis: Primary: bronchitis, dizziness/dehydration Secondary: HIV, reactive airway disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CHEST RADIOGRAPH PERFORMED ON ___ ___. CLINICAL HISTORY: Cough, question pneumonia. FINDINGS: PA and lateral views of the chest provided. There is a small area of opacity at the left lung base abutting the left heart border, could represent pneumonia in the correct clinical setting. Otherwise, the lungs are clear. No pleural effusion or pneumothorax. Heart and mediastinum contours are unchanged. Bony structures are intact. IMPRESSION: Possible focal opacity at the inferior lingula, could represent pneumonia in the correct clinical setting. Clinical correlation is advised. Findings discussed with Dr. ___ at the time of initial review. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ASTHMA EXACERBATION / SOB Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DEHYDRATION, ASYMPTOMATIC HIV INFECTION temperature: 99.4 heartrate: 113.0 resprate: 20.0 o2sat: 93.0 sbp: 178.0 dbp: 86.0 level of pain: 3 level of acuity: 2.0

It was a pleasure to participate in your care at ___ ___. You came to the hospital for shortness of breath and dizziness. We gave you antibiotics, steroids, nebulizer breathing treatments and IV fluids. Please keep all of your follow up appointments. Please take all of medications as prescribed. You will be taking steroids (prednisone) and antibiotics for a few days after leaving the hosptials.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headache, 'foggyness', left sided sensory changes Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ F with history of right cavernous hemangioma found in setting of severe migraines and complex partial seizures, s/p resection in ___, with resolution of seizures, who was found to have new right cavernous hemangiom ain ___ in setting of recurrence of migraine, who presents after episode of left sided numbness/tingling three days ago and then migrain this morning associated with 'foggyness' as well as cold sensation on left side of body. Patient reports that in ___ she started having sever migraines which were bifrontal throbbing, associated with photophobia and phonophobia, nausea and sometimes vomiting, which could last the entire day and were happening three to four times weekly. Around the same time, she started having complex partial seizures consisting of head and eye shaking with head turning to the left and difficulty with speech production, but retained consciousness (could hear and see her surroundings). these would last ~ 2minutes but were quite frequent, sometimes clustering three in one day. In that setting, she underwent MRI brain which showed right cavernous hemangioma. She was also started on Keppra for seizure prophylaxis at that time, but continued to have seizures despite Keppra. She had serial MRI's to monitor hemagioma and this was find to have significantly grown and had hemorrhage in 3 months. That together with persistent seizures made surgeons decide to recent the cavernous hemangioma in ___. Post-operatively, patient reports initially she had left face and body paralysis, but no sensory loss. She underwent aggressive rehab and ___ and recovered most function except her left hand which is still very weak. After surgery, she continued on Keppra but few months aftre had two GTC seizures, each brief ~ 1 minute. A year afterwards, she was seizure free and weaned off Keppra. Continued to be seizure and headache free for a long time. However, starting ___, she started having severe migraines which were very similar to her prior migraines in quality and intensity. She saw her Neurologist at the time at ___ who recommended MRI brain. This showed new, albeit smaller right cavernous hemangioma. Patient was started on Topamax initially 25mg po BID just for headaches, but then increased to 50mg po BID also for seizure prophylaxis. She was also started on Sumatriptan 50mg prn severe migraine. She had repeat MRI at 6 months which showed stable hemangioma and no hemorrhage. In the interim, she moved to ___ to go to college to ___. She was lost to follow-up. She continues to have migraines initially once weekly but now once every couple of months, last had been 1.5 months ago. Patient now presents because three days ago she sat up from laying down and had sudden sensation of numbness and tngling over the left side of her face and her left arm and leg. This lasted through the night and dissipated by the next morning. This was not associated with other symptoms and did not have a headache with it. Patient states she has never had anything similar in the past. This morning, patient woke up with typical migraine and took Sumatriptan. Afterwards at work, however, she felt very 'foggy' as if she were 'in a cloud' feeling 'sluggish' and with slowed speech. The left side of her body also started feeling cold. She was concerned because in pat before a seizure she would get a similar 'foggy' sensation. No abnormal movements or shaking. Came to our ED for further eval. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: -Right cavernous hemangioma s/p resection ___ -New right cavernous hemangioma diagnosed ___ -History complex partial seizures and GTCs x2 as per HPI -Migraine headaches Social History: ___ Family History: No Fh seizures, migraines, vascular malformations, brain tumors. Physical Exam: Physical Exam: Vitals: T: 98.7 P: 73 BP: 107/66 RR: 16 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx Neck: Supple, no nuchal rigidity. No carotid bruits Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly. Skin: no rashes or lesions Neurologic: -Mental Status: Alert, oriented x 3. Attentive, able to name ___ backward without difficulty. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Decreased LT and PP over V1-V3. VII: Subtle left NLFF, 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 and has symmetric strengh. -Motor: Normal bulk, tone throughout. No pronator drift. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE FF IP Quad Ham TA ___ L 5- 4- 5- 4- ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: Decreased light touch, pinprick, cold sensation over left arm and leg. Intact vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3 3 3 3 2+ R 2 2 2 2 1 Plantar response was up on left, down on right. -Coordination: No dysmetria on FNF or HKS bilaterally. UE RAMs symmetric. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Pertinent Results: ___ 08:20PM BLOOD WBC-10.9 RBC-5.05 Hgb-12.9 Hct-40.2 MCV-80* MCH-25.5* MCHC-32.1 RDW-13.1 Plt ___ ___ 08:20PM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-140 K-4.3 Cl-102 HCO3-26 AnGap-16 ___ 08:20PM BLOOD Calcium-10.0 Phos-3.7 Mg-2.2 ___ 08:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG NCHCT ___ Status post right frontal craniotomy and a cavernoma resection with associated postsurgical changes. No definitive acute intracranial hemorrhage is identified. MRI brain ___. Encephalomalacic and gliotic changes in the right frontal lobe, at the site of prior resection of known cavernoma as per the history. A small focus of negative susceptibility at the medial aspect, can relate to prior blood products or any residual component of the cavernoma; differentiation between the two can be difficult on non-contrast imaging. This focus is not hyperdense on the noncontrast CT to suggest obvious acute hemorrhage within. No change in size compared to recent CT done a few hours earlier. No remote studies are available to assess for interval change. Consider close followup CT to assess for any interval change if there is continued concern. 2. Small pituitary-? Normal Variant or abnormal. Correlate clinically and with labs 3. Slightly hypointense marrow signal diffusely, may relate to cellular marrow. Correlate with hematology labs for anaemia, etc. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Topiramate (Topamax) 50 mg PO BID 2. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine 3. Loestrin Fe ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20 mcg (21)/75 mg (7) oral daily Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth every 8 hours Disp #*30 Tablet Refills:*2 2. Verapamil 40 mg PO Q12H RX *verapamil 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 3. Loestrin Fe ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20 mcg (21)/75 mg (7) oral daily Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: paresthesias Secondary Diagnosis: cavernous angioma 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 hx cavernous hemangioma p/w left sided numbness // ?intracranial bleed? TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. Reformatted coronal, sagittal and thin section bone algorithm-reconstructed images were then generated. DOSE: CTDIvol: 53.84 mGy DLP: 891.93 mGy-cm COMPARISON: None available. FINDINGS: The patient is status post a right frontal cavernoma resection from ___ per history. A tract of the associated encephalomalacia noted along the upper margin of this resection. A small region of adjacent hyperdensity likely reflects normal cortical gray matter. There is extra-axial fluid collection or discrete intracranial hemorrhage identified. The ventricles and sulci are normal in size and configuration except for mild ex-vacuo dilation of right frontal horn related to adjacent encephalomalacic changes. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. Sella, pineal gland and the craniocervical junction regions are grossly unremarkable. The patient is status post right frontal approach craniotomy. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The partially included globes are unremarkable. IMPRESSION: Status post right frontal craniotomy and a cavernoma resection with associated postsurgical changes. No definitive acute intracranial hemorrhage is identified. Correlate clinically to decide on the need for further workup with MRI if not contraindicated of followup. Radiology Report EXAMINATION: MR HEAD W/O CONTRAST INDICATION: ___ year old woman with right cavernous hemangioma p/w severe migraine and left sided sensory symptoms // evaluate cavernous hemangioma for growth or bleeding TECHNIQUE: MRI of the head without IV contrast COMPARISON: CT head ___ FINDINGS: Postsurgical changes are noted in the right frontal lobe, with encephalomalacic and gliotic changes. There is a small focus of negative susceptibility with T2 hypointense signal, in the medial aspect adjacent to the right lateral ventricle series 7, image 15 and series 5, image 15 the can relate to prior blood products or any residual component of the cavernoma; differentiation between the two can be difficult on non-contrast imaging. This focus is not hyperdense on the noncontrast CT to suggest obvious acute hemorrhage within. No remote studies are available to assess for interval change. No acute infarct, mass effect, shift of normally midline structures or hydrocephalus. Mild ex vacuo dilation of the right lateral ventricle, related to the encephalomalacic changes. Otherwise, the ventricles, the cerebral sulci and the cerebellar folia are normal. Minimal periventricular FLAIR hyperintense signal, non-specific The pituitary is slightly small. The pineal gland and the craniocervical junction regions are grossly unremarkable. Cerebellar tonsils are located at the level of the foramina magnum. The major intracranial arterial flow voids are noted. Venous sinuses are unremarkable. Retention cysts in the right maxillary sinuses. A few small nodes in the upper neck, not abnormally enlarged. Mildly prominent adenoids. Slightly hypointense marrow signal diffusely, may relate to cellular marrow. IMPRESSION: 1. Encephalomalacic and gliotic changes in the right frontal lobe, at the site of prior resection of known cavernoma as per the history. A small focus of negative susceptibility at the medial aspect, can relate to prior blood products or any residual component of the cavernoma; differentiation between the two can be difficult on non-contrast imaging. This focus is not hyperdense on the noncontrast CT to suggest obvious acute hemorrhage within. No change in size compared to recent CT done a few hours earlier. No remote studies are available to assess for interval change. Consider close followup CT to assess for any interval change if there is continued concern. 2. Small pituitary-? Normal Variant or abnormal. Correlate clinically and with labs 3. Slightly hypointense marrow signal diffusely, may relate to cellular marrow. Correlate with hematology labs for anaemia, etc. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: L Numbness, PRE-SEIZURE Diagnosed with SKIN SENSATION DISTURB temperature: 95.3 heartrate: 98.0 resprate: 18.0 o2sat: 99.0 sbp: 128.0 dbp: 82.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure to take care of you at ___ ___. You were admitted to the hospital due to your tingling, and you were monitored with EEG which did not show any seizures. We changed the medications for your migraine given your history of cavernous angiomas. Please follow up with stroke/vascular neurologist and also with Dr. ___. We will try to arrange for the appointments, but if you do not hear from us, please call ___ and ask for Dr. ___.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: eggs / environmental Attending: ___. Chief Complaint: Right intertrochanteric femur fracture Major Surgical or Invasive Procedure: Right trochanteric fixation nail placement History of Present Illness: ___ female hx developmental delay presents with right hip pain. Per family, she was in her USOH until about 2 weeks ago, when she had a fall. The circumstances of the fall are unknown, as she was at her day program. 3 days ago, she began refusing to walk. She was diagnosed with UTI (gets these frequently; is incontinent of urine at baseline, but develops increased frequency) and started on Bactrim. However, walking didn't improve, and pt was grimacing when she tried to bear weight. They also noted increased swelling in her legs. They therefore brought her to the ED for further evaluation. In ED, she was found to have a hip fracture, for which we were consulted. Past Medical History: PAST MEDICAL HISTORY: - Mild/moderate mental retardation (with significant cognitive decline over the past ___ years) - Pyloric stenosis s/p repair as infant - Ventricular septal defect s/p repair - Laryngeal ?stenosis vs. web - Chronic cough and congestion (vs. reflux?) - Severe scoliosis, s/p thoracolumbar ___ rod Social History: ___ Family History: Negative for epilepsy or any other neurologic problems. Pertinent Results: ADMISSION LABS: ___ 07:33PM BLOOD WBC-13.0* RBC-4.18 Hgb-11.4 Hct-36.4 MCV-87 MCH-27.3 MCHC-31.3* RDW-14.1 RDWSD-44.9 Plt ___ ___ 07:33PM BLOOD Neuts-81.0* Lymphs-8.2* Monos-9.2 Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.51* AbsLymp-1.07* AbsMono-1.19* AbsEos-0.03* AbsBaso-0.04 ___ 07:33PM BLOOD ___ PTT-28.7 ___ ___ 07:33PM BLOOD Plt ___ ___ 07:33PM BLOOD Glucose-156* UreaN-15 Creat-0.6 Na-136 K-5.6* Cl-98 HCO3-23 AnGap-15 ___ 07:33PM BLOOD ALT-16 AST-28 CK(CPK)-230* AlkPhos-175* TotBili-0.4 ___ 07:33PM BLOOD cTropnT-<0.01 ___ 07:33PM BLOOD Lipase-22 ___ 07:33PM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.7 Mg-2.0 DISCHARGE LABS: IMAGING/STUDIES: TTE ___: CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlar ged. There is no evidence for an atrial septal defect by 2D/color Doppler . The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. There is no resting left ventricular outflow tract gradient. No abnormal flow associated with ventricular septal defect or obvious structural abnormality in the ventricular septum are seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). 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 valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regur gitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a trivial pericardial ef fusion. There is a prominent anterior fat pad. IMPRESSION: Suboptimal image quality . Normal biventricular wall thicknesses, cavity sizes, and regional/global systolic function. Elevated PCWP suggested CXR ___: FINDINGS: Improvement in bilateral mild pulmonary edema. Stable mild cardiomegaly with unremarkable cardiomediastinal silhouette. Small bilateral pleural effusions. No pneumothorax. Spinal surgical material, unchanged. IMPRESSION: Interval improvement of mild bilateral pulmonary edema. ___ Knee XR: FINDINGS: No fracture or dislocation is seen. There is mild-to-moderate medial compartment joint space narrowing. A quadriceps tendon enthesophyte is seen. There is no knee joint effusion. There is normal osseous mineralization. No suspicious lytic or sclerotic lesions are identified. Radio opaque material seen overlying the anterior soft tissue of the thigh is likely exterior to the patient. IMPRESSION: No evidence of acute fracture or dislocation. ___ CXR: IMPRESSION: Compared to chest radiographs since ___ most recent ___. Mild pulmonary edema is new. No pneumothorax or pleural effusion. Moderate cardiomegaly is stable. This examination neither suggests nor excludes the diagnosis of acute pulmonary embolism. ___ CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Constellation of diffuse ground-glass opacities, interlobular septal thickening, and small bilateral pleural effusions is most compatible with mild pulmonary edema. ___ CT A/P 1. Comminuted, laterally angulated intertrochanteric right femoral neck fracture. 2. Irregular thickening of the anterior and superior bladder wall. Correlate with urinalysis to exclude infection and consider further evaluation with cystoscopy on nonemergent basis. 3. No acute intra-abdominal process. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY 2. Sertraline 100 mg PO DAILY 3. ALPRAZolam 0.5 mg PO TID:PRN anxiety 4. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Enoxaparin Sodium 40 mg SC QPM end on ___. ALPRAZolam 0.5 mg PO TID:PRN anxiety 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Sertraline 100 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R intertrochanteric femur fracture Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused - sometimes. Followup Instructions: ___ Radiology Report EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT IN O.R. INDICATION: ORIF RIGHT HIP FX IN O.R. IMPRESSION: Fluoroscopic documentation of right hip procedure. No radiologist was present. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with cough// ? consolidation ? consolidation IMPRESSION: Compared to chest radiographs since ___ most recent ___. Mild pulmonary edema is new. No pneumothorax or pleural effusion. Moderate cardiomegaly is stable. This examination neither suggests nor excludes the diagnosis of acute pulmonary embolism. NOTIFICATION: The findings were discussed with ___. by ___ ___, M.D. on the telephone on ___ at 2:01 pm, 1 minutes after discovery of the findings. Radiology Report EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old woman with new O2 req, tachycardia// ? PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Total DLP (Body) = 388 mGy-cm. COMPARISON: None 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. Mild cardiomegaly. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: Small right and trace left pleural effusions. No pneumothorax. LUNGS/AIRWAYS: There is mild diffuse interlobular septal thickening throughout the lungs bilaterally. In addition, there are ground-glass opacities within the upper and lower lobes bilaterally. The constellation of these findings is most compatible with mild pulmonary edema. There is mild diffuse bronchial wall thickeing. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES AND SOFT TISSUES: Thoracolumbar fixation hardware is partially imaged without evidence of hardware complication. There is persistent severe levoconvex scoliosis of the lumbar spine. No suspicious osseous abnormality is seen.? There is no acute fracture. Coarse calcification within the right breast. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Constellation of diffuse ground-glass opacities, interlobular septal thickening, and small bilateral pleural effusions is most compatible with mild pulmonary edema. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with SOB// ? pulm edema IMPRESSION: In comparison with the study of ___, there is increasing pulmonary edema with continued substantial enlargement of the cardiac silhouette. Otherwise, little change. Radiology Report INDICATION: ___ year old woman with hypoxia, poss PNA// ? PNA vs pulm edema TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with mild interstitial edema. There is evidence of internal fixation of the thoracic spine. Cardiomediastinal silhouette is stable. Small left pleural effusions unchanged. No pneumothorax is seen Radiology Report EXAMINATION: KNEE (2 VIEWS) LEFT INDICATION: ___ year old woman with knee pain// ? fracture ? fracture TECHNIQUE: Frontal and lateral view radiographs of the left knee. COMPARISON: Radiograph from ___ FINDINGS: No fracture or dislocation is seen. There is mild-to-moderate medial compartment joint space narrowing. A quadriceps tendon enthesophyte is seen. There is no knee joint effusion. There is normal osseous mineralization. No suspicious lytic or sclerotic lesions are identified. Radio opaque material seen overlying the anterior soft tissue of the thigh is likely exterior to the patient. IMPRESSION: No evidence of acute fracture or dislocation. Radiology Report EXAMINATION: Chest radiograph INDICATION: ___ year old woman with likely iatrogenic pulmonary edema from IVF// evaluate for interval change, ? pulm edema, ?PNA TECHNIQUE: Chest PA and lateral COMPARISON: Multiple prior chest radiographs, most recent ___. FINDINGS: Improvement in bilateral mild pulmonary edema. Stable mild cardiomegaly with unremarkable cardiomediastinal silhouette. Small bilateral pleural effusions. No pneumothorax. Spinal surgical material, unchanged. IMPRESSION: Interval improvement of mild bilateral pulmonary edema. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: Leg swelling Diagnosed with Displaced intertrochanteric fracture of right femur, init, Unspecified fall, initial encounter temperature: 97.9 heartrate: 80.0 resprate: 20.0 o2sat: 99.0 sbp: 140.0 dbp: 97.0 level of pain: 5 level of acuity: 3.0

Dear ___, You came to ___ because you had a fall. You were found to have a right hip fracture. 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: - You had surgery to repair the right hip fracture. - You were transferred to the medicine service afterwards because you had some trouble with your breathing. We gave you a medicine to remove extra fluid from the lungs to help with breathing. - You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please follow up with your primary care doctor and other health care providers (see below) - Please take all of your medications as prescribed (see below). - Seek medical attention if you have breathing difficulty, chest pain, shortness of breath or other symptoms of concern. 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 on the right leg. MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Please take all medications as prescribed by your physicians at discharge. 3) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take enoxaparin daily for 4 weeks (stop on ___. 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 <30 DAYS OF REHAB

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: sudden onset R hip pain, fever Major Surgical or Invasive Procedure: right hip washout, exam under anesthesia, endometrial biopsy History of Present Illness: Ms. ___ a ___ s/p SVD on ___ who presents as a transfer from ___ after experiencing sudden onset severe R hip pain with limited ROM on ___ ___s a rash, with concern for septic arthritis. Pt presented to ___ and was noted to be febrile to 103. She underwent a pelvic US which was normal and a pelvic CT which showed a joint effusion of the R hip. She also had LENIs which were negative. She also underwent a R hip XR which did not show evidence of a fracture. Aspiration of 13cc of synovial fluid of the R hip by ___ was performed; fluid analysis revealed 22K WBCs, 3K RBCs, glucose 6, gram stain growing +GPCs. The remainder of her labs showed WBC of 11.2 with 21 bands. CRP 172, ESR 45. Lactate and BMP were within normal limits. She was started on unasyn and vancomycin. Decision was made to transfer to ___ for further evaluation and workup. Upon evaluation here, she was noted to be well appearing however uncomfortable. She denied any recent traumatic injury to the hip, no cough/cold/flu symptoms, no CP/SOB, no significant breast engorgement or tenderness, no abdominal pain, no pain in the calves. She reported that she had one day of slight increase in lochia, no foul smelling discharge. Past Medical History: None Social History: Lives with children and husband; homemaker; no smoking, alcohol, or drugs Physical Exam: ___ ___ Temp: 98.3 PO BP: 116/72 R Lying HR: 68 RR: 18 O2 sat: 96% O2 delivery: RA ___ 0017 Temp: 98.3 PO BP: 121/79 L Sitting HR: 70 RR: 18 O2 sat: 96% O2 delivery: RA ___ 0017 Temp: 98.3 PO BP: 121/79 L Sitting HR: 70 RR: 18 O2 sat: 96% O2 delivery: RA ___ BP: 124/71 ___ 1548 BP: 126/73 ___ 1157 BP: 116/76 R Sitting ___ 0804 BP: 113/71 R Lying General: NAD Breasts: non-tender, no erythema, soft, nipples intact Lungs: No respiratory distress Abd: soft, nontender, fundus firm below umbilicus Lochia minimal Extremities: no calf tenderness, no edema Pertinent Results: ___ 06:40PM WBC-12.0* RBC-3.58* HGB-11.6 HCT-35.6 MCV-99* MCH-32.4* MCHC-32.6 RDW-14.1 RDWSD-51.7* ___ 06:40PM NEUTS-83* BANDS-9* LYMPHS-3* MONOS-3* EOS-2 BASOS-0 ___ MYELOS-0 AbsNeut-11.04* AbsLymp-0.36* AbsMono-0.36 AbsEos-0.24 AbsBaso-0.00* ___ 06:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-1+* MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL ___ 06:40PM PLT SMR-NORMAL PLT COUNT-211 ___ 01:01PM OTHER BODY FLUID CT-NEG NG-NEG ___ 12:51PM LACTATE-1.3 ___ 11:44AM GLUCOSE-112* UREA N-6 CREAT-0.7 SODIUM-138 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-12 ___ 11:44AM WBC-13.3* RBC-3.81* HGB-12.4 HCT-38.2 MCV-100* MCH-32.5* MCHC-32.5 RDW-14.2 RDWSD-52.0* ___ 11:44AM PLT COUNT-213 ___ 04:02AM URINE HOURS-RANDOM ___ 04:02AM URINE UHOLD-HOLD ___ 04:02AM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 04:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* ___ 04:02AM URINE RBC-5* WBC-110* BACTERIA-FEW* YEAST-NONE EPI-0 ___ 04:02AM URINE MUCOUS-RARE* ___ 12:53AM LACTATE-1.1 ___ 12:17AM GLUCOSE-77 UREA N-8 CREAT-0.6 SODIUM-139 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-17* ANION GAP-14 ___ 12:17AM estGFR-Using this ___ 12:17AM CRP-233.6* ___ 12:17AM WBC-10.4* RBC-3.80* HGB-12.1 HCT-37.9 MCV-100* MCH-31.8 MCHC-31.9* RDW-13.8 RDWSD-50.2* ___ 12:17AM NEUTS-92* BANDS-2 LYMPHS-2* MONOS-0 EOS-1 BASOS-1 ___ METAS-2* MYELOS-0 AbsNeut-9.78* AbsLymp-0.21* AbsMono-0.00* AbsEos-0.10 AbsBaso-0.10* ___ 12:17AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL BURR-1+* ___ 12:17AM PLT SMR-NORMAL PLT COUNT-199 ___ 12:17AM ___ PTT-27.7 ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*20 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. CefTRIAXone 2 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24 hour Disp #*7 Intravenous Bag Refills:*6 4. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 6. walker 1 device miscellaneous PRN Dx: I&D of R hip with excision of posterior capsule for septic arthritis Px: good ___: 13 months RX *walker daily Disp #*1 Each Refills:*0 7. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: septic arthritis, post-partum, group A strep infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: AP portable chest radiograph INDICATION: PICC line TECHNIQUE: AP portable chest radiograph COMPARISON: None FINDINGS: The distal tip of the left PICC line terminates in the right atrium. Recommend retracting by 2.5 cm. There is no focal consolidation, pleural effusion or pneumothorax. The size of the cardiac silhouette is enlarged. IMPRESSION: The distal tip of the left PICC line terminates in the right atrium. Recommend retracting by 2.5 cm. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abnormal labs, R Hip pain Diagnosed with Oth complications of the puerperium, NEC, Pyogenic arthritis, unspecified temperature: 99.4 heartrate: 114.0 resprate: 18.0 o2sat: 96.0 sbp: 121.0 dbp: 70.0 level of pain: 4 level of acuity: 3.0

- weekly blood work - daily IV ceftriaxone with ___ until ___ - home ___ - weight bearing as tolerated - please call for any of the below symptoms

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / Penicillins / Aranesp (in polysorbate) Attending: ___. Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: ___ F NH resident w/ IDDM, CHF, CKD, pulm HTN, AFib, UTIs w/ indwelling foley, recurrent left exudative pleural effusion s/p pleuroscopy and pleural catheter placement ___ p/w hemoptysis. Pt returned to ___ yesterday. Has been having worsening cough since. Woke up this morning at 4am coughing blood-streaked sputum a/w nausea. About a teaspoon worth of blood. No vomiting. CP and dyspnea since discharge. CP is on left side associated with catheter site. Also notes her legs appear more swollen than usual. Subjective fever and sweats. Coumadin was held for 5 days prior to procedure, then started on lovenox bridge and coumadin restarted. In the ED, initial vital signs were: 100.2 126 157/78 20 94% Labs were notable for WBC 17.6, Cl 94, Bicarb 33, INR 1.5, Lactate 3.1 Studies performed include CXR Patient was given vancomycin 1 g, levaquin 750 mg, metoprolol tartrate 50 mg, acetaminophen 500 mg x 4, oxycodone x 1, 500 cc bolus. Coumadin held due to hemoptysis Vitals on transfer: 98.8 89 132/70 19 99% 2L Nasal Cannula Past Medical History: 1. Insulin Dependent diabetes. 2. Diabetic neuropathy. 3. Peripheral vascular disease. 4. Chronic kidney disease, stage 3. 5. Diastolic CHF, chronic. 6. Asthma, COPD. 7. Pulmonary hypertension, right heart failure. 8. Recurrent UTIs, including ESBL, E. coli, Proteus, and VRE. 9. History of GI bleed. 10. Morbid obesity. 11. Bipolar disorders. 12. Hypertension. 13. Iron-deficiency anemia. 14. Cirrhosis, with splenomegaly, of unknown etiology. 15. Dilated common bile duct, possible retained stone. 16. BSO, secondary to adhesions. 17. Depression. 18. Hemorrhoidal disease. 19. Vitamin D deficiency with osteopenia. 20. Paroxysmal atrial fibrillation, currently on Coumadin. 21. GERD. 22. Anasarca. 23. Gout. 24. Spastic urinary bladder Social History: ___ Family History: Father died of CVA, mother died of colon cancer at unknown age Physical Exam: Admission Physical Exam: Vitals- 98.2 127/55 75 18 98 1L Wt 136.7 kg General: NAD, resting comfortably in bed, appears stated age HEENT: PERRL, EOMI, MMM, oropharynx clear Neck: Supple, no LAD, no thyromegaly, unable for assess for JVP due to large neck CV: Irregularly irregular rhythm, ___ early peaking systolic murmur, no rubs/gallops Lungs: Crackles with lower dullness to percussion bilaterally Abdomen: Obese, soft, NT, ND, +BS Ext: DP pulses 1+, legs large with 2+ pitting edema Neuro: AAOx3, CN2-12 intact, moving all extremities Skin: Warm, well perfused, numerous seb kers, back sweaty Drain: serosanguinois output. Area of skin around drain with small erythema, Discharge Physical Exam: Vitals: Tm 99.2 BP 134/84 (110s-140s/40s-80s) P 69 (60s-80s) RR 18 (___) Sat 98% RA (94-98) Wt 132.3kg AM BG 174 General: NAD, resting comfortably in bed HEENT: PERRL, EOMI, MMM, Neck: Supple, unable for assess for JVP due to large neck CV: Irregularly irregular rhythm, ___ early peaking systolic murmur, no rubs/gallops Lungs: Trace crackles bilaterally, some dullness to percussion at bases bilaterally, improved from previous but poor effort Abdomen: Obese, soft, NT, ND, +BS Ext: DP pulses 1+, legs large with 1+ pitting edema Neuro: AAOx3, CN2-12 intact, moving all extremities Skin: Warm, well perfused, numerous seb kers Drain: serosanguinous output. Area of skin around drain slightly erythematous, improved from previous. Dressing c/d/i Pertinent Results: Admission Labs: ___ 06:30AM BLOOD WBC-17.1*# RBC-4.45 Hgb-12.9 Hct-40.7 MCV-91 MCH-29.0 MCHC-31.7 RDW-16.8* Plt ___ ___ 06:30AM BLOOD Neuts-85.1* Lymphs-9.0* Monos-4.6 Eos-1.3 Baso-0.2 ___ 06:30AM BLOOD ___ PTT-32.6 ___ ___ 06:30AM BLOOD Glucose-260* UreaN-11 Creat-0.8 Na-137 K-3.5 Cl-94* HCO3-33* AnGap-14 ___ 07:58AM BLOOD Lactate-3.1* Pertinent Labs: ___ 07:05PM BLOOD Vanco-9.3* ___ 10:18AM BLOOD Lactate-2.5* ___ 06:30AM BLOOD proBNP-2325* Discharge Labs: ___ 08:00AM BLOOD Glucose-194* UreaN-12 Creat-0.7 Na-140 K-3.7 Cl-97 HCO3-37* AnGap-10 ___ 08:00AM BLOOD ___ ___ 08:00AM BLOOD WBC-7.5 RBC-4.14* Hgb-11.9* Hct-37.5 MCV-91 MCH-28.8 MCHC-31.8 RDW-16.8* Plt ___ Imaging: - CXR ___: As compared to the previous radiograph, the left lung base has minimally increased in radiolucency, indicating a decrease in extent of the pleural effusion and the subsequent left basal and retrocardiac atelectasis. The vascular diameters have also decreased, indicating a decrease in pulmonary fluid. No new parenchymal opacities are visible. The patient is still strongly rotated to the left. Mild cardiomegaly persists. No pneumothorax. - CXR ___: Heart size and mediastinum are unchanged. Mild vascular congestion is re- demonstrated. No interval accumulation of pleural effusion is per septated. Mild interstitial pulmonary edema is noted with no substantial change since the prior study - CXR ___: 1. Vascular engorgement 2. Right basilar atelectasis and small effusion 3. Left atelectasis and moderate size effusion - EKG ___: Atrial fibrillation with a rapid ventricular response and a single ventricular premature beat versus aberrant ventricular conduction. Non-specific ST-T wave changes. Delayed R wave transition. Compared to the previous tracing of ___ the ventricular response is faster and QRS voltage has increased Micro: - Sputum cx ___: GRAM STAIN (Final ___: ___ PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. - Blood cx x ___: Pending Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO TID 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Duloxetine 60 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO DAILY 9. Gabapentin 800 mg PO TID 10. Lantus (insulin glargine) 100units/ml 22 subcutaneous daily breakfast 11. Lantus (insulin glargine) 100unit/ml 20 subcutaneous daily bedtime 12. HumaLOG (insulin lispro) 100 unit/mL subcutaneous prn hypergly 13. Isosorbide Dinitrate 20 mg PO BID 14. Metoprolol Tartrate 100 mg PO BID 15. Omeprazole 40 mg PO BID 16. Pregabalin 50 mg PO BID 17. Senna 8.6 mg PO BID 18. Tiotropium Bromide 1 CAP IH DAILY 19. TraZODone 25 mg PO HS 20. TraMADOL (Ultram) 25 mg PO Q4H:PRN pain 21. Enoxaparin Sodium 120 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 22. Lidocaine 5% Patch 1 PTCH TD QAM 23. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 24. Ascorbic Acid ___ mg PO BID 25. Bismatrol (bismuth subsalicylate) 262 mg oral q4h:prn diarrhea 26. Benzonatate 100 mg PO BID:PRN cough 27. Bisacodyl 10 mg PR HS:PRN constipation 28. Calcium Carbonate 500 mg PO TID:PRN indigestion 29. cranberry (cranberry extract) 450 mg oral BID 30. calcium polycarbophil 625 mg oral BID 31. Hydrocortisone Acetate Suppository ___AILY: PRN constipation 32. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB 33. Lactulose 30 mL PO DAILY:PRN constipation 34. melatonin 6 mg oral daily 35. Milk of Magnesia 30 mL PO QHS 36. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 37. Nystatin Cream 1 Appl TP BID rash on back 38. Tears Naturale Forte (artificial tear(dxtrn-hpm-gly)) 0.1-0.3-0.2 % ophthalmic q2h:prn dryness 39. Vitamin D 50,000 UNIT PO 2X/WEEK (___) 40. Zolpidem Tartrate 5 mg PO HS:PRN insomnia Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Allopurinol ___ mg PO DAILY 3. Ascorbic Acid ___ mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO DAILY 6. Benzonatate 100 mg PO BID:PRN cough 7. Bisacodyl 10 mg PR HS:PRN constipation 8. Calcium Carbonate 500 mg PO TID:PRN indigestion 9. Docusate Sodium 100 mg PO BID:PRN constipation 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 11. Furosemide 80 mg PO DAILY 12. Gabapentin 800 mg PO TID 13. Hydrocortisone Acetate Suppository ___AILY: PRN constipation 14. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB 15. Isosorbide Dinitrate 20 mg PO BID 16. Lactulose 30 mL PO DAILY:PRN constipation 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. Metoprolol Tartrate 100 mg PO BID 19. Milk of Magnesia 30 mL PO QHS 20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 21. Nystatin Cream 1 Appl TP BID rash on back 22. Omeprazole 40 mg PO BID 23. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 24. Pregabalin 50 mg PO BID 25. Senna 8.6 mg PO BID 26. Tiotropium Bromide 1 CAP IH DAILY 27. TraMADOL (Ultram) 25 mg PO Q4H:PRN pain 28. TraZODone 25 mg PO HS 29. Vitamin D 50,000 UNIT PO 2X/WEEK (___) 30. Azithromycin 250 mg PO Q24H Duration: 3 Days 31. Bismatrol (bismuth subsalicylate) 262 mg oral q4h:prn diarrhea 32. calcium polycarbophil 625 mg oral BID 33. cranberry (cranberry extract) 450 mg oral BID 34. Duloxetine 60 mg PO DAILY 35. HumaLOG (insulin lispro) 100 unit/mL subcutaneous prn hypergly 36. Lantus (insulin glargine) 100units/ml 22 subcutaneous daily breakfast 37. Lantus (insulin glargine) 100 20 SUBCUTANEOUS DAILY BEDTIME 38. melatonin 6 mg oral daily 39. Tears Naturale Forte (artificial tear(dxtrn-hpm-gly)) 0.1-0.3-0.2 % ophthalmic q2h:prn dryness 40. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 41. Warfarin 3 mg PO DAILY16 titrate to INR ___. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 10 Days Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Hemoptysis secondary to procedure Pneumonia Congestive heart failure SECONDARY DIAGNOSES Chronic pleural effusion 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: r/i infectious process TECHNIQUE: Chest PA and Lateral COMPARISON: Multiple prior exams including CT from ___ and radiographs most recently from ___ FINDINGS: In comparison to the most recent prior radiograph, there is increasing right-sided pleural effusion along with right-sided platelike atelectasis. There is also increasing opacities near the right middle lobe concerning for a superimposed infectious process. On the left, there continues to be a pleural effusion and atelectasis, and again pneumonia cannot be ruled out in this area. Cardiomegaly remains. No vascular engorgement is also noted on today's film. IMPRESSION: 1. Vascular engorgement 2. Right basilar atelectasis and small effusion 3. Left atelectasis and moderate size effusion Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with recurrent pleural effusion, left pleur-x, interval worsening since last d/c, ? CHF contribution, will be diuresing overnight // ? improvement of cxr after diuresis TECHNIQUE: CHEST (PA AND LAT) COMPARISON: ___. IMPRESSION: Heart size and mediastinum are unchanged. Mild vascular congestion is re- demonstrated. No interval accumulation of pleural effusion is per septated. Mild interstitial pulmonary edema is noted with no substantial change since the prior study Radiology Report EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with pleural effusion, new consolidate RML on recent cxr // ? improvement after diuresis x 2 days COMPARISON: ___ IMPRESSION: As compared to the previous radiograph, the left lung base has minimally increased in radiolucency, indicating a decrease in extent of the pleural effusion and the subsequent left basal and retrocardiac atelectasis. The vascular diameters have also decreased, indicating a decrease in pulmonary fluid. No new parenchymal opacities are visible. The patient is still strongly rotated to the left. Mild cardiomegaly persists. No pneumothorax. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Hemoptysis Diagnosed with OTHER HEMOPTYSIS, DIABETES UNCOMPL JUVEN temperature: 100.2 heartrate: 126.0 resprate: 20.0 o2sat: 94.0 sbp: 157.0 dbp: 78.0 level of pain: 8 level of acuity: 2.0

It was a pleasure taking care of you during your hospitalization at ___. You were admitted for coughing up blood. The Interventional Pulmonary physicians thought that this was not concerning and can continue for a few more days. It is okay to continue your coumadin. Because of your fever and white count, we treated you for a lung infection and you will continue these antibiotics. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you a full and speedy recovery. ~ Your ___ Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Morphine / Sudafed Attending: ___ Chief Complaint: palpitations Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ year-old R-handed man with recent admission to the stroke service for a L cerebellar stroke who presents after he was found to be dizzy at his rehab and an OSH NCHCT found hemorrhagic conversion of his stroke. Please see recent D/C summary for full details of his admission, but briefly, the pt presented to ___ on ___ with vertigo, nausea and unsteadiness and was transferred to ___, where he was found to have a hypodensity of the left inferior medial cerebellar hemisphere. He has a hx of afib, but at presentation was not on anticoagulation, so he was started on aspirin and coumadin. However, he had difficult to control afib and EP was consulted, who recommended amiodarone and diltiazem, and given their interaction with coumadin, also recommended that the pt be switched to rivoroxabin, which he was. The patient was discharged to ___ on ___ at which point he was no longer vertiginous and requring less assistance to walk, but still unsteady. He was doing well at rehab until today when he was woken up from sleep by a very loud roommate who was agitated and he felt palpitations and some chest pain. He was noted to have a rapid heartbeat on palpation of his radial artery, and because of his known difficult to control afib he was sent to ___. There, he was noted to be in aflutter with some mild chest pain. He was given SL NTG and diltiazem and his sx improved and his HR decreased to the low 100's. He had an EKG that did not show any ischemia. He was not feeling dizzy anymore after his HR decreased, but they did a NCHCT at the OSH, which showed some hemorrhagic transformation of his known L cerebellar stroke and he was transferred to ___ for further evaluation and neurosurgical consultation. In the ED here, the pt reported feeling "fine" and was without dizziness or CP. He did report a mild frontal headache, but that it was "barely there". On neuro ROS, the pt reports headache as above, chronic facial asymmetry from a childhood accident, and unsteadiness when walking as above, but denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, current vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt reports recent CP and palpitation as above, but denies ecent 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: 1.Atrial fibrillation, initially diagnosed in the setting of an upper respiratory illness in ___, at which point he had a successful cardioversion with recurrence of atrial fibrillation 1 week later, at which point he converted to sinus rhythm after a single dose of flecainide 300 mg p.o., previously on Pradaxa, stopped on ___. 2.Bipolar on lithium 3.GERD. 4.Hyperlipidemia 5.Thyroid nodule with normal TFTs. 6.Esophagial stricture s/p dilatation. 7.Back fusion surgery 8.Large left cerebellar stroke thought to be embolic from afib Social History: ___ Family History: Noncontributory for sudden cardiac death, arrhythmia, or coronary artery disease. There is no history of seizures, developmental disability, learning disorders, migraine headaches, strokes less than 50, neuromuscular disorders, or movement disorders. Physical Exam: ADMISSION EXAM: Vitals: T: 97.6 P: 120 R: 20 BP: 148/82 SaO2: 99% on 2L Orthostatics (pre-IVF) - lying HR 98, BP 98/59, sitting HR 113, BP 89/58, standing HR 120, BP 85/59 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: irregularly 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 w/ one self-corrected error. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall ___ at 5 minutes. 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 wiggling fingers. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: L ptosis, per pt this is his basline. facial asymmetry s/p childhood accident 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. Intention tremor bilaterally. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation or vibratory sense. Pt would not let me test proprioception in his big toe on the R as he is having a gout flair and moving the toe is incredibly painful. Very mild difficulty with proprioception in the L big toe. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2+ 2+ 2 1 0 R 2+ 2 2 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, slowed fine finger mvmts on the L. Mild dysmetria on FNF on the L, but not the R, with bilateral intention tremor on FNF. Mild overshoot bilaterally on mirroring tasks L > R. -Gait: pt unsteady when standing with eyes open, Romberg positive for sway, did not attempt to walk more than a few steps as pt very unsteady. Pertinent Results: ADMISSION LABS: ___ 03:15AM BLOOD WBC-13.1* RBC-4.58* Hgb-13.9* Hct-42.4 MCV-93 MCH-30.4 MCHC-32.8 RDW-13.3 Plt ___ ___ 03:15AM BLOOD ___ PTT-45.0* ___ ___ 10:45AM BLOOD ___ PTT-37.4* ___ ___ 03:15AM BLOOD Glucose-112* UreaN-23* Creat-1.3* Na-138 K-4.6 Cl-102 HCO3-24 AnGap-17 ___ 03:15AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.1 RELEVANT LABS: ___ 03:15AM BLOOD cTropnT-<0.01 ___ 10:45AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03:15AM BLOOD Lithium-1.1 URINALYSIS: ___ 05:16AM URINE Color-Straw Appear-Clear Sp ___ ___ 05:16AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG' IMAGING: OSH Head CT: some poorly defined hyperdensity in the left cerebellar stroke. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Amiodarone 200 mg PO TID Duration: 1 Days 3. Amiodarone 200 mg PO BID 4. Atorvastatin 10 mg PO HS 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Lithium Carbonate 300 mg PO BID 8. Loratadine *NF* 10 mg Oral daily 9. Pantoprazole 40 mg PO Q24H 10. Rivaroxaban 20 mg PO DAILY 11. Senna 2 TAB PO HS 12. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit Oral daily 13. Acetaminophen 650 mg PO Q6H:PRN pain/fever 14. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 15. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection prn anaphylaxis 16. Meclizine 25 mg PO Q12H:PRN nausea 17. Naproxen 500 mg PO Q8H:PRN pain 18. Ondansetron 4 mg PO Q8H:PRN nausea 19. Sorbitol 30 mL QHS PRN dry mouth Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain/fever 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 10 mg PO HS 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Diltiazem Extended-Release 360 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Lithium Carbonate 150 mg PO TID 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Pantoprazole 40 mg PO Q24H 10. Senna 1 TAB PO BID:PRN constipation 11. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection prn anaphylaxis 12. Loratadine *NF* 10 mg Oral daily 13. Naproxen 500 mg PO Q8H:PRN pain 14. Sorbitol 30 mL QHS PRN dry mouth 15. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit Oral daily 16. Metoprolol Tartrate 25 mg PO TID 17. Rivaroxaban 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: hemorrhagic conversion of left cerebellar infarct, atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neurologic Exam at Discharge: hypometric saccades on left gaze. Intention tremor on finger-nose-finger on left. Remainder exam nonfocal. Followup Instructions: ___ Radiology Report INDICATION: History of lightheadedness and new atrial flutter, question infection. COMPARISONS: Portable radiograph from ___ from ___ ___ and portable radiograph from ___. TECHNIQUE: PA and lateral chest radiographs were provided. FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal aside from leftward deflection of the upper trachea most commonly due to thyroid enlargement, which has been imaged in this patient's past. Osseous structures are intact. IMPRESSION: No acute cardiopulmonary process. Radiology Report HISTORY: ___ male with atrial fibrillation on rivaroxaban, and recent cerebellar stroke with hemorrhagic transformation; assess for interval change. COMPARISON: Multiple head CTs dating back to ___, most recent from ___ and MR ___ from outside hospital from ___. TECHNIQUE: MDCT images of the brain were obtained without intravenous contrast NON-CONTRAST HEAT CT: Hemorrhagic transformation at the site of a known left inferior medial cerebellar infarct appears slightly larger and more confluent as compared to recent prior examination. Hemorrhage continues to cross the midline resulting in severe mass effect upon the dorsal aspect of the fourth ventricle (2:5). Ventricular size overall appears similar to prior with the atria of the left lateral ventricle measuring 17 mm compared to 16 mm previously (2:13). There is no evidence of developing obstructive hydrocephalus. Cerebellar tonsils remain low-lying, though unchanged from prior. No new intra- or extra-axial hemorrhage is identified. There is no mass or acute large territorial infarction. There is no shift of usually midline structures. Suprasellar and basilar cisterns are widely patent. There is no scalp or osseous abnormality. Mucosal thickening within the ethmoid air cells and imaged maxillary sinuses appear unchanged from prior. Mastoid air cells remain well aerated. IMPRESSION: Hemorrhagic transformation of a left cerebellar infarct, slightly increased in size with effacement of the fourth venticle. No current evidence of obstructive hydrocephalus or further cerebellar tonsillar herniation. Radiology Report HISTORY: Evaluate for interval change of hemorrhagic conversion of left cerebellar CVA. COMPARISON: Head CT from ___. FINDINGS: The parenchymal hemorrhage in the left cerebellum appears slightly denser than on the prior study from the ___, however the overall size and the mass effect it causes appears unchanged. Once again noted is that the hemorrhage crosses the midline resulting in effacement of the dorsal aspect of the ___ ventricle. The remaining ventricles are unchanged in size, making obstructive hydrocephalus unlikely at this point. Otherwise, there is no new acute hemorrhage, vascular territorial infarction, or mass. The basal cisterns are patent. Again noted is mucosal thickening in the bilateral ethmoid and sphenoid air cells. The middle ear cavities and mastoid air cells are clear. IMPRESSION: Overall stable size and mass effect caused by hemorrhagic conversion of left cerebellar infarction. Gender: M Race: OTHER Arrive by AMBULANCE Chief complaint: ? HEAD BLEED Diagnosed with INTRACRANIAL HEMORR NOS, ATRIAL FLUTTER, ATRIAL FIBRILLATION, ALTERED MENTAL STATUS temperature: 97.6 heartrate: 120.0 resprate: 20.0 o2sat: 99.0 sbp: 148.0 dbp: 82.0 level of pain: 0 level of acuity: 2.0

Dear Mr. ___, You were brought to the hospital due to palpitations, which were likely secondary to your atrial fibrillation/flutter. In the ED, head CT was done and showed some blood in the area where your stroke is. The CT was repeated and showed some increase in the amount of blood, so the Rivaroxaban was held. A subsequent CT scan was performed and showed that the bleeding is stable. You should restart your Rivaroxaban on ___. With regards to your heart, your rhythm was atrial flutter and the rate remained elevated (>100) when you were admitted, so cardiology decided to stop the amiodarone and Metoprolol was started instead; the Metoprolol dose is 25 mg three times daily. The daily dose of the Diltiazem was also increased to 360 mg. This resulted in improvement of your heart rate. Your stroke risk factors were checked during the last hospitalization. Please take your other medications as prescribed. 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: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dysuria Major Surgical or Invasive Procedure: None History of Present Illness: ___ MEDICINE ATTENDING ADMISSION NOTE . Date: ___ Time: 0100 _ ________________________________________________________________ PCP: Dr. ___ . CC: ___, abdominal pain, nausea, vomiting and light headedness _ ________________________________________________________________ HPI:The patient is a ___ year old female with h/o recurrent nephrolithiasis - path in ___ c/w Carbonate Apatite stones, recurrent UTIs- proteus and Ecoli who was found to have a UTI with a positive UA on ___. She was started on Bactrim but now presents with abdominal pain. UA from that day with > three colony types. Previous urine cultures with proteus and E coli sensitive to Bactrim. S/p Cystoscopy, left ureteroscopy, laser lithotripsy, left ureteral stent placement by Dr. ___ in ___. Not all stones could be removed and the plan was for a repeat procedure which has been scheduled for ___. Despite continuing on Bactrim bid she continued to have worsening abdominal pain with sweats. She denies chills. She then developed n/v and inability to tolerate po intake x 2 days. She also developed LH which prompted her to come in. She denies feves, chest pain, shortness of breath. She has lost 14 lbs since ___. She has not had a bm "in a few days" which she thinks is because she has not eaten but she does not feel constipated. At baseline she has stress and overflow incontinence and this has been exacerbated. She requires surgery for this but she confesses to being "overwhelmed" and has not scheduled it. In ER: (Triage Vitals:9 |97.8 |102 |20| 134/93 100% RA ) Meds Given: IV Morphine Sulfate 4 mg |Ondansetron 4 mg| cefepime and 4 LNS Radiology Studies:CTU consults called: None Cr elevated to 1.5 with AG = 23 with HCO3 = 19 . PAIN SCALE: ___ periumbilical REVIEW OF SYSTEMS: CONSTITUTIONAL: As per HPI HEENT: [X] All normal RESPIRATORY: [X] All normal CARDIAC: [X] All normal GI: As per HPI GU: [+] per HPI SKIN: [X] All normal MUSCULOSKELETAL: [X] All normal NEURO: [X] All normal ENDOCRINE: [X] All normal HEME/LYMPH: [X] All normal PSYCH: [X] All normal All other systems negative except as noted above Past Medical History: HYPERTENSION RECURRENT NEPHROLITHIASIS c/b RECURRENT UTI- S/P Cystoscopy, left ureteroscopy, laser lithotripsy, left ureteral stent placement- ___ OBESITY S/P LAP CHOLE SICKLE TRAIT PYELONEPHRITIS RECURRENT URINARY TRACT INFECTION SMOKER H/O BACK PAIN H/O ELEVATED LFT H/O ABDOMINAL PAIN H/O URINARY RETENTION Social History: ___ Family History: Mother DIABETES ___ - died of DM complications at age ___ Father CORONARY ARTERY DISEASE- died age ___. Brother COLON CANCER MGM still alive at ___- now getting dementia- active, dancing and singing. Physical Exam: Vitals: 98.1 PO |151 / 105 L| Lying ___ RA CONS: She look uncomfortable but not toxic HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: b/l ae no w/c/r GI: +bs, soft, + umbilical tenderness with palpation GU: No CVAT B/l MSK:no c/c/e 2+pulses SKIN: no rash NEURO: face symmetric speech fluent PSYCH: calm, cooperative LAD: No cervical LAD DISCHARGE EXAM VS: T 98.2 BP 140 / 82 HR 87 RR 18 O2 sat 97 RA Gen: NAD, resting Eyes: EOMI, no scleral icterus HENT: NCAT, trachea midline CV: RRR, S1-S2, no m/r/r/g, no edema, 2+ ___ BLE Lungs: CTA B, no w/r/r/c GI: +BS, soft, NTTP, ND GU: No foley MSK: ___ strength bilaterally, intact ROM Neuro: Moving all extremities, no focal deficits, A+Ox3 Skin: No rash or ecchymosis Psych: Congruent affect, good judgment Pertinent Results: ___ 07:05PM LACTATE-1.6 ___ 06:55PM GLUCOSE-109* UREA N-19 CREAT-1.5* SODIUM-141 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-23* ___ 06:55PM estGFR-Using this ___ 06:55PM WBC-7.9# RBC-4.74# HGB-10.2* HCT-34.2 MCV-72* MCH-21.5* MCHC-29.8* RDW-19.6* RDWSD-49.1* ___ 06:55PM NEUTS-74.3* LYMPHS-17.0* MONOS-7.9 EOS-0.1* BASOS-0.3 IM ___ AbsNeut-5.90 AbsLymp-1.35 AbsMono-0.63 AbsEos-0.01* AbsBaso-0.02 ___ 06:55PM PLT COUNT-429* ___ 06:09PM URINE HOURS-RANDOM ___ 06:09PM URINE UHOLD-HOLD ___ 06:09PM URINE COLOR-DKMB APPEAR-Cloudy SP ___ ___ 06:09PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-4* PH-8.5* LEUK-LG ___ 06:09PM URINE RBC-35* WBC-19* BACTERIA-FEW YEAST-RARE EPI-6 ___ 06:09PM URINE 3PHOSPHAT-OCC ___ 06:09PM URINE MUCOUS-RARE ============================ ABDOMINAL CTU IMPRESSION: 1. Multiple bilateral large nonobstructing renal stones similar to prior, with unchanged mild left hydronephrosis. No CT evidence of pyelonephritis. 2. Extensive areas of renal cortical scarring bilaterally, likely the sequela prior infection. 3. Diffuse mild bladder wall thickening is unchanged, and may be due to underdistention, however infection cannot be excluded. Recommend correlation with urinalysis. 4. A 1.9 cm cystic lesion within the left adnexa is not changed since ___, however could be better evaluated with pelvic ultrasound if the patient is postmenopausal. 5. Left adrenal adenoma. RECOMMENDATION(S): 1. Recommend correlation with urinalysis. 2. Pelvic ultrasound for 1.9 cm left adnexal cystic lesion the patient is postmenopausal. DISCHARGE LABS ___ 06:43AM BLOOD WBC-5.1 RBC-3.80* Hgb-8.3* Hct-27.2* MCV-72* MCH-21.8* MCHC-30.5* RDW-19.1* RDWSD-48.4* Plt ___ ___ 06:43AM BLOOD Glucose-76 UreaN-11 Creat-1.3* Na-141 K-3.8 Cl-109* HCO3-23 AnGap-13 ___ 06:43AM BLOOD ALT-14 AST-14 AlkPhos-80 TotBili-<0.2 ___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.4 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous GLUCONATE 236 mg PO BID 2. Citalopram 40 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lisinopril 40 mg PO DAILY 5. NIFEdipine CR 90 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*1 2. Citalopram 40 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Ferrous GLUCONATE 236 mg PO BID 5. NIFEdipine CR 90 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Sulfameth/Trimethoprim DS 1 TAB PO BID 8. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until ___ with PCP ___: Home Discharge Diagnosis: Abdominal Pain Constipation Complicated Urinary tract infection Nausea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: CT U with and without contrast INDICATION: History: ___ with known bilateral nephrolithiasis s/p lithotripsy in past, symptoms suggestive of pyelonephritis not improving with course of Bactrim, left upper quadrant abdominal pain, nausea, vomiting // Please evaluate for signs of pyelonephritis and/or obstructing ureteral stone, if non-con phase is unrevealing, please proceed with contrast phase for evaluation of alternative etiologies TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired prior to and after intravenous contrast administration with the patient in prone position. The contrast scan was performed with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,769 mGy-cm. COMPARISON: CT abdomen and pelvis on ___, CT abdomen pelvis ___ 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. Subcentimeter hepatic hypodensities are too small to characterize, however not significantly changed from prior, and likely represent hepatic cysts or biliary hamartomas. Mild intrahepatic biliary duct dilatation is similar to prior, and likely secondary to postcholecystectomy state. Common bile duct appears normal in caliber. 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 adrenal gland is normal in size and shape. A 2.4 cm left adrenal nodule is not significantly changed and has a measured density of 5.5 ___ on noncontrast scan, consistent with an adenoma. URINARY: Symmetric and normal nephrograms are noted bilaterally. Both kidneys demonstrate multiple areas of cortical thinning, likely the sequela of prior infectious insult. Multiple large bilateral nonobstructing renal stones are again seen in the right upper and lower poles and left lower pole. There is no ureterolithiasis. Mild left hydronephrosis is not significantly changed. There is no perinephric abnormality. Subcentimeter cortical hypodensities are too small to characterize, however likely represent cysts. There is no evidence of gross urothelial lesions. The distal ureters are unremarkable. Diffuse thickening of the bladder wall is similar to prior. 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 (4:59. PELVIS: There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is within normal limits. A 1.9 cm cystic lesion within the left adnexa is not changed. 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: Degenerative changes in lumbar spine, worst at L4-L5, are not significantly changed. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Multiple bilateral large nonobstructing renal stones similar to prior, with unchanged mild left hydronephrosis. No CT evidence of pyelonephritis. 2. Extensive areas of renal cortical scarring bilaterally, likely the sequela prior infection. 3. Diffuse mild bladder wall thickening is unchanged, and may be due to underdistention, however infection cannot be excluded. Recommend correlation with urinalysis. 4. A 1.9 cm cystic lesion within the left adnexa is not changed since ___, however could be better evaluated with pelvic ultrasound if the patient is postmenopausal. 5. Left adrenal adenoma. RECOMMENDATION(S): 1. Recommend correlation with urinalysis. 2. Pelvic ultrasound for 1.9 cm left adnexal cystic lesion the patient is postmenopausal. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, N/V Diagnosed with Unspecified abdominal pain temperature: 97.8 heartrate: 102.0 resprate: nan o2sat: 100.0 sbp: nan dbp: nan level of pain: 9 level of acuity: 3.0

Ms. ___, It was a pleasure taking care of you at BID. You were admitted with abdominal pain, constipation, and nausea in the setting of antibiotic use. A CT of your abdomen was done which did not show any new infection in your kidneys or bladder. We recommend you continue your Bactrim with nausea medication as an outpatient to complete a 10 day course for your UTI. Please make sure you keep your appointment with urology as your procedure in ___ will be beneficial. Please ensure you drink plenty of fluids >2Liters per day of water. Your kidneys were dry when you came in but improved with fluids. However, we would like you to continue holding your lisinopril until follow up with your PCP. I have contacted your PCP to see if your labs could be checked next week and they will contact you during office business hours. 1. Please hold your lisinopril until cleared by your PCP 2. Please continue your Bactrim until complete

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ female with medical history notable for EtOH cirrhosis decompensated with esophageal varices and hepatic encephalopathy, IDDM, depression, and anemia with recent hospitalization requiring an ICU stay for altered mental status attributed to hepatic encephalopathy and possible polypharmacy complicated by urinary tract infection referred by ___ clinic for worsening ___. While at rehab, patient's labs are notable for worsening anemia as well as an elevated creatinine to 2.1 (baseline 1.0). Patient was seen in ___ clinic where her creatinine was elevated to 2.5, referred to the ED for evaluation. While in rehab, the patient was having very frequent bowel movements up to 10 daily secondary to lactulose, was down titrated to 3 bowel movements daily. Reports feeling generally fatigued and dizzy while standing up. Denies any falls, syncope. Denies chest pain, shortness of breath, fever, chills. Of note patient was recently admitted (___) for toxic metabolic encephalopathy thought to be secondary to hepatic encephalopathy and overmedication. Course complicated by Coag negative staph bacteremia (completed x2 week course of vancomycin ___ and was also treated for UTI with Ceftriaxone. She was discharged to rehab. Patient was seen in ___ clinic on ___ for follow up of worsening renal function. Her Cr during her last admission peaked at 1.9 and was 1.4 at time of discharge. her Cr at rehab was 2.1 and increased to 2.4 when checked at ___ clinic. ___ thought to be prerenal secondary to diarrhea vs hepatorenal syndrome in setting of cirrhosis. Her urine sediment showed no e/o AIN or ATN. Recommended admission for ___ with plan to hold nadolol in favor of non-renally cleared beta blocker and recommended IV fluid challenge. In the ED, initial VS were: T97.4, HR 73, BP 155/78, RR 18, O2 100% RA Exam notable for: suprapubic tenderness, guaiac positive EKG: Rate 66, normal sinus rhythm, no ST changes Labs showed: Hb 7.6, BUN 26, Cr 2.5 UA Mod leuks, few bacteria nitrite negative Imaging showed: Renal US with There is mild fullness of the right renal pelvis without frank hydronephrosis. No significant postvoid residual. Consults: Hepatology Patient received: 1L normal saline, rifaxamin, gabapentin, acetaminophen, sertraline Transfer VS were: T97.2, HR 68, BP 142/85, RR 18, O2 100% RA On arrival to the floor, patient reports her main complaint is dizziness that has been ongoing for the last month. The dizziness is most notable with positional changes- sitting up in bed or going from sitting to standing. Occassionally she feels that the room is spinning, but usually feels more lightheaded. Notes occasional dots of blood in her stool. Reports her dysrusia has been improving since discharge. Reports cough and nasal congestion over the weekend that has subsequently improved. Denies fevers, chills, blurred vision, chest pain, shortness of breath, abdominal pain, constipation or leg swelling. Past Medical History: Cirrhosis likely ___ NASH and ASH. Depression. Obesity. IDDM. Hypothyroidism. Peripheral neuropathy. Asthma. Iron-deficiency anemia. History of nephrolithiasis. History of cholecystectomy with LBX ___. History of left breast abscess. Social History: ___ Family History: Mother, deceased, liver cancer, unknown if was primary or secondary. Father, deceased, alcohol-excess. Sister, alive, DM. Physical Exam: ADMISSION EXAM: =============== VS: 98.0 139 / 83 72 18 98 Ra GENERAL: NAD 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: LLQ tenderness to palpation, nondistended, bowel sounds present EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, no asterexis SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: =============== VS: 98.2 BP 132/85 Sitting 84 16 99 RA GENERAL: NAD, sitting up on edge of 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 ABDOMEN: NT, ND. No rebound or guarding. Normoactive bowel sounds. No organomegaly. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, no asterexis SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 08:47PM URINE HOURS-RANDOM ___ 08:47PM URINE HOURS-RANDOM ___ 08:47PM URINE UHOLD-HOLD ___ 08:47PM URINE GR HOLD-HOLD ___ 08:47PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* ___ 08:47PM URINE RBC-1 WBC-11* BACTERIA-FEW* YEAST-NONE EPI-6 ___ 08:47PM URINE MUCOUS-RARE* ___ 03:57PM GLUCOSE-169* UREA N-23* CREAT-2.1* SODIUM-141 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17 ___ 03:57PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-1.9 ___ 03:57PM WBC-5.0 RBC-3.09* HGB-7.7* HCT-24.0* MCV-78* MCH-24.9* MCHC-32.1 RDW-21.9* RDWSD-61.8* ___ 03:57PM PLT COUNT-128* ___ 05:54AM GLUCOSE-91 UREA N-24* CREAT-2.1* SODIUM-142 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 ___ 05:54AM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-71 TOT BILI-0.3 ___ 05:54AM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-1.8 ___ 05:54AM WBC-4.8 RBC-2.69* HGB-6.3* HCT-20.6* MCV-77* MCH-23.4* MCHC-30.6* RDW-22.2* RDWSD-61.2* ___ 05:54AM PLT COUNT-123* ___ 05:54AM ___ PTT-31.2 ___ ___ 10:30PM URINE HOURS-RANDOM ___ 10:30PM URINE UHOLD-HOLD ___ 10:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD* ___ 10:30PM URINE RBC-1 WBC-4 BACTERIA-FEW* YEAST-NONE EPI-2 TRANS EPI-<1 ___ 07:19PM GLUCOSE-133* UREA N-26* CREAT-2.5* SODIUM-139 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 ___ 07:19PM ALT(SGPT)-16 AST(SGOT)-24 ALK PHOS-100 TOT BILI-0.2 ___ 07:19PM ALBUMIN-4.1 ___ 07:19PM WBC-7.0 RBC-3.28* HGB-7.6* HCT-25.3* MCV-77* MCH-23.2* MCHC-30.0* RDW-22.4* RDWSD-61.4* ___ 07:19PM NEUTS-73.7* LYMPHS-18.2* MONOS-6.3 EOS-1.1 BASOS-0.4 IM ___ AbsNeut-5.15 AbsLymp-1.27 AbsMono-0.44 AbsEos-0.08 AbsBaso-0.03 ___ 07:19PM PLT COUNT-178 ___ 07:19PM ___ PTT-32.3 ___ DISCHARGE LABS: =============== ___ 04:49AM BLOOD WBC-4.9 RBC-3.69* Hgb-9.4* Hct-29.2* MCV-79* MCH-25.5* MCHC-32.2 RDW-22.5* RDWSD-64.0* Plt ___ ___ 04:49AM BLOOD Glucose-94 UreaN-34* Creat-2.2* Na-140 K-3.2* Cl-95* HCO3-28 AnGap-17 ___ 04:49AM BLOOD ALT-13 AST-19 LD(LDH)-155 AlkPhos-72 TotBili-0.3 ___ 04:49AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.5* MICROBIOLOGY: ============= **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 CFU/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-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING: ======== RENAL U/S ___: IMPRESSION: Minimal fullness of the right renal pelvis without frank hydronephrosis. No significant postvoid residual. CT ABDOMEN PELVIS WITHOUT CONRAST ___: IMPRESSION: 1. No acute intra-abdominopelvic abnormality. 2. Findings consistent with cirrhosis and portal hypertension. New small volume abdominopelvic ascites. RENAL U/S ___: FINDINGS: The right kidney measures 11.2 cm. The left kidney measures 11.9 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended and normal in appearance. IMPRESSION: No hydronephrosis or nephrolithiasis. Radiology Report EXAMINATION: CT ABD AND PELVIS W/O CONTRAST 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 = 12.3 mGy (Body) DLP = 636.4 mGy-cm. Total DLP (Body) = 636 mGy-cm. COMPARISON: ___ FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: There is hypertrophy of the left lobe of the liver in addition to a diffusely nodular contour in keeping with known cirrhosis. 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 CBD measures up to 7 mm, unchanged since prior. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen measures up to 14 cm in craniocaudal dimension. No focal lesions are seen on this nonenhanced study. 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 focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. There is trace perihepatic free fluid as well as a small amount of free fluid within the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There are shotty retroperitoneal and mesenteric lymph nodes. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. The paraumbilical vein is recanalized. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Nodular densities in the subcutaneous tissues of the anterior abdominal wall are likely related to injections. IMPRESSION: 1. No acute intra-abdominopelvic abnormality. 2. Findings consistent with cirrhosis and portal hypertension. New small volume abdominopelvic ascites. Radiology Report EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with unexplained ___ on CKD and prior fullness noted in her kidney// Persistence of fullness in kidney, concern for possible retroperitoneal fibrosis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: CT abdomen pelvis from ___ FINDINGS: The right kidney measures 11.2 cm. The left kidney measures 11.9 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended and normal in appearance. IMPRESSION: No hydronephrosis or nephrolithiasis. Gender: F Race: HISPANIC/LATINO - PUERTO RICAN Arrive by WALK IN Chief complaint: Acute renal failure, Weakness Diagnosed with Acute kidney failure, unspecified temperature: 97.4 heartrate: 73.0 resprate: 18.0 o2sat: 100.0 sbp: 155.0 dbp: 78.0 level of pain: 8 level of acuity: 2.0

Dear ___, ___ was a pleasure taking care of your ___ ___. Why were you in the hospital? -You were sent into the hospital by her kidney doctors. They noted that your kidney function was worse than it had been. What happened in the hospital? -Your kidney function was watched closely. -You had a CT scan of your belly Since he also had some abdominal pain. Fortunately, this did not show anything very concerning. -He received medications to help regulate your bowels. -You also received antibiotics to treat a urinary tract infection. What should you do after leaving the hospital What should you do after leaving the hospital? -He should take all of your medications as prescribed. -You should follow-up with other doctors as previously ___. -You should call your doctors ___ experience any worsening abdominal pain that is not improved after having a bowel movement. We wish you the best, Your ___ Care Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: hydromorphone Attending: ___ Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ pmhx asthma, presenting with 1 day of n/v, inability to tolerate PO. Sudden onset night of ___, 20+ episodes of NBNB emesis. No PO in this time. + epigastric pain. + intermittent dyspnea - hx abdominal surgeries - dysuria, hematuria, diarrhea. Patient reports usually drinks 1 glass of wine before bed. On ___ (2 night prior to onset of symptoms) she drank several shots of hard liquor for her sister's birthday party. She does not remember exactly how many. She denies illicit drug use, IVDU. Usually cooks at home, no raw seafood. No travel. Sexually active with 1 partner, intermittent condom usage. In the ED: - Initial vital signs were notable for: 97.6, 99, 116/85, 18, 98% RA Orthostatic positive: 146/104 sitting -> 117/94 standing - Exam notable for: Dry MM +Nystagmus +RUQ & epigastric TTP - Labs were notable for: AST/ALT: 200/103 Leukopenia Mild thrombocytopenia AG 21 UCG negative - Studies performed include: RUQUS 1. No acute findings. 2. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. - Patient was given: 2L LR Zofran 4mg IV On my evaluation she gives the above history. Past Medical History: Asthma Depression Social History: ___ Family History: Mother EtOH abuse Physical Exam: ADMISSION EXAM: VITALS: 133/72, HR Mid-80's, 99% RA GEN: tired appearing, not in distress HEENT: MM tacky, scattered cervical LAD CV: RRR s1s2 no mrg PULM: CTA anteriorly GI: Mild RUQ & epigastric tenderness EXT: WWP non-edematous DISCHARGE EXAM: VITALS: 24 HR Data (last updated ___ @ 648) Temp: 98.2 (Tm 98.2), BP: 124/86 (124-141/86-94), HR: 87 (74-87), RR: 16, O2 sat: 97%, O2 delivery: RA GEN: tired appearing, not in distress HEENT: MMM CV: RRR s1s2 no mrg PULM: CTA anteriorly GI: Mild RUQ & epigastric tenderness EXT: WWP non-edematous Pertinent Results: ADMISSION LABS: ___ 11:15PM PLT COUNT-143* ___ 11:15PM NEUTS-54.3 ___ MONOS-15.2* EOS-0.6* BASOS-0.9 IM ___ AbsNeut-1.78 AbsLymp-0.94* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.03 ___ 11:15PM WBC-3.3* RBC-4.74 HGB-15.0 HCT-44.9 MCV-95 MCH-31.6 MCHC-33.4 RDW-15.0 RDWSD-52.2* ___ 11:15PM HCV Ab-NEG ___ 11:15PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG ___ 11:15PM ALBUMIN-5.1 ___ 11:15PM LIPASE-41 ___ 11:15PM ALT(SGPT)-103* AST(SGOT)-200* ALK PHOS-83 TOT BILI-1.2 ___ 11:15PM GLUCOSE-96 UREA N-9 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-27 ANION GAP-21* ___ 02:35AM URINE RBC-3* WBC-31* BACTERIA-MANY* YEAST-NONE EPI-2 ___ 02:35AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-80* BILIRUBIN-SM* UROBILNGN-8* PH-6.5 LEUK-LG* ___ 02:35AM URINE UCG-NEGATIVE DISCHARGE LABS: ___ 09:38AM BLOOD WBC-2.9* RBC-4.33 Hgb-13.9 Hct-41.2 MCV-95 MCH-32.1* MCHC-33.7 RDW-14.6 RDWSD-51.3* Plt ___ ___ 09:38AM BLOOD Glucose-97 UreaN-6 Creat-0.8 Na-142 K-4.0 Cl-99 HCO3-26 AnGap-17 ___ 09:38AM BLOOD ALT-88* AST-162* AlkPhos-71 TotBili-1.0 ___ 09:38AM BLOOD Calcium-9.8 Phos-2.4* Mg-1.6 ___ 11:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-PND ___ 09:38AM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV IgG-PND EBNA-PND EBV IgM-PND EBVI-PND IMAGING: ___ RUQUS IMPRESSION: 1. No acute findings. Specifically, normal appearance of the gallbladder without sonographic findings to suggest acute cholecystitis. 2. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the Liver Center (FibroScan), or the Radiology Department with MR ___, in conjunction with a GI/Hepatology consultation" * Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze Discharge Disposition: Home Discharge Diagnosis: #Nausea and emesis #Transaminitis #Leukopenia #Thrombocytopenia #Dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: History: ___ with ruq pain, vomiting// r/o cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: No relevant comparison study. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The head and body of the pancreas are within normal limits. The tail of the pancreas is not visualized due to the presence of gas. SPLEEN: Normal echogenicity. Spleen length: 7.7 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. Right kidney: 10.5 cm Left kidney: 9.9 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. No acute findings. Specifically, normal appearance of the gallbladder without sonographic findings to suggest acute cholecystitis. 2. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ (FibroScan), or the Radiology Department with MR ___, in conjunction with a GI/Hepatology consultation" * * Chalasani et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the ___ Association for the Study of Liver Diseases. Hepatology ___ 67(1):328-357 Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by WALK IN Chief complaint: Dizziness, Vomiting Diagnosed with Dizziness and giddiness temperature: 97.6 heartrate: 99.0 resprate: 18.0 o2sat: 98.0 sbp: 116.0 dbp: 85.0 level of pain: 0 level of acuity: 3.0

Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you were nauseous and vomiting. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given fluids because you were dehydrated. - You liver enzymes were elevated. They were monitored and were downtrending at time of discharge. - Your nausea and vomiting improved. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. We wish you the best! Sincerely, Your ___ 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: Pelvic Ultrasound - ___ History of Present Illness: Ms. ___ is a ___ female with no pertinent past medical history presented to outside hospital for abdominal pain, n/v, found to have liver mass. Ms. ___ states symptoms started on ___ with fatigue and vague RUQ pain. Over the course of the week she developed associated lightheadedness and nausea/emesis on day prior to presentation. Also endorses shaking chills and referred pain to right scapula on day of admission. Denies chest pain, cough, shortness of breath. Denies dysuria, urgency. She has had a history of an appendectomy and breast mass excision as below. At ___, bedside ultrasound at the OSH showed no gallstones and a normal gallbladder wall. Chest x-ray without focal infiltrate. Was febrile to 102.8 at outside hospital, labs remarkable for WBC 7.8, hemoglobin 11.8, platelets 285, LFTs within normal limits. Given Toradol and Zofran. CT abdomen with indeterminate hepatic lesion segment 4B with no adjacent mass effect, no size given. Transferred here for further w/u. In the ED, initial vitals: 98.4 66 105/41 15 98% RA Vitals remained stable in ED. - Labs notable for: WBC 6.1, normal chem panel and lactate, flu negative, UA unremarkable. - Imaging notable for: Abd U/S w/ Indeterminate mass at the bifurcation of the left and right anterior portal veins, measuring 5.1 x 4.8 x 3.5 cm without significant internal vascularity. There is a small focus of hypoechogenicity measuring 1.2 cm within the lesion. The lesion is incompletely characterized CT and ultrasound, a hepatic MRI would be warranted for further evaluation. 2. No ascites. The main portal vein is patent. - Patient was given: IV zosyn, IV ___ @ 75/hr - Consults: Hepatology consulted who recommended re-read of OSH CT scan and do RUQUS -- Ok to start empiric Abx for suspected abscess -- Based on these findings, will see if additional imaging is needed -- obtain blood cultures -- if desired, medicine team should formally consult hepatology team once admitted On arrival to the floor, patient reports the above history. States nausea has not bothered her for several hours but still with fatigue and ___ right upper quadrant pain described as aching in nature. Denies ongoing fever, chills, lightheadedness, chest pain, palpitations, bright red blood per rectum, melena, leg swelling. Patient states that she had a breast mass excised at ___ last year and was taking ibuprofen intermittently after that time but does not know much more information about this. She states that she was told that she should take another medication whose name she cannot remember if breast symptoms recur. She has never taken oral contraceptives. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative less otherwise noted in the HPI. Past Medical History: - Breast mass, excised at ___ in ___. Patient does not recall details - Appendectomy Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== ___ Temp: 99.6 PO BP: 145/86 HR: 64 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: Pleasant, lying in bed comfortably with husband, sister and kids at bedside. AAOx3 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, nondistended, no splenomegaly. Tenderness to moderate palpation in RUQ with no rebound or guarding 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 DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 717) Temp: 98.6 (Tm 98.6), BP: 122/65 (114-130/61-78), HR: 59 (59-69), RR: 18, O2 sat: 98% (98-100), O2 delivery: Ra GENERAL: Pleasant, lying in bed, AAOx3 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, nondistended, no splenomegaly. Tenderness to moderate palpation in RUQ with no rebound or guarding 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: ADMISSION LABS: =============== ___ 04:43AM BLOOD WBC-6.1 RBC-3.98 Hgb-10.3* Hct-33.3* MCV-84 MCH-25.9* MCHC-30.9* RDW-16.9* RDWSD-51.5* Plt ___ ___ 04:43AM BLOOD Neuts-50.1 ___ Monos-13.2* Eos-12.6* Baso-0.7 Im ___ AbsNeut-3.03 AbsLymp-1.40 AbsMono-0.80 AbsEos-0.76* AbsBaso-0.04 ___ 04:43AM BLOOD ___ PTT-29.3 ___ ___ 04:43AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-136 K-3.9 Cl-106 HCO3-22 AnGap-8* ___ 04:43AM BLOOD ALT-8 AST-13 AlkPhos-73 TotBili-0.3 ___ 04:43AM BLOOD Lipase-27 ___ 04:43AM BLOOD Albumin-3.4* Calcium-8.6 Phos-4.0 Mg-2.0 ___ 06:23AM BLOOD Lactate-0.7 ___ 05:57PM URINE Color-Straw Appear-Hazy* Sp ___ ___ 05:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:25AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE MICROBIOLOGY: ============= ___ 5:57 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 6:15 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 6:10 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. DISCHARGE LABS: =============== ___ 04:52AM BLOOD WBC-6.2 RBC-4.24 Hgb-10.8* Hct-35.3 MCV-83 MCH-25.5* MCHC-30.6* RDW-16.9* RDWSD-50.8* Plt ___ ___ 04:52AM BLOOD Neuts-37.4 ___ Monos-11.7 Eos-21.1* Baso-0.5 Im ___ AbsNeut-2.31 AbsLymp-1.79 AbsMono-0.72 AbsEos-1.30* AbsBaso-0.03 ___ 04:52AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-139 K-4.3 Cl-106 HCO3-23 AnGap-10 ___ 04:52AM BLOOD ALT-10 AST-18 LD(LDH)-209 AlkPhos-82 TotBili-<0.2 ___ 04:52AM BLOOD Albumin-3.6 Calcium-9.1 Phos-4.5 Mg-2.1 IMAGING/STUDIES: ================ ___ Abd US: IMPRESSION: 1. Indeterminate mass at the bifurcation of the left and right anterior portal veins, measuring 5.1 x 4.8 x 3.5 cm without significant internal vascularity. There is a small focus of hypoechogenicity measuring 1.2 cm within the lesion. The lesion is incompletely characterized CT and ultrasound, a hepatic MRI would be warranted for further evaluation. 2. No ascites. The main portal vein is patent. ___ Hepatic MRI IMPRESSION: 1. The liver lesion correspond to a simple hemangioma. 2. Left external iliac lymphadenopathy measuring 11 x 25 mm. 3. T2 bright left adnexal lesion to be further characterized by either pelvic ultrasound or pelvic MRI. ___ Pelvic US: IMPRESSION: 1. No left adnexal abnormality. Previously seen T2 bright signal in the left adnexa likely represents a small amount of free fluid. 2. When read in conjunction with the same day MRI, cystic spaces in the right adnexa likely represent an ovarian or paraovarian cyst. However, hydrosalpinx could also be considered. Significant shadowing from fibroid uterus obscures fine detail of the right adnexa which is deep in the pelvis. 3. Fibroid uterus. Radiology Report EXAMINATION: ABDOMEN US (COMPLETE STUDY) INDICATION: ___ female with no pertinent past medical history presented to outside hospital for abdominal pain, nausea, and vomiting// eval for liver pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: Outside hospital CT ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. Within the left hepatic lobe, near the bifurcation of the left and right anterior portal vein, there is a slightly hyperechoic round mass measuring 5.1 x 4.8 x 3.5 cm, without significant internal vascularity. Within the lesion, there is a focal area measuring approximately 1.2 cm of hypoechogenicity. The main portal vein is patent with hepatopetal flow. The left and right anterior portal veins appear patent where visualized. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The head and body of the pancreas was within normal limits. The tail was not visualized. SPLEEN: Normal echogenicity. Spleen length: 10.1 cm KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Right kidney: 10.7 cm Left kidney: 10.2 cm IMPRESSION: 1. Indeterminate mass at the bifurcation of the left and right anterior portal veins, measuring 5.1 x 4.8 x 3.5 cm without significant internal vascularity. There is a small focus of hypoechogenicity measuring 1.2 cm within the lesion. The lesion is incompletely characterized CT and ultrasound, a hepatic MRI would be warranted for further evaluation. 2. No ascites. The main portal vein is patent. Radiology Report EXAMINATION: MRI of the Abdomen INDICATION: ___ year old woman with new liver mass on ___ ultrasound// Eval liver mass TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 10 mL Gadavist. COMPARISON: Abdominal pelvis CT from ___ FINDINGS: Lower Thorax: No pleural effusion. Liver: The liver is not cirrhotic and there is no hepatic steatosis. At the junction of segment ___, there is a lobulated 4.1 x 6.2 cm lesion demonstrating T2 hyper signal as well as peripheral progressive nodular contrast enhancement. These features are suggestive of a hemangioma. Biliary: No intra or extra biliary duct dilatation. The gallbladder is unremarkable. Pancreas: The pancreas is normal in signal and bulk. No main duct dilatation. No focal pancreatic lesion. Spleen: The spleen is normal in size and is homogeneous. Adrenal Glands: Unremarkable. No focal lesion. Kidneys: The kidneys are unremarkable. No hydronephrosis. No focal lesion. Gastrointestinal Tract: No bowel obstruction. No ascites. Lymph Nodes: There is a 11 x 25 mm left iliac adenopathy (series 2, image 18). Vasculature: No abdominal aortic aneurysm. Left renal vein is retroaortic. Osseous and Soft Tissue Structures: No concerning bone lesions. The adnexal region is partially covered on this exam. However, there is a T2 bright density in the pelvis measuring 6.5 x 2.9 cm likely originating from the left adnexa. This is to be further characterized by pelvic ultrasound or pelvic MRI. IMPRESSION: 1. The liver lesion correspond to a simple hemangioma. 2. Left external iliac lymphadenopathy measuring 11 x 25 mm. 3. T2 bright left adnexal lesion to be further characterized by either pelvic ultrasound or pelvic MRI. Radiology Report EXAMINATION: PELVIS, NON-OBSTETRIC INDICATION: ___ year old woman with left adnexal mass and enlarged left external iliac lymph node seen as incidental findings on MRI liver// Characterize left adnexal mass seen on MRI 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: MRI performed earlier on the same date. FINDINGS: The uterus is anteverted and measures 10.3 x 8.3 x 7.9 cm. There are multiple uterine masses consistent with fibroids. The largest measures 5.2 x 4.4 x 4.9 cm in the left anterior uterus. The second largest is an exophytic fibroid arising from the right fundus measuring 4.1 x 4.1 x 3.6 cm. The endometrium is distorted and partially obscured by adjacent fibroids, but where seen appears normal and measures 1.0 cm. The ovaries are not well seen due to shadowing from the adjacent fibroid uterus. However, the left ovary is normal in appearance. In the right adnexa, are anechoic, avascular cystic spaces, which may represent a ovarian or paraovarian cyst versus a hydrosalpinx. There is a small amount of free fluid. IMPRESSION: 1. No left adnexal abnormality. Previously seen T2 bright signal in the left adnexa likely represents a small amount of free fluid. 2. When read in conjunction with the same day MRI, cystic spaces in the right adnexa likely represent an ovarian or paraovarian cyst. However, hydrosalpinx could also be considered. Significant shadowing from fibroid uterus obscures fine detail of the right adnexa which is deep in the pelvis. 3. Fibroid uterus. Gender: F Race: BLACK/AFRICAN AMERICAN Arrive by AMBULANCE Chief complaint: Abd pain, Abnormal CT Diagnosed with Unspecified abdominal pain temperature: 98.4 heartrate: 66.0 resprate: 15.0 o2sat: 98.0 sbp: 105.0 dbp: 41.0 level of pain: 6 level of acuity: 3.0

Dear ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were transferred to ___ for further workup of a concerning liver mass seen on a CT scan at ___. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were started on antibiotics because there was concern that the mass seen on your liver was a pocket of infection, called an abscess. An MRI scan was obtained to further evaluate this mass. This scan showed that the mass was in fact not an abscess, but was something called a hemangioma (a non-cancerous tumor, made up of blood vessels). Your antibiotics were stopped when we were sure that you did not have an abscess. Our interventional radiology team reviewed your MRI scan and felt that the best course of action would be to have you follow up in liver clinic for further management. -There was an incidental finding on your liver MRI that was concerning for something going on with your left ovary. We had an ultrasound performed that your left ovary was normal. You do have an enlarged lymph node in your groin on the left side, but radiology felt that this was not concerning. WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. - You will need to call your insurance company to identify a primary care doctor who can see you and will accept your insurance. Please do this as soon as possible! You should bring this packet of paperwork with you when you go to your first appointment. We wish you the best! 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: Left arm pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o male with PMMhx of HTN, anxiety, bipolar who presented to the ED yesterday with sharp left arm pain. He describes pain on the entire left arm from left arm with radiation without involvement of chest. Denies associated dyspnea or diaphoresis. Symptoms failed to resolve after taking 2 tabs of ASA. Denies recent injuries, falls, or heavy lifting. He did not have any associated nausea, vomiting, abdominal pain, and substernal chest discomfort. He did have some shortness of breath that was transient earlier in the day. Reports an episode like this before, but it was very transient and went away shortly. His last stress test was in ___, which showed no local inducible ischemia on TTE. At the time of evaluation, his pain improved to a dull ache in his biceps area. In the ED, initial vitals were 98.0 66 195/87 20 100% on room air. Initial labs with WBC 7.8 Hbg/Hct 13.3/37.4 Plt 174. Chemistries panel normal, with BUN/Cr ___. Troponins and CKMB were negative x2. He was observed overnight and had ETT stress test performed on ___, significant for subjective "fluttering" and atypical symptoms with nonspecific ST segment changes noted at peak exercise and transient ST segment elevation noted inferiorly early post-exercise. Cardiology recommended initiation of treatment for unstable angina and admission to Cardiology Service for likely cardiac catheterization. He was given ASA 325mg, atorvastatin 80mg, metoprolol tartrate 12.5mg, and started on a heparin drip. He was also given his home medications of lisinopril 20mg, divalproex ___, and citalopram 60mg. Upon arrival to the floor, pt complained of left bicep pain that was reproducible upon palpation. Past Medical History: PMH: htn, hypercholesterolemia, depression PSH: left rotator cuff ___, left knee ___ and right big toe surgery in remote past Social History: ___ Family History: NC Physical Exam: General: Well developed male, NAD HEENT: NCAT, scleral anicteric. Neck: JVP at clavicle CV: Distant heart sounds, grossly RRR, normal S1/S2 Lungs: CTABL Abdomen: soft, NT/ND Ext: No edema. 2+ pulses throughout. Reproducible left arm pain upon palpation Neuro: Alert, oriented Skin: no rashes PULSES: 2+ throughout Pertinent Results: ___ 05:00AM BLOOD WBC-7.0 RBC-4.26* Hgb-12.8* Hct-37.1* MCV-87 MCH-30.2 MCHC-34.6 RDW-13.6 Plt ___ ___ 05:00AM BLOOD Glucose-97 UreaN-12 Creat-1.3* Na-140 K-4.2 Cl-101 HCO3-26 AnGap-17 ___ 01:35AM BLOOD CK-MB-4 cTropnT-<0.01 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO QPM 2. Omeprazole 40 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Divalproex (EXTended Release) 250 mg PO DAILY 5. Citalopram 60 mg PO DAILY Discharge Medications: 1. Citalopram 60 mg PO DAILY 2. Divalproex (EXTended Release) 250 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Simvastatin 40 mg PO QPM 6. Cyclobenzaprine 10 mg PO TID:PRN left arm pain RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice daily as needed Disp #*20 Tablet Refills:*0 7. Indomethacin 50 mg PO TID Duration: 3 Days RX *indomethacin 50 mg 1 capsule(s) by mouth 1 tablet every 8 hours for 3 days Disp #*9 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Left arm pain, musculoskeletal etiology 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 shortness of breath TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiograph, CT torso ___ FINDINGS: Heart size is normal. Aortic knob demonstrates minimal atherosclerotic calcifications. Mediastinal and hilar contours are otherwise unremarkable. The pulmonary vasculature is not engorged. Chronic interstitial opacities are re- demonstrated in the lung bases, likely reflective of paraseptal emphysema as seen on the prior CT torso. No focal consolidation, pleural effusion or pneumothorax is present. No acute osseous abnormality is detected. IMPRESSION: No radiographic evidence for pneumonia. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: Arm pain Diagnosed with PAIN IN LIMB, ABN CARDIOVASC STUDY NEC temperature: 98.0 heartrate: 66.0 resprate: 20.0 o2sat: 100.0 sbp: 195.0 dbp: 87.0 level of pain: 5 level of acuity: 2.0

Dear Mr ___, It was a pleasure taking care of you. You were admitted to the cardiology service for evaluation of left arm pain. You had an exercise tolerance test which was indeterminant, thus you underwent additional testing during your hospitalization. Although we initially discussed cardiac catheterization, we ultimately cancelled the procedure because your physical exam and lab work argued against cardiac cause for your pain. Your left arm pain was reproducible upon palpation which suggests muscle pain. Your cardiac enzymes, which are markers for damage to heart tissue, were normal. You had a nuclear stress test prior to discharge which was normal. This supports that your left arm pain is NOT coming from the heart. You were prescribed a short course of muscle relaxant (flexeril), we advise you NOT to drive while taking flexeril as it may cause drowsiness. It was a pleasure to be a part of your care, Your ___ treatment 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: Dizzyness Major Surgical or Invasive Procedure: None History of Present Illness: Interview in ___ and ___ Ms. ___ is a ___ woman with stage IIIC high-grade serous ovarian carcinoma s/p suboptimal debulking and adjuvant ___ most recently treated w/ Cycle 5 of ___ on ___. She presents to ED today with 2 days of feeling "mareada". primarily when she is walking she feels dizzy. Denies vertigo, denies any presyncope or falls. no change in vision. has mild HA she attributes to anemia, improved w/ tylenol and drinking alot of water. Also having nausea. No vomiting, sl ab pain in epigastric region, no heartburn. BM regular to sl constipated but taking stool softeners. No chest pain or SOB. No numbness or focal weakness. Initial VS in ED 17:17 0 98.2 112 145/83 18 100% Pt was given 1L NS and zofran and admitted to oncology states her nausea improved with this but still feels lightheaded w/ standing. REVIEW OF SYSTEMS: GENERAL: No fever, chills, night sweats, recent weight changes. HEENT: No mouth sores, odynophagia, sinus tenderness, rhinorrhea, or congestion. CARDS: No chest pain, chest pressure, exertional symptoms, or palpitations. PULM: No cough, shortness of breath, hemoptysis, or wheezing. GI: No vomiting, diarrhea, or abdominal pain. No hematochezia, or melena. GU: No dysuria, hematuruia or frequency. MSK: has chronic muscle aches and on prednisone, no joint pain or swelling DERM: Denies rashes, itching, or skin breakdown. NEURO: No headache, visual changes, numbness, paresthesias, focal weakness, or neurologic symptoms. HEME: No bleeding or clotting Past Medical History: PAST ONCOLOGIC HISTORY: per OMR Ms. ___ is a ___ woman with ovarian carcinoma initially diagnosed in ___ after she developed abdominal pain and vaginal discharge. Pelvic US showed a complex right adnexal mass, and CA-125 was 555. MRI showed large right adnexal lesion with heterogeneously enhancing solid and cystic components, and moderate pelvic free fluid. CT at ___ in ___ showed the mass as well as retroperitoneal intercaval and left pelvic lymphadenopathy, and a nodular, thickened appearance of the omentum, two adjacent small nodules in the left lower lung lobe, and a possible pericardiophrenic lymph node. She underwent ex-lap, TAH/BSO, radical resection of pelvic mass, appendectomy, and gastrocolic omentectomy on ___. However, debulking was suboptimal; she had residual disease along the right hemidiaphragm and the nodal disease involving the aorta, vena cava, and left internal iliac artery, as well as disease within the rectosigmoid colon. Lymphovascular invasion was noted in the hilum of the left ovary. She received adjuvant carboplatin/Taxol from ___. On ___, she reported back pain, constipation, gas, and abdominal pains, as well as intermittent nausea and abdominal swelling. Although her CA-125 had decreased slightly, it had not normalized, and we obtained repeat imaging to assess for disease recurrence. CT ___ showed signs of disease recurrence. On ___ she was started on ___ ___ - C1D1 ___ ___ - C2D1 ___ ___ - C3D1 ___ ___ - C4D1 ___ OTHER PAST MEDICAL HISTORY: -Back pain, since ___. MRI ___ showed no evidence of malignant lesions. -Seasonal allergies -Osteoarthritis PAST SURGICAL HISTORY: -Sinus surgery -D&C x2 Social History: ___ Family History: Patient does not have any biological children. She has limited contact with her sister and half siblings. She has only reconnected with her mother since receiving this cancer diagnosis w/ no knowledge of other malignancies in fmialy Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD,cushingoid VITAL SIGNS: 98.6 122/80 80 99%RA HEENT: MMM, no OP lesions Neck: supple, no JVD 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, face symmetric, no tongue deviation, full hand grip, shoulder shrug and bicep flexion, full toe dorsiflexion and hip flexion against resistance bilateral, sensation intact to light touch, no clonus, no dysmetria w/ FTN and HTS testing, gait slow but normal DISCHARGE EXAM: VS: 98.6 108/56 91 16 100 RA General: NAD HEENT: MMM, no OP lesions Neck: supple, no JVD 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: grossly intact, ambulating and mentating well Pertinent Results: ADMISSION LABS: ___ 07:00PM BLOOD WBC-3.2* RBC-2.58* Hgb-8.5* Hct-24.7* MCV-96 MCH-33.1* MCHC-34.5 RDW-20.3* Plt ___ ___ 07:00PM BLOOD Neuts-61.9 ___ Monos-2.2 Eos-0.6 Baso-0.2 ___ 07:00PM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-141 K-3.9 Cl-100 HCO3-26 AnGap-19 ___ 07:00PM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2 ___ 10:55PM BLOOD Lactate-1.4 ___ 09:54PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG DISCHARGE LABS: ___ 05:16AM BLOOD WBC-2.6* RBC-2.34* Hgb-7.5* Hct-22.5* MCV-96 MCH-32.2* MCHC-33.4 RDW-19.8* Plt ___ ___ 05:16AM BLOOD Neuts-43* Bands-0 Lymphs-57* Monos-0 Eos-0 Baso-0 ___ Myelos-0 CXR ___: No evidence of acute cardiopulmonary process. BLOOD CULTURES X 2 NGTD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nasuea 2. PredniSONE 20 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN pain 4. Prochlorperazine 10 mg PO Q6H:PRN nasuea 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. Omeprazole 40 mg PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN nasuea 5. PredniSONE 20 mg PO DAILY 6. Prochlorperazine 10 mg PO Q6H:PRN nasuea Discharge Disposition: Home Discharge Diagnosis: Ovarian Cancer 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 a history of ovarian cancer, presenting with malaise, fatigue, on chemo // ? PNA TECHNIQUE: Chest PA and lateral COMPARISON: CT chest dated ___. FINDINGS: There is no evidence of focal consolidation, pleural effusion, pneumothorax, or pulmonary edema. The cardiomediastinal silhouette is within normal limits. A rounded density in the superior portion of the left lower lobe correlates with a calcified granulomas seen on recent CT. A right-sided Port-A-Cath is noted with the tip terminating in the right atrium. IMPRESSION: No acute cardiopulmonary process. Gender: F Race: HISPANIC/LATINO - SALVADORAN Arrive by WALK IN Chief complaint: Weakness Diagnosed with NAUSEA, VOLUME DEPLETION, UNSPECIFIED, MALIGN NEOPL OVARY temperature: 98.2 heartrate: 112.0 resprate: 18.0 o2sat: 100.0 sbp: 145.0 dbp: 83.0 level of pain: 0 level of acuity: 3.0

You were admitted to the hospital after you were found to be feeling dizzy likely because your blood counts are low due to chemotherapy. You improved after getting blood and were discharged home in a stable condition.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Stadol / Robaxin / Valium / Stadol / Robaxin / Valium / morphine / codeine / Vicodin / Percocet / Dilaudid / latex / Penicillins / Tetracycline / Septra / Keflex / Phenergan / Compazine / Tigan / Dilantin Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP with stent placement History of Present Illness: ___ year old woman with CAD s/p prior MI, sjogren's, MS, athma, recurrent abdominal pain associated with abnormal LFT's who underwent ERCP on ___ who now returns with post ERCP pancreatitis. She says that following her procedure she had mild abdominal pain that responded to tylenol. After returning home, she had worsening abdominal pain, nausea and vomiting. She saw her PMD who referred her to her local ED who sent her to ___ where she had the procedure. Labs notable for lipase elevation to 12,000. LFT's normal. She was admitted for management of post-ERCP pancreatitis. She denies fevers or chills. No blood in stool or in vomitus. ROS: negative except as above Past Medical History: 1. Coronary artery disease with MI status post stent in ___. 2. rheumatoid arthritis. 3. Sjogren's syndrome. 4. Multiple sclerosis. 5. Sciatica. 6. Asthma. 7. Trigeminal neuralgia. 8. Endometriosis. 9. Sensorineural hearing loss. 10. Migraine headaches. 11. Temporomandibular joint syndrome, status post surgery. 12. Osteoarthritis. 13. Postherpetic neuralgia. 15. Interstitial lung disease. 16. Status post cholecystectomy. 17. Status post appendectomy. 18. Status post hysterectomy and oophorectomy. Social History: ___ Family History: Multiple family members with CAD. Physical Exam: Vitals: 99.7 147/83 83 16 99%RA Gen: uncomfortable but not distressed HEENT: no jaundice, dry mm CV: rrr, no r/m/g Pulm: CTAB Abd: soft, moderate epigastric tenderness Ext: no edema Neuro: alert and oriented x 3 Pertinent Results: ___ 08:20PM GLUCOSE-97 UREA N-16 CREAT-0.6 SODIUM-136 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16 ___ 08:20PM ALT(SGPT)-16 AST(SGOT)-31 ALK PHOS-171* TOT BILI-0.4 ___ 08:20PM ___ ___ 08:20PM ALBUMIN-3.5 ___ 08:20PM WBC-7.1# RBC-3.29* HGB-8.8* HCT-28.2* MCV-86 MCH-26.8* MCHC-31.3 RDW-15.0 ___ 08:20PM PLT COUNT-450* ERCP ___: A mild dilation was seen at the main duct. S/P cholecystectomy. Otherwise normal biliary tree. A biliary stent was placed successfully. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Restasis (cycloSPORINE) 0.05 % ophthalmic bid 4. Fentanyl Patch 25 mcg/h TD Q72H 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. FoLIC Acid 1 mg PO DAILY 7. HydrOXYzine 25 mg PO Q6H:PRN itch 8. Hyoscyamine 0.125 mg PO TID 9. Meperidine 100 mg PO Q6H:PRN pain 10. Metoprolol Succinate XL 12.5 mg PO DAILY 11. Montelukast 10 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. FoLIC Acid 1 mg PO DAILY 5. Hyoscyamine 0.125 mg PO TID 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Montelukast 10 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Restasis (cycloSPORINE) 0.05 % ophthalmic bid 10. Fentanyl Patch 25 mcg/h TD Q72H 11. HydrOXYzine 25 mg PO Q6H:PRN itch 12. Meperidine 100 mg PO Q6H:PRN pain 13. Methylprednisolone 4 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Post-ERCP pancreatitis SECONDARY: possible gouty arthritis, right great toe possible erythema nodosum, BLE rheumatoid arthritis osteoarthritis Sjogren's disease spinal stenosis CAD s/p PCI ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Abdominal pain after ERCP. TECHNIQUE: Chest, AP upright and lateral. COMPARISON: None. FINDINGS: The heart is normal in size. The mediastinal and hilar contours are unremarkable. There is no pleural effusion or pneumothorax. The lungs appear clear. No free air is identified. A biliary stent projects over the right upper quadrant of the abdomen. There are also surgical clips projecting over the right upper quadrant, mostly commonly seen after cholecystectomy. IMPRESSION: No evidence of acute disease. No free air identified. Radiology Report EXAMINATION: TOE(S), 2+ VIEW RIGHT INDICATION: ___ year old woman with RA now with acute right great toe pain, erythema, edema // r/o chondrocalcinosis, evaluate right great toe TECHNIQUE: Three views right great toe. COMPARISON: None FINDINGS: No erosion is seen. There is mild to moderate degenerative change at the first metatarsophalangeal joint, with joint space narrowing and osteophyte formation. There is degenerative change at the interphalangeal joints of the second toe. No chondrocalcinosis is evident. IMPRESSION: Degenerative changes as above, no erosion or chondrocalcinosis is identified. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Abd pain, Transfer Diagnosed with CHRONIC PANCREATITIS temperature: 98.4 heartrate: 77.0 resprate: 18.0 o2sat: 100.0 sbp: 136.0 dbp: 76.0 level of pain: 7 level of acuity: 3.0

You were admitted with pancreatitis after an ERCP procedure. You were treated with pain medicine and nausea medicine and you got better. Your other medical issues were stable. You may have developed gout in your right great toe but this has not been confirmed as you do not have enough fluid in the joint to try to remove with a needle. Please follow up with your primary rheumatologist about this as well as the new bumps on your legs, which may go away if they were associated with the pancreatitis. If they do not resolve, then they need further evaluation including possible biopsy.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea, weakness, hypotension, acute renal failure, dehydration, and chest pain. Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ ___-speaking man with relapsed DLBCL s/p cycle #1 DHAP last week admitted for nausea, weakness, hypotension, acute renal failure, dehydration, and chest pain. Completed cycle #1 ___. Over the last few days, he has become gradually weaker with nausea, dizziness, and chest pressure last a few minutes each time. He has not been taking any analgesics. He also describes right eye blurriness which started on the day of admission. . ROS: He has been constipated for several days. He denies F/C/S, wght loss, headache, dyspnea, cough, abdominal pain, back pain, diarrhea, hematochezia, hematuria, other urinary symptoms, parasthesias, or rash. All other ROS were negative. Past Medical History: 1. Non-Hodgkin's lymphoma. 2. Latent TB infection, consulted by Dr. ___ with previous treatment. 3. Hep B core positivity. 4. Hypertension. 5. Atrial fibrillation, currently on metoprolol; warfarin stopped for chemotherapy. 6. Glaucoma. Social History: ___ Family History: Non-contributory. Physical Exam: Admission Physical Examination: VS: T 97.6F, BP 98/62, HR 78, RR 18, O2 Sat 94% RA, wght 134.4 lbs, ht 63in. GEN: A&O, NAD. HEENT: Sclerae non-icteric, EOM intact, o/p clear, dry MM. Neck: Supple, no thyromegaly, no cervical LAD. CV: S1S2, RRR, no MRG. RESP: Good air movement bilaterally, no rhonchi or wheezing. BACK: No spine, rib, or iliac tenderness. ABD: Soft, non-tender, non-distended, no HSM, no inguinal LAD. EXTR: No edema or calf tenderness. No finger clubbing. No axillary LAD. DERM: No rash. Neuro: Strength ___, sensation to touch normal, down-going plantar reflexes, no focal deficits. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS: ___ 09:35AM BLOOD WBC-27.1*# RBC-4.91 Hgb-14.9 Hct-42.6 MCV-87 MCH-30.4 MCHC-35.1* RDW-11.7 Plt Ct-47*# ___ 09:35AM BLOOD Neuts-95.6* Lymphs-2.6* Monos-1.6* Eos-0.2 Baso-0 ___ 09:35AM BLOOD UreaN-63* Creat-2.3*# Na-128* K-3.4 Cl-82* HCO3-34* AnGap-15 ___ 09:35AM BLOOD Albumin-3.8 Calcium-7.8* Phos-5.2* Mg-2.4 ___ 09:35AM BLOOD ALT-27 AST-15 LD(LDH)-245 CK(CPK)-22* AlkPhos-103 TotBili-2.7* ___ 09:35AM BLOOD cTropnT-<0.01 ___ 12:49PM BLOOD Lactate-1.6 . ___ CXR: IMPRESSION: 1. No evidence of pneumonia. Chronic biapical scarring and pleural thickening is stable. 2. Mild cardiomegaly is stable. . ___ u/s:The liver is normal echogenicity with no focal lesions present. The portal vein is patent with hepatopetal flow. The CBD measures 8 mm and is normal. The gall bladder is normal with no evidence of cholelithiasis. IMPRESSION: Normal liver, gall bladder ultrasound.: . Medications on Admission: Amlodipine 10 mg PO once a day. Lamivudine 100 mg PO DAILY. Lisinopril 5 mg PO DAILY. Metoprolol succinate 25 mg Tablet Extended Release 24 hr PO BID. Codeine sulfate ___ mg PO q4HR PRN pain. Allopurinol ___ mg PO DAILY. Bactrim 400-80 mg PO once a day. Acyclovir 400 mg PO q8HR. Aspirin 81mg PO daily (NOT TAKING) Warfarin stopped last admission for chemo. Discharge Medications: 1. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H (Every 8 Hours). Disp:*60 Tablet(s)* Refills:*0* 6. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*300 Tablet(s)* Refills:*0* 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*0* 8. potassium & sodium phosphates ___ mg Powder in Packet Sig: One (1) Powder in Packet PO twice a day for 10 days: Do not take together with calcium. Disp:*20 Powder in Packet(s)* Refills:*0* 9. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for Nausea. Disp:*30 Tablet(s)* Refills:*0* 10. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. pentamidine 300 mg Recon Soln Sig: One (1) Inhalation once a month. Discharge Disposition: Home Discharge Diagnosis: Hypotension Acute renal failure Atrial fibrillation with rapid ventricualr rate Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: Shortness of breath and increased white count, question pneumonia. COMPARISON: Chest radiograph on ___. FINDINGS: PA and lateral views of the chest. The biapical fibrosis and bronchiectasis, right greater than left, representing scarring is unchanged. Mild cardiomegaly is stable. There is no evidence of pneumonia. No pleural effusion. No pneumothorax. Mediastinal and hilar contours are normal and stable. IMPRESSION: 1. No evidence of pneumonia. Chronic biapical scarring and pleural thickening is stable. 2. Mild cardiomegaly is stable. Radiology Report INDICATION: ___ year old man with DLBCL admitted for dehydration, chest pain. New hyperbilirubinemia. COMPARISON: CT from ___. FINDINGS: The liver is normal echogenicity with no focal lesions present. The portal vein is patent with hepatopetal flow. The CBD measures 8 mm and is normal. The gall bladder is normal with no evidence of cholelithiasis. IMPRESSION: Normal liver, gall bladder ultrasound. Gender: M Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: CP/ LIGHTHEADEDNESS/HYPOTENSION Diagnosed with CHEST PAIN NOS, LEUKOCYTOSIS, UNSPECIFIED temperature: 98.5 heartrate: 90.0 resprate: 18.0 o2sat: 99.0 sbp: 106.0 dbp: 81.0 level of pain: 5 level of acuity: 2.0

Mr ___ you were admitted with nausea, vomiting and dehydration after receiving chemotherapy. You received medications for the nausea and vomiting as well as IV fluids. You also had low blood pressure which improved with the IV fluids.In addition your blood counts were low and you did get a transfusion of platelets.You were started on pentamidine inhalations for infection prevention instead of bactrim. Changes in medications; Metoprolol succinate changed to metorpolol tartrate 12.5 mg TID Discontinue amlodipine Discontinue lisinopril for now Start magnesium oxide 400 mg po daily Start calcium 1000 mg daily Start neutraphos 2 packets daily Discontinue bactrim Pending results: Final results of blood and urine cultures

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: fluocinolone acetonide Attending: ___. Chief Complaint: L leg weakness Major Surgical or Invasive Procedure: T5 laminectomy and T2-T7 posterior fusion DL POC placement ___ History of Present Illness: ___ ___ speaking male with a PMH of HTN, T2DM, HLD, Fe-deficiency anemia, L iliac lesion of unknown etiology; presenting with L leg pain and weakness. Over past month, patient has needed to use a cane and then walker; has had two falls over the past week. Also has BLE numbness which has contributed to the falls, initially weakness and numbness was on left side and continues to be worse on that side but is bilateral now. No HS, no LOC, no HA, no dbl vision, no n/v. Patient does have left shoulder pain from his falls but no other pain in his body. Patient has no numbness in his arms but does feel weak in the left arm only after his fall. In the ED, 97.1 107 141/63 18 98% RA. Labs notable for BMP, CBC WBC 7.4, H/H 6.8/23.9, Plt 485. Lactate of 5.1 -> 4.8 Physical exam notable for LLE ___ strength, with intact rectal pressure. The patient 1L, acetaminophen 1000 mg, and 4 mg IV morphine. Shoulder xray with destructive left mid/distal clavicle osseous process. MRI spine with enhancement of T3, T4, T5, T6, and T11 vertebral bodies consistent with malignancy, likely representing metastasis. There is intradural, extramedullary extension at the level of T5-T6 causing severe cord compression, with tumor extension at T11 without significant cord compression. He was seen by neurosurgery who felt that his neurological deficits were inconsistent with a lesion at the T5 level. They recommended no surgical intervention at this time and recommended oncology work up. Upon arrival to the floor, the patient is interviewed with a ___ interpreter via phone. He reports that he came to the hospital because he had 2 falls, one occurring the night prior to admission and once on the morning of presentation. He reports that the falls were mechanical, that he felt weak in both legs. He denies lightheadedness. He reports that his legs have been getting progressively weak, prompting him to begin using a walker over the past month. He also reports that he has pain in his legs and his pelvic area. He endorses significant left shoulder pain, slight headache which she attributes to not eating, nausea without vomiting, 20 pound weight loss occurring over the last 3 months. He otherwise denies fevers, chills, shortness of breath, abdominal pain, difficulty urinating, urinary incontinence, bowel incontinence. He reports that he had a single episode of bloody diarrhea which occurred in ___. He reports he had an EGD which was negative and was asked to get a colonoscopy. On the day of the colonoscopy, he was feeling very weak, so colonoscopy was subsequently not performed. He reports he had a normal colonoscopy approximately ___ years ago. He otherwise denies hematuria, rashes, bruises. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Hypercholesterolemia - Type 2 diabetes - Hypertension - Diabetic retinal microaneurysm - GERD - Nephritis and nephropathy - Continue corporis - Folliculitis - Anemia - Achilles tendinitis - Unstable angina - Constipation - Iron deficiency anemia - Prior removal of a skin lesion (noncancerous) Social History: ___ Family History: Denies relevant family history. Denies family history of cancer. Denies family history of heart disease. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 98.3 PO 169 / 80 93 18 95 Ra GENERAL: Alert and in no apparent distress, follows commands EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Mucous membranes moist CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally GU: foley in place GI: Abdomen soft, non-distended, non-tender to palpation MSK: Neck supple, moves all extremities, 4+/5 RLE strength, 4+/5 ___ strength, decreased sensation of the lateral shins noted bilaterally, upper extremity strength 5 out of 5 bilaterally for grip strength, biceps flexion, biceps extension, no spinal tenderness, plus tenderness over the left clavicle SKIN: No rashes or ulcerations noted NEURO: CN II-XII, alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, answers questions appropriately, strength exam as noted above, +rectal tone PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 1103) Temp: 98.1 (Tm 98.9), BP: 133/69 (120-144/64-69), HR: 84 (76-92), RR: 20 (___), O2 sat: 95% (95-99), O2 delivery: RA HEENT: MMM, thrush absent, R lower inside lip aphthous ulcer. no other lesions noted. CV: RR, NL S1S2 no S3S4, no MRG. Chest tenderness over L ___ ribs PULM: Normal work of breathing, CTAB ABD: soft, nontender, distention, BS+ BACK: surgical incision, healing no dressing. No new hematoma appreciated. normal w/o erythema or edema. LIMBS: WWP. B/L trace ankle edema, tenderness at L HIP. SKIN: White patchy discoloration on legs/groin, arms nontender, nonpruitic. ACCESS: DL chest port c/d/i Pertinent Results: ADMISSION LABS: ============== ___ 03:39PM LACTATE-4.8* ___ 02:47PM GLUCOSE-128* UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-25 ANION GAP-17 ___ 02:47PM estGFR-Using this ___ 02:47PM ALT(SGPT)-24 AST(SGOT)-30 ALK PHOS-108 TOT BILI-0.3 ___ 02:47PM LIPASE-25 ___ 02:47PM ALBUMIN-3.2* CALCIUM-9.9 PHOSPHATE-4.5 MAGNESIUM-1.8 ___ 02:47PM WBC-7.4 RBC-4.89 HGB-6.8* HCT-23.9* MCV-49* MCH-13.9* MCHC-28.5* RDW-22.9* RDWSD-35.1 ___ 02:47PM NEUTS-81.5* LYMPHS-6.1* MONOS-9.7 EOS-1.7 BASOS-0.3 IM ___ AbsNeut-6.06 AbsLymp-0.45* AbsMono-0.72 AbsEos-0.13 AbsBaso-0.02 ___ 02:47PM PLT COUNT-485* ___ 02:42PM LACTATE-5.1* IMAGING: ======== CT ___ ___: No acute intracranial process. CXR ___: 1. Left mid/distal clavicle destructive osseous process better evaluated on thoracic spine CT and dedicated glenohumeral radiograph from same day. 2. Bibasilar atelectasis and mild cardiomegaly. Shoulder XR ___: 1. Destructive left mid/distal clavicle osseous process, with likely underlying fractures. 2. Age-indeterminate, left posterolateral sixth rib deformity likely representing a healing fracture is better assessed on dedicated chest radiograph. CT SPINE C/T/L ___ IMPRESSION: 1. T5 compression fracture without retropulsion, likely acute, with small perivertebral hematoma. Mottled lucency of the T3, T4 and T6 vertebral bodies concerning for metastatic involvement. 2. Left clavicle destructive osseous process and additional osseous lesions as described above may represent malignancy/metastasis. 3. Morphologically abnormal enlarged mediastinal and retrocrural lymph nodes. Correlate with full oncology workup. RECOMMENDATION(S): Dedicated oncology workup is recommended, if not previously performed. IMPRESSION: 1. No cervical spine fracture or malalignment. 2. Partially imaged left destructive lesion of lateral/mid clavicle. IMPRESSION: 1. No acute fracture or traumatic malalignment of the lumbar spine. 2. Retroperitoneal and partially imaged left pelvic sidewall lymphadenopathy, which may be secondary to malignancy. 3. Partially imaged diffuse left iliac bone sclerosis which may represent malignancy or metastasis. RECOMMENDATION(S): Oncologic workup is recommended if not previously performed. MRI spine C/T ___: IMPRESSION: 1. Pathologic compression fracture of the T5 vertebral body with approximately 50% vertebral body height loss. 2. Vertebral body metastatic disease involving the T3 through T6 and T11 vertebral bodies with posterior soft tissue component at T3, T5 and T11. 3. There is severe spinal canal stenosis at T5 caused by retropulsed material from the fracture and circumferential involvement of the spinal canal. 4. Soft tissue obliteration of the bilateral T4-T5, bilateral T5-T6 and right T11-T12 neuroforamen. 5. Multilevel degenerative changes of the cervical spine with disc protrusion at C3-C4 resulting in remodeling of the ventral cord but no cord signal abnormality. 6. Mild degenerative changes along the lumbar spine without significant spinal canal stenosis or neural foraminal narrowing. CT BIOPSY ___ IMPRESSION: Technically successful CT-guided biopsy of the soft tissue component of the large left iliac lesion. PATHOLOGIC DIAGNOSIS: ___ Left iliac mass, biopsy: HIGH GRADE B-CELL LYMPHOMA MORPHOLOGICALLY CONSISTENT WITH DIFFUSE LARGE B-CELL LYMPHOMA; SEE NOTE. Note: Sections show fibrotic tissue and skeletal muscle FISH: POSITIVE for GAIN of MYC and REARRANGEMENT of MYC with LOSS 3'MYC. CT A/P ___: 1. Destructive lesion centered in left iliac bone with soft tissue extension into the adjacent iliacus and gluteal musculature may represent metastatic disease but is also concerning for primary malignancy such as osteosarcoma. 2. Multiple hypoenhancing hepatic and splenic lesions concerning for metastases. 3. Retroperitoneal, mesenteric, and pelvic lymphadenopathy. Chest IMPRESSION: No evidence of primary it malignancy arising in the chest. Lungs essentially clear. Mild mediastinal lymph node enlargement, probably pathologic. No vital structures compromised. Extensive skeletal malignancy, detailed above. Important features of thoracic spine involvement are detailed report of the thoracic spine MRI performed on ___. MR ___ ___: IMPRESSION: 1. Approximately 2.4 x 2.3 cm enhancing soft tissue mass centered at the right greater wing of the sphenoid bone with underlying osseous destruction as seen on CT from ___ is concerning for metastasis. The mass slightly bulges into the right orbit contacting the right lateral rectus muscle without definitive evidence for tumoral invasion. The lesion does extend into the temporal fossa with involvement of the right temporalis muscle. 2. The lesion likely erodes through the inner table of the right greater wing of the sphenoid. There is thickening and enhancement of the dura overlying the right anterior temporal lobe adjacent to the greater wing of the sphenoid, potentially reactive in nature. 3. No evidence of intracranial metastasis. No acute intracranial abnormalities. 4. Additional findings described above. ___: PATHOLOGIC DIAGNOSIS: Epidural mass, biopsy: HIGH GRADE B-CELL LYMPHOMA MORPHOLOGICALLY CONSISTENT WITH DIFFUSE LARGE B-CELL LYMPHOMA; SEE NOTE. Note: Sections show fibrotic tissue TSPINE XR ___: IMPRESSION: The patient is status post T2 through T7 posterior fusion with vertical rods and transpedicular screws at T 2, T3, T4, T6 and T7. Re-demonstrated is a compression deformity of T5. There is no evidence of hardware related complications or interval change in alignment. Skin staples remain present. The visualized lungs are grossly apart from probable atelectasis seen in the left lung base TTE ___: IMPRESSION: EF >75% Moderate symmetric left ventricular hypertrophy with normal cavity size, and hyperdynamic regional/global systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. LENIS ___: No evidence of deep venous thrombosis in the left lower extremity veins. CT pelvis ___: IMPRESSION: 1. Overall unchanged large destructive lytic lesion encompassing the left hemipelvis. This was characterized CT examination from ___ and biopsied on that same day, with pathology consistent with known DLBCL. 2. The patient is at high risk for left iliac pathologic fracture from normal weight bearing. Recommend orthopedic consultation regarding weight bearing restrictions. 3. Additional metastasis in the distal left femur is also noted. 4. Metastatic left iliac and retroperitoneal adenopathy are again noted. HIP XR ___ IMPRESSION: There are extensive lytic lesions in the left ilium, ischium and pubic bones. Additional lytic lesions are also seen in the right inferior trochanteric region and proximal left femur. There is a pathological fracture through the right lesser trochanter with superior and anterior displacement. No acute fracture is seen in the left hip or pelvis. There is no evidence of dislocation. There are mild degenerative changes in the bilateral hips and lower lumbar spine. KUB ___: IMPRESSION: Unremarkable. CXR ___ IMPRESSION: Heart size and mediastinum are stable. Spinal hardware has been inserted in the interim. Lungs overall clear. There is no pneumothorax. There is no appreciable pleural effusion.Central venous line tip terminates in the proximal right atrium.No pulmonary edema. No pleural effusion. No pneumothorax. MR complete spine and pelvis ___: IMPRESSION: 1. Extensive tumor involvement in the pelvis, with replacement of nearly the entire left hemipelvis by a large destructive lesion centered in the left iliac wing. A soft tissue component of the mass is within the vicinity of the sciatic nerve, however the nerve does not appear to be invaded. There is bone marrow involvement in the left hemi-sacrum, however there does not appear to be invasion of the sacral neuroforamen. 2. Bone marrow replacing lesion in the left femoral diaphysis. 3. Bone marrow replacing lesion in the right iliac bone extending to the mid to inferior aspect of the right SI joint as well as a lesion in the right lesser trochanter with redemonstration of a pathologic avulsion fracture at the right trochanter. 4. Extensive muscular edema in the bilateral hips, left greater than right, including partial tears of the left gluteus tendons, avulsion of the proximal left iliotibial band and partial-thickness injury of the distal right gluteus minimus tendon. Associated left greater than right greater trochanteric bursitis. 5. Left pelvic sidewall lymphadenopathy, not significantly changed. IMPRESSION: 1. Interval resolution of previously severe spinal canal narrowing and cord compression at T5 due status post interval T5 laminectomy and posterior spinal fusion, T2-T7. There is no longer any identifiable high-grade spinal narrowing, nor any spinal cord compression. 2. Possible short-segment cord signal abnormality in the right aspect of the cord at the level of T5 at the area prior compression, although cord is somewhat obscured due to mild artifact from hardware. 3. Re-demonstration of probable metastatic lesions within the T3-T6 vertebral bodies, with moderate height loss of T5, unchanged. 4. Unchanged T11 probable metastatic lesion. 5. Unchanged obliteration of the left T4-5 and bilateral T5-6 neural foramina due to soft tissue extension of T5 tumor. 6. Mild right C4-5, moderate right T10-11, and mild right T11-12 neural foraminal narrowing is unchanged. 7. No evidence of cervical or lumbar spine metastasis. 8. Small left layering pleural effusion. IMPRESSION: Postoperative changes as described. CXR ___: IMPRESSION: There is a right chest wall Port-A-Cath with the tip terminating in the upper right atrium.Linear opacities in the lung bases most likely represent subsegmental atelectasis. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable in appearance. There is posterior spinal fusion hardware in the upper thoracic spine. Back US ___: IMPRESSION: Heterogeneously echogenic, avascular collection in the subcutaneous tissues along the surgical incision may reflect a hematoma, more completely evaluated on the recent MRI. Superinfection cannot be excluded. CT C/T/L ___: IMPRESSION: 1. Patient body habitus and partially visualized thoracic spinal fusion hardware limits examination. 2. Within limits of study, no definite evidence of acute cervical spine fracture. 3. Multilevel cervical spondylosis, better evaluated on ___ full spine contrast MRI. 4. Partially visualized clavicles again demonstrate left midclavicle destructive lesion. 5. Approximately 1 cm right supraclavicular lymph node with findings concerning for malignancy, as described. 6. Within limits of study, no definite evidence of enhancing paravertebral or paraspinal mass. 7. Please see concurrently obtained contrast lumbar spine CT for description of lumbar spine structures. IMPRESSION: 1. Study is limited secondary to patient body habitus and spinal fusion hardware streak artifact. 2. Postsurgical changes related to T2-T7 fusion with T5 laminectomy. 3. Interval enlargement of fluid collection overlying the thoracic spine surgical bed compared to prior MR, the superior extent of which is incompletely imaged, but extends inferiorly to the spinous process of T9. While findings may represent postoperative seroma, differential considerations of hematoma, or infectious or inflammatory etiologies are not excluded on the basis of this examination. If clinically indicated, consider correlation with fluid sampling. Recommend follow-up imaging to resolution. 4. Diffuse metastatic osseous involvement of the bilateral clavicles, sternum, thoracic vertebral bodies, and left scapula, with soft tissue destruction of the bilateral clavicles with associated comminuted fractures as described. 5. Grossly stable narrowing at the left T4-5 and bilateral T5-6 neuroforamina, better demonstrated on recent full spine MRI. 6. Left paraesophageal lymphadenopathy, with additional nonspecific mediastinal lymph nodes as described. Differential considerations include infectious, inflammatory, and neoplastic etiologies. 7. New thickening along the left major fissure. If clinically indicated, consider correlation with dedicated chest imaging. 8. Several regions of hypodensity within the visualized liver, which were not well evaluated on prior imaging studies. If concern for hepatic metastatic lesions, consider hepatic MRI for further evaluation. 9. Please see concurrently obtained cervical spine and lumbar spine CT reports for description of cervical and lumbar findings. IMPRESSION: 1. New pathologic left iliac bone fracture likely extending into the superior acetabulum. The large underlying metastatic lesion is better characterized on pelvic MRI obtained 1.5 weeks prior. 2. Sacral and right iliac bone metastases are not definitely seen on current examination, which may be related to differences in technique. 3. Necrotic lymphadenopathy as described. 4. Multilevel lumbar spondylosis without definite evidence of moderate or severe bony vertebral canal narrowing, better evaluated on ___ full spine MRI ___ aspiration ___: IMPRESSION: Successful US-guided aspiration of a heterogeneous Fluid collection in the dorsal chest wall. MICROBIOLOGY: ============= All cultures negative DISCHARGE LABS: =============== ___ 12:00AM BLOOD WBC-6.5 RBC-3.72* Hgb-7.9* Hct-25.8* MCV-69* MCH-21.2* MCHC-30.6* RDW-UNABLE TO RDWSD-UNABLE TO Plt ___ ___ 12:00AM BLOOD Neuts-94* Lymphs-4* Monos-1* Eos-0* Baso-1 AbsNeut-6.11* AbsLymp-0.26* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.07 ___ 12:00AM BLOOD Hypochr-3+* Anisocy-1+* Poiklo-1+* Microcy-3+* Spheroc-2+* Target-2+* Schisto-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 12:00AM BLOOD Glucose-94 UreaN-19 Creat-0.6 Na-143 K-4.5 Cl-105 HCO3-24 AnGap-14 ___ 12:00AM BLOOD ALT-23 AST-13 LD(LDH)-402* AlkPhos-187* TotBili-0.3 ___ 12:00AM BLOOD Calcium-7.6* Phos-3.9 Mg-1.9 ___ 12:01AM BLOOD calTIBC-242* Ferritn-2394* TRF-186* ___ 06:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 04:00AM BLOOD PEP-NO SPECIFI FreeKap-35.7* FreeLam-31.4* Fr K/L-1.14 b2micro-3.0* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY 2. Alaway (ketotifen fumarate) 0.025 % (0.035 %) ophthalmic (eye) DAILY 3. Loratadine 10 mg PO DAILY 4. Lidocaine 5% Ointment 1 Appl TP DAILY 5. Colchicine 0.6 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. GlipiZIDE 10 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 10. Simvastatin 20 mg PO QPM 11. Polyethylene Glycol 17 g PO DAILY 12. Ferrous GLUCONATE 240 mg PO DAILY 13. Januvia (SITagliptin) 100 mg oral DAILY 14. Gabapentin ___ mg PO QHS Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Allopurinol ___ mg PO DAILY 3. Filgrastim-sndz 300 mcg SC Q24H 4. Glargine 14 Units Breakfast Glargine 14 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Morphine SR (MS ___ 15 mg PO Q12H 6. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Mild 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Vitamin D ___ UNIT PO 1X/WEEK (TH) Duration: 7 Doses Weekly, last dose is ___. Gabapentin 600 mg PO QHS 11. Gabapentin 300 mg PO BID 12. Alaway (ketotifen fumarate) 0.025 % (0.035 %) ophthalmic (eye) DAILY 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 14. Lidocaine 5% Ointment 1 Appl TP DAILY 15. Loratadine 10 mg PO DAILY 16. MetFORMIN (Glucophage) 1000 mg PO BID 17. Polyethylene Glycol 17 g PO DAILY 18. Simvastatin 20 mg PO QPM 19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= Diffuse large Bcell Lymphoma SECONDARY DIAGNOSIS: =================== s/p T5 lamenectomy and T2-T7 fusion pathologic Left iliac bone fracture T2DM Thrush Cancer associated pain 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: CT HEAD W/O CONTRAST INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder pain, fall.// eval fracture, bleed, infection 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: Total DLP (Head) = 903 mGy-cm. COMPARISON: Noncontrast head CT ___. FINDINGS: There is no evidence of acute large territorial infarction, intracranial hemorrhage, edema, or large mass. There is prominence of the ventricles and sulci suggestive of age-related cerebral volume loss. No acute osseous abnormalities seen. There is a tiny mucous retention cyst in the right maxillary sinus. Otherwise, the partially imaged paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits demonstrate no acute abnormalities. IMPRESSION: No acute intracranial process. Radiology Report EXAMINATION: CT C-SPINE W/O CONTRAST INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder pain, fall.// eval fracture, bleed, infection TECHNIQUE: Contiguous axial images obtained through the cervical spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Total DLP (Body) = 470 mGy-cm. COMPARISON: None. FINDINGS: Destructive changes are noted involving the of the left lateral/mid clavicle likely complicated with a pathologic fracture, partially imaged concerning for metastatic disease. Cervical spinal alignment is normal. No definite cervical spine fracture. There is no severe canal or foraminal narrowing.There is no prevertebral edema. The thyroid and included lung apices are unremarkable. IMPRESSION: 1. No cervical spine fracture or malalignment. 2. Partially imaged left destructive lesion of lateral/mid clavicle. NOTIFICATION: Final report impression was discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:44 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT T-SPINE W/O CONTRAST INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder pain, fall.// eval fracture, bleed, infection TECHNIQUE: Contiguous axial images obtained through the thoracic spine without intravenous contrast. Coronal and sagittal reformats were reviewed. DOSE: Total DLP (Body) = 1,234 mGy-cm. COMPARISON: None. FINDINGS: Alignment is normal. There is a likely acute compression fracture of T5 without evidence of significant retropulsion a greater than 50% loss of vertebral body height. Adjacent perivertebral soft tissue is noted possibly representing hematoma. No additional thoracic spine fracture. However, a mottled appearance of the T3, T4 and T6 vertebral bodies also concerning for metastatic infiltration. There is a partially imaged destructive process of the left mid and distal clavicle (2:9). Partial imaging of the right distal clavicle demonstrates a moth-eaten appearance. There are morphologically abnormal mediastinal and retrocrural lymph nodes may represent malignancy. IMPRESSION: 1. T5 compression fracture without retropulsion, likely acute, with small perivertebral hematoma. Mottled lucency of the T3, T4 and T6 vertebral bodies concerning for metastatic involvement. 2. Left clavicle destructive osseous process and additional osseous lesions as described above may represent malignancy/metastasis. 3. Morphologically abnormal enlarged mediastinal and retrocrural lymph nodes. Correlate with full oncology workup. RECOMMENDATION(S): Dedicated oncology workup is recommended, if not previously performed. NOTIFICATION: Final impression was discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:46 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: CT L-SPINE W/O CONTRAST INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder pain, fall.// eval fracture, bleed, infection 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) = 926 mGy-cm. COMPARISON: None. FINDINGS: There is diffuse mixed sclerotic and lytic changes of the partially imaged left iliac bone which may represent malignancy. No evidence annual lying pathologic fracture. Alignment is normal. No acute fractures are identified. There is no evidence of severe spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. Limited imaging of the abdomen and pelvis demonstrates retroperitoneal and partially imaged left pelvic sidewall lymphadenopathy measuring up to 2 cm in short axis diameter (for example pericaval and left pelvic sidewall nodes, 2:61, 101) which may represent malignancy. There is moderate aortic atherosclerotic disease. There is relative hypoattenuation of the blood pool which may represent anemia. IMPRESSION: 1. No acute fracture or traumatic malalignment of the lumbar spine. 2. Retroperitoneal and partially imaged left pelvic sidewall lymphadenopathy, which may be secondary to malignancy. 3. Partially imaged diffuse left iliac bone sclerosis which may represent malignancy or metastasis. RECOMMENDATION(S): Oncologic workup is recommended if not previously performed. Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: *** CODE CORD *** History: ___ with LLE weakness, c/f malignancyIV contrast to be given at radiologist discretion as clinically needed// eval cord compression TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: CT of the entire spine from ___ FINDINGS: CERVICAL: There is mild retrolisthesis of C3 on C4 and C4 on C5. Vertebral body height and alignment is otherwise preserved. There is multilevel degenerative disc disease with grossly preserved disc space heights. Bone marrow signal intensity is within normal limits. At C2-C3, there is a shallow disc bulge, facet joint arthropathy and uncovertebral hypertrophy but no spinal canal stenosis or significant neural foraminal narrowing. At C3-C4, there is a central/right paracentral disc protrusion with remodeling of the ventral cord but no cord signal abnormality. In addition, there is facet joint arthropathy, mild ligamentum flavum thickening and uncovertebral hypertrophy but no spinal canal stenosis or significant neural foraminal narrowing. At C4-C5, there is a posterior disc osteophyte complex, facet joint arthropathy, mild ligamentum flavum thickening and uncovertebral hypertrophy, no spinal canal stenosis but mild right neural foraminal narrowing. At C5-C6, there is a posterior disc osteophyte complex, facet joint arthropathy and mild ligamentum flavum thickening as well as uncovertebral hypertrophy but no spinal canal stenosis or significant neural foraminal narrowing. At C6-C7, there is a shallow disc bulge, facet joint arthropathy, mild ligamentum flavum thickening and uncovertebral hypertrophy but no spinal canal stenosis or significant neural foraminal narrowing. THORACIC: There is increased STIR signal intensity in the T3 through T6 and T11 vertebral bodies with extension into the posterior elements and patchy enhancement after contrast administration. There is a T5 compression fracture with approximately 50% vertebral body height loss. There is discontinuity of the posterior cortical border of the T3 and T5 vertebral bodies with extra-axial enhancing soft tissue extending posteriorly and resulting in mild narrowing of the spinal canal at T3 and severe spinal canal stenosis at T5. The soft tissue component at the T3 level is slightly asymmetric and more pronounced along the right aspect of the ventral cord. At the T5 level, there is circumferential involvement around the spinal canal. The bilateral T5-T6 neuroforamen appear obliterated by soft tissue material. There is mild neural foraminal narrowing at T4-T5 bilaterally. There is an indistinct posterior border of the T11 vertebral body with possible soft tissue cortical breakthrough (series 9, image 9) and a tumor infiltrating posteriorly through the right pedicle along the right extra-axial aspect of the spinal canal (series 13, image 27). The right T11-T12 neuroforamen appears partially obliterated by soft tissue material. At T11-T12, there is also a shallow disc bulge, facet joint arthropathy and moderate ligamentum flavum thickening but no significant spinal canal stenosis. The remainder of the thoracic vertebral bodies show appropriate alignment and preserved vertebral body heights. There is no spinal canal stenosis or significant neural foraminal narrowing at the remaining thoracic levels. LUMBAR: Vertebral body heights and alignment is preserved. There is mild degenerative disc disease predominantly involving the L3-L4 and L5-S1 levels with grossly preserved disc space heights. Bone marrow signal intensity is within normal limits. The axial postcontrast images of the lumbar spine are degraded by motion artifact. Allowing for this limitation, no definitive enhancement of the conus or cauda equina nerve roots is identified. There is no spinal canal stenosis or significant neural foraminal narrowing along the lumbar spine. OTHER: IMPRESSION: 1. Pathologic compression fracture of the T5 vertebral body with approximately 50% vertebral body height loss. 2. Vertebral body metastatic disease involving the T3 through T6 and T11 vertebral bodies with posterior soft tissue component at T3, T5 and T11. 3. There is severe spinal canal stenosis at T5 caused by retropulsed material from the fracture and circumferential involvement of the spinal canal. 4. Soft tissue obliteration of the bilateral T4-T5, bilateral T5-T6 and right T11-T12 neuroforamen. 5. Multilevel degenerative changes of the cervical spine with disc protrusion at C3-C4 resulting in remodeling of the ventral cord but no cord signal abnormality. 6. Mild degenerative changes along the lumbar spine without significant spinal canal stenosis or neural foraminal narrowing. Radiology Report EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD, anemia, enhancement of left iliac bone, destructive lesion of the clavicle, and spine with T5 lesion with severe cord compression, consistent with disease of unknown primary.// brain lesions 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: Head CT dated ___. FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are within expected limits in caliber and configuration. No suspicious parenchymal FLAIR signal abnormality. There is no abnormal intracranial enhancement after contrast administration. The major intracranial flow voids are preserved. The dural venous sinus is patent. Centered at the right greater wing of the sphenoid bone is an approximately 2.4 x 2.3 cm enhancing soft tissue mass with underlying osseous destruction, also seen on CT from ___, concerning for metastatic disease. The mass appears to slightly bulging into the right orbit contacting lateral rectus muscle, although no definite invasion of lateral rectus muscle identified. There is likely erosion through the inner table of the right greater wing of the sphenoid. The lesion does appear to invade into the right temporalis muscle (series 9, image 69). There is dural thickening and enhancement of the anterior middle cranial fossa (series 9, image 65), likely reactive in nature. No additional suspicious osseous lesions. There is mild mucosal thickening of the ethmoid air cells and right maxillary sinus. The remaining paranasal sinuses and bilateral mastoid air cells are unremarkable. Other than the abnormality described above, the orbits are unremarkable. IMPRESSION: 1. Approximately 2.4 x 2.3 cm enhancing soft tissue mass centered at the right greater wing of the sphenoid bone with underlying osseous destruction as seen on CT from ___ is concerning for metastasis. The mass slightly bulges into the right orbit contacting the right lateral rectus muscle without definitive evidence for tumoral invasion. The lesion does extend into the temporal fossa with involvement of the right temporalis muscle. 2. The lesion likely erodes through the inner table of the right greater wing of the sphenoid. There is thickening and enhancement of the dura overlying the right anterior temporal lobe adjacent to the greater wing of the sphenoid, potentially reactive in nature. 3. No evidence of intracranial metastasis. No acute intracranial abnormalities. 4. Additional findings described above. Radiology Report EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD, anemia, enhancement of left iliac bone, destructive lesion of the clavicle, and spine with T5 lesion with severe cord compression, consistent with disease of unknown primary.// investigate primary lesion TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen without and with IV contrast. Initially the abdomen was scanned without IV contrast. Subsequently a single bolus of IV contrast was injected and the abdomen and pelvis was scanned in the portal venous phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.0 s, 32.4 cm; CTDIvol = 11.0 mGy (Body) DLP = 348.9 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 3) Stationary Acquisition 10.9 s, 0.2 cm; CTDIvol = 145.3 mGy (Body) DLP = 29.1 mGy-cm. 4) Spiral Acquisition 10.6 s, 68.9 cm; CTDIvol = 9.9 mGy (Body) DLP = 677.4 mGy-cm. 5) Spiral Acquisition 5.1 s, 32.9 cm; CTDIvol = 11.0 mGy (Body) DLP = 354.7 mGy-cm. Total DLP (Body) = 1,412 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 are numerous poorly defined hypoenhancing lesions throughout the liver. Near the largest in segment 6 measures up to 2.2 cm (06:56). There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones but is otherwise unremarkable. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Hypoenhancing lesion in the midportion of the spleen measures up to 1.4 cm (06:59). A similar lesion in the inferior tip of the spleen measures up to 1.1 cm (6:68). ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. No hydronephrosis. A 1.0 cm simple cyst arises exophytically from the interpolar region of the right kidney. Subcentimeter hypodensities in left kidney are too small to characterize, but also likely represent simple cysts. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate and seminal vesicles are unremarkable. LYMPH NODES: There are several enlarged periaortic lymph nodes measuring up to 1.5 cm in the aortocaval region (6:82). Enlarged peripancreatic node measures up to 11 mm (6:62). Few enlarged mesenteric nodes are also noted with an enlarged left pelvic sidewall lymph node measures up to 2.1 cm (6:103). VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES AND SOFT TISSUES: There is diffusely mottled appearance with several areas of frank destruction of the anterior left iliac bone and left acetabulum. A surrounding soft tissue mass measures 8 x 11cm. Internal density is heterogeneous. Lesion centered in this location extends into the surrounding gluteus and iliacus musculature which are expanded. Multiple known thoracic vertebral metastases are better assessed on recent MRI of the spine. IMPRESSION: 1. Destructive lesion centered in left iliac bone with soft tissue extension into the adjacent iliacus and gluteal musculature may represent metastatic disease but is also concerning for primary malignancy such as osteosarcoma. 2. Multiple hypoenhancing hepatic and splenic lesions concerning for metastases. 3. Retroperitoneal, mesenteric, and pelvic lymphadenopathy. Radiology Report EXAMINATION: CT guided biopsy INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD, anemia, enhancement of left iliac bone, destructive lesion of the clavicle, and spine with T5 lesion with severe cord compression, consistent with disease of unknown primary.// Liver lesion bx Note that the optimal site of biopsy was discussed with the primary team and a decision was made to obtain tissue from the large left iliac bone lesion. COMPARISON: CT abdomen pelvis ___ PROCEDURE: CT-guided left pelvic mass biopsy. OPERATORS: Dr. ___, radiology resident 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 CT scan table. Limited preprocedure CTscan of the intended biopsy area was performed. Based on the CT findings an appropriate position for the biopsy was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the lesion. An 18 gauge core biopsy device with a 22 mm throw was used to obtain three core biopsy specimens, which were sent for pathology. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.8 s, 25.4 cm; CTDIvol = 12.4 mGy (Body) DLP = 317.3 mGy-cm. 2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. 9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.3 mGy (Body) DLP = 3.9 mGy-cm. Total DLP (Body) = 349 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 1 mg Versed and 50 mcg fentanyl throughout the total intra-service time of 12 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: The large destructive lesion of the left iliac bone extending into the adjacent gluteal and iliacus musculature. IMPRESSION: Technically successful CT-guided biopsy of the soft tissue component of the large left iliac lesion. Radiology Report EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ ___ speaking male with a PMH of HTN, T2DM, HLD, anemia, enhancement of left iliac bone, destructive lesion of the clavicle, and spine with T5 lesion with severe cord compression, consistent with disease of unknown primary.// investigate primary lesion TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with intravenous infusion of nonionic, iodinated contrast agent, following oral administration of contrast agent for selected abdominal studies, and/or followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck will be reported separately. All images of the chest were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.0 s, 32.4 cm; CTDIvol = 11.0 mGy (Body) DLP = 348.9 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5 mGy-cm. 3) Stationary Acquisition 10.9 s, 0.2 cm; CTDIvol = 145.3 mGy (Body) DLP = 29.1 mGy-cm. 4) Spiral Acquisition 10.6 s, 68.9 cm; CTDIvol = 9.9 mGy (Body) DLP = 677.4 mGy-cm. 5) Spiral Acquisition 5.1 s, 32.9 cm; CTDIvol = 11.0 mGy (Body) DLP = 354.7 mGy-cm. Total DLP (Body) = 1,412 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS) COMPARISON: No prior chest CT scans available. This study should be read in conjunction with findings of extensive skeletal MR. ___: CHEST PERIMETER: There are no thyroid lesions warranting further imaging. Supraclavicular and and multiple subcentimeter left axillary and peripectoral lymph nodes are not pathologically enlarged. Findings below the diaphragm will be reported separately. CARDIO-MEDIASTINUM: Above a small hiatus hernia, esophagus is unremarkable. Atherosclerotic calcification is not apparent head neck vessels or coronary arteries. Aorta and pulmonary arteries are normal size and pericardium is physiologic. THORACIC LYMPH NODES: Enlarged as follows: Mediastinum, left upper paratracheal 11 mm, 06:17. Mediastinum, right lower paratracheal, 10 mm, left lower paratracheal, 11 mm, ___. Hilar nodes are not enlarged. LUNGS, AIRWAYS, PLEURAE: Mild bibasilar subpleural atelectasis. Tiny left pleural effusion. No measurable nodules or focal lung lesions of consequence. CHEST CAGE: Extensive malignant involvement of the thoracic spine, including moderate to severe compression of the T5 vertebral body, with invasion of neural elements is described in the report of the MRI performed ___. Additional chest cage skeletal lesions of note are a nondisplaced pathologic fracture mid body of the sternum with surrounding edema, expansile destruction, distal ___ of the left scapula, and permeative destruction of the body and tip of the left scapula, lateral aspect of at least one left middle rib and the manubrium manubrium. IMPRESSION: No evidence of primary it malignancy arising in the chest. Lungs essentially clear. Mild mediastinal lymph node enlargement, probably pathologic. No vital structures compromised. Extensive skeletal malignancy, detailed above. Important features of thoracic spine involvement are detailed report of the thoracic spine MRI performed on ___. Radiology Report EXAMINATION: T-SPINE IN O.R. INDICATION: T2-T9 fusion. COMPARISON: Preoperative MRI cervical spine ___. FINDINGS: 26 intraoperative images were acquired without a radiologist present. Images show posterior fusion of the upper to midthoracic spine, for pathologic fracture of T5. Total fluoroscopic time 28.1 seconds. IMPRESSION: Please refer to the operative note for details of the procedure. Radiology Report EXAMINATION: T-SPINE INDICATION: ___ year old man POD#3 T5 lami, T2-T7 posterior fusion// Postop eval, eval for retained drain TECHNIQUE: Frontal and lateral view radiographs of the thoracic spine. COMPARISON: Intraoperative images dated ___ IMPRESSION: The patient is status post T2 through T7 posterior fusion with vertical rods and transpedicular screws at T 2, T3, T4, T6 and T7. Re-demonstrated is a compression deformity of T5. There is no evidence of hardware related complications or interval change in alignment. Skin staples remain present. The visualized lungs are grossly apart from probable atelectasis seen in the left lung base. Radiology Report INDICATION: ___ year old man with DLBCL// please place DL chest port and leave both access for chemo blanch aware, plt 418, INR 1 COMPARISON: None TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr. ___, Interventional Radiology fellow performed the procedure. Dr. ___ supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 125mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service time of 56 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: 1 g of Ancef CONTRAST: None FLUOROSCOPY TIME AND DOSE: 1 minutes, 5 mGy PROCEDURE 1. Right internal jugular approach chest double lumen Port-a-cath placement PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. The right upper neck was examined under ultrasound, the internal jugular vein was atretic. Attempts to access the internal jugular vein at the level of the confluence with the subclavian vein were unsuccessful due to absence of a safe window. Under continuous ultrasound guidance, the patent right external jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced to make appropriate measurements for catheter length. The ___ wire was then passed distally into the IVC. Next, attention was turned towards creation of a subcutaneous pocket over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse incision was made and a subcutaneous pocket was created by using blunt dissection. The double lumen port was then connected to the catheter. The catheter was tunneled from the subcutaneous pocket towards the venotomy site from where it was brought out using a tunneling device. The port was then connected to the catheter and checks were made for any leakage by accessing the diaphragm using a non-coring ___ needle. No leaks were found. The port was then placed in the subcutaneous pocket and secured with ___ prolene sutures on either side. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the port was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-strips were used to close the venotomy incision site. Steri-Strips were applied over the sutures. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The port was accessed using a non coring ___ needle and could be aspirated and flushed easily. Sterile dressings were applied. The patient tolerated the procedure well without immediate complication. The port was left accessed as requested. FINDINGS: Patent right internal jugular vein. Final fluoroscopic image showing port with catheter tip terminating in the right atrium. IMPRESSION: Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology Report EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ year old man with s/p spine surgery ___ new dx of DLBCL with altered sensation in LLE.// ?DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, color flow, and spectral doppler 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. Radiology Report EXAMINATION: CT PELVIS W/CONTRAST INDICATION: ___ year old man with new dx DLBCL s/p T5 lamenectomy and T2-T7 fusion ___ with worsening L leg pain// ?fluid collection, new lesions TECHNIQUE: Multidetector CT images of the pelvis were acquired with intravenous contrast. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 15.0 s, 64.9 cm; CTDIvol = 9.3 mGy (Body) DLP = 595.2 mGy-cm. Total DLP (Body) = 595 mGy-cm. COMPARISON: Abdominal pelvis CT from ___ FINDINGS: PELVIS: The partially visualized small and large bowel are unremarkable. The urinary bladder and distal ureters are unremarkable. There is air gas in the bladder likely related to recent manipulation. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: Unchanged large retroperitoneal and left iliac adenopathies. A right para-aortic lymph node measures 16 x 21 mm (series 3, image 5). A left internal iliac adenopathy measures 31 x 21 mm (series 3, image 53). A left external iliac adenopathy measures 19 x 14 mm (series 3, image 47). Other abnormal external iliac nodes are also noted on images 50 and 55 of series 3. No new adenopathy in the interim. VASCULAR: Mild atherosclerotic disease is noted. BONES: Again noted is an extensive lytic aspect of the left iliac bone extending to the left superior ramus pubic. There is a large soft tissue component around the left iliac bone measuring 13.1 x 8.6 cm which is grossly unchanged from recent prior. In the distal diaphysis of the left femur, there is also an endosteal scalloping with intramedullary soft tissue extending on 8.8 cm concerning for a distal bone metastasis. No pathological fracture. No soft tissue component. SOFT TISSUES: Diffuse subcutaneous edema. IMPRESSION: 1. Overall unchanged large destructive lytic lesion encompassing the left hemipelvis. This was characterized CT examination from ___ and biopsied on that same day, with pathology consistent with known DLBCL. 2. The patient is at high risk for left iliac pathologic fracture from normal weight bearing. Recommend orthopedic consultation regarding weight bearing restrictions. 3. Additional metastasis in the distal left femur is also noted. 4. Metastatic left iliac and retroperitoneal adenopathy are again noted. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:43 pm, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS INDICATION: ___ year old man with DLBCL with L Hip Lesion// ? pathological fracture A/P pelvis and L hip TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of bilateral hips. COMPARISON: CT pelvis ___. IMPRESSION: There are extensive lytic lesions in the left ilium, ischium and pubic bones. Additional lytic lesions are also seen in the right inferior trochanteric region and proximal left femur. There is a pathological fracture through the right lesser trochanter with superior and anterior displacement. No acute fracture is seen in the left hip or pelvis. There is no evidence of dislocation. There are mild degenerative changes in the bilateral hips and lower lumbar spine. Radiology Report INDICATION: ___ year old man with DLBCL s/p EPOCH// s/p vincristine dilated loops of bowel? TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: Prior CT abdomen pelvis from ___ FINDINGS: Supine portable AP view of the abdomen provided. Bowel gas pattern is unremarkable showing no signs of ileus or obstruction. Fecal loading is moderate. Bony structures are intact. No worrisome calcification. IMPRESSION: Unremarkable. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with DLBCL s/p EPOCH// ?PNA ?PNA IMPRESSION: Heart size and mediastinum are stable. Spinal hardware has been inserted in the interim. Lungs overall clear. There is no pneumothorax. There is no appreciable pleural effusion. Central venous line tip terminates in the proximal right atrium. No pulmonary edema. No pleural effusion. No pneumothorax. Radiology Report EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: ___ year old man with DBLCL s/p T5 lamenectomy and T2-T5 fusion with L leg weakness// s/p T5 lamenectomy and T2-T5 fusion with L leg weakness. TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: 1. Thoracic spine radiographs ___. 2. MRI total spine ___. 3. CT total spine ___. FINDINGS: CERVICAL: Alignment is normal. Vertebral heights are maintained. Marrow signal is unremarkable. Cervical spinal cord is normal in caliber and signal intensity. There is no abnormal cervical spine enhancement or epidural collection. There are mild to moderate cervical spine degenerative changes. C2-3: Unremarkable. C3-4: There is a right paracentral disc protrusion at C3-4 causing mild spinal canal narrowing, contacting and remodeling the ventral spinal cord (09:13). No neural foraminal narrowing. C4-5: There is a posterior disc osteophyte complex at C4-5 causing mild spinal canal narrowing and slight cord remodeling. Uncovertebral and facet osteophytes cause mild-to-moderate bilateral neural foraminal narrowing. C5-6: Mild posterior disc bulge causes mild spinal canal narrowing. Moderate right and mild left neural foraminal narrowing due to uncovertebral and facet osteophytes. C6-7: Unremarkable. C7-T1: Unremarkable. There is mild edema in the lower cervical spine posterior paraspinal musculature. Otherwise, the cervical prevertebral and paraspinal soft tissues are unremarkable. THORACIC: There are new postsurgical changes from interval T5 laminectomy and T2-T7 posterior spinal fusion with bilateral vertical rods and transpedicular screws. Hardware artifact somewhat limits evaluation of adjacent structures. Within these confines: Alignment is within normal limits. There is unchanged moderate anterior height loss of T5. Remaining vertebral body heights are maintained. There is unchanged T2/STIR hyperintense, T1 hypointense, enhancing marrow signal within the T3, T4, T5, and T6 vertebral bodies. Abnormal, expansile signal is again seen extending into the remaining T5 posterior elements. The STIR hyperintense, enhancing lesion seen involving the posterior half of the T11 vertebral body extending into the pedicles, laminae, and spinous process, consistent with metastasis, is unchanged. There may be slight posterior epidural soft tissue extension of tumor on the right into the anterior epidural space, similar in appearance to prior. There is an equivocal short-segment focus of abnormal cord signal in the right aspect of the spinal cord at the level of T5 at the prior compression (series 10, image 23 as well as series 3, image 9, 6:9). The remainder of the thoracic spinal cord appears normal in caliber and signal intensity, within limitations detailed above. Previously severe spinal canal narrowing at T5 is markedly improved, with the central spinal canal now widely patent at this level. There is no longer any discernible cord compression at any level. No discernible high-grade spinal canal narrowing the thoracic spine. There is unchanged obliteration of the left T4-5 and bilateral T5-6 neural foraminal due to soft tissue extension of T5 tumor. This also causes unchanged mild right T4-5 neural foraminal narrowing. There is also unchanged moderate right T10-11 and mild right T11-12 neural foraminal narrowing due to tumor involvement of the right T11 pedicle and pars (8:5). Spanning essentially the entire length of the posterior spinal fusion hardware is a posterior soft tissue midline fluid collection with peripheral rim enhancement spanning up to 13.9 by 4.4 x 3.7 cm (SI by TV by AP) (6:10 and 10:7, 16:7). The collection overlies the midline laminectomy and extends superiorly along the course of the hardware. There is no evidence of contiguity with the thecal sac. There is no evidence of an epidural fluid collection. LUMBAR: Alignment is normal. Vertebral heights maintained. Marrow signal is normal. The distal spinal cord and conus medullaris is normal and terminates at L1. The cauda equina nerve roots are normal. There is no abnormal lumbar spine enhancement. There is no lumbar spine epidural collection. Mild signal loss of the L3-4 intervertebral disc is consistent with degenerative change. Mild posterior disc bulge, ligamentum flavum thickening and small facet osteophytes at L4-5 cause minimal spinal canal and subarticular zone narrowing. There is no significant neural foraminal narrowing in the lumbar spine. There is a moderate amount of dependent subcutaneous edema overlying the lumbar spine. Otherwise, the lumbar prevertebral and paraspinal soft tissues are unremarkable. OTHER: There is a small layering left pleural effusion and adjacent atelectasis. IMPRESSION: 1. Interval resolution of previously severe spinal canal narrowing and cord compression at T5 due status post interval T5 laminectomy and posterior spinal fusion, T2-T7. There is no longer any identifiable high-grade spinal narrowing, nor any spinal cord compression. 2. Possible short-segment cord signal abnormality in the right aspect of the cord at the level of T5 at the area prior compression, although cord is somewhat obscured due to mild artifact from hardware. 3. Re-demonstration of probable metastatic lesions within the T3-T6 vertebral bodies, with moderate height loss of T5, unchanged. 4. Unchanged T11 probable metastatic lesion. 5. Unchanged obliteration of the left T4-5 and bilateral T5-6 neural foramina due to soft tissue extension of T5 tumor. 6. Mild right C4-5, moderate right T10-11, and mild right T11-12 neural foraminal narrowing is unchanged. 7. No evidence of cervical or lumbar spine metastasis. 8. Small left layering pleural effusion. Radiology Report EXAMINATION: MR PELVIS WANDW/O CONTRAST INDICATION: ___ year old man with DBLCL s/p T5 lamenectomy and T2-T5 fusion with L leg weakness// s/p T5 lamenectomy and T2-T5 fusion with L leg weakness, DLBCL? TECHNIQUE: Multiplanar imaging the pelvis was obtained with and without contrast using a mass/infection protocol. COMPARISON: Radiograph on ___, CT pelvis on ___, CT abdomen and pelvis on ___ FINDINGS: Again seen is extensive lymphomas involvement of the pelvic bones. There is a large lesion centered in the left iliac wing with extension into the left superior sacral ala, ilium and inferior pubic ramus with a soft tissue component extending into the adjacent musculature including the iliacus, obturator internus, piriformis, and overlying gluteal musculature. There is altered bone marrow signal indicative of tumor involvement of the adjacent left hemi sacrum, however there is no evidence of tumor invasion into the left sacral neuroforamen. Soft tissue component of this mass abuts a portion of the left sciatic nerve which has surrounding edema, however the nerve does not appear to be invaded, with a preserved fat plane between the nerve and the mass. There is diffuse edema in the left hip musculature, with partial-thickness tears of the distal gluteus medius and minimus, as well as obturator internus and piriformis. The iliotibial band is partially torn and retracted off its insertion on the iliac crest which is invaded with tumor. There is edema in the left iliopsoas which may be partially injured. There is cortical destruction at the ischial tuberosity at the insertion of the hamstring tendon, however there is no full-thickness retracted tendon tear. There is associated mild-to-moderate left greater trochanteric bursitis. There is an additional lesion in the left femoral diaphysis (10:17). No pathologic fracture in the visualized portion of the femur. There are lesion right iliac bone extending to the mid to inferior sacroiliac joint, and in the right lesser trochanter with an associated pathologic avulsion fracture with anterior and superior displacement of the fractured component of the lesser trochanter (09:32). There is associated edema and hematoma distal to the fracture fragment, and edema within the iliopsoas tendon. There is edema in the right hip musculature, slightly less prominent than on the left, including a partial tear of the gluteus minimus tendon. Mild right greater trochanter bursitis. There is left pelvic sidewall lymphadenopathy, the largest lymph node measuring 3.0 x 2.1 cm, not significantly changed. IMPRESSION: 1. Extensive tumor involvement in the pelvis, with replacement of nearly the entire left hemipelvis by a large destructive lesion centered in the left iliac wing. A soft tissue component of the mass is within the vicinity of the sciatic nerve, however the nerve does not appear to be invaded. There is bone marrow involvement in the left hemi-sacrum, however there does not appear to be invasion of the sacral neuroforamen. 2. Bone marrow replacing lesion in the left femoral diaphysis. 3. Bone marrow replacing lesion in the right iliac bone extending to the mid to inferior aspect of the right SI joint as well as a lesion in the right lesser trochanter with redemonstration of a pathologic avulsion fracture at the right trochanter. 4. Extensive muscular edema in the bilateral hips, left greater than right, including partial tears of the left gluteus tendons, avulsion of the proximal left iliotibial band and partial-thickness injury of the distal right gluteus minimus tendon. Associated left greater than right greater trochanteric bursitis. 5. Left pelvic sidewall lymphadenopathy, not significantly changed. Radiology Report EXAMINATION: T-SPINE INDICATION: 66 with thoracic lesions and a T5 pathologiccompression fracture underwent a T5 laminectomy with T2-T7 posterior instrumentation and fusionon ___, now with worsening left leg weakness, pls assess for hardware malfunction// 66 with thoracic lesions and a T5 pathologiccompression fracture underwent a T5 laminectomy with T2-T7 posterior instrumentation and fusionon ___, now with worsening left leg weakness, pls assess for hardware malfunction TECHNIQUE: AP and lateral views of the thoracic spine COMPARISON: Chest radiograph obtained on the same date, thoracic spine radiographs ___ FINDINGS: Patient is status post posterior stabilization from approximately T2-T7 with an unchanged compression deformity at T5 level. Surgical hardware appears intact and unchanged in position when compared to the prior study. A dual lumen Port-A-Cath right internal jugular Port-A-Cath terminates in the cavoatrial junction. Chronic fracture of the right clavicle. Heterogenous appearance of the left clavicle. IMPRESSION: Postoperative changes as described. Radiology Report EXAMINATION: CR - CHEST PORTABLE AP INDICATION: ___ w/ HTN, DM2 who p/w LLE pain and weakness, found to have DLBCL with masses in thoracic spine w/ T5 pathologic compression fracture now s/p T5 laminectomy and T2-T7 fusion. SP C1 EPOCH. New hypotension// eval hypotension, infection TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: There is a right chest wall Port-A-Cath with the tip terminating in the upper right atrium. Linear opacities in the lung bases most likely represent subsegmental atelectasis. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable in appearance. There is posterior spinal fusion hardware in the upper thoracic spine. Radiology Report EXAMINATION: US UPPER BACK, SOFT TISSUE INDICATION: ___ year old man with DLBCL s/p T5 laminectomy, T2-T7 fusion on ___ now with new tender mass adjacent to incision.// ?new mass next to surgical incision on right thoracic back. ?fluid collection, new lymphoma TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the midline upper back in the region of a surgical incision. COMPARISON: MRI spine dated ___. FINDINGS: There is a heterogenously echogenic avascular collection in the subcutaneous tissues along the entire duration of the surgical incision measuring 2.7 x 20 x 5.7 cm. IMPRESSION: Heterogeneously echogenic, avascular collection in the subcutaneous tissues along the surgical incision may reflect a hematoma, more completely evaluated on the recent MRI. Superinfection cannot be excluded. Radiology Report EXAMINATION: CT T-SPINE W/ CONTRAST Q322 CT SPINE INDICATION: ___ year old man with DLBCL s/p T5 lamenectomy and T2-T7 fusion w/new mass on right of healing incision// pls eval mass adjacent to surgical incision. ?fluid collection ?mass pls eval mass adjacent to surgical incision. ?fluid collection ?mass TECHNIQUE: Non-contrast helical multidetector CT was performed after the intravenous administration of Omnipaque contrast agent. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Please see concurrently obtained contrast cervical spine CT report for dose information. COMPARISON: CT T-spine ___. Soft tissue ultrasound ___. MR spine ___. FINDINGS: Study is limited secondary to patient body habitus and spinal fusion hardware streak artifact. Levels were established by counting down from the C2 level using concurrently obtained cervical spine CT series 7. There is dextroscoliosis of the thoracic spine. Patient is status post T2-T7 fusion with T5 laminectomy. Metallic hardware are present along the posterior aspect the spinous processes of T2 through T7, with parallel rods oriented cranial caudally and pedal screws at T2, T3, T4 T6, and T7. The screws appear to be positioned intraosseously without definite evidence of adjacent lucency. There is no definite evidence of hardware fracture. There is diffuse metastatic osseous involvement of the bilateral clavicles, sternum, thoracic vertebral bodies, and left scapula. Within the lateral aspects of the bilateral clavicles, there is soft tissue destruction with associated comminuted fractures. There is compression deformity of the vertebral body of T5, similar in extent to prior MR with cortical irregularity, again suggestive of metastatic disease. There is no evidence of bony thoracic spinal canal narrowing. There is grossly stable osseous narrowing at the left T4-5 and bilateral T5-6 neural foramina due to osseous disease. The disc heights are grossly preserved. There is no prevertebral soft tissue swelling. In the soft tissue overlying the thoracic spine surgical bed, there is a large hypodense homogeneous fluid collection with a peripheral rim of calcification. The most superior extent of this fluid collection is not fully captured on current study, but is included on concurrently obtained cervical spine CT. The fluid collection extends from the C7 spinous process to T9 spinous process, measuring and measures 6.0 x 5.7 cm in its largest axial plane, and appears to have had interval enlargement since prior MR. ___: Within the visualized mediastinum, there are several conspicuous although not pathologically enlarged lymph nodes in the paratracheal and paraesophageal regions. However, there appears to have been interval growth of the largest lymph node in the left paraesophageal region (Series 8, image 27) now measuring 11 mm, previously 9 mm on prior CT T-spine. However, the remainder of the lymph nodes appear unchanged to minimally decreased in size from prior. A central venous catheter is seen terminating in the right atrium. Within the visualized lung fields, the left major fissure appears mildly thickened, new since prior exam. Within the visualized abdomen, there is a 1.0 x 1.8 cm rounded region of hypodensity adjacent to the right posterior portal vein (series 8, image 89), not well evaluated on prior exam. There are 2 additional subcentimeter regions of hypodensity within the right posterior segment of the liver. There is also mild thickening of the body of the left adrenal gland, not significantly changed since prior exam. There is a tiny 6 mm hypodense rounded structure within the lower pole left kidney (series 8, image 143), too small to characterize. IMPRESSION: 1. Study is limited secondary to patient body habitus and spinal fusion hardware streak artifact. 2. Postsurgical changes related to T2-T7 fusion with T5 laminectomy. 3. Interval enlargement of fluid collection overlying the thoracic spine surgical bed compared to prior MR, the superior extent of which is incompletely imaged, but extends inferiorly to the spinous process of T9. While findings may represent postoperative seroma, differential considerations of hematoma, or infectious or inflammatory etiologies are not excluded on the basis of this examination. If clinically indicated, consider correlation with fluid sampling. Recommend follow-up imaging to resolution. 4. Diffuse metastatic osseous involvement of the bilateral clavicles, sternum, thoracic vertebral bodies, and left scapula, with soft tissue destruction of the bilateral clavicles with associated comminuted fractures as described. 5. Grossly stable narrowing at the left T4-5 and bilateral T5-6 neuroforamina, better demonstrated on recent full spine MRI. 6. Left paraesophageal lymphadenopathy, with additional nonspecific mediastinal lymph nodes as described. Differential considerations include infectious, inflammatory, and neoplastic etiologies. 7. New thickening along the left major fissure. If clinically indicated, consider correlation with dedicated chest imaging. 8. Several regions of hypodensity within the visualized liver, which were not well evaluated on prior imaging studies. If concern for hepatic metastatic lesions, consider hepatic MRI for further evaluation. 9. Please see concurrently obtained cervical spine and lumbar spine CT reports for description of cervical and lumbar findings. RECOMMENDATION(S): Interval enlargement of fluid collection overlying the thoracic spine surgical bed compared to prior MR, the superior extent of which is incompletely imaged, but extends inferiorly to the spinous process of T9. While findings may represent postoperative seroma, differential considerations of hematoma, or infectious or inflammatory etiologies are not excluded on the basis of this examination. If clinically indicated, consider correlation with fluid sampling. Recommend follow-up imaging to resolution. Radiology Report EXAMINATION: CT C-SPINE W/CONTRAST Q312 CT SPINE INDICATION: ___ year old man with DLCBL, s/p spine surgery// ?interval change TECHNIQUE: Non-contrast helical multidetector CT was performed after the intravenous administration of Omnipaque contrast agent. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.5 s, 23.8 cm; CTDIvol = 20.4 mGy (Body) DLP = 491.9 mGy-cm. 2) Spiral Acquisition 6.9 s, 36.6 cm; CTDIvol = 23.8 mGy (Body) DLP = 879.0 mGy-cm. 3) Spiral Acquisition 5.2 s, 27.6 cm; CTDIvol = 23.8 mGy (Body) DLP = 664.5 mGy-cm. Total DLP (Body) = 2,035 mGy-cm. COMPARISON: ___ contrast full spine MRI. ___ noncontrast cervical spine CT. FINDINGS: Spinal fusion hardware artifact and patient body habitus limits examination. Vertebral body alignment is preserved. Vertebral body heights are preserved. No definite acute cervical spine fracture is identified. Partially visualized is patient's known thoracic spine posterior fusion with transpedicular screws and rods imaged at T2 and T3 levels. Within limits of study, there is no definite evidence of spinal fusion hardware fracture or perihardware lucency. Grossly stable probable degenerative calcification posterior dens is grossly unchanged, and again demonstrates well corticated margins. Multilevel degenerative changes of the cervical spine are again noted, better demonstrated on 2 week prior full spine MRI. There is no definite evidence of bony vertebral canal narrowing. There is no prevertebral soft tissue swelling. OTHER: Again partially imaged is patient's known left midclavicle destructive lesion. There is no definite evidence of paravertebral or paraspinal enhancing mass. Atherosclerotic vascular calcifications are seen in bilateral carotid bifurcations. Approximately 1 cm right supraclavicular node with suggested central low density is noted (see 4:93). IMPRESSION: 1. Patient body habitus and partially visualized thoracic spinal fusion hardware limits examination. 2. Within limits of study, no definite evidence of acute cervical spine fracture. 3. Multilevel cervical spondylosis, better evaluated on ___ full spine contrast MRI. 4. Partially visualized clavicles again demonstrate left midclavicle destructive lesion. 5. Approximately 1 cm right supraclavicular lymph node with findings concerning for malignancy, as described. 6. Within limits of study, no definite evidence of enhancing paravertebral or paraspinal mass. 7. Please see concurrently obtained contrast lumbar spine CT for description of lumbar spine structures. Radiology Report EXAMINATION: CT L-SPINE W/ CONTRAST Q332 CT SPINE INDICATION: ___ year old man with DLCBL, s/p spine surgery. TECHNIQUE: Contrast enhanced helical multidetector CT was performed without contrast. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Please see concurrently obtained cervical spine CT report. COMPARISON: ___ total spine MRI ___ pelvic MRI ___ total spine MRI ___ lumbar spine CT FINDINGS: For the purposes of numbering, the lowest rib bearing vertebral body was designated the T12 level. Vertebral body alignment is preserved. Vertebral body heights are preserved.No definite lumbar spine fractures are identified.There is no prevertebral soft tissue swelling. Multilevel degenerative changes of the lumbar spine are again noted, better demonstrated on ___ full spine MRI. OTHER: A partially imaged large mass replacing most of the partially imaged left iliac bone is better assessed on MRI obtained 1.5 weeks prior, but much more lucent than 1 month prior. Compared to the ___ lumbar spine CT, there is a new nondisplaced pathologic fracture extending throughout the imaged portion of the left iliac bone, possibly into the superior left acetabulum. Metastases in the sacrum and right iliac bone are not well appreciated on CT, which may be related to differences in technique. A partially necrotic left external iliac lymph node has decreased in size and measures 1.5 cm, 1.8 cm 1 month prior and 2.1 cm 1.5 weeks prior. An aortocaval lymph node has decreased in size and measures 0.7 cm, 1.7 cm 1 month prior. Small periampullary duodenal diverticulum. Atherosclerotic vascular calcifications noted. IMPRESSION: 1. New pathologic left iliac bone fracture likely extending into the superior acetabulum. The large underlying metastatic lesion is better characterized on pelvic MRI obtained 1.5 weeks prior. 2. Sacral and right iliac bone metastases are not definitely seen on current examination, which may be related to differences in technique. 3. Necrotic lymphadenopathy as described. 4. Multilevel lumbar spondylosis without definite evidence of moderate or severe bony vertebral canal narrowing, better evaluated on ___ full spine MRI. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:13 pm, approximately 30 minutes after discovery of the findings. Radiology Report EXAMINATION: Ultrasound-guided aspiration INDICATION: ___ year old man with DLBCL s/p t5 lamenectomy and t2-t7 fusion. Developed a egg shaped lump to R of incision which then progressed to half way up incision and to L of incision. It is tender, but w/o erythema or overlying edema. NSGY c/f infection we are requesting stat drain and fluid culture.// please drain and culture fluid collection on back to the right of healing surgical incision. COMPARISON: Prior CTs and ultrasounds of the upper back, most recent ___.. PROCEDURE: Ultrasound-guided aspiration of superficial dorsal collection. OPERATORS: Dr. ___, radiology trainee and Dr. ___, ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a left lateral position on the bed. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the aspiration was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, a sample of fluid was aspirated using an 18 gauge needle. Approximately 10 cc of serosanguineous fluid was drained with a sample sent for microbiology evaluation and cultures. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: None. FINDINGS: Complex Fluid collection in the right paraspinal dorsal chest wall is previously depicted by a thoracic spine CT from ___, suggestive of a hematoma. IMPRESSION: Successful US-guided aspiration of a heterogeneous Fluid collection in the dorsal chest wall. Radiology Report EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder pain, fall.// eval fracture, bleed, infection TECHNIQUE: frontal, lateral and oblique views of the left shoulder. COMPARISON: None. FINDINGS: There is a destructive osseous process of the left mid to distal clavicle with likely underlying fracture/comminution. A left posterolateral sixth rib deformity, likely representing an healing fracture, is better assessed on dedicated chest radiograph. There is no dislocation involving the glenohumeral or AC joint. There are moderate degenerative changes. No periarticular calcification or radio-opaque foreign body is seen. IMPRESSION: 1. Destructive left mid/distal clavicle osseous process, with likely underlying fractures. 2. Age-indeterminate, left posterolateral sixth rib deformity likely representing a healing fracture is better assessed on dedicated chest radiograph. Radiology Report EXAMINATION: CHEST (SINGLE VIEW) INDICATION: ___ with severe diffuse weakness, T spine tenderness, L shoulder pain, fall.// eval fracture, bleed, infection TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Lung volumes are well expanded. There is bibasilar atelectasis. Otherwise, no large consolidation. The cardiomediastinal silhouette is mildly enlarged. No large appreciable pneumothorax or pleural effusions. There is a step-off of the posterolateral left sixth rib which likely represents an old fracture. The left mid/distal clavicle destructive osseous process better evaluated on thoracic spine CT and dedicated glenohumeral radiograph from same day. IMPRESSION: 1. Left mid/distal clavicle destructive osseous process better evaluated on thoracic spine CT and dedicated glenohumeral radiograph from same day. 2. Bibasilar atelectasis and mild cardiomegaly. Gender: M Race: ASIAN Arrive by WALK IN Chief complaint: Pelvic pain, Weakness Diagnosed with Oth fracture of T5-T6 vertebra, init for clos fx, Unspecified fall, initial encounter temperature: 97.1 heartrate: 107.0 resprate: 18.0 o2sat: 98.0 sbp: 141.0 dbp: 63.0 level of pain: 5 level of acuity: 2.0

Dear Mr ___, It was a privilege caring for you at ___. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL? - For left leg weakness WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You had spine surgery due to your leg weakness - We found that your leg weakness was due to lymphoma pressing on your spine - We also found lymphoma lesions in other parts of your body, the largest lesion in your left hip which resulted in a fracture. - We started treatment for your lymphoma with chemotherapy - We worked with the neurosurgery, orthopedic oncology, radiation oncology, ___ (diabetes management), and physical therapy to coordinate your care. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - You will have radiation to help treat your cancer - Seek medical attention if you have new or concerning symptoms or you develop new pain, worsening pain in your hip/legs, weakness in your legs, changes in your vision, fever/chills. It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team Surgery •Do not apply any lotions or creams to the site. •Please avoid swimming for two weeks after staple removal. •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. ___ 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. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc… until cleared by your neurosurgeon. •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. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •New weakness or changes in sensation in your arms or legs.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ ___ prostate CA sp radical prostatectomy, salvage radiation and chemotherapy for rising PSA although with negative PET and bone scan in ___ presents with right sided LBP for approximately 10 days radiating to RLE. Patient states that on ___ he went to bend over and pick something up when he experienced acute onset of a "popping" sensation along with lower back pain located in the right paraspinal region. This pain had some radiation into the right hip down along the anterior thigh to about the level of tyhe knee. Took ibuprofen with some relief. Reports pain has returned and has gotten worse last few days, worse with standing. Reports ___ pain at rest up to ___ with ambulation. No loss of bowel or bladder, no other complaints. Initial Vitals in the ED were 97.8 74 145/84 18 100% RA. Plain spine films showed no sign of acute fracture or other abnormality. received Percocet 2 tabs - minimal relief. Received IV toradol, morphine pain improved but still with difficulty ambulating. In the ED exam was notable for minimal right sided paraspinal tenderness in the L-spine region, no midline spinous process tenderness. Negative straight leg raise bilaterally, good rectal tone. Extreme discomfort with ambulation. will be admitted for pain control and ___. Vitals prior to transfer to floor were: pain ___ 97.8 81 133/73 18 100% On arrival to the floor, reports pain ___ but ___ when stands up. no other complaints. REVIEW OF SYSTEMS: (+) as in 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: Gout HL HTN prostate cancer s/p radical prostatectomy, salvage radiation and chemotherapy HCV - treated/cured per patient Social History: ___ Family History: Father had CABG in ___. Physical Exam: Admission Exam GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) LYMPH - no cervical LAD SPINE - mild left sided sacral paraspinal tenderness, no midline tenderness. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, standing up painful back. straight leg raising test bilaterally negative. feels some pain at the very low back right sided when checking for hip flexion on the right side. Discharge Exam VS - 98.4, BP 94/58, HR 53, R 18, O2-sat 98% RA pain ___ GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear NECK - supple 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 rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SPINE - mild left sided sacral paraspinal tenderness, no midline tenderness. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric. straight leg raising test bilaterally negative. no pain on bilateral hip abduction/adduction, flexion/extension. Pertinent Results: LABORATORY DATA ___ 08:40AM BLOOD WBC-4.9 RBC-4.61 Hgb-14.2 Hct-41.4 MCV-90 MCH-30.7 MCHC-34.2 RDW-14.3 Plt ___ ___ 08:40AM BLOOD Glucose-122* UreaN-17 Creat-1.2 Na-140 K-3.8 Cl-102 HCO3-26 AnGap-16 ___ 08:40AM BLOOD estGFR-Using this ___ 08:40AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2 ___ 07:10PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG IMAGING ___ LUMBO-SACRAL SPINE (AP & LAT) FINDINGS: Frontal and lateral views the lumbar spine: There are 5 non rib-bearing lumbar like vertebrae. There is no fracture or malalignment. Mild degenerative changes of the lower lumbar spine are noted with loss of intervertebral disc height seen between L5-S1. Clips within the pelvis from prior prostatectomy are noted. Calcifications within the aorta are seen. There is a nonobstructive bowel gas pattern. IMPRESSION: No evidence of acute fracture. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. ALPRAZolam 0.5-1 mg PO QHS:PRN sleep disturbance 4. Aspirin 81 mg PO DAILY 5. Bicalutamide 50 mg PO DAILY 6. Citalopram 10 mg PO DAILY 7. Ibuprofen 200 mg PO QHS:PRN pain 8. Lisinopril 20 mg PO DAILY 9. Lorazepam 1 mg PO HS:PRN insomnia 10. Multivitamins 1 TAB PO DAILY 11. Pravastatin 40 mg PO DAILY 12. Prochlorperazine 10 mg PO Q6H:PRN nausea 13. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 14. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. ALPRAZolam 0.5-1 mg PO QHS:PRN sleep disturbance 3. Aspirin 81 mg PO DAILY 4. Citalopram 10 mg PO DAILY 5. Colchicine 0.6 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Lorazepam 1 mg PO HS:PRN insomnia 8. Multivitamins 1 TAB PO DAILY 9. Pravastatin 40 mg PO DAILY 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 12. Acetaminophen 1000 mg PO Q8H pain RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day Disp #*90 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. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain RX *oxycodone 10 mg 1 tablet(s) by mouth four times a day Disp #*40 Tablet Refills:*0 15. Bicalutamide 50 mg PO DAILY 16. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm 17. Ibuprofen 800 mg PO Q8H pain Duration: 5 Days This medication can cause stomach upset so you should take it with food. You should only take it around the clock for 5 days. If you notice any black or bloody stools, stop taking the medication and seek medical attention immediately. RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp #*15 Tablet Refills:*0 18. Outpatient Physical Therapy. Evaluate and treat for acute lower back pain. Discharge Disposition: Home Discharge Diagnosis: PRIMARY Acute lower back pain SECONDARY Prostate cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report HISTORY: Prostate cancer status post radical prostatectomy with rising PSA now with acute right-sided low back pain. COMPARISON: None. FINDINGS: Frontal and lateral views the lumbar spine: There are 5 non rib-bearing lumbar like vertebrae. There is no fracture or malalignment. Mild degenerative changes of the lower lumbar spine are noted with loss of intervertebral disc height seen between L5-S1. Clips within the pelvis from prior prostatectomy are noted. Calcifications within the aorta are seen. There is a nonobstructive bowel gas pattern. IMPRESSION: No evidence of acute fracture. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: TRAUMATIC BACK/SPINE INJURY Diagnosed with LUMBAGO temperature: 97.8 heartrate: 74.0 resprate: 18.0 o2sat: 100.0 sbp: 145.0 dbp: 84.0 level of pain: 9 level of acuity: 3.0

Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. You were admitted to the hospital for acute lower back pain and difficulty walking. Your pain was controlled with medications and you were evaluated by physical therapy, who determined that you need to start outpatient physical therapy as soon as possible. It is important that you do not take lorazepam, alprazolam, cyclobenzaprine, and oxycodone at the same time, as all of these medications can cause drowsiness, and they potentiate each other's effects. DO NOT TAKE THESE MEDICATIONS BEFORE DRIVING.

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: peanuts Attending: ___. Chief Complaint: PICC line removed Major Surgical or Invasive Procedure: ___ PICC line placement (___) History of Present Illness: This is a ___ with a PMHx of IDDM, HTN, s/p MVA with head plate, s/p cholecystectomy c/b biliary duct leak and stent placement, who presented to the ___ ED because of inadvertent PICC line removal. Around 9pm on ___ the staff found the patient with PICC line on his chest. He has never moved it before. There was no bleeding. He had a prolonged admission from ___ for incarcerated periumbilical hernia with high-grade obstruction. His hospital course was complicated by sepsis secondary to bowel perforation and he underwent small bowel resection. He had a PICC line placed for TPN. He takes very minimal PO intake on his own and per daughter and staff at nursing facility, he would not want an NG tube. In the ED: - Initial vitals at 22:55 on ___ were T 98.2 HR 80 BP 133/77 RR 18 SpO2 97% - Labs notable for: glucose of 206. - ___ RN was unsuccessfuly placing the PICC line. She recommended admission, and if the PICC line does not readjust by morning, would need ___. - Pt given: ___ 05:59 IVF 1000 mL ___ @ 100 mL/hr ___ 08:49 PO/NG Lisinopril 2.5 mg ___ 08:49 PO/NG Sertraline 50 mg ___ 08:49 PO/NG Aspirin 81 mg ___ 08:49 PO/NG Metoprolol Tartrate 25 mg - Vitals prior to transfer: T 98.8 HR 77 BP 143/66 RR 16 SpO2 98%RA On arrival to the floor, patient is asked why he is here and says "I think I am sick." He says he feels cold. He reports no pain or other symptoms. Denies fever, chills, shortness of breath, chest pain, abdominal pain, nausea/vomiting, diarrhea/constipation and urinary symptoms. Says he walks without assistance. Past Medical History: Type II diabetes mellitus Hypertension Benign prostatic hypertrophy Mild dementia s/p MVA with plate in the head s/p cholecystectomy, complicated by biliary duct leak requiring ERCP and stent insertion Social History: ___ Family History: Noncontributory. Physical Exam: On Admission: Vitals- T 98.3 BP 132/68 HR 82 RR 20 O2 97%RA General- Alert, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear. 2cm keratotic papule on R side of face. Neck- supple, JVP not elevated Lungs- CTAB no wheezes, rales, rhonchi CV- Regular rate and rhythm, ___ holosystolic murmur Abdomen- soft, NT/ND, normoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly; horizontal surgical incision with 2 areas that probe 0.5cm deep, some granulation tissue, no surrounding erythema or pus GU- no foley. Patient has diaper. Ext- warm, well perfused, no clubbing, cyanosis or edema; RUE PICC is c/d/i Neuro- EOMI, tongue midline, face symmetric, motor function grossly normal. Oriented to self, but not time or place (thought year was ___, place was ___. On Discharge: Vitals- T 97.3-98.3 BP 95-148/65-70 HR ___ RR ___ O2 93-96%RA BS 104//124 General- Alert, no acute distress, lying comfortably under blankets HEENT- Sclerae anicteric, MMM, oropharynx clear. 2cm hyperkeratotic patch on R side of face (patient says this is longstanding). Neck- supple, JVP not elevated Lungs- Mild bibasilar rales, no wheezes or rhonchi CV- Regular rate and rhythm, ___ holosystolic murmur Abdomen- soft, NT/ND, normoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly; horizontal surgical incision with 2 areas that probe 0.5cm deep, some granulation tissue, no surrounding erythema or pus GU- no foley. Patient has diaper. Ext- warm, well perfused, no clubbing, cyanosis or edema; RUE PICC is c/d/i Neuro- EOMI, tongue midline, face symmetric, motor function grossly normal. Oriented to self and knows he's in hospital. Not oriented to time. Pertinent Results: On Admission: ___ 12:15PM BLOOD WBC-7.9 RBC-3.18* Hgb-9.0* Hct-29.5*# MCV-93 MCH-28.3 MCHC-30.5* RDW-14.9 RDWSD-50.0* Plt ___ ___ 12:15PM BLOOD Neuts-62 Bands-1 ___ Monos-6 Eos-4 Baso-0 Atyps-1* Metas-1* Myelos-0 AbsNeut-4.98 AbsLymp-2.05 AbsMono-0.47 AbsEos-0.32 AbsBaso-0.00* ___ 12:20PM BLOOD ___ PTT-32.4 ___ ___ 12:15PM BLOOD Glucose-206* UreaN-16 Creat-0.6 Na-137 K-4.2 Cl-101 HCO3-21* AnGap-19 ___ 08:55AM BLOOD Albumin-3.4* Calcium-9.2 Phos-4.6*# Mg-1.9 Imaging/Studies: ___ CXR Portable Interval placement of a right approach PICC, which courses superiorly and terminates in the right internal jugular vein. Per the notes in the ED dashboard, the team is aware of the malpositioned PICC. ___ CXR Portable After flushing, the PICC line is now correctly positioned, with the tip in the mid SVC. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. galantamine 8 mg oral DAILY 2. GlipiZIDE XL 10 mg PO DAILY 3. Januvia (sitaGLIPtin) 50 mg oral DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Sertraline 50 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO BID 8. Mirtazapine 15 mg PO QHS 9. Simvastatin 20 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 25 mg PO QHS:PRN insomnia 12. Glargine 26 Units Bedtime Insulin SC Sliding Scale using REG Insulin 13. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 14. Hibiclens (chlorhexidine gluconate) 4 % topical DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Insulin SC Sliding Scale Fingerstick Q6H Insulin SC Sliding Scale using REG Insulin 3. Lisinopril 2.5 mg PO DAILY 4. Metoprolol Tartrate 25 mg PO BID 5. Mirtazapine 15 mg PO QHS 6. Simvastatin 20 mg PO QPM 7. Tamsulosin 0.4 mg PO QHS 8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 9. TraZODone 25 mg PO QHS:PRN insomnia 10. galantamine 8 mg oral DAILY 11. GlipiZIDE XL 10 mg PO DAILY 12. Hibiclens (chlorhexidine gluconate) 4 % topical DAILY 13. Januvia (sitaGLIPtin) 50 mg oral DAILY 14. Sertraline 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: PRIMARY ___ line placement Wound care s/p bowel resection SECONDARY Dementia Hypertension Diabetes 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: Evaluate for retained PICC line, in a patient with dimension loop pulled out her PICC. COMPARISON: Chest radiograph from ___. FINDINGS: Frontal views of the chest demonstrate no radiopaque foreign body to suggest retained PICC fragment. Lung volumes are low, resulting in increased prominence of the cardiac silhouette and bronchovascular crowding. Allowing for this, heart size is likely normal. There is atelectasis in the bilateral lower lobes, without concerning focal consolidation or pleural effusion. There is no pneumothorax. The visualized upper abdomen is unremarkable. IMPRESSION: No radiopaque foreign body to suggest a retained PICC fragment. Radiology Report INDICATION: Evaluate PICC placement. TECHNIQUE: None. COMPARISON: Chest radiographs from ___ and ___. FINDINGS: A portable frontal chest radiograph demonstrates interval placement of a right PICC, which courses superiorly into the right internal jugular vein. Lung volumes are low, resulting in increased prominence of the cardiac silhouette and bronchovascular crowding. Allowing for this, heart size is likely normal. There is no focal consolidation, pleural effusion, or pneumothorax. The visualized upper abdomen is unremarkable. IMPRESSION: Interval placement of a right approach PICC, which courses superiorly and terminates in the right internal jugular vein. Per the notes in the ED dashboard, the team is aware of the malpositioned PICC. Radiology Report INDICATION: Evaluate PICC placement. COMPARISON: Chest radiographs from approximately 30 minutes and 7 hours prior on the same day, as well as ___. FINDINGS: A portable frontal chest radiograph again demonstrates a right approach PICC, which courses superiorly and terminates in the right internal jugular vein, unchanged compared to prior exam. The remainder the exam is unchanged, with slightly low lung volumes and bibasilar atelectasis. IMPRESSION: Unchanged right approach PICC, which courses superiorly and terminates in the right internal jugular vein. According to the ED dashboard, the clinical team is aware of the malpositioned PICC. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with dementia, HTN, IDDM, PICC line for TPN, presenting for PICC line placement correction. // PICC line placement correct? Contact name: ___: ___ PICC line placement correct? IMPRESSION: In comparison with the earlier study of ___, there is no change in the appearance of the right subclavian PICC line, which extends well up into the neck in the jugular system. Little change in the appearance of the heart and lungs. Radiology Report EXAMINATION: Chest radiograph COMPARISON: ___, 07:22 IMPRESSION: The right PICC line continues to be malpositioned in the right jugular vein. No complications, notably no pneumothorax. Gender: M Race: ASIAN - CHINESE Arrive by AMBULANCE Chief complaint: PICC line eval Diagnosed with DUE TO OTHER VASCULAR DEVICE,IMPLANT,GRAFT, ABN REACT-PROCEDURE NEC, DEHYDRATION temperature: 98.2 heartrate: 80.0 resprate: 18.0 o2sat: 97.0 sbp: 133.0 dbp: 77.0 level of pain: 0 level of acuity: 4.0

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted because your PICC line had fallen out-this line is important because you receive nutrition through it. The line was replaced and you can continue to receive total parenteral nutrition (TPN). In addition, your wound in your abdomen (from your surgery in ___ was cleaned and bandaged. It is healing and should continue to be cleaned and bandaged daily. Please follow up with your primary care provider ___ this hospitalization for ongoing health care. We wish you a safe and healthy return home. Sincerely, Your BIMDC Team

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Prochlorperazine / Ambien / ciprofloxacin / sulfasalazine / hydrochlorothiazide / leflunomide Attending: ___. Chief Complaint: Right lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ female with Addison's disease on prednisone who slipped down one stair 4 day landing on her left arm and lower back. She immediately had severe lower back pains ago, radiating to the right side. She did not hit her head or lose consciousness. She went home and has been icing her back with some benefit but continued severe pain. She went and saw her PCP on ___ who prescribed Dilaudid and Valium which were not particularly helpful. She presented to the emergency department today for her ongoing severe pain. She received a CT scan which demonstrated L2/3 right transverse process fractures and mild perisplenic fluid consistent with a grade 1 splenic laceration. She reports that since her injury, she has had no incontinence, lack of sensation, pain radiating down legs, weakness, or other neurologic symptoms. She has had no abdominal pain, nausea/vomiting, blood in urine or stool, and she continues to tolerate a regular diet at home. She reports being hungry as she has not eaten since she has arrived in the emergency department. Past Medical History: Past Medical History: - hypertension - Addisons - collagenous colitis? vs IBS - gout - GERD - hyperlipidemia - spinal stenosis s/p lumbar surgery Past Surgical History: Lumbar surgery L4-5 fusion ___ years Social History: ___ Family History: CAD in 1 sister. ___ cancer in 2 sisters. Mother with dementia and arthritis. Father with hx of heart disease. Physical Exam: Admission Physical Exam: Vitals: 98.0 93 129/92 96% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, no palpable masses Back: Exquisite pain to palpation on lumbar palpation, 3x3cm hematoma noted to right of lumbar spine, scattered ecchymoses extending bilaterally around hematoma. Ext: No ___ edema, ___ warm and well perfused. Left forearm ecchymoses, full range of motion in all extremities. Neuro: Intact sensation and strength in all extremities Vital signs at time of discharge: VS: T: 97.6 PO BP: 151/87 R Sitting Pulse: 82 RR: 18 O2: 99% Ra Pertinent Results: ___: CXR: No acute cardiopulmonary process. ___: CT Abdomen/Pelvis: 1. Fluid-filled colon suggests an ongoing diarrheal disease, potentially viral enteritis, and correlation with clinical symptoms is recommended. 2. Chronic fractures of the right L2 and L3 transverse process. LABS: ___ 09:37PM WBC-10.3* RBC-2.90* HGB-9.1* HCT-28.8* MCV-99* MCH-31.4 MCHC-31.6* RDW-12.3 RDWSD-44.3 ___ 09:37PM PLT COUNT-272 ___ 11:58AM K+-4.5 ___ 08:59AM ___ PTT-25.0 ___ ___ 08:38AM GLUCOSE-106* UREA N-24* CREAT-1.7* SODIUM-129* POTASSIUM-6.3* CHLORIDE-95* TOTAL CO2-18* ANION GAP-16 ___ 08:38AM WBC-16.9* RBC-3.60* HGB-11.5 HCT-35.4 MCV-98 MCH-31.9 MCHC-32.5 RDW-12.3 RDWSD-44.7 ___ 08:38AM NEUTS-87.8* LYMPHS-7.4* MONOS-4.0* EOS-0.1* BASOS-0.2 IM ___ AbsNeut-14.86* AbsLymp-1.25 AbsMono-0.68 AbsEos-0.01* AbsBaso-0.04 ___ 08:38AM PLT COUNT-351 ___ 07:55AM URINE COLOR-ORANGE* APPEAR-Clear SP ___ ___ 07:55AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 07:55AM URINE RBC-<1 WBC-3 BACTERIA-FEW* YEAST-NONE EPI-0 ___ 07:55AM URINE HYALINE-1* ___ 07:55AM URINE MUCOUS-RARE* Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. ClonazePAM 0.5 mg PO QHS 3. Fludrocortisone Acetate 0.1 mg PO DAILY 4. Hydroxychloroquine Sulfate 200 mg PO DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. PredniSONE 5 mg PO DAILY 8. Esomeprazole ___ mg Other DAILY 9. Losartan Potassium 25 mg PO DAILY 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Urinary tract infection Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Wean as tolerated. Patient may request partial fill. RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 3. Allopurinol ___ mg PO DAILY 4. ClonazePAM 0.5 mg PO QHS 5. Esomeprazole ___ mg Other DAILY 6. Fludrocortisone Acetate 0.1 mg PO DAILY 7. Hydroxychloroquine Sulfate 200 mg PO DAILY 8. Levothyroxine Sodium 100 mcg PO DAILY 9. Losartan Potassium 25 mg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Urinary tract infection 12. PredniSONE 5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right L2 and L3 transverse process fractures Grade 1 splenic laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ with fall, hematuria, flank pain, midline spinal pain// eval for renal injury, spinal injury TECHNIQUE: PA and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: The lungs are clear. There is no consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is within normal limits. No displaced rib fractures. IMPRESSION: No acute cardiopulmonary process. Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with fall, hematuria, flank pain, midline spinal painNO_PO contrast// eval for renal injury, spinal injury TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.0 s, 47.1 cm; CTDIvol = 18.5 mGy (Body) DLP = 870.1 mGy-cm. Total DLP (Body) = 870 mGy-cm. COMPARISON: CT abdomen pelvis from ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits besides mild dependent atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions or laceration. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions or laceration. There is trace perisplenic free fluid. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Bilateral renal hypodensities are too small to characterize though statistically cysts. No evidence of laceration. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are grossly within normal limits. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild to moderate atherosclerotic disease is noted. BONES: There are acute minimally displaced right L2 and L3 transverse process fractures. L4 laminectomy changes noted with L4 and L5 pedicle screws in place without hardware related complication. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Acute right L2 and L3 transverse process fractures. 2. Trace perisplenic free fluid without underlying laceration or other evidence of intra-abdominal injury. Gender: F Race: WHITE Arrive by WALK IN Chief complaint: R Flank pain, s/p Fall Diagnosed with Unspecified laceration of spleen, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr, Unsp fracture of third lumbar vertebra, init for clos fx, Unspecified abdominal pain temperature: 97.4 heartrate: 83.0 resprate: 16.0 o2sat: 100.0 sbp: 111.0 dbp: 52.0 level of pain: 10 level of acuity: 4.0

Dear Ms. ___, You were admitted to ___ after your fall. You were found to have a spleen laceration as well as fractures of the tip of your thoracic spine. Your blood counts were monitored and remained stable. Your spine tip fractures will heal on their own. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Liver/ Spleen lacerations: *AVOID contact sports and/or any activity that may cause injury to your abdominal area for the next ___ weeks. *If you suddenly become dizzy, lightheaded, feeling as if you are going to pass out go to the nearest Emergency Room as this could be a sign that you are having internal bleeding from your liver or spleen injury. *AVOID any blood thinners such as Motrin, Naprosyn, Indocin, Aspirin, Coumadin or Plavix for at least ___ days unless otherwise instructed by the MD/NP/PA. Right L2/L3 Transverse Process Fractures: * Your injury caused two transverse process fractures (part of your lumbar spine) which can cause severe pain. * You should take your pain medication as directed to stay ahead of the pain. If the pain medication is too sedating take half the dose and notify your physician. General 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 driving or operating heavy machinery while taking pain medications.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___ Chief Complaint: Fever, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yo woman with AML s/p 7+3 induction ___ followed by MiDAC consolidation ___, who presents with a few hours of fever and vomiting. Mrs. ___ reports she has been feeling "great" until 6 am this morning, when she woke up gagging. She vomited up approximately half a cup of "foamy white" emesis. No blood, no bile. She felt a little feverish but went back to bed. 2 hours later, she awoke again gagging and had another episode of emesis. She checked her temperature and noted it was elevated around ___. She also felt chilly. She called her oncologist and presented to the ED for further evaluation. She reports that otherwise she does not have night sweats, chest pain, shortness of breath, cough, myalgias, cold symptoms, dysuria, abdominal pain, diarrhea. No sick contacts. She has been taking her medications including ciprofloxacin and acyclovir ppx without any lapses. Mrs. ___ recent clinical course is notable for Neutropenic fever during her induction therapy in ___. She was treated with cefepime. No clear source was identified although there was a question of URI and CT showing bronchial wall thickening w/ scattered tree in ___ opacities. In the ED, she spiked a temperature to TMax 102.6F. Labs showed neutropenia (WBC 0.1) and mildly elevated lactate to 2.8 that corrected to 1 with 1L NS. She received a CT A/P and CXR which did not reveal an acute source of infection. She received cefepime and vancomycin prior to admission. When seen at bedside on the floor, Mrs. ___ reports she feels generally unwell-- chilly, tired, and weak, without localizing symptoms. Past Medical History: PAST ONCOLOGIC HISTORY: As per last clinic note by Dr ___ "- Recent breast imaging series as summarized in Dr. ___ notes with ___ radiology review as outlined below. Of note, second right breast biopsy (done here on ___ was indicated due to MRI finding of second area of concern. - ___ right breast biopsy, performed at ___ (reviewed at ___: 0.5 cm grade 2 IDC, ER/PR pos, HER2 neg by IHC - ___ right breast CNB (11:00): 0.45 cm grade 2 IDC, ER/PR pos, HER neg by FISH (ratio 0.8), also DCIS - ___ right lumpectomy/SNB: 0.3 cm grade 2 IDC, node neg ___ - ___ finished RT (Dr. ___ and started anastrozole - ___: held anastrazole per Dr. ___ in setting of cytopenias" PAST MEDICAL HISTORY: - S/P hyst/BSO age ___ in context of ovarian cyst and heavy periods, benign pathology per the pt - HTN - Bladder suspension - Cataracts - Osteopenia - Osteoarthritis Social History: ___ Family History: No known history of breast or ovarian cancers or leukemia in the family. - Father lung ca (smoker) Physical Exam: ADMISSION PHYSICAL EXAM ============================= VITALS: T 100.3 F | 121/70 | 103 | 97% RA General: Well appearing pleasant elderly Caucasian woman resting in bed comfortably Neuro: Alert, oriented to place and time. Provides crisp history PERRL, face symmetric, hearing intact to finger rub bilaterally, palate elevates symmetrically, tongue midline HEENT: Oropharynx clear, no lesions, no palpable cervical or supraclavicular adenopathy, no sinus tenderness Cardiovascular: Slightly tachycardic, regular, no murmurs Chest/Pulmonary: Clear to auscultation bilaterally Abdomen: Soft, nontender, nondistended. Bowel sounds are present Extr/MSK: WWP, no peripheral edema Skin: Slightly warm to the touch, no rashes seen Access: L POC is c/d/I. Nontender to palpation, no surrounding erythema PHYSICAL PHYSICAL EXAM ============================= VITALS: 98.3F PO BP: 139/81 HR: 92 RR: 18 O2 sat: 95% O2 delivery: RA General: Well appearing Caucasian woman lying on bed HEENT: Oropharynx clear, no lesions. No sinus tenderness. Cardiovascular: RRR. No R/M/G. Pulmonary: CTAB, no R/R/W Abdomen: Soft, nontender, nondistended. Extr/MSK: WWP, no peripheral edema Skin: dry, no visible rashes. Access: L POC is c/d/I. Nontender to palpation, no surrounding erythema Pertinent Results: ADMISSIONS LABS =============================== ___ 01:00PM BLOOD WBC-0.1* RBC-2.20* Hgb-7.2* Hct-21.3* MCV-97 MCH-32.7* MCHC-33.8 RDW-13.6 RDWSD-48.4* Plt Ct-10* ___ 01:00PM BLOOD Neuts-ND Lymphs-ND Monos-ND Eos-ND Baso-ND AbsNeut-ND AbsLymp-ND AbsMono-ND AbsEos-ND AbsBaso-ND ___ 01:00PM BLOOD ___ PTT-24.8* ___ ___ 01:00PM BLOOD Glucose-105* UreaN-9 Creat-0.8 Na-139 K-3.7 Cl-101 HCO3-24 AnGap-14 ___ 01:00PM BLOOD ALT-26 AST-25 AlkPhos-109* TotBili-0.6 ___ 01:00PM BLOOD Lipase-14 ___ 01:00PM BLOOD Albumin-3.6 ___ 02:55PM BLOOD Calcium-7.6* Phos-4.1 Mg-1.3* ___ 01:12PM BLOOD Lactate-2.8* RELEVANT LABS =============================== ___ 12:00AM BLOOD WBC-0.4* RBC-1.89* Hgb-6.3* Hct-18.4* MCV-97 MCH-33.3* MCHC-34.2 RDW-13.6 RDWSD-48.8* Plt Ct-7* ___ 12:00AM BLOOD WBC-3.6* RBC-2.06* Hgb-6.6* Hct-19.2* MCV-93 MCH-32.0 MCHC-34.4 RDW-14.6 RDWSD-50.0* Plt Ct-39* ___ 12:00AM BLOOD WBC-11.3* RBC-2.62* Hgb-8.2* Hct-24.0* MCV-92 MCH-31.3 MCHC-34.2 RDW-15.6* RDWSD-52.4* Plt Ct-37* ___ 12:00AM BLOOD Neuts-10* Bands-4 Lymphs-76* Monos-10 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.06* AbsLymp-0.30* AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Neuts-51 Bands-0 ___ Monos-16* Eos-1 Baso-0 Atyps-1* Metas-4* Myelos-0 AbsNeut-1.84 AbsLymp-1.01* AbsMono-0.58 AbsEos-0.04 AbsBaso-0.00* ___ 12:00AM BLOOD Neuts-72* Bands-6* Lymphs-7* Monos-15* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.81* AbsLymp-0.79* AbsMono-1.70* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD ALT-40 AST-41* LD(LDH)-315* AlkPhos-125* TotBili-2.1* DirBili-1.0* IndBili-1.1 ___ 12:00AM BLOOD ALT-30 AST-24 LD(LDH)-443* AlkPhos-148* TotBili-0.6 DirBili-0.2 IndBili-0.4 ___ 12:12PM BLOOD ___ pO2-110* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 Comment-GREEN TOP ___ 04:57PM BLOOD Lactate-1.0 RELEVANT IMAGING =============================== ___ CXR PA/LAT No acute intrathoracic process. Proximal migration of the left Port-A-Cath tip. This tip is still within the mid SVC ___ CT ABD/PELVIS WITH CONTRAST No specific CT findings of infection in the abdomen or pelvis. ___ CXR AP Pulmonary edema and cardiomegaly, new from prior, suggestive of volume overload. No evidence of pneumonia. ___ TTE CONCLUSION: The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative 3D volumetric left ventricular ejection fraction is 56 %. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. 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. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear tructurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Mild pulmonary artery systolic hypertension. Compared with the prior TTE (images reviewed) of ___, the estimated PA systolic pressure is now increased. RELEVANT MICRO =============================== ___ BLOOD CULTURES X2: NGTD ___ BLOOD CULUTRES X2: NGTD ___ BLOOD CULTURE: NGTD ___ BLOOD CULTURE: NGTD ___ URINE CULTURE: NGTD DISCHARGE LABS =============================== ___ 12:00AM BLOOD WBC-14.1* RBC-2.66* Hgb-8.3* Hct-24.3* MCV-91 MCH-31.2 MCHC-34.2 RDW-15.4 RDWSD-51.7* Plt Ct-46* ___ 12:00AM BLOOD Neuts-81* Bands-1 Lymphs-8* Monos-7 Eos-0 Baso-0 Atyps-1* ___ Myelos-2* AbsNeut-11.56* AbsLymp-1.27 AbsMono-0.99* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-143 K-3.4* Cl-102 HCO3-25 AnGap-16 ___ 12:00AM BLOOD ALT-25 AST-21 LD(LDH)-496* AlkPhos-170* TotBili-0.3 ___ 12:00AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.1 Mg-2.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ciprofloxacin HCl 500 mg PO Q12H 2. Acyclovir 400 mg PO Q12H 3. amLODIPine 5 mg PO HS 4. Valsartan 160 mg PO DAILY 5. Anastrozole 1 mg PO DAILY 6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID 7. TraMADol ___ mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Lidocaine-Prilocaine 1 Appl TP PRN port irritation RX *lidocaine-prilocaine 2.5 %-2.5 % apply to port site as needed Disp #*1 Kit Refills:*0 2. Acyclovir 400 mg PO Q12H 3. amLODIPine 5 mg PO HS 4. Anastrozole 1 mg PO DAILY 5. TraMADol ___ mg PO Q4H:PRN Pain - Moderate 6. Valsartan 160 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES #Febrile neutropenia #Flash pulmonary edema SECONDARY DIAGNOSES #AML #Chemotherapy induced pancytopenia #HTN #R breast CDIS #Arthritis 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 neutropenic fever// ? PNA TECHNIQUE: Chest PA and lateral COMPARISON: The prior chest radiographs, most recently from ___. FINDINGS: Dual-lumen left Port-A-Cath terminates in the upper SVC. The catheter has migrated more proximally since the prior CT scan and there is a loop extending more superiorly. The lungs are clear with no focal consolidation. Cardiomediastinal silhouette is stable. No pleural effusion or pneumothorax. IMPRESSION: No acute intrathoracic process. Proximal migration of the left Port-A-Cath tip. This tip is still within the mid SVC Radiology Report EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with neutropenic fever, N/VNO_PO contrast// ? abd 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 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8 mGy-cm. 2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 13.5 mGy (Body) DLP = 661.6 mGy-cm. Total DLP (Body) = 666 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: With the exception of bibasilar subsegmental dependent atelectasis, the lung bases are clear. 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. Numerous bilateral peripelvic cysts are re-demonstrated, left greater than right. Simple cysts on the right measure up to 6 cm, as before. Additional subcentimeter hypodensities are too small to characterize, but most likely reflect simple cysts. No suspicious renal lesion or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a moderate hiatus hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not definitely seen, however no secondary inflammatory changes are noted in the right lower quadrant to suggest acute appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not seen. No adnexal abnormality. 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. BONES: There is no evidence of worrisome osseous lesions or acute fracture. The bones are diffusely demineralized. Mild multilevel lumbar spine degenerative changes are noted, including grade 1 anterolisthesis of L4 on L5 and L5 on S1. SOFT TISSUES: There is a small fat containing umbilical hernia. IMPRESSION: No specific CT findings of infection in the abdomen or pelvis. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ w/ AML s/p chemo here w/ Neutropenic fever, now w/ increased hypoxia after receiving 1L IVF.// ?PNA vs. fluid overload COMPARISON: Chest x-ray ___, chest CT ___ FINDINGS: Single upright AP view of the chest is provided. Again seen is a dual-lumen left chest wall Port-A-Cath with distal tip terminating in the upper SVC. The catheter appears to have changed to a horizontal orientation when compared to prior chest radiograph from 1 day prior a which is oriented vertically. Compared to prior, increased interstitial markings and enlarged cardiomediastinal silhouette are suggestive of volume overload. No pleural effusion or pneumothorax. No focal consolidation to suggest pneumonia. IMPRESSION: Pulmonary edema and cardiomegaly, new from prior, suggestive of volume overload. No evidence of pneumonia. Left Port-A-Cath distal tip has changed orientation from vertical to horizontal. Gender: F Race: PORTUGUESE Arrive by WALK IN Chief complaint: Fever, Nausea, Tachycardia Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere temperature: 102.6 heartrate: 124.0 resprate: 24.0 o2sat: 100.0 sbp: 130.0 dbp: 73.0 level of pain: 0 level of acuity: 2.0

Dear Ms. ___, It was our pleasure taking care of you at the ___ ___! WHAT BROUGHT YOU THE HOSPITAL? You were vomiting and had a fever at home. WHAT HAPPENED IN THE HOSPITAL? - You were found to have a low white blood cell count. This is due to the chemotherapy for your leukemia. - You were given antibiotics to treat a likely infection. As your white blood cell count recovered, the antibiotics were stopped. - In the Emergency Room, you were enrolled in a clinical trial, which will help healthcare providers determine what kinds of treatments future patients with infections should get. - You underwent a swab of your nose to determine whether you have a viral infection. The results of this are pending. - You developed shortness of breath after receiving IV fluids. It was because fluid built up in your lungs. Why this happened is unclear. You underwent an echocardiogram of your heart, which did not find significant differences compared to one month ago. WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL? - Please take all your medications as prescribed and attend your doctor's appointments. We wish you all the best! Your ___ Healthcare 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: abdominal pain, intractable nausea and vomiting Major Surgical or Invasive Procedure: EUS ERCP History of Present Illness: PCP: ___ ___ patient is an ___ year old man with known hypothyrodism, here with an acute illness including abdominal pain and nausea with vomiting. He notes that two days prior to presentation he developed acute nausea and intractable vomiting several hours after going out to dinner. He reports eating fried scallops and soup, and felt well immediately after the meal. Subsequently he noted acute onset of the n/v without fever, chills, diarrhea, chest pain or shortness of breath. He notes that after several hours to one day of vomiting, he did develop some mid-sternal chest pain which felt like a 'lump' in his chest, without radiation or association with exertion. He notes that the pain persisted for several hours before resolving. The patient notes that 5 weeks prior to admission, he had an episode of nausea with vomiting and a 'migraine' headache with blurry vision. These symptoms resolved, and he was seen electively three days prior to this admission by his internist and reports he was not told to change his medication or other regimen. ROS: Otherwise negative for changes in weight, sweats, prior episodes like this one, diarrhea, chest pain with exertion, shortness of breath, or other associated symptoms. The remainder of a 10-system ROS is negative by patient report. Past Medical History: Hiatal hernia Biopsy proven prostate adeno CA s/p seed implant brachytherapy, Colonic polyps Hyperthyroid (s/p radioiodine therapy for hyperthyroidism, now on levothyroxine Cholelithiasis Surgical/Procedure History: Seed implant brachytherapy ___, colonoscopy and benign polyp excision ___ Social History: ___ Family History: Denies history of skin cancer, otherwise non-contributory. Physical Exam: Admission examination: VS: 98.5F BP 106/53 HR 62 RR 18 95% on RA Subsequent to initial exam: Patient developed a temp of ___ Gen: Patient comfortable, lying in bed in no distress, no dyspnea HEENT: No JVD (approx 7cm > RA), mmm, no scleral icterus CV: Reg, S1S2, no murmurs, no rub Lungs: Rales bibasilar ___ up, no rhonchi Abd: moderately distended, slightly hypoactive but present bowel sounds, diffuse upper quadrant tenderness without rebound. Neuro: Alert and oriented, fluent speech, no tremor. Able to sit up independently in bed. Skin/LExt: trace pitting edema bilateral legs, warm and well-perfused. Pertinent Results: ___ 09:00AM GLUCOSE-97 UREA N-24* CREAT-1.2 SODIUM-139 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17 ___ 09:00AM ALT(SGPT)-19 AST(SGOT)-32 ALK PHOS-50 TOT BILI-0.9 ___ 09:00AM LIPASE-4010* ___ 09:00AM ALBUMIN-4.3 CALCIUM-9.5 ___ 09:00AM cTropnT-<0.01 ___ 02:00PM LACTATE-1.1 ___ 09:10AM LACTATE-1.3 ___ 09:00AM WBC-17.8*# RBC-4.97 HGB-14.7 HCT-45.1 MCV-91 MCH-29.5 MCHC-32.6 RDW-13.8 ___ 09:00AM NEUTS-94.8* LYMPHS-2.4* MONOS-2.6 EOS-0 BASOS-0.1 CT abdomen: formal read pending, preliminary suggestive of gallstones without intrahepatic ductal dilatation Abdominal Ultrasound: formal read pending, suggestive of pancreatic duct stone 6mm, within 4mm duct. CXR ___: Cardiac size is top normal. There are low lung volumes with large bibasilar atelectasis, increased from prior study. There is no pneumothorax or pleural effusion or pulmonary edema. EUS on ___: Impression: 5 mm stone wedged into the distal pancreatic duct. No definitive filling defects in the CBD. After discussion with Dr. ___ was made not to proceed to ERCP for biliary evaluation, but rather to reschedule patient for ERCP with both biliary and pancreatic sphincterotomy. Recommendations: Recommend ERCP with likely biliary and pancreatic duct sphincterotomy and stone extraction with Dr. ___ on ___. 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:Significant edema of the duodenal mucosa was noted suggestive of changes due to recent pancreatitis. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Cannulation of the pancreatic duct was successful and deep with a cannula using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree fluoroscopic interpretation:The CBD appeared to be of normal size and measured 6 mm. No filling defects were noted within the CBD. In order to expose the pancreatic orifice, it was decided to perform a sphincterotomy. Pancreas fluoroscopic interpretation: There appeared to be a filling defect at the lower end of PD suggesting of a stone. This stone could represent the stone seen on recent imaging studies. The PD proximal to this area appeared to be dilated uniformly. No changes suggestive of chronic pancreatitis were seen in the PD. A 7cm by ___ single pigtail pancreatic stent was placed successfully. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. Total flouro time: 7.4 min Procedures: A biliary sphincterotomy was performed successfully with a sphincterotome at 12'o clock position. Given the possibility of PD stone, a small pancreatic sphincterotomy was carefully performed using a needle-knife over the PD stent. Impression: Significant edema of the duodenal mucosa was noted suggestive of changes due to recent pancreatitis. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique The CBD appeared to be of normal size and measured 6 mm. No filling defects were noted within the CBD. It was decided to perform a sphincterotomy in order to expose the pancreatic orifice A biliary sphincterotomy was performed successfully with a sphincterotome at 12'o clock position. Cannulation of the pancreatic duct was successful and deep with a cannula using a free-hand technique There appeared to be a filling defect at the lower end of PD suggesting stone. This stone could represent the stone seen on recent imaging studies. The PD proximal to this area appeared to be dilated uniformly. No changes suggestive of chronic pancreatitis were seen in the PD. A 7cm by ___ single pigtail pancreatic stent was placed successfully. A pancreatic sphincterotomy was carefully performed using a needle-knife over the PD stent to allow fragmentation and passage of the stone. Otherwise normal ercp to third part of the duodenum Recommendations: Return to floor. NPO tonight. If patient's condition remains clinically stable, could advance diet as tolerated tomorrow. Hydration with LR as tolerated hemodynamically. Repeat ERCP in 2 months for PD stent pull and extraction of any remaining PD stone fragments. Medications on Admission: Levothyroxine 125 mcg daily OTC: PRN ibuprofen Discharge Medications: 1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*7 Tablet(s)* Refills:*0* 3. potassium chloride 10 mEq Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO once a day. Disp:*14 Capsule, Extended Release(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - gallstone pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report CLINICAL HISTORY: ___ man with history of small-bowel obstruction a few years ago presenting with abdominal distention, pain, nausea and vomiting. Last bowel movement was two days ago. ___. TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness with 130 mL Omnipaque intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm slice thickness. CT ABDOMEN: Visualized lung bases demonstrate bilateral linear atelectasis with volume loss in the lower lobes, similar to ___. There is no pleural or pericardial effusion. Mild coronary artery calcifications are seen in the LAD. Mild enlargement of the right main pulmonary artery to 28 mm suggests underlying pulmonary arterial hypertension. The liver is normal without focal liver lesion. There is minimal intrahepatic bile duct dilation. The common duct is not dilated allowing for age, measuring 8 mm. Gallstones are seen within the gallbladder without wall edema or pericholecystic fluid. A stone in the gallbladder neck is unchanged from ___. A 6-mm high-density stone is seen the pancreatic duct at the ampulla (2:42) with mild pancreatic duct dilation to 4 mm (601b:28). There is mild adjacent peripancreatic stranding at the body. The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. Small hypodensities in the kidneys bilaterally are too small to characterize, the largest measuring 7 mm in the right renal inferior pole, statistically most likely representing cysts. The spleen and the right adrenal gland are normal. A 2.5 x 2.2 cm lesion on the left adrenal gland previously characterized as an adenoma is minimally larger than in ___ when it measured 18 x 20 mm, and essentially unchanged from ___. The small and large bowel are normal in course and caliber without obstruction. There are a few loops of nondilated fluid-filled small bowel which are nonspecific, but can be seen in enteritis. There is no free fluid and no free air. The aorta is of normal caliber throughout with mild atherosclerotic calcifications. The main portal vein, splenic vein and SMV are patent. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. CT PELVIS: The rectum is normal. Diverticula are seen throughout the sigmoid colon without inflammatory changes. The bladder is normal. Brachytherapy seeds are seen in the prostate. There is no free fluid and no pelvic or inguinal lymphadenopathy. There is a small right inguinal fat containing hernia. A fatty spermatic cord is seen on the left. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. IMPRESSION: 1. Mild pancreatitis probably related to a 6mm pancreatic ductal stone at the ampulla, with mild pancreatic ductal dilation and minimal intrahepatic bile duct dilation, new from ___. 2. Cholelithiasis without evidence of acute cholecystitis. No definite common duct stones. 3. Nondilated fluid-filled loops of small bowel are nonspecific but can be seen in enteritis in the appropriate clinical setting. 4. Diverticulosis without diverticulitis. Radiology Report CLINICAL HISTORY: ___ man with gallstone pancreatitis. Evaluate for cholecystitis. COMPARISON: CT abdomen ___. FINDINGS: The left hepatic lobe is not well visualized due to overlying bowel gas and its small size as seen on CT. The right hepatic lobe shows normal textural abnormality without focal liver lesion identified. Doppler assessment of the main portal vein shows patency and normal hepatopetal flow. There is no intra- or extra-hepatic bile duct dilation. The common duct is not dilated measuring 7 mm. Numerous shadowing mobile gallstones are seen within the gallbladder, without pericholecystic fluid, wall edema or gallbladder wall dilation to suggest acute cholecystitis. The pancreas is not visualized due to overlying bowel gas. The spleen is normal measuring 11.1 cm. IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. 2. Pancreas is not seen. 3. No intra- or extra-hepatic bile duct dilation. Radiology Report SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Pancreatitis and cholangitis with new oxygen requirement. Comparison is made with prior study abdomen CT from ___. Cardiac size is top normal. There are low lung volumes with large bibasilar atelectasis, increased from prior study. There is no pneumothorax or pleural effusion or pulmonary edema. Gender: M Race: WHITE Arrive by WALK IN Chief complaint: ABD PAIN Diagnosed with ACUTE PANCREATITIS, CHOLEDOCHOLITHIASIS NOS temperature: 98.8 heartrate: 67.0 resprate: nan o2sat: 97.0 sbp: 132.0 dbp: 112.0 level of pain: 10 level of acuity: 2.0

You were admitted for acute pancreatitis. You were treated with IV fluids and pain medication. Your CT scan showed a pancreatic duct stone. You had an EUS which confirmed that it was a stone. You later had an ERCP which showed a billiary stone. A stent was placed. . Please continue to take all of your medications. You have been provided with doses of lasix and potassium to take to decrease your edema.

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: lactose / shellfish derived Attending: ___ Chief Complaint: Abdominal distention, nausea and emesis, decreased ileostomy output Major Surgical or Invasive Procedure: ___: Exploratory laparotomy, lysis of adhesions, and reduction of internal hernia, application of ABThera VAC. ___: Exploratory laparotomy with small bowel resection and temporary vacuum-assisted closure. ___: Exploratory laparotomy, formation of an end ileostomy and fascial closure. History of Present Illness: ___ with h/o sigmoid volvulus s/p colectomy ___ and ex-lap, loop ileostomy diversion presents ___ presents with abdominal distention, nausea and NBNB emesis over the last 36 hours. She has limited ileostomy output (~100ml) and has decreased urine output. She was seen at ___ where she was found to have lactic acidosis, leukocytosis, and had a KUB with evidence of SBO. She was given 3L crystalloid IVF, NGT was placed (1000ml gastric contents evacuated) and transferred to ___ via the ED. Upon presentation she was found to have WBC 11.1 lactate 5.2 and ___ of 3.8. She received 3L of crystalloid in the ED and was placed on noriepinephrine drip for hypotension of approximately 80/50. Although lucid during evaluation, her partner ___ commented that she was confused earlier. Hypotension, symtpoms, and oliguria improved with IVF. CT AP w/ IV contrast concerning for high grade SBO just proximal to the loop ileostomy with significant proximal SB distention without evidence of pneumatosis intesinalis or perforation. Digitalization at the bedside and ___ catheterization of the loop ileostomy did not provide relief of pressure or evacuation of any contents. NGT output in ED no more than 100ml. Past Medical History: PMH: obesity, lactose intolerance, bowel dysmotility & possible bacterial overgrowth (Dr. ___, parastomal hernia PSH: ___ - Colectomy for Sigmoid volvulus (reported as near total colectomy and reanastomosis per patient) Social History: ___ Family History: DM, HTN, HLD in parents Physical Exam: Admission Physical Exam: Afebrile HR 124 82/51-> 100/60, 21, 97%RA Gen: AAOx3, affable, accompanied by partner ___ CV: tachycardic, no MRG Pulm: CTAB ant lung fields GI: diffuse abdominal distention, tympany diffusely, ttp on right abdomen, left ileostomy pink and healthy, digitalized with minimal blood on glove and stool, no gas, diffusely tender but non peritoneal, old ileostomy bag replaced previous had 100ml liquid brown output w minimal gas ___: minimal b/l ___ edema Discharge Physical Exam: 98.1 F | 120/61 | 98 | 18 | 98%RA Gen: A&Ox3, NAD CV: Normal rate regular rhythm, no MRG Pulm: No respiratory distress, CTAB GI: Soft, non-tender, non-distended, left ileostomy pink and healthy with gas and brown stool, surgical incision with dressing c/d/i ___: minimal b/l ___ edema Pertinent Results: ___ 10:22PM TYPE-ART PO2-166* PCO2-36 PH-7.18* TOTAL CO2-14* BASE XS--13 ___ 10:22PM LACTATE-4.3* ___ 10:10PM GLUCOSE-127* UREA N-69* CREAT-2.6*# SODIUM-136 POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-13* ANION GAP-24* ___ 10:10PM CALCIUM-7.5* PHOSPHATE-4.8* MAGNESIUM-1.5* ___ 10:10PM WBC-5.5# RBC-5.83* HGB-16.9* HCT-49.9* MCV-86 MCH-29.0 MCHC-33.9 RDW-13.2 RDWSD-40.8 ___ 10:10PM NEUTS-25* BANDS-20* LYMPHS-18* MONOS-9 EOS-6 BASOS-0 ATYPS-6* METAS-12* MYELOS-4* AbsNeut-2.48 AbsLymp-1.32 AbsMono-0.50 AbsEos-0.33 AbsBaso-0.00* ___ 10:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 10:10PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO ___ 10:10PM ___ PTT-45.8* ___ ___ 08:33PM TYPE-ART PO2-115* PCO2-40 PH-7.14* TOTAL CO2-14* BASE XS--15 ___ 08:33PM GLUCOSE-104 LACTATE-4.1* NA+-133 K+-4.4 CL--109* ___ 08:33PM HGB-16.0 calcHCT-48 O2 SAT-96 ___ 08:33PM freeCa-1.02* ___ 02:39PM LACTATE-5.2* ___ 02:30PM GLUCOSE-158* UREA N-69* CREAT-3.8*# SODIUM-133 POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-11* ANION GAP-33* ___ 02:30PM WBC-11.1*# RBC-6.87*# HGB-19.7*# HCT-59.1*# MCV-86 MCH-28.7 MCHC-33.3 RDW-14.6 RDWSD-40.5 ___ 02:30PM NEUTS-40 BANDS-26* LYMPHS-10* MONOS-10 EOS-0 BASOS-0 ATYPS-10* METAS-4* MYELOS-0 AbsNeut-7.33* AbsLymp-2.22 AbsMono-1.11* AbsEos-0.00* AbsBaso-0.00* ___ 02:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 02:30PM PLT SMR-NORMAL PLT COUNT-324 Imaging: ___: CT Abd/Pel: Patient is status post subtotal colectomy, left lower quadrant loop ileostomy, and ileal sigmoid anastomosis. There is a high-grade small-bowel obstruction with a transition point in the left mid abdomen as described above without CT evidence for bowel wall ischemia. ___: Pathology: Small intestine, resection : - Small intestinal segment with subtotal transmural infarction; mucosal and submucosal ischemia extends to one margin. - Seven unremarkable lymph nodes. ___: ECHO: Mildly depressed left ventricular systolic function. Moderately dilated right ventricular size. Mild right ventricular systolic function. ___: CXR: Comparison to ___. No relevant change. Moderate cardiomegaly. Elevation of the left hemidiaphragm. Monitoring and support devices are constant. The pre-existing parenchymal changes and the moderate to severe cardiomegaly are unchanged. No pneumothorax. ___: KUB: No unexplained radiopaque foreign bodies in the abdomen. ___: CXR: Moderate pulmonary edema which developed between ___ and ___ has improved although pulmonary vasculature is still very engorged. Opacification at the lung bases, particularly the left above the chronically elevated left hemidiaphragm, is probably a combination of atelectasis and edema but there is no way to exclude pneumonia. Moderate cardiomegaly which also worsened after ___ and mediastinal vascular engorgement are unchanged. ET tube, right internal jugular line are in standard placements and the nasogastric tube is looped widely in the stomach. ___: CXR Portable PICC: Type of tube tip is in the stomach. Right internal jugular line tip at the level of lower SVC. Right PICC line tip is at the level of proximal right atrium. Left pleural effusion and basal consolidation are unchanged. Elevated hemidiaphragm with high position of the colon is re- demonstrated. ___: Left Upper Extremity US: No evidence of deep vein thrombosis in the left upper extremity. ___: CT Abd/Pel: 1. High-grade small-bowel obstruction with single abrupt transition point just proximal to the end ileostomy. 2. Inflammatory changes of the distal residual small bowel with wall thickening, surrounding stranding and trace free fluid. 3. No organizing abdominal fluid collection. 4. Apparent non opacification of a few subsegmental pulmonary arterial branches of the right lower lobe posterior basal segment may be due to bolus timing which is not optimized for evaluating the pulmonary arteries. However, if there is clinical concern for pulmonary embolus, this would be best evaluated with dedicated chest CTA. 5. Left hemidiaphragm elevation, likely paretic. ___: Liver or gallbladder u/s 1. Echogenic liver compatible with steatosis. 2. Normal appearance of the gallbladder with no stones or wall thickening. 3. Trace perihepatic ascites and trace right pleural effusion. ___: CT Abd/Pel with contrast: 1. Mild improvement in distension of small bowel loops compared to the most recent prior study. Transition point remains near the ileostomy 2. New small amount of ascites without discrete fluid collection. 3. Increased right pleural effusion, now moderate, and adjacent atelectasis. Medications on Admission: None Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. OxycoDONE Liquid ___ mg PO Q4H:PRN pain do NOT drink alcohol or drive while taking this medication RX *oxycodone 5 mg/5 mL ___ mL by mouth every four (4) hours Disp #*1000 Milliliter Refills:*0 4. Psyllium Powder 2 PKT PO TID 5. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN pain Do not drink alcohol or drive when taking this medication 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Simethicone 40-80 mg PO QID:PRN gas 8. Sodium Chloride 1 gm PO BID Hold if nauseated 9. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 3 billion cell oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Small-bowel obstruction -Internal hernia -High ostomy output Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Followup Instructions: ___ Radiology Report INDICATION: ___ year female with KUB showing small bowel obstruction, evaluate for small bowel obstruction. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,195 mGy-cm. COMPARISON: Prior CTs of the abdomen and pelvis dated ___, and ___. FINDINGS: LOWER CHEST: The lung bases demonstrate stable elevation of the left hemidiaphragm, rightward shift of mediastinal structures, and bibasilar atelectasis. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. Severe atrophy left lobe of the liver is unchanged. 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. Hyperenhancement of the adrenal glands suggests hypovolemia. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. A low-density lesion in the anterior interpolar region of the right kidney is unchanged from multiple prior studies, previously described as an angiomyolipoma (02:51). There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is decompressed with an enteric tube. Patient is status post subtotal colectomy with left lower quadrant loop ileostomy and distal ileosigmoid anastomosis. There are multiple dilated loops of small bowel with a gradual transition from the decompressed loops in the left upper quadrant to the chronically dilated loops of small bowel with an abrupt transition point in the mid left abdomen (2:59, 601b:24). There is slight swirling in this area but no convincing evidence for volvulus. Overall, the degree of distention appears similar to the prior study of ___. There is no pneumatosis, pneumoperitoneum, abnormal bowel wall enhancement or thickening, or free fluid in the pelvis. There is no portal venous air. The previously seen herniated loop of bowel within the ostomy site has resolved. The ileosigmoid anastamosis appears unremarkable. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no evidence of adnexal abnormality bilaterally. LYMPH NODES: Scattered non pathologically enlarged lymph nodes are throughout the central mesentery and retroperitoneum. There is no lymphadenopathy by CT size criteria. 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: Aside from the previously described ostomy site, abdominal and pelvic wall is within normal limits. IMPRESSION: Patient is status post subtotal colectomy, left lower quadrant loop ileostomy, and ileal sigmoid anastomosis. There is a high-grade small-bowel obstruction with a transition point in the left mid abdomen as described above without CT evidence for bowel wall ischemia. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ in person on ___ at 3:40 ___, 2 minutes after the discovery of the findings. The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3:47 ___, 9 minutes after the discovery of the findings. Radiology Report EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old woman with sbo s/p ij and intubation // eval line placement eval line placement IMPRESSION: In comparison with study of ___, there has been placement of a nasogastric tube that extends at least to the lower body of the stomach where it crosses the lower margin of the image. Endotracheal tube tip lies approximately 6 cm above the carina. Right IJ catheter extends to the mid to lower SVC. Continued elevation of the left hemidiaphragm with atelectatic changes above it and blunting of the costophrenic angle. The right lung is clear and there is no evidence of vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with history of several SBO's presenting with high grade SBO, hypotension and elevated lactate now s/p ex-lap, SBR, left in discontinuity. // Interval assesment Interval assesment IMPRESSION: In comparison with the study of ___, the monitoring and support devices are essentially unchanged. There are lower lung volumes, which accentuate the size of the cardiac silhouette. Elevation of the left hemidiaphragmatic contour is again seen with atelectatic changes above it. Central opacifications on the left probably represent engorged pulmonary vessels related to low lung volumes, essence on the right there is no evidence of substantial vascular congestion. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with septic shock // assess ETT assess ETT IMPRESSION: Comparison to ___. No relevant change. Moderate cardiomegaly. Elevation of the left hemidiaphragm. Monitoring and support devices are constant. The pre-existing parenchymal changes and the moderate to severe cardiomegaly are unchanged. No pneumothorax. Radiology Report EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with history of several SBO's presenting with high grade SBO, hypotension and elevated lactate now s/p ex-lap. // Interval assesment Interval assesment COMPARISON: Prior chest radiographs one ___ through ___. IMPRESSION: Moderate pulmonary edema which developed between ___ and ___ has improved although pulmonary vasculature is still very engorged. Opacification at the lung bases, particularly the left above the chronically elevated left hemidiaphragm, is probably a combination of atelectasis and edema but there is no way to exclude pneumonia. Moderate cardiomegaly which also worsened after ___ and mediastinal vascular engorgement are unchanged. ET tube, right internal jugular line are in standard placements and the nasogastric tube is looped widely in the stomach. Radiology Report INDICATION: Intraoperative film to assess for missing sponge TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: None. FINDINGS: An enteric tube is seen terminating in the stomach. Multiple vascular clips are noted in the left upper quadrant, mid abdomen, and right lower quadrant. Stoma is in the left lower quadrant. Sutures are seen in the left lower quadrant. Suture-like material is also noted in the left upper quadrant. Contrast material is seen in the rectum. There are no unexplained radiopaque foreign bodies. IMPRESSION: No unexplained radiopaque foreign bodies in the abdomen. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the ___ ___ at 4:31 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with picc // r dl power picc 48cm iv ___ ___ Contact name: ping, ___: ___ r dl power picc 48cm iv ___ ___ COMPARISON: ___ IMPRESSION: Type of tube tip is in the stomach. Right internal jugular line tip at the level of lower SVC. Right PICC line tip is at the level of proximal right atrium. Left pleural effusion and basal consolidation are unchanged. Elevated hemidiaphragm with high position of the colon is re- demonstrated. Radiology Report EXAMINATION: UNILAT UP EXT VEINS US LEFT INDICATION: ___ year old woman with bowel resection, now left upper extremity pain // ?DVT LEFT upper extremity TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper extremity veins. COMPARISON: None. FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Radiology Report EXAMINATION: CT abdomen and pelvis with contrast INDICATION: High-grade small bowel obstruction status post ex lap, reduction internal hernia, small bowel resection, anastomosis, and end ileostomy with abdominal pain. Evaluate for abscess or fluid collection. 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 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP = 14.4 mGy-cm. 2) Spiral Acquisition 5.6 s, 61.9 cm; CTDIvol = 17.1 mGy (Body) DLP = 1,055.3 mGy-cm. Total DLP (Body) = 1,070 mGy-cm. COMPARISON: CT abdomen and pelvis examinations dating from ___ through ___. FINDINGS: Heart size is normal without significant pericardial fluid. There are apparent areas of non opacification of of a few of the a subsegmental branches of the posterior basal segmental pulmonary arteries of the right lower lobe (2: 20). There is mild bibasilar atelectasis. There is prominent elevation of the left hemidiaphragm. CT abdomen with contrast: The lateral left lobe of the liver appears atretic. Liver otherwise enhances homogeneously without focal lesion or biliary dilatation. There is trace pericholecystic fluid, nonspecific. Gallbladder is otherwise unremarkable. Portal vein is patent. Spleen, pancreas and adrenal glands are unremarkable. There is a 13 mm right lower pole simple renal cyst. Other scattered millimetric renal hypodensities are too small to fully characterize by CT but likely represent cysts. Kidneys otherwise present symmetric nephrograms and excretion of contrast without hydronephrosis. Stomach is distended with air and ingested material but is otherwise grossly unremarkable. There is dilatation of the small bowel up to a diameter of roughly 7 cm in portions with fecalization distally suggestive of slowed motility with a single abrupt transition point just proximal to the end ileostomy (2:77). Portions of the distal ileum appear thickened and indistinct with relative hyper enhancement and surrounding stranding and trace free fluid consistent with inflammatory change. Abdominal aorta is normal in caliber. A few top-normal mesenteric lymph nodes are identified. There is trace free fluid. No organizing fluid collection is seen. No pneumoperitoneum. CT pelvis with contrast: ___ pouch is identified, opacified with contrast, likely from prior administration. Uterus, adnexa and bladder are are unremarkable. There is no inguinal or pelvic sidewall lymphadenopathy by CT size criteria. Bones and soft tissues: There is no suspicious focal bone lesion. IMPRESSION: 1. High-grade small-bowel obstruction with single abrupt transition point just proximal to the end ileostomy. 2. Inflammatory changes of the distal residual small bowel with wall thickening, surrounding stranding and trace free fluid. 3. No organizing abdominal fluid collection. 4. Apparent non opacification of a few subsegmental pulmonary arterial branches of the right lower lobe posterior basal segment may be due to bolus timing which is not optimized for evaluating the pulmonary arteries. However, if there is clinical concern for pulmonary embolus, this would be best evaluated with dedicated chest CTA. 5. Left hemidiaphragm elevation, likely paretic. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ on the telephoneon ___ at 5:21 ___, 5 minutes after discovery of the findings. Radiology Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with new onset RUQ pain and tenderness. // r/o cholelithiasis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is trace perihepatic ascites. There is a trace right pleural effusion. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 11 cm. Limited images of the right kidney are normal with no hydronephrosis. IMPRESSION: 1. Echogenic liver compatible with steatosis. 2. Normal appearance of the gallbladder with no stones or wall thickening. 3. Trace perihepatic ascites and trace right pleural effusion. Radiology Report INDICATION: ___ year old woman with abdominal pain/cramping // ? new intra-abdominal process/fluid collection/abscess compare to prior study 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 5.0 s, 1.0 cm; CTDIvol = 11.6 mGy (Body) DLP = 11.6 mGy-cm. 3) Spiral Acquisition 16.1 s, 55.4 cm; CTDIvol = 20.7 mGy (Body) DLP = 1,113.8 mGy-cm. Total DLP (Body) = 1,140 mGy-cm. COMPARISON: CT abdomen pelvis ___. FINDINGS: LOWER CHEST: There is a moderate right pleural effusion, larger on the prior study, with adjacent atelectasis. Atelectasis is also present at the left lung base. There is no pericardial effusion, and the visualized heart is normal in size. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. The lateral left lobe liver appears atretic. 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 hydronephrosis. A 13 mm hypodensity in the lower pole of the right kidney is consistent with a simple cyst. Additional small hypodensities in both kidneys are too small for further characterization. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Again seen are multiple dilated loops of small bowel, slightly less distended than the prior study, with a transition point near the ileostomy, similar in appearance the prior study. The ileostomy itself is unremarkable in appearance. A ___ pouch is again identified, opacified with oral contrast. The appendix is surgically absent. There is a small amount of fluid in the paracolic gutters, slightly increased compared to the prior study but nonspecific. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: Multiple prominent mesenteric lymph nodes at the root of the mesentery are noted. Several small retroperitoneal lymph nodes are noted which are not pathologically enlarged. 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 aside from left lower quadrant ileostomy. IMPRESSION: 1. Mild improvement in distension of small bowel loops compared to the most recent prior study. Transition point remains near the ileostomy 2. New small amount of ascites without discrete fluid collection. 3. Increased right pleural effusion, now moderate, and adjacent atelectasis. Radiology Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ y/o F w/ RUE double-lumen PICC, now w/frequent clotting and difficulty drawing back // please eval for current PICC position TECHNIQUE: Single frontal view of the chest COMPARISON: ___ IMPRESSION: Right PICC tip is in themid SVC. Cardiac size is normal. There are bibasilar atelectasis. The left hemidiaphragm is elevated. There is dilatation of bowel projecting in the left upper quadrant. There are surgical clips in the left upper quadrant of the abdomen. There is no pneumothorax or large pleural effusion. Gender: F Race: WHITE Arrive by AMBULANCE Chief complaint: Transfer, SBO Diagnosed with Unspecified intestinal obstruction temperature: 99.5 heartrate: 76.0 resprate: 18.0 o2sat: 97.0 sbp: 92.0 dbp: 55.0 level of pain: 6 level of acuity: 2.0

Dear Ms. ___, You presented to the ___ on ___ and were found to have an internal hernia and high grade small bowel obstruction. You were taken to the Operating Room several times and underwent exploratory laparotomy, lysis of adhesions, reduction of your internal hernia, a small bowel resection and ileostomy creation. Your abdominal fascia (muscle) was surgically repaired and you had an abdominal wound vac to help close the remainder of your wound. Your ileostomy output was monitored and medications were started to help slow your output. You experienced increased abdominal pain and an ileus and these medications were weaned. Your output is now within normal limits. You are now tolerating a regular diet and your pain is better controlled. You are now cleared to be discharged to rehab to continue receiving IV fluid overnight and to have your electrolytes monitored. Please 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. Monitoring Ostomy output/ Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours.